Search

India has the highest burden of Tuberculosis (TB) and multidrug-resistant TB (MDR-TB) worldwide. Innovative technology is the need of the hour to identify these cases that remain either undiagnosed or inadequately diagnosed due to the unavailability of appropriate tools at primary healthcare settings. We developed and evaluated 3 kits, namely ‘TB Detect’ (containing BioFM-Filter device), ‘TB Concentration and Transport’ (containing Trans-Filter device) and ‘TB DNA Extraction’ kits. These kits enable bio-safe equipment-free concentration of sputum on filters and improved fluorescence microscopy at primary healthcare centres, ambient temperature transport of dried inactivated sputum filters to central laboratories and molecular detection of drug resistance by PCR and DNA sequencing (Mol-DST). In a 2-site evaluation (n = 1190 sputum specimens) on presumptive TB patients, BioFM-Filter smear exhibited a significant increase in positivity of 7% and 4% over ZN smear and LED-FM smear (p<0.05), respectively and an increment in smear grade status (1+ or 2+ to 3+) of 16% over ZN smear and 20% over LED-FM smear. The sensitivity of Mol-DST in presumptive MDR-TB and XDR-TB cases (n = 148) was 90% for Rifampicin (95% confidence interval [CI], 78–96%), 84% for Isoniazid (95% CI, 72–92%), 83% for Fluoroquinolones (95% CI, 66–93%) and 75% for Aminoglycosides (95% CI, 35–97%), using phenotypic DST as the reference standard. Test specificity was 88–93% and concordance was ~89–92% (κ value 0.8–0.9). The patient-friendly kits described here address several of the existing challenges and are designed to provide ‘Universal Access’ to rapid TB diagnosis, including drug-resistant disease. Their utility was demonstrated by application to sputum at 2 sites in India. Our findings pave the way for larger studies in different point-of-care settings, including high-density urban areas and remote geographical locations. [ABSTRACT FROM AUTHOR]

The changing population age structure has a significant influence on the economy, society, and numerous other aspects of a country. This paper has innovatively applied the method of compositional data forecasting for the prediction of population age changes of the young (aged 0–14), the middle-aged (aged 15–64), and the elderly (aged older than 65) in China, India, and Vietnam by 2030 based on data from 1960 to 2016. To select the best-suited forecasting model, an array of data transformation approaches and forecasting models have been extensively employed, and a large number of comparisons have been made between the aforementioned methods. The best-suited model for each country is identified considering the root mean squared error and mean absolute percent error values from the compositional data. As noted in this study, first and foremost, it is predicted that by the year 2030, China will witness the disappearance of population dividend and get mired in an aging problem far more severe than that of India or Vietnam. Second, Vietnam’s trend of change in population age structure resembles that of China, but the country will sustain its good health as a whole. Finally, the working population of India demonstrates a strong rising trend, indicating that the age structure of the Indian population still remains relatively “young”. Meanwhile, the continuous rise in the proportion of elderly population and the gradual leveling off growth of the young population have nevertheless become serious problems in the world. The present paper attempts to offer crucial insights into the Asian population size, labor market and urbanization, and, moreover, provides suggestions for a sustainable global demographic development. [ABSTRACT FROM AUTHOR]

The gut microbial community structure of adult Thrips tabaci collected from 10 different agro-climatically diverse locations of India was characterized by using the Illumina MiSeq platform to amplify the V3 region of the 16S rRNA gene of bacteria present in the sampled insects. Analyses were performed to study the bacterial communities associated with Thrips tabaci in India. The complete bacterial metagenome of T. tabaci was comprised of 1662 OTUs of which 62.25% belong to known and 37.7% of unidentified/unknown bacteria. These OTUs constituted 21 bacterial phyla of 276 identified genera. Phylum Proteobacteria was predominant, followed by Actinobacteria, Firmicutes, Bacteroidetes and Cyanobacteria. Additionally, the occurrence of the reproductive endosymbiont, Wolbachia was detected at two locations (0.56%) of the total known OTUs. There is high variation in diversity and species richness among the different locations. Alpha-diversity metrics indicated the higher gut bacterial diversity at Bangalore and lowest at Rahuri whereas higher bacterial species richness at T. tabaci samples from Imphal and lowest at Jhalawar. Beta diversity analyses comparing bacterial communities between the samples showed distinct differences in bacterial community composition of T. tabaci samples from different locations. This paper also constitutes the first record of detailed bacterial communities associated with T. tabaci. The location-wise variation in microbial metagenome profile of T. tabaci suggests that bacterial diversity might be governed by its population genetic structure, environment and habitat. [ABSTRACT FROM AUTHOR]

Background: A new contraceptive microarray patch (MAP) for women is in development. Input on this method from potential end-users early in the product development process is important to guide design decisions. This paper presents the qualitative component of a broader study exploring initial acceptability of the MAP and selected product features. The qualitative research was intended to identify product features that are most salient to end-users and to contextualize preferences around them with subsequent research planned to assess quantitatively the relative importance of those features. Methods: We conducted 16 focus group discussions and 20 in-depth interviews with women and 20 IDIs with family planning providers in New Delhi, India, and Ibadan, Nigeria. Input from the MAP developer served to identify plausible features of the MAP to include in the focus group discussions and in-depth interviews. Interviews were audio-recorded, transcribed into English, coded, and analyzed to examine key dimensions of MAP features. Results: Many participants viewed the MAP as potentially easy to use. Interest in self-application after learning correct use was high, especially in India. Participants favored formulations affording protection from pregnancy for three or six months, if not longer. Interest in a shorter-acting MAP was particularly low in Nigeria. Non-desirable MAP features included a potential localized skin rash and pain at application. Views on patch size and location of application were related to the potential for rash and pain, with a desire to permit discreet use and minimize pain. Results indicate that the side effect profile, effectiveness, and pricing are also important factors for acceptability and uptake of a future product. Conclusion: Study findings indicate that a contraceptive MAP is of potential interest to women and that specific MAP attributes will be important to acceptability. [ABSTRACT FROM AUTHOR]

Background: Asymptomatic Leishmania donovani infections outnumber clinical presentations, however the predictors for development of active disease are not well known. We aimed to identify serological, immunological and genetic markers for progression from L. donovani infection to clinical Visceral Leishmaniasis (VL). Methods: We enrolled all residents >2 years of age in 27 VL endemic villages in Bihar (India). Blood samples collected on filter paper on two occasions 6–12 months apart, were tested for antibodies against L. donovani with rK39-ELISA and DAT. Sero converters, (negative for both tests in the first round but positive on either of the two during the second round) and controls (negative on both tests on both occasions) were followed for three years. At the start of follow-up venous blood was collected for the following tests: DAT, rK39- ELISA, Quantiferon assay, SNP/HLA genotyping and L.donovani specific quantitative PCR. Results: Among 1,606 subjects enrolled,17 (8/476 seroconverters and 9/1,130 controls) developed VL (OR 3.1; 95% CI 1.1–8.3). High DAT and rK39 ELISA antibody titers as well as positive qPCR were strongly and significantly associated with progression from seroconversion to VL with odds ratios of 19.1, 30.3 and 20.9 respectively. Most VL cases arose early (median 5 months) during follow-up. Conclusion: We confirmed the strong association between high DAT and/or rK39 titers and progression to disease among asymptomatic subjects and identified qPCR as an additional predictor. Low predictive values do not warrant prophylactic treatment but as most progressed to VL early during follow-up, careful oberservation of these subjects for at least 6 months is indicated. [ABSTRACT FROM AUTHOR]

This paper explores the social inclusiveness of agricultural extension services in India. We estimate the probability and frequency of farmers’ access to extension services and resulting changes in crop income across different caste groups. The literature suggests that caste-based social segregation manifests in various spheres of life, and perpetuates economic inequality and oppression. An econometric analysis of nationally-representative data from rural India verifies this with respect to the agricultural sector. Farmers belonging to the socially-marginalized castes are found to have a lower chance of accessing the public extension services, primarily due to their inferior resource-endowment status. Contacting extension agents at least once increased the average annual crop income by about 12 thousand Indian rupees per household, which is equivalent to 36% of the annual crop income of those without access to extension services. There exists significant impact heterogeneity. Farmers from the socially-marginalized castes hardly benefited from accessing the extension services. Based on these observations, we have developed a number of policy recommendations that could improve the social inclusiveness of agricultural development strategies in rural India. [ABSTRACT FROM AUTHOR]

Poverty affects many people, but the ramifications and impacts affect all aspects of society. Information about the incidence of poverty is therefore an important parameter of the population for policy analysis and decision making. In order to provide specific, targeted solutions when addressing poverty disadvantage small area statistics are needed. Surveys are typically designed and planned to produce reliable estimates of population characteristics of interest mainly at higher geographic area such as national and state level. Sample sizes are usually not large enough to provide reliable estimates for disaggregated analysis. In many instances estimates are required for areas of the population for which the survey providing the data was unplanned. Then, for areas with small sample sizes, direct survey estimation of population characteristics based only on the data available from the particular area tends to be unreliable. This paper describes an application of small area estimation (SAE) approach to improve the precision of estimates of poverty incidence at district level in the State of Bihar in India by linking data from the Household Consumer Expenditure Survey 2011–12 of NSSO and the Population Census 2011. The results show that the district level estimates generated by SAE method are more precise and representative. In contrast, the direct survey estimates based on survey data alone are less stable. [ABSTRACT FROM AUTHOR]

Background: Migrant labourers living in the slums of urban and industrial patches across India make up a key sub-population so far controlling Tuberculosis (TB) in the country is concerned. This is because many TB patients from these communities- remain under reached by the Revised National Tuberculosis Control Programme (RNTCP) of India. This marginalized community usually seeks early-stage healthcare from “friendly neighbourhood” non-formal health providers (NFHPs). Because, RNTCP has limited capacity to involve the NFHPs, an implementation research project was conceived, whereby an external partner would engage with the NFHPs to enable them to identify early TB symptomatics from this key sub-population who would be then tested using Xpert MTB/RIF technology. Diagnosed TB cases among them would be referred promptly to RNTCP for treatment. This paper aimed to describe the project and its impact. Methods: Adopting a quasi-experimental before-after design, four RNTCP units from two major urban-industrial areas of Odisha were selected for intervention, which spanned five quarters and covered 151,400 people, of which 30% were slum-dwelling migrants. Two similar units comprised the control population. The hypothesis was, reaching the under reached in the intervention area through NFHPs would increase TB notification from these traditionally under-notifying units. RNTCP notification data during intervention was compared with pre-intervention era, adjusted for contemporaneous changes in control population Results: The project detected 488 Xpert+ TB cases, of whom 466 were administered RNTCP treatment. This translated into notification of additional 198 new bacteriologically positive cases to RNTCP, a 30% notification surge, after adjustment for 2% decline in control. This meant an average quarterly increase in notification of 41.20(20.08, 62.31; p<0.001) cases. The increase was immediate, evident from the rise in level in the time series analysis by 50.42(10.28, 90.55; p = 0.02) cases. Conclusion: Engagement with NFHPs contributed to an increase in TB notification to RNTCP from key under reached, slum-dwelling migrant populations. [ABSTRACT FROM AUTHOR]

In this paper, we model the bus networks of six major Indian cities as graphs in L-space, and evaluate their various statistical properties. While airline and railway networks have been extensively studied, a comprehensive study on the structure and growth of bus networks is lacking. In India, where bus transport plays an important role in day-to-day commutation, it is of significant interest to analyze its topological structure and answer basic questions on its evolution, growth, robustness and resiliency. Although the common feature of small-world property is observed, our analysis reveals a wide spectrum of network topologies arising due to significant variation in the degree-distribution patterns in the networks. We also observe that these networks although, robust and resilient to random attacks are particularly degree-sensitive. Unlike real-world networks, such as Internet, WWW and airline, that are virtual, bus networks are physically constrained. Our findings therefore, throw light on the evolution of such geographically and constrained networks that will help us in designing more efficient bus networks in the future. [ABSTRACT FROM AUTHOR]

Out-of-pocket spending at out-patient departments (OPD) by households is relatively less analyzed compared to hospitalization expenses in India. This paper provides new evidence on the levels and drivers of expenditure on out-patient care, as well as choice of providers, using household survey data from 8 districts in 3 states of India. Results indicate that the economically vulnerable spend more on OPD as a proportion of per capita consumption expenditure, out-patient care remains overwhelmingly private and switches of providers—while not very prevalent—is mostly towards private providers. A key result is that choice of public providers tend to lower OPD spending significantly. It indicates that an improvement in the overall quality and accessibility of government facilities still remain an important tool that should be considered in the context of financial protection. [ABSTRACT FROM AUTHOR]

In the present study, antibiotic residues were detected in milk samples collected from the dairy herds located in Karnataka, India, by microbiological assay. Subsequently, the detected antibiotics were identified as azithromycin and tetracycline, by high-performance liquid chromatography, further both the antibiotics detected in the cow milk samples were found to be at high concentration (9708.7 and 5460 μg kg-1, respectively). We then investigated the effects of temperature and pH on the stabilities of azithromycin and tetracycline to determine the degradation rate constant k using first-order kinetic equation. Results indicated that significant reduction in stability and antibacterial activity of azithromycin solution when subjected to 70 and 100°C for 24 h. While stability of tetracycline was significantly reduced when subjected to 70 and 100°C for 24 h. However no significant reduction in antibacterial activity of tetracycline was observed at respective temperatures when compared with that of control. In addition, the stabilities of azithromycin and tetracycline were found to be decreased in acidic pH 4–5. The results of the present study revealed the high risk of contamination of milk sample with veterinary antibiotics and also demonstrated the effect of temperature and pH on stability of antibiotics. Therefore the study suggest that the qualitative and quantitative screening of milk for the presence of antibiotics need to be strictly performed to ensure safe drinking milk for consumers. [ABSTRACT FROM AUTHOR]

Background: Malnutrition among children is one of the most pressing health concerns middle- and low-income countries face today, particularly those in Sub-Saharan Africa and South Asia. Early-life malnutrition has been shown to affect long-term health and income. One hypothesized channel linking early-life malnutrition and long-term outcomes is cognitive development. However, there is limited empirical evidence on the relationship between nutritional status and cognitive achievement in middle childhood. Study design: As part of the South India Community Health Study (SICHS), we collected educational attainment and anthropometric data from 1,194 children in rural Vellore district of Tamil Nadu, India, and assessed their math and reading skills. We analyzed the relationship between continuous and binary anthropometric measures of nutritional status and three measures of cognitive achievement (reading, math, and grade level), adjusting for potential confounders, using a regression framework. Results: Lower height-for-age and weight-for-age and their corresponding binary measures (stunting, underweight) were associated with lower reading scores, lower math scores, and lower grade level, with the exception of the association between weight-for-age and reading, which was marginally significant. A stunted child had one-third of a grade disadvantage compared to a non-stunted counterpart, whereas an underweight child had one-fourth of a grade disadvantage compared to a non-underweight counterpart. Lower BMI-for-age was associated with grade level and marginally associated with lower math scores, and its binary measure (thinness) was marginally associated with lower math scores. Conclusions: Acute and chronic malnutrition in middle childhood were negatively associated with math scores, reading scores, and educational attainment. Our study provides new evidence that cognitive achievement during middle childhood could be an important mechanism underlying the association between early-life malnutrition and long-term wellbeing. [ABSTRACT FROM AUTHOR]

Background: India has recently introduced telemedicine initiatives to enhance access to specialized care at a low cost for the pediatric HIV patients, who face multiple challenges due to growing disease burden and limited preparedness of the health system to address it. There are limited evidences on the cost-effectiveness of these interventions. This study was undertaken in Maharashtra, a province, located in the western region of the country, to inform policy regarding the effectiveness of this programme. The objective was to estimate the unit cost of ART services for pediatric HIV patients and examine the efficiency in the use of resource and treatment compliance resulting from telemedicine initiatives in pediatric HIV compared to usual ART services. Methods: We selected 6 ART centers (3 from linked centers linked to Pediatric HIV Centre of Excellence (PCoE) and 3 from non-linked centers) randomly from three high, middle and low ART centers, categorized on the basis of case load in each arm. A bottom up costing methodology was adopted to understand the unit cost of services. Loss to follow up and timeliness of the visits were compared between the two arms and were linked to the cost. Results: The average cost per-visit was INR 1803 in the linked centers and that for the non-linked centers was INR 3412. There has been 5 percentage point improvement in lost to follow-up in the linked centers compared to non-linked centers against a back-drop of a reduction in per-pediatric patient cost of INR 557. The linkage has resulted in increase in timeliness of the visits in linked centers compared to non-linked centers. Discussion and conclusion: The telemedicine linkage led to an increase in the case load leading to a decrease in cost. The evidence on efficiency in the use of resource and improvement in treatment compliance as suggested by this study could be used to scale up this initiative. [ABSTRACT FROM AUTHOR]

Background: Rabies is a devastating zoonotic disease of mammals that causes encephalitis and death. It is endemic in India, with an estimated annual 20,000 human deaths (one-third of the global rabies burden). The magnitude of animal rabies incidence is unknown. Methods: In four sub-districts of Punjab, India, we monitored canine and livestock populations from August 15, 2016 to August 14, 2017. Demographic, clinical and rabies diagnostic laboratory (RDL) data were collected from suspected cases of rabies. The annual incidence rate / 10,000 animal years at risk (95% CI) in each sub-district was estimated for each species. Results: During 2016–2017, a total of 41 suspected rabies cases were detected in the four selected sub-districts in Punjab. Laboratory confirmed rabies (LCR) incidence was 2.03/10,000 dog years (0.69, 5.96) and 2.71/10,000 dog years (1.14, 6.43) in stray and pet dogs, respectively. The LCR incidence in farmed buffalo and cattle was 0.19/10,000 buffalo years (0.07, 0.57) and 0.23/10,000 cattle years (0.06, 0.88), respectively. The LCR incidence amongst equine was 4.28/10,000 equine years (0.48, 38.10). Stray cattle rabies incidence in the selected sub-districts was 9.49/10,000 cattle years (3.51, 25.67). If similar enhanced surveillance for rabies was conducted state-wide, we estimate that 98 (34–294) buffalo, 18 (2–156) equine, 56 (15–214) farmed cattle, 96 (35–259) stray cattle, 128 (54–303) pet dogs and 62 (21–182) stray dogs would be expected to be confirmed with rabies in Punjab annually. Conclusion: These results indicate that rabies incidence in animals, particularly in dogs and stray cattle, is much higher than previously suspected. We recommend that statewide enhanced disease surveillance should be conducted to obtain more accurate estimates of rabies incidence in Punjab to facilitate better control of this important disease. [ABSTRACT FROM AUTHOR]

Introduction: Malaria is a public health emergency in India and Odisha. The national malaria elimination programme aims to expedite early identification, treatment and follow-up of malaria cases in hot-spots through a robust health system, besides focusing on efficient vector control. This study, a result of mass screening conducted in a hot-spot in Odisha, aimed to assess prevalence, identify and estimate the risks and develop a management tool for malaria elimination. Methods: Through a cross-sectional study and using WHO recommended Rapid Diagnostic Test (RDT), 13221 individuals were screened. Information about age, gender, education and health practices were collected along with blood sample (5 μl) for malaria testing. Altitude, forestation, availability of a village health worker and distance from secondary health center were captured using panel technique. A multi-level poisson regression model was used to analyze association between risk factors and prevalence of malaria, and to estimate risk scores. Results: The prevalence of malaria was 5.8% and afebrile malaria accounted for 79 percent of all confirmed cases. Higher proportion of Pv infections were afebrile (81%). We found the prevalence to be 1.38 (1.1664–1.6457) times higher in villages where the Accredited Social Health Activist (ASHA) didn’t stay; the risk increased by 1.38 (1.0428–1.8272) and 1.92 (1.4428–2.5764) times in mid- and high-altitude tertiles. With regard to forest coverage, villages falling under mid- and highest-tertiles were 2.01 times (1.6194–2.5129) and 2.03 times (1.5477–2.6809), respectively, more likely affected by malaria. Similarly, villages of mid tertile and lowest tertile of education had 1.73 times (1.3392–2.2586) and 2.50 times (2.009–3.1244) higher prevalence of malaria. Conclusion: Presence of ASHA worker in villages, altitude, forestation, and education emerged as principal predictors of malaria infection in the study area. An easy-to-use risk-scoring system for ranking villages based on these risk factors could facilitate resource prioritization for malaria elimination. [ABSTRACT FROM AUTHOR]

Background: With India preparing for the next decennial Census in 2021, we compared the disability estimates and data collection methodology between the Census 2011 and the most recent population-level survey for India and its states, to highlight the issues to be addressed to improve robustness of the disability estimates in the upcoming Census. Methods: Data from the Census 2011 and from two complementary nationally representative household surveys that covered all Indian states with the same methodology and survey instruments–the District-Level Household Survey-4 (DLHS-4, 2012–2013) and the Annual Health Surveys (AHS three rounds, 2010–11, 2011–12 and 2012–13) were used. Data from DLHS-4 and AHS 2012–13 round were pooled to generate estimates for the year 2012–13. Data collection methodology between the sources was compared, including the review of definitions of each type of disability. The overall, mental, visual, hearing, speech, and movement disability rate (DR) per 100,000 population were compared between the sources for India and for each state, and the percent difference in the respective rates was calculated. We explored the reliability of these estimates comparing yearly data from the AHS for three successive rounds. Results: Survey data were collected through proxy reporting, however, it is not entirely clear whether the data were proxy- or self-reported or a mix of both in the Census. The overall DR was 25.1% higher in the Census (2,242; 95% CI 2,241–2,243) than the survey (1,791; 95% CI 1,786–1,797) per 100,000 population, with the state-level difference ranging from -64% in Tamil Nadu to 107% in Sikkim state. Despite both sources using nearly similar definitions for overall disability and disability by type, the difference in DR was 125.5%, 54.2%, -25.7%, -19.7%, and 21.9% for hearing, speech, mental, movement, and visual DR, respectively. At the state-level, the difference in disability-specific estimates ranged from -84% to 450%. The extent of variations in the disability-specific estimates in AHS successive rounds ranged from -25% to 929% at the state-level. Conclusions: There is momentum globally towards building disability measurement that is consistent with the data required for monitoring of the Sustainable Development Goals to ensure robust estimation of disability. The current estimates from the Census and surveys seem much lower than would be expected at the population level. We make recommendations that India needs to take serious note of in order to improve the validity and reliability of India’s disability estimates. [ABSTRACT FROM AUTHOR]

In India, 66% of 8 million married adolescents (~5.3 million) are nulliparous and likely to conceive soon. Among married young women aged 20–24 years about 9.1 million are nulliparous. This group remains relatively less reached in maternal nutrition programs. Current estimates of their nutritional status and predictors of body mass index (BMI) are unavailable. Thinness (BMI <18.5 kg/m2), severe thinness (BMI <16 kg/m2), overweight or obesity (BMI ≥ 23kg/m2) prevalence estimates are presented based on a sample of 11,265 married nulliparous adolescents (15–19 years, married, no parity) and 15,358 young women (20–24 years, married, no parity) drawn from the National Family Health Surveys 2005–06 and 2015–16. Trends by age, time and state were analysed. Predictors of BMI were investigated using linear regression. Using BMI for age z score (BAZ) as standard reference, BMI cut-off was calculated for thinness (-2SD) and overweight or obesity (+1SD) among married nulliparous adolescents as recommended for population under 19 years. 35% sampled adolescents and 26% young women were thin; 4%-5% severely thin. Overweight or obesity was higher among married nulliparous young women than married nulliparous adolescents (21% versus 11%). Eight in 1000 were short, thin and young and six in 1000 were short, thin, anemic and young. At 15 years of age, prevalence of thinness based on BMI was 46.5% while based on BAZ, 7.6%. At 24 years of age thinness was 22.5%. Decadal reduction in thinness was half among married nulliparous adolescents (4% points) compared with married nulliparous young women (8% points). Decadal increase in overweight/ obesity ranged from 4% to 5% in both age groups. Western states had high prevalence of thinness; Tamil Nadu had highest prevalence of overweight or obesity. Incremental increase in age and wealth increased BMI among young women more than adolescents. BMI was lower among adolescents and young women wanting a child later than soon [β -0.28 (CI -0.49- -0.07), β -0.33(CI -0.56- -0.093), respectively]. BMI cut-off 16.49 kg/m2 and 24.12 kg/m2 had a high sensitivity (100%, 99.7%) and specificity (98.9%, 98.5%) to screen thin and overweight or obese adolescents, respectively. Owing to the high prevalence of both thinness and overweight/obesity among nulliparous married adolescents and women, nutritional anthropometry based screening should be initiated for this target group, along with a treatment package in states with high and persistent malnutrition. Family planning services should be integrated in nutrition programs for this target group to achieve normal nutritional status before conception. [ABSTRACT FROM AUTHOR]

There has been growing recognition of menstrual hygiene management (MHM) as a significant public health issue. However, research has predominately focused on the experiences of adolescent girls in school settings. The purpose of this research is to examine detailed accounts of menstruation for women in rural Odisha, India at various life stages with a view toward improving international monitoring of MHM. Focus group discussions and in-depth interviews were conducted to understand women’s experiences of menstruation across four life stages (unmarried women, recently married women, married women, and older women). Thematic analysis was used to identify menstruation-related challenges and needs. We found women voiced needs that aligned with those captured by the WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene (JMP) definition for MHM: access to clean materials, privacy for changing materials, soap and water for bathing, and disposal facilities for materials. However, we also found women require materials that are not only clean but comfortable and reliable; soap and water for more than bathing; privacy for the full spectrum of menstruation-related practices, not just when changing; and disposal facilities that are private and safe, not just accessible. Additionally, we identified needs that extend beyond the existing definition: pain management, social support, and an enabling sociocultural environment. Overall, women representing all life stages discussed menstruation challenges, including bathing, pain, and washing, drying, and storing cloth materials. Cloth management challenges were most acute for unmarried and recently married women, who were concerned that practices could reveal their menstrual status and harm their reputations, thus informing their preference for disposable materials, if attainable. We propose a revised definition of adequate MHM for this population that more comprehensively captures their needs. This definition may also prove useful for other populations, future research, creating measures of assessment, and guiding interventions and program priorities. [ABSTRACT FROM AUTHOR]

Background: Prioritizing zoonotic diseases is one of the emerging tasks for developing multi-sectoral collaboration within One Health. Globally, many efforts have been made to prioritize zoonotic diseases at national levels, especially in low resource settings. Prioritization of zoonoses has been conducted in different countries at different levels (i.e. national, regional and local) for different purposes. India has also initiated prioritization of zoonotic diseases at the national level. However, in a country like India with wide climatic variations, different animal-human and vector densities, it is important to look at these zoonotic conditions in local settings too. The present study aims to determine which zoonoses should be prioritized for collaboration between stakeholders in the Indian city of Ahmedabad. Methods: The present study followed a participatory research method, entailing a stakeholder workshop for prioritizing zoonotic diseases in Ahmedabad. It was carried out through a facilitated consultative process involving 19 experts in zoonoses from the human and animal health systems during a one-day workshop in September 2018. To prioritize the zoonotic diseases, the One Health Zoonotic Disease Prioritization (OHZDP) tool of the U.S. Centers for Disease Control and Prevention was adopted. The Analytical Hierarchical Process (AHP) and decision-tree analysis were used to rank the diseases. Results: Out of 38 listed zoonotic diseases, 14 were selected for prioritization. These were scored and weighed against five criteria: severity of disease in humans, potential for epidemic and/or pandemic, availability of prevention and/or control strategies, burden of animal disease existing inter-sectoral collaboration. The top five diseases that have been prioritized for Ahmedabad are Rabies, Brucellosis, Avian Influenza (H5N1), Influenza A (H1N1) and Crimean-Congo Hemorrhagic Fever. Sensitivity analysis did not indicate significant changes in zoonotic disease prioritization based on criteria weights. Conclusion: Prioritization of zoonotic diseases at the local level is essential for development of effective One Health strategies. This type of participatory disease prioritization workshop is highly recommended and can be replicated in other Indian cities, as well as in other low and middle-income countries. [ABSTRACT FROM AUTHOR]

Recent molecular systematic studies of arvicoline voles of the genera Neodon, Lasiopodomys, Phaiomys, and Microtus from Central Asia suggest the inclusion of Phaiomys leucurus, Microtus clarkei, and Lasiopodomys fuscus into Neodon and moving Neodon juldaschi into Microtus (Blanfordimys). In addition, three new species of Neodon (N. linzhiensis, N. medogensis, and N. nyalamensis) have recently been described from Tibet. Analyses of concatenated mitochondrial (Cytb, COI) and nuclear (Ghr, Rbp3) genes recovered Neodon as a well-supported monophyletic clade including all the recently described and relocated species. Kimura-2-parameter distance between Neodon from western Nepal compared to N. sikimensis (K2P = 13.1) and N. irene (K2P = 13.4) was equivalent to genetic distances observed between recognized species of this genus. The specimens sampled from western Nepal were recovered sister to N. sikimensis in the concatenated analysis. However, analyses conducted exclusively with mitochondrial loci did not support this relationship. The occlusal patterns of the first lower (m1) and third upper (M3) molars were simpler in specimens from western Nepal in comparison to N. sikimensis from eastern Nepal and India. Twelve craniodental characters and four external field measurements were examined from specimens of N. sikimensis from eastern Nepal and India, N. irene, and Neodon from western Nepal. Neodon from western Nepal were significantly different from N. sikimensis from eastern Nepal and India in ten out of 16 characters measured and from N. irene for all characters except ear height. Specimens from western Nepal were smaller in size than N. sikimensis from Eastern Nepal and India and larger than N. irene. Together the results of the molecular and morphological analyses indicate that Neodon from western Nepal are distinct under the phylogenetic, genetic and morpho species concepts. [ABSTRACT FROM AUTHOR]

The East African Indian (EAI) and Central Asian (CAS) lineages of Mycobacterium tuberculosis complex (MTBC) mainly infect tuberculosis (TB) patients in the eastern hemisphere which contains many of the 22 high TB burden countries including China and India. We investigated if phylogeographical, epidemiological and demographical characteristics for these 2 lineages differed in SITVIT2 database. Genotyping results and associated data (age, sex, HIV serology, drug resistance) on EAI and CAS lineages (n = 10,974 strains) were extracted. Phylogenetic and Bayesian, and other statistical analyses were used to compare isolates. The male/female sex ratio was 907/433 (2.09) for the EAI group vs. 881/544 (1.62) for CAS (p-value<0.002). The proportion of younger patients aged 0–20 yrs. with CAS lineage was significantly higher than for EAI lineage (18.07% vs. 10.85%, p-value<0.0001). The proportion of multidrug resistant and extensively drug resistant TB among CAS group (30.63% and 1.03%, respectively) was significantly higher than in the EAI group (12.14% and 0.29%, respectively; p-value<0.0001). Lastly, the proportion of HIV+ patients was 20.34% among the EAI group vs. 3.46% in the CAS group (p-value<0.0001). This remarkable split observed between various parameters for these 2 lineages was further corroborated by their geographic distribution profile (EAI being predominantly found in Eastern-Coast of Africa, South-India and Southeast Asia, while CAS was predominantly found in Afghanistan, Pakistan, North India, Nepal, Middle-east, Libya, Sudan, Ethiopia, Kenya and Tanzania). Some geo-specificities were highlighted. This study demonstrated a remarkable cleavage for aforementioned characteristics of EAI and CAS lineages, showing a North-South divide along the tropic of cancer in Eastern hemisphere–mainly in Asia, and partly prolonged along the horn of Africa. Such studies would be helpful to better comprehend prevailing TB epidemic in context of its historical spread and evolutionary features, and provide clues to better treatment and patient-care in countries and regions concerned by these lineages. [ABSTRACT FROM AUTHOR]

Background: Low birth weight is an important predictor of maternal and child health. Birth weight is likely to be affected by maternal health, socioeconomic status and quality of health care facilities. Objective: To assess trends in the birth weight, the proportion of low birth weight, maternal factors and health care facilities for delivery in villages of Western Maharashtra from the year 2004 to 2016 and to analyze factors associated with low birth weight for total birth data of 2004–2016. Methods: Data collected for 19244 births from 22 villages in Vadu Health and Demographic Surveillance System (HDSS), Pune, Maharashtra, India from the year 2004 to 2016 were used for this analysis. Results: There was an overall increase in the annual mean birth weight from 2640.12 gram [95% CI 2602.21–2686.84] in the year 2004 to 2781.19 gram [95% CI 2749.49–2797.95] in the year 2016. There was no secular trend to show increase or decrease in the proportion of low weight at birth. Increasing maternal age (>18 years) compounded with better education, reduced parity and increasing number of institutional deliveries were significant trends observed during the past decade. Low birth weight was found to be associated with female gender, first birth order, poor maternal education and occupation as cultivation. Conclusion: Changes in maternal age, education, occupation, and increased institutionalized deliveries contributed in to increasing birth weights in rural Maharashtra. Female gender, first birth order, poor maternal education and occupation of cultivation are associated with increased risk of low birth weight. [ABSTRACT FROM AUTHOR]

Background: Although most Indians live in rural settings, data on cardiovascular disease risk factors in these groups are limited. We describe the association between socioeconomic position and cardiovascular disease risk factors in a large rural population in north India. Methods: We performed representative, community-based sampling from 2013 to 2014 of Solan district in Himachal Pradesh. We used education, occupation, household income, and household assets as indicators of socioeconomic position. We used tobacco use, alcohol use, low physical activity, obesity, hypertension, and diabetes as risk factors for cardiovascular disease. We performed hierarchical multivariable logistic regression, adjusting for age, sex and clustering of the health sub-centers, to evaluate the cross-sectional association of socioeconomic position indicators and cardiovascular disease risk factors. Results: Among 38,457 participants, mean (SD) age was 42.7 (15.9) years, and 57% were women. The odds of tobacco use was lowest in participants with graduate school and above education (adjusted OR 0.11, 95% CI 0.09, 0.13), household income >15,000 INR (adjusted OR 0.35, 95% CI 0.29, 0.43), and highest quartile of assets (adjusted OR 0.28, 95% CI 0.24, 0.34) compared with other groups but not occupation (skilled worker adjusted OR 0.93, 95% CI 0.74, 1.16). Alcohol use was lower among individuals in the higher quartile of income (adjusted OR 0.75, 95% CI 0.64, 0.88) and assets (adjusted OR 0.70, 95% CI 0.59, 0.82). The odds of obesity was highest in participants with graduate school and above education (adjusted OR 2.33, 95% CI 1.85, 2.94), household income > 15,000 Indian rupees (adjusted OR 1.89, 95% CI 1.63, 2.19), and highest quartile of household assets (adjusted OR 2.87, 95% CI 2.39, 3.45). The odds of prevalent hypertension and diabetes were also generally higher among individuals with higher socioeconomic position. Conclusions: Individuals with lower socioeconomic position in Himachal Pradesh were more likely to have abnormal behavioral risk factors, and individuals with higher socioeconomic position were more likely to have abnormal clinical risk factors. [ABSTRACT FROM AUTHOR]

The 2018 outbreak of Nipah virus in Kerala, India, highlights the need for global surveillance of henipaviruses in bats, which are the reservoir hosts for this and other viruses. Nipah virus, an emerging paramyxovirus in the genus Henipavirus, causes severe disease and stuttering chains of transmission in humans and is considered a potential pandemic threat. In May 2018, an outbreak of Nipah virus began in Kerala, > 1800 km from the sites of previous outbreaks in eastern India in 2001 and 2007. Twenty-three people were infected and 21 people died (16 deaths and 18 cases were laboratory confirmed). Initial surveillance focused on insectivorous bats (Megaderma spasma), whereas follow-up surveys within Kerala found evidence of Nipah virus in fruit bats (Pteropus medius). P. medius is the confirmed host in Bangladesh and is now a confirmed host in India. However, other bat species may also serve as reservoir hosts of henipaviruses. To inform surveillance of Nipah virus in bats, we reviewed and analyzed the published records of Nipah virus surveillance globally. We applied a trait-based machine learning approach to a subset of species that occur in Asia, Australia, and Oceana. In addition to seven species in Kerala that were previously identified as Nipah virus seropositive, we identified at least four bat species that, on the basis of trait similarity with known Nipah virus-seropositive species, have a relatively high likelihood of exposure to Nipah or Nipah-like viruses in India. These machine-learning approaches provide the first step in the sequence of studies required to assess the risk of Nipah virus spillover in India. Nipah virus surveillance not only within Kerala but also elsewhere in India would benefit from a research pipeline that included surveys of known and predicted reservoirs for serological evidence of past infection with Nipah virus (or cross reacting henipaviruses). Serosurveys should then be followed by longitudinal spatial and temporal studies to detect shedding and isolate virus from species with evidence of infection. Ecological studies will then be required to understand the dynamics governing prevalence and shedding in bats and the contacts that could pose a risk to public health. [ABSTRACT FROM AUTHOR]

Background: Misuse of antibiotics is a well-known driver of antibiotic resistance. Given the decentralized model of the Indian health system and the shortage of allopathic doctors in rural areas, a wide variety of healthcare providers cater to the needs of patients in urban and rural settings. This qualitative study explores the drivers of antibiotic use among formal and informal healthcare providers as well as patients accessing care at primary health centers across Paschim Bardhaman district in West Bengal. Materials and methods: We conducted 28 semi-structured, in-depth interviews with four groups of healthcare providers (allopathic doctors, informal health providers, nurses, and pharmacy shopkeepers) as well as patients accessing care at primary health centers and hospitals across Paschim Bardhaman district. Qualitative data was analyzed using the framework method in an inductive and deductive manner. Results: Our results indicate that patients demand antibiotics from healthcare providers and seek the fastest cure possible, which influences the prescription choices of healthcare providers, particularly informal health providers. Many allopathic doctors provide antibiotics without any clinical indication due to inconsistent follow up, lack of testing facilities, risk of secondary infections, and unhygienic living conditions. Pharmaceutical company representatives actively network with informal health providers and formal healthcare providers alike, and regularly visit providers even in remote areas to market newer antibiotics. Allopathic doctors and informal health providers frequently blame the other party for being responsible for antibiotic resistance, and yet both display interdependence in referring patients to one another. Conclusions: A holistic approach to curbing antibiotic resistance in West Bengal and other parts of India should focus on strengthening the capacity of the existing public health system to deliver on its promises, improving patient education and counseling, and including informal providers and pharmaceutical company representatives in community-level antibiotic stewardship efforts. [ABSTRACT FROM AUTHOR]

Background: The Global Programme to Eliminate Lymphatic Filariasis (GPELF) provides antifilarial medications to hundreds of millions of people annually to treat filarial infections and prevent elephantiasis. Recent trials have shown that a single-dose, triple-drug treatment (ivermectin with diethylcarbamazine and albendazole [IDA]) is superior to a two-drug combination (diethylcarbamazine plus albendazole [DA]) that is widely used in LF elimination programs. This study was performed to assess the safety of IDA and DA in a variety of endemic settings.Methods and Findings: Large community studies were conducted in five countries between October 2016 and November 2017. Two studies were performed in areas with no prior mass drug administration (MDA) for filariasis (Papua New Guinea and Indonesia), and three studies were performed in areas with persistent LF despite extensive prior MDA (India, Haiti, and Fiji). Participants were treated with a single oral dose of IDA (ivermectin, 200 μg/kg; diethylcarbamazine, 6 mg/kg; plus albendazole, a fixed dose of 400 mg) or with DA alone. Treatment assignment in each study site was randomized by locality of residence. Treatment was offered to residents who were ≥5 years of age and not pregnant. Adverse events (AEs) were assessed by medical teams with active follow-up for 2 days and passive follow-up for an additional 5 days. A total of 26,836 persons were enrolled (13,535 females and 13,300 males). A total of 12,280 participants were treated with DA, and 14,556 were treated with IDA. On day 1 or 2 after treatment, 97.4% of participants were assessed for AEs. The frequency of all AEs was similar after IDA and DA treatment (12% versus 12.1%, adjusted odds ratio for IDA versus DA 1.15, 95% CI 0.87-1.52, P = 0.316); 10.9% of participants experienced mild (grade 1) AEs, 1% experienced moderate (grade 2) AEs, and 0.1% experienced severe (grade 3) AEs. Rates of serious AEs after DA and IDA treatment were 0.04% (95% CI 0.01%-0.1%) and 0.01% (95% CI 0.00%-0.04%), respectively. Severity of AEs was not significantly different after IDA or DA. Five of six serious AEs reported occurred after DA treatment. The most common AEs reported were headache, dizziness, abdominal pain, fever, nausea, and fatigue. AE frequencies varied by country and were higher in adults and in females. AEs were more common in study participants with microfilaremia (33.4% versus 11.1%, P < 0.001) and more common in microfilaremic participants after IDA than after DA (39.4% versus 25.6%, P < 0.001). However, there was no excess of severe or serious AEs after IDA in this subgroup. The main limitation of the study was that it was open-label. Also, aggregation of AE data from multiple study sites tends to obscure variability among study sites.Conclusions: In this study, we observed that IDA was well tolerated in LF-endemic populations. Posttreatment AE rates and severity did not differ significantly after IDA or DA treatment. Thus, results of this study suggest that IDA should be as safe as DA for use as a MDA regimen for LF elimination in areas that currently receive DA.Trial Registration: Clinicaltrials.gov registration number: NCT02899936. [ABSTRACT FROM AUTHOR]

Introduction: Women in developing countries continue to face barriers to accessing sexual and reproductive health (SRH) services, with marginalized women facing increased challenges to accessing care. The Diagonal Interventions to Fast-Forward Enhanced Reproductive Health (DIFFER) project implemented a package of interventions for female sex workers and women from the general population which integrated horizontal health services for the general population with existing vertical targeted interventions aimed at sex workers with an aim to improve SRH and HIV services. We present an outcome evaluation of the DIFFER project in terms of uptake rates for SRH services among sex workers in Mysore, India. Methods: Ashodaya Samithi, a sex worker-led organization, implemented the DIFFER strategy through their community-based clinic and a Well Women Clinic (WWC), established at a partner private hospital that provided SRH services for women living with HIV. Mixed methods were used to evaluate the intervention that included a baseline (2012–13) and end of project (2015–16) cross sectional surveys (CSS), focus group discussions (FGDs), key informant interviews, and analysis of service statistics from 2013–2016. Results: The CSS found that condom use, STI testing, and treatment were high before, and throughout the intervention; cervical cancer screening and treatment increased significantly, from 11.5% to 56% (aOR 9.85, p<0.001) and HIV testing in the last 3 months increased from 26.3% to 73.3% (aOR 7.25, p<0.001). The proportion of sex workers using any SRH service in the past year doubled from 25.7% to 51.4% (aOR 2.91, p<0.001). Service statistics showed similar trends. The FGDs and key informant interviews showed that women and stakeholders held high levels of satisfaction with the strategy, and affirmed potential for scale up. Conclusion: The DIFFER strategy demonstrated that SRH service uptake can occur in conjuction with HIV services offered to sex workers. This model of integrated service delivery has been accepted by policy makers and needs further analysis for scaling up. [ABSTRACT FROM AUTHOR]

This open-label study assessed the safety and immunogenicity of two doses (14 days apart) of an indigenously manufactured, killed, bivalent (Vibrio cholerae O1 and O139), whole-cell oral cholera vaccine (SHANCHOL; Shantha Biotechnics) in healthy adults (n = 100) and children (n = 100) in a cholera endemic area (Vellore, South India) to fulfill post-licensure regulatory requirements and post-World Health Organization (WHO) prequalification commitments. Safety and reactogenicity were assessed, and seroconversion rates (i.e. proportion of participants with a ≥ 4-fold rise from baseline in serum vibriocidal antibody titers against V. cholerae O1 Inaba, O1 Ogawa and O139, respectively) were determined 14 days after each vaccine dose. No serious adverse events were reported during the study. Commonly reported solicited adverse events were headache and general ill feeling. Seroconversion rates after the first and second dose in adults were 67.7% and 55.2%, respectively, against O1 Inaba; 47.9% and 45.8% against O1 Ogawa; and 19.8% and 20.8% against O139. In children, seroconversion rates after the first and second dose were 80.2% and 68.8%, respectively, against O1 Inaba; 72.9% and 67.7% against O1 Ogawa; and 26.0% and 18.8% against O139. The geometric mean titers against O1 Inaba, O1 Ogawa, and O139 in both adults and children were significantly higher after each vaccine dose compared to baseline titers (P < 0.001; for both age groups after each dose versus baseline). The seroconversion rates for O1 Inaba, O1 Ogawa, and O139 in both age groups were similar to those in previous studies with the vaccine. In conclusion, the killed, bivalent, whole-cell oral cholera vaccine has a good safety and reactogenicity profile, and is immunogenic in healthy adults and children. Trial Registration: ClinicalTrials.gov ; CTRI/2012/01/002354. [ABSTRACT FROM AUTHOR]

Accurate and timely diagnosis is very critical for management, control and elimination of the malaria. Malaria rapid diagnostic tests (RDTs) have improved the diagnosis and management of malaria in remote areas, community and places where microscopy is not available for diagnosis. According to WHO report 2018, Plasmodium falciparum malaria constitutes more than 50% of malaria cases in India. Most of the RDTs used for diagnosis of falciparum malaria today employ HRP2 as a target antigen. However, low density parasitemia and deletion of hrp-2 gene in P. falciparum leads to false negative results and necessitates the development of alternative/ new or improved RDT for malaria diagnosis. We have analysed the genetic diversity and homology modelling of Pfgdh (glutamate dehydrogenase), ldh (lactate dehydrogenase) and aldolase genes in P. falciparum isolates from the eight endemic states of India to assess their potential as antigen for RDT development. We observed negligible sequence diversity in Pfgdh in comparison to the low level of diversity in ldh and aldolase gene. No structural or functional changes were observed in modelling studies and all three genes were under negative purifying selection pressure. The highly conserved nature of pfgdh gene suggests that GDH could be a potential target molecule for Pan/Pf diagnostic test for malaria. [ABSTRACT FROM AUTHOR]

We have attempted to reproduce the results in Development and validation of a deep learning algorithm for detection of diabetic retinopathy in retinal fundus photographs, published in JAMA 2016; 316(22), using publicly available data sets. We re-implemented the main method in the original study since the source code is not available. The original study used non-public fundus images from EyePACS and three hospitals in India for training. We used a different EyePACS data set from Kaggle. The original study used the benchmark data set Messidor-2 to evaluate the algorithm's performance. We used another distribution of the Messidor-2 data set, since the original data set is no longer available. In the original study, ophthalmologists re-graded all images for diabetic retinopathy, macular edema, and image gradability. We have one diabetic retinopathy grade per image for our data sets, and we assessed image gradability ourselves. We were not able to reproduce the original study's results with publicly available data. Our algorithm's area under the receiver operating characteristic curve (AUC) of 0.951 (95% CI, 0.947-0.956) on the Kaggle EyePACS test set and 0.853 (95% CI, 0.835-0.871) on Messidor-2 did not come close to the reported AUC of 0.99 on both test sets in the original study. This may be caused by the use of a single grade per image, or different data. This study shows the challenges of reproducing deep learning method results, and the need for more replication and reproduction studies to validate deep learning methods, especially for medical image analysis. Our source code and instructions are available at: . [ABSTRACT FROM AUTHOR]

Background: Private providers dominate health care in India and provide most tuberculosis (TB) care. Yet efforts to engage private providers were viewed as unsustainably expensive. Three private provider engagement pilots were implemented in Patna, Mumbai and Mehsana in 2014 based on the recommendations in the National Strategic Plan for TB Control, 2012–17. These pilots sought to improve diagnosis and treatment of TB and increase case notifications by offering free drugs and diagnostics for patients who sought care among private providers, and monetary incentives for providers in one of the pilots. As these pilots demonstrated much higher levels of effectiveness than previously documented, we sought to understand program implementation costs and predict costs for their national scale-up. Methods and findings: We developed a common cost structure across these three pilots comprising fixed and variable cost components. We conducted a retrospective, activity-based costing analysis using programmatic data and qualitative interviews with the respective program managers. We estimated the average recurring costs per TB case at different levels of program scale for the three pilots. We used these cost estimates to calculate the budget required for a national scale up of such pilots. The average cost per privately-notified TB case for Patna, Mumbai and Mehsana was estimated to be US$95, US$110 and US$50, respectively, in May 2016 when these pilots were estimated to cover 50%, 36% and 100% of the total private TB patients, respectively. For Patna and Mumbai pilots, the average cost per case at full scale, i.e. 100% coverage of private TB patients, was projected to be US$91 and US$101, respectively. In comparison, the national TB program’s budget for 2015 averages out to $150 per notified TB case. The total annual additional budget for a national scale up of these pilots was estimated to be US$267 million. Conclusions: As India seeks to eliminate TB, extensive national engagement of private providers will be required. The cost per privately-notified TB case from these pilots is comparable to that already being spent by the public sector and to the projected cost per privately-notified TB case required to achieve national scale-up of these pilots. With additional funds expected to execute against national TB elimination commitments, the scale-up costs of these operationally viable and effective private provider engagement pilots are likely to be financially viable. [ABSTRACT FROM AUTHOR]

Introduction: Antibiotic misuse is widespread and contributes to antibiotic resistance, especially in less regulated health systems such as India. Although informal providers are involved with substantial segments of primary healthcare, their level of knowledge, attitudes, and practices is not well documented in the literature. Objectives: This quantitative study systematically examines the knowledge, attitudes, and practices of informal and formal providers with respect to antibiotic use. Methods: We surveyed a convenience sample of 384 participants (96 allopathic doctors, 96 nurses, 96 informal providers, and 96 pharmacy shopkeepers) over a period of 8 weeks from December to February using a validated questionnaire developed in Italy. Our team created an equivalent, composite KAP score for each respondent in the survey, which was subsequently compared between providers. We then performed a multivariate logistic regression analysis to estimate the odds of having a low composite score (<80) based on occupation by comparing allopathic doctors (referent category) with all other study participants. The model was adjusted for age (included as a continuous variable) and gender. Results: Doctors scored highest in questions assessing knowledge (77.3%) and attitudes (87.3%), but performed poorly in practices (67.6%). Many doctors knew that antibiotics were not indicated for viral infections, but over 87% (n = 82) reported prescribing them in this situation. Nurses, pharmacy shopkeepers, and informal providers were more likely to perform poorly on the survey compared to allopathic doctors (OR: 10.4, 95% CI 5.4, 20.0, p<0.01). 30.8% (n = 118) of all providers relied on pharmaceutical company representatives as a major source of information about antibiotics. Conclusions: Our findings indicate poor knowledge and awareness of antibiotic use and functions among informal health providers, and dissonance between knowledge and practices among allopathic doctors. The nexus between allopathic doctors, pharmaceutical company representatives, and informal health providers present promising avenues for future research and intervention. [ABSTRACT FROM AUTHOR]

Background: Evidence highlights a global shortage of wheelchair service provision education and training that results in inappropriate wheelchair provision with associated health and economic consequences. Two learning methodologies, a hybrid and an in-person course, based on the World Health Organization Wheelchair Service Training Package Basic Level, currently are available to train wheelchair service providers worldwide. The effectiveness of the in-person methodology, used as the standard of practice, has never been tested. Meanwhile, the Hybrid Course, which combines online and in-person training, was developed to reduce training costs and to scale training interventions and has shown potential effectiveness in increasing basic level wheelchair service provision knowledge. The objective of this study was to compare the effectiveness of both learning methodologies based on knowledge and satisfaction among a group of wheelchair service providers in India and Mexico. Methods: We conducted a controlled quasi-experimental study to evaluate changes in basic wheelchair knowledge and levels of satisfaction between Hybrid and In-person course learners in India and Mexico. A convenience sampling method guided by local stakeholders’ input was used to recruit participants. Outcomes were assessed using self-administered online surveys, the International Society of Wheelchair Professionals Wheelchair Service Provision Basic Test (primary outcome) completed pre- and post- the learning intervention and an anonymous Satisfaction Survey (secondary outcome) completed post- intervention. Baseline characteristics were compared among groups using hypothesis tests based on their assumptions. The primary analysis was intention-to-treat. To address missing values and lost to follow-up, multiple chained imputations were conducted. The primary outcome was analyzed using linear mixed models. The secondary outcome was analyzed using a two-tailed two independent samples t-test. Results: A total of 81 participants, 43 (53.1%) in the In-person group and 38 (46.9%) in the Hybrid group, participated in the study. Mean baseline knowledge scores were below the passing cutoff of the test (53 points) in both groups. Both study groups experienced statistically significant improvements in the primary outcome when comparing pre- and post-test scores (p<0.0001) with total mean scores above the passing cutoff of the test. The in-person group experienced, on average, larger effects on the primary outcome. The difference in mean change from post-test to pre-tests between In-person groups and Hybrid was 3.6 (95% Confidence Interval: 1.7;5.4), Cohen’s d = 0.36, with a small effect size favoring the In-person training. With regards to satisfaction, the difference between the two interventions was 0.23±0.07 in favor of the In-person group (p = 0.0021). Conclusions: Both learning methodologies had a statistically significant effect in increasing wheelchair service knowledge with overall high levels of satisfaction. However, the In-person group reported overall larger effects when compared with the Hybrid methodology. This study provided recommendations on how organizations can improve blended learning interventions to enhance participants’ learning experiences and reduce potential barriers and limitations. [ABSTRACT FROM AUTHOR]

Reference evapotranspiration (ET0) plays a fundamental role in irrigated agriculture. The objective of this study is to simulate monthly ET0 at a meteorological station in India using a new method, an improved support vector machine (SVM) based on the cuckoo algorithm (CA), which is known as SVM-CA. Maximum temperature, minimum temperature, relative humidity, wind speed and sunshine hours were selected as inputs for the models used in the simulation. The results of the simulation using SVM-CA were compared with those from experimental models, genetic programming (GP), model tree (M5T) and the adaptive neuro-fuzzy inference system (ANFIS). The achieved results demonstrate that the proposed SVM-CA model is able to simulate ET0 more accurately than the GP, M5T and ANFIS models. Two major indicators, namely, root mean square error (RMSE) and mean absolute error (MAE), indicated that the SVM-CA outperformed the other methods with respective reductions of 5–15% and 5–17% compared with the GP model, 12–21% and 10–22% compared with the M5T model, and 7–15% and 5–18% compared with the ANFIS model, respectively. Therefore, the proposed SVM-CA model has high potential for accurate simulation of monthly ET0 values compared with the other models. [ABSTRACT FROM AUTHOR]

The invasion of the Western Hemisphere native fall armyworm (Spodoptera frugiperda; J. E. Smith) (Lepidoptera: Noctuidae) into the Eastern Hemisphere has been notable for the rapidity and geographical breadth of new detections. In the year following the first discovery in western sub-Saharan Africa in 2016, infestations have been documented in most sub-Saharan maize growing regions and has now expanded beyond Africa with populations recently reported in India. These observations could indicate a remarkable capacity for rapid establishment and long-distance dissemination. However, while fall armyworm does exhibit extended migration in North America where it annually traverses thousands of kilometers, this behavior is known to be dependent on highly favorable wind patterns and so can’t be assumed to occur in all locations. An alternative possibility is that the species has long been present in Africa, and perhaps the rest of the hemisphere, but was undetected until the enhanced monitoring that resulted after its initial discovery. Determining whether the fall armyworm in the Eastern Hemisphere is newly arrived or long pre-existing is important for assessing the risks of significant economic impacts, as the former indicates a change in pest composition while the latter does not. This study examined this issue by comparing collections from two geographically distant locations, South Africa and India. Sequence comparisons were used to quantify differences between the South Africa and India collections, assess the likelihood of their sharing a common source population, and their possible relationship with previously characterized fall armyworm from other regions of Africa. The results indicate genetic homogeneity between the South African and Indian fall armyworm populations tested and substantial similarities between these and collections from eastern Africa. The implications of these findings on fall armyworm population behavior and composition are discussed. [ABSTRACT FROM AUTHOR]

Culex quinquefasciatus is a vector of lymphatic filariasis and vector control strategies normally involve the use of synthetic insecticides targeted against them. Extensive and uncontrolled use of these synthetic insecticides has led to the development of insecticide resistance in the mosquito vectors. In this context, to study the resistance status of Cx. quinquefasciatus, field populations were collected from three districts of Northern part of West Bengal and tested against insecticides (5% malathion, 0.05% deltamethrin, 0.05% lambdacyhalothrin,0.75% permethrin, 0.1% propoxur, 4% DDT and Temephos). Qualitative and quantitative enzyme assay was also conducted in order to find the role of detoxifying enzymes behind the development of insecticide resistance. This study revealed the presence of widespread resistance amongst the field populations of Cx. quinquefasciatus throughout the studied regions. Moreover, the result of native PAGE and biochemical enzyme assay may be linked to some extent in the involvement of the detoxifying enzymes in conferring resistance against insecticides in most of the tested Cx. quinquefasciatus populations. The present study involving the survey of resistance status may be of immense help during the implementation of vector control strategies throughout this region. [ABSTRACT FROM AUTHOR]

Introduction: Glucosamine dietary supplements are commonly used for the management of osteoarthritis (OA). However, clinical trials have reported varying outcomes with regard to joint function and disease progression. One of the possible reasons for variability in observed effects of glucosamine could be that, unlike prescription drugs, the quality of manufactured dietary supplements is not closely monitored in many countries. Therefore, there is the possibility that the actual amount of glucosamine present in a dietary supplement is different from that claimed on the label. The quality control of glucosamine supplements is further complicated by the unavailability of a simple and effective analytical method for the analysis of glucosamine. Therefore, the aim of this study was to develop a simple analytical method that could be easily adapted by the pharmaceutical industry for routine analysis of glucosamine. Aims: To develop a novel high-performance liquid chromatography (HPLC) method for the quantification of glucosamine, and determine the amount of glucosamine present in a sample of dietary supplements commercially available in Australia and India. Methods: Chromatographic separation of glucosamine was achieved using a zwitter-ionic hydrophilic interaction liquid chromatography column with a mobile phase consisting of 60% acetonitrile and 40% of 85 mM ammonium acetate, at a flow rate of 0.3 mL/min and column temperature 40°C. The developed method was validated for intra- and inter-day linearity, accuracy, precision, and reproducibility. The newly-developed method was subsequently used to analyse 12 glucosamine supplements. Results: The developed method was selective for glucosamine, which had a retention time of 5.9 min. The standard curve was linear with a correlation coefficient (r2) exceeding 0.99, over the range of 10–200 μg/mL for glucosamine. The relative standard deviations for intra- and inter-day accuracy, precision and reproducibility were all less than 4%. The amount of glucosamine determined in six Australian and six Indian glucosamine supplements ranged between 98.7–101.7% and 85.9–101.8% of the labelled values, respectively. Discussion: Unlike previous HPLC methods, this newly-developed HPLC technique does not require pre-derivatisation and can separate glucosamine from both hydrochloride and sulphate salts, and from other amino sugars, such as chondroitin sulphate present in dietary supplements. This simple and effective technique can be employed by analytical laboratories for the quality control of glucosamine dietary supplements. Conclusion: The current study has developed a new analytical technique using HPLC-Corona CAD, which can analyse underivatised glucosamine hydrochloride and sulphate within 6 minutes. Using the novel assay, we confirmed that unlike the tested Australian dietary supplements, only half of the tested Indian products had a glucosamine content within ±10% of what was claimed on the label. [ABSTRACT FROM AUTHOR]

Cities comprise of mixed green patches that vary in size and are highly scattered and disconnected. Although small green spaces largely dominate the cityscape, they are often neglected and ignored by the naturalists and conservationists, as they do not fulfill the large green spaces criteria. The citizens on the other hand seem to have a different perception and requirements from small green spaces as they are within their neighbourhood. Bangalore, a developing city within South India, consists of a large number of newly formed residential areas which have pocket green spaces in the form of neighbourhood parks (henceforth NPs). They are maintained by the municipality and are mainly designed for recreation purposes, completely neglecting the fact that these spaces could be essential for biodiversity. Here, there is a disconnect between the requirements of the citizens, conservationists and the end product that the municipality delivers. Here, through a questionnaire survey we assess the biodiversity citizens are fond off, and use them as surrogate taxa for the not so immediately obvious taxa, insects to enumerate the biodiversity within NPs. We analyze and identify landscape characteristics around NPs which could enhance the biodiversity within NPs. Our results reveal that people are fond of Birds and Butterflies and we use them as surrogates for the inconspicuous taxa to assess biodiversity within NPs. 55 tree species, 45 species of birds, 41 species of butterflies and 68 morpho species of insects were recorded. We demonstrate that small green spaces are critical systems and help support biodiversity across three scale within the city. Interestingly, results suggests that density of NPs is more important rather than the size of NPs. Also, the presence of high density of NPs within a neighbourhood could support similar biodiversity that large green spaces support. Finally, this study provides insights on the landscape matrix that could help enhance biodiversity support service within NPs and the surrounding neighbourhood. [ABSTRACT FROM AUTHOR]

Childhood pneumonia accounts for 17% of IMR in India, posing a major health burden. With cultural beliefs influencing care seeking behaviour and disparities existing in health infrastructure across the country, an understanding of the underlying issues merits exploration. Study assessed prevalence of probable pneumonia and examined care seeking behaviour of mothers in three states, Madhya Pradesh (MP), Uttar Pradesh (UP) and Tamil Nadu (TN). This mixed methods study involved a household survey and qualitative interviews with mothers in three districts from each state. Households with children aged 2–59 months were screened to identify those with probable pneumonia; sub-sample of mothers participated in qualitative interviews. Care seeking behaviour was explored in the context of recognition of symptoms, nature of first care provided, time when care was sought outside the home and choice of health provider. Overall 17,442 children from 13,544 households were screened, of which 729 (MP), 752 (UP) and 713 (TN) children respectively, were identified with probable pneumonia; 72 mothers participated in the qualitative interviews. Three months period prevalence was estimated in study districts at 22.2%—MP 13.3%—UP and 8.4%—TN. Most mothers in MP and UP were not perceptive to severity of illness; type of care sought was often inappropriate, delayed, with home remedies and visits to unqualified care providers being their first response. In contrast, in TN, use of home remedies was minimal, going to untrained care providers, non-existent and more than 90% mothers sought appropriate care. Private doctors were the preferred choice among all mothers but utilization of government care was highest in TN (20%). Community health workers were underutilized, with less than 10% mothers consulting them. Need for educating mothers about appropriate care seeking and development of good health infrastructure as essential to attainment of better child health indices are advocated. [ABSTRACT FROM AUTHOR]

This study examined the burden of food insecurity in India’s un-notified slums, using an SDG framework to identify correlates of food insecurity. A convenience sampling approach was employed in selecting 38 slums from 675 un-notified slums across four geographic zones. Ten percent of the households in each slum site were selected from each zone, and one household member was interviewed, based on their availability and fulfilment of the eligibility criteria. Eligible individuals included those aged 18 years and above, who were resident in the selected slums and provided consent. Individuals with mental or physical challenges were excluded. A total sample of 907 study participants were included. Results showed that 43% (n = 393) of the participants were food insecure. More than half were females (73%, n = 285), who had not completed any schooling (51%, n = 202). One-third (n = 128) resided in the Northern Region of Delhi. SDG-related predictors of food insecurity included: household educational level (SDG 4 Quality education) (p = 0.03), coverage of health service needs (SDG 3 Good health and well-being) (p = 0.0002), electricity needs (SDG 7 affordable and clean energy) (p<0.0001), and employment needs (SDG 8 Decent and economic growth) (p = 0.003). Having healthcare needs that were partially or fully met was equally associated with higher food insecurity: this could be attributed to high healthcare costs and the lack of federal subsidies in un-notified slums, collectively contributing to high out-of-pocket health costs. Failure to fully meet employment needs was also significantly associated with higher food insecurity. However, met needs for electricity, finance, women’s safety and satisfactory family relationships, were associated with lower food insecurity. Household predictors of food insecurity included: number of household members, and the presence of physically disabled household members. Necessary interventions should include connecting food insecure households to existing social services such as India’s Public Distribution System, and multi-sector partnerships to address the existing challenges. [ABSTRACT FROM AUTHOR]

The present study explored the motivation of rural-urban migrants who moved from the Himalaya foothills of Uttarakhand to its capital city, Dehradun. A survey of 100 migrant families reported their socio-economic profile before and after migration, personal and general reasons for migration, problems in the village and in the city, and perception of push- and pull factors. A remote sensing-based analysis of land cover and forest changes was conducted for two villages of the migrants’ origin, aiming to link the reasons for migration to land cover changes. This was contextualised by reported large scale changes in forest cover. Major reasons for migration mentioned in this study were education, employment opportunities with the associated income, and facilities. These were perceived as both, push and pull factors, whereas environmental factors ranked very low. Declining environment or agriculture were never mentioned spontaneously as personal reason, and only occasionally as a presumed general reason for migration, but were frequently confirmed as a major problem in the village. Thus, although such problems existed, they seemed not a major driver of rural-urban migration. For most of the respondents their migration resulted in a profound change of livelihoods and significantly improved their socio-economic situation. Land and forest cover around the chosen villages fluctuated by up to 15% with a trend to increasing forest cover in recent years. At the district and state scales, forest cover was rather stable. These results question the narrative of deforestation and environmental degradation in the Himalayas as major push-factors for rural-urban migration in Uttarakhand. Even if environmental constraints were felt, it was rather the differences in socio-economic opportunities (education, employment, facilities) that drove people to migrate to the city. Regarding the push-pull paradigm, we conclude that scenarios of external conditions under which people migrate cannot be evaluated without taking the migrants’ attitudes and choices into account. [ABSTRACT FROM AUTHOR]

Effective vaccine design relies on accurate knowledge of protection against a pathogen, so as to be able to induce relevant and effective protective responses against it. An ideal Human Immunodeficiency virus (HIV) vaccine should induce humoral as well as cellular immune responses to prevent initial infection of host cells or limit early events of viral dissemination. A Phase I HIV-1 prophylactic vaccine trial sponsored by the International AIDS Vaccine Initiative (IAVI) was conducted in India in 2009.The trial tested a HIV-1 subtype C vaccine in a prime-boost regimen, comprising of a DNA prime (ADVAX) and Modified Vaccine Ankara (MVA) (TBC-M4) boost. The trial reported that the vaccine regimen was safe, well tolerated, and resulted in enhancement of HIV-specific immune responses. However, preliminary immunological studies were limited to vaccine-induced IFN-γ responses against the Env and Gag peptides. The present study is a retrospective study to characterize in detail the nature of the vaccine-induced cell mediated immune responses among volunteers, using Peripheral Blood Mononuclear Cells (PBMC) that were archived during the trial. ELISpot was used to measure IFN-γ responses and polyfunctional T cells were analyzed by intracellular multicolor flow cytometry. It was observed that DNA priming and MVA boosting induced Env and Gag specific bi-functional and multi-functional CD4+ and CD8+ T cells expressing IFN-γ, TNF-α and IL-2. The heterologous prime-boost regimen appeared to be slightly superior to the homologous prime-boost regimen in inducing favorable cell mediated immune responses. These results suggest that an in-depth analysis of vaccine-induced cellular immune response can aid in the identification of correlates of an effective immunogenic response, and inform future design of HIV vaccines. [ABSTRACT FROM AUTHOR]

Introduction: Health interventions implemented with self-help groups (SHGs) enhance the relevance and acceptability of the health services. The Parivartan program was implemented in eight districts of Bihar with women’s self-help groups to increase adoption of maternal and newborn health behaviors through layering health behavior change communication. This study estimates the cost and cost-effectiveness of a health behavior change program with SHGs in Bihar. Methods: Cost analysis was conducted from a provider’s perspective. All costs have been presented in US dollars for the purpose of international comparisons and converted to constant values. The effectiveness estimate was based on the reported changes in select newborn care practices. A decision model approach was used to estimate the potential number of neonatal deaths averted based on adoption of key newborn care practices. Using India’s life expectancy of 65 years, cost per life year saved was calculated. A one-way sensitivity analysis was conducted using the upper and lower estimates for various variables in the model, and functionality of SHGs. Results: The cost of forming an SHG group was US$254 and that of reaching a woman within the group was US$19. The unit cost for delivering health interventions through the Parivartan program was US$148 per group and US$11 per woman reached. During an 18 months period, Parivartan program reached around 17,120 SHGs and an estimated 20,544 pregnant women resulting in an estimated prevention of 23 neonatal deaths at a cost of US$3,825 per life year saved. Conclusion: SHGs can be an effective platform to increase uptake of women’s health interventions and follow-up care, and also to broaden their utility beyond microfinance, particularly when they operate at a larger scale. [ABSTRACT FROM AUTHOR]

Background: The prevalence of diabetes is increasing rapidly in low- and middle-income countries (LMICs), urgently requiring detailed evidence to guide the response of health systems to this epidemic. In an effort to understand at what step in the diabetes care continuum individuals are lost to care, and how this varies between countries and population groups, this study examined health system performance for diabetes among adults in 28 LMICs using a cascade of care approach.Methods and Findings: We pooled individual participant data from nationally representative surveys done between 2008 and 2016 in 28 LMICs. Diabetes was defined as fasting plasma glucose ≥ 7.0 mmol/l (126 mg/dl), random plasma glucose ≥ 11.1 mmol/l (200 mg/dl), HbA1c ≥ 6.5%, or reporting to be taking medication for diabetes. Stages of the care cascade were as follows: tested, diagnosed, lifestyle advice and/or medication given ("treated"), and controlled (HbA1c < 8.0% or equivalent). We stratified cascades of care by country, geographic region, World Bank income group, and individual-level characteristics (age, sex, educational attainment, household wealth quintile, and body mass index [BMI]). We then used logistic regression models with country-level fixed effects to evaluate predictors of (1) testing, (2) treatment, and (3) control. The final sample included 847,413 adults in 28 LMICs (8 low income, 9 lower-middle income, 11 upper-middle income). Survey sample size ranged from 824 in Guyana to 750,451 in India. The prevalence of diabetes was 8.8% (95% CI: 8.2%-9.5%), and the prevalence of undiagnosed diabetes was 4.8% (95% CI: 4.5%-5.2%). Health system performance for management of diabetes showed large losses to care at the stage of being tested, and low rates of diabetes control. Total unmet need for diabetes care (defined as the sum of those not tested, tested but undiagnosed, diagnosed but untreated, and treated but with diabetes not controlled) was 77.0% (95% CI: 74.9%-78.9%). Performance along the care cascade was significantly better in upper-middle income countries, but across all World Bank income groups, only half of participants with diabetes who were tested achieved diabetes control. Greater age, educational attainment, and BMI were associated with higher odds of being tested, being treated, and achieving control. The limitations of this study included the use of a single glucose measurement to assess diabetes, differences in the approach to wealth measurement across surveys, and variation in the date of the surveys.Conclusions: The study uncovered poor management of diabetes along the care cascade, indicating large unmet need for diabetes care across 28 LMICs. Performance across the care cascade varied by World Bank income group and individual-level characteristics, particularly age, educational attainment, and BMI. This policy-relevant analysis can inform country-specific interventions and offers a baseline by which future progress can be measured. [ABSTRACT FROM AUTHOR]

Children in slums are at high risk of acute malnutrition and death. Cost-effectiveness of community-based management of severe acute malnutrition programmes has been demonstrated previously, but there is limited evidence in the context of urban slums where programme cost structure is likely to vary tremendously. This study assessed the cost-utility of adding a community based prevention and treatment for acute malnutrition intervention to Government of India Integrated Child Development Services (ICDS) standard care for children in Mumbai slums. The intervention is delivered by community health workers in collaboration with ICDS Anganwadi community health workers. The analysis used a decision tree model to compare the costs and effects of the two options: standard ICDS services with the intervention and prevention versus standard ICDS services alone. The model used outcome and cost data from the Society for Nutrition, Education & Health Action’s Child Health and Nutrition programme in Mumbai slums, which delivered services to 12,362 children over one year from 2013 to 2014. An activity-based cost model was used, with calculated costs based on programme financial records and key informant interviews. Cost data were coupled with programme effectiveness data to estimate disability adjusted life years (DALYs) averted. The community based prevention and treatment programme averted 15,016 DALYs (95% Uncertainty Interval [UI]: 12,246–17,843) at an estimated cost of $23 per DALY averted (95%UI:19–28) and was thus highly cost-effective. This study shows that ICDS Anganwadi community health workers can work efficiently with community health workers to increase the prevention and treatment coverage in slums in India and can lead to policy recommendations at the state, and potentially the national level, to promote such programmes in Indian slums as a cost-effective approach to tackling moderate and severe acute malnutrition. [ABSTRACT FROM AUTHOR]

With less than 3200 wild tigers in 2010, the heads of 13 tiger-range countries committed to doubling the global population of wild tigers by 2022. This goal represents the highest level of ambition and commitment required to turn the tide for tigers in the wild. Yet, ensuring efficient and targeted implementation of conservation actions alongside systematic monitoring of progress towards this goal requires that we set site-specific recovery targets and timelines that are ecologically realistic. In this study, we assess the recovery potential of 18 sites identified under WWF’s Tigers Alive Initiative. We delineated recovery systems comprising a source, recovery site, and support region, which need to be managed synergistically to meet these targets. By using the best available data on tiger and prey numbers, and adapting existing species recovery frameworks, we show that these sites, which currently support 165 (118–277) tigers, have the potential to harbour 585 (454–739) individuals. This would constitute a 15% increase in the global population and represent over a three-fold increase within these specific sites, on an average. However, it may not be realistic to achieve this target by 2022, since tiger recovery in 15 of these 18 sites is contingent on the initial recovery of prey populations, which is a slow process. We conclude that while sustained conservation efforts can yield significant recoveries, it is critical that we commit our resources to achieving the biologically realistic targets for these sites even if the timelines are extended. [ABSTRACT FROM AUTHOR]

Human killing is the decisive and most critical expression of human-leopard conflict and needs to be addressed sensitively to maintain local support for leopard conservation in India. This research was undertaken to investigate the ecological aspects of human killing and injury, spatial characteristic and pattern of such sites, temporal and seasonal trends of attacks and perception of local communities towards leopard in the Indian Himalayan region (IHR). We surveyed two sites i) Pauri Garhwal in the western part and ii) North Bengal (Dooars) in the eastern part of IHR, compiled secondary data on human-leopard conflict records and made field visits to (N = 101) conflict sites. We also conducted (N = 186) semi-structured questionnaire surveys in each of the sites to assess perception of local communities towards leopard. We analyzed the conflict data using rare events model in a binary logistic regression framework to understand spatial patterns of such incidents for Pauri Garhwal and North Bengal. The average number of injuries and deaths to leopard attacks in Pauri was estimated to be 11 (SE 1.13) and 3 (SE 0.6) per year between 2006–2016 whereas in North Bengal it was estimated to be 70 (SE 9.2) and 1.6 (SE 0.3) respectively between 2004–2016. About 97% of the leopard attacks in North Bengal and 60% of the leopard attacks in Pauri resulted in human injuries. Majority of the leopard attack victims in Pauri were children and young people, whereas in North Bengal it was middle aged tea estate workers. Attack on humans in Pauri were recorded mostly near areas with dense scrub cover whereas in North Bengal it was reported within tea-estates. The percentage of human deaths to leopard attacks in Pauri were higher (40%) compared to a mere (3%) in North Bengal. Forty-one percent of respondents in Pauri and 75% in North Bengal were positive towards presence and conservation of leopard. A predictive risk map revealed central and northern regions of Pauri Garhwal and protected areas, peripheral areas in central and south-western dooars (North Bengal) as high “human-leopard conflict risk zones”. This analytical procedure can be adopted in other sites to identify potential human-carnivore conflict risk zones. [ABSTRACT FROM AUTHOR]

Background: Improving quality of maternal healthcare services is key to reducing maternal mortality across developing nations, including India. Expanding access to institutionalized care alone has failed to address critical quality barriers to safe, effective, patient-centred, timely and equitable care. Multi-dimensional quality improvement focusing on Person Centred Care(PCC) has an important role in expanding utilization of maternal health services and reducing maternal mortality. Methods: Nine public health facilities were selected in two rural districts of Uttar Pradesh(UP), India, to understand women’s experiences of childbirth and identify quality gaps in the process of maternity care. 23 direct, non-participant observations of uncomplicated vaginal deliveries were conducted using checklists with special reference to PCC, capturing quality of care provision at five stages—admission; pre-delivery; delivery; post-delivery and discharge. Data was thematically analysed using the framework approach. Case studies, good practices and gaps were noted at each stage of delivery care. Results: Admission to maternity wards was generally prompt. All deliveries were conducted by skilled providers and at least one staff was available at all times. Study findings were discussed under two broad themes of care ‘structure’ and ‘process’. While infrastructure, supplies and human resource were available across most facilities, gaps were observed in the process of care, particularly during delivery and post-delivery stages. Key areas of concern included compromised patient safety like poor hand hygiene, usage of unsterilized instruments; inadequate clinical care like lack of routine monitoring of labour progression, inadequate postpartum care; partially compromised privacy in the labour room and postnatal ward; and few incidents of abuse and demand for informal payments. Conclusions: The study findings reflect gaps in the quality of maternity care across public health facilities in the study area and support the argument for strengthening PCC as an important effort towards quality improvement across the continuum of delivery care. [ABSTRACT FROM AUTHOR]

Background: India has the highest burden of tuberculosis (TB). Although most patients with TB in India seek care from the private sector, there is limited evidence on quality of TB care or its correlates. Following our validation study on the standardized patient (SP) method for TB, we utilized SPs to examine quality of adult TB care among health providers with different qualifications in 2 Indian cities.Methods and Findings: During 2014-2017, pilot programs engaged the private health sector to improve TB management in Mumbai and Patna. Nested within these projects, to obtain representative, baseline measures of quality of TB care at the city level, we recruited 24 adults to be SPs. They were trained to portray 4 TB "case scenarios" representing various stages of disease and diagnostic progression. Between November 2014 and August 2015, the SPs visited representatively sampled private providers stratified by qualification: (1) allopathic providers with Bachelor of Medicine, Bachelor of Surgery (MBBS) degrees or higher and (2) non-MBBS providers with alternative medicine, minimal, or no qualifications. Our main outcome was case-specific correct management benchmarked against the Standards for TB Care in India (STCI). Using ANOVA, we assessed variation in correct management and quality outcomes across (a) cities, (b) qualifications, and (c) case scenarios. Additionally, 2 micro-experiments identified sources of variation: first, quality in the presence of diagnostic test results certainty and second, provider consistency for different patients presenting the same case. A total of 2,652 SP-provider interactions across 1,203 health facilities were analyzed. Based on our sampling strategy and after removing 50 micro-experiment interactions, 2,602 interactions were weighted for city-representative interpretation. After weighting, the 473 Patna providers receiving SPs represent 3,179 eligible providers in Patna; in Mumbai, the 730 providers represent 7,115 eligible providers. Correct management was observed in 959 out of 2,602 interactions (37%; 35% weighted; 95% CI 32%-37%), primarily from referrals and ordering chest X-rays (CXRs). Unnecessary medicines were given to nearly all SPs, and antibiotic use was common. Anti-TB drugs were prescribed in 118 interactions (4.5%; 5% weighted), of which 45 were given in the case in which such treatment is considered correct management. MBBS and more qualified providers had higher odds of correctly managing cases than non-MBBS providers (odds ratio [OR] 2.80; 95% CI 2.05-3.82; p < 0.0001). Mumbai non-MBBS providers had higher odds of correct management than non-MBBS in Patna (OR 1.79; 95% CI 1.06-3.03), and MBBS providers' quality of care did not vary between cities (OR 1.15; 95% CI 0.79-1.68; p = 0.4642). In the micro-experiments, improving diagnostic certainty had a positive effect on correct management but not across all quality dimensions. Also, providers delivered idiosyncratically consistent care, repeating all observed actions, including mistakes, approximately 75% of the time. The SP method has limitations: it cannot account for patient mix or care-management practices reflecting more than one patient-provider interaction.Conclusions: Quality of TB care is suboptimal and variable in urban India's private health sector. Addressing this is critical for India's plans to end TB by 2025. For the first time, we have rich measures on representative levels of care quality from 2 cities, which can inform private-sector TB interventions and quality-improvement efforts. [ABSTRACT FROM AUTHOR]

Background: This study evaluates an eight-session behavior change health intervention with women’s self-help groups (SHGs) aimed to promote healthy maternal and newborn practices among the more socially and economically marginalized groups. Methods: Using a pre-post quasi-experimental design, a total of 545 SHGs were divided into two groups: a control group, which received the usual microcredit intervention; and an intervention group, which received additional participatory training around maternal, neonatal, and child health issues. Women members of SHGs who had a live birth in the 12 months preceding the survey were surveyed on demographics, practices around maternal, neonatal and child health (MNCH), and collectivization. Outcome effects were assessed using difference-in-difference (DID) methods. Results: Women from the SHGs with health intervention, relative to controls over time (time 1 to time 2), were more likely to: use contraceptive methods (DID: 9 percentage points [pp], p<0.001), have institutional delivery (DID: 9pp, p<0.05), practice skin-to-skin care (DID: 17pp, p<0.05), delay bathing for 3 or more days (DID: 19pp, p<0.001), initiate timely breastfeeding (DID: 21pp, p<0.001), exclusively breastfeed the child (DID: 27pp, p<0.001), and provide age-appropriate immunization (DID: 9pp, p<0.001). Additionally, women from the SHGs with health intervention when compared to the control group over time were more likely to report: collective efficacy (DID: 17pp, p<0.001), support through accompanying SHG members for antenatal care (DID: 8pp, p<0.05), receive a visit from SHG member within 2 days post-delivery (DID: 32pp, p<0.001), and receive reproductive, maternal, neonatal and child health information from an SHG member (DID: 45pp, p<0.001). Conclusion: Findings demonstrate that structured participatory communication on MNCH with women’s groups improve positive health practices. In addition, SHGs can reach a substantial proportion of women while providing an avenue for pregnant women and young mothers to be assisted by others in learning and practicing healthy behaviors, thus building social cohesion on health. [ABSTRACT FROM AUTHOR]