Preparedness of primary & secondary care health facilities for the management of non-communicable diseases in tribal population across 12 districts in India

Background and objectives: Non-communicable diseases (NCDs) are highly prevalent in the tribal populations; however, there are limited data regarding health system preparedness to tackle NCDs among these populations. We estimated the availability of human resources, equipment, drugs, services and knowledge of doctors for NCD management in the selected tribal districts in India. Methods: A cross-sectional survey was conducted in 12 districts (one from each State) with at least 50 per cent tribal population in Andaman and Nicobar Islands, Himachal Pradesh, Madhya Pradesh, Odisha and eight northeastern States. Primary health centres (PHCs), community health centres (CHCs) and district/sub-district hospitals (DHs) were surveyed and data on screening and treatment services, human resources, equipment, drugs and information systems indicators were collected and analysed. The data were presented as proportions.Results: In the present study 177 facilities were surveyed, including 156 PHCs/CHCs and 21 DHs. DHs and the majority (82-96%) of the PHCs/CHCs provided outpatient treatment for diabetes and hypertension. Overall, 97 per cent of PHCs/CHCs had doctors, and 78 per cent had staff nurses. The availability of digital blood pressure monitors ranged from 35 to 43 per cent, and drugs were either not available or inadequate. Among 213 doctors, three-fourths knew the correct criteria for hypertension diagnosis, and a few correctly reported diabetes diagnosis criteria. Interpretation & conclusions: The results of this study suggest that the health system of the studied tribal districts was not adequately prepared to manage NCDs. The key challenges included inadequately trained workforce and a lack of equipment and drugs. It is suggested that capacity building and, procurement and distribution of equipment, drugs and information systems to track NCD patients should be the key focus areas of national programmes

Non-communicable diseases as a major contributor to deaths in 12 tribal districts in India

Background & objectives: Non-communicable diseases (NCDs) are the leading cause of death in India. Although studies have reported a high prevalence of NCD in tribal populations, there are limited data pertaining mortality due to NCDs. Therefore, in this study we estimated the proportion of deaths due to NCDs among 15 yr and older age group in tribal districts in India. Methods: We conducted a community-based survey in 12 districts (one per State) with more than 50 per cent tribal population. Data were collected using a verbal autopsy tool from the family member of the deceased. The estimated sample size was 452 deaths per district. We obtained the list of deaths for the reference period of one year and updated it during the survey. The cause of death was assigned using the International Classification of Diseases-10 classification and analyzed the proportions of causes of death. The age-standardized death rate (ASRD) was also estimated. Results: We surveyed 5292 deaths among those above 15 years of age. Overall, NCDs accounted for 66 per cent of the deaths, followed by infectious diseases (15%) and injuries (11%). Cardiovascular diseases were the leading cause of death in 10 of the 12 sites. In East Garo Hills (18%) and Lunglei (26%), neoplasms were the leading cause of death. ASRD due to NCD ranged from 426 in Kinnaur to 756 per 100,000 in East Garo Hills. Interpretation & conclusions: The findings of this community-based survey suggested that NCDs were the leading cause of death among the tribal populations in India. It is hence suggested that control of NCDs should be one of the public health priorities for tribal districts in India.

The Design And Development Of Carvedilol Gastroretentive Floating Drug Delivery Systems Using Hydrophilic Polymers And In Vitro Characterization

Objective: The primary aim of the present examination was to create carvedilol phosphate floating tablets using factorial designs and for retention in the upper portion of the gastrointestinal (GI) tract to sustain the dissolution where the solubility of carvedilol phosphate is more in an acidic medium. Methods: The floating tablets of carvedilol phosphate were ready to employ different concentrations and a combination of these polymers of Na-alginate, Carbopol 934P, and sodium carboxymethyl cellulose (NaCMC) with lubricants magnesium stearate by direct compression technique. In the present experiment, involved sodium bicarbonate and citric acid as a gas-producing agent. Fifteen formulations structured and judged for pre-compression components like the angle of repose, bulk and tapped density, Hausner’s ratio, compressibility index, and post-compression factors are weight uniformity, hardness, drug content, friability, in vitro buoyancy, dissolution studies, and Fourier transforms infrared spectroscopy (FTIR). Results: The drug released 90.02% in 12 h by combining NaCMC (7.5 mg) and Na-alginate (7.5 mg) in the formulation F14 towards the achievement of sustained release. Batch F14 selected as optimized, as provided desired zero-order release profile as well as floating lag time 20 s and total floating time>12 h, and the mechanism of drug release observed (n = 1.098, super case-II transport). Conclusion: From the results fulfilled that all the preparation found to be within the pharmacopeia limits and was the best dosage form to treat moderate heart failure and hypertension. The in vitro dissolution profiles of all formulations placed into various kinetic models, the statistical parameters like slope, regression coefficient and intercept determined. The gastro-retentive dosage form to maintain the sustain drug delivery, which would improve the maximum therapeutic efficacy and patient compliance.

In Silico Screening Of Zinc Database For Discovery Of Novel Urease Inhibitors As A Remedy To Gastro-Duodenal Ulcer Caused By Helicobacter Pylori

Design and synthesis of novel urease inhibitors taking center stage now days with specific attention as a remedy to Helicobacter pylori infection. A number of inhibitors fail in vivo and in clinical trial owing to the toxicity and hydrolytic profile. In the present study, we are making an attempt to screen a large small molecule database, ZINC, for a potential urease inhibitor. The structure based drug discovery approach has been adopted with acceptable ADMET parameters so that the lead molecules may have fair chances of passing in vitro and in vivo trails. The lead molecule in our study, with ID ZINC90446454 is a urea derivative and predicted to be nontoxic. It comes out to be a promising drug candidate with pKd value 7.83, LE 0.429 and LD50 value 10100 mg/kg body weight. Its sulfanyl derivative, with predicted high LD50 (10100 mg/kg body weight), exhibits the feasibility of a disulfide covalent bond with Cys321 in the active site. The derivative may serve as a novel covalent inhibitor with high specificity, high potency and low toxicity. The derivative, in future, may be a successful drug candidate for H. pylori induced gastro-duodenal ulcer.

Larvicidal activity of few select indigenous plants of North East India against disease vector mosquitoes (Diptera: Culicidae)

Mosquitoes are the vectors of several life threatening diseases like dengue, malaria, Japanese encephalitis and lymphatic filariasis, which are widely present in the north-eastern states of India. Investigations on five local plants of north-east India, selected on the basis of their use by indigenous communities as fish poison, were carried out to study their mosquito larvicidal potential against Anopheles stephensi (malaria vector), Stegomyia aegypti (dengue vector) and Culex quinquefasciatus (lymphatic filariasis vector) mosquitoes. Crude Petroleum ether extracts of the roots of three plants viz. Derris elliptica, Linostoma decandrum and Croton tiglium were found to have remarkable larvicidal activity; D. elliptica extract was the most effective and with LC50 value of 0.307 μg/ml its activity was superior to propoxur, the standard synthetic larvicide. Half-life of larvicidal activity of D. elliptica and L. decandrum extracts ranged from 2-4 days.

Effect of Andrographis serpyllifolia Leaves Extract on Experimentally Induced Typhoid Using Salmonella Typhi.

Aims: The aim of the study was to evaluate the effect of the standardized ethanolic extract of Andrographis serpyllifolia leaves on experimentally induced typhoid. Study Design: Single dose of 1 ml Salmonella Typhi (106 CFU/mL) was administered orally to rats to induce typhoid in rats. Blood culture test confirmed typhoid infectioned rats received orally the ethanolic extract of Andrographis serpyllifolia at dose levels of 200 and 400 mg/kg twice daily for 10 days, respectively and control animals received physiological saline. Place and Duration of Study: CSIR-National Botanical Research Institute (NBRI), Lucknow, between December 2011 and June 2013. Methodology: Leaves of Andrographis serpyllifolia was extracted with ethanol and concentrated on rotavapour. Single dose of 1 ml S. Typhi (106 CFU/mL) was administered orally to rats with the help of orogastric tube to induce typhoid in rats. After seven days, typhoid confirmed rats received the standardized extract subsequently subjected to in vitro antimicrobial susceptibility test. Results: The treatment with ethanolic extract of Andrographis serpyllifolia at dose level of 200 mg/kg showed 75.0% to 87.5% protection and 100% protection observed at higher dose of 400 mg/kg on widal, blood culture and typhidot test respectively. Biochemical test carried out on blood culture isolates confirmed the presence or absence of S. Typhi. A. serpyllifolia extract at a concentration of 1.50 mg/disc showed antimicrobial activity susceptibility against S. Typhi. Conclusion: Andrographis serpyllifolia leaves extract showed antimicrobial activity against S. Typhi and accomplished the extract of A. serpyllifolia is recommended for clinical applications in the treatment of typhoid.

Community practices of using bed nets & acceptance & prospects of scaling up insecticide treated nets in north-east India.

Background & objectives: The National Vector Borne Disease Control Programme (NVBDCP), India has been promoting and scaling up the use of insecticide-treated nets (ITNs) in the tribal dominated malarious areas of north-east India. But, information on sleeping habits, bed net ownership and use practices, and feedback of communities in ITN - targeted areas is needed for formulating a strategic framework for upscaling the coverage of ITNs. We carried out a community-based cross-sectional survey in select areas of Nagaland and Mizoram (where ITNs were introduced) along with Assam (where ITNs were not introduced) to know the response of community. Methods: Following large scale introduction of ITNs during 2001-2002 in the north-eastern States of Nagaland and Mizoram by NVBDCP, India, a cross-sectional community-based survey was undertaken in April-May, 2003 covering 435 households of Nagaland and 464 households in Mizoram, using a structured questionnaire, to assess the demographic variables relevant to bed net use, bed net washing practices and acceptability of ITNs etc., for upscaling the coverage of ITNs in the surveyed communities. A total of 448 households in 8 villages in a non-ITN PHC area of Assam were served as the control area. Results: The average bet net usage per family (2.01 to 2.65). Bed net use was mostly seasonal in Nagaland where a majority (65.1-78.7%) used bed nets only during summers and monsoon as compared to the year round use in Mizoram (83.5%) and Assam (78.9%). Frequent washing of nets was most common in Assamese communities with 77 per cent households washing their nets at least once in a month. More than two third users favoured use of ITNs over the conventional indoor residual spray of DDT for malaria control. Interpretation & conclusion: ITNs are widely acceptable in the user communities and a demand for ITNs is evident in the non-user communities of north-east India. Approach of treating community owned nets through an efficient service delivery mechanism will be a viable option for upscaling the ITN coverage.

Community practices of using bed nets & acceptance & prospects of scaling up insecticide treated nets in north-east India.

BACKGROUND & OBJECTIVE: The National Vector Borne Disease Control Programme (NVBDCP), India has been promoting and scaling up the use of insecticide-treated nets (ITNs) in the tribal dominated malarious areas of north-east India. But, information on sleeping habits, bed net ownership and use practices, and feedback of communities in ITN--targeted areas is needed for formulating a strategic framework for upscaling the coverage of ITNs. We carried out a community-based cross-sectional survey in select areas of Nagaland and Mizoram (where ITNs were introduced) along with Assam (where ITNs were not introduced) to know the response of community. METHODS: Following large scale introduction of ITNs during 2001-2002 in the north-eastern States of Nagaland and Mizoram by NVBDCP, India, a cross-sectional community-based survey was undertaken in April-May, 2003 covering 435 households of Nagaland and 464 households in Mizoram, using a structured questionnaire, to assess the demographic variables relevant to bed net use, bed net washing practices and acceptability of ITNs etc., for upscaling the coverage of ITNs in the surveyed communities. A total of 448 households in 8 villages in a non-ITN PHC area of Assam were served as the control area. RESULTS: The average bet net usage per family (2.01 to 2.65). Bed net use was mostly seasonal in Nagaland where a majority (65.1-78.7%) used bed nets only during summers and monsoon as compared to the year round use in Mizoram (83.5%) and Assam (78.9%). Frequent washing of nets was most common in Assamese communities with 77 per cent households washing their nets at least once in a month. More than two third users favoured use of ITNs over the conventional indoor residual spray of DDT for malaria control. INTERPRETATION & CONCLUSION: ITNs are widely acceptable in the user communities and a demand for ITNs is evident in the non-user communities of north-east India. Approach of treating community owned nets through an efficient service delivery mechanism will be a viable option for upscaling the ITN coverage.

Detection & molecular confirmation of a focus of Plasmodium malariae in Arunachal Pradesh, India.

BACKGROUND & OBJECTIVE: During a malaria epidemiological study in Arunachal Pradesh, Plasmodium malariae like human malaria parasites were seen in blood smears from fever cases. The study was undertaken to detect the presence of P. malariae and to confirm its identity through DNA based polymerase chain reaction approach. METHODS: Fever survey was carried out in 22 villages in Indo-Myanmar bordering district of Lohit, Arunachal Pradesh in 2005. Morphologically suspected P. malariae cases were confirmed using nested PCR based on 18S small subunit ribosomal DNA gene sequence. RESULTS: Screening of 1,995 fever cases resulted in 9 probable cases of P. malariae based on morphological identification in Chakma tribe people residing in 2 villages. Nested PCR confirmed the identity of all probable cases of P. malariae by producing diagnostic band of 144 bp. PCR method was able to detect mixed infection of P. malariae with P. vivax and with P. falciparum. INTERPRETATION & CONCLUSION: P. malariae may have been present in Arunachal Pradesh but most probably is being misdiagnosed due to its close resemblance with P. vivax, especially in ring forms. Estimation of actual case load of P. malariae in north-east India is, therefore, important with accurate species identification using molecular methods.

Characterization of ITS2 rDNA of Anopheles philippinensis and Anopheles nivipes (Diptera: Culicidae) from north-east India.

Anopheles (Cellia) philippinensis Ludlow and Anopheles (Cellia) nivipes (Theobald) are two closely related, morphologically very similar, mosquito species in the Annularis group, which play a supportive role in malaria transmission in north-east India. We amplified and performed sequence analysis for the internal transcribed spacer 2 (ITS2) locus of ribosomal DNA (rDNA) gene of morphologically confirmed specimens of these two species from the states of Assam and Nagaland. An. philippinensis and An. nivipes shared 85.2% sequence similarity and no intra-species variation was found in the nucleotide sequences of the two species. Overall, sequence data of the ITS2 marker revealed that both these species from north-east India differed by as much as have been reported from specimens of eastern Thailand.

Potential of Anopheles philippinensis-nivipes complex mosquitoes as malaria vector in north-east India.

Anopheles philippinensis-nivipes complex mosquitoes, captured in outdoor human landing catches and light traps in human dwellings from four different sites in Assam state and adjoining areas, were examined (n=1670) for the presence of circumsporozoite antigen (CSA) through enzyme linked immunosorbent assays (ELISA), using species specific capture monoclonal antibodies, of Plasmodium falciparum and two Plasmodium vivax polymorphs (Pv 210 and VK 247). In ELISA, 28 pools were found positive for CSA that accounted for minimum sporozoite rate of 1.7% (95% CI 1.11-2.41). Twenty five percent (7/28) of the positive pools were reactive for P. falciparum and between the two polymorphs of P. vivax, VK 247 was predominant with 77% (20/26) of all P. vivax positive pools. Results were suggestive of most likely involvement of Anopheles philippinensis-nivipes complex mosquitoes in malaria transmission in north-east India.

Taxonomical observations on Anopheles philippinensis/nivipes group mosquitoes in north-east India.

To examine the distribution pattern of Anopheles philippinensis and An. nivipes, mosquitoes belonging to An. philippinensis/nivipes group were collected from five sites in north-east Indian state of Assam and its adjoining areas and identified. Presence of both An. philippinensis and An. nivipes, with predominance of the latter taxon, was recorded with conformity on the basis of pupal paddle characteristics. Based on adult wing characters, 91.4% specimens were identified as An. philippinensis and 8.6% as An. nivipes with gradually increasing proportion of An. nivipes in westwardly direction. An. philippinensis/ nivipes was noted to be mid night biter, mainly exophagic and exclusively exophilic. Of the two species, An. philippinensis appears to be mostly anthropophilic and available in broken forest areas whereas An. nivipes seems to be mostly zoophilic and generally found in ecotone zones in plains areas.

Therapeutic efficacy of anti-malarials in Plasmodium falciparum malaria in an Indo-Myanmar border area of Arunachal Pradesh.

BACKGROUND & OBJECTIVES: Malaria is one of the major public health problems in the north eastern region of India. Antimalarial drug resistance is widespread and one of the important causes of recent resurgence of falciparum malaria in this region. Antimalarial drugs are seen to be used sequentially one after another in many areas of the region, when therapeutic failure is observed with a drug. In view of this, the present study was undertaken to assess the therapeutic efficacy of common antimalarial drugs viz., chloroquine, sulfadoxine+pyrimethamine (S-P) and quinine, administered sequentially to the patients with Plasmodium falciparum infection in a Myanmar bordering area of Arunachal Pradesh. METHODS: A hospital based in vivo study was carried out with 53 patients with uncomplicated falciparum malaria. All patients were first treated with chloroquine and therapeutic efficacy assessed. In case of therapeutic failure of chloroquine combination drug (S-P) was given and those showing failure with S-P combination, oral quinine was administered and followed up for 28 days to assess both clinical and parasitological responses. RESULTS: Therapeutic failure was observed with chloroquine in 83.1 per cent (44 of 53) and to both chloroquine and S-P combination drug in 44.1 per cent (19/43) patients. Further, 15.8 per cent patients (3 of 19) failed to respond even to quinine. Overall, 5.7 per cent patients (3 of 53) showed unresponsiveness to all the three drugs i.e., chloroquine, S-P combination and quinine. Asexual parasite clearance and also fever clearance was slowest with chloroquine and fastest with quinine. INTERPRETATION & CONCLUSION: The findings of this study show the presence of multi drug failure P. falciparum in Jairampur-Nampong, a western Myanmar bordering area of Arunachal Pradesh. Anti malarial drug resistance is increasing in Indo-Myanmar border areas and systematic studies need to be done to review the situation.

Malaria control in a forest camp in an oil exploration area of Upper Assam.

BACKGROUND: Assam, in north-east India, is extremely rich in hydrocarbon deposits and the oil industry is the major contributor to its economy. A large number of oil fields and related installations in Assam are located in forest areas or on their fringes where malaria is a serious problem among field staff and security personnel, adversely affecting oil production. We carried out an operational research study for one year in a forest-based industrial security camp of Dibrugarh district and developed an effective malaria control strategy for such areas. METHODS: The specific strategy was formulated and implemented after taking into account the local epidemiology of malaria, vector's ecology and malaria risk behaviour of the camp inmates. The strategy was based on reducing the man-vector contact, using deltamethrin-treated mosquito nets in conjunction with mosquito repellent cream and weekly chemoprophylaxis with 300 mg chloroquine. The impact of the strategy was monitored entomologically and epidemiologically for one year after implementation. RESULTS: The mean landing rate of Anopheles dirus, the vector mosquito in the camp area, was 5.03 per person per night during the monitoring. In spite of such a high density of the vector, the man-vector contact was effectively checked by the intervention measures adopted. As a result, the incidence of malaria in the camp was reduced by > 90% as compared to previous years and the number of malaria cases came down from 6.7 per 1000 man-nights in 1998-99 to 0.06 in 2000-01. Mortality due to malaria was completely eliminated. CONCLUSION: Control of malaria should be based on the local determinants of transmission. The use of insecticide-treated mosquito nets in conjunction with a mosquito repellent cream is a good intervention for controlling Anopheles dirus-transmitted malaria in the forests of north-east India. The control module developed on the principle of reducing man-mosquito contact is easy to implement, cost-effective and replicable in similar forest-based locations.

Physico-chemical characteristics of breeding habitats of Anopheles dirus (Diptera:Culicidae) in Assam, India.

Larval ecology of Anopheles dirus, the main vector of forest malaria in north-eastern region of India, was studied in relation to physico-chemical characteristics of its breeding habitats in a rain forest area of Assam, India. Shady stream side pools, positive for the breeding of An. dirus, had significantly higher amounts of total hardness (P < 0.024) in comparison to negative pools of similar type. When compared with An. dirus negative breeding habitats, in hot-wet as well as in cool-dry seasons, An. dirus positive shady ground pools showed higher mean values of total alkalinity, hardness and chloride content, whereas lower pH, dissolved oxygen along with higher total alkalinity and hardness were possessed by An. dirus positive stream side pools. Specificity of breeding habitats of An. dirus in relation to its ecology has been discussed.

Risk factors of malaria in the fringes of an evergreen monsoon forest of Arunachal Pradesh.

BACKGROUND: The forested hilly and foothill regions of north-east India are highly endemic for malaria and have a distinct epidemiological pattern. Nearly half the reported cases of malaria are from these areas. A knowledge of the risk factors in this eco-geographic entity may be helpful in formulating a specific control strategy. Hence, we conducted a community-based epidemiological study in a hilly, forested terrain of Arunachal Pradesh and examined different socio-demographic factors to identify those predisposing to the occurrence of malaria, especially Plasmodium falciparum infection, in such areas. METHODS: Four epidemiological surveys were carried out during 1997 in 7 villages located at the fringes of a forest (total population: 1177) under Nompong Primary Health Centre of Changlang district, Arunachal Pradesh. Blood slides were collected randomly from the inhabitants, irrespective of their fever status, ensuring at least 50% coverage. One hundred and thirty-four microscopically confirmed Plasmodium falciparum cases were identified and 536 controls were randomly selected from the list of uninfected inhabitants. Relevant socio-demographic information was obtained from both cases and controls. The data were analysed by simple and multiple logistic regression using the unconditional maximum likelihood method. RESULTS: Factors which were found to be strongly associated with Plasmodium falciparum malaria on univariate analysis were age, ethnicity, village of residence and accessibility to the nearest health care facility. However, in multiple regression analysis, after controlling for the effects of confounding variables, the only risk factor identified was accessibility to the nearest health care facility (adjusted odds ratio: 4.5; 95% CI: 1.8-11.3; p < 0.0001 for those at a distance of 2-8 km and adjusted odds ratio: 11.1; 95% CI: 4.1-30.0; p < 0.0001 for those > 8 km away). CONCLUSION: Distance, particularly non-motorable distance, from the place of residence to the nearest health care facility was a major risk factor for malaria in this hilly forested terrain. This indicates the need for special efforts to detect cases early and institute treatment promptly in such areas of the north-eastern region, so as to reduce the morbidity and mortality of malaria.

Epidemiology of malaria outbreak (April/May, 1999) in Titabor Primary Health Centre, district Jorhat (Assam).

An investigation was undertaken of a malaria outbreak in the Primary Health Centre Titabor, district Jorhat, Assam during May/June 1999. The fever rate in the community since March 1999, was 44.4 per cent with an average case load of 2.5 per family. The fever cases peaked in the third week of May. Slide positive and slide falciparum rates in mass blood survey, in the study village were 16.1 and 14.5 per cent respectively with 90 per cent infection of Plasmodium falciparum. Males (SPR 17.5%) suffered relatively more than females (SPR 14.7%). Malaria prevalence was significantly less in individuals above 15 yr of age (SPR 11.0%) as compared to those below 15 yr (SPR 22.9%). Prevalence of malaria as well as mosquito densities in different clusters of the village were inversely related to the distance from the forested Naga hills. Anopheles minimus and A. dirus were collected in good numbers with comparatively higher densities of the former. Several factors like unusual climatic conditions, inadequate surveillance, unsatisfactory laboratory services and inadequate indoor residual insecticide spray were instrumental for the outbreak.

Lymphatic filariasis in two distinct communities of upper Assam.

Current status of bancroftian filariasis among two distinct communities of Upper Assam was evaluated. High prevalence (10.3% mf rate) in tea workers descendents of tribals migrated from endemic states such as Orissa, Bengal, Uttar Pradesh and southern states of India, were recorded. Among non tea workers (indigenous population) significantly low mf rate was found in spite of the fact that both the communities are living in close vicinity and in similar ecological and mosquitogenic conditions. Culex quinquefasciatus was incriminated as vector in the areas of both the communities. A group of recent migrants of Bihar and Bengal living in the locality of non tea worker population were also found microfilaraemic. Significantly lower infection rate in non tea worker population appears to be associated with host susceptibility to the infection. Familial clustering in microfilaraemic subjects noticed in tea workers group also suggests involvement of racial susceptibility to infection.