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Rural population-based estimates of airflow obstruction based on spirometry are unavailable from southern India. This study assessed the prevalence of spirometry-defined airflow obstruction in Vellore, Tamil Nadu.A cross sectional survey was done in nine villages, among adults aged ≥30 years, where previous cardiovascular surveys had been conducted (1994, 2011). Population proportional to size sampling was used to select 20 clusters, with sampling from all streets proportional to the number of households. One person randomly selected per household was interviewed for symptoms and risk factors. A respiratory therapist performed pre and post bronchodilator spirometry on all, following American Thoracic Society criteria. Airflow obstruction was defined as pre-bronchodilator Forced Expiratory Volume 1 s/Forced Vital Capacity (FEV1/FVC) Lower Limit of Normal (LLN, derived from local prediction equations) and compared to other criteria.Of 1015 participants, 787 completed technically acceptable spirometry. The prevalence of airflow obstruction was 9.0% (95% CI: 5.8%-9.6%, 71). Fixed obstruction (post bronchodilator FEV1/FVC LLN) was 4.6% (95% CI: 3.1%-6.1%, 36), and 4.1% (95% CI: 2.7%-5.5%, 32) using post bronchodilator FEV1/FVC 70%. The GOLD criteria missed 56% (40) of those with airflow obstruction, of which 87.5% were females. Although 63.4% with airflow obstruction had moderate to severe disease, 82.2% were not on treatment and only 48.9% reported symptoms in the previous year.This study estimates prevalence of airflow obstruction based on spirometry in rural southern India. Despite significant impairment on spirometry, majority were undiagnosed, and half did not report symptoms.

Lean diabetes is an entity that has been observed to be higher in Asian populations. The estimates of the burden of lean diabetes in India are mainly from hospital-based studies. This study reports the prevalence of lean diabetes among individuals with newly detected diabetes, from Vellore, Tamil Nadu, South India. A cross-sectional WHO STEPS survey was conducted among adults aged 30–64 years, in one rural block and 48 urban wards, in Vellore. Physical and anthropometric parameters were assessed in addition to fasting lipid profile and plasma glucose. Newly detected diabetes was defined as fasting plasma glucose ≥ 126 mg/dl and lean diabetes as non-ketotic diabetes mellitus, without clinical features to suggest pancreatic diabetes, with a body mass index (BMI)

Background: To reduce neonatal mortality in North Bihar, evidence is required about the impact of sick newborn care units (SNCUs) in secondary level hospitals on mortality at the end of the neonatal period. Objectives: The objective of the study is to assess the profile of neonates admitted to an SNCU and the outcome at the completion of neonatal period. Methods: A cohort of neonates admitted from March to June 2014 to an SNCU was assessed through family interviews and hospital records. Demographic details (age, sex, and socioeconomic status) and clinical details (antenatal care, birthplace, weight, diagnosis, and family history) were documented. Follow-up was done at discharge or death or referral and the completion of neonatal period. The primary outcome was survival at the completion of neonatal period. Secondary outcomes were case fatality rate at discharge and weight gain. Results: Of 210 neonates assessed, 87.6% (95% confidence interval [CI] 82.4–91.4) survived till the end of the neonatal period. The case fatality rate at the time of discharge was 0.9% (95% CI 0.3–3.4). Majority of the diagnoses were infections, hyperbilirubinemia, and infant of diabetic mother. Mean weight gain at the end of neonatal period (n = 157) was 706 g (P = 0.00). Sex ratio at admission was 567 girls to 1000 boys (95% CI 428/1000–751/1000). No neonate from lower socioeconomic families was admitted. Conclusions: SNCUs in remote areas can bring down neonatal mortality in North Bihar. Unequal access of SNCUs services to girls and lower socioeconomic groups highlighted the existing barriers which require attention.

Background: Malnutrition plays an important role in the economic burden of society as well as the country. This study aimed to identify the various risk factors and determinants of severe acute malnutrition (SAM) as defined by WHO growth reference standards in children aged 6 months to 59 months living in Vellore. Methods: A community-based case-control study matched for age (±2months), gender and location was done among the children of the age group 6- 59 months residing in both rural and urban Vellore. Children of age group 6-59 months with SAM according to WHO definition, i.e., weight for height of less than -3SD with or without nutritional oedema were classified as cases. Children with weight-for-height z-score more than -1 SD and MUAC ≥13.5cms were classified as controls. With 2 controls per case, the required sample size was 54 cases and 108 controls. A questionnaire used to identify the risk factors including dietary intake. Uni-variate and multivariate analysis was done to generate an odds ratio and 95% confidence interval for the risk factors. Results: Majority of the cases 64.8% and 50% of the controls belonged to low SES. After adjusting all confounders, Severe Acute Malnutrition was significantly associated with birth weight

Background The Achutha Menon Centre Diabetes Risk Score (AMCDRS), which was developed in rural Kerala State, South India, had not previously been externally validated. We examined the performance of the AMCDRS in urban and rural areas in the district of Vellore in the South Indian state of Tamil Nadu, and compared it with other diabetes risk scores developed from India. Methods We used the data from 4,896 participants (30 to 64 years) of a cross-sectional study conducted in Vellore (2010 to 2012), to calculate the AMCDRS scores using age, family history, and waist circumference. Sensitivity, specificity, positive predictive value (PPV), and negative predictive values (NPV), and the area under the receiver operating characteristic curve (AROC) were calculated for undiagnosed and total diabetes. Results Of the 4,896 individuals surveyed, 274 (5.6%) had undiagnosed diabetes and 759 (15.5%) had total diabetes. The AMCDRS, with an optimum cut-point of ≥4, identified 45.0% for further testing with 59.5% sensitivity, 60.5% specificity, 9.1% PPV, 95.8% NPV, and an AROC of 0.639 (95% confidence interval [CI], 0.608 to 0.670) for undiagnosed diabetes. The corresponding figures for total diabetes were 75.1%, 60.5%, 25.9%, 93.0%, and 0.731 (95% CI, 0.713 to 0.750), respectively. The AROC for the AMCDRS was not significantly different from that of the Indian Diabetes Risk Score, the Ramachandran or the Chaturvedi risk scores for total diabetes, but was significantly lower than the AROC of the Chaturvedi score for undiagnosed diabetes. Conclusion The AMCDRS is a simple diabetes risk score that can be used to screen for undiagnosed and total diabetes in low-resource primary care settings in India. However, it probably requires recalibration to improve its performance for undiagnosed diabetes.

Background: Early detection of breast and cervical cancer by organized screening has been found to reduce mortality rates in trials, but documentation of programme results and challenges is rarely done from non-trial settings. This study reports results of a population-based cancer control programme in a rural block in Vellore, Tamil Nadu, population size (116,085), targeting a population of 18,490 women aged 25–60 years, between November 2014 and March 2018. Methods: Village-based health education sessions were conducted by social workers, using trained volunteers and health workers to motivate eligible women. Screening was done at a secondary level hospital, by trained general physicians using visual inspection with acetic acid and clinical breast examination, followed by colposcopy, radiological imaging (breast) and biopsy as required. Results: A total of 8 volunteers and 17 health workers motivated women for 93 health education and screening sessions, in 46 out of 82 villages. While 1,890/18,490 (10.2 per cent) were screened for breast cancer, 1,783 (9.6 per cent) were screened for cervical cancer, with a yield of 3.4/1,000 for cervical pre-cancer/cancer. The main challenges were creating time for screening activities in a busy secondary hospital and difficulty in ensuring treatment completion of screen-detected cases. Conclusions: Population-based cancer screening programs can be offered by secondary hospitals that also run primary care services, to increase screening rates. Clear referral systems need to be established, bearing in mind that social factors, especially poor family support, may pose a threat to treatment, in spite of easy availability of cure.

To estimate the incidence of unintentional childhood injuries and to assess the impact of injury during childhood. This is a cross sectional study, conducted in 13 clusters of a rural block in Vellore. Children were screened by two-stage cluster sampling method by two weeks and three months recall method. The primary caregivers of injured children were administered a questionnaire to assess the impact of the injury. Childhood injury related morbidity was 292.5 per 1000 y. Children between 10 and 14 y (4.6%) and boys (4.5%) had a higher rate of injury. Fall (43.1 %) was the most common cause of injury followed by RTIs (Road Traffic Incidents- 27.6%). Work absenteeism for primary caregivers ranged from 1 to 60 (IQR 2–7) days. Sickness absenteeism ranged from 1 to 45 d with a mean of 7.64 (IQR 2–7) days. Half of the children missed school after an injury. The days spent with temporary disability ranged from 1 to 60 d with a mean of 11.79 (IQR 2–7) d and 7.73% had permanent disability. Unintentional childhood injury is a neglected public health problem which leads to sickness absenteeism and disability. Boys and older children are the most common victims of injury. There is a need for establishing state or nationwide injury registries to help understand accurate estimates of disability-adjusted life year (DALY) and loss of productivity.

Objective To study the prevalence and types of congenital anomalies that present at birth in a secondary-level hospital in South India and its contribution to perinatal mortality. Materials and methods A total of 36,074 births over 10 years, from 2003 to 2013, were studied for the prevalence of gross congenital malformations at birth. It was a descriptive, cross-sectional study using data from the birth register and available medical records. Results The incidence of birth defects was 12.5 per 1000 live births, with musculoskeletal disorders being the commonest, followed by craniovertebral anomalies. The prevalence of anomalies over the past 10 years has not shown any significant change (p= 0.555). Discussion The high prevalence of neural tube defects indicates the need for periconceptional folic acid supplementation and early detection of anomalies, which would help in timely management. Detection of musculoskeletal anomalies would help in counseling patients antenatally.

Background: Worldwide, hazardous use of alcohol is common among many cultures and societies and adversely impacts families and communities, with significant morbidity and mortality. Scheduled Tribes (STs) who are socially deprived and marginalised have higher rates of alcohol use. Aim: We attempted to determine the nature, prevalence, and risk factors associated with hazardous consumption of alcohol in the tribal community. Methodology: A cross-sectional study was conducted among adult male and permanent residents of Jawadhi hills. A total of 1200 men were interviewed. Study participants were chosen by Probability Proportionate to Size (PPS) sampling method. The questionnaire that documented socio-demographic characteristics and patterns of alcohol use was used. AUDIT tool was used to assess the hazardous use of Alcohol. Data were analysed using SPSS. Results: Majority of the men were middle-aged, married, and were from lower socio-economic strata. A large proportion of men (65%) had a history of alcohol consumption in the last one year using one-year, of whom a quarter showed hazardous use (29%) and another quarter exhibited alcohol dependency (24%). Tobacco use, higher income and local alcohol production were found to be significant risk factors for Hazardous alcohol use. Conclusion: Alcohol consumption needs to be treated as a social problem and has to be tackled at the policy level. Population-based interventions, legislation, taxation, policies regarding the manufacture and sale of alcohol, are some of the ways to address this problem.

Objectives Most World Health Organisation (WHO) STEPS surveys use cluster sampling to assess the prevalence of risk factors for non-communicable diseases (NCDs) for which design effects need to be estimated using intracluster correlation (ICCs) coefficients, for sample size calculation. Although there are many reports of risk factor surveys reported from developing countries, there are very few reports of ICCs for risk factors for NCDs, which can inform planning the appropriate sample size needed for such surveys. This study reports the ICCs for NCD risk factors, obtained from a WHO STEPS survey conducted in Vellore district, in the state of Tamil Nadu, South India. Study design Cross-sectional study. Methods A cross-sectional study was carried out in 48 urban clusters (wards) and nine rural clusters (villages) between 2011 and 2012, using the WHO STEPS methodology for assessing behavioural, anthropometric, physical and biochemical risk factors. The ICC estimates for various risk factors were obtained using loneway and xtmelogit commands using STATA to study clustering of risk factors. Results The number of respondents was 6196 adults aged 30–64 years. The median ICC of cardiovascular risk factors in the urban area was 0.046, while it was 0.064 in the rural area. Clustering was higher for behavioural risk factors such as physical activity (ICC: 0.179 rural, 0.049 urban) and fruit and vegetable intake (ICC: 0.105 rural, 0.091 urban) as compared with physical risk factors (ICCs for hypertension: 0.044 rural, 0.006 urban; body mass index: 0.046 rural, 0.041 urban) and biochemical outcomes such as fasting plasma glucose (ICC: 0.017 rural, 0.027 urban). Conclusions This study provides estimates of ICCs for cardiovascular risk factors from Vellore, South India, as such data have not been reported from WHO STEPS surveys in India or neighbouring countries. Such estimates of ICCs if reported from various WHO STEPS being carried out across the country can contribute to better planning of epidemiological surveys. Clustering of behavioural risk factors at village/ward level as seen in this study points to the need for community-based interventions for health promotion, as spatial clustering influences behaviour, which in turn affects chronic disease outcomes.

Background: As the burden of noncommunicable diseases (NCDs) has been rising globally, various educational programs have introduced chronic disease epidemiology teaching, which is now a component of most of the Master of Public Health (MPH) programs. However, the process of curriculum development for these courses has not been adequately documented for use by educators planning such courses. Methods: A detailed process of curriculum development based on David Kern's six-step approach was undertaken for a 2-week course on NCDs, as part of the MPH program of a tertiary institution in South India. The processes were documented so that the method of curriculum development for such a course could be made available for educators across this field. Results: The course on NCDs was carried out over 73 learning hours (2 weeks) for a group of MPH students including medical, dental, allied health, and nursing graduates. Evaluation of the revised curriculum at the end of the 2 weeks revealed that mean scores for knowledge and confidence in skills increased by 50% (11.1–16.6, t-test, P < 0.001) and 79% (3.3–5.9, t-test, P = 0.002), respectively, from baseline scores. Discussion: The revised curriculum was effective in improving knowledge and confidence in epidemiological skills. The documented process of curricular development using standard methods if made publicly available can be of use to those involved in planning similar educational programs for students of public health.

Parental perception of safe and risk-free environment is critical in the prevention of unintentional childhood injury. In this cross-sectional study, hundred mothers from 13 clusters were interviewed to assess the perception of mothers regarding the risks and hazards leading to unintentional childhood injuries from March to April 2013. A tool developed by Glik et al. was used. Mothers' perception of likelihood of injury from hazards such as household door and drawers, small toys, plastic bags, and cribs was poor. Mothers had a poor perception of injury by entrapment in refrigerators, choking, and strangulation by a rope. Age, education, and literacy (P < 0.05) were found to be significant predictors of perception of risk and hazard. Very few mothers (9%) believed injuries can be completely prevented and illiteracy (P < 0.05) was associated with poor perception on prevention. Health education should focus on improving maternal perception which may bring positive impact on prevention.

Background & objectives: Surveillance of risk factors is important to plan suitable control measures for non-communicable diseases (NCDs). The objective of this study was to assess the behavioural, physical and biochemical risk factors for NCDs in Vellore Corporation and Kaniyambadi, a rural block in Vellore district, Tamil Nadu, India. Methods: This cross-sectional study was carried out among 6196 adults aged 30-64 yr, with 3799 participants from rural and 2397 from urban areas. The World Health Organization-STEPS method was used to record behavioural risk factors, anthropometry, blood pressure, fasting blood glucose and lipid profile. Multiple logistic regression was used to assess associations between risk factors. Results: The proportion of tobacco users (current smoking or daily use of smokeless tobacco) was 23 per cent in the rural sample and 18 per cent in the urban, with rates of smoking being similar. Ever consumption of alcohol was 62 per cent among rural men and 42 per cent among urban men. Low physical activity was seen among 63 per cent of the urban and 43 per cent of the rural sample. Consumption of fruits and vegetables was equally poor in both. In the urban sample, 54 per cent were overweight, 29 per cent had hypertension and 24 per cent diabetes as compared to 31, 17 and 11 per cent, respectively, in the rural sample. Physical inactivity was associated with hypertension, body mass index (BMI) ≥25 kg/m[2], central obesity and dyslipidaemia after adjusting for other factors. Increasing age, male sex, BMI ≥25 kg/m[2] and central obesity were independently associated with both hypertension and diabetes. Interpretation & conclusions: Diabetes, hypertension, dyslipidaemia, physical inactivity and overweight were higher in the urban area as compared to the rural area which had higher rates of smokeless tobacco use and alcohol consumption. Smoking and inadequate consumption of fruits and vegetables were equally prevalent in both the urban and rural samples. There is an urgent need to address behavioural risk factors such as smoking, alcohol consumption, physical inactivity and inadequate intake of fruits and vegetables through primary prevention.

Background: With a high prevalence of diabetes in India, there is a need to study the impact of this disease on the quality of life (QoL) of the patients. Materials and Methods: This facility-based cross-sectional study assessed the QoL of patients attending the diabetic clinic using the World Health Organization (WHO) QoL BREF instrument in Tamil Nadu. The QoL was analyzed domain-wise and various socio-demographic factors affecting the QoL were studied. Results: The mean total score of the QoL scale was 58.05 (95% CI, 22.18–93.88). Domain-wise, 63% had good physical, 69% had good psychological, 27% had good social and 85% had good environmental QoL scores. Males, currently married and those with BMI more than 25 had a statistically significantly better QoL compared to their counterparts. Conclusions: Diabetes does impair the QoL of patients but not to a great extent. There is a need to specifically target and improve the QoL of women, widowed and separated, and non-obese diabetics who are at risk of a poor QoL. QoL assessment should be routinely practiced in diabetic clinics.

Objective: To determine the relationship between birth weight and the evolution of obesity in adult life in women from a rural developmental block in southern India. Design: Non-concurrent cohort Setting: General community- a rural developmental block in southern India. Participants: Two hundred and seventy one young healthy females were recruited from a birth cohort. The study subjects were 98 women in the age group of 19-23 years who had been born with low birth weight (LBW) and 173 women in the same age group who had been born with normal birth weight (NBW). Materials and Methods: Data collection involved interview using a structured questionnaire and anthropometric measurements. Analysis: Chi-square test to assess significance of association, independent sample t test to assess the difference between means, odds ratios for measuring magnitude of association, stratified analysis to identify various interactions and confounders, and multiple logistic regression models to identify the relationship between birth weight and young adult obesity (BMI > 25). Results: A crude odds ratio of 0.564 (95% CI 0.262 - 1.214) was obtained for the association between LBW and development of obesity later in life. In the final logistic regression model, it was found that a young adult female with low birth weight who belonged to a higher socio-economic group had a higher risk of developing obesity (Adjusted odds for the interaction term between LBW and high SES 6.251; 95% CI 1.236 - 31.611). Conclusion: The study could not find any significant association between LBW and development of obesity later in life, but it found a higher probability of developing obesity later in life among low birth weight female children born in high socio-economic status families.

Background The Revised National Tuberculosis Control Program (RNTCP) envisages shifting from thrice-weekly to a daily anti-tuberculosis treatment (ATT) regimen. The potential merits and demerits of both regimens continue to be debated. Methods This retrospective study compared treatment outcomes in 191 HIV-negative, newly diagnosed, sputum-positive adults with pulmonary tuberculosis from Vellore district of Tamil Nadu who were treated at a private medical college during 2009 to 2012 with intermittent Directly Observed Treatment Short Course (intermittent DOTS cohort, n = 132) or who opted for daily Self-Administered Treatment (daily SAT cohort, n = 59). Treatment outcomes obtained from medical records were supplemented by interviews with consenting, traceable patients. Results The rates for the RNTCP-recommended sputum smear examinations were suboptimal (42% for daily SAT and 72% for intermittent DOTS). However, treatment success with daily SAT and intermittent DOTS (76.2% vs. 70.4%); default (11.9% vs. 18.2%); death (6.8% vs. 5.3%); treatment failure (5.1% vs. 4.6%); and relapse (0% vs. 1.5%) did not significantly differ. Conclusions While evaluable treatment outcomes were not significantly different with daily SAT and intermittent DOTS, rates for timely smear examinations and for treatment success were lower, and for default higher, in both cohorts than comparable RNTCP data from Vellore district. Further strengthening of RNTCP facilities within private medical colleges and regular, real-time audits of performance and outcomes are needed if daily ATT regimen under the RNTCP is to succeed.

Background Rabies is a 100% fatal disease but preventable with vaccines and immunoglobulins. We have developed a new purified vero cell rabies vaccine (Rabivax-S) and evaluated its safety and immunogenicity in post-exposure prophylaxis by intramuscular (IM) and intradermal (ID) routes. Methods This was a randomized active-controlled non-inferiority study in 180 individuals (age 5 years and above) with suspected rabies exposure (90 each with WHO Category II and Category III exposures). The participants received either Rabivax-S (1 mL IM; five doses), Rabivax-S (0.1 mL ID; eight doses) or purified chick embryo cell vaccine (PCEC, Rabipur®) (1 mL IM; five doses). The IM doses were given on Day 0, 3, 7, 14 and 28 while the ID doses were given on days 0, 3, 7 and 28. Category III patients also received a human rabies immunoglobulin (HRIG) on Day 0. Adverse events (AEs) were recorded with diary cards till day 42. Rabies neutralizing antibody levels were measured on day 0, 7, 14, 28 and 42. Results In both the category II and III patients, the geometric mean concentration (GMC) ratios of Rabivax-S IM and Rabivax-S ID groups to PCEC IM were more than 1, thus proving the non-inferiority. GMCs were similar or higher in Rabivax-S groups at all the time points. Seroresponse against rabies (RFFIT titre ⩾ 0.5 IU/mL) was achieved in all participants. Mostly mild local and systemic adverse events were reported across the three groups and all resolved without sequelae. Conclusions Rabivax-S was well tolerated and showed immunogenicity comparable to a licensed rabies vaccine by both IM and ID routes in post-exposure prophylaxis. Registry No.: CTRI/2012/11/003135

Background and Objectives: Physical inactivity is an important cardiovascular risk factor. This study assessed the prevalence and factors associated with insufficient physical activity (PA) in urban and rural Vellore, Tamil Nadu, India, among adults aged 30–64 years. Methodology: A cross-sectional World Health Organization STEPS survey was carried out in 48 wards of Vellore Municipality and nine rural villages of Tamil Nadu in 2010–2012. Adults (n = 6164, men 43.9%) aged 30–64 years were interviewed using the Global PA Questionnaire (2390 urban and 3774 rural). Insufficient PA was defined as not meeting the recommendation of 150 min of moderate aerobic PA, or 75 min of vigorous aerobic PA, or an equivalent combination, achieving at least 600 metabolic equivalent-minutes per day. Results: The prevalence of insufficient PA was 63.3% (95% confidence interval [CI]: 61.3%–65.3%) in the urban area and 40.6% (95% CI: 39.0%–42.2%) in the rural area. Women had a higher prevalence of insufficient PA compared to men, in both urban (70.8% vs. 53.8%) and rural (44.5% vs. 35.6%) areas. Those with higher education (odds ratio [OR]: 1.36, 95% CI: 1.20–1.53) and who were unemployed (OR: 2.97, 95% CI: 2.59–3.39) reported insufficient PA which was significantly higher than their counterparts. While urban participants had higher leisure time PA, rural participants had higher work- and travel-related PA. Conclusions: The high prevalence of insufficient PA found in this study shows that targeted interventions are needed to reduce insufficient PA, especially for women and urban populations.

Background: Over the last decade many programmes have been implemented to improve the health of pregnant women and neonates. This study aims to look at the changes in modes of delivery and perinatal mortality rates in a rural block of Tamil Nadu between 2006 and 2015.Methods: Data on all the births that have occurred in this rural block of Tamil Nadu that has been prospectively collected between 2006 and 2015 was analysed. A longitudinal analysis was done to calculate the primary and overall caesarean section rate and the average annual rate of increase. The perinatal mortality rate was also calculated.Results: The primary LSCS rate has increased from 9.08% in 2005 to 16.1% in 2015. The overall caesarean section rate has increased from 11.7% to 19.2% in the same time with an average annual rate of increase of 5.1%. During this period the perinatal mortality has decreased from 33 per 1000 live births to 17 per 1000 live births.Conclusions: Though the overall caesarean section rate is higher than the 15% prescribed by WHO the rates are lower than the rest of the country and rural Tamil Nadu.

Background: Population based estimates from India on the prevalence of Peripheral Artery Disease (PAD) are scarce. This study aimed to assess the population-based prevalence of PAD in rural and urban Vellore, Tamil Nadu, South India.Methods: A cross sectional survey was conducted using the WHO STEPS methodology and the WHO/Rose questionnaire for intermittent claudication for identifying symptomatic PAD among adults aged 30-64 years. The study was done in nine villages of one rural block and in 48 urban wards of Vellore, between 2011-12. Risk factors for PAD such as sociodemographic factors, tobacco use, anthropometry, known medical conditions, Fasting Plasma Glucose and lipid profile were also assessed and association with PAD estimated using odds ratios, chi-square tests and logistic regression.Results: Among 5429 adults aged 30-64 years, the prevalence of PAD (intermittent claudication) was 4.9/1000 (95% Confidence Interval CI: 3.0/1000 - 6.8/1000). The prevalence in urban Vellore was higher than in the rural area (6.9/1000 vs. 3.8/1000). After adjusting for sociodemographic factors and other confounding factors, current tobacco use was found to be significantly associated with the presence of PAD (adjusted Odds Ratio: 2.89, 95% CI: 1.10-7.54).Conclusions: This study provides estimates of the burden of PAD in rural and urban adults in Vellore, Tamil Nadu. The trend of this condition needs to be monitored in various locations to assess the public health significance and the need for population level measures for diagnosis, treatment and screening. Education regarding harmful effects of tobacco use should also involve education regarding risk of PAD.

We present the results of two surveys of measles outbreaks near Vellore, which perhaps supports the cause for introduction of a second dose of measles vaccine. Survey one had 590 under 10-year olds. The attack rate was 15.1, 11.7 and 5.7% in the unimmunized, among those vaccinated at 6 months and at 9 months, respectively. The overall vaccine efficacy (VE) was 28% if vaccinated at 6 months and 66% if at 9 months. Second survey had 1702 children and adolescents. There were 59 cases of measles of which 49 were over 5 years of age, the mean age being 8.8 years. The VE was 66% for children up to 6 years and 48.4% for those aged 7-15. The data suggests that measles vaccine is better given at 9 months. The low VE in school age children could be improved by introducing a second dose of measles vaccine.

Alcohol use is common in many cultures. Excessive use of alcohol adversely impacts individuals, families and communities. Medicine, which uses biomedical models and perspectives, views alcohol dependence as a disease. Alcohol use and dependence are complex societal problems, which need to be viewed through multidisciplinary approaches and corrected by adopting intersectoral efforts involving local communities.We used qualitative methods such as focus group discussions and in-depth interviews to document perspectives on alcohol use among a tribal community in southern India. We recorded traditional norms, changing patterns of use of alcohol and its consequences for individuals, families and the community.Eight focus group discussions and eleven in-depth interviews were conducted. Though consumption of alcohol is part of the local culture, changes in occupation and availability of alcohol has made its consumption a problem. The introduction and easy availability of Indian-made foreign liquor, which is stronger than the locally brewed variety, in government-run outlets has changed the culture of drinking at festivals to drinking more often. This leads to public fights, domestic violence and increasing mortality and morbidity due to road traffic incidents and ill health. The age of initiation into drinking has decreased.The introduction of non-traditional and commercial alcohol use has put a heavy price on tribal and rural people. Community-based interventions targeting young children and adolescents may pay more dividends than pursuing purely medical treatments for problem drinkers.

Introduction Perinatal mortality rate has been regarded as an indicator of the quality of prenatal, obstetric and neonatal care in an area, which also reflects the maternal health and socioeconomic environment. The objective of the current study was to identify causes and risk factors for perinatal deaths among the tribal population in Jawadhi Hills, Tamil Nadu, southern India. Methods A community-based case control study design was used, where a case was a perinatal death and controls were from a sampling frame of all children who were born alive in the same area ±7 days from the day of birth of the case. The WHO Standard International Verbal Autopsy form was used to arrive at the cause of death. Univariate and multivariate analyses for factors associated with perinatal deaths were done. Results A total of 40 cases, including 22 early neonatal deaths and 18 stillbirths, and 110 controls were included in the study. Among the perinatal deaths, 40% were born prematurely. Sepsis (17.5%) and birth asphyxias (12.5%) were the major causes of deaths. In the final logistic regression model, parity ≥4 (odds ratio [OR] 5.75 [95% confidence interval (CI) 1.88-17.54]), preterm births (OR 5.62 [95% CI 2.12-16.68]) and time to reach the nearest health facility more than two hours (OR 2.51 [95% CI 1.086.73]) were significantly associated with the perinatal deaths. Conclusions Prematurity, poor accessibility and a high parity were significantly associated with perinatal deaths in the tribal population of Jawadhi Hills.

Melioidosis is increasingly being reported from India in the past few years. Since it can mimic tuberculosis during the initial presentation, treatment with antituberculosis drugs is common. It should be considered in the differential diagnosis of any pyrexia of unknown origin. We report two cases of melioidosis that presented with pyrexia of unknown origin and a localized cutaneous abscess over the chest wall.

Background Spinocerebellar ataxia type 1 (SCA1) is a late onset autosomal dominant cerebellar ataxia, caused by CAG triplet repeat expansion in the ATXN1 gene. The frequency of SCA1 occurrence is more in Southern India than in other regions as observed from hospital-based studies. However there are no reports on variability of CAG repeat expansion, phenotype-genotype association and founder mutations in a homogenous population from India. Methods Genomic DNA isolated from buccal mouthwash of the individuals in the cohort was used for PCR-based diagnosis of SCA1. Subsequently SNP’s found within the ATXN1 loci were identified by Taqman allelic discrimination assays. Significance testing of the genotype-phenotype associations was calculated by Kruskal-Wallis ANOVA test with post-hoc Dunnett’s test and Pearson’s correlation coefficient. Results By genetic analysis of an affected population in Southern India we identified 21 pre-symptomatic individuals including four that were well past the average age of disease onset of 44 years, 16 symptomatic and 63 normal individuals. All pre-symptomatic cases harbor “pure” expansions of greater than 40 CAGs. Genotyping to test for the presence of two previously identified SNPs showed a founder effect of the same repeat carrying allele as in the general Indian population. We show that SCA1 disease onset is significantly delayed when transmission of the disease is maternal. Conclusions Our finding of early disease onset in individuals with a paternally inherited allele could serve as valuable information for clinicians towards early detection of SCA1 in patients with affected fathers. Identification of older pre-symptomatic individuals (n = 4) in our cohort among individuals with a shared genetic and environmental background, suggests that second site genetic or epigenetic modifiers might significantly affect SCA1 disease progression. Moreover, such undetected SCA1 cases could underscore the true prevalence of SCA1 in India.

Education in ethics is now a formal part of the undergraduate medical curriculum. However, most courses are structured around principles and case studies more appropriate to western countries. The cultures and practices of countries like India differ from those of western countries. It is, therefore, essential that our teaching should address the issues which are the most relevant to our setting. An anonymised, questionnaire-based, cross-sectional survey of medical students was carried out to get a picture of the ethical problems faced by students in India. The data were categorised into issues related to professional behaviour and ethical dilemmas. Unprofessional behaviour was among the issues reported as a matter of concern by a majority of the medical students. The survey highlights the need to design the curriculum in a way that reflects the structure of medical education in India, where patients are not always considered socio-culturally equal by students or the medical staff. This perspective must underpin any further efforts to address education in ethics in India.

OBJECTIVE To measure the protective effect of measles vaccine administered before 9 months of age and compare overall mortality of children vaccinated at 6-8 months and at 9-11 months. METHOD Non-concurrent cohort study involving all 13 134 children born between 16 January 1986 and 31st December 1991 in Kaniyambadi block near Vellore who had not left the area by six months of age. Main outcome measures were risk of disease and death among the under-five-year-olds according to age at measles immunization. RESULTS Unimmunized children had a higher risk of developing measles compared to the immunized (P < 0.05). There was no significant difference in risk of measles among those vaccinated prior to and after nine months of age. Unvaccinated children were at significantly higher risk of death than vaccinated children (P < 0.001). There was no difference in risk of death between infants vaccinated between 6 and 8 months and those vaccinated between 9 and 11 months. There was no difference in the risk of death between boys and girls vaccinated between 6 and 8 months with standard-titre Edmonston-Zagreb vaccine. CONCLUSION Administration of standard-titre Edmonston-Zagreb measles vaccine at 6-8 months is an effective and safe preventive measure for measles, especially where the age-specific attack rate for children < 9 months is high.

Objectives To estimate the prevalence, spatial patterns and clustering in the distribution of soil-transmitted helminth (STH) infections, and factors associated with hookworm infections in a tribal population in Tamil Nadu, India. Methods Cross-sectional study with one-stage cluster sampling of 22 clusters. Demographic and risk factor data and stool samples for microscopic ova/cysts examination were collected from 1237 participants. Geographical information systems mapping assessed spatial patterns of infection. Results The overall prevalence of STH was 39% (95% CI 36%–42%), with hookworm 38% (95% CI 35–41%) and Ascaris lumbricoides 1.5% (95% CI 0.8–2.2%). No Trichuris trichiura infection was detected. People involved in farming had higher odds of hookworm infection (1.68, 95% CI 1.31–2.17, P

This study compares the persistence of measles IgG antibody in 239 children vaccinated at 6–8 months of age with 76 children vaccinated after 8 months of age. Among the children vaccinated prior to 9 months 49 per cent of the children between 16 and 44 months and 33 per cent of children over 54 months had levels of measles IgG antibody conventionally considered protective. Among the children older than 48 months 67 per cent of children vaccinated before 9 months and 13 per cent of children vaccinated after 8 months had antibody levels below the conventionally accepted protective levels of 0.2 IU/ml. Older children had lower antibody levels than younger children. Measles immunization before 9 months with the standard titer Edmonston–Zagreb vaccine has not provided a large proportion of under-five children with protective levels of measles IgG antibody. A significant proportion of children vaccinated at the currently recommended age also had suboptimal levels. It is difficult to protect the majority of the measles-susceptible population with a single dose regardless of the immunization schedule used. A second dose of measles vaccine may be necessary to increase the herd immunity. (authors)

Background Unintentional childhood injury is a major cause of mortality and morbidity among children (upto 18 years) across the globe and contributes to over 875,000 deaths annually worldwide. Global Childhood Unintentional Injury Surveillance estimates that nearly 50% of children under 12 years suffered severe unintentional injuries leading to some form of disability. Unintentional childhood injury is an under-reported public health problem in India. This study was undertaken to estimate the incidence and assess economic impact and medical consequences of unintentional childhood injuries among children between 0–14 years. Methods This is a non-concurrent cohort study, conducted in 13 clusters of a rural block in Vellore. Double stage cluster sampling method was used to screen 1600 children with injury. Information regarding the impact and consequences of injury was obtained. Results Childhood injury related morbidity was 292.5/1000/year. Children between 10–14 years (4.6%) and boys (4.5%) had a higher rate of injury. Majority of injuries occurred at home (44.8%) and most commonly on the lower extremity (51.7%). Falls (43.1%) was the most common cause of injury followed by RTIs (27.6%). The direct medical and non medical cost of treatment ranged from $US0.14 to $US74. The wages lost by the primary caregiver ranged from $US1.4 to $US90 and absenteeism from work ranged from 1–60 days. Sick absenteeism ranged from 0–45 days with a mean of 5.17 days. 50% of children missed school after an injury. The days spent with temporary disability ranged from 1–60 days with a mean of 4.08 days and 7.73% had permanent disability. Conclusion Unintentional childhood injuries is an emerging public health problem which leads to significant injury related sickness absenteeism and disability. Boys and older children are the most common victims of injury. Prospective trials on the economic impact and medical consequences will help to gain a clear understanding of DALY and loss of productivity.

Background Parental perception of safe and risk-free environment is critical in the prevention of unintentional childhood injury. An accurate perception of risky situations is essential to minimise the rate of childhood injuries. Knowledge on parental perception in rural India will be helpful in planning preventive strategies. This study was conducted to assess parental perception on risks and hazards leading to unintentional childhood injuries. Methods A cross sectional study was conducted in 13 clusters of a rural block in South India. Double stage cluster sampling method was used to recruit 100 mothers and they were interviewed using a tool developed by Glik and Kronenfeld. Two FGDs were also conducted. Results Mothers’ perception of likelihood of injury from hazards such as household door and drawers, small toys, plastic bags and cribs was poor. These objects were also perceived as less dangerous hazards. Mothers had a poor perception of injury by entrapment in refrigerators, choking and strangulation by a rope or a cord. Choking bruises, puncture wounds were perceived as less serious events. Age, education and literacy were found to be significant predictors of perception of risk and hazard in univariate analysis, the logistic regression model did not show any significant associated factors for perception of risk and hazard. 9% of mothers believed injuries can be completely prevented and illiteracy (p = 0.04) was associated with poor perception on prevention in univariate analysis. Few mothers in FGD believed that injuries cannot be prevented as it is natural ( Vidhi ) for children to sustain injuries. Conclusions It is a fact that the mother’s literacy and schooling is closely related to child health and survival. Promotion of injury preventive engineering strategies and enforcement will only be effective when the literacy of the mother increases. Health education can improve maternal perception and have a positive impact on prevention of unintentional injuries.