Disruptions, restorations and adaptations to health and nutrition service delivery in multiple states across India over the course of the COVID-19 pandemic in 2020: An observational study

BACKGROUND

Modeling studies estimated severe impacts of potential service delivery disruptions due to COVID-19 pandemic on maternal and child nutrition outcomes. Although anecdotal evidence exists on disruptions, little is known about the actual state of service delivery at scale. We studied disruptions and restorations, challenges and adaptations in health and nutrition service delivery by frontline workers (FLWs) in India during COVID-19 in 2020.

METHODS

We conducted phone surveys with 5500 FLWs (among them 3118 Anganwadi Workers) in seven states between August-October 2020, asking about service delivery during April 2020 (T1) and in August-October (T2), and analyzed changes between T1 and T2. We also analyzed health systems administrative data from 704 districts on disruptions and restoration of services between pre-pandemic (December 2019, T0), T1 and T2.

RESULTS

In April 2020 (T1), village centers, fixed day events, child growth monitoring, and immunization were provided by <50% of FLWs in several states. Food supplementation was least disrupted. In T2, center-based services were restored by over a third in most states. Administrative data highlights geographic variability in both disruptions and restorations. Most districts had restored service delivery for pregnant women and children by T2 but had not yet reached T0 levels. Adaptations included home delivery (60 to 96%), coordinating with other FLWs (7 to 49%), and use of phones for counseling (~2 to 65%). Personal fears, long distances, limited personal protective equipment, and antagonistic behavior of beneficiaries were reported challenges.

CONCLUSIONS

Services to mothers and children were disrupted during stringent lockdown but restored thereafter, albeit not to pre-pandemic levels. Rapid policy guidance and adaptations by FLWs enabled restoration but little remains known about uptake by client populations. As COVID-19 continues to surge in India, focused attention to ensuring essential services is critical to mitigate these major indirect impacts of the pandemic.

Changes in anemia and anthropometry during adolescence predict learning outcomes: findings from a 3-year longitudinal study in India

BACKGROUND

Anemia and poor physical growth during adolescence have far-ranging consequences, but limited longitudinal evidence exists on how changes in these factors relate to changes in learning skills as adolescents mature.

OBJECTIVES

We examined the association between changes in anemia and physical growth during adolescence and learning outcomes.

METHODS

We used longitudinal data from the Understanding the Lives of Adolescents and Young Adults (UDAYA) project, which surveyed adolescents aged 10-19 y in northern India in 2015-2016 and 2018-2019 (n = 5963). We used multilevel mixed-effects logistic regression models to examine associations between changes in anemia/thinness/stunting status (4 groups: never, improved, new, and persistent) and reading (ability to read a story) and math proficiency (ability to solve division problems) at follow-up.

RESULTS

Persistent anemia and stunting were higher among girls than among boys (46% compared with 8% and 37% compared with 14%, respectively), but persistent thinness was lower (7% compared with 16%). Improvement in anemia, thinness, and stunting was 1.4-1.7 times higher among boys than among girls. Boys who were anemic in both waves were 74% [adjusted odds ratio (AOR): 0.26; 95% CI: 0.12, 0.59] and 65% (AOR: 0.35; 95% CI: 0.16, 0.76) less likely to be able to read a story and solve division problems, respectively, than boys who were nonanemic in both waves. Persistent thinness in boys was negatively associated with both reading (AOR: 0.37; 95% CI: 0.21, 0.66) and math proficiency (AOR: 0.27; 95% CI: 0.16, 0.46). Persistent stunting contributed to lower reading and math proficiency in boys and girls (AORs: 0.29-0.46). Boys whose anemia or thinness status improved and girls whose stunting status improved had similar learning skills at follow-up as those who were never anemic/thin/stunted.

CONCLUSIONS

Persistent anemia, thinness, and short stature during adolescence were associated with poor learning. Programs targeted at adolescents should contribute to nurturing environments that foster healthy growth and learning.

Unequal coverage of nutrition and health interventions for women and children in seven countries

Objective

To examine inequalities and opportunity gaps in co-coverage of health and nutrition interventions in seven countries.

Methods

We used data from the most recent (2015–2018) demographic and health surveys of mothers with children younger than 5 years in Afghanistan (n = 19 632), Bangladesh (n = 5051), India (n = 184 641), Maldives (n = 2368), Nepal (n = 3998), Pakistan (n = 8285) and Sri Lanka (n = 7138). We estimated co-coverage for a set of eight health and eight nutrition interventions and assessed within-country inequalities in co-coverage by wealth and geography. We examined opportunity gaps by comparing coverage of nutrition interventions with coverage of their corresponding health delivery platforms.

Findings

Only 15% of 231 113 mother–child pairs received all eight health interventions (weighted percentage). The percentage of mother–child pairs who received no nutrition interventions was highest in Pakistan (25%). Wealth gaps (richest versus poorest) for co-coverage of health interventions were largest for Pakistan (slope index of inequality: 62 percentage points) and Afghanistan (38 percentage points). Wealth gaps for co-coverage of nutrition interventions were highest in India (32 percentage points) and Bangladesh (20 percentage points). Coverage of nutrition interventions was lower than for associated health interventions, with opportunity gaps ranging from 4 to 54 percentage points.

Conclusion

Co-coverage of health and nutrition interventions is far from optimal and disproportionately affects poor households in south Asia. Policy and programming efforts should pay attention to closing coverage, equity and opportunity gaps, and improving nutrition delivery through health-care and other delivery platforms.

COVID-19 Disrupted Provision and Utilization of Health and Nutrition Services in Uttar Pradesh, India: Insights from Service Providers, Household Phone Surveys, and Administrative Data

BACKGROUND

The coronavirus (COVID-19) pandemic may substantially affect health systems, but little primary evidence is available on disruption of health and nutrition services.

OBJECTIVES

This study aimed to 1) determine the extent of disruption in provision and utilization of health and nutrition services induced by the pandemic in Uttar Pradesh, India; and 2) identify how adaptations were made to restore service provision in response to the pandemic.

METHODS

We conducted longitudinal surveys with frontline workers (FLWs, n = 313) and mothers of children <2 y old (n = 659) in December 2019 (in-person) and July 2020 (by phone). We also interviewed block-level managers and obtained administrative data. We examined changes in service provision and utilization using Wilcoxon matched-pairs signed-rank tests.

RESULTS

Compared with prepandemic, service provision reduced substantially during lockdown (83-98 percentage points, pp), except for home visits and take-home rations (∼30%). Most FLWs (68%-90%) restored service provision in July 2020, except for immunization and hot cooked meals (<10%). Administrative data showed similar patterns of disruption and restoration. FLW fears, increased workload, inadequate personal protective equipment (PPE), and manpower shortages challenged service provision. Key adaptations made to provide services were delivering services to beneficiary homes (∼40%-90%), social distancing (80%), and using PPE (40%-50%) and telephones for communication (∼20%). On the demand side, service utilization reduced substantially (40-80 pp) during the lockdown, but about half of mothers received home visits and food supplementation. Utilization for most services did not improve after the lockdown, bearing the challenges of limited travel (30%), nonavailability of services (26%), and fear of catching the virus when leaving the house (22%) or meeting service providers (14%).

CONCLUSIONS

COVID-19 disrupted the provision and use of health and nutrition services in Uttar Pradesh, India, despite adaptations to restore services. Strengthening logistical support, capacity enhancement, performance management, and demand creation are needed to improve service provision and utilization during and post-COVID-19.

Vulnerability of agriculture to climate change increases the risk of child malnutrition: Evidence from a large-scale observational study in India

INTRODUCTION

The impact of climate change on agriculture and food security has been examined quite thoroughly by researchers globally as well as in India. While existing studies provide evidence on how climate variability affects the food security and nutrition, research examining the extent of effect vulnerability of agriculture to climate change can have on nutrition in India are scarce. This study examined a) the association between the degree of vulnerability in agriculture to climate change and child nutrition at the micro-level b) spatial effect of climate vulnerability on child nutrition, and c) the geographical hotspots of both vulnerability in agriculture to climate change and child malnutrition.

METHODS

The study used an index on vulnerability of agriculture to climate change and linked it to child malnutrition indicators (stunting, wasting, underweight and anaemia) from the National Family Health Survey 4 (2015-16). Mixed-effect and spatial autoregressive models were fitted to assess the direction and strength of the relationship between vulnerability and child malnutrition at macro and micro level. Spatial analyses examined the within-district and across-district spill-over effects of climate change vulnerability on child malnutrition.

RESULTS

Both mixed-effect and spatial autoregressive models found that the degree of vulnerability was positively associated with malnutrition among children. Children residing in districts with a very high degree of vulnerability were more like to have malnutrition than those residing in districts with very low vulnerability. The analyses found that the odds of a child suffering from stunting increased by 32%, wasting by 42%, underweight by 45%, and anaemia by 63% if the child belonged to a district categorised as very highly vulnerable when compared to those categorised as very low. The spatial analysis also suggested a high level of clustering in the spatial distribution of vulnerability and malnutrition. Hotspots of child malnutrition and degree of vulnerability were mostly found to be clustered around western-central part of India.

CONCLUSION

Study highlights the consequences that vulnerability of agriculture to climate change can have on child nutrition. Strategies should be developed to mitigate the effect of climate change on areas where there is a clustering of vulnerability and child malnutrition.

Effect of exposure to PM10 on child health: evidence based on a large-scale survey from 184 cities in India

Introduction

Air pollution is increasingly becoming a serious global public health concern. Prior studies examining the effect of air pollution on health have ignored the role of households’ hygienic practices and socioeconomic condition, which are key determinants of the health status of a country like India. This study examines the effects of air pollution, measured in levels of particulate matters of size below 10 µg/m³ (PM₁₀), on child-health outcomes after adjusting for hygiene practices.

Methods

Health data from the National Family Health Survey-4 (NFHS-4) and PM₁₀ levels provided by the Central Pollution Control Board were matched for 184 Indian towns/cities. Child health outcomes included neonatal mortality, post-neonatal mortality, premature births, children with symptoms of acute respiratory infections (ARI) and low birth weight. Multilevel mixed-effects models were used to estimate the risk associated with exposure to PM₁₀.

Result

Analyses based on 23 954 births found that every 10-unit increase in PM₁₀ level, increased the risk of neonatal mortality by 6% (adjusted RR (95% CI): 1.02 (1.02 to 1.09)), and the odds of symptoms of ARI among children by 7% (adjusted OR (95% CI): 1.07 (1.03 to 1.12)), and premature births by 8% (adjusted OR (95% CI): 1.08 (1.03 to 1.12)). There was no statistically significant difference in the effect of PM₁₀ on child health regardless of household’s hygienic practices. Effects of PM₁₀ on child health outcomes remained similar for cities whether or not they were part of the National Clean Air Program (NCAP).

Conclusion

Exposure to PM₁₀, regardless of hygienic practices, increases the risk of adverse child health outcomes. Study findings suggest that the focus of mitigating the effects of air pollution should be beyond the towns/cities identified under NCAP. Given the increasing industrialisation and urbanisation, a systemic, coherent approach is required to address the issue of air pollution in India.

Effects of Persistent Undernutrition During Adolescence on Learning Skills: Findings From a Longitudinal Study of 16,000 Adolescents in India

Objectives

Limited evidence exists on longitudinal impacts of undernutrition on learning skills as adolescents mature. This study aimed to examine the effect of undernutrition in early adolescence on learning skills in late adolescence.

Methods

We used longitudinal data from a project called UDAYA that surveyed 16,929 adolescents aged 10–19 years from Bihar and Uttar Pradesh, India in 2015–16 (wave 1) and again in 2018–19 (wave 2). Adolescents’ ability to read a story and solve division problems at age 19–22 years was assessed using the Annual Status of Education Report tools. We characterized adolescents’ nutrition status into 4 groups: never undernourished (e.g., not stunted in wave 1 and 2), recovered (e.g., stunted in in wave 1 but not stunted in wave 2), faltered (e.g., not stunted in wave 1 but stunted in wave 2), and persistent (e.g., stunted in both waves). These 4 groups were created for stunting, thinness, and anemia. We used multivariable logistic regression models adjusted for key demographics, environmental factors, and sampling design.

Results

Undernutriton was high (51% were anemic, 19% thin, and 36% stunted) in both survey rounds. Nearly one third of adolescents had persistent stunting or anemia, and 11% had persistent thinness. Compared to those who were never stunted, adolescents with persistent stunting had poorer reading (adjusted odds ratio: 0.66, 95% confidence interval: 0.53–0.83) and math (0.70, 0.56–0.89) skills. Reading ability was also poorer in adolescents who experienced growth faltering (0.61, 0.42–0.90) or who were stunted in wave 1 but not stunted in wave 2 (0.64, 0.44–0.93). Persistent thinness was negatively associated with reading (0.71, 0.54–0.93) but not math skills. Persistent anemia was also negatively associated with reading skills, but the association did not remain significant in the fully adjusted model.

Conclusions

In a high poverty sample of Indian adolescents, persistent undernutrition during adolescence was associated with poor learning skill. Promisingly, most of those who recovered from undernutrition in the 2–3 year period between surveys showed catch-up in learning. Ensuring appropriate nutrition during this period of rapid physical and cognitive maturation will yield long-term dividends for wellbeing.

Funding Sources

Bill & Melinda Gates Foundation.

India's 2.42 Million Frontline Health Workers Enable Restoration of Health and Nutrition Service Delivery After Early COVID-19 Lockdowns

Objectives

Modeling studies have estimated impacts of potential service delivery disruptions due to COVID-19 pandemic on maternal and child nutrition outcomes, but little is known about actual delivery status. We studied disruptions and restorations of health and nutrition services by frontline workers (FLWs) in India during COVID-19.

Methods

We conducted phone surveys with 5500 FLWs in seven states between August–October 2020, asking about service delivery during April 2020 (T1) and in the August-October period (T2) and

analyzed changes between T1 and T2. We also analyzed publicly available administrative data (AD) from 704 districts including the pre-pandemic period (T0) to examine disruptions and restoration of services.

Results

Phone surveys suggest, in T1, opening of village centers, fixed day events, growth monitoring, and immunization services was <50% in several states. In T2, restorations of center-based services were seen, with increases of >33% in >= 3 states. Food supplementation was least disrupted both in T1 and T2. AD highlights geographic variability both in disruptions in T1 compared to T0 and restorations in T2. FLWs’ adaptations to ensure service provision included home delivery (60 to 96%), ensuring physical distancing (33 to 86%), coordinating with other FLWs (7 to 49%), and using phone (∼2 to 65%). Challenges included personal fears, walking long distances, and beneficiaries’ non-cooperation.

Conclusions

Services to mothers and children were disrupted during lockdown and restored thereafter. Rapid policy guidance and local adaptations by a strong cadre of FLWs likely enabled service resumption. However, gaps remain, and more research is needed on use of services by clients.

Funding Sources

Bill & Melinda Gates Foundation through POSHAN, led by International Food Policy Research Institute.

Teenage Birth Leads to Short Stature and Anemia: Evidence From a Longitudinal Study of 10,000 Girls in India

Objectives

Home to one in five adolescents globally and a tradition of marrying young, India faces a huge challenge of teenage births. Early birth can be detrimental to the health and wellbeing of the teenage mother and her child, but few studies have followed teenage girls over time to understand these effects. We assessed the impact of early birth on female adolescents' undernutrition status.

Methods

We used longitudinal data collected under a project called UDAYA that surveyed adolescent girls in northern India (Uttar Pradesh and Bihar) in 2015–16, with a follow-up round in 2018–19. Girls with no prior birth in round one were grouped as follows: still no birth in round two (reference group; n = 7,197), birth at age &lt; 19 years by round two (early birth group; EB; n = 1,192), and birth at age &gt; = 19 years by round two (later birth group; LB; n = 1,474). Using multivariate logistic and ordinary least square regression models, we examined whether EB or LB predicted height for age z-score (HAZ), stunting, BMI for age z-score (BMIZ), thinness, hemoglobin (Hb), and anemia. Models were controlled for cluster sampling design and individual and household characteristics.

Results

The prevalence of undernutrition was higher in the EB group (stunting: 53%, thinness: 23%, anemia: 77%) and the LB group (stunting: 55%, thinness: 29%, anemia: 64%) compared to the reference group (stunting: 35%, thinness: 16%, anemia: 63%). The EB group was more likely to be short for their age (adjusted odds ratio (AOR): 1.30, 95% confidence interval (95%CI): 0.96,1.76), thin (AOR: 1.09, 95%CI: 0.68, 1.75), and anemic (AOR: 2.01, 95%CI: 1.39, 2.90) compared to the reference group. HAZ and Hb levels were on average 0.16 SD (95%CI: –0.30, –0.03) and 0.49 gm/DL (95%CI: –0.76, –0.22) lower, respectively, and BMIZ level was 0.22 SD (95%CI: 0.00, 0.43) higher for the EB group. Similar findings were observed for the LB group but were non-significant. The impact of EB on stunting and thinness was non-significant.

Conclusions

In adolescent girls, early birth can contribute to stunting and anemia. Policy initiatives to increase age at marriage and at birth would likely also benefit nutritional outcomes in adolescents.

Funding Sources

Bill & Melinda Gates Foundation.

Impacts of COVID-19 on Provision and Utilization of Health and Nutrition Services in Uttar Pradesh, India: Insights From Phone Surveys and Administrative Data

Objectives

The COVID-19 pandemic has significant potential implications for health systems, but little primary evidence is available on effects on health and nutrition services. We aimed to examine changes in service provision and utilization during the pandemic in Uttar Pradesh, India and identify positive adaptations to service delivery.

Methods

We conducted longitudinal surveys with frontline workers (FLW, n = 313) and mothers of children < 2 years (n = 659) in December 2019 (in-person) and July 2020 (by phone). We also interviewed block-level managers and obtained administrative data. We examined changes in service provision and utilization using Wilcoxon matched-pairs signed-rank tests.

Results

Compared to pre-pandemic, service provision reduced substantially during lockdown (83–98 percentage points, pp), except for home visits and take-home-rations (∼30%). Most FLWs (68–90%) resumed service provision in July 2020, except for immunization and hot-cooked meals (< 10%). Administrative data showed similar patterns of disruption and resumption. FLW fears, increased workload, inadequate personal protective equipment (PPE), and manpower shortages challenged service delivery. Key adaptations made to provide services included: delivering services to beneficiary homes (∼40–90%), social distancing (80%), using PPE (40–50%), and telephones for communication (∼20%). On the demand side, service utilization also reduced substantially (40–80pp) during the lockdown, but about half of mothers received home visits and food supplementation. Utilization for most services did not improve after the lockdown, bearing challenges of limited travel (30%), non-availability of services (26%), fear of catching virus when leaving the house (22%) or meeting service providers (14%).

Conclusions

COVID-19 affected the provision and use of health and nutrition services despite efforts at service restoration and adaptations. Strengthening logistics support, capacity enhancement, performance management, and demand creation are needed to improve service provision and utilization during and post-COVID-19.

Funding Sources

Bill & Melinda Gates Foundation through POSHAN, led by International Food Policy Research Institute; and Alive & Thrive, led by FHI Solutions.

Practical consensus recommendations for neo-adjuvant chemotherapy in triple negative breast cancer

This manuscript provides a practical and easy to use consensus recommendation to community oncologists on how to use neoadjuvant chemotherapy in triple negative breast cancer patients.

Practical consensus recommendations on duration of adjuvant hormonal therapy in breast cancer

Optimization of adjuvant systemic therapy in women with early-stage hormone receptor-positive breast cancer includes the consideration of chemotherapy and duration of hormone therapy. Adjuvant hormonal therapy significantly improves long-term survival of breast cancer patients with hormone receptor-positive disease. Despite the proven clinical efficacy of tamoxifen and aromatase inhibitors, many breast cancer survivors either fail to take the correct dosage at the prescribed frequency (adherence) or discontinue therapy (persistence). Expert oncologist discussed on the duration of adjuvant hormonal therapy for improvement of OS and quality of life of breast cancer patients by providing reduction in recurrence and mortality. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.

Migration and family planning in the state with highest total fertility rate in India

BACKGROUND

This study examined the relationship between male out-migration and family planning (FP) behaviour of women in rural Bihar.

METHODS

Data was collected from 937 currently married women aged 15-34 years from two districts of Bihar, namely Nawada and Gopalganj. Respondents were selected through a multi-stage systematic sampling and were recruited from both low and high male out-migration blocks. Differences in FP outcomes-use of modern contraceptive methods, intention to use contraceptives in next 12 months and access to FP services-were assessed by volume of migration, husband's migration status, frequency of return, and duration of husband's stay at home during visits.

RESULTS

Women with migrant husbands were about 50% less likely to use modern contraceptive methods. Further, the odds of using modern contraceptives was about half among women with migrant husbands if they resided in high out-migration areas (HMA) than low out-migration areas (LMA) (15% vs 29%, AOR: 0·50, p = 0·017). A higher proportion of women with migrant husbands, specifically from HMA, reported greater intention of using contraceptives in next 12 months than their counterparts (37% vs 23%, AOR: 1·83, p = 0·015). Similarly, access to FP services was negatively associated with the volume of male out-migration, specifically for women with migrant husbands.

CONCLUSIONS

The migratory environment as well as the migration of husbands affect contraceptive use and access to FP services among women. Given that a significant proportion of married males leave their home states for work, it is imperative that FP programs in migration affected areas plan and implement migration-centric FP implementation strategies.

Sustaining consistent condom use among female sex workers by addressing their vulnerabilities and strengthening community-led organizations in India

Introduction

Between 2014 and 2017, a program aimed at reducing HIV risk and promoting safe sex through consistent use of condoms sought to work through addressing social and economic vulnerabilities and strengthening community-led organizations (COs) of female sex workers (FSWs). This study examines if the program was effective by studying relationship between strengthening of COs, vulnerability reduction, and sustaining of consistent condom use behavior among FSWs.

Methods

We used a longitudinal study design to assess the change in outcomes. A three-stage sampling design was used to select FSWs for the study. Panel data of 2085 FSWs selected from 38 COs across five states of India was used to examine the change in various outcomes from 2015 (Survey Round 1) to 2017 (Survey Round 2). The CO level program pillar measuring institutional development assessed performance of COs in six domains critical for any organization’s functionality and sustainability: governance, project management, financial management, program monitoring, advocacy and networking, and resource mobilization. Overall, 32 indicators from all these domains were used to compute the CO strength score. A score was computed by taking mean of average dimension scores. The overall score was divided into two groups based on the median cutoff; COs which scored below the median were considered to have low CO strength, while COs which scored above or equal to median were considered to have high CO strength. Multivariable regression modeling techniques were used to examine the effect of program pillars on outcome measures.

Results

Analyses showed a significant improvement in the strength of the COs over time; percentage of COs having high strength improved from 50% in 2015 to 87% in Round 2. The improvement in CO’s strength increased financial security (Adjusted Odds Ratio [AOR]: 2.18, p<0.01), social welfare security (AOR: 1.71, p<0.01), and socio-legal security (AOR: 2.20, p<0.01) among FSWs. Further, improvement in financial security led to significant increase in consistent condom use with client among FSWs (AOR: 1.69, p<0.01) who were members of COs having high strength. Sustained consistent condom use was positively associated with young age (<30 years), ability to negotiate with clients for condom use, membership in self-help groups, high self-efficacy, self-confidence, and client solicitation in streets and brothels.

Conclusions

Improving financial security and strengthening FSW led CO can improve sustained and consistent condom use. In addition, the program should focus on enhancing ability of FSWs to negotiate with clients for condom use, promote membership in self-help groups and target FSWs who are 30 years or older, and soliciting from homes to sustain consistent condom use across all FSWs.

Effect of sharing health messages on antenatal care behavior among women involved in microfinance-based self-help groups in Bihar India

Background

Bihar state in India has one of the highest rates of maternal and infant mortality in South Asia. Microfinance-based self-help groups (SHGs), involving rural women, are being utilized to improve maternal and child health practice and reduce mortality. SHG members receive information on key maternal and child health practices as well as encouragement for their practice. This study measures the association of health messaging to SHG members with their antenatal care (ANC) behaviors.

Methods

The study was conducted in eight districts of Bihar in 2016. A three-stage cluster sampling design (with a random selection of blocks, villages, and SHGs) selected the sample of 1204 SHG members who had an infant child; of these, 597 women were members of SHGs that received dedicated sessions on health messages, while 607 women belonged to SHGs that did not. To examine the impact of the health intervention on ANC practice, radius caliper method of propensity score matching controlled for various socio-demographic characteristics between the two groups.

Results

Most of the interviewed women (91.5%) belonged to a scheduled caste or tribe. Nearly 44% of SHG members exposed to the health intervention were engaged in some occupation, compared to 35% of those not exposed to the intervention. After matching unexposed SHG women with exposed SHG women, no significant differences were found in their socio-demographic characteristics. Findings suggest that exposure to a health intervention is associated with increased likelihood of at least four ANC visits by SHG women (ATE = 7.2, 95% CI: 0.76–13.7, p < 0.05), consumption of iron-folic acid for at least 100 days (ATE = 8.7, 95% CI: 5.0–12.5, p < 0.001) and complete ANC (ATE = 3.6, 95% CI: 2.3–4.9, p < 0.001), when compared to women not exposed to the health intervention.

Conclusions

The study shows that sharing health messages in microfinance-based SHGs is associated with significant increase in ANC practice. While the results suggest the potential of microfinance-based SHGs for improved maternal health services, the approach’s sustainability needs to be further examined.

Frequency and risk factors for mental disorders following pancreatitis: a nationwide cohort study

Objective: To investigate the frequency and risk factors for mental disorders following pancreatitis. Methods: Patients with acute pancreatitis (AP) and chronic pancreatitis (CP) were identified (n = 18,074) from a nationwide database in New Zealand (1998-2015). They were followed from their first hospital admissions for AP or CP to incident mental disorders. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated using multivariable Cox regression analyses. Results: CP (vs AP) was associated with a significantly higher risk of mental disorders (adjusted HR = 2.00 [95% CI = 1.53-2.62]). Pre-existing diabetes (adjusted HR = 8.99 [95% CI = 6.23-12.96] for AP and adjusted HR = 3.42 [95% CI = 2.37-4.96] for CP) and post-pancreatitis diabetes mellitus (adjusted HR = 7.10 [95% CI = 4.14-12.19] for AP and adjusted HR = 2.97 [95% CI = 1.83-4.82] for CP) were risk factors for mental disorders in individuals following pancreatitis. Severe (adjusted HR = 2.07 [95% CI = 1.39-3.06] vs mild) and recurrent (adjusted HR = 1.62 [95% CI = 1.07-2.45] vs single episode) attacks were associated with significantly higher risks of mental disorders following AP. Conclusions: Patients following CP, recurrent AP, severe AP, and those with diabetes are at high risk for developing mental disorders.

Effect of behavioral change intervention around new-born care practices among most marginalized women in self-help groups in rural India: analyses of three cross-sectional surveys between 2013 and 2016

OBJECTIVE

To assess the effects of new-born care intervention through self-help groups in improving new-born healthcare practices in rural India.

METHODS

A quasi-experimental design was used to evaluate behavioral change intervention integrated in >25,000 microfinance-based self-help groups in rural Bihar. Three rounds of cross-sectional surveys were conducted to understand the impact of intervention on new-born healthcare practices by talking to women who delivered a baby in the last 6 months.

RESULTS

Intervention groups showed greater improvement than control groups in the timely initiation of breastfeeding (adjusted odds ratio (AOR) = 6.3, 95% CI: 2.8, 14.3), exclusive breastfeeding on day 1 (AOR = 4.3, 95% CI: 1.9, 9.9), initiation of skin-to-skin care (AOR = 1.9, CI: 1.0, 3.8), and delayed bathing (AOR = 2.8, 95% CI: 1.4, 5.9) with greater effect of on home deliveries where clinical care is often absent.

CONCLUSION

Sharing messages on appropriate new-born practices through self-help groups improve new-born care practices.

HIV Research for Prevention 2018: From Research to Impact Conference Summary and Highlights

The HIV Research for Prevention (HIVR4P) conference is dedicated to advancing HIV prevention research, responding to a growing consensus that effective and durable prevention will require a combination of approaches as well as unprecedented collaboration among scientists, practitioners, and community workers from different fields and geographic areas. The conference theme in 2018, "From Research to Impact," acknowledged an increasing focus on translation of promising research findings into practical, accessible, and affordable HIV prevention options for those who need them worldwide. HIVR4P 2018 was held in Madrid, Spain, on 21-25 October, with >1,400 participants from 52 countries around the globe, representing all aspects of HIV prevention research and implementation. The program included 137 oral and 610 poster presentations. This article presents a brief summary of highlights from the conference. More detailed information, complete abstracts as well as webcasts and daily Rapporteur summaries may be found on the conference website.

Calcitonin gene-related peptide: neuroendocrine communication between the pancreas, gut, and brain in regulation of blood glucose

Background

Calcitonin gene-related peptide (CGRP), a ubiquitous neuropeptide, plays a diverse and intricate role in chronic low-grade inflammation, including conditions such as obesity, type 2 diabetes, and diabetes of the exocrine pancreas. Diabetes of exocrine pancreas is characterised by chronic hyperglycemia and is associated with persistent low-grade inflammation and altered secretion of certain pancreatic and gut hormones. While CGRP may regulate glucose homeostasis and the secretion of pancreatic and gut hormones, its role in chronic hyperglycemia after acute pancreatitis (CHAP) is not known. The aim of this study was to investigate the association between CGRP and CHAP.

Methods

Fasting blood samples were collected to measure insulin, HbA1c, CGRP, amylin, C-peptide, glucagon, pancreatic polypeptide (PP), somatostatin, gastric inhibitory peptide, glicentin, glucagon-like peptide-1 and 2, and oxyntomodulin. Modified Poisson regression analysis and linear regression analyses were conducted. Five statistical models were used to adjust for demographic, metabolic, and pancreatitis-related risk factors.

Results

A total of 83 patients were recruited. CGRP was significantly associated with CHAP in all five models (P-trend <0.005). Further, it was significantly associated with oxyntomodulin (P<0.005) and glucagon (P<0.030). Oxyntomodulin and glucagon independently contributed 9.7% and 7%, respectively, to circulating CGRP variance. Other pancreatic and gut hormones were not significantly associated with CGRP.

Conclusions

CGRP is involved in regulation of blood glucose in individuals after acute pancreatitis. This may have translational implications in prevention and treatment of diabetes of the exocrine pancreas.

Gastrin-Releasing Peptide and Glucose Metabolism Following Pancreatitis

Background

Gastrin-releasing peptide (GRP) is a pluripotent peptide that has been implicated in both gastrointestinal inflammatory states and classical chronic metabolic diseases such as diabetes. Abnormal glucose metabolism (AGM) after pancreatitis, an exemplar inflammatory disease involving the gastrointestinal tract, is associated with persistent low-grade inflammation and altered secretion of pancreatic and gut hormones as well as cytokines. While GRP is involved in secretion of many of them, it is not known whether GRP has a role in AGM. Therefore, we aimed to investigate the association between GRP and AGM following pancreatitis.

Methods

Fasting blood samples were collected to measure GRP, blood glucose, insulin, amylin, glucagon, pancreatic polypeptide (PP), somatostatin, cholecystokinin, gastric-inhibitory peptide (GIP), gastrin, ghrelin, glicentin, glucagon-like peptide-1 and 2, oxyntomodulin, peptide YY (PYY), secretin, vasoactive intestinal peptide, tumor necrosis factor-α (TNF-α), monocyte chemoattractant protein (MCP)-1, and interleukin-6. Modified Poisson regression analysis and linear regression analyses were conducted. Four statistical models were used to adjust for demographic, metabolic, and pancreatitis-related risk factors.

Results

A total of 83 individuals after an episode of pancreatitis were recruited. GRP was significantly associated with AGM, consistently in all four models (P -trend < 0.05), and fasting blood glucose contributed 17% to the variance of GRP. Further, GRP was significantly associated with glucagon (P < 0.003), MCP-1 (P < 0.025), and TNF-α (P < 0.025) - consistently in all four models. GRP was also significantly associated with PP and PYY in three models (P < 0.030 for both), and with GIP and glicentin in one model (P = 0.001 and 0.024, respectively). Associations between GRP and other pancreatic and gut hormones were not significant.

Conclusion

GRP is significantly increased in patients with AGM after pancreatitis and is associated with increased levels of pro-inflammatory cytokines, as well as certain pancreatic and gut hormones. Detailed mechanistic studies are now warranted to investigate the exact role of GRP in derangements of glucose homeostasis following pancreatitis.

Characterization and anti-microbial susceptibility of bacterial isolates: Experience from a tertiary care cancer center in Delhi

BACKGROUND

Hospitalization for fever in cancer patients is associated with considerable morbidity, mortality, and cost.

AIM

The aim of this study was to study the bacterial spectrum and susceptibility patterns of pathogens in culture positive patients from the oncology unit of our hospital.

METHODS

We retrospectively reviewed the medical records of patients admitted in our cancer center (medical, radiation, and surgical oncology) from January to December 2013. Blood and respiratory secretions from the indoor patients were evaluated.

RESULTS

Of the total 693 samples, 76.4% were Gram-negative and 23.6% were Gram-positive. The most common bacterial isolates among Gram-negative organisms in blood were Escherichia coli, Salmonella and among the Gram-positive organism were Staphylococcus aureus and Enterococcus. Among the blood isolates extended spectrum of beta-lactamase, multidrug-resistant (carbapenem-resistant) and pan resistant bugs were seen in 47%, 15%, and 5% of the blood isolates. Among the Gram-positive organisms, 25% respiratory isolates were vancomycin-resistant Enterococci.

CONCLUSION

We observed a high incidence of Gram-negative isolates with clinically significant resistance to first-line antibiotics such as cephalosporin's, piperacillin tazobactum, and fluoroquinolones.

Evaluation of Antioxidant Activity of Picrorhiza kurroa (Leaves) Extracts

Picrorhiza kurroa is a well-known herb in Ayurvedic medicine. Although it shows antioxidant, antiinflammatory and immunomodulatory activities, it is most valued for its hepatoprotective effect. The rhizomes are widely used against indigestion problems since ancient times due to improper digestive secretions. Aim of this study was to explore antioxidant study of P. kurroa leaves for a new source of naturally occurring antioxidants. Two pure compounds, luteolin-5-O-glucopyranoside (1) and picein (2) were isolated from butanol extract through column chromatography. Different extracts of P. kurroa leaves (ethanol, ethyl acetate, butanol) were quantified for isolated compound (2) by high-performance liquid chromatography. All the extracts and isolated compounds were evaluated for its antioxidant activity using two assays, 2,2-diphenyl-1-picrylhydrazyl radical and 2,2’-azino-bis(3-ethylbenzothiazoline-6-sulphonic acid) assay. The linear detection range was 1.56-200 μg/ml for picein. The limit of detection and limit of quantification for picein were 2.34 and 7.81 μg/ml, respectively. Butanol and ethyl acetate extract showed greater antioxidant activity as compare to ethanol extract. Compound 1 and ascorbic acid showed nearly similar antioxidant activity where as 2 showed no activity at standard concentration. The IC₅₀ values for 2,2-diphenyl-1-picrylhydrazyl radical and 2,2’-azino-bis(3-ethylbenzothiazoline-6-sulphonic acid) assay for ascorbic acid, compound 1, ethanol extract and its different fractions (ethyl acetate and butanol) were found to be 0.81, 1.04, 67.48, 39.58, 37.12 and 2.59, 4.02, 48.36, 33.24, 29.48 μg, respectively.

Gemella haemolysans spondylodiscitis: a report of two cases

We report on two cases of infective spondylodiscitis caused by Gemella haemolysans in otherwise healthy patients. This organism has only rarely been identified as a cause of bone and joint infection, with only two previous reports of infective spondylodiscitis. We describe the clinical features, investigations and treatment options.

Idiopathic pulmonary hemosiderosis: clinical profile and follow up of 26 children

OBJECTIVES

To describe the clinical details and follow up of children with idiopathic pulmonary hemosiderosis.

DESIGN

Retrospective case series.

SETTING

Pediatric chest clinic of a tertiary care hospital.

SUBJECTS

Children diagnosed as suffering from idiopathic pulmonary hemosiderosis (IPH).

METHODS

Charts of patients diagnosed as IPH were reviewed for clinical features and treatment regimen. Diagnosis was based on presence of iron deficiency anemia, chest radiography and demonstration of hemosiderin laden macrophages in bronchoalveolar lavage (BAL), gastric aspirate, or sputum. Treatment consisted of oral prednisolone, hydroxychloroquine (HCQ) and inhaled corticosteroids (ICS).

RESULTS

The common clinical features in 26 children with IPH (mean age 75 months) included: cough, breathlessness, fever, hemoptysis and wheezing in 26 (100%), 22 (85%), 19 (73%),15 (58%) and 14 (54%) children, respectively. Clubbing, hepatomegaly and splenomegaly was seen in 16 (62%), 15 (58%) and 10 (38%) children, respectively. Hemosiderin laden macrophages were documented in BAL and gastric aspirate in 92% and 30% patients, respectively. Symptoms did not recur in 17 patients who received prednisolone and HCQ initially. 5 patients had recurrence of symptoms and required short courses of oral prednisolone, 4 patients required frequent courses of prednisolone and were started on azathioprine. Older age, longer duration of illness, history of hemoptysis and jaundice were associated with poor response.

CONCLUSION

Treatment with prednisolone and hydroxychloroquine followed by inhaled corticosteroids may improve survival in children with IPH.

Caloxin: a novel plasma membrane Ca2+ pump inhibitor

Plasma membrane (PM) Ca2+ pump is a Ca+-Mg2+-ATPase that expels Ca2+ from cells to help them maintain low concentrations of cytosolic Ca2+ . There are no known extracellularly acting PM Ca2+ pump inhibitors, as digoxin and ouabain are for Na+ pump. In analogy with digoxin, we define caloxins as extracellular PM Ca2+ pump inhibitors and describe caloxin 2A1. Caloxin 2A1 is a peptide obtained by screening a random peptide phage display library for binding to the second extracellular domain (residues 401-413) sequence of PM Ca2+ pump isoform 1b. Caloxin 2A1 inhibits Ca2+-Mg2+-ATPase in human erythrocyte leaky ghosts, but it does not affect basal Mg2+-ATPase or Na+-K+-ATPase in the ghosts or Ca2+-Mg2+-ATPase in the skeletal muscle sarcoplasmic reticulum. Caloxin 2A1 also inhibits Ca2+-dependent formation of the 140-kDa acid-stable acylphosphate, which is a partial reaction of this enzyme. Consistent with inhibition of the PM Ca2+ pump in vascular endothelium, caloxin 2A1 produces an endothelium-dependent relaxation that is reversed by N(G)-nitro-L-arginine methyl ester. Thus caloxin 2A1 is a novel PM Ca2+ pump inhibitor selected for binding to an extracellular domain.

Effects of hydrogen peroxide on pig coronary artery endothelium

Peroxides and other reactive oxygen species damage arteries during ischemia-reperfusion. Here, we report on the effects of H(2)O(2) on contractility of pig coronary artery. We either treated 3-mm coronary artery rings with 0 to 0.5 mM H(2)O(2) in organ baths or we perfused the arteries with H(2)O(2) and then cut them into rings. In each instance, we monitored the force of contraction of 3-mm rings in H(2)O(2)-free solution with 30 mM KCl and then we determined the A23187 induced endothelium dependent relaxation as a percent of this contraction. Treatment with H(2)O(2) in the organ bath caused a decrease in the contraction but it did not affect the percent relaxation. Treating arteries with H(2)O(2) by luminal perfusion did not affect the contraction but it decreased the percent relaxation. Perfusion alone decreased the amount of endothelium remaining in the arteries and perfusing with H(2)O(2) decreased it further. The percent relaxation with A23187 correlated well with the endothelium remaining in the arteries. We propose that H(2)O(2) and shear stress can cause a loss of endothelium and that endothelium can also protect the underlying smooth muscle against luminal H(2)O(2).

Prevalence of coronary risk factors in non-insulin dependent (type 2) diabetics

OBJECTIVES

A cross sectional study was conducted to find the prevalence of coronary risk factors in non-insulin dependent diabetic (NIDDM) patients and to compare and co-relate these risk factors in type II diabetics with and without electrocardiographic and/or symptomatic evidence of coronary heart disease (CHD).

METHODS

One hundred sixty-seven consecutive NIDDM patients (77 males, and 90 females) attending the diabetic clinic at Dr. RML Hospital, New Delhi were studied. Only known NIDDM cases, already on treatment and without any history of ketosis or congestive heart failure were included. Coronary risk factors comprising of age, gender, duration and treatment for diabetes, smoking, physical activity, hypertension, truncal obesity, lipids, microalbuminuria (semiquantitative) and glycemic control have been particularly ascertained in all the cases. The data was analysed using 'Epi Info version 6.0'.

RESULTS

The mean age of patients was 53.12 year and 8.86 year was the mean duration of diabetes. 28.6% of the diabetic men were found to be currently smoking and/or consuming alcohol, 82% were involved in sedentary physical activity and 20.4% had family history of CHD. Central obesity was observed in 46.7% of the cases; more so in females. 31.74% of cases were hypertensive; more females than males had hypertension (33.8% vs 30%). Poor glycemic control (HbA1c > = 9.5%) was seen in 16.8% of the cases. In about 52.5% of the total group hypertriglyceridemia was noted. Microalbuminuria could be found in 35.93%. CHD was diagnosed in 15.57% of cases in this study.

CONCLUSIONS

The present study revealed that high levels of serum cholesterol (p = 0.000004), LDL (p = 0.00003), HbA1c (p = 0.002), microalbuminuria (p = 0.000006) and hypertension (p = 0.00006) are significant associates of CHD in NIDDM (both the sexes). Among the female NIDDM cases, in addition BMI (p = 0.01), Waist-hip ratio (WHR) (p = 0.003) and low HDL level (p = 0.008) are important correlates of CHD. Multiple logistic regression analysis was used to allow for confounding between variables. Microalbuminuria alone entered the 'best' model for CHD prediction. Other risk factors, though significant, provided inadequate models for CHD prediction.

AIDS awareness among nursing students of Delhi

A total of 233 students of nursing school affiliated to a major hospital of Delhi were surveyed anonymously employing a predesigned, pretested and self-administered questionnaire. Although, 78.6 per cent students knew that AIDS stands for "Acquired Immuno-deficiency Syndrome," 15.5 per cent students were unaware of the fact that AIDS had reached India. Majority of them were aware of various aspects of HIV/AIDS. However, they also had few misconceptions particularly regarding HIV transmission. Contrary to our belief, only one-fourth students acquired AIDS information from scientific journals. One training session on AIDS conducted for a small group of students could not bring any significant change in their knowledge. Findings suggest organization of AIDS-training sessions at regular intervals from the very inception of nursing programme to impart complete and correct knowledge of these future Florence Nightingales regarding various aspects of HIV/AIDS and for removal of misconceptions.

Serum adenosine deaminase, 5'-nucleotidase & alkaline phosphatase in breast cancer patients

Serum levels of adenosine deaminase (ADA), 5-nucleotidase (5'-NT) and alkaline phosphatase (ALP) were studied in 25 patients of carcinoma breast and 25 normal subjects. Adenosine deaminase was found to be the better probable parameter for the detection of cancer and to assess the development of various stages of cancer whereas 5'-nucleotidase had only diagnostic significance. Serum alkaline phosphatase levels were important for assessing the spread of cancer at secondary sites. After mastectomy a significant decrease was found in the levels of serum ADA and 5'-NT whereas no variations were found in case of serum ALP.

Pediatric trauma: differences in pathophysiology, injury patterns and treatment compared with adult trauma

Although multiple trauma remains the leading cause of death among children, fewer resources and less attention have been directed to treatment of the injured child than to treatment of the injured adult. Insufficient training of medical personnel and hence lack of expertise in the management of injured children are factors contributing to disability and death in such children. Although the principles of resuscitation of injured children are similar to those for adults, appreciation of the differences in cardiorespiratory variables, airway anatomy, response to blood loss, thermoregulation and equipment required is essential for successful initial resuscitation. Cerebral, abdominal and thoracic injuries account for most of the disability and death among injured children. Cerebral damage may be due to secondary injuries to the brain and is potentially preventable. The need to preserve the spleen in children complicates the management of abdominal trauma. Although children usually have large cardiorespiratory reserves, they are likely to need airway control and ventilation with thoracic injuries. The psychologic effect of trauma may pose long-term problems and needs close follow-up.