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Surge capacity-the ability to acquire additional workers and resources during unexpected increases in service demand-is often perceived as a luxury. However, the COVID-19 pandemic necessitated an urgent expansion of surge capacity within health systems globally. Health systems in Bangladesh, Nepal, and Sri Lanka managed to scale up their capacities despite severely limited budgets. This study employs a mixed-methods approach, integrating qualitative interviews with quantitative data analysis, to propose a comprehensive framework for understanding Human Resources for Health (HRH) surge capacity from 2018 to 2021, termed ARRAS: Anticipate, Recruit, Retain, Adapt, Sustain. We present national-level data to demonstrate how each country was able to maintain their per capita health care workforce during the crisis. Interviews with key informants from each country reinforce the ARRAS framework. Quantitative data revealed ongoing increases in doctors and nurses pre- and post-pandemic, but no country could rapidly expand its health workforce during the crisis. Qualitative findings highlighted critical strategies such as pre-crisis planning, financial incentives, telemedicine, and re-skilling the workforce. Despite adaptive measures, challenges included inadequate funding, poor data systems, and coordination issues. This study underscores the necessity for robust, long-term strategies to enhance surge capacity and better prepare health systems for future crises.

Study Design: Cross-sectional study., Objectives: To evaluate etiologic factors associated with spinal cord injury (SCI) severity and to identify predictive factors of reduction in SCI severity in six countries., Setting: SCI centers in Bangladesh, India, Malaysia, Nepal, Sri Lanka, and Thailand., Methods: Data from centers collected between October 2015 and February 2021 were analyzed using descriptive statistics and logistic regression., Results: Among 2634 individuals, the leading cause of SCIs was falls (n = 1410, 54%); most occurred from ≥1 meter (n = 1078). Most single-level neurological injuries occurred in the thoracic region (n = 977, 39%). Greater than half of SCIs (n = 1423, 54%) were graded American Spinal Injury Association Impairment Scale (AIS) A. Thoracic SCIs accounted for 53% (n = 757) of all one-level AIS A SCIs. The percentage of thoracic SCIs graded AIS A (78%) was significantly higher than high cervical (52%), low cervical (48%), lumbar (24%), and sacral (31%) SCIs (p < 0.001). Regression analyses isolated predictive factors both of SCI severity and inpatient improvement. Four factors predicted severity: age, neurological level, etiology, and country of residence. Four factors predicted improvement: age, neurological level, AIS grade on intake, and country of residence., Conclusions: Findings can be used by healthcare providers and public health agencies in these countries to inform the public of the risk of SCI due to falls. Future studies should examine the social and occupational milieux of falls. Country-to-country comparisons of prehospital and inpatient care are also justified. Fall prevention policies can encourage the use of safety equipment when performing tasks at heights ≥1 meter., (© 2024. The Author(s), under exclusive licence to International Spinal Cord Society.)

Objectives: To explore associations between type and number of abnormal glucose values on antenatal oral glucose tolerance test (OGTT) with postpartum diabetes in South Asian women diagnosed with gestational diabetes (GDM) using International Association of the Diabetes and Pregnancy Study Groups criteria., Methods: This post-hoc evaluation of the Lifestyle Intervention IN Gestational Diabetes (LIVING) study, a randomized controlled trial, was conducted among women with GDM in the index pregnancy, across 19 centers in Bangladesh, India, and Sri Lanka. Postpartum diabetes (outcome) was defined on OGTT, using American Diabetes Association (ADA) criteria., Results: We report data on 1468 women with GDM, aged 30.9 (5.0) years, and with median (interquartile range) follow-up period of 1.8 (1.4-2.4) years after childbirth following the index pregnancy. We found diabetes in 213 (14.5%) women with an incidence of 8.7 (7.6-10.0)/100 women-years. The lowest incidence rate was 3.8/100 women years, in those with an isolated fasting plasma glucose (FPG) abnormality, and highest was 19.0/100 women years in participants with three abnormal values. The adjusted hazard ratios for two and three abnormal values compared to one abnormal value were 1.73 (95% confidence interval [CI], 1.18-2.54; p = .005) and 3.56 (95% CI, 2.46-5.16; p < .001) respectively. The adjusted hazard ratio for the combined (combination of fasting and postglucose load) abnormalities was 2.61 (95% CI, 1.70-4.00; p < .001), compared to isolated abnormal FPG., Conclusions: Risk of diabetes varied significantly depending upon the type and number of abnormal values on antenatal OGTT. These data may inform future precision medicine approaches such as risk prediction models in identifying women at higher risk and may guide future targeted interventions., (© 2024 The Authors. Journal of Diabetes published by Ruijin Hospital, Shanghai Jiaotong University School of Medicine and John Wiley & Sons Australia, Ltd.)

Hypertension is a leading risk factor for cardiovascular disease in South Asia. The authors aimed to assess the cross-country differences in 24-h ambulatory, daytime, and nighttime systolic blood pressure (SBP) among rural population with uncontrolled clinic hypertension in Bangladesh, Pakistan, and Sri Lanka. The authors studied patients with uncontrolled clinic hypertension (clinic BP ≥ 140/90 mmHg) who underwent ambulatory blood pressure monitoring (ABPM) during the baseline assessment as part of a community-based trial. The authors compared the distribution of ABPM profiles of patients across the three countries, specifically evaluating ambulatory SBP levels with multivariable models that adjusted for patient characteristics. Among the 382 patients (mean age, 58.3 years; 64.7% women), 56.5% exhibited ambulatory hypertension (24-h ambulatory BP ≥ 130/80 mmHg), with wide variation across countries: 72.6% (Bangladesh), 50.0% (Pakistan), and 51.0% (Sri Lanka; P < .05). Compared to Sri Lanka, adjusted mean 24-h ambulatory, daytime, and nighttime SBP were higher by 12.24 mmHg (95% CI 4.28-20.20), 11.96 mmHg (3.87-20.06), and 12.76 mmHg (4.51-21.01) in Bangladesh, separately. However, no significant differences were observed between Pakistan and Sri Lanka (P > .05). Additionally, clinic SBP was significantly associated with 24-h ambulatory (mean 0.38, 95% CI 0.28-0.47), daytime (0.37, 0.27-0.47), and nighttime SBP (0.40, 0.29-0.50) per 1 mmHg increase. The authors observed substantial cross-country differences in the distribution of ABPM profiles among patients with uncontrolled clinic hypertension in rural South Asia. The authors findings indicated the need to incorporate 24-h BP monitoring to mitigate cardiovascular risk, particularly in Bangladesh., (© 2024 The Authors. The Journal of Clinical Hypertension published by Wiley Periodicals LLC.)

Aim: To study, the incidence and risk factors for postpartum diabetes (DM), in women with gestational diabetes mellitus (GDM) from South Asia (Bangladesh, India and Sri Lanka), followed for nearly two years after delivery., Methods: Women with prior GDM diagnosed using IADPSG criteria were invited at 19 centres across Bangladesh, India and Sri Lanka for an oral glucose tolerance test (OGTT) following childbirth, and were enrolled in a randomized controlled trial. The glycaemic category (outcome) was defined from an OGTT based on American Diabetes Association criteria., Results: Participants (n = 1808) recruited had a mean ± SD age of 31.0 ± 5.0 years. Incident DM was identified, between childbirth and the last follow-up, in 310 (17.1 %) women [incidence 10.75/100 person years], with a median follow-up duration of 1.82 years after childbirth. Higher age, lower education status, higher prior pregnancy count, prior history of GDM, family history of DM, and postpartum overweight/obese status were significantly associated with incident DM. Women in Bangladesh had a higher cumulative incidence of DM [16.49/100 person years] than in Sri Lanka [12.74/100 person years] and India [7.21/100 person years]., Conclusions: A high incidence of DM was found in women with prior GDM in South Asia, with significant variation between countries. Women from Bangladesh had a significantly higher pregnancy count, family history of DM and overweight/obese status, despite having significantly lower age, which could be responsible for their higher rates of DM. Registration of this study: The study was registered with the Clinical Trials Registry of India (CTRI/2017/06/008744), Sri Lanka Clinical Trials Registry (SLCTR/2017/001), and ClinicalTrials.gov (NCT03305939)., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Introduction: Worsening air quality and pollution lead to numerous environmental health and sustainability issues in the South Asia region. This study analyzes India, Nepal, Bangladesh, Pakistan, Sri Lanka, and Nepal for air quality data trends and sustainability indicators., Methodology: By using a population-based study design, six South Asian countries were analyzed using a step-wise approach. Data were obtained from government websites and publicly available repositories for region dynamics and key variables., Results: Between 1990 and 2020, air quality data indicated the highest rise in CO 2 emissions in India (578.5 to 2441.8 million tons) (MT), Bangladesh, Nepal, and Pakistan. Greenhouse gas emissions, from 1990 to 2018, nearly tripled in India (1990.4 to 3346.6 MT of CO 2 -equivalents), Nepal (20.6 to 54.6 MT of CO 2 -equivalents), and Pakistan, and doubled in Bangladesh. Methane emissions rose the highest in Pakistan (70.4 to 151 MT of CO 2 -equivalents), followed by Nepal (17 to 31 MT of CO 2 -equivalents) and India (524.8 to 669.3 MT of CO 2 -equivalents). Nitrous oxide nearly doubled in Bangladesh (16.5 to 29.3 MT of CO 2 -equivalents), India (141.6 to 256.9 MT of CO 2 -equivalents), Nepal (17 to 31 MT of CO 2 -equivalents), and more than doubled in Pakistan (27 to 61 MT of CO 2 -equivalents). On noting particulate matter 2,5 annual exposure, India saw the highest rise from 81.3 µg/m 3 (in 1990) to 90.9 µg/m 3 (2017), whereas trends were steady in Pakistan (60.34 to 58.3 µg/m 3 ). The highest rise was noted in Nepal (87.6 to 99.7 µg/m 3 ) until 2017. During the coronavirus disease 19 pandemic, the pre-and post-pandemic changes between 2018 and 2021 indicated the highest PM 2.5 concentration in Bangladesh (76.9 µg/m 3 ), followed by Pakistan (66.8 µg/m 3 ), India (58.1 µg/m 3 ), Nepal (46 µg/m 3 ) and Sri Lanka (17.4 µg/m 3 ). Overall, South Asian countries contribute to the worst air quality and sustainability trends regions worldwide., Conclusions: Air pollution is prevalent across a majority of South Asia countries. Owing to unsustainable industrial practices, pollution trends have risen to hazardous levels. Economic, environmental, and human health impacts have manifested and require urgent, concerted efforts by governing bodies in the region.

Background: The highly contagious nature of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) places physicians in South Asia at high risk of contracting the infection. Accordingly, we conducted this study to provide an updated account of physician deaths in South Asia during the COVID-19 pandemic and to analyze and compare the different characteristics associated with physician mortality amongst the countries of the region., Methods: We performed a cross-sectional study by using published news reports on the websites of news agencies from 9 selected countries in South Asia. Our study included only those physicians and doctors who died after contracting COVID-19 from their respective workplaces. All available data about the country of origin, type of, sex, age, medical or surgical specialty, and date of death were included., Results: The total number of physician deaths reported due to COVID-19 in our study was 170, with half (87/170, 51%) of the deaths reported from Iran. Male physician deaths were reported to be 145 (145/170 = 85%). Internal Medicine (58.43%) was the most severely affected sub-specialty. The highest physician mortality rate in the general population recorded in Afghanistan (27/1000 deaths). General physicians from India [OR = 11.00(95% CI = 1.06-114.08), p = 0.045] and public sector medical practitioners from Pakistan [aOR = 4.52 (95% CI = 1.18-17.33), p = 0.028] were showing significant mortality when compared with other regions in multivariate logistic regression., Conclusion: An increased number of physician deaths, owing to COVID-19, has been shown in South Asia. This could be due to decreased personal protective equipment and the poor health care management systems of the countries in the region to combat the pandemic. Future studies should provide detailed information of characteristics associated with physician mortalities along with the main complications arising due to the virus., (© 2021. The Author(s).)

Background: Although therapeutic hypothermia reduces death or disability after neonatal encephalopathy in high-income countries, its safety and efficacy in low-income and middle-income countries is unclear. We aimed to examine whether therapeutic hypothermia alongside optimal supportive intensive care reduces death or moderate or severe disability after neonatal encephalopathy in south Asia., Methods: We did a multicountry open-label, randomised controlled trial in seven tertiary neonatal intensive care units in India, Sri Lanka, and Bangladesh. We enrolled infants born at or after 36 weeks of gestation with moderate or severe neonatal encephalopathy and a need for continued resuscitation at 5 min of age or an Apgar score of less than 6 at 5 min of age (for babies born in a hospital), or both, or an absence of crying by 5 min of age (for babies born at home). Using a web-based randomisation system, we allocated infants into a group receiving whole body hypothermia (33·5°C) for 72 h using a servo-controlled cooling device, or to usual care (control group), within 6 h of birth. All recruiting sites had facilities for invasive ventilation, cardiovascular support, and access to 3 Tesla MRI scanners and spectroscopy. Masking of the intervention was not possible, but those involved in the magnetic resonance biomarker analysis and neurodevelopmental outcome assessments were masked to the allocation. The primary outcome was a combined endpoint of death or moderate or severe disability at 18-22 months, assessed by the Bayley Scales of Infant and Toddler Development (third edition) and a detailed neurological examination. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, NCT02387385., Findings: We screened 2296 infants between Aug 15, 2015, and Feb 15, 2019, of whom 576 infants were eligible for inclusion. After exclusions, we recruited 408 eligible infants and we assigned 202 to the hypothermia group and 206 to the control group. Primary outcome data were available for 195 (97%) of the 202 infants in the hypothermia group and 199 (97%) of the 206 control group infants. 98 (50%) infants in the hypothermia group and 94 (47%) infants in the control group died or had a moderate or severe disability (risk ratio 1·06; 95% CI 0·87-1·30; p=0·55). 84 infants (42%) in the hypothermia group and 63 (31%; p=0·022) infants in the control group died, of whom 72 (36%) and 49 (24%; p=0·0087) died during neonatal hospitalisation. Five serious adverse events were reported: three in the hypothermia group (one hospital readmission relating to pneumonia, one septic arthritis, and one suspected venous thrombosis), and two in the control group (one related to desaturations during MRI and other because of endotracheal tube displacement during transport for MRI). No adverse events were considered causally related to the study intervention., Interpretation: Therapeutic hypothermia did not reduce the combined outcome of death or disability at 18 months after neonatal encephalopathy in low-income and middle-income countries, but significantly increased death alone. Therapeutic hypothermia should not be offered as treatment for neonatal encephalopathy in low-income and middle-income countries, even when tertiary neonatal intensive care facilities are available., Funding: National Institute for Health Research, Garfield Weston Foundation, and Bill & Melinda Gates Foundation., Translations: For the Hindi, Malayalam, Telugu, Kannada, Singhalese, Tamil, Marathi and Bangla translations of the abstract see Supplementary Materials section., Competing Interests: Declaration of interests JW reports a grant from the National Institutes for Health (number 1R21HD093563-01) outside the submitted work. RP reports personal fees from UCB and Kephala outside the submitted work. All other authors declare no competing interests., (Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

South Asians constitute approximately 1.6 billion people from the Indian subcontinent, comprising Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka; and make up the largest diaspora globally. Compared to the White European population, this group is at a higher risk of developing type 2 diabetes along with cardiovascular, renal and eye complications. Over the recent years, a number of new therapies for type 2 diabetes have become available for which cardiovascular outcome trials (CVOTs) have been published. The recent ADA/EASD consensus guidelines on diabetes, pre-diabetes and cardiovascular diseases' offer a transitional shift in type 2 diabetes management. The new consensus recommendations are based on recent CVOTs, many of which had a representation of South Asian cohorts. In light of this new evidence, there is urgent need for an integrated, evidence-based, cost-effective and individualised approach specific for South Asians. This review takes into consideration the evidence from these CVOTs and provides best practice recommendations for optimal management of South Asian people with type 2 diabetes, alongside the previously published consensus report from South Asian Health Foundation in 2014 [1]., (© 2020 Diabetes UK.)

Background: The purpose of the study was to compare  trends in the progression of COVID-19 among South Asian countries with more developed Western countries. Methods: COVID-19 data from South Asian countries were used for this observational study. Data were taken up to April 21, 2020 from the outbreak of the COVID-19. Four of the seven countries met the inclusion criteria and were included in the analysis. Results: An exponential increase in the average number of weekly cases was reported after the fifth week following the first case. The correlation between reported cases and tests was found to be strong and significant (r=0.90, p=0.037). However, on average, 315.25 tests per million population were performed, which was at least 12 times lower than the number of tests performed in countries with a large number of COVID-19 cases. Conclusions: At present, the number of confirmed cases from South Asia was found to be significantly lower than in Western countries. However, this could be due to the smaller number of tests performed. Hence, an increase in the strength of performing diagnostic tests is highly recommended. Strict measures are required to make the people of these countries follow the instructions of social distancing and comply with preventive measures., Competing Interests: No competing interests were disclosed., (Copyright: © 2021 Khan SQ et al.)

Diabetes is a major non-communicable disease with long-term complications. Over one million children and adolescents are affected with type 1 diabetes in the world. The number of children and adolescents with type 2 diabetes is also on the rise due to the increase incidence of childhood diabetes. South East Asian (SEA) contributes 184 100 children and adolescents with type 1 diabetes under the age of 20 years for this global health issue as at 2019. Countries of SEA region share same socio demographic, cultural, and economic challenges when it comes to holistic care of affected children. It is timely to discuss common concerns of these countries to give the best possible care for children affected with diabetes to minimize the burden of diabetes related complications, which would potentially affect the socioeconomic development of the respective countries., (© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Despite a large population and limited health infrastructure, the incidence and mortality of Coronavirus Disease 2019 (COVID-19) has been lower in South Asia than many regions. The underlying reasons and mechanisms for this relative protection are not established. However both genetic and environmental factors might play a role. Polymorphisms in ACE2 gene, ACE gene and in genes for some of the host cell proteases could affect the viral entry and replication. There is some evidence that HLA polymorphisms and several pathways involved in immune and inflammatory response could contribute to ethnic variation. Cross immunity because of past exposure to viral infections as well as malaria is likely to protect from the severe manifestations of disease. Role of BCG vaccination in trained innate immunity is recognised and could be a protective factor against COVID-19. There is limited evidence of the possibility of a less virulent viral strain circulating in South Asia. There is evidence from different parts of the world that temperature and humidity can influence viral survival as well as the host immune response. Finally implementation of early containment measures by some South Asian countries has also contributed to a less disease burden., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Toxocariosis is an important neglected tropical helminth disease of zoonotic significance for which canids are the definitive hosts. Dogs are also considered the sentinel host for the occurrence of T. canis infections in humans. Therefore, understanding its prevalence in canine population is imperative for any effective disease control in humans. A comprehensive review of literature on the prevalence of T. canis in canids was lacking from the Indian subcontinent which necessitated our efforts to compile available data published on this topic. Data on prevalence, incidence and occurrence of this helminths in canids were presented in this review as tabular format for easy comprehension. Moreover, the data were categorized based on the region where the studies were conducted with an aim to understand the spatial distribution of this parasite in the subcontinent. Factors influencing the regional prevalence/occurrence of T. canis such as type of canids (stray or pet), age, sex, breed, season and the choice of analytical methods were also discussed. In addition, data on the prevalence of T. canis in environmental samples and in zoo canids were also compiled and presented. We anticipate such an exhaustive review of literature available mostly in the journals published from the subcontinent would become a point source of information necessary for prioritizing future surveillance efforts in this region and for making informed policy decision to control this zoonotic helminth infection., (© 2020 Elsevier Ltd All rights reserved.)

Background: We aimed to determine the prevalence of chronic kidney disease (CKD) and its cross-country variation among hypertensive individuals in rural Bangladesh, Pakistan and Sri Lanka. We also explored the factors associated with CKD in these populations., Method: We studied baseline data from the Control of Blood Pressure and Risk Attenuation-Bangladesh, Pakistan and Sri Lanka (COBRA-BPS) trial, an ongoing cluster randomized controlled trial on 2643 hypertensive adults ≥40 years of age from 30 randomly selected rural clusters, 10 in each of the three countries. CKD was defined as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2 or a urine albumin:creatinine ratio (UACR)  ≥30 mg/g. Determinants for CKD were assessed using logistic regression analysis., Results: The overall prevalence of CKD was 38.1% (95% confidence interval 36.2-40.1%): 21.5% with eGFR <60 mL/min/1.73 m2 and 24.4% with UACR ≥30 mg/g. CKD prevalence varied across the three countries (58.3% in Sri Lanka, 36.4% Bangladesh and 16.9% Pakistan; P <0.001). The factors independently associated with higher odds of CKD were older age, being unmarried, higher 24-h urinary sodium excretion, presence of diabetes, elevated systolic blood pressure, diuretic use and living in Bangladesh or Sri Lanka (versus Pakistan)., Conclusions: The prevalence of CKD is alarmingly high in community-dwelling hypertensive adults, with significant cross-country variation in South Asia. Our findings underscore the urgency for further research into the etiology of CKD and address associated factors in targeted public health strategies with hypertension care outreach services in rural South Asia., Clinicaltrials.gov: NCT02657746., (© The Author(s) 2018. Published by Oxford University Press on behalf of ERA-EDTA.)

Objective: To determinate the prevalence and correlates of cardiometabolic multimorbidity (CMM), and their cross-country variation among individuals with hypertension residing in rural communities in South Asia., Design: A cross-sectional study., Setting: Rural communities in Bangladesh, Pakistan and Sri Lanka., Participants: A total of 2288 individuals with hypertension aged ≥40 years from the ongoing Control of Blood Pressure and Risk Attenuation- Bangladesh, Pakistan and Sri Lanka clinical trial., Main Outcome Measures: CMM was defined as the presence of ≥2 of the conditions: diabetes, chronic kidney disease, heart disease and stroke. Logistic regression was done to evaluate the correlates of CMM., Results: About 25.4% (95% CI 23.6% to 27.2%) of the hypertensive individuals had CMM. Factors positively associated with CMM included residing in Bangladesh (OR 3.42, 95% CI 2.52 to 4.65) or Sri Lankan (3.73, 95% CI 2.48 to 5.61) versus in Pakistan, advancing age (2.33, 95% CI 1.59 to 3.40 for 70 years and over vs 40-49 years), higher waist circumference (2.15, 95% CI 1.42 to 3.25) for Q2-Q3 and 2.14, 95% CI 1.50 to 3.06 for Q3 and above), statin use (2.43, 95% CI 1.84 to 3.22), and higher levels of triglyceride (1.01, 95% CI 1.01 to 1.02 per 5 mg/dL increase). A lower odds of CMM was associated with being physically active (0.75, 95% CI 0.57 to 0.97). A weak inverted J-shaped association between International Wealth Index and CMM was found (p for non-linear=0.058), suggesting higher risk in the middle than higher or lower socioeconomic strata., Conclusions: CMM is highly prevalent in rural South Asians affecting one in four individuals with hypertension. There is an urgent need for strategies to concomitantly manage hypertension, cardiometabolic comorbid conditions and associated determinants in South Asia., Competing Interests: Competing interests: THJ is funded by senior clinician scientist award from Singapore National Medical Research Council., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

We aimed to explore the cross-country variation in the prevalence of comorbid prediabetes or diabetes and determine the sociodemographic, lifestyle, and clinical factors, especially body mass index (BMI) and waist circumference, associated with comorbid diabetes in individuals with hypertension in rural South Asia. We analyzed cross-sectional data of 2426 hypertensive individuals of ≥40 years from 30 randomly selected rural communities in Bangladesh, Pakistan, and Sri Lanka. Prediabetes was defined as fasting plasma glucose (FPG) between 100 and 125 mg/dL without use of antidiabetic treatment and diabetes as FPG ≥126 mg/dL or use of antidiabetic medication. The prevalence (95% CI) of prediabetes or diabetes (53.5% (51.5%, 55.5%)) and diabetes (27.7% (25.9%, 29.5%)) was high in the overall hypertensive study population in rural communities in 3 countries. Rural communities in Sri Lanka had the highest crude prevalence of prediabetes or diabetes and diabetes (73.1% and 39.3%) with hypertension, followed by those in Bangladesh (47.4% and 23.1%) and Pakistan (39.2% and 20.5%). The factors independently associated with comorbid diabetes and hypertension were residing in rural communities in Sri Lanka, higher education, international wealth index, waist circumference, pulse pressure, triglyceride, and lower high-density lipoprotein. The association of diabetes with waist circumference was stronger than with BMI in hypertensive individuals. Prediabetes or diabetes are alarmingly common among adults with hypertension and vary among countries in rural South Asia. The high prevalence of comorbid diabetes in Sri Lanka among hypertensives is not fully explained by conventional risk factors and needs further etiological research. Urgent public health efforts are needed to integrate diabetes control within hypertension management programs in rural South Asia, including screening waist circumference.

Children are particularly vulnerable to environmental hazards because they receive higher doses of pollutants in any given environment and often do not have equitable access to social protection mechanisms such as environmental and health care services. The World Health Organization established a global network of collaborating centres that address children's environmental health (CEH). The network developed a focus on low- and middle-income countries (LMICs) and is broadening its reach by conducting regional workshops for CEH.Objective: This paper reports on the outcomes of a workshop held in conjunction with the 17th International Conference (November 2017) of the Pacific Basin Consortium for Environment and Health, focused on the state of CEH in South and Southeast Asia as presented by seven countries from the region (India, Bangladesh, Nepal, Bhutan, Vietnam, Thailand, Sri Lanka).Workshop outcomes: Country reports presented at the meeting show a high degree of similarity with respect to the issues threatening the health of children. The most common problems are outdoor and household air pollution in addition to exposure to heavy metals, industrial chemicals, and pesticides. Many children still do not have adequate access to clean water and improved sanitation while infectious diseases remain a problem, especially for children living in poverty. Child labour is widely prevalent, generally without adequate training or personal protective equipment. The children now face the dual burden of undernutrition and stunting on the one hand and overnutrition and obesity on the other.Conclusion: It is evident that some countries in these regions are doing better than others in varying areas of CEH. By establishing and participating in regional networks, countries can learn from each other and harmonise their efforts to protect CEH so that all can benefit from closer interactions., Competing Interests: The authors have no competing interests to declare., (© 2019 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See http://creativecommons.org/licenses/by/4.0/.)

Hypertension is the leading risk factor for cardiovascular disease and leading cause of premature death globally. In 2008, approximately 40% of adults were diagnosed with hypertension, with more than 1.5 billion people estimated to be affected globally by 2025. Hypertension disproportionally affects low- and middle-income countries, where the prevalence is higher and where the health systems are more fragile. This qualitative study explored patients' experiences on the management and control of hypertension in rural Bangladesh, Sri Lanka and Pakistan. We conducted sixty semi-structured interviews, with 20 participants in each country. Hypertensive individuals were recruited based on age, gender and hypertensive status. Overall, patients' reported symptoms across the three countries were quite similar, although perceptions of hypertension were mixed. The majority of patients reported low knowledge on how to prevent or treat hypertension. The main barriers to accessing health services, as reported by participants, were inadequate services and poor quality of existing facilities, shortage of medicine supplies, busyness of doctors due to high patient load, long travel distance to facilities, and long waiting times once facilities were reached. Patients also mentioned that cost was a barrier to accessing services and adhering to medication. Many patients, when asked for areas of improvement, reported on the importance of the provider-patient relationship and mentioned valuing doctors who spent time with them, provided advice, and could be trusted. However, most patients reported that, especially at primary health care level and in government hospitals, the experience with their doctor did not meet their expectations. Patients in the three countries reported desire for good quality local medical services, the need for access to doctors, medicine and diagnostics and decreased cost for medication and medical services. Patients also described welcoming health care outreach activities near their homes. Areas of improvement could focus on reorienting community health workers' activities; involving family members in comprehensive counseling for medication adherence; providing appropriate training for health care staff to deliver effective information and services for controlling hypertension to patients; enhancing primary health care and specialist services; improving supplies of hypertensive medication in public facilities; taking into account patients' cultural and social background when providing services; and facilitating access and treatment to those who are most vulnerable., Competing Interests: The authors have declared that no competing interests exist.

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and have no interests to declare.

Type 2 diabetes has rapidly developed into a major public health problem in south Asia (defined here as Bangladesh, Bhutan, India, Nepal, Pakistan, and Sri Lanka) in recent decades. During this period, major lifestyle changes associated with economic transition, industrialisation, urbanisation, and globalisation have been key determinants in the increasing burden of non-communicable diseases. A decline in nutrition quality, reduced physical activity, and increased sedentary behaviours are reflected in the increasing prevalence of type 2 diabetes and related risk factors in the region. The International Diabetes Federation 2017 estimates of the prevalence of diabetes in adults in the region range from 4·0% in Nepal to 8·8% in India. The prevalence of overweight ranges from 16·7% in Nepal to 26·1% in Sri Lanka, and the prevalence of obesity ranges from 2·9% in Nepal to 6·8% in Sri Lanka. An increasing proportion of children, adolescents, and women are overweight or obese, leading to a heightened risk of type 2 diabetes. Ethnic south Asians present with greater metabolic risk at lower levels of BMI compared with other ethnic groups (referred to as the south Asian phenotype), with type 2 diabetes often developing at a younger age, and with rapid progression of diabetic complications. Because of the presence of multiple risk factors and a body composition conducive to the development of type 2 diabetes, south Asians should be aggressively targeted for prevention. In this Series paper, we detail trends in the prevalence of diabetes in the region and address major determinants of the disease in the context of nutrition and physical activity transitions and the south Asian phenotype., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

South Asia is a unique geopolitical region covering 3.4% of the world's surface area and supporting 25% of the world's population (1.75 billion). Available evidence from South Asia shows variable estimates of the magnitude of disability. The projected magnitude depends on whether an impairment focus is highlighted (approximately 1.6⁻2.1%) or functionality is given precedence (3.6⁻15.6%). People with disability (PWD) face significant challenges to accessing health care in the region. Studies show that adults with disability reported a four times higher incidence of a serious health problem in a year's recall period. Evidence shows a significantly higher rate (17.8%) of hospitalization among PWD compared to others (5%). Chronic conditions like diabetes were also significantly higher. Women with disability had significantly more concerns on reproductive health issues. Studies from the South Asia region reveal that not only did PWD have a higher load of adverse health outcomes but they also faced significantly more barriers in accessing health services.

Background: Uncontrolled blood pressure (BP) is a leading risk factor for death and disability in South Asia. We aimed to determine the cross-country variation, and the factors associated with uncontrolled BP among adults treated for hypertension in rural South Asia., Methods: We enrolled 1,718 individuals aged ≥40 years treated for hypertension in a cross-sectional study from rural communities in Bangladesh, Pakistan, and Sri Lanka. Multivariable logistic regression model was used to determine the factors associated with uncontrolled BP (systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg)., Results: Among hypertensive individuals, 58.0% (95% confidence interval (CI) 55.7, 60.4) had uncontrolled BP: 52.8% (49.0, 56.6) in Bangladesh, 70.6% (65.7, 75.1) in Pakistan, and 56.5% (52.7, 60.1) in Sri Lanka. The odds (odds ratio (95% CI)) of uncontrolled BP were significantly higher in individuals with lower wealth index (1.17 (1.02, 1.35)); single vs. married (1.46 (1.10, 1.93)); higher log urine albumin-to-creatinine ratio (1.41 (1.24, 1.60)); lower estimated glomerular filtration rate (1.23 (1.01, 1.49)); low vs. high adherence to antihypertensive medication (1.50 (1.16, 1.94)); and Pakistan (2.91 (1.60, 5.28)) vs. Sri Lanka. However, the odds were lower in those with vs. without self-reported kidney disease (0.51 (0.28, 0.91)); and receiving vs. not receiving statins (0.62 (0.44, 0.87))., Conclusions: The majority of individuals with treated hypertension have uncontrolled BP in rural Bangladesh, Pakistan, and Sri Lanka with significant disparities among and within countries. Urgent public health efforts are needed to improve access and adherence to antihypertensive medications in disadvantaged populations in rural South Asia.

Background: Autism spectrum disorders (ASD) are a group of complex neurodevelopmental disorders. The prevalence of ASD in many South Asian countries is still unknown. The aim of this study was to systematically review available epidemiological studies of ASD in this region to identify gaps in our current knowledge., Methods: We searched, collected and evaluated articles published between January 1962 and July 2016 which reported the prevalence of ASD in eight South Asian countries. The search was conducted in line with the PRISMA guidelines., Results: We identified six articles from Bangladesh, India, and Sri Lanka which met our predefined inclusion criteria. The reported prevalence of ASD in South Asia ranged from 0.09% in India to 1.07% in Sri Lanka that indicates up to one in 93 children have ASD in this region. Alarmingly high prevalence (3%) was reported in Dhaka city. Study sample sizes ranged from 374 in Sri Lanka to 18,480 in India. The age range varied between 1 and 30 years. No studies were found which reported the prevalence of ASD in Pakistan, Nepal, Bhutan, Maldives and Afghanistan. This review identifies methodological differences in case definition, screening instruments and diagnostic criteria among reported three countries which make it very difficult to compare the studies., Conclusions: Our study is an attempt at understanding the scale of the problem and scarcity of information regarding ASD in the South Asia. This study will contribute to the evidence base needed to design further research and make policy decisions on addressing this issue in this region. Knowing the prevalence of ASD in South Asia is vital to ensure the effective allocation of resources and services.

Objective: Known risk factors do not fully explain the comparatively high susceptibility to coronary heart disease (CHD) in South Asians (Indian, Pakistani, Bangladeshi, and Sri Lankan populations in South Asia and overseas). The search for explanatory hypotheses and cofactors that raise susceptibility of South Asians to CHD continues. The aim of this study was to propose "the high-heat food preparation hypothesis," where neo-formed contaminants (NFCs) such as trans-fatty acids (TFAs) and advanced glycation end-products (AGEs) are the cofactors., Methods: We reviewed the actions of AGEs and TFAs, the burden of these products in tissues and blood in South Asians, the relationship between these products and CHD, the effects of preparing food and reheating oils at high temperatures on NFCs, and the foods and mode of preparation in South Asian and Chinese cuisines., Results: Animal and human studies show NFCs increase the risk for CHD. Evidence on the consumption and body burden of these products across ethnic groups is not available, and comparable data on the NFC content of the cuisine of South Asians and potential comparison populations (e.g., the Chinese with lower CHD rates) are limited. South Asians' cuisine is dominated by frying and roasting techniques that use high temperatures. South Asian foods have high TFA content primarily through the use of partially hydrogenated fats, reheated oils, and high-heat cooking. Reheating oils greatly increases the TFA content. In comparison, Chinese cuisine involves mostly braising, steaming, and boiling rather than frying., Conclusion: We hypothesize that South Asians' susceptibility to CHD is partly attributable to high-heat treated foods producing high NFCs. Research to accrue direct evidence is proposed., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Dengue is endemic in many countries visited by Swedish travellers. We aimed to determine the attack rate of dengue in Swedish travellers and analyse the trends over time and the geographical variation., Methods: We obtained the following data from the Swedish Institute for Communicable Disease Control for the y 1995-2010: number of Swedish residents with confirmed dengue, the country and year of infection. We also obtained registers on the Swedish annual air traveller arrivals to dengue endemic areas from the United Nations World Tourist Organization for the time period. We estimated attack rates with 95% confidence intervals (CI)., Results: In total, 925 Swedish travellers with confirmed dengue were reported. We found an increasing trend over time for most destinations. The majority of the dengue cases were acquired in Thailand (492 out of 925 travellers; 53%), with an attack rate of 13.6 (95% CI 12.7, 14.4) per 100,000 travellers. However, the 2 highest attack rates per 100,000 travellers were found for Sri Lanka (45.3, 95% CI 34.3, 56.4) and Bangladesh (42.6, 95% CI 23.8, 61.5)., Conclusions: Information on attack rates in travellers is more helpful in guiding travel medicine practitioners than reports of absolute numbers, as the latter reflect travel preferences rather than the true risk. Although the majority of dengue infections in Swedish travellers were acquired in Thailand, the attack rates for dengue in travellers to Sri Lanka and Bangladesh were much higher. These data aid in refining information on the risk of dengue in travellers.

This article attempts to highlight the prevalence of zinc deficiency and its health and economic consequences in South Asian developing countries and to shed light on possible approaches to combating zinc deficiency. A computer-based search was performed on PubMed, Google, and ScienceDirect.com to retrieve relevant scientific literature published between 2000 and 2012. The search yielded 194 articles, of which 71 were culled. Studies were further screened on the basis of population groups, age and sex, pregnancy, and lactation. The most relevant articles were included in the review. Cutoffs for serum zinc concentration defined for zinc deficiency were 65 microg/dL for males and females aged < 10 years, 66 microg/dL for non-pregnant females, and 70 microg/dL for males aged > or = 10 years. Population segments from rural and urban areas of South Asian developing countries were included in the analysis. They comprised pregnant and lactating women, preschool and school children. The analysis reveals that zinc deficiency is high among children, pregnant and lactating women in India, Pakistan, Bangladesh, Sri Lanka, and Nepal. Diarrhoea has been established as a leading cause to intensify zinc deficiency in Bangladesh. Little has been done in Sri Lanka and Nepal to estimate the prevalence of zinc deficiency precisely. A substantial population segment of the South Asian developing countries is predisposed to zinc deficiency which is further provoked by increased requirements for zinc under certain physiological conditions. Supplementation, fortification, and dietary diversification are the most viable strategies to enhancing zinc status among various population groups.

The Indian Subcontinent has emerged as a scene of many mosquito-borne infectious diseases, including malaria and dengue fever. After the 1990s, the rate of malaria declined owing largely to preventive measures, but at the same time dengue fever (DF) and dengue hemorrhagic fever (DHF) were increasing in the region. Outbreaks were recorded in all countries of the Indian Subcontinent with India, Pakistan, Bangladesh and Sri Lanka on the forefront and suffering from the largest number of cases and deaths. We discuss annual cases of DF/DHF in these four countries and possible factors involved in DF outbreaks. We also discuss prevalent serotypes in this region where data suggest the emergence of DEN2 and DEN3 as the most dominant and lethal serotypes. Climate is an important factor influencing DF outbreaks, and rainfall, temperature and humidity play a pivotal role in DF outbreaks. Finally the economic impact of DF/DHF cases is discussed showing that direct and indirect economic loss due to DF/DHF reaches millions of USD each year.

Of the 1.5 million people of South Asia, a large number live in extreme poverty in rural urban areas and have limited access to health care. End-stage renal disease (ESRD) is a devastating medical, social, and economic problem. Lack of registries prevent an accurate assessment of the incidence or prevalence of ESRD, but a recent population-based study assessed the age-adjusted incidence at 232 cases per million population per year. ESRD treatment facilities are available only in major cities, requiring many patients to travel long distances to seek care. Many patients never come to medical attention. Until recently, infection-related glomerulonephritides were considered the most common cause of ESRD, but recent years have shown rapid emergence of diabetic nephropathy as the most frequent cause among new ESRD patients who are younger compared to their Western counterparts. A large number presents with a short history of ESRD of undetermined etiology and often require emergency dialysis. Non-availability of health insurance limits the ability of patients to afford costly ESRD care. The quality of chronic dialysis is dictated mostly by non-medical, financial factors. Maintenance hemodialysis (HD) facilities are scarce. Chronic peritoneal dialysis is not cheaper than HD; high cost and nephrologist bias have limited the growth of peritoneal dialysis in South Asia. Transplants using organs from a related donor is the only viable form of renal replacement therapy for the majority. Cost issues and lack of an effective deceased donor program have limited its availability. Improvement in ESRD care would require strong support from the government, awareness on the part of the medical community of the need of timely referral of these patients to the nephrologist, appropriate pre-dialysis education and development of a network of integrated ESRD treatment facilities for optimal utilization of all forms of renal replacement therapy so that the outcomes of these patients can be improved.

Although one-third of the world cervical cancer burden is endured in India, Bangladesh, Nepal and Sri Lanka, there are important gaps in our knowledge of the distribution and determinants of the disease in addition to inadequate investments in screening, diagnosis and treatment in these countries. Prevalence of human papillomavirus (HPV) infection among the general populations varies from 7-14% and the age-specific prevalence across age groups is constant with no clear peak in young women. This observation may be the result of a low clearance rate of incident infections, frequent re-infection/reactivation, limited or no data in target high-risk age groups (teenagers), and sexual behavioural patterns in the population. High-risk HPV types were found in 97% of cervical cancers, and HPV-16 and 18 were found in 80% of cancers in India. Beyond research studies, demonstration projects and provincial efforts in selected districts, there are no serious initiatives to introduce population-based screening by public health authorities in these countries. Cervical cancer is a relatively neglected disease in terms of advocacy, screening and prevention from professional or public health organizations. Cytology, HPV testing and visual screening with acetic acid (VIA) or Lugol's iodine (VILI) are known to be accurate and effective methods to detect cervical cancer and could contribute to the reduction of disease in these countries. While HPV vaccination provides hope for the future, several barriers prohibit the introduction of prophylactic vaccines in these countries such as high costs and low public awareness of cervical cancer. Efforts to implement screening based on the research experiences in the region offer the only currently viable means of rapidly reducing the heavy burden of disease.

Analysis of malaria imported into eight European countries from the Indian Sub-continent (ISC) (India, Pakistan, Bangladesh and Sri Lanka) led to a consensus statement on the use of chemoprophylaxis within TropNetEurop. The proportion of cases from the ISC in 2004 ranged from 1.4%-4.6% of total imported cases. Plasmodium falciparum cases reported from the eight countries was only 23 (13% of all cases from the region). Total malaria reports between 1999-2004 fell from 317 to 180. The risk of malaria in UK residents visiting the region was > 1 case per 1,000 years exposed. The group recommended non-selective prescribing of chemoprophylaxis for visitors to India, Pakistan, Bangladesh and Sri Lanka should be dropped.

Background and Objectives: A Gonococcal Antimicrobial Susceptibility Program (GASP) under the World Health Organization South East Asia Region (WHO SEAR) is continuing in India and neighboring countries and is being coordinated by the WHO Regional Reference Laboratory (RRL), Vardhman Mahavir Medical College, and Safdarjung Hospital, New Delhi., Goal: The present communication describes the current status and trends of antimicrobial resistance patterns of Neisseria gonorrhoeae, isolated in different focal-point laboratories under GASP, as presented in WHO SEAR intercountry consultative meeting conducted in December 2001., Study: Seven laboratories from India and 1 each from Bangladesh, Sri Lanka, and Nepal presented their data for the year 2000/2001. In addition, RRL Delhi, Bangladesh, and Sri Lanka presented data for the years 1995 to 2001, 1997 to 2001, and 1996 to 2000, respectively. Either National Committee for Clinical Laboratory Standards or calibrated dichotomous sensitivity technique was used in the different laboratories for determining antimicrobial susceptibility., Results: It was observed that in the Indian laboratories, penicillin resistance varied from 20% to 79%, tetracycline resistance from 0% to 45.6%, and ciprofloxacin from 10.6% to 100%. Chromosomal, as well as plasmid-mediated resistance, was observed. The strains were reported to be less sensitive to ceftriaxone in 5 out of 7 laboratories, while none reported spectinomycin resistance. The reasons for wide variation in the results could be due to geographical strain difference in different parts of this vast country. At Sri Lanka, gonococci showed resistance towards penicillin (96.8%) and ciprofloxacin (8.2%). Bangladesh reported N. gonorrhoeae with ciprofloxacin (76%), penicillin (33%), and tetracycline (50%) resistance and decreased susceptibility to ceftriaxone (1.5%). Both the laboratories did not report any spectinomycin resistance. The resistance trends in these 2 centers and the RRL, New Delhi, showed different patterns., Conclusion: The report indicates the necessity for continuous surveillance of antimicrobial resistance pattern in this region of WHO for establishing antimicrobial policy guidelines for management of this common but important sexually transmitted infection (STI) pathogen, known to facilitate human immunodeficiency virus (HIV) infection. It also highlights the importance of ensuring quality assurance in the techniques in order to generate uniform data.