Magnitude of unreported kala-azar cases in a highly endemic district of Bihar, India: A positive impact of Indian elimination programme.

BACKGROUND & OBJECTIVES: In India, kala-azar surveillance is weak and no public-private partnership exists for disease containment. Estimate of disease burden is not reliably available and still cases are going to private providers for the treatment. The present study aimed to assess the magnitude of kala-azar cases actually detected and managed at private set-up and unreported to existing health management information system. METHODS: Institution based cross-sectional prospective pilot study was conducted. List of facilities was created with the help of key informants. The information about incidence of kala-azar cases were captured on monthly basis from July 2010 to June 2011. Rapid diagnostic strip test (rk-39) or bone marrow/splenic puncture were applied as laboratory methods for the diagnosis of kala-azar. Descriptive statistics as well as chi-square test for comparison between proportions was conducted. RESULTS: Overall availability of private practitioners (PPs) was 4.59/1,00,000 population and maximum PPs (46; 93.9%) were from qualified category. The median years of medical practice was 25 yr (inter quartile-range [18, 28]). Interestingly, only a small proportion (240; 19%) of cases was managed by PPs. Amongst the PPs, only low proportion (32; 18.2%) managed >2 cases per month. The mean number of kala-azar suspects and cases identified varied significantly between different PPs' professions with p <0.048 and p <0.032, respectively. A highly significant difference (p <0.0001) was observed for kala-azar case load between qualified and unqualified practitioners. A small proportion (38; 15.8%) of kala-azar cases was not present in the public health system record. INTERPRETATION & CONCLUSION: Still sizeable proportions of cases are going to PPs and unrecorded into government surveillance system. A mechanism need to be devised to involve at least qualified PPs in order to reduce treatment delay and increase case detection in the region.

Hypertriglyceridemia: a possible diagnostic marker of disease severity in visceral leishmaniasis.

PURPOSE: Visceral leishmaniasis (VL), a protozoan disease, is 100% fatal if left untreated. Anemia is common in VL which plays a role in expression of clinically overt VL disease. Laboratory clues are scarce for strengthening clinical suspicion for severity in VL. Hypertriglyceridemia has emerged as a new concept for the diagnosis and prognosis in VL. The present study is aimed at correlating the magnitude of hypertriglyceridemia with the severity in VL. MATERIALS AND METHODS: A retrospective case-control study was conducted between January 2012 to December 2013 among 124 patients coming for treatment from VL endemic areas, who had fever of more than 15 days and did not respond to antimalarials and antibiotics. The parasitologically confirmed VL cases (n = 87) were categorized as mild/moderate (n = 60) and severe (n = 27) groups according to WHO classification for anemia and parasite burden. Serum triglycerides were assayed in VL groups along with controls (n = 37). RESULTS: Serum triglyceride level was significantly higher in VL than controls [mean values were 173.50 ± 47.67 versus 127.1 ± 53.79 mg/dl, respectively (p < 0.0001)]. Triglyceride level was significantly higher in severe than in mild/moderate group of VL [211.3 ± 50.2 mg/dl versus 134 ± 45.09 mg/dl, respectively (p < 0.0001)]. Hypertriglyceridemia (>161.7 mg/dl) was noted in all severe VL patients, compared to 31.66% of mild or moderate group (p < 0.0001). There was no significant difference between mild/moderate VL and controls. CONCLUSIONS: It is hypothesized that hypertriglyceridemia could be of additional diagnostic benefit to assess the probability and severity of VL in endemic areas.

Post-kala-azar dermal leishmaniasis in a patient treated with injectable paromomycin for visceral leishmaniasis in India.

Post kala-azar dermal leishmaniasis (PKDL) is a skin manifestation that usually develops after treatment of visceral leishmaniasis (VL), a major public health problem in India. The diagnosis and management of PKDL is complex. This is the first case report from India in which PKDL occurred after paromomycin treatment for VL in an Indian patient.

Asymptomatic infection of visceral leishmaniasis in hyperendemic areas of Vaishali district, Bihar, India: a challenge to kala-azar elimination programmes.

A cohort of 91 asymptomatic individuals with visceral leishmaniasis (VL) were identified during base line screening using recombinant 39-aminoacid antigen (rk-39) and polymerase chain reaction (PCR) conducted from December 2005 to June 2006 involving 997 individuals of two highly endemic villages of Vaishali district, Bihar. The point prevalence of asymptomatic infection was 98 per 1000 persons at baseline. There was no statistically significant difference between rk-39 and PCR positivity rate (P>0.05), even though PCR positivity alone was found significantly higher (4.2%) than rk-39 positivity alone (2.6%). The monthly follow-up of the asymptomatic cohort revealed a disease conversion rate of 23.1 per 100 persons within a year. There was a statistically significant difference in conversion of disease when individuals were positive by both tests as compared to single tests by rk-39 and PCR (P<0.01). Disease conversion rate in the subjects residing in households with a history of VL (62%, 13/21) was higher than those residing in the households without a history of VL (38%, 8/21). Most of the identified asymptomatic individuals were from low socio-economic strata similar to that of VL cases in general. Apart from rk-39, PCR may be considered for screening of asymptomatic Leishmania donovani infection in large-scale epidemiological studies. Screening of asymptomatic cases and their close follow-up to ascertain early detection and treatment of VL may be considered in addition to the existing VL control strategies.

Awareness about kala-azar disease and related preventive attitudes and practices in a highly endemic rural area of India.

This study was undertaken to assess the extent of community awareness and related practices about kala-azar undertaken by them to control the disease, in an highly endemic focus of Bihar, India. A household-based cross-sectional knowledge, attitude, and practices (KAP) survey consisting of quantitative components on knowledge, attitude, and practices concerning kala-azar was administered to heads-of-household through a semi-structured questionnaire. Data indicated that 61% respondents were illiterate, 4% had correct knowledge that sandfly bites caused kala-azar, 26% do not know any specific transmission agents for kala-azar. A majority (72%) of respondents were not able to recognize sandfly, 33% had no specific knowledge about the symptoms. All of them (100%) believed that this disease could affect his or her family income. Nearly all (95%) were positive that the kala-azar cases could be reduced with implementation of proper health measures. A few (11%) suggested isolation of patients to avoid contacting kala-azar while a high proportion (93%) of respondents favored specific allopathic medicine, and a majority (72%) favored the utilization of the services offered by primary health centers or government hospitals. Just over half (66%) of the respondents were not using any prevention measures to avoid contacting disease. These results could prove to be useful for health planners in developing suitable control strategies.

Knowledge about sandflies in relation to public and domestic control activities of kala-azar in rural endemic areas of Bihar.

Visceral Leishmaniasis (VL) control is a global cause of concern. To identify the gaps in People's knowledge/awareness about sand flies and control activities of kala-azar in rural endemic areas of Bihar, this study consisting of 450 respondents with 288 male and 162 female was carried out. The result showed that 95% respondents had heard about the disease up to some extent, but majority respondents were neither aware about the vector of kala-azar, nor they had any idea about transmission of the disease. About 61% had wrong impression that mosquitoes were causing kala-azar. Regarding knowledge about breeding and resting sites of vectors, 20% reported cattle shed, 16% crevices in the household followed by 15% damp dark places. The attitude of respondents towards vector control programme was poor, as 99% lost faith in the DDT spraying because of ineffectiveness, like no reduction in mosquito nuisance. Bed net was considered the best protection method against sand fly or mosquito nuisance but the cost was considered the major constraint in its use. Proper health education programme in Simple and local language along with visual demonstration should be promoted to enhance the awareness and co-operation at community level.

A community-based, comparative evaluation of direct agglutination and rK39 strip tests in the early detection of subclinical Leishmania donovani infection.

In the Indian state of Bihar, the sensitivities and specificities of direct agglutination tests (DAT) and rK39 test strips for the detection of Leishmania donovani infection in humans were explored and found to be generally good (92%-100%). When 172 asymptomatic individuals [16 'case-contacts' who lived in the same households as past or current, confirmed cases of visceral leishmaniasis (VL) and 156 other subjects from neighbouring households] were tested, the same 36 (21%) individuals, including all 16 'case-contacts', were found seropositive using each type of test. When followed-up after 3 months, 18 of the individuals who had been found seropositive in the baseline survey remained seropositive, and eight (44%) of these had developed symptomatic VL, with amastigotes in their splenic aspirates. Seven (44%) of the 16 'case-contacts' but only one (5%) of the other 20 subjects found seropositive at baseline went on to develop VL within 3 months. Although the strip test appeared slightly better than DAT for predicting the development of VL in the 172 subjects, either type of test may be very useful for the early detection of asymptomatic L. donovani infection and thus the identification of those at relatively high risk of developing VL.

Wilson disease with visceral leishmaniasis: an extremely uncommon presentation.

Visceral leishmaniasis (VL), which is caused by the protozoa Leishmania donovani and transmitted by the bite of the female sand fly Phlebotomus argentipes, is common in Bihar, India. Wilson disease is an autosomal recessive disorder of copper metabolism in which copper is deposited in the brain and liver. We report a case of an extremely uncommon combination of these diseases in a patient. Treatment options for such a combination of diseases are limited and difficult.

A pilot study on the status of lymphatic filariasis in a rural community of Bihar.

A pilot study of lymphatic filariasis was conducted in two contiguous villages of Patna district in Bihar situated at the side of the river Ganges, known to be endemic for lymphatic filariasis, to study present status of transmission parameters of filariasis. Of the 1872 persons examined, 8.4% were found asymptomatic but microfilaraemic. Morbidity pattern due to filarial infection showed an increase with advancement of age and significantly high in males as compared to female (p < 0.001). Acute and chronic filarial disease was observed as 0.5% and 9% respectively. Microfilaria was found in 10% of acute and 11.2% of chronic filarial cases. The Mf rate was found to be 9.9% in males and 9.0% in females respectively. The parasite species was identified as W. bancrofti. The vector fauna surveyed show highest prevalence of vector species of Cx. quinquefasciatus (43%) in both domestic as well as predomestic area in the community. Other species like Cx. vishnui and Ma. uniformis were also seen. Each household and predomestic area was searched for mosquito fauna at night. The infection rate in vectors was found to be 14% and infectivity rate (L3) was 8%. The filariasis cases detected in the study were treated with 12 days course of DEC 6 mg/kg body weight.

The treatment of trapeziometacarpal arthritis with arthrodesis.

In this article, the authors discussed the indications for TM arthrodesis, the surgical approach, the types of fixation, expected outcome, and complications. Fusion of the thumb TM joint allows maintenance of pinch and grip strength and provides relief of pain, but limits thumb mobility. An important factor in the success of the arthrodesis is correct thumb position. Trapeziometacarpal joint arthrodesis is advantageous over soft tissue interposition when grip and pinch strength are to be maintained. After TM fusion, however, there are increased stresses across the peritrapezial joints that can cause laxity, pain, and arthritis. Treatment of this may require additional surgical intervention. Treatment of TM arthritis with soft tissue interposition has the advantages of pain relief and increased mobility, but pinch and grip strength are reduced to approximately 75% of normal and rate of reoperation is minimal. The authors recommend TM arthrodesis in the young active person with arthritis limited to the TM joint in whom strong pinch and grip are required. Arthrodesis of the TM joint is safe and predictable and has good subjective and objective results.

Athletic stress fractures: part I. History, epidemiology, physiology, risk factors, radiography, diagnosis, and treatment.

This 3-part article is a comprehensive review of the literature on athletically induced (fatigue) stress fractures. As typical signs and symptoms of stress fracture may differ slightly depending on the bone involved, physicians examining a fracture need to be aware of these subtle differences. Stress fractures are the result of excessive loading of bone. (Excessive loading is caused by muscle pull, fatigue loading, or both and may be exacerbated by anatomic risk factors, age, and sex. Loading leads to a metabolic response by osteoclasts and osteoblasts. This response, which normally helps bone heal, instead causes the stress fracture.) Stress fractures resolve with 6 to 8 weeks of rest and rehabilitation. Part 1 of this article focuses on the history, epidemiology, physiology, risk factors, radiography, diagnosis, and treatment of stress fractures. Part 2 reviews the specifics of stress fractures involving the lower body--the lower extremities, pelvic girdle, and feet and ankles. Part 3 reviews the specifics of stress fractures involving the upper body-shoulder girdle and thoracic region, upper extremities, hands and wrists, and pars interarticularis--and includes a special section on the female athlete. (Parts 2 and 3 will appear in the next issue.)

Athletic stress fractures: part II. The lower body. Part III. The upper body--with a section on the female athlete.

Part I of this article (published in the November issue) focused on the history, epidemiology, physiology, risk factors, radiography, diagnosis, and treatment of stress fractures. Part II reviews the specifics of stress fractures involving the lower body, the upper body, and includes a special section on the female athlete.

Visible minority fertility in Canada, 1981-1986.

PIP: This study uses Canadian vital records and the 1981 and 1986 census to analyze levels and trends in fertility among minorities during 1981-86. The number of births for 1981 and 1986 were derived by averaging the annual number of births by birthplace and age of the mother over the periods 1980-82 and 1985-87. The authors calculated age specific fertility rates, the total fertility rate, and the mean age of the mother by birth place for Canada and regions by visible minority group for 1981 and 1986. Visible minority groups include Chinese, Indian/Pakistani, other Asians, Latin Americans, Caribbeans, and Africans. Regions include Maritime Provinces, Quebec, Ontario, and other provinces. Findings indicate that Canadian-born mothers had the lowest fertility rates in 1981 and 1986. The highest fertility rate in 1981 was 2.7 children/woman among other Asians, followed by 2.6 children/woman among Indians or Pakistanis. The Chinese had the lowest fertility rate of 1.8 children/woman. In 1986, the highest fertility was 2.5 children/woman among the Indians or Pakistanis, followed by 2.4 children/woman among the Chinese and Latin Americans. The lowest fertility was 2.2 children/woman among other Asians. Fertility rates varied widely during 1981 compared to 1986. Fertility declined for all minorities, with the exception of the Chinese and Africans. Fertility variations were greatest for the Chinese during 1981-86 and smallest for the Canadian-born. The mean age of childbearing increased by more than a year, with the exception of Chinese women, where the mean age decreased. The highest mean age was among Latin American women in 1981 and among other Asians in 1986. Other Asians had the highest relative index of total fertility. In 1986, minority women, excluding Chinese and African women, living in Quebec had the highest fertility. Caribbean-born women living in other provinces had lower fertility than Canadian-born women.^ieng

Surveillance of drug induced diseases in children.

A hospital based prospective study on drug induced diseases (DID) in children below 14 years of age was done for a duration of two years. A total number of 20,310 patients were examined in pediatric department during this period, out of which 204 (1.004%) patients were diagnosed as DID. Children with severe reactions were admitted in pediatric ward for in hospital intensive surveillance. The male:female ratio in DID was 1.2:1. DID were most common in neonates (24.51%). Erythmatous maculopapular rashes (67.12%) formed the most common pool of DID in neonates. Thrombophlebitis (41.56%) was most commonly seen in infants above 28 days of life, and in children up to 14 years of age. Out of 204 cases of DID, 9 (4.41%) died. Aplastic anemia was most morbid DID, as all the 7 patients of aplastic anemia died. Chloramphenicol was responsible for all the cases of aplastic anemia. Other two deaths were from erythma multiforme and C.C.F. The most commonly involved drugs, other substances and vaccines were baby powders, massage oils, ampicillin, co-trimoxazole, i.v. infusions (electrolytes and mannitol), DPT and measles vaccines.

Characterization of dopamine receptors involved in central thermoregulation in rabbits.

Intracerebroventricularly administered dopamine produced dose dependent hyperthermia in rabbits. Haloperidol, a D1 receptor blocker produced consistent hypothermia, whereas D2 receptor blocker metoclopramide produced hyperthermia, pretreatment with haloperidol competitively blocked the hyperthermic response of dopamine. Pretreatment with metoclopramide augmented the onset and peak response of dopamine. It is suggested that D1 receptors are involved in producing hyperthermia and D2 receptors in hypothermia.

Mortality differentials among immigrant populations in Canada.

PIP: Mortality among different groups of migrants to Canada is compared with that of native-born Canadians and with trends in the migrants' countries of origin, using data for the period 1981-1985. Results show that life expectancy at birth among migrants in Canada is generally higher than that of the populations at place of origin and destination. (SUMMARY IN FRE AND SPA)^ieng

Population estimates for small areas in Canada.

The author outlines population estimation techniques used by Statistics Canada. "The objectives of this paper are to (i) describe the methodology and data sources for estimating the population for census divisions (CDs) and census metropolitan areas (CMAs), and (ii) present the results of the evaluations of 1986 population estimates."