What 'outliers' tell us about missed opportunities for tuberculosis control: a cross-sectional study of patients in Mumbai, India

BACKGROUND: India's Revised National Tuberculosis Control Programme (RNTCP) is deemed highly successful in terms of detection and cure rates. However, some patients experience delays in accessing diagnosis and treatment. Patients falling between the 96th and 100th percentiles for these access indicators are often ignored as atypical 'outliers' when assessing programme performance. They may, however, provide clues to understanding why some patients never reach the programme. This paper examines the underlying vulnerabilities of patients with extreme values for delays in accessing the RNTCP in Mumbai city, India. METHODS: We conducted a cross-sectional study with 266 new sputum positive patients registered with the RNTCP in Mumbai. Patients were classified as 'outliers' if patient, provider and system delays were beyond the 95th percentile for the respective variable. Case profiles of 'outliers' for patient, provider and system delays were examined and compared with the rest of the sample to identify key factors responsible for delays. RESULTS: Forty-two patients were 'outliers' on one or more of the delay variables. All 'outliers' had a significantly lower per capita income than the remaining sample. The lack of economic resources was compounded by social, structural and environmental vulnerabilities. Longer patient delays were related to patients' perception of symptoms as non-serious. Provider delays were incurred as a result of private providers' failure to respond to tuberculosis in a timely manner. Diagnostic and treatment delays were minimal, however, analysis of the 'outliers' revealed the importance of social support in enabling access to the programme. CONCLUSION: A proxy for those who fail to reach the programme, these case profiles highlight unique vulnerabilities that need innovative approaches by the RNTCP. The focus on 'outliers' provides a less resource- and time-intensive alternative to community-based studies for understanding the barriers to reaching public health programmes

Nutritional status of young children in Mumbai slums: a follow-up anthropometric study

<p>Abstract</p> <p>Background</p> <p>Chronic childhood malnutrition remains common in India. As part of an initiative to improve maternal and child health in urban slums, we collected anthropometric data from a sample of children followed up from birth. We described the proportions of underweight, stunting, and wasting in young children, and examined their relationships with age.</p> <p>Methods</p> <p>We used two linked datasets: one based on institutional birth weight records for 17 318 infants, collected prospectively, and one based on follow-up of a subsample of 1941 children under five, collected in early 2010.</p> <p>Results</p> <p>Mean birth weight was 2736 g (SD 530 g), with a low birth weight (<2500 g) proportion of 22%. 21% of infants had low weight for age standard deviation (z) scores at birth (<−2 SD). At follow-up, 35% of young children had low weight for age, 17% low weight for height, and 47% low height for age. Downward change in weight for age was greater in children who had been born with higher z scores.</p> <p>Discussion</p> <p>Our data support the idea that much of growth faltering was explained by faltering in height for age, rather than by wasting. Stunting appeared to be established early and the subsequent decline in height for age was limited. Our findings suggest a focus on a younger age-group than the children over the age of three who are prioritized by existing support systems.</p> <p>Funding</p> <p>The trial during which the birth weight data were collected was funded by the ICICI Foundation for Inclusive Growth (Centre for Child Health and Nutrition), and The Wellcome Trust (081052/Z/06/Z). Subsequent collection, analysis and development of the manuscript was funded by a Wellcome Trust Strategic Award: Population Science of Maternal and Child Survival (085417ma/Z/08/Z). D Osrin is funded by The Wellcome Trust (091561/Z/10/Z).</p

Waste assimilative capacity of coastal waters along Mumbai mega city, west coast of India using MIKE-21 and WASP simulation models

Coastal waters are the ultimate receivers of the organic waste materials generated by upstream cities and towns. This waste can cause dissolved oxygen depletion due to increased oxygen demand, affecting the natural ability of water bodies to withstand certain amount of pollution - the Waste Assimilative Capacity. The pollution load (Biochemical Oxygen Demand) calculated using the Population Equivalent value of 0.225 m3/day for the present Mumbai population of 13 million is 731,250 kg/day. Simulations using MIKE-21 and WASP models along with the observed water quality data as well as current meter data indicated that the coastal waters can withstand the present pollution load since the simulated Biochemical Oxygen Demand was with in the range of 0.2-1.5 mg/L, the National Standard limits. A projected population increase exceeded the target BOD value of 2 mg/L, indicating the deterioration of ambient quality of coastal waters. Waste Assimilative Capacity studies are crucial in the present-day regional, as well as global issues, such as population explosion, water shortage and climate change