Gijs Walraven

Aga Khan University, Pakistan, Kurrachee, Sindh, Pakistan

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Publications (111)741.09 Total impact

  • Source
    J Durocher · J Blum · G Walraven · Nf Zuberi · N Mobeen
    BJOG An International Journal of Obstetrics & Gynaecology 08/2011; 118(9):1144-5. DOI:10.1111/j.1471-0528.2011.02985.x · 3.86 Impact Factor
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    J Durocher · J Blum · G Walraven · Nf Zuberi · N Mobeen
    BJOG An International Journal of Obstetrics & Gynaecology 07/2011; 118(8):1018-9. DOI:10.1111/j.1471-0528.2011.03016.x · 3.86 Impact Factor
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    N Mobeen · J Durocher · Nf Zuberi · N Jahan · J Blum · S Wasim · G Walraven · J Hatcher
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    ABSTRACT: to determine if misoprostol is safe and efficacious in preventing postpartum haemorrhage (PPH) when administered by trained traditional birth attendants (TBA) at home deliveries. a randomised, double-blind, placebo-controlled trial. Chitral, Khyber Pakhtunkhwa Province, Pakistan. a total of 1119 women giving birth at home. from June 2006 to June 2008, consenting women were randomised to receive 600 microg oral misoprostol (n = 534) or placebo (n = 585) after delivery to determine whether misoprostol reduced the incidence of PPH (≥ 500 ml). the primary outcomes were measured blood loss ≥ 500 ml after delivery and drop in haemoglobin >2 g/dl from before to after delivery. oral misoprostol was associated with a significant reduction in the rate of PPH (≥ 500 ml) (16.5 versus 21.9%; relative risk 0.76, 95% CI 0.59-0.97). There were no measurable differences between study groups for drop in haemoglobin >2 g/dl (relative risk 0.79, 95% CI 0.62-1.02); but significantly fewer women receiving misoprostol had a drop in haemoglobin >3 g/dl, compared with placebo (5.1 versus 9.6%; relative risk 0.53, 95% CI 0.34-0.83). Shivering and chills were significantly more common with misoprostol. There were no maternal deaths among participants. postpartum administration of 600 microg oral misoprostol by trained TBAs at home deliveries reduces the rate of PPH by 24%. Given its ease of use and low cost, misoprostol could reduce the burden of PPH in community settings where universal oxytocin prophylaxis is not feasible. Continual training and skill-building for TBAs, along with monitoring and evaluation of programme effectiveness, should accompany any widespread introduction of this drug.
    BJOG An International Journal of Obstetrics & Gynaecology 02/2011; 118(3):353-61. DOI:10.1111/j.1471-0528.2010.02807.x · 3.86 Impact Factor
  • International Journal of Gynecology & Obstetrics 10/2009; 107. DOI:10.1016/S0020-7292(09)60371-4 · 1.56 Impact Factor
  • Gijs Walraven · Sikolia Wanyonyi · William Stones
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    ABSTRACT: The provision of safe and effective delivery care for all women in poor countries remains elusive, resulting in a continuing burden of mortality in general and mortality from post-partum haemorrhage in particular. Deployment of a functional health system and effective linkage of the health system to communities are the necessary prerequisites for the provision of the life-saving technical interventions that will make a difference in individual cases. Sadly, two factors militate against progress: the mantra that 'we know what works' (resulting in some serious gaps in evidence for best practice in resource-poor settings) and a lack of large-scale investment in maternity services to counteract the degradation of infrastructure and depletion of human resources evident in many countries.
    Best practice & research. Clinical obstetrics & gynaecology 11/2008; 22(6):1013-23. DOI:10.1016/j.bpobgyn.2008.08.002 · 3.00 Impact Factor
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    ABSTRACT: Postpartum hemorrhage (PPH) remains a major killer of women worldwide. Standard uterotonic treatments used to control postpartum bleeding do not always work and are not always available. Misoprostol's potential as a treatment option for PPH is increasingly known, but its use remains ad hoc and available evidence does not support the safety or efficacy of one particular regimen. This study aimed to determine the adjunct benefit of misoprostol when combined with standard oxytocics for PPH treatment. A randomized controlled trial was conducted in four Karachi hospitals from December 2005 - April 2007 to assess the benefit of a 600 mcg dose of misoprostol given sublingually in addition to standard oxytocics for postpartum hemorrhage treatment. Consenting women had their blood loss measured after normal vaginal delivery and were enrolled in the study after losing more than 500 ml of blood. Women were randomly assigned to receive either 600 mcg sublingual misoprostol or matching placebo in addition to standard PPH treatment with injectable oxytocics. Both women and providers were blinded to the treatment assignment. Blood loss was collected until active bleeding stopped and for a minimum of one hour after PPH diagnosis. Total blood loss, hemoglobin measures, and treatment outcomes were recorded for all participants. Due to a much lower rate of PPH than expected (1.2%), only sixty-one patients were diagnosed and treated for their PPH in this study, and we were therefore unable to measure statistical significance in any of the primary endpoints. The addition of 600 mcg sublingual misoprostol to standard PPH treatments does, however, suggest a trend in reduced postpartum blood loss, a smaller drop in postpartum hemoglobin, and need for fewer additional interventions. Women who bled less overall had a significantly smaller drop in hemoglobin and received fewer additional interventions. There were no hysterectomies or maternal deaths among study participants. The rate of transient shivering and fever was significantly higher among women receiving misoprostol A 600 mcg dose of misoprostol given sublingually shows promise as an adjunct treatment for PPH and its use should continue to be explored for its life-saving potential in the care of women experiencing PPH. Clinical, Registry No. NCT00116480.
    BMC Pregnancy and Childbirth 02/2008; 8:40. DOI:10.1186/1471-2393-8-40 · 2.15 Impact Factor
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    Z Alfirevic · J Blum · G Walraven · A Weeks · B Winikoff
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    ABSTRACT: As a stable, orally active and cheap uterotonic, misoprostol would appear ideally suited to the prevention of postpartum hemorrhage (PPH) in the developing world. Following numerous clinical trials, it appears that misoprostol prophylaxis using an oral or sublingual dose of 600 microg is more effective than placebo at preventing PPH in community births (relative risk 0.59, 95% confidence intervals 0.41-0.84), but not in hospital settings (RR 1.23, 95% CI 0.86-1.74). It is, however, not as effective as injectable oxytocin (RR 1.34, 95% CI 1.16 to 1.55). Misoprostol is therefore indicated for prevention of PPH in settings where injectable conventional uterotonics are not available. In the event of continued hemorrhage, a minimum of 2 h should lapse after the original dose before a second dose is given. If the initial dose was associated with pyrexia or marked shivering, at least 6 h should lapse before the second dose is given.
    International Journal of Gynecology & Obstetrics 01/2008; 99 Suppl 2:S198-201. DOI:10.1016/j.ijgo.2007.09.012 · 1.56 Impact Factor
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    J Blum · Z Alfirevic · G Walraven · A Weeks · B Winikoff
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    ABSTRACT: A literature review was conducted to determine whether misoprostol is an effective treatment for postpartum hemorrhage (PPH) and in what dose. All English language articles published before March 2007 reporting on misoprostol for treatment of PPH were reviewed. Unpublished data previously presented at international scientific meetings were also included in the review. Little evidence exists in support of misoprostol for treatment of postpartum hemorrhage (PPH). Nonetheless, PPH remains a major killer of women worldwide, and new treatment options are widely sought. For this reason, we recommend a single dose of misoprostol 600 microg oral or sublingual for PPH treatment in instances when other treatments have either failed to work or are not available.
    International Journal of Gynecology & Obstetrics 01/2008; 99 Suppl 2:S202-5. DOI:10.1016/j.ijgo.2007.09.013 · 1.56 Impact Factor
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    ABSTRACT: To illustrate how maternal mortality audit identifies different causes of and contributing factors to maternal deaths in different settings in low- and high-income countries and how this can lead to local solutions in reducing maternal deaths. Descriptive study of maternal mortality from different settings and review of data on the history of reducing maternal mortality in what are now high-income countries. Kalabo district in Zambia, Farafenni division in The Gambia, Onandjokwe district in Namibia, and The Netherlands. Population of rural areas in Zambia and The Gambia, peri-urban population in Namibia and nationwide data from The Netherlands. Data from facility-based maternal mortality audits from three African hospitals and data from the latest confidential enquiry in The Netherlands. Maternal mortality ratio (MMR), causes (direct and indirect) and characteristics. MMR ranged from 10 per 100,000 (The Netherlands) to 1,540 per 100,000 (The Gambia). Differences in causes of deaths were characterized by HIV/AIDS in Namibia, sepsis and HIV/AIDS in Zambia, (pre-)eclampsia in The Netherlands and obstructed labour in The Gambia. Differences in maternal mortality are more than just differences between the rich and poor. Acknowledging the magnitude of maternal mortality and harnessing a strong political will to tackle the issues are important factors. However, there is no single, general solution to reduce maternal mortality, and identification of problems needs to be promoted through audit, both national and local.
    World health & population 02/2007; 9(1):5-13. DOI:10.12927/whp.2007.18744
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    ABSTRACT: Depression is the commonest mental illness in developing countries and impoverished women are most at risk. Formal mental health services in these situations are rare. Depression commonly co-presents with physical symptoms or else is unspectacular, so the condition often goes unrecognised. To strengthen the prevention and management of depression, information is required on easily recognisable correlates of depression. This study explored associations between depression and reproductive health conditions in rural African women of reproductive age. A community-based reproductive health survey among rural women aged 15-54 years in The Gambia, West Africa, included screening with a modified Edinburgh Depression Scale (EDS), a reproductive health questionnaire and a gynaecological examination. Depression was then assessed clinically and data for 565 women were used to estimate the prevalence of depression and examine associations with reproductive health conditions and demographic factors. The weighted prevalence of depression was 10.3% (95% CI 8.3-12.7). Being depressed was most significantly associated with widowhood or divorce (adjusted Odds Ratio (aOR) 8.42, 2.77-25.57), infertility (3.69, 1.42-9.65) and severe menstrual pain (3.94, 1.52-10.27). There were significant differences between ethnic groups. Being in the postpartum period was not associated with an increased likelihood of depression. This study points to the importance of reproductive potential and reproductive health in maintaining women's mental well-being across different strata of a rural and resource-poor society. It could provide an initial focus for the management of women with depression as well as directing future research in reproductive health and psychiatry.
    Social Psychiatry and Psychiatric Epidemiology 10/2006; 41(9):720-7. DOI:10.1007/s00127-006-0085-8 · 2.58 Impact Factor
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    ABSTRACT: We investigated the ability of intermittent preventive treatment in pregnancy (IPTp) with sulphadoxine/pyrimethamine to prevent anaemia and low birthweight in Gambian multigravidae. Between July 2002 and February 2004, 2688 multigravidae living in a rural area of The Gambia received SP (1346 women) or placebo (1342 women) up to four times during pregnancy and were followed until 6-weeks post-partum. Shortly after delivery, 10.7% of women in the intervention group and 8.8% in the control group were severely anaemic [Hb < 7 g/dl, risk difference = 0.02 (95% CI -0.01, 0.04), P = 0.17]. The overall mean birthweight of infants born to women who had received SP (3103 g) was very similar to that observed in infants born to women in the control group [3075 g; difference = 28 g (95% CI -11 g, 67 g), P = 0.16]. However, among women who did not use a bednet (either insecticide treated or untreated), infants born to women who had received SP weighed more than infants born to women in the control group [3147 g vs. 3044 g; difference 143 g (95% CI 53 g, 232 g), interaction test P < 0.001]. This study did not show that IPTp with SP benefited Gambian multigravidae overall but that it may benefit a sub-group of women who do not use a bednet. In areas such as The Gambia, provision of insecticide-treated bednets to multigravidae may provide an adequate means of protection against malaria in pregnancy without the need for additional IPTp.
    Tropical Medicine & International Health 08/2006; 11(7):992-1002. DOI:10.1111/j.1365-3156.2006.01649.x · 2.30 Impact Factor
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    ABSTRACT: In the Gambia, the combination of chloroquine (CQ) and sulphadoxine-pyrimethamine (SP) has replaced CQ monotherapy for treatment of malaria caused by Plasmodium falciparum. We measured the efficacy of the combination CQ/SP, and the prevalence of parasites carrying alleles associated with resistance to CQ or SP. We conducted a single-blind, randomised, controlled trial to compare the efficacy of CQ/SP to that of SP or CQ alone. The study took place in the town of Farafenni and surrounding villages in the Gambia. Participants were children aged 12 mo to 10 y presenting as outpatients with uncomplicated P. falciparum malaria. 500 children were randomised to receive CQ, SP, or CQ/SP as supervised treatment and actively followed over 28 d. Primary outcome was parasitaemia at any time during follow-up. Secondary outcomes were PCR-confirmed recrudescent infections among treatment failures, and clinical failure requiring rescue medication by day 28. Pretreatment parasite isolates from 161 patients were tested for the presence of resistance-associated genetic markers. The prevalence of parasitological failure by day 28 for the CQ group was 60.3%, compared to 17.6% for SP (odds ratio [OR], 0.106; 95% confidence interval [CI], 0.057-0.194; p < 0.001) and 13.9% for CQ/SP (OR versus CQ, 0.140; 95% CI, 0.078-0.250; p < 0.001). There was no difference between the SP and CQ/SP groups (OR, 1.324; 95% CI, 0.705-2.50). The projected prevalence of PCR-corrected treatment failure was 30.2, 6.06, and 3.94% in the CQ, SP, and CQ/SP groups, respectively. The pfdhfr-triple mutant and pfdhps-437G mutation were common, with prevalences of 67.4 and 51.2%, respectively. Pretreatment carriage of pfdhps-437G and of multidrug-resistant parasite genotypes was associated with treatment failure in the SP group, but not in the CQ or CQ/SP groups. The combination of CQ/SP was an efficacious treatment for uncomplicated malaria in Gambian children in this study, but the frequent occurrence of multidrug-resistant parasites suggests that this observed efficacy is not sustainable.
    PLoS Clinical Trials 07/2006; 1(3):e14. DOI:10.1371/journal.pctr.0010014 · 4.77 Impact Factor
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    ABSTRACT: Folic acid is frequently given to pregnant women at the same time as intermittent preventive treatment (IPTp) with sulfadoxine/pyrimethamine (SP), but it is not known if it interferes with the anti-malarial activity of SP. To investigate this concern, 1,035 Gambian primigravidae were randomized to receive either folic acid (500-1,500 microg/day) together with oral iron (522) or oral iron alone (513) for 14 days at the same time as they received IPTp with SP. On presentation, 261 women (25%) had Plasmodium falciparum asexual parasitemia. Prevalences of parasitemia on day 14 after treatment were similar in both groups: 5.7% (26 of 458) in the iron plus folic acid group and 4.9% (22 of 446) in the iron alone group (risk difference = 0.74%, 95% confidence interval [CI] = -2.2% to 3.7%). Parasitologic cure was observed in 116 (91%) of 128 of women who were parasitemic on presentation and who received iron and folic acid and in 122 (92%) of 133 women who received iron alone (difference = 1.1%, 95% CI = -5.6% to 8.0%). Women who received folic acid and iron had a slightly higher mean hemoglobin concentration at day 14 than women who had received iron alone (difference = 0.14 g/dL, 95% CI = 0.01-0.27 g/dL). The results of this study suggest that in an area of low SP resistance, administration of folic acid to pregnant women in a dose of 500-1,500 mug/day will not interfere with the protective effect of SP when used for IPTp.
    The American journal of tropical medicine and hygiene 07/2006; 74(6):960-4. · 2.74 Impact Factor
  • Peter Aaby · Henrik Jensen · Gijs Walraven
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    ABSTRACT: According to studies from Guinea-Bissau and Senegal, live vaccines may reduce the female-male mortality ratio (MR) whereas inactivated vaccines increase this ratio. We used data from The Gambia to examine whether similar tendencies could be found in a different setting. Forty villages in the Farafenni area in rural Gambia. A population of 17,000 was followed with demographic surveillance between 1998 and 2002; 537 children less than 5 years of age died in this period. We used two vaccination surveys and community mortality data to examine, first, the female-male mortality ratio (MR) in the age groups in which DTP and MV are recommended and have a high coverage. Second, using vaccination cards seen post-mortem, we examined the distribution of live or inactivated vaccines as last vaccination in different age groups. Third, we examined the effect of DTP and MV administered simultaneously. The female-male MR in different age groups and for different vaccines. Vaccination coverage was high for BCG, third dose of DTP (DTP3) and MV, reaching a level of 80-90% within a few months of the recommended age of vaccination. First, the female-male MR was 0.93 (0.63-1.38) in the first 2 months of life when children had received no vaccination or the combination of BCG, HBV and OPV. From 2 to 8 months of age, with DTP and HBV being the main vaccinations, the female-male MR was 1.28 (0.86-1.89). Between 9 and 17 months of age, with MV as the main vaccination, this ratio dropped to 0.73 (0.50-1.07), a significant inversion of the female-male MR (p=0.045). Second, using information from vaccination cards of dead children, boys who died at 2-4 months of age were more likely to have received live BCG and girls to have received inactivated DTP and HBV as last vaccination (p<0.001). At 5-8 months of age, essentially all dead children had received DTP as last vaccination and the female-male MR was 1.68 (0.96-2.93), whereas the MR was 0.70 (0.43-1.15) at 12-17 months of age when nearly all dead children had received MV (p=0.022). Third, compared with the general population of children who had received MV, dead children who had received MV were more likely to have received DTP3 simultaneously with MV (relative risk (RR)=5.59 (2.10-14.8)) or after MV (RR=2.61 (1.13-6.05)). Most children dying at a specific age had received the recommended vaccines. BCG and MV as last vaccination was associated with a low female-male MR, whereas DTP as last vaccination was associated with a high female-male MR. These trends are consistent with observations from other African countries.
    Vaccine 06/2006; 24(22):4701-8. DOI:10.1016/j.vaccine.2006.03.038 · 3.49 Impact Factor
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    ABSTRACT: We investigated the long-term impact of early childhood malaria prophylaxis on cognitive and educational outcomes. This was a household-based cluster-controlled intervention trial. The study was conducted in 15 villages situated between 32 km to the east and 22 km to the west of the town of Farafenni, the Gambia, on the north bank of the River Gambia. A total of 1,190 children aged 3-59 mo took part in the trial. We traced 579 trial participants (291 in the prophylaxis group and 288 in the placebo group) in 2001, when their median age was 17 y 1 mo (range 14 y 9 mo to 19 y 6 mo). Participants received malaria chemoprophylaxis (dapsone/pyrimethamine) or placebo for between one and three malaria transmission seasons from 1985 to 1987 during the controlled trial. At the end of the trial, prophylaxis was provided for all children under 5 y of age living in the study villages. The outcome measures were cognitive abilities, school enrolment, and educational attainment (highest grade reached at school). There was no significant overall intervention effect on cognitive abilities, but there was a significant interaction between intervention group and the duration of post-trial prophylaxis (p = 0.034), with cognitive ability somewhat higher in the intervention group among children who received no post-trial prophylaxis (treatment effect = 0.2 standard deviations [SD], 95% confidence interval [CI] -0.03 to 0.5) and among children who received less than 1 y of post-trial prophylaxis (treatment effect = 0.4 SD, 95% CI 0.1 to 0.8). The intervention group had higher educational attainment by 0.52 grades (95% CI = -0.041 to 1.089; p = 0.069). School enrolment was similar in the two groups. The results are suggestive of a long-term effect of malaria prophylaxis on cognitive function and educational attainment, but confirmatory studies are needed.
    PLoS Clinical Trials 02/2006; 1(4):e19. DOI:10.1371/journal.pctr.0010019 · 4.77 Impact Factor
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    ABSTRACT: In the Gambia, chloroquine (CQ) plus sulphadoxine-pyrimethamine (SP) is the first-line antimalarial treatment. Plasmodium falciparum parasites carrying mutations associated with resistance to each of these drugs were present in 2001 but did not cause a significant loss of therapeutic efficacy among children receiving the combination CQ/SP. We measured their effect on parasite transmission to Anopheles gambiae mosquitoes. We conducted a single-blind, randomised, controlled trial with follow-up over 28 d. Mosquito feeding experiments were carried out 7, 10, or 14 d after treatment. The study took place in the town of Farafenni and surrounding villages in the Gambia. Participants were 500 children aged 6 mo to 10 y with uncomplicated P. falciparum malaria. Children were randomised to receive CQ, SP, or CQ/SP. Outcomes related to transmission were determined, including posttreatment gametocyte prevalence and density. Infectiousness was assessed by membrane-feeding A. gambiae mosquitoes with blood from 70 gametocyte-positive patients. Mutations at seven loci in four genes associated with drug resistance were measured pre- and posttreatment and in the midguts of infected mosquitoes. After SP treatment, the infectiousness of gametocytes was delayed, compared to the other two treatment groups, despite comparable gametocyte densities. Among bloodmeal gametocytes and the midguts of infected mosquitoes, the presence of the four-locus multidrug-resistant haplotype TYRG (consisting of mutations pfcrt-76T, pfmdr1-86Y, pfdhfr-59R, and pfdhps-437G) was associated with significantly higher oocyst burdens after treatment with the combination CQ/SP. Parasites with a multidrug-resistant genotype had a substantial transmission advantage after CQ/SP treatment but did not have a significant impact on in vivo efficacy of this drug combination. Protocols that include measuring transmission endpoints as well as therapeutic outcomes may be a useful strategy when monitoring the evolution of drug resistance in malaria parasites in vivo.
    PLoS Clinical Trials 02/2006; 1(3):e15. DOI:10.1371/journal.pctr.0010015 · 4.77 Impact Factor
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    ABSTRACT: Two hundred thirty-four Gambian children with severe falciparum malaria who were admitted to the pediatric ward of a rural district hospital each were matched for age with a same-sex control subject presenting as an outpatient with uncomplicated falciparum malaria. Severe malarial anemia (SMA) was the most common presentation (152 cases), followed by cerebral malaria (38 cases) and hyperparasitemia (26 cases). Children presenting with SMA were significantly younger and more likely to carry gametocytes than were children with other severe presentations. Alleles of the genes pfcrt and pfmdr1 associated with chloroquine-resistant parasites occurred together among cases presenting with SMA alone more often than among their matched controls (odds ratio, 2.08 [95% confidence interval, 1.04-4.38]; P=.039). Costs of travel to the hospital of more than US $0.20, use of mosquito repellents, and carriage of resistant parasites were identified as independent risk factors for severe malaria in the case-control analysis. We conclude that, in this setting, poor access to the hospital and a high prevalence of chloroquine-resistant parasites lead to a delay of adequate treatment for young children with malaria, who may then develop SMA.
    The Journal of Infectious Diseases 12/2005; 192(9):1651-7. DOI:10.1086/496887 · 5.78 Impact Factor
  • Source
    Gijs Walraven · Nadeem Zuberi · Marleen Temmerman
    BJOG An International Journal of Obstetrics & Gynaecology 10/2005; 112(9):1177-9. DOI:10.1111/j.1471-0528.2005.00707.x · 3.86 Impact Factor

Publication Stats

4k Citations
741.09 Total Impact Points


  • 2008–2011
    • Aga Khan University, Pakistan
      • Department of Obstetrics and Gynaecology, Pakistan
      Kurrachee, Sindh, Pakistan
    • Aga Khan University Hospital, Karachi
      • Department of Obstetrics and Gynaecology
      Kurrachee, Sindh, Pakistan
  • 2006
    • Imperial College London
      • Department of Infectious Disease Epidemiology
      London, ENG, United Kingdom
  • 1996–2006
    • Medical Research Council Unit, The Gambia Unit
      • Disease Control & Elimination
      Bakau, Banjul, Gambia
  • 2001–2005
    • London School of Hygiene and Tropical Medicine
      • • Tropical Epidemiology Group (TEG)
      • • Department of Infectious Disease Epidemiology
      London, ENG, United Kingdom
  • 2003
    • Johns Hopkins University
      Baltimore, Maryland, United States
  • 2002
    • University of Cambridge
      Cambridge, England, United Kingdom
  • 2000–2002
    • Durham University
      • School of Biological and Biomedical Sciences
      Durham, England, United Kingdom
  • 1999
    • Harvard Medical School
      Boston, Massachusetts, United States
  • 1995
    • Leiden University
      Leyden, South Holland, Netherlands