Improved survival among oral cancer patients: findings from a retrospective study at a tertiary care cancer centre in rural Kerala, India.

BACKGROUND: Oral cancer is very common in India. The reported 5-year survival of such patients is around 50% after treatment with surgery and radiotherapy, much lower than most of the developed countries. METHODS: A retrospective study of a prospective database of oral cancer patients undergoing surgery from June 2009 to June 2013 was conducted. Follow-up details were updated from case records and by phone calls. Data were double entered in EpiData Entry version 3.1 and were analysed using EpiData Analysis software 2.1.0.73. RESULTS: Two-hundred and twenty patients were analysed (136 males); 85% were consuming tobacco, mainly in chewable form. The majority (51.1%) had tongue cancer, of whom 75 patients (34.1%) had T4 tumours. Postoperative radiotherapy was given to 108 patients (49.1%). Forty had recurrence, of which 23 were in early stage. Of these, 19 showed node positivity (p < 0.01). Node-negative patients had 79% 5-year survival while node positive had 59% which is comparable to that reported in developed countries. Median disease-free survival duration was 48.2 months. CONCLUSIONS: Node positivity is the single factor affecting recurrence and survival. The overall survival and disease-free survival is better in patients without lymph node involvement and in patients with early stage of cancer as compared to the patients with node involvement and in advanced stages.

"Small small interventions, big big roles"- a qualitative study of patient, care-giver and health-care worker experiences of a palliative care programme in Kerala, India.

BACKGROUND: Home-based palliative care is an essential resource for many communities. We conducted a qualitative study to explore perceptions of a home-based palliative care programme in Kerala, India, from the perspective of patients, their care-givers and the doctors, nurses and volunteers running the intervention. METHODS: A descriptive qualitative study was carried out. One focus group discussion (FGD) was conducted with patients (n = 8) and two with male and female volunteers (n = 12); and interviews were conducted with doctors (n = 3), nurses (n = 3) and care-givers (n = 14). FGDs and interviews were conducted in Malayalam, audio-recorded, transcribed verbatim and translated into English. Transcripts were coded and analysed using manual content analysis. RESULTS: Doctors, nurses and volunteers have interdependent roles in providing palliative care to patients, including mentorship, training, patient care and advocating for patient needs. Volunteers also considered themselves to be mediators between families and the programme. Care-givers were mainly female and were caring for relatives. They have physically demanding, psychologically stressful and socially restrictive experiences of care-giving. They felt that the programme facilitated their role as care-givers by giving them training and support. Patients with long standing illnesses felt that the programme enabled them to become more independent and self-reliant. The local community supports the programme through economic contributions and offering practical assistance to patients. CONCLUSION: The salient features of this programme include the provision of regular holistic care through a team of doctors, nurses and patients. The programme was perceived to have improved the lives of patients and their care-givers. The involvement of volunteers from the local community was perceived as a strength of the programme, whilst simultaneously being a challenge.

Twenty years of home-based palliative care in Malappuram, Kerala, India: a descriptive study of patients and their care-givers.

BACKGROUND: The well lauded community-based palliative care programme of Kerala, India provides medical and social support, through home-based care, for patients with terminal illness and diseases requiring long-term support. There is, however, limited information on patient characteristics, caregivers and programme performance. This study was carried out to describe: i) the patients enrolled in the programme from 1996 to 2016 and their diagnosis, and ii) the care-giver characteristics and palliative care support from nurses and doctors in a cohort of patients registered during 2013-2015. METHODS: A descriptive study was conducted in the oldest community-based palliative clinic in Kerala. Data were collected from annual patient registers from 1996 to 2016 and patient case records during the period 2013-2015. RESULTS: While 91% of the patients registered in the clinic in 1996 had cancer, its relative proportion came down to 32% in 2016 with the inclusion of dementia-related illness (19%) cardiovascular accidents (17%) and severe mental illness (5%).Among patients registered during 2013-15, the median number of home visits from nurses and doctors in 12 months were five and one respectively. In the same cohort, twelve months' post-enrolment, 56% of patients died, 30% were in continuing in active care and 7% opted out. Those who opted out of care were likely to be aged < 60 years, received one or less visit annually from a doctor or have a serious mental illness. 96% of patients had a care-giver at home, 85% of these care-givers being female. CONCLUSIONS: The changing dynamics over a 20-year period of this palliative care programme in Kerala, India, highlights the need for similar programmes to remain flexible and adapt their services in response to a growing global burden of Non Communicable Diseases. While a high death rate is expected in this population, the high proportion of patients choosing to stay in the programme suggests that home-based care is valued within this particular group. A diverse range of clinical and psycho-social support skills are required to assist families and their caregivers when caring for a cohort such as this one.

Situation Analysis of Early Implementation of Programmatic Management of Tuberculosis Preventive Treatment among Household Contacts of Pulmonary TB Patients in Delhi, India.

Tuberculosis Preventive Treatment (TPT) is a powerful tool for preventing the TB infection from developing into active TB disease, and has recently been expanded to all household contacts of TB cases in India. This study employs a mixed-methods approach to conduct a situational analysis of the initial phase of TPT implementation among household contacts of pulmonary TB patients in three districts of Delhi, India. It was completed using a checklist based assessments, care cascade data, and qualitative analysis. Our observations indicated that organizational structure and planning were established, but implementation of TPT was suboptimal with issues in drug availability and procurement, budget, human resources, and training. Awareness and motivation, and shorter regimen, telephonic assessment, and collaboration with NGOs emerged as enablers. Apprehension about taking TPT, erratic drug supply, long duration of treatment, side effects, overburden, large population, INH resistance, data entry issues, and private provider reluctance emerged as barriers. The study revealed potential solutions for optimizing TPT implementation. It is evident that, while progress has been made in TPT implementation, there is room for improvement and refinement across various domains.

Psychological distress and burnout among healthcare worker during COVID-19 pandemic in India-A cross-sectional study.

BACKGROUND: COVID-19 has inundated the entire world disrupting the lives of millions of people. The pandemic has stressed the healthcare system of India impacting the psychological status and functioning of health care workers. The aim of this study is to determine the burnout levels and factors associated with the risk of psychological distress among healthcare workers (HCW) engaged in the management of COVID 19 in India. METHODS: A cross-sectional study was conducted from 1 September 2020 to 30 November 2020 by telephonic interviews using a web-based Google form. Health facilities and community centres from 12 cities located in 10 states were selected for data collection. Data on socio-demographic and occupation-related variables like age, sex, type of family, income, type of occupation, hours of work and income were obtained was obtained from 967 participants, including doctors, nurses, ambulance drivers, emergency response teams, lab personnel, and others directly involved in COVID 19 patient care. Levels of psychological distress was assessed by the General health Questionnaire -GHQ-5 and levels of burnout was assessed using the ICMR-NIOH Burnout questionnaire. Multivariable logistic regression analysis was performed to identify factors associated with the risk of psychological distress. The third quartile values of the three subscales of burnout viz EE, DP and PA were used to identify burnout profiles of the healthcare workers. RESULTS: Overall, 52.9% of the participants had the risk of psychological distress that needed further evaluation. Risk of psychological distress was significantly associated with longer hours of work (≥ 8 hours a day) (AOR = 2.38, 95% CI(1.66-3.41), income≥20000(AOR = 1.74, 95% CI, (1.16-2.6); screening of COVID-19 patients (AOR = 1.63 95% CI (1.09-2.46), contact tracing (AOR = 2.05, 95% CI (1.1-3.81), High Emotional exhaustion score (EE ≥16) (AOR = 4.41 95% CI (3.14-6.28) and High Depersonalisation score (DP≥7) (AOR = 1.79, 95% CI (1.28-2.51)). About 4.7% of the HCWs were overextended (EE>18); 6.5% were disengaged (DP>8) and 9.7% HCWs were showing signs of burnout (high on all three dimensions). CONCLUSION: The study has identified key factors that could have been likely triggers for psychological distress among healthcare workers who were engaged in management of COVID cases in India. The study also demonstrates the use of GHQ-5 and ICMR-NIOH Burnout questionnaire as important tools to identify persons at risk of psychological distress and occurrence of burnout symptoms respectively. The findings provide useful guide to planning interventions to mitigate mental health problems among HCW in future epidemic/pandemic scenarios in the country.

Community engagement to control dengue and other vector-borne diseases in Alappuzha municipality, Kerala, India.

Introduction Vector-borne diseases (VBDs) are a serious threat in many Indian states, including Kerala. Community-based decentralized planning and engagement are effective strategies that can make positive behavioral changes to control VBDs. Methods This community-based implementation research was conducted during November 2016 - October 2018 in Alappuzha municipality in Kerala, India. It was conducted in two phases. In the first phase, formative research was conducted to know the community's profile and perceptions and thus to plan and develop an appropriate intervention. Baseline data on some entomological indicators were also collected. These data were used to assess the impact of the intervention by comparing with the post-intervention data. In the second phase, an intervention through the community's engagement was implemented in selected wards. The activities included the formation of community committees and the vector control and source reduction activities with the community engagement and inter-sectoral coordination. Results The intervention resulted in a positive change among the community to engage in vector control activities. These efforts along with inter-sectoral coordination resulted in successfully implementing vector source reduction activities. In both wards, pre- and post-intervention entomological data (house index: 16.7 vs 6.0 and 64.2 vs. 8.6; container index: 24.8 vs. 12.1 and 37.7 vs. 18.1; and Breteau index: 21.3 vs. 7.3 and 47.7 vs. 8.6) revealed a considerable vector source reduction. Conclusion The findings of this study suggest considering and including community engagement in public health policy as the main thrust to control VBDs.

Genetic characterization of dengue virus serotypes causing concurrent infection in an outbreak in Ernakulam, Kerala, South India.

Dengue fever, a mosquito-borne viral infection, causes significant morbidity and has become endemic in the Indian subcontinent. Virus strains currently circulating in many parts of the country are not well studied at the molecular level. In the present study, genetic characterization of virus strains from a dengue outbreak that occurred in and around a tertiary care hospital in Ernakulam, Kerala in the year 2008 has been reported. By reverse transcription polymerase chain reaction (RT-PCR), 37 out of 75 (49.3%) clinically suspected cases were positive for dengue viral RNA. Among these, 21 (56.8%) samples showed concurrent infection with multiple serotypes of the virus. Majority of the combined infections were caused by dengue serotype 2 and 3. Co-infections with type 1 and 2 in two patients, and type 1, 2 and 3 in one patient were also observed. The core-pre-Membrane (CprM) junction nucleotide sequencing and phylogenetic analysis revealed that the type 1 strains were related to the viral strains reported from Delhi-2001 and Gwalior-2002 dengue outbreaks, while the type 2 strains were related to the strains from Gwalior-2001 epidemic. Sequences of type 3 strains did not show clear relation to any of the previous Indian isolates, and in the phylogenetic analysis, they formed a distinct lineage within the Indian type 3 strains. This study indicates hyperendemicity of dengue in the region with the presence of multiple serotypes and high rates of co-infection, and local genomic evolution of the viral strains involved in this outbreak.

Barriers for involvement of private doctors in RNTCP - Qualitative study from Kerala, India.

INTRODUCTION: Engaging the private sector effectively has been considered as the single most important intervention required for Revised National TB Control Program (RNTCP) to achieve the overall goal of universal access and early detection. This study attempts to identify the barriers and facilitators in the involvement of private practioners in signed schemes of RNTCP. MATERIALS AND METHODS: Six focus group discussions - four among private sector doctors and two among RNTCP TB key workers and 10 key informant interviews were conducted. Themes were divided into private sector involvement in RNTCP, barriers for private sector involvement, facilitators for private sector involvement and suggestions for better PPP. RESULTS: General feel was that private sector involvement in RNTCP was increasing. Public sector at ground level has not really understood the need to engage the private sector. Lack of capacity for public sector staff to understand and deal with private sector, power relations and not taking hospital managements to trust emerged as important barriers for engagement while private sector doctors expressed concerns over patient confidentiality and patient choices, apprehension of losing patients, inability of program to keep commitments and timely payments, poor recognition to private sector, bureaucratic hurdles and cumbersome formalities. Building locally customised partnership schemes, behaviour change for PPP, building managerial capacity of Public sector to deal with private sector, presence of an interphase agency and quality control through a participatory body were important suggestions for improvement of PPP. CONCLUSION: Strategies have to be formulated to customise partnership for private sector doctors using the flexibilities of the program. Strengthening PPP will be possible in presence of strong administrative will and the understanding that personal relationships are the best key to Public Private Partnerships.

Why are people dying due to tuberculosis? A study from Alappuzha District, Kerala, India.

BACKGROUND: Tuberculosis (TB)is a major killer disease worldwide. It is the ninth leading cause of death worldwide and the leading cause from a single infectious agent. In India also, TB kills about 480,000 persons every year and more than 1400 every day. Vision of the National TB Control Programme is TB-Free India with zero deaths, disease and poverty due to TB. Specific targets set in the End TB strategy include a 90% reduction in TB deaths and an 80% reduction in TB incidence by 2030, compared with 2015. Understanding about real cause of death is important to plan strategies to further prevent TB deaths. In the above circumstances we conducted a study, the objective of which was to find out the cause of deaths among patients registered in RNTCP unit of Alappuzha district of Kerala, India. METHODS: In RNTCP a patient who died during the course of treatment regardless of cause is declared as 'Died' due to TB. During the year 2015, 1618 cases were registered in RNTCP of Alappuzha district of which 90 patients died, showing a case fatality rate of 5.56%. Verbal autopsy can be considered as an essential public health tool for studying reasonable estimate of the cause of death at a community level even though not an accurate method at individual level. As part of the study, we visited the 4 RNTCP units of the district and collected the address of the TB patients who died in the area. With the help of the field staff we visited their houses and filled the death audit form of RNTCP along with the additional details. Verbal autopsy was conducted using WHO verbal autopsy format 2012 with immediate house hold contacts. RESULTS: Out of 90 deaths which occurred, three addresses could not be traced and another 15 patient relatives could not be contacted as they migrated out or were not available at their homes on two visits. Among them, mean age was found to be 62.6 years (SD+12.9). Males were 67 (77%) and rest 20 (23%)were females. Cause of death was analysed after Verbal autopsy for 72 deaths. Among 72 deaths, it was found that 29 (40.3%) had nothing other than TB, where as cause of death for 13 (18.1%) patients was myocardial infarction, 11 (15.3%) had cancer, 2 (2.8%) stroke and 17 (23.7%) other causes which include bronchiectasis, COPD, chicken pox, hepatitis, renal failure, and suicide. Only in 35 cases nothing other than TB could be suggested as a cause of death. Thus in 52 out of 87 (60%) cases, the causes of death were diseases other than TB. CONCLUSION: Among the TB deaths in Alappuzha district, 60% of deaths were due to diseases other than TB. Along with early diagnosis of all TB cases, screening for co-morbidity, appropriate management of co-morbidity and periodic clinical review of TB patients should also be part of the major strategies to prevent TB related deaths.

Community engaged breast cancer screening program in Kannur District, Kerala, India: A ray of hope for early diagnosis and treatment.

INTRODUCTION: Community based programs can assist in early detection and improved survival of breast cancer. AIMS: To assess the feasibility and explore challenges of a district-wide door-to-door breast cancer screening program "ASWAS" conducted in Kannur district, Kerala, India from 2011 to 2014. METHODS: Aggregate data from survey records were collected in terms of the population screened, referred, diagnosed, and treated. Case records of breast cancer patients who were identified were reviewed and updated. In-depth interviews were conducted with program stakeholders. The contents of the interview were organized into a strength, weakness, opportunity and threat (SWOT) matrix to describe the screening program. RESULTS: A total of 1,049,410 eligible women above 30 years residing in 81 panchayats were visited door-to-door by 8,200 community volunteers; of them, 93% were screened using a symptom-risk factor checklist. Of those referred with symptoms (n = 5353), 81% attended the cancer camp. In total, 23 breast cancer cases were confirmed. 14 (61%) were in early stages, treated, and are disease free at 3-year follow-up. Those in the advanced stage and old age had poor outcomes. SWOT analysis identified political support, female volunteers, community engagement, dedicated fund for treatment, and teamwork as strengths. Weaknesses included poor healthcare access, maintaining volunteer motivation, and issues around sustainability. CONCLUSION: Community participation with the engagement of the health system and local self-government are required for implementing a comprehensive cancer screening strategy. Breast-cancer screening program using local volunteers for early detection is feasible in low-income settings, thereby improving survival.

Population-based cancer screening through community participation: Outcome of a district wide oral cancer screening program from rural Kannur, Kerala, India.

BACKGROUND: Oral cancer is a major public health challenge, and about one-fifth of all oral cancer cases reported globally are from India. In spite of the potential for early detection by simple visual examination, the majority of patients report in later stages of the disease, especially in low and middle-income countries. We report the results from a district level population-based oral cancer screening program. METHODS: A cross-sectional survey was carried out among people aged >15 years in 48 panchayats of Kannur district in Kerala, India. This comprehensive multi-stakeholder district-wide screening was carried out in six stages including planning, sensitization, recruiting of community volunteers and training, survey, organization of specialist camps and referring to cases to cancer center. The descriptive statistical analysis was performed using EpiData analysis software (Version 2.2.2.180). RESULTS: Among the 1,061,088 people in 265,272 houses surveyed, 2507 of them attended the screening camps, and 13 oral cancers and 174 oral precancers were detected. Majority of the oral cancer patients were male (69%), with primary education or illiterate (62%) and low socioeconomic status (61%). Five of the patients diagnosed with early-stage cancer are alive and have good oral health-related quality of life. CONCLUSION: Detection of precancerous and early-stage cancers should be a priority of oral cancer screening programs. The possible key for addressing cancer screening needs of the rural population is to equip the primary health centers in cancer screening activities with available human resources while adapting to local context.

Why don't key populations access HIV testing and counselling centres in Nepal? Findings based on national surveillance survey.

OBJECTIVES: To assess the demographic, behavioural, psychosocial and structural factors associated with non-utilisation of HIV testing and counselling (HTC) services by female sex workers (FSWs) and men who have sex with men/transgender (MSM/TG). METHODS: This study involved a cross-sectional design. We used the national surveillance survey data of 2012, which included 610 FSWs and 400 MSM/TG recruited randomly from 22 and three districts of Nepal, respectively. Adjusted prevalence ratio (aPR) and 95% confidence interval (CI) using modified Poisson regression was used to assess and infer the association between outcome (non-utilisation of HTC in last year) and independent variables. RESULTS: Non-utilisation of HTC in the last year was 54% for FSWs and 55% for MSM/TG. The significant factors for non-utilisation of HTC among FSWs were depression (aPR=1.4 (95% CI 1.1 to 1.6)), injectable drug abuse (ever) (aPR=1.4 (95% CI 1.1 to 1.8)), participation (ever) in HIV awareness programmes (aPR=1.2 (95% CI 1.0 to 1.4)), experience of forced sex in previous year (aPR=1.1 (95% CI 1.0 to 1.3)) and absence of dependents in the family (aPR=1.1 (95% CI 1.0 to 1.3)). Non-utilisation of HTC among MSM/TG had significant association with age 16-19 years (aPR=1.4 (95% CI 1.1 to 1.7)), non-condom use (aPR=1.2 (95% CI 1.0 to 1.4)), participation (ever) in HIV awareness programmes (aPR=1.6 (95% CI 1.3 to 2.0)), physical assault in previous year (aPR=1.8 (95% CI 1.0 to 3.1)), experience of forced sex in previous year (aPR=0.5 (95% CI 0.3 to 0.9)). CONCLUSION: Although limited by cross-sectional design, we found many programmatically relevant findings. Creative strategies should be envisaged for effective behavioural change communication to improve access to HIV testing. Psychosocial and structural interventions should be integrated with HIV prevention programmes to support key populations in accessing HIV testing.

Prevalence of depression among middle aged women in the rural area of Kerala.

AIMS: The aim of this study was to determine the prevalence of Depression among women aged 40-60 years in the rural area of Kerala using Patient Health Questionnaire 9 (PHQ-9). SETTINGS AND DESIGN: Ambalappuzha is an area of rural background under the District of Alappuzha. The study was conducted by Preventive and Social Medicine department of Govt. T. D. Medical College, Kerala in collaboration with the department of Psychiatry with the help of Ambalappuzha health centre. METHODS AND MATERIAL: A cross-sectional survey was carried out among 594 women from 18 wards of Amabalappuzha North Panchayat using cluster sampling technique. Data on sociodemographic factors, health factors, and behavioral factors were collected from the women by investigator administered the semi-structured questionnaire. Patient Health Questionnaire9 (PHQ-9), was used for diagnosing Major Depression. RESULTS: The prevalence of Major Depression among middle aged women was 26.09% using the PHQ-9 diagnostic criteria and 24.2% using a PHQ-9 cut off score ≥ 10. With increasing age, there was an increasing trend in the prevalence of Depression up to the age of 55years followed by a small decline. A higher prevalence of Depression was observed among widows (43.37%), women not in a marital relation (41.38%), a woman with a history of postpartum Depression (OR 3.471), with peri-menopausal symptoms (40.28%, OR 2.86). CONCLUSIONS: One fourth of the women screened positive for Depression in Ambalappuzha North Panchayat (26.09%). This study highlights the need for understanding the high prevalence and myriad determinants of depression among women living in villages.

Factors associated with long turnaround time for early infant diagnosis of HIV in Myanmar.

BACKGROUND: A previous review of early infant diagnosis (EID) using polymerase chain reaction technology (PCR) under integrated HIV care (IHC) program in Myanmar revealed a low uptake of timely (within 6 to 8 weeks of babies' age) EID and a long turnaround time (TAT) of receiving results. OBJECTIVE: This study aimed to determine the proportion and factors associated with the composite outcome of a long TAT (≥7 weeks; from sample collection to receipt of result by mother) or nonreceipt of result among HIV-exposed babies whose blood samples were collected for PCR at <9 months of age under the IHC program, Myanmar (2013-15). METHODS: Cohort study involving record review of routinely collected data. A predictive Poisson regression model with robust variance estimates was fitted for risk factors of long TAT or nonreceipt of result. RESULTS: Blood samples of 1 000 babies were collected; among them, long TAT or nonreceipt of results was seen in 690 (69%), and this was more than 50% across all subgroups. Babies with a mother's CD4 count of 100-350 cells/mm3 at enrollment [adjusted RR (0.95 confidence intervals, CI): 0.8 (0.7, 0.9)] had a 20% lower risk of long TAT or nonreceipt of results when compared with ≥350 cells/mm3. Distance between ART center and PCR facility ≥105 km [adjusted RR (0.95 CI): 1.2 (1.1, 1.4)], when compared with <105 km, was associated with 20% higher risk of long TAT or nonreceipt of results. CONCLUSIONS: The proportion of babies with long TAT or nonreceipt of result by the mother was high. Point-of-care testing for EID may reduce TAT/nonreceipt of results by the mother. Health system, laboratory, and logistic factors such as sample transportation, laboratory procedures, and result dispatching associated with long TAT should be further explored.

Early infant diagnosis of HIV in Myanmar: call for innovative interventions to improve uptake and reduce turnaround time.

BACKGROUND: In collaboration with the national AIDS program, early infant diagnosis (EID) is implemented by Integrated HIV Care (IHC) program through its anti-retroviral therapy (ART) centers across 10 cities in five states and regions of Myanmar. Blood samples from the ART centers are sent using public transport to a centralized PCR facility. OBJECTIVES: Among HIV-exposed babies <9 months at enrolment into IHC program (2013-15), to describe the EID cascade (enrolment, sample collection for PCR, result receipt by mother, HIV diagnosis and ART initiation) and factors associated with delayed (>8 weeks of age) or no blood sample collection for EID. METHODS: Retrospective cohort study involving record review. A predictive poisson regression model with robust variance estimates was fitted for risk factors of delayed or no sample collection. RESULTS: Of 1349 babies, 523 (39%) of the babies' mothers were on ART before pregnancy. Timely uptake of EID (<8 weeks of age) was 47% (633/1349); sample collection was delayed in 27% (367/1349) and not done in 26% (349/1349) babies. Among samples collected (n = 1000), 667 results were received by the mother; 52 (5%) were HIV-infected; among them 42 (81%) were initiated on ART. Median (IQR) turnaround time from sample collection to result receipt by mother and time to initiate ART from result receipt by mother was 7 (4,12) and 8.5 (6,16) weeks, respectively. Mothers not on ART before pregnancy and distance of ART center from PCR facility (more than 128 km) were the risk factors of delayed or no sample collection. CONCLUSIONS: Improving provision of ART to mothers (through universal 'test and treat') is urgently required, which has the potential to improve the timely uptake of EID as well. Interventions to reduce turnaround times, like point of care EID testing and/or systematic use of mobile technology to communicate results, are needed.

"They know, they agree, but they don't do"--the paradox of tuberculosis case notification by private practitioners in Alappuzha district, Kerala, India.

BACKGROUND: Despite being a recognized standard of tuberculosis (TB) care internationally, mandatory TB case notification brings forth challenges from the private sector. Only three TB cases were notified in 2013 by private practitioners compared to 2000 TB cases notified yearly from the public sector in Alappuzha district. The study objective was to explore the knowledge, opinion and barriers regarding TB Notification among private practitioners offering TB services in Alappuzha, Kerala state, India. METHODS & FINDINGS: This was a mixed-methods study with quantitative (survey) and qualitative components conducted between December 2013 and July 2014. The survey, using a structured questionnaire, among 169 private practitioners revealed that 88% were aware of mandatory notification. All patient-related details requested in the notification form (except government-issued identification number) were perceived to be important and easy to provide by more than 80% of practitioners. While more than 95% felt that notification should be mandatory, punitive action in case of failure to notify was considered unnecessary by almost two third. General practitioners (98%) were more likely to be aware of notification than specialists (84 %). (P<0.01). Qualitative purposive personal interviews (n=34) were carried out among private practitioners and public health providers. On thematic framework analysis of the responses, barriers to TB notification were grouped into three themes: 'private provider misconceptions about notification', 'patient confidentiality, and stigma and discrimination 'and 'lack of cohesion and coordination between public and private sector'. Private practitioners did not consider it necessary to notify TB cases treated with daily regimen. CONCLUSION: Communication strategies like training, timely dissemination of information of policy changes and one-to-one dialogue with private practitioners to dispel misconceptions may enhance TB notification. Trust building strategies like providing feedback about referred cases from private sector, health personnel visit or a liaison private doctor may ensure compliance to public health activities.

Treatment outcome of neuro tuberculosis patients put on DOTS--an observation study from the field.

BACKGROUND: Effectiveness of intermittent Short Course Chemotherapy for Neuro Tuberculosis has not been well studied. There are only few reported studies on this issue in the world literature under filed conditions. Neurologists all over India are reluctant to accept Directly Observed Treatment Short course for neuro tuberculosis since its introduction in India. AIM: Assessing effectiveness of Revised National TB Control Programme (RNTCP-DOTS) regimens among neuro tuberculosis patients registered under the programme. METHODS: All the neuro tuberculosis patients referred to RNTCP for treatment were included in the study. Study population included only those patients diagnosed at higher centre and referred to RNTCP during the period Jan - Dec 2002, Alappuzha District. Diagnostic Algorithm as per RNTCP guidelines was strictly followed and treatment outcome and follow-up status were taken from tuberculosis register. No pediatric age group was included in the study. RESULTS: A total of 32 cases registered for DOTS regimen were included in the study, of whom 29 completed the treatment and all were asymptomatic at the end of treatment (85%). All patients received treatment as DOTS, but only 70% received actual DOTS. All patients were given nine months intermittent regimen as per RNTCP guidelines. Five patients died during the treatment (14%). This result shows that DOTS under field programme conditions are efficient in curing Neuro Tuberculosis. CONCLUSION: Good result was obtained with intermittent short course chemotherapy under programme conditions in neurotuberculosis.