Assessment of functioning of public health facilities in a North Indian state

Background: This study was conducted to assess the current status of functioning of health facilities in Punjab.Methods: A checklist based on six building blocks of health system proposed by WHO and the IPHS was developed, validated and pretested. District hospital (DH), one sub district hospital (SDH) and two Community Health Centres or Block Primary Health Centres (CHCs/BPHCs) were randomly selected from each of 22 districts of Punjab and evaluated against checklist. Total score was thus assigned to each facility. Additionally, workload of healthcare workforce, presence of health functionaries as against total posted strength and feedback from administrators of these facilities were also recorded.Results: Health services are concentrated at the DH and SDH. Functional equipment like ECG, oxygen, mask, ambubag etc. are deficient at all levels of health facilities. Nearly 50% of expected medicines were in stock at the DH and SDH and 66% at CHC/BPHC level. Patient to doctor ratio is highest at SDH in outpatient department and CHC/BPHC in emergency section. Number of lab tests per lab technician are highest at CHC/BPHC level. Administrators express the need for reducing staff shortage, more intensive training in the financial and administrative processes and simplification of procedures for management of equipment.Conclusions: Strengthening CHC/BPHC level institutions may improve utilization of public health system and reduce referrals. Lifesaving drugs and equipment need to be available and operational at all levels of facilities. Content of training to administrators needs to be tailored to the felt needs.

Retaining health workforce in rural and underserved areas of India: What works and what doesn't? A critical interpretative synthesis.

Background. Human resource for health is critical in quality healthcare delivery. India, with a large rural population (68.8%), needs to urgently bridge the gaps in health workforce deployment between urban and rural areas. Methods. We did a critical interpretative synthesis of the existing literature by using a predefined selection criteria to assess relevant manuscripts to identify the reasons for retaining the health workforce in rural and underserved areas. We discuss different strategies for retention of health workforce in rural areas on the basis of four major retention interventions, viz. education, regulation, financial incentives, and personal and professional support recommended by WHO in 2010. This review focuses on the English-language material published during 2005–14 on human resources in health across lowand middle-income countries. Results. Healthcare in India is delivered through a diverse set of providers. Inequity exists in health manpower distribution across states, area (urban–rural), gender and category of health personnel. India is deficient in health system development and financing where health workforce education and training occupy a low priority. Poor governance, insufficient salary and allowances, along with inability of employers to provide safe, satisfying and rewarding work conditions—are causing health worker attrition in rural India. The review suggests that the retention of health workers in rural areas can be ensured by multiplicity of interventions such as medical schools in rural

Frequency Of Alloantibody In Multiple-Transfused Thalassemia Major Patients And Factors Influencing On Alloimmunization.

Background & Objective: The recommended treatment for beta thalassemia major involves regular blood transfusions, whichstimulate the patient’s immune system and results in the formation of antierytrocyte antibodies usually IgG class. They can result in clinical hemolysis and complication of blood cross matching. The purpose of this study was to determine the frequency of RBC alloantibodies, the type of these antibodies, factors influencing on alloimmunization among multiple- transfused thalassemia major patients. Methodology: ABO blood grouping,Rh (D) typesand Phenotyping done by the electromagnetic technology using Qwalys 3 Diagast. Antibody screening was done by using 3-cell panel followed by11- cell panel of Biorad Corporation. Results: 10 patients developed alloantibodies against RBC Antigen. Among total alloimmunizedpatients, 7.35%were female and 4.27% were male. Majority of alloantibodies were directed against antigen in the Rh and Kell system. i. e. Anti c, Anti E and Anti K. Frequency of Alloantibody positivism is maximum in AB positive patients. From extended Antigen typing of voluntary donors, we can see the frequency of D, C and e Antigens are more than frequency of c, E and K Antigens. Conclusion: Frequency of red cell alloimmunizationwas 5.40% in this study. Alloantibodies found were mainly against Rh blood group systemand Kell system. Red cell alloantibody formation was not influenced by age at first transfusion, number of blood transfusion, splenectomy and leuckodepleted blood transfusion. In our study alloimmunized patients did not revealed any evidence of haemolytic transfusion reaction. The frequency of Antibody positivity depends on immunogenicity of Antigen. Females and group AB patients are showing more frequency of alloimmunization. Routine pretransfusion matching of blood, other than ABO and RhD antigen is not recommended because of low rate of red cell alloimmunization and high cost associated with such testing.

Prevalence of HIV-I/II, HCV, HBsAg& Syphilis in Blood Donors Of Western Region In India.

Background & Objective: The high prevalence of HIV, HBV, HCV and syphilis has heightened the problems of blood safety in India. TTIs cause fatal, chronic and life-threatening disorders because of their prolonged viraemia and carrier or latent state. Serologic tests utilized routinely in the screening of blood donors, totally not guarantee the absence of these infections among blood donors. Methodology: Samples of HIV, HBsAg, HCV were tested by ELISA and samples of syphilis were tested by RPR method following manufacturer’s instructions. Results: Prevalence of HBV was highest within at the age groups 26-35 years, HCV within the age group between 36-45years, syphilis within the age group between 46-55 years and HIV between 26-35 years. The prevalence of hepatitis B and syphilis was higher among males as compared to females, while for hepatitis C and HIV, it was higher among females as compared to males. Conclusion: Availability of safe blood for transfusion can be achieved by vigorous screening of donors and donated blood. Screening of blood is now mandatory for many diseases and is undertaken routinely in blood banks. The prevalence of TTIs among the Indian blood donors is reported to be ranging as follows; HBV – 0.66% to 12%, HCV – 0.5% to 1.5%, HIV– 0.084% to 3.87%, and syphilis – 0.85% to 3% respectively. Hence strict selection of blood donors with stringent screening and safe methods of detection can minimise risk if TTI.

Widespread inequalities in smoking & smokeless tobacco consumption across wealth quintiles in States of India: Need for targeted interventions.

Background & objectives: India is a large country with each state having distinct social, cultural and economic characteristics. Tobacco epidemic is not uniform across the country. There are wide variations in tobacco consumption across age, sex, regions and socio-economic classes. This study was conducted to understand the wide inequalities in patterns of smoking and smokeless tobacco consumption across various states of India. Methods: Analysis was conducted on Global Adult Tobacco Survey, India (2009-2010) data. Prevalence of both forms of tobacco use and its association with socio-economic determinants was assessed across states and Union Territories of India. Wealth indices were calculated using socio-economic data of the survey. Concentration index of inequality and one way ANOVA assessed economic inequality in tobacco consumption and variation of tobacco consumption across quintiles. Multiple logistic regression was done for tobacco consumption and wealth index adjusting for age, sex, area, education and occupation. Results: Overall prevalence of smoking and smokeless tobacco consumption was 13.9 per cent (14.6, 13.3) and 25.8 per cent (26.6, 25.0), respectively. Prevalence of current smoking varied from 1.6 per cent (richest quintile in Odisha) to 42.2 per cent (poorest quintile in Meghalaya). Prevalence of current smokeless tobacco consumption varied from 1.7 per cent (richest quintile in Jammu and Kashmir) to 59.4 per cent (poorest quintile in Mizoram). Decreasing odds of tobacco consumption with increasing wealth was observed in most of the states. Reverse trend of tobacco consumption was observed in Nagaland. Significant difference in odds of smoking and smokeless tobacco consumption with wealth quintiles was observed. Concentration index of inequality was significant for smoking tobacco -0.7 (-0.62 to-0.78) and not significant for smokeless tobacco consumption -0.15 (0.01to-0.33) Interpretation & conclusions: The findings of our analysis indicate that tobacco control policy and public health interventions need to consider widespread socio-economic inequities in tobacco consumption across the states in India.

India’s Last Battle in the War Against Polio.

Type 2 vaccine virus is the predominant cause of Vaccine-derived poliovirus and Vaccine-associated paralytic poliomyelitis. Therefore, World Health Organization recommends global synchronized switching from trivalent to bivalent Oral polio vaccine. To prevent the risk of type 2 poliovirus re-emergence, atleast one dose of Inactivated polio vaccine is recommended at 14 weeks of age in routine immunization, before the switch. To protect immunocompromised children and those under 14 weeks of age, an additional dose must be given at 6 weeks of age. Mass campaigns of Injectable polio vaccine in states with poor Routine immunization coverage, before the trivalent to bivalent Oral polio vaccine switch, will reduce risk of Vaccine-derived poliovirus by covering all under-immunized pockets. The additional costs are justified as it is our ethical obligation to eliminate any iatrogenic risk.

Inequity in Awareness and Utilization of Adolescent Reproductive and Sexual Health Services in Union Territory, Chandigarh, North India.

Background: Adolescents are a heterogeneous, vulnerable, and sexually active group. Geographical and educational health disparities exist among urban, rural, and slum adolescents and among out-of-school and school-going adolescents, respectively. Adolescent reproductive and sexual health (ARSH) services should be implemented in a manner to minimize health inequities among them. Objectives: To ascertain the extent of awareness and utilization of ARSH services provided under reproductive and child health(RCH) program among adolescents in Chandigarh. Materials and Methods: A crosssectional study was conducted among 854 adolescents (402 household, 200 out-of-school, and 252 school-going adolescents) in Chandigarh using pretested validated interview schedule on awareness and utilization of adolescent reproductive and sexual health services from February to April 2011 in North Indian Union Territory of Chandigarh. Ordinal regression analysis was done to study the association of socio-demographic variables with awareness and utilization of ARSH. Results: Awareness about contraception and health services was significantly less among rural (12.7% and 1.1%, respectively) adolescents as compared to slum (17.9% and 4.6%, respectively) and urban adolescents (33.5% and 7.8%, respectively) (P < 0.05). Out-ofschool adolescents were utilizing the preventive [odds ratio (OR) 0.39, P < 0.001] and curative services significantly lesser (OR = 0.54, P < 0.001) and had higher substance abuse (OR = 4.26, P= 0.006). Awareness was significantly associated with older age of adolescents (OR = 4.4,P < 0.001), poor education of father (OR = 0.5, P = 0.002), rural area (OR = 0.56, P = 0.001), and out-of-school status (OR = 0.35, P < 0.001). Conclusion: Awareness and utilization of ARSH services was inequitable and was more among urban and school-going adolescents. Educational status was the most important factor affecting it.

Inequity in dental care utilisation: what gets delivered gets known - evidence from Chandigarh and Haryana.

Background: Studies till date have focussed on the prevalence of dental disorders and the related health seeking behaviour. Inequity in seeking dental health care is debated based on age, wealth and education. This study focussed on geographical inequity in awareness and treatment seeking for dental health care. Methods: Paper compares awareness for dental problems and related treatment practices of rural population of a district in Haryana with rural area of adjoining union territory Chandigarh. Results: In rural Chandigarh, more than 90% knew about dental caries and dentures, whereas, in rural Haryana only 50% knew about dental caries and 70% about dentures. Knowledge about gum problems, mal-alignment, and growth of plaque was low. Knowledge about scaling, and root canal treatment was low in both rural areas. Majority of subjects (66.7%) attending health camp in rural Haryana never underwent a dental check-up, compared to 41% in rural Chandigarh. In rural Haryana, commonly available dental services are extractions and filling, whereas, Chandigarh has wider spectrum of services available. Conclusions: Poor awareness of dental morbidity, treatment practices and treatment seeking is possibly linked to the availability of the services. Overall, penetration of newer treatments for dental health care in the community has been slower and more so in the rural areas.

Introducing Combined Measles, Mumps and Rubella Vaccine in Chandigarh, India: Issues and Concerns.

Cyclical outbreaks of mumps have been noticed across Chandigarh city during winter months. Chandigarh does not provide measles, mumps and rubella (MMR) vaccination in the State immunization schedule. Epidemiological shift in age at diagnosis of mumps was noticed with higher incidence in older children and adults. Increased occurrence of complications can be predicted with this age shift. Silent burden of rubella with serious outcomes in newborns further strengthen the case for MMR vaccine inclusion in routine immunization program of Chandigarh.

Frequency of ABO and Rh blood groups in blood donors: a study from a Tertiary Care Teaching Hospital in India.

Background & Objectives: Out of total 328 antigens recognized by the International Society of Blood Transfusion (ISBT), ABO and RhD antigens are the most important from the transfusion medicine perspective. The present study was conducted with larger sample size than prior studies to determine frequencies of ABO and Rh alleles and obtain distribution of ABO and RhD blood group pattern among blood donors. Methods: A retrospective study was conducted in the Department of IHBT, Civil Hospital, Ahmedabad from October 2007 to September 2012. ABO grouping and RhD typing was done using conventional tube technique on a total of 109771 donors. Commercial anti-sera and in-house prepared cells were used for cell and serum grouping respectively in those tests. Departmental Standard Operating Procedures (SOPs) were followed for each aspect of testing. Observed ABO and RhD antigen frequencies were noted. Bernstein and Hardy-Weinberg equations were applied to determine the allele frequencies of ABO and RhD respectively. Results: Blood group B has the highest prevalence (35.81%) in the population under study followed by O (32.74%), A (22.68%) and AB (8.77%). Female donors comprised only 1.75% of the sample size. Rh D positivity was noted in 94.48% donors. Conclusion: Results obtained were quite similar to prior studies from Ahmedabad with smaller sample size. Remarkable differences were noted as compared with western population. The data generated in the present study combined with several other studies of different geographical region of India has significant implications in inventory management of blood transfusion services.

Feasibility of blood bank data management system (Bdms) in record keeping and prevention of near miss events: an experience at Tertiary Care Center.

Introduction and Aim-Objective: Regulatory authority and voluntary accreditation organization require particular records and documents to be maintained for the operation of the blood bank. It can be accomplished using blood bank data management (BDMS) software in a less labor-intensive manner as compared to manual methods provided that the technical staff is properly trained. Many of the near miss events could be prevented with the use of blood bank software ensuring better patient safety. Hemovigilance scheme though not yet well established in our country which requires robust data management and compilation can be easily retrieved from the software. We present below reports on the effectiveness of Blood Bank Data Management System in strengthening of Blood Transfusion Services. The main aim of the study was to compare computer software with traditional hand-written documents for record management and evaluate BDMS in prevention of near-miss events. Materials and Methods: A comparative study between record keeping by conventional registers and Blood bank Data Management System (BDMS) software was done for period of six months from September 2011 to February 2012. Each of the entry was duplicated in both during this study period. Each of the technicians using the software was asked to rate the user friendliness of the system using an objective method of scoring to prevent any bias. The time taken to enter each donor/patient data manually and on software was also compared. Results: All mandatory registers were electronically maintained. The time taken for the each register was significantly less by the software. The inventory of consumables was excellently managed. Also, the equipment records required to be maintained were available at the click of a mouse. 6 out of 15,220 samples were found to contain Wrong Blood In Tube (WBIT) based on traceability system of prior sample received of the same patient which could have been undetected with manual methods and 4 out of these 6 would have resulted in fatal Hemolytic Transfusion Reaction. Apart from this, two-way traceability of blood products was maintained. 30 out of 35 technicians rated the software as “Excellent” with respect to user friendliness. Conclusion: BDMS is a reinforcing tool in the data management and prevention of near miss events leading to improved safety in Blood transfusion Services.

Effect of entertainment on adverse donor reactions during & after blood donation.

Background & objectives: Blood is lifesaving fluid that cannot be created artificially. So, Blood donors are the precious resources. Whole blood donation is generally considered to be a safe procedure but sometimes adverse donor reaction (ADR) may occur. Recognition and evaluation of the so called adverse donor reactions during and after whole blood donation has a great value for improving the supply of the blood donation. The present prospective study was carried out with an aim to estimate the frequency and severity of adverse events occurring in whole blood donors at our Regional Blood Transfusion Centre and to study the effect of entertainment as an anxiolytic on development of ADR. Material and Method:The present prospective study was carried out at the IHBT Department of B.J. Medical College, Civil Hospital Campus, Ahmedabad. The period of the study was 2 years ranging from 1st September, 2009 to 31st October, 2011. A total of 42,684 whole blood donations were accepted during the period either on replacement basis in house in blood bank or on voluntary basis in outdoor blood donation camps. On 22-02-2011 television set with entertaining channels was installed at the donor reception area and phlebotomy room of the blood bank. Result:It was noted that 632 (1.48 %) donors had developed one of ADR. Conclusion: Because of anxiety syndrome, the rate of ADR was very high in first-time donors (3.25 %) as compared to repeat donors. Television set with entertaining channels had anxiolytic effect on the donors and striking decline (0.81 % to 0.45 %) was noted in the adverse reactions in replacement donors at blood bank.

Prevalence of HIV, HBsAg, HCV and Syphilis in Voluntary & Replacement donors at a Tertiary care Blood bank.

Background & Objectives: To study the prevalence of HIV, HBsAg, HCV & syphilis in blood donors. Methods: The seroprevalence of HIV, HBsAg & syphilis among voluntary and replacement donors was analyzed for a period of 16 years (January 1996 to December 2011) and for HCV for a period of 10 years and 7 months (June 2001 to December 2011) at Department of Immunohaematology & Blood Transfusion, Civil Hospital, Ahmedabad. In this period, a total of 2, 81,665 donors were tested, out of which, 2, 00,903 (71.3%)were replacement donors and 80,762 (28.7%)were voluntary donors. HIV, HBsAg & HCV were tested by ELISA method and syphilis by RPR method. Results: Total seropositivity was 1071(0.380%) for HIV, 2900 (1.102%) for HBsAg, 599 (0.306 %) for HCV & 1522(0.540 %) for syphilis. In replacement donors, seropositivity for HIV was 891(0.443%), HBsAg was 2299(1.144%), HCV was 437(0.330%) & syphilis was 1130(0.562%). In voluntary donors, seropositivity for HIV was 180(0.222%), HBsAg was 601(0.744%), HCV was 162(0.257%) & syphilis was 392(0.485%). Conclusion: The present study indicates that higher seroprevalence rates for HIV, HBsAg, HCV & syphilis were observed in replacement donors as compared to voluntary donors.

Evaluation of response to donor notification of reactive transfusion transmitted infections (TTIs) result.

Background:Although blood transfusion is a life saving therapy, it is associated with various ill effects, which can cause increased morbidity and mortality in recipients. Testing of all donated blood for transfusion transmitted infections (TTIs) such as HIV I & II, hepatitis B, hepatitis C and syphilis is one of the strategies recommended by WHO to ensure safe blood. However, if the donor is already having an infection, transmissible by blood, the transfusion will be rather hazardous for the recipient. The national blood policy of India 2002 advocates the disclosure of results of transfusion transmitted infections (TTIs) to blood donors. Aim:To assess the attitude of the transfusion transmitted infections (TTIs) reactive blood donor in response to the post-donation calls from blood bank. Material and methods: A total of 20865 blood donors came to the department of IHBT in period of one year from 1St November 2009 to 31St October 2010.All donated blood was screened against HIV I & II , Hepatitis B, hepatitis C and syphilis and malaria. On screening the units, it was found that 391 donation units (1.874 %) were positive for one of the TTIs, namely HIV I & II, HBsAg, HCV or syphilis. As follow-up, these donors were recalled at blood bank by a phone call. Results: out of 391 reactive donors only 236 responded to call (average response rate was 60.36%). Conclusion: The study suggest that authorities should frame some guidelines and rules that can increase the response rate among reactive donors and make them assessable because it enables their future investigation and treatment and the prevention of diseases transmission to the community.