Out of Pocket Expenditure for Hospitalization among Below Poverty Line Households in District Solan, Himachal Pradesh, India, 2013.

INTRODUCTION: Health insurance schemes, like Rashtriya Swasthya Bima Yojana (RSBY), should provide financial protection against catastrophic health costs by reducing out of pocket expenditure (OOPE) for hospitalizations. We estimated and compared the proportion and extent of OOPE among below poverty line (BPL) families beneficiaries and not beneficiaries by RSBY during hospitalizations in district Solan, H.P., India, 2013. METHODS: We conducted a cross sectional survey among hospitalized BPL families in the beneficiaries and non-beneficiaries groups. We compared proportion incurring OOPE and its extent during hospitalization, pre/post-hospitalization periods in different domains. RESULTS: Overall, proportion of non-beneficiaries who incurred OOPE was higher than the beneficiaries but it was not statistically significant (87.2% vs. 80.9%). The median overall OOPE was $39 (Rs 2567) in the non-beneficiaries group as compared to $11 (Rs 713) in the beneficiaries group (p<0.01). Median expenditure on in house and out house drugs and consumables was $23 (Rs 1500) in the non beneficiaries group as compared to nil in the beneficiaries group (p<0.01). Non-beneficiary status was significantly associated [OR: 2.4 (1.3-4.3)] with OOPE above median independently and also after adjusting for various covariates. CONCLUSION: RSBY has decreased the extent of OOPE among the beneficiaries; however OOPE was incurred mainly due to purchase of drugs from outside the health facility. The treatment seeking behaviour in beneficiaries group has improved among comparatively older group with chronic conditions. RSBY has enabled beneficiaries to get more facilities such as drugs, consumables and diagnostics from the health facility.

Application of lot sampling of sputum AFB smears for the assessment of microscopy centres.

SETTING: Designated microscopy centres (DMC) and additional microscopy centres (AMC) performing sputum acid-fast bacilli (AFB) microscopy, the District TB Centre (DTC) and a reference laboratory (RL). OBJECTIVES: To ascertain the feasibility of adopting lot sampling of AFB smears and to assess the performance of MCs employing Senior Tuberculosis Laboratory Supervisors (STLS) with no knowledge about the principles of quality assurance of AFB microscopy and RL-based laboratory technicians with training on quality assurance for blinded checking of AFB smears. METHODS: Slides from MCs were transported to the DTC and the RL; 20 smears per month per MC were selected systematically; 1547 slides from DMCs and 726 from AMCs were checked, respectively, by STLSs at the DTC and by RL laboratory technicians. Discrepancies were resolved by referee. RESULTS: The discrepancy between MC laboratory technicians and STLSs at the DTC was 4.7%, compared to 1% at the RL. The STLSs and RL-based laboratory technicians had 70 and 2 errors, respectively. CONCLUSIONS: Lot sampling of AFB smears is feasible under field conditions. Assessment of MCs was more valid with RL-based technicians trained in principles of quality assurance of sputum AFB microscopy than with STLSs with no such training and working in the field.

Lot quality assurance sampling of sputum acid-fast bacillus smears for assessing sputum smear microscopy centers.

Assessment of 12 microscopy centers in a tuberculosis unit by blinded checking of eight sputum smears selected by using a lot quality assurance sampling (LQAS) method and by unblinded checking of all positive and five negative slides, among the slides examined in a month in a microscopy centre, revealed that the LQAS method can be implemented in the field to monitor the performance of acid-fast bacillus microscopy centers in national tuberculosis control programs.

Application of lot quality assurance sampling for leprosy elimination monitoring--examination of some critical factors.

BACKGROUND: The concept of elimination of an infectious disease is different from eradication and in a way from control as well. In disease elimination programmes the desired reduced level of prevalence is set up as the target to be achieved in a practical time frame. Elimination can be considered in the context of national or regional levels. Prevalence levels depend on occurrence of new cases and thus could remain fluctuating. There are no ready pragmatic methods to monitor the progress of leprosy elimination programmes. We therefore tried to explore newer methods to answer these demands. With the lowering of prevalence of leprosy to the desired level of 1 case per 10000 population at the global level, the programme administrators' concern will be shifted to smaller areas e.g. national and sub-national levels. For monitoring this situation, we earlier observed that lot quality assurance sampling (LQAS), a quality control tool in industry was useful in the initially high endemic areas. However, critical factors such as geographical distribution of cases and adoption of cluster sampling design instead of simple random sampling design deserve attention before LQAS could generally be recommended. The present exercise was aimed at validating applicability of LQAS, and adopting these modifications for monitoring leprosy elimination in Tamil Nadu state, which was highly endemic for leprosy. METHODS: A representative sample of 64000 people drawn from eight districts of Tamil Nadu state, India, with maximum allowable number of 25 cases was considered, using LQAS methodology to test whether leprosy prevalence was at or below 7 per 10000 population. Expected number of cases for each district was obtained assuming Poisson distribution. Goodness of fit for the observed and expected cases (closeness of the expected number of cases to those observed) was tested through chi(2). Enhancing factor (design effect) for sample size was obtained by computing the intraclass correlation. RESULTS: The survey actually covered a population of 62157 individuals, of whom 56469 (90.8%) were examined. Ninety-six cases were detected and this number far exceeded the critical value of 25. The number of cases for each district and the number of cases in the entire surveyed area both followed Poisson distribution. The intraclass correlation coefficients were close to zero and the design effect was observed to be close to one. CONCLUSIONS: Based on the LQAS exercises leprosy prevalence in the state of Tamil Nadu in India was above 7 per 10000. LQAS method using clusters was validated for monitoring leprosy elimination in high endemic areas. Use of cluster sampling makes this method further useful as a rapid assessment procedure. This method needs to be tested for its applicability in moderate and low endemic areas, where the sample size may need increasing. It is further possible to consider LQAS as a monitoring tool for elimination programmes with respect to other disease conditions.

Components of small area variation in fertility rates among married women in south India.

OBJECTIVE: To adapt and develop a method for finding out what proportion of the variation among small areas in the number of births to married women is excess (systematic) variation over and above the chance (random) variation. METHODS: We adopted a two-stage sampling procedure to select 20 sub-centres in south India. We contacted all households and collected information on recent births and socioeconomic variables from all ever married women aged 15-49 years. Systematic and random components of variance were estimated using Poisson regression, adjusting for socioeconomic factors. RESULTS: Of the observed variance in fertility, 65% is explained by the estimated systematic variation. Though many important explanatory variables are considered, the systematic variance is significant mainly among illiterate women, those aged under 18 years at marriage, the marginalized population, and those with labourer husbands. CONCLUSIONS: Poisson regression can be adapted to estimate the random and systematic components of variation in fertility among small areas. The systematic component of variance can further be adjusted for socioeconomic factors. Identification of the significant predictors will help health planners develop necessary interventions at the small area level.

Implications of genetic traits on vaccine efficacy.

Literature on genetic screening in the community suggests that people having specific genotypes may either get or protect from infection, for example, malaria, human papilloma virus, and haemophilic influenza, for which vaccines are either already developed or being targeted. In such a situation, the evaluation of the efficacy of vaccine in the community needs to be examined with caution. In this paper, I present a method for the estimation of vaccine efficacy (VE) in the presence of genetic traits/component (theta) and the sample size required to estimate the 95 per cent CI with a given relative width for the estimated vaccine efficacy. Considering true efficacy ranging from 40 to 80 per cent and the possible values of the genetic component (theta) ranging from 0 to 60 per cent, the VE was estimated. The 95 per cent confidence intervals (CI) for the estimated VE for relative widths (R) 1.0 and 0.1 were computed. The sample sizes required for each of the unvaccinated and vaccinated cohorts were computed for estimating the 95 per cent CI for given incidence rates in the unvaccinated (Iu) cohort. In the presence of genetic traits I found that the VE was consistently overestimated. There existed change in the location as well as the asymmetry of the 95 per cent CIs over the point estimate of VE. The sample size required for estimating 95 per cent CI of VE was substantially reduced, resulting in savings. The more the genetic component (theta) affecting disease in the community, the more the savings in sample size. I examined the above estimators for (i) VE, (ii) 95 per cent CI for VE and (iii) sample size required for estimating 95 per cent CI of VE using the real-life data from the Haemophilus influenzae type b vaccine trial conducted in Finland and the global genetic structure of encapsulated H. influenza. Because of escalated VE and large savings in sample size for estimating the 95 per cent CI for VE, I recommend that the design should consider the genetic component that causes/protects from infection/disease for the evaluation of efficacy of vaccine in the field.

Natural abundance nitrogen-15 nuclear magnetic resonance spectral studies on selected donors.

The natural abundance 15N-NMR chemical shifts of selected aliphatic amines, 2-substituted pyridine type compounds, bialicyclic tertiary amines have been measured as a function of the nature of the solvent. In the case of cyclic aliphatic amines, like piperidine, morpholine, piperazine, thiomorpholine, the nitrogen is more shielded in concentrated solution compared to that in dilute solution whereas in the hydrogen bonding and protonating solvents there is a prominent deshielding. 2-Substituted pyridines studied can be further divided into four sub groups. The site of hydrogen bonding and protonation in 2-amino, 2-hydroxy and 2-mercapto pyridines have been conclusively proved from the 15N-NMR chemical shifts and the well-known tautomeric forms of the above compounds. Similarly in the case of 2-(2-thienyl)pyridine and 2-(3-thienyl)pyridine, the site of donation has been proved as the nitrogen of the pyridine ring in both the compounds. In a similar manner, the site of hydrogen bonding and protonation in two individual compounds 2-anilinopyridine and 2-(2-pyridyl)benzimidazole have also been established. Among the bialicyclic amines, 1,2-diazabicyclo[2.2.2]octane (DABCO) behaved differently from the other two compounds. In both 1,8-diazabicyclo[5.4.0]undec-7-ene (DBU) and 1,5-diazabicyclo[4.3.0]non-5-ene (DBN), it was possible to show that N1-nitrogen in both the compounds is the site of donation. The effect of the second donor site on the 15N-NMR chemical shift, the site of donation in the selected compounds and some typical compounds reported in literature have been presented and discussed.

Lot quality assurance sampling (LQAS) for monitoring leprosy elimination in an endemic district in Tamilnadu.

This paper examines whether the health administration can use lot quality assurance sampling (LQAS) for identifying high prevalence areas for leprosy for initiating necessary corrective measures. The null hypothesis was that leprosy prevalence in the district was at or above ten per 10,000 and the alternative hypothesis was that it was at or below five per 10,000. A total of 25,500 individuals were to be examined with 17 as an acceptable maximum number of cases (critical value). Two-stage cluster sample design was adopted. The sample size need not be escalated as the estimated design effect was 1. During the first phase, the survey covered a population of 4,837 individuals out of whom 4,329 (89.5%) were examined. Thirty-five cases were detected and this number far exceeded the critical value. It was concluded that leprosy prevalence in the district should be regarded as having prevalence of more than ten per 10,000 and further examination of the population in the sample was discontinued. LQAS may be used as a tool by which one can identify high prevalence districts and target them for necessary strengthening of the programme. It may also be considered for certifying elimination achievement for a given area.

Bronchioloalveolar carcinoma mimicking miliary tuberculosis.

A case of bronchioloalveolar carcinoma, with widespread dissemination to both lungs and miliary mottling on chest X-ray is reported in a 40 year old male.

Prevalence of known diabetes in Chennai City.

AIM: To determine prevalence of known diabetes in those more than 20 years of age in Chennai city. METHODOLOGY: Urban population was selected for the survey. Assuming the prevalence of known diabetes as 5.0% in those aged > 20 years, the cluster sample size calculated to estimate it with 95% CI and +/- 10% precision, was 25800 individuals of all ages. This population obtained from 200 households in each of 30 randomly selected corporation divisions of the city, was surveyed by social workers by house to house enquiry. General information and health status of every member of the household were recorded on prescribed forms. This survey was conducted during January-July, 1998. RESULTS: Among 26,066 individuals of all ages 779 had known diabetes and 99.4% of them had type 2 diabetes. The prevalence of known diabetes was 2.9% for all ages and both sexes combined. Crude and age-standardized prevalence was 4.9% (95% CI 4.6-5.2) for those aged > 20 years. The standardized prevalence was 10.5% (95% CI 9.8 - 11.2) in those aged > or = 40 years. The prevalence was significantly high (P < 0.05) in females. CONCLUSION: The prevalence of known diabetes was low in total population but increased in those aged > 20 and further increased in those aged > or = 40 years. The causes for high prevalence in > or = 40 year age group needs to be explored in this population.

Prevalence and pattern of epilepsy in India.

PURPOSE: To estimate the prevalence of epilepsy in India by meta-analysis of previously published and unpublished studies and to determine patterns of epilepsy by using community-based studies. METHODS: We attempted to identify as many previously published and unpublished studies as possible on the prevalence of epilepsy in India. The studies were assessed with regard to methods and definitions. The prevalence rates for rural and urban populations and for men and women were calculated with a 95% confidence interval (CI). The studies that provided details on age structure, age-specific rates, and patterns of epilepsy were chosen for meta-analysis. Both crude values and age-standardized prevalence rates were calculated after accounting for heterogeneity. RESULTS: Twenty studies were found involving a sample population of 598,910, among whom 3,207 had epilepsy. This resulted in a crude prevalence of 5.35/1,000. After a correction for heterogeneity due to interstudy variation, the overall prevalence per 1,000 (and its 95% CI) was 5.33 (4.25-6.41); with urban areas at 5.11 (3.49-6.73); rural areas, 5.47 (4.04-6.9); men, 5.88 (3.89-7.87); and women 5.51 (3.49-7.53). After correction for the variability in estimates of heterogeneity, age-standardized rates (from five studies) revealed that the prevalence rates per 1,000 (and the 95% CI), were as follows: overall, 5.59 (4.15-7.03); men, 6.05 (3.79-8.31); women, 5.18 (3.04-7.32); urban, 6.34 (3.43-9.25); rural, 4.94 (3.12-6.76). Urban men and women had a higher prevalence of epilepsy compared with rural ones, however the difference was not statistically significant. Age-specific prevalence rates were higher in the younger age group, with the onset of epilepsy reported mostly in the first three decades of the sample population's lives. The treatment gap (i.e., the percentage of those with epilepsy who were receiving no or inadequate treatment) was more than 70% in the rural areas. CONCLUSIONS: Based on the total projected population of India in the year 2001, the estimated number of people with epilepsy would be 5.5 million. Based on a single study on the incidence of epilepsy, the number of new cases of epilepsy each year would be close to half a million. Because rural population constitutes 74% of the Indian population, the number of people with epilepsy in rural areas will be approximately 4.1 million, three fourths of whom will not be getting any specific treatment as per the present standard.

Lot quality assurance sampling for monitoring immunization coverage in Madras City.

OBJECTIVE: To explore the usefulness of Lot Quality Assurance Sampling (LQAS) to identify divisions in a city that had immunization coverage levels of 80% for any of the four EPI vaccines. METHODS: Only 43 divisions were considered for the study, the stratification factor being the death rate. The hypothesis that 80% coverage is 'unacceptable' was stipulated. Critical value (the number of unimmunized children) was chosen as 3. A simple random sample of 36 children in the age-group 12-23 months was taken from each selected division. Since sampling frames of children were not available, a simple random sample of 36 households was selected. Immunization status of each child was assessed by interviewing the child's mother/guardian. If the number of unimmunized children exceeded 3, then the division was regarded having coverage level 80% and rejected. RESULTS: The coverage was classified as unacceptable(i. e., below 80%) in 19 divisions for Polio and DPT vaccines, in 26 divisions for Measles vaccine and in 4 divisions for BCG vaccine. The average time spent for undertaking the LQAS survey was 6 man-days per division. CONCLUSION: This study demonstrated the utility of the LQAS technique in identifying 'unsatisfactory' pockets in Madras City, when the overall coverage was satisfactory. The technique will have greater application with an increase in the number of large units (cities/districts) having an overall coverage of 90% or more.

Somatic embryogenesis and plant regeneration of neem (Azadirachta indica A. Juss.).

Somatic embryos were initiated with mature seeds of neem (Azadirachta indica A. Juss.) when cultured on Murashige and Skoog's medium supplemented with thidiazuron (TDZ). Regeneration occurred via somatic embryogenesis: direct embryo formation and through an intermediary callus phase. TDZ was very effective and induced somatic embryogenesis across a wide range of concentrations (1-50 µM). However, somatic embryogenesis was accompanied by callus formation at concentrations of 20 µM and above. Cell suspension cultures were established with the TDZ-induced callus and groups of large cell clumps were formed within 2-3 weeks. Plants were regenerated from both directly formed somatic embryos and somatic embryos derived from cell suspensions plated on semisolid medium devoid of growth regulators. Regenerated plantlets continued to grow after transfer to a greenhouse environment and were similar phenotypically to zygotic seedlings. This simple regeneration system may be beneficial for mass propagation of selected elite clones of neem.

Induction of high-frequency somatic embryogenesis in geranium (Pelargonium x hortorum Bailey cv Ringo Rose) cotyledonary cultures.

The cv Ringo Rose of hybrid seed geranium (Pelargonium x hortorum Bailey), previously shown to be recalcitrant in culture, produced somatic embryos when cotyledonary explants were cultured on regeneration medium containing thidiazuron (TDZ), forchlorfenuron (CPPU), or a combination of indole-3-acetic acid and N(6) benzylaminopurine (IAA+BAP). Amendment of the basal medium with TDZ (0.5 µM) was the most effective treatment. Addition of amino acids to the medium promoted the growth of somatic embryos. Retention of the proximal region of the cotyledon was crucial for regeneration, but the removal of the distal 1/3 to 1/2 cotyledon had no significant effect on somatic embryogenesis. Cotyledonary explants formed somatic embryos in higher frequency and much earlier than hypocotyl explants cultured on the same medium. The somatic embryos induced on cotyledonary explants were germinated on basal medium. More than 70% of the somatic embryos were converted into plants and transferred to soil.

A concurrent comparison of a WHO-recommended 30-cluster survey and a modified version of it under Indian conditions in the estimation of immunization coverages.

A concurrent comparison of the WHO 30-cluster sample survey method for estimating immunization coverages (DPT, Polio, BCG, Measles) and an Indian modification of (GOI) was undertaken in five districts in South India. The essential difference between the two methods is the manner in which the first household is selected in the chosen clusters. With the WHO method, it is chosen clusters. With the WHO method, it is chosen at random, whereas with the GOI method it is often close to the village centre. Estimates with the required degree of precision, i.e., 95% confidence limits of +/- 10 percentage points, were provided in 18 (90%) of 20 instances by the WHO method and in 19 (95%) by the GOI method, findings which are in accordance with expectation. The estimated coverages were, however, higher by the GOI method than by the WHO method in two districts, lower in one district, and in the remaining two districts there was no clear pattern. On the average, there was a suggestion that the GOI method yielded slightly higher coverages, but the differences were not statistically significant.

A comparison of a 30-cluster survey method used in India and a purposive method in the estimation of immunization coverages in Tamil Nadu.

A 30-cluster survey method that is employed for estimating immunization coverages by the Government of India (GOI) was compared with a Purposive method, to investigate whether the likely omission of SC/ST and backward classes in the former would lead to the reporting of higher coverages. The essential difference between the two methods is in the manner in which the first household is selected in the chosen first stage sampling units (villages). With the GOI method, it is often close to the village centre, whereas with the Purposive method it is always in the periphery or in a pocket consisting of SC/ST or backward classes. A concurrent comparison of the two methods in three districts in Tamil Nadu showed no real differences in the coverage with DPT and BCG vaccines. However, the coverage was consistently higher by the GOI method in the case of the Polio vaccine (by 1.5%, 3.1% and 5.3% in the 3 districts), and the Measles vaccine (by 4.8%, 13.3% and 13.9%); the average difference was 3.3% for Polio vaccine (p = 0.08) and 7.3% for Measles vaccine (p = 0.01).

Somatic embryogenesis in peanut (Arachis hypogaea L.): stimulation of direct differentiation of somatic embryos by forchlorfenuron (CPPU).

The ability of forchlorfenuron (CPPU), a substituted phenylurea compound, for inducing somatic embryogenesis in peanut (Arachis hypogaea L.) seedlings has been demonstrated. CPPU promoted somatic embryogenesis at a range of concentrations in all three peanut cultivars tested. Embryogenic response was dependent on applied CPPU concentrations. Exposure of seedlings for only two days to CPPU induced somatic embryogenesis, but the most effective treatment was to induce seed germination on media supplemented with either 2.5 or 4.0 µM CPPU and to maintain the seedlings on the same medium. Number of somatic embryos and the frequency of embryogenesis was higher for younger seedlings (up to 9 days), regardless of the CPPU concentrations and seedlings older than 21 days failed to produce somatic embryos. Removal of cotyledons from the seeds drastically reduced the embryogenic potential of the seedlings. Somatic embryos developed into whole plants following their separation and subculture on a medium lacking growth regulators. The induction of somatic embryos using CPPU as a sole growth regulator may provide a useful system to study the role of this compound in plant morphogenesis.

Estimation of immunisation coverages in children by WHO 30-cluster survey.

A WHO 30-cluster survey for estimating immunisation coverages in infancy was undertaken in each of 5 districts in Tamil Nadu, strictly according to the specifications laid out in the WHO manual. The main aim was to examine whether the technique would provide estimates with the required degree of precision under Indian conditions. Of 60 sample survey estimates, 57 had the targeted degree of precision (i.e., 95% confidence limits of +/- 10 percentage points), which is in excellent agreement with expectation. The proportions of infants on whom immunisation was initiated, were very high for DPT vaccine (88-99%) and polio vaccine (85-99%); however, of those who had received the first dose, 23-39 per cent did not complete the 3-dose schedule. Estimated coverage with measles vaccine ranged from 15 to 54 per cent, while BCG coverage ranged from 53 to 97 per cent. Better health education regarding the need and correct age for immunisation, and more effective motivation at the time of administration of the first dose of DPT/polio vaccine, are recommended.