Anurag Bhargava

Can social interventions prevent tuberculosis?: the Papworth experiment (1918-1943) revisited.

RATIONALE There is consensus on the need to address social determinants of tuberculosis (TB) to achieve TB control, but evidence based on interventions is lacking. OBJECTIVES We reanalyzed data from the sociomedical experiment performed at the Papworth Village Settlement in England, where the impact of stable employment and adequate housing and nutrition on the incidence of TB infection and disease in children living with parents with active TB was documented during 1918-1943. METHODS Information on 315 children of patients, who lived at Papworth, was abstracted from a published monograph. Overall and age-specific occurrence of TB infection, disease, and deaths among children born in the settlement (village-born cohort) were compared with those of children born outside and admitted later (admitted cohort) to Papworth. MEASUREMENTS AND MAIN RESULTS The annual risks of infection in the village-born and admitted cohorts were 20 and 24%, respectively. Of 24 children who developed TB disease, only one was village-born. Among children 5 years of age or less, there was zero incidence of TB in the village-born, compared with five cases (1,217/100,000 person-years) among children born outside Papworth. In the admitted cohort, among children 13 years of age and older, the incidence of TB before admission to Papworth was 5,263/100,000 person-years, whereas it was 341/100,000 person-years while living in Papworth. CONCLUSIONS At Papworth social interventions including adequate nutrition did not reduce TB transmission but did reduce the incidence of TB disease in children living with parents with active TB. These results are relevant today for prevention of TB in children of patients with active TB, particularly with multidrug-resistant TB in high-burden settings.

Chikungunya fever, falciparum malaria, dengue fever, Japanese encephalitis... are we listening to the warning signs for public health in India?

The 2005-epidemic of Chikungunya fever highlights the weaknesses of public health in India. The failure to control mosquitoes, and the illnesses transmitted by them, has resulted in recurrent outbreaks all over the country. This is inevitable given the larger scenario: neglect of the basic requirements of health; poor political support for health; a weak public health capacity; centralised programmes for control based on selective interventions, and poorly-planned development projects which have created conditions ideal for the outbreak of disease. All these issues are concerns for public health ethics and must be addressed to tackle the problems posed by mosquito-borne as well as other communicable diseases.

The crisis in access to essential medicines in India: key issues which call for action.

The government is planning to introduce free generic and essential medicines in public health facilities. Most people in India buy healthcare from the private sector, a compulsion that accounts for a high proportion of healthcare-related expenditure. To reduce the burden of healthcare costs, the government must improve availability and affordability of generic and essential medicines in the market. It can do so because Indias large pharmaceutical industry is a major source of generic medicines worldwide. In this article, we discuss three factors that have impeded access to generic and essential medicines: (1) mistaken notions among policymakers, prescribers and patients about branded drugs and generic drugs in India; (2) high prices of medicines due to the progressive dismantling of the system of regulation of medicine prices, and (3) a drug approval and regulatory system that allows medicines (including fixed dose combinations) of doubtful efficacy, rationale, safety and public health relevance to dominate the market at the cost of access to affordable generic and essential medicines. The consequences of ill-health and wasted expenditure on drugs raise issues of public health ethics.Improving access to essential medicines in India is an urgent public health and ethical imperative. This should include improved public provisioning, a system of regulation of drug prices, and an evidence-based drug approval process.

Use of injectable depot medroxyprogesterone acetate in lactating Indian women

Depo-Provera injectable depot medroxyprogesterone acetate (DMPA) has been licensed in India for use as a contraceptive in lactating women. This use has been ruled safe by Upjohn (the manufacturer) the Drugs Controller of India and the World Health Organization (WHO) based on assessment of 3 criteria: 1) transfer of the drug in breast milk; 2) changes in milk composition and volume; and 3) resultant effect on infant. However a study in New Zealand has demonstrated that women using DMPA had significantly lower bone density in the lumbar spine (mean difference 7.5% 95% CI 1.9-13.1% p = 0.002) and femoral neck (6.6% 0.8-12.3% p = 0.007) than control premenopausal women. This reduction was equivalent to that seen in other estrogen deficient states. Extended lactation is associated with bone loss. In the United States a prospective cohort study of 98 women showed that those with a lactation duration greater than 6 months had mean bone mineral density (BMD) losses of 5.1% (lumbar spine) and 4.8% (femoral neck) compared to controls and in spite of increased dietary intakes of calcium to more than meet the nutritional needs of the infant. Although there was a return to baseline BMD 12 months after parturition these women had increased their dietary intake of calcium during lactation and in India women are malnourished. A study by Nordin indicates that osteoporosis is common in Indian women over age 34 that fractured hips occur at all ages (reflecting the age distribution of osteomalacia) and that there is an earlier reduction in spinal density and metacarpal cortical thickness among Indian women. In view of these findings the authors have grave reservations concerning the use of Depo-Provera in breastfeeding women in a population where there is a high prevalence of calcium deficiency.

Financial incentives and the prescription of newer vaccines by doctors in India.

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Scrub typhus in Uttarakhand & adjoining Uttar Pradesh: Seasonality, clinical presentations & predictors of mortality

Background & objectives: Scrub typhus is a re-emerging mite-borne rickettsiosis, which continues to be underdiagnosed, with lethal consequences. The present study was conducted to determine the seasonality, clinical presentation and predictors of mortality in patients with scrub typhus at a tertiary care teaching hospital in northern India. Methods: Scrub typhus was suspected in patients attending the hospital as per the standard case definition and serological evidence was obtained by performing an IgM ELISA. Results: A total of 284 patients with scrub typhus from urban and rural areas were seen, predominantly from July to November. The most common clinical presentation was a bilateral community-acquired pneumonia (CAP), which resembled pneumonia due to atypical pathogens and often progressed to acute respiratory distress syndrome (ARDS). An acute undifferentiated febrile illness (AUFI) or a febrile illness associated with altered sensorium, aseptic meningitis, shock, abdominal pain, gastrointestinal bleeding or jaundice was also seen. Eschars were seen in 17 per cent of patients, and thrombocytopenia, transaminitis and azotaemia were frequent. There were 24 deaths (8.5%) caused predominantly by ARDS and multi-organ dysfunction. The mortality in patients with ARDS was high (37%). ARDS [odds ratio (OR)=38.29, 95% confidence interval (CI): 9.93, 147.71] and acute kidney injury (OR=8.30, 95% CI: 2.21, 31.21) were the major predictors of death. Interpretation & conclusions: The present findings indicate that scrub typhus may be considered a cause of CAP, ARDS, AUFI or a febrile illness with multisystem involvement, in Uttarakhand and Uttar Pradesh, especially from July to November. Empiric therapy of CAP may include doxycycline or azithromycin to ensure coverage of underlying unsuspected scrub typhus.

Current Options in Treatment and Issues in Tuberculosis Care in Low- and Middle-Income Countries

The successful treatment of tuberculosis (TB) requires long-term administration of multiple antibiotics. In patients whose TB is caused by drug-sensitive strains, modern regimens provide rapid reduction of contagiousness and relief of symptoms as well as reduction in risk of death and disability. The most effective regimen requires four drugs for the initial 2 months, followed by 4 additional months of treatment with the two most effective anti-TB drugs, Isoniazid and Rifampin. In multiple randomized control trials, this regimen was highly effective in treating drug sensitive TB and had low rates of treatment failure, relapse, and acquired drug resistance.