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ABSTRACT Generally, hypertension control programs are cost-effective, including in low- and middle-income countries, but country governments and civil society are not likely to support hypertension control programs unless value is demonstrated in terms of public health benefits, budget impact, and value-for-investment for the individual country context. The World Health Organization (WHO) and the Pan American Health Organization (PAHO) established a standard, simplified Global HEARTS approach to hypertension control, including preferred antihypertensive medicines and blood pressure measurement devices. The objective of this study is to report on health economic studies of HEARTS hypertension control package cost (especially medication costs), cost-effectiveness, and budget impact and describe mathematical models designed to translate hypertension control program data into the optimal approach to hypertension care service delivery and financing, especially in low- and middle-income countries. Early results suggest that HEARTS hypertension control interventions are either cost-saving or cost-effective, that the HEARTS package is affordable at between US$ 18-44 per person treated per year, and that antihypertensive medicines could be priced low enough to reach a global standard of an average <US$ 5 per patient per year in the public sector. This health economic evidence will make a compelling case for government ownership and financial support for national scale hypertension control programs.
RESUMEN En general, los programas de control de la hipertensión son costo-eficaces, incluso en los países de ingresos bajos y medios. Aun así, es poco probable que los gobiernos nacionales y la sociedad civil apoyen los programas de control de la hipertensión a menos que se demuestre su valor en términos de beneficios para la salud pública, impacto presupuestario y valor de la inversión para el contexto individual del país. La Organización Mundial de la Salud (OMS) y la Organización Panamericana de la Salud (OPS) implementaron la iniciativa HEARTS, un enfoque mundial estandarizado y simplificado para el control de la hipertensión, que incluye los medicamentos antihipertensivos y los dispositivos de medición de la presión arterial de preferencia. El objetivo de este estudio es informar sobre los estudios en el ámbito de la economía de la salud relativos al costo de las medidas de control de la hipertensión previstas en HEARTS (especialmente, de los medicamentos), la costo-efectividad y el impacto presupuestario, así como describir los modelos matemáticos diseñados para traducir los datos de este programa en un enfoque óptimo para la prestación y el financiamiento de los servicios de atención de la hipertensión, especialmente en países de ingresos medianos y bajos. Los primeros resultados indican que las intervenciones de HEARTS para el control de la hipertensión son de bajo costo o costo-eficaces, que el conjunto de medidas HEARTS es asequible, a un precio que oscila entre US$ 18 y US$ 44 al año por paciente tratado, y que los medicamentos antihipertensivos podrían tener un precio lo suficientemente bajo como para alcanzar un estándar medio mundial de <US$ 5 por paciente al año en el sector público. Estos datos del ámbito de la economía de la salud serán argumentos convincentes para que los gobiernos se involucren en los programas de control de la hipertensión a escala nacional y les brinden apoyo financiero.
RESUMO Geralmente, os programas de controle de hipertensão são custo-efetivos, inclusive em países de baixa e média renda, mas os governos dos países e a sociedade civil provavelmente não apoiarão tais programas a menos que demonstrem valor em termos de benefícios à saúde pública, impacto orçamentário e retorno sobre o investimento no contexto individual do país. A Organização Mundial da Saúde (OMS) e a Organização Pan-Americana da Saúde (OPAS) criaram a Global HEARTS, uma abordagem padrão e simplificada ao controle da hipertensão arterial, que inclui medicamentos anti-hipertensivos preferidos e dispositivos para aferição da pressão arterial preferidos. O objetivo deste estudo é relatar os estudos de economia em saúde que analisaram o custo (especialmente custos de medicamentos), custo-benefício e impacto orçamentário do pacote HEARTS para controle da hipertensão e descrever modelos matemáticos elaborados para traduzir os dados do programa de controle de hipertensão em uma abordagem ideal para a prestação e financiamento de serviços de atenção às pessoas com hipertensão, especialmente em países de baixa e média renda. Os primeiros resultados sugerem que as intervenções HEARTS para controle da hipertensão são de baixo custo ou custo-efetivas, que o pacote HEARTS é acessível (custando de US$ 18 a 44 por pessoa tratada por ano) e que o preço dos medicamentos anti-hipertensivos poderia ser baixo o suficiente para atingir uma média global de <US$ 18 por paciente por ano no setor público. Estas evidências do campo da economia em saúde serão um argumento convincente para que os governos se responsabilizem por programas de controle de hipertensão em escala nacional e os dotem de recursos financeiros.
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Background & objectives: Childhood obesity is a known precursor to obesity and other non-communicable diseases (NCDs) in adulthood. However, the magnitude of the problem among children and adolescents in India is unclear due to paucity of well-conducted nationwide studies and lack of uniformity in the cut-points used to define childhood overweight and obesity. Hence an attempt was made to review the data on trends in childhood overweight and obesity reported from India during 1981 to 2013. Methods: Literature search was done in various scientific public domains from the last three decades using key words such as childhood and adolescent obesity, overweight, prevalence, trends, etc. Additional studies were also identified through cross-references and websites of official agencies. Results: Prevalence data from 52 studies conducted in 16 of the 28 States in India were included in analysis. The median value for the combined prevalence of childhood and adolescent obesity showed that it was higher in north, compared to south India. The pooled data after 2010 estimated a combined prevalence of 19.3 per cent of childhood overweight and obesity which was a significant increase from the earlier prevalence of 16.3 per cent reported in 2001-2005. Interpretation & conclusions: Our review shows that overweight and obesity rates in children and adolescents are increasing not just among the higher socio-economic groups but also in the lower income groups where underweight still remains a major concern.
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Diabetes and urbanization are major contributors to increased risk factors of cardiovascular diseases. Studying whether atherogenic dyslipidaemia increases with urbanization in type 2 diabetes mellitus is, therefore, important. The sample of the present study consisted of 400 subjects. They were categorized according to residential area and diabetes into four groups: urban diabetic group, urban non-diabetic control group (from a metropolitan city Delhi), rural non-diabetic diabetic group, and rural control group (from villages of Khanpur Kalan, Sonepat, Haryana). Differences in lipid levels and risk factors of emerging cardiovascular diseases between groups were evaluated with analysis of variance. Diabetic patients of both urban and rural areas had significantly higher total cholesterol (TC), triglycerides (TG), very low-density lipoproteins (VLDL), TC to high-density lipoprotein cholesterol (TC/HDL) ratio, TG to high‑density lipoprotein cholesterol (TG/HDL) ratio, and atherogenic index (AI) compared to respective controls (p<0.05). The HDL concentrations in urban diabetics were significantly lower (p<0.05) than in urban non-diabetic group and rural diabetic group. Comparison between urban and rural diabetic groups showed significantly higher atherogenic dyslipidaemia (AD) in the urban patient-group (p<0.05). We evaluated significant relationships of diabetes and urbanization with AD by multiple regression analysis. Receiver operating curve (ROC) analysis showed high area under curve (AUC) for TG/HDL in urban diabetic group (0.776, p<0.0001) and in rural diabetic group (0.692, p<0.0001). It is concluded that diabetes was associated with higher AD parameters. Urbanization in diabetes is also associated with elevated levels of AD, indicating higher risk in urban population. This study suggests that TG/HDL may be particularly useful as atherogenic risk predictor in newly-diagnosed type 2 diabetic patients.
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Background: Both rural and urban areas in India are currently experiencing a great spurt in lifestyle diseases such as diabetes mellitus, hypertension and ischaemic heart disease. The shift in epidemiology from communicable diseases to non-communicable diseases indicates that the rural population is also at a high-risk for developing diabetes mellitus. Aims & Objective: The overall objective of present study was to estimate the prevalence of diabetes mellitus in rural population of district Sonepat, Haryana state. Material and Methods: The study was planned to estimate the prevalence of diabetes mellitus in various age groups by analysing the hospital record based data. Blood for glucose estimation was collected in a fluoride vacutainer and glucose was estimated by kit based GOD –POD method. Fasting plasma glucose ≥ 126 mg/dl and or 2 hour postprandial glucose ≥ 200 mg/dl were taken as the diagnostic criteria for diagnosis. Results: Gender specific prevalence for diabetes was 19.36% and 16.98% for male and female respectively. Maximum prevalence of diabetes 41.96% was found in the age group of 46-60 yrs. In this age group Mean fasting plasma glucose among males was 149.36 ± 19.51 and among female it was 147.43 ± 18.19. Mean 2 hour postprandial plasma glucose was 259.94 ± 51.36 & 259.65 ± 51.39 in male and female respectively. Conclusion: Rural population remains exposed to high level of blood sugar for long time due to lack of screening facility of diabetes at PHC level, and this increases the chance of developing various complication of diabetes mellitus.
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Background: A World Health Organization (WHO) package of essential noncommunicable (PEN) disease interventions was piloted in two districts of Bhutan by non-physician health workers. They conducted risk assessment among patients aged over 40 years who visited the outpatient department of health institutions. Blood glucose was also measured among those who were overweight/ obese (body mass index ≥23 kg/m2) or had a high waist circumference (>80 cm in women and >90 cm in men). Appropriate counselling, treatment and referral were provided to the patients. The performance of the PEN project in detecting and managing noncommunicable diseases (NCDs) and their risk factors was assessed. Methods: All health institutions of Paro (one district hospital and three basic health units [BHUs]) and Bumthang districts (one district hospital and four BHUs), were included in the PEN pilot assessment study. All patients who had presented to the clinics in the pilot districts from 1 June to 31 August 2012 constituted the study population. The data were collected from the clinical form, supervisor’s report and monthly report of the PEN project. The characteristics of patients with an NCD at registration and at the third follow-up visit were compared in a before–after analysis. Absolute changes in the characteristics of patients were computed for those who had completed the required followups during a 3-month assessment period. Results: In a 3-month period, 39 079 patients had attended clinics in the pilot districts. About 10% of the clinic attendees (3818/39 079) were aged over 40 years; of these, 22.6% (864/3818) had a high blood pressure, and 49.7% (1896/3818) were overweight/obese or had a high waist circumference. Screening of overweight/ obese/high waist circumference cases revealed that 26.1% (494/1896) had high blood sugar levels. Out of the 896 patients who were registered on PEN protocols, 13% had >20% risk of developing cardiovascular diseases (CVDs) in next 10 years as per the WHO/International Society of Hypertension risk-assessment charts. Among 444 who had three follow-up visits, high 10-year-CVD risk (>20%) had declined from 13% to 7.3%. Among 400 persons with hypertension, use of medication increased and high blood pressure declined from 42.3% to 21.5%. Among 115 persons with diabetes, use of anti-diabetes medication increased and high blood sugar declined from 68/100 to 51/100. Conclusion: Implementation of the PEN intervention in the primary health-care setting of Bhutan led to improvement in blood pressure and diabetes control, and reduction in CVD risk.
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Most of the leiomyomas are situated in the body of the uterus, but in 1-2% of the cases, they are confined to cervix and usually to the supravaginal portion. A cervical leiomyoma is commonly single and is either interstitial or subserous. Rarely it becomes submucous and polypoidal (Kumar et al, 2008). Two cases of cervical leiomyoma admitted with symptoms of menstrual abnormality are being presented. Cervical fibroids were attached to the cervical lips, were sub-mucous, sessile and were removed by vaginal myomectomy leaving the uteres intact.
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Non-communicable diseases (NCDs) are a global health and developmental emergency, as they cause premature deaths, exacerbate poverty and threaten national economies. In 2008, they were the top killers in the South-East Asia region, causing 7.9 million deaths; the number of deaths is expected to increase by 21% over the next decade. One-third of the 7.9 million deaths (34%) occurred in those <60 years of age (compared to 23% in the rest of the world). Of the total deaths in the South-East Asia region (14.5 million), cardiovascular diseases accounted for 25%, chronic respiratory diseases 9.6%, cancer 7.8% and diabetes 2.1%. NCDs are largely attributable to a few preventable risk factors, all of which are highly prevalent in the region—tobacco use, unhealthy diet, lack of physical activity and harmful use of alcohol. Key strategies for the prevention and control of NCDs include (i) reducing exposure to risk factors through health promotion and primary prevention, (ii) early diagnosis and management of people with NCDs, and (iii) surveillance to monitor trends in risk factors and diseases. Tackling NCDs calls for a paradigm shift: from addressing each NCD separately to collectively addressing a cluster of diseases in an integrated manner, and from using a biomedical approach to a public health approach guided by the principles of universal access and social justice. High levels of commitment and multisectoral actions are needed to reverse the growing burden of NCDs in the South-East Asia region.
Subject(s)
Asia, Southeastern/epidemiology , Cardiovascular Diseases/epidemiology , Cardiovascular Diseases/prevention & control , Cause of Death , Cost of Illness , Diabetes Mellitus/epidemiology , Diabetes Mellitus/prevention & control , Female , Health Promotion , Humans , Male , Neoplasms/epidemiology , Neoplasms/prevention & control , Prevalence , Primary Prevention , Pulmonary Disease, Chronic Obstructive/epidemiology , Pulmonary Disease, Chronic Obstructive/prevention & control , Risk FactorsABSTRACT
Tobacco use is a serious public health problem in the South East Asia Region where use of both smoking and smokeless form of tobacco is widely prevalent. The region has almost one quarter of the global population and about one quarter of all smokers in the world. Smoking among men is high in the Region and women usually take to chewing tobacco. The prevalence across countries varies significantly with smoking among adult men ranges from 24.3% (India) to 63.1% (Indonesia) and among adult women from 0.4% (Sri Lanka) to 15% (Myanmar and Nepal). The prevalence of smokeless tobacco use among men varies from 1.3% (Thailand) to 31.8% (Myanmar), while for women it is from 4.6% (Nepal) to 27.9% (Bangladesh). About 55% of total deaths are due to Non communicable diseases (NCDs) with 53.4% among females with highest in Maldives (79.4%) and low in Timor-Leste (34.4%). Premature mortality due to NCDs in young age is high in the region with 60.7% deaths in Timor Leste and 60.6% deaths in Bangladesh occurring below the age of 70 years. Age standardized death rate per 100,000 populations due to NCDs ranges from 793 (Bhutan) and 612 (Maldives) among males and 654 (Bhutan) and 461 (Sri Lanka) among females respectively. Out of 5.1 millions tobacco attributable deaths in the world, more than 1 million are in South East Asia Region (SEAR) countries. Reducing tobacco use is one of the best buys along with harmful use of alcohol, salt reduction and promotion of physical activity for preventing NCDs. Integrating tobacco control with broader population services in the health system framework is crucial to achieve control of NCDs and sustain development in SEAR countries.
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Background & objective: HIV sentinel surveillance (HSS) among antenatal clinic (ANC) attendees is used to monitor HIV trends in general population. Recently, information on HIV infection has also become available from prevention of parent-to-child transmission (PPTCT) programmes. Systematic appraisal of routinely collected programme data is needed for choosing a scientific, cost-effective, and ethical surveillance strategy. In this study HIV prevalence estimates obtained from PPTCT programme and HSS were compared to find out the utility of PPTCT programme data for HIV surveillance. Methods: The data of HSS and PPTCT programme were obtained from National AIDS Control Organization, New Delhi. A list of PPTCT programme sites where ANC HSS was also conducted during 2005 to 2007 was prepared. HIV prevalence and 95 per cent confidence interval (CI) were estimated from antenatal attendees in PPTCT and HSS. Correlation coefficient of HIV prevalence in PPTCT and HSS was also examined according to the level of HIV test acceptance in PPTCT programme. Pregnant women presenting directly for labour in PPTCT centers were not included in the analyses. Results: In 2007, HIV test acceptance ranged from 8 to 100 per cent (average 76%) in 372 sites where both PPTCT and HSS were carried out. HIV prevalence was similar in the PPTCT (0.68%, 95% CI 0.66%, 0.70%) as compared to the HSS (0.61%, 95% CI 0.58%, 0.66%). Overall the correlation of HIV prevalence between PPTCT and HSS was quite high at state level (r = 0.9) but low at district or site level (r = 0.6). Interpretation & conclusions: HIV prevalence estimates among pregnant women in PPTCT program were similar to that of ANC HSS. Routinely collected PPTCT program data therefore has potential for providing reliable HIV time trends in various states of India.
Subject(s)
Female , HIV Infections/epidemiology , HIV Infections/transmission , Humans , India/epidemiology , Infectious Disease Transmission, Vertical/prevention & control , Mass Screening/methods , Pregnancy , Prevalence , Sentinel SurveillanceABSTRACT
Background. We aimed to analyse treatment outcomes of patients receiving first-line antiretroviral therapy (ART) through the national AIDS control programme of India. Methods. Using routinely collected programme data, we analysed mortality, CD4 evolution and adherence outcomes over a 2-year period in 972 patients who received first-line ART between 1 October 2004 and 31 January 2005 at 3 government ART centres. Cox regression analysis was used to identify independent predictors of mortality. Results. Of the 972 patients (median age 35 years, 66% men), 71% received the stavudine/lamivudine/nevirapine regimen. The median CD4 count of enrolled patients was 119 cells/cmm (interquartile range [IQR] 50–200 cells/ cmm) at treatment initiation; 44% had baseline CD4 count <100 cells/cmm. Of the 927 patients for whom treatment outcomes were available, 71% were alive after 2 years of treatment. The median increase in CD4 count was 142 cells/ cmm (IQR 57–750 cells/cmm; n=616) at 6 months and 184 cells/cmm (IQR 102–299 cells/cmm; n=582) at 12 months after treatment. Over 2 years, 124 patients (13%) died; the majority of deaths (68%) occurred within the first 6 months of treatment. Those with baseline CD4 count <50 cells/cmm were significantly more likely to die (adjusted hazard ratio 2.5, 95% confidence interval 1.3–3.2) compared with patients who had baseline CD4 count >50 cells/cmm. Over the 2-year period, 323 patients (35%) missed picking up their monthly drugs at least once and 147 patients (16%) were lost to follow up. Conclusion. Survival rates of HIV-infected patients on first-line ART in India were comparable with those from other resource-limited countries. Most deaths occurred early and among patients who had advanced disease. Earlier initiation of HIV treatment and improving long term treatment adherence are key priorities for India’s ART programme.
Subject(s)
Acquired Immunodeficiency Syndrome/drug therapy , Acquired Immunodeficiency Syndrome/immunology , Adolescent , Adult , Aged , Anti-HIV Agents/adverse effects , Anti-HIV Agents/therapeutic use , CD4 Lymphocyte Count , Cohort Studies , Female , Humans , India , Male , Middle Aged , National Health Programs , Proportional Hazards Models , Retrospective Studies , Treatment OutcomeABSTRACT
BACKGROUND & OBJECTIVE: HIV estimates in India were based on HIV sentinel surveillance (HSS) data and several assumptions. Expansion of sentinel surveillance to all districts and community based HIV prevalence measured by National Family Health Survey-3 (NFHS-3) in 2006 provided opportunity to replace many of the assumptions with evidence based information and improve the HIV estimate closer to reality. This article presents a detailed account of the methodology used for the 2006 HIV burden estimates for India. METHODS: State-wise adult HIV prevalence among different risk groups observed from HSS 2006 was adjusted for site level variations using a random effects model and for the previous four years the same was back calculated using trend equations derived from a mixed effects logistic regression model based on consistent sites prevalence. The adjusted HIV prevalence among the general population was calibrated to the estimates from NFHS-3. Overall point estimates of adult HIV prevalence in each State for 2002-2006 were derived from the UNAIDS Workbook and projected for the period 1985-2010. The results were put into Spectrum to derive estimates of the number of people living with HIV in all ages and other epidemic impacts. RESULTS: National adult HIV prevalence was 0.36 per cent (range 0.29-0.46%) and the estimated number of people living with HIV was 2.47 million (range 2.0-3.1 million) in 2006. The national adult HIV prevalence remains stable around 0.4 per cent between 2002 and 2006. The States with the highest estimated prevalence were Manipur, Nagaland and Andhra Pradesh. The States with the highest burden were Andhra Pradesh, Maharashtra, Karnataka and Tamil Nadu. INTERPRETATION & CONCLUSION: The improvement in the 2006 estimates of the HIV burden in India is attributable to the expanded sentinel surveillance and representative data from the population-based survey in 2006, combined with an improved analysis. Despite the downward revision, India continues to face a formidable challenge to provide prevention, treatment and care to those in need.