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INVITED COLUMN ON TOPICS OF PUBLIC HEALTH IMPORTANCE

A decade of field epidemiology training in India

Manoj Murhekar and FETP-India Team

Edutweets

COLUMN ON TOPICS OF ACADEMIC INTEREST

BASICS OF SPATIAL STATISTICS - Dr. Vasna Joshua, NIE

Technofile

APPLICATIONS OF TECHNOLOGY IN PUBLIC HEALTH

Nanoparticle based drug delivery system for tuberculosis chemotherapy
- Dr. Sriram Selvaraju, MBBS,MPH

Healthlines

HEALTH NEWS ITEMS FROM LEADING NEWSPAPERS
- Dr. Chitra Grace

Scholastic

SCIENTIFIC REPORTS & CAREER EXPERIENCES BY SCHOLARS

My first national public health conference
- Dr.Latika Nath, MPH Scholar cohort-4

Shastrarth

HEALTH MESSAGES FROM THE SCRIPTURES

Food and health – wisdom from Thirukkural

BrowNIE

ASSORTED ARTICLES BY NIE STAFF/SCHOLARS

SANITATION WITH A CIVIC SENSE -- Dr.M.Karthikeyan, MPH Scholar, 4th Cohort, NIE
SWAMI VIVEKANANDA -- A. Murugarasan, PS to Director, NIE

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Sciport

Impact of behaviour change communication targeting the bridging population of clients of female sex workers in India
--- Dipak Suryawanshi (TISS, Mumbai), Pushpanjali Swain (NIHFW, Delhi), Reena Kumari (NIMS (ICMR), Delhi), Tarun Bhatnagar (NIE (ICMR), Chennai), Weiwei Zhou (LSHTM, London), Shalini Bharat (TISS, Mumbai), M Bhattacharya (NIHFW, Delhi), Arvind Pandey (NIMS (ICMR), Delhi), Martine Collumbien(LSHTM, London)
 
Sexual behaviours and HIV-related issues among truck drivers and their wives: Implications for HIV prevention in South India
--- Tarun Bhatnagar (NIE(ICMR), Chennai), PS Saravanamurthy (VHS-CHARTERED, Chennai), Roger Detels (UCLA, USA)
 
MAE/MPH SCHOLARS OF ICMR SCHOOL OF PUBLIC HEALTH, NIE AT TEPHINET SEVENTH GLOBAL SCIENTIFIC CONFERENCE, AMMAN, JORDAN, NOVEMBER 2012
 
Outbreak of Kyasanur Forest Disease (KFD) in Shimoga district, Karnataka, India 2011-12
--- Gudadappa S. Kasabi (NIE-Chennai, DHFW-Shimoga), MV Murhekar (NIE-Chennai), PD Yadav (NIV-Pune), Raghunandan (DHFW-Shimoga), SK Kiran (DHFW-Shimoga), VK Sandhya (VDL-Shimoga), GH Channabasappa (DHFW-Shimoga), AC Mishra (NIV-Pune), DT Mourya (NIV-Pune), Sanjay M Mehendale (NIE-Chennai)
 
Neonatal care practices among mothers of Nadia district, West Bengal, India, 2011
--- Bibhash Roy (MAE, 2010-NIE), Prabhdeep Kaur (NIE-Chennai)
 
Lack of safe water supply following a tropical cyclonic storm led to cholera outbreaks in an urban locality, Pondicherry, India, 2012
--- Tony Fredrick (MPH 2011, NIE), Manickam P (NIE-Chennai), Murhekar M (NIE-Chennai), Yuvaraj J (NIE-Chennai)
 
Predictors of Lost to follow-up among patients enrolled in India’s National first-line antiretroviral therapy programme, Andhra Pradesh, 2008-2011
--- Ramesh R Allam (MAE 2010, NIE), M. Murhekar (NIE-Chennai), C.Nalini, K. Chengappa
 
Outbreak of Cutaneous Anthrax — Andhra Pradesh, India, June-August 2011
--- Ramesh R Allam (MAE 2010, NIE-Chennai), MV Murhekar (NIE-Chennai), U Prasada Rao, P. Geetha, K. Chengappa (SHARE-India, Hyderabad)
 
 

ORAL PRESENTATION AT 19TH INTERNATIONAL AIDS CONFERENCE, WASHINGTON DC, USA, JULY 2012

Impact of behaviour change communication targeting the bridging population of clients of female sex workers in India

---- Dipak Suryawanshi (TISS, Mumbai), Pushpanjali Swain (NIHFW, Delhi), Reena Kumari (NIMS (ICMR), Delhi), Tarun Bhatnagar (NIE (ICMR), Chennai), Weiwei Zhou (LSHTM, London), Shalini Bharat (TISS, Mumbai), M Bhattacharya (NIHFW, Delhi), Arvind Pandey (NIMS (ICMR), Delhi), Martine Collumbien(LSHTM, London)

BACKGROUND: Clients of female sex workers (FSW) are a key group in India’s HIV prevention programme due to their bridging role in HIV transmission to women in the general population. Our objective was to determine the impact of condom promotion and STI messages on consistent condom use with sex workers and other partners among clients of FSWs.

METHODS: We analyzed data from 2009 Integrated Biological and Behavioral Assessment IBBA

survey among clients of FSWs sampled at hotspots using time-location-cluster-sampling in Andhra Pradesh, Maharashtra and Tamil Nadu (n=5045). We used propensity score matching to estimate the impact of ‘media messages’ on clients’ consistent condom use with all partners (except their spouse); having heard/seen messages on condoms and on STIs were considered as the exposures. We stratified the analyses by place of solicitation of FSWs. Consistent condom use with all FSWs was an aggregate measure combining answers to ten different questions on condom use with regular and occasional FSWs. Consistent condom use with all partners, except main partner was an aggregate measure adding another 5 questions on condoms used with casual female, male and hijra partners. We used STATA 11.2 for the analysis.

RESULTS: Clients of street- based FSWs were older (31 vs 29.5 yrs, p < 0.05) and better educated (77% vs 61% secondary and above, p < 0.001) than clients at brothels. Exposure to messages on condoms (95%) was too high to detect an association with condom use. Exposure to STI messages was 77% among street-soliciting clients compared to 51% among those frequenting brothels. Only among the brothel-soliciting clients could we demonstrate an effect: 44% of exposed clients used condoms consistently vs 30% among the matched controls [p < 0.001]. The observed differential is most likely due to the local environment: more intense and varied exposure to safer sex messages at brothels including stronger interpersonal communication with FSWs more effectively negotiating condom use.

CONCLUSIONS: : Like sex workers the population of clients is quite heterogenous. Consistent condom use is lowest among clients soliciting brothel-based FSWs but STI messages have impact. Consistent condom use is higher among clients soliciting FSWs from public places but we did not find any effect of exposure to STI messages. Among clients soliciting home-based FSWs consistent condom use was highest but with no effect of STI messages when considering all partner groups. Characteristics of clients soliciting different types of FSWs may influence their risk perception and thus condom use. FSWs’ negotiating power for condom use also differs by typology. Our data suggests that STI messages may get reinforced at brothels. Media messages are important but not sufficient to increase condom use with FSWs. Clients have a lot of other partners and messages should more explicitly address condom use with all partners.

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POSTER PRESENTATION AT 19TH INTERNATIONAL AIDS CONFERENCE, WASHINGTON DC, USA, JULY 2012

Sexual behaviours and HIV-related issues among truck drivers and their wives: Implications for HIV prevention in South India

---- Tarun Bhatnagar (NIE(ICMR), Chennai), PS Saravanamurthy (VHS-CHARTERED, Chennai), Roger Detels (UCLA, USA)

BACKGROUND: Women constituted 39% of the 2.4 million people living with HIV/AIDS in India in 2009. Marriage makes Indian women more vulnerable to HIV infection, more so those married to men from bridge population such as truck drivers. We explored the sexual behaviors, knowledge, and risk perception related to HIV/AIDS among the truck drivers and their wives.

METHODS: We conducted semi-structured open-ended interviews with 15 couples in a district of Tamil Nadu in south India in 2010. Interviewers of same gender digitally recorded the interviews. We did a content analysis of the interview transcripts and organized the statements into major themes to describe the pattern of responses.

RESULTS: The wives of truck drivers expressed gratifying sexual relationship with their husbands. However, they reported that “wives of other men” were involved in extra-marital relationships and paid sex. There was perceived ability by the wives to communicate with their husbands about their own sexual desires (or lack thereof), and husband’s risk of HIV infection from indiscriminate heterosexual relationships. Condom use with spouse was infrequent, and identified with contraception and mutual trust by both the truck drivers and their wives. The wives expressed concern for their husbands acquiring HIV infection but had low self risk perception. Concern translated into faith or warnings for the husbands to not indulge in illicit sexual relationships. Although truck drivers were highly aware of the risk for HIV infection for themselves and their families, indulgence in commercial sex was commonly reported by them.

CONCLUSIONS: The study underscores the need to inform wives of the risk of HIV infection from their husband and to develop culturally acceptable strategies which wives can implement themselves.

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MAE/MPH SCHOLARS OF ICMR SCHOOL OF PUBLIC HEALTH, NIE AT TEPHINET SEVENTH GLOBAL SCIENTIFIC CONFERENCE, AMMAN, JORDAN, NOVEMBER 2012

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ORAL PRESENTATION AT TEPHINET SEVENTH GLOBAL SCIENTIFIC CONFERENCE, AMMAN, JORDAN, NOVEMBER 2012
Outbreak of Kyasanur Forest Disease (KFD) in Shimoga district, Karnataka, India 2011-12
--- Gudadappa S. Kasabi (NIE-Chennai, DHFW-Shimoga), MV Murhekar (NIE-Chennai), PD Yadav (NIV-Pune), Raghunandan (DHFW-Shimoga), SK Kiran (DHFW-Shimoga), VK Sandhya (VDL-Shimoga), GH Channabasappa (DHFW-Shimoga), AC Mishra (NIV-Pune), DT Mourya (NIV-Pune), Sanjay M Mehendale (NIE-Chennai)

BACKGROUND: KFD, a tick-borne viral haemorrhagic disease, has unique existence in Karnataka state of India and occurs as seasonal outbreaks. As a part of mass vaccination campaigns, two doses of the vaccine an interval of one month are administered. The booster doses are recommended at an interval of 6-9 months. Suspected KFD cases were reported from Thirthahalli Taluka of Shimoga district since December 2011. We investigated the outbreak to confirm the aetiology, identify risk factors and propose recommendations for control.

METHODS: We established a stimulated passive surveillance in health facilities of Thirthahalli to identify suspected

case-patients defined as sudden onset of fever, headache and myalgia since December 2011. Blood specimens from the suspected case-patients were tested for the presence of virus using RT-PCR. We collected and analysed the data to describe the disease by time, place and person. We conducted a matched case-control study to identify the risk factors of the illness, by including 51 lab-confirmed case-patients and 102 age, gender and locality matched controls.

RESULTS: During Dec’2011 and Mar’2012, 215 suspected case-patients were identified (attack rate: 9.7/1000), 61 of which were laboratory confirmed. Of the 61 case-patients, 20 had received two doses while 2 received one dose of KFD vaccine during April-May 2011 and none received the booster before November 2011. Handling cattle (adjusted OR: 5.1, 95% CI=1.3-20.5), frequent visits to forest for livelihood (aOR: 4.8, 95% CI=1.2-21) and presence of pile of dry leaves within the compounds of the house (aOR: 4.1, 95% CI=1.3-12.9) were independently associated with the illness.

CONCLUSION: During 2011, booster vaccination campaign was not conducted in the district because of its non-availability and this could be a possible reason for upsurge of KFD cases. Health authorities must ensure that vaccination campaigns are initiated on time and completed before November every year. Use of tick repellent should be encouraged.

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ORAL PRESENTATION AT TEPHINET SEVENTH GLOBAL SCIENTIFIC CONFERENCE, AMMAN, JORDAN, NOVEMBER 2012
Neonatal care practices among mothers of Nadia district, West Bengal, India, 2011
---- Bibhash Roy (MAE, 2010-NIE), Prabhdeep Kaur (NIE-Chennai)

Introduction: Neonatal mortality is key challenge in reducing infant mortality in West Bengal. Home based newborn care by mothers to neonates can reduce neonatal mortality. We conducted a survey among mothers of Nadia district to describe their neonatal care practices, determine its associated factors and assess their response to neonatal sickness.

Methods: We conducted cross-sectional survey in Nadia among mothers having live birth between June and December 2011. We needed 575 mothers in 23 clusters assuming 52% prevalence at 5% precision, 95% Confidence interval and design effect 1.48.Structured

questionnaire was used for data collection on selected indicators. Data was analysed using Epi info 3.5 software.

Results: Among 575 mothers, 518 (90.1%) kept the neonate’s cord stump clean and 51% delayed first neonatal bath. Thirty-nine (6.8%) mothers adopted six key safe practices. Poverty (AOR 5.2, C.I. 3.4-7.8), not registering pregnancy early (AOR 2.6, C.I 1.6-4.2), low maternal education (AOR 2.3, C.I. 1.3-3.9) and home delivery(AOR 3.2, C.I. 1.5-6.8) were significantly associated with not adopting at least five safe practices. The overall neonatal morbidity (33/575) and mortality rates (6/575) per thousand live births were 57 and 10 respectively. Median contacts with health system among mothers having unsafe practices was 6(range 0-11) compared to 10(range 1-11) among the rest. Overall neonatal sickness (26/33; 78.8%) was high in mothers with unsafe neonatal practices.

Conclusion: Mothers unaware of safe neonatal practice especially those preventing hypothermia. Poor and uneducated had higher risk leading to sick neonates and deaths. Low contact with health system posed further challenge to save such neonates. Training of health workers in home based newborn care and educating mothers in safe neonatal care can be low cost feasible intervention.

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ORAL PRESENTATION AT TEPHINET SEVENTH GLOBAL SCIENTIFIC CONFERENCE, AMMAN, JORDAN, NOVEMBER 2012
Lack of safe water supply following a tropical cyclonic storm led to cholera outbreaks in an urban locality, Pondicherry, India, 2012
--- Tony Fredrick (MPH 2011, NIE), Manickam P (NIE-Chennai), Murhekar M (NIE-Chennai), Yuvaraj J (NIE-Chennai)

BACKGROUND: In the aftermath of a severe cyclonic storm on 7 January 2012, a cluster of acute diarrhea cases were reported from two localities in central Pondicherry. We investigated the cluster to identify risk factors and recommend control measures.

METHODS: We defined a case as occurrence of diarrhea with or without vomiting in a resident of affected areas during 6-18 January 2012.We used active (door-to-door survey) and stimulated passive surveillance (health-facility based) to identify cases. We described the outbreak by time, place and person. We compared cases with neighborhood controls. We calculated matched odds ratio (MOR), 95% confidence intervals (CI) and population attributable fractions (PAF). We collected rectal swabs for laboratory diagnosis. We collected water specimens for microbiological testing.

RESULTS: DWe identified 921 cases and one death among 8367 residents (Attack rate: 11%, case-fatality: 1%). The attack rate was highest among 50 years and above (14%) and female (12%). The outbreak started on 6 January and peaked on 9th and lasted till 14thJanuary. Attack rate was highest (20%) in two pockets where we detected major leakages in public water supply system. Nine of 16 stool yielded V.cholerae O1 Ogawa. We identified that consumption of water from the public water distribution system (MOR: 37;95% CI: 4.9-285;PAF:97%) and drinking unboiled water (MOR: 35;95% CI: 4.5-269;PAF:97%) were independently associated with cholera.

CONCLUSIONS: Epidemiological evidence suggested that this cholera outbreak was due to ingestion of water contaminated by drainage system following rains during cyclonic storm. We recommended repair of the water supply lines and cleaning-up of the drains and promote hand washing and drinking of boiled water.

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ORAL PRESENTATION AT TEPHINET SEVENTH GLOBAL SCIENTIFIC CONFERENCE, AMMAN, JORDAN, NOVEMBER 2012
Predictors of Lost to follow-up among patients enrolled in India’s National first-line antiretroviral therapy programme, Andhra Pradesh, 2008-2011
--- Ramesh R Allam (MAE 2010, NIE), M. Murhekar (NIE-Chennai), C.Nalini, K. Chengappa

Introduction: National Anti-Retro Viral Therapy (ART) program in India had started on 1 April 2004 where nearly 4.5 lakh were on ART. Non-adherence and Lost to Follow-up (LFU) of ART would result in HIV drug resistance and undermine benefits in morbidity and mortality. We aim to estimate the mean cumulative probability of retention in care and predictors of LFU of patients on ART.

METHODS: : We identified the cohort of PLHIV only aged =15 years, initiated on ART in Andhra Pradesh Chest and general Hospital and Gandhi general Hospitals in Hyderabad between January 1 2008 and December 31 2008 and were followed up to Dec 31 2011. Patients transferred out to other centres during the study period were excluded. Kaplan-Meier estimation method and Cox regression model were used to estimate mean cumulative probability of retention in care, Hazard Ratio (HR) and Adjusted Hazard ratios (AHR) of LFU respectively. Patients missing follow-up visits for >3 consecutive months were considered as LFU.

RESULTS: Of the 1690 patients initiated on ART, 14.5% (245) were transferred out. At the end of 48 months, 18.4% (263) were LFU. Mean time of retention in care was 41.7 months (CI-40.3-42.0). Cumulative probability of retention in care at 12, 24, 36 and 48 months were 86%, 82%, 79% and 76% respectively. Total follow up period was 3609.4 person years, where LFU was 7.2 per 100 person years. During first six months of therapy 66.9% (176 of 263) patients were LFU. Mean time of retention was higher in patients with base line CD4 count greater than 200 cells (p < 000) and men (P < 0.001). Males (HR-1.49, CI-1.152-1.93), Illiterates (AHR-2.47, CI-1.4-4.3), patients on Efavarenz containing Stavudine based regimen (AHR-3.82, CI-1.09-13.27), baseline CD4 count < 100 cells (AHR-1.52, CI-1.12-2.09) and weight < 48 kgs (AHR-1.52, CI-1.10-2.09) are more likely to LFU.

CONCLUSIONS: Targeted counseling during the preparation phase and intensifying after three years of therapy along with addressing sociocultural, financial, systemic and operational constraints, besides provision of free ART are to be prioritised to increase the rates of retention.

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POSTER PRESENTATION AT TEPHINET SEVENTH GLOBAL SCIENTIFIC CONFERENCE, AMMAN, JORDAN, NOVEMBER 2012
Outbreak of Cutaneous Anthrax — Andhra Pradesh, India, June-August 2011
--- Ramesh R Allam (MAE 2010, NIE-Chennai), MV Murhekar (NIE-Chennai), U Prasada Rao, P. Geetha, K. Chengappa (SHARE-India, Hyderabad)

BACKGROUND: In August 2011, Chittoor district authorities reported a cluster of suspected human anthrax cases, to Andhra Pradesh state surveillance unit. We investigated this cluster to confirm its etiology, describe its magnitude, identify potential risk factors, and make recommendations for preventing similar outbreaks in future.

METHODS: A suspected case of cutaneous anthrax was defined as a painless skin lesion (papule, vesicle, or eschar) that appeared between July-August 2011 in resident of Musalimadugu. We undertook active house-to-house search for cases and collected clinical details and, smears from skin lesions of suspected cases and describe the outbreak by time, place and person. A retrospective cohort study was conducted only among villagers aged > 15 years (Population =377) to identify risk factors.

RESULTS: During 24 June-7August 2011, 16 livestock in the village died. Blood smears collected from 5 of 16 dead livestock showed gram positive, spore bearing, bacillus characteristic of Bacillus anthracis. Villagers butchered and skinned the dead animals, and consumed the meat after boiling it for 2 hours. The outbreak in humans started on 30 July, and 9 suspected cases of cutaneous anthrax (attack rate: 2%, no deaths) occurred till 7 August. Nine skin-smears from suspected cases were negative on gram staining due to delay in skin-smear collection and antibiotic therapy. Persons who had handled [Relative risk (RR): 56, 95% confidence interval (CI): 8.4 –571.8, population attributable fraction (PAF): 87%)], skinned (RR: 28, 95% CI: 8.4-93, PAF=54%) and slaughtered (RR: 21, 95% CI: 6.5-68.4, PAF: 42%) dead livestock were at higher risk. Vaccination of animals was not practised.

CONCLUSION: We recommended ciprofloxacin prophylaxis to all contacts; vaccination of livestock and; community education against slaughtering and consumption of dead or ill livestock.

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