Diagnostic and treatment delay among new pulmonary tuberculosis patients in Southern India: A cross-sectional study.

Background: Delay in diagnosis and treatment enhances tuberculosis (TB) transmission and mortality. Understanding causes for delay can help in TB elimination by 2025, the stated goal of India. Objectives: Estimate diagnostic and treatment delay in Ernakulam district of Kerala, identify associated factors, and determine health-seeking behavior and knowledge regarding TB among new pulmonary TB patients. Materials and Methods: Community-based cross-sectional study among the new pulmonary TB patients registered under Revised National TB Control Program. Patients interviewed in-person and data collected using pretested semi-structured questionnaire. Descriptive statistics expressed as frequency, percent, interquartile range, median, and mean. The Chi-square test was used to assess statistical significance (P < 0.05) of association. Backward conditional method logistic regression done using variables with P < 0.2 in univariate analysis and adjusting for possible confounders. Results: Two hundred and twenty-nine patients interviewed and the median patient, health-care system, and treatment delay were 25 days, 22 days, and 1 day, respectively. While the patient delay (>30 days) and treatment delay (>2 days) were seen in 47.6% and 41% of patients, respectively, health-care system delay was seen in 79.9% of the patients. Choosing pharmacy for initial treatment (adjusted odds ratio [aOR] = 5.217), unskilled occupation (aOR = 3.717), female gender (aOR = 3.467), previously not heard about TB (aOR = 3.410), and lower education level (aOR = 2.774) were the independent predictors of the patient delay. Visiting two or more doctors (aOR = 5.855) and initially visiting a doctor of undergraduate qualification (aOR = 3.650) were the independent predictors of health-care system delay. The diagnosis in private sector (aOR = 8.989), not being admitted (aOR = 3.441), and age above 60 years (aOR = 0.394) was the independent predictors of treatment delay. Conclusion: Initial treatment from pharmacy, consulting multiple physicians, and diagnosis by private sector cause significant delay in diagnosis and treatment of pulmonary TB.

Prevalence of Neglected Tropical Diseases (Leishmaniasis and Lymphatic Filariasis) and Malaria Among a Migrant Labour Settlement in Kerala, India.

Neglected tropical diseases (visceral leismaniasis, lymphatic filariasis) and malaria are endemic in northern states of India. Kerala has become a hub of construction activities employing a large number of migrants from these endemic states. Studies on morbidity pattern among migrants in Kerala are lacking. It is essential to look into the burden of these infections among migrant laborers who can act as reservoirs and are a threat to native population. A cross sectional study was done among migrant laborers in Ernakulam district, Kerala. After getting informed consent, a questionnaire was administered to each participant to collect sociodemographic details and 5 ml of blood was collected for detection of antigens using rapid diagnostic tests (RDT). Of the 309 migrants tested, none of them were positive for leishmaniasis, while 3.8% were positive for malaria and 3.6% for filariasis. With 2.5 million migrant laborers in Kerala, the magnitude of the problem in absolute numbers is enormous. Active surveillance and treatment is needed to prevent the reemergence of these diseases in Kerala.

Adherence to treatment among hypertensives of rural Kerala, India.

INTRODUCTION: Poor adherence is an important barrier to adequate blood pressure control among the diagnosed hypertensives. The study aimed at assessing the level of adherence to medication and to identify factors associated with it in people with hypertension in a rural population of Kerala. SUBJECTS AND METHODS: A community-based cross-sectional study was conducted in July 2016 among 189 known hypertensives of a rural population in Kerala. Data was collected by interview method using a semistructured questionnaire. Medication adherence was assessed using 4-item Morisky Medication Adherence Scale. Chi-square was used to test the significance of association, and logistic regression was done to identify independent predictors along with odds ratio (OR). RESULT: The mean age of study participants was 65.12 ± 11.71 years and the mean duration of disease was 8.69 ± 7.99 years. High adherence was seen in 46% of the patients, while medium and low adherence was seen in 41.3% and 12.7%, respectively. Risk factors of poor adherence identified were poor knowledge of the complications (OR - 2.120; 95% confidence interval [CI] 1.110-4.048), availing government pharmacy (OR - 2.379; 95% CI 1.131-5.004), and being asymptomatic at the time of diagnosis (OR - 2.120; 95% CI 1.110-4.048). CONCLUSION: Adherence to medication among people with hypertension in the current study is poor. A comprehensive strategy to improve adherence to antihypertensive medications is the need of the hour.

Prevalence of Exposure to Secondhand Smoke among Higher Secondary School Students in Ernakulam District, Kerala, Southern India.

INTRODUCTION: The association between secondhand smoke and health outcomes, such as frequent respiratory infections, ischemic heart disease, lung cancer, asthma, and stroke, has long been established. The study aimed to estimate the prevalence of secondhand smoking exposure among higher secondary school students in Ernakulam district, Kerala, Southern India. MATERIALS AND METHODS: A structured questionnaire was administered to all students from four randomly selected higher secondary schools in Ernakulam district. Descriptive statistics was done using frequencies and percentages. Univariate and multivariate analyses were done for factors associated with household exposure to tobacco smoke generating odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: A total of 629 students participated in the study. The prevalence of ever smokers was 11.9% and of current smokers was 5.2%. Among the study participants, 23.2% were exposed to secondhand smoking from a family member and 18.8% from friends. Lower educational status of father was associated with the household exposure to secondhand smoke (adjusted OR 4.51 [95% CI 1.66-12.22]). More than half of the study participants (56.3%) reported that they were exposed to cigarette smoke in past 1 week in a public place and 10.2% in closed public places. Nearly one-third of the students reported that they have seen somebody smoking inside school campus in the past 30 days. CONCLUSION: Exposure to secondhand smoke at home, schools, and public places was higher among the late adolescent higher secondary school students in Ernakulam district. The findings underscore the urgent need for increased efforts to implement the strategies to reduce secondhand smoke exposure among adolescents.

Prevalence of bronchial asthma and factors associated with it among higher secondary school children in Ernakulam district, Kerala, Southern India.

CONTEXT: Bronchial asthma is one of the leading causes of hospitalization and cause of frequent absenteeism among children and adolescents. Studies reporting the prevalence of bronchial asthma among adolescents from India are limited and the available studies report wide geographic variations in the prevalence of bronchial asthma. AIMS: The current study was aimed to estimate the prevalence of bronchial asthma among higher secondary school children and to identify various factors associated with it in Ernakulam district, Kerala, Southern India. SETTINGS AND DESIGN: The study was conducted in Ernakulam district, the industrial capital of Kerala. A school-based cross-sectional study was conducted. SUBJECTS AND METHODS: Data were collected from 629 students from 4 randomly selected higher secondary schools using a structured questionnaire. Section on details of respiratory symptoms was adapted from International Union Against Tuberculosis and Lung Disease bronchial symptoms questionnaire. STATISTICAL ANALYSIS USED: Descriptive statistics was done with frequencies and percentages and confidence intervals (CIs) were calculated. Univariate and multivariate analysis was done for factors associated with bronchial asthma generating odds ratios (ORs) and 95% CIs. RESULTS: A total of 629 students participated in this study. The prevalence of bronchial asthma was estimated to be 9.9% (95% CI = 7.53%-12.27%). Students residing in a rural area (adjusted OR = 1.95, 95% CI = 1.10-3.46) having family history of bronchial asthma (adjusted OR = 2.84, 95% CI = 1.57-5.11) and usual exposure to friend's smoke (adjusted OR = 2.16, 95% CI = 1.17-3.97) were significantly associated with bronchial asthma. CONCLUSIONS: The prevalence of bronchial asthma was higher among higher secondary school students of Ernakulam district. Considering high prevalence and its contributions to morbidity and mortality, a comprehensive program to tackle the issue of chronic respiratory diseases may be needed. The issue of active and passive smoking at schools exists and need to be resolved.

Developing a fully integrated tobacco curriculum in medical colleges in India.

BACKGROUND: This paper describes a pioneering effort to introduce tobacco cessation into India's undergraduate medical college curriculum. This is the first ever attempt to fully integrate tobacco control across all years of medical college in any low and middle income country. The development, pretesting, and piloting of an innovative modular tobacco curriculum are discussed as well as challenges that face implementation and steps taken to address them and to advocate for adoption by the Medical Council of India. METHODS: In-depth interviews were conducted with administrators and faculty in five medical colleges to determine interest in and willingness to fully integrate smoking cessation into the college curriculum. Current curriculum was reviewed for present exposure to information about tobacco and cessation skill training. A modular tobacco curriculum was developed, pretested, modified, piloted, and evaluated by faculty and students. Qualitative research was conducted to identify challenges to future curriculum implementation. RESULTS: Fifteen modules were successfully developed focusing on the public health importance of tobacco control, the relationship between tobacco and specific organ systems, diseases related to smoking and chewing tobacco, and the impact of tobacco on medication effectiveness. Culturally sensitive illness specific cessation training videos were developed. Faculty and students positively evaluated the curriculum as increasing their competency to support cessation during illness as a teachable moment. Students conducted illness centered cessation interviews with patients as a mandated part of their coursework. Systemic challenges to implementing the curriculum were identified and addressed. CONCLUSIONS: A fully integrated tobacco curriculum for medical colleges was piloted in 5 colleges and is now freely available online. The curriculum has been adopted by the state of Kerala as a first step to gaining Medical Council of India review and possible recognition.

Assessing the readiness to integrate tobacco control in medical curriculum: experiences from five medical colleges in Southern India.

BACKGROUND: Making tobacco cessation a normative part of all clinical practice is the only way to substantially reduce tobacco-related deaths and the burden of tobacco-related morbidity in the short term. This study was undertaken because information on receptivity to integrate tobacco control education in the medical curriculum is extremely limited in low- and middle-income countries. METHODS: From five medical colleges (two government) in southern India, 713 (men 59%) faculty and 2585 (men 48%) students participated in our cross-sectional survey. Information on self-reported tobacco use and readiness to integrate tobacco control education in the medical curriculum was collected from both the faculty and students using a pretested structured questionnaire. Multiple logistic regression analysis was done to find the associated factors. RESULTS: Current smoking was reported by 9.0% (95% CI 6.6-12.1) of men faculty and 13.7% (CI 11.8-15.9) by men students. Faculty who were teaching tobacco-related topics [odds ratio (OR) 2.29; 95% CI 1.65-3.20] compared to those who were not, faculty in government colleges (OR 1.69; CI 1.22-2.35) compared to those in private colleges and medical pecialists (OR 1.79; CI 1.23-2.59) compared to surgical and non-clinical specialists were more likely to be ready to integrate tobacco control education in the medical curriculum. Non-smoking students (OR 2.58; CI 2.01-3.33) compared to smokers, and women students (OR 1.80; CI 1.50-2.17) compared to men were more likely to be ready to integrate a tobacco control education in the curriculum. CONCLUSION: Faculty and students are receptive to introduce tobacco control in the medical curriculum. Government faculty, medical specialists and faculty who already teach tobacco-related topics are likely to be early introducers of this new curriculum.

Cervical cancer screening: Current knowledge & practice among women in a rural population of Kerala, India.

BACKGROUND & OBJECTIVES: Cervical cancer has a major impact on woman's lives worldwide and one in every five women suffering from cervical cancer belongs to India. Hence the objectives of this study were to find the knowledge of women regarding cervical cancer, to determine screening practices and determinants, and to identify factors for non screening. METHODS: A cross-sectional study was conducted in Vypin Block of Ernakulam District, Kerala, India where four of the seven Panchayats were randomly chosen. Households were selected by systematic random sampling taking every second house in the tenth ward of the Panchayat till at least 200 women were interviewed. Thus, 809 women were interviewed from four Panchayats. RESULTS: Mean age of the study population was 34.5 + 9.23 yr. Three fourths of the population (74.2%) knew that cervical cancer could be detected early by a screening test. Majority of respondents (89.2%) did not know any risk factor for cervical cancer. Of the 809 women studied, only 6.9 per cent had undergone screening. One third of the population were desirous of undergoing screening test but had not done it due to various factors. These factors related to knowledge (51.4%) such as no symptoms, not being aware of Pap test, not necessary, etc. This was followed by resource factors (15.1%) like no time, no money, etc. and psychosocial factors (10.2%) included lack of interest, fear of procedure, etc. Independent predictors for doing Pap test included age >35, having knowledge of screening for cervical cancer and Pap test (P<0.05). INTERPRETATION & CONCLUSIONS: Specific knowledge on cervical cancer screening is a critical element in determining whether a woman will undergo Pap test in addition to making cancer screening facilities available in the primary health centre.

A post-epidemic study on awareness of vector habits of Chikungunya and vector indices in a rural area of Kerala.

Chikungunya struck Kerala in a devastating form in the years 2006 and 2007 and its after effects continued to 2008. In May 2008, a post epidemic study of the awareness of vector habits and prevalence of the vectors was done. A cross sectional study was conducted in a randomly selected Panchayat affected by Chikungunya in a rural area of Kerala, India. 93.3% respondents were aware that mosquitoes spread Chikungunya though 31.3% knew the type of mosquito that spreads it. 69% knew that the vector breeds in artificial collections of water. Although three-fourths (73.6%) had good knowledge, only 39% had actually took control measures. Four of the six wards were high risk areas as per House Index and Breteau Index. All the larval samples collected were identified as Aedes albopictus. About 94.3% of the respondents used one or the other measure of personal protection against mosquito. An analysis of the high risk areas showed a significant association with education (p < .001) and information on control measures (p < .01). It therefore appears that integrated vector control is the key though converting vector control knowledge into practice by influencing human behaviour is the challenge.

Mass drug administration against filariasis in India: perceptions and practices in a rural community in Kerala.

In India, annual rounds of mass drug administration (MDA) based on diethylcarbamazine and albendazole are used to control filariasis, which is a major public-health problem. In December 2007/January 2008, a few weeks after one such MDA, a household survey was conducted in the Ernakulam district of Kerala to evaluate coverage and compliance. After one member aged >14 years from each of 599 households was interviewed, coverage of the last MDA was estimated to be 77.0% and compliance only 39.6%. Most (67.4%) of the interviewees were not aware of the term 'mass drug administration' but 20.9% of the others thought that MDA prevented the occurrence of filariasis. Most (62.3%) of those interviewed said that they obtained information about MDA from television or radio programmes and/or newspapers and most (66.3%) considered MDA to be useful (only 5.0% said that MDA were not useful, the other interviewees saying that they did not know whether MDA were useful or not). Those who had not ingested the tablets given to them in the last MDA said that they were fearful of the drugs (39.4% of the non-compliers), were too ill to take the drugs (22.5%) or had misconceptions about the aims of the MDA (12.5%). Only 2.7% of the interviewees who had ingested the distributed tablets reported adverse effects and these were mild (fever, drowsiness, swelling/oedema and/or vomiting) and only occurred within 24 h of tablet ingestion. In a univariate analysis, individual compliance in the last MDA was found to be positively associated with perceived benefits to the individual (P<0.001), the perceived usefulness of MDA (P=0.001) and certain study wards within the panchayat (P=0.032). It therefore appears that communication exercises targeted at the areas with relatively low compliance and designed to improve perceptions of the benefits and usefulness of MDA against filariasis could be the key to a successful control programme.

Prevalence of diphtheria carriers among pre-school children.

PIP: The carrier rate of Corynebacterium diphtheriae in 453 pre-school children in Ulloor Panchayat, Trivandrum, Kerala State, India was assessed from November 1976-July 1977. Throat and nasal swabs were cultured by standard techniques, and suspect colonies tested for virulence in rabbits. 16 or 3.5% of the children harbored diphtheria; 7 of these were 4-5 years old. Only 1 of the C. diphtheriae strains was found to be virulent. Several of the isolates were nonvirulent mitis strains, while no intermedius strains were found. 9 of the children were partially immunized, 4 were completely immunized and 3 were not immunized. Proportionally more carriers lived in thatched huts with mud floors or less ventilation than did children from wood or plaster houses.^ieng