Rheumatic fever and rheumatic heart disease: primary prevention is the cost effective option.

OBJECTIVE: To measure the economic output/input ratios for the various options of prevention of rheumatic fever/rheumatic heart disease (RF/RHD) and check the viability of primary prevention vis-à-vis secondary and tertiary preventions. METHODS: Cost accounting of the various prevention options was calculated for each variable as available in literature. Actual data as obtainable for the financial year ending March 2006 were computed for the Pondicherry population. Both direct and indirect costs (including community/social costs) were worked out using mostly primary data and wherever necessary, secondary data. Certain scientific assumptions were used where exact data was not available. RESULTS: Primary prevention is the definite viable economic option (1:1.56) compared to secondary (1: 1.07) and tertiary (1: 0.12) preventions. In fact, the current stress on only secondary and tertiary preventions is found to be economically unviable. CONCLUSION: It is postulated that primary prevention as a practical policy in tackling RF and RHD can be recommended.

Feeding of infants and young children in tsunami affected villages in Pondicherry.

The study was conducted to identify the problems related to feeding of children post tsunami in four villages in Pondicherry. Data were collected from 100 randomly chosen families who had an infant or a young child below 3 years of age during Tsunami. Informants were the mothers. In the population studied, 30% mothers did not exclusively breast feed for 6 months; 58% bottle fed their children and 51% fed their infants with commercial formula. The occurrence of diarrhea was three times higher among children who were fed with free breast milk substitutes (BMS) than in those who were not fed with the same. Those populations, wherein a pre-existing tradition of artificial feeding is present, infants are at further risk during a crisis situation like Tsunami. Breast feeding practices need strengthening even in routine conditions to tackle a disaster rather than intervention after the disaster.

Magnitude and risk factors of injuries in a glass bottle manufacturing plant.

A study was conducted in a glass bottle manufacturing plant in Pondicherry, India, to assess the magnitude and identify the risk factors of work-related injuries between January and December 1998. Three hundred and seventy-seven injuries were reported among 341 permanent workers followed up for one year (incidence=1,105.5/1,000 workers/yr). A higher load of injuries was noted in the first half of the night shifts and the second half of the other three shifts. Injuries were higher in the second half of the week and during the first half of the year. Hands and wrists were the most common sites of injury (40.6%), whereas the eye, foot, ankles and other body parts had 30%, 14.6%, 10.6% and 4.2% of injuries respectively. The commonest type of injury was cuts and lacerations (50.1%); injuries to the eye (due to foreign bodies, chemicals and welding sparks) accounted for 30%, sprains 8% and burns 7.1% of the injuries. A cohort of 75 workers chosen from the 341 permanent workers were followed up for the one year for identification of risk factors. Significant risk factors were age (less than 30 yr) and experience (less than 2 yr). Technical factors responsible for injury were a hazardous worksite in 37 (38.5%) cases, inadequate protection with safety wear in 32 (33%) cases and proximity to machines in 14 (14.6%) cases. Human factors identified were non-use of protective wear in 43 (45%), overconfidence in 18 (18.7%) and timing error while working with machines in 11 (11.4%) episodes.

Poliomyelitis trends in Pondicherry, south India, 1989-91.

STUDY OBJECTIVES: To assess the poliomyelitis trend, including study of the epidemiological features, and to correlate this with the immunisation coverage of infants. DESIGN: Three annual lameness surveys in children aged 0-60 months employing cluster sampling methods and a series of five cross sectional surveys of immunisation coverage in children aged 12-23 months of age were undertaken. SETTING: Pondicherry, India, 1988-92. SUBJECTS: More than 10,000 children in the age group of 0-60 months took part in the three annual lameness surveys and samples of 210 children aged 12-23 months were covered each year in immunisation coverage surveys. MEASUREMENTS AND MAIN RESULTS: Altogether 50 of 11,461, 24 of 10,093, and 17 of 11,218 children surveyed during 1989, 1990, and 1991 respectively had become lame as a result of poliomyelitis, giving prevalences of 4.4, 2.4, and 1.5 per 1000 children for the three surveys. The corrected prevalences of poliomyelitis were 5.9, 3.2, and 2.0 per 1000 children during 1989, 1990, and 1991 respectively. The proportion of cases aged up to 36 months fell from 48% in 1989 to 12.5% in 1990 and 6% in 1991. The age at onset was less than 1 year in most. The median age at onset was 10.7 months. About 54% of the affected children had received three doses of oral poliomyelitis vaccine (OPV) before the onset of paralysis. In 1988 immunisation coverage for the third dose of OPV was 91% and in 1992 it was 97.6%. The drop out rate for the first versus the third dose of OPV fell from 6.3 in 1988 to 1.9% in 1992. CONCLUSION: Three successive annual lameness surveys showed that poliomyelitis was declining between 1989 and 1991. Five immunisation coverage surveys conducted from 1988 to 1992 showed high initial coverage followed by an improvement in the form of almost universal coverage for OPV.

Natural history, trend of prevalence and spectrum of manifestations of Bancroftian filarial disease in Pondicherry (South India).

The study examines the changes in the disease parameters of lymphatic filariasis over a period of time based on three surveys during 1957, 1986 and 1992 in Pondicherry, South India. The overall prevalence of filarial disease in the three surveys was 4.7, 6.7 and 9.9% respectively. It was significantly higher in males (1957:5.3%; 1986:13.7%; 1992:18.8%) when compared to females (1957:3.8%; 1986:2.3%; 1992:2.7%) in all the three surveys (P <0.05). The overall prevalence of acute adenolymphangitis declined from 1.0 in 1957 to 0.2 in 1986 and 0.04% in 1992. While the prevalence of hydrocele showed an increasing trend from 2.7 in 1957 to 11.9 in 1986 and 17.3% in 1992, the prevalence of lymphoedema (1.9 in 1957; 1.9 in 1986 and 1.8% in 1992) was stable over the same period. The prevalence of disease was relatively higher in all age groups of both male and female population in 1992 when compared either to 1957 or 1986. Similarly a monotonic increase in the prevalence of hydrocele was observed in all age groups in 1992 when compared to previous surveys. The implications of the changes in prevalence of the chronic manifestations when compared to the changes in the acute manifestations over a period of 35 years are discussed.

Teaching epidemiology of acute diarrheal diseases to medical undergraduates--a new approach.

A total of 165 students of first clinical year were taught the epidemiology of acute diarrheal diseases, during three successive years using a detailed lesson plan. The usual didactic lecture was minimised and supplemented by slide shows, and transparencies based on the contents of a handout on the subject distributed to all students a day prior to the class. This was followed by participatory discussions by the students on the diagnosis and management of some case examples presented. A video clip summarising the entire lesson was screened for reinforcement. Feed-back from the students showed that the teaching methodology was rated very good by 41%, and satisfactory by 59%. While 73% of the students mentioned videoclips as a factor favouring their learning, 69% cited the handouts and 49% felt that case discussions were helpful. Objective evaluation of the performance in the sessional test showed that out of 158 students who attended the test, 75% scored above 50% marks, 21% below 50% and the remaining 4% did not attempt that question.

Research as a tool for the teaching of epidemiology.

At a medical school in India, undergraduates have been given the opportunity to volunteer to conduct research as a means of improving their knowledge and understanding of epidemiology. First-year clinical students have conducted case-control studies with emphasis on methodological detail. Second-year students have been involved in community-based epidemiological studies. At the intern level, projects related to social factors in health and disease and to health administration have been encouraged. This initiative has been largely welcomed by the students and has yielded highly encouraging results.

PIP: Starting in 1985, at the Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India, modifications concerning teaching community medicine and epidemiology were introduced. Students were encouraged to conduct epidemiological investigations for better understanding of the subject. First-year students were free to participate in a hospital-based case control study involving 3-7 students over a period of 6-8 months. 5 projects were completed between 1990 and 1992 pertaining to risk factor analysis in oral cancers, protein-energy malnutrition, myocardial infarction, birth asphyxia, and cervical carcinoma. Methodology included objectives, review of the literature, definitions, questionnaires, and statistical methods. Faculty members monitored progress. Each student made a presentation to a gathering of 1st- and 2nd-year students and answered their questions. 2nd-year students undertook projects in community medicine lasting 2 months during vacation. Each student had a separate project of value for planning urban and rural field practice areas. Between 1987 and 1992, field studies were carried out on immunization coverage and mothers' knowledge about child immunization; the prevalence of caries among preschool children; cultural and economic factors affecting pregnancy; the epidemiology of cataract; blood pressure and hypertension; the nutritional status of preschool and school-age children; and drug compliance by leprosy patients. Case school studies were also undertaken on risk-factor analysis of low birth weight; factors affecting the acceptance of tubectomy; and treatment-seeking behavior among patients with cervical carcinoma. Similar public presentations were made. Interns were invited to assist in difficult subjects. A hospital study was completed by 2 students on injections given unnecessarily to children aged under 5 years. 111 out of 149 1st- year students questioned stated that they had gained knowledge and skills. Benefits reported included improved thinking, communication, statistical knowledge, understanding of human behavior, and a social view on health and disease.

Paralytic poliomyelitis in children under 6 years in Pondicherry: a community survey.

STUDY OBJECTIVES: To assess the amount of poliomyelitis and its epidemiological features including risk factors. DESIGN: This was a retrospective study of cases of paralytic poliomyelitis among children 0-6 years of age. SETTING: Pondicherry, India, 1983-89. SUBJECTS: A total of 47,960 children aged less than 6 years. MEASUREMENTS AND MAIN RESULTS: In 1989, 469 field workers undertook a door to door survey of children 0-6 years old to identify those with limb paralysis. This was followed by clinical examination to establish the cause, supplemented by case notes held by the Child Development Services. Altogether 203 cases of limb paralysis were identified, 188 of which were judged a result of paralytic poliomyelitis. The prevalence of poliomyelitis in 1989 was 3.9/1000 among children below 6 years of age. There was a male preponderance with a male:female ratio of 1.4:1. The prevalence was least in infants (1/1000) and highest in children aged 2 to 3 years (6.4/1000). The age at onset was less than 12 months in 42% of cases and less than 3 years in 98%. The median age at onset was 13.4 months. Time series analysis showed a high occurrence of cases from May to September between 1983 and 1989. The legs were affected in 97%. About 41% of children had received three doses of oral polio vaccine. There was a history of intramuscular injection, possibly provoking a paralytic attack, in 54% of cases. CONCLUSION: This retrospective community study involving the staff of the Integrated Child Development Services provided valid data about poliomyelitis with little additional cost and minimum training. Because the study covered a whole population of children under 6 years, rather than a sample, the data will help in monitoring and surveillance of poliomyelitis and also in planning strategies for effective control.

Unnecessary injections given to children under five years.

Adults accompanying 64 children attending a hospital out-patient clinic were questioned about treatment and injections given for illnesses in the previous month. Half the children had received injections, almost all given by private doctors: we consider most of these injections to have been unnecessary. Three girls were paralysed by aggravation poliomyelitis after unnecessary injections. Adults approved of injections although they did not know what was injected.

Community experience for medical students.

This article outlines the features of community postings for medical students in their second clinical year at the Jawaharlal Institute of Postgraduate Medical Education and Research, in Pondicherry, India. Their exposure to the realities of preventive and social medicine in the field clearly helps them to cope with what would otherwise be only theoretical knowledge.