Trends in Urban Immunization Coverage in India: A Meta-Analysis and Meta-Regression.

OBJECTIVES: To assess the gaps and trends in child immunization coverage among urban and rural areas in India, and compare the success of immunisation program in each. METHODS: PubMed, Scopus, and Crossref, and Google Scholar electronic databases were searched on October 9, 2019, and March 21, 2020, for studies that measured and reported immunization coverage indicators in India. Random-effects meta-analyses and meta-regressions were conducted. RESULTS: The authors' search identified 545 studies, and 2 were obtained by expert suggestion. Among these 68 studies and 6 surveys were included. They found that full immunization coverage has grown yearly at 2.65% and 0.82% in rural and urban areas, respectively whereas partial immunization coverage declined by -2.44% and -0.69%, respectively. Percentage of nonimmunized children did not show a statistically significant trend in either. CONCLUSION: While rural immunization coverage has seen a large increase over the past two decades, the progress in urban areas is weak and negligible. This was largely attributable to a focus on minimizing dropouts in rural areas. However, a lack of significant reduction in unimmunized children may indicate left-out children or pockets in both rural and urban areas. The poor performance of immunization programs in urban areas, coupled with a larger impact of COVID-19, warrants that India urgently adopts urban-sensitive and urban-focused policies and programs.

Breastfeeding in Coronavirus Disease 2019 (COVID-19): Position Statement of Indian Academy of Pediatrics and Infant and Young Child Feeding Chapter.

JUSTIFICATION: Recent research has provided evidence for lack of transmission of SARS-CoV-2 through human milk and breastfeeding. Updating the practice guidelines will help in providing appropriate advice and support regarding breastfeeding during the coronavirus 2019 (COVID-19) pandemic. OBJECTIVES: To provide evidence-based guidelines to help the healthcare professionals to advise optimal breastfeeding practices during the COVID-19 pandemic. PROCESS: Formulation of key questions was done under the chairmanship of President of the IAP. It was followed by review of literature and the recommendations of other international and national professional bodies. Through Infant and Young child (IYCF) focused WhatsApp group opinion of all members was taken. The final document was prepared after the consensus and approval by all members of the committee. RECOMMENDATIONS: The IYCF Chapter of IAP strongly recommends unabated promotion, protection and support to breastfeeding during the COVID-19 pandemic with due precautions.

Assessment, outcomes and implications of multiple anthropometric deficits in children.

BACKGROUND: Malnutrition in children is widely prevalent around the world. It has been observed that malnourished children with multiple anthropometric deficits have higher mortality. However, adequate studies are not available on the outcome and recovery of these children.Nandurbar, a tribal district from Maharashtra, India, shows high prevalence of all three forms of malnutrition, often occurring simultaneously. A project previously undertaken in Nandurbar from July 2014 to June 2016 studied the effect of various therapeutic feeds in treatment of children with uncomplicated severe acute malnutrition (SAM). In this study, we analyse secondary data from it to correlate effects of stunting, wasting and underweight on treatment recovery. METHODS: Analysis was done on 5979 children with SAM using linear and logistic regression on R software for recovery rates and weight gain in children with SAM with single versus multiple anthropometric deficits, their relation to age, sex, and recovery from severe stunting by gain in height. RESULTS: The mean age of children was 35 months and 53.1% of the children were males. 2346 (39.2%) children recovered at the end of the 8-week treatment. 454 (7.6%) had single anthropometric deficit (SAM only), 3164 (52.9%) had two anthropometric deficits (SAM and severe underweight (SUW)) and 2355 (39.4%) children had three anthropometric deficits (SAM, SUW and severe stunting). Out of the 5979 children with SAM, only 52 (0.9%) of children were not underweight (severe or moderate).44.94% of children with SAM who were severely stunted recovered, compared with 35.52% of children who were not (p<0.001). After controlling for confounders, severe stunting was found to increase the odds of recovery by 1.49. Severely stunted children with SAM also showed faster recovery and weight gain by 1.93 days (p<0.012) and 0.29 g/kg/day (p<0.001), respectively. Recovery was higher in females and younger age group. Recovery was also found to depend on the therapeutic feed, with children receiving medical nutrition therapy showing better recovery for severely stunted children. CONCLUSION: Our findings corroborate previous literature that stunting is a way for the body to deal with chronic stress of nutritional deprivation and provides a survival advantage to a child.

COVID-19 treatment by repurposing drugs until the vaccine is in sight.

Corona virus disease (COVID-19) has created pandemic in the world as declared by WHO on March 12, 2020. It is a viral disease caused by SARS-CoV 2 virus and has affected large populations in over 120 countries. There is no specific treatment available and management is empirical. Until such time that an effective vaccine is available for COVID-19 viral infection, one can repurpose known therapeutic drug molecules such as angiotensin receptor 2 blocker, a commonly used antihypertensive drug, to control COVID-19 virus from gaining entry into the host cell by blocking the angiotensin receptor. Clinical trials should also be undertaken to use statins, which are lipid-lowering drugs but have anti-inflammatory and immunomodulatory properties to prevent acute lung injury in COVID-19 infection.

Is chromium from stainless steel utensils responsible for epidemic of type 2 diabetes?

Type 2 diabetes prevalence is rising rapidly in developing world especially in India in last few decades. 'Thrifty phenotype' and 'westernization of lifestyle' is used to explain this epidemic. Chromium is an important modulator in insulin and glucose metabolism. Preconceptional chromium exposure has been demonstrated to raise the corticosterone and glucose levels in offspring of rodent model. Chromium is chelated when acidic food is stored in the stainless steel utensils. Chromium levels are shown to be high in Asian Indians. The hyperinsulinemia and insulin resistance is demonstrated in Indians from the newborn stage. We hypothesize that increased exposure to chromium in preconceptional and/or fetal stage leads to altered epigenetic control and altered endocrine and metabolic functioning. Increasing urbanization has led to increasing use of stainless steel and resultant exposure to chromium is at the least partly responsible for rising prevalence of type 2 diabetes. If proven avoiding or modifying the use of stainless steel utensils will halt the present epidemic of type 2 diabetes.

Chronic umbilical cord entanglements causing intrauterine fetal demise in the second trimester.

Entanglement of the umbilical cord with fetal body parts is known to occur in early pregnancy. This can potentially compromise the cord blood flow and cause fetal demise. We report 3 instances of intrauterine fetal deaths in the 2nd trimester of pregnancy with longstanding cord entanglement. The cord had left impressions of entanglement on the entrapped growing fetal part. Restricted movements of the fetus due to cord entanglement led to reduced spiraling of the umbilical cord. Our case series demonstrates that tight entanglement of fetal body parts by the umbilical cord can cause fetal demise in the 2nd trimester. This event is associated with a straight umbilical cord. Thus, the presence of reduced spiraling in intrauterine fetal demise warrants a search for possible cord entanglement along with established causes, such as chromosomal and congenital anomalies.

Repeated pregnancy among women with known HIV status in Pune, India.

HIV-positive women of reproductive age face challenges in decision making related to pregnancy. Understanding factors influencing repeat pregnancies in women with known HIV status are necessary to guide interventions and counseling strategies to better inform and support them. We compared three groups of women attending a large antenatal clinic in Pune, India. They include: Group A--63 HIV-positive women coming for care for a repeat pregnancy after being diagnosed in a previous pregnancy; Group B--64 HIV-negative (repeat) pregnant women attending this antenatal clinic; and Group C--63 HIV-positive non-pregnant women currently enrolled in an ongoing clinical trial. Comparisons of Group A and B indicate that the likelihood of unplanned repeat pregnancies was significantly higher in HIV-positive (70%) than HIV-negative (36%) women (OR=4.1, CI: 2.0-8.7). Inability to terminate the pregnancy (31%) and familial obligations (40%) appear to be important for continuing the unplanned repeat pregnancy. Despite high reported contraceptive use by HIV-positive women, pregnancies still occurred. Death of their youngest child is an important factor as 21% of HIV-positive pregnant women lost their youngest child compared with 3% of HIV-negative women and 3% of HIV-positive non-pregnant women (p<0.001). Repeat pregnancies were more likely to occur for women who did not disclose their HIV status to their spouse. Thus the majority of the repeat pregnancies for HIV-positive women were both unplanned and unwanted.

Nurses' health education program in India increases HIV knowledge and reduces fear.

Few health care facilities are adequately prepared to manage and care for HIV/AIDS patients in India. Nurses play a critical role in patient care but are often ill-equipped to deal with their own fears of occupational risk and handle the clinical aspects of HIV/AIDS care, leading to stigma and discrimination toward HIV-positive patients. The authors examine the impact of a 4-day HIV/AIDS health education program on knowledge and attitudes of nurses in a government hospital. This education program was developed using a training of trainers model and qualitative research. A total of 21 master trainers underwent 6 days of training and began training of 552 hospital nurses (in 2004-2005). Using a pretest-posttest design, the authors assessed changes in knowledge and attitudes of 371 trained nurses. Significant improvements were seen in nurses' HIV/AIDS knowledge in all areas including care, treatment, and issues of confidentiality and consent. Fear of interaction with people living with HIV/AIDS was reduced significantly. The short course was successful in increasing nurses' knowledge in all aspects. There is great potential to expand this stigma-reduction intervention to other public and private hospitals.

Declining HIV infection rates among recently married primigravid women in Pune, India.

BACKGROUND: A single recent study has suggested a decrease in HIV risk for women attending antenatal clinics (ANCs) in southern India. Yet, some have questioned the validity of the Indian national surveillance data and analyses. Previous studies suggest that the only major HIV risk factor for married Indian women is the risk behavior of their husbands. Therefore, to address concerns about potential selection bias in the analysis of sentinel surveillance data from multiple sites, we estimated the trajectory of HIV transmission rates among recently married, monogamous, primigravid women attending a single large ANC in Pune, India. METHODS: Participants were self-referred, young, primigravid women from 18 to 27 years of age consenting to HIV screening. Time trends in HIV prevalence over 3.5 years were evaluated by logistic regression adjusted for age. HIV incidence was estimated by dividing the number of HIV-infected mothers by an estimate of exposure person-time, which was an estimate of the average age-specific duration of marriage. RESULTS: Between August 16, 2002 and February 28, 2006, 30,085 (79.5%) of 37,858 pregnant women consented to HIV screening; 10,982 (36.5%) were primigravid and their age range was from 18 to 27 years. HIV infection risk declined over 3.5 years among primigravid women. An estimated 19,739 person-years (PYs) of exposure yielded an overall HIV incidence rate 1.25/100 PYs (95% confidence interval [CI]: 1.10 to 1.42). Estimated HIV incidence decreased from 2.2/100 PYs (95% CI: 1.6 to 3.0) in 2002 to 2003 to 0.73/100 PYs (95% CI: 0.5 to 1.0) in 2006. DISCUSSION: HIV infection risk among young primigravid women in Pune seems to have decreased over the past 3.5 years. A decreasing HIV risk among pregnant women in Pune would also decrease the number of HIV-exposed infants. We hypothesize that decreased high-risk sexual behavior among young recently married men is most likely contributing to a decreasing risk to their wives and children in Pune.

Clinically significant anemia in HIV-infected pregnant women in India is not a major barrier to zidovudine use for prevention of maternal-to-child transmission.

OBJECTIVES: To determine the prevalence of anemia (serum hemoglobin <10 g/dL) and assess zidovudine use and toxicity in HIV-positive pregnant women in India. METHODS: From 2002 through 2006, 24,105 pregnant women in Pune were screened for HIV and anemia. As part of an infant prevention of mother-to-child transmission (PMTCT) trial, enrolled HIV-positive women (n = 467) were assessed for anemia and associated outcomes, comparing women receiving zidovudine for >or=2 weeks versus no zidovudine. RESULTS: The prevalence of anemia was 38.7% in HIV-positive women. Anemic women were as likely as nonanemic women to receive zidovudine. At delivery, regardless of anemia status at enrollment, women receiving >or=2 weeks of zidovudine were 70% less likely to be anemic compared with women receiving no zidovudine (odds ratio = 0.28, 95% confidence interval: 0.14 to 0.57; P < 0.01), received iron and folic acid supplements for longer periods, and had no increased adverse delivery or newborn birth outcomes. CONCLUSIONS: A significant proportion of HIV-positive pregnant women in India present for antenatal care with anemia. With concurrent iron and folic acid supplementation, however, zidovudine use is not associated with persistent or worsening anemia or associated adverse outcomes. In Indian community settings, all pregnant HIV-positive women should receive early anemia treatment. Mild anemia should not limit zidovudine use for PMTCT in India.

Correlates of anxiety and depression among HIV test-seekers at a Voluntary Counseling and Testing facility in Pune, India.

OBJECTIVE: We assessed the extent of anxiety/depression/distress using Hospital Anxiety and Depression Scale (HADS) among a cross-section of HIV test-seekers at a Voluntary Counseling and Testing (VCT) facility in Pune, India. METHODS: HADS has 14 items for uniscale with 7 items each for anxiety and depression rated on a four-point Likert scale. Between September 2002 and March 2003, HADS was administered to 150 consecutive HIV tests-seekers attending NARI-Talera VCT facility. Subsequently, HIV testing was done after obtaining informed consent. RESULTS: HADS showed strong internal consistency (Cronbach-alpha 0.77). The prevalence of risk behavior (73.3%) and HIV (45.5%) were high. Education levels influenced anxiety (p = 0.033; 0.008), more so in women (p = 0.044). Repeat test-seekers exhibited significant depression (AOR: 2.9; 95% CI: 1.4-6.1; p = 0.004) and distress (AOR: 2.5; 95% CI: 1.2-5.3; p = 0.017). Marital status influenced the uniscale scores. The HIV positive repeat test-seekers were more anxious (p = 0.035) and depressed (0.037). CONCLUSIONS: Existence of emotional distress among HIV test-seekers, particularly among repeat test-seekers, possibly 'AIDS-anxious' individuals indicates additional counseling needs specifically by introducing gender and education sensitive interventions. VCT staff can be trained to assess emotional distress among HIV test-seekers to formulate long-term intervention.

Infant feeding practices of HIV-positive mothers in India.

Exclusive breast-feeding is widely accepted and advocated in India; however, clinicians are now faced with advising women infected with human immunodeficiency virus (HIV) about the risks and benefits of other infant feeding options. This study assessed factors that influence the infant feeding decisions of HIV-infected mothers in Pune, India. From December 2000 to April 2002, HIV-positive (HIV(+)) pregnant women (n = 101) from a government hospital antenatal clinic were interviewed prepartum about infant feeding intention, feeding practice immediately postpartum and feeding after a minimum of 2 wk postpartum. Of the HIV(+) sample, the last 39 were interviewed more intensively to examine factors affecting feeding decision making. We found that an equal number of HIV(+) women intended to breast-feed (44%) or give top milk (44%) (diluted animal milk). Women who chose to top feed were also more likely to disclose their HIV status to family members. Mixed feeding occurred frequently in our sample (29%); however, for the majority of those (74%), it lasted only 3 d postpartum. The hospital counselor had an important role in assisting women in their intended feeding choice as well as actual practice. The time immediately after delivery was noted as critical for recounseling about infant feeding and further support of the woman's decision, thus lowering the risk of mixed feeding. Lack of funds, poor hygienic conditions and risk of social repercussions were more commonly noted as reasons to breast-feed. Top milk, the alternative for breast-milk used in this population, however, must be investigated further to assess its nutritional value and safety before it can be endorsed widely for infants of HIV(+) women.