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Background: Despite free immunisation services through the Universal Immunisation Programme (UIP), around 14% of Indian households seek immunisation in the private sector. We examined the potential impact of rotavirus vaccine (RVV) introduction in the Universal Immunisation Programme (UIP) on private-sector rotavirus vaccine utilisation., Methods: We analysed nationally representative private-sector vaccine sales data. The intervention under consideration is RVV introduction in the UIP in selected Indian states. The outcome is the 'monthly RVV sales volume'-a proxy for vaccine utilisation. We performed a Poisson regression interrupted time series analysis to detect the pre-intervention trend, post-intervention level change and trend change relative to the pre-intervention for monthly rotavirus vaccine utilisation., Results: Poisson segmented regression analysis showed that immediately after RVV introduction in the UIP private-sector RVV sales showed a decline in Rajasthan by 37.4% (Incidence Risk Ratio (IRR): 0.626; 95% CI: 0.504-0.779), in Tamil Nadu by 26% (IRR: 0.740; 95% CI: 0.513-1.068), in Uttar Pradesh-East by 72.2% (IRR: 0.278; 95% CI: 0.178-0.436) and in Kerala by 3% (IRR: 0.970; 95% CI: 0.651-1.447). Rajasthan, Tamil Nadu and Kerala had sustained reduction in the postintervention trend relative to the preintervention trend by 20.1% (IRR: 0.799; 95% CI: 0.763-0.836), 6.4% (IRR: 0.936; 95% CI: 0.906-0.967) and 3.3% (IRR: 0.967; 95% CI: 0.926-0.960) per month, respectively. However, in Haryana and UP-west, in the first-month post-UIP introduction, the private-sector RVV sales increased by 101% and 3.8%, respectively which was followed by a sustained decrease of 14.2% (IRR: 0.858; 95% CI: 0.688-1.070) and 5.8% (IRR: 0.942; 95% CI: 0.926-0.960) per month, respectively. In terms of long-term impact, the private sector RVV sales post-UIP introduction decreased at a monthly rate of 4.4% (IRR: 0.956, 95% CI: 0.939-0.974) in Rajasthan but increased by 5.5% (IRR: 1.055; 95% CI: 1.040-1.070) in UP-east, 0.3% (IRR: 1.003, 95% CI: 0.976-1.031)) in Kerala and 0.2% (IRR: 1.002, 95% CI: 0.993-1.011) in Tamil Nadu whereas Haryana and UP-west had a reduction in RVV utilisation by 2.8% (IRR: 0.972; 95% CI: 0.955-0.990) and 1% (IRR: 0.990; 95% CI: 0.982-0.998), respectively., Conclusions: The study provides evidence that access to RVV through UIP leads to a reduction in private-sector RVV utilisation. We recommend strengthening UIP to expand the basket of new vaccines., (© 2024. The Author(s).)

This study develops a hybrid machine learning (ML) algorithm integrated with IoT technology to improve the accuracy and efficiency of soil monitoring and tomato crop disease prediction in Anakapalle, a south Indian station. An IoT device collected one-minute and critical soil parameters-humidity, temperature, pH values, nitrogen (N), phosphorus (P), and potassium (K), during the vegetative growth stage, which are essential for assessing soil health and optimizing crop growth. Kendall's correlations were computed to rank these parameters for utilization in hybrid ML techniques. Various ML algorithms including K-nearest neighbors (KNN), support vector machines (SVM), decision tree (DT), random forest (RF), and logistic regression (LR) were evaluated. A novel hybrid algorithm, 'Bayesian optimization with KNN', was introduced to combine multiple ML techniques and enhance predictive performance. The hybrid algorithm demonstrated superior results with 95% accuracy, precision, and recall, and an F1 score of 94%, while individual ML algorithms achieved varying results: KNN (80% accuracy), SVM (82%), DT (77%), RF (80%), and LR (81%) with differing precision, recall, and F1 scores. This hybrid ML approach proved highly effective in predicting tomato crop diseases in natural environments, underscoring the synergistic benefits of IoT and advanced ML techniques in optimizing agricultural practices.

Background: Type 2 diabetes (T2DM) poses an enormous global health care challenge, especially among rural communities. Healthcare in these areas can be inadequate and inaccessible due to socio-demographic barriers. To overcome this situation, many low- and middle-income countries are resorting to task shifting, using community health workers (CHWs) for diabetes management. However, its successful implementation depends on the practice behaviours and knowledge of these workers., Objective: This cross-sectional study aimed to evaluate the proficiency of CHWs involved in diabetes screening and management in rural South India by identifying the existing practice behaviours and knowledge gaps., Methods: Employing a customised questionnaire, developed through inputs from experts and government officials, we assessed practice behaviours and the corresponding knowledge base of 275 CHWs. Analytical methodologies consisted of descriptive statistics, logistic regression, and mosaic plots for comprehensive data interpretation., Results: The study showcased significant deficiencies in both practice behaviours (97%) and knowledge (95%) with current mean levels ranging from 48 to 50%, respectively, among the participants. The identified areas of insufficiency were broadly representative of the core competencies required for effective diabetes management, encompassing diabetes diagnosis and referral, HbA1c testing, diabetes diet, diabetes type and self-management, microvascular complications and their screening, peripheral neuropathy management, and diabetes risk assessment. In several areas, correct practice behaviour was reported by a relatively large number of CHWs despite incorrect answers to the related knowledge questions such as referral to the health centres, self-management, and calculation of diabetes risk assessment., Conclusion: This study highlights widespread deficiencies (97% CHWs) in diabetes management practices and knowledge (95% CHWs). To overcome these deficiencies, a thorough needs assessments is vital for effective CHW training. Training of CHWs should not only identify prior knowledge and/or behaviour but also their interrelationship to help create a robust and flexible set of practice behaviours.

Background: Timely detection and management of gestational diabetes mellitus (GDM) have been identified as a high priority for policymakers in low- and middle-income countries (LMICs). The GUIDES trial will evaluate a package of three interconnected film-based interventions aimed at improving the timely detection and management of GDM. The protocol for this trial has previously been published; this publication outlines the statistical analysis plan for the trial., Methods and Design: The GUIDES study is a multi-country cluster-randomised controlled trial consisting of one trial conducted in Uganda and one in India (30 clusters in each country). Mixed effects models will be used to compare the primary study outcomes of the proportion of women who are tested for GDM between 24 and 32 weeks of pregnancy and the mean fasting blood sugar of women with GDM at 34-week follow-up while accounting for clustering. Secondary analyses will compare the proportion of women with self-reported GDM diagnosis at 32 weeks of pregnancy and the proportion of women with adverse perinatal outcomes related to GDM up to 4 weeks after birth in each trial arm., Trial Status and Discussion: Follow-up is expected to end in March 2023 in Uganda and in May 2023 in India. Analyses will be carried out following this statistical analysis plan in the month following trial completion., Trial Registration: ClinicalTrials.gov NCT03937050. Registered on 3 May 2019. Clinical Trials Registry India CTRI/2020/02/023605. Registered on 26 February 2020., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Vitamins B12 and B6 and folate are known to have implications for pregnancy outcomes. We aimed to describe B6, B12, and folate status in pregnancy and investigate their associations with low birth weight and preterm delivery in mothers recruited from public hospitals in urban Bengaluru. Pregnant women between 18 and 45 years were included in the MAASTHI prospective cohort study. Each participant's age, socioeconomic status, and anthropometry were recorded during baseline and followed up after delivery. Blood samples were collected between the 24th and 32nd weeks of gestation and stored at -80° for analysis. B6, B12, folate, homocysteine, and methylmalonic acid (MMA) levels were analyzed in the stored samples. We found low plasma vitamin B12, folate, and B6 levels in 48.5%, 42.0%, and 10.4% of the women ( n = 230), respectively. Elevated MMA and homocysteine were observed among 73.6% and 6.1% of the women, respectively. We found B6 levels were significantly associated with birth weight (β(SE) -0.002(0.0), p = 0.001) after adjusting for age, parity, adiposity, gestational diabetes, and socioeconomic status of the mother. Those with impaired folate deficiency were twice at risk (AOR 1.95 (1.29, 3.07), p = 0.002) of low birth weight. Vitamin B6 levels and impaired folate status were associated with low birth weight in the MAASTHI birth cohort.

Importance: Hypertension contributes to more than 1.6 million deaths annually in India, with many individuals being unaware they have the condition or receiving inadequate treatment. Policy initiatives to strengthen disease detection and management through primary care services in India are not currently informed by population preferences., Objective: To quantify population preferences for attributes of public primary care services for hypertension., Design, Setting, and Participants: This cross-sectional study involved administration of a household survey to a population-based sample of adults with hypertension in the Bengaluru Nagara district (Bengaluru City; urban setting) and the Kolar district (rural setting) in the state of Karnataka, India, from June 22 to July 27, 2021. A discrete choice experiment was designed in which participants selected preferred primary care clinic attributes from hypothetical alternatives. Eligible participants were 30 years or older with a previous diagnosis of hypertension or with measured diastolic blood pressure of 90 mm Hg or higher or systolic blood pressure of 140 mm Hg or higher. A total of 1422 of 1927 individuals (73.8%) consented to receive initial screening, and 1150 (80.9%) were eligible for participation, with 1085 (94.3%) of those eligible completing the survey., Main Outcomes and Measures: Relative preference for health care service attributes and preference class derived from respondents selecting a preferred clinic scenario from 8 sets of hypothetical comparisons based on wait time, staff courtesy, clinician type, carefulness of clinical assessment, and availability of free medication., Results: Among 1085 adult respondents with hypertension, the mean (SD) age was 54.4 (11.2) years; 573 participants (52.8%) identified as female, and 918 (84.6%) had a previous diagnosis of hypertension. Overall preferences were for careful clinical assessment and consistent availability of free medication; 3 of 5 latent classes prioritized 1 or both of these attributes, accounting for 85.1% of all respondents. However, the largest class (52.4% of respondents) had weak preferences distributed across all attributes (largest relative utility for careful clinical assessment: β = 0.13; 95% CI, 0.06-0.20; 36.4% preference share). Two small classes had strong preferences; 1 class (5.4% of respondents) prioritized shorter wait time (85.1% preference share; utility, β = -3.04; 95% CI, -4.94 to -1.14); the posterior probability of membership in this class was higher among urban vs rural respondents (mean [SD], 0.09 [0.26] vs 0.02 [0.13]). The other class (9.5% of respondents) prioritized seeing a physician (the term doctor was used in the survey) rather than a nurse (66.2% preference share; utility, β = 4.01; 95% CI, 2.76-5.25); the posterior probability of membership in this class was greater among rural vs urban respondents (mean [SD], 0.17 [0.35] vs 0.02 [0.10])., Conclusions and Relevance: In this study, stated population preferences suggested that consistent medication availability and quality of clinical assessment should be prioritized in primary care services in Karnataka, India. The heterogeneity observed in population preferences supports considering additional models of care, such as fast-track medication dispensing to reduce wait times in urban settings and physician-led services in rural areas.

Background: India has experienced the second largest outbreak of COVID-19 globally, yet there is a paucity of studies analysing contact tracing data in the region which can optimise public health interventions (PHI's)., Methods: We analysed contact tracing data from Karnataka, India between 9 March and 21 July 2020. We estimated metrics of transmission including the reproduction number (R), overdispersion (k), secondary attack rate (SAR), and serial interval. R and k were jointly estimated using a Bayesian Markov Chain Monte Carlo approach. We studied determinants of risk of further transmission and risk of being symptomatic using Poisson regression models., Findings: Up to 21 July 2020, we found 111 index cases that crossed the super-spreading threshold of ≥8 secondary cases. Among 956 confirmed traced cases, 8.7% of index cases had 14.4% of contacts but caused 80% of all secondary cases. Among 16715 contacts, overall SAR was 3.6% [95% CI, 3.4-3.9] and symptomatic cases were more infectious than asymptomatic cases (SAR 7.7% vs 2.0%; aRR 3.63 [3.04-4.34]). As compared to infectors aged 19-44 years, children were less infectious (aRR 0.21 [0.07-0.66] for 0-5 years and 0.47 [0.32-0.68] for 6-18 years). Infectors who were confirmed ≥4 days after symptom onset were associated with higher infectiousness (aRR 3.01 [2.11-4.31]). As compared to asymptomatic cases, symptomatic cases were 8.16 [3.29-20.24] times more likely to cause symptomatic infection in their secondary cases. Serial interval had a mean of 5.4 [4.4-6.4] days, and case fatality rate was 2.5% [2.4-2.7] which increased with age., Conclusion: We found significant heterogeneity in the individual-level transmissibility of SARS-CoV-2 which could not be explained by the degree of heterogeneity in the underlying number of contacts. To strengthen contact tracing in over-dispersed outbreaks, testing and tracing delays should be minimised and retrospective contact tracing should be implemented. Targeted measures to reduce potential superspreading events should be implemented. Interventions aimed at children might have a relatively small impact on reducing transmission owing to their low symptomaticity and infectivity. We propose that symptomatic cases could cause a snowballing effect on clinical severity and infectiousness across transmission generations; further studies are needed to confirm this finding., Competing Interests: The authors have declared that no competing interests exist.

This paper answers research questions on screening and management of severe thinness in pregnancy, approaches that may potentially work in India, and what more is needed for implementing these approaches at scale. A desk review of studies in the last decade in South Asian countries was carried out collating evidence on six sets of strategies like balanced energy supplementation (BEP) alone and in combination with other interventions like nutrition education. Policies and guidelines from South Asian countries were reviewed to understand the approaches being used. A 10-point grid covering public health dimensions covered by World Health Organization and others was created for discussion with policymakers and implementers, and review of government documents sourced from Ministry of Health and Family Welfare. Eighteen studies were shortlisted covering Bangladesh, India, Nepal, and Pakistan. BEP for longer duration, preconception initiation of supplementation, and better pre-supplementation body mass index (BMI) positively influenced birthweight. Multiple micronutrient supplementation was more effective in improving gestational weight gain among women with better pre-supplementation BMI. Behavior change communication and nutrition education showed positive outcomes on dietary practices like higher dietary diversity. Among South Asian countries, Sri Lanka and Nepal are the only two countries to have management of maternal thinness in their country guidelines. India has at least nine variations of supplementary foods and three variations of full meals for pregnant women, which can be modified to meet additional nutritional needs of those severely thin. Under the National Nutrition Mission, almost all of the globally recommended maternal nutrition interventions are covered, but the challenge of reaching, identifying, and managing cases of maternal severe thinness persists. This paper provides four actions for addressing maternal severe thinness through available public health programs, infrastructure, and human resources., (International Journal of Gynecology & Obstetrics© 2021 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Background: Cesarean section (C-section) delivered infants are more likely to be colonized by opportunistic pathogens, resulting in altered growth. We examined whether C-section (elective/emergency) vs vaginal delivery was associated with altered weight and linear growth at 1 year of life., Methods: A total of 638 mother-infant pairs were included from MAASTHI cohort 2016-2019. Information on delivery mode was obtained from medical records. Based on WHO child growth standards, body mass index-forage z-score (BMI z) and length-for-age z-score (length z) were derived. We ran multivariable linear and Poisson regression models before and after multiple imputation., Results: The rate of C-section was 43.4% (26.5%: emergency, 16.9%: elective). Percentage of infant overweight was 14.9%. Compared to vaginal delivery, elective C-section was associated with β = 0.57 (95% CI 0.20, 0.95) higher BMI z. Also infants born by elective C-section had RR = 2.44 (95% CI 1.35, 4.41) higher risk of being overweight; no such association was found for emergency C-section. Also, elective C-section delivery was associated with reduced linear growth at 1 year after multiple imputation (β = -0.38, 95% CI -0.76, -0.01)., Conclusions: Elective C-section delivery might contribute to excess weight and also possibly reduced linear growth at 1 year of age in children from low- and middle-income countries., Impact: Our study, in a low-income setting, suggests that elective, but not emergency, C-section is associated with excess infant BMI z at 1 year of age and elective C (C-section) was also associated with altered linear growth but only in multiple imputation analyses. Elective C-section was associated with a higher risk of being overweight at 1 year of age. Our results indicate that decreasing medically unnecessary elective C-section deliveries may help limit excess weight gain and stunted linear growth among infants., (© 2021. The Author(s).)

Objective: To examine prevalence, risk factors, and consequences of maternal severe thinness in India., Methods: This mixed methods study analyzed data from the Indian National Family Health Survey (NFHS)-4 (2015-2016) to estimate the prevalence of and risk factors for severe thinness, followed by a desk review of literature from India., Results: Prevalence of severe thinness (defined by World Health Organization as body mass index [BMI] <16 in adult and BMI for age Z score < -2 SD in adolescents) was higher among pregnant adolescents (4.3%) compared with pregnant adult women (1.9%) and among postpartum adolescent women (6.3%) than postpartum adult women (2.4%) 2-6 months after delivery. Identified research studies showed prevalence of 4%-12% in pregnant women. Only 13/640 districts had at least three cases of severely thin pregnant women; others had lower numbers. Three or more postpartum women aged ≥20 years were severely thin in 32 districts. Among pregnant adolescents, earlier parity increased odds (OR 1.96; 95% CI, 1.18-3.27) of severe thinness. Access to household toilet facility reduced odds (OR 0.72; 95% CI, 0.52-0.99]. Among mothers aged ≥20 years, increasing education level was associated with decreasing odds of severe thinness (secondary: OR 0.74; 95% CI, 0.57-0.96 and Higher: OR 0.54; 95% CI, 0.32-0.91, compared with no education); household wealth and caste were also associated with severe thinness., Conclusion: This paper reveals the geographic pockets that need priority focus for managing severe thinness among pregnant women and mothers in India to limit the immediate and intergenerational adverse consequences emanating from these deprivations., (© 2021 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Background: Estimating total body fat in public hospitals using gold-standard measurements such as air displacement plethysmography (ADP), deuterium oxide dilution, or dual-energy X-ray absorptiometry (DXA) is unaffordable, and it is challenging to use skinfold thickness. We aimed to identify the appropriate substitute marker for skinfold thickness to estimate total body fat in pregnant women and infants., Methods: The study is part of a prospective cohort study titled MAASTHI in Bengaluru, from 2016 to 19. Anthropometric measurements such as body weight, head circumference, mid-upper arm circumference (MUAC), and skinfold thickness were measured in pregnant women between 14 and 36 weeks of gestational age; while measurements such as birth weight, head, chest, waist, hip, mid-upper arm circumference, and skinfold thickness were recorded for newborns. We calculated Kappa statistics to assess agreement between these anthropometric markers with skinfold thickness., Results: We found the highest amount of agreement between total skinfold thickness and MUAC (Kappa statistic, 0.42; 95 % CI 0.38-0.46) in pregnant women. For newborns, the highest agreement with total skinfold thickness was with birth weight (0.57; 95 % CI 0.52-0.60). Our results indicate that MUAC higher than 29.2 cm can serve as a suitable alternative to total skinfolds-based assessments for obesity screening in pregnancy in public facilities. Similarly, a birth weight cut-off of 3.45 kg can be considered for classifying obesity among newborns., Conclusion: Mid-upper arm circumference and birth weight can be used as markers of skinfold thickness, reflecting total body fat in pregnant women and the infant, respectively. These two anthropometric measurements could substitute for skinfold thickness in low- and middle-income urban India settings.

Objective: To estimate the burden of active infection and anti-SARS-CoV-2 IgG antibodies in Karnataka, India, and to assess variation across geographical regions and risk groups., Methods: A cross-sectional survey of 16,416 people covering three risk groups was conducted between 3-16 September 2020 using the state of Karnataka's infrastructure of 290 healthcare facilities across all 30 districts. Participants were further classified into risk subgroups and sampled using stratified sampling. All participants were subjected to simultaneous detection of SARS-CoV-2 IgG using a commercial ELISA kit, SARS-CoV-2 antigen using a rapid antigen detection test (RAT) and reverse transcription-polymerase chain reaction (RT-PCR) for RNA detection. Maximum-likelihood estimation was used for joint estimation of the adjusted IgG, active and total prevalence (either IgG or active or both), while multinomial regression identified predictors., Results: The overall adjusted total prevalence of COVID-19 in Karnataka was 27.7% (95% CI 26.1-29.3), IgG 16.8% (15.5-18.1) and active infection fraction 12.6% (11.5-13.8). The case-to-infection ratio was 1:40 and the infection fatality rate was 0.05%. Influenza-like symptoms or contact with a COVID-19-positive patient were good predictors of active infection. RAT kits had higher sensitivity (68%) in symptomatic people compared with 47% in asymptomatic people., Conclusion: This sentinel-based population survey was the first comprehensive survey in India to provide accurate estimates of the COVID-19 burden. The findings provide a reasonable approximation of the population immunity threshold levels. Using existing surveillance platforms coupled with a syndromic approach and sampling framework enabled this model to be replicable., (Copyright © 2021. Published by Elsevier Ltd.)

Introduction: There are ongoing policies and programs to reduce tobacco use and minimise the associated health burden in India. However, there are several challenges in practice leading to different outcomes across Indian states. Inadequate understanding of how national tobacco control policies achieve their results under varied circumstances obstruct the implementation and scaling up of effective strategies. This study is a realist evaluation using largely qualitative methods to understand the implementation process of India's tobacco control policies. It will do so by evaluating India's Cigarettes and Other Tobacco Products Act (COTPA) and the National Tobacco Control Program (NTCP). The study aims to examine how, why, for whom and under which circumstances COTPA and NTCP are implemented in India., Methods and Analysis: A realist synthesis on implementation of tobacco control policies in low-income and middle-income countries is conducted. This is followed by qualitative data collection and analysis in three Indian states selected based on data from two rounds of the Global Adult Tobacco Survey. The study comprises of three steps (1): development of initial programme theories, (2) testing and refinement of initial programme theories and (3) testing and validation of refined programme theories. We will interview policy-makers, programme managers and implementers to identify facilitators and barriers of implementation. The purpose is to identify context-specific evidence-based strategies to gain insights into the implementation process of COTPA and NTCP. Further we aim to contribute to tobacco control research by establishing communities of practice to engage with cross-cutting issues., Ethics and Dissemination: The Institutional Ethics Committee, at the Institute of Public Health (Bengaluru), has approved the protocol. Written informed consent forms will be obtained from all the participants. Dissemination has been planned for researchers, policy-makers and implementers as well as the public through peer-reviewed publications, conference presentation, webinars and social media updates., Prospero Registration Number: CRD42020191541., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Objective: Physical inactivity leads to depression and other adverse health consequences. Pregnant women are an important subgroup to study the health consequences due to physical inactivity since it can lead to adverse outcomes in pregnancy and even after delivery. Therefore, we aimed at understanding the level of physical activity among pregnant women, prevalence of prenatal and postnatal depressive symptoms and whether level of physical activity is associated with prenatal and postnatal depressive symptoms., Methods: In an ongoing cohort study, we measured the physical activity using a validated Physical Activity Level (PAL) questionnaire. We administered the Edinburgh Postnatal Depression Scale (EPDS) during pregnancy and within seven days of delivery to assess depressive symptoms in 1406 women. Associations were adjusted for potential confounders such as maternal age, education, socioeconomic status, gravida, EPDS score during pregnancy, social support, skinfold thickness, blood pressure, blood sugar level., Results: We found that 7.2% of pregnant women had low levels of physical activity. The prevalence of prenatal and postnatal depressive symptoms was 9.0% and 31.9% respectively. Pregnant women with a low level of physical activity had significantly higher odds of developing postpartum depressive symptoms (OR = 3.15, CI: 1.98-5.02, p < 0.001) when adjusted for potential confounders., Conclusions: Moderate level of physical activity among pregnant mothers is essential and has its association with postnatal depressive symptoms. Health care professionals need to counsel pregnant women to assess depressive symptoms at both the prenatal and postpartum period and inform them about the importance of the optimal level of physical activity., (Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Women developing Gestational Diabetes Mellitus (GDM) are subsequently at a higher risk of developing Type 2 Diabetes later in life. Screening and effective management of women with GDM are essential in preventing progression to type 2 diabetes mellitus. We aimed to explore the perspectives of healthcare providers regarding the barriers from the health system context that restrict the timely screening and effective management of GDM., Methods: We conducted six in-depth interviews of health care providers- four with nurses and two with obstetricians in the public hospitals in India's major city (Bengaluru). The interviews were conducted in the preferred language of the participants (Kannada for nurses, English for the obstetricians) and audio-recorded. All Kannada interviews were transcribed and translated into English for analysis. The primary data were analyzed using the grounded theory approach by NVivo 12 plus. The findings are put into perspective using the socio-ecological model., Results: Health care providers identified delayed visits to public hospitals and stress on household-level responsibilities as barriers at the individual level for GDM screening. Also, migration of pregnant women to their natal homes during first pregnancy is a cultural barrier in addition to health system barriers such as unmet nurse training needs, long waiting hours, uneven power dynamics, lack of follow-up, resource scarcity, and lack of supportive oversight. The barriers for GDM management included non-reporting women to follow - up visits, irregular self-monitoring of drug and blood sugar, trained staff shortage, ineffective tracking, and lack of standardized protocol., Conclusion: There is a pressing need to develop and improve existing GDM Screening and Management services to tackle the growing burden of GDM in public hospitals of India.

Introduction: Type 2 diabetes mellitus is responsible for high mortality and morbidity globally and in India. India has high prevalence of the condition and the burden is set to increase exponentially in the next decade. Indians traditionally reside in rural or semi-urban areas with limited access to healthcare facilities. To overcome this, the government has introduced a cadre of health workers called Accredited Social Health Activists (ASHA) for such areas. These workers were initially trained to provide maternal & infant care but now need improved competence training to improve type 2 diabetes screening & management in these locations. The objective of the study is to assess the competence training provided to ASHA workers at the chosen study sites., Methodology: A cluster randomized control trial has been designed. It will be conducted across 8 centers in Hyderabad & Rangareddy districts of Telangana, India. The training will be provided to ASHA workers. The tool used for training will be developed from existing sources with an emphasis on topics which require training. The training will be delivered across 6 months at each center as a classroom training. Each participant's baseline competence will be recorded using a questionnaire tool and a practical evaluation by trained public health experts. The same experts will use the same tools to assess the training post the intervention., Discussion: This trial will evaluate the use of health worker training as a tool for improving the clinical competence in relation to type 2 diabetes mellitus. We anticipate that the module will provide a greater understanding of type 2 diabetes mellitus, the importance of screening of both disease and complications and improved skills for the same. The study has received the ethical approval form the Institutional Ethics Committee of the Indian Institute of Public Health Hyderabad. The registration number is: IIPHH/TRCIEC/218/2020. The trial has also been registered under the Clinical trial registry of India (CTRI) on 27 July 2020. The registration number of the trial is: CTRI/2020/07/026828. The URL of the registry trial is: http://ctri.nic.in/Clinicaltrials/showallp.php?mid1=45342&EncHid=&userName=CTRI/2020/07/026828.

Introduction: Despite national efforts for promoting exclusive breastfeeding (EBF) during the first 6 months of the infants' life, breastfeeding rates are low in India. Evidence on the interference of supplementary food on optimal nourishment and growth of the infant has also been well-established. Our study was undertaken to assess the effect of breastfeeding practices on infant anthropometry and determine the various factors affecting breastfeeding practices., Methods: A prospective cohort study - Maternal antecedents of adiposity and studying the transgenerational role of hyperglycemia and insulin (MAASTHI) was conducted at a tertiary care public hospital in Bengaluru, South India. From the consenting women, data such as obstetric history, infant feeding practices, anthropometry of mother and child, the psychosocial status of the women using the Edinburgh Postnatal Depression Scale (EPDS), was collected at baseline and subsequent follow-up: post-delivery and 14 weeks after birth. In this study, we analyzed data collected from April 2016 to April 2018, with descriptive statistics presented in mean and standard deviation, and logistic regression adjusting for confounders., Results: Among the 240 women enrolled in the study, 33% (n= 80) were using supplementary food for their infants at 14 weeks of infants age. Infants who received supplementary feeding at age 14 weeks had nearly 2.5 times higher odds of being wasted (OR: 2.449, p -value: 0.002) as compared to exclusively breastfed infants., Conclusion: Infants between 14 to 16 weeks of age who received supplementary feeding were at risk of wasting as compared to exclusively breastfed infants. Despite strong evidence in support of the benefits of exclusive breastfeeding, awareness in urban women in India is low. Increased focus on promoting exclusive breastfeeding is necessary to ensure proper nutritional intake and healthy growth of infants., Competing Interests: Conflict of Interest: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Objective: To examine prevalence, risk factors, and consequences of maternal obesity; and provide evidence on current policies and programs to manage maternal obesity in India., Methods: This is a mixed-methods study. We analyzed the National Family Health Survey (NFHS)-4 data (2015-16) to estimate the prevalence and risk factors of obesity, followed by a desk review of literature and stakeholder mapping with interviews to develop policy guidance., Results: National prevalence of obesity (defined by WHO as body mass index ≥25) was comparable among pregnant (12%) and postpartum women (13%) ≥20 years of age. A high prevalence of obesity (>40%) was observed in over 30 districts in multiple states. Older maternal age, urban residence, increasing wealth quintile, and secondary education were associated with increased odds of obesity among pregnant and postpartum women; higher education increased odds among postpartum women only (OR 1.90; 95% CI, 1.44-2.52). Dietary variables were not associated with obesity. Several implementation challenges across healthcare system blocks were observed at policy level., Conclusion: Overall prevalence of obesity in India during and after pregnancy is high, with huge variation across districts. Policy and programs must be state-specific focusing on prevention, screening, and management of obesity among pregnant and postpartum women., (© 2020 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Background & Objectives: Population-based seroepidemiological studies measure the extent of SARS-CoV-2 infection in a country. We report the findings of the first round of a national serosurvey, conducted to estimate the seroprevalence of SARS-CoV-2 infection among adult population of India., Methods: From May 11 to June 4, 2020, a randomly sampled, community-based survey was conducted in 700 villages/wards, selected from the 70 districts of the 21 States of India, categorized into four strata based on the incidence of reported COVID-19 cases. Four hundred adults per district were enrolled from 10 clusters with one adult per household. Serum samples were tested for IgG antibodies using COVID Kavach ELISA kit. All positive serum samples were re-tested using Euroimmun SARS-CoV-2 ELISA. Adjusting for survey design and serial test performance, weighted seroprevalence, number of infections, infection to case ratio (ICR) and infection fatality ratio (IFR) were calculated. Logistic regression was used to determine the factors associated with IgG positivity., Results: Total of 30,283 households were visited and 28,000 individuals were enrolled. Population-weighted seroprevalence after adjusting for test performance was 0.73 per cent [95% confidence interval (CI): 0.34-1.13]. Males, living in urban slums and occupation with high risk of exposure to potentially infected persons were associated with seropositivity. A cumulative 6,468,388 adult infections (95% CI: 3,829,029-11,199,423) were estimated in India by the early May. The overall ICR was between 81.6 (95% CI: 48.3-141.4) and 130.1 (95% CI: 77.0-225.2) with May 11 and May 3, 2020 as plausible reference points for reported cases. The IFR in the surveyed districts from high stratum, where death reporting was more robust, was 11.72 (95% CI: 7.21-19.19) to 15.04 (9.26-24.62) per 10,000 adults, using May 24 and June 1, 2020 as plausible reference points for reported deaths., Interpretation & Conclusions: Seroprevalence of SARS-CoV-2 was low among the adult population in India around the beginning of May 2020. Further national and local serosurveys are recommended to better inform the public health strategy for containment and mitigation of the epidemic in various parts of the country., Competing Interests: None

Conducting population-based serosurveillance for severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) will estimate and monitor the trend of infection in the adult general population, determine the socio-demographic risk factors and delineate the geographical spread of the infection. For this purpose, a serial cross-sectional survey would be conducted with a sample size of 24,000 distributed equally across four strata of districts categorized on the basis of the incidence of reported cases of COVID-19. Sixty districts will be included in the survey. Simultaneously, the survey will be done in 10 high-burden hotspot cities. ELISA-based antibody tests would be used. Data collection will be done using a mobile-based application. Prevalence from the group of districts in each of the four strata will be pooled to estimate the population prevalence of COVID-19 infection, and similarly for the hotspot cities, after adjusting for demographic characteristics and antibody test performance. The total number of reported cases in the districts and hotspot cities will be adjusted using this seroprevalence to estimate the expected number of infected individuals in the area. Such serosurveys repeated at regular intervals can also guide containment measures in respective areas. State-specific context of disease burden, priorities and resources should guide the use of multifarious surveillance options for the current COVID-19 epidemic., Competing Interests: None

The Indian health infrastructure is struggling to handle the burgeoning number of people with diabetes. Managing the complications of diabetes in an organized manner through the government health programs is still a distant reality. Here, we describe a program aimed at addressing the problem of diabetic retinopathy in rural areas of Tumkur district in Karnataka. By amalgamating telescreening and our own novel distributive care model, we were able to screen 85% of the registered diabetics in the Government noncommunicable disease clinics and treat 95% of those needing laser therapy. We also describe the importance of using electronic medical records in public health programs which not only increase the efficiency in screening for disease but help in increasing uptake of treatment by tracking defaulters., Competing Interests: None

Introduction: The carbohydrate 'fuel' metabolism in a pregnant woman may have a long-term impact on the development of her offspring ('fuel-mediated teratogenesis' hypothesis) including in utero exposure to maternal hyperglycaemia leading to fetal hyperinsulinaemia, and the consequent increase in fetal fat cells. Therefore, a feed-forward loop can exist of rising adiposity and hyperinsulinaemia throughout childhood, perhaps leading to obesity and diabetes in later life. There is a need for prospective examination of body fat distribution in children born to mothers with different glycaemic levels to understand the plausible association between glucose metabolism and future risk of diabetes in offspring. The hypothesis is that maternal glucose levels in pregnant women are related to skinfold thickness in their infants., Methods and Analysis: Hyperglycaemia in pregnancy and adiposity in infants is a multicentre cohort study to evaluate the effects of glucose levels in pregnancy on the risk of adverse infant outcomes, especially in predicting the risk of chronic diseases in infants. The study aims to recruit 1045 participants over a period of 1 year, who will be followed up irrespective of their glycaemia status for a period of 15 months, beginning in the 24th week of gestation. The glucose levels in pregnant women would be obtained through oral glucose tolerance testing. The primary outcome of our study was skinfold thickness in infants at the age of 6 weeks, 3rd and 9th month (as a proxy for fat distribution/adiposity)., Ethics and Dissemination: The institutional review board at The Indian Institute of Public Health (IIPH)-Hyderabad, Public Health Foundation of India has approved the protocol. All participants are required to provide written informed consent., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

This is a review of the manner in which the Revised National Tuberculosis Control Programme (RNTCP) is being implemented, with a focus on the attention being paid to ethical principles and the incorporation of these into the programme. The article elucidates how ethical principles can be applied to protect the rights of the potential beneficiaries of the RNTCP. The authors consider the RNTCP in the light of a framework that is usually applied in research to evaluate ethical principles in public health practice. The three key principles of the framework are: respect for persons, beneficence and justice. The authors propose that this framework be used to make an ethical evaluation of other pu health programmes at several levels, since this could bring far-reaching benefits to society.

Background: It is important to understand the perceptions of oncologists to understand the comprehensive picture of clinical presentation of breast cancer. In the absence of clear evidence, clinical practice involving patients of breast cancer in India should provide insights into stages of breast cancer with which women present to their clinics and mode of screening of breast cancer prevalent in Andhra Pradesh., Materials and Methods: A qualitative study was conducted to understand the perceptions of oncologists regarding clinical presentation of breast cancer, stages at which women present to clinics, and mode of screening of breast cancer prevalent in Andhra Pradesh. In-depth interviews (IDI) were conducted with ten practising oncologists from various public and private cancer hospitals in Hyderabad city to understand their perspectives on breast cancer and screening. The data were triangulated to draw inferences suitable for the current public Health scenario., Results: Late presentation was indicated as the most important cause of decreased survival among women. Most women present at Stage 3 and 4 when there is no opportunity for surgical intervention. The results indicate that there is a huge gap in awareness about breast cancer, especially in rural areas and among poor socioeconomic groups. Even despite knowledge, most women delay in reporting due to reasons like fear, embarrassment, cost, ignorance, negligence, and easy going attitude., Conclusions: It is important to improve awareness about breast cancer and screening methods for promoting early screening. The study inferred that it would be beneficial to establish cancer registries in rural areas. Also, the policymakers need to make key decisions which among three methods (breast self examination (BSE), clinical breast examination and mammography) can best be used as a screening tool and how to successfully implement population wide screening program to prevent mortality and morbidity from breast cancer in India.

W.H.O. defines Totally Drug-Resistant Tuberculosis (TDR-TB) as Tuberculosis caused due to a virulent strain of tuberculosis that seems to be resistant to all known treatments. In a recent correspondence, Zarir F. Udwadia and others described what they termed as "first patients from India with TDR tuberculosis". The processes and weakness ingrained in the vastness of Indian society and health system leading to drug resistance reveal multitude layers of weakness. This review aims at listing some of the important factors and levels responsible for the development of resistance in TB. The review identifies access issues, poor adherence to short-course chemotherapy, poor knowledge, practices and quality TB drugs in the private sector, resistance against some of second-line drugs prevalent in India and poor utilization of diagnostic services as the factors for causing TB resistance in India., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

There is still a paucity of research on the sociodemographic and other underlying factors associated with HIV transmission among women in India. This study was designed to investigate such factors in sexually experienced Indian women. We used data from the National Family Health Survey 3 (NFHS-3), which tested 52,853 women for HIV, including 27,556 husband and wife pairs. Significant risk factors for all women and married women only were: aged 26-35 years (adjusted odds ratios [AORs] = 3.65 and 2.53, respectively), being poor (AORs = 1.57 and 1.79), having had a genital sore in the last 12 months (AORs = 3.16 and 3.01) and having more than one sexual partner (AORs = 5.95 and 5.15). For husband and wife pairs, suffering sexual violence (AOR = 2.63), husband having other wife/wives (AOR = 3.40) and husband's education being secondary level or higher (AOR = 0.43) were significant. Intervention strategies in India should target young married (aged 25-35 years) and formerly married urban women who are poor, as well as those who have suffered sexual violence from their husbands, and/or are (or whose husbands are) multi-partnered. Empowerment of women is fundamental to HIV/AIDS prevention in India.

Background: Eye disease and visual impairment due to leprosy are not uncommon, but their prevalence and the risk factors for such pathology have yet to be fully characterized., Methods: An observational study of leprosy-affected individuals in the community, in three districts in Eastern India was performed to determine the prevalence of ocular morbidity and blindness. The subjects were chosen by stratified random sampling, according to stage of treatment, or stage of post-treatment surveillance. Each subject underwent ophthalmic examination according to a standard pro-forma., Results: Thirty-three out of 1137 (2.9%) subjects were blind according to the WHO classification, and 232/1137 (20.7%) had moderate visual impairment. The prevalence of blindness and visual impairment was greatest in one centre, Jhalda. Multivariate Logistic Regression analysis showed that longer duration of disease, more advanced treatment stage and older age were independently associated with blindness. One hundred and forty-one cases (28%) in Muzaffarpur, 95 cases (63%) in Saldoha and 378 cases (78%) in Jhalda had active or treated multibacillary leprosy., Discussion: The prevalence of blindness in leprosy varies in different population groups, with differing patterns of leprosy-related ocular morbidity, blindness and disease type evident even in different areas of the same region. Leprosy screening and surveillance programmes should include ocular examination as part of routine screening, particularly in individuals with a history of multi-bacillary disease. Individuals with known sight- threatening pathology should undergo continued active follow up. Local epidemiological studies would enable appropriate programme planning and efficient allocation of resources.