The burden of skin diseases in India: Global Burden of Disease Study 2017

Background: The prevalence of skin diseases has increased over the last few decades, and they contribute to a significant burden on health-care systems across the world. Aims/Objective: This report looks at the burden of skin and subcutaneous diseases in terms of years lived with disability and age-standardised years lived with disability in India using the Global Burden of Disease Study results from 2017. Methods: Data were obtained from the Global Burden of Disease online interactive tool. Updated estimates of the world’s health for 359 diseases and injuries and 84 risk factors from 1990 to 2017 are available in this interactive tool. Results: Years lived with disability due to skin and subcutaneous diseases accounted for 4.02% of the total years lived with disability in India in 2017. There was an increase of 53.7% in all age standardised years lived with disability for all the skin and subcutaneous diseases from 1990 to 2017. Among skin and subcutaneous diseases, dermatitis contributed maximum years lived with disability (1.40 million; 95% uncertainty interval, 0.82–2.21) in 2017, followed by urticaria (1.02 million; 95% uncertainty interval, 0.06–1.44) with percentage increases of 48.9% and 45.7% respectively. Conclusion: The burden due to infectious skin diseases (e.g., scabies, fungal skin disease and bacterial skin disease) and non-infectious diseases (e.g., dermatitis, urticaria and psoriasis) has increased over the past three decades, however the age-standardised years lived with disability for leprosy, scabies, fungal infections, sexually transmitted infections and non-melanoma skin cancer (basal cell carcinoma) has decreased. The high burden of skin and subcutaneous diseases demand that they be given due importance in the national programmes and health policy of India.

Nurse-led Cardiovascular Diseases Risk Assessment and Communication using WHO/ISH Risk Prediction Chart in a Tertiary care Hospital of North India

Cardiovascular diseases (CVDs) contribute to most of the potentially preventable burden through early risk assessment. Nurse-led CVD risk assessment is an effective strategy to address the human resource crisis for CVD prevention. An interventional study was conducted in medicine wards of a tertiary care hospital in North India to train nurses in CVD risk assessment and its communication. All bedside nurses (n = 30) of selected wards were enrolled and trained in CVD risk assessment and communication using WHO/ISH risk prediction charts. Once fully trained, each nurse enrolled patients (>40 years of age) from their respective wards to assess and communicate CVD risk. To calculate the reliability of risk assessment, investigator simultaneously assessed CVD risk with nurses. The mean age of nurses was 32.07 ± 6.31 years. The results revealed that training significantly increased the knowledge of nursing personnel (P < 0.001). There was perfect inter?rater reliability agreement (Cohen’s k = 0.929) between nurses and investigators while assessing CVD risk. Nurses demonstrated good communication skills. The study concluded that nurses can be trained successfully in CVD risk assessment and communication. The study recommends the task shifting of CVD risk assessment to nurses after providing proper training

Use of Fluoridated Dentifrices amoung Children:Are We in the Right Direction?

Introduction Use of topical fluorides in dentifrices has always been an important tool in prevention of dental caries in young children. Due to the easy availability of various low and high fluoride dentifrices, the parents have no clear understanding about their correct age-appropriate use in children. This study was undertaken to evaluate and understand the trend and current practices among the end user. Materials and Methods A total of 173 children aged 4 to 6 years were enrolled in the study from schools located in two different geographical areas of the Chandigarh city; group 1 (n = 90) from a peri-urban slum cluster: (Govt. Primary School, Indira Colony, Mani Majra, n = 51); Govt. Middle School, Mani Majra (n = 39); group 2 (n = 83) from an urban private city school (Ankur, Punjab University, Sector 14) using cluster sampling method. Two examiners using type IV examination examined all the children aged 4 to 6 years present using a preinstructed close-ended questionnaire. Data were analyzed using SPSS Software Version 25 (SPSS Inc., Chicago, IL, United States). Results The data regarding the knowledge of fluoride in pastes showed that 85% of the children were using high fluoride pastes, 10% were using nonfluoride pastes, and 5% were using low fluoride pastes. In group 1, none of the users were aware about the benefits/risk of using fluoride toothpastes and only 22% were aware in group 2. Only 27% of children in group 1 dispensed the correct amount of dentifrice for this age group i.e., a pea head size versus 67% in group 2; a half brush length was dispensed by 61.5% in group 1 and 28% in group 2, and just a smudge by 11.5% in group 1 and 5% in group 2. Forty one percent children in both the groups had a history of having intentionally consumed the toothpaste. The toothpaste was dispensed to the child by parent in 89% of cases in group 2 and only 50% in group 1 and 88% parents claimed to always supervise the child while tooth brushing versus only 53% in group 1. Majority of the respondents’, i.e., 97% in group 1 and 63% in group 2 had never been explained about the correct method of use of fluoride paste in children. Conclusion Knowledge about fluoridated toothpastes is low am

Determinants of smokeless tobacco use in India

Non-communicable diseases (NCDs) contributes to more than 50 per cent disability adjusted life years (DALYs) in India; and tobacco contributes to 7·4 per cent of DALYs which is next to diet and high blood pressure. According to Global Burden of Disease (GBD) 2015, tobacco use contributed to 5.9 per cent out of total DALYs in India. Smokeless tobacco (SLT) consumption is a multifactorial process influenced by varied range of contextual factors i.e., social, environmental, psychological and the genetic factors which are linked to the tobacco use. The determinants associated with the SLT use are gender, educational level, wealth index (inverse association), urban-rural residence, socio-economic status and low tax. Taking the view from tobacco control programmes, there is a need to address determinants of SLT use with State level monitoring and socio-economic inequalities, progress and review of the taxation of the SLT use in India.

Widespread inequalities in smoking & smokeless tobacco consumption across wealth quintiles in States of India: Need for targeted interventions.

Background & objectives: India is a large country with each state having distinct social, cultural and economic characteristics. Tobacco epidemic is not uniform across the country. There are wide variations in tobacco consumption across age, sex, regions and socio-economic classes. This study was conducted to understand the wide inequalities in patterns of smoking and smokeless tobacco consumption across various states of India. Methods: Analysis was conducted on Global Adult Tobacco Survey, India (2009-2010) data. Prevalence of both forms of tobacco use and its association with socio-economic determinants was assessed across states and Union Territories of India. Wealth indices were calculated using socio-economic data of the survey. Concentration index of inequality and one way ANOVA assessed economic inequality in tobacco consumption and variation of tobacco consumption across quintiles. Multiple logistic regression was done for tobacco consumption and wealth index adjusting for age, sex, area, education and occupation. Results: Overall prevalence of smoking and smokeless tobacco consumption was 13.9 per cent (14.6, 13.3) and 25.8 per cent (26.6, 25.0), respectively. Prevalence of current smoking varied from 1.6 per cent (richest quintile in Odisha) to 42.2 per cent (poorest quintile in Meghalaya). Prevalence of current smokeless tobacco consumption varied from 1.7 per cent (richest quintile in Jammu and Kashmir) to 59.4 per cent (poorest quintile in Mizoram). Decreasing odds of tobacco consumption with increasing wealth was observed in most of the states. Reverse trend of tobacco consumption was observed in Nagaland. Significant difference in odds of smoking and smokeless tobacco consumption with wealth quintiles was observed. Concentration index of inequality was significant for smoking tobacco -0.7 (-0.62 to-0.78) and not significant for smokeless tobacco consumption -0.15 (0.01to-0.33) Interpretation & conclusions: The findings of our analysis indicate that tobacco control policy and public health interventions need to consider widespread socio-economic inequities in tobacco consumption across the states in India.

Women and tobacco: A cross sectional study from North India.

BACKGROUND: Tobacco is a leading risk factor for different types of diseases globally. Tobacco smoking by women is culturally unacceptable in India, but still women smoke tobacco at various times of their life. AIMS: The aim was to estimate the prevalence and pattern of tobacco use among women and to study the associated sociodemographic factors. SETTINGS AND DESIGN: This cross‑sectional study was conducted among women aged 30 years or over in an urban resettlement colony for the migrant population at Chandigarh, India. METHODOLOGY: The study included women used tobacco products on one or more days within the past 30 days. Through systematic random sampling, 262 women were studied. As a part of the study 144 bidi smoking women were interviewed using detailed semi‑structured questionnaire. STATISTICAL ANALYSIS: Descriptive statistics and hypothesis testing with Chi‑squared test and logistic regression were done using SPSS 16.0 version. RESULTS: Overall, the prevalence of tobacco use was 29.4% and that of bidi, zarda and hookah were 19.8%, 8.8%, and 2.7%, respectively. Around 6.2% women used tobacco during pregnancy. Teenage was the most common age of initiation of bidi smoking. Logistic regression analysis showed that the prevalence of tobacco use was high among Hindu unemployed women with no formal education belonged to scheduled caste, and those having grandchildren. CONCLUSIONS: This study highlighted high rates of tobacco use and explored both individual and family factors related to tobacco use among women. Affordable, culturally acceptable, sustainable and gender‑sensitive individual and community‑specific interventions will reduce the prevalence and effects of tobacco use.

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.

Risk factors for cardiovascular diseases: Is the social gradient reversing in northern India.

Background. In the past century, most developed countries witnessed a reversal of social gradient in cardiovascular diseases. To examine whether this phenomenon is also under way in developing countries, we assessed the prevalence of selected risk factors for cardiovascular diseases among different social groups living in urban and rural areas of northern India. Methods. Four hundred adults >30 years of age, selected by cluster sampling, were surveyed from 8 purposively selected communities of Chandigarh and Haryana during 2004–05. The WHO STEPS tool for surveillance of risk factors was used to enquire about sociodemographic characteristics, tobacco use, alcohol intake, physical activity and to measure weight, height, blood pressure, and waist and hip circumference. Prevalence of risk factors such as tobacco use, physical inactivity, overweight (BMI >25 kg/m2), and hypertension (>140/90 mmHg or on anti-hypertension treatment) were estimated according to the area of residence and across educational categories after controlling for the effects of confounding variables. Results. The prevalence of hypertension in urban (39%; 95% CI 29.5%–49.2%), slum (35%; 95% CI 27.2%– 42.9%) and rural (33%; 95% CI 25.4%–40.8%) communities was found to be statistically similar (p>0.05) after controlling for age, gender and education. The prevalence of physical inactivity (17% v. 12%), central obesity (90% v. 88%), overweight (20% v. 19%) and hypertension (34% v. 36%), were found to be statistically similar among literate and illiterate population after controlling for the effect of age, sex and place of residence (p>0.05). However, the risk of tobacco use was significantly lower among literates (OR 0.3, 95% CI 0.1–0.8). Conclusion. In selected communities of northern India, most of the cardiovascular disease risk factors did not have a social gradient except tobacco use, which was more common in the lower social group.

Why youth smoke? An exploratory community-based study from Chandigarh Union Territory of Northern India.

Background: Tobacco use is a serious public health challenge in several regions of the world, including India. Increasingly, steps are being taken at policy level to curb the problem. Aim: This study was done to find out the determinants of tobacco use so that effective intervention programs can be designed and implemented for the prevention and cessation of this growing pandemic. Methods: A community-based cross-sectional study was done adapting Global Youth Tobacco Survey questionnaire prepared by the Centre for Disease Control, Atlanta, among youth (15-24 years). Patterns of smoking and their determinants were calculated using univariate and multivariate analyses. Results: Prevalence of current smoking among youth was 20.4% (95% confidence interval: 16.9-23.9%). Male sex, smoking peers, cigarette advertisements, and feeling comfortable in social gatherings were significant determinants for smoking after adjusting for all explanatory variables. Conclusion: Strict enforcement of regulations pertaining to cigarette advertisements in any form, enabling environment and community interventions focusing on parents and peers are required for effective control of tobacco problem among youth in India.

Association of air pollution and mortality in the Ludhiana city of India: A time-series study.

Background : With rapid industrialization, the quality of the air is being compromised in several Indian cities. Hence, the effect of air pollution on mortality was studied in the Ludhiana city of Punjab in northern India. Materials and Methods: Air quality and meteorological and mortality data were obtained for 2002-2004. Punjab Pollution Control Board monitored air quality on specific week days at different sites. Respirable suspended particulate matter (RSPM) (equivalent of PM 10 ) was measured by the gravimetric method and NOx and SO 2 by chemical method. The estimation of the daily average RSPM level was attempted by combining 24-h average of the monitoring stations working on a particular day. Sahnewal Airport records temperature, dew point, and relative humidity at 8.30 am, 11.30 am, and 5.30 pm. Visibility of fixed landmarks is observed manually every hour from 6.30 am to 6.30 pm. Daily death records were obtained from the civil registration system. The association between visibility as proxy for RSPM and mortality was established using the generalized additive model (GAM) with natural spline smoothers at 6, 3, 3 df in R software with deaths (excluding accidents) as a dependent variable. Smoothers for day of the week, temperature, and relative humidity were also included in the model. Results: Air quality monitoring days for different monitoring stations ranged from 86 to 138 per year. The annual mean RSPM ranged from 226.7 to 269 μg/m 3 , SO 2 from 11.6 to 20.9 μg/m 3 , and NOx from 32.2 to 46.3 μg/m 3 . The mean (SD) temperature was 25.6 (7.9)°C, relative humidity was 58.1 (19.3)%, and visibility was 3398 (1418) m. Overall 28,007 deaths were registered, with an average of 25.4 deaths (SD 5.8) per day. The association between air quality as indicated by visibility (haze) and daily mortality was found to be statistically significant. For every 1 km decrease in visibility at midday, mortality due to natural causes increased by 2.4%. Conclusions: In Ludhiana, air pollution levels were quite high. The air quality (as measured by visibility) was significantly associated with mortality.

Cisplatin-based chemotherapy: Add high-frequency audiometry in the regimen.

Background : Cisplatin-induced ototoxicity shows high interindividual variability and is often accompanied by transient or permanent tinnitus. It is not possible to identify the susceptible individuals before commencement of the treatment. We conducted a prospective, randomized and observational study in a tertiary care centre and evaluated the effects of different doses of cisplatin on hearing. Materials and Methods : Fifty-seven patients scheduled for cisplatin-based chemotherapy were included in the study. All patients were divided into three groups depending on the dose of cisplatin infused in 3 weeks. Results : The subjective hearing loss was found in seven patients, while six patients had tinnitus during the chemotherapy. The hearing loss was sensorineural, dose dependent, symmetrical, bilateral and irreversible. Higher frequencies were first to be affected in cisplatin chemotherapy. Conclusion : As use of high-frequency audiometry is still limited in research work only, we need a strict protocol of adding high-frequency audiometry in the cisplatin-based chemotherapy regimen.

Cardiovascular disease risk management in a primary health care setting of north India.

OBJECTIVE: This study was primarily carried out to assess the feasibility of an adapted WHO CVD risk management package in a primary care setting. METHODS: A community intervention trial was conducted in eight health posts located in rural, urban, and slum areas of northern India. After a 4 day training, eight health workers implemented the package among 1010 adults > or =30 years of age from a randomly chosen cluster of households. Locally adapted scenario 1 WHO protocol was used for the assessment of CVD risks. The health workers inquired about smoking, alcohol, diet, physical activity, symptoms of angina, and transient ischaemic attacks; and measured systolic blood pressure (SBP7), height, and weight. Those with a risk were counseled and referred to a physician. Hypertensives were followed at 1, 3, and 5-month interval to reinforce risk prevention and adherence to treatment. In a 20% random sub sample, in the study and control area before and after the intervention, WHO STEPS instrument was used to evaluate effectiveness of the package. FINDINGS: After training, the knowledge of health workers regarding risk factors and symptoms of CVDs increased from 47% to 92.5%, and their performance in detection of risks was comparable to the investigator. All health workers could pay scheduled home visits regularly. They referred 279 (27.6%) individuals having raised systolic blood pressure (SBP), and 74.5% contacted the doctor. Significant decrease in mean SBP (8.8 mm Hg) was observed during follow-up. Significantly higher reports of intention to quit tobacco (60.3% vs 25.5%) and regular intake of anti-hypertensive medication (58.3% vs 34.8%) were observed in the intervention area compared to the control area. CONCLUSION: Adapted WHO CVD risk management package can be implemented through primary care system.

Impact of mass supplementation of vitamin A.

OBJECTIVE: To study the impact of mass supplementation of Vitamin A solution on morbidity due to diarrhea, Acute respiratory infection (ARI) and xerophthalmia. METHODS: The two rounds of age specific mass distribution of Vitamin A solution were undertaken during January 2000 and December 2000 respectively covering 27,642 (98.7%) and 31,762 (88.0%) children respectively out of total beneficiaries in two round of PPI in Chandigarh. A random sample of 276 children from intervention area and 252 children from control area in the age group of 1-5 yr were followed up on monthly basis for morbidity pattern for a period of nine mth. The morbidity pattern for intervention and control area children was compared to see the impact of mass supplementation of Vitamin A solution. RESULTS: The average annual episodes of diarrhea in intervention children were lower (3.9 per yr) as compared to control children (5.2 per yr) although difference was not statistically significant (P>0.05) except in initial month. The average annual episodes of ARI in intervention children were lower (5.1 per yr) as compared to Control children (6.0 per yr) although difference was not significant (P>0.05) except in initial first mth. There was significant decline in vitamin A deficiency (VAD) as no case of Bitot's spot was found in intervention children as compared to control children where the prevalence of Bitot's spot ranged from 4.3-5.08% during different visits. The mortality rate was found to be higher in control children with a death rate of 8 per 1000 children during the study period as compared to intervention children where no death was recorded. CONCLUSION: It is concluded that mass supplementation of vitamin A led to significant reduction in xerophthalmia and decline in mortality in the intervention area as compared to control area.

Private sector involvement in tuberculosis control in Chandigarh.

Background: Private practitioners in India treat a substantial proportion of the TB cases. The present study is an attempt to find out the extent of private sector involvement in the control of tuberculosis in the Union Territory of Chandigarh. Methodology: The study was conducted in Union Territory of Chandigarh, during 2003-04. This study was a cross-sectional study involving 20 per cent of private practitioners practising allopathic system of medicine in Chandigarh. A questionnaire was used for collection of data after pre-testing. Results: Out of 114 doctors interviewed, 71 per cent dealt with TB patients. In response to a question as to how many sputum samples were required for routine microscopy, 72 per cent stated 3 samples but only 6 per cent knew the correct timing of sputum collection. 8.6 per cent of the practitioners followed the recommended guidelines of RNTCP treatment. As to reasons for not following the standard guidelines, 46.6 per cent said that they were not aware of these guidelines. About 82 oer cent were willing to be partners for implementation of RNTCP. A case history was given to practitioners to assess their knowledge regarding DOTS. It was observed that only 7.8 per cent knew the correct dosage and 21per cent knew the correct duration of treatment. Conclusion: Knowledge of private practitioners regarding RNTCP and DOTS strategy was poor and they were not following recommended guidelines for control of tuberculosis, but they were willing to participate in the programme.

Validity of verbal autopsy in determining causes of adult deaths.

A verbal autopsy (VA) questionnaire, which had an open-ended description of the deceased's illness followed by a series of close-ended questions on specific symptoms and signs, was used by three trained field workers to interview relatives of the deceased who had died in a Chandigarh hospital in previous year. The sensitivity and specificity of the cause of death assigned by physician from the verbal autopsy was calculated against the cause of death derived from the hospital records. Of the 262 verbal autopsies, 60% were males and 23% belonged to rural area. Specificity of VA cause of death was high (>95%) for all broad cause groups except cardiovascular (79%) diseases. Sensitivity was highest for injuries (85%) and it was in the range of 60% to 65% for circulatory diseases, neoplasms, and infectious diseases. Sensitivity was low (20% to 40%) for respiratory, digestive and endocrine diseases. Cause specific proportionate mortality for major cause groups by the VA were statistically similar to the causes of deaths derived from the hospital records (p>0.05). Therefore, VA can be used for determining causes of adult deaths.

High prevalence of bacteriuria in pregnancy and its screening methods in north India.

The study aims at finding out the prevalence of bacteruria in pregnancy in an urban setting and ascertaining methods to screen them in primary care clinics. A total of 1 61 pregnant ladies visiting a primary care clinic were screened for bacteriuria based on the symptomatology. Urine culture was done to know the prevalence of bacteriuria. Sensitivities and specificities were calculated for each symptom and risk assessment. A score card was developed based on combination of positive risk assessment and constellation of symptoms. Prevalence of symptomatic and asymptomatic bacteriuria was found to be 19.87% and 4.34% respectively. Prevalence of bacteriuria was significantly high among those who had intercourse more frequently and those with less water intake. Those with a score of more than or equal to 4, as per score card were 60% more likely to suffer from bacteriuria. When combined with microscopic examination for leucocytes on positively screened, the positive predictive value was found to be 89%. It is concluded that prevalence of symptomatic bacteriuria is common among pregnant women. Syndromic management of cases on the basis of score card is helpful in resource constraint areas. This may be combined with microscopic examination of urine to entail rational use of antibiotics.

Improving environmental conditions of a slum in Chandigarh by an awareness campaign.

An intervention project, in the form of an environmental awareness campaign was conducted in a slum of Chandigarh with a population of about 40,000, from December 1998-April 1999. The activities enforced during this campaign included focus group discussions with general public and mothers, household visit by medical students, distribution of literature, use of mass media by involving local residents, primary child care workers, teachers and school children. Evaluation of this campaign was carried out in May 1999 and compared with the baseline data obtained from a survey done in 1997. The study revealed that the method of storing water in covered buckets and utensils had improved significantly from 14.3% and 4.7% in the baseline survey to 35.2% (P < 0.001) and 16.2% (P < 0.01) respectively. Refuse disposal in the community bin and own bin had significantly improved to 22.2% (P < 0.001) and 19% (P < 0.01) from 8.4% and 11.2% respectively in the baseline survey. 51.2% of the residents using own bins disposed the refuse finally into the community bin. The use of community latrines had significantly increased among males (50.0%), females (47.7%) and children (41.2%) after intervention as compared to 32.8%, 32.5% and 16.7% respectively as found in the baseline survey (P < 0.001) and similarly open defaecation had significantly reduced among them. Further the study shows that the awareness regarding diarrhoea as hazard of unsafe water had improved significantly from 28.7% in baseline survey to 55.6% after intervention (P < 0.001). Knowledge of the residents regarding hazards of refuse disposal in the open and open defaecation had also improved significantly. Simple environmental awareness campaign can change the knowledge and behavioural practices of slum dwellers and could be a model for launching similar projects in other slums of India and other developing countries.