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To present evaluation of a quality improvement program for Accredited Social Health Activists (ASHAs). This community intervention trial was conducted in Ballabgarh, India during 2012–2014 with two Primary Health Center (PHC) areas being the intervention areas and two PHC areas being non-intervention areas receiving standard care. Interventions included two-day training in technical and communication skills of ASHAs followed by supportive supervision in the field. Intervention was evaluated by comparing pre and post training scores, feedback from postnatal mothers and a difference-in-difference (DID) analysis on baseline and endline knowledge-practice survey of recently delivered mothers with 95% confidence intervals. Only 11.1% ASHAs addressed specific barriers for adopting healthy behaviors. Sixty eight (91.8%) ASHAs attended the training after which knowledge improved by 33.3% (p

The present manuscript reports a numerical investigation of fully developed mixed convective flow in a parallel channel filled with porous medium. The motion in the channel is induced by external pressure gradient and buoyancy force. The non-Darcy Brinkman-Forchheimer extended model has been used. The Chebyshev spectral collocation method has been used to solve the coupled differential equations numerically. The main emphesize has been given on the influence of Forchheimer number (F), Darcy number (Da) and Rayleigh number (Ra) on velocity and temperature profiles. From this investegation we have found that the velocity aswell as temperature profiles possess point of inflection beyond a threshold value of Ra. The back flow starts near the center of the channel on increasing the value of Ra beyond the threshold value of Ra. The point of inflection on the velocity as well as temperature profile dies out on decreasing of Da. The strength of the velocity is decreases on the increasing of F', it also changes the velocity profile drastically. The point of inflection on the basic flow dies out on increasing of F'.

To assess the effectiveness of a multi-component school based intervention in improving knowledge and behavioral practices regarding diet, physical activity and tobacco use in middle schoolchildren of rural-Ballabgarh, North-India. A total of 40 middle schools were grouped into two, based on geographic proximity and randomly assigned to the intervention or control group in a cluster randomized controlled trial. The target population consisted of 2,348 children studying in 6th and 7th grades in these schools. The intervention consisted of a school component (policies), a classroom component (activities) and a family component [Information Education & Communication (IEC) material]. The main outcome measures were knowledge and behavioral changes in physical activity, diet and tobacco which were self- reported. Post-intervention, a significant number of intervention schools adopted the tobacco policy (16/19), physical activity policy (6/19) and healthy food policy (14/19) as compared to the control schools (n = 21). Knowledge about physical activity, diet and tobacco improved significantly in the intervention group as compared to the control group. Proportion of students attending Physical Training (PT) classes for five or more days in a week in the intervention group compared to the control group increased significantly (17.8 %; p

Submerged fermentation for the production of polysaccharides has received the greatest interest in recent years due to its increased demand as drug. Response surface methodology was employed to optimize the conditions for extraction of polysaccharides fromGanoderma lucidum. Central composite rotatable design was employed to optimize temperature, time, sodium hydroxide (NaOH) concentration and volume of NaOH for polysaccharide extraction. The various effects of the factors were studied by β-coefficient and Fischer’s F-test for analysis of variance (ANOVA) and a second order model was developed. The results indicated that the optimum conditions were an extraction temperature of 100°C, an extraction time of 3 h, NaOH concentration of 6% and ratio of liquid to solid of 20 ml. The experimental polysaccharide production at predicted optimum conditions was 4.96% that validates the high degree of accuracy. Fourier transform infrared spectroscopy (FTIR) was used to obtain vibrational spectra of GL-2 mycelium and fruit body. The bands in the range of 1200 to 800 cm-1 indicated the presence of polysaccharides. Key words: Central composite rotatable design (CCRD), Fourier transform infrared spectroscopy (FTIR), Ganoderma lucidum, polysaccharides, response surface methodology.

Background Most of the standard verbal autopsy tools are long and are used in a research setting. This study aims to compare a short verbal autopsy (VA) tool developed at Ballabgarh, India to be used by health workers for routine mortality surveillance with a standard tool. Methods A short VA tool was developed which was used by health workers during their routine house visits while a standard International Network of Field Sites with continuous Demographic Evaluation (INDEPTH) VA tool was filled by trained research workers for all adult deaths that occurred in 2008. The cause-specific mortality fraction using two tools, validity of the Comprehensive Rural Health Services Project (CRHSP) VA tool with INDEPTH VA tool as reference and agreement between the two tools, was compared. Results The cause-specific mortality fraction was 11.6% and 12% for ischaemic heart disease (IHD), 10.6% and 11.8% for chronic pulmonary obstructive disease (COPD), and 9.4% and 7.3% for tuberculosis, using the INDEPTH and CRHSP VA tool, respectively. 16% and 21% of the deaths could not be classified using the INDEPTH and CRHSP VA tool respectively. The sensitivity of the CRHSP VA tool was 78.5% for IHD, 80% for COPD, 58.3% for tuberculosis, 92.8% for malignant neoplasm and 97.2% for intentional self harm. The kappa between two tools for IHD, COPD, tuberculosis, malignant neoplasm and intentional self harm was 0.754, 0.711, 0.628, 0.876 and 0.892 respectively. Conclusion The short VA tool had a good sensitivity and fair to excellent agreement with the standard tool in different age groups across the major causes of death. It can be used within the routine healthcare delivery framework and can fill the gap in mortality surveillance.

SUMMARY This paper reports the results of formative and outcome evaluation of two ongoing community-based intervention programmes for integrated non-communicable disease (NCD) prevention and control in urban low-income settings of Ballabgarh near New Delhi, India, and in Depok, West Java Province of Indonesia. At both sites, a coalition of community members facilitated by academic institution and the World Health Organization, planned and implemented the intervention since 2004. The intervention consisted of advocacy and mediation with stakeholders, training of volunteers and school teachers, communication campaigns, risk assessment camps and reorientation of health services. The formative evaluation was based on the review of documents, and outcomes were assessed using the standardized surveys for NCD risk factors in 2003 –2004 and 2006 –2007. The baseline surveys showed that tobacco use, low intake of fruits and vegetable, suboptimal levels of physical activity and obesity were prevalent in both the communities. A frequent change in local administrators and lack of perceived priority for health and NCDs limited their involvement. Pre-existing engagement of community-based organizations and volunteers in health activities facilitated its implementation. The reach of the programme among the population was modest (25 –32%). Health system interventions resulted in increased diagnosis and better management of NCDs at health facilities. Early outcome measures showed mixed results of change in different risk factors. The experiences gained are being used in both countries to expand and provide technical support to national efforts. This paper adds to the knowledge base on the feasibility of designing and implementing largescale community-based interventions for integrated prevention of NCDs through modification of risk factors.

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

Deficiencies of micronutrients (zinc, iron, folic acid and iodine) during pregnancy are known causes of Low Birth Weight (LBW). Studies have documented status of one or two micronutrients amongst pregnant women (PW). However, no attempt has been made to concurrently assess the prevalence of multiple micronutrient deficiencies and the factors associated with them amongst PW.Objective: The present study was undertaken to assess the prevalence of multiple micronutrient deficiencies amongst PW in a rural area.Methods: A community based cross sectional survey was conducted in six villages of a rural area of district Faridabad in Haryana state, India during November 2000 and October 2001. All PW aged 18 years or more, with pregnancy duration of more than 28 weeks were enrolled. Data were collected on socio-economic status and other demographic parameters. Serum zinc, copper and magnesium levels were estimated by utilizing the Atomic absorption spectrophotometry (AAS); serum ferritin and folate was estimated by Enzyme Linked Immuno Sorbent Assay (ELISA) method and the Radio-lmmuno Assay (RIA) method, respectively and serum thyroid stimulating hormone (TSH) level was estimated by the Abbot AxSYM System. Serum zinc, copper, magnesium, ferritin, and folate levels less than 70.0 μg/dl, 80.0 μg/dl, 1.80 mg/dl, 15 ng/ml, and 3 ng/ml, respectively were considered as indicative of deficiency for respective micronutrients. The TSH levels of 4.670 and more indicated iodine deficiency status. Dietary intake of micronutrients was assessed utilizing 1-day 24-hour dietary recall methodology. Food consumption pattern was assessed utilizing the food frequency questionnaire methodology.Results: Nearly 73.5, 2.7, 43.6, 73.4, 26.3, and 6.4 percent PW were deficient in zinc, copper, magnesium, iron, folic acid and iodine, respectively. The highest concurrent prevalence of two, three, four and five micronutrient deficiency was of zinc and iron (54.9%); zinc, magnesium and iron (25.6%); zinc, magnesium, iron and folic acid (9.3%) and zinc, magnesium, iron, folic acid and iodine (0.8%), respectively. No pregnant woman was found to have concomitant deficiencies of all the six micronutrients. Dietary intake data revealed an inadequate nutrient intake. Over 19% PW were consuming less than 50% of the recommended calories. Similarly, 99, 86.2, 75.4, 23.6, 3.9 percent of the PW were consuming less than 50% of the recommended folic acid, zinc, iron, copper, and magnesium. The consumption of food groups rich in micronutrients (pulses, vegetables, fruits, nuts and oil seeds, animal foods) was infrequent. Univariate and Multivariate logistic regression analysis revealed that low dietary intake of nutrients, low frequency of consumption of food groups rich in micronutrients and increased reproductive cycles with short interpregnancy intervals were important factors leading to micronutrient deficiencies.Conclusion: There was a high prevalence of micronutrient deficiencies amongst the PW of the area, possibly due to the poor dietary intake of food and low frequency of consumption of food groups rich in micronutrients. The concurrent prevalence of two, three, four and five micronutrient deficiencies were common.

Zinc deficiency during pregnancy affects the outcome of pregnancy. A high prevalence of zinc deficiency (55.5%) has been reported among pregnant women. It is not known whether pregnancy leads to zinc deficiency due to the increased fetal needs or whether the women are zinc deficient when they become pregnant. No data are available on the zinc status of nulliparous nonpregnant women from India. To assess the magnitude of zinc deficiency among nulliparous nonpregnant women in a rural community of Haryana State, India. A community-based cross-sectional survey was conducted in six villages of a rural area in a district of Haryana State, India. All nulliparous nonpregnant women aged 18 years or over who were willing to participate in the study were enrolled. Each woman was questioned about her age, socioeconomic status, and dietary pattern with the use of a pretested semistructured questionnaire. Blood from the antecubital vein was drawn to assess the serum zinc levels using an atomic absorption spectrophotometer. Serum zinc levels less than 70.0 μg/dl were considered to indicate zinc deficiency. The dietary intakes of zinc, protein, and calories were assessed by the 24-hour dietary recall method. Two hundred eighty-eight nulliparous nonpregnant women were enrolled. Forty-one percent had zinc deficiency, and 75.7%, 1.4%, and 7.3% of the women consumed less than 50% of the recommended intake of zinc, protein, and calories, respectively. Women who consumed less than 50% of the recommended intake of calories (1,875 kcal) were at a 4.9 times higher risk of zinc deficiency than women who consumed more than 50% of the recommended intake. A high prevalence of zinc deficiency was found among the nulliparous nonpregnant women in the area studied.

Redox reactions of pyridoxal (P-OH) with e¯aq, .OH, N.3, SO.4¯ and various organo-haloperoxyl radicals have been studied using pulse radiolysis technique. The rate constants for the reaction of P-OH or P-O¯ with the above-mentioned radicals and the transient absorption spectra have been measured. The transients formed in the reaction of hydrated electron and oxidizing radicals with pyridoxal have been assigned. An attempt has been made to find a correlation between the rate constants and Taft parameter for the reactions with the organo-haloperoxyl radicals. It has also been observed that the one-electron oxidized radical of pyridoxal is repaired by uric acid. The reduction potential for the P-OH.+/P-OH couple at pH 7, as measured by cyclic voltammetry, has been found to be +1.11 V vs. NHE.

Background Planning a comprehensive program addressing neonatal mortality will require a detailed situational analysis of available neonatal-specific health infrastructure. Methods We identified facilities providing essential and sick neonatal care (ENC, SNC) by a snowballing technique in Ballabgarh Block. These were assessed for infrastructure, human resource and equipment along with self-rated competency of the staff and compared with facility-based or population-based norms. Results A total of 35 facilities providing ENC and 10 facilities for SNC were identified. ENC services were largely in the public-sector domain (68.5% of births) and were well distributed in the block. SNC burden was largely being borne by the private sector (66% of admissions), which was urban-based. The private sector and nurses reported lower competency especially for SNC. Only 53.9% of government facilities and 17.5% of private facilities had a fully equipped newborn care corner. Conclusions Serious efforts to reduce neonatal mortality would require major capacity strengthening of the health system, including that of the private sector.

Bronchial asthma is one of the most common illnesses in children. Factors influencing development of asthma have not been studied in rural population. 2000 school going children from five schools of Chhainsa and Dayalpur Primary Health Centre area in Ballabgarh Block of Haryana state were screened for presence of symptoms of asthma using a questionnaire suggested by International Study of Asthma and Allergy in Children (ISSAC). 40 children were identified as cases of bronchial asthma. For each child with asthma two age and sex matched non-asthmatic controls were selected from the study population. History, clinical examination and in-depth interview were carried out for all cases and controls. Factors associated with presence of symptoms of asthma on multivariate analysis were passive smoking (OR 3.33, 95% CI 1.85-7.65), pets at home (OR 5.5, 95% CI 1.04-29.15), and absence of windows in living rooms (OR 4.03, 95% CI 1.17-13.79). Factors such as family history of asthma, history of worm infestation, fuel used for cooking, location of kitchen and food allergy were not significant on statistical analysis. Thus, passive smoking, inadequate ventilation and pets (dogs and cats) at home are significant risk factors associated with presence of symptoms of asthma in rural children.

Cerebral palsy is a major cause of crippling in children, but it's etiology is poorly understood. This case control study was done to assess some of the identified risk factors for cerebral palsy, 125 cerebral palsy cases selected from hospital clinic and 125 age and sex matched neighbourhood controls, all aged less than 5 years and residing in Delhi (India) were studied. Information regarding antenatal, natal and postnatal period was collected by mother's interview, and wherever available, from hospital records with the study subjects. Most common type of cerebral palsy was spastic (88%). Quadriplegia was the commonest topographical subtype (86.4%). Birth asphyxia was found to be present in only 25.6% of cases. The commonest risk factor amongst cases was low birth weight (28.8%). The multivariate odds ratios (confidence limits) for the risk factors found to be significantly associated with cerebral palsy were 36.1 (7.76-160) for birth asphyxia, 13.8 (4.95-38.3) for low birth weight, 37.4 (4.47-313) for neonatal convulsion, 23 (4.7-112) for neonatal jaundice, 14.4 (3.69-56.4) for neonatal infection, 24.9 (2.78-223) for instrument assisted delivery and 15.4 (1.57-152) for antepartum hemorrhage. Precipitate labour, caesarean section, twins, toxemia, breech delivery and head injury were not found to be significantly associated with cerebral palsy. Thus birth asphyxia, low birth weight, neonatal convulsions, neonatal jaundice, neonatal infection, instrument assisted delivery and antepartum hemorrhage are significant risk factors for cerebral palsy.

To assess sex-specific differentials in child survival from 1992-2011.We analyzed data from the electronic database of Health and Demographic Surveillance System (HDSS) site in Ballabgarh in North India.Sex ratio at birth was adverse for girls throughout the study period (821 to 866 girls per 1,000 boys) and was lowest in the period 2004-2006 at 821 girls per 1,000 boys. Overall, under-five mortality rates during the period 1992-2011 remained stagnant due to increasing neonatal mortality rate (9.2 to 27.7 P0.001). Mortality rates among girls were consistently and significantly higher than boys during the post-neonatal period (160% to 200% higher) as well as in childhood(160% to 230% higher).Strategies to address the neonatal mortality and gender differences are required for further reductions in child mortality in India.

STUDY OBJECTIVE: To determine the most appropriate surrogate indicator and its cut off point for identifying low birthweight babies in northern India. STUDY SETTING: A secondary level hospital at Ballabgarh. The patients were from nearby rural and urban areas and mostly belonged to lower and middle socioeconomic strata. PARTICIPANTS: These comprised 733 singleton newborns delivered in the hospital between April and December 1991. DESIGN: Birth weight, arm circumference, and chest circumference were measured in all the newborns. Different cut off points for each index were identified and their validity was tested. Based on the regression equations, a simple chart was drawn up and was used to predict weights for different arm and chest circumferences in the hospital and community settings. MAIN RESULTS: Cut off points for arm and chest circumferences of 8.5 cm and 29.5 cm respectively gave a sensitivity and specificity of around 80%. When the chart based on the regression equations was tested in both the hospital and the community, chest circumference was found to be the better of the two indicators. CONCLUSION: Chest circumference seems to be the most appropriate surrogate measure for birth weight. Cut off points of 29.5 cm and 27.5 cm seem to be satisfactory for predicting birth weight below 2500 g and 1800 g respectively. The birthweight prediction card using chest circumference was effective in predicting birth weight.

Of 613 children evaluated in a village in Haryana 94 (15.3%) were observed to have chronic suppurative otitis media (CSOM). Fifty eight (61.7%) children had hearing impairment. CSOM contributed to 71.6% of the hearing impaired (58/81). On analysis of association of CSOM with literacy and socio-economic status of mothers, and age, sex, and upper respiratory tract infections (URI) in children positive correlation was observed only with URIs (P

Noncommunicable diseases (NCDs) are emerging as an important public health problem in developing countries. The risk factors for NCDs are initiated during childhood and adolescence. The aim of this review was to assess the effectiveness of school-based interventions for prevention of NCD risk factors (physical inactivity, diet, and tobacco consumption), and identify processes that affect the main outcome. The retrieved studies from 2001 to 2010 were analyzed for their methodological quality (using standard guidelines), settings, intervention components, and main outcomes. The literature search identified 37 studies. The proportion of studies showing a positive result was 83% (10/12) among those that involved family, 87%(7/8) that involved both community and family, and 76% (13/17) that involved school only. Overall, 80% of the studies reported at least some evidence of a positive intervention effect. The current literature search supports the effectiveness of school-based interventions for prevention of risk factors associated with NCDs.

This study was conducted at a secondary level hospital at Ballabgarth, run by Centre for Community Medicine, All India Institute of Medical Sciences. The still birth rate during the study period 1987-1992 was 19.5 per 1,000 births. It showed a sudden decline during these six years probably reflecting the change in the admission policy of the hospital. A case control study of 72 still births and 144 controls was carried out to identify risk factors for still births. Maternal age, gravidity, previous history of still births or abortion were not found to be significantly associated with still births. Poor socio-economic status measured by parental literacy and occupation were significantly associated with still births. Lack of antenatal care [(OR 9.2 (2.5-37.9)], low birth weight (2500 gms) [OR-18.1 (4.4-74.5)], non-vertex presentation [(OR 41.2 (66-257.3)], maternal illiteracy [OR 2.75 (1.01-11.3)] were found to be the important predictors of still birth as identified by logistic regression analysis. The provision of good antenatal care and improvement of the socio-economic status, especially female literacy, will help in decreasing the still birth rate in the country.

All births (1211) were recorded in a rural area for 1985 by monthly domiciliary visits and the sociological characteristics were collected from mothers within a month. The analysis of 1201 births is presented: 52.7% were male births, 95.7% were delivered in village itself, 80.4% were delivered by trained dais, 99.5% were live born, 12.9% were born before 37 weeks of gestation, 61.5% were put to breast feed within 6 hours, 35% were of gravida 4 and above, 68.9% did not receive any antenatal care, 67.1% had not received any tetanus toxoid, 70.8% did not receive any folifer tablet, 0.8% had abortion and another 0.8% had still birth in preceding outcome, 1.58% had lost a live born dead in preceding out come, 89.6% stopped breast feeding at conception, 31.7% had birth interval less than 2 years, but 2.2% had less than one year, 2/3rd were born in second half of the year, 17.8% had taken extra food during pregnancy, 21.2% reduced the work after becoming pregnant, 9.5% were born to mothers of less than 20 years age, 98.5% of mothers were housewives and 95.9% mothers were illiterate, 33.5% were born in nuclear family, 22.3% were living in 'Kacha' house, 34.8% had no electricity connection, 37.0% were born to land less, 42.2% had no radio in the house, 7.1% had no conveyance, 52.0% families had piped water supply. These findings have been discussed here.

The prevalence of rheumatoid arthritis was studied in the adult Indian population. As the first step, a house-to-house survey of a rural population near Delhi was conducted by two trained health workers. The target population comprised 44,551 adults (over 16 years old). The health workers identified the possible cases of rheumatoid arthritis (RA) using a questionnaire. These cases were then further evaluated by the authors using the 1987 revised ARA criteria for the diagnosis of RA. A response rate of 89.5% was obtained and 3393 persons were listed as possible cases of RA by the health workers. Of these, 299 satisfied the revised ARA criteria for the diagnosis of RA, giving a prevalence of 0.75%. Projected to the whole population, this would give a total of about seven million patients in India. The prevalence of RA in India is quite similar to that reported from the developed countries. It is higher than that reported from China, Indonesia, Philippines and rural Africa. These findings are in keeping with the fact that the north Indian population is genetically closer to the Caucasians than to other ethnic groups.

WHO advocated a standard case management for control of ARI related mortality. India has started an ARI control programme in 15 districts. Conflicting reports appeared regarding the effectiveness of case management strategy. Authors reported earlier that it was not effective. The coverage was only about 57% in pneumonias, and 23% in severe pneumonias. Health agencies & health workers have a low utilizaticn (13.7%), and RMPs were used in large numbers (36.9%). Most of the deaths were in those treated by RMPs (75%). The efficacy of standard case management (88%) is highlighted. The problem of coverage and assumptions behind the strategy were discussed and recommendations for improvement were suggested.

Background: The International Network of field sites with continuous Demographic Evaluation of Populations and Their Health (INDEPTH) has 34 Health and Demographic Surveillance System (HDSS) in 17 different low and middle-income countries. Of these, 23 sites are in Africa, 10 sites are in Asia, and one in Oceania. The INDEPTH HDSS sites in Asia identified chronic non-communicable diseases (NCDs) as a neglected area of attention. As a first step, they conducted NCD risk factor surveys within nine sites in five countries. These sites are now looking to broaden the agenda of research on NCDs using the baseline data to inform policy and practice. Methods: A conceptual framework for translating research into action for NCDs at INDEPTH sites was developed. This had five steps - assess the problem, understand the nature of the problem, evaluate different interventions in research mode, implement evidence-based interventions in programme mode, and finally, share knowledge and provide leadership to communities and countries. Ballabgarh HDSS site in India has successfully adopted these steps and is used as a case study to demonstrate how this progress was achieved and what factors were responsible for a successful outcome. Results: Most of the HDSS sites are in the second step of the process of translating research to action (understand the problem). The conduct of NCD risk factor surveys has enabled an assessment of the burden of NCD risk together with determinants in order to understand the burden at the population level. The experience from Ballabgarh HDSS exemplifies that the following steps - pilot testing the interventions, implementing activities in programme mode, and finally, share knowledge and provide leadership - are also possible in rural settings in low-income countries. The critical success factors identified were involvement of a premier medical institution, pre-existing links to policy makers and programme managers, strong commitment of the HDSS team and adequate human resource capacity. Conclusion: All INDEPTH HDSS sites now need to strengthen their links to health systems at different levels and enhance their capacity to engage different stakeholders in their respective country settings so as to translate the current knowledge into actions that can benefit the health of the population they serve and beyond. Keywords: non-communicable diseases; surveillance; policy; translational research (Published: 28 September 2009) Citation: Global Health Action Supplement 1, 2009. DOI: 10.3402/gha.v2i0.1990

Experience in the control of tetanus neonatorum (TN) in a rural area is presented. TN was reduced by training of dais, increasing the coverage of tetanus toxoid to pregnant women and distribution of presterilized delivery kits to pregnant ladies for use by birth attendants. The problems of untrained birth attendants, effectiveness of tetanus toxoid coverage and place of delivery are discussed.Researchers analyzed 1972, 1977, 1982, 1987 data on neonatal tetanus death and birth attendants from the Comprehensive Rural Health Services Project in rural Ballabgarh, India which comprised 28 villages. Health workers visited each house in an area monthly. Even though they began vaccinating pregnant women with the tetanus toxoid (TT) in 1970, the TT coverage percentage did not fall substantially until between 1977-1982 (31.6%-70%), by 1983, TT coverage stood at 93%. It was not until TT coverage reached 85% did neonatal tetanus deaths fall significantly. In 1982, they gave every women near the end of pregnancy a sterilized delivery kit complete with gauze, half a razor blade, and thread. The health workers instructed the women to request anyone who delivers the child to use the contents of the kit. Regardless of the year, around 90% of deliveries occurred at home. Except for 1982, untrained individuals attended about 70% of deliveries. 1982 was the year with the highest percentage of trained dais involved in home delivery (27.6%). The percentage of deliveries my primary health care staff did rise from 4.2-12.1% between 1972-1987, however. In this time period, neonatal mortality fell gradually from 42.3-17.9. Moreover neonatal deaths from tetanus fell consistently but dramatically from 14.6-0. The drop in tetanus related deaths between 1972-1977, was not significant, however, because tetanus and septicemia were not differentiated and health staff seldom saw tetanus cases in hospitals. In conclusion, the Comprehensive Rural Health Services Project of India should expand prenatal care including TT to all pregnant women, distribute sterilized delivery kits to these women between 36-40 weeks gestation, and include instructions on how to use the contents of the kit.

This study was conducted in children under the age of four years for a period of one year. By domiciliary visits the diarrheal episodes were recorded, analysed and presented. The findings are based on the diarrheal experience of 4860 children. The attack rate was 2.6/child/year. Family with more than one child had more attacks. Mean duration was 5.76 days and 11.2% had lasted more than 7 days. All the age groups are similarly affected. 75.6% were just plain loose motions and only 4.9% had blood, mucus or fever associated with loose motions. Case fatality was 0.6%. Attack rate was more in June-August and December-February than the other quarters. 42.2% were shown to R.M.P.s. and 33.6% consulted friends or relatives. More than 2/3 gave mainly home made ORS. 69.9% restricted food during attack.

Background Iron, folate, and vitamin B12 deficiencies have adverse effects on pregnancy outcome. In India, data on the concomitant prevalence of these deficiencies among pregnant women are meager. Objective We conducted a community-based study to assess the prevalence of deficiencies of iron, folate, and vitamin B12 among pregnant women in a rural block of Haryana State. Methods The study was approved by the ethics committee of the All India Institute of Medical Sciences, New Delhi. A total of 283 pregnant women were enrolled in the study. After oral informed consent had been obtained from the women, blood was drawn from the antecubital vein for estimation of the levels of serum ferritin by enzyme-linked immunosorbent assay (levels < 12 ng/mL were considered as indicative of poor iron stores); serum folate was determined by radioimmunoassay (levels < 3 ng/mL were considered as indicative of poor folate stores); and serum vitamin B12 was estimated by the microbiologic method (levels < 200 pg/mL were considered as indicative of poor vitamin B12 stores). Results The results indicated that 67.7%, 26.3%, and 74.1% of the women had poor iron, folate, and vitamin B12 stores, respectively. Concomitant deficiencies of iron, folate, and vitamin B12 occurred in 16.2% of the women. We found that 59.9% of the women were consuming less than 75% of the recommended daily caloric allowance (2,175 kcal), indicating an overall poor food intake. This could be one of the predominant reasons for poor iron, folate, and vitamin B12 stores among the women. Conclusions Our findings suggest that apart from iron and folate, vitamin B12 deficiencies may play an important role in causing anemia.

Rural underfives (5335) were followed for a period of one year from January to December 1987 for acute respiratory infections (ARI). Those affected with pneumonias were studied in detail to know the epidemiology. The children reported an attack rate of 0.29/child/year. Severe cases constitute 0.5%. Infants had higher attack rate (0.59/child/year), 47.7% of episodes occurred in infants and 87.7% occurred in children below 3 years. Males had a higher attack rate (0.32 vs 0.27). Mean duration of attack was 5.45 +/- 1.95 days. The attack rate was higher in winter. The case fatality rate was 1.26%. It was highest in neonates (10.7%) Females had higher case fatality rate than males (1.5% Vs 1.1%). Mortality was very high in severe cases. Case fatalities were high in seasons when the climatic change occurred, the highest being in autumn.

Respiratory syncytial virus (RSV) is the most commonly identified viral agent of acute respiratory tract infection (ARI) of young children and causes repeat infections throughout life. Limited data are available on the molecular epidemiology of RSV from developing countries, including India. This study reports on the genetic variability in the glycoprotein G gene among RSV isolates from India. Reverse transcription-PCR for a region of the RSV G protein gene was done with nasopharyngeal aspirates (NPAs) collected in a prospective longitudinal study in two rural villages near Delhi and from children with ARI seen in an urban hospital. Nucleotide sequence comparisons among 48 samples demonstrated a higher prevalence of group A (77%) than group B (23%) RSV isolates. The level of genetic variability was higher among the group A viruses (up to 14%) than among the group B viruses (up to 2%). Phylogenetic analysis revealed that both the GA2 and GA5 group A RSV genotypes were prevalent during the 2002-2003 season and that genotype GA5 was predominant in the 2003-2004 season, whereas during the 2004-2005 season both genotype GA5 and genotype BA, a newly identified group B genotype, cocirculated in almost equal proportions. Comparison of the nonsynonymous mutation-to-synonymous mutation ratios ( dN / dS ) revealed greater evidence for selective pressure between the GA2 and GA5 genotypes ( dN / dS , 1.78) than within the genotypes ( dN / dS , 0.69). These are among the first molecular analyses of RSV strains from the second most populous country in the world and will be useful for comparisons to candidate vaccine strains.

Respiratory syncytial virus (RSV) causes repeat infections throughout life. Antigenic variability in the RSV G protein may play a significant role in reinfections. A variable region of the RSV G gene was analyzed for 14 viruses from seven children who experienced initial and repeat infections. Eleven group A strains were in clades GA2 and GA5 and the three group B viruses were in the newly identified BA clade. In five children reinfections were caused by a heterologous group or genotype of RSV. Two children experienced infection and reinfection by viruses of the same clade, these virus pairs differed by only two to three amino acids in the region compared. This is the first report of RSV nucleotide sequence analysis from India and one of the few molecular characterizations of paired RSV from reinfections. Determining the molecular basis of reinfections may have important implications for RSV vaccine development. J. Med. Virol. 78:659–665, 2006. © 2006 Wiley-Liss, Inc.

Objective : To estimate the cost of ambulatory (out-patient) and in-patient pediatric health services for the year 1999 provided by All India Institute of Medical Sciences (AIIMS) at all the three levels-primary, secondary and tertiary level.Methods: The costing module developed by Children’s Vaccines Initiative (CVI) was used. This rapid assessment tool focuses on collection of data at macro level by using key informants like doctors, nursing staff, accountant, store keeper, engineer etc. Cost per beneficiary was estimated separately for in-patients and out-patients and was calculated by dividing the total cost of the services by the number of beneficaries for the year 1999. For the out-patient, the beneficiaries were the total out-patient attendees and for the in-patient, it was the total pediatric admissions multiplied by mean duration of stay in days.Results: The cost per out-patient visit was INR.20.2 (US$0.44@1US$=INR.46) at primary level, higher than INR14.5 (US$ 0.31) at the secondary level, while at tertiary level it was INR 33.8 (US$ 0.73). At the primary and secondary level, non-physician cost was more than the physician cost, and for tertiary level, physician cost was much higher than the other costs. There were no inpatient services at primary level. The cost of in-patient services at secondary level was estimated as INR 419.30 (US$ 9.1) per patient per day with a bed occupancy rate of 60%. Two-fifths of the cost was due to nursing and other supportive staff and one fifth due to the doctor costs and overhead costs. The unit cost of INR 928 (US$ 20.2) per patient per day incurred at AIIMS with a bed occupancy rate of 100% was almost twice that of secondary level. In contrast to the secondary level, almost half the total costs at tertiary level was due to the doctors costs.Conclusions: Effective use of resources at lower level of care especially ambulatory care at primary level and inpatient care at secondary level can result in much higher savings for the system and also, the society. These would need to be appropriately strengthened.

The aim of the study was to evaluate the knowledge of mothers and grandmothers regarding breastfeeding and health-seeking behavior for neonatal sickness in a rural community. A cross-sectional survey, using a triangulation of qualitative (focus group discussion) and quantitative (structured questionnaire) methods was carried out. Although most of the grandmothers and mothers believed in early feeding within 2 h of delivery, they often administered prelacteal feeds such as ghutti and honey. Colostrum was considered beneficial. Most respondents believed that ghutti, water, or both should be given along with breastmilk. Diluted buffalo milk was the preferred choice if supplementation was required. It was thought that weaning should be introduced after 6 months of life. Mothers preferred to give dalia and khichri as the initial weaning food compared to roti and dal water by grandmothers. Both grandmothers and mothers felt that a baby who was playful and not crying excessively was usually healthy. Most of the respondents described the normal pattern of breathing, feeding, urination, and defecation adequately. Most of the grandmothers and mother's felt that by touching forehead and limbs of baby could reliably assess temperature. Refusal to feed was considered as a marker of a sickness by most grandmothers and mothers. However, they also believed that health-seeking for poor feeding could be delayed for 1 day. Respiratory distress was described by the presence of fast respiration, chest retractions, or noisy breathing. Most respondents did not know how to assess cyanosis or seizures. Jaundice was descried as yellowish discoloration of skin, eyes, and urine. Failure to pass urine for 4-6 h bothered most of the respondents. The first response to illness was home remedies. The choice of healthcare was unqualified village practitioners followed by government hospital. Knowledge regarding desirable breastfeeding practices was inadequate and quite a few inappropriate beliefs were widely prevalent. Although knowledge regarding sickness was present, health-seeking from qualified providers was considerably delayed with most respondents preferring village practitioners to government hospitals.

Summary: Purpose: To develop and test a clinical case definition for identification of generalized tonic–clonic seizures (GTCSs) by community-based health care providers. Methods: To identify symptoms that can help identify GTCSs, patients with history of a jerky movements or rigidity in any part of the body ever in life were recruited from three sites: the community, secondary care hospital, and tertiary care hospital. These patients were administered a 14-item structured interview schedule focusing on the circumstances surrounding the seizure. Subsequently, a neurologist examined each patient and, based on available investigations, classified them as GTCS or non-GTCS cases. A logistic regression analysis was performed to select symptoms that were to be used for case definition of GTCSs. Validity parameters for the case definition at different cutoff points were calculated in another set of subjects. Results: In total, 339 patients were enrolled in the first phase of the study. The tertiary care hospital contributed the maximal number of GTCS cases, whereas cases of non-GTCS were mainly from the community. At the end of phase I, the questionnaire was shortened from 14 to eight questions based on statistical association and clinical judgment. After phase II, which was conducted among 170 subjects, three variables were found to be significantly related to the presence of GTCSs by logistic regression: absence of stress (13.1; 4.1–41.3), presence of frothing (13.7; 4.0–47.3), and occurrence in sleep (8.3; 2.0–34.9). As a case definition using only three variables did not provide sufficient specificity, three more variables were added based on univariate analysis of the data (incontinence during the episode and unconsciousness) and review of literature (injury during episode). A case definition consisting of giving one point to an affirmative answer for each of the six questions was tested. At a cutoff point of four, sensitivity was 56.9 (47.4–66.0) and specificity, 96.3 (86.2–99.4). Among the 197 GTCS and 26 new non-GTCS patients recruited from hospitals from select SEAR Member Countries, in phase III, the sensitivity of this clinical case definition was 72% and specificity, 100%. A stratified analysis by gender in all the three phases did not show any differences between the sexes. Conclusions: Based on these criteria, we recommend that all patients with a history of two or more episodes of jerking or rigidity of limbs, having a score of ≥4 in the case definition, be identified as having GTCSs and started on antiepileptic medications. This clinical case definition can be very useful for community-based health care providers to identify and manage cases of GTCSs in the community. This should play a major role in the reduction of treatment gap for epilepsy in developing countries.

An estimated 35 million persons with epilepsy today live in developing countries. The diagnosis of some types of epilepsy is complex and requires a high level of sophistication on the part of physicians specializing in neurosciences, supported by high-technology laboratory tests. Conversely, identification of major seizures (grand mal seizures, estimated to account for∼60–70% of all epilepsy cases) is possible by simple observation of a seizure without the help of EEGs, computed tomography (CT), and magnetic resonance imaging (MRI) scans. The major seizures have the highest morbidity and a good outcome if treated early with easily available and effective antiepileptic drugs (AEDs).

The study objective was out to provide an estimate of cost of epilepsy in a secondary level hospital in northern India where a once a week epilepsy clinic is run. Cost data were based on existing information on costs of the hospital and market rates for drugs and investigations. Other necessary information was extracted from patient records for the year 2001. Both direct (consultation fees, cost of investigation, drugs and facility costs) and indirect (traveling and loss of productivity) were estimated. A 25% loss of productivity was assumed based on interviews with the epilepsy patients attending the clinic. There were a total of 184 patients attending the epilepsy clinic during the year 2001. The annual drug cost of epilepsy treatment using phenobarbitone was 11 US dollars. The cost of drugs was in the ratio 1:2:3:4 for phenobarbitone, phenytoin, carbamazepine and sodium valproate. The average annual cost of outpatient treatment of epilepsy was found to be 47 US dollars per patient. The annual cost incurred in emergency and inpatient management was estimated at 810.50 US dollars and 168.30 US dollars for all the patients attending the secondary hospital during the year 2001. The total annual treatment cost for patients attending the hospital was 11,470 US dollars. The annual productivity loss for the same patients was estimated at 20,475 US dollars. Applying these to the estimated 5 million epilepsy patients in India, it comes to about 0.2% of the GNP of the country. As disease cost is much lower than productivity loss, epilepsy treatment is a worthwhile investment for the society. Treating epilepsy patients at primary level using phenobarbitone will increase the treatment coverage and reduce treatment costs. Simultaneous efforts must be made to bring the epilepsy patients on mainstream so as to reduce the productivity loss.

Objective: Assessment of serum magnesium levels among pregnant women in a rural community. Design: A community-based cross-sectional study. Setting: Investigation was conducted in six villages of a rural block of District Faridabad, Haryana State, India. Subjects: In total, 283 pregnant women with pregnancy duration of 28 weeks and more were enrolled for the detailed study. Blood from the antecubital vein was drawn and serum magnesium levels were estimated by the atomic absorption spectrophotometric method. Results: In all, 44% of the pregnant women had serum levels less than the normal level (1.80 mg/dl). There was a significant decrease (P=0.01) in serum magnesium levels with the increase in parity. Conclusion: A high prevalence of magnesium deficiency was found among the pregnant women. Sponsorship: Indian Council of Medical Research, New Delhi.

Subdistrict hospitals form the first referral level facilities for essential newborn care services. However, there is a paucity of information on the pattern of neonatal admission and outcomes at this level. The objective of this study was to describe the spectrum of neonatal mortality at a subdistrict hospital. The study was conducted at a 50-bed hospital at Ballabgarh in northern India. The data of the neonates born in this hospital (inborns) and those admitted with sickness after being delivered at home (outborns) were separately analysed for the period 1994-1999. The main outcomes of interests were incidence, distribution, and primary causes of neonatal mortality. Of 6746 inborns and 385 outborns admitted (total 7,137) there were 56 deaths (0.8 per cent) and 38 (0.6 per cent) referrals among inborn and 70 deaths (18.2 per cent) and 37 (9.6 per cent) referrals among outborns. The deaths or referral rates among inborn for different weight groups were 27.7 per cent for1,500 g, 7.2 per cent for 1500-1999 g, 1.2 per cent for 2,000-2,499 g, and 0.6 per cent for weightor = 2,500 g. Most deaths under 7 days of age were related to prematurity [41 per cent (28/69)] and birth asphyxia [38 per cent (26/68)], while those aged between 7 and 27 days were mostly due to sepsis [91 per cent (42/46)]. The results of this study indicate that babies with a birthweight above 1,500 g have a good outcome at this level. Deaths under 7 days of age were mostly due to birth asphyxia and prematurity, while those after 7 days were almost entirely due to sepsis. Referral is an important outcome at this level of service.

Introduction Treatment of drinking water at home is commonly advocated for prevention of diarrhoea by health personnel. The methods of disinfection include chlorination, boiling or use of filters. Among others, the cost of water treatment is a known barrier to its practice. Methods A total of 96 households treating water at home, by boiling (n=15), filtration (n=6) or sodium hypochlorite solution (Safewat® n=75) in urban slums of Haridwar and Dehradun districts of Uttarakhand were studied. Respondents were administered a pre tested semi-structured interview schedule for identification, measurement and valuation of all the resources involved in these three methods. The mean and 95% CIs of cost of treating ten litres of drinking water were estimated. Results The cost of using Safewat, water filter and boiling was estimated to be INR 1.44[1] (1.29–1.50) INR 1.79 (1.31–2.27) INR 5.82 (5.24–6.40) per ten litres of water treated respectively. The cost of boiling was high because of the cost of fuel (69%) despite a subsidy by the government on the gas. The use of filter required an initial capital investment for. purchase of filter (Approximately INR 500). Safewat solution accounted for 13% of the total cost of treatment by chlorination. Conclusion Assuming similar effectiveness rates, Safewat use appears a more affordable alternative, with little initial investment. This makes a case for promotion, by the physicians, of water chlorination in place of the more costly option of boiling, which has been advocated for long.

In order to control the stroke problem, its magnitude should be assessed. India is ranked among the countries where the information on stroke is minimal. We decided to review the information available in order to estimate the mortality and morbidity due to stroke in India. Information was collected through electronic search, hand search and contact with experts. Each article was reviewed for relevance and epidemiological rigor. The demographic data were as derived from published government figures. The prevalence from individual studies was pooled and weighted based on sample size. Analysis was done separately for males and females at 10-year intervals (20 years onwards). A total of 7 studies was located, but 2 were discarded. All were done in rural areas except 2 which also included urban areas. The prevalence was estimated as 203 per 100,000 population above 20 years amounting to a total of about 1 million cases. The male to female ratio was 1.7. Around 12% of all strokes occurred in population below 40 years. The estimation of stroke mortality was seriously limited by the method of classification of cause of death in the country. The best estimate derived was 102,000 deaths; which represented 1.2% of total deaths in the country. There is need to initiate steps to collect data on morbidity and mortality due to stroke in the country as a first step towards control measures.

India currently has an infant mortality rate (IMR) of 73 and aims to reach 60 per 1000 live births by 2000 A.D. The “at risk” approach which has been traditionally used for Maternal and Child Health services could help to reduce costs. The main objective of the study was to identity socio-demographic “risk factors” at family level for underfive deaths and assess the validity and efficiency of a risk index scale for this purpose. A computerised database on about 71,000 individuals in 28 villages in Ballabgarh Block exists since 1987. All the underfive deaths in the study area during the period 1991–95 were compared with age and sex matched controls on socio-demographic variables. All variables which were found significant at 10% level were taken in for logistic regression. The variables found significant were used to construct a ten point scale. This scaling system was applied to all the families with an underfive child during the two year period 1996–97. Validity and efficiency of this approach was calculated. A total of 849 cases and their age and sex matched controls were studied. The variables which were significantly associated with risk of underfive deaths were: not received measles vaccine (2.19; 1.58–3.04), history of sibling death (2.03; 1.19–3.45), maternal illiteracy (1.86; 1.23–2.81), never used a contraceptive (1.59; 1.17–2.14), having more than 4 children (1.46; 1.04–2.05). About 40% of houses were labelled as high risk. The sensitivity and specificity were around 60%. The improvement in efficiency by the risk approach was 33%. Risk approach is helpful in identifying families who are at greater risk of having underfive deaths. It results in a modest increase in the efficiency of services.

All the children between 1-4 year old were followed from January 1985 to December 1987 and all eligible children 9-24 months were given measles vaccine using annual pulse method in November-December 1985 and 86 in the study area. The children in C.R.H.S. Project area were used as controls for comparison. At the end of 2 years and 2 rounds of immunization with measles, significant reductions were observed in 1-4 year old mortality due to diarrhea and malnutrition in the study area in contrast to control area. Using epidemiological data and method of pulse immunization with measles vaccine can bring considerable benefit to this age group.

One hundred and six mothers in a rural area were interviewed to determine as to how they recognise pneumonia in children, what therapies they practice with mild acute respiratory illnesses and pneumonias and the feeding practices they adopt. Most mothers recognised pneumonia by noticing fast respiratory rate and difficulty in breathing. More severe cases were recognised by these signs among a higher percentage of mothers. As regards management of mild ARI episodes, more than half the mothers preferred not to give any treatment or use only home remedies. In pneumonias, a majority of them preferred to consult a qualified doctor. Nearly a third of them were of the opinion that they would take the child to hospital if the disease was severe. Regarding feeding practices, most of them stated that they would continue feeding, fluids and breast feeds. Only 10% desired to stop and another 15% would decrease the amounts.106 mothers in a rural area were interviewed to determine how they would recognize pneumonia in children, what therapies they would practice with mild acute respiratory illnesses (ARI) and pneumonia, and the feeding practices they have adopted. Most mothers recognized pneumonia by observing the quick respiratory rate and difficulty in breathing. More severe cases were recognized by these among a higher % of mothers. With regard to management of mild ARI episodes, more that 1/2 of the mothers preferred not to give any treatment or to use only home remedies. In pneumonias, a majority preferred to consult a qualified doctor. Nearly 1/3 of them were of the opinion that they would take the child to a hospital if the disease was severe. Insofar as feeding is concerned, most of them stated that they would continue feeding, fluids, and breastfeeds. Only 10% said they would stop and 15% said they would decrease the amounts.

India has adopted the World Health Organisation’s recommended strategy of National Immunization Days (that is, Pulse Polio Immunization) from the year 1995. Oral polio vaccine (OPV) was introduced at national level in 1985. 1 However, no community based surveillance has been instituted. The data from the sentinel centres based in cities suggest a decline in the incidence of poliomyelitis. 34 As the surveillance is passive and the extent of under reporting is not known, sentinel surveillance may not reflect the true situation in the community. We report our experience with oral polio immunisation and its impact on prevalence of poliomyelitis in Ballabgarh Block of Haryana state in Northern India. The information on poliomyelitis occurrence in this community is available for past 30 years.

BACKGROUND The routine use of verbal autopsy in health-care delivery settings has been limited. Hence, the performance of neonatal and postneonatal verbal autopsy (VA) tools developed at the Comprehensive Rural Health Services Project (CRHSP), Ballabgarh (India), were assessed. METHODS Short VA tools developed by CRHSP were filled by health workers during their routine house visits while standard VA tools of the International Network of Field Sites with continuous Demographic Evaluation (INDEPTH) were filled by trained research workers for all 143 under-five-children deaths that occurred in 2008. The level of agreement in the cause of death assigned by the two VA tools was assessed by kappa and by comparison of the cause-specific mortality fractions. RESULTS Among 65 neonatal deaths, the cause specific mortality fraction (CSMF) was 43.1% and 40% for low birthweight, 15.4% and 26.2% for birth asphyxia, and 7.7% and 10.8% for pneumonia by INDEPTH and CRHSP VA tools respectively. In 78 deaths among 29-days to