Impact of training on awareness and Knowledge of Birth Defects among Community Health Workers in tribal district of Maharashtra, India

OBJECTIVE

Early identification, referrals and timely treatment is crucial to improve the outcome of Birth Defects (BDs). The role of Community Health Workers (CHWs) in India is largely fulfilled by Accredited Social Health Activists (ASHAs) who can play an important role in community-based reporting and referrals of BDs in newborn. In the study area, ASHAs have been previously trained for identification of BDs under Rashtriya Bal Swasthya Karyakram (RBSK); however, reporting through them was found to be sub-optimal.

METHODS

To strengthen the community based reporting of BDs through ASHAs, audio visual based training was provided to 1225 ASHAs in 6 tribal blocks of Palghar district in Maharashtra, India. The change in knowledge about BDs before and after training among 1023 participants was analyzed using paired sample t test & McNemar test.

RESULTS

Findings reveal a significant increase in the knowledge of participants with regards to prevention, risk factors and identification of BDs after intervention as compared to before intervention.

DISCUSSION

The study suggests that audio-visual based refresher training increased knowledge of ASHAs with respect to identification, prevention and risk factors of BDs which may eventually improve reporting and referrals of BDs at community level.

Challenges in screening for sickle cell disease among newborns from the tribal region of Palghar, Maharashtra during the COVID-19 pandemic

BACKGROUND OBJECTIVES

Despite several adversities imposed by the COVID-19 pandemic, it was crucial to sustain research having public health relevance such as investigations around sickle cell disease (SCD). Against this background, an ongoing ICMR-multicentric study for newborn screening of SCD in the tribal population at Model Rural Health Research Unit (MRHRU-Dahanu) in Palghar District, Maharashtra constituted the current study setting. This was a descriptive study wherein, certain measures were undertaken and strategies were developed in view of the challenges in newborn screening for SCD due to the COVID-19 pandemic during December 2019-September 2021 at Sub District Hospital, MRHRU-Dahanu.

METHODS

During the onset of the pandemic, (December 2019-March 2020), the follow up was possible in 26.7 per cent (20/75) of the newborns. Subsequently, challenges such as travel restrictions, fear of COVID-19, shortage of staff were experienced with respect to enrolment and follow up visits.

RESULTS

After implementing certain pragmatic strategies (ASHA involvement, usage of virtual platform and flexible visits), follow up rate increased to 47.5 per cent (66/139) between July 2020-April 2021 (post first lockdown) and to 66 per cent (65/98) during the second wave (May 2021-August 2021).

INTERPRETATION CONCLUSIONS

The study emphasizes the importance of network building, use of virtual platform and engaging health workers in tribal settings. Such pragmatic approaches have the potential to pave a path for further implementation research involving specific interventions to improve health outcomes in tribal settings.

Factors associated with stigma and manifestations experienced by Indian health care workers involved in COVID-19 management in India: A qualitative study

Healthcare personnel who deal with COVID-19 experience stigma. There is a lack of national-level representative qualitative data to study COVID-19-related stigma among healthcare workers in India. The present study explores factors associated with stigma and manifestations experienced by Indian healthcare workers involved in COVID-19 management. We conducted in-depth interviews across 10 centres in India, which were analysed using NVivo software version 12. Thematic and sentiment analysis was performed to gain deep insights into the complex phenomenon by categorising the qualitative data into meaningful and related categories. Healthcare workers (HCW) usually addressed the stigma they encountered when doing their COVID duties under the superordinate theme of stigma. Among them, 77.42% said they had been stigmatised in some way. Analyses revealed seven interrelated themes surrounding stigma among healthcare workers. It can be seen that the majority of the stigma and coping sentiments fall into the mixed category, followed by the negative sentiment category. This study contributes to our understanding of stigma and discrimination in low- and middle-income settings. Our data show that the emergence of fear of the virus has quickly turned into a stigma against healthcare workers.

Challenges in Accessing and Delivering Maternal and Child Health Services during the COVID-19 Pandemic: A Cross-Sectional Rapid Survey from Six States of India

BACKGROUND/OBJECTIVES

Globally, the COVID-19 pandemic and its prevention and control policies have impacted maternal and child health (MCH) services. This study documents the challenges faced by patients in accessing MCH services, and the experiences of health care providers in delivering those services during the COVID-19 outbreak, explicitly focusing on the lockdown period in India.

METHODS

A cross-sectional study (rapid survey) was conducted in 18 districts from 6 states of India during March to June, 2020. The sample size included 540 MCH patients, 18 gynaecologists, 18 paediatricians, 18 district immunisation officers and 108 frontline health workers. Bivariate analysis and multivariable analysis were used to assess the association between sociodemographic characteristics, and challenges faced by the patients.

RESULTS

More than one-third of patients (n = 212; 39%) reported that accessing MCH services was a challenge during the lockdown period, with major challenges being transportation-related difficulties (n = 99; 46%) unavailability of hospital-based services (n = 54; 23%) and interrupted outreach health services (n = 39; 18.4%). The supply-side challenges mainly included lack of infrastructural preparedness for outbreak situations, and a shortage of human resources.

CONCLUSIONS/RECOMMENDATIONS

A holistic approach is required that focuses on both preparedness and response to the outbreak, as well reassignment and reinforcement of health care professionals to continue catering to and maintaining essential MCH services during the pandemic.

Incidence & factors influencing maternal near miss events in tertiary hospitals of Maharashtra, India

Background & objectives

Government of India (GoI) released operational guidelines for maternal near miss-review (MNM-R) in 2014 for use by programme managers of public health system to assist them for conducting MNM-R. The objective of the present study was to review the incidence and factors influencing MNM events in two tertiary hospitals of Maharashtra, India, as per the operational guidelines of the GoI released in 2014 and identify delays based on three-delay model to prevent such events in future.

Methods

This prospective observational study was conducted in two tertiary hospitals of Maharashtra, from July 2018 to November 2020. All women during pregnancy, childbirth or postpartum upto 42 days meeting the eligibility criteria of MNM as per the 2014 GoI guidelines were included as cases (n=228), interviewed and discussed during the monthly MNM meetings at these hospitals.

Results

The incidence of MNM was 11/1000 live births; the ratio of MNM to maternal deaths was 1.2:1. Leading causes of MNM were haemorrhage (36.4%) and hypertensive disorders of pregnancy (30.3%). Haemorrhage was maximum (70.6%) in abortion and ectopic pregnancies. Majority of the women (80.2%) were anaemic, of whom 32.4 per cent had severe anaemia. Eighty six per cent of women included in the study had MNM events at the time of admission and 81 per cent were referred from lower facilities. Level one and two delays were reported by 52.6 and 32.5 per cent of women, respectively. Level three delay at referral centres and at tertiary hospitals was reported by 69.7 and 48.2 per cent of women, respectively.

Interpretation & conclusions

The findings of this study suggest that MNM-R should be undertaken at all tertiary hospitals in India as per GoI guidelines to identify gaps based on three-delay model. These hospitals should implement interventions as per the identified gaps with emphasis on strengthening the infrastructure, facilities and manpower at the first-referral units.

Assessing the potential of self-help group women for improving reproductive health of women in a tribal block of Maharashtra, India

Background & objectives

In the current health system, cash incentives are given to accredited social health activists for referring women to public health facilities for specific maternal and child health services, however many reproductive health problems are not included in these services. The objective of this study was to assess the impact of involvement of self-help groups (SHGs) in improving reproductive health seeking behaviour and service utilization by tribal women.

Methods

An experimental study was conducted in two tribal blocks of Nasik district (Kalvan and Surgana) in Maharashtra, India, over a period of 18 months. Interventions included training of SHG women and providing incentives to them for conducting health education sessions for reproductive age group women in the community and referring those with the requisite problems, to the health facilities. Pre- and post-intervention focus group discussions and in-depth interviews among SHG women were conducted. Training of service providers on diagnosis and treatment of reproductive morbidities was done, and health service utilization was assessed.

Results

Sixty five per cent of the referred women with reproductive morbidities availed services at the public health facilities. A review of records of women seeking services for reproductive health problems showed that there was a significant improvement in the intent for seeking services in the study block as compared to the control block (χ^[2]-9.06, P<0.002).

Interpretation & conclusions

This study demonstrates the feasibility of utilizing the potential of SHGs for improving reproductive health seeking behaviour of the tribal women. The results suggest that this model could be scaled up to address the neglected reproductive health needs of women without burdening the existing human resources.

Impact of intervention on nutritional status of under-fives in tribal blocks of Palghar District in Maharashtra, India

BACKGROUND

There is a need to improve their nutritional status of under-five children through specific targeted interventions. The present study discusses the impact of intervention on nutritional status among under-five children in Palghar district from Maharashtra.

OBJECTIVE

The objective is to improve the nutritional status of under-five children by implementing multi-component health and nutrition education intervention, focusing on dietary counseling and modification keeping in view the cultural and socio-economic status of population.

METHODS

A prospective pre- and post-intervention study was conducted in two tribal blocks. Total 480 under-five children were included in pre- and post-intervention survey each.

RESULTS

Exclusive breastfeeding rates improved from 48.9% to 50.5% and initiation of complementary feeding at 6 months improved from 48.3% to 72.5% in post intervention survey as compared to preintervention survey. Among other Infant and Young Child Feeding indicators, Minimum Meal Frequency increased significantly to 67.03% from 5.91% and minimum acceptable diet improved from 5.37% to 47.2% in post intervention survey. The prevalence of Severe Acute Malnutrition (SAM) reduced from 5.4% to nil whereas severe stunting and underweight significantly decreased by 17% and 8% respectively in post intervention survey. Severe anemia decreased from 16.24% to nil post intervention.

CONCLUSION

The study reveals a substantial improvement in timely initiation of complementary feeds, nil cases of SAM, stunting, and underweight along with severe anemia in postintervention phase. This highlights the impact of multicomponent health and nutrition education interventions which may be adapted at a programmatic level to reduce child mortality and morbidity in India.

Psychological distress and burnout among healthcare worker during COVID-19 pandemic in India-A cross-sectional study

BACKGROUND

COVID-19 has inundated the entire world disrupting the lives of millions of people. The pandemic has stressed the healthcare system of India impacting the psychological status and functioning of health care workers. The aim of this study is to determine the burnout levels and factors associated with the risk of psychological distress among healthcare workers (HCW) engaged in the management of COVID 19 in India.

METHODS

A cross-sectional study was conducted from 1 September 2020 to 30 November 2020 by telephonic interviews using a web-based Google form. Health facilities and community centres from 12 cities located in 10 states were selected for data collection. Data on socio-demographic and occupation-related variables like age, sex, type of family, income, type of occupation, hours of work and income were obtained was obtained from 967 participants, including doctors, nurses, ambulance drivers, emergency response teams, lab personnel, and others directly involved in COVID 19 patient care. Levels of psychological distress was assessed by the General health Questionnaire -GHQ-5 and levels of burnout was assessed using the ICMR-NIOH Burnout questionnaire. Multivariable logistic regression analysis was performed to identify factors associated with the risk of psychological distress. The third quartile values of the three subscales of burnout viz EE, DP and PA were used to identify burnout profiles of the healthcare workers.

RESULTS

Overall, 52.9% of the participants had the risk of psychological distress that needed further evaluation. Risk of psychological distress was significantly associated with longer hours of work (≥ 8 hours a day) (AOR = 2.38, 95% CI(1.66-3.41), income≥20000(AOR = 1.74, 95% CI, (1.16-2.6); screening of COVID-19 patients (AOR = 1.63 95% CI (1.09-2.46), contact tracing (AOR = 2.05, 95% CI (1.1-3.81), High Emotional exhaustion score (EE ≥16) (AOR = 4.41 95% CI (3.14-6.28) and High Depersonalisation score (DP≥7) (AOR = 1.79, 95% CI (1.28-2.51)). About 4.7% of the HCWs were overextended (EE>18); 6.5% were disengaged (DP>8) and 9.7% HCWs were showing signs of burnout (high on all three dimensions).

CONCLUSION

The study has identified key factors that could have been likely triggers for psychological distress among healthcare workers who were engaged in management of COVID cases in India. The study also demonstrates the use of GHQ-5 and ICMR-NIOH Burnout questionnaire as important tools to identify persons at risk of psychological distress and occurrence of burnout symptoms respectively. The findings provide useful guide to planning interventions to mitigate mental health problems among HCW in future epidemic/pandemic scenarios in the country.

Improving public health service delivery response to address contraceptive needs of socio-economically disadvantaged HIV positive people in Maharashtra, India

Background

People living with HIV (PLHIV) receive free antiretroviral treatment (ART) in public health facilities of India. With improved life expectancy, unmet sexual and reproductive health needs of PLHIV have to be addressed through a converged programmatic response strategy. Evidence shows that socioeconomically disadvantaged women are most vulnerable to high reproductive morbidities, especially HIV positive women with an unmet need of contraception.

Methods

Programmatic convergence by linking ART and family planning services were strengthened at two public health facilities (district hospitals) generally accessed by disadvantaged socio-economic sections of the society. Barriers to linking services including stigma and discrimination were addressed through analysis of existing linkage situation, sensitization and training of healthcare providers and system-level interventions. This facilitated provider-initiated assessment of contraceptive needs of PLHIV, counseling about dual contraception using a couple approach, linkage to family planning centers and maintaining data about these indicators. Six hundred eligible PLHIV seeking care at ART centers were enrolled and followed up for a duration of 6 months. Acceptance of family planning services as a result of the intervention, use of dual contraception methods and their determinants were assessed.

Results

Eighty-seven percent HIV couples reached FP centers and 44.6% accepted dual methods at the end of the study period. Dual methods such as oral contraceptive pills (56.2%), IUCDs (19.4%), female sterilization (11.6%), injectable contraception (9.9%) and vasectomy (2.9%) in addition to condoms were the most commonly accepted methods. Condom use remained regular and consistently high throughout. The study witnessed seven unintended pregnancies, all among exclusive condom users. These women availed medical abortion services and accepted dual methods after counseling. Female index participants, concordant couples, counseling by doctors and women with CD4 count above 741 had higher odds of accepting dual contraception methods. Standard operating procedures (SOP) were developed in consultation with key stakeholders to address operational linkage of HIV and family programs.

Conclusion

The study saw significant improvement in acceptance of dual contraception by PLHIV couples as a result of the intervention. Implementation of SOPs with supportive supervision can ensure efficient linkage of programs and provide holistic sexual and reproductive healthcare for PLHIV in India.

Clinical features and presentation of cervicofacial infection: a Maxillofacial Trainee Research Collaborative (MTReC) study

Cervicofacial infection (CFI) is a common presentation to the Oral and Maxillofacial (OMFS) department and accounts for significant emergency activity. The current study aims to understand the aetiology, management, and clinical features of patients hospitalised with CFI. Our study included all patients admitted for management of CFI from May to October 2017 at 25 OMFS units across 17 UK regions. Data were collected prospectively and included age, comorbidities, prior treatment received, markers of sepsis, and presenting clinical features. One thousand and two (1002) admissions were recorded; 546 (54.5%) were male. Median (range) age was 34 (1-94) years. The most common presenting complaints were trismus (46%) and dysphagia (27%). Airway compromise was present in 1.7% of cases. Odontogenic infection accounted for 822/1002 (82%) admissions. Of those with an infection of odontogenic origin, 453/822 (55.1%) had received previous treatment. Two-thirds of those who had received treatment were managed by antibiotics alone (300/453, 66.2%). Patients met criteria for sepsis in 437/1002 (43.6%) of CFI, and in 374/822 (45.5%) of odontogenic infections. This is the largest study worldwide of patients requiring inpatient management for CFI. Infection due to odontogenic origin is the most frequent reason for admission and nearly half do not seek treatment before presentation. Patients with CFI often present late in their disease and frequently meet criteria for sepsis, requiring timely and aggressive treatment to ensure optimum outcomes. Trismus is an emerging dominant feature with all the implications related to the anaesthetic management of these patients. Knowledge of these factors has implications for the referrer, triage, the emergency department, the anaesthetic team, and members of the OMFS team.

Delays and barriers to early treatment initiation for childhood tuberculosis in India

BACKGROUND: India accounts for 27% of global childhood tuberculosis (TB) burden. Understanding barriers to early diagnosis and treatment in children may improve care and outcomes.METHODS: A cross-sectional study was performed among 89 children initiated on anti-TB treatment from a public hospital in Pune during 2016, using a structured questionnaire and hospital records. Health care providers (HCPs) were defined as medical personnel consulted about the child's TB symptoms. Time-to-treatment initiation (TTI) was defined as the number of days between onset of TB symptoms and anti-TB treatment initiation. Based on Revised National TB Control Programme recommendations, delayed TTI was defined as >28 days.RESULTS: Sixty-seven (75%) of 89 enrolled children had significant TTI delays (median 51 days, interquartile range [IQR] 27-86). Sixty-six (74%) children visited 1-8 HCPs in the private sector before approaching the public sector. The median HCP delay was 28 days (IQR 10-75). Bacille Calmette-Guérin vaccination (aOR 10.96, P = 0.04) and loss of appetite (aOR 4.44, P = 0.04) were associated with delayed TTI.CONCLUSION: The majority of the children had TTI delays due to delays by HCPs in the private sector. Strengthening HCP competency in TB symptom screening and encouraging early referrals are crucial for rapid scaling up of early treatment initiation in childhood TB.

Volatile organic compound measurements point to fog-induced biomass burning feedback to air quality in the megacity of Delhi

We report the first ambient measurements of thirteen VOCs for investigations of emissions and air quality during fog and non-fog wintertime conditions at a tower site (28.57° N, 77.11° E, 220 m amsl) in the megacity of Delhi. Measurements of acetonitrile (biomass burning (BB) tracer), isoprene (biogenic emission tracer in daytime), toluene (a traffic exhaust tracer) and benzene (emitted from BB and traffic), together with soluble and reactive oxygenated VOCs such as methanol, acetone and acetaldehyde were performed during the winters of 2015-16 and 2016-17, using proton transfer reaction mass spectrometry. Remarkably, ambient VOC composition changes during fog were not governed by solubility. Acetaldehyde, toluene, sum of C8-aromatics (e.g. xylenes), sum of C9-aromatics (e.g. trimethyl benzenes) decreased by ≥30% (>95% confidence interval), whereas acetonitrile and benzene showed significant increases by 20% (>70% confidence interval), even after accounting for boundary layer dilution. During fog, the lower temperatures appeared to induce an emissions feedback from enhanced open BB within Delhi for warming, releasing both gaseous and aerosol pollutants with consequences for fog chemistry, sustenance and intensity. The potential feedback is important to consider for improving current emission parametrizations in models used for predicting air quality and fog in such atmospheric environments.

Nutritional Status of Adolescent Girls in Tribal Blocks of Maharashtra

Context

Undernutrition among adolescents in tribal areas is an area of concern in India.

Aims

This study aims to assess nutritional status of adolescent girls and to study their hygienic practices and awareness regarding adolescent programs.

Settings and Design

Two blocks (Palghar and Dahanu) in Palghar district of Maharashtra.

Subjects and Methods

The present study was a community-based cross-sectional study conducted among 240 unmarried adolescent girls in ten villages of the study area.

Results

The mean age of adolescent girls was 14.5 ± 1.62 years. Mean body mass index was 18.13 ± 7.11 kg/m²; 55% of them were wasted and 67% were stunted. Mean hemoglobin was 9.57 ± 1.4 g/dl and 81.6% had moderate anemia. Ninety-two percent reported hand washing with soap after defecation. Only 2.5% had awareness regarding adolescent government programs.

Conclusion

The present study indicated very poor nutritional status among tribal adolescent girls. Interventions to reduce the prevalence of malnutrition and anemia in this age group is the need of the hour.

What information and the extent of information research participants need in informed consent forms: a multi-country survey

Background

The use of lengthy, detailed, and complex informed consent forms (ICFs) is of paramount concern in biomedical research as it may not truly promote the rights and interests of research participants. The extent of information in ICFs has been the subject of debates for decades; however, no clear guidance is given. Thus, the objective of this study was to determine the perspectives of research participants about the type and extent of information they need when they are invited to participate in biomedical research.

Methods

This multi-center, cross-sectional, descriptive survey was conducted at 54 study sites in seven Asia-Pacific countries. A modified Likert-scale questionnaire was used to determine the importance of each element in the ICF among research participants of a biomedical study, with an anchored rating scale from 1 (not important) to 5 (very important).

Results

Of the 2484 questionnaires distributed, 2113 (85.1%) were returned. The majority of respondents considered most elements required in the ICF to be ‘moderately important’ to ‘very important’ for their decision making (mean score, ranging from 3.58 to 4.47). Major foreseeable risk, direct benefit, and common adverse effects of the intervention were considered to be of most concerned elements in the ICF (mean score = 4.47, 4.47, and 4.45, respectively).

Conclusions

Research participants would like to be informed of the ICF elements required by ethical guidelines and regulations; however, the importance of each element varied, e.g., risk and benefit associated with research participants were considered to be more important than the general nature or technical details of research. Using a participant-oriented approach by providing more details of the participant-interested elements while avoiding unnecessarily lengthy details of other less important elements would enhance the quality of the ICF.

Electronic supplementary material

The online version of this article (10.1186/s12910-018-0318-x) contains supplementary material, which is available to authorized users.

Efficacy, safety and pharmacokinetics of a new high-purity factor X concentrate in women and girls with hereditary factor X deficiency

Essentials Plasma-derived factor X concentrate (pdFX) is used to treat hereditary factor X deficiency. pdFX pharmacokinetics, safety and efficacy were assessed in factor X-deficient women/girls. Treatment success rate was 98%; only 6 adverse events in 2 subjects were possibly pdFX related. On-demand pdFX 25 IU kg-1 was effective and safe in women/girls with factor X deficiency.

SUMMARY

Background A high-purity, plasma-derived factor X concentrate (pdFX) has been approved for the treatment of hereditary FX deficiency, an autosomal recessive disorder. Objective To perform post hoc assessments of pdFX pharmacokinetics, safety and efficacy in women and girls with hereditary FX deficiency. Patients/Methods Subjects aged ≥ 12 years with moderate/severe FX deficiency (plasma FX activity of < 5 IU dL-1 ) received on-demand or preventive pdFX (25 IU kg-1 ) for ≤ 2 years. Results Of 16 enrolled subjects, 10 women and girls (aged 14-58 years [median, 25.5 years]) received 267 pdFX infusions. Mean monthly infusions per subject were higher among women and girls (2.48) than among men and boys (1.62). In women and girls, 132 assessable bleeding episodes (61 heavy menstrual bleeds, 47 joint bleeds, 15 muscle bleeds, and nine other bleeds) were treated with pdFX, with a 98% treatment success rate versus 100% in men and boys. Mean pdFX incremental recovery was similar in the two groups (2.05 IU dL-1 versus 1.91 IU dL-1 per IU kg-1 ), as was the mean half-life (29.3 h versus 29.5 h). Of 142 adverse events in women and girls, headache was the most common (12 events in six subjects). Six events (two infusion-site erythema, two fatigue, one back pain, one infusion-site pain) in two subjects were considered to be possibly pdFX-related. Following the trial, pdFX was used to successfully maintain hemostasis in two subjects undergoing obstetric delivery. Conclusions pdFX was well tolerated and effective in women and girls with FX deficiency. Although women and girls had different bleeding symptoms and sites than men and boys, their pdFX pharmacokinetic profile was comparable.

Community based kangaroo mother care for low birth weight babies: A pilot study

Background & objectives:

Kangaroo mother care (KMC - early continuous skin-to-skin contact between mother and infants) has been recommended as an alternative care for low birth weight infants. There is limited evidence in our country on KMC initiated at home. The present study was undertaken to study acceptability of KMC in different community settings.

Methods:

A community-based pilot study was carried out at three sites in the States of Odisha, Gujarat and Maharashtra covering rural, urban and rural tribal population, respectively. Trained health workers provided IEC (information, education and communication) on KMC during antenatal period along with essential newborn care messages. These messages were reinforced during the postnatal period. Outcome measures were the proportion of women accepting KMC, duration of KMC/day and total number of days continuing KMC. Focus group discussions and in-depth interviews were also carried out.

Results:

KMC was provided to 101 infants weighing 1500-2000 g; 57.4 per cent were preterm. Overall, 80.2 per cent mothers received health education on KMC during antenatal period, family members (68.3%) also attended KMC sessions along with pregnant women and 55.4 per cent of the women initiated KMC within 72 h of birth. KMC was provided on an average for five hours per day. Qualitative survey data indicated that the method was acceptable to mothers and family members; living in nuclear family, household work, twin pregnancy, hot weather, etc., were cited as reasons for not being able to practice KMC for a longer duration.

Interpretation & conclusions:

It was feasible to provide KMC using existing infrastructure, and the method was acceptable to most mothers of low birth infants.

Capacity Assessment of District Health System in India on Services for Prevention and Management of Infertility

BACKGROUND

Infertility is a neglected service component in the public health-care system in India.

OBJECTIVES

This study aims to assess the availability and practices on prevention and management services for infertility in the district health system.

METHODOLOGY

A cross-sectional survey of selected health facilities and the staff from 12 district hospitals (DHs), 24 community health centers (CHCs), 48 primary health centers (PHCs), and 48 subcenters was conducted using qualitative and quantitative methods. Interviewed staff included 26 gynecologists; 91 medical officers; 91 auxiliary nurse midwife; 67 laboratory technicians; and 84 accredited social health activist workers.

RESULTS

The findings indicate that adequate staff was in place at more than 70% of health facilities, but none of the staff had received any in-service training on infertility management. Most of the DHs had basic infrastructural and diagnostic facilities. However, the majority of the CHCs and PHCs had inadequate physical and diagnostic facilities related to infertility management. Semen examination service was not available at 94% of PHCs and 79% of CHCs. Advanced laboratory services were available in <42% at DHs and 8% at CHCs. Diagnostic laparoscopy and hysteroscopy were available in 25% and 8% of DHs, respectively. Ovulation induction with clomiphene was practiced at 83% and with gonadotropins at 33% of DHs.

CONCLUSION

The district health infrastructure in India has a potential to provide basic services for infertility. With some policy decisions, resource inputs and capacity strengthening, it is possible to provide advanced services for infertility in the district health system.

Use of telehealth in the delivery of comprehensive care for patients with haemophilia and other inherited bleeding disorders

Advances in technology such as telemedicine (TM) have made access to cost-effective, quality health care feasible for remote patients. TM is especially well suited for patients with chronic disorders such as haemophilia and related haemostatic disorders that benefit not only from more frequent interaction with care providers at a specialized haemophilia treatment center but also from consultations with other specialists. Telehealth refers to a broader application of TM and includes non-clinical services such as education, provider training, administrative meetings etc. Collaboration with the local primary care provider for management and implementation is key for successful and sustainable TM. This review article provides an overview of types of telemedicine, technical aspects, its benefits and challenges and focuses on the applicability of this technology to persons with bleeding and other blood disorders. Examples of TM strategies, process flow of TM clinic and experiences at the authors haemophilia treatment center (HTC) setting are shared. In addition, mobile health (mHealth) and electronic health (eHealth), both a part of telehealth, and their applications are briefly described. Clearly, widespread adoption of this technology will not only enhance care of patients but will enable more people, especially in underserved areas, to receive specialty care.

Improved joint health in subjects with severe haemophilia A treated prophylactically with recombinant factor VIII Fc fusion protein

INTRODUCTION

Joint arthropathy is the long-term consequence of joint bleeding in people with severe haemophilia.

AIM

This study assessed change in joint health over time in subjects receiving recombinant factor VIII Fc fusion protein (rFVIIIFc) prophylaxis.

METHODS

ALONG is the phase 3 pivotal study in which the benefit of rFVIIIFc as a prophylactic treatment for bleeding control was shown in previously treated severe haemophilia patients ≥12 years of age (arm 1: 25-65 IU/kg every 3-5 days, arm 2: 65 IU/kg weekly and arm 3: episodic). After completing ALONG, subjects had the option to enrol into the extension study (ASPIRE). This interim, post hoc analysis assessed changes in joint health over ~2.8 years in these patients.

RESULTS

Forty-seven subjects had modified Haemophilia Joint Health Score (mHJHS) data at A-LONG baseline, ASPIRE baseline and ASPIRE Year 1 and Year 2. Compared with A-LONG baseline (23.4), mean improvement at ASPIRE Year 2 was -4.1 (95% confidence interval [CI], -6.5, -1.8; P = .001). Regardless of prestudy treatment regimen, subjects showed continuous improvement in mHJHS from A-LONG baseline through ASPIRE Year 2 (prestudy prophylaxis: -2.4, P = .09; prestudy episodic treatment: -7.2, P = .003). Benefits were seen in subjects with target joints (-5.6, P = .005) as well as those with severe arthropathy (-8.8, P = .02). The mHJHS components with the greatest improvement at ASPIRE Year 2 were swelling (-1.4, P = .008), range of motion (-1.1, P = .03) and strength (-0.8, P = .04).

CONCLUSIONS

Prophylaxis with rFVIIIFc may improve joint health over time regardless of prestudy prophylaxis or episodic treatment regimens.

Differences in bleeding phenotype and provider interventions in postmenarchal adolescents when compared to adult women with bleeding disorders and heavy menstrual bleeding

INTRODUCTION

Due to lack of patient/health care provider awareness causing delayed diagnosis, the bleeding phenotype and provider interventions in adolescents with heavy menstrual bleeding (HMB) and bleeding disorders (BD) may be different when compared to adults.

AIM

The aim of this study was to compare/characterize bleeding phenotype and provider interventions in postmenarchal adolescents < 18 years and premenopausal adults ≥ 18 years with HMB and BD.

METHODS

Patient demographics, BD, and provider interventions/therapy details for HMB were compared between both age groups enrolled in the Centers for Disease Control and Prevention (CDC) Female Universal Data Collection (UDC) surveillance project in United States hemophilia treatment centres. Cross-sectional descriptive analyses including frequency distributions, summary statistics, bivariate and logistic regression analyses were performed.

RESULTS

Of 269 females (79 adolescents; median age 16 years, interquartile range (IQR) = 2; 190 adults; median age 27 years, IQR = 13) evaluated, BD distribution was similar in both groups. Compared to adolescents, adults more often had family history of bleeding (Adjusted odds ratios [AOR] = 2.6, 1.3-5.6), delay in diagnosis (AOR = 2.5, 1.2-4.9), bleeding with dental procedures (AOR = 2.0, 1.0-4.0), gastrointestinal bleeding (AOR = 4.6, 1.0-21.9), anaemia (AOR = 2.7, 1.4-5.2), utilized desmopressin less often (AOR = 0.4, 0.2-0.8) and underwent gynaecologic procedure/surgery more frequently (AOR = 5.9, 1.3-27.3).

CONCLUSION

Bleeding phenotypes of adolescents and adults with HMB and BD were different with more frequent bleeding complications, anaemia, gynaecologic procedures/surgeries, less desmopressin use and more delay in diagnosing BD in adults. Longitudinal studies are needed to determine whether improved patient/provider awareness and education will translate to early diagnosis and timely management of BD/HMB in adolescents that may prevent/reduce future haematologic/gynaecologic complications.

Linking HIV & family planning services to improve dual methods of contraception among women infected with HIV in Mumbai, Maharashtra, India

Background & objectives:

Preventing unintended pregnancies among people living with HIV (PLHIV) is one of the strategies of WHO for preventing parent-to-child transmission (PPTCT). Given the limitation of only condom use, the objective of this study was to improve use of dual contraceptive methods among HIV infected women.

Methods:

An experimental study among HIV positive women was conducted at two tertiary care level hospitals in Mumbai. Linking HIV with family planning services was the focus of intervention at one site and standard level of care was maintained at the control site. At each site, 150 HIV+ve women attending counselling and testing centres, who did not intend to get pregnant in the next one year and were eligible to use dual methods, were enrolled and followed up to one year.

Results:

At the end of one year, 60 per cent women in the intervention group reached Family Planning Centres compared to eight per cent in the control group. There was three times more acceptance and continuation of use of dual methods along with increase in consistent use of condoms and less number of unplanned pregnancies in the intervention group than the control group.

Interpretation & conclusions:

The study findings demonstrate that linking HIV and family planning services may facilitate the uptake of dual methods of contraception without reducing consistent condom use among HIV infected women. The PPTCT programmes need to focus on the component of Prong 2 of PPTCT which aims to prevent unintended pregnancies among HIV positive women.

Probing the magnetic ground state of single crystalline Ce3TiSb5

Motivated by the report of superconductivity in R₃TiSb₅ (R  =  La and Ce) and possibly Nd₃TiSb₅ at  ∼4 K, we grew single crystals of La₃TiSb₅ and Ce₃TiSb₅ by the high-temperature solution method using Sn as a flux. While in both compounds we observed a superconducting transition at 3.7 K for resistivity and low-field magnetization, our data conclusively show that it arose from residual Sn flux present in the single crystals. In particular, the heat capacity data do not present any of the anomalies expected from a bulk superconducting transition. The anisotropic magnetic properties of Ce₃TiSb₅, crystallizing in a hexagonal P6₃/mcm structure, were studied in detail. We find that the Ce ions in Ce₃TiSb₅ form a Kondo lattice and exhibited antiferromagnetic ordering at 5.5 K with a reduced moment and a moderately normalized Sommerfeld coefficient of 598 mJ/mol K². The characteristic single-ion Kondo energy scale was found to be  ∼8 K. The magnetization data were subjected to a crystal electric field (CEF) analysis. The experimentally observed Schottky peak in the 4f-electron heat capacity of Ce₃TiSb₅ was reproduced fairly well by the energy levels derived from the CEF analysis.

Efficacy of a virtual assistance-based lifestyle intervention in reducing risk factors for Type 2 diabetes in young employees in the information technology industry in India: LIMIT, a randomized controlled trial

AIMS

To investigate a virtual assistance-based lifestyle intervention to reduce risk factors for Type 2 diabetes in young employees in the information technology industry in India.

METHODS

LIMIT (Lifestyle Modification in Information Technology) was a parallel-group, partially blinded, randomized controlled trial. Employees in the information technology industry with ≥3 risk factors (family history of cardiometabolic disease, overweight/obesity, high blood pressure, impaired fasting glucose, hypertriglyceridaemia, high LDL cholesterol and low HDL cholesterol) from two industries were randomized to a control or an intervention (1:1) group. After initial lifestyle advice, the intervention group additionally received reinforcement through mobile phone messages (three per week) and e-mails (two per week) for 1 year. The primary outcome was change in prevalence of overweight/obesity, analysed by intention to treat.

RESULTS

Of 437 employees screened (mean age 36.2 ± 9.3 years; 74.8% men), 265 (61.0%) were eligible and randomized into control (n=132) or intervention (n=133) group. After 1 year, the prevalence of overweight/obesity reduced by 6.0% in the intervention group and increased by 6.8% in the control group (risk difference 11.2%; 95% CI 1.2-21.1; P=0.042). There were also significant improvements in lifestyle measurements, waist circumference, and total and LDL cholesterol in the intervention group. The number-needed-to-treat to prevent one case of overweight/obesity in 1 year was 9 (95% CI 5-82), with an incremental cost of INR10665 (£112.30) per case treated/prevented. A total of 98% of participants found the intervention acceptable.

CONCLUSIONS

A virtual assistance-based lifestyle intervention was effective, cost-effective and acceptable in reducing risk factors for diabetes in young employees in the information technology industry, and is potentially scalable.

Accreditation of ethics committees: experience of an ethics committee

Many ethics committees (ECs) approving clinical trials in India have got themselves registered with the Drugs Controller General of India as per regulatory requirements. However, there is still scope to improve their functioning. Accreditation, which entails adherence to national and international standards, helps an EC to protect the rights, safety and well-being of research participants. The National Institute for Research in Reproductive Health (NIRRH) ethics committee for clinical studies has received recognition, or accreditation, from the Strategic Initiative for Developing Capacity in Ethical Review (SIDCER). An EC receives recognition from SIDCER if it meets five standards related to its structure and composition; adherence to specific policies; completeness of the review process; after-review process; and documentation and archiving. The extent to which these standards have been met is assessed in various ways, such as review of the EC's records, interviews of selected EC members and observation of a full board meeting of the EC. This paper describes the experiences of the NIRRH EC during and after the process of receiving recognition.

Complications of haemophilia in babies (first two years of life): a report from the Centers for Disease Control and Prevention Universal Data Collection System

AIM

To describe the prevalence and complications in babies ≤2 years with haemophilia.

METHODS

We used a standardized collection tool to obtain consented data on eligible babies aged ≤2 years with haemophilia enrolled in the Centers for Disease Control and Prevention Universal Data Collection System surveillance project at US Hemophilia Treatment Centers (HTCs).

RESULTS

Of 547 babies, 82% had haemophilia A, and 70% were diagnosed within one month of birth. Diagnosis was prompted by known maternal carrier status (40%), positive family history (23%), bleeding (35%) and unknown 2%; 81% bled during the first two years. The most common events were bleeding (circumcision, soft tissue, oral bleeding) and head injury. There were 46 episodes of intracranial haemorrhage (ICH) in 37 babies (7%): 18 spontaneous, 14 delivery related, 11 traumatic, 2 procedure related and 1 unknown cause. Of the 176 central venous access devices (CVADs) in 148 (27%) babies, there were 137 ports, 22 surgically inserted central catheters and 20 peripherally inserted central catheters. Ports had the lowest complication rates. Inhibitors occurred in 109 (20%) babies who experienced higher rates of ICH (14% vs. 5%; P = 0.002), CVAD placement (61% vs. 19%; P < 0.001) and CVAD complications (44% vs. 26%; P < 0.001). The most common replacement therapy was recombinant clotting factor concentrates.

CONCLUSION

Bleeding events in haemophilic babies ≤2 years were common; no detectable difference in the rates of ICH by the mode of delivery was noted. Neonatal factor exposure did not affect the inhibitor rates. Minor head trauma, soft tissue and oropharyngeal bleeding were the leading indications for treatment.

Prevalence & factors associated with chronic obstetric morbidities in Nashik district, Maharashtra

Background & objectives:

In India, community based data on chronic obstetric morbidities (COM) are scanty and largely derived from hospital records. The main aim of the study was to assess the community based prevalence and the factors associated with the defined COM - obstetric fistula, genital prolapse, chronic pelvic inflammatory disease (PID) and secondary infertility among women in Nashik district of Maharashtra State, India.

Methods:

The study was cross-sectional with self-reports followed by clinical and gynaecological examination. Six primary health centre areas in Nashik district were selected by systematic random sampling. Six months were spent on rapport development with the community following which household interviews were conducted among 1560 women and they were mobilized to attend health facility for clinical examination.

Results:

Of the 1560 women interviewed at household level, 1167 women volunteered to undergo clinical examination giving a response rate of 75 per cent. The prevalence of defined COM among 1167 women was genital prolapse (7.1%), chronic PID (2.5%), secondary infertility (1.7%) and fistula (0.08%). Advancing age, illiteracy, high parity, conduction of deliveries by traditional birth attendants (TBAs) and obesity were significantly associated with the occurrence of genital prolapse. History of at least one abortion was significantly associated with secondary infertility. Chronic PID had no significant association with any of the socio-demographic or obstetric factors.

Interpretation & conclusions:

The study findings provided an insight in the magnitude of community-based prevalence of COM and the factors associated with it. The results showed that COM were prevalent among women which could be addressed by interventions at personal, social and health services delivery level.

Outcome of operable oral cavity cancer and impact of maintenance metronomic chemotherapy: A retrospective study from rural India

BACKGROUND

Oral cavity cancer is the most common cancer among rural India. There is a paucity of data for outcomes of operable oral cavity cancer from rural India. Use of maintenance metronomic may delay or avoid relapse.

AIM

To evaluate outcomes of operable oral cavity carcinoma and evaluate impact of maintenance metronomic chemotherapy.

OBJECTIVES

To evaluate disease-free survival (DFS), overall survival (OS), and factors affecting the outcome in operable oral cavity cancer.

MATERIALS AND METHODS

Data of patients diagnosed with oral cavity cancer registered between May 2008 and May 2014 were retrieved. Only those patients with operable oral cavity cancer and upfront definitive surgery were included in the study. Demographic profile, stage, tobacco consumption, adjuvant therapy, and pattern of failure were collected. Kaplan-Meir survival analysis was used to determine DFS and OS. Log-rank test was used to evaluate factors affecting outcome.

RESULTS

Median follow-up is 24 months. Out of 335 patients, 225 (67%) had advanced operable cancer with 42/225 (18%) and 183/225 (82%) as Stages III and IVA, respectively. Buccal mucosa was the most common subsite (178/335, 53%) followed by tongue (63/335, 19%). Ninety-two percent patients were addicted to smokeless tobacco, whereas 27% were smokers. Median DFS is 13 months with 2 years relative DFS 32%. Median OS is 30 months, with 2 years OS of 54%. Metronomic adjuvant oral chemotherapy was given in 130/225 (58%); Stage III and IVA patients with median of 14 months (3-18 months). Use of metronomic chemotherapy improved DFS (8 vs. 14 months, P = 0.22) and OS (14 vs. 26 months, P = 0.04).

CONCLUSION

Oral cavity cancer is a major health care problem in rural India. Presentation at advanced stage leads to suboptimal outcomes. Benefit of metronomic maintenance chemotherapy in locally advanced oral cavity needs to be further evaluated prospectively.

Inhibitors in haemophilia A: a perspective on clotting factor products as a potential contributing factor

INTRODUCTION

The occurrence of a neutralizing antibody in previously untreated patients (PUPs) with haemophilia A appears to be the result of an intricate interplay of both genetic and environmental factors. Recently, the type of factor VIII (FVIII) product used in the PUPs population has been implicated as a risk factor for inhibitor development.

AIM

The aim of this review was to explore in a systematic manner potential hypotheses for the product-related findings in these studies (i.e. differences in the expression system of the cell lines used to produce recombinant FVIII [rFVIII], differences in the administered antigen load or changes in clinical practice over time).

RESULTS

Review of the available clinical studies illustrates the high degree of variability for the risk of inhibitor development for the same products across different studies. Differences in cell lines or antigen load were not found to provide a reasonable explanation.

CONCLUSION

The possibility of changes in clinical practice over time and patient selection bias (i.e. the preferential use of one product over another in patients at higher risk for inhibitors) offers a potential explanation and should be carefully considered when evaluating the studies.