Climate uncertainty and vulnerability of urban flooding associated with regional risk using multi-criteria analysis in Mumbai, India

The study made a comprehensive effort to examine climatic uncertainties at both yearly and monthly scales, along with mapping flood risks based on different land use categories. Recent studies have progressively been engrossed in demonstrating regional climate variations and associated flood probability to maintain the geo-ecological balance at micro to macro-regions. To carry out this investigation, various historical remote sensing record, reanalyzed and in-situ data sets were acquired with a high level of spatial precision using the Google Earth Engine (GEE) web-based remote sensing platform. Non-parametric techniques and multi-layer integration methods were then employed to illustrate the fluctuations in climate factors alongside creating maps indicating the susceptibility to floods. The study reveals an increased pattern in LST (Land Surface Temperature) (0.03 °C/year), albeit marginal declined in southern coastal regions (-0.15 °C/year) along with uneven rainfall patterns (1.42 mm/year). Moreover, long-term LULC change estimation divulges increased trends of urbanization (16.4 km2/year) together with vegetation growth (8.7 km2/year) from 2002 to 2022. Furthermore, this inquiry involves numerous environmental factors that influence the situation (elevation data, topographic wetness index, drainage density, proximity to water bodies, slope, and soil properties) as well as socio-economic attributes (population) to assess flood risk areas through the utilization of Analytical Hierarchy Process and overlay methods with assigned weights. The outcomes reveal nearly 55 percent of urban land is susceptible to flood in 2022, which were 45 and 37 percent in 2012 and 2002 separately. Additionally, 106 km2 of urban area is highly susceptible to inundation, whereas vegetation also occupies a significant proportion (52 km2). This thorough exploration offers a significant chance to formulate flood management and mitigation strategies tailored to specific regions during the era of climate change.

Social cost--benefit analysis of solid waste management options with application to Mumbai, India

Managing solid waste continues to be an environmental, technical and economic challenge, especially for developing countries. Though these countries' urban local bodies (ULBs) are moving up the waste management hierarchy, most waste is still openly dumped. One key reason for this choice is the non-accounting of (a) social costs associated with open dumping (OD) and (b) direct/indirect benefits of other options. The current study conducts a complete social cost-benefit analysis (SCBA) comparing OD to sanitary landfilling, composting, bio-methanation, incineration and gasification alternatives. The study finds that when only private costs/benefits are considered, a mix of OD and sanitary landfills is preferred; however, when external costs/benefits are factored in, the mix shifts towards alternatives like incineration and gasification. These learnings from the SCBA are then applied to Mumbai, which generates 9000 tonnes of waste daily. To determine the optimal mix for Mumbai ULB, a constrained optimization exercise is carried out considering the technical feasibility of the alternatives and the ULB's capital budget. The study finds that with the current practice of OD, the net present value (NPV) of the social costs over a 30-year horizon will be over US$ 6-9 billion. However, even if one-fifth of the ULB's capital budget is allocated towards other waste management alternatives, the mix would shift towards sophisticated technologies and the NPV of social costs would reduce to around half that amount.

Types of health service utilization in Mumbai slums: a community-based survey

OBJECTIVE

Sociodemographic factors play a crucial role in shaping the health-seeking behaviors of individuals residing in slum areas, particularly in their choice of healthcare facilities. Recognizing the importance of strengthening the existing healthcare systems, this research project was undertaken with the primary objective of comprehending the health-seeking behaviors among residents of Mumbai's slum dwellings in India. To achieve this goal, a comprehensive cross-sectional community needs assessment was conducted spanning from October 2018 to January 2019.

RESULTS

432 respondents reported utilizing at least one health facility in the past year. They reported using private hospitals (172), public hospitals (208), Community Health clinics [23], or other healthcare services (29). To gain further insights into the factors influencing these choices, logistic regression analysis was conducted. The analysis revealed that being female was found to be negatively associated with the selection of a general practitioner as a preferred healthcare provider. On the other hand, higher levels of education and income were found to have a positive association with the preference for private hospitals. Conversely, these factors were negatively associated with the choice of government hospitals.

PCR Test Positivity and Viral Loads during Three SARS-CoV-2 Viral Waves in Mumbai, India

SARS-CoV-2 polymerase chain reaction (PCR) tests generally report only binary (positive or negative) outcomes. Quantitative PCR tests can provide epidemiological information on viral transmission patterns in populations. SARS-CoV-2 transmission patterns during India's SARS-CoV-2 viral waves remain largely undocumented. We analyzed 2.7 million real-time PCR testing records collected in Mumbai, a bellwether for other Indian cities. We used the inverse of cycle threshold (Ct) values to determine the community-level viral load. We quantified wave-specific differences by age, sex, and slum population density. Overall, PCR positivity was 3.4% during non-outbreak periods, rising to 23.2% and 42.8% during the original (June-November 2020) and Omicron waves (January 2022), respectively, but was a surprisingly low 9.9% during the Delta wave (March-June 2021; which had the largest increase in COVID deaths). The community-level median Ct values fell and rose ~7-14 days prior to PCR positivity rates. Viral loads were four-fold higher during the Delta and Omicron waves than during non-outbreak months. The Delta wave had high viral loads at older ages, in women, and in areas of higher slum density. During the Omicron wave, differences in viral load by sex and slum density had disappeared, but older adults continued to show a higher viral load. Mumbai's viral waves had markedly high viral loads representing an early signal of the pandemic trajectory. Ct values are practicable monitoring tools.

COVID-19 vaccine rollout: data from informal settlements in Harare, Kampala, Lilongwe and Mumbai

While the COVID-19 pandemic's effect on the health of low-income urban communities in the global South has not been insignificant, the results of state responses carried out without full consideration of poverty consequences have been very serious. Vaccination, which supports both health and economic recovery, is one way people can reduce the risk of further exclusion. This field note, drawing on surveys from informal settlements in Harare, Kampala, Lilongwe and Mumbai between August and November 2021 by national affiliates of Slum Dwellers International (SDI), provides a snapshot of how global vaccine inequalities have played out across these cities. We find that access to local vaccine programmes is influenced by both global supply and existing local-level inequities; that a low or unreliable supply, among other factors, limits political will to invest in reaching already underserved communities; and that local context and the heterogeneity of communities are key to understanding low vaccine uptake.

Impact of individual counseling on the knowledge and attitudes of type 2 diabetics regarding diabetic retinopathy: The Aditya Jyot Diabetic Retinopathy in Urban Mumbai Slums Study - Report 3

Purpose

Baseline knowledge and attitudes regarding diabetic retinopathy (DR) have not been previously reported for type 2 diabetes mellitus adults (T2DM) in Dharavi, one of the largest slums in Mumbai. Furthermore, a pre- and post-intervention survey study regarding this topic has not been conducted to date in Dharavi. This pre- and post-intervention survey study analyzes the impacts of DR counseling sessions administered individually on the knowledge and attitudes of T2DM participants recruited from Dharavi.

Methods

Potential subjects (>30 years old) from Dharavi were enrolled by community workers and screened for T2DM. Those with confirmed T2DM were each registered for an individual DR counseling session. A survey was distributed to participants before the counseling session to determine their baseline knowledge and attitudes. The same survey was distributed after the counseling session, and changes in pre- and post-survey responses were analyzed.

Results

Exactly 1718 T2DM study participants were given pre- and post-surveys. Before the counseling, T2DM participants showed low baseline knowledge and attitudes regarding DR, with only 30.8% (530/1718) participants being aware that diabetes can affect the eye. Participants showed significant improvements after the counseling session, with more participants showing willingness to attend DR screenings (pre: 38.3.%, post: 56.8%; P < 0.0001) and more becoming aware that diabetes can affect the eye (90.4%, 1553/1718; P < 0.0001).

Conclusion

Targeted educational interventions for T2DM individuals from the slums of western India, such as Dharavi, can lead to significant improvements in knowledge and attitudes, representing a promising avenue in tackling the burden of avoidable blindness caused by DR in India.

Emergency obstetric referrals in public health facilities: A descriptive study from urban Maharashtra, India

Background

An effective referral system is key to access timely emergency obstetric care. The criticality of referrals makes it necessary to understand its pattern at the health system level. This study aims to document the patterns and primary reasons of obstetric case referral and the maternal and perinatal outcome of the cases in public health institutions in select areas of urban Maharashtra, India.

Methods

The study is based on the health records of public health facilities in Mumbai and its adjoining three municipal corporations. The information on pregnant women referred for obstetric emergencies was collected from patient referral forms of municipal maternity homes and peripheral health facilities between 2016 and 2019. Maternal and child outcome data was obtained from "Received-In" peripheral and tertiary health facilities to track whether the referred woman reached the referral facility for delivery. Descriptive statistics were used to analyze demographic details, referral patterns, reasons of referrals, referral communication and documentation, time and mode of transfer and delivery outcomes.

Results

14% (28,020) women were referred to higher health facilities. The most common reasons for referral were pregnancy-induced hypertension or eclampsia (17%), previous caesarean section (12%), fetal distress (11%) and Oligohydramnios (11%). 19% of all referrals were entirely due to unavailability of human resources or health infrastructure. Non-availability of emergency Operation Theatre (47%) and Neonatal Intensive Care Unit (45%) were the major non-medical reasons for referrals. Absence of health personnel such as anaesthetist (24%), paediatrician (22%), physician (20%) or obstetrician (12%) was another non-medical reason for referrals. Referring facility had a phone-based communication about the referral with the receiving facility in less than half of the cases (47%). 60% of the referred women could be tracked in higher health facilities. Of the tracked cases, 45% women delivered via caesarean section. Most of the deliveries (96%) resulted in live birth outcomes. 34% of the newborns weighed less than 2,500 grams.

Conclusion

Improving referral processes are critical to enhance the overall performance of emergency obstetric care. Our findings emphasize the need for a formal communication and feedback system between referring and receiving facilities. Simultaneously, ensuring EmOC at different levels of health facilities by upgradation of health infrastructure is recommended.

Community transmission of SARS-CoV-2 with B.1.1.7 lineage in Mumbai, India

The B.1.1.7 (Alpha) variant has been detected in Mumbai, India during February 2021. Subsequently, we retrieved 43 sequences from specimens of 51 COVID-19 cases from Mumbai. The sequence analysis revealed that the cases were mainly affected with Alpha variant which suggests its role in community transmission of SARS-CoV-2 in Mumbai, India.

Understanding drug resistance patterns across different classes of antiretrovirals used in HIV-1-infected treatment-Naïve and experienced patients in Mumbai, India

Background

The aim of this study is to find out the proportion of treatment-naïve (Tn) and treatment-experienced (Te) patients experiencing HIV drug resistance (DR) to different classes of antiretrovirals (ARVs) being used for HIV treatment and their in class DR correlation.

Methods

A cross-sectional study was done on 109 HIV patients enrolled at a private hospital in Thane, India, from 2014 to 2019. All patients were tested for CD4 count, viral load, and resistance to ARVs.

Results

Sixty-six patients were Tn and 43 patients were Te. Among Tn and Te patients, the percentage of high-level resistance (HLR) for nonnucleoside reverse transcriptase inhibitors (NNRTI) was 4.55% and 37.8%, respectively, for nucleoside reverse transcriptase inhibitors (NRTI) was 0.43% and 36.4%, respectively. No HLR was observed for protease inhibitors (PIs) among Tn patients, while Te patients showed 2.62% HLR. Tn and Te patients showed high susceptibility for Darunavir (98.48% and 95.34%, respectively) followed by Atazanavir and Lopinavir (96.96%, each and 90.69%, each). Tn patients showed HLR for Lamivudine and Emtricitabine (1.52%, each). Integrase Strand Transfer Inhibitors were susceptible (100%) in both Tn and Te patients. A positive correlation was observed for within class across ARVs.

Conclusion

An increased incidence of HLR was observed for NNRTI as compared to NRTI while PIs and integrase strand transfer inhibitors (INSTIs) demonstrated no HLR in either group of patients. When selecting a regimen for Tn patients consisting of NRTIs + NNRTIs genotypic DR test is essential. While with PIs or INSTIs its optional. Among Te patients, DR testing is recommended for all classes of drugs.

Occurrences and Potential Sources of Halogenated Polycyclic Aromatic Hydrocarbons Associated with PM2.5 in Mumbai, India

Occurrences of chlorinated and brominated polycyclic aromatic hydrocarbons (ClPAHs and BrPAHs, respectively) in fine aerosol particulate matter <2.5 μm in diameter were investigated in urban and suburban sites in Mumbai, India; and the possible sources from association with indicators, such as hopanes, steranes, and trace elements are discussed. The mean concentrations of total ClPAHs and BrPAHs were 0.54 and 0.25 ng/m³ in the urban site and 0.16 and 0.02 ng/m³ in the suburban site during the campaign, respectively. The variations in total Cl-/BrPAH concentrations showed a similar trend between the urban and suburban sites, whereas the composition profiles varied in each air sample. The relationships between the concentrations among individual compounds in the urban site suggest that dominant sources of Cl-/BrPAHs could be common to PAHs but not in the suburban site. Principal component analysis using the data set of certain compounds showed that Cl-/BrPAH concentrations in urban and suburban sites are occasionally driven by specific sources of either coal combustion or traffic emissions. In contrast, most air samples during the campaign could be attributed to a mix of those sources. Environ Toxicol Chem 2022;41:312-320. © 2021 SETAC.

A regression-based three-phase approach to assess outdoor thermal comfort in informal micro-entrepreneurial settings in tropical Mumbai

Urban heat poses a public health risk to the residents of megacities in developing countries because the population spends a significant amount of time outdoors to work and socialize with limited cooling resources. Understanding the drivers of outdoor comfort and heat stress in informal work settings is important to design climate-sensitive outdoor spaces and reduce heat vulnerability. We present outdoor thermal comfort perceptions (OTCPs) of people engaged in outdoor micro entrepreneurial activities in Mumbai using seasonal surveys and biometeorological observations. We propose a three-phase approach to analyze the relative importance of climatic and non-climatic variables for OTCPs. The first phase evaluates the seasonal and intra-neighborhood variation of thermal sensation votes (TSV) with respect to physiological equivalent temperature (PET) and air temperature. Second, we include physiological parameters to evaluate the seasonal and intra-neighborhood variation of overall sensation votes (OSV). Third, we consider aggregated survey responses and include behavioral and perceptual variables to determine their relative significance. We employ three linear modeling techniques to assess model performance in explaining the variability of OTCP using OSV as dependent variable. Results reveal that microclimatic parameters alone are unable to explain the variability of OTCP. Our results yield a neutral PET value (PET_neutral) of 23.75 °C for Mumbai in the winter. PET_neutral was higher for activities at the clothing market compared to other micro entrepreneurial activities. Acclimatization significantly improved comfort in the summer, while evaporative cooling was beneficial in the winter. Further, an ANCOVA and ordinal logistic regressions demonstrate the importance of behavioral attributes (presence in the location, expectation, beverage intake) in explaining the variance in OTCP. Our study also reveals that wind speed and humidity play an important role in shaping overall comfort in the Mumbai neighborhoods.

Towards Integrated Management of Dengue in Mumbai

With increasing urbanisation, the dengue disease burden is on the rise in India, especially in large cities such as Mumbai. Current dengue surveillance in Mumbai includes municipal corporation carrying out specific activities to reduce mosquito breeding sites and the use of insecticides to suppress the adult mosquito populations. Clinical cases remain either underreported or misreported due to the restriction to government clinics, missing the large private health care sector. There is a need for an integrated approach to manage dengue outbreaks in Mumbai. There are various novel strategies available for use that can be utilised to improve disease detection, mosquito surveillance, and control of mosquito-borne diseases. These novel technologies are discussed in this manuscript. Given the complex ecosystem of mosquito-borne diseases in Mumbai, integrating data obtained from these technologies would support the ongoing mosquito control measures in Mumbai.

Linezolid resistance in Mycobacterium tuberculosis isolates at a tertiary care centre in Mumbai, India

Background & objectives:

Linezolid (LZD) is increasingly being used in tuberculosis (TB) treatment. However, LZD resistance has already been reported, which is highly alarming, given its critical therapeutic role. This study was aimed to phenotypically and genotypically assess LZD resistance in Mycobacterium tuberculosis (MTB) isolates at a laboratory in a tertiary care centre in Mumbai, India.

Methods:

A sample of 32 consecutive LZD-resistant MTB isolates identified by liquid culture susceptibility testing was subjected to whole-genome sequencing (WGS) on the Illumina NextSeq platform. Sequences were analyzed using BioNumerics software to predict resistance for 12 antibiotics within 15 min.

Results:

Sixty eight of the 2179 isolates tested for LZD resistance by MGIT-based susceptibility testing (June 2015 to June 2016) were LZD-resistant. Thirty two consecutive LZD-resistant isolates were analyzed by WGS to screen for known mutations conferring LZD resistance. WGS of 32 phenotypically LZD-resistant isolates showed that C154R in the rplC gene and G2814T in the rrl gene were the major resistance determinants.

Interpretation & conclusions:

LZD resistance poses an important risk to the success of treatment regimens, especially those designed for resistant isolates; such regimens are extensively used in India. As LZD-containing regimens increase in prominence, it is important to support clinical decision-making with an improved understanding of the common mutations conferring LZD resistance and their frequency in different settings.

Neighborhood Exposures and Blood Pressure Outcomes: A Cross-Sectional Environmental Study among 19-53 Years-Old Parsis in Mumbai

The correlation between high blood pressure (BP) and urban neighborhood-level environmental determinants is understudied in low-income and middle-income countries (LMICs). We hypothesized that neighborhoods constitute exposures that affect resident-behaviors, metabolism and increased susceptibility to high BP. We studied urban clusters of Mumbai-Parsis (Zoroastrians), a founder population group, to minimize genetic variation and maximize exposure assessment. Participants from four neighborhoods were 19–53 years old and comprised 756 females and 774 males. We recorded healthy BPs (≤120/80 mmHg) in 59%, pre-hypertensive (≥121–139/81–89 mmHg) in 21% and high BP (≥140/90 mmHg) in 21% of the participants. A family history of hypertension had no correlation with high BP. We used the Neighborhood Accessibility Framework to compile a questionnaire in order to collect data on participants’ perception of space, third places, streetscape and experience, land use, connectivity, surveillance, pedestrian safety and public transport. Our results suggested that participants in neighborhoods with poorer BP outcomes reported lower accessibility scores for space, streetscape and experience, third places and connectivity. Our study evaluates how neighborhood-level determinants affect BP outcomes in order to contribute to the body of knowledge on primary preventive measures for high BP in urban LMIC populations. We concluded that neighborhood exposures affect resident-behaviors, which cause metabolic changes and increase susceptibility to high BP.

Impact of COVID-19 pandemic on non-COVID patient's management in urology: a public hospital experience in Mumbai

Background

To evaluate the impact of COVID-19 lockdown on non-COVID urological patient’s management in tertiary care urology centres.

Methods

This is an observational study in which data of patients visiting the urology department of all the MCGM run tertiary care hospitals were recorded for the duration of 1 April 2020 to 31 July 2020 and were compared to data of pre-COVID-19 period of similar duration.

Results

There was a decrease of 93.86% in indoor admissions of urology patients during the COVID-19 lockdown. Indoor admissions for stone disease, haematuria, malignancy accounted for 53.65%, 15.85%, 9.75%, respectively. Elective surgeries had the highest percentage decrease followed by emergency and semi-emergency procedures. There was a reduction of more than 80% in patients attending outpatient clinics. Stone disease and its consequences were the main reasons for visiting outdoor clinics (39%). A substantial number of patients presented with flank and abdominal pain (14.8%) and benign enlargement of the prostate (10.23%). Malignancy accounted for a very small number of patients visiting outdoor clinics (1.58%).

Conclusions

COVID-19 pandemic has a profound impact on patient care and education in Urology. There was more than ninety percent reduction in indoor admissions, operative procedures, and outpatient clinics attendance. Once the pandemic is controlled, there will be a large number of patients seeking consultation and management for urological conditions and we should be prepared for it. Surgical training of urology residents needs to be compensated in near future. Long-term impact on urological patient outcome remains to be defined.

Association Between Air Pollution and COVID-19 Pandemic: An Investigation in Mumbai, India

Spatial hot spots of COVID-19 infections and fatalities are observed at places exposed to high levels of air pollution across many countries. This study empirically investigates the relationship between exposure to air pollutants that is, sulfur dioxide, nitrogen dioxide, and particulate matter (SO2, NO2, and PM10) and COVID-19 infection at the smallest administrative level (ward) of Mumbai City in India. The paper explores two hypotheses: COVID-19 infection is associated with air pollution; the pollutants act as determinants of COVID-19 deaths. Kriging is used to assess the spatial variations of air quality using pollution data, while information on COVID-19 are retrieved from the database of Mumbai municipality. Annual average of PM10 in Mumbai over the past 3 years is much higher than the WHO specified standard across all wards; further, suburbs are more exposed to SO2, and NO2 pollution. Bivariate local indicator of spatial autocorrelation finds significant positive relation between pollution and COVID-19 infected cases in certain suburban wards. Spatial Auto Regressive models suggest that COVID-19 death in Mumbai is distinctly associated with higher exposure to NO2, population density and number of waste water drains. If specific pollutants along with other factors play considerable role in COVID-19 infection, it has strong implications for any mitigation strategy development with an objective to curtail the spreading of the respiratory disease. These findings, first of its kind in India, could prove to be significant pointers toward disease alleviation and better urban living.

Association Between Air Pollution and COVID-19 Pandemic: An Investigation in Mumbai, India

Spatial hot spots of COVID-19 infections and fatalities are observed at places exposed to high levels of air pollution across many countries. This study empirically investigates the relationship between exposure to air pollutants that is, sulfur dioxide, nitrogen dioxide, and particulate matter (SO₂, NO₂, and PM₁₀) and COVID-19 infection at the smallest administrative level (ward) of Mumbai City in India. The paper explores two hypotheses: COVID-19 infection is associated with air pollution; the pollutants act as determinants of COVID-19 deaths. Kriging is used to assess the spatial variations of air quality using pollution data, while information on COVID-19 are retrieved from the database of Mumbai municipality. Annual average of PM₁₀ in Mumbai over the past 3 years is much higher than the WHO specified standard across all wards; further, suburbs are more exposed to SO₂, and NO₂ pollution. Bivariate local indicator of spatial autocorrelation finds significant positive relation between pollution and COVID-19 infected cases in certain suburban wards. Spatial Auto Regressive models suggest that COVID-19 death in Mumbai is distinctly associated with higher exposure to NO₂, population density and number of waste water drains. If specific pollutants along with other factors play considerable role in COVID-19 infection, it has strong implications for any mitigation strategy development with an objective to curtail the spreading of the respiratory disease. These findings, first of its kind in India, could prove to be significant pointers toward disease alleviation and better urban living.

Determinants of stunting among children under 2 years in urban informal settlements in Mumbai, India: evidence from a household census

BACKGROUND

There is limited evidence on the determinants of childhood stunting across urban India or specifically in slum settlements. This study aims to assess the extent of stunting among children under 2 years of age and examine its determinants in informal settlements of Mumbai.

METHODS

Data were collected in 2014-2015 in a post intervention census of a cluster randomized controlled trial to improve the health of women and children. Census covered 40 slum settlements of around 600 households each. A total of 3578 children were included in the study. Mixed effects logistic regression models were used to identify factors associated with stunting.

RESULTS

The prevalence of stunting among children aged 0-23 months was 38%. In the adjusted model, higher maternal education (AOR 0.59; 95% CI 0.42, 0.82), birth interval of at least 2 years (AOR 0.71; 95% CI 0.58, 0.87) and intended conception of the child (AOR 0.80; 95% CI 0.64, 0.99) were associated with lower odds of stunting. Maternal exposure to physical violence (AOR 1.83; 95% CI 1.21, 2.77) was associated with higher odds of being stunted. A child aged 18-23 months had 5.04 times greater odds (95% CI 3.91, 6.5) of being stunted than a child less than 6 months of age. Male child had higher odds of being stunted (AOR 1.33; 95% CI 1.14, 1.54).

CONCLUSIONS

Our findings support a multidimensional aetiology for stunting. The results of the study emphasize the importance of women's status and decision-making power in urban India, along with access to and uptake of family planning and services to provide support for survivors of domestic violence. Ultimately, a multilateral effort is needed to ensure the success of nutrition-specific interventions by focusing on the underlying health and social status of women living in urban slums.

TRIAL REGISTRATION

ISRCTN Register: ISRCTN56183183 , and Clinical Trials Registry of India: CTRI/2012/09/003004.

Using Participatory Learning and Action in a Community-Based Intervention to Prevent Violence Against Women and Girls in Mumbai's Informal Settlements

For over 3 decades, participatory learning and action (PLA) techniques have been prominent in formative and evaluative studies in community-based development programs in the Global South. In this paper, we describe and discuss the use of PLA approaches at the beginning of a community-based program for prevention of violence against women and girls in Mumbai's urban informal settlements. We adapted six PLA techniques as part of a formative community mobilization and rapid needs assessment exercise, addressing perceptions of violence prevalence, sources of household conflict, experiences of safety and mobility, access to services, preferences for service and support, and visualization of an ideal community free from violence. We describe the collaborative process of developing and implementing PLA techniques and discuss its relevance in generating contextual and grounded understandings of violence as well as in identifying factors which can potentially enable and constrain interventions.

Women and Infertility in a Pronatalist Culture: Mental Health in the Slums of Mumbai

Background

Infertility is a global problem, with high prevalence in India. As a pronatalist society, infertility is particularly problematic in India, causing stigma, shame, and blame especially for women. Infertility consequences for women include discrimination, social exclusion, and abandonment, putting them at high risk for mental health distress. Furthermore, mental health is highly stigmatized and specialized care is largely unavailable. Despite the cultural importance of childbearing, research on infertility distress and resulting mental health sequelae is lacking, particularly among low-income women. The purpose of this study is to assess mental health, using validated scales, among Mumbai slum-dwelling women with a history of infertility.

Methods

We conducted a mixed-method, cross-sectional study. A focus group discussion with community health workers (n = 7) informed the development of a comprehensive survey. The survey consisted of validated scales whenever possible, in addition to questions pertaining to women’s sociodemographic and reproductive history. After rigorous forward and back translation, the surveys were conducted as face-to-face structured interviews due to low literacy levels and the research naiveté of our respondents. Interviews were conducted by culturally, linguistically, gender-matched, trained research assistants.

Results

Mumbai slum-dwelling women of reproductive age suffering from infertility (N = 74) participated. Most (85%) women and their husbands (66%) reported previous infertility testing. Participants had elevated mental health distress (anxiety and depression symptomology) largely explained by general health, length of marriage, and coping strategy employed.

Conclusion

Women facing the double stigma of mental health and infertility need innovative programs to address their challenges.

Proposition of Belief and Practice Theory for Men Undergoing Infertility Treatment: A Hospital Based Study in Mumbai, India

The paper aims to understand the treatment seeking behavior and the experiences of men with male factor infertility. A cross-sectional study was conducted at consented hospitals/infertility centers in Mumbai, India in purview of the fact that men are not considered as important as a part of infertility treatment as women. An infertile man is defined here as one who is diagnosed with primary or secondary infertility, undergoing infertility treatment, irrespective of the fertility status of his wife. Primary data of 150 men undergoing infertility treatment from a variety of socioeconomic backgrounds was collected through semi-structured interviews. The initial effect of the infertility status led the men to feel depressed, guilty, shocked, and isolated. A large proportion of the respondents never discussed the problem with anyone except their wives. More than one third of the respondents consulted with Ayurvedic, Unani, Siddha, and Homeopathy (AYUSH) practitioners. Changes of doctors or clinics were more attributed to unsuccessful treatment cycles and success rate of other clinics than the referral by doctors. Destiny, bad luck, lifestyle, medical reasons, and late marriage are found as perceived causes of male infertility. Age above 40, younger age at marriage, marriage duration for 6 and more years, secondary infertility, self-employment, and higher income have significant association with longer time gap between marriage and initiation of infertility treatment. Based on study findings, we propose Belief and Practice theory where we elaborate the progression in treatment for male infertility. Men should be given due consideration in infertility treatment. They must be taken into consideration at an early stage of fertility evaluation due to the fact that minor problems of male infertility can be cured with modest medication. Proper Information Education and Communication (IEC) is essential for creating awareness in society on male infertility. Better counseling services during treatment and standardization of cost can help infertile men to manage treatment-related stress. Since infertility treatment is a time-consuming and exhaustive process, considering the timing for patient's income generating work, evening out patient department, and comprehensive knowledge dissemination at health centers can be improve male factor infertility treatment.

Nine year trends of dengue virus infection in Mumbai, Western India

INTRODUCTION:

Dengue virus (DENV) causes a wide range of diseases in humans, from acute febrile illness Dengue fever (DF) to life-threatening Dengue hemorrhagic fever (DHF) or Dengue shock syndrome (DSS). Factors believed to be responsible for spread of Dengue virus infection include explosive population growth, unplanned urban overpopulation with inadequate public health systems, poor standing water and vector control, climate changes and increased international recreational, business, military travel to endemic areas. All of these factors must be addressed to control the spread of Dengue and other mosquito-borne infections. The detection of Dengue virus RNA by reverse transcriptase PCR (RT-PCR) in human serum or plasma samples is highly indicative of acute Dengue fever. Moreover, the method is able to identify the Dengue virus serotype by demonstrating defined sequence homologies in the viral genomic RNA.

METHODS AND RESULTS:

During the nine year period of this study analysis, 6767 strongly suspected cases were tested by RT-PCR. 1685 (24.9%) were Dengue PCR positive and confirmed as Dengue cases. Observations on the seasonality were based on the nine year's data as the intensity of sampling was at its maximum during monsoon season. Dengue typing was done on 100 positive samples after storage of Dengue RNA at – 80°C. Dengue serotypes were detected in 69 samples of which Dengue 2 was most predominant. 576 samples were processed for NS1 antigen and PCR simultaneously. 19/576 were positive (3.3 %) for NS1 as well as by PCR. 23/576 samples were negative for NS1 antigen, but were positive by RT-PCR. The remaining 534 samples which were negative for NS1 antigen were also negative by Dengue RT-PCR.

CONCLUSION:

In this study we sought to standardize rapid, sensitive, and specific fluorogenic probe-based RT-PCR assay to screen and serotype a representative range of Dengue viruses that are found in and around Mumbai. Qualitative Dengue virus TaqMan assays could have tremendous utility for the epidemiological investigation of Dengue illness and especially for the study of the viremic response with candidate live-attenuated dengue virus vaccines.

Tapping private health sector for public health program? Findings of a novel intervention to tackle TB in Mumbai, India

BACKGROUND

India carries one-fourth of the global tuberculosis (TB) burden. Hence the country has drafted the ambitious National Strategic Plan to eliminate tuberculosis by 2025. To realise this goal, India's Revised National Tuberculosis Control Programme (RNTCP) and partners piloted a novel strategy to engage private-providers for tuberculosis care via a "Private-provider Interface Agency" (PPIA) in Mumbai and other locations.

INTERVENTION

The program mapped and engaged private-providers, chemists, and laboratories; facilitated TB notification via call centers and field staff; provided free tuberculosis diagnostic tests and anti-TB drugs using novel electronic vouchers; monitored quality of care; and supported patients to ensure anti-TB treatment adherence and completion. This report summarises the descriptive analysis of PPIA implementation data piloted in Mumbai from 2014 to 2017.

FINDINGS

The program mapped 8789 private doctors, 3438 chemists, and 985 laboratories. Of these, 3836 (44%) doctors, 285 (29%) laboratories, and 353 (10%) chemists were prioritized and engaged in the program. Over three and a half years, the program recorded 60,366 privately-notified tuberculosis patients, of which, 24,146 (40%) were microbiologically-confirmed, 5203 (9%) were rifampicin-resistant, and 4401 (7%) were paediatric TB patients. Mumbai's annual total TB case notification rate increased from a pre-program baseline of 272 per 100,000/year in 2013 to 416 per 100,000/year in 2017. Overall, 42,300 (78%) patients completed the TB treatment, and 4979 (9%) could not be evaluated.

INTERPRETATION

The PPIA program in Mumbai demonstrated that private-providers can be effectively engaged for TB control in urban India. This program has influenced national policy and has been adapted and funded for a country-wide scale up. The model may also be considered in conditions where private-provider engagement is needed to improve access and quality of care for any area of public health.

Community interventions to prevent violence against women and girls in informal settlements in Mumbai: the SNEHA-TARA pragmatic cluster randomised controlled trial

BACKGROUND

In a cluster randomised controlled trial in Mumbai slums, we will test the effects on the prevalence of violence against women and girls of community mobilisation through groups and individual volunteers. One in three women in India has survived physical or sexual violence, making it a major public health burden. Reviews recommend community mobilisation to address violence, but trial evidence is limited.

METHODS

Guided by a theory of change, we will compare 24 areas receiving support services, community group, and volunteer activities with 24 areas receiving support services only. These community mobilisation activities will be evaluated through a follow-up survey after 3 years. Primary outcomes will be prevalence in the preceding year of physical or sexual domestic violence, and prevalence of emotional or economic domestic violence, control, or neglect against women 15-49 years old. Secondary outcomes will describe disclosure of violence to support services, community tolerance of violence against women and girls, prevalence of non-partner sexual violence, and mental health and wellbeing. Intermediate theory-based outcomes will include bystander intervention, identification of and support for survivors of violence, changes described in programme participants, and changes in communities.

DISCUSSION

Systematic reviews of interventions to prevent violence against women and girls suggest that community mobilisation is a promising population-based intervention. Already implemented in other areas, our intervention has been developed over 16 years of programmatic experience and 2 years of formative research. Backed by public engagement and advocacy, our vision is of a replicable community-led intervention to address the public health burden of violence against women and girls.

TRIAL REGISTRATION

Controlled Trials Registry of India, CTRI/2018/02/012047. Registered on 21 February 2018. ISRCTN, ISRCTN84502355. Registered on 22 February 2018.

Coverage, quality, and correlates of childhood immunization in slums under national immunization program of India: A cross-sectional study

Adequate and quality immunization coverage plays a key role in controlling the outbreaks of vaccine preventable diseases. Places where immunization coverage is low, vaccine preventable diseases contribute to worse health outcomes. This is especially true in Indian slum dwellings where 33.0% of the urban population live. The aim of the study was to explore the coverage, quality, and correlates of primary immunization under national immunization program among children aged 12–23 months, living in slums of Mumbai. A community based cross-sectional survey was conducted. Parents or caretakers of 550 eligible children aged 12–23 months were interviewed using a structured interview schedule. Regression analysis was used to detect correlates of full immunization coverage (children who received one dose each of BCG, measles, and three doses each of DPT, OPV, and HBV by his/her first birthday) and of quality immunization coverage (children who received primary vaccines at appropriate age and intervals as mentioned above and had filled immunization card). Out of total 550 children, 402 (73.1%), 131 (23.8%), and 17 (3.1%) were fully, partially, and unimmunized, respectively. Almost 86.0% children received quality immunization coverage. In the regression analysis, reminder for immunization services was found to be the single most significant correlate of full and quality immunization coverage.

In this study, full immunization coverage was found to be below the expected level. This study also revealed that the awareness regarding the importance of adequate immunization was still lacking in the slum population. Emphasizing on reminders for immunization services, encouraging institutional deliveries, and scaling up use of postnatal care services may act as keys to improving the immunization coverage in Indian slums.

Age estimation and comparison by dental and skeletal maturity in the age range of 9-18 years in the Mumbai region

Background:

Age estimation is crucial in the identification of juveniles in conflicts with law, survivor of sexual assault, sportsperson, and civil cases.

Aims:

To estimate and compare the age (9–18 years) by dental and skeletal maturity in the Mumbai region.

Settings and Design:

This was a cross-sectional study.

Materials and Methods:

A total of 70 cases from 9 to 18 years of age were studied in 1 year in the urban population of the Mumbai region. Among 70 cases, 45 were males and 25 were females. Orthopantomogram and elbow joint radiographs were taken to assess the dental age through modified Demirjian's method and the radiological age through Sangma et al. staging method, respectively.

Statistical Analysis:

Data were analyzed using SPSS Statistics Version 26; descriptive statistics and regression statistics were used in the study.

Results:

Dental age by Demirjian's method in males with standard deviation was 15.25 (2.17), with a mean difference of 1.08 and significant P = 0.03. However, in females, dental age by Demirjian's method with standard deviation was 14.30 (1.94) with a mean difference of 0.74 and insignificant P = 0.07. Interclass correlation coefficient of dental age with chronological age, in males and females, showed 0.85 and 0.87 correlation, respectively. Correlation between the skeletal maturity and the dental age was reflected by the association of Demirjian stage 9 in the second molar with radiological stage 5 in males and stage 4 in females.

Conclusions:

It was concluded that Demirjian's method shows a significant correlation and P value for the age estimation in males of the Mumbai region.

A theory of change for community interventions to prevent domestic violence against women and girls in Mumbai, India

Background: We describe the development of a theory of change for community mobilisation activities to prevent violence against women and girls. These activities are part of a broader program in urban India that works toward primary, secondary, and tertiary prevention of violence and includes crisis response and counselling and medical, police, and legal assistance. Methods: The theory of change was developed in five phases, via expert workshops, use of primary data, recurrent team meetings, adjustment at further meetings and workshops, and a review of published theories. Results: The theory summarises inputs for primary and secondary prevention, consequent changes (positive and negative), and outcomes. It is fully adapted to the program context, was designed through an extended consultative process, emphasises secondary prevention as a pathway to primary prevention, and integrates community activism with referral and counselling interventions. Conclusions: The theory specifies testable causal pathways to impact and will be evaluated in a controlled trial.

Prevalence and Correlates of Undernutrition in Young Children Living in Urban Slums of Mumbai, India: A Cross Sectional Study

Background: Young children living in urban slums are vulnerable to malnutrition and subsequently poor health outcomes, but data on the correlates of stunting, underweight, wasting, and anemia specifically among 10-18 month-old children in India remain limited. Objective: In this analysis, we sought to describe the prevalence of and examine correlates for different markers of undernutrition, including stunting, underweight, and anemia among 10-18 month-old children living in urban slums, an understudied vulnerable group. Methods: Children and their mothers (n = 323) were screened for anthropometry, demographics, and complete blood counts for hemoglobin concentration between March and November 2017 (Clinicaltrials.gov ID: NCT02233764). Correlates included child and mother's age, sex, birth order, birth weight, illness episodes, hemoglobin concentration, family income, maternal height, and maternal education level. Risk ratios (RR, 95% CI) for binary outcomes (stunting, underweight, wasting and anemia) and mean differences (β, 95% CI) for continuous outcomes (anthropometric Z-scores, hemoglobin concentration) were calculated using multivariate binomial and linear regression (SAS 9.4). Results: The prevalence of stunting was 31.2%, underweight 25.1%, wasting (9.0%), and anemia (76%) among all children. Male children had a higher prevalence of poor growth indices and lower anthropometric Z-scores than females. Male sex, low birthweight, shorter maternal height, report of ≥1 episodes of illness within the past month, older maternal age, and birth order ≥2 were also associated with poor growth and anemia in multivariate models. Correlates of undernutrition were different among females and males. Female children had a 40% (20, 60%) higher risk of anemia associated with diarrhea, and male children who were firstborn had a 20% (0, 70%) lower risk of anemia. Conclusions: These results show that poor growth and anemia among young children is prevalent in urban slums of Mumbai, and that sex of the child may play an important role in informing interventions to address undernutrition.

Prevalence of Traumatic Injuries to Anterior Teeth in 9-14 Year School-going Children in Mumbai, India

AIM

The aim of this study is to assess the prevalence and causes of traumatic dental injury (TDI) in 9-14 year school-going children in Mumbai, Maharashtra, India.

MATERIALS AND METHODS

A cross-sectional study consisting of 2,055 primary and secondary school-going children aged between 9 and 14 years, from 20 municipal corporation schools of Mumbai city, was selected through a stratified random sampling technique. Children were examined clinically for any signs of TDI in the permanent anterior teeth in their respective schools by two examiners trained in using WHO criteria for oral and dental examination. Data analysis involved descriptive statistics including a frequency distribution.

RESULTS

The prevalence of TDI to anterior teeth in school children of Mumbai was 16.3%. The commonest cause of trauma was fall followed by sports activities, collision, and road traffic accidents.

CONCLUSION

The occurrence and various etiologies of traumatic injuries to maxillary anterior teeth in school children of Mumbai were approximately the same as found in other countries.

CLINICAL SIGNIFICANCE

The present study gives a bird's eye view on the prevalence and common etiology of TDI in school children of Mumbai.

A theory of change for community interventions to prevent domestic violence against women and girls in Mumbai, India

Background: We describe the development of a theory of change for community mobilisation activities to prevent violence against women and girls. These activities are part of a broader program in urban India that works toward primary, secondary, and tertiary prevention of violence and includes crisis response and counselling and medical, police, and legal assistance. Methods: The theory of change was developed in five phases, via expert workshops, use of primary data, recurrent team meetings, adjustment at further meetings and workshops, and a review of published theories. Results: The theory summarises inputs for primary and secondary prevention, consequent changes (positive and negative), and outcomes. It is fully adapted to the program context, was designed through an extended consultative process, emphasises secondary prevention as a pathway to primary prevention, and integrates community activism with referral and counselling interventions. Conclusions: The theory specifies testable causal pathways to impact and will be evaluated in a controlled trial.

The Department of Neurosurgery, Grant Medical College and Sir J.J Group of Hospitals, Mumbai

The Department of Neurosurgery was founded in the Grant Medical College, Mumbai, in the year 1958, and is celebrating its 60^th anniversary. The history of Neurosurgery in this Institute is synonymous with the history of Neurosurgery in the state as this was one of the first government medical colleges to start a Neurosurgery Department within the state. The students after undergoing their rigorous training in the department, went on to establish advanced neurosurgical centers throughout Maharasthra and in several other parts of the country. The patients opt for this institution to get a standard of care that may be comparable with the highest standards prevalent, and the students achieve their goal of getting excellent education in Neurosurgery at par with the best institutes of the world. The department has, therefore, over the years, established its place in the country as a premier training facility and an epitome of medical excellence. This article traces the illustrious history of the Department of Neurosurgery, Grant Medical College and Sir J.J. Group of Hospitals, Mumbai, and also of the eminent faculty members and residents, who helped in advancing the standards of Neurosurgery in the region as well as the rest of India.

Humanizing an Invisible Population in India: Voices from Bisexual Men Concerning Identity, Life Experiences, and Sexual Health

Research examining the sexual identities, behaviors, and experiences of bisexual men outside of Western contexts (including in India) is limited. Individuals who self-identify as bisexual due to their orientation toward partners of more than one gender face distinct psychosocial challenges relative to exclusively heterosexual, gay/lesbian, or other individuals. We conducted four focus group discussions (n = 22) and in-depth interviews (n = 50) with self-identified bisexual men (age 18 years and older) who were recruited from the metropolitan area of Mumbai, India, between June and August 2013. We triangulated and analyzed focus group and interview data using standard qualitative research techniques. Findings from our study suggest that multiple factors influence the sexual experiences of self-identified bisexual men in Mumbai, including contexts of sexual interactions, sexual positioning, and the gender of sexual partners. Participants described cultural meaning systems and psychosocial dynamics that regulate bisexual identity development, disclosure, and sexual decision making with male, female, and other partners. Secrecy, discretion, and sexual pleasure also influenced sexual behaviors and relationships. Although Western sexual identity categories are not necessarily equivalent in the Indian context, it is interesting and important to note that a number of individuals in India continue to use the identity label of "bisexual." Before developing interventions to meet unique sexual health needs of bisexual men, it is crucial to understand how these men perceive themselves, reconcile the ordinary aspects of their lives with their sexuality, and structure their relationships with partners.

Economic analysis and life cycle impact assessment of municipal solid waste (MSW) disposal: A case study of Mumbai, India

Municipal solid waste (MSW) management is a major concern in Indian cities. This work rigorously assesses the relative costs and the environmental and health benefits of alternative MSW management methods. Management of MSW over the next 20 years for the city of Greater Mumbai was considered. A generic model was developed to determine the costs for (i) dumping on open ground, (ii) sanitary landfill without leachate treatment, (iii) landfilling with leachate treatment and (iv) regional composting and landfilling. LandGEM was used to quantify the gaseous emissions from landfill, while emissions from leachate and composting were taken from literature. The life cycle impact model of one tonne of MSW was developed using OpenLCA software and the International Reference Life Cycle Data System (ILCD) 2011 method was used for impact assessment. The cost of disposal of one tonne of waste was found to be INR344 (US$5.17), INR741 (US$11.13) and INR1367 (US$20.53), respectively, for the first three scenarios. As compared to open dumping, landfill gas flaring reduced the global warming potential by 32% and leachate treatment reduced freshwater ecotoxicity and total human toxicity marginally, by 20% and 60%, respectively. Composting-landfilling was the most preferred option, with a cost of INR531 tonne^-1 (US$7.97), leading to a reduction in global warming potential by 79% and a slight decrease in freshwater ecotoxicity by 64%. Further, emissions due to accidental fires were also quantified. The study provides valuable insights for the selection of MSW management options for large metropolitan cities in developing countries.

Total mercury status in an urban water body, Mithi River, Mumbai and analysis of the relation between total mercury and other pollution parameters

Mercury is a heavy metal which has garnered attention recently in India. Minamata Convention on mercury was established on October 2013 and was joined by India on September 30, 2014. India is seen as a major mercury pollution source after China according to many studies in the past. Various mercury pollution sites that are currently recognized in India are Kodai Lake, Kodaikanal, Tamil Nadu, and Thane Creek, Mumbai. Since 1992, chlor-alkali plants have been regulated to eliminate mercury cell process of manufacturing. Also, medical and health care facilities are discarding mercury-containing equipment and processes. Various anthropogenic sources of mercury to the atmosphere include combustion of fossil fuels, processing and mining of primary metal ores, cement manufacturing units, chlor-alkali plants, and use of mercury in various products like paints, electric switches, and relays. The hazard associated with mercury pollution becomes extremely serious when we consider its ability to be transported over long-range distances. Various atmospheric transport models suggest India and other Asian countries to be a major source of long-range transport of mercury to North America. Considering the hazards of mercury and its widespread presence in our life, a study on mercury pollution in an urban water body is conducted. This study deals with Mithi River located in Mumbai Metropolitan Region (19.0760° N, 72.8777° E) to study the total mercury in water and derive its relationship with other pollution parameters.

Good girls and boys: findings from a cross-sectional survey on adolescent rights, relationships, and sexuality in an urban informal settlement in India

Around 20% of India’s population are adolescents aged 10–19 years. Our objective was to strengthen program interventions on gender equity, health, and participation by gauging adolescents’ levels of understanding and opinions. In a cross-sectional survey, we interviewed 2005 adolescents on their opinions on rights, friendship and sex, sexual refusal and coercion, and communication with family, using a two-stage probability proportional to size sample. Opinions on gender allocations were generally equitable, although females supported clothing proscriptions. Premarital sex, multiple partners, masturbation and non-heterosexual partnerships were frowned upon. Few respondents said that they felt pressure to be sexually active, 79% said that sexual coercion was a form of violence, but 14% of older adolescents said that it would be unreasonable to refuse sex. Our interviews described young people negotiating the terrain between perceived normative expectations and contemporary aspirations, showing limited manoeuvring within assumed gender roles in which family control was prominent.

Poliovirus Excretion in Children with Primary Immunodeficiency Disorders, India

Prolonged excretion of poliovirus can occur in immunodeficient patients who receive oral polio vaccine, which may lead to propagation of highly divergent vaccine-derived polioviruses (VDPVs), posing a concern for global polio eradication. This study aimed to estimate the proportion of primary immunodeficient children with enterovirus infection and to identify the long-term polio/nonpolio enterovirus excreters in a tertiary care unit in Mumbai, India. During September 2014–April 2017, 151 patients received diagnoses of primary immunodeficiency (PID). We isolated 8 enteroviruses (3 polioviruses and 5 nonpolio enteroviruses) in cell culture of 105 fecal samples collected from 42 patients. Only 1 patient with severe combined immunodeficiency was identified as a long-term VDPV3 excreter (for 2 years after identification of infection). Our results show that the risk of enterovirus excretion among children in India with PID is low; however, systematic screening is necessary to identify long-term poliovirus excreters until the use of oral polio vaccine is stopped.

Pathway to care for drug resistant tuberculosis cases identified during a retrospective study conducted in high TB burden wards in Mumbai

Background: Mumbai is witnessing a rising incidence of all forms of drug resistant tuberculosis (DR-TB).

Methods: A population-based, retrospective study was conducted between April and July 2014, in 15 high TB burden wards in Mumbai, to capture the patient pathways to TB care. A total of 23 DR-TB patients were identified and their pathways to access DR-TB care were recorded using semi-structured interviews.

Results: The total DR-TB pathway time of new patients (who did not report any past episode of TB) (180 days; IQR 123,346) was found to be more than twice that of retreatment patients (who reported a past episode of TB) (69 days; IQR 42,128).

Conclusions: The unacceptable delay for diagnosis and treatment of DR-TB in Mumbai advocates for consistent implementation of early screening of patients using rapid gene-based technologies.

Catastrophic costs of treating drug resistant TB patients in a tertiary care hospital in India

BACKGROUND

Private healthcare is choice of point of care for 70% of Indians. Multidrug resistant tuberculosis (MDR-TB) treatment is costly and involves duration as long as 2 years.

AIM

To estimate costs to patients undergoing treatment for MDR-TB.

METHODS

A health-economics questionnaire was administered to 50 consecutive patients who successfully completed ambulatory private treatment for MDR-TB. Direct costs included drug costs, investigations, consultation fees, travel costs, hospitalisation and invasive procedures and cost prior to presentation to us. Indirect costs included loss of income.

RESULTS

Of our cohort of 50 patients, 36 had pulmonary TB while 14 had extra-pulmonary TB (EPTB). 40 had MDR-TB and 10 had XDR-TB. There were 15 males and 35 females. Mean age was 30 years (range 16-61 years). Treatment cost for pulmonary MDR-TB averaged $5723 while it averaged $8401 for pulmonary XDR-TB and $5609 for EPTB. The major expense was due to drug costs (37%) while consultation fees were only 5%. Annual individual income for the cohort ranged from $0 to $63,000 (mean $11,430). On average, the cost of treatment ranged from 2.56% to 180.34% of the annual family income. 34/50 (68%) had total costs greater than 20% of annual family income and 39/50 (78%) had total costs greater than 10% of annual family income. The number of patients with total costs >40% of total family income was 22.

CONCLUSION

MDR-TB in the private sector results in "catastrophic health costs". Financial and social support is essential for patients undergoing treatment for MDR-TB.

A long-term comparative assessment of human health risk to leachate-contaminated groundwater from heavy metal with different liner systems

The handling and management of municipal solid waste (MSW) are major challenges for solid waste management in developing countries. Open dumping is still the most common waste disposal method in India. However, landfilling also causes various environmental, social, and human health impacts. The generation of heavily polluted leachate is a major concern to public health. Engineered barrier systems (EBSs) are commonly used to restrict potentially harmful wastes by preventing the leachate percolation to groundwater and overflow to surface water bodies. The EBSs are made of natural (e.g., soil, clay) and/or synthetic materials such as polymeric materials (e.g., geomembranes, geosynthetic clay liners) by arranging them in layers. Various studies have estimated the human health risk from leachate-contaminated groundwater. However, no studies have been reported to compare the human health risks, particularly due to the leachate contamination with different liner systems. The present study endeavors to quantify the human health risk to contamination from MSW landfill leachate using multiple simulations for various EBSs. To quantify the variation in health risks to groundwater consumption to the child and adult populations, the Turbhe landfill of Navi Mumbai in India has been selected. The leachate and groundwater samples were collected continuously throughout January-September in 2015 from the landfill site, and heavy metal concentrations were analyzed using an inductively coupled plasma system. The LandSim 2.5 Model, a landfill simulator, was used to simulate the landfill activities for various time slices, and non-carcinogenic human health risk was determined for selected heavy metals. Further, the uncertainties associated with multiple input parameters in the health risk model were quantified under a Monte Carlo simulation framework.

You can't burn the house down because of one bedbug: a qualitative study of changing gender norms in the prevention of violence against women and girls in an urban informal settlement in India

Background: The contribution of structural inequalities and societal legitimisation to violence against women, which 30% of women in India survive each year, is widely accepted. There is a consensus that interventions should aim to change gender norms, particularly through community mobilisation. How this should be done is less clear. Methods: We did a qualitative study in a large informal settlement in Mumbai, an environment that characterises 41% of households. After reviewing the anonymised records of consultations with 1653 survivors of violence, we conducted 5 focus group discussions and 13 individual interviews with 71 women and men representing a range of age groups and communities. We based the interviews on fictitious biographical vignettes to elicit responses and develop an understanding of social norms. We wondered whether, in trying to change norms, we might exploit the disjunction between descriptive norms (beliefs about what others actually do) and injunctive norms (beliefs about what others think one ought to do), focusing program activities on evidence that descriptive norms are changing. Results: We found that descriptive and injunctive norms were relatively similar with regard to femininity, masculinity, the need for marriage and childbearing, resistance to separation and divorce, and disapproval of friendships between women and men. Some constraints on women's dress and mobility were relaxing, but there were more substantial differences between descriptive and injunctive norms around women's education, control of income and finances, and premarital sexual relationships. Conclusions: Programmatically, we hope to exploit these areas of mismatch in the context of injunctive norms generally inimical to violence against women. We propose that an under-appreciated strategy is expansion of the reference group: induction of relatively isolated women and men into broader social groups whose descriptive and injunctive norms do not tolerate violence.

A Framework for Assessing Uncertainty Associated with Human Health Risks from MSW Landfill Leachate Contamination

Landfilling is a cost-effective method, which makes it a widely used practice around the world, especially in developing countries. However, because of the improper management of landfills, high leachate leakage can have adverse impacts on soils, plants, groundwater, aquatic organisms, and, subsequently, human health. A comprehensive survey of the literature finds that the probabilistic quantification of uncertainty based on estimations of the human health risks due to landfill leachate contamination has rarely been reported. Hence, in the present study, the uncertainty about the human health risks from municipal solid waste landfill leachate contamination to children and adults was quantified to investigate its long-term risks by using a Monte Carlo simulation framework for selected heavy metals. The Turbhe sanitary landfill of Navi Mumbai, India, which was commissioned in the recent past, was selected to understand the fate and transport of heavy metals in leachate. A large residential area is located near the site, which makes the risk assessment problem both crucial and challenging. In this article, an integral approach in the form of a framework has been proposed to quantify the uncertainty that is intrinsic to human health risk estimation. A set of nonparametric cubic splines was fitted to identify the nonlinear seasonal trend in leachate quality parameters. LandSim 2.5, a landfill simulator, was used to simulate the landfill activities for various time slices, and further uncertainty in noncarcinogenic human health risk was estimated using a Monte Carlo simulation followed by univariate and multivariate sensitivity analyses.

Vertical distribution, composition profiles, sources and toxicity assessment of PAH residues in the reclaimed mudflat sediments from the adjacent Thane Creek of Mumbai

A study on vertical distribution of magnetic susceptibility, carcinogenic and endocrine disrupting PAHs was performed in the reclaimed mudflat sediments adjacent to the Thane Creek of Mumbai. The 5-rings PAHs and ΣC-PAHs were more dominant at 120cm depth contributing 52.23% and 60.19% respectively to ∑PAHs. The average ratio values of LMW/HMW PAHs (0.58); Fla/(Fla+Pyr) (0.50); Ant/(Ant+Phe) (0.50); BaA/(Chry+BaA) (0.48); BaP/BghiP (2.06), Phe/Ant (1.03) and BaA/Chr (0.93) indicate that the PAH contamination might have raised due to inefficient combustion and pyrogenic emissions during the open burning of solid waste in the vicinity. This was further supported by the anthropogenic ferri(o)magnetic loading over the last 100years influencing the Creek sediments. The PAHs toxicity estimation was performed by calculating the toxic equivalent quantity (TEQ) value of 8.62ng TEQ/g which was below the safe level (600ng TEQ/g) suggested by the Canadian risk-based soil criterion for protection of human health.

Economic evaluation of Mumbai and its satellite cancer registries: Implications for expansion of data collection

BACKGROUND

The Mumbai Cancer Registry is a population-based cancer registry that has been in operation for more than five decades and has successfully initiated and integrated three satellite registries in Pune, Nagpur, and Aurangabad, each covering specific urban populations of the Indian state Maharashtra. Data collectors at the satellites perform data abstraction, but Mumbai carries out all other core registration activities such as data analysis and quality assurance. Each of the three satellite registries follows the same data collection methodology as the main Mumbai Cancer Registry. This study examines the cost of operating the Mumbai and its satellite cancer registries.

METHODS

We modified and used the Centers for Disease Control and Prevention's (CDC's) International Registry Costing Tool (IntRegCosting Tool) to collect cost and resource use data for the Mumbai Cancer Registry and three satellites.

RESULTS

Almost 60% of the registration expenditure was borne by the Indian Cancer Society, which hosts the Mumbai Cancer Registry, and more than half of the registry expenditure was related to data collection activities. Across the combined registries, 93% of the expenditure was spent on labor. Overall, registration activities had a low cost per case of 226.10 Indian rupees (or a little less than 4.00 US dollars in 2014 [used average exchange rate in 2014: 1 US $=60 Indian rupees]).

CONCLUSION

The centralization of fixed-cost activities in Mumbai likely resulted in economies of scale in operating the Mumbai and satellite registries, which, together, report on almost 20,000 cancer cases annually. In middle-income countries like India, where financial resources are limited, the operational framework provided by the Mumbai and satellite registries can serve as a model for other registries looking to expand data collection.

Factors Associated with Tobacco Use in Students Attending Local Government Schools in Mumbai, India

Purpose:

Factors associated with ever-use and differences between ever-users and non-users of tobacco among adolescent school students from low income families in Mumbai were assessed.

Materials and Methods:

A self-administered questionnaire, completed by 1918 students from grades 7, 8 and 9 in 12 schools managed by the city municipal corporation in July 2015, gathered data on socio-demographic characteristics, tobacco use and tobacco-related knowledge, attitudes and beliefs.

Results:

Although only 1% of respondents thought tobacco was cool, nearly 35% were unaware of associations between tobacco use and health problems. Male students were almost twice as likely (OR=2.5, P <= 0.05) to have ever used tobacco compared to females and Supari (areca nut) users were eight times more likely (OR=8.99, P < 0.001) than Supari non -users. Tobacco-users were more likely to agree with statements: ‘People who use tobacco have more friends’ (OR=2.8, P = 0.004), ‘Smoking relieves stress’ (OR=5.6, P = 0.002) and ‘It is possible to purchase any tobacco product within 100 yards of school’ (OR=10.8, P < 0.001).

Conclusion:

This study highlights the gains made by tobacco prevention campaigns in that almost all students did not consider tobacco as cool or a stress reliever. However, they still need education about health consequences of tobacco-use. In addition, Supari use has to be addressed in school-based tobacco prevention and cessation initiatives. Furthermore, programs must also address perceptions and norms related to peers and tobacco use and ensure active implementation of existing laws. Such integrated measures will help ensure tobacco-free spaces around schools.

A framework for assessment and characterisation of municipal solid waste landfill leachate: an application to the Turbhe landfill, Navi Mumbai, India

Rapid industrialisation, growing population and changing lifestyles are the root causes for the generation of huge amounts of solid waste in developing countries. In India, disposal of municipal solid waste (MSW) through open dumping is the most common waste disposal method. Unfortunately, leachate generation from landfill is high due to the prolonged and prominent monsoon season in India. As leachate generation rate is high in most of the tropical countries, long-term and extensive monitoring efforts are expected to evaluate actual environmental pollution potential due to leachate contamination. However, the leachate characterisation involves a comprehensive process, which has numerous shortcomings and uncertainties possibly due to the complex nature of landfilling process, heterogeneous waste characteristics, widely varying hydrologic conditions and selection of analytes. In order to develop a sustainable MSW management strategy for protecting the surface and ground water resources, particularly from MSW landfill leachate contamination, assessment and characterisation of leachate are necessary. Numerous studies have been conducted in the past to characterise leachate quality from various municipal landfills; unfortunately, none of these propose a framework or protocol. The present study proposes a generic framework for municipal landfill leachate assessment and characterisation. The proposed framework can be applied to design any type of landfill leachate quality monitoring programme and also to facilitate improved leachate treatment activities. A landfill site located at Turbhe, Navi Mumbai, India, which had not been investigated earlier, has been selected as a case study. The proposed framework has been demonstrated on the Turbhe landfill site which is a comparatively new and the only sanitary landfill in Navi Mumbai.

Trends in mouth cancer incidence in Mumbai, India (1995-2009): An age-period-cohort analysis

INTRODUCTION

Despite tobacco control and health promotion efforts, the incidence rates of mouth cancer are increasing across most regions in India. Analysing the influence of age, time period and birth cohort on these secular trends can point towards underlying factors and help identify high-risk populations for improved cancer control programmes.

METHODS

We evaluated secular changes in mouth cancer incidence among men and women aged 25-74 years in Mumbai between 1995 and 2009 by calculating age-specific and age-standardized incidence rates (ASR). We estimated the age-adjusted linear trend for annual percent change (EAPC) using the drift parameter, and conducted an age-period-cohort (APC) analysis to quantify recent time trends and to evaluate the significance of birth cohort and calendar period effects.

RESULTS

Over the 15-year period, age-standardized incidence rates of mouth cancer in men in Mumbai increased by 2.7% annually (95% CI:1.9 to 3.4), p<0.0001) while rates among women decreased (EAPC=-0.01% (95% CI:-0.02 to -0.002), p=0.03). APC analysis revealed significant non-linear positive period and cohort effects in men, with higher effects among younger men (25-49 years). Non-significant increasing trends were observed in younger women (25-49 years).

CONCLUSIONS

APC analyses from the Mumbai cancer registry indicate a significant linear increase of mouth cancer incidence from 1995 to 2009 in men, which was driven by younger men aged 25-49 years, and a non-significant upward trend in similarly aged younger women. Health promotion efforts should more effectively target younger cohorts.

Sweat, Skepticism, and Uncharted Territory: A Qualitative Study of Opinions on Data Sharing Among Public Health Researchers and Research Participants in Mumbai, India

Efforts to internalize data sharing in research practice have been driven largely by developing international norms that have not incorporated opinions from researchers in low- and middle-income countries. We sought to identify the issues around ethical data sharing in the context of research involving women and children in urban India. We interviewed researchers, managers, and research participants associated with a Mumbai non-governmental organization, as well as researchers from other organizations and members of ethics committees. We conducted 22 individual semi-structured interviews and involved 44 research participants in focus group discussions. We used framework analysis to examine ideas about data and data sharing in general; its potential benefits or harms, barriers, obligations, and governance; and the requirements for consent. Both researchers and participants were generally in favor of data sharing, although limited experience amplified their reservations. We identified three themes: concerns that the work of data producers may not receive appropriate acknowledgment, skepticism about the process of sharing, and the fact that the terrain of data sharing was essentially uncharted and confusing. To increase data sharing in India, we need to provide guidelines, protocols, and examples of good practice in terms of consent, data preparation, screening of applications, and what individuals and organizations can expect in terms of validation, acknowledgment, and authorship.

Prevalence and molecular characterization of Cryptosporidium species in cattle and buffalo calves in Mumbai region of India

Faecal samples of cattle and buffaloes of Mumbai region collected between November 2012 to June 2013 were analysed by conventional and molecular tools to note the prevalence of cryptosporidiosis and species involved in the infection. Conventional analysis viz., direct faecal smear examination, faecal smear examination after normal saline sedimentation, Sheather's floatation and Sheather's floatation sedimentation smear methods demonstrated oocysts of Cryptosporidium in 141 (36.06 %) of 391 samples with higher occurrence in buffaloes (36.99 %) than cattle (34.48 %). Diarrhoeic loose faeces showed higher prevalence (42.07 %) than apparently normal faeces (31.72 %) irrespective of the host species. When data were arranged as per age groups viz., calves of 0-1 month, 1-2 months, 2-3 months and adults, the highest prevalence was noted in the youngest group (47.12 %) declining gradually with the advancing age with lowest (6.25 %) in adults indicating inverse correlation between prevalence rate and age of the host. These differences were statistically significant in case of buffaloes. Cryptosporidium andersoni was tentatively identified by morphometric analysis. By employing molecular tools like nested PCR, PCR-RFLP and sequence analysis of few samples showed good correlation in the identification of species of Cryptosporidium involved in the infection and demonstrated occurrence of C. parvum, C. ryanae and C. bovis. Thus all the four commonly occurring bovine species of Cryptosporidium were encountered in the study area which appears to be a first record reporting the occurrence of Cryptosporidium with species level identification in large ruminants from Western region of India. Additionally, the public health significance of C. parvum was also discussed in light of epidemiological factors pertaining to the region.

Reconstructing communities in cluster trials?

Background

There is growing interest in the ethics of cluster trials, but no literature on the uncertainties in defining communities in relation to the scientific notion of the cluster in collaborative biomedical research.

Methods

The views of participants in a community-based cluster randomised trial (CRT) in Mumbai, India, were solicited regarding their understanding and views on community. We conducted two focus group discussions with local residents and 20 semi-structured interviews with different respondent groups. On average, ten participants took part in each focus group, most of them women aged 18–55. We conducted semi-structured interviews with ten residents (nine women and one man) lasting approximately an hour each and seven individuals (five men and two women) identified by residents as local leaders or decision-makers. In addition, we interviewed two Municipal Corporators (locally elected government officials involved in urban planning and development) and one representative of a political party located in a slum community.

Results

Residents’ sense of community largely matched the scientific notion of the cluster, defined by the investigators as a geographic area, but their perceived needs were not entirely met by the trial.

Conclusion

We examined whether the possibility of a conceptual mismatch between ‘clusters’ and ‘communities’ is likely to have methodological implications for a study or to lead to potential social disharmony because of the research interventions, arguing that it is important to take social factors into account as well as statistical efficiency when choosing the size and type of clusters and designing a trial. One method of informing such a design would be to use existing forums for community engagement to explore individuals’ primary sense of community or social group and, where possible, to fit clusters around them.

Trial registration

ISRCTN Register: ISRCTN56183183 Clinical Trials Registry of India: CTRI/2012/09/003004.