Designing for a Healthier Makassar, Indonesia: Participatory Systems Mapping

In Makassar, Indonesia, the USAID-funded Building Healthy Cities (BHC) project engaged 240 multi-sector stakeholders to gather qualitative data across three workshops and two citizen town halls from 2019 to 2021. These data were synthesized with results from BHC's nine other Makassar activities to build maps of the current system and identify high-impact areas for engagement. Contextual findings showed that Makassar leadership has actively innovated and used new technology to improve the city, resulting in improved connectivity and responsiveness. However, this drive toward innovation has strained existing infrastructure and workforce capacity. When this strain fails to meet promised results, citizens are less likely to engage and support the innovations. This is central to the systems map that BHC developed, and is expanded upon through additional patterns that fall within four main areas: (1) leadership, governance, and financing; (2) infrastructure and workforce; (3) collaboration and data; and (4) community cohesion and awareness. Stakeholders found three key leverage points within this context that, if included in every action, could help overcome barriers. These leverage opportunities are: (1) increasing data-driven decision-making; (2) ensuring equitable policy and leadership; and (3) increasing community participation. By combining key patterns discovered in the Context Map with the leverage opportunities, BHC was able to co-create with stakeholders six "coherent actions" that can move Makassar to a healthier, "Sombere (kind-hearted and hospitable) and Smart City." BHC has been working with the city planning office to incorporate the map findings into its bottom-up planning processes and the 5-year mid-term plan for Makassar.

Engaging Citizens Via Journey Maps to Address Urban Health Issues

Effectively addressing urban health challenges requires engagement of citizens. However, citizens often face barriers providing feedback, and city officials likewise face difficulties incorporating feedback in a meaningful and systematic way. This paper shares one innovative approach to capturing citizens' stories about urban health concerns, developed by the Building Healthy Cities (BHC) project in 2 Asian cities (Indore, India, and Makassar, Indonesia). Using ethnographic methods, BHC developed "journey maps" as a monitoring tool to follow key service issues over time. Several urban health-related issues were identified in each city. For this paper, we focus on wastewater management, which was a serious health issue in both cities. Qualitative data were collected from citizens in one neighborhood and city officials quarterly starting in early 2018; these data were supplemented by city spending data, usage statistics, photos and news articles. In both cities, the journey maps captured notable changes during the first 2 years of the project. At the start of the journeys (2018), informal settlement citizens in Indore reported poor drainage which was compounded by trash, narrow roads blocking vehicular removal of waste, and unsafe infrastructure leading to waterborne diseases and injuries (including several child deaths). Likewise in Makassar, dirty water overflowed from open drains due to frequent flooding and garbage. Citizens reported exposure to diarrhea, dengue and skin symptoms due to the drains, which was confirmed by the local health post. By the end of Year 2 (2019), these journeys captured increasing dialogue between citizens and the city, which resulted in several improvements. In Indore, changes included garbage vans built for narrow streets and construction of a safer bridge. In Makassar, while they still suffer from seasonal flooding, the city has increased garbage pickup, included drainage activities in the village-level budgeting process, and a slum improvement project has pledged funding to improve drainage and street issues in 41 neighborhoods. Journey maps work on the premise that capturing a community's experience and relaying it to government officials can bring about positive change. They also provide crucial grassroots level evidence to support more traditional research findings, which can lead to effective urban health solutions. As this work continues, BHC is training citizens to collect and share their own journeys.

Prevalence of anemia among elderly persons residing in old age homes in national capital territory, Delhi, India

Background

Anemia is a common morbidity in elderly persons (aged 60 years or above). In India, in recent years, the number of old age homes (OAHs) and the residents living in them has increased significantly.

Objective

The aim of this study was to estimate the prevalence of anemia among elderly persons living in OAHs.

Methods

This was a cross-sectional study among individuals living in OAH in Delhi, India. Using combination of location and type of OAH, 28 clusters of almost equal sizes were created, of which 13 clusters were randomly selected, and all elderly persons living therein were selected for the study. Sociodemographic profile was recorded using a self-designed, semistructured interview schedule. Hemoglobin (Hb) was estimated using HemoCue Hb 201+ system. Binary Logistic regression was used to assess the socioeconomic determinants of anemia.

Results

The study included 334 elderly persons, with a mean (standard deviation [SD]) age of 75.2 (8.6) years and mean (SD) Hb of 11.6 (1.7) g/dL. The mean (SD) Hb in men was 12.1 (1.7) g/dL compared to 10.9 (1.5) g/dL among women (P < 0.0001). The overall prevalence of anemia was 68.7% (95% confidence interval 63.9, 73.4); among those who were anemic, 47.4% had mild anemia, 47.0% had moderate anemia, and 5.6% had severe anemia. The prevalence of mild anemia was 45% in men compared to 24.8% in women. The odds of anemia among ≥80 years was 2 times that among 60-69 years (P < 0.029).

Conclusions

The prevalence of anemia among elderly persons in OAHs is high in Delhi, India and increased with age.

Factors affecting adherence to treatment in children living with HIV

Background:

With the successful introduction of ART, the life expectancy of children living with HIV (CLHIV) is substantially increased. However, strict compliance is a necessary step to begin with as noncompliance is again associated with its own demerits of incomplete suppression and decreasing the overall survival of the patients.

Aims:

The aim of this study was to measure factors associated with adherence to ART among CLHIV.

Materials and Methods:

This is a 1-year follow-up study conducted from November 2012 to December 2013. A total of 171 children between 18 months and 15 years living with HIV and on ART attending the two ART centers of Delhi were enrolled in the study. Adherence and factors affecting adherence were obtained from the study participants using a semi-structured interview schedule.

Statistical Analysis Used:

Collected data were transformed into variables and analyzed into SPSS. All observations were in terms of mean, median, standard deviations, percentages, and proportions. Tests of significance such as Chi-square test and t-test were applied wherever required.

Results:

In nearly 89% of the study participants, adherence to ART was ≥95% at the end of the study. The most common reason for nonadherence was forgetfulness (59%), and 57% of the parents/caretakers were facing monetary problems. Long distance, greater duration to reach center, and unavailability of the parents/caretakers were also quoted as problems.

Conclusion:

Adherence is genesis to successful treatment outcome and is strongly associated with availability of support by their parents/caretakers. Professional help along with guidance and encouragement is required not only at the caretaker level but also to the family as a whole.

Risk assessment of Diabetes using the Indian Diabetes Risk Score in an urban resettlement colony of East Delhi

Background- The burden of diabetes in India is expected to worsen in the coming years. Indian Diabetes Risk Score (IDRS) is a validated and cost‑effective tool to identify risk of developing diabetes among population. Objectives- To assess the risk of Type 2 Diabetes mellitus using the IDRS in adults aged 30 years and above and to study the association of risk of diabetes with other factors. Material & Methods- A cross-sectional study was conducted in Kalyanpuri area of East Delhi. Data collection was done from August to December, 2018. 494 residents aged 30 years and above were included in the study. Data was collected using a semi-structured questionnaire. SPSS version 23 was used for data analysis. Results- 43.7 % of the study subjects were aged 50 years or above and majority (65.38%) were females. More than half (59.31%) of the subjects were found to have high risk of diabetes. Age and central obesity were found to be significantly associated with risk of diabetes (p<0.05). Risk of developing diabetes was not associated with gender. Conclusion- Early detection of risk of diabetes by periodic screening and appropriate behavioral change communication would be effective in controlling the diabetes crisis.

Resource and Infrastructure-Appropriate Management of ST-Segment Elevation Myocardial Infarction in Low- and Middle-Income Countries

The 143 low- and middle-income countries (LMICs) of the world constitute 80% of the world's population or roughly 5.86 billion people with much variation in geography, culture, literacy, financial resources, access to health care, insurance penetration, and healthcare regulation. Unfortunately, their burden of cardiovascular disease in general and acute ST-segment-elevation myocardial infarction (STEMI) in particular is increasing at an unprecedented rate. Compounding the problem, outcomes remain suboptimal because of a lack of awareness and a severe paucity of resources. Guideline-based treatment has dramatically improved the outcomes of STEMI in high-income countries. However, no such focused recommendations exist for LMICs, and the unique challenges in LMICs make directly implementing Western guidelines unfeasible. Thus, structured solutions tailored to their individual, local needs, and resources are a vital need. With this in mind, a multicountry collaboration of investigators interested in LMIC STEMI care have tried to create a consensus document that extracts transferable elements from Western guidelines and couples them with local realities gathered from expert experience. It outlines general operating principles for LMICs focused best practices and is intended to create the broad outlines of implementable, resource-appropriate paradigms for management of STEMI in LMICs. Although this document is focused primarily on governments and organizations involved with improvement in STEMI care in LMICs, it also provides some specific targeted information for the frontline clinicians to allow standardized care pathways and improved outcomes.

Students' perception of lacunae in medical education in India, and suggestions for reforms

Background

The methods of classroom and clinical teaching in the MBBS course in India have not seen major modifications or innovations in recent decades, leading to dissatisfaction among students. Lack of conclusive data in this regard and absence of a mechanism for students' feedback are also areas of concern. We aimed to assess the satisfaction levels and identify lacunae in undergraduate medical education in India.

Methods

We used an 8-item questionnaire to identify lacunae in medical education. A total of 336 undergraduate medical students from second and third professional years and interns of Delhi voluntarily participated in the study. Data were analysed using SPSS 17 version.

Results

Eighty-one per cent of students were not satisfied with teaching methods due to lack of coordination between different departments and lack of problem-based learning. Sixty-five per cent of students did not find the classroom environment conducive to learning due to large sizes of teaching batches and inadequate maintenance of infrastructure. Eighty-six per cent of students were not satisfied with learning experience during clinical postings attributing it to 'doctors being too busy to teach in clinics'.

Conclusion

There is dissatisfaction among students indicating their desire for improved methods in medical education. Suggestions include short-term reforms such as encouraging interdepartmental planning and introducing problem-based learning, coupled with long-term measures such as improving infrastructure.

Prevalence of fall, and determinants of repeat incidents of fall in older persons living in old age homes in the National Capital Territory of Delhi, India

Background

Fall is a common morbidity in older persons. In India, the number of old age homes and persons living in them are increasing. We studied the prevalence of fall among older persons living in old age homes.

Methods

We did a cross-sectional survey among persons aged 60 years or above, living in old age homes of Delhi, India. Information on location, type and bed-strength was collected for old age homes, and using their combination, 28 clusters of almost equal sizes (25-35) were created, of which, 13 were selected randomly to meet an estimated sample size of 340. All residents of the selected old age homes were recruited for the study. A self-developed, semi-structured interview schedule was used for recording the sociodemographic profile and history of fall in the past 6 months. Logistic regression was used to explore factors that might be associated with fall. Poisson regression was used to model the frequency of incidents of fall.

Results

A total of 335 older persons, with mean (SD) age of 75.2 (8.6) years were studied. At least 1 episode of fall was reported by 55 (16.4%), of whom, injury and disability were sustained by 54.5% and 23.3%, respectively. On multivariate logistic regression, for each additional morbidity, odds ratio of fall was 1.5 (95% confidence interval [CI] 1.09-1.95). Multivariate Poisson regression showed that age and tobacco use were significantly associated with the incidents of fall. For each unit increase in age, the incident rate ratio increased by 1.02 times (95% CI 1.01-1.03). Being a past user of tobacco had a statistically significant incident rate of 1.57 times (95% CI 1.01-2.45) compared to non-users of tobacco.

Conclusion

One-sixth of individuals living in old age homes had experienced a fall in the past 6 months. Measures should be taken to prevent falls in old age home settings in India.

Tuberculosis-diabetes screening: how well are we doing? A mixed-methods study from North India

Setting

Public health care facilities in Sonipat District, Haryana State, India.

Objectives

To assess 1) the proportion of tuberculosis (TB) patients screened for diabetes mellitus (DM) and vice versa, 2) factors associated with screening, and 3) the enablers, barriers and solutions related to screening.

Design

A mixed-methods study with quantitative (cohort study involving record reviews of patients registered between November 2016 and April 2017) and qualitative (interviews of patients, health care providers [HCPs] and key district-level staff) components.

Results

Screening for TB among DM patients was not implemented, despite documents indicating that it had been. Of 562 TB patients, only 137 (24%) were screened for DM. TB patients registered at tertiary and secondary health centres were more likely to be screened than primary health centres. Low patient awareness, poor knowledge of guidelines among HCPs, lack of staff and inadequate training were barriers to screening. Enablers were the positive attitude of HCPs and programme staff. The key solutions suggested were to improve awareness of HCPs and patients regarding the need for screening, training of HCPs and wider availability of DM testing facilities.

Conclusion

The implementation of bidirectional screening was poor. Adequate staffing, regular training, continuous laboratory supplies for DM diagnosis and widespread publicity should be ensured.

Childhood Morbidity and Mortality in India - Analysis of National Family Health Survey 4 (NFHS-4) Findings

National Family Health Survey (NFHS)-4 report was recently released for health-related data. This review compares the child health indicators across NFHS-3 and NFHS-4 with a background of existing health programs catering to child health. Reports of NFHS-4 and NFHS-3, along with ministry reports and existing literature were reviewed to understand the current status of child health. Child health indicators were compared between the two rounds of NFHS and among Empowered Action Group states of India. National Health Policy 2017 and National Health Programs related to child health were also analyzed. There has been an improvement in almost all child health indicators from NFHS-3 to NFHS-4. The infant mortality rate has reduced to 41 per 1000 live births. The immunization rate is 62%, and has almost doubled in the states of Uttar Pradesh, Rajasthan and Madhya Pradesh. Despite existence of many health programs, there is still a substantial lack of achievement in most of the indicators.

Air pollution and environmental risk factors for altered lung function among adult women of an urban slum area of Delhi: A prevalence study

Background:

Household and ambient air pollution are jointly responsible for about 7 million premature deaths annually. Women living in slums, with unhealthy environment, both indoors and outdoors, particularly those living close to industrial and/or vehicular pollution zones due to multiple sources of air pollution, are at the higher risk of having impaired lung function tests.

Objective:

The aim of this study was to estimate the prevalence of abnormal lung functions and to identify the environmental risk factors associated with them among adult women of 18–59 years.

Materials and Methods:

A total of 550 women aged 18–59 years were approached in a representative urban slum. Five hundred consented to participate and 299 had prebronchodilator spirometry satisfying ATS standards. House visits to assess environmental conditions were conducted to determine their association with forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC). Chi-square test was used to test the association of risk factors with lung functions. ANOVA was used to test the association of mean values of FEV1 and FVC with age.

Results:

Out of 299 participants with acceptable spirometric curves, 5% had reduced FEV1/FVC ratio than the normal and 26.8% and 17.4% had lower values than predicted for FVC and FEV1, respectively. Altered lung function was related to age, tobacco smoking, and history of respiratory disease.

Conclusions:

Both ambient and household air pollution have a deleterious pulmonary effect on long-term women residents of a representative urban slum in Delhi.

Respiratory symptoms and their determinants among adult women in an urban slum area of Delhi

Background: Globally, respiratory disorders accounted for 7.4% deaths, out of total deaths during the year 2015. Aim & Objective: - To estimate the magnitude of respiratory symptoms and their determinants in adult women of 18-59 years. Material & Methods: A cross sectional study was conducted among 500 women of 18-59 years in an urban slum of Delhi. Assessment of respiratory symptoms was done using questionnaire and observations on environmental conditions. Results: Overall prevalence of major respiratory symptoms was 24.8% in the study population. Dyspnea, chronic cough, chronic phlegm, wheeze was observed in 14.2%, 5.6%, 2.4% and 2.6% respectively.

Socio-Demographic, Reproductive and Clinical Profile of Women Diagnosed with Advanced Cervical Cancer in a Tertiary Care Institute of Delhi

INTRODUCTION

Cervical cancer is one of the leading cancers among Indian women with estimated 123,000 new cases and 67,477 deaths in 2012. Cervical cancer is a multi-etiological disease. Factors such as low socioeconomic status, tobacco use, sexual and reproductive factors, HIV and other sexually transmitted diseases and long-term oral contraceptive use have been suggested as determinants. Assessment of socio-demographic profile and reproductive history gives a better picture of the determinants of cervical carcinoma in low-resource settings.

METHODS

This hospital-based cross-sectional study was undertaken at a tertiary healthcare institute at New Delhi, India. Sixty-seven newly diagnosed women with advanced cervical cancer (stage 2B-4B), who were undertaking radio- and/or chemotherapy, were included to assess their socio-demographic, reproductive and clinical profile.

RESULTS

The mean age of women at the time of detection of cervical cancer was 52.28 ± 11.29 years (range 30-75 years). More than 60 % of patients were illiterate and belonged to middle socioeconomic status. Thirty-nine percentage of the study subjects had their first sexual experience before 15 years of age. Nearly 54 % women had 5 or more pregnancies. Nearly 73 % of women had all deliveries at home. Majority (69 %) of women had symptoms suggestive of reproductive tract infection. Among them, unusual discharge from vagina (73.13 %) followed by bleeding after menopause (55.10 %) and pain in abdomen (44.77 %) were the most common presenting complaints. Pallor was present in nearly two-third (63.93 %) study subjects. More than half (56.72 %) study subjects had moderate anemia, and 7.46 % had severe anemia before treatment. Mean hemoglobin level of the study subjects was 10.35 ± 1.72 gm% before treatment and 9.69 ± 1.29 gm% after treatment. This difference was statistically significant. Around 97 % of the study subjects had squamous cell carcinoma of the cervix. Majority (53.73 %) of the study subjects were in stage 3B of cervical cancer. Combination of radiotherapy and chemotherapy was the most common (77.67 %) modality of treatment.

CONCLUSIONS AND RECOMMENDATIONS

Illiteracy, low socioeconomic status, early sexual debut, high fertility, home delivery, reproductive tract infections, use of insanitary clothes during menstruation and anemia were observed in majority of women with advanced cancer cervix. Presence of these factors indicates possible risk of cervical cancer and should be kept in mind when women seek health services. Early diagnosis through high risk or opportunistic screening and timely management of cervical cancer needs to be ensured for better outcomes.

Obesity, Diabetes and Cardiovascular Diseases in India: Public Health Challenges

Non-communicable diseases (NCDs; including coronary heart disease and type 2 diabetes) are rapidly increasing in India causing nearly 5.8 million deaths per year. Primary reasons for rise in NCDs in India are nutrition and lifestyle transitions. Further, presence of higher body fat, abdominal fat, liver and pancreatic fat and lower lean mass than whites, contribute to heightened metabolic and cardiovascular risk in Asian Indians. Importantly, conversion from pre-diabetes to diabetes occurs more rapidly, and reversion to normal glucose regulation with appropriate lifestyle measures is more difficult in Asian Indians than white population. Huge number of patients with diabetes and with complications increase morbidity, mortality and pose substantial economic burden. It is difficult, though not impossible, to decrease pace of rapidly expanding juggernaut of NCDs in India. Only concerted efforts from multiple stakeholders, consistently sincere efforts and intensely focused attention from health officialdom and clear political will may help counter this increasingly difficult challenge. Finally, all prevention and management approaches should be cost-effective, pragmatic, and focused on children and underprivileged populations.

Thalassemia Major: how do we improve quality of life?

Background

Thalassemia Major is a preventable genetic disorder characterized by abnormal hemoglobin synthesis and lifelong blood transfusions. The children suffering from Thalassemia Major have poor quality of life. This study was conducted to assess the factors influencing quality of life of these children and how it can be improved.

Methods

A descriptive cross sectional study was conducted in 2014 at Thalassemia Day Care Centre of a tertiary level children’s hospital in Delhi, to assess quality of life of children suffering from Thalassemia Major. A total of 241 eligible children (age 2–18 years) were enrolled in the study. Socio demographic and clinical characteristics were collected from interview and existing medical records. The PedsQL 4.0 generic core scale was used for assessing the quality of life of the children.

Results

The mean age of children was 8.69 ± 4.98 years. Two-thirds (63.5%) were boys. The total mean QoL score of the children was 82.0 ± 14.4. The quality of life scores were better for boys as compared to girls. The most affected domain was the emotional domain which showed statistically significant (p = 0.025) difference between boys and girls. The total QoL scores were significantly affected by the current age of the child (p = 0.000) and presence of co-morbidity (p = 0.026). Children not on any form of iron chelation therapy (p = 0.003) and fewer hospital visits (p = 0.044) had better QoL scores.

Conclusions

Factors improving the quality of life were control of iron overload and adverse effects of ICTs, management of co morbidities and fewer hospital visits.

Quality of Life of Patients with Advanced Cervical Cancer before and after Chemoradiotherapy

BACKGROUND

Cervical cancer is the most frequently diagnosed cancer among women in India. Understanding quality of life (QOL) in women undergoing chemoradiotherapy for cervical cancer will help in introducing interventions for better care and outcomes in these women. This study assessed QOL before and after chemo radiotherapy in cervical cancer patients.

MATERIALS AND METHODS

This followup study covered sixtyseven newly diagnosed women with advanced cervical cancer (stages 2b to 4b). Structured questionnaires (the European Organization for Research and Treatment of Cancer, EORTC QLQC30 and EORTC QLQCX24) were used to assess the change in QOL after 6 months of treatment.

RESULTS

The mean age of women at the time of detection of cervical cancer was 52.3±11.29 years (Range 3075 years). Six months survival was 92.53%. The mean global health score of cervical cancer patients after six months of treatment was 59.52, which was significantly higher than the pretreatment score of 50.15 (p=0.00007). Physical, cognitive and emotional functioning improved significantly (p<0.05) after treatment. Fatigue, pain, insomnia and appetite loss improved but episodes of diarrhea increased after treatment. The mean "symptoms score" using EORTC QLQCX24 post treatment was 20.0 which was significantly lower as compared to the pre treatment score 30.0 (p<0.00001). Sexual enjoyment and sexual functioning decreased significantly after treatment.

CONCLUSIONS

QOL of newly diagnosed cervical cancer patients improved significantly following chemoradio therapy. Enhancement was also demonstrated on three of the five functional scales of EORTC QLQC30. To further improve QOL, interventions focusing on social and psychological support and physical rehabilitation may be needed.

Level of suboptimal adherence to first line antiretroviral treatment & its determinants among HIV positive people in India

BACKGROUND & OBJECTIVES

National Anti-retroviral treatment (ART) programme in India was launched in 2004. Since then, there has been no published country representative estimate of suboptimal adherence among people living with HIV (PLHIV) on first line ART in public settings. Hence a multicentric study was undertaken in 15 States of India to assess the level of suboptimal adherence and its determinants among PLHIV.

METHODS

Using a prospective observational study design, 3285 PLHIV were enrolled and followed up to six months across 30 ART centres in India. Adherence was assessed using pill count and self-reported recall method and determinants of suboptimal adherence were explored based on the responses to various issues as perceived by them.

RESULTS

Suboptimal adherence was found in 24.5 per cent PLHIV. Determinants of suboptimal adherence were illiteracy (OR--1.341, CI--1.080-1.665), on ART for less than 6 months (OR--1.540, CI--1.280-1.853), male gender (OR for females--0.807, CI--0.662-0.982), tribals (OR--2.246, CI--1.134-4.447), on efavirenz (EFA) regimen (OR--1.479, CI--1.190-1.837), presence of anxiety (OR--1.375, CI--1.117-1.692), non-disclosure of HIV status to family (OR--1.549, CI--1.176-2.039), not motivated for treatment (OR--1.389, CI--1.093-1.756), neglect from friends (OR--1.368, CI--1.069-1.751), frequent change of residence (OR--3.373, CI--2.659-4.278), travel expenses (OR--1.364, CI--1.138-1.649), not meeting the PLHIV volunteer/community care coordinator at the ART center (OR--1.639, CI--1.330-2.019).

INTERPRETATION & CONCLUSIONS

To enhance identification of PLHIV vulnerable to suboptimal adherence, the existing checklist to identify the barriers to adherence in the National ART Guidelines needs to be updated based on the study findings. Quality of comprehensive adherence support services needs to be improved coupled with vigilant monitoring of adherence measurement.

Pretreatment loss-to-follow-up after HIV diagnosis from 27 counseling and testing centers across India: findings from a cohort study

Individuals testing HIV positive were interviewed at testing centers, followed prospectively and interviewed again when they registered at referral antiretroviral therapy (ART) centers (ARTCs). Those who did not register at ARTCs were traced and interviewed in the community. A total of 1057 newly diagnosed people living with HIV (PLHIV; 52% women; mean age, 34.7 years) were recruited. A total of 73.5% of PLHIV registered at referral ARTCs within 60 days, 17.9% did not register and were interviewed in the community, and 8.6% were not interviewed. The 2 main reasons cited for not registering were a perception of good health (30%) and work/family engagements (22%). Single clients (adjusted relative risk [ARR]: 1.54; 95% confidence interval [CI]: 1.02-2.34), participants who had not disclosed their HIV status (ARR: 2.32; 95%CI: 1.77-3.05), participants who knew a PLHIV (ARR: 1.89; 95% CI: 1.41-2.53), and participants from laborer households (ARR: 2.66; 95%CI:1.15-6.15) were more likely to not register. In conclusion, the majority of newly diagnosed PLHIV do reach ARTCs. Disclosure concerns and a perception of good health prevent PLHIV from accessing services.

Need for a national epilepsy control program

This article briefly outlines the proposed national epilepsy control program. The content of the article is based on four meetings held by invitation of the Ministry of Health. Invitees by ministry – Drs. D. C. Jain, M. Gourie Devi, V. Saxena, S. Jain, P. Satish. Chandra, M. Gupta, K. Bala, V. Puri, K. S. Anand, S. Gulati, S. Johri, P. S. Chandra, M. Behari, K. Radhakrishnan, D. Bachani. Presentations were made by Dr. M. Tripathi.The program will involve all neurologists across the country in teaching and training at state levels and a central monitoring committee.

Burden of NCDs, Policies and Programme for Prevention and Control of NCDs in India

Noncommunicable diseases and injuries account for 52% of deaths in India. Burden of noncommunicable diseases and resultant mortality is expected to increase unless massive efforts are made to prevent and control NCDs and their risk factors. Based on available evidence, cancer, diabetes, hypertension, cardiovascular diseases, stroke, chronic obstructive pulmonary disease, chronic kidney disease, mental disorders and trauma are the leading causes of morbidity, disability and mortality in India. Government of India had supported the States in prevention and control of NCDs through several vertical programs since 1980s. However, during the 11^th plan, there was considerable upsurge to prevent and control NCDs. New programs were started on a low scale in limited number of districts. However, there has not been any considerable change in the burden of NCDs. Based on experiences in the past, there is need to emphasize on health promotion and preventive measures to reduce exposure to risk factors. Facilities and capacity for screening, early diagnosis and effective management are required within the public health care system. Public awareness program, integrated management and strong monitoring system would be required for successful implementation of the program and making services universally accessible in the country.

Surveillance of transmitted HIV type 1 drug resistance among HIV type 1-positive women attending an antenatal clinic in Kakinada, India

The World Health Organizations HIV Drug Resistance (WHO HIVDR) Threshold survey method was used to assess transmitted HIVDR in newly diagnosed HIV-1-infected primigravida women attending the Prevention of Parent to Child Transmission (PPTCT) centers in Kakinada, in whom it is likely that the infection had recently occurred. Out of the 56 consecutively collected eligible specimens, 51 were tested using the ViroSeq RT-PCR method (Abbott Germany) to obtain 47 consecutive sequences for the HIV-1 protease (PR) and reverse transcriptase (RT) region. As per the 2009 WHO list of mutations for surveillance of transmitted HIVDR, only one nonnucleoside reverse transcriptase inhibitor (NNRTI) mutation was detected at K101E from all specimens tested, suggesting a low prevalence (<5%) of resistance to NNRTIs and no mutations were detected at other sites, suggesting a low prevalence (<5%) of resistance to nucleoside reverse transcriptase inhibitors (NRTI) and protease inhibitors (PI) drug classes as well. Phylogenetic analysis showed all sequences belonged to HIV-1 subtype C. In the wake of antiretroviral treatment (ART) scale-up, future evaluation of transmitted HIVDR is essential in Kakinada as well as in other regions of India.

Will adoption of the 2010 WHO ART guidelines for HIV-infected TB patients increase the demand for ART services in India?

Background

In 2010, WHO expanded previously-recommended indications for anti-retroviral treatment to include all HIV-infected TB patients irrespective of CD4 count. India, however, still limits ART to those TB patients with CD4 counts <350/mm³ or with extrapulmonary TB manifestations. We sought to evaluate the additional number of patients that would be initiated on ART if India adopted the current 2010 WHO ART guidelines for HIV-infected TB patients.

Methods

We evaluated all TB patients recorded in treatment registers of the Revised National TB Control Programme in June 2010 in the high-HIV prevalence state of Karnataka, and cross-matched HIV-infected TB patients with ART programme records.

Results

Of 6182 TB patients registered, HIV status was ascertained for 5761(93%) and 710(12%) were HIV-infected. 146(21%) HIV-infected TB patients were on ART prior to TB diagnosis. Of the remaining 564, 497(88%) were assessed for ART eligibility; of these, 436(88%) were eligible for ART according to 2006 WHO ART guidelines. Altogether, 487(69%) HIV-infected TB patients received ART during TB treatment. About 80% started ART within 8 weeks of TB treatment and 95% received an efavirenz based regimen.

Conclusion

In Karnataka, India, about nine out of ten HIV-infected TB patients were eligible for ART according to 2006 WHO ART guidelines. The efficiency of HIV case finding, ART evaluation, and ART initiation was relatively high, with 78% of eligible HIV-infected patients actually initiated on ART, and 80% within 8 weeks of diagnosis. ART could be extended to all HIV-infected TB patients irrespective of CD4 count with relatively little additional burden on the national ART programme.

Transmitted HIV drug resistance among HIV-infected voluntary counseling and testing centers (VCTC) clients in Mumbai, India

A survey for transmitted HIV drug resistance (HIVDR) was conducted according to WHO guidelines among clients newly diagnosed with HIV-1 infection at two voluntary counseling and testing centers (VCTC) in Mumbai. HIVDR testing was performed using the ViroSeq RT-PCR method (Abbott). Out of 50 successfully amplified and sequenced specimens, analysis of the first 34 consecutively collected specimens revealed no nucleoside reverse transcriptase inhibitor, nonnucleoside reverse transcriptase inhibitor, or protease inhibitor mutations from the 2007 WHO list of mutations for surveillance of transmitted HIVDR, indicating that the prevalence of transmitted HIVDR to all three drug classes was <5% among recently infected VCTC clients in Mumbai. The phylogenetic analysis revealed that all samples belonged to HIV-1 subtype C. Continued ART program monitoring and further evaluation of transmitted HIV drug resistance in coming years are essential in Mumbai as well as in other regions of the country in which ART is being scaled up rapidly.

National estimate of HIV seroprevalence among tuberculosis patients in India

The national estimate for human immunodeficiency virus (HIV) prevalence among tuberculosis (TB) patients in India has previously been estimated indirectly from global data. To derive an improved national estimate from local data, we correlated district-level HIV surveillance data from antenatal clinics and TB diagnostic centres, and applied this correlation to state-level HIV prevalence estimates for the antenatal population. We estimate that among the 1.96 million incident TB cases in 2007, 4.85% (95%CI 4.12-5.73) or 95 240 (95%CI 80 730-112 478) were HIV-infected. With these estimates from local data, the national programme can better plan TB-HIV collaborative activities and monitor efforts to detect HIV infection in this large population.

Two-year treatment outcomes of patients enrolled in India's national first-line antiretroviral therapy programme

BACKGROUND

We aimed to analyse treatment outcomes of patients receiving first-line antiretroviral therapy (ART) through the national AIDS control programme of India.

METHODS

Using routinely collected programme data, we analysed mortality, CD4 evolution and adherence outcomes over a 2-year period in 972 patients who received first-line ART between 1 October 2004 and 31 January 2005 at 3 government ART centres. Cox regression analysis was used to identify independent predictors of mortality.

RESULTS

Of the 972 patients (median age 35 years, 66% men), 71% received the stavudinellamivudine/nevirapine regimen. The median CD4 count of enrolled patients was 119 cells/cmm (interquartile range [IQR] 50-200 cells/ cmm) at treatment initiation; 44% had baseline CD4 count <100 cells/cmm. Of the 927 patients for whom treatment outcomes were available, 71% were alive after 2 years of treatment. The median increase in CD4 count was 1 42 cells/ cmm (IQR 57-750 cells/cmm; n=616) at 6 months and 184 cells/cmm (IQR 102-299 cells/cmm; n=582) at 12 months after treatment. Over 2 years, 124 patients (13%) died; the majority of deaths (68%) occurred within the first 6 months of treatment. Those with baseline CD4 count <50 cells/cmm were significantly more likely to die (adjusted hazard ratio 2.5, 95% confidence interval 1.3-3.2) compared with patients who had baseline CD4 count >50 cells/cmm. Over the 2-year period, 323 patients (35%) missed picking up their monthly drugs at least once and 147 patients (16%) were lost to follow up.

CONCLUSION

Survival rates of HIV-infected patients on first-line ART in India were comparable with those from other resource-limited countries. Most deaths occurred early and among patients who had advanced disease. Earlier initiation of HIV treatment and improving long term treatment adherence are key priorities for India's ART programme.

Assessment of ART centres in India: client perspectives

Drug adherence and quality of antiretroviral therapy (ART) services are the keys for the successful ART programme. Hence, an attempt has been made to assess ART centres in India from client perspectives that are receiving services from the centres. Data were gathered through exit interviews with 1366 clients from 27 ART centres that were selected on the basis of drug adherence and client load. Analyses revealed that more than 80 per cent of the clients reported overall satisfaction with the services availed from the centre and 60 per cent reported that the quality of life has improved to a great extent after getting ART. Most of the clients strongly demanded to open ART centre in each district for better access as that will increase drug adherence and eventually control the HIV progression. It has been found that as many as 14% of respondents, ever been on ART, reported non-adherence and 70% of them cited distance and economic factors as the reasons for non-adherence. Study concludes that while majority of the clients were satisfied with ART services, shortage of staff, high level of non-drug adherence, long distances and poor referring system are the weak areas requiring attention.

Antiretroviral therapy: practice guidelines and National ART Programme

Presently there are 15 U.S. FDA approved antiretroviral agents available in India. The efficacy of the drugs is well decumented and various options available. The antiretroviral drugs act on various stages of replication of HIV in the body and interrupt the process of viral replication. Principally a combination of at least three agents.from different classes of antiretroviral drugs is the regimen of choice. Antiretroviral treatment regimen as approved by NACO is discussed in this article. In the case of treatment failure, second line regimen is being necessitated. Antiretroviral therapy initiative in India has already been taken with objectives, targets, National Paediatric HIV/AIDS initiative, etc.

Are persons living with HIV timely accessing ART services in India?

CD4+ T-cell level is one of the important criteria for categorising HIV-related clinical conditions to determine initiation of antiretroviral therapy (ART). The present study is undertaken to analyse baseline CD4 count at which persons living with HIV/AIDS (PLHA) were getting registered for ART in India. It also examines the profile of the PLHA with baseline CD4 count over a period of time. Data of 1,10,974 registered PLHAs at ART centres were analysed for the last three years (April 2005 to March 2008) in the computerised management information system. It was revealed that 85 per cent of PLHA were registered when their baseline CD4 count was less than 250 cells/mm3 and thus were eligible for initiation of ART. No significant change in the proportion of PLHA by CD4 categories was observed in the last three years. These findings suggest that registration for ART at early stages of infection is still uncommon. Significant decline in the proportion of PLHA in the age group of 21-30 years, literate and employed was noticed. The proportion of PLHA referred by counselling and testing centres has increased from 62.6% in 2005-06 to 71.3% in 2007-08. Sexual transmission, followed by mother to child transmission has been reported as two major modes of HIV transmission by PLHA registered at ART centres in the last three years. Though the number of ART centres has increased in India which in turn has increased the number of PLHAs registered and on ART, it is evident from this study that the programme is still far behind to achieve the goal of early detection for timely ART.

Status of speciality training in ophthalmology in India

PURPOSE

To systematically evaluate the quality of ophthalmology training in India.

METHODS

Questionnaires were sent to existing medical schools and accredited training institutions. Institutions were followed up thrice to obtain responses. Data were analysed using Stata 8.0.

RESULTS

Responses were received from 128 (89.5%) of the 143 institutions. Each year, 900 training slots were available across the country. Faculty: student ratios were better in accredited training institutions than in postgraduate medical schools. Fifty three (41.4%) of 128 institutions subscribed to more than 2 international journals. Fewer than 1 in 6 institutions conducted research projects. 11 (8.6%) institutions reported more than five publications in international peer-reviewed journals over three years. Only a third of the responding institutions had a wet lab.

CONCLUSIONS

There is a need to improve the training facilities and optimally utilise the infrastructure available in postgraduate medical schools.

Current estimates of blindness in India

BACKGROUND

Evidence based planning has been the hallmark of the blindness control programme in India. A nationwide survey was undertaken in 1999-2001 to document the magnitude and causes of blindness.

METHODS

One district each in 15 populous states was covered. 25 clusters were randomly selected in each district and all individuals aged 50 years and above were enumerated. Presenting and best corrected vision was recorded using retroilluminated logMAR tumbling E charts and detailed eye examination was offered.

RESULTS

The response rate was 89.3%. Presenting vision <6/60, in the better eye, was observed in 8.5% (95% CI: 8.1 to 8.9). Age, sex, residence, literacy, and working status were associated with blindness. The highest risk was among those aged 70+ and the illiterate. Cataract was responsible for 62.4% of bilateral blindness. Prevalence of cataract blindness was 5.3% (95% CI: 4.97 to 5.62). Reduction in blindness prevalence among people aged 50 years and above was observed compared to earlier studies.

CONCLUSION

Blindness control efforts seem to have played a part in arresting the increasing prevalence of blindness in India and there is hope that the goals of the "Vision 2020--right to sight" initiative can be achieved if there is strong political will and prioritised action.

Community ophthalmology in the Indian perspective

Community ophthalmology is as important as practice of clinical ophthalmology. Community ophthalmology deals the part of ophthalmology which is meant for identifying common causes of ocular morbidity in different regions, assessing the needs of the population, selecting appropriate intervention strategies, planning education programmes and analysing the utilisation patterns. Community ophthalmology denotes the use of appropriate strategies to reduce the burden of eye diseases in the community and the consequences of ocular ill health, while striving to ensure the best possible ocular health status for a major proportion of the community. Community-based services do not mean that institutional care is being downgraded. Institutions will always be central to the success of community-directed programme. The rational for practising community ophthalmology has been pointed in the text portion.

Human resources and infrastructure for eye care in India: current status

BACKGROUND

An ophthalmic workforce and infrastructure planning survey was undertaken to provide a valid evidence base for human resource and infrastructure requirements for elimination of avoidable blindness. This is the first time that such an extensive survey has been done in India.

METHODS

Pre-tested questionnaires were administered to all district-level blindness officials and ophthalmology training institutions during April 2002-March 2003. Supplementary data sources were used wherever necessary. Data analysis was done in Stata 8.0. Projections of the existing ophthalmologists and dedicated eye beds were made for the entire country using the mean, median and range for each individual state.

RESULTS

The response rate was 89.3%. More than half the eye care facilities were located in the private sector. Sixty-nine per cent of the ophthalmologists were employed in the private and non-governmental sectors; 71.5% of all dedicated eye beds were managed by these two sectors. Five states (Maharashtra, Uttar Pradesh, Karnataka, Andhra Pradesh and Tamil Nadu) had half the practising ophthalmologists in India. There was a wide disparity in access to ophthalmologists and dedicated eye beds across the country. Using the median to obtain medium projections, it is estimated that there are 9478 practising ophthalmologists and 59 828 dedicated eye beds in India.

CONCLUSIONS

India will be able to meet the requirements for trained ophthalmologists and dedicated eye beds to achieve the goals of Vision 2020. Some states will need special attention. Instead of an across-the-board increase in ophthalmologists and eye beds, regions which are deficient will need to be prioritized and concerted action initiated to achieve an equitable distribution of the available resources.

Refractive error in children in an urban population in New Delhi

PURPOSE

To assess the prevalence of refractive error and related visual impairment in school-aged children in an urban population in New Delhi, India.

METHODS

Random selection of geographically defined clusters was used to identify a sample of children 5 to 15 years of age. From December 2000 through March 2001, children in 22 selected clusters were enumerated through a door-to-door survey and examined at a local facility. The examination included visual acuity measurements, ocular motility evaluation, retinoscopy and autorefraction under cycloplegia, and examination of the anterior segment, media, and fundus. Myopia was defined as spherical equivalent refractive error of at least -0.50 D and hyperopia as +2.00 D or more. Children with reduced vision and a sample of those with normal vision underwent independent replicate examinations for quality assurance in four of the clusters.

RESULTS

A total of 7008 children from 3426 households were enumerated, and 6447 (92.0%) examined. The prevalence of uncorrected, baseline (presenting), and best corrected visual acuity of 20/40 or worse in the better eye was 6.4%, 4.9%, and 0.81%, respectively. Refractive error was the cause in 81.7% of eyes with vision impairment, amblyopia in 4.4%, retinal disorders in 4.7%, other causes in 3.3%, and unexplained causes in the remaining 5.9%. There was an age-related shift in refractive error from hyperopia in young children (15.6% in 5-year-olds) toward myopia in older children (10.8% in 15-year-olds). Overall, hyperopia was present in 7.7% of children and myopia in 7.4%. Hyperopia was associated with female gender. Myopia was more common in children of fathers with higher levels of education.

CONCLUSIONS

Reduced vision because of uncorrected refractive error is a major public health problem in urban school-aged children in India. Cost-effective strategies are needed to eliminate this easily treated cause of vision impairment.

A population-based eye survey of older adults in a rural district of Rajasthan: I. Central vision impairment, blindness, and cataract surgery

PURPOSE

To assess the prevalence of central vision blindness and cataract surgery in older adults in rural northwest India.

DESIGN

Population-based, cross-sectional study.

PARTICIPANTS

A total of 4284 examined persons 50 years of age or older.

METHODS

A random selection of village-based clusters was used to identify a population sample in the predominantly rural Bharatpur district of Rajasthan. Eligible subjects in the 25 selected clusters were enumerated through a door-to-door household survey and invited to village sites for visual acuity testing and eye examination early in 1999. The principal cause of reduced central vision was identified for eyes that had visual acuity worse than 6/18. Independent replicate testing for quality assurance monitoring took place in participants with reduced vision and in a sample of those with normal vision in five of the study clusters.

MAIN OUTCOME MEASURES

Presenting and best-corrected visual acuity and lens status.

RESULTS

A total of 4728 eligible persons in 2821 households were enumerated, and 4284 (90.6%) were examined. The prevalence of presenting and best-corrected visual acuity worse than 6/60 in both eyes was 11.9% (95% confidence interval: 10.0%-13.9%) and 6.1% (95% CI: 4.7%-7.4%), respectively. Presenting blindness was associated with increasing age, female gender, lack of schooling, and rural residence. Cataract was the principal cause of blindness in one or both eyes in 67.5% of blind persons, with uncorrected aphakia and other refractive error affecting 18.4% in at least one eye. The prevalence of cataract surgery was 12.8% (95% CI: 11.6%-14.0%), with an estimated 65.7% of the cataract blind operated on; low surgical coverage was associated with lack of schooling.

CONCLUSIONS

Blindness, particularly blindness because of cataract, continues to be a significant problem among the elderly living in remote areas of rural northwest India. Increased attention should be given to reaching women and the illiterate.

Visual outcomes after cataract surgery and cataract surgical coverage in India

Visual outcomes of 2369 cataract operated persons(3655 eyes) across seven major Indian states were assessed in 1998. This is the largest ever study over the past decade in the country. 9.54 per cent of the examined population had undergone operation for cataract in one or both eyes. Intra-capsular cataract extraction was the commonest surgical modality adopted (91.62%). Intraocular lens implants resulted in better visual outcomes with 71.4 per cent of such patients achieving a good visual outcome (> or = 6/18 in operated eyes). Visual outcome was also good if ICCE operated patients were provided good quality aphakic spectacles. There were no gender differentials in surgical uptake rates. The risk of poor postsurgical visual outcome was strongly associated by type of surgery (Adjusted OR for ICCE-2.78; 95% CI: 1.41-5.49) and the non-availability or poor quality aphakic spectacles (Adjusted OR for poor/no spectacles 4.59-95% CI: 3.53-5.97). Duration since surgery and the source of surgery did not influence visual outcomes. Half the cataract blind remained unoperated in the study population.

Rapid assessment of cataract blindness in India

28,055 persons aged 50 yrs+ from seven states in India were surveyed by a rapid assessment technique for cataract blindness. The prevalence of bilateral blindness (vision < 6/60 in the better eye) was 11.68 percent (95% C.I. 10.54-12.81). The age-gender adjusted blindness prevalence rate was 11.04 percent (95% C.I. 11.033-11.044). Age and occupational status were associated with blindness prevalence. Cataract was the commonest cause of low vision and blindness in this population. Respondents aged 60-69 years had a 2.74 times higher risk, while those aged 70 years+ had a 4.86 times higher risk of being blind, compared to those 50-59 years. Productively employed individuals had lowest blindness rates. Blindness rates were five times higher among respondents who were not working and two times higher among those engaged solely in household activities. The prevalence of cataract was 43.32 percent (95% C.I. 41.14-45.50) among those aged 50+ years. The prevalence increased with increasing age. Gender did not influence the prevalence of cataract in the present survey. Extrapolating from the present survey, it is estimated that 11.9 million blind people (vision < 6/60 in the better eye) in India are in urgent need of cataract surgery.

Monitoring and evaluating cataract intervention in India

AIM

To identify indicators to monitor and evaluate the cataract intervention programme in India.

METHODS

Available data on blindness due to cataract, demography, staffing levels, and infrastructure available under the programme were reviewed. Four key elements of the programme were identified: the magnitude of blindness due to cataract and the need for surgical services; the available resources; the output, in quantity and in quality, as well as the resource utilisation; and lastly the impact this has on society and the problem of blindness due to cataract. Indicators to quantify these key elements were designed and available data were used to calculate the defined indicators.

RESULTS

At least 2.5 million sight restoring cataract operations will have to be performed annually. Staffing levels and infrastructure resources at present allow for increased output. The effectiveness of cataract services can be increased with better case selection.

CONCLUSION

The use of these indicators provides an insight into the dynamics of the problem of cataract blindness and its intervention. They facilitate adequate management and evaluation of the efficiency and effectiveness of the intervention programme and may ensure optimal utilisation of the available resources for cataract surgery.