Improving cold chain systems: Challenges and solutions.

While a number of new vaccines have been rolled out across the developing world (with more vaccines in the pipeline), cold chain systems are struggling to efficiently support national immunization programs in ensuring the availability of safe and potent vaccines. This article reflects on the Clinton Health Access Initiative, Inc. (CHAI) experience working since 2010 with national immunization programs and partners to improve vaccines cold chains in 10 countries-Ethiopia, Nigeria, Kenya, Malawi, Tanzania, Uganda, Cameroon, Mozambique, Lesotho and India - to identify the root causes and solutions for three common issues limiting cold chain performance. Key recommendations include: Collectively, the solutions detailed in this article chart a path to substantially improving the performance of the cold chain. Combined with an enabling global and in-country environment, it is possible to eliminate cold chain issues as a substantial barrier to effective and full immunization coverage over the next few years.

Reduced burden of childhood diarrheal diseases through increased access to water and sanitation in India: A modeling analysis.

Each year, more than 300,000 children in India under the age of five years die from diarrheal diseases. Clean piped water and improved sanitation are known to be effective in reducing the mortality and morbidity burden of diarrhea but are not yet available to close to half of the Indian population. In this paper, we estimate the health benefits (reduced cases of diarrheal incidence and deaths averted) and economic benefits (measured by out-of-pocket treatment expenditure averted and value of insurance gained) of scaling up the coverage of piped water and improved sanitation among Indian households to a near-universal 95% level. We use IndiaSim, a previously validated, agent-based microsimulation platform to model disease progression and individual demographic and healthcare-seeking behavior in India, and use an iterative, stochastic procedure to simulate health and economic outcomes over time. We find that scaling up access to piped water and improved sanitation could avert 43,352 (95% uncertainty range [UR] 42,201-44,504) diarrheal episodes and 68 (95% UR 62-74) diarrheal deaths per 100,000 under-5 children per year, compared with the baseline. We estimate a saving of (in 2013 US$) $357,788 (95% $345,509-$370,067) in out-of-pocket diarrhea treatment expenditure, and $1646 (95% UR $1603-$1689) in incremental value of insurance per 100,000 under-5 children per year over baseline. The health and financial benefits are highly progressive, i.e. they reach poorer households more. Thus, scaling up access to piped water and improved sanitation can lead to large and equitable reductions in the burden of childhood diarrheal diseases in India.

Trends in antibiotic resistance among major bacterial pathogens isolated from blood cultures tested at a large private laboratory network in India, 2008-2014.

OBJECTIVE: There have been no long-term studies on trends in antibiotic resistance (ABR) on a national scale in India. Using a private laboratory network, the ABR patterns of organisms most commonly associated with bacteremia, obtained from patients across India between 2008 and 2014, were examined. METHODS: A retrospective study of patient blood cultures collected over a 7-year period (January 1, 2008-December 31, 2014) was conducted. Data on the microorganism(s) identified and their antimicrobial susceptibility were obtained from SRL Diagnostics (Mumbai, India). RESULTS: Of 135268 blood cultures, 18695 (14%) had at least one identified pathogen. In addition to continual high rates of methicillin-resistant Staphylococcus aureus (MRSA; approximately 44.2%), high resistance to nalidixic acid among Salmonella Typhi (98%) was observed, and carbapenem resistance increased in both Escherichia coli (7.8% to 11.5%; p=0.332) and Klebsiella pneumoniae (41.5% to 56.6%; p<0.001). Carbapenem resistance was also stable and high for both Acinetobacter species (approximately 69.6%) and Pseudomonas aeruginosa (approximately 49%). Resistance was also detected to colistin in the Gram-negatives and to vancomycin and linezolid in S. aureus. CONCLUSION: Increasing resistance to antibiotics of last-resort, particularly among Gram-negatives, suggests an urgent need for new antibiotics and improved antimicrobial stewardship programs in India.

Health and economic benefits of scaling up a home-based neonatal care package in rural India: a modelling analysis.

Approximately 900 000 newborn children die every year in India, accounting for 28% of neonatal deaths globally. In 2011, India introduced a home-based newborn care (HBNC) package to be delivered by community health workers across rural areas. We estimate the disease and economic burden that could be averted by scaling up the HBNC in rural India using IndiaSim, an agent-based simulation model, to examine two interventions. In the first intervention, the existing community health worker network begins providing HBNC for rural households without access to home- or facility-based newborn care, as introduced by India's recent programme. In the second intervention, we consider increased coverage of HBNC across India so that total coverage of neonatal care (HBNC or otherwise) in the rural areas of each state reaches at least 90%. We find that compared with a baseline of no coverage, providing the care package through the existing network of community health workers could avert 48 [95% uncertainty range (UR) 34-63] incident cases of severe neonatal morbidity and 5 (95% UR 4-7) related deaths, save $4411 (95% UR $3088-$5735) in out-of-pocket treatment costs, and provide $285 (95% UR $200-$371) in value of insurance per 1000 live births in rural India. Increasing the coverage of HBNC to 90% will avert an additional 9 (95% UR 7-12) incident cases, 1 death (95% UR 0.72-1.33), and $613 (95% UR $430-$797) in out-of-pocket expenditures, and provide $55 (95% UR $39-$72) in incremental value of insurance per 1000 live births. Intervention benefits are greater for lower socioeconomic groups and in the poorer states of Chhattisgarh, Uttarakhand, Bihar, Assam and Uttar Pradesh.

Early Childhood Nutrition Is Positively Associated with Adolescent Educational Outcomes: Evidence from the Andhra Pradesh Child and Parents Study (APCAPS).

BACKGROUND: India's Integrated Child Development Scheme, which provides supplementary nutrition and other public health services to >91 million women and children aged <6 y, is the largest program of its kind in the world. OBJECTIVE: We estimated the long-term associations of maternal and early childhood nutrition provided under the Integrated Child Development Scheme with educational outcomes when the children became adolescents. METHODS: We used longitudinal data from a controlled nutrition trial conducted near the city of Hyderabad, India. From 1987 to 1990, a balanced protein-energy supplement (corn-soya meal, called upma) was offered to pregnant women and children aged <6 y in 15 intervention villages, whereas no supplementation was offered in 14 control villages. Both groups had equal access to other public programs such as immunization and anemia control in pregnancy. Children born during the original trial period were resurveyed (654 intervention and 511 control group children) in 2003-2005. We used propensity score matching methods to correct for estimation bias in our regression models to assess the associations of supplementary nutrition with school enrollment, schooling grades completed, and academic test performance of these adolescents. RESULTS: Children born in intervention villages were 7.8% (95% CI: 0.1%, 15.4%; P < 0.05) more likely to be enrolled in school and completed 0.84 (95% CI: 0.28, 1.39; P < 0.005) more schooling grades than children born in control villages. We found no association between supplementary nutrition and academic performance, as measured by school test scores. CONCLUSION: Offering a nutritional supplement to pregnant women and children <6 y of age during the Hyderabad Nutrition Trial was associated with improved school enrollment and completion of more schooling grades when the children became adolescents.

Estimates of the economic contributions of the bidi manufacturing industry in India.

BACKGROUND: Bidis, the most common smoking tobacco product in India, remain largely untaxed and are subject to very few regulations to discourage their use. A major argument against tax increases is the large potential loss of economic activity and employment in the bidi industry from reduced consumption. METHODS: We used a nationally representative survey of unorganised bidi manufacturing firms (n=2841) in India to estimate the economic contribution of the industry. RESULTS: We find that of the 35 states and union territories of India, the bidi industry operated across 17 states, with over 95% of its production concentrated in 10 states. Bidi manufacturing firms contributed 0.50% of total sales and 0.6% of the gross value added by the manufacturing economy in 2005-2006. The industry employed approximately 3.4 million full-time workers, which comprise about 0.7% of employment in all sectors. A further 0.7 million were part-time workers. Bidi workers were also among the lowest paid employees in India. The industry offered only 0.09% of all compensation provided in the manufacturing sector (organised and unorganised). CONCLUSIONS: Considering the relatively small economic footprint of the bidi industry in India, higher excise taxes and regulations on bidis are unlikely to disrupt economic growth at an aggregate level, or lead to mass unemployment and economic hardship among small bidi workers. On average, the economic annual output per bidi worker is about US$143, which is an order of magnitude smaller than the large economic losses from the several hundred thousand deaths due to bidi smoking per year.

Global antibiotic consumption 2000 to 2010: an analysis of national pharmaceutical sales data.

BACKGROUND: Antibiotic drug consumption is a major driver of antibiotic resistance. Variations in antibiotic resistance across countries are attributable, in part, to different volumes and patterns for antibiotic consumption. We aimed to assess variations in consumption to assist monitoring of the rise of resistance and development of rational-use policies and to provide a baseline for future assessment. METHODS: With use of sales data for retail and hospital pharmacies from the IMS Health MIDAS database, we reviewed trends for consumption of standard units of antibiotics between 2000 and 2010 for 71 countries. We used compound annual growth rates to assess temporal differences in consumption for each country and Fourier series and regression methods to assess seasonal differences in consumption in 63 of the countries. FINDINGS: Between 2000 and 2010, consumption of antibiotic drugs increased by 36% (from 54 083 964 813 standard units to 73 620 748 816 standard units). Brazil, Russia, India, China, and South Africa accounted for 76% of this increase. In most countries, antibiotic consumption varied significantly with season. There was increased consumption of carbapenems (45%) and polymixins (13%), two last-resort classes of antibiotic drugs. INTERPRETATION: The rise of antibiotic consumption and the increase in use of last-resort antibiotic drugs raises serious concerns for public health. Appropriate use of antibiotics in developing countries should be encouraged. However, to prevent a striking rise in resistance in low-income and middle-income countries with large populations and to preserve antibiotic efficacy worldwide, programmes that promote rational use through coordinated efforts by the international community should be a priority. FUNDING: US Department of Homeland Security, Bill & Melinda Gates Foundation, US National Institutes of Health, Princeton Grand Challenges Program.

The Socioeconomic and Institutional Determinants of Participation in India's Health Insurance Scheme for the Poor.

The Rashtriya Swasthya Bima Yojana (RSBY), which was introduced in 2008 in India, is a social health insurance scheme that aims to improve healthcare access and provide financial risk protection to the poor. In this study, we analyse the determinants of participation and enrolment in the scheme at the level of districts. We used official data on RSBY enrolment, socioeconomic data from the District Level Household Survey 2007-2008, and additional state-level information on fiscal health, political affiliation, and quality of governance. Results from multivariate probit and OLS analyses suggest that political and institutional factors are among the strongest determinants explaining the variation in participation and enrolment in RSBY. In particular, districts in state governments that are politically affiliated with the opposition or neutral parties at the centre are more likely to participate in RSBY, and have higher levels of enrolment. Districts in states with a lower quality of governance, a pre-existing state-level health insurance scheme, or with a lower level of fiscal deficit as compared to GDP, are significantly less likely to participate, or have lower enrolment rates. Among socioeconomic factors, we find some evidence of weak or imprecise targeting. Districts with a higher share of socioeconomically backward castes are less likely to participate, and their enrolment rates are also lower. Finally, districts with more non-poor households may be more likely to participate, although with lower enrolment rates.