Evaluation of the Protection Provided by Hepatitis B Vaccination in India.

OBJECTIVE: In India, Hepatitis B vaccination is recommended at 6 wk except for hospital-deliveries. The authors examined protection afforded by the birth dose. METHODS: A case-control study was done. HBsAg and HBcAb were tested in 2671 children, 1 to 5 y and HBsAb was evaluated in a subset of 1413 children. Vaccination history was recorded. Cases were HBsAg carriers. In another analysis, children who got infected (HBsAg and/or HBcAb positive) were considered as cases. Exposed were the unvaccinated. In another analysis, exposed were those vaccinated without the birth dose. RESULTS: The odds ratio (OR) for HBsAg positivity with birth vaccination was 0.35 (95% CI 0.19-0.66); while with vaccination at 6 wk was 0.29 (95%CI 0.14-0.61), both compared to unvaccinated. Birth vaccination has no added protection when compared to the unvaccinated. Unvaccinated children in index study had HBsAg positivity of 4.38%. The number needed to treat (NNT) to prevent one case of HBsAg positivity was 32.6 (95% CI, 20.9 to 73.6). The odds of getting HBV infection was 0.42 (CI 0.25-0.68) with birth dose and 0.49 (CI 0.30-0.82) without the birth dose compared to the unvaccinated. Protective antibody (HBsAb) was present in about 70% of the vaccinated. In the unimmunised, in the first 2 y HBsAb protection was present in 40%. The odds ratio (OR) for HBsAb in the fully vaccinated between 4 and 5 y was 1.4 (95%CI 0.9-2.18) compared to the unvaccinated. CONCLUSIONS: The present study lends support to the pragmatic approach of the Government to vaccinate babies born at home starting at 6 wk.

Food Choices and Consequences for the Nutritional Status: Insights into Nutrition Transition in an Hospital Community.

INTRODUCTION: Although economic development is generally accompanied by improvements in the overall nutritional status of the country's population the 'nutritional transition' often involves a shift to high energy diets and less exercise with negative consequences. This pilot study was done to examine if education of parents operates at the household level to influence dietary choices and the nutritional status of children in a small community of hospital workers. MATERIAL AND METHODS: 3 groups of persons with varying skill and education levels participated. Weighed food logs were used in all households to calculate 'adult equivalent' per-capita-consumption. Nutrients were calculated using nutrients calculator software. BMI was used to classify children as underweight, normal weight and overweight. RESULTS: 128 individuals participated from 30 families included 47 children. 10 children (21%) were underweight, 29 (62%) were normal and 8 (17%) were overweight. Energy consumption was highest in families with overweight children 2692 +/-502 compared to 2259 +/-359 in families with normal weight and 2031+/-354 in the family of underweight children. These differences were statistically significant. 42% underweight children belonged to Class 1 at the lowest skill level and there were no overweight children in this group. Most of the overweight children belonged to Class 2. In Class 3 there were no underweight children and the majority was normal weight children. CONCLUSION: Underweight children came from the poorer households. Per capita intake of the family as a whole correlated well with BMI in the children. There was increased obesity in middle income families belonging to Class 2-probably in families who move up the scale from deprivation. Nutritional status in children correlated mostly with maternal education status.

Public Report on Health: Development of a Nutritive Value Calculator for Indian Foods and Analysis of Food Logs and Nutrient Intake in six States.

UNLABELLED: The Public Report on Health (PRoH) was initiated in 2005 to understand public health issues for people from diverse backgrounds living in different region specific contexts. States were selected purposively to capture a diversity of situations from better-performing states and not-so-well performing states. Based on these considerations, six states - the better-performing states of Tamil Nadu (TN), Maharashtra (MH) and Himachal Pradesh (HP) and the not-so-well performing states of Madhya Pradesh (MP), Uttar Pradesh (UP) and Orissa (OR) - were selected. This is a report of a study using food diaries to assess food intakes in sample households from six states of India. METHOD: Food diaries were maintained and all the raw food items that went into making the food in the household was measured using a measuring cup that converted volumes into dry weights for each item. The proportion consumed by individual adults was recorded. A nutrient calculator that computed the total nutrient in the food items consumed, using the 'Nutritive Value of Indian Foods by Gopalan et al., was developed to analyze the data and this is now been made available as freeware (http://bit.ly/ncalculator). The total nutrients consumed by the adults, men and women was calculated. RESULTS: Identifying details having been removed, the raw data is available, open access on the internet http://bit.ly/foodlogxls.The energy consumption in our study was 2379 kcal per capita per day. According to the Summary Report World Agriculture the per capita food consumption in 1997-99 was 2803 which is higher than that in the best state in India. The consumption for developing countries a decade ago was 2681 and in Sub-Saharan Africa it was 2195. Our data is compatible in 2005 with the South Asia consumption of 2403 Kcal per capita per day in 1997-99. For comparison, in industrialized countries it was 3380. In Tamil Nadu it was a mere 1817 kcal. DISCUSSION: The nutrient consumption in this study suggests that food security in the villages studied is far from achieved. It is hoped that the new Food Security Ordinance will make a dent in the situation. The calculator for computing nutrients of foods consumed which we developed based on the ICMR defined nutrient values for Indian foods has been made available as freeware on the internet. This is with the hope that more such studies can be carried out at the household level.

Nebulized hypertonic-saline vs epinephrine for bronchiolitis; proof of concept study of cumulative sum (CUSUM) analysis.

OBJECTIVE: To apply cumulative sum (CUSUM) to monitor a drug trial of nebulized hypertonic-saline in bronchiolitis. To test if monitoring with CUSUM control lines is practical and useful as a prompt to stop the drug trial early, if the study drug performs significantly worse than the comparator drug. DESIGN: Prospective, open label, controlled trial using standard therapy (epinephrine) and study drug (hypertonic-saline) sequentially in two groups of patients. SETTING: Hospital offering tertiary-level pediatric care. PATIENTS: Children, 2 months to 2 years, with first episode of bronchiolitis, excluding those with cardiac disease, immunodeficiency and critical illness at presentation. INTERVENTIONS: Nebulized epinephrine in first half of the bronchiolitis season (n = 35) and hypertonic saline subsequently (n = 29). Continuous monitoring of response to hypertonic-saline using CUSUM control charts developed with epinephrine-response data. MAIN OUTCOME MEASURES: Clinical score, tachycardia and total duration of hospital stay. RESULTS: In the epinephrine group, the maximum CUSUM was +2.25 (SD 1.34) and minimum CUSUM was -2.26 (SD 1.34). CUSUM score with hypertonic saline group stayed above the zero line throughout the study. There was no statistical difference in the post-treatment clinical score at 24 hours between the treatment groups {Mean (SD) 3.516 (2.816): 3.552 (2.686); 95% CI: -1.416 to 1.356}, heart rate {Mean (SD) 136 (44): 137(12); 95% CI: -17.849 to 15.849) or duration of hospital stay (Mean (SD) 96.029 (111.41): 82.914 (65.940); 95% CI: -33.888 to 60.128}. CONCLUSIONS: The software we developed allows for drawing of control lines to monitor study drug performance. Hypertonic saline performed as well or better than nebulized epinephrine in bronchiolitis.

Validation of "Signs of Inflammation in Children that Kill" (SICK) score for immediate non-invasive assessment of severity of illness.

OBJECTIVE: To validate the SICK scoring system's ability to differentiate between individuals with higher and lower probabilities of death METHOD: We performed a one year two-centre prospective evaluation of all children aged between one month and 12 years referred to the Paediatric team at St Stephens Hospital in Delhi and admitted to the Paediatric Department at West Middlesex University Hospital in London. We calculated SICK scores at presentation and correlated them with subsequent in-hospital mortality. We used discrimination by areas under receiver operating characteristic (ROC) curves to measure performance. RESULTS: We prospectively evaluated 3895 children in Delhi and 1473 children in London. The areas under the ROC curves were 84.8% in Delhi, 81.0% in London and 84.1% (95% CI 77.4-90.8%) for combined data. Hosmer-Lemeshow goodness of fit for the combined data was good (Hosmer-Lemeshow Chi-square=2.13 (p=0.345). CONCLUSIONS: We propose the SICK score as a useful triage tool at initial presentation and highlight its particular suitability for resource poor settings.