Heart failure, the global pandemic: A call to action consensus statement from the global presidential conclave at the platinum jubilee conference of cardiological society of India 2023

Heart failure (HF) is emerging as a major public health problem both in high- and low - income countries. The mortality and morbidity due to HF is substantially higher in low-middle income countries (LMICs). Accessibility, availability and affordability issues affect the guideline directed therapy implementation in HF care in those countries. This call to action urges all those concerned to initiate preventive strategies as early as possible, so that we can reduce HF-related morbidity and mortality. The most important step is to have better prevention and treatment strategies for diseases such as hypertension, ischemic heart disease (IHD), type-2 diabetes, and rheumatic heart disease (RHD) which predispose to the development of HF. Setting up dedicated HF-clinics manned by HF Nurses, can help in streamlining HF care. Subsidized in-patient care, financial assistance for device therapy, use of generic medicines (including polypill strategy) will be helpful, along with the use of digital technologies.

Association of transient mitochondrial functional impairment with acute heat exposure in children from Muzaffarpur region of Bihar, India

Over the past several years, the Muzaffarpur district of Bihar (India) has witnessed recurrent outbreaks of acute encephalitis illness of unknown etiology, called acute encephalitis syndrome (AES) among young children, especially during the peak-summer season. Pesticide exposure, viral encephalitis, and litchi toxin intake have all been postulated as potential sources of the ailment. However, no conclusive etiology for AES has been identified in the affected children. During recent rounds of the outbreak, metabolic abnormalities have been documented in these children, and a direct correlation was observed between higher environmental temperature during the peak-summer month and AES caseload. The clinical and metabolic profiles of these children suggested the possible involvement of mitochondrial dysfunction during heat stress as one of the several contributory factors leading to multisystem metabolic derangement. The present study observed that mitochondrial function parameters such as cell death, mitochondrial membrane potential, oxidative stress, and mitochondrial pathway-related gene expression in peripheral blood mononuclear cells (PBMCs) isolated from children were affected in peak-summer when compared to post-summer months. Similar observations of mitochondrial function parameters along with impaired bioenergetic parameters were demonstrated in the heat-exposed model of PBMCs isolated from healthy adult individuals. In conclusion, the results suggested that there is an association of transient mitochondrial dysfunction when exposed to sustained heat during the summer months. One may consider mitochondrial dysfunction as one of the important factors leading to an outbreak of AES among the children from affected regions though this needs to be substantiated with further studies.

Impact of COVID-19 on heart failure hospitalization and outcome in India - A cardiological society of India study (CSI-HF in COVID 19 times study - "The COVID C-HF study")

OBJECTIVES

The presentation and outcomes of acute decompensated heart failure (ADHF) during COVID times (June 2020 to Dec 2020) were compared with the historical control during the same period in 2019.

METHODS

Data of 4806 consecutive patients of acute HF admitted in 22 centres in the country were collected during this period. The admission patterns, aetiology, outcomes, prescription of guideline-directed medical therapy (GDMT) and interventions were analysed in this retrospective study.

RESULTS

Admissions for acute heart failure during the pandemic period in 2020 decreased by 20% compared to the corresponding six-month period in 2019, with numbers dropping from 2675 to 2131. However, no difference in the epidemiology was seen. The mean age of presentation in 2019 was 61.75 (±13.7) years, and 59.97 (±14.6) years in 2020. There was a significant decrease in the mean age of presentation (p = 0.001). Also. the proportion of male patients decreased significantly from 68.67% to 65.84% (p = 0.037). The in-hospital mortality for acute heart failure did not differ significantly between 2019 and 2020 (4.19% and 4.,97%) respectively (p = 0.19). The proportion of patients with HFrEF did not change in 2020 compared to 2019 (76.82% vs 75.74%, respectively). The average duration of hospital stay was 6.5 days.

CONCLUSION

The outcomes of ADHF patients admitted during the Covid pandemic did not differ significantly. The length of hospital stay remained the same. The study highlighted the sub-optimal use of GDMT, though slightly improving over the last few years.

Acute Encephalopathy in Children From Muzaffarpur, Bihar, India, and the Potential Role of Ambient Heat Stress-Induced Mitochondrial Dysfunction

BACKGROUND

Periodic outbreaks of acute encephalopathy in children have been reported from Muzaffarpur, Bihar, India. No infectious cause has been identified for this. This study presents the clinical and metabolic profile of children hospitalized with acute encephalopathy and the potential role of ambient heat stress.

METHODS

This cross-sectional study included children (<15 years) with acute encephalopathy admitted from April 4, 2019, to July 4, 2019. The clinical and laboratory investigations included infections, metabolic abnormalities, and muscle tissue analysis. The children who had metabolic derangements but no infectious cause were labeled as acute metabolic encephalopathy. The descriptive analysis summarized the clinical, laboratory, and histopathology findings, and their association with the ambient heat parameters was explored.

RESULTS

Out of the 450 children hospitalized (median age, four years), 94 (20.9%) died. Children had early morning onset (89%), seizures (99%), fever (82%), hypoglycemia at admission (64%), raised aminotransferases (60%), and high blood urea (66%). Blood lactate (50%), lactate dehydrogenase (84%), pyruvate (100%), ammonia (32%), and creatinine phosphokinase (69%) were raised. Viral marker tests were negative. The patients had abnormal metabolic markers like decreased blood-free carnitine, elevated blood acylcarnitines, and elevated urinary lactate, oxalate, maleate, adipate, and fatty acid metabolites. Blood carnitine and acylcarnitine levels normalized in 75% of the patients treated with carnitine and coenzyme-Q. Muscle tissues showed megamitochondria on electron microscopy and reduced respiratory enzyme complex-I activity. A significant correlation between the number of admissions and ambient heat indices was observed.

CONCLUSIONS

The findings suggest secondary mitochondrial dysfunction as a possible mechanism for acute encephalopathy in children from Muzaffarpur, Bihar, and ambient heat stress as a possible risk factor.

A note on the insecticide susceptibility status of secondary malaria vector An. annularis in Jharkhand state of India

BACKGROUND & OBJECTIVES

An. annularis van der Wulp (1884) is the secondary malaria vector of importance in India. In Jharkhand state it is present in almost all the districts abundantly and transmits malaria. The development of resistance to Dichlorodipheny ltrichloroethane (DDT) in An. annularis was reported from various parts of India. The main objective of this study was to generate information on insecticide susceptibility status of An. annularis to DDT, malathion, deltamethrin and permethrin in different districts of Jharkhand state. Methods; Adult An. annularis female mosquitoes were collected form villages of six tribal districts Simdega (Kurdeg and Simdega CHC), Khunti (Murhu and Khunti CHCs), Gumla (Bharno and Gumla CHCs), West Singhbhum (Chaibasa and Bada Jamda CHCs), Godda (Poraiyahat and Sunderpahari (CHCs) and Sahibganj (Borio and Rajmahal CHCs). Insecticide susceptibility status was determined by using WHO tube test method against prescribed discriminatory dosages of insecticides, DDT - 4.0%, malathion - 5.0%, deltamethrin - 0.05% and permethrin - 0.75%.

RESULTS

An. annularis was reported resistant to DDT in six districts, possible resistant to malathion in districts Gumla, Khuntiand Sahibganj and susceptible to deltamehrin (98% to100% mortality) and permethrin (100% mortality).

INTERPRETATION & CONCLUSION

An. annularis, the secondary vector species is associated with the transmission of malaria reported resistant to DDT and susceptible to pyrerthroids deltamethrin and permethrin. In view of large-scale distribution of long-lasting insecticidal nets (LLINs) in all the districts, the response to synthetic pyrethroid needs to be periodically monitored to assess the effectiveness.

A Longer Quarantine Period May Be Needed for Effective Control of COVID-19 Transmission: Experience From Odisha, India

Background

The novel coronavirus disease (COVID-19) has become pandemic. For effective disease control, quarantine of the infected and exposed cases for an optimal period is critical. Currently, infected individuals are quarantined for 14 days. We tried to check if the quarantine period practiced is optimal in the Indian context.

Methods

This cross-sectional study was conducted in Odisha, India. We compiled and analyzed the information of 152 laboratory-confirmed SARS-CoV-2 positive cases. Descriptive analysis was conducted.

Results

Out of the 152 cases, 80% were males, 9.8% were symptomatic, 66.4% had travel history, and 53.9% had contact with COVID-19 cases. The incubation period ranged from 1-50 days with a median of 19.5 days (IQR: 17-27 days). The median periods were similar according to gender, history of contact, and presence of symptoms. Interestingly, 84.7% of the cases had an incubation period of more than 14 days. To cover 95% and 90% of the individuals, the quarantine period may have to be extended to 38 days and 35 days, respectively.

Conclusion

A longer observed incubation period (minimum 28 days) suggests the extension of the quarantine period for adults beyond the presently practiced 14 days. Considering the fast-spreading outbreak, an extended quarantine period for 28 days or active periodic follow-up could be more effective.

Rheumatic Heart Disease in India in 2020: Advances in Diagnostic and Therapeutic Options

Rheumatic Fever (RF)/ Rheumatic Heart Disease (RHD) is the result of autoimmune response triggered by group A Beta-haemolytic streptococcal pharyngitis leading to immune-inflammatory injury to cardiac valves. It is practically disappeared in developed countries. However, it continues to be a major cause of disease burden among children, adolescents, and young adults in low-income countries and even in high-income countries with socioeconomic inequalities. For decades, many cases of Acute Rheumatic Fever (ARF) and RHD were missed and were denied the secondary prophylaxis, as a result these patients used to end up with complications and untimely death. Advanced understanding of the echocardiography can prevent both under diagnosis and over diagnosis and thus help in management strategy. Another new advancement in recent past is the mitral valve repair, which is technically demanding, and the results are acceptable in experienced cardiac surgical units. Whenever feasible, valve repair should be preferred over valve replacement since it precludes the need for anticoagulation and future risks of prosthesis dysfunction.

Insecticide susceptibility status of malaria vectors, Anopheles culicifacies, Anopheles fluviatilis and Anopheles minimus in the tribal districts of Jharkhand state of India

BACKGROUND AND OBJECTIVES

Insecticide resistance in malaria vectors has been a major challenge to vector control programs and updated information to the commonly used insecticides is essential for planning appropriate vector control measures. Anopheles culicifacies and An. fluviatilis are the two main vectors prevalent in Jharkhand state of India and role of An. minimus is contemplated in the transmission of malaria in this state. All the districts in the state are predominantly inhabited by the tribal population and are endemic for malaria. A study was undertaken in 12 districts of Jharkhand state to determine the insecticide susceptibility status of the 3 prevalent primary vector species, An. culicifacies, An. fluviatilis, and An. minimus.

METHODS

Wild-caught adult female An. culicifacies, An. fluviatilis, and An. minimus, mosquitoes were collected from stratified ecotypes from different localities of 12 tribal districts of Jharkhand state during 2018 and 2019. Susceptibility tube tests were conducted following the WHO method using test kits. Mosquitoes were exposed to WHO impregnated papers with the prescribed discriminatory dosages of DDT - 4%, malathion - 5%, deltamethrin - 0.05%, permethrin - 0.75%, cyfluthrin - 0.15% and lambda cyhalothrin - 0.05%.

RESULTS

Results indicated that An. culicifacies has developed multiple insecticide resistance in all the 12 districts of Jharkhand state. An. fluviatilis was reported resistant for the first time to DDT in all the districts but was susceptible to malathion, deltamethrin, and permethrin whereas in one district it showed possible resistance to malathion. An. minimus was studied in Noamundi CHC of West Singhbhum district, showed possible resistance against DDT but was susceptible to malathion, deltamethrin, and permethrin.

INTERPRETATION & CONCLUSION

The development of multiple insecticide resistance in An. culicifacies including to pyrethroids, has been a concern for malaria control programmes for effective vector management but a report of resistance to DDT for the first time in An. fluviatlis in all the districts in the state is alarming, An. minimus was found in possible resistance category to DDT in one district and both the species were reported susceptible to malathion, deltamethrin, and permethrin. The result of the present study indicates a need for regular monitoring to assess the insecticide susceptibility to formulate effective vector control measures and resistance management.

Consensus and development of document for management of stabilized acute decompensated heart failure with reduced ejection fraction in India

Aim

Ensuring adherence to guideline-directed medical therapy (GDMT) is an effective strategy to reduce mortality and readmission rates for heart failure (HF). Use of a checklist is one of the best tools to ensure GDMT. The aim was to develop a consensus document with a robust checklist for stabilized acute decompensated HF patients with reduced ejection fraction. While there are multiple checklists available, an India-specific checklist that is easy to fill and validated by regional and national subject matter experts (SMEs) is required.

Methodology

A total of 25 Cardiology SMEs who consented to participate from India discussed data from literature, current evidence, international guidelines and practical experiences in two national and four regional meetings.

Results

Recommendations included HF management, treatment optimization, and patient education. The checklist should be filled at four time points- (a) transition from intensive care unit to ward, (b) at discharge, (c) 1st follow-up and (d) subsequent follow-up. The checklist is the responsibility of the consultant or the treating physician which can be delegated to a junior resident or a trained HF nurse.

Conclusion

This checklist will ensure GDMT, simplify transition of care and can be used by all doctors across India. Institutions, associations, and societies should recommend this checklist for adaptability in public and private hospital. Hospital administrations should roll out policy for adoption of checklist by ensuring patient files have the checklist at the time of discharge and encourage practice of filling it diligently during follow-up visits.

Cardiological Society of India: Document on acute MI care during COVID-19

The unprecedented and rapidly spreading Coronavirus Disease-19 (COVID-19) pandemic has challenged public health care systems globally. Based on worldwide experience, India has initiated a nationwide lockdown to prevent the exponential surge of cases. During COVID-19, management of cardiovascular emergencies like acute Myocardial Infarction (MI) may be compromised. Cardiological Society of India (CSI) has ventured in this moment of crisis to evolve a consensus document for care of acute MI. However, this care should be individualized, based on local expertise and governmental advisories.

Promoting family integrated early child development (during first 1000 days) in urban slums of India (fine child 3-3-1000): Study protocol

AIMS

This project tests a novel, targeted home visitation programme for child development targeted behaviour change during the first 1,000 days for families in Delhi urban slums.

BACKGROUND

The first 1,000 days have highest brain development potential and is dependent on the available nutrition, health, social and cognitive stimulus. Over 1.3 million children are born annually in the slums of India and are at risk of limited development potential. The children in urban slums at multiplicity of adversities at family, society and environmental levels. No tools are available for the community health functionaries to support the families to promote child development.

DESIGN

This cohort study targets provision of behaviour change interventions targeted at three groups (pregnant women, infants and children in year 2) to document the impact on child development.

METHODS

This implementation project delivers nutrition, health and child stimulation integrated services for the families through existing government community health workers and nurses. These workers shall train the families using audio-visual messages in tablets and demonstration kits for practice through quarterly home visits. Data on health, nutrition and child development shall be collected at baseline, midterm and after one year. The data from these participants shall be compared with data from recently delivered women, children aged 13 months and 25 months without intervention to document the impact.

DISCUSSION

The successful implementation of the project has potential for future integration of the child development components into the existing programme at scale. The learning from this project shall be useful for India and other developing countries.

IMPACT

The first 1,000 days are critical period in human brain development and cognitive function acquisition potential, which is dependent on the available nutrition, health, social and cognitive stimulus. The development potential in children born and living in the slums, who are exposed to various adversities, can be mitigated through appropriate family-level practices with support from the community health workers and Nurses. This study is documenting the feasibility and impact of home visit linked coaching of families for improving child development status during the first 1,000 days in three sums of Delhi, India.

How coping can hide larger systems problems: the routine immunisation supply chain in Bihar, India

Introduction

Coping occurs when health system personnel must make additional, often undocumented efforts to compensate for existing system and management deficiencies. While such efforts may be done with good intentions, few studies evaluate the broader impact of coping.

Methods

We developed a computational simulation model of Bihar, India’s routine immunisation supply chain where coping (ie, making additional vaccine shipments above stated policy) occurs. We simulated the impact of coping by allowing extra trips to occur as needed up to one time per day and then limiting coping to two times per week and three times per month before completely eliminating coping.

Results

Coping as needed resulted in 3754 extra vaccine shipments over stated policy resulting in 56% total vaccine availability and INR 2.52 logistics cost per dose administered. Limiting vaccine shipments to two times per week reduced shipments by 1224 trips, resulting in a 7% vaccine availability decrease to 49% and an 8% logistics cost per dose administered increase to INR 2.73. Limiting shipments to three times per month reduced vaccine shipments by 2635 trips, which decreased vaccine availability by 19% to 37% and increased logistics costs per dose administered by 34% to INR 3.38. Completely eliminating coping further reduced shipments by 1119 trips, decreasing total vaccine availability an additional 24% to 13% and increasing logistics cost per dose administered by 169% to INR 9.08.

Conclusion

Our results show how coping can hide major system design deficiencies and how restricting coping can improve problem diagnosis and potentially lead to enhanced system design.

Comparison of Ultrasonogram of Brain Findings of Asphyxiated and Non-Asphyxiated Baby Admitted in Neonatal Ward in a Tertiary Level Hospital

Perinatal asphyxia is a major cause of neonatal mortality and morbidity in developing countries. A significant portion of patient with perinatal asphyxia is admitted with complications. Cerebral complications are the most devastating and the child may be left with lifelong neurological impairment. Therefore, the high index of suspicion, prompt recognition and thorough understanding of common sonographic abnormalities are necessary to ensure timely intervention, management and counseling. A hospital based case control study was conducted in the neonatal unit of Mymensingh Medical College Hospital, Mymensingh, Bangladesh. Study period was six months (June 2012 to December 2012). This study was done to compare the ultra sonogram of brain findings of admitted asphyxiated babies with admitted non-asphyxiated babies. A total of 30 asphyxiated (case) and another 30 non-asphyxiated (control) neonate of this department were enrolled in the study. Necessary information was collected by taking detailed history, clinical examination and also close follow up of the neonates according to pre-designed questionnaire. The main outcome variable was abnormality in cranial ultrasound. Among case group (30 neonates), ultrasonogram of brain findings were abnormal in 9(30.0%) cases. Among them most common was ventricular dilatation 5(16.6%), followed by Intraventricular hemorrhage (IVH) 1(3.0%), intracranial hemorrhage 1(3.0%), HIE 1(3.0%) and cerebral edema in 1(3.0%) cases. On the contrarary, among asphyxiated control group all 30 cases had normal ultra sonogram of brain. In case group 22 babies had normal birth weight and 08 had low birth weight. Among the 22 normal birth weight neonates in case group total 6(27.2%) cases had abnormal ultra sonogram findings. Among normal birth weight cases 3(13.6%) had ventricular dilatation, 1(4.5%) Intracranial hemorrhage (ICH), 1(4.5%) HIE, 1(4.5%) cerebral edema. Among 08 low birth weight neonates in case group total 3(37.5%) cases had abnormal ultrasonogram of brain finding. Among low birth weight cases 2(25%) had ventricular dilatation, 1(12.5%) IVH. Ultrasonogram brain findings difference between two groups was statistically significant. Abnormal findings were also common in low birth weight babies than normal birth weight babies. So, early detection of abnormal brain changes can help us for proper management and counseling.

Adaptation of 2016 European Society of Cardiology/European Atherosclerosis Society guideline for lipid management to Indian patients - A consensus document

In the year 2016, European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines provided recommendations on dyslipidemia management. The recommendation from these guidelines are restricted to European subcontinent. To adapt the updated recommendations for Indian subset of dyslipidemia, a panel of experts in management of dyslipidemia provided their expert opinions. This document provides expert consensus on adapting 2016 ESC dyslipidemia guidelines recommendations in Indian setting. The document also discussed India-specific relevant literature to support the consensus opinions provided in management of dyslipidemia.

Establishing a Demographic, Development and Environmental Geospatial Surveillance Platform in India: Planning and Implementation

BACKGROUND

Inadequate administrative health data, suboptimal public health infrastructure, rapid and unplanned urbanization, environmental degradation, and poor penetration of information technology make the tracking of health and well-being of populations and their social determinants in the developing countries challenging. Technology-integrated comprehensive surveillance platforms have the potential to overcome these gaps.

OBJECTIVE

This paper provides methodological insights into establishing a geographic information system (GIS)-integrated, comprehensive surveillance platform in rural North India, a resource-constrained setting.

METHODS

The International Clinical Epidemiology Network Trust International established a comprehensive SOMAARTH Demographic, Development, and Environmental Surveillance Site (DDESS) in rural Palwal, a district in Haryana, North India. The surveillance platform evolved by adopting four major steps: (1) site preparation, (2) data construction, (3) data quality assurance, and (4) data update and maintenance system. Arc GIS 10.3 and QGIS 2.14 software were employed for geospatial data construction. Surveillance data architecture was built upon the geospatial land parcel datasets. Dedicated software (SOMAARTH-1) was developed for handling high volume of longitudinal datasets. The built infrastructure data pertaining to land use, water bodies, roads, railways, community trails, landmarks, water, sanitation and food environment, weather and air quality, and demographic characteristics were constructed in a relational manner.

RESULTS

The comprehensive surveillance platform encompassed a population of 0.2 million individuals residing in 51 villages over a land mass of 251.7 sq km having 32,662 households and 19,260 nonresidential features (cattle shed, shops, health, education, banking, religious institutions, etc). All land parcels were assigned georeferenced location identification numbers to enable space and time monitoring. Subdivision of villages into sectors helped identify socially homogenous community clusters (418/676, 61.8%, sectors). Water and hygiene parameters of the whole area were mapped on the GIS platform and quantified. Risk of physical exposure to harmful environment (poor water and sanitation indicators) was significantly associated with the caste of individual household (P=.001), and the path was mediated through the socioeconomic status and density of waste spots (liquid and solid) of the sector in which these households were located. Ground-truthing for ascertaining the land parcel level accuracies, community involvement in mapping exercise, and identification of small habitations not recorded in the administrative data were key learnings.

CONCLUSIONS

The SOMAARTH DDESS experience allowed us to document and explore dynamic relationships, associations, and pathways across multiple levels of the system (ie, individual, household, neighborhood, and village) through a geospatial interface. This could be used for characterization and monitoring of a wide range of proximal and distal determinants of health.

Comparison of Serum Electrolytes Abnormality and Renal Function Status in Asphyxiated and Normal Baby in a Tertiary Level Hospital

Complication of perinatal asphyxia is a major cause of neonatal mortality & morbidity in developing countries. This comparative cross sectional study was conducted in Mymensingh Medical College Hospital, Mymensingh, Bangladesh from May 2012 to September 2012 to determine electrolytes & renal function status in perinatal asphyxia & their impact on outcome. Thirty term normal birth weight babies with perinatal asphyxia in neonatal ward were included as a case group and thirty term normal birth weight neonates of same gestational age, without perinatal asphyxia in the department of Gynae & Obs were enrolled as a control group. Necessary information was collected by clinical examination; investigation and close follow up according to predetermined plan. There was no significant different in sex distribution, number of Antenatal care (ANC), number of gravidum of mother and mode of delivery between two groups. Among perinatal Asphyxia group most common risk factor was prolonged labor. Electrolyte abnormalities were documented (16) 53.3% cases. Among 16 electrolyte abnormalities isolated hyponatremia was found in 6(37.5%) cases, hyponatremia with hyperkalaemia 1(6.25%) case, hyponatremia with hypokalaemia in 1(6.25%) case, isolated hypokalaemia in 3(18.75%) cases and isolated hyperkalaemia in 5(31.25%) cases. None case had hypernatremia. On the other hand in control group Hypokalaemia was 3(10%) cases Hyperkalaemia 1(33.33%) case and none had Hyponatraemia. Among total cases 6 (20%) had renal impairment. Serum creatinine level was higher in case group. Twenty percent (20%) case initial value >1.5mg/dl, 20% 1.2-1.5mg/dl and17% had 0.3-0.8mg/dl. On the other hand in control group 83 % had 0.3-0.8 mg/dl & none hade above 1.1 mg/dl. Among case group 8 were died (27%). There was no death in control group. Among 8 neonatal death cases 3(37.5%) had normal electrolytes, isolated hyponatraemia were in 2(25%) cases, hyponatraemia with Hyperkalaemia in 1(6.25%) case and Isolated Hyperkalaemia in 2(25%) cases. Among those death 3(37.5%) had renal impairment. Case fatality was significantly associated with renal failure 50%, isolated Hyponatraemia 33.33%, Isolated hyperkalaemia 40%, Hyperkalaemia with Hyponatremia 100%. Hospital stay was also prolonged among alive case with abnormal electrolytes. So, we can conclude that electrolyte & renal impairments are significantly associated with morbidity & mortality of perinatal Asphyxia.

Neurodevelopmental disorders in children aged 2-9 years: Population-based burden estimates across five regions in India

BACKGROUND

Neurodevelopmental disorders (NDDs) compromise the development and attainment of full social and economic potential at individual, family, community, and country levels. Paucity of data on NDDs slows down policy and programmatic action in most developing countries despite perceived high burden.

METHODS AND FINDINGS

We assessed 3,964 children (with almost equal number of boys and girls distributed in 2-<6 and 6-9 year age categories) identified from five geographically diverse populations in India using cluster sampling technique (probability proportionate to population size). These were from the North-Central, i.e., Palwal (N = 998; all rural, 16.4% non-Hindu, 25.3% from scheduled caste/tribe [SC-ST] [these are considered underserved communities who are eligible for affirmative action]); North, i.e., Kangra (N = 997; 91.6% rural, 3.7% non-Hindu, 25.3% SC-ST); East, i.e., Dhenkanal (N = 981; 89.8% rural, 1.2% non-Hindu, 38.0% SC-ST); South, i.e., Hyderabad (N = 495; all urban, 25.7% non-Hindu, 27.3% SC-ST) and West, i.e., North Goa (N = 493; 68.0% rural, 11.4% non-Hindu, 18.5% SC-ST). All children were assessed for vision impairment (VI), epilepsy (Epi), neuromotor impairments including cerebral palsy (NMI-CP), hearing impairment (HI), speech and language disorders, autism spectrum disorders (ASDs), and intellectual disability (ID). Furthermore, 6-9-year-old children were also assessed for attention deficit hyperactivity disorder (ADHD) and learning disorders (LDs). We standardized sample characteristics as per Census of India 2011 to arrive at district level and all-sites-pooled estimates. Site-specific prevalence of any of seven NDDs in 2-<6 year olds ranged from 2.9% (95% CI 1.6-5.5) to 18.7% (95% CI 14.7-23.6), and for any of nine NDDs in the 6-9-year-old children, from 6.5% (95% CI 4.6-9.1) to 18.5% (95% CI 15.3-22.3). Two or more NDDs were present in 0.4% (95% CI 0.1-1.7) to 4.3% (95% CI 2.2-8.2) in the younger age category and 0.7% (95% CI 0.2-2.0) to 5.3% (95% CI 3.3-8.2) in the older age category. All-site-pooled estimates for NDDs were 9.2% (95% CI 7.5-11.2) and 13.6% (95% CI 11.3-16.2) in children of 2-<6 and 6-9 year age categories, respectively, without significant difference according to gender, rural/urban residence, or religion; almost one-fifth of these children had more than one NDD. The pooled estimates for prevalence increased by up to three percentage points when these were adjusted for national rates of stunting or low birth weight (LBW). HI, ID, speech and language disorders, Epi, and LDs were the common NDDs across sites. Upon risk modelling, noninstitutional delivery, history of perinatal asphyxia, neonatal illness, postnatal neurological/brain infections, stunting, LBW/prematurity, and older age category (6-9 year) were significantly associated with NDDs. The study sample was underrepresentative of stunting and LBW and had a 15.6% refusal. These factors could be contributing to underestimation of the true NDD burden in our population.

CONCLUSIONS

The study identifies NDDs in children aged 2-9 years as a significant public health burden for India. HI was higher than and ASD prevalence comparable to the published global literature. Most risk factors of NDDs were modifiable and amenable to public health interventions.

Research priorities in Maternal, Newborn, & Child Health & Nutrition for India: An Indian Council of Medical Research-INCLEN Initiative

In India, research prioritization in Maternal, Newborn, and Child Health and Nutrition (MNCHN) themes has traditionally involved only a handful of experts mostly from major cities. The Indian Council of Medical Research (ICMR)-INCLEN collaboration undertook a nationwide exercise engaging faculty from 256 institutions to identify top research priorities in the MNCHN themes for 2016-2025. The Child Health and Nutrition Research Initiative method of priority setting was adapted. The context of the exercise was defined by a National Steering Group (NSG) and guided by four Thematic Research Subcommittees. Research ideas were pooled from 498 experts located in different parts of India, iteratively consolidated into research options, scored by 893 experts against five pre-defined criteria (answerability, relevance, equity, investment and innovation) and weighed by a larger reference group. Ranked lists of priorities were generated for each of the four themes at national and three subnational (regional) levels [Empowered Action Group & North-Eastern States, Southern and Western States, & Northern States (including West Bengal)]. Research priorities differed between regions and from overall national priorities. Delivery domain of research which included implementation research constituted about 70 per cent of the top ten research options under all four themes. The results were endorsed in the NSG meeting. There was unanimity that the research priorities should be considered by different governmental and non-governmental agencies for investment with prioritization on implementation research and issues cutting across themes.

Management protocols for chronic heart failure in India

Heart failure is a common clinical syndrome and a global health priority. The burden of heart failure is increasing at an alarming rate worldwide as well as in India. Heart failure not only increases the risk of mortality, morbidity and worsens the patient's quality of life, but also puts a huge burden on the overall healthcare system. The management of heart failure has evolved over the years with the advent of new drugs and devices. This document has been developed with an objective to provide standard management guidance and simple heart failure algorithms to aid Indian clinicians in their daily practice. It would also inform the clinicians on the latest evidence in heart failure and provide guidance to recognize and diagnose chronic heart failure early and optimize management.

Efficacy of Mycophenolate Mofetil as a Remission Maintaining Agent in Idiopathic Childhood Nephrotic Syndrome

Of all cases of idiopathic steroid-sensitive nephrotic syndrome (NS) in children, 40%-75% cases need long-term continuous steroids and/or other immunosuppressants to maintain remission, the effects of which on growth and renal function remain an issue of concern. The study aimed at exploring the safety and efficacy of mycophenolate mofetil (MMF) as a remission-maintaining agent in children with a diagnosis of frequent relapsing or steroid-dependent NS (FRNS/SDNS) requiring continuous medication for at least 1 year. Thirty-two children thus included received MMF (1000-1200 mg/m²/day) for 7 months along with tapering doses of oral prednisolone if it was being given from before with an attempt at tapering at 0.25 mg/kg/month ultimately stopping it altogether. Individuals were followed up for at least 5 more months after stopping MMF. Out of 32 children, 26 had SDNS and 6 had FRNS with male:female ratio being 2.2:1. The mean standard deviation (± SD) age of onset of disease was 2.72 ± 1.3 years and that entry to the study was 7.17 ± 2.2 years. Significant fall in number of relapses was observed following the introduction of MMF (110 in pre-MMF12 month period vs. 52 in post-MMF 12 months [p = 0.002]). The mean relapse rate/year/patient also decreased from 3.43 ± 1.26 to 1.62 ± 1.14 after entry in the study. Significant reduction of the cumulative dose of steroid regarding mean ± SD of mg/kg/year was also found following the introduction of MMF (190.9 ± 47.81 vs. 119.09 ± 60.09 [p = 0.001]). MMF is an efficacious agent in maintaining remission and reducing steroid requirement in children with FRNS and SDNS.

Cardiovascular involvement in severe malaria: A prospective study in Ranchi, Jharkhand

BACKGROUND & OBJECTIVES

Malaria is considered as the most important parasitic disease of humans, causing seri- ous illness that can be fatal, if not diagnosed and treated immediately. It is a multisystem disorder affecting nearly every system of the body. The aim of the present study was to evaluate the involvement of cardiovascular system in severe malaria using non-invasive methods.

METHODS

This prospective study was conducted on patients of severe malaria who were admitted between June and November 2015 in the Department of Medicine, Rajendra Institute of Medical Sciences and Hospital, Ranchi, Jharkhand, India. A total of 27 cases (18 males and 9 females; age ranging between 15 and 70 yr) of severe malaria (P. falciparum 24; P. vivax 1; mixed 2) were diagnosed by microscopic examination of peripheral blood smear and bivalent rapid diagnostic test (RDT) kit. The assessment of cardiovascular system was done by clinical examination, chest X-ray, ECG and transthoracic echocardiography.

RESULTS

In all, 7 (26%) patients were found to be suffering from circulatory failure, out of which one was P. vivax case and rest were cases of P. falciparum infection with high parasite density. One patient died due to cardiovascular collapse. ECG revealed sinus bradycardia [Heart rate (HR): 40-60] in 7% of the cases, extreme tachycardia (HR: 120-150) in 3.7% of cases and premature arterial ectopic with tachycardia in 3.7% of patients (p <0.05). The echo- cardiographic findings were global hypokinesia with decreased left ventricular ejection fraction (<55%) in 11.1%, grade 1 left ventricular diastolic dysfunction in 3.7%, mild tricuspid regurgitation (TR) with mild pulmonary artery hypertension (PAH) in 3.7% and mild pericardial effusion in 3.7% of the cases. The ECG and echocardiography changes indicated myocardial involvement in severe malaria.

INTERPRETATION & CONCLUSION

The present study indicated involvement of cardiovascular system in severe malaria as evidenced from ECG and echocardiography. The study also revealed that cardiovascular instabilities are common in falciparum malaria, but can also be observed in vivax malaria.

Diversity of breeding habitats of anophelines (Diptera: Culicidae) in Ramgarh district, Jharkhand, India

BACKGROUND & OBJECTIVES

The Ramgarh district of Jharkhand state, India is highly malarious owing to abundance of different malaria vector species, namely Anopheles culicifacies, An. fluviatilis and An. annularis. In spite of high prevalence of malaria vectors in Ramgarh, their larval ecology and climatic conditions affecting malaria dynamics have never been studied. Therefore, the objective of this study was to identify the diversity of potential breeding habitats and breeding preferences of anopheline vectors in the Ramgarh district.

METHODS

Anopheles immature collection was carried out at potential aquatic habitats in Ramgarh and Gola sites using the standard dipper on fortnightly basis from August 2012 to July 2013. The immatures were reared till adult emergence and further identified using standard keys. Temperature of outdoor and water bodies was recorded through temperature data loggers, and rainfall through standard rain gauges installed at each site.

RESULTS

A total of 6495 immature specimens representing 17 Anopheles species including three malaria vectors, viz. An. culicifacies, An. fluviatilis and An. annularis were collected from 11 types of breeding habitats. The highly preferred breeding habitats of vector anophelines were river bed pools, rivulets, wells, ponds, river margins, ditches and irrigation channels. Larval abundance of vector species showed site-specific variation with temperature and rainfall patterns throughout the year. The Shannon-Weiner diversity index ranged from 0.19 to 1.94 at Ramgarh site and 0.16 to 1.76 at Gola site.

INTERPRETATION & CONCLUSION

The study revealed that malaria vector species have been adapted to breed in a wide range of water bodies. The regular monitoring of such specific vector breeding sites under changing ecological and environmental conditions will be useful in guiding larval control operations selectively for effective vector/ malaria control.

Anopheline mosquitoes in District Ramgarh (Jharkhand), India

BACKGROUND & OBJECTIVES

Jharkhand is one of the highly malaria endemic states in India and experiencing vast ecological and human-induced changes over the years. These changes have provided more favourable conditions for malaria transmission in the region. The present study was carried out to find out the distribution and prevalence of anopheline vector and non-vector species in District Ramgarh of Jharkhand state.

METHODS

Daytime indoor resting adult female anopheline mosquitoes were collected from four subcentres comprising of eight study villages in District Ramgarh. The collections were made from fixed as well as random human dwellings and cattlesheds on fortnightly basis using manual aspiration method from January to December 2012. Mosquito identification was done by using standard identification keys.

RESULTS

A total of 18,875 anophelines belonging to 19 species were collected. Of these, 61.87% were vector species (An. culicifacies, An. fluviatilis and An. annularis). Of total vector collection, 57.44% was observed in Gola block and 42.55% in Ramgarh. An. culicifacies was predominant species followed by An. fluviatilis and An. annularis in the study area. Out of 19, eight anopheline species exhibited successional changes in their composition over the period of years. Statistical analysis revealed positive correlation between meteorological variables and man hour density in case of An. culicifacies, whereas these were negatively correlated in case of An. fluviatilis and An. annularis.

INTERPRETATION & CONCLUSION

The study revealed the prevalence of three recognised malaria vector species (An. culicifacies, An. fluviatilis and An. annularis) in high density throughout the year in this area, which indicates possibility of widening of malaria transmission window in the presence of malaria parasites. The shifting of anopheline species in Ramgarh also indicate alteration in ecological, environmental and sociological conditions, which necessitate routine monitoring on ecology and successional changes of vector species as well as malariological survey for management and adoption of appropriate vector control strategies in this area.

L1014F-kdr Mutation in Indian Anopheles subpictus (Diptera: Culicidae) Arising From Two Alternative Transversions in the Voltage-Gated Sodium Channel and a Single PIRA-PCR for Their Detection

Leucine-to-phenylalanine substitution at residue L1014 in the voltage-gated sodium channel, target site of action for dichlorodiphenyltrichloroethane (DDT) and pyrethroids, is the most common knockdown resistance (kdr) mutation reported in several insects conferring resistance against DDT and pyrethroids. Here, we report presence of two coexisting alternative transversions, A>T and A>C, on the third codon position of L1014 residue in malaria vector Anopheles subpictus Grassi (species A) from Jamshedpur (India), both leading to the same amino acid substitution of Leu-to-Phe with allelic frequencies of 19 and 67%, respectively. A single primer-introduced restriction analysis-polymerase chain reaction (PIRA-PCR) was devised for the identification of L1014F-kdr mutation in An. subpictus resulting from either type of point mutation. Genotyping of samples with PIRA-PCR revealed high frequency (82%) of L1014F-kdr mutation in the study area.

Identification of risk factors for malaria control by focused interventions in Ranchi district, Jharkhand, India

BACKGROUND & OBJECTIVES

Ranchi, the capital of Jharkhand state is endemic for malaria, particularly the Bundu Primary Health Centre (PHC) is the worst affected. Therefore, a study was initiated during 2009 using remote sensing (RS) and geographical information system (GIS) to identify risk factors responsible for high endemicity in this PHC.

METHODS

Bundu and Angara in Ranchi district were identified as high and low malaria endemic PHCs based on epidemiological data of three years (2007-09). The habitation, streams, other water body, landform, PHC and village boundary thematic maps were prepared using IRS-P6/LISS III-IV imageries and macro level breeding sites were identified. Digital elevation model (DEM) of the PHCs was generated using Cartosat Stereo Pair images and from DEM, slope map was derived to calculate flat area. From slope, aspect map was derived to indicate direction of water flow. Length of perennial streams, area under rocky terrain and buffer zones of 250, 500 and 750 m were constructed around streams. High resolution remote sensing imageries were used to identify micro level breeding sites. Based on macro-micro breeding sites, six villages from each PHC were selected randomly having combination of different parameters representing all ecotypes. Entomological data were collected during 2010-11 in pre- and post-monsoon seasons following standard techniques and analyzed statistically. Differential analysis was attempted to comprehend socioeconomic and other determinants associated with malaria transmission.

RESULTS

The study identified eight risk factors responsible for higher malaria endemicity in Bundu in comparison to Angara PHC based on ecological, entomological, socioeconomic and other local parameters.

CONCLUSION

Focused interventions in integrated vector management (IVM) mode are required to be carried out in the district for better management and control of disease.

A note on the insecticide susceptibility status of principal malaria vector Anopheles culicifacies in four states of India

BACKGROUND & OBJECTIVES

The major malaria vector, Anopheles culicifacies Giles is reported to contribute ~ 65% of the malaria cases in India. This species developed resistance to DDT and later to HCH, malathion and also to pyrethroids in some states due to their use in the national malaria control programme. In the present study, insecticide susceptibility of this species was monitored in four states of India.

METHODS

To determine insecticide susceptibility status of the major malaria vector An. culicifacies, adult mosquitoes were collected from different localities of 32 tribal districts in the states of Andhra Pradesh, Odisha, Jharkhand and West Bengal during October/November 2009-10. Mosquitoes were collected from stratified ecotypes comprising a group of districts in West Bengal and individual districts in three other states. Mosquitoes were exposed to papers treated with WHO diagnostic dose: 4% DDT, 5% malathion and 0.05% deltamethrin following the WHO tube method.

RESULTS

RESULTS provided the susceptibility status of An. culicifacies to different insecticides used in the public health programme in 32 districts in four states. An. culicifacies was found resistant to DDT (mortality range 0-36%) in all the 32 districts; to malathion it was resistant in 14 districts, verification required in 10 districts and susceptible in eight districts (mortality range 32.2-100%). It was resistant to deltamethrin in four districts, verification required in 11 districts and susceptible in 17 districts (mortality range 43.3-100%).

INTERPRETATION & CONCLUSION

Development of widespread resistance to insecticides used in public health sprays for vector control including to pyrethroids in An. culicifacies in the surveyed districts is of great concern for the malaria control programme as the major interventions for vector control are heavily reliant on chemical insecticides, mainly synthetic pyrethroids used both for indoor residual spraying and for long-lasting insecticidal nets. Thus, there is a need to periodically monitor and update the susceptibility status of malaria vector(s) to suggest alternative vector control strategies for effective disease management.

Attenuation coefficients and absorbed gamma radiation energy of different varieties of potato, mango and prawn at different storage time and physiological condition

Attenuation coefficients of different varieties of gamma irradiated potato (Kufri Chandramukhi, Kufri Jyoti, and Kufri Sindhuri), mango (Himsagar, Langra, Dashehri and Fazli) and prawn (Tiger prawn and Fresh water prawn) of different storage time and physiological stages were determined. After six months storage attenuation coefficient of Kufri Chandramukhi was decreased by 30.8% with decrease of density and moisture content. Decreasing trend of attenuation coefficient during storage was more prominent (almost 50%) in other two varieties of potato. On the other hand in all four varieties, unripe mango consisted of significantly less (p ≤ 0.05) attenuation coefficient (around 11-14%) than the ripe one due to changes in physiological properties and density. Different varieties of prawn had different attenuation coefficients due to subtle differences in their proximate composition. Due to having different attenuation coefficients, different food components, even different varieties of same food component absorbed different gamma radiation energy though exposed to same radiation dose.

Malaria among the Jarawas, a primitive and isolated tribe on the Andaman islands, India

The Jarawas are a primitive Negrito tribe of the Andaman islands, India. The members of this tribe have been geographically and socially isolated from the other inhabitants of the islands. None had attended a hospital or health unit until 1997, when a Jarawa boy with a fractured leg was taken to a hospital in Port Blair, and successfully treated. Since then, increasing numbers of Jarawas have sought treatment at the hospital and/or begun to make other contact with non-Jarawas on the islands. No malaria had ever been reported in the tribe until 2001, when an outbreak of febrile illness triggered a malariological survey. Malarial parasites, all identified microscopically as Plasmodium falciparum, were detected in the bloodsmears of 30 of the 179 Jarawas investigated. Although most malaria among the non-Jarawa inhabitants of the islands is caused by P. vivax, only P. falciparum was detected when blood samples from 26 of the subjects were investigated in PCR-based assays. Genetic-diversity studies, based on the msp(1) and msp(2) polymorphic markers, also revealed a relatively low level of polymorphism in the P. falciparum parasites infecting the Jarawas, compared with that seen in other areas of India. It seems possible that malarial parasites have only recently reached the Jarawas, as the result of the weakening of the tribe's isolation from other humans on the Andaman islands.

Urinary potassium loss in children with acute liver failure and acute viral hepatitis

OBJECTIVES

The aim of the present study was to determine urinary potassium (K⁺) loss (as measured by fractional excretion of K⁺ [FEK] and transtubular K⁺ gradient [TTKG]) in children with acute liver failure (ALF) and acute viral hepatitis (AVH) at the time of presentation to the hospital and day 45 of follow-up.

METHODS

Twenty-five patients with ALF and 84 patients with AVH were worked up for clinical features, liver function tests, and hepatitis viral infections and monitored for outcome. All of the patients with ALF were hospitalized. FEK and TTKG were estimated on the day patients were first seen in the hospital or hospitalized and later on day 45 of follow-up.

RESULTS

Sixty percent (15/25) of patients with ALF were hypokalemic (serum K⁺ <3.5 mEq/L) as compared with only 12% (10/84) in the AVH group (P = 0.000) at the time of presentation in the hospital. Inappropriate kaliuresis was present in 80% to 100% of hypokalemic children compared with 0% to 30% of normokalemic individuals at the time of first contact in either the ALF or AVH group. Inappropriate urinary K⁺ loss and serum K⁺ levels in the hypokalemic individuals improved as the hepatic functions recovered by day 45 of follow-up (P = 0.014-0.000). No significant change in kaliuresis was observed among normokalemic subjects between first contact and later on day 45 of follow-up (P = 0.991-0.228). Despite different physiologic mechanisms, appropriateness of kaliuresis measured by FEK and TTKG showed results in the same direction.

CONCLUSIONS

Hypokalemia and inappropriate kaliuresis observed during the acute phase of ALF and AVH reversed with clinical and biochemical recovery. In the absence of major gastrointestinal losses and renal abnormalities, there is need to investigate the contributory role of factors like hyperaldosteronism and food intake, which may have therapeutic implications.

Kearns-Sayre Syndrome: A Rare Mitochondrial Deletion Disorder

A 9 yr girl presented with bilateral ptosis and deafness of gradual onset for the last four years. Associated ophthalmoplegia and pigmentary retinopathy, heart block, raised CSF protein and serum lactate was suggestive of the diagnosis of Kearns-Sayre syndrome (KSS), a rare entity in the spectrum of the mitochondrial deletion syndrome. Search for endocrinopathy revealed no abnormality. DOI: http://dx.doi.org/10.3126/jnps.v33i1.6696 J Nepal Paediatr Soc. 2013;33(1):61-62

Determinants of childhood obesity: need for a trans-sectoral convergent approach

The emerging burden of non communicable diseases is likely to erode the "Demographic-Dividend" of India and compromise the national growth and development. Increasing rates of childhood obesity globally and in India is a cause for serious public health concern. It is becoming increasingly apparent that obesity is result of complex interplay between multiple genes, environmental factors and human behavior. Clear comprehension of this interaction and pathway is still not clear, making the prevention and management of obesity especially challenging. Globalization and rapid economic growth has led to dramatic changes in the life style of the population including food intake, physical activity, market, environmental factors and social structures. A growing economy, urbanization and motorized transport have increased physical inactivity. A systematic multi-sectoral approach with population health as the center of discourse and attention is the only key to tackle this problem.

Monitoring antimalarial drug resistance in India via sentinel sites: outcomes and risk factors for treatment failure, 2009-2010

OBJECTIVE

To describe India's National Antimalarial Drug Resistance Monitoring System, measure the efficacy of first-line malaria treatments, and determine risk factors for treatment failure.

METHODS

In 2009-2010, prospective studies with 28 days of follow-up were conducted at 25 sentinel sites. Patients infected with Plasmodium falciparum were given artesunate plus sulfadoxine-pyrimethamine (AS+SP); those infected with P. vivax were given chloroquine. Polymerase chain reaction was used to distinguish post-treatment reinfection from treatment failure. Isolates of P. falciparum were checked for dhfr and dhps mutations.

FINDINGS

Overall, 1664 patients were enrolled. Kaplan-Meier survival analysis showed an efficacy of 98.8% for AS+SP. Most patients with P. falciparum parasitaemia cleared their parasitaemias within 24 hours of treatment initiation, but six, including four with treatment failure, remained parasitaemic after 72 hours. Double mutants in dhfr were found in 68.4% of the genotyped isolates. Triple or quadruple mutants in dhfr and mutations in dhps were rare. A daily dose of artesunate of < 3 mg per kg of body weight, age of less than 5 years, and fever at enrolment were associated with an increased risk of treatment failure. Chloroquine remained 100% efficacious and generally cleared P. vivax parasitaemias within 48 hours. Vomiting (seen in 47 patients) was the most common adverse event.

CONCLUSION

India's National Antimalarial Drug Resistance Monitoring System provides wide coverage. The first-line antimalarials used in the country remain safe and efficacious. The treatment of malaria in young children and the relative benefits of age- and weight-based dosing need further exploration.

Evaluation of indoor residual spray and insecticide treated bed nets in a malaria endemic area of Santhal Pargana, Dumka district (Jharkhand)

The study was carried out for evaluation of various activities of malaria control programme in five different tribal and malaria endemic Primary Health Centres of Dumka district (Jharkhand) during 2007-08. A total of 321 houses of 18 villages were surveyed on use of indoor residual spray (IRS) and insecticide-treated bed nets (ITN) and other activities as tool for vector control and interrupting the transmission of malaria. Out of 690 living rooms and 343 verandahs examined, IRS with Dichlorodiphenyl-trichloro-ethane (DDT) was done only in 16.23% living rooms and 64.72% verandahs. Refusal rate of IRS in living rooms was 81.93% due to lack of knowledge regarding the importance of IRS, no prior information to villagers, houses locked, reluctance to remove domestic articles, dislike of smell of DDT spray. Compliance rate of ITN uses was 71.66% during the night, which might be a factor for decline in malaria cases in the study area. Various important components of the programme, viz. surveillance and compliance to treatment activities, use of rapid diagnostic test kits (RDKs), involvement of accredited social health activist (ASHA's) and fever treatment depots (FTDs), laboratory activities, adult mosquito collection, other activities like constitution of village health sanitation committee, information education and communication activities, capacity building, use of larvivorous fishes, supervision of IRS etc. require much strengthening. However, 100% community acceptance was recorded for ITN in the villages surveyed. In addition, an entomological study was carried out for information on prevalence of mosquito species in this area to find out effectiveness of IRS activities. Eleven anopheline species, including three malaria vectors i.e., An. culicifacies, An. stephensi, An. fluviatilis, An. annularis, An. subpictus, An. nigerrimus, An. pallidus, An. aconitus, An. vagus, An. jamsii and An. splendidus were collected from cattle and human dwellings.

Interdistrict variations in child health status and health services utilization: lessons for health sector priority setting and planning from a cross-sectional survey in rural India

BACKGROUND

There are limited data on interdistrict variations in child health status and health services utilization within the states of India. We conducted this study to identify and understand district-wise variations in child morbidity, mortality, healthcare seeking, and the status of health facilities in India.

METHODS

A cross-sectional population-based cluster survey was conducted from April to July 2007 in 16 districts of eight states in India. Two districts with similar demographic profile and health criteria were selected from each study state.

RESULTS

A total of 216 794 households and 24 812 under-5 children were surveyed. There were wide interdistrict variations in the health status of children within the same state and between different states across India. Interdistrict difference of >5 points/1000 live-births was found for infant mortality rate and under-5 mortality rate in all eight study states, while in six out of eight states this difference was >10 points/1000 live-births. Four states had a difference of >10 points/1000 live-births between respective districts for neonatal mortality rate. The interdistrict differences were also noted in childhood morbidity and health-seeking behaviour. Analysis of proportion of health facilities conforming to Indian public health standards revealed that the difference was m10% for availability of vaccines in five states, emergency services in three, laboratory services and logistics in four each, and referral facility in three of the eight study states.

CONCLUSION

This study underscores an important information gap in the country where planners seem to rely heavily on a few selected national-level databases that may not be adequate at the micro level. The current process of sporadic health surveys also appears inadequate and inappropriate. There is a need for district-specific data for planning, improving quality of service and generating demand for health service utilization to improve child survival in India. The findings of this study may prove useful for child health programme planning in India.

Determinants of utilization of services under MMJSSA scheme in Jharkhand 'Client Perspective': a qualitative study in a low performing state of India

Preventing maternal death associated with pregnancy and child birth is one of the greatest challenges for India. Approximately 55,000 women die in India due to pregnancy- and childbirth- related conditions each year. Increasing the coverage of maternal and newborn interventions is essential if Millennium Development Goals (MDG) 4 and 5 are to be reached. With a view to accelerate the reduction in maternal and neonatal mortality through institutional deliveries, Government of India initiated a scheme in 2005 called Janani Suraksha Yojna (JSY) under its National Rural Health Mission (NRHM). In Jharkhand the scheme is called the Mukhya Mantri Janani Shishu Swasthya Abhiyan (MMJSSA). This paper focuses on community perspectives, for indentifying key areas that require improvement for proper implementation of the MMJSSA in Jharkhand. Qualitative research method was used to collect data through in-depth interviews (IDIs) and focus group discussions (FGDs) in six districts of Jharkhand- Gumla, West Singhbhum, Koderma, Deoghar, Garhwa, and Ranchi. Total 300 IDIs (24 IDIs each from mother given birth at home and institution respectively; two IDIs each with members of Village Health and Sanitation Committees (VHSC) / Rogi Kalyan Samitis (RKS) from each district) and 24 FGDs (four FGDs were conducted from pools of husbands, mothers-in-law and fathers-in-law in each district) were conducted. Although people indicated willingness for institutional deliveries (generally perceived to be safe deliveries), several barriers emerged as critical obstacles. These included poor infrastructure, lack of quality of care, difficulties while availing incentives, corruption in disbursement of incentives, behavior of the healthcare personnel and lack of information about MMJSSA. Poor (and expensive) transport facilities and difficult terrain made geographical access difficult. The level of utilization of maternal healthcare among women in Jharkhand is low. There was an overwhelming demand for energizing sub-centers (including for deliveries) in order to increase access to maternal and child health services. Having second ANMs will go a long way in achieving this end. The MMJSSA scheme will thus have to re-invent itself within the overall framework of the NRHM.

Butea Monosperma (LAM.) Kuntze – A Comprehensive Review

The traditional systems of medicine together with folklore medicine continue to play a significant role in our health care system for the betterment of mankind. Butea monosperma (Lam.) kuntze is a commonly used herb in Ayurvedic medicine. Butea monosperma (Palas) belongs to the family Fabaceae, grown wildly in many parts of India. The plant is used highly by the rural and tribal people in curing various disorders. Butea monosperma has an effective natural origin that has a  tremendous future for research. The novelty and applicability of Butea monosperma are hidden. Such things can be overcome through modern scientific research. The present article describes various traditional and medicinal utility of the plant and an attempt was made to gather information about the chemical composition and pharmacological activity of the plant and/ or its constituents. 

Immunoprophylactic potential of filarial glutathione-s-transferase in lymphatic filariaisis

OBJECTIVE

To elucidates the immunoprophylactic potential of glutathion-s-transferase (GST) from cattle filarial parasite Setaria digitata (S. digitata) against lymphatic filariasis.

METHODS

GST was purified through affinity chromatography (SdGST) and chacterized by SDS-PAGE and Nano-LC MS/MS analysis. Antibody isotypes to SdGST were measured by ELISA. Antibody dependant cellular cytotoxicity (ADCC) was performed in vitro using sera from immunized animals and immune individuals. T-cell proliferation and cytokine response to SdGST in different groups of filariasis were measured. Immunoprophylactic potential of SdGST was evaluate in animal model.

RESULTS

SdGST exhibited 30-fold enhancement of enzyme activity over crude parasitic extract. It was found to be 26 kDa by SDS-PAGE. Nano LC-MS/MS analysis followed by blast search showed 100% homology with Dirofilaria immitis (D. immitis) and only 43% with Homo sapiens (H. sapiens). Immunoblotting analysis showed putatively immune individuals carry significant level of antibodies to SdGST as compared with microfilaraemics. Immunized sera and sera endemic normal could neutralize the enzymatic activity of SdGST and inducing in vitro cytotoxicity of microfilariae. Peripheral blood mononuclear cells (PBMC) from endemic normals upon stimulation with SdGST showed a mixed type of Th1/Th2 response. SdGST immunization clear microfilariae from circulation in S. digitata implanted mastomys.

CONCLUSIONS

The heterologous GST could be potentially developed as a vaccine candidate against lymphatic filarial parasite.

Situation analysis of malaria in Godda district of Jharkhand during malaria epidemic

The epidemiological and entomological investigations were carried out in 18 tribal villages of Godda district of Jharkhand state revealed average slide positivity rate (SPR) 9.9% and slide positivity rate for Plasmodium falciparum (SfR) 5.0%, respectively. P. falciparum was the dominant parasite accounting 51.2 per cent of the total infections. All the villages are situated in the deep forest and forest fringes. A total of 416 blood slides were collected and examined. Out of which 41 slides were found positive for malaria parasite (21 positive for P. falciparum and 20 positive for P. vivax). All the positive cases were treated with Blister Packs of anti-malarial of chloroquine and primaquine as per NBVDCP schedule to prevent further transmission of malaria, which were available. Rapid diagnostic Kits were used selectively only on the recommendation of the Physician/Medical Officer. Results of house to house fever survey indicated the presence of high percentage of symptomatic carriers of malaria parasites in the local population and in our study Pf % is more than reported data by District Malaria Office, Godda district, Jharkhand. In entomological studies, for mosquito fauna with reference to both Anopheline, 11 species belonging to one genus Anopheles were collected and identified during the survey; among them some species were most prevalent. A total of 599 mosquitoes were recorded and average density of mosquitoes recorded was 13.19 in human dwellings and 86.11 in cattle sheds.

Lymphatic filariasis in children: age dependent prevalence in an area of India endemic for Wuchereria bancrofti infection

Lymphatic filariasis has been considered as a disease of adults and most epidemiological surveys have excluded children. The prevalence of infection and clinical manifestations of the disease among children in the age group of 1-15 years was determined in a Wuchereria bancrofti endemic area. The 1383 children from the rural villages of a coastal district (Khurda), State of Orissa, India, were studied. The finger prick blood (50ìl) samples were collected between 20:30 and 23:30 hours for parasitological and immunological evaluation. At the same time clinical examination was also recorded. Circulating Filarial Antigen (CFA) status and antibody (IgG) to filarial antigen was also determined in the study population. The prevalence of asymptomatic microfilaraemic carriers (AS), acute disease (AC), hydrocele (Hyd) cases and cryptic infection (CFA +ve) were 9.9%, 14.6%, 3.8% and 17.1% respectively. It was observed that 45.4% of the children below 15 years of age were either infected or had clinical manifestations of the disease. IgG antibody positivity 75.4%, 84% and 95.8% were observed in 1-5 yr, 6-10 yr and 11-15 years age group respectively. The study suggested that asymptomatic infection and acute form of disease were common occurrence among the children and more than half of the children population were either infected or having clinical manifestations of the diseased by pre-adult stage (11-15 years of age) in the endemic area.

An intervention study on compliance of diabetes mellitus patients

The effect of intervention (counselling) on compliance was observed in 106 diabetes mellitus patients with poor glycaemic control attending a clinic. They were selected at random and the period of study extended over 3 months. Intervention (counselling) improved significantly their compliance with advices on diet, exercise and drug as well as their glycaemic status.

Alpha 1 antitrypsin deficiency in children with chronic liver disease in North India

OBJECTIVE

We attempted to determine the role of alpha-1-antitrypsin (AAT) deficient variants as an etiologic factor for chronic liver disease in North Indian children.

DESIGN

This study investigated 1700 children (682 retrospectively and 1018 prospectively) (840 CLD, 410 neonatal cholestasis and 450 without liver disease) for AAT deficiency.

SETTING

Tertiary referral center, All India Institute of Medical Sciences, New Delhi.

PATIENTS

Of 1250 liver disease patients, 98 (7.8%) were suspected to be AAT deficient on the basis of screening tests (low serum AAT levels and/or absent/faint alpha-1-globulin band on serum agarose electrophoresis and/or diastase resistant PAS positive granules on liver biopsy).

MAIN OUTCOME MEASURES

AAT deficient Z or S allele in suspected patients.

RESULTS

Z or S allele was not observed on phenotyping (1700 subjects), or with PCR-RFLP, SSCP and sequencing done in 50 of 98 suspected AAT deficient patients. A novel mutation G-to-A at position 333 in exon V was found in two siblings having positive immunohistochemistry for AAT on liver biopsy, both of whom had significant liver disease with portal hypertension.

CONCLUSION

In conclusion, AAT deficiency as an etiologic factor for chronic liver disease in childhood appeared to be uncommon in North India.

Study of the physical properties of a mesogenic mixture showing induced smectic A(d) phase by refractive index, density and x-ray diffraction measurements

The binary mixture of 4-n-pentyl phenyl 4-n'-hexyloxy benzoate (ME6O.5) and p-cyanophenyl trans-4-pentyl cyclohexane carboxylate (CPPCC) shows the presence of an induced smectic A(d) phase in a certain concentration range 0.03<x(CPPCC)<0.6. The results of the differential scanning calorimetry (DSC), refractive indices, densities and x-ray diffraction measurements are reported here. In general, the change in birefringence is continuous at the smectic A(d) to nematic phase transition for mixtures with x>0.33, whereas there is a discontinuity in these values for mixtures with x<0.33, consistent with the density and transition entropy measurements done on this system. The orientational order parameter, measured from x-ray diffraction studies, are somewhat smaller than those obtained from refractive index measurement in the induced smectic phase for all the mixtures. In the smectic phase, the OOP values initially increases with molar concentration up to x = 0.24 and then decreases showing a broad minima around x = 0.4. The variation of layer thickness in the induced smectic phase with composition has been explained by assuming the formation of homo- and heterodimers. We conclude that the possible packing of molecules in the induced smectic A(d) phase stabilizes the layers but increases the orientational free volume, consistent with the lower orientational order parameter.

Antigenemia in young children living in Wuchereria bancrofti-endemic areas of Orissa, India

The prevalence of filarial antigenemia (an indicator of adult worm burden) among 610 children, aged 3-15 years, was determined in three endemic villages of Khurda District, Orissa, India, during 2005. Prevalence of antigenemia, detected using Og4C3 circulating filarial antigen ELISA, was 32.6% compared with 10% microfilaraemia. Although the prevalence of antigenemia increased marginally with increase in age, no significant difference was observed among the children of different age groups (28.3% in 3-5 years, 31.5% in 6-10 years and 35.2% in 11-15 years), indicating that the adult worm burdens did not vary much according to the age of the study children. Gender did not influence the prevalence of antigenemia. The study emphasizes the advantage of using the circulating filarial antigen assay for detecting true filarial infection and demonstrates a high prevalence of antigenemia among the 610 children studied.

Genetic variation of 13 STR loci in the four endogamous tribal populations of Eastern India

We have analysed 13 autosomal STR loci in four endogamous tribal populations from two eastern states (Orissa and Nagaland) of India. The Gadaba, Kuvi Khond and Lotha Naga populations have not been analysed for microsatellite genetic variation previously. The allele frequencies for all loci are within the range observed in the geographical region and racial background, though some alleles showed greater variation. Departures from the Hardy-Weinberg equilibrium were tested by three methods and two loci (THO1 and TPOX) showed significant departures for all measures in Gadaba and Lotha Naga populations. The exclusion probability and discrimination probability were high for all analysed loci in all populations. There is no evidence for association of alleles among the STR loci studied. This allele frequency information will be useful for forensic, paternity and population genetic studies.