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Current soil-transmitted helminth (STH) programs target morbidity control with school-based deworming. Increasing interest in steering neglected tropical disease (NTD) programmes from morbidity control towards disease elimination has prompted evaluation of strategies that may interrupt transmission. The feasibility of interrupting transmission of STH with community-wide deworming is being tested in the ongoing DeWorm3 cluster randomized trial. Gender-based perspectives about susceptibility to infection and need for treatment have been shown to influence both health-seeking behaviour and health outcomes. We carried out a qualitative study among men and women in the community to understand their knowledge, beliefs, and attitudes about STH infections and community-wide mass drug administration (cMDA). Eight semi-structured focus group discussions were conducted among men and women residing in the DeWorm3 study site in India—Vellore and Tiruvannamalai districts of Tamil Nadu. Thematic coding was used to analyse the transcripts in ATLAS.ti 8.0. Both men and women in this study demonstrated a high level of STH knowledge but some men had misconceptions that intestinal worms were beneficial. Men and women shared several similar beliefs and attitudes regarding STH treatment. Both believed that adults were likely to have STH infections and both reported that stigma prevented them from seeking treatment. Influenced by gender norms, women were more likely to associate STH infections with inadequate sanitation and hygiene, while men were more likely to believe that those engaged in agricultural work were at risk. Both genders reported a positive attitude towards cMDA for STH. Barriers to cMDA implementation differed by gender; women expressed concern regarding side-effects and drug quality while men were concerned that treatment coverage may be affected due to the absence of people during the day when the drug is distributed. Both men and women perceived the treatment of adults for STH infections to be important, however, the perceived barriers to participating in cMDA differed by gender in this community. The study identified key messages to be incorporated in communication and outreach strategies for cMDA programmes., Author summary In this qualitative study, we conducted focus group discussions with men and women residing in communities participating in a cluster-randomized trial of community-wide deworming for soil-transmitted helminth (STH) in order to understand how knowledge, beliefs, and attitudes are influenced by gender. Men and women shared similar beliefs and attitudes, although there were differences in knowledge about STH infection and its treatment. While both genders understood that STH transmission is associated with poor sanitation and hygiene, women voiced a greater appreciation of these risk factors, perhaps because of the STH knowledge gained from the frontline health workers during school MDA and anaemia programs. Men and women both believed that adults may be re-infecting children in the community and both articulated acceptance of deworming medications. However, both men and women also noted that stigma associated with an adult having STH infection prevented them from actively seeking treatment. The cMDA for STH, may provide important socio-behavioural benefits to communities, as it provides an opportunity to treat all community members over one year of age without discrimination by infection status or age. However, compliance with treatment may be affected by community beliefs; women expressed concerns regarding treatment safety while men specifically expressed concerns about achieving treatment coverage due to the absence of some individuals during cMDA due to migration and people being absent for work. Findings from this study suggest that communication and dissemination messages should include a rationale for cMDA and stress the safety and benefits of the drug. In addition, these results highlight the importance of carefully timing the delivery of cMDA to ensure that working adults and migratory populations have access.

Over the past decade, two movements have profoundly changed the environment in which global health epidemiologists work: research integrity and research fairness. Both ought to be equally nurtured by global health epidemiologists who aim to produce high quality impactful research. Yet bridging between these two aspirations can lead to practical and ethical dilemmas. In the light of these reflections we have proposed the BRIDGE guidelines for the conduct of fair global health epidemiology, targeted at stakeholders involved in the commissioning, conduct, appraisal and publication of global health research. The guidelines follow the conduct of a study chronologically from the early stages of study preparation until the dissemination and communication of findings. They can be used as a checklist by research teams, funders and other stakeholders to ensure that a study is conducted in line with both research integrity and research fairness principles. In this paper we offer a detailed explanation for each item of the BRIDGE guidelines. We have focused on practical implementation issues, making this document most of interest to those who are actually conducting the epidemiological work.

Interpretation of spirometry involves comparing lung function parameters with predicted values to determine the presence/severity of the disease. The Global Lung Function Initiative (GLI) derived reference equations for healthy individuals aged 3–95 years from multiple populations but highlighted India as a “particular group” for whom further data are needed. We aimed to derive predictive equations for spirometry in a rural Western Indian adult population.We used spirometry data previously collected (2008–2012) from 1258 healthy adults (aged 18 years and over) by the Vadu Health and Demographic Surveillance System. We constructed sex-stratified prediction equations for forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), and FEV1/FVC using the Generalised Additive Model for Location, Scale and Shape (GAMLSS) method to derive the best fitting model of each outcome as a function of age and height.When compared with GLI Ethnicity Codes 1 (White Caucasian) and 5 (Other/Mixed), the Western Indian adult population appears to have lower lung volumes on average, though the FEV1/FVC ratio is comparable. Both age and height were predictive of mean FEV1 and FVC; and for females, the variability of response was also dependent on age. FEV1/FVC appears to have a very strong age effect, highlighting the limitations of using a fixed 0.7 cut-off value.The use of GLI normal values may result in overdiagnosis of lung disease in this population. We recommend that the values and equations generated from this study should be used by physicians in their routine practice for diagnosing disease and its severity in adults from the Western Indian population.

The NIHR Global Health Research Unit in Respiratory Health (henceforth ‘RESPIRE’) is a research and academic capacity development initiative funded by the UK Government through its National Institute of Health Research (NIHR). RESPIRE’s focus is to undertake applied respiratory health in both communicable and non-communicable disorders, which has the potential to improve the respiratory health of children and adults in Bangladesh, India, Malaysia and Pakistan [1]. RESPIRE’s working ethos is to work bottom-up to undertake research priorities that have been identified by RESPIRE investigators in our partner low- and middle-income countries (LMICs) [1]. To this end, we conducted an internal process of identifying research priorities within the RESPIRE collaboration using the Child Health and Nutrition Research Initiative's (CHNRI) method [2]. The outcomes of this process were then used, in conjunction with other approaches, to develop the list of the research projects led by RESPIRE investigators that would receive financial support from the RESPIRE budget [2].

Traditionally, health care-seeking for child illness is assessed through population-based and nationally representative demographic and health surveys (DHS) that are conducted once every five to seven years and are based on maternal recall. These maternal reports are subject to recall bias. Mobile phones (with the use of GPS technology) have the potential to constantly track movements of phone owners and provide high quality and more accurate data at a population level in low and middle income countries (LMICs) to assess the validity of maternal recall. We provided a group of mothers with smartphones installed with a location-aware application and visited them monthly to administer a survey questionnaire on care-seeking for diarrhoea, fever and cough with fever. This paper assesses for any reactivity to smartphones or repeated study contacts for measuring care-seeking and if this resulted in change in health care provider preference.We enrolled 749 mothers from rural areas of Pune district in Maharashtra, India and randomly allocated them to one of three groups - a longitudinal phone group, a longitudinal control group and a cross-sectional control group. We collected baseline information from mothers, including individual and household demographic and socio-economic characteristics and care-seeking preferences for child illness. We followed up both longitudinal groups monthly and each cross-sectional sub-group once over a period of 6 months. At each follow up, we administered questions identical to those in the National Family Health Survey (NFHS) questionnaire to determine an episode of diarrhoea, fever or cough within the last 15 days, care seeking for the same, and the type of provider. The data were analysed using the χAll three groups were similar in their socio-demographic characteristics at baseline. We did not observe any significant difference in care seeking for diarrhoea, fever or cough with fever between groups. Also, we did not observe any significant difference in proportion of children seeking care from the private sector.We did not observe any reactivity in this study due to the presence of the phone (Hawthorne effect) or repeated study visits. The study also shows the potential of using GPS enabled smartphones to enrich DHS surveys in LMICs like India. However, further studies need to be conducted in other population groups before the findings can be generalised.

Background. Recent Indian policies have vastly expanded access to clean fuels. Access does not necessarily lead to displacement of traditional stoves and fuels, however. We evaluated methods to enc...

A newly developed bovine-human reassortant pentavalent vaccine (BRV-PV, ROTASIIL®) was tested for its potential effect on the immunogenicity of concomitantly administered EPI vaccines in infants in a randomized controlled study in India.In this Phase III, multicenter, open label, randomized, controlled study, three doses of BRV-PV or two doses of Rotarix® and one dose of placebo were given to healthy infants at 6, 10, and 14 weeks of age. Subjects also received three doses of DTwP-HepB-Hib (diphtheria, tetanus, whole-cell pertussis, hepatitis B, and haemophilus influenzae type b conjugate - pentavalent vaccine) and oral polio vaccine concomitantly at 6, 10, and 14 weeks of age and a single dose of inactivated polio vaccine at 14 weeks of age. Blood samples were collected four weeks after the final vaccination to assess immune responses to all the vaccines administered. For diphtheria, tetanus, hepatitis B, Hib, polio type 1, and polio type 3 antibodies, non-interference was to be supported if the lower limit of the two-sided 90% confidence interval (CI) for the seroprotection rate difference for the BRV-PV group minus the Rotarix® group was10.0%. For pertussis antibodies, non-interference was to be supported if the lower limit of the two-sided 90% CI for the ratio of geometric mean concentrations (GMCs) was0.5.A total of 1500 infants were randomized to either BRV-PV (1125 infants) or Rotarix® (375 infants), of which 1341 completed the study as per the protocol. More than 97% of subjects achieved seroprotective antibody titres against diphtheria, tetanus, hepatitis B, Hib, polio type 1, and polio type 3 in both groups. The difference in seroprotection rates between the BRV-PV group and the Rotarix® group for all these antibodies was less than 1%. The ratio of GMCs of anti-pertussis IgG concentrations for the BRV-PV group versus Rotarix® was 1.04 [90% CI: 0.90; 1.19].BRV-PV does not interfere with the immunogenicity of concomitantly administered routine infants vaccines.

Conditional cash transfers (CCTs)-cash payments provided to households or specific household members who meet defined conditions or fulfill certain behaviors-have been extensively used in India to encourage antenatal care, institutional delivery, and vaccination. This paper describes the social design and technical development of a low-cost, meal-counting stove use monitor (the Pink Key) that enables a CCT based on liquefied petroleum gas (LPG) usage and presents pilot data from its testing and the initial deployment. The system consists of a sensing harness attached to a two-burner LPG stove and an easily removable datalogger. For each cooking event with LPG, households receive 2 rupees-less than the cost of fuel, but enough to partially defray LPG refill costs. The system could enable innovative "self-monitoring" at a large scale-participants initiate the CCT by bringing their Pink Key to antenatal clinic visits, where care providers download data and initiate payments, and participants return the sensor to their stove at home. The system aligns with existing Indian programs to improve health among poor, pregnant women, and contributes a new method to encourage the use of clean cooking technologies.

Many diseases are affected by changes in weather. There have been limited studies, however, which have examined the relationship between heat and cold and cause-specific mortality in low and middle-income countries. In this study, we aimed to estimate the effects of heat and cold days on total and cause-specific mortality in the Vadu Health and Demographic Surveillance System (HDSS) area in western India. We used a quasi-Poisson regression model allowing for over-dispersion to examine the association of total and cause-specific mortality with extreme high (98th percentile, &gt, 39 °C) and low temperature (2nd percentile, &lt, 25 °C) over the period January 2003 to December 2012. Delays of 0 and 0–4 days were considered and relative risks (RR) with 95% confidence intervals (CI) were calculated. Heat was significantly associated with daily deaths by non-infectious diseases (RR = 1.57, CI: 1.18–2.10). There was an increase in the risk of total mortality in the age group 12–59 years on lag 0 day (RR = 1.43, CI: 1.02–1.99). A high increase in total mortality was observed among men at lag 0 day (RR = 1.38, CI: 1.05–1.83). We did not find any short-term association between total and cause-specific mortality and cold days. Deaths from neither infectious nor external causes were associated with heat or cold. Our results showed a strong and rather immediate relationship between high temperatures and non-infectious disease mortality in a rural population located in western India, during 2003–2012. This study may be used to develop targeted interventions such as Heat Early Warning Systems in the area to reduce mortality from extreme temperatures.

Background. Mass vaccination campaigns of the population aged 1–29 years with 1 dose of group A meningococcal (MenA) conjugate vaccine (PsA-TT, MenAfriVac) in African meningitis belt countries has resulted in the near-disappearance of MenA. The vaccine was tested in clinical trials in Africa and in India and found to be safe and highly immunogenic compared with the group A component of the licensed quadrivalent polysaccharide vaccine (PsACWY). Antibody persistence in Africa and in India was investigated. Methods. A total of 900 subjects aged 2–29 years were followed up for 4 years in Senegal, Mali, and The Gambia (study A). A total of 340 subjects aged 2–10 years were followed up for 1 year in India (study B). In study A, subjects were randomized in a 2:1 ratio, and in study B a 1:1 ratio to receive either PsA-TT or PsACWY. Immunogenicity was evaluated by measuring MenA serum bactericidal antibody (SBA) with rabbit complement and by a group A–specific immunoglobulin G (IgG) enzyme-linked immunosorbent assay. Results. In both studies, substantial SBA decay was observed at 6 months postvaccination in both vaccine groups, although more marked in the PsACWY group. At 1 year and 4 years (only for study A) postvaccination, SBA titers were relatively sustained in the PsA-TT group, whereas a slight increasing trend, more pronounced among the youngest, was observed in the participants aged

The International Network for the Demographic Evaluation of Populations and Their Health (INDEPTH) is a global network of research centers that conduct longitudinal health and demographic evaluation of populations in low- and middle-income countries (LMICs) currently in 52 health and demographic surveillance system (HDSS) field sites situated in sub-Saharan Africa (14 countries), Asia (India, Bangladesh, Thailand, Vietnam, and Indonesia), and Oceania (Papua New Guinea). Through this network of HDSS field sites, INDEPTH is capable of producing reliable longitudinal data about the lives of people in the research communities as well as how development policies and programs affect those lives. The aim of the INDEPTH Data Repository is to enable INDEPTH member centers and associated researchers to contribute and share fully documented, high-quality datasets with the scientific community and health policy makers.

Water, sanitation and hygiene (WASH) installations are indispensable in health care facilities. Their quality might also influence the decision whether to visit a health facility. We investigated the WASH infrastructure in small health facilities in rural Pune, India, and surveyed expectations and satisfactoriness among women. The availability and quality of WASH installations was assessed in 12 facilities using a checklist. Dedicated questions in a household survey provided the community perspective, complemented by qualitative methods. A few public facilities had no latrine or hand washing station. On the contrary, all private facilities offered such installations. The bed/outpatient-to-installation ratio was also lower in private compared to public facilities. While most latrines were functional and well maintained, they often lacked garbage bins. Soap was often missing from hand washing stations. Dedicated latrines for women were rare. Women were generally satisfied with the WASH installations in the local health facility, but considered private facilities as better. WASH installations in health facilities are generally acceptable in private facilities while improvements are needed in some government facilities. Women expect WASH installations in health facilities, and view their quality in a broader framework of ‘cleanliness,’ which they consider when choosing facilities.

Nearly three billion people use solid fuels for cooking and heating, which leads to extremely high levels of household air pollution and is a major cause of morbidity and mortality. Many stove manufacturers have developed alternative cookstoves (ACSs) that are aimed at reducing emissions and fuel consumption. Here, we tested a traditional clay chulha cookstove (TCS) and five commercially available ACSs, including both natural draft (Greenway Smart Stove, Envirofit PCS-1) and forced draft stoves (BioLite HomeStove, Philips Woodstove HD4012, and Eco-Chulha XXL), in a test kitchen in a rural village of western India. Compared to the TCS, the ACSs produced significant reductions in particulate matter less than 2.5 µm (PM2.5) and CO concentrations (Envirofit: 22%/16%, Greenway: 24%/42%, BioLite: 40%/35%, Philips: 66%/55% and Eco-Chulha: 61%/42%), which persisted after normalization for fuel consumption or useful energy. PM2.5 and CO concentrations were lower for forced draft stoves than natural draft stoves. Furthermore, the Philips and Eco-Chulha units exhibited higher cooking efficiency than the TCS. Despite significant reductions in concentrations, all ACSs failed to achieve PM2.5 levels that are considered safe by the World Health Organization (ACSs: 277–714 μg/m3 or 11–28 fold higher than the WHO recommendation of 25 μg/m3;).

Background: Disability and quality of life are key outcomes for older people. Little is known about how these measures vary with age and gender across lower income and middle-income countries; such information is necessary to tailor health and social care policy to promote healthy ageing and minimise disability. Methods: We analysed data from participants aged 50 years and over from health and demographic surveillance system sites of the International Network for the Demographic Evaluation of Populations and their Health Network in Ghana, Kenya, Tanzania, South Africa, Vietnam, India, Indonesia and Bangladesh, using an abbreviated version of the WHO Study on global AGEing survey instrument. We used the eight-item WHO Quality of Life (WHOQoL) tool to measure quality of life and theWHO Disability Assessment Schedule, version 2 (WHODAS-II) tool to measure disability. We collected selected health status measures via the survey instrument and collected demographic and socioeconomic data from linked surveillance site information. We performed regression analyses to quantify differences between countries in the relationship between age, gender and both quality of life and disability, and we used anchoring vignettes to account for differences in interpretation of disability severity. Results: We included 43 935 individuals in the analysis. Mean age was 63.7 years (SD 9.7) and 24 434 (55.6%) were women. In unadjusted analyses across all countries, WHOQoL scores worsened by 0.13 points (95% CI 0.12 to 0.14) per year increase in age and WHODAS scores worsened by 0.60 points (95% CI 0.57 to 0.64). WHODAS-II and WHOQoL scores varied markedly between countries, as did the gradient of scores with increasing age. In regression analyses, differences were not fully explained by age, socioeconomic status, marital status, education or health factors. Differences in disability scores between countries were not explained by differences in anchoring vignette responses. Conclusions: The relationship between age, sex and both disability and quality of life varies between countries. The findings may guide tailoring of interventions to individual country needs, although these associations require further study.

Lower airway colonisation with species of potentially pathogenic bacteria (PPB) is associated with defective bacterial phagocytosis, in monocyte-derived macrophages (MDMs) and alveolar macrophages, from tobacco smoke-associated chronic obstructive pulmonary disease (S-COPD) subjects. In the developing world, COPD among nonsmokers is largely due to biomass smoke (BMS) exposure; however, little is known about PPB colonisation and its association with impaired innate immunity in these subjects.We investigated the PPB load (Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis and Pseudomonas aeruginosa) in BMS-exposed COPD (BMS-COPD) subjects compared with S-COPD and spirometrically normal subjects. We also examined the association between PPB load and phagocytic activity of MDMs and lung function. Induced sputum and peripheral venous blood samples were collected from 18 healthy nonsmokers, 15 smokers without COPD, 16 BMS-exposed healthy subjects, 19 S-COPD subjects and 23 BMS-COPD subjects. PPB load in induced sputum and MDM phagocytic activity were determined using quantitative PCR and fluorimetry, respectively.Higher bacterial loads of S. pneumoniae, H. influenzae and P. aeruginosa were observed in BMS-COPD subjects. Increased PPB load in BMS-exposed subjects was significantly negatively associated with defective phagocytosis in MDMs and spirometric lung function indices (pIncreased PPB load in airways of BMS-COPD subjects is inversely associated with defective bacterial phagocytosis and lung function.

In Ayurveda system of medicine individuals are classified into seven constitution types, "Prakriti", for assessing disease susceptibility and drug responsiveness. Prakriti evaluation involves clinical examination including questions about physiological and behavioural traits. A need was felt to develop models for accurately predicting Prakriti classes that have been shown to exhibit molecular differences. The present study was carried out on data of phenotypic attributes in 147 healthy individuals of three extreme Prakriti types, from a genetically homogeneous population of Western India. Unsupervised and supervised machine learning approaches were used to infer inherent structure of the data, and for feature selection and building classification models for Prakriti respectively. These models were validated in a North Indian population. Unsupervised clustering led to emergence of three natural clusters corresponding to three extreme Prakriti classes. The supervised modelling approaches could classify individuals, with distinct Prakriti types, in the training and validation sets. This study is the first to demonstrate that Prakriti types are distinct verifiable clusters within a multidimensional space of multiple interrelated phenotypic traits. It also provides a computational framework for predicting Prakriti classes from phenotypic attributes. This approach may be useful in precision medicine for stratification of endophenotypes in healthy and diseased populations.

Objectives: We aimed to examine associations between CAO and unemployment across the world. Methods: Cross-sectional data from 26 sites in the Burden of Obstructive Lung Disease (BOLD) Study were used to analyze effects of CAO on unemployment. Odds ratios (OR) for unemployment in subjects 40-65 years old were estimated with multilevel mixed-effects generalized linear model with study site as random effect. Site-by-site heterogeneity was assessed using individual participant data meta-analyses. Results: Of 18710 participants, 11.3% had CAO. Ratio of unemployed subjects with CAO divided by unemployed subjects without CAO showed large discrepancies between sites, particularly in low-to-middle income countries with ratio from 0.5 (lower unemployment among CAO cases) in the Philippines to 5.8 (higher unemployment among CAO cases) in India. Site-adjusted OR for unemployment (95% confidence interval) was 1.79 (1.41, 2.27) for participants with CAO, decreasing to 1.43 (1.14, 1.79) after adjusting for gender, age, smoking, comorbidities, education and forced vital capacity (FVC). Risk factors for unemployment in high-income sites were age (OR (95%CI) 4.02 (3.53, 4.57), and primary education vs university education 3.86 (2.80, 5.30). Female gender was the most important factor for unemployment in low-to-middle-income sites (OR 3.23 (2.66, 3.91). Conclusions: CAO was associated with unemployment even after adjusting for sociodemographic factors, comorbidities and FVC. We observed that the association was particularly strong in high-income sites.

Highlights • Pentavalent reassortant rotavirus vaccine was tested for efficacy in infants. • The vaccine (BRV-PV) showed excellent tolerability and a good safety profile. • Primary analysis efficacy was 36% against SRVGE and up to 60.5% against VSRVGE. • The efficacy through 2 years of age was 39.5% (SRVGE) and 54.7% (VSRVGE). • The intent to treat analyses confirmed all the per protocol analyses., Rotavirus is the most common cause of moderate-to-severe infant diarrhoea in developing countries, resulting in enormous morbidity, mortality, and economic burden. A bovine-human reassortant pentavalent rotavirus vaccine (BRV-PV) targeting the globally most common strains was developed in India and tested in a randomized, double-blind, placebo-controlled end-point driven Phase III efficacy clinical trial implemented at six sites across India. Infants 6 to 8 weeks of age were randomized (1:1) to receive three oral doses of BRV-PV or placebo at 6, 10, and 14 weeks of age along with routine vaccines. Home visit surveillance was conducted to detect severe rotavirus gastroenteritis (SRVGE) and safety outcomes until the children reached two years of age. A total of 3749 infants received BRV-PV while 3751 received placebo. At the time of the primary end-point (when the minimum number of cases needed for analysis were accrued) the vaccine efficacy against SRVGE was 36% (95% CI 11.7, 53.6, p = 0.0067) in the per protocol (PP) analysis, and 41.9% (95% CI 21.1, 57.3, p = 0.0005) in the intent to treat (ITT) analysis. Vaccine efficacy over the entire follow-up period (until children reached two years of age) was 39.5% (95% CI 26.7, 50, p

Current classifications of Chronic Obstructive Pulmonary Disease (COPD) severity are complex and do not grade levels of obstruction. Obstruction is a simpler construct and independent of ethnicity. We constructed an index of obstruction severity based on the FEV1/FVC ratio, with cut-points dividing the Burden of Obstructive Lung Disease (BOLD) study population into four similarly sized strata to those created by the GOLD criteria that uses FEV1. We measured the agreement between classifications and the validity of the FEV1-based classification in identifying the level of obstruction as defined by the new groupings. We compared the strengths of association of each classification with quality of life (QoL), MRC dyspnoea score and the self-reported exacerbation rate. Agreement between classifications was only fair. FEV1-based criteria for moderate COPD identified only 79% of those with moderate obstruction and misclassified half of the participants with mild obstruction as having more severe COPD. Both scales were equally strongly associated with QoL, exertional dyspnoea and respiratory exacerbations. Severity assessed using the FEV1/FVC ratio is only in moderate agreement with the severity assessed using FEV1 but is equally strongly associated with other outcomes. Severity assessed using the FEV1/FVC ratio is likely to be independent of ethnicity.

This study examined sources of psychosocial stress related to the use of toilet facilities or open defecation by women and adolescent girls at home, public places, workplaces and in schools in a rural community in Pune, India. The mixed methods approach included focus group discussions among women, key informant interviews, free listing and a community survey of 306 women. Nine per cent of the study households and most seasonal migrant women workers lacked access to toilets. Fear for personal safety, injury or accidents, lack of cleanliness, indignity, shame and embarrassment due to a lack of privacy were significant sources of stress related to open defecation. Seasonal migrant women workers perceived the lack of privacy as a significant source of psychosocial stress but did not fear for their personal safety or injuries, despite their general lack of access to toilet facilities. Women resorting to open defecation feel stressed and harassed by community leaders trying to enforce open defecation-free policies. Our study highlights the need for sanitation programs to consider the specific needs of women with regard to latrine maintenance, safety and privacy offered by sanitation installations. Specific strategies to address the sanitation and hygiene issues of seasonal migrant populations are also required.

Objective: To use anchoring vignettes to evaluate reporting heterogeneity (RH) in self-rated mobility and cognition in older adults. Method: We analyzed vignettes and self-rated mobility and cognition in 2,558 individuals aged 50 years and above. We tested for assumptions of vignette equivalence (VE) and response consistency (RC). We used a joint hierarchical ordered probit (HOPIT) model to evaluate self-rating responses for RH. Results: The assumption of VE was met except for “learning” vignettes. Higher socioeconomic status (SES) and education significantly lowered thresholds for cognition ratings. After correction for RH, women, lower SES, and older respondents were significantly more likely to report greater difficulty in mobility. The influence of age, SES, and education on thresholds was less apparent for cognition. Discussion: Our study provides strong evidence of RH in self-rated mobility and cognition. We highlight the need to formally test basic assumptions before using vignettes to adjust self-rating responses for RH.

Summary Background Rotavirus is the most common cause of severe dehydrating gastroenteritis in developing countries. Safe, effective, and affordable rotavirus vaccines are needed in these countries. We aimed to assess the efficacy and tolerability of a monovalent human-bovine rotavirus vaccine for severe rotavirus gastroenteritis in low-resource urban and rural settings in India. Methods We did a randomised double-blind, placebo-controlled, multicentre trial at three sites in Delhi (urban), Pune (rural), and Vellore (urban and rural) between March 11, 2011, and Nov 5, 2012. Infants aged 6–7 weeks were randomly assigned (2:1), via a central interactive voice or web response system with a block size of 12, to receive either three doses of oral human-bovine natural reassortant vaccine (116E) or placebo at ages 6–7 weeks, 10 weeks, and 14 weeks. Infants' families, study investigators, paediatricians in referral hospitals, laboratory staff, and committee members were all masked to treatment allocation. The primary outcome was incidence of severe rotavirus gastroenteritis (≥11 on the Vesikari scale). Efficacy outcomes and adverse events were ascertained through active surveillance. Analysis was by intention to treat and per protocol. The trial is registered with Clinical Trial Registry–India (CTRI/2010/091/000102) and ClinicalTrials.gov (NCT01305109). Findings 4532 infants were assigned to receive the 116E vaccine and 2267 to receive placebo, of whom 4354 (96%) and 2187 (96%) infants, respectively, were included in the primary per-protocol efficacy analysis. 71 events of severe rotavirus gastroenteritis were reported in 4752 person-years in infants in the vaccine group compared with 76 events in 2360 person-years in those in the placebo group; vaccine efficacy against severe rotavirus gastroenteritis was 53·6% (95% CI 35·0–66·9; p=0·0013) and 56·4% (36·6–70·1; p Interpretation Monovalent human-bovine (116E) rotavirus vaccine is effective and well tolerated in Indian infants. Funding Department of Biotechnology and the Biotechnology Industry Research Assistance Council, Government of India; Bill & Melinda Gates Foundation to PATH, USA; Research Council of Norway; UK Department for International Development; National Institutes of Health, Bethesda, USA; and Bharat Biotech International, Hyderabad, India.

We compared prevalence estimates of self-rated health (SRH) derived indirectly using four different small area estimation methods for the Vadu (small) area from the national Study on Global AGEing (SAGE) survey with estimates derived directly from the Vadu SAGE survey. The indirect synthetic estimate for Vadu was 24% whereas the model based estimates were 45.6% and 45.7% with smaller prediction errors and comparable to the direct survey estimate of 50%. The model based techniques were better suited to estimate the prevalence of SRH than the indirect synthetic method. We conclude that a simplified mixed effects regression model can produce valid small area estimates of SRH.

Summary Background Typhoid vaccination is a public health priority in developing countries where young children are greatly affected by typhoid fever. Because present vaccines are not recommended for children younger than 2 years, the Novartis Vaccines Institute for Global Health developed a conjugate vaccine (Vi-CRM 197 ) for infant immunisation. We aimed to assess the immunogenicity and safety of Vi-CRM 197 in participants of various ages in endemic countries in south and southeast Asia. Methods We did two randomised, observer-blind, age de-escalation, phase 2 trials at two sites in Pakistan and India (study A), and at one site in the Philippines (study B), between March 2, 2011, and Aug 9, 2012. Adults aged 18–45 years, children aged 24–59 months, older infants aged 9–12 months, and infants aged 6–8 weeks were randomly assigned (1:1) with a computer-generated randomisation list (block size of four) to receive either 5 μg Vi-CRM 197 or 25 μg Vi-polysaccharide vaccine (or 13-valent pneumococcal conjugate vaccine in children younger than 2 years). Both infant populations received Vi-CRM 197 concomitantly with vaccines of the Expanded Programme on Immunization (EPI), according to WHO schedule. With the exception of designated study site personnel responsible for vaccine preparation, study investigators, those assessing outcomes, and data analysts were masked to treatment allocation. We specified no a-priori null hypothesis for the immunogenicity or safety objectives and all analyses were descriptive. Analyses were by modified intention-to-treat. These studies are registered with ClinicalTrials.gov, numbers NCT01229176 and NCT01437267. Findings 320 participants were enrolled and vaccinated in the two trials: 200 in study A (all age groups) and 120 in study B (children and infants only), of whom 317 (99%) were included in the modified intention-to-treat analysis. One dose of Vi-CRM 197 significantly increased concentrations of anti-Vi antibody in adults (from 113 U/mL [95% CI 67–190] to 208 U/mL [117–369]), children (201 U/mL [138–294] to 368 U/mL [234–580]), and older infants (179 U/mL [129–250] to 249 U/mL [130–477]). However, in children and older infants, a second dose of conjugate vaccine had no incremental effect on antibody titres and, at all ages, concentrations of antibodies increased substantially 6 months after vaccination (from 55 U/mL [33–94] to 63 U/mL [35–114] in adults, from 23 U/mL [15–34] to 51 U/mL [34–76] in children, and from 21 U/mL [14–31] to 22 U/mL [14–33] in older infants). Immune response in infants aged 6–8 weeks was lower than that in older participants and, 6 months after third vaccination, antibody concentrations were significantly higher than pre-vaccination concentrations in Filipino (21 U/mL [16–28] vs 2·88 U/mL [1·95–4·25]), but not Pakistani (3·76 U/mL [2·77–5·08] vs 2·77 U/mL [2·1–3·66]), infants. Vi-CRM 197 was safe and well tolerated and did not induce any significant interference with EPI vaccines. No deaths or vaccine-related serious adverse events were reported throughout the studies. Interpretation Vi-CRM 197 is safe and immunogenic in endemic populations of all ages. Given at 9 months of age, concomitantly with measles vaccine, Vi-CRM 197 shows a promise for potential inclusion in EPI schedules of countries endemic for typhoid. An apparent absence of booster response and a reduction in antibody titres 6 months after immunisation should be further investigated, but data show that an immunogenic typhoid vaccine can be safely delivered to infants during EPI visits recommended by WHO. Funding Sclavo Vaccines Association and Regione Toscana.

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

To assess the effectiveness of micronutrient powder (MNP) supplementation in reducing anemia levels in children aged 6 mo to 6 y in India. Sixty sachets of MNP (Sprinkles Plus) were administered flexibly over a 4 mo period to 17,124 children at anganwadi centers or at home through Integrated Child Development Services (ICDS). Compliance was monitored using compliance cards and an assessment of mother’s recall at post-intervention survey. Hemoglobin was measured in separate random samples of 1,786 children before and 1,782 children after MNP supplementation. Mean compliance rate was estimated at 56.4 % (based on mother’s recall) and 91.7 % (based on compliance cards) for children who received MNP at home. Mean compliance was 96.9 % (based on compliance cards) for children who received MNP at anganwadis. A significant reduction in anemia (50 % to 33 % in boys; p-value

The Study on global AGEing and adult health (SAGE) aims at improving empirical understanding of the health and well-being of older adults in low- and middle-income countries. A total of 321 adults ...

Background: Microbiota in the lower respiratory tract is largely derived from microaspirations from oral and nasal cavities and has been shown to vary between healthy and TSCOPD in the western world. Aim: To study and compare the microbiota from oral and nasal cavities of healthy, TSCOPD and BMSCOPD subjects from a rural population. Methods: Oral washing and nasal swab samples were collected from 12 healthy, 12 TSCOPD and 12 BMSCOPD subjects. Samples were sequenced using 16S rRNA gene v4 region (Illumina HiSeq, 2500 platform, USA). Downstream analysis was carried out using QIIME pipeline (v1.8), Mothur software (v1.34) and R scripts. Results: Significant differences were observed in bacterial diversity and their abundance between healthy and COPD subjects (p

Population ageing is rapidly becoming a global issue and will have a major impact on health policies and programmes. The World Health Organization’s Study on global AGEing and adult health (SAGE) aims to address the gap in reliable data and scientific knowledge on ageing and health in low- and middle-income countries. SAGE is a longitudinal study with nationally representative samples of persons aged 50+ years in China, Ghana, India, Mexico, Russia and South Africa, with a smaller sample of adults aged 18–49 years in each country for comparisons. Instruments are compatible with other large high-income country longitudinal ageing studies. Wave 1 was conducted during 2007–2010 and included a total of 34 124 respondents aged 50+ and 8340 aged 18–49. In four countries, a subsample consisting of 8160 respondents participated in Wave 1 and the 2002/04 World Health Survey (referred to as SAGE Wave 0). Wave 2 data collection will start in 2012/13, following up all Wave 1 respondents. Wave 3 is planned for 2014/15. SAGE is committed to the public release of study instruments, protocols and meta- and micro-data: access is provided upon completion of a Users Agreement available through WHO’s SAGE website (www.who.int/healthinfo/systems/sage) and WHO’s archive using the National Data Archive application (http://apps.who.int/healthinfo/systems/surveydata).

Background: Studies from Africa have suggested marked non-specific effects (NSEs) of routine vaccinations with effects on child survival. There have been few studies from Asia. We re-analyzed a study from Maharashtra India which had collected information on vaccinations during infancy and survival until 5 years of age. Design: 4138 children born between 1987 and 1989 were visited at home every three months to collect information on nutritional status and vaccinations. Since nutritional status was a determinant of time to vaccinations we adjusted for nutritional status in the analyzes of the association between vaccinations and mortality. Setting: 45 contiguous villages in Shirur Administrative Block in Pune District. Main outcome measures: Mortality rate ratios (MRR) for different vaccination status groups. Results: The study area has male preferential treatment but the female-male mortality ratio varied between age groups with different pre-dominant vaccines; it was high in the age group in which diphtheria-tetanus-pertussis (DTP) vaccine predominates and low in the age group in which measles vaccine (MV) is given. Children who followed the WHO recommended schedule of first BCG and then DTP vaccination were vaccinated earlier than other children (p

OBJECTIVE To compare the results obtained from 26 proxy indicators of domestic hand-washing practices with those obtained from direct, 'structured' observation of hand-washing in a sample of 387 households and to assess the potential of these indicators for use in the evaluation of hygiene promotion campaigns. METHODS Fieldwork in rural India between February 2005 and April 2006. Household-level data on hand-washing practices and the availability of soap and water were collected by structured observation, questionnaire survey, pocket voting, hand-wash demonstration and environmental check. Between them these techniques produced 27 binary indicators of hand-washing practices, each of which was used to classify households as 'hand-washing' or 'non-hand-washing. To assess the extent to which household classification based on each of 26 proxy indicators concurred with classification based on observation, we used the kappa statistic. The prevalence of households defined as 'hand-washing' according to each indicator was compared statistically with the prevalence according to structured observations by testing for a significant difference between two proportions. RESULTS Agreement between all the proxy indicators and the observation data was poor and all but two of the indicators produced estimates of hand-washing prevalence that were significantly different from that resulting from observation. CONCLUSION Although some interventions may be able to use proxy indicators as a guide to the magnitude and direction of their impact, these indicators do not provide an accurate guide to the actual practice or prevalence of hand-washing. Structured observation remains the best indicator of those tested.

Background. The group A meningococcal vaccine (PsA-TT) clinical development plan included clinical trials in India and in the West African region between 2005 and 2013. During this period, the Meningitis Vaccine Project (MVP) accumulated substantial experience in the ethical conduct of research to the highest standards. Methods. Because of the public–private nature of the sponsorship of these trials and the extensive international collaboration with partners from a diverse setting of countries, the ethical review process was complex and required strategic, timely, and attentive communication to ensure the smooth review and approval for the clinical studies. Investigators and their site teams fostered strong community relationships prior to, during, and after the studies to ensure the involvement and the ownership of the research by the participating populations. As the clinical work proceeded, investigators and sponsors responded to specific questions of informed consent, pregnancy testing, healthcare, disease prevention, and posttrial access. Results. Key factors that led to success included (1) constant dialogue between partners to explore and answer all ethical questions; (2) alertness and preparedness for emerging ethical questions during the research and in the context of evolving international ethics standards; and (3) care to assure that approaches were acceptable in the diverse community contexts. Conclusions. Many of the ethical issues encountered during the PsA-TT clinical development are familiar to groups conducting field trials in different cultural settings. The successful approaches used by the MVP clinical team offer useful examples of how these problems were resolved. Clinical Trials Registration. ISRCTN17662153 (PsA-TT-001); ISRTCN78147026 (PsA-TT-002); ISRCTN87739946 (PsA-TT-003); ISRCTN46335400 (PsA-TT-003a); ISRCTN82484612 (PsA-TT-004); CTRI/2009/091/000368 (PsA-TT-005); PACTR ATMR2010030001913177 (PsA-TT-006); PACTR201110000328305 (PsA-TT-007).

Introduction: The geographic variation and correlates of unemployment in COPD is unknown. We set out to examine associations between employment status and COPD in the Burden of Obstructive Lung Disease (BOLD) study. Methods: Spirometry and interviews were performed at 26 sites in 22 countries. Unemployment was defined as not having had a paid job the preceding year, and was the main outcome in Poisson regression analysis with sex, age, lung function, education, smoking habits, airway symptoms, study site and self-reported comorbidities as covariates. COPD was defined as post-bronchodilator FEV1/FVC < lower limit of normal (LLN)(NHANES III prediction equation for Caucasians). Results: Altogether, 11.3% (2123 of 18710 subjects) had spirometric COPD. In total, 863 subjects with COPD (40.7%) and 9345 subjects without COPD (56.3%) had a paid job the preceding year. The prevalence of employment in COPD varied from 20% (Algeria) to 64% (India). Spirometric COPD was associated with increased risk of unemployment in unadjusted analyses (relative risk (RR) 1.36, 95% CI 1.31-1.41). In multivariable analyses the effect of COPD was reduced to RR 1.09 (1.05-1.13). Stronger effects were found for hypertension, heart disease, diabetes and stroke. We observed increased prevalence of unemployment for (RR, 95% CI) ex-smokers (1.06, 1.02-1.10), 10 yrs increased age (1.47, 1.45-1.49), primary school educated vs university (1.65, 1.55 -1.76) and for women (1.63, 1.57-1.68). Site variation was considerable (RR from 1.78 (Iceland) to 5.38 (Morocco)). Conclusion: There was substantial variation in employment of COPD-patients, but the overall effect of COPD on unemployment was modest when we adjusted for geography, demographic factors and comorbidities.

Background: We used data from the Burden of Obstructive Lung Disease (BOLD) study to examine correlates of productivity losses in COPD. Methods: Spirometry and interviews were performed at 26 sites in 22 countries. The main outcome was number of sick leave days (SLDs) the preceding year. We examined correlates of this outcome by zero-inflated negative binomial regression analysis. The analyses were adjusted for sex, age, lung function, education, smoking habits, airway symptoms, study site and self-reported comorbidities. COPD was defined as post-bronchodilator FEV1/FVC Results: In total 10119 individuals reported number of sick leave days, and of these, 8.5% had spirometric COPD. The latter group reported a mean (SD) of 8.7 (36.6) SLDs the preceding year, whereas subjects without COPD reported a mean (SD) of 4.7 (24.7) SLDs. Site variation was considerable, ranging from zero days in Tunis, China and Algeria to 24.7 days in the Netherlands. In the multivariable regression model, the relative risk (RR) for number of SLDs with spirometric COPD (95% CI) was 3.00 (1.98-4.54), whereas hypertension and heart disease were considerably lower (RR 1.49 and 1.76, respectively). The RR (95% CI) associated with being female and being an ex-smoker (vs never-smokers) was 1.44 (1.14-1.82) and 1.44 (1.09-1.92), respectively. When we added airway symptoms to the model, the signal of other covariates disappeared, except for sex and study site. Conclusion: Sick leave was considerably higher in COPD patients than in subjects without COPD, even in comprehensively adjusted regression models. Nearly all productivity losses associated with COPD was explained by airway symptoms.

Background: An estimated 263 million people are engaged in farming in India. Use of pesticides has increased in recent years to improve crop yield. We aimed to study the prevalence of COPD among farmers in rural India and to study whether farmers using pesticide sprays have a higher disease burden. Methods: All male and female resident farmers above the age of 25yrs from 4 randomly selected villages of rural India were invited to participate. A pre-tested questionnaire were administered to obtain information about use of pesticides and other exposures such as smoking history and biomass exposure, using a mobile phone device. Post bronchodilator spirometry was performed to determine the prevalence of COPD (FEV 1 /FVC Results: 938 participants (Mean age: 45.3 ± 13.2; M: 53.4%) completed the questionnaire and performed acceptable spirometry. The prevalence of COPD among farmers was 4.9% (M:6.2%, F: 3.4%). Farmers using pesticide sprays had a greater odds of having small airways obstruction on spirometry (FEF25-75% Conclusion: Two thirds of farmers who have COPD in rural India are never smokers, although smoking increased the risk further by 7 fold. Farmers using pesticides have greater prevalence of small airways obstruction.

Background An estimated 700 million people suffer from mosquito-borne diseases worldwide. Various types of mosquito repellents are widely used to prevent mosquito bites. The objectives of this study were (1) to measure the indoor levels of particulate matter 2.5 ) and carbon monoxide (CO) during the burning of mosquito coils (MCs) and study the impact of indoor ventilation patterns; and (2) to study and compare the prevalence of respiratory ailments in homes using different types of mosquito repellents. Methods Indoor PM 2.5 and CO levels were measured inside a bedroom during the burning of MCs keeping the window and/or door open/closed over a 6-h duration. A cross-sectional survey was conducted in three villages where 465 individuals were administered a questionnaire that captured demographic details, type and duration of mosquito repellents used, and prevalence of respiratory symptoms and diseases. Results Fifty-three percent of the subjects burned MCs on most days of the week, and 63% did so with their doors and windows closed. Burning of MCs produced very high levels of PM 2.5 (1,031 μg/m 3 mean, 1,613 μg/m 3 peak) and CO (6.50 parts per million (ppm) mean, 10.27 ppm peak) when both the door and window were closed. These levels reduced by around 50% when the window was opened and > 95% when both the window and the door were opened. The prevalence rates of respiratory symptoms and diseases were higher in subjects using MCs, although not statistically significant. Those living in smaller homes and using MCs had significantly greater morbidity. Conclusions Burning of MCs produces indoor levels of PM 2.5 and CO that are higher than those reported during the burning of biomass fuels for cooking purposes and may be associated with respiratory morbidity.

Background : As the HIV/AIDS pandemic has evolved over recent decades, Africa has been the most affected region, even though a large proportion of HIV/AIDS deaths have not been documented at the individual level. Systematic application of verbal autopsy (VA) methods in defined populations provides an opportunity to assess the mortality burden of the pandemic from individual data. Objective : To present standardised comparisons of HIV/AIDS-related mortality at sites across Africa and Asia, including closely related causes of death such as pulmonary tuberculosis (PTB) and pneumonia. Design : Deaths related to HIV/AIDS were extracted from individual demographic and VA data from 22 INDEPTH sites across Africa and Asia. VA data were standardised to WHO 2012 standard causes of death assigned using the InterVA-4 model. Between-site comparisons of mortality rates were standardised using the INDEPTH 2013 standard population. Results : The dataset covered a total of 10,773 deaths attributed to HIV/AIDS, observed over 12,204,043 person-years. HIV/AIDS-related mortality fractions and mortality rates varied widely across Africa and Asia, with highest burdens in eastern and southern Africa, and lowest burdens in Asia. There was evidence of rapidly declining rates at the sites with the heaviest burdens. HIV/AIDS mortality was also strongly related to PTB mortality. On a country basis, there were strong similarities between HIV/AIDS mortality rates at INDEPTH sites and those derived from modelled estimates. Conclusions : Measuring HIV/AIDS-related mortality continues to be a challenging issue, all the more so as anti-retroviral treatment programmes alleviate mortality risks. The congruence between these results and other estimates adds plausibility to both approaches. These data, covering some of the highest mortality observed during the pandemic, will be an important baseline for understanding the future decline of HIV/AIDS. Keywords : HIV/AIDS; tuberculosis; Africa; Asia; Mortality; INDEPTH Network; Verbal Autopsy; InterVA (Published: 29 October 2014) Citation: Glob Health Action 2014, 7 : 25370 - http://dx.doi.org/10.3402/gha.v7.25370 SPECIAL ISSUE : This paper is part of the Special Issue: INDEPTH Network Cause-Specific Mortality . More papers from this issue can be found at http://www.globalhealthaction.net

Background : Because most deaths in Africa and Asia are not well documented, estimates of mortality are often made using scanty data. The INDEPTH Network works to alleviate this problem by collating detailed individual data from defined Health and Demographic Surveillance sites. By registering all deaths over time and carrying out verbal autopsies to determine cause of death across many such sites, using standardised methods, the Network seeks to generate population-based mortality statistics that are not otherwise available. Objective : To build a large standardised mortality database from African and Asian sites, detailing the relevant methods, and use it to describe cause-specific mortality patterns. Design : Individual demographic and verbal autopsy (VA) data from 22 INDEPTH sites were collated into a standardised database. The INDEPTH 2013 population was used for standardisation. The WHO 2012 VA standard and the InterVA-4 model were used for assigning cause of death. Results : A total of 111,910 deaths occurring over 12,204,043 person-years (accumulated between 1992 and 2012) were registered across the 22 sites, and for 98,429 of these deaths (88.0%) verbal autopsies were successfully completed. There was considerable variation in all-cause mortality between sites, with most of the differences being accounted for by variations in infectious causes as a proportion of all deaths. Conclusions : This dataset documents individual deaths across Africa and Asia in a standardised way, and on an unprecedented scale. While INDEPTH sites are not constructed to constitute a representative sample, and VA may not be the ideal method of determining cause of death, nevertheless these findings represent detailed mortality patterns for parts of the world that are severely under-served in terms of measuring mortality. Further papers explore details of mortality patterns among children and specifically for NCDs, external causes, pregnancy-related mortality, malaria, and HIV/AIDS. Comparisons will also be made where possible with other findings on mortality in the same regions. Findings presented here and in accompanying papers support the need for continued work towards much wider implementation of universal civil registration of deaths by cause on a worldwide basis. Keywords : mortality; cause of death; Africa; Asia; verbal autopsy; INDEPTH Network (Published: 29 October 2014) Citation : Glob Health Action 2014, 7 : 25362 - http://dx.doi.org/10.3402/gha.v7.25362 SPECIAL ISSUE : This paper is part of the Special Issue: INDEPTH Network Cause-Specific Mortality . More papers from this issue can be found at http://www.globalhealthaction.net

Rotavirus gastroenteritis is one of the leading causes of diarrhea in Indian children less than 2 years of age. The 116E rotavirus strain was developed as part of the Indo-US Vaccine Action Program and has undergone efficacy trials. This paper reports the efficacy and additional safety data in children up to 2 years of age. In a double-blind placebo controlled multicenter trial, 6799 infants aged 6–7 weeks were randomized to receive three doses of an oral human-bovine natural reassortant vaccine (116E) or placebo at ages 6, 10, and 14 weeks. The primary outcome was severe (≥11 on the Vesikari scale) rotavirus gastroenteritis. Efficacy outcomes and adverse events were ascertained through active surveillance. We randomly assigned 4532 and 2267 subjects to receive vaccine and placebo, respectively, with over 96% subjects receiving all three doses of the vaccine or placebo. The per protocol analyses included 4354 subjects in the vaccine and 2187 subjects in the placebo group. The overall incidence of severe RVGE per 100 person years was 1.3 in the vaccine group and 2.9 in the placebo recipients. Vaccine efficacy against severe rotavirus gastroenteritis in children up to 2 years of age was 55.1% (95% CI 39.9 to 66.4; p

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.

Approximately 3 billion people-half the worldwide population-are exposed to extremely high concentrations of household air pollution due to the burning of biomass fuels on inefficient cookstoves, accounting for 4 million annual deaths globally. Yet, our understanding of the pulmonary responses to household air pollution exposure and the underlying molecular and cellular events is limited. The two most prevalent biomass fuels in India are wood and cow dung, and typical 24-hour mean particulate matter (PM) concentrations in homes that use these fuels are 300 to 5,000 μg/m(3). We dissected the mechanisms of pulmonary responses in mice after acute or subchronic exposure to wood or cow dung PM collected from rural Indian homes during biomass cooking. Acute exposures resulted in robust proinflammatory cytokine production, neutrophilic inflammation, airway resistance, and hyperresponsiveness, all of which were significantly higher in mice exposed to PM from cow dung. On the contrary, subchronic exposures induced eosinophilic inflammation, PM-specific antibody responses, and alveolar destruction that was highest in wood PM-exposed mice. To understand the molecular pathways that trigger biomass PM-induced inflammation, we exposed Toll-like receptor (TLR)2-, TLR3-, TLR4-, TLR5-, and IL-1R-deficient mice to PM and found that IL-1R, TLR4, and TLR2 are the predominant receptors that elicit inflammatory responses via MyD88 in mice exposed to wood or cow dung PM. In conclusion, this study demonstrates that subchronic exposure to PM collected from households burning biomass fuel elicits a persistent pulmonary inflammation largely through activation of TLR and IL-1R pathways, which could increase the risk for chronic respiratory diseases.

Background : Mortality from external causes, of all kinds, is an important component of overall mortality on a global basis. However, these deaths, like others in Africa and Asia, are often not counted or documented on an individual basis. Overviews of the state of external cause mortality in Africa and Asia are therefore based on uncertain information. The INDEPTH Network maintains longitudinal surveillance, including cause of death, at population sites across Africa and Asia, which offers important opportunities to document external cause mortality at the population level across a range of settings. Objective : To describe patterns of mortality from external causes at INDEPTH Network sites across Africa and Asia, according to the WHO 2012 verbal autopsy (VA) cause categories. Design : All deaths at INDEPTH sites are routinely registered and followed up with VA interviews. For this study, VA archives were transformed into the WHO 2012 VA standard format and processed using the InterVA-4 model to assign cause of death. Routine surveillance data also provide person-time denominators for mortality rates. Results : A total of 5,884 deaths due to external causes were documented over 11,828,253 person-years. Approximately one-quarter of those deaths were to children younger than 15 years. Causes of death were dominated by childhood drowning in Bangladesh, and by transport-related deaths and intentional injuries elsewhere. Detailed mortality rates are presented by cause of death, age group, and sex. Conclusions : The patterns of external cause mortality found here generally corresponded with expectations and other sources of information, but they fill some important gaps in population-based mortality data. They provide an important source of information to inform potentially preventive intervention designs. Keywords: external causes; accidents; suicide; assault; transport; drowning; Africa; Asia; mortality; INDEPTH Network; verbal autopsy; InterVA (Published: 29 October 2014) Citation: Glob Health Action 2014, 7 : 25366 - http://dx.doi.org/10.3402/gha.v7.25366 SPECIAL ISSUE : This paper is part of the Special Issue: INDEPTH Network Cause-Specific Mortality . More papers from this issue can be found at http://www.globalhealthaction.net

Background: Comparing self-rating health responses across individuals and cultures is misleading due to different reporting behaviors. Anchoring vignettes is a technique that allows identifying and adjusting selfrating responses for reporting heterogeneity (RH). Objective: This article aims to test two crucial assumptions of vignette equivalence (VE) and response consistency (RC) that are required to be met before vignettes can be used to adjust self-rating responses for RH. Design: We used self-ratings, vignettes, and objective measures covering domains of mobility and cognition from theWHOstudy on global AGEing and adult health, administered to older adults aged 50 years and above from eight low- and middle-income countries in Africa and Asia. For VE, we specified a hierarchical ordered probit (HOPIT) model to test for equality of perceived vignette locations. For RC, we tested for equality of thresholds that are used to rate vignettes with thresholds derived from objective measures and used to rate their own health function. Results: There was evidence ofRHin self-rating responses for difficulty in mobility and cognition. Assumptions of VE and RC between countries were violated driven by age, sex, and education. However, within a country context, assumption of VE was met in some countries (mainly in Africa, except Tanzania) and violated in others (mainly in Asia, except India). Conclusion: We conclude that violation of assumptions of RC and VE precluded the use of anchoring vignettes to adjust self-rated responses for RH across countries in Asia and Africa. Keywords: reporting heterogeneity; mobility; cognition; self-rating; anchoring vignettes; vignette equivalence; response consistency (Published: 5 September 2013) Citation: Glob Health Action 2013, 6 : 21064 - http://dx.doi.org/10.3402/gha.v6i0.21064

Female sex workers (FSWs) report of suffering from symptoms of sexually transmitted infections (STIs), the most common are: lower abdominal pains (LAP), white discharge, genital ulcers and warts. It is important to study the proportion of FSW-reported symptoms of STIs to understand non-use of condoms with clients, their treatment seeking pattern to plan appropriate interventions to control STIs among FSWs. Mixed methods were used. A total of 80 FSWs were selected by two-stage cluster sampling method, followed by selection of 20 FSWs by convenient sampling for in-depth interviews. 55% FSWs reported of suffering from symptoms of STIs in last 6 months. FSWs preferred visiting private doctor for seeking treatment for symptoms of STIs; they had different misconceptions regarding transmission of STIs.