Augmenting progress on the elimination of vertical transmissions of HIV in India: Insights from Spectrum-based HIV burden estimations

The government of India has adopted the elimination of vertical transmission of HIV as one of the five high-level goals under phase V of the National AIDS and STD Control Programme (NACP). In this paper, we present the data from HIV estimations 2021 for India and select States detailing the progress as well as the attributable causes for vertical transmissions. The NACP spearheads work on mathematical modelling to estimate HIV burden based on the periodically conducted sentinel surveillance for guiding program implementation and policymaking. Using the results of the latest round of HIV Estimations in 2021, we analysed the mother-to-child transmission (MTCT) during the perinatal and postnatal (breastfeeding) period. In 2021, overall, around 5,000 [3,000-7,800] vertical transmissions were estimated nationally with 58% being perinatal infections and remaining during breastfeeding. MTCT at 6 weeks was around 12.95% [9.45-16.02] with the final transmission rate at 24.25% [18.50-29.50]. Overall, 57% of vertical transmissions were among HIV-positive mothers who did not receive ART during pregnancy or breastfeeding, 19% among mothers who dropped off ART during pregnancy or delivery, and 18% among mothers who were infected during pregnancy or breastfeeding. There were significant variations between States. Depending upon the States, the programme needs to focus on the intervention domains of timely engagement in antenatal care-HIV testing-ART initiation as well as programme retention and adherence support. Equally important would be strengthening the strategic information to generate related evidence for inputting India and State-specific parameters improving the MTCT-related modelled estimates.

Comparison of prevention of parent-to-child HIV transmission programme & national biennial HIV sentinel surveillance data for tracking HIV epidemic in India

Background & objectives

HIV sentinel surveillance (HSS) among antenatal women in India has been used to track the epidemic for many years. However, reliable tracking at the local level is not possible as ANC sentinel sites are limited in number and cover a smaller sample size at each site. Prevention of parent-to-child-transmission (PPTCT) programme data has a potential advantage due to better geographical coverage, which could provide more precise HIV case estimates; therefore, we compared HSS ANC data with PPTCT programme data for HIV tracking.

Methods

Out of the 499 surveillance sites, where HSS and PPTCT programme was being conducted in 2015, 210 sites (140 urban and 70 rural) were selected using a stratified random sampling method. HSS (n=72,981) and PPTCT (n=112,832) data records were linked confidentially. The socio-demographic characteristics of HSS and PPTCT attendees were compared. HIV prevalence from HSS ANC was compared with the PPTCT programme data using Chi-square test. State- and site-level correlation of HIV prevalence was also done. Concordance between HSS and PPTCT HIV positivity was estimated using kappa statistics.

Results

The age distribution of HSS and PPTCT attendees was similar (range: 23 to 27 yr); however, HSS ANC participants were better educated, whereas PPTCT recorded a higher proportion of homemakers. The correlation of HIV prevalence between HSS and PPTCT was high (r=0.9) at the State level and moderate at the site level (r=0.7). The HIV positivity agreement between HSS ANC and PPTCT was good (kappa=0.633). A similar prevalence was reported across 26 States, whereas PPTCT had a significantly lower prevalence than HSS in three States where PPTCT coverage was low. Overall HIV prevalence was 0.31 per cent in HSS and 0.22 per cent in PPTCT (P<0.001).

Interpretation & conclusions

High-quality PPTCT programme data can provide reliable HIV trends in India. An operational framework for PPTCT-based surveillance should be pilot-tested in a phased manner before replacing HSS with PPTCT.

Migrant crisis in India during COVID-19 lockdown: through photos

The Coronavirus pandemic saw a lockdown in the country. With the factories and workplaces shut down, many migrants in different cities of the country are stranded. The migrant workers were left with no livelihood. Many people traveling was stuck at stations or state. Amidst many other crises that the current pandemic situation brought about, the migrant exodus seen nationwide in India was an unprecedented crisis. Indian media covered this migrant crisis extensively through write-ups and photographs. This paper attempts to analyse the photographs covering the migrant crisis. Two hundred two photos published by Indian media houses were analysed for stylistic framing and visual patterns. More than 3000 migrants from north-central India were daily wagers and the workers majorly suffered. The extensive media coverage of the mass movements of the migrants has ensured that the crisis is seen, heard, and felt. The study found that the most dominant frames were human interest frames, and they highlighted human suffering, grief, and misery. This paper tries to see how Indian media has visually framed the migrant crisis during the COVID-19 lockdown in India.

Personality type of consumers and their engagement with brands on Instagram

Social media platforms like Facebook, Twitter, Instagram, etc., help create an additional channel of communication with consumers, each offering unique value to the brand and consumers. To use the potential of these sites, brands must understand consumer psychology and behavior related to various social media sites and then devise their strategy. Although there is a rise in the number of users across social media platforms, the surge of Instagram users is substantially high, making it imperative for brands to be active on Instagram. Thus, our study aims to understand the factors affecting the positive behaviors of consumers for a brand and whether these behaviors are a result of personality types. Three personality types were, namely (i) Openness to Experience, (ii) Neuroticism, and (iii) Extroversion were considered along with two modes of interaction -(i) Broadcasting and (ii) Communicating. Also, the two relevant behaviors for customer engagement on Instagram were (i) Liking and (ii). Data for the study was collected through structured questionnaires from respondents between 18 and 28 years through convenience sampling. Exploratory Factor Analysis and Regression analysis were used to analyze the data. The study revealed that extroversion and openness to experience personality type engage through the broadcasting mode of interaction and neuroticism personality type engage through communicating mode. In addition, those who engage through broadcasting mode tend to like and comment on the brand post. On the other hand, those who use communicating mode just like on the brand post on Instagram. This study is important to understand factors affecting consumers’ Instagram behavior, which will help the brand manager, formulate a better Instagram strategy for consumer engagement.

Diversity in HIV epidemic transitions in India: An application of HIV epidemiological metrices and benchmarks

Background

The Joint United Nations Programme on AIDS (UNAIDS) has emphasized on the incidence-prevalence ratio (IPR) and incidence-mortality ratio (IMR) to measure the progress in HIV epidemic control. In this paper, we describe the status of epidemic control in India and in various states in terms of UNAIDS’s recommended metrices.

Method

The National AIDS Control Programme (NACP) of India spearheads work on mathematical modelling to estimate HIV burden based on periodically conducted sentinel surveillance for providing guidance to program implementation and policymaking. Using the results of the latest round of HIV Estimations in 2019, IPR and IMR were calculated.

Results

National level IPR was 0.029 [0.022–0.037] in 2019 and ranged from 0.01 to 0.15 in various States and Union Territories (UTs). Corresponding Incidence-Mortality Ratio was at 0.881 [0.754–1.014] nationally and ranged between 0.20 and 12.90 across the States/UTs.

Conclusions

Based on UNAIDS recommended indicators for HIV epidemic control, namely IPR and IMR; national AIDS response in India appears on track. However, the program success is not uniform and significant heterogeneity as well as expanding epidemic was observed at the level of States or UTs. Reinforcing States/UTs specific and focused HIV prevention, testing and treatment initiatives may help in the attainment of 2030 Sustainable Development Goals of ending AIDS as a public health threat by 2030.

E-learning in formal education under forced conditions using SDT and TAM

This study aims to understand the students’ attitude towards e-learning under the forced environment of the COVID-19 pandemic. This study gives a fresh insight into e-learning, considering the lack of comprehensive research on the influencing variables that impact the user acceptance of e-learning by learners in the Indian Universities during COVID-19 pandemic. The rational model has been constituted based on the Technological Acceptance Model (TAM) and Self-Determination Theory (SDT) to study the effective influence of Autonomy, Relatedness & Competency on the construct of TAM. The result showed significant relations of the self-determination variables with perceived ease of use & perceived usefulness, which further helps us establish a relationship between intrinsic & extrinsic factors of SDT framework with attitude and satisfaction level of Indian University students towards e-learning. This study will assist in bridging the gap between the understanding of organizations and actual factors impacting students’ learning process during the pandemic of COVID-19.

Sero-Surveillance to Monitor the Trend of SARS-CoV-2 Infection Transmission in India: Study Protocol for a Multi Site, Community Based Longitudinal Cohort Study

Introduction

Large-scale sero-prevalence studies with representation from all age groups are required to estimate the true burden of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections in the community. Serial serological surveys in fixed cohorts enable study of dynamics of viral transmission and correlates of immune response over time in the context of gradual introduction of COVID-19 vaccines and repeated upsurge of cases during the pandemic.

Methods

This longitudinal study will involve follow-up of a cohort of 25,000 individuals (5,000 per site) aged 2 years and above recruited from five existing demographic surveillance sites in India. The cohort will be tested for the presence of IgG antibodies against S1/S2 spike protein subunits of SARS-CoV-2 in four rounds; once at baseline and subsequently, at intervals of 4 months for a year between January 2021 and January 2022. Neutralization assays will be carried out in a subset of seropositive samples in each round to quantify the antibody response and to estimate the durability of antibody response. Serial serological surveys will be complemented by fortnightly phone based syndromic surveillance to assess the burden of symptomatic acute febrile illness/ influenza like illness in the same cohort. A bio-repository will also be established to store the serum samples collected in all rounds of serological surveys.

Discussion

The population based sero-epidemiological studies will help to determine the burden of COVID-19 at the community level in urban and rural Indian populations and guide in monitoring the trends in the transmission of SARS-CoV-2 infection. Risk factors for infection will be identified to inform future control strategies. The serial serological surveys in the same set of participants will help determine the viral transmission dynamics and durability of neutralizing immune response in participants with or without symptomatic COVID infection.

The Evolution of Regulatory Elements in the Emerging Promoter-Variant Strains of HIV-1 Subtype C

In a multicentric, observational, investigator-blinded, and longitudinal clinical study of 764 ART-naïve subjects, we identified nine different promoter variant strains of HIV-1 subtype C (HIV-1C) emerging in the Indian population, with some of these variants being reported for the first time. Unlike several previous studies, our work here focuses on the evolving viral regulatory elements, not the coding sequences. The emerging viral strains contain additional copies of the existing transcription factor binding sites (TFBS), including TCF-1α/LEF-1, RBEIII, AP-1, and NF-κB, created by sequence duplication. The additional TFBS are genetically diverse and may blur the distinction between the modulatory region of the promoter and the viral enhancer. In a follow-up analysis, we found trends, but no significant associations between any specific variant promoter and prognostic markers, probably because the emerging viral strains might not have established mono infections yet. Illumina sequencing of four clinical samples containing a coinfection indicated the domination of one strain over the other and establishing a stable ratio with the second strain at the follow-up time points. Since a single promoter regulates viral gene expression and constitutes the master regulatory circuit with Tat, the acquisition of additional and variant copies of the TFBS may significantly impact viral latency and latent reservoir characteristics. Further studies are urgently warranted to understand how the diverse TFBS profiles of the viral promoter may modulate the characteristics of the latent reservoir, especially following the initiation of antiretroviral therapy.

District-level HIV estimates using the spectrum model in five states of India, 2017

Decentralized response has been the hallmark of the National AIDS Control Programme in India. District-level HIV burden estimates quantifying the distribution of the epidemics are needed to enhance this decentralized response further to monitor the progress on prevention, testing, and treatment interventions. In this paper, we describe the methodology and results of district-level estimates using the Spectrum model piloted in 5 states of India under National AIDS Control Programme.Using state spectrum model for HIV estimations 2017, we disaggregated state results by the district in pilot states. Each district was considered a subepidemic and HIV epidemic configuration was carried out in its general population as well as in key population. We used HIV surveillance data from antenatal clinics and routine pregnant women testing to model the general population's epidemic curve. We used HIV prevalence data available from HIV sentinel surveillance and integrated biological and behavioral surveys to inform the epidemic curve for key population. Estimation and projection packgage classic platform was used for the curve fitting. District-wide estimates extracted from subpopulation summary in Spectrum results section were used to calculate relative burden for each district and applied to approved State HIV Estimations 2017 estimates.No district in Tamil Nadu had an adult HIV prevalence of higher than 0.5% except for one, and the epidemic seems to be declining. In Maharashtra, the epidemic has shown a decline, with all except 5 districts showing an adult prevalence of less than 0.50%. In Gujarat and Uttar Pradesh, few districts showed rising HIV prevalence. However, none had an adult prevalence of higher than 0.50%. In Mizoram, 6 of 8 districts showed a rising HIV trend with an adult prevalence of 1% or more in 5 districts.Disaggregation of state-level estimates by districts provided insights on epidemic diversity within the analyzed states. It also provided baseline evidence to measure the progress toward the goal of end of AIDS by 2030.

Impact of surgical approach on short-term oncological outcomes and recovery following low anterior resection for rectal cancer

AIM

The aim was to evaluate the influence of operative approach for low anterior resection (LAR) on oncological and postoperative outcomes. Minimally invasive surgical approaches are increasingly used for the treatment of rectal cancer with mixed outcomes.

METHOD

We compared patients undergoing LAR in the National Cancer Database between 2010 and 2015 by surgical approach. Multivariable regression was used to identify risk factors associated with conversion rate, prolonged length of stay (LOS) and 30-day unplanned readmission.

RESULTS

During the study period, 41 282 patients underwent LAR: 6035 robotic-assisted (RLAR) (14.6%), 13 826 laparoscopic (LLAR) (33.5%) and 21 421 open (OLAR) (51.9%). In propensity score matched analysis, RLAR compared to LLAR was associated with shorter LOS (6.3 vs 6.8 days, P < 0.0001), lower risk of prolonged LOS (22.1% vs 25.6%, P < 0.0001) and lower rate of conversion to open (7.5% vs 14.95%, P < 0.0001). Compared to OLAR, RLAR had shorter LOS (6.3 vs 7.8 days, P < 0.0001) and less prolonged LOS (14.1% vs. 20.9%, P < 0.0001). In multivariable analysis, for conversion to open, the laparoscopic approach was one of the risk factors; for prolonged LOS, conversion to open and non-robotic approaches (i.e. LLAR and OLAR) were risk factors; and for unplanned 30-day readmission, conversions and prolonged LOS were risk factors.

CONCLUSIONS

For patients with rectal cancer, RLAR shows recovery benefits over both open and laparoscopic LAR with reduced conversion to open compared with LLAR and less prolonged LOS compared with LLAR and OLAR. RLAR is associated with short-term oncological outcomes comparable to OLAR, supporting its use in minimally invasive surgery for rectal cancer.

How reliable and valid are the self-reports of sexual behavior among HIV discordant couples in Pune, INDIA

Reliability of self-reported sexual and safe sex behavior among heterosexual HIV discordant couples was assessed by matching individual responses of couples to a common set of questions and validated by matching with pregnancy and seroconversion during study period. Demographic, clinical and sexual behavior information was collected individually from 457 consenting married discordant couples using structured questionnaires at screening, enrollment and at four quarterly visits. Reliability of self-reports tested using Kappa statistics. At screening, level of agreement about spouse being regular partner (Kappa = 0.96) and having had sexual intercourse with spouse in the last quarter (Kappa = 0.84) was noted. Moderate agreement observed about frequency of condom use (Kappa = 0.639) and condom tear (Kappa = 0.428). Agreement on reporting sexual contacts with spouse and consistent condom use increased (P < 0.001) over follow-ups. Four of 6 couples that seroconverted reported using condoms consistently, and 2 of these seroconverted. Couple histories of all 11 sero-discordant couples reporting pregnancy matched, of these 8 couples reported use of condoms and only 3 couples reported non-use of condoms during the preceding period. Sensitive sexual information can be collected using self-reports but it should be used with caution. Involving couples and using biological parameters concurrently may enhance validity of self-reports.

Rotavirus gastroenteritis in Indian children < 5 years hospitalized for diarrhoea, 2012 to 2016

Background

In 2016, the Government of India introduced the oral rotavirus vaccine (ROTAVAC, Bharat Biotech, India) in 4 states of India as part of the Universal Immunization Programme, and expanded to 5 more states in 2017. We report four years of data on rotavirus gastroenteritis in hospitalized children < 5 years of age prior to vaccine introduction.

Methods

Children from 7 sites in southern and northern India hospitalized for diarrhoea were recruited between July 2012 and June 2016. Stool samples were screened for rotavirus using enzyme immunoassay (EIA). The EIA positive samples were genotyped by reverse-transcription polymerase chain reaction.

Results

Of the 5834 samples from the 7 sites, 2069 (35.5%) were positive for rotavirus by EIA. Genotyping was performed for 2010 (97.1%) samples. G1P[8](56.3%), G2P[4](9.1%), G9P[4](7.6%), G9P[8](4.2%), and G12P[6](3.7%) were the common genotypes in southern India and G1P[8](36%), G9P[4](11.4%), G2P[4](11.2%), G12P[6](8.4%), and G3P[8](5.9%) in northern India.

Conclusions

The study highlights the high prevalence of rotavirus gastroenteritis in India and the diversity of rotavirus genotypes across different geographical regions. Pre- vaccine surveillance data is necessary to evaluate the potential change in admission rates for gastroenteritis and circulating rotavirus genotypes after vaccine introduction, thus assessing impact.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6406-0) contains supplementary material, which is available to authorized users.

Reimagining Health Data Exchange: An Application Programming Interface-Enabled Roadmap for India

In February 2018, the Government of India announced a massive public health insurance scheme extending coverage to 500 million citizens, in effect making it the world’s largest insurance program. To meet this target, the government will rely on technology to effectively scale services, monitor quality, and ensure accountability. While India has seen great strides in informational technology development and outsourcing, cellular phone penetration, cloud computing, and financial technology, the digital health ecosystem is in its nascent stages and has been waiting for a catalyst to seed the system. This National Health Protection Scheme is expected to provide just this impetus for widespread adoption. However, health data in India are mostly not digitized. In the few instances that they are, the data are not standardized, not interoperable, and not readily accessible to clinicians, researchers, or policymakers. While such barriers to easy health information exchange are hardly unique to India, the greenfield nature of India’s digital health infrastructure presents an excellent opportunity to avoid the pitfalls of complex, restrictive, digital health systems that have evolved elsewhere. We propose here a federated, patient-centric, application programming interface (API)–enabled health information ecosystem that leverages India’s near-universal mobile phone penetration, universal availability of unique ID systems, and evolving privacy and data protection laws. It builds on global best practices and promotes the adoption of human-centered design principles, data minimization, and open standard APIs. The recommendations are the result of 18 months of deliberations with multiple stakeholders in India and the United States, including from academia, industry, and government.

Coverage of childhood vaccination among children aged 12-23 months, Tamil Nadu, 2015, India

Background & objectives:

District-Level Household Survey-4 (DLHS-4) indicated that during 2012-2013, only 56 per cent of children aged 12-23 months in Tamil Nadu were fully vaccinated, which were lesser than those reported in earlier national surveys. We, therefore, conducted cluster surveys to estimate coverage of childhood vaccination in the State, and also to identify the factors associated with low coverage.

Methods:

Cross-sectional surveys were conducted in 15 strata [municipal corporation non-slum (n=1), municipal corporation slum (n=1), hilly (n=1), rural (n=6) and urban (n=6)]. From each stratum, 30 clusters were selected using probability proportional to the population size linear systematic sampling; seven children aged 12-23 months were selected from each cluster and their mothers/care-takers were interviewed to collect information about vaccination status of the child. A child was considered fully vaccinated if he/she received bacillus Calmette-Guérin (BCG), three doses of pentavalent, three doses of oral polio vaccine and one dose of measles vaccine, and appropriately vaccinated if all vaccine doses were given at right age and with right interval. Further, coverage of fully vaccinated children (FVC) as per vaccination cards or mothers’ recall, validated coverage of FVC (V-FVC) among those having cards, and coverage of appropriately vaccinated children (AVC) were estimated using survey data analysis module with appropriate sampling weights.

Results:

A total of 3150 children were surveyed, of them 2528 (80.3%) had vaccination card. The weighted coverage of FVC, V-FVC and AVC in the State was 79.9 per cent [95% confidence interval (CI): 78.2-81.5], 78.8 per cent (95% CI: 76.9-80.5) and 69.7 per cent (95% CI: 67.7-71.7), respectively. The coverage of individual vaccine ranged between 84 per cent (measles) and 99.8 per cent (BCG). About 12 per cent V-FVC were not vaccinated as per the vaccination schedule.

Interpretation & conclusions:

The coverage of FVC in Tamil Nadu was high, with about 80 per cent children completing primary vaccination. Efforts to increase vaccination coverage in the State need to focus on educating vaccinators about the need to adhere to the national vaccination schedule and strengthening supervision to ensure that children are vaccinated appropriately.

Sputum Conversion and Treatment Success among Tuberculosis Patients with Diabetes Treated under the Tuberculosis Control Programme in an Urban Setting in South India

Background:

Studies from India on sputum conversion and tuberculosis (TB) treatment outcomes among TB patients with diabetes are limited.

Objective:

The objective of this study is to estimate the proportion of sputum smear conversion and successful treatment outcomes among diabetic–TB patients treated under Revised National TB Control Programme (RNTCP).

Methodology:

Information on TB disease, diabetes, sputum conversion, and treatment outcomes were collected from treatment cards of adult TB patients (age >18 years) treated in the District TB Centre TB Unit, Tiruchirapalli, Tamil Nadu from July 1, 2014, to October 31, 2015.

Results:

Diabetes was documented in 163 (14%) of 1131 TB patients. Sputum conversion was in 107 (94%) of 114 smear positive-TB patients. Successful TB treatment outcome was in 116 (85%) of 136 patients and 107 (86%) of 124 new TB patients.

Conclusion:

Sputum conversion was as per RNTCP target while treatment success rate among the new TB patients with diabetes was suboptimal.

A single weighting approach to analyze respondent-driven sampling data

Background and objectives:

Respondent-driven sampling (RDS) is widely used to sample hidden populations and RDS data are analyzed using specially designed RDS analysis tool (RDSAT). RDSAT estimates parameters such as proportions. Analysis with RDSAT requires separate weight assignment for individual variables even in a single individual; hence, regression analysis is a problem. RDS-analyst is another advanced software that can perform three methods of estimates, namely, successive sampling method, RDS I and RDS II. All of these are in the process of refinement and need special skill to perform analysis. We propose a simple approach to analyze RDS data for comprehensive statistical analysis using any standard statistical software.

Methods:

We proposed an approach (RDS-MOD - respondent driven sampling-modified) that determines a single normalized weight (similar to RDS II of Volz-Heckathorn) for each participant. This approach converts the RDS data into clustered data to account the pre-existing relationship between recruits and the recruiters. Further, Taylor's linearization method was proposed for calculating confidence intervals for the estimates. Generalized estimating equation approach was used for regression analysis and parameter estimates of different software were compared.

Results:

The parameter estimates such as proportions obtained by our approach were matched with those from currently available special software for RDS data.

Interpretation & conclusions:

The proposed weight was comparable to different weights generated by RDSAT. The estimates were comparable to that by RDS II approach. RDS-MOD provided an efficient and easy-to-use method of estimation and regression accounting inter-individual recruits’ dependence.

Prevalence of disability in Tamil Nadu, India

BACKGROUND

Information on disability is essential for the government to formulate policies, allocate adequate resources and implement appropriate programmes. We aimed to estimate the prevalence of disability and describe the types of disability by gender, age and geographical regions in Tamil Nadu, India.

METHODS

We analysed the 2011 Census cross-sectional survey data of Tamil Nadu. Age-adjusted disability rates and disability rates per 100 000 population were calculated.

RESULTS

There were 1 179 963 disabled individuals in Tamil Nadu in 2011, a disability rate of 1635 per 100 000 population. Disability in movement, hearing and sight individually accounted for 24%, 19% and 11% of the total disability, respectively. Sixteen districts had disability rates above the state average. As age advanced, disability rates increased; the highest disability rate of 2533 per 100 000 was among people aged 60 years and above. The disability rates were higher in males compared to females (1819 v. 1451 per 100 000). Rural areas had higher disability areas compared to urban (1670 v. 1599 per 100 000). Currently married, working populations and literate populations had lower disability rates. Disability rate in the Scheduled Castes was higher at 1763 per 100 000 compared to the Scheduled Tribes and other social groups. Multiple disability was high in the age groups 0-19 years and 60 years and above.

CONCLUSION

Physical or mental disability was observed in 1.6% of the population of Tamil Nadu. Research is warranted to identify underlying causes and interventions to reduce the burden of disability in the state.

Expanded Indian National Rotavirus Surveillance Network in the Context of Rotavirus Vaccine Introduction

OBJECTIVE

To extend a nation-wide rotavirus surveillance network in India, and to generate geographically representative data on rotaviral disease burden and prevalent strains.

DESIGN

Hospital-based surveillance.

SETTING

A comprehensive multicenter, multi-state hospital based surveillance network was established in a phased manner involving 28 hospital sites across 17 states and two union territories in India.

PATIENTS

Cases of acute diarrhea among children below 5 years of age admitted in the participating hospitals.

RESULTS

During the 28 month study period between September 2012 and December 2014, 11898 children were enrolled and stool samples from 10207 children admitted with acute diarrhea were tested; 39.6% were positive for rotavirus. Highest positivity was seen in Tanda (60.4%) and Bhubaneswar (60.4%) followed by Midnapore (59.5%). Rotavirus infection was seen more among children aged below 2 years with highest (46.7%) positivity in the age group of 12-23 months. Cooler months of September to February accounted for most of the rotavirus associated gastroenteritis, with highest prevalence seen during December to February (56.4%). 64% of rotaviru -infected children had severe to very severe disease. G1 P[8] was the predominant rotavirus strain (62.7%) during the surveillance period.

CONCLUSION

The surveillance data highlights the high rotaviral disease burden in India. The network will continue to be a platform for monitoring the impact of the vaccine.

Indicators to Ensure Treatment Initiation of All Diagnosed Sputum Positive Pulmonary Tuberculosis Patients under Tuberculosis Control Programme in India

Background:

Pretreatment loss to follow-up (PTLFU) is used as performance indicator of Revised National Tuberculosis Control Programme (RNTCP) of India.

Objective:

To document the PTLFU, identify additional indicators and examine documentation of all the diagnosed sputum positive pulmonary tuberculosis (PTB) patients under RNTCP.

Methodology:

Tuberculosis (TB) laboratory, referral for treatment registers, and referral forms were perused for information on sputum positive PTB patients diagnosed from January to June 2014, in 3 TB Units in Chennai.

Results:

PTLFU was 24% (572 out of 2361). However, in pursuance with the principle of ensuring that all diagnosed patients must be started on treatment following referral, it was inflated to 44% (1046 out of 2361).

Conclusion:

The existing PTLFU indicator does not reflect the proportion of treatment initiation of all diagnosed smear-positive PTB patients. We propose additional indicators for monitoring referral and treatment initiation of all diagnosed sputum positive PTB patients.

Towards a single step process to create high purity gold structures by electron beam induced deposition at room temperature

Highly pure metallic structures can be deposited by electron beam induced deposition and they have many important applications in different fields. The organo-metallic precursor is decomposed and deposited under the electron beam, and typically it is purified with post-irradiation in presence of O2. However, this approach limits the purification to the surface of the deposit. Therefore, 'in situ' purification during deposition using simultaneous flows of both O2 and precursor in parallel with two gas injector needles has been tested and verified. To simplify the practical arrangements, a special concentric nozzle has been designed allowing deposition and purification performed together in a single step. With this new device metallic structures with high purity can be obtained more easily, while there is no limit on the height of the structures within a practical time frame. In this work, we summarize the first results obtained for 'in situ' Au purification using this concentric nozzle, which is described in more detail, including flow simulations. The operational parameter space is explored in order to optimize the shape as well as the purity of the deposits, which are evaluated through scanning electron microscope and energy dispersive x-ray spectroscopy measurements, respectively. The observed variations are interpreted in relation to other variables, such as the deposition yield. The resistivity of purified lines is also measured, and the influence of additional post treatments as a last purification step is studied.

Intussusception in Children Aged Less than Five years

OBJECTIVE

To enumerate the cases of intussusception in Chennai during 2012-2013, describe the clinical profile, outcomes of case management and highlight the importance of systematically collecting this data in lieu of rotavirus vaccine introduction in India.

METHODS

Medical records of pediatric intussusception cases admitted in eight large hospitals in Chennai from July 2012 through June 2013 were retrospectively reviewed. Demographic and clinical data including diagnostic and treatment practices were obtained. Cases were categorized based on the diagnostic certainty criteria stipulated by the Brighton collaboration on intussusception.

RESULTS

During the one year of study period, 205 cases of intussusception were diagnosed in 8 hospitals in Chennai city of India. The median age at presentation was 9 mo (Inter Quartile Range, IQR 6-14) with a male to female ratio of 1.8:1. The commonest site of intussusception was ileocolic (80.4 %). Most of the cases (59.8 %) were managed non-surgically. Direct surgical intervention was carried out in 26.5 % cases whereas in 11.8% of cases, surgery was required after failure of non-surgical measures. Median duration of hospital stay was 3 d (IQR 1-5).

CONCLUSIONS

This study documents the case burden of intussusception among children in Chennai in a calendar year. Data on receipt of rotavirus vaccine was not available. The authors recommend collection of rotavirus vaccine data among all cases of intussusception in the country, and do retrospective analysis in other parts of the country and prospective surveillance in pediatric / immunization clinics to assess impact of rotavirus vaccine on intussusception rates in the post rotavirus vaccine introduction scenario.

The prevalence of disability in elderly in India - Analysis of 2011 census data

BACKGROUND

Advancing age leads to physical and sensory impairment with varying degrees of disability. There is lack of publication focusing on disability of elderly in India with a countrywide state-based analysis of all types of disabilities.

OBJECTIVE

To measure the prevalence of disability and describe the types of disability in the elderly Indian population by gender, advancing age, states and geographical regions.

METHODS

The 2011 Census cross-sectional survey data restricted to elderly in India was analyzed. 'Elderly' is defined as a person who is of age 60 years or above. Disability rates per 100,000 elderly population and age-adjusted disability rates were calculated.

RESULTS

A total of 5,376,205 elderly individuals were disabled in India in 2011; disability rate of 5178 per 100,000 elderly population. Movement and seeing disabilities individually accounted for 25% of total disabilities and disability in hearing was 19%. Disability rates in 17 Indian States and Union Territories were above the national average. Disability rates increased as age advanced with the highest disability rate of 8409 per 100,000 among people aged 80 yrs or above. The disability rates were higher in males than females (5314 vs. 5045 per 100,000) and in rural compared to urban areas (5593 vs. 4181 per 100,000). Currently married and working populations had lower disability rates.

CONCLUSION

One in every twenty Indian citizens aged 60 yrs and above is either physically or mentally disabled. Identification of the underlying causes, employing effective and focused preventive strategies will help to reduce the prevalence of disability in the elderly.

Kyasanur Forest disease outbreak and vaccination strategy,Shimoga District, India, 2013-2014

We investigated a Kyasanur Forest disease outbreak in Karnataka, India during December 2013–April 2014. Surveillance and retrospective study indicated low vaccine coverage, low vaccine effectiveness, and spread of disease to areas beyond those selected for vaccination and to age groups not targeted for vaccination. To control disease, vaccination strategies need to be reviewed.

Male circumcision for HIV prevention in India: emerging viewpoints and practices of health care providers

A compelling case for promoting male circumcision (MC) as an intervention for reducing the risk of heterosexually acquired HIV infection was made by dissemination of the results of three studies in Africa. The WHO/UNAIDS recommendation for MC for countries like India, where the epidemic in concentrated in high-risk groups, advocates MC for specific population groups such as men at higher risk for HIV acquisition. A multicentre qualitative study was conducted in four geographically distinct districts (Belgaum, Kolkata, Meerut and Mumbai) in India during June 2009 to June 2011. Two categories of health care providers: Registered Healthcare Providers (RHCPs) and traditional circumcisers were interviewed by trained research staff who had received master's level education using interview guides with probes and open-ended questions. Respondents were selected using purposive sampling. A comparative analysis of the perspectives of the RHCP vs. traditional circumcisers is presented. Representatives of both categories of providers expressed the need for Indian data on MC. Providers feared that promoting circumcision might jeopardize/undermine the progress already made in the field of condom promotion. Reservation was expressed regarding its adoption by Hindus. Behavioural disinhibition was perceived as an important limitation. A contrast in the practice of circumcision was apparent between the traditional and the trained providers. MC should be mentioned as a part of comprehensive HIV prevention services in India that includes HIV counselling and testing, condom distribution and diagnosis and treatment of sexually transmitted infections. It should become an issue of informed personal choice rather than ethnic identity.

The effects of antiretroviral treatment initiation on cognition in HIV-infected individuals with advanced disease in Pune, India

There has been a reduction in the most severe cases of HIV-associated neurocognitive disorders (HAND) with advances in antiretroviral treatment (ART). But the prevalence of milder forms of HAND still remains high. Data from systematically conducted studies on the effects of ART on cognition are scanty in India, where HIV-1 clade C is prevalent. The purpose of the present study was to assess the effect of antiretroviral therapy in HIV-seropositive (HIV+) individuals (n = 92) with CD4 cell counts <200 cells/mm(3). The overall and domain-specific levels of cognitive functioning were determined using a locally recruited normative sample, and a change in neurocognitive functioning at the 1-year follow-up visit was analyzed. Results revealed cognitive impairment in 44.6 % of the HIV+ group at baseline. At the 1-year follow-up, the group showed significant improvement in the Learning domain (p < 0.05). HIV+ individuals showing improvement in the global cognitive scores had a significantly lower baseline CD4 cell count compared to others. Overall, the degree of improvement associated with the magnitude of rise in CD4 suggests the possibility that early, mild subclinical deficits may also benefit from treatment.

A surveillance model for sexually transmitted infections in India

The strategy for prevention and control of sexually transmitted infections (STIs) in India is based on syndromic case management delivered through designated STI/reproductive tract infection (RTI) centers (DSRCs) situated in medical colleges, district hospitals, and STI-clinics of targeted interventions programs. Laboratory tests for enhanced syndromic management are available at some sites. To ensure country-level planning and effective local implementation of STI services, reliable and consistent epidemiologic information is required on the distribution of STI cases, rate and trends of newly acquired infections, and STI prevalence in specific population groups. The present STI management information system is inadequate to meet these requirements because it is based on syndromic data and limited laboratory investigations on STIs reported passively by DSRCs and laboratories. Geographically representative information on the etiology of STI syndromes and antimicrobial susceptibility of STI pathogens although essential for optimizing available treatment options, is deficient. Surveillance must provide high quality information on: (a) prevalence of STIs such as syphilis, trichomoniasis, gonorrhea, and chlamydia among high-risk groups; syphilis in the general population and pregnant antenatal women; (b) demographic characteristics such as age, sex, new/recurrent episode, and type of syndromically diagnosed STI cases; (c) proportion of acute infections such as urethral discharge (UD) in men and nonherpetic genital ulcer disease (GUD) in men and women; (d) etiology of STI syndromes; and (e) gonococcal antimicrobial susceptibility. We describe here a framework for an STI sentinel surveillance system in India, building on the existing STI reporting systems and infrastructure, an overview of the components of the proposed surveillance system, and operational challenges in its implementation.

Post-traumatic immunosuppression is reversed by anti-coagulated salvaged blood transfusion: deductions from studying immune status after knee arthroplasty

Major trauma increases vulnerability to systemic infections due to poorly defined immunosuppressive mechanisms. It confers no evolutionary advantage. Our objective was to develop better biomarkers of post-traumatic immunosuppression (PTI) and to extend our observation that PTI was reversed by anti-coagulated salvaged blood transfusion, in the knowledge that others have shown that non-anti-coagulated (fibrinolysed) salvaged blood was immunosuppressive. A prospective non-randomized cohort study of patients undergoing primary total knee arthroplasty included 25 who received salvaged blood transfusions collected post-operatively into acid-citrate-dextrose anti-coagulant (ASBT cohort), and 18 non-transfused patients (NSBT cohort). Biomarkers of sterile trauma included haematological values, damage-associated molecular patterns (DAMPs), cytokines and chemokines. Salvaged blood was analysed within 1 and 6 h after commencing collection. Biomarkers were expressed as fold-changes over preoperative values. Certain biomarkers of sterile trauma were common to all 43 patients, including supranormal levels of: interleukin (IL)-6, IL-1-receptor-antagonist, IL-8, heat shock protein-70 and calgranulin-S100-A8/9. Other proinflammatory biomarkers which were subnormal in NSBT became supranormal in ASBT patients, including IL-1β, IL-2, IL-17A, interferon (IFN)-γ, tumour necrosis factor (TNF)-α and annexin-A2. Furthermore, ASBT exhibited subnormal levels of anti-inflammatory biomarkers: IL-4, IL-5, IL-10 and IL-13. Salvaged blood analyses revealed sustained high levels of IL-9, IL-10 and certain DAMPs, including calgranulin-S100-A8/9, alpha-defensin and heat shock proteins 27, 60 and 70. Active synthesis during salvaged blood collection yielded increasingly elevated levels of annexin-A2, IL-1β, Il-1-receptor-antagonist, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-17A, IFN-γ, TNF-α, transforming growth factor (TGF)-β1, monocyte chemotactic protein-1 and macrophage inflammatory protein-1α. Elevated levels of high-mobility group-box protein-1 decreased. In conclusion, we demonstrated that anti-coagulated salvaged blood reversed PTI, and was attributed to immune stimulants generated during salvaged blood collection.

Community and healthcare providers' perspectives on male circumcision: a multi-centric qualitative study in India

BACKGROUND

Although male circumcision (MC) is recommended as an HIV prevention option, the religious, cultural and biomedical dimensions of its feasibility, acceptability and practice in India have not been explored till date. This study explores beliefs, experiences and understanding of the community and healthcare providers (HCPs) about adult MC as an HIV prevention option in India.

METHODS

This qualitative study covered 134 in-depth interviews from Belgaum, Kolkata, Meerut and Mumbai cities of India. Of these, 62 respondents were the members of circumcising (CC)/non-circumcising communities (NCC); including medically and traditionally circumcised men, parents of circumcised children, spouses of circumcised men, and religious clerics. Additionally, 58 registered healthcare providers (RHCPs) such as general and pediatric surgeons, pediatricians, skin and venereal disease specialists, general practitioners, and operation theatre nurses were interviewed. Fourteen traditional circumcisers were also interviewed. The data were coded and analyzed in QSR NUD*IST ver. 6.0. The study has not explored the participants' views about neonatal versus adult circumcision.

RESULTS

Members of CC/NCC, traditional circumcisers and RCHPs expressed sharp religious sensitivities around the issue of MC. Six themes emerged: Male circumcision as the religious rite; Multiple meanings of MC: MC for 'religious identity/privilege/sacrifice' or 'hygiene'; MC inflicts pain and cost; Medical indications outweigh faith; Hesitation exists in accepting 'foreign' evidence supporting MC; and communication is the key for acceptance of MCs. Medical indications could make members of NCC accept MC following appropriate counseling. Majority of the RHCPs demanded local in-country evidence.

CONCLUSION

HCPs must educate high-risk groups regarding the preventive and therapeutic role of MC. Communities need to discuss and create new social norms about male circumcision for better societal acceptance especially among the NCC. Feasibility studies on MC as an individual specific option for the high risk groups in health care setting needs to be explored.

Heterosexual anal sex among female sex workers in high HIV prevalence states of India: need for comprehensive intervention

Introduction

Role of vaginal sex in heterosexual transmission of HIV has been investigated but that of heterosexual anal sex (HAS) is not fully understood. This paper examines practice of HAS among Female Sex Workers (FSWs) and its correlates in India where the HIV epidemic is being primarily driven by core groups like FSWs.

Methods

Data for this paper are drawn from Round I survey of 9667 FSWs in the Integrated Biological and Behavioral Assessment (IBBA) from 23 districts of 4 high HIV prevalent states of India. Bivariate and multivariate analysis identified factors associated with HAS.

Results

Ever having anal sex was reported by 11.9% FSWs (95% CI: 11.3%–12.6%). Typology (AOR 2.20, 95% CI 1.64–2.95) and literacy (AOR 1.28, 95% CI 1.10–1.49) were positively associated with practice of HAS. Longer duration in sex trade (AOR 1.69, 95% CI 1.44–1.99), entertaining larger number of clients the previous week (AOR 1.78, 95% CI 1.47–2.15), alcohol consumption (AOR 1.21, 95% CI 1.03–1.42) and inability to negotiate condom use (AOR 1.53, 95% CI 1.28–1.83) were also correlated with HAS. Self-risk perception for HIV (AOR 1.46, 95% CI 1.25–1.71) did not impede HAS. Although symptoms of sexually transmitted infections (STIs) in the last 12 months were associated with anal sex (AOR 1.39, 95% CI 1.13–1.72) there was no significant association between laboratory confirmed HIV and other STIs with HAS.

Conclusion

Practice of HAS by FSWs might significantly contribute to HIV transmission in India. This study also shows that despite self-risk perception for HIV, even literate FSWs with longer duration in sex work report HAS. General messages on condom use may not influence safe HAS. FSWs need to be targeted with specific messages on HIV transmission during anal sex. Women controlled prevention methods, such as rectal microbicides and vaginal microbicides are needed.

Acceptability of coitally-associated versus daily use of 1% tenofovir vaginal gel among women in Pune, India

This study reports on the acceptability of 1% tenofovir microbicide gel among participants randomised to the coitally-associated use (n = 50) or daily use (n = 50) arms of a Phase II clinical trial in Pune, India. In a 6-month follow-up study, information on behavioural domains was collected on a 6-point Likert scale and gel acceptability was measured on a 5-point Likert scale. Random intercept logistic modelling was performed to examine the simultaneous effects of study arm, follow-up time, sociodemographic factors and behavioural domains on gel acceptability. The mean age of female participants was 32.7 years. Women in both study arms had similar sociodemographic profiles. Women liked features such as easy use of the gel and its protective effect against HIV. Messiness was the most disliked feature. Gel acceptability increased during subsequent follow-up visits in both arms, especially in the coitally-associated use arm. Non-acceptability of the gel was almost two and a half times higher in daily users (adjusted odds ratio 2.55, 95% CI 1.18-5.51; p = 0.017). Acceptability differed significantly between the two study arms at 2 months (68% vs 40%; p = 0.006) and 6 months (64% vs 46%; p = 0.07). Acceptability was significantly lower in those participants who reported 'messiness' as the most disliked feature (odds ratio 2.42, 95% CI 1.02-5.72; p = 0.045). In conclusion, microbicides were more acceptable in coitally-associated users than in daily users. Leakage was a problem that requires attention. Positioning of the product in a setting such as India where the majority of decision-making is done by men would need extensive and systematic education of men.

Genetic attributes of blood-derived subtype-C HIV-1 tat and env in India and neurocognitive function

Genetic elements in HIV-1 subtype B tat and env are associated with neurotoxicity yet less is known about other subtypes. HIV-1 subtype C tat and env sequences were analyzed to determine viral genetic elements associated with neurocognitive impairment in a large Indian cohort. Population-based sequences of HIV-1 tat (exon 1) and env (C2-V3 coding region) were generated from blood plasma of HIV-infected patients in Pune, India. Participants were classified as cognitively normal or impaired based on neuropsychological assessment. Tests for signature residues, positive and negative selection, entropy, and ambiguous bases were performed using tools available through Los Alamos National Laboratory (http://www.hiv.lanl.gov) and Datamonkey (http://www.datamonkey.org). HIV-1 subtype C tat and env sequences were analyzed for 155 and 160 participants, of which 34-36% were impaired. Two signature residues were unique to impaired participants in exon 1 of tat at codons 29 (arginine) and 68 (proline). Positive selection was noted at codon 29 among normal participants and at codon 68 in both groups. The signature at codon 29 was also a signature for low CD4+ (<200 cells/mm(3)) counts but remained associated with impairment after exclusion of those with low CD4+ counts. No unique genetic signatures were noted in env. In conclusion, two signature residues were identified in exon 1 of HIV-1 subtype C tat that were associated with neurocognitive impairment in India and not completely accounted for by HIV disease progression. These signatures support a linkage between diversifying selection in HIV-1 subtype C tat and neurocognitive impairment.

Experiences in recruiting volunteers through community based initiatives in phase-1 vaccine trials in India

Success of HIV vaccine trials is dependent on infrastructural preparedness of the site, technical expertise of the trial team and strong Socio-political support of the local community. The processes followed and experiences gained while implementing various community based initiatives for recruitment of healthy volunteers during the three HIV vaccine trials in India are described. Major initiatives in community engagement implemented for the first time in India included establishment and involvement of Community Advisory Board and capacity building and engagement of lay community based volunteers called "peers" using "lay health promotion" model. Community education program designed for trial participants' education, identification and enrollment was a three-tiered approach, moving from large community awareness meetings (first step) to facility-based small group meeting to provide trial specific information (second step); ending with one-to-one vaccine center based meeting with the volunteers to clear doubts, myths, and misconceptions about HIV/AIDS, the experimental vaccine and HIV vaccine trials as well as to explain trial specific procedures (third step). It is important to focus on gender issues, locally relevant socio-cultural factors, informed consent, and post-trial care related matters during the conduct of sensitive clinical trials in socio-culturally diverse and resource limited setting like India.

Correlates of sex initiation among school going adolescents in Pune, India

OBJECTIVE

To identify the correlates of sex initiation among school going adolescents in Pune, India.

METHODS

A study among 910 school going adolescents was conducted in five schools and one junior college in and around Pune, Maharashtra (India) between 2003-2006. Case control analysis (n = 205) was performed among 41 cases who reported ever having sex and 164 controls matched for gender, location and type of school. Correlates of sex initiation were identified using conditional logistic regression.

RESULTS

Adolescents studying in vernacular schools, accessing pornography and having unfriendly relationship with parents had higher likelihood of sex initiation. Adolescents who reported sexual abuse, Sexually Transmitted Diseases (STDs) symptoms, smoking habit and those who had not read scientific literature on reproductive and sexual health were more likely to have initiated sex early. In the multivariate model, unfriendly relationship with parents and reported symptoms of STDs were found to be independently associated with 'early initiation of sex' among school going adolescents in this study.

CONCLUSIONS

Premarital sexual activity, both consensual and non-consensual, was reported indicating a need for school based adolescent reproductive and sexual health education (ARSHE) programs in Maharashtra, India. The program in India should focus on specialized interventions for young adolescents. Routine health check-ups and probing on symptoms of STDs, non-consensual sex and other risky practices should be implemented in schools.