Prevalence of diabetes and prediabetes (impaired fasting glucose and/or impaired glucose tolerance) in urban and rural India: phase I results of the Indian Council of Medical Research-INdia DIABetes (ICMR-INDIAB) study.

AIMS/HYPOTHESIS: This study reports the results of the first phase of a national study to determine the prevalence of diabetes and prediabetes (impaired fasting glucose and/or impaired glucose tolerance) in India. METHODS: A total of 363 primary sampling units (188 urban, 175 rural), in three states (Tamilnadu, Maharashtra and Jharkhand) and one union territory (Chandigarh) of India were sampled using a stratified multistage sampling design to survey individuals aged ≥ 20 years. The prevalence rates of diabetes and prediabetes were assessed by measurement of fasting and 2 h post glucose load capillary blood glucose. RESULTS: Of the 16,607 individuals selected for the study, 14,277 (86%) participated, of whom 13,055 gave blood samples. The weighted prevalence of diabetes (both known and newly diagnosed) was 10.4% in Tamilnadu, 8.4% in Maharashtra, 5.3% in Jharkhand, and 13.6% in Chandigarh. The prevalences of prediabetes (impaired fasting glucose and/or impaired glucose tolerance) were 8.3%, 12.8%, 8.1% and 14.6% respectively. Multiple logistic regression analysis showed that age, male sex, family history of diabetes, urban residence, abdominal obesity, generalised obesity, hypertension and income status were significantly associated with diabetes. Significant risk factors for prediabetes were age, family history of diabetes, abdominal obesity, hypertension and income status. CONCLUSIONS/INTERPRETATIONS: We estimate that, in 2011, Maharashtra will have 6 million individuals with diabetes and 9.2 million with prediabetes, Tamilnadu will have 4.8 million with diabetes and 3.9 million with prediabetes, Jharkhand will have 0.96 million with diabetes and 1.5 million with prediabetes, and Chandigarh will have 0.12 million with diabetes and 0.13 million with prediabetes. Projections for the whole of India would be 62.4 million people with diabetes and 77.2 million people with prediabetes.

Impact of HIV/AIDS on the national economy of India.

BACKGROUND INFORMATION: Human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) is a major public health problem in India. In general, it affects mainly young people who are at their most productive part of life. Despite initial fears that AIDS will be disastrous for the economy, recent experience and estimations have shown that there is a need for reappraisal of its economic impact on society. RESEARCH QUESTION: From the viewpoint of the society of India, what is the total cost and equivalent annual cost of HIV infections for the period 1986-1995 (10 years) in India? METHODS: Type of analysis: Cost-descriptive based on predictive modelling cohort analysis using human capital approach. A discount rate of 5% was used. The cost of HIV infections include (i) loss of productivity among HIV patients due to sickness and death, (ii) productivity loss due to caregivers of AIDS patients, and (iii) cost of management of AIDS patients. To estimate the loss of productivity due to premature death attributable to AIDS, a life table approach using two cohorts, one with and one without HIV/AIDS infection at assumed rates was used. The demographic data of 1991 census were used. The difference in the person-years lived in the two scenarios gave the person-years lost due to HIV/AIDS. This was calculated separately for rural and urban areas. To convert this to monetary terms, national per capita income for 1992-93 of Rs. 5529 was used. The data on the days of inpatient care and the cost of management of AIDS patients were based on currently available data and 'expert opinion'. We analysed, using three different sets of assumptions for determination, the low, medium and high estimates of the impact of HIV/AIDS in India. Some of the costs were not included in the present analysis: (i) use of antiviral AZT, (ii) cost of retraining of new workforce, (iii) cost of strengthening of health care system, (iv) cost of research and development, (v) cost of communication activities, (vi) cost of prevention of vertical transmission, and (vii) the intangible cost of pain and suffering to the patients and their families. RESULTS: The total cumulative number of HIV-infected persons in India until 1995 was estimated to be 1.5 million (low estimate), 2.5 million (medium estimate) and 4.5 million (high estimate). The estimated total annual cost (in billion Rupees) of HIV/AIDS in India under low, medium and high assumptions was 6.73, 20.16 and 59.19, respectively. Cost of treatment of AIDS and loss in productivity were the two major components of the cost. CONCLUSIONS: The estimated annual cost of HIV/AIDS appears to be about 1% of the GDP of India if based on high assumptions. However, as mentioned earlier, all costs of HIV have not been taken into account. Its significance has to be assessed in the context of annual growth of GDP (3.5%) and cost of other major diseases in India.

Monitoring oral iron therapy with protoporphyrin/heme ratios in pregnant women.

Assessment of the efficacy of iron therapy has usually been done in populations/patients by monitoring changes in hemoglobin concentration, serum iron, percent transferrin saturation, and serum ferritin. In this study the protoporphyrin heme (P/H) ratio (a measure of free erythrocyte protoporphyrin) was measured before and after iron therapy in three groups of pregnant women, who received 60 mg (group A), 120 mg (group B), and 240 mg (group C) of elemental iron with folic acid (0.5 mg) per day for a period of 12 weeks, to evaluate its efficacy to monitor iron therapy. The three groups were comparable regarding the initial mean Hb concentration and serum ferritin levels. The initial mean P/H ratios were markedly elevated in all three groups and were different in the three groups, being highest in group A (113.2+/-92.6), intermediate in group B (87.5+/-62.5), and lowest in group C (69.8+/-43.3). The initial P/H ratio was significantly higher in group A than in group C (p<0.05). This probably affected the efficacy of iron therapy in the three groups. The P/H ratio decreased significantly in each of the three groups after iron therapy (A and B: p<0.001; C p<0.01). Mean Hb concentration and serum ferritin increased in all three groups post therapy; however, the magnitude of change in P/H ratio in all three groups was much greater. This indicated that the predominant contributory factor for anemia was iron deficiency in this group of pregnant women. Serum iron and percent transferrin saturation are difficult to interpret in our population, as iron is freely available over the counter and is prescribed as soon as anemia is detected in patients; therefore, the reduction in P/H ratio may be used to monitor response to iron therapy in population groups.

Development of an activities of daily living scale to screen for dementia in an illiterate rural older population in India.

OBJECTIVE: to develop a measure of activities of daily living appropriate for use in assessing the presence of dementia in illiterate rural elderly people in India. DESIGN: identification of relevant items, pre-testing of items and refinement of administrative procedures and scoring in four successive groups of 30 subjects each, pilot testing in a group of 100 subjects comparable to those for whom the measure is intended, administration to a representative sample of 387 people aged 55 and older, and assessment of the reliability of the final measure. SETTING AND SUBJECTS: age-stratified random sample of older men and women in rural areas of Ballabgarh, Northern India. RESULTS: the original pool of 35 items covering mobility, instrumental and personal care activities was reduced to an 11-item unidimensional scale (to which an additional item on mobility was added) with internal consistency (Cronbach's alpha)=0.82, perfect inter- and intra-rater reliability, test-retest reliability (intraclass correlation)=0.82 (any disability) and 0.92 (unable to perform for 'mental' reasons). Women, older subjects, the totally illiterate and subjects with poorer cognitive function performed significantly more poorly (P < or = 0.02 for all). PRODUCT: a brief, reliable and valid activities of daily living measure, with norms, which is appropriate for use in assessing dementia in illiterate rural elderly people in India.

Iodine deficiency disorders in Car Nicobar (Andaman and Nicobar Islands).

BACKGROUND: The term 'Iodine deficiency disorders' (IDDs) reflects the spectrum of health effects due to iodine deficiency at all ages. So far, no survey for IDD has been carried out in the Andaman and Nicobar Islands (A&N). Therefore, we aimed to determine the status of IDDs at Car Nicobar Island and to assess the iodine content of salt available for consumption on the island. METHODS: The study population comprised tribal school children between 7 and 18 years of age in government schools of Car Nicobar, A&N. Children were selected from each school by the simple random sampling method using the random number table. The same sampling method was used for each school till completion of the desired sample size for that school. Casual urine samples (in screw-capped plastic bottles for iodine estimation) and blood samples (on No. 3 Whatman filter paper for TSH estimation) were collected from a randomly selected sub-sample of students. Salt samples for iodine estimation were collected from 'captains' (village headman) of each village and the headmasters of the schools and 'canteens' in government retail outlets in the villages. RESULTS: Of the 969 children surveyed, 160 (16.5%) had goitre. The prevalence was significantly more among females (23.6%) than males (9.7%). Analysis of 105 urine samples showed that the median urinary iodine excretion level was 7.0 micrograms/dl. The median TSH values in subjects was 5.7 mU/L. Fifty (82.5%) of the 54 salt samples had adequate iodine (> or = 15 parts per million). CONCLUSIONS: IDDs pose a mild-to-moderate public health problem in Car Nicobar Island. The supply of iodized salt and its iodine content was found to be satisfactory at the time of the study.

Knowledge beliefs and practices regarding iodine deficiency disorders among the tribals in Car Nicobar.

It is estimated that 1,570 million people are at risk of iodine deficiency. Because of the wide spectrum of disorders that IDD includes, and lack of any obvious association between iodine deficiency and its health effects, IDD is not perceived as a major public health problem. For any disease to be effectively controlled, awareness at all levels from community to policy makers is necessary. This study was conducted to assess knowledge, beliefs and practices regarding iodine deficiency Disorders in Car Nicobar districts of Andaman and Nicobar Islands. The population is predominantly tribals involved in coconut plantations. All the village heads of the sixteen villages and parents of 10% of the school children examined for goiter were interviewed. Initial focus group discussions were conducted as no prior knowledge about local names for goitre or other related IDD information was available. The interview schedule was designed in English which was then translated into Hindi and Nicobarese and back translated into Hindi and English. A total of 114 persons were interviewed 60 males, 54 females. The local name for goiter was "Rulo" and 44% felt that it only affected females. No one had correct knowledge of the cause of goiter. About half of the respondents believed that these swellings caused problems. Sixty three (55.3%) of respondents believed that there was treatment, of which 33 said there was medical treatment, 18 respondents said traditional treatment by "LAM-EEN" and 12 felt that both therapies are required. Majority (85%) brought salt samples from the Government canteen. They did not now whether this salt was iodised. Salt was not washed before use and storage practice was satisfactory. The awareness about IDD needs reinforcement. At present the community is a passive participant in the I.D.D. Control Programme.

Economic consequences of HIV/AIDS in India.

BACKGROUND: HIV/AIDS is one of the pressing public health problems in India. Available information indicates a rising trend of infection. The impact of HIV/AIDS on the economic front is important as it affects mainly the young, who are in the reproductive age group. We estimated the cost of productivity losses in a lifetime attributable to HIV-related mortality in India in the population of the year 1991 at current HIV infection rates. METHODS: The analysis was done from the societal viewpoint, adopting a discount rate of 5%. To estimate the loss in person-years due to HIV/AIDS, two scenarios were considered. Firstly, the population without HIV/AIDS, and secondly, the population with HIV/AIDS. The difference in person-years lived by the cohort in both populations would provide the person-years lost due to HIV/AIDS. To calculate the person-years lived in each, the life table approach was used. The demographic data from the 1991 Census were used. The population was divided into 15 five-year cohorts and the current age-specific death rates were used. Assumptions regarding HIV incidence rates in urban and rural areas in different age groups were made based on the available data and consensus of experts. The estimate was first done for a cohort of 100,000 population for rural and urban areas and then extrapolated to the population in the different age groups. To convert the person-years lost into monetary terms, minimum wages were estimated to be Rs 14,460 per annum. RESULTS: The total undiscounted life-years lost due to HIV/ AIDS by the present population of India will be 238.4 million years-123.7 million years for urban and 114.7 million years for rural areas. On an average this is 0.4 years lost per person. The life-years lost per case of HIV was 44.4 years. Assuming minimum wages of Rs 14460 as the value of one year, the total economic loss is Rs 3447 billion. The productivity loss per case is Rs 642,024 (US$ 20,710). For an estimated national per capita income of Rs 4252.4 the total economic loss is Rs 1014 billion. If a discount rate of 5% is applied for future losses then the total potential years of life lost will be 23 million-11.3 million for urban and 11.7 million for rural areas. In monetary terms this will be Rs 332.6 billion by minimum wages assumption, and 97.8 billion if the national per capita income is assumed to be the cost of one year. CONCLUSION: HIV/AIDS imposes a significant burden on the economic front. The productivity losses are likely to be an underestimate as the costs of treatment of HIV/AIDS patients, prevention programmes and labour costs have not been taken into account. To decide whether HIV/AIDS needs a high priority int he Indian context, it is necessary to have similar estimates for other important diseases such as tuberculosis and cancer.

Challenge and response: HIV in Asia and the Pacific.

Inexorably, the epicentre of the global HIV pandemic is moving from Africa to Asia. Despite many years of much-publicised analysis of the African epidemic, most countries in Asia and many in the Pacific have not introduced the public health strategies known to minimise the spread of HIV. What must be done now, and how can the developed countries in the region, such as Australia, assist their neighbours?

PIP: In the Asia-Pacific region, almost 5000 people become infected with HIV every day. The leading mode of HIV transmission is heterosexual intercourse. Sharing of injecting equipment among drug users is also a major mode of HIV transmission. Myanmar is the epicenter of the HIV epidemic in Asia. The political tensions there interfere with attempts to curb the spread of HIV in-country and to neighboring countries. The lack of effective cross-border programs has resulted in an explosive situation in China's south Yunnan province, especially among drug abusers. In many countries in the region, the blood supply is unsafe. Thailand is the only country politically committed to curbing HIV transmission. Government-facilitated massive education programs and other interventions preceded a decline in the overall rate of sexually transmitted diseases (STDs) in Thailand. Key strategies in Thailand include detailed epidemiologic studies to determine the incidence and prevalence of HIV infection nationwide, promotion of safer sex practices in commercial sex establishments (e.g., 100% condom campaign), and official willingness to work with nongovernmental organizations. The government of India has not responded appropriately to the HIV/AIDS epidemic and the outcome has been disastrous. India will likely soon have more HIV-infected people than any other Asia-Pacific country. Preventive programs may spare western Pacific countries, where HIV incidence is low. Obstacles to tackling the HIV epidemic include poverty, poor facilities for the treatment of STDs, failure to address discrimination against those infected with HIV, and problems associated with the very low status of women. Many years of national development can be lost to the HIV epidemic. Australia has model HIV prevention and control policies and can help its Asia-Pacific neighbors fight HIV/AIDS. Health professionals in only Thailand, Australia, and New Zealand are prepared for the future AIDS caseload. Australia offers clinical programs for the region's health professionals. Greater political commitment is needed in the region to minimize the HIV/AIDS epidemic.

A management technique for effective management of medical store in hospitals. Medical store management technique.

BACKGROUND: Almost one third of hospital' annual budget is spent on buying material and supplies including medicines. There is wide variation in cost of these items and effective management of store is necessary to ensure optimal use of money spent. OBJECTIVES: (i) To explore the feasibility of alphabetical analysis (where items are classified into A, B and C categories depending on their annual consumption value) in effective management of a medical store and to compare the present (fixed period re-order) and the proposed (fixed quantity re-order) as alternative inventory management technique. METHODS: Using multistage random sample technique, two sub-categories out of total of 37 listed in stock register (medicine) of a large hospital of Delhi were selected for detailed analysis. Alphabetical (ABC) analysis based on total annual consumption value of different items was done. Six medicines, the first and the last from each of the ABC categories, were also analysed for fixed quantity re-order. RESULTS: It was observed that ABC analysis, if practised, would allow effective control over two third of the total expenditure by controlling only one fourth of the items. The existing order size (based on fixed period re-order) was more than three times order size if based on fixed quantity re-order. CONCLUSIONS: Alphabetical analysis is a feasible and efficient technique for effective management of store in hospitals. Considerable financial savings is possible if the order size is based on fixed quantity re-order. RECOMMENDATIONS: The Assistant Store Officer should apply alphabetical analysis for more efficient management of the medical store. The present practice of fixed period re-order should be replace by fixed quantity re-order.

Cost of health services provided at a primary health centre.

BACKGROUND: Information on the cost of health services is essential for good planning and management and leads to an efficient use of resources. Very little information on this is available in India. We estimated the distribution of costs incurred on the Primary Health Centre, Chhainsa, Haryana by the type of service provided and their average unit costs. METHODS: We calculated the total costs incurred in running the primary health centre for one year using standard costing methods. This cost was apportioned under different heads on the basis of time and space utilization. The number of activities carried out, between April 1991 and March 1992, was obtained from the monthly reports of the centre maintained by the health assistant and supervised by the medical officer. RESULTS: The total cost incurred for one year was Rs 777,020 (US$ 24,250). Curative care accounted for 32% of the total costs followed by communicable disease control (17%), child care (17%), maternal care (11%) and family welfare (10%). An expenditure of Rs 24 was incurred on each outpatient. The cost of giving full primary immunization to a child was estimated at Rs 131, while Rs 127 was incurred on providing antenatal, natal and postnatal care to each pregnant woman. Tuberculosis-related activities in the community cost Rs 3 per head per year and malaria-related activities Rs 2 per head per year. The cost incurred annually on family welfare services to an eligible couple was Rs 19. CONCLUSIONS: Our findings suggest that the cost estimates from this primary health centre are comparable with the estimates from other developing countries. These cost estimates may be used to determine user fees by health agencies or for premiums for community health insurance schemes.

Health care in rural areas.

PIP: In India, although the health care system infrastructure is extensive, the people often regard government facilities as family planning (FP) centers instead of primary health care centers. This problem has been compounded by the separation of health care and FP at all stages, even down to the storage of the same medication in two different locations depending upon whether it is to be used for "health" or for "FP." In rural areas where the government centers are particularly desolate, the community has chosen to erect its own health care system of private practitioners of all sorts and qualifications. Even in rural areas where a comprehensive health service is provided, with each household visited regularly by health workers, and where this service has resulted in a lowering of the crude death rate from 14.6 to 7 and the maternal mortality rate from 4.7 to 0.5/1000, people depend upon practitioners of various types. Upon analysis, it was discovered that the reason for using this multiplicity of practitioners had nothing to do with the level of satisfaction with the government service or with the accessibility of the services. Rather, when ill, the people make a diagnosis and then go to the proper place for treatment. If, for instance, they believe their malady was caused by the evil eye, they consult a magico-religious practitioner. These various types of practitioners flourish in areas with the best primary health care because they fulfill a need not met by the primary health care staff. If government agencies work with the local practitioners and afford them the proper respect, their skills can be upgraded in selected areas and the whole community will benefit.^ieng

Supplementary feeding pattern in children living in a resettlement colony.

PIP: A nutrition survey was conducted among 543 mothers of 547 3-year old children living in Sector 1 of Dr. Ambedkar Nagar, a resettlement community, in South Delhi, India to examine weaning practices and the supplementation pattern among these poor urban women. 33.3% of the 3-month old infants had already received animal milk. In fact, 22.9% of these infants 1st received animal milk within the 1st month. 44.6% of 3-6 month infants received animal milk and other supplements. This figure was 74.2% for 6-9 month olds and 88.7% for 9-12 month olds. When mothers 1st began giving animal milk, most (80%) added plain water to the animal milk at a ratio of 3:1. Those giving their infants infant formula also diluted it. Of the children using bottles, 92.2% and 88.6% had only 1 bottle and 1 nipple, respectively. Only 1.2% of the mothers sterilized the bottle properly. 84.5% gave their infants supplementary feeds because they believed they no longer had enough breast milk. They also tended to start supplementary feeds themselves (80.5%). Mothers had a tendency to delay supplementation as evidenced by the average age for introduction of semisolid foods which was 10.3 months. Weaning foods were dal, khichri, rice, chapati, and biscuits. 34.2% of the children were not weaned until after they reached their 1st birthday. These results indicated a high risk of infection due to the early introduction of fluids other than breast milk to young infants. The children were also at risk of malnutrition because of the tendency to introduced semisolid foods later than the recommended age of 4-6 months. Health workers must educate mothers about proper child feeding practices whenever possible since most made the decision to supplement breast milk on their own.^ieng

Pilot study of the prevalence of major neurologic disorders in a rural population of India.

A study of the prevalence of major neurologic diseases will be carried out in a rural population near Ballabgarh. India, using the World Health Organization protocol for epidemiologic studies of neurologic disorders and other internationally standardized survey techniques, screening procedures, and diagnostic criteria. Before applying any protocol developed in one population to another population, it must be intensively tested. Here, we describe the adaptation of the WHO protocol to the local conditions in rural Ballabgarh, and the findings of the pilot study conducted to test the protocol.

The state of India's health: reasons for hope and despair.

PIP: Participants in a panel discussion on the state of health in India (Dr Meera Chatterjee, scientist and health planner; Dr Ashish Bose, Director of the Institute of Economic Growth; Dr L M Nath, Professor of Community Medicine; and Dr Almas Ali, an expert on tribal issues) voiced serious concerns about the adequacy of existing policy approaches for improving the health status of the majority of Indians. It appears that goals established by the National Health Policy are not going to be met, and there are greater differentials in health indicators by region and between rural and urban areas. Existing science and technology is adequate to meet the people's health needs; but there is a need for a new technology more acceptable to the sociocultural situation of the population. Specific problems in India's health sector include linkage between nutrition programs and other health schemes, neglect of the needs of female children, women's subordinate social and economic status; a lack of support and supervision of the voluntary health worker network, and bureaucratization in the voluntary sector. Action plans need to be formulated at the district level and more reliable statistics must be generated. If India's health problems are to be ameliorated, health must be conceptualized in a broader context through greater intersectorial coordination.^ieng

Factors influencing prevalence of breastfeeding in a resettlement colony of New Delhi.

Influence of some family and maternal characteristics on prevalence of breastfeeding was studied in a cross sectional study using WHO suggested methodology. 547 mothers with children less than three years of age were interviewed with the help of a schedule. Age and parity of the mother, sex of the child, length of urban stay, mother's going for work did not influence the prevalence of breastfeeding. Prevalence was higher among illiterate mothers and mothers belonging to lower socio-economic status. The mothers from higher socio-economic status initiated breastfeeding earlier. More mothers from higher socio-economic status and those with better education thought that supplementation was needed before the child was 4 months old and felt that breastfeeding was needed for less than two years.

Breast feeding practices in a resettlement colony and its implications for promotional activities.

The mothers of 547 children less than three years of age were interviewed for breastfeeding practices using WHO suggested methodology in a resettlement colony of South Delhi. Only 1.8% of children were never breastfed. Prelacteal feeds were given in 90.9% of infants. More than half received their first breastfeed on 3rd day or later. Among children under three months of age, one third were already receiving top milk. 68.4% of mothers felt that the child should be breastfed for as long as possible. Demand feeding was practised by 95% of the mothers. Most of the mothers did not seek privacy to breastfeed their children. The need to identify desirable and undesirable infant feeding practices prevalent in an area has been stressed so that appropriate promotional activities can be carried out more effectively.