Jagadish Mahanta

Injecting and sexual risk behaviours, sexually transmitted infections and HIV prevalence in injecting drug users in three states in India.

Objective:To describe and compare sexual and injecting risk behaviours and sexually transmitted infections (STI), hepatitis C virus (HCV) and HIV prevalence in injecting drug users (IDU) in six districts in three states of India: Manipur, Nagaland, and Maharashtra. Method:The respondent-driven sample consisted of 2075 IDU. Consenting participants were administered a structured questionnaire and samples of blood and urine were collected to test for HIV and STI. Data were analysed using RDSAT. Results:In two districts in Manipur, 77 and 98% of IDU injected heroin, whereas the main injecting drug in Nagaland was dextropropoxyphene (99%). In Mumbai/Thane, Maharashtra, the majority of respondents reported using chlorpheniramine (87%) and heroin (99%). In all districts, almost half of IDU reported generally sharing needles and syringes; consistent condom use with non-paid female partners was also low. Approximately one-quarter of IDU in Mumbai/Thane visited a paid partner in the past year. IDU with reactive syphilis serology were higher in Nagaland (7 and 19%) than in Manipur and Maharashtra. HIV in two districts of Manipur (23%, 32%) and Mumbai/Thane (16%) was greater than Nagaland (<2%). HCV prevalence was more than 50% in Mumbai/Thane and Manipur. Conclusion:Irrespective of regional differences, high-risk behaviour of needle sharing and low condom use makes IDU a critical subpopulation for HIV prevention interventions. Interventions need to address the differing drug use patterns in the regions and transmission prevention among non-paid regular and casual female partners of IDU in the northeast districts and paid female partners in Mumbai/Thane.

Factors Associated with Immunization Coverage of Children in Assam, India: Over the First Year of Life

The children of Assam in the North-East Region of India have consistently evidenced low rates for routine childhood immunizations. This study has been conducted to evaluate the factors affecting the immunization coverage in the first year of life of the children. About 62.2% of the children were fully immunized. Lack of information among the parents was one of the major causes of drop out of vaccinations. The children from urban areas and mothers education level showed significant role in immunization coverage. Improvement in female literacy coupled with the reduction in the drop out rate would add to achieve a higher target of immunization among children in the study area.

Role of the prevalent Anopheles species in the transmission of Plasmodium falciparum and P. vivax in Assam state, north-eastern India.

Abstract In north–eastern India, Anopheles minimus, An. dirus and An. fluviatilis are considered the three major vectors of the parasites causing human malaria. The role in transmission of the other Anopheles species present in this region is not, however, very clear. To examine the vectorial role of the more common anopheline mosquitoes, the heads and thoraces of 4126 female Anopheles belonging to 16 species (collected using miniature light traps set in human dwellings in a foothill village in the Jorhat district of Assam state) were tested, in ELISA, for the circumsporozoite proteins (CSP) of Plasmodium falciparum or the VK-210 and VK-247 polymorphs of P. vivax. Sixty-five pools of head–thorax homogenates, representing 10 different species of Anopheles , were found reactive, giving an overall minimum prevalence of infection (MPI) of 1.58%, with a 95% confidence interval (CI) of 1.21%–2.0%. Among the CSP-reactive pools of mosquitoes, 31% were positive only for P. falciparum, 45% only for P. vivax VK 247, 6% only for P. vivax VK 210, and 18% for both P. falciparum and P. vivax VK 247. The results indicate that not only the proven vector, An. minimus s.l. (MPI = 0.71%), but also several species of Anopheles previously considered unimportant in the epidemiology of malaria, especially An. aconitus (MPI = 3.95%), An. annularis (MPI = 5.8%), the An. hyrcanus group (MPI = 0.48%), An. kochi (MPI = 1.28%), the An. philippinensis-nivipes complex (MPI = 0.94%), and An. vagus (MPI = 3.87%), are important vectors in the foothills of Assam.

West Nile virus infection, Assam, India.

To the Editor: West Nile virus (WNV) is a mosquito-borne flavivirus. Sporadic infections with this virus have been found in Africa, Europe, Asia, and the United States. In humans, most infections with WNV cause subclinical or a mild influenza-like illness; encephalitis occurs in some (1). In India, antibodies against WNV were first detected in humans in Bombay in 1952 (2). Virus activity has been reported in southern, central, and western India. WNV has been isolated in India from Culex vishnui mosquitoes in Andhra Pradesh and Tamil Nadu, from Cx. quinquefasciatus mosquitoes in Maharashtra, and from humans in Karnataka State (3). Assam (26°–27°30′N, 89°58′–95°41′E) is the most populated state in northeastern India; it contains ≈50% of the 38.8 million inhabitants of northeastern India. Japanese encephalitis virus (JEV) has caused sporadic epidemics in Assam since 1976. Studies conducted during 2000–2002 in Assam showed that 187 (53.7%) of 348 persons with acute encephalitis syndrome were infected with JEV (4). JEV-negative persons also showed symptoms of neurotropic viral infection. Suspecting the presence of some other closely related flavivirus in this region, we screened samples from persons with acute encephalitis syndrome for WNV in 2006. To our knowledge, no study has been conducted on the prevalence of WNV in this region. We report WNV activity in the state of Assam in northeastern India. Ethical approval for this study was obtained from the institutional ethical committee, Regional Medical Research Center, Dibrugarh, India. A JEV vaccination campaign (SA14-14-2 vaccine) was started in Assam during May 2006. During its first phase, children 1–15 years of age in Dibrugarh and Sivasagar Districts were vaccinated. Mosquito surveillance in the study area and in an earlier study (5) identified Cx. vishnui mosquitoes. During the study period, 103 serum samples and 88 cerebrospinal fluid samples were obtained from 167 patients with acute encephalitis syndrome admitted to the Assam Medical College and Hospital in Dibrugarh, which administers to the health needs of >7 districts of Upper Assam and neighboring states of Arunachal Pradesh and Nagaland. Among the 167 patients, 124 (74.2%) were children <15 years of age. Among the 103 serum samples, 80 were positive for immunoglobulin (Ig) M against JEV (IgM monoclonal antibody–capture ELISA; National Institute of Virology, Pune, India) and 12 (11.6%) were positive for IgM against WNV (IgM antigen-capture ELISA; Panbio, Sinnamon Park, Queensland, Australia). These samples were from persons in 4 districts in Assam (Dibrugarh, Golaghat, Sivasagar, and Tinsukia) and negative for IgM against JEV (Table). Follow-up was conducted for 9 patients; 3 died, and 1 was lost to follow-up. Table Incidence of JEV and WNV infections among patients with acute encephalitis syndrome, Assam, India* Virus-neutralizing antibody titers against JEV and WNV were estimated in pig kidney epithelial cells by using JEV (isolate 733913) and WNV (isolate 68856) and a cytopathic-effect assay in 96-well tissue culture plates (6). Mouse polyclonal antibodies against JEV and WNV and nonimmune serum samples were included in the assay. Of 9 paired serum samples, 6 showed neutralizing antibody for WNV, of which 4 showed a 4-fold increase in antibody titer. The remaining 3 paired samples showed cross-reactivity with WNV (titer <80) and JEV (titer <40). All 12 WNV-infected patients had high fever and headache. Convulsions (6 patients), altered sensorium (7 patients), vomiting (5 patients), and neck rigidity (2 patients) were also observed. Signs and symptoms at the time of hospitalization and at follow-up for 6 months (at 3-month intervals) were similar for persons infected with JEV and those infected with WNV. Neurologic sequelae observed at <6 months follow-up were impaired memory (6 patients), irritable behavior (5 patients), impaired hearing (3 patients), incoherent speech and disorientation (1 patient), breathing difficulty (1 patient), impaired speech (1 patient), and quadriparesis (1 patient). We identified WNV in regions of Assam to which JEV is endemic. The finding indicates that WNV might be the cause of a substantial number of acute encephalitis syndrome cases in this region. Fever and headache were the most common signs and symptoms, as reported (7). There were 3 deaths (all children) in 13 patients. Our results corroborate a similar observation in the Kolar District of Karnataka (8). In contrast, in western countries, the attack rate and case-fatality rate for WNV infection are higher among immunocompromised elderly patients (9). Our findings may be caused by strain variations and host susceptibility to the virus. Identification of circulating genotypes of WNV and its vectors and epidemiologic studies are needed to obtain additional information on WNV infection in this region and identify WNV as a cause of acute encephalitis syndrome.

Prevalence of diabetes and prediabetes in 15 states of India: results from the ICMR–INDIAB population-based cross-sectional study

BACKGROUND Previous studies have not adequately captured the heterogeneous nature of the diabetes epidemic in India. The aim of the ongoing national Indian Council of Medical Research-INdia DIABetes study is to estimate the national prevalence of diabetes and prediabetes in India by estimating the prevalence by state. METHODS We used a stratified multistage design to obtain a community-based sample of 57 117 individuals aged 20 years or older. The sample population represented 14 of Indias 28 states (eight from the mainland and six from the northeast of the country) and one union territory. States were sampled in a phased manner: phase I included Tamil Nadu, Chandigarh, Jharkhand, and Maharashtra, sampled between Nov 17, 2008, and April 16, 2010; phase II included Andhra Pradesh, Bihar, Gujarat, Karnataka, and Punjab, sampled between Sept 24, 2012, and July 26, 2013; and the northeastern phase included Assam, Mizoram, Arunachal Pradesh, Tripura, Manipur, and Meghalaya, with sampling done between Jan 5, 2012, and July 3, 2015. Capillary oral glucose tolerance tests were used to diagnose diabetes and prediabetes in accordance with WHO criteria. Our methods did not allow us to differentiate between type 1 and type 2 diabetes. The prevalence of diabetes in different states was assessed in relation to socioeconomic status (SES) of individuals and the per-capita gross domestic product (GDP) of each state. We used multiple logistic regression analysis to examine the association of various factors with the prevalence of diabetes and prediabetes. FINDINGS The overall prevalence of diabetes in all 15 states of India was 7·3% (95% CI 7·0-7·5). The prevalence of diabetes varied from 4·3% in Bihar (95% CI 3·7-5·0) to 10·0% (8·7-11·2) in Punjab and was higher in urban areas (11·2%, 10·6-11·8) than in rural areas (5·2%, 4·9-5·4; p<0·0001) and higher in mainland states (8·3%, 7·9-8·7) than in the northeast (5·9%, 5·5-6·2; p<0·0001). Overall, 1862 (47·3%) of 3938 individuals identified as having diabetes had not been diagnosed previously. States with higher per-capita GDP seemed to have a higher prevalence of diabetes (eg, Chandigarh, which had the highest GDP of US

Treatment-seeking for febrile illness in north-east India: an epidemiological study in the malaria endemic zone

3433, had the highest prevalence of 13·6%, 12.8-15·2). In rural areas of all states, diabetes was more prevalent in individuals of higher SES. However, in urban areas of some of the more affluent states (Chandigarh, Maharashtra, and Tamil Nadu), diabetes prevalence was higher in people with lower SES. The overall prevalence of prediabetes in all 15 states was 10·3% (10·0-10·6). The prevalence of prediabetes varied from 6·0% (5·1-6·8) in Mizoram to 14·7% (13·6-15·9) in Tripura, and the prevalence of impaired fasting glucose was generally higher than the prevalence of impaired glucose tolerance. Age, male sex, obesity, hypertension, and family history of diabetes were independent risk factors for diabetes in both urban and rural areas. INTERPRETATION There are large differences in diabetes prevalence between states in India. Our results show evidence of an epidemiological transition, with a higher prevalence of diabetes in low SES groups in the urban areas of the more economically developed states. The spread of diabetes to economically disadvantaged sections of society is a matter of great concern, warranting urgent preventive measures. FUNDING Indian Council of Medical Research and Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Dietary habits and stomach cancer in Mizoram, India

BackgroundThis paper studies the determinants of utilization of health care services, especially for treatment of febrile illness in the malaria endemic area of north-east India.MethodsAn area served by two districts of Upper Assam representing people living in malaria endemic area was selected for household survey. A sample of 1,989 households, in which at least one member of household suffered from febrile illness during last three months and received treatment from health service providers, were selected randomly and interviewed by using the structured questionnaire. The individual characteristics of patients including social indicators, area of residence and distance of health service centers has been used to discriminate or group the patients with respect to their initial and final choice of service providers.ResultsOf 1,989 surveyed households, initial choice of treatment-seeking for febrile illness was self-medication (17.8%), traditional healer (Vaidya)(39.2%), government (29.3%) and private (13.7%) health services. Multinomial logistic regression (MLR) analysis exhibits the influence of occupation, area of residence and ethnicity on choice of health service providers. The traditional system of medicine was commonly used by the people living in remote areas compared with towns. As all the febrile cases finally received treatment either from government or private health service providers, the odds (Multivariate Rate Ratio) was almost three-times higher in favour of government services for lower households income people compared to private.ConclusionThe study indicates the popular use of self-medication and traditional system especially in remote areas, which may be the main cause of delay in diagnosis of malaria. The malaria training given to the paramedical staff to assist the health care delivery needs to be intensified and expanded in north-east India. The people who are economically poor and living in remote areas mainly visit the government health service providers for seeking treatment. So, the improvement of quality health services in government health sector and provision of health education to people would increase the utilization of government health services and thereby improve the health quality of the people.

Tobacco Use and Stomach Cancer in Mizoram, India

BackgroundAn extremely high prevalence of stomach cancer was observed in Mizoram (India), where the population consumes uncommon food. The relation of food habits and stomach cancer was examined in this study.MethodsA hospital-based case-control study was conducted during 2001–2004 to determine the risk factors among 329 patients with histologically confirmed stomach cancer and 658 matched controls. Food habits were determined by personal interview.ResultsAn elevated risk of stomach cancer was observed with frequent consumption of sa-um [odds ratio (OR) 3.4] (sa-um is fermented pork fat, a traditional food) and with frequent consumption of smoked dried salted meat (OR 2.8) and fish (OR 2.5). Soda (alkali), used as a food additive, increased the risk of stomach cancer (OR 2.9). Helicobacter pylori infection was not found to be an independent risk factor for carcinogenesis of stomach cancer in this study. However, when H. pylori infection interacted with consumption of sa-um or smoked dried meat, it showed a significant association.ConclusionPeculiar food habits in Mizoram might be associated with the high prevalence of stomach cancer in Mizoram along with other factors. H. pylori infection might increase the risk of stomach cancer, or it may play a role as a promoter of stomach cancer in Mizoram.

Investigation on the Role of p53 Codon 72 Polymorphism and Interactions with Tobacco, Betel Quid, and Alcohol in Susceptibility to Cancers in a High-Risk Population from North East India

The incidence of stomach cancer in India is lower than that of any other country around the world. However, in Mizoram, one of the north-eastern state of India, a very high age-adjusted incidence of stomach cancer is recorded. A hospital-based case-control study was carried out to identify the influence of tobacco use on the risk of developing stomach cancer in Mizoram. Among the cases, the risk of stomach cancer was significantly elevated among current smokers [odds ratio (OR), 2.3; 95% confidence interval (95% CI), 1.4-8.4] but not among ex-smokers. Higher risks were seen for meiziol (a local cigarette) smokers (OR, 2.2; 95% CI, 1.3-9.3). The increased risk was apparent among subjects who had smoked for ≥30 years. The increased risk was significant with 2-fold increase in risk among the subjects who smoked for ≥11 pack-years. The risk increased with increasing cumulative dose of tobacco smoked (mg). Tuibur (tobacco smoke–infused water), used mainly in Mizoram, was seemed to increased the risk of stomach cancer among current users in both univariate and multivariate models (OR, 2.1; 95% CI, 1.3-3.1). Tobacco chewer alone (OR, 2.6; 95% CI, 1.1-4.2) showed significant risk. Tobacco use in any form [smoking and smokeless (tuibur and chewing)] increased the risk of stomach cancer in Mizoram independently after adjusting for confounding variables.

A comparison of clinical features of Japanese encephalitis virus infection in the adult and pediatric age group with Acute Encephalitis Syndrome

The association of TP53 codon 72 polymorphism with cancer susceptibility remains uncertain and varies with ethnicity. Northeast India represents a geographically, culturally, and ethnically isolated population. The area reports high rate of tobacco usage in a variety of ways of consumption, compared with the rest of Indian population. A total of 411 cancer patients (161 lung, 134 gastric, and 116 oral) and 282 normal controls from the ethnic population were analyzed for p53 codon 72 polymorphism by polymerase chain reaction-restriction fragment length polymorphism. No significant difference in genotypic distribution of p53 between cases and controls was observed. Results suggested betel quid chewing as a major risk factor for all the three cancers (odds ratio [OR]=3.54, confidence interval [CI]=2.01-6.25, p<0.001; OR=1.74, CI=1.04-2.92, p=0.03; and OR=1.85, CI=1.02-3.33, p=0.04 for lung, gastric, and oral cancers, respectively). Tobacco smoking was associated with risk of lung and oral cancers (OR=1.88, CI=1.11-3.19, p=0.01 and OR=1.68, CI=1.00-2.81, p=0.04). Interactions between p53 genotypes and risk factors were analyzed to look for gene-environment interactions. Interaction of smoking and p53 genotype was significant only for oral cancer. Interactions of betel quid with p53 genotypes in lung cancer showed significant increase for all the three genotypes, indicating a major role of betel quid (OR=5.90, CI=1.67-20.81, p=0.006; OR=5.44, CI=1.67-17.75, p=0.005; and OR=5.84, CI=1.70-19.97, p=0.005 for Arg/Arg, Arg/Pro, and Pro/Pro, respectively). In conclusion, high incidence of these cancers in northeast India might be an outcome of risk habits; further, tissue- and carcinogen-specific risk modification by p53 gene is probable.