Community Control of Hypertension and Diabetes (CoCo-HD) program in the Indian states of Kerala and Tamil Nadu: a study protocol for a type 3 hybrid trial.

INTRODUCTION: India grapples with a formidable health challenge, with an estimated 315 million adults afflicted with hypertension and 100 million living with diabetes mellitus. Alarming statistics reveal rates for poor treatment and control of hypertension and diabetes. In response to these pressing needs, the Community Control of Hypertension and Diabetes (CoCo-HD) program aims to implement structured lifestyle interventions at scale in the southern Indian states of Kerala and Tamil Nadu. AIMS: This research is designed to evaluate the implementation outcomes of peer support programs and community mobilisation strategies in overcoming barriers and maximising enablers for effective diabetes and hypertension prevention and control. Furthermore, it will identify contextual factors that influence intervention scalability and it will also evaluate the program's value and return on investment through economic evaluation. METHODS: The CoCo-HD program is underpinned by a longstanding collaborative effort, engaging stakeholders to co-design comprehensive solutions that will be scalable in the two states. This entails equipping community health workers with tailored training and fostering community engagement, with a primary focus on leveraging peer supportat scale in these communities. The evaluation will undertake a hybrid type III trial in, Kerala and Tamil Nadu states, guided by the Institute for Health Improvement framework. The evaluation framework is underpinned by the application of three frameworks, RE-AIM, Normalisation Process Theory, and the Consolidated Framework for Implementation Research. Evaluation metrics include clinical outcomes: diabetes and hypertension control rates, as well as behavioural, physical, and biochemical measurements and treatment adherence. DISCUSSION: The anticipated outcomes of this study hold immense promise, offering important learnings into effective scaling up of lifestyle interventions for hypertension and diabetes control in low- and middle-income countries (LMICs). By identifying effective implementation strategies and contextual determinants, this research has the potential to lead to important changes in healthcare delivery systems. CONCLUSIONS: The project will provide valuable evidence for the scaling-up of structured lifestyle interventions within the healthcare systems of Kerala and Tamil Nadu, thus facilitating their future adaptation to diverse settings in India and other LMICs.

India Hypertension Control Initiative: decentralization of hypertension care to health wellness centres in Punjab and Maharashtra, India, 2018-2022.

INTRODUCTION: The India Hypertension Control Initiative (IHCI) emphasizes decentralized patient-centric care to boost hypertension control in public healthcare facilities. We documented the decentralization process, enrolment pattern by facility type, and treatment outcomes in nine districts of Punjab and Maharashtra states, India, from 2018-2022. METHODS: We detailed the shift in hypertension care from higher facilities to Health and Wellness Centres (HWCs) using the World Health Organization (WHO) health system pillar framework. We reviewed hypertension treatment records in 4,045 public facilities from nine districts in the two states, focusing on indicators including registration numbers, the proportion of controlled, uncontrolled blood pressure (BP), and missed visits among those under care. RESULTS: The decentralization process involved training, treatment protocol provision, supervision, and monitoring. Among 394,038 individuals registered with hypertension from 2018-2021, 69% were under care in 2022. Nearly half of those under care (129,720/273,355) received treatment from HWCs in 2022. Care of hypertensive individuals from district hospitals (14%), community health centres (20%), and primary health centres (24%) were decentralized to HWCs. Overall BP control rose from 20% (4,004/20,347) in 2019 to 58% (157,595/273,355) in 2022, while missed visits decreased from 61% (12,394/20,347) in 2019 to 26% (70,894/273,355) in 2022. This trend was consistent in both states. HWCs exhibited the highest BP control and the lowest missed visits throughout the study period compared to other facility types. CONCLUSION: We documented an increase in decentralized access to hypertension treatment and improved treatment outcomes over four years. We recommend operationalizing hypertension care at HWCs to other districts in India to improve BP control.

Epidemiology of Coronavirus Disease 2019 during the Second and Third Wave in Chennai, India: An Analysis of the Coronavirus Disease 2019 Surveillance System, February 2021-February 2022.

INTRODUCTION: Analysis of the coronavirus disease 2019 (COVID-19) surveillance system in the first wave indicated that the data-driven approach helped in resource allocation and public health interventions. OBJECTIVES: We described the epidemiology of COVID-19 cases in Chennai, Tamil Nadu, India, from February 2021 to February 2022. MATERIALS AND METHODS: We analyzed the COVID-19 surveillance data from Chennai City, Tamil Nadu, India's Greater Chennai Corporation. We described the deidentified line list of COVID-19 cases and deaths by months, zones, age, and gender. We estimated the incidence of COVID-19 cases per million population, test positivity rate (TPR), and case fatality ratio (CFR). RESULTS: Of the 434,040 cases reported in Chennai from February 1, 2021, to February 28, 2022, 53% were male. The incidence per million peaked in May 2021 (19,210) and January 2022 (15,881). Age groups more than 60 years reported maximum incidence. Southern region zones reported higher incidence. Overall TPR was 5.8%, peaked in May 2021 (17.5%) and January 2022 (15.1%). Over half of the 4929 reported deaths were in May 2021 (56%). Almost half of the deaths were 61-80 years (52%), followed by 41-60 years (26%). Overall CFR was 1%, which peaked in June 2021 (4%). CONCLUSION: We conclude that Chennai city experienced a surge in COVID-19 due to delta and omicron variants. Understanding descriptive epidemiology is vital for planning the public health response, resource allocation, vaccination policies, and risk communication to the community.

India Field Epidemiology Training Program Response to COVID-19 Pandemic, 2020-2021.

The India Field Epidemiology Training Program (FETP) has played a critical role in India's response to the ongoing COVID-19 pandemic. During March 2020-June 2021, a total of 123 FETP officers from across 3 training hubs were deployed in support of India's efforts to combat COVID-19. FETP officers have successfully mitigated the effect of COVID-19 on persons in India by conducting cluster outbreak investigations, performing surveillance system evaluations, and developing infection prevention and control tools and guidelines. This report discusses the successes of select COVID-19 pandemic response activities undertaken by current India FETP officers and proposes a pathway to augmenting India's pandemic preparedness and response efforts through expansion of this network and a strengthened frontline public health workforce.

Adverse events in India's Ayush interventions for cervical and lumbar spondylosis: a systematic review.

INTRODUCTION: Low back and neck pain are common musculoskeletal disorders with multiple treatment options. India's traditional medical systems, known as Ayush (Ayurveda, Yoga and Naturopathy, Unani, Siddha, Sowa-Rigpa and Homoeopathy) offer range of interventions and are widely used. In view of limited documentation of adverse events following Ayush interventions for lumbar and cervical spondylosis, we synthesized evidence and estimated proportion of studies reporting adverse events. METHODS: We systematically searched all published documents from biomedical and multidisciplinary abstract and citation databases and Ayush-specific repositories from their inception to April 2021. We selected studies as per inclusion criteria and extracted information, adhering to PRISMA guidelines. We systematically reviewed the qualitative evidence form the selected studies. RESULTS: Majority (94%) of the selected 113 studies were interventional studies and included 77 (68.1%) journal articles and 35 (31%) academic dissertations. Among the Ayush systems, considerable proportion was from Ayurveda (32.7%), followed by Siddha (24.8%), Yoga (22.1%), Unani (15.9%) and Homoeopathy (4.4%). Almost three-fourths of the studies were on lumbar spondylosis (65%; n = 74), followed by cervical spondylosis (31%; n = 35), and the remaining four included both. Thirteen percent of the 113 studies described adverse events [Yoga = 9.7%; Unani = 1.8% and Homoeopathy = 1.8%]. More adverse events were reported among the studies on lumbar (9.7%) than cervical spondylosis (2.7%). The nature of interventions were non-pharmacological (10.6%; n = 12), pharmacological (n = 2; 1.8%) or combined (n = 1; 0.9%). CONCLUSIONS: Only one in eight studies reported any adverse event following Ayush interventions for cervical and lumbar spondylosis. There could be certain degree of underreporting of adverse events and requires further exploration. PROSPERO Registration ID CRD42020167433.

Public health preparedness, syndromic surveillance, and response during the largest religious gathering at the Catholic pilgrimage center of Velankanni in South India: 2016.

Background: The dynamicity and mobility of the population in a mass gathering setting pose a challenge to traditional disease surveillance methods and strain the local health services. Velankanni is one of the most sacred Christian pilgrimage places located in Nagapattinam, Tamil Nadu, India. We participated in the Velankanni festival to describe the public health preparedness, surveillance, and response activities carried out during the festival. Methods: This was a cross-sectional study. We reviewed the national and international guidelines and published literature and discussed with the key stakeholders. We developed a checklist to observe public health preparedness activities. We facilitated the staff and monitored the activities by the implementers. We established the syndromic surveillance in the designated locations of the event and used tracker software to capture the data. Emergency medical teams were formed with trained health personnel to respond to medical emergencies. Results: The team monitored all the public health activities. There are 59 primary care public health facilities and nine ambulatory Mobile Medical Units, with 160 medical officers available at the site. Of the 16,169 persons who attended the medical camps, 9863 (61%) were males and 8408 (52%) were aged 15-44. Acute diarrheal disease was the most frequent of the reported syndromes, followed by injuries, acute febrile illness, and animal bites. Conclusions: There was no outbreak of any disease either identified or reported. Our findings suggest that risk assessments should be used, and establishing an Incident Command Center is vital for executing command and control mechanisms during mass gatherings.

An outbreak of H1N1 Influenza A among the students and staff of school X, Kozhikode, January 2020.

Background: An outbreak of fever and cough was notified to public health authorities by the management of school X among their students, Kozhikode district, Kerala, on Jan 1, 2020. We conducted an outbreak investigation to confirm the diagnosis, describe the case patients by time, place, and person, and propose appropriate recommendations. Materials and Methods: We defined a probable case of influenza as any student or staff of school X, Kozhikode district with a fever and cough between Dec 30, 2019, and Jan 14, 2020. We conducted an active case search and contact tracing in the school. We described the cases by date of symptom onset using an Epicurve, plotted cases by their classroom, and calculated the attack rate by age, and gender. Results: We identified 270 cases of influenza; among them, 264 (98%) were students, and 6 (2%) were the staff. The overall attack rate was 36%. The attack rate was higher among the students (39%) than the staff (12%, 6/49, P < 0.0003). The attack rate was higher among students of class 10E (90%, 37/41) and class 10A (80%, 33/41), where the index case had contact with the students during the symptomatic phase. Conclusion: An outbreak of influenza A (H1N1) occurred among students and staff, predominantly affecting the 10th division. School and health authorities implemented several interventions to limit the outbreak, including training students on personal hygiene. We recommended conducting surveillance of influenza, maintaining adequate spacing of benches, self-hygiene practices, and classroom ventilation.

Shifting roles of community health workers in the prevention and management of noncommunicable disease during the COVID-19 pandemic: a scoping review.

Community Health Workers (CHWs) play a crucial role in the prevention and management of noncommunicable diseases (NCDs). The COVID-19 pandemic triggered the implementation of crisis-driven responses that involved shifts in the roles of CHWs in terms of delivering services for people with NCDs. Strategically aligning these shifts with health systems is crucial to improve NCD service delivery. The aim of this review was to identify and describe COVID-19-triggered shifting roles of CHWs that are promising in terms of NCD service delivery. We searched Ovid Medline, Embase, CINAHL, Web of Science and CABI for Global Health for relevant articles published between 1 January 2020 and 22 February 2022. Studies that were conducted within a COVID-19 context and focused on the shifted roles of CHWs in NCD service delivery were included. We used Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines to report the findings. A total of 25 articles from 14 countries were included in this review. We identified 12 shifted roles of CHWs in NCD service delivery during COVID-19, which can be categorized in three dimensions: 'enhanced' role of CHWs that includes additional tasks such as medication delivery; 'extended' roles such as the delivery of NCD services at household level and in remote communities; and 'enabled' roles through the use of digital health technologies. Health and digital literacy of people with NCDs, access to internet connectivity for people with NCDs, and the social and organizational context where CHWs work influenced the implementation of the shifted roles of CHWs. In conclusion, the roles of CHWs have shifted during the COVID-19 pandemic to include the delivery of additional NCD services at home and community levels, often supported by digital technologies. Given the importance of the shifting roles in the prevention and management of NCDs, adaptation and integration of these shifted roles into the routine activities of CHWs in the post-COVID period is recommended.

Improving the availability of antihypertensive drugs in the India Hypertension Control Initiative, India, 2019-2020.

BACKGROUND: Antihypertensive drug supply is sometimes inadequate in public sector health facilities in India. One of the core strategies of the India Hypertension Control Initiative (IHCI) is to improve the availability of antihypertensive drugs in primary and secondary care facilities. We quantified the availability of antihypertensive drugs in 2019-20 and described the practices in supply chain management in 22 districts across four states of India. METHODS: Twenty-two districts from 4 states (Punjab, Madhya Pradesh, Telangana, and Maharashtra) were studied. We described the practices and challenges in supply chain management. We collected data on drug procurement from 2018 to 2020 and drug availability from April 2019 to March 2020. Quantity procured, the proportion of facilities with stockout at the end of each quarter, and availability of drugs in patient days were tabulated. RESULTS: All states selected drug- and dose-specific protocols with Amlodipine as the initial drug and shifted to morbidity-based forecasting. The total number of antihypertensive tablets procured for the 22 districts increased from 16 million in 2017-2018 to 160 million in 2019-2020. The proportion of facilities with Amlodipine stock-out was below 5% during the study period. Amlodipine stock was available for at least 60 patient days from the third quarter of 2019 onward in all districts. CONCLUSIONS: This study demonstrates that including best practices can gradually strengthen the procurement and supply chain for antihypertensives in a low-resource setting. As the program was rapidly growing, there were still gaps in the procurement and distribution system which needed to be addressed to ensure the adequacy of drugs. We recommend that best practices, including choosing a single protocol, basing supply on projected patient load rather than an increment from historical levels, and using simple stock management tools, be replicated in other districts in India to increase and sustain coverage of hypertension treatment.

Digital Health Solutions for Community-Based Control of Diabetes During COVID-19 Pandemic: A Scoping Review of Implementation Outcomes.

BACKGROUND: The COVID-19 pandemic has added to the pre-existing challenges of diabetes management in many countries. It has accelerated the wider use of digital health solutions which have tremendous potential to improve health outcomes for people with diabetes. However, little is known about the attributes and the implementation of these solutions. OBJECTIVE: To identify and describe digital health solutions for community-based diabetes management and to highlight their key implementation outcomes. METHODS: We searched Ovid Medline, CINAHL, Embase, PsycINFO, and Web of Science for relevant articles. A purposive search was also used to identify grey literature. Articles that described digital health solutions that aimed to improve community-based diabetes management were included in this review. We applied a thematic synthesis of evidence to describe the characteristics of digital health solutions, and to summarize their key implementation outcomes. RESULTS: We included 15 articles that reported digital health solutions that primarily focused on community-based diabetes management. Nine of the 15 innovations involved were mobile applications and/or web-based platforms, and five were based on social media platforms. The majority of the digital health solutions were used for diabetes education and support. High engagement, utilization, and satisfaction rates with digital health solutions were observed. The use of digital health solutions was also associated with improvement in self-management, taking medication, and reduction in glycated hemoglobin (HbA1c) levels. CONCLUSION: COVID-19 triggered digital health solutions have tremendous potential to improve health outcomes for people with diabetes. Further studies are needed to evaluate the sustainability and scale-up of these solutions.

India Hypertension Control Initiative-Hypertension treatment and blood pressure control in a cohort in 24 sentinel site clinics.

The India Hypertension Control Initiative (IHCI) is a multi-partner initiative, implementing and scaling up a public health hypertension control program across India. A cohort of 21,895 adult hypertension patients in 24 IHCI sentinel site facilities in four Indian states (Punjab, Madhya Pradesh, Maharashtra, and Telangana), registered from January 2018 until June 2019 were assessed at baseline and then followed up for blood pressure (BP) control and antihypertensive medication use. Among all registrations, 11 274 (51%) of the patients returned for a follow-up visit between July 2019 and September 2019. Among patients returning for follow-up, 26.3% had BP controlled at registration, and 59.8% had BP controlled at follow-up (p < .001). The absolute improvement in BP control was more than two times greater in primary care (48.1 percentage point increase) than secondary care facilities (22.9 percentage point increase). Most IHCI patients received prescriptions according to state-specific treatment protocols. This study demonstrates that a scalable public health hypertension control program can yield substantial BP control improvements, especially in primary care settings. However, high loss to follow-up limits population health impact; future efforts should focus on improving systems to increase the likelihood that patients will return to the clinic for routine hypertension care.

Lifestyle-associated risk for cardiovascular diseases among doctors and nurses working in a medical college hospital in Tamil Nadu, India.

CONTEXT: Globally, about 17 million people die of cardiovascular diseases (CVDs) every year and a substantial number of these deaths are attributed to four major risk factors namely unhealthy diet, physical inactivity, tobacco consumption, and alcohol consumption. Doctors and nurses often have a sedentary lifestyle. AIMS: This study aimed at assessing the lifestyle-associated risk for CVDs among doctors and nurses in a medical college hospital. SETTING AND DESIGN: Cross-sectional study among 250 doctors and nurses, selected using a stratified random sampling, working at a medical college hospital in Tamil Nadu. SUBJECTS AND METHODS: After consenting, each participant answered a questionnaire comprising questions pertaining to the sociodemographic characteristics as well as lifestyle-related risk factors. Risk was categorized into low, moderate, and high based on general risk factors, physical activity risk factors, and dietary risk factors separately. STATISTICAL ANALYSIS: Descriptive statistics and Chi-square analysis were used to analyze the data. RESULTS: It was found that 31.2% of all study subjects and 49.2% of doctors were at high general risk for CVDs; 30.4% of all study subjects and 42.1% of doctors were at high physical activity-related risk for CVDs; 14.4% of all study subjects and 19.8% of all doctors were at high dietary pattern-related risk for CVDs. Advancing age is a statistically significant risk factor across all risk groups. CONCLUSIONS: Doctors are at a higher risk for CVDs as compared to nurses as well as the general population.