Non-communicable diseases as a major contributor to deaths in 12 tribal districts in India

Background & objectives

Non-communicable diseases (NCDs) are the leading cause of death in India. Although studies have reported a high prevalence of NCD in tribal populations, there are limited data pertaining mortality due to NCDs. Therefore, in this study we estimated the proportion of deaths due to NCDs among 15 yr and older age group in tribal districts in India.

Methods

We conducted a community-based survey in 12 districts (one per State) with more than 50 per cent tribal population. Data were collected using a verbal autopsy tool from the family member of the deceased. The estimated sample size was 452 deaths per district. We obtained the list of deaths for the reference period of one year and updated it during the survey. The cause of death was assigned using the International Classification of Diseases-10 classification and analyzed the proportions of causes of death. The age-standardized death rate (ASRD) was also estimated.

Results

We surveyed 5292 deaths among those above 15 years of age. Overall, NCDs accounted for 66 per cent of the deaths, followed by infectious diseases (15%) and injuries (11%). Cardiovascular diseases were the leading cause of death in 10 of the 12 sites. In East Garo Hills (18%) and Lunglei (26%), neoplasms were the leading cause of death. ASRD due to NCD ranged from 426 in Kinnaur to 756 per 100,000 in East Garo Hills.

Interpretation & conclusions

The findings of this community-based survey suggested that NCDs were the leading cause of death among the tribal populations in India. It is hence suggested that control of NCDs should be one of the public health priorities for tribal districts in India.

Preparedness of primary & secondary care health facilities for the management of non-communicable diseases in tribal population across 12 districts in India

Background and objectives

Non-communicable diseases (NCDs) are highly prevalent in the tribal populations; however, there are limited data regarding health system preparedness to tackle NCDs among these populations. We estimated the availability of human resources, equipment, drugs, services and knowledge of doctors for NCD management in the selected tribal districts in India.

Methods

A cross-sectional survey was conducted in 12 districts (one from each State) with at least 50 per cent tribal population in Andaman and Nicobar Islands, Himachal Pradesh, Madhya Pradesh, Odisha and eight northeastern States. Primary health centres (PHCs), community health centres (CHCs) and district/sub-district hospitals (DHs) were surveyed and data on screening and treatment services, human resources, equipment, drugs and information systems indicators were collected and analysed. The data were presented as proportions.

Results

In the present study 177 facilities were surveyed, including 156 PHCs/CHCs and 21 DHs. DHs and the majority (82-96%) of the PHCs/CHCs provided outpatient treatment for diabetes and hypertension. Overall, 97 per cent of PHCs/CHCs had doctors, and 78 per cent had staff nurses. The availability of digital blood pressure monitors ranged from 35 to 43 per cent, and drugs were either not available or inadequate. Among 213 doctors, three-fourths knew the correct criteria for hypertension diagnosis, and a few correctly reported diabetes diagnosis criteria.

Interpretation & conclusions

The results of this study suggest that the health system of the studied tribal districts was not adequately prepared to manage NCDs. The key challenges included inadequately trained workforce and a lack of equipment and drugs. It is suggested that capacity building and, procurement and distribution of equipment, drugs and information systems to track NCD patients should be the key focus areas of national programmes.

Antifolate drug resistance: Novel mutations and haplotype distribution in dhps and dhfr from Northeast India

Malaria is a major public health concern in Northeast India with a preponderance of drug-resistant strains. Until recently the partner drug for artemisinin combination therapy (ACT) was sulphadoxine pyrimethamine (SP). Antifolate drug resistance has been associated with the mutations at dihydropteroate synthase (dhps) and dihydrofolatereductase (dhfr) genes. This study investigated antifolate drug resistance at the molecular level. A total of 249 fever cases from Arunachal Pradesh, NE India, were screened for malaria, and of these, 75 were found to be positive for Plasmodium falciparum. Samples were sequenced and analysed with the help of BioEdit and ClustalW. Three novel point mutations were found in the dhps gene with 10 haplotypes along with the already reported mutations. A single haplotype having quadruple mutation was found in the dhfr gene. The study reports higher degree of antifolate drug resistance as evidenced by the presence of multiple point mutations in dhps and dhfr genes. The findings of this study strongly discourage the use SP as a partner drug in ACT.

Alcohol use among school-going adolescent boys and girls in an industrial town of Assam, India

BACKGROUND

Some people in Northeast India prepare rice-based alcoholic drinks in the household. People use these drinks in religious and social functions, and these are taken even in the presence of parents and elders. Easy access to illicit substances in industrial towns and lack of social inhibition for intake of homemade alcohol might increase the vulnerability of youth to these habits.

OBJECTIVE

To estimate the prevalence of alcoholic drink user among school-going adolescent students in an industrial town of Assam.

MATERIALS AND METHODS

A cross-sectional survey was designed to collect the data using a predesigned questionnaire. Personal interview was conducted to collect the data about pattern of alcohol use, type of alcoholic drinks they use, duration, and information about parents and peer. Data were analyzed using Epi-info 17 and Statistical Package for Social Sciences-17.0 (Chicago, USA, SPSS Inc.).

RESULTS

About 36% out of 1285 students have tasted/used homemade alcoholic drinks (HADs) and 12.3% used commercially available alcoholic drinks (CADs). Significantly higher numbers (P < 0.001) of adolescent students (≥15 years) used CAD in comparison to children (<15 years). However, the number of younger students was higher in using HAD. Minimum age at first experience of CAD was 7 years and that of HAD was 4 years; the duration varied from 1 to 8 years and 1-15 years, respectively. Parent's behavior of taking tobacco and/or alcohol influenced the habit of their children. Father's habit was found to be associated with male offspring's habit of taking CAD. About 16% of the students used one or more substances along with alcohol.

CONCLUSION

High percentage of adolescents in the industrial town of Assam use alcoholic drinks with a male preponderance. They taste alcoholic drinks at a very young age. Parent's indulgence in taking tobacco, alcohol, or both was found to influence higher intake by their offspring.

Prevalence of lymphatic filariasis in a tea garden worker population of Dibrugarh (Assam), India after six rounds of mass drug administration

BACKGROUND & OBJECTIVES

Lymphatic filariasis (LF) is endemic in the state of Assam and mass drug administration (MDA) programme for LF elimination is being implemented in the state since 2004. A study on prevalence of microfilaria (mf), disease endemicity and vector infection was carried out in a tea garden population of Dibrugarh, Assam (India) to assess the effect of ongoing MDA programme on elimination of LF.

METHODS

Finger prick thick blood smears (20 mm3) were made from individuals aged ≥2 yr old during night blood survey in between 2000-0000 hrs during the period of November 2012 to February 2013. Blood smears were dehaemoglobinised, stained with Giemsa and examined under microscope for presence of mf. Indoor resting mosquitoes were collected during 0600-1000 hrs and female Culex quinquefasciatus were dissected and examined under microscope for larval forms of the parasite.

RESULTS

A total of 634 blood smears were collected and screened for mf and 47 (7.41%) individuals were found microfilaraemic, with predominance of males (74.5%). Highest mf rate (20.0%) was seen in the males of 30-39 yr age group while in females, age group of 10-19 yr recorded maximum mf rate (5.48%). Entomological collection and dissection of Cx. quinquefasciatus revealed presence of larval stages of the parasite and infection and infectivity rates recorded were 13.20 and 3.70%, respectively. Chronic clinical manifestations in the form of elephantiasis and hydrocele were recorded in 33 (5.73%) subjects of the 575 examined.

INTERPRETATION & CONCLUSION

Mass drug administration data showed six rounds of MDA with drug distribution coverage in between 63.42 and 95.93% in the study population. Out of 634 individuals examined 47 were found microfilaraemic giving an overall infection rate of 7.41%. Mosquito vector infection and infectivity rates were 13.20 and 3.70%, respectively. Presence of high mf rate, vector infectivity rate and clinical cases in the study population after six rounds of MDA warrants concerted efforts to be made for effective implementation and monitoring of MDA for success of LF elimination programme.

Genetic polymorphisms associated with sulphadoxine-pyrimethamine drug resistance among Plasmodium falciparum field isolates in malaria endemic areas of Assam

Background:

The emergence of antimalarial drug resistance malaria parasite is widespread in North eastern region of India. During January 2012-December 2013, we conducted active surveillance for detection of antifolate resistance-associated genetic polymorphisms in Plasmodium falciparum malaria parasite from different malaria endemic areas of Assam.

Materials and Methods:

A total of 281 field samples were collected from suspected malaria patients of which 106 malaria P. falciparum positive cases were detected in microscopic slide examination. A nested PCR was done for amplification of a 648 bp portion of the dhfr gene and 710 bp portion of the dhps gene.

Results:

Mutation analysis revealed existence of three different haplotypes of the P. falciparum dhfr gene of which ANRNI was highly prevalent (90%). Triple mutant haplotypes AIRNI (N51I + C59R + S108N) of the dhfr gene associated with pyrimethamine resistance were prevalent in Chirang district of Assam. Whereas, dhps mutation study revealed that triple mutant haplotype AGEAA (S436A + A437G + K540E) associated with Sulphadoxine resistance was found among 26% of P. falciparum field isolates. However, P. falciparum dhfr-dhps two locus mutation analysis showed that there were a total of nine dhfr-dhps genotypes.

Conclusion:

It was noticed that 93.62% (88/94) isolates had mutations in the sequences of both enzymes, which is an indication of prevalence of high grade of Sulphadoxine — pyrimethamine resistance in P. falciparum malaria parasites in Assam.

Microfilarial periodicity of Wuchereria bancrofti in Assam, Northeast India

BACKGROUND & OBJECTIVES

Wuchereria bancrofti has shown nocturnal periodicity in India and other endemic countries of the world except pacific regions where non-periodic or diurnal sub-periodic forms have been reported. Presence of sub-periodic form of W. bancrofti in Andaman and Nicobar Islands, India and a case report of sub- periodic form of W. bancrofti from Mysore, India provide basis for exploring the periodicity pattern of microfilaria of W. bancrofti prevalent in Assam, Northeastern region of India. State of Assam has unique geographical location as its Northeastern region shares international boundaries with Nepal, China, Bhutan, Myanmar and Bangladesh. Evolutionary association of W. bancrofti found in Assam is not known and possibility of its link with W. bancrofti form, prevalent in neighbouring countries may not be ruled out. Hence, this study was undertaken to know the microfilarial periodicity of W. bancrofti in Assam.

METHODS

Ten microfilaria positive adult male individuals having moderate to high microfilaraemia were selected. Informed written consent from each participant was obtained. The presence of microfilaria was observed at two hourly intervals over a period of 24 h using 50 μl of finger prick peripheral blood samples. Peripheral blood smears were processed, stained and examined under microscope and microfilaria counts were recorded.

RESULTS

Data collected were calculated and analyzed using modified statistical method, and the periodicity curve was prepared. Typical nocturnal periodicity was observed at a peak time of 0003 hrs with a periodicity index of 136.2.

INTERPRETATION & CONCLUSION

Analysis of the data revealed nocturnal periodicity of the W. bancrofti prevalent in the Assam with peak periodicity about one hour ahead of the other states in India. Findings will be helpful in evaluation and monitoring of ongoing MDA programme for elimination of LF in Assam.

Mitochondrial DNA-based genetic diversity of Anopheles nivipes in North East India

Malaria is a major public health problem in north-east India mainly transmitted by Anopheles baimai and An. minimus while Anopheles nivipes plays an important supportive role. The genetic diversity of An. nivipes in north-east India was investigated by employing two mitochondrial DNA markers namely NADH dehydrogenase 5 (ND5) and cytochrome oxidase sub unit II (COII). High genetic diversity in An. nivipes was observed by the detection of 16 haplotypes among 30 sequences of ND5 gene and 29 haplotypes among 29 COII sequences. Anopheles nivipes of north-east India was significantly differentiated genetically with that of neighboring South-east Asian An. nivipes as revealed by pairwise F_ST values of 0.127 (p < 0.01) and 0.044 (p < 0.001) for ND5 and COII genes, respectively, suggesting geographical barriers to gene flow in this species between the two geographical areas resulting in significant population structuring.

Larvicidal activity of few select indigenous plants of North East India against disease vector mosquitoes (Diptera: Culicidae)

Mosquitoes are the vectors of several life threatening diseases like dengue, malaria, Japanese encephalitis and lymphatic filariasis, which are widely present in the north-eastern states of India. Investigations on five local plants of north-east India, selected on the basis of their use by indigenous communities as fish poison, were carried out to study their mosquito larvicidal potential against Anopheles stephensi (malaria vector), Stegomyia aegypti (dengue vector) and Culex quinquefasciatus (lymphatic filariasis vector) mosquitoes. Crude Petroleum ether extracts of the roots of three plants viz. Derris elliptica, Linostoma decandrum and Croton tiglium were found to have remarkable larvicidal activity; D. elliptica extract was the most effective and with LC50 value of 0.307 μg/ml its activity was superior to propoxur, the standard synthetic larvicide. Half-life of larvicidal activity of D. elliptica and L. decandrum extracts ranged from 2-4 days.

Faunal richness and the checklist of Indian mosquitoes (Diptera: Culicidae)

A review of published studies revealed that the Indian mosquito fauna comprises 393 species in 49 genera and 41 subgenera. The subfamily Anophelinae contains 61 species in one genus followed by Culicinae with 332 species in 11 tribes and 48 genera. The tribe Aedini (subfamily Culicinae) contains the highest number of species (176 species in 33 genera and two groups of incertae sedis; i.e., “Aedes” sensu auctorum and “Ochlerotatus” sensu auctorum). With the recent taxonomic changes in tribe Aedini, the Indian mosquito genera have gone up from 22 to 49. Changes to the Indian Aedini fauna subsequent to the reclassification of tribe Aedini are discussed. A total of 31 species are currently recognized in India for transmitting various mosquito-borne agents of human diseases. A checklist for the Indian mosquito species is presented and the need for a comprehensive study is emphasized.

Forecasting Japanese encephalitis incidence from historical morbidity patterns: Statistical analysis with 27 years of observation in Assam, India

BACKGROUND & OBJECTIVES

Japanese encephalitis (JE) is one of the dreaded mosquito-borne viral diseases mostly prevalent in south Asian countries including India. Early warning of the disease in terms of disease intensity is crucial for taking adequate and appropriate intervention measures. The present study was carried out in Dibrugarh district in the state of Assam located in the northeastern region of India to assess the accuracy of selected forecasting methods based on historical morbidity patterns of JE incidence during the past 22 years (1985-2006).

METHODS

Four selected forecasting methods, viz. seasonal average (SA), seasonal adjustment with last three observations (SAT), modified method adjusting long-term and cyclic trend (MSAT), and autoregressive integrated moving average (ARIMA) have been employed to assess the accuracy of each of the forecasting methods. The forecasting methods were validated for five consecutive years from 2007-2012 and accuracy of each method has been assessed.

RESULTS

The forecasting method utilising seasonal adjustment with long-term and cyclic trend emerged as best forecasting method among the four selected forecasting methods and outperformed the even statistically more advanced ARIMA method. Peak of the disease incidence could effectively be predicted with all the methods, but there are significant variations in magnitude of forecast errors among the selected methods. As expected, variation in forecasts at primary health centre (PHC) level is wide as compared to that of district level forecasts.

INTERPRETATION & CONCLUSION

The study showed that adopted forecasting techniques could reasonably forecast the intensity of JE cases at PHC level without considering the external variables. The results indicate that the understanding of long-term and cyclic trend of the disease intensity will improve the accuracy of the forecasts, but there is a need for making the forecast models more robust to explain sudden variation in the disease intensity with detail analysis of parasite and host population dynamics.

Genotyping of chloroquine resistant Plasmodium falciparum in wild caught Anopheles minimus mosquitoes in a malaria endemic area of Assam, India

We validated the feasibility of using Plasmodium falciparum, the human malaria parasite, DNA present in wild caught vector mosquitoes for the characterization of chloroquine resistance status. House frequenting mosquitoes belonging to Anopheles minimus complex were collected from human dwellings in a malaria endemic area of Assam, Northeast India and DNA was extracted from the head-thorax region of individual mosquitoes. Anopheles minimus complex mosquitoes were identified to species level and screened for the presence of Plasmodium sp. using molecular tools. Nested PCR-RFLP method was used for genotyping of P. falciparum based on K76T mutation in the chloroquine resistance transporter (pfcrt) gene. Three of the 27 wild caught An. minimus mosquitoes were harbouring P. falciparum sporozoites (positivity 11.1%) and all 3 were had 76T mutation in the pfcrt gene, indicating chloroquine resistance. The approach of characterizing antimalarial resistance of malaria parasite in vector mosquitoes can potentially be used as a surveillance tool for monitoring transmission of antimalarial drug resistant parasite strains in the community.

Genetic analyses of ribosomal loci of Anopheles minimus species from north east India

Anopheles minimus is one of the major vectors for transmission of malaria disease in north eastern (NE) region of India. The minimus species complex of Minimus subgroup of Myzomyia series of anophelines were studied in malaria affected states--Assam and Arunachal Pradesh (AP) of NE India. Ribosomal DNA markers--second internal transcribed spacer (ITS2) and third domain (D3) of 28S gene were used to characterize An. minimus species. Sequence homogeneity was observed in D3 sequences of An.minimus specimens throughout both the states. However, a transversion in ITS2 sequence of single specimen collected from Assam-Meghalaya border areas illustrates possibility of intra population polymorphism in ITS2 sequence within the geographical region.

Dengue outbreak in an Indo-Myanmar boarder area: epidemiological aspects and risk factors

During October 2007, a large outbreak of suspected dengue fever (DF) was reported in Moreh township, Manipur: the first widespread outbreak in Northeast India. A cross sectional study was carried out in Moreh. The information on outbreak was collected and then described in time, place and person characteristics to arrive at aetiological hypotheses. Two hundred and eighty two serum samples were collected. Ninety one samples were reported positive for acute infection with dengue virus. Co-circulation of all the four dengue virus serotypes (1-4) and concurrent infection of 2 & 3, 1 & 3, and 1 & 4 serotypes was found. Predominant clinical features of the patients were fever (100%), headache (39%), vomiting (9.8%) and joint pain (4.16%). Haemorrhagic manifestation was recorded in one patient who subsequently died. Entomological surveys revealed profuse breeding of Aedes mosquitoes in all the affected municipal wards with high HI (37.5-71.43%), CI (53.84-86.95%) and BI (80-208.33%). Presence of IgM antibody, co-circulation of all the serotypes and concurrent infection with more than one serotype in the same individual confirmed the outbreak due to dengue virus infection. Preventive and control measures undertaken following the epidemiological investigation helped in controlling the outbreak.

Role of the prevalentAnophelesspecies in the transmission ofPlasmodium falciparumandP. vivaxin Assam state, north–eastern India

In north-eastern India, Anopheles minimus, An. dirus and An. fluviatilis are considered the three major vectors of the parasites causing human malaria. The role in transmission of the other Anopheles species present in this region is not, however, very clear. To examine the vectorial role of the more common anopheline mosquitoes, the heads and thoraces of 4126 female Anopheles belonging to 16 species (collected using miniature light traps set in human dwellings in a foothill village in the Jorhat district of Assam state) were tested, in ELISA, for the circumsporozoite proteins (CSP) of Plasmodium falciparum or the VK-210 and VK-247 polymorphs of P. vivax. Sixty-five pools of head-thorax homogenates, representing 10 different species of Anopheles, were found reactive, giving an overall minimum prevalence of infection (MPI) of 1.58%, with a 95% confidence interval (CI) of 1.21%-2.0%. Among the CSP-reactive pools of mosquitoes, 31% were positive only for P. falciparum, 45% only for P. vivax VK 247, 6% only for P. vivax VK 210, and 18% for both P. falciparum and P. vivax VK 247. The results indicate that not only the proven vector, An. minimus s.l. (MPI = 0.71%), but also several species of Anopheles previously considered unimportant in the epidemiology of malaria, especially An. aconitus (MPI = 3.95%), An. annularis (MPI = 5.8%), the An. hyrcanus group (MPI = 0.48%), An. kochi (MPI = 1.28%), the An. philippinensis-nivipes complex (MPI = 0.94%), and An. vagus (MPI = 3.87%), are important vectors in the foothills of Assam.

Direct and early detection of Mycobacterium tuberculosis complex and rifampicin resistance from sputum smears

SETTING

Four district DOTS centres in Sikkim, India.

OBJECTIVE

Direct and early detection of Mycobacterium tuberculosis complex and rifampicin (RMP) susceptibility using the INNO-LiPA Rif.TB assay.

DESIGN

DNA was extracted from 44 inactivated acid-fast bacilli-positive sputum slides using the Gen Elute bacterial genomic DNA kit. Eluted DNA were ethanol precipitated. The LiPA kit detected RMP susceptibility by detection of mutation in the 81 base pair (bp) rpoB gene. Culture of sputum from the same person was used for drug susceptibility testing for RMP using the proportion method.

RESULTS

Amplification of 88.6% (39 slides) was achieved from DNA extracted using kits (66.7% for 1+, 81.8% for 2+ and 100% for 3+ slides). Hybridisation using the LiPA kit was applied to 31 amplified products. There was a concordance of 96.8% (24 RMP-resistant and 6 RMP-susceptible samples) and discordance of 3.2% (one sample resistant using the proportion method and susceptible on LiPA) between LiPA and the proportion method.

CONCLUSION

LiPA proved useful on DNA extracted from smear-positive slides. Appropriate treatment regimen could be decided early. Slide smear preparation could replace sputum transport in cetylpyridinium chloride, reducing biohazard and thereby controlling the transmission of multidrug-resistant tuberculosis in the community.

Syphilis infection among female sex workers in Nagaland, Northeast India: analysing their vulnerability to the infection

This paper describes the sex work characteristics and factors associated with syphilis among female sex workers (FSWs) in Dimapur district of high HIV prevalence Indian state, Nagaland. The study recruited 426 FSWs in 2006 using respondent-driven sampling. The prevalence of syphilis was 21.1% and HIV prevalence was 11.7%. Approximately half were under 25 years of age. Clients were solicited mainly in public places (32.7%), while hotels/lodges/rented rooms were the most common places of entertainment (57.2%). Condom use during the last sex was 36.5% with occasional and 27% with regular clients. Being married, being widowed/divorced/separated, being illiterate or having a history of drug use increased the likelihood of syphilis infection. Entertaining clients in bars/booze joints decreased the probability of syphilis. FSWs who moved between soliciting in public places or bars/booze joints and then entertaining in hotels/lodges/rented rooms had a higher vulnerability to syphilis. In summary, we found that the vulnerability to syphilis among mostly young FSWs in Dimapur varied according to their sex work characteristics, marital and educational status and drug use habits. They may be more vulnerable to HIV and sexually transmitted infections (HIV/STIs) due to the low rate of condom use. The findings have direct implications for HIV/STI prevention programmes in Northeast India.

Survey of new mosquito species of Meghalaya, India

A study on mosquitoes in parts of Meghalaya revealed the presence of 64 species of mosquitoes under 10 genera. In monsoon (June to October) and post-monsoon (November to May) survey, 42 and 48 species of mosquitoes were detected, respectivily. Higher species diversity was found at lower elevations (up to 1050 m). Anopheles peditaeniatus, An. sinensis, Aedes vexans, Ae. nigrostriatus, Ae. annandalei, Culex. fuscocephala, Cx. pseudovishnui, Cx. murrelli, Cx. brevipalpis, Coquillettidia novochracea, Lutzia halifaxii, Malaya genurostris, Ml. jacobsoni, Tripteroides aranoides, Toxorhynchites minimus, Uranotaenia campestris, Ur. edwardsi and Ur. testaceae which were never reported earlier from Meghalaya state were detected in the present study and the findings were discussed with previously published reports from the state.

Anopheles (Cellia) maculatus group: its spatial distribution and molecular characterization of member species in north-east India

Anopheles (Cellia) maculatus is considered a group of at least nine formally named species. Faced with the difficulty of correct morphological identification due to overlapping characters, several member species of the An. maculatus group are known to play important role in malaria transmission in the Oriental region. Current assemblage, distribution and vectorial importance of the member species within the Maculatus group is far from clear in the north-eastern region of India. Our study encompassing 410 individuals, collected from 67 geo-referenced spots across the eight north-east Indian states, identified the presence of 6 member species of the Maculatus group using the molecular tools. Anopheles dravidicus and Anopheles rampae were documented for the first time in this part of India with latter forming the new country record. While Anopheles pseudowillmori (59.5%) and An. maculatus (32%) were widely available species in most of the north-eastern states, restricted distribution of Anopheles willmori to Nagaland and that of Anopheles sawadwongporni and An. rampae to Mizoram state was noted. None of the species was found positive for human malaria parasite. While no intraspecific differences existed in the sequences of second internal transcribed spacer (ITS2) region of ribosomal DNA (r-DNA) of the member species of the Maculatus group within north-east India, few differences were detected in the sequences of An. dravidicus, An. maculatus and An. pseudowillmori from north-east India with species from the neighbouring countries.

Hypertension subtypes and angiotensin converting enzyme (ACE) gene polymorphism in Indian population

OBJECTIVE

To find out the association of angiotensin converting enzyme (ACE) gene polymorphism with hypertension subtypes in a population from India.

METHODS

Consecutive subjects of either sex, aged > or =18 years attending in temporary field clinics arranged in various localities of Assam and Mizoram were interviewed to record information about socio-demographic characteristics, alcohol consumption and smoking. Three readings of blood pressure, height and weight of all subjects were measured. Hypertension and its subtypes were defined as per JNC-VI criteria. Fasting venous blood samples were collected to estimate blood glucose level and to extract genomic DNA followed by PCR analysis for ACE gene polymorphism.

RESULTS

A total of 916 (male=465, female=451) consecutive subjects comprising of 407 (44.4%) hypertensive subjects and 509 (55.6%) normotensive controls were included in the study. Of the hypertensive subjects, majority (69.0%) had systolic diastolic hypertension with male predominance (70.3% vs. 67.6%) which was followed by isolated diastolic hypertension (16.7%) and isolated systolic hypertension (14.3%). The predominant ACE genotype was Ins/Ins (50.0%) and Del/Del genotype showed lowest prevalence (11.4%). After adjusting confounding variables, the Del/Del genotype revealed significant association with isolated systolic hypertension.

CONCLUSION

Del/Del polymorphism of ACE gene showed significant association with ISH in our study population.

Mycotic corneal ulcers in upper Assam

Purpose:

To study the association of various risk factors and epidemiological variables of mycotic keratitis treated at a tertiary referral hospital of upper Assam.

Materials and Methods:

In this hospital-based prospective study a total of 310 consecutive corneal ulcer cases attending the ophthalmology outpatient department of Assam Medical College were enrolled between April 2007 and March 2009. After clinical and slit-lamp biomicroscopic examination in all suspected cases, smears and culture examination for fungus was done to establish the etiology. Demographic information and associated probable risk factors of individual cases were noted in a predesigned questionnaire.

Results:

In 188 (60.6%) cases fungal etiology could be established. Out of them 67.6% were males. The most commonly affected age group was 41-50 years (25.5%). The maximum (23.4%) cases were reported during the paddy harvesting season in Assam (January and February). Fungal element could be demonstrated in 65.2% cases in direct potassium hydroxide (KOH) mount. The commonest predisposing factor was corneal injury (74.5%). While diabetes was a significant systemic predisposing factor in mixed bacterial and fungal infections in 11.1% cases, blocked naso-lacrimal duct was the local predisposing factor in 11.1% of cases. Fusarium solani (25%) was the commonest isolate followed by Aspergillus species (19%), Curvularia species (18.5%) and Penicillium species (15.2%). Yeasts were isolated in 2.7% (n=5) cases.

Conclusions:

Ocular trauma was the commonest cause of fungal corneal ulcer in Assam and Fusarium solani was the commonest species responsible for it. Most of the mycotic ulcer cases come from rural areas including the tea gardens.

Determinants for the retreatment groups of pulmonary tuberculosis patients treated in a DOTS programme in Sikkim, India

OBJECTIVE

To assess knowledge, attitude and different health-seeking behaviours among 250 cured and 250 category-II tuberculosis patients.

METHODS

A case-control study was conducted in different health settings in Sikkim, a part of the Indian continent. A questionnaire was filled for the purpose.

RESULTS

Results showed significant differences in overcrowding, smoking and alcohol intake. There was a general unawareness with the disease and its treatment between the two groups. 45% of the respondents reported that tuberculosis is caused by germs. 81.4% stated that tuberculosis presents only as cough. 94.8% of the case group and 90.8% of the control group stated that it is a transmissible disease. Sharing food with tuberculosis patients (64% of case group, 55% of the control group; p < 0.05), inadequate diet (16.4% of case group, 9.6% of the control group; p < 0.03) were mentioned as modes of transmission. Sixty six per cent of the case group and 56.8% of the control group mentioned the use of DOTS for prevention and control (p < 0.05). Sixty three per cent of the control group regarded tuberculosis as a life threatening condition (p < 0.00) [(adjusted OR = 2.04, (95% CI: 1.43, 2.93)]. Tuberculosis was considered as a completely curable disease by 96.4% of the case group (p < 0.05). 40.6% of the respondents agreed to be in contact with a tuberculosis infected person. 64% of the retreatment group discontinued their treatment due to frequent travelling for work.

CONCLUSION

The study revealed lack of knowledge, positive attitude and inappropriate health seeking behaviours among of the tuberculosis patients, irrespective of their categorization.

Molecular epidemiology of measles in India, 2005-2010

Measles is a childhood disease that causes great morbidity and mortality in India and worldwide. Because measles surveillance in India is in its infancy, there is a paucity of countrywide data on circulating Measles virus genotypes. This study was conducted in 21 of 28 States and 2 of 7 Union Territories of India by MeaslesNetIndia, a national network of 27 centers and sentinel practitioners. MeaslesNetIndia investigated 52 measles outbreaks in geographically representative areas from 2005 through June 2010. All outbreaks were serologically confirmed by detection of antimeasles virus immunoglobulin M (IgM) antibodies in serum or oral fluid samples. Molecular studies, using World Health Organization (WHO)-recommended protocols obtained 203 N-gene, 40 H-gene, and 4 M-gene sequences during this period. Measles genotypes D4, D7, and D8 were found to be circulating in various parts of India during the study period. Further phylogenetic analysis revealed 4 lineages of Indian D8 genotypes: D8a, D8b, D8c, and D8d. This study generated a large, countrywide sequence database that can form the baseline for future molecular studies on measles virus transmission pathways in India. This study has created support and capabilities for countrywide measles molecular surveillance that must be carried forward.

Anaemia & expression levels of CD35, CD55 & CD59 on red blood cells in Plasmodium falciparum malaria patients from India

BACKGROUND & OBJECTIVES

Severe anaemia in Plasmodium falciparum (Pf) associated malaria is a leading cause of death despite low levels of parasitaemia. In an effort to understand the pathogenesis of anaemia we studied expression level of RBC complement regulatory proteins, CR1 (CD35), CD55 and CD59 with haemoglobin status in a group of malaria cases from Assam, Goa and Chennai, and in healthy controls.

METHODS

Flowcytometry was used to study expression of CR1, CD55 and CD59 in 50 Pf cases and 30 normal healthy volunteers. Giemsa stained thick and thin blood films were used for microscopic detection and identification of malarial parasites and parasite count.

RESULTS

No correlation was found between degree of expression of RBC surface receptors CR1, CD55 and CD59 with haemoglobin level. However, expression of CD55 was less in malaria cases than in healthy controls.

INTERPRETATION & CONCLUSIONS

The present findings indicate that malaria infection changes the expression profile of complement regulatory protein CD55 irrespective of severity status of anaemia. Further studies are needed to explore the pathophysiology of anaemia in malaria cases in Assam where expression of RBC complement receptors appears to be low even in normal healthy population.

Malaria control in a forest fringe area of Assam, India: a pilot study

A study was conducted to evaluate the preventive efficacy of insecticide-treated mosquito nets (ITMNs) and mosquito repellent (MR) in a malaria-endemic foothill area of Assam, India, with forest ecosystem. During the first year, a survey was conducted in four demarcated sectors (A-D) to observe the malaria endemicity and vector prevalence patterns before implementing intervention measures. All four sectors were endemic for malaria. The prevalence of established malaria vectors such as Anopheles dirus, A. minimus and A. philippinensis was observed. During the second year, intervention measures were implemented in the four sectors as follows: A, ITMN + MR; B, ITMN; C, MR; D, no intervention. The most effective intervention was in sector A, followed by sectors B and C. Sectors A and B exhibited significantly higher (P < 0.001) malaria protective efficacy during both the first and second years of intervention compared with sector D. The total vector population in the three intervention sectors decreased significantly compared with that of the non-intervention one. Information-education-communication activities motivated the residents to participate actively in the intervention programme. The finding could be an effective model for containment of high malaria morbidity in inaccessible forest fringe areas of the northeastern region of India.

First evidence of chikungunya virus infection in Assam, Northeast India

During June-September 2008, an illness characterized by fever, headache and joint pain was reported in Assam state, northeast India. It presented characteristic features resembling chikungunya or dengue virus infection based on clinical symptoms. Dengue and chikungunya IgM antibody was detected in 10.0% (28/280) and 3.6% (10/280) patients respectively. The chikungunya positive patients did not travel to and from any endemic region confirming indigenous transmission. Persistent arthralgia and hearing loss has been observed in a recovered patient. Entomological surveys revealed the presence of vectors viz. Aedes aegypti and Aedes albopictus. This is the maiden report of chikungunya occurrence in Northeast India.

Molecular evidence for the involvement of Anopheles nivipes (Diptera: Culicidae) in the transmission of Plasmodium falciparum in north-eastern India

The Anopheles philippinensis and An. nivipes mosquitoes that form part of the An. annularis species group are morphologically very similar and difficult to differentiate as adults. In consequence, researchers generally refer to all field-collected individuals of these species simply as the An. philippinensis-nivipes species complex. Although this species complex is understood to play a role in the transmission of parasites causing human malaria in north-eastern India, the identity of the exact species involved, and the relative importance of the local An. philippinensis and An. nivipes, are far from clear. To settle this issue, house-frequenting female adults of the An. philippinensis-nivipes species complex were collected from 23 localities in the six north-eastern states, identified to species (using an allele-specific PCR to explore the insects' ribosomal-DNA internal-transcribed-spacer-2 sequences) and checked for Plasmodium DNA (using a nested PCR based on the 18S subunit of the parasite's ribosomal DNA). Of the 337 females of the An. philippinensis-nivipes species complex that were investigated, 275 were identified as An. nivipes and 62 as An. philippinensis. Malarial infection was detected in the heads/thoraces of just two specimens, with P. falciparum DNA detected in one An. nivipes from Nagaland state and one An. nivipes from Assam state. These results provide unambiguous evidence of the presence of both An. philippinensis and An. nivipes in the north-eastern region of India and the involvement of An. nivipes in transmitting P. falciparum in this area.

Population-specific left ventricular hypertrophy in three groups from the northeastern region of India

BACKGROUND

People living in the hills are continuously exposed to strenuous physical activity for their day-to-day work. Besides hypertension, left ventricular hypertrophy in different populations may be related to continuous physical activity.

METHODS

Electrocardiogram, blood pressure and sociodemographic information of 12 252 subjects > or = 30 years of age from three different population groups living in Mizoram (hilly) and Assam (plain) were recorded. Of them, 8058 were from Mizoram and 3180 and 1014 were Indigenous Assamese and tea garden workers of Assam.

RESULTS

Among the subjects from Mizoram the percentage of smokers (41.9%), mean (SD) BMI (21.9 [3.8]) and waist-hip ratio (0.87 [0.02]) were significantly higher than in those from other groups. Tea garden workers had a higher mean systolic blood pressure (145.2 [25.7]) and diastolic blood pressure (87.6 [13.6]). The prevalence of left ventricular hypertrophy was highest among tea garden workers (16.5%) followed by people from Mizoram (3.7%) and the indigenous Assamese (2%) people. In spite of a significantly higher prevalence of hypertension among the indigenous Assamese community than among those from Mizoram, left ventricular hypertrophy was found to be lower in the former.

CONCLUSION

High prevalence of left ventricular hypertrophy among tea garden workers was possibly related to a higher prevalence of hypertension but the higher prevalence of left ventricular hypertrophy among people from Mizoram might be related to more physical activity.

Mosquito biodiversity of Dibru-Saikhowa biosphere reserve in Assam, India

Entomological surveys were conducted for three consecutive years in core and buffer zone of the Dibru-Saikhowa biosphere reserve in pre monsoon, monsoon and post-monsoon seasons. A total of 52 species of mosquitoes under eleven genera have been detected. The genus Anopheles (18 species) was the predominant followed by Culex, Aedes, Mansonia, Armigeres, Mimomyia, Ochlerostatus, Malaya, Toxorhynchites, Ficalbia and Aedeomyia. The buffer zone of the forest reserve where human habitations are there exhibited the presence of maximum number of species (49 species under 10 genera) in comparison to core zone (42 species under 10 genera). In buffer zone, maximum numbers of species (38) were recorded in monsoon season followed by post- monsoon (35 species) and Pre-monsoon season (34 species). Whereas in core zone, maximum number of species were collected in post monsoon season followed by pre monsoon season and monsoon season. In Core and buffer zone, the maximum species were recorded from the ground pool habitat and slow flowing stream respectively. Among the disease vectors, the potential Japanese encephalitis vectors incriminated in India were very much prevalent. This study provides the list of available mosquito species recorded for the first time in the Dibru-Saikhowa biosphere reserve.

Atypical cutaneous lesions of Penicillium marneffei infection as a manifestation of the immune reconstitution inflammatory syndrome after highly active antiretroviral therapy

Penicillium marneffei infections normally manifest as molluscum contagiosum like skin lesion in HIV-infected persons. We report a case with verrucous lesions over nose and face due to Penicillium marneffei infection after HAART treatment. A 28-year-old man presented, after two weeks of HAART treatment, with multiple erythematous, scaly, papules and nodules with central necrosis predominantly in face and both extremities and scrotum. Microbiological investigations confirmed the diagnosis of Penicillium marneffei infection. This is perhaps the first case report with such manifestation due to Penicillium marneffei infection.

A novel HBV recombinant (genotype I) similar to Vietnam/Laos in a primitive tribe in eastern India

Genotyping of 20 strains of Hepatitis B virus (HBV) from the Idu Mishmi primitive tribe of northeast India identified multiple genotypes and the presence of a unique cluster grouping with strains from Vietnam and Laos identified as novel recombinants/genotype I. Sequence analysis (similarity and bootscan plots) of three complete HBV genomes from the tribe provided evidence of recombination. Phylogenetic analyses supported recombination between genotypes A, G and C. The Pre-S gene between nt 2943 and 397 was clearly of genotype A origin, whereas nt 397-1397 represented genotype G and nt 1397-2943 represented genotype C. Percentage divergence from genotypes B, D, E, F, G and H varied from 9.2 +/- 0.45% to 13.8 +/- 0.53%, whereas genotype A and C differed by 7.9 +/- 0.42% and 7.4 +/- 0.39% respectively. The identification of similar recombinant viruses in three countries, especially in a primitive tribe with no contact with the outside world suggests that these viruses do not represent recent recombination events, but circulation of closely related viruses highly divergent from known HBV genotypes and should be classified as members of genotype 'I'.

An updated checklist of species of Aedes and Verrallina of northeastern India

A mosquito faunistic survey conducted during 1999-2005 in 7 different states of the northeastern (NE) region of India revealed that the region is very rich in mosquito fauna, particularly of the genus Aedes. From the present survey and earlier published reports, a total of 48 species of Aedes and a related genus Verrallina were recorded. The state of Assam contributed the highest number of species compared to the other 6 states, namely Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, and Tripura. Larvae of 46 species were collected from 16 different habitats and for some species the habitats were species specific. The known dengue vectors, Aedes aegypti and Ae. albopictus, were recorded from all 7 states, although Ae. aegypti was not known earlier from Mizoram, Nagaland, and Tripura states. Aedes albotaeniatus was a new addition to the Aedes fauna of the region.

Spatial distribution and r-DNA second internal transcribed spacer characterization of Anopheles dirus (Diptera: Culicidae) complex species in north-east India

The identity and distribution of the prevalent member species of the Anopheles dirus complex mosquitoes in the north-eastern region of India was investigated in a cross-sectional study. We altogether collected 267 individuals of An. dirus s.l. from 27 forested/forest fringed locations spread across the seven north-eastern states, identified the species using a ribosomal DNA (r-DNA) second internal transcribed spacer (ITS2) based allele specific polymerase chain reaction (ASPCR) method and sequenced the ITS2 locus in a sub set of mosquitoes. An. baimaii was identified as the main, almost exclusive (266/267), species of the Dirus complex throughout the north-east India with no intraspecific variation in the 479 base pair long ITS2 sequences in 59 of the 60 individuals sequenced. Ribosomal DNA of one individual from Assam state did not amplify in the ASPCR, possessed 786 base pair long ITS2 sequence and showed 99.7% similarity with the sequence of An. dirus species D (An. baimaii) from Yunnan province of China, later referred to as species X of the Dirus complex. These observations suggest the presence of another, possibly the new, species of the Dirus complex, sympatric with An. baimaii, in Assam warranting investigations on its distribution, biology and role in human malaria transmission in north-east India.

Contribution of germ line BRCA2 sequence alterations to risk of familial esophageal cancer in a high-risk area of India

The incidence of esophageal squamous cell carcinoma (ESCC) is very high in the northeast region of India. An earlier study from China and Iran suggested that mutations in BRCA2 gene may play a role in the etiology of familial ESCC. However, the frequency of BRCA2 gene germ line mutations and its contribution to risk of familial aggregation of ESCC in high-risk region of India are not known. In the current study of 317 cases of esophageal cancer, 92 (29%) cases had a family history of esophageal and/or other cancers. Of these 92 patients, 45 (49%) patients had a family history of esophageal cancer. The risk of developing esophageal cancer was higher in cases where family history showed occurrence of cancers in first-degree relatives (odds ratio [OR]: 3.1; confidence interval [CI]: 1.9-5.3) than in second-degree relatives (OR: 1.3; CI: 0.25-3.2). Moreover, the risk of developing esophageal cancer was higher in subjects whose predegree suffered from esophageal cancer (OR: 2.4; CI: 1.1-4.1) than from any other cancers (OR: 1.1; CI: 0.32-3.3). The subjects with family history of cancer were more likely to develop ESCC if they were tobacco chewers (OR: 4.2; CI: 2.1-5.8) and betel quid users (OR: 3.6; CI: 1.8-4.6). Screening for mutations of the BRCA2 gene in the germ line DNA was carried out for 20 familial and 80 nonfamilial ESCC patients. One hundred unrelated healthy controls from the same population were included in this study. Nonsynonymous variants in exon 18 (K2729N) and exon 27 (I3412V) of BRCA2 gene were found in 3 of 20 patients with familial ESCC. No sequence alterations were found in 80 nonfamilial ESCC cases (P=0.01) and 100 healthy controls (P=0.0037), suggesting that germ line BRCA2 gene mutation may play a role in familial aggregation of ESCC in high-risk region of India.