Comparative immune profiling in survivors of the 2023 Nipah outbreak in Kerala state, India.

Immune profiling of Nipah virus (NiV) infection survivors is essential for advancing our understanding of NiV pathogenesis, improving diagnostic and therapeutic strategies, and guiding public health efforts to prevent future outbreaks. There is currently limited data available on the immune response to NiV infection. We aimed to elucidate the specific immune mechanisms involved in protection against NiV infection by analyzing the immune profiles of survivors of the Nipah outbreak in Kerala, India 2023. Immune cell populations were quantified and compared between survivors (up to 4 months post onset day of illness) and healthy controls. Statistical analysis was performed to explore associations between immune profiles and clinical outcomes. Immune signatures common to all three cases were: a heretofore undescribed persistent lymphopenia including the CD4+ Treg compartment with the relative expansion of memory Tregs; trends indicative of global leukopenic modulation were observed in monocytes and granulocytes including an expansion of putatively immunosuppressive low-density granulocytes described recently in the context of severe COVID-19; altered mucosal homing with respect to integrin beta-7 (ITGB7) expressing subsets; increased mobilization of activated T-cells (CD4+ and CD8+) and plasmablasts in the early phase of infection. Comparative analysis based on clinical presentation and outcome yielded lower initial viremia, increased activated T-cell responses, expanded plasmablasts, and restoration of ITGB7 expressing CD8+ T-cells as possible protective signatures. This longitudinal study delineates putative protective signatures associated with milder NiV disease. It emphasizes the need for the development of immunotherapeutic interventions such as monoclonal antibodies to blunt early viremia and ameliorate pathogenesis.

Clinico-epidemiological presentations and management of Nipah virus infection during the outbreak in Kozhikode district, Kerala state, India 2023.

India experienced its sixth Nipah virus (NiV) outbreak in September 2023 in the Kozhikode district of Kerala state. The NiV is primarily transmitted by spillover events from infected bats followed by human-to-human transmission. The clinical specimens were screened using real-time RT-PCR, and positive specimens were further characterized using next-generation sequencing. We describe here an in-depth clinical presentation and management of NiV-confirmed cases and outbreak containment activities. The current outbreak reported a total of six cases with two deaths, with a case fatality ratio of 33.33%. The cases had a mixed presentation of acute respiratory distress syndrome and encephalitis syndrome. Fever was a persistent presentation in all the cases. The Nipah viral RNA was detected in clinical specimens until the post-onset day of illness (POD) 14, with viral load in the range of 1.7-3.3 × 104 viral RNA copies/mL. The genomic analysis showed that the sequences from the current outbreak clustered into the Indian clade similar to the 2018 and 2019 outbreaks. This study highlights the vigilance of the health system to detect and effectively manage the clustering of cases with clinical presentations similar to NiV, which led to early detection and containment activities.

Kerala's progress towards universal health coverage: the road travelled and beyond.

BACKGROUND: Kerala has initiated many Universal Health Coverage (UHC) reforms in the last decade. The Aardram Mission launched in 2017 stands out owing to its scope, objectives, and commitments for strengthening Primary Health Care (PHC) in the State. The current study proposes to explore access and financial protection through the lens of equity in Kerala especially in the context of major UHC reforms carried out during the last decade. This paper will also highlight the key lessons from Kerala's approach towards UHC and health systems strengthening through a political economy approach. METHODS: Data from the Kerala state sample of 75th Round (2017-18) National Sample Survey is used for this study. Comparison is also drawn from the 71st Round Sample Survey, 2014, to measure the state's progress in terms of access and financial protection. Logistic regression was used for the calculation. The findings were further explored through a political economy approach. RESULTS: The share of public facilities for outpatient care is 47.5%, which is a significant increase from 34.0% (in 2014) in the state. The share of public sector for out-patient care has increased for the lower socio-economic population in the state. The share of public sector for in-patient care has also increased to 37.3% in 2017-18 from 33.9% in 2014, but not to the extent as the increase shown in outpatient care. The average out-of-pocket-expenditure during hospitalization has increased more in private facilities as compared to public for both outpatient care and hospitalization. CONCLUSIONS: Overall increase in the share of public facilities for both outpatient care and hospitalization is indicative of the enhanced trust among the people at large of the public healthcare delivery system in Kerala, post the launch of UHC reforms in the State. The insurance linked UHC reforms would be insufficient for the State to progress further towards UHC. Kerala with a long and successful history in 'public provisioning' should focus more on strengthening PHC through Aardram Mission in its journey towards pursuit of UHC.

Skin diseases among the tribal population of Kerala: the challenges and way forward.

BACKGROUND: Kerala has a history of achievements in health through acting on the distal social determinants, but certain communities like tribals were pushed back from the stream of social development and health achievements. Subsequently, the lifestyle and the poor living conditions of tribes make them more prone to several diseases including skin diseases. However, neither the burden nor the situation of the same in the tribal population in several parts including Kerala is seldom assessed. MAIN BODY: The lack of awareness about the symptoms, complications, and management options as a part of the social backwardness has led to the concentration of certain diseases like Leprosy among the tribal community. In addition, the tribal population is under the threat of infectious diseases of public health significance like Leishmaniasis (CL). The tribal population owing to ignorance neglects the skin lesions or uses their local remedies. Tribes might have been using many local remedies for their issues, but the emerging skin diseases may not be amenable to local remedies and often impose significant public health concerns. Developing and maintaining an effectively functioning health system in these difficult-to-reach terrains is also a challenge. The pattern of skin diseases among tribals residing in environmentally sensitive localities is an indicator for the need for more social, economic and geospatial inclusion. Skin lesions of the tribal population should be kept under active surveillance activities through the integrated health information platform (IHIP) and it should follow a vigilant public health response if there are clusterings. A dedicated evidence-based system should be developed to diagnose and treat skin diseases of tribal people residing away from the availability of specialist care using local resources and community-level workers. CONCLUSION: The rampant skin diseases among tribals are the product of their unacceptable socio-economic status and living conditions. It could only improve through interventions focusing on social determinants of health. Improvements in the living conditions of tribals are sustainable long-term solutions, but such solutions should be coupled with medium-term and short-term strategies.

Gender disparity in prevalence of mental health issues in Kerala: a systematic review and meta-analysis.

BACKGROUND: Kerala is a state in south India, appreciated for its education, better health indicators and quality of life. However, there is a proportionately high prevalence of mental health illnesses and suicides reported in the state. It is unclear if there is any disparity in the gender categories in this. With this systematic review, we aim to systematically study the gender disparity in the prevalence of mental health (MH) issues among adolescents, younger and older adults in Kerala. METHODS: A search strategy was built and several databases like Pubmed, Cochrane, Scopus, EMBASE, EBSCOhost, Web of Science, and ProQuest were used alongside grey literature to identify relevant articles. The study was conducted according to the PRISMA guidelines following a prespecified protocol. After relevant data extraction, the estimates were pooled using random effects model due to the high heterogeneity assessed by tau-squared, Cochran Q, and prediction interval. Subgroup analyses, and meta-regression were used to reduce heterogeneity. We also identified the influence and heterogeneity contributed by individual studies using influence plots, Baujat plot, clustering, and performed several sensitivity analyses. RESULTS: Twenty articles were included in the review and meta-analysis. The pooled odds ratio of mental health illnesses amongst females compared to males in Kerala was 1.31 (95% CI: 1.0 - 1.73) and falls within a prediction interval of 0.38 to 4.53. The individual studies showed high heterogeneity (I2 = 92%, p = p < 0.01) and hence, subgroup analysis was done for several prespecified subgroups based on etiology, geography, demography, study settings, and age groups. Heterogeneity was significantly reduced by subgrouping based on etiology, study setting and age (p, 0.001, p < 0.001, p = 0.001). In etiologic subgrouping the highest pooled odds was in comorbidities associated MH issues (2.54) and least in non-specific (0.97). In age subgrouping, the highest pooled odds was in elderly (2.53) and least in adolescents (0.63). The odds was highest in health care facility (2.21) and least in educational institution (0.78) based studies. Meta-regression based on the size of the study failed to reduce heterogeneity. INTERPRETATIONS: A gender disparity was evident in the prevalence of mental health issues, with a higher Odds in females especially among the elderly and adults. A Gender transformative approach in legislative, health systems and policy frameworks will be the answer to this.

Estimation of State and district-specific disability adjusted life years (DALYs) due to tuberculosis for Kerala, India, 2017-2020.

Background & objectives Tuberculosis (TB) control programmes routinely use indicators like incidence and mortality. A single indicator, like disability-adjusted life years (DALYs) may yield a more comprehensive burden estimate. This study attempted to estimate the state and district-specific TB burden in Kerala. Methods The sole data source for these computations was the Ni-kshay, notification register for 2017 to 2020, Kerala. Age of the patient and outcome are available in the register. Notified incident TB/1000, the median age of onset of TB, case fatality due to TB, and the median age of mortality were computed using SPSS software. DALYs was calculated using the DALYs package of the R program, using these input parameters. Disability weight was taken as 0.333. The absolute and relative DALY/100,000 population was estimated along with the 95% confidence interval (CI). Results Relative DALYs was highest in 2019 at 1482/100,000 and lowest at 1124/100,000 in the year 2020 during the period 2017 to 2020. The districts, which had the highest incidence were not the same as those with the highest DALYs. Ernakulam and Thrissur districts had the highest burden and Idukki had the least burden. Interpretation & conclusions DALYs estimates for Kerala showed an increasing trend before 2020, which could be due to the increased efforts to detect TB as part of the elimination drive. The study points towards the need for using DALYs as a measure for prioritizing districts for resource allocation.

'We did not want to marry then, but': understanding early marriage among Muslims in the context of the 'Kerala model' of development.

Kerala, the Indian state with the highest reported level of social development, faces a challenge with persistent early marriage, particularly among Muslims in Malappuram. This study explores the sociocultural factors influencing this situation, in which child marriage rates among Muslims are significantly higher than those of Hindus and Christians. Employing a qualitative research strategy within a specific Malappuram mahallu, a Muslim-majority village cluster encompassing three villages, we identify a multifaceted interplay of micro and macro forces perpetuating early marriage. Lack of social networks, stemming from limited higher education options and career opportunities, restricts girls' choices and makes them susceptible to parental pressure to marry early. Parents, on the other hand, often view early marriage as an appropriate solution to their anxieties concerning parental responsibility, dowry and family honour. This pressure is amplified by the narrative promoted by religious leaders who portray early marriage as the ideal path. This narrative, in turn, resonates with a subset of young men, particularly temporary Gulf migrants who prefer to marry adolescent girls, thereby perpetuating the cycle. We also argue that, unlike most regions in India, poverty and illiteracy are not the primary drivers of early marriage among Muslims in Malappuram.

Emergence of imported cutaneous leishmaniasis caused by Leishmania major: a case series from Kerala, India.

Cutaneous leishmaniasis (CL) is often considered a 'great imitator' and is the most common form of leishmaniasis. The Leishmania species responsible for CL varies among countries, as these species exhibit specific distribution patterns. The increased mobility of people across countries has resulted in the imported incidences of leishmaniasis caused by non-endemic species of Leishmania. During 2023, we confirmed three CL cases caused by L. major from Kerala, India, and upon detailed investigation, these were identified to be imported from the Middle East and Kazakhstan regions. This is the first report of CL caused by L. major from Kerala. The lesion morphology, detection of anti-rK 39 antibody and Leishmania parasite DNA from the blood samples were the unique observations of these cases. Kerala, being an emerging endemic zone of visceral leishmaniasis (VL) and CL, the imported incidences of leishmaniasis by non-endemic species can pose a significant threat, potentially initiating new transmission cycles of leishmaniasis caused by non-endemic species.

Spatio-temporal classification of land use and land cover and its changes in Kerala using remote sensing and machine learning approach.

Land use and land cover (LULC) analysis gives important information on how the region has evolved over time. Kerala, a land with an extensive and dynamic history of land-use changes, has, until now, lacked comprehensive investigations into this history. So the current study focuses on Kerala, one of the ecologically diverse states in India with complex topography, through Landsat images taken from 1990 to 2020 using two different machine learning classifications, random forest (RF) and classification and regression trees (CART) on Google Earth Engine (GEE) platform. RF and CART are versatile machine learning algorithms frequently employed for classification and regression, offering effective tools for predictive modelling across diverse domains due to their flexibility and data-handling capabilities. Normalised Difference Vegetation Index (NDVI), Normalised Differences Built-up Index (NDBI), Modified Normalised Difference Water Index (MNDWI), and Bare soil index (BSI) are integral indices utilised to enhance the precision of land use and land cover classification in satellite imagery, playing a crucial role by providing valuable insights into specific landscape attributes that may be challenging to identify using individual spectral bands alone. The results showed that the performance of RF is better than that of CART in all the years. Thus, RF algorithm outputs are used to infer the change in the LULC for three decades. The changes in the NDVI values point out the loss of vegetation for the urban area expansion during the study period. The increasing value of NDBI and BSI in the state indicates growth in high-density built-up areas and barren land. The slight reduction in the value of MNDWI indicates the shrinking water bodies in the state. The results of LULC showed the urban expansion (158.2%) and loss of agricultural area (15.52%) in the region during the study period. It was noted the area of the barren class, as well as the water class, decreased steadily from 1990 to 2020. The results of the current study will provide insight into the land-use planners, government, and non-governmental organizations (NGOs) for the necessary sustainable land-use practices.

A peer support program results in greater health benefits for peer leaders than other participants: evidence from the Kerala diabetes prevention program.

BACKGROUND: Peer support programs are promising approaches to diabetes prevention. However, there is still limited evidence on the health benefits of peer support programs for lay peer leaders. PURPOSE: To examine whether a peer support program designed for diabetes prevention resulted in greater improvements in health behaviors and outcomes for peer leaders as compared to other participants. METHODS: 51 lay peer leaders and 437 participants from the Kerala Diabetes Prevention Program were included. Data were collected at baseline, 12 months, and 24 months. We compared behavioral, clinical, biochemical, and health-related quality of life parameters between peer leaders and their peers at the three time-points. RESULTS: After 12 months, peer leaders showed significant improvements in leisure time physical activity (+ 17.7% vs. + 3.4%, P = 0.001) and health-related quality of life (0.0 vs. + 0.1, P = 0.004); and a significant reduction in alcohol use (-13.6% vs. -6.6%, P = 0.012) and 2-hour plasma glucose (-4.1 vs. + 9.9, P = 0.006), as compared to participants. After 24 months, relative to baseline, peer leaders had significant improvements in fruit and vegetable intake (+ 34.5% vs. + 26.5%, P = 0.017) and leisure time physical activity (+ 7.9% vs. -0.9%, P = 0.009); and a greater reduction in alcohol use (-13.6% vs. -4.9%, P = 0.008), and waist-to-hip ratio (-0.04 vs. -0.02, P = 0.014), as compared to participants. However, only the changes in fruit and vegetable intake and waist-to-hip ratio were maintained between 12 and 24 months. CONCLUSION: Being a peer leader in a diabetes prevention program was associated with greater health benefits during and after the intervention period. Further studies are needed to examine the long-term sustainability of these benefits.

The long-term effects of Kerala Diabetes Prevention Program on diabetes incidence and cardiometabolic risk: a study protocol.

INTRODUCTION: India currently has more than 74.2 million people with Type 2 Diabetes Mellitus (T2DM). This is predicted to increase to 124.9 million by 2045. In combination with controlling blood glucose levels among those with T2DM, preventing the onset of diabetes among those at high risk of developing it is essential. Although many diabetes prevention interventions have been implemented in resource-limited settings in recent years, there is limited evidence about their long-term effectiveness, cost-effectiveness, and sustainability. Moreover, evidence on the impact of a diabetes prevention program on cardiovascular risk over time is limited. OBJECTIVES: The overall aim of this study is to evaluate the long-term cardiometabolic effects of the Kerala Diabetes Prevention Program (K-DPP). Specific aims are 1) to measure the long-term effectiveness of K-DPP on diabetes incidence and cardiometabolic risk after nine years from participant recruitment; 2) to assess retinal microvasculature, microalbuminuria, and ECG abnormalities and their association with cardiometabolic risk factors over nine years of the intervention; 3) to evaluate the long-term cost-effectiveness and return on investment of the K-DPP; and 4) to assess the sustainability of community engagement, peer-support, and other related community activities after nine years. METHODS: The nine-year follow-up study aims to reach all 1007 study participants (500 intervention and 507 control) from 60 randomized polling areas recruited to the original trial. Data are being collected in two phases. In phase 1 (Survey), we are admintsering a structured questionnaire, undertake physical measurements, and collect blood and urine samples for biochemical analysis. In phase II, we are inviting participants to undergo retinal imaging, body composition measurements, and ECG. All data collection is being conducted by trained Nurses. The primary outcome is the incidence of T2DM. Secondary outcomes include behavioral, psychosocial, clinical, biochemical, and retinal vasculature measures. Data analysis strategies include a comparison of outcome indicators with baseline, and follow-up measurements conducted at 12 and 24 months. Analysis of the long-term cost-effectiveness of the intervention is planned. DISCUSSION: Findings from this follow-up study will contribute to improved policy and practice regarding the long-term effects of lifestyle interventions for diabetes prevention in India and other resource-limited settings. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Registry-(updated from the original trial)ACTRN12611000262909; India: CTRI/2021/10/037191.

Isolation and identification of Streptococcus agalactiae in cage-cultured green chromide Etroplus suratensis in Kerala, India.

Streptococcus agalactiae is one of the main aetiological agents in large-scale mortalities of tilapia, having caused major economic losses to the aquaculture industry in recent years. This study describes the isolation and identification of the bacteria from cage-cultured Etroplus suratensis that experienced moderate to severe mortalities in Kerala, India. Gram-positive, catalase-negative S. agalactiae was identified from brain, eye and liver of the fish by antigen grouping and 16S rDNA sequencing. Multiplex PCR confirmed that the isolate belonged to capsular serotype Ia. Antibiotic susceptibility tests showed that the isolate was resistant to methicillin, vancomycin, tetracycline, kanamycin, streptomycin, ampicillin, oxacillin and amikacin. Histological sections of the infected E. suratensis brain revealed infiltration of inflammatory cells, vacuolation and meningitis. This report is the first description of S. agalactiae as a primary pathogen causing mortalities in E. suratensis culture in Kerala.

Two novel SNPs identified in STAT1 gene adjoining a QTL for milk production in Holstein Friesian crossbreds of Kerala.

We analyzed the effect of a single nucleotide polymorphism, g. C3141T in the 3' UTR of Signal transducer and activator of transcription-1 gene (STAT1) on milk production traits in the Holstein Friesian crossbred cattle of Kerala (n = 144) by association analysis and expression study. The population was genotyped by restriction fragment length polymorphism using Pag1. Association study using the General Linear Model-Analysis of Variance revealed that none of the yield or composition traits analyzed were significantly differed. The expression profile of STAT1 gene in leucocytes of animals bearing homozygous genotypes was compared by quantitative real time PCR using SYBR green chemistry with and relative expression was not found to be significantly differed. The second stage of the study, the STAT1 mRNA spanning 3213 bp was amplified from leucocytes and sequenced (GenBank: MT459802.1). Two novel SNPs were identified; one synonymous mutation in the coding region (g.A1212G) and the other in the 3'UTR (g.T3042C). The novel SNPs might contribute to STAT1 gene regulation mediated by alternate spicing or binding sites for regulatory molecules. The results reiterate the importance of extensive studies of STAT1 gene variants to substantiate the presence of a quantitative trait loci for dairy traits in the vicinity of STAT1 gene.

Weather integrated multiple machine learning models for prediction of dengue prevalence in India.

Dengue is a rapidly spreading viral disease transmitted to humans by Aedes mosquitoes. Due to global urbanization and climate change, the number of dengue cases are gradually increasing in recent decades. Hence, an early prediction of dengue continues to be a major concern for public health in countries with high prevalence of dengue. Creating a robust forecast model for the accurate prediction of dengue is a complex task and can be done through various data modelling approaches. In the present study, we have applied vector auto regression, generalized boosted models, support vector regression, and long short-term memory (LSTM) to predict the dengue prevalence in Kerala state of the Indian subcontinent. We consider the number of dengue cases as the target variable and weather variables viz., relative humidity, soil moisture, mean temperature, precipitation, and NINO3.4 as independent variables. Various analytical models have been applied on both datasets and predicted the dengue cases. Among all the models, the LSTM model was outperformed with superior prediction capability (RMSE: 0.345 and R2:0.86) than the other models. However, other models are able to capture the trend of dengue cases but failed in predicting the outbreak periods when compared to LSTM. The findings of this study will be helpful for public health agencies and policymakers to draw appropriate control measures before the onset of dengue. The proposed LSTM model for dengue prediction can be followed by other states of India as well.

'Ecological determinants' of health in the global south: practising sustainable consumption in Kerala, India.

Health promotion has long recognized the ecological determinants of health, underscoring the interconnections between planetary health, economic systems and human health. Despite calls for synergy across them, these domains are governed by fundamentally divergent paradigms leading to unaddressed conceptual and institutional gaps. Sustainability, meanwhile, is reduced to personal responsibility and behaviour change. This qualitative research explores ecological determinants through a focus on sustainable consumption in the under-researched context of the global south where rapid modernization has profoundly impacted the natural environment. The article uses the theoretical framework of 'practice'-namely, the social routines, values, conventions and norms that drive consumption-to critically examine everyday household sustainable consumption in India's southern state of Kerala. The findings show that in most households, sustainability is a health promotion practice. People practice sustainability fundamentally for its beneficial health outcomes. However, the institutional structures set up in favour of economic development continue to dominate society and is the paradigm that contextualizes everyday social life for consumers. The findings suggest that the practice of sustainable consumption is complex and caught in the space that is neither 'upstream' or 'downstream'; instead, the focus on the 'mid-stream' reveals complex calculations that go into everyday negotiation of healthy living.

Consumerism is rapidly spreading through the global south. While the conveniences associated with easily available goods are appreciated, population health has been adversely impacted by attendant decline in ecosystems through the increase in plastics, waste and toxicity in the food chain. Health promoters, for decades, have sought to draw attention to the misalignment between the values that govern environment, economy, and health policies. This article investigates policy misalignment through the experiences of everyday consumers. Set in the context Kerala, in south India, which has recently seen rapid consumerism, the study shows that everyday consumption, even unsustainable ones, are part of meaningful social practices actively negotiated around health. Thus, people buy goods wrapped in plastic, despite its environmental impacts, because it is perceived as safer. Individuals act 'unsustainably' largely because they have little control over systemic factors­like urbanization, changes in social life, lack of government regulation and infrastructure­that shape their consumption practices. The study shows that initiatives that focus on knowledge and behaviour modification are not sufficient to ensure sustainable consumption. Instead, what is needed are institutional convergences across environment, economy and health priorities so that individuals can create new consumption practices that are both sustainable and healthy.

Effectiveness of an oral health education intervention among 6-12-year-old children: A cluster randomized controlled trial.

OBJECTIVES: Literature on the effectiveness of theory-based oral health education on the oral hygiene of children is limited. We aimed to determine the effectiveness of an health behaviour theory-based school oral health education intervention on 1) oral hygiene and 2) oral health-related knowledge, attitude and practices among 6-12-year-old children in Kerala, India. METHODS: Cluster randomized controlled trial. Sixteen class divisions (clusters) were randomized into intervention and control groups of 225 and 228 children respectively. Primary and secondary outcomes were plaque score as measured using the simplified oral hygiene index (OHI-S) and oral health-related knowledge, attitude and practices respectively. The intervention group received structured oral health education classes for three months and materials including pamphlets. Children in the control group were not given the classes or materials. RESULTS: Post-intervention OHI-S scores in the intervention group and control groups were 1.65 and 2.17 respectively (difference = -0.52, 95%CI -0.86, -0.18). All the secondary outcomes improved in the intervention group compared to the control group. CONCLUSIONS: The intervention improved the oral hygiene status, oral health-related knowledge, attitude and practices of the children. Longer term follow-up and economic appraisal are needed to help policymakers plan and develop OHEI based on health behaviour theories.

One goal: Health for all; Post-COVID public health initiatives.

WHO's theme on its 75th year, "Health for All", is both appropriate and meaningful on account of the unfinished agenda of primary health care (PHC), the Sustainable Development Goals, and the aftermath of the COVID-19 pandemic. The Kerala experience of the pandemic amply demonstrated that the application of these PHC principles helped to address diverse aspects of physical, mental, and social dimensions. The need for 'internalization' of One Health principles and operational strategies cannot be over-emphasized.

Burkholderia pseudomallei in Environment of Adolescent Siblings with Melioidosis, Kerala, India, 2019.

In 2019, Burkholderia pseudomallei was isolated from the backyard of 2 siblings with melioidosis in Kerala, India. This finding highlights the value of healthcare providers being aware of risk for melioidosis in febrile patients, of residents taking precautions when outside, and of increasing environmental surveillance for B. pseudomallei in this region.

Bargaining with patriarchy through the life course: obstacles faced (and overcome) by women leaders in Kerala's health sector.

BACKGROUND: The COVID-19 pandemic has helped shine the spotlight on the role of women's leadership in tackling the world's health and health system challenges. The proportion of women occupying senior leadership positions in the health sector is less compared to males, even as they constitute a vast majority of the work force. The South Indian state of Kerala is an exception to this trend, a phenomenon that we sought to understand and contextualise. We undertook a study to understand the personal and professional journeys of some women leaders in the Kerala health sector to determine the antecedents of their leadership positions, the challenges that came their way in leadership, and strategies adopted to overcome these challenges. We also investigated into how these experiences shaped their styles and approaches to leadership. METHODS: We conducted a qualitative study involving semi-structured in-depth interviews with women leaders. Sixteen women leaders were identified from public records and through peer nomination and interviewed in their language of preference following written informed consent procedures. Interviews focused on participants' professional and personal trajectories, work-life balance, style of leadership, challenges, enablers, lessons learned in their path, and their vision for the health system. The interviews conducted in Malayalam were transliterated into English and thematically analysed using Atlas.Ti8 software by three researchers. RESULTS: Our study participants were aged 40 to around 80 years, from 8 out of 14 districts of the state. Women leaders in Kerala's health sector faced challenges through the life-course: during their early school education, in professional service as well as in their roles as leaders. There were myriad experiences - including gender stereotyping and discrimination at the intersection of gender and other social identities. Women developed manifold ways of overcoming them and evolve unique - and again myriad-leadership styles. CONCLUSIONS: Women leaders in Kerala have faced shared challenges through their life-course to climb up the ranks of leadership; each leader has adopted unique ways of overcoming them and developed similarly unique leadership styles. At each life stage there were bargains with patriarchy - involving family members (often as allies), against formal and informal institutional rules, managers, peers and subordinates., which in turn suggests a feminist consciousness on the part of Kerala women leaders as well as the society in which they are seeking to lead.

Intersecting sex-related inequalities in self-reported testing for and prevalence of Non-Communicable Disease (NCD) risk factors in Kerala.

BACKGROUND: Non-Communicable Diseases (NCDs) are among India's top burdens, particularly in states like Kerala, which is at an advanced stage of the epidemiological transition. Evidence in India points towards intersectional inequalities in risk factors of NCDs and testing, both of which are understudied in Kerala. We estimated the self-reported testing and prevalence of key NCD risk factors-blood pressure (BP) and blood glucose (BG) comparing Kerala men and women across educational, wealth, religion, as well as caste and tribal status subgroups. METHOD: A multistage random sample survey of 3398 women and 2982 men aged 30 years and over was administered in 4 districts of Kerala from July to October 2019. Descriptive analysis for men and women was undertaken using survey weights. Slope index of Inequality and Relative Concentration Index for wealth and education related inequalities, and, Weighted Mean Difference from Mean and Index of Disparity for caste and tribal status, as well as religion related inequalities were calculated using World Health Organisation's Health Equity Assessment Toolkit Plus and Stata 12. RESULTS: A significantly higher proportion of women reported BP and BG testing by medical personnel in the previous year than men (BP Testing among Women (BPTw): 90.3% vs BP Testing among Men (BPTM):80.8%, BG Testing among Women (BGTw): 86.2% vs BG Testing among Women (BGTM):78.3%). Among those tested, more women (11.2%) than men (7.9%) reported High Blood Pressure (HBP) but not High Blood Glucose (HBG). Testing for BP was concentrated among less-educated women while BG testing was concentrated among both less educated women and men. HBP and HBG were concentrated among less educated and wealthier groups. Although sex differences were insignificant across caste and tribal status and religion subgroups, magnitude of inequalities was high for HBP and HBG. CONCLUSION: Distinct patterns of sex inequalities were present in self-reported testing and prevalence of NCD risk factors in Kerala. Education and wealth seem to be associated with testing while prevalence appeared to vary by religious groups. Given the low rates of illiteracy, it is encouraging but maybe a data artefact that a small population of less-educated persons was getting tested; however, exclusion of poor groups and inequalities by other dimensions raise concerns. Further exploration is needed to understand underlying mechanisms of these inequalities to ensure we leave no one behind.