Burden of Rotavirus Diarrhea in Under five Indian Children.

NEED AND PURPOSE: Rotavirus is the most common cause of severe diarrhea in infants and young children worldwide. The burden of rotavirus diarrhea in Indian children is not well established. The present study reviewed the epidemiology of rotavirus diarrhea in hospitalized children and in the community, molecular serotyping and under-five mortality caused by rotavirus diarrhea. METHODS: Publications, reporting rotavirus diarrhea in Indian children, were retrieved through a systematic search of databases including Medline, PubMed, IndMed, websites of WHO, UNICEF, National Family Health Survey, Ministry of Health and Family Welfare, and Government of India. Human studies in English language were included. Age group selected was 0 month to 5 years. No restrictions were applied in terms of study design and time frame. CONCLUSIONS: Stool sample positivity varied from 4.6% in Kolkata to 89.8% in Manipur, among hospitalized children, and from 4% in Delhi to 33.7% in Manipur in community. Most cases of rotavirus diarrhea in India are caused by G1, G2, and G untypeable strains with distinct regional variations. Rotavirus was identified as an etiological agent in 5.2 to 80.5% cases of nosocomial diarrhea. Data are lacking for rotavirus mortality.

Feasibility of using partograph by practitioners of Indian system of medicine (AYUSH): An exploratory observation.

OBJECTIVE: to understand the use of the partograph by Skilled Birth Attendance/Basic Emergency Obstetric Care (SBA/BEmOC) trained practitioners from Indian systems of medicine called AYUSH practitioners (APs). DESIGN: mixed method observational study, including an exploration of the views of APs, programme managers and SBA trainers on the necessity, feasibility and barriers to the use of partograph. SETTING: primary and community health centres in two purposively selected districts in each of the three states (Rajasthan, Maharashtra and Odisha) in India where SBA/BEmOC trained APs are deployed to provide SBA services. In-depth interviews with state, district and block level programme managers were held at their respective headquarters. PARTICIPANTS: 83 APs plotted the simplified partograph based on a given labour case scenario. In-depth interviews were conducted with 36 programme managers and 37 APs (24 Ayurvedic and 13 Homoeopathic). MEASUREMENTS AND FINDINGS: the completed simplified partograph was analysed according to a previously devised scoring system with a score of 70% or more indicating competency. APs in Rajasthan and Maharashtra demonstrated good partograph plotting skills (72.1% and 82% respectively) obtaining a competency score of more than 70%. However, overall performance of APs in Odisha was poor (11.1%) and except correct recording of fetal condition, the APs did not score well in the plotting of the other partograph components. Errors occurred mainly in the recording of cervical dilatation and uterine contractions. The in-depth interviews revealed that most APs demonstrated a good understanding of the tool in the context of decision making regarding timely referral in case of prolonged labour or fetal distress. There was a high perception of the need for more hands-on training in the SBA training curriculum. The programme managers also expressed the need for appropriate training and supervision to ensure good plotting of partograph. The barriers for partograph use included increased workload, insufficient training, unavailability of partograph forms and its non-utility for women coming late in labour. KEY CONCLUSIONS: knowledge of plotting and correct interpretation of partograph were generally good in two states but more practice is needed to improve providers׳ skills. Identified barriers could be addressed with further training and local managerial support. An analysis of the causes for the poor performance of APs in Odisha should be carried out. Pre-service and periodic in-service training of APs on the completion of the partograph, regular supportive supervision, implementation of programme guidelines on mandatory completion of partograph and an environment that supports its correct and consistent use are recommended. IMPLICATIONS FOR PRACTICE: with appropriate training, it is feasible for AYUSH practitioners to use partograph for monitoring progress of labour.

Assessing providers' vaccination behaviors during routine immunization in India.

Progress has been made toward improving routine immunization coverage in India, but universal coverage has not been achieved. Little is known about how providers' vaccination behaviors affect coverage rates. The purpose of this study was to identify provider behaviors that served as barriers to vaccination that could lead to missed opportunities to vaccinate. We conducted a study of health-care providers' vaccination behaviors during clinic visits for children <3 years of age. Information on provider behaviors was collected through parent report and direct observation. Compared with illness visits, parents were eight times more likely to report vaccination status was verified (p < 0.001) and three times more likely to report receiving counseling on immunization (p = 0.022) during vaccination visits. Training of all vaccination practitioners should focus on behaviors such as the necessity of verifying vaccination status regardless of visit type, stressing the importance of counseling parents on immunization and emphasizing what is a valid contraindication to vaccination.

Task-shifting challenges for provision of skilled birth attendance: a qualitative exploration.

BACKGROUND: Shortage of skilled birth attendants (SBA) is one of the determinants of maternal mortality in India. To combat this shortage, innovative task-shifting strategies to engage providers of the Indian system of medicine (Ayurveda and Homeopathy), called AYUSH practitioners (AP), to provide SBA services is being implemented. METHODS: Engagement of APs for SBA service provision was assessed in 3 states of India (Maharashtra, Rajasthan and Odisha) through 73 in-depth interviews (37 with APs and 36 with programme managers). The interviews explored the providers' SBA training experience, barriers for SBA service provision, workplace and community acceptance, and the perspective of programme managers on the competence and quality of SBA services provided. RESULTS: SBA training led to skill enhancement with adoption of appropriate maternal and newborn care practices. A dedicated trainer, more hands-on practice, and strengthening training on newborn care practices and management of complications emerged as the training needs. Conditional involvement in SBA-related work, a discriminatory attitude at the workplace and lack of legal/regulatory authorisation were identified as barriers to the inclusion of APs in SBA service provision. CONCLUSIONS: Quality skill enhancement measures, an enabling work environment, a systematic task-shifting process, role definition, supportive supervision and credentialing could be key for the integration of APs and their acceptance in the health system.

Indian Academy of Pediatrics (IAP) recommended immunization schedule for children aged 0 through 18 years--India, 2014 and updates on immunization.

JUSTIFICATION: There is a need to review/revise recommendations about existing vaccines in light of recent developments in the field of vaccinology. PROCESS: Following an IAP ACVIP meeting on April 19 and 20, 2014, a draft of revised recommendations for the year 2014 and updates on certain vaccine formulations was prepared and circulated among the meeting participants to arrive at a consensus. OBJECTIVES: To review and revise recommendations for 2014 Immunization timetable for pediatricians in office practice and issue statements on certain new and existing vaccine formulations. RECOMMENDATIONS: The major changes in the 2014 Immunization Timetable include two doses of MMR vaccine at 9 and 15 months of age, single dose recommendation for administration of live attenuated H2 strain hepatitis A vaccine, inclusion of two new situations in high-risk category of children in context with pre-exposure prophylaxis of rabies, creation of a new slot at 9-12 months of age for typhoid conjugate vaccine for primary immunization, and recommendation of two doses of human papilloma virus vaccines with a minimum interval of 6 months between doses for primary schedule of adolescent/preadolescent girls aged 9-14 years. There would not be any change to the committee's last year's (2013) recommendations on pertussis vaccination and administration schedule of monovalent human rotavirus vaccine. There is no need of providing additional doses of whole-cell pertussis vaccine to children who have earlier completed their primary schedule with acellular pertussis vaccine-containing products. A brief update on the new Indian Rotavirus vaccine, 116E is also provided. The committee has reviewed and offered its recommendations on the currently available pentavalent vaccine (DTwP+Hib+Hepatitis-B) combinations in Indian market. The comments and footnotes for several vaccines are also updated and revised.

Pediatricians' perceptions of vaccine effectiveness and safety are significant predictors of vaccine administration in India.

BACKGROUND: New vaccine introduction is important to decrease morbidity and mortality in India. The goal of this study was to identify perceptions that are associated with administration of four selected vaccines for prevention of Japanese encephalitis (JE), typhoid fever, influenza and human papillomavirus (HPV) infection. METHODS: A random sample of 785 pediatricians from a national list of Indian Academy of Pediatrics members was selected for a survey to assess perceptions of vaccine effectiveness and safety, and vaccine administration practices. Logistic regression was used to assess factors associated with selective or routine use. RESULTS: Pediatricians reported administering typhoid (91.6%), influenza (60.1%), HPV (46.0%) and JE (41.9%) vaccines selectively or routinely. Pediatricians who perceived the vaccine to be safe were significantly more likely to report administration of JE (OR 2.6, 95% CI 1.3 to 5.3), influenza (OR 4.3, 95% CI 2.0 to 9.6) and HPV vaccine (OR 6.2, 95% CI 3.1 to 12.7). Pediatricians who perceived the vaccine to be effective were significantly more likely to report administration of JE (OR 3.3, 95% CI 1.6 to 6.5), influenza (OR 7.7, 95% CI 2.5 to 23.1) and HPV vaccine (OR 3.2, 95% CI 1.6 to 6.4) CONCLUSION: Understanding the role perceptions play provides an opportunity to design strategies to build support for vaccine use.

Consensus Statement of the Indian Academy of Pediatrics on integrated management of severe acute malnutrition.

JUSTIFICATION: Severe acute malnutrition (SAM) is a major public health issue. It afflicts an estimated 8.1 million under-five children in India causing nearly 0.6 million deaths. The improved understanding of pathophysiology of SAM as well as new internationally accepted growth charts and newer modalities of integrated intervention have necessitated a relook at IAP recommendations. PROCESS: A National Consultative Meeting on Integrated Management of Severe Acute Malnutrition was held in Mumbai on 16th and 17th October, 2010. It was attended by the invited experts in the field. Extensive discussions were held as per the program. The participants were then divided into six groups for detailed discussions. The groups deliberated on various issues pertaining to the task assigned and presented recommendations of the groups in a plenary session. The participants made a list of recommendations after extensive discussions. A Writing Committee was formed and was entrusted with the task of drawing a Consensus Statement on the basis of these Recommendations. After multiple deliberations, the following Consensus Statement was adopted. OBJECTIVES: To critically evaluate the current global evidence to formulate a consensus among stakeholders regarding diagnosis and management of SAM. RECOMMENDATIONS: An integrated management of malnutrition is likely to yield more dividends. Thus, management of SAM should constitute an important component of Integrated Management of Neonatal and Childhood Illnesses (IMNCI) program. Determination of SAM on the basis of Z-scores using WHO Growth charts is considered statistically more appropriate than cut-offs based on percentage weight deficit of the median. Considering the fact that many children with SAM can be successfully managed on outpatient basis and even in the community, it is no more considered necessary to advise admission of all children with SAM to a healthcare facility. Management of SAM should not be a stand-alone program. It should integrate with community management therapeutic programs and linkages with child treatment center, district hospitals and tertiary level centers offering inpatient management for SAM and include judicious use of ready-to-use-therapeutic Food (RUTF). All sections of healthcare providers need to be trained in the integrated management of SAM.

Attitudes and practices of auxiliary nurse midwives and accredited social health activists in Uttar Pradesh and Bihar regarding polio immunization in India.

Although India was removed from the list of polio endemic countries in January 2012, maintaining the focus on polio vaccination is critically important to prevent reintroduction of the virus. In 2009-2010, we conducted a study to assess the attitudes and practices of frontline health workers in India regarding polio immunization in Uttar Pradesh and Bihar. More than 95% of auxiliary nurse midwives (ANMs) and accredited social health activists (ASHAs) agreed that polio supplementary immunization campaigns helped in increasing acceptance of all vaccines. The majority of ANMs (60-70%) and ASHAs (56-71%) believed that polio immunization activities benefitted or greatly benefitted other activities they were carrying out. Less than 5% of ANMs and ASHAs felt they were very likely to face resistance when promoting or administering polio vaccine. This study provides information that may be useful for programs in other countries for polio eradication and in India for measles elimination.

Haemophilus influenza type b disease and vaccination in India: knowledge, attitude and practices of paediatricians.

BACKGROUND: Haemophilus influenza type b (Hib) causes significant morbidity and mortality among young children in India. Hib vaccines are safe and efficacious; nevertheless, their introduction to India's national immunization programme has been hindered by resistance from certain sectors of academia and civil society. We aimed to ascertain the attitudes and perceptions of Indian paediatricians towards Hib disease and vaccination. MATERIALS AND METHODS: A cross-sectional survey of knowledge, attitude and practices on Hib and vaccines was undertaken among 1000 Indian paediatricians who attended 49 th National Conference of Indian Academy of Pediatrics in 2012 through use of a 21-point questionnaire. RESULTS: 927 (93%) paediatricians completed the survey. 643 (69%) responded that Hib is a common disease in India. 788 (85%) reported prescribing Hib vaccine to their patients and 453 (49%) had done so for the past 5-15 years. Hib vaccine was used in combination with other vaccines by 814 (88%) of the participants. 764 (82%) respondents thought Hib vaccine effective while 750 (81%) thought it to be safe. Fever, pain and redness were the most frequently reported post vaccination side-effects. 445 (48%) paediatricians ranked universal use of Hib vaccine in the national immunization programme as the most important strategy to prevent and control Hib disease in India. CONCLUSION: The excellent profile as reported by a large number of paediatricians from throughout India further strengthens evidence to support expanded use of currently available Hib vaccines. These findings should encourage the Government of India to initiate mass use of this vaccine nationwide.

Indian Academy of Pediatrics (IAP) recommended immunization schedule for children aged 0 through 18 years, India, 2013 and updates on immunization.

JUSTIFICATION: There is a need to review/revise recommendations about existing vaccines in light of recent developments in the field of vaccinology where new developments are taking place regularly at short intervals. PROCESS: Following an IAP ACVIP meeting on 3rd and 4th August, 2013, a draft of revised recommendations for the year 2013 and updates on certain new vaccine formulations was prepared and circulated among the meeting participants to arrive at a consensus. OBJECTIVES: To review and revise recommendations for 2013 Immunization timetable for pediatricians in office practice and issue statements on new vaccine formulations. RECOMMENDATIONS: The major change in the 2013 Immunization timetable was made in the recommendations pertaining to pertussis immunization. Taking in to the consideration of recent outbreaks of pertussis in many industrialized countries using acellular pertussis (aP) vaccines and subsequent finding of faster waning of the same in comparison to whole-cell pertussis (wP) vaccines and superior priming with wP vaccines than aP vaccines, the committee has now recommended wP vaccines for the primary series of infant vaccination. Guidelines are now also issued on the preference/selection of a particular aP vaccine in case it is not feasible to use wP vaccine, and use of Tdap vaccine during pregnancy. The administration schedule of monovalent human rotavirus vaccine, RV1 has been revised to 10 and 14 weeks from existing 6 and 10 weeks. Recommendation is made for the need of booster dose of live attenuated SA-14-14-2 JE vaccine. Updates and recommendations are issued on new typhoid conjugate vaccine, inactivated vero-cell culture derived SA-14-14-2 JE vaccine, inactivated vero-cell derived Kolar strain, 821564XY JE vaccine, and new meningococcal conjugate vaccines. This year the recommended immunization schedule with range for persons aged 0 through 18 years is being published together instead of two separate schedules. A subcategory of general instruction is added in footnotes. The comments and footnotes for several vaccines are revised and separate instructions for routine vaccination and catch-up vaccination are added in the footnotes section wherever applicable.

Promoting appropriate management of diarrhea: a systematic review of literature for advocacy and action: UNICEF-PHFI series on newborn and child health, India.

BACKGROUND: Scaling up of evidence-based management and prevention of childhood diarrhea is a public health priority in India, and necessitates robust literature review, for advocacy and action. OBJECTIVE: To identify, synthesize and summarize current evidence to guide scaling up of management of diarrhea among under-five children in India, and identify existing knowledge gaps. METHODS: A set of questions pertaining to the management (prevention, treatment, and control) of childhood diarrhea was identified through a consultative process. A modified systematic review process developed a priori was used to identify, synthesize and summarize, research evidence and operational information, pertaining to the problem in India. Areas with limited or no evidence were identified as knowledge gaps. RESULTS: Childhood diarrhea is a significant public health problem in India; the point (two weeks) prevalence is 9 to 20%. Diarrhea accounts for 14% of the total deaths in under-five children in India. Infants aged 6 to 24 months are at the highest risk of diarrhea. There is a lack of robust nation-wide data on etiology; rotavirus and diarrheogenic E.coli are the most common organisms identified. The current National Guidelines are sufficient for case-management of childhood diarrhea. Exclusive breastfeeding, handwashing and point of use water treatment are effective strategies for prevention of all-cause diarrhea; rotavirus vaccines are efficacious to prevent rotavirus specific diarrhea. ORS and zinc are the mainstay of management during an episode of childhood diarrhea but have low coverage in India due to policy and programmatic barriers, whereas indiscriminate use of antibiotics and other drugs is common. Zinc therapy given during diarrhea can be upscaled through existing infrastructure is introducing the training component and information, education and communication activities. CONCLUSION: This systematic review summarizes current evidence on childhood diarrhea and provides evidence to inform child health programs in India.

Predictors of administration and attitudes about pneumococcal, Haemophilus influenzae type b and rotavirus vaccines among pediatricians in India: a national survey.

INTRODUCTION: According to the World Health Organization in 2008, pneumonia accounted for 20% of deaths and diarrheal diseases accounted for 13% of deaths among children under 5 in India. Vaccines are available for Streptococcus pneumoniae (pneumococcal conjugate vaccine (PCV)), Haemophilus influenzae type b (Hib vaccine), and rotavirus. Barriers to including these vaccines in routine immunization schedule in India include potential negative impacts on fragile existing immunization programs and cost. Pediatricians who are members of the Indian Academy of Pediatrics (IAP) are important stakeholders for vaccine delivery and maintaining public confidence in vaccines. METHODS: A random sample of 785 pediatricians belonging to IAP was selected for the survey conducted from June 2009 to June 2010. Descriptive analyses using sampling weights were performed to evaluate the distributions of variables assessing vaccine-related attitudes and behaviors among pediatricians. Logistic regression was used to assess factors associated with routine vaccine use. RESULTS: The majority of pediatricians reported administering PCV (85.6%), Hib (95.9%), and rotavirus (80.2%) vaccine selectively or routinely. Pediatricians who had high perceived disease susceptibility were 2.42 times more likely to report routine administration of Hib vaccine (OR 2.42, 95% CI 1.24, 4.74). Pediatricians who had high perceived Hib vaccine efficacy were 4.74 times more likely to administer Hib vaccine routinely (OR 4.74, 95% CI 2.09, 10.74). Perceptions of disease susceptibility and severity or of vaccine safety and efficacy were not associated with routine administration of PCV or rotavirus vaccine. CONCLUSIONS: Understanding predictors of routine use of a new vaccine could help focus interventions to improve the routine use of other vaccines. The importance of perceived susceptibility to and severity of diseases caused by S. pneumoniae, Hib, and rotavirus and perceived efficacy and safety of the vaccines by pediatricians presents an opportunity to design strategies to build support for new vaccine introduction and may have important implications for national immunization policy in India.

Comparison of attitudes about polio, polio immunization, and barriers to polio eradication between primary health center physicians and private pediatricians in India.

OBJECTIVES: The objectives of this study were to compare attitudes and perceptions of primary health center (PHC) physicians and pediatricians in Uttar Pradesh and Bihar toward polio disease, immunization, and eradication, and to identify barriers to polio eradication. METHODS: PHC physicians from blocks with at least one confirmed polio case during January 2006 to June 2009 were selected for an in-person survey. Pediatricians were members of the Indian Academy of Pediatrics and were selected from a national directory of members for telephone or mail survey. RESULTS: A higher percentage of PHC physicians than pediatricians reported that an unvaccinated child was susceptible to polio (82.1% vs. 63.0%, p<0.0001) and that polio disease was severe in a child aged 1-5 years (77.7% vs. 62.2%, p<0.0001). PHC physicians and pediatricians expressed confidence in the protectiveness and safety of oral polio vaccine and cited parents' lack of awareness of the importance of polio eradication as an important barrier to eradication. Strengthening routine immunization efforts was reported as the leading intervention required to eradicate polio. CONCLUSIONS: PHC physicians and pediatricians support and have confidence in the success of polio eradication efforts. These findings will be useful for policy-makers involved in the planning of eradication strategies. Providers and parents need to maintain confidence in polio vaccination if polio is to be eradicated.

Attitudes of pediatricians and primary health center physicians in India concerning routine immunization, barriers to vaccination, and missed opportunities to vaccinate.

BACKGROUND: India has some of the lowest immunization rates in the world. The objective of this study was to determine the attitudes and practices of pediatricians and physicians working in primary health centers (PHCs) regarding routine immunization and identify correlates of missed opportunities to vaccinate children. We focused on Uttar Pradesh and Bihar, which has faced some of the greatest challenges to achieving high routine immunization coverage. METHODS: A sample of pediatricians from Uttar Pradesh and Bihar was selected from the national membership of the Indian Academy of Pediatrics to participate in either a phone or mail survey. For the sampling frame, the PHCs within selected blocks were enumerated to provide a list from which individuals could be randomly sampled. In all, 614 PHCs in Uttar Pradesh and 159 PHCs were selected for in-person surveys. RESULTS: The response rate for pediatricians was 47% (238/505) and 93% for PHC physicians (719/773). The greatest barrier to vaccinating children with routine immunizations, reported by both pediatricians (95.7%) and PHC physicians (95.1%), was parents' lack of awareness of their importance. Correlates of missing an opportunity to vaccinate for PHC physicians included holding other health care workers responsible for vaccination. PHC physicians were 50% to 70% less likely to vaccinate a child themselves if they thought another type of health care worker was responsible. CONCLUSIONS: Future interventions to increase vaccination coverage should address parental knowledge about the importance of vaccines. Understanding and addressing factors associated with missed opportunities to vaccinate may help improve vaccine coverage in Uttar Pradesh and Bihar.

Attitudes and perceptions of private pediatricians regarding polio immunization in India.

BACKGROUND: India has faced considerable challenges in eradicating polio. Uttar Pradesh (UP) and Bihar are the two states in India where transmission of polio has never been interrupted. Private pediatricians are important stakeholders for vaccine delivery and maintaining public confidence in vaccines. The purpose of this study was to investigate the attitudes and perceptions of pediatricians in India regarding polio immunization and their opinions about various strategies regarding polio eradication in the country. METHODS: A random sample of 785 pediatricians belonging to the Indian Academy of Pediatrics (IAP) were selected for the survey with over sampling of members located in Bihar and UP. Potential participants were either contacted by phone or sent a self-administered anonymous questionnaire by mail. For this analysis both sets of responses were combined. Surveys were conducted from June 2009 to June 2010. RESULTS: A total of 398 surveys were completed (51%). Nearly all respondents indicated that polio eradication is still an important priority (99.7%). Ninety-six percent of pediatricians believed that strengthening routine immunization efforts remains the best way to eradicate polio in endemic areas. Other measures thought to be important in eradicating polio are mass campaigns with IPV (73%) and mass campaigns with bivalent OPV (59%). Pediatricians also identified several barriers to polio eradication which included parents' lack of awareness of the importance of polio vaccination (88.8%), parents' lack of confidence in polio vaccine (64.0%), religious beliefs (59.2%), fear of side effects (59.2%), lack of time or priority (56.6%), superstition (50.3%) and cultural beliefs (46.4%). CONCLUSION: There is still strong support for polio eradication efforts among IAP members. Pediatricians in India strongly believe that improving the coverage of routine immunization remains the best way to eradicate polio. There is an urgent need to improve awareness, build confidence in the program, and remove barriers among parents.

Infant and young child feeding guidelines: 2010.

JUSTIFICATION: The first National Guidelines on Infant and Young Child Feeding (IYCF) were formulated by Ministry of Women and Child Development (Food and Nutrition Board) in 2004, and the same guidelines were revised in 2006. India is committed to halving the prevalence of under weight children by 2015 as one of the key indicators of progress towards the Millennium Development Goals (MDG). By the end of 2009 nutritional achievement goals did not make for happy reading. So there was need to revise the existing guidelines and to have more viable and scientifically accepted national guidelines on Infant and Young child feeding. PROCESS: A National Consultative Meet was organized by Indian Academy of Pediatrics at Gurgaon in 2009 where members of IYCF and Nutrition Chapters of IAP, BPNI, WHO, UNICEF, USAID, WFP were present. Each group made detailed presentations after reviewing recent literature on the subject. After extensive discussions a consensus was reached and the guidelines were formulated. OBJECTIVES: To formulate, endorse, adopt and disseminate guidelines related to Infant and Young Child feeding from an Indian perspective (including infant feeding in the context of HIV infection). RECOMMENDATIONS: Optimal infant and young child feeding: Early initiation of breastfeeding, exclusive breastfeeding for the first six month of life followed by continued breastfeeding for up to two years and beyond with adequate complementary foods is the most appropriate feeding strategy for infants and young children. Adequate nutrition and anemia control for adolescent girls, pregnant and lactating mother is also advocated.