Development of a community orientation program (COP) as a community-based medical education method for undergraduate medical students: an experience from India

BACKGROUND

Intra-regional cultural and linguistic differences are common in low- and middle-income countries. To sensitise undergraduate medical students to the social and contextual determinants of health to achieve the 'health for all' goal, these countries must focus on innovative teaching methods. The early introduction of a Community Orientation Program (COP) as a Community-based Medical Education (CBME) method could be a game changing strategy. In this paper the methods, evaluation, and implication of the COP in an Indian setting are described.

METHODS

The curriculum of the COP was developed based on the analysis, design, development, implementation, and evaluation (ADDIE) model for educational intervention. In this learner-centric and supervised educational program, the key aim was to focus on developing students' communication skills, observation power and enhancing their motivation for learning through collaborative learning. To meet the objectives of the COP, a situated learning model under the constructivism theory was adopted.

RESULTS

Between 2016 and 2019, 557 students were trained through the COP by visiting more than 1300 households in ten villages. To supplement the students' observations in the community, more than 150 small group discussions, a health education programme for the community and summary presentations were conducted. The students' feedback indicated the need to improve the clinical examinations demonstration quality and increase the number of instruments for clinical examinations. More than 80% of students felt that the program would assist them to improve their communication skills, their understanding of the various socio-demographic factors associated with the common diseases, and it will enable them to respect the local culture during their clinical practice.

CONCLUSIONS

Early initiation of the COP as a CBME method in the undergraduate medical curriculum in an Indian setting has shown promising results. Further evidence is required to adopt such a program routinely for under-graduate medical teaching in the low- and middle- income settings.

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.

Morbidity profile of children from birth to 18 years of age referred for intervention to the district early intervention centre in a District Hospital, Andhra Pradesh

Background

The "Child Health Screening and Early Intervention Services" program aims at early detection and management of the four dimensions prevalent in children-defects at birth, diseases in children, deficiency conditions, and developmental delays, including disabilities.

Objective

The objective of the study was to assess the morbidity profile of children from birth to 18 years of age screened in the district early intervention center (DEIC).

Methods

A record-based descriptive study was done in the DEIC in Chittoor, Andhra Pradesh. The data were retrieved for 1-year from April 2017 to March 2018 into the excel sheet, and the combined master sheet was prepared for analysis. The analysis was done with SPSS 21.0 Version.

Results

A total of 10571 children were screened and referred to the DEIC during the period. Out of them, 5679 (53.7%) were male and 4892 (46.3%) were female. Among all the four types of morbidities screened, majority 4847 (45.9%) were having the childhood diseases, 4177 (39.5%) had developmental delays including disabilities, 1067 (10.1%) had different deficiencies, and 361 (3.4%) had birth defects. Among the adolescent health issues, 119 (1.1%) were screened and sent for the early intervention to the district hospital.

Conclusions

A huge number of children were screened and referred to the DEIC every year for intervention. The health sector has to focus more on the resources like workforce, training of peripheral health workers at regular intervals about the different morbidities screened, that would help in identifying the morbidities at the earliest possible time and receive the intervention at the best center.

A study on prevalence of depression and associated risk factors among elderly in a rural block of Tamil Nadu

Background

Depression among elderly is an important public health problem responsible for considerable morbidity and disability. Causes of depression are multifactorial and often preventable. As there was dearth of community studies in Tamil Nadu, the present study was undertaken.

Objectives

The objective of this study is to estimate the prevalence of depression and to assess the factors which are associated with depression among elderly.

Methods

A cross-sectional study was done from July 2014 to July 2015 among elderly in Kattankulathur block with a sample size of 690 by cluster sampling method. House-to-house interview was conducted using a predesigned, pre-tested questionnaire, and depression was assessed using geriatric depression scale-30. Data were analyzed using SPSS version 20 (Trial). The statistical tests used were proportions, Chi-square test. P<0.05 was considered to be statistically significant.

Results

The overall prevalence of depression was 35.5% (95% confidence interval: 31.9%-39.0%). Sociodemographic factors such as female sex, nuclear family, being widowed, unemployed status, low socioeconomic status, financially dependent, medical factors such as cardiac disease, visual impairment, arthritis, anemia, life events such as conflicts in family, death of the family member or close relative, and illness of self/family member were significantly associated with depression (P < 0.05).

Conclusions

More strength of association for depression was seen with low socioeconomic status, nuclear family, low-intensity work, conflicts in the family, death of family members using multiple logistic regression. These findings show the need for proper care by the family members and counseling for the elderly which are of much importance in preventing depression.

A Community-Based Case-Control Study on the Risk of Fall among the Elderly in Rural Kattankulathur Block, Tamil Nadu

Background:

Approaching 100 million in number, India has the second largest population of elderly people after China. India's elderly are growing faster than the general population. By the year 2050, the number of elderly population is expected to increase to 323 million. In the geriatric population, fall is the leading cause of nonfatal injuries and hospital admissions. Falls account for 40% of all injury deaths, and the death rates are the highest among 60 years and above in all the regions of the world.

Objectives:

The objective of this study is to assess the factors associated with the risk of fall among the elderly of 60 years and older in rural Kattankulathur block.

Materials and Methods:

The study is a community-based case–control design among the elders in a rural setting. Those who had fallen in the past 12 months were selected as cases, and an equal number of age- and gender-matched controls were selected. Multiple logistic regression was conducted with biological, behavioral, environmental, and socioeconomic variables.

Results:

Of the 747 elderly contacted for the survey, 140 cases and 140 controls each were selected based on self-reported fall in the previous 12 months. The mean age of the participants was 66 with 95% confidence interval (65–67). Individual risk factors for fall were fear of falling (odds ratio [OR] 6.7) and dizziness (OR 4.9).

Conclusions:

There is now, more than ever, a need to refocus public health priorities for falls prevention in rapidly aging elders in India. This study provides a much-needed information for further investigation into fall and fall-related injury in developing countries like India.

Effectiveness of structured group reminiscence therapy in decreasing the feelings of loneliness, depressive symptoms and anxiety among inmates of a residential home for the elderly in Chittoor district

Background: The proportion of the elderly population is increasing in low and middle-income countries. Apart from systemic illnesses, elderly people face mental illnesses. Effect of group reminiscence therapy in reducing some of the mental health aspects showing a promising effect but the evidence is lacking in Indian settings. The present study aimed to determine the effect of reminiscence therapy in decreasing the level of loneliness, depressive symptoms, and anxiety among the elderly population at an institutional level.Methods: In this quasi-experimental study, residents of an old age home were evaluated for loneliness, depressive symptoms and anxiety through revised UCLA, geriatric depression scale, and Geriatric Anxiety Scale respectively. Group reminiscence therapy was applied to them and post-intervention assessment was done by the same scales.Results: Significant reduction of anxiety score [1.33 (0.03, 2.64)] was noticed in anxiety. Depressive symptoms showed a mean reduction in score [0.59 (-0.41, 1.6)] but statistically not significant. When graded into severity, all three outcomes showed improvement from higher severity grade to lower grade in post-intervention assessment. The intervention resulted in an improvement of 66.7% in depressive symptoms, 33.3% in anxiety and 30.8% in loneliness.Conclusions: The study found reminiscence therapy could be encouraging in resource-poor Indian settings. We recommend for further exploration of the long-term effects of this program, its feasibility, cost-effectiveness, and validation of the content for large-scale implementation. 

Impaired toll like receptor 9 response in pulmonary tuberculosis

BACKGROUND & AIM

Innate immune responses are important in susceptibility to pulmonary tuberculosis (TB). In order to test the hypothesis that Toll-like receptor (TLR) 2 function would be abnormal in patients with active pulmonary TB we compared the cytokine responses of peripheral blood mononuclear cells (PBMC) to innate immune ligands in a case-control study.

METHODS

PBMC from 19 untreated pulmonary TB patients, 17 healthy controls, and 11 treated pulmonary TB patients, were cultured for 24h with TLR 2 ligand (PAM-CSK) and other TLR ligands (muramyl dipeptide, flagellin, lipopolysaccharide (LPS), CpG oligodeoxynucleotide (CpG-ODN)). Interleukin-8 (IL-8) was estimated in the supernatant by ELISA. Messenger RNA expression for inflammatory cytokines was quantitated using real time PCR.

RESULTS

The important findings were (1) reduced PBMC secretion of IL-8 in response to all ligands in active TB; (2) normal to increased PBMC secretion of IL-8 in response to all ligands except CpG ODN (TLR 9 ligand) in TB patients who had recovered; (3) absence of difference in mRNA expression for a consortium of inflammatory pathway genes between healthy controls, active pulmonary tuberculosis and treated pulmonary tuberculosis patients.

CONCLUSION

There was a generalized post-translational suppression of the IL-8 response to innate immune ligands in active TB. There appears to be a defect of TLR 9 signaling in patients with tuberculosis, the nature of which needs to be further explored.

Adjunctive vitamin D for treatment of active tuberculosis in India: a randomised, double-blind, placebo-controlled trial

BACKGROUND

Vitamin D has immunomodulatory effects that might aid clearance of mycobacterial infection. We aimed to assess whether vitamin D supplementation would reduce time to sputum culture conversion in patients with active tuberculosis.

METHODS

We did this randomised, double-blind, placebo-controlled, superiority trial at 13 sites in India. Treatment-naive patients who were sputum-smear positive, HIV negative, and had pulmonary tuberculosis were randomly assigned (1:1), with centrally labelled, serially numbered bottles, to receive standard active tuberculosis treatment with either supplemental high-dose oral vitamin D3 (four doses of 2·5 mg at weeks 0, 2, 4, and 6) or placebo. Neither the patients nor the clinical and laboratory investigators and personnel were aware of treatment assignment. The primary efficacy outcome was time to sputum culture conversion. Analysis was by modified intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00366470.

FINDINGS

Between Jan 20, 2010, and Aug 23, 2011, we randomly assigned 247 participants to the vitamin D group (n=121) or the placebo group (n=126), of whom 211 participants (n=101 and n=110, respectively) were included in the primary efficacy analysis. Median time to culture conversion in the vitamin D group was 43·0 days (95% CI 33·3-52·8) versus 42·0 days (33·9-50·1) in the placebo group (log-rank p=0·95). Three (2%) patients died in the vitamin D group and one (1%) patient died in the placebo group; no death was considered attributable to the study intervention. No patients had hypercalcaemia.

INTERPRETATION

Our findings show that vitamin D supplementation did not reduce time to sputum culture conversion. Further studies should investigate the role of vitamin D in prevention or reactivation of tuberculosis infection.

FUNDING

Dalhousie University and Infectious Diseases Training and Research Centre.

Isolation and characterization of a ranavirus from koi, Cyprinus carpio L., experiencing mass mortalities in India

We investigated mass mortalities of koi, Cyprinus carpio Linnaeus, 1758, experienced in South Indian fish farms by virus isolation, electron microscopy, PCR detection, sequencing of capsid protein gene and transmission studies. Samples of moribund koi brought to the laboratory suffered continuous mortality exhibiting swimming abnormalities, intermittent surfacing and skin darkening. Irido-like virus was isolated from the infected fish in the indigenous snakehead kidney cell line (SNKD2a). Icosahedral virus particles of 100 to 120 nm were observed in the infected cell cultures, budding from the cell membrane. Virus transmission and pathogenicity studies revealed that horizontal transmission occurred associated with mortality. PCR analysis of infected fish and cell cultures confirmed the presence of Ranavirus capsid protein sequences. Sequence analysis of the major capsid protein gene showed an identity of 99.9% to that of largemouth bass virus isolated from North America. Detection and successful isolation of this viral agent becomes the first record of isolation of a virus resembling Santee-Cooper Ranavirus from a koi and from India. We propose the name koi ranavirus to this agent.

Trends in the annual risk of tuberculous infection in India

SETTING

Twenty-four districts in India.

OBJECTIVES

To evaluate trends in annual risk of tuberculous infection (ARTI) in each of four geographically defined zones in the country.

STUDY DESIGN

Two rounds of house-based tuberculin surveys were conducted 8-9 years apart among children aged 1-9 years in statistically selected clusters during 2000-2003 and 2009-2010 (Surveys I and II). Altogether, 184,992 children were tested with 1 tuberculin unit (TU) of purified protein derivative (PPD) RT23 with Tween 80 in Survey I and 69,496 children with 2TU dose of PPD in Survey II. The maximum transverse diameter of induration was measured about 72 h after test administration. ARTI was computed from the prevalence of infection estimated using the mirror-image method.

RESULTS

Estimated ARTI rates in different zones varied between 1.1% and 1.9% in Survey I and 0.6% and 1.2% in Survey II. The ARTI declined by respectively 6.1% and 11.7% per year in the north and west zones; no decline was observed in the south and east zones. National level estimates were respectively 1.5% and 1.0%, with a decline of 4.5% per year in the intervening period.

CONCLUSION

Although a decline in ARTI was observed in two of the four zones and at national level, the current ARTI of about 1% in three zones suggests that further intensification of TB control activities is required.

Agreement between skin testing and QuantiFERON-TB Gold In-Tube assay (QFT-TB) in detecting latent tuberculosis infection among household contacts in India

AIMS

The present study was designed to find the agreement between Tuberculin Skin Test and interferon gamma assay test in detecting latent tuberculosis infection in household contacts of sputum culture positive tuberculosis cases.

SETTING

Department of Community Medicine, Christian Medical College, Vellore.

METHODS

One hundred and fifty household contacts of sputum culture positive tuberculosis cases were tested with both the methods simultaneously and actual as well as kappa agreement was determined.

RESULTS

The overall actual agreement between both the tests was found to be 82% with a kappa agreement of 0.57.

CONCLUSION

The agreement was very high (both percentage agreement and Kappa) in pediatric contacts but it was poor in adult contacts.

Evaluation of the microscopic observational drug susceptibility assay for rapid and efficient diagnosis of multi-drug resistant tuberculosis

PURPOSE

Tuberculosis (TB) is endemic in India and the burden of multi-drug-resistant tuberculosis (MDR-TB) is high. Early detection of MDR-TB is of primary importance in controlling the spread of TB. The microscopic observational drug susceptibility (MODS) assay has been described as a cost-effective and rapid method by which mycobacterial culture and the drug susceptibility test (DST) can be done at the same time.

MATERIALS AND METHODS

A total of 302 consecutive sputum samples that were received in an accredited mycobacteriology laboratory for conventional culture and DST were evaluated by the MODS assay.

RESULTS

In comparison with conventional culture on Lowenstein Jensen (LJ) media, the MODS assay showed a sensitivity of 94.12% and a specificity of 89.39% and its concordance with the DST by the proportion method on LJ media to isoniazid and rifampicin was 90.8% and 91.5%, respectively. The turnaround time for results by MODS was 9 days compared to 21 days by culture on LJ media and an additional 42 days for DST by the 1% proportion method. The cost of performing a single MODS assay was Rs. 250/-, compared to Rs. 950/- for culture and 1st line DST on LJ.

CONCLUSION

MODS was found to be a sensitive and rapid alternative method for performing culture and DST to identify MDR-TB in resource poor settings.

Rapid diagnosis of tuberculosis with the Xpert MTB/RIF assay in high burden countries: a cost-effectiveness analysis

BACKGROUND

Xpert MTB/RIF (Xpert) is a promising new rapid diagnostic technology for tuberculosis (TB) that has characteristics that suggest large-scale roll-out. However, because the test is expensive, there are concerns among TB program managers and policy makers regarding its affordability for low- and middle-income settings.

METHODS AND FINDINGS

We estimate the impact of the introduction of Xpert on the costs and cost-effectiveness of TB care using decision analytic modelling, comparing the introduction of Xpert to a base case of smear microscopy and clinical diagnosis in India, South Africa, and Uganda. The introduction of Xpert increases TB case finding in all three settings; from 72%-85% to 95%-99% of the cohort of individuals with suspected TB, compared to the base case. Diagnostic costs (including the costs of testing all individuals with suspected TB) also increase: from US$28-US$49 to US$133-US$146 and US$137-US$151 per TB case detected when Xpert is used "in addition to" and "as a replacement of" smear microscopy, respectively. The incremental cost effectiveness ratios (ICERs) for using Xpert "in addition to" smear microscopy, compared to the base case, range from US$41-$110 per disability adjusted life year (DALY) averted. Likewise the ICERS for using Xpert "as a replacement of" smear microscopy range from US$52-$138 per DALY averted. These ICERs are below the World Health Organization (WHO) willingness to pay threshold.

CONCLUSIONS

Our results suggest that Xpert is a cost-effective method of TB diagnosis, compared to a base case of smear microscopy and clinical diagnosis of smear-negative TB in low- and middle-income settings where, with its ability to substantially increase case finding, it has important potential for improving TB diagnosis and control. The extent of cost-effectiveness gain to TB programmes from deploying Xpert is primarily dependent on current TB diagnostic practices. Further work is required during scale-up to validate these findings.

Pilot randomized trial of nutritional supplementation in patients with tuberculosis and HIV-tuberculosis coinfection receiving directly observed short-course chemotherapy for tuberculosis

OBJECTIVE

To investigate the effects of nutritional supplementation on the outcome and nutritional status of south Indian patients with tuberculosis (TB) with and without human immunodeficiency virus (HIV) coinfection on anti-tuberculous therapy.

METHOD

Randomized controlled trial on the effect of a locally prepared cereal-lentil mixture providing 930 kcal and a multivitamin micronutrient supplement during anti-tuberculous therapy in 81 newly diagnosed TB alone and 22 TB-HIV-coinfected patients, among whom 51 received and 52 did not receive the supplement. The primary outcome evaluated at completion of TB therapy was outcome of TB treatment, as classified by the national programme. Secondary outcomes were body composition, compliance and condition on follow-up 1 year after cessation of TB therapy and supplementation.

RESULTS

There was no significant difference in TB outcomes at the end of treatment, but HIV-TB coinfected individuals had four times greater odds of poor outcome than those with TB alone. Among patients with TB, 1/35 (2.9%) supplemented and 5/42(12%) of those not supplemented had poor outcomes, while among TB-HIV-coinfected individuals, 4/13 (31%) supplemented and 3/7 (42.8%) non-supplemented patients had poor outcomes at the end of treatment, and the differences were more marked after 1 year of follow-up. Although there was some trend of benefit for both TB alone and TB-HIV coinfection, the results were not statistically significant at the end of TB treatment, possibly because of limited sample size.

CONCLUSION

Nutritional supplements in patients are a potentially feasible, low-cost intervention, which could impact patients with TB and TB-HIV. The public health importance of these diseases in resource-limited settings suggests the need for large, multi-centre randomized control trials on nutritional supplementation.

Health care utilisation in Indian leprosy patients in the era of elimination

OBJECTIVE

The health care utilisation pattern among Indian leprosy patients accessing a tertiary care centre over an 18 month period was studied.

DESIGN

A study was conducted at the Dermatology Outpatient Clinic at the Christian Medical College, Vellore, from January 2005 to June 2006. The profile of patients was assessed and a subgroup was interviewed on their healthcare use, including any delays and costs incurred.

RESULTS

198 patients presented of which 115 patients (58.1%) were on treatment for leprosy or a leprosy reaction (active) including 35 new patients (17.7%), and 83 (41.9%) patients were not on active treatment (inactive). 81 patients were interviewed in depth, 14 (17.3%) were new patients included among 54 (66.7%) patients with active disease, and 27 (33.3%) with inactive disease. The average delay from the onset of symptoms to starting treatment in those interviewed was 13.4 months, 7.9 months of which was a patient-related delay and 5.4 months of which was the health care system-related delay. In patients who had been released from treatment, 78.6% (22/28) required care after cure.

CONCLUSIONS

Improved awareness is required to reduce patient-related delays and systems for sustained training need to be in place to tackle the problem of health care system-related delays. Care after cure is a felt need for many patients released from treatment.

Detection of human immunodeficiency virus infection in the sputum of tuberculosis patients in South India

SETTING

A DOTS clinic in an academic tertiary referral hospital in South India.

OBJECTIVE

To evaluate the performance of two rapid enzyme-linked immunoassays (EIAs) for the detection of human immunodeficiency virus (HIV) infection in sputum samples of patients with tuberculosis (TB).

DESIGN

We prospectively recruited 522 consecutive out-patients presenting to the DOTS clinic with confirmed TB of any type to undergo HIV testing using reference serum EIA and index-blinded parallel sputum HIV testing with two rapid EIAs designed for oral mucosal transudate.

RESULTS

HIV positivity was 14.9% (95%CI 12.1-18.4). Compared to reference serum EIA, the Oraquick™ assay was 93.1% sensitive (95%CI 83.8-97.4) and 95.3% specific (95%CI 92.7-96.9), while the Aware™ assay was 92.3% sensitive (95%CI 83.4-96.8) and 96.6% specific (95%CI 94.4-98.0). The positive predictive values were respectively 77.0% and 82.7%. After freezing of sputum, the sensitivity of both assays declined, but the specificity significantly increased. Higher sputum volume reduced the odds of obtaining a true result with both assays.

CONCLUSION

HIV testing of fresh sputum is not sufficiently accurate for anonymous HIV surveillance among TB patients in a setting of low (<10%) HIV prevalence. Freezing sputum samples and limiting sputum volume for HIV testing may improve assay specificity.

Indian isolates of white spot syndrome virus exhibit variations in their pathogenicity and genomic tandem repeats

To detect genomic variation of white spot syndrome virus (WSSV) isolates from different geographical regions of India, the variable number of the tandem repeat (VNTR) region of the ORF 94 (Thailand WSSV isolate - GeneBank Accession No. AF369029) was analysed using five specific sets of primers. Analysis of 70 WSSV-positive samples showed the presence of 14 different genotypes of WSSV with VNTRs ranging from 2 to 16 tandem repeats with the majority (85.47%) having 6-12 tandem repeats. Occurrence of different genotypes of WSSV was found to be neither correlated to any specific geographical region nor to the different growth stage of the tiger shrimp, Penaeus monodon. Pathogenicity studies conducted with 25 isolates of WSSV revealed the presence of virulent and avirulent strains of WSSV in Indian shrimp farms. However, an unambiguous link could not be established between the different genotypes and their virulence.

Diagnostic accuracy of the microscopic observation drug susceptibility assay: a pilot study from India

SETTING

The microscopic observation drug susceptibility (MODS) assay is a rapid, sensitive, low-cost liquid culture technique.

OBJECTIVE

To establish the accuracy of MODS for the detection of active pulmonary tuberculosis (TB), and to document the costs and challenges of setting up this assay in a low-income setting.

DESIGN

Prospective blinded pilot study of 200 adult TB suspects at a tertiary referral hospital in India. Reference standard included culture (Löwenstein-Jensen and automated liquid culture) and clinical diagnosis.

RESULTS

Patients were mostly male (n = 122, 61.1%) and out-patients (n = 184, 92.0%), with a mean age of 40.4 years (standard deviation 16.2). Seventeen (8.5%) were human immunodeficiency virus infected and 47 (23.5%) were reference culture-positive. Compared to reference culture, MODS was 78.9% sensitive (95%CI 62.2-90.0) and 96.7% specific (95%CI 92.0-98.8). Clinical assessment suggested that MODS was false-negative in 3/8 reference culture-positive MODS-negatives and true-positive in 4/6 reference culture-negative MODS-positives. MODS was faster than solid (P < 0.001) and liquid culture (P = 0.088), and cheaper than both.

CONCLUSION

MODS may be a good alternative to automated liquid culture, but there were several challenges in setting up the assay. Prior training and validation, setup costs and inability to rule out cross-contamination need to be taken into account before the test can be established.

Risk factors for MDR and XDR-TB in a tertiary referral hospital in India

BACKGROUND

India has a high burden of drug resistant TB, although there are few data on XDR-TB. Although XDR-TB has existed previously in India, the definition has not been widely applied, and surveillance using second line drug susceptibility testing has not been performed. Our objective was to analyze clinical and demographic risk factors associated with isolation of MDR and XDR TB as compared to susceptible controls, at a tertiary center.

METHODOLOGY/FINDINGS

Retrospective chart review based on positive cultures isolated in a high volume mycobacteriology laboratory between 2002 and 2007. 47 XDR, 30 MDR and 117 susceptible controls were examined. Drug resistant cases were less likely to be extrapulmonary, and had received more previous treatment regimens. Significant risk factors for XDR-TB included residence outside the local state (OR 7.43, 3.07-18.0) and care costs subsidized (OR 0.23, 0.097-0.54) in bivariate analysis and previous use of a fluoroquinolone and injectable agent (other than streptomycin) (OR 7.00, 95% C.I. 1.14-43.03) and an initial treatment regimen which did not follow national guidelines (OR 5.68, 1.24-25.96) in multivariate analysis. Cavitation and HIV did not influence drug resistance.

CONCLUSIONS/SIGNIFICANCE

There is significant selection bias in the sample available. Selection pressure from previous treatment and an inadequate initial regimen increases risk of drug resistance. Local patients and those requiring financial subsidies may be at lower risk of XDR-TB.

Costs incurred by patients with pulmonary tuberculosis in rural India

SETTING

Vellore District, Tamil Nadu, India.

OBJECTIVE

To measure patient costs associated with diagnosis and the complete treatment of tuberculosis (TB).

DESIGN

Prospective structured interview of 100 new smear-positive adult patients being treated for TB in Tamil Nadu, India, selected evenly from 10 representative health facilities in the state. Direct (out-of-pocket) and indirect (lost-time) costs were quantified by period of illness using a standardised questionnaire, and univariate regression investigated predictors of total cost.

RESULTS

Seventy-four per cent of patients were male, with a mean age of 40.2 years. All were given a first-line regimen, and none had been previously treated. The mean direct cost was US$34.91 (SD $46.94), the mean indirect cost was $526.87 (SD $375.71), and the total mean cost per patient was $562.66 (SD $287.48). Twenty-five patients were admitted to hospital, at a mean cost of $279.43 (SD $142.88) per admission. Variation in costs was associated with admission.

CONCLUSION

TB patients in India incur large costs associated with TB illness. The greatest single cost was time lost during admission. Total patient costs represent 193% of the estimated monthly income of a manual labourer.

Costing of severe pneumonia in hospitalized infants and children aged 2-36 months, at a secondary and tertiary level hospital of a not-for-profit organization

OBJECTIVES

To determine health care provider cost and household cost of the treatment of severe pneumonia in infants and young children admitted to secondary and tertiary level health care facilities.

METHODS

The study was done in a private, not-for-profit medical college hospital, in Vellore, India, in mid-2008. Children aged 2-36 months admitted with severe pneumonia with no underlying chronic disease were included in the study. The relatives were interviewed daily on matters relating to patients' view point of the costs. These were direct medical costs, direct non-medical costs which comprised travel, accommodation and special food during the period of illness, and indirect costs of productivity loss for family members. Patient specific resource consumption and related charges were recorded from charts, nursing records, pharmacy lists and hospital bills, and the providers view point of the costs was estimated. Unit cost estimates for bed days, treatment and investigation inputs were calculated.

RESULTS

Total cost to health care provider for one episode of hospitalized childhood pneumonia treated at secondary level was US$ 83.89 (INR 3524) and US$ 146.59 (INR 6158) at tertiary level. At both levels the greatest single cost was the hospital stay itself, comprising 74% and 56% of the total cost, respectively. Diagnostic investigations were a large expense and supportive treatment with nebulization and oxygen therapy added to the costs. Mean household expenditure on secondary level was US$ 41.35 (INR 1737) and at tertiary level was US$ 134.62 (INR 5655), the largest single expense being medicines in the former and the hospitalization in the latter. (one US$=INR 42.1 at time of study)

CONCLUSIONS

A considerable cost difference exists between secondary and tertiary level treatment. Admission at lowest possible treatment level for appropriate patients could decrease the costs borne by the provider and the patient.

Blinded evaluation of commercial urinary lipoarabinomannan for active tuberculosis: a pilot study

SETTING

Urine antigen testing is an attractive strategy for the diagnosis of active tuberculosis (TB), but accuracy data are scarce.

OBJECTIVE

To prospectively evaluate the diagnostic performance of commercial urinary lipoarabinomannan (LAM) antigen testing for active TB among pulmonary and extra-pulmonary TB suspects.

DESIGN

Prospective blinded evaluation of 200 adult TB suspects at a tertiary referral hospital in India. Reference standards included culture and clinical diagnosis.

RESULTS

Patients were 61% male (mean age 40.4 years): 8.5% were human immunodeficiency virus (HIV) infected and 47 of 200 (23.5%) were culture-positive for TB. Compared to positivity on either Löwenstein-Jensen (LJ) or BACTEC cultures, LAM sensitivity was 17.8% (95%CI 8.5-32.6), while specificity was 87.7% (95%CI 81.3-92.3). Compared to positivity on both LJ and BACTEC, LAM sensitivity was 5.8% (95%CI 12.5-44.9), with a specificity of 88.8% (95%CI 82.7-92.9). Compared to the clinical diagnosis, LAM sensitivity was 20.0% (95%CI 1.1-70.1), with a specificity of 83.3% (95%CI 50.9-97.0). HIV and smear status did not influence test accuracy.

CONCLUSION

In its current form, LAM is insensitive for the diagnosis of active TB, although its specificity is adequate.

A pilot study of short-duration sputum pretreatment procedures for optimizing smear microscopy for tuberculosis

BACKGROUND

Direct sputum smear microscopy for tuberculosis (TB) lacks sensitivity for the detection of acid fast bacilli. Sputum pretreatment procedures may enhance sensitivity. We did a pilot study to compare the diagnostic accuracy and incremental yield of two short-duration (<1 hour) sputum pretreatment procedures to optimize direct smears among patients with suspected TB at a referral hospital in India.

METHODOLOGY/FINDINGS

Blinded laboratory comparison of bleach and universal sediment processing (USP) pretreated centrifuged auramine smears to direct Ziehl-Neelsen (ZN) and direct auramine smears and to solid (Loweinstein-Jensen (LJ)) and liquid (BACTEC 460) culture. 178 pulmonary and extrapulmonary TB suspects were prospectively recruited during a one year period. Thirty six (20.2%) were positive by either solid or liquid culture. Direct ZN smear detected 22 of 36 cases and direct auramine smears detected 26 of 36 cases. Bleach and USP centrifugation detected 24 cases each, providing no incremental yield beyond direct smears. When compared to combined culture, pretreated smears were not more sensitive than direct smears (66.6% vs 61.1 (ZN) or 72.2 (auramine)), and were not more specific (92.3% vs 93.0 (ZN) or 97.2 (auramine).

CONCLUSIONS/SIGNIFICANCE

Short duration sputum pretreatment with bleach and USP centrifugation did not increase yield as compared to direct sputum smears. Further work is needed to confirm this in a larger study and also determine if longer duration pre-treatment might be effective in optimizing smear microscopy for TB.

A cost comparison of open versus percutaneous approaches to management of large staghorn calculi

Aim:

This paper compares the cost of open versus percutaneous approaches to the management of large staghorn calculi in a tertiary care hospital in India.

Materials and Methods:

Patients who underwent surgery for staghorn calculi larger than 6 cm between January 1998 and December 2003 were included. Those who had confounding factors in terms of cost such as additional surgical or medical procedures and complications unrelated to the surgery were excluded. The process of costing was done by following the clinical pathway.

Results:

There were 13 patients who had open stone surgery and 19 patients who underwent percutaneous nephrolithotripsy (PCNL). The major differences in cost were seen in the higher cost of instruments and consumables in the PCNL group. The cost of management of complications widened this gap. Two patients in the PCNL group and none in the residual group required redo surgery. The residual stones in the open and PCNL groups required a mean of 2525 and 3623 shocks per patient respectively. Complete clearance after redo surgery and Shockwave lithotripsy (SWL) was seen in 92% and 58% in the open and PCNL arms respectively. The overall cost per patient was $625 per PCNL and $499 per open surgery. The final mean residual stone size in the PCNL group was 4.84 mm whereas it was 0.38 mm in the open group. The effective cost of achieving complete clearance in one patient was $1078 in the PCNL group and $543 in the open group.

Conclusion:

Open stone surgery is less costly than PCNL in large staghorn calculi.

Brief communication: economic comparison of opportunistic infection management with antiretroviral treatment in people living with HIV/AIDS presenting at an NGO clinic in Bangalore, India

CONTEXT

Highly active antiretroviral treatment (HAART) usage in India is escalating. With the government of India launching the free HAART rollout as part of the "3 by 5" initiative, many people living with HIV/AIDS (PLHA) have been able to gain access to HAART medications. Currently, the national HAART centers are located in a few district hospitals (in the high- and medium-prevalence states) and have very stringent criteria for enrolling PLHA. Patients who do not fit these criteria or patients who are too ill to undergo the prolonged wait at the government hospitals avail themselves of nongovernment organization (NGO) services in order to take HAART medications. In addition, the government program has not yet started providing second-line HAART (protease inhibitors). Hence, even with the free HAART rollout, NGOs with the expertise to provide HAART continue to look for funding opportunities and other innovative ways of making HAART available to PLHA. Currently, no study from Indian NGOs has compared the direct and indirect costs of solely managing opportunistic infections (OIs) vs HAART.

OBJECTIVE

Compare direct medical costs (DMC) and nonmedical costs (NMC) with 2005 values accrued by the NGO and PLHA, respectively, for either HAART or exclusive OI management.

STUDY DESIGN

Retrospective case study comparison.

SETTING

Low-cost community care and support center--Freedom Foundation (NGO, Bangalore, south India).

PATIENTS

Retrospective analysis data on PLHA accessing treatment at Freedom Foundation between January 1, 2003 and January 1, 2005. The HAART arm included case records of PLHA who initiated HAART at the center, had frequent follow-up, and were between 18 and 55 years of age. The OI arm included records of PLHA who were also frequently followed up, who were in the same age range, who had CD4+ cell counts < 200/microliter (mcL) or an AIDS-defining illness, and who were not on HAART (solely for socioeconomic reasons). A total of 50 records were analyzed. Expenditures on medication, hospitalization, diagnostics, and NMC (such as food and travel for a caregiver) were calculated for each group.

RESULTS

At 2005 costs, the median DMC plus NMC in the OI group was 21,335 Indian rupees (Rs) (mean Rs 24,277/-) per patient per year (pppy) (US $474). In the HAART group, the median DMC plus NMC was Rs 18,976/- (mean Rs 21,416/-) pppy (US $421). Median DMC plus NMC pppy in the OI arm was Rs 13623.7/- paid by NGO and Rs 1155/- paid by PLHA. Median DMC and NMC pppy in the HAART arm were Rs 1425/- paid by NGO and Rs 17,606/- paid by PLHA.

CONCLUSIONS

Good health at no increased expenditure justifies providing PLHA with HAART even in NGO settings.

PCR amplification of the IS6110 insertion element of Mycobacterium tuberculosis in fecal samples from patients with intestinal tuberculosis

PCR amplification of insertion element IS6110 of Mycobacterium tuberculosis in fecal samples was evaluated in the diagnosis of intestinal tuberculosis (ITB). The numbers of samples that tested positive by PCR with SalI digestion were 16/18 untreated-ITB samples, 0/8 treated-ITB samples, 12/14 smear-positive pulmonary tuberculosis samples, and 0/30 control samples. The sensitivity, specificity, positive predictive value, and negative predictive value of fecal PCR were 88.8%, 100%, 100%, and 93.7%, respectively.

Genetic heterogeneity among Vibrio alginolyticus isolated from shrimp farms by PCR fingerprinting

AIMS

To study the strain variability among Vibrio alginolyticus isolates from different sources by insertion sequence-targeted PCR fingerprinting and whole cell protein profile analysis.

METHODS AND RESULTS

Eleven strains of V. alginolyticus were isolated from seven different sources including healthy, infected, farm-reared and wild shrimps. Following biochemical characterization, the isolates were analysed by PCR fingerprinting and whole cell protein analysis by SDS-PAGE. The strains were genetically different irrespective of the sources of isolation.

CONCLUSIONS

Strain variation exists in V. alginolyticus isolates obtained even from the same source, and PCR fingerprinting is a simple and efficient method in identifying strain-specific variations among the different isolates.

SIGNIFICANCE AND IMPACT OF THE STUDY

Vibrio alginolyticus is implicated in severe vibriosis of marine aquaculture systems although many strains are avirulent and could be used as probiotic strains. As a wide variation exists among this species, differentiating the harmful and beneficial strains would help in finding ways of controlling the infections by eliminating harmful shrimp pathogenic vibrios.

A Comparison of Economic Aspects of Hospitalization Versus Ambulatory Care in the Management of Neuritis Occurring in Lepra Reaction

Neuritis is one of the important causes of deformities and disabilities in leprosy. Neuritis has been managed both in the field and in hospital. This study was done to compare the economic aspects of cost of ambulatory vs in-patient management of neuritis in leprosy. The quality of life of the affected patients and the clinical improvement in the 2 groups were also studied. Twenty six patients fulfilling the study criteria were randomized into the ambulatory and in-patient group (13 in each group). The primary outcome examined was cost, in various categories; the secondary outcomes included pre- and post-treatment comparison of Quality of Life (QOL) scores and tests of sensory and motor function. The direct and indirect medical costs incurred by patients in the hospitalized group were higher than those patients in the ambulatory group. The difference in the direct medical costs between the two groups was Rs. 9110.5, and the extra direct non medical costs incurred by patients in the hospitalized group was Rs. 888.50 because of more frequent visits of family members. A greater percentage of ambulatory than in-patients returned to work in </= 15 days (53.8% vs 15.3%), and the mean duration before returning to work was 19.5 days ambulatory patients compared to 66.8 days for in-patients group. The QOL scores and motor and sensory function tests showed no significant difference between groups. Although the sample size was small, these preliminary results suggest that substantial cost minimization by ambulatory care is possible without significantly affecting the quality of life or peripheral nerve function.

Quality of hysterectomy care in rural Gujarat: the role of community-based health insurance

Community-based health insurance (CBHI) may be a mechanism for improving the quality of health care available to people outside the formal sector in developing countries. The purpose of this paper is to identify problems associated with the quality of hysterectomy care accessed by members of SEWA (Self-Employed Women's Association), an Indian CBHI scheme, and discuss mechanisms that would optimize quality of care. Data on hysterectomy care were collected through a review of 63 insurance claims and semi-structured interviews with 12 providers. Quality of hysterectomy care accessed by SEWA's members varied from potentially dangerous to excellent. Dangerous conditions included operating theatres without separate hand-washing facilities or proper lighting, the absence of qualified nursing staff, performing hysterectomy on demand, removing both ovaries without consulting or notifying the patient, and failing to send the excised organs for histopathology, even when signs were suggestive of disease. Women paid substantial amounts of money, even for poor and potentially dangerous care. In order to improve the quality of care for its members, a CBHI scheme can: (1) gather data on the costs and complications for each provider, and investigate where these are excessive; (2) use incentives to encourage providers to make efficient and equitable resource allocations; (3) contract with providers giving a high standard of care or who agree to certain conditions; and (4) inform and advise doctors and the insured about the costs and benefits of different interventions. In the case of SEWA, it is most feasible to identify a limited number of hospitals providing better quality care and contract directly with them.

Attitudes toward tuberculosis of final year medical students from Canada, India, and Uganda

BACKGROUND

Tuberculosis, although both preventable and treatable, continues to be the world's leading cause of death from an infectious agent.

PURPOSE

To extend the results of our previous study of knowledge and practices of final year medical students regarding tuberculosis at three medical schools from endemic and nonendemic areas and to describe their attitudes.

METHODS

Eight statements assessing attitudes, as part of a larger survey, were administered to final year medical students at McMaster University in Canada, Christian Medical College in India, and Makerere University in Uganda.

RESULTS

One hundred sixty surveys were returned with 155 completed attitude responses. The response rate was 68.4% (65 of 95) for McMaster University, 39.7% (23 of 58) for the Christian Medical College, and 78.3% (72 of 92) for Makerere University. Analysis showed that six of eight attitude items were slightly statistically different among the schools with minimal effect of curriculum time and patient exposure.

CONCLUSIONS

Despite quite varied exposure to tuberculosis, students from endemic and nonendemic areas responded similarly on statements addressing attitudes toward tuberculosis.

Quality of hysterectomy care in rural Gujarat: the role of community-based health insurance

Community-based health insurance (CBHI) may be a mechanism for improving the quality of health care available to people outside the formal sector in developing countries. The purpose of this paper is: (1) to identify problems associated with the quality of hysterectomy care accessed by members of SEWA, an Indian CBHI scheme; and (2) to discuss mechanisms that might be put in place by SEWA, and CBHI schemes more generally, to optimize quality of health care. Data on the structure and process of hysterectomy care were collected primarily through review of 63 insurance claims and semi-structured interviews with 12 providers. Quality of hysterectomy care accessed by SEWA's members varies tremendously, from potentially dangerous to excellent. Seemingly dangerous aspects of structure include: operating theatres without separate hand-washing facilities or proper lighting; and the absence of qualified nursing staff. Dangerous aspects of process include: performing hysterectomy on demand; removing both ovaries without consulting or notifying the patient; and failing to send the excised organs for histopathology, even when symptoms and signs are suggestive of disease. Women pay substantial amounts of money even for care of poor, and potentially dangerous, quality. In order to improve the quality of hospital care accessed by its members, a CBHI scheme can: (1) gather data on the costs and complications for each provider, and investigate cases where these are excessive; (2) use incentives to encourage providers to make efficient and equitable resource allocation decisions; (3) select, and contract with, providers who provide a high standard of care or who agree to certain conditions; and (4) inform and advise doctors and the insured about the costs and benefits of different interventions. In the case of SEWA, it is most feasible to identify a limited number of hospitals providing better-quality care and contract directly with them.

Characteristics of a new reovirus isolated from epizootic ulcerative syndrome infected snakehead fish

Epizootic ulcerative syndrome (EUS) has been infecting a wide range of fishes in the South and Southeast Asia for the last 2 decades. One reovirus-like agent (snakehead reovirus, SKRV), isolated from an EUS-infected snakehead fish and investigated in the present study, is the only reovirus so far isolated from an EUS-infected fish. SKRV was characterised by the presence of a double-stranded RNA genome with icosahedral symmetry and double capsid. The virus had an average size of 71 nm, a buoyant density of 1.36 g ml(-1) in CsCl and lacked a lipid-containing envelope. Apart from the above, the presence of a segmented genome and structural proteins falling into 3 specific size classes confirmed that the virus belongs to the family Reoviridae. SKRV differed from aquareoviruses by the lack of a cytopathic effect (CPE) with syncitium formation and in the segmentation pattern of RNA genome. The resistance to pH (3.0 to 9.0) and heat treatment and inability to multiply in mammalian cell lines and haemagglutinate human 'O' red blood cells (RBCs) differentiated SKRV from the rest of the similar genera in the family Reoviridae. Serological comparison indicated the antigenic distinctness of the isolate from selected American and European aquareoviruses. SKRV grew well in SSN-1 and SSN-3 cells at 25 to 30 degrees C but not in the most common Aquareovirus susceptible coldwater fish cell line--CHSE-214.

Knowledge and practices regarding tuberculosis: a survey of final-year medical students from Canada, India and Uganda

CONTEXT

Tuberculosis is one of the most common infectious diseases worldwide and is responsible for the largest number of deaths from a single infectious cause.

OBJECTIVE

The objective of this study was to compare the knowledge of and practices regarding tuberculosis in final-year medical students at schools from endemic and non-endemic areas.

SUBJECTS

Final-year medical students at McMaster University in Canada, the Christian Medical College in India, and Makerere University in Uganda.

METHODS

A questionnaire consisting of 20 multiple-choice questions assessing knowledge, practices, and exposure. A total knowledge score (maximum=13) and a total practice score (maximum=5) were created for each study site.

RESULTS

160 questionnaires were returned; the response rate was 68.4% (65/95) for McMaster University, 39.7% (23/58) for the Christian Medical College and 78.3% (72/92) for Makerere University. Students from Makerere University had the highest knowledge scores but differences were non-significant after adjustment for patient exposure and curriculum time (F(2,153)= 1.80, P=0.16). Differences in practice scores, however, remained significant after adjusting for curriculum time and patient exposure (F(2,153)=5.14, P=0.006). Knowledge score (F(1,156)=5.05, P=0.02), patient exposure (F(1,153)=9.11, P=0.003), and curriculum time and patient exposure (F(2,153)=5.14, P=0.006) were statistically significant positive predictors of the total practice score.

CONCLUSIONS

This study demonstrated significant differences in undergraduate exposure to tuberculosis, total knowledge, and practice competency at three medical schools in Canada, India, and Uganda. In general, the knowledge base and practice competency of all three graduating classes was adequate.

The impact of lymphatic filariasis on labour inputs in southern India: results of a multi-site study

A multi-site study was undertaken, in the rural areas of three districts in Tamil Nadu state, in southern India, to examine the impact of acute and chronic forms of lymphatic filariasis, caused by infection with Wuchereria bancrofti, on labour inputs. More than half of the acute episodes of adenolymphangitis (ADL) observed in the study communities caused total disability. The mean (S.D.) time that each ADL case was able to allocate to economic activity each day during these acute episodes was much less than seen in the controls matched for sex, age and occupation [0.97 (2.36) v. 4.48 (3.82) h; P < 0.01]. The acute disease also severely affected domestic activities, with female ADL cases spending only 1.54 (2.12) h/day on domestic activity, compared with 4.18 (2.61) h by controls. The subjects with chronic filariasis also spent significantly less time in economic activity than their matched controls [4.40 (3.79) v. 5.13 (3.83) h/day; P < 0.01). Although the acute episodes have a dramatic effect on the productivity of the affected individual, the labour loss caused by chronic disease is more serious, as the manifestations of chronic disease mostly affect the most productive age-groups, persist for life and are mostly irreversible. The adverse impact of acute and chronic filariasis was observed in males and females, farmers and non-farmers and during the rainy, winter and summer seasons. It is estimated that about 3.8% of the potential labour inputs of the men and 0.77% of those of the women were lost because of lymphatic filariasis. In addition to this loss, the total economic burden of the disease must include the costs of treatment and other health care and of the resources spent on control programmes. Estimates of the disease burden are likely to be useful in determining the costs and benefits of the recently launched campaign to eliminate lymphatic filariasis.

Variation in in-patient stroke management in ten centres in different countries: the INCLEN multicentre stroke collaboration

BACKGROUND AND PURPOSE

Large within-country variations have been described in stroke management and there have been a few studies of between-country variation (in the USA and the UK). We designed a study to examine stroke management across a wide range of countries representing different stages of economic development. Large variations would suggest the need to explore methods of increasing the uptake of evidence-based stroke practice.

METHODS

Members of the International Clinical Epidemiology Network (INCLEN) from 14 centres in ten countries agreed to review the records of the last 50 patients admitted to hospital with a clinical diagnosis of stroke. Information on demographic variables, the clinical diagnosis of stroke type, investigations performed and treatments given and the discharge destination of the patient were recorded and sent to the coordinating centre in Australia for analysis.

RESULTS

There were statistically significant between-centre differences in the proportions of patients cared for by a neurologist, staying in hospital for at least ten days and having CT or MRI scans. Significant between-centre differences were also seen for treatment, for example, the use of aspirin in non-haemorrhagic stroke varied from 11 to 79%. The variation (for all interventions studied) was no longer statistically significant when examined within strata according to availability of facilities.

CONCLUSIONS

The large variation between centres in the management of stroke is largely 'explained' by the availability of resources, even for interventions that do not depend on resource availability. It will be important to develop management guidelines that reflect evidence-based practice of relevance across a range of economic settings.

Measles vaccination before nine months

OBJECTIVE

To measure the protective effect of measles vaccine administered before 9 months of age and compare overall mortality of children vaccinated at 6-8 months and at 9-11 months.

METHOD

Non-concurrent cohort study involving all 13 134 children born between 16 January 1986 and 31st December 1991 in Kaniyambadi block near Vellore who had not left the area by six months of age. Main outcome measures were risk of disease and death among the under-five-year-olds according to age at measles immunization.

RESULTS

Unimmunized children had a higher risk of developing measles compared to the immunized (P < 0.05). There was no significant difference in risk of measles among those vaccinated prior to and after nine months of age. Unvaccinated children were at significantly higher risk of death than vaccinated children (P < 0.001). There was no difference in risk of death between infants vaccinated between 6 and 8 months and those vaccinated between 9 and 11 months. There was no difference in the risk of death between boys and girls vaccinated between 6 and 8 months with standard-titre Edmonston-Zagreb vaccine.

CONCLUSION

Administration of standard-titre Edmonston-Zagreb measles vaccine at 6-8 months is an effective and safe preventive measure for measles, especially where the age-specific attack rate for children < 9 months is high.

Morbidity pattern, health care utilization and per capita health expenditure in a rural population of Tamil Nadu

BACKGROUND

Information on the existing morbidity pattern, pattern of health care utilization and the per capita health expenditure is essential to provide need-based health care delivery to a rural population. To obtain this information we performed a study in the K.V. Kuppam Block, North Arcot Ambedkar District, Tamil Nadu.

METHODS

We did a cross-sectional study, interviewing respondents from 300 households, from 3 panchayats using a multistage sampling technique. Information relating to 1440 persons was collected. The morbidity data was obtained initially for the week prior to the day of interview, followed by one week to one month and then for two months to one year.

RESULTS

During 1990-91, 825 of the 1440 persons (57.3%) did not have any illness. Sex had no bearing on the number of illnesses. Of the 60 children less than 2 years of age, 42 (70%) had one or two illnesses. The period prevalence of infective and parasitic diseases was found to be 21.9% with an average of 3 episodes. Services rendered by private practitioners (registered, non-registered and indigenous) were utilized by 59% of the households and 79% of the households had used allopathic treatment at some time. The average per capita per annum health expenditure was Rs 89.9 (Rs 449 per household). This increased significantly with increase in the household size (p < 0.001) and per capita income (p < 0.01).

CONCLUSION

The health-seeking behaviour of this population can be changed if efficient services are rendered through government primary health centres and subcentres. This would allow the existing voluntary agency to withdraw without much change in the per capita health expenditure.

Prescription patterns and cost analysis of drugs in a base hospital in south India

BACKGROUND

In the rural areas of developing countries the cost of drugs is a major concern to both physician and patient; yet there are few data on prescribing patterns and expenditure. We examined the cost of commonly prescribed drugs in a community health care programme in a base hospital of the Christian Medical College, Vellore.

METHODS

The study was carried out over a period of 3 months during which 2756 prescriptions were analysed. The number and type of drugs prescribed and the frequency and total cost of the prescriptions were noted.

RESULTS

The number of drugs prescribed for each patient ranged from 1 to 7 with a mean (SD) of 2.4 (1.1). The most commonly prescribed groups of drugs were vitamins, analgesics, antibiotics, sulphonamides and anti-inflammatory agents. The mean (SD) cost per prescription was Rs 8.8 (8.6). The expenditure on the most commonly used drugs was approximately 50% of the total cost. The cost per prescription was less than Rs 10 in 70% of the cases. All the drugs were from the World Health Organization's essential drugs list.

CONCLUSIONS

Most prescriptions for drugs given at our hospital could be afforded by villagers.

The role of intrahousehold contact in the transmission of leprosy

This study examines the role of intrahousehold contact in the transmission of leprosy using the case control methodology. The study was done in the leprosy control area of the Community Health and Development (CHAD) Programme of the Christian Medical College. Three age, sex and village matched controls were selected for each case. This study shows that persons with intrahousehold contact with leprosy have a higher risk of acquiring leprosy compared with those who did not (RR 2.509; 95% confidence limits 1.23-5.109).