Tobacco Control Policies in India: Implementation and Challenges.

Tobacco use is a major public health challenge in India with 275 million adults consuming different tobacco products. Government of India has taken various initiatives for tobacco control in the country. Besides enacting comprehensive tobacco control legislation (COTPA, 2003), India was among the first few countries to ratify WHO the Framework Convention on Tobacco Control (WHO FCTC) in 2004. The National Tobacco Control Programme was piloted during the 11 th Five Year Plan which is under implementation in 42 districts of 21 states in the country. The advocacy for tobacco control by the civil society and community led initiatives has acted in synergy with tobacco control policies of the Government. Although different levels of success have been achieved by the states, non prioritization of tobacco control at the sub national level still exists and effective implementation of tobacco control policies remains largely a challenge.

Antidiabetic activity of aqueous extract and non polysaccharide fraction of Cynodon dactylon Pers.

Petroleum ether (60 degrees-80 degrees C), chloroform, acetone, ethanol, aqueous and crude hot water extracts of the whole plant of C. dactylon and the two fractions of aqueous extract were tested for antihyperglycaemic activity in glucose overloaded hyperglycemic rats and in alloxan induced diabetic model at two-dose levels, 200 and 400 mg/kg (po) respectively. The aqueous extract of C. dactylon and the non polysaccharide fraction of aqueous extract were found to exhibit significant antihyperglycaemic activity and only the non polysaccharide fraction was found to produce hypoglycemia in fasted normal rats. Treatment of diabetic rats with aqueous extract and non polysaccharide fraction of the plant decreased the elevated biochemical parameters, glucose, urea, creatinine, serum cholesterol, serum triglyceride, high density lipoprotein, low density lipoprotein, haemoglobin and glycosylated haemoglobin significantly. Comparatively, the non polysaccharide fraction of aqueous extract was found to be more effective than the aqueous extract.

A rare case of trypanosomiasis in a two month old infant in Mumbai, India.

Human Trypanosomiasis is a rare occurrence in India. In the cases reported so far the disease causative species have been the species infective to animals viz., Trypanosoma lewisi and Trypanosoma evansi. These animal species usually non pathogenic in humans can acquire the desired virulence and emerge as human pathogens causing serious disease, in the right combination of environmental, host related and organism related factors. We report here a case of trypanosomiasis caused by the rodent parasite T. lewisi in a two months old infant in urban Mumbai. Under the fastly changing environmental scenario there is an urgent need to be prepared for the emerging zoonoses. Any unusual disease occurrence in a given geographical area acquires a special significance in this context and should be reported to assess its public health importance and be prepared to deal with the consequent challenges posed, if any.

Chikungunya viral disease in district Bhilwara (Rajasthan) India.

An investigation of chikungunya outbreak cases was carried out in Bhilwara District, Rajasthan during Aug-Sep 2006. Fever with multiple joint pains was the first presenting feature. Aedes larval surveys indicate high Breteau index (78.6 to 200), House index (48.0 to 83.3) & Container index (41.1 to 73.6) above the critical index. Out of 40 sera samples tested, 12 showed HI antibodies for chikungunya virus in high titres and another five were positive for IgM antibodies against chikungunya. The clinico-epidemiological, laboratory and entomological investigations confirm that this episode of fever was due to chikungunya fever. Strengthening and intensification of surveillance along with educating the community were recommended for control of outbreak.

Epidemiological characteristics of rabies in Delhi and surrounding areas, 1998.

OBJECTIVE: To describe the epidemiological characteristics of rabies in Delhi in 1998. METHODS: Analysis of the records of hydrophobia cases admitted to the Infectious Diseases Hospital, Delhi (IDH) in 1998. RESULTS: About 46 percent (99/215) of the hydrophobia cases admitted to the IDH in 1998 belonged to Delhi. The remaining came from the adjoining states, both urban and rural areas. In Delhi residents, overall hospitalization rate was 0.81 per 100,000 population. It was significantly higher in 5-14 year old than in other age groups and in males than in females (p <0.0009). Cases occurred round the year. Almost 96 percent cases (206/215) gave history of animal exposure, 13 days to 10 years (median 60 days) before hospitalization. Majority (195/206) had class III exposure. Animals involved were stray dog (193/206 = 90 percent), pet dog, cat, jackal, mongoose, monkey and fox. Most of cases were never vaccinated (78 percent) or inadequately vaccinated (22 percent); only 1 percent each received appropriate wound treatment, or rabies immunoglobulin. CONCLUSIONS: Rabies is a major public health problem in Delhi. Its incidence is significantly higher in 5-14 year old children than in other age groups. The results indicate the need to educate the community and health care workers about the importance of immediate and adequate post-exposure treatment and to start an effective control program for dogs, the principal vector of rabies.

An outbreak of dengue fever in rural areas of northern India.

During the past few decades, epidemics of dengue fever are causing concern in several South-East Asian countries including India. The rural areas of Hissar district of Haryana state, situated about 170 km North-West of Delhi, experienced an outbreak of febrile illness during July-August 1996. A total of 13 villages in eight affected primary health centres reported fever cases. The clinical, epidemiological and entomological findings indicated that the present episode was due to dengue fever. The aetiological agent of the current outbreak, the DEN-2 virus, was isolated from 12 acute-phase sera specimens. Though, in the recent past outbreaks have been reported from the rural areas of southern and western India, the present episode is the first outbreak being reported from the rural areas of northern India. The increasing frequency of dengue fever outbreaks in rural areas of various Indian states reflects the changing life style of the rural population as a result of urbanization process and calls for a suitable prevention and control policy based on strengthened surveillance, appropriate health education to the community coupled with proper training of health personnel.

Knowledge, attitude and practice towards malaria in rural tribal communities of south Bastar district of Madhya Pradesh.

A sample survey of 100 household heads was carried out in Bastar district to assess villagers knowledge, attitude and practice (KAP) about malaria and their implications for malaria control. Results show that 64.4% of respondents were illiterate and only 20.6% of respondents know the factor for cause of malaria though 45% of household heads received some form of health education from various sources. Respondents who suffered from malaria in previous year constituted 35.8% while 46.8% respondents reported for treatment to nearby PHC, 59.1% respondents admitted the responsibility of male head-of-family to take decision to seek health care malaria. About 34.6% of respondents suspect malaria to any fever. A meagre respondents (8.2%) knew the drug for treatment of malaria, and majority of respondents (70.9%) had taken a complete course of malaria treatment. About 55% respondents did not take any measure to prevent mosquito bite, while 92.4% admitted that they had not taken any measures to prevent malaria. All most all respondents (99.7%) agreed to allow their houses to be sprayed and 99.1% thought that spraying was necessary. The study shows, for successful control of malaria in tribal areas, proper health education about the disease, awareness of personal protection and preventive measures against malaria should be carried out in such a way that should be need based, suitable for the area concern and acceptable, along with active involvement of the communities.

Pre- and extra-marital heterosexual behaviour of an urban community in Rajasthan, India.

A study conducted among the teachers of senior secondary schools of a city in Rajasthan state to know the magnitude of pre- and extra-marital heterosexual practices and some related characteristics revealed that one third of unmarried and one fifth of married males had experienced pre-marital sex. The same for unmarried and married females was 11.8 per cent and 1.5 per cent, respectively. The prevalence of extra-marital heterosexual act among married males was 15.5 per cent. One out of ten married males reported to have had both pre- and extra-marital sex. A male having pre-marital sex was 15 times more likely to have extra-marital sex. Friends, acquaintances and relatives were the important sexual partners while role of commercial sex workers was negligible. The study reports that heterosexual act with person other than the legal spouse is very much prevalent among this group of middle class professionals. This situation is conducive for the spread of HIV infection among general population and may adversely influence the sexual attitudes of students. The study, therefore, suggests that, besides intensifying the health education on HIV/AIDS, serious considerations about the sexual behaviours of school teachers are needed.

Community studies on prevalence of HBsAg in two urban populations of southern India.

OBJECTIVE: To find out prevalence of HBsAg in general population, especially in under-five children. SETTING: Bangalore and Rajahmundry towns in southern India. METHODS: Localities were chosen as the sampling units in each town. About 10-20 households were randomly selected from each locality. Only the youngest but apparently healthy person present in the household was interviewed for age, sex and history of jaundice any time in life. Mothers were interviewed to collect data for children below 15 years of age. Blood samples were collected from these persons on filter paper strips (18-mm diameter disc, Whatman filter paper No. 3) by finger prick method. The samples were tested for HBsAg by Micro ELISA (Ortho-Clinical Diagnostics). RESULTS: Overall, 3.3% (95% CI, 2.0-4.5) of 737 persons in Rajahmundry and 4.2% (95% CI, 2.8-5.5) of 816 persons in Bangalore were found carriers of HBsAg. Age-specific or sex specific carrier rates were similar in Rajahmundry as well as in Bangalore. Most of the carriers (96%) denied having jaundice ever in life. CONCLUSIONS: The results from this community based study are in agreement with the historical data from hospital based studies that about 3-5% of persons may be carriers of HBsAg and that the pool of chronic carriers of hepatitis B virus in India is built up in childhood and is then maintained in older children and adults. The results highlight the need of completing hepatitis B immunization during the infancy.

Epidemiological characteristics of poliomyelitis in Delhi, 1997.

OBJECTIVE: To describe the epidemiological characteristics of poliomyelitis in Delhi in 1997 after four consecutive statewide immunization campaigns with oral polio vaccine (OPV). METHODS: Stool samples were collected from 158 cases of acute flaccid paralysis (AFP) along with their age, sex, residential address, immunization history and dates of onset of paralysis, reporting and investigation. The samples were processed for isolation of polioviruses. In addition, historical data on vaccination coverage surveys and OPV testing were reviewed. These data were analyzed to understand the epidemiological patterns of poliomyelitis in Delhi. RESULTS: Of 158 cases of AFP, about 23% were investigated within 2 days of onset of paralysis. Two samples each were collected from 97 (61%) cases, and one each from the remaining cases. Detection of 158 cases of AFP gave an incidence of 1.34 per 100,000 population. About 36% (57/158) of AFP cases excreted poliovirus, mostly (53/158) wild poliovirus. Of the wild poliovirus isolates, 72% (38/53) and 25% (13/53) were serotypes P1 and P3 respectively; 2 isolates were P2. Almost 95% (146/154) of AFP cases and all the laboratory confirmed cases (excreting wild poliovirus) occurred in children below 5 years of age. Only one-third of AFP (55/158) or laboratory confirmed cases (18/53) had received 3 or more doses of OPV before onset of paralysis. About one-fourth of cases in both the categories were totally unvaccinated. AFP cases occurred round the year but peaked in November-December. Peaks were always observed during July-August in the past. The cases were widely scattered without any obvious clustering in any locality. CONCLUSIONS: Poliomyelitis has declined substantially in Delhi. The study underscores the need for further efforts to improve vaccine coverage levels, AFP surveillance, and cold chain maintenance to achieve the complete interruption of transmission.

Widespread outbreaks of measles in rural Uttar Pradesh, India, 1996: high risk areas and groups.

OBJECTIVE: To describe outbreaks of measles which affected many districts in Uttar Pradesh (UP) during 1996. DESIGN: Outbreak investigations. SETTING: The state of Uttar Pradesh, India. METHODS: The reported data on measles morbidity, mortality and vaccine coverage from 1991 through 1996 were reviewed. Reported vaccine coverage levels were compared with the results of coverage surveys carried out in UP from 1992 through 1996. Line lists on measles cases were analyzed to ascertain the age, immunization status, geographical distribution, and age and sex-specific fatality ratios during the outbreaks. A community survey was organized in 7 affected villages to estimate vaccine effectiveness. RESULTS: Fifty one of 68 districts in UP reported 6922 measles cases and 281 deaths in 1996. The majority of cases and deaths occurred in June and July which are usually low transmission months. Overall cases fatality ratio (CFR) was 4.1%. CFRs were significantly higher in females and young children. The median age of cases was found to be below 5 years. There was heavy clustering of cases and deaths in rural areas. About 85% of the cases and virtually all the measles associated deaths occurred in unvaccinated children. Published documents on statewide coverage surveys revealed that the measles vaccine coverage levels ranged between 26% and 36% during 1992-96. Large gaps were found between reported coverage and survey results. Nevertheless, epidemiological studies indicated a vaccine effectiveness of more than 90%. CONCLUSIONS: The outbreaks occurred due to poor vaccine coverage levels and an inefficient surveillance system which failed to generate early warning signals. The study highlights the urgent need to raise the vaccine coverage levels rapidly in all districts to achieve measles control and prevent future outbreaks in UP.

Transplacental transfer of measles antibody in Delhi.

OBJECTIVE: To find out the patterns of and the factors, if any, affecting the transplacental transfer of measles antibody. DESIGN: Comparison of measles antibody titres in mothers with titres in cord blood samples. METHODS: Maternal and cord blood samples from 174 full-term pregnant women of middle socio-economic status were tested for hemagglutination inhibition (HI) antibody against measles in Delhi during October 1993 to January 1995. None of the mothers had been immunized against measles. RESULTS: Antibody were undetectable in both maternal and cord samples in only 4 (2.3%) pairs. Mean maternal titre was found to be 2.94 Log2. Transplacental concentration and dilution were respectively observed in 34% and 26% of the samples. Cord titres were more often higher than the maternal values only if the maternal values were low. Overall, cord/maternal ratio of mean titre (Log2) was found to be 1.06. Although the age of the mother and parity had had no significant bearing on the transplacental transfer of measles antibody, cord titres were significantly more often higher than the maternal values as the birth weight increased (Chi-square for linear trend = 5.4; p = 0.02). CONCLUSIONS: The study failed to show appreciable concentration of measles antibodies across the placenta.

Acute sporadic viral hepatitis in urban population of a tribal district in Madhya Pradesh.

OBJECTIVE: To estimate the incidence of acute sporadic viral hepatitis and describe its epidemiology in an urban population. DESIGN: A retrospective community survey for jaundice cases. SETTING: Headquarter town of a tribal district, Bastar, in Madhya Pradesh state, India. METHOD: Trained paramedics surveyed about 51,643 population to detect cases of jaundice which occurred in the past one year. Cases were examined to collect clinical and epidemiological data. blood samples were drawn from all cases who had jaundice in the past 3 months for testing them for markers of viral hepatitis. RESULTS: Study estimated the annual incidence of jaundice cases as 244 (95% CI 201-287) per 100,000 population. Almost 95% jaundice cases occurred in summer and monsoon months. People from all socio-economic strata were affected. The incidence of jaundice was found to be the highest in children below 15 years of age (3.7 per 1000) which declined significantly with the increase in age (p = 0.0000). The overall incidence in two sexes was not different statistically (p = 0.7). Of 57 cases who had jaundice in the past 3 months, 19 (33%) were confirmed as having viral hepatitis. Hepatitis A and E combined together contributed 68% (13/19) of acute sporadic cases of viral hepatitis, whereas hepatitis B, C and D accounted for the remaining 32% of the cases. CONCLUSION: The study found the annual incidence of laboratory supported cases of viral hepatitis to be 81 (95 CI 57-106) per 100,000 population, which suggests that it is an important public health problem in India. Hepatitis A was much more prevalent than hepatitis E. Etiology of almost two-thirds of jaundice cases could not be established which require further community studies.

V. cholerae 01 outbreak in remote villages of Shimla district, Himachal Pradesh, 1994.

An outbreak of V. cholerae 01 occurred in remote villages of Rohru tehsil, district Shimla, Himachal Pradesh, during June-July 1994. Seven villages were affected. Overall attack rate was 16.4 per cent in surveyed villages. Attack rate in children < 5 was significantly high. Suspected source was spring water contaminated from open air defaecation. V. cholerae was resistant to co-trimoxazole and streptomycin.