High incidence of pulmonary tuberculosis in an indigenous Saharia tribe in Madhya Pradesh, central India-A prospective cohort study

BACKGROUND

Lack of TB incidence data is an important evidence gap among Saharia-a high TB burden indigenous community in Madhya Pradesh, central India. The present study was undertaken to calculate the incidence of pulmonary tuberculosis in this tribe.

OBJECTIVE

To calculate the incidence of pulmonary tuberculosis (PTB) among the Saharia tribal population in Madhya Pradesh, central India.

METHODS

A prospective cohort study was conducted among the Saharia tribal population (aged 15 years and above) of Shivpuri district in Madhya Pradesh state in central India. A total of 9,756 individuals were screened for TB in the baseline TB prevalence survey during 2012-13. All available household members were screened for symptoms suggestive of pulmonary TB (presumptive TB). Two sputum specimens were collected from persons having symptoms suggestive of TB and examined by smear and culture tests. A cohort of all non-TB individuals in the baseline survey was followed-up for one year and re-screened for the sysmptoms of PTB in the year 2014-15. Based on the data collected, the incidence of TB over one year period was estimated per 100,000 population.

RESULTS

A total of 9756 and 9044 individuals (≥ 15 years) were screened for symptoms suggestive of PTB during baseline and endline surveys respectively. The sputum specimens of presumptive TB cases were collected and examined by smear and culture tests. The overall incidence of bacteriologically positive (smear and/or culture) PTB over one year period was 1504 (95% Confidence Interval (CI): 1273-1776) per 100,000 in the study population, the incidence of smear-positive PTB was 1106 (95% CI: 910-1343), and the incidence of culture-positive PTB was 1084 (95% CI: 890-1319) per 100,000 population. The incidence for both smear and culture-positive PTB was 686 (95% CI: 535-878) per 100,000 population in the year 2014-15. The incidence of PTB was 2.8 times higher in males compared to females (2259 vs 807 per 100,000) and was positively correlated with age.

CONCLUSION

The findings of the study, the first of its kind in the Saharia tribal population, indicate a high incidence of TB in this tribal community thereby highlighting the urgent need for focused and intensified efforts to achieve the goal of TB elimination in the country.

TB free India: Reaching the unreached tribal population under National Tuberculosis Elimination Programme

India is the highest TB burden country in the world. The burden however is not uniform in different strata including tribal population - one of the key affected populations in the country. As the evidences from tribal population are hardly available, most of the policies and strategies implemented under National Tuberculosis Elimination Programme (NTEP) are usually based on the evidences from general populations. NTEP is continuously taking steps to strengthen TB services in tribal areas. The Social Action Plan including Tribal Action Plan is in place and the appropriate strategies are incorporated in the National Strategic Plan (NSP) to ensure universal access to quality TB services to vulnerable population groups. However, its implementation becomes challenging especially in tribal areas as different tribal groups have their own unique ways of dealing with health issues. These issues are therefore required to be addressed holistically involving all the stakeholders. In view of this a symposium was jointly organized by the Central TB Division (CTD), Govt. of India and ICMR - National Institute of Research in Tribal Health (NIRTH), Jabalpur on 17th and 18th December, 2019 at ICMR - NIRTH, Jabalpur. It provided an excellent platform for all the stakeholders from different parts of the country to share their experiences in tuberculosis particularly among marginalized populations. The recommendations emerged out of this interactive symposium highlight the sincere effort of NTEP to tackle TB situation in tribal population and show the way forward towards India's TB elimination goal by 2025 especially in hard to reach tribal areas.

Reasons for loss to follow-up (LTFU) of pulmonary TB (PTB) patients: A qualitative study among Saharia, a particularly vulnerable tribal group of Madhya Pradesh, India

BACKGROUND

Loss to follow-up (LTFU) among pulmonary tuberculosis (PTB) patients is a significant challenge for TB control. However, there is a dearth of information about the factors leading to LTFU among marginalized communities. This study highlights the factors associated with LTFU in Saharia, a tribe of Madhya Pradesh having high tuberculosis (TB) prevalence.

METHODS

A qualitative study was carried out during January-April 2020 among twenty-two pulmonary TB patients, recorded as LTFU in NIKSHAY, with ten treatment supporters and ten patient's family members. Semi-structured personal interview tools were used to collect the information on the history of anti-tuberculosis treatment, adverse drug events (ADE), social cognitive, behaviors, myths, and misbeliefs. The interviews were transcribed and thematically analysed to examine underlying themes.

RESULTS

The study explored various social, behavioral factors leading to loss to follow-up among PTB patients. Drug side effects, alcoholism, social stigma, lack of awareness of the seriousness of the diseases and poor counseling are the main barriers to treatment adherence in this community.

CONCLUSIONS

The study highlights the need to address the issues related to LTFU during TB treatment. The enhanced efforts of treatment supporters, health staff, and family & community persons must motivate and support the patients.

Persistent high prevalence of pulmonary tuberculosis in a resource-limited setting: threat to India's TB Free campaign

BACKGROUND

Tuberculosis (TB) is a major public health problem among Saharia, a particularly vulnerable tribal group residing in remote rural areas in central India. This article presents the findings from the baseline survey among Saharias and provides comprehensive prevalence data of pulmonary TB (PTB) in this marginalised community.

METHODS

A community-based cross-sectional PTB prevalence survey was carried out during January-May 2019 in selected villages using multistage stratified cluster sampling. All eligible adults (≥15 years of age) were screened for the symptoms of PTB. Sputum samples were collected and processed for microscopy and culture for Mycobacterium tuberculosis.

RESULTS

A total of 20 114 eligible individuals were screened for symptoms of PTB. Among these, 3001 (14.9%) individuals reported at least one PTB symptom and sputum was collected from 2890 (96.3%) individuals. Among these, 273 (9.4%) were bacteriologically positive for PTB. The overall prevalence was 1357 per 100 000 population.

CONCLUSIONS

The findings indicate that TB continues to be a major health problem in this marginalised community despite large investments by the government for TB control. This emphasizes the need to look into the causes and barriers in implementation of the TB elimination programme in the community, especially in view of India's TB elimination goal by 2025.

Comparative Yield of Pulmonary Tuberculosis by Different Symptoms among Saharia Tribe of Madhya Pradesh, India

Background

Symptom elicitation is a simple and inexpensive screening tool used for population screening in tuberculosis (TB) prevalence surveys. However, the information on the yield of TB cases by symptoms is sparsely available.

Methods

A cross-sectional pulmonary TB (PTB) prevalence survey was conducted. All available eligible individuals were interviewed for symptoms of PTB. Sputum samples were collected and tested for PTB by smear microscopy and culture.

Results

Among 2890 individuals tested for PTB, 77% had cough for 2 weeks or more and one-third reported chest pain for 1 month or more. About 31% were having a history of anti-TB treatment. Cough contributed to 82% PTB cases and the history of anti-TB treatment contributed to another 8.4% confirmed cases. Fever recorded lowest yield among the symptoms of PTB.

Conclusion

The study suggests that fever alone may be ignored from symptomatic elicitation, and history of previous anti-TB treatment should be treated as an important indication for PTB symptomatic elicitation.

Extensively drug-resistant tuberculosis treated with bedaquiline: A case report in the particularly vulnerable tribal group of Madhya Pradesh, India

The management of drug-resistant (DR) tuberculosis (TB) remains a challenge particularly in remote rural areas of the country. Although the treatment with wholly oral drug regimens, including bedaquiline (BDQ) and delamanid, is rolled out under the National TB Elimination Program, little is known about its coverage and the effectiveness in hard-to-reach tribal areas. The present report describes the early identification and successful management, through team effort, of a case of extensively DR TB belonging to the Saharia tribe - a Particularly Vulnerable Tribal Groups (PVTGs) of Madhya Pradesh, which has a very high prevalence of TB. The BDQ-containing regimen was well tolerated and found effective with minimal side effects and contributed to the reduced time to culture conversion and radiological improvements. The concerted efforts and strategies need to be adopted for effective implementation of Programmatic management of DR TB (PMDT) guidelines in remote tribal areas of the country.

Long-term survival of patients treated for tuberculosis: a population-based longitudinal study in a resource-poor setting

OBJECTIVE

We assessed the long-term survival of TB patients belonging to the Saharia tribe, a high TB burden community in Shivpuri district, Madhya Pradesh, central India.

METHODS

Population-based, longitudinal study conducted among 9756 Saharia population in 2013, and a resurvey done 2 years later in 2015 using the same methods. The status of the individuals during resurvey was recorded as non-TB, relapse and death. The deaths recorded in this period were used to measure the mortality among TB-affected population and the non-TB population in this cohort.

RESULTS

The standardised mortality ratio for the study cohort was 122.9 per 1000 population; males had higher mortality than females (129.9 vs. 96.8). The expected mortality among the non-TB population was 30.2, and the observed mortality among TB-affected population was 122.9 per 1000 population.

CONCLUSION

In the Saharia tribe, post-treatment mortality in the TB-affected population is significantly higher than in the general population. This highlights an urgent need for implementation of effective public health strategies to prevent disproportionate deaths among TB-affected individuals in resource-poor settings, and the importance of periodic follow-up of patients after cure/completion of treatment, especially in vulnerable populations.

Prevalence of pulmonary tuberculosis among the tribal populations in India

Importance

There is no concrete evidence on the burden of TB among the tribal populations across India except for few studies mainly conducted in Central India with a pooled estimation of 703/100,000 with a high degree of heterogeneity.

Objective

To estimate the prevalence of TB among the tribal populations in India.

Design, participants, setting

A survey using a multistage cluster sampling design was conducted between April 2015 and March 2020 covering 88 villages (clusters) from districts with over 70% tribal majority populations in 17 States across 6 zones of India. The sample populations included individuals ≥15 years old.

Main outcome and measures

Eligible participants who were screened through an interview for symptoms suggestive of pulmonary TB (PTB); Two sputum specimens were examined by smear and culture. Prevalence was estimated after multiple imputations for non-coverage and a correction factor of 1.31 was then applied to account for non-inclusion of X-ray screening.

Results

A total of 74532 (81.0%) of the 92038 eligible individuals were screened; 2675 (3.6%) were found to have TB symptoms or h/o ATT. The overall prevalence of PTB was 432 per 100,000 populations. The PTB prevalence per 100,000 populations was highest 625 [95% CI: 496–754] in the central zone and least 153 [95% CI: 24–281] in the west zone. Among the 17 states that were covered in this study, Odisha recorded the highest prevalence of 803 [95% CI: 504–1101] and Jammu and Kashmir the lowest 127 [95% CI: 0–310] per 100,000 populations. Findings from multiple logistic regression analysis reflected that those aged 35 years and above, with BMI <18.5 Kgs /m², h/o ATT, smoking, and/or consuming alcohol had a higher risk of bacteriologically positive PTB. Weight loss was relatively more important symptom associated with tuberculosis among this tribal populations followed by night sweats, blood in sputum, and fever.

Conclusion and relevance

The overall prevalence of PTB among tribal groups is higher than the general populations with a wide variation of prevalence of PTB among the tribal groups at zone and state levels. These findings call for strengthening of the TB control efforts in tribal areas to reduce TB prevalence through tribal community/site-specific intervention programs.

Community-based active case-finding to reach the most vulnerable: tuberculosis in tribal areas of India

<sec> <title>BACKGROUND</title> India has the world's largest indigenous/tribal population. Many areas with large tribal populations suffer from weak infrastructure and services. Surveys have shown a high prevalence of TB among Saharia communities, who rarely access public services. We evaluated a community-based active TB case-finding intervention. </sec> <sec> <title>METHODS</title> Community health workers screened people for TB symptoms in Saharia communities, made referrals, collected sputum for transport to laboratories, and initiated and supported anti-tuberculosis treatment. Microscopy testing was performed at government laboratories. The intervention tracked the people screened, referrals, the people tested, laboratory results, treatment initiation and outcomes. </sec> <sec> <title>RESULTS</title> Community health workers verbally screened 65 230 people, 8723 (13%) of whom had symptoms. Of these, 5600 were tested, 964 (17%) of whom were smear-positive. During the intervention, we observed a +52% increase in people tested at laboratories and an +84% increase in TB case notifications. Pre-treatment loss to follow-up decreased and treatment success increased slightly. </sec> <sec> <title>CONCLUSIONS</title> In India, particularly among tribal populations, many people with TB are missed by current approaches due to poor access. Community-based active case-finding can help identify more people with TB in tribal and remote rural areas by addressing barriers to health seeking as well as help reach ambitious country and global notification targets. </sec>.

Declining tuberculosis prevalence in Saharia, a particularly vulnerable tribal community in Central India: evidences for action

Background

In spite of an alarmingly high tuberculosis (TB) burden amongst the Saharia tribe of central India, there is hardly any study to investigate the impact of DOTS implementation on the magnitude of tuberculosis disease and the changes over time. This article present the findings of TB prevalence surveys conducted amongst this indigenous population in two different time periods to know the change in the prevalence of TB.

Methods

A cross sectional survey was conducted among Saharia population in Shivpuri district, Madhya Pradesh during February 2013 to May 2013 and resurvey during March 2015 to July 2015. All individuals (≥15 years) were examined for chest symptoms suggestive of TB. Sputum samples were collected from all presumptive TB cases and were confirmed by laboratory examination by Ziehl-Neelsen smear microscopy and solid media culture methods. All detected cases were referred to health facility for anti-tuberculosis treatment as per RNTCP guidelines.

Results

There was significant reduction (trend Chi square 19.97; OR = 1.521; p = 0.000) in the prevalence of TB at the endline (1995 per 100,000) as compared to baseline (3003 per 100,000). The reduction was significant among males as compared to females (OR 1.55; p = 0.000) and in the age group of 25–34 years (OR 2.0; p = 0.007) and 45–54 years (OR 4.39; p = 0.003). There was significant reduction in the prevalence in both smear (OR 1.29; p = 0.02) and culture positive (OR 1.57; p = 0.000) TB at the endline survey.

Conclusion

The study findings highlight a reduction in the prevalence of TB among Saharia tribal population. Further studies are needed to identify the factors associated with reduction in prevalence among this population and also further surveys to monitor the prevalence trend over a period.

Investigation of the risk factors for pulmonary tuberculosis: A case-control study among Saharia tribe in Gwalior district, Madhya Pradesh, India

BACKGROUND & OBJECTIVES

Prevalence of pulmonary tuberculosis (PTB) is known to be high in the indigenous tribal community Saharia in Madhya Pradesh, India. The risk factors for PTB are not well known among them. This study was done to determine various risk factors associated with PTB in the indigenous community Saharia.

METHODS

A prevalence survey was conducted among Saharias of Gwalior district of Madhya Pradesh. The population surveyed was 12,123 which was the source of cases and controls for the present study. All the bacillary-positive cases and controls in the ratio of 1:5 were included in the survey. Data were collected by the trained health workers from the patients and controls using a semi-structured pre-coded and pre-tested questionnaire which included data on risk factors including demographic factors, host-related factors and household factors. The individuals were also screened for diabetes mellitus and HIV.

RESULTS

Malnutrition and history of asthma were associated with an increased risk of PTB. More than 56 per cent cases were attributed to malnutrition and 12 per cent attributed to asthma. Low family income, alcohol consumption and smoking were the other contributors. The risk was higher in males as compared to females.

INTERPRETATION & CONCLUSIONS

The study emphasized that the main contributors were social factors. Nutrition supplementation, especially in tuberculosis (TB) patients and integrated approach to improve their living conditions are needed to control TB in this community.

Research on tuberculosis in tribal areas in India: A systematic review

BACKGROUND

Tuberculosis (TB) remains a major public health problem in resource-poor countries including India. Scientific knowledge is used to guide policy and practice. There is however, a limited, systematically collected data required for guiding the scale-up of interventions particularly amongst vulnerable populations including tribal groups in the country. In view of this, a systematic review of the TB research studies carried out in tribal areas of different parts of the country was undertaken.

OBJECTIVE

To undertake a systematic review of the TB research studies carried out in tribal areas of India between 1996 and 2016.

METHODS

A systematic review of English articles published between 1996 and 2016 on any aspect of TB was done through internet searches using Literature search EndNote programme. The words used for searching were tuberculosis, India, tribal, indigenous, disadvantaged, adivasi. The most common topics classified as annual risk of tuberculosis infection (ARTI), prevalence of TB, laboratory studies, clinical symptoms of TB, risk factors for TB, knowledge attitude practice, community Directly Observed Treatment (DOT) providers, performance of Revised National Tuberculosis Control Programme (RNTCP), and drug resistant TB. Classification was also done on the basis of the type of tribe studied and place of study conducted. A total of 47 studies identified through the search were included in the review.

RESULTS

Of the 47 studies reviewed, 12 were on TB prevalence, 7 were laboratory studies, four on ARTI and 5 on performance of RNTCP in tribal areas. Among these, majority (23 studies) of the tribal studies did not mention the type of tribe. Ten studies were conducted among Saharia, a particularly vulnerable tribal group in the Indian state of Madhya Pradesh mainly by the National Institute for Research on Tribal Health, five were among the mixed tribes and very few on other tribes.

CONCLUSION

The systematic review indicates that the research studies on TB among tribal population are very few. There is a need to invest and encourage researcher to work on the research plans for the control of TB in tribal areas.

Health literacy on tuberculosis amongst vulnerable segment of population: special reference to Saharia tribe in central India

BACKGROUND & OBJECTIVES

Health literacy on tuberculosis (TB) is an understanding about TB to perform activities with regard to prevention, diagnosis and treatment. We undertook a study to assess the health literacy on TB among one of the vulnerable tribal groups (Saharia) in central India.

METHODS

In this cross-sectional study, 2721 individuals aged >15 yr from two districts of Madhya Pradesh State of India were interviewed at their residence during December 2012-July 2013. By using a short-form questionnaire, health literacy on cause, symptoms, mode of transmission, diagnosis, treatment and prevention of TB was assessed.

RESULTS

Of the 2721 (Gwalior 1381; Shivpuri 1340) individuals interviewed; 76 per cent were aged <45 yr. Living condition was very poor (62% living in huts/katcha houses, 84 per cent with single room, 89 per cent no separate kitchen, 97 per cent used wood/crop as a fuel). Overall literacy rate was 19 per cent, and 22 per cent had >7 members in a house. Of the 2721 respondents participated, 52 per cent had never heard of TB; among them 8 per cent mentioned cough as a symptom, 64 per cent mentioned coughing up blood, and 91 per cent knew that TB diagnosis, and treatment facilities were available in both government and private hospitals. Health literacy score among participants who had heard of TB was <40 per cent among 36 per cent of respondents, 41-60 per cent among 54 per cent and >60 per cent among 8 per cent of respondents.

INTERPRETATION & CONCLUSIONS

The finding that nearly half of the respondents had not heard of TB indicated an important gap in education regarding TB in this vulnerable population. There is an urgent need to implement targeted interventions to educate this group for better TB control.

Pulmonary tuberculosis - a health problem amongst Saharia tribe in Madhya Pradesh

Background & objectives:

The information on tuberculosis (TB) situation amongst Saharia, one of the particularly vulnerable tribal groups (PVTGs) in Madhya Pradesh, is not available from Gwalior division of the State. Hence, this study was undertaken to estimate the prevalence of pulmonary tuberculosis (PTB) disease amongst them.

Methods:

A community based cross-sectional TB prevalence survey was undertaken among Saharia PVTG in Gwalior district of Madhya Pradesh. A random sample of villages predominated by Saharia tribe was selected from all the blocks in proportion to the size of Saharia population in each block of the district. All eligible individuals were questioned for chest symptoms relating to TB. Two sputum samples were collected from each of the eligible individuals, transported to the laboratory, and were examined by Ziehl-Neelsen(ZN) smear microscopy and solid media culture methods.

Results:

Of the total 10,259 individuals eligible for screening, 9,653 (94.1%) were screened for symptoms. Overall prevalence of PTB was found to be 3294 per 100,000. The prevalence increased with age and the trend was significant (P<0.001). The prevalence of TB was significantly higher amongst males (5497/100,000) as compared to females (1376/100,000) (P<0.001).

Interpretation & conclusions:

The study results provide vital information on the current situation of pulmonary TB disease among the Saharia tribal community in Gwalior district of Madhya Pradesh. In view of high PTB disease prevalence among this PVTG, there is an urgent need to improve and further intensify TB control measures in this area.

Situation of drug resistant tuberculosis in Saharia tribe of central India

BACKGROUND & OBJECTIVES

The information on multidrug resistant tuberculosis (MDR-TB) situation amongst Saharia, one of the Particularly Vulnerable Tribal Groups (PVTGs) in Madhya Pradesh, India, is not available. Hence, this study was undertaken to find the situation of MDR-TB amongst Saharia PVTG in two districts of Madhya Pradesh.

METHODS

Community based cross-sectional TB prevalence surveys were conducted among Saharia PVTG in Gwalior and Shivpuri districts of Madhya Pradesh. Chest symptomatics were identified from the individual registered for the study. Two sputum samples were collected from each of the eligible individuals, transported to the laboratory, and were examined by Ziehl-Neelsen (Z-N) smear microscopy and solid medium culture methods. Drug susceptibility testing of the isolates was done by indirect proportion method on solid medium.

RESULTS

MDR rate was 2.2 per cent of new cases and 8.2 per cent among the previously treated cases of TB in Gwalior while it was two per cent among the previously treated cases in Shivpuri district.

INTERPRETATION & CONCLUSIONS

Though the prevalence of tuberculosis in these districts was alarmingly high, the MDR rates were more or less similar to national average. However, the findings of this study highlight the need for active intervention so that the MDR-TB is kept under control.

Is bleach-sedimented smear microscopy an alternative to direct microscopy under programme conditions in India?

This cross-sectional multi-centric study compared the yield of and potential benefit for detecting smear-positive pulmonary tuberculosis (PTB) by bleach sedimentation (2% sodium-hypochlorite) versus direct microscopy under programme conditions in India. Among 3168 PTB suspects, 684 (21.6%) were detected by bleach sedimentation vs. 625 (19.7%) by direct microscopy, with a proportional overall agreement of 96% (κ = 0.88). While 594 patients were smear-positive with both methods, 31 patients detected by direct microscopy were missed and an additional 90 patients were detected by bleach sedimentation. Overall, bleach sedimentation increased the yield of smear-positive TB detection; however; it also increased the time to results.

Yield of pulmonary tuberculosis cases by symptoms: Findings from a community survey in Madhya Pradesh, central India

A cross-sectional tuberculosis prevalence survey was undertaken in Jabalpur district, Madhya Pradesh, central India. All individuals were questioned for chest symptoms. Sputum samples were collected and examined for microscopy and culture. Overall prevalence of sputum positive pulmonary tuberculosis was found to be 255.3 per 100,000 population. Cough, with or without other symptoms, was present in 75.5% individuals and yielded 88.2% of the detected pulmonary tuberculosis cases. Elicitation of a previous history of treatment yielded 5.9%, and chest pain 4.5% cases. History of fever alone yielded no cases. The findings suggest that a history of fever alone may be safely excluded from the list of symptoms to be elicited in future TB prevalence surveys in India.

Knowledge and attitude towards tuberculosis amongst the tribal population of Jhabua, Madhya Pradesh

A community-based cross-sectional survey was carried out amongst the tribal population of Jhabuain Madhya Pradesh. A total of 1385 individuals from randomly selected villages were interviewed using structured questionnaire. Eighty five per cent respondents had knowledge of the symptoms of tuberculosis. About a quarter of the respondents were not aware of any method for preventing TB. Though majority of the respondents (68.2%) stated that TB is a curable disease, most of them (67.2%) were not aware of the DOTS programme. The study emphasizes the need for extensive health education programme to create awareness about tuberculosis in tribal population of the region.

Yield of culture of Mycobacterium tuberculosis complex in sputum samples transported from tribal areas

BACKGROUND

There is little information on the recovery of Mycobacterium tuberculosis complex from sputum samples collected in the field for bacteriological examination.

SETTING

Tribal areas in the State of Madhya Pradesh, in central India.

METHODS

Sputum specimens collected from subjects with chest symptoms in a disease prevalence survey were refrigerated until transportation to the laboratory. The specimens were processed for microscopy and culture. The samples were grouped based on the delay in processing for culture from the day of collection into three groups: 0-3, 4-7 and ≥8 days, and the recovery of M. tuberculosis complex in these groups was analysed. The statistical analysis was performed using χ(2) test.

RESULTS

Of the 3651 processed specimens, 114 were positive for M. tuberculosis complex by culture and 96 by smear microscopy. The differences in the proportion of 'smear-positive, culture-positive', 'smear-positive, culture-negative' and 'smear-negative, culture-positive' samples between the three groups were not significant.

CONCLUSION

In difficult-to-reach areas with limited resources, refrigeration of sputum specimens until they are transported for processing at a reference laboratory for culture seems not to significantly affect the recovery of M. tuberculosis complex isolates.

Annual risk of tuberculosis infection among the tribal children of Jhabua, Madhya Pradesh

A cross sectional tuberculin survey was undertaken to estimate the Annual Risk of Tuberculosis Infection (ARTI) amongst tribal children aged 1-9 years in Jhabua district, Madhya Pradesh, India. Of the 1056 test-read children, 774 (73.3%) had no BCG scar. The prevalence of infection was estimated as 6.3% (95% CI: 4.8-7.7) and ARTI as 1.2% (95% CI: 0.9-1.5). The findings suggest that the tuberculosis situation in the tribal population of Jhabua district is not that different from the situation among the non-tribal population in the country. However, there is a need to further intensify tuberculosis control measures in the area.

Prevalence of pulmonary tuberculosis amongst the Baigas--a primitive tribe of Madhya Pradesh, Central India

BACKGROUND

A community-based cross-sectional tuberculosis (TB) disease prevalence survey was undertaken amongst the Baiga primitive tribal community of Baiga Chak in central India.

MATERIAL AND METHODS

A population of 2,359 was covered under the study. Sputum samples were collected from chest symptomatics and examined for smear microscopy and culture.

RESULTS

Overall prevalence of PTB was 146 (95% C.I: 0-318) per 100,000 population.

CONCLUSION

The findings suggest that TB is not a major public health problem amongst this tribal group. However, there is still the need to maintain and further strengthen TB control measures on a sustained and long term basis in the area.

Prevalence of pulmonary tuberculosis among the Bharia, a primitive tribe of Madhya Pradesh, central India

A cross-sectional survey was undertaken to estimate the prevalence of pulmonary tuberculosis (TB) among the primitive Bharia tribe of Madhya Pradesh, India. Virtually the entire community in Patalkot valley of Chhindwara District was covered. Individuals aged > or =15 years were questioned about chest symptoms relating to TB. Sputum samples were collected and examined by smear microscopy and culture. The overall prevalence of pulmonary TB was found to be 432 per 100 000 population-not dissimilar to that seen in the wider population in India. There is, however, an urgent need to strengthen TB services in the area to improve access for this group.

Sexually transmitted infections in tribal populations of central India

This community-based cross-sectional study was carried out in 17 tribal villages of the Kundam block of the Jabalpur district of India. Individuals with sexually transmitted disease (STD) syndromes were enumerated and the specimens were collected for the laboratory diagnosis of sexually transmitted infections (STIs). Trichomoniasis, gonorrhoea, bacterial vaginosis and syphilis sero-reactivity were diagnosed by standard microbiological techniques. Chlamydia infection was detected by using polymerase chain reaction (PCR). A definite laboratory diagnosis of STIs could be established in 36.5% individuals. The most common STI in females was trichomoniasis, while in males, gonorrhoea was the most common. The highest proportion of individuals with STIs (39.2%) was in the age group 30-39 years. There is a need to focus on the primary prevention of STIs in the area.

Prevalence of sexually transmitted disease syndromes in tribal population of central India

BACKGROUND

A syndromic approach has been advocated for identification and management of sexually transmitted diseases (STDs) in countries where diagnostic laboratory tests are not consistently available. A community-based cross-sectional study was conducted to discover the prevalence of STD syndromes in tribal population of central India.

METHODS

All married men and women in the age group of 15-49 years from selected villages were enumerated by house-to-house visit. Individuals were interviewed using pre-coded, pre-tested questionnaires about STD syndromes of urethral discharge, vaginal discharge, dysurea, genital ulcer, inguinal swelling, scrotal swelling and lower abdominal pain.

RESULTS

Of the 2568 individuals interviewed, 326 (12.7%) had at least one STD syndrome. The prevalence was almost double in women (17.6%) than in men (8.4%). The highest prevalence (16.2%) was observed in the age group 30-34 years followed by 35-39 years (14.7%). The commonest syndrome in women was vaginal discharge (16.0%) while in men the commonest syndrome was dysurea (1.8%).

CONCLUSION

The low level of STD syndromes among tribal populations offers an opportunity to prevent a potential epidemic in this disadvantaged community. As no baseline data are available, the findings form the basis for future work in this area.

Annual risk of tuberculosis infection among tribal population of central India

OBJECTIVE

To estimate the annual risk of tuberculosis infection (ARTI) among tribal children of Madhya Pradesh, central India.

METHODS

Community-based, cross-sectional tuberculin survey among children aged 1-9 years in the tribal population of Madhya Pradesh. Multistage stratified cluster sampling was used to select a representative random sample of villages predominated by tribal population from selected districts. A total of 4802 children were tuberculin-tested with 1TU of PPD RT 23 and the reaction sizes read after 72 h.

RESULTS

A total of 3062 (64%) children had no BCG scar. The frequency distribution of children by reaction sizes indicated a fair mode at 18 mm in the right hand side of the distribution. By mirror-image technique, the prevalence of infection among children with no recognizable BCG scar was estimated as 6.8% (95% CI: 4.8-8.9%). The ARTI was computed as 1.3% (0.9-1.7%). The corresponding figures for children irrespective of scar status were 7.1% (95% CI: 5.5-8.8%) and 1.3% (1.0-1.7%) respectively.

CONCLUSIONS

The risk of tuberculosis infection in tribal population of Madhya Pradesh, central India is not different from other areas of the country. There is, however, a need to further intensify tuberculosis control measures on a sustained and long-term basis.

Tuberculous infection in Saharia, a primitive tribal community of Central India

A cross-sectional tuberculin survey was carried out to estimate the prevalence of tuberculous infection and the annual risk of tuberculosis infection (ARTI) among children of Saharia, a primitive ethnic group in Madhya Pradesh, Central India. A total of 1341 children aged 1-9 years were subjected to tuberculin testing with 1 TU of PPD RT 23 and the reaction sizes were read after 72 h. The proportion of BCG scar-positive children was 34.6%. The frequency distribution of children by reaction sizes indicated a clear-cut anti-mode at 11 mm and a mode at 18 mm at the right-hand side of the distribution. The prevalence of infection among children irrespective of BCG scar was estimated as 20.4% (95% CI 18.2-22.5%) and the ARTI was 3.9% (95% CI 3.5-4.3%). The corresponding figures were 21.1% (95% CI 18.3-23.8%) and 3.9% (95% CI 3.4-4.5%) among BCG scar-negative children and 19.0% (95% CI 15.4-22.5%) and 4.0% (95% CI 3.2-4.8%) among BCG scar-positive children. The findings of the present study show a high prevalence of tuberculous infection and high ARTI in this primitive ethnic group. There is an urgent need to further intensify tuberculosis control measures on a sustained and long-term basis in this area.

Cercarial dermatitis in central India: an emerging health problem among tribal communities

Although cercarial dermatitis is an emerging disease world-wide, cases of such dermatitis may often go undiagnosed, especially in communities that are affected by various skin infections. Between August 2001 and July 2002, 1336 individuals from tribal villages in central India were examined for dermatitis. Skin scrapings were collected and examined for Sarcoptes scabiei and each subject's response to antiscabies treatment was recorded. Freshwater snails were collected from the local ponds used for bathing, and examined for cercariae. The recorded prevalence of dermatitis ranged between 2.1% and 12.5% during the study year, peaking at the end of winter (February-March) and during the rainy season (August-October). Snail positivity for cercariae peaked in the rainy season. The prevalence and the severity of dermatitis were both higher in children than in adults. As most recorded cases of dermatitis were associated with a rash that developed soon after bathing in the local pond, all the skin scrapings were negative for itch mites, and the response to antiscabies treatment was poor, most if not all of the dermatitis observed was probably cercarial. Cercarial dermatitis therefore appears to be a significant health problem among the tribal populations of central India.

Malnutrition and high childhood mortality among the Onge tribe of the Andaman and Nicobar Islands

OBJECTIVES

A study was conducted among the Onge tribe of the Andaman and Nicobar Islands with the objectives of identifying demographic factors responsible for the decline in their population and assessing their nutritional status, which is an important determinant of child survival.

STUDY DESIGN AND SUBJECTS

The study included estimation of indices of fertility and child mortality, and assessment of nutritional status. All individuals of the Onge community settled on Little Andaman Island were included.

RESULTS

The mean total marital fertility rate was estimated to be 5.15 live births per woman and the general fertility rate was 200 live births per 1000 married-woman-years. Although the gross reproduction rate was estimated to be 2.2 female children per married woman, the net reproduction rate was only 0.9 surviving female child per married woman. The mean infant mortality rate during the past 30 years was 192.7 per 1000 live births, and the child survival rate was found to be only 53.2%. A mild to moderate degree of malnutrition was found in 85% of children of pre-school age and severe malnutrition in 10%. The Onges had low intakes of iron, vitamin A and vitamin C. All the screened Onges were found to be infested with one or more intestinal parasites.

CONCLUSIONS

High childhood mortality appears to be the predominant demographic factor responsible for the decline in the Onge population. The high prevalence of undernutrition and micronutrient deficiency disorders could be important factors contributing to the high childhood mortality.

Undernutrition & childhood morbidities among tribal preschool children

BACKGROUND & OBJECTIVE

Undernutrition and various morbidities go hand in hand, particularly in children. Nutritional status is a sensitive indicator of community health and nutrition. The present study is an attempt to assess the nutritional status of pre-school children of Gond tribal community in Madhya Pradesh.

METHODS

The study was a community-based, cross- sectional survey carried out in tribal preschool children. Anthropometric measurements were taken. Various indices of nutritional status were expressed in standard deviation units (z scores) from the reference median. The children were examined for nutritional deficiencies and other morbidities. The haemoglobin concentration was measured and the children were classified into various grades of nutritional anaemias. Data on socio-cultural and hygienic practices were also collected.

RESULTS

More than 60 per cent children were underweight. Micronutrient deficiency disorders such as anaemia and vitamin A deficiency were common among them. Unhygienic personal habits and adverse cultural practices relating to child rearing, breast-feeding and weaning were also prevalent among them.

INTERPRETATION & CONCLUSION

The findings of the present study revealed the widespread prevalence of undernutrition among pre-school tribal children and highlight a need for an integrated approach towards improving the child health as well as nutritional status in this area.

HIV epidemic in Central India: trends over 18 years (1986-2003)

In this report, we present the occurrence of HIV seropositivity and trends over last 18 years in a heterogenous group of people attending Voluntary Counselling and Testing Centre (VCTC) in Central India. The first Indian HIV positive person was reported in 1992 at the Centre. The occurrence of HIV infection increased from nil in 1986 to 19.9% in 2003. The HIV seropositivity was higher in males (6.9%) than in females (3.3%). Highest prevalence was seen in the age group of 25-29 years in both males and females. Heterosexual route was the commonest route of transmission. Relative decline was observed as regards to the blood borne transmission. No intravenous drug abuser was reported. The study highlights a need for comprehensive policies to control the HIV epidemic in Central India.

Worm infestation and anaemia: a public health problem among tribal pre-school children of Madhya Pradesh

A study to assess the status of intestinal parasitosis and anaemia was carried out among the pre-school children of Gond tribal community in Kundam block of Jabalpur district, Madhya Pradesh. A total of 985 pre-school children were covered. The results revealed that 48% pre-school children had intestinal parasitic infections. Common parasites observed among them were Hymenolepis nana, hookworms and roundworms. Mean epg for these parasites ranged from 371.2 to 1221.8. High prevalence of anaemia (86.7%) was also observed among them. This high prevalence of intestinal parasitic infections and anaemia could be due to indiscriminate defecation, low socio-economic status, ignorance and low standard of personal hygiene. Comprehensive control strategy with specific intervention measures need to be evolved and implemented specially in tribals as serious efforts are being madeby the Govt. for their overall development.

A neural network approach to identifying adolescent adjustment

This study examined the relationship between the quality of adjustment in adolescents and a set of psychiatric diagnoses, personality traits, parental bonding, and social support variables. One hundred fifty adolescents were administered the Millon Adolescent Personality Inventory, the Parental Bonding Questionnaire, the Social Support Questionnaire, and the Diagnostic Interview for Children and Adolescents. A neural network approach was then utilized, and it was found that several of the variables (e.g., Major Depressive Disorder, Conduct Disorder, and Societal Conformity) had a significant role in classifying adolescents into three groups: maladjusted, nominally adjusted, and well-adjusted.

Functional role of the slow activation property of ERG K+ channels

ERG (ether-à-go-go-related gene) K+ channels are crucial in human heart physiology (h-ERG), but are also found in neuronal cells and are impaired in Drosophila 'seizure' mutants. Their biophysical properties include the relatively fast kinetics of the inactivation gate and much slower kinetics of the activation gate. In order to elucidate how the complex time- and voltage-dependent activation properties of ERG channels underlies distinct roles in excitability, we investigated different types of ERG channels intrinsically present in cells or heterologously expressed in mammalian cells or Xenopus oocytes. Voltage-dependent activation curves were highly dependent on the features of the eliciting protocols. Only very long preconditioning times produced true steady-state relationships, a fact that has been largely neglected in the past, hampering the comparison of published data on ERG channels. Beyond this technical aspect, the slow activation property of ERG can be responsible for unsuspected physiological roles. We found that around the midpoint of the activation curve, the time constant of ERG open-close kinetics is of the order of 10-15 s. During sustained trains of depolarizations, e.g. those produced in neuronal firing, this leads to the use-dependent accumulation of open-state ERG channels. Accumulation is not observed in a mutant with a fast activation gate. In conclusion, it is well established that other K+ channels (i.e. Ca2+-activated and M) control the spike-frequency adaptation, but our results support the notion that the purely voltage-dependent activation property of ERG channels would allow a slow inhibitory physiological role in rapid neuronal signalling.

Nutritional deficiency disorders and high mortality among children of the Great Andamanese tribe

BACKGROUND

The population of the Great Andamanese tribe of the Andaman Islands has been declining at a rapid pace. The case fatality rate during a recent outbreak of dysentery was 30.8%, all the deaths being among under-fives. As malnutrition is known to potentiate susceptibility to death due to infectious diseases, we undertook a study to determine the prevalence of malnutrition among the Great Andamanese tribe and its role in contributing to the high mortality among them due to infectious diseases.

METHODS

The study included a diet survey, nutritional anthropometry, clinical examination, haemoglobin estimation and stool examination for intestinal parasitic infestations. Information was also collected about every pregnancy in all ever-married women in the community and deaths of their children. All 36 members of the tribe were covered.

RESULTS

The Andamanese had a poor intake of iron, vitamin A and riboflavin but a good intake of energy, protein and fats. More than 85% of the children below 6 years were under-nourished and more than 77% of children and adolescents below 19 years were stunted, wasted or both. Anaemia, vitamin A deficiency and goitre were also common among them. Almost the entire population suffered from intestinal parasitic infestations. They also have a comparatively high fertility rate and a high infant mortality rate.

CONCLUSION

The population attributable risk for death due to malnutrition is probably one of the foremost reasons for the observed high infant mortality rate among the Great Andamanese tribe and could be one of the reasons for the continuous decline in their population.

The cardiac troponin C isoform and the length dependence of Ca2+ sensitivity of tension in myocardium

The Ca2+ sensitivity of tension in cardiac muscle is length dependent, such that the sensitivity is diminished with decreasing sarcomere length below 2.4 microm. This length dependence of Ca2+ sensitivity of tension also forms the basis for the Frank-Starling mechanism in the heart. The fast-twitch skeletal muscle has a much lower length dependence of Ca2+ sensitivity. In a recent study of skinned cardiotrabeculae, we indicated that the exchange of endogenous cardiac troponin C (TnC) for skeletal troponin C also resulted in a major reduction in the length dependence to the level of skeletal muscle. These findings suggested that cardiac troponin C has a key role in the length-sensing mechanism. The present investigation supports this conclusion and delineates the specific domain in cardiac TnC responsible for the length effect. Chimeras splicing either 41, 61, or 96 N-terminal cardiac amino acids with the remaining skeletal residues have indicated that while Ca2+ binding in all three constructs is similar to that in wild type cardiac TnC, the functional responsiveness of the 96-cardiac residue construct is improved over the other two. This 96-cardiac residue construct yielded a tension response indistinguishable from that of wild-type cardiac TnC. A tryptophan variant of the chimera indicated fluorescence characteristics indistinguishable from cardiac troponin C. The findings provide further support for the idea that cardiac troponin C in situ is modified in response to sarcomere length change and thereby participates in the Frank-Starling mechanism. Moreover, the study indicates that the tropinin C length-sensing attribute originates within the N-terminal domain constituted by these 96 residues.

Molecular basis of depression of Ca2+ sensitivity of tension by acid pH in cardiac muscles of the mouse and the rat

BACKGROUND

Acid pH decreases the Ca2+ sensitivity of myocardial tension generation, and recent studies have suggested that regulatory proteins are involved. The current study defines the molecular basis of this effect on troponin C (TnC) and troponin I (TnI) and also addresses previous differences between the rat and mouse.

METHODS AND RESULTS

Endogenous cardiac TnC and cardiac TnI in isolated trabeculae from mice and rats were exchanged with their fast-twitch skeletal muscle counterparts. A cardiac-skeletal TnC chimera was used to define the target region for proton action on cardiac TnC. Finally, cardiac TnC and skeletal TnC were genetically modified by insertion of a tryptophan for phenylalanine-26 to probe the pH effects with fluorescence spectroscopy. The pH 6.2 effects on Ca2+ sensitivity of force development in mouse and rat cardiotrabeculae are largely accounted for by the proton influences on TnC (23%) and TnI (53%). In cardiac TnC, residues 1 to 41 provide the target region. Comparison of the Ca(2+)-induced fluorescence in isolated cardiac TnC and skeletal TnC also indicated a greater pH effect in the cardiac isoform.

CONCLUSIONS

The studies provide firm evidence that both TnC and TnI moieties are involved in the mechanism of acidosis causing reduction in the Ca sensitivity of force development in the myocardium. The findings rule out the possibility of interspecies variations in the underlying mechanisms. The genetically designed TnCs and a chimera demonstrate that the observed TnC-mediated difference in the pH effects on Ca2+ sensitivity of tension between cardiac and skeletal muscles is preserved in these isolated proteins. The N-terminal amino acid residues 1 to 41 in cardiac TnC are established as the pH sensor of this protein in the mouse as in the rat.

Relationship of personality, environmental, and DICA variables to adolescent hopelessness: a neural network sensitivity approach

OBJECTIVE

This study identified critical factors from a set of psychiatric diagnoses, personality traits, and family and social support variables that relate to hopelessness in adolescents.

METHOD

One hundred fifty adolescents were selected in a systematic sample from 1,700 high school students; they completed the Millon Adolescent Personality Inventory, the Parental Bonding Questionnaire, the Social Support Questionnaire, the Hopelessness Scale for Children and were interviewed by trained clinicians on the Diagnostic Interview for Children and Adolescents. Selected variables were chosen for a back-propagation neural network model and for subsequent sensitivity and statistical analysis.

RESULTS

Sensitive adolescents and adolescents with less impulse control scored high on hopelessness. Forceful adolescents were less hopeless.

CONCLUSIONS

Using the neural network models, the authors suggest that assertive training as well as group activities that increase cooperativeness may ameliorate hopelessness.

Molecular mobility of the Ca(2+)-deficient EF-hand of cardiac troponin C as revealed by fluorescence polarization of genetically inserted tryptophan

To probe attitudinal features of the Ca(2+)-deficient site (site I) in the Ca2+ switch of cardiac troponin C (cTnC), we have examined steady-state fluorescence emission and polarization of a Trp26 inserted in a recombinant cardiac TnC (cTnC3.W) and compared these with the properties of the Ca(2+)-competent site I in skeletal TnC (sTnC4.W). The Ca(2+)-induced fluorescence emission in cTnC3.W was a fraction (25-30%) of that in sTnC4.W, in agreement with previous observations on the Ca(2+)-deficient site incorporated in a cardiac/skeletal chimera c1/s.W [Gulati, J. & Rao, V. G. (1994) Biochemistry 33, 9052-9056]. Thus, the fractional quantum yield reflected intrinsic properties of the cardiac metal ion-deficient site I. Conversely, in sTnC-1.W, where the skeletal site I also was made Ca(2+)-deficient by D27-->A substitution, the Ca(2+)-induced quantum yield was lower than that in cTnC3.W. Nevertheless, similar steady-state fluorescence polarizations for Ca(2+)-saturated sTnC4.W and cTnC3.W indicated indistinguishable final conformations in the two activated TnC isoforms. In EGTA, the polarization parameter (PEGTA) of sTnC4.W is greater than that of cardiac TnC, and the cardiac PEGTA value is closer to the activated PCa. Comparison of the chimera c1/s.W with sTnC-1.W indicated that the differences in conformation of the site I Trp for the EGTA-treated cardiac/skeletal isoforms were due to the structural disparities in this region. This contention was further supported by examination of the chimera CBc1/s.W, where the cardiac EF-hand was altered by 27VLGA30-->DAD substitution. Polarization of the relaxed form was similar to that for sTnC4.W. These findings suggest that the relaxed conformation of the cardiac Ca2+ switch is more favorably predisposed to activation than the skeletal switch.

Disparate contributions of Tyr10 and Tyr109 to fluorescence intensity of rabbit skeletal muscle troponin C identified using a genetically engineered mutant

Intrinsic tyrosines, as monitored by fluorescence spectroscopy, are sensitive reporters of local, Ca(2+)-induced conformational changes in troponin C (TnC). Rabbit skeletal TnC contains two tyrosines (Y10 in the N-helix, and Y109 in site 3 in the C-terminal domain) in distinct microenvironments: their individual contributions to total fluorescence intensity are elucidated here utilizing bacterially synthesized rabbit skeletal TnC (sTnC4) and a genetically engineered variant, termed 109YF, lacking one of the tyrosines (Y109 replaced with F109). The steady-state fluorescence emission spectra following excitation at 280 nm were recorded in EGTA (Ca(2+)-free) and Ca(2+)-saturated (pCa4) solutions. For the wild-type sTnC4, pCa4 causes a significant (46%) increase in the peak fluorescence intensity over the value in EGTA. For the mutant 109YF, the EGTA fluorescence is only marginally affected (74% of the wild-type FEGTA), but interestingly the Ca2+ effect is completely suppressed (delta F = FpCa4-FEGTA = 2% of the wild-type value). These results indicate that the two tyrosines make disparate contributions to the fluorescence spectrum of wild-type sTnC, both in the presence and absence of Ca2+; whereas Y10 in the N-helix is dominant in Ca(2+)-free solution, Y109 is the sole contributor to the Ca2+ effect. Furthermore, to explain the biphasic fluorescence response of Y109 obtained during Ca2+ titrations, the findings yield the most unequivocal evidence that Ca(2+)-induced conformational changes in the trigger sites operating the contractile switch modify properties of the C-terminal sites in TnC pari passu.

The cardiac Ca(2+)-deficient EF-hand governs the phenotype of the cardiac-skeletal TnC-chimera in solution by Sr(2+)-induced tryptophan fluorescence emission

In the development of force during Sr2+ activation, phenotypically cardiac muscle is more sensitive than fast-twitch skeletal muscle, and TnC is central in this mechanism. The uncertainty has remained, however, whether such functional manifestations in situ relied critically on protein-protein interactions in the fiber or whether the Sr2+ sensitivities were governed intrinsically within the TnC molecule. To resolve this, we substituted a tryptophan for phenylalanine-26 in both rabbit sTnC (sTnC.W26) and in a chimera (c1/s.W26) where the 41 N-terminal amino acid residues were of bovine cTnC and the remaining 42-160 residues of rabbit sTnC. The metal ion dependent fluorescence emissions of the constructs could be examined in solution isolated from the protein-protein interactions found in situ. The Sr2+ sensitivities of these proteins differed by 0.55 +/- 0.02 pSr unit, but Ca2+ sensitivities were indistinguishable, as in the fiber. In another mutant, where the 27VLGA30 cluster was replaced with D-AD to enable site 1 to coordinate metal ion binding despite closely preserved cardiac structure, the Sr(2+)-sensitivity response was transformed into the skeletal-type. The Hill coefficients were also characteristically distinct for the various constructs. The findings indicate that cardiac N-terminal 41 residues define TnC performance in solution similar to that in situ. Moreover, the study provides unambiguous evidence that TnC isoforms intrinsically dominate the phenotype in the switching mechanisms for both cardiac and skeletal contractilities.

Detecting dysfunctional behavior in adolescents: the examination of relationships using neural networks

We describe a neural network that models the effect of personality, social, and environmental variables on hopelessness in adolescents. A sensitivity analysis suggests the effect that variation in each of the input variables will have on the output. Clinical implications are that health professionals can focus their attention on the variables most likely to impact upon the outcome.