Introducing double fortified salt in social safety net programmes in Madhya Pradesh and Gujarat in India: Success factors, challenges and lessons learned.

Double fortified salt (DFS; with iron and iodine) was introduced in social safety net programmes (SSNPs) in Madhya Pradesh (MP) and Gujarat states in 2018. Nutrition International (NI) provided critical support for the intervention. An impact evaluation in MP found high DFS uptake, exceeding 90%. Conduct a process evaluation of the DFS programmes in MP and Gujarat states to identify success factors, challenges, and recommend considerations for scale-up. Twenty-eight qualitative interviews were conducted with NI staff, national and state level government officials, and DFS producers in 2022. Enabling environmental factors included national-level support for food fortification, consensus that anaemia was essential to address, and institutional trust in NI for technical assistance. In programme implementation, the primary challenges were reports of black specks in DFS and the darkening of food cooked with DFS. NI supported the government in improving handling practices, ensuring a regular and stable supply, introducing quality monitoring efforts and launching targeted behaviour change communication (BCC) campaigns regarding the value of DFS. Long-term implementation of the programmes is a weak point, as DFS production is more expensive than iodised salt, there is no existing market outside of institutional demand, and BCC must be long-term, high-quality, and requires resourcing for continued high uptake among SSNP beneficiaries. Strong government buy-in and technical support along the supply chain to address quality issues and beneficiary acceptance were key factors for the successful introduction of DFS. Comparative studies of DFS programmes should be conducted to improve confidence in the success factors that lead to high DFS uptake.

National and Sub-National Estimates of Household Coverage of Iodized Salt and Urinary Iodine Status among Women of Reproductive Age in India: Insights from the India Iodine Survey, 2018-19.

BACKGROUND: Iodine deficiency is a significant public health problem for many populations worldwide, including India, particularly during the "first 1000 days" of life. Though Universal Salt iodization (USI) is mandatory in India, prior to 2018-19, there was no state-wide survey with estimates of iodine concentrations in salt using iodometric titration. Taking cognizance of this fact, Nutrition International commissioned the first-of-its-kind national-level survey in India, titled the India Iodine Survey 2018-19. OBJECTIVES: The study was conducted across the country to provide national and subnational estimates of iodine concentrations in household salt using iodometric titration and iodine nutrition status among women of reproductive age (15-49 y). METHODS: The survey adopted a multi-stage randomcluster probability proportional to size sampling design, covering 21,406 households in all the states and union territories (UTs) of India. RESULTS: At the national level, the household coverage of edible salt with adequate iodine (content ≥15 parts/million) was 76.3%. At the sub-national level, the coverage varied, with 10 states and 3 UTs achieving USI and 11 states and 2 UTs falling below the national average, with the highest among all the states and UTs, being Jammu and Kashmir and the lowest being Tamil Nadu. At the national level, the median urinary iodine concentration for pregnant women was 173.4 µg/L, for lactating women was 172.8 µg/L, and for non-pregnant, non-lactating women, it was 178.0 µg/L, which is within the adequate iodine nutrition range according to the WHO guidelines. CONCLUSIONS: The survey results can be widely used by various stakeholders, including government, academia, and industry, to understand the iodine nutrition status of the population, enable the scale-up of sustained efforts toward consolidating gains and achieving USI, leading to the reduction and elimination of Iodine Deficiency Disorders.

Public health supply chain for iron and folic acid supplementation in India: Status, bottlenecks and an agenda for corrective action under Anemia Mukt Bharat strategy.

PURPOSE: The IFA supplementation program under the Anemia Mukt Bharat (AMB) program is one of the most ambitious nutrient supplementation programs in India. The delivery of services often suffers due to frequent stock outs and shortages. It is critical to understand the bottleneck in the supply chain adversely affecting the performance and coverage of the program. The paper attempts to identify the bottlenecks of the IFA supply chain in key areas of supply chain i.e., forecasting, procurement, warehousing and inventory management, transportation, distribution, logistic information system and suggests a plan of action aimed at ensuring uninterrupted supplies to the end beneficiaries. DESIGN/METHODOLOGY/APPROACH: The data source for the present paper is the nationwide IFA Supply Chain Assessment (2018-19) conducted across 29 Indian states with a total of 58 districts, 116 blocks, 232 Sub-Centres, 232 Anganwadi centres and 232 schools covered under the assessment as a multi-partner collaborative initiative. Field insights from supply chain strengthening interventions under different public health programs in India and other developing countries were taken to arrive at corrective actions and recommendations. Findings were disseminated to government and an action plan was suggested for connecting service delivery points through an app-based system, developing a micro plan for ensuring fixed distribution schedule, followed by continuous monitoring and review meetings identified for follow up. FINDINGS: The average lead time across states was 35 weeks with top three performing states being Goa, Sikkim, and Telangana. The average per unit cost of procurement was Rs 0.35 for IFA Red, Rs 0.25 for IFA Blue, Rs 0.31 for IFA Pink and Rs 7.30 for IFA syrup. Out of the 704 districts in India, only 213 has IFA Red, only 140 had IFA Blue, 152 had IFA Pink and 163 had IFA Syrup available in four quarters of 2018-19. The key issues identified in the assessment were-a lack of standardized forecasting process, absence of inventory management techniques, no fixed distribution schedule, inadequate availability of transport vehicles and an absence of an integrated MIS. ORIGINALITY/VALUE: The identification of bottlenecks in the IFA supply chain and its impact on the performance of the supply chain would provide policy guidelines for the government as well as development partner agencies to design an effective and efficient supply chain. It would also enable the policy planners to understand the challenges associated with managing different components of a supply chain, their interrelation and impact on the overall performance of the supply chain. The suggested recommendations would equip program managers with the tool to devise and implement field level solutions.

Improving the approach to assess impact of anaemia control programs during pregnancy in India: a critical analysis.

Around 42.7% of women experience anaemia during pregnancy in low- and middle-income countries. Countries in southeast Asia (with prevalence ranging between 40 and 60%) have reported a modest decline over the past 25 years. Nearly half the pregnant women continue to be anaemic in India between 2005-06 and 2015-16, although severe anaemia has reduced from 2.2% to 1.3%.India has been committed to achieving a target of 32% prevalence of anaemia in pregnant women from 50% by 2022. There are concerns around stagnancy in the prevalence of anaemia in pregnancy despite a strong political commitment. The paper puts forth the arguments that should be considered while introspecting why India might run the risk of not achieving the expected reduction. The reported findings highlight several methodological issues such as hemoglobin cut-offs used to determine anaemia during pregnancy, method of estimation of Hb, and less emphasis on causes other than iron deficiency anemia.

Anaemia in Indians aged 10-19 years: Prevalence, burden and associated factors at national and regional levels.

Anaemia control programmes in India are hampered by a lack of representative evidence on anaemia prevalence, burden and associated factors for adolescents. The aim of this study was to: (1) describe the national and subnational prevalence, severity and burden of anaemia among Indian adolescents; (2) examine factors associated with anaemia at national and regional levels. Data (n = 14,673 individuals aged 10-19 years) were from India's Comprehensive National Nutrition Survey (CNNS, 2016-2018). CNNS used a multistage, stratified, probability proportion to size cluster sampling design. Prevalence was estimated using globally comparable age- and sex-specific cutoffs, using survey weights for biomarker sample collection. Burden analysis used prevalence estimates and projected population from 2011 Census data. Multivariable logistic regression models were used to analyse factors (diet, micronutrient deficiencies, haemoglobinopathies, sociodemographic factors, environment) associated with anaemia. Anaemia was present in 40% of girls and 18% of boys, equivalent to 72 million adolescents in 2018, and varied by region (girls 29%-46%; boys 11%-28%) and state (girls 7%-62%; boys 4%-32%). Iron deficiency (ferritin < 15 µg/L) was the strongest predictor of anaemia (odds ratio [OR]: 4.68, 95% confidence interval [CI]: [3.21,6.83]), followed by haemoglobinopathies (HbA2 > 3.5% or any HbS) (OR: 2.81, 95% CI: [1.66,4.74]), vitamin A deficiency (serum retinol <20 ng/ml) (OR: 1.86, 95% CI: [1.23,2.80]) and zinc deficiency (serum zinc < 70 µg/L) (OR: 1.32, 95% CI: [1.02,1.72]). Regional models show heterogeneity in the strength of association between factors and anaemia by region. Adolescent anaemia control programmes in India should continue to address iron deficiency, strengthen strategies to identify haemoglobinopathies and other micronutrient deficiencies, and further explore geographic variation in associated factors.

Evaluation of the Efficacy of Liposomal Bupivacaine in Total Joint Arthroplasty.

BACKGROUND: Appropriate pain control is one of the cornerstones necessary to promote positive clinical outcomes. A new bupivacaine liposomal formulation was designed to extend its analgesic effect for up to 72-hours post-surgery, reportedly leading to significant opioid-sparing. METHOD: Retrospective and prospective chart review conducted in a 178-bed academic institution between January 2013 to December 2013 and August 2014 to November 2014, in 115 patients that receive hip and knee arthroplasty. The primary outcome was the measurement of average daily pain score on post-operative days 1 and 2. Secondary outcomes included length of stay, overall opioid use post-surgery and pain control satisfaction using Press-Ganey® scores. RESULTS: The average pain scores in the HCl group were 4.64 and 4.38 (Likert score: 0-10) for POD 1 and POD 2, compared to 4.72 POD 1 and 4.2 POD 2 in the liposome group (POD 1: p = 0.413; POD 2: p = 0.303). The difference in LOS for knee arthroplasty was statistically significant [HCl group: 1.94 days (± 0.66) versus liposome group: 2.27 days (±0.77) p-value = 0.038)] favoring the standard of care. For hip arthroplasty or bilateral knee arthroplasty the differences in LOS were not statistically significant (p = 0.052 and p = 0.484 respectively). 93% of the patients in the HCl group, pain was well controlled, versus 88.5% in the liposome group with similar oxycodone IR use among groups. CONCLUSION: Liposome bupivacaine did not offer a notable benefit compared to the HCl formulation in our study.

Human Prostate Cancer Cells Secrete Neuro-Protective Factors in Response to Cryotherapy.

Cryoablation is one of the established treatment modalities for prostate cancer management. Although, it is target specific, it may still lead to damage to the nerve fibers around the prostate tumor. In this study, by directly exposing the co-cultures of prostate cancer cells, PC-3 and Schwann cell-Dorsal Root Ganglion neuron (SC-DRG) to cryo-shock and by exposing SC-DRG to cryo-shock conditioned media (CSCM) obtained from PC-3 cells, robust neuro-protective effects were observed. Since this neuro-protective effect originated from cryotherapy-treated PC-3 cells, the presence of putative factors secreted by PC-3 cells in the medium following cryo-shock was analyzed. Using human cytokine antibody array analysis, differential release of cytokines in CSCM was observed with induced release of cytokines involved in neuro-protection like IL-1α, MIP-4, MIP-5, Leptin, IL-15 and ICAM-1 with simultaneous inhibition of TNFRI and TNFRII that are implicated in killing of nerve cells. Further, using Matrix Assisted Laser Desorption/Ionization-Time Of Flight (MALDI-TOF) sequencing, two proteins were identified namely, CypA (cyclophilin A) and NM23 (nonmetastatic protein 23) in the CSCM. CypA functions as a mediator of intracellular as well as extracellular neuro-protective mechanisms and NM23 has been implicated as a potential suppressor protein of tumor metastasis. Thus, this study revealed the presence of factors in CSCM that has the potential to protect normal neuronal cells and suppress metastasis.