Prevalence and Pattern of Morbidity, Febrile Illness, and Treatment-Seeking Behavior in a Tribal-Dominated District in Odisha, India: An Observational Study.

Background Tribal populations constitute a major portion of India's total population, especially in the eastern and northeastern states. We lack comprehensive information on the community burden of general morbidity and febrile illness in tribal population-dominated areas, which is quite essential for the microplanning of healthcare expenditure and implementation. This study aimed to provide evidence on the prevalence and pattern of general morbidity and febrile illness at the community level as well as the treatment-seeking behaviour in a tribal-dominated area. Methods The study was undertaken as an observational study in the community setting; looking into seasonal cross-sectional evidence on period prevalence (two weeks) of morbidity and qualitative/semiquantitative information on treatment-seeking behaviour of the selected community during 2012 and 2013. Result This study involved 5541, 5482, and 5638 individuals during the rainy season 2012, winter 2012-13, and rainy season 2013 seasons, respectively, from 25 tribal villages of Odisha, India. A period prevalence (two weeks) of overall morbidities was shown to be 27.28% and 28.9% during the rainy seasons of 2012 and 2013, respectively, of which 13% and 11.5%, respectively, were febrile, with low prevalence (6.44% overall morbidity and 1.81% febrile illness) in the winter of 2012-13. It indicated inadequacy in skills of the village-level health staff, monitoring of supplies/logistics, and population awareness for early reporting of fever to healthcare providers at the community level. Conclusion The evidence provided by the study would be helpful in making public health plans in tribal settings and also highlighted the opportunity to improve tribal health status through community awareness, especially in areas and populations with limited health access.

A community based study on haemoglobinopathies and G6PD deficiency among particularly vulnerable tribal groups in hard-to-reach malaria endemic areas of Odisha, India: implications on malaria control.

BACKGROUND: Haemoglobinopathies and G6PD deficiency are inherited disorders found mostly in malaria-endemic areas among different tribal groups of India. However, epidemiological data specific to Particularly Vulnerable Tribal Groups (PVTGs), important for planning and implementing malaria programmes, is limited. Therefore, the present community-based study aimed to assess the prevalence of haemoglobinopathies and G6PD deficiency among the 13 PVTGs found in the state of Odisha, reporting the maximum malaria cases in the country. METHODS: This cross-sectional study was conducted from July 2018 to February 2019 in 12 districts, home to all 13 PVTGs, in an estimated sample size of 1461, selected two-stage sampling method. Detection of haemoglobinopathies was done by the variant analyser. Screening of G6PD deficiency was carried out using DPIP method followed by quantification using spectrophotometry. The PCR-RFLP technology was used to determine variant of G6PD deficiency and haplotype analysis of sickle cell, while ARMS-PCR and GAP-PCR was used for detecting the mutation pattern in ß-thalassaemia and α-thalassaemia respectively. The diagnosis of malaria was done by Pf-PAN RDT as point of care, followed by nPCR for confirmation and Plasmodium species identification. RESULTS: The prevalence of sickle cell heterozygotes (AS) was 3.4%, sickle cell homozygous (SS) 0.1%, ß-thalassaemia heterozygotes 0.3%, HbS/ß-thalassaemia compound heterozygote 0.07%, HbS-α-thalassaemia 2.1%, G6PD deficiency 3.2% and malaria 8.1%. Molecular characterization of ßS revealed the presence of Arab-Indian haplotype in all HbS cases and IVS 1-5 G → C mutation in all ß-thalassaemia cases. In case of α-thal, αα/α-3.7 gene deletion was most frequent (38%), followed by αα/α-4.2 (18%) and α-3.7/α-3.7 (4%). The frequency of G6PD Orissa (131C → G) mutation was found to be 97.9% and G6PD Mediterranean (563C → T) 2.1%. Around 57.4% of G6PD deficient individuals and 16% of the AS were found to be malaria positive. CONCLUSION: The present study reveals wide spread prevalence of sickle cell anaemia, α-thalassaemia, G6PD deficiency and malaria in the studied population. Moderate to high prevalence of G6PD deficiency and malaria warrants G6PD testing before treating with primaquine (PQ) for radical cure of Plasmodium vivax. Screening and counselling for HbS is required for the PVTGs of Odisha.

Scrub typhus associated acute kidney injury: An emerging health problem in Odisha, India.

BACKGROUND & OBJECTIVES: Acute kidney injury associated with scrub typhus is an emerging health problem in the tropics including India. This study intended to find out the incidence, clinical outcome, cytokine response and genotypes of Orientia tsutsugamushi associated with AKI patients in Odisha, a state in eastern India. METHODS: Acute febrile illness or history of acute fever with various degrees of kidney involvement admitted to SCB Medical College Hospital, Cuttack were included in the study. A detailed demographic characteristics and clinical features were recorded with pre-tested questionnaire at the time of admission. Scrub Typhus was detected by 'IgM ELISA' test (OD > 0.5) and PCR. Routine urine, haematological and biochemical tests were performed. Genotyping of the Orientia tsutsugamushi was done using 56-kDa gene for Orientia species and phylogenetic tree by neighbor-joining method. The plasma level of the IFN-γ (pro-inflammatory cytokine) and IL10 (anti-inflammatory) were measured by commercially available ELISA kit. The statistical analysis was performed using Graph Pad Prism software (version 4). RESULTS: Out of 140 acute febrile illness or history of acute febrile illness patients with AKI admitted to hospital, 32.14% were confirmed to be scrub typhus positive; eschar was seen in 17.8% of them. Of the total scrub typhus positive cases, 24.4% were having multi organ dysfunction. Majority of the AKI patients (60%) were in the "failure" category under RIFLE criteria. The mortality rate was 20.0%. Risk of dialysis requirement and mortality increases with RIFLE classification. "Karp" was the predominant circulating genotype. IFN-γ and IL10 level was high among the scrub typhus associated AKI patients. INTERPRETATION & CONCLUSION: The study shows a high incidence of scrub typhus associated AKI and high case fatality rate. Hence, emphasis should be given on differential diagnosis. RIFLE classification is applicable with increment risk of dialysis requirement and death. An in-depth study is required to determine the role of O. tsutsugamuchi KARP strain and INF-γ/ IL-10 in disease severity so as to identify a prognostic marker.

Filarial infection during pregnancy has profound consequences on immune response and disease outcome in children: A birth cohort study.

BACKGROUND: Current Global Program to Eliminate Lymphatic Filariasis (GPELF) that prohibits pregnant mothers and children below two years of age from coverage targeted interruption of transmission after 5-6 rounds of annual mass drug administration (MDA). However, after more than 10 rounds of MDA in India the target has not been achieved, which poses challenge to the researchers and policy makers. Several studies have shown that in utero exposure to maternal filarial infections plays certain role in determining the susceptibility and disease outcome in children. But the mechanism of which has not been studied extensively. Therefore the present study was undertaken to understand the mechanism of immune modulation in children born to filarial infected mother in a MDA ongoing area. METHODOLOGY AND PRINCIPAL FINDING: To our knowledge this is the first study to conduct both cellular and humoral immunological assays and follow up the children until older age in a W bancrofti endemic area,where the microfilariae (Mf) rate has come down to <1% after 10 rounds of MDA. A total 57 (32: born to infected, 25: born to uninfected mother) children were followed up. The infection status of children was measured by presence of Mf and circulating filarial antigen (CFA) assay. Filaria specific IgG1, IgG2, IgG3 and IgG4 responses were measured by ELISA. Plasma level of IL-10 and IFN-γ were evaluated by using commercially available ELISA kit. The study reveals a high rate of acquisition of filarial infection among the children born to infected mother compared to uninfected mothers. A significantly high level of IgG1 and IgG4 was observed in children born to infected mother, whereas high level of IgG3 was marked in children born to uninfected mother. Significantly high level of IL-10 positively correlated with IgG4 have been observed in infected children born to infected mother, while high level of IFN-γ positively correlated with IgG3 was found in infection free children born to mother free from infection at the time of pregnancy. Moreover a negative correlation between IL-10 and IFN-γ has been observed only among the infected children born to infected mother. SIGNIFICANCE CONCLUSION: The study shows a causal association between maternal filarial infection and impaired or altered immune response in children more susceptible to filarial infection during early childhood. As lymphatic damage that commences in childhood during asymptomatic stage has major implications from public health point of view, understanding maternal programming of the newborn immune system could provide a basis for interventions promoting child health by implementing MDA campaigns towards all women of childbearing age and young children in achieving the target of global elimination of LF.

An Estimation of Private Household Costs to Receive Free Oral Cholera Vaccine in Odisha, India.

BACKGROUND: Service provider costs for vaccine delivery have been well documented; however, vaccine recipients' costs have drawn less attention. This research explores the private household out-of-pocket and opportunity costs incurred to receive free oral cholera vaccine during a mass vaccination campaign in rural Odisha, India. METHODS: Following a government-driven oral cholera mass vaccination campaign targeting population over one year of age, a questionnaire-based cross-sectional survey was conducted to estimate private household costs among vaccine recipients. The questionnaire captured travel costs as well as time and wage loss for self and accompanying persons. The productivity loss was estimated using three methods: self-reported, government defined minimum daily wages and gross domestic product per capita in Odisha. FINDINGS: On average, families were located 282.7 (SD = 254.5) meters from the nearest vaccination booths. Most family members either walked or bicycled to the vaccination sites and spent on average 26.5 minutes on travel and 15.7 minutes on waiting. Depending upon the methodology, the estimated productivity loss due to potential foregone income ranged from $0.15 to $0.29 per dose of cholera vaccine received. The private household cost of receiving oral cholera vaccine constituted 24.6% to 38.0% of overall vaccine delivery costs. INTERPRETATION: The private household costs resulting from productivity loss for receiving a free oral cholera vaccine is a substantial proportion of overall vaccine delivery cost and may influence vaccine uptake. Policy makers and program managers need to recognize the importance of private costs and consider how to balance programmatic delivery costs with private household costs to receive vaccines.

Effectiveness of an oral cholera vaccine campaign to prevent clinically-significant cholera in Odisha State, India.

BACKGROUND: A clinical trial conducted in India suggests that the oral cholera vaccine, Shanchol, provides 65% protection over five years against clinically-significant cholera. Although the vaccine is efficacious when tested in an experimental setting, policymakers are more likely to use this vaccine after receiving evidence demonstrating protection when delivered to communities using local health department staff, cold chain equipment, and logistics. METHODS: We used a test-negative, case-control design to evaluate the effectiveness of a vaccination campaign using Shanchol and validated the results using a cohort approach that addressed disparities in healthcare seeking behavior. The campaign was conducted by the local health department using existing resources in a cholera-endemic area of Puri District, Odisha State, India. All non-pregnant residents one year of age and older were offered vaccine. Over the next two years, residents seeking care for diarrhea at one of five health facilities were asked to enroll following informed consent. Cases were patients seeking treatment for laboratory-confirmed V. cholera-associated diarrhea. Controls were patients seeking treatment for V. cholerae negative diarrhea. RESULTS: Of 51,488 eligible residents, 31,552 individuals received one dose and 23,751 residents received two vaccine doses. We identified 44 V. cholerae O1-associated cases and 366 non V. cholerae diarrhea controls. The adjusted protective effectiveness for persons receiving two doses was 69.0% (95% CI: 14.5% to 88.8%), which is similar to the adjusted estimates obtained from the cohort approach. A statistical trend test suggested a single dose provided a modicum of protection (33%, test for trend, p=0.0091). CONCLUSION: This vaccine was found to be as efficacious as the results reported from a clinical trial when administered to a rural population using local health personnel and resources. This study provides evidence that this vaccine should be widely deployed by public health departments in cholera endemic areas.

Uptake during an oral cholera vaccine pilot demonstration program, Odisha, India.

Approximately 30% of reported global cholera cases occur in India. In 2011, a household survey was conducted 4 months after an oral cholera vaccine pilot demonstration project in Odisha India to assess factors associated with vaccine up-take and exposure to a communication and social mobilization campaign. Nine villages were purposefully selected based on socio-demographics and demonstration participation rates. Households were stratified by level of participation and randomly selected. Bivariate and ordered logistic regression analyses were conducted. 517/600 (86%) selected households were surveyed. At the household level, participant compared to non-participant households were more likely to use the local primary health centers for general healthcare (P < 0.001). Similarly, at the village level, higher participation was associated with use of the primary health centers (P < 0.001) and private clinics (p = 0.032). Also at the village level, lower participation was associated with greater perceived availability of effective treatment for cholera (p = 0.013) and higher participation was associated with respondents reporting spouse as the sole decision-maker for household participation in the study. In terms of pre-vaccination communication, at the household level verbal communication was reported to be more useful than written communication. However written communication was perceived to be more useful by respondents in low-participating villages compared to average-participating villages (p = 0.007) These data on participation in an oral cholera vaccine demonstration program are important in light of the World Health Organization's (WHO) recommendations for pre-emptive use of cholera vaccine among vulnerable populations in endemic settings. Continued research is needed to further delineate barriers to vaccine up-take within and across targeted communities in low- and middle-income countries.

Mass vaccination with a new, less expensive oral cholera vaccine using public health infrastructure in India: the Odisha model.

INTRODUCTION: The substantial morbidity and mortality associated with recent cholera outbreaks in Haiti and Zimbabwe, as well as with cholera endemicity in countries throughout Asia and Africa, make a compelling case for supplementary cholera control measures in addition to existing interventions. Clinical trials conducted in Kolkata, India, have led to World Health Organization (WHO)-prequalification of Shanchol, an oral cholera vaccine (OCV) with a demonstrated 65% efficacy at 5 years post-vaccination. However, before this vaccine is widely used in endemic areas or in areas at risk of outbreaks, as recommended by the WHO, policymakers will require empirical evidence on its implementation and delivery costs in public health programs. The objective of the present report is to describe the organization, vaccine coverage, and delivery costs of mass vaccination with a new, less expensive OCV (Shanchol) using existing public health infrastructure in Odisha, India, as a model. METHODS: All healthy, non-pregnant residents aged 1 year and above residing in selected villages of the Satyabadi block (Puri district, Odisha, India) were invited to participate in a mass vaccination campaign using two doses of OCV. Prior to the campaign, a de jure census, micro-planning for vaccination and social mobilization activities were implemented. Vaccine coverage for each dose was ascertained as a percentage of the censused population. The direct vaccine delivery costs were estimated by reviewing project expenditure records and by interviewing key personnel. RESULTS: The mass vaccination was conducted during May and June, 2011, in two phases. In each phase, two vaccine doses were given 14 days apart. Sixty-two vaccination booths, staffed by 395 health workers/volunteers, were established in the community. For the censused population, 31,552 persons (61% of the target population) received the first dose and 23,751 (46%) of these completed their second dose, with a drop-out rate of 25% between the two doses. Higher coverage was observed among females and among 6-17 year-olds. Vaccine cost at market price (about US$1.85/dose) was the costliest item. The vaccine delivery cost was $0.49 per dose or $1.13 per fully vaccinated person. DISCUSSION: This is the first undertaken project to collect empirical evidence on the use of Shanchol within a mass vaccination campaign using existing public health program resources. Our findings suggest that mass vaccination is feasible but requires detailed micro-planning. The vaccine and delivery cost is affordable for resource poor countries. Given that the vaccine is now WHO pre-qualified, evidence from this study should encourage oral cholera vaccine use in countries where cholera remains a public health problem.