Socioeconomic and demographic predictors of high blood pressure, diabetes, asthma and heart disease among adults engaged in various occupations: evidence from India.

In India, non-communicable diseases (NCDs) accounted for nearly 62% of all deaths in 2016. Four NCDs - high blood pressure, diabetes, asthma and heart disease - together accounted for over 34% of these deaths. Using data from two rounds of the India Human Development Surveys (IHDSs), levels and changes in the prevalence rates of the four NCDs (based on diagnosed cases) among adults aged 15-69 years in India between 2004-05 and 2011-12 were examined by socioeconomic and demographic factors and for five broad occupation categories. The socioeconomic and demographic risk factors for each of these NCDs were determined using multiple linear logistic regression analysis of pooled data from two rounds of the IHDS. The results showed that while urban residence, age, female sex and education were associated with higher odds of high blood pressure, diabetes and heart disease, household economic status was associated with higher odds for all four NCDs. Furthermore, increased higher odds of high blood pressure, diabetes and heart disease were found for the legislator/senior official/professional occupation group compared with non-workers. Skilled agricultural/elementary workers had lower odds of high blood pressure, diabetes, asthma and heart disease. Craft/machine-related trade workers had higher odds of high blood pressure and diabetes, and reduced odds of asthma and heart disease. Compared with non-workers, the odds ratios for asthma were lower for all other occupational categories. During the two study decades, the Government of India implemented several programmes designed to improve the health and well-being of its people. However, more focused attention on the adult population is needed, and special attention should be paid to the issue of the occupational health of the working population through the strict implementation of work place safety protocols and the removal of potential health hazards.

Adding interventions to mass measles vaccinations in India.

OBJECTIVE: To quantify the impact on mortality of offering a hypothetical set of technically feasible, high-impact interventions for maternal and child survival during India's 2010-2013 measles supplementary immunization activity. METHODS: We developed Lives Saved Tool models for 12 Indian states participating in the supplementary immunization, based on state- and sex-specific data on mortality from India's Million Deaths Study and on health services coverage from Indian household surveys. Potential add-on interventions were identified through a literature review and expert consultations. We quantified the number of lives saved for a campaign offering measles vaccine alone versus a campaign offering measles vaccine with six add-on interventions (nutritional screening and complementary feeding for children, vitamin A and zinc supplementation for children, multiple micronutrient and calcium supplementation in pregnancy, and free distribution of insecticide-treated bednets). FINDINGS: The measles vaccination campaign saved an estimated 19 016 lives of children younger than 5 years. A hypothetical campaign including measles vaccine with add-on interventions was projected to save around 73 900 lives (range: 70 200-79 300), preventing 73 700 child deaths (range: 70 000-79 000) and 300 maternal deaths (range: 200-400). The most effective interventions in the whole package were insecticide-treated bednets, measles vaccine and preventive zinc supplementation. Girls accounted for 66% of expected lives saved (12 712/19 346) for the measles vaccine campaign, and 62% of lives saved (45 721/74 367) for the hypothetical campaign including add-on interventions. CONCLUSION: In India, a measles vaccination campaign including feasible, high-impact interventions could substantially increase the number of lives saved and mitigate gender-related inequities in child mortality.

Making the health system work for over 25 million births annually: drivers of the notable decline in maternal and newborn mortality in India.

INTRODUCTION: India's progress in reducing maternal and neonatal mortality since the 1990s was faster than the regional average. We systematically analysed how national health policies, services for maternal and newborn health, and socioeconomic contextual changes, drove these mortality reductions. METHODS: The study's mixed-methods design integrated quantitative trend analyses of mortality, intervention coverage and equity since the 1990s, using the sample registration system and national surveys, with interpretive understandings from policy documents and 13 key informant interviews. RESULTS: India's maternal mortality ratio (MMR) declined from 412 to 103 maternal deaths per 100 000 live births between 1997-1998 and 2017-2019. The neonatal mortality rate (NMR) declined from 46 to 22 per 1000 live births between 1997 and 2019. The average annual rate of mortality reduction increased over time. During this period, coverage of any antenatal care (57%-94%), quality antenatal care (37%-85%) and institutional delivery (34%-90%) increased, as did caesarean section rates among the poorest tertile (2%-9%); these coverage gains occurred primarily in the government (public) sector. The fastest rates for increasing coverage occurred during 2005-2012.The 2005-2012 National Rural Health Mission (which became the National Health Mission in 2012) catalysed bureaucratic innovations, additional resources, pro-poor commitments and accountability. These efforts occurred alongside smaller family sizes and improvements in macroeconomic growth, mobile and road networks, women's empowerment, and nutrition. These together reduced high-risk births and improved healthcare access, particularly among the poor. CONCLUSION: Rapid reduction in NMR and MMR in India was accompanied by increased coverage of maternal and newborn health interventions. Government programmes strengthened public sector services, thereby expanding the reach of these interventions. Simultaneously, socioeconomic and demographic shifts led to fewer high-risk births. The study's integrated methodology is relevant for generating comprehensive knowledge to advance universal health coverage.

A tale of two exemplars: the maternal and newborn mortality transitions of two state clusters in India.

BACKGROUND: India's progress in reducing maternal and newborn mortality since the 1990s has been exemplary across diverse contexts. This paper examines progress in two state clusters: higher mortality states (HMS) with lower per capita income and lower mortality states (LMS) with higher per capita income. METHODS: We characterised state clusters' progress in five characteristics of a mortality transition model (mortality levels, causes, health intervention coverage/equity, fertility and socioeconomic development) and examined health policy and systems changes. We conducted quantitative trend analyses, and qualitative document review, interviews and discussions with national and state experts. RESULTS: Both clusters reduced maternal and neonatal mortality by over two-thirds and half respectively during 2000-2018. Neonatal deaths declined in HMS most on days 3-27, and in LMS on days 0-2. From 2005 to 2018, HMS improved coverage of antenatal care with contents (ANCq), institutional delivery and postnatal care (PNC) by over three-fold. In LMS, ANCq, institutional delivery and PNC rose by 1.4-fold. C-sections among the poorest increased from 1.5% to 7.1% in HMS and 5.6% to 19.4% in LMS.Fewer high-risk births (to mothers <18 or 36+ years, birth interval <2 years, birth order 3+) contributed 15% and 6% to neonatal mortality decline in HMS and LMS, respectively. Socioeconomic development improved in both clusters between 2005 and 2021; HMS saw more rapid increases than LMS in women's literacy (1.5-fold), household electricity (by 2-fold), improved sanitation (3.2-fold) and telephone access (6-fold).India's National (Rural) Health Mission's financial and administrative flexibility allowed states to tailor health system reforms. HMS expanded public health resources and financial schemes, while LMS further improved care at hospitals and among the poorest. CONCLUSION: Two state clusters in India progressed in different mortality transitions, with efforts to maximise coverage at increasingly advanced levels of healthcare, alongside socioeconomic improvements. The transition model characterises progress and guides further advances in maternal and newborn survival.

Human rights approach to maternal & child health: has India fared well?

BACKGROUND & OBJECTIVES: The objectives of the study were to examine: right to access maternal health; right to access child health; and right to access improved water and sanitation in India. METHODS: We used large-scale data sets like District Level Household Survey conducted in 2007-08 and National Family Health Surveys conducted during 1992-93, 1998-99, and 2005-06 to fulfil the objectives. The selection of the indicator variables was guided by the Human Rights' Framework for Health and Convention of the Rights of the Child- Articles 7, 24 and 27. We used univariate and bivariate analysis along with ratio of access among non-poor to access among poor to fulfil the objectives. RESULTS: Evidence clearly suggested gross violation of human rights starting from the birth of an individual. Even after 60 years of independence, significant proportions of women and children do not have access to basic services like improved drinking water and sanitation. INTERPRETATION & CONCLUSIONS: There were enormous socio-economic and residence related inequalities in maternal and child health indicators included in the study. These inequalities were mostly to the disadvantage of the poor. The fulfilment of the basic human rights of women and children is likely to pay dividends in many other domains related to overall population and health in India.

First 72-hours after birth: Newborn feeding practices and neonatal mortality in India.

BACKGROUND: The reductions in mortality levels among children under five years are observed in most populations, including populations that were lagging the progress in the past. However, the reduction is not uniform across ages during childhood. The mortality declines within the first month have shown relatively slow progress. Early initiation of breastfeeding and discarding pre-lacteal feed protects the newborn from acquiring infection and, thereby, reduces mortality. This paper assesses the change in the prevalence of early initiation of breastfeeding and pre-lacteal feed along with their associated factors, and their association with neonatal mortality in India. METHODS: We used data from the three rounds of National Family Health Surveys conducted during 2005-06, 2015-16 and 2019-21 in India. We used bivariate and multivariate analyses to examine prevalence rates, risk factors, and relationships between breastfeeding practices, including early initiation of breastfeeding and pre-lacteal feed, and neonatal mortality. RESULTS: Early initiation of breastfeeding within one hour after birth increased rapidly from 25% in 2005-06 to 42% in 2019-21, and the pre-lacteal feeding practice declined from 57% in 2005-06 to 15% in 2019-21. Pre-lacteal feed is lower in states/districts where early breastfeeding initiation is predominant and vice versa. The role of health professionals during pregnancy and the first two days after delivery significantly improved breastfeeding practice. Further, the findings suggest that an early breastfeeding initiation is associated with lower neonatal mortality, whereas pre-lacteal feed is not harmful compared to late breastfeeding initiation. CONCLUSION: Prevalence of pre-lacteal feed reduced, and initiation of early breastfeeding increased considerably after the launch of the National Rural Health Mission in India. However, after 2015-16, early breastfeeding initiation has stagnated, and the decline in pre-lacteal feed has slowed down. The future program needs special attention to emphasize the availability and accessibility of breastfeeding advisers and observers in health facilities to help mitigate adverse neonatal outcomes.

Trends in selective abortions of girls in India: analysis of nationally representative birth histories from 1990 to 2005 and census data from 1991 to 2011.

BACKGROUND: India's 2011 census revealed a growing imbalance between the numbers of girls and boys aged 0-6 years, which we postulate is due to increased prenatal sex determination with subsequent selective abortion of female fetuses. We aimed to establish the trends in sex ratio by birth order from 1990 to 2005 with three nationally representative surveys and to quantify the totals of selective abortions of girls with census cohort data. METHODS: We assessed sex ratios by birth order in 0·25 million births in three rounds of the nationally representative National Family Health Survey covering the period from 1990 to 2005. We estimated totals of selective abortion of girls by assessing the birth cohorts of children aged 0-6 years in the 1991, 2001, and 2011 censuses. Our main statistic was the conditional sex ratio of second-order births after a firstborn girl and we used 3-year rolling weighted averages to test for trends, with differences between trends compared by linear regression. FINDINGS: The conditional sex ratio for second-order births when the firstborn was a girl fell from 906 per 1000 boys (99% CI 798-1013) in 1990 to 836 (733-939) in 2005; an annual decline of 0·52% (p for trend=0·002). Declines were much greater in mothers with 10 or more years of education than in mothers with no education, and in wealthier households compared with poorer households. By contrast, we did not detect any significant declines in the sex ratio for second-order births if the firstborn was a boy, or for firstborns. Between the 2001 and 2011 censuses, more than twice the number of Indian districts (local administrative areas) showed declines in the child sex ratio as districts with no change or increases. After adjusting for excess mortality rates in girls, our estimates of number of selective abortions of girls rose from 0-2·0 million in the 1980s, to 1·2-4·1 million in the 1990s, and to 3·1-6·0 million in the 2000s. Each 1% decline in child sex ratio at ages 0-6 years implied 1·2-3·6 million more selective abortions of girls. Selective abortions of girls totalled about 4·2-12·1 million from 1980-2010, with a greater rate of increase in the 1990s than in the 2000s. INTERPRETATION: Selective abortion of girls, especially for pregnancies after a firstborn girl, has increased substantially in India. Most of India's population now live in states where selective abortion of girls is common. FUNDING: US National Institutes of Health, Canadian Institute of Health Research, International Development Research Centre, and Li Ka Shing Knowledge Institute.

Causes of neonatal and child mortality in India: a nationally representative mortality survey.

BACKGROUND: More than 2·3 million children died in India in 2005; however, the major causes of death have not been measured in the country. We investigated the causes of neonatal and child mortality in India and their differences by sex and region. METHODS: The Registrar General of India surveyed all deaths occurring in 2001-03 in 1·1 million nationally representative homes. Field staff interviewed household members and completed standard questions about events that preceded the death. Two of 130 physicians then independently assigned a cause to each death. Cause-specific mortality rates for 2005 were calculated nationally and for the six regions by combining the recorded proportions for each cause in the neonatal deaths and deaths at ages 1-59 months in the study with population and death totals from the United Nations. FINDINGS: There were 10,892 deaths in neonates and 12,260 in children aged 1-59 months in the study. When these details were projected nationally, three causes accounted for 78% (0·79 million of 1·01 million) of all neonatal deaths: prematurity and low birthweight (0·33 million, 99% CI 0·31 million to 0·35 million), neonatal infections (0·27 million, 0·25 million to 0·29 million), and birth asphyxia and birth trauma (0·19 million, 0·18 million to 0·21 million). Two causes accounted for 50% (0·67 million of 1·34 million) of all deaths at 1-59 months: pneumonia (0·37 million, 0·35 million to 0·39 million) and diarrhoeal diseases (0·30 million, 0·28 million to 0·32 million). In children aged 1-59 months, girls in central India had a five-times higher mortality rate (per 1000 livebirths) from pneumonia (20·9, 19·4-22·6) than did boys in south India (4·1, 3·0-5·6) and four-times higher mortality rate from diarrhoeal disease (17·7, 16·2-19·3) than did boys in west India (4·1, 3·0-5·5). INTERPRETATION: Five avoidable causes accounted for nearly 1·5 million child deaths in India in 2005, with substantial differences between regions and sexes. Expanded neonatal and intrapartum care, case management of diarrhoea and pneumonia, and addition of new vaccines to immunisation programmes could substantially reduce child deaths in India. FUNDING: US National Institutes of Health, International Development Research Centre, Canadian Institutes of Health Research, Li Ka Shing Knowledge Institute, and US Fund for UNICEF.

Timing of first sex before marriage and its correlates: evidence from India.

While several studies have documented the extent of pre-marital sexual experience among young people in India, little work has been done to explore the factors that are correlated with the timing of pre-marital sexual initiation. This paper examines age at initiation of pre-marital sex, circumstances in which first sex was experienced, nature of first sexual experience and correlates of age at initiation of pre-marital sex. Life table estimates suggest that pre-marital sexual initiation occurred in adolescence for 1 in 20 young women and 1 in 10 young men. For the majority of these young people, their first sex was with an opposite-sex romantic partner. First sex, moreover, was unprotected for the majority and forced for sizeable proportion of young women. A number of individual, family-, peer- and community-level factors were correlated with age at first pre-marital sex. Moreover, considerable gender differences were apparent in the correlates of age at first pre-marital sex, with peer- and parent-level factors found more often to be significant for young women than men.

Trends in missing females at birth in India from 1981 to 2016: analyses of 2·1 million birth histories in nationally representative surveys.

BACKGROUND: Half of the world's missing female births occur in India, due to sex-selective abortion. It is unknown whether selective abortion of female fetuses has changed in recent years across different birth orders. We sought to document the trends in missing female births, particularly among second and third children, at national and state levels. METHODS: We examined birth histories from five nationally representative household surveys (National Family Health Surveys 1-4 and District Level Household Survey 2) to compute the conditional sex ratio (defined as the number of girls born per 1000 boys depending on previous birth sex) in India during 1981-2016. We estimated decadal variation in conditional sex ratio for 1987-96, 1997-2006, and 2007-16, and quantified trends in the numbers of missing female births for the states constituting >95% of India's population, as well as in 5-year intervals for each survey round. We used multivariate logistic regression to calculate the odds ratio of a second (or third) girl depending on the sex of the earlier child (or children), adjusting for education, wealth, religion, caste, and place of residence. FINDINGS: We assessed 2·1 million birth histories across the five surveys. Applying the conditional sex ratios from the surveys to national births, we found that 13·5 million female births were missing during the three decades of observation (1987-2016), on the basis of a natural sex ratio of 950 girls per 1000 boys. Missing female births increased from 3·5 million in 1987-96 to 5·5 million in 2007-16. Contrasting the conditional sex ratio from the first decade of observation (1987-96) to the last (2007-16) showed worsening for the whole of India and almost all states, among both birth orders. Punjab, Haryana, Gujarat, and Rajasthan had the most skewed sex ratios, comprising nearly a third of the national totals of missing second-born and third-born females at birth. From about 1986, the conditional sex ratio for second-order or third-order births after an earlier daughter or daughters diverged notably from that after an earlier son or sons. From 1981 to 2016, the sex ratio for second-born children after an earlier daughter decreased from 930 (99% CI 869-990) to 885 (859-912), and that for third-born children after two earlier daughters decreased from 968 (866-1069) to 788 (746-830). The probability of missing girls was mostly determined by earlier daughters, even after considering wealth quintile and education levels. The conditional sex ratio among the richest and most educated mothers was most distorted compared with lower wealth and education groups, and generally decreased with time, until a modest improvement in 2007-16. INTERPRETATION: In contrast to the substantial improvements in female child mortality in India, missing female births, driven by selective abortion of female fetuses, continues to increase across the states. Inclusion of a question on sex composition of births in the forthcoming census would provide local information on sex-selective abortion in each village and urban area of the country. FUNDING: None. TRANSLATION: For the Hindi translation of the abstract see Supplementary Materials section.

Perceived gender role that shape youth sexual behaviour: Evidence from rural Orissa, India.

The study attempts to understand the association of perceived gender role with youth sexual behavior using qualitative data such as focus group discussions (N=8), in-depth interviews (N=42), and free listing (N=50) of rural married youths from Orissa, India. Data collection was conducted during July 2006-April 2007. Atlas. ti and ANTHROPAC packages have been used for the analysis. Youths in general are expected to adhere to the roles ascribed for them based on their biological construct and any deviation is not warranted for, more so for young women. Moreover, for many young men perceived gender role coupled with poor self risk perception result into unsafe sexual activities, putting them as well as their partners at the risk of STI/HIV and unintended parenthood.

Participation in civil society and political life among young people in Maharashtra: Findings from the Youth in India - Situation and Needs study.

Youth participation in civil society and political life is increasingly recognised to be an important development objective. Nonetheless, research that sheds light on the extent to which youth participate in these arenas, and the factors that facilitate or inhibit such participation remain limited in most developing countries including India. Drawing on data from a representative survey of young people in the state of Maharashtra, India, this paper explores the extent of and the factors associated with youth participation in civil society, their adherence to pro-social values, and their participation in political processes. Findings suggest that for many youth, particularly for young women, opportunities to engage in civil society and political life are limited, and that pro-social values are not uniformly observed. Findings underline the importance of education, agency and close parental interaction in facilitating youth participation in civil society and political life and their expression of pro-social values.

Factors Associated with Disposable Menstrual Absorbent Use Among Young Women in India.

CONTEXT: Hygienic use of absorbent products during menstruation is a challenge for young women in India, especially among the underprivileged, who lack knowledge and access to resources. Reuse of menstrual absorbents can be unhygienic and result in adverse health and other outcomes. METHODS: Data from the 2015-2016 National Family Health Survey-4 for 233,606 menstruating women aged 15-24 were used to examine levels and correlates of exclusive use of disposable absorbents during menstruation. Bivariate and logistic regression analyses were conducted to identify disparities in exclusive use by such characteristics as caste, mass media exposure and interaction with health workers. RESULTS: Exclusive use of disposable absorbents was low among young women overall (37%), and varied substantially by caste and other characteristics. Compared with women from general castes, those from scheduled castes, scheduled tribes and other backward classes had reduced odds of exclusive disposable absorbent use (odds ratios, 0.8-0.9). Disposable absorbent use was negatively associated with lower levels of education and household wealth, and rural residence. Compared with women who reported daily media exposure, those exposed less frequently had reduced odds of disposable absorbent use (0.7-0.9). Among those who recently met with a health worker, odds of use were lower if menstrual hygiene had not been discussed (0.9). CONCLUSIONS: Promoting awareness of proper menstrual hygiene-through education, media campaigns and discussion with reproductive health workers-and targeted interventions to disseminate and subsidize the purchase of disposable sanitary napkins should be pursued to address health disparities.

RESUMEN Contexto: El uso higiénico de productos absorbentes durante la menstruación es un reto para las mujeres jóvenes en India, especialmente entre las carentes de privilegios que no tienen el conocimiento y el acceso a recursos. Reusar los productos absorbentes del flujo menstrual puede ser antihigiénico y derivar en resultados adversos para la salud y de otro tipo. Métodos: Se utilizaron datos correspondientes a los años 2015-2016 de la Encuesta Nacional de Salud Familiar 4 de 233,606 mujeres menstruantes en edades de 15 a 24 años, para examinar niveles y correlatos del uso exclusivo de productos absorbentes desechables durante la menstruación. Se condujeron análisis de regresión bivariada y logística para identificar las disparidades en el uso exclusivo por características tales como la casta, la exposición a medios masivos y la interacción con trabajadores sanitarios. Resultados: El uso exclusivo de productos absorbentes desechables fue bajo en mujeres jóvenes en general (37%) y varió sustancialmente en función de la casta y otras características. En comparación con mujeres de castas generales, aquellas pertenecientes a castas y tribus oficialmente reconocidas y otras clases en desventaja, tuvieron reducidas probabilidades de un uso exclusivo de productos absorbentes desechables (razón de probabilidades, 0.8-0.9). El uso de productos absorbentes desechables se asoció negativamente con más bajos niveles educativos y de riqueza familiar, así como con el hecho de residir en zonas rurales. En comparación con las mujeres que reportaron tener exposición diaria a los medios, aquellas con una exposición menos frecuente tuvieron probabilidades reducidas de usar productos absorbentes desechables (0.7-0.9). Entre aquellas que tuvieron contacto reciente con un trabajador sanitario las probabilidades de uso exclusivo fueron menores si la higiene menstrual no había sido abordada durante la consulta (0.9). Conclusiones: Debe procurarse la promoción de la conciencia acerca de una apropiada higiene menstrual -a través de la educación, las campañas de medios y las conversaciones con trabajadores de la salud reproductiva- así como las intervenciones para diseminar y subsidiar la compra de toallas sanitarias desechables con el fin de hacer frente a las disparidades en salud.

RÉSUMÉ Contexte: L'utilisation hygiénique de produits absorbants pendant la menstruation pose un défi aux jeunes femmes d'Inde, en particulier celles défavorisées, qui manquent d'information et d'accès aux ressources. La réutilisation d'absorbants menstruels peut être contraire à l'hygiène et donner lieu à des résultats de santé et autres défavorables. Méthodes: Les données de l'Enquête nationale 2015-2016 sur la santé familiale-4 relatives à 233 606 femmes réglées âgées de 15 à 24 ans ont servi à examiner les niveaux et les corrélats de l'utilisation exclusive d'absorbants jetables pendant la menstruation. Les disparités en ont été identifiées par analyses de régression logistique et bivariée en fonction de caractéristiques telles que la caste, l'exposition aux médias et l'interaction avec les agents de santé. Résultats: L'utilisation exclusive d'absorbants jetables s'est révélée faible parmi les jeunes femmes dans leur ensemble (37%), avec une variation nette suivant la caste et d'autres caractéristiques. Par rapport aux femmes des castes générales, celles des castes et tribus répertoriées et des autres classes inférieures présentaient une probabilité réduite d'utilisation exclusive d'absorbants jetables (RC, 0,8-0,9). L'utilisation d'absorbants jetables était associée négativement aux niveaux d'éducation et de richesse du ménage inférieurs, ainsi qu'à la résidence en milieu rural. Par rapport aux femmes ayant fait état d'une exposition journalière aux médias, celles qui y étaient exposées moins fréquemment étaient moins susceptibles d'utiliser des produits absorbants jetables (0,7-0,9). Parmi celles qui s'étaient entretenues récemment avec un agent de santé, la probabilité d'utilisation était moindre si la question de l'hygiène menstruelle n'avait pas été abordée (0,9). Conclusions: La promotion de la sensibilisation à une bonne hygiène menstruelle ­ par l'éducation, les campagnes médiatiques et la discussion avec les agents de santé reproductive ­ et des interventions de dissémination et de subvention de l'achat de serviettes hygiéniques jetables doivent être poursuivies pour éliminer les disparités sanitaires.

National, regional, and state-level burden of Streptococcus pneumoniae and Haemophilus influenzae type b disease in children in India: modelled estimates for 2000-15.

BACKGROUND: India accounts for a disproportionate burden of global childhood illnesses. To inform policies and measure progress towards achieving child health targets, we estimated the annual national and state-specific childhood mortality and morbidity attributable to Streptococcus pneumoniae and Haemophilus influenzae type b (Hib) between 2000 and 2015. METHODS: In this modelling study, we used vaccine clinical trial data to estimate the proportion of pneumonia deaths attributable to pneumococcus and Hib. The proportion of meningitis deaths attributable to each pathogen was derived from pathogen-specific meningitis case fatality and bacterial meningitis case data from surveillance studies. We applied these proportions to modelled state-specific pneumonia and meningitis deaths from 2000 to 2015 prepared by the WHO Maternal and Child Epidemiology Estimation collaboration (WHO/MCEE) on the basis of verbal autopsy studies from India. The burden of clinical and severe pneumonia cases attributable to pneumococcus and Hib was ascertained with vaccine clinical trial data and state-specific all-cause pneumonia case estimates prepared by WHO/MCEE by use of risk factor prevalence data from India. Pathogen-specific meningitis cases were derived from state-level modelled pathogen-specific meningitis deaths and state-level meningitis case fatality estimates. Pneumococcal and Hib morbidity due to non-pneumonia, non-meningitis (NPNM) invasive syndromes were derived by applying the ratio of pathogen-specific NPNM cases to pathogen-specific meningitis cases to the state-level pathogen-specific meningitis cases. Mortality due to pathogen-specific NPNM was calculated with the ratio of pneumococcal and Hib meningitis case fatality to pneumococcal and Hib meningitis NPNM case fatality. Census data from India provided the population at risk. FINDINGS: Between 2000 and 2015, estimates of pneumococcal deaths in Indian children aged 1-59 months fell from 166 000 (uncertainty range [UR] 110 000-198 000) to 68 700 (44 600-86 000), while Hib deaths fell from 82 600 (52 300-112 000) to 15 600 (9800-21 500), representing a 58% (UR 22-78) decline in pneumococcal deaths and an 81% (59-91) decline in Hib deaths. In 2015, national mortality rates in children aged 1-59 months were 56 (UR 37-71) per 100 000 for pneumococcal infection and 13 (UR 8-18) per 100 000 for Hib. Uttar Pradesh (18 900 [UR 12 300-23 600]) and Bihar (8600 [5600-10 700]) had the highest numbers of pneumococcal deaths in 2015. Uttar Pradesh (9300 [UR 5900-12 700]) and Odisha (1100 [700-1500]) had the highest numbers of Hib deaths in 2015. Less conservative assumptions related to the proportion of pneumonia deaths attributable to pneumococcus indicate that as many as 118 000 (UR 69 000-140 000) total pneumococcal deaths could have occurred in 2015 in India. INTERPRETATION: Pneumococcal and Hib mortality have declined in children aged 1-59 months in India since 2000, even before nationwide implementation of conjugate vaccines. Introduction of the Hib vaccine in several states corresponded with a more rapid reduction in morbidity and mortality associated with Hib infection. Rapid scale-up and widespread use of the pneumococcal conjugate vaccine and sustained use of the Hib vaccine could help accelerate achievement of child survival targets in India. FUNDING: Bill & Melinda Gates Foundation.

National, regional, and state-level all-cause and cause-specific under-5 mortality in India in 2000-15: a systematic analysis with implications for the Sustainable Development Goals.

BACKGROUND: India had the largest number of under-5 deaths of all countries in 2015, with substantial subnational disparities. We estimated national and subnational all-cause and cause-specific mortality among children younger than 5 years annually in 2000-15 in India to understand progress made and to consider implications for achieving the Sustainable Development Goal (SDG) child survival targets. METHODS: We used a multicause model to estimate cause-specific mortality proportions in neonates and children aged 1-59 months at the state level, with causes of death grouped into pneumonia, diarrhoea, meningitis, injury, measles, congenital abnormalities, preterm birth complications, intrapartum-related events, and other causes. AIDS and malaria were estimated separately. The model was based on verbal autopsy studies representing more than 100 000 neonatal deaths globally and 16 962 deaths among children aged 1-59 months at the subnational level in India. By applying these proportions to all-cause deaths by state, we estimated cause-specific numbers of deaths and mortality rates at the state, regional, and national levels. FINDINGS: In 2015, there were 25·121 million livebirths in India and 1·201 million under-5 deaths (under-5 mortality rate 47·81 per 1000 livebirths). 0·696 million (57·9%) of these deaths occurred in neonates. There were disparities in child mortality across states (from 9·7 deaths [Goa] to 73·1 deaths [Assam] per 1000 livebirths) and regions (from 29·7 deaths [the south] to 63·8 deaths [the northeast] per 1000 livebirths). Overall, the leading causes of under-5 deaths were preterm birth complications (0·330 million [95% uncertainty range 0·279-0·367]; 27·5% of under-5 deaths), pneumonia (0·191 million [0·168-0·219]; 15·9%), and intrapartum-related events (0·139 million [0·116-0·165]; 11·6%), with cause-of-death distributions varying across states and regions. In states with very high under-5 mortality, infectious-disease-related causes (pneumonia and diarrhoea) were among the three leading causes, whereas the three leading causes were all non-communicable in states with very low mortality. Most states had a slower decline in neonatal mortality than in mortality among children aged 1-59 months. Ten major states must accelerate progress to achieve the SDG under-5 mortality target, while 17 are not on track to meet the neonatal mortality target. INTERPRETATION: Efforts to reduce vaccine-preventable deaths and to reduce geographical disparities should continue to maintain progress achieved in 2000-15. Enhanced policies and programmes are needed to accelerate mortality reduction in high-burden states and among neonates to achieve the SDG child survival targets in India by 2030. FUNDING: Bill & Melinda Gates Foundation.

Survival outcomes post percutaneous coronary intervention: Why the hype about stent type? Lessons from a healthcare system in India.

A prospective, multicenter study was initiated by the Government of Maharashtra, India, to determine predictors of long-term outcomes of percutaneous coronary intervention (PCI) for coronary artery disease, and to compare the effectiveness of drug-eluting stents (DESs) and bare-metal stents (BMSs) in patients undergoing PCI under government-funded insurance. The present analysis included 4595 patients managed between August 2012 and November 2016 at any of 110 participating centers. Using the classical multivariable regression and propensity-matching approach, we found age to be the most important predictor of 1-year mortality and target lesion revascularization at 1 year post-PCI. However, using machine learning methods to account for unmeasured confounders and bias in this large observational study, we determined total stent length and number of stents deployed as the most important predictors of 1-year survival, followed by age and employment status. The unadjusted death rates were 5.0% and 3.8% for the BMS and DES groups, respectively (p = 0.185, log-rank test). The rate of re-hospitalization (p<0.001) and recurrence of unstable angina (p = 0.08) was significantly lower for DESs than for BMSs. Increased use of DES after 2015 (following establishment of a price cap on DESs) was associated with a sharp decrease in adjusted hazard ratios of DESs versus BMSs (from 0.94 in 2013 to 0.58 in 2016), suggesting that high price was limiting DES use in some high-risk patients. Since stented length and stent number were the most important predictors of survival outcomes, adopting an ischemia-guided revascularization strategy is expected to help improve outcomes and reduce procedural costs. In the elderly, PCI should be reserved for cases where the benefits outweigh the higher risk of the procedure. As unemployed patients had poorer long-term outcomes, we expect that implementation of a post-PCI cardiovascular rehabilitation program may improve long-term outcomes.

Patterns, factors associated and morbidity burden of asthma in India.

BACKGROUND: Asthma is a non-curable but preventable disease, responsible for higher morbidity worldwide. According to recent WHO report, nearly 235 million people are suffering from asthma leading to 383000 deaths in 2015. The burden of asthma morbidity is higher in developed countries and is increasing in developing countries. OBJECTIVE: The present study was aimed at studying the change in prevalence rate of asthma, associated risk factors and estimation of morbidity burden and avoidable cases of asthma in India. METHODS: The second round of Indian Human Development Survey (IHDS-II), 2011-12, was used for the study. For the present study, asthma was defines as ever diagnosed with asthma or having cough with short breath. Multiple-logistic regression was used to identify the possible risk factors associated with prevalence of reporting asthma. Population attributable fractions (PAFs) were computed to estimate the overall and risk factors specific burden of morbidity due to asthma using the extrapolated population of year 2015 using 2011 census. RESULTS: Overall prevalence rate of asthma increased from 41.9 (per 1000 population) in 2004-05 to 54.9 (per 1000 population) in 2011-12. The prevalence rate of reporting asthma was higher in poorer states compared to richer states, and also varied by sub-geographies, with higher prevalence rate in northern states of the country and lower rates in north-eastern states of the country. The odds of reporting asthma was higher for younger and older ages, individual with fewer years of schooling (OR: 1.41; 95% CI: 1.21-1.64) for individual with zero years of schooling compared to those with 11 or more years of schooling, individual from lower economic status, individual living in household using unclean fuels (OR:1.21; 95% CI: 1.08-1.34) and smokers (OR: 1.34; 95% CI: 1.17-1.55) compared to their counterparts. In the year 2015, the overall morbidity burden of asthma was estimated at nearly 65 million and more than 82 thousand deaths were attributed due to asthma. The burden was highest among individuals living in households using solid fuels (firewood~80%, Kerosene~78%). One-third of the cases could be eliminated by minimising the use of any solid fuels. Around 17% of all the asthma cases in population could be attributed to underweight. CONCLUSION: Eliminating the modifiable risk factors could help reduce in huge amount of asthma cases for example by providing education, cessation in smoking, and schemes like Pradhan Mantri Ujjwala Yojana (PMUY), by providing clean fuel (LPG) to poor and vulnerable households.

Threshold Levels of Infant and Under-Five Mortality for Crossover between Life Expectancies at Ages Zero, One and Five in India: A Decomposition Analysis.

OBJECTIVES: Under the prevailing conditions of imbalanced life table and historic gender discrimination in India, our study examines crossover between life expectancies at ages zero, one and five years for India and quantifies the relative share of infant and under-five mortality towards this crossover. METHODS: We estimate threshold levels of infant and under-five mortality required for crossover using age specific death rates during 1981-2009 for 16 Indian states by sex (comprising of India's 90% population in 2011). Kitagawa decomposition equations were used to analyse relative share of infant and under-five mortality towards crossover. FINDINGS: India experienced crossover between life expectancies at ages zero and five in 2004 for menand in 2009 for women; eleven and nine Indian states have experienced this crossover for men and women, respectively. Men usually experienced crossover four years earlier than the women. Improvements in mortality below ages five have mostly contributed towards this crossover. Life expectancy at age one exceeds that at age zero for both men and women in India except for Kerala (the only state to experience this crossover in 2000 for men and 1999 for women). CONCLUSIONS: For India, using life expectancy at age zero and under-five mortality rate together may be more meaningful to measure overall health of its people until the crossover. Delayed crossover for women, despite higher life expectancy at birth than for men reiterates that Indian women are still disadvantaged and hence use of life expectancies at ages zero, one and five become important for India. Greater programmatic efforts to control leading causes of death during the first month and 1-59 months in high child mortality areas can help India to attain this crossover early.

Facility Delivery, Postnatal Care and Neonatal Deaths in India: Nationally-Representative Case-Control Studies.

OBJECTIVE: Clinical studies demonstrate the efficacy of interventions to reduce neonatal deaths, but there are fewer studies of their real-life effectiveness. In India, women often seek facility delivery after complications arise, rather than to avoid complications. Our objective was to quantify the association of facility delivery and postnatal checkups with neonatal mortality while examining the "reverse causality" in which the mothers deliver at a health facility due to adverse perinatal events. METHODS: We conducted nationally representative case-control studies of about 300,000 live births and 4,000 neonatal deaths to examine the effect of, place of delivery and postnatal checkup on neonatal mortality. We compared neonatal deaths to all live births and to a subset of live births reporting excessive bleeding or obstructed labour that were more comparable to cases in seeking care. FINDINGS: In the larger study of 2004-8 births, facility delivery without postnatal checkup was associated with an increased odds of neonatal death (Odds ratio = 2.5; 99% CI 2.2-2.9), especially for early versus late neonatal deaths. However, use of more comparable controls showed marked attenuation (Odds ratio = 0.5; 0.4-0.5). Facility delivery with postnatal checkup was associated with reduced odds of neonatal death. Excess risks were attenuated in the earlier study of 2001-4 births. CONCLUSION: The combined effect of facility deliveries with postnatal checks ups is substantially higher than just facility delivery alone. Evaluation of the real-life effectiveness of interventions to reduce child and maternal deaths need to consider reverse causality. If these associations are causal, facility delivery with postnatal check up could avoid about 1/3 of all neonatal deaths in India (~100,000/year).