Manoja Kumar Das

Pneumomediastinum and subcutaneous emphysema in acute miliary tuberculosis

Pneumomediastinum and subcutaneous emphysema are rare complications of miliary tuberculosis in children. In this report, a 5-year-old girl with miliary tuberculosis complicated by pneumomediastinum and subcutaneous emphysema, is presented and relevant literature is discussed

Determinants of Childhood Obesity: Need for a Trans-Sectoral Convergent Approach

The emerging burden of non communicable diseases is likely to erode the “Demographic-Dividend” of India and compromise the national growth and development. Increasing rates of childhood obesity globally and in India is a cause for serious public health concern. It is becoming increasingly apparent that obesity is result of complex interplay between multiple genes, environmental factors and human behavior. Clear comprehension of this interaction and pathway is still not clear, making the prevention and management of obesity especially challenging. Globalization and rapid economic growth has led to dramatic changes in the life style of the population including food intake, physical activity, market, environmental factors and social structures. A growing economy, urbanization and motorized transport have increased physical inactivity. A systematic multi-sectoral approach with population health as the center of discourse and attention is the only key to tackle this problem.

Extra Hepatic Portal Venous Obstruction in Children

Portal hypertension is the commonest cause of upper gastrointestinal bleeding in children and up to 30% of cases with upper gastrointestinal hemorrhage can be fatal. Extrahepatic portal venous obstruction (EHPVO) is the commonest cause of portal hypertension in children and also one of the common causes in adults in India and other tropical countries (Arora, 1998; Poddar, 2008; Poddar 2000). In India, EHPVO is responsible for portal hypertension in about one third cases of adults and more than half of the cases in children (Sarin 2002; Dilawari 1992). EHPVO is characteristically refers to obstruction in the trunk of portal vein and it can extend to its branches and even splanchnic veins. Unlike cirrhosis, in EHPVO, the liver function is normal. The causes of portal venous obstruction and risk factors for upper gastrointestinal hemorrhage in children with EHPVO are not clearly understood. Most of the bleeds are spontaneous and some may be preceded by febrile illness, ingestion of drugs. Management of EHPVO involves acute management of the bleeding, secondary prophylaxis and shunting to reduce the portal pressure. This chapter attempts to compile the available evidences on EHPVO in children with special reference to experiences from India.

Vaccine Safety and Surveillance for Adverse Events Following Immunization (AEFI) in India

Rationale: Assured quality vaccines and safe immunization practices are pre-requisite to successful immunization programs. All vaccines go through stringent safety checks during pre-licensure stage. Adverse Events Following Immunization (AEFI) Surveillance program is an integral part of routine immunization program in India to monitor the vaccine safety in the post licensure phase. Indian AEFI Program: National AEFI surveillance relies on passive surveillance and reporting by the health functionaries and practitioners. Vigorous strengthening of AEFI surveillance has resulted in manifold rise in absolute number of AEFI reports across several reporting units in the country in the last decade. Establishment of National AEFI Secretariat, National Technical Collaborating Centre, and development of risk communication strategy as well as quality management certification are some of the unique aspects of this public health program. All serious AEFI reports undergo a systematic causality assessment as per WHO-algorithm by trained committees. National AEFI surveillance system has forged formal linkages with national pharmacovigilance program, the regulators, and professional bodies. Challenges: The number of the reported serious AEFIs are still far less than the expected numbers. Although the AEFI committees at the district and state levels have been established, a large proportion are far from functional. Way forward: As the national immunization program introduces newer vaccines for different age groups and coverage improves, the issues of vaccine hesitancy and confidence are likely to be raised more often and the AEFI surveillance program will have to assume greater responsibility to comprehensively respond to the community concerns and sustain public confidence in vaccines.

Intussusception in Young Children: Protocol for Multisite Hospital Sentinel Surveillance in India

India has recently introduced a rotavirus vaccine under a universal immunization program. There is limited information on intussusception, an adverse event, following immunization in children from India. We are conducting sentinel surveillance for intussusception in children aged under two years at 19 hospitals. The sentinel sites’ selection followed a multistage process. The surveillance combines retrospective surveillance for 69 months and prospective surveillance for 18 months. The suspected intussusception cases shall be reviewed for capturing confirmed cases and detailed data collection and classification according to Brighton Collaboration criteria. Data shall be analysed to describe epidemiology, trends, regional and seasonal variations, clinical profiles, management modalities, and outcomes of intussusception. The combination of prospective and retrospective surveillance shall be informative about the trend of intussusception over the last seven years in India. At four sites where rotavirus vaccines have been introduced, the change in intussusception trends shall be documented. The potential association with rotavirus vaccines and other vaccines shall be assessed using case-control and self-controlled case series methodology. Results are forthcoming. The results shall support the national vaccine safety surveillance effort by providing baseline estimates of intussusception for continued monitoring. The surveillance protocol and site selection processes shall inform similar vaccine-safety surveillance in India and other developing countries.

Establishing a Demographic, Development and Environmental Geospatial Surveillance Platform in India: Planning and Implementation

Background Inadequate administrative health data, suboptimal public health infrastructure, rapid and unplanned urbanization, environmental degradation, and poor penetration of information technology make the tracking of health and well-being of populations and their social determinants in the developing countries challenging. Technology-integrated comprehensive surveillance platforms have the potential to overcome these gaps. Objective This paper provides methodological insights into establishing a geographic information system (GIS)-integrated, comprehensive surveillance platform in rural North India, a resource-constrained setting. Methods The International Clinical Epidemiology Network Trust International established a comprehensive SOMAARTH Demographic, Development, and Environmental Surveillance Site (DDESS) in rural Palwal, a district in Haryana, North India. The surveillance platform evolved by adopting four major steps: (1) site preparation, (2) data construction, (3) data quality assurance, and (4) data update and maintenance system. Arc GIS 10.3 and QGIS 2.14 software were employed for geospatial data construction. Surveillance data architecture was built upon the geospatial land parcel datasets. Dedicated software (SOMAARTH-1) was developed for handling high volume of longitudinal datasets. The built infrastructure data pertaining to land use, water bodies, roads, railways, community trails, landmarks, water, sanitation and food environment, weather and air quality, and demographic characteristics were constructed in a relational manner. Results The comprehensive surveillance platform encompassed a population of 0.2 million individuals residing in 51 villages over a land mass of 251.7 sq km having 32,662 households and 19,260 nonresidential features (cattle shed, shops, health, education, banking, religious institutions, etc). All land parcels were assigned georeferenced location identification numbers to enable space and time monitoring. Subdivision of villages into sectors helped identify socially homogenous community clusters (418/676, 61.8%, sectors). Water and hygiene parameters of the whole area were mapped on the GIS platform and quantified. Risk of physical exposure to harmful environment (poor water and sanitation indicators) was significantly associated with the caste of individual household (P=.001), and the path was mediated through the socioeconomic status and density of waste spots (liquid and solid) of the sector in which these households were located. Ground-truthing for ascertaining the land parcel level accuracies, community involvement in mapping exercise, and identification of small habitations not recorded in the administrative data were key learnings. Conclusions The SOMAARTH DDESS experience allowed us to document and explore dynamic relationships, associations, and pathways across multiple levels of the system (ie, individual, household, neighborhood, and village) through a geospatial interface. This could be used for characterization and monitoring of a wide range of proximal and distal determinants of health.

Prevalence of nonalcoholic fatty liver disease in normal-weight and overweight preadolescent children in Haryana, India

ObjectiveTo document the prevalence of non-alcoholic fatty liver disease (NAFLD) and metabolic parameters among normalweight and overweight schoolchildren.DesignCross-sectional study.SettingThirteen private schools in urban Faridabad, Haryana.Participants961 school children aged 5-10 years.MethodsUltrasound testing was done, and 215 with fatty liver on ultrasound underwent further clinical, biochemical and virological testing.Outcome measuresPrevalence of fatty liver on ultrasound, and NAFLD and its association with biochemical abnormalities and demographic risk factors.ResultsOn ultrasound, 215 (22.4%) children had fatty liver; 18.9% in normal-weight and 45.6% in overweight category. Presence and severity of fatty liver disease increased with body mass index (BMI) and age. Among the children with NAFLD, elevated SGOT and SGPT was observed in 21.5% and 10.4% children, respectively. Liver enzyme derangement was significantly higher in overweight children (27% vs 19.4% in normal-weight) and severity of fatty liver (28% vs 20% in mild fatty liver cases). Eleven (8.1%) children with NAFLD had metabolic syndrome. Higher BMI (OR 35.9), severe fatty liver disease (OR 1.7) and female sex (OR 1.9) had strong association with metabolic syndrome.Conclusions22.4% of normal-weight and overweight children aged 5-10 years had fatty liver. A high proportion (18.9%) of normal-weight children with fatty liver on ultrasound indicates the silent burden in the population.

Research priorities in Maternal, Newborn, & Child Health & Nutrition for India: An Indian Council of Medical Research-INCLEN Initiative

In India, research prioritization in Maternal, Newborn, and Child Health and Nutrition (MNCHN) themes has traditionally involved only a handful of experts mostly from major cities. The Indian Council of Medical Research (ICMR)-INCLEN collaboration undertook a nationwide exercise engaging faculty from 256 institutions to identify top research priorities in the MNCHN themes for 2016-2025. The Child Health and Nutrition Research Initiative method of priority setting was adapted. The context of the exercise was defined by a National Steering Group (NSG) and guided by four Thematic Research Subcommittees. Research ideas were pooled from 498 experts located in different parts of India, iteratively consolidated into research options, scored by 893 experts against five pre-defined criteria (answerability, relevance, equity, investment and innovation) and weighed by a larger reference group. Ranked lists of priorities were generated for each of the four themes at national and three subnational (regional) levels [Empowered Action Group & North-Eastern States, Southern and Western States, & Northern States (including West Bengal)]. Research priorities differed between regions and from overall national priorities. Delivery domain of research which included implementation research constituted about 70 per cent of the top ten research options under all four themes. The results were endorsed in the NSG meeting. There was unanimity that the research priorities should be considered by different governmental and non-governmental agencies for investment with prioritization on implementation research and issues cutting across themes.