Rawalpindi General Hospital Research Articles

Association of CYP24A1 gene, Vitamin D deficiency and heart diseases in Pakistani patients

To analyze the association of CYP24A1 gene polymorphism with vitamin D deficiency and its related cardiovascular disorders in the Pakistani population. The present prospective cohort study was carried out at KRL and Rawalpindi General Hospital from January 2017 to December 2018. A total of 110 subjects suffering from heart diseases like hypertension, myocardial infarction, or congestive cardiac failure (age range 12-90 years) were enrolled in this study with informed consent. Sampling was done by non-probability convenience sampling. Blood 24Hydroxyvitmin D levels were assessed in the participants by using an electrochemiluminescence system. Genetic polymorphism in the CYP24A1 gene was screened in selected patients (n=15) through PCR-RFLP, after genomic DNA extraction from the whole blood. Data were analyzed using SPSS version 24 for Mac. Fisher’s exact test and chi-square tests were applied for qualitative variables. The risk of polymorphism in CYP24A1(SNP rs6013897) genotypes TT, AT, and AA was determined by calculating the odds ratio and confidence interval. P-value <0.05 was considered statistically significant. We observed the highest level of vitamin D deficiency in patients of age group 18-45 years and insufficiency in age group 50-60years. A greater percentage of female patients (34.19%) were deficient in Vitamin D as compared to males (25.72%). Vitamin D deficiency was found to be associated with cardiovascular diseases like hypertension (P=0.000*), myocardial infarction (P=0.334), and heart failure (0.001*). CYP24A1 (SNP rs6013897) was significantly associated (P=0.000*) with vitamin D deficiency and heart diseases (P=0.004*). Moreover, significant polymorphism of genotype AT was observed in our subjects. {P=0.007*, Cramer’s V =.003 and 95% CI (0.44-17.27)}. There is an association of CYP24A1 gene polymorphism with vitamin D deficiency and heart diseases. Prevention of low vitamin D levels in individuals with this known genetic marker may help to avert the development of heart diseases in Pakistan.

Underestimation of malnutrition among Pakistani infants weighed with clothes on

Manygrowth monitoring programmes at health facilities and in communities in Pakistan weigh children with their clothes on. The nutritional status of infants at the Rawalpindi General Hospital was estimated from weight without clothes on and showed that about 8% of malnourished children were being missed. This underestimation mostly affected children with grade II and grade III malnutrition. Generally, more boys have normal nutritional status than girls. Accordingly, weight with clothes on was found to underestimate the malnutrition status of girls more than that of boys. Children should be weighed without clothes on so as estimate their nutritional status and risk accurately

Professor Jawaid-ur-Rehman

Born on March, 31st 1957 in Attock to Capt. Abdur Rehman Shaheed and Mubarka Jamila Akthar. His father was martyred in the line of duty when he was three years old. As a young man, he joined Cadet College Petaro as a student at the age of twelve, where he learned to be a valuable member of his community and an asset for his country. His love for, and commitment to, help and serve his fellow man drove him to choose medicine as his profession. To pursue his dreams of a career in medicine, he joined Army Medical College (AMC) in 1978. He was part of the second intake batch of this prestigious institution. After two years in AMC, he transferred to Punjab Medical College (PMC), Faisalabad, where he completed his MBBS. He built on his skills by completing his house job training at Rawalpindi General Hospital.

Presentation and complications of snakebite in a tertiary care hospital.

To determine frequency of various modes of presentation, complications and management of snakebite. Descriptive case series. Medical Unit II, Rawalpindi General Hospital, Rawalpindi, Pakistan, from September 2006 to August 2007. All patients over 12 years of age and presenting to emergency department with history of snakebite and features of envenomation were included in the study. All these patients were given Anti-Snake Venom. Symptomatic treatment of complications was done. Semi-structured questionnaire was filled during hospital stay to analyze various characteristics of snakebite and people's attitude towards this problem. A total of 65 patients were enrolled in the study with 40 males (61.5%) and 25 (38.5%) females. Maximum cases 15 (23%) were seen in the month of August. Age group, that was maximally affected, was between 26-30 years (12 cases or 18.5%). Only 2 patients had neurotoxic snakebite, whereas rest of the cases were vasculo toxic in nature. Gum bleeding and cellulitis were the main presenting complaints. Mortality was 4.6% (3 cases). A great majority of patients arrived late in the hospital because of lack of awareness and use of traditional though ineffective measures. Snakebite is a major public health problem. Patients with snakebite can be managed effectively provided timely administration of anti-snake Venom is done.

'Human bocavirus in Pakistani children with gastroenteritis'.

Human Bocaviruses (HBoV) have been detected in human respiratory and gastrointestinal infections worldwide. Four genotypes of HBoV (HBoV1-4) have been described; HBoV-1 is associated with respiratory tract infections while HBoV-2, -3, and -4 genotypes are considered as entero-pathogenic although the exact role largely remains unclear. The global prevalence of HBoV has been reported, but the epidemiological data from Pakistan is largely unavailable to date. This study was conducted to understand the genetic diversity and disease prevalence of HBoV in hospitalized Pakistani children with acute diarrhea. During 2009, a total of 365 stool samples were collected from children hospitalized with gastrointestinal symptoms (as per WHO case definitions) at Rawalpindi General Hospital, Pakistan. Demographic and clinical data were recorded using a standardized questionnaire. The samples were tested for HBoV and rotavirus using real-time RT-PCR and ELISA, respectively. There were 47 (13%) samples positive for HBoV with 98% (n = 46) showing co-infection with rotavirus. HBoV-1 was the most frequently detected and was found in 94% samples followed by HBoV-2 and HBoV-3 genotypes. The mean age of infected children was 7.57 ± 5.4 months while detection was more frequent in males (n = 32, 68%). All cases recovered after 2.43 ± 1.0 mean days of treatment. On phylogenetic analysis, HBoV strains from Pakistan clustered closely with viruses from neighboring Bangladesh and China. These findings represent the first known epidemiological study in Pakistan to investigate the role of HBoV in acute gastroenteritis. The clinical data demonstrates that HBoV is not significantly associated with gastroenteritis alone and predominantly co-infections with rotavirus are found.

Practice of Electroconvulsive Therapy in a Tertiary Care Hospital in Pakistan

This study aimed to describe the practice of an unmodified electroconvulsive therapy (ECT) in a typical urban hospital setting in Pakistan. This is a retrospective naturalistic study of patients who received ECT at Rawalpindi General Hospital between June 2000 and June 2008 by chart review. All useful data that could be retrieved from the charts were recorded. The process of administering ECT at the hospital is described. During the study period, of a total of 5240 patients who were admitted to the hospital, 1520 (29%) were administered ECT. Of these, 1352 (88.9%) did not get any kind of anesthesia during the procedure. The mean age of patients was 34.89 years, and the leading diagnoses were depression (60.8%), bipolar disorder (17.8%), and schizophrenia (9.1%). The mean number of ECTs received for these diagnoses were 5.78, 5.52, and 6.34, respectively. A total of 249 (16.7%) patients discontinued ECT against medical advice. In countries with limited resources, ECT is practiced in a markedly different way from more developed countries; although administering ECT without anesthesia is not desirable, in the face of severe economic constraints, it is often necessary.

PREVENTIVE MEDICINE DEPARTMENT;

Objectives: To measure the current status of preventive activities in civil and military hospitals. To compare the quantum ofpreventive and curative activities in the hospitals. To make recommendations for promotion of preventive activities to reduce the curative burdenfrom the hospitals. Study Design: This was a cross-sectional study. Sampling Technique: Universal sampling. All the major military and publicsector hospitals having bed strength more than 400 in Rawalpindi were included in the study. All the preventive and curative work was taken intoaccount. Methodology: A structured questionnaire was developed and data regarding the quantum of work was collected from all the fourmajor Military and civil hospitals having bed strength more than 400 beds through registers and annual reports of the hospital and was analyzedin the form of frequencies, tabulation, cross tabulation, percentages and was displayed in tables and graphs using SPSS (10.5), Microsoft Exceland calculus. Results: Only seven percent work is preventive and ninety three percent is curative. In the preventive activity MH is marginallyhigher than the rest of the hospitals. In all the hospitals among the preventive activities 31% are antenatal visits, 20 % tetanus toxoid injection,19% BCG, Growth monitoring 13%, Measles injection 11% and family planning 6% in all the hospitals. Ante natal activities in the army sectorhospitals are more prominent 39-44% and also in the public sector 17-26%. Next to the antenatal are tetanus toxoids to pregnant ladies whichrange from 16-35% in military and 16-20 % in the public sector hospitals. Growth monitoring is more efficiently carried out in the RawalpindiGeneral Hospital i.e. 17% while in others 7-12%. Family Planning services are delivered very poorly only 9% in RGH and 6% in DHQ, zero % inCMH and 5% in MH. Measles vaccination is carried out efficiently in DHQ 27%, 11% in RGH and 8% in MH and again poorly 3% in CMH. BCG is27% in DHQ, 20% in MH, 17% in RGH and 10% in CMH. Conclusions: The study show that hospitals are showing very poor performance inpreventive aspect and this is the reason that countries like Pakistan are facing economic burden on the national exchequer and this burden willkeep on increasing if no appropriate action is taken.

LAPAROSCOPIC CHOLECYSTECTOMY

Objective: To determine the frequency of common bile duct (CBD) injury in laparoscopic cholecystectomy in our settings, in my last 500 cases, after going through the learning curve associated CBD injuries. Design: Descriptive study. Place and Duration of Study: Surgical Unit-I, Rawalpindi General Hospital and the author’s Surgical Clinics from January 2003 to December 2008. Patients and Methods: Five hundred patients undergoing laparoscopic cholecystectomy by the same surgeon were included. The important variables included demographic data, intra operative time and findings, frequency of CBD injury and post operative hospital stay. Results: There were 419(83.8%) females and 81(16.2%) males with mean age 45.04±11.03 years. 294(58.8% )patients had chronic cholecystitis with Cholelithiasis and were admitted through Out Patient Department whereas 206(41.2%) were admitted through Accident and Emergency Department with acutecholecystitis. Abdominal ultrasound showed multiple calculi in 351(70.2%) patients and 149(29.8%) patients had single calculus preoperatively. Empyema was found in 97(19.4%) cases whereas adhesions were present in 182( 36.4%) patients. In our study frequency of CBD injury was 1%. Mean operating time was 35 minutes. 96.8 % of the patients were discharged within 48 hrs of operation. Conclusion: LaparoscopicCholecystectomy in our set up proved to be a safe procedure, having frequency of CBD injury of only 1% and a short hospital stay 493(96.8% )being discharged in less than 2 days.

Role of Muscle Relaxant (Tizanidine) In Painful Muscle Spasm

Background: Muscle spasms and cramps are spontaneous, often painful muscle contractions. Most cases of simple cramps require no treatment other than rest. More prolonged or regular cramps may be treated with drugs. Tizanidine which is an agonist at á 2-adrenergic receptor sites and presumably reduces spasticity by increasing presynaptic inhibition of motor neurons is one such drug which relieves spasm, cramps and tightness of muscles.Objective: To evaluate effectiveness and tolerability of Tizanidine in painful muscle spasm of various etiologies.Patients and methods: This Quasi experimental study was carried out from July 1995 to July 2007 in outpatient department of Rawalpindi general hospital and Holy family hospital, Rawalpindi. Inclusion criteria included all the patients suffering from painful muscle spasm in back, neck, shoulder, knee or other anatomical sites with onset not more than two days prior to presentation. The patients suffering from rheumatoid arthritis, ankylosingspondylitis, osteoporosis, infective arthritis, prolapsed disc, patients with history of NSAID or analgesics intake less than 6 hours prior to receiving the first dose of study medication, severe systemic disease, uncontrolled hypertension, pregnant women and lactating mothers were excluded from the study. After initial evaluation, patients took Tizanidine three times daily for 5 days with re-evaluation on day 3 and day 6.Results: 5300 patients comprised of 60% (n=3180) males and40% (n=2120) females with age range of 18-75 yrs. very good effectwas seen in 57% (n=3021) patients while no effect was seen in 10%(n=530) patients.14% (n=742) patients suffered from drowsiness,2% (n=106) patients suffered from dry mouth and 2%(n=106)patients suffered from GI symptoms and nausea.Conclusion: This study confirms efficacy, safety and tolerabilityof Tizanidine for relief of painful muscle spasm.

Frequency and associated factors for postnatal depression.

To determine the frequency and associated sociodemographic, obstetric and medical factors for postnatal depression in an outpatient sample. A descriptive, cross-sectional study. Department of Obstetrics and Gynaecology, Benazir Bhutto Hospital (formerly Rawalpindi General Hospital), Rawalpindi, between June 2006 and February 2007. The sample consisted of women who were in the puerperal period (6 weeks postpartum). They were screened with the help of Edinburgh Postnatal Depression Scale (Urdu version) and the severity of depression was rated with the Hamilton Rating Scale for Depression. A total of 51 participants, or 33.1% of a sample of 154 women suffered from postnatal depression, the majority of whom were either moderately or severely depressed. The demographic profile of depressed patients showed that they were young (mean age around 25 years), had a low level of education (below the matriculate level) and came from the lower socioeconomic class. They had small families comprising of fewer than 3 children, were married for less than 5 years and the majority were from extended families (living with in-laws). Postnatal depression was found in almost 1/3rd of the study participants and the preponderance of them suffered from moderate or severe depression. They were young and came from a background of socio-economic adversity. Since postnatal depression had adverse consequences for the mother and her newborn baby, there was an urgent need to direct more attention to this problem, in particular towards its early detection, so that morbidity could be reduced in this group of women.

LAPAROSCOPY

Objective: To identify the various acute and chronic abdominal conditions presenting as non specific abdominal pain inwhich diagnostic laparoscopy was indicated to establish a definite diagnosis and treatment. Design: Descriptive study. Setting: Surgicalunit-l of Rawalpindi General Hospital Rawalpindi. Period: From February 2005 to February 2006. Materials & Methods: All patients whopresented with non specific abdominal pain and fulfilled the inclusion criteria were included in the study. The sample size was 150 cases,out of which 71 (47%) were male and 79 (53%) were female. Mean age was 32.65± 17 years. Fifty five (36%) patients were admitted throughemergency department while 95 (63%) were admitted through OPD. Four main groups were identified who presented with nonspecificabdominal pain in which diagnostic laparoscopy was indicated. These were patients with acute or chronic inflammatory conditions (66%),acute or chronic intestinal obstruction (14%), patients with blunt/penetrating abdominal trauma (11 %), and patients of intra abdominal tumor(9%). Out of these 150 cases, 53 cases (35%) had laparoscopy to confirm the diagnosis (diagnostic laparoscopy) while the remaining 97cases (65%) had both the diagnostic as well as therapeutic laparoscopy. Mean hospital stay was 1.7 Days. Conclusion: The study hasdemonstrated the various acute and chronic abdominal conditions in which laparoscopy in indicated and proved to have higher diagnosticand therapeutic yield, and hence improved the management of these patients.

Type of presentation of dissociative disorder and frequency of co-morbid depressive disorder.

To determine the frequency distribution of various types of dissociative disorders, along with existing co-morbid depression and its level of severity in patients with dissociative disorder. Observational, cross-sectional study. The Institute of Psychiatry, Rawalpindi General Hospital from October 2004 to March 2005. Fifty consecutive patients were included in the study through non-probable purposive sampling technique. Encounter form included socio-demographic profile and brief psychiatric history. ICD 10 diagnostic criteria for research were administered for determining the presentation of dissociative disorder. Present state examination was applied to make diagnosis of depressive disorder in the studied patients. Descriptive statistics for frequency analysis of sociodemographic variables, type of presentation of dissociative disorder and the frequency of depressive disorder in patients of dissociative disorder. The mean age was 23.6+/-8.67 years with female preponderance (n=40, 80% patients). Most of them were single, unemployed and belonged to urban population. Main stress was primary support group issue. Mixed category of dissociative disorder was highest (n=18, 38%) followed by unspecified and motor symptoms (n=13, 26%) in each group. Depression was present in 42 (84%) patients. Moderate depression was most frequent (n=19, 38%). Mixed dissociative symptoms were found in 38%, while 26% had motor and unspecified category of dissociative symptoms respectively. Depressive disorder was present in 42 (84%) cases of dissociative disorder with 38% having moderate depression.

Frequency of tuberculous cervical lymphadenitis detection at a single laboratory in islamabad.

To determine the frequency of tuberculous cervical lymphadenitis and to evaluate the diagnostic efficacy of microscopy and conventional Lowenstein Jensen (LJ) culture technique in the diagnosis of cervical lymphadenitis caused by M. tuberculosis (MTB) Study Design: A descriptive, cross-sectional study. Place and Duration of the Study: Department of Mycobacteriology, Public Health Laboratories Division, National Institute of Health, Islamabad, from January 2003 to December 2004. A total of 220 patients from Pakistan Institute of Medical Sciences (PIMS), Islamabad, Federal Government Services Hospital (FGSH), Islamabad and Rawalpindi General Hospital (RGH), Rawalpindi, presenting with enlarged cervical lymph nodes (for at least six months), pain/ weight loss and low grade fever were studied for the presence of MTB from 142 lymph node biopsies, 60 FNA samples and 18 discharge fluids/swabs. All the samples were examined at NIH by ZN staining smear and culture on conventional LJ medium as well as on Bactec 12B medium using Bactec 460 TB system. The drug susceptibility testing of the isolates was performed on Bactec 460 TB system. NAP test on Bactec 460-TB system, Accuprobe and biochemical tests were employed to identify the mycobacterial isolates. M. tuberculosis accounted for 173 out of 220 cases of cervical lymphadenopathy. Maximum incidence was found to be in the age group 10-30 years with male to female ratio of 1:1.7. Discharge sinuses and abscess formation were uncommon. Biopsy tissue samples gave the maximum yield of positive mycobacterial cultures as all 142 biopsy samples being positive while only 50% (30/60) of FNA and 5.5% (1/18) of discharge fluids/swabs were positive. All the isolates were identified as M. tuberculosis. No atypical mycobacteria were recovered from the samples examined. All isolates were found to be susceptible to first line anti-tuberculous drugs i.e. Streptomycin, Isoniazid, Rifampicin and Ethambutol (SIRE). Tuberculosis was the major cause of cervical lymphadenopathy in the referral area. Culture of the biopsy tissue from the affected lymph nodes is a method of choice for laboratory diagnosis of tuberculous cervical lymphadenopathy.

Complications in Patients With Spinal Cord Injuries Sustained in an Earthquake in Northern Pakistan

Background: Spinal cord injury (SCI) is a devastating trauma suffered by many of the victims of an earthquake that struck Northern Pakistan on October 8, 2005. It rendered approximately 600 patients paraplegic, which is the highest number ever reported in any disaster. This study was conducted to evaluate the risk of complications.Methods: The cross-sectional retrospective study covering a 2-month period was conducted on 194 patients admitted to the surgical/neurosurgical wards of Rawalpindi Medical College and allied hospitals (Holy Family Hospital, Rawalpindi General Hospital, and District Headquarter Hospital) and Melody Relief and Rehabilitation Center, Islamabad.Results: The male-to-female ratio was approximately 1:3 (n = 50 [26%] and n = 144 [74%], respectively). The majority (78% [n = 151 ]) were 16 to 39 years of age; 62% (n = 120) had lumbar-level injuries, 25% (n = 48) had thoracic-level injuries, 9% (n = 18) had thoracolumbar-level injuries, and a few had cervical- or sacral-level injuries. Forty-six percent (n = 90) had American Spinal Injury Association type A injuries; 4% (n = 8) were graded B, 11 % (n = 21) were graded C, 9% (n = 18) were graded D, and 14% (n = 27) were graded E. Twenty percent (n = 39) developed pressure ulcers, of which 38% (n = 15) had grade 1, 36% (n = 14) had grade 2, 23% (n = 9) had grade 3, and 3% (n = 1) had grade 4. All patients developed urinary tract infections; 15% (n = 30) had bowel complaints; 2% (n = 3) developed deep-vein thrombosis (1 died of pulmonary embolism); and 0.05% (n = 1) developed wound infection.Conclusion: Awareness of potential complications in patients with paraplegia is essential to care planning in the disaster setting. The priorities include skin, bowel, and bladder care and provision of prophylactic heparin. SCI post-disaster care requires comprehensive long-term planning.

Predictive power of Mannheim Peritonitis Index.

To evaluate Mannheim Peritonitis Index (MPI) in predicting outcome in patients with secondary peritonitis and to assess each risk factor independently regarding its contribution towards final outcome. Prospective analytical study. Surgical Unit-II of Rawalpindi General Hospital, from December 1999 to January 2001. One hundred and twenty-six patients who presented to the department with secondary peritonitis were included in the study. MPI score was calculated for each patient on a pre-designed proforma and the patients were followed-up till death or discharged from the hospital. Death was the main outcome measure against which the MPI scores were analyzed under two categories; (i) score > or = 26 and < 26 (ii) scores < 21, 2-29, and > 29. Data was analyzed on software SPSS (version 11.0). Chi-square test was used to assess any significant association between scores and outcome. Odds ratios were calculated for individual risk factors. Mortality rate for MPI score > or = 26 was 28.1% while for scores less than 26 it was 4.3%. For MPI scores pound 20 mortality rate was 1.9%, for scores 21-29 it was 21.9% and for score 30 or more it was 28.1%. Chi-square showed significant association between mortality and increasing MPI score (p < 0.01). Odd ratios calculated were significant for age > 50 years, malignancy, organ failure, pre-operative duration of peritonitis > 24 hours and cloudy, purulent exudate. Increasing MPI score is strongly associated with outcome in secondary peritonitis.

Surgical management of epithelial parotid tumours.

To describe the clinicopathological presentation and treatment options in epithelial parotid tumours with emphasis on surgery. Descriptive study. ENT Departments of Pakistan Institute of Medical Sciences, Islamabad and Holy Family Hospital, Rawalpindi and Surgical Units at Rawalpindi General Hospital and DHQ Teaching Hospital, Rawalpindi, during a ten year period 1993-2003. Epithelial parotid tumours diagnosed and operated by an ENT surgeon and a general surgeon in 10 years during their posting in different teaching hospitals were included in the study. Clinical presentation, preoperative investigations, operative procedure, histopathology report, postoperative complications and further management were recorded. The data was collected and reviewed from the records of all the patients maintained by the authors. Fifty-two patients presented with parotid tumour. Average age was 38 years. Commonest presentation was a painless lump over the parotid region (85%), pain (15%), facial palsy, and enlarged neck nodes. Majority of tumours were benign, only two were recurrent. Parotid pleomorphic Adenoma (PPA) was the commonest benign tumour, others being Warthin's tumour and monomorphic adenoma. Adenoid cystic carcinoma was the commonest malignant tumour 29% followed by mucoepidermoid carcinoma. Others were carcinoma in PPA, squamous cell carcinoma, malignant mixed tumour, malignant lymphoepithelioma and undifferentiated carcinoma. Superficial parotidectomy (SP) was the commonest operation performed in 69%. Other procedures were total conservative parotidectomy in 11%, total radical surgery in 9% and enucleation in only one patient earliest in the series. Neck node dissection was done in 2 patients. Except for one child, rest of the 13 patients received postoperative radiotherapy and one patient of lymphoepithelioma received chemotherapy in addition. Commonest postoperative complication was temporary facial weakness in 35% (18/52). Permanent facial palsy occurred in 08 patients. Of these 07 had a malignant process and only one patient had excision biopsy. Benign and malignant epithelial parotid tumours can be diagnosed by their clinical presentation supplemented with FNAC. Superficial parotidectomy (SP) was the operation of choice. Facial nerve can be saved in total conservative parotidectomy for benign tumour in deep lobe and early malignant tumour. Radical parotidectomy followed by radiotherapy and in selected cases neck node dissection are the recommended procedures for advanced malignant parotid tumours.

Assessment of coverage levels of single dose measles vaccine.

To study the consequences of low coverage levels of a single dose of measles vaccine. Case series. The study was conducted in the Department of Paediatrics, Rawalpindi General Hospital (RGH) from January 2001 to August 2001. Information about 68 admitted cases of measles was collected on a structured proforma with reference to epidemiological profile, vaccination history and comorbidities. Mean age observed in measles cases was 2 years and 8 months with a range from 3 months to 8 years. Maximum number of cases reported were <1 year of age (n=22, 32%). Fifty percent of cases were seen among vaccinated children. Seventy-five percent (n=51) had history of contact with a measles case. Pneumonia was the commonest complication followed by acute gastroenteritis, encephalitis, febrile convulsions, oral ulcers, oral thrush, eye changes of vitamin-A deficiency and pulmonary tuberculosis (T.B.) in descending order of frequency. Fifty-four cases were successfully treated for complications of measles and discharged. Nine cases left against medical advice. Five patients died--all of them had encephalitis either alone (n=1) or in combination with pneumonia and acute gastroenteritis (n=4). There is a dire need to increase the immunization coverage to reduce the rate of vaccine failure and achieve effective control of measles.