Measles Surveillance in Kashmir: A Mixed Methods Study

Background: Measles surveillance serves as the means of monitoring program success. The quintessential purpose of measles surveillance is to identify gaps and garner effective public health responses to achieve measles elimination. Objectives: There were two key objectives: (i) to conduct an in-depth review of the existing measles surveillance system in Kashmir and highlight its strengths and weaknesses and (ii) to assess the pattern of measles?containing vaccine (MCV1) coverage and MCV2 coverage among under?5 years children and describe the health-seeking patterns of suspected cases of measles. Methods: The mixed methods study was conducted in the Kashmir valley from March 2018 to March 2019. An explorative qualitative design was followed using individual face?to?face interviews with thirty-two (n = 32) different stakeholders from the state, district, medical block, and primary health center (PHC) levels. To complement the qualitative study, a quantitative survey was done in two districts, Srinagar and Ganderbal, which consist of 5 and 4 medical blocks, respectively. Results: Among the suspected cases of measles, 52% had visited PHCs. Sixty?four suspected cases of measles (64) were immunized with two doses of MCV. None of the clinically suspected cases of measles were further investigated. In the qualitative analysis, five themes were generated viz, “measles surveillance description of Kashmir valley;” “factors affecting measles surveillance, perceptions, and experiences of stakeholders;” “barriers to measles surveillance;” “measles surveillance activities need to be intensified;” and “respondent recommendations for building an effective and sensitive measles surveillance system.” Conclusion: The current measles surveillance system in Kashmir was not effectively functioning; case-based measles surveillance is not being done as per the WHO guidelines. There is a lack of planning, advocacy, awareness, and communication of measles surveillance among the stakeholders. The visible barriers in measles surveillance included lack of training, logistics, incentives, and monitoring by internal and external agencies.

The Lived-In Experience and Psychological Recount of Dog Bite VictimsVisiting the Anti-Rabies Clinic in Kashmir: A Qualitative Study

Introduction: There is a necessitated need for canvassing and prioritizing measures towards rabies elimination beyond existing statuesque post-exposure prophylaxis. Moreover, there is a need to characterize the psychological and intrusive experiences of dog-bite victims to portray a picture beyond the public health perspective. To get an expressive understanding of the psychological and lived-in experience ofObjective: dog bite victims' to complement existing concepts. The study was conducted at the anti-rabiesMethod: clinic(ARC) of SMHS hospital which receives animal bite cases from the whole of Kashmir valley. Participants were selected by purposive sampling based on the inclusion criteria, and data saturation was reached with eleven participant interviews. One to one in-depth interviews were conducted with eleven (11) dog bite victims, using a preformed interview guide. Data analysis was performed using Colaizzi's phenomenological method to describe the individualistic experiences faced in peculiar conditions with familiar phenomena embedded in them. Data analysis yielded three overarching themes and nine subthemes viz:-Results: 1.Spiritual and emotional ineffectualness. (Suffering and affliction, Spiritual sulkiness, Emotional emergence) 2. Flashbacks of being hindered and defenseless. (Lack of focus in one's work, lacking the courage to protect, Being shaky) 3. Social and economical implications. (Financial loss, group and peer detachment, preferring isolation) The results of this study showed that dog bite patients experience an unpleasantConclusion: phenomenon in the face of being bitten by the dogs and are subjected to severe psychological pressures that require attention and support of medical professionals, psychologists and government authorities.

Assessment of Delivery of Routine Immunization in Kashmir: A Qualitative Study

Introduction: Immunization is one of the splendid public health interventions that remarkably reduced child morbidity, mortality, and disability. Despite attaining substantial immunization coverage in Kashmir, assessment of the immunization system is quintessential for sustaining the gains and exploring the gaps. Objective: To assess the gaps in the delivery of routine immunization services in Kashmir Valley. Method: In-depth face-to-face interviews were conducted with thirty-two (32) important stakeholders, who were purposively selected as they play an active role in the planning and implementation of the Immunization Program and devise strategies at different levels of healthcare delivery. At the state level, SEPIO and SMO were interviewed at the District level, DIO/Deputy CMO was interviewed in all ten (10) districts of Kashmir Valley. From all ten Districts, two Medical-Blocks were selected from each District, and one Block Medical Officer and one Medical Officer were interviewed alternatively from each Medical-Block. Results: The thematic qualitative analysis approach was used and the analysis process generated five themes. Each of these themes included many sub-themes. 1. Factors facilitating the implementation of Routine Immunization (RI), 2. Limitations and deficits related to knowledge, attitude, monitoring, 3. Constraints encountered in the implementation of (RI) program, 4. Difficulties in the implementation of RI revealed by respondents, 5. Transformational steps to bridge gaps in the delivery of Immunization (RI) Conclusion: There were visible deficits related to knowledge, attitude, and monitoring among health professionals. Certain constraints encountered in the implementation of the program were financial constraints in the training of health care professionals and human resources constraints. The study showed the need for transformational steps to bridge gaps in the delivery of the Immunization (RI), which included regular monitoring and review meetings, teamwork and peer learning, training, and improvement in cold chain maintenance

Economic Burden of Rabies: An Experience from a Tertiary Care Hospital in Kashmir, India

Background:Post-exposureprophylaxis(PEP) is the mainstay of prevention in suspected exposure to rabies virus.Exposedpatients are able to obtain anti-rabies vaccine in the anti-rabies clinicpro bono butthey have to pay forpassive immunization and cover otherassociated costs.Aim:To estimate and analyze the direct and indirect costs of rabies PEP.Methods: This study was conducted on 429 patients, who were exposed to bites from various animals and reported to Shri Mahraja Hari Singh Hospital (SMHS), an associated tertiary hospital of Government Medical College, Srinagar, Kashmir. Patient socio-demographic profile, details of animal bite exposure, the cost incurred for PEP wascollected. The data were analyzed using a descriptive statistic.Results: The study revealed a total median cost incurred on patients for receiving a PEP as 29.3 USD (United States Dollar), with an Inter-quartile Range (IQR) of 0.2 USD to 43.1USD. The direct median cost was 20.5 USD with an IQR of 6.2 USD to 29.4USD, while the indirect median cost was 20.3USD with an IQR of 13.5USD to 24.4USD.Conclusion:Post-exposure prophylaxis imposesa significant economic burden to bite victims especially those of low socio-economic strata for whom the cost issubstantial.Original ResearchArticle

Relationship of neck circumference and difficult endotracheal intubation in obese patients

Background and Objectives: Patient identification with difficult intubation is important in planning anesthetic management and one major factor for difficult intubation in t he obese patients is large neck circumference. The need for prediction of a potentially difficult airway received great importance as it plays a significant role in reducing morbidity and mortality. Therefore, this study was done to glimpse the effect of neck circumference on endotracheal intubation and to determine the frequency of difficult intubation.Material and Methods: The study was cross sectional descriptive study and convenient sampling technique was used. Seventy patients of age between 19-50 years of both sexes were enrolled. Neck circumference was measured at the level of cricoid cartilage along with other airway assessments. Direct laryngoscopy was done and checked whether it is difficult one or easy using Intubation difficulty scale. Data were entered and analyzed by using statistical software SPSS version 15.0. Results: Mean BMI was noted as 33.02±2.30 kg/m2 and the mean neck circumference was 43.64±2.30 cm. Difficult intubation was observed in 23 (32.86%) patients with mean neck circumference of 45.44±1.88 cm and normal intubation observed in 47(67.14%) patients with mean neck circumference of 42.77±1.98 cm. Linear correlation was found between the neck circumference and Intubation Difficulty Scale score with value of Pearson correlation=0.617 .Conclusion: Neck circumference of patient was found to have significant effects on difficult intubation. Frequency of difficult intubation was found in almost one third of obese patients with increasing neck circumference.