Emerging & re-emerging infections in India: an overview.

The incidence of emerging infectious diseases in humans has increased within the recent past or threatens to increase in the near future. Over 30 new infectious agents have been detected worldwide in the last three decades; 60 per cent of these are of zoonotic origin. Developing countries such as India suffer disproportionately from the burden of infectious diseases given the confluence of existing environmental, socio-economic, and demographic factors. In the recent past, India has seen outbreaks of eight organisms of emerging and re-emerging diseases in various parts of the country, six of these are of zoonotic origin. Prevention and control of emerging infectious diseases will increasingly require the application of sophisticated epidemiologic and molecular biologic technologies, changes in human behaviour, a national policy on early detection of and rapid response to emerging infections and a plan of action. WHO has made several recommendations for national response mechanisms. Many of these are in various stages of implementation in India. However, for a country of size and population of India, the emerging infections remain a real and present danger. A meaningful response must approach the problem at the systems level. A comprehensive national strategy on infectious diseases cutting across all relevant sectors with emphasis on strengthened surveillance, rapid response, partnership building and research to guide public policy is needed.

Contribution of medical colleges to tuberculosis control in India under the Revised National Tuberculosis Control Programme (RNTCP): lessons learnt & challenges ahead.

Medical college faculty, who are academicians are seldom directly involved in the implementation of national public health programmes. More than a decade ago for the first time in the global history of tuberculosis (TB) control, medical colleges of India were involved in the Revised National TB Control Programme (RNTCP) of Government of India (GOI). This report documents the unique and extraordinary course of events that led to the involvement of medical colleges in the RNTCP of GOI. It also reports the contributions made by the medical colleges to TB control in India. For more than a decade, medical colleges have been providing diagnostic services (Designated Microscopy Centres), treatment [Directly Observed Treatment (DOT) Centres] referral for treatment, recording and reporting data, carrying out advocacy for RNTCP and conducting operational research relevant to RNTCP. Medical colleges are contributing to diagnosis and treatment of human immunodeficiency virus (HIV)-TB co-infection and development of laboratory infrastructure for early diagnosis of multidrug-resistant and/or extensively drug-resistant TB (M/XDR-TB) and DOTS-Plus sites for treatment of MDR-TB cases. Overall, at a national level, medical colleges have contributed to 25 per cent of TB suspects referred for diagnosis; 23 per cent of 'new smear-positives' diagnosed; 7 per cent of DOT provision within medical college; and 86 per cent treatment success rate among new smear-positive patients. As the Programme widens its scope, future challenges include sustenance of this contribution and facilitating universal access to quality TB care; greater involvement in operational research relevant to the Programme needs; and better co-ordination mechanisms between district, state, zonal and national level to encourage their involvement.

Pneumonia in South-East Asia Region: public health perspective.

Globally, pneumonia is the leading cause of death in young children and burden of disease is disproportionately high in South-East Asia Region of WHO. This review article presents the current status of pneumonia disease burden, risk factors and the ability of health infrastructure to deal with the situation. Literature survey was done for the last 20 years and data from country offices were also collected. The estimated incidence of pneumonia in under five children is 0.36 episodes per child, per year. Risk factors are malnutrition (40% in India), Indoor air pollution, non-breast feeding, chronic obstructive pulmonary disease, etc. Strengthening of health care delivery system for early detection and treatment and as well as minimization of preventable risk factors can avert a large proportion of death due to pneumonia.

Tobacco use: a major risk factor for non communicable diseases in South-East Asia region.

Tobacco use is a serious public health problem in the South East Asia Region where use of both smoking and smokeless form of tobacco is widely prevalent. The region has almost one quarter of the global population and about one quarter of all smokers in the world. Smoking among men is high in the Region and women usually take to chewing tobacco. The prevalence across countries varies significantly with smoking among adult men ranges from 24.3% (India) to 63.1% (Indonesia) and among adult women from 0.4% (Sri Lanka) to 15% (Myanmar and Nepal). The prevalence of smokeless tobacco use among men varies from 1.3% (Thailand) to 31.8% (Myanmar), while for women it is from 4.6% (Nepal) to 27.9% (Bangladesh). About 55% of total deaths are due to Non communicable diseases (NCDs) with 53.4% among females with highest in Maldives (79.4%) and low in Timor-Leste (34.4%). Premature mortality due to NCDs in young age is high in the region with 60.7% deaths in Timor Leste and 60.6% deaths in Bangladesh occurring below the age of 70 years. Age standardized death rate per 100,000 populations due to NCDs ranges from 793 (Bhutan) and 612 (Maldives) among males and 654 (Bhutan) and 461 (Sri Lanka) among females respectively. Out of 5.1 millions tobacco attributable deaths in the world, more than 1 million are in South East Asia Region (SEAR) countries. Reducing tobacco use is one of the best buys along with harmful use of alcohol, salt reduction and promotion of physical activity for preventing NCDs. Integrating tobacco control with broader population services in the health system framework is crucial to achieve control of NCDs and sustain development in SEAR countries.

Epidemiological and behavioural correlates of drug-resistant tuberculosis in a Tertiary Care Centre, Delhi, India.

BACKGROUND: Multidrug-resistant tuberculosis (MDR-TB) is a major public health challenge in India. It is associated with poor treatment outcomes, multiple adverse effects to treatment and involves enormous social and economic losses. The objective of the study was to ascertain the epidemiological and behavioural correlates contributing to drug resistance among patients admitted in a tertiary hospital in Delhi with drug-resistant TB (DR-TB). METHODOLOGY: A descriptive cross-sectional study was carried out during the period of July-November 2013 at the Rajan Babu Institute of Pulmonary Medicine and Tuberculosis (RBIPMT), Delhi. All patients admitted with DR-TB for treatment were interviewed regarding social, demographic, and treatment aspects, using a semi-structured questionnaire. Their medical records were also reviewed. RESULTS: A total of 250 patients were included in the study; 198 (79.2%) with multidrug-resistant (MDR-TB) and 52 (20.8%) with extensively drug-resistant TB (XDR-TB). Of these, 66% patients were male and 46% came from poor socioeconomic background. All the patients had history of receiving anti-tubercular treatment (a mean of 2.3 times, range 1-6 times) before the current diagnosis of DR-TB. While 81 (32%) took treatment from private practitioner during the first episode of TB, 146 (58%) received treatment exclusively at government health facilities. Almost 87% of DR-TB patients were previously treated with category-II under RNTCP. Irregularity of treatment was reported by 88 (35%) patients. CONCLUSION: The study explores the epidemiological and behavioural correlates among the patients with drug-resistant TB. History of previous treatments for TB was a common feature among all the enrolled patients. The fact that more than half of DR-TB patients received anti-tubercular treatment exclusively in government facilities is a matter of concern. There is an urgent need to ensure treatment adherence through improved quality in service delivery in public sector and strong linkage with the private sector. Health education and patient counseling is needed to address personal level risk factors and to ensure treatment adherence.

Can visceral leishmaniasis be eliminated from Asia?

Data on the burden of visceral leishmaniasis (VL) in Indian sub-continent are vital for elimination programme planners for estimating resource requirements, effective implementation and monitoring of elimination programme. In Indian sub-continent, about 200 million population is at risk of VL. Nearly 25,000-40,000 cases and 200-300 deaths are reported every year, but these are grossly underestimates. Recent well-designed multicentric studies identified VL burden of 21 cases/10,000 among sampled population in Indian sub-continent (Bangladesh, India and Nepal). This estimates 4,20,000 cases per 200 million risk population clearly indicating that the disease is highly under-reported. Chemical and environmental vector control studies show that the indoor residual spraying (IRS) and long-lasting insecticidal nets (LLINs) are effective and significantly reduce sandfly densities. The findings documented from different sources revealed that some gaps and weakness in existing policies for introducing VL vector control interventions. Our studies emphasize the need of integrated vector management with both IRS and LLIN vector control interventions. Active case detection with rK39 strip test as diagnostic tool is the key element for detection of VL cases. The use of oral drug miltefosine for the treatment after assessing feasibility at community level is important. Kala-azar elimination in Indian sub-continent is possible if elimination programmes ensure access to health care and prevention of kala-azar for people at risk with particular attention to the poorest and marginalized groups. The evidence-based policy should be designed that motivates to implement the programmes, which will be cost-effective. Maintaining the acceptable level of incidence requires public awareness, vector control, appropriate diagnosis and treatment. The five pillars of VL elimination strategies identified are: early diagnosis and complete treatment; integrated vector management and vector surveillance; effective disease surveillance through passive and active case detection; social mobilization and building partnerships; and clinical and operational research which need to be re-enforced to effective implementation.

Risk factors for HIV transmission in India.

PIP: HIV was introduced in India much later than in other parts of the world, but is spreading with unprecedented rapidity and is becoming a public health problem with enormous social and economic implications. HIV in India is spread mainly through heterosexual intercourse, moving from high-risk behavior populations to the general population as indicated by the growing HIV prevalence among voluntary blood donors and women attending antenatal clinics. The main risk behaviors and practices associated with a higher risk of HIV transmission in India include unprotected sexual intercourse, IV drug use, and transfusion of contaminated blood and blood products. Factors affecting the sexual transmission of HIV include the presence of ulcerative STDs, irregular use of condoms, frequency of sexual contact, and age at sexual initiation. Knowledge, attitudes, and beliefs about sexual practices, low literacy, and economic conditions also affect high-risk sex behaviors. The authors discuss the historical perspective on HIV/AIDS in India, heterosexual transmission, IV drug use, blood transfusion and blood products, transmission in the healthcare system, perinatal transmission of HIV, homosexuality, and homosexual and bisexual behavior. Though openly tolerated by society, sex between men is common in India. There are few data on HIV prevalence among homosexual men. The risk of HIV transmission among homosexual men could be high because only 0-21% use condoms. Homosexual liaisons are short-lived, especially among bisexuals.^ieng

AIDS in the Americas: a public health priority for the region.

PIP: 156 countries have reported over 250,000 AIDS cases to the WHO. Taking underreporting into account in developing countries, this figure grows to over 600,000 with 300,000 deaths. HIV-1 infection rates are estimated at between 5-10 million people. Projections indicate that there will be 5 million AIDS cases by 2000. AIDS is an unprecedented health problem that has enormous social, political, medical, and economic implications. The Americas account for 61% of the total cases reported to the WHO. Of the 46 countries in the Americas there have been 153,720 cases reported as of May 1, 1990. 96% of these cases were reported in the US, Brazil, Canada, Haiti, and Mexico. The geographic distribution of AIDS is not homogeneous because of a variety of factors. It was not introduced simultaneously in all countries; some were exposed later than others. Some countries have better detection systems. Excluding North America, the English-speaking Caribbean countries account for only 2% of the population, while the Latin Caribbean countries have 6%, yet they have 10% and 21% of the cases, respectively. Sexual transmission patterns reveal that bisexual men are the largest bridge between the homosexual and heterosexual community, not IV drug users. Studies show that blood donors who are paid are 18 times more likely to be HIV-1 positive in some areas. As AIDS prevalence increases in the heterosexual community, the rate of perinatal transmission also increases. This in turn increases the infant mortality rate because of increases in pediatric AIDS cases. Pediatric cases currently threaten much of the progress that has been made in developing countries in lowering the infant mortality rate. If this pandemic is to be stopped, prevention efforts must be increased as well as a shift in resources at the local, national, and global levels to find some effective method of containment.^ieng

HIV and AIDS in Asia and the Pacific: an epidemiological overview.

PIP: The authors define for the purpose of this overview Asia and the Pacific to be the 46 countries and other administrative areas belonging to the Southeast Asia and Western Pacific regions of the World Health Organization. Defined as such, 55% of the world's population lives in the Asia-Pacific region. China, India, and Indonesia, three of the four most populous countries in the world, are part of the region. The region is highly diverse with highly diverse systems in place to monitor the course of the HIV epidemic. This diversity makes it difficult to develop an accurate picture of the epidemiology of HIV and AIDS in Asia and the Pacific. Despite underreporting and data of varying quality, one may reasonably conclude on the basis of available evidence that countries overall in Asia and the Pacific are in a relatively early stage of the HIV/AIDS epidemic. Reported modes of transmission vary widely and include heterosexual sexual contact, homosexual sexual contact, IV drug use, the receipt of blood products, and mother-to-child transmission. A cumulative total of 851,628 AIDS cases had been reported to the World Health Organization (WHO) by December 31, 1993. Reports from the Asia-Pacific region represent 1% of that total. The WHO estimates that there have been more than 3 million AIDS cases and 14 million infections in adults worldwide since the beginning of the epidemic, while other estimates are substantially higher. The Asia-Pacific region accounts for 3% of the estimated AIDS cases, but 15% of the total estimated HIV infections, indicating the relatively recent arrival of the epidemic to that part of the world. The authors discuss HIV case reporting, surveys of HIV prevalence, risk factors for HIV infection, geographic patterns of HIV transmission, molecular and clinical epidemiology, and the future of the HIV epidemic in Asia and the Pacific.^ieng

Preventive chemotherapy for HIV-associated tuberculosis in Uganda: an operational assessment at a voluntary counselling and testing centre.

OBJECTIVE: To assess the operational aspects of isoniazid preventive chemotherapy (IPT) for tuberculosis in persons dually infected with HIV and Mycobacterium tuberculosis identified at an independent HIV voluntary counselling and testing centre in Kampala, Uganda. DESIGN: HIV-infected persons were counselled, had active tuberculosis excluded by medical examination, and were offered purified protein derivative (PPD) skin testing. PPD-positive persons were offered isoniazid 300 mg daily for 6 months. Drugs were supplied, and toxicity and compliance were assessed monthly. Utilization of service, cost, and sustainability were also assessed. RESULTS: Between 14 June 1991 and 30 September 1992, 9862 persons tested HIV-positive. Of 5594 HIV-infected clients who returned to collect test results, only 1524 (27%) were enrolled. Of those, 1344 were tuberculin-tested (88%); 180 were not tested because of active tuberculosis, serious illnesses, refusal, and other reasons. Of the 1344, 250 (19%) did not return for test reading and 515 were negative (47% of tests read). Of 579 tuberculin-positive persons, 59 (10%) were excluded from preventive chemotherapy because of tuberculosis and other respiratory illnesses. Of 520 persons given isoniazid, 62% collected at least 80% of their drug supplies. No major toxicity was observed. One case of tuberculosis occurred in the first month of treatment. Cost of HIV counselling and testing was US $18.54 per person and cost of follow-up counselling and social support was US $7.89. CONCLUSIONS: Important factors were identified which caused attrition, such as limited motivation by counsellors to discuss tuberculosis issues during HIV pre- and post-test counselling, insufficient availability of medical screening, shifting of sites to collect pills, and frequent tuberculin-negative tests. Active tuberculosis among 6% of persons screened suggests that voluntary counselling and testing sites may be important for tuberculosis case finding and underscores the need to exclude tuberculosis carefully before starting IPT. In developing countries, further studies assessing the feasibility of IPT within tuberculosis and HIV/AIDS programme conditions are needed. Cost-effectiveness of IPT, compared with passive case finding, and its sustainability should be assessed before national policies are established.

PIP: Those infected with human immunodeficiency virus (HIV) have a 5-10% risk per year of developing active tuberculosis, and this disease may accelerate the clinical course of HIV infection. Thus, a study was conducted in Uganda to assess the cost-effectiveness and acceptability of isoniazid preventive chemotherapy (IPT) for patients dually diagnosed with HIV and Mycobacterium tuberculosis. Of the 1344 HIV-infected patients at an independent HIV testing and counseling center in Kampala who were initially screened for participation in this study, 6% had signs of active tuberculosis. Selected for participation in the study were 520 subjects with no signs of active tuberculosis. Of these, 322 (62%) were considered compliant with the treatment regimen on the basis of their appearance for all scheduled appointments for pill distribution. One case of active tuberculosis occurred during the first month of IPT and most likely represented a case that went undetected in the screening process. No treatment-associated toxicity was reported. The cost of the HIV testing and counseling was US$18.54 per patient; that of follow-up counseling and support was $7.89. When administrative costs for the study were included in the calculation, the cost of IPT increased to $60.19 per person. Although reactivation of tuberculosis may have been prevented in up to 62% of subjects who received IPT, numerous factors mitigate against the routine implementation of such a treatment program, most notably its high cost and a shortage of voluntary HIV centers in developing countries. Needed are studies that evaluate the long-term community health, social, and economic benefits of such a program as well as further investigations of the impact of tuberculosis on the pace of progression from HIV to acquired immunodeficiency syndrome (AIDS).

Epidemic measles in an isolated unvaccinated population, India.

Between June and September, 1986, an outbreak of measles occurred in Pilkhi Primary Health Centre area (population 56,000) in Tehri Garhwal district, Uttar Pradesh, India. Overall, 1092 cases were identified and 62 died; case-fatality ratio was 5.7%. Illness was restricted primarily to children below 15 years of age; 38% cases were in children under 5 and 58% between 5-14 years of age. To better characterize the outbreak, a survey was conducted in 13 affected villages. The age of the cases ranged from 5 months to 19 years (median = 7.0 years). The age-specific attack rates were 22.4%, 54.5%, 46.2% and 35.3% for children under 1, 1-4, 5-9, 10-14 years of age respectively. In as many as four villages, the attack rate in children below ten was 80% or more. Secondary attack rate among family members was 70%. Overall, 82% of children with measles developed complications which consisted mainly of pneumonia, diarrhoea and dysentery. The age-specific case-fatality ratios in infants and children 1-4 years of age were 23.1% and 11.5% respectively; thereafter the rates tended to decline with increasing age and was higher in females than in males (less than 0.05). Pneumonia which was a complication in 39% of measles cases contributed to 56% of deaths. Traditional beliefs and customs in the area were strong and did not encourage treatment of measles cases. Although a measles vaccination programme has been launched in India since 1985, only 30 districts could be covered during the first year and another 90 during 1986.(ABSTRACT TRUNCATED AT 250 WORDS)

Epidemic tuberculosis in a nursing home: a retrospective cohort study.

In a retrospective study, the results of tuberculin skin tests done in a nursing home were examined, where most residents admitted during 1972-1981 were tested using purified protein derivative of tuberculin administered intradermally. Of 514 residents who were tested at least once during the study period, results of the admission skin test were available for 254 and follow-up skin test results were available for 226. On admission, 13 per cent (35/254) were skin-test positive (greater than or equal to 10 mm induration at 48 hours). Skin test positivity for males was 16 per cent, females, 11 per cent, nonwhites, 19 per cent, and whites, 12 per cent. Highest skin test positivity was for persons received as transfers from other nursing homes (24 per cent) and lowest was for those entering from individual homes (8 per cent, P = 0.016, Fisher's Exact Test). On follow-up, 38/226 (17 per cent) residents who had been tuberculin-negative on at least two previous occasions were found to be positive; 24 (63 per cent) of these conversions occurred in a single year (1975) following detection of an infectious patient. The infection rate for persons residing in the nursing home during that year was 28 per cent (28/99) compared with 7.9 per cent (10/127) for persons either discharged before or admitted after 1975 (relative risk = 3.6, P less than 0.001). Ten to 15 per cent of new residents are tuberculin-positive (harbour a dormant tuberculous infection), leaving 85-90 per cent of newly admitted persons who are tuberculin-negative and thus susceptible to infection if exposed. The study shows that tuberculosis must be considered as a potential nosocomial infection in nursing homes.(ABSTRACT TRUNCATED AT 250 WORDS)

Poor reliability of the first meal tolerance test.

The poor reproducibility of oral glucose tolerance test (OGTT) has been known for a long time. Some recent reports indicate that postprandial glycaemia achieved during the test is likely to be higher on the first occasion than on subsequent visits. We have analysed our recent data on meal tolerance tests (MTT) from this angle. Fifteen healthy subjects and 9 subjects having NIDDM were administered two essentially identical meals one or two weeks apart. In case of healthy subjects, the absolute as well as incremental postprandial glycaemia achieved at 0.5 h and 1.0 h on the first visit was significantly higher (P < 0.05) than on the subsequent visit. The effect of visit was insignificant in case of NIDDM subjects. The effect observed in healthy subjects may be due to the release of adrenaline during the first visit brought about by apprehension. In NIDDM subjects the apprehension is likely to be much less because of their having undergone such tests in the past. Hence a single casual OGTT or MTT is unreliable as a diagnostic tool in borderline cases of impaired glucose tolerance test. The test needs to be repeated at least once more to eliminate false positives.

Effect of coingestion of paracetamol on glycaemic response.

Rate of gastric emptying is a frequently measured variable in glycaemic response studies. One of the indices employed for measurement of the gastric emptying rate is the blood level of paracetamol at frequent intervals of time following coingestion of paracetamol with the meal. But the effect of paracetamol itself on glycaemic response is not known. The present study was performed on ten healthy and five NIDDM subjects. Each subject underwent two meal tolerance tests in random sequence. On one occasion the meal was white bread; on the other occasion, the meal consisted of the same quantity of white bread and 1.5 g paracetamol. The postprandial glycaemica following the two meals was not significantly different. Thus the results validate the use of the paracetamol technique for gastric emptying in glycaemic response studies.

Glycaemic response to maize, bajra and barley.

The postprandial glycaemic response to maize (Zea mays), bajra (Pennisetum typhoideum) and barley (Hordeum vulgare) was studied in a pool of 18 healthy volunteers and 14 patients having non-insulin-dependent diabetes mellitus (NIDDM). In response to maize, none of the variables examined was significantly different as compared to white bread. The glycaemic response to bajra was significantly lower than that to white bread in healthy subjects, but the two responses were indistinguishable in NIDDM subjects. The insulinaemic responses to bajra and white break were not significantly different in either group of subjects. The glycaemic response to barley was significantly lower than that to white bread in both groups of subjects. But the insulinaemic response to barley was significantly lower than that to white bread only in healthy subjects. In NIDDM subjects, there was a tendency for the response to barley to be higher than that to white bread 0.5 h after ingestion. Barley, with a low glycaemic index (68.7 in healthy and 53.4 in NIDDM subjects) and a high insulinaemic index (105.2) in NIDDM subjects seems to mobilize insulin in NIDDM. This makes it a specially suitable cereal for diabetes mellitus.