Search

Background & objectives Core Outcome Sets (COS) are consensus-derived standardized outcomes that improve the transparency, consistency, homogeneity, and usefulness of outcomes. While COS are being increasingly developed, not much is known about their awareness, use, knowledge, and attitudes among trialists and systematic reviewers. This study aimed to examine the use, knowledge, and attitudes about COS among clinical trialists and systematic reviewers in India. Methods We conducted an anonymous online survey between August 2023 to November 2023, using a questionnaire hosted on REDCap including trialists and/or systematic reviewers as participants. The survey tool evaluated awareness, use and attitudes on COS, including through a couple of open-ended questions. Results A total of 523 trialists/ systematic reviewers participated in this survey. Of these, only 51.4 per cent indicated that they were aware of COS. Only 13.9 per cent trialists and 10.5 per cent systematic reviewers were using them, while mere 6 per cent had been involved in COS development. Lack of available COS for conditions of interest in an Indian context was identified as one of the barriers in its uptake. Even among participants who were aware, many were not clear about COS concepts, and although they expressed positive attitudes about the benefits of COS usage, they also indicated that they perceived COS as restrictive, costly, blocking innovation, and increasing patient burden. We identified health conditions relevant to India, where there is no COS available or where COS is present but were mentioned to be not relevant or valid for the Indian context. Interpretation & conclusions As per our knowledge, this study is the largest survey on this domain globally. Through this study several barriers for enhancing COS awareness and uptake were identified indicating the need for resources and systematic efforts to address these barriers in India and globally. We also identify COS which need to be developed or updated to be relevant to Indian context. [ABSTRACT FROM AUTHOR]

There is a growing burden of lung cancer cases in India, incidence projected to increase from 63,708 cases (2015) to 81,219 cases (2025). The increasing numbers are attributed to smoking (India currently has nearly 100 million adult smokers) and environmental pollution. Most patients present with advanced disease (80-85% are incurable), causing nearly 60,000 annual deaths from lung cancer. Early detection through lung cancer screening (LCS) can result in curative therapies for earlier stages of lung cancer and improved survival. Annual low-dose computerized tomography (LDCT) is the standard method for LCS. Usually, high-risk populations (age>50 yr and >20 pack-years of smoking) are considered for LCS, but even such focused screening may be challenging in resource-limited countries like India. However, developing a smart LCS programme with high yield may be possible by leveraging demographic and genomic data, use of smart tools, and judicious use of blood-based biomarkers. Developing this model over the next several years will facilitate a structured cancer screening programme for populations at the highest risk of lung cancer. In this paper, we discuss the demographics of lung cancer in India and its relation to smoking patterns. Further, we elaborate on the potential applications and challenges of bringing a smart approach to LCS in high-risk populations in India. [ABSTRACT FROM AUTHOR]

Background & objectives Surgical site infections (SSIs) are among the most prevalent healthcare-associated infections (HCAIs). They cause significant morbidity, leading to excess health expenditures and increased length of hospital stay. Despite a high population burden, data on post-discharge SSIs is lacking from low-and middle-income countries (LMICs). There is no existing surveillance system of SSIs in India that covers the post-discharge period. Therefore, we proposed a multicentric analysis to estimate the proportion and identify the risk factors associated with SSIs occurring during hospital stay and after discharge. Methods SSI Surveillance was conducted in three hospitals in different parts of India according to the Centers for Disease Control and Prevention (CDC) guidelines (30 days-6 months). An indigenous database was developed for data entry and analysis. Logistic regression analysis was performed to test for an association between SSI and potential risk factors. Results A total of 161 out of 3090 patients acquired SSI, resulting in a 5.2 per cent SSI incidence. Debridement surgery, which was carried out with either an amputation, open reduction internal fixation surgery (ORIF), or closed reduction internal fixation (CRIF) surgery, had the highest SSI rate (54.2%). Clean, polluted wound class and surgeries lasting longer than 120 minutes were substantially linked to an increased risk of SSI. Interpretation & conclusions Post-discharge surveillance helped with the detection of 66 per cent of SSI cases. Combination surgeries were seen to increase the risk of SSIs in patients. [ABSTRACT FROM AUTHOR]

Background & objectives Cancer is one of the leading causes of death among older adults worldwide. The global burden of cancer among older individuals is increasing due to the ageing population. The increasing burden of cancer among older adults will pose significant social and economic challenges for the delivery of healthcare services. Materials Estimated cancer new cases, deaths, age-standardized truncated incidence and mortality rate per 100,000 for older adults (60 yr or above) were reported using GLOBOCAN 2020 estimates (gco.iarc.fr). Mortality to Incidence ratio (M/I ratio) expressed in percentage by gender and continent was provided. Results Globally, of all cancer cases, 11.3 million cases (representing 62.3%) and 7.5 million deaths (representing 71.2%) were seen among older adults. The top five leading sites of cancer account for 62.2 per cent of older men and 55.9 per cent of older women; however, a widespread geographical variation across world regions is observed. The number of new cancer cases among older adults is expected to rise from 11.3 to 19.8 million (a 75.2% increase) and deaths from 3.99 to 7.3 million (82.8% increase) by 2040. Interpretation & conclusions The expected rise will bring exceptional challenges to healthcare systems, especially in lower- or lower-medium-income countries where resources are limited. Data on cancer among older adults will help health planners and policymakers develop global geriatric cancer control policies. [ABSTRACT FROM AUTHOR]

Background & objectives Cancer is a leading cause of death worldwide and constitutes a public health priority. Delays in diagnosis and treatment of cancer can adversely impact survival, recovery, and cost of treatment. The objective of this study was to estimate the proportion seeking timely care among those having early warning signals for oral, breast or cervical cancer and to explore the facilitators and barriers to early detection. Methods The study was conducted among 241 participants, including those having early signals for selected cancers and women who underwent opportunistic cervical cancer screening in the selected health facilities. Information regarding symptom appearance, presentation to any registered medical practitioner, confirmatory diagnosis, and treatment initiation were obtained from medical records. In-depth Interviews (IDIs) were conducted among six participants to explore facilitators and barriers to cancer detection. Results Among 7300 people screened using the Community Based Assessment Checklist (CBAC), 128 (1.7%) had warning signals for any one of the cancers. The percentage of people who sought medical care for oral, breast and cervical cancer symptoms were 80 per cent, 82 per cent and 57 per cent, respectively. Among those who underwent opportunistic cervical cancer screening in health centres (113), the screen positivity rate was 11 per cent, and adherence to referral for confirmation was 80 per cent. The median pre-diagnostic and diagnostic delays for the three cancers were 79 [Interquartile range (IQR): 44-126] and 27 (IQR: 13-73) days. One individual was diagnosed with oral cancer, and the treatment delay was 27 days. Facilitators identified for early seeking of care were encouragement by family and low-cost treatment at public facilities. Major barriers identified were neglect of symptoms by participants and their responsibilities towards family. Interpretation & conclusions Although very few people were identified to have early warning symptoms using CBAC, a substantial proportion of them sought medical care and underwent confirmatory diagnosis. Screen positivity rate and treatment-seeking behaviour were better among women undergoing opportunistic cervical cancer screening in the health centres. Measures need to be taken to improve health literacy among people to reduce diagnostic delay for cancers. [ABSTRACT FROM AUTHOR]

Background & objectives Studies on the effects of COVID-19 vaccination among pregnant women in Asian settings, more specifically in India, are scarce. The present study evaluated the feto-maternal outcomes among Indian pregnant women who received the COVID-19 vaccine. Methods A prospective cohort study was undertaken among 430 pregnant women from two primary health centres (PHC) in Chandigarh, India during 2021-2022. The feto-maternal outcomes evaluated in the study included abortions, live birth/stillbirth, term/pre-term/post-term delivery, mode of delivery (normal vaginal/caesarean section/forceps), birth weight and intrauterine growth retardation. Results Of the 430 study participants, 295 pregnant women received COVID-19 vaccines, with an uptake rate of 68.6 per cent. Majority of vaccinated women (280- who completed the study) were in their second trimester (133, 47.5%), while 92 (32.9%) were in their third, and 55 (19.6%) were in their first trimester when they were enrolled in the study. Neonatal intensive care unit (NICU) admission was significantly lower among the vaccinated pregnant women, while other feto-maternal and neonatal outcomes were similar between vaccinated and unvaccinated pregnant women. Interpretation & conclusions The findings of this study suggest COVID-19 vaccination in pregnant women in India might be safe, in terms of feto-maternal outcomes [ABSTRACT FROM AUTHOR]

Background & objectives India accounts for about seven per cent of the global cancer burden with the highest cancer incidence reported from the North-Eastern Region (NER), including Meghalaya. Despite this, there is paucity of published studies on health seeking behaviour for cancer in the NER. To address this gap, this study used a qualitative approach to document patient, caregiver and provider perspectives to understand the factors influencing healthcare seeking for cancers in Meghalaya. Methods In-depth interviews were undertaken with 37 individuals diagnosed with one of the top five cancers in Meghalaya, namely, oesophageal, breast, oral, cervical and lung cancer. They were identified from the State referral cancer hospital. Twelve caregivers and five healthcare providers were also interviewed. All interviews were conducted in the local language using semi-structured interview guides. Transcripts were translated to English, coded, categorized and analyzed using thematic framework content analysis approach. Results A key factor influencing delayed cancer treatment in Meghalaya included misconceptions regarding the causes of cancer and cultural concepts such as bih and skai (Khasi language), i.e. notions of a figurative 'poison' or ill intent that makes one susceptible to illness. A general reluctance to discuss cancer diagnoses, perceived stigma, apprehension of treatment methods influenced their decision. Other factors included negligence and misinterpretation of early symptoms of cancer, self-management, preference for traditional medicines, financial constraints and health system-related factors. Interpretation & conclusions This study underscores the importance of addressing barriers to cancer diagnosis and treatment in indigenous populations in northeast India, advocating for culturally appropriate messaging, capacity building for healthcare workers, integration of traditional healers, and community involvement to enhance early healthcare seeking and improve outcomes. [ABSTRACT FROM AUTHOR]

Background & objectives Ayushman Bharat Digital Mission (ABDM) envisages a unique digital health ID for all citizens of India, to create electronic health records (EHR) of individuals. The present study assessed the uptake of Digital Health IDs by the patient and general population, their attitude toward EHR, and explored the barriers to digital ID and utilizing electronic health records services. Methods A concurrent explanatory mixed methods study was undertaken in Chandigarh, India, with an analytical cross-sectional design as a quantitative part and a qualitative descriptive study. The study participants were 419 individuals aged ≥18 yr who attended the urban primary healthcare centre (n=399) and the community-based screening camps (n=20) between July 2021 and January 2022. Latent Class Analysis (LCA) was undertaken to identify hidden sub-population characteristics. In-depth interviews were done to identify the barriers to health ID uptake. Results The digital health ID uptake rate was 78 per cent (n=327). Among the study participants, those who were aware of EHR, those who wanted a national EHR system, those who were confident with the government on EHR security, and those who were willing to make national EHR accessible for research showed significantly higher digital health ID uptake than their counterparts. The themes identified under barriers of uptake from the qualitative interviews were lack of awareness, technology-related (including digital literacy) and utility-related. Interpretation & conclusions Increasing EHR awareness, digital health literacy, and enacting data protection laws may improve the acceptance of the digital health ecosystem in India. [ABSTRACT FROM AUTHOR]

Background & objectives Under-five mortality is high among the Scheduled Tribes (ST) in India compared with the general population. This study examined the association of different maternal, child, socio demographic, and household factors associated with under-five mortality among Scheduled Tribes in India. Methods Data from the National Family and Health Survey (NFHS)-5 (2019-2021) for the ST, across all Indian States and Union Territories were used for analyses. Binary and multivariate logistic regression were performed to identify the association of maternal, child, socio-demographic, and household factors with under-five mortality among the ST population. Results Different maternal, child, socio demographic, and household factors were significantly associated with under-five mortality. The odds of under-five mortality were highest among women who gave birth to their children at home [Adjusted odds ratio (AOR): 1.42; 95% confidence interval (CI): 1.268-1.59] as compared with women who gave birth at institution. Literate women have lesser odds of under-five mortality than women with no formal education (AOR: 0.666; 95% CI: 0.501-0.885). The risk of under-five mortality was higher among four or more birth order children (AOR: 1.422; 95% CI: 1.246-1.624) compared with the first to third birth order children. The odds of under-five mortality decreased among children with a rich wealth index (AOR: 0.742; 95% CI: 0.592-0.93) compared to children with a poor wealth index. Interpretation & conclusions Analyses of under-five mortality among ST in India showed a significant association between different maternal, child, sociodemographic, and household factors. Grass-roots-level interventions such as promoting female education, addressing vast wealth differentials, and providing family planning services with a focus on reducing under-five mortality are essential in improving the survival of under-five children among the ST population in India. [ABSTRACT FROM AUTHOR]

Background & objectives Scrub typhus is an emerging mite-borne zoonotic infection that has been overlooked, despite being one of the most widespread severe vector-borne diseases. With an estimated one billion people at risk worldwide and one million annual cases, it poses a significant public health concern. While various studies have investigated the prevalence of scrub typhus in different regions of India, a comprehensive regional systematic review and meta-analysis on the seropositivity of scrub typhus among acute febrile cases has been lacking. To address this gap, we conducted a systematic review and meta-analysis to compile information on the current seroprevalence of scrub typhus in acute febrile illness cases in India. Methods A literature search of multiple databases on prevalence of scrub typhus in acute febrile illness in India, 60 eligible studies out of 573 studies. The prevalence of individual studies was double arcsine transformed, and the pooled prevalence was calculated using inverse variance method. Results In total, these studies encompassed 34,492 febrile cases. The overall seroprevalence of scrub typhus among acute febrile illness cases in India was found to be 26.41 per cent [95% confidence interval (CI): 22.03-31.03]. Additionally, the pooled case fatality rate (based on data from six studies) among scrub typhus-positive cases yielded a case fatality rate of 7.69 per cent (95% CI: 4.37-11.72). Interpretation & conclusions This meta-analysis shows that scrub typhus is a significant health threat in India. Preventive measures to control scrub typhus need to be given priority. [ABSTRACT FROM AUTHOR]

Background & objectives Candida spp. cause candidiasis in humans under conditions disrupting the host defence. While Candida albicans is the most reported cause of candidiasis, there is a surge in the incidence of infections by non- albicans Candida species (NACs), such as C. tropicalis, C. glabrata and C. auris. These species can infect all organs of the human body. To effectively manage these outbreaks, it is important to track the epidemiology of candidiasis. A consolidated resource describing the landscape of candidiasis in India is absent. Methods To address this gap, we have developed an online resource named Epidemiology of Candida Infections in India (EpiCandIn) by manually curating published literature on Candida infections in the Indian population obtained from PubMed and ScienceDirect databases. Results EpiCandIn contains data available since 1972 from 51 sites across 16 States and four Union Territories of India. It provides information on geographical location, Candida species, niche affected, disease characteristics and drug therapy details extracted from the publications. This resource is integrated with visualization tools. Interpretation & conclusions EpiCandIn will be useful for public health researchers and policymakers as it will help them gain insights into the emerging trends and management of Candida infections in India. It can be accessed at epicandin.bicnirrh.res.in. [ABSTRACT FROM AUTHOR]

Background & objectives Tuberculosis (TB) control programmes routinely use indicators like incidence and mortality. A single indicator, like disability-adjusted life years (DALYs) may yield a more comprehensive burden estimate. This study attempted to estimate the state and district-specific TB burden in Kerala. Methods The sole data source for these computations was the Ni-kshay , notification register for 2017 to 2020, Kerala. Age of the patient and outcome are available in the register. Notified incident TB/1000, the median age of onset of TB, case fatality due to TB, and the median age of mortality were computed using SPSS software. DALYs was calculated using the DALYs package of the R program, using these input parameters. Disability weight was taken as 0.333. The absolute and relative DALY/100,000 population was estimated along with the 95% confidence interval (CI). Results Relative DALYs was highest in 2019 at 1482/100,000 and lowest at 1124/100,000 in the year 2020 during the period 2017 to 2020. The districts, which had the highest incidence were not the same as those with the highest DALYs. Ernakulam and Thrissur districts had the highest burden and Idukki had the least burden. Interpretation & conclusions DALYs estimates for Kerala showed an increasing trend before 2020, which could be due to the increased efforts to detect TB as part of the elimination drive. The study points towards the need for using DALYs as a measure for prioritizing districts for resource allocation. [ABSTRACT FROM AUTHOR]

Background & objectives Snakebite envenoming (SBE) is a major public health concern, with India bearing the highest global burden of SBE-related deaths. SBE is concentrated in rural and tribal regions of India, where the knowledge, attitude and behaviour of the dwelling communities largely influence mortality and morbidity. Understanding these factors is crucial to designing effective SBE prevention and management strategies. The present study's objective was to document the perspectives of community members and practices in selected blocks of Maharashtra and Odisha States regarding SBE prevention, first aid and health-seeking behaviour. Methods Between March and April 2022, 28 focus group discussions (FGDs) were conducted. Study sites included Shahapur block in Thane district, Aheri block in Gadchiroli district of Maharashtra, and Khordha block in Khordha district, Kasipur block in Rayagada district of Odisha. Separate FGDs were held for males (n=14) and females (n=14), involving about 8-16 participants above 18 yr. All discussions were audio recorded, and a grounded theory approach was employed to identify key themes from the translated transcripts. Results The findings of this study revealed a variety of perspectives and practices determining the SBE burden at the study sites. The findings included insufficient knowledge about snake species and their nature of toxicity, use of non-scientific first aid techniques, inaccessible health care and reliance on traditional healers, non-utilization of prevention methods, varied cultural beliefs and practices, and differential treatments based on gender. The findings have been collated in two simplistic frameworks; barriers to effective prevention and barriers to effective management. Interpretation & conclusions SBE burden results from a complex interplay between socioeconomic, cultural, and demographic factors, necessitating a collaborative inter-sectoral effort for adequate control. Through crucial regional inputs and the barriers to prevention and management models, this study provides critical insights and priority intervention areas to strengthen India's upcoming National Action Plan for Prevention and Control of Snakebite Envenoming (NAPSE) in all high-burden States. [ABSTRACT FROM AUTHOR]

Background & objectives Sickle cell disease (SCD) is a common genetic disorder, predominantly found in the tribal population of India. The examples of models providing comprehensive care and management to individuals with SCD in public health facilities are sparse. The Sickle Cell Anaemia Control Mission is one such model implemented by Jan Swasthya Sahyog, a non-profit organization in collaboration with the National Health Mission in the Anuppur district of Madhya Pradesh. This article aimed to identify the key learnings from this programme that can guide the public health system strengthening with respect to SCD. Methods The Sickle Cell Anemia Control Mission Programme included door to door screening for anaemia, SCD and blood group. SCD cases were included in the programme and other individuals with Anemia were referred for further care. Care for individuals with SCD included counselling, provision of hydroxyurea, regular follow up of clinical parameters and management of complications. Care for individuals with SCD was provided through monthly patient support group (PSG) meetings and regular outpatient /in-patient care at public health facilities. Quantitative data on programme design, screening and patient management collected during programme implementation were used for analysis. Results A total of 39421 persons were screened in 18 months (August 2018-March 2020). Of these 81.9 per cent persons were anaemic, 16.9 per cent had sickle cell trait and 779 (1.98%) had SCD. Eighty-six already diagnosed individuals joined the programme for care. People from all caste categories were diagnosed with SCD. Out of 865 individuals with SCD, 157 underwent regular 9-11 months follow up and showed improvement in clinical symptoms and drug compliance. Interpretation & conclusions Central India has a significant burden of anaemia and SCD. This study found that SCD is present in non-tribals as well. PSGs are an efficient way to deliver non-emergency care for chronic diseases such as SCD. [ABSTRACT FROM AUTHOR]

India is home to one-fifth of the world's population and is currently the fastest-growing economy. As the health industry is growing, India needs to develop robust implementation of evidence-based health care addressing the major public health issues. Two of such issues India is grappling with are the establishment of stroke care and the reduction of road accidents. Australia has achieved notable success in implementing stroke care and reducing road accidents. In stroke, Australian initiatives include dedicated stroke units, the development of clinical guidelines, the implementation of acute interventions, the establishment of a national stroke foundation, and the stroke registry. As a result, the combined, primary, and secondary prevention measures, acute treatment, and rehabilitation have reduced the total disease burden of stroke from 2003 to 2023 by 53 per cent, from 7.4 to 3.5 Disability Adjusted Life Years (DALYS) per 1,000 population, which is a 56 per cent decline in fatal burden and 23 per cent decline in non-fatal burden. For road safety, Australia implemented evidence-based practices such as education, legislation including mandatory use of seat belts, and other road safety initiatives. Data show that seat belt use reached 98 per cent in Australia in 2023. Furthermore, about 20 per cent of drivers as well as passengers who were killed in crashes in 2024 did not wear seat belts. The reduction of speed limits in built-up areas, the adoption of monitoring technology, and the clever use of infrastructure are proving to be effective in reducing fatalities and serious injuries. Australia's implementation research can provide valuable insights into the efforts of mitigating the impact of stroke and enhancing road safety in India. [ABSTRACT FROM AUTHOR]

Background & objectives: In view of anecdotal reports of sudden unexplained deaths in India's apparently healthy young adults, linking to coronavirus disease 2019 (COVID-19) infection or vaccination, we determined the factors associated with such deaths in individuals aged 18-45 years through a multicentric matched case–control study. Methods: This study was conducted through participation of 47 tertiary care hospitals across India. Cases were apparently healthy individuals aged 18-45 years without any known co-morbidity, who suddenly (<24 h of hospitalization or seen apparently healthy 24 h before death) died of unexplained causes during 1st October 2021-31st March 2023. Four controls were included per case matched for age, gender and neighborhood. We interviewed/perused records to collect data on COVID-19 vaccination/infection and post-COVID-19 conditions, family history of sudden death, smoking, recreational drug use, alcohol frequency and binge drinking and vigorous-intensity physical activity two days before death/interviews. We developed regression models considering COVID-19 vaccination ≤42 days before outcome, any vaccine received anytime and vaccine doses to compute an adjusted matched odds ratio (aOR) with 95 per cent confidence interval (CI). Results: Seven hundred twenty nine cases and 2916 controls were included in the analysis. Receipt of at least one dose of COVID-19 vaccine lowered the odds [aOR (95% CI)] for unexplained sudden death [0.58 (0.37, 0.92)], whereas past COVID-19 hospitalization [3.8 (1.36, 10.61)], family history of sudden death [2.53 (1.52, 4.21)], binge drinking 48 h before death/interview [5.29 (2.57, 10.89)], use of recreational drug/substance [2.92 (1.1, 7.71)] and performing vigorous-intensity physical activity 48 h before death/interview [3.7 (1.36, 10.05)] were positively associated. Two doses lowered the odds of unexplained sudden death [0.51 (0.28, 0.91)], whereas single dose did not. Interpretation & conclusions: COVID-19 vaccination did not increase the risk of unexplained sudden death among young adults in India. Past COVID-19 hospitalization, family history of sudden death and certain lifestyle behaviors increased the likelihood of unexplained sudden death. [ABSTRACT FROM AUTHOR]

Background & objectives: Government of India (GoI) released operational guidelines for maternal near miss-review (MNM-R) in 2014 for use by programme managers of public health system to assist them for conducting MNM-R. The objective of the present study was to review the incidence and factors influencing MNM events in two tertiary hospitals of Maharashtra, India, as per the operational guidelines of the GoI released in 2014 and identify delays based on three-delay model to prevent such events in future. Methods: This prospective observational study was conducted in two tertiary hospitals of Maharashtra, from July 2018 to November 2020. All women during pregnancy, childbirth or postpartum upto 42 days meeting the eligibility criteria of MNM as per the 2014 GoI guidelines were included as cases (n=228), interviewed and discussed during the monthly MNM meetings at these hospitals. Results: The incidence of MNM was 11/1000 live births; the ratio of MNM to maternal deaths was 1.2:1. Leading causes of MNM were haemorrhage (36.4%) and hypertensive disorders of pregnancy (30.3%). Haemorrhage was maximum (70.6%) in abortion and ectopic pregnancies. Majority of the women (80.2%) were anaemic, of whom 32.4 per cent had severe anaemia. Eighty six per cent of women included in the study had MNM events at the time of admission and 81 per cent were referred from lower facilities. Level one and two delays were reported by 52.6 and 32.5 per cent of women, respectively. Level three delay at referral centres and at tertiary hospitals was reported by 69.7 and 48.2 per cent of women, respectively. Interpretation & conclusions: The findings of this study suggest that MNM-R should be undertaken at all tertiary hospitals in India as per GoI guidelines to identify gaps based on three-delay model. These hospitals should implement interventions as per the identified gaps with emphasis on strengthening the infrastructure, facilities and manpower at the first-referral units. [ABSTRACT FROM AUTHOR]

Background & objectives: Celiac disease (CD) is a genetic immune mediated disorder characterised by gluten intolerance. This single centre study, from north India was aimed to assess the clinical, serological and histological profile of CD in a large cohort of children and the changing trends in its presentation. Methods: A review of clinical details of CD children diagnosed between 2000 and 2019 and currently on follow up was performed. Information on demography, symptoms, associated conditions, serology, biopsy findings and gluten-free diet were analyzed. Results: The mean age (±standard deviation) of 891 children included in the study, at onset and at diagnosis was 4.0±2.7 and 6.2±3.1 yr, respectively. Growth faltering, abdominal pain, abdominal distension and diarrhoea were presenting symptoms in 70, 64.2, 61.2 and 58.2 per cent, respectively. A positive family history of CD was present in 14 per cent and autoimmune conditions in 12.3 per cent of children. Thyroid disorders were seen in 8.5 per cent of children and Type 1 diabetes mellitus (T1DM) in 5.7 per cent. The duration of breastfeeding had a weak positive correlation with age at onset and diagnosis of CD (P<0.001). Non-classical CD was significantly more common in children aged >10 yr and in those presenting after 2010 (P<0.01). T1DM and hypothyroidism occurred more frequently in non-compliant children. Interpretation & conclusions: This was the largest single centre study, pertaining to the presentation and follow up of CD in children. Infants and young children were more likely to present with classical symptoms of diarrhoea, abdominal distension and growth failure while older children presented with non-classical CD. There was a trend towards non-classical forms of CD in recent years. [ABSTRACT FROM AUTHOR]

Background & objectives: The COVID-19 pandemic exposed the strengths and weaknesses of the healthcare systems across the world. Many directives, guidelines and policies for pandemic control were laid down centrally for its implementation; however, its translation at the periphery needs to be analyzed for future planning and implementation of public health activities. Hence, the objectives of this study were to identify the challenges faced by frontline health managers in selected States in India during the pandemic with regard to implementation of the COVID-19-related policies at the district level and also to assess the challenges faced by the them in adapting the centrally laid down COVID-19 guidelines as per the local needs of the district. Methods: A qualitative study using the grounded theory approach was conducted among frontline district-level managers from eight different States belonging to the north, south, east and west zones of India. The districts across the country were selected based on their vulnerability index, and in-depth interviews were conducted among the frontline managers to assess the challenges faced by them in carrying out COVID-19 related activities. Recorded data were transcribed verbatim, manually coded and thematically analyzed. Results: Challenges faced in implementing quarantine rules were numerous, and it was also compounded by stigma attached with the disease. The need for adapting the guidelines as per local considerations, inclusion of components of financial management at local level, management of tribal and vulnerable populations and migrants in COVID context were strongly suggested. The need to increase human resource in general and specifically data managers and operators was quoted as definite requirement. Interpretation & conclusions: The COVID-19 guidelines provided by the Centre were found to be useful at district levels. However, there was a need to make some operational and administrative modifications in order to implement these guidelines locally and to ensure their acceptability. [ABSTRACT FROM AUTHOR]

Background & objectives: Scrub typhus is a rickettsial infection seen along the Asian-Pacific rim and imposes a considerable burden on affected people in low- and middle-income countries. The present study was aimed to determine the direct cost of hospitalization of scrub typhus and its trend over six years. Methods: This was a retrospective, observational, hospital based study of individuals admitted to the hospital, diagnosed with scrub typhus over six years, from January 2013 to December 2018. The potential out of pocket expenditure was evaluated. Results: A total of 198 patients were included in the study. The median cost of admission (adjusted to INR 2020) for the six years (2013 to 2018) was found to be ₹ 37,026 (US $ 490) [interquartile range (IQR) 22,996-64,992]. The median cost for patients admitted to the intensive care unit (ICU) was ₹ 128,046 (US $ 1695) (IQR 71,575-201,171), while the cost for patients admitted to the ward-alone was ₹ 33,232 (US $ 440) (IQR 19,609-45,373). The multivariable analysis showed that ARDS and SOFA score were the independent predictors of ICU admission. Interpretation & conclusions: Hospitalisation for scrub typhus is associated with a substantial healthcare expense. The predictors of increased cost were the presence of acute respiratory distress syndrome (ARDS), shock, increasing sequential organ failure assessment (SOFA) score and duration of hospital stay. [ABSTRACT FROM AUTHOR]

Background & objectives: Demographic attributes of cancer patients are associated with the awareness of diagnosis, the prognosis of cancer and their associated psychological distress. This study was aimed to assess the knowledge of diagnosis, prognosis and psychological distress among patients reporting to the pain and palliative care department in a tertiary cancer hospital, south India. Methods: Data of all patients visiting the palliative care outpatient department of a tertiary cancer centre in south India between January and June 2018 were included in the study (n=754). A structured pro forma was used to collect information on the sociodemographic details and clinical aspects and a distress thermometer was used to assess the level of distress. Information, thus collected, were analysed using descriptive statistics and logistic regression. Results: Around 16.2 per cent of the patients were unaware of their diagnosis while two third (68%) were unaware of the prognosis. More than half of the patients reported significant distress (54.1%). Gender, education, not working and being diagnosed with head-and-neck cancers were associated with knowledge of diagnosis, while educational level predicted the knowledge of prognosis. Younger age group, head-and-neck cancer, haematology cancer, state of being unaware of diagnosis and prognosis were found to be associated with distress. Interpretation & conclusions: Higher educational levels and better socio-economic status increase the likelihood of patients being aware of their diagnosis and prognosis. Being unaware of the prognosis remains associated with the higher level of distress. [ABSTRACT FROM AUTHOR]

Background & objectives: Investment in mental health is quite meagre worldwide, including in India. The costs of new interventions must be clarified to ensure the appropriate utilization of available resources. The government of Gujarat implemented QualityRights intervention at six public mental health hospitals. This study was aimed to project the costs of scaling up of the Gujarat QualityRights intervention to understand the additional resources needed for a broader implementation. Methods: Economic costs of the QualityRights intervention were calculated using an ingredients-based approach from the health systems' perspective. Major activities within the QualityRights intervention included assessment visits, meetings, training of trainers, provision of peer support and onsite training. Results: Total costs of implementing the QualityRights intervention varied from Indian Rupees (₹) 0.59 million to ₹ 2.59 million [1United States Dollars (US $) = ₹ 74.132] across six intervention sites at 2020 prices with 69-79 per cent of the cost being time cost. Scaling up the intervention to the entire State of Gujarat would require about two per cent increase in financial investment, or about 7.5 per cent increase in total cost including time costs over and above the costs of usual care for people with mental health conditions in public health facilities across the State. Interpretation & conclusions: The findings of this study suggest that human resources were the major cost contributor of the programme. Given the shortage of trained human resources in the mental health sector, appropriate planning during the scale-up phase of the QualityRights intervention is required to ensure all staff members receive the required training, and the treatment is not compromised during this training phase. As only about two per cent increase in financial cost can improve the quality of mental healthcare significantly, the State government can plan for its scale-up across the State. [ABSTRACT FROM AUTHOR]

Background & objectives: The diagnosis of scrub typhus (ST) is usually done using enzyme-linked immunosorbent assay (ELISA) due to its ease of performance and reading objectivity. The cut-off value for ELISA needs to be calculated for each geographical location as it depends on zonal endemicity of the disease. This study was, therefore, undertaken to calculate the pan-India cut-off for anti-Orientia tsutsugamushi (OT) immunoglobulin M (IgM) by ELISA. Methods: Samples from cases (cases of ST) and controls (voluntary, consenting, healthy adults) were collected by a network of 29 laboratories across India and tested for anti-OT IgM by immunofluorescence assay (IFA), the considered gold standard test. These samples were retested by ELISA for anti-OT IgM and their optical densities (ODs) were used for cut-off estimation by receiver operating characteristic (ROC) curve. Results: Anti-OT IgM ELISA ODs from 273 controls and 136 cases were used for the cut-off estimation. The ODs of the anti-OT IgM ELISA on healthy individuals and those of confirmed ST cases ranged from 0.1 to 0.75 and 0.5 to 4.718, respectively. ROC curve-based cut-off for ELISA was calculated as 0.554 at a sensitivity of 95.2 per cent and specificity of 95.1 per cent. A value of >1 was noted to have a specificity of 100 per cent in diagnosing ST. Interpretation & conclusions: The cut-off calculated for India was similar to the previous cut-off that was used until now. [ABSTRACT FROM AUTHOR]

Background & objectives: The Government of India has initiated a population based screening (PBS) for noncommunicable diseases (NCDs). A health technology assessment agency in India commissioned a study to assess the cost-effectiveness of screening diabetes and hypertension. The present study was undertaken to estimate the cost of PBS for Type II diabetes and hypertension. Second, out-of-pocket expenditure (OOPE) for outpatient care and health-related quality of life (HRQoL) among diabetes and hypertension patients were estimated. Methods: Economic cost of PBS of diabetes and hypertension was assessed using micro-costing methodology from a health system perspective in two States. A total of 165 outpatients with diabetes, 300 with hypertension and 497 with both were recruited to collect data on OOPE and HRQoL. Results: On coverage of 50 per cent, the PBS of diabetes and hypertension incurred a cost of ₹ 45.2 per person screened. The mean OOPE on outpatient consultation for a patient with diabetes, hypertension and both diabetes and hypertension was ₹ 4381 (95% confidence interval [CI]: 3786-4976), ₹ 1427 (95% CI: 1278-1576) and ₹ 3932 (95% CI: 3614-4250), respectively. Catastrophic health expenditure was incurred by 20, 1.3 and 14.8 per cent of patients with diabetes, hypertension and both diabetes and hypertension, respectively. The mean HRQoL score of patients with diabetes, hypertension and both was 0.76 (95% CI: 0.72-0.8), 0.89 (95% CI: 0.87-0.91) and 0.68 (95% CI: 0.66-0.7), respectively. Interpretations & conclusions: The findings of our study are useful for assessing cost-effectiveness of screening strategies for diabetes and hypertension. [ABSTRACT FROM AUTHOR]

Background & objectives: Sepsis, including neonatal sepsis, remains a prevalent cause of morbidity and mortality in low- and middle-income countries such as India, representing 85 per cent of all sepsis-related deaths globally. Early diagnosis and timely initiation of treatment is challenging due to non-specific clinical manifestations and non-availability of rapid diagnostic tests. There is an urgent need for affordable diagnostics with fast turnaround time catering to the needs of end-users. Target product profiles (TPPs) have been found instrumental in developing ‘fit-for-use’ diagnostics, thus reducing the time taken to facilitate development and improving diagnosis. Hitherto, no such guidance or criteria has been defined for rapid diagnostics for sepsis/neonatal sepsis. We propose an innovative approach for developing the diagnostics for sepsis screening and diagnosis which can be utilized by diagnostic developers in the country. Methods: Three-round Delphi method, including two online surveys and one virtual consultation, was adopted to define criteria for minimum and optimum attributes of TPPs and build consensus on characteristics. Expert panel (n=23) included infectious disease physicians, public health specialists, clinical microbiologists, virologists, researchers/scientists and technology experts/ innovators. Results: We present a three-component product profile for sepsis diagnosis, (i) screening with high sensitivity, (ii) detection of aetiological agent, and (iii) profiling of antimicrobial susceptibility/ resistance, in adults and neonates with an option of testing different considerations. An agreement of >75 per cent was achieved for all TPP characteristics by Delphi. These TPPs are tailored to the Indian healthcare settings and can also be extrapolated to other resource-constraint and high-disease burden settings. Interpretation & conclusions: Diagnostics developed using these TPPs will facilitate utilization of invested resources leading to development of the products that have potential to ease the economic burden on patient and save lives. [ABSTRACT FROM AUTHOR]

Sustainable development goals (SDGs) were meant to put each and everywhere ‘at par’. The tobacco epidemic globally is one major deterrent to their achievement. While it gets addressed under SDG 3 through the Framework Convention on Tobacco Control (FCTC) - the World Health Organization (WHO) global treaty (the target 3.a of SDG 3), the progress made globally and by India is slow. As a result, many countries may fall short of achieving the target of reducing tobacco usage (taking 2016 as base year) by 30 per cent by the year 2030. India with its high burden of tobacco use and abysmally low quitting along with soaring economic costs of tobacco related diseases and deaths can do better with the engagement of multisectoral stakeholders to strengthen tobacco control under SDGs. Moreover, there is a need to emphasize that the goal of O - Offer to Quit of WHO MPOWER can be achieved through increasing ‘onus’ on policy makers, and strategists, and opportunities for masses, tobacco users, healthcare professionals (HCPs) and enforcers to have tobacco cessation delivered optimally. By doing so, the United Nations can significantly facilitate a reduction in tobacco use and the resultant economic costs. Furthermore, it will assist the WHO to fulfil the targets set for 2030 under SDG 3.a by the FCTC member countries. In addition, it will fulfil the vision and mission defined in the Chandigarh declaration of the 5th National Conference on Tobacco or Health for India to be tobacco free by 2030. [ABSTRACT FROM AUTHOR]

Mental disorders in India form a major public health concern and the efforts to tackle these dates back to four decades, by way of the National Mental Health Programme (NMHP) and its operational arm, the District Mental Health Programme (DMHP). Although the progress of NMHP (and DMHP) was relatively slower till recently, the last 4-5 years have seen rapid strides with several initiatives, including (i) expansion of DMHPs to 90 per cent of the total districts of the country, (ii) the National Mental Health Policy and (iii) strengthening the Mental Health Legislation by way of providing explicit provisions for rights of persons with mental illnesses. Among others, factors responsible for this accelerated growth include the easily accessible digital technology as well as judicial activism. Federal and State cooperation is another notable feature of this expansion. In this review, the authors summarize the available information on the evolution of implementation and research aspects related to India’s NMHP over the years and provide a case for the positive turn of events witnessed in the recent years. However, the authors caution that these are still baby steps and much more remains to be done. [ABSTRACT FROM AUTHOR]

Background & objectives: Assessing healthcare seeking behaviour (HSB), healthcare utilization and related out-of-pocket expenditures of Particularly Vulnerable Tribal Groups (PVTGs) of India through a prism of the health system may help to achieve equitable health outcomes. Therefore, this comprehensive study was envisaged to examine these issues among PVTGs of Odisha, India. However, there exists no validated questionnaire to measure these variables among PVTGs. Therefore, a study questionnaire was developed for this purpose and validated. Methods: Questionnaire was constructed in four phases: questionnaire development, validity assessment, pilot testing and reliability assessment. Nine domain experts face validated questionnaire in two rounds, followed by a single round of quantitative content validity. Next, the questionnaire was pretested in three rounds using cognitive interviews and pilot-tested among 335 and 100 eligible individuals for the two sections healthcare seeking behaviour (HSB-Q) and maternal and child healthcare service utilization (MCHSU-Q). Internal consistency reliability was assessed for de novo HSB-Q. Results: On two rounds of expert-driven face validity, 55 items were eliminated from 200 items. Questionnaire showed moderate to high content validity (item-level content validity index range: 0.78 to 1, scale-level content validity index/universal agreement: 0.73; scale-level content validity index/average: 0.96 and multirater kappa statistics range: 0.6 to 1). During the pre-test, items were altered until saturation was achieved. Pilot testing helped to refine interview modalities. The Cronbach alpha and McDonald’s omega assessing internal consistency of HSB-Q were 0.8 and 0.85, respectively. Interpretation & conclusions: The questionnaire was found to be valid and reliable to explore healthcare seeking behaviour, maternal and child healthcare utilization and related out-of-pocket expenditure incurred by PVTGs of Odisha, India. [ABSTRACT FROM AUTHOR]

Background & objectives: There is a paucity of data regarding immunogenicity of recently introduced measles–rubella (MR) vaccine in Indian children, in which the first dose is administered below one year of age. This study was undertaken to assess the immunogenicity against rubella and measles 4-6 wk after one and two doses of MR vaccine administered under India’s Universal Immunization Programme (UIP). Methods: In this longitudinal study, 100 consecutive healthy infants (9-12 months) of either gender attending the immunization clinic of a tertiary care government hospital affiliated to a medical college of Delhi for the first dose of routine MR vaccination were enrolled. MR vaccine (0.5 ml, subcutaneous) was administered to the enrolled participants (1st dose at 9-12 months and 2nd dose at 15-24 months). On each follow up (4-6 wk post-vaccination), 2 ml of venous blood sample was collected to estimate the antibody titres against measles and rubella using quantitative ELISA kits. Seroprotection (>10 IU/ml for measles and >10 WHO U/ml for rubella) and antibody titres were evaluated after each dose. Results: The seroprotection rate against rubella was 97.5 and 100 per cent and against measles was 88.7 per cent and 100 per cent 4-6 wk after the first and second doses, respectively. The mean (standard deviation) titres against rubella and measles increased significantly (P<0.001) after the second dose in comparison to the levels after the first dose by about 100 per cent and 20 per cent, respectively. Interpretation & conclusions: MR vaccine administered below one year of age under the UIP resulted in seroprotection against rubella and measles in a large majority of children. Furthermore, its second dose resulted in seroprotection of all children. The current MR vaccination strategy of two doses, out of which the first is to be given to infants below one year of age, appears robust and justifiable among Indian children. [ABSTRACT FROM AUTHOR]

Background & objectives: Sandflies are implicated as vectors of Chandipura virus (CHPV) (Vesiculovirus: Rhabdoviridae). The virus is prevalent in central India including Vidarbha region of Maharashtra. CHPV causes encephalitis in children below 15 yr of age with case fatality rates ranging from 56 to 78 per cent. The present study was undertaken to determine the sandfly fauna in the CHPV endemic Vidharba region. Methods: A year round survey of sandflies was conducted at 25 sites in three districts of Vidarbha region. Sandflies were collected from their resting sites using handheld aspirators and identified using taxonomical keys. Results: A total of 6568 sandflies were collected during the study. Approximately 99 per cent of the collection belonged to genus Sergentomyia, which was represented by Ser. babu, Ser. bailyi and Ser. punjabensis. Genus Phlebotomus was represented by Ph. argentipes and Ph. papatasi. Ser. babu was the predominant species (70.7%) collected during the study. Ph. argentipes was detected in four villages with 0.89 per cent, whereas Ph. papatasi was detected in only one village with 0.32 per cent of the total collection. CHPV could not be isolated despite processing all the sandflies for virus isolation in cell culture. Interpretation & conclusions: The present study showed influence of higher temperature and relative humidity on sandfly population dynamics. An important observation during the study was the absence or decline in the population of Ph. papatasi and Ph. argentipes in the study area. Surge in Sergentomyia population and their breeding/resting in close vicinity to humans pose a concern as they are known to harbour CHPV and other viruses of public health importance. [ABSTRACT FROM AUTHOR]

Background & objectives: Screening of individuals for early detection and identification of undiagnosed diabetes can help in reducing the burden of diabetic complications. This study aimed to evaluate the performance of Madras Diabetes Research Foundation (MDRF)-Indian Diabetes Risk Score (IDRS) to screen for undiagnosed type 2 diabetes in a large representative population in India. Methods: Data were acquired from the Indian Council of Medical Research–INdia DIABetes (ICMR–INDIAB) study, a large national survey that included both urban and rural populations from 30 states/union territories in India. Stratified multistage design was followed to obtain a sample of 113,043 individuals (94.2% response rate). MDRF-IDRS used four simple parameters, viz. age, waist circumference, family history of diabetes and physical activity to detect undiagnosed diabetes. Receiver operating characteristic (ROC) with area under the curve (AUC) was used to assess the performance of MDRF-IDRS. Results: We identified that 32.4, 52.7 and 14.9 per cent of the general population were under high-, moderate- and low-risk category of diabetes. Among the newly diagnosed individuals with diabetes [diagnosed by oral glucose tolerance test (OGTT)], 60.2, 35.9 and 3.9 per cent were identified under high-, moderate- and low-risk categories of IDRS. The ROC-AUC for the identification of diabetes was 0.697 (95% confidence interval: 0.684-0.709) for urban population and 0.694 (0.684-0.704) for rural, as well as 0.693 (0.682-0.705) for males and 0.707 (0.697-0.718) for females. MDRF-IDRS performed well when the population were sub-categorized by state or by regions. Interpretation & conclusions: Performance of MDRF-IDRS is evaluated across the nation and is found to be suitable for easy and effective screening of diabetes in Asian Indians. [ABSTRACT FROM AUTHOR]

Background & objectives: Postpartum intrauterine contraceptive device (PPIUCD) is well accepted and recommended for contraception. However, anxiety at the time of delivery may restrict the acceptance of a PPIUCD for its immediate insertion. So far there is limited evidence to conclude anything concrete on the association between the expulsion rates and the timing of insertion following a vaginal delivery. Thus, this study was undertaken to compare the expulsion rates in immediate and early insertions and their safety and complications. Methods: This prospective comparative study was carried out over 17 months on women delivering vaginally in a tertiary care teaching hospital in South India. A copper device (CuT380A) was inserted using Kelly’s placental forceps either within 10 min of placental delivery (immediate group, n=160) or between 10 min upto 48 h postpartum (early group, n=160). Ultrasound was done before discharge from the hospital. The expulsion rates and any other complications at six-week and three-month follow up were studied. Chi-square test was used to compare the difference in expulsion rates. Results: The expulsion rate was five per cent in the immediate compared to 3.7 per cent in the early group (no significant difference). In ten cases, the device was found to be in the lower uterus upon ultrasound before discharge. These were repositioned. There was no case with perforation, irregular bleeding or infection up to the three-month follow up. Higher age, higher parity, lack of satisfaction and motivation to continue were predictors of expulsion. Interpretation & conclusions: In the present study PPIUCD was found to be safe with overall expulsion in 4.3 per cent. It was marginally, though not significantly, higher in the immediate group. [ABSTRACT FROM AUTHOR]

Background & objectives: Information and communications technology (ICT) has often been endorsed as an effective tool to improve primary healthcare. However, evidence on the cost of ICT-enabled primary health centre (PHC) is lacking. The present study aimed at estimating the costs for customization and implementation of an integrated health information system for primary healthcare at a public sector urban primary healthcare facility in Chandigarh. Methods: We undertook economic costing of an ICT-enabled PHC based on health system perspective and bottom-up costing. All the resources used for the provision of ICT-enabled PHC, capital and recurrent, were identified, measured and valued. The capital items were annualized over their estimated life using a discount rate of 3 per cent. A sensitivity analysis was undertaken to assess the effect of parameter uncertainties. Finally, we assessed the cost of scaling up ICT-enabled PHC at the state level. Results: The estimated overall annual cost of delivering health services through PHC in the public sector was ₹ 7.88 million. The additional economic cost of ICT was ₹ 1.39 million i.e. 17.7 per cent over and above a non-ICT PHC cost. In a PHC with ICT, the cost per capita increased by ₹ 56. On scaling up to the state level (with 400 PHCs), the economic cost of ICT was estimated to be ₹ 0.47 million per year per PHC, which equates to approximately six per cent expenditure over and above the economic cost of a regular PHC. Interpretation & conclusions: Implementing a model of information technology-PHC in a state of India would require an augmentation of cost by about six per cent, which seems fiscally sustainable. However, contextual factors related to the availability of infrastructure, human resources and medical supplies for delivering quality PHC services will also need to be considered. [ABSTRACT FROM AUTHOR]

Venous thromboembolism (VTE), which entails the formation of a thrombus (blood clot) in a vein, has a significant disease burden worldwide. While VTE has traditionally been considered to predominantly affect Caucasian populations, recent studies have indicated a gradual shift in the disease burden towards Asian populations, with added significance of it being a key driver of post-operative mortality. It is imperative to develop a sound understanding of the various factors that affect VTE in stratified local populations. However, there is a glaring paucity of quality data on VTE and its ramifications among Indians - both in terms of quality of life and cost of healthcare. This review aims to throw light on the disease burden, epidemiology, risk factors, environmental factors, food and nutrition that plays a key role in VTE. We also explored the association of VTE with coronavirus disease 2019 to grasp the interplay between the two most significant public health crises of our time. It is vital to place a special emphasis on future research on VTE in India to plug the gaps, which exist in our current knowledge of the disease, particularly with respect to Indian population. [ABSTRACT FROM AUTHOR]

Background & objectives: The National Prevalence Survey of India (2019-2021) estimated 31 per cent tuberculosis infection (TBI) burden among individuals above 15 years of age. However, so far little is known about the TBI burden among the different risk groups in India. Thus, this systematic review and meta-analysis, aimed to estimate the prevalence of TBI in India based on geographies, sociodemographic profile, and risk groups. Methods: To identify the prevalence of TBI in India, data sources such as MEDLINE, EMBASE, CINAHL, and Scopus were searched for articles reporting data between 2013-2022, irrespective of the language and study setting. TBI data were extracted from 77 publications and pooled prevalence was estimated from the 15 community-based cohort studies. Articles were reviewed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines and were sourced using a predefined search strategy from different databases. Results: Out of 10,521 records, 77 studies (46 cross-sectional and 31 cohort studies) were included. The pooled TBI prevalence for India based on the community-based cohort studies was estimated as 41 per cent [95% confidence interval (CI) 29.5-52.6%] irrespective of the risk of acquiring it, while the estimation was 36 per cent (95% CI 28-45%) prevalence observed among the general population excluding highrisk groups. Regions with high active TB burden were found to have a high TBI prevalence such as Delhi and Tamil Nadu. An increasing trend of TBI was observed with increasing age in India. Interpretation & conclusions: This review demonstrated a high prevalence of TBI in India. The burden of TBI was commensurate with active TB prevalence suggesting possible conversion of TBI to active TB. A high burden was recorded among people residing in the northern and southern regions of the country. Such local epidemiologic variation need to be considered to reprioritize and implement-tailored strategies for managing TBI in India. [ABSTRACT FROM AUTHOR]

Background & objectives: Vaccination will play an important role in meeting the end tuberculosis (TB) goals. While certain vaccine candidates in advanced stages of clinical trials raise hope for the future availability of new tools, in the immediate term, there is also increasing interest in Bacille Calmette– Guérin revaccination among adults and adolescents as a potential strategy. Here, we sought to estimate the potential epidemiological impact of TB vaccination in India. Methods: We developed a deterministic, age-structured, compartmental model of TB in India. Data from the recent national prevalence survey was used to inform epidemiological burden while also incorporating a vulnerable population who may be prioritized for vaccination, the latter consistent with the burden of undernutrition. Using this framework, the potential impact on incidence and mortality of a vaccine with 50 per cent efficacy was estimated, if rolled out in 2023 to cover 50 per cent of the unvaccinated each year. Simulated impacts were compared for disease- vs. infection-preventing vaccines, as well as when prioritizing vulnerable groups (those with undernutrition) rather than the general population. A sensitivity analyses were also conducted with respect to the duration, and efficacy, of vaccine immunity. Results: When rolled out in the general population, an infection-preventing vaccine would avert 12 per cent (95% Bayesian credible intervals (Crl): 4.3-28%) of cumulative TB incidence between 2023 and 2030, while a disease-preventing vaccine would avert 29 per cent (95% Crl: 24-34%). Although the vulnerable population accounts for only around 16 per cent of India’s population, prioritizing this group for vaccination would achieve almost half the impact of rollout in the general population, in the example of an infection-preventing vaccine. Sensitivity analysis also highlights the importance of the duration and efficacy of vaccine-induced immunity. Interpretation & conclusions: These results highlight how even a vaccine with moderate effectiveness (50%) could achieve substantial reductions in TB burden in India, especially when prioritized for the most vulnerable. [ABSTRACT FROM AUTHOR]

Background & objectives: This study was aimed at estimating the proportion among sputum smear-positive tuberculosis (TB) patients diagnosed at a tertiary care centre in India, who did not undergo universal drugsusceptibility testing (UDST), assessing the sociodemographic and morbidity-related factors associated with it, ascertaining the reasons for not getting tested and estimating the proportion with any drug resistance (DR). Methods: TB Notification Register and TB Laboratory Register, maintained in Designated Microscopy Centre and Intermediate Research Laboratory, respectively were used to obtain the patient details and information regarding UDST and DR-TB status. Under UDST, the TB patients had undergone rapid molecular tests to check for any DR. TB patients who dropped out of this strategy (those who did not submit a sputum sample for DR testing even after being instructed) were telephonically contacted and asked regarding reasons for not getting themselves tested. Results: Of the 215 patients, 74 [34.4%, 95% confidence interval (CI): 28.1-41.2] did not undergo UDST. Of these 74 participants, 60 per cent reported the reason that they were not informed regarding the drug-susceptibility test. Among the 141 patients who underwent UDST, six (4.3%, 95% CI: 1.58-9.03) had DR. Non-UDST patients were significantly more in percentage among TB patients who were aged <30 years (adjusted prevalence ratio 2.36; 95% CI: 1.19-4.68) compared to >60 years. Interpretation & conclusions: The present findings point towards a need to sensitize healthcare workers and TB patients to improve UDST. [ABSTRACT FROM AUTHOR]

Background & objectives: The National Tuberculosis (TB) Control Programme has transitioned from thrice-weekly to daily drug treatment regimens in India. This preliminary study was conceived to compare the pharmacokinetics of rifampicin (RMP), isoniazid (INH) and pyrazinamide (PZA) in TB patients being treated with daily and thrice weekly anti-TB treatment (ATT). Methods: This prospective observational study was undertaken in 49 newly diagnosed adult TB patients receiving either daily ATT (n=22) or thrice-weekly ATT (n=27). Plasma RMP, INH and PZA were estimated by high-performance liquid chromatography. Results: The peak concentration (Cmax) of RMP was significantly higher (RMP: 8.5 µg/ml vs. 5.5 µg/ml; P=0.003) and Cmax of INH was significantly lower (INH: 4.8 µg/ml vs. 10.9 µg/ml; P<0.001) in case of daily dosing compared to thrice-weekly ATT. Cmax of drugs and doses was significantly correlated. A higher proportion of patients had subtherapeutic RMP Cmax (8.0 µg/ml) during thrice-weekly compared to daily ATT (78% vs. 36%; P=0.004). Multiple linear regression analysis showed that Cmax of RMP was significantly influenced by the dosing rhythm, pulmonary TB and Cmax of INH and PZA by the mg/kg doses. Interpretation & conclusions: RMP concentrations were higher and INH concentrations were lower during daily ATT, suggesting that INH doses may need to be increased in case of a daily regimen. Larger studies are, however, required using higher INH doses when monitoring for adverse drug reactions and treatment outcomes. [ABSTRACT FROM AUTHOR]

Background & objectives: Female genital tuberculosis (FGTB) is an important variety of extrapulmonary TB causing significant morbidity, especially infertility, in developing countries like India. The aim of this study was to evaluate the laparoscopic findings of the FGTB. Methods: This was a cross-sectional study on 374 cases of diagnostic laparoscopy performed on FGTB cases with infertility. All patients underwent history taking and clinical examination and endometrial sampling/biopsy for acid-fast bacilli, microscopy, culture, PCR, GeneXpert (only last 167 cases) and histopathological evidence of epithelioid granuloma. Diagnostic laparoscopy was performed in all the cases to evaluate the findings of FGTB. Results: Mean age, parity, body mass index and duration of infertility were 27.5 yr, 0.29, 22.6 kg/m2 and 3.78 years, respectively. Primary infertility was found in 81 per cent and secondary infertility in 18.18 per cent of cases. Endometrial biopsy was positive for AFB microscopy in 4.8 per cent, culture in 6.4 per cent and epithelioid granuloma in 15.5 per cent. Positive peritoneal biopsy granuloma was seen in 5.88 per cent, PCR in 314 (83.95%) and GeneXpert in 31 (18.56%, out of last 167 cases) cases. Definite findings of FGTB were seen in 164 (43.86%) cases with beaded tubes (12.29%), tubercles (32.88%) and caseous nodules (14.96%). Probable findings of FGTB were seen in 210 (56.14%) cases with pelvic adhesions (23.52%), perihepatic adhesions (47.86%), shaggy areas (11.7%), pelvic adhesions (11.71%), encysted ascites (10.42%) and frozen pelvis in 3.7 per cent of cases. Interpretation & conclusions: The finding of this study suggests that laparoscopy is a useful modality to diagnose FGTB with a higher pickup rate of cases. Hence it should be included as a part of composite reference standard. [ABSTRACT FROM AUTHOR]