Newer TB diagnostics: An update.

In recent years, nucleic-acid amplification tests (NAATs), which are highly specific and sensitive, have helped to transform the TB diagnostic landscape. According to the WHO 2021 Guidelines on Diagnostics, the NAATs used in TB diagnosis at the point of care (POC) include Xpert MTB/RIF a cartridge-based test manufactured by Cepheid, and Truenat a chip-based test manufactured by Molbio. Other POC tests that are expected to be implemented in near future include Xpert Omni and Xpert MTB/XDR. The use of line probe assay is involved at the level of reference labs for the detection of MTB and its resistance to first-line (Isoniazid and Rifampicin) and second-line (fluoroquinolones and second-line injectables) drugs. When the currently available NAATs detect mutations for drug resistance at a particular region of MTB sequence, the Whole genome sequencing (WGS) platform demonstrates the exceptional potential for reliable and comprehensive resistance prediction for MTB isolates, by multiple gene regions or whole genome sequence analysis allowing for accurate clinical decisions.

Renal Allograft Cortical Necrosis in a COVID-19 Positive Patient.

The incidence of acute kidney injury (AKI) has been reported to be higher in kidney transplant recipients infected with SARS-CoV-2 compared with the general population. Here, we report a case of cortical necrosis in the graft kidney due to COVID infection in a patient with stable graft function over the years. The patient was started on hemodialysis and treated with steroids, and anticoagulants for COVID infection. Later, he had gradual improvement in his graft function and became dialysis independent on follow up.

Household Air Pollution and Adult Lung Function Change, Respiratory Disease, and Mortality across Eleven Low- and Middle-Income Countries from the PURE Study.

BACKGROUND: Globally, household air pollution (HAP) is a major environmental hazard that affects respiratory health. However, few studies have examined associations between HAP and lung function decline and respiratory disease and mortality. METHODS: We used data from the Prospective Urban and Rural Epidemiology study and examined adults residing in 240 rural communities in 11 low- and middle-income countries where HAP from cooking with solid fuels is common. Spirometry was conducted for 28,574 individuals at baseline and 12,489 individuals during follow-up (mean of 8 y between spirometry measures). In cross-sectional analyses, we compared lung function measurements [forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), and FEV1/FVC ratio] in those who used solid fuels for cooking in comparison with clean fuels. Using repeated measurements of lung function, we examined the percent change in lung function measures per year, comparing individuals by baseline fuel type and individuals who used solid fuels at baseline but switched to clean fuels during follow-up. We also examined associations with prospective health events (any respiratory diseases, respiratory disease hospitalizations, and all-cause mortality). RESULTS: In adjusted cross-sectional models, use of solid fuel in comparison with clean fuels was associated with lower FEV1 of -17.5mL (95% CI: -32.7, -2.3) and FVC of -14.4mL (95% CI: -32.0, 3.2), but not FEV1/FVC. In longitudinal analyses, individuals who switched from solid fuels to clean cooking fuels during follow-up (n=3,901, 46% of those using solid fuel at baseline), showed no differences in the annual rate of change in FEV1 or FVC, but had small improvements in FEV1/FVC change (0.2% per year, 95% CI: 0.03, 0.3). Individuals who switched from solid to clean fuels had a decreased hazard ratio for respiratory events of 0.76 (95% CI: 0.57, 1.00) in comparison with persistent solid fuel users, which was not attenuated by lung function measures. CONCLUSION: We observed modest associations between HAP exposure and lung function, lung function change, and respiratory disease and mortality. https://doi.org/10.1289/EHP11179.

Hypertension control in Kerala, India: A prescription-based study at primary and secondary level health care institutions.

OBJECTIVE: We undertook a prescription-based study to identify the provider and institution-level factors related to achieving guideline-recommended control of hypertension and diabetes mellitus in Kerala, India. METHODS: This cross-sectional study in primary and secondary care hospitals in Kerala included both public and private institutions. One practitioner was selected from each institution. Data on institutional and provider factors were collected using a structured questionnaire. Prescriptions were photographically captured and data on disease status and drugs prescribed were recorded. Factors associated with disease control were identified using binary logistic regression. RESULTS: Totally 4679 prescriptions were included for analysis. For hypertension-only patients, control levels were 31.5% and was significantly higher in public hospitals (Adjusted odds ratio (AOR) 1.96, 95% confidence intervals (CI) 1.50-2.57). Among patients with diabetes only, diabetes control was seen in 36.6%. When both conditions were present, control was achieved in only 17.0% patients. Being prescribed two or more drugs indicated lower control, whatever the respective condition. Among antihypertensive prescriptions rationality of 26.7% were questioned, such as lack of Renin Angiotensin System (RAS) inhibitor in diabetic hypertensives, dual RAS blockage, and indication for beta-blocker monotherapy. CONCLUSIONS: In this prescription-based study in Kerala, India, a majority of hypertensive patients did not have controlled blood pressure levels, particularly if diabetes coexisted. This has serious implications as Kerala is the state with the highest burden of hypertension in India. Several prescription patterns were of questionable rationality. Further research and actions on rationality of anti-hypertensive prescriptions and barriers to treatment intensification is warranted.

Personal and household PM2.5 and black carbon exposure measures and respiratory symptoms in 8 low- and middle-income countries.

BACKGROUND: Household air pollution (HAP) from cooking with solid fuels has been associated with adverse respiratory effects, but most studies use surveys of fuel use to define HAP exposure, rather than on actual air pollution exposure measurements. OBJECTIVE: To examine associations between household and personal fine particulate matter (PM2.5) and black carbon (BC) measures and respiratory symptoms. METHODS: As part of the Prospective Urban and Rural Epidemiology Air Pollution study, we analyzed 48-h household and personal PM2.5 and BC measurements for 870 individuals using different cooking fuels from 62 communities in 8 countries (Bangladesh, Chile, China, Colombia, India, Pakistan, Tanzania, and Zimbabwe). Self-reported respiratory symptoms were collected after monitoring. Associations between PM2.5 and BC exposures and respiratory symptoms were examined using logistic regression models, controlling for individual, household, and community covariates. RESULTS: The median (interquartile range) of household and personal PM2.5 was 73.5 (119.1) and 65.3 (91.5) µg/m3, and for household and personal BC was 3.4 (8.3) and 2.5 (4.9) x10-5 m-1, respectively. We observed associations between household PM2.5 and wheeze (OR: 1.25; 95%CI: 1.07, 1.46), cough (OR: 1.22; 95%CI: 1.06, 1.39), and sputum (OR: 1.26; 95%CI: 1.10, 1.44), as well as exposure to household BC and wheeze (OR: 1.20; 95%CI: 1.03, 1.39) and sputum (OR: 1.20; 95%CI: 1.05, 1.36), per IQR increase. We observed associations between personal PM2.5 and wheeze (OR: 1.23; 95%CI: 1.00, 1.50) and sputum (OR: 1.19; 95%CI: 1.00, 1.41). For household PM2.5 and BC, associations were generally stronger for females compared to males. Models using an indicator variable of solid versus clean fuels resulted in larger OR estimates with less precision. CONCLUSIONS: We used measurements of household and personal air pollution for individuals using different cooking fuels and documented strong associations with respiratory symptoms.

Spatial analysis of chronic obstructive pulmonary disease and its risk factors in an urban area of Trivandrum, Kerala, India.

Background: Chronic obstructive pulmonary disease (COPD) is the second leading cause of death in India. The objective of this study was to map COPD cases and its risk factors and to determine the association between them using geographic information system (GIS) in a semi-urban area of Trivandrum, South India. Materials and Methods: This community-based cross-sectional, descriptive study (n = 494) was conducted in a subcenter area of a primary health center. Location was mapped and COPD population screener questionnaire was administered to all the study subjects enrolled by census method. Lifetime firewood exposure (person-hours) and tobacco smoking were enquired and distance from road was mapped using portable differential global positioning system. The association with COPD was assessed by kriging and hotspot analysis using ArcGIS software. Results: The prevalence of COPD (6.5%) was comparable to national prevalence estimates. Spatial maps showed COPD case clustering in areas with higher firewood exposure, greater smoking exposure, and in households with closer proximity to local roads. A particular high-risk cluster was obtained which had a significant association with all the risk factors. Conclusion: GIS technology is useful in identification of spatial clustering of COPD cases and its environmental risk factors, making it an important tool for targeted interventions for COPD.

Kidney complications of parasitic diseases.

Parasitic agents have been known to cause human disease since ancient times and are endemic in tropical and subtropical regions. Complications of parasitic diseases, including kidney involvement, are associated with worse outcomes. Chagas disease, filariasis, leishmaniasis, malaria and schistosomiasis are important parasitic diseases that can damage the kidney. These diseases affect millions of people worldwide, primarily in Africa, Asia and Latin America, and kidney involvement is associated with increased mortality. The most common kidney complications of parasitic diseases are acute kidney injury, glomerulonephritis and tubular dysfunction. The mechanisms that underlie parasitic disease-associated kidney injury include direct parasite damage; immunological phenomena, including immune complex deposition and inflammation; and systemic manifestations such as haemolysis, haemorrhage and rhabdomyolysis. In addition, use of nephrotoxic drugs to treat parasitic infections is associated with acute kidney injury. Early diagnosis of kidney involvement and adequate management is crucial to prevent progression of kidney disease and optimize patient recovery.

Proportion of rapid eye movement sleep related obstructive sleep apnea (REM related OSA) in patients with sleep disordered breathing: A cross sectional study.

BACKGROUND AND OBJECTIVES: Obstructive sleep apnea (OSA) during rapid eye movement (REM) stage of sleep is gaining importance in recent years. This study was done to determine the proportion of REM-related OSA and its associated polysomnographic features. METHODS: One hundred forty-two patients were included in the study. REM-related OSA was defined based on previously established broad and strict criteria (REM apnea-hypopnea index [AHI]/non-REM [NREM] AHI ratio ≥2 and REM AHI >5 with NREM AHI <5, respectively), and its association with polysomnographic features was studied using appropriate statistical tools. RESULTS: The proportion of REM-related OSA in the study was 56.3% and 25.3% as per broad and strict criterion, respectively. The REM-related OSA group had a mean younger age (47.4 ± 13.2 years) as compared to NREM-related OSA group (52.6 ± 15.8 years). Females (34 out of 45; 75.6%) were more likely to have REM-related OSA as compared to males (46 out of 107; 47.4%). Supine AHI, arousal index, oxygen desaturation index, length of the longest event, and the lowest oxygen saturation recorded during sleep had a significant association with REM-related OSA. 74% of patients with overall AHI <5 and 87% patients with overall AHI 5 to 15 satisfied the criteria for REM-related OSA as per broad criterion. CONCLUSION: REM-related OSA was quite prevalent in the study population (56.3%) and was more common in the mild and moderate severity subgroups of OSA.

Measuring and predicting personal and household Black Carbon levels from 88 communities in eight countries.

Black Carbon (BC) is an important component of household air pollution (HAP) in low- and middle- income countries (LMICs), but levels and drivers of exposure are poorly understood. As part of the Prospective Urban and Rural Epidemiological (PURE) study, we analyzed 48-hour BC measurements for 1187 individual and 2242 household samples from 88 communities in 8 LMICs (Bangladesh, Chile, China, Colombia, India, Pakistan, Tanzania, and Zimbabwe). Light absorbance (10-5 m-1) of collected PM2.5 filters, a proxy for BC concentrations, was calculated via an image-based reflectance method. Surveys of household/personal characteristics and behaviors were collected after monitoring. The geometric mean (GM) of personal and household BC measures was 2.4 (3.3) and 3.5 (3.9)·10-5 m-1, respectively. The correlation between BC and PM2.5 was r = 0.76 for personal and r = 0.82 for household measures. A gradient of increasing BC concentrations was observed for cooking fuels: BC increased 53% (95%CI: 30, 79) for coal, 142% (95%CI: 117, 169) for wood, and 190% (95%CI: 149, 238) for other biomass, compared to gas. Each hour of cooking was associated with an increase in household (5%, 95%CI: 3, 7) and personal (5%, 95%CI: 2, 8) BC; having a window in the kitchen was associated with a decrease in household (-38%, 95%CI: -45, -30) and personal (-31%, 95%CI: -44, -15) BC; and cooking on a mud stove, compared to a clean stove, was associated with an increase in household (125%, 95%CI: 96, 160) and personal (117%, 95%CI: 71, 117) BC. Male participants only had slightly lower personal BC (-0.6%, 95%CI: -1, 0.0) compared to females. In multivariate models, we were able to explain 46-60% of household BC variation and 33-54% of personal BC variation. These data and models provide new information on exposure to BC in LMICs, which can be incorporated into future exposure assessments, health research, and policy surrounding HAP and BC.

Multinational prediction of household and personal exposure to fine particulate matter (PM2.5) in the PURE cohort study.

INTRODUCTION: Use of polluting cooking fuels generates household air pollution (HAP) containing health-damaging levels of fine particulate matter (PM2.5). Many global epidemiological studies rely on categorical HAP exposure indicators, which are poor surrogates of measured PM2.5 levels. To quantitatively characterize HAP levels on a large scale, a multinational measurement campaign was leveraged to develop household and personal PM2.5 exposure models. METHODS: The Prospective Urban and Rural Epidemiology (PURE)-AIR study included 48-hour monitoring of PM2.5 kitchen concentrations (n = 2,365) and male and/or female PM2.5 exposure monitoring (n = 910) in a subset of households in Bangladesh, Chile, China, Colombia, India, Pakistan, Tanzania and Zimbabwe. PURE-AIR measurements were combined with survey data on cooking environment characteristics in hierarchical Bayesian log-linear regression models. Model performance was evaluated using leave-one-out cross validation. Predictive models were applied to survey data from the larger PURE cohort (22,480 households; 33,554 individuals) to quantitatively estimate PM2.5 exposures. RESULTS: The final models explained half (R2 = 54%) of the variation in kitchen PM2.5 measurements (root mean square error (RMSE) (log scale):2.22) and personal measurements (R2 = 48%; RMSE (log scale):2.08). Primary cooking fuel type, heating fuel type, country and season were highly predictive of PM2.5 kitchen concentrations. Average national PM2.5 kitchen concentrations varied nearly 3-fold among households primarily cooking with gas (20 µg/m3 (Chile); 55 µg/m3 (China)) and 12-fold among households primarily cooking with wood (36 µg/m3 (Chile)); 427 µg/m3 (Pakistan)). Average PM2.5 kitchen concentration, heating fuel type, season and secondhand smoke exposure were significant predictors of personal exposures. Modeled average PM2.5 female exposures were lower than male exposures in upper-middle/high-income countries (India, China, Colombia, Chile). CONCLUSION: Using survey data to estimate PM2.5 exposures on a multinational scale can cost-effectively scale up quantitative HAP measurements for disease burden assessments. The modeled PM2.5 exposures can be used in future epidemiological studies and inform policies targeting HAP reduction.

Variations in the association of height with mortality, cardiovascular disease and cancer in low-, middle- and high-income countries.

BACKGROUND: Final adult height is a useful proxy measure of childhood nutrition and disease burden. Tall stature has been previously associated with decreased risk of all-cause mortality, decreased risk of major cardiovascular events and an increased risk of cancer. However, these associations have primarily been derived from people of European and East Asian backgrounds, and there are sparse data from other regions of the world. METHODS: The Prospective Urban-Rural Epidemiology study is a large, longitudinal population study done in 21 countries of varying incomes and sociocultural settings. We enrolled an unbiased sample of households, which were eligible if at least one household member was aged 35-70 years. Height was measured in a standardized manner, without shoes, to the nearest 0.1 cm. During a median follow-up of 10.1 years (interquartile range 8.3-12.0), we assessed the risk of all-cause mortality, major cardiovascular events and cancer. RESULTS: A total of 154 610 participants, enrolled since January 2003, with known height and vital status, were included in this analysis. Follow-up event data until March 2021 were used; 11 487 (7.4%) participants died, whereas 9291 (6.0%) participants had a major cardiovascular event and 5873 (3.8%) participants had a new diagnosis of cancer. After adjustment, taller individuals had lower hazards of all-cause mortality [hazard ratio (HR) per 10-cm increase in height 0.93, 95% confidence interval (CI) 0.90-0.96] and major cardiovascular events (HR 0.97, 95% CI 0.94-1.00), whereas the hazard of cancer was higher in taller participants (HR 1.23, 95% CI 1.18-1.28). The interaction p-values between height and country-income level for all three outcomes were <0.001, suggesting that the association with height varied by country-income level for these outcomes. In low-income countries, height was inversely associated with all-cause mortality (HR 0.88, 95% CI 0.84-0.92) and major cardiovascular events (HR 0.87, 95% CI 0.82-0.93). There was no association of height with these outcomes in middle- and high-income countries. The respective HRs for cancer in low-, middle- and high-income countries were 1.14 (95% CI 0.99-1.32), 1.12 (95% CI 1.04-1.22) and 1.20 (95% CI 1.14-1.26). CONCLUSIONS: Unlike high- and middle-income countries, tall stature has a strong inverse association with all-cause mortality and major cardiovascular events in low-income countries. Improved childhood physical development and advances in population-wide cardiovascular treatments in high- and middle-income countries may contribute to this gap. From a life-course perspective, we hypothesize that optimizing maternal and child health in low-income countries may improve rates of premature mortality and cardiovascular events in these countries, at a population level.

Prevalence of Tuberculosis Infection among Adults of Thiruvananthapuram District of Kerala as Measured by Interferon Gamma Release Assay - A Cross-Sectional Study.

Background: To achieve the goals of the end tuberculosis (TB) strategy, strategies for management of TB infection (TBI) have to be expanded. The first step to devise policies is to understand the distribution and determinants of TBI in the community. The objectives of the study were to estimate the prevalence of TBI using Interferon Gamma Release Assay (IGRA) and its determinants among the adult population of Thiruvananthapuram district, Kerala. Materials and Methods: A community-based, cross-sectional study using the stratified cluster sampling was carried out among the adults. TBI was detected using IGRA conducted on whole blood sample. Data on determinants were collected using a structured questionnaire by the face-to-face interview. The prevalence of TBI was estimated. Univariate and multivariate analysis was conducted to identify the determinants. Results: Age standardized prevalence of TBI among 396 adults was 20.5% (95% confidence interval [CI] 16.52-24.48). On adjusting for the possible confounders, increasing age (adjusted odds ratio [OR] 1.028; 95% CI 1.008-1.048; P = 0.005), history of contact with active TB disease (adjusted OR 7.61; 95% CI 4.43-13.05; P < 0.001), childhood contact (adjusted OR 8.20; 95% CI 3.14-21.41; P < 0.001), and household contact (adjusted OR 10.12; 95% CI 5.39-18.98; P < 0.001) were found to be the determinants of TBI in this population. Conclusion: The present study observed that nearly one-fifth of the adult population in the Thiruvananthapuram district has TBI. For the programmatic management, factors such as increasing age and contact history may be considered for the elimination of TBI in the state.

Diagnostic yield of CBNAAT in the diagnosis of extrapulmonary tuberculosis: A prospective observational study.

Background: Extrapulmonary Tuberculosis (EPTB) accounts for 15%-53% of all TB cases. In recent years, cartridge-based nucleic acid amplification test (CBNAAT) has emerged as an important diagnostic tool since the diagnostic yield is higher. We conducted this study to evaluate the diagnostic yield of CBNAAT in EPTB. Methods: One hundred and four patients with EPTB were included in the study. Samples were subjected to CBNAAT, AFB smear, culture for Mycobacterium tuberculosis and histopathology examination (HPE). Yield of each was estimated as compared to a composite reference standard (CRS). Results: The most common EPTB was lymph node TB (48.1%). CBNAAT was positive in 30.76% of EPTB cases. The highest yield was for bone and joint TB (35.7%), followed by lymph node TB (34%) and abdominal TB (33.3%). Taking CRS as the gold standard, sensitivity of CBNAAT was 32.3%, that of AFB culture was 33.3% and that of HPE was 87.2%. Conclusion: When taken as a single diagnostic tool, HPE had highest sensitivity in diagnosing EPTB when compared to CBNAAT and AFB culture. Use of CBNAAT alone for diagnosis of EPTB may result in missing the diagnosis. A combined modality incorporating CBNAAT, histopathology and AFB culture is the best approach for diagnosis of EPTB.

A study of Factors Affecting Dialysis Recovery Time in Haemodialysis Patients in India.

BACKGROUND: Patients on maintenance haemodialysis (MHD) often complain of fatigue and tiredness following haemodialysis sessions leading to poor compliance with the dialysis schedule. There is limited Indian data on dialysis recovery time (DRT). The present study was designed to assess the factors affecting DRT in our haemodialysis population. METHODS: We recorded self-reported patient recovery times of 120 patients who satisfied the inclusion criteria, over three consecutive dialysis sessions by asking the question, 'How long does it take to recover from a dialysis session'? Data recorded included patient factors like age, sex, co-morbidities, Charlson comorbidity index score (CCI), dialysis vintage, duration of kidney disease, interdialytic weight gain (IDWG), treatment factors like ultrafiltration rate (UFR), SpKt/V, blood pump speed, dialysate sodium, session length, pre and post HD blood pressure and laboratory parameters. Health-related quality of life (HRQoL) was assessed with the KDQOL-SF v. 1.3 questionnaire. Results from the SF-36 score were summarised into the physical composite score (PCS), mental composite score (MCS) and kidney disease composite score (KDCS). RESULTS: The mean age of the study population was 50.6 ± 12.6 years. Among the 120 patients, 77 (64.2%) were males. Thirty-nine patients (32.5%) were diabetic and 95 (79.1%) patients were hypertensive. The mean dialysis vintage of the study population was 26.1 ± 18.6 months, 41 (34.2%) patients reported DRT <2 h; 48 (40%) reported DRT between 2-6 h and 31 (25.8%) reported DRT >6 h. On multivariate regression analysis, higher IDWG, CCI score and UFR were associated with prolonged DRT. Reported DRT also inversely correlated with PCS (r = - 0.66), MCS (r = - 0.65) and KDCS (r = - 0.59) scores which was statistically significant. CONCLUSION: The present study showed that higher CCI scores, IDWG and UFR were associated with prolonged DRT in Indian haemodialysis patients and patients with longer recovery time had poor HRQoL. Interventions to reduce DRT need to be assessed in further trials in Indian MHD patients.

Effect of low dialysate sodium in the management of intradialytic hypertension in maintenance hemodialysis patients: A single-center Indian experience.

BACKGROUND: High dialysate sodium is a significant contributor to intradialytic hypertension (IDH) in maintenance hemodialysis patients. In this study, we aimed to study the effect of low dialysate sodium on IDH in Indian hemodialysis patients. MATERIALS AND METHODS: Fifty patients on maintenance hemodialysis for atleast 3 months with episodes of IDH were enrolled in this study. The study was performed in two different stages. In the first phase, patients were dialyzed with standard dialysate sodium (140 mEq/L) for eight consecutive sessions and in the second phase, they were dialyzed with low sodium dialysate (136 mEq/L) for eight consecutive sessions. Differences in pre, intradialytic, and post-HD blood pressure, interdialytic weight gain, mean serum sodium, intradialytic adverse events, and number of IDH episodes requiring intervention between the two phases were assessed. RESULTS: The mean age of the study population was 52 years (36 males,14 females). The mean post-HD systolic and diastolic BP was 163.26 ± 9.58 mmHg and 88.60 ± 5.27 mmHg in the standard dialysate phase and 142.38 ± 14.09 mmHg and 84.58 ± 4.276 mmHg, respectively, in the low dialysate phase (p < 0.01). Interdialytic weight gain was 3.34 ± 0.9 and 3.11 ± 0.86 in the standard and low sodium dialysate phases, respectively (p = 0.19).The mean pre-HD plasma sodium level was 138.48 ± 3.69 and 135.80 ± 1.35 mEq/dl, respectively, in standard and low dialysate phases (p = 0.01). There was significant reduction in number of IDH episodes requiring intervention. There was no difference in hypotensive episodes, adverse events between the two phases. CONCLUSION: In patients with intradialytic hypertension, low dialysate sodium significantly reduces the post-HD blood pressure and intradialytic hypertensive episodes, when compared with standard sodium dialysate.

The first state-level public health program for obstructive airway disease in India: An early field-level evaluation.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is the second leading cause of mortality in India; however, there are no programs for COPD in India at primary care level. Kerala became the first state in India to implement a program at primary care for COPD, called the Step Wise Approach to Airway Syndrome program. OBJECTIVE: The objective of the study was to evaluate and document the implementation status of a program for obstructive airway disease (OAD) in Trivandrum district of Kerala state in India and compare the treatment characteristics of patients with OAD seeking care from the centers implementing and not implementing this program for OADs. METHODS: A cross-sectional study was done as early evaluation of a program for OAD implemented in Kerala state, India, from October 2018 to February 2019. RESULTS: A reflection of the health-seeking behavior due to better facilities at the FHCs. There was no difference in the hospital visits or emergency department visits between the two groups. However, there was a statistically significant difference in the average number of visits per patient to health center for taking injectable drugs and visits for nebulization. Forty-nine (94%) of the COPD and 36 (100%) of the asthma patients underwent spirometry from implementing center itself. A higher proportion of patients receiving care from implementing centers (30.9%) never had to buy inhalers from outside. CONCLUSION: This is the first time that a public health programme for chronic respiratory disease management at primary care level was evaluated in India. The study has provided valuable insights on the need for strengthening the training for health care providers as well as patient education in bringing about a change in patient attitudes.

Household and personal air pollution exposure measurements from 120 communities in eight countries: results from the PURE-AIR study.

BACKGROUND: Approximately 2·8 billion people are exposed to household air pollution from cooking with polluting fuels. Few monitoring studies have systematically measured health-damaging air pollutant (ie, fine particulate matter [PM2·5] and black carbon) concentrations from a wide range of cooking fuels across diverse populations. This multinational study aimed to assess the magnitude of kitchen concentrations and personal exposures to PM2·5 and black carbon in rural communities with a wide range of cooking environments. METHODS: As part of the Prospective Urban and Rural Epidemiological (PURE) cohort, the PURE-AIR study was done in 120 rural communities in eight countries (Bangladesh, Chile, China, Colombia, India, Pakistan, Tanzania, and Zimbabwe). Data were collected from 2541 households and from 998 individuals (442 men and 556 women). Gravimetric (or filter-based) 48 h kitchen and personal PM2·5 measurements were collected. Light absorbance (10-5m-1) of the PM2·5 filters, a proxy for black carbon concentrations, was calculated via an image-based reflectance method. Surveys of household characteristics and cooking patterns were collected before and after the 48 h monitoring period. FINDINGS: Monitoring of household air pollution for the PURE-AIR study was done from June, 2017, to September, 2019. A mean PM2·5 kitchen concentration gradient emerged across primary cooking fuels: gas (45 µg/m3 [95% CI 43-48]), electricity (53 µg/m3 [47-60]), coal (68 µg/m3 [61-77]), charcoal (92 µg/m3 [58-146]), agricultural or crop waste (106 µg/m3 [91-125]), wood (109 µg/m3 [102-118]), animal dung (224 µg/m3 [197-254]), and shrubs or grass (276 µg/m3 [223-342]). Among households cooking primarily with wood, average PM2·5 concentrations varied ten-fold (range: 40-380 µg/m3). Fuel stacking was prevalent (981 [39%] of 2541 households); using wood as a primary cooking fuel with clean secondary cooking fuels (eg, gas) was associated with 50% lower PM2·5 and black carbon concentrations than using only wood as a primary cooking fuel. Similar average PM2·5 personal exposures between women (67 µg/m3 [95% CI 62-72]) and men (62 [58-67]) were observed. Nearly equivalent average personal exposure to kitchen exposure ratios were observed for PM2·5 (0·79 [95% 0·71-0·88] for men and 0·82 [0·74-0·91] for women) and black carbon (0·64 [0·45-0·92] for men and 0·68 [0·46-1·02] for women). INTERPRETATION: Using clean primary fuels substantially lowers kitchen PM2·5 concentrations. Importantly, average kitchen and personal PM2·5 measurements for all primary fuel types exceeded WHO's Interim Target-1 (35 µg/m3 annual average), highlighting the need for comprehensive pollution mitigation strategies. FUNDING: Canadian Institutes for Health Research, National Institutes of Health.