Development and implementation of a strategy for early diagnosis and management of scrub typhus: an emerging public health threat.

Scrub typhus, caused by Orientia tsutsugamushi, is a re-emerging zoonotic disease in the tropics with considerable morbidity and mortality rates. This disease, which is mostly prevalent in rural areas, remains underdiagnosed and underreported because of the low index of suspicion and non-specific clinical presentation. Limited access to healthcare, diagnostics, and treatment in rural settings further makes it challenging to distinguish it from other febrile illnesses. While easily treatable, improper treatment leads to severe forms of the disease and even death. As there is no existing public health program to address scrub typhus in India, there is an urgent need to design a program and test its effectiveness for control and management of the disease. With this backdrop, this implementation research protocol has been developed for a trial in few of the endemic "pockets" of Odisha, an eastern Indian state that can be scalable to other endemic areas of the country, if found effective. The main goal of the proposed project is to include scrub typhus as a differential diagnosis of fever cases in every tier of the public health system, starting from the community level to the health system, for the early diagnosis among suspected cases and to ensure that individuals receive complete treatment. The current study aimed to describe the protocol of the proposed Scrub Typhus Control Program (STCP) in detail so that it can receive valuable views from peers which can further strengthen the attempt.

To leave no one behind: Assessing utilization of maternal newborn and child health services by all the 13 particularly vulnerable tribal groups (PVTGs) of Odisha, India.

BACKGROUND: Indigenous tribal people experience lower coverage of maternal, newborn and child healthcare (MNCH) services worldwide, including in India. Meanwhile, Indian tribal people comprise a special sub-population who are even more isolated, marginalized and underserved, designated as particularly vulnerable tribal groups (PVTGs). However, there is an extreme paucity of evidence on how this most vulnerable sub-population utilizes health services. Therefore, we aimed to estimate MNCH service utilization by all the 13 PVTGs of the eastern Indian state of Odisha and compare that with state and national rates. METHODS: A total of 1186 eligible mothers who gave birth to a live child in last 5 years, were interviewed using a validated questionnaire. The weighted MNCH service utilization rates were estimated for antenatal care (ANC), intranatal care (INC), postnatal care (PNC) and immunization (for 12-23-month-old children). The same rates were estimated for state (n = 7144) and nationally representative samples (n = 176 843) from National Family Health Survey-5. RESULTS: The ANC service utilization among PVTGs were considerably higher than national average except for early pregnancy registration (PVTGs 67% versus national 79.9%), and 5 ANC components (80.8% versus 82.3%). However, their institutional delivery rates (77.9%) were lower than averages for Odisha (93.1%) and India (90.1%). The PNC and immunization rates were substantially higher than the national averages. Furthermore, the main reasons behind greater home delivery in the PVTGs were accessibility issues (29.9%) and cultural barriers (23.1%). CONCLUSION: Ours was the first study of MNCH service utilization by PVTGs of an Indian state. It is very pleasantly surprising to note that the most vulnerable subpopulation of India, the PVTGs, have achieved comparable or often greater utilization rates than the national average, which may be attributable to overall significantly better performance by the Odisha state. However, PVTGs have underperformed in terms of timely pregnancy registration and institutional delivery, which should be urgently addressed.

Development, validation & pilot testing of a questionnaire to assess healthcare seeking behaviour, healthcare service utilization & out-of-pocket expenditure of Particularly Vulnerable Tribal Groups of Odisha, India.

Background & objectives: Assessing healthcare seeking behaviour (HSB), healthcare utilization and related out-of-pocket expenditures of Particularly Vulnerable Tribal Groups (PVTGs) of India through a prism of the health system may help to achieve equitable health outcomes. Therefore, this comprehensive study was envisaged to examine these issues among PVTGs of Odisha, India. However, there exists no validated questionnaire to measure these variables among PVTGs. Therefore, a study questionnaire was developed for this purpose and validated. Methods: Questionnaire was constructed in four phases: questionnaire development, validity assessment, pilot testing and reliability assessment. Nine domain experts face validated questionnaire in two rounds, followed by a single round of quantitative content validity. Next, the questionnaire was pretested in three rounds using cognitive interviews and pilot-tested among 335 and 100 eligible individuals for the two sections healthcare seeking behaviour (HSB-Q) and maternal and child healthcare service utilization (MCHSU-Q). Internal consistency reliability was assessed for de novo HSB-Q. Results: On two rounds of expert-driven face validity, 55 items were eliminated from 200 items. Questionnaire showed moderate to high content validity (item-level content validity index range: 0.78 to 1, scale-level content validity index/universal agreement: 0.73; scale-level content validity index/average: 0.96 and multirater kappa statistics range: 0.6 to 1). During the pre-test, items were altered until saturation was achieved. Pilot testing helped to refine interview modalities. The Cronbach alpha and McDonald's omega assessing internal consistency of HSB-Q were 0.8 and 0.85, respectively. Interpretation & conclusions: The questionnaire was found to be valid and reliable to explore healthcare seeking behaviour, maternal and child healthcare utilization and related out-of-pocket expenditure incurred by PVTGs of Odisha, India.

Costs and models used in the economic analysis of Total Knee Replacement (TKR): A systematic review.

OBJECTIVES: The main objective of this review is to summarize the evidence on the core modelling specifications and methodology on the cost-effectiveness of TKR compared to non-surgical management. Another objective of this study is to synthesize evidence of TKR cost and compare it across countries using purchasing power parity (PPP). METHODOLOGY: The electronic databases used for this review were MEDLINE (PubMed), Cochrane Central Register of Controlled Trials (CENTRAL), HTAIn repository, Cost effectiveness Analysis (CEA) registry, and Google Scholar. Consolidated Health Economic Evaluation Reporting Standards (CHEERS) was used to assess the validity of the methods and transparency in reporting the results. The Quality of Health Economic Studies (QHES) was used to check the quality of economic evaluation models of the studies included. The cost of TKR surgery from high income and low- or middle-income countries were extracted and converted to single USD ($) using purchasing power parities (PPP) method. RESULT: Thirty-two studies were included in this review, out of which eight studies used Markov model, five used regression model, one each reported Marginal structure model, discrete simulation model, decision tree and Osteoarthritis Policy Model (OAPol) respectively to assess the cost-effectiveness of TKR. For PPP, twenty-six studies were included in the analysis of TKR cost. The average cost of TKR surgery was the lowest in developing country-India ($3457) and highest in USA ($19568). CONCLUSION: The findings of this review showed that the Markov model was most widely used in the analysis of the cost effectiveness of TKR. Our review also concluded that the cost of TKR was higher in the developed countries as compared to the developing countries.

What causes concordance of hypertension between spouses in India? Identifying a critical knowledge gap from a nationally representative cross-sectional sample of 63,020 couples aged 15 + years.

BACKGROUND: Hypertension, a critical risk factor for cardiovascular diseases, is found to cluster between spouses due to within-couple aggregation of antecedent environmental risk factors, either through assortative mating or cohabitation. However, majority of the evidence of spousal concordance of hypertension is from Caucasoid couples from western societies, whereas marriage, partner selection, and post-marital roles of husband and wives are very different in Indian society. Therefore, we aimed to comprehensively examine the phenomenon of spousal concordance of hypertension in Indian couples. METHOD: Couples from Longitudinal Ageing Study in India Wave 1 (n = 10,994) and National Family Health Survey Round 5 (n = 52,026) represented 15 years + Indian spouses. Hypertension was defined when systolic and/or diastolic blood pressure was > 139 and > 89 mmHg respectively, and/or if the individual was previously diagnosed or on anti-hypertensive medication. Odds Ratios (OR) estimated the within-couple concordance of hypertension while adjusting for five environmental risk factors of hypertension: individual-level body mass index, education and caste, and household-level wealth and place of residence. RESULT: OR marginally attenuated from 1.84 (95% Confidence Interval: 1.77, 1.92) to 1.75 (1.68, 1.83) after adjustment, signifying negligible explanation by environmental risk factors, and plausibility of "novel" risk factors. Concordance continued to weaken with age (OR: 2.25 (2.02, 2.52) in < 30 versus 1.36 (1.20, 1.53) in ≥ 60 years). CONCLUSION: Our study underscores two critical knowledge gaps: first, the identity of "novel" risk factors of hypertension and second, the mechanism behind weakening of concordance with age. Future research should explore these novel risk factors rigorously and try to modify them. Also, primary healthcare policy of the country should focus on couples in addition to individuals for hypertension and cardiovascular disease screening and management.

Effectiveness of Fortified Mid-Day Meal in Reducing Anemia Among School Children in Dhenkanal, Odisha: A Quasi-Experimental Study.

BACKGROUND: Iron-deficiency anemia among school-aged children is widespread in India. The efficacy of micronutrient and iron fortified school-served meals in reducing iron deficiency anemia has been demonstrated in randomized controlled trials in other parts of the globe. The current study evaluates its effectiveness in real-world Indian settings. METHODS: Mid-day-Meal (MDM) programme provides free lunch to students of grades 1 to 8 in all public-funded Indian schools. An implementation research project fortified MDM of all public schools of 4 out of 8 sub-districts ("blocks") of Dhenkanal district of Odisha state with fortified rice kernel (FRK). All the schools of the other 4 blocks fortified with micronutrient powders (MNP)-both FRK and MNP containing equal amounts of supplementary iron and other micronutrients. Schools of 4 matched blocks of neighboring nonimplementing Angul district served as control. Cross-sectional representative samples of students were drawn from the 3 arms, before and after intervention (n = 1764 and n = 1640 respectively). Pre-post changes in anemia prevalence and hemoglobin levels were estimated in the sampled children using difference-in-difference analysis after controlling for inter-arm differences in socioeconomic status, and iron and deworming tablet consumptions. RESULTS: Factoring in pre-post changes in control and adjusting for potential confounders, the proportion of children without anemia and mean hemoglobin improved by 1.93 (1.38, 2.24, P < .001) times and 0.24 (-0.03, 0.51, P = .083) g/dL in MNP; and 1.63 (1.18, 2.24, P = .002) times and 0.18 (-0.09, 0.45, P = .198) g/dL in FRK arms. CONCLUSIONS: Fortified MDM could effectively improve anemia status among Indian school-aged children under real-world conditions.

To what extent classic socio-economic determinants explain trends of anaemia in tribal and non-tribal women of reproductive age in India? Findings from four National Family Heath Surveys (1998-2021).

BACKGROUND: Despite unprecedented socio-economic growth experienced by Indians in the past few decades, and a long history of anti-anaemia public health measures, prevalence of anaemia in Indian non-pregnant women of reproductive age group (NPWRA) has not declined. This warrants a firm understanding of what explains the anaemia situation over time, preferably by sub-populations. Therefore, we aimed to examine the trends of anaemia in tribal NPWRA (least privileged) and compare with the trends in the NPWRA of general caste (most privileged) between 1998 to 2021. Additionally, the study also explored explanation of any decline and tribal/general narrowing of these trends. METHODS: We studied four rounds of National Family Health Survey (1998-99, 2005-06, 2015-16, 2019-21). We examined the trend of anaemia (haemoglobin < 12 g/dl) and its possible determinants in tribal and general NPWRA and estimated the portion of "decline" and "narrowing" that could be explained by the underlying and intermediate determinants (wealth, education, residence, parity and food security) using multiple logistic regression. RESULTS: The distribution of determinants improved over 23 years in both the groups but more in tribals. But anaemia either remained unchanged or increased in both except 7.1 points decline in tribals between 2006-2016, leading also to 7 points narrowing of tribal/general gap. The modest attenuation of beta coefficients representing the change of anaemia prevalence (log of odds) in tribals from -0.314(-0.377, -0.251) to -0.242(-0.308, -0.176) after adjustment with determinants could explain only 23% of the decline. Similarly, only 7% of the narrowing of the tribal/general anaemia gap could be explained. CONCLUSIONS: The structural determinants wealth, education, food security, parity and urban amenities improved immensely in India but anaemia did not decline in this 23-year period. This implies that the "usual suspects" - the structural determinants are not the main drivers of anaemia in the country. The main driver may be absolute and/or functional deficiency status of micronutrients including iron attributable to inadequate uptake and absorption of these elements from Indian diets; and therefore, their effects are noticeable in every socio-economic stratum of India. Future research for aetiologies and new interventions for anaemia alleviation in India may focus on these factors.

Impact of Sub-patent Malaria During Pregnancy on Birth-Weight in Odisha, India: Time-to-Event Analysis of Prospective Longitudinal Follow-Up of a Survey.

OBJECTIVE: The current study aimed to estimate prevalence of malaria infection, especially sub-patent infection, in pregnant women residing in high malaria-endemic, hard-to-reach pockets of the Indian state of Odisha; and also measure its impact on birth-weight of their new-borns. METHOD: A time-to-event analysis of prospective longitudinal follow-up study nested within a cross-sectional survey of people residing in high malaria-endemic six districts of Odisha was conducted during July-November 2019. Malaria status in pregnant mothers was categorized as malaria free; sub-patent, and patent. Hazards Ratio (HR) of low birth-weight (LBW; birth-weight < 2500 gms) was estimated in these three categories (n = 308) adjusted for residence (block), gravida, caste, age and gestational age at testing. RESULTS: 50.3% pregnant women had sub-patent malaria infection, 3.9% had patent infection. In fully adjusted model, hazards ratio of LBW was 3.76 (95% CI 1.12, 12.64, p = 0.032) in pregnant women with patent infection and 1.82 (95% CI 0.87, 3.81, p = 0.109) in women with sub-patent infection when compared to no malaria group. CONCLUSION: The study showed that half of the pregnant women in high-endemic pockets had sub-patent infection which posed deleterious influence on birth-weight of their new-borns. The study thereby flags the prevalence of sub-patent infection as a public health concern, because sub-patent infection in pregnant mothers may persist as a "silent" reservoir, with the potential to derail the malaria control program, especially when the country plans malaria elimination by 2030.

Characteristics of Households' Vulnerability to Extreme Heat: An Analytical Cross-Sectional Study from India.

High ambient temperature is a key public health problem, as it is linked to high heat-related morbidity and mortality. We intended to recognize the characteristics connected to heat vulnerability and the coping practices among Indian urbanites of Angul and Kolkata. In 2020, a cross-sectional design was applied to 500 households (HHs) each in Angul and Kolkata. Information was gathered on various characteristics including sociodemographics, household, exposure, sensitivity, and coping practices regarding heat and summer heat illness history, and these characteristics led to the computation of a heat vulnerability index (HVI). Bivariate and multivariable logistic regression analyses were used with HVI as the outcome variable to identify the determinants of high vulnerability to heat. The results show that some common and some different factors are responsible for determining the heat vulnerability of a household across different cities. For Angul, the factors that influence vulnerability are a greater number of rooms in houses, the use of cooling methods such as air conditioning, having comorbid conditions, the gender of the household head, and distance from nearby a primary health centre (PHC). For Kolkata, the factors are unemployment, income, the number of rooms, sleeping patterns, avoidance of nonvegetarian food, sources of water, comorbidities, and distance from a PHC. The study shows that every city has a different set of variables that influences vulnerability, and each factor should be considered in design plans to mitigate vulnerability to extreme heat.

Gender difference in prevalence of hypertension among Indians across various age-groups: a report from multiple nationally representative samples.

BACKGROUND: Prevalence of hypertension increases with age, but there is a general perception in India that women are less affected at every stage of life, although empiric evidence hardly exists regarding gender difference in hypertension in Indians of different ages. Therefore, we aimed to examine the gender difference in hypertension among Indians across various age-groups; and the contribution of variation in body mass index (BMI) to this difference. METHODS: Data were analysed after combining National Family Health Survey 4 (n = 294,584 aged 35-49 years) and Study of Ageing and Health wave 2 (n = 7118 aged 50 + years) datasets (NFHS-SAGE). Longitudinal Ageing Study of India (LASI) dataset (n = 65,900 aged > 45years) was analysed to replicate the results. Hypertension was defined if systolic and diastolic blood pressure was > 89 and/or > 139 respectively and/or if there was a history of anti-hypertensive medication. Descriptive summaries were tabulated and plotted to examine the gender difference in hypertension in various age-groups (35-39,40-44, 45-49, 50-54, 55-59, 60-64, 65-69, ≥ 70). Odds Ratios (ORs) from logistic regression models estimated the age gradient of hypertension and their male-female difference, adjusted for Body Mass Index (BMI). RESULTS: Males had a higher prevalence of hypertension up to 50 years; after that, females had higher rates. The estimates of age gradient, expressed as ORs, were 1.02 (1.02, 1.02) in males versus 1.05(1.05, 1.06) in females (p < 0.001) in NFHS-SAGE and 1.01(1.01, 1.02) in males versus 1.04(1.03, 1.04)in females (p < 0.001) in LASI;these differences marginally changed after adjustment with BMI. CONCLUSION: This is perhaps the first study to comprehensively demonstrate that cardio-metabolic risk in Indian females surpasses males after 50 years of age, "busting the myth" that Indian females are always at much lower risk than males; and this evidence should inform the Indian healthcare system to prioritise older women for screening and treatment of hypertension.

Disability Weights Estimates From India in 2018: Measurements From Community Members From Two Distinct States of India.

Background: India is undergoing a rapid demographic and epidemiologic transition. Thus demanding prioritization of diseases based on burden estimation is befitting our cultural diversity. Disability weights (DWs) by Global burden of disease (GBD) studies may not be representative. Hence, a study was conducted to estimate state-specific disability weights to capture the community health perceptions that included urban-rural settings as well as different socio-economic and literacy levels. Methods: A total of 2,055 community members (participants) from two distinct states of India, Odisha and Telangana, were interviewed to assign disability weights to the selected 14 health states based on the state burden and relevance. Each health state was described to the participants using pictorial representations of the health states and valuated using visual analog scale and card sort methods. Results: We noted that DWs in Odisha ranged from 0.32 (0.30-0.34) for upper limb fracture due to road traffic accident (least severe) to 0.90 (0.88-0.93) for breast cancer (most severe) among the 14 health states. While, in Telangana, diarrhea was considered least severe [DW = 0.22 (0.19-0.24)] and breast cancer remained most severe [DW = 0.85 (0.83-0.88)] as in Odisha. Marked difference in the DWs for other health states was also seen. Further, on comparison of community weights with GBD weights using Spearman correlation, we observed a low correlation (ρ = 0.104). Conclusion: Our study provides community-based findings that show how participants valued noncommunicable diseases higher than short-term ailments or infectious diseases. Additionally, the low correlation between GBD also suggests the need for local disability weights rather than universal acceptance. We therefore recommend that decisions in policy-making, especially for resource allocation and priority setting, need to be based not only on expert opinion but also include community in accordance with high scientific standards.

Impact of the malaria comprehensive case management programme in Odisha, India.

BACKGROUND: The Comprehensive Case Management Project (CCMP), was a collaborative implementation research initiative to strengthen malaria early detection and complete treatment in Odisha State, India. METHODS: A two-arm quasi-experimental design was deployed across four districts in Odisha, representing a range of malaria endemicity: Bolangir (low), Dhenkanal (moderate), Angul (high), and Kandhamal (hyper). In each district, a control block received routine malaria control measures, whereas a CCMP block received a range of interventions to intensify surveillance, diagnosis, and case management. Impact was evaluated by difference-in-difference (DID) analysis and interrupted time-series (ITS) analysis of monthly blood examination rate (MBER) and monthly parasite index (MPI) over three phases: phase 1 pre-CCMP (2009-2012) phase 2 CCMP intervention (2013-2015), and phase 3 post-CCMP (2016-2017). RESULTS: During CCMP implementation, adjusting for control blocks, DID and ITS analysis indicated a 25% increase in MBER and a 96% increase in MPI, followed by a -47% decline in MPI post-CCMP, though MBER was maintained. Level changes in MPI between phases 1 and 2 were most marked in Dhenkanal and Angul with increases of 976% and 287%, respectively, but declines in Bolangir (-57%) and Kandhamal (-22%). Between phase 2 and phase 3, despite the MBER remaining relatively constant, substantial decreases in MPI were observed in Dhenkanal (-78%), and Angul (-59%), with a more modest decline in Bolangir (-13%), and an increase in Kandhamal (14%). CONCLUSIONS: Overall, CCMP improved malaria early detection and treatment through the enhancement of the existing network of malaria services which positively impacted case incidence in three districts. In Kandhamal, which is hyperendemic, the impact was not evident. However, in Dhenkanal and Angul, areas of moderate-to-high malaria endemicity, CCMP interventions precipitated a dramatic increase in case detection and a subsequent decline in malaria incidence, particularly in previously difficult-to-reach communities.

A comparison of three types of targeted, community-based methods aimed at promoting early detection of new leprosy cases in rural parts of three endemic states in India.

BACKGROUND: India achieved elimination of leprosy nationally in 2005, but since then the number of patients with grade 2 disability at diagnosis increased steadily indicating delay in diagnosis. Therefore, there was a need for public health interventions which can increase case finding in their earlier stage. The objective of this study is to compare the effectiveness of three such community-based interventions; 1) Enhancement of community awareness on leprosy; 2) Education and motivation of "Index" leprosy cases; and 3) Involvement of Non-Formal Health Practitioners (NFHPs) to promote early detection of new cases of leprosy. METHODOLOGY/PRINCIPAL FINDINGS: Three community-based interventions were implemented between April 2016 and March 2018, embedded within the National Leprosy Eradication Program (NLEP) of India. Interventions were 1) increasing awareness through involvement of Gram Panchayat (local government) in the community regarding early signs of leprosy (Awareness), 2) providing health education and motivating newly diagnosed leprosy patients to bring suspects from their contacts (Index) and 3) training local non-formal health practitioners (NFHP). Each intervention was implemented in a group of ten blocks (sub-division of district) with an additional ten blocks as control (with no intervention). The main outcomes were number of new cases detected and number of grade 2 disability among them. They were obtained from the routine NLEP information system and compared between these interventions. On an average, there was an addition of 1.98 new cases in Awareness blocks, 1.13 in NFHP blocks and 1.16 cases in Index intervention blocks per month per block after adjusting for changes in control blocks during the same period. In terms of ratio, there was a 61%, 40% and 41% increase in case notification in awareness, Index and NFHP intervention, respectively. Overall, the percentage of grade 2 disability across intervention blocks declined. CONCLUSION: The Awareness intervention appears to be more effective in detection of new cases, compared to Index case motivation and sensitization of NFHPs. However, it is important to stress that while selecting strategies to increase early diagnosis it is important to determine, which is the most appropriate for each context or area and must be decided depending on the local context.

Neglected malaria parasites in hard-to-reach areas of Odisha, India: implications in elimination programme.

BACKGROUND: Information on the foci of Plasmodium species infections is essential for any country heading towards elimination. Odisha, one of the malaria-endemic states of India is targeting elimination of malaria by 2030. To support decision-making regarding targeted intervention, the distribution of Plasmodium species infections was investigated in hard-to-reach areas where a special malaria elimination drive, namely Durgama Anchalare Malaria Nirakaran (DAMaN) began in 2017. METHODS: A cross-sectional survey was conducted in 2228 households during July to November 2019 in six districts, to evaluate the occurrence of Plasmodium species. The species were identified by polymerase chain reaction (PCR) followed by sequencing, in case of Plasmodium ovale. RESULTS: Of the 3557 blood specimens tested, malaria infection was detected in 282 (7.8%) specimens by PCR. Of the total positive samples, 14.1% were P. ovale spp. and 10.3% were Plasmodium malariae infections. The majority of P. ovale spp. (75.8%) infections were mixed with either Plasmodium falciparum and/or Plasmodium vivax and found to be distributed in three geophysical regions (Northern-plateau, Central Tableland and Eastern Ghat) of the State, while P. malariae has been found in Northern-plateau and Eastern Ghat regions. Speciation revealed occurrence of both Plasmodium ovale curtisi (classic type) and Plasmodium ovale wallikeri (variant type). CONCLUSIONS: In the present study a considerable number of P. ovale spp. and P. malariae were detected in a wide geographical areas of Odisha State, which contributes around 40% of the country's total malaria burden. For successful elimination of malaria within the framework of national programme, P. ovale spp. along with P. malariae needs to be incorporated in surveillance system, especially when P. falciparum and P. vivax spp. are in rapid decline.

A Heat Vulnerability Index: Spatial Patterns of Exposure, Sensitivity and Adaptive Capacity for Urbanites of Four Cities of India.

Extreme heat and heat waves have been established as disasters which can lead to a great loss of life. Several studies over the years, both within and outside of India, have shown how extreme heat events lead to an overall increase in mortality. However, the impact of extreme heat, similar to other disasters, depends upon the vulnerability of the population. This study aims to assess the extreme heat vulnerability of the population of four cities with different characteristics across India. This cross-sectional study included 500 households from each city across the urban localities (both slum and non-slum) of Ongole in Andhra Pradesh, Karimnagar in Telangana, Kolkata in West Bengal and Angul in Odisha. Twenty-one indicators were used to construct a household vulnerability index to understand the vulnerability of the cities. The results have shown that the majority of the households fell under moderate to high vulnerability level across all the cities. Angul and Kolkata were found to be more highly vulnerable as compared to Ongole and Karimnagar. Further analysis also revealed that household vulnerability is more significantly related to adaptive capacity than sensitivity and exposure. Heat Vulnerability Index can help in identifying the vulnerable population and scaling up adaptive practices.

Assessment of effectiveness of DAMaN: A malaria intervention program initiated by Government of Odisha, India.

India, a persistently significant contributor to the global malaria burden, rolled out several anti-malaria interventions at the national and state level to control and recently, to eliminate the disease. Odisha, the eastern Indian state with the highest malaria burden experienced substantial gains shown by various anti-malaria initiatives implemented under the National Vector-borne Disease Control Programme (NVBDCP). However, recalcitrant high-transmission "pockets" of malaria persist in hard-to-reach stretches of the state, characterised by limited access to routine malaria surveillance and the forested hilly topography favouring unbridled vector breeding. The prevalence of asymptomatic malaria in such pockets serves as perpetual malaria reservoir, thus hindering its elimination. Therefore, a project with the acronym DAMaN was initiated since 2017 by state NVBDCP, targeting locally identified high endemic 'pockets' in 23 districts. DAMaN comprised biennial mass screening and treatment, provisioning of long-lasting insecticidal net (LLIN) and behavioural change communication. Subsequently, to inform policy, assessment of DAMaN was conceived that aims to estimate the coverage of the various components of the project; the prevalence of malaria, even at sub-patent level especially among pregnant/lactating women and children; and its impact on malaria incidence. A survey of DAMaN beneficiaries will measure coverage; and knowledge and practices related to LLIN; along with collection of blood specimens from a probability sample. A multi-stage stratified clustered sample of 2228 households (~33% having pregnant/lactating women) will be selected from 6 DAMaN districts. Routine DAMaN project data (2017-2018) and NVBDCP data (2013-2018) will be extracted. Rapid Diagnostic Test, Polymerase Chain Reaction and blood smear microscopy will be conducted to detect malarial parasitemia. In addition to measuring DAMaN's coverage and malarial prevalence in DAMaN pockets, its impact will be estimated using pre-post differences and Interrupted Time Series analysis using 2017 as the "inflection" point. The assessment may help to validate the unique strategies employed by DAMaN.

Effect of caste on health, independent of economic disparity: evidence from school children of two rural districts of India.

Caste, a stratifying axis of the Indian society, is associated with wealth and health. However, to what extent caste-based health inequality is explained by wealth disparities, is not clear. Therefore, we aimed to examine the caste-based differences in anaemia (haemoglobin < 11 gm/dl) and self-reported sickness absenteeism in schoolchildren and the mediating role of economic disparity. Students (n = 1764) were surveyed from 54 government schools of Dhenkanal and Angul, Odisha state. Socioeconomic data, anaemia and absenteeism were recorded. The relative risks of anaemia among Scheduled Tribe (least advantaged) and Scheduled Caste (second least advantaged) students were 1.19 (95% CI: 1.08, 1.26) and 1.13 (1.03, 1.20), respectively, as compared to students of the most advantaged caste and that for sickness absenteeism were 2.78 (2.03, 3.82) and 2.84 (2.13, 3.78); p < 0.05, with marginal attenuation when controlled for inter-caste economic disparities. Caste had an independent effect on anaemia and sickness absenteeism in school children, unexplained by inter-caste economic disparities.

At which temperature do the deleterious effects of ambient heat "kick-in" to affect all-cause mortality? An exploration of this threshold from an eastern Indian city.

Despite experiencing hot weathers, limited studies from India explored relationships between ambient heat and health. We studied associations between heat and all-cause mortality to estimate heat threshold(s) affecting health, and examine other affecting dimensions. We conducted time-series analysis with daily maximum temperature and all-cause mortality data of Bhubaneswar city (March-July, 2007-2017), and explored their interactions. Mortality risks rose when daily maximum temperatures were >36.2°C (lower threshold), and even more when >40.5°C (upper threshold). Every degree above36.2°C increased the mortality risk by 2% (mortality rate ratio: 1.02; 95% CI 1.01, 1.03). The effects of maximum temperature increased on days when minimum temperatures were >25.6°C (median). The effect of heat was immediate and lasted for 0-1 day with no lagged effect. Two temperature thresholds with varying mortality risks provided an opportunity for a graded heat warning system. The accentuation of the deleterious effects of heat by the higher minimum temperature calls for its inclusion in the heat warning system in future.

Vulnerability and Adaptation to Extreme Heat in Odisha, India: A Community Based Comparative Study.

BACKGROUND: Extreme heat and heat illness are becoming very frequent in India. We aimed to identify the factors associated with heat illness and the coping practices among city dwellers of Odisha, India during the summer. METHODS: A cross-sectional study included 766 households (HHs) in twin cities of Odisha covering a population of 1099 (slum: 404 and non-slum: 695) in the year 2017. We collected information on sociodemographic, household characteristics, coping practices to heat and the heat illness history reported during the summer. Multivariate logistic regression accounting for clustering effects at the household and slum levels was used to identify the associated factors of heat illness after adjustment of other variables. RESULT: Nearly, 49% of the study participants were female and the mean age was 38.36 years (95% confidence interval (CI): 37.33-39.39 years). A significant difference of living environment was seen across the groups. More than two-thirds of the study participants at least once had heat illness. In the non-slum population, males (adjusted odds ratio (aOR): 3.56; 95% CI: 2.39-5.29), persons under medication (aOR: 3.09; 95% CI: 1.15-8.29), and chronic conditions had higher association with heat illness. Whereas, in the slum population, having a kitchen outside the home (aOR: 1.63; 95% CI: 1.02-3.96) and persons with chronic conditions were positively associated with heat illness. Use of cooling practices in slum areas reduced the risk of heat illness by 60%. CONCLUSION: Heat illness is associated with the living environment and physical health of the individuals. Identifying the vulnerable population and scaling up adaptive practices can strengthen the public health preparedness.