Hypertension and its correlates among pregnant women consuming tobacco in India: Findings from the National Family health Survey-4.

Background: Hypertension (high blood pressure) during pregnancy has significant implications on maternal and perinatal morbidity and mortality. Tobacco use during pregnancy amplifies this burden and increases the risk of hypertensive disorders along with adverse birth outcomes. The current study aimed to evaluate the joint risk atpopulation-level of tobacco use and hypertension among pregnant women in India. Methodology: Data of 32,428 "currently pregnant" women aged 15-49 years was obtained from the National Family Health Survey (NFHS-4) 2015-16to estimate bivariate (tobacco user vs. non-user) and binomial logistic regression analysis in order to get odds ratios of having hypertension. The analysis included socio-demographic variables such as the respondent's age, type of residence, wealth index, and education status. Results: Prevalence of hypertension among pregnant tobacco users (7.5%) was significantly higher than that of non-users (6.1%). The unadjusted odds of having hypertension were 1.17 (95% CI: 1.02-1.35) times among tobacco users than non-users and increased with age (p < 0.001) and in rural areas (p = 0.02) after adjusting for other covariates. However, it varied inversely with education status (p > 0.05; NS) and wealth quintile (p = 0.01). Conclusion: The present study identifies the higher co-existence of hypertension among tobacco-using pregnant women and highlights the need for tobacco control/cessation and hypertension prevention and management during pregnancy considering socio-demographic disparities.

Determinants of severity among hospitalised COVID-19 patients: Hospital-based case-control study, India, 2020.

BACKGROUND: Risk factors for the development of severe COVID-19 disease and death have been widely reported across several studies. Knowledge about the determinants of severe disease and mortality in the Indian context can guide early clinical management. METHODS: We conducted a hospital-based case control study across nine sites in India to identify the determinants of severe and critical COVID-19 disease. FINDINGS: We identified age above 60 years, duration before admission >5 days, chronic kidney disease, leucocytosis, prothrombin time > 14 sec, serum ferritin >250 ng/mL, d-dimer >0.5 ng/mL, pro-calcitonin >0.15 µg/L, fibrin degradation products >5 µg/mL, C-reactive protein >5 mg/L, lactate dehydrogenase >150 U/L, interleukin-6 >25 pg/mL, NLR ≥3, and deranged liver function, renal function and serum electrolytes as significant factors associated with severe COVID-19 disease. INTERPRETATION: We have identified a set of parameters that can help in characterising severe COVID-19 cases in India. These parameters are part of routinely available investigations within Indian hospital settings, both public and private. Study findings have the potential to inform clinical management protocols and identify patients at high risk of severe outcomes at an early stage.

Opportunistic screening for diabetes mellitus and hypertension in primary care settings in Karnataka, India: a few steps forward but still some way to go.

Background: Opportunistic screening for individuals aged ≥30 years at all levels of healthcare for early detection of diabetes mellitus (DM) and hypertension (HTN) is an integral strategy under the national program to control non-communicable diseases. There has been no systematic assessment of the screening process in primary care settings since its launch. The objective was to determine the number and proportion eligible for screening, number screened, diagnosed and treated for DM and HTN among persons aged ≥30 years in two selected primary health centres (PHCs) in Dakshina Kannada district, Karnataka, India during March-May 2019 and to explore the enablers and barriers in the implementation of screening from the perspective of the health care providers (HCPs) and beneficiaries . Methods: This was a sequential explanatory mixed-methods study with a quantitative (cohort design) and a descriptive qualitative component (in-depth interviews and focus group discussions) with HCPs and persons seeking care. Those that were not known DM/HTN and not screened for DM/HTN in one year were used to estimate persons eligible for screening. Results: Of 2697 persons, 512 (19%) were eligible for DM screening, 401 (78%) were screened; 88/401 (22%) were diagnosed and 67/88 (76%) were initiated on treatment. Of 2697, 337 (13%) were eligible for HTN screening, 327 (97%) were screened, 55 (17%) were diagnosed with HTN; of those diagnosed, 44/55 (80%) were initiated on treatment.  The documentation changes helped in identifying the eligible population. Patient willingness to undergo screening and recognition of relevance of screening were screening enablers.  Overworked staff, logistical and documentation issues, inadequate training were the barriers. Conclusion: Nearly 19% were eligible for DM screening and 13% were eligible for HTN screening. The yield of screening was high. We noted several enablers and barriers. The barriers require urgent attention to reduce the gaps in delivery and uptake of services.

"YES it's the Perfect Time to Quit": Fueling Tobacco Cessation in India during COVID-19 Pandemic.

Entire world is battling the Novel Coronavirus Disease (COVID-19) pandemic. India too, has undertaken stringent containment measures to combat this disease. The country is in a state of national lockdown, which has inadvertently led more than a quarter of the Indian population to not use tobacco. This paper discusses the opportunity that surfaces with unavailability of tobacco products, and advocates the need for escalation of tobacco cessation services as well as strategic management of stress to stay tobacco-free.

Tobacco Use Among the Youth in India: Evidence From Global Adult Tobacco Survey-2 (2016-2017).

BACKGROUND: Worldwide, tobacco use is a serious public health concern affecting the youth. A vast majority of tobacco users start using tobacco well before the age of 18 years which has enormous psychosocial and health effects. OBJECTIVES: To estimate the prevalence of individual forms of tobacco usage among youth aged 15 to 24 years and to assess the association of sociodemographic factors with tobacco use. METHODS: The source of data was a cross-sectional GATS-2 survey in India (analysed using SPSSv17.0) which used a multistage, geographically stratified cluster sampling method. Bivariate analysis was done for evaluation of the possible association of tobacco use with sociodemographic factors. Multivariable logistic regression analysis was conducted to determine the relative strength of association between those factors and tobacco use. RESULTS: There were 13 329 respondents (44.9% males and 55.1% females) aged 15 to 24 years. Overall, 11.9% of respondents were using tobacco. The prevalence of smoke and smokeless tobacco usage was 5% and 10.9%, respectively, whereas 2% of respondents reported dual usage. The odds of using any form of tobacco were significantly higher among respondents aged 20 to 24 years (odds ratio [OR]: 2 [1.76-2.77]) who were primarily residing in rural areas (adjusted odds ratio [aOR]: 1.36 [1.2-1.54]) and were unmarried (aOR: 1.56 [1.37-1.88]). The odds of using any form of tobacco were significantly lower among females (aOR: 0.21 [0.19-0.24]), literate individuals (aOR: 0.33 [0.29-0.37]), and those who were unemployed/students/homemakers (aOR: 0.44 [0.39-0.50]). CONCLUSIONS: The overall tobacco usage of 11.9% among young people in the age group of 15 to 24 years is a matter of concern. The study identified several sociodemographic factors significantly associated with tobacco use, implying the need for designing interventions considering social vulnerabilities of youth.

Quit attempts among tobacco users identified in the Tamil Nadu Tobacco Survey of 2015/2016: a 3 year follow-up mixed methods study.

OBJECTIVES: To determine current tobacco use in 2018/2019, quit attempts made and to explore the enablers and barriers in quitting tobacco among tobacco users identified in the Tamil Nadu Tobacco Survey (TNTS) in 2015/2016. SETTING: TNTS was conducted in 2015/2016 throughout the state of Tamil Nadu (TN) in India covering 111 363 individuals. Tobacco prevalence was found to be 5.2% (n=5208). PARTICIPANTS: All tobacco users in 11 districts of TN identified by TNTS (n=2909) were tracked after 3 years by telephone. In-depth interviews (n=26) were conducted in a subsample to understand the enablers and barriers in quitting. PRIMARY AND SECONDARY OUTCOMES: Current tobacco use status, any quit attempt and successful quit rate were the primary outcomes, while barriers and enablers in quitting were considered as secondary outcomes. RESULTS: Among the 2909 tobacco users identified in TNTS 2015/2016, only 724 (24.9%) could be contacted by telephone, of which 555 (76.7%) consented. Of those who consented, 210 (37.8%) were currently not using tobacco (ie, successfully quit) and 337 (60.7%) continued to use any form of tobacco. Of current tobacco users, 115 (34.1%) have never made any attempt to quit and 193 (57.3.8%) have made an attempt to quit. Those using smoking form of tobacco products (adjusted relative risk (aRR)=1.2, 95% CI: 1.1 to 1.4) and exposure to smoke at home (aRR=1.2, 95% CI: 1.1 to 1.3) were found to be positively associated with continued tobacco use (failed or no quit attempt). Support from family and perceived health benefits are key enablers, while peer influence, high dependence and lack of professional help are some of the barriers to quitting. CONCLUSION: Two-thirds of the tobacco users continue to use tobacco in the last 3 years. While tobacco users are well aware of the ill-effects of tobacco, various intrinsic and extrinsic factors play a major role as a facilitator and lack of the same act as a barrier to quit.

Are they there yet? Linkage of patients with tuberculosis to services for tobacco cessation and alcohol abuse - a mixed methods study from Karnataka, India.

BACKGROUND: Tobacco use and alcohol abuse are associated with higher risk of tuberculosis (TB) infection, progression to active TB and adverse treatment outcomes among patients with TB. Revised National Tuberculosis Control Programme (RNTCP) treatment guidelines (2016) require the documentation of tobacco and alcohol use among patients with TB and their linkage to tobacco and alcohol abuse treatment services. This study aimed to assess the extent of documentation of tobacco and alcohol usage data in the TB treatment card and to explore in-depth, the operational issues involved in linkage. METHODS: A convergent parallel mixed methods study was conducted. All new TB treatment cards of adult patients registered under RNTCP between January and June 2017 in Dakshina Kannada district were reviewed to assess documentation. Document review was done to understand the process of linkage (directing patients to tobacco and alcohol abuse treatment services). In-depth interview of health care providers (n = 7) and patients with TB (n = 5) explored into their perspectives on linkage. RESULTS: Among 413 treatment cards reviewed, tobacco use was documented in 322 (78%), of whom 86 (21%) were documented as current tobacco users. Sixteen (19%) out of these 86 patients were linked to tobacco cessation services. Alcohol usage status was documented in 319 (77%) cards of whom 71(17%) were documented as alcohol users. Eleven (16%) out of these 71 patients were linked to alcohol abuse treatment services. The questions in the treatment card lacked clarity. Guidelines on eliciting history of substance abuse and criteria for linkage were not detailed. Perceived enablers for linkage included family support, will power of the patients and fear of complications. Challenges included patient's lack of motivation, financial and time constraints, inadequate guidelines and lack of co-ordination mechanisms between TB programme and tobacco/alcohol abuse treatment services. CONCLUSION: Documentation was good but not universally done. Clear operational guidelines on linkage and treatment guidelines for health care providers to appropriately manage the patients with comorbidities are lacking. Lack of coordination between the TB treatment programme and tobacco cessation as well as alcohol treatment services was considered a major challenge in effective implementation of the linkage services.

Integrating screening for non-communicable diseases and their risk factors in routine tuberculosis care in Delhi, India: A mixed-methods study.

BACKGROUND: Evidence supports the integration of prevention and management for tuberculosis (TB) with non-communicable diseases (NCDs). Bi-directional screening for TB and diabetes mellitus (DM) is already implemented in India, a country with a dual burden of TB and NCDs. However, very limited programmatic data are available on the feasibility of adding other NCDs and their risk factors in such screening programme. OBJECTIVE: To assess the yield, feasibility, and acceptability of a two-stage integrated screening for NCDs and risk factors for NCDs among patients with TB ≥20 years and treated in DOTS centres of two medical colleges in Delhi, between October 2016 and March 2017. METHODS: It was a mixed-methods, triangulation study with a quantitative component (cross-sectional study using questionnaires, anthropometric measurements and records review) and a qualitative component (descriptive study using interview data). RESULTS: Amongst 403 patients screened, the prevalence of hypertension was 7% (n = 28) with 20 new cases detected and 8% for DM (n = 32) with 6 new cases diagnosed. The number needed to screen to find a new case was 20 and 63 for hypertension and DM respectively. The most frequent NCD-risk factors were inadequate vegetable (80%) and fruits (72%) intake, alcohol use (34%), use of smokeless tobacco (33%) and smoking (32%). Clustering of four or more risk factors was associated with increasing age and male sex (p<0.05). Both patients and health providers considered the screening relevant and acceptable. However, waiting time and costs involved in blood tests were considered as bothersome by the patients, while health providers perceived increased workload, inadequate medical supplies and inadequate skills and knowledge as key challenges in implementation of the screening. CONCLUSION: Integrating screening for NCDs and their risk factors in the existing TB programme produces high yield and it is feasible and acceptable by patients and health providers provided the challenges are overcome.

Awareness About Anti-Smoking Related Laws and Legislation Among General Population in Slums of Delhi, India.

Introduction: Almost 40% of Delhi's population lives in slums and is vulnerable to tobacco use. It is therefore important to assess their opinion and ensure compliance to antismoking legislation. The present study was undertaken to assess the awareness of the general public residing in slums in Delhi regarding the smoke-free initiative of 2009, 3 years after intensive implementation. Methods: It was a cross-sectional study conducted among participants selected by cluster sampling from the slums in six districts of Delhi using a pretested semistructured questionnaire. A total of 708 slum dwellers were interviewed. Results: Out of the total, only 16.1% (n = 114) of the participants had heard of The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003 (COTPA), though, they were aware about some of the provisions of the COTPA. Majority (n = 529; 74.7%) perceived the smoke-free zones as the places where smoking forms of tobacco are banned. Regarding the awareness about the places designated as smoke-free zones, 82.1% (n = 581) of the respondents named educational institutions. About 61% of the people interviewed reported to have seen people smoking at public places on the day of interview while only 21.5% reported to have seen any one getting punished for smoking. Conclusions: Awareness about COTPA was low. The study respondents perceived that no action was being taken against persons acting in violation of the law. Thus, there is a need for stricter implementation of COTPA and increased spreading of awareness among the general public. Implications: While awareness about antismoking legislation among general population (particularly slums) has been studied world over, this has not been the case in India. The study depicts opinion of one of the susceptible populations regarding tobacco control legislation, which has hitherto not been studied in the Indian context. This study has an important implication as it highlights the need for stringent enforcement of antismoking legislation for tobacco control.

Preventive Health Practices among Doctors in Delhi.

INTRODUCTION: With times, increasing attention is being given to doctor's own health as it is known to influence their patient care. Little is known about preventive health practices among them. OBJECTIVE: To assess preventive health practices among doctors in Delhi. MATERIAL AND METHODS: It was a cross-sectional study undertaken amongst the doctors working in selected hospitals, dispensaries and private clinics in Delhi. A self-administered questionnaire containing items for assessment of preventive health and self-care practices was used to collect the data. RESULTS: Out of the total 160 participants, there were 118 males (73.8%) and 42 (26.2%) females. The mean age of the participants was 29.9±7.4 years. There were 55 doctors (34.4%) who were suffering from chronic diseases like vision problems, dental problems, hypertension and diabetes. Nearly half of the doctors (n=74; 46.2%) did not have any for health insurance. Majority of the doctors (n=65; 40.6%) were obese. The knowledge regarding preventive health guidelines regarding all of the tests asked for, was low among the study participants. As far as preventive health practices were concerned, only 8.8% (14) had checked their blood pressure according to recommended guidelines while none of them had their lipid profile done. While there were 9 female doctors (21.4%) who had done their self breast examination in last six months, there was only 1 participant who had undergone pap test. With respect to self-care practices when the physicians last fell ill, majority had self-managed themselves (n=108; 67.5%). CONCLUSION: Preventive health care practices among the doctors are low. There an urgent need for them to follow good health care practices which they in turn can advocate to their patients.

Decadal impact of Directly Observed Treatment Short course program on age and gender among New Infectious Tuberculosis cases in Delhi.

BACKGROUND: Burden of tuberculosis in India remains enormous. The Revised National Tuberculosis Control Programme (RNTCP), based on the Directly Observed Treatment Short course (DOTS) strategy, was launched in 1997 in India. The question of what DOTS has or has not accomplished over the past 15 years is a central technical question. OBJECTIVES: To assess the decadal impact of DOTS strategy on some epidemiological factors such as age and gender of new sputum positive (NSP) TB patients in Delhi. MATERIAL AND METHODS: Secondary Data for Delhi was obtained from the state wise performance of RNTCP (Annual Summary) for the year 2001 and year 2012. Data was analyzed in Microsoft Excel 2007. RESULTS: The population of Delhi covered under DOTS has considerably increased over the decade. The case detection rate has also shown a considerable increase from 196/100,000 population in 2001 to 306/100,000 population at the end of Quarter 3 of 2011. The number of NSP male and female patients have increased in all age groups from 2001 to 2011 except in 25-34 years age group. NSP male patients on DOTS aged 15-44 years showed a left ward shift in increase, a significant right ward shift was noted in increase in female NSP patients of similar age group. CONCLUSIONS: The decadal assessment of DOTS in Delhi on TB epidemiology has pointed towards beginning of epidemiological transition in TB control in India.

Prevalence of Risk Factors for Chronic Non-communicable Diseases Using WHO Steps Approach in an Adult Population in Delhi.

OBJECTIVE: The burden of non-communicable diseases (NCDs) is increasing worldwide largely due to prevalence of various risk factors, which can be controlled. Therefore, the present study was undertaken to measure the prevalence of major preventable risk factors for chronic non-communicable diseases in an urban resettlement colony of Delhi, using STEPS approach. MATERIALS AND METHODS: A cross-sectional study, that included a random sample of 200 adults, was conducted. A study tool based on the WHO STEPS questionnaire for assessing non-communicable diseases and their risk factors was used. Fasting venous blood sample was collected to assess the lipid profile and fasting blood sugar. Anthropometric measurements of the participants were also taken. Data was analyzed using SPSS version 17. RESULTS: Out of the 200 participants, 26% (n = 52) were consuming alcohol and 17% (n = 34) were smoking. Majority (77.5%) had a raised waist circumference, and more than two-thirds were either overweight or obese. Fasting blood sugar levels were found to be raised in 18% of the study population. More than third participants had raised systolic and diastolic blood pressures and abnormal lipid profiles. More males were found to be overweight in comparison to females (P < 0.01), but in contrast, obesity (P < 0.05) and raised waist circumference (P < 0.001) were more common in females. Tobacco use was more common in lower class (P < 0.05), whereas obesity was commoner in the upper socio-economic class (P < 0.05). CONCLUSIONS: Study showed a high burden of risk factors for NCDs in the study population, pointing towards changing disease epidemiology of non-communicable diseases in India.

Issues in prevention of iron deficiency anemia in India.

Iron deficiency anemia (IDA) continues to be major public health problem in India. It is estimated that about 20% of maternal deaths are directly related to anemia and another 50% of maternal deaths are associated with it. The question, therefore, is why, despite being the first country to launch the National Nutritional Anemia Prophylaxis Programme in 1970, the problem of IDA remains so widespread. As is to be expected, the economic implications of IDA are also massive. The issues of control of IDA in India are multiple. Inadequate dietary intake of iron, defective iron absorption, increased iron requirements due to repeated pregnancies and lactation, poor iron reserves at birth, timing of umbilical cord clamping, timing and type of complementary food introduction, frequency of infections in children, and excessive physiological blood loss during adolescence and pregnancy are some of the causes responsible for the high prevalence of anemia in India. In addition, there are other multiple programmatic and organizational issues. This review, therefore, is an attempt to examine the current burden of anemia in India, its epidemiology, and the various issues regarding its prevention and control, as well as to offer some innovative approaches to deal with this major health problem.

Occupational hazard exposure and general health profile of welders in rural Delhi.

BACKGROUND: Welding is a common industrial process associated with various health hazards. The aspect of duration of hazard exposure among welders at their workplace has been studied to limited extent in India. OBJECTIVE: To assess the duration of occupational hazard exposure and its association with symptoms among the welders. MATERIALS AND METHODS: A cross-sectional study was conducted amongst 106 welders in North Delhi. Data was collected using a questionnaire containing items to assess the socio-demographic profile, their medical history and individual hazard exposure. RESULTS: Majority of them were involved in skilled/semi-skilled job (n = 99; 93%). The predominant nature of work for majority was manual. More than half reported their work to be physically hard (n = 56; 53%), involves much lifting of weight (n = 61; 57%), and is dangerous (n = 59; 56%). Dust/smoke followed by noise was reported to be most common hazards at the workplace by them. Most of them were suffering from eye related symptoms (n = 63; 59%) followed by skin conditions (n = 28; 26%). Skin diseases were reported to be significantly common among group of welders who were exposed to dust and radiation for ≥4 hours in a day (P < 0.05). CONCLUSIONS: Nearly half of the welders found their job to be dangerous and were being exposed to at least one hazardous substance at their workplace. Majority of them complained of eye symptoms. There is a need for health and safety training of this economically productive group.

Evaluating awareness and practices pertaining to radioactive waste management among scrap dealers in Delhi, India.

OBJECTIVES: With nuclear technology rapidly taking the spotlight in the last 50 years, radiation accidents seem to be a harsh reality of the modern world. The Mayapuri Radiation accident of 2010 was the worst radiation accident India has yet dealt with. Two years thereafter, we designed a study to assess the awareness and practices regarding radioactive waste among scrap dealers aiming to assess deficiencies in radiation disaster preparedness. METHODOLOGY: A community based cross-sectional study. The study population consisted of 209 volunteers (from 108 scrap dealerships) including 108 shop-owners and 101 workers segregated as Group A consisting of 54 dealerships in Mayapuri and Group B of 54 dealerships from the rest of the city. Subjects were then interviewed using a semi-structured questionnaire. RESULTS: Awareness about radioactive waste varied significantly with level of education (p = 0.024), Kuppuswamy's socio-economic scale (p = 0.005), age of the scrap dealer (p = 0.049) and his work experience (p = 0.045). The larger dealerships in Mayapuri were more aware about radioactive waste (p = 0.0004), the accident in 2010 (p = 0.0002), the symbol for radiation hazard (p = 0.016), as well as the emergency guidelines and the agencies to contact in the event of a radiation accident. CONCLUSIONS: Our findings seem to signify that while governmental and non-governmental agencies were successful in implementing prompt disaster response and awareness programs, the community continues to be inadequately prepared. These go on to suggest that though concerted awareness and training programs do benefit the affected community, economic and social development is the key to disaster prevention and mitigation.