Burden of congenital and hereditary anomalies in the war-affected territory at Pakistan–Afghanistan border

Abstract Background Pashtun populations of Pakistan are the victim of long-lasting military combats, rendering 1.9 million inhabitants internally displaced. Studies highlighting congenital and hereditary anomalies in these populations are deficient. Objectives To elucidate the spectrum anomalies in the north-western war-affected territories of Pakistan. Methods A cross-sectional study was carried out from 2017 to 2019 and individuals or families with anomalies were ascertained through convenience and cluster random sampling. Phenotypic and pedigree data and information on bio-demographic variables were collected. Descriptive statistics were applied. Results A total of 361 independent individuals or families with anomalies were recruited. The anomalies were grouped into 8 major and 72 minor entities. Among major categories, neurological disorders had the highest representation (n = 100; proportion: 0.277; 95% CI: 0.231–0.323), followed by sensorineural defects (n = 70; prop.: 0.194), limb defects (n = 60; prop.: 0.166), visual impairments (n = 55; prop.: 0.152), and musculoskeletal defects (n = 37; prop.: 0.102). Among the neurological disorders, intellectual disability had the highest occurrence (58%), whereas talipes and limb amputations were the most prominent in limb defects (22% and 20%, respectively). The anomalies had sporadic and isolated presentations most often (76% each), while parental consanguinity was observed in 34% of index cases. Conclusions The high incidence of neurological, sensorineural, and limb defects, the preponderance of sporadic cases, and low level of parental consanguinity may indicate a potentially high contribution of nongenetic factors in the etiology of anomalies. The majority of anomalies are the cause of severe disability.

but collectively they make a significant impact on the populations. The prevalence of anomalies varies from country to country and from population to population [1][2][3].
Pakistan bears a high burden of anomalies [3][4][5][6][7]. Hussain et al. [3] carried out a prospective hospital-based study at a tertiary care hospital in Kharian, Pakistan and witnessed that out of 3210 admissions, 226 (7%) neonates had a certain type of anomaly. Perveen and Tyyab [4] conducted a cross-sectional observational study at the Gynecology and Obstetrics department of a tertiary care hospital in Karachi, Pakistan, and observed that among the 5776 deliveries, 76 had babies with anomalies, rendering a prevalence rate of 11.4/1000 births. The authors further observed that consanguineous marriage was the most frequently associated risk factor for anomalies. Gustavson [5] studied the health and development of children in 4 different areas in Lahore and witnessed that the incidence of serious birth defects was 5%.
High-risk pregnancies are common in Pakistan due to the lack of education and awareness and antenatal care. Further, large family size and extended sibships, overlapping generations, and high consanguinity are the factors that increase the likelihood of occurrence of recessively inherited disorders [4,6,7]. There is, however, a lack of baseline epidemiological and phenotypic data on anomalies prevalent in various population strata. This aspect is further challenged by the absence of anomaly registries, lack of genetic counseling services, and inadequate resources. Epidemiological studies are particularly difficult to carry out in regions with geopolitical unrest and regional conflicts, and undergoing post-war recovery [8][9][10][11].
The Pashtun populations of Pakistan inhabiting northwestern territories along the Afghanistan border are the victim of war-on-terror. Long-lasting military combats, cross-border infiltration, and poor law-and-order situation have rendered at least 1.9 million individuals internally displaced persons (IDPs) and gravely impacted the health and education systems [9,[11][12][13]. Even though the military operations are now over and the majority of the IDPs have returned to their "places," it may take time to revive the socio-economic infrastructure and wellbeing of inhabitants. Studies highlighting morbidities of chronic nature and long-term illnesses including anomalies are lacking [11,14]. To this end, through a cross-sectional study design, this study aimed to elucidate the spectrum and prevalence pattern of anomalies in the north-western territories of Pakistan.

Study population
The Federally Administered Tribal Areas (FATA) is a tribal assemblage in north-west Pakistan, comprising 7 agencies (districts) stretching in a series at the Pakistan-Afghanistan mountainous border (Figure 1). It has an estimated population of 5 million individuals. Due to geopolitical unrest and war situations, FATA has remained highly impoverished and many of the socio-economic indicators are well below the national average; i.e., the rural population is 97% (compared to a national estimate of 64%), the poverty rate is 74% (compared to a national rate of 39%), the literacy rate is 33% (compared to a national rate of 60%), and persons with disability are 3.7% (compared to a national rate of 1.6%) [11,12,15].
Owing to the unique socio-cultural tribal norms in the area, the FATA region is a difficult place to approach for population-based studies. Traveling and accessibility are difficult in this mountainous territory without a local resource person and proper permission from the tribal heads who are authorized by the political administration to resolve disputes among tribesmen [12,15]. War situation and mass migration (of IDPs) have an adverse impact on the health of the inhabitants. Post-traumatic stress disorders are common, particularly among children and women [10][11][12][13]. The local people are not welcoming to the enumerators from outside, and hence, data collection and maneuvering in the area have been a profound challenge. Further, information gathering on the morbidity status of females is even more difficult due to the specific socio-cultural norms of the area [9,14,15]. Internal displacements and migrations have significant effects on the public health and well-being of IDPs. Several risk factors like overcrowding, malnutrition, lack of clean water, poor sanitation, and the outbreak of infections synergistically augment the occurrence of morbidities during displacements [16,17]. During the flight and early settlement, women may be forced to give birth alongside roads, in forests, or in temporary shelters, resulting in complications of pregnancy and childbirth [16][17][18].

Study participants recruitment
This cross-sectional clinico-epidemiological study was conducted in the upper FATA region (mainly Bajaur, Mohmand, Khyber, and Orakzai districts) of Pakistan between January 2017 and March 2019 (Figure 1) [15]. This study was approved by the Ethical Review Committee of Quaid-i-Azam University (certificate of approval No. DAS13/-). Approval was also taken from the tribal heads and local health authorities. All the data were acquired and documented in the presence of the family head or guardian after participants had provided informed written or formally documented verbal consent when illiterate. The cross-sectional reporting guideline of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement was used [19].
Participating individuals or families (here referred to as participants or cases) with congenital and hereditary anomalies (here referred to as anomalies) were recruited through a combination of convenience sampling and cluster random sampling from hospitals, community centers (rural gathering places; hujra), and schools (or madarsa), and were brought to the nearest medical center for examination. There were at least 30 sampling sites covering the major towns or villages of 4 districts depending upon the availability of the local resource persons and the permission received from tribal heads. Each participant was physically examined by a local physician and the data on phenotypic, pedigree, and bio-demographic variables were collected on a structured proforma in face-to-face interviews. The fieldwork and data collection were performed by the first 2 authors who have formal training in medical genetics.

Inclusion and exclusion criteria
To avoid any bias, the participants were recruited irrespective of their gender, ethnicity, origin, and type of anomalies. Only those participants were included that had a permanent residence in the study area. The anomalies with a confirmed congenital nature, hereditary nature, or both were included in the analyses. Participating individuals or families providing incomplete information were not included. Anomalies with accidental and traumatic natures were not included. The individuals with psychiatric or behavioral disorders were skipped. Muscle wasting with a likely poliomyelitis presentation was also skipped. Data were not collected from any special education school or disability center.

Classification of anomalies, definitions and statistical methods
The initial assessment was provided by the specialist resident doctors and only the individuals with the confirmed diagnosis were recruited. Syndromic cases were identified with respect to the more severe symptoms in the following order: neurological disorders, neuromuscular defects, musculoskeletal defects, eye or visual impairments, sensorineural or ear anomalies, and limb defects [5,14]. A pedigree comprising 3 or more generations was drawn for each case, but only the index participant from each family was considered in data analyses.
The definitions of anomalies were based on a standard coding system of the International Classification of Diseases (ICD-10; Ver.16), OMIM, and ORPHANET databases [20][21][22]. The patients with intellectual disability (ID) types were assessed according to the criteria of the American Psychiatric Association [23]. Limb defects were further characterized into minor entities [24][25][26]. Descriptive summaries were generated. For each anomaly, the proportions and 95% confidence intervals (95% CI) were estimated from the total number of anomalies. The analyses were carried out through GraphPad Prism (5.00) and Stata11.

Results
A total of 361 independent participating individuals or families having certain types of anomalies were recruited. The index males were 74% (n = 267). The majority of the participants belonged to rural areas (n = 304; 84%), lived in extended or joint families (n = 288; 80%), and spoke Pashto (100%) ( Table 1).
The anomalies were grouped into 8 major groups ( Table 2). With respect to their familial nature, the majority of the anomalies (76%) had sporadic presentations compared to 24% of familial cases. However, among the major groups, ectodermal anomalies and blood disorders were more often familial (P = 0.0001).
Further, there was a high preponderance of anomalies with isolated presentations (76%), while 24% of cases were syndromic. However, neurological disorders were an exception where 51% of the cases had syndromic presentations (P = 0.0001).
Parental consanguinity was observed in 34% of the cases. Among the major categories, consanguinity was prominent in ectodermal anomalies, blood disorders, and sensorineural defects (54%, 50%, and 47%, respectively) ( Table 2). It is pertinent to mention that among the familial cases, the majority of the pedigrees were suggestive of autosomal recessive inheritance patterns (data not shown). The representation of index males was generally higher in the major categories. Further, in all families, the total number of affected participants was estimated to be 613 (males 403; females 210) ( Table 3).
Collectively there were at least 72 minor entities of anomalies ( Table 4)    *Differences in distribution were statistically highly significant.   Table 4.

Burden of neurological disorders
Among the neurological disorders (n = 100), ID types had the highest representation (58%), followed by cerebral palsy (16%), and Down syndrome (11%) ( Table 4). The cases with ID were further resolved into mild, moderate, and severe or profound types and were observed to be n = 27, n = 18, and n = 13, respectively.

Burden of limb defects
Among the limb defects (n = 60), there were at least 20 distinct phenotypic entities. Talipes and limb amputations had the highest representation (22% and 20%, respectively). Most of the cases of amputations were transverse and unilateral and were the cause of severe disability (data not shown).

Other anomalies
Among the eye or visual impairments (n = 55), there were at least 7 entities, and squint eye types were the most prominent anomaly (44%), represented as esotropia or exotropia. Musculoskeletal defects were represented by at least 12 distinct entities, and of those, dwarfism was the most common type. Among the ectodermal anomalies, there was a representation of 8 minor types. A detailed distribution of major and minor anomalies is presented in Table 4.

Associations among the syndromic cases
Among the syndromic cases, neurological disorders were most prominent (n = 48), followed by limb defects and eye or visual impairments. The most common associated anomaly was deafmute (n = 35), followed by eye or visual impairments (n = 16). The combinations of associated anomalies are depicted in Table 5.

Discussion
This study presents the broad spectrum of anomalies in the north-west territories at the Pakistan-Afghanistan border. The majority of the anomalies were of severe nature and a cause of disability in the individuals. In this cohort, the category of neurological disorders, including ID, was the most prevalent. This observation is similar to the one drawn in Hussain et al.'s study [3], wherein it was discovered that in a cohort of 226 neonates monitored at a tertiary care hospital in Kharian, Pakistan, the anomalies related to the central nervous system were most common (20%). In a similar study carried out by Perveen and Tyyab [4] in Karachi, Pakistan, neural tube defects were found to be the commonest (66%). Among the participants with ID in our study, the cases with mild ID types were more frequent, followed by moderate and severe ID types. These findings are similar to Koirala et al.'s study [27], in which also a high prevalence of mild ID was reported, followed by moderate, severe, and profound types. Further, the proportion of sensorineural defects was 19% and it constituted the second most prevalent category. In many of the reported epidemiological studies, neurological disorders and sensorineural defects show high representations, which could be because both these organ systems require an extended period during embryonic development and any perturbance during this period may cause morbidity [28]. Limb defects comprised 17% of our cohort. Curiously, among the limb defects, talipes and limb amputations had the highest representations (22% and 20%, respectively). In the experience of Bhatti et al. [29], who conducted an  epidemiological study in the population of the Sialkot district of Pakistan, clubfoot and polydactyly types were the most prevalent types of limb defects. However, in a study carried out in Chitral, Pakistan, talipes and limb amputations comprised only 3% each of the total limb or musculoskeletal anomalies, whereas polydactyly was the most common [30].
In another study conducted in the Sindh region of Pakistan, talipes and limb amputations were 2% and 8%, respectively, of the total limb anomalies [31]. A very high preponderance of such defects in our cohort could be a strong indication of nongenetic etiological factors and complications during pregnancy [32].
In the present study, most of the anomalies had sporadic occurrence (76% compared to 24% familial cases). A marked variation, however, was evident in the sporadic or familial presentation among the major categories. Here, the sporadic occurrence was common in neurological disorders, sensorineural defects, limb defects, eye or visual impairments, and musculoskeletal defects, whereas ectodermal anomalies and blood disorders were familial most often. Concordantly, in the experience of Zahra et al. [14] and Bhatti et al. [29], the sporadic occurrence was common in limb defects, neurological disorders, musculoskeletal defects, and sensorineural defects assembled from Kurram and Sialkot, Pakistan.
In the present sample, the parental consanguinity was 34%, which is very low compared to the baseline consanguinity rate of 57%-62% reported for other Pakistani populations [6][7][8]33]. The differences in the distribution of consanguineous and nonconsanguineous unions among the major categories of anomalies were statistically significant (P < 0.0001). The rate of consanguinity was higher in the ectodermal anomalies, blood disorders, and sensorineural defects (54%, 50%, and 47%, respectively). The potentially low rate of parental consanguinity is similar to the observations recorded in Bhatti et al.'s study [29], in which a parental consanguinity rate of 17% was ascertained in a cohort of anomalies assembled from the population of Sialkot, Pakistan. Concordant to our study, Bhatti et al. [29] also observed that the differences in the distribution of consanguineous and nonconsanguineous unions among the major categories of anomalies were statistically significant. Further, the rate of consanguinity was higher in subjects with neuromuscular anomalies and neurological disorders (30% and 21%, respectively), and significantly higher in familial cases compared to sporadic ones. In our data, the low rate of consanguinity may also indicate the potentially high role of nongenetic factors in the etiology of these anomalies.
The current study has several limitations. First, the true prevalence rate of each anomaly has not been established. Due to various reasons, it was not possible to launch a true cluster or stratified sampling encompassing the whole area. We, therefore, primarily relied on a combination of convenience sampling and cluster random sampling, which was facilitated by the local resource persons. Second, the recruited anomalies were generally typable through physical examination and non-invasive medical investigation. The anomalies requiring invasive diagnostic characterization and detailed biochemical tests may be underrepresented in this sample. Further, prenatal and postnatal mortality, maternal morbidities and pregnancy conditions, and potential risk and etiological factors remain to be elucidated. The findings of this study may not be generalizable to the rest of the Pakistani population.
This study has several strengths. It is the first report of anomalies prevalent in the war-affected territory of the upper FATA region. In Pakistan, in general, there is no systematic monitoring and compilation of anomalies and there is currently no national database of anomalies. The surveillance of anomalies is difficult because of inadequate funding, poor infrastructure, and the lack of trained staff and enumerators. It is almost impossible to evaluate the potential risk factors and to implement effective prevention and management services without detailed epidemiological data. In this context, the present study is a pilot effort to record and document anomalies prevalent in the population. These data would be very valuable for assigning priorities, resource allocation, and establishing management systems for these disorders.

Conclusion
The high incidence of neurological, sensorineural, and limb disorders, the preponderance of cases with sporadic nature, and the relatively low level of parental consanguinity may indicate a likely high contribution of environmental factors in the etiology of these anomalies. Further, the high occurrence of talipes and limb amputations among the limb defects may also clue toward the role of nongenetic factors. Further, it is quite likely that continued warfare might have added environmental pollutants, residues from explosives, and heavy metals to the human food chain [34]. Further studies are warranted to understand the role of nongenetic factors in the etiology of anomalies and there is a dire need for the management of the anomalies.
Author contributions. SM contributed substantially to the concept and design of this study. SM, MN, and BA contributed substantially to acquiring the data, reviewing the literature, and its analysis and interpretation. SM contributed to drafting the manuscript. MN and BA edited the manuscript critically for important intellectual content. All authors approved the final version submitted for publication and take responsibility for statements made in the published article.