Emerging & re-emerging infections in India: An overview.

The incidence of emerging infectious diseases in humans has increased within the recent past or threatens to increase in the near future. Over 30 new infectious agents have been detected worldwide in the last three decades; 60 per cent of these are of zoonotic origin. Developing countries such as India suffer disproportionately from the burden of infectious diseases given the confluence of existing environmental, socio-economic, and demographic factors. In the recent past, India has seen outbreaks of eight organisms of emerging and re-emerging diseases in various parts of the country, six of these are of zoonotic origin. Prevention and control of emerging infectious diseases will increasingly require the application of sophisticated epidemiologic and molecular biologic technologies, changes in human behaviour, a national policy on early detection of and rapid response to emerging infections and a plan of action. WHO has made several recommendations for national response mechanisms. Many of these are in various stages of implementation in India. However, for a country of size and population of India, the emerging infections remain a real and present danger. A meaningful response must approach the problem at the systems level. A comprehensive national strategy on infectious diseases cutting across all relevant sectors with emphasis on strengthened surveillance, rapid response, partnership building and research to guide public policy is needed.

Contribution of medical colleges to tuberculosis control in India under the Revised National Tuberculosis Control Programme (RNTCP): Lessons learnt & challenges ahead.

Medical college faculty, who are academicians are seldom directly involved in the implementation of national public health programmes. More than a decade ago for the first time in the global history of tuberculosis (TB) control, medical colleges of India were involved in the Revised National TB Control Programme (RNTCP) of Government of India (GOI). This report documents the unique and extraordinary course of events that led to the involvement of medical colleges in the RNTCP of GOI. It also reports the contributions made by the medical colleges to TB control in India. For more than a decade, medical colleges have been providing diagnostic services (Designated Microscopy Centres), treatment [Directly Observed Treatment (DOT) Centres] referral for treatment, recording and reporting data, carrying out advocacy for RNTCP and conducting operational research relevant to RNTCP. Medical colleges are contributing to diagnosis and treatment of human immunodeficiency virus (HIV)-TB co-infection and development of laboratory infrastructure for early diagnosis of multidrug-resistant and/or extensively drug-resistant TB (M/XDR-TB) and DOTS-Plus sites for treatment of MDR-TB cases. Overall, at a national level, medical colleges have contributed to 25 per cent of TB suspects referred for diagnosis; 23 per cent of ‘new smear-positives’ diagnosed; 7 per cent of DOT provision within medical college; and 86 per cent treatment success rate among new smear-positive patients. As the Programme widens its scope, future challenges include sustenance of this contribution and facilitating universal access to quality TB care; greater involvement in operational research relevant to the Programme needs; and better co-ordination mechanisms between district, state, zonal and national level to encourage their involvement.

Pneumonia in South-East Asia Region: Public health perspective.

Globally, pneumonia is the leading cause of death in young children and burden of disease is disproportionately high in South-East Asia Region of WHO. This review article presents the current status of pneumonia disease burden, risk factors and the ability of health infrastructure to deal with the situation. Literature survey was done for the last 20 years and data from country offices were also collected. The estimated incidence of pneumonia in under five children is 0.36 episodes per child, per year. Risk factors are malnutrition (40% in India), Indoor air pollution, non-breast feeding, chronic obstructive pulmonary disease, etc. Strengthening of health care delivery system for early detection and treatment and as well as minimization of preventable risk factors can avert a large proportion of death due to pneumonia.

Tobacco use: A major risk factor for non communicable diseases in South-East Asia region.

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.

Can visceral leishmaniasis be eliminated from Asia?

Data on the burden of visceral leishmaniasis (VL) in Indian sub-continent are vital for elimination programme planners for estimating resource requirements, effective implementation and monitoring of elimination programme. In Indian sub-continent, about 200 million population is at risk of VL. Nearly 25,000-40,000 cases and 200-300 deaths are reported every year, but these are grossly underestimates. Recent well-designed multicentric studies identified VL burden of 21 cases/10,000 among sampled population in Indian sub-continent (Bangladesh, India and Nepal). This estimates 4,20,000 cases per 200 million risk population clearly indicating that the disease is highly under-reported. Chemical and environmental vector control studies show that the indoor residual spraying (IRS) and long-lasting insecticidal nets (LLINs) are effective and significantly reduce sandfly densities. The findings documented from different sources revealed that some gaps and weakness in existing policies for introducing VL vector control interventions. Our studies emphasize the need of integrated vector management with both IRS and LLIN vector control interventions. Active case detection with rK39 strip test as diagnostic tool is the key element for detection of VL cases. The use of oral drug miltefosine for the treatment after assessing feasibility at community level is important. Kala-azar elimination in Indian sub-continent is possible if elimination programmes ensure access to health care and prevention of kala-azar for people at risk with particular attention to the poorest and marginalized groups. The evidence-based policy should be designed that motivates to implement the programmes, which will be cost-effective. Maintaining the acceptable level of incidence requires public awareness, vector control, appropriate diagnosis and treatment. The five pillars of VL elimination strategies identified are: early diagnosis and complete treatment; integrated vector management and vector surveillance; effective disease surveillance through passive and active case detection; social mobilization and building partnerships; and clinical and operational research which need to be re-enforced to effective implementation.

Good progress with DOTS in the South-East Asia Region.

The South-East Asia Region (SEAR) accounts for 38% of the global tuberculosis (TB). Encouraging progress has been made since the DOTS strategy was introduced in all SEAR Member States between 1993-94. Operational guidelines for and joint plans of action for disease control activities in the border districts of Bangladesh, Bhutan, India and Nepal have been drawn up. The key issues involved in the good progress with DOTS are: Resource mobilisation, case detection, case management, drugs and logistics, supervision, monitoring and surveillance, preventing emergence of multidrug resistant TB and lastly health sector reform. Given the current momentum and commitment, it is expected that the region will active the set targets of universal coverage by 2006.

Poor reliability of the first meal tolerance test.

The poor reproducibility of oral glucose tolerance test (OGTT) has been known for a long time. Some recent reports indicate that postprandial glycaemia achieved during the test is likely to be higher on the first occasion than on subsequent visits. We have analysed our recent data on meal tolerance tests (MTT) from this angle. Fifteen healthy subjects and 9 subjects having NIDDM were administered two essentially identical meals one or two weeks apart. In case of healthy subjects, the absolute as well as incremental postprandial glycaemia achieved at 0.5 h and 1.0 h on the first visit was significantly higher (P < 0.05) than on the subsequent visit. The effect of visit was insignificant in case of NIDDM subjects. The effect observed in healthy subjects may be due to the release of adrenaline during the first visit brought about by apprehension. In NIDDM subjects the apprehension is likely to be much less because of their having undergone such tests in the past. Hence a single casual OGTT or MTT is unreliable as a diagnostic tool in borderline cases of impaired glucose tolerance test. The test needs to be repeated at least once more to eliminate false positives.

Effect of coingestion of paracetamol on glycaemic response.

Rate of gastric emptying is a frequently measured variable in glycaemic response studies. One of the indices employed for measurement of the gastric emptying rate is the blood level of paracetamol at frequent intervals of time following coingestion of paracetamol with the meal. But the effect of paracetamol itself on glycaemic response is not known. The present study was performed on ten healthy and five NIDDM subjects. Each subject underwent two meal tolerance tests in random sequence. On one occasion the meal was white bread; on the other occasion, the meal consisted of the same quantity of white bread and 1.5 g paracetamol. The postprandial glycaemica following the two meals was not significantly different. Thus the results validate the use of the paracetamol technique for gastric emptying in glycaemic response studies.

Glycaemic response to maize, bajra and barley.

The postprandial glycaemic response to maize (Zea mays), bajra (Pennisetum typhoideum) and barley (Hordeum vulgare) was studied in a pool of 18 healthy volunteers and 14 patients having non-insulin-dependent diabetes mellitus (NIDDM). In response to maize, none of the variables examined was significantly different as compared to white bread. The glycaemic response to bajra was significantly lower than that to white bread in healthy subjects, but the two responses were indistinguishable in NIDDM subjects. The insulinaemic responses to bajra and white break were not significantly different in either group of subjects. The glycaemic response to barley was significantly lower than that to white bread in both groups of subjects. But the insulinaemic response to barley was significantly lower than that to white bread only in healthy subjects. In NIDDM subjects, there was a tendency for the response to barley to be higher than that to white bread 0.5 h after ingestion. Barley, with a low glycaemic index (68.7 in healthy and 53.4 in NIDDM subjects) and a high insulinaemic index (105.2) in NIDDM subjects seems to mobilize insulin in NIDDM. This makes it a specially suitable cereal for diabetes mellitus.

La lucha contra el SIDA en el Caribe: Un enfoque subregional coordinado / Combatting AIDS in the Caribbean: A coordinated subregional approach

Combatting AIDS in the Caribbean: A coordinated subregional approach