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The reported financial losses from railroad accidents since 2009 have been more than US$4.11 billion dollars. This considerable loss is a major concern for the industry, society, and the government. Therefore, identifying and ranking the factors that contribute to financial losses from railroad accidents would inform strategies to minimize them. To achieve that goal, this paper evaluates and compares the results of applying different non-parametric statistical and regression methods to 15 years of railroad Class I freight train accident data. The models compared are random forest, k-nearest neighbors, support vector machines, stochastic gradient boosting, extreme gradient boosting, and stepwise linear regression. The results indicate that these methods are all suitable for analyzing non-linear and heterogeneous railroad incident data. However, the extreme gradient boosting method provided the best performance. Therefore, the analysis used that model to identify and rank factors that contribute to financial losses, based on the gain percentage of the prediction accuracy. The number of derailed freight cars and the absence of territory signalization dominated as contributing factors in more than 57% and 20% of the accidents, respectively. Partial-dependence plots further explore the complex non-linear dependencies of each factor to better visualize and interpret the results.

Problem India and sub-Saharan Africa contributes about 85% of the global malaria burden, and India is committed to eliminating malaria by 2030. Approach Two novel initiatives—the Malaria Elimination Demonstration Project (MEDP) in Madhya Pradesh and Durgama Anchalare Malaria Nirakaran (DAMaN) in Odisha—were initiated independently to demonstrate that indigenous malaria can be eliminated in a short period of time. Local setting These initiatives focused on rural, tribal areas where there is a high malaria burden and complex epidemiology. Relevant changes The case management and vector control strategies used in these programmes were based on the national guidelines, with context-specific changes and introduction of accountability at management, operational, technical and financial levels. The MEDP achieved a 91% reduction in malaria cases and recorded zero transmission for 6 consecutive and a total of 9 mo. The DAMaN project brought about an 88% reduction in malaria cases. Lessons learned Malaria elimination will require robust surveillance and case management, monitoring of vector control interventions, community-centric information education communication and behaviour change communication initiatives and management controls, as well as regular internal and external reviews.

Tracks are critical and expensive railroad asset, requiring frequent maintenance. The stress from heavy car axle loads increases the risk of deviations from uniform track geometry. Irregularities in track geometry, such as track warping, can cause an excessive harmonic rocking condition that can lead to derailments, traffic delays, and associated financial losses. This article presents an approach to enhance the location identification accuracy of track geometry irregularities by combining measurements from sensors aboard Hi-Rail vehicles. However, speed variations, position recording errors, low GPS update rates, and the non-uniform sampling rates of inertial sensors pose significant challenges for signal processing, feature extraction, and signal combination. This study introduces a method of extracting features from the fused data of inertial sensors and GPS receivers with multiple traversals to locate and characterize irregularities of track geometry. The proposed method provides robust detection and enhanced accuracy in the localization of irregularities within spatial windows along the track segment. Tradeoff analysis found that the optimal spatial window size is 5-meter.

In India, a National Framework for Malaria Elimination (NFME) has been developed and launched on 11 February 2016 align with the Global Technical Strategy (GTS) for malaria elimination 2016-2030. Malaria elimination will be carried out in a phased manner. In accordance with the NFME, National Strategy Plan for malaria elimination 2017-2022 has been developed by National Vector Borne Disease (NVBDCP), MoH & FW, Govt. of India in collaboration with WHO Country Office India and launched in July 2017. The country has made significant improvement in the malaria situation in recent years. Reported malaria cases were reduced by 49 % and deaths by 50% in 2018 compared to 2017. However, India and ten countries in Africa contribute approximately 70% of the world’s malaria cases and deaths. These countries adopted the “High Burden to High Impact (HBHI) approach”. HBHI has four response elements: (i) Political will to reduce malaria deaths; (ii) Strategic information to drive impact, (iii) Better guidance, policies and strategies, and (iv) A coordinated national malaria response. India has adopted this approach in May 2019 to further accelerate and sustain the progress in the states with high malaria burden. Initially, HBHI approaches are being adopted by NVBDCP with the support of WHO in four high burden states namely Jharkhand, Chhattisgarh, West Bengal and Madhya Pradesh. During the first phase, an in-depth situation analysis on malaria in these states have been conducted using the tools provided by WHO. Key features of adaptation of HBHI approaches in India and detail analysis of one state Madhya Pradesh are presented in the article. How to cite this article:Kumari R, Jayswar H, Dhingra N. High Burden to High Impact (HBHI) Approaches - Country Perspective for Adoption and Adaptation in India. J Commun Dis 2020; 52(3): 5-16. DOI: https://doi.org/10.24321/0019.5138.202023

A continuous condition monitoring system to detect and localize railroad track irregularities is achievable with inertial sensors onboard revenue service trains. However, the inaccurate geospatial position estimates of GPS receivers and the non-uniform sampling of inertial sensors adds noise and reduces signal strength. Consequently, the signal-to-noise ratio decreases, which leads to higher rates of false positives and false negatives. Appropriate signal filtering, alignment, and combination from multiple traversals can enhance the signal-to-noise ratio. However, it is not straightforward in determining the best cut-off frequency for the filter. This paper introduces a method that is suitable for any signal filtering approach. The frequency window of the resultant energy and variance of ensemble averaged FFTs informs the best cut-off frequency. The results affirm that a low-pass finite impulse response filter with the selected cutoff frequency progressively increases the signal-to-noise ratio with increasing filter order, thus demonstrating the effectiveness and practicality of the method.

There are 670 million people at risk of contracting lymphatic filariasis (LF) in India, which bears 40% of the global burden of the disease. The National Program to Eliminate LF was launched in 2004 first with a single-drug therapy—diethylcarbamazine (DEC), followed by a two-drug therapy—DEC + albendazole (DA). In 2017, following successful drug trials, World Health Organization endorsed a new triple-drug therapy to fight LF using ivermectin with DEC and albendazole (IDA).1 In June 2018, India made new commitments to accelerate their program to eliminate LF and initiated the new IDA protocol in five districts in the country. This article looks at the experience of India in the roll out of the new drug protocol and shares their preparations, successes, challenges, and lessons learned.

Introduction and aims Non-fatal opioid overdose (NFOO) predicts future fatal opioid overdose and is associated with significant morbidity. There is limited literature on the rates and risk factors for NFOO in people who inject drugs (PWID) from India. We aimed to study the rates of NFOO and documented risk factors for NFOO, as well as knowledge-level of NFOO among PWID from India. Design and methods Community-based, cross-sectional and observational study. We interviewed 104 adult male participants receiving HIV prevention services. Drug use patterns, rates of NFOO and opioid overdose risk factors, knowledge about opioid overdose and its management were assessed. Results The mean age of the participants was 27.9 years. The most common opioid used for injecting was heroin followed by buprenorphine. About 45% (n = 47) participants had experienced an opioid overdose at least once in their lifetime. Around 25% (n = 26) participants had overdosed in the past year, while 21% (n = 22) participants had overdosed within the past 3 months. The majority had risk factors that could predispose them to NFOO. No participant was aware of the use of naloxone for opioid overdose. Discussion and conclusion The rates of NFOO as well as risk factors for overdose among PWID from India are high, with poor knowledge on overdose management. There is urgent need for a program to prevent and manage opioid overdose among PWID in India.

Summary Background India had the largest number of under-5 deaths of all countries in 2015, with substantial subnational disparities. We estimated national and subnational all-cause and cause-specific mortality among children younger than 5 years annually in 2000–15 in India to understand progress made and to consider implications for achieving the Sustainable Development Goal (SDG) child survival targets. Methods We used a multicause model to estimate cause-specific mortality proportions in neonates and children aged 1–59 months at the state level, with causes of death grouped into pneumonia, diarrhoea, meningitis, injury, measles, congenital abnormalities, preterm birth complications, intrapartum-related events, and other causes. AIDS and malaria were estimated separately. The model was based on verbal autopsy studies representing more than 100 000 neonatal deaths globally and 16 962 deaths among children aged 1–59 months at the subnational level in India. By applying these proportions to all-cause deaths by state, we estimated cause-specific numbers of deaths and mortality rates at the state, regional, and national levels. Findings In 2015, there were 25·121 million livebirths in India and 1·201 million under-5 deaths (under-5 mortality rate 47·81 per 1000 livebirths). 0·696 million (57·9%) of these deaths occurred in neonates. There were disparities in child mortality across states (from 9·7 deaths [Goa] to 73·1 deaths [Assam] per 1000 livebirths) and regions (from 29·7 deaths [the south] to 63·8 deaths [the northeast] per 1000 livebirths). Overall, the leading causes of under-5 deaths were preterm birth complications (0·330 million [95% uncertainty range 0·279–0·367]; 27·5% of under-5 deaths), pneumonia (0·191 million [0·168–0·219]; 15·9%), and intrapartum-related events (0·139 million [0·116–0·165]; 11·6%), with cause-of-death distributions varying across states and regions. In states with very high under-5 mortality, infectious-disease-related causes (pneumonia and diarrhoea) were among the three leading causes, whereas the three leading causes were all non-communicable in states with very low mortality. Most states had a slower decline in neonatal mortality than in mortality among children aged 1–59 months. Ten major states must accelerate progress to achieve the SDG under-5 mortality target, while 17 are not on track to meet the neonatal mortality target. Interpretation Efforts to reduce vaccine-preventable deaths and to reduce geographical disparities should continue to maintain progress achieved in 2000–15. Enhanced policies and programmes are needed to accelerate mortality reduction in high-burden states and among neonates to achieve the SDG child survival targets in India by 2030. Funding Bill & Melinda Gates Foundation.

Background Malaria is a major public health problem in India and accounts for about 88% of malaria burden in South-East Asia. India alone accounted for 2% of total malaria cases globally. Anti-malarial drug resistance is one of the major problems for malaria control and elimination programme. Artemether-lumefantrine (AL) is the first-line treatment of uncomplicated Plasmodium falciparum in north eastern states of India since 2013 after confirming the resistance against sulfadoxine-pyrimethamine. In the present study, therapeutic efficacy of artemether-lumefantrine and k13 polymorphism was assessed in uncomplicated P. falciparum malaria. Methods This study was conducted at four community health centres located in Koraput district of Odisha, Bastar district of Chhattisgarh, Balaghat district of Madhya Pradesh and Gondia district of Maharashtra state. Patients with uncomplicated P. falciparum malaria were administered with fixed dose combination (6 doses) of artemether-lumefantrine for 3 days and clinical and parasitological response was recorded up to 28 days as per World Health Organization protocol. Nucleotide sequencing of msp1 and msp2 gene was performed to differentiate between recrudescence and reinfection. Amplification and sequencing of k13 propeller gene region covering codon 450–680 was also carried out to identify the polymorphism. Results A total 376 malaria patients who fulfilled the enrolment criteria as well as consented for the study were enrolled. Total 356 patients were followed up successfully up to 28 days. Overall, the adequate clinical and parasitological response was 98.9% and 99.4% with and without PCR correction respectively. No case of early treatment failure was observed. However, four cases (1.1%) of late parasitological failure were found from the Bastar district of Chhattisgarh. Genotyping of msp1 and msp2 confirmed 2 cases each of recrudescence and reinfection, respectively. Mutation analysis of k13 propeller gene showed one non-synonymous mutation Q613H in one isolate from Bastar. Conclusions The study results showed that artemether-lumefantrine is highly effective in the treatment of uncomplicated P. falciparum malaria among all age groups. No functional mutation in k13 was found in the study area. The data from this study will be helpful in implementation of artemether-lumefantrine in case of treatment failure by artesunate plus sulfadoxine-pyrimethamine.

BackgroundIndia has made major progress in improving control of visceral leishmaniasis (VL) in recent years, in part through shortening the time infectious patients remain untreated. Active case detection decreases the time from VL onset to diagnosis and treatment, but requires substantial human resources. Targeting approaches are therefore essential to feasibility.MethodsWe analyzed data from the Kala-azar Management Information System (KAMIS), using village-level VL cases over specific time intervals to predict risk in subsequent years. We also graphed the time between cases in villages and examined how these patterns track with village-level risk of additional cases across the range of cumulative village case-loads. Finally, we assessed the trade-off between ACD effort and yield.ResultsIn 2013, only 9.3% of all villages reported VL cases; this proportion shrank to 3.9% in 2019. Newly affected villages as a percentage of all affected villages decreased from 54.3% in 2014 to 23.5% in 2019, as more surveillance data accumulated and overall VL incidence declined. The risk of additional cases in a village increased with increasing cumulative incidence, reaching approximately 90% in villages with 12 cases and 100% in villages with 45 cases, but the vast majority of villages had small cumulative case numbers. The time-to-next-case decreased with increasing case-load. Using a 3-year window (2016–2018), a threshold of seven VL cases at the village level selects 329 villages and yields 23% of cases reported in 2019, while a threshold of three cases selects 1,241 villages and yields 46% of cases reported in 2019. Using a 6-year window increases both effort and yield.ConclusionDecisions on targeting must consider the trade-off between number of villages targeted and yield and will depend upon the operational efficiencies of existing programs and the feasibility of specific ACD approaches. The maintenance of a sensitive, comprehensive VL surveillance system will be crucial to preventing future VL resurgence.

As India moves toward the elimination of visceral leishmaniasis (VL) as a public health problem, comprehensive timely case detection has become increasingly important, in order to reduce the period of infectivity and control outbreaks. During the 2000s, localized research studies suggested that a large percentage of VL cases were never reported in government data. However, assessments conducted from 2013 to 2015 indicated that 85% or more of confirmed cases were eventually captured and reported in surveillance data, albeit with significant delays before diagnosis. Based on methods developed during these assessments, the CARE India team evolved new strategies for active case detection (ACD), applicable at large scale while being sufficiently effective in reducing time to diagnosis. Active case searches are triggered by the report of a confirmed VL case, and comprise two major search mechanisms: 1) case identification based on the index case’s knowledge of other known VL cases and searches in nearby houses (snowballing); and 2) sustained contact over time with a range of private providers, both formal and informal. Simultaneously, house-to-house searches were conducted in 142 villages of 47 blocks during this period. We analyzed data from 5030 VL patients reported in Bihar from January 2018 through July 2019. Of these 3033 were detected passively and 1997 via ACD (15 (0.8%) via house-to-house and 1982 (99.2%) by light touch ACD methods). We constructed multinomial logistic regression models comparing time intervals to diagnosis (30-59, 60-89 and ≥90 days with =90 days compared to the referent of

Purpose: The Hijra community is a cultural and gender grouping in South Asia broadly similar to western transgender communities, but with literature suggesting some differences in gender experience and patterns of psychosocial adversity. The present study aims to describe patterns of mental illness and psychoactive substance use in Hijra subjects and study their association with gender experience and psychosocial adversity. Methods: Fifty self-identified Hijras availing HIV-prevention services in New Delhi, India, were interviewed. Data on mental disorders, psychoactive substance use, quality of life, discrimination, empowerment, violence and gender identity were assessed using structured instruments. Results: Subjects were mostly in their mid-twenties, and had joined the Hijra community in their mid-teens. More subjects (46%) were involved in begging than in traditional Hijra roles (38%). Sex work was reported by 28% subjects. The rates of lifetime mental illness was 38%, most commonly alcohol abuse (26%); others had anxiety or depressive disorders (8% each), somatoform disorders (6%) and bulimia nervosa ( n = 1). Disempowerment was mostly experienced in domains of autonomy and community participation; 52% had experienced sexual or psychological violence. Discrimination was attributed to gender (100%), appearance (28%) or sexual orientation (28%). There were negative correlations between the physical domain of WHO-QOL and physical violence and depression scores; and between discrimination and WHO-QOL environmental, physical and psychological domains. Conclusions: This Hijra group showed high rates of mental disorder and substance involvement, related to QOL domains and experiences of discrimination and disempowerment.

To assess the survival probability and associated factors among children living with human immunodeficiency virus (CLHIV) receiving antiretroviral therapy (ART) in India.The data on 5874 children (55% boys) from one of the high HIV burden states of India from the cohort were analyzed. Data were extracted from the computerized management information system of the National AIDS Control Organization (NACO). Children were eligible for inclusion if they had started ART during 2007-2013, and had at least one potential follow-up. Kaplan Meier survival and Cox proportional hazards models were used to measure survival probability.The baseline median (IQR) CD4 count at the start of antiretroviral therapy was 244 (153, 398). Overall, the mortality was 30 per 1000 child years; 39 in the5 year age group and 25 in 5-9 year age group. Mortality was highest among infants (86 per 1000 child years). Those with CD4 count ≤ 200 were six times more likely to die (adjusted HR: 6.3, 95% CI 3.5, 11.4) as compared to those with a CD4 count of ≥350/mm3.Mortality rates among CLHIV is significantly higher among children less than five years when the CD4 count at the start of ART is above 200. Additionally, lower CD4 count, HIV clinical staging IV, and lack of functional status seems to be associated with high mortality in children who are on ART.

Railroad companies spend a significant portion of their revenue on track inspections to maintain safety and maximize operational efficiency. Deviations from the designed track geometry over time could lead to poor ride quality and possible derailments. The existing approaches to track inspections are expensive and laborious. The use of low-cost sensors aboard revenue service trains to screen the infrastructure for track irregularities could improve the cost-efficiency of track inspections by targeting the available resources to high-risk locations. Unevenness of rail track running surfaces cause dynamic forces generated at the wheel/rail contacts which in return results the vibration of the car. This study focuses on detecting track unevenness by associating its influence on vibration with it. A comparative analysis is carried out on unevenness response prediction and the accuracy of detecting such track surface unevenness is analyzed with the ground truth location collected by the railroad track inspectors. The main finding of the study were 1) the unevenness event estimation error are within 15 matters with one run for one phone based system and 2) the three-phone based track surface anomaly detection system can improve its forecasting accuracy to 5 meters and to 3 meters with two traversals.

e17549 Background: Carcinoma tongue is a common malignancy with increasing trend. Studies have suggested poor outcomes in young patients. To better understand ,we reviewed survival in young patients of tongue cancer from Surveillance and Epidemiologic and End Results (SEER) analysis. Methods: We identified 261 patients, aged 15 to 29 years, with squamous cell carcinoma tongue reported to SEER program between 2004 to 2015. Cases were categorized by age, sex, laterality, stage. Survival rates were compared using SPSS software. Results: The group had male to female ratio of 1.2:1, with a median age of 26 years. According to ICD-03, 85 patients (32.6%) had keratinizing variant of squamous cell carcinoma. About 40 patients (15.2%) had grade I, 161(61.7%) grade II and 46 (17%) – had grade III tumors. Out of 216 patients laterality was not paired in the majority (214-82%), while 24 (9.2%) had left side and 21 (8%) had right side primaries. According to the AJCC staging classification - 90 patients (34.5%) had stage I, 36 (13.6%)- stage II, 50 (18.9%)- stage III, and 83 (30%) as stage IV disease. Surgical procedures included- excisional biopsy in 13 patients (4.9%), 183 (69.3%) had wide local excision, 37 (14%) underwent radical excision of the tumor. Overall 193 patients were alive (73%), 40 patients (15.2%) died of cancer and 20 (7.6%) died of other causes. Average survival was 41 months (range 0-142 months). The median survival did not differ between male and female (35 vs 45, p = NS). Grade of the tumor had no impact on survival (33, 44 and 32 months-well, moderately and poorly differentiated respectively). Similarly keratinizing tumors had equal to other squamous non classified tumors ( 45 vs 31 months). The staging of the tumor was predictive of the survival(p < 0.01) .Median survival as per the stage was 62, 46, 36 and 20 months for stage I,II,III and IV respectively .There was no statistical difference based on laterality of the tumor( left sided 28 months vs right sided 22 months).As per TNM staging small lesions survived better : 60, 45, 17 and 13 months respectively for T1 ,T2 ,T3 and T4 size (p < 0.006). Nodal status was also strong predictor of the survival p < 0.001) , 49,45,31 and 19 months respectively for N0, N1, N2 and N3 tumors. Metastatic disease also shortened survival significantly (p < 0.001) , 42 month with M0, while 3 months only for M1 disease. Conclusions: In young patients with tongue cancer, stage of the disease, size of the tumor, nodal status has significant impact on survival. Other parameters like sex, histological type, grade of the tumor, laterality has no major impact.

Developing countries face diminishing development aid and time-limited donor commitments that challenge the long-term sustainability of donor-funded programs to improve the health of local populations. Increasing country ownership of the programs is one solution. Transitioning managerial and financial responsibility for donor-funded programs to governments and local stakeholders represents a highly advanced form of country ownership, but there are few successful examples among large-scale programs. We present a transition framework and describe how it was used to transfer the Bill & Melinda Gates Foundation's HIV/AIDS prevention program, the Avahan program, to the Government of India. Essential features recommended for the transition of donor-funded programs to governments include early planning with the government, aligning donor program components with government structures and funding models prior to transition, building government capacity through active technical and management support, budgeting for adequate support during and after the transition, and dividing the transition into phases to allow time for adjustments and corrections. The transition of programs to governments is an important sustainability strategy for efforts to scale up HIV prevention programs to reach the populations most at risk.

BackgroundOver 75% of the annual estimated 9.5 million deaths in India occur in the home, and the large majority of these do not have a certified cause. India and other developing countries urgently need reliable quantification of the causes of death. They also need better epidemiological evidence about the relevance of physical (such as blood pressure and obesity), behavioral (such as smoking, alcohol, HIV-1 risk taking, and immunization history), and biological (such as blood lipids and gene polymorphisms) measurements to the development of disease in individuals or disease rates in populations. We report here on the rationale, design, and implementation of the world's largest prospective study of the causes and correlates of mortality.Methods and findingsWe will monitor nearly 14 million people in 2.4 million nationally representative Indian households (6.3 million people in 1.1 million households in the 1998-2003 sample frame and 7.6 million people in 1.3 million households in the 2004-2014 sample frame) for vital status and, if dead, the causes of death through a well-validated verbal autopsy (VA) instrument. About 300,000 deaths from 1998-2003 and some 700,000 deaths from 2004-2014 are expected; of these about 850,000 will be coded by two physicians to provide causes of death by gender, age, socioeconomic status, and geographical region. Pilot studies will evaluate the addition of physical and biological measurements, specifically dried blood spots. Preliminary results from over 35,000 deaths suggest that VA can ascertain the leading causes of death, reduce the misclassification of causes, and derive the probable underlying cause of death when it has not been reported. VA yields broad classification of the underlying causes in about 90% of deaths before age 70. In old age, however, the proportion of classifiable deaths is lower. By tracking underlying demographic denominators, the study permits quantification of absolute mortality rates. Household case-control, proportional mortality, and nested case-control methods permit quantification of risk factors.ConclusionsThis study will reliably document not only the underlying cause of child and adult deaths but also key risk factors (behavioral, physical, environmental, and eventually, genetic). It offers a globally replicable model for reliably estimating cause-specific mortality using VA and strengthens India's flagship mortality monitoring system. Despite the misclassification that is still expected, the new cause-of-death data will be substantially better than that available previously.

Background India has long been thought to have more snakebites than any other country. However, inadequate hospital-based reporting has resulted in estimates of total annual snakebite mortality ranging widely from about 1,300 to 50,000. We calculated direct estimates of snakebite mortality from a national mortality survey. Methods and Findings We conducted a nationally representative study of 123,000 deaths from 6,671 randomly selected areas in 2001–03. Full-time, non-medical field workers interviewed living respondents about all deaths. The underlying causes were independently coded by two of 130 trained physicians. Discrepancies were resolved by anonymous reconciliation or, failing that, by adjudication. A total of 562 deaths (0.47% of total deaths) were assigned to snakebites. Snakebite deaths occurred mostly in rural areas (97%), were more common in males (59%) than females (41%), and peaked at ages 15–29 years (25%) and during the monsoon months of June to September. This proportion represents about 45,900 annual snakebite deaths nationally (99% CI 40,900 to 50,900) or an annual age-standardised rate of 4.1/100,000 (99% CI 3.6–4.5), with higher rates in rural areas (5.4/100,000; 99% CI 4.8–6.0), and with the highest state rate in Andhra Pradesh (6.2). Annual snakebite deaths were greatest in the states of Uttar Pradesh (8,700), Andhra Pradesh (5,200), and Bihar (4,500). Conclusions Snakebite remains an underestimated cause of accidental death in modern India. Because a large proportion of global totals of snakebites arise from India, global snakebite totals might also be underestimated. Community education, appropriate training of medical staff and better distribution of antivenom, especially to the 13 states with the highest prevalence, could reduce snakebite deaths in India., Author Summary Earlier hospital based reports estimate about 1,300 to 50,000 annual deaths from snakebites per year in India. Here, we present the first ever direct estimates from a national mortality survey of 1.1 million homes in 2001–03. Full-time, non-medical field workers interviewed living respondents about all deaths. The underlying causes were independently coded by two of 130 trained physicians. The study found 562 deaths (0.47% of total deaths) were assigned to snakebites, mostly in rural areas, and more commonly among males than females and peaking at ages 15–29. Snakebites also occurred more often during the rainy monsoon season. This proportion represents about 45,900 annual snakebite deaths nationally (99% CI 40,900 to 50,900) or an annual age-standardised rate of 4.1/100,000 (99% CI 3.6–4.5), with higher rates in rural areas (5.4) and with the highest rate in the state of Andhra Pradesh (6.2). Annual snakebite deaths were greatest in the states of Uttar Pradesh (8,700), Andhra Pradesh (5,200), and Bihar (4,500). Thus, snakebite remains an underestimated cause of accidental death in modern India, causing about one death for every two HIV-related deaths. Because a large proportion of global totals of snakebites arise from India, global snakebite totals might also be underestimated. Effective interventions involving education and antivenom provision would reduce snakebite deaths in India.

Summary Background National malaria death rates are difficult to assess because reliably diagnosed malaria is likely to be cured, and deaths in the community from undiagnosed malaria could be misattributed in retrospective enquiries to other febrile causes of death, or vice-versa. We aimed to estimate plausible ranges of malaria mortality in India, the most populous country where the disease remains common. Methods Full-time non-medical field workers interviewed families or other respondents about each of 122 000 deaths during 2001–03 in 6671 randomly selected areas of India, obtaining a half-page narrative plus answers to specific questions about the severity and course of any fevers. Each field report was sent to two of 130 trained physicians, who independently coded underlying causes, with discrepancies resolved either via anonymous reconciliation or adjudication. Findings Of all coded deaths at ages 1 month to 70 years, 2681 (3·6%) of 75 342 were attributed to malaria. Of these, 2419 (90%) were in rural areas and 2311 (86%) were not in any health-care facility. Death rates attributed to malaria correlated geographically with local malaria transmission ratesderived independently from the Indian malaria control programme. The adjudicated results show 205 000 malaria deaths per year in India before age 70 years (55 000 in early childhood, 30 000 at ages 5–14 years, 120 000 at ages 15–69 years); 1·8% cumulative probability of death from malaria before age 70 years. Plausible lower and upper bounds (on the basis of only the initial coding) were 125 000–277 000. Malaria accounted for a substantial minority of about 1·3 million unattended rural fever deaths attributed to infectious diseases in people younger than 70 years. Interpretation Despite uncertainty as to which unattended febrile deaths are from malaria, even the lower bound greatly exceeds the WHO estimate of only 15 000 malaria deaths per year in India (5000 early childhood, 10 000 thereafter). This low estimate should be reconsidered, as should the low WHO estimate of adult malaria deaths worldwide. Funding US National Institutes of Health, Canadian Institute of Health Research, Li Ka Shing Knowledge Institute.

Objectives Differences in sexual networks probably explain the disparity in the scale of HIV epidemics in sub-Saharan Africa and India. HIV and sexually transmitted infection (STI) discordant couple studies provide insights into important aspects of these sexual networks. The authors quantify the role of male sexual behaviour in HIV transmission in married couples in India. Methods The authors analysed patterns of HIV and STI discordance in married couples from two community surveys in India: the National Family Health Study-3 for HIV-1 and the Centre for Global Health Research health check-up for HSV-2 and syphilis. A statistical model was used to estimate the fraction of infections introduced by each of the two partners. Results Only 0.8%, 16.0% and 3.5% of couples were infected (either partner or both) with HIV-1, HSV-2 and syphilis, respectively. A large proportion of infected couples were discordant (73.0%, 56.3% and 84.2% for HIV-1, HSV-2 and syphilis, respectively). This model estimated that, among couples with any STI, the male partner introduced the infection the majority of the time (HIV-1: 85.4%, HSV-2: 64.1%, syphilis: 75.0%). Conclusions Male sexual activity outside of marriage appears to be a driving force for the Indian HIV/STI epidemic. Male client and female sex worker contacts should remain a primary target of the National AIDS Control Program in India.

Background Between 2009–2013 the Bill and Melinda Gates Foundation transitioned its HIV/AIDS prevention initiative in India from being a stand-alone program outside of government, to being fully government funded and implemented. We present an independent prospective evaluation of the transition. Methods The evaluation drew upon (1) a structured survey of transition readiness in a sample of 80 targeted HIV prevention programs prior to transition; (2) a structured survey assessing institutionalization of program features in a sample of 70 targeted intervention (TI) programs, one year post-transition; and (3) case studies of 15 TI programs. Findings Transition was conducted in 3 rounds. While the 2009 transition round was problematic, subsequent rounds were implemented more smoothly. In the 2011 and 2012 transition rounds, Avahan programs were well prepared for transition with the large majority of TI program staff trained for transition, high alignment with government clinical, financial and managerial norms, and strong government commitment to the program. One year post transition there were significant program changes, but these were largely perceived positively. Notable negative changes were: limited flexibility in program management, delays in funding, commodity stock outs, and community member perceptions of a narrowing in program focus. Service coverage outcomes were sustained at least six months post-transition. Interpretation The study suggests that significant investments in transition preparation contributed to a smooth transition and sustained service coverage. Notwithstanding, there were substantive program changes post-transition. Five key lessons for transition design and implementation are identified.

Major increases in HIV-1 prevalence in India have been predicted. Incident infections need to be tracked to understand the epidemic's course, especially in some southern states of India where the epidemic is more advanced. To estimate incidence, we investigated the prevalence of HIV-1 in young people attending antenatal and sexually transmitted infection (STI) clinics in India.We analysed unlinked, anonymous HIV-1 prevalence data from 294 050 women attending 216 antenatal clinics and 58 790 men attending 132 STI clinics in 2000-04. Southern and northern states were analysed separately.The age-standardised HIV-1 prevalence in women aged 15-24 years in southern states fell from 1.7% to 1.1% in 2000-04 (relative reduction 35%; p(trend)0.0001, yearly reduction 11%), but did not fall significantly in women aged 25-34 years. Reductions in women aged 15-24 years were seen in key demographic groups and were similar in sites tested continuously or in all sites. Prevalence in the north was about a fifth of that in the south, with no significant decreases (or increases) in 2000-04. Prevalence fell in men aged 20-29 years attending STI clinics in the south (p(trend)0.0001), including those with ulcerative STIs (p(trend)=0.0008), but reductions were more modest in their northern counterparts.A reduction of more than a third in HIV-1 prevalence in 2000-04 in young women in south India seems realistic, and is not easily attributable to bias or to mortality. This fall is probably due to rising condom use by men and female sex workers in south India, and thus reduced transmission to wives. Expansion of peer-based condom and education programmes for sex workers remains a top priority to control HIV-1 in India.

Summary Background Fewer girls than boys are born in India. Various hypotheses have been proposed to explain this low sex ratio. Our aim was to ascertain the contribution of prenatal sex determination and selective abortion as measured by previous birth sex. Methods We analysed data obtained for the Special Fertility and Mortality Survey undertaken in 1998. Ever-married women living in 1·1 million households in 6671 nationally-representative units were asked questions about their fertility history and children born in 1997. Findings For the 133 738 births studied for 1997, the adjusted sex ratio for the second birth when the preceding child was a girl was 759 per 1000 males (99% CI 731–787). The adjusted sex ratio for the third child was 719 (675–762) if the previous two children were girls. By contrast, adjusted sex ratios for second or third births if the previous children were boys were about equal (1102 and 1176, respectively). Mothers with grade 10 or higher education had a significantly lower adjusted sex ratio (683, 610–756) than did illiterate mothers (869, 820–917). Stillbirths and neonatal deaths were more commonly male, and the numbers of stillbirths were fewer than the numbers of missing births, suggesting that female infanticide does not account for the difference. Interpretation Prenatal sex determination followed by selective abortion of female fetuses is the most plausible explanation for the low sex ratio at birth in India. Women most clearly at risk are those who already have one or two female children. Based on conservative assumptions, the practice accounts for about 0·5 million missing female births yearly, translating over the past 2 decades into the abortion of some 10 million female fetuses.

Background & objectives: Evidence-based planning has been the cornerstone of India's response to HIV/AIDS. Here we describe the process, method and tools used for generating the 2015 HIV estimates and provide a summary of the main results. Methods: Spectrum software supported by the UNAIDS was used to produce HIV estimates for India as a whole and its States/Union Territories. This tool takes into consideration the size and HIV prevalence of defined population groups and programme data to estimate HIV prevalence, incidence and mortality over time as well as treatment needs. Results: India's national adult prevalence of HIV was 0.26 per cent in 2015. Of the 2.1 million people living with HIV/AIDS, the largest numbers were in Andhra Pradesh, Maharashtra and Karnataka. New HIV infections were an estimated 86,000 in 2015, reflecting a decline by around 32 per cent from 2007. The declining trend in incidence was mirrored in most States, though an increasing trend was detected in Assam, Chandigarh, Chhattisgarh, Gujarat, Sikkim, Tripura and Uttar Pradesh. AIDS-related deaths were estimated to be 67,600 in 2015, reflecting a 54 per cent decline from 2007. There were variations in the rate and trend of decline across India for this indicator also. Interpretation & conclusions: While key indicators measured through Spectrum modelling confirm success of the National AIDS Control Programme, there is no room for complacency as rising incidence trends in some geographical areas and population pockets remain the cause of concern. Progress achieved so far in responding to HIV/AIDS needs to be sustained to end the HIV epidemic.

Ugra Mohan Jha,1 Yujwal Raj,1 Srinivas Venkatesh,1 Neeraj Dhingra,1 Ramesh S Paranjpe,2 Niranjan Saggurti3 1Department of AIDS Control, Ministry of Health and Family Welfare, Government of India, New Delhi, India; 2National AIDS Research Institute, Pune, India; 3Population Council, New Delhi, India Background: Although India has demonstrated success in the overall reduction of human immunodeficiency virus (HIV) incidence by 57% in the past 10 years, its control among men who have sex with men (MSM) remains a critical challenge. This paper describes the current status, geographic variability, and factors associated with HIV among MSM from the national perspective. Methods: Data on the levels and trends of HIV seropositivity and associated risk behaviors among MSM were analyzed and presented from the following data sources: 1) annual HIV Sentinel Surveillance (HSS) conducted during 2003–10, 2) two rounds of the high-risk group size estimation conducted in 2005 and 2009, 3) two rounds of the Behavioral Surveillance Survey conducted in 2006 and 2009, and 4) the Integrated Bio-behavioral Assessment Round 2. Data were analyzed according to selected sociodemographic characteristics and sexual identities of MSM to understand the factors associated with high HIV prevalence. Results: HSS data indicate that at the national level, HIV prevalence among MSM overall is declining (from 12.3% in 2003 to 4.43% in 2010). However, marginal increasing trends were observed in Chandigarh (from 1.4% in 2004 to 2.8% in 2008) and Haryana (from 0% in 2006 to 3.2% in 2008). HSS data indicate high (>5%) levels and increasing trends in HIV prevalence among MSM in eight states of India during 2003–10. Analysis of 2010 HSS data indicates that HIV prevalence was >10% in seven states. The factors associated with high HIV prevalence among MSM were being a kothi (the receptive partner in oral and anal sex, and typically with effeminate mannerisms) or a double-decker (both penetrative and receptive partner) rather than being a panthi (the penetrative partner in oral or anal sex) (8% vs 4.3%; P

Heterosexual transmission of HIV in India is driven by the male use of female sex workers (FSW), but few studies have examined the factors associated with using FSW. This nationally representative study examined the prevalence and correlates of FSW use among 31,040 men aged 15-49 years in India in 2006. Nationally, about 4% of men used FSW in the previous year, representing about 8.5 million FSW clients. Unmarried men were far more likely than married men to use FSW overall (PR = 8.0), but less likely than married men to use FSW among those reporting at least one non-regular partner (PR = 0.8). More than half of all FSW clients were married. FSW use was higher among men in the high-HIV states than in the low-HIV states (PR = 2.7), and half of all FSW clients lived in the high-HIV states. The risk of FSW use rose sharply with increasing number of non-regular partners in the past year. Given the large number of men using FSW, interventions for the much smaller number of FSW remains the most efficient strategy for curbing heterosexual HIV transmission in India.

BACKGROUND: The nationwide effects of smoking on mortality in India have not been assessed reliably. METHODS: In a nationally representative sample of 1.1 million homes, we compared the prevalence of smoking among 33,000 deceased women and 41,000 deceased men (case subjects) with the prevalence of smoking among 35,000 living women and 43,000 living men (unmatched control subjects). Mortality risk ratios comparing smokers with nonsmokers were adjusted for age, educational level, and use of alcohol. RESULTS: About 5% of female control subjects and 37% of male control subjects between the ages of 30 and 69 years were smokers. In this age group, smoking was associated with an increased risk of death from any medical cause among both women (risk ratio, 2.0; 99% confidence interval [CI], 1.8 to 2.3) and men (risk ratio, 1.7; 99% CI, 1.6 to 1.8). Daily smoking of even a small amount of tobacco was associated with increased mortality. Excess deaths among smokers, as compared with nonsmokers, were chiefly from tuberculosis among both women (risk ratio, 3.0; 99% CI, 2.4 to 3.9) and men (risk ratio, 2.3; 99% CI, 2.1 to 2.6) and from respiratory, vascular, or neoplastic disease. Smoking was associated with a reduction in median survival of 8 years for women (99% CI, 5 to 11) and 6 years for men (99% CI, 5 to 7). If these associations are mainly causal, smoking in persons between the ages of 30 and 69 years is responsible for about 1 in 20 deaths of women and 1 in 5 deaths of men. In 2010, smoking will cause about 930,000 adult deaths in India; of the dead, about 70% (90,000 women and 580,000 men) will be between the ages of 30 and 69 years. Because of population growth, the absolute number of deaths in this age group is rising by about 3% per year. CONCLUSIONS: Smoking causes a large and growing number of premature deaths in India.

BACKGROUND: We characterize the human immunodeficiency virus (HIV) care continuum for men who have sex with men (MSM) and persons who inject drugs (PWID) across India. METHODS: We recruited 12 022 MSM and 14 481 PWID across 26 Indian cities using respondent-driven sampling (September 2012 to December 2013). Participants were aged >/=18 years and either self-identified as male and reported sex with a man in the prior year (MSM) or reported injection drug use in the prior 2 years (PWID). Correlates of awareness of HIV-positive status were characterized using multilevel logistic regression. RESULTS: A total of 1146 MSM were HIV infected of whom a median of 30% were aware of their HIV-positive status 23% were linked to care 22% were retained before antiretroviral therapy (ART) 16% had started ART 16% were currently receiving ART and 10% had suppressed viral loads. There was site variability (awareness range 0%-90%; suppressed viral load range 0%-58%). A total of 2906 PWID were HIV infected of whom a median of 41% were aware 36% were linked to care 31% were retained before ART 20% had started ART 18% were currently receiving ART and 15% had suppressed viral loads. Similar site variability was observed (awareness range: 2%-93%; suppressed viral load range: 0%-47%). Factors significantly associated with awareness were region older age being married (MSM) or female (PWID) use of other services (PWID) more lifetime sexual partners (MSM) and needle sharing (PWID). Ongoing injection drug use (PWID) and alcohol use (MSM) were associated with lower awareness. CONCLUSIONS: In this large sample the major barrier to HIV care engagement was awareness of HIV-positive status. Efforts should focus on linking HIV testing to other essential services. CLINICAL TRIALS REGISTRATION: NCT01686750. (c) The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions please e-mail: journals.permissions@oup.com.

Fewer girls than boys are born in India. Various hypotheses have been proposed to explain this low sex ratio. Our aim was to ascertain the contribution of prenatal sex determination and selective abortion as measured by previous birth sex.We analysed data obtained for the Special Fertility and Mortality Survey undertaken in 1998. Ever-married women living in 1.1 million households in 6671 nationally-representative units were asked questions about their fertility history and children born in 1997.For the 133 738 births studied for 1997, the adjusted sex ratio for the second birth when the preceding child was a girl was 759 per 1000 males (99% CI 731-787). The adjusted sex ratio for the third child was 719 (675-762) if the previous two children were girls. By contrast, adjusted sex ratios for second or third births if the previous children were boys were about equal (1102 and 1176, respectively). Mothers with grade 10 or higher education had a significantly lower adjusted sex ratio (683, 610-756) than did illiterate mothers (869, 820-917). Stillbirths and neonatal deaths were more commonly male, and the numbers of stillbirths were fewer than the numbers of missing births, suggesting that female infanticide does not account for the difference.Prenatal sex determination followed by selective abortion of female fetuses is the most plausible explanation for the low sex ratio at birth in India. Women most clearly at risk are those who already have one or two female children. Based on conservative assumptions, the practice accounts for about 0.5 million missing female births yearly, translating over the past 2 decades into the abortion of some 10 million female fetuses.

THE STUDY was carried out at the Emergency Department of Jawaharlal Nehru Medical College Hospital, Aligarh Muslim University, Aligarh, India, to ascertain the pattern of trauma in the patients. A total of 2446 trauma cases were recorded in the year 1987. Accidental falls were the commonest cause of injury, i.e 35.7%, followed by motor-vehicle collisions (23.5%), pedal cyclists (8%), occupational injuries (5.2%) and sports injuries (5.2%). The com monest age group involved was 5-15 years which accounted for 32.8% of all trauma. Fractures (44%) were the most frequently observed nature of injury. Death due to trauma was highest in motor-vehicle collisions (31%) followed by accidental falls (16%), and occupational injuries (12%).