High prevalence of multi-drug resistant organisms in the gut flora of healthy rural individuals in northern India.

Background & objectives Presence of resistant gut flora in the community is associated with increasing multi-drug resistance (MDR) infections. In this study, the prevalence of MDR organisms in the gut flora of a healthy rural population residing in northern India was determined. Methods Healthy individuals aged 18-45 yr from Nuh district, Haryana, India were included in this study. Risk factors associated with dysbiosis, diet, lifestyle and exposure to animals was assessed. Qualitative food frequency questionnaire and inflammatory diet score was calculated. Pathogens in stool sample were detected by MALDI-TOF. Evaluation of antimicrobial susceptibility was done by automated Vitek-2 System. The presence of antimicrobial resistance (AMR) genes was evaluated using PCR. An isolate having resistance to at least one antibiotic out of the three or more classes of antibiotics tested was labelled as MDR. Results Among 153 individuals included in this study (mean age-32.5±8.6 yr, females-58.2%, vegetarian-68.6%), the most frequent organism isolated was E. coli (n=137, 89.5%) followed by K. pneumoniae (n=19, 12.4%) and Enterobacter species (n=23, 15%). Forty seven (30.7%) individuals had sensitive and 42 (27.4%) had MDR organisms. Fifty one (33.3%) were positive for ESBL, 5 (3.3%) were positive for carbapenems, and 18 (11.8%) were positive for both genes. Age, gender, body mass index, diet pattern, or diet score were similar between participants with sensitive and resistant organisms. Resistance against fluoroquinolones was highest [92(48.7%)] among all isolates. Forty nine (25.9%), 25 (13.2%), 24 (12.7%) and 21 (11.1%) isolates, respectively were positive for blaTEM, blaSHV, blaCTXM-1 and OXA-48 genes. Interpretation & conclusions Overall the study findings suggest that 27 per cent individuals from rural northern India carry MDR organisms in their fecal flora, with an ESBL carriage rate of 44 per cent.

Chronic Illnesses and Depression among Community-based Adolescents in Rural Haryana, India.

Evidence on the association of chronic illnesses with depression among adolescents in the Indian community setting is limited. A simple random sample of 583 adolescents, comprising 56.6% of boys and 43.4% of girls, were interviewed on home visits. Self-reports on chronic illnesses were elicited, followed by administration of Patient Health Questionnaire-9 (PHQ-9) questionnaire to screen for depression, and for confirmation of diagnosis by age-appropriate Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI Kid), or MINI. The prevalence of chronic illnesses was 8.4% (95% confidence interval [CI]: 6.3-11.0). Of these participants, 42.8% screened positive for depression. The prevalence of depression was 10.2% (95% CI: 3.4-22.2) among adolescents with chronic illness. The prevalence of physical-mental multimorbidity was 0.8% (95% CI: 0.3-2.0). The presence of chronic illness was associated with depression identified using both PHQ-9 (adjusted odds ratio [AOR] =3.1 [95% CI: 1.7-5.8], P < 0.001) and MINI Kid/MINI (AOR = 3.2 [95% CI: 1.1-9.4], P = 0.037). Adolescents with chronic illnesses can be targeted for mental morbidity screening in a bid to improve functional outcomes.

Sex disparity in childhood cancer in India: a multi-centre, individual patient data analysis.

BACKGROUND: Sex disparity and its determinants in childhood cancer in India remain unexplored, with scarce information available through summary statistics of cancer registries. This study analysed the degree of sex bias in childhood cancer in India and its clinical and demographical associations. METHODS: In this retrospective, multicentre cohort study, we collected individual data of children (aged 0-19 years) with cancer extracted from the hospital-based records of three cancer centres in India between Jan 1, 2005, and Dec 31, 2019, and two population-based cancer registries (PBCRs; Delhi [between Jan 1, 2005, and Dec 31, 2014] and Madras Metropolitan Tumour Registry [between Jan 1, 2005, and Dec 31, 2017]). We extracted data on age, sex, and confirmed diagnosis of malignancy (according to the International Classification of Diseases-10 coding),and excluded participants if they were without a recorded diagnosis, had a benign diagnosis, had missing sex information, resided outside of India, or were a donor for haematopoietic stem cell transplantation (HSCT). The primary outcome was the male-to-female incidence rate ratio (MF-IRR) in the two PBCRs and the male-to-female ratios (MFR) from the hospital-based and the HSCT data. For PBCR data, MF-IRR was estimated by dividing the MFR by the total population at risk. MFR was analysed for patients seeking treatment at the cancer centres and for those undergoing HSCT. Logistic regression analyses were done to explore the association of clinical and demographical variables with sex of the patients seeking treatment and those undergoing HSCT in hospital-based data and multivariable analyses were done to determine independent sociodemographic predictors of sex bias. Annual time trends of MFR and MF-IRR during the 15-year study period were ascertained by time series regression analyses. FINDINGS: We included 11 375 children from PBCRs in the study. 26 891 children from hospital-based records were screened, and data from 22 893 (85·1%) were included (including 514 who underwent HSCT). Residence details were missing for 257 (1·1%) of 22 893 patients from hospital-based records. The crude MFR of children at diagnosis was in favour of boys: 2·00 (95% CI 1·92-2·09) in the Delhi PBCR and 1·44 (1·32-1·57) in Madras Metropolitan Tumour Registry. The MF-IRRs for cancer diagnosis were also skewed in favour of boys in both PBCRs (Delhi 1·69 [95% CI 1·61-1·76]; Madras Metropolitan Tumour Registry 1·37 [1·26-1·49]). The MFR for children seeking treatment from hospital-based records was 2·06 (95% CI 2·00-2·12) in favour of boys. In subgroup analyses, the proportion of boys seeking treatment was higher in northern India than southern India (p<0·0001); in private centres than in centres providing subsidised treatment (p<0·0001); in patients with haematological malignancies than those with solid malignancies (p<0·0001); in those residing 100 km or further from the hospital than those within 100 km of a hospital (p<0·0001); and those living in rural areas than those living in urban areas (p=0·0006). The MFR of 514 children who underwent HSCT was 2·81 (95% CI 2·32-3·43) in favour of boys. Time trend analysis showed that MFR did not show any significant annual change in either the overall cohort or in any of the individual centres for hospital-based data; however, the analysis did show a declining MF-IRR in the Delhi PBCR from 2005 to 2014 (p=0·031). INTERPRETATION: The sex ratio for childhood cancer in India has a bias towards boys at the level of diagnosis, which is more pronounced in northern India and in situations demanding greater financial commitment. Addressing societal sex bias and enhancing affordable health care for girls should be pursued simultaneously in India. FUNDING: None. TRANSLATION: For the Hindi translation of the abstract see Supplementary Materials section.

Sugar-sweetened beverage consumption and socioeconomic status: A systematic review and meta-analysis.

BACKGROUND: Sugar-sweetened beverages (SSB) are an independent risk factor for obesity and other non-communicable diseases. Socioeconomic status (SES) is one of the key drivers for the purchase and consumption of SSBs among children and adults; however, there is a lack of strong evidence. This study aims to determine the association between SES and consumption patterns of SSBs across populations. RESULTS: The review was conducted according to PRISMA guidelines. PubMed, MEDLINE, Scopus, EMBASE, LILACS, Web of Science, Cochrane, and CINHAL databases were searched for relevant articles until 2022. Participants included children, adolescents, and adults who consumed different SSBs and were assessed based on their SES. The random-effects model was used to obtain the pooled odds ratio (OR). Twenty-one studies (152,070 participants) met the inclusion criteria. The risk of bias was assessed using the Newcastle-Ottawa tool, with the majority of the studies indicating medium to high quality. Eight ORs from four studies (34,454 participants) were considered for meta-analysis. Results showed those belonging to high SES had 48% lower odds of consuming the SSBs (OR 0.52; 95% CI: 0.42-0.61; p = 0.017). The overall quality of evidence was ascertained using GRADE criteria, illustrating a moderate certainty of evidence between SSB consumption and SES. CONCLUSION: Meta-analysis suggests that SES influences the consumption pattern of SSBs, with high SES having lower odds of SSB consumption.

Virulence gene mutations as a differentiator of clinical phenotypes: insights from community-acquired uropathogenic Escherichia coli.

Uropathogenic Escherichia coli (UPEC) remains an important cause of urinary tract infection during pregnancy. Multiple molecular virulence determinants and antibiotic resistant genes facilitate its pathogenesis and virulence phenotype. Hence it is hypothesized that there will be considerable variation in genes among the isolates from symptomatic as well as asymptomatic bacteriuria (ABU) during pregnancy. The aim of this study was to decipher the genetic variation among the two phenotypes. Six different UPEC isolates collected from urine specimens of consecutive pregnant females (five, symptomatic bacteriuria and one, ABU) were tested for their growth kinetics, and biofilm formation. A total of 87 virulence determinants and 56 antibiotic resistance genes were investigated using whole-genome sequencing, to identify putative drives of virulence phenotype. In this analysis, we identified eight different types of fully functional toxin antitoxin (TA) systems [HipAB, YefM-YoeB, YeeU-YeeV (CbtA), YhaV-PrlF, ChpBS, HigAB, YgiUT and HicAB] in the isolates from symptomatic bacteriuria; whereas partially functional TA system with mutations were observed in the asymptomatic one. Isolates of both the groups showed equivalent growth characteristics and biofilm-formation ability. Genes for an iron transport system (Efe UOB system, Fhu system except FhuA) were observed functional among all symptomatic and asymptomatic isolates, however functional mutations were observed in the latter group. Gene YidE was observed predominantly associated with the biofilm formation along with few other genes (BssR, BssS, YjgK, etc.). This study outlines putative critical relevance of specific variations in the genes for the TA system, biofilm formation, cell adhesion and colonization among UPEC isolates from symptomatic and asymptomatic bacteriuria among pregnant women. Further functional genomic study in the same cohort is warranted to establish the pathogenic role of these genes.

High-density lipoproteins may play a crucial role in COVID-19.

BACKGROUND: Lipids play a central role in the virus life cycle and are a crucial target to develop antiviral therapeutics. Importantly, among the other lipoproteins, the 'good cholesterol' high-density lipoprotein (HDL) has been widely studied for its role in not only cardiovascular but several infectious diseases as well. Studies have suggested a role of serum lipids and lipoproteins including HDL, total cholesterol (TC), triglycerides (TG), and low-density lipoproteins (LDL) in several viral infections including COVID-19. This disease is currently a major public health problem and there is a need to explore the role of these host lipids/lipoproteins in virus pathogenesis. METHODOLOGY: A total of 75 retrospective COVID-19 positive serum samples and 10 COVID-19 negative controls were studied for their lipid profiles including TC, HDL, LDL, and very-low-density lipoproteins (VLDL), and TG. RESULTS: Systematic literature search on dyslipidemia status in India shows that low HDL is the most common dyslipidemia. In this cohort, 65% (49) of COVID-19 patients had severely low HDL levels whereas 35% (26) had moderately low HDL and none had normal HDL levels. On the other hand, ~ 96% of samples had normal TC (72) and LDL (72) levels. VLDL and TG levels were also variable. In the controls, 100% of samples had moderately low HDL but none severely low HDL levels. CONCLUSION: HDL likely plays a crucial role in COVID-19 infection and outcomes. The causal relationships between HDL levels and COVID-19 need to be studied extensively for an understanding of disease pathogenesis and management.

Antibiotic resistance of uropathogens among the community-dwelling pregnant and nonpregnant female: a step towards antibiotic stewardship.

BACKGROUND: Indiscriminate and widespread use of antibiotics has resulted in emergence of many antibiotic-resistant organisms. Antibiotic administration during pregnancy is mostly avoided, unless there is compelling medical condition. We hypothesized that the uropathogens isolated from pregnant women would be more susceptible to antibiotics compared to those isolated from nonpregnant women, thus will be helpful in formulating separate empiric guideline for pregnant women based on the resistance pattern. METHODS: This was a prospective cross-sectional study conducted over a period of 2 years in which females with the clinical diagnosis of either cystitis or asymptomatic bacteriuria during pregnancy were included from the community settings. Uropathogen species and their antimicrobial resistance pattern were compared between the pregnant and nonpregnant groups. After accounting for centre-to-centre variation and adjusting for age and socio-economic status, the adjusted odds ratio for antibiotic resistance was calculated and compared between pregnant and nonpregnant women using logistic regression analysis. RESULTS: A total of 1758 women (pregnant: 43.3%; nonpregnant: 56.6%) were screened in the study over a period of 2 years, out of which 9.3% (163/1758) were having significant bacteriuria. Escherichia coli and Klebsiella pneumoniae were the two commonest uropathogen in both the groups; their prevalence being 83.6% in pregnant women and 85.2% in nonpregnant women, respectively. Resistance against ampicillin, cefixime, cefoxitin, ceftazidime, ceftriaxone and amoxicillin-clavulanic acid were found significantly lower in the pregnant women compared to nonpregnant. After adjusting the age and socio-economic status accounting for centre-to-centre variation, the odds of resistance for cefixime, amoxicillin-clavulanic acid and co-trimoxazole were found lower and statistically significant among the pregnant women group. CONCLUSIONS: The antimicrobial resistance was significantly higher among the community-dwelling nonpregnant women compared to pregnant women in case of few antibiotics. The study highlighted the need of building local antibiogram that could help to initiate the empirical treatment and thus prevent emergence of antimicrobial resistance.

Excess Screen Time and its Associated Factors among Young Men in a Rural Community of North India.

Screen-based media usage among young people is blooming rapidly due to technological and digital revolution. We conducted community-based cross-sectional study to determine the prevalence of excess screen time and its association with sociodemographic and behavioral patterns in a rural block of Haryana, India. A semi-structured interview schedule was administered by trained physicians to ascertain screen time in a typical day and various socioeconomic and behavioral factors among a random sample of 860 young men aged 18-24 years. The prevalence of excess screen time was 61.8% (95% confidence interval [CI] 58.4-65.1). It was significantly associated with education (adjusted odds ratio [AOR] 1.7, 95% CI 1.1-2.6) and occupation (AOR 2.2, 95% CI 1.2-3.9) of the father and their sleep duration of ≤8 h (AOR 1.6, 95% CI 1.2-2.3). Limiting the screen time as per international standards and behavioral interventions are needed for this young population.

Intravenous ferric carboxymaltose rapidly increases haemoglobin and serum ferritin among pregnant females with moderate-to-severe anaemia: A single-arm, open-label trial.

Background: . Infusion of ferric carboxymaltose (FCM) can correct iron deficiency anaemia in the second or third trimester of pregnancy. However, large-scale public health use of FCM is constrained by two issues. First, there is limited evidence on the efficacy and safety profile of FCM in the Indian context. Second, logistic challenges in administering FCM at a subdistrict healthcare setting have not been assessed. We aimed to measure the mean increase in haemoglobin (Hb) level 2 weeks after infusion of FCM to pregnant females with moderate-to-severe anaemia attending a subdistrict hospital in India. Methods: . During June-December 2016, we did a single-arm, open-label trial among pregnant females with a gestation of 16-32 weeks, Hb 5.0-9.9 g/dl. FCM was infused (per Ganzoni formula) in a single session up to a maximum of 1000 mg of iron. Hb and s-ferritin levels were measured at recruitment, 2 weeks post-infusion and at delivery. Adverse events were noted. Results: Seventy-seven pregnant females were enrolled with mean (SD) age 23.2 (3.1) years, gestation 27.6 (3.8) weeks and Hb 8.4 (0.9) g/dl. At 2 weeks post-infusion (n=63), the mean Hb level increased by 1.9 g/dl (95% confidence interval [CI] 1.6-2.3) and at delivery (n = 64) by 2.9 g/dl (95% CI 2.4-3.4). The median (interquartile range) (in ng/ml) for serum ferritin at baseline (n = 68), 2 weeks post-FCM infusion (n = 61) and at delivery (n = 39) was 6.3 (5.1-11.7), 275.4 (186.4-330.3) and 61.3 (42.5-132.0), respectively. No major adverse effects were reported. Conclusion: Infusion of FCM rapidly corrected anaemia, sustained its effect till delivery and replenished body iron reserves. FCM is safe and effective in treating anaemia in pregnant females in the second and third trimester at the subdistrict healthcare setting in India.

Access and utilization of sanitation facilities in a Rural Area of Haryana, North India.

BACKGROUND: Ensuring universal access to sanitation in households is essential for public health. OBJECTIVES: The objective of the study was to assess the availability of sanitary latrine at the household level and its use at the individual level in a rural area and factors associated with availability and use of sanitary latrine. METHODS: This cross-sectional study was conducted from December, 2016 to January 2017 (mention month and year) at the rural Health and Demographic Surveillance Site, Ballabgarh, in district Faridabad, Haryana, North India. A total of 16,896 households were studied. House-to-house visits were made by trained health workers who conducted interviews regarding availability and pattern of use of sanitary latrine in the household. The health worker also observed the type of sanitation facility, its functional status, availability of water, and hand-washing facility. RESULTS: Individual household latrine (IHL) was present in 87.3% of the households. An improved sanitation facility was available in 84.8% of the households, while 15.2% of the households had unimproved or no sanitation facility. Hand-washing facility along with improved sanitation was present in 70.4% of the households. Nonavailability of latrine among socially disadvantaged communities (scheduled caste households) was significantly higher (19.4%) as compared to other castes (10.4%) (P < 0.001). A significantly higher proportion of households below poverty line (28.9%) lacked IHL as compared to those above the poverty line (11.0%) (P < 0.001). Nearly 11% of the individuals reported open defecation. CONCLUSION: The availability of sanitary latrines in the study area was high. Nonavailability of in-house sanitary latrine was higher among economically poor households and those belonging to socially disadvantaged communities.

Effectiveness of intravenous ferric carboxymaltose in improving hemoglobin level among postpartum women with moderate-to-severe anemia at a secondary care hospital in Faridabad, Haryana - An interventional study.

BACKGROUND: Postpartum anemia is associated with postpartum anxiety, depression, poor cognitive interaction, and delayed infant development. Oral iron is the currently recommended therapy but is associated with gastrointestinal complaints and poor compliance. Parenteral iron dextran may cause serious side effects, whereas iron sucrose requires repeated visits. Intravenous ferric carboxymaltose (FCM) is given as an infusion in a single setting, which is logistically convenient both to patients and health system. It can be particularly beneficial for postpartum women who are usually discharged from health facility 48 h after delivery. OBJECTIVES: The objectives of this study were to estimate the change in mean hemoglobin (Hb) level 6 weeks after administration of intravenous FCM and to document any adverse events following administration among postpartum women. METHODS: A prospective, interventional follow-up study was conducted from August to December 2018. One hundred eligible postpartum women with Hb level of 5-9.9 g/dl were administered a calculated dose of intravenous FCM based on Ganzoni's formula with Hb target of 12 g/dl. Hb and serum ferritin were measured at baseline and at 6 weeks after FCM infusion and compared for mean increase. RESULTS: There was a significant increase in Hb and serum ferritin levels after administration of FCM. The mean (95% confidence interval) increase in the Hb and serum ferritin after 6 weeks was 4.2 (3.9-4.5) g/dl and 137.3 (113.6-161.0) ng/ml, respectively. No major adverse events were reported. CONCLUSION: Administration of FCM was safe and effective in the treatment of moderate-to-severe anemia among postpartum women.

Use of spectacles for distance vision: coverage, unmet needs and barriers in a rural area of North India.

BACKGROUND: Uncorrected refractive errors contribute enormously to the burden of avoidable visual impairment worldwide. There is a huge disparity in different parts of the globe in context to spectacle coverage for distance vision. This study was undertaken with objectives of determining prevalence of spectacle coverage, unmet needs and associated factors among adults in a rural community of north India. METHODS: A community-based cross-sectional study was carried out within selected clusters of Jhajjar district of Haryana. All participants aged > 15 years underwent visual acuity assessment by LogMAR "E" screening chart. Participants with presenting visual acuity < 6/12 in any eye and all current spectacle users underwent detailed ophthalmic examination and refraction. Additional details about spectacles, barriers for their use and willingness to pay for them were collected. Participants with met and unmet need for spectacle use at visual acuity > 6/12 was computed. These are reported as proportions with 95% confidence intervals. Associated factors with unmet need were determined using bivariable and multivariable logistic regression analysis. RESULTS: A total of 6910 participants were examined. The current spectacle use was 7.5% (95% Confidence Interval CI: 6.5, 8.7). The spectacle coverage was found in 33.3% (95% CI: 30.0, 36.7) participants among those in need. The unmet need was found in 10.8% of participants (95% CI: 10.1, 11.6). On multivariable analysis, odds of unmet need was associated with age, gender, level of education and marriage status. The most common barrier for refractive correction was lack of perceived need for refraction and its correction. CONCLUSION: There is substantial unmet need for distance vision spectacles in this population. It is imperative that multi-component intervention be implemented to improve spectacle coverage in this rural north Indian setting.

Prevalence of blindness in India: A systematic review and meta-analysis.

Background: The National Programme for Control of Blindness and Visual Impairment modified the definition of blindness in 2017 in line with the internationally accepted definition. We did a systematic review and meta-analysis to compute pooled estimate of blindness in India among adults aged 50 years and above by using recent and old definitions of blindness. Methods: We retrieved population-based studies/surveys reporting the prevalence of blindness using recent (presenting vision <3/60 better eye) and previous (presenting vision <6/ 60 better eye) definitions in India during 1990-2017 from key search engines and grey literature. Two authors did an independent literature search and extracted relevant information. Pooled prevalence estimates were computed using Stata 12.0 by using the random effects model. Forest and funnel plots were generated. Stratification of results was also performed using two time periods: 1995-2005 and 2006-17. Results: A total of 18 published articles/reports were included for recent and 20 for previous definitions of blindness, involving 211 502 participants. The pooled prevalence (95% confidence interval [CI]) obtained for recent and previous definitions of blindness in India was found to be 6.11% (5.07%-7.14%) and 9.91% (8.57%-11.25%), respectively. The stratified pooled prevalence (95% CI) from rapid surveys was 4.81% (3.26%-6.35%) and 4.68% (2.91%-6.46%) for studies published during 1995-2005 and 2006-17, respectively, using the new definition. The corresponding figures for comprehensive surveys were 9.22% (95% CI 6.48%-11.96%) for the period 1995-2005 and 3.81% (95% CI 2.76%-4.84%) for the period 2006-17. Conclusion: There is a decrease in the prevalence of blindness in India using recent and previous definitions and a declining trend over time. High quantum of blindness remains an unfinished public health agenda for implementing programmes in larger populations to reduce its burden.

Diabetic retinopathy screening programme utilising non-mydriatic fundus imaging in slum populations of New Delhi, India.

OBJECTIVES: To develop and implement a community-based programme for screening of diabetic retinopathy (DR) in urban populations of Delhi. METHODS: Known diabetics (KDs) aged 40 years and older were identified through house-to-house surveys, volunteers and publicity. All KDs were referred to DR screening camps organised locally where procedures included brief medical history, ocular examination and non-mydriatic fundus photography using portable handheld camera. Fundal images were graded on the spot by trained optometrists for DR. Patients with DR were referred to tertiary centre for management. RESULTS: A total of 11 566 KDs were identified, of whom 9435 (81.6%) visited DR screening camps and 8432 (89.4%) had DR gradable images. DR was identified in 13.5% of subjects; 351 cases were mild NPDR, 567 moderate, 92 severe. Seventy-seven had PDR, and 49 had DME, and 2.7% of participants were blind (presenting visual acuity <3/60 in better eye). Non-use of lifestyle management, presence of systemic complications, BMI <18.5 kg/m2 , disease duration of >5 years and uncontrolled diabetes were associated with increased odds of DR. All cases with DR were referred, and 420 (37%) successful referrals to base hospital were observed. CONCLUSION: The programme of creating awareness about DR, identifying KDs and optometrist-led DR screening using non-mydriatic fundus camera based in slums was successful.

Anemia at the time of delivery and its association with pregnancy outcomes: A study from a secondary care hospital in Haryana, India.

Maternal anemia has been reportedly associated with increased risk of maternal and fetal morbidity and mortality. Adverse pregnancy outcomes such as preterm birth, low birth weight, and stillbirth have been reported to be associated with anemia. However, different studies have shown inconsistent results. In the present study, we report the association between maternal hemoglobin levels at the time of delivery and outcomes among women at a secondary care hospital in northern India. Secondary analysis of routinely collected hospital data from January 2015 to December 2016 was carried out. Sociodemographic details, hemoglobin levels at the time of admission, and birth outcomes were retrieved from the records of women admitted for delivery. The outcomes were compared among anemic and nonanemic women. About 78% of the women were found to have anemia at the time of delivery. A significantly higher proportion of anemic women had preterm labor.

Delay in initiation of treatment after diagnosis of pulmonary tuberculosis in primary health care setting: eight year cohort analysis from district Faridabad, Haryana, North India.

INTRODUCTION: Delay in initiation of tuberculosis (TB) treatment may have a tremendous impact on disease transmission, development of drug resistance, poor outcome and overall survival of TB patients. The delay can occur at various levels. Delay in initiation of treatment after diagnosis is mostly due to health system failure and has immense programmatic implications. It has not been studied extensively in the Indian setting. METHODS: The authors did a cohort analysis of all TB patients initiated on treatment from two primary health centres (PHCs) at Ballabgarh Health and Demographic Surveillance System between January 2007 and December 2014. Diagnosis and treatment of TB in the study area was done as per the protocol envisaged in the national program. Information related to demography, details of diagnosis and treatment of TB and outcome of treatment were extracted from the TB register. Delay in initiation of treatment after diagnosis was considered if the gap between diagnosis and treatment was greater than 7 days. Bivariate and multivariate analyses were done to find the association of various factors with delay in initiation of treatment after diagnosis. RESULTS: Out of 885 patients, 662 patients started treatment for pulmonary TB. Mean time interval between diagnosis and initiation of treatment was 8.95 days. Only 57.7% of pulmonary TB patients were started on treatment within 7 days of diagnosis, and an additional 24.5% were started on treatment 8-14 days after diagnosis. Patients on retreatment regimens and those residing in villages without a PHC were more likely to have delayed initiation of treatment (odds ratio (OR)=1.82 (1.3-2.7, p=0.001) and OR=1.62 (1.1-2.5, p=0.01) respectively). Delay in initiation of treatment was also associated with unfavourable treatment outcome such as default, failure or death. CONCLUSIONS: There is a need to have healthcare changes related to TB care to enable initiation of treatment as early as possible. Pretreatment counselling especially for retreatment patients is of utmost importance.

Assessment of essential newborn care services in secondary-level facilities from two districts of India.

India faces a formidable burden of neonatal deaths, and quality newborn care is essential for reducing the high neonatal mortality rate. We examined newborn care services, with a focus on essential newborn care (ENC) in two districts, one each from two states in India. Nagaur district in Rajasthan and Chhatarpur district in Madhya Pradesh were included. Six secondary-level facilities from the districts-two district hospitals (DHs) and four community health centres (CHCs) were evaluated, where maximum institutional births within districts were taking place. The assessment included record review, facility observation, and competency assessment of service providers, using structured checklists and sets of questionnaire. The domains assessed for competency were: resuscitation, provision of warmth, breastfeeding, kangaroo mother care, and infection prevention. Our assessments showed that no inpatient care was being rendered at the CHCs while, at DHs, neonates with sepsis, asphyxia, and prematurity/low birthweight were managed. Newborn care corners existed within or adjacent to the labour room in all the facilities and were largely unutilized spaces in most of the facilities. Resuscitation bags and masks were available in four out of six facilities, with a predominant lack of masks of both sizes. Two CHCs in Chhatarpur did not have suction device. The average knowledge score amongst service providers in resuscitation was 76% and, in the remaining ENC domains, was 78%. The corresponding average skill scores were 24% and 34%, highlighting a huge contrast in knowledge and skill scores. This disparity was observed for all levels of providers assessed. While knowledge domain scores were largely satisfactory (> 75%) for the majority of providers in domains of kangaroo mother care and breastfeeding, the scores were only moderately satisfactory (50-75%) for all other knowledge domains. The skill scores for all domains were predominantly non-satisfactory (< 50%). The findings underpin the need for improving the existing ENC services by making newborn care comers functional and enhancing skills of service providers to reduce neonatal mortality rate in India.

A Quality Improvement Initiative to Reduce Prescription Error in a Pediatrics Outpatient Department at a Secondary-Level Community Hospital.

Background Medication errors are common, especially by new trainees in primary care settings. Our study aimed at reducing the rate of prescription error in the pediatric outpatient department (OPD) of a secondary healthcare center in suburban north India using a quality improvement methodology. Methods Based on a survey and focused group discussion (FGD) involving all stakeholders, the identified problems and difficulties faced during outpatient prescriptions, interventions, and outcome parameters were drafted. The primary outcome measure was the prescription error rate evaluated by a senior resident (SR) of pediatrics, and the secondary outcome measures included the frequency of antibiotic prescriptions and investigations. Intervention Two cycles of Plan-Do-Study-Act (PDSA) were conducted on accessible drug formularies and standard treatment protocols for common pediatric conditions. Results The mean baseline prescription error was 72.2% (95% confidence interval (CI): 63.2-81.1). After the implementation of the first PDSA cycle, the mean error rate was 46.5% (95% CI: 36.6-56.5). There were eight consecutive points of prescription error below the control limit (63.2% and 81.1%) of the baseline. The PDSA-2 cycle showed the same shift to below the control limit (36.6% and 56.5%). The mean error rate found at the end of the PDSA-2 cycle was 22.5% (95% CI 15.7-29.5). There was no clinically significant difference in the number of investigations or antibiotics prescribed. Conclusion The application of standardized drug formularies and standard treatment protocols (STPs) can help reduce prescription errors, especially in a primary care setting. Expansion of such techniques to other centers could be particularly useful.