Impact and cost-effectiveness evaluation of nutritional supplementation and complementary interventions for tuberculosis treatment outcomes under mukti pay-for-performance model in Madhya Pradesh, India: A study protocol

Background

A.

"pay-for-performance" (P4P) intervention model for improved tuberculosis (TB) outcomes, called "Mukti," has been implemented in an underdeveloped tribal area of central India. The target of this project is to improve nutritional status, quality of life (QoL), and treatment outcomes of 1000 TB patients through four interventions: food baskets, personal counseling, peer-to-peer learning and facilitation for linkage to government schemes. The current study aims to assess the success of this model by evaluating its impact and cost-effectiveness using a quasi-experimental approach.

Methods

Data for impact assessment have been collected from 1000 intervention and control patients. Study outcomes such as treatment completion, sputum negativity, weight gain, and health-related QoL will be compared between matched samples. Micro costing approach will be used for assessing the cost of routine TB services provision under the national program and the incremental cost of implementing our interventions. A decision and Markov hybrid model will estimate long-term costs and health outcomes associated with the use of study interventions. Measures of health outcomes will be mortality, morbidity, and disability. Cost-effectiveness will be assessed in terms of incremental cost per quality-adjusted life-years gained and cost per unit increase in patient weight in intervention versus control groups.

Results

The evidence generated from the present study in terms of impact and cost-effectiveness estimates will thus help to identify not only the effectiveness of these interventions but also the optimal mode of financing such measures. Our estimates on scale-up costs for these interventions will also help the state and the national government to consider scale-up of such interventions in the entire state or country.

Discussion

The study will generate important evidence on the impact of nutritional supplementation and other complementary interventions for TB treatment outcomes delivered through P4P financing models and on the cost of scaling up these to the state and national level in India.

What is the Out-of-Pocket Expenditure on Medicines in India? An Empirical Assessment using a Novel Methodology

The share of expenditure on medicines as part of the total out-of-pocket (OOP) expenditure on healthcare services has been reported to be much higher in India than in other countries. This study was conducted to ascertain the extent of this share of medicines expenditure using a novel methodology. OOP expenditure data were collected through exit-interviews with 5252 out-patient department (OPD) patients in three states of India. Follow-up interviews were conducted after day 1 and 15 of the baseline to identify any additional expenditure incurred. In addition, medicine prescription data were collected from the patients through prescription audits. Self-reported expenditure on medicines was compared with the amount imputed using local market prices based on prescription data. The results were also compared with the mean expenditure on medicines per spell of ailment among non-hospitalized cases from National Sample Survey (NSS) 75th round for the corresponding states and districts, which is based on household survey methodology. The share of medicines in OOP expenditure did not change significantly for organized private hospitals using patient-reported versus imputation-based method (30.74% to 29.61%). Large reductions were observed for single-doctor clinics, especially in case of Ayurvedic (64.51% to 36.51%) and Homeopathic (57.53% to 42.74%) practitioners. After adjustment for socio-demographic factors and types of ailments, we found that household data collection as per NSS methodology leads to an increase of 25% and 26% in reported share of medicines for public and private sector out-patient consultations respectively, as compared to facility based exit interviews with imputation of expenditure for medicines as per actual quantity and price data. The nature of health care transactions at single-doctor clinics in rural India leads to an over-reporting of expenditure on medicines by patients. While household surveys are valid to provide total expenditure, these are less likely to correctly estimate the share of medicines expenditure.

Biology and molecular interactions of Parastagonospora nodorum blotch of wheat

Parastagonospora nodorum is one of the important necrotrophic pathogens of wheat which causes severe economical loss to crop yield. So far, a number of effectors of Parastagonospora nodorum origin and their target interacting genes on the host plant have been characterized. Since targeting effector-sensitive gene carefully can be helpful in breeding for resistance. Therefore, constant efforts are required to further characterize the effectors, their interacting genes, and underlying biochemical pathways. Furthermore, to develop effective counter-strategies against emerging diseases, continuous efforts are required to determine the qualitative resistance that demands to screen of diverse genotypes for host resistance. Stagonospora nodorum blotch also refers to as Stagonospora glume blotch and leaf is caused by Parastagonospora nodorum. The pathogen deploys necrotrophic effectors for the establishment and development on wheat plants. The necrotrophic effectors and their interaction with host receptors lead to the establishment of infection on leaves and extensive lesions formation which either results in host cell death or suppression/activation of host defence mechanisms. The wheat Stagonospora nodorum interaction involves a set of nine host gene-necrotrophic effector interactions. Out of these, Snn1-SnTox1, Tsn1-SnToxA and Snn-SnTox3 are one of the most studied interaction, due to its role in the suppression of reactive oxygen species production, regulating the cytokinin content through ethylene-dependent wayduring initial infection stage. Further, although the molecular basis is not fully unveiled, these effectors regulate the redox state and influence the ethylene biosynthesis in infected wheat plants. Here, we have discussed the biology of the wheat pathogen Parastagonospora nodorum, role of its necrotrophic effectors and their interacting sensitivity genes on the redox state, how they hijack the resistance mechanisms, hormonal regulated immunity and other signalling pathways in susceptible wheat plants. The information generated from effectors and their corresponding sensitivity genes and other biological processes could be utilized effectively for disease management strategies.

Cost of Illness Due to Severe Enteric Fever in India

Background

Lack of robust data on economic burden due to enteric fever in India has made decision making on typhoid vaccination a challenge. Surveillance for Enteric Fever network was established to address gaps in typhoid disease and economic burden.

Methods

Patients hospitalized with blood culture-confirmed enteric fever and nontraumatic ileal perforation were identified at 14 hospitals. These sites represent urban referral hospitals (tier 3) and smaller hospitals in urban slums, remote rural, and tribal settings (tier 2). Cost of illness and productivity loss data from onset to 28 days after discharge from hospital were collected using a structured questionnaire. The direct and indirect costs of an illness episode were analyzed by type of setting.

Results

In total, 274 patients from tier 2 surveillance, 891 patients from tier 3 surveillance, and 110 ileal perforation patients provided the cost of illness data. The mean direct cost of severe enteric fever was US$119.1 (95% confidence interval [CI], US$85.8–152.4) in tier 2 and US$405.7 (95% CI, 366.9–444.4) in tier 3; 16.9% of patients in tier 3 experienced catastrophic expenditure.

Conclusions

The cost of treating enteric fever is considerable and likely to increase with emerging antimicrobial resistance. Equitable preventive strategies are urgently needed.

Cost effectiveness of typhoid vaccination in India

INTRODUCTION

World Health Organization has prequalified the use of typhoid conjugate vaccine (TCV) in children over six months of age in typhoid endemic countries. We assessed the cost-effectiveness of introducing TCV separately for urban and rural areas of India.

METHODS

A decision analytic model was developed, using a societal perspective, to compare long-term costs and outcomes (3% discount rate) in a new-born cohort of 100,000 children immunized with or without TCV. Three vaccination scenarios were modelled, assuming the protective efficacy of TCV to last for 5, 10 and 15 years following immunization. Incidence of typhoid infection estimated under 'National Surveillance System for Enteric Fever' (NSSEFI)' was used. The prices of vaccine and cost of service delivery were included for vaccination arm. Both health system cost and out-of-pocket expenditures for treatment of typhoid illness and its complications was included.

RESULTS

TCV introduction in urban areas would result in prevention of 17% to 36% typhoid cases and deaths. With exclusion of indirect costs, the incremental cost per QALY gained was ₹ 151,346 (54,730-307,975), ₹ 61,710 (-5250 to 163,283) and ₹ 45,188 (-17,069 to 141,093) for scenario 1, 2 and 3 respectively. While, with inclusion of indirect costs, all 3 scenarios were cost saving. Further, in rural areas, TCV is estimated to reduce the typhoid cases and deaths by 19% to 36%, with ICER (incremental cost per QALY gained) ranging from ₹ 2340 (1316-4370) to ₹ 3574 (2057 - 6691) thousand (inclusive of indirect costs) among the 3 vaccination scenarios.

CONCLUSION

From a societal perspective, introduction of TCV is a cost saving strategy in urban India. Further, due to low incidence of typhoid infection, introduction of TCV is not cost-effective in rural settings of India.

Geographic Inequities in Coverage of Maternal and Child health Services in Haryana State of India

Introduction India aims to achieve universal health coverage, with a focus on equitable delivery of services. There is significant evidence on extent of inequities by income status, gender and caste. In this paper, we report geographic inequities in coverage of reproductive, maternal and child health (MCH) services in Haryana state of India. Methods Cross-sectional data on utilization of maternal, child health and family planning services were collected from 12,191 women who had delivered a child in the last one year, 10314 women with 12-23 months old child, and 45864 eligible couples across all districts in Haryana state. Service coverage was assessed based on eight indicators - 6 for maternal health, one for child health and one for family planning. Inter- and intra-district inequalities were compared based on four and three indicators respectively. Results Difference in coverage of full ante-natal care, full immunization and contraceptive prevalence rate between districts performing best and worst was found to be 54%, 65% and 63% respectively. More than one-thirds of the sub-centres (SCs) in Panchkula, Ambala, Gurgaon and Mewat districts had their ante-natal care coverage less than 50% of the respective district average. Similarly, a significant proportion of SCs in Mewat, Panipat and Hisar districts had full immunization rate below 50% of the district average. Conclusion Widespread inter- and intra-district inequities in utilization of MCH services exist. A comprehensive geographical targeting to identify poor performing districts, community development blocks and SCs could result in significant equity gains, besides contributing to quick achievement of sustainable development goals.

Isolation and analysis of the molecular epidemiology and zoonotic significance of Mycobacterium tuberculosis in domestic and wildlife ruminants from three states in India

The majority of tuberculosis cases in ruminants are caused by Mycobacterium bovis (MB). However, in this study, the authors reported the isolation of Mycobacterium tuberculosis (MT) from bovine milk, nasal swabs and post-mortem tissue samples (n = 841) collected from cattle and buffaloes in the states of Telangana, Maharashtra and Gujarat in India in the period from 2010 to 2015. The isolates (n = 7) were confirmed as Mycobacterium due to their growth characteristics and colony morphology in a commercial liquid medium Mycobacterial Growth Indicator Tube (MGIT)™ employing the BD BACTEC™ MGIT™ 960 system and the Löwenstein-Jensen (LJ) medium supplemented with glycerol but not with sodium pyruvate, and BD-DIFCO™ Middlebrook 7H10 agar containing oleic albumin dextrose catalase (OADC). These isolates were initially identified as members of the M. tuberculosis complex (MTC) using a commercial nested polymerase chain reaction (PCR) kit based on the IS6110 MTC specific nucleotide sequence. The isolates were confirmed as MT using three commercial line probe assay kits, were further genotyped, and the spoligotypes identified were of East African Indian (EAI) 3_IND, EAI5, Central-Asian (CAS) 1_DELHI, U and T1 lineages. Two MT isolates from one antelope (Antilope cervipara) andone gazelle (Gazella bennettii) from Gujarat, which were identified previously, were spoligotyped during this study and identified as belonging to EAI3_IND and EAI5 lineages, respectively. The epidemiological significance and zoonotic implications of regional presence and documentation of the same or two differents poligotypes in different species within the family Bovidae as well as humans is discussed.

Sub-national health accounts: Experience from Punjab State in India

INTRODUCTION

Public health spending in India has been traditionally one of the lowest globally. Punjab is one of the states with highest proportion of out-of-pocket expenditures for healthcare in India. We undertook this study to produce the sub-national health accounts (SNHA) for Punjab state in India.

METHODOLOGY

We used System of Health Accounts (SHA) 2011 framework for preparing health accounts for Punjab state. Data on health spending by government was obtained from concerned public sector departments both at state and central level. Estimates on Out-of-Pocket Expenditures (OOPE) expenditure were derived from National Sample Survey (NSS) 71st round data, Consumer Expenditure Survey (CES) data and Pharmatrac. Primary surveys were done for assessing health expenditure data by firms and non-governmental organizations. All estimates of healthcare expenditures reported in our paper pertain to 2013-14, and are reported in both Indian National Rupee (INR) and United States Dollar (US $),using average conversion rate of INR 60.50 per US $.

RESULTS

In 2013-14, the current health expenditures (CE) in Punjab was INR 134,680million (US $ 2245 million) which was 4.02% of its gross state domestic product (GSDP).However, public spending on health was 0.95% of GSDP i.e. 21% of the total health expenditure (THE), while 79% was private expenditure. In per capita terms, THE in Punjab was INR 4963 (US $ 82.03). In terms of functions, medical goods (41.6%) and curative care (37%) consumed larger share of expenditure in the Punjab state. Households spent 52% of expenditures for medicines and other pharmaceutical goods. Risk pooling mechanisms are being adopted to a lesser extent in the state.

CONCLUSION

The healthcare in Punjab is largely financed through private OOPE. Currently, public health spending in Punjab is inadequate to meet the healthcare demands of population, which is less than 1% of state's GSDP. Monitoring public resources is very important for better resource allocations. Health Accounts production is useful in order to assess future trends and impact of health financing policies on goals of universal health coverage and should be made a part of routine monitoring system both at national and sub-national level.

Out-of-pocket expenditure for hospitalization in Haryana State of India: Extent, determinants & financial risk protection

Background & objectives:

India aspires to achieve universal health coverage, which requires ensuring financial risk protection (FRP). This study was done to assess the extent of out-of-pocket (OOP) expenditure and FRP for hospitalization in Haryana State, India. Further, the determinants for FRP were also evaluated.

Methods:

Data collected as a part of a household level survey conducted in Haryana ‘Concurrent Evaluation of National Rural Health Mission: Haryana Health Survey’ were analyzed. Descriptive analysis was undertaken to assess socio-demographic characteristics, hospitalization rate, extent and determinants of OOP expenditure and FRP. Prevalence of catastrophic health expenditure (CHE) (more than 40% of non-food expenditure) and impoverishment (Int$ 1.25) were estimated. Multivariate logistic regression was used to assess determinants of FRP.

Results:

Hospitalization rate was found to be 3106 persons or 3307 episodes per 100,000 population. Median OOP expenditure on hospitalization was ₹ 8000 (USD 133), which was predominantly attributed to medicines (37%). Prevalence of CHE was 25.2 per cent with higher prevalence amongst males [odds ratio (OR)=1.30], those belonging to scheduled caste and scheduled tribes (OR=1.35), poorest 20 per cent households (OR=3.05), having injuries (OR=4.03) and non-communicable diseases (OR=3.13) admitted in a private hospital (OR=2.69) and those who were insured (OR=1.74). There was a 12 per cent relative increase in poverty head count due to OOP payments on healthcare.

Interpretation & conclusions:

Our findings showed that hospitalization resulted in significant OOP expenditure, leading to CHEs and impoverishment of households. Impact of OOP expenditures was inequitably more on the vulnerable groups. OOP expenditure may be curtailed through provision of free medicines and diagnostics and removal of any form of user charges.

Out-of-pocket expenditure for health care: District level estimates for Haryana state in India

INTRODUCTION

In this paper, we present district level out-of-pocket (OOP) expenditures with respect to outpatient consultation within last 15 days and hospitalization in last 1 year for Haryana state.

METHODS

The data from a large cross-sectional household survey covering all 21 districts of Haryana comprising of randomly selected 79 742 households were analyzed. Of the total sample, 56 056 households consisting of 314 639 individuals in 21 districts of Haryana state were surveyed to gather information on OOP expenditure incurred on outpatient consultation within last 15 days. Similarly, 59 901 households and 324 977 respondents were interviewed to elicit OOP expenditures for any hospitalization during the 1 year preceding the survey. Mean OOP expenditure per OP consultation, per hospitalization as well as per capita were computed. Mean OOP expenditure was also estimated by the type of provider, gender, and district.

RESULTS

The mean OOP expenditure for OP consultation and hospitalization in Haryana was Indian National Rupees (INR) 1005 (US Dollar [USD] 16.1; 95% CI: INR 934-1076) and INR 22 489 (USD 360.0; 95% CI: INR 21 375-23 608), respectively. Mean per capita OOP expenditure for OP consultation, which was INR 85 (USD 1.3) in Haryana, varied from INR 595 (USD 9.5) in district Panipat to INR 29 (USD 0.5) in district Kaithal.

CONCLUSION

This is the first study to comprehensively present district level estimates for OOP expenditure for health care. These estimates are useful for policy planning, and preparation for district and state health accounts.

Inequalities in nutritional status among under five children in Haryana state, India: Role of social determinants

Background: Under-nutrition is a major cause of ill health and childhood mortality in India. So far, little attempt has been made to assess whether improvements in nutritional status have masked widening socioeconomic inequalities or produced slower progress among the poor and the disadvantaged. Aims & objective: We undertook this study to estimate the burden of under-nutrition among children less than five years in four districts of Haryana and explore the inequalities in rates of malnutrition across different social and economic groups. Material & Methods: A community based cross-sectional survey was carried out in four districts of Haryana namely Ambala, Karnal, Panchkula and Yamunanagar. Multi-stage stratified random sampling technique was used to select 2763 children under 5 years of age. Standard anthropometric methods were used. Rates of underweight (WAZ ? -2 z-score), wasting (WHZ ? -2 z-score) and stunting (HAZ ? -2 z-score) were estimated. Multivariate logistic regression was used to determine risk factors and evaluate inequalities across population by social and economic sub-groups. Results: The prevalence of underweight, stunting and wasting in four districts of Haryana was 37.4%, 38.2% and 16.4% respectively. Similarly, 12.7%, 13.2% and 3.5% of under-weight children were severely underweight, stunted and wasted respectively. Age of the child, social group and wealth status were significant predictors of malnutrition. The odds of underweight and stunting increased among the poorest by 2.3 and 1.8 times respectively as compared to the richest category. Conclusion: There is persistent problem of under-nutrition in Haryana mostly among the poor, uneducated, and among children of women who do not take ANC care/ breastfeed. Actions on social determinants need urgent prioritization.

Widespread inequalities in smoking & smokeless tobacco consumption across wealth quintiles in States of India: Need for targeted interventions

Background & objectives:

India is a large country with each State having distinct social, cultural and economic characteristics. Tobacco epidemic is not uniform across the country. There are wide variations in tobacco consumption across age, sex, regions and socio-economic classes. This study was conducted to understand the wide inequalities in patterns of smoking and smokeless tobacco consumption across various States of India.

Methods:

Analysis was conducted on Global Adult Tobacco Survey, India (2009-2010) data. Prevalence of both forms of tobacco use and its association with socio-economic determinants was assessed across States and Union Territories of India. Wealth indices were calculated using socio-economic data of the survey. Concentration index of inequality and one way ANOVA assessed economic inequality in tobacco consumption and variation of tobacco consumption across quintiles. Multiple logistic regression was done for tobacco consumption and wealth index adjusting for age, sex, area, education and occupation.

Results:

Overall prevalence of smoking and smokeless tobacco consumption was 13.9 per cent (14.6, 13.3) and 25.8 per cent (26.6, 25.0), respectively. Prevalence of current smoking varied from 1.6 per cent (richest quintile in Odisha) to 42.2 per cent (poorest quintile in Meghalaya). Prevalence of current smokeless tobacco consumption varied from 1.7 per cent (richest quintile in Jammu and Kashmir) to 59.4 per cent (poorest quintile in Mizoram). Decreasing odds of tobacco consumption with increasing wealth was observed in most of the States. Reverse trend of tobacco consumption was observed in Nagaland. Significant difference in odds of smoking and smokeless tobacco consumption with wealth quintiles was observed. Concentration index of inequality was significant for smoking tobacco -0.7 (-0.62 to-0.78) and not significant for smokeless tobacco consumption -0.15 (0.01to-0.33)

Interpretation & conclusions:

The findings of our analysis indicate that tobacco control policy and public health interventions need to consider widespread socio-economic inequities in tobacco consumption across the States in India.

Quality of Health Management Information System for Maternal & Child Health Care in Haryana State, India

Background

Despite increasing importance being laid on use of routine data for decision making in India, it has frequently been reported to be riddled with problems. Evidence suggests lack of quality in the health management information system (HMIS), however there is no robust analysis to assess the extent of its inaccuracy. We aim to bridge this gap in evidence by assessing the extent of completeness and quality of HMIS in Haryana state of India.

Methods

Data on utilization of key maternal and child health (MCH) services were collected using a cross-sectional household survey from 4807 women in 209 Sub-Centre (SC) areas across all 21 districts of Haryana state. Information for same services was also recorded from HMIS records maintained by auxiliary nurse midwives (ANMs) at SCs to check under- or over-recording (Level 1 discordance). Data on utilisation of MCH services from SC ANM records, for a subset of the total women covered in the household survey, were also collected and compared with monthly reports submitted by ANMs to assess over-reporting while report preparation (Level 2 discordance) to paint the complete picture for quality and completeness of routine HMIS.

Results

Completeness of ANM records for various MCH services ranged from 73% for DPT1 vaccination dates to 94.6% for dates of delivery. Average completeness level for information recorded in HMIS was 88.5%. Extent of Level 1 discordance for iron-folic acid (IFA) supplementation, 3 or more ante-natal care (ANC) visits and 2 Tetanus toxoid (TT) injections was 41%, 16% and 2% respectively. In 48.2% cases, respondents from community as well as HMIS records reported at least one post-natal care (PNC) home visit by ANM. Extent of Level 2 discordance ranged from 1.6% to 6%. These figures were highest for number of women who completed IFA supplementation, contraceptive intra-uterine device insertion and provision of 2nd TT injection during ANC.

Conclusions

HMIS records for MCH services at sub-centre level in Haryana state were satisfactory in terms of completeness. However, there were significant differences in terms of reported and evaluated coverage of MCH services. Quality of HMIS needs to be improved in order to make it relevant for public health program planning and research.

Coverage and Financial Risk Protection for Institutional Delivery: How Universal Is Provision of Maternal Health Care in India?

BACKGROUND

India aims to achieve universal access to institutional delivery. We undertook this study to estimate the universality of institutional delivery care for pregnant women in Haryana state in India. To assess the coverage of institutional delivery, we analyze service coverage (coverage of public sector institutional delivery), population coverage (coverage among different districts and wealth quintiles of the population) and financial risk protection (catastrophic health expenditure and impoverishment as a result of out-of-pocket expenditure for delivery).

METHODS

We analyzed cross-sectional data collected from a randomly selected sample of 12,191 women who had delivered a child in the last one year from the date of data collection in Haryana state. Five indicators were calculated to evaluate coverage and financial risk protection for institutional delivery--proportion of public sector deliveries, out-of-pocket expenditure, percentage of women who incurred no expenses, prevalence of catastrophic expenditure for institutional delivery and incidence of impoverishment due to out-of-pocket expenditure for delivery. These indicators were calculated for the public and private sectors for 5 wealth quintiles and 21 districts of the state.

RESULTS

The coverage of institutional delivery in Haryana state was 82%, of which 65% took place in public sector facilities. Approximately 63% of the women reported no expenditure on delivery in the public sector. The mean out-of-pocket expenditures for delivery in the public and private sectors in Haryana were INR 771 (USD 14.2) and INR 12,479 (USD 229), respectively, which were catastrophic for 1.6% and 22% of households, respectively.

CONCLUSION

Our findings suggest that there is considerably high coverage of institutional delivery care in Haryana state, with significant financial risk protection in the public sector. However, coverage and financial risk protection for institutional delivery vary substantially across districts and among different socio-economic groups and must be strengthened. The success of the public sector in providing high coverage and financial risk protection in maternal health provides encouragement for the role that the public sector can play in universalizing health care.

Evaluation of the Flinders Technology Associates Cards for Storage and Temperature Challenges in Field Conditions for Foot-and-Mouth Disease Virus Surveillance

Foot-and-mouth disease virus (FMDV) samples transported to the laboratory from far and inaccessible areas for diagnosis and identification of FMDV pose a major problem in a tropical country like India, where wide fluctuation of temperature over a large geographical area is common. Inadequate storage methods lead to spoilage of FMDV samples collected from clinically positive animals in the field. Such samples are declared as non-typeable by the typing laboratories with the consequent loss of valuable epidemiological data. In this study, an attempt was made to evaluate the robustness of Flinders Technology Associates (FTA) cards for storage and transportation of FMDV samples in different climatic conditions which will be useful for FMDV surveillance. Simulation transport studies were conducted using FTA impregnated FMDV samples during post-monsoon (September-October 2010) and summer season (May-June 2012). FMDV genome or serotype could be identified from the FTA cards after the simulation transport studies with varying temperature (22-45°C) and relative humidity (20-100%). The stability of the viral RNA, the absence of infectivity and ease of processing the sample for molecular methods make the FTA cards an useful option for transport of FMDV genome for identification and type determination. The method can be used routinely for FMDV research as it is economical and the cards can be transported easily in envelopes by regular courier/postal systems. The absence of live virus in FTA card can be viewed as an advantage as it restricts the risk of transmission of live virus.

Rabies virus isolates of India - simultaneous existence of two distinct evolutionary lineages

Rabies is a fatal viral disease of serious public health implication. The disease is enzootic in India. In the present study, thirty six rabies virus isolates were obtained from terrestrial mammals of India during 2002-2012. Ecto-domain coding region of the glycoprotein gene from all the isolates were sequenced and the phylogenetic analysis was performed in relation to the global rabies and rabies related virus isolates. The Indian isolates grouped into two distinctly separate lineages with majority of the Indian isolates in Arctic like 1 lineage and the remaining isolates in sub-continental lineage. Isolates of the two distinct lineages were identified simultaneously from the same geographical region. Time scaled phylogenetic tree indicated that the sub-continental lineage of the virus is one of the earliest clade of rabies virus that diverged from bat rabies virus. On the contrary, the Arctic-like 1 lineage of India appeared to be a more recent divergence event. The amino acid sequence comparison revealed that all the major antigenic sites were almost conserved among the Indian isolates whereas few amino acid variations could be identified around site IIa, minor site I and IV. The dN/dS study based on G ecto-domain is in support of the earlier reports of strong purifying selection. In conclusion, it is evident that the Indian rabies virus isolates are of two major distinct lineages with distant phylogenetic and evolutionary relationship.

Streptococcal pharyngitis, rheumatic fever and rheumatic heart disease: Eight-year prospective surveillance in Rupnagar district of Punjab, India

BACKGROUND

Rheumatic fever (RF)/rheumatic heart disease (RHD) continue to be a neglected public health priority. We carried out a registry-based control project, prospective surveillance and sample surveys to estimate the burden of disease.

METHODS

We trained healthcare providers and established a surveillance system for the 1.1 million population of Rupnagar district in Punjab. In sample surveys conducted among schools, physicians examined the sampled children. Children with a cardiac murmur were investigated by echocardiography. Throat swabs were obtained from a sub-sample, and group A streptococci (GAS) were identified and emm typed by standard laboratory methods. We estimated the morbidity rates for RF/RHD from surveillance data and school surveys using a correction factor to account for under-registration of cases in the registry.

RESULTS

A total of 813 RF/RHD cases were registered from 2002 to 2009. Of the 203 RF and 610 RHD cases, respectively, 51.2% and 36.7% were males. In the age group of 5-14 years, RF was more common (80%) than RHD (27%). The prevalence of RF/RHD in 5-14-year-old students was 1.0/1000 (95% CI 0.8-1.3). The school survey indicated that about two-thirds of the RF/RHD cases were enrolled in the hospital-based registries. Based on the school survey, the prevalence of RF/RHD was estimated to be 143/100,000 population. In the registry, the annual incidence of acute RF was estimated to be at least 8.7/100 000 children in the age group of 5-14 years. The prevalence of GAS was 2% (13/656) in children with sore throat and 0.5% (14/2920) among those not having sore throat. Typing of 27 GAS revealed 16 emm types. We estimate that about 1000 episodes of GAS pharyngitis lead to one episode of acute RF.

CONCLUSION

RF/RHD continue to be a public health problem in Punjab, India.

Reproducibility and validity of a quantitative food frequency questionnaire in an urban and rural area of northern India

Background. Food frequency questionnaires (FFQs) have been used in epidemiological studies across the world to capture the usual food intake of individuals. As food habits vary in different population groups, FFQs should be validated before use. Hence, we determined the reproducibility and validity of FFQs designed for urban and rural populations of northern India. Methods. Separate FFQs, designed for urban and rural populations using standard methods, were administered to a sample of 200 subjects (100 urban and 100 rural) in the age group of 35-70 years in the beginning (baseline FFQ) of the study and after an interval of 1 year (1-year FFQ) to assess their reproducibility. Six 24-hour dietary-recalls, taken at an interval of 2 months over a period of 1 year, were used as a reference method to test the validity. Crude and energy- adjusted nutrient intakes estimated from FFQs and 24-hour dietary-recalls were compared using Pearson correlation coefficients. Bland and Altman plots were also used to test the agreement between the two methods. Results. Nutrient intakes were found to be similar at the baseline and 1-year FFQs in urban and rural areas. The unadjusted Pearson correlation between 24-hour dietary- recalls and 1-year FFQ ranged from 0.22 for vitamin C to 0.63 for iron in the urban area. It ranged from 0.06 for vitamin C to 0.74 for energy in the rural area. The correlations lowered after adjusting for energy and there was a minimal increase after de-attenuation. Conclusion. The FFQs were reproducible and valid for assessing nutrient intakes except for some micronutrients.

Short term benefits of post-operative oral dietary supplements in surgical patients

The present study was undertaken to investigate the short term clinical efficacy of oral dietary supplements administered post-operatively to patients undergoing predetermined moderate to severe gastrointestinal surgery. Trial end points for comparison included effects of oral dietary supplements on nutritional intake, nutritional status and incidence of serious complications. 54 patients who were scheduled to undergo predetermined moderate to major gastrointestinal surgical procedures entered the study. They were randomly assigned to receive a normal ward diet post-operatively or the same diet supplemented ad libitum by an oral nutritional sip feed. The study period was defined as commencing from the day patients were adjudged to be capable of ingesting 'free fluids' to the day of hospital discharge. 40 patients (20 in each group) completed the study. The mean daily energy intake (KCal/day) assessed from 7 day food diaries was significantly higher in the treatment group (1833 +/- SEM 99) than in the control group (1108 +/- 56, p < 0.0001). This increase occurred not only as a consequence of energy intake from the oral dietary supplements (470 +/- 30) but also because more energy was consumed from the ward diet by the treatment than the control patients (1353 +/- 92 vs 1108 +/- 56, p < 0.02). The mean daily protein intake g/day in the treatment group (66.0 +/- 3.4) was also greater than in the control group (52.9 +/- 29 p < 0.0001). This difference was due solely to the intake in protein from the oral dietary supplements (15.7 +/- 1.0), protein intake from the ward diet being similar in the treatment (50.1 +/- 3.2) and control (52.9 +/- 29) groups. Patients in the treatment group maintained their pre-operative weight where as control patients had lostsignificant amount of their pre-operative weight by study day 3 (4.5 +/- 12 kg and by discharge (4.7 +/- 1.2 kg, p < 0.02). Pre-operative muscle function as evidenced by grip strength dynamometry decreased to a greater extent in the control than treatment group patients by study day 3 (14.6 +/- 2.2 KPa vs 2.8 +/- 2.4 < 0.03) and by discharge (10.4 +/- 3.1 KPa vs 0.10 +/- 1.9 p < 0.03). The incidence of serious infections (pneumonia, wound infection) was significantly higher in the control group (10) than in the treatment group (3, p < 0.02). It is concluded that the prescription of oral dietary supplements on an ad libitum basis to post-operative patients undergoing moderate to major gastrointestinal surgery results in clinically significant short term benefits.

Serological response in cattle immunized with inactivated oil and Algel adjuvant vaccines against infectious bovine rhinotracheitis

Infectious bovine rhinotracheitis (IBR) virus was grown in Madin Darby bovine kidney (MDBK) cell line using a roller culture system for its large-scale production. Optimum multiplicity of infection (MOI) of 1:750 was found to give consistent virus yield. To determine the appropriate payload, three batches of antigen with virus titres ranging from 10(8.37) to 10(6.37) TCID50 per ml were used to prepare experimental inactivated IBR oil adjuvant vaccine. Beta-propiolactone (BPL) was used as inactivant. The vaccine formulation using inactivated BHV-1 virus antigen with a pre-inactivation titer of 10(8.37) TCID50 per dose elicited better sero-conversion in cattle calves as evidenced from the mean log SN titre of 1.02. To choose the appropriate adjuvant, two batches of vaccine each containing aluminum hydroxide gel (Algel) and Montanide oil respectively were tested in calves. Two groups of 16 calves each were inoculated with Algel and oil adjuvant vaccine respectively twice at four weeks to test the immunogenicity. Adequate titres of vaccine induced anti BHV-1 antibodies could be demonstrated both by ELISA and MNT up to 180 days post vaccination in both the groups.

Artificial nutrition support in hospitals in the United Kingdom — 1991: Second national survey

Objective - to determine current clinical practice of nutrition support in hospitals in the UK and to determine whether there have been any apparent changes in practices since 1988. Design - An 81 question survey about enteral and parenteral nutriton was sent to all District Dietitians registered with the British Dietetic Association. Information was collected additionally from pharmacists and clinicians. Results - 61.2% of questionnaires distributed were completed and returned. 32.5% of respondents had access to nutrition support teams, compared with 27% in 1988. The documentation of usage of nutrition support was poor, only 33% being able to accurately quantify administation of enteral nutrition, and 53% parenteral nutrition. Since 1988 the number of respondents using peripheral parenteral nutrition had doubled to 15%. Those using percutaneous gastrostomies had increased from 6% to 74%. Those using respiratory enteral diet formulations had quadrupled to 33%. There have been no other apparent major changes in nutrition support practice in the UK, in the last 3 years. Conclusions - Despite increasing awareness about the role of artificial nutrition support, and the value of Nutrition Support Teams there has been little or no progress in the provision or monitoring of support in the last 3 years. This has important implications when considering audit of such practices.

Retrograde (ascending) bacterial contamination of enteral diet administration systems

A prospective clinical study in three phases was performed to determine whether it was possible that enteral diet containers could become contaminated as a result of endogenous organisms ascending retrogradely from the enteral feeding tube via the giving set, and if this did occur whether the incidence could be altered by modifying enteral delivery systems. Each phase observed patients on enteral feeding over a 48-hour study period (phase I, n = 18; phase II, n = 17; phase III, n = 18). Each patient was prescribed an enteral diet of 2 L/24 h administered by continuous pump infusion from a closed 1-L sterile diet container. Four containers were used for each patient, and one giving set was used in the 48-hour period. Diet samples were taken at 12-hour intervals: two from the giving set before and after flushing with residual diet, and one from the diet container. Phases differed only in the design of the giving set: phase I had no drip chamber, phase II had a drip chamber, phase III had a drip chamber and an anti-reflux ball valve at the distal end. Both phase I and III had greater numbers of giving set samples colonized at 24, 36, and 48 hours. In phase I, 3 of 14 sterile diet containers were colonized with greater than 10(4) colony-forming organisms/mL of diet at 48 hours. Only phase II had no organisms contaminating the containers at 48 hours. We conclude that the retrograde spread of organisms from patient to sterile diet container does occur in clinical practice, and that a drip chamber in the giving set may prevent the problem.(ABSTRACT TRUNCATED AT 250 WORDS)

Topical nonsteroidal anti-inflammatory gel for the prevention of peripheral vein thrombophlebitis. A double-blind, randomised, placebo-controlled trial in normal subjects

A double-blind, randomised, placebo-controlled study was undertaken to determine whether topical application of a nonsteroidal anti-inflammatory gel to skin overlying peripheral vein cannula sites has a role in reducing the incidence or delaying the onset of peripheral vein thrombophlebitis. Fifty normal subjects had intravenous cannulae placed in right and left arms. Subjects were randomised to receive twice daily application of either active nonsteroidal anti-inflammatory gel or placebo gel to each cannula site. Cannula sites were observed and signs and symptoms of inflammation recorded up to 108 h. If any site had signs extending beyond 2 cm then the cannula was removed. Cannula sites that had 'active' gel applied had half the incidence of marked signs at 108 h (44% vs 22%, p less than 0.05). These results suggest that local application of topical nonsteroidal anti-inflammatory gel to cannula sites may have a significant role to play in the prevention of peripheral vein thrombophlebitis.

Development of thrombophlebitis in peripheral veins with Vialon and PTFE-Teflon cannulas: a double-blind, randomised, controlled trial

A series of 54 normal subjects were randomised to have either a Vialon or a PTFE-Teflon peripheral vein cannula inserted in a vein in each forearm to observe the development of thrombophlebitis. Cannulas were inspected twice daily for up to 5 days to observe the development of three signs, erythema, oedema or hardness and one symptom, pain. Each sign and symptom was recorded twice daily at three points, the cannula insertion site, the mid-point of the cannula and the cannula tip. The degree of change was recorded as less than 1, 1-2 and greater than 2 cm. Any cannula causing any sign greater than 2 cm was removed. By the end of the study over 40% of both types of cannula had been removed. There were no significant differences between the numbers of each type of cannula removed at any time point throughout the duration of the study. There were no significant differences in the amounts of erythema or hardness, but minimally increased swelling was observed at the mid-point of the PTFE-Teflon cannulas (P = 0.022). Despite the theoretical superiority of Vialon as a cannula material, under controlled conditions there appears to be little difference in its inherent capacity to cause the thrombophlebitis.

Occult abdominal wall peristomal abscess following percutaneous endoscopic gastrostomy

This case report describes the complication of peristomal abscess formation associated with the insertion of a percutaneous endoscopic gastrostomy (PEG). The formation of a peristomal anterior abdominal wall abscess in this patient was associated with the failure to give prophylactic antibiotics. The development of this potentially fatal complication may be avoided by strict observance of insertion protocols. This case was treated by removal of the gastrostomy tube after diagnosis which allowed drainage of the abscess. In similar cases of occult abscess formation, where symptoms are present but signs are absent, ultrasonography may be useful in diagnosis.

Comparison of the metabolism of linoleic and linolenic acids in the fetal rat

The metabolism by the fetal rat of [1-14C] linoleic acid (18:2 n-6) was compared with that of [1-14C] alpha-linolenic acid (18:3 n-3) studied in vivo and in vitro. Both linoleic and alpha-linolenic acid were rapidly converted to long-chain derivatives in fetal brain but rates of delta 6 desaturation were higher for alpha-linolenic than for linoleic acid. In the liver alpha-linolenic, but not linoleic acid, was rapidly converted to long-chain derivatives in vivo. Measurements of delta 6 and delta 5 desaturation by fetal liver in vitro showed significant desaturase activity but this was lower than in the brain. It is suggested that the observed difference in the hepatic metabolism of linoleic compared with that of alpha-linolenic acid reflects their differing affinities for alternative metabolic pathways.

Metabolism of taurine during reproduction in women

The pattern of excretion of taurine was measured in four omnivore and four vegan/vegetarian women during pregnancy and lactation, and was compared with the changes in urinary excretion of other amino acids, including the precursors of endogenous taurine, observed in ten pregnant omnivores. The loss of taurine in breast milk was also determined in fourteen omnivore and fourteen vegan mothers. In contrast to the rise in excretion of all amino acids during pregnancy, including methionine and cysteine, taurine excretion fell dramatically from week 9 of pregnancy in all subjects, and, in the vegan/vegetarian subjects, fell still further during lactation. Although the concentration of taurine in breast milk was lower in vegan subjects, the mean value fell within the range found in omnivore subjects. Our findings indicate that the suppression of urinary taurine excretion, both during pregnancy and lactation, is a physiological response to reproduction that satisfies the needs of the fetus and the suckling infant for this amino acid. The data also suggest that taurine is stored in the maternal tissues in early pregnancy for later transfer to the fetus.

Taurine concentrations in the diet, plasma, urine and breast milk of vegans compared with omnivores

1. The concentration of taurine in the diets, plasma, urine and breast milk were measured in vegans and age- and sex-matched omnivore controls. Plasma and urinary amino acid concentrations were also determined. 2. Taurine was absent from the vegan diet and occurred in variable amounts in the diets of the omnivores. Urinary taurine levels were less than half those of the omnivores but plasma and breast-milk levels were only slightly lower. 3. Dietary energy intakes were similar in the vegans and omnivores, but protein intakes tended to be lower in the vegans.