Challenges in conducting communitybased trials of primary prevention of cardiovascular diseases in resourceconstrained rural settings.

Cardiovascular diseases account for almost half of all deaths from noncommunicable diseases, and almost 80% of these deaths occur in low- and middle-income countries such as India. The PrePAre (Primary pREvention strategies at the community level to Promote treatment Adherence to pREvent cardiovascular disease) trial was a primary prevention trial of community health workers aimed at improving adherence to prescribed pharmacological and nonpharmacological therapies in cardiovascular diseases. It was conducted at three geographically, culturally and linguistically diverse sites across India, comprising 28 villages and 5699 households. Planning and implementing large-scale community-based trials is filled with numerous challenges that must be tackled, while keeping in mind the local community dynamics. Some of the challenges are especially pronounced when the focus of the activities is on promoting health in communities where treating disease is considered a priority rather than maintaining health. This report examines the challenges that were encountered while performing the different phases of the trial, along with the solutions and strategies used to tackle those difficulties. We must strive to find feasible and cost-effective solutions to these challenges and thereby develop targeted strategies for primary prevention of cardiovascular diseases in resource-constrained rural settings.

Changing landscape of acute encephalitis syndrome in India: A systematic review.

Background. Seasonal outbreaks of acute encephalitis syndrome (AES) occur with striking regularity in India and lead to substantial mortality. Several viruses, endemic in many parts of India, account for AES. Although Japanese encephalitis virus (JEV) is a key aetiological agent for AES in India, and has attracted countrywide attention, many recent studies suggest that enteroviruses and rhabdoviruses might account for outbreaks of AES. We did a systematic review of published studies to understand the changing landscape of AES in India. Methods. Data sources: Electronic databases (PubMed, Web of Science and BIOSIS) from the start of the database to 2010. We also hand-searched journals and screened reference lists of original articles, reviews and book chapters to identify additional studies. Study selection: We included studies only on humans and from three time-periods: pre-1975, 1975–1999 and 2000– 2010. Data extraction: Independent, duplicate data extraction and quality assessment were conducted. Data extracted included study characteristics, type of study and aetiological agent identified. Data synthesis: Of the 749 unique published articles screened, 57 studies met the inclusion criteria (35 outbreak investigations and 22 surveillance studies). Results. While most studies from 1975 to 1999 identified JEV as the main cause of AES, many studies published after 2000 identified Chandipura and enteroviruses as the most common agents, in both outbreaks and surveillance studies. Overall, a positive yield with respect to identification of aetiological agents was higher in outbreak investigations as compared to surveillance studies. Conclusion. The landscape of AES in India has changed in the previous decade, and both outbreak investigations and surveillance studies have increasingly reported non-JEV aetiologies. Because of these findings, there is a need to explore additional strategies to prevent AES beyond vector control and JEV vaccination.

Chikungunya epidemic: an Indian perspective.

Chikungunya, caused by the chikungunya virus, recently emerged as an important public health problem in the Indian Ocean Islands and India. In 2006, an estimated 1.38 million people across southern and central India developed symptomatic disease. The incidence of the disease may have been higher but may have been underreported due to lack of accurate reporting. First isolated in Tanzania in 1953, the chikungunya virus belongs to the family Togaviridae (single-stranded RNA alphaviruses) and has 3 distinct genotypes: East African, West African and Asian. Previous outbreaks in India (1963 and 1973) were caused by the Asian genotypes, but the 2005 epidemic in the Indian Ocean islands and the 2006 epidemic in India have been attributed to the East African genotype. The virus is transmitted to humans by the bites of mosquitoes of the species Aedes aegypti and A. albopictus. Researchers speculate that mutation of the virus, absence of herd immunity, lack of vector control, and globalization of trade and travel might have contributed to the resurgence of the infection. Chikungunya is characterized by high fever, severe arthralgia and rash. Although viral diagnostics (culture, serological tests and polymerase chain reaction tests) can be used to confirm the infection, these tests are not accessible during outbreaks to the majority of the population. The disease is a self-limiting febrile illness and treatment is symptomatic. As no effective vaccine or antiviral drugs are available, mosquito control by evidence-based interventions is the most appropriate strategy to contain the epidemic and pre-empt future outbreaks.

Accuracy and reliability of palpation and percussion for detecting hepatomegaly: a rural hospital-based study.

BACKGROUND: Palpation and percussion are standard bedside techniques used to diagnose hepatomegaly. Ultrasonography is a noninvasive and accurate method for measurement of liver size, but many patients in developing countries have limited access to it. We compared the accuracy of palpation and percussion in a rural population in central India, using ultrasonography as a reference standard. METHODS: The study design was a blinded, cross-sectional analysis of a hospital-based case series. Three physicians, blind to clinical data and to each other's results, independently used palpation and percussion to detect hepatomegaly. Diagnostic accuracy was measured by computing sensitivity, specificity, and likelihood ratio values. Inter-physician agreement was assessed using the kappa statistic. RESULTS: Of the 180 study patients, 36 (20%) had enlarged liver on ultrasonography. The likelihood ratios for findings at both palpation (2.2, 3.0, and 2.5 for the three physicians, respectively) and percussion (1.1 for all three physicians) as predictors of true hepatomegaly were low. The kappa values for inter-observer agreement between three physicians for the presence of hepatomegaly at palpation (=0.44-0.53) and percussion (=0.17-0.33) were low, indicating poor reliability of these techniques. CONCLUSION: Clinical assessment of hepatomegaly by palpation and percussion lacks both accuracy and reliability.

Risk factors for acute myocardial infarction in a rural population of central India: a hospital-based case-control study.

BACKGROUND: There is a paucity of data on the relative importance of various traditional risk factors for coronary artery disease among rural Indians. We conducted a prospective case-control study to determine the risk factors for acute myocardial infarction in a rural population of central India. METHODS: We recruited 111 consecutive patients admitted to our hospital with a first episode of acute myocardial infarction and 222 age- and sex-matched controls. Demographics, anthropometric measures, lipids, blood glucose, smoking and other lifestyle factors were compared among cases and controls. Multivariate analyses were used to identify the risk factors independently associated with acute myocardial infarction. RESULTS: Elevated fasting blood glucose (odds ratio [OR] 8.9; 95% confidence interval [CI] 4.5, 17.9), abnormal waist-hip ratio (OR 3.0; 95% CI 1.7, 5.4) and income (OR 4.0 and 5.9 for the high- and middle-income categories, compared to the lowest category) were independently associated with the first episode of acute myocardial infarction. Abnormal triglycerides (OR 1.7; 95% CI 0.9, 3.1) and current smoking (OR 1.9; 95% CI 0.9, 4.0) were risk factors but were not statistically significant. CONCLUSION: Reduction in blood glucose levels and truncal obesity may be important in controlling the burden of coronary artery disease in rural Indians.