Stillbirths: progress and unfinished business.

This first paper of the Lancet Series on ending preventable stillbirths reviews progress in essential areas, identified in the 2011 call to action for stillbirth prevention, to inform the integrated post-2015 agenda for maternal and newborn health. Worldwide attention to babies who die in stillbirth is rapidly increasing, from integration within the new Global Strategy for Women's, Children's and Adolescents' Health, to country policies inspired by the Every Newborn Action Plan. Supportive new guidance and metrics including stillbirth as a core health indicator and measure of quality of care are emerging. Prenatal health is a crucial biological foundation to life-long health. A key priority is to integrate action for prenatal health within the continuum of care for maternal and newborn health. Still, specific actions for stillbirths are needed for advocacy, policy formulation, monitoring, and research, including improvement in the dearth of data for effective coverage of proven interventions for prenatal survival. Strong leadership is needed worldwide and in countries. Institutions with a mandate to lead global efforts for mothers and their babies must assert their leadership to reduce stillbirths by promoting healthy and safe pregnancies.

Research priorities in Maternal, Newborn, & Child Health & Nutrition for India: An Indian Council of Medical Research-INCLEN Initiative.

In India, research prioritization in Maternal, Newborn, and Child Health and Nutrition (MNCHN) themes has traditionally involved only a handful of experts mostly from major cities. The Indian Council of Medical Research (ICMR)-INCLEN collaboration undertook a nationwide exercise engaging faculty from 256 institutions to identify top research priorities in the MNCHN themes for 2016-2025. The Child Health and Nutrition Research Initiative method of priority setting was adapted. The context of the exercise was defined by a National Steering Group (NSG) and guided by four Thematic Research Subcommittees. Research ideas were pooled from 498 experts located in different parts of India, iteratively consolidated into research options, scored by 893 experts against five pre-defined criteria (answerability, relevance, equity, investment and innovation) and weighed by a larger reference group. Ranked lists of priorities were generated for each of the four themes at national and three subnational (regional) levels [Empowered Action Group & North-Eastern States, Southern and Western States, & Northern States (including West Bengal)]. Research priorities differed between regions and from overall national priorities. Delivery domain of research which included implementation research constituted about 70 per cent of the top ten research options under all four themes. The results were endorsed in the NSG meeting. There was unanimity that the research priorities should be considered by different governmental and non-governmental agencies for investment with prioritization on implementation research and issues cutting across themes.

The World Health Organization Measles Programmatic Risk Assessment Tool-Pilot Testing in India, 2014.

Measles is a leading cause of child mortality, and reduction of child mortality is a key Millennium Development Goal. In 2014, the World Health Organization and the U.S. Centers for Disease Control and Prevention developed a measles programmatic risk assessment tool to support country measles elimination efforts. The tool was pilot tested in the State of Uttarakhand in August 2014 to assess its utility in India. The tool assessed measles risk for the 13 districts of Uttarakhand as a function of indicator scores in four categories: population immunity, surveillance quality, program delivery performance, and threat. The highest potential overall score was 100. Scores from each category were totaled to assign an overall risk score for each district. From this risk score, districts were categorized as low, medium, high, or very high risk. Of the 13 districts in Uttarakhand in 2014, the tool classified one district (Haridwar) as very high risk and three districts (Almora, Champawat, and Pauri Garhwal) as high risk. The measles risk in these four districts was largely due to low population immunity from high MCV1-MCV2 drop-out rates, low MCV1 and MCV2 coverage, and the lack of a supplementary immunization activity (SIA) within the past three years. This tool can be used to support measles elimination in India by identifying districts that might be at risk for measles outbreaks, and to guide risk mitigation efforts, including strengthening routine immunization services and implementing SIAs.

Detection of diphtheritic polyneuropathy by acute flaccid paralysis surveillance, India.

Diphtheritic polyneuropathy is a vaccine-preventable illness caused by exotoxin-producing strains of Corynebacterium diphtheriae. We present a retrospective convenience case series of 15 children (6 girls)<15 years of age (mean age 5.2 years, case-fatality rate 53%, and 1 additional case-patient who was ventilator dependent at the time of last follow-up; median follow-up period 60 days) with signs and symptoms suggestive of diphtheritic polyneuropathy. All cases were identified through national acute flaccid paralysis surveillance, which was designed to detect poliomyelitis in India during 2002-2008. We also report data on detection of diphtheritic polyneuropathy compared with other causes of acute flaccid paralysis identified by this surveillance system.

Evaluation of opportunities to implement community-wide mass drug administration for interrupting transmission of soil-transmitted helminths infections in India.

BACKGROUND: The World Health Organization Neglected Tropical Disease (NTD) guidelines recommend control of soil transmitted helminth (STH)-associated morbidity with targeted deworming of preschool and school-aged children who are disproportionately affected by STH-associated morbidity. However, this strategy leaves many adults untreated and reinfection within communities perpetuates transmission even when mass drug administration (MDA) coverage of children is high. Evidence suggests that it may be possible to interrupt STH transmission by expanding MDA to a community-wide MDA (cMDA). METHODS: This multi-methods study of organizational readiness survey, key informant interviews, and program mapping, were conducted with government stakeholders in three Indian states, Goa, Sikkim, and Odisha, to assess readiness of the states for transitioning from school-based MDA to cMDA and identify opportunities to leverage existing infrastructure from other NTD programs like lymphatic filariasis (LF) for STH cMDA. PRINCIPAL FINDINGS: Overall, all three states indicated a highly favorable policy environment, effective leadership structure, adequate material resources, demonstrated technical capacity, and adequate community infrastructure needed to launch a STH cMDA program. The findings indicated a high-level of health system readiness to implement provided human resources and financial resources to deliver cMDA is strengthened. Areas with a significant overlap between LF and STH MDA platforms, particularly at the community-level, may be best primed for transitioning. Immunization, maternal child health, and non-communicable disease control programs were the other programs for possible integration of cMDA. States indicated having effective leadership structures in place at the state-level, however, engaging local leaders and community groups were considered crucial for successful implementation of cMDA. In-migration was a perceived challenge for estimating drug requirement and preventing possible stockouts. CONCLUSIONS: Findings from this study are intended to proactively support government decision making, prioritization, and program planning across heterogenous implementation contexts in India to speed the translation of research findings into practice. CLINICAL TRIAL REGISTRATION: NCT03014167; ClinicalTrials.gov.

Low Prevalence of Soil-Transmitted Helminth Infections among Children in the States of Chhattisgarh and Himachal Pradesh, India, 2018.

Large-scale impact assessments of soil-transmitted helminth (STH) programs are essential for determining the frequency of mass drug administration (MDA). In baseline surveys, the prevalence of STHs in the Indian States of Chhattisgarh and Himachal Pradesh was 80.2% in 2015 and 29.0% in 2016, respectively. In 2018, we estimated the prevalence and intensity of STHs after six rounds of biannual MDA in Chhattisgarh and annual MDA in Himachal Pradesh. We conducted multistage cluster sampling surveys in preschool-age children (PSAC), school-age children (SAC), and adolescent cohorts. Stool samples from 3,033 respondents (PSAC, n = 625; SAC, n = 1,363; adolescents, n = 1,045) in Chhattisgarh and 942 respondents (PSAC, n = 192; SAC, n = 388; adolescents, n = 362) in Himachal Pradesh were examined for presence of STH infection using the Kato-Katz method. The overall cluster-adjusted prevalence in Chhattisgarh was 11.6% among all age groups (95% CI, 5.6-22.4)-an 85.5% reduction in the prevalence since 2015. Prevalence was not significantly different across cohorts (PSAC, 11.0% [95% CI, 5.0-22.6]; SAC, 10.9% [95% CI, 5.2-21.6]; adolescents, 12.8% [95% CI, 6.2-24.5]). Ascaris lumbricoides was the most common helminth, with most infections of light intensity. In Himachal Pradesh, only three STH infections were detected in 2018, resulting in a cluster-adjusted prevalence of 0.3% (95% CI, 0.1-1.7)-a 99.0% reduction in prevalence since 2016. All infections were of light intensity. Both states showed substantial improvements in socioeconomic and water, sanitation, and hygiene (WASH) indicators since the baseline surveys. Extensive reductions in prevalence and intensity are linked to sustained, high deworming coverage, as well as socioeconomic WASH indicators.

Assessment of population-level effect of Avahan, an HIV-prevention initiative in India.

BACKGROUND: The aim of Avahan, the India AIDS Initiative, was to reduce HIV transmission in the general population through large-scale prevention interventions focused on high-risk groups. It was launched in 2003 in six states with a total population of 300 million and a high HIV burden. We assessed the population-level effect of the first phase of Avahan (2003-08). METHODS: Population prevalence was estimated by use of adjustment factors from the national HIV sentinel surveillance data obtained annually from antenatal clinics. A mixed-effects multilevel regression model was developed to estimate the association between intervention intensity and population HIV prevalence trends, taking into account differences in the underlying epidemic trends in states and other potential confounders, and to estimate the number of HIV infections averted with Avahan. FINDINGS: 80 (61%) of 131 districts in the six Avahan states received funding from Avahan for HIV prevention, as the only or shared source. Greater intensity of Avahan, measured as amount of grant per HIV population (medians US$24-432 in the six states), was significantly associated with lower HIV prevalence in Andhra Pradesh (p=0·004), Karnataka (p=0·004), and Maharashtra (p=0·008) states; this association was not significant in Tamil Nadu (p=0·06), Manipur (p=0·62), and Nagaland (p=0·67). Overall, we estimated that 100,178 HIV infections (95% CI 25,897-207,713) were averted at the population level from 2003 up to 2008 as a result of Avahan. INTERPRETATION: The results of our analysis suggest that Avahan had a beneficial effect in reducing HIV prevalence at the population level over 5 years of programme implementation in some of the states. With stagnating funding for HIV prevention globally, our findings support investment in well planned and managed HIV prevention programmes in low-income and middle-income countries. FUNDING: Bill & Melinda Gates Foundation.

Rotavirus mortality in India: estimates based on a nationally representative survey of diarrhoeal deaths.

OBJECTIVE: To estimate the number of rotavirus-associated deaths among Indian children younger than five years. METHODS: We surveyed more than 23 000 child deaths from a nationally representative survey of 1.1 million Indian households during 2001-2003. Diarrhoeal deaths were characterized by region, age and sex and were combined with the proportion of deaths attributable to rotavirus, as determined by hospital microbiologic data collected by the Indian Rotavirus Strain Surveillance Network from December 2005 to November 2007. Rotavirus vaccine efficacy data from clinical trials in developing countries were used to estimate the number of deaths preventable by a national vaccination programme. Data were analysed using Stata SE version 10. FINDINGS: Rotavirus caused an estimated 113 000 deaths (99% confidence interval, CI: 86 000-155 000); 50% (54 700) and 75% (85 400) occurred before one and two years of age, respectively. One child in 242 died from rotavirus infection before five years of age. Rotavirus-associated mortality rates overall, among girls and among boys were 4.14 (99% CI: 3.14-5.68), 4.89 (99% CI: 3.75-6.79) and 3.45 (99% CI: 2.58-4.66) deaths per 1000 live births, respectively. Rates were highest in Bihar, Uttar Pradesh and Madhya Pradesh, which together accounted for > 50% of deaths (64 400) nationally. Rotavirus vaccine could prevent 41 000-48 000 deaths among children aged 3-59 months. CONCLUSION: The burden of rotavirus-associated mortality is high among Indian children, highlighting the potential benefits of rotavirus vaccination.

Promising practices for the collaborative planning of integrated health campaigns from a synthesis of case studies.

A combination of public health campaigns and routine primary healthcare services are used in many countries to maximise the number of people reached with interventions to prevent, control, eliminate or eradicate diseases. Health campaigns have historically been organised within vertical (disease-specific) programmes, which are often funded, planned and implemented independently from one another and from routinely offered primary healthcare services. Global health agencies have voiced support for enhancing campaign effectiveness, including campaign efficiency and equity, through collaboration among vertical programmes. However, limited guidance is available to country-level campaign planners and implementers about how to effectively integrate campaigns. Planning is critical to the implementation of effective health campaigns, including those related to neglected tropical diseases, malaria, vitamin A supplementation and vaccine-preventable diseases, including polio, measles and meningitis. However, promising approaches to planning integrated health campaigns have not been sufficiently documented. This manuscript highlights promising practices for the collaborative planning of integrated health campaigns that emerged from the experiences of eight project teams working in three WHO regions. Adoption of the promising practices described in this paper could lead to enhanced collaboration among campaign stakeholders, increased agreement about the need for and anticipated benefits of campaign integration, and enhanced understanding of effective planning of integrated health campaigns.

An Assessment of Implementation of Family Participatory Care in Special Newborn Care Units in Three States of India.

OBJECTIVE: To study special newborn care units (SNCUs) in terms of family participatory care (FPC) quality initiative as per Government of India guidelines in select public health facilities, and to document the perspectives of the doctors and mothers. DESIGN: Cross-sectional. SETTINGS: SNCUs with functional FPC units in the states of Odisha, Madhya Pradesh and Rajasthan. PARTICIPANTS: 38 SNCUs; doctors and nurses in-charge of the unit; and two eligible mothers per unit, one inside the step-down unit and second outside the step-down unit whose newborns were admitted to special new-born care unit, having a stable baby weighing above 1500 g. INTERVENTION: The states implemented FPC as per Government of India guidelines using National Health Mission funds across special newborn care units. This assessment involved onsite observation and interviews of key providers. OUTCOME: Proportion of facilities providing regular counselling sessions, enabling support to mothers, recording FPC information; perspectives of health providers on improvement of breastfeeding and kangaroo mother care; proportion of eligible mothers practicing FPC, exclusively breastfeeding, and providing kangaroo mother care services. RESULTS: Out of 38 SNCUs, we found that FPC sessions for mothers were happening in 36 (95%) facilities. SNCUs provided enabling support to mothers on FPC (74.2%), held regular sessions for the families (70.6%), nurses assisted mothers and family members for breastfeeding and kangaroo mother care (76.4%) and FPC information were recorded (70.6%). CONCLUSIONS: The assessment of facilities where FPC was implemented showed that SNCUs were equipped to implement FPC in public health settings.

Tracking Weight-for-Age of Infants Using Home Based Newborn Care Plus by ASHA Workers.

BACKGROUND: Malnutrition in all its forms remains a serious global concern, particularly affecting children, a highly vulnerable population group. Home visits during the first year of life using the community worker platform is an unexplored opportunity for making improvements in nutritional status. OBJECTIVE: To analyze the nutritional status (weight for age) of a cohort of infants between 3 and 12 months of age. DESIGN: Tracking weight for age of infants by ASHA workers. SETTINGS: 13 districts in the states of Bihar, Madhya Pradesh, Odisha and Rajasthan. INTERVENTION: Home visits under a home-based newborn care program, home-based newborn care plus (HBNC+). METHODS: Norway India Partnership Initiative (NIPI) project supported implementation of HBNC+, in 13 districts across four states in India. A descriptive analysis of infants based on retrospective record based program data was done. The nutritional status (weight-for-age) of the cohort was analyzed. Categories were defined based on the z-scores of weight for age (≤-3 SD; ≤-2 SD and > -3 SD; and > -2 SD). Trend of malnutrition and proportions of children in each category at 3, 6, 9 and 12 months were assessed. RESULTS: At 3 months of age, out of 3,50,986 infants provided home visits, 1,82,049 (51.97%) were underweight as per WHO definition with weight for age z-score ≤- 2 SD; this reduced to 11.1% at 12 months of age. Difference of means at 3 months and 12 months significantly different for weight for age z-score (P<0.001). There was a decline in the proportion of children in severe and moderate malnutrition categories by 15% and 26%, respectively. CONCLUSIONS: Catch-up growth in terms of weight-for-age among malnourished children is possible within one year of age. Frequent contacts with the health care functionaries may result in this improvement, though it is difficult to conclude in the absence of an appropriate control.

Situational Analysis of Management of Childhood Diarrhea and Pneumonia in 13 District Hospitals in India.

OBJECTIVE: To generate evidence on the current situation of hospital care (emergency, inpatient and outpatient), for managing children presenting with diarrhea and pneumonia at 13 district hospitals in India. DESIGN: Facility-based assessment of district hospitals. SETTINGS: 13 district hospitals in four states of Bihar, Madhya Pradesh, Odisha and Rajasthan. PARTICIPANTS: Staff nurses and doctors. INTERVENTION: None. METHODS: An assessment was done across 13 district hospitals in four states by a group or trained assessors using an adapted quality assurance tool developed by Government of India where each aspect of care was scored (maximum score 5). Emergency services and triage, case management practices, laboratory support, and record maintenance for diarrhea and pneumonia were assessed. RESULTS: Separate diarrhea treatment unit was not earmarked in any of the DHs surveyed. Overall score obtained for adequate management of diarrhea and pneumonia was 2 and 2.2 which were poor. Pediatric beds were 6.8% of the total bed strength against the recommended 8-10%. There was a 65 percent short-fall in the numbers of medical officers in position and 48 percent shortfall of nurses. There were issues with availability and utilization of drugs and equipment at appropriate places with cumulative score of 2.8. Triage for sick children was absent in all the facilities. CONCLUSIONS: The standards of pediatric care for management of diarrhea and pneumonia were far from satisfactory. This calls for improvement of pediatric care units and implementation of operational guidelines for improving management of diarrhea and pneumonia.

Catalytic Support for Improving Clinical Care in Special Newborn Care Units (SNCU) Through Composite SNCU Quality of Care Index (SQCI).

OBJECTIVE: To develop a composite index that serves as a proxy marker of quality of clinical service and pilot test its use in 11 special neonatal care units (SNCUs) across two states in India. DESIGN: Secondary data from SNCU webportal. SETTING: Special new-born care units in Rajasthan and Orissa. INTERVENTION: We developed a composite SNCU Quality of care Index (SQCI) based on seven indices from SNCU online database. These included rational admission index, index for rational use of antibiotics, inborn birth asphyxia index, index for mortality in normal weight babies, low birth weight admission index, low birth weight survival index, and optimal bed utilization index. OUTCOME: Based on the SQCI score, the performance of SNCUs was labelled as good (SQCI 0.71- 1.0), satisfactory (SQCI 0.4- 0.7) or unsatisfactory (SQCI <0.4). RESULTS: The mean difference in SQCI between Jan-Mar 2016 and 2017 was 0.20 (95% CI 0.13- 0.28; P<0.001). Similar results were obtained for rational admission index, rational use of antibiotics, mortality in normal weight babies, low birth weight survival and optimal bed utilization. A significant improvement in the overall composite score was noted in Odisha (Mean difference 0.22, 95% CI 0.11-0.33, P=0.003) and Rajasthan (Mean difference 0.17, 95% CI 0.05- 0.3, P=0.002). CONCLUSIONS: QI approach using SQCI tool is a useful and replicable intervention. Preliminary results show that it does lead to strengthening of implementation of the programs at SNCUs based on the comprehensive scores generated as part of routine system.

Lessons from implementation research on community management of Possible Serious Bacterial Infection (PSBI) in young infants (0-59 days), when the referral is not feasible in Palwal district of Haryana, India.

BACKGROUND: Neonatal sepsis is a major cause of death in India, which needs hospital management but many families cannot access hospitals. The World Health Organization and the Government of India developed a guideline to manage possible serious bacterial infection (PSBI) when a referral is not feasible. We implemented this guideline to achieve high coverage of treatment of PSBI with low mortality. METHODOLOGY: The implementation research study was conducted in over 50 villages of Palwal district, Haryana during August 2017-March 2019 and covered a population of 199143. Policy dialogue with central, state and district health authorities was held before initiation of the study. A baseline assessment of the barriers in the implementation of the PSBI intervention was conducted. The intervention was implemented in the program setting. The research team collected data throughout and also co-participated in the implementation of the intervention for the first six months to identify bottlenecks in the health system and at the community level. RE-AIM framework was utilized to document implementation strategies of PSBI management guideline. Implementation strategies by the district technical support unit (TSU) included: (i) empower mothers and families through social mobilization to improve care-seeking of sick young infants 0-59 days of age, (ii) build capacity through training and build confidence through technical support of health staff at primary health centers (PHC), community health centers (CHC) and sub-centers to manage young infants with PSBI signs and (iii) improve performance of accredited social health activists (ASHAs). FINDINGS: A total of 370 young infants with signs of PSBI were identified and managed in 5270 live births. Treatment coverage was 70% assuming that 10% of live births would have PSBI within the first two months of life. Mothers identified 87.6% (324/370) of PSBI cases. PHCs and CHCs became functional and managed 150 (40%) sick young infants with PSBI. Twenty four young infants (7-59days) who had only fast breathing were treated with oral amoxicillin without a referral. Referral to a hospital was refused by 126 (84%); 119 had clinical severe infection (CSI), one 0-6 days old had fast breathing and six had critical illness (CI). Of 119 CSI cases managed on outpatient injection gentamicin and oral amoxicillin, 116 (96.7%) recovered, 55 (45.8%) received all seven gentamicin injections and only one died. All 7-59 day old infants with fast breathing recovered, 23 on outpatient oral amoxicillin treatment; and 19 (79%) received all doses. Of 65 infants managed at either district or tertiary hospital, two (3.1%) died, rest recovered. Private providers managed 155 (41.9%) PSBI cases, all except one recovered, but sub-classification and treatment were unknown. Sub-centers could not be activated to manage PSBI. CONCLUSION: The study demonstrated resolution of implementation bottlenecks with existing resources, activated PHCs and CHCs to manage CSI and fast breathers (7-59 day old) on an outpatient basis with low mortality when a referral was not feasible. TSU was instrumental in these achievements. We established the effectiveness of oral amoxicillin alone in 7-59 days old fast breathers and recommend a review of the current national policy.

The Effects of a Single Freeze-Thaw Cycle on Concentrations of Nutritional, Noncommunicable Disease, and Inflammatory Biomarkers in Serum Samples.

Background The stability of biological samples is vital for reliable measurements of biomarkers in large-scale survey settings, which may be affected by freeze-thaw procedures. We examined the effect of a single freeze-thaw cycle on 13 nutritional, noncommunicable diseases (NCD), and inflammatory bioanalytes in serum samples. Method Blood samples were collected from 70 subjects centrifuged after 30 minutes and aliquoted immediately. After a baseline analysis of the analytes, the samples were stored at - 70°C for 1 month and reanalyzed for all the parameters. Mean percentage differences between baseline (fresh blood) and freeze-thaw concentrations were calculated using paired sample t -tests and evaluated according to total allowable error (TEa) limits (desirable bias). Results Freeze-thaw concentrations differed significantly ( p < 0.05) from baseline concentrations for soluble transferrin receptor (sTfR) (- 5.49%), vitamin D (- 12.51%), vitamin B12 (- 3.74%), plasma glucose (1.93%), C-reactive protein (CRP) (3.45%), high-density lipoprotein (HDL) (7.98%), and cholesterol (9.76%), but they were within respective TEa limits. Low-density lipoprotein (LDL) (- 0.67%), creatinine (0.94%), albumin (0.87%), total protein (1.00%), ferritin (- 0.58%), and triglycerides (TAG) (2.82%) concentrations remained stable following the freeze-thaw cycle. In conclusion, single freeze-thaw cycle of the biomarkers in serum/plasma samples after storage at - 70°C for 1 month had minimal effect on stability of the studied analytes, and the changes in concentration were within acceptable limit for all analytes.

Hospital-based sentinel surveillance for bacterial meningitis in under-five children prior to the introduction of the PCV13 in India.

INTRODUCTION: A hospital-based sentinel surveillance network for bacterial meningitis was established in India to estimate the burden of bacterial meningitis, and the proportion of major vaccine-preventable causative organisms. This report summarises the findings of the surveillance conducted between March 2012, and September 2016 in eleven hospitals. METHODS: We enrolled eligible children with bacterial meningitis in the age group of one to 59 months. CSF samples were collected and processed for biochemistry, culture, latex agglutination, and real-time PCR. Pneumococcal isolates were serotyped and tested for antimicrobial susceptibility. RESULTS: Among 12 941 enrolled suspected meningitis cases, 586 (4.5%) were laboratory confirmed. S. pneumoniae (74.2%) was the most commonly detected pathogen, followed by H. influenzae (22.2%), and N. meningitidis (3.6%). Overall 58.1% of confirmed bacterial meningitis cases were children aged between one, and 11 months. H. influenzae meningitis cases had a high (12.3%) case fatality rate. The serotypes covered in PCV13 caused 72% pneumococcal infections, and the most common serotypes were 14 (18.3%), 6B (12.7%) and 19F (9.9%). Non-susceptibility to penicillin was 57%. Forty-five (43.7%) isolates exhibited multidrug resistance, of which 37 were PCV13 serotype isolates. CONCLUSIONS: The results are representative of the burden of bacterial meningitis among under-five children in India. The findings were useful in rolling out PCV in the National Immunization Program. The non-susceptibility to penicillin and multidrug resistance was an important observation. Timely expansion of PCV across India will significantly reduce the burden of antimicrobial resistance. Continued surveillance is needed to understand the trend after PCV expansion in India.

Utility of Prevention of Parent-to-Child Transmission (PPTCT). Programme data for HIV surveillance in general population.

BACKGROUND & OBJECTIVES: HIV sentinel surveillance (HSS) among antenatal clinic (ANC) attendees is used to monitor HIV trends in general population. Recently, information on HIV infection has also become available from prevention of parent-to-child transmission (PPTCT) programmes. Systematic appraisal of routinely collected programme data is needed for choosing a scientific, cost-effective, and ethical surveillance strategy. In this study HIV prevalence estimates obtained from PPTCT programme and HSS were compared to find out the utility of PPTCT programme data for HIV surveillance. METHODS: The data of HSS and PPTCT programme were obtained from National AIDS Control Organization, New Delhi. A list of PPTCT programme sites where ANC HSS was also conducted during 2005 to 2007 was prepared. HIV prevalence and 95 per cent confidence interval (CI) were estimated from antenatal attendees in PPTCT and HSS. Correlation coefficient of HIV prevalence in PPTCT and HSS was also examined according to the level of HIV test acceptance in PPTCT programme. Pregnant women presenting directly for labour in PPTCT centers were not included in the analyses. RESULTS: In 2007, HIV test acceptance ranged from 8 to 100 per cent (average 76%) in 372 sites where both PPTCT and HSS were carried out. HIV prevalence was similar in the PPTCT (0.68%, 95% CI 0.66%, 0.70%) as compared to the HSS (0.61%, 95% CI 0.58%, 0.66%). Overall the correlation of HIV prevalence between PPTCT and HSS was quite high at state level (r = 0.9) but low at district or site level (r = 0.6). INTERPRETATION & CONCLUSIONS: HIV prevalence estimates among pregnant women in PPTCT program were similar to that of ANC HSS. Routinely collected PPTCT program data therefore has potential for providing reliable HIV time trends in various states of India.

Measuring accuracy of plethysmography based respiratory rate measurement using pulse oximeter at a tertiary hospital in India.

BACKGROUND: Childhood pneumonia continues to be a major infectious killer in India. WHO recommended respiratory rate and oxygen saturation (SpO2) measurements are not well implemented in Indian public health outpatient facilities with the result that treatment decision-making rely on subjective assessments from variably trained and supervised healthcare providers. The introduction of a multi-modal pulse oximeter (POx) that gives reliable measurements would mitigate incorrect diagnosis. In light of future potential use of pulse oximeter in peripheral health centres, it becomes important to measure accuracy of respiratory rate and oxygen saturation of such an instrument. The current study measures accuracy of plethysmography based respiratory rate (RR) using a pulse oximeter (Masimo Rad-G) by comparing it with a gold standard (pediatrician) measurement. STUDY DESIGN: A cross sectional study was conducted in the OPD and emergency ward of Kalawati Saran Children's Hospital over a 2 week period wherein a convenience sample of 97 children (2 to 59 months) were assessed by a pediatrician as part of routine assessment alongside independent measure by a consultant using pulse oximeter. The level of agreement between plethymography based RR and pediatrician measure was analyzed along with sensitivity and specificity of fast breathing of plethymography based RR measure. RESULTS: Both methods of measurement show strong association (97%, p < 0.001) and observed values, falling on line of unity, obtained either from pulse oximeter or by pediatrician are very close to each other. Fast breathing measured by POx has a sensitivity of 95% and specificity of nearly 94%. CONCLUSION: The current study provides evidence of the accuracy of a plethysmography based RR using a pulse oximeter which can potentially be of use in planning of pneumonia management in public health facilities.

Effect of Differences in Month and Location of Measurement in Estimating Prevalence and Trend of Wasting and Stunting in India in 2005-2006 and 2015-2016.

BACKGROUND: Child undernutrition in India remains widespread. Data from the National Family Health Survey 3 and 4 (NFHS-3 and NFHS-4) suggest that wasting prevalence has increased while stunting prevalence has declined. OBJECTIVE: The objectives of this study were to do the following: 1) describe wasting and stunting by month of measurement in India in children <5 y of age in NFHS-3 and NFHS-4 surveys, and 2) test whether differences in the timing of anthropometric data collection and in states between survey years introduced bias in the comparison of estimates of wasting and stunting between NFHS-3 and NFHS-4. METHODS: Data on wasting and stunting for 42,608 and 232,744 children aged >5 y in the NFHS-3 and NFHS-4 survey rounds were analyzed. Differences in the prevalence of wasting and stunting by month of year and by state of residence were examined descriptively. Regression analyses were conducted to test the sensitivity of the estimate of differences in wasting and stunting prevalence across survey years to both state differences and seasonality. RESULTS: Examination of the patterns of wasting and stunting by month of measurement and by state across survey years reveal marked variability. When both state and month were adjusted, regardless of the method used to account for sample size, there was a small negative difference from 2005-2006 to 2015-2016 in the prevalence of wasting (-0.8 ± 0.6 percentage points; P = 0.2) and a negative difference in stunting prevalence (-8.3 ± 0.7 percentage points; P < 0.001), indicating a small bias for wasting but not for stunting in unadjusted analyses. CONCLUSIONS: State and seasonal differences may have introduced bias to the estimated difference in prevalence of wasting between the survey years but did not do so for stunting. Future data collection should be designed to maximize consistency in coverage of both time and place.