Vinod Joseph Abraham

Suicides in young people in rural southern India

Different rates of suicide have been reported in India. In Vellore, southern India, we have noted that the rates of suicides are several fold higher than those reported anywhere in the world, especially in young women. The department of community health at the Christian Medical College, Vellore, has obtained data prospectively on births, deaths, and morbidity in a population of 108?000. We used the verbal autopsy method to assign cause of death. The mortality rates were analysed for 10 years, from 1992 to 2001, for the age-group 10-19 years. Suicides accounted for about a quarter of all deaths in young men and between 50% and 75% of all deaths in young women. The average suicide rate for young women was 148 per 100?000, and for young men 58 per 100?000. We believe that our findings are reliable. The system of surveillance is well established and the verbal autopsy method has been validated. These very high rates of suicide need urgent intervention.

Solar disinfection of water for diarrhoeal prevention in southern India

Aims: To evaluate the efficacy and acceptability of solar irradiation in the prevention of diarrhoeal morbidity in children under 5 years of age, in an urban slum in Vellore, Tamil Nadu. Methods: A total of 100 children were assigned to receive drinking water that had been subjected to solar disinfection in polyethylene terephthalate bottles. One hundred age and sex matched controls were also selected. Both groups were followed by weekly home visits for a period of six months for any diarrhoeal morbidity. At the end of the follow up period, the acceptability of the intervention was assessed by interviews, questionnaires, and focus group discussions. Results: There was significant reduction in the incidence, duration, and severity of diarrhoea in children receiving solar disinfected water, despite 86% of the children drinking water other than that treated by the intervention. The incidence of diarrhoea in the intervention group was 1.7 per child-year, and among controls 2.7 per child-year, with an incidence rate ratio of 0.64 (95% CI −0.48 to 0.86). The risk of diarrhoea was reduced by 40% by using solar disinfection. In qualitative evaluation of acceptability, most women felt that solar disinfection was a feasible and sustainable method of disinfecting water. Conclusions: Solar disinfection of water is an inexpensive, effective, and acceptable method of increasing water safety in a resource limited environment, and can significantly decrease diarrhoeal morbidity in children.

Efficacy of a monovalent human-bovine (116E) rotavirus vaccine in Indian children in the second year of life

UNLABELLED Rotavirus gastroenteritis is one of the leading causes of diarrhea in Indian children less than 2 years of age. The 116E rotavirus strain was developed as part of the Indo-US Vaccine Action Program and has undergone efficacy trials. This paper reports the efficacy and additional safety data in children up to 2 years of age. In a double-blind placebo controlled multicenter trial, 6799 infants aged 6-7 weeks were randomized to receive three doses of an oral human-bovine natural reassortant vaccine (116E) or placebo at ages 6, 10, and 14 weeks. The primary outcome was severe (≥11 on the Vesikari scale) rotavirus gastroenteritis. Efficacy outcomes and adverse events were ascertained through active surveillance. We randomly assigned 4532 and 2267 subjects to receive vaccine and placebo, respectively, with over 96% subjects receiving all three doses of the vaccine or placebo. The per protocol analyses included 4354 subjects in the vaccine and 2187 subjects in the placebo group. The overall incidence of severe RVGE per 100 person years was 1.3 in the vaccine group and 2.9 in the placebo recipients. Vaccine efficacy against severe rotavirus gastroenteritis in children up to 2 years of age was 55.1% (95% CI 39.9 to 66.4; p<0.0001); vaccine efficacy in the second year of life of 48.9% (95% CI 17.4 to 68.4; p=0.0056) was only marginally less than in the first year of life [56.3% (95% CI 36.7 to 69.9; p<0.0001)]. The number of infants needed to be immunized to prevent one episode of severe RVGE in the first 2 years of life was 40 (95% CI 28.0 to 63.0) and for RVGE of any severity, it was 21 (95% CI 16.0 to 32.0). Serious adverse events were observed at the same rates in the two groups. None of the eight intussusception events occurred within 30 days of a vaccine dose and all were reported only after the third dose. The sustained efficacy of the 116E in the second year of life is reassuring. CLINICAL TRIAL REGISTRY The trial is registered with Clinical Trial Registry-India (# CTRI/2010/091/000102) and Clinicaltrials.gov (# NCT01305109).

Rheumatic Heart Disease: Progress and Challenges in India

Rheumatic heart disease, a neglected disease, continues to be a burden in India and other developing countries. It is a result of an autoimmune sequalae in response to group A beta hemolytic streptococcus (GAS) infection of the pharynx. Acute rheumatic fever (RF), a multisystem inflammatory disease, is followed by rheumatic heart disease (RHD) and has manifestations of joints, skin and central nervous system involvement. A review of epidemiological studies indicates unchanged GAS pharyngitis and carrier rates in India. The apparent decline in RHD rates in India as indicated by the epidemiological studies has to be taken with caution as methodological differences exist among studies. Use of echocardiography increases case detection rates of RHD in population surveys. However, the significance of echo based diagnosis of carditis needs further evaluation to establish the significance. Research in this area through prospective follow up studies will have to be undertaken by the developing countries as the interest of developed countries in the disease has waned due the declined burden in their populations. Prevention of RHD is possible through treatment of GAS pharyngitis (primary prophylaxis) and continued antibiotic treatment for number of years in patients with history of RF to prevent recurrences (secondary prophylaxis). The cost effectiveness and practicality of secondary prophylaxis is well documented. The challenge to any secondary prophylaxis program for prevention of RF in India will be the availability of benzathine penicillin G and dissipation of fears of allergic reactions to penicillin among practitioners, general public and policy makers. The authors review here the progress and challenges in epidemiology, diagnosis and primary and secondary prevention of RF and RHD.

The Vellore screening instruments and strategies for the diagnosis of dementia in the community.

BACKGROUND Many screening instruments for the diagnosis of dementia are not education and culture fair. In addition, despite good sensitivity and specificity, they result in unacceptable levels of false positives when used in the community. This study aimed to develop appropriate instruments for populations with low literacy and to consider strategies to reduce the false positive rates in low prevalence settings. METHODS Activities of daily living, which are not influenced by education and culture, were used to develop a patient screen and an informant version to identify people with dementia. The instruments were validated in the hospital and in the community setting against the standards of DSM-IV and the education-adjusted 10/66 Dementia Research Group diagnosis of dementia. RESULTS The instruments were administered to 90 patients attending a hospital and 101 subjects living in the community in Vellore, South India. The psychometric properties and inter-rater reliability of these screening instruments were good. While the sensitivity and specificity of the patient screen and the informant version were good their false positive rates were high in the community setting. However, the false positive rates reduced when these instruments were used in combination. CONCLUSION The patient screen and the informant version are short culture- and education-fair instruments. They reduce false positive rates, when used in combination in the community.

Clinical and Microbiologic Characteristics of Invasive Streptococcus pyogenes Infections in North and South India

ABSTRACT The lack of epidemiologic data on invasive Streptococcus pyogenes infections in many developing countries is concerning, as S. pyogenes infections are commonly endemic in these areas. Here we present the results of the first prospective surveillance study of invasive Streptococcus pyogenes infections in India. Fifty-four patients with invasive S. pyogenes infections were prospectively enrolled at two study sites, one in the north and one in the south of India. Sterile-site isolates were collected, and clinical information was documented using a standardized questionnaire. Available acute-phase sera were tested for their ability to inhibit superantigens produced by the patients own isolate using a cell-based neutralizing assay. The most common clinical presentations were bacteremia without focus (30%), pneumonia (28%), and cellulitis (17%). Only two cases of streptococcal toxic shock syndrome and no cases of necrotizing fasciitis were identified. Characterization of the isolates revealed great heterogeneity, with 32 different emm subtypes and 29 different superantigen gene profiles being represented among the 49 sterile-site isolates. Analyses of acute-phase sera showed that only 20% of the cases in the north cohort had superantigen-neutralizing activity in their sera, whereas 50% of the cases from the south site had neutralizing activity. The results demonstrate that there are important differences in both clinical presentation and strain characteristics between invasive S. pyogenes infections in India and invasive S. pyogenes infections in Western countries. The findings underscore the importance of epidemiologic studies on streptococcal infections in India and have direct implications for current vaccine developments.

Foot care knowledge and practices and the prevalence of peripheral neuropathy among people with diabetes attending a secondary care rural hospital in southern India

Background: Diabetes mellitus is a multifaceted disease and foot ulceration is one of its most common complications. Poor foot care knowledge and practices are important risk factors for foot problems among people with diabetes. Aims: To assess the knowledge and practices regarding foot care and to estimate the proportion of people with peripheral neuropathy among people with diabetes. Settings and Design: The cross-sectional study was conducted in 212 consecutive diabetes patients attending the out-patient department of a rural secondary care hospital. Materials and Methods: A questionnaire which included demographic details, knowledge questionnaire, and Nottingham assessment of functional foot care was administered. The Michigan Neuropathy Screening Instrument was used to identify peripheral neuropathy. Statistical Analysis Used: Descriptive analysis with frequency distribution for knowledge and practice scores, univariate analysis, and multiple logistic regressions to find significant variables associated with good knowledge and practice scores. Results: About 75% had good knowledge score and 67% had good foot care practice score. Male gender (OR 2.36, 95% CI 1.16–4.79), poor education status (OR 2.40, 95% CI 1.19–4.28), and lesser duration of diabetes (OR 2.24, 95% CI 1.15–4.41) were significantly associated with poor knowledge on foot care. Poor knowledge was associated with poor foot care practices (OR 3.43, 95% CI 1.75–6.72). The prevalence of neuropathy was 47% (95% CI 40.14–53.85) and it was associated with longer duration of the disease (OR 2.18, 95% CI 1.18–4.04). Conclusion: There exist deficiencies in knowledge and practices regarding foot care. Male gender, low education, and lesser duration of diabetes are associated with poor knowledge scores. The prevalence of diabetic peripheral neuropathy is high.

Rising trend of cardiovascular risk factors between 1991–1994 and 2010–2012: A repeat cross sectional survey in urban and rural Vellore

BACKGROUND Repeat cross sectional surveys document the trend of prevalence rates for non-communicable diseases and their risk factors. In this study, we compare the prevalence rates for risk factors for cardiovascular disease in urban and rural Vellore between 1991-1994 and 2010-2012. METHODS Cross sectional survey was carried out in 1991-1994 in a rural block in Vellore district and in Vellore town, to study the prevalence of cardiovascular risk factors among adults aged 30-60 years. A repeat survey was done in 2010-2012 using the WHO STEPS method. In both surveys, socio-demographic and behavioral history, physical measurements, biochemical measurements, and medical history were obtained. Age adjusted rates were used to compare the rates in the two surveys. RESULTS In the rural areas, there was a three times increase in diabetes and body mass index (BMI) ≥25kg/m(2) (overweight/obese) with a doubling of the prevalence of hypertension. In urban areas there was a tripling of diabetes, doubling of proportion with BMI≥25kg/m(2) and 50% increase in prevalence of hypertension. While the proportion of male current smokers reduced by 50% in both rural and urban Vellore, lifetime abstainers to alcohol decreased in the rural area from 46.8% to 37.5% (p<0.001). CONCLUSIONS There has been an alarming rise in diabetes, hypertension, and overweight/obese with an even greater increase in rural areas. Alcohol use is increasing while smoking is on the decline. Primary prevention programs are required urgently to stem the rising incidence of non-communicable diseases in India.

Prevalence of coronary heart disease in rural and urban Vellore: A repeat cross-sectional survey

Background With the increase of cardiovascular risk factors in India, the prevalence of coronary heart disease (CHD) is also expected to rise. A cross-sectional study in 2010–2012 assessed the prevalence and risk factors for CHD in urban and rural Vellore, Tamil Nadu. The secondary objectives were to compare the current prevalence with the prevalence of CHD in the same areas in 1991–1994. Methods A cross-sectional survey was carried out among adults aged 30–64 years to determine the prevalence of CHD (previously diagnosed disease, symptoms detected using Rose angina questionnaire, or ischemic changes on electrocardiography). The study used the WHO STEPS method in addition to the Rose angina questionnaire and resting electrocardiography and was conducted in nine clusters of a rural block in Vellore district and 48 wards of Vellore town. The results were compared with a similar study in the same area in 1991–1994. Results The prevalence of CHD was 3.4% (95% CI: 1.6–5.2%) among rural men, 7.4% (95% CI: 4.7–10.1%) among rural women, 7.3% (95% CI: 5.7–8.9%) among urban men, and 13.4% (95% CI: 11.2–15.6%) among urban women in 2010–2012. The age-adjusted prevalence in rural women tripled and in urban women doubled, with only a slight increase among males, between 1991–1994 and 2010–2012. Conclusions The large increase in prevalence of CHD, among both pre- and post-menopausal females, suggests the need for further confirmatory studies and interventions for prevention in both rural and urban areas.

Differential patterns, trends and hotspots of road traffic injuries on different road networks in Vellore district, southern India

To describe spatial and temporal profiles of Road Traffic Injuries (RTIs) on different road networks in Vellore district of southern India.