Intra-dermal administration of rabies vaccines in developing countries: at an affordable cost

Rabies is a virtually 100% fatal acute viral encephalitis. Rabies occurs in more than 150 countries and territories. Globally there are 17.4 million animal bite cases and more than 55,000 deaths annually. India's 20,000 deaths accounts for 36% of global and 65% of the Asian (31,000) deaths. The Intradermal Rabies Vaccine (IDRV) was first started in Thailand in 1984. In 1992, World Health Organization approved it for use in developing countries which face a shortage of rabies vaccine due to paucity of funds. Vaccines like Purified Vero cell vaccine (PVRV), Purified chick embryo cell vaccine (PCECV) and Human diploid cell vaccine (HDCV) that can be injected by the intradermal route for Post Exposure Prophylaxis as approved by WHO. The regimen approved by the WHO/DCGI India is the Updated Thai Red Cross Regimen, which involves injection of 0.1 mL of reconstituted vaccine per ID site and on two such ID site per visit on Days 0, 3, 7 and 28 (2-2-2-0-2). All reconstituted vaccine unused at the end of 6-8 h must be discarded. The ID route is ideal in terms of economic benefits, safety and efficacy. This reduces the cost of vaccination by about 68%, which is clearly an attractive option for resource-starved countries like India.

Cost effectiveness of targeted HIV prevention interventions for female sex workers in India

OBJECTIVE

To ascertain the cost effectiveness of targeted interventions for female sex workers (FSW) under the National AIDS Control Programme in India.

METHODS

A compartmental mathematical Markov state model was used over a 20-year time horizon (1995-2015) to estimate the cost effectiveness of FSW targeted interventions, with a health system perspective. The incremental costs and effects of FSW targeted interventions were compared against a baseline scenario of mass media for the general population alone. The incremental cost-effectiveness ratio was computed at a 3% discount rate using HIV infections averted and disability-adjusted life-years (DALY) as benefit measures. It was assumed that the transmission of the HIV virus moves from a high-risk group (FSW) to the client population and finally to the general population (partners of clients).

RESULT

Targeted interventions for FSW result in a reduction of 47% (1.6 million) prevalent and 36% (2.7 million) cumulative HIV cases, respectively, in 2015. Adult HIV prevalence in India, with and without (mass media only) FSW interventions, would be 0.25% and 0.48% in 2015. Indian government and development partners spend an average US $104 (INR4680) per HIV infection averted and US $10.7 (INR483) per DALY averted. Discounting at 3%, FSW targeted interventions cost US $105.5 (INR4748) and US $10.9 (INR490) per HIV case and DALY averted, respectively.

CONCLUSION

At the current gross domestic product in India, targeted intervention is a cost-effective strategy for HIV prevention in India.

Role of ideas and ideologies in evidence-based health policy

Policy making in health is largely thought to be driven by three 'I's namely ideas, interests and institutions. Recent years have seen a shift in approach with increasing reliance being placed on role of evidence for policy making. The present article ascertains the role of ideas and ideologies in shaping evidence which is used to aid in policy decisions. The article discusses different theories of research-policy interface and the relative freedom of research-based evidence from the influence of ideas. Examples from developed and developed countries are cited to illustrate the contentions made. The article highlights the complexity of the process of evidence-based policy making, in a world driven by existing political, social and cultural ideologies. Consideration of this knowledge is paramount where more efforts are being made to bridge the gap between the 'two worlds' of researchers and policy makers to make evidence-based policy as also for policy analysts.

Adverse reproductive and child health outcomes among people living near highly toxic waste water drains in Punjab, India

BACKGROUND

Environmental influence plays a major role in determining health status of individuals. Punjab has been reported as having a high degree of water pollution due to heavy metals from untreated industrial effluent discharge and high pesticide consumption in agriculture. The present study ascertained the association of heavy metal and pesticide exposure on reproductive and child health outcomes in Punjab, India.

METHODS

A cross-sectional community-based survey was conducted in which 1904 women in reproductive age group and 1762 children below 12 years of age from 35 villages in three districts of Punjab were interviewed on a semistructured schedule for systemic and general health morbidities. Medical doctors conducted a clinical examination and review of records where relevant. Out of 35 study villages, 25 served as target (exposed) and 10 as non-target (less exposed or reference). Effluent, ground and surface water, fodder, vegetables and milk (bovine and human) samples were tested for chemical composition, heavy metals and pesticides.

RESULTS

Spontaneous abortion (20.6 per 1000 live births) and premature births (6.7 per 1000 live births) were significantly higher in area affected by heavy metal and pesticide pollution (p<0.05). Stillbirths were about five times higher as compared with a meta-analysis for South Asian countries. A larger proportion of children in target area were reported to have delayed milestones, language delay, blue line in the gums, mottling of teeth and gastrointestinal morbidities (p<0.05). Mercury was found in more than permissible limits (MPL) in 84.4% samples from the target area. Heptachlor, chlorpyriphos, beta-endosulfan, dimethoate and aldrin were found to be more than MPL in 23.9%, 21.7%, 19.6%, 6.5% and 6.5% ground water samples respectively.

CONCLUSION

Although no direct association could be established in this study, heavy metal and pesticide exposure may be potential risk factors for adverse reproductive and child health outcomes.

Effectiveness of planning and management interventions for improving age-appropriate immunization in rural India

OBJECTIVE

To study the effectiveness of planning and management interventions for ensuring children in India are immunized at the appropriate age.

METHODS

The study involved children aged less than 18 months recruited from Haryana, India, in 2005-2006: 4336 in a pre-intervention cohort and 5213 in a post-intervention cohort. In addition, immunization of 814 hospitalized children from outside the study area was also assessed. Operational barriers to age-appropriate immunization with diphtheria, pertussis and tetanus (DPT) vaccine were investigated by monitoring vaccination coverage, observing immunization sessions and interviewing parents and health-care providers. An intervention package was developed, with community volunteers playing a pivotal role. Its effectiveness was assessed by monitoring the ages at which the three DPT doses were administered.

FINDINGS

The main reasons for delayed immunization were staff shortages, non-adherence to plans and vaccine being out of stock. In the post-intervention cohort, 70% received a third DPT dose before the age of 6 months, significantly more than in the pre-intervention cohort (62%; P = 0.002). In addition, the mean age at which the first, second and third DPT doses were administered decreased by 17, 21 and 34 days, respectively, in the study area over a period of 18 months (P for trend < 0.0001). No change was observed in hospitalized children from outside the study area.

CONCLUSION

An intervention package involving community volunteers significantly improved age-appropriate DPT immunization in India. The Indian Government's intention to recruit village-based volunteers as part of a health sector reform aimed at decentralizing administration could help increase timely immunization.

Pilot testing of WHO child growth standards in Chandigarh: implications for India's child health programmes

OBJECTIVE

To compare the prevalence of underweight as calculated from Indian Academy of Paediatrics (IAP) growth curves (based on the Harvard scale) and the new WHO Child Growth Standards.

METHODS

We randomly selected 806 children under 6 years of age from 45 primary anganwadi (childcare) centres in Chandigarh, Punjab, India, that were chosen through multistage stratified random sampling. Children were weighed, and their weight for age was calculated using IAP curves and WHO growth references. Nutritional status according to the WHO Child Growth Standards was analysed using WHO Anthro statistical software (beta version, 17 February 2006). The chi2 test was used to determine statistical significance at the 0.05 significance level.

FINDINGS

The prevalence of underweight (Z score less than -2) in the first 6 months of life was nearly 1.6 times higher when calculated in accordance with the new WHO standards rather than IAP growth curves. For all ages combined, the estimated prevalence of underweight was 1.4 times higher when IAP standards instead of the new WHO standards were used. Similarly, the prevalence of underweight in both sexes combined was 14.5% higher when IAP standards rather than the new WHO growth standards were applied (P < 0.001). By contrast, severe malnutrition estimated for both sexes were 3.8 times higher when the new WHO standards were used in place of IAP standards (P < 0.001).

CONCLUSION

The new WHO growth standards will project a lower prevalence of overall underweight children and provide superior growth tracking than IAP standards, especially in the first 6 months of life and among severely malnourished children.

Investigation of viral hepatitis E outbreak in a town in Haryana

An outbreak of 160 cases of viral hepatitis which occurred in Shahbad, Haryana, was investigated to ascertain the agent, cause of the outbreak and to initiate remedial measures. Out of the 30 samples tested, 26 (86.7%) were positive for IgM antibody against HEV, establishing hepatitis E virus responsible for the outbreak. Significant association of higher attack rates (4%) in ward 14 (OR = 17.9; 95% CI = 12.7-25.2) of the town along with leakage in water distribution system running co-existent with open drains containing household waste and sewage; and absence of residual chlorine in water samples tested at household level in ward 14 established fecal contamination of water as the cause of the outbreak. Remedial repair work was initiated along with superchlorination of water which contained the outbreak.

Health care seeking behavior of adolescents: comparative study of two service delivery models

OBJECTIVES

To assess the perceived health problems and help seeking behaviour and utilization pattern of adolescent health clinics.

METHODS

A pre-tested, semi-structured questionnaire was administered to 360 school going adolescents who were selected by stratified random sampling from two sectors of Chandigarh where services were being provided by a school-based and dispensary-based adolescent health clinic.

RESULTS

Majority (81%) of the adolescents reported having some health problem during last three months prior to the survey; predominant (60%) problems were psychological and behavioural in nature. To resolve these problems boys consulted mainly friends/peers (48%) while girls consulted their mothers (63%). Compared to the dispensary-based adolescent health clinic, utilisation was significantly higher in a school-based clinic where proportion of psychological or behavioural problems reported was also significantly higher (P<0.01).

CONCLUSION

Adolescents have greater counselling needs for psychosocial problems than for medical problems. School-based adolescent health clinic was utilized more often than the dispensary-based clinic particularly for psychosocial problems.