Review of the India Adolescent Health Strategy in the context of disease burden among adolescents.

Background: A nuanced understanding of the health needs of adolescents in the context of the India Adolescent Health Strategy (IAHS) is needed to inform policy interventions for improving the health and well-being of adolescents in India. Methods: Using data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019, we identified the top ten causes of years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life years (DALYs) disaggregated by sex and age group (10-14 and 15-19 years) for India and its states in 2019. To inform the IAHS of refinement or expansion in focus needed to improve adolescent health in India, we reviewed the extent to which the top 10 causes of disease burden are addressed in the IAHS, and the availability of and age- and sex-disaggregation in the service utilisation data for adolescents captured in the Adolescent Friendly Health Clinic monitoring information system (AFHC MIS) and Health Management Information System (HMIS). We also reviewed the availability of and age-and sex-disaggregation in the data capture at the population level for the IAHS outcome indicators in the data sources identified in the IAHS operational framework. Findings: Females in the 10-14 and 15-19 years age groups suffered 6.75 million and 9.25 million DALYs, respectively, 39.1% and 44.2% of which were YLLs; the corresponding DALYs for males were 6.71 million and 9.65 million (42.3% and 41.1% YLLs), respectively. Within the 6 thematic areas of the IAHS, most strategies and indicators identified are for sexual and reproductive health followed by nutrition, and broadly these conditions accounted for YLDs and not YLLs in adolescents. Significant gaps in the IAHS in comparison to the disease burden for fatal diseases and conditions were seen across injuries, communicable diseases, and non-communicable diseases. Injuries accounted for 65.9% and 45.3% of YLLs in males and females aged 15-19 years, and 40.8% in males aged 10-14 years. Specifically, road injuries (15.3%, 95% UI 11.0-18.0) and self-harm (11.3%, 95% UI 8.7-14.2) accounted for most of the injury deaths in 15-19 years whereas drowning (7.7% 95% UI 5.8-9.6) and road injuries (6.9%, 95% UI 4.7-8.6) accounted for the most injury deaths in 10-14 years males. However, only self-harm and gender-based violence are specifically addressed in the IAHS with non-specific interventions for other injuries. Diarrhoea, lower respiratory infections, malaria, encephalitis, tuberculosis, typhoid, cirrhosis, and hepatitis are the other disease conditions accounting for YLLs and DALYs in adolescents but these are neither addressed in the IAHS nor in service provision under the AFHC MIS. There is no age- or sex-disaggregation in the cause of death data captured in the HMIS to allow an understanding of mortality in adolescents. For the IAHS outcome indicators at the population level, data capture for the 10-14 years irrespective of sex was largely missing from the population surveys and none of the surveys captured data for either females or males aged 15-19 years for physical inactivity and mental health indicators. Interpretation: The considerable differences seen in the IAHS thematic focus as compared with the leading causes of fatal and non-fatal disease burden in adolescents in India, and in the availability of population-level data to monitor the outcome indicators of the IAHS can pose substantial limitations for improving adolescent health in India. The findings in this paper can be utilized by decision makers to refine action aimed at improving adolescent health and well-being. Funding: Bill & Melinda Gates Foundation.

Occurrences, sources and health hazard estimation of potentially toxic elements in the groundwater of Garhwal Himalaya, India.

High concentrations of potentially toxic elements (PTEs) in potable water can cause severe human health disorders. Present study examined the fitness of groundwater for drinking purpose based on the occurrence of nine PTEs in a heavy pilgrim and tourist influx region of the Garhwal Himalaya, India. The concentrations of analyzed PTEs in groundwater were observed in the order of Zn > Mn > As > Al > Cu > Cr > Se > Pb > Cd. Apart from Mn and As, other PTEs were within the corresponding guideline values. Spatial maps were produced to visualize the distribution of the PTEs in the area. Estimated water pollution indices and non-carcinogenic risk indicated that the investigated groundwater is safe for drinking purpose, as the hazard index was < 1 for all the water samples. Assessment of the cancer risk of Cr, As, Cd, and Pb also indicated low health risks associated with groundwater use, as the values were within the acceptable range of ≤ 1 × 10-6 to 1 × 10-4. Multivariate statistical analyses were used to describe the various possible geogenic and anthropogenic sources of the PTEs in the groundwater resources although the contamination levels of the PTEs were found to pose no serious health risk. However, the present study recommends to stop the discharge of untreated wastewater and also to establish cost-effective as well as efficient water treatment facility nearby the study area. Present work's findings are vital as they may protect the health of the massive population from contaminated water consumption. Moreover, it can help the researchers, governing authorities and water supplying agencies to take prompt and appropriate decisions for water security.

Substantial increase in stillbirth rate during the COVID-19 pandemic: results from a population-based study in the Indian state of Bihar.

INTRODUCTION: We report on the stillbirth rate (SBR) and associated risk factors for births during the COVID-19 pandemic, and change in SBR between prepandemic (2016) and pandemic periods in the Indian state of Bihar. METHODS: Births between July 2020 and June 2021 (91.5% participation) representative of Bihar were listed. Stillbirth was defined as fetal death with gestation period of ≥7 months where the fetus did not show any sign of life. Detailed interviews were conducted for all stillbirths and neonatal deaths, and for 25% random sample of surviving live births. We estimated overall SBR, and during COVID-19 peak and non-peak periods per 1000 births. Multiple logistic regression models were run to assess risk factors for stillbirth. The change in SBR for Bihar from 2016 to 2020-2021 was estimated. RESULTS: We identified 582 stillbirths in 30 412 births with an estimated SBR of 19.1 per 1000 births (95% CI 17.7 to 20.7); SBR was significantly higher in private facility (38.4; 95% CI 34.3 to 43.0) than in public facility (8.6; 95% CI 7.3 to 10.1) births, and for COVID-19 peak (21.2; 95% CI 19.2 to 23.4) than non-peak period (16.3; 95% CI 14.2 to 18.6) births. Pregnancies with the last pregnancy trimester during the COVID-19 peak period had 40.4% (95% CI 10.3% to 70.4%) higher SBR than those who did not. Risk factor associations for stillbirths were similar between the COVID-19 peak and non-peak periods, with gestation age of <8 months with the highest odds of stillbirth followed by referred deliveries and deliveries in private health facilities. A statistically significant increase of 24.3% and 68.9% in overall SBR and intrapartum SBR was seen between 2016 and 2020-2021, respectively. CONCLUSIONS: This study documented an increase in SBR during the COVID-19 pandemic as compared with the prepandemic period, and the varied SBR based on the intensity of the COVID-19 pandemic and by the place of delivery.

Increase in birthweight coverage of neonatal deaths is needed to monitor low birthweight prevalence in India: lessons from the National Family Health Survey.

BACKGROUND: Low birthweight (LBW), defined as birthweight < 2500gms, is the largest contributor to the malnutrition disability-adjusted-live-years in India. We report on the inadequacy of birthweight data, which is a significant barrier in the understanding of LBW epidemiology, to address malnutrition in India. METHODS: Data from the recent round of the National Family Survey (NFHS-5) were utilised. Birthweight of livebirths in the last 5 years was documented in grams either from the health card or based on mother's recall. We computed the coverage of birthweight measurement availability and the extent of heaping (values of 2500, 3000 and 3500gms) by the place of delivery and by the survival of newborn during the neonatal period. Heaping of > 55% was considered as poor-quality birthweight data. LBW prevalence per 100 livebirths was estimated and extrapolated for under-reporting of birthweight. Findings are reported for India and its 30 states. RESULTS: Birthweight measurement coverage irrespective of the place of delivery was (89·8%; 95% CI 89·7-90) for India, and varied by 2 times among the states with the highest coverage in Tamil Nadu (99·3%) and the lowest in Nagaland (49·7%). Home deliveries had the least coverage of birthweight measurement (49.6%; 95% CI 49.0-50.1) as compared with public health facility (96.3%; 95% CI 96.2-96.3) and private health facility (96%; 95% CI 95.8-96.1) deliveries. This coverage was 66·5% (95% CI 65·2-67·7) among neonatal deaths as compared with 90.4 (95% CI 90.3-90.6) for livebirths who survived the neonatal period for India. The proportion of health card as the data source increased for livebirths born in year 2015 to year 2020 but then dropped for livebirths born in year 2021 (p < 0.001). The proportion of heaping was 52·0% (95% CI 51·7-52·2) in the recorded birthweight for India, and heaping > 55% was seen in 10 states irrespective of the type data source; and 3 states in addition had heaping > 55% in mother's recall. LBW prevalence was estimated at 17·4% (95% CI 17·3-17·6) for India, and ranged from 4.5% in Nagaland and Mizoram to 22.5% in Punjab for livebirths for whom birthweight was available. We estimated LBW at 77.8% for whom birthweight was not available, and the adjusted LBW prevalence for all livebirths was estimated at 23.5% (95% CI 23.3-23.8) for India. CONCLUSIONS: Without measuring birthweight for every newborn irrespective of the survival and place of delivery, India may not able to address reduction in low birthweight and neonatal mortality effectively to meet global or national targets.

Sociodemographic characteristics of women who died by suicide in India from 2014 to 2020: findings from surveillance data.

BACKGROUND: Women in India have twice the suicide death rate (SDR) compared with the global average for women. The aim of this study is to present a systematic understanding of sociodemographic risk factors, reasons for suicide deaths, and methods of suicide among women in India at the state level over time. METHODS: Administrative data on suicide deaths among women by education level, marital status, and occupation, and reason for and method of suicide were extracted from the National Crimes Record Bureau reports for years 2014 to 2020. We extrapolated SDR at the population level for Indian women by education, marital status, and occupation to understand the sociodemography of these suicide deaths for India and its states. We reported the reasons for and methods of suicide deaths among Indian women at the state level over this period. FINDINGS: SDR was higher among women with education of class 6 or more (10·2; 95% CI 10·1-10·4) than those with no education (3·8; 3·7-3·9) or education until class 5 (5·4; 5·2-5·5) in India in 2020, with similar patterns in most states. SDR declined between 2014 and 2020 for women with education until class 5. Women currently married accounted for 28 085 (63·1%) of 44 498 suicide deaths in India, 8336 (56·2%) of 14 840 in less developed states, and 19 661 (66·9%) of 29 407 in more developed states in 2020. For India, women currently married had a significantly higher SDR (8·1; 8·0-8·2) than those never married in 2014. However, women who never married had a significantly higher SDR (8·4; 8·2-8·5) in 2020 than those who were currently married. Many individual states in 2020 had similar SDR for women who never married and those who are currently married. Housewife as an occupation accounted for 50% or more of suicide deaths from 2014 to 2020 in India and its states. Family problems was the most common reason for suicide from 2014 to 2020, accounting for 16 140 (36·3%) of 44 498 suicide deaths in India, 5268 (35·5%) of 14 840 in less developed states, and 10 803 (36·7%) of 29 407 in more developed states in 2020. Hanging was the leading mean of suicide from 2014 to 2020. Insecticide or poison consumption was the second leading cause of suicide, accounting for 2228 (15·0%) of all 14 840 suicide deaths in less developed states and 5753 (19·6%) of 29 407 in more developed states, with a near 70·0% increase in the use of this method from 2014 to 2020. INTERPRETATION: The higher SDR among women who have received an education, similar SDR between women currently married and never married, and variations in the reasons for and means of suicide at the state level highlight the need to incorporate sociological insights into how the external social environment can matter for women to better understand the complexity of suicide and determine how to effectively intervene. FUNDING: Bill & Melinda Gates Foundation.

Stillbirth undercount in the sample registration system and national family health survey, India.

Objective: To assess the extent of under-reporting of stillbirths in India by comparing stillbirth and neonatal mortality rates from two national data sources and to review possible reasons for undercounting of stillbirths. Methods: We extracted data on stillbirth and neonatal mortality rates from the annual reports for 2016-2020 of the sample registration system, the Indian government's main source of vital statistics. We compared the data with estimates of stillbirth and neonatal mortality rates from the fifth round of the Indian national family health survey covering events from 2016-2021. We reviewed the questionnaires and manuals from both surveys and compared the sample registration system's verbal autopsy tool with other international tools. Findings: The stillbirth rate for India from the national family health survey (9.7 stillbirths per 1000 births; 95% confidence interval: 9.2-10.1) was 2.6 times higher than the average rate reported in the sample registration system over 2016-2020 (3.8 stillbirths per 1000 births). However, neonatal mortality rates in the two data sources were similar. We identified issues with the definition of stillbirth, documentation of gestation period, and categorization of miscarriages and abortions that could result in undercounting stillbirths in the sample registration system. In the national family health survey only one adverse pregnancy outcome is documented, irrespective of the number of adverse pregnancy outcomes in the given period. Conclusion: For India to attain its 2030 target of single-digit stillbirth rate and to monitor actions to end preventable stillbirths, efforts are needed to improve the documentation of stillbirths in its data collection systems.

Assessment of quality of antenatal care services in public sector facilities in India.

OBJECTIVES: We undertook assessment of quality of antenatal care (ANC) services in public sector facilities in the Indian state of Bihar state delivered under the national ANC programme (Pradhan Mantri Surakshit Matritva Abhiyan, PMSMA). SETTING: Three community health centres and one subdistrict hospital each in two randomly selected districts of Bihar. PARTICIPANTS: Pregnant women who sought ANC services under PMSMA irrespective of the pregnancy trimester. PRIMARY AND SECONDARY MEASURES: Quality ANC services were considered if a woman received all of these services in that visit-weight, blood pressure and abdomen check, urine and blood sample taken, and were given iron and folic acid and calcium tablets. The process of ANC service provision was documented. RESULTS: Eight hundred and fourteen (94.5% participation) women participated. Coverage of quality ANC services was 30.4% (95% CI 27.3% to 33.7%) irrespective of pregnancy trimester, and was similar in both districts and ranged 3%-83.1% across the facilities. Quality ANC service coverage was significantly lower for women in the first trimester of pregnancy (6.8%, 95% CI 3.3% to 13.6%) as compared with those in the second (34.4%, 95% CI 29.9% to 39.1%) and third (32.9%, 95% CI 27.9% to 38.3%) trimester of pregnancy. Individually, the coverage of weight and blood pressure check-up, receipt of iron folic acid (IFA) and calcium tablets, and blood sample collection was >85%. The coverage of urine sample collection was 46.3% (95% CI 42.9% to 49.7%) and of abdomen check-up was 62% (95% CI 58.6% to 65.3%). Poor information sharing post check-up was done with the pregnant women. Varied implementation of ANC service provision was seen in the facilities as compared with the PMSMA guidelines, in particular with laboratory diagnostics and doctor consultation. Task shifting from doctors to ANMs was observed in all facilities. CONCLUSIONS: Grossly inadequate quality ANC services under the PMSMA needs urgent attention to improve maternal and neonatal health outcomes.

A systematic study on occurrence, risk estimation and health implications of heavy metals in potable water from different sources of Garhwal Himalaya, India.

The occurrence of heavy metals (HMs) in drinking water has been a critical water quality concern for a long time and can compromise its aesthetic value to the larger extent. Chronic exposure of human beings to these toxic and non-toxic HMs through water ingestion can result in significant health risks. To assess these associated health risks, the present study was planned, designed and carried out for analyses of nine HMs namely, Al, Cr, Mn, Co, Ni, Cu, Zn, Cd and Pb in the potable water samples collected from different sources located across the Mandakini valley of Garhwal Himalaya, India using Inductively Coupled Plasma Mass Spectrometry. The measured values of Al, Cr, Mn, Co, Ni, Cu, Zn, Cd and Pb were found in the range of BDL-27.4 µg l-1, 0.26-4.5 µg l-1, BDL-139 µg l-1, 0.02-0.9 µg l-1, 0.4-5.5 µg l-1, 0.07-9.2 µg l-1, BDL-4164 µg l-1, BDL-0.8 µg l-1, and BDL-11.2 µg l-1, respectively. The observed values of analyzed HMs except Zn and Pb were found below the reference values prescribed by the WHO, USEPA and BIS. In addition, Zn concentration exceeded its maximum permissible limit (4000 µg l-1) recommended by WHO for infants at one station only. The observed indices show that there are no health risks from HMs contamination via drinking water in the region. Moreover, the estimated hazard quotients for children and adults also revealed no potential health risks. The results of present study will be useful as baseline data for state and national regulatory agencies.

Implications of the availability and distribution of birth weight on addressing neonatal mortality: population-based assessment from Bihar state of India.

OBJECTIVE: A large proportion of neonatal deaths in India are attributable to low birth weight (LBW). We report population-based distribution and determinants of birth weight in Bihar state, and on the perceptions about birth weight among carers. DESIGN: A cross-sectional household survey in a state representative sample of 6007 live births born in 2018-2019. Mothers provided detailed interviews on sociodemographic characteristics and birth weight, and their perceptions on LBW (birth weight <2500 g). We report on birth weight availability, LBW prevalence, neonatal mortality rate (NMR) by birth weight and perceptions of mothers on LBW implications. SETTING: Bihar state, India. PARTICIPANTS: Women with live birth between October 2018 and September 2019. RESULTS: A total of 5021 (83.5%) live births participated, and 3939 (78.4%) were weighed at birth. LBW prevalence among those with available birth weight was 18.4% (95% CI 17.1 to 19.7). Majority (87.5%) of the live births born at home were not weighed at birth. LBW prevalence decreased and birth weight ≥2500 g increased significantly with increasing wealth index quartile. NMR was significantly higher in live births weighing <1500 g (11.3%; 95% CI 5.1 to 23.1) and 1500-1999 g (8.0%; 95% CI 4.6 to 13.6) than those weighing ≥2500 g (1.3%, 95% CI 0.9 to 1.7). Assuming proportional correspondence of LBW and NMR in live births with and without birth weight, the estimated LBW among those without birth weight was 35.5% (95% CI 33.0 to 38.0) and among all live births irrespective of birth weight availability was 23.0% (95% CI 21.9 to 24.2). 70% of mothers considered LBW to be a sign of sickness, 59.5% perceived it as a risk of developing other illnesses and 8.6% as having an increased probability of death. CONCLUSIONS: Missing birth weight is substantially compromising the planning of interventions to address LBW at the population-level. Variations of LBW by place of delivery and sociodemographic indicators, and the perceptions of carers about LBW can facilitate appropriate actions to address LBW and the associated neonatal mortality.

Domestic violence in Indian women: lessons from nearly 20 years of surveillance.

BACKGROUND: Prevalence of self-reported domestic violence against women in India is high. This paper investigates the national and sub-national trends in domestic violence in India to prioritise prevention activities and to highlight the limitations to data quality for surveillance in India. METHODS: Data were extracted from annual reports of National Crimes Record Bureau (NCRB) under four domestic violence crime-headings-cruelty by husband or his relatives, dowry death, abetment to suicide, and protection of women against domestic violence act. Rate for each crime is reported per 100,000 women aged 15-49 years, for India and its states from 2001 to 2018. Data on persons arrested and legal status of the cases were extracted. RESULTS: Rate of reported cases of cruelty by husband or relatives in India was 28.3 (95% CI 28.1-28.5) in 2018, an increase of 53% from 2001. State-level variations in this rate ranged from 0.5 (95% CI  - 0.05 to 1.5) to 113.7 (95% CI 111.6-115.8) in 2018. Rate of reported dowry deaths and abetment to suicide was 2.0 (95% CI 2.0-2.0) and 1.4 (95% CI 1.4-1.4) in 2018 for India, respectively. Overall, a few states accounted for the temporal variation in these rates, with the reporting stagnant in most states over these years. The NCRB reporting system resulted in underreporting for certain crime-headings. The mean number of people arrested for these crimes had decreased over the period. Only 6.8% of the cases completed trials, with offenders convicted only in 15.5% cases in 2018. The NCRB data are available in heavily tabulated format with limited usage for intervention planning. The non-availability of individual level data in public domain limits exploration of patterns in domestic violence that could better inform policy actions to address domestic violence. CONCLUSIONS: Urgent actions are needed to improve the robustness of NCRB data and the range of information available on domestic violence cases to utilise these data to effectively address domestic violence against women in India.

Administrative data deficiencies plague understanding of the magnitude of rape-related crimes in Indian women and girls.

BACKGROUND: This paper investigates trends in rape-related crimes against women and girls reported in the Indian administrative data from 2001 to 2018 to assess the burden of crime, describe sub-national variations, and highlight data gaps to address sexual violence effectively in India. METHODS: Data on five rape-related crimes were extracted from the annual reports of National Crimes Record Bureau (NCRB), and included assault with the intent to outrage modesty of woman, rape, insult to the modesty of women, attempt to commit rape, and murder with rape/gang-rape. Rates for all categories combined, and for each crime were estimated for women and girls for India and its states. Trends for type of offender for rape, mean number of people arrested, and legal status of the cases was also assessed. RESULTS: The rate of all rape-related crime increased from 11.6 in 2001 to 19.8 in 2018 per 100,000 women and girls. Most of the 70.7% increase in rate between 2001 and 2018 was post 2012 following a gang-rape and murder case in India's capital. The largest proportion of crimes was recorded as assault with the intent to outrage modesty of the woman, followed by rape. The cited offender in rape cases was for the majority a close known person (44·3%) or other known person (43·1%). By the end of 2018, only 9·6% of the cases had completed trials, with acquittals in 73% cases. CONCLUSIONS: The wide variations in the yearly crime rates at state-level highlighted significant issues in data quality including under-reporting, non-comparability, possible bias in data reporting in NCRB, definition of rape-related crime in India, and access in reporting of crimes. Addressing barriers to reporting, improving quality and scope of administrative data recorded on sexual violence is urgently needed for India to meet SDG targets of eliminating all forms of violence against women and girls.

ZrxCa30-xP70 thermoluminescent bio glass, structure and elasticity.

Phosphate glasses of calcium oxide have been well proved materials for various bio bones and dental implants. However, still there is a lot of scope and demand to produce efficient elastic bio implants and resource. In view of this, ZrxCa30-xP70 phosphate materials are prepared by using melt quenching method. Bio, physical, thermoluminescence and elastic techniques are used to characterize the samples. Additionally, simulated body fluid was prepared and it is used especially for bio techniques. Further, the glasses are taken for different dose (~0, 10, 20 & 50 kGy) of gamma irradiation around half an hour. And again similar techniques are used to characterize the samples. All the findings from bio, physical, thermoluminescence and elastic characterization results are analysed and took for better comparison with previous studies to develop various bio bone (or) bio dental resource. Structural reports suggests that the ZrxCa30-xP70 materials were glassy before immersion in SBF solution and immersed (~720 h) samples are showing partial ceramic nature. The weight loss and pH reports suggests them for alternative bio resource as a bio bones and dental implants. Observed thermal stability, microhardness and elastic modulus evaluations of ZrxCa30-xP70 materials in required standards are also additional advantage. Furthermore, thermoluminiscence (TL) under different γ-irradiation doses is reported for glasses with and without immersing in a simulated body fluid. The glasses lose TL intensity when immersed in simulated body fluid for nearly 720 h. This is useful to modulate bio-behaviour in terms of hydroxyapatite layer growth on the glass surface.

Estimating patterns in the under-reporting of suicide deaths in India: comparison of administrative data and Global Burden of Disease Study estimates, 2005-2015.

BACKGROUND: It has been proposed that the National Crime Records Bureau (NCRB), which reports suicides in India, differentially underenumerates suicides by geographic and demographic factors. We assessed the extent of potential underenumeration by comparing suicides recorded in NCRB data with recent estimates of Indian suicides developed by the Global Burden of Disease (GBD) initiative. METHODS: Age-standardised suicide rates were calculated for both data sources by sex, age and state, and rate ratios of NCRB to GBD estimates by corresponding strata were compared to ascertain the relative under-reporting in the NCRB report. RESULTS: The GBD Study reported an additional 802 684 deaths by suicide (333 558 male and 469 126 female suicide deaths) compared with the NCRB report between 2005 and 2015. Among males, the average under-reporting was 27% (range 21%-31%) per year, and among females, the average under-reporting was 50% (range 47%-54%) per year. Under-reporting was more evident among younger (15-29 years) and older age groups (≥60 years) compared with middle age groups. Indian states belonging to low Socio-Demographic Index (SDI) generally had greater underenumeration compared with middle and high-SDI states. CONCLUSION: NCRB data under-report suicides in India, and differentially by sex, age and geographic area, possibly because of lack of community-level reporting of suicides due to social stigma and legal consequences. While the recent decriminalisation of suicide is expected to improve community-level reporting of suicides, suicide prevention policies should be developed, with a priority to address social stigma attached with suicide and suicidal behaviour, especially among females.

The global burden of falls: global, regional and national estimates of morbidity and mortality from the Global Burden of Disease Study 2017.

BACKGROUND: Falls can lead to severe health loss including death. Past research has shown that falls are an important cause of death and disability worldwide. The Global Burden of Disease Study 2017 (GBD 2017) provides a comprehensive assessment of morbidity and mortality from falls. METHODS: Estimates for mortality, years of life lost (YLLs), incidence, prevalence, years lived with disability (YLDs) and disability-adjusted life years (DALYs) were produced for 195 countries and territories from 1990 to 2017 for all ages using the GBD 2017 framework. Distributions of the bodily injury (eg, hip fracture) were estimated using hospital records. RESULTS: Globally, the age-standardised incidence of falls was 2238 (1990-2532) per 100 000 in 2017, representing a decline of 3.7% (7.4 to 0.3) from 1990 to 2017. Age-standardised prevalence was 5186 (4622-5849) per 100 000 in 2017, representing a decline of 6.5% (7.6 to 5.4) from 1990 to 2017. Age-standardised mortality rate was 9.2 (8.5-9.8) per 100 000 which equated to 695 771 (644 927-741 720) deaths in 2017. Globally, falls resulted in 16 688 088 (15 101 897-17 636 830) YLLs, 19 252 699 (13 725 429-26 140 433) YLDs and 35 940 787 (30 185 695-42 903 289) DALYs across all ages. The most common injury sustained by fall victims is fracture of patella, tibia or fibula, or ankle. Globally, age-specific YLD rates increased with age. CONCLUSIONS: This study shows that the burden of falls is substantial. Investing in further research, fall prevention strategies and access to care is critical.

India's disability estimates: Limitations and way forward.

BACKGROUND: With India preparing for the next decennial Census in 2021, we compared the disability estimates and data collection methodology between the Census 2011 and the most recent population-level survey for India and its states, to highlight the issues to be addressed to improve robustness of the disability estimates in the upcoming Census. METHODS: Data from the Census 2011 and from two complementary nationally representative household surveys that covered all Indian states with the same methodology and survey instruments-the District-Level Household Survey-4 (DLHS-4, 2012-2013) and the Annual Health Surveys (AHS three rounds, 2010-11, 2011-12 and 2012-13) were used. Data from DLHS-4 and AHS 2012-13 round were pooled to generate estimates for the year 2012-13. Data collection methodology between the sources was compared, including the review of definitions of each type of disability. The overall, mental, visual, hearing, speech, and movement disability rate (DR) per 100,000 population were compared between the sources for India and for each state, and the percent difference in the respective rates was calculated. We explored the reliability of these estimates comparing yearly data from the AHS for three successive rounds. RESULTS: Survey data were collected through proxy reporting, however, it is not entirely clear whether the data were proxy- or self-reported or a mix of both in the Census. The overall DR was 25.1% higher in the Census (2,242; 95% CI 2,241-2,243) than the survey (1,791; 95% CI 1,786-1,797) per 100,000 population, with the state-level difference ranging from -64% in Tamil Nadu to 107% in Sikkim state. Despite both sources using nearly similar definitions for overall disability and disability by type, the difference in DR was 125.5%, 54.2%, -25.7%, -19.7%, and 21.9% for hearing, speech, mental, movement, and visual DR, respectively. At the state-level, the difference in disability-specific estimates ranged from -84% to 450%. The extent of variations in the disability-specific estimates in AHS successive rounds ranged from -25% to 929% at the state-level. CONCLUSIONS: There is momentum globally towards building disability measurement that is consistent with the data required for monitoring of the Sustainable Development Goals to ensure robust estimation of disability. The current estimates from the Census and surveys seem much lower than would be expected at the population level. We make recommendations that India needs to take serious note of in order to improve the validity and reliability of India's disability estimates.

Completeness of death registration in the Civil Registration System, India (2005 to 2015).

Background & objectives: In many developing countries including India, the civil registration data are incomplete, inadequate and not timely, therefore, compromising the usefulness of these data. The completeness of registration of death (CoRD) in the Indian Civil Registration System (CRS) was assessed from 2005 to 2015 at State level to understand its current status and trends over time and also to identify gaps in data to improve CRS data quality. Methods: CoRD for each year for each State was calculated from the CRS reports for 2005-2015. Data were analyzed nationally by geographic region and individual State. The availability of CoRD by age group and sex was also reported. Results: About 40 per cent increase in CoRD was documented for India between 2005 and 2015, with CoRD of 76.6 per cent in 2015. CoRD was >90 per cent in the western and southern regions and the eastern, central and northeastern regions had CoRD lower than the Indian average in 2015. Among the 29 States, 16 (55.2%) State had CoRD >80 per cent and five (17.2%) <50 per cent and 10 States recorded 100 per cent CoRD. Despite the highest per cent increase during 2005-2015 (108.5%), CoRD in Uttar Pradesh was 44.2 per cent in 2015. Varying levels of progress in 2015 were seen between the State with similar CoRD estimates in 2015. Nagaland (-63.3%), Manipur (-33.1%) and Tripura (-30.3%) were the only States that documented a decrease in CoRD during 2005-2015. The age non-availability for India ranged from 37.0 per cent in 2009 to 37.9 per cent in 2015, an average of 41.5 per cent over the seven years and was an average of 35.6 and 36.6 per cent for males and females, respectively. Age was available for all registered deaths only in five (17.2%) of the 29 States in 2009 and four (13.8%) in 2015. Sex non-availability for the recorded deaths was much lower as compared with that for age. Interpretation & conclusions: Despite the significant progress made in CoRD in India, critical differences between the States within the CRS remain, with poor availability of reporting by age and sex. Concentrated efforts to assess the strengths and weaknesses at the State level of the CRS processes, quality of data and plausibility of information generated are needed in India.

Distinct mortality patterns at 0-2 days versus the remaining neonatal period: results from population-based assessment in the Indian state of Bihar.

BACKGROUND: The objectives of this study were to understand the differences in mortality rate, risk factors for mortality, and cause of death distribution in three neonatal age sub-groups (0-2, 3-7, and 8-27 days) and assess the change in mortality rate with previous assessments to inform programmatic decision-making in the Indian state of Bihar, a large state with a high burden of newborn deaths. METHODS: Detailed interviews were conducted in a representative sample of 23,602 live births between January and December 2016 (96.2% participation) in Bihar state. We estimated the neonatal mortality rate (NMR) for the three age sub-groups and explored the association of these deaths with a variety of risk factors using a hierarchical logistic regression model approach. Verbal autopsies were conducted using the PHMRC questionnaire and the cause of death assigned using the SmartVA automated algorithm. Change in NMR from 2011 to 2016 was estimated by comparing it with a previous assessment. RESULTS: The NMR 0-2-day, 3-7-day, and 8-27-day mortality estimates in 2016 were 24.7 (95% CI 21.8-28.0), 13.2 (11.1 to 15.7), 5.8 (4.4 to 7.5), and 5.8 (4.5 to 7.5) per 1000 live births, respectively. A statistically significant reduction of 23.3% (95% CI 9.2% to 37.3) was seen in NMR from 2011 to 2016, driven by a reduction of 35.3% (95% CI 18.4% to 52.2) in 0-2-day mortality. In the final regression model, the highest odds for mortality in 0-2 days were related to the gestation period of ≤ 8 months (OR 16.5, 95% CI 11.9-22.9) followed by obstetric complications, no antiseptic cord care, and delivery at a private health facility or home. The 3-7- and 8-27-day mortality was driven by illness in the neonatal period (OR 10.33, 95% CI 6.31-16.90, and OR 4.88, 95% CI 3.13-7.61, respectively) and pregnancy with multiple foetuses (OR 5.15, 95% CI 2.39-11.10, and OR 11.77, 95% CI 6.43-21.53, respectively). Birth asphyxia (61.1%) and preterm delivery (22.1%) accounted for most of 0-2-day deaths; pneumonia (34.5%), preterm delivery (33.7%), and meningitis/sepsis (20.1%) accounted for the majority of 3-7-day deaths; meningitis/sepsis (30.6%), pneumonia (29.1%), and preterm delivery (26.2%) were the leading causes of death at 8-27 days. CONCLUSIONS: To our knowledge, this is the first study to report a detailed neonatal epidemiology by age sub-groups for a major Indian state, which has highlighted the distinctly different mortality rate, risk factors, and causes of death at 0-2 days versus the rest of the neonatal period. Monitoring mortality at 0-2 and 3-7 days separately in the traditional early neonatal period of 0-7 days would enable more effective programming to reduce neonatal mortality.