Association of ultra-processed food intake with risk of inflammatory bowel disease: prospective cohort study

OBJECTIVE

To evaluate the relation between intake of ultra-processed food and risk of inflammatory bowel disease (IBD).

DESIGN

Prospective cohort study.

SETTING

21 low, middle, and high income countries across seven geographical regions (Europe and North America, South America, Africa, Middle East, south Asia, South East Asia, and China).

PARTICIPANTS

116 087 adults aged 35-70 years with at least one cycle of follow-up and complete baseline food frequency questionnaire (FFQ) data (country specific validated FFQs were used to document baseline dietary intake). Participants were followed prospectively at least every three years.

MAIN OUTCOME MEASURES

The main outcome was development of IBD, including Crohn's disease or ulcerative colitis. Associations between ultra-processed food intake and risk of IBD were assessed using Cox proportional hazard multivariable models. Results are presented as hazard ratios with 95% confidence intervals.

RESULTS

Participants were enrolled in the study between 2003 and 2016. During the median follow-up of 9.7 years (interquartile range 8.9-11.2 years), 467 participants developed incident IBD (90 with Crohn's disease and 377 with ulcerative colitis). After adjustment for potential confounding factors, higher intake of ultra-processed food was associated with a higher risk of incident IBD (hazard ratio 1.82, 95% confidence interval 1.22 to 2.72 for ≥5 servings/day and 1.67, 1.18 to 2.37 for 1-4 servings/day compared with <1 serving/day, P=0.006 for trend). Different subgroups of ultra-processed food, including soft drinks, refined sweetened foods, salty snacks, and processed meat, each were associated with higher hazard ratios for IBD. Results were consistent for Crohn's disease and ulcerative colitis with low heterogeneity. Intakes of white meat, red meat, dairy, starch, and fruit, vegetables, and legumes were not associated with incident IBD.

CONCLUSIONS

Higher intake of ultra-processed food was positively associated with risk of IBD. Further studies are needed to identify the contributory factors within ultra-processed foods.

STUDY REGISTRATION

ClinicalTrials.gov NCT03225586.

Burden of dengue infection in India, 2017: a cross-sectional population based serosurvey

BACKGROUND

The burden of dengue virus (DENV) infection across geographical regions of India is poorly quantified. We estimated the age-specific seroprevalence, force of infection, and number of infections in India.

METHODS

We did a community-based survey in 240 clusters (118 rural, 122 urban), selected from 60 districts of 15 Indian states from five geographical regions. We enumerated each cluster, randomly selected (with an Andriod application developed specifically for the survey) 25 individuals from age groups of 5-8 years, 9-17 years, and 18-45 years, and sampled a minimum of 11 individuals from each age group (all the 25 randomly selected individuals in each age group were visited in their houses and individuals who consented for the survey were included in the study). Age was the only inclusion criterion; for the purpose of enumeration, individuals residing in the household for more than 6 months were included. Sera were tested centrally by a laboratory team of scientific and technical staff for IgG antibodies against the DENV with the use of indirect ELISA. We calculated age group specific seroprevalence and constructed catalytic models to estimate force of infection.

FINDINGS

From June 19, 2017, to April 12, 2018, we randomly selected 17 930 individuals from three age groups. Of these, blood samples were collected and tested for 12 300 individuals (5-8 years, n=4059; 9-17 years, n=4265; 18-45 years, n=3976). The overall seroprevalence of DENV infection in India was 48·7% (95% CI 43·5-54·0), increasing from 28·3% (21·5-36·2) among children aged 5-8 years to 41·0% (32·4-50·1) among children aged 9-17 years and 56·2% (49·0-63·1) among individuals aged between 18-45 years. The seroprevalence was high in the southern (76·9% [69·1-83·2]), western (62·3% [55·3-68·8]), and northern (60·3% [49·3-70·5]) regions. The estimated number of primary DENV infections with the constant force of infection model was 12 991 357 (12 825 128-13 130 258) and for the age-dependent force of infection model was 8 655 425 (7 243 630-9 545 052) among individuals aged 5-45 years from 30 Indian states in 2017.

INTERPRETATION

The burden of dengue infection in India was heterogeneous, with evidence of high transmission in northern, western, and southern regions. The survey findings will be useful in making informed decisions about introduction of upcoming dengue vaccines in India.

FUNDING

Indian Council of Medical Research.

White Rice Intake and Incident Diabetes: A Study of 132,373 Participants in 21 Countries

OBJECTIVE

Previous prospective studies on the association of white rice intake with incident diabetes have shown contradictory results but were conducted in single countries and predominantly in Asia. We report on the association of white rice with risk of diabetes in the multinational Prospective Urban Rural Epidemiology (PURE) study.

RESEARCH DESIGN AND METHODS

Data on 132,373 individuals aged 35-70 years from 21 countries were analyzed. White rice consumption (cooked) was categorized as <150, ≥150 to <300, ≥300 to <450, and ≥450 g/day, based on one cup of cooked rice = 150 g. The primary outcome was incident diabetes. Hazard ratios (HRs) were calculated using a multivariable Cox frailty model.

RESULTS

During a mean follow-up period of 9.5 years, 6,129 individuals without baseline diabetes developed incident diabetes. In the overall cohort, higher intake of white rice (≥450 g/day compared with <150 g/day) was associated with increased risk of diabetes (HR 1.20; 95% CI 1.02-1.40; P for trend = 0.003). However, the highest risk was seen in South Asia (HR 1.61; 95% CI 1.13-2.30; P for trend = 0.02), followed by other regions of the world (which included South East Asia, Middle East, South America, North America, Europe, and Africa) (HR 1.41; 95% CI 1.08-1.86; P for trend = 0.01), while in China there was no significant association (HR 1.04; 95% CI 0.77-1.40; P for trend = 0.38).

CONCLUSIONS

Higher consumption of white rice is associated with an increased risk of incident diabetes with the strongest association being observed in South Asia, while in other regions, a modest, nonsignificant association was seen.

Household and personal air pollution exposure measurements from 120 communities in eight countries: results from the PURE-AIR study

BACKGROUND

Approximately 2·8 billion people are exposed to household air pollution from cooking with polluting fuels. Few monitoring studies have systematically measured health-damaging air pollutant (ie, fine particulate matter [PM2·5] and black carbon) concentrations from a wide range of cooking fuels across diverse populations. This multinational study aimed to assess the magnitude of kitchen concentrations and personal exposures to PM2·5 and black carbon in rural communities with a wide range of cooking environments.

METHODS

As part of the Prospective Urban and Rural Epidemiological (PURE) cohort, the PURE-AIR study was done in 120 rural communities in eight countries (Bangladesh, Chile, China, Colombia, India, Pakistan, Tanzania, and Zimbabwe). Data were collected from 2541 households and from 998 individuals (442 men and 556 women). Gravimetric (or filter-based) 48 h kitchen and personal PM2·5 measurements were collected. Light absorbance (10-5m-1) of the PM2·5 filters, a proxy for black carbon concentrations, was calculated via an image-based reflectance method. Surveys of household characteristics and cooking patterns were collected before and after the 48 h monitoring period.

FINDINGS

Monitoring of household air pollution for the PURE-AIR study was done from June, 2017, to September, 2019. A mean PM2·5 kitchen concentration gradient emerged across primary cooking fuels: gas (45 μg/m3 [95% CI 43-48]), electricity (53 μg/m3 [47-60]), coal (68 μg/m3 [61-77]), charcoal (92 μg/m3 [58-146]), agricultural or crop waste (106 μg/m3 [91-125]), wood (109 μg/m3 [102-118]), animal dung (224 μg/m3 [197-254]), and shrubs or grass (276 μg/m3 [223-342]). Among households cooking primarily with wood, average PM2·5 concentrations varied ten-fold (range: 40-380 μg/m3). Fuel stacking was prevalent (981 [39%] of 2541 households); using wood as a primary cooking fuel with clean secondary cooking fuels (eg, gas) was associated with 50% lower PM2·5 and black carbon concentrations than using only wood as a primary cooking fuel. Similar average PM2·5 personal exposures between women (67 μg/m3 [95% CI 62-72]) and men (62 [58-67]) were observed. Nearly equivalent average personal exposure to kitchen exposure ratios were observed for PM2·5 (0·79 [95% 0·71-0·88] for men and 0·82 [0·74-0·91] for women) and black carbon (0·64 [0·45-0·92] for men and 0·68 [0·46-1·02] for women).

INTERPRETATION

Using clean primary fuels substantially lowers kitchen PM2·5 concentrations. Importantly, average kitchen and personal PM2·5 measurements for all primary fuel types exceeded WHO's Interim Target-1 (35 μg/m3 annual average), highlighting the need for comprehensive pollution mitigation strategies.

FUNDING

Canadian Institutes for Health Research, National Institutes of Health.

Association of Sitting Time With Mortality and Cardiovascular Events in High-Income, Middle-Income, and Low-Income Countries

Importance

High amounts of sitting time are associated with increased risks of cardiovascular disease (CVD) and mortality in high-income countries, but it is unknown whether risks also increase in low- and middle-income countries.

Objective

To investigate the association of sitting time with mortality and major CVD in countries at different economic levels using data from the Prospective Urban Rural Epidemiology study.

Design, Setting, and Participants

This population-based cohort study included participants aged 35 to 70 years recruited from January 1, 2003, and followed up until August 31, 2021, in 21 high-income, middle-income, and low-income countries with a median follow-up of 11.1 years.

Exposures

Daily sitting time measured using the International Physical Activity Questionnaire.

Main Outcomes and Measures

The composite of all-cause mortality and major CVD (defined as cardiovascular death, myocardial infarction, stroke, or heart failure).

Results

Of 105 677 participants, 61 925 (58.6%) were women, and the mean (SD) age was 50.4 (9.6) years. During a median follow-up of 11.1 (IQR, 8.6-12.2) years, 6233 deaths and 5696 major cardiovascular events (2349 myocardial infarctions, 2966 strokes, 671 heart failure, and 1792 cardiovascular deaths) were documented. Compared with the reference group (<4 hours per day of sitting), higher sitting time (≥8 hours per day) was associated with an increased risk of the composite outcome (hazard ratio [HR], 1.19; 95% CI, 1.11-1.28; Pfor trend < .001), all-cause mortality (HR, 1.20; 95% CI, 1.10-1.31; Pfor trend < .001), and major CVD (HR, 1.21; 95% CI, 1.10-1.34; Pfor trend < .001). When stratified by country income levels, the association of sitting time with the composite outcome was stronger in low-income and lower-middle-income countries (≥8 hours per day: HR, 1.29; 95% CI, 1.16-1.44) compared with high-income and upper-middle-income countries (HR, 1.08; 95% CI, 0.98-1.19; P for interaction = .02). Compared with those who reported sitting time less than 4 hours per day and high physical activity level, participants who sat for 8 or more hours per day experienced a 17% to 50% higher associated risk of the composite outcome across physical activity levels; and the risk was attenuated along with increased physical activity levels.

Conclusions and Relevance

High amounts of sitting time were associated with increased risk of all-cause mortality and CVD in economically diverse settings, especially in low-income and lower-middle-income countries. Reducing sedentary time along with increasing physical activity might be an important strategy for easing the global burden of premature deaths and CVD.

Household air pollution and stillbirths in India: analysis of the DLHS-II National Survey

BACKGROUND

Several studies have linked biomass cooking fuel with adverse pregnancy outcomes such as preterm births, low birth weight and post-neonatal infant mortality, but very few have studied the associations with cooking fuel independent of other factors associated with stillbirths.

METHOD

We analyzed the data from 188,917 ever-married women aged 15-49 included in India's 2003-2004 District Level Household Survey-II to investigate the association between household use of cooking fuels (liquid petroleum gas/electricity, kerosene, biomass) and risk of stillbirth. Prevalence ratios (PRs) were obtained using Poisson regression with robust standard errors after controlling for several potentially confounding factors (socio-demographic and maternal health characteristics).

RESULTS

Risk factors significantly associated with occurrence of stillbirth in the Poisson regression with robust standard errors model were: literacy status of the mother and father, lighting fuel and cooking fuel used, gravida status, history of previous abortion, whether the woman had an antenatal check up, age at last pregnancy >35 years, labor complications, bleeding complications, fetal and other complications, prematurity and home delivery. After controlling the effect of these factors, women who cook with firewood (PR 1.24; 95% CI: 1.08-1.41, p=0.003) or kerosene (PR 1.36; 95% CI: 1.10-1.67, p=0.004) were more likely to have experienced a stillbirth than those who cook with LPG/electricity. Kerosene lamp use was also associated with stillbirths compared to electric lighting (PR 1.15; 95% CI: 1.06-1.25, p=0.001). The population attributable risk of firewood as cooking fuel for stillbirths in India was 11% and 1% for kerosene cooking.

CONCLUSION

Biomass and kerosene cooking fuels are associated with stillbirth occurrence in this population sample. Assuming these associations are causal, about 12% of stillbirths in India could be prevented by providing access to cleaner cooking fuel.

Diagnostic accuracy of tests for type 2 diabetes and prediabetes: A systematic review and meta-analysis

AIM

This systematic review aimed to ascertain the diagnostic accuracy (sensitivity and specificity) of screening tests for early detection of type 2 diabetes and prediabetes in previously undiagnosed adults.

METHODS

This systematic review included published studies that included one or more index tests (random and fasting tests, HbA1c) for glucose detection, with 75-gram Oral Glucose Tolerance Test (or 2-hour post load glucose) as a reference standard (PROSPERO ID CRD42018102477). Seven databases were searched electronically (from their inception up to March 9, 2020) accompanied with bibliographic and website searches. Records were manually screened and full text were selected based on inclusion and exclusion criteria. Subsequently, data extraction was done using standardized form and quality assessment of studies using QUADAS-2 tool. Meta-analysis was done using bivariate model using Stata 14.0. Optimal cut offs in terms of sensitivity and specificity for the tests were analysed using R software.

RESULTS

Of 7,151 records assessed by title and abstract, a total of 37 peer reviewed articles were included in this systematic review. The pooled sensitivity, specificity, positive (LR+) and negative likelihood ratio (LR-) for diagnosing diabetes with HbA1c (6.5%; venous sample; n = 17 studies) were 50% (95% CI: 42-59%), 97.3% (95% CI: 95.3-98.4), 18.32 (95% CI: 11.06-30.53) and 0.51 (95% CI: 0.43-0.60), respectively. However, the optimal cut-off for diagnosing diabetes in previously undiagnosed adults with HbA1c was estimated as 6.03% with pooled sensitivity of 73.9% (95% CI: 68-79.1%) and specificity of 87.2% (95% CI: 82-91%). The optimal cut-off for Fasting Plasma Glucose (FPG) was estimated as 104 milligram/dL (mg/dL) with a sensitivity of 82.3% (95% CI: 74.6-88.1%) and specificity of 89.4% (95% CI: 85.2-92.5%).

CONCLUSION

Our findings suggest that at present recommended threshold of 6.5%, HbA1c is more specific and less sensitive in diagnosing the newly detected diabetes in undiagnosed population from community settings. Lowering of thresholds for HbA1c and FPG to 6.03% and 104 mg/dL for early detection in previously undiagnosed persons for screening purposes may be considered.

Estimating mortality using data from civil registration: a cross-sectional study in India

Objective

To analyse the design and operational status of India’s civil registration and vital statistics system and facilitate the system’s development into an accurate and reliable source of mortality data.

Methods

We assessed the national civil registration and vital statistics system’s legal framework, administrative structure and design through document review. We did a cross-sectional study for the year 2013 at national level and in Punjab state to assess the quality of the system’s mortality data through analyses of life tables and investigation of the completeness of death registration and the proportion of deaths assigned ill-defined causes. We interviewed registrars, medical officers and coders in Punjab state to assess their knowledge and practice.

Findings

Although we found the legal framework and system design to be appropriate, data collection was based on complex intersectoral collaborations at state and local level and the collected data were found to be of poor quality. The registration data were inadequate for a robust estimate of mortality at national level. A medically certified cause of death was only recorded for 965 992 (16.8%) of the 5 735 082 deaths registered.

Conclusion

The data recorded by India’s civil registration and vital statistics system in 2011 were incomplete. If improved, the system could be used to reliably estimate mortality. We recommend improving political support and intersectoral coordination, capacity building, computerization and state-level initiatives to ensure that every death is registered and that reliable causes of death are recorded – at least within an adequate sample of registration units within each state.

Contrasting Associations Between Diabetes and Cardiovascular Mortality Rates in Low-, Middle-, and High-Income Countries: Cohort Study Data From 143,567 Individuals in 21 Countries in the PURE Study

OBJECTIVE

We aimed to compare cardiovascular (CV) events, all-cause mortality, and CV mortality rates among adults with and without diabetes in countries with differing levels of income.

RESEARCH DESIGN AND METHODS

The Prospective Urban Rural Epidemiology (PURE) study enrolled 143,567 adults aged 35-70 years from 4 high-income countries (HIC), 12 middle-income countries (MIC), and 5 low-income countries (LIC). The mean follow-up was 9.0 ± 3.0 years.

RESULTS

Among those with diabetes, CVD rates (LIC 10.3, MIC 9.2, HIC 8.3 per 1,000 person-years, P < 0.001), all-cause mortality (LIC 13.8, MIC 7.2, HIC 4.2 per 1,000 person-years, P < 0.001), and CV mortality (LIC 5.7, MIC 2.2, HIC 1.0 per 1,000 person-years, P < 0.001) were considerably higher in LIC compared with MIC and HIC. Within LIC, mortality was higher in those in the lowest tertile of wealth index (low 14.7%, middle 10.8%, and high 6.5%). In contrast to HIC and MIC, the increased CV mortality in those with diabetes in LIC remained unchanged even after adjustment for behavioral risk factors and treatments (hazard ratio [95% CI] 1.89 [1.58-2.27] to 1.78 [1.36-2.34]).

CONCLUSIONS

CVD rates, all-cause mortality, and CV mortality were markedly higher among those with diabetes in LIC compared with MIC and HIC with mortality risk remaining unchanged even after adjustment for risk factors and treatments. There is an urgent need to improve access to care to those with diabetes in LIC to reduce the excess mortality rates, particularly among those in the poorer strata of society.

Biomass fuel and risk of tuberculosis: a case-control study from Northern India

BACKGROUND

Although a known risk factor for several respiratory diseases, the relationship between cooking smoke and tuberculosis has not been conclusively established. Hence, a case-control study was conducted among adult women of Chandigarh Union Territory in India.

METHODS

Physician-diagnosed cases of sputum positive pulmonary tuberculosis (n=126) and age- and residence area-matched controls (n=252) were enrolled from clinics in urban, rural and slum areas. Interviews were conducted in the clinic using a pretested questionnaire to collect information on type of cooking fuel, education, occupation, socio-economic status, smoking, overcrowding and type of kitchen, etc. The conditional logistic regression model was used for control of confounding.

RESULTS

The study population was predominantly in the 20-29-year-old age group (58%) and lived in urban areas (67%). The majority were illiterate (52%) and housewives (93%), and nearly half (46%) had an income of no more than Rs 25 000. Among the cases, 20.6%, 27% and 52.4% used biomass fuel, kerosene and liquid petroleum gas (LPG), respectively, whereas among controls, the respective figures were: 12.3%, 26.2% and 61.5%. The unadjusted OR for biomass fuel compared with LPG was 2.33 (95% CI 1.18 to 4.59, p 0.01). Adjustment for confounding factors (education, type of kitchen, smoking tobacco and TB in a family member) and interaction between cooking fuel and smoker in family revealed an OR of 3.14 (95% CI 1.15 to 8.56, p=0.02) for biomass fuel in comparison with LPG.

CONCLUSIONS

Cooking with biomass fuel increases the risk for pulmonary tuberculosis.

Multiple treatment and indirect treatment comparisons: An overview of network meta-analysis

Randomized control trials and its meta-analysis has occupied the pinnacle in levels of evidence available for research. However, there were several limitations of these trials. Network meta-analysis (NMA) is a recent tool for evidence-based medicine that draws strength from direct and indirect evidence generated from randomized control trials. It facilitates comparisons across multiple treatment options, direct comparisons of which have not been attempted till date due to multitude of reasons. These indirect treatment comparisons of randomized controlled trials are based on similarity and consistency assumptions that follow Bayesian or frequentist statistics. Most NMAuntil date use Microsoft Windows WinBUGs Software for analysis which relies on Bayesian statistics. Methodology of NMA is expected to undergo further refinements and become robust with usage. Power and precision of indirect comparisons in NMA is a concern as it is dependent on effective number of trials, sample size and complete statistical information. However, NMA can synthesize results of considerable relevance to experts and policy makers.

Out-of-pocket expenditure and catastrophic health expenditure for hospitalization due to injuries in public sector hospitals in North India

Background

Injuries are a major public health problem, resulting in high health care demand and economic burden. They result in loss of disability adjusted life years (DALYs) and high out-of-pocket expenditure. However, there is little evidence on the economic burden of injuries in India. We undertook this study to report out-of-pocket expenditure and the prevalence of catastrophic health expenditure for injuries related hospitalizations in public sector hospitals in North India. Further, we also evaluate the determinants of catastrophic health expenditure.

Methods and analysis

A prospective observational study was conducted. Participants were recruited from three hospitals for all injury cases. Data were collected via face-to-face baseline interviews and follow-up interviews over the phone at 1, 2, 4 and 12 months post-injury. Prevalence of catastrophic health expenditure (more than 30% of consumption expenditure) and impoverishment (International dollar 1.90) were estimated.

Results

Road traffic injuries (57%) were the leading cause of injury. Direct out-of-pocket expenditure for hospitalizations was INR 16,768 (USD 263) while indirect productivity loss was INR 8,164 (USD 128). The prevalence of catastrophic expenditure was 22.2% with 12.2% slipping below poverty line. Prevalence of catastrophic health expenditure and impoverishment was higher and significantly associated with poorest quintile, tertiary care hospital and increased duration of hospitalization (p< 0.001).

Conclusion

The economic impact of injuries is notably high both in terms of out-of-pocket expenditure and productivity loss. A high proportion of households experienced catastrophic expenditure and impoverishment following an injury, highlighting need for programs to prevent injuries.

The syndemic of violence victimisation, drug use, frequent alcohol use, and HIV transmission risk behaviour among men who have sex with men: Cross-sectional, population-based study in India

The theory of syndemics has been used to explain elevated HIV risk facing men who have sex with men (MSM). However, few studies have employed suitable analytical methods to test this theory. Using data from a probability-based sample of MSM in India, we tested three proposed models linking the co-occurring epidemics of violence victimisation, drug use, and frequent alcohol use to HIV risk: 1) the syndemic model of synergistically interacting epidemics; 2) the "chains of risk" model; and 3) the model of mutually causal epidemics. The primary outcome was inconsistent condom use with male or hijra (transgender women) partners in the past month. For the syndemic model, we included product terms between the exposures and assessed for interaction on the additive (linear probability regression) and multiplicative (logistic regression) scales. Path analysis was used to test the models of serially causal epidemics and mutually causal epidemics. Among 22,297 HIV-negative MSM, violence victimisation (24.7%), frequent alcohol use (27.5%), and drug use (10.9%) frequently co-occurred. We found evidence for a three-way interaction between violence victimisation, drug use and frequent alcohol use on both the multiplicative (semi-elasticity = 0.28; 95% CI 0.10, 0.47) and additive (b = 0.14; 95% CI 0.01, .27) scales. We also estimated statistically significant two-way interactions between violence victimisation and frequent alcohol use on the multiplicative (semi-elasticity = .10; 95% CI 0.008, 0.20) and additive (b = 0.05, 95% CI 0.002, 0.107) scales, and between drug use and frequent alcohol use on the multiplicative (semi-elasticity = 0.13, 95% CI 0.02, 0.24) and additive (b = 0.06, 95% CI 0.007, 0.129) scales. Thus, we found strong evidence for the syndemic model. The models of serially causal and mutually causal epidemics were partially supported. These findings highlight the need to sharpen how syndemic models are specified so that their empirical predictions can be adequately tested and distinguished from other theories of disease distribution.

Role of self-care in COVID-19 pandemic for people living with comorbidities of diabetes and hypertension

People living with comorbidities especially chronic non-communicable disease (NCDs) like diabetes and hypertension are at greater risk of acquiring severe form of Corona Virus Disease (COVID-19) infection known to be caused by Severe Acute Respiratory Syndrome-CoV -2 (SARS-CoV-2) due to underlying immunodeficiency. The government has taken various public health measures to reduce the risk of infection, such as physical distancing, Information Education and Communication (IEC) messages regarding hand-washing, usage of masks, and avoidance of unnecessary travel including lockdown to combat the spread of disease. However, nationwide lockdown due to COVID-19 pandemic has also confronted the existing health care system (clinician centric approach) for the management of diabetes and hypertension in India. Using secondary source of data from specific website and search engine a review was done for existing guidelines and literature focusing on the various components of self-care management (patient-centered care) and highlights the importance of self-care management education to cope up with twin pandemic of COVID-19 and NCDs. An attempt was also made to highlight the use of eHealth to manage diabetes and hypertension which may act as a bridge to fill the gap between primary care physician and patient's amid lockdown and help physician to deliver comprehensive care for people suffering from comorbidities.

Demographic & clinical profile of patients with COVID-19 at a tertiary care hospital in north India

Background & objectives:

The COVID-19 pandemic emerged as a major public health emergency affecting the healthcare services all over the world. It is essential to analyze the epidemiological and clinical characteristics of patients with COVID-19 in different parts of our country. This study highlights clinical experience in managing patients with COVID-19 at a tertiary care centre in northern India.

Methods:

Clinical characteristics and outcomes of consecutive adults patients admitted to a tertiary care hospital at Chandigarh, India, from April 1 to May 25, 2020 were studied. The diagnosis of SARS-CoV-2 infection was confirmed by real-time reverse transcriptase polymerase chain reaction (RT-PCR) on throat and/or nasopharyngeal swabs. All patients were managed according to the institute's consensus protocol and in accordance with Indian Council of Medical Research guidelines.

Results:

During the study period, 114 patients with SARS-CoV-2 infection were admitted. The history of contact with COVID-19-affected individuals was available in 75 (65.8%) patients. The median age of the patients was 33.5 yr (13-79 yr), and there were 66 (58%) males. Of the total enrolled patients, 48 (42%) were symptomatic. The common presenting complaints were fever (37, 77%), cough (26, 54%) and shortness of breath (10, 20.8%). Nineteen (17%) patients had hypoxia (SpO2<94%) at presentation and 36 (31%) had tachypnoea (RR >24). Thirty four (29.8%) patients had an accompanying comorbid illness. Age more than 60 yr and presence of diabetes and hypertension were significantly associated with severe COVID-19 disease. Admission to the intensive care unit (ICU) was needed in 18 patients (52%), with three (2.6%) patients requiring assisted ventilation. Mortality of 2.6 per cent (3 patients) was observed.

Interpretation & conclusions:

Majority of the patients with COVID-19 infection presenting to our hospital were young and asymptomatic. Fever was noted only in three-fourth of the patients and respiratory symptoms in half of them. Patients with comorbidities were more vulnerable to complications. Triaged classification of patients and protocol-based treatment resulted in good outcomes and low case fatality.

Urbanization and physical activity in the global Prospective Urban and Rural Epidemiology study

Urbanization may influence physical activity (PA) levels, although little evidence is available for low- and middle- income countries where urbanization is occurring fastest. We evaluated associations between urbanization and total PA, as well as work-, leisure-, home-, and transport-specific PA, for 138,206 adults living in 698 communities across 22 countries within the Prospective Urban and Rural Epidemiology (PURE) study. The 1-week long-form International PA Questionnaire was administered at baseline (2003-2015). We used satellite-derived population density and impervious surface area estimates to quantify baseline urbanization levels for study communities, as well as change measures for 5- and 10-years prior to PA surveys. We used generalized linear mixed effects models to examine associations between urbanization measures and PA levels, controlling for individual, household and community factors. Higher community baseline levels of population density (- 12.4% per IQR, 95% CI - 16.0, - 8.7) and impervious surface area (- 29.2% per IQR, 95% CI - 37.5, - 19.7), as well as the rate of change in 5-year population density (- 17.2% per IQR, 95% CI - 25.7, - 7.7), were associated with lower total PA levels. Important differences in the associations between urbanization and PA were observed between PA domains, country-income levels, urban/rural status, and sex. These findings provide new information on the complex associations between urbanization and PA.

Epidemiological transition in a rural community of northern India: 18-year mortality surveillance using verbal autopsy

BACKGROUND

Information on causes of death is vital for planning of health services. However, vital events registration systems are weak in developing countries. Therefore, verbal autopsy (VA) tools were incorporated in a community-based surveillance system to track causes of death.

METHOD AND FINDINGS

Trained fieldworker identified all deaths and interviewed a living relative of those who had died during 1992-2009, using VA, in eight villages of Haryana (11,864 populations). These field reports detailing events preceding death were reviewed by two trained physicians, who independently assigned an International Classification of Disease-10 code to each death. Discrepancies were resolved through reconciliation and, if necessary, adjudication. Non-communicable conditions were the leading causes of death (47.6%) followed by communicable diseases including maternal, perinatal and nutritional conditions (34.0%), and injuries (11.4%). Cause of death could not be determined in 6.9% cases. Deaths due to cardiovascular diseases showed a significant rise, whereas deaths due to diarrhoeal diseases have declined (p<0.01). Majority (90.0%) of the deceased had contacted a healthcare provider during illness but only 11.5% were admitted in hospital before death.

CONCLUSION

Rising trend of cardiovascular diseases observed in a rural community of Haryana in India calls for reorientation of rural healthcare delivery system for prevention and control of chronic diseases.

Household, Community, Sub-National and Country-level Predictors of Primary Cooking Fuel Switching in Nine Countries from the PURE Study

INTRODUCTION

Switching from polluting (e.g. wood, crop waste, coal) to clean cooking fuels (e.g. gas, electricity) can reduce household air pollution (HAP) exposures and climate-forcing emissions. While studies have evaluated specific interventions and assessed fuel-switching in repeated cross-sectional surveys, the role of different multilevel factors in household fuel switching, outside of interventions and across diverse community settings, is not well understood.

METHODS

We examined longitudinal survey data from 24,172 households in 177 rural communities across nine countries within the Prospective Urban and Rural Epidemiology (PURE) study. We assessed household-level primary cooking fuel switching during a median of 10 years of follow up (~2005-2015). We used hierarchical logistic regression models to examine the relative importance of household, community, sub-national and national-level factors contributing to primary fuel switching.

RESULTS

One-half of study households (12,369) reported changing their primary cooking fuels between baseline and follow up surveys. Of these, 61% (7,582) switched from polluting (wood, dung, agricultural waste, charcoal, coal, kerosene) to clean (gas, electricity) fuels, 26% (3,109) switched between different polluting fuels, 10% (1,164) switched from clean to polluting fuels and 3% (522) switched between different clean fuels. Among the 17,830 households using polluting cooking fuels at baseline, household-level factors (e.g. larger household size, higher wealth, higher education level) were most strongly associated with switching from polluting to clean fuels in India; in all other countries, community-level factors (e.g. larger population density in 2010, larger increase in population density between 2005-2015) were the strongest predictors of polluting-to-clean fuel switching.

CONCLUSIONS

The importance of community and sub-national factors relative to household characteristics in determining polluting-to-clean fuel switching varied dramatically across the nine countries examined. This highlights the potential importance of national and other contextual factors in shaping large-scale clean cooking transitions among rural communities in low- and middle-income countries.

Evaluation of publicly financed and privately delivered model of emergency referral services for maternal and child health care in India

Background

Emergency referral services (ERS) are being strengthened in India to improve access for institutional delivery. We evaluated a publicly financed and privately delivered model of ERS in Punjab state, India, to assess its extent and pattern of utilization, impact on institutional delivery, quality and unit cost.

Methods

Data for almost 0.4 million calls received from April 2012 to March 2013 was analysed to assess the extent and pattern of utilization. Segmented linear regression was used to analyse month-wise data on number of institutional deliveries in public sector health facilities from 2008 to 2013. We inspected ambulances in 2 districts against the Basic Life Support (BLS) standards. Timeliness of ERS was assessed for determining quality. Finally, we computed economic cost of implementing ERS from a health system perspective.

Results

On an average, an ambulance transported 3–4 patients per day. Poor and those farther away from the health facility had a higher likelihood of using the ambulance. Although the ERS had an abrupt positive effect on increasing the institutional deliveries in the unadjusted model, there was no effect on institutional delivery after adjustment for autocorrelation. Cost of operating the ambulance service was INR 1361 (USD 22.7) per patient transported or INR 21 (USD 0.35) per km travelled.

Conclusion

Emergency referral services in Punjab did not result in a significant change in public sector institutional deliveries. This could be due to high baseline coverage of institutional delivery and low barriers to physical access. Choice of interventions for reduction in Maternal Mortality Ratio (MMR) should be context-specific to have high value for resources spent. The ERS in Punjab needs improvement in terms of quality and reduction of cost to health system.

Adverse health impacts of cooking with kerosene: A multi-country analysis within the Prospective Urban and Rural Epidemiology Study

BACKGROUND

Kerosene, which was until recently considered a relatively clean household fuel, is still widely used in low- and middle-income countries for cooking and lighting. However, there is little data on its health effects. We examined cardiorespiratory effects and mortality in households using kerosene as their primary cooking fuel within the Prospective Urban Rural Epidemiology (PURE) study.

METHODS

We analyzed baseline and follow-up data on 31,490 individuals from 154 communities in China, India, South Africa, and Tanzania where there was at least 10% kerosene use for cooking at baseline. Baseline comorbidities and health outcomes during follow-up (median 9.4 years) were compared between households with kerosene versus clean (gas or electricity) or solid fuel (biomass and coal) use for cooking. Multi-level marginal regression models adjusted for individual, household, and community level covariates.

RESULTS

Higher rates of prevalent respiratory symptoms (e.g. 34% [95% CI:15-57%] more dyspnea with usual activity, 44% [95% CI: 21-72%] more chronic cough or sputum) and lower lung function (differences in FEV1: -46.3 ml (95% CI: -80.5; -12.1) and FVC: -54.7 ml (95% CI: -93.6; -15.8)) were observed at baseline for kerosene compared to clean fuel users. The odds of hypertension was slightly elevated but no associations were observed for blood pressure. Prospectively, kerosene was associated with elevated risks of all-cause (HR: 1.32 (95% CI: 1.14-1.53)) and cardiovascular (HR: 1.34 (95% CI: 1.00-1.80)) mortality, as well as major fatal and incident non-fatal cardiovascular (HR: 1.34 (95% CI: 1.08-1.66)) and respiratory (HR: 1.55 (95% CI: 0.98-2.43)) diseases, compared to clean fuel use. Further, compared to solid fuel users, those using kerosene had 20-47% higher risks for the above outcomes.

CONCLUSIONS

Kerosene use for cooking was associated with higher rates of baseline respiratory morbidity and increased risk of mortality and cardiorespiratory outcomes during follow-up when compared to either clean or solid fuels. Replacing kerosene with cleaner-burning fuels for cooking is recommended.

A pilot study of a hospital-based injury surveillance system in a secondary level district hospital in India: lessons learnt and way ahead

Background

Reliable epidemiological information on injury burden and pattern is essential to formulate effective injury control and prevention strategies. Injury surveillance systems are globally gaining ground as a tool for collecting such systematic data on injuries, but less so in low and middle income countries. This study describes the experience of setting up a District Level Hospital-Based Injury Surveillance System in India and the pattern of injuries encountered therein.

Methods

A prospective study was conducted during Jan-Dec 2012 at the emergency department of a District Hospital in Fatehgarh Sahib in a North Indian state of Punjab. A comprehensive injury proforma was devised to record information on all injury cases reporting to the hospital. Emergency Medical Officers were trained to record data.

Results

A total of 649 injuries were reported in 2012. The surveilance system used the existing resources at the hospital to collect data without the need for additional manpower, equipments etc. About 78 % of injuries reported were unintentional in nature. More than half (52.9 %) of the patients had injuries due to Road Traffic Crashes. Head (29.7 %) was the most common site of injury. Incised injury (50.2 %) was the most common type of injury and most of the injuries occurred while travelling (61.8 %).

Conclusion

Developing better and sustainable systems of routine injury surveillance or trauma registries is essential to generate reliable information for formulating effective intervention policies.

Hepatitis-B virus infection in India: Findings from a nationally representative serosurvey, 2017-18

INTRODUCTION

India introduced a hepatitis-B (HB) vaccine in the Universal Immunization Program in 2002-2003 on a pilot basis, expanded to ten states in 2007-2008 (phase-1), and the entire country in 2011-2012 (phase-2). We tested sera from a nationally representative serosurvey conducted duing 2017, to estimate the seroprevalence of different markers of HB infection among children aged 5-17 years in India and to assess the impact of vaccination.

METHODS

We tested sera from 8273 children for different markers of HB infection and estimated weighted age-group specific seroprevalence of children who were chronically infected (HBsAg and anti-HBc positive), and immune due to past infection (anti-HBc positive and HBsAg negative), and having serological evidence of HB vaccination (only anti-HBs positive). We compared the prevalence of serological markers among children born before (aged 11-17 years) and after (aged 5-10 years) introduction of HB-vaccine from phase-1 states.

RESULTS

Among children aged 5-8 years, 1.1% were chronic carriers, 5.3% immune due to past infection, and 23.2% vaccinated. The corresponding proportions among children aged 9-17 years were 1.1%, 8.0%, and 12.0%, respectively. In phase-1 states, children aged 5-10 years had a significantly lower prevalence of anti-HBc (4.9% vs. 7.6%, p<0.001) and higher prevalence of anti-HBs (37.7% vs. 14.7%, p<0.001) compared to children aged 11-17 years. HBsAg positivity, however, was not different in the two age groups.

CONCLUSIONS

Children born after the introduction of HB vaccination had a lower prevalence of past HBV infection and a higher prevalence of anti-HBs. The findings of our study could be considered as an interim assessment of the impact of the hepatitis B vaccine introduction in India.

Health care seeking behavior of adolescents: comparative study of two service delivery models

OBJECTIVES

To assess the perceived health problems and help seeking behaviour and utilization pattern of adolescent health clinics.

METHODS

A pre-tested, semi-structured questionnaire was administered to 360 school going adolescents who were selected by stratified random sampling from two sectors of Chandigarh where services were being provided by a school-based and dispensary-based adolescent health clinic.

RESULTS

Majority (81%) of the adolescents reported having some health problem during last three months prior to the survey; predominant (60%) problems were psychological and behavioural in nature. To resolve these problems boys consulted mainly friends/peers (48%) while girls consulted their mothers (63%). Compared to the dispensary-based adolescent health clinic, utilisation was significantly higher in a school-based clinic where proportion of psychological or behavioural problems reported was also significantly higher (P<0.01).

CONCLUSION

Adolescents have greater counselling needs for psychosocial problems than for medical problems. School-based adolescent health clinic was utilized more often than the dispensary-based clinic particularly for psychosocial problems.

The impact of road traffic injury in North India: a mixed-methods study protocol

BACKGROUND

Road traffic injuries are a large and growing public health burden, especially in low and middle income countries where 90% of the world's deaths due to road traffic injuries are estimated to occur. India is one of the fastest growing economies, with rapid motorisation and increasing road traffic burden. However, there are limited data addressing the problem of non-fatal road traffic injuries, with existing data being of poor quality, non-representative and difficult to access, and encompassing a limited number of relevant variables. This study aims to determine the outcomes of road traffic injuries on function and health-related quality of life, to assess their social impact and to weigh the economic cost of road traffic crashes in an urban setting in India.

METHODS AND ANALYSIS

This prospective observational study will recruit approximately 1500 participants injured in road traffic crashes, who are admitted to hospital for >24 h at any of three participating hospitals in Chandigarh, India. Face-to-face baseline interviews will be conducted by telephone at 1, 2, 4 and 12 months postinjury. Standardised tools will be used to collect data on health and social outcomes, and on the economic impact of road traffic crashes. Descriptive analysis and multivariate models will be used to report outcome data and associations. The qualitative in-depth interviews will be analysed thematically using content analysis. This study will provide the first comprehensive estimates on outcomes of serious road traffic injury in India, including economic and social costs, and the impact on individuals and families.

ETHICS AND DISSEMINATION

Primary ethics approval was received from the Postgraduate Institute for Medical Education and Research, institute's ethics committee, Chandigarh, India. Results will be disseminated via the usual scientific forums including peer-reviewed publications and presentations at international conferences.