Impact of the COVID-19 pandemic on an online cancer screening training programme for healthcare providers in the public sector in India: learnings from a hub and spoke model perspective

Introduction

This article elicits our experiences and strategic approaches to ensure the sustainability of the online capacity-building programmes for healthcare providers (HCPs) in comprehensive cancer screening through the 'Hub and Spoke' model during the coronavirus disease (COVID-19) pandemic.

Methods

During the first wave of COVID-19, training for three cohorts of medical officers (MO) (Batch-A) was ongoing (May-December 2020). The Indian health system abruptly shifted focus towards containing the COVID-19 spread, leading to new challenges in conducting training courses. A new five-step strategic approach for cohort MO-14 (Batch-B) was adopted to spread awareness about the importance of cancer screening and the roles and responsibilities of HCPs in the implementation and conduct of practical sessions in their states in collaboration with their respective state governments. We also adopted social media - WhatsApp for official communication.

Results

Enrolling Batch-B following the new strategic approach reduced refusals by 25% and dropouts by 36% compared to Batch-A. Course compliance and completion was a significant 96% in Batch-B.

Conclusion

The COVID-19 pandemic opened a window of opportunity to understand the need for vital changes to improve the quality of our hybrid cancer screening training. Inclusion of the state government in planning and implementing the changes, awareness among HCPs about the importance of training and responsible acceptance of cancer screening, district-wise approach, use of social media in sharing course materials and conducting in-person training in the respective state have demonstrated significant impact on the quality of the training and in scaling-up of cancer screening. Prolonged mentorship, robust Internet connectivity for providers and training on handling gadgets and online video communication would profoundly benefit remote training programmes.A well-devised backup system is essential for training programmes during unforeseen eventualities such as the COVID pandemic.

Challenges in setting up a primary human papillomavirus-DNA testing facility in a lower and middle income country: lessons learned from a pilot programme

Introduction

Detection of high-risk human papillomavirus (hrHPV) is the most sensitive test for the screening of cervical cancer. Although most high-income countries have adopted this strategy in their screening programme, there are a lot of barriers in low and middle-income countries (LMICs) in setting up this facility for screening. The lessons learned based on this experience can be useful for other LMICs in their first steps to integrate HPV testing into a screening programme.

Methods

HPV testing using self-sampling was offered to eligible women residing in one district of Sikkim state. To implement the same, a testing laboratory was set up in the district and the challenges faced are listed.

Results

The cost of testing equipment, sampler and cold storage was beyond the budget capping. Setting up of the HPV testing lab accessible to study sites and referral centre was a difficult decision to make. Training the health care providers in their proficiency in triaging and treatment was challenging. Coordinating with community health workers and beneficiaries for effective screening and establishing referral linkages was not easy, as we expected. The cost of transportation, consumables and contingencies was higher due to the difficult terrain.

Conclusion

The cost of the equipment and consumables for primary HPV screening can be reduced in bulk purchases through negotiations. Adequate knowledge of the terrain and economic implications of the area of interest is crucial during the budgeting of the programme. Collaborating with the state government, integration with the existing health system and repurposing the available resources are key for success. The barriers faced during implementation are stepping stones for improvement.

Advanced virtual mentoring of dentists in oral cancer screening and tobacco cessation - An interventional study

Context

Oral cancer is the third common cancer in India. Its mortality can be reduced through early detection and tobacco cessation ideally by dentists owing to their forte of work.

Aim

This study was conducted to discuss effectiveness of an advanced tele-mentoring programme in oral cancer screening and tobacco cessation for dentists across India.

Settings and Design

Online, interventional study.

Methods and Material

The 14-week long training programme with 52 participants/spokes from across India had weekly hour-long online sessions comprising of an expert-led didactic and case discussions by spokes. Online evaluation (pre- and post-training, post-session), weekly and post-one-year feedback were conducted. Successful spokes attended a hands-on workshop subsequently.

Statistical Analysis Used

One and independent sample t-tests determined the significance of the evaluation scores of the participants. Findings on attitudes and practice-related questions are presented as simple percentages.

Results

A notable increase in the overall and per-session mean knowledge score, and confidence in oral cancer screening was observed. Many participants started these services at their clinics, thereby reducing further referrals, and were also motivated to spread community awareness about the same.

Conclusion

This tele-mentoring programme, based on the novel Extension for Community Healthcare Outcomes model, is the first oral cancer screening training programme for dentists. This model-comprising of expert didacts, case discussions, and significant spoke-expert interaction-is a promising best-practices tool for reducing the disparity in knowledge and skills regarding oral cancer prevention among dentists across different locations. This would enable these most appropriate healthcare providers to contribute toward the overall goal of oral cancer prevention.

High Prevalence of Cervical High-Grade Lesions and High-Risk Human Papillomavirus Infections in Women Living with HIV: A Case for Prioritizing Cervical Screening in This Vulnerable Group

INTRODUCTION

Women living with HIV (WLHIV) are at an increased risk of developing cervical precancerous lesions and cervical human papillomavirus (HPV) infection. This study aimed at evaluating the prevalence of cervical lesions and high-risk HPV (HR-HPV) infection in WLHIV in comparison to the HIV-negative women undergoing opportunistic screening. In addition, these findings among WLHIV were correlated with the clinic-demographic factors.

METHODS

A cross-sectional study was conducted among WLHIVs at a tertiary hospital and linked antiretroviral therapy (ART) center, while HIV-negative women were recruited from the health promotion clinic at our institute. With informed consent, a semi-structured questionnaire was filled on demographic and epidemiological parameters. Conventional cervical smears and samples for HPV DNA detection by HC2 high-risk HPV DNA test were collected in all participants. Cervical smears were reported using the Bethesda system 2014. Appropriate statistical analysis was performed for bivariate and multivariate logistic regression analysis for comparison between WLHIV and HIV-negative women and for correlation of abnormal cervical cytology and HR-HPV infection among WLHIVs.

RESULTS

The clinic-demographic characteristics of WLHIVs and HIV-negative women were similar. On cytology, the prevalence of cervical cytological abnormalities were significantly higher (p < 0.001) among WLHIVs (14.1%) compared to HIV-negative women (3.1%). High-grade lesions were seen in 3.7% of WLHIVs, while no high-grade lesions were detected in HIV-negative women. Cervical HR-HPV infection was also significantly higher (p < 0.001) in WLHIVs (28.9%) than HIV-negative women (9.3%). Cervical precancerous lesions in WLHIVs showed positive association with current sexually transmitted infection (STI), multiple sexual partners, tobacco use, and CD4 count less than 200/µL, while cervical HPV was positively associated with current STI, tobacco use, CD4 count less than 200/µL and negatively with ART intake. On multivariate logistic regression, cervical cytological abnormalities showed a significant association with multiple sexual partners (p < 0.001), while cervical HR-HPV infection was positively associated with current STI (p = 0.01), nadir CD4 count <200/µL (p = 0.004), abnormal cervical cytology (p = 0.002) and negatively with ART intake (p = 0.03).

CONCLUSION

Women living with HIV have a significantly higher prevalence of cervical precancerous lesions and HR-HPV infection compared to the general population. Considering the lack of an organized population-based cervical cancer screening program in many low-resource countries like ours, specific focus on screening this highly vulnerable population to reduce the morbidity and mortality due to cervical cancer is imperative.

Concomitant pulmonary disease is common among patients with extrapulmonary TB

BACKGROUND :

Microbiologic screening of extrapulmonary TB (EPTB) patients could inform recommendations for aerosol precautions and close contact prophylaxis. However, this is currently not routinely recommended in India. Therefore, we estimated the proportion of Indian patients with EPTB with microbiologic evidence of pulmonary TB (PTB).

METHODS :

We characterized baseline clinical, radiological and sputum microbiologic data of 885 adult and pediatric TB patients in Chennai and Pune, India, between March 2014 and November 2018.

RESULTS :

Of 277 patients with EPTB, enhanced screening led to the identification of 124 (45%) with concomitant PTB, including 53 (19%) who reported a cough >2 weeks; 158 (63%) had an abnormal CXR and 51 (19%) had a positive sputum for TB. Of 70 participants with a normal CXR and without any cough, 14 (20%) had a positive sputum for TB. Overall, the incremental yield of enhanced screening of patients with EPTB to identify concomitant PTB disease was 14% (95% CI 12–16).

CONCLUSIONS :

A high proportion of patients classified as EPTB in India have concomitant PTB. Our results support the need for improved symptom and CXR screening, and recommends routine sputum TB microbiology screening of all Indian patients with EPTB.

Feasibility of Training Community Health Workers in the Detection of Oral Cancer

IMPORTANCE

Visual screening for oral cancer has been found to be useful in a large randomized clinical trial in Kerala, India, showing substantial reduction in mortality. To address the shortage of medical personnel in resource-deficient regions, using the services of community health workers has been proposed as a strategy to fill the gap in human resources in health care.

OBJECTIVE

To assess the feasibility of community health workers in screening and early detection of oral cancer using a mobile application capturing system.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study using a household sample was conducted in 10 areas of Gautam Budhnagar district, Uttar Pradesh, India, from January 31, 2020, to March 31, 2021, to assess the feasibility of identification of oral lesions by community health workers using a mobile phone application compared with diagnosis by trained dentists in a screening clinic. Men and women aged 30 years or older as well as tobacco users younger than 30 years were eligible for screening.

INTERVENTIONS

Screening by trained community health workers vs dentists.

RESULTS

A total of 1200 participants were screened by the community health workers during their home visits; of these, 1018 participants (526 [51.7%] men; mean [SD] age, 35 [16] years) were also referred and screened by the dentists a clinic. There was near-perfect agreement (κ = 0.9) between the findings of the community health workers and the dentists in identifying the positive or negative cases with overall sensitivity of 96.69% (95% CI, 94.15%-98.33%) and specificity of identification of 98.69% (95% CI, 97.52%-99.40%).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, trained community health workers were able after initial supervision by qualified dentists to perform oral cancer screening programs. These findings suggest that community health workers can perform this screening in resource-constrained settings.

Educational intervention on cervical and breast cancer screening: Impact on nursing students involved in primary care

Introduction:

Nurses are the foundation of the Indian health system. They play a crucial role in primary care and implementation of community-centered government health initiatives such as cancer screening. The purpose of this manuscript is to share the experience of this educational intervention study and emphasize the need for drastic medical education reforms to include curricula to strengthen knowledge about cancer screening among nursing students.

Methods:

A one-day workshop on “Cervical and breast cancer screening” was conducted for nursing students pursuing BSc Nursing (Group 1) and General Nursing and Midwifery (GNM) (Group 2) in India. A structured, self-administered questionnaire was administered among consented participants before and after the workshop to assess their knowledge and awareness on the subject at the baseline and the improvement they gained after the workshop.

Results:

Ninety-one students attempted both pre and post-surveys, of which 56 were from Group 1 and 35 from Group 2. Students demonstrated statistically significant improvements in knowledge on cervical and breast cancer screening after participating in the workshop.

Conclusion:

Undergraduate nursing education curricula must undergo medical education reform to include education and training for nurses in cancer screening and further motivate their increased participation in preventive cancer screening programs.

Asking physicians how best to implement cervical cancer prevention services in India: A qualitative study from Mysore

Cervical cancer is the second most common cancer among Indian women. Screening is an effective prevention strategy, but achieving high screening rates depend upon identifying barriers at multiple levels of healthcare delivery. There is limited research on understanding the perspectives of providers who deliver cancer prevention services. The objective of this study was to explore physician perspectives on cervical cancer prevention, barriers to effective implementation, and strategies to overcome these barriers in India. Guided by the "Multilevel influences on the Cancer Care Continuum" theoretical framework, we conducted semi-structured interviews with physicians in Mysore, India. From November 2015- January 2016, we interviewed 15 (50.0%) primary care physicians, seven (23.3%) obstetrician/gynecologists, six (20.0%) oncologists, and two (6.7%) pathologists. We analyzed interview transcripts in Dedoose using a grounded theory approach. Approximately two-thirds (n = 19, 63.3%) of the participants worked in the public sector. Only seven (23.3%) physicians provided cervical cancer screening, none of them primary care physicians. Physicians discussed the need for community-level, culturally-tailored education to improve health literacy and reduce stigma surrounding cancer and gynecologic health. They described limited organizational capacity in the public sector to provide cancer prevention services, and emphasized the need for further training before they could perform cervical cancer screening. Physicians recommend an integrated strategy for cervical cancer prevention at multiple levels of uptake and delivery with specific efforts focused on culturally-tailored stigma-reducing education, community-level approaches utilizing India's community health workers, and providing physician training and continuing education in cancer prevention.

Congenital Transformation Zone Mimicking Cervical Premalignant Lesion

Introduction

Congenital transformation zone (CTZ) of the uterine cervix is a non-neoplastic, rare condition resembling high-grade lesions on colposcopic examination which leads to diagnostic dilemmas.Case DescriptionA multiparous woman was screened for cervical cancer. Visual inspection using acetic acid was positive for which further evaluation with colposcopy was done. An aceto-white lesion resembling high-grade precancerous condition was seen. Punch biopsy was taken from multiple areas and the histopathology report demonstrated chronic cervicitis with increased maturation of the superficial layers of squamous epithelium. The lesion persisted on the follow-up colposcopy even after a course of antibiotics.

Discussion

CTZ could be difficult to differentiate from cervical premalignant lesions. The main aim of this article is to help other colposcopists to understand this physiological variant.

Conclusion

The CTZ is a physiological entity and differential diagnosis for cervical premalignant lesions on colposcopy.

Leveraging Technology for Nation-Wide Training of Healthcare Professionals in Cancer Screening in India: a Methods Article

The Indian Council of Medical Research-National Institute of Cancer Prevention and Research (ICMR-NICPR) has been conducting online cancer screening training certificate courses since 2017. Thereafter, multiple cohorts have been trained successfully in cancer screening using the Extensions for Community Healthcare Outcomes (ECHO) platform. A 14-week course was designed for various cadres of healthcare professionals (HCP), through which they were trained in cancer screening and their roles and responsibilities in implementing the population-based cancer screening, as per the operational framework released by the Ministry of Health and Family Welfare. Then, a contact program was held to upskill the participants in cancer screening techniques. Eight cohorts have been successfully trained using the hybrid model of online training and hands-on training. Cancer screening conducted utilizing the hybrid model, consisting of the online ECHO model, followed by hands-on training is a suitable training model to train large cohorts, such as the one in populous countries like India.

Abstract 87: Virtual Mentoring of Dentists in Oral Cancer Screening and Tobacco Cessation: An Advanced Level Program

Purpose: Oral cancer is the third common cancer in India, the mortality of which can be reduced by early detection. Dentists are ideal for this task and tobacco cessation owing to their forte of work. This paper discusses findings of a Project ECHO (Extension for Community Health Outcome)-based advanced telementoring program in these areas for dentists across India.

Methods: The 14-week long training program in 2018, with weekly, hour-long sessions conducted by our Organization (hub) on Zoom app, had 52 participants (spokes) from across India. Each session comprised of an expert-led didactic, and case discussions by spokes. Participants were evaluated through online, pre- and post-training, and weekly post-session quizzes, along with weekly and post-one-year feedback. Successful spokes attended a hands-on workshop at our organization subsequently.

Results: A notable increase in the overall and per-session mean knowledge score, and confidence in oral cancer screening was seen among the spokes. Many started such services at their respective clinics (and continued till even a year later) and reduced referrals to other healthcare facilities for confirmation of their diagnosis. They also felt motivated to spread community awareness about oral cancer prevention.

Conclusion: The ECHO telementoring model comprising of expert didactics, case discussions by spokes, along with significant interaction between the spokes and experts, is a promising best-practice tool to reduce knowledge and skills disparity regarding oral cancer prevention among dentists situated across different locations. This in turn would enable these most appropriate healthcare providers to contribute towards the overall goal of oral cancer prevention.

Citation Format: Suzanne Nethan, Amrita John, Priyanka Ravi, Vipin Kumar, Kavitha Dhanasekaran, Roshni Babu, Roopa Hariprasad. Virtual Mentoring of Dentists in Oral Cancer Screening and Tobacco Cessation: An Advanced Level Program [abstract]. In: Proceedings of the 9th Annual Symposium on Global Cancer Research; Global Cancer Research and Control: Looking Back and Charting a Path Forward; 2021 Mar 10-11. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2021;30(7 Suppl):Abstract nr 87.

Developing a Robust and Flexible Web Service Framework for Medical Care

The rapid growth of Internet technologies and availability of web tools created an opportunity to develop a robust and user-friendly web service model for medical care, and it demands urgent solutions as the uncertainty of disease spread threaten humanity. With changing Quality of Service principles, many existing web services need to offer specific medical services that suit practical needs. The provision of an effective service selection and recommendation features that best meet the user's requirements will be able to improve the quality of web service model. The Quality of Service metrics should be calculated and analyzed before optimizing a recommendation technique. Evaluation therefore forms an important part of the process for designing and implementing recommendation systems. Further, predicting Quality of Service indicators accurately from historical background dataset under complex scenarios and combination of conditions is useful. In this perspective, lots of web service methods are studied, and this paper presents our comprehensive analysis mainly focusing on the development of better web service based framework for medical applications.

Subtherapeutic Rifampicin Concentration Is Associated With Unfavorable Tuberculosis Treatment Outcomes

BACKGROUND

The relationships between first-line drug concentrations and clinically important outcomes among patients with tuberculosis (TB) remain poorly understood.

METHODS

We enrolled a prospective cohort of patients with new pulmonary TB receiving thrice-weekly treatment in India. The maximum plasma concentration of each drug was determined at months 1 and 5 using blood samples drawn 2 hours postdose. Subtherapeutic cutoffs were: rifampicin <8 µg/mL, isoniazid <3 µg/mL, and pyrazinamide <20 µg/mL. Factors associated with lower log-transformed drug concentrations, unfavorable outcomes (composite of treatment failure, all-cause mortality, and recurrence), and individual outcomes were examined using Poisson regression models.

RESULTS

Among 404 participants, rifampicin, isoniazid, and pyrazinamide concentrations were subtherapeutic in 85%, 29%, and 13%, respectively, at month 1 (with similar results for rifampicin and isoniazid at month 5). Rifampicin concentrations were lower with human immunodeficiency virus coinfection (median, 1.6 vs 4.6 µg/mL; P = .015). Unfavorable outcome was observed in 19%; a 1-μg/mL decrease in rifampicin concentration was independently associated with unfavorable outcome (adjusted incidence rate ratio [aIRR], 1.21 [95% confidence interval {CI}, 1.01-1.47]) and treatment failure (aIRR, 1.16 [95% CI, 1.05-1.28]). A 1-μg/mL decrease in pyrazinamide concentration was associated with recurrence (aIRR, 1.05 [95% CI, 1.01-1.11]).

CONCLUSIONS

Rifampicin concentrations were subtherapeutic in most Indian patients taking a thrice-weekly TB regimen, and low rifampicin and pyrazinamide concentrations were associated with poor outcomes. Higher or more frequent dosing is needed to improve TB treatment outcomes in India.

Capacity Building of Gynecologists in Cancer Screening Through Hybrid Training Approach

Training health care professionals (HCPs) is one of the most challenging and key factors for the success of a cancer screening program. In order to make this onerous task possible, a hybrid training model, combining the online knowledge-sharing tool of ECHO (Extension of Community Health Outcomes) and in-person training, was proposed by the National Institute of Cancer Prevention and Research (NICPR). The main aim of this article is disseminating our experience on the effectiveness of this hybrid model in training health care providers in cancer prevention. A group of gynecologists was trained using a structured curriculum in cervical and breast cancer screening through a 14-week online course, followed by a three-day in-person training (group A). To analyze the effectiveness of this model, a group of gynecologists who were not part of the online course were enrolled for face-to-face training (group B). All the participants were offered pre- and post-training questionnaires and a pictorial quiz. Group A participants had 60% and 40% more knowledge in cervical and breast cancer screening, respectively, compared with group B before the in-person training. Though group B demonstrated a 51% increase in knowledge post-training, group A performed 26% better than group B in the pictorial quiz-demonstrating better knowledge acquisition. This hybrid training model, when employed in capacity building in cancer screening among gynecologists, works very effectively in improving knowledge and skill set in cancer screening. This can be a potent tool for the government for efficient training of HCPs in cancer screening.

Evaluation of a Chip-Based, Point-of-Care, Portable, Real-Time Micro PCR Analyzer for the Detection of High-Risk Human Papillomavirus in Uterine Cervix in India

PURPOSE

Currently available human papillomavirus (HPV) detection devices are expensive, requiring a continuous power supply, high-priced reagents, skilled laboratory personnel, and infrastructure. These make it difficult to implement primary HPV screening in high-risk (HR) populations, particularly in low-income settings such as in India. The objective of our study was to evaluate the diagnostic performance of a point-of-care, portable, battery-operated device called Truenat, which detects 4 HR HPV genotypes (16, 18, 31, and 45), as a potentially cost-effective alternative to conventional HPV diagnostic tests.

PATIENTS AND METHODS

This was a single-site, blinded, cross-sectional study that evaluated the performance of the Trunat HPV-HR using cervical samples collected from nonpregnant women > 30 years old via consecutive sampling. The comparison was conducted against the Hybrid Capture 2 (HC2) method. All the positive samples were validated by 14 Real-TM Quant Kit.

RESULTS

Of 615 cervical samples, the HR-HPV DNA test was positive in 78 women (12.7%) by HC2 and in 49 (8%) by Truenat. With the consideration of limited genotype inclusivity, the sensitivity and specificity of Truenat HPV-HR were 97.7% and 98.9%, respectively.

CONCLUSION

The performance of Truenat HPV-HR test was comparable to that of HC2 in the 4 HPV genotypes and would be appropriate to consider for use in primary HR cervical cancer screening and particularly in low-income settings.

Factors influencing the retention of participants in online cancer screening training programs in India

BACKGROUND

Online courses have broken the boundaries in imparting knowledge. While in western countries e-learning in medical education is well accepted, it is still an upcoming field in low- and middle-income countries like India. Attrition is a major threat to online courses world-wide. The objective of this article is to share the experiences in conducting online cancer screening courses, reasons for attrition and ways to improve retention.

METHODS

Online training program in preventive oncology for medical professionals is being conducted since 2017, which is 14-week long with weekly one-hour sessions and specific curriculum for healthcare professionals. Since the retention of participants was a major challenge in all the courses, a short online survey was conducted to identify the reason behind quitting the course and suggestions to improve retention. The data was analyzed in November 2019.

RESULTS

Among 614 enrolments, 26% (159/614) refused to attend the course and only 55% (252/455) completed the course successfully. Among the attendees 52% (238/455) were females, 71% (325/455) were from the public sector and 71% (324/455) were non-specialists. The attrition was high among non-specialists 49% (160/324), male participants 57% (124/217) and public sector doctors 52% (170/325). The main reasons for quitting the course were high workload in the health facilities 75% (52/69) and poor internet connectivity 12% (8/69).

CONCLUSION

The internet connectivity should be strengthened in all the healthcare centers to facilitate e-learning. A dedicated time-slot should be allotted to the providers for e-learning and updating their knowledge in addition to their routine work.

Malignant perivascular epithelioid tumor of the vagina: Report of a rare case with brief review of literature

Perivascular epithelioid cell tumors (PEComas) are rare mesenchymal tumors with immunohistochemical co-expression of melanocytic and myoid markers. Vaginal PEComas have been described in only nine cases so far. We describe the case of a 65-year-old female with a large growth in the left lateral vaginal wall. Biopsy imprint smears showed dispersed tumor cells with anisonucleosis, multinucleation, and bizarre forms, suggestive of a malignant tumor. Histopathology, however, showed perivascular arrangement of clear epithelioid cells, focal necrosis, intracellular brown pigment in few cells, and mitotic activity at 2 to 3 per 50 high power fields. Immunohistochemical positivity for vimentin, HMB-45, S-100 protein, desmin, and MyoD1 assisted in rendering a final pathological diagnosis of malignant PEComa of the vagina. Further work-up revealed metastatic deposits in liver and retroperitoneal lymph nodes. PEComa arising in vagina is an unusual phenomenon with the malignant variant being an extremely rare tumor. Awareness of the characteristic morphology and utilization of a panel of immunohistochemical stains are mandatory to be able to make a precise diagnosis and appropriate prognostication.

Association of metabolic NCD risk factors with oral, breast and cervical precancers and cancers in India

OBJECTIVE

To find an association between metabolic non-communicable disease (NCD) risk factors (high blood pressure (BP), high random blood sugar (RBS) and overweight /obesity) and oral, breast, cervical cancers/precancerous or potentially malignant conditions.

DESIGN

This is an observational study using convenience sampling. The participants were screened through opportunistic or population-based screening.

SETTING

The study was conducted at a health promotion clinic (HPC) located in Northern India under the Indian Council of Medical Research. HPC is a screening clinic where screening is done for hypertension (HT), diabetes mellitus (DM), obesity, and oral, breast and cervical cancers. The study was conducted between December 2016 and January 2019.

PARTICIPANT

The number of participants screened was 8352 (6712 women and 1640 men). All consenting men and women above 18 years were included. All participants were screened for oral cancer, DM, HT and obesity. All women were also screened for breast and cervical cancers. Cervical screening was done for non-pregnant women 21 years and above with history of sexual activity.

RESULT

Oral potentially malignant disease (OPMD) was the most prevalent, followed by breast cancer, oral cancer, cervical cancer and cervical precancer. High RBS had a strong association with oral cancer (OR=2.29, 95% CI 1.09 to 4.82, p=0.03) and breast cancer (OR=1.95, 95% CI 1.01 to 3.76, p=0.05). High BP had a strong association with breast cancer (OR=2.50, 95% CI 1.43 to 4.35, p<0.0001). An inverse association was noted between oral cancer and overweight/obesity (OR=0.20, 95% CI 0.08 to 0.48, p<0.0001). Current tobacco use was strongly associated with oral cancer (OR=6.51, 95% CI 3.63 to 11.67, p<0.0001) and OPMD (OR=9.82, 95% CI 8.13 to 11.86, p<0.0001). No association was elicited between the metabolic NCD risk factors and cervical cancer/precancer.

CONCLUSIONS

The study reaffirms that NCD metabolic risk factors determine oral and breast cancers. Besides NCD risk factors, current tobacco use was a strong determinant of OPMD and oral cancer. Hence, primary and primordial prevention measures to control NCD metabolic risk factors and tobacco use should move along with secondary prevention of breast and oral cancers.

Reappraisal of cytology-histology correlation in cervical cytology based on the recent American Society of Cytopathology guidelines (2017) at a cancer research centre

OBJECTIVE

To assess the impact of recently published American Society of Cytopathology (ASC) guidelines (2017) on the conduct of cervical cytology-histology correlation (CHC).

METHODS

A retrospective review was conducted for cervical biopsies with their corresponding conventional cervical smears over a 7.5-year period (January 2011-June 2018). As per the ASC guidelines, a discrepancy assessment grid was prepared. Major cytology-histology discordance was defined as a diagnosis of high-grade squamous intraepithelial lesion (HSIL) or CIN2+ in one of the tests with negative result in the other. Smears and biopsies of all discordant cases were reviewed for reasons of overcall and undercall.

RESULTS

Of the 341 cervical biopsies with corresponding Papanicolaou smear, cytology-histology agreement was noted in 249 (73%) cases. Major discordance was observed in 22 cases (6.4%)-16 undercalls and six overcalls on cytology-while minor discrepancies were noted in 70 cases. Atypical metaplasia and repair changes were the main reasons for overcall while small HSIL cells in atrophic smear and scant HSIL cells were important causes of undercall on cytology review. Using the ASC guidelines, we could improvise upon the existing CHC methodology for categorisation of cyto-histological pairs of cases with a cytological diagnosis of atypical glandular cells.

CONCLUSION

The present study demonstrates, for the first time, that the recent ASC guidelines facilitate cervical CHC, especially for categorisation of cases with atypical glandular cells on cytology. Uniform application of these guidelines would standardise the conduct of cervical CHC internationally and provide scope for inter-laboratory comparison of data as well as enhance self-learning and peer learning.

Smoking, alcohol use disorder and tuberculosis treatment outcomes: A dual co-morbidity burden that cannot be ignored

BACKGROUND

More than 20% of tuberculosis (TB) disease worldwide may be attributable to smoking and alcohol abuse. India is the second largest consumer of tobacco products, a major consumer of alcohol particularly among males, and has the highest burden of TB globally. The impact of increasing tobacco dose, relevance of alcohol misuse and past versus current or never smoking status on TB treatment outcomes remain inadequately defined.

METHODS

We conducted a multi-centric prospective cohort study of newly diagnosed adult pulmonary TB patients initiated on TB treatment and followed for a minimum of 6 months to assess the impact of smoking status with or without alcohol abuse on treatment outcomes. Smokers were defined as never smokers, past smokers or current smokers. Alcohol Use Disorder Identification Test (AUDIT) scores were used to assess alcohol misuse. The association between smoking status and treatment outcomes was assessed in univariate and multivariate random effects poisson regression models.

RESULTS

Of 455 enrolled, 129 (28%) had a history of smoking with 94 (20%) current smokers and 35 (8%) past smokers. Unfavourable treatment outcomes were significantly higher among past and current smokers as compared to never smokers. Specifically, the risk of treatment failure was significantly higher among past smokers (aIRR = 2.66, 95% CI: 1.41-4.90, p = 0.002), recurrent TB among current smokers (aIRR = 2.94, 95% CI: 1.30-6.67, p = 0.010) and death among both past (2.63, 95% CI: 1.11-6.24, p = 0.028) and current (aIRR = 2.59, 95% CI: 1.29-5.18, p = 0.007) smokers. Furthermore, the combined effect of alcohol misuse and smoking on unfavorable treatment outcomes was significantly higher among past smokers (aIRR: 4.67, 95% CI: 2.17-10.02, p<0.001) and current smokers (aIRR: 3.58, 95% CI: 1.89-6.76, p<0.001).

CONCLUSION

Past and current smoking along with alcohol misuse have combined effects on increasing the risk of unfavourable TB treatment outcomes. Innovative interventions that can readily address both co-morbidities are urgently needed.

Diabetes and pre-diabetes among household contacts of tuberculosis patients in India: is it time to screen them all?

SETTING

Pre-diabetes mellitus (pre-DM) and DM increase the risk of developing tuberculosis (TB). Screening contacts of TB patients for pre-DM/DM and linking them to care may mitigate the risk of developing TB and improve DM management.

OBJECTIVE

To measure the prevalence of pre-DM/DM and associated factors among the adult household contacts (HHCs) of pulmonary TB patients.

METHODS

Between August 2014 and May 2017, adult HHCs of newly diagnosed adult PTB patients in Pune and Chennai, India, had single blood samples tested for glycosylated haemoglobin (HbA1c) at enrolment. DM was defined as previously diagnosed, self-reported DM or HbA1c 6.5%, and pre-DM as HbA1c between 5.7% and 6.4%. Latent tuberculous infection (LTBI) was defined as a positive tuberculin skin test (5 mm induration) or QuantiFERON® Gold In-Tube (0.35 international units/ml).

RESULTS

Of 652 adult HHCs, 175 (27%) had pre-DM and 64 (10%) had DM. Forty (64%) HHCs were newly diagnosed with DM and 48 (75%) had poor glycaemic control (HbA1c 7.0%). Sixty-eight (22%) pre-DM cases were aged 18-34 years. Age 35 years, body mass index 25 kg/m2, chronic disease and current tobacco smoking were significantly associated with DM among HHCs.

CONCLUSIONS

Adult HHCs of TB patients in India have a high prevalence of undiagnosed DM, pre-DM and LTBI, putting them at high risk for developing TB. Routine DM screening should be considered among all adult HHCs of TB.

Cervical Cancer Screening Services at Tertiary Healthcare Facility: An Alternative Approach

Introduction:

India fights massive cervical cancer burden. This article highlights an innovative feasible approach enabling tertiary hospitals to contribute to cancer prevention without compromising their primary mandate to provide treatment.

Methodology:

Since 1979, National Institute of Cancer Prevention and Research (NICPR) support a tertiary hospital in cervical cancer screening through a satellite clinic. Record review of 5328 attendees of this clinic between January-December 2016 was done. Pap-smear testing and reporting were performed by trained NICPR personnel. Patients’ demographics, reproductive history, Pap-test date, cytology results were recorded and results were communicated to respective units for further management.

Results:

Among 5328 women screened, 2% (96/5328) had abnormal cytology, which included malignancy(33%; 32/96), Atypical Squamous Cells-Undetermined Significance(ASC-US) (20%; 19/96), Atypical Glandular Cells(AGC) (23%; 22/96) with complaints of pain in lower abdomen 65.6%(59/90), white discharge per vaginum 46.7%(42/90) and backache 23.3%(21/90). In which, Muslims- 67% (65/96), illiterates- 58% (56/96). Age>35(p<0.001), parity>3(p<0.05), illiteracy (p<0.05), Muslim women (p<0.05) had positive association with abnormal cytology.

Conclusion:

Awareness about cervical cancer screening is the immediate need in resource-limited countries. Government hospitals in such countries should house dedicated preventive oncology unit for cancer screening.

Tuberculin skin test and QuantiFERON-Gold In Tube assay for diagnosis of latent TB infection among household contacts of pulmonary TB patients in high TB burden setting

BACKGROUND

World Health Organization (WHO) recommends systematic screening of high-risk populations, including household contacts (HHCs) of adult pulmonary tuberculosis (TB) patients, as a key strategy for elimination of TB. QuantiFERON-TB Gold In-Tube (QFT-GIT) assay and tuberculin skin test (TST) are two commonly used tools for the detection of latent tuberculosis infection (LTBI) but may yield differential results, affecting eligibility for TB preventive therapy.

MATERIALS AND METHODS

A prospective cohort study of adult pulmonary TB patients and their HHCs were recruited in 2 cities of India, Pune and Chennai. HHCs underwent QFT-GIT (QIAGEN) and TST (PPD SPAN 2TU/5TU). A positive QFT-GIT was defined as value ≥0.35 IU/ml and a positive TST as an induration of ≥5 mm. A secondary outcome of TST induration ≥10mm was explored. Proportion positive by either or both assays, discordant positives and negatives were calculated; test concordance was assessed using percentage agreement and kappa statistics; and risk factors for concordance and discordance including age categories were assessed using logistic regression. Sensitivity and specificity was estimated by latent class model.

RESULTS

Of 1048 HHCs enrolled, 869 [median (IQR) age: 27 years (15-40)] had both TST and QFT-GIT results available and prevalence of LTBI by QFT-GIT was 54% [95% CI (51, 57)], by TST was 55% [95% CI (52, 58)], by either test was 74% [95% CI (71, 77) and by both tests was 35% [95% CI (31, 38)]. Discordance of TST+/QFT-GIT- was 21% while TST-/QFT-GIT+ was 26%. Poor to fair agreement occurred with TST 5mm or 10mm cutoff (60 and 61% agreement with kappa value of 0.20 and 0.25 respectively). Test agreement varied by age, TST strength and induration cut-off. In multivariate analysis, span PPD was a risk factor for QFT-GIT+ and TST- while absence of BCG scar was for TST+ and QFT-GIT-. Being employed and exposure to TB case outside the household case were associated with positivity by both the tests. Sensitivity of TST and QFT-GIT to diagnose LTBI was 77% and 69%. Probability of having LTBI was >90% when both tests were positive irrespective of exposure gradient.

CONCLUSION

Prevalence of LTBI among HHCs of adult pulmonary TB patients in India is very high and varies by test type, age, and exposure gradient. In our high TB burden setting, a strategy to treat all HHCs or a targeted strategy whereby an exposure index is used should be assessed in future preventive therapy and vaccine studies as HHCs have several factors that place them at high risk for progression to TB disease.

Pharmacokinetics of norethisterone following its oral administration and by spraying it nasally or sublingually to male bonnet monkeys

Pharmacokinetic parameters of norethisterone (NET) were studied in eight adult male bonnet monkeys following the administration of a single dose of 300 ug. The animals were crossed over between the following three routes of administration: oral ingestion, nasal and sublingual spraying. The results indicate that NET was readily absorbed by all three routes but the Cmax and AUC of NET were significantly greater by the sublingual route. No significant difference in the t 1/2 alpha or t 1/2 beta was observed between the three routes. These findings suggest that the sublingual route offers the possibility of reducing the effective dose of NET, which is widely used for contraceptive purposes.