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

BACKGROUND: Several studies have linked biomass cooking fuel with adverse pregnancy outcomes such as preterm births, low birth weight and post-neonatal infant mortality, but very few have studied the associations with cooking fuel independent of other factors associated with stillbirths. METHOD: We analyzed the data from 188,917 ever-married women aged 15-49 included in India's 2003-2004 District Level Household Survey-II to investigate the association between household use of cooking fuels (liquid petroleum gas/electricity, kerosene, biomass) and risk of stillbirth. Prevalence ratios (PRs) were obtained using Poisson regression with robust standard errors after controlling for several potentially confounding factors (socio-demographic and maternal health characteristics). RESULTS: Risk factors significantly associated with occurrence of stillbirth in the Poisson regression with robust standard errors model were: literacy status of the mother and father, lighting fuel and cooking fuel used, gravida status, history of previous abortion, whether the woman had an antenatal check up, age at last pregnancy >35 years, labor complications, bleeding complications, fetal and other complications, prematurity and home delivery. After controlling the effect of these factors, women who cook with firewood (PR 1.24; 95% CI: 1.08-1.41, p=0.003) or kerosene (PR 1.36; 95% CI: 1.10-1.67, p=0.004) were more likely to have experienced a stillbirth than those who cook with LPG/electricity. Kerosene lamp use was also associated with stillbirths compared to electric lighting (PR 1.15; 95% CI: 1.06-1.25, p=0.001). The population attributable risk of firewood as cooking fuel for stillbirths in India was 11% and 1% for kerosene cooking. CONCLUSION: Biomass and kerosene cooking fuels are associated with stillbirth occurrence in this population sample. Assuming these associations are causal, about 12% of stillbirths in India could be prevented by providing access to cleaner cooking fuel.

Utility of Prevention of Parent-to-Child Transmission (PPTCT). Programme data for HIV surveillance in general population.

BACKGROUND & OBJECTIVES: HIV sentinel surveillance (HSS) among antenatal clinic (ANC) attendees is used to monitor HIV trends in general population. Recently, information on HIV infection has also become available from prevention of parent-to-child transmission (PPTCT) programmes. Systematic appraisal of routinely collected programme data is needed for choosing a scientific, cost-effective, and ethical surveillance strategy. In this study HIV prevalence estimates obtained from PPTCT programme and HSS were compared to find out the utility of PPTCT programme data for HIV surveillance. METHODS: The data of HSS and PPTCT programme were obtained from National AIDS Control Organization, New Delhi. A list of PPTCT programme sites where ANC HSS was also conducted during 2005 to 2007 was prepared. HIV prevalence and 95 per cent confidence interval (CI) were estimated from antenatal attendees in PPTCT and HSS. Correlation coefficient of HIV prevalence in PPTCT and HSS was also examined according to the level of HIV test acceptance in PPTCT programme. Pregnant women presenting directly for labour in PPTCT centers were not included in the analyses. RESULTS: In 2007, HIV test acceptance ranged from 8 to 100 per cent (average 76%) in 372 sites where both PPTCT and HSS were carried out. HIV prevalence was similar in the PPTCT (0.68%, 95% CI 0.66%, 0.70%) as compared to the HSS (0.61%, 95% CI 0.58%, 0.66%). Overall the correlation of HIV prevalence between PPTCT and HSS was quite high at state level (r = 0.9) but low at district or site level (r = 0.6). INTERPRETATION & CONCLUSIONS: HIV prevalence estimates among pregnant women in PPTCT program were similar to that of ANC HSS. Routinely collected PPTCT program data therefore has potential for providing reliable HIV time trends in various states of India.

Package of essential noncommunicable disease (PEN) interventions in primary health-care settings of Bhutan: a performance assessment study.

BACKGROUND: A World Health Organization (WHO) package of essential noncommunicable (PEN) disease interventions was piloted in two districts of Bhutan by non-physician health workers. They conducted risk assessment among patients aged over 40 years who visited the outpatient department of health institutions. Blood glucose was also measured among those who were overweight/ obese (body mass index ≥23 kg/m2) or had a high waist circumference (>80 cm in women and >90 cm in men). Appropriate counselling, treatment and referral were provided to the patients. The performance of the PEN project in detecting and managing noncommunicable diseases (NCDs) and their risk factors was assessed. METHODS: All health institutions of Paro (one district hospital and three basic health units [BHUs]) and Bumthang districts (one district hospital and four BHUs), were included in the PEN pilot assessment study. All patients who had presented to the clinics in the pilot districts from 1 June to 31 August 2012 constituted the study population. The data were collected from the clinical form, supervisor's report and monthly report of the PEN project. The characteristics of patients with an NCD at registration and at the third follow-up visit were compared in a before-after analysis. Absolute changes in the characteristics of patients were computed for those who had completed the required followups during a 3-month assessment period. RESULTS: In a 3-month period, 39 079 patients had attended clinics in the pilot districts. About 10% of the clinic attendees (3818/39 079) were aged over 40 years; of these, 22.6% (864/3818) had a high blood pressure, and 49.7% (1896/3818) were overweight/obese or had a high waist circumference. Screening of overweight/ obese/high waist circumference cases revealed that 26.1% (494/1896) had high blood sugar levels. Out of the 896 patients who were registered on PEN protocols, 13% had >20% risk of developing cardiovascular diseases (CVDs) in next 10 years as per the WHO/International Society of Hypertension risk-assessment charts. Among 444 who had three follow-up visits, high 10-year-CVD risk (>20%) had declined from 13% to 7.3%. Among 400 persons with hypertension, use of medication increased and high blood pressure declined from 42.3% to 21.5%. Among 115 persons with diabetes, use of anti-diabetes medication increased and high blood sugar declined from 68/100 to 51/100. CONCLUSION: Implementation of the PEN intervention in the primary health-care setting of Bhutan led to improvement in blood pressure and diabetes control, and reduction in CVD risk.

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

BACKGROUND: Although a known risk factor for several respiratory diseases, the relationship between cooking smoke and tuberculosis has not been conclusively established. Hence, a case-control study was conducted among adult women of Chandigarh Union Territory in India. METHODS: Physician-diagnosed cases of sputum positive pulmonary tuberculosis (n=126) and age- and residence area-matched controls (n=252) were enrolled from clinics in urban, rural and slum areas. Interviews were conducted in the clinic using a pretested questionnaire to collect information on type of cooking fuel, education, occupation, socio-economic status, smoking, overcrowding and type of kitchen, etc. The conditional logistic regression model was used for control of confounding. RESULTS: The study population was predominantly in the 20-29-year-old age group (58%) and lived in urban areas (67%). The majority were illiterate (52%) and housewives (93%), and nearly half (46%) had an income of no more than Rs 25 000. Among the cases, 20.6%, 27% and 52.4% used biomass fuel, kerosene and liquid petroleum gas (LPG), respectively, whereas among controls, the respective figures were: 12.3%, 26.2% and 61.5%. The unadjusted OR for biomass fuel compared with LPG was 2.33 (95% CI 1.18 to 4.59, p 0.01). Adjustment for confounding factors (education, type of kitchen, smoking tobacco and TB in a family member) and interaction between cooking fuel and smoker in family revealed an OR of 3.14 (95% CI 1.15 to 8.56, p=0.02) for biomass fuel in comparison with LPG. CONCLUSIONS: Cooking with biomass fuel increases the risk for pulmonary tuberculosis.