Development of a community orientation program (COP) as a community-based medical education method for undergraduate medical students: an experience from India.

BACKGROUND: Intra-regional cultural and linguistic differences are common in low- and middle-income countries. To sensitise undergraduate medical students to the social and contextual determinants of health to achieve the 'health for all' goal, these countries must focus on innovative teaching methods. The early introduction of a Community Orientation Program (COP) as a Community-based Medical Education (CBME) method could be a game changing strategy. In this paper the methods, evaluation, and implication of the COP in an Indian setting are described. METHODS: The curriculum of the COP was developed based on the analysis, design, development, implementation, and evaluation (ADDIE) model for educational intervention. In this learner-centric and supervised educational program, the key aim was to focus on developing students' communication skills, observation power and enhancing their motivation for learning through collaborative learning. To meet the objectives of the COP, a situated learning model under the constructivism theory was adopted. RESULTS: Between 2016 and 2019, 557 students were trained through the COP by visiting more than 1300 households in ten villages. To supplement the students' observations in the community, more than 150 small group discussions, a health education programme for the community and summary presentations were conducted. The students' feedback indicated the need to improve the clinical examinations demonstration quality and increase the number of instruments for clinical examinations. More than 80% of students felt that the program would assist them to improve their communication skills, their understanding of the various socio-demographic factors associated with the common diseases, and it will enable them to respect the local culture during their clinical practice. CONCLUSIONS: Early initiation of the COP as a CBME method in the undergraduate medical curriculum in an Indian setting has shown promising results. Further evidence is required to adopt such a program routinely for under-graduate medical teaching in the low- and middle- income settings.

Morbidity profile of children from birth to 18 years of age referred for intervention to the district early intervention centre in a District Hospital, Andhra Pradesh.

BACKGROUND: The "Child Health Screening and Early Intervention Services" program aims at early detection and management of the four dimensions prevalent in children-defects at birth, diseases in children, deficiency conditions, and developmental delays, including disabilities. OBJECTIVE: The objective of the study was to assess the morbidity profile of children from birth to 18 years of age screened in the district early intervention center (DEIC). METHODS: A record-based descriptive study was done in the DEIC in Chittoor, Andhra Pradesh. The data were retrieved for 1-year from April 2017 to March 2018 into the excel sheet, and the combined master sheet was prepared for analysis. The analysis was done with SPSS 21.0 Version. RESULTS: A total of 10571 children were screened and referred to the DEIC during the period. Out of them, 5679 (53.7%) were male and 4892 (46.3%) were female. Among all the four types of morbidities screened, majority 4847 (45.9%) were having the childhood diseases, 4177 (39.5%) had developmental delays including disabilities, 1067 (10.1%) had different deficiencies, and 361 (3.4%) had birth defects. Among the adolescent health issues, 119 (1.1%) were screened and sent for the early intervention to the district hospital. CONCLUSIONS: A huge number of children were screened and referred to the DEIC every year for intervention. The health sector has to focus more on the resources like workforce, training of peripheral health workers at regular intervals about the different morbidities screened, that would help in identifying the morbidities at the earliest possible time and receive the intervention at the best center.

Cost and outcome of a community-based paediatric hearing screening programme in rural India with application of tele-audiology for follow-up diagnostic hearing assessment.

OBJECTIVE: This study evaluated the cost and outcome of a community-based hearing screening programme in which village health workers (VHWs) screened children in their homes using a two-step DPOAE screening protocol. Children referred in a second screening underwent tele diagnostic ABR testing in a mobile tele-van using satellite connectivity or at local centre using broadband internet at the rural location. DESIGN: Economic analysis was carried out to estimate cost incurred and outcome achieved for hearing screening, follow-up diagnostic assessment and identification of hearing loss. Two-way sensitivity analysis determined the most beneficial cost-outcome. STUDY SAMPLE: 1335 children under 5 years of age underwent screening by VHWs. RESULTS: Nineteen of the 22 children referred completed the tele diagnostic evaluation. Five children were identified with hearing loss. The cost-outcomes were better when using broadband internet for tele-diagnostics. The use of least expensive human resources and equipment yielded the lowest cost per child screened (Rs.1526; $23; €21). When follow-up expenses were thus maximised, the cost per child was reduced considerably for diagnostic hearing assessment (Rs.102,065; $1532; €1368) and for the cost per child identified (Rs.388,237; $5826; €5204). CONCLUSION: Settings with constrained resources can benefit from a community-based programme integrated with tele diagnostics.

A study on prevalence of depression and associated risk factors among elderly in a rural block of Tamil Nadu.

BACKGROUND: Depression among elderly is an important public health problem responsible for considerable morbidity and disability. Causes of depression are multifactorial and often preventable. As there was dearth of community studies in Tamil Nadu, the present study was undertaken. OBJECTIVES: The objective of this study is to estimate the prevalence of depression and to assess the factors which are associated with depression among elderly. METHODS: A cross-sectional study was done from July 2014 to July 2015 among elderly in Kattankulathur block with a sample size of 690 by cluster sampling method. House-to-house interview was conducted using a predesigned, pre-tested questionnaire, and depression was assessed using geriatric depression scale-30. Data were analyzed using SPSS version 20 (Trial). The statistical tests used were proportions, Chi-square test. P<0.05 was considered to be statistically significant. RESULTS: The overall prevalence of depression was 35.5% (95% confidence interval: 31.9%-39.0%). Sociodemographic factors such as female sex, nuclear family, being widowed, unemployed status, low socioeconomic status, financially dependent, medical factors such as cardiac disease, visual impairment, arthritis, anemia, life events such as conflicts in family, death of the family member or close relative, and illness of self/family member were significantly associated with depression (P < 0.05). CONCLUSIONS: More strength of association for depression was seen with low socioeconomic status, nuclear family, low-intensity work, conflicts in the family, death of family members using multiple logistic regression. These findings show the need for proper care by the family members and counseling for the elderly which are of much importance in preventing depression.

Impaired toll like receptor 9 response in pulmonary tuberculosis.

BACKGROUND & AIM: Innate immune responses are important in susceptibility to pulmonary tuberculosis (TB). In order to test the hypothesis that Toll-like receptor (TLR) 2 function would be abnormal in patients with active pulmonary TB we compared the cytokine responses of peripheral blood mononuclear cells (PBMC) to innate immune ligands in a case-control study. METHODS: PBMC from 19 untreated pulmonary TB patients, 17 healthy controls, and 11 treated pulmonary TB patients, were cultured for 24h with TLR 2 ligand (PAM-CSK) and other TLR ligands (muramyl dipeptide, flagellin, lipopolysaccharide (LPS), CpG oligodeoxynucleotide (CpG-ODN)). Interleukin-8 (IL-8) was estimated in the supernatant by ELISA. Messenger RNA expression for inflammatory cytokines was quantitated using real time PCR. RESULTS: The important findings were (1) reduced PBMC secretion of IL-8 in response to all ligands in active TB; (2) normal to increased PBMC secretion of IL-8 in response to all ligands except CpG ODN (TLR 9 ligand) in TB patients who had recovered; (3) absence of difference in mRNA expression for a consortium of inflammatory pathway genes between healthy controls, active pulmonary tuberculosis and treated pulmonary tuberculosis patients. CONCLUSION: There was a generalized post-translational suppression of the IL-8 response to innate immune ligands in active TB. There appears to be a defect of TLR 9 signaling in patients with tuberculosis, the nature of which needs to be further explored.

Faecal microbiota of healthy adults in south India: Comparison of a tribal & a rural population.

BACKGROUND & OBJECTIVES: The relevance of the gut microbiota to human health is increasingly appreciated. The objective of this study was to compare the gut microbiota of a group of adult tribals with that of healthy adult villagers in Tamil Nadu, India. METHODS: Faeces were collected from 10 healthy tribal adults (TAs) in the Jawadhi hills and from 10 healthy villagers [rural adults (RAs)] in Vellore district, Tamil Nadu. DNA was extracted, and 456 bp segments comprising hypervariable regions 3 and 4 of the 16S rRNA gene were amplified, barcoded and 454 sequenced. RESULTS: Totally 227,710 good-quality reads were analyzed. TAs consumed a millets-based diet, ate pork every day, and did not consume milk or milk products. RAs consumed a rice-based diet with meat intake once a week. In both groups, Firmicutes was the most abundant phylum, followed by Proteobacteria, Bacteroidetes and Actinobacteria. The median Firmicutes-to-Bacteroidetes ratio was 34.0 in TA and 92.9 in RA groups. Actinobacteria were significantly low in TA, possibly due to non-consumption of milk. Clostridium constituted the most abundant genus in both groups, but was significantly more abundant in TAs than RAs, while Streptococcus was significantly more abundant in RA (P<0.05). Analyses of genetic distance revealed that the microbiota were distinctly different between TA and RA, and principal component analysis using 550 distinct taxonomically identifiable sequences revealed a clear separation of microbiota composition in the two groups. Phylogenetic analysis of major microbiota indicated clustering of microbial groups at different major branch points for TAs and RAs. INTERPRETATION & CONCLUSIONS: Phylum Firmicutes and genus Clostridium constituted the bulk of the faecal microbiota, while significant differences in composition between the groups were probably due to differences in diet and lifestyle.

COST OF INTENSIVE CARE IN INDIA.

OBJECTIVES: The majority of patients in India access private sector providers for curative medical services. However, there is scanty information on the cost of treatment of critically ill patients in this setting. The study evaluates the cost and extent of financial subsidy required for patients admitted to an intensive care unit (ICU) in India. METHODS: Data on direct medical, direct nonmedical, and indirect cost were prospectively collected from critically ill patients admitted to a tertiary teaching hospital in India. Willingness-to-pay (WTP) amount was obtained from the next-of-kin following admission and the actual cost paid by the family at discharge was recorded. RESULTS: The main diagnoses (n = 499) were infection (26 percent) and poisoning (21 percent). The mean APACHE-II score was 13.9 (95 percent confidence interval [CI], 13.3-14.5); 86 percent were ventilated. ICU stay was 7.8 days (95 percent CI, 7.3-8.3). Hospital mortality was 27.9 percent. Direct medical cost accounted for 77 percent (US$ 2164) of the total treatment cost (US$ 2818). Indirect cost and direct nonmedical cost contributed to 19 percent (US$ 547.5) and 4 percent (US$ 106.5), respectively. Average total and daily ICU cost were US$ 1,897 and US$ 255, respectively. Although the family's WTP was 53 percent (US$ 1146; 95 percent CI, 1090-1204) of direct medical cost, their final contribution was 67.7 percent (US$ 1465; 95 percent CI, 1327-1604). CONCLUSIONS: The cost of an ICU admission in our setting is US$ 2818. Although the family's contribution to expenses exceeded their initial WTP, a substantial subsidy (33 percent) is still required. Alternate financing strategies for the poor and optimization of ICU resources are urgently required.

Isolation and characterization of a ranavirus from koi, Cyprinus carpio L., experiencing mass mortalities in India.

We investigated mass mortalities of koi, Cyprinus carpio Linnaeus, 1758, experienced in South Indian fish farms by virus isolation, electron microscopy, PCR detection, sequencing of capsid protein gene and transmission studies. Samples of moribund koi brought to the laboratory suffered continuous mortality exhibiting swimming abnormalities, intermittent surfacing and skin darkening. Irido-like virus was isolated from the infected fish in the indigenous snakehead kidney cell line (SNKD2a). Icosahedral virus particles of 100 to 120 nm were observed in the infected cell cultures, budding from the cell membrane. Virus transmission and pathogenicity studies revealed that horizontal transmission occurred associated with mortality. PCR analysis of infected fish and cell cultures confirmed the presence of Ranavirus capsid protein sequences. Sequence analysis of the major capsid protein gene showed an identity of 99.9% to that of largemouth bass virus isolated from North America. Detection and successful isolation of this viral agent becomes the first record of isolation of a virus resembling Santee-Cooper Ranavirus from a koi and from India. We propose the name koi ranavirus to this agent.

Contribution of medical colleges to tuberculosis control in India under the Revised National Tuberculosis Control Programme (RNTCP): lessons learnt & challenges ahead.

Medical college faculty, who are academicians are seldom directly involved in the implementation of national public health programmes. More than a decade ago for the first time in the global history of tuberculosis (TB) control, medical colleges of India were involved in the Revised National TB Control Programme (RNTCP) of Government of India (GOI). This report documents the unique and extraordinary course of events that led to the involvement of medical colleges in the RNTCP of GOI. It also reports the contributions made by the medical colleges to TB control in India. For more than a decade, medical colleges have been providing diagnostic services (Designated Microscopy Centres), treatment [Directly Observed Treatment (DOT) Centres] referral for treatment, recording and reporting data, carrying out advocacy for RNTCP and conducting operational research relevant to RNTCP. Medical colleges are contributing to diagnosis and treatment of human immunodeficiency virus (HIV)-TB co-infection and development of laboratory infrastructure for early diagnosis of multidrug-resistant and/or extensively drug-resistant TB (M/XDR-TB) and DOTS-Plus sites for treatment of MDR-TB cases. Overall, at a national level, medical colleges have contributed to 25 per cent of TB suspects referred for diagnosis; 23 per cent of 'new smear-positives' diagnosed; 7 per cent of DOT provision within medical college; and 86 per cent treatment success rate among new smear-positive patients. As the Programme widens its scope, future challenges include sustenance of this contribution and facilitating universal access to quality TB care; greater involvement in operational research relevant to the Programme needs; and better co-ordination mechanisms between district, state, zonal and national level to encourage their involvement.

Rapid diagnosis of tuberculosis with the Xpert MTB/RIF assay in high burden countries: a cost-effectiveness analysis.

BACKGROUND: Xpert MTB/RIF (Xpert) is a promising new rapid diagnostic technology for tuberculosis (TB) that has characteristics that suggest large-scale roll-out. However, because the test is expensive, there are concerns among TB program managers and policy makers regarding its affordability for low- and middle-income settings. METHODS AND FINDINGS: We estimate the impact of the introduction of Xpert on the costs and cost-effectiveness of TB care using decision analytic modelling, comparing the introduction of Xpert to a base case of smear microscopy and clinical diagnosis in India, South Africa, and Uganda. The introduction of Xpert increases TB case finding in all three settings; from 72%-85% to 95%-99% of the cohort of individuals with suspected TB, compared to the base case. Diagnostic costs (including the costs of testing all individuals with suspected TB) also increase: from US$28-US$49 to US$133-US$146 and US$137-US$151 per TB case detected when Xpert is used "in addition to" and "as a replacement of" smear microscopy, respectively. The incremental cost effectiveness ratios (ICERs) for using Xpert "in addition to" smear microscopy, compared to the base case, range from US$41-$110 per disability adjusted life year (DALY) averted. Likewise the ICERS for using Xpert "as a replacement of" smear microscopy range from US$52-$138 per DALY averted. These ICERs are below the World Health Organization (WHO) willingness to pay threshold. CONCLUSIONS: Our results suggest that Xpert is a cost-effective method of TB diagnosis, compared to a base case of smear microscopy and clinical diagnosis of smear-negative TB in low- and middle-income settings where, with its ability to substantially increase case finding, it has important potential for improving TB diagnosis and control. The extent of cost-effectiveness gain to TB programmes from deploying Xpert is primarily dependent on current TB diagnostic practices. Further work is required during scale-up to validate these findings.

Economic implications of three strategies for the control of taeniasis.

OBJECTIVE: To evaluate the cost-effectiveness of three strategies for the control of taeniasis in a community, in terms of cost per case treated. METHODS: A study was conducted in South India to determine the prevalence of taeniasis by screening stool samples from 653 randomly chosen subjects, for coproantigens. The costs incurred in the project were used to estimate the cost per case screened and treated. A one-way sensitivity analysis was carried out for varying rates of taeniasis, different screening strategies and mass therapy. Further sensitivity analysis was carried out with different manpower and test costs. RESULTS: The rate of taeniasis as detected by ELISA for coproantigen was 3 per 1000 (2 of 653 samples). Our study showed that mass therapy without screening for taeniasis would be the most economical strategy in terms of cost per case treated if field workers are employed exclusively for either mass therapy or screening. For each strategy, costs per case treated are higher at low prevalence of taeniasis, with a sharp rise below 15%. CONCLUSIONS: In places that are endemic for taeniasis and neurocysticercosis, mass therapy or screening for taeniasis should be considered. Screening by stool microscopy is not cost-effective in terms of cost per case of taeniasis treated owing to its low sensitivity. Although the cost per case of taeniasis treated is high at low prevalence of taeniasis for all options, incorporating mass therapy into existing mass drug distribution programmes might prove to be the most cost-effective control strategy.

Pilot randomized trial of nutritional supplementation in patients with tuberculosis and HIV-tuberculosis coinfection receiving directly observed short-course chemotherapy for tuberculosis.

OBJECTIVE: To investigate the effects of nutritional supplementation on the outcome and nutritional status of south Indian patients with tuberculosis (TB) with and without human immunodeficiency virus (HIV) coinfection on anti-tuberculous therapy. METHOD: Randomized controlled trial on the effect of a locally prepared cereal-lentil mixture providing 930 kcal and a multivitamin micronutrient supplement during anti-tuberculous therapy in 81 newly diagnosed TB alone and 22 TB-HIV-coinfected patients, among whom 51 received and 52 did not receive the supplement. The primary outcome evaluated at completion of TB therapy was outcome of TB treatment, as classified by the national programme. Secondary outcomes were body composition, compliance and condition on follow-up 1 year after cessation of TB therapy and supplementation. RESULTS: There was no significant difference in TB outcomes at the end of treatment, but HIV-TB coinfected individuals had four times greater odds of poor outcome than those with TB alone. Among patients with TB, 1/35 (2.9%) supplemented and 5/42(12%) of those not supplemented had poor outcomes, while among TB-HIV-coinfected individuals, 4/13 (31%) supplemented and 3/7 (42.8%) non-supplemented patients had poor outcomes at the end of treatment, and the differences were more marked after 1 year of follow-up. Although there was some trend of benefit for both TB alone and TB-HIV coinfection, the results were not statistically significant at the end of TB treatment, possibly because of limited sample size. CONCLUSION: Nutritional supplements in patients are a potentially feasible, low-cost intervention, which could impact patients with TB and TB-HIV. The public health importance of these diseases in resource-limited settings suggests the need for large, multi-centre randomized control trials on nutritional supplementation.

Identification of Substances Produced by Cercospora brachiata in Absence of Light and Evaluation of Antibacterial Activity.

Cercospora brachiata is a phytopathogenic fungus. To know more about the metabolites produced by this fungus, the objective of this work was to identify, isolate and characterize substances present in extracts of the growth broth and mycelium, using gas chromatography with mass spectrometry (GC-MS) and nuclear magnetic resonance (NMR). It was also objective to evaluate the antibacterial activity of the extracts. Among the compounds identified, fatty acids, esters, and steroids can be highlighted. The main compounds identified are 9-hexadecenoic, hexadecenoic, oleic, octadecanoic, lauric, myristic, palmitic, doceno-13-enoic, stearic, linoleic, and nonadecanoic acids present in almost all extracts. For the antibacterial activity, the broth microdilution method was used. The ethyl acetate extract of the mycelium presented inhibitory concentrations (MICs) against the bacterium Actinomyces naeslundii (100 µg mL-1) and Streptococcus sanguinis (200 µg mL-1). Finally, two steroids were isolated and identified in the hexane extract of mycelium: ergosta-6,22-dien-3ß,5α,8α-triol and brassicasterol.

Prevalence of pulmonary tuberculosis among the tribal populations in India.

IMPORTANCE: There is no concrete evidence on the burden of TB among the tribal populations across India except for few studies mainly conducted in Central India with a pooled estimation of 703/100,000 with a high degree of heterogeneity. OBJECTIVE: To estimate the prevalence of TB among the tribal populations in India. DESIGN, PARTICIPANTS, SETTING: A survey using a multistage cluster sampling design was conducted between April 2015 and March 2020 covering 88 villages (clusters) from districts with over 70% tribal majority populations in 17 States across 6 zones of India. The sample populations included individuals ≥15 years old. MAIN OUTCOME AND MEASURES: Eligible participants who were screened through an interview for symptoms suggestive of pulmonary TB (PTB); Two sputum specimens were examined by smear and culture. Prevalence was estimated after multiple imputations for non-coverage and a correction factor of 1.31 was then applied to account for non-inclusion of X-ray screening. RESULTS: A total of 74532 (81.0%) of the 92038 eligible individuals were screened; 2675 (3.6%) were found to have TB symptoms or h/o ATT. The overall prevalence of PTB was 432 per 100,000 populations. The PTB prevalence per 100,000 populations was highest 625 [95% CI: 496-754] in the central zone and least 153 [95% CI: 24-281] in the west zone. Among the 17 states that were covered in this study, Odisha recorded the highest prevalence of 803 [95% CI: 504-1101] and Jammu and Kashmir the lowest 127 [95% CI: 0-310] per 100,000 populations. Findings from multiple logistic regression analysis reflected that those aged 35 years and above, with BMI <18.5 Kgs /m2, h/o ATT, smoking, and/or consuming alcohol had a higher risk of bacteriologically positive PTB. Weight loss was relatively more important symptom associated with tuberculosis among this tribal populations followed by night sweats, blood in sputum, and fever. CONCLUSION AND RELEVANCE: The overall prevalence of PTB among tribal groups is higher than the general populations with a wide variation of prevalence of PTB among the tribal groups at zone and state levels. These findings call for strengthening of the TB control efforts in tribal areas to reduce TB prevalence through tribal community/site-specific intervention programs.

Malnutrition in free-living elderly in rural south India: prevalence and risk factors.

OBJECTIVE: To estimate the prevalence of malnutrition among free-living elderly in a rural population of south India. DESIGN: Cross-sectional study. Nutritional status was assessed using the Mini Nutritional Assessment (MNA) questionnaire, which is an eighteen-item nutritional screening instrument used in the elderly. SETTING: Kaniyambadi block, a rural development block in the state of Tamil Nadu, south India. SUBJECTS: Community-dwelling elderly (aged 60 years and above). RESULTS: As evaluated by the MNA, 14 % of the 227 subjects were malnourished and 49 % were at risk of malnourishment. No significant difference was found between men and women. The majority of the elderly were living with their children, had no income and consumed three meals per day. Older age (P < 0.001), decreased food intake (P < 0.001) and consuming fewer meals (P < 0.001) were independently associated with lower MNA scores. CONCLUSIONS: More than 60 % of the subjects had low MNA scores (<23.5) indicating that deficient protein-energy intake is common among rural elderly of south India and requires more attention.

Health care utilisation in Indian leprosy patients in the era of elimination.

OBJECTIVE: The health care utilisation pattern among Indian leprosy patients accessing a tertiary care centre over an 18 month period was studied. DESIGN: A study was conducted at the Dermatology Outpatient Clinic at the Christian Medical College, Vellore, from January 2005 to June 2006. The profile of patients was assessed and a subgroup was interviewed on their healthcare use, including any delays and costs incurred. RESULTS: 198 patients presented of which 115 patients (58.1%) were on treatment for leprosy or a leprosy reaction (active) including 35 new patients (17.7%), and 83 (41.9%) patients were not on active treatment (inactive). 81 patients were interviewed in depth, 14 (17.3%) were new patients included among 54 (66.7%) patients with active disease, and 27 (33.3%) with inactive disease. The average delay from the onset of symptoms to starting treatment in those interviewed was 13.4 months, 7.9 months of which was a patient-related delay and 5.4 months of which was the health care system-related delay. In patients who had been released from treatment, 78.6% (22/28) required care after cure. CONCLUSIONS: Improved awareness is required to reduce patient-related delays and systems for sustained training need to be in place to tackle the problem of health care system-related delays. Care after cure is a felt need for many patients released from treatment.

Indian isolates of white spot syndrome virus exhibit variations in their pathogenicity and genomic tandem repeats.

To detect genomic variation of white spot syndrome virus (WSSV) isolates from different geographical regions of India, the variable number of the tandem repeat (VNTR) region of the ORF 94 (Thailand WSSV isolate - GeneBank Accession No. AF369029) was analysed using five specific sets of primers. Analysis of 70 WSSV-positive samples showed the presence of 14 different genotypes of WSSV with VNTRs ranging from 2 to 16 tandem repeats with the majority (85.47%) having 6-12 tandem repeats. Occurrence of different genotypes of WSSV was found to be neither correlated to any specific geographical region nor to the different growth stage of the tiger shrimp, Penaeus monodon. Pathogenicity studies conducted with 25 isolates of WSSV revealed the presence of virulent and avirulent strains of WSSV in Indian shrimp farms. However, an unambiguous link could not be established between the different genotypes and their virulence.

Costing of severe pneumonia in hospitalized infants and children aged 2-36 months, at a secondary and tertiary level hospital of a not-for-profit organization.

OBJECTIVES: To determine health care provider cost and household cost of the treatment of severe pneumonia in infants and young children admitted to secondary and tertiary level health care facilities. METHODS: The study was done in a private, not-for-profit medical college hospital, in Vellore, India, in mid-2008. Children aged 2-36 months admitted with severe pneumonia with no underlying chronic disease were included in the study. The relatives were interviewed daily on matters relating to patients' view point of the costs. These were direct medical costs, direct non-medical costs which comprised travel, accommodation and special food during the period of illness, and indirect costs of productivity loss for family members. Patient specific resource consumption and related charges were recorded from charts, nursing records, pharmacy lists and hospital bills, and the providers view point of the costs was estimated. Unit cost estimates for bed days, treatment and investigation inputs were calculated. RESULTS: Total cost to health care provider for one episode of hospitalized childhood pneumonia treated at secondary level was US$ 83.89 (INR 3524) and US$ 146.59 (INR 6158) at tertiary level. At both levels the greatest single cost was the hospital stay itself, comprising 74% and 56% of the total cost, respectively. Diagnostic investigations were a large expense and supportive treatment with nebulization and oxygen therapy added to the costs. Mean household expenditure on secondary level was US$ 41.35 (INR 1737) and at tertiary level was US$ 134.62 (INR 5655), the largest single expense being medicines in the former and the hospitalization in the latter. (one US$=INR 42.1 at time of study) CONCLUSIONS: A considerable cost difference exists between secondary and tertiary level treatment. Admission at lowest possible treatment level for appropriate patients could decrease the costs borne by the provider and the patient.

Blinded evaluation of commercial urinary lipoarabinomannan for active tuberculosis: a pilot study.

SETTING: Urine antigen testing is an attractive strategy for the diagnosis of active tuberculosis (TB), but accuracy data are scarce. OBJECTIVE: To prospectively evaluate the diagnostic performance of commercial urinary lipoarabinomannan (LAM) antigen testing for active TB among pulmonary and extra-pulmonary TB suspects. DESIGN: Prospective blinded evaluation of 200 adult TB suspects at a tertiary referral hospital in India. Reference standards included culture and clinical diagnosis. RESULTS: Patients were 61% male (mean age 40.4 years): 8.5% were human immunodeficiency virus (HIV) infected and 47 of 200 (23.5%) were culture-positive for TB. Compared to positivity on either Löwenstein-Jensen (LJ) or BACTEC cultures, LAM sensitivity was 17.8% (95%CI 8.5-32.6), while specificity was 87.7% (95%CI 81.3-92.3). Compared to positivity on both LJ and BACTEC, LAM sensitivity was 5.8% (95%CI 12.5-44.9), with a specificity of 88.8% (95%CI 82.7-92.9). Compared to the clinical diagnosis, LAM sensitivity was 20.0% (95%CI 1.1-70.1), with a specificity of 83.3% (95%CI 50.9-97.0). HIV and smear status did not influence test accuracy. CONCLUSION: In its current form, LAM is insensitive for the diagnosis of active TB, although its specificity is adequate.

A Community-Based Case-Control Study on the Risk of Fall among the Elderly in Rural Kattankulathur Block, Tamil Nadu.

BACKGROUND: Approaching 100 million in number, India has the second largest population of elderly people after China. India's elderly are growing faster than the general population. By the year 2050, the number of elderly population is expected to increase to 323 million. In the geriatric population, fall is the leading cause of nonfatal injuries and hospital admissions. Falls account for 40% of all injury deaths, and the death rates are the highest among 60 years and above in all the regions of the world. OBJECTIVES: The objective of this study is to assess the factors associated with the risk of fall among the elderly of 60 years and older in rural Kattankulathur block. MATERIALS AND METHODS: The study is a community-based case-control design among the elders in a rural setting. Those who had fallen in the past 12 months were selected as cases, and an equal number of age- and gender-matched controls were selected. Multiple logistic regression was conducted with biological, behavioral, environmental, and socioeconomic variables. RESULTS: Of the 747 elderly contacted for the survey, 140 cases and 140 controls each were selected based on self-reported fall in the previous 12 months. The mean age of the participants was 66 with 95% confidence interval (65-67). Individual risk factors for fall were fear of falling (odds ratio [OR] 6.7) and dizziness (OR 4.9). CONCLUSIONS: There is now, more than ever, a need to refocus public health priorities for falls prevention in rapidly aging elders in India. This study provides a much-needed information for further investigation into fall and fall-related injury in developing countries like India.