Digitizing tools for post introduction evaluation of rotavirus vaccine introduction in India.

Background and aims: The Rotavirus vaccine (RVV) introduction is a landmark event in the history of Indian public health as for the first time a novel, low-cost indigenous vaccine was introduced in a short timeline between 2016 and 2019. As per WHO mandate, post-introduction evaluation (PIE) be conducted within 6 to 12 months of vaccine introduction to provide an understanding of the operational aspects of the program. For RVV PIE, an innovative approach to developing and deploying a digitized tool was employed. The present study aims to document the processes followed for digitizing the data collection and analysis tools. Methods: The development of the RVV-PIE digital tool was undertaken in two phases. In the first phase, conceptualization and iteration of the modified WHO PIE tool were undertaken. Questions were organized sequentially to ensure natural progression in responses. The finalized questionnaire was converted to a digital version and extensive dummy data was entered to improve automated qualitative data analysis. Phase 2 involved updating the draft tool and incorporating changes to provide a field-tested version for deployment. Results: The digital version of the tool was successfully developed. The GPS functionality of the tool allowed live tracking of data collection making the process more accountable. The tool was prepopulated with reference materials and data points for easy reference and retrieval by the evaluators. The digitization of the tool also allowed easy visualization of data through maps, charts, and graphs on a real-time user-friendly dashboard. Conclusions: The digitization of the PIE tool for RVV in India has been a great learning experience where the dire situation of an ongoing pandemic catapulted us towards a more efficient and comprehensive process innovation. The RVV PIE tool could serve as a customizable digital PIE tool for other health programs heralding an era of a more effective and proficient process of PIE.

Enablers and barriers to rotavirus vaccine coverage in Assam, India- A qualitative study.

Background: Estimates suggest that 78,000 children died due to rotavirus gastroenteritis annually between 2011 and 2013 in India. The north eastern state of Assam reported 38.4% pediatric diarrheal admissions testing positive for rotavirus. Rotavirus vaccine (RVV) was introduced in Assam in 2017 following which the National Family Health Survey-5 (NFHS-5) (2019) revealed low RVV coverage in Assam with wide variation between the districts. the current study was conceptualized and undertaken to capture the enablers and barriers to RVV coverage in Assam. Methods: Qualitative study conducted in 5 randomly selected districts in Assam. Participants (key informants) were recruited by purposive sampling at each level of the health system including healthcare officials, service providers and caregivers based on availability. Thirty-five in-depth interviews (IDIs) and five focus group discussions (FGDs) were conducted. Interviews were tape recorded and transcribed. Data was coded and analyzed using the thematic framework approach. Results: Findings from the qualitative data collection were collated and analyzed under 7 identified themes. Difficult terrain, limited service provider availability and no catch-up training for new recruits were some of the barriers to RVV coverage. In contrast, Information, Education & Communication (IEC) in vernacular language, RVV safety profile, development partner support and adequate RVV supply were identified as some of the enablers of RVV coverage. Conclusion: Few broad recommendations to overcome identified barriers include comprehensive inter-sectoral coordination, regular monitoring and frequent refresher training sessions. There is a need for a future study utilizing existing coverage data and larger sample size to triangulate the findings of this study.

Enablers and Barriers to the Scaling Up of Pneumococcal Conjugate Vaccine in India During the COVID-19 Pandemic: A Qualitative Study.

Background: Pneumonia is one of the leading causes of death in under-5 children in India. This led the Ministry of Health & Family Welfare (MoHFW) in India to decide for the nationwide roll-out of the Pneumococcal Conjugate Vaccine (PCV). However, the introduction of PCV became more complex in the face of unprecedented challenges set forth by the COVID-19 pandemic. The study aims to assess enablers and barriers to the introduction of PCV in India during the pandemic. Methodology: Qualitative research approach involving key-informant interviews from John Snow India (JSI), the lead technical agency that supported MoHFW in the PCV expansion was employed to delineate the enablers and barriers. Principle of saturation was employed to derive the sample size. Thematic analysis using inductive approach was based on the modified World Health Organization (WHO) framework for new vaccine introduction impact on the Immunization and Health Systems, using NVIVO 12 qualitative data analysis software. Results: A total of 11 key informants (4 national-level program managers and 7 state technical officers) were telephonically interviewed. The study found social acceptance, lower cost of the vaccine, and intensive communication activities as potential enablers. Other enablers for PCV introduction included a robust vaccine supply-chain system, ample cold-chain space availability, and strong political commitment, despite the ongoing second wave. Further, the identified barriers included poor physical access, insufficient social mobilization, and limited advocacy along with a stretched workforce. Conclusion: The study delineated several enablers and barriers to introducing PCV in the country during the pandemic. The existing barriers in the PCV roll-out prompted the need to address these gaps, making key program-based recommendations to improve future new vaccine introductions during the pandemic.

Critical factors in the successful expansion of Pneumococcal Conjugate Vaccine in India during the COVID-19 pandemic.

India had decided to roll out PCV in India in 2015, but successful implementation of any new vaccine introduction mandates an enormous effort. PCV was scaled up during the COVID-19 pandemic, which posed new, unprecedented challenges in the vaccine rollout. However, India successfully expanded PCV in the country in record time across all states and Union Territories. During the pandemic, supply-side restrictions, delayed vaccine shipments, staff shortages, and restrictions in conducting training negatively affected the roll-out of PCV across the country. However, despite the ongoing pandemic, India successfully rolled out PCV across the country in 7 months. In this review, the authors have conducted a narrative review to delineate the crucial factors that helped in the successful expansion of PCV.

Framework Convention on Tobacco Control 2030-A Program to Accelerate the Implementation of World Health Organization Framework Convention for Tobacco Control in Low- and Middle-Income Countries: A Mixed-Methods Evaluation.

BACKGROUND: Framework Convention on Tobacco Control (FCTC) 2030 Program (2017-2021) was launched to accelerate World Health Organization (WHO) FCTC implementation in 15 low- and middle-income countries (LMICs). We evaluated the Program in six domains: Governance; Smoke-Free Policies; Taxation; Packaging and Health Warnings; Tobacco Advertising, Promotion, and Sponsorship (TAPS) bans; and International and Regional Cooperation. AIMS AND METHODS: Following a mixed-methods design, we surveyed (June-September 2020) FCTC focal persons in 14 of the 15 countries, to understand the Program's financial and technical inputs and progress made in each of the six domains. The data were coded in terms of inputs (financial = 1, technical = 1, or both = 2) and progress (none = 1, some = 2, partial = 3, or strong = 4) and a correlation was computed between the inputs and progress scores for each domain. We conducted semi-structured interviews with key stakeholders in five countries. We triangulated between the survey and interview findings. RESULTS: FCTC 2030 offered substantial financial and technical inputs, responsive to country needs, across all six domains. There was a high positive correlation between technical inputs and progress in five of the six domains, ranging from r = 0.61 for taxation (p < .05) to r = 0.91 and for smoke-free policies (p < .001). The interviews indicated that the Program provided timely and relevant evidence and created opportunities for influencing tobacco control debates. CONCLUSIONS: The FCTC 2030 Program might have led to variable, but significant progress in advancing FCTC implementation in the 15 countries. As expected, much of the progress was in augmenting existing structures and resources for FCTC implementation. The resulting advances are likely to lead to further progress in FCTC policy implementation. IMPLICATIONS: What this study adds: In many LMICs, WHO FCTC policies are not in place; and even when enshrined in law, they are poorly enforced. It is not clear how financial and technical assistance to high tobacco-burden LMICs can most effectively accelerate the implementation of WHO FCTC policies and offer value for money. Bespoke and responsive assistance, both financial and technical, to LMICs aimed at accelerating the implementation of WHO FCTC policies are likely to lead to progress in tobacco control.

Comparative Evaluation of Load-Bearing Capacity and Fracture Analysis of PEEK and Zirconia Three-Unit Fixed Dental Prostheses: An In Vitro Study.

PURPOSE: The purpose of this exploratory in vitro study was to compare and evaluate the load-bearing capacity (LBC) of ceramic-veneered zirconia and composite-veneered polyetheretherketone (PEEK) three-unit fixed dental prostheses (FDPs) with and without thermocycling (TC). MATERIALS AND METHODS: The study included 40 samples of three-unit FDPs replacing mandibular first molars. The four groups included were: ceZIR (feldspathic ceramic-layered zirconia), ceZIR TC (feldspathic ceramic-layered thermocycled zirconia), cPEEK (composite-layered PEEK), and cPEEK TC (composite-layered thermocycled PEEK) (n = 10 per group). All frameworks were CAD/CAM milled. Ten PEEK and 10 zirconia samples were subjected to TC (6,000 cycles). All 40 FDP specimens were loaded by applying static load, using a universal testing machine. The maximum load required to fracture the specimens denoted the LBC. The comparison of LBC between the four groups was done by using two-way ANOVA with Tukey's post-hoc analysis (α = .05). RESULTS: There was no statistically significant difference between LBC of cPEEK and ceZIR (P > .001) without thermal aging. LBC values decreased considerably for thermally aged specimens. Statistically significant differences were observed between LBC of cPEEK TC and ceZIR TC (P < .001), cPEEK TC and cPEEK (P < .001), and ceZIR TC and ceZIR (P = .001). On fracture analysis, cPEEK showed delamination failures whereas ceZIR displayed catastrophic connector fractures. CONCLUSION: This comparative evaluation offers preliminary data highlighting substantial depreciation in the LBC of layered PEEK under simulated intraoral conditions, thus raising a question regarding the clinical longevity of layered PEEK multi-unit restorations. In contrast, feldspathic-layered zirconia can be suitable for use in posterior FDPs.

Banning Loose Cigarettes and Other Tobacco Products in India: A Policy Analysis.

BACKGROUND: Sale of single cigarettes (also known as singles or loosies) is a key driver for early initiation of smoking and is a leading contributor to the smoking epidemic in India. Sale of singles additionally deter implementation of tobacco control strategies of pictorial health warnings including plain packaging and defeat effective taxation and promote illicit trade. We review India's tobacco control policy responses towards banning singles and other products sold as loose tobacco and identify opportunities for future policy intervention especially in the context of the ongoing COVID-19 pandemic. METHODS: Existing national and sub-national policy documents were analyzed for their content since the inception of the tobacco control laws in the country. RESULTS: There are no effective provisions at national level to ban loose tobacco products in India. However, the implementation of multiple legislative and regulatory measures (Acts/circulars/letters/notifications/orders/court judgements) in 16 Indian states and jurisdictions provide sufficient legal framework to substantiate its complete ban pan India. While the majority of state governments have adopted state level measures, Rajasthan had issued specific directive to all the 33 districts banning loose cigarettes and other tobacco products. Himachal Pradesh introduced the most unique and comprehensive legislation, for banning the sale of cigarettes and beedis (Dated November 7, 2016). The most recent notification in the state of Maharashtra (September 24, 2020) is the first to leverage powers using a mix of national and state legislations including the legislation addressing the rapidly emerging challenge of managing COVID-19. CONCLUSION: A robust national policy which supports strong provision to deter tobacco companies, their distribution network and vendors from selling singles or loose tobacco products is urgently needed. Such policy should be backed by cautionary messaging for consumers as well. Eliminating singles and loose tobacco sale will help in blunting tobacco use prevalence besides curbing spread of infectious diseases like COVID-19 pandemic.

Role and influence of growth factors on early osseointegration in animal jaw bone: A meta-analysis.

AIM: Growth factors (GFs) are polypeptides, which are intricately involved in the regulation of bone formation, preservation, and regeneration through gene expression. However, the role of these bioactive agents in osseointegration of dental implants has not been substantially proven. The objective of this systematic review (SR) and meta-analysis was to explore the effect of GFs on early osseointegration of dental implants in animal jaws. An attempt to decipher an adjunctive role of GFs in modulating predictable bone growth in peri-implant areas was done. MATERIALS AND METHODS: An electronic and manual search of different databases was performed. Only randomized controlled trials (RCTs) were included and reviewed. The risk of bias (ROB) of the selected studies was assessed using the SR Centre for Laboratory Animal Experimentation (Cochrane) tool. A meta-analysis was also performed to evaluate the different study characteristics quantitatively. STATISTICAL ANALYSIS USED: The total Weighted mean difference was evaluated using the Rev-Manv5.3 algorithm. Chi-square test and I2 test were done to assess the heterogeneity between the studies. RESULTS: Seven RCTs were included in the study. These were associated with a high ROB. The total weighted mean difference (WMD) of the percentage of bone-implant contact was 3.25% (95% confidence interval [CI] = 1.49%-6.03%; P = 0.001; I2 = 91%) between groups with and without exogenous application of GFs. The total WMD of the percentage of newly formed bone area was 4.48% (95% CI = 2.31%-5.90%; P < 0.00001, I2 = 84%). A high level of heterogeneity (P < 0.001 for Chi-square test; I 2>50 %) among comparable studies was observed. CONCLUSION: The ancillary application of external GFs exhibited evidence of early osseointegration, resulting in more predictable and faster results. However, a careful discernment of conclusions drawn from this SR is a must before conducting any human trials.

Afghan Frontier: Understanding Tobacco Practices among Migrant Population in India.

BACKGROUND: According to the World Refugee Survey by US Committee for Refugees and Immigrants, migrants from Afghanistan constitute the 4th largest group of migrants to India. No previous study has been conducted to assess the tobacco consumption status and pattern among this marginalised migrant population. AIM: To get an insight of the tobacco usage pattern, accessibility and attitude towards tobacco cessation among the migrant population from Afghanistan. METHODOLOGY: A cross-sectional study was conducted among a convenience sample of Afghan tobacco users residing in Delhi, India in the month of June 2017. A close-ended self-administered validated questionnaire in Persian language was distributed at local cafés and restaurants. STATISTICAL ANALYSIS: Data was entered in MS Excel Spreadsheet and descriptive statistics using SPSS version 21 were carried out. RESULTS: A total of 127 male Afghan tobacco users with mean age of 33.49± 11.97 years completed the questionnaire. Better work opportunities were the most common reason for migration. Most of them (69%) smoked tobacco and 15.5% used only Naswar. Half (52%) of the respondents continue to use tobacco products manufactured in Afghanistan with 62% procuring the product through social means (friends/family). On assessing barriers to tobacco use, majority (85%) found higher cost of tobacco products to be a deterrent while19% agreed lack of availability to be a barrier. 50% felt that law enforcement and tobacco use regulation in India curbed their tobacco use. Tobacco usage was a stress buster for 64% of the respondents. Although 72% were interested in quitting tobacco, 58% feared losing friends if they quit. Strikingly, 93% were unaware about the availability of cessation services. CONCLUSION: Even as Afghans migrate from their homeland, they carry their cultural and social practices with them, including tobacco products, patterns and practices.

Prevalence, patterns and sociocultural factors associated with use of tobacco-based dentifrices (Gul) in India.

BACKGROUND: India poses a novel tobacco problem with majority of the tobacco users consuming smokeless form of tobacco (21.4%). Gul is one such Smokeless Tobacco (ST) product that is manufactured commercially as a dentifrice to be applied to the teeth and then to gums many times during the day, making it a cheap and easy tobacco source. Hence, the aim of the present study was to estimate the usage of Gul and its social determinants among adults in the capital city of India, Delhi. METHODS: The cross-sectional study was conducted among 1300 adults across 27 Delhi government dispensaries across 3 districts of Delhi through multistage stratified random sampling. A structured, close-ended, validated questionnaire inquiring about the tobacco practices was used for all the participants and a specially constructed, structured, close-ended, validated proforma was used for Gul users to assess practice and pattern of use. RESULTS: The overall prevalence of Gul users was found to be 4.9% with a mean usage duration of 6.28 ± 6.75 years. The usage was found to be more among males (67.7%) and unskilled workers (45.2%). 74.9% started using Gul to treat dental pain with 93.47% of them reporting pain relief. CONCLUSION: Gul usage is an emerging menace in Delhi. Awareness programs and initiatives are the need of the hour to bring this tobacco product under the tobacco control policy radar and at the same time educate people about the actual contents and ill effects of Gul usage.

Bacterial contamination of packaged smokeless tobacco sold in India.

INTRODUCTION: About 21.4% of India's population uses smokeless tobacco products (SLT), yet limited data are available on their microbial contamination. To understand the potential microbiological risks associated with SLT use, the present study aims to investigate bacterial contamination of tobacco and the types of microbes that could be cultured from SLT products. METHODS: Twenty-two brands of SLT products, including paan masala, khaini, gutka and tobacco-containing dentifrices were examined and cultured by using appropriate selective and differential media including MacConkey agar and CLED agar. This was followed by a sequence of further identification by biochemical tests. RESULTS: All 22 types of SLT products showed growth of aerobic bacteria. The most common bacteria isolated were Pseudomonas aeruginosa followed by Streptococcus faecalis. Other bacteria that were isolated from products, in traces, included Klebsiella spp., E. coli, and Bacillus subtilus. CONCLUSIONS: This study raises and addresses the issue of bacterial contamination of packaged SLT products. SLT users might be subjected to a significant health hazard, especially those who are immunocompromised.