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Background: Environmental enteropathy (EE), the adverse impact of frequent and numerous enteric infections on the gut resulting in a state of persistent immune activation and altered permeability, has been proposed as a key determinant of growth failure in children in low- and middle-income populations. A theory-driven systems model to critically evaluate pathways through which enteropathogens, gut permeability, and intestinal and systemic inflammation affect child growth was conducted within the framework of the Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) birth cohort study that included children from eight countries. Methods: Non-diarrheal stool samples (N = 22,846) from 1253 children from multiple sites were evaluated for a panel of 40 enteropathogens and fecal concentrations of myeloperoxidase, alpha-1-antitrypsin, and neopterin. Among these same children, urinary lactulose:mannitol (L:M) (N = 6363) and plasma alpha-1-acid glycoprotein (AGP) (N = 2797) were also measured. The temporal sampling design was used to create a directed acyclic graph of proposed mechanistic pathways between enteropathogen detection in non-diarrheal stools, biomarkers of intestinal permeability and inflammation, systemic inflammation and change in length- and weight- for age in children 0–2 years of age. Findings: Children in these populations had frequent enteric infections and high levels of both intestinal and systemic inflammation. Higher burdens of enteropathogens, especially those categorized as being enteroinvasive or causing mucosal disruption, were associated with elevated biomarker concentrations of gut and systemic inflammation and, via these associations, indirectly associated with both reduced linear and ponderal growth. Evidence for the association with reduced linear growth was stronger for systemic inflammation than for gut inflammation; the opposite was true of reduced ponderal growth. Although Giardia was associated with reduced growth, the association was not mediated by any of the biomarkers evaluated. Interpretation: The large quantity of empirical evidence contributing to this analysis supports the conceptual model of EE. The effects of EE on growth faltering in young children were small, but multiple mechanistic pathways underlying the attribution of growth failure to asymptomatic enteric infections had statistical support in the analysis. The strongest evidence for EE was the association between enteropathogens and linear growth mediated through systemic inflammation. Funding: Bill & Melinda Gates Foundation.

Summary: Background: Optimum management of childhood diarrhoea in low-resource settings has been hampered by insufficient data on aetiology, burden, and associated clinical characteristics. We used quantitative diagnostic methods to reassess and refine estimates of diarrhoea aetiology from the Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) cohort study. Methods: We re-analysed stool specimens from the multisite MAL-ED cohort study of children aged 0–2 years done at eight locations (Dhaka, Bangladesh; Vellore, India; Bhaktapur, Nepal; Naushero Feroze, Pakistan; Venda, South Africa; Haydom, Tanzania; Fortaleza, Brazil; and Loreto, Peru), which included active surveillance for diarrhoea and routine non-diarrhoeal stool collection. We used quantitative PCR to test for 29 enteropathogens, calculated population-level pathogen-specific attributable burdens, derived stringent quantitative cutoffs to identify aetiology for individual episodes, and created aetiology prediction scores using clinical characteristics. Findings: We analysed 6625 diarrhoeal and 30 968 non-diarrhoeal surveillance stools from 1715 children. Overall, 64·9% of diarrhoea episodes (95% CI 62·6–71·2) could be attributed to an aetiology by quantitative PCR compared with 32·8% (30·8–38·7) using the original study microbiology. Viral diarrhoea (36·4% of overall incidence, 95% CI 33·6–39·5) was more common than bacterial (25·0%, 23·4–28·4) and parasitic diarrhoea (3·5%, 3·0–5·2). Ten pathogens accounted for 95·7% of attributable diarrhoea: Shigella (26·1 attributable episodes per 100 child-years, 95% CI 23·8–29·9), sapovirus (22·8, 18·9–27·5), rotavirus (20·7, 18·8–23·0), adenovirus 40/41 (19·0, 16·8–23·0), enterotoxigenic Escherichia coli (18·8, 16·5–23·8), norovirus (15·4, 13·5–20·1), astrovirus (15·0, 12·0–19·5), Campylobacter jejuni or C coli (12·1, 8·5–17·2), Cryptosporidium (5·8, 4·3–8·3), and typical enteropathogenic E coli (5·4, 2·8–9·3). 86·2% of the attributable incidence for Shigella was non-dysenteric. A prediction score for shigellosis was more accurate (sensitivity 50·4% [95% CI 46·7–54·1], specificity 84·0% [83·0–84·9]) than current guidelines, which recommend treatment only of bloody diarrhoea to cover Shigella (sensitivity 14·5% [95% CI 12·1–17·3], specificity 96·5% [96·0–97·0]). Interpretation: Quantitative molecular diagnostics improved estimates of pathogen-specific burdens of childhood diarrhoea in the community setting. Viral causes predominated, including a substantial burden of sapovirus; however, Shigella had the highest overall burden with a high incidence in the second year of life. These data could improve the management of diarrhoea in these low-resource settings. Funding: Bill & Melinda Gates Foundation.

Summary: Background: Enteropathogen infections in early childhood not only cause diarrhoea but contribute to poor growth. We used molecular diagnostics to assess whether particular enteropathogens were associated with linear growth across seven low-resource settings. Methods: We used quantitative PCR to detect 29 enteropathogens in diarrhoeal and non-diarrhoeal stools collected from children in the first 2 years of life obtained during the Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) multisite cohort study. Length was measured monthly. We estimated associations between aetiology-specific diarrhoea and subclinical enteropathogen infection and quantity and attained length in 3 month intervals, at age 2 and 5 years, and used a longitudinal model to account for temporality and time-dependent confounding. Findings: Among 1469 children who completed 2 year follow-up, 35 622 stool samples were tested and yielded valid results. Diarrhoeal episodes attributed to bacteria and parasites, but not viruses, were associated with small decreases in length after 3 months and at age 2 years. Substantial decrements in length at 2 years were associated with subclinical, non-diarrhoeal, infection with Shigella (length-for-age Z score [LAZ] reduction −0·14, 95% CI −0·27 to −0·01), enteroaggregative Escherichia coli (−0·21, −0·37 to −0·05), Campylobacter (−0·17, −0·32 to −0·01), and Giardia (−0·17, −0·30 to −0·05). Norovirus, Cryptosporidium, typical enteropathogenic E coli, and Enterocytozoon bieneusi were also associated with small decrements in LAZ. Shigella and E bieneusi were associated with the largest decreases in LAZ per log increase in quantity per g of stool (−0·13 LAZ, 95% CI −0·22 to −0·03 for Shigella; −0·14, −0·26 to −0·02 for E bieneusi). Based on these models, interventions that successfully decrease exposure to Shigella, enteroaggregative E coli, Campylobacter, and Giardia could increase mean length of children by 0·12–0·37 LAZ (0·4–1·2 cm) at the MAL-ED sites. Interpretation: Subclinical infection and quantity of pathogens, particularly Shigella, enteroaggregative E coli, Campylobacter, and Giardia, had a substantial negative association with linear growth, which was sustained during the first 2 years of life, and in some cases, to 5 years. Successfully reducing exposure to certain pathogens might reduce global stunting. Funding: Bill & Melinda Gates Foundation.

Objective: To identify predictors of recovery in children with uncomplicated severe acute malnutrition (SAM).Design: This is a secondary data analysis from an individual randomised controlled trial, where children with uncomplicated SAM were randomised to three feeding regimens, namely ready-to-use therapeutic food (RUTF) sourced from Compact India, locally prepared RUTF or augmented home-prepared foods, under two age strata (6-17 months and 18-59 months) for 16 weeks or until recovery. Three sets of predictors that could influence recovery, namely child, family and nutritional predictors, were analysed.Setting: Rural and urban slum areas of three states of India, namely Rajasthan, Delhi and Tamil Nadu.Participants: In total, 906 children (age: 6-59 months) were analysed to estimate the adjusted hazard ratio (AHR) using the Cox proportional hazard ratio model to identify various predictors.Results: Being a female child (AHR: 1·269 (1·016, 1·584)), better employment status of the child's father (AHR: 1·53 (1·197, 1·95)) and residence in a rental house (AHR: 1·485 (1·137, 1·94)) increased the chances of recovery. No hospitalisation (AHR: 1·778 (1·055, 2·997)), no fever, (AHR: 2·748 (2·161, 3·494)) and ≤ 2 episodes of diarrhoea (AHR: 1·579 (1·035, 2·412)) during the treatment phase; availability of community-based peer support to mothers for feeding (AHR: 1·61 (1·237, 2·097)) and a better weight-for-height Z-score (WHZ) at enrolment (AHR: 1·811 (1·297, 2·529)) predicted higher chances of recovery from SAM.Conclusion: The probability of recovery increases in children with better WHZ and with the initiation of treatment for acute illnesses to avoid hospitalisation, availability of peer support and better employment status of the father. [ABSTRACT FROM AUTHOR]

Background: Children 0–14 years constitute about 31.4% of Indian population, among whom the magnitude and risk factors of childhood injuries have not been adequately studied. Objective: To study the prevalence of and assess the factors associated with unintentional injuries among children aged 6 month–18 years in various regions. Methodology: This multi-centric, cross-sectional, community-based study was conducted at 11 sites across India. States included were Gujarat, Karnataka, Madhya Pradesh, Punjab, Sikkim, Tamil Nadu, Uttarakhand, and West Bengal between March, 2018 and September, 2020. A total of 2341 urban and rural households from each site were selected based on probability proportionate to size. The World Health Organization (WHO) child injury questionnaire adapted to the Indian settings was used after validation. Information on injuries was collected for previous 12 months. Definitions for types (road traffic accidents, falls, burns, poisoning, drowning, animal-related injuries) and severity of injuries was adapted from the WHO study. Information was elicited from parents/primary caregivers. Data were collected electronically, and handled with a management information system. Results: In the 25751 households studied, there were 31020 children aged 6 months–18 years. A total of 1452 children (66.1% males) had 1535 unintentional injuries (excluding minor injuries) had occurred in the preceding one year. The overall prevalence of unintentional injuries excluding minor injuries was 4.7% (95% CI: 4.4–4.9). The commonest type of injury was fall-related (842, 54.8%) and the least common was drowning (3, 0.2%). Injuries in the home environment accounted for more than 50% of cases. Conclusions: The findings of the study provide inputs for developing a comprehensive child injury prevention policy in the country. Child safe school with age-appropriate measures, a safe home environment, and road safety measures for children should be a three-pronged approach in minimizing the number and the severity of child injuries both in urban and rural areas. [ABSTRACT FROM AUTHOR]

Background: India attributes to about 15% of the maternal mortality globally. Many a time poor maternal and neonatal outcomes occur unanticipated during intrapartum and postpartum period. An efficient referral system identifies the indications necessitating prompt referrals besides ensuring patient friendliness and continuity of care. Methodology: The descriptive, retrospective study was done in a secondary care hospital of a teaching institution in South India, run by primary care physicians, obstetricians and pediatricians. It describes the referrals from labour room in a year, identifying the referral rate, indications, maternal and neonatal outcomes. Results: The referral rate was found to be 3 per cent. The most common indication for the referrals was hypertensive disorders of pregnancy (54.5 percent). Among the women referred, there were no maternal deaths and majority had uncomplicated postpartum period. Eleven women developed postpartum hemorrhage. Neonatal outcome reflected a good trend as 83 per cent had an uneventful hospital stay. There were eight early neonatal deaths. Conclusion: The hospital could reduce the referral load to its tertiary care due to adequate training of primary care post graduates in basic obstetrics and anaesthesia skills, establishing standardized referral protocol and monitoring with regular clinical audits. Patient experience could be improved with inter referral unit communication and linking the health information system. [ABSTRACT FROM AUTHOR]

Introduction Rotavirus infection accounts for 39% of under-five diarrhoeal deaths globally and 22% of these deaths occur in India. Introduction of rotavirus vaccine in a national immunisation programme is considered to be the most effective intervention in preventing severe rotavirus disease. In 2016, India introduced an indigenous rotavirus vaccine (Rotavac) into the Universal Immunisation Programme in a phased manner. This paper describes the protocol for surveillance to monitor the performance of rotavirus vaccine following its introduction into the routine childhood immunisation programme. Methods An active surveillance system was established to identify acute gastroenteritis cases among children less than 5 years of age. For all children enrolled at sentinel sites, case reporting forms are completed and a copy of vaccination record and a stool specimen obtained. The forms and specimens are sent to the referral laboratory for data entry, analysis, testing and storage. Data from sentinel sites in states that have introduced rotavirus vaccine into their routine immunisation schedule will be used to determine rotavirus vaccine impact and effectiveness. Ethics and dissemination The Institutional Review Board of Christian Medical College, Vellore, and all the site institutional ethics committees approved the project. Results will be disseminated in peer-reviewed journals and with stakeholders of the universal immunisation programme in India. [ABSTRACT FROM AUTHOR]

Background: Providing treatment to patients with diabetes mellitus in rural areas at a cost they can afford is a public health challenge. Aims: This study aims to measure the rate of compliance to oral hypoglycemic agents among patients with type 2 diabetes mellitus attending peripheral mobile clinics in rural South India. To study factors that impact glycemic control. Setting and Design: A cross-sectional study was done among patients attending peripheral mobile clinics in a rural block in Southern India. Materials and Methods: Pill counts were done to assess compliance. Participants' dietary intake was measured using a 24 h diet recall and their level of physical activity was measured using the WHO Global Physical Activity Questionnaire. Glycated hemoglobin (HbA1c) was measured for all participants. Statistical Analyses Used: Data were entered on EpiData and analyzed using SPSS. The prevalence of good glycemic control and good compliance was measured. A multiple linear regression was done to study factors affecting glycemic control. Results: Overall 52% of the participants were compliant to at least one drug and 50% had achieved good glycemic control. Compliance increased by 2.1% with every passing year since the diagnosis of diabetes. HbA1c reduced by 0.09% for every 10% increase in overall compliance. Conclusions: Levels of compliance and glycemic control achieved through this primary care team is comparable to those achieved through other systems. [ABSTRACT FROM AUTHOR]

Background: Occupational health has never been a priority for policy makers in India, despite 63% of the Indian population being in the economically productive age group. Objectives: The study was designed to find out the morbidity as a result of long‑term exposure to pesticides among professional pesticide sprayers in a rural block in Tamil Nadu. Subjects and Methods: A cross‑sectional study was done in Kaniyambadi block of Vellore district, Tamil Nadu, during July to October 2013. A total of 70 professional pesticide sprayers and 66 people engaged in other occupations were enrolled into the study. The participants were administered a standardized questionnaire apart from measuring pulmonary function and peripheral sensations. Venous blood samples were collected for measuring serum cholinesterase. Results: The pesticide sprayers had higher prevalence of breathlessness on activities of daily living (odds ratio [OR]: 3.14, 95% confidence interval [CI]: 1.22-8.07), chronic cough/phlegm (OR: 3.53, 95% CI: 1.09-11.46), symptoms of peripheral sensory neuropathy (OR: 6.66, 95% CI: 2.53-17.51) and recurrent abdominal pain (OR: 3.05, 95% CI: 1.03-9.01), when compared to people engaged in other occupations. Pesticide sprayers also had significantly lower mean peak expiratory low rates and poor peripheral sensations. The serum cholinesterase levels were not statistically different between the groups. Conclusion: The pesticide sprayers had a higher morbidity when compared to people engaged in other occupations, and further research is needed to find out methods to prevent the same. Serum cholinesterase may not be a good marker for quantifying exposure to pesticide among sprayers, during a spraying season. [ABSTRACT FROM AUTHOR]

Background: A variety of musculoskeletal disorders and discomfort are seen among brick kiln workers, where heavy physical work is associated with awkward working postures and manual handling of materials, leading to significant morbidity. Materials and Methods: This cross-sectional study was conducted in unorganized brick kiln industries in villages of Vellore district of Tamil Nadu and included 310 brick kiln workers. Modified Nordic Questionnaire was used to survey the prevalence of musculoskeletal disorders and the intensity of pain was assessed by the body pain discomfort scale. Results: The mean age of the workers was 37 ± 13.2 years with a range of 18-85 years. 62% (n = 192) had normal body mass index, whereas 27% (n = 85) were undernourished. The commonest posture adopted at work was squatting (67%) followed by standing (14%). Majority of workers (87%, n = 269) reported to having symptoms of pain currently of which 51% (n = 158) had pain during work. Chronic low back ache (LBA) (1 year prevalence -59%) and acute LBA (1 week prevalence-33%) were the commonest followed by chronic knee pain. More than 10 years of work was significantly associated (P < 0.05) with acute LBA and acute and chronic knee pain. Severity of the pain was also significantly (t statistic 2.476, P < 0.05) associated with job dissatisfaction. Conclusion: Long-term brick kiln workers, who adopt a specific posture for prolonged periods, have severe musculoskeletal pain that interferes with activities of daily living and reduces job satisfaction. Health education on frequent postural change, implementation and monitoring of laws among unorganized industries are recommended to bring down morbidity due to musculoskeletal disorders (MSD). [ABSTRACT FROM AUTHOR]