Cohort study on association between catastrophic costs and unfavorable tuberculosis treatment outcomes among TB-HIV and TB-diabetes comorbid patients in India.

BACKGROUND: India grapples with an alarming burden of tuberculosis (TB), reporting 2.6 million incident cases in 2023, necessitating intensified efforts toward TB elimination. The prevalence of catastrophic costs, defined as expenses exceeding 20% of annual household income, varies widely. Our objective was to determine the association between catastrophic costs from TB-HIV and TB-diabetes care and unfavorable TB treatment outcomes. METHODS: We conducted a cohort study in Bhavnagar, India, from July 2019 to January 2021, involving 234 TB-HIV and 304 TB-diabetes patients. Catastrophic costs were assessed using the World Health Organization's tool. Unfavorable TB treatment outcomes included positive results from sputum smear, nucleic acid amplification, or culture tests at treatment completion, death during treatment, or treatment cessation for a month (for drug-sensitive TB) or two months (for drug-resistant TB). Firth regression was employed to address quasi-separation issues and identify predictors. RESULTS: Among TB-HIV patients, 12% faced catastrophic costs, with 20% experiencing unfavorable TB outcomes. In this group, significant predictors included weight (OR: 0.93, 95% CI: 0.89-0.98), family type (OR: 2.5, 95% CI: 1.2-5.5), and initial hospitalization (OR: 2.6, 95% CI: 1.1-6.3). For TB-diabetes patients, 5% faced catastrophic costs, and 14% had unfavorable outcomes, with significant predictors being below the poverty line (BPL) (OR: 2.9, 95% CI: 1.5-5.9) and initial hospitalization (OR: 3.4, 95% CI: 1.1-11.1). Catastrophic cost incidence was higher in TB-HIV (12% vs. 4% in TB only) and TB-diabetes (5% vs. 4% in TB only) patients. However, catastrophic costs did not show a direct association with unfavorable outcomes in either group. CONCLUSIONS: Our study found no direct association between catastrophic costs and unfavorable TB outcomes among TB-HIV/TB-diabetes patients. Instead, factors such as weight, family type, BPL status, and initial hospitalization were significant predictors. These findings underscore the importance of socio-economic conditions and initial hospitalization, advocate for enhanced support mechanisms including nutritional and financial aid, especially for BPL families.

Costs incurred by patients with tuberculosis co-infected with human immunodeficiency virus in Bhavnagar, western India: a sequential explanatory mixed-methods research.

BACKGROUND: India reports the highest number of tuberculosis (TB) and second-highest number of the human immunodeficiency virus (HIV) globally. We hypothesize that HIV might increase the existing financial burden of care among patients with TB. We conducted this study to estimate the costs incurred by patients with TB co-infected with HIV and to explore the perspectives of patients as well as program functionaries for reducing the costs. METHODS: We conducted a descriptive cross-sectional study among 234 co-infected TB-HIV patients notified in the Bhavnagar region of western India from 2017 to 2020 to estimate the costs incurred, followed by in-depth interviews among program functionaries and patients to explore the solutions for reducing the costs. Costs were estimated in Indian rupees (INR) and expressed as median (interquartile range IQR). The World Health Organization defines catastrophic costs as when the total costs incurred by patients exceed 20% of annual household income. The in-depth interviews were audio-recorded, transcribed, and analyzed as codes grouped into categories. RESULTS: Among the 234 TB-HIV co-infected patients, 78% were male, 18% were sole earners in the family, and their median (IQR) monthly family income was INR 9000 (7500-11,000) [~US$ 132 (110-162)]. The total median (IQR) costs incurred for TB were INR 4613 (2541-7429) [~US$ 69 (37-109)], which increased to INR 7355 (4337-11,657) [~US$ 108 (64-171)] on adding the costs due to HIV. The catastrophic costs at a 20% cut-off of annual household income for TB were 4% (95% CI 2-8%), which increased to 12% (95% CI 8-16%) on adding the costs due to HIV. Strengthening health systems, cash benefits, reducing costs through timely referral, awareness generation, and improvements in caregiving were some of the solutions provided by program functionaries and the patients. CONCLUSION: We conclude that catastrophic costs due to TB-HIV co-infection were higher than that due to TB alone in our study setting. Bringing care closer to the patients would reduce their costs. Strengthening town-level healthcare facilities for diagnostics as well as treatment might shift the healthcare-seeking of patients from the private sector towards the government and thereby reduce the costs incurred.

Severe acute respiratory syndrome coronavirus 2 immunoglobulin G antibody: Seroprevalence among contacts of COVID-19 cases.

BACKGROUND: Multiple serosurveillance studies have focused on the presence of antibodies against severe acute respiratory syndrome coronavirus 2 in the general population and confirmed cases. However, seroprevalence of immunoglobulin G (IgG) among contacts of confirmed cases can add further value to the scientific findings. OBJECTIVES: The objective is to estimate COVID-19 seropositivity among contacts of COVID-19 cases and to compare the seropositivity between types of contact for the assessment of differential risk and transmission dynamics. METHODS: Large scale population-based serosurveillance on contacts of COVID-19 cases was carried out during the second half of August 2020 in Ahmedabad using the COVID-Kavach. The seropositivity among contacts was estimated and correlated-compared with type of contact and other demographic factors. RESULTS: With 1268 positive for IgG antibodies from 3973 samples, the seropositivity against COVID-19 among contacts of cases in Ahmedabad was 31.92% (95% confidence interval 30.48%-33.38%). The seropositivity among family contacts was significantly higher (39.36%) as compared to other contacts (28.72%) (Z = 6.60, P < 0.01). This trend is seen across all age groups and both the sex groups. The seropositivity has increasing trend with increasing age and is significantly higher among females (35.11%) than males (28.95%) (Z = 4.16, P < 0.01). CONCLUSION: Seropositivity of 31.92% among contacts indicates that a large proportion of contacts have already acquired immunity on account of their contact with the case. Higher seropositivity among family contacts justifies the risk categorization and testing strategy adopted for the contacts of the cases. This also reaffirms the need for contact tracing strategy for controlling the inevitable spread of pandemic.

A sequential explanatory mixed-methods study on costs incurred by patients with tuberculosis comorbid with diabetes in Bhavnagar, western India.

Diabetes is one of the commonest morbidity among patients with tuberculosis (TB). We conducted this study to estimate the costs incurred by patients with TB comorbid with diabetes and to explore the perspectives of program managers as well as patients on the reasons and solutions for the costs incurred due to TB-diabetes. We conducted a descriptive cross-sectional study to estimate costs among 304 patients with TB-diabetes comorbidity registered in the public health system during 2017-2020 in the Bhavnagar region of western India, which was followed by in-depth interviews among program functionaries and patients to explore solutions for reducing the costs. Costs, when exceeded 20% of annual household income, were defined as catastrophic as this cut-off was most significantly related to adverse TB outcomes. Among the 304 patients with TB-diabetes comorbidity, 72% were male and the median (interquartile IQR) monthly family income was Indian rupees (INR) 9000 (8000-11,000) [~ US$ 132 (118-162)]. The median (IQR) total costs due to combined TB-diabetes were INR 1314 (788-3170) [~ US$ 19 (12-47)], while that due to TB were INR 618 (378-1933) [~ US$ 9 (6-28)]. Catastrophic costs due to TB were 4%, which increased to 5% on adding the costs due to diabetes. Health system strengthening, an increase in cash assistance, and other benefits such as a nutritious food kit were suggested for reducing the costs incurred. We conclude that, in addition to a marginal increase in the percentage of catastrophic costs, co-existent diabetes nearly doubled the median total costs incurred among patients with TB. Strengthening the TB-diabetes bi-directional activities, tailoring the cash transfer scheme for comorbid patients, and making the common two-drug combination diabetes tablets available at government drug stores would help TB-diabetes comorbid patients cope with the costs of care.

COVID-Kavach-Based Seropositivity in the General Population of Ahmedabad: Just Before the Start of the Vaccination for the Elderly in India.

Background The present study was carried out in succession of three serosurvey studies carried out during 2020 in Ahmedabad with an objective to estimate the seroprevalence of immunoglobulin G (IgG) antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) in Ahmedabad city so as to scientifically understand the pandemic progression. Methods Polio booth-based stratification was followed for the population-based stratified sampling among the general population of Ahmedabad. The seroprevalence was compared with various factors for valid and precise predictions regarding the immunity status of the population. Results As on February 2021, the seroprevalence for IgG antibodies against SARS-CoV2 in the general population of Ahmedabad was 27.92% (95% confidence interval 27.06-28.80), much below the minimum desired for herd immunity. Comparison of seropositivity with age groups showed higher seroprevalence with increasing age groups. Seroprevalence was higher among males (29.08%) than females (27.01%) and the difference was statistically significant (Z=2.30, P=0.02). Calculating the seropositivity among the subcategories, cases had a seropositivity of 64.90% and family contacts had a seropositivity of 28.00%. Seronegative cases indicate the possibility of absent, undetectable, or disappearing IgG antibodies. Seropositivity of 37% among the vaccinated individuals may be related to dose and duration of vaccination, as the COVID vaccination had started just before the present study and none had completed 14 days after the second dose. Conclusions The low level of IgG antibodies against SARS-CoV2 using the COVID-Kavach test kit in the general population of Ahmedabad city of India, as on February 2021, before the start of COVID vaccination for the general population suggests that the preventive measures be strongly followed for continued control of the pandemic situation at least till majority of the population is effectively covered with vaccination.

Presentation and complications among the malaria death cases from municipal corporation hospitals & civil hospital of Ahmedabad during the year 2007.

The present study was carried out to have understanding of characterisation including symptoms, signs and laboratory parameters which are associated with fatality of malaria cases on arrival to hospital which may lead to early recognition and improved management. Information about deaths due to Malaria, as reported to malaria Department of Ahmedabad Municipal Corporation by municipal corporation hospitals and civil hospital from January 07 to December 07, was used to locate details of those deaths in respective hospitals by obtaining indoor case papers and death reports of those cases from Medical Record Section of respective hospitals and were analyzed by using appropriate statistical software. Total 57 malaria deaths occurred in the above mentioned 4 hospitals. Overall Case Fatality Rate was 3.03% for indoor malaria cases. Complete information could be obtained about 42 cases. Mean age of cases was 36.50 years. 45.23% of patients falling in the age group > = 40 yrs. There were 57.1% males and 42.9% females. 55 cases were positive for P. falciparum, 1 case for P. vivax and 1 case was having mixed infection. Average duration of Hospital stay was 2.87 days and average total duration of illness was 6.82 days. The most common presenting symptom was intermittent fever with vomiting & altered sensorium in 38.88% & most common complication was Acute Renal Failure in 45.2% of cases. Paired t-test was applied on the investigations carried out on the day of admission and those carried out on the day or before a day of death and found significant for the levels of Haemoglobin, Blood Urea & Serum Billirubin. Malaria still remains one of the important causes of admission and mortality. In view of changes in anti-malarial drug policy and introduction of costly artemisinin combination therapy accurate, rapid diagnostic tools are necessary to target treatment to people in need.

Community-based Interventional Study for Tobacco Cessation in Urban Slums of Ahmedabad City: A Cluster-Randomized Trial.

BACKGROUND: Tobacco is one of the most important preventable causes of death and a leading public health problem all over the world. The present study was conducted to determine the effect of community-based intervention for tobacco cessation in urban slums of Ahmedabad city. MATERIALS AND METHODS: A total of 20 slums (10 slums each) in the intervention and control group were randomly selected through the process of randomization. A total of 200 participants each in the intervention and control group were studied through a cluster-randomized trial. RESULTS: The outcome of the community-based tobacco intervention measured after 6 months depicted that the odds ratio (OR) of the prevalence of tobacco abstinence, quit rate, and reduction of more than 50% of tobacco use was significantly higher (30.37 times, 2.84 times, and 2.19 times respectively more) in the intervention as compared to the control group. However, after 1 year of the first and immediately after the second intervention, the OR of tobacco point prevalence abstinence, quit rate, and reduction of more than 50% was more pronounced (5.11 times, 3.52 times, and 4.31 times, respectively, more) in the intervention group than the control group. Post intervention, it was also observed that there was a significant increase in the average quit attempt. CONCLUSION: The community-based intervention was very effective in reducing the consumption of tobacco in urban slums in any form. As per the study findings, there is a wide possibility for the integration of tobacco cessation activity into the health program.

Seroprevalence of Immunoglobulin-G Antibody Among Confirm Cases of COVID-19.

Background Sero-surveillance to find the presence of IgG antibodies among COVID-19 cases helps in the better understanding of the immune response after COVID-19 infection. Objectives To estimate seropositivity among confirmed COVID-19 cases and to correlate the seropositivity with various factors affecting seropositivity. Methods Population-based sero-surveillance among COVID-19 cases was carried out during the second half of August 2020 in Ahmedabad using the COVID KAVACH, Immunoglobulin-G (IgG) Antibody Detection Enzyme-Linked Immunosorbent Assay (ELISA) kits. Seropositivity among cases was measured and compared with various other factors to understand the immunity status among COVID-19 cases. Results With 1073 positive for IgG antibodies from 1720 samples, the seropositivity among COVID-19 cases is 62.38% [95%CI 60.07-64.64%]. The difference in seropositivity based on gender was statistically not significant (Z=0.26, P=0.79). Children have the highest seropositivity (94.44%) and from young adults, to the elderly, the proportion of positivity among cases shows an increasing trend. Time gap analysis from the date of diagnosis shows that the proportion of cases with IgG antibodies increases gradually reaching its peak at around 10 weeks (third month) and then declines gradually. Conclusion Seropositivity among COVID-19 cases is 62.38%. The proportion of cases with IgG antibodies reaches its peak at around 10 weeks (third month) after diagnosis and then declines gradually. This fall indicates that the detected antibodies may not be long-lasting and may become undetectable/absent over a period of time. The reason for seronegative results in COVID-19 cases needs further in-depth scientific research.

Population-based seropositivity for IgG antibodies against SARS-CoV-2 in Ahmedabad city.

CONTEXT: Ahmedabad city with approximately 7 million population was one of the earliest cities to witness the high case load of COVID-19 pandemic in India. A population-based sero-survey was ideally suited in Ahmedabad to guide the public health response for managing COVID-19 pandemic. OBJECTIVES: To study the percentage sero-positivity for SARS-CoV-2 to understand the pandemic status and deriving conclusions for guiding the public health measures for managing the COVID-19 pandemic. SETTINGS AND DESIGN: Population-based cross-sectional sero-surveillance. METHODS AND MATERIAL: Large scale sero-surveillance with population-based stratified sampling covering more than 10,000 samples from general population of Ahmedabad was carried out during second half of August 2020. The seropositivity was correlated and compared with various demographic factors and other parameters for valid and precise predictions on the immunity status of the population. RESULTS: With 2,396 samples positive for IgG antibodies from a total of 10,310 samples, the seropositivity against COVID-19 in the general population of Ahmedabad is around 23.24%. The seropositivity has increasing trend with increasing age and is significantly higher among females (25.37%) than males (21.81%). The zone wise positivity ranged from 11.74% to 33.14%. This closely correlates with the cases recorded so far, higher for those zones with high current or past cases. CONCLUSIONS: Seropositivity of 23.24% in general population indicate the overall current level of protection. Since effective vaccine is not yet available, it is required to continue emphasis on the public health preventive measures for controlling and managing the COVID-19 pandemic.

SARS-CoV2 IgG antibody: Seroprevalence among health care workers.

BACKGROUND: Health Care Workers (HCWs) are at higher risk for Covid19. Sero-surveillance among HCWs using IgG antibodies can add further value to the scientific findings. OBJECTIVES: To estimate seropositivity among HCWs and to correlate it with various factors affecting seropositivity. METHODS: Population based large scale sero-surveillance among HCWs was carried out during second half of August'20 in Ahmedabad using "Covid-Kavach" IgG Antibody Detection ELISA kits. Seropositivity among HCWs was estimated and compared with various demographic & other factors to understand their infection & immunity status. Proportions and Z-test were used as appropriate. RESULTS: As on August'20, Seropositivity among HCWs from Ahmedabad is 23.65% (95% Confidence Interval 21.70-25.73%). Seropositivity of 25.98% (95%CI 23.47-28.66) among female HCWs is significantly higher than 19.48% (95%CI 16.53-22.80) among male HCWs. The zone wise positivity among HCWs closely correlate with cases reported from the respective zone. The sero-positivity among HCWs from the earliest and worst affected zones have lower level of seropositivity as compared to the zones affected recently. This might be pointing towards the fact that the IgG Antibodies may not be long lasting. CONCLUSION: As on August 2020, the seropositivity of 23.65% in HCWs indicate high level of disease transmission and higher risk of infection among HCWs in Ahmedabad. The seropositivity is significantly higher among female HCWs. Zone wise seropositivity, closely correlate with the reported cases from the respective zone. Their comparison also indicates the possibility of reducing IgG seropositivity, which necessitates further in-depth scientific research to generate greater scientific evidences.

Assessing seropositivity for IgG antibodies against SARS-CoV-2 in Ahmedabad city of India: a cross-sectional study.

OBJECTIVES: To study the percentage seropositivity for SARS-CoV-2 to understand the pandemic status and predict the future situations in Ahmedabad. STUDY DESIGN: Cross-sectional study. SETTINGS: Field area of Ahmedabad Municipal Corporation. PARTICIPANTS: More than 30 000 individuals irrespective of their age, sex, acute/past COVID-19 infection participated in the serosurvey which covered all the 75 Urban Primary Health Centres (UPHCs) across 48 wards and 7 zones of the city. Study also involved healthcare workers (HCWs) from COVID-19/non-COVID-19 hospitals. INTERVENTIONS: Seropositivity of IgG antibodies against SARS-CoV-2 was measured as a mark of COVID-19 infection. PRIMARY AND SECONDARY OUTCOMES: Seropositivity was used to calculate cumulative incidence. Correlation of seropositivity with available demographic detail was used for valid and precise assessment of the pandemic situation. RESULTS: From 30 054 samples, the results were available for 29 891 samples and the crude seropositivity is 17.61%. For all the various age groups, the seropositivity calculated between 15% and 20%. The difference in seropositivity for both the sex group is statistically not significant. The seropositivity is significantly lower (13.64%) for HCWs as compared with non-HCWs (18.71%). Seropositivity shows increasing trend with time. Zone with maximum initial cases has high positivity as compared with other zones. UPHCs with recent rise in cases are leading in seropositivity as compared with earlier and widely affected UPHCs. CONCLUSIONS: The results of serosurveillance suggest that the population of Ahmedabad is still largely susceptible. People still need to follow preventive measures to protect themselves till an effective vaccine is available to the people at large. The data indicate the possibility of vanishing immunity over time and need further research to cross verify with scientific evidences.

Assessment of Perception and Effectiveness of Concept Mapping in Learning Epidemiology.

BACKGROUND AND OBJECTIVES: Current programs in medical education technology concentrate mainly upon "how-to-teach." The focus is needed on learner's memory retention too. An innovative strategy like concept mapping might be a way forward. The study was carried out to assess its effectiveness and to know students' perceptions. MATERIALS AND METHODS: During community medicine classes, a student-group was sensitized on how to make and use concept maps out of taught contents. At the end of epidemiology exercises sessions, this group was given additional minutes to prepare concept maps, interact, and brainstorm followed by quick QA session. Others were taught same contents in conventional way. Performances of both groups were assessed in one immediate (term-ending) and one distant (preliminary) exam. Feedback was also taken from study group. RESULTS: Study group consistently scored higher in both exams. Difference in scored mean marks was highly significant in term-ending-examination (P < 0.0001, t = 5.754, df = 121.9). Largely positive feedback was received on utility of concept maps in memorizing, confidence-boosting, and understanding subject. Felt need for innovations in conventional teaching-learning (T-L) was palpable. CONCLUSION: Time has come to start focusing on enhancing students' learning. Performance-enhancing utility of concept maps is proven and should be integrated in regular T-L.

An epidemiological study of multi drug resistant tuberculosis cases registered under Revised National Tuberculosis Control Programme of Ahmedabad City.

BACKGROUND: The emergence of resistance to anti-tuberculosis drugs in general and Multi Drug Resistan Tuberculosis (MDR-TB) in particular, has become a significant public health problem and an obstacle to effective TB control. Baseline and adequate information on epidemiological factors and their interaction are prerequisites for its effective control. OBJECTIVES: To study socio-demographic profile, housing environment, health-seeking behaviour, present and past history regarding treatment of tuberculosis, drug resistance pattern and the preventive practice adopted by the patients. METHODOLOGY: A cross-sectional study was carried out on 81 MDR-TB patients registered under RNTCP of Ahmedabad city during July 2007-June 2008. To accomplish the objectives, information was collected by personal interviews using pre-designed, pre-tested proforma. Data, so collected, was analyzed and tabulated using appropriate statistical software. RESULTS: More than 2/3rd were males and majority were in age group 16-45 years, educated up to primary level, living in overcrowded and ill-ventilated houses. Initially almost all had pulmonary TB. At the start of category II, maximum number of patients were defaulters, the prime cause being financial crunch. The mean number of Anti Tubercular Treatment (ATT) taken before start of category IV was 2.85. More than 90% experienced side-effects of drugs. Although indiscriminate spitting was less, other methods of sputum disposal were also unsafe. Resistance to all four drugs (H, R, S & E) was found in more than 2/3rd of cases. Smear and culture conversion rate at three month follow up was 62.0% and 58.7% respectively. Only one patient (1.2%) was reactive for HIV in the study. Most of the patients perceived some degree of improvement in their condition following treatment. CONCLUSION: Most of the MDR cases were living in poor environmental conditions, had previous history of TB and defaulter of treatment regimen prescribed. Motivation of private practitioners for increasing referrals, use of incentives and enablers, enhancing contact tracing and increasing awareness regarding sputum disposal practices and measures to prevent the spread are necessary for effective control of tuberculosis.

Prevalence and pattern of stress relaxation practices in Ahmedabad city: A cross-sectional study.

BACKGROUND: Research has shown the growing importance of stress relaxation practices (SRPs) in many noncommunicable diseases. But there is little information on the prevalence of SRPs in Indian population. OBJECTIVES: To study the prevalence of different types of SRPs and their sociodemographic profile. MATERIALS AND METHODS: A community-based cross-sectional study was carried out in Ahmedabad city, Gujarat, India. One ward from each zone of the city was selected by stratified sampling. All individuals above 20 years were included in the study. Detailed information regarding different SRPs practiced by the participants was collected in a standard pretested proforma by house-to-house survey. Univariate regression analysis was applied to compare the groups. RESULTS: Of 1157 persons surveyed, 904 were included in the final analysis. Of these, 310 (34.3%) were doing SRPs and 594 (65.7%) were not doing any type of SRPs. Respondents doing SRPs were compared with non-SRP group. Significant (P<0.05) differences were noticed between the two groups; in females, it was (SRP 58.4% vs non-SRP 49.8%) in the age group 40 to 59 years (44.2 vs 33.8%), those from sedentary occupation (93.9% vs 85.4%), the persons belonging to upper socioeconomic status (70.6% vs 61.8%), and living in central and western zones (66.5% vs 24.6%) and had less number of diabetes (SRP 10.8% vs non-SRP 19.7%) and hypertension (20.7% vs 34.2%). People doing SRPs were able to maintain balance between work and other activities than non-SRPs group (198/310, 63.9% vs 42/594, 7.1%). Among SRPs, majority (243, 78.4%) were involved in religious activities followed by yoga, 36(11.6%), and meditation, 15 (4.8%). CONCLUSION: Persons practicing SRPs in Ahmedabad are more likely to be above 40 years of age, females, college educated, in sedentary occupation, from upper and middle class, married and living in new-west and central zones, and were less likely to have diabetes and hypertension as compared with those who do not practice SRPs.