Community, system and policy level drivers of bovine tuberculosis in smallholder periurban dairy farms in India: a qualitative enquiry.

BACKGROUND: Rapid urbanization has led to expansion of peri-urban fringes, where intensive, industry-style livestock rearing has led to emerging vulnerabilities at the human-animal-environment interface. This study was undertaken to understand the health system and farm-level factors that influenced the risk of transmission of bovine Tuberculosis (bTB) in animals and humans in peri-urban smallholder dairy farms of India. METHODS: Thematic guides were developing through literature review and expert consultation. In-depth interviews were conducted till attainment of saturation. Identification of core themes was followed by etiological enquiry and generation of a conceptual model. RESULTS: Veterinarians were consulted as a last resort after home-remedies and quacks had failed. Damage control measures, especially with respect to- selling or abandoning sick animals, added to the risk of disease transmission. Although civic authorities believed in the adequacy of a functioning laboratory network, end users were aggrieved at the lack of services. Despite the presence of extension services, knowledge and awareness was limited, promoting risky behaviour. The absence of cogent policies in dealing with bTB was a significant barrier. Stakeholders did not consider bTB to be a major concern. It is possible that they underestimate the problem. CONCLUSION: The current study helps to identify gaps which need to be addressed through collaborative research, and OneHealth interventions to build community awareness.

One Health approach to cost-effective rabies control in India.

Over 20,000 rabies deaths occur annually in India, representing one-third of global human rabies. The Indian state of Tamil Nadu has pioneered a "One Health" committee to address the challenge of rabies in dogs and humans. Currently, rabies control in Tamil Nadu involves postexposure vaccination of humans after dog bites, whereas potential supplemental approaches include canine vaccination and sterilization. We developed a data-driven rabies transmission model fit to human rabies autopsy data and human rabies surveillance data from Tamil Nadu. Integrating local estimates for canine demography and costs, we predicted the impact of canine vaccination and sterilization on human health outcomes and evaluated cost-effectiveness according to the WHO criteria for India, which correspond to thresholds of $1,582 and $4,746 per disability-adjusted life-years (DALYs) for very cost-effective and cost-effective strategies, respectively. We found that highly feasible strategies focused on stray dogs, vaccinating as few as 7% of dogs annually, could very cost-effectively reduce human rabies deaths by 70% within 5 y, and a modest expansion to vaccinating 13% of stray dogs could cost-effectively reduce human rabies by almost 90%. Through integration over parameter uncertainty, we find that, for a cost-effectiveness threshold above $1,400 per DALY, canine interventions are at least 95% likely to be optimal. If owners are willing to bring dogs to central point campaigns at double the rate that campaign teams can capture strays, expanded annual targets become cost-effective. This case study of cost-effective canine interventions in Tamil Nadu may have applicability to other settings in India and beyond.

One Health/EcoHealth capacity building programs in South and South East Asia: a mixed method rapid systematic review.

BACKGROUND: Although One Health (OH) or EcoHealth (EH) have been acknowledged to provide comprehensive and holistic approaches to study complex problems, like zoonoses and emerging infectious diseases, there remains multiple challenges in implementing them in a problem-solving paradigm. One of the most commonly encountered barriers, especially in low- and middle-income countries, is limited capacity to undertake OH/EH inquiries. A rapid review was undertaken to conduct a situation analysis of the existing OH/EH capacity building programs, with a focused analysis of those programs with extensive OH engagement, to help map the current efforts in this area. METHODS: A listing of the OH/EH projects/initiatives implemented in South Asia (SA) and South East Asia (SEA) was done, followed by analysis of documents related to the projects, available from peer-reviewed or grey literature sources. Quantitative data was extracted using a data extraction format, and a free listing of qualitative themes was undertaken. RESULTS: In SEA, 13 unique OH/EH projects, with 37 capacity building programs, were identified. In contrast, in SA, the numbers were 8 and 11 respectively. In SA, programs were oriented to develop careers in program management, whereas, in SEA, the emphasis was on research. Two thirds of the programs in SEA had extensive OH engagement, whereas only one third of those in SA did. The target for the SEA programs was wider, including a population more representative of OH stakes. SEA program themes reveal utilization of multiple approaches, usually in shorter terms, and are growing towards integration with the traditional curricula. Such convergence of themes was lacking in SA programs. In both regions, the programs were driven by external donor agencies, with minimal local buy-in. CONCLUSIONS: There is limited investment in research capacity building in both SA and SEA. The situation appears to be more stark in SA, whilst SEA has been able to use the systematic investment and support to develop the OH/EH agenda and strategize capacity building in the core competencies. In order to effectively address the disease emergence hotspots in these regions, there needs to be strategic funding decisions targeting capacity building in the core OH/EH competencies especially related to transdisciplinarity, systems thinking, and adaptive management.

Perceptions, practices and health seeking behaviour constrain JE/AES interventions in high endemic district of North India.

BACKGROUND: Acute Encephalitis Syndrome (AES) and Japanese Encephalitis (JE) stay as poorly understood phenomena in India. Multiple linkages to determinants such as poverty, socio-economic status, gender, environment, and population distribution, make it a greater developmental issue than just a zoonotic disease. METHODS: A qualitative study was conducted to map knowledge, perceptions and practices of community and health systems level stakeholders. Seventeen interviews with utilizers of AES care, care givers from human and veterinary sectors, Non-governmental Organizations (NGOs), and pig owners and 4 Focused Group Discussions (FGDs) with farmers, community leaders, and students were conducted in an endemic north Indian district-Kushinagar. RESULTS: Core themes that emerged were: JE/AES been perceived as a deadly disease, but not a major health problem; filthy conditions, filthy water and mosquitoes seen to be associated with JE/AES; pigs not seen as a source of infection; minimal role of government health workers in the first-contact care of acute Illness; no social or cultural resistance to JE vaccination or mosquito control; no gender-based discrimination in the care of acute Illness; and non-utilization of funds available with local self govt. Serious challenges and systematic failures in delivery of care during acute illness, which can critically inform the health systems, were also identified. CONCLUSION: There is an urgent need for promotive interventions to address lack of awareness about the drivers of JE/AES. Delivery of care during acute illness suffers with formidable challenges and systematic failures. A large portion of mortality can be prevented by early institution of rational management at primary and secondary level, and by avoiding wastage of time and resources for investigations and medications that are not actually required.

Acute encephalitis syndrome surveillance, Kushinagar district, Uttar Pradesh, India, 2011-2012.

In India, quality surveillance for acute encephalitis syndrome (AES), including laboratory testing, is necessary for understanding the epidemiology and etiology of AES, planning interventions, and developing policy. We reviewed AES surveillance data for January 2011-June 2012 from Kushinagar District, Uttar Pradesh, India. Data were cleaned, incidence was determined, and demographic characteristics of cases and data quality were analyzed. A total of 812 AES case records were identified, of which 23% had illogical entries. AES incidence was highest among boys<6 years of age, and cases peaked during monsoon season. Records for laboratory results (available for Japanese encephalitis but not AES) and vaccination history were largely incomplete, so inferences about the epidemiology and etiology of AES could not be made. The low-quality AES/Japanese encephalitis surveillance data in this area provide little evidence to support development of prevention and control measures, estimate the effect of interventions, and avoid the waste of public health resources.

An appraisal of peer-reviewed published literature on Influenza, 2000-2021 from countries in South-East Asia Region.

Background: Influenza poses a major public health challenge in South-East Asia Region (SEAR). To address the challenge, there is a need to generate contextual evidence that could inform policy makers and program managers for response preparedness and impact mitigation. The World Health Organization has identified priority areas across five streams for research evidence generation at a global level (WHO Public Health Research Agenda). Stream 1 focuses on research for reducing the risk of emergence, Stream 2 on limiting the spread, Stream 3 on minimizing the impact, Stream 4 on optimizing the treatment and Stream 5 on promoting public health tools and technologies for Influenza. However, evidence generation from SEAR has been arguably low and needs a relook for alignment with priorities. This study aimed to undertake a bibliometric analysis of medical literature on Influenza over the past 21 years to identify gaps in research evidence and for identifying major areas for focusing with a view to provide recommendations to member states and SEAR office for prioritizing avenues for future research. Methods: We searched Scopus, PubMed, Embase, and Cochrane databases in August 2021. We identified studies on influenza published from the 11 countries in WHO SEAR in the date range of 1 January 2000-31 December 2021. Data was retrieved, tagged and analyzed based on the WHO priority streams for Influenza, member states, study design and type of research. Bibliometric analysis was done on Vosviewer. Findings: We included a total of 1,641 articles (Stream 1: n = 307; Stream 2: n = 516; Stream 3: n = 470; Stream 4: n = 309; Stream 5: n = 227). Maximum number of publications were seen in Stream 2, i.e., limiting the spread of pandemic, zoonotic, and seasonal epidemic influenza which majorly included transmission, spread of virus at global and local levels and public health measures to limit the transmission. The highest number of publications was from India (n = 524) followed by Thailand (n = 407), Indonesia (n = 214) and Bangladesh (n = 158). Bhutan (n = 10), Maldives (n = 1), Democratic People's Republic of Korea (n = 1), and Timor-Leste (n = 3) had the least contribution in Influenza research. The top-most journal was PloS One which had the maximum number of influenza articles (n = 94) published from SEAR countries. Research that generated actionable evidence, i.e., implementation and intervention related topics were less common. Similarly, research on pharmaceutical interventions and on innovations was low. SEAR member states had inconsistent output across the five priority research streams, and there was a much higher scope and need for collaborative research. Basic science research showed declining trends and needed reprioritization. Interpretation: While a priority research agenda has been set for influenza at the global level through the WHO Global Influenza Program since 2009, and subsequently revisited in 2011 and again in 2016-2017, a structured contextualized approach to guide actionable evidence generation activities in SEAR has been lacking. In the backset of the Global Influenza Strategy 2019-2030 and the COVID-19 pandemic, attuning research endeavors in SEAR could help in improved pandemic influenza preparedness planning. There is a need to prioritize contextually relevant research themes within priority streams. Member states must inculcate a culture of within and inter-country collaboration to produce evidence that has regional as well as global value.

Continuing challenge of infectious diseases in India.

In India, the range and burden of infectious diseases are enormous. The administrative responsibilities of the health system are shared between the central (federal) and state governments. Control of diseases and outbreaks is the responsibility of the central Ministry of Health, which lacks a formal public health department for this purpose. Tuberculosis, malaria, filariasis, visceral leishmaniasis, leprosy, HIV infection, and childhood cluster of vaccine-preventable diseases are given priority for control through centrally managed vertical programmes. Control of HIV infection and leprosy, but not of tuberculosis, seems to be on track. Early success of malaria control was not sustained, and visceral leishmaniasis prevalence has increased. Inadequate containment of the vector has resulted in recurrent outbreaks of dengue fever and re-emergence of Chikungunya virus disease and typhus fever. Other infectious diseases caused by faecally transmitted pathogens (enteric fevers, cholera, hepatitis A and E viruses) and zoonoses (rabies, leptospirosis, anthrax) are not in the process of being systematically controlled. Big gaps in the surveillance and response system for infectious diseases need to be addressed. Replication of the model of vertical single-disease control for all infectious diseases will not be efficient or viable. India needs to rethink and revise its health policy to broaden the agenda of disease control. A comprehensive review and redesign of the health system is needed urgently to ensure equity and quality in health care. We recommend the creation of a functional public health infrastructure that is shared between central and state governments, with professional leadership and a formally trained public health cadre of personnel who manage an integrated control mechanism of diseases in districts that includes infectious and non-infectious diseases, and injuries.

Rationalizing antibiotic use to limit antibiotic resistance in India.

Antibiotic resistance, a global concern, is particularly pressing in developing nations, including India, where the burden of infectious disease is high and healthcare spending is low. The Global Antibiotic Resistance Partnership (GARP) was established to develop actionable policy recommendations specifically relevant to low- and middle-income countries where suboptimal access to antibiotics - not a major concern in high-income countries - is possibly as severe a problem as is the spread of resistant organisms. This report summarizes the situation as it is known regarding antibiotic use and growing resistance in India and recommends short and long term actions. Recommendations aim at (i) reducing the need for antibiotics; (ii) lowering resistance-enhancing drug pressure through improved antibiotic targeting, and (iii) eliminating antibiotic use for growth promotion in agriculture. The highest priority needs to be given to (i) national surveillance of antibiotic resistance and antibiotic use - better information to underpin decisions on standard treatment guidelines, education and other actions, as well as to monitor changes over time; (ii) increasing the use of diagnostic tests, which necessitates behavioural changes and improvements in microbiology laboratory capacity; (iii) setting up and/or strengthening infection control committees in hospitals; and (iv) restricting the use of antibiotics for non-therapeutic uses in agriculture. These interventions should help to reduce the spread of antibiotic resistance, improve public health directly, benefit the populace and reduce pressure on the healthcare system. Finally, increasing the types and coverage of childhood vaccines offered by the government would reduce the disease burden enormously and spare antibiotics.

Research priorities for control of zoonoses in South Africa.

BACKGROUND: Zoonoses pose major threats to the health of humans, domestic animals and wildlife, as seen in the COVID-19 pandemic. Zoonoses are the commonest source of emerging human infections and inter-species transmission is facilitated by anthropogenic factors such as encroachment and destruction of wilderness areas, wildlife trafficking and climate change. South Africa was selected for a 'One Health' study to identify research priorities for control of zoonoses due to its complex disease burden and an overstretched health system. METHODS: A multidisciplinary group of 18 experts identified priority zoonotic diseases, knowledge gaps and proposed research priorities for the next 5 y. Each priority was scored using predefined criteria by another group of five experts and then weighted by a reference group (n=28) and the 18 experts. RESULTS: Seventeen diseases were mentioned with the top five being rabies (14/18), TB (13/18), brucellosis (11/18), Rift Valley fever (9/11) and cysticercosis (6/18). In total, 97 specific research priorities were listed, with the majority on basic epidemiological research (n=57), such as measuring the burden of various zoonoses (n=24), followed by 20 on development of new interventions. The highest research priority score was for improving existing interventions (0.77/1.0), followed by health policy and systems research (0.72/1.0). CONCLUSION: Future zoonotic research should improve understanding of zoonotic burden and risk factors and new interventions in public health. People with limited rural services, immunocompromised, in informal settlements and high-risk occupations, should be the highest research priority.

Extended spectrum beta-lactamase-producing Escherichia coli surveillance in the human, food chain, and environment sectors: Tricycle project (pilot) in Indonesia.

The World Health Organization (WHO) has been implementing antimicrobial surveillance with a "One Health" approach, known as the Global Surveillance ESBL E. coli Tricycle Project. We describe the implementation of the Tricycle Project (pilot) in Indonesia, focusing on its results, challenges and recommendations. The samples were 116 patients with bloodstream infections caused by ESBL E. coli, 100 rectal swabs collected from pregnant women, 240 cecums of broiler, and 119 environmental samples, using the standardized method according to the guidelines. ESBL-producing E. coli was found in 40 (40%) of the 100 pregnant women, while the proportion of ESBL-producing E. coli was 57.7% among the total E. coli-induced bloodstream infections. ESBL-producing E. coli was isolated from 161 (67.1%) out of 240 broilers. On the other hand, the average concentration of E. coli in the water samples was 2.0 × 108 CFU/100 mL, and the ratio of ESBL-producing E. coli was 12.8% of total E. coli. Unfortunately, 56.7% of questionnaires for patients were incomplete. The Tricycle Project (pilot) identified that the proportion of ESBL-producing E. coli was very high in all types of samples, and several challenges and obstacles were encountered during the implementation of the study in Indonesia. The finding of this study have implication to health/the antimicrobial resistance (AMR) surveillance. We recommend continuing this project and extending this study to other provinces to determine the AMR burden as the baseline in planning AMR control strategies in Indonesia. We also recommend improving the protocol of this study to minimize obstacles in the field.

Influenza pandemic preparedness and response: A review of legal frameworks in India.

BACKGROUND: the potential of pandemics to cause global destabilization calls for robust pandemic preparedness plans with supportive health legislation. Few international studies have investigated their national legal preparedness in case of a pandemic. This study reviews India's legal preparedness in the face of an epidemic. MATERIALS AND METHODS: this study reviewed and analyzed seminal publications pertinent to pandemic preparedness and relevant legal frameworks in India. The analyses are presented in matrix formats and reviewed by national experts. RESULTS: current legal frameworks are largely 'policing' in nature. These provisions seem to be adequate to deal with small scale emergencies but do not appear to be sufficient for large scale health crises during pandemics. CONCLUSION: india needs a critical mass of public health legislations to make impact and not police acts to control epidemics. This study aims to assist policy makers to create comprehensive pandemic preparedness plans, translating preparedness 'on paper' to 'in practice'.

Monitoring COVID-19 where capacity for testing is limited: use of a three-step analysis based on test positivity ratio.

In an effort to monitor coronavirus disease 2019 (COVID-19), many countries have been calculating the ratio of cases confirmed to tests performed (test positivity ratio - TPR). While inferior to sentinel surveillance, TPR has the benefit of being easily calculated using readily available data; however, interpreting TPR and its trends can be complex because both the numerator and the denominator are constantly changing. We describe a three-step process where the ratio of relative increase in cases to relative increase in tests is accounted for in an adjusted TPR. This adjusted value more appropriately reflects the case number and factors out the effect of changes in the number of tests done. Unadjusted and adjusted TPRs are then assessed step-wise with reference to the epidemic curve and the cumulative numbers of cases and tests. Use of this three-step analysis and its potential use in guiding public health interventions are demonstrated for selected countries and subnational areas of the World Health Organization South-East Asia Region, together with the Republic of Korea as a reference. To date, application of the three-step analysis to data from countries of the region has signalled potential inadequacies of testing strategies. Further work is needed on approaches to support countries where testing capacity is likely to remain constrained. One example would be enumeration of the average number of tests needed to detect one COVID-19 case, which could be stratified by factors such as location and population. Such data would allow evidence-informed strategies that best balance the highest detection rate with the prevailing testing capacity.

The Extent and Structure of Peri-urban Smallholder Dairy Farming in Five Cities in India.

Livestock keeping is common in many cities in India, driven by the demand for animal-source foods, particularly perishable milk. We selected five cities from different regions of the country and conducted a census in 34 randomly selected peri-urban villages to identify and describe all smallholder dairy farms. In total 1,690 smallholder dairy farms were identified, keeping on average 2.2 milking cows and 0.7 milking buffaloes. In Bhubaneswar, the proportion of cows milking was only 50%, but in other cities it was 63-73%. In two of the five cities, more than 90% of the farmers stated that dairy production was their main source of income, while <50% in the other cities reported this. In one of the cities, only 36% of the households kept milk for themselves. Market channels varied considerably; in one city about 90% of farms sold milk to traders, in another, 90% sold to the dairy cooperative, and in another around 90% sold directly to consumers. In conclusion, peri-urban dairy systems in India are important but also varying between different cities, with only one city, Bengaluru, having a well-developed cooperative system, and the northeastern poorer region being more dependent on traders. Further studies may be needed to elucidate the importance and to design appropriate developmental interventions.

Pesticide Residues in Peri-Urban Bovine Milk from India and Risk Assessment: A Multicenter Study.

Pesticides residue poses serious concerns to human health. The present study was carried out to determine the pesticide residues of peri-urban bovine milk (n = 1183) from five different sites (Bangalore, Bhubaneswar, Guwahati, Ludhiana and Udaipur) in India and dietary exposure risk assessment to adults and children. Pesticide residues were estimated using gas chromatography with flame thermionic and electron capture detectors followed by confirmation on gas chromatography-mass spectrometer. The results noticed the contamination of milk with hexachlorocyclohexane (HCH), dichloro-diphenyl trichloroethane (DDT), endosulfan, cypermethrin, cyhalothrin, permethrin, chlorpyrifos, ethion and profenophos pesticides. The residue levels in some of the milk samples were observed to be higher than the respective maximum residue limits (MRLs) for pesticide. Milk samples contamination was found highest in Bhubaneswar (11.2%) followed by Bangalore (9.3%), Ludhiana (6.9%), Udaipur (6.4%) and Guwahati (6.3%). The dietary risk assessment of pesticides under two scenarios i.e. lower-bound scenario (LB) and upper-bound (UB) revealed that daily intake of pesticides was substantially below the prescribed acceptable daily intake except for fipronil in children at UB. The non-cancer risk by estimation of hazard index (HI) was found to be below the target value of one in adults at all five sites in India. However, for children at the UB level, the HI for lindane, DDT and ethion exceeded the value of one in Ludhiana and Udaipur. Cancer risk for adults was found to be in the recommended range of United States environment protection agency (USEPA), while it exceeded the USEPA values for children.

Comparative analysis of virulence determinants, phylogroups, and antibiotic susceptibility patterns of typical versus atypical Enteroaggregative E. coli in India.

Enteroaggregative Escherichia coli (EAEC) is an evolving enteric pathogen that causes acute and chronic diarrhea in developed and industrialized nations in children. EAEC epidemiology and the importance of atypical EAEC (aEAEC) isolation in childhood diarrhea are not well documented in the Indian setting. A comparative analysis was undertaken to evaluate virulence, phylogeny, and antibiotic sensitivity among typical tEAEC versus aEAEC. A total of 171 EAEC isolates were extracted from a broad surveillance sample of diarrheal (N = 1210) and healthy children (N = 550) across North India. Polymerase chain reaction (PCR) for the aggR gene (master regulator gene) was conducted to differentiate tEAEC and aEAEC. For 21 virulence genes, we used multiplex PCR to classify possible virulence factors among these strains. Phylogenetic classes were identified by a multiplex PCR for chuA, yjaA, and a cryptic DNA fragment, TspE4C2. Antibiotic susceptibility was conducted by the disc diffusion method as per CLSI guidelines. EAEC was associated with moderate to severe diarrhea in children. The prevalence of EAEC infection (11.4%) was higher than any other DEC group (p = 0.002). tEAEC occurrence in the diarrheal group was higher than in the control group (p = 0.0001). tEAEC strain harbored more virulence genes than aEAEC. astA, aap, and aggR genes were most frequently found in the EAEC from the diarrheal population. Within tEAEC, this gene combination was present in more than 50% of strains. Also, 75.8% of EAEC strains were multidrug-resistant (MDR). Phylogroup D (43.9%) and B1 (39.4%) were most prevalent in the diarrheal and control group, respectively. Genetic analysis revealed EAEC variability; the comparison of tEAEC and aEAEC allowed us to better understand the EAEC virulence repertoire. Further microbiological and epidemiological research is required to examine the pathogenicity of not only typical but also atypical EAEC.

Single dose oral nefopam for acute postoperative pain in adults.

BACKGROUND: Nefopam is a centrally-acting but non-opioid analgesic drug of the benzoxazocine chemical class, developed in the early 1970s. It is widely used, mainly in European countries, for the relief of moderate to severe pain as an alternative to opioid analgesic drugs, and used in rheumatic disease and other musculoskeletal disorders in the UK. This review sought to evaluate the efficacy and safety of oral nefopam in acute postoperative pain, using clinical studies of patients with established pain, and with outcomes measured primarily over 6 hours using standard methods. This type of study has been used for many decades to establish that drugs have analgesic properties. OBJECTIVES: To assess the efficacy of single dose oral nefopam in acute postoperative pain, and any associated adverse events. SEARCH STRATEGY: We searched CENTRAL (Issue 2, 2009), MEDLINE (1966 to May 2009); EMBASE via Ovid (1980 to May 2009); the Oxford Pain Relief Database (1950 to 1994); and reference lists of studies found. SELECTION CRITERIA: Randomised, double-blind, placebo-controlled clinical trials of oral nefopam for relief of acute postoperative pain in adults. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial quality and extracted data. The area under the "pain relief versus time" curve was used to derive the proportion of participants with nefopam and placebo experiencing least 50% pain relief over 4 to 6 hours, using validated equations. The number-needed-to-treat-to-benefit (NNT) was calculated using 95% confidence intervals (CIs). The proportion of participants using rescue analgesia over a specified time period, and time to use of rescue analgesia, were sought as additional measures of efficacy. Information on adverse events and withdrawals was also collected. MAIN RESULTS: No included studies were identified after examining in detail thirteen studies on oral nefopam in participants with established postoperative pain. AUTHORS' CONCLUSIONS: In the absence of evidence of efficacy for oral nefopam in acute postoperative pain, its use in this indication is not justified. Because trials clearly demonstrating analgesic efficacy in the most basic of acute pain studies are lacking, use in other indications should be evaluated carefully. Given the large number of available drugs of this and similar classes, there is no urgent research agenda.