Expanding Roles of Accredited Social Health Activists (ASHAs) in the 2019 Hepatitis E Outbreak in a Peri-urban Slum, Nagpur, India.

OBJECTIVE: Due to constraints in the dedicated health work force, outbreaks in peri-urban slums are often reported late. This study explores the feasibility of deploying Accredited Social Health Activists (ASHAs) in outbreak investigation and understand the extent to which this activity gives a balanced platform to fulfil their roles during public health emergencies to reduce its impact and improve mitigation measures. METHODS: Activities of ASHAs involved in the hepatitis E outbreak were reviewed from various registers maintained at the subcenter. Also, various challenges perceived by ASHAs were explored through focus group discussion (FGD). During March to May 2019, 13 ASHAs involved in the hepatitis outbreak investigation and control efforts in a peri-urban slum of Nagpur with population of around 9000. In total, 192 suspected hepatitis E cases reported. RESULTS: During the outbreak, ASHAs performed multiple roles comprising house-to-house search of suspected cases, escorting suspects to confirm diagnosis and referral, community mobilization for out-reach investigation camps, risk communication to vulnerable, etc. During the activity, ASHAs faced challenges such as constraints in the logistics, compromise in other health-related activities, and challenges in sustaining behavior of the community. CONCLUSIONS: It is feasible to implement the investigation of outbreaks through ASHAs. Despite challenges, they are willing to participate in these activities as it gave them an opportunity to fulfil the role as an activist, link worker, as well as a community interface.

Haematology audit of 801 COVID-19 patients' basics and beyond- Prospective observational study.

Background and Objective: COVID-19 has become a major health concern since 2020. Its clinical presentation varies from asymptomatic cases to cases with respiratory failure needing ICU management. It has created a huge burden on limited health care resources. We need better understanding of the pathogenesis and interplay between virus and other factors which decide outcome. We seek biomarkers to predict severe illness to offer better triaging of patients to provide hospital-based care to the patients at risk of severe illness. Material and Methods: We took 801 consecutive RT-PCR-positive COVID cases coming to our center. Their hematological work-up, such as complete blood count, peripheral smear, reticulocyte count, and G6PD activity, was tested. The pattern of hematological abnormalities was assessed across disease severity groups to identify predictors of severe illness from basic investigation. Also, the interplay between iron deficiency and possible hemoglobinopathy trait and COVID was explored. Results Discussion and Conclusion: We found old age, male gender, diabetes, neutrophilia, lymphopenia, monocytopenia, and eosinopenia at presentation to be associated with moderate to severe illness and may help in triaging with other inflammatory and radiological parameters. We found thrombocytosis rather than thrombocytopenia as a predictor of severe illness. Our preliminary findings suggest the need to explore the protective role of hemoglobinopathy traits and iron deficiency against severe COVID illness.

Tracing, Tracking and Treating COVID-19 Associated Rhino-Orbito Cerebral Mucormycosis (ROCM).

Surge in the number of mucormycosis cases following second wave of coronavirus disease-19 (COVID-19) infection posed several diagnostic and prognostic challenges. This study was aimed to describe clinical, diagnostic features and survival outcomes among patients of mucormycosis in post COVID-19 context. Retrospective chart review. This study included 44 COVID-19 positive screened cases who presented with clinical features suggestive of mucormycosis. Demography, clinical profile, diagnostic findings, and the treatment outcome are studied. Medical and surgical outcomes are summarised as frequencies and percentages. The reliability of microbiological, and radiological findings against the pathological findings was analyzed using Kappa statistics (k). Based on constellation of microbiological, pathological and radiological findings 28 cases (63%) confirmed with mucormycosis infection. The mean (SD) age was 54.9 (12.9) years and two-third were males. The majority (90%) of cases presented with the feature of facial swelling, headache nasal blockade. Inpatient care for treatment of COVID-19 was recorded in 33 (75%). Diabetes mellitus was the commonest comorbidity in 27 (61.4%), 38 (86.4%) cases were treated by steroids and 30 (68.2%) were given oxygen therapy. There is a strong agreement (k = 0.83) between pathological and microbiological investigations. In thirty-eight cases (86.3%) remission was achieved when assessed after 8 weeks. Of the 44 cases, four patients died. The results of the current study suggest that the disease residues and/or recurrences in critical areas are frequent in mucormycosis. However, using the strategy of screening at risk patients, diagnosing, treating them with combination of antifungals, surgical debridement, and timely follow up may help in improving outcomes as compared to pre COVID-19 era.

Hyperglycemia and steroid use increase the risk of rhino-orbito-cerebral mucormycosis regardless of COVID-19 hospitalization: Case-control study, India.

BACKGROUND: In the ongoing COVID-19 pandemic, an increased incidence of ROCM was noted in India among those infected with COVID. We determined risk factors for rhino-orbito-cerebral mucormycosis (ROCM) post Coronavirus disease 2019 (COVID-19) among those never and ever hospitalized for COVID-19 separately through a multicentric, hospital-based, unmatched case-control study across India. METHODS: We defined cases and controls as those with and without post-COVID ROCM, respectively. We compared their socio-demographics, co-morbidities, steroid use, glycaemic status, and practices. We calculated crude and adjusted odds ratio (AOR) with 95% confidence intervals (CI) through logistic regression. The covariates with a p-value for crude OR of less than 0·20 were considered for the regression model. RESULTS: Among hospitalised, we recruited 267 cases and 256 controls and 116 cases and 231 controls among never hospitalised. Risk factors (AOR; 95% CI) for post-COVID ROCM among the hospitalised were age 45-59 years (2·1; 1·4 to 3·1), having diabetes mellitus (4·9; 3·4 to 7·1), elevated plasma glucose (6·4; 2·4 to 17·2), steroid use (3·2; 2 to 5·2) and frequent nasal washing (4·8; 1·4 to 17). Among those never hospitalised, age ≥ 60 years (6·6; 3·3 to 13·3), having diabetes mellitus (6·7; 3·8 to 11·6), elevated plasma glucose (13·7; 2·2 to 84), steroid use (9·8; 5·8 to 16·6), and cloth facemask use (2·6; 1·5 to 4·5) were associated with increased risk of post-COVID ROCM. CONCLUSIONS: Hyperglycemia, irrespective of having diabetes mellitus and steroid use, was associated with an increased risk of ROCM independent of COVID-19 hospitalisation. Rational steroid usage and glucose monitoring may reduce the risk of post-COVID.

Bacterial Isolates and Antibiotic Resistance of Escherichia coli Isolated from Fresh Poultry Excreta Used for Vegetable Farming in Freetown, Sierra Leone.

The transfer of antibiotic resistance from animals to humans is of concern in recent times. One potential source of such transfer is the untreated poultry excreta used as manure in farming. We aim to identify bacterial isolates and antibiotic susceptibility patterns of Escherichia coli in poultry excreta in Sierra Leone. This was a cross-sectional study of fresh poultry excreta samples collected from four commercial poultry sites in Freetown, Sierra Leone, from June−September 2021. Bacterial isolates were tested against eight antibiotics using established standards. Of 100 samples, 93 showed Escherichia coli (93%): of those, eight isolates also had Salmonella (8%). E. coli was 100% resistant to all three 'Watch' drugs (erythromycin, cefoxitin and streptomycin) and tetracycline. E. coli was least resistant to ampicillin (12%), followed by chloramphenicol (35%). The prevalence of multidrug resistance was 95.6%. Multiple antibiotic resistance index ranged from 0.5−0.7 (optimal < 0.2), indicating high prior exposure to antibiotics in these poultries. Such high levels of resistance in E. coli isolated from poultry excreta could pose a serious threat to humans. We recommend (i) routine surveillance to monitor antibiotic resistance in poultry excreta, (ii) using poultry excreta as manure only after treatment and (iii) restricting the use of antibiotics as prophylactics and growth promoters in poultry feeds.

Antibiotic Use in Suspected and Confirmed COVID-19 Patients Admitted to Health Facilities in Sierra Leone in 2020-2021: Practice Does Not Follow Policy.

Inappropriate use of antibiotics during the COVID-19 pandemic has the potential to increase the burden of antimicrobial resistance. In this study, we report on the prevalence of antibiotic use and its associated factors among suspected and confirmed COVID-19 patients admitted to 35 health facilities in Sierra Leone from March 2020-March 2021. This was a cross-sectional study using routinely collected patient data. Of 700 confirmed COVID-19 patients, 47% received antibiotics. The majority (73%) of the antibiotics belonged to the 'WATCH' group of antibiotics, which are highly toxic and prone to resistance. The most frequently prescribed antibiotics were azithromycin, ceftriaxone, amoxicillin, metronidazole, and amoxicillin-clavulanic acid. Antibiotic use was significantly higher in patients aged 25-34 years than in those with severe disease. Of 755 suspected COVID-19 patients, 61% received antibiotics, of which the majority (58%) belonged to the 'WATCH' category. The most frequently prescribed antibiotics were ceftriaxone, metronidazole, azithromycin, ciprofloxacin, and amoxycillin. The prevalence of antibiotic use among suspected and confirmed COVID-19 patients admitted to healthcare facilities in Sierra Leone was high and not in line with national and WHO case management guidelines. Training of health care providers, strengthening of antimicrobial stewardship programs, and microbiological laboratory capacity are urgently needed.

Conventional Naso-Oropharyngeal Sampling Versus Self-Collected Saliva Samples in COVID-19 Testing.

Comparing the diagnostic utility of salivary specimen samples with conventional nasopharynx-oropharynx (NP-OP) specimen samples to identify COVID-19 cases by reverse transcription-polymerase chain reaction (RT-PCR). Eighty COVID-19 suspects enrolled for the paired sampling. In addition to conventional sampling, suspects were asked to follow stepwise pictorial instructions for self salivary sampling. Separate nylon swab stick was used for taking the samples from NP-OP and the floor of the oral cavity. The data were analyzed for sensitivity, specificity, concordance of COVID-19 status, and limits of agreement for cycle threshold (ct) values by either method. Forty-nine suspects (61.3%) were males, the mean age was 36.4 years. To determine the diagnostic test performance of the saliva, RT-PCR results of the NP-OP samples were used as the reference standard. Out of 80 suspects, 41 showed positivity by NP-OP swabs and 12 by salivary samples. The salivary samples showed significantly lesser positivity rate. The sensitivity and specificity of salivary samples against conventional reference standards are 24.4%, 94.9% respectively. Concordance of these two types of samples in terms of agreement kappa statistics is estimated as K = 0.252 (0.09-0.42). Median ct values of both the E and ORF1ab gene for the salivary samples were higher compared to the corresponding NP-OP sample. This study showed lesser sensitivity with salivary swab samples as compared to conventional NP-OP sampling for RT-PCR, COVID-19 detection. Hence, we are of opinion that more studies are required to establish the utility of salivary sampling in COVID-19 diagnostics.

Urban health and nutrition day or only immunisation day? barriers and bottlenecks in implementing Urban health and nutrition day in an Urban primary health centre of Nagpur, Central India.

BACKGROUND: This study was carried out to evaluate the implementation status of Urban Health and Nutrition Day (UHND) and to explore barriers and bottlenecks as perceived by community-level service providers in the selected city of Nagpur, Maharashtra. MATERIAL AND METHODS: This mixed-method study was conducted using a triangulation design. An initial gap assessment was carried out quantitatively using an observation checklist. Focus group discussion among ASHAs and interviews among frontline health workers involved in community mobilisation were carried out to understand the bottlenecks and barriers. RESULTS: Supplies of drugs and logistics, like paediatric iron and folic acid tablets, calcium tablets, and weighing machines, were inadequate. Services like distribution of conventional contraceptives, testing for malaria, urine albumin/sugar, haemoglobin estimation, screening for diabetes and hypertension, sputum collection, and qualitative iodine test kits are not available in any of the UHND sessions. Major challenges in the implementation of UHND were found to be as follows: unserved areas and left-out urban slum pockets; the distribution paradox of UHND location with an ill-defined geographic boundary; restriction of range of services to antenatal registration and immunisation with gross neglect of other components; suboptimal training of staff; insufficient availability of space, logistics, and health manpower; non-involvement of community members and Urban Local Bodies; and poor monitoring and supervision. CONCLUSION: The conduct, use, and list of services offered in UHND are far from the desired goal. For optimal use, reallocation of the UHND sessions, preferably in unserved and underserved slums, need to be carried out after suitable vulnerability assessment. Integration of the Health, Women, and Child Department and Urban Local Bodies is required for convergent planning, monitoring, and supervision.

Exploration of dietary diversity and its associated factors among infant and young children in Rural Tamil Nadu - A mixed-method study.

BACKGROUND: A child receiving an acceptable diet is expected to reach the optimal anthropometric measures. More than 60% of dietary requirement has to be met through complimentary diet. OBJECTIVES: This aimed to estimate the prevalence of dietary diversity and to assess factors associated with it from caregivers' perceptions by quantitative and qualitative participatory techniques. METHODS: A mixed-method study comprising community-based cross-sectional quantitative and participatory rural appraisal qualitative components was conducted in 25 villages from the field practice area of medical institute in South India during 2017. Caregivers of eligible children 6-23 months from villages were interviewed regarding various food groups consumed in the last 24 h using a validated checklist. Association of demographic-, child, and mother-related characteristics with inappropriate dietary diversity was identified using multivariate negative log-binomial model. RESULTS: Of the 603 eligible children, 75.1% had inappropriate dietary diversity. Although inappropriate dietary diversity prevailed across all categories, mothers with less than primary education (adjusted prevalence ratio [PR]: 1.26) children <1 year (adjusted PR: 1.29) and not on current breastfeeding (adjusted PR: 1.15) had significantly more inappropriate diversity. Restraining and motivating forces for dietary diversity were initially recorded from free listing and subjected to force-field analysis. Ignorance, lack of literacy, affordability issues, nuclear family pattern, and influence of junk foods are restraining forces. CONCLUSION: Inappropriate dietary diversity among 6-23 months children in the rural block of Tamil Nadu, South India, is extensive (75%). Current Child development programs should focus to address these issues based on these identified contextual factors.

A comparison of swab types on sample adequacy, suspects comfort and provider preference in COVID-19.

AIM: This study was aimed to compare the virological, suspect reported outcomes and provider preferences during COVID-19 swab taking procedure used for sampling. METHODS: The COVID-19 suspects are subjected to nasopharyngeal (NP) and oropharyngeal (OP) swabs for testing. Two types of swabs (Nylon and Dacron) are used for sample collection. Prospectively each suspect's response is collected and assessed for self-reported comfort level. The provider's experience with each suspect and virological outcomes recorded separately. The sample adequacy was compared based on swab types and demographic characteristics. RESULTS: A total of 1008 COVID-19 suspects were considered for comparison of various outcomes. Dacron and flocked Nylon swab sticks are used for taking 530 and 478 samples, respectively. Suspects who underwent the procedure using Nylon swabs were six times more likely to have pain/discomfort compared to when Dacron swab was used (Adj RR (95% CI: 6.76 (3.53 to 13, p=0.0001))). The providers perceived six times more resistance with the Nylon swabs compared to Dacron Swabs (Adj RR (95% CI: 5.96 (3.88 to 9.14, p=0.0001))). The pediatric population had a higher rate of blood staining in Dacron swab [Dacron 66 (80.5%); Nylon 51 (54.8%) p=0.0001]. The sample adequacy rate and laboratory positivity rate were not significantly different from each other. CONCLUSIONS: Given the comparable virological outcomes, the difference in suspect and providers comfort should drive swab selection based on characteristics of the suspects. The bulbous Nylon swab caused more pain/discomfort in adults compared to Dacron.

Testing Olfactory and Gustatory Dysfunctions among Quarantine COVID-19 Suspects.

The World Health Organization (WHO) has cautioned on specific respiratory symptoms for suspecting an individual of Corona Virus Disease 2019 (COVID-19). Meanwhile, many suspects are reporting dysfunctions of smell and taste. This study aimed to investigate the percentage of positive COVID-19 who had associated loss of sensation as detected by psychophysical testing. Eight hundred and thirty two suspects were enrolled. At the time of sampling for testing COVID-19 status, olfactory dysfunction (OD) and gustatory dysfunction (GD) tested using odorants like coffee and camphor and solutions of sweet and salty solvants, respectively. The strength of the association between test results of these sensory losses and COVID-19 positivity was assessed by calculating sensitivity, specificity, and predictive values. The responses in positive and negative individuals presented as age-adjusted odds ratio with 95% CI. Seventy six (9.1%) [95% CI: 7.4%-11.3%] of 832 suspects were tested positive for COVID-19. Paediatric cases of age between 2 and 10 years could not reply appropriately, hence OD in 134 and GD in 118 could not be tested. Anosmia or hyposmia was present in 62 (81.6%) and ageusia in 64 (84.2%) of the total 76 confirmed cases. The OD and GD dysfunctions were significantly higher among confirmed COVID-19 cases compared to negative subjects [Adj OR (95% CI): Smell 3.22 (1.77-5.88); taste 3.05 (1.61-5.76), p < 0.001]. In this study, testing of smell and taste dysfunctions had higher sensitivity in identifying recent-onset loss of sensations in COVID-19 cases. Hence, it may be used as a simple and cost-effective screening test.

High Prevalence of Prehypertension and its Association with Modifiable Risk Factors: Findings of Household STEPS Survey from Urban Puducherry, South India.

BACKGROUND: Prehypertension increases the likelihood of hypertension, cardiovascular diseases, and renal failure, and it is amenable to control if it is detected early. The burden of prehypertension prevalent in the community is not much explored. This study aimed to estimate the prevalence and to identify the socio-behavioral and dietary factors related to prehypertension in South India. METHODS: A community-based cross-sectional study was carried out where data related to socio-demographic status, substance use, dietary patterns, physical activity, and associated comorbidities were assessed using the WHO STEPwise survey tool. Adults aged >=18 years who were not previously diagnosed and treated for hypertension were assessed for prehypertension. Prevalence of prehypertension is reported as percentage with 95% CI. Association was reported as adjusted prevalence ratio obtained through multivariable log binomial regression adjusted for potential confounders. RESULTS: Among 2399 participants, 2213 underwent screening. Among 2213 adults, 810 (36.6%, 95% CI: 34.6-38.6%) were in the prehypertension range. The adjusted prevalence for prehypertension was 36.2% among males and 37.2% among females, respectively. Being in the age group of 45-54 years aPR-1.36, body mass index (BMI) >23 Kg/m2 aPR-1.25, consumption of more than 6 grams of salt per day aPR-1.15 times were more likely to be associated with prehypertension. The comorbid conditions such as diabetes are less likely to be associated with prehypertension aPR-0.54 (0.41-0.72). CONCLUSIONS: This community-based surveillance showed 36% of prehypertension among adults which would have been missed if we were to follow the routine cares such as opportunistic and high-risk-based screening. Since prehypertension increases the risk for various end organ failures, there is an impending need to focus on screening and promote healthy lifestyles.

Geospatial clustering, seasonal trend and forecasting of Kyasanur Forest Disease in the state of Goa, India, 2015-2018.

INTRODUCTION: Five states in India are reporting sporadic outbreaks of Kyasanur Forest Disease (KFD). Goa experienced an outbreak of KFD in 2015. It remains as an important differential diagnosis for tropical fever in the endemic regions. Few studies among neighboring two states (Karnataka and Kerala) have described the epidemiological characteristics of KFD. However, there is no study which describes the same among cases in the state of Goa. Hence, we planned to understand the epidemiology (time, place, and person distribution) of the disease including seasonal pattern with forecasting using zero-inflated negative binomial regression and time series models. We also explored geo-spatial clustering of KFD cases in Goa during 2015-2018 which would help design effective intervention to curb its transmission in Goa. RESULTS: Blood samples of all suspected cases of KFD during 2015 to 2018 were tested using reverse transcriptase-polymerase chain reaction technique. Reports of these results were periodically shared with the state surveillance unit. Records of 448 confirmed cases of KFD available at the State Integrated Disease Surveillance Programme were analyzed. The mean (SD) age of the patients was 41.6 (14.9) years. Of 143 cases with documented travel history, 135 (94.4%) had history of travel to forest for cashew plucking. Two thirds of cases (66.3%) did not receive KFD vaccine prior to the disease. Case fatality rate of 0.9% was reported. Seasonal peaks were observed during January to April, and forecasting demonstrated a peak in cases in the subsequent year also during January-April persisting till May. Around 40 villages located along the Western Ghats had reported KFD, and affected villages continued to report cases in the subsequent years also. Case density-based geographic maps show clustering of cases around the index village. CONCLUSION: Most of the confirmed cases did not receive any vaccination. KFD cases in Goa followed a specific seasonal pattern, and clustering of cases occurred in selected villages located in North Goa. Most of the patients who had suffered from the disease had visited the forest for cashew plucking. Planning for public health interventions such as health education and vaccination campaigns should consider these epidemiological features.

Halving Time of BCR-ABL1 in Chronic Myeloid Leukemia: Is It Better Than Day-90 Value-A Multicenter Study From South India.

BACKGROUND: The 90-day BCR-ABL1 (breakpoint cluster region-Abelson 1) level has been one of the accepted milestones for predicting the molecular response in patients with chronic myeloid leukemia (CML). The rate of decline in BCR-ABL1 has been considered a better predictor of the response but has not been uniformly accepted. A paucity of evidence is available to predict the accuracy of the rate of decline in the Indian context. Therefore, we tested the accuracy of the rate of decline of BCR-ABL1 in predicting the molecular response compared with the single 90-day values in a retrospective cohort study of selected cancer centers in south India. METHODS AND MATERIALS: Patients with chronic-phase CML diagnosed from January 2013 to December 2018, the serial BCR-ABL1 levels were estimated at 0, 45, and 90 days, 6 months, and 1 year. Data on patient demographics, risk stratification assessed using the Sokal and EUTOS (European Treatment and Outcome Study) scores were extracted using a mobile-based data capture tool from the medical records of the enrolled patients. The halving time, determined by log reduction, was compared with the 90-day BCR-ABL1 values using the receiver operating characteristic curve for the major and complete molecular response at 6 months and 1 year as standards. Accuracy was determined from the area under the curve. The cutoff for the halving time was chosen to balance the sensitivity and specificity. RESULTS: The rate of decline had more predictive accuracy compared with the 90-day BCR-ABL1 values (area under the curve for rate of decline, 0.83; 90-day, 0.80). A halving time of < 20 days identified 95% of the patients who had achieved major molecular response at 12 months compared with 80% using the single 90-day BCR-ABL1 response. CONCLUSIONS: The halving time of BCR-ABL1 appears promising as a predictor of the outcomes for patients with CML.

Injury and its associated factors among residents of an urban slum during the festival month in South India: A community-based survey.

INTRODUCTION: Injury morbidity and mortality have been steadily increasing in both developed and developing countries including India. The current study tried to assess the incidence of injury and identify the risk factors associated with injuries during the festival month in a selected urban area in Puducherry. METHODS: It is a community-based cross-sectional survey conducted among the residents in the urban field practice area of a medical college in Puducherry. Participants were interviewed using a pretested questionnaire. Information on the incidence of injury and its associated factors were collected. Data were entered in EpiData and analyzed using Stata. Generalized linear models with Poisson distribution were used to identify the risk factors associated with the injuries. RESULTS: Overall, 1380 participants from two selected clusters were interviewed. The incidence rate of injuries was 5.2% (95% CI: 4.0-6.4). In adjusted analysis male (RR 1.96, 95% CI: 1.15-3.37) and student (RR 2.91, 95% CI: 1.13-7.54) were independently associated with having an injury. Most of the injuries were unintentional and accidental. CONCLUSION: The reported incidence of at least one injury was 52 per 1000 population per month and the majority were accidental in nature. It was higher during the festival week. Public health strategies at the primary healthcare level targeting adult males and school children will be effective in the reduction and prevention of injury.

Delays in Diagnosis and Treatment of Breast Cancer and the Pathways of Care: A Mixed Methods Study from a Tertiary Cancer Centre in North East India.

INTRODUCTION: In India, mortality rate in breast cancer is high because more than half are diagnosed late at locally advanced or metastatic stages. This might be due to presentation delay (recognition of symptoms to first provider consultation) and treatment delay (first provider consultation to initiation of treatment), together known as overall delay. We aimed to estimate the overall delay in diagnosis and treatment in breast cancer and the associated factors, describe pathway of care and explore the reasons for delay from a patients' and providers' perspective. METHODS: Explanatory sequential mixed-methods study with a quantitative component (retrospective cohort study including breast cancer patients registered at Dr. Borooah Cancer Institute (BBCI), Guwahati during February-June 2019) followed by descriptive qualitative component (in-depth interviews with 15 patients and 10 care providers). RESULTS: Of 269 breast cancer patients, median (Inter Quartile Range) overall delay was 203 (110-401) days, presentation delay was 35 (10-112) days and treatment delay was 130 (75-258) days. Majority of patients approached private sector (190, 70.6%) as the first care provider. Nearly half of all patients (136, 50.6%) visited one health care provider before reaching the BBCI and another one-third (90, 33.5%) visited two providers. Reasons for presentation delay were misconception about the disease, perceived stigma, fear and denial of cancer, attribution of symptoms to trivial conditions, family responsibilities and embarrassment of breast examination by a male doctor. Treatment delay was due to initial visit to, misclassification of disease severity, dissatisfaction with care at public facilities, poor accessibility and affordability, fear of treatment and its side effects. CONCLUSION: Treatment delay was the major contributor to overall delay. Private providers need to be sensitized and trained in screening of breast cancer and referral of suspected cases of cancer. More awareness is needed about warning symptoms of breast cancer and misconceptions regarding the disease.
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Coverage of mass drug administration for elimination of lymphatic filariasis in urban Nagpur, Central India: A mixed method study.

BACKGROUND AND AIMS: Mass Drug Administration (MDA) coverage remains an important indicator in elimination of Lymphatic Filariasis (LF), especially in context of recent changes in programme strategies in India, such as incorporation of Ivermectin and involvement of urban Accredited Social Health Activists (ASHAs). This study aimed at assessing the coverage and compliance with MDA of Filariasis as well as exploring perspective of beneficiaries for non-consumption in selected slum area of Nagpur city. METHODS: Mixed-method study design comprising of quantitative assessment of MDA coverage, followed by qualitative method to explore the reasons of non-compliance was used in selected slum areas of Nagpur city. Using cluster sampling, 240 households were selected and house-to-house visits were made to interview the eligible participants. In-depth interviews were conducted among selected non-compliant participants. STATISTICAL ANALYSIS: Multivariable logistic regression analysis to identify the factors associated with non-consumption. Thematic analysis was done to obtain the reasons of non-consumption as perceived by the beneficiaries. RESULTS: Among the 1096 individuals studied, distribution and consumption coverage were 55.2% and 48.5%, respectively. Effective supervised consumption was further low (28.9%). Coverage compliance gap (CCG) was 12.1%. Male sex and younger age (2-5 years) were significant socio-demographic determinants of non-consumption. No repeat visit to houses left in first round, fear of side effects, pill burden, poor understanding about the need were important reasons as revealed by qualitative inquiry. CONCLUSION: Effective pre-campaign awareness, incorporation of context specific drug delivery strategies and strengthening monitoring system are essential for successful MDA implementation.

Clustering of cardiovascular disease risk factors - Syndemic approach: Is sit a time to shift toward integrated noncommunicable disease clinic?

BACKGROUND: The concurrent occurrence of many noncommunicable disease (NCD) risk factors is common, and it can play a synergistic role in occurrence of NCDs. OBJECTIVES: This study aimed to identify the magnitude of clustering of NCD risk factors, patterns of risk factors emerged in clustering, and variations in clustering of risk factors based on socioeconomic factors. METHODS: A cross-sectional survey was undertaken in an urban area of Puducherry among 2399 adults during 2014-2015. Sociodemographic and behavioral risk factors were assessed through a validated STEPS survey tool. Individuals with three or more risk factors were classified to have clustering of NCD risk factors. Socioeconomic positions in relation to clustering were identified through Chi-square analysis followed by multiple logistic regression where clustering at family and area was adjusted through multilevel modeling techniques. RESULTS: Of the 2399 adults, 1741 (73%) had clustering of NCD risk factors. Inadequate consumption of fruits and vegetables, high salt intake, and high waist circumference are the three predominant risk factors across all subgroups. Adults belonging to Christian religion (adjusted odds ratio [adjOR]: 2.8, 95% confidence interval [CI]: 1.5-5.2), aged 35 years and over (adjOR: 2.0, 95% CI: 1.4-6.0), and illiterates (adjOR: 1.8, 95% CI: 1.1-5.5) are more likely to have clustered NCD risk factors compared to others. CONCLUSIONS: Clustering of NCD risk factors is highly prevalent in this region and mainly driven by dietary practices and obesity measures. There is an urgent need to reorient the health system toward integrated approach with mandated inclusion of nutritionist in NCD health service delivery.

Status of coverage of MR vaccination, after supplementary immunization activities in a rural area of South India: a rapid immunization coverage survey.

INTRODUCTION: After a commendable achievement on polio-free status for the South-East Asian Region (SEAR), WHO is now focusing towards measles elimination, which is still a major contributor of under-five mortality in SEAR. India has introduced measles and rubella (MR) vaccination throughout the country through supplementary immunization activity, followed by introducing the same in the routine vaccination. Health indicators and public health system functioning in the southern states of India are good, so India introduced the MR campaign in the southern high-performing states as phase 1 on 5 April 2017. The aim of the campaign was to vaccinate more than 95% of eligible children (aged 9 months to 15 years). At the same time, rumors and negative campaigning about this initiative started in social media. This study aimed to measure the coverage of MR vaccination among the target population in South India. METHODS: Data was collected immediately after phase 1 of the MR vaccine campaign in April 2017. Data was collected based on the WHO-recommended 30/7 rapid monitoring method. Thirty villages around the Rural Health Training Centre of Pondicherry Institute of Medical Sciences were selected and seven children aged 9 months to 5 years and seven children aged 6 to 15 years from each village were included. Children were classified as 'vaccinated' or 'not vaccinated' based on the WHO 'card or history' method. RESULTS: Among the total sample of 420 children, 380 children (90.5% (range 87.4-93.0%)) were found to be vaccinated and 40 children (9.5% (range 7.0-12.6%)) were found to be unvaccinated. Most of the people came to know about the MR vaccination through auxiliary nurses and midwives, followed by school teachers. The main reasons for not getting vaccinated was fear of an adverse event following vaccination or fear of injection. Reasons for not getting vaccinated were significantly associated with usage of smartphone by at least one of the parents (adjusted odds ratio (OR) 2.1 (1.1-4.2)), better literacy level among mothers (adjusted OR 5.2 (1.1-24.8)) and poor literacy level among fathers (adjusted OR 3.6 (1.1-11.5)). CONCLUSION: Despite the negative propaganda by social media, the coverage of vaccination by the public healthcare providers was near optimal in phase 1, which shows the strength of the public health system in this rural area of southern India. In accordance with the modern technology, public health policymakers should think about and plan information education and communication activities.

Pain Management in Children With Cancer Using World Health Organization Guidelines at a Tertiary Cancer Center in Rural India.

Management of cancer pain among children is a difficult process due to the way they perceive pain, their dependence on parents, complexity of assessment, and limited availability of safe analgesics. Pain among children with cancer is still a less explored problem in India. This descriptive study was carried out in a tertiary cancer center to explore the characteristics of pain and its management among the children with cancer. We analyzed children diagnosed with hematologic malignancies, aged 4-18 years, admitted between January 2013 and December 2017. This retrospective cohort study involved the review of patient records available at the medical records department. During the study period, there were 290 admission episodes, of which 93 (32.1%) episodes were associated with pain. Of these 93 episodes, 14 (15%) were primarily for pain management. Step I analgesic was utilized in the majority (83%) of the admission episodes involving younger age group (4-9 years) children, whereas for the older age group (10-18 years) Step 2 analgesic (tramadol) was utilized in 29 (58%) episodes, and this was found to be statistically significant (P < .001). Only in 9 (9.7%) episodes Step 3 analgesic was utilized. A significant proportion of children with hematologic malignancies had pain episodes, and these episodes in older age group children were managed with weak opioids.