Narendra K Arora

Status of epidemiology in the WHO South-East Asia region: burden of disease, determinants of health and epidemiological research, workforce and training capacity

BACKGROUND The South-East Asia region (SEAR) accounts for one-quarter of the worlds population, 40% of the global poor and ∼30% of the global disease burden, with a disproportionately large share of tuberculosis (35%), injuries (30%), maternal (33%) and <5-year-old mortality (30%). In this article, we describe the disease burden and status of epidemiological research and capacity in the SEAR to understand, analyse and develop capacity in response to the diverse burdens of diseases in the region. METHODS Data on morbidity, mortality, risk factors, social determinants, research capacity, health education, workforce and systems in the SEAR were obtained using global data on burden of disease, peer-reviewed journals, World Health Organization (WHO) technical and advisory reports, and where available, validated country reports and key informants from the region. RESULTS SEAR countries are afflicted with a triple burden of disease-infectious diseases, non-communicable diseases and injuries. Of the seven WHO regions, SEAR countries account for the highest proportion of global mortality (26%) and due to relatively younger ages at death, the second highest percentage of total years of life lost (30%). The SEAR exceeds the global average annual mortality rate for all three broad cause groupings-communicable, maternal, perinatal and nutritional conditions (334 vs 230 per 100 000); non-communicable diseases (676 vs 573 per 100 000); and injuries (101 vs 78 per 100 000). Poverty, education and other social determinants of health are strongly linked to inequities in health among SEAR countries and within socio-economic subgroups. India, Thailand and Bangladesh produce two-thirds of epidemiology publications in the region. Significant efforts to increase health workforce capacity, research and training have been undertaken in the region, yet considerable heterogeneity in resources and capacity remains. CONCLUSIONS Health systems, statistics and surveillance programmes must respond to the demographic, economic and epidemiological transitions that define the current disease burden and risk profile of SEAR populations. Inequities in health must be critically analysed, documented and addressed through multi-sectoral approaches. There is a critical need to improve public health intelligence by building epidemiological capacity in the region.

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.

Taken to Health Care Provider or Not, Under-Five Children Die of Preventable Causes: Findings from Cross-Sectional Survey and Social Autopsy in Rural India.

Background: Under-five children in India continue to die from causes that can either be treated or prevented. The data regarding causes of death, community care-seeking practices, and events prior to death are needed to guide and refine health policies for achieving national goals and targets. Materials and Methods: A cross-sectional survey covering rural areas of 16 districts from eight states across India was conducted to understand the causes of deaths and the health-seeking patterns of caregivers prior to the death of such children. Mothers of the deceased children were interviewed. The physician review process was used to assign cause of death. The qualitative data were analyzed as per standard methods, while STATA version 10 was used for analysis of quantitative data. Findings: A total of 1,488 death histories were captured through verbal autopsy. Neonatal etiologies, acute respiratory infection (ARI), and diarrhea accounted for approximately 63.1% of all deaths in the under-five age group. The causes of death in neonates showed that birth asphyxia, prematurity, and neonatal infections contributed to more than 67.5% of all neonatal deaths, while in children aged 29 days to 59 months, ARI and diarrhea accounted for 54.3% of deaths. Care providers of 52.6% of the neonates and 21.7% of infants and under-five children did not seek any medical care before the death of the child. Substantial delays in seeking care occurred at home and during transit. For those who received medical care, there was an apparent amongst in their caregivers toward private health providers. Conclusion: The deaths of neonates and postneonates taken to any health facilities highlight the need for providing equitable and high-quality health services in India. The findings could be used for policy planning and program refinement in India.

Setting research priorities for maternal, newborn, child health and nutrition in india by engaging experts from 256 indigenous institutions contributing over 4000 research ideas: A CHNRI exercise by ICMR and INCLEN

Background Health research in low– and middle– income countries (LMICs) is often driven by donor priorities rather than by the needs of the countries where the research takes place. This lack of alignment of donor’s priorities with local research need may be one of the reasons why countries fail to achieve set goals for population health and nutrition. India has a high burden of morbidity and mortality in women, children and infants. In order to look forward toward the Sustainable Development Goals, the Indian Council of Medical Research (ICMR) and the INCLEN Trust International (INCLEN) employed the Child Health and Nutrition Research Initiative’s (CHNRI) research priority setting method for maternal, neonatal, child health and nutrition with the timeline of 2016–2025. The exercise was the largest to–date use of the CHNRI methodology, both in terms of participants and ideas generated and also expanded on the methodology. Methods CHNRI is a crowdsourcing–based exercise that involves using the collective intelligence of a group of stakeholders, usually researchers, to generate and score research options against a set of criteria. This paper reports on a large umbrella CHNRI that was divided into four theme–specific CHNRIs (maternal, newborn, child health and nutrition). A National Steering Group oversaw the exercise and four theme–specific Research Sub–Committees technically supported finalizing the scoring criteria and refinement of research ideas for the respective thematic areas. The exercise engaged participants from 256 institutions across India – 4003 research ideas were generated from 498 experts which were consolidated into 373 research options (maternal health: 122; newborn health: 56; child health: 101; nutrition: 94); 893 experts scored these against five criteria (answerability, relevance, equity, innovation and out–of–box thinking, investment on research). Relative weights to the criteria were assigned by 79 members from the Larger Reference Group. Given India’s diversity, priorities were identified at national and three regional levels: (i) the Empowered Action Group (EAG) and North–Eastern States; (ii) States and Union territories in Northern India (including West Bengal); and (iii) States and Union territories in Southern and Western parts of India. Conclusions The exercise leveraged the inherent flexibility of the CHNRI method in multiple ways. It expanded on the CHNRI methodology enabling analyses for identification of research priorities at national and regional levels. However, prioritization of research options are only valuable if they are put to use, and we hope that donors will take advantage of this prioritized list of research options.

Adaptation of locally available portion sizes for food frequency questionnaires in nutritional epidemiological studies: How much difference does it make?

Introduction: There is need for employing strategies to minimize measurement errors while administering semi-quantitative FFQ. The current study was planned to adapt and standardize locally available portion sizes for semi-quantitative FFQ to improve its validity and document the process of standardization of portion sizes. Methodology: The study was conducted in 9 villages of the INCLEN-SOMAARTH DDESS (Demographic, Development and Environmental Surveillance Site), Palwal district, Haryana, India. The subjects in these nine villages are part of a cohort study to assess the interaction between societal and household factors with food intake and physical activity of children. Systematic utensil survey was undertaken in 3 randomly chosen households per village i.e. 27 households and the portion sizes were derived from a total of 74 serving utensils. The derived sizes were classified as small (240 ml), medium (320 ml) and large (600 ml). The semi-quantitative FFQ with locally derived portion sizes was then administered to 63 children in 6-12 year age group. Results: The volume of food measured by the reference portion sizes generally being employed in the national surveys, would have been underestimated the food consumed by the child by 55-60% as compared to what was being consumed by the children in the study area. The correlation between food intake assessed by 24-hr recall method and FFQ using derived (local) portion sizes was better as compared to that obtained with the semi-quantitative FFQ done with reference portions. Conclusion: In conclusion, local portion size adaptation of FFQ for semi-quantification is useful to mitigate measurement errors associated with this technique.

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.

An International Perspective on Vaccine Safety

Vaccines are a near-integral part of every child’s growing up. Expectedly, each inoculation is a matter of concern and anxiety, notwithstanding the fact that vaccines are by and large safe. Much like commercial flying, a lot needs to go into making the process safe and reliable every time. Global efforts have been on to make vaccines, vaccination, and injection waste safe for all concerned. The Adverse Events Following Immunization (AEFI) surveillance system is a cornerstone of that process. This chapter takes an international perspective in understanding that experience. Developing countries such as India are in the process of setting up surveillance systems and are also a fertile ground for vaccine controversies. The controversies over the pediatric pentavalent vaccine is the most recent such example. Vaccinations are repeated acts making parents prone to hesitancy and in extreme cases frank resistance.

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.