Prevalence of Noncommunicable Disease (NCDs) risk factors in Tamil Nadu: Tamil Nadu STEPS Survey (TN STEPS), 2020.

BACKGROUND: Noncommunicable diseases (NCDs) account for nearly 75% of all deaths in Tamil Nadu. The government of Tamil Nadu has initiated several strategies to control NCDs under the Tamil Nadu Health Systems Reform Program (TNHSRP). We aimed to estimate the prevalence of NCD risk factors and determine the predictors of diabetes and hypertension, which will be helpful for planning and serve as a baseline for evaluating the impact of interventions. METHODS: A state-wide representative cross-sectional study was conducted among 18-69-year-old adults in Tamil Nadu in 2020. The study used a multi-stage sampling method to select the calculated sample size of 5780. We adapted the study tools based on WHO's STEPS surveillance methodology. We collected information about sociodemographic factors, NCD risk factors and measured blood pressure and fasting capillary blood glucose. The predictors of diabetes and hypertension were calculated using generalised linear models with 95% confidence intervals (95% CI). RESULTS: Due to the COVID-19 pandemic lockdown, we could cover 68% (n = 3800) of the intended sample size. Among the eligible individuals surveyed (n = 4128), we had a response rate of 92%. The mean age of the study participants was 42.8 years, and 51% were women. Current tobacco use was prevalent in 40% (95% CI: 33.7-40.0) of men and 7.9% (95% CI: 6.4-9.8) of women. Current consumption of alcohol was prevalent among 39.1% (95% CI: 36.4-42.0) of men. Nearly 28.5% (95% CI: 26.7-30.4) of the study participants were overweight, and 11.4% (95% CI: 10.1-12.7) were obese. The prevalence of hypertension was 33.9% (95% CI: 32.0-35.8), and that of diabetes was 17.6% (95% CI: 16.1-19.2). Older age, men, and obesity were independently associated with diabetes and hypertension. CONCLUSION: The burden of NCD risk factors like tobacco use, and alcohol use were high among men in the state of Tamil Nadu. The prevalence of other risk factors like physical inactivity, raised blood pressure and raised blood glucose were also high in the state. The state should further emphasise measures that reduce the burden of NCD risk factors. Policy-based and health system-based interventions to control NCDs must be a high priority for the state.

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.

A Direct Link Implicating Loss of SLC26A6 to Gut Microbial Dysbiosis, Compromised Barrier Integrity and Inflammation.

BACKGROUND: Putative anion transporter-1 (PAT1, SLC26A6) plays a key role in intestinal oxalate and bicarbonate secretion. PAT1 knockout (PKO) mice exhibit hyperoxaluria and nephrolithiasis. Notably, diseases such as inflammatory bowel diseases (IBD) are also associated with higher risk of hyperoxaluria and nephrolithiasis. However, the potential role of PAT1 deficiency in gut barrier integrity and susceptibility to colitis is currently elusive. METHODS: Age-matched PKO and wild-type (WT) littermates were administered 3.5%-DSS in drinking water for 6 days. Ileum and colon of control and treated mice were harvested. mRNA and protein expression of tight junction (TJ) proteins were determined by RT-PCR and western blotting. Severity of inflammation was assessed by measuring diarrheal phenotype, cytokine expression and H&E staining. Gut microbiome and associated metabolome were analyzed by 16S rRNA sequencing and mass spectrometry, respectively. RESULTS: PKO mice exhibited significantly higher loss of body weight, gut permeability, colonic inflammation, and diarrhea in response to DSS treatment. Additionally, PKO mice showed microbial dysbiosis and significantly reduced levels of butyrate and butyrate-producing microbes compared to controls. Cohousing WT and PKO mice for 4 weeks resulted in PKO-like signatures on the expression of TJ proteins in the colon of WT mice. CONCLUSION: Our data demonstrate that loss of PAT1 disrupts gut microbiome and related metabolites, decreases gut barrier integrity, and increases host susceptibility to intestinal inflammation. These findings, thus, highlight a novel role of the oxalate transporter PAT1 in promoting gut barrier integrity and its deficiency appears to contribute to the pathogenesis of IBD.

Global estimate of burnout among the public health workforce: a systematic review and meta-analysis.

INTRODUCTION: Burnout is an occupational phenomenon resulting from chronic workplace stress. We conducted this review to estimate the pooled global prevalence of burnout among the public health workforce. METHODS: We conducted this review as per the PRISMA 2020 guidelines. We included only cross-sectional studies reporting outcome estimates among the study population. We included articles published before December 2023. We used a search strategy to systematically select the articles from PubMed, Embase, and Google Scholar. We assessed the quality of the studies using an adapted version of NIH's study tool assessment for cross-sectional and observational cohort studies. We estimated the pooled proportion using the random-effects model. RESULTS: We included eight studies in our review, covering a sample size of 215,787. The pooled proportion of burnout was 39% (95% CI: 25-53%; p-value: < 0.001). We also identified high heterogeneity among the included studies in our review (I2: 99.67%; p-value: < 0.001). Seven out of the eight studies were of good quality. The pooled proportion of the studies conducted during the COVID-19 pandemic was 42% (95% CI: 17-66%), whereas for the studies conducted during the non-pandemic period, it was 35% (95% CI: 10-60%). CONCLUSION: In our review, more than one-third of public health workers suffer from burnout, which adversely affects individuals' mental and physical health. Burnout among the public health workforce requires attention to improve the well-being of this group. Multisite studies using standardized definitions are needed for appropriate comparisons and a better understanding of variations in burnout in various subgroups based on sociodemographic characteristics and type of work responsibilities. We must design and implement workplace interventions to cope with burnout and increase well-being. LIMITATIONS: Due to the limited research on burnout among public health workers, we could not perform a subgroup analysis on various factors that could have contributed to burnout.

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.

An educational intervention for improving knowledge, attitude, and practice of dietary salt intake among individuals with hypertension in public sector secondary care facilities, Agra, India, 2021.

We conducted a pre-post intervention study to determine knowledge, attitude, and practice toward dietary salt intake before, immediately, and 1-month after nurse-led one-on-one counseling. We purposively selected three public health facilities in Agra, India, and enrolled all eligible hypertensive patients aged 18-60 under treatment for ≥6 months. Of the 153 patients at the 1-month follow-up, counseling improved knowledge (4% vs. 42%, p < .001), a greater prioritization of a low salt diet (34% vs. 52%, p < .001), and practice of adding less salt to the dough (48% to 41%, p < .001). The counseling intervention improved knowledge, attitude, and practice toward dietary salt intake.

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.

In-vivo expressed mycobacterial transcripts as diagnostic targets for pulmonary tuberculosis.

The nucleic acid amplification tests (NAATs) such as Xpert MTB/RIF have transformed the TB diagnostic field by significantly increasing the case detection. However, newer improved diagnostic assays are still needed to meet the WHO targets to end TB. Present study is based on a novel approach of utilizing the in-vivo expressed specific mycobacterial transcriptomic biomarkers for the diagnosis of pulmonary tuberculosis (PTB). Total 61 subjects were recruited including smear positive (smear+; n = 15), smear negative (smear-; n = 30) PTB patients and disease controls (n = 16). Transcripts of three mycobacterial genes Rv0986, Rv0971c and Rv3121 were analyzed using real time PCR (qRT-PCR) in sputum samples. qRT-PCR with Rv0986, Rv0971c and Rv3121 identified smear + PTB patients with 100 %, 78.6 % and 86.7 % sensitivity respectively. In smear- PTB patients, both Rv0986 and Rv0971c based qRT-PCR resulted in 63 %, sensitivity whereas Rv3121 identified these patients with ∼40 % sensitivity only. The sensitivity of the assay for smear-patients increased to 85 % when combinatorial analysis of qRT-PCR data for all the three genes was used. Thus, in-vivo expressed mycobacterial transcripts have promising potential as biomarkers for PTB diagnosis.

Antibody response to mycobacterial Rpf B protein and its immunodominant peptides in HIV-TB co-infected individuals.

Diagnosis of TB at early stages of HIV infection may lead to timely intervention for improving patient outcome. Antibodies to Mycobacterium tuberculosis recombinant RpfB protein and two immunodominant peptides of Rpf B protein were evaluated in the sera of HIV +TB+, HIV+ and HIV- pulmonary TB patients by ELISA. Serum antibodies from 90 % and 65 % of HIV+TB+ patients reacted to recombinant RpfB protein and synthetic peptide RpfP1 respectively. Overall, this study shows that resuscitation promoting factor B elicits humoral antibody response in HIV+TB+ co-infected individuals and be proposed as a potential biomarker for diagnosis of HIV+TB+ patients, however further longitudinal follow up studies are warranted.

Improving the availability of antihypertensive drugs in the India Hypertension Control Initiative, India, 2019-2020.

BACKGROUND: Antihypertensive drug supply is sometimes inadequate in public sector health facilities in India. One of the core strategies of the India Hypertension Control Initiative (IHCI) is to improve the availability of antihypertensive drugs in primary and secondary care facilities. We quantified the availability of antihypertensive drugs in 2019-20 and described the practices in supply chain management in 22 districts across four states of India. METHODS: Twenty-two districts from 4 states (Punjab, Madhya Pradesh, Telangana, and Maharashtra) were studied. We described the practices and challenges in supply chain management. We collected data on drug procurement from 2018 to 2020 and drug availability from April 2019 to March 2020. Quantity procured, the proportion of facilities with stockout at the end of each quarter, and availability of drugs in patient days were tabulated. RESULTS: All states selected drug- and dose-specific protocols with Amlodipine as the initial drug and shifted to morbidity-based forecasting. The total number of antihypertensive tablets procured for the 22 districts increased from 16 million in 2017-2018 to 160 million in 2019-2020. The proportion of facilities with Amlodipine stock-out was below 5% during the study period. Amlodipine stock was available for at least 60 patient days from the third quarter of 2019 onward in all districts. CONCLUSIONS: This study demonstrates that including best practices can gradually strengthen the procurement and supply chain for antihypertensives in a low-resource setting. As the program was rapidly growing, there were still gaps in the procurement and distribution system which needed to be addressed to ensure the adequacy of drugs. We recommend that best practices, including choosing a single protocol, basing supply on projected patient load rather than an increment from historical levels, and using simple stock management tools, be replicated in other districts in India to increase and sustain coverage of hypertension treatment.

Central and local arterial stiffness in White Europeans compared to age-, sex-, and BMI-matched South Asians.

BACKGROUND: Ethnicity impacts cardiovascular disease (CVD) risk, and South Asians demonstrate a higher risk than White Europeans. Arterial stiffness is known to contribute to CVD, and differences in arterial stiffness between ethnicities could explain the disparity in CVD risk. We compared central and local arterial stiffness between White Europeans and South Asians and investigated which factors are associated with arterial stiffness. METHODS: Data were collected from cohorts of White Europeans (the Netherlands) and South Asians (India). We matched cohorts on individual level using age, sex, and body mass index (BMI). Arterial stiffness was measured with ARTSENS® Plus. Central stiffness was expressed as carotid-femoral pulse wave velocity (cf-PWV, m/s), and local carotid stiffness was quantified using the carotid stiffness index (Beta) and pressure-strain elastic modulus (Epsilon, kPa). We compared arterial stiffness between cohorts and used multivariable linear regression to identify factors related to stiffness. RESULTS: We included n = 121 participants per cohort (age 53±10 years, 55% male, BMI 24 kg/m2). Cf-PWV was lower in White Europeans compared to South Asians (6.8±1.9 vs. 8.2±1.8 m/s, p<0.001), but no differences were found for local stiffness parameters Beta (5.4±2.4 vs. 5.8±2.3, p = 0.17) and Epsilon (72±35 vs. 70±31 kPa, p = 0.56). Age (standardized ß, 95% confidence interval: 0.28, 0.17-0.39), systolic blood pressure (0.32, 0.21-0.43), and South Asian ethnicity (0.46, 0.35-0.57) were associated with cf-PWV; associations were similar between cohorts (p>0.05 for interaction). Systolic blood pressure was associated with carotid stiffness in both cohorts, whereas age was associated to carotid stiffness only in South Asians and BMI only in White Europeans. CONCLUSION: Ethnicity is associated with central but not local arterial stiffness. Conversely, ethnicity seems to modify associations between CVD risk factors and local but not central arterial stiffness. This suggests that ethnicity interacts with arterial stiffness measures and the association of these measures with CVD risk factors.

Pathophysiology of Enteropathogenic Escherichia coli-induced Diarrhea.

Enteropathogenic Escherichia coli (EPEC) are important diarrheal pathogens of infants and young children. Since the availability of molecular diagnosis methods, we now have new insights into the incidence and prevalence of these infections. Recent epidemiological studies indicate that atypical EPEC (aEPEC) are seen more frequently than typical EPEC (tEPEC) worldwide, including in both endemic diarrhea and diarrhea outbreaks. Therefore, it is important to further characterize the pathogenicity of these emerging strains. The virulence mechanisms and pathophysiology of the attaching and effacing lesion (A/E) and the type-three-secretion-system (T3SS) are complex but well-studied. A/E strains use their pool of locus of enterocyte effacement (LEE)-encoded and non-LEE-encoded effector proteins to subvert and modulate cellular and barrier properties of the host. However, the exact mechanisms of diarrhea in EPEC infection are not completely understood. From the clinical perspective, there is a need for fast, easy, and inexpensive diagnostic methods to define optimal treatment and prevention for children in endemic areas. In this article, we present a review of the classification of EPEC, epidemiology, pathogenesis of the disease caused by these bacteria, determinants of virulence, alterations in signaling, determinants of colonization vs. those of disease, and the limited information we have on the pathophysiology of EPEC-induced diarrhea. This article combines peer-reviewed evidence from our own studies and the results of an extensive literature search in the databases PubMed, EMBASE, and Scopus.

Hypertension treatment capacity in India by increased workforce, greater task-sharing, and extended prescription period: a modelling study.

Background: The worldwide control rate for hypertension is dismal. An inadequate number of physicians to treat patients with hypertension is one key obstacle. Innovative health system approaches such as delegation of basic tasks to non-physician health workers (task-sharing) might alleviate this problem. Massive scale up of population-wide hypertension management is especially important for low- and middle-income countries such as India. Methods: Using constrained optimization models, we estimated the hypertension treatment capacity and salary costs of staff involved in hypertension care within the public health system of India and simulated the potential effects of (1) an increased workforce, (2) greater task-sharing among health workers, and (3) extended average prescription periods that reduce treatment visit frequency (e.g., quarterly instead of monthly). Findings: Currently, only an estimated 8% (95% uncertainty interval 7%-10%) of ∼245 million adults with hypertension can be treated by physician-led services in the Indian public health system (assuming the current number of health workers, no greater task-sharing, and monthly visits for prescriptions). Without task-sharing and with continued monthly visits for prescriptions, the least costly workforce expansion to treat 70% of adults with hypertension would require ∼1.6 (1.0-2.5) million additional staff (all non-physicians), with ∼INR 200 billion (≈USD 2.7 billion) in additional annual salary costs. Implementing task-sharing among health workers (without increasing the overall time on hypertension care) or allowing a 3-month prescription period was estimated to allow the current workforce to treat ∼25% of patients. Joint implementation of task-sharing and a longer prescription period could treat ∼70% of patients with hypertension in India. Interpretation: The combination of greater task-sharing and extended prescription periods could substantially increase the hypertension treatment capacity in India without any expansion of the current workforce in the public health system. By contrast, workforce expansion alone would require considerable, additional human and financial resources. Funding: Resolve to Save Lives, an initiative of Vital Strategies, was funded by grants from Bloomberg Philanthropies; the Bill and Melinda Gates Foundation; and Gates Philanthropy Partners (funded with support from the Chan Zuckerberg Foundation).

Understanding the Role of Staff Nurses in Hypertension Management in Primary Care Facilities in India: A Time-Motion Study.

INTRODUCTION: India is facing a shortage of staff nurses; thus, a better understanding of nurses' workloads is essential for improving and implementing noncommunicable disease (NCD) control strategies. We estimated the proportion of time spent by staff nurses on hypertension and other NCD activities in primary care facilities in 2 states in India. METHODS: We conducted a cross-sectional study in 6 purposively selected primary care facilities in Punjab and Madhya Pradesh during July through September 2021. We used a standardized stopwatch to collect data for time spent on direct hypertension activities (measuring blood pressure, counseling, recording blood pressure measurement, and other NCD-related activities), indirect hypertension activities (data management, patient follow-up calls), and non-NCD activities. We used the Mann-Whitney U test to compare the median time spent on activities between facilities using paper-based records and the Simple mobile device-based app (open-source software). RESULTS: Six staff nurses were observed for 213 person-hours. Nurses spent 111 person-hours (52%; 95% CI, 45%-59%) on direct hypertension activities and 30 person-hours (14%; 95% CI, 10%-19%) on indirect hypertension activities. The time spent on blood pressure measurement (34 minutes) and documentation (35 minutes) was the maximum time on any given day. Facilities that used paper records spent more median time (39 [IQR, 26-62] minutes) for indirect hypertension activities than those using the Simple app (15 [IQR, 11-19] minutes; P < .001). CONCLUSION: Our study found that hypertension activities required more than half of nurses' time in India's primary care facilities. Digital systems can help to reduce the time spent on indirect hypertension activities.

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.

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.

Metabolic switching and cell wall remodelling of Mycobacterium tuberculosis during bone tuberculosis.

OBJECTIVES: Bone tuberculosis (TB) is the third most common types of extrapulmonary tuberculosis. It is critical to understand mycobacterial adaptive strategies within bone lesions to identify mycobacterial factors that may have role in disease pathogenesis. METHODS: Whole genome microarray was used to characterize the in-vivo transcriptome of Mycobacterium tuberculosis (M.tb) within bone TB specimens. Mycobacterial virulent proteins were identified by bioinformatic software. An in vitro osteoblast cell line model was used to study the role of these proteins in bone TB pathogenesis. RESULTS: 914 mycobacterial genes were significantly overexpressed and 1688 were repressed in bone TB specimens. Pathway analysis of differentially expressed genes demonstrated a non-replicative and hypometabolic state of M.tb, reinforcement of the mycobacterial cell wall and induction of DNA damage repair responses, suggesting possible survival strategies of M.tb within bone. Bioinformatics mining of microarray data led to identification of five virulence proteins. The genes encoding these proteins were also upregulated in the in vitro MC3T3 osteoblast cell line model of bone TB. Further, exposure of osteoblast cells to two of these virulence proteins (Rv1046c and Rv3663c) significantly inhibited osteoblast differentiation. CONCLUSION: M.tb alters its transcriptome to establish infection in bone by upregulating certain virulence genes which play a key role in disturbing bone homeostasis.

The India Hypertension Control Initiative-early outcomes in 26 districts across five states of India, 2018-2020.

Hypertension is the leading single preventable risk factor for cardiovascular disease. The India Hypertension Control Initiative (IHCI) project was designed to improve hypertension control in public sector clinics. The project was launched in 2018-2019 in 26 districts across five states: Punjab (5), Madhya Pradesh (3), Kerala (4), Maharashtra (4), and Telangana (10), with five core strategies: standard treatment protocol, reliable supply of free antihypertensive drugs, team-based care, patient-centered care, and an information system to track individual patient treatment and blood pressure control. All states implemented simple treatment protocols with three drugs: a long-acting dihydropyridine calcium channel blocker (amlodipine), angiotensin receptor blocker (telmisartan), and thiazide or a thiazide-like diuretic (hydrochlorothiazide or chlorthalidone). Medication supplies were adequate to support at least one month of treatment. Overall, 570,365 hypertensives were enrolled in 2018-2019; 11% did not have follow-up visits in the most recent 12 months. Clinic-level blood pressure control averaged 43% (range 22-79%) by Jan-March, 2020. The proportion of the estimated people with hypertension who had it controlled and documented in public clinics increased three-fold, albeit from very low levels (1.4-5.0%). The IHCI demonstrated the feasibility of implementing protocol-based hypertension treatment and control supported by a reliable drug supply and accurate information systems at scale in Indian primary health care facilities. Lessons from the IHCI's initial phase will inform plans to improve screening in health care facilities, increase retention in care, and ensure a sustained supply of drugs as part of a nationwide hypertension control program.

Comparison of complete and spatial sampling frames for estimation of the prevalence of hypertension and diabetes mellitus.

A complete sampling frame (CSF) is needed for the development of probability sampling structures; utilisation of a spatial sampling frame (SSF) was the objective of the present study. We used two sampling methods, simple random sampling (SRS) and stratified random sampling (STRS), to compare the prevalence estimates delivered by a CSF to that by a SSF when applied to self-reported hypertension and diabetes mellitus in a semi-urban setting and in a rural one. A CSF based on Geodatabase of all households and all individuals was available for our study that focused on adults aged 18-69 years in the two settings. A single digitized shapefile of solely household regions/structures as SSF was developed using Google Earth and employed for the study. The results from the two sampling frames were similar and not significantly different. All 95%CI calculations contained the prevalence rates of the two medical conditions except for one occasion based on STRS and CSF. The SRS based on CSF showed a minimum 95% CI width for diabetes mellitus, whereas SSF showed a minimum 95% CI width for hypertension. The coefficient of variation exceeded 10.0% on six occasions for CSF but only once for SSF, which was found to be as efficient as CSF.

India Field Epidemiology Training Program Response to COVID-19 Pandemic, 2020-2021.

The India Field Epidemiology Training Program (FETP) has played a critical role in India's response to the ongoing COVID-19 pandemic. During March 2020-June 2021, a total of 123 FETP officers from across 3 training hubs were deployed in support of India's efforts to combat COVID-19. FETP officers have successfully mitigated the effect of COVID-19 on persons in India by conducting cluster outbreak investigations, performing surveillance system evaluations, and developing infection prevention and control tools and guidelines. This report discusses the successes of select COVID-19 pandemic response activities undertaken by current India FETP officers and proposes a pathway to augmenting India's pandemic preparedness and response efforts through expansion of this network and a strengthened frontline public health workforce.