Protocol of systematic reviews on implementation research on cardiovascular diseases, diabetes mellitus and mental ailments in India.

Introduction: The burden of non-communicable diseases (NCDs) is a major public health concern across the world. Various initiatives have tried to address these with varying degrees of success. Objective: The objective is to assess and collate existing evidence in implementation research done in India on three broad domains of NCDs namely, cardiovascular diseases (CVD), diabetes mellitus (DM), and mental health (MH) in India. Materials and methods: Three systematic review protocols have been drafted to explore and collate extant evidence of implementation research on cardiovascular diseases, diabetes mellitus, and mental health in India, in accordance with the PRISMA-P statement. Academic databases including PubMed, Embase and Science Direct will be searched. Search strategies will be formulated in iterative processes and in accordance with the formats that are specific to the databases that will be searched. In addition, grey literature and non-academic databases will also be explored. Data extracted from the selected studies will be analysed and a narrative summary of the selected articles, using the SWiM (Synthesis without meta-analysis) guidelines will be produced. Intended Outcomes: The outputs of these systematic reviews could help in a better understanding of implementation research gaps and also how to address them. Apart from giving insights into how healthcare initiatives for CVDs, diabetes and mental health could be implemented in a better way, the study could also advocate the need to build and consolidate capacity for implementation research in the country.

Knowledge, Attitude, and Practice of epilepsy in Wayanad, Kerala.

OBJECTIVE: Epilepsy is a common neurological condition characterized by recurrent seizures. The aim of the study was to assess the level of Knowledge, Attitude, and Practices (KAP) in epilepsy in the district of Wayanad. METHODS: This study was conducted among adults residing in Wayanad. This was a community-based door-to-door survey conducted among adults residing in Wayanad District between August 2021 and November 2021. A semi-structured questionnaire was used for data collection. The questionnaire included 23 items that could define the information on the level of knowledge and attitude toward epilepsy. RESULT: A total of 394 subjects without epilepsy were included in this study. According to the results of this study, 68.8% of respondents were female and 85.3% of them had completed at least primary school education. 93.1% of participants had heard about epilepsy and 64.5% of participants were aware that epilepsy was a brain disorder. 30.5% of participants believed that a person with epilepsy could not get married. 73.9% of participants recommended allopathic treatment for epilepsy and only 9.9% of participants knew about surgical treatment option for epilepsy. CONCLUSION: Despite having a good understanding of the disease, there is a general tendency in the population to consider patients with epilepsy as incapable of leading a normal life. The choice of modern treatment methods over traditional is also a positive aspect.

Potential implementation strategies, acceptability, and feasibility of new and repurposed TB vaccines.

Recently, two Phase 2B tuberculosis vaccine trials reported positive efficacy results in adolescents and adults. However, experience in vaccinating these age groups is limited. We identified potential implementation strategies for the M72/AS01E vaccination and BCG-revaccination-like candidates and explored their acceptability and feasibility. We conducted in-depth semi-structured interviews among key decision makers to identify implementation strategies and target groups in South Africa, India, and China. Thematic and deductive analysis using a coding framework were used to identify themes across and within settings. In all three countries there was interest in novel TB vaccines, with school-attending adolescents named as a likely target group. In China and India, older people were also identified as a target group. Routine vaccination was preferred in all countries due to stigma and logistical issues with targeted mass campaigns. Perceived benefits for implementation of M72/AS01E were the likely efficacy in individuals with Mycobacterium tuberculosis (Mtb) infection and efficacy for people living with HIV. Perceived challenges for M72/AS01E included the infrastructure and the two-dose regimen required. Stakeholders valued the familiarity of BCG but were concerned about the adverse effects in people living with HIV, a particular concern in South Africa. Implementation challenges and opportunities were identified in all three countries. Our study provides crucial information for implementing novel TB vaccines in specific target groups and on country specific acceptability and feasibility. Key groups for vaccine implementation in these settings were identified, and should be included in clinical trials and implementation planning.

Clinical and Laboratory Diagnostic Features of Kyasanur Forest Disease: A Study From Wayanad, South India.

Background Kyasanur forest disease (KFD), also known as monkey fever, was first recognized in the Shimoga district of Karnataka, India, in 1957. This study was conceived to address the paucity of medical literature on KFD, to describe the clinical and laboratory features of real-time reverse-transcriptase-polymerase chain reaction (rRT-PCR) confirmed cases of KFD, and to detect any change in the clinical picture and presentation of the disease over the last 30 years. Aim The study sought to document the clinical and laboratory features of Kyasanur forest disease (KFD), a tick-borne arboviral disease, now emerging in many parts of southern India. Material and methods This was a retrospective study using secondary data of patients with real-time reverse transcription-polymerase chain reaction (rRT-PCR)-confirmed KFD in a secondary care hospital in Wayanad, Kerala, India. Results Sixty rRT-PCR-proven KFD patients were included in the study. Commonly noted clinical symptoms were fever (98%), headache (80%), body ache (86%), vomiting (61%), and prostration (83%). Relative bradycardia, hypotension (45%), and oral lesions (23%) were the frequent physical signs. The median total leukocyte count and median platelet count at admission were 2600 per µL and 1.62 per µL, respectively. The median erythrocyte sedimentation rate was 10 mm/hr. Urinary sediments and albuminuria were seen in 66% and 60% respectively. The major complications observed were neurological complications (23%), bleeding manifestations (20%), and persistent shock (20%). The common neurological complications were seizures, altered sensorium, aseptic meningitis, and focal neurological deficits. The case fatality rate in the study was 6.7%. Conclusions The clinical picture of a prostrating viral syndrome in an epidemiological setting of KFD with marked leucopenia, moderate thrombocytopenia, low erythrocyte sedimentation rate (ESR), albuminuria, urinary sediments, and moderately elevated transaminases help in making an early diagnosis of KFD. Neurological complications in the initial two weeks are associated with poor outcomes.

Comparison of Health-care Utilization Pattern and its Correlates among the Tribal and NonTribal Population of Kerala.

BACKGROUND: The isolation from mainstream development activities, together with poverty and inaccessibility to health facilities made the tribal communities specifically vulnerable to various health problems. OBJECTIVES: This study aimed to compare the utilization of antenatal care, immunization, and supplementary nutrition services by tribal and nontribal mothers and its correlates in the selected districts. MATERIALS AND METHODS: The study was a comparative cross-sectional study. The study population comprised tribal and nontribal mothers utilizing antenatal care, immunization, and supplementary nutrition services. A multi-stage cluster sampling strategy was employed for the study. The Chi-square test was used to assess the association between antenatal care services utilization, utilization of immunization services, supplementary nutrition services utilization and sociodemographic variables, and other service characteristics. RESULTS: Effective utilization of antenatal care services was not seen in 5.6% of tribal mothers. The incidence of low-birth weight (≤2500) was significantly more among tribal mothers (31%) when compared to nontribal mothers (15%). The proportion of tribal children receiving complete immunization without delay was 74%, and among nontribal children, it was 78%. Effective immunization coverage was significantly lower among children of tribal mothers with education below high school level. Receipt of take-home ration was reported by nearly 90% of tribal and nontribal mothers. 90% of tribal mothers felt that quality of take-home ration that they received was of good quality. CONCLUSIONS: The comparison of health-care utilization restricted to the domains of antenatal care, immunization services, and supplementary nutrition suggests that the tribal mothers and children had a relatively comparable utilization pattern in most of the indicators measured.

Impediments to Optimal Health-care Utilization of a Particularly Vulnerable Tribal Group in Wayanad: A Qualitative Study.

INTRODUCTION: The pathways and mechanisms through which constraints that impede optimal utilization of the government health-care service provisions translate into health inequities among Particularly Vulnerable Tribal Groups seem to be an area that warrants research. OBJECTIVE: The objective is to explore and understand the mechanisms/pathways through which various factors result in health care inequity among the Kattunayakan tribe in Wayanad. MATERIALS AND METHODS: Designed as a qualitative case study, using observations and interviews with mothers, community members, and frontline health-care personnel, the study was conducted in a Kattunayakan hamlet in Wayanad. The data, in the form of digital audio recordings and field notes, were transcribed, coded, and analyzed using a thematic approach. RESULTS AND DISCUSSION: Axes of inquiry like access to health-care institutions, acceptability of the services provided, hurdles faced by the tribes, the health-care personnel, and how the system responded to these issues were explored. Disregard for the identity and culture of the tribes, geographical barriers for utilization and providing health services, proactive efforts from government systems, collaborations with private and professional bodies are important factors that possibly influence health inequities among tribes. CONCLUSION: Acknowledgment of the sociocultural identity of the tribes, gaining their trust, proactive efforts from the government machinery, innovative context-specific programs, strategic partnerships and a departure from the "blame the victim" philosophy are key in the effort to provide services that meet the health-care needs of the tribes.

Assessing health-seeking behavior among Asthma and COPD patients in urban South India.

CONTEXT: Health-seeking behavior of patients with chronic obstructive pulmonary disease (COPD) and asthma and the diagnosis told to them by doctors before they reach tertiary care is not well documented. AIMS: This study aimed at describing the health-seeking behavior of asthma and COPD patients before they present to a tertiary care hospital in Trivandrum in South India. METHODS AND MATERIALS: The hospital-based cross-sectional study was done at one government and one private tertiary care hospital in Trivandrum, Kerala, including diagnosed COPD and asthma patients. Data were collected using a pretested semistructured questionnaire paired with the results of clinical evaluation and spirometry. RESULTS: Among the studied population, about half (53%) of the patients in this study sought initial treatment from government facilities and most patients continued the same pattern of government care or private providers till the final level. Most of them (91%) were likely to have a history of first care from modern medicine system. High proportion of patients (89%) did not have a diagnosis known after the initial consultations, among patients with asthma only 3.4% were given a correct diagnosis and only one person was given a correct diagnosis of COPD out of 129 patients with COPD as the final diagnosis. Out of 739 patients, only 135 patients had done pulmonary functtion test as investigation. CONCLUSIONS: High proportions of patients do not know the diagnosis of their disease when they reached tertiary care. Patients tended to follow the same sector of health care (private/government) where they sought initial care.

Are WHO approved nucleic acid amplification tests causing large-scale "false identification" of rifampicin-resistant tuberculosis?: Programmatic experience from south india.

INTRODUCTION: The nucleic acid amplification tests (NAATs): Line probe assay and GeneXpert (Xpert) have evolved as the primary tool for identification of rifampicin (RIF)-resistant (RR) tuberculosis (TB) worldwide, primarily because of the ease and speed. We rechecked RR isolates identified by NAATs from presumptive RR TB cases belonging to South India by the Revised National TB Control Program, India using multiple RIF concentrations on Bactec MGIT system and compared the mutation patterns with the resistance levels. METHODOLOGY: Standard protocol for Bactec MGIT system as given by the manufacturer modified for the multiple RIF concentrations was used. All the retests were done in a certified BSL3 laboratory. RESULTS: We found that there is a mismatch of up to 20% (RIF breakpoint 0.5 mg/L); the NAATs probably overidentifying RR TB. Half of the cases with mismatch showed a sub-breakpoint rise in resistance level (0.125 mg/L to 0.5 mg/L RIF). DISCUSSION AND CONCLUSION: The probable reasons for the mismatch are "sub-breakpoint low-level resistance mutants," hetero-resistant bacterial populations, and other inherent test limitations along with the low RR TB prevalence in South India (<5%) among "presumptive multidrug-resistants." This could be due to the incomplete selection pressure by an inadequate RIF exposure caused by various factors including a low-RIF dosage being used widely and poor Directly observed treatment. To prevent the false diagnosis of RR TB in a massive scale when using NAATs, we may need to enforce a carefully targeted testing approach and a phenotypic susceptibility testing with multiple RIF concentrations for confirmatory purposes.