title: Enhanced disease surveillance through private health care sector cooperation in Karachi, Pakistan: experience from a vaccine trial.
abstract: BACKGROUND
  In research projects such as vaccine trials, accurate and complete surveillance of all outcomes of interest is critical. In less developed countries where the private sector is the major health-care provider, the private sector must be included in surveillance systems in order to capture all disease of interest. This, however, poses enormous challenges in practice. The process and outcome of recruiting private practice clinics for surveillance in a vaccine trial are described.
  
  
  METHODS
  The project started in January 2002 in two urban squatter settlements of Karachi, Pakistan. At the suggestion of private practitioners, a phlebotomy team was formed to provide support for disease surveillance. Children who had a reported history of fever for more than three days were enrolled for a diagnosis.
  
  
  RESULTS
  Between May 2003 and April 2004, 5540 children younger than 16 years with fever for three days or more were enrolled in the study. Of the children, 1312 (24%) were seen first by private practitioners; the remainder presented directly to study centres. In total, 5329 blood samples were obtained for microbiology. The annual incidence of Salmonella typhi diagnosed by blood culture was 407 (95% confidence interval (95% CI), 368-448) per 100 000/year and for Salmonella paratyphi A was 198 (95% CI, 171-227) per 100 000/year. Without the contribution of private practitioners, the rates would have been 240 per 100 000/year (95% CI, 211-271) for S. typhi and 114 (95% CI, 94-136) per 100 000/year for S. paratyphi A.
  
  
  CONCLUSIONS
  The private sector plays a major health-care role in Pakistan. Our experience from a surveillance and burden estimation study in Pakistan indicates that this objective is possible to achieve but requires considerable effort and confidence building. Nonetheless, it is essential to include private health care providers when attempting to accurately estimate the burden of disease in such settings.
authors.affiliation: Department of Paediatrics, Aga Khan University, Karachi, Pakistan.
authors.forename: Mohammad Imran
authors.initials: MI
authors.lastname: Khan
authors.forename: Shah Muhammad
authors.initials: SM
authors.lastname: Sahito
authors.forename: Mohammad Javed
authors.initials: MJ
authors.lastname: Khan
authors.forename: Shafi Mohammad
authors.initials: SM
authors.lastname: Wassan
authors.forename: Abdul Wahab
authors.initials: AW
authors.lastname: Shaikh
authors.forename: Ashok Kumar
authors.initials: AK
authors.lastname: Maheshwari
authors.forename: Camilo J
authors.initials: CJ
authors.lastname: Acosta
authors.forename: Claudia M
authors.initials: CM
authors.lastname: Galindo
authors.forename: Rion Leon
authors.initials: RL
authors.lastname: Ochiai
authors.forename: Shahid
authors.initials: S
authors.lastname: Rasool
authors.forename: Sheeraz
authors.initials: S
authors.lastname: Peerwani
authors.forename: Mahesh K
authors.initials: MK
authors.lastname: Puri
authors.forename: Mohammad
authors.initials: M
authors.lastname: Ali
authors.forename: Afia
authors.initials: A
authors.lastname: Zafar
authors.forename: Rumina
authors.initials: R
authors.lastname: Hassan
authors.forename: Lorenz
authors.initials: L
authors.lastname: von Seidlein
authors.forename: John D
authors.initials: JD
authors.lastname: Clemens
authors.forename: Shaikh Qamaruddin
authors.initials: SQ
authors.lastname: Nizami
authors.forename: Zulfiqar A
authors.initials: ZA
authors.lastname: Bhutta
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D002986:Clinical Trials as Topic; D003299:Cooperative Behavior; D003695:Delivery of Health Care; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D010154:Pakistan; D017149:Private Sector; D012485:Salmonella typhi / Q000276:immunology; D018571:Sentinel Surveillance; D014612:Vaccines
chemical_list: D014612:Vaccines