Surveillance based estimation of burden of malaria in India, 2015-2016.

BACKGROUND: India has launched the malaria elimination initiative in February 2016. Studies suggest that estimates of malaria are useful to rationalize interventions and track their impact. Hence, a national study was launched to estimate burden of malaria in India in 2015. METHODS: For sampling, all 624 districts of India were grouped in three Annual Parasite Incidence (cases per thousand population) categories, < two (low); two-five (moderate) and > five (high) API. Using probability proportional to size (PPS) method, two districts from each stratum were selected covering randomly 200,000 persons per district. Active surveillance was strengthened with 40 trained workers per study district. Data on malaria cases and deaths was collated from all health care providers i.e. pathological laboratories, private practitioners and hospitals in private and public health sectors and was used for analysis and burden estimation. RESULTS: Out of 1215,114 population under surveillance, 198,612 (16.3%) tests were performed and 19,386 (9.7%) malaria cases were detected. The malaria cases estimated in India were 3875,078 (95% confidence interval 3792,018-3958,137) with API of 3.05 (2.99-3.12) including 2789,483 (2740,577-2838,389) Plasmodium falciparum with Annual Falciparum Incidence of 2.2 (2.16-2.24). Out of 8025 deaths investigated, 102 (1.27%) were attributed to malaria. The estimated deaths in India were 29,341 (23,354-35,327) including 19,067 (13,665-24,470) confirmed and 10,274 (7694-12,853) suspected deaths in 2015-2016. CONCLUSIONS: Estimated malaria incidence was about four folds greater than one million reported by the national programme, but three folds lesser than thirteen million estimated by the World Health Organization (WHO). However, the estimated deaths were 93 folds more than average 313 deaths reported by the national malaria programme in 2015-2016. The 29,341 deaths were comparable with 24,000 deaths in 2015 and 22,786 deaths in 2016 estimated by the WHO for India. These malaria estimates can serve as a benchmark for tracking the success of malaria elimination campaign in India.

Determination of cut-off and correlates of delay in treatment-seeking of febrile illness: a retrospective analysis.

BACKGROUND: Early diagnosis and treatment of malaria symptoms reduces the risk of severe complication and malaria transmission. However, delay in malaria diagnosis and treatment is a major public health problem in India. The primary aim of the study was to determine cut-off for the delay in seeking treatment of fever, and the secondary aim was to identify the factors associated with delay in malaria-endemic areas of Assam, Northeast India. METHODS: The present study analysed data from two prior cross-sectional surveys (community- and hospital-based) that was conducted to study the health-seeking behaviour of people residing in high malaria-endemic areas of Assam, Northeast India. The hospital-based survey data were used to determine optimal cut-off for the delay in reporting, and further, used to identify the factors associated with delay using community-based data. RESULTS: Mean age of fever cases was similar in both community- and hospital-based surveys (23.1 years vs 24.2 years, p = 0.229). Delay in reporting fever was significantly higher among hospital inpatients compared to community-based fever cases (3.6 ± 2.1 vs 4.0 ± 2.6 days; p = 0.006). Delay of > 2 days showed higher predictive ability (sensitivity: 96.4%, and ROC area: 67.5%) compared to other cut-off values (> 3, > 4, and > 5 days). Multivariable logistic regression analysis revealed that the adjusted odds ratio (aOR) of delay was significantly higher for people living in rural areas (1.52, 95%CI: 1.11-2.09), distance (> 5 km) to health facility (1.93, 95%CI: 1.44-2.61), engaged in agriculture work (2.58, 95%CI: 1.97-3.37), and interaction effect of adult male aged 20-40 years (1.71, 95%CI: 1.06-2.75). CONCLUSION: The delay (> 2 days) in seeking treatment was likely to be twice among those who live in rural areas and travel > 5 km to assess health care facility. The findings of the study are useful in designing effective intervention programmes for early treatment of febrile illness to control malaria.

Association of religion and cultural tradition with alcohol use among some tribal communities of Arunachal Pradesh, India.

Arunachal Pradesh, a land of high mountains and dense forest, is home to many tribal communities, which comprise two thirds of the state's population. Alcohol is one of the common addictive substances used traditionally among them despite much awareness about its harmful effect on health. The present study is focused on finding the association of religion, ethnicity, and demographic characteristics with alcohol use among some tribal communities in Changlang district of Arunachal Pradesh. A cross-sectional household survey was conducted on substance use in Changlang district of Arunachal Pradesh, India. A sample of 3,421 tribal respondents (1,795 males and 1,626 females) aged 15 years and older was extracted and analyzed. Sociodemographic differences in the prevalence of alcohol use among the tribes were analyzed and compared using the chi-square and t test. Multivariate logistic regression analysis was applied to identify the predictor variables of alcohol use. Data analysis indicates high prevalence of alcohol use (39.1%) among the tribes; and it was higher among males (49.3%) than among females (27.9%). Alcohol use was higher among Indigenous (65%) and Hindu (55.1%) religions compared with Buddhist (24.7%) and Christian (10%). It was also recorded high among Tangsa (42.0%) and Tutsa (76%) tribes compared with Singpho (13.6%) and Khamti (11.4%). High association of alcohol use among the tribal community with age, occupation, ethnicity, and religion was also recorded. Association of alcohol use with demographic characteristics, religion, and ethnic group shows the traditional and cultural belief in alcohol use persists among the tribes.

Determinants of malaria prevention and control at household level in Assam: An analysis of data using composite index.

Background: Malaria prevention and control is a major public health problem of tropical countries including India. Usage of insecticide-treated bed nets, and early treatment especially in high-risk areas are the crucial factors for the malaria prevention at household levels. This study aimed to determine the crucial factors associated with malaria prevention at households' level such as household's characteristics, education, knowledge and awareness, insecticide treated bed nets usage, early treatment etc. Methods: Data of 1989 households was used from the cross-sectional survey of malaria-endemic areas of Assam. Principal component analysis and multinomial logistic regression model were used to compute the composite scores of malaria awareness and prevention practices, and to estimate the associated factors with malaria prevention practices, respectively. Results: The average age of household respondents were 41.1 ± 12.0 years and among them 71% were males. Almost 47% respondents were illiterate, and 38.6% of the respondents were farmers and 35% were employed. Multinomial logistic regression analysis indicates that malaria prevention practices are associated with age, education, religion, type of house and occupation of household heads and their level of malaria awareness among them. The prevention practices were significantly five times associated [Adjusted Rates Ratio (ARR): 5.0, 95% CI: 2.7-9.4] with the high level of malaria awareness compared with the low level of awareness. Overall, the level of prevention awareness, education, occupation, and house type related to the standard of living was significantly associated with the malaria prevention practices. Conclusion: Malaria awareness and education are the key factors of malaria prevention practices that need to be accelerated for effective control of malaria. Malaria education and increasing awareness of people have a high impact on malaria prevention practices and their control.

Gender-dependent multiple cross-phenotype association of interferon lambda genetic variants with peripheral blood profiles in healthy individuals.

BACKGROUND: Type III interferons (IFN), also called as lambda IFNs (IFN-λs), are antiviral and immunomodulatory cytokines that are evolutionarily important in humans. Given their central roles in innate immunity, they could be influencing other aspects of human biology. This study aimed to examine the association of genetic variants that control the expression and/or activity of IFN-λ3 and IFN-λ4 with multiple phenotypes in blood profiles of healthy individuals. METHODS: In a cohort of about 550 self-declared healthy individuals, after applying several exclusion criteria to determine their health status, we measured 30 blood parameters, including cellular, biochemical, and metabolic profiles. We genotyped them at rs12979860 and rs28416813 using competitive allele-specific PCR assays and tested their association with the blood profiles under dominant and recessive models for the minor allele. IFN-λ4 variants rs368234815 and rs117648444 were also genotyped or inferred. RESULTS: We saw no association in the combined cohort under either of the models for any of the phenotypes. When we stratified the cohort based on gender, we saw a significant association only in males with monocyte (p = 1 × 10-3 ) and SGOT (p = 7 × 10-3 ) levels under the dominant model and with uric acid levels (p = 0.01) under the recessive model. When we tested the IFN-λ4 activity modifying variant within groupings based on absence or presence of one or two copies of IFN-λ4 and on different activity levels of IFN-λ4, we found significant (p < 0.05) association with several phenotypes like monocyte, triglyceride, VLDL, ALP, and uric acid levels, only in males. All the above significant associations did not show any confounding when we tested for the same with up to ten different demographic and lifestyle variables. CONCLUSIONS: These results show that lambda interferons can have pleiotropic effects. However, gender seems to be an effect modifier, with males being more sensitive than females to the effect.

Correlates of opium use: retrospective analysis of a survey of tribal communities in Arunachal Pradesh, India.

BACKGROUND: Household survey data of Changlang district, Arunachal Pradesh, were used in the present study to assess the prevalence of opium use among different tribes, and to examine the association between sociodemographic factors and opium use. METHODS: A sample of 3421 individuals (1795 men and 1626 women) aged 15 years and older was analyzed using a multivariate logistic regression model to determine factors associated with opium use. Sociodemographic information such as age, education, occupation, religion, ethnicity and marital status were included in the analysis. RESULTS: The prevalence of opium use was significantly higher (10.6%) among men than among women (2.1%). It varied according to age, educational level, occupation, marital status and religion of the respondents. In both sexes, opium use was significantly higher among Singpho and Khamti tribes compared with other tribes. Multivariate logistic regression indicated that opium use was significantly associated with age, occupation, ethnicity, religion and marital status of the respondents of both sexes. Multivariate rate ratios (MRR) for opium use were significantly higher (4-6 times) among older age groups (≥35 years) and male respondents. In males, the MRR was also significantly higher in respondents of Buddhist and Indigenous religion, while in females, the MRR was significantly higher in Buddhists. Most of the female opium users had taken opium for more than 5 years and were introduced to it by their husbands after marriage. Use of other substances among opium users comprised mainly tobacco (76%) and alcohol (44%). CONCLUSIONS: The study reveals the sociodemographic factors, such as age, sex, ethnicity, religion and occupation, which are associated with opium use. Such information is useful for institution of intervention measures to reduce opium use.

A retrospective study of environmental predictors of dengue in Delhi from 2015 to 2018 using the generalized linear model.

Dengue fever is a mosquito-borne infection with a rising trend, expected to increase further with the rise in global temperature. The study aimed to use the environmental and dengue data 2015-2018 to examine the seasonal variation and establish a probabilistic model of environmental predictors of dengue using the generalized linear model (GLM). In Delhi, dengue cases started emerging in the monsoon season, peaked in the post-monsoon, and thereafter, declined in early winter. The annual trend of dengue cases declined, but the seasonal pattern remained alike (2015-18). The Spearman correlation coefficient of dengue was significantly high with the maximum and minimum temperature at 2 months lag, but it was negatively correlated with the difference of average minimum and maximum temperature at lag 1 and 2. The GLM estimated ß coefficients of environmental predictors such as temperature difference, cumulative rainfall, relative humidity and maximum temperature were significant (p < 0.01) at different lag (0 to 2), and maximum temperature at lag 2 was having the highest effect (IRR 1.198). The increasing temperature of two previous months and cumulative rainfall are the best predictors of dengue incidence. The vector control should be implemented at least 2 months ahead of disease transmission (August-November).

Temporal variation and geospatial clustering of dengue in Delhi, India 2015-2018.

OBJECTIVES: The study was focused on geographical mapping of dengue cases and also to identify the hotspots or high-risk areas of dengue in Delhi. DESIGN: A retrospective spatial-temporal (ecological) study. Descriptive analysis was used to know the distribution of dengue cases by age, sex, seasons and districts of Delhi. The spatiotemporal analysis was performed using inverse distance weighting and Getis-Ord Gi* statistic to know the geographical distribution and identify the hotspot areas. SETTINGS: All the confirmed and diagnosed dengue cases (IgM +ve or NS1 Antigen +ve ELISA) recorded by the Municipal Corporation of Delhi for the last 4 years (2015-2018) were collected with their local address. The location of all the dengue cases was geocoded using their address to prepare the spatiotemporal dengue database. PARTICIPANTS: Record of all the dengue cases (4179) reported for treatment in the hospitals during the past 4 years were extracted and included in the study. Data were not collected directly from dengue patients. RESULTS: Seasonal occurrence of dengue cases (4179) shows that the cases start emerging in July, peaked in September-October and declined in December. The proportions of dengue cases were recorded high among the males 57.3% compared with females 42.6%, and differences were also recorded in all the age groups with more cases in age groups <15 and 16-30 years. Mapping of the cases reflects the spatial heterogeneity in the geographical distribution. The geomapping of cases indicates the presence of a significantly high number of cases in West, Southwest, South and Southeast districts of Delhi. High-risk areas or hotspots were also identified in this region. CONCLUSION: Dengue occurrence shows significant association with age, sex and seasons. The spatial analysis identified the high-risk areas, which can aid health administrators to take necessary action for prevention and better disease management.

How varying CD4 criteria for treatment initiation was associated with mortality of HIV-patients? A retrospective analysis of electronic health records from Andhra Pradesh, India.

BACKGROUND: HIV treatment and care services were scaled up in 2007 in India with objective to increase HIV-care coverage. CD4 count based criteria was mainly used for treatment initiation with increasing threshold in later years. Therefore, this paper aimed to evaluate the survival by varying CD4 criteria for antiretroviral treatment (ART) initiation among of HIV-positive patients, and independent factors associated with the mortality. METHODS: This retrospective cohort study included 127 949 HIV-positive patients aged ≥15 years, who initiated ART between 2007 and 2013 in Andhra Pradesh state, India. The patient's demographic and clinical characteristics were extracted from the patient's health records from electronic Computerized Management Information System Software (CMIS). Incidence of mortality/100 person-years was calculated for CD4 and treatment initiation categories. Kaplan-Meier and multivariable Cox-regression analyses were used to explore the association. RESULTS: Median CD4 count was 172 (inter-quartile range (IQR) = 102-240) at the time of treatment initiation, and 19.3% of them had ≤ 100 CD4 count. Incidence of mortality for the period 2007-08 (CD4 ≤ 200 cells/mm3) was 8.5/100 person-years compared to 6.4/100 person-years at risk for the period 2012 onwards (CD4 ≤ 350 cells/mm3). Earlier thresholds for treatment initiation showed higher risk of mortality (2007-08 (CD4 ≤ 200 cells/mm3), adjusted hazard ratio (HR): 1.86, 95% confidence interval (CI): 1.68-2.07; 2009-11 (CD4 ≤ 250 cells/mm3), HR = 1.67, 95% CI = 1.51-1.85) compared to 2012 onwards (CD4 ≤ 350 cells/mm3) criteria for treatment initiation. CONCLUSIONS: Increasing CD4 threshold for treatment initiation over time was independently associated with lower risk of mortality. More efforts are required to detect and treat early, monitoring of follow-ups, promote health education to improve ART adherence, and provide supportive environment that encourages HIV-infected patients to disclose their HIV status in confidence.

Treatment-seeking for febrile illness in north-east India: an epidemiological study in the malaria endemic zone.

BACKGROUND: This paper studies the determinants of utilization of health care services, especially for treatment of febrile illness in the malaria endemic area of north-east India. METHODS: An area served by two districts of Upper Assam representing people living in malaria endemic area was selected for household survey. A sample of 1,989 households, in which at least one member of household suffered from febrile illness during last three months and received treatment from health service providers, were selected randomly and interviewed by using the structured questionnaire. The individual characteristics of patients including social indicators, area of residence and distance of health service centers has been used to discriminate or group the patients with respect to their initial and final choice of service providers. RESULTS: Of 1,989 surveyed households, initial choice of treatment-seeking for febrile illness was self-medication (17.8%), traditional healer (Vaidya)(39.2%), government (29.3%) and private (13.7%) health services. Multinomial logistic regression (MLR) analysis exhibits the influence of occupation, area of residence and ethnicity on choice of health service providers. The traditional system of medicine was commonly used by the people living in remote areas compared with towns. As all the febrile cases finally received treatment either from government or private health service providers, the odds (Multivariate Rate Ratio) was almost three-times higher in favour of government services for lower households income people compared to private. CONCLUSION: The study indicates the popular use of self-medication and traditional system especially in remote areas, which may be the main cause of delay in diagnosis of malaria. The malaria training given to the paramedical staff to assist the health care delivery needs to be intensified and expanded in north-east India. The people who are economically poor and living in remote areas mainly visit the government health service providers for seeking treatment. So, the improvement of quality health services in government health sector and provision of health education to people would increase the utilization of government health services and thereby improve the health quality of the people.

Risk of malaria among febrile patients: retrospective analysis of a hospital-based study in an endemic area of northeast India.

BACKGROUND: Febrile illness is the most common symptom experienced by patients suspected of having malaria, especially in the malaria endemic areas of northeast India. Hospital-based data from two districts of upper Assam, namely Golaghat and Tinsukia, were analysed to assess the prevalence of malaria among inpatients who reported to health centres with febrile illness. METHODS: A total of 16 hospitals were selected for the study. These included six government hospitals (three in rural and three in urban areas) and 10 private hospitals, which included four tea-garden hospitals. Selection was dependant on the availability of patients and inpatient treatment facilities. During the study, a total of 350 inpatients reported to the selected hospitals with fever; 324 were suspected of having malaria and were interviewed and included in the study. RESULTS: The average age of patients was 24.2±15.2 years and 63.3% (205/324) of them were male. The majority of patients (77.5%; 251/324) belonged to the lower household income category (<5000 Indian rupees) and travelled to the nearest town or city for treatment. Overall, the prevalence of malaria (as diagnosed by clinical examination and blood tests) across the different categories such as location, types of hospitals and household income was found to be 29.9% (97/324). Multivariate analysis revealed that the adjusted odds ratios (AOR) of malaria cases was higher based on location (2.13), type of health centre (1.75) and the distance travelled to a health centre (2.09). The mean duration of hospital treatment was 4.2±3.6 days and the delay in reporting to hospital was 3.9±2.6 days. CONCLUSION: The study emphasises the need to strengthen and improve the treatment facilities for malaria in government hospitals, and to create more awareness among people regarding early treatment, especially in the rural periphery villages of the endemic areas.