Pharmacoinformatics and molecular dynamics simulation approach to identify anti-diarrheal potentials of Centella asiatica (L.) Urb. against Vibrio cholerae.

Vibrio cholerae, the etiological agent of cholera, causes dehydration and severe diarrhea with the production of cholera toxin. Due to the acquired antibiotic resistance, V. cholerae has drawn attention to the establishment of novel medications to counteract the virulence and viability of the pathogen. Centella asiatica is a medicinal herb native to Bangladesh that has a wide range of medicinal and ethnobotanical applications including anti-bacterial properties. In the present investigation, a total of 25 bioactive phytochemicals of C. asiatica have been screened virtually through molecular docking, ADMET (Absorption, Distribution, Metabolism, Excretion, and Toxicity) analyses, and molecular dynamics simulation. Our results revealed four lead compounds as Viridiflorol (-8.7 Kcal/mol), Luteolin (-8.1 Kcal/mol), Quercetin (-8.0 Kcal/mol) and, Geranyl acetate (-7.1 Kcal/mol) against V. cholerae Toxin co-regulated pilus virulence regulatory protein (ToxT). All the lead compounds have been found to possess favorable pharmacokinetic, pharmacodynamics, and molecular dynamics properties. Toxicity analysis revealed satisfactory results with no major side effects. Molecular dynamics simulation was performed for 100 ns that revealed noteworthy conformational stability and structural compactness for all the lead compounds, especially for Quercetin. Target class prediction unveiled enzymes in most of the cases and some experimental and investigational drugs were found as structurally similar analogs of the lead compounds. These findings could aid in the development of novel therapeutics targeting Cholera disease and we strongly recommend in vitro trials of our experimental findings.Communicated by Ramaswamy H. Sarma.

Virtual screening reveals liquiritigenin as a broad-spectrum inhibitor of SARS-CoV-2 variants of concern: an in silico study.

The SARS-CoV-2 has severely impacted the lives of people worldwide. Global concern is on the rise due to a large number of unexpected mutations in the viral genome, resulting in new variants. Nature-based bioactive phytochemicals hold great promise as inhibitors against pathogenic viruses. The current study was aimed at evaluating some bioactive antiviral phytochemicals against SARS-CoV-2 variants of concern. A total of 46 phytochemicals were screened against the pathogenic spike protein of Alpha, Beta, Delta, Gamma, and Omicron variants. In addition to molecular docking, screening for favorable pharmacokinetic and pharmacodynamic properties such as absorption, distribution, metabolism, excretion, and toxicity was undertaken. For each of the aforementioned five SARS-CoV-2 variants of concern, a 100 ns molecular dynamics simulation was run to assess the stability of the complexes between their respective spike protein receptor-binding domain and the best-selected compound. From our current investigation, the natural compound liquiritigenin turned out to be the most promising potential lead compound against almost all the variants. These findings could pave the way for the development of effective medications against SARS-CoV-2 variants. However, in vivo trials in future studies are necessary for further validation of our results.Communicated by Ramaswamy H. Sarma.

COVID-19 and Bangladeshi health professionals: Infection status, vaccination and its immediate health consequences.

Healthcare professionals play a pivotal role in protecting and saving the lives of general people. As health workers are more likely to be infected with COVID-19, it is inevitable to safeguard them through vaccination in advance to continue healthcare services. Hence the study aimed to explore the infection and vaccination status along with immediate health consequences among these frontiers. This was a cross-sectional, web-delivered study conducted among the 300 healthcare frontiers working at COVID-19 dedicated hospitals in eight divisions of Bangladesh. The study questionnaire encompasses infection, vaccination status with dose information, and demographical and organizational information among the respondents. A multivariate logistic regression model and Chi-square test was used for the analytical exploration. Adjusted and Unadjusted Odds Ratio with a 95% confidence interval was calculated for the specified setting indicators. The study revealed that 49% of all respondents tested positive whereas 98% of them were found vaccinated of which mostly (52.3%) had their 2nddoses and 68.7% faced immediate health consequences for having the vaccination. As predictor for COVID-19 infection status, young and senior adult group (30-39 years: AOR = 2.01/0.03; 95% CI: 1.08-3.76; >50 years: AOR = 4.36/0.01; 95% CI: 1.65-11.55) and respondents who received Sinopharm as their vaccine found to have more significant positive infection history. The predictors regarding experiencing immediate health effects after vaccination, surprisingly female (AOR = 3.31/0.01; 95% CI: 1.82-6.04) health professionals of the capital city (AOR = 1.91/0.03; 95% CI: 1.06-3.46) were observed to have health consequences on vaccination. As the older female group (>50 years) in the nursing profession was found more infected with COVID-19 and a significant number of health professionals especially the age group (30-39 years) in the nursing profession experienced immediate health effects of COVID-19 vaccination, implementation of specific strategies and policies are needed to ensure the safety precaution and effective vaccination among the health professionals of Bangladesh.

An algorithmic approach to identifying the aetiology of acute encephalitis syndrome in India: results of a 4-year enhanced surveillance study.

BACKGROUND: Annual outbreaks of acute encephalitis syndrome pose a major health burden in India. Although Japanese encephalitis virus (JEV) accounts for around 15% of reported cases, the aetiology of most cases remains unknown. We aimed to establish an enhanced surveillance network and to use a standardised diagnostic algorithm to conduct a systematic evaluation of acute encephalitis syndrome in India. METHODS: In this large-scale, systematic surveillance study in India, patients presenting with acute encephalitis syndrome (ie, acute onset of fever with altered mental status, seizure, or both) to any of the 18 participating hospitals across Uttar Pradesh, West Bengal, and Assam were evaluated for JEV (serum and cerebrospinal fluid [CSF] IgM ELISA) per standard of care. In enhanced surveillance, JEV IgM-negative specimens were additionally evaluated for scrub typhus, dengue virus, and West Nile virus by serum IgM ELISA, and for Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis, dengue virus, herpes simplex virus, and enterovirus by CSF PCR across five referral laboratories. In 2017, chikungunya and Leptospira serum IgM by ELISA and Zika virus serum and CSF by PCR were also tested. FINDINGS: Of 10 107 patients with acute encephalitis syndrome enrolled in enhanced surveillance between Jan 1, 2014, and Dec 31, 2017, 5734 (57·8%) of 9917 participants with available data were male and 6179 (62·7%) of 9856 were children aged 15 years and younger. Among patients who provided a sample of either CSF or serum in enhanced surveillance, an aetiology was identified in 1921 (33·2%) of 5786 patients enrolled between 2014 and 2016 and in 1484 (34·3%) of 4321 patients enrolled in 2017. The most commonly identified aetiologies were JEV (1023 [17·7%] of 5786 patients), scrub typhus (645 [18·5%] of 3489), and dengue virus (161 [5·2%] of 3124). Among participants who provided both CSF and serum specimens, an aetiology was identified in 1446 (38·3%) of 3774 patients enrolled between 2014 and 2016 and in 936 (40·3%) of 2324 enrolled in 2017, representing a 3·1-times increase in the number of patients with acute encephalitis syndrome with an identified aetiology compared with standard care alone (299 [12·9%]; p<0·0001). INTERPRETATION: Implementation of a systematic diagnostic algorithm in an enhanced surveillance platform resulted in a 3·1-times increase in identification of the aetiology of acute encephalitis syndrome, besides JEV alone, and highlighted the importance of scrub typhus and dengue virus as important infectious aetiologies in India. These findings have prompted revision of the national testing guidelines for this syndrome across India. FUNDING: US Centers for Disease Control and Prevention.

Duration and Risk Factors of Post-COVID Symptoms Following Recovery Among the Medical Doctors in Bangladesh.

A large number of coronavirus disease 2019 (COVID-19) recovered patients are suffering from related symptoms. We conducted telephone interviews with 186 COVID-19 recovered medical doctors to determine the post-COVID symptoms, duration, and associated risk factors. About 70% of participants had at least one acute post-COVID symptom, including fatigue (43.0%), sleep disturbance (13.4%), lack of concentration (11.8%), breathing difficulty (10.2%), headache (6.5%), and muscle pain (6.5%). However, about 24% of participants reported having long post-COVID symptoms. Logistic regression analysis showed that female sex (odds ratio {OR}, 2.79; 95% CI, 1.28-6.06; p-value: 0.010) and comorbid conditions (OR, 2.28; 95% CI, 1.08-4.79; p: value, 0.030) are risk factors for the long post-COVID symptoms.

Population structure and diet generalism define a preliminary ecological profile of zoonotic virus hosts in the Western Ghats, India.

The rainforests of the Western Ghats exhibit some of the highest biodiversity on the planet, and yet are undergoing rapid land use change due to the expansion of agriculture and other industries. As the landscape of the region is transformed, more people are coming into conflict with wildlife and becoming exposed to pathogens that previously circulated beyond the boundaries of human incursion. Despite an ecological knowledge imperative, this emerging landscape is ill-defined with respect to the ecology of zoonotic viruses and their mammalian wildlife hosts. Without a better understanding of the underlying infection ecology, the epidemiology of viral spillover will remain elusive and unsuited to the task of predicting and preventing outbreaks. The current investigation explored the association between mammalian zoonotic virus richness and species-level landscape, life-history, and dietary traits to describe an initial ecological profile of zoonotic virus hosts in the Western Ghats. Social group composition and dietary forage were both non-linearly associated with greater zoonotic viral richness among these species, whereby species active in smaller social groups, albeit in higher population densities, and exhibiting a tendency toward a generalist diet hosted more zoonotic viruses. While these findings provide no definitive ecological demarcation of zoonotic virus hosts or their contribution to viral maintenance or amplification, it is expected that this preliminary profile can help to develop targeted wildlife pathogen surveillance programs and to expand the current approach to epidemiological modelling of emerging zoonoses in the region, which typically do not account for the macroecological parameters of infection transmission.

Highly Pathogenic Avian Influenza (H5N1) Landscape Suitability Varies by Wetland Habitats and the Degree of Interface between Wild Waterfowl and Poultry in India.

Highly pathogenic avian influenza (HPAI) virus, subtype H5N1, constitutes one of the world's most important health and economic concerns given the catastrophic impact of epizootics on the poultry industry, the high mortality attending spillover in humans, and its potential as a source subtype for a future pandemic. Nevertheless, we still lack an adequate understanding of HPAI H5N1 epidemiology and infection ecology. The nature of the wild waterfowl-poultry interface, and the sharing of diverse wetland habitat among these birds, currently underscore important knowledge gaps. India has emerged as a global hotspot for HPAI H5N1, while also providing critical wintering habitat for many species of migratory waterfowl and year-round habitat for several resident waterfowl species. The current study sought to examine the extent to which the wild waterfowl-poultry interface, varied wetland habitat, and climate influence HPAI H5N1 epizootics in poultry in India. Using World Organisation for Animal Health reported outbreaks, this study showed that the wild waterfowl-poultry interface and lacustrine, riparian, and coastal marsh wetland systems were strongly associated with landscape suitability, and these relationships varied by scale. Although increasing poultry density was associated with increasing risk, this was only the case in the absence of wild waterfowl habitat, and only at a local scale. In landscapes increasingly shared between wild waterfowl and poultry, suitability was greater among lower density poultry, again at a local scale only. These findings provide further insight into the occurrence of HPAI H5N1 in India and suggest important landscape targets for blocking the waterfowl-poultry interface to interrupt virus transmission and prevent future outbreaks.

Whence the next pandemic? The intersecting global geography of the animal-human interface, poor health systems and air transit centrality reveals conduits for high-impact spillover.

The health and economic impacts of infectious disease pandemics are catastrophic as most recently manifested by coronavirus disease 2019 (COVID-19). The emerging infections that lead to substantive epidemics or pandemics are typically zoonoses that cross species boundaries at vulnerable points of animal-human interface. The sharing of space between wildlife and humans, and their domesticated animals, has dramatically increased in recent decades and is a key driver of pathogen spillover. Increasing animal-human interface has also occurred in concert with both increasing globalisation and failing health systems, resulting in a trifecta with dire implications for human and animal health. Nevertheless, to date we lack a geographical description of this trifecta that can be applied strategically to pandemic prevention. This investigation provides the first geographical quantification of the intersection of animal-human interfaces, poor human health system performance and global connectivity via the network of air travel. In so doing, this work provides a systematic, data-driven approach to classifying spillover hazard based on the distribution of animal-human interfaces while simultaneously identifying globally connected cities that are adjacent to these interfaces and which may facilitate global pathogen dissemination. We present this geography of high-impact spillover as a tool for developing targeted surveillance systems and improved health infrastructure in vulnerable areas that may present conduits for future pandemics.

A preliminary ecological profile of Kyasanur Forest disease virus hosts among the mammalian wildlife of the Western Ghats, India.

Kyasanur Forest disease (KFD) virus is one of India's severe arboviruses capable of causing prolonged debilitating disease. It has been expanding beyond its historical endemic locus at an alarming rate over the last two decades. The natural nidus of this zoonosis is located in the monsoon rainforest of the Western Ghats, India, which is one of the world's most important biodiversity hotspots. Definitive reservoir hosts for KFD virus (KFDV) have yet to be delineated, and thus much of the infection ecology of this virus, and its consequent transmission dynamics, remains uncertain. Given its unique biogeographical context, identifying ecological parameters of KFDV relevant to the virus' epidemiology has been complex and challenging. The challenge has been exacerbated by diminished research efforts in wildlife surveillance over the last two decades, coinciding with the expansion of the range of KFD across the region. The current investigation sought to define a preliminary ecological profile of KFDV hosts based on their life history and feeding traits to aid in re-establishing targeted wildlife surveillance and to discern those ecological traits of wildlife hosts that may improve our understanding of KFD epidemiology. The importance of fast-living among KFDV hosts was of special interest with respect to the latter aim. We compared mammalian traits between host and non-host species using general additive models and phylogenetic generalised linear models. This study found that both body mass and forest forage were strongly associated with mammalian host infection status, but that reproductive life history traits were not. These findings will help in structuring ecologically based wildlife surveillance and field investigations, while also helping to parameterise novel epidemiological models of zoonotic infection risk that incorporate species functional traits in a region where biogeography, landscape ecology, and community ecology manifest extraordinary complexity, particularly under growing anthropogenic pressure.

Forest loss shapes the landscape suitability of Kyasanur Forest disease in the biodiversity hotspots of the Western Ghats, India.

BACKGROUND: Anthropogenic pressure in biodiversity hotspots is increasingly recognized as a major driver of the spillover and expansion of zoonotic disease. In the Western Ghats region of India, a devastating tick-borne zoonosis, Kyasanur Forest disease (KFD), has been expanding rapidly beyond its endemic range in recent decades. It has been suggested that anthropogenic pressure in the form of land use changes that lead to the loss of native forest may be directly contributing to the expanding range of KFD, but clear evidence has not yet established the association between forest loss and KFD risk. METHODS: The current study sought to investigate the relationship between KFD landscape suitability and both forest loss and mammalian species richness, to inform its epidemiology and infection ecology. A total of 47 outbreaks of KFD between 1 January 2012 and 30 June 2019 were modelled as an inhomogeneous Poisson process. RESULTS: Both forest loss [relative risk (RR) = 1.83; 95% confidence interval (CI) 1.33-2.51] and mammalian species richness (RR = 1.29; 95% CI 1.16-1.42) were strongly associated with increased risk of KFD and dominated its landscape suitability. CONCLUSIONS: These results provide the first evidence of a clear association between increasing forest loss and risk for KFD. Moreover, the findings also highlight the importance of forest loss in areas of high biodiversity. Therefore, this evidence provides strong support for integrative approaches to public health which incorporate conservation strategies simultaneously protective of humans, animals and the environment.

The elephant-livestock interface modulates anthrax suitability in India.

Anthrax is a potentially life-threatening bacterial disease that can spread between wild and livestock animals and humans. Transmission typically occurs indirectly via environmental exposure, with devastating consequences for human and animal health, as well as pastoralist economies. India has a high annual occurrence of anthrax in some regions, but a country-wide delineation of risk has not yet been undertaken. The current study modelled the geographical suitability of anthrax across India and its associated environmental features using a biogeographic application of machine learning. Both biotic and abiotic features contributed to risk across multiple scales of influence. The elephant-livestock interface was the dominant feature in delineating anthrax suitability. In addition, water-soil balance, soil chemistry and historical forest loss were also influential. These findings suggest that the elephant-livestock interface plays an important role in the cycling of anthrax in India. Livestock prevention efforts targeting this interface, particularly within anthropogenic ecotones, may yield successes in reducing ongoing transmission between animal hosts and subsequent zoonotic transmission to humans.

Role of courtyard counselling meeting in improving household food safety knowledge and practices in Munshiganj district of Bangladesh.

Unsafe food is linked to the deaths of an estimated two million people annually. Food containing harmful agents is responsible for more than 200 diseases ranging from diarrhoea to cancers. A one-sample pilot intervention study was conducted to evaluate the role of courtyard counselling meetings as the means of intervention for improving food safety knowledge and practices among household food handlers in a district of Bangladesh. The study was conducted in three phases: a baseline survey, the intervention and an end-line survey between April and November 2015 where 194 food handlers took part. Data were collected through observations and face-to-face interviews. The mean age of the respondents was 38.8 (±12.4) years, all of whom were females. Hand washing before eating, and washing utensils with soap were significantly improved at the end-line in comparison to the baseline (57% vs. 40% and 83% vs. 69%, respectively). Hand washing with soap was increased by 4%. The mean score of food handling practices was significantly increased after the intervention (20.5 vs. 22.1; P<0.001). However, hand washing after use of toilet was unchanged after the intervention (75% vs.76%). Knowledge about safe food and the necessity of thorough cooking were significantly increased after the intervention (88% from 64% and 34% from 21%, respectively). Mean scores of knowledge and practice on food safety were significantly increased by 1.9 and 1.6, respectively after the one month intervention. Thus this food safety education in rural communities should be scaled up and, indeed, strengthened using the courtyard counselling meetings in Bangladesh.

Template protocol for clinical trials investigating vaccines--focus on safety elements.

This document is intended as a guide to the protocol development for trials of prophylactic vaccines. The template may serve phases I-IV clinical trials protocol development to include safety relevant information as required by the regulatory authorities and as deemed useful by the investigators. This document may also be helpful for future site strengthening efforts.

Rationalizing antibiotic use to limit antibiotic resistance in India.

Antibiotic resistance, a global concern, is particularly pressing in developing nations, including India, where the burden of infectious disease is high and healthcare spending is low. The Global Antibiotic Resistance Partnership (GARP) was established to develop actionable policy recommendations specifically relevant to low- and middle-income countries where suboptimal access to antibiotics - not a major concern in high-income countries - is possibly as severe a problem as is the spread of resistant organisms. This report summarizes the situation as it is known regarding antibiotic use and growing resistance in India and recommends short and long term actions. Recommendations aim at (i) reducing the need for antibiotics; (ii) lowering resistance-enhancing drug pressure through improved antibiotic targeting, and (iii) eliminating antibiotic use for growth promotion in agriculture. The highest priority needs to be given to (i) national surveillance of antibiotic resistance and antibiotic use - better information to underpin decisions on standard treatment guidelines, education and other actions, as well as to monitor changes over time; (ii) increasing the use of diagnostic tests, which necessitates behavioural changes and improvements in microbiology laboratory capacity; (iii) setting up and/or strengthening infection control committees in hospitals; and (iv) restricting the use of antibiotics for non-therapeutic uses in agriculture. These interventions should help to reduce the spread of antibiotic resistance, improve public health directly, benefit the populace and reduce pressure on the healthcare system. Finally, increasing the types and coverage of childhood vaccines offered by the government would reduce the disease burden enormously and spare antibiotics.

Strategies to improve the performance of female health workers in West Bengal: a cross-sectional survey.

BACKGROUND: Female health workers in India face an increasing workload that affects their performance. We did a study in 2 districts of West Bengal, India, to quantify their workload and identify determinants of good performance. METHODS: We randomly sampled female health workers from the health department's list. First, we quantified the time allocated to tasks through observations of work sessions. Second, we estimated the prevalence ratio (PR) of above-average performance for three indicators (DPT-booster coverage, antenatal check-up coverage and family planning performance) according to selected potential determinants. RESULTS: Female health workers spent 26% of their time in documentation. We recruited 42 female health workers (average population covered: 6495). Larger floor space (PR 2.5; 95% CI 1.2-5.3), use of simplified documentation procedures (PR 2.5; 95% CI 1.2-5.2) and monthly supervision (PR 3.0; 95% CI 1.1-8.5) were associated with above-average DPT-booster coverage. Availability of a private space was associated with above-average coverage in antenatal check-up (PR 1.9; 95% CI 1.0-3.5) and family planning (PR 2.5; 95% CI 1.2-5.2). Workers who used existing resources to cope with multi-tasking performed better. CONCLUSION: Female health workers spent excessive time in documentation which left less time for service delivery. Infrastructure, planning and supervision affected performance and these areas must be strengthened to improve primary healthcare services.

Indigenous Plasmodium ovale malaria in Bangladesh.

In spite of the high prevalence of malaria in Southeastern Bangladesh, there remains a significant shortage of information regarding the presence of three of five human malaria parasites: Plasmodium ovale, P. malariae, and P. knowlesi. The presence of P. ovale and P. knowlesi has previously never been reported from Bangladesh. We used a genus- and species-specific nested polymerase chain reaction, targeting highly conserved regions of the small subunit ribosomal RNA (SSU rRNA) gene, to investigate the presence of malaria parasites in a total number of 379 patient samples in a survey of patients with febrile illnesses in the Chittagong Hill Tracts in Southeastern Bangladesh. We identified the first cases of P. ovale in Bangladesh. They were confirmed by sequence analysis; 189 of 379 samples (49.9%; 95% confidence interval = 44.9-54.9%) were positive for Plasmodium sp. by PCR. P. falciparum monoinfections accounted for 68.3% (61.3-74.5%), followed by P. vivax (15.3%; 10.9-21.2%), P. malariae (1.6%; 0.5-4.6%), P. ovale (1.6%; 0.5-4.6%), and mixed infections (13.2%; 9.1-18.8%). We found no evidence of P. knowlesi in this region.

The first case of Plasmodium ovale malaria from Bangladesh.

The authors report the first indigenous case of Plasmodium ovale infection from Bangladesh. The diagnosis was confirmed by PCR and sequence analysis. The patient had neither been outside of the country nor ever received blood transfusions. The authors concluded that there was evidence for a local transmission of P ovale malaria in Bangladesh. P ovale malaria should therefore always be considered a potential differential diagnosis in the indigenous population as well as travellers and migrants returning from South Asia, possibly up to years after their return.

An evaluation of diarrheal diseases and acute respiratory infections control programmes in a Delhi slum.

OBJECTIVE: Effective early management at home level and health seeking behavior in case of appearance of danger signs are key strategies in Acute respiratory Infections (ARI) and Acute Diarrheal Diseases (ADD) where majority of episodes are self-limiting and viral in origin. Integrated Management of Childhood illnesses (IMNCI) also envisages that family and community health practices especially health care seeking behaviors are to be improved to reduce childhood morbidity, mortality and cost of admissions to hospitals. Thus, a study was undertaken at an urban slum area--'Gokul Puri' in Delhi, among under-5 children with the aim to assess the magnitudes of ARI and ADD. METHODS: A Cross-sectional survey was conducted in this urban slum of Trans-Yamuna, covering 1307 under-5 children for five days starting from 9th of August, 2004. Survey team consisted of 14 FETP Participants (WHO Fellows) from India, Nepal, Myanmar, Bhutan and Sri Lanka. A pre-tested, house-hold tally marking form was used to interview the caretakers/mothers. History of episodes of ARI and/or ADD in the last two weeks was asked. Health care practices including use of ORS &home available fluids in diarrhea, continued feeding during diarrhea, awareness of danger signs of ARI &ADD and medical advice sought were asked of those mothers whose children had such an episode. RESULTS: 191 (14.6 %) of 1307 children surveyed, had an attack of ARI in the preceding two wk. The common symptoms of ARI cases were mild running nose (78%), cough (76.4%) and/or fever (45.5%). Only 8 (4%) had fast breathing. One or more danger signs were known to 80% (152/191) of mothers and an equal number (80%) of mothers had sought treatment. ARIs are mostly mild or self limiting but only 16% of caretakers perceived so and doctors also prescribed medicines. The attack rate of Acute Diarrheal Diseases was 7.73% in the study and ADD's annual adjusted morbidity rate was 1.69 episodes per child per year. Though nearly three-fourth of mothers (71.3%) had reported to be seeking medical advice (which is not needed in mild episodes of diarrhea) the ORS use was 38.6%, use of Home available fluids (HAF) was 42% and continued feeding was 50% during the ADD episode and awareness of at least two danger signs was present in 34%. CONCLUSION: Though aware of danger signs of ARI, care takers were still seeking medical advice for mild cases of ARI and doctors were prescribing drugs. Correct home based management e.g. use of ORS, continued feeding etc. was deficient in the community. Knowledge of danger symptoms was low and medical advice was being sought and drugs were being prescribed for ADD, too.