Prevalence of high-risk HPV among marginalized urban women in India and its implications on vaccination: A cross sectional study.

OBJECTIVE: To discover the prevalence and distribution of high-risk human papilloma virus (HPV) subtypes in urban slums and their implications. METHODS: A cross-sectional study was performed to discover prevalence and distribution of high-risk HPV subtypes. We screened 956 women. Data were analyzed using SPSS v.25. Inclusion criterion was married women between 30 and 45 years of age. Exclusion criteria were women with known cervical cancer at the time of the survey or those who had undergone hysterectomy. RESULTS: Of the women, 32.47% were HPV positive and of these, about 84.50% were positive for high-risk HPV. HPV type 6 (HPV 6) and HPV 11 were not seen in the population. After HPV 16 and HPV 18, type 58 was the most common variant seen in our study. Currently-used vaccines in India do not cover HPV 58. CONCLUSION: Knowing and understanding the distribution of high-risk HPV are necessary for an effective strategy to eliminate cervical cancer from India. Deoxyribonucleic acid-based HPV screening is a useful method along with vaccination to prevent cervical cancer.

Association of family history of cardiometabolic diseases (CMDs) and individual health behaviours: Analysis of CARRS study from South Asia.

OBJECTIVES: Family history is considered as an important predictor of cardiovascular diseases (CVDs) and diabetes. Available research findings suggest that family history of chronic diseases is associated with perceived risk of disease and adoption of healthy behaviours. We examined the association between family history of cardio-metabolic diseases (CMDs) and healthy behaviours among adults without self-reported CMDs. METHODS: Cross-sectional data of 12,484 adults, without self-reported CMDs, from the baseline survey of Centre for cArdiometabolic Risk Reduction in South-Asia (CARRS) cohort study were analysed. RESULTS: Family history was positively associated with non-smoking and high fruits & vegetables consumption in the age group of 45-64 years and moderate to high physical activity in the age group ≥65 years after adjusting for sex, education, wealth index, city and body mass index. CONCLUSIONS: Understanding perceived risks and cultural or psychological factors related to family history through ethnographic studies may deepen understanding of these associations.

SARS-CoV-2 infection during pregnancy and pregnancy-related conditions: Concerns, challenges, management and mitigation strategies-a narrative review.

The ongoing coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a global public health problem. The SARS-CoV-2 triggers hyper-activation of inflammatory and immune responses resulting in cytokine storm and increased inflammatory responses on several organs like lungs, kidneys, intestine, and placenta. Although SARS-CoV-2 affects individuals of all age groups and physiological statuses, immune-compromised individuals such as pregnant women are considered as a highly vulnerable group. This review aims to raise the concerns of high risk of infection, morbidity and mortality of COVID-19 in pregnant women and provides critical reviews of pathophysiology and pathobiology of how SARS-CoV-2 infection potentially increases the severity and fatality during pregnancy. This article also provides a discussion of current evidence on vertical transmission of SARS-CoV-2 during pregnancy and breastfeeding. Lastly, guidelines on management, treatment, preventive, and mitigation strategies of SARS-CoV-2 infection during pregnancy and pregnancy-related conditions such as delivery and breastfeeding are discussed.

Usefulness of the Sauvegrain Method of Bone Age Assessment in Indian Children.

INTRODUCTION: Bone age estimation is very useful in children undergoing epiphysiodesis or guided growth surgery especially during the years of accelerated growth. It may be noted that no data are available on bone age estimation for Indian children of this age group. Sauvegrain (French) method is a very useful and simple method for bone age assessment during the years of accelerated growth. We decided to check the usefulness and the accuracy of the Sauvegrain method in Indian children. MATERIALS AND METHODS: A team of two pediatric orthopaedic surgeons and a radiologist scored elbow X-rays of 80 healthy children (40 boys and 40 girls), using the Sauvegrain method twice. Interobserver reliability and intraobserver reproducibility of the Sauvegrain scoring were assessed. RESULTS: There was a very strong correlation between all observers in both rounds (r = > 0.8) and an excellent reproducibility by the same observer in both rounds (r = 0.955). Chronological and bone age are considered the same if the difference between them is less than 6 months. With this criterion bone and chronological ages matched in > 37% of boys and girls, similar to the study done in French children. In the nonmatching group, more children had delayed bone age compared to their chronological age. CONCLUSION: The Sauvegrain method of bone age assessment described for French children was found to be useful in estimating bone age in Indian children. It is especially helpful in the clinical practice for detecting mismatch between the chronological and the radiological age before undertaking guided growth or epiphysiodesis.

COVID-19 in the elderly people and advances in vaccination approaches.

The rapid worldwide spread of the COVID-19 pandemic, caused by the newly emerged severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has resulted in tens of millions of infections and over one million deaths. SARS-CoV-2 infection affects all age groups; however, those over 60 years old are affected more severely. Moreover, pre-existing co-morbidities result in higher COVID-19-associated mortality in the geriatric population. This article highlights the associated risk factors of SARS-CoV-2 infection in older people and progress in developing COVID-19 vaccines, especially for efficient vaccination of the older population. There is also a summary of immunomodulatory and immunotherapeutic approaches to ameliorate the outcome of COVID-19 in older individuals.

Impact of COVID-19 on women and children and the need for a gendered approach in vaccine development.

The COVID-19 pandemic has imposed unprecedented health and socioeconomic challenges on public health, disrupting it on a global scale. Given that women and children are widely considered the most vulnerable in the times of emergency, whether in war or during a pandemic, the current pandemic has also severely disrupted access to reproductive and child health services. Despite this, data on the effect of the pandemic on pregnant women and newborns remain scarce, and gender-disaggregated indicators of mortality and morbidity are not available. In this context, we suggest the implementation of a gendered approach to ensure the specific needs of women and their newborns are considered during the development of COVID-19 vaccines. Taking into account gender-based biological differences, the inclusion of pregnant and lactating mothers in clinical trials for the development of COVID-19 vaccines is of vital importance.

Nipah virus: epidemiology, pathology, immunobiology and advances in diagnosis, vaccine designing and control strategies - a comprehensive review.

Nipah (Nee-pa) viral disease is a zoonotic infection caused by Nipah virus (NiV), a paramyxovirus belonging to the genus Henipavirus of the family Paramyxoviridae. It is a biosafety level-4 pathogen, which is transmitted by specific types of fruit bats, mainly Pteropus spp. which are natural reservoir host. The disease was reported for the first time from the Kampung Sungai Nipah village of Malaysia in 1998. Human-to-human transmission also occurs. Outbreaks have been reported also from other countries in South and Southeast Asia. Phylogenetic analysis affirmed the circulation of two major clades of NiV as based on currently available complete N and G gene sequences. NiV isolates from Malaysia and Cambodia clustered together in NiV-MY clade, whereas isolates from Bangladesh and India clusterered within NiV-BD clade. NiV isolates from Thailand harboured mixed population of sequences. In humans, the virus is responsible for causing rapidly progressing severe illness which might be characterized by severe respiratory illness and/or deadly encephalitis. In pigs below six months of age, respiratory illness along with nervous symptoms may develop. Different types of enzyme-linked immunosorbent assays along with molecular methods based on polymerase chain reaction have been developed for diagnostic purposes. Due to the expensive nature of the antibody drugs, identification of broad-spectrum antivirals is essential along with focusing on small interfering RNAs (siRNAs). High pathogenicity of NiV in humans, and lack of vaccines or therapeutics to counter this disease have attracted attention of researchers worldwide for developing effective NiV vaccine and treatment regimens.

Journey to Death: Are Health Systems Failing Mothers?

BACKGROUND: Annually, about 44,000 maternal deaths occur in India, which is 20% of the global burden. Despite persistent efforts, India failed to meet the fifth millennium development goal by 2015. Lack of reliable data on maternal mortality demands utilization of tools for counting maternal deaths which is vital to implement preventative actions. OBJECTIVES: Our study aims to determine health system-related issues of maternal mortality using the WHO validated tool - Maternal Death Review and demonstrates usefulness of maternal death surveillance and review as a monitoring tool. METHODS: Fourteen maternal deaths were evaluated through community based and facility-based audits from July 2013 to June 2014 in three districts of Gujarat. Pathways to death were traced through Global Positioning System (GPS). Factors contributing to the three delays were analyzed. RESULTS: Type III delay, that is, delay in receiving adequate care was frequently observed in our review including weak referral linkages, lack of blood banking services, inadequate surgical facilities. and staff shortages. Mothers succumbed, not because they did not seek treatment or reach facilities in time but because facilities were incapable of providing appropriate medical care. CONCLUSION: Scaling up of maternal death audits and subsequent use of these findings will help to reduce maternal mortality in India. As we continue to push for institutional deliveries, we need to reevaluate if our health system is prepared to manage an increasing number of facility births and obstetric complications.

Effect of previous utilization and out-of-pocket expenditure on subsequent utilization of a state led public-private partnership scheme "Chiranjeevi Yojana" to promote facility births in Gujarat, India.

BACKGROUND: In Gujarat, India, a state led public private partnership scheme to promote facility birth named Chiranjeevi Yojana (CY) was implemented in 2005. Institutional birth is provided free of cost at accredited private health facilities to women from socially disadvantaged groups (eligible women). CY has contributed in increasing facility birth and providing substantially subsidized (but not totally free) birth care; however, the retention of mothers in this scheme in subsequent child birth is unknown. Therefore, we conducted a study aimed to determine the effect of previous utilization of the scheme and previous out of pocket expenditure on subsequent child birth among multiparous eligible women in Gujarat. METHODS: This was a retrospective cohort study of multiparous eligible women (after excluding abortions and births at public facility). A structured questionnaire was administered by trained research assistant to those with recent delivery between Jan and Jul 2013. Outcome of interest was CY utilization in subsequent child birth (Jan-Jul 2013). Explanatory variables included socio-demographic characteristics (including category of eligibility), pregnancy related characteristics in previous child birth, before Jan 2013, (including CY utilization, out of pocket expenditure) and type of child birth in subsequent birth. A poisson regression model was used to assess the association of factors with CY utilization in subsequent child birth. RESULTS: Of 997 multiparous eligible women, 289 (29%) utilized and 708 (71%) did not utilize CY in their previous child birth. Of those who utilized CY (n = 289), 182 (63%) subsequently utilized CY and 33 (11%) gave birth at home; whereas those who did not utilize CY (n = 708) had four times higher risk (40% vs. 11%) of subsequent child birth at home. In multivariable models, previous utilization of the scheme was significantly associated with subsequent utilization (adjusted Relative Risk (aRR): 2.7; 95% CI: 2.2-3.3), however previous out of pocket expenditure was not found to be associated with retention in the CY scheme. CONCLUSION: Women with previous CY utilization were largely retained; therefore, steps to increase uptake of CY are expected to increase retention of mothers within CY in their subsequent child birth. To understand the reasons for subsequent child birth at home despite previous CY utilization and previous zero/minimal out of pocket expenditure, future research in the form of systematic qualitative enquiry is recommended.

Utilization of the state led public private partnership program "Chiranjeevi Yojana" to promote facility births in Gujarat, India: a cross sectional community based study.

BACKGROUND: "Chiranjeevi Yojana (CY)", a state-led large-scale demand-side financing scheme (DSF) under public-private partnership to increase institutional delivery, has been implemented across Gujarat state, India since 2005. The scheme aims to provide free institutional childbirth services in accredited private health facilities to women from socially disadvantaged groups (eligible women). These services are paid for by the state to the private facility with the intention of service being free to the user. This community-based study estimates CY uptake among eligible women and explores factors associated with non-utilization of the CY program. METHODS: This was a community-based cross sectional survey of eligible women who gave birth between January and July 2013 in 142 selected villages of three districts in Gujarat. A structured questionnaire was administered by trained research assistant to collect information on socio-demographic details, pregnancy details, details of childbirth and out-of-pocket (OOP) expenses incurred. A multivariable inferential analysis was done to explore the factors associated with non-utilization of the CY program. RESULTS: Out of 2,143 eligible women, 559 (26 %) gave birth under the CY program. A further 436(20 %) delivered at free public facilities, 713(33 %) at private facilities (OOP payment) and 435(20 %) at home. Eligible women who belonged to either scheduled tribe or poor [aOR = 3.1, 95 % CI:2.4 - 3.8] or having no formal education [aOR = 1.6, 95 % CI:1.1, 2.2] and who delivered by C-section [aOR = 2.1,95 % CI: 1.2, 3.8] had higher odds of not utilizing CY program. Of births at CY accredited facilities (n = 924), non-utilization was 40 % (n = 365) mostly because of lack of required official documentation that proved eligibility (72 % of eligible non-users). Women who utilized the CY program overall paid more than women who delivered in the free public facilities. CONCLUSION: Uptake of the CY among eligible women was low after almost a decade of implementation. Community level awareness programs are needed to increase participation among eligible women. OOP expense was incurred among who utilized CY program; this may be a factor associated with non-utilization in next pregnancy which needs to be studied. There is also a need to ensure financial protection of women who have C-section.

Has Chiranjeevi Yojana changed the geographic availability of free comprehensive emergency obstetric care services in Gujarat, India?

BACKGROUND: The high rate of maternal mortality in India is of grave concern. Poor rural Indian women are most vulnerable to preventable maternal deaths primarily because they have limited availability of affordable emergency obstetric care (EmOC) within reasonable geographic proximity. Scarcity of obstetricians in the public sector combined with financial barriers to accessing private sector obstetrician services preclude this underserved population from availing lifesaving functions of comprehensive EmOC such as C-section. In order to overcome this limitation, Government of Gujarat initiated a unique public-private partnership program called Chiranjeevi Yojana (CY) in 2005. The program envisaged leveraging private sector providers to increase availability and thereby accessibility of EmOC care for vulnerable sections of society. Under CY, private sector providers render obstetric care services to poor women at no cost to patients. This paper examines the CY's effectiveness in improving availability of CEmOC services between 2006 and 2012 in three districts of Gujarat, India. METHODS: Primary data on facility locations, EmOC functionality, and obstetric bed availability were collected in the years 2012 and 2013 in three study districts. Secondary data from Census 2001 and 2011 were used along with required geographic information from Topo sheets and Google Earth maps. ArcGIS version 10 was used to analyze the availability of services using two-step floating catchment area (2SFCA) method. RESULTS: Our analysis suggests that the availability of CEmOC services within reasonable travel distance has greatly improved in all three study districts as a result of CY. We also show that the declining participation of the private sector did not result in an increase in distance to the nearest facility, but the extent of availability of providers for several villages was reduced. Spatial and temporal analyses in this paper provide a comprehensive understanding of trends in the availability of EmOC services within reasonable travel distance. CONCLUSIONS: This paper demonstrates how GIS could be useful for evaluating programs especially those focusing on improving availability and geographic accessibility. The study also shows usefulness of GIS for programmatic planning, particularly for optimizing resource allocation.

Options for Optimal Coverage of Free C-Section Services for Poor Mothers in Indian State of Gujarat: Location Allocation Analysis Using GIS.

BACKGROUND: Gujarat, a western state of India, has seen a steep rise in the proportion of institutional deliveries over the last decade. However, there has been a limited access to cesarean section (C-Section) deliveries for complicated obstetric cases especially for poor rural women. C-section is a lifesaving intervention that can prevent both maternal and perinatal mortality. Poor women bear a disproportionate burden of maternal mortality, and lack of access to C-section, especially for these women, is an important contributor for high maternal and perinatal mortality in resource limited settings. To improve access for this underserved population in the context of inadequate public provision of emergency obstetric services, the state government of Gujarat initiated a public private partnership program called "Chiranjeevi Yojana" (CY) in 2005 to increase the number of facilities providing free C-section services. This study aimed to analyze the current availability of these services in three districts of Gujarat and to identify the best locations for additional service centres to optimize access to free C-section services using Geographic Information System technology. METHODOLOGY: Supply and demand for obstetric care were calculated using secondary data from sources such as Census and primary data from cross-sectional facility survey. The study is unique in using primary data from facilities, which was collected in 2012-13. Information on obstetric beds and functionality of facilities to calculate supply was collected using pretested questionnaire by trained researchers after obtaining written consent from the participating facilities. Census data of population and birth rates for the study districts was used for demand calculations. Location-allocation model of ArcGIS 10 was used for analyses. RESULTS: Currently, about 50 to 84% of populations in all three study districts have access to free C-section facilities within a 20km radius. The model suggests that about 80-96% of the population can be covered for free C-section services with addition of 4-6 centres in critical but underserved regions. It was also suggested that upgrading of public sector facilities with minimal investment can improve the services. CONCLUSION: This study highlights utility of Geographic Information System technology for planning service centres to optimize access to vital lifesaving procedure such as C-section. Although the location allocation methodology has been available for decades, it has been used sparsely by public health professionals. This paper makes an important contribution to the literature for use of the method for planning in resource limited settings.

Predictors of maternal health services utilization by poor, rural women: a comparative study in Indian States of Gujarat and Tamil Nadu.

BACKGROUND: India leads all nations in numbers of maternal deaths, with poor, rural women contributing disproportionately to the high maternal mortality ratio. In 2005, India launched the world's largest conditional cash transfer scheme, Janani Suraksha Yojana (JSY), to increase poor women's access to institutional delivery, anticipating that facility-based birthing would decrease deaths. Indian states have taken different approaches to implementing JSY. Tamil Nadu adopted JSY with a reorganization of its public health system, and Gujarat augmented JSY with the state-funded Chiranjeevi Yojana (CY) scheme, contracting with private physicians for delivery services. Given scarce evidence of the outcomes of these approaches, especially in states with more optimal health indicators, this cross-sectional study examined the role of JSY/CY and other healthcare system and social factors in predicting poor, rural women's use of maternal health services in Gujarat and Tamil Nadu. METHODS: Using the District Level Household Survey (DLHS)-3, the sample included 1584 Gujarati and 601 Tamil rural women in the lowest two wealth quintiles. Multivariate logistic regression analyses examined associations between JSY/CY and other salient health system, socio-demographic, and obstetric factors with three outcomes: adequate antenatal care, institutional delivery, and Cesarean-section. RESULTS: Tamil women reported greater use of maternal healthcare services than Gujarati women. JSY/CY participation predicted institutional delivery in Gujarat (AOR = 3.9), but JSY assistance failed to predict institutional delivery in Tamil Nadu, where mothers received some cash for home births under another scheme. JSY/CY assistance failed to predict adequate antenatal care, which was not incentivized. All-weather road access predicted institutional delivery in both Tamil Nadu (AOR = 3.4) and Gujarat (AOR = 1.4). Women's education predicted institutional delivery and Cesarean-section in Tamil Nadu, while husbands' education predicted institutional delivery in Gujarat. CONCLUSIONS: Overall, assistance from health financing schemes, good road access to health facilities, and socio-demographic and obstetric factors were associated with differential use of maternity health services by poor, rural women in the two states. Policymakers and practitioners should promote financing schemes to increase access, including consideration of incentives for antenatal care, and address health system and social factors in designing state-level interventions to promote safe motherhood.