A review of tracking progress towards elimination of Iodine deficiency disorders in Tamil Nadu, India.

Background : Iodine deficiency disorders (IDD) are significant health problem in India. But there is dearth of regional/state level information for the same. Objective: This study was designed to study the current status of IDD in Tamil Nadu. Materials and Methods: A cross-sectional community-based survey was conducted in the state of Tamil Nadu. The study population was children in the age group of 6-12 years and the probability proportional to size 30 cluster methodology was used for sample selection. The parameters studied were prevalence of goiter, urinary iodine excretion, and iodine content in salt at the household level. Results: A total of 1230 children aged between 6 and 12 years were studied. The total goiter rate was 13.5% (95% CI: 11.1-14.9). The median urinary iodine excretion was found to be 89.5 μg/L (range, 10.2-378 μg/L). The 56% of the urinary iodine excretion values were <100 μg/L. The proportion of households consuming adequately iodized salt (iodine content ≥ 15 parts per million) was 18.2% (95% CI: 16.1-20.5). Conclusion: The total goiter rate of 13.5% and median urinary iodine excretion of 89.5 μg/L is indicative of iodine deficiency in Tamil Nadu.

Effective participation of TB sanatoria in Revised National TB Control Programme (DOTS) in a metropolitan city.

BACKGROUND: Revised National TB Control Programme has been implemented since 1998 in Bangalore metropolitan city which has several big general hospitals, including two TB sanatoria which attract a large number of respiratory symptomatic and TB patients. Till recently there was significant loss of patients for follow up because of lack of mechanism to reach the patients, good recording practices and linkage with district TB control office. OBJECTIVE: To establish an effective referral mechanism between TB sanatoria and peripheral health institutions of the government for providing un-interrupted supervised treatment (DOT) to all newly detected TB patients. METHOD: TB sanatoria remain as "islands" when Reyised National TB Control Programme (RNTCP) with DOTS strategy is implemented. Damien Foundation India Trust (DFIT) provided a Technical Support Team (one medical consultant and three supervisors) to assist in implementation of RNTCP in the district. DFIT liaised with both partners and established procedures for recording correct address, informing health institutions and Senior TB Supervisors (STS) and monitoring referrals. Referral slip and a copy of treatment card were given to patients. One copy of treatment card was sent to respective health facility. Initially the number of STS was not adequate to follow up the patients. The supervisors of Technical Support Team ensured that they were treated in peripheral health institutions or near patients' residence. All STS were in position one year after initiation of this effort. RESULTS: The referral system is functional. Case holding improved from about 50% to 85% during 2002-2005 by effective transfer through referrals. CONCLUSION: Interfacing of NGO between district TB control office and TB sanatoria enabled the establishment of effective collaboration. Initial reluctance was replaced by complete participation in the TB control programme.

Diagnosis of leprosy.

Of all the diagnoses of dermatological disorders, the leprosy is perhaps the easiest one to be done on one side but difficult also on the other side. Proper history taking in the diagnosis is very important. Clinical examination is intended to find out if the patient has any skin or nerve lesion. The most important is the definite sensory deficit in the skin lesions which if present confirms the diagnosis of leprosy. Nerve examination necessitates to see the involvement of peripheral nerves eg, ulnar, lateral popliteal, posterior tibial, median or facial. In the routine diagnosis of cases, slit-skin smear from skin lesions and ear lobes is generally not required. The presence of any cardinal sign, related to skin patch or nerve, confirms the diagnosis.

Trends in new case-detection leprosy in Bihar, India.

Multi-drug therapy (MDT) has been successfully implemented in all leprosy endemic countries. Prevalence of leprosy has declined remarkably after the introduction of MDT. Detection of new cases did not show expected decline in many endemic and low endemic situations. Bihar in India started implementing MDT in 1993. The Damien Foundation India Trust (DFIT) supported the leprosy control programme in Bihar by providing a district technical support team (DTST) for each district assigned to DFIT. Effective coverage was achieved in 1996-98. Data for the period 1996-2004 from 10 districts are presented in this paper. The total population in these districts was 29.4 million. Deformity among newly detected leprosy patients declined to 1% indicating effective early case-detection. Intensive new case-detection activities were in vogue contributing to high new case-detection rate (NCDR). The NCDR remained high during the 9-year period reported here and did not show any declining trend.

Community prevalence of hepatitis B infection and modes of transmission in Tamil Nadu, India.

BACKGROUND AND OBJECTIVE: There have been very few community based studies on prevalence of hepatitis B virus (HBV) infection in India. We undertook this study to determine the prevalence of HBV infection in a southern State of India, Tamil Nadu and to describe the important factors related to transmission of the virus in the community. METHODS: Analysis of stored blood samples from a representative population of Tamil Nadu from an earlier community cluster survey on sexually transmitted diseases (STD) prevalence using proportionate to population size (PPS) technique was done. Serum markers of HBV viz., hapatitis B surface antigen (HBsAg), hepatitis B e antigen (HBe Ag) and antibody to surface antigen (anti-HBs) were performed. RESULTS: 1981 subjects were screened in the study. HBsAg prevalence was 5.7 per cent (CI 4.6- 6.8) with 23.5 per cent (25/106) of these having positive HBe-antigen. Community seroprevalence (HbsAg + anti-HBs) of hepatitis B infection was 27.4 per cent (CI: 25.3-29.5) with the highest prevalence of 32.7 per cent (CI: 30.2-35.2) noted in the 15-20 yr age group. Significant independent association (OR 1.4; P=0.006) was detected with family history of exposure to HBV infection by logistic modeling. Other risk factors noted to have significant association were use of disposable needles during injection (OR 0.5; P=0.02) in men, smoking (OR 3; P=0.04) and use of condom (OR 0.6; P=0.08) in women. INTERPRETATION AND CONCLUSION: This community based study shows a high prevalence of hepatitis B infection in the state of Tamil Nadu with the highest prevalence being in the younger (15-20 yr) age group. High prevalence rate in childhood with e-antigenemia seen in 23.5 per cent of HBsAg positive subjects suggest childhood transmission. Poor injection practices and high-risk sexual behavior were found to be additional risk factors for transmission of the disease in the community.

Evaluation of the modified leprosy elimination campaign in a high leprosy endemic district of Jharkhand.

An evaluation of the third Modified Leprosy Eradication Campaign (MLEC) was carried out in Potka block in the high endemic district of East Singhbhum, Jharkhand State, India, by our external evaluation team, from 29 October to 8 November 2001. The searchers in this block detected 389 suspects during the MLEC; of these, 181 (46%) were examined, and 69 (38%) of them were confirmed as cases by the Programme staff. The evaluators examined 189 (48.5%) of the total 389 suspects detected by the searchers, including 31 of the 69 cases confirmed by the Programme staff. Concordance of diagnosis of leprosy cases by the Programme staff and the evaluators was found to be high (90%). However, concordance of the type of leprosy was found to be variable (PB 38%, MB 72%, SSL 100%). Specificity and sensitivity of diagnosis by the Programme staff (as against those by the evaluators) were found to be 85.7% and 79.2% respectively. There was no case of re-registration. The evaluators examined 108 of the suspects detected by the Search Team, but not screened by the Programme staff, and diagnosed 47 cases (44%; PB 20, MB 9, SSL 18) from among them. The evaluators also diagnosed additional 30 new cases (PB 18, MB 5, SSL 7), during their visit. An assessment of knowledge about the disease and treatment among confirmed cases revealed that most of the patients did not know correctly about their disease. All the cases were referred by the searchers. About 45% of cases were aware of the duration for which they needed to take the treatment, 97% of cases showed the blister calendar packs and had taken the supervised dose. Availability of MDT to the patients and drug compliance were found to be adequate. Assessment of the impact of IEC activities on the awareness of leprosy among the community showed that about 50% of those interviewed were aware of the campaign. Most of them had information about the availability of leprosy drugs and knew that treatment was free. A majority of those aware of the disease said that they would refer suspects, if they come across any, to PHC centres for treatment.

"Instant" new leprosy case-detection: an experience in Bihar State in India.

The National Leprosy Eradication Programme (NLEP) is based on survey, education and treatment, including coverage of all the registered cases with multi-drug therapy (MDT). The Government of India introduced MDT in all leprosy endemic districts through a vertical set-up, and through mobile leprosy treatment units in low endemic districts. Anti-leprosy work has not been uniform in all the states and needed push-start in some, such as Bihar. There have been spurts of leprosy elimination activities and the entire populations of the regions have not been covered because of various administrative reasons and logistic problems. In Singhbhum district of Bihar, a successful attempt was made to cover the maximum population by campaign approach. The strategy was to involve all the field workers of the leprosy programme in the district, supported by a small group of experienced personnel. The campaign, lasting for 39 working days, resulted in detecting leprosy cases equivalent to 64% of cases detected during the previous one full year. The entire operation helped the local staff to gain experience that would be useful for the future of the NLEP, and also provide an insight into working practices. Similar campaign approach can be used in situations where case-detection activities are feeble and the implementation of MDT is slow. If such campaigns are repeated at appropriate intervals, it will be a great support to achieving the goal of leprosy elimination.

Dengue fever outbreaks in two villages of Dharmapuri district in Tamil Nadu.

BACKGROUND & OBJECTIVES: Dengue fever is an important public health problem in India. In recent years this disease has extended to rural areas also due to rapid urbanization. In Tamil Nadu, fever outbreaks were reported in two villages of Dharmapuri district during May and September 2001 with clinical symptoms suggestive of dengue fever. Epidemiological, virological and entomological investigations were carried out in these two villages to ascertain the etiology of the outbreaks. METHODS: Paired serum samples were collected from febrile patients clinically suspected to have dengue and were tested for the presence of IgM antibodies to dengue virus by MAC ELISA. Samples were also tested by Dengue Duo IgM/IgG rapid strip. Surveys of larval and adult Aedes mosquitoes were carried out before and after anti-larval and anti-adult measures were implemented. Female Ae. aegypti mosquitoes collected in Mampatti village were tested individually for the presence of dengue-2 viral antigen by indirect immunofluorescence assay (IIFA). In addition, two pools of female Ae. aegypti mosquitoes were tested for the presence of dengue viral antigen by ELISA and then subjected to Toxo-IFA system for demonstration of dengue virus. RESULTS: A total of 124 and 267 fever cases with clinical symptoms and signs suggestive of dengue were reported in Kadumuchandiram and Mampatti villages of Dharmapuri district, respectively. Serodiagnosis revealed that 13 of 31 and 14 of 52 patients tested were positive for dengue-2 virus by MAC ELISA in Kadumuchandiram and Mampatti villages respectively. Dengue Duo rapid strip test also detected 14 (of 31 tested) patients positive for dengue virus specific IgM antibodies in Kadumuchandiram village and 8 (of 12 tested) in Mampatti village. Application of temephos and fogging with pyrethrum 2 per cent extract were found to be effective against immatures and adults respectively. Both the pools of Ae. aegypti tested for the presence of dengue viral antigen were positive by ELISA and one mosquito (tested individually) was positive by IIFA. Supernatants of two pools were found to be positive for dengue-2 virus by Toxo-IFA. INTERPRETATION & CONCLUSION: Virological and serological investigations confirmed that the outbreaks of fever were due to dengue virus infection. High breeding of Ae. aegypti in the study villages, detection of dengue-2 viral antigen and isolation of dengue-2 virus in Ae. aegypti mosquitoes confirmed the etiology.

Community prevalence of sexually transmitted diseases and human immunodeficiency virus infection in Tamil Nadu, India: a probability proportional to size cluster survey.

BACKGROUND: Human immunodeficiency virus (HIV) infection and AIDS is threatening the survival of many nations. To evaluate ongoing interventional strategies and burden of illness estimates, valid data on the prevalence of HIV are required. Often, in the absence of community prevalence data, estimates are based on surrogate markers such as prevalence of HIV in antenatal clinics. Even though the antenatal prevalence of HIV is easier to measure and can be repeated for evaluation, it is important to establish the association between antenatal and community prevalence of sexually transmitted diseases (STDs) and HIV, so that the validity of the estimates can be verified. METHODS: A 'probability proportional to size' cluster survey was conducted in three randomly selected districts of Tamil Nadu in India. The basic unit of the survey was households from rural and urban clusters. Adults 15-45 years of age from the selected households were eligible for recruitment. Demographic, behavioural and laboratory data were collected. Clinical examination was done to identify STD syndromes and blood, urine, vaginal/urethral and endocervical swabs were taken for laboratory diagnosis of STDs from the subjects. Direct smear examination for Trichomonas vaginalis; serological tests for syphilis, hepatitis B, HIV, herpes simplex virus 2, Chlamydia trachomatis; and culture of Neisseria gonorrhoeae and Haemophilus ducreyi were performed on the collected specimens. The data were analysed adjusting for cluster effect. RESULT: We selected and screened 1981 individuals (1157 women and 824 men) for STDs and HIV from 1114 households representing the 25 million projected adult population of Tamil Nadu. The overall community prevalence of STDs including HIV and hepatitis B in Tamil Nadu was 14.6% (CI: 14.1-15.1), and 8.3% (CI: 7.9-8.6) when HIV and hepatitis B were excluded. Community prevalence of HIV and hepatitis B infection was 1.8% (CI:1.7-1.9) and 5.3% (CI: 5.1-5.5), respectively. The distribution of HIV involved both rural and urban regions of Tamil Nadu. On clinical examination, at least one STD syndrome was noted in 486 (24.5%) of the women subjects; vaginal discharge was the most common and found in 421 women (38.4%). CONCLUSION: The prevalence of STD and HIV in Tamil Nadu is higher than expected and has extended into the non-high risk population (generalized epidemic).

Management of simple plantar ulcers by home based self-care.

Seeking a solution to bring down the prevalence of simple plantar ulcers in the field, Damien Foundation India Trust (DFIT), Chennai, developed a curriculum to teach the field staff of all its projects. The purpose was to make patients self-reliant in the care of their plantar ulcers in their homes. The strategy used was to make patients take care of their ulcers using tools found in their homes and surroundings and become responsible for the care of their limbs. This strategy was implemented in eight projects of DFIT and the programme was followed regularly for one year. Regular monitoring and evaluation showed that under this strategy the prevalence of plantar ulcers was reduced by about 50%.

A comparative study of the cost and effectiveness of a modified system of MDT drug delivery system in a high endemic district (Nalagonda) of South India.

Fall in the case load (from 17,000 to 4,500), has changed the disease profile and introduction of fixed duration Therapy (FDT) has made management of leprosy cases rather easy in Nalgonda, a backward district in Andhra Pradesh. The system of drug delivery which was conceived for managing large case load, however, remains unchanged, thereby resulting not only in considerable wastage of resources but also in hampering other activities like case detection and patient care. This study was undertaken to develop and assess a modified system of drug delivery in terms of the cost and effectiveness, its overall effect on other activities in the programme and its acceptability by the field staff. Four Leprosy Control Units (LCUs) were selected and were randomly assigned either to study (Gudibanda, Suryapet) or control (Nalgonda, Bhuvanagiri) group. In the study group the modified drug delivery system replaced the existing system. The modified system consisted of the para medical worker being made responsible for patients at all the DDPs in his subcentre. The clinics were managed alternately by medical officers and non medical supervisors every month. In the control group each clinic was managed by medical officers every month and it covered two sub centers with each drug delivery point being assisted by a para medical worker. The study revealed that the modified system resulted in a saving of 130 man-days a month, a 30% saving in use of vehicle, a 30% saving in POL and improvement in case detection. There was no change in the clinic attendance and drug consumption compliance in the units where modified system was introduced.

Utilizing primary health care workers for case detection.

Under the National Leprosy Elimination Programme it takes at least one year for the paramedical worker to survey the allotted population for case detection. An alternative strategy in warranted for States like Bihar still having a high case load and poorly functioning leprosy programme. An intensive case finding programme using Primary Health Care (PHC) workers was organized in Bhojpur district, Bihar State, India. The whole population (3, 173, 701 in 1996) of the district was screened within a period of four days and confirmation of suspected cases was carried out in four days. During this screening procedure, 1586 new leprosy cases were detected (NCDR = 5 cases per 10,000) and all were started on MDT. The new cases constituted 26.4% of active cases existing on record before the screening. After this experience, the prevalence rate of active cases increased from 19 to 24 10,000. If such rapid screening programmes are done at least twice a year, it will greatly hasten the process of elimination of leprosy.

Restriction fragment length polymorphism of Mycobacterium tuberculosis strains from various regions of India, using direct repeat probe.

Intraspecies differentiation was studied on 68 M. tuberculosis strains obtained from 6 states of India by restriction fragment length polymorphism (RFLP) using a direct repeat probe (DR probe) hybridised with Alu I digest of DNA. Most strains showed polymorphism based patterns that comprised between 2 to 7 bands and were grouped into 26 RFLP types. Of the 11 strains tested from Amritsar, 8 were RFLP type 5; the remaining 3 were of type 11 and were exclusively confined to this region. The strains from other regions were more heterogeneous. We confirm that DR-associated RFLP can be an excellent tool for the differentiation of M. tuberculosis strains. Depending on their geographical origin, these strains can be differentiated to a large extent by DR fingerprinting.

Acute myeloid leukemia in TAR syndrome.

TAR syndrome is a rare inherited autosomal recessive disorder with a mortality rate of 30-40% mainly as a result of haemorrhage, in the first year of life. Most of the infants recover from the effects of thrombocytopenia and associated haematological complications with the modern medical care. Very rarely, the outcome is fatal, with the occurrence of acute leukemias.

A study on the effect of patient and community education in prevention of disability programme.

The effect of self-care learning by leprosy patients in prevention of disabilities was studied by adapting two strategies in two subcentres of a project in South India, one through patient education by trained field staff and the other through community education involving trained animators and health committees. One of the subcentres was taken as control where neither of the strategies was employed. In terms of results, though both the strategies were found to be effective in containing occurrence of new deformities among high risk patients and healing of trophic ulcers in hands and feet, strategy I i.e. self-care education of patients by concerned field personnel without prejudice to their routine work is recommended because of ease in diffusion of strategy.

Tuberculous meningitis in children--clinical profile, mortality and morbidity of bacteriologically confirmed cases.

One hundred and seven cases of tuberculous meningitis were registered as a part of a case-control study during the period 1990-1992. The CSF of all cases was positive for culture and/or smear for acid fast bacilli. Children were examined at the time of admission and at the time of discharge and they were contacted at the end of 1 year. Clinical picture, mortality and morbidity were analyzed. Mortality of children during the first month of illness was 22%. Some of the cases presented as acute neurological illness. We also came across CSF picture with minimal cytological and biochemical changes but with positive culture results.

Testing compliance of drug taking--a simple bed side method.

Assessment of compliance in drug taking is a problem in a crowded Outpatient Department. Using riboflavin as a urinary marker is a simple and rational method. Identifying riboflavin in the urine by fluorescence on exposure to ultraviolet (UV) rays or torch light is being used in medical practice but not extensively. In this study, the validity and reliability of these methods were assessed. The sensitivity and specificity of this test by UV method was 86% and 82% for Reader I (medical person) and 82% and 94% for Reader II (paramedical person). For Reader I, the accuracy of reading by UV lamp was the same as torch light (85%) whereas for Reader II the accuracy was better with UV lamp (87%) than with torch (79%). In reading the fluorescence by UV lamp the crude agreement between the 2 readers was 82% and chance corrected agreement was 64%. UV lamp method appears to be a reliable way of assessing compliance both by medical and paramedical persons whereas torch method appears to be more reliable when used by a medical person than by a paramedical person.

Early bactericidal action of pulsed exposure to rifampicin, ethambutol, isoniazid & pyrazinamide in pulmonary tuberculosis patients.

The bactericidal action of two therapeutic regimens on Mycobacterium tuberculosis was assessed by viable counts in serial sputum samples in 49 pulmonary tuberculosis patients being treated with rifampicin (R), ethambutol (Emb), isoniazid (I) and pyrazinamide (Z) together in a single dose thrice weekly (REmbIZ3) or with REmb and IZ on alternate days (REmb3IZ3alt). In both groups of patients, there was a significant reduction (P < or = 0.02) in the colony forming units (cfu) of M. tuberculosis per ml of sputum during the first two days of treatment itself. This early bactericidal action (EBA) as well as the reduction in counts during the subsequent days of treatment were similar (P > 0.2) for both REmbIZ3 and REmb3IZ3alt regimens indicating that splitting up REmbIZ into REmb on one day and IZ on the next day in short course chemotherapy (SCC) regimens may not affect the bactericidal action of the regimens.

Evaluation of a cold staining method for acid-fast bacilli in sputum.

Comparison between the Ziehl-Neelsen staining method for acid-fast bacilli, applied with and without heating, was carried out in a controlled investigation using smears prepared from 306 sputum samples collected prior to treatment from suspected cases of pulmonary tuberculosis. Smear and culture positivity were graded and the colour intensity of bacilli recorded. Results showed that the chance corrected agreement (Kappa) between Z-N and cold methods was only 78%. The sensitivity of the Z-N and cold methods were 84% and 77% respectively when compared with culture results. Assuming 10% smear positivity among symptomatics reporting to Peripheral Health Institutions (PHIs), the positive predictive value of the cold method was very low (53%). When compared to culture, the positive predictive value is 71% for the Z-N method and 57% for the cold method for a symptomatic population with 15% culture positivity. In the absence of heating, penetration of the stain was significantly reduced and consequently the number of bacilli detected was less. The inability to take the stain without heating was seen in smears from all grades of culture positive samples; thus even heavy positives were missed by the cold method. The evaluation of the cold method against the standard Z-N method highlights its limitations and demonstrates that it is not as reliable as the standard Z-N method.