Monkeypox Disease Outbreak (2022): Epidemiology, Challenges, and the Way Forward

The biggest-ever outbreak of monkeypox disease in non-endemic countries started in May, 2022. Though no monkeypox case has been reported from India, till mid-June, 2022, yet, considering the rate of spread to the non-endemic countries, there is an urgent need of better understanding of the monkeypox virus and disease epidemiology to help clinicians, public health specialists, and policymakers to be prepared for any eventuality. This review summarises the monkeypox disease epidemiology, clinical features, therapies, vaccines and outlines the measures for preparedness and response for a possible outbreak. The disease is known to cause severe outcome in children, pregnant women, and immunocompromised hosts and this group need to be given special attention. The monkeypox disease outbreak (2022) in non-endemic countries should be used as an opportunity by India and other low and middle income countries to strengthen public health surveillance and health system capacity for outbreak and epidemic preparedness and response..

What brings people to government urban primary care facilities? A community-based study from Delhi, India

Introduction: Mohalla or Community Clinics of Delhi, India, provides free primary care services to the general population, with special focus on the underserved and marginalized. This study was conducted to analyze the perception and experience of target beneficiaries and to understand and document the determinants of people visiting these clinics. Material and Methods: A community-based study was conducted from October 2019 to April 2020. A semi-structured questionnaire was used for data collection. Correlation and comparative analysis were used. Thirty-seven Mohalla Clinics and their catchment areas were visited. A total of 391 respondents (including 35 health staff and 356 community members) were included. Results: Proximity of clinics, waiting times, age, perceived quality of treatment, and cleanliness at facilities were the factors that influenced the usage of clinics. Lack of first-aid facilities and long waiting time (at a few facilities) were identified challenges. There is a need for wider publicity and awareness about the clinics and regular analysis of data to determine an appropriate mid-course action to further increase utilization. Conclusion: Community Clinics of Delhi, India, have brought people back to government primary healthcare (PHC) facilities. The popularity of these clinics has encouraged a number of Indian states to set up similar facilities. The factors behind their success need to be studied in detail to derive lessons for making urban PHC accessible in other low- and middle-income countries.

Non-alcoholic Fatty Liver Disease (NAFLD) in India : Challenges and the Ways Forward

Non-alcoholic Fatty Liver Disease (NAFLD) is a distinct hepatic condition and one of the most common causes of Chronic Liver Disease globally. In February, 2021, the Government of India had launched and integrated interventions to prevent and control NAFLD in the ongoing National Programme for Prevention & Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS). This review was conducted to identify challenges and proposes solutions for effective program implementation. The authors identified that since NPCDCS has been implemented as District-based program and NAFLD being new component, the lack of familiarity of various sub-group of staff could be a major challenge in roll-out. The sensitization of Health Workers, Medical Officer in Primary Healthcare System, the specialist doctors at all levels of care as well as private practitioners, on various aspects of NAFLD (including epidemiology, clinical features, treatment approach and other aspects) should be conducted. The Information Education Communication (IEC) material should be developed and campaigns for awareness generation amongst general public in prevention and management of the disease should be conducted.Ongoing activities to set up Health and Wellness Centres under Ayushman Bharat Program, is a good opportunity to integrate of NAFLD in primary care level. This will help India to accelerate progress towards Universal Health Coverage

Ayushman Bharat’ Program and Universal Health Coverage in India

India’s National Health Policy 2017 (NHP-2017) has its goal fully aligned with the concept of Universal health coverage. The AyushmanBharat Program announced in the Union budget 2018-19 of the Government of India, aims to carry NHP-2017 proposals forward. TheAyushman Bharat Program has two initiatives/components – Health and Wellness Centers, and National Health Protection Scheme –aiming for increased accessibility, availability and affordability of primary-, secondary- and tertiary-care health services in India.Afterwards, the second component has been renamed as Pradhan Mantri Rashtriya Swasthya Suraksha Mission. The new programhas received an unprecedented public, political and media attention; and is being attributed to have placed health higher on politicalagenda. This review article analyzes and provides critical reflections, suggestions and way forward for rapid and effectiveimplementation of Ayushman Bharat Program. To be effective and impactful in achieving the desired health outcomes, there is a need forgetting both design and implementation of Ayushman Bharat Program right, from the very beginning. If implemented fully andsupplemented with additional interventions, the program can prove a potential platform to reform Indian healthcare system and toaccelerate India’s journey towards universal health coverage

A brief history of vaccines & vaccination in India.

The challenges faced in delivering lifesaving vaccines to the targeted beneficiaries need to be addressed from the existing knowledge and learning from the past. This review documents the history of vaccines and vaccination in India with an objective to derive lessons for policy direction to expand the benefits of vaccination in the country. A brief historical perspective on smallpox disease and preventive efforts since antiquity is followed by an overview of 19th century efforts to replace variolation by vaccination, setting up of a few vaccine institutes, cholera vaccine trial and the discovery of plague vaccine. The early twentieth century witnessed the challenges in expansion of smallpox vaccination, typhoid vaccine trial in Indian army personnel, and setting up of vaccine institutes in almost each of the then Indian States. In the post-independence period, the BCG vaccine laboratory and other national institutes were established; a number of private vaccine manufacturers came up, besides the continuation of smallpox eradication effort till the country became smallpox free in 1977. The Expanded Programme of Immunization (EPI) (1978) and then Universal Immunization Programme (UIP) (1985) were launched in India. The intervening events since UIP till India being declared non-endemic for poliomyelitis in 2012 have been described. Though the preventive efforts from diseases were practiced in India, the reluctance, opposition and a slow acceptance of vaccination have been the characteristic of vaccination history in the country. The operational challenges keep the coverage inequitable in the country. The lessons from the past events have been analysed and interpreted to guide immunization efforts.

Visceral Leishmaniasis (Kala Azar) Elimination from Indian Sub-continent by 2015.

Objective: To review the progress towards the goal of elimination of visceral leishmaniasis (Kala azar) from the Indian sub-continent by 2015. Method: Both electronic and print databases were searched for studies related to Kala azar. Finding: The burden of Kala azar is grossly underestimated by the health systems in the Indian sub-continent due to over-reliance on passive surveillance. Poly-parasitism and co-infections are the major emerging problems in the world of Kala azar. Resistance has been reported for DDT indoor residual spraying. Treatment drugs are not ideal, and supplies of these drugs are irregular as well. Conclusion: Achievement of elimination of Kala azar from Indian sub-continent is still unpredictable. To improve the elimination of Kala azar it should be classified as a notifiable disease. There is a need to refocus current strategies and monitor the program more closely. Furthermore, there is a need to assess alternative vector control methods. Policies to control Kala azar will have to include health education and behaviour change. Kala azar may not affect the national economy or the national GDP, but it devastates the families affected.

An assessment of hepatitis B vaccine introduction in India: Lessons for roll out and scale up of new vaccines in immunization programs.

Background: Hepatitis B vaccine was introduced in the Universal Immunization Program (UIP) of 10 states of India in the year 2007-08. This assessment was planned and conducted to ascertain the reasons for low reported coverage of Hepatitis B (Hep B) vaccine in comparison of similarly timed diphtheria, pertussis, and tetanus (DPT) vaccine; to identify operational and programmatic challenges in new vaccine introductions, and to derive lessons for further scale up of Hep B vaccination (or for introduction of any new vaccine) in UIP of India. Materials and Methods: Purposive sampling with both quantitative and qualitative data collection. Two districts each were purposively selected from 5 of the 10 states, which introduced Hep B vaccine, in the year 2007-08. A protocol was devised and data was collected through desk review, in-depth interviews and on-site observation at state, districts and facility levels. The assessment was completed in December 2009. Results: Coverage with three doses of Hep B vaccine was lower than similarly timed three doses of DPT vaccine. Poor stock management ("stock outs or nil stocks" at various levels), incomplete recording and reporting, perceived high cost & related fear of wastage of vaccine in 10 dose vial, and incomplete knowledge amongst health functionaries about vaccination schedule were the main reasons cited for reported lower coverage. Hep B vaccine birth dose was introduced in only 3 of 5 states evaluated. The additional reasons for low Hep B birth dose coverage were lack of knowledge amongst Health Workers about birth dose administration, no mechanism for recording birth dose, and insufficient trainings, official communications, and coordination at various levels. Conclusions: This assessment documents challenges faced in the introduction of hepatitis B vaccine in UIP in India and summarizes the lessons learnt. It is concluded that for successful introduction and scale up of any new vaccine in national or state immunization program; clear and timely central level instructions and oversight and improved stock management is required. At state and district levels; quality trainings, effective supervision and monitoring, improving data recording and reporting are key factor for success. The additional focus on Hep B birth dose administration may help in improving coverage. The lessons from this assessment can possibly be utilized for future introduction and scale up of any new vaccine (or other similar interventions) in India or in any other developing country setting.

Impact of Janani Suraksha Yojana on Institutional Delivery Rate and Maternal Morbidity and Mortality: An Observational Study in India.

The Government of India initiated a cash incentive scheme—Janani Suraksha Yojana (JSY)—to promote institutional deliveries with an aim to reduce maternal mortality ratio (MMR). An observational study was conducted in a tertiary-care hospital of Madhya Pradesh, India, before and after implementation of JSY, with a sample of women presenting for institutional delivery. The objectives of this study were to: (i) determine the total number of institutional deliveries before and after implementation of JSY, (ii) determine the MMR, and (iii) compare factors associated with maternal mortality and morbidity. The data were analyzed for two years before implementation of JSY (2003-2005) and compared with two years following implementation of JSY (2005-2007). Overall, institutional deliveries increased by 42.6% after implementation, including those among rural, illiterate and primary-literate persons of lower socioeconomic strata. The main causes of maternal mortality were eclampsia, pre-eclampsia and severe anaemia both before and after implementation of JSY. Anaemia was the most common morbidity factor observed in this study. Among those who had institutional deliveries, there were significant increases in cases of eclampsia, pre-eclampsia, polyhydramnios, oligohydramnios, antepartum haemorrhage (APH), postpartum haemorrhage (PPH), and malaria after implementation of JSY. The scheme appeared to increase institutional delivery by at-risk mothers, which has the potential to reduce maternal morbidity and mortality, improve child survival, and ensure equity in maternal healthcare in India. The lessons from this study and other available sources should be utilized to improve the performance and implementation of JSY scheme in India.

Additional cash Incentive within a conditional cash transfer scheme: A 'controlled before and during' design evaluation study from India.

Background : Conditional Cash Transfer (CCT) schemes have shown largely favorable changes in the health seeking behavior. This evaluation study assesses the process and performance of an Additional Cash Incentive (ACI) scheme within an ongoing CCT scheme in India, and document lessons. Material and Methods: A controlled before and during design study was conducted in Madhya Pradesh state of India, from August 2007 to March 2008, with increased in institutional deliveries as a primary outcome. In depth interviews, focus group discussions and household surveys were done for data collection. Results: Lack of awareness about ACI scheme amongst general population and beneficiaries, cumbersome cash disbursement procedure, intricate eligibility criteria, extensive paper work, and insufficient focus on community involvement were the major implementation challenges. There were anecdotal reports of political interference and possible scope for corruption. At the end of implementation period, overall rate of institutional deliveries had increased in both target and control populations; however, the differences were not statistically significant. No cause and effect association could be proven by this study. Conclusions: Poor planning and coordination, and lack of public awareness about the scheme resulted in low utilization. Thus, proper IEC and training, detailed implementation plan, orientation training for implementer, sufficient budgetary allocation, and community participation should be an integral part for successful implementation of any such scheme. The lesson learned this evaluation study may be useful in any developing country setting and may be utilized for planning and implementation of any ACI scheme in future.

How endemic countries can accelerate lymphatic filariasis elimination? An analytical review identify strategic and programmatic interventions.

Lymphatic filariasis (LF) is endemic in 81 countries in the world, and a number of these countries have targeted for LF elimination. This review of literature and analysis was conducted to identify additional and sustainable strategies to accelerate LF elimination from endemic countries. This review noted that adverse events due to mass drug administration (MDA) of diethyl carbamazine (DEC) tablets, poor knowledge and information about LF amongst health workers & community members, and limited focus on information, education & communication (IEC) activities and interpersonal communication are the major barriers in LF elimination. The new approaches to increase compliance with DEC tablets (including exploring the possibility for DEC fortification of salt), targeted education programmes for physicians and health workers, and IEC material and inter personal communication to improve the knowledge of community are immediately required. There is a renewed and pressing need to conduct operational research, evolve sustainable and institutional mechanisms for education of physicians and health workers, ensure quality of trainings on MDA, strengthen IEC delivery mechanisms, implement internal and external monitoring of MDA activities, sufficient funding in timely manner, and to improve political and programmatic leadership. It is also time that lessons from other elimination programmes are utilized to accelerate targeted LF elimination from the endemic countries.

Burden, Differentials, and Causes of Child Deaths in India.

Objective To review the current information on trends, burden, differentials, causes, and timing of under five (U5) child deaths in India. Methods We reviewed and analyzed data on child deaths in India from official government sources, reports, surveys, and from the published literature. The secondary analyses were carried out to provide additional insight. Results An estimated 1.84 million under 5 child deaths, including approx 1.44 million infant and 940,000 neonatal deaths occurred in India during 2007. More than 60% of these Under 5 child deaths occurred in 5 states: Uttar Pradesh (27.0%), Bihar (11.3%), Madhya Pradesh (9.9%), Rajasthan (8.0%) and Andhra Pradesh (5.7%). Approximately 41% of all Under 5 child deaths happen in the first week of life and the risk of deaths during neonatal period was at least 68 times higher than the rest of childhood. The children living in rural areas, in the central Indian states, in the lowest 20% of wealth index have the highest risk of death in India. The mortality rates in under 5, infant, neonates and early neonatal period in India declined by 43.5%, 31.2%, 32.1%, and 21.6%, respectively, between 1990 to 2007. However, the rate of reduction has slowed in last 4 years (2003–2007), with negative trend in the early neonatal mortality rate. Neonatal conditions (33%), pneumonia (22%) and diarrhea (14%) are the leading causes of under 5 deaths in India. Sepsis, pneumonia (30.4%), birth asphyxia (19.5%), and pre-maturity (16.8%) are the 3 commonest causes of neonatal deaths (0–27 days). Conclusions The reduction in under 5 child mortality in India during 1990–2007 has been insufficient to attain Millennium Development Goal 4 (MDG4). However, there have been variable declines in early neonatal, neonatal, infant and child mortality. Despite the well known importance of neonatal survival to attain MDG4, our data suggest the early neonatal mortality rate in India may be increasing in the recent years, which is a cause for serious concern. Achievement of MDG4 in India will require further acceleration in the reduction of the under 5 mortality rate, particularly, in the 5 highest burden states: Uttar Pradesh, Bihar, Madhya Pradesh, Rajasthan and Andhra Pradesh.

Causes of Child Deaths in India, 1985-2008: A Systematic Review of Literature.

Objective To understand the causes of child deaths in order to implement appropriate child survival interventions in the country. We present a systematic review of studies reporting causes of child, infant, and neonatal deaths from India for 1985 to 2008. Methods PubMed, EMBASE, Google Scholar, and WHO regional databases were searched along with a hand search and personal communication with researchers in child health to obtain studies and reports for the database. Study data was summarized and analyzed using appropriate statistical tools. Results We identified 28 published/unpublished studies and reports (6 multi-centric and 22 single sites). There was one nation wide study and rest were from 15 unique sites in 9 different states of India. There were differences in study design and cause of death assignment methods between the studies, which made comparisons and synthesis difficult. The median percentage of causes of deaths in neonatal period were sepsis/pneumonia: 24.9% (Q1: 19.6% and Q3: 33.4%); asphyxia: 18.5% (Q1: 14.2% and Q3: 21.9%); and pre-maturity/LBW: 16.8% (Q1: 12.5% and Q3: 26.5%). Amongst the infants, sepsis/pneumonia, asphyxia, and prematurity/low birth weight (LBW) remain substantial causes of deaths. The median proportional contribution of neonatal deaths to total infant deaths was 48.5% (Q1: 36.5– Q3: 57.5%). The proportion of deaths due to infectious diseases like diarrhoea, pneumonia, and measles seem to be greater in infancy, in comparison to that in neonatal period. There was no statistically significant difference in the proportional contribution of neonatal deaths to total deaths occurring during infancy (<1 year) between the two equal periods before and after 1996 (p=0.141). There also was no difference in the proportional contribution by cause of death assignment method (Verbal autopsy vs. other methods; p=0.715) or by study setting (urban vs. rural; p= 0.175). The median percentage of neonatal deaths by day 1 is 36.7% (Range: 20.0–58.0%). The median cumulative percentage of neonatal deaths by day 3 was 49.7% (Range 35.0–64.6%), and 70.9% (Range: 46.5–92.3%) by day 7. In addition, the timing of deaths during neonatal period seems to be static during the last 2 decades, with majority of deaths occurring during first week of life. Conclusions This review demonstrates the need for more studies with consistent methodological rigor investigating the causes of child death in India. We conclude that the structure of neonatal causes of death in India may be different from the rest of the world and that interventions to reduce neonatal deaths in first week of life may rapidly improve child survival in the country.

Insecticide treated nets, antimalarials and child survival in India.

Malaria has been a complex public health problem affecting mainly the poor and the rural communities in India. Insecticide treated nets (ITN) and antimalarials are the two proven interventions for prevention and control of malaria. ITN has been amply demonstrated to be an effective intervention to protect children from malaria, and in preventing deaths due to falciparum malaria. Antimalarials are a therapeutic intervention for management of malaria, and prevention of complications due to Plasmodium falciparum infection. However, implementation of these interventions is fraught with problems of complex and multidimensional nature at the periphery. These can be addressed by optimizing the use of the 2 interventions, the insecticide treated nets and antimalarials, for area specific application and country specific needs, determined by the eco-epidemiological diversity of malaria in India. This article reviews the significant role of ITN in reducing child mortality, and the judicious use of antimalarials in the management of malaria patient, and the problems associated with the use of these interventions in protecting children against malaria in India.

Micronutrient supplementation and child survival in India.

India contributes to a large number and proportion of child deaths, both due to higher under five mortality rate and large child population cohort in the country. The micronutrient malnutrition is an ignored area as it is not a direct cause of child mortality but a contributory factor in many deaths. The repeated surveys and studies have noted that iron deficiency anemia, vitamin A deficiency, iodine deficiency are highly prevalent amongst the children in the country and the preventive interventions are reaching only small proportion of 10-50% of the targeted populations. The contribution of these micronutrients (Iron, Vitamin A, Iodine and Zinc) towards child survival depends upon number of factors that are responsible for child mortality, and these situations vary from region to region, time to time and depend upon number of other socio demographic characteristics of the population. This paper discusses that although there may be debate on the role of some micronutrients in reducing childhood mortality, there is no doubt that these micronutrients are needed in small amount for overall child development. These micronutrients, both directly and indirectly, contribute to the child survival and should reach to each and every child in the country and the strategy is proven cost effective.

Health research strengthening and operational research needs for improving child survival in India.

Health research can be utilized to improve the policies, interventions and outputs of the health systems, and ultimately the health of individuals and population. This requires systematic evaluation of evidence and its integration into national policies and programs after suitable adoption at the local level. It has been noted that there has been limited focus upon strengthening health research in India, due to weak research systems or institutional mechanisms, lack of trained human resources and enabling environment, absence of well defined priorities, perceived low quality of research, and inadequate funding. Though various vertical and integrated health programs for improving child survival in the country have been introduced, the decline in child mortality has been excessively slow. Operational research, a sub theme of health research, which uses systematic research techniques to provide evidence to the policymakers and program managers, can be used to assess programmatic issues and improve their effectiveness. This article analyzes the current situation of health research in India, describes briefly the process of operational research, and summarizes the areas of programmatic concern and priority topics for future research in five key fields of child health (Newborn health, Immunization, Malnutrition, Disease prevention and control, health systems strengthening). Finally, it outlines the immediate need of strengthening health research system in the country for improving child survival through increased funding, development of institutional mechanisms, building pool of talented researchers and provision of an enabling environment, to facilitate health and operational research in a scientifically credible manner and to ensure wider dissemination of results.