Community preparedness for COVID-19 and frontline health workers in Chhattisgarh.

At the end of April 2020, there had already been three million cases of COVID-19 in the world pandemic. Chhattisgarh might expect 90,000 diagnosed cases of COVID-19 in the end. The first step taken in March was to ensure a simple checklist of activities that needed to continue. Handbills were given with the basic information on the symptoms and what to do in the community. In urban areas, the lockdown affected the poorer section of the society, especially who are not having BPL card and no other means of availing necessary eatables. Issues that arose affecting regular activities such as tuberculosis and immunization. Residents of informal settlements are also vulnerable during any COVID-19 responses. Frontline workers such as Mitanins in the community are an important asset in the capacity building and preparedness strategies.

Exploratory study on the operational issues faced in collection, transportation, and laboratory testing related to COVID-19 in remote areas of selected EAG states of North East and East India.

BACKGROUND: COVID-19 ongoing pandemic has proved beyond doubt that all countries in the world from high income to low- and middle-income countries were unprepared with under-diagnosed and underreported losses of precious human lives on already overstretched healthcare delivery infrastructure. Thus, the urgent need of the hour is to understand and identify the operational issues and challenges encountered in the sample collection process and also at the testing labs in order to respond at the earliest. This early and effective response will help not only to address the identified issues in the whole chain of sample collecting to test result communication but also it will help to improve the functioning of the entire system involved in this process. OBJECTIVES: The present study was undertaken to identify the issues faced during various steps involved in laboratory testing as part of the COVID-19 control activities in selected remote districts of North East and East India. Further, perceived adequacy of human resources, equipment, diagnostic kits, and other essential consumables including PPEs vis-a-vis the load of samples received from the catchment areas of the testing laboratories were also explored. METHODS: The study was a qualitative research using in-depth interview method to collect and collate the data from the chain of personnel involved in sample collection, storage, transportation, and testing by recorded telephonic interview by state-level collaborators as per the study protocol. The respondents were recruited from randomly selected sites of remote districts for sample collection, storage, transportation, and dedicated testing labs in six states of North East and Eastern India. The study findings were analyzed by two-dimensional scaling and hierarchical cluster analysis to get the collective picture involving transcription, preliminary data scrutiny, content analysis, and interpretation of the verbal IDI; classified and summarized by triangulation; free listing and pile sorting of suggestions. RESULTS: The entire laboratory testing related human resources has been working on war-footing round-the-clock to fulfil the expectation of the stakeholders and maintaining high quality despite the ever-increasing load of sample testing in both the public and private sectors. The findings indicated that the healthcare workers from all levels of laboratory diagnosis have taken it as a challenge to control the pandemic even with limitations of logistics to capacity building. Positive suggestions to improve laboratory services were to increase human resources, infrastructure, IT with the robust mechanism of monitoring and supervision. CONCLUSIONS: Upgradation of laboratory capacities and expertise in public health has become one of the points of concern to contain the COVID-19 pandemic of the new millennium.

Evidence-based National Vaccine Policy.

India has over a century old tradition of development and production of vaccines. The Government rightly adopted self-sufficiency in vaccine production and self-reliance in vaccine technology as its policy objectives in 1986. However, in the absence of a full-fledged vaccine policy, there have been concerns related to demand and supply, manufacture vs. import, role of public and private sectors, choice of vaccines, new and combination vaccines, universal vs. selective vaccination, routine immunization vs. special drives, cost-benefit aspects, regulatory issues, logistics etc. The need for a comprehensive and evidence based vaccine policy that enables informed decisions on all these aspects from the public health point of view brought together doctors, scientists, policy analysts, lawyers and civil society representatives to formulate this policy paper for the consideration of the Government. This paper evolved out of the first ever ICMR-NISTADS national brainstorming workshop on vaccine policy held during 4-5 June, 2009 in New Delhi, and subsequent discussions over email for several weeks, before being adopted unanimously in the present form.

Response to Jain et al on emergency healthcare in low resource areas.

"Sustaining for-profit emergency healthcare services in low resource areas" by Jain et al is an excellent reply to the Bawaskars. Clearly, the state must prevent both patients from going bankrupt and practitioners from running into negative balances.

Cost effectiveness of decentralised care model for managing MDR-TB in India.

BACKGROUND: In India, multidrug-resistant tuberculosis (MDR-TB) patients are usually treated in hospitals. Decentralised care model, however, has been suggested as a possible alternative by the World Health Organization (WHO). In the "End TB Strategy", the WHO highlights, as one of the key targets for 2035, that 'no TB-affected families should face catastrophic hardship due to the tuberculosis'. Removal of financial barriers to health-care access and mitigation of catastrophic expenditures are therefore considered vital to achieve the universal health coverage (UHC) goal. Since forgoing healthcare due to the financial constraints is a known fact in India, decentralised care as an intervention choice (as against hospital-based care) might enhance equity provided it is an affordable choice. Thus, an economic evaluation was conducted, from the perspective of the national health system in India, to assess the cost-effectiveness of decentralised care compared to centralised care for MDR-TB. METHODS: This study uses a decision-analytic model with a follow-up of two years to assess the expected costs of the decentralised versus the centralised approaches for MDR-TB treatment. A published systematic review of observational studies yielded the MDR-TB treatment outcomes, which included treatment success, treatment default, treatment failure, and mortality parameters. It was observed that these parameters did not vary significantly between the two alternatives. Treatment costs included the following costs: hospital admission costs, clinic costs, visits to laboratory and MDR-TB centre, drug therapy, injections and food. Costs data of drugs, diagnosis, hospital stay and travel to public facilities, based on a simple market survey, were taken from a recently published study on MDR-TB expenditures in the Chhattisgarh state of India. Potential cost savings related to the implementation of decentralised MDR-TB care for all patients who initiated MDR-TB treatment in India were additionally estimated. RESULTS: Estimated average expected total treatment cost was US$ 3390.56 for the hospital-based model and US$ 1724.1 for the decentralised model for a patient treated for MDR-TB in India, generating potential savings of US$1666.50 per case, with ICER US$ 2382.68 per QALY gained. One of the primary drivers of this difference was the significantly more intensive (thus expensive) stay charges in the hospital. If the costs and treatment probabilities are extrapolated to the whole country, with 48114 MDR-TB patients initiated on treatment in 2017, decentralised care would have additional 1058 patients cured, gain additional 3824 QALYs, and avert 2165 deaths, as compared to centralised care, in India. At various scenarios of coverage rates of decentralised and centralised care the cost difference would range between 23% and 94% for the country. CONCLUSION: Our study provides evidence of cost savings for MDR-TB patients if patients choose decentralised treatment in comparison to suggested hospitalisation of these patients for centralised treatment with similar outcomes. The economic evaluation presented in this study expected significant efficiency gains in choice of two treatment options and the cost savings may improve equity. In India, treatment of MDR-TB using decentralised care is expected to result in similar patient outcomes at markedly reduced public health costs compared with centralised care.

Access and availability of essential medicines in Chhattisgarh: Situation in public health facilities.

BACKGROUND: In 2013, the Government of Chhattisgarh announced a policy guaranteeing access to free generic medicines in all the public health facilities. This study was conducted with the objectives of evaluating the prescribing patterns of physicians in public health facilities with regard to generic medicines, and whether the prescribed generic medicines were made available to patients. MATERIALS AND METHODS: This cross-sectional study was conducting from December 2013-October 2014, using exit interviews of patients. Out of the total 27 districts of the state, 15 districts were selected, and one district hospital, three community health centers, and three primary health centers were selected from each of these districts, as per logistics feasibility. Descriptive statistics in the form of frequencies and percentages were calculated. RESULTS: During the data collection period, a total of 1290 prescriptions were reviewed from 100 public health facilities. Around 68.89% of the medicines prescribed were generic and were from the 2013 generic drugs list. Around 58.28% of the prescribed generic medicines were available to the patients from these public health facilities, and the rest of the medicines were procured from private pharmacies. CONCLUSION: Chhattisgarh has made considerable progress in increasing access of generic medicines to patients in public health facilities. Our study shows that for the year 2013-14, about 58% of the prescribed medicines were available in various public health facilities. There is opportunity to further improve the state financial allocation for generic medicines, to improve supply chain and logistics for better distribution, and to mandate that physicians in these facilities prescribe generic medicines.

Dynamics of the antibodies in cohorts of cured cases of visceral leishmaniasis: its implication on the validity of serological test, value in prognosis and in post therapeutic assessment.

The major disadvantage of a Serological test like Direct Agglutination Test (DAT) for Visceral Leishmaniasis (also called Kala-azar) is its inability to distinguish between recent and past infection. The objective of our study was to look at rate of decline of antibodies in fully cured cases of Kala-azar and length of time it takes for DAT to become negative. Cohort Study involving completely treated Kala-azar cases from Government Hospital during one calendar year of study. Cases were selected on the basis of treatment cohorts 0, 3, 6, 9 & 12 mo after completion of treatment.. Phase I--The cases were traced and after obtaining the informed consent they were subjected to Direct Agglutination Test (DAT). Phase II--The five treatment cohorts, constituting 82 cured cases (average of 15 cured cases per each treatment cohort) were tested again with DAT three months after the first test. The titers of Phase-I and phase-II tests were analyzed for the dynamics of the antibodies for the period. Cutoff-Values of DAT below 1:800 are considered negative. Values of 1:800, 1:1200, 1:1600 and so on are considered positive. The mean titer [Geometric Mean Titer (GMT)] at the start of treatment was 1:1120, which showed steady decline up to six months, plummeting below the cutoff titer for the DAT (1:800) at the ninth month. Antibodies continue to linger for about one year in cured Kala-azar cases even after correct and complete treatment. Single DAT results may be misleading due to high false positivity up to one year after the cure. Paired test defined as two tests 3 mo apart on the same subject. Paired test is highly recommended for diagnosis and prognosis. DAT is still a very useful tool for diagnosis if used along with clinical correlation.