Rabies death in an adolescent tribal girl diagnosed postmortem, in Kerala - the precious life, preventable loss and equity concerns.

BACKGROUND: Rabies is a neglected tropical disease endemic in 150 countries, including India where it is present in all states and union territories except Andaman and Nicobar Islands Lakshadweep. Kerala reports high incidence of animal bites. This article discusses the preventable death of a 17-year-old tribal girl due to rabies in Kerala and the equity concerns it raises. METHODS: The case study was conducted using qualitative methods such as rapid key informant interviews, interactions in tribal assembly meetings, unstructured participant observations, and document verification. Thematic analysis was used, and the results are presented as an ethnographic summary with the use of quotes to substantiate the observations. RESULTS: The girl had gone to a town with her sister for a few days when she developed difficulty in eating, behavioral abnormalities, and injuries on her body. She subsequently died, and a post-mortem revealed Negri bodies in her brain, confirming rabies as the cause of death. The girl had been bitten by a puppy from the forest eight months prior, but she did not receive post-exposure prophylaxis. Multiple dogs are kept in each household in the settlement, and the community takes good care of them since they protect them from wild animals. However, awareness about the need for post-exposure prophylaxis is low, and access to it is difficult for this population. The social problems in the settlement affect their quality of life and their interactions with the outside world. CONCLUSIONS: To prevent such deaths, it is essential to increase awareness and ensure equitable access to life-saving vaccines and immunoglobulin in hard-to-reach tribal areas. The cost-effectiveness of pre-exposure prophylaxis for children in high-risk areas such as this tribal settlement should be evaluated and compared with the WHO-recommended strategies of mass canine vaccination and One Health.

The burden of dengue and force of infection among children in Kerala, India; seroprevalence estimates from Government of Kerala-WHO Dengue study.

Background: Dengue shows high geographic heterogeneity within and across endemic countries. In the context of increasing burden and predicted outbreaks due to climate change, understanding the heterogeneity will enable us to develop region specific targeted interventions, including vaccination. World Health Organisation (WHO) suggests standard methodologies to study the burden and heterogeneity at national and subnational levels. Regional studies with robust and standard methodology to capture heterogeneity are scarce. We estimated the seroprevalence of dengue in children aged 9-12 years and the force of infection in Kerala, India, from where Zika cases also have been reported recently. Methods: We conducted a school-based cross-sectional survey in 38 clusters; selected by stratified random sampling, representing rural, urban, high burden and low-burden administrative units. Validation of Indirect IgG ELISA was done by Plaque Reduction Neutralization Test (PRNT90) using the local isolates of all four serotypes. Force of infection (FOI) was estimated using the WHO-FOI calculator. We conducted a follow-up survey among a subsample of seronegative children, to estimate the rate of sero-conversion. Results: Among 5236 children tested, 1521 were positive for anti-dengue IgG antibody. The overall seroprevalence in the state was 29% (95% CI 24.1-33.9). The validity corrected seroprevalence was 30.9% in the overall sample, 46.9% in Thiruvananthapuram, 26.9% in Kozhikkode and 24.9% in Kollam. Age-specific seroprevalence increased with age; 25.7% at 9 years, 29.5% at 10 years, 30.9% at 11 years and 33.9% at 12 years. Seroprevalence varied widely across clusters (16.1%-71.4%). The estimated force of infection was 3.3/100 person-years and the seroconversion rate was 4.8/100 person-years. 90% of children who tested positive were not aware of dengue infection. All the four serotypes were identified in PRNT and 40% of positive samples had antibodies against multiple serotypes. Interpretation: The study validates the WHO methodology for dengue serosurveys and confirms its feasibility in a community setting. The overall seroprevalence in the 9-12 year age group is low to moderate in Kerala; there are regional variations; high burden and low burden clusters co-exist in the same districts. The actual burden of dengue exceeds the reported numbers. Heterogeneity in prevalence, the high proportion of inapparent dengue and the hyperendemic situation suggest the need for region-specific and targeted interventions, including vaccination. Funding: World Health Organization.

Obesity Burden and Physical Activity Pattern Among Doctors in South India.

Context: A career as a doctor makes him prone to develop health issues like obesity and obesity-related noncommunicable diseases. Aims: This study aims to find the burden and determinants of obesity among Modern Medicine doctors in Kerala. Settings and Design: We conducted a cross-sectional study among 240 doctors working in South Kerala from 2018 to 2019. Methods and Material: The sample size was calculated using a formula and stratified random sampling was done for the selection of study participants. An interviewer-administered structured questionnaire was used for data collection. Physical activity was measured using International Physical Activity Questionnaire. Statistical Analysis: Data were entered in MS Excel and was analyzed using Statistical Package for Social Sciences version 26.0. The significance of association was tested using the χ2 test. Binary logistic regression was done to predict the factors associated with overweight and obesity. Results: Out of 240 study participants, 128 (54%) were females and 112 (46%) were males. Among the 240 doctors, 54% (114) were either overweight or obese. A low level of physical activity was reported among 54.5% of doctors. Male gender odds ratio (OR) = 2.8 (95% confidence interval [CI] = 1.29-6.06), nuclear family OR = 2.7 (95% CI = 1.32-5.42), daily hours of sleep <6 hours OR = 4.92 (95% CI = 2.29-10.5), history of obesity among parents OR = 3.54 (95% CI = 1.04-12.02), reported the presence of private practice OR = 3.34 (95% CI = 1.25-8.96), and holding a graduation degree alone were found to be significantly associated with obesity. Conclusions: The study found that majority of the doctors (55%) were either overweight or obese. Awareness and behavior change communication among doctors on modifiable risk factors like having adequate sleep and reducing the hours spent in private practice is needed to reduce the burden of obesity among doctors.

Effectiveness of a Non-pharmacological Intervention to Control Diabetes Mellitus in a Primary Care Setting in Kerala: A Cluster-Randomized Controlled Trial.

Background: Despite being the first Indian state with a dedicated Non-Communicable Disease (NCD) program, glycemic control among a large proportion of patients is low in Kerala. This study tries to find evidence for a standardized non-pharmacological strategy delivered through Junior Public Health Nurses (JPHNs) in achieving and maintaining glycemic control among diabetic patients registered with NCD clinics of primary health care settings. Design: A cluster randomized controlled trial was conducted among adult patients with Diabetes Mellitus attending NCD clinics of primary care settings of South Kerala, India. JPHNs of the intervention group received additional module-based training while standard management continued in the control group. Sequence generation was done by random permuted blocks method and a cluster of 12 patients was selected from each of the 11 settings by computer-generated random numbers. Patients were followed up for 6 months with monthly monitoring of Fasting Blood Sugar (FBS), Post-Prandial Blood Sugar (PPBS), blood pressure, Body Mass Index (BMI), and health-related behaviors. Knowledge and skills/practice of JPHNs were also evaluated. Analysis of Covariance was done to study the final outcome adjusting for the baseline values and a model for glycemic control was predicted using multilevel modeling. Results: We analyzed 72 participants in the intervention group and 60 participants in the control group according to the intention-to-treat principle. The intervention was associated with a significant reduction in FBS (p < 0.001) and PPBS (p < 0.001) adjusting for the baseline values. The achievement of glycemic control was 1.5 (95% CI: 1.05-2.3) times better with intervention and they showed a better trend of maintenance of glycemic control (FBS, p = 0.003 and PPBS, p = 0.039). Adjusting for clustering and the baseline values, the intervention showed a significant effect on FBS (B = -3.1, SE = 0.57; p < 0.001) and PPBS (B = -0.81, SE = 0.3; p < 0.001) with time. Drug adherence score (p < 0.001), hours of physical activity (p < 0.001), BMI (p = 0.002), fruit intake (p = 0.004), and green leafy vegetable intake (p = 0.01) were the major predictors of FBS control. The practice/skills score of the JPHNs significantly improved with intervention (p < 0.001) adjusting for baseline values. Conclusion: A well-designed health worker intervention package incorporated into the existing health system can translate into attitude change and skill development in the health workers which can reflect in the improvement of glycemic control among the patients. Trial registration: [URL: http://www.ctri.nic.in], identifier [CTRI/2017/11/010622].

Institutional quarantine centres as a strategy in control of COVID-19 outbreak: An evolving model from Kerala, India.

BACKGROUND: Institutional quarantine centres were set up in all districts in Kerala as a novel strategy in the fight against novel COVID-19 virus. These were meant for returnees from affected areas, for whom home quarantine was not possible due to lack of facilities. This research aims to evaluate facilities and services of Institutional quarantine centres in Thiruvananthapuram district, Kerala state and to study profile of persons under quarantine in these centres. METHODS: A cross-sectional study was conducted to evaluate institutional quarantine centres established in Thiruvananthapuram district of Kerala in April 2020. Evaluation was done using a checklist based on standard operating procedures for functioning of centres issued by Health department. Inspection of facilities and registers was done. Details of a subset of inmates were collected by telephonic interviews using a semi-structured questionnaire. RESULTS: Two (0.41%) inmates in the centre turned positive on testing while in quarantine. Both of them were foreign returnees and were asymptomatic. There was not a single case of transmission of infection between inmates or to staff and volunteers. The adherence to infection control practices was satisfactory in all centres. One third of inmates were from listed highly affected countries and were mandatorily quarantined. CONCLUSION: Institutional quarantine centres were functioning effectively to provide quarantine facilities for high-risk individuals and thereby controlling the spread of COVID-19. Selection of facilities, staffing pattern and day to day functioning of these centres is a model which can be replicated at other COVID-19 affected areas.

Reliability and validity of PHQ-9 when administered by health workers for depression screening among women in primary care.

BACKGROUND: Depression is twice more prevalent among women but remains unidentified in primary care. OBJECTIVE: We aimed to estimate the reliability and validity of PHQ-9, when administered by health workers, a cadre of public health staff, posted in primary health centres. We translated PHQ-9 to Malayalam, a language spoken by 30 million people in Kerala, India. Health workers administered PHQ-9 to women (n = 238) aged 18-60 years in a high prevalent primary care setting. Mini International Neuropsychiatric Interview (MINI) was administered by the psychiatrist on the same day to diagnose depressive disorder. Two health workers administered PHQ-9, independently, in a subset of 21 women. RESULTS: The internal consistency reliability (Cronbach's alpha 0.89) and inter-rater reliability (intra class correlation coefficient, 0.94; 95% CI, 0.86-0.95) were high. On ROC analysis, area under curve was 0.92 (95% CI 0.88-0.96). For a cut-off score of ≥9, PHQ-9 had a sensitivity of 82.5%, (95% CI, 72.4-92.6), specificity of 90.1% (95% CI, 84.5-95.6%), positive predictive value of 73.4% (95% CI, 62.4-84.4%) and negative predictive value of 93.9% (95% CI, 90.2-97.6%). The accuracy was 88.2% (84.0-92.4%) and positive likelihood ratio was 8.3. Factor analysis supported a single factor, with eigen value above 1, with high loading for all items (0.73-0.79), except item related to appetite (0.58). This explained 62% of variance in the data. Prevalence of MINI diagnosed depressive disorders was 25%. CONCLUSION: When administered by health workers, PHQ-9 has good reliability and at cut off score ≥9, it has good validity to identify depression in primary care.

Effectiveness of community-based depression intervention programme (ComDIP) to manage women with depression in primary care- randomised control trial.

BACKGROUND: In low and middle income countries where mental health resources are limited, community based depression intervention models, which can be implemented through the existing health system, are extremely relevant. OBJECTIVE: To test the effectiveness of Community based Depression Intervention Programme (ComDIP), newly developed by us, to reduce severity of depression in women, compared to the treatment as usual (TAU). METHODS: An RCT (Trial registration Number: CTRI/2011/08/001978, Clinical Trials Registry -India) was conducted in a primary care setting in Trivandrum, Kerala, South India. Health workers screened 422 women, aged 18-60 years, using PHQ-9. Sixty women with HAM-D (Hamilton Depression Rating scale) score above 19 were randomized to receive either ComDIP or TAU. Primary care physicians and health workers together implemented ComDIP which had psycho-social intervention and drug treatment. Those in TAU arm were referred to available mental health services. Primary outcome was measured at 8 weeks, by HAM-D. RESULTS: At baseline and 8 weeks, mean (SD) HAM-D scores were 29.2 (5.8) and 12.2 (9.3) respectively among women in ComDIP; and 28.6 (5.1) and 21.7 (12.4) respectively among those in TAU (p = 0.02, effect size = 0.82). CONCLUSIONS: ComDIP, implemented through existing health system is an effective public health programme to manage women with depression in primary care.

Prevalence of depression and past suicide attempt in primary care.

BACKGROUND: It is known that persons who die by suicide commonly visit a primary care physician (PCP) shortly before the fatal act.There is little information on history of suicide attempt in depressed patients who consult PCPs for non-mental health indications.This information is important because past history of suicide attempt is a known predictor of future suicide risk. OBJECTIVE: To estimate the prevalence of depression among outpatients in primary care and to determine the prevalence and determinants of past suicide attempt among them. METHOD: This cross-sectional study was conducted in six primary care settings, both public and private, in Kerala, India. A psychiatrist evaluated adult outpatients (n=827), diagnosed depression using ICD-10 Diagnostic Criteria for Research, and elicited history of suicide attempt. RESULTS: Overall depression prevalence was 27.2% and was higher in women. Past suicide attempt was identified in 6.9% (95% CI, 5.17-8.63%) of all outpatients; higher in women (9.2%) than men (3.6%). Among the depressed, 21.3% had previously attempted suicide; while this figure was 1.5% in the non-depressed. The prevalence of current depression was 81% (severe depression, 61%) in patients reporting past suicide attempts. In univariate analyses, female gender, perceived financial stress, and being depressed were significantly associated with past suicide attempts. In multivariate analysis, current depression was the largest predictor of past suicide attempt (adjusted odds ratio, 14.3; 95% CI, 6.60-31.07). CONCLUSION: Depression and suicide attempt are both common in primary care. Depression is the single most important predictor of suicide attempt.

Primary care Screening Questionnaire for Depression: reliability and validity of a new four-item tool.

BACKGROUND: Unidentified depression in primary care is a public health concern, globally. There is a need for brief, valid and easily administered tools in primary care. AIMS: To estimate reliability and validity of the newly developed Primary care Screening Questionnaire for Depression (PSQ4D), a four-item tool, with 'yes' or 'no' options. METHOD: PSQ4D was administered verbally (time required, <1 min) by primary care physicians to adult outpatients (n=827) in six primary care settings in Kerala, India. A psychiatrist evaluated each patient on the same day, using ICD-10 Diagnostic Criteria for Research, based on unstructured clinical interview. RESULTS: The Cronbach's alpha for internal consistency reliability was 0.80; kappa coefficient for test-retest reliability was 0.9 and that for interrater reliability was 0.72. At a score ≥2, sensitivity was 0.96, specificity was 0.87, positive predictive value was 0.74, negative predictive value was 0.98, positive likelihood ratio was 7.4 and negative likelihood ratio was 0.05. CONCLUSIONS: When physician administered, PSQ4D has good reliability. At a cut-off score of ≥2, it has high sensitivity and specificity to identify depressive disorder in primary care. DECLARATION OF INTEREST: None. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.