Trends in Malaria in Odisha, India-An Analysis of the 2003-2013 Time-Series Data from the National Vector Borne Disease Control Program

Background

Although Odisha is the largest contributor to the malaria burden in India, no systematic study has examined its malaria trends. Hence, the spatio-temporal trends in malaria in Odisha were assessed against the backdrop of the various anti-malaria strategies implemented in the state.

Methods

Using the district-wise malaria incidence and blood examination data (2003–2013) from the National Vector Borne Disease Control Program, blood examination-adjusted time-trends in malaria incidence were estimated and predicted for 2003–2013 and 2014–2016, respectively. An interrupted time series analysis using segmented regression was conducted to compare the disease trends between the pre (2003–2007) and post-intensification (2009–2013) periods. Key-informant interviews of state stakeholders were used to collect the information on the various anti-malaria strategies adopted in the state.

Results

The state annual malaria incidence declined from 10.82/1000 to 5.28/1000 during 2003–2013 (adjusted annual decline: -0.54/1000, 95% CI: -0.78 to -0.30). However, the annual blood examination rate remained almost unchanged from 11.25% to 11.77%. The keyinformants revealed that intensification of anti-malaria activities in 2008 led to a more rapid decline in malaria incidence during 2009–2013 as compared to that in 2003–2007 [adjusted decline: -0.83 (-1.30 to -0.37) and -0.27 (-0.41 to -0.13), respectively]. There was a significant difference in the two temporal slopes, i.e., -0.054 (-0.10 to -0.002, p = 0.04) per 1000 population per month, between these two periods, indicating almost a 200% greater decline in the post-intensification period. Although, the seven southern high-burden districts registered the highest decline, they continued to remain in that zone, thereby, making the achievement of malaria elimination (incidence <1/1000) unlikely by 2017.

Conclusion

The anti-malaria strategies in Odisha, especially their intensification since 2008, have helped improve its malaria situation in recent years. These successful measures need to be sustained and perhaps intensified further for eliminating malaria from Odisha.

How supportive supervision influences immunization session site practices: a quasi-experimental study in Odisha, India

BACKGROUND

Routine immunization (RI) is a key child survival intervention. Ensuring acceptable standards of RI service delivery is critical for optimal outcomes. Accumulated evidences suggest that 'supportive supervision' improves the quality of health care services in general. During 2009-2010, the Government of Odisha and UNICEF jointly piloted this strategy in four districts to improve RI program outcomes. The present study aims to assess the effect of this strategy on improvement of skills and practices at immunization session sites.

DESIGN

A quasi-experimental 'post-test only' study design was adopted to compare the opinion and practices of frontline health workers and their supervisors in four intervention districts (IDs) with two control districts (CDs). Altogether, we interviewed 111 supervisor-supervisee (health worker) pairs using semi-structured interview schedules and case vignettes. We also directly observed health workers' practices during immunization sessions at 111 sites. Data were analyzed with SPSS version 16.0.

RESULTS

The mean knowledge score of supervisors in CDs was significantly higher than in intervention groups. Variegated responses were obtained on case vignettes. The control group performed better in solving certain hypothetically asked problems, whereas the intervention group scored better in others. Health workers in IDs gave a lower rating to their respective supervisors' knowledge, skill, and frequency of supervision. Logistics and vaccine availability were better in CDs.

CONCLUSION

Notwithstanding other limitations, supportive supervision may not have independent effects on improving the quality of immunization services. Addressing systemic issues, such as the availability of essential logistics, supply chain management, timely indenting, and financial resources, could complement the supportive supervision strategy in improving immunization service delivery.

Effect of supportive supervision on routine immunization service delivery-a randomized post-test study in Odisha

Introduction:

Routine immunization is a key child survival intervention. Issues related to quality of service delivery pose operational challenges in delivering effective immunization services. Accumulated evidences suggest that “supportive supervision” improves the quality of health care services. During 2009-10, Govt. of Odisha (GoO) and UNICEF jointly piloted this strategy in four districts to improve routine immunization. The present study aims to assess the effect of supportive supervision strategy on improvement of knowledge and practices on routine immunization among service providers.

Materials and Methods:

We adopted a ‘post-test only’ study design to compare the knowledge and practices of frontline health workers and their supervisors in four intervention districts with that of two control districts. Altogether we interviewed 170 supervisors and supervisees (health workers), each, using semi-structured interview schedules. We also directly observed 25 ice lined refrigerator (ILR) points in both groups of districts. The findings were compared with the baseline information, available only for the intervention districts.

Results:

The health workers in the intervention districts displayed a higher knowledge score in selected items than in the control group. No significant difference in knowledge was observed between control and intervention supervisors. The management practices at ILR points on key routine immunization components were found to have improved significantly in intervention districts.

Conclusion and Recommendations:

The observed improvements in the ILR management practices indicate positive influence of supportive supervision. Higher level of domain knowledge among intervention health workers on specific items related to routine immunization could be due to successful transfer of knowledge from supervisors. A ‘pre-post’ study design should be undertaken to gain insights into the effectiveness of supportive supervision in improving routine immunization services.

Monitoring data quality in syndromic surveillance: learnings from a resource limited setting

Background:

India is in the process of integrating all disease surveillance systems with the support of a World Bank funded program called the Integrated Disease Surveillance System. In this context the objective of the study was to evaluate the components of the Orissa Multi Disease Surveillance System.

Materials and Methods:

Multistage sampling was carried out, starting with four districts, followed by sequentially sampling two blocks; and in each block, two sectors and two health sub-centers were selected, all based on the best and worst performances. Two study instruments were developed for data validation, for assessing the components of the surveillance and diagnostic algorithm. The Organizational Ethics Group reviewed and approved the study.

Results:

In all 178 study subjects participated in the survey. The case definition of suspected meningitis in disease surveillance was found to be difficult, with only 29.94%, who could be correctly identified. Syndromic diagnosis following the diagnostic algorithm was difficult for suspected malaria (28.1%), ‘unusual syndrome’ (28.1%), and simple diarrhea (62%). Only 17% could correctly answer questions on follow-up cases, but only 50% prioritized diseases. Our study showed that 54% cross-checked the data before compilation. Many (22%) faltered on timeliness even during emergencies. The constraints identified were logistics (56%) and telecommunication (41%). The reason for participation in surveillance was job responsibility (34.83%).

Conclusions:

Most of the deficiencies arose from human errors when carrying out day-to-day processes of surveillance activities, hence, should be improved by retraining. Enhanced laboratory support and electronic transmission would improve data quality and timeliness. Validity of some of the case definitions need to be rechecked. Training Programs should focus on motivating the surveillance personnel.

Fluoride and silicon intake in normal and endemic fluorotic areas

Precise quantitative information on (a) the contribution of diet to the daily intake of fluoride; and (b) the intake of silicon, which the current work suggests can aggravate fluorosis, is not available for fluorotic and non-fluorotic areas of India. Therefore, an attempt has been made in the present study to collect the above information in normal and fluorotic villages. The daily intake of fluoride (mean +/- SD) over water and diet in normal villages was 1.2 +/- 0.67 mg and 1.0 +/- 0.60 mg, while the corresponding values in a normal urban area were 0.5 +/- 0.03 mg and 1.2 +/- 0.73 mg, respectively. With respect to the intake over water the mean values in normal areas (urban vs. rural) were significantly different (P < 0.001), while there was no significant difference in dietary contribution in the normal areas. In fluorotic villages the daily intake of fluoride was 12.1 +/- 4.11 mg over water and 3.4 +/- 2.43 mg over the diet. These values from fluorotic villages were significantly higher (P < 0.001) than those observed in the normal rural areas. The total intake of silicon (mean +/- SD) in rural and urban normal areas was 204 +/- 58.6 mg and 143 +/- 29.4 mg per day, respectively. The corresponding value from fluorotic villages was 277 +/- 65.5 mg, which was significantly higher (P < 0.01) than those observed in both the normal areas. The situation was similar in fluorotic villages with respect to silicon intake over diet and water. However, the intake of this element over water in the normal rural area (74.0 +/- 18.51 mg per day) was significantly higher (P < 0.001) than the value obtained in the normal urban area (7.5 +/- 1.82 mg per day). This study clearly shows that in the fluorosis-affected areas studied, (a) the total intake of both fluoride and silicon is significantly higher than the intake in non-fluorotic areas; and (b) diets contribute significantly to the intake of both these elements. Our observations on silicon intake and its probable relation to fluorosis are the first of their kind in the literature.

Contribution of vitamin A deficiency to calculogenic risk factors of urine: studies in children

Studies in experimental animals showed that vitamin A deficiency enhanced the severity of urinary calculi disease. In India, children with low socioeconomic status are the major victims of bladder stone disease, and vitamin A deficiency is also more prevalent among these children. However, no systematic study is available to correlate the vitamin A-deficient status of children with their predisposition to urinary calculi disease. Vitamin A-deficient and normal boys were the subjects of this study. Twenty-four-hour samples of urine were collected from all the children at the beginning of the study and after normalizing the vitamin A status of the deficient children. Important risk factors were estimated in urine. Plasma vitamin A levels were also measured in these children. Among the deficient group, only children with plasma vitamin A levels of 15 micrograms and lower exhibited calcium oxalate crystalluria. Most importantly, abnormal crystalluria was observed in all children whose plasma vitamin A levels were 13 micrograms/dl or less. Compared to normal children the urine of vitamin A-deficient children showed the following changes: (a) reduced concentration of crystal growth inhibitors, namely citrate and glycosaminoglycans; (b) a decline in inhibitory activity toward calcium oxalate crystal growth; and (c) enhanced excretion of high risk factors, namely calcium and oxalate. Correction of vitamin A status normalized the above abnormal properties of urine. The results of this study strongly support the hypothesis that the vitamin A-deficient state is one of the factors that can enhance the risk of urolithiasis in susceptible populations.

Effect of fluoride, silicon, and magnesium on the mineralizing capacity of an inorganic medium and stone formers urine tested by a modified in vitro method

An in vitro mineralizing system using bovine achilles tendon developed by Thomas and Tomita (3) was modified to enable quantitative evaluation of mineralization. Using this modified method, the potential effect of various ions on the rate of calcium uptake from inorganic mineralization medium was measured. Of the elements tested, only silicon and fluoride accelerated calcium uptake, whereas magnesium had an inhibitory effect. The simultaneous presence of silicon and fluoride in the medium had a synergistic action on calcium uptake. Urine of stone formers showed high propensity to mineralize tendon collagen, but not the urine of non-stone formers. Total content, and concentration of silicon in urine of stone formers was significantly higher than in normal urine. Addition of silicon to non-stone formers urine enhanced its capacity to mineralize collagen in vitro. These results strongly suggest the possible involvement of silicon and fluoride in the genesis of urinary calculi in man.

Role of fluoride in formation of urinary calculi: studies in rats

The effect of fluoride on urinary calculi formation in young rats was investigated. Two studies, in which rats received diets that included either higher calcium (9 g/kg diet) or normal calcium (5 g/kg diet), were conducted At each level of calcium, one group of rats received a high level of fluoride and another a low level of fluoride in the diet. Rats ingesting high fluoride diets exhibited a higher incidence of crystalluria and bladder stones compared with those receiving low fluoride diets. However, compared with higher calcium diets, normal calcium diets delayed the appearance of crystalluria and produced smaller calculi. Calcium and oxalate were the major components of the calculi. Calculi of rats fed the higher calcium and high fluoride diet contained relatively less protein and more calcium compared with calculi formed in rats ingesting the higher calcium and low fluoride diet. The concentration of fluoride in calculi from rats fed high fluoride diets was significantly higher than that of calculi from rats fed low fluoride diets. A significant positive correlation between calcium and fluoride concentration of calculi was observed in rats fed the higher calcium diet only. These studies indicate that ingestion of excess fluoride facilities calcium oxalate crystalluria and promotes the formation of bladder stones in rats, under the experimental conditions used.

Relationship between body collagen and urinary hydroxyproline excretion in young rats fed on a low-protein or low-calorie diet

1. Hydroxyproline was determined in urine, carcass, and skin of young rats fed on low-protein and low-calorie diets.

2. Protein and calorie deprivation in young rats resulted in a marked fall in the soluble as well as insoluble collagen content of the skin.

3. The collagen content of the carcass (excluding skin) was slightly greater in the deficient rats than in the weanling rats, but very much lower than in the well-fed rats.

4. In rats subjected to protein and calorie deficiency, urinary hydroxyproline was markedly reduced. In these rats, most of the reduction in urinary hydroxyproline was observed within 1 week of feeding the deficient diet. Protein deficiency had affected urinary excretion of hydroxyproline more severely than calorie deficiency.

5. The reduction of urinary hydroxyproline in the deficient animals can be attributed to decreased turnover rate of their body collagen. This apparent decrease in turnover rate is explained as being due to an increase in the proportion of collagen of slow turnover in these animals.

6. Protein and calorie deficiency had also resulted in the depletion of non-collagen nitrogen of both carcass and skin.