Community health volunteer for blood pressure control in rural people with stroke in India: Pilot randomised trial

OBJECTIVE

To test the hypothesis that an Accredited social health activist (ASHA), a community health volunteer in a task-sharing model can help in sustained control of systolic blood pressure (BP) in rural people with Stroke and hypertension at 6 months follow up.

METHODS

In this randomized trial two rural areas (Pakhowal and Sidhwan bet) with 70 and 94 villages respectively were screened for people with stroke and hypertension. They were assigned to either ASHA-assisted BP control in addition to standard-of-care (Pakhowal-intervention Group) or standard-of-care alone (Sidhwan bet- Control Group). Assessors blinded to intervention conducted the baseline and 6 months follow-up visits to measure risk factors in both the rural areas.

RESULTS

A total of 140 people with stroke with mean age of 63.7 ± 11.5 years and 44.3% females were randomised. The baseline systolic BP was higher in the intervention group (n = 65,173.5 ± 22.9 mmHg) compared to the control group (n = 75,163 ± 18.7 mmHg, p = 0.004). The follow-up systolic BP was lower in the intervention group compared to the control group 145 ± 17.2 mmHg and 166.6 ± 25.7 mmHg respectively (p < 0.0001). According to the intention-to-treat analysis a total of 69.2% of patients in the intervention group achieved systolic BP control compared to 18.9% in the control group patients (OR 9, 95% CI 3.9-20.3; p < 0.0001).

CONCLUSION

Task sharing with ASHA a community health volunteer can improve BP control in rural people with stroke and hypertension. They can also help in the adoption of healthy behaviour.

CLINICAL TRIAL REGISTRATION NUMBER

ctri.nic.in, CTRI/2018/09/015709.

Safety and immunogenicity of SII-NVX-CoV2373 (COVID-19 vaccine) in adults in a phase 2/3, observer-blind, randomised, controlled study

Background

NVX-CoV2373, a Covid-19 vaccine was developed in the USA with ∼90% efficacy. The same vaccine is manufactured in India after technology transfer (called as SII-NVX-CoV2373), was evaluated in this phase 2/3 immuno-bridging study.

Methods

This was an observer-blind, randomised, phase 2/3 study in 1600 adults. In phase 2, 200 participants were randomized 3:1 to SII-NVX-CoV2373 or placebo. In phase 3, 1400 participants were randomized 3:1 to SII-NVX-CoV2373 or NVX-CoV2373 (940 safety cohort and 460 immunogenicity cohort). Two doses of study products (SII-NVX-CoV2373, NVX-CoV2373 or placebo) were given 3 weeks apart. Primary objectives were to demonstrate non-inferiority of SII-NVX-CoV2373 to NVX-CoV2373 in terms of geometric mean ELISA units (GMEU) ratio of anti-S IgG antibodies 14 days after the second dose (day 36) and to determine the incidence of causally related serious adverse events (SAEs) through 180 days after the first dose. Anti-S IgG response was assessed using an Enzyme-Linked Immunosorbent Assay (ELISA) and neutralizing antibodies (nAb) were assessed by a microneutralization assay using wild type SARS CoV-2 in participants from the immunogenicity cohort at baseline, day 22, day 36 and day 180. Cell mediated immune (CMI) response was assessed in a subset of 28 participants from immunogenicity cohort by ELISpot assay at baseline, day 36 and day 180. The total follow-up was for 6 months. Trial registration: CTRI/2021/02/031554.

Findings

Total 1596 participants (200 in Phase 2 and 1396 in Phase 3) received the first dose. SII-NVX-CoV2373 was found non-inferior to NVX-CoV2373 (anti-S IgG antibodies GMEU ratio 0.91; 95% CI: 0.79, 1.06). At day 36, there was more than 58-fold rise in anti-S IgG and nAb titers compared to baseline in both the groups. On day 180 visit, these antibody titers declined to levels slightly lower than those after the first dose (13-22 fold-rise above baseline). Incidence of unsolicited and solicited AEs was similar between the SII-NVX-CoV2373 and NVX-CoV2373 groups. No adverse event of special interest (AESI) was reported. No causally related SAE was reported.

Interpretation

SII-NVX-CoV2373 induced a non-inferior immune response compared to NVX-CoV2373 and has acceptable safety profile.

Funding

SIIPL, Indian Council of Medical Research, Novavax.

Rural Stroke Surveillance and Establishment of Acute Stroke Care Pathway Using Frontline Health Workers in Rural Northwest India: The Ludhiana Experience

BACKGROUND AND PURPOSE

The role of community health workers (CHWs) in stroke surveillance and in establishing the stroke care pathway has not been studied. The aim of the study was to evaluate the feasibility of using CHWs in the public health system to identify stroke patients for population-based stroke registration and to study the establishment of acute stroke care pathway in rural areas of Ludhiana, Punjab, Northwest India.

METHODS

Two rural blocks in Ludhiana district, comprising 164 villages and a population of 259,778, were selected. Phase-1 (feasibility study) was from August to November 2016 and phase-2 from December 2016 to November 2018. All first-ever stroke cases in adults (aged ≥18 years) were included. The accredited social health activists (ASHAs) were trained to identify stroke patients in the community, who were later evaluated by a neurologist. Stroke characteristics were recorded, and the outcome was assessed at 6 months using modified Rankin scale (0-2, good outcome).

FINDINGS

During phase-2, 359 first-ever stroke patients and 102 stroke mimics were identified. The age-standardized incidence rate was 218.5/100,000 and 197∙6/100,000 for each year. Half (52.4%) of the patients reached health-care facilities within 4.5 h, yet none of them received thrombolysis. Very few patients (1.9%) utilized free government 108 ambulance service to reach a health-care facility. Out of 359 stroke cases, the majority (306, 85.23%) were reported by ASHAs and 14.77% were reported by other sources. Brain imaging was available in 127 (35.4%) patients, and 100 (78.7%) had ischemic stroke. The most common risk factor was hypertension (320, 89%) and drug abuse (154, 42.9%). At 6 months, 168 (64%) patients had a good outcome.

CONCLUSION

ASHAs were able to identify stroke patients in the villages. Despite high numbers of patients reaching health-care facilities within a window period, the hospitals were unable to provide acute stroke treatment like thrombolysis. The health-care system needs to be strengthened to improve stroke care.

Multicomponent Short-Term Training of ASHAs for Stroke Risk Factor Management in Rural India

Background Stroke is one of the leading causes of disability-adjusted life years and may be the leading cause of death in rural regions in India. We aim to train the ASHAs (Accredited Social Health activist) for nonpharmacological management of risk factors for secondary stroke prevention in rural India. We tested the hypothesis that focused, multicomponent, short-term training on secondary prevention of stroke enhances the knowledge of ASHAs about risk factor management.

Objectives To test the hypothesis that focused, multicomponent, short-term training on secondary prevention of stroke enhances the knowledge of ASHAs about risk factor management.

Materials and Methods This study is part of the ASSIST trial (Training ASHA to Assist in Secondary Stroke Prevention in Rural Population). The study design is quasi-experimental (pretest and posttest). Culturally appropriate and pragmatic training material was developed by the study team. Three focused group training sessions were conducted in Sidhwan Bet and Pakhowal blocks of Ludhiana district, Punjab.

Results A total of 274 ASHAs from 164 villages with mean ± SD age of 39.5 ± 7.6 years participated in the three training sessions. The perceived knowledge of stroke risk factors and blood pressure assessment was 67.5 ± 18.3% and 84.4 ± 16.7%, respectively. The objective baseline knowledge about stroke prevention and management among ASHAs was lower 58.7 ± 19.7% compared with perceived knowledge ( p = 0.04). This increased to 82.5 ± 16.36% ( p < 0.001) after the mop-up training after a mean of 191 days. More than 30% increment was seen in knowledge about the stroke symptoms (35.9%, p < 0.001), avoiding opium after stroke for treatment (39.5%, p < 0.001), causes of stroke (53.3%, p < 0.001), modifiable risk factors for stroke (45.4%, p < 0.001), and lifestyle modifications for stroke prevention (42.1%, p < 0.001).

Conclusions Focused group training can help enhance the knowledge of ASHAs about stroke prevention and management. ASHAs are also able to retain this complex multicomponent knowledge over a 6-month period. ASHA may be able to partake in reducing the secondary stroke burden in rural India.