Discovery, development, and deployment of a user-centered point-of-care digital information system to treat and track hypertension and diabetes patients under India Hypertension Control Initiative 2019-2022, India.

Background: Hypertension affects 28.5% of Indians aged 18-69. Real-time registration and follow-up of persons with hypertension are possible with point-of-care digital information systems. We intend to describe herein the experiences of discovering, developing, and deploying a point-of-care digital information system for public health facilities under the India Hypertension Control Initiative. Methods: We have adopted an agile and user-centered approach in each phase in selected states of India since 2017. A multidisciplinary team adopted a hybrid approach with quantitative and qualitative methods, such as contextual inquiries, usability testing, and semi-structured interviews with healthcare workers, to document and monitor utility and usability. Results: During the discovery phase, we adopted a storyboard technique to understand the requirement of a digital information system. The participatory approach in discovery phase co-designed the information system with the nurses and doctors at Punjab state of India. Simple, which is the developed information system, has a front-end Android mobile application for healthcare workers and a backend dashboard for program managers. As of October 2022, over 24,31,962 patients of hypertension and 8,99,829 diabetes were registered in the information system of 10,017 health facilities. The median duration of registering a new patient was 50 seconds, and for recording a follow-up visit was 14 seconds in the app. High satisfaction was reported in 100 app users' quarterly interviews. Conclusion: Simple was implemented by administering a user-centered approach and agile techniques. It demonstrated high utility and usability among users, highlighting the benefits of a user-centered approach for effective digital health solutions.

Face mask use in the city of Chennai, India: Results from three serial cross-sectional surveys, 2021.

INTRODUCTION: The Government of Tamil Nadu, India, mandated wearing face masks in public places to combat the COVID-19 pandemic. We established face mask surveillance and estimated the prevalence of appropriate mask use (covering the nose, mouth, and chin) in the slums and non-slums of Chennai at different time points in 2021. METHODS: We conducted three serial cross-sectional surveys in the outdoors and indoors of Chennai in March, July, and October 2021. We observed the mask wearing among 3200 individuals in the outdoors and 1280 in the indoors. We divided the outdoor and indoor locations into slums and non-slums. In October 2021, we also surveyed 150 individuals from each of the 11 shopping malls in the city. We calculated the proportions and 95% confidence interval (95%CI) for the appropriate mask use in the outdoor, indoor, and malls by age, gender, region, and setting (slum and non-slum). RESULTS: We observed 3200 individuals in the outdoor and 1280 individuals in the indoor setting, each from a slum and non-slum, during the three rounds of the study. In outdoor and indoors, males comprised three-fourths and middle-aged individuals were half the study population. Mask compliance changed significantly with time (p-value <0.001). Males consistently demonstrated better compliance in all rounds. The south region had the highest mask compliance in slums indoors and outdoors in rounds 4 and 5. Young adults had the highest mask compliance in both outdoor slums and non-slums in all rounds. Overall mask compliance in shopping malls was 57% (95% CI: 48-65). CONCLUSION: The mask compliance in Chennai outdoors during the COVID-19 pandemic was less than 50%, with variations across time points by gender, age groups, and geographical locations. We must develop more effective communication strategies for older age groups and crowded indoor settings.

India Hypertension Control Initiative: Blood Pressure Control Using Drug and Dose-Specific Standard Treatment Protocol at Scale in Punjab and Maharashtra, India, 2022.

Background: Hypertension treatment coverage is low in India. A stepwise simple treatment protocol is one of the strategies to improve hypertension treatment in primary care. We estimated the effectiveness of various protocol steps to achieve blood pressure (BP) control in public sector health facilities in Punjab and Maharashtra, India, where the India Hypertension Control Initiative (IHCI) was implemented. Methods: We analyzed the records of people enrolled for hypertension treatment and follow-up under IHCI between January 2018 and December 2021 in public sector primary and secondary care facilities across 23 districts from two states. Each state followed a different treatment protocol. We calculated the proportion with controlled BP at each step of the protocol. We also estimated the mean decline in BP pre- and post-treatment. Results: Of 281,209 patients initiated on amlodipine 5 mg, 159,292 continued on protocol drugs and came for a follow-up visit during the first quarter of 2022. Of 33,450 individuals who came for the follow-up in Punjab and 125,842 in Maharashtra, 70% and 76% had controlled BP, respectively, at the first step with amlodipine 5 mg. In Punjab, at the second step with amlodipine 10 mg, the cumulative BP control increased to 75%. A similar 5% (76%-81%) increase was seen in the second step after adding telmisartan 40 mg in Maharashtra. Overall, the mean (SD) systolic blood pressure (SBP) decreased by 16 mmHg from 148 (15) mmHg at the baseline in Punjab. In Maharashtra, the decline in the mean (SD) SBP was about 15 mmHg from the 144 (18) mmHg baseline. Conclusion: Simple drug- and dose-specific protocols helped achieve a high control rate among patients retained in care under program conditions. We recommend treatment protocols starting with a single low-cost drug and escalating with the same or another antihypertensive drug depending on the cost and availability.

Rapid assessment of coverage of doxycycline/azithromycin chemoprophylaxis against leptospirosis following floods, Kozhikode district, Kerala, 2018.

BACKGROUND: We estimated coverage of doxycycline chemoprophylaxis (200 mg once weekly) following floods in Kerala, India. METHODS: A cross-sectional survey was conducted to gather data on exposure to flood or stagnant water and receipt and consumption of chemoprophylaxis. RESULTS: Of 1573 individuals interviewed, 152 (10%) were exposed to flood water. Among these, 119 (78%) were eligible for chemoprophylaxis. Of those eligible, 58 (38.2% [95% confidence interval 30.8 to 46.1]) reported consuming the prescribed chemoprophylaxis. CONCLUSIONS: Despite the availability of chemoprophylaxis, consumption was less than ideal. We recommend targeted interventions to improve chemoprophylaxis coverage and public awareness campaigns to enhance its consumption among the affected population.

Implementation of a Triage Protocol Outside the Hospital Setting for Timely Referral During the COVID-19 Second Wave in Chennai, India.

India experienced a surge in COVID-19 cases during the second wave in the period of April-June 2021. A rapid rise in cases posed challenges to triaging patients in hospital settings. Chennai, the fourth largest metropolitan city in India with an 8 million population, reported 7564 COVID-19 cases on May 12, 2021, nearly 3 times higher than the number of cases in the peak of COVID-19 in 2020. A sudden surge of cases overwhelmed the health system. We had established standalone triage centers outside the hospitals in the first wave, which catered to up to 2500 patients per day. In addition, we implemented a home-based triage protocol from May 26, 2021, to evaluate patients with COVID-19 who were aged ≤45 years without comorbidities. Among the 27,816 reported cases between May 26 and June 24, 2021, a total of 16,022 (57.6%) were aged ≤45 years without comorbidities. The field teams triaged 15,334 (55.1%), and 10,917 (39.2%) patients were evaluated at triage centers. Among 27,816 cases, 19,219 (69.1%) were advised to self-isolate at home, 3290 (11.8%) were admitted to COVID-19 care centers, and 1714 (6.2%) were admitted to hospitals. Only 3513 (12.7%) patients opted for the facility of their choice. We implemented a scalable triage strategy covering nearly 90% of the patients in a large metropolitan city during the COVID-19 surge. The process enabled early referral of high-risk patients and ensured evidence-informed treatment. We believe that the out-of-hospital triage strategy can be rapidly implemented in low-resource settings.

Syndromic surveillance system during mass gathering of Panchkroshi Yatra festival, Ujjain, Madhya Pradesh, India.

Background: The health implications surrounding a mass gathering pose significant challenges to public health officials. The use of syndromic surveillance provides an ideal method for achieving the public health goals and objectives at such events. In the absence of published reports of systematic documentation of public health preparedness in mass gatherings in the local context, we describe the public health preparedness and demonstrate the operational feasibility of a tablet-based participatory syndromic surveillance among pilgrims during the annual ritual circumambulation- Panchkroshi Yatra. Methods: A real-time surveillance system was established from 2017-2019 to capture all the health consultations done at the designated points (medical camps) in the Panchkroshi yatra area of the city Ujjain in Madhya Pradesh. We also surveyed a subset of pilgrims in 2017 to gauge satisfaction with the public health measures such as sanitation, water, safety, food, and cleanliness. Results: In 2019, injuries were reported in the highest proportion (16.7%; 794/4744); most numbers of fever cases (10.6%; 598/5600) were reported in 2018, while 2017 saw the highest number of patient presentations of abdominal pain (7.73%; 498/6435). Conclusion: Public health and safety measures were satisfactory except for the need for setting up urinals along the fixed route of the circumambulation. A systematic data collection of selected symptoms among yatris and their surveillance through tablet could be established during the panchkroshi yatra, which can complement the existing surveillance for detecting early warning signals. We recommend the implementation of such tablet-based surveillance during such mass gathering events.

Experiences, Challenges, and Lessons Learned During Implementation of a Remote Monitoring Program for Home-Isolated COVID-19 Patients in Chennai, India.

During the early months of the COVID-19 pandemic in 2020, the majority of the identified COVID-19 patients in Chennai, a southern metropolitan city of India, presented as asymptomatic or with mild clinical illness. Providing facility-based care for these patients was not feasible in an overburdened health system. Thus, providing home-based clinical care for patients who were asymptomatic or with mild clinical illnesses was a viable solution. Because of the imminent possibility of worsening clinical conditions in home-isolated COVID-19 patients, continuous monitoring for red flag signs was essential. With growing evidence of the effectiveness of remote monitoring of patients, the Greater Chennai Corporation in partnership with the National Institute of Epidemiology conceptualized and implemented a remote monitoring program for home-isolated COVID-19 patients. The key steps used to develop the program were to (1) decentralize triage systems and establish a home-isolation protocol, (2) develop a remote monitoring platform and remote health care workforce, and (3) onboard patients and conduct remote hybrid monitoring. In this article, we share the pragmatic solutions, critical components of the systems and processes, lessons, and experiences in implementing a remote monitoring program for home-isolated COVID-19 patients in a large metropolitan setting.

Health-seeking behaviour and its determinants of health of Under-5 Children living in urban slums of Chennai, India 2018.

Background: Appropriate health-seeking behaviour could help in reducing child mortality and morbidity. Information on social factors of mortality and health-seeking behaviours of caregivers of under-5 children from slums of Indian cities is minimal in literature. Objectives: We estimated the prevalence of health-seeking behaviour for morbidity ofunder-5 children and its determinants in urban slums in Chennai city, India. Methods: A cross-sectional study was conducted using a mixed-method design among primary caregivers of under-5 children living in Chennai slums, India. Two-stage cluster sampling was adopted to select 40 slums. A total of 233 primary caregivers were interviewed. Nine focus group discussions and 18 in-depth interviews were conducted among the primary caregivers. Prevalence of inappropriate health-seeking behaviour was estimated, and determinants were identified by multivariate binary logistic regression analysis. Thematic analysis was done on qualitative data. Results: We interviewed 233 primary caregivers. The weighted prevalence of inappropriate health-seeking behaviour for under-five children in urban slums of Chennai was 53.9% (95% CI: 46.9 - 60.8). Primary caregivers educated above secondary school were more likely (AOR of 2.3, 95% CI: 1.3-4.1) to follow inappropriate health-seeking behaviour compared to those educated below. Similarly, caregivers who were unaware of young child feeding practices (AOR of 3.6, 95% CI: 1.9-6.5) and early care-seeking and health practices (AOR of 2.5, 95% CI: 1.3-4.9) were more likely to engage in inappropriate health-seeking behaviour compared to those who were aware and we found that illness symptoms influenced health-seeking behaviour and that early disease detection might prevent severe illness. Conclusion: Health-seeking behaviour was found to be suboptimal among under-5 children in Chennai's urban slums. We suggest policymakers improve interventions on early care-seeking of common childhood illnesses in the urban health programme.

Knowledge, attitude, and practice towards face mask use among residents of Greater Chennai Corporation, India, March 2021.

Background: Wearing a mask is one of the simplest ways to reduce the spread of COVID-19. Studies reported poor mask compliance in Greater Chennai Corporation, India. Hence, we described the knowledge, attitude, and practice regarding mask use among adults (≥18 years) in Greater Chennai Corporation, Tamil Nadu, India. Methods: We conducted a cross-sectional survey among residents of Greater Chennai Corporation in March 2021. We estimated the sample size to be 203 per strata (slum and non-slum). We used a simple random sampling technique to select 20 locations using a digital map in the slum and non-slum areas. After reaching the location chosen, we selected 10 consecutive households and one adult (≥18 years of age) from each household. We used a validated, semi-structured questionnaire for collecting data regarding knowledge, attitudes, and practices for mask use. We estimated proportions and 95% CI for key variables and compared the variables between slums and non-slums. Results: Of 430 participants included in the study, 51.4% were males. The mean (S.D.) age of the participants is 41.1 (14.6) years. The majority (86.7%) of the participants felt that wearing a mask helped in reducing the spread of coronavirus and the knowledge differed (p-value < 0.05) between the slum (81.4%) and non-slum (92.3%). Nearly half (46.5%) of the participants did not like being forced to wear the mask. About 63.9% of the participants reported the practice of mask use while going out which was similar across slums and non-slums. Conclusion: Although the knowledge regarding mask use was good among the public, the attitude was unfavorable. We suggest continuous reinforcement by spreading awareness and educating the community on the appropriate use of the mask.

Case report: An outbreak of viral conjunctivitis among the students and staff of visually impaired school, Tamil Nadu, India, 2020.

Introduction: On February 2, 2020, the head of a visually impaired school notified similar eye symptoms among the students. We investigated the cluster to confirm the diagnosis, identify potential exposures, and propose recommendations. Methodology: We defined a case as redness/watering/discharge from any eye among the students and staff, January-February 2020. We actively searched for the cases and calculated attack rates. We drew epicurve by date of symptoms onset. We conducted a retrospective cohort study of students and staff. We collected data on potential exposures and calculated Risk Ratio (RR), 95% Confidence Interval (95%CI), and Population Attributable Risk (PAR). We sent a conjunctival swab of the three cases for microbiological analysis. Results: We diagnosed the cases as acute conjunctivitis and identified 39 (76%) cases among 51 individuals. All the 39 cases reported watering and redness; 28 (72%) and 12 (31%) reported eye pain and discharge, respectively. The median age of the case was 11 years (range: 6-48 years). The attack rate didn't differ significantly between males [77% (20/26)] and females [76% (19/25), p = 0.9]. The attack rate was higher among the students [86%, (38/44)] than staffs [14%, (1/7), p = <0.01]. Contact with a case [RR = 2.5, 95%CI = 1.3-4.8, PAR = 51%] and staying inside campus [RR = 6.0, 95%CI = 1.0-37.3, PAR = 81%] were associated with the acute conjunctivitis outbreak. All the three conjunctival swabs were negative for bacterial growth. Conclusion: Close contact with the case and staying inside the campus led to the outbreak of acute conjunctivitis among the students and staff of the visually impaired school.

Effectiveness of the ChAdOx1 nCoV-19 Coronavirus Vaccine (CovishieldTM) in Preventing SARS-CoV2 Infection, Chennai, Tamil Nadu, India, 2021.

We estimated the effectiveness of two doses of the ChAdOx1 nCoV-19 (Covishield) vaccine against any COVID-19 infection among individuals ≥45 years in Chennai, Tamil Nadu, India. A community-based cohort study was conducted from May to September 2021 in a selected geographic area in Chennai. The estimated sample size was 10,232. We enrolled 69,435 individuals, of which 21,793 were above 45 years. Two-dose coverage of Covishield in the 18+ and 45+ age group was 18% and 31%, respectively. Genomic analysis of 74 out of the 90 aliquots collected from the 303 COVID-19-positive individuals in the 45+ age group showed delta variants and their sub-lineages. The vaccine's effectiveness against COVID-19 disease in the ≥45 age group was 61.3% (95% CI: 43.6-73.4) at least 2 weeks after receiving the second dose of Covishield. We demonstrated the effectiveness of two doses of the ChAdOx1 vaccine against the delta variant in the general population of Chennai. We recommend similar future studies considering emerging variants and newer vaccines. Two-dose vaccine coverage could be ensured to protect against COVID-19 infection.

Sudden deaths due to accidental leakage of Lindane from a storage tank in a village, Sitapur, Uttar Pradesh, India, 2020: A field epidemiological investigation.

Background: Chemical leakages cause devastating health effects on humans. On 6 February 2020, seven deaths were reported following a hazardous chemical leakage in a village in Uttar Pradesh, India. We investigated the event to identify the cause and propose recommendations. Methods: We defined a case as sudden onset of breathlessness, headache, or death in the village, 6-7 February 2020. We conducted a house-to-house case search and calculated attack rate (AR) and case-fatality rate (CFR) by age and gender. We conducted an environmental investigation at the leakage site and sent the chemicals for forensic analysis. We obtained the cause of death through autopsy reports. Results: Out of 2,942 residents, we identified 23 cases (AR = 8/1,000) and seven deaths (CFR = 30%). The median age of the case was 42 years (range, 2-64 years). The AR was higher among males (14/1,000 [19/1,402]). All the 23 case-patients who were sleeping at the chemical leakage site or visited to witness the event developed symptoms, and all seven cases who were sleeping within 150 meters of the leakage site died. The environmental investigation revealed leakage of hazardous substances from the storage tank. Toxicology analysis confirmed the leaked chemical as Lindane (gamma-hexachlorocyclohexane), and autopsy reports confirmed the cause of death as asphyxia. Conclusions: Asphyxia following the leakage of Lindane from the storage tank possibly led to sudden deaths. We recommend using leak-proof tanks to ensure safe storage and disposal, law enforcement, and regulations to prevent people from staying close to chemical storage sites.

"Design and implementation challenges of massive open online course on research methods for Indian medical postgraduates and teachers -descriptive analysis of inaugural cycle".

BACKGROUND: In view of the growing popularity, reach and access for Massive Open Online Courses (MOOCs), India's apex body for medical education, the National Medical Commission (NMC) mandated uniform foundational course on research methods for the medical post graduates (PGs) and faculty members of the medical institutions under NMC as MOOC. This course is a pioneering effort in the field of India's PG medical education. NMC entrusted Indian Council of Medical Research (ICMR)-National Institute of Epidemiology (NIE) to design and offer the MOOC, named as Basic Course in Biomedical Research (BCBR). We describe the experience of designing and that of implementation challenges in the inaugural cycle of the course. METHODS: The course objective was to inculcate the fundamental concepts in research methods covering epidemiology and biostatistics in the form of video lectures, resource materials, discussion forum, assignments, feedback and a final proctored examination. The course was delivered over 16 weeks through MOOCs platform under the Indian Ministry of Education. We reviewed records, documents and faculty notes and described the course conceptualization, development, design and implementation process. We abstracted information from course portal on enrolment profile of the participants, self-reported course feedback (structured and open-ended on format, lectures and quality of contents), examination registration form, scores obtained in the assignments/examination and that of the participant queries. We described quantitative data using descriptive statistics. We presented the thematic analysis of qualitative data from open-ended questions in the feedback system and that of email interactions. RESULTS: The inaugural cycle (September-December 2019) was taken by 24,385 participants. Majority, 15,879 (65%) were from medical background. 13,242 (54%) were medical postgraduates and 2637 (11%) were medical teachers. Among the enrolled, 14,720 (60%) cleared the assignments. A total of 11,392 (47%), 8,205 (62%) medical PGs and 896 (34%) faculty members successfully completed the course. Feedback from 1305 (5%) participants had mean score of 4.5/5 (±0.7) for quality of teaching. We faced challenges in customizing the course for medical participants, unawareness among target group, digital illiteracy and the ongoing pandemic. CONCLUSIONS: During the inaugural cycle of the online Basic Course in Biomedical Research course, nearly half of the enrolled participants successfully completed and received the certificate. India's MOOC for enhancing research capabilities of future medical researchers encountered successes and challenges. Lessons learnt from the inaugural cycle will guide future directions and to address larger issues in terms of sustainability and replication by stakeholders in medical education in India or elsewhere.

Do unmanned aerial vehicles reduce the duration and costs in transporting sputum samples? A feasibility study conducted in Himachal Pradesh, India.

BACKGROUND: The feasibility of and advantages of using an unmanned aerial vehicle (UAV) for sputum transportation for TB in Chamba, Himachal Pradesh, India, were evaluated. METHODS: We conducted a non-randomized interventional study and compared the advantages of sputum transport between UAVs and motorbikes (conventional). RESULTS: We completed 151 transportations. Transportation by UAV (7.1±0.8 min) was faster than by motorbike (22.7±4.6 min, p<0.001). Motorbikes covered a greater distance (12.09±1.6 km) than UAVs (2.89±0.35 km, p<0.001). The recurrent cost per transport using an UAV (US${\$}$0.68) was less than by motorbike (US${\$}$1.4). All 26 stakeholders agreed that UAVs would reduce the turnaround time for diagnosis of drug-resistant TB. CONCLUSIONS: Sputum transportation by UAVs was feasible, cheaper and an efficacious potential alternative to conventional modes of transportation.

Effectiveness of ChAdOx1 nCoV-19 Corona Virus Vaccine (CovishieldTM) in preventing SARS-CoV2 infection, Chennai, Tamil Nadu, India, 2021

BackgroundIndia experienced the second wave of the COVID-19 pandemic in March 2021, driven by the delta variant. Apprehensions around the usefulness of vaccines against delta variant posed a risk to the vaccination program. Therefore, we estimated the effectiveness of two doses of the ChAdOx1 nCoV-19 (Covishield) vaccine against COVID-19 infection among individuals [≥]45 years in Chennai, India. MethodsA community-based cohort study was conducted from May to September 2021 in a selected geographic area in Chennai, Tamil Nadu. The estimated sample size was 10,232. We enumerated individuals from all eligible households and periodically updated vaccination and COVID-19 infection data. We computed vaccine effectiveness with its 95% confidence interval for two doses of the Covishield vaccine against any COVID-19 infection. ResultsWe enrolled 69,435 individuals, of which 21,793 were above 45 years. Two dose coverage of Covishield in the 18+ and 45+ age group was 18% and 31%, respectively. The overall incidence of COVID-19 infection was 1099 per 100,000 population. The vaccine effectiveness against COVID-19 disease in the [≥]45 age group was 61.3% (95% CI: 43.6 - 73.4) at least two weeks after receiving the second dose of Covishield. Genomic analysis of 74 (28 with two doses, 15 with one dose, and 31 with zero dose) out of the 90 aliquots collected from the 303 COVID-19 positive individuals in the 45+ age group showed delta variants and their sub-lineages. ConclusionWe demonstrated the effectiveness of two doses of the ChAdOx1 vaccine against the delta variant in the general population of Chennai. We recommend similar future studies considering emerging variants and newer vaccines. Two-dose vaccine coverage could be ensured to protect against COVID-19 infection.

Epidemiology of COVID-19 and effect of public health interventions, Chennai, India, March-October 2020: an analysis of COVID-19 surveillance system.

OBJECTIVES: To describe the public health strategies and their effect in controlling the COVID-19 pandemic from March to October 2020 in Chennai, India. SETTING: Chennai, a densely populated metropolitan city in Southern India, was one of the five cities which contributed to more than half of the COVID-19 cases in India from March to May 2020. A comprehensive community-centric public health strategy was implemented for controlling COVID-19, including surveillance, testing, contact tracing, isolation and quarantine. In addition, there were different levels of restrictions between March and October 2020. PARTICIPANTS: We collected the deidentified line list of all the 192 450 COVID-19 cases reported from 17 March to 31 October 2020 in Chennai and their contacts for the analysis. We defined a COVID-19 case based on the real-time reverse transcriptase-PCR (RT-PCR) positive test conducted in one of the government-approved labs. OUTCOME MEASURES: The primary outcomes of interest were incidence of COVID-19 per million population, case fatality ratio (CFR), deaths per million, and the effective reproduction number (Rt). We also analysed the surveillance, testing, contact tracing and isolation indicators. RESULTS: Of the 192 450 RT-PCR confirmed COVID-19 cases reported in Chennai from 17 March to 31 October 2020, 114 889 (60%) were males. The highest incidence was 41 064 per million population among those 61-80 years. The incidence peaked during June 2020 at 5239 per million and declined to 3627 per million in October 2020. The city reported 3543 deaths, with a case fatality ratio of 1.8%. In March, Rt was 4.2, dropped below one in July and remained so until October, even with the relaxation of restrictions. CONCLUSION: The combination of public health strategies might have contributed to controlling the COVID-19 epidemic in a large, densely populated city in India. We recommend continuing the test-trace-isolate strategy and appropriate restrictions to prevent resurgence.

Syndromic surveillance during religious mass gatherings, southern India 2015-2018.

BACKGROUND: Mass gathering events carry a risk of public health emergencies such as outbreaks of infectious diseases, stampedes, and injuries and pose an increased risk for individuals with non-communicable diseases. India celebrates many festivals mass gatherings. However, operational research on syndromic surveillance during such events is limited. In this context, we documented the use of information technology tools for syndromic surveillance during selected mass gatherings in South India during 2015-2018. METHOD: We collaborated with health systems for syndromic surveillance during selected religious mass gatherings. We finalized priority syndromes and their surveillance definitions through stakeholder meetings. We used open-source software for surveillance data collection and trained the health care professionals and volunteers for data capture and collation. We consolidated, analyzed, generated near-real-time daily reports and shared them with health authorities for action. RESULTS: The number of participants in these mass gatherings ranged from 100 thousand to 3 million, and recorded out-patients seeking care for syndromic illness ranged from 4,000 to 25,000 per event. We used more than five platforms and captured information on 17 syndromes. We captured a total of 61,523 patient details during syndromic surveillance. The most frequently reported syndromes were injuries, fever, and diarrhea of the reported illness. CONCLUSIONS: These cost-effective open-source technologies are intuitive, adaptable, and inexpensive to maintain and operate in real-time. Therefore, enhanced syndromic surveillance could detect diseases early in mass gatherings.

Referral mechanism and beneficiary adherence in cervical cancer screening program in Tiruchirappalli district, Tamil Nadu state, India, 2012-2015.

Background: A screening program for cervical cancer was established in 2011 in Tamil Nadu. Since the inception of the program, coverage, and dropout of screening has not been analyzed. We conducted a study to describe the referral mechanism in the cervical cancer screening program implemented in Tamil Nadu, to estimate the level of adherence to the referral process by the beneficiaries, and to identify strengths and weaknesses related to the referral mechanism in the program. Methods: ">This descriptive study was conducted during 2015-2016 in the Tiruchirappalli administrative district of Tamil Nadu. All women aged 30 years and above, who were screened in public health facilities, were the participants. Using a structured form, we collected the data maintained in the registers at the district health administration. We estimated the screening coverage, follow-up evaluation, and dropout rates at different stages of the referral mechanism. We used SPSS and Epi Info software for analysis. Results: Coverage of cervical cancer screening was 4,838(41.6%). We estimated 4,838(41.6%) of screened positives were lost to follow-up for a colposcopy examination. Biopsy samples were obtained from 3425(84%) of those who required a biopsy. Cervical cancer was diagnosed in 159(4.6%) and precancerous lesions in 528(15.4%) women. Conclusion: More than half of the target population was screened in public health facilities. The dropout rate was less than half of those screened at the colposcopy evaluation level. Major pitfalls of the program were human resource issues at referral centers and poor maintenance of meaningful data.

Provision of the Continuum of Care to Noncommunicable Diseases Post-Floods in Kerala, India 2018.

Integrating noncommunicable disease (NCD) in health care delivery during emergency response posed a major challenge post-floods in Kerala. Kerala experienced an abnormally high rainfall during mid-2018 where more than 400 people lost their lives. State health officials and the Disaster Response Team were sensitized about the importance of including NCDs in the response action. More than 80% of patients with hypertension and diabetes were not under control in Kerala. Under the state NCD cell, an NCD expert group was consulted for drafting the treatment and referral strategies. Steps to tackle NCDs during the disaster response were formulated. The state NCD cell decided to integrate NCDs in the response measures. The technical guidance document by the World Health Organization South-East Asia Region was consulted to formulate actions. The activities were implemented in 6 steps: prioritizing of major NCDS, patient estimation and drug stock preparation, standard treatment protocol, mapping of referral facilities, public engagement, and daily reporting of NCD consultations. Prioritizing the continuum of care of NCDs during floods among the program managers and care providers was crucial. The health education and communication campaign was done to sensitize the known NCD patients to seek early care. Daily reporting of consultations was established.