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Introduction: We evaluated knowledge, attitudes, and practices (KAP) related to influenza and influenza vaccination among pregnant women in three selected countries. Methods: During 2017, pregnant women seeking antenatal care at hospitals at participating sites were enrolled. We described characteristics and responses to KAP questions. We also evaluated predictors associated with influenza vaccination during pregnancy at sites with substantial influenza vaccine uptake by multivariable logistic regression. Results: Overall, 4,648 pregnant women completed the survey. There were substantial differences among the three survey populations; only 8% of the women in Nagpur had heard of influenza, compared to 90% in Lima and 96% in Bangkok (p-value

Summary: Background: Paediatric vaccination against influenza can result in indirect protection, by reducing transmission to their unvaccinated contacts. We investigated whether influenza vaccination of children would protect them and their household members in a resource-limited setting. Methods: We did a cluster-randomised, blinded, controlled study in three villages in India. Clusters were defined as households (ie, dwellings that shared a courtyard), and children aged 6 months to 10 years were eligible for vaccination as and when they became age-eligible throughout the study. Households were randomly assigned (1:1) by a computer-based system to intramuscular trivalent inactivated influenza vaccine (IIV3) or a control of inactivated poliovirus vaccine (IPV) in the beginning of the study; vaccination occurred once a year for 3 years. The primary efficacy outcome was laboratory-confirmed influenza in a vaccinated child with febrile acute respiratory illness, analysed in the modified intention-to-treat population (ie, children who received at least one dose of vaccine, were under surveillance, and had not an influenza infection within 15 days of last vaccine dose). The secondary outcome for indirect effectiveness (surveillance study) was febrile acute respiratory illness in an unvaccinated household member of a vaccine study participant. Data from each year (year 1: November, 2009, to October, 2010; year 2: October, 2010, to October, 2011; and year 3: October, 2011, to May, 2012) were analysed separately. Safety was analysed among all participants who were vaccinated with at least one dose of the vaccine. This trial is registered with ClinicalTrials.gov, number NCT00934245. Findings: Between Nov 1, 2009, to May 1, 2012, we enrolled 3208 households, of which 1959 had vaccine-eligible children. 1010 households were assigned to IIV3 and 949 households were assigned to IPV. In 3 years, we vaccinated 4345 children (2132 with IIV3 and 2213 with IPV) from 1868 households (968 with IIV3 and 900 with IPV) with 10 813 unvaccinated household contacts. In year 1, influenza virus was detected in 151 (10%) of 1572 IIV3 recipients and 206 (13%) of 1633 of IPV recipients (total IIV3 vaccine efficacy 25·6% [95% CI 6·8–40·6]; p=0·010). In year 2, 105 (6%) of 1705 IIV3 recipients and 182 (10%) of 1814 IPV recipients had influenza (vaccine efficacy 41·0% [24·1–54·1]; p

Historical specimens collected from hospitalized children were tested for the following 13 viruses: influenza A and B; respiratory syncytial virus (RSV); parainfluenza viruses 1–3; human metapneumovirus; rhinovirus; coronaviruses 229E, OC43, NL63 and HKU1 and Adenovirus using monoplex real-time reverse transcriptase polymerase chain reaction (rRT-PCR). They were retested using TaqMan Array Card (TAC), a micro-fluidic system, capable of simultaneous multi-pathogen testing, to evaluate its sensitivity and specificity against monoplex rRT-PCR. TAC showed high sensitivity (71%–100%) and specificity (98%–100%) for these viruses in comparison to monoplex rRT-PCR. Multi-specimen detection with high sensitivity and specificity makes TAC a potentially useful tool for both surveillance and outbreak investigations.

Background There are limited data on incidence, risk factors and etiology of acute lower respiratory tract infection (LRTI) among older adults in low- and middle-income countries. Methods We established a cohort of community dwelling older adults ≥60 years and conducted weekly follow-up for acute respiratory infections (ARI) during 2015-2017. Nurses assessed ARI cases for LRTI, collecting combined nasal/throat swabs from all LRTI cases and an equal number of age- and sex-matched asymptomatic neighbourhood controls. Swabs were tested for influenza viruses, respiratory syncytial virus (RSV), human metapneumovirus (hMPV), and parainfluenza viruses (PIV) using polymerase chain reaction. LRTI and virus-specific LRTI incidence was calculated per 1000 person-years. We estimated adjusted incidence rate ratios (IRR) for risk factors using Poisson regression and calculated etiologic fractions (EF) using adjusted odds ratios for detection of viral pathogens in LRTI cases vs controls. Results We followed 1403 older adults for 2441 person-years. LRTI and LRTI-associated hospitalization incidences were 248.3 (95% confidence interval (CI) = 229.3-268.8) and 12.7 (95% CI = 8.9-18.1) per 1000 person-years. Persons with pre-existing chronic bronchitis as compared to those without (incidence rate ratio (IRR) = 4.7, 95% CI = 3.9-5.6); aged 65-74 years (IRR = 1.6, 95% CI = 1.3-2.0) and ≥75 years (IRR = 1.8, 95% CI = 1.4-2.4) as compared to 60-64 years; and persons in poorest wealth quintile (IRR = 1.4, 95% CI = 1.1-1.8); as compared to those in wealthiest quintile were at higher risk for LRTI. Virus was detected in 10.1% of LRTI cases, most commonly influenza (3.8%) and RSV (3.0%). EF for RSV and influenza virus was 83.9% and 83.6%, respectively. Conclusion In this rural cohort of older adults, the incidence of LRTI was substantial. Chronic bronchitis was an important risk factor; influenza virus and RSV were major viral pathogens.

Background Influenza is a cause of febrile acute respiratory infection (FARI) in India; however, few influenza vaccine trials have been conducted in India. We assessed absolute and relative efficacy of live attenuated influenza vaccine (LAIV) and inactivated influenza vaccine (IIV) among children aged 2 to 10 years in rural India through a randomized, triple-blind, placebo-controlled trial conducted over 2 years. Methods and findings In June 2015, children were randomly allocated to LAIV, IIV, intranasal placebo, or inactivated polio vaccine (IPV) in a 2:2:1:1 ratio. In June 2016, vaccination was repeated per original allocation. Overall, 3,041 children received LAIV (n = 1,015), IIV (n = 1,010), nasal placebo (n = 507), or IPV (n = 509). Mean age of children was 6.5 years with 20% aged 9 to 10 years. Through weekly home visits, nasal and throat swabs were collected from children with FARI and tested for influenza virus by polymerase chain reaction. The primary outcome was laboratory-confirmed influenza-associated FARI; vaccine efficacy (VE) was calculated using modified intention-to-treat (mITT) analysis by Cox proportional hazards model (PH) for each year. In Year 1, VE was 40.0% (95% confidence interval (CI) 25.2 to 51.9) for LAIV and 59.0% (95% CI 47.8 to 67.9) for IIV compared with controls; relative efficacy of LAIV compared with IIV was −46.2% (95% CI −88.9 to −13.1). In Year 2, VE was 51.9% (95% CI 42.0 to 60.1) for LAIV and 49.9% (95% CI 39.2 to 58.7) for IIV; relative efficacy of LAIV compared with IIV was 4.2% (95% CI −19.9 to 23.5). No serious adverse vaccine-attributable events were reported. Study limitations include differing dosage requirements for children between nasal and injectable vaccines (single dose of LAIV versus 2 doses of IIV) in Year 1 and the fact that immunogenicity studies were not conducted. Conclusions In this study, we found that LAIV and IIV vaccines were safe and moderately efficacious against influenza virus infection among Indian children. Trial registration Clinical Trials Registry of India CTRI/2015/06/005902., Anand Krishnan and co-workers study the efficacy and safety of influenza vaccines for children in India., Author summary Why was this study done? In recent years, 2 community-based trials of the single-dose Russian-backbone live attenuated influenza vaccine (LAIV) in low- and middle-income countries (LMIC) have been published, with contrasting results. In Senegal, LAIV vaccine efficacy (VE) was demonstrated to be 0.0% (95% confidence interval (CI) −26.4 to 20.9), and in Bangladesh, LAIV VE was demonstrated to be 41.0% (95% CI 28.0 to 51.6) against all influenza virus strains. In addition, observational studies for VE of LAIV such as in the United States and Europe have also shown mixed results. While the World Health Organization (WHO) continues to recommend LAIV use in children, conflicting data on LAIV have led countries to review and reconsider national preferential recommendations for LAIV use in children. Given these gaps in evidence and the potential for indigenously produced LAIV to be used for prevention of influenza virus infection in Indian children, we evaluated the absolute efficacy of LAIV and inactivated influenza vaccine (IIV) and relative efficacy of LAIV versus IIV among children aged 2 to 10 years in rural India. What did the researchers do and find? We conducted a 2-year, triple (participant–observer–analyst) blind, community-based vaccine trial. We randomly assigned 3,041 children aged 2 to 10 years to receive age appropriate doses of LAIV, IIV, or a control vaccine. In Year 1, VE was 40.0% (95% CI 25.2 to 51.9) for LAIV and 59.0% (95% CI 47.8 to 67.9) for IIV compared with controls; relative efficacy of LAIV compared with IIV was −46.2% (95% CI −88.9 to −13.1). In Year 2, VE was 51.9% (95% CI 42.0 to 60.1) for LAIV and 49.9% (95% CI 39.2 to 58.7) for IIV; relative efficacy of LAIV compared with IIV was 4.2% (95% CI −19.9 to 23.5). We found that LAIV and IIV were safe and moderately efficacious against laboratory-confirmed influenza virus infection. In Year 1, LAIV, as a single dose in a vaccine-naïve population, was significantly less efficacious than IIV, whereas in Year 2, VE for LAIV and IIV was similar. This was the first randomized controlled trial to our knowledge in a developing country setting that compared LAIV efficacy with IIV and provided VE by age group and influenza type/subtype across seasons spanning 2 consecutive years. Importantly, during both years, LAIV and IIV were protective against influenza A(H3N2) viruses. However, LAIV had limited efficacy against influenza A(H1N1)pdm09 for both years. What do these findings mean? Influenza vaccination is an important tool for preparedness and response against seasonal epidemics and pandemics. However, decisions on specific vaccine introductions into national immunization platforms depend on multiple factors including effectiveness, presence of existing immunization platforms and cold chain infrastructure, cost, and local production of the vaccines. Availability of indigenous, safe, and moderately efficacious influenza vaccines, including LAIV, should initiate discussion on the optimal use of vaccines for the national strategy for influenza prevention and control in India.

Pneumococcal carriage studies are important for vaccine introduction and treatment strategies. Pneumococcal carriage rates estimated in this cohort study among children in a rural community of northern India. Between August 2012 and August 2014, trained nurses made weekly home visits to screen enrolled children aged

Background The World Health Organization (WHO) recommends case definitions for influenza surveillance that are also used in public health research, although their performance has not been assessed in many risk groups, including pregnant women in whom influenza may manifest differently. We evaluated the performance of symptom-based definitions to detect influenza in a cohort of pregnant women in India, Peru, and Thailand. Methods In 2017 and 2018, we contacted 11 277 pregnant women twice weekly during the influenza season to identify illnesses with new or worsened cough, runny nose, sore throat, difficulty breathing, or myalgia and collected data on other symptoms and nasal swabs for influenza real-time reverse transcription–polymerase chain reaction (rRT-PCR) testing. We calculated sensitivity, specificity, positive-predictive value, and negative-predictive value of each symptom predictor, WHO respiratory illness case definitions, and a de novo definition derived from results of multivariable modeling. Results Of 5444 eligible illness episodes among 3965 participants, 310 (6%) were positive for influenza. In a multivariable model, measured fever ≥38°C (adjusted odds ratio [95% confidence interval], 4.6 [3.1–6.8]), myalgia (3.0 [2.2–4.0]), cough (2.7 [1.9–3.9]), and chills (1.6 [1.1–2.4]) were independently associated with influenza illness. A definition based on these 4 (measured fever, cough, chills, or myalgia) was 95% sensitive and 27% specific. The WHO influenza-like illness (ILI) definition was 16% sensitive and 98% specific. Conclusions The current WHO ILI case definition was highly specific but had low sensitivity. The intended use of case definitions should be considered when evaluating the tradeoff between sensitivity and specificity.

Background Influenza causes substantial morbidity and mortality worldwide, however, reliable burden estimates from developing countries are limited, including India. We aimed to quantify influenza-associated mortality for India utilizing 2010-2013 nationally representative data sources for influenza virus circulation and deaths. Methods Virological data were obtained from the influenza surveillance network of 10 laboratories led by National Institute of Virology, Pune covering eight states from 2010-2013. Death data were obtained from the nationally representative Sample Registration System for the same time period. Generalized linear regression with negative binomial distribution was used to model weekly respiratory and circulatory deaths by age group and proportion of specimens positive for influenza by subtype; excess deaths above the seasonal baseline were taken as an estimate of influenza-associated mortality counts and rates. Annual excess death rates and the 2011 India Census data were used to estimate national influenza-associated deaths. Results Estimated annual influenza-associated respiratory mortality rates were highest for those ≥65 years (51.1, 95% confidence interval (CI) = 9.2-93.0 deaths/100 000 population) followed by those

Evidence on influenza vaccine effectiveness from low and middle countries (LMICs) is limited due to limited institutional capacities; lack of adequate resources; and lack of interest by ministries of health for influenza vaccine introduction. There are concerns that the highest ethical standards will be compromised during trials in LMICs leading to mistrust of clinical trials. These factors pose regulatory and operational challenges to researchers in these countries. We conducted a community-based vaccine trial to assess the efficacy of live attenuated influenza vaccine and inactivated influenza vaccine in rural north India. Key regulatory challenges included obtaining regulatory approvals, reporting of adverse events, and compensating subjects for trial-related injuries; all of which were required to be completed in a timely fashion. Key operational challenges included obtaining audio-visual consent; maintaining a low attrition rate; and administering vaccines during a narrow time period before the influenza season, and under extreme heat. We overcame these challenges through advanced planning, and sustaining community engagement. We adapted the trial procedures to cope with field conditions by conducting mock vaccine camps; and planned for early morning vaccination to mitigate threats to the cold chain. These lessons may help investigators to confront similar challenges in other LMICs.

PurposeWe describe here a multicentric community-dwelling cohort of older adults (>60 years of age) established to estimate incidence, study risk factors, healthcare utilisation and economic burden associated with influenza and respiratory syncytial virus (RSV) in India.ParticipantsThe four sites of this cohort are in northern (Ballabgarh), southern (Chennai), eastern (Kolkata) and western (Pune) parts of India. We enrolled 5336 participants across 4220 households and began surveillance in July 2018 for viral respiratory infections with additional participants enrolled annually. Trained field workers collected data about individual-level and household-level risk factors at enrolment and quarterly assessed frailty and grip strength. Trained nurses surveilled weekly to identify acute respiratory infections (ARI) and clinically assessed individuals to diagnose acute lower respiratory infection (ALRI) as per protocol. Nasal and oropharyngeal swabs are collected from all ALRI cases and one-fifth of the other ARI cases for laboratory testing. Cost data of the episode are collected using the WHO approach for estimating the economic burden of seasonal influenza. Handheld tablets with Open Data Kit platform were used for data collection.Findings to dateThe attrition of 352 participants due to migration and deaths was offset by enrolling 680 new entrants in the second year. All four sites reported negligible influenza vaccination uptake (0.1%–0.4%), low health insurance coverage (0.4%–22%) and high tobacco use (19%–52%). Ballabgarh had the highest proportion (54.4%) of households in the richest wealth quintile, but reported high solid fuel use (92%). Frailty levels were highest in Kolkata (11.3%) and lowest in Pune (6.8%). The Chennai cohort had highest self-reported morbidity (90.1%).Future plansThe findings of this cohort will be used to inform prioritisation of strategies for influenza and RSV control for older adults in India. We also plan to conduct epidemiological studies of SARS-CoV-2 using this platform.

Background No estimates of influenza-associated mortality exist for India. Objective To evaluate national mortality and viral surveillance data from India for assessing their appropriateness in estimating influenza-associated mortality using varied analytic approaches. Methods We reviewed influenza virus surveillance data from a national influenza surveillance network. We also reviewed national mortality data from Civil Registration System (CRS), Medical Certification of Cause of Death (MCCD) and the Sample Registration System (SRS). We compared and scored the different sources of mortality data using specific criteria, including the process of cause of death assignment, sample size, proportion of ill-defined deaths, representativeness and availability of time series data. Each of these 5 parameters was scored on a scale from 1 to 5. To evaluate how to generate an influenza-associated mortality estimate for India, we also reviewed 4 methodologic approaches to assess the appropriateness of their assumptions and requirements for these data sets. Results The influenza virus surveillance data included year-round sample testing for influenza virus and was found to be suitable for influenza mortality estimation modelling. Based on scoring for the 5 mortality data criteria, the SRS data had the highest score with 20 of 25 possible score, whereas MCCD and CRS scored 16 and 12, respectively. The SRS which used verbal autopsy survey methods was determined to be nationally representative and thus adequate for estimating influenza-associated mortality. Evaluation of the modelling methods demonstrated that Poisson regression, risk difference and mortality multiplier methods could be applied to the Indian setting. Conclusion Despite significant challenges, it is possible to estimate influenza-associated mortality in India.

Background In India, community-based acute lower respiratory infections (ALRI) burden studies are limited, hampering development of prevention and control strategies. Methods We surveyed children

Background & objectives: Respiratory tract infections are common among Hajj and Umrah pilgrims which pose a public health risk of spread of respiratory infections. Influenza has been reported from Indian Hajj and Umrah returning pilgrims, but data on other respiratory pathogens are sparse in India. Here we report the presence of common respiratory viral pathogens in returning Hajj and Umrah pilgrims suffering from acute respiratory illness (ARI) in 2014-2015. Methods: Respiratory specimens (nasopharyngeal and throat swabs) were collected from 300 consenting pilgrims with ARI in the past one week and tested for influenza and Middle East Respiratory Syndrome coronavirus (MERS-CoV) and other respiratory viruses using in-house standardized quantitative real-time reverse-transcription polymerase chain reaction. Clinical features among the pathogen positive and negative patients were compared. The patients received symptomatic treatment and antivirals where appropriate and were followed telephonically to collect data on illness outcome. Results: Ninety seven (32.3%) of the 300 participants were tested positive for any virus, most common being influenza viruses (n=33, 11%). Other respiratory viruses that were detected included human coronaviruses [n=26, 8.7%; OC43 (n=19, 6.3%) and C229E (n=7, 2.3%)], rhinovirus (n=20, 6%), adenoviruses (n=8, 2.6%), parainfluenza viruses (n=7, 2.3%), respiratory syncytial virus (n=3, 1%) and bocaviruses (n=2, 0.6%). Clinical features observed in pathogen positive and pathogen negative patients did not differ significantly. Eighteen influenza positive patients were treated with oseltamivir. Interpretation & conclusions: Pilgrims returning from mass gatherings are often afflicted with respiratory pathogens with a potential to facilitate transmission of respiratory pathogens across international borders. The study reinforces the need for better infection prevention and control measures such as vaccination, health education on cough etiquette and hand hygiene.

The function of suspension system is to absorb vibrations due to rough terrains or road disturbances and to provide stability under circumstances like accelerating, cornering, uneven road, braking, loading and unloading etc. Control arm is one of the most important part of the suspension system, as it joins the steering knuckle to the vehicle frame. Also suspension arm is responsible for up and down movement of wheels when hitting bumps. It is also designed to maximize the friction between tire contacts, patch the road surface to provide vehicle stability under any circumstances. It can be seen in many types of the suspensions like wishbone or double wishbone suspensions. Many times it is also called as A-type control arm. In this study control arm was reverse engineered. Reverse engineering refers to the process of obtaining a CAD model from an existing physical part. CAD model was prepared using CATIA v5 software and finite element analysis was done using ANSYS 14.5 software by importing the parasolid file to ANSYS. The model is subjected to loading and boundary conditions and then analyzed using the FEA techniques. The static structural analysis was done to find out the stress, deformation and safety factor of component. The model was meshed using 10-noded tetrahedral elements. Result obtained from the analysis were studied to check whether the design is safe or not. In some cases the stresses becomes more than safe limit. In that case optimization approach is carried out to increase the structural strength of the component. In this case maximum von-misses stress is 211 MPa which is below the yield strength of the material.

Summary Objectives Though respiratory viruses are thought to cause substantial morbidity globally in children aged

Background The World Health Organization (WHO) recommends case definitions for influenza surveillance that are also used in public health research, though their performance has not been assessed in many risk groups, including pregnant women in whom influenza may manifest differently. Â We evaluated the performance of symptom-based case definitions to detect influenza in a cohort of pregnant women in India, Peru, and Thailand. Methods In 2017, we contacted 4774 pregnant women twice a week during the influenza season to identify illnesses with new or worsened cough, runny nose, sore throat, difficulty breathing or myalgia, and collected data on other symptoms and nasal swabs for influenza rRT–PCR testing. To identify symptom predictors of influenza, we used multivariable logistic regression with forward selection of symptoms significant in univariate analysis after controlling for country, chronic conditions, influenza vaccination, and time from symptom onset to swab collection. We calculated sensitivity and specificity of each symptom, WHO respiratory illness case definitions and a case definition based on significant predictors from the multivariable model. Results Of 2431 eligible illness episodes among 1,716 participants, 142 (5.8%) were positive for influenza. Among individual symptoms, runny nose was most sensitive and measured fever ≥ 38° Celsius was most specific (Figure 1). In a multivariable model, measured fever ≥ 38° Celsius [adjusted odds ratio = 3.8, 95% confidence interval [CI] = 2.0–7.2], cough [2.7, CI 1.6–4.7], chills [2.2, CI 1.2–3.8], and myalgia [1.2, CI 2.2, 5.3] were independently associated with influenza illness. A case definition based on these four (measured fever, cough, chills or myalgia), was 91%-sensitive and 37% specific. Sensitivity and specificity of case definitions varied (Figure 2). Conclusion While a case definition based on one or more of fever, chills, cough or myalgia is highly-sensitive and moderately specific among pregnant women, case definitions requiring measured or subjective fever may miss many influenza cases making them sub-optimal for studies of burden or vaccine efficacy. The intended use of case definitions should be considered when evaluating the tradeoff between sensitivity and specificity. Disclosures All authors: No reported disclosures.

Background The World Health Organization recommends influenza vaccination for pregnant women. However, few data exist on influenza incidence and clinical course among pregnant women in middle-income countries where influenza vaccine use during pregnancy is often limited. We conducted a prospective cohort study of pregnant women to estimate incidences of influenza in Lima, Peru; Bangkok, Thailand; and Nagpur, India. Methods Prior to and early in the 2017 and 2018 influenza seasons, we enrolled pregnant women aged > 18 years with expected delivery dates > 8 weeks after the start of the season. We contacted women twice weekly until end of pregnancy to identify illnesses with myalgia, cough, runny nose, sore throat, or difficulty breathing and collected nasal swabs from symptomatic women for influenza real-time reverse transcription polymerase chain reaction testing. Using 2017 cohort data, we calculated crude incidences per 10,000 pregnancy-months during influenza season by site and trimester and overall incidence weighted for population of women of childbearing age in each country. Results We enrolled 4774 women with a median age of 26 years (interquartile range [IQR] 23–31) and gestational age of 20 weeks (IQR 15–24); 15% received influenza vaccine. Local influenza seasons spanned 4.5–8 months. Overall, 143 participants (3%) had influenza (113 (79%) influenza A and 30 (21%) influenza B). Weighted influenza incidence was 88.7/10,000 pregnancy-months (95% CI 68.6–114.8), though incidences varied up to two-fold by site (Figure 1). Incidences did not differ by pregnancy trimester (Figure 2). Among the 143 influenza episodes, the median duration was 7 days (IQR 5–10), 30% involved fever or chills, 43% disrupted daily activities, 47% prompted medical attention, 4% were associated with hospitalization, and < 1% were treated with antiviral medications. Conclusion Overall, pregnant women had an average risk of influenza of 0.9% per month of pregnancy spent in the influenza season with almost half of illnesses disrupting daily activities and prompting medical attention. Influenza-associated hospitalization was infrequent. These findings provide valuable inputs to estimate illnesses averted by vaccine programs and evaluate their cost–benefit among pregnant women in middle-income countries. Disclosures All authors: No reported disclosures.

Socioeconomic status is a measurement of economic and social position of an individual in the society. It influences the accessibility to the resources, livelihood pattern, food and nutritional security. The present study was conducted in Jhitkari, Chhabariya and Chandana villages of Sardhana block of Meerut district with the objectives to find out the socioeconomic status and to identify problems faced by dairy farmers. The data was collected from 120 farmers, 40 from each village. The result indicated that majority of the farmers belonged to the age group 36-50 years; the agriculture along with dairying was their main occupation and education level of 78 percent of dairy farmers was above high school. The average annual income from animal husbandry and agriculture was Rs. 46,000/- and Rs.1,33,000/- respectively; the average total annual income from all sources was Rs.1,84,000/-. The problems identified in selected villages were lack of knowledge about modern technologies, unavailability of veterinarian/ para-vet, infertility in dairy animals, lack of agricultural market etc.

Background The increasing reports of Middle East Respiratory Syndrome (MERS) caused by MERS coronavirus (MERS-CoV) from many countries emphasize its importance for international travel. Muslim pilgrimages of Hajj and Umrah involve mass gatherings of international travellers. We set out to assess the presence of influenza and MERS-CoV in Hajj/Umrah returnees with acute respiratory infection. . Methods Disembarking passengers (n = 8753) from Saudi Arabia (October 2014 to April 2015) were interviewed for the presence of respiratory symptoms; 977 (11%) reported symptoms and 300 (age 26–90, median 60 years; 140 male) consented to participate in the study. After recording clinical and demographic data, twin swabs (nasopharyngeal and throat) were collected from each participant, pooled in viral transport media and tested by real-time RT PCR for MERS-CoV and influenza A and B viruses and their subtypes. Results The participants had symptoms of 1–15 days (median 5d); cough (90%) and nasal discharge (86%) being the commonest. None of the 300 participants tested positive for MERS-CoV; however, 33 (11%) tested positive for influenza viruses (A/H3N2 = 13, A/H1N1pdm09 = 9 and B/Yamagata = 11). Eighteen patients received oseltamivir. No hospitalizations were needed and all had uneventful recovery. Conclusion Despite a high prevalence of acute respiratory symptoms, MERS coV was not seen in returning pilgrims from Hajj and Umrah. However detection of flu emphasises preventive strategies like vaccination.

Objective To estimate rates of community-level influenza-like-illness (ILI) and influenza-associated ILI in rural north India. Methods During 2011, we conducted household-based healthcare utilization surveys (HUS) for any acute medical illness (AMI) in preceding 14days among residents of 28villages of Ballabgarh, in north India. Concurrently, we conducted clinic-based surveillance (CBS) in the area for AMI episodes with illness onset ≤3days and collected nasal and throat swabs for influenza virus testing using real-time polymerase chain reaction. Retrospectively, we applied ILI case definition (measured/reported fever and cough) to HUS and CBS data. We attributed 14days of risk-time per person surveyed in HUS and estimated community ILI rate by dividing the number of ILI cases in HUS by total risk-time. We used CBS data on influenza positivity and applied it to HUS-based community ILI rates by age, month, and clinic type, to estimate the community influenza-associated ILI rates. Findings The HUS of 69,369 residents during the year generated risk-time of 3945 person-years (p-y) and identified 150 (5%, 95%CI: 4–6) ILI episodes (38 ILI episodes/1,000 p-y; 95% CI 32–44). Among 1,372 ILI cases enrolled from clinics, 126 (9%; 95% CI 8–11) had laboratory-confirmed influenza (A (H3N2) = 72; B = 54). After adjusting for age, month, and clinic type, overall influenza-associated ILI rate was 4.8/1,000 p-y; rates were highest among children

Background The burden estimation studies for respiratory syncytial virus (RSV) have been based on varied case definitions, including case–definitions designed for influenza surveillance systems. We used all medical admissions among children aged 0–59 months to study the effect of case definitions on estimation of RSV–associated hospitalizations rates. Methods The hospital–based daily surveillance enrolled children aged 0–59 months admitted with acute medical conditions from July 2009–December 2012, from a well–defined rural population in Ballabgarh in northern India. All study participants were examined and nasal and throat swabs taken for testing by real–time polymerase chain reaction (RT–PCR) for RSV and influenza virus. Clinical data were used to retrospectively evaluate World Health Organization (WHO) case definitions (2011) commonly used for surveillance of respiratory pathogens, ie, acute respiratory illness (WHO–ARI), severe ARI (SARI) and influenza–like illness (ILI), for determination of RSV–associated hospitalization. RSV–associated hospitalization rates adjusted for admissions at non–study hospitals were calculated. Findings Out of 505 children enrolled, 82 (16.2%) tested positive for RSV. Annual incidence rates of RSV–associated hospitalization per 1000 children were highest among infants aged 0–5 months (15.2; 95% confidence interval (CI) 8.3–26.8), followed by ages 6–23 months (5.3, 95% CI 3.2–8.7) and lowest among children 24–59 months (0.5, 95% CI 0.1–1.5). The RSV positive children were more likely to have signs of respiratory distress like wheeze, chest in–drawing, tachypnea, and crepitation compared to RSV–negative based on bivariate comparisons. Other less commonly seen signs of respiratory distress, ie, nasal flaring, grunting, accessory muscle usage were also significantly associated with being RSV positive. Compared to the estimated RSV hospitalization rate based on all medical hospitalizations, the WHO–ARI case definition captured 86% of the total incidence, while case definitions requiring fever like ILI and SARI underestimated the incidence by 50–80%. Conclusions Our study suggests that RSV is a substantial cause of hospitalization among children aged

Background Despite acute respiratory infections being a major cause of death among children in developing countries including India, there is a lack of community-based studies that document its burden and aetiology. Methods A dynamic cohort of children aged 0–10 years was established in four villages in a north Indian state of Haryana from August 2012 onwards. Trained health workers conducted weekly home visits to screen children for acute respiratory infection (ARI) defined as one of the following: cough, sore throat, nasal congestion, earache/discharge, or breathing difficulty. Nurses clinically assessed these children to grade disease severity based on standard age-specific guidelines into acute upper or lower respiratory infection (AURI or ALRI) and collected nasal/throat swabs for pathogen testing. Results Our first year results show that ARI incidence in 0–10 years of age was 5.9 (5.8–6.0) per child-year with minimal gender difference, the ALRI incidence in the under-five age group was higher among boys (0.43; 0.39–0.49) as compared to girls (0.31; 0.26–0.35) per child year. Boys had 2.4 times higher ARI-related hospitalization rate as compared to girls. Conclusion ARI impose a significant burden on the children of this cohort. This study platform aims to provide better evidence for prevention and control of pneumonia in developing countries.

Background Despite the high mortality and morbidity resulting from acute respiratory infections (ARI) globally, there are few data from low-income countries on costs of ARI to inform public health policy decisions We conducted a prospective survey to assess costs of ARI episodes in selected primary, secondary, and tertiary healthcare facilities in north India where no respiratory pathogen vaccine is routinely recommended. Methods Face-to-face interviews were conducted among a purposive sample of patients with ARI from healthcare facilities. Data were collected on out-of-pocket costs of hospitalization, medical consultations, medications, diagnostics, transportation, lodging, and missed work days. Telephone surveys were conducted two weeks after medical encounters to ask about subsequent missed work and costs incurred. Costs of prescriptions and diagnostics in public facilities were supplemented with WHO-CHOICE estimates of hospital bed costs. Missed work days were assigned cost based on the national annual per capita income (US$1,104). Non-medically attended ARI cases were identified from an ongoing community-based ARI surveillance project in Faridabad. Results During September 2012-March 2013, 1766 patients with ARI were enrolled, including 451 hospitalized patients, 1056 outpatients, and 259 non-medically attended patients. The total direct cost of an ARI episode requiring outpatient care was US$4- $6 for public and $3-$10 for private institutions based on age groups. The total direct cost of an ARI episode requiring hospitalized care was $54-$120 in public and $135-$355 in private institutions. The cost of ARI among those hospitalized was highest among persons aged > = 65 years and lowest among children aged

The global burden of influenza is increasingly recognized, but data from India remain sparse. We conducted a multi-site population-based surveillance study to estimate and compare rates of influenza-associated hospitalization at two rural Indian health and demographic surveillance system (HDSS) sites at Ballabgarh and Vadu during 2010-2012.Prospective facility-based surveillance for all hospitalizations (excluding those for trauma, elective surgery and obstetric, ophthalmic or psychiatric reasons) was conducted at 72 health facilities. After collection of clinical details, patients had nasopharyngeal swabs taken and tested by reverse transcription polymerase chain reaction for influenza viruses. Annual healthcare utilization surveys (HUS) were conducted in HDSS households to identify proportion of hospitalizations occurring at non-study facilities to adjust for hospitalizations missed through facility-based surveillance.HUS showed that 69% and 67% of hospitalizations occurred at study facilities at Ballabgarh and Vadu, respectively. Overall, 6004 patients hospitalized with acute medical illness at participating facilities were enrolled (1717 from Ballabgarh; 4287 from Vadu). The proportion of patients with influenza was higher at Vadu than Ballabgarh annually (2010: 21% vs. 5%, p 0.05; 2011: 18% vs. 5%, p 0.05; 2012: 23% vs. 5%, p 0.05). Annual adjusted influenza-associated hospitalization rates were 5-11 fold higher in Vadu (20.3-51.6 per 10,000) vs Ballabgarh (4.4-6.3 per 10,000). At both sites, influenza A/H1N1pdm09 and B predominated during 2010, A/H3N2 and B during 2011, and A/H1N1pdm09 and B during 2012.The markedly different influenza hospitalization rates by season and across communities in India highlight the need for sustained multi-site surveillance system for estimating national influenza disease burden. That would be the first step for initiating discussions around Influenza prevention and control strategies in the country.

Some parts of world, including India observed a recrudescent wave of influenza A/H1N1pdm09 in 2012. We undertook a study to examine the circulating influenza strains, their clinical association and antigenic characteristics to understand the recrudescent wave of A/H1N1pdm09 from November 26, 2012 to Feb 28, 2013 in Kashmir, India. Of the 751 patients (545 outpatient and 206 hospitalized) presenting with acute respiratory infection at a tertiary care hospital in Srinagar; 184 (24.5%) tested positive for influenza. Further type and subtype analysis revealed that 106 (58%) were influenza A (H1N1pdm09 =105, H3N2=1) and 78 (42%) were influenza B. The influenza positive cases had a higher frequency of chills, nasal discharge, sore throat, body aches and headache, compared to influenza negative cases. Of the 206 patients hospitalized for pneumonia/acute respiratory distress syndrome or an exacerbation of an underlying lung disease, 34 (16.5%) tested positive for influenza (22 for H1N1pdm09, 11 for influenza B). All influenza-positive patients received oseltamivir and while most patients responded well to antiviral therapy and supportive care, 6 patients (4 with H1N1pdm09 and 2 with influenza B) patients died of progressive respiratory failure and multi-organ dysfunction. Following a period of minimal circulation, H1N1pdm09 re-emerged in Kashmir in 2012-2013, causing serious illness and fatalities. As such the healthcare administrators and policy planners need to be wary and monitor the situation closely.

In the last few decades, a large number of studies have been carried out on vibration exposure and its transmissibility from the handle of a powered hand tool to the hands of the operator. Vascular, neurological and musculoskeletal disorders which Manifest as hand-arm vibration syndrome are commonly observed amongst workers in MSME sector and, therefore, its study assumes importance. This review article is a compilation of the work done by various researchers in the area of hand-arm vibration exposure. Measurement of vibration exposure along with their limits as given in international standards is reported. Different methods of vibration transmissibility and parameters influencing the same are also presented. A detailed chart is prepared to compare the research work done by different researchers in this field. Gaps in literature are compiled. Variations of grip force, elbow angle, resonance frequency and handle diameter are found to be significant factors when considering transmitted vibration to hand and arm. Further studies towards standardisation of methods and procedures are also suggested.

This study investigates the prevalence of hand arm vibration symptoms and musculoskeletal disorders in the hand and arm of the angle grinder operators of sheet metal industries located in Chandigarh and nearby industrial areas in Northern India. Hand-transmitted vibration was measured in 42 sheet metal industries. A total of 83 workers, who were mainly employed for grinding job, were interviewed and vibration characteristics were measured using tri-axial accelerometer. Hand arm vibration symptoms, musculoskeletal complaints in hands and its correlation with tool weight were investigated. Results shown 84% daily vibration exposure measurements exceeded exposure action value (EAV) and 24% measurements exceeded exposure limit value (ELV). Hand arm vibration symptoms were finger numbness (40%), tingling (29%) and vibration white finger (VWF) (13%). Hand arm vibration symptoms in the workers were not significantly associated with tool weight. However, tool weight was significantly associated with musculoskeletal complaints in wrist, forearm and elbow of the workers. Preventive measures to reduce musculoskeletal complaints are proposed.

High-performance routers need to store temporarily a large number of packets in response to congestion. DRAM is typically used to implement the needed packet buffers, but DRAM devices are too slow to match the bandwidth requirements. To bridge the bandwidth gap, a number of hybrid SRAM/DRAM packet buffer architectures have been proposed (S. Iyer and N. Mckeown, 2002) (S. Kumar et al., 2005). These packet buffer architectures assume a very general model where the buffer consists of many logically separated FIFO queues that may be accessed in random order. For example, virtual output queues (VOQs) are used in crossbar routers, where each VOQ corresponds to a logical queue corresponding to a particular output. Depending on the scheduling algorithm used, the access pattern to these logical queues may indeed be at random. However, for a number of router architectures, this worst-case random access assumption is unnecessary since packet departure times are deterministic. One architecture is the switch-memory-switch router architecture (A. Prakash et al., 2002) (S. Iyer et al., 2002) that efficiently mimics an output queueing switch. Another architecture is the load-balanced router architecture (C.S. Chang et al., 2002) (I. Keslassy et al., 2003) that has interesting scalability properties. In these architectures, for best-effort routing, the departure times of packets can be deterministically calculated before inserting packets into packet buffers. In this paper, we describe a novel packet buffer architecture based on interleaved memories that takes advantage of the known packet departure times to achieve simplicity and determinism. The number of interleaved DRAM banks required to implement the proposed packet buffer architecture is independent of the number of logical queues, yet the proposed architecture can achieve the performance of an SRAM implementation

IP anycasting was considered to be non-scalable, until Katabi et al 5 proposed a scheme called GIA. This scheme makes two important assumptions. One, the anycast addresses have a specific format distinguisable from unicast address. Two, it is only necessary to reach the nearest anycast member only if there is a lot of traffic to the anycast group. In this paper, we propose an extension of GIA to achieve load balancing in the Internet. Our scheme builds upon GIA by adding load information exchange features. This enables the client to choose a member of the anycast group which is not just routing-wise nearest to it, but the one which actually improves its response time, by a proper balance of routing proximity and load. An advantage of our scheme is that it does on-demand routing information exchange, resulting in less overhead. We evaluate the performance of our design through simulation, and show that it achieves better load balancing, compared to GIA, which sends packets to the nearest server, irrespective of the load.