Diethylcarbamazine citrate-fortified salt for lymphatic filariasis elimination in India.

Lymphatic filariasis (LF) is a vector-borne neglected tropical disease, causing permanent disability. The disease is debilitating and widespread, leading to tremendous productivity and economic loss. The Government of India (GOI) prioritized the elimination of LF through the annual mass drug administration (MDA) programme in 2004 and continued with a single dose of diethylcarbamazine citrate (DEC), 6 mg/kg of body weight, plus albendazole annually over a period of 5-6 years. The GOI had set the target to achieve LF elimination by 2015 and now by 2030. The progress so far has been suboptimal. Much remains to be done as about 84 per cent of the total 328 endemic districts are still under MDA. The major challenge in implementing MDA is poor compliance. It is necessary to have a feasible alternative strategy addressing the above challenge to achieve the desired goal of LF elimination. At this juncture, a well-researched approach, i.e. the use of DEC-fortified salt, also advocated by the World Health Organization, as a unique form of MDA, is proposed. As per this strategy, a low dose of DEC (0.2% w/w) is added to the cooking salt at the manufacturing facility of iodized salt and consumed by the LF-endemic communities for about two years. Many examples of successful use of this strategy for LF elimination in small- and large-scale trials have been documented in India and several other endemic countries in the world. Implementing DEC-iodine-fortified salt is a safe, less expensive, more efficient and prompt approach for achieving the elimination of LF in India. Adverse effects are none or minor and self-limiting. The DEC-fortified salt strategy can easily piggyback on the existing countrywide deployment of iodized salt under the National Iodine Deficiency Disorders Control Programme (NIDDCP), which has achieved a great success in reducing iodine-deficiency disorders such as hypothyroidism. This existing robust programme can be leveraged to launch DEC-fortified salt for the community. If implemented appropriately, this strategy will ensure the complete cessation of LF transmission within two years from its introduction. If the said strategy is implemented in 2022, it is expected that India will be able to achieve the LF elimination by 2024, much before the global target of 2030.

A prospective comparison of times to presentation and treatment of regional and remote head and neck patients in North Queensland, Australia.

BACKGROUND/AIM: This study aims to examine differences between outer regional (OR) and remote/very remote (RVR) patients in northern Queensland, Australia in the times taken to receive various aspects of head and neck cancer management. METHODS: Our study prospectively recruited head and neck cancer patients presenting to three North Queensland regional hospitals from January 2009 to January 2011. Data on demographic and cancer-specific details, comorbidities and timing of presentation to various services, were collected using a self-administered questionnaire that included two questions in relation to possible reason for delays to health services. Multivariate linear regression analyses were conducted to assess the effects of various demographic characteristics on time delays. Survival and disease recurrence data were analysed in 2014. RESULTS: One hundred and fifty-eight patients participated. RVR patients had significantly longer median times between diagnosis and first treatment compared with OR patients (P = 0.015). Indigenous patients had significant delays from diagnosis to first treatment (P = 0.013) and visit to first specialist and treatment (P = 0.031) compared to non-Indigenous patients. Longer median times between symptoms and first treatment was associated with low income (P = 0.03) and lower education level (P = 0.04). Disease recurrence was higher for RVR patients compared with OR patients (P = 0.04), without significant differences in overall survival. Possible reasons for delays included patient and professional factors. CONCLUSION: Significant delays in various aspects of head and neck cancer management were associated with remoteness, Indigenous and socioeconomic status. While patient and professional factors could be addressed at local levels, sustainable improvement in outcomes requires a state and national level approach.

Health-related quality of life among Indigenous Australians diagnosed with cancer.

PURPOSE: Health-related quality of life (HRQoL) and associated factors were assessed among 155 Indigenous Australian adult cancer patients 6 months post-diagnosis. METHODS: The Assessment of Quality of Life-4D Questionnaire was used to assess HRQoL. Differences in the median utility score among subgroups of interest were examined using nonparametric tests. Factors associated with excellent HRQoL were assessed through logistic regression. RESULTS: Participants' mean age was 52 years (range 20-78), and the majority were female (60 %), unemployed (72 %), and recruited from outpatients clinics (64 %). Breast cancer (27 %) was the most common diagnosis. The median HRQoL score was 0.62; 14 % of participants reported excellent HRQoL (>0.90). After adjusting for age, admission status, and treatment, excellent HRQoL was more likely among participants of Torres Strait Islander origin [adjusted odds ratio (AOR) 3.68; 95 % CI 1.23-11.01], those living in regional areas (AOR 5.59; 95 % CI 1.42-22.06), and those whose main language spoken at home was not English (AOR 3.60; 95 % CI 1.08-11.99) and less likely among those reporting less contact with Indigenous people (AOR 0.23; 95 % CI 0.68-0.81). CONCLUSION: Assessing HRQoL is important to identifying and improving the length and quality of cancer survivorship, especially in groups that have significantly poorer cancer outcomes, such as Indigenous Australians. Acknowledging the study's observational nature, we found HRQoL was lower than reported for other Australians, and we identified some socio-demographic factors that were associated with excellent HRQoL. Such assessments are an important component of identifying and evaluating appropriate interventions to improve the health and well-being of Indigenous cancer patients.

Remote chemotherapy supervision model for rural cancer care: perspectives of health professionals.

Townsville Cancer Centre (TCC), a tertiary cancer centre in North Queensland, Australia, provides chemotherapy services to surrounding small rural towns using the Queensland Remote Chemotherapy Supervision model (QReCS). Under this model, selected chemotherapy regimens are administered in rural hospitals by rural based generalist doctors and nurses, under the supervision of TCC-based medical oncologists and chemotherapy competent nurses through videoconferencing. We sought to explore the perspectives of health professionals participating in QReCS. This qualitative study used semi-structured interviews with 19 participants, including nine nurses, eight doctors, one rural pharmacist and one administration officer. The interviews were recorded and transcribed. Transcripts were examined using iterative thematic analysis. Four major themes were identified from the data: (1) benefits of the model, (2) enablers of implementation, (3) operational requirements for optimal functioning and (4) disadvantages of the model. The reported benefits of the model were patient convenience, inter-professional communication across health district borders, expanded scope of practice, continuity of care and maintenance of patient safety and compliance with guidelines while delivering chemotherapy. Further improvements in the quality of training for rural nurses, coordination between urban and rural sites and between health professionals and documentation of clinical encounters would optimise the operation of the model. QReCS appears to provide many benefits to patients and health professionals and a framework for safe administration of chemotherapy in rural areas. Coordination of care, the quality of training for rural nurses as well as clinical documentation needs to improve to optimise the operation of the model.

Dengue vector abundance and diversity of breeding habitats in Puducherry, South India.

Puducherry had reported regular dengue outbreaks since 2003 with many-fold increase in number of cases every year. This study was done to assess the intensity of dengue vector breeding and diversity of breeding habitats. Aedes surveys were conducted in 8 Primary Health Centres (PHCs) representing both rural and urban areas of Puducherry district throughout the year 2012. Containers inside and outside randomly (simple) selected houses and vacant sites around houses were examined for presence of Aedes mosquitoes. The containers containing water with immature larvae were designated as positive containers (PC), while the containers holding only water were designated as wet containers and all the larvae/pupae from the positive containers were collected and entomological indices were determined using standard WHO methods. The vectors, Aedes aegypti and Ae. albopictus were encountered in the survey, with Ae. aegypti present in high numbers in urban as well as rural areas. The plastic containers were found as the most productive indoor breeding habitat as the 27.2% of the total pupae collected was contributed by plastic containers followed by flower vase (22.8%) and grinding stone (17.6%). Larval indices were found to vary throughout the year and highest indices were recorded during the months of October and November indicating the potential risk of dengue fever during this period.

Community knowledge, awareness and preventive practices regarding dengue fever in Puducherry - South India.

OBJECTIVES: To ascertain the knowledge, attitudes and practices of adult population in Puducherry, India, regarding Dengue Fever (DF). STUDY DESIGN: A cross-sectional survey was carried out to assess the Knowledge, Awareness and Preventive practices (KAP) among a selected community in Puducherry on DF, following a major dengue outbreak in 2012. METHODS: Between October 2012 & February 2013, an epidemiological survey was conducted among 400 households (HHs) from the most affected areas during dengue outbreak, which came under eight health delivery jurisdictions i.e. Primary Health Centres (PHCs) in Puducherry. Knowledge of dengue and the use of preventive measures were assessed by means of a pre-tested structured questionnaire. Logistic regression analysis was done to examine the association between different levels of education and income status with the knowledge of DF. The DF knowledge map was created based on the results achieved through the questionnaire using Arc GIS 10.2 software. RESULTS: Although about 86% of the participants had heard of dengue, although there was no adequate knowledge on dengue vector breeding habitat as 68% of the respondents thought drains & garbage as breeding places of dengue vectors. Only 25% of participants were aware of clean water as a breeding habitat. Insufficient knowledge of disease symptoms was found, with fever (59%) being the most common symptom. CONCLUSIONS: There is a lack of in-depth knowledge on dengue epidemiology in the Puducherry community and observation revealed that more needs to be done by the Government as well as community members to prevent vector mosquito breeding.

Are teleoncology models merely about avoiding long distance travel for patients?

Teleoncology models are used increasingly throughout the world as a means to provide access to quality cancer care for people in rural, remote and other disadvantaged settings. Some authors have suggested that teleoncology is merely about avoiding long distance travel. In this commentary we argue that the benefits of teleoncology extend beyond those of the patients and their families to the rural health system and beyond. We draw upon the literature and results of an evaluation of the Townsville Teleoncology Network (TTN) in North Queensland, Australia to support our arguments.

Practical aspects of telehealth: establishing telehealth in an institution.

The fifth in a series of papers on practical aspects of telehealth, this paper discusses telehealth models that can facilitate the provision of specialist services to rural and remote patients closer to home. Some of the barriers to successful implementation of these models relates to workforce, funding and infrastructure at rural sites, as well as the traditional mindset of healthcare professionals. Therefore, the rural sector needs to be adequately resourced for telehealth models to be substantive and successful. This paper describes the development of a large teleoncology network over a vast geographical area in North Queensland. Adequate resourcing for the rural sites and undertaking quality improvement activities has continually enhanced the model over a 5- to 6-year period. The benefits of this model of care are twofold: (i) patients received their care closer to home and (ii) the workforce, service capabilities and infrastructure for the hospital in Mt Isa (a rural town 900 km away from its tertiary centre) has improved.

Practical aspects of telehealth: doctor-patient relationship and communication.

The fourth in a series of articles about the practical aspects of telehealth, this paper provides advice and information for specialists to communicate effectively with patients during a telehealth video consultation.

Predatory potential of Platynectes sp. (Coleoptera: Dytiscidae) on Aedes albopictus, the vector of dengue/chikungunya in Kerala, India.

Unused and discarded latex collection containers (LCCs) are the major breeding habitats of Aedes albopictus in the rubber plantations of Kerala, India. Platynectes sp. (Family: Dytiscidae) was observed to invade these habitats during the monsoon season and voraciously devour the larval instars of this major vector species of arbo-viral diseases. Field observations showed a reduction of 70.91% (p = 0.0017) and 100% in Aedes larval density, on the first and four days post release of eight beetles per LCC respectively. In laboratory, a beetle was found to devour 17.75 + 5.0 late larval instars of Ae. albopictus per day. Our findings indicate Platynectes sp. could be a potential bio-control agent against Ae. albopictus, the vector of chikungunya/dengue fevers, in rubber plantations.

Practical aspects of telehealth: set-up and preparation for video consultations.

The third in a series of articles about the practical aspects of telehealth, this paper gives guidance on suitable setup for video consultations, including layout of rooms, managing sound and image quality, scheduling, testing and best practice in telehealth videoconferencing.

Practical aspects of telehealth: financial considerations.

The second in a series of articles about the practical aspects of telehealth, this paper includes information and a case history on the cost-benefits for patients and practitioners using telehealth. The case history demonstrates that telehealth can save travel time for patients, carers and specialists, and can reduce out-of-pocket expenses. The practical aspects of telehealth article series considers the contextual, clinical, technical and ethical components of online video consultations.

Practical aspects of telehealth: are my patients suited to telehealth?

The first in a series of articles that demonstrate the practical aspects of telehealth, this paper provides three case studies that examine the suitability of telehealth for patients living in rural and remote areas who require ongoing specialist care.

DNA Barcodes indicate members of the Anopheles fluviatilis (Diptera: Culicidae) species complex to be conspecific in India.

Anopheles fluviatilis, a major vector of malaria in India has been described as a complex of three sibling species members, named as S, T and U, based on variations in chromosomal inversions. Also, ribosomal DNA markers (repetitive Internal Transcribed Spacer 2 (ITS2) and 28S D3 region) were described to differentiate these three sibling species members. However, controversies prevail on the genetic isolation status of these cryptic species. Hence, we evaluated this taxonomic incongruence employing DNA barcoding, the well established methodology for species identification, using 60 An. fluviatilis sensu lato specimens, collected from two malaria endemic eastern states of India. These specimens were also subjected to sibling species characterization by ITS2 and D3 DNA markers. The former marker identified 31 specimens among these as An. fluviatilis S and 21 as An. fluviatilis T. Eight specimens amplified DNA fragments specific for both S and T. The D3 marker characterized 39 specimens belonging to species S and 21 to species T. Neither marker identified species U. Neighbor Joining analysis of mitochondrial cytochrome c oxidase gene 1 sequences (the DNA barcode) categorized all the 60 specimens into a single operational taxonomic unit, their Kimura 2 parameter (K2P) genetic variability being only 0.8%. The genetic differentiation (FST ) and gene flow (Nm ) estimates were 0.00799 and 62.07, respectively, indicating these two 'species' (S & T) as genetically con-specific intermixing populations with negligible genetic differentiation. Earlier investigations have refuted the existence of species U. Also, this study demonstrated that An. fluviatilis and the closely related An. minimus could be taxonomically differentiated by the DNA Barcode approach (K2P = 5.0%).

Genetic characterization of dengue viruses prevalent in Kerala State, India.

Dengue fever is re-emerging as a major scourge in south-east Asian countries, affecting about 50-100 million people and causing about 25,000 deaths annually. The Indian population as a whole is at risk of succumbing to this disease. This study genetically characterized viruses causing dengue infection in Kerala, one of the worst affected states of the country, during the disease outbreaks in 2008-2010. All four serotypes of dengue virus (DENV), DENV-1, DENV-2, DENV-3 and DENV-4, were found to be prevalent in the state. The genotypes recognized for these were III, IV, III and I, respectively. Phylogenetic analysis showed that the re-emergence of serotype DENV-4 reported in Maharashtra and Andhra Pradesh recently is spreading to different regions of the country. The circulation of all four DENV serotypes in Kerala may lead to an increase in the prevalence of more severe complications of this emerging disease, such as dengue haemorrhagic fever and dengue shock syndrome.

Is intensive chemotherapy safe for rural cancer patients?

BACKGROUND: To provide equality of cancer care to rural patients, Townsville Cancer Centre administers intensive chemotherapy regimens to rural patients with node-positive breast and metastatic colorectal cancers at the same doses as urban patients. Side-effects were usually managed by rural general practitioners locally. AIM: The aim is to determine the safety of this practice by comparing the profile of serious adverse events and dose intensities between urban and rural patients at the Townsville Cancer Centre. METHOD: A retrospective audit was conducted in patients with metastatic colorectal and node-positive breast cancers during a 24-month period. Fisher's exact test was used for analysis. Rurality was determined as per rural, remote and metropolitan classification. RESULTS: Of the 121 patients included, 70 and 51 patients had breast and colon cancers respectively. The urban versus rural patient split among all patients, breast and colorectal cancer subgroups was 68 versus 53, 43 versus 27 and 25 versus 26 respectively. A total of 421 cycles was given with dose intensity of >95% for breast cancer in both groups (P > 0.05). Rate of febrile neutropenia was 9.3% versus 7.4% (P = 0.56). For XELOX, rate of diarrhoea was 20% versus 19% (P = 0.66) and rate of vomiting was 20% versus 11% (P = 0.11). Only two patients were transferred to Townsville for admission. No toxic death occurred in either group. CONCLUSION: It appears safe to administer intensive chemotherapy regimens at standard doses to rural patients without increased morbidity or mortality. Support for general practitioners through phone or videoconferencing may reduce the safety concerns.

Telerheumatology: an idea whose time has come.

Australia is a vast country with one-third of the population living outside capital cities. Providing specialist rheumatologist services to regional, rural and remote Australians has generally required expensive and time-consuming travel for the patient and/or specialist. As a result, access to specialist care for remote Australians is poor. Rheumatoid arthritis is a common disease, but like many rheumatic diseases, it is complex to treat. Time-dependent joint damage and disability occur unless best evidence care is implemented. The relatively poor access to rheumatologist care allotted to nonmetropolitan Australians therefore represents a significant cause of potentially preventable disability in Australia. Telehealth has the potential to improve access to specialist rheumatologists for patients with rheumatoid arthritis and other rheumatic diseases, thereby decreasing the burden of disability caused by these diseases. Advances in videoconferencing technology, the national broadband rollout and recent Federal government financial incentives have led to a heightened interest in exploring the use of this technology in Australian rheumatology practice. This review summarises the current evidence base, outlines telehealth's strengths and weaknesses in managing rheumatic disease, and discusses the technological, medicolegal and financial aspects of this model of care. A mixed model offering both face-to-face and virtual consultations appears to be the best option, as it can overcome the barriers to accessing care posed by distance while also mitigating the risks of virtual consultation.

Medical oncology clinics through videoconferencing: an acceptable telehealth model for rural patients and health workers.

BACKGROUND: Since 2007, Townsville Cancer Centre (Queensland, Australia) has provided routine and urgent medical oncology services to rural and remote communities through videoconferencing. At remote sites, patients were accompanied by doctors and other health workers. The aim of this study was to describe satisfaction of patients and rural health workers with this model of teleoncology. METHODS: Between May 2007 and June 2010, 55 videoconferencing patients were invited to participate in a questionnaire-based telephone survey after informed consent. The survey included responses to 16 satisfaction statements using a 5-point Likert scale. Perspectives of health workers involved were recorded using open-ended questions on six themes related to telehealth. RESULTS: Among the 50 participating cancer patients, median age was 56 years (range 28-83). Seventy-six per cent of patients thought specialist physical examination was important despite local doctors performing it. Seventy-six per cent of patients felt the presence of accompanying local health workers was not important. Seventy-eight per cent of patients preferred to be seen in Mt Isa for the first consultation through videoconferencing than travelling to Townsville. More than 80% of patients were in agreement with the rest of the satisfaction statements. Ninety-six per cent of patients were in agreement with the question relating to overall satisfaction. Eighteen health workers participated and their responses and attitudes were favourable towards telehealth. CONCLUSION: Satisfaction with this model of care was proven to be high among both patients and health workers. Benefits perceived included effective communication between patients and specialists, reduced travel time and money expenditure, and superior specialist support for rural health workers.