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Background: Lack of robust data on economic burden due to enteric fever in India has made decision making on typhoid vaccination a challenge. Surveillance for Enteric Fever network was established to address gaps in typhoid disease and economic burden.Methods: Patients hospitalized with blood culture-confirmed enteric fever and nontraumatic ileal perforation were identified at 14 hospitals. These sites represent urban referral hospitals (tier 3) and smaller hospitals in urban slums, remote rural, and tribal settings (tier 2). Cost of illness and productivity loss data from onset to 28 days after discharge from hospital were collected using a structured questionnaire. The direct and indirect costs of an illness episode were analyzed by type of setting.Results: In total, 274 patients from tier 2 surveillance, 891 patients from tier 3 surveillance, and 110 ileal perforation patients provided the cost of illness data. The mean direct cost of severe enteric fever was US$119.1 (95% confidence interval [CI], US$85.8-152.4) in tier 2 and US$405.7 (95% CI, 366.9-444.4) in tier 3; 16.9% of patients in tier 3 experienced catastrophic expenditure.Conclusions: The cost of treating enteric fever is considerable and likely to increase with emerging antimicrobial resistance. Equitable preventive strategies are urgently needed. [ABSTRACT FROM AUTHOR]

Background: Ileal perforation occurs in about 1% of enteric fevers as a complication, with a case fatality risk (CFR) of 20%-30% in the early 1990s that decreased to 15.4% in 2011 in South East Asia. We report nontraumatic ileal perforations and its associated CFR from a 2-year prospective enteric fever surveillance across India.Methods: The Surveillance for Enteric Fever in India (SEFI) project established a multitiered surveillance system for enteric fever between December 2017 and March 2020. Nontraumatic ileal perforations were surveilled at 8 tertiary care and 6 secondary care hospitals and classified according to etiology.Results: Of the 158 nontraumatic ileal perforation cases identified,126 were consented and enrolled. Enteric fever (34.7%), tuberculosis (19.0%), malignancy (5.8%), and perforation of Meckel diverticulum (4.9%) were the common etiology. In those with enteric fever ileal perforation, the CFR was 7.1%.Conclusions: Enteric fever remains the most common cause of nontraumatic ileal perforation in India, followed by tuberculosis. Better modalities of establishing etiology are required to classify the illness, and frame management guidelines and preventive measures. CFR data are critical for comprehensive disease burden estimation and policymaking. [ABSTRACT FROM AUTHOR]

The aim was to study the feto-maternal outcome of pregnancies complicated by systemic lupus erythematosus (SLE). Analysis of a prospectively-maintained database of 73 patients (June 2006-March 2016) was done. Diagnosis of SLE was made by ACR(American College of Rheumatology)-criteria. Protocol scans and blood tests were done and patients with active disease were followed biweekly for 28 weeks, and weekly thereafter. Mean age + SD was 29 ± 4.9. SLE was diagnosed before conception in 86% of patients. A total of 33% had active disease status during pregnancy and out of them 58% had a flare of SLE, compared to 26% who were in remission (p = .008). SLE activity had no effect on the rate of foetal demise (p = .57). Overall pregnancy loss was 14% with no maternal mortality. The incidence of SLE flare during pregnancy was significantly higher in patients who had active disease. But the incidence of foetal demise was not affected by disease activity. Impact Statement What is already known on this subject: SLE is one of the most common immunological disorders associated with pregnancy. Both SLE and pregnancy tend to influence each other due to complex interaction. The opinion seems to be divided regarding influence of pregnancy on SLE flare in world literature. What the results of this study add: Our data suggests a significantly greater incidence of SLE flare during pregnancy in patients with active disease, than in those in remission. What the implications are of these findings for clinical practice and/or further research: Though the majority of these flares were not major and did not require hospitalisation, these patients usually have a bad obstetric history. However, with multidisciplinary involvement, SLE activity in our series was not an independent predictor of a poor pregnancy outcome. [ABSTRACT FROM AUTHOR]

Purpose: To determine effects of denosumab (DMAb) in postmenopausal osteoporotic women from India. Materials and Methods: Double-blind, multicenter study. Two hundred and fifty Indian postmenopausal women from 55 to 75 years of age, with osteoporosis (dual-energy X-ray absorptiometry bone mineral density (DXA BMD)) equivalent to a T score of <-0.5 and >- 4.0 at either lumbar spine (LS) or total hip (TH) and serum levels of 25-(OH) vitamin D³20 ng/mLwere randomized to DMAb 60 mg subcutaneous (SC) injection or placebo. BMD, serum bone turnover markers (serum C-terminal telopeptide of type I collagen (s-CTx) and serum procollagen type I N propeptide (s-PINP)), and safety were evaluated. All subjects received daily calcium (≥1,000 mg) and vitamin D (³400 IU). All sites obtained Ethics Committee approval and all subjects signed informed consent. Results: Baseline age and years since menopause were similar with mean 62.6 years (standard deviation (SD) 4.96) and median 15 years since menopause. At month 6, compared with placebo, the DMAb group showed a statistically significant increase in percentage change in BMD from baseline at the LS (primary endpoint) (3.1%; 95% CI: 1.9%, 4.2%; P < 0.0001), TH (1.7%; 95% confidence interval (CI): 0.9%, 2.5%; P< 0.0001), femoral neck (FN) (2.3%; 95% CI: 1.1%, 3.4%; P = 0.0001), and trochanter (1.8%; 95% CI: 0.8%, 2.8%; P = 0.0006]. A decrease in percentage change from baseline was observed for s-CTx (median: -33.4%; 95% CI: -40.8%; -26.0%; P< 0.0001 ] and s-PINP (median: -37.6%; 95% CI: -44.2%, -31.2%; P < 0.0001). 31 % DMAb and 37% placebo subjects experienced adverse events (AEs). The most common DMAb AE was upper respiratory infection (6%) vs 2% in the placebo group. One subject (DMAb) and three (placebo) experienced seriousAEs (SAEs), none attributed to study drug. Conclusions: After 6 months, DMAb statistically significantly increased percentage change from baseline in BMDatthe LS,TH, FN, and trochanter; and significantly decreased percentage change from baseline s-CTx and s-PINP compared to placebo. No new or unexpected safety signals were detected. This study was sponsored by GlaxoSmithKline Pharmaceuticals. [ABSTRACT FROM AUTHOR]

Background: In 2017, more than half the cases of typhoid fever worldwide were projected to have occurred in India. In the absence of contemporary population-based data, it is unclear whether declining trends of hospitalization for typhoid in India reflect increased antibiotic treatment or a true reduction in infection., Methods: From 2017 through 2020, we conducted weekly surveillance for acute febrile illness and measured the incidence of typhoid fever (as confirmed on blood culture) in a prospective cohort of children between the ages of 6 months and 14 years at three urban sites and one rural site in India. At an additional urban site and five rural sites, we combined blood-culture testing of hospitalized patients who had a fever with survey data regarding health care use to estimate incidence in the community., Results: A total of 24,062 children who were enrolled in four cohorts contributed 46,959 child-years of observation. Among these children, 299 culture-confirmed typhoid cases were recorded, with an incidence per 100,000 child-years of 576 to 1173 cases in urban sites and 35 in rural Pune. The estimated incidence of typhoid fever from hospital surveillance ranged from 12 to 1622 cases per 100,000 child-years among children between the ages of 6 months and 14 years and from 108 to 970 cases per 100,000 person-years among those who were 15 years of age or older. Salmonella enterica serovar Paratyphi was isolated from 33 children, for an overall incidence of 68 cases per 100,000 child-years after adjustment for age., Conclusions: The incidence of typhoid fever in urban India remains high, with generally lower estimates of incidence in most rural areas. (Funded by the Bill and Melinda Gates Foundation; NSSEFI Clinical Trials Registry of India number, CTRI/2017/09/009719; ISRCTN registry number, ISRCTN72938224.)., (Copyright © 2023 Massachusetts Medical Society.)

Many patients with hypertension will require multiple antihypertensive drugs to achieve blood pressure (BP) control. This double-blind study evaluated the efficacy and safety of aliskiren/amlodipine single-pill combinations (SPCs) in patients with mild-to-moderate hypertension who were non-responsive to aliskiren monotherapy. After a 4-week run-in with aliskiren 300 mg, patients with mean sitting diastolic BP (msDBP) ≥ 90 and < 110 mmHg were randomized to oncedaily aliskiren/ amlodipine 300/10 mg or 300/5 mg, or aliskiren 300 mg for 8 weeks. Aliskiren/amlodipine SPCs provided significantly greater mean reductions in mean sitting systolic BP/msDBP (300/10 mg, 18.0/13.1 mmHg; 300/5 mg, 14.4/10.5 mmHg) than aliskiren 300 mg (6.4/5.8 mmHg) at week 8 endpoint. This represents additional mean reductions of 11.6/7.2 mmHg (300/10 mg) and 8.0/4.7 mmHg (300/5 mg) over aliskiren alone (both p < 0.0001). Significantly more patients achieved BP control ( < 140/90 mmHg) with aliskiren/amlodipine 300/10 mg (65.5%) and 300/5 mg (56.6%) than with aliskiren (31.5% both p < 0.0001). Aliskiren, alone and in combination with amlodipine, was well tolerated, with a slightly higher incidence of adverse events with SPCs (29.0-30.1%) than with monotherapy (22.7%). In conclusion, aliskiren/amlodipine SPCs offer an effective next step for patients who have an inadequate BP response to aliskiren alone.

The paper highlights the fish diversity in major wetlands of Mysore district, Karnataka, India and its conservation status. Forty-five species of fishes belonging to 15 families, 31 genera have been identified. Fish species belonging to genus Puntius were more common in many of these lakes. However it was observed that the fish diversity was decreasing since last two years unprecedently mainly due to manifold human activities. Fish diversity in the lakes is becoming rare and about seven species were identified as endangered. Out of the 45 identified fishes, six fish species were identified as threatened species. Tork hudree, also known as Deccan mahseer and seven other species were identified as vulnerable fish species. Though there were 40 species of fish endemic to this region, their number decreased with introduction of more exotic species. Conservation of endemic fishes, propagation of endangered and threatened fishes should be therefore, undertaken to preserve and protect fish diversity in the wetlands of Mysore district.

Background and Objective: People with HIV in India frequently encounter discrimination while seeking and receiving healthcare services. The knowledge and attitudes of healthcare workers (HCWs) influences the willingness and ability of people with HIV to access care, and the quality of the care they receive. Previous studies of HIV-related knowledge and attitudes amongst Indian HCWs have been conducted primarily in large urban hospitals. The objective of this study was to asses HIV-related knowledge, attitudes and risk perception among a group of rural north Indian HCWs, and to identify predictors of willingness to provide care for patients with HIV infection., Methods: A cross-sectional survey of 266 HCWs (78% female) from seven rural north Indian health settings was undertaken in late 2002. A self-administered written questionnaire was made available in English and Hindi, and the response rate was 87 per cent. Information was gathered regarding demographic details (age, sex, duration of employment, job category); HIV-related knowledge and attitudes; risk perception; and previous experience caring for HIV-positive patients. Logistic regression modelling was undertaken to identify factors associated with willingness to care for patients with HIV., Results: The HCWs in this study generally had a positive attitude to caring for people with HIV. However, this was tempered by substantial concerns about providing care, and the risk of occupational infection with HIV was perceived by most HCWs to be high. After controlling for confounding, HCWs willingness to provide care for patients with HIV was strongly associated with having previously cared for patients with HIV (P = 0.001). Knowledge of HIV transmission and perception of risk were not associated with willingness to provide care., Interpretation and Conclusion: The findings of this study showed a general willingness of HCWs to provide care for patients with HIV, tempered by concerns regarding provision of such care. Strategies to address HCWs concerns are likely to ameliorate the discrimination experienced by people with HIV when accessing healthcare services. These include the development of programmes to promote occupational safety of HCWs and involving people with HIV in awareness training of HCWs.

Background: Unsafe injection practices result in a substantial burden of preventable blood-borne viral disease (BBV). The reasons are complex and include structural, economic and socio-cultural factors., Objective: To describe injection-related practices in two rural north Indian health settings including the contextual factor, highlight some of the challenges facing those endeavouring to translate injection safety policies into safe injection practice, and to identify appropriate intervention strategies., Method: Qualitative data collection (participant observation and in-depth interviews) in two rural north Indian hospitals with affiliated community-based programmes over a 4-month period. A total of 130 h of observation took place in a range of clinical areas characterized by frequent use of needles and other sharps, and 40 healthcare workers were interviewed. Field notes and interview transcripts were thematically analysed., Results: Managers in these health settings were clearly endeavouring to promote injection safety by implementing the widespread use of disposable needles and syringes and attempting to address the difficult issue of safe healthcare waste management. However, some unsafe practices were still occurring: reuse of syringes (with and without sterilization) was relatively common, and use of multi-dose vials, blood sampling, sterilization and disinfection, and healthcare waste management were sub-optimal in some instances, placing both staff and patients at unnecessary risk of BBV infection., Conclusion: Strategies for promoting injection safety are necessary if the risk of nosocomial transmission of BBV diseases via unsafe injection practices in rural north India is to be minimized.

Background: Approximately 3 million health care workers (HCWs) experience percutaneous exposure to bloodborne viruses (BBVs) each year. This results in an estimated 16,000 hepatitis C, 66,000 hepatitis B, and 200 to 5000 human immunodeficiency virus (HIV) infections annually. More than 90% of these infections are occurring in low-income countries, and most are preventable. Several studies report the risks of occupational BBV infection for HCWs in high-income countries where a range of preventive interventions have been implemented. In contrast, the situation for HCWs in low-income countries is not well documented, and their health and safety remains a neglected issue., Objective: To describe the extent of occupational exposure to blood and the risk of BBV infection among a group of HCWs in rural north India., Methods: A cross-sectional survey of HCWs from 7 rural health settings gathered data pertaining to occupational exposure to blood and a range of other relevant variables (eg, demographic information, compliance with Universal Precautions, perception of risk, knowledge of BBVs). A mass action model was used to estimate the risk of occupational BBV infection for these HCWs over a 10-year period., Results: A total of 266 HCWs returned questionnaires (response rate, 87%). Sixty-three percent reported at least 1 percutaneous injury (PI) in the last year (mean no. = 2.3) and 73% over their working lifetime (mean no. = 4.2). Predictors of PI during the last year were hospital site, job category, perception of risk, and compliance with Universal Precautions., Conclusion: The high level of occupational exposure to blood found among this group of rural north Indian HCWs highlights the urgent need for interventions to enhance their occupational safety to prevent unnecessary nosocomial transmission of BBVs.

Background: Universal Precautions (UPs) and more recently Standard Precautions have been widely promoted in high-income countries to protect health care workers (HCWs) from occupational exposure to blood and the consequent risk of infection with bloodborne pathogens. In low-income countries, the situation is very different: UPs are often practiced partially, if at all, thereby exposing the HCWs to unnecessary risk of infection. The aim of this study is to describe rural north Indian HCWs knowledge and understanding of UPs and identify predictors of compliance to target intervention programs appropriately., Methods: A cross-sectional survey was undertaken, involving 266 HCWs (response rate, 87%) from 7 rural north Indian health care settings. Information was gathered regarding compliance with UPs and a range of other relevant variables that potentially influence compliance (eg, demographic information, perception of risk, knowledge of bloodborne pathogen transmission, perception of safety climate, and barriers to safe practice)., Results: Knowledge and understanding of UPs were partial, and UPs compliance was suboptimal, eg, only 32% wore eye protection when indicated, and 40% recapped needles at least sometimes. After controlling for confounding, compliance with UPs was associated with being in the job for a longer period, knowledge of bloodborne pathogen transmission, perceiving fewer barriers to safe practice and a strong commitment to workplace safety climate., Conclusion: Interventions to improve UPs compliance among HCWs in rural north India need to address not only their knowledge and understanding but also the safety climate created by the organizations that employ them.