Post-campaign coverage evaluation of a measles and rubella supplementary immunization activity in five districts in India, 2019-2020

BACKGROUND

In alignment with the Measles and Rubella (MR) Strategic Elimination plan, India conducted a mass measles and rubella vaccination campaign across the country between 2017 and 2020 to provide a dose of MR containing vaccine to all children aged 9 months to 15 years. We estimated campaign vaccination coverage in five districts in India and assessed campaign awareness and factors associated with vaccination during the campaign to better understand reasons for not receiving the dose.

METHODS AND FINDINGS

Community-based cross-sectional serosurveys were conducted in five districts of India among children aged 9 months to 15 years after the vaccination campaign. Campaign coverage was estimated based on home-based immunization record or caregiver recall. Campaign coverage was stratified by child- and household-level risk factors and descriptive analyses were performed to assess reasons for not receiving the campaign dose. Three thousand three hundred and fifty-seven children aged 9 months to 15 years at the time of the campaign were enrolled. Campaign coverage among children aged 9 months to 5 years documented or by recall ranged from 74.2% in Kanpur Nagar District to 90.4% in Dibrugarh District, Assam. Similar coverage was observed for older children. Caregiver awareness of the campaign varied from 88.3% in Hoshiarpur District, Punjab to 97.6% in Dibrugarh District, Assam, although 8% of children whose caregivers were aware of the campaign were not vaccinated during the campaign. Failure to receive the campaign dose was associated with urban settings, low maternal education, and lack of school attendance although the associations varied by district.

CONCLUSION

Awareness of the MR vaccination campaign was high; however, campaign coverage varied by district and did not reach the elimination target of 95% coverage in any of the districts studied. Areas with lower coverage among younger children must be prioritized by strengthening the routine immunization programme and implementing strategies to identify and reach under-vaccinated children.

Recurrence of pulmonary tuberculosis in India: Findings from the 2019-2021 nationwide community-based TB prevalence survey

Recurrent Tuberculosis patients contribute to a significant proportion of TB burden in India. A nationwide survey was conducted during 2019-2021 across India among adults to estimate the prevalence of TB. A total of 322480 individuals were screened and 1402 were having TB. Of this, 381 (27.1%) had recurrent TB. The crude prevalence (95% CI) of recurrent TB was 118 (107-131) per 100,000 population. The median duration between episodes of TB was 24 months. The proportion of drug resistant TB was 11.3% and 3.6% in the recurrent group and new TB patients respectively. Higher prevalence of recurrent TB was observed in elderly, males, malnourished, known diabetics, smokers, and alcohol users. (p<0.001). To prevent TB recurrence, all treated tuberculosis patients must be followed at least for 24 months, with screening for Chest X-ray, liquid culture every 6 months, smoking cessation, alcohol cessation, nutritional interventions and good diabetic management.

Prevalence and factors associated with tuberculosis infection in India

BACKGROUND

The risk of tuberculosis (TB) disease is higher in individuals with TB infection. In a TB endemic country like India, it is essential to understand the current burden of TB infection at the population level. The objective of the present analysis is to estimate the prevalence of TB infection in India and to explore the factors associated with TB infection.

METHODS

Individuals aged > 15 years in the recently completed National TB prevalence survey in India who were tested for TB infection by QuantiFERON-TB Gold Plus (QFT-Plus) assay were considered for this sub-analysis. TB infection was defined as positive by QFT-Plus (value >0.35 IU/ml). The estimates for prevalence, prevalence ratio (PR) and adjusted risk ratio (aRR) estimates with 95% confidence intervals (CIs) were calculated.

RESULTS

Of the 16864 individuals analysed, the prevalence of TB infection was 22.6% (95% CI:19.4 -25.8). Factors more likely to be associated with TB infection include age > 30 years (aRR:1.49;95% CI:1.29-1.73), being male (aRR:1.26; 95%CI: 1.18-1.34), residing in urban location (aRR:1.58; 95%CI: 1.03-2.43) and past history of TB (aRR:1.49; 95%CI: 1.26-1.76).

CONCLUSION

About one fourth (22.6%) of the individuals were infected with TB in India. Individuals aged > 30 years, males, residing in urban location, and those with past history of TB were more likely to have TB infection. Targeted interventions for prevention of TB and close monitoring are essential to reduce the burden of TB in India.

Evaluating the effect of measles and rubella mass vaccination campaigns on seroprevalence in India: a before-and-after cross-sectional household serosurvey in four districts, 2018-2020

Background

India did phased measles–rubella supplementary immunisation activities (MR-SIAs; ie, mass-immunisation campaigns) targeting children aged 9 months to less than 15 years. We estimated measles–rubella seroprevalence before and after the MR-SIAs to quantify the effect on population immunity and identify remaining immunity gaps.

Methods

Between March 9, 2018 and March 19, 2020 we did community-based, cross-sectional serosurveys in four districts in India before and after MR-SIAs. 30 villages or wards were selected within each district, and one census enumeration block from each was selected as the survey cluster. Households were enumerated and 13 children in the younger age group (9 months to <5 years) and 13 children in the older ager group (5 to <15 years) were randomly selected by use of computer-generated random numbers. Serum samples were tested for IgG antibodies to measles and rubella viruses by enzyme immunoassay.

Findings

Specimens were collected from 2570 children before the MR-SIA and from 2619 children afterwards. The weighted MR-SIA coverage ranged from 73·7% to 90·5% in younger children and from 73·6% to 93·6% in older children. Before the MR-SIA, district-level measles seroprevalence was between 80·7% and 88·5% among younger children in all districts, and between 63·4% and 84·5% among older children. After the MR-SIA, measles seroprevalence among younger children increased to more than 90% (range 91·5 to 96·0) in all districts except Kanpur Nagar, in which it remained unchanged 80·4%. Among older children, measles seroprevalence increased to more than 90·0% (range 93·7% to 96·5%) in all districts except Hoshiarpur (88·7%). A significant increase in rubella seroprevalence was observed in all districts in both age groups, with the largest effect in Dibrugarh, where rubella seroprevalence increased from 10·6% to 96·5% among younger children.

Interpretation

Measles–rubella seroprevalence increased substantially after the MR-SIAs but the serosurvey also identified remaining gaps in population immunity.

Funding

The Bill & Melinda Gates Foundation and Indian Council of Medical Research.

To Evaluate the Efficacy of Tissue Autofluorescence (Velscope) in the Visualization of Oral Premalignant and Malignant Lesions among High-Risk Population Aged 18 Years and Above in Haroli Block of Una, Himachal Pradesh

Introduction

Visually enhanced lesion scope (Velscope) that identifies reduction in tissue fluorescence in dysplasia can prove to be effective in screening for potentially malignant lesions. The objective of the present study was to evaluate the effectiveness of device that utilizes the principles of tissue autofluorescence (Velscope) in the detection of dysplastic and/or neoplastic changes in oral mucosal lesions using biopsy and histopathology as "gold standard."

Materials and Methods

Out of nine hundred fifty patients with suspicious oral mucosal lesions, 250 patients were subjected to conventional oral examination followed by Velscope examination. The autofluorescence characteristics of 250 patients were compared with the results of histopathology. Biopsies were obtained from all suspicious areas identified on examination. The sensitivity, specificity, positive and negative predictive values were calculated for Velscope examination.

Results

The Velscope examination showed sensitivity and specificity values of 75.00% (95% CI: 69.63%-80.37%) and 61.39% (95% CI: 55.35%-67.42%) respectively while the positive and negative predictive values were 31.58% (95% CI: 25.82%-37.34%) and 91.18% (95% CI: 87.66%-94.69%) respectively.

Conclusion

The definite diagnosis of the presence of dysplastic tissue changes in the oral lesions cannot be made alone with the Velscopic examination. The high number of false-positive results limits its efficiency as an adjunct despite its reasonable sensitivity. However, It can serve to alleviate patient anxiety regarding suspicious mucosal lesions in a general practice setting due to high negative predictive value. Also, a combined approach of Velscope examination and conventional oral examination may prove to be an effective diagnostic tool for early detection of malignant oral mucosal lesions.

Seroprevalence of IgG antibodies against SARS-CoV-2 among the general population and healthcare workers in India, June-July 2021: A population-based cross-sectional study

BACKGROUND

India began COVID-19 vaccination in January 2021, initially targeting healthcare and frontline workers. The vaccination strategy was expanded in a phased manner and currently covers all individuals aged 18 years and above. India experienced a severe second wave of COVID-19 during March-June 2021. We conducted a fourth nationwide serosurvey to estimate prevalence of SARS-CoV-2 antibodies in the general population aged ≥6 years and healthcare workers (HCWs).

METHODS AND FINDINGS

We did a cross-sectional study between 14 June and 6 July 2021 in the same 70 districts across 20 states and 1 union territory where 3 previous rounds of serosurveys were conducted. From each district, 10 clusters (villages in rural areas and wards in urban areas) were selected by the probability proportional to population size method. From each district, a minimum of 400 individuals aged ≥6 years from the general population (40 individuals from each cluster) and 100 HCWs from the district public health facilities were included. The serum samples were tested for the presence of IgG antibodies against S1-RBD and nucleocapsid protein of SARS-CoV-2 using chemiluminescence immunoassay. We estimated the weighted and test-adjusted seroprevalence of IgG antibodies against SARS-CoV-2, along with 95% CIs, based on the presence of antibodies to S1-RBD and/or nucleocapsid protein. Of the 28,975 individuals who participated in the survey, 2,892 (10%) were aged 6-9 years, 5,798 (20%) were aged 10-17 years, and 20,285 (70%) were aged ≥18 years; 15,160 (52.3%) participants were female, and 21,794 (75.2%) resided in rural areas. The weighted and test-adjusted prevalence of IgG antibodies against S1-RBD and/or nucleocapsid protein among the general population aged ≥6 years was 67.6% (95% CI 66.4% to 68.7%). Seroprevalence increased with age (p < 0.001) and was not different in rural and urban areas (p = 0.822). Compared to unvaccinated adults (62.3%, 95% CI 60.9% to 63.7%), seroprevalence was significantly higher among individuals who had received 1 vaccine dose (81.0%, 95% CI 79.6% to 82.3%, p < 0.001) and 2 vaccine doses (89.8%, 95% CI 88.4% to 91.1%, p < 0.001). The seroprevalence of IgG antibodies among 7,252 HCWs was 85.2% (95% CI 83.5% to 86.7%). Important limitations of the study include the survey design, which was aimed to estimate seroprevalence at the national level and not at a sub-national level, and the non-participation of 19% of eligible individuals in the survey.

CONCLUSIONS

Nearly two-thirds of individuals aged ≥6 years from the general population and 85% of HCWs had antibodies against SARS-CoV-2 by June-July 2021 in India. As one-third of the population is still seronegative, it is necessary to accelerate the coverage of COVID-19 vaccination among adults and continue adherence to non-pharmaceutical interventions.

Mycobacterium tuberculosis strain lineage in mixed tribal population across India and Andaman Nicobar Island

In India, the tribal population constitutes almost 8.6% of the nation's total population. Despite their large presence, there are only a few reports available on Mycobacterium tuberculosis (M. tb) strain prevalence in Indian tribal communities considering the mobile nature of this population and also the influence of the mainstream populations they coexist within many areas for their livelihood. This study attempts to provide critical information pertaining to the TB strain diversity, its public health implications, and distribution among the tribal population in eleven Indian states and Andaman & Nicobar (A&N) Island. The study employed a population-based molecular approach. Clinical isolates were received from 66 villages (10 states and Island) and these villages were selected by implying situation analysis. A total of 78 M. tb clinical isolates were received from 10 different states and A&N Island. Among these, 16 different strains were observed by spoligotyping technique. The major M. tb strains spoligotype belong to the Beijing, CAS1_DELHI, and EAI5 family of M. tb strains followed by EAI1_SOM, EAI6_BGD1, LAM3, LAM6, LAM9, T1, T2, U strains. Drug-susceptibility testing (DST) results showed almost 15.4% of clinical isolates found to be resistant to isoniazid (INH) or rifampicin (RMP) + INH. Predominant multidrug-resistant (MDR-TB) isolates seem to be Beijing strain. Beijing, CAS1_DELHI, EAI3_IND, and EAI5 were the principal strains infecting mixed tribal populations across India. Despite the small sample size, this study has demonstrated higher diversity among the TB strains with significant MDR-TB findings. Prevalence of Beijing MDR-TB strains in Central, Southern, Eastern India and A&N Island indicates the transmission of the TB strains.

Detection of Drug Resistance Mutations in the Reverse Transcriptase Gene of HIV-1-Infected North Indian Population Failing First-Line Antiretroviral Therapy "A Follow-Up Cohort Study"

We aim to characterize the drug resistance mutations in reverse transcriptase gene of HIV-1 subtype C-infected North Indian population in those who are failing first-line antiretroviral therapy (ART) and if these mutations are associated with mortality. We also attempted the assessment of switch over to second-line antiretroviral therapy in these patients. Based on the immunological marker CD4 count (<350 cubic/mm), 192 HIV/AIDS patients were selected and viral load was estimated in those who were enrolled from December 2009 to November 2016. Based on viral load, genotyping was carried out in 57 HIV-1 isolates (VL ≥1,000 copies/mL) by sequencing and drug resistance mutations were examined through the Stanford HIV Drug Resistance Database, USA. Among them, 21 (36.84%) first-line ART failure patients were shifted to second-line ART. These patients were followed for a period wide ranging from 10 months to 11 years. Drug resistance mutation M184V (ATG to GTA) (63.15%) associated with lamivudine and abacavir and K103N (AAG or AAA to AAU) (36.84%) associated with efavirenz and nevirapine were predominantly identified in first-line ART failure patients. During follow-up, it was observed that 3 out of 21 who were in second-line ART died, whereas 9 out of 36 died who were in the first-line ART. No mutation could be associated with mortality although TAM-2 mutations were absent in patients who died. This study indorses the need for a facility for viral load estimation and resistance monitoring in each treatment failure patient and availability of appropriate antiretroviral therapies.

SARS-CoV-2 seroprevalence among the general population and healthcare workers in India, December 2020-January 2021

BACKGROUND

Earlier serosurveys in India revealed seroprevalence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) of 0.73% in May-June 2020 and 7.1% in August-September 2020. A third serosurvey was conducted between December 2020 and January 2021 to estimate the seroprevalence of SARS-CoV-2 infection among the general population and healthcare workers (HCWs) in India.

METHODS

The third serosurvey was conducted in the same 70 districts as the first and second serosurveys. For each district, at least 400 individuals aged ≥10 years from the general population and 100 HCWs from subdistrict-level health facilities were enrolled. Serum samples from the general population were tested for the presence of immunoglobulin G (IgG) antibodies against the nucleocapsid (N) and spike (S1-RBD) proteins of SARS-CoV-2, whereas serum samples from HCWs were tested for anti-S1-RBD. Weighted seroprevalence adjusted for assay characteristics was estimated.

RESULTS

Of the 28,598 serum samples from the general population, 4585 (16%) had IgG antibodies against the N protein, 6647 (23.2%) had IgG antibodies against the S1-RBD protein, and 7436 (26%) had IgG antibodies against either the N protein or the S1-RBD protein. Weighted and assay-characteristic-adjusted seroprevalence against either of the antibodies was 24.1% [95% confidence interval (CI) 23.0-25.3%]. Among 7385 HCWs, the seroprevalence of anti-S1-RBD IgG antibodies was 25.6% (95% CI 23.5-27.8%).

CONCLUSIONS

Nearly one in four individuals aged ≥10 years from the general population as well as HCWs in India had been exposed to SARS-CoV-2 by December 2020.

Prevalence of pulmonary tuberculosis among the tribal populations in India

Importance

There is no concrete evidence on the burden of TB among the tribal populations across India except for few studies mainly conducted in Central India with a pooled estimation of 703/100,000 with a high degree of heterogeneity.

Objective

To estimate the prevalence of TB among the tribal populations in India.

Design, participants, setting

A survey using a multistage cluster sampling design was conducted between April 2015 and March 2020 covering 88 villages (clusters) from districts with over 70% tribal majority populations in 17 States across 6 zones of India. The sample populations included individuals ≥15 years old.

Main outcome and measures

Eligible participants who were screened through an interview for symptoms suggestive of pulmonary TB (PTB); Two sputum specimens were examined by smear and culture. Prevalence was estimated after multiple imputations for non-coverage and a correction factor of 1.31 was then applied to account for non-inclusion of X-ray screening.

Results

A total of 74532 (81.0%) of the 92038 eligible individuals were screened; 2675 (3.6%) were found to have TB symptoms or h/o ATT. The overall prevalence of PTB was 432 per 100,000 populations. The PTB prevalence per 100,000 populations was highest 625 [95% CI: 496–754] in the central zone and least 153 [95% CI: 24–281] in the west zone. Among the 17 states that were covered in this study, Odisha recorded the highest prevalence of 803 [95% CI: 504–1101] and Jammu and Kashmir the lowest 127 [95% CI: 0–310] per 100,000 populations. Findings from multiple logistic regression analysis reflected that those aged 35 years and above, with BMI <18.5 Kgs /m², h/o ATT, smoking, and/or consuming alcohol had a higher risk of bacteriologically positive PTB. Weight loss was relatively more important symptom associated with tuberculosis among this tribal populations followed by night sweats, blood in sputum, and fever.

Conclusion and relevance

The overall prevalence of PTB among tribal groups is higher than the general populations with a wide variation of prevalence of PTB among the tribal groups at zone and state levels. These findings call for strengthening of the TB control efforts in tribal areas to reduce TB prevalence through tribal community/site-specific intervention programs.

Understanding health care-seeking behaviour of the tribal population in India among those with presumptive TB symptoms

BACKGROUND AND OBJECTIVES

Understanding the drivers for care-seeking among those who present with symptoms of TB is crucial for early diagnosis of TB and prompt treatment, which will in turn halt further TB transmission. While TB is a challenge among the tribal population, little is known about the care-seeking behaviour and the factors influencing care-seeking behaviour among the tribal population across India.

METHODOLOGY

This community-based descriptive study was carried out in 17 states of India across 6 zones, covering 88 villages from tribal districts with over 70% tribal population. The sample population included individuals ≥15 years old who were screened through an interview for symptoms suggestive of pulmonary TB (PTB), currently and/or previously on anti-TB treatment. Those with symptoms were then assessed on their health-seeking behavior using a semi-structured interview schedule.

RESULTS

Among 74532 eligible participants screened for symptoms suggestive of TB, 2675 (3.6%) were found to be presumptive TB cases. Of them, 659 (24.6%) sought care for their symptoms. While 48.2% sought care after a week, 19.3% sought care after one month or more, with no significant difference in the first point of care; 46.9% approaching a private and 46.7% a public facility. The significant factors influencing care-seeking behaviour were knowledge on TB (OR: 4.64 (3.70-5.83), p < 0.001), age<35 years (OR: 1.60 (1.28-2.00), p < 0.001), co-morbidities like asthma (OR: 1.80 (1.38-2.35), p < 0.001) and blood pressure (OR: 2.59 (1.75-3.85), p < 0.001), symptoms such as blood in sputum (OR: 1.69 (1.32-2.16), p < 0.001), shortness of breath (OR: 1.43 (1.19-1.72), p < 0.001) and weight loss (OR: 1.59 (1.33-1.89), p < 0.001). The cough was the most often reported symptom overall. There were gender differences in symptoms that prompted care-seeking: Males were more likely to seek care for weight loss (OR: 1.78 (1.42-2.23), p<0.001), blood in the sputum (OR: 1.69 (1.25-2.28), p<0.001), shortness of breath (OR: 1.49 (1.18-1.88), p<0.001) and fever (OR: 1.32 (1.05-1.65), p = 0.018). Females were more likely to seek care for blood in sputum (OR: 1.68 (1.10-2.58), p = 0.018) and shortness of breath (OR = 1.35, (1.01-1.82), p = 0.048). The cough did not feature as a significant symptom that prompted care-seeking.

CONCLUSION

Delayed healthcare-seeking behaviour among those with symptoms presumptive of TB in the tribal population is a major concern. Findings point to differences across gender about symptoms that prompt care-seeking in this population. Gender-sensitive interventions with health system strengthening are urgently needed to facilitate early diagnosis and treatment among this population.

Dominant marker (inter-simple sequence repeat-polymerase chain reaction) versus codominant marker (RLEP-polymerase chain reaction) for laboratory diagnosis of leprosy: A comparative evaluation

Background

Leprosy is a contagious disease and was eliminated globally in 2002. Since then, new cases were continuously detected from different parts of the world. Untreated leprosy cases shed millions of bacteria and are the main cause of dissemination of the disease. Currently, leprosy is detected by acid-fast bacilli (AFB) microscopy and has a low sensitivity ranging from 10% to 50%. The correlation between clinical findings and microscopy is unable to provide a conclusive case detection. Thus, in the present study, we compared to molecular methods, namely RLEP-polymerase chain reaction (RLEP-PCR) and inter-simple sequence repeat-PCR (ISSR-PCR) taking AFB microscopy as a gold standard for the detection of leprosy.

Methods

A total of 168 clinically diagnosed leprosy patients were recruited in this study including 58 multibacillary and 110 paucibacillary patients. Slit-skin smear samples were taken for both microscopy and molecular study. Primers for RLEP-PCR were taken from the previous reports. The primers for ISSR-PCR were designed by screening the whole genome of Mycobacterium leprae TN strain (GenBank accession AL450380) for the presence of simple sequence repeats. One primer (TA)₈CA₃was synthesized and used for molecular amplification of ISSR-PCR.

Results

We found that the efficacy of the AFB microscopy was 24.40%, whereas the efficacy of RLEP-PCR and ISSR-PCR was 63.09% and 73.21% (P = 0.000, 0.000, and 0.469), respectively. The area under the curve of receiver operating characteristic curve for the comparison of three diagnostic methods was 0.845. An enhancement of 48.81% in the case detection rate by ISSR-PCR over AFB microscopy and 10.12% over RLEP-PCR was also found. Our study clearly reveals that ISSR-PCR is a better tool for diagnosis of leprosy than AFB microscopy and RLEP-PCR. Interestingly, both the PCR techniques RLEP-PCR and ISSR-PCR are able to detect samples which were negative for AFB microscopy.

Conclusion

Thus, the demonstration of ISSR-PCR in SSS samples can provide a better sensitive and confirmative tool for early diagnosis of leprosy.

Dimension reduction of subjective motivational values toward child gender tool tested in women of reproductive age from a hospital in rural area of Himachal Pradesh, India

Background

A novel subjective Motivational Value toward Child Gender (MVCG) tool was developed using the theoretical construct of 10 motivational domains described by Shalom H Schwartz.

Objective

The study aimed to summarize the pattern of correlations of (MVCG) in women of reproductive age in Himachal Pradesh, India.

Methods

A cross-sectional study was conducted from October 2018 to November 2019 among a sample of 355 women. Required data were collected through an interviewer-administered questionnaire. Maximum likelihood exploratory factor analysis (EFA) with oblique rotation was done with Bartlett's test sphericity and Kaiser-Meyer-Olkin test.

Results

A total of 28 (53.8%) questions loaded on eight factors explaining maximum variance (68.7%). Reliability analysis of these questions, with high loadings on extracted factors, of the questionnaire, observed with poor Cronbach's alpha of 0.61 and intraclass cluster coefficient (ICC) 0.49. However, selected domains such as tradition, power, achievement, self-direction, and benevolence were observed with a good Cronbach's alpha and ICC.

Conclusion

MCVG is novel tool in its kind with well scalable properties in measuring subjective motivational values towards child gender. After EFA, total questions across 10 domains reduced from 52 to 28, across 8 domains, loaded on 8 factors with good reliability and agreement.

Prevalence of SARS-CoV-2 infection in India: Findings from the national serosurvey, May-June 2020

BACKGROUND & OBJECTIVES

Population-based seroepidemiological studies measure the extent of SARS-CoV-2 infection in a country. We report the findings of the first round of a national serosurvey, conducted to estimate the seroprevalence of SARS-CoV-2 infection among adult population of India.

METHODS

From May 11 to June 4, 2020, a randomly sampled, community-based survey was conducted in 700 villages/wards, selected from the 70 districts of the 21 States of India, categorized into four strata based on the incidence of reported COVID-19 cases. Four hundred adults per district were enrolled from 10 clusters with one adult per household. Serum samples were tested for IgG antibodies using COVID Kavach ELISA kit. All positive serum samples were re-tested using Euroimmun SARS-CoV-2 ELISA. Adjusting for survey design and serial test performance, weighted seroprevalence, number of infections, infection to case ratio (ICR) and infection fatality ratio (IFR) were calculated. Logistic regression was used to determine the factors associated with IgG positivity.

RESULTS

Total of 30,283 households were visited and 28,000 individuals were enrolled. Population-weighted seroprevalence after adjusting for test performance was 0.73 per cent [95% confidence interval (CI): 0.34-1.13]. Males, living in urban slums and occupation with high risk of exposure to potentially infected persons were associated with seropositivity. A cumulative 6,468,388 adult infections (95% CI: 3,829,029-11,199,423) were estimated in India by the early May. The overall ICR was between 81.6 (95% CI: 48.3-141.4) and 130.1 (95% CI: 77.0-225.2) with May 11 and May 3, 2020 as plausible reference points for reported cases. The IFR in the surveyed districts from high stratum, where death reporting was more robust, was 11.72 (95% CI: 7.21-19.19) to 15.04 (9.26-24.62) per 10,000 adults, using May 24 and June 1, 2020 as plausible reference points for reported deaths.

INTERPRETATION & CONCLUSIONS

Seroprevalence of SARS-CoV-2 was low among the adult population in India around the beginning of May 2020. Further national and local serosurveys are recommended to better inform the public health strategy for containment and mitigation of the epidemic in various parts of the country.

Evaluation of 'TBDetect' sputum microscopy kit for improved detection of Mycobacterium tuberculosis: a multi-centric validation study

OBJECTIVES

The present study aimed to evaluate the performance of the 'TBDetect' kit-based bio-safe fluorescent microscopy filter (BioFM-Filter) microscopy in comparison with direct smear microscopy and culture for the detection of pulmonary tuberculosis (TB) in a multi-centric setting in India.

METHODS

The TBDetect kit enables sputum concentration through filtration using the BioFM-Filter for improved and bio-safe smear microscopy. We evaluated the performance of the TBDetect kit in a six-site multi-centric validation study on sputum collected from 2086 presumptive TB patients.

RESULTS

The combined positivity of TBDetect microscopy performed on these sputum samples was 20% (n = 417/2086) vs 16.1% of light-emitting diode fluorescence microscopy (LED-FM, n = 337/2086) and 16% of Ziehl Neelsen (ZN) smear microscopy (n = 333/2086). The increment in positivity of TBDetect over both LED-FM and ZN smears was significant (p < 0.001). The overall sensitivity of TBDetect for six sites was ~55% (202/367, 95% confidence interval (CI): 50, 60%) vs 52% (191/367, 95% CI: 47, 57%) for LED-FM (p 0.14) and 50.9% (187/367, 95% CI: 46, 56%) for ZN smear (p < 0.05), using Mycobacterium Growth Indicator Tube culture (MGIT, n = 1949, culture positive, n = 367) as the reference standard. A bio-safety evaluation at six sites confirmed efficient sputum disinfection by TBDetect; 99.95% samples (1873/1874) were sterile after 42 days of incubation. Scientists and technicians at the study sites indicated the ease of use and convenience of TBDetect microscopy during feedback.

CONCLUSIONS

TBDetect added value to the smear microscopy test due to its improved performance, convenience and user safety. These findings indicate that equipment-free TBDetect technology has the potential to improve TB diagnosis in basic laboratory settings by leveraging on the existing nationwide network of designated microscopy centres and primary healthcare centres.

Multiple strain infection of Mycobacterium leprae in a family having 4 patients: A study employing short tandem repeats

Background

Leprosy is a slow, chronic disorder caused by Mycobacterium leprae. India has achieved elimination of leprosy in December 2005 but new cases are being detected and continue to occur in some endemic pockets. The possible ways of transmission of leprosy is not fully understood and is believed that leprosy is transmitted from person to person in long term contact. Studying the transmission dynamics is further complicated by inability to grow M. leprae in culture medium and lack of animal models. More than one family members were found to be affected by leprosy in some highly endemic pockets. This study reported the transmission pattern of leprosy in a family having 4 patients.

Methodology/Principal findings

We investigated the transmission of leprosy in a single family having 4 patients using microsatellite typing. DNA was isolated from slit skin smear samples taken from the patients and the isolated DNA were amplified using microsatellite loci TA₁₁CA₃. The amplified products were sequenced using Sanger’s sequencing methods and the copy number variation in the microsatellite loci between strains were elucidated by multiple sequence alignment. The result showed that all the 4 members of the family acquired infection from 3 different strains of M. leprae from 3 different sources. The elder and middle daughters were infected by same types of strains having the repeat unit TA₁₃CA₃ and could have acquired the infection from social contacts of leprosy cases while the father and younger daughter were infected by strains with the repeat unit TA₁₂CA₃ and TA₁₁CA₃ and could have acquired infection from social contacts_.

Conclusions/Significance

The study suggested that three family members viz, elder daughter, father and younger daughter could be infected by M. leprae from 3 different sources and the history of the disease and genetic analysis showed that the middle daughter acquired infection from her elder sister in due course of contact. This study implies that the transmission of leprosy not only occurred amongst the house hold members but also has been transmitted from social and neighborhood contacts in long term association with the them.

Chronic stress, sense of coherence and risk of type 2 diabetes mellitus

AIMS

The study was conducted to ascertain whether chronic stress and sense of coherence are associated with risk of type 2 diabetes mellitus.

METHODS

Stress questionnaires - Presumptive Stressful Life Events Scale (PSLES), Perceived Stress Scale (PSS) and Sense of Coherence (SOC) - were administered to 500 Newly Detected Diabetes Mellitus (NDDM) cases and 500 Normal Glucose Tolerance (NGT) controls recruited following 75 g OGTT. Assessment of stress was completed before the diagnosis of diabetes was revealed to them.

RESULTS

PSLES and PSS scores were significantly higher and SOC score was significantly lower in NDDM subjects compared to those with NGT. PSLES and PSS correlated positively with anthropometric parameters (waist circumference, BMI), glycemic parameters (FPG, 2 hPG, A1C) and HOMA-IR and inversely with HOMA-β whereas SOC correlated inversely with glycemic parameters (FPG, 2 hPG, A1C) and HOMA-IR and positively with HOMA-β. In stepwise logistic regression analysis, SOC emerged as the strongest independent predictor of diabetes (OR: 0.774) after HOMA-IR (OR: 1.621) and BMI (OR: 1.288). Other significant predictors included PSS (OR:1.153), PSLES-LT (OR: 1.005) and HOMA-β (OR: 0.894).

CONCLUSION

Chronic stress and low sense of coherence are associated with a higher risk of type 2 diabetes mellitus.

Delineating the factors associated with recurrence of tuberculosis in programmatic settings of rural health block, Himachal Pradesh, India

BACKGROUND

Tuberculosis (TB) recurrence observed to be an important event in its treatment and has future implications under national TB control efforts. The present study was carried out to assess the recurrence rate along with its risk factors among patients undergoing treatment for TB under Revised National TB Control Program (RNTCP).

MATERIAL AND METHODS

Total 204 patients in health block of district Una, Himachal Pradesh were studied using pretested structured interviewer-administered questionnaire. Along with univariate a non-hierarchal multi-way frequency analysis (MFA) was done to study the one and multi-way effects between the discrete variables included in a hypothesized model. The variables were under-nutrition, pulmonary TB, injecting drug use (IDU), multi-drug resistant (MDR) TB, and past TB (recurrent cases).

RESULTS

Total 29 cases (14.2%) had recurrence (17.7/100,000 population) with significantly high fraction for alternate residence (Recurrent: 50.0%, Non-recurrent: 47.4%; p = 0.001), Multi-drug resistance (MDR) TB (Recurrent: 13.8%, Non-recurrent: 2.3%; p = 0.003), and sputum negative patients (Recurrent: 51.7%, Non-recurrent: 14.5%; p = 0.000). Non-recurrent cases had significantly high fraction for sputum positive cases (Recurrent: 48.3%, Non-recurrent: 72.1%; p = 0.011), and extra-pulmonary TB (Recurrent: 00.0%, Non-recurrent: 13.4%; p = 0.036). MFA observed all significant one-way effects. Significant two-way effects were IDU and pulmonary TB (p = 0.001), MDR and past TB (p = 0.004), IDU and past TB (p = 0.019), and IDU and MDR-TB (p = 0.039).

CONCLUSION

Proportion of TB recurrence was expected with a significant difference between the history of change of residence, MDR-TB, pulmonary and extra-pulmonary nature of the disease. Hypothesized model observed with a significant association of IDU, pulmonary TB, MDR-TB and past TB.

Ribonucleotide reductase as a drug target against drug resistance Mycobacterium leprae: A molecular docking study

Leprosy is a chronic infection of skin and nerve caused by Mycobacterium leprae. The treatment is based on standard multi drug therapy consisting of dapsone, rifampicin and clofazamine. The use of rifampicin alone or with dapsone led to the emergence of rifampicin-resistant Mycobacterium leprae strains. The emergence of drug-resistant leprosy put a hurdle in the leprosy eradication programme. The present study aimed to predict the molecular model of ribonucleotide reductase (RNR), the enzyme responsible for biosynthesis of nucleotides, to screen new drugs for treatment of drug-resistant leprosy. The study was conducted by retrieving RNR of M. leprae from GenBank. A molecular 3D model of M. leprae was predicted using homology modelling and validated. A total of 325 characters were included in the analysis. The predicted 3D model of RNR showed that the ϕ and φ angles of 251 (96.9%) residues were positioned in the most favoured regions. It was also conferred that 18 α-helices, 6 β turns, 2 γ turns and 48 helix-helix interactions contributed to the predicted 3D structure. Virtual screening of Food and Drug Administration approved drug molecules recovered 1829 drugs of which three molecules, viz., lincomycin, novobiocin and telithromycin, were taken for the docking study. It was observed that the selected drug molecules had a strong affinity towards the modelled protein RNR. This was evident from the binding energy of the drug molecules towards the modelled protein RNR (-6.10, -6.25 and -7.10). Three FDA-approved drugs, viz., lincomycin, novobiocin and telithromycin, could be taken for further clinical studies to find their efficacy against drug resistant leprosy.

Assessment of vocation of rifabutin and rifapentine in replace of rifampcin in drug resistance leprosy patients: a molecular simulation study

The emergence of drug resistance in leprosy is a major hurdle in leprosy elimination programme. Although the problem of drug resistance is presently not acute, it is important that we collect data more systematically and monitor the trend carefully so that effective measures to combat this problem can be developed. The present study aimed at the explication of cross resistance of rifabutin and rifapentine to rifampicin which would be helpful to programme managers for implementing rifabutin or rifapentine in replace of rifampicin. In this study we built 3D model of the M. leprae rpoB using Swiss Model and the modelled structure was docked with rifampicin, rifabutin and rifapentine. We established that these 3 antibiotics interact with the same binding region in the modelled rpoB of M. leprae. Thus we conclude that vocation of rifabutin and rifapentine could not be suitable in replace of rifampicin to combat with drug resistance leprosy.

Modulation of N-nitrosodiethylamine (NDEA) induced oxidative stress by vitamin E in rat erythrocytes

Nitrosamines, such as N-nitrosodiethylamine (NDEA), induced oxidative stress due to the generation of reactive oxygen species, which are capable of initiating peroxidative damage to the cell. The present study was designed to establish whether pre-treatment with vitamin E (40 mg/kg body wt, intraperitoneally (ip), twice a week for 4 weeks) to NDEA induced rats provides protection against oxidative stress caused by NDEA. A single necrogenic dose of NDEA (200 mg/kg body wt) was administered intraperitoneally (ip) to the rats with or without vitamin E pre-treatment and the animals were sacrificed on Day 7, 14 or 21 after NDEA administration. Lipid peroxidation (LPO) and the activities of antioxidant enzymes were determined in erythrocytes as indices of oxidative damage. The result showed elevated levels of LPO in erythrocytes with NDEA treatment, however, vitamin E pre-treated rats administered NDEA showed decreased LPO (Day 14 and 21). Superoxide dismutase (SOD) enzyme activity and the glutathione (GSH) content increased with NDEA treatment and remained high in vitamin E pre-treated group. Catalase (CAT), glutathione reductase (GSH-R) and glutathione-S-transferase (GST) enzyme activities declined with NDEA treatment; however, vitamin E pre-treated rats administered NDEA, showed elevation in the enzyme activities. Glutathione peroxidase (GSH-Px) activity increased in erythrocytes in vitamin E pre-treated rats administered NDEA, while SeGSH-Px activity was not affected significantly. This study demonstrates that the pre-treatment with vitamin E prior to the administration of NDEA was effective in counteracting and modulating oxidative stress in rat erythrocytes in a time-dependent manner.

Photophysical and structural characterisation of in situ formed quantum dots

Conjugated polymer-semiconductor quantum dot (QD) composites are attracting increasing attention due to the complementary properties of the two classes of materials. We report a convenient method for in situ formation of QDs, and explore the conditions required for light emission of nanocomposite blends. In particular we explore the properties of nanocomposites of the blue emitting polymer poly[9,9-bis(3,5-di-tert-butylphenyl)-9H-fluorene] together with cadmium sulphide (CdS) and cadmium selenide (CdSe) precursors. We show the formation of emissive quantum dots of CdSe from thermally decomposed precursor. The dots are formed inside the polymer matrix and have a photoluminescence quantum yield of 7.5%. Our results show the importance of appropriate energy level alignment, and are relevant to the application of organic-inorganic systems in optoelectronic devices.

Hypofractionated stereotactic body radiotherapy in spinal metastasis - with or without epidural extension

AIMS

To evaluate clinical outcome and the effect of malignant epidural compression (MEC) in the treatment of spine metastasis with stereotactic body radiotherapy (SBRT).

MATERIALS AND METHODS

Seventy-six lesions in 52 patients with spinal metastasis received SBRT during the period July 2010 to December 2012. MEC was detected in 20 patients (38.4%) and was separately contoured. The median dose prescribed to involved vertebra (planning target volume) was 24 Gy (range 24-27 Gy) in a median of three fractions (range 1-3). Uninvolved elements were prescribed 21 Gy in three fractions. In 59 lesions (77.6%), the entire vertebra was treated and in 17 lesions (22.4%) only the anterior elements were treated. All patients were treated with volumetric modulated arc therapy with image guidance on a Novalis Tx linear accelerator with the ExacTrac system. Dosimetric and clinical outcomes were compared in patients with or without MEC.

RESULTS

At a median follow-up of 8.48 months (range 3-40 months), 1 year local control and overall survival was 94 and 68%, respectively. In patients with or without epidural extension, the median dose to the gross tumour volume (GTV; 95%) was 23.48 Gy (range 13.70-25.75) and 22.99 Gy (range 13.55-26.84), the median spinal cord Dmax was 17.36 Gy (range 8.47-21.63) and 15.71 Gy (range 8.39-23.33). The median GTV epidural (D95%) was 21.16 Gy (range 15.43-23.92). Complete pain relief was seen in 90% of patients with MEC and 93.75% without MEC (P=NS) and neurological improvement was seen in 60% of patients in both groups of patients.

CONCLUSION

It is feasible to deliver a high dose of radiation (∼90% of the prescription dose) to the epidural component with volumetric modulated arc therapy SBRT and image guidance. It yielded high rates of pain control and local control in patients with spine metastases with or without MEC.

FT-Raman, FT-IR, UV spectroscopic, NBO and DFT quantum chemical study on the molecular structure, vibrational and electronic transitions of clopidogrel hydrogen sulfate form 1: a comparison to form 2

Clopidogrel hydrogen sulfate (+)-(S)-(2-chlorophenyl)-6,7-dihydrothieno[3,2-c]pyridine-5(4H)-acetate sulfate (1:1), is a selective adenosine diphosphate (ADP) receptor antagonist often used in the treatment of coronary artery, peripheral vascular and cerebrovascular diseases. In the present communication, a comparative study of two polymorphic forms (forms 1 and 2) of clopidogrel hydrogen sulfate (CLP) has been reported. There is difference in conformation and intermolecular hydrogen bonding pattern of two forms. These differences are nicely reflected in the vibrational spectra. The molecular structure, fundamental vibrational frequencies and intensity of the vibrational bands of CLP form 1 are interpreted with the aid of structure optimizations and normal mode analysis based on ab initio HF and DFT method employing 6-311++G(d,p) basis. Polymorphism in CLP have been studied using various characterization tools like FT-Raman, FT-IR spectroscopy and DSC in combination with the quantum chemical calculations. UV-vis spectroscopic studies along with HOMO-LUMO analysis of both polymorphs were performed. The solvent effect calculated by TD-DFT/IEF-PCM/6-31G model results complements with the experimental findings. Stability of the molecule arising from hyper conjugative interactions and charge delocalization has been analyzed using natural bond orbital (NBO) analysis.

Study of polymorphism in imatinib mesylate: a quantum chemical approach using electronic and vibrational spectra

Imatinib mesylate, 4-(4-methyl-piperazin-1-ylmethyl)-N-u[4-methyl-3-(4-pyridin-3-yl)pyrimidine-2-ylamino)phenyl]benzamide methanesulfonate is a therapeutic drug that is approved for the treatment of chronic myelogeneous leukemia (CML) and gastrointestinal stromal tumors (GIST). It is known that imatinib mesylate exists in two polymorphic forms α and β. However, β-form is more stable than the α-form. In this work, we present a detailed vibrational spectroscopic investigation of β-form by using FT-IR and FT-Raman spectra. These data are supported by quantum mechanical calculations using DFT employing 6-311G(d,p) basis set, which allow us to characterize completely the vibrational spectra of this compound. The FT-IR spectrum of α-form has also been discussed. The importance of hydrogen-bond formation in the molecular packing arrangements of both forms has been examined with the vibrational shifts observed due to polymorphic changes. The red shift of the NH stretching bands in the infrared spectrum from the computed wavenumber indicates the weakening of the NH bond. The UV-vis spectroscopic studies along with the HOMO-LUMO analysis of both polymorphs (α and β) were performed and their chemical activity has been discussed. The TD-DFT method was used to calculate the electronic absorption spectra in the gas phase as well as in the solvent environment using IEF-PCM model and 6-31G basis set. Finally, the results obtained complements to the experimental findings.

Use of Verbal Autopsy as a Proxy to Determine the Possible Cause of Neonatal Deaths

Introduction: Information on causes of death is extremely important for policy making, planning, monitoring, field research, future management statergies and epidemic awareness. The best method of finding the cause of death is by post mortem examination but since this is difficult, post death analysis by verbal autopsy is a good method to determine the same. Objective: To asses the role of verbal autopsy method in the investigation of neonatal death and to determine the probable, causes of neonatal death. Materials and Methods: A pre-tested questionnaire in Hindi was administered to 50 mothers and/or next of kin or other care givers of the deceased residing in villages around 200 Kms. of Bhopal and in urban slums of Municipal Corporation, Bhopal. Results: 84 % of the total death occurred with in seven days of birth, 88 % of death occurred in villages where health facilities were available. As per verbal autopsy 36 % and 20 % of the infants died because of Birth asphyxia and Respiratory Distress Syndrome respectively and further 2%, 4% and 6% because of neonatal tetanus, hypothermia and other causes respectively. Conclusion: Verbal autopsy could be one of the possible cost effective and a reliable tool for determining the causes of neonatal deaths at present. Key words: Verbal Autopsy; Neonatal death; Reliable respondents and category of villages. DOI: 10.3126/jnps.v31i1.2942J Nep Paedtr Soc 2010;31(1):44-48

The methods of survival analysis for clinicians

The methods of survival analysis are required to analyze duration data but their use is restricted possibly due to lack of awareness and the intricacies involved. We explain common methods of survival analysis, namely, life table, Kaplan Meier, log rank and Cox model, in a simple and friendly language so that the medical fraternity can use them with confidence where applicable.

Co-relationship of physical stability of amorphous dispersions with enthalpy relaxation

Physical stability studies of valdecoxib (VLB) and its solid dispersions with PVP (1, 2, 5, 10, 15 and 20% w/w) were carried out by Differential Scanning Calorimetry (DSC). Change in specific heat with time was measured to determine the degree of crystallinity of amorphous drug and its binary dispersions after storage at 40 degrees C and 75% RH. The rate of crystallization was found to decrease with increasing PVP concentration and time for 10% crystallization (t90%) was found to increase significantly for the amorphous drug when formulated as PVP dispersions. Enthalpy relaxation was found to be inversely correlated with t90% (min) values and was found to be a good predictor of devitrification tendency and hence stability of amorphous VLB.

Characterization of solid-state forms of mebendazole

This study deals with the generation and characterization of various solid-state forms of mebendazole (MBZ), a benzimidazole antihelmentic. The drug was subjected to polymorphic screen using different solvents to explore the possibility of existence of different solid forms. Different reported polymorphic forms of MBZ, i.e. form A, B and C were found to be recrystallized from acetic acid:methanol mixture (1:1), ethyl acetate and methanol, respectively. N,N-Dimethyl acetamide (DMA) and N,N-dimethyl formamide (DMF) yielded two new solvates of MBZ. These solid-state forms were characterized by thermoanalytical (DSC, TGA, HSM), crystallographic (XRD), microscopic (optical, polarized), and spectroscopic (FTIR) techniques. Solubility studies were carried out for the solvates to identify the solubility advantage. Molecular modeling studies revealed moderately strong hydrogen bonding between the solvent molecules and MBZ.

Variance in the treatment of vertebral haemangiomas

Vertebral haemangiomas constitute an infrequently encounterd entity in clinical practice. Although x-ray, computerised tomography scan and magnetic resonance Imaging scan provide a pathognomic picture confirming the diagnosis of vertebral haemangiomas, angiography constitutes an important tool for diagnosis and helps in deciding and execution of treatment. Various treatment modalities like surgery, radiotherapy, pre-operative embolisation, percutaneous vertebroplasty and intralesional ethanol have been discussed in the setting of asymptomatic vertebral haemangiomas to those presenting with features of cord compression.

Ternary amorphous composites of celecoxib, poly(vinyl pyrrolidone) and meglumine with enhanced solubility

The present study highlights the development of ternary amorphous composites to enhance the solubility of a poorly soluble crystalline drug, celecoxib (CEL). These systems comprised of an 'amorphous drug,' and its 'stabilizer' and 'solubilizer.' The ternary amorphous system of CEL, poly(vinyl pyrrolidone) (PVP) and meglumine (MEG) (7:2:1 w/w) enhanced CEL solubility by approximately equal to 10.2-fold over that for the crystalline drug, and maintained the thermodynamic stability of the amorphous drug. However, MEG alone was unable to stabilize the amorphous CEL against thermally-induced crystallization, and so gave no solubility advantage. The PVP-MEG combination provided a 'synergistic' enhancement of CEL solubility, as compared to their use alone in the amorphous systems. Phase-solubility studies provided greater insight into molecular mechanisms underlying stability and solubility of these amorphous systems. MEG exhibited phase-specific interaction with CEL molecules, when stabilized by PVP in the amorphous state. The higher solubility of CEL from ternary amorphous systems was also thermodynamically favored, as analyzed by van't Hoff plots. A possible molecular level interaction of MEG with PVP-stabilized amorphous CEL seems to be responsible for the solubility advantage of the CEL-PVP-MEG ternary amorphous system.

Stabilization against Hyperthermal Denaturation through Increased CG Content Can Explain the Discrepancy between Whole Genome and 16S rRNA Analyses

Based largely upon analysis of ribosomal RNA, a third domain of life, called archaea, had been proposed in addition to bacteria and eukaryotes. However, quantitative analysis of 73 whole genomes shows only a two-domain division of life: into eukaryotes and prokaryotes. Thousands of orthologous genes in archaea and bacteria show an essentially unimodal distribution of sequence identities. Thus, whole genome analyses indicate that archaea are a phylum of bacteria rather than a separate domain of life. In contrast, archaeal rRNA and that of hyperthermophilic bacteria differ from the rRNA of mesophilic bacteria. Thus, there is a bimodal distribution of rRNA sequence identities which differ by 12%. This discrepancy in rRNA and gene content based analyses of whole genomes is likely due to a 15% elevated C:G content of the rRNA of archaea and hyperthermophilic bacteria. The elevated C:G content is consistent with stabilization against thermal denaturation caused by additional hydrogen bonding (3 bonds) in C:G pairs compared to A:U pairs (2 bonds). Based upon this premise, there is no reliable way to correct rRNA for such differences in base composition and it is not possible to quantitatively compare hyperthermophiles with mesophiles by the rRNA method. Furthermore, quantitative study of whole genomes shows that the extent of change in both bacterial and archaeal genes, including rRNA, has reached a limit. Thus, direct sequence comparisons work with closely related genomes, but it is not possible to differentiate the most divergent prokaryotic species, which are currently designated as separate phyla. We believe that the differences in characteristics of archaeal species is based primarily upon selection of genes and pathways compatible with the extreme environmental lifestyle, i.e., hyperthermophily.

Outcome of pterygium surgery: analysis over 14 years

AIM

To report the outcome of pterygium surgery performed at a tertiary eye care centre in South India.

METHODS

Retrospective analysis of medical records of 920 patients (989 eyes) with primary and recurrent pterygia operated between January 1988 and December 2001. The demographic variables, surgical technique (bare sclera, primary closure, amniotic membrane transplantation (AMT), conjunctival autograft (CAG), conjunctival-limbal autograft (CLAG), or surgical adjuvants), recurrences and postoperative complications were analysed.

RESULTS

A total of 496 (53.9%) were male and 69 (7.5%) had bilateral pterygia. Bare sclera technique was performed in 267 (27.0%) eyes, primary conjunctival closure in 32 (3.2%), AMG in 123 (12.4%), CAG in 429 (43.4%), and CLAG in 70 (7.1%). Adjuvant mitomycin C was used in 44 (4.4%) cases. The mean duration of follow-up was 8.9+/-17.0 and 5.9+/-8.8 months for unilateral primary and recurrent pterygia, respectively. The overall recurrence rate was 178 (18.0%). Following primary and recurrent unilateral pterygium excision respectively, recurrences were noted in 46 (19.4%) and 1 (33.3%) eyes after bare sclera technique, five (16.7%) and 0 after primary closure, 28 (26.7%) and 0 with AMG, 42 (12.2%) and five (31.3%) with CAG, and nine (17.3%) and two (40%) with CLAG. Recurrences were significantly more in males with primary (23.3 vs 10.7%, P<0.0001) and recurrent (26.7 vs 0%, P=0.034) pterygia, and in those below 40 years (25.2 vs 14.8%, P=0.003).

CONCLUSION

CAG appears to be an effective modality for primary and recurrent pterygia. Males and patients below 40 years face greater risk of recurrence. Bare sclera technique has an unacceptably high recurrence. Prospective studies comparing CAG, CLAG, and AMG for primary and recurrent pterygia are needed.

In Vitro–In Vivo Characterization of Release Modifying Agents for Parenteral Sustained‐Release Ketorolac Formulation

One of the prerequisites for a parenteral preparation is that the excipients incorporated are biocompatible and biodegradable. In the present study hydrophilic and hydrophobic excipients were investigated for developing an intramuscular sustained-release formulation of ketorolac. Kollidon 17 PF, Peceol (glyceryl monooleate), and castor oil were chosen as the potential release-retarding agents, each with a distinct mechanism of action. They were evaluated by in vitro drug-release profiles and in vivo pharmacodynamic and pharmacokinetic study in mice. Cumulative drug release was determined for standard and test formulations in modified Franz diffusion cell. Pharmacodynamic parameter, T = 70% response of peak analgesic response, was used to compare the performance of test formulations. Based on pharmacodynamic/pharmacokinetic correlation in the animal studies, Css(max) and Css(min) of 51.39 and 30.0 microg/mL, respectively, were determined and considered as performance markers for pharmacokinetic evaluation of test formulations. The study suggested that the sustained-release capability of glyceryl monooleate was maximum followed by that of castor oil and Kollidon 17 PF, when compared to conventional ketorolac tromethamine formulation. It was inferred that water soluble excipient, though, showed release retarding property in vitro but could not maintain it in the in vivo environment. Glyceryl monooloeate-based formulation produced the most favorable drug blood concentration vs. time profile.

Pellucid marginal corneal degeneration*1

OBJECTIVE

To report the clinical features and outcome of patients with pellucid marginal corneal degeneration (PMCD).

DESIGN

Retrospective noncomparative case series.

METHODS

Retrospective chart review of 116 eyes of 58 patients with PMCD seen between 1990 and 2002 at the Cornea Service at L.V. Prasad Eye Institute, Hyderabad, India. The diagnosis of PMCD was based on the presence of corneal thinning with ectasia of the normal cornea above or below the area of thinning with no evidence of scarring, vascularization, or lipid deposition and typical topographic features whenever topography was performed. A detailed history including the age of presentation, onset of symptoms, systemic diseases, atopy, and relevant family history was reviewed. The visual acuity (VA) at presentation; the location, extent, and degree of thinning; presence of concurrent keratoconus and keratoglobus; and complications, if any, were noted. The mode of visual rehabilitation; surgical procedure, if any; and the final VA achieved were analyzed.

MAIN OUTCOME MEASURES

Clinical features, associations, complications, and outcome of treatment.

RESULTS

There were 45 males (77.6%) and 13 females (22.4%). All cases were bilateral. In one eye, no clinical features of PMCD were seen, but the diagnosis was made based on topographic features of typical PMCD. The age of the patients ranged from 8 to 66 years, with a mean of 34.0+/-14.8. One patient (1.7%) had associated vernal keratoconjunctivitis (VKC), 1 (1.7%) had Marfan's syndrome, and 1 (1.7%) had ocular hypertension. The degree of astigmatism was <5.0 diopters (D) in 19 eyes (19.2%), 5 to 10 D in 36 (36.4%), 10 to 15 D in 23 (23.2%), 15 to 20 D in 15 (15.2%), and >20 D in 6 (6.1%). Typical inferior PMCD was seen in 99 eyes (85.3%), and superior PMCD was seen in 17 (14.7%). The thinning was commonly seen between the 5-o'clock and 7-o'clock positions. In 12 eyes (10.3%), PMCD was associated with keratoconus, and in 15 eyes (12.9%), keratoglobus was associated. Seven eyes (6.0%) had hydrops. Visual acuity improved in 52 eyes (55.3%) with correction, in 40 eyes (42.6%) it remained the same as that of the initial presentation, and in 2 eyes (2.1%) it worsened relative to the initial presentation. Forty-one eyes (35.3%) received spectacles, and 31 eyes (26.7%) were fitted with rigid gas-permeable contact lenses. Five eyes (4.3%) underwent surgery. Lamellar keratoplasty was performed in 3 eyes, and a crescentic lamellar graft was done in 2 eyes. Visual acuity improved in 4 eyes after surgery with a follow-up of 2 to 37 months. The final astigmatism in the operated eyes at the last follow-up ranged from 4 to 11 D.

CONCLUSIONS

Pellucid marginal corneal degeneration was seen predominantly in males in this series, and was not strongly associated with VKC. Keratoconus was seen in approximately 10% of the eyes, and keratoglobus in approximately 13%. Superior PMCD was seen in approximately 15% of the eyes. In our study, patients presented with severe astigmatism, and hydrops was a common complication. The majority of patients were treated with spectacles or contact lens. Surgery for PMCD-lamellar keratoplasty and crescentic lamellar keratoplasty, if indicated-usually results in significant residual astigmatism.

Superior pellucid marginal corneal degeneration

PURPOSE

To report the clinical features and topographic findings of superior pellucid marginal corneal degeneration (PMCD).

METHODS

Retrospective chart review of 15 eyes of eight patients of superior PMCD. Detailed history, visual acuity at presentation, degree of astigmatism, slit-lamp examination findings, topographic features, and Orbscan findings were noted where available. Improvement in visual acuity with spectacles or contact lens correction, surgical procedure if any, and final visual acuity were analysed.

RESULTS

In all, six patients were males and two were females. All cases except one were bilateral. The patients ranged in age from 18 to 48 years. All cases had isolated superior PMCD. One patient was a diagnosed case of vernal keratoconjunctivitis. The visual acuity at presentation ranged from hand motions to 20/25. The degree of thinning varied from 30 to 90%. The extent of thinning was commonly seen between the 10 and 2 o'clock positions. Ectasia was seen below the site of thinning in all the cases of superior PMCD. Topographic features including vertical corridor of reduced power, against-the-rule astigmatism and superior loop cylinder were seen in 10 eyes. Orbscan was carried out in two eyes of one patient and revealed an area of increased elevation in relation to the best-fit sphere superiorly corresponding to the area of ectasia in both the eyes. The visual acuity improved with rigid gas-permeable contact lens in six eyes and the final visual acuity ranged from 20/400 to 20/30. Two eyes were subjected to surgical intervention (peripheral annular graft=1 and lamellar graft=1).

CONCLUSIONS

PMCD can occur superiorly. It should be considered in the differential diagnosis of superior ectatic disorders. The topographic findings, of reduced power in the vertical meridian and superior loop cylinder, are typical of superior pellucid marginal degeneration. Visual rehabilitation is usually possible with contact lenses, with surgical management required in selected cases.

Cleaning of leprosy case registers in Chhattisgarh

Cleaning of register exercise was based on examination of records and not of patients. Because of this exercise, names of 5676 patients were deleted for various reasons viz. completed FDT, Defaulter, AMDT etc. The findings of the present study are more or less similar to the finding of similar other studies carried out in different countries from time to time. Updating of leprosy registers should be a routine activity. For this sensitization of health functionaries at various level must be carried out about importance of cleaning of register and for systematic effort to review the registers at least on sample basis.

Birth weight patterns in rural undernourished pregnant women

OBJECTIVE

To study the birth weight pattern in chronic as well as currently undernourished pregnant women.

DESIGN

Prospective study of rural pregnant women by following eligible women.

SETTING

Two adjoining blocks of rural Varanasi.

METHOD

3700 pregnant women from rural areas of Varanasi for whom data for anthropometry, hemoglobin, dietary intake, birth weight, fundal height and abdominal girth at 16 +/- 2, 28 +/- 2 and 36 +/- 2 weeks of gestation were recorded. Outcome measure was birth weight pattern of newborns.

RESULTS

Of the births, 7.2% were < 2250 g and 27.4% < 2500 g. The weekly birth weight increments in gestation 36-42 weeks were 5-53 g, only. The fundal height did not increase during 35-39 weeks of gestation (lower by 5 cm as compared to normal). Nutrition supplement in the third trimester significantly increased fundal height and abdominal girth. Fundal height below 24.5 cm at 28 weeks of gestation (1368 women) was associated with higher low birth weight deliveries.

CONCLUSION

Birth weight and fundal height increments during later pregnancy are low in undernourished pregnant women. Fundal height < 24.5 cm at 28 weeks of gestation identified women with higher risk for lowbirth weight infants. The prevalence of low birth weight was 27.4% and of prematurity was 6.6%.

Physical growth assessment in adolescence

OBJECTIVE

To describe ponderosity indices body mass index--"BMI" and ponderal index "PI" and skin fold thicknesses (triceps, biceps, subscapular and suprailiac) for affluent Indian school going adolescents.

DESIGN

Cross sectional.

METHODS

Measurements were recorded in healthy affluent school going adolescents in public schools of 12 cities in India (boys=11,863 and girls 7,694). Means and percentiles of ponderosity indices and skinfold thicknesses at yearly intervals were derived for each sex and related to sexual maturity.

RESULTS

BMI, PI and skin fold thickness (SFT) were higher in girls. There was lower variability of these parameters with sexual maturity rating (breast/genital development stages) as compared to age, suggesting use of these indices in relation to sexual maturity for assessment of adolescent growth.

CONCLUSION

Pediatricians and endocrinologists can use these indices for assessment of thinness and obesity, in adolescent Indian children, in relation to sexual maturity for the age.

Anterior stromal puncture in bullous keratopathy: a clinicopathologic study

PURPOSE

We report our experience of anterior stromal puncture (ASP) in symptomatic chronic corneal edema patients awaiting penetrating keratoplasty (PK) and hypothesize the mechanism of action of ASP in bullous keratopathy (BK).

METHODS

We reviewed the medical records of 28 patients with BK who underwent ASP between November 1996 and September 1999 with at least 1 month of follow-up. In all these patients, approximately 200 punctures were given with a bent 26-gauge needle sparing the peripheral cornea. Patients were examined on days 1 and 7, 1 month, and every 3 months after the procedure. The symptoms, corneal findings, and visual acuity of the patients at last follow-up were noted and compared with the preprocedure findings. For 11 patients who underwent PK, histopathologic study of corneal buttons was performed and a clinicopathologic correlation was attempted.

RESULTS

Of the 28 patients, there were 15 men and 13 women with a mean age of 61.1 years. The clinical diagnosis was pseudophakic BK in 11 (39.3%), aphakic BK in 11 (39.3%), Fuchs' dystrophy in 4 (14.3%), failed graft in 1 (3.6%), and chronic corneal edema of unknown etiology in 1 (3.6%). The follow-up ranged from 1 to 33 months with a mean of 9.5 +/- 7.5 months. Symptomatic relief was noted in all. Twenty patients (71.4%) had complete relief, whereas eight patients (28.6%) experienced mild symptoms such as tearing and occasional pain. Visual acuity improved in 7 patients (25%), decreased in 12 (42.8%), and remained the same in 9 (32.4%). Objective evidence of scarring after ASP was noted in all patients. Complete regression of epithelial bullae and epithelial edema was found in 10 (35.7%) and partial regression in 18 (62.25%) patients. There was no progression or appearance of new blood vessels except in one patient (3.6%). Histologically, puncture marks and superficial stromal scarring were noted in all corneal buttons. Adhesion of epithelium with varying degrees of subepithelial fibrosis was seen in six, whereas in the remaining five buttons, there was complete denudation of the epithelium. Vascularization was seen in five and inflammation in two buttons. Clinicopathologic correlation revealed that symptomatic patients had persistent edema and loose adhesion of the epithelium to the stroma, resulting in detachment.

CONCLUSIONS

ASP is a simple, safe, and cost-effective outpatient procedure for symptomatic relief in patients with BK. The possibility of decreased visual acuity after the procedure should be explained to all patients. Although ASP promoted subepithelial fibrosis in all cases, its subsequent adhesion is variable and probably has clinical relevance. Further studies could be directed toward identifying specific mediators that promote epithelial-stromal interaction and firm anchoring of epithelium to the underlying stroma.

Laser refractive surgery: technological advance and tissue response

Photorefractive keratectomy (PRK) and laser assisted in situ keratomileusis (LASIK), using an excimer laser, are the currently popular techniques of correcting refractive errors. Since these techniques work by selective ablation of corneal stroma, the tissue healing response plays a great role in the ultimate outcome of surgery. Also, various methods of wound healing modulation can be used to achieve better results. While these procedures do lead to a decrease in dioptric power and increase in unaided visual acuity, higher visual functions like contrast sensitivity can sometimes be compromised after the surgery.