Anand S. Ahankari

Parameters for the mathematical modelling of Clostridium difficile acquisition and transmission: a systematic review.

Introduction Mathematical modelling of Clostridium difficile infection dynamics could contribute to the optimisation of strategies for its prevention and control. The objective of this systematic review was to summarise the available literature specifically identifying the quantitative parameters required for a compartmental mathematical model of Clostridium difficile transmission. Methods Six electronic healthcare databases were searched and all screening, data extraction and study quality assessments were undertaken in duplicate. Results were synthesised using a narrative approach. Results Fifty-four studies met the inclusion criteria. Reproduction numbers for hospital based epidemics were described in two studies with a range from 0.55 to 7. Two studies provided consistent data on incubation periods. For 62% of cases, symptoms occurred in less than 4 weeks (3-28 days) after infection. Evidence on contact patterns was identified in four studies but with limited data reported for populating a mathematical model. Two studies, including one without clinically apparent donor-recipient pairs, provided information on serial intervals for household or ward contacts, showing transmission intervals of <1 week in ward based contacts compared to up to 2 months for household contacts. Eight studies reported recovery rates of between 75% - 100% for patients who had been treated with either metronidazole or vancomycin. Forty-nine studies gave recurrence rates of between 3% and 49% but were limited by varying definitions of recurrence. No study was found which specifically reported force of infection or net reproduction numbers. Conclusions There is currently scant literature overtly citing estimates of the parameters required to inform the quantitative modelling of Clostridium difficile transmission. Further high quality studies to investigate transmission parameters are required, including through review of published epidemiological studies where these quantitative estimates may not have been explicitly estimated, but that nonetheless contain the relevant data to allow their calculation. [Systematic review reference: CRD42012003081]

Assessment of a non-invasive haemoglobin sensor NBM 200 among pregnant women in rural India

Objective This study aimed to assess a non-invasive haemoglobin (Hb) sensor NBM 200 in pregnant women in a rural Indian setting. Methods The study population consisted of women between 3 and 5 months of pregnancy, from 33 villages in Tuljapur and Lohara blocks of Osmanabad district, Maharashtra, between April 2014 and June 2015. Hb measurements obtained from the non-invasive sensor NBM 200 were compared with measurements obtained from an automated haematology analyser Sysmex XP-100, using the Bland Altman method and Spearmans Rank correlation coefficient. Interclass correlation coefficient (ICC), sensitivity and specificity values were used to assess the anaemia diagnostic accuracy of NBM 200 against the gold standard (Sysmex XP-100). Results Data were obtained from 269 pregnant women (median age: 21 years, IQR: 19–23 years). Hb levels estimated by the Sysmex XP-100 analyser ranged from 5.5 g/dL to 14.1 g/dL (mean: 10.0 g/dL, SD: 1.28), while measurements obtained from NBM 200 ranged from 9.5 g/dL to 14.6 g/dL (mean: 11.9 g/dL, SD: 1.43). Spearmans test found a significant, moderately positive correlation between the two methods (rs=0.4, p<0.001), ICC was 0.22, and the Bland-Altman analysis showed a mean difference of −1.8 g/dL (95% CI −2.06 to −1.71), indicating a systematic overestimation of Hb using the NBM 200. The NBM 200 showed low sensitivity (33.7%; 95% CI 27.3% to 40.5%) but high specificity (91.8%; 95% CI 81.9% to 97.3%) for the diagnosis of anaemia. Conclusions Hb measurements obtained from the NBM 200 were higher with consequent underestimation of anaemia as compared with the gold standard reference method. This limits the use of the NBM 200 as an anaemia diagnostic test in our study population consisting of women during pregnancy.

Banning of fetal sex determination and changes in sex ratio in India.

www.thelancet.com/lancetgh Vol 3 September 2015 e523 increase in the annual sex ratio at livebirth between 1980 and 2004 of 0·005 units per year (p<0·0001), with a decrease of 0·011 units per year after 2004 (p=0·03). This is, to our knowledge, the fi rst analysis of temporal trends in sex ratio at livebirth in Maharashtra State. Our data show a clear increase in the sex ratio at livebirth that peaked in 2003 and 2004 and then decreased in subsequent years. The strengths of our data are the availability of information on the number and sex of livebirths over 32 consecutive years from a well defined population. Although visual inspection of these data suggests temporal trends, the use of Joinpoint analysis permits optimal fi tting of these data without the necessity of previous hypotheses, and most importantly the identifi cation of periods of time when the linear trends change. These periods can then be compared with the timing of known societal interventions such as the introduction of laws banning prenatal sex determination to assist interpretation of these observations. However, these data are applicable to Maharashtra State, and are not necessarily generalisable to other states in India. Since we were using routinely collected data, we were unable to exclude the possibility of misclassifi cation where livebirths might have been classifi ed as stillbirths. Our analysis of the total population shows a significant increase in the sex ratio at livebirth from 1980 to 2004 and then a subsequent decrease in sex ratio. We consider that the increase in the sex ratio is consistent with the hypothesis of both increasing availability and acceptability of ultrasound scanning during this period, resulting in feticide of females in utero. The reasons for the decrease in sex ratio after 2004 might be a consequence of the legislation banning sex-specific feticide, which was strengthened in 2003, finally having an eff ect on access to prenatal sex determination. These changes Banning of fetal sex determination and changes in sex ratio in India

Household air pollution and lung function in Indian adults: a cross-sectional study.

Exposure to air pollution produced by cooking is common in developing countries, and represents a potentially avoidable cause of lung disease. Cross-sectional data were collected by the World Health Organizations Study on Global AGEing and Adult Health conducted in India between 2007 and 2010. Exposure to biomass cooking was also associated with a decrease in forced expiratory volume in 1 s (FEV1) (-70 ml, 95%CI -111 to -30) and FEV1/FVC (forced vital capacity) ratio (-0.025, 95%CI -0.035 to -0.015) compared to those who were not exposed. These associations were predominantly observed in males (P < 0.05 for interaction analyses). Intervention studies using non-biomass fuels in India are required to ascertain potential respiratory health benefits.

Comparison of the NBM 200 non-invasive haemoglobin sensor with Sahli's haemometer among adolescent girls in rural India

Objective The study objective was to compare haemoglobin (Hb) measurements between the NBM 200 (non-invasive Hb sensor) and Sahlis haemometer in adolescent girls in a rural Indian setting. Methods Participants included girls aged between 13 and 17 years from 34 villages in Tuljapur and Lohara blocks of Osmanabad district, Maharashtra, India. Hb measurements from the non-invasive sensor (NBM 200) were compared with measurements obtained from Sahlis haemometer using the Bland-Altman plot, Spearman correlation coefficient, sensitivity, specificity and area under the receiver operating characteristic curve analysis (AUROC). Results Paired measurements from both methods were obtained from 766 adolescent girls (N=766). Hb levels estimated by Sahlis haemometer ranged from 5.0 to 14.0 g/dL (mean 10.1 g/dL, SD 1.41), whereas measurements obtained from the NBM 200 ranged from 9.5 to 15.2 g/dL (mean 12.8 g/dL, SD 1.42). The Bland-Altman analysis indicated a mean difference of −2.70 g/dL (95% CI −2.84 to −2.55) demonstrating an overestimation of Hb measurement by the NBM 200 compared with the Sahlis haemometer measurements. The NBM 200 showed low sensitivity (23.6%) and moderate specificity (61.8%) for the diagnosis of anaemia. The AUROC score was 0.43 indicating an underestimation of anaemia in our study population by the NBM 200. Conclusions Hb measurements obtained from the NBM 200 were consistently higher leading to an underestimation of prevalence of anaemia compared with Sahlis haemometer estimates among adolescent girls in India.

An investigation to identify potential risk factors associated with common chronic diseases among the older population in India

Background: In India, chronic diseases are the leading cause of death and their prevalence has constantly increased over the last decade. Objective: This study aimed to identify risk factors associated with common chronic diseases among people aged 50 years and over in India. Materials and Methods: Data from Wave 1 of the 2007/2008 Indian Study on Global Ageing and Adult Health (SAGE) was used to investigate the association between lifestyle choices and chronic diseases using logistic regression. Result: The fully adjusted model showed that significant independent risk factors for angina included area of residence, being diagnosed with diabetes, chronic lung disease (CLD) [highest odds ratio (OR) 4.77, 95% confidence interval (CI): 2.95-7.70] and arthritis. For arthritis, risk factors included having underlying diabetes, CLD diagnosis, or angina (highest OR 2.32, 95% CI: 1.63-3.31). Risk factors associated with CLD included arthritis, angina (highest OR 4.76, 95% CI: 2.94-7.72), alcohol use, and tobacco use. Risk factors associated with diabetes included level of education, area of residence, socioeconomic status, angina (highest OR 3.59, 95% CI: 2.44-5.29), CLD, arthritis, stroke, and vegetable consumption. Finally, risk factors associated with stroke included diabetes and angina (highest OR 3.34, 95% CI: 1.72-6.50). The presence of any other comorbidity was significantly associated with all five chronic diseases studied. Conclusion: The results show that within the older population, the contribution of lifestyle risk factors to the common chronic diseases investigated in this study was limited. Our findings showed that the major health issue within the study population was multimorbidity.

Factors associated with preterm delivery and low birth weight: a study from rural Maharashtra, India

Background: Although preterm delivery and low birth weight (LBW) have been studied in India, findings may not be generalisable to rural areas such as the Marathwada region of Maharashtra state. There is limited information available on maternal and child health indicators from this region. We aimed to present some local estimates of preterm delivery and LBW in the Osmanabad district of Marathwada and assess available maternal risk factors. Methods: The study used routinely collected data on all in-hospital births in the maternity department of Halo Medical Foundation’s hospital from 1 st January 2008 to 31 st December 2014. Multivariable logistic regression analysis provided odds ratios (OR) with 95% confidence intervals (CI) for preterm delivery and LBW according to each maternal risk factor. Results: We analysed 655 live births, of which 6.1% were preterm deliveries. Of the full term births (N=615), 13.8% were LBW (<2.5 kilograms at birth). The odds of preterm delivery were three times higher (OR=3.23, 95% CI 1.36 to 7.65) and the odds of LBW were double (OR=2.03, 95% CI 1.14 to 3.60) among women <22 years of age compared with older women. The odds of both preterm delivery and LBW were reduced in multigravida compared with primigravida women regardless of age. Anaemia (Hb<11g/dl), which was prevalent in 91% of women tested, was not significantly related to these birth outcomes. Conclusions: The odds of preterm delivery and LBW were much higher in mothers under 22 years of age in this rural Indian population. Future studies should explore other related risk factors and the reasons for poor birth outcomes in younger mothers in this population, to inform the design of appropriate public health policies that address this issue.

Healthcare benefits linked with Below Poverty Line registration in India: Observations from Maharashtra Anaemia Study (MAS)

A 2015 Lancet paper by Patel et al. on healthcare access in India comprehensively discussed national health programmes where some benefits are linked with the country’s Below Poverty Line (BPL) registration scheme. BPL registration aims to support poor families by providing free/subsidised healthcare. Technical issues in obtaining BPL registration by poor families have been previously reported in the Indian literature; however there are no data on family assets of BPL registrants. Here, we provide evidence of family-level assets among BPL registration holders (and non-BPL households) using original research data from the Maharashtra Anaemia Study (MAS). Social and health data from 287 pregnant women and 891 adolescent girls (representing 1178 family households) across 34 villages in Maharashtra state, India, were analysed. Several assets were shown to be similarly distributed between BPL and non-BPL households; a large proportion of families who would probably be eligible were not registered, whereas BPL-registered families often had significant assets that should not make them eligible. This is likely to be the first published evidence where asset distribution such as agricultural land, housing structures and livestock are compared between BPL and non-BPL households in a rural population. These findings may help planning BPL administration to allocate health benefits equitably, which is an integral part of national health programmes.

A qualitative study exploring factors influencing clinical decision-making for influenza-like illness in Solapur city, Maharashtra, India

ABSTRACT The co-existence of different types of medical systems (medical pluralism) is a typical feature of Indias healthcare system. For conditions such as influenza-like illness (ILI), where non-specific disease signs/symptoms exist, clinical reasoning in the context of medical pluralism becomes crucial. Recognising this need, we undertook a qualitative study, which explored factors underpinning clinical decisions on diagnosis and management of ILI. The study involved semi-structured interviews including clinical vignettes with 20 healthcare practitioners (working within allopathy, homeopathy and Ayurveda) working in the private healthcare sector in Solapur city, India. An inquiry was conducted into criteria influencing the diagnosis, treatment, referral to specialist care and role of treatment guidelines for ILI. Thematic analysis was used to identify aspects relating to ILI diagnosis, treatment and referral. The diagnosis of influenza was based largely on clinical symptoms suggestive of influenza in the absence of other diagnoses. Referral for laboratory tests was only initiated if illness did not resolve, generally after 2–3 consultations. Antibiotics were often prescribed for persistent illness, with antivirals rarely considered. Some differences between practitioners from different medical systems were observed in relation to treatment and referral in case of persistent illness. A combination of analytical and intuitive clinical reasoning was used by the participants and clinical decisions were based on both social and clinical factors. Clinical decision-making was rarely a linear process and respondents felt that broad guidelines on influenza that allowed doctors to account for the sociocultural context within which they practised medicine would be helpful.

PCPNDT seems to benefit India's birth sex ratios.

The possibility of lifting a ban on sex determination is an important ongoing debate in India.1 The introduction of prenatal diagnostic techniques legislation in 1994 and an amendment in 2003 aim to prevent female feticide (sex selective abortion of female fetuses) and represent milestones for the Indian …