Early Mortality in Adults Initiating Antiretroviral Therapy (ART) in Low- and Middle-Income Countries (LMIC): A Systematic Review and Meta-Analysis

BackgroundWe systematically reviewed observational studies of early mortality post-antiretroviral therapy (ART) initiation in low- and middle-income countries (LMIC) in Asia, Africa, and Central and South America, as defined by the World Bank, to summarize what is known.Methods and FindingsStudies published in English between January 1996 and December 2010 were searched in Medline and EMBASE. Three independent reviewers examined studies of mortality within one year post-ART. An article was included if the study was conducted in a LMIC, participants were initiating ART in a non-clinical trial setting and were ≥15 years. Fifty studies were included; 38 (76%) from sub-Saharan Africa (SSA), 5 (10%) from Asia, 2 (4%) from the Americas, and 5 (10%) were multi-regional. Median follow-up time and pre-ART CD4 cell count ranged from 3–55 months and 11–192 cells/mm3, respectively. Loss-to-follow-up, reported in 40 (80%) studies, ranged from 0.3%–27%. Overall, SSA had the highest pooled 12-month mortality probability of 0.17 (95% CI 0.11–0.24) versus 0.11 (95% CI 0.10–0.13) for Asia, and 0.07 (95% CI 0.007–0.20) for the Americas. Of 14 (28%) studies reporting cause-specific mortality, tuberculosis (TB) (5%–44%), wasting (5%–53%), advanced HIV (20%–37%), and chronic diarrhea (10%–25%) were most common. Independent factors associated with early mortality in 30 (60%) studies included: low baseline CD4 cell count, male sex, advanced World Health Organization clinical stage, low body mass index, anemia, age greater than 40 years, and pre-ART quantitative HIV RNA.ConclusionsSignificant heterogeneity in outcomes and in methods of reporting outcomes exist among published studies evaluating mortality in the first year after ART initiation in LMIC. Early mortality rates are highest in SSA, and opportunistic illnesses such as TB and wasting syndrome are the most common reported causes of death. Strategies addressing modifiable risk factors associated with early death are urgently needed

Evaluation of revised national tuberculosis control program, district Kangra, Himachal Pradesh, India, 2007

Background: The present evaluation study has been conducted with the following objectives: (i) To assess the treatment outcomes of revised national tuberculosis control program (RNTCP) in five microscopic centers of Kangra district under five tuberculosis units and (ii) To identify gaps and underlying contributing factors. Based upon the findings of (i) and (ii) we suggest appropriate measures to narrow down the existing gaps. Materials and Methods: We identified and interviewed health personnel involved, reviewed the documents and records pertaining to evaluation plan/guidelines, training records and reports generated by five tuberculosis units. We assessed the inputs, processes and outputs of the program across five tuberculosis units. We calculated the proportion of staff of various categories trained and internal quality control (case detection); availability of drugs, directly observed treatment short course (DOTS) providers, and supervision (case management) and information, education and communication (IEC), and funds distribution. (logic model). Result: Around 60%-88% of staffs of various categories trained with overall 25% gap of supervisory visits. In tuberculosis unit (TU) Nurpur, the discordant slides while cross-checking were 8% and 25%. The total proportions of sputum positivity are 5.1%; the highest in Kangra, i.e., 2.3% (national norms of 10-15%.). There was no full cross-checking of the positive slides despite internal quality in place. Increased numbers of the extra pulmonary tuberculosis cases (EPTB) are present in all TUs, as high as 61% in TU Dharamshala (Normal range 15%-20%). A gap of 20% DOT center exists-the least in (58%) in TU Nurpur. The awareness level in the TU Dehra is minimum (51%); more so in females and rural set up. Conclusion: RNTCP has successfully achieved all its targets in all the five TUs of Kangra District as per national norms despite several gaps. We recommend (i) filling of vacancies of medics and paramedics with reorientation trainings/refresher courses; (ii) conduction of supportive supervision by the seniors; (iii) investigation of cause of increased number of the extra pulmonary cases, and (iv) need of aggressive IEC activities

Modified measles versus rubella versus atypical measles: One and same thing

Introduction: In outbreak settings, more than one virus may be infecting the given population. In twin or triple outbreak of measles, German measles (rubella), and varicella in highly immunized hilly areas, maximal number of the case patients in all the hilly villages belonged to the older age group. It suggested an obvious shift to the higher age group, warranting second dose opportunity in such case scenario. The clinical presentations of viral diseases are too similar to differentiate. The aim is to clearly categorize the case patients of modified measles, rubella, and atypical measles in outbreak settings. Results: Four outbreaks are listed. In the first one, sixty case patients were identified from 1026 people in 5 villages. Of these, 41 were diagnosed by clinically, 8 were laboratory confirmed as measles and 11 were epidemiologically linked German measles case patients. Seventy percent of the cases were vaccinated for measles. In second case, we identified 29/35 measles and 6/35 were confirmed as epidemiologically linked unvaccinated chickenpox case patients. In third one, we identified 116 cases in eight villages (112/116 clinically and 04/116 laboratory confirmed). Majority of cases were immunized against measles, but only minor cases for rubella. In fourth case, we identified 505 case patients from mixed outbreaks of varicella, measles and rubella (30/505 clinically, 467/505 epidemiologically linked and 8/505 laboratory confirmed case patients from a study population of 3280). In all the four outbreaks, prima facie, the clinical presentations of both rubella and modified measles were difficult to differentiate. Discussion: On the basis of outbreak investigation and analytical inference, it has been observed that the symtomatology of modified measles and laboratory confirmed rubella case patients/epidemiologically linked cases are so similar placed that many a time, it becomes much difficult to line list the cases in one section of modified measles or rubella or atypical cases. Conclusion: Similarities of morphological symptoms between modified measles and rubella is the point of challenge and it causes debate between pediatrician and field epidemiologist to differentiate and classify them

Water borne epidemic of gastroenteritis in Ghallour sub-centre of Jawalamukhi block, Kangra District, Himachal Pradesh, India

Background: On August 31, 2014, eighty cases of the gastroenteritis were reported in Ghallour sub-center area. We investigated the outbreak to identify the source, propose control, and preventive measures. Materials and Methods: We defined a case as occurrence of three or more watery stools with or without vomiting, w.e.f January 27, till February 2, 2014 in residents of Ghallour sub-center area of Jawalamukhi block. We hypothesized it as a water borne outbreak. We determined age and sex specific attack rate. We collected information about personal history on age, sex, residence, and date of onset of symptom from case patient and established line list. We collected nine stool samples/rectal swabs from the cases; three pre and four post chlorination water samples and sent them for microbiological testing. We mapped water supply pipelines of the area and reviewed the water chlorination record. Results: We identified 390 cases in 16 villages under the sub center. The overall attack rate was 8% with a range of 1.3% to 36%. The cases patients were reported from all age groups and both the genders with the youngest student; 1-year old to the oldest one as 88 years. Two-third of the cases reported vomiting with some complaining of pain abdomen. Villages like Jathman, Khattni, Rajol Patta, Kohara has 100% case patients of loose motions while villages like Dhroli, (100%), Sasan (63%) and Ghallour (50%), etc., have combined symptoms of loose motions and vomiting. No fatality was reported. Escherichia coli was detected in the samples from water samples. Records of chlorination were not properly maintained. Conclusion / Recommendation: The outbreak was associated due to contamination of water at the source in Jolly Khad. Regular treatment of the water needs to be done right at the source before being lifted

Concurrent multiple outbreaks of varicella, rubeola, german measles outbreak in unvaccinated children of co-educational mount carmel senior secondary school, Thakurdwara Palampur of Northern Himachal, India

Background: In April, 2009, in a co-education school, we investigated suspected triple outbreak; varicella first and then with chance detection of rubeola and rubella. The aim was to confirm diagnosis and recommend remedial measures to prevent further outbreaks. Materials and Methods: We defined a case of varicella with maculopapulovesicular rash without other apparent cause in students or staff of the school and residents of neighboring villages of Khalet and Roady since 23 rd March to 14 th October, 2009. We line listed case patients and collected information on age, sex, residence, date of onset, symptoms, signs, traveling, treatment history, and vaccination status. The outbreak was described by time, place, and person characteristics. Diagnosis was confirmed epidemiologically and serologically; first to chickenpox, measles, and german measles viruses. Results: We identified 505 case patients from mixed outbreaks of varicella, measles, and german measles (30/505 clinically, 467/505 epidemiologically linked and 8/505 laboratory confirmed case patients from a study population of 3280. We investigated the suspected outbreak with case definition of varicella but measles 20/3280 (0.60%) and rubella 34/3280 (1.03%) cases were also observed. The overall attack rate (AR) was 15% while in school; it was 22% but highest (56%) in Nursery up to 4 th standard with index case in first standard. Sex-specific AR was (23%) more in boys. Triple concurrent infection caused 05% complications but no death was reported. Severity of the symptoms was more in 5 th standard onwards with 49-249 lesions and severer in poor villages Roady and Khalet (P < 0.05). Only 4% were immunized against varicella/german measles privately. Seventeen percent of the cases went for traditional treatment vs modern medicine (P < 0.001). 5/10 samples for IgM antibodies for chickenpox and 2/10 samples were positive for rubella. Conclusions: Triple infection of varicella, measles, and rubella was confirmed epidemiologically and serologically. We recommended local authorities for MMRV in the school and near villages with aggressive IEC activities in affected areas

Surveillance data analysis of revised national tuberculosis control program of Kangra, Himachal Pradesh

Background: The annual risk of tuberculosis infection is 1.9% in Himachal Pradesh against a national average of 1%. Revised national tuberculosis control program (RNTCP) in Kangra was introduced in October, 1998. We analyzed the 5-year (2001-2005) RNTCP secondary data from Kangra to evaluate the performance of the program. Materials and Methods: We collected data from all the five tuberculosis units the district. We calculated the following indicators-case detection rate, tuberculosis cases by category-new smear positive (or smear negative but seriously ill) defaulters, relapses and failures, extra-pulmonary, and new smear negative cases. We compared the results with Himachal Pradesh and India. We employed the standardized program indicators-sputum positivity, cure, death, failure and default rates. Results: Extra pulmonary cases ranged in between 56% and 73%, normal being 15-20%. The highest category-1 varies from 42% to 48%. New smear positive case detection rates (78-90%) and cure rates (88-91%) were the highest as compared to figures of the state and country. Failure rate was maximum in Kangra Tuberculosis Units (TU)-6.5% and the default rate was 7.2% in TU Palampur. The tuberculosis cases have fallen down from 6,462/100, 000 in 1999 to 2,195/100, 000 in 2005 following the introduction of RNTCP in 1999. Age specific (15-55 years) and sex-wise males were more affected than the females (59-64%). Conclusions: Continue investment in the program to sustain progress achieved. Investigate the cause of high proportion of extra-pulmonary tuberculosis. Investigate Kangra TU unit with a high default rate

Abstracts of AICTE Sponsored International Conference on Post-COVID Symptoms and Complications in Health

This book presents the selected abstracts of the International Conference on Post-COVID Symptoms and Complications in Health, hosted from the 28th to 29th of April 2022 in virtual mode by the LR Institute of Pharmacy, Solan (H.P.)-173223 in Collaboration with AICTE, New Delhi. This conference focuses on the implications of long-term symptoms on public health, ways to mitigate these complications, improve understanding of the disease process in COVID-19 patients, use of computational methods and artificial intelligence in predicting complications, and the role of various drug delivery systems in combating the complications. Conference Title:  International Conference on Post-COVID Symptoms and Complications in HealthConference Sponsor: AICTE, New Delhi.Conference Date: 28-29 April 2022Conference Location: OnlineConference Organizer: LR Institute of Pharmacy, Solan (H.P.)-173223