Glucocorticoid Use and Misuse in a Rural Community of Kerala, India.

Background: Glucocorticoids (GCs) are anti-inflammatory steroid medications prescribed globally by doctors for various illnesses and they are known to produce quick symptom relief. In India, they are among the cheapest and easily accessible over-the-counter medications. Thus, it can be misused, leading to many life-threatening illnesses such as diabetes mellitus, hypertension, overwhelming infections, Cushing's syndrome, and hypo-adrenal crisis. Objective: This study reports the misuse of GCs in a rural community in the state of Kerala, India, and compares it with the only other community GC misuse study in India, from the state of Bihar. Methods: A community-based cross-sectional survey of 452 households comprising 1,734 people was conducted in rural Konni, Kerala, during June and July of 2019. In each house, people who had been taking medications over the previous 6 months were interviewed. Results: Almost 2% (n = 31) had consumed one or more GCs in the last 6 months (95% CI: 1.3-2.5%). Of these, 26% (n = 8) were taking oral GCs and 36% (n = 11) of them were inappropriately using them based on current clinical guidelines. 29% (n = 9) had used GCs for more than 1 month. Conclusions: GC misuse exists in Kerala but not to the extent seen in Bihar. In Kerala, inhaled GCs are more common than oral GCs, and the prescription is obtained predominantly from qualified medical practitioners. The prevalence of prolonged GC use could be implicated as an underlying factor for diabetes, hypertension, osteoporosis, and cataracts. It is possible that approximately 220,000 people in Kerala may have a suppressed hypothalamus-pituitary-adrenal axis which can predispose them to a fatal hypo-adrenal crisis.

Evaluation of Glucocorticoids Utilization in Central Kerala using Pharmacy Sales Overview.

Background: Misuse of prescription drugs is a major public health problem in India and developing countries. Emerging evidence indicates that glucocorticoids are a class of drugs that are silently misused. These drugs are inexpensive and easily available as over-the-counter drugs in India are widely used by local practitioners and self-prescribed by patients for swift symptomatic relief of febrile illnesses, joint pain, asthma, other respiratory illnesses, and skin diseases. Many people have become dependent on glucocorticoids unintentionally and remain completely unaware of the metabolic changes occurring in their bodies. Methodology: A descriptive cross-sectional study involving 38 pharmacies in Thiruvalla municipality of South India was conducted to indirectly assess the utilization of glucocorticoids in the region using a pharmacy sales overview. Results: Most people approach pharmacies with prescriptions than without. A high majority of pharmacists do not have any knowledge about the uses (37%) or adverse effects (66%) of glucocorticoids. More than 50% of the community pharmacies have more than 1% of their sales attributed to glucocorticoids when compared with the total sales volume of drugs.

Comparing community and hospital data of snakebite in North Bihar: a community incidence survey and a parallel hospital-based clinical study.

In Bihar, an estimated 4500 snakebite deaths occur per year, but community data are scarce. Using a multi-stage cluster design, 4159 households were interviewed across six Community Development (CD) blocks in North Bihar, identifying 206 snakebites and 254 deaths between the Chhaat festivals of 2014 and 2015. Concurrently, 357 snakebite victims presented to Duncan Hospital from this area. None of the 254 verbal autopsies were attributed to snakebite envenoming. The annual community snakebite incidence was 643/100,000 person-years (95% confidence interval [CI] = 556-730) with peak incidence in women aged 30-39 years at 1323/100,000 person-years (95% CI = 837-1809). Two-thirds of snakebite victims attended traditional healers first for help (95% CI = 59.9-73.2). The community envenomation rate was 24.9/100,000 person-years (95% CI = 7.6-42.2). The hospital envenomation rate was 4.6% (95% CI = 3.5-5.7). Of the hospital snakebite deaths, 91% (10/11) were aged <16 years. Only 4.6% (95% CI = 4.1-5.1) of snakebite victims from this area presented at the local hospital.

Admissions to a sick new born care unit in a secondary care hospital: Profile and outcomes.

BACKGROUND: To reduce neonatal mortality in North Bihar, evidence is required about the impact of sick newborn care units (SNCUs) in secondary level hospitals on mortality at the end of the neonatal period. OBJECTIVES: The objective of the study is to assess the profile of neonates admitted to an SNCU and the outcome at the completion of neonatal period. METHODS: A cohort of neonates admitted from March to June 2014 to an SNCU was assessed through family interviews and hospital records. Demographic details (age, sex, and socioeconomic status) and clinical details (antenatal care, birthplace, weight, diagnosis, and family history) were documented. Follow-up was done at discharge or death or referral and the completion of neonatal period. The primary outcome was survival at the completion of neonatal period. Secondary outcomes were case fatality rate at discharge and weight gain. RESULTS: Of 210 neonates assessed, 87.6% (95% confidence interval [CI] 82.4-91.4) survived till the end of the neonatal period. The case fatality rate at the time of discharge was 0.9% (95% CI 0.3-3.4). Majority of the diagnoses were infections, hyperbilirubinemia, and infant of diabetic mother. Mean weight gain at the end of neonatal period (n = 157) was 706 g (P = 0.00). Sex ratio at admission was 567 girls to 1000 boys (95% CI 428/1000-751/1000). No neonate from lower socioeconomic families was admitted. CONCLUSIONS: SNCUs in remote areas can bring down neonatal mortality in North Bihar. Unequal access of SNCUs services to girls and lower socioeconomic groups highlighted the existing barriers which require attention.

Correction: A High Malaria Prevalence Identified by PCR among Patients with Acute Undifferentiated Fever in India.

[This corrects the article DOI: 10.1371/journal.pone.0158816.].

Outcome determinants of snakebites in North Bihar, India: a prospective hospital based study.

Bihar is the state with the third largest number of snakebite deaths per year in India. This prospective, one-year study of 608 snakebites provides the first data from Bihar on determinants of unfavourable outcomes in snakebites. Any delay in reaching hospital raised the risk of a snakebite patient for an unfavourable outcome [OR 8.88, CI 2.04-38.8]. Attending a traditional practitioner prior to presenting to the hospital was the only specific, significant delay [OR 3.52, CI 1.26-9.7]. Prevention of unfavourable outcomes occurred by presenting to hospital in less than 1.5 hours [OR 0.23, CI 0.052-1.0]. Motorbike was the best mode of transport [OR 0.37, CI 0.12-1.1]. Other risk factors were patients aged under 15 years [OR 3.79, CI 1.57-9.12] and bites to the upper limb [OR 2.47, CI 1.01-6.04]. Patients who were envenomated had a higher risk of unfavourable outcome, if referred due to antivenom being unavailable [OR 12.2, CI 1.49-100]. To save lives, it is imperative that measures to reduce delays in getting patients to hospital must be included in snakebite management, alongside continued availability of antivenom and assisted ventilation.

A High Malaria Prevalence Identified by PCR among Patients with Acute Undifferentiated Fever in India.

BACKGROUND: Approximately one million malaria cases were reported in India in 2015, based on microscopy. This study aims to assess the malaria prevalence among hospitalised fever patients in India identified by PCR, and to evaluate the performance of routine diagnostic methods. METHODS: During June 2011-December 2012, patients admitted with acute undifferentiated fever to seven secondary level community hospitals in Assam (Tezpur), Bihar (Raxaul), Chhattisgarh (Mungeli), Maharashtra (Ratnagiri), Andhra Pradesh (Anantapur) and Tamil Nadu (Oddanchatram and Ambur) were included. The malaria prevalence was assessed by polymerase chain reaction (PCR), routine microscopy, and a rapid diagnostic test (RDT) with PCR as a reference method. RESULTS: The malaria prevalence by PCR was 19% (268/1412) ranging from 6% (Oddanchatram, South India) to 35% (Ratnagiri, West India). Among malaria positive patients P. falciparum single infection was detected in 46%, while 38% had P. vivax, 11% mixed infections with P. falciparum and P. vivax, and 5% P. malariae. Compared to PCR, microscopy had sensitivity of 29% and specificity of 98%, while the RDT had sensitivity of 24% and specificity of 99%. CONCLUSIONS: High malaria prevalence was identified by PCR in this cohort. Routine diagnostic methods had low sensitivity compared to PCR. The results suggest that malaria is underdiagnosed in rural India. However, low parasitaemia controlled by immunity may constitute a proportion of PCR positive cases, which calls for awareness of the fact that other pathogens could be responsible for the febrile disease in submicroscopic malaria.

Use and misuse of glucocorticoids in the community of Raxaul Block, North Bihar.

BACKGROUND: Glucocorticoid misuse is widely recognised but inadequately addressed issue in India. This study reports the use and misuse of glucocorticoids in Raxaul Block, North Bihar, India. METHODS: A two-stage sampling method was used to interview 240 households during April and May 2013. In each household, anyone who had been sick in the last 6 months had their medication use recorded. RESULTS: In total, 113 out of 334 (33·8%) were found to have taken a glucocorticoid in the last 6 months (95% CI: 28.7-38.9%). One hundred (88.4%) of these were considered to be inappropriate. Seventy-nine percent had been using glucocorticoids for more than 1 month; 60.2% were prescribed by local, unlicensed practitioners. CONCLUSIONS: Glucocorticoid misuse will contribute to the burden of hypertension, diabetes, osteoporotic fracture, tuberculosis, cataracts and deaths due to hypoadrenal crisis. One in 15 people in Raxaul Block are likely to have a suppressed hypothalamo-pituitary-adrenal axis.

Hypokalaemic periodic paralysis in rural northern India--most have secondary causes.

Hypokalaemic periodic paralysis (HPP) is a life-threatening condition. Our aim was to study the clinical profile and laboratory parameters of HPP patients and to develop an algorithm to determine the causes of HPP. 84 patients presented with HPP over a 3 year period. 58 (69.0%) were found to have renal tubular acidosis (RTA). The other causes were idiopathic HPP (8 (9.5%)), acute gastroenteritis (4 (4.8%)), suspected primary hyperaldosteronism and familial HPP (2 each (2.4%)) and suspected Gitelman/Bartter Syndrome and thyrotoxic periodic paralysis (1 each (1.2%)). The number of cases peaks in the hot season. Over a third of the patients (35.7%) had recurrent episodes. 80% had secondary HPP and therefore a biochemical evaluation is mandatory. A simple algorithm was developed. Both health professionals and patients need further education regarding this problem in order to improve diagnosis and treatment and to improve compliance.

Glucocorticoid misuse in a rural and semi-urban community of North Bihar: a pilot study.

Glucocorticoid misuse is a common problem in northern Bihar. There is very little published literature regarding the magnitude of glucocorticoid misuse in South Asia. All inpatients and medical outpatients presenting to Duncan Hospital with suspected glucocorticoid abuse were screened over a six-month period. Patients presenting with iatrogenic Cushing's syndrome and hypoadrenal crisis were assessed clinically and biochemically for the side effects of glucocorticoid misuse. Twenty-two patients were seen in the hospital over a period of six months. Fifteen patients presented with iatrogenic Cushing's syndrome (68.2%) and seven with hypoadrenal crisis (31.8%). Ten were found to have cataracts, six had a recent onset of diabetes, five had a recent onset of hypertension and 12 had osteoporotic fractures of the spine. Glucocorticoid misuse is an important problem which has been inadequately addressed in the rural and semi-urban communities of northern Bihar.

High annual risk of tuberculosis infection among nursing students in South India: a cohort study.

BACKGROUND: Nurses in developing countries are frequently exposed to infectious tuberculosis (TB) patients, and have a high prevalence of TB infection. To estimate the incidence of new TB infection, we recruited a cohort of young nursing trainees at the Christian Medical College in Southern India. Annual tuberculin skin testing (TST) was conducted to assess the annual risk of TB infection (ARTI) in this cohort. METHODOLOGY/PRINCIPAL FINDINGS: 436 nursing students completed baseline two-step TST testing in 2007 and 217 were TST-negative and therefore eligible for repeat testing in 2008. 181 subjects completed a detailed questionnaire on exposure to tuberculosis from workplace and social contacts. A physician verified the questionnaire and clinical log book and screened the subjects for symptoms of active TB. The majority of nursing students (96.7%) were females, almost 84% were under 22 years of age, and 80% had BCG scars. Among those students who underwent repeat testing in 2008, 14 had TST conversions using the ATS/CDC/IDSA conversion definition of 10 mm or greater increase over baseline. The ARTI was therefore estimated as 7.8% (95%CI: 4.3-12.8%). This was significantly higher than the national average ARTI of 1.5%. Sputum collection and caring for pulmonary TB patients were both high risk activities that were associated with TST conversions in this young nursing cohort. CONCLUSIONS: Our study showed a high ARTI among young nursing trainees, substantially higher than that seen in the general Indian population. Indian healthcare providers and the Indian Revised National TB Control Programme will need to implement internationally recommended TB infection control interventions to protect its health care workforce.

Tuberculosis infection among young nursing trainees in South India.

BACKGROUND: Among healthcare workers in developing countries, nurses spend a large amount of time in direct contact with tuberculosis (TB) patients, and are at high risk for acquisition of TB infection and disease. To better understand the epidemiology of nosocomial TB among nurses, we recruited a cohort of young nursing trainees at Christian Medical College, a large, tertiary medical school hospital in Southern India. METHODOLOGY/PRINCIPAL FINDINGS: Among 535 nursing students enrolled in 2007, 468 gave consent to participate, and 436 underwent two-step tuberculin skin testing (TST). A majority (95%) were females, and almost 80% were under 22 years of age. Detailed TB exposure information was obtained using interviews and clinical log books. Prevalence of latent TB infection (LTBI) was estimated using Bayesian latent class analyses (LCA). Logistic regression analyses were done to determine the association between LTBI prevalence and TB exposure and risk factors. 219 of 436 students (50.2%, 95% CI: 45.4-55.0) were TST positive using the 10 mm or greater cut-off. Based on the LCA, the prevalence of LTBI was 47.8% (95% credible interval 17.8% to 65.6%). In the multivariate analysis, TST positivity was strongly associated with time spent in health care, after adjusting for age at entry into healthcare. CONCLUSIONS: Our study showed a high prevalence of LTBI even in young nursing trainees. With the recent TB infection control (TBIC) policy guidance from the World Health Organization as the reference, Indian healthcare providers and the Indian Revised National TB Control Programme will need to implement TBIC interventions, and enhance capacity for TBIC at the country level. Young trainees and nurses, in particular, will need to be targeted for TBIC interventions.