To assess the effectiveness of various communication strategies for improving childhood pneumonia case management: study protocol of a community based behavioral open labeled trial in rural Lucknow, Uttar Pradesh, India.

BACKGROUND: Community Acquired Pneumonia (CAP) is the leading cause of childhood morbidity and mortality worldwide including India. Many of these deaths can be averted by creating awareness in community about early symptoms of CAP and by ensuring availability of round the clock, quality health care. The objective was to assess the effectiveness of an innovative package of orienting doctors and community health workers about community perceptions on CAP barriers to qualified health care seeking, plus infrastructural strengthening by (i) providing "Pneumonia Drug Kit" (PDK) (ii) establishing "Pneumonia Management Corner" (PMC) at additional primary health center (PHCs) and (iii) "Pneumonia Management Unit" (PMU) at Community health center (CHCs) along with one of 4 different behavior change communication interventions: 1. Organizing Childhood Pneumonia Awareness Sessions (PAS) for caregivers of children < 5 years of age during a routine immunization day at PHCs and CHCs by Auxillary Nurse Midwives (ANM) 2. Organizing PAS on Village Health and Nutrition Day only once a month in villages by Accredited Social Health Activist (ASHA) 3. Combination of both Interventions 1 & 2 4. Usual Care as measured by number of clinical pneumonia cases-treated by ANM/doctors with PDK or treated at either PMC or PMU. METHODS: Prospective community based open labeled behavioral trial (2 by 2 factorial design) conducted in 8 rural blocks of Lucknow district. Community survey will be done by multistage cluster sampling to collect information on changes in types of health care providers' service utilization for ARI/CAP pre and post intervention. DISCUSSION: CAP is one of the leading killers of childhood deaths worldwide. Studies have reported that recognition of pneumonia and its danger signs is poor among caregivers. The proposed study will assess effectiveness of various communication strategies for improving childhood pneumonia case management interventions at mother/community level, health worker and health center level. The project will generate demand and improve supply of quality of care of CAP and thus result in reduced mortality in Lucknow district. Since the work will be done in partnership with government, it can be scaled up. TRIAL REGISTRATION: This study has been registered retrospectively in the AEARCT Registry and the registration number is: AEARCTR-0003137 .

Isolation and process parameter optimization of Brevibacterium casei for simultaneous bioremediation of hexavalent chromium and pentachlorophenol.

Chromate and pentachlorophenol are major pollutants discharged through tanneries. Three bacteria resistant to high Cr(6+) and PCP concentrations simultaneously were isolated. The TVS-3 strain was tolerant to highest 850 mg l(-1) Cr(6+) and 1000 mg l(-1) PCP concentration and concomitantly reduced 69% Cr(6+) and degraded 72% PCP within 168 h at pH 7.5, 35 ± 1°C temperature, was selected and identified as Brevibacterium casei. At 168 h of growth, bacterium showed maximum PCP utilization of 720 mg l(-1) and released 900 mg l(-1) chloride ion. The bacterium exhibited remarkable ability to significantly reduce Cr(6+) and degrade PCP in presence of other metals, between 100-120 rpm aeration and over broad pH (6.5-10.0) and temperature (30-40°C) range. Maximum 78% Cr(6+) reduction and 82% PCP degradation was observed at pH 8.0, 35 ± 1°C within 168 h of incubation, 120 rpm and initial concentration of 850 mg l(-1) Cr(6+) and 1000 mg l(-1) PCP. This is the first study reporting 78% Cr(6+) reduction and 82% PCP degradation simultaneously by single native bacteria under wide growth conditions utilizing PCP as sole carbon source. This bacterium may potentially be useful for simultaneous bioremediation of Cr(6+) and PCP containing wastes in the environment.

Incidence of community acquired pneumonia in children aged 2-59 months of age in Uttar Pradesh and Bihar, India, in 2016: An indirect estimation.

INTRODUCTION: Community Acquired Pneumonia (CAP) is the leading cause of mortality in children younger than five years of age in developing countries, including India. Hence, this prospective study was performed to estimate the incidence of CAP in children (2-59 months)in four districts of Northern India. METHODS: A cross-sectional survey in rural Lucknow was conducted using cluster sampling technique to assess the proportion of CAP cases that were hospitalized in last 12 months (hospitalization fraction). Another prospective study was done to assess number of hospitalized CAP cases in same districts in 2016. For this, a surveillance network of hospitals that admitted children was established. Cases with WHO-defined CAP with less than 14 days of illness were eligible for inclusion. Informed written parental consent was obtained. A mathematical model was developed to estimate the incidence of CAP in each district, taking into account number of cases hospitalized in one year, assuming it to be equal to hospitalization fraction and using Lucknow district as reference, correcting for child-population per hospital for each district. Population census data of 2011 was taken as denominator. RESULTS: In cross-sectional survey (February to May 2016), 3351 children (2-59 months) from 240 villages were included. Of these 24.58% (824/3351) children suffered from CAP in last 12 months and out of these 4% (33/824) children were hospitalized. Computed incidence of CAP per 1000 child-year for Lucknow was 86.50 (95%CI: 85.72-87.29); Etawah 177.01(95%CI: 175.44-178.58); Patna 207.78 (95%CI: 207.20-208.37) and Darbhanga 221.18 (95%CI: 220.40-221.97). Infants (2-11 months)had almost five to ten times higher incidence of CAP than those in 12-59 months age category. CONCLUSIONS: Incidence of CAP in Uttar Pradesh and Bihar is high, being much higher in infants. Hence there is an urgent need for introduction of preventive strategies, improving health seeking behavior and quality of care for CAP.

Revisiting community case management of childhood pneumonia: perceptions of caregivers and grass root health providers in Uttar Pradesh and Bihar, northern India.

BACKGROUND: Community-acquired pneumonia (CAP) is the leading cause of under-five mortality globally with almost one-quarter of deaths occurring in India. OBJECTIVES: To identify predisposing, enabling and service-related factors influencing treatment delay for CAP in rural communities of two states in India. Factors investigated included recognition of danger signs of CAP, health care decision making, self-medication, treatment and referral by local practitioners, and perceptions about quality of care. METHODS: Qualitative research employing case studies (CS) of care-seeking, key informant interviews (KII), semi-structured interviews (SSI) and focus group discussions (FGD) with both video presentations of CAP signs, and case scenarios. Interviews and FGDs were conducted with parents of under-five children who had suffered CAP, community health workers (CHW), and rural medical practitioners (RMP). RESULTS: From September 2013 to January 2014, 30 CS, 43 KIIs, 42 SSIs, and 42 FGDs were conducted. Recognition of danger signs of CAP among caregivers was poor. Fast breathing, an early sign of CAP, was not commonly recognized. Chest in-drawing was recognized as a sign of serious illness, but not commonly monitored by removing a child's clothing. Most cases of mild to moderate CAP were brought to RMP, and more severe cases taken to private clinics in towns. Mothers consulted local RMP directly, but decisions to visit doctors outside the village required consultation with husband or mother-in-law. By the time most cases reached a public tertiary-care hospital, children had been ill for a week and treated by 2-3 providers. Quality of care at government facilities was deemed poor by caregivers. CONCLUSION: To reduce CAP-associated mortality, recognition of its danger signs and the consequences of treatment delay needed to be better recognized by caregivers, and confidence in government facilities increased. The involvement of RMP in community based CAP programs needs to be investigated further given their widespread popularity.

Effect of ecological factors on conjugal transfer of chromium-resistant plasmid in Escherichia coli isolated from tannery effluent.

The influence of total organic carbon (TOC), pH, and mating temperature on transfer of chromium-resistant plasmid between Escherichia coli strains in terms of variation in the number of transconjugants formed and variation in transfer frequency was investigated. In vitro transfer was studied in five chromate-tolerant E. coli strains isolated from tannery effluent using E. coli K12 J62 (Nal(r) Lac-) as a recipient. Conjugal transfer of different selection markers was observed in three strains. The study was carried out in sterile wastewater. A gradual decrease was observed both in the number of transconjugants and in transfer frequencies as the concentration of TOC in the mating medium descended from 10,095 to 1.2 mg of C/L, obtaining the maximum values with a TOC concentration of 10,095 mg of C/L. The number of transconjugants and the transfer frequency were maximum at 30 degrees C. However, neither the transfer frequency nor the transconjugant number varied significantly in the range of pHs assayed. The strains were also found resistant to different heavy metals and antibiotics. Curing of these strains resulted in loss of one or more resistance markers indicating the plasmid-borne resistance. Itis inferred that plasmid transferby conjugation occurs in wastewater bodies within a wide range of conditions.

Occurrence of chromium resistant thermotolerant coliforms in tannery effluent.

Twenty six thermotolerant strains resistant to high levels of chromium (50-250 microg/ml) were isolated from treated tannery effluent. They were also found resistant to multiple heavy metals and antibiotics. Majority of them were resistant to copper and bacitracin. Nine strains representing different resistance patterns were selected for plasmid profile and conjugation studies. Agarose gel electrophoresis results revealed that 6 strains harboured a single plasmid, whereas 3 strains exhibited 2 plasmid bands. Among antimicrobials, co-trimazole and bacitracin and among metals, Cu2+, Cd2+, Zn2+ and Ni2+ resistance were transferred most frequently at variable rates. However, chromium resistance was transferred in 6 strains with a frequency ranging 19-49x10(-2). Resistance to Co2+ and Hg2+ did not transfer under environmental conditions. Among the nine strains, three were found predominantly uropathogenic Escherichia coli (UPEC) serotype 04, whereas two strains were untypable. In addition, 4 transconjugants also showed a positive result after serotyping.

Anemia and undernutrition among preschool children in Uttar Pradesh, India.

This study was conducted to assess the prevalence of anemia among preschool children (3-5 years) and its association with malnutrition in rural Barabanki district of Uttar Pradesh, India. Three out of 18 sub-centers in Nindura block, Barabanki, each with six villages, were randomly selected for this survey and 654 boys and 546 girls were included. Mean hemoglobin level in g/dL among boys and girls was 10.1 (SD: 1.66) and 9.9 (SD: 1.67) (P <0.06) respectively. The proportion of anemic children (Hb <11 g/dL) was 70%. Boys were heavier and taller as compared to girls. Among the 67.3% underweight children the mean hemoglobin level was 9.85 (SD: 1.67) as compared to 10.39 (SD: 1.62) in those without malnutrition (P <0.0001). Likewise, stunted children (87.6%) had statistically significantly lower mean hemoglobin levels than those not stunted. The odds ratio of an underweight and stunted child having moderate to severe anemia was 1.66. While more than half caretakers knew about the term "anemia " and associated physical weakness with it, only very few (2.5%) knew that iron intake will improve it. They relied on "doctors" (86.7%) for anemia prevention.

Quality assessment of treated tannery wastewater with special emphasis on pathogenic E. coli detection through serotyping.

The present study was undertaken to assess the quality of treated tannery effluent discharged from Common Effluent Treatment Plant (CETP), Unnao, India, to various water bodies and agricultural lands. The physico-chemical analyses revealed that the effluent was yellowish-brown in colour, having alkaline pH, high BOD, COD values and contained large quantities of organic and inorganic constituents well above the prescribed standards. The bacteriological quality was assessed in terms of the presence of heterotrophs and total as well as faecal coliforms. All faecal coliforms were identified as Escherichia coli, of which 50% were found pathogenic after serotyping. Most of the serotypes were uropathogenic Escherichia coli (UPEC) 04. The potential risks of the contamination of different ecosystems situated to the vicinity of such sites are obvious. The observations of this investigation indicate that the treated tannery effluent released for various purposes is not satisfactory, and is far from optimal in attaining the safe limits of disposal.

Danger signs of neonatal illnesses: perceptions of caregivers and health workers in northern India.

OBJECTIVE: To assess household practices that can affect neonatal health, from the perspective of caregivers and health workers; to identify signs in neonates leading either to recognition of illness or health-care seeking; and to ascertain the proportion of caregivers who recognize the individual items of the integrated management of neonatal and childhood illnesses (IMNCI) programme. METHODS: The study was carried out in a rural community in Sarojininagar Block, Uttar Pradesh, India, using qualitative and quantitative research designs. Study participants were mothers, grandmothers, grandfathers, fathers or "nannies" (other female relatives) caring for infants younger than 6 months of age and recognized health-care providers serving the area. Focus group discussions (n = 7), key informant interviews (n = 35) and structured interviews (n = 210) were conducted with these participants. FINDINGS: Many household practices were observed which could adversely affect maternal and neonatal health. Among 200 caregivers, 70.5% reported home deliveries conducted by local untrained nurses or relatives, and most mothers initiated breastfeeding only on day 3. More than half of the caregivers recognized fever, irritability, weakness, abdominal distension/vomiting, slow breathing and diarrhoea as danger signs in neonates. Seventy-nine (39.5%) of the caregivers had seen a sick neonate in the family in the past 2 years, with 30.38% in whom illness manifested as continuous crying. Health care was sought for 46 (23%) neonates. Traditional medicines were used for treatment of bulging fontanelle, chest in-drawing and rapid breathing. CONCLUSION: Because there is no universal recognition of danger signs in neonates, and potentially harmful antenatal and birthing practices are followed, there is a need to give priority to implementing IMNCI, and possible incorporation of continuous crying as an additional danger sign.

Effectiveness of biweekly versus daily iron-folic acid administration on anaemia status in preschool children.

Three-quarters of preschool children in India are anaemic. With the aim of identifying a cost-effective strategy for iron supplementation, the study objective was to assess the effectiveness of daily versus biweekly iron-folic acid (IFA: 20 mg elemental iron and 0.1 mg folic acid/tablet) on change in haemoglobin (Hb) levels of preschool children (3-6 years). This was a rural community-based effectiveness study in Uttar Pradesh, North India. IFA was given in two schedules: biweekly (2 tablets/dose) and daily (1 tablet/dose) for 1 year with fortnightly monitoring for adherence. A total of 400 and 403 children were enrolled in daily and biweekly regimes, respectively, of which 57.32 per cent and 50.25 per cent were anaemic (Hb <11 g/dl) in each group. Adherence in biweekly and daily regimes was 89.05 per cent vs. 63.5 per cent. After 1 year, the mean Hb rise in daily and biweekly regime was 1.063 g/dl (SD: 1.6; p = 0.000) and 1.053 g/dl (SD: 1.73; p = 0.001), respectively. Reduction in point prevalence of anaemia was 65.7 per cent daily vs. 56.1 per cent in biweekly regimen (p = 0.0047). We conclude that biweekly as well as daily IFA administration is effective in raising Hb levels and decreasing community prevalence of anaemia significantly. However, since there is better adherence and lower drug costs associated with biweekly IFA administration, this can be considered for programme use.