Occupational Exposure of Healthcare Workers during COVID-19 Field Surveillance Activities in South India: A Cross-Sectional Qualitative Study

Context: Health Care Workers (HCWs) involved in field-level activities are exposed to COVID-19 which puts them under physical and psychological stress. Aim: The objective of this study was to understand the perception of the health care workers regarding their occupational exposure to COVID-19, including the safety measures used during field surveillance activities. Settings and Design: This cross-sectional study was conducted from June 2020 to July 2020 among the health care workers involved in COVID-19 field containment activities in two south Indian states—Telangana and Tamil Nadu. Methods and Material: Respondents were purposively sampled based on their involvement in the COVID-19 field level activities. Sixteen In-Depth Interviewees (IDIs) were conducted telephonically with medical officers, district epidemiologists, community health workers, sanitary workers, emergency medical technicians, and ambulance coordinators. Statistical Analysis Used: IDIs were analyzed using manual thematic analysis. Results: Seven themes and sub-themes emerged: awareness and training, occupational exposure to COVID-19 and duration, safety measures, occupational burnout, social stigma, psychological violence, and facilitating factors. Respondents felt a high level of occupational exposure to COVID-19 in addition to increased workload and stress due to fear of infection, shortage of workforce, denial of week off, psychological violence, and social stigma which affected them deeply. Support from supervisors and family, and measures ensuring the safety of women were facilitating factors to cope with the situation. Conclusions: It is important to safeguard the general and mental health of field-level health workers involved in COVID-19 activities, to keep their morale high during the continuing pandemic.

Role of lumbar puncture in clinical outcome of suspected acute bacterial meningitis

BACKGROUND Meningitis remains a significant source of mortality and morbidity,with an incidence of 1 per 100000 persons in the United States.Guidelines recommend obtaining blood cultures and cerebrospinal fluid(CSF)studies in patients presenting with acute meningitis syndrome,and beginning treatment with broad spectrum antibiotics based on the age and certain predisposing conditions.In some patients however,the diagnostic lumbar puncture(LP)is not performed due to a multitude of reasons,ranging from increased intracranial pressure to failed attempt.In such situations,appropriate therapy is initiated empirically and often continued without establishment of a definitive diagnosis.AIM To determine whether a diagnostic LP in acute meningitis syndrome was associated with a better outcome and less duration of antibiotic therapy,along with potential causes for deferral of procedure.METHODS A retrospective study was conducted amongst the patients presenting to a 360 bedded community hospital in central Massachusetts with a diagnosis of acute meningitis syndrome between January 2010-September 2022.The electronic health records were accessed to collect necessary demographic and clinical data,including etiology of meningitis,lumbar puncture results,reason for procedure deferral,duration of antibiotic therapy and clinical outcome.The patients were subsequently divided into two groups based on whether they received a LP or not,and data was analyzed.RESULTS A total of 169 patients admitted with acute meningitis syndrome between September 2010-2022 were included in the study.The mean age of the participants was 54.3 years(SD+/-19.2 years).LP was performed for 130(76.9%)participants,out of which,28(21.5%)showed some growth in CSF culture.The most commonly identified organism was streptococcus pneumoniae.Amongst the 39 patients in whom LP was deferred,the major reasons recorded were:Body habitus(n=6,15.4%),and unsuccessful attempt(n=4,10.3%).While 93(71.5%)patients with LP received antibiotic therapy,only 19(48.7%)patients without LP received the antibiotics,with the principal reason being spontaneous improvement in sensorium without any diagnosed source of infection.The mean duration of antibiotic use was 12.3 days(SD+/-5.6)in the LP group and 11.5 days(SD+/-7.0)in the non-LP group(P=0.56;statistically not significant).We observed higher long term sequalae in the non-LP group(n=6,15.4%)compared to the LP group(n=9,6.9%).Similarly,the death rate was higher in the non-LP group(n=7,18.0%)compared to the LP group(n=9,6.9%).CONCLUSION LP remains the cornerstone for diagnosing meningitis,but often CSF results are unavailable,leading to empiric treatment.Our study identified that body habitus and unsuccessful attempts were the most common reasons for LP not being performed,leading to empiric antibiotic coverage.There was no difference between the duration of antibiotics received by the two groups,but a lower proportion of patients without LP received antibiotics,attributed to a spontaneous improvement in sensorium.However,the residual neurological sequelae and death rates were higher in patients without LP,signifying a potential under-treatment.A LP remains crucial to diagnose meningitis,and a lack of CSF analysis predisposes to under-treatment,leading to higher neurological sequelae and increased chances of death.

An Interrupted Time Series Analysis of COVID-19 Positivity before, during and after Lockdown in Four States of India

Objectives: The objective of this study was to examine the impact of large scale non-pharmaceutical interventions on COVID-19 pandemic. Methods: We used interrupted time series analysis (ITS), a quasi-experimental model to evaluate the effect of interventions in four states of India by comparing the COVID-19 positivity before lockdown, during lockdown and opening-up period. Results: The positivity in all the four states declined during lockdown and the trends reversed soon after the lockdown measures were relaxed as the states opened-up. The rate of reduction of positivity was significantly different between states. Between the lockdown and opening-up period, an increase in positivity was recorded in all the states with significant variation between states. Conclusion: The analysis provides conclusive evidence that the lockdown measures had a positive effect in reducing the burden of COVID-19 and establishes a causal relationship.

Effect of El Nino Southern Oscillations on the incidence of enteric fever in Ahmedabad,India from 1985 to 2017

Objective:To explore the relationship between climate variables and enteric fever in the city of Ahmedabad and report preliminary findings regarding the influence of El Nino Southern Oscillations and Indian Ocean Dipole over enteric fever incidence.Method:A total of 29808 Widal positive enteric fever cases reported by the Ahmedabad Municipal Corporation and local climate data in 1985-2017 from Ahmedabad Meteorology Department were analysed.El Nino,La Nina,neutral and Indian Ocean Dipole years as reported by the National Oceanic and Atmospheric Administration for the same period were compared for the incidence of enteric fever.Results:Population-normalized average monthly enteric fever case rates were the highest for El Nino years(25.5),lower for La Nina years(20.5)and lowest for neutral years(17.6).A repeated measures ANOVA analysis showed no significant difference in case rates during the three yearly El Nino Southern Oscillations categories.However,visual profile plot of estimated marginal monthly means showed two distinct characteristics:an early rise and peaking of cases in the El Nino and La Nina years,and a much more restrained rise without conspicuous peaks in neutral years.Further analysis based on monthly El Nino Southern Oscillations categories was conducted to detect differences in median monthly case rates.Median case rates in strong and moderate El Nino months and strong La Nina months were significantly dissimilar from that during neutral months(P<0.001).Conclusions:El Nino Southern Oscillations events influence the incidence of enteric fever cases in Ahmedabad,and further investigation from more cities and towns is required.

Community Based Health Insurance in India: Prospects and Challenges

The health inequities remain high in India with government and private health expenditures clearly favoring the rich, urban population and organized sector workers and the Out Of Pocket (OOP) spending as high as 80%, afflicting the poor in the worst manner. The focus of the paper is to examine the potential Community Based Health Insurance (CBHI) offers to improve the healthcare access to rural, low-income population and the people in unorganized sector. This is done by drawing empirical evidence from various countries on their experiences of implementing CBHI schemes and its potential for applications to India, problems and challenges faced and the policy and management lessons that may be applicable to India. It can be concluded that CBHI schemes have proved to be effective in reducing the Catastrophic Health Expenditure (CHE) of people. But success of such schemes depends on its design, benefit package it offers, its management, economic and non-economic benefits perceived by enrollees and solidarity among community members. Collaboration of government, NGO’s and donor agencies is very crucial in extending coverage;similarly overcoming the mistrust that people have from such schemes and subsidizing the insurance for the many who cannot pay the premiums are important factors for success of CBHI in India. One of the biggest challenges for the health system is to address the piecemeal approach of CBHI schemes in extending health insurance and inability of such schemes to cover a large number of poor and the unorganized sector workers. Also, there is a need for a stronger policy research to demonstrate: 1) how such schemes can create a larger risk pool, 2) how such schemes can enroll a large number of people in the unorganized sector, 3) the interaction of CBHI schemes with other financing schemes and its link to the health system.

Drinking Water Quality Surveillance in a Vulnerable Urban Ward of Ahmedabad

The World Bank estimates that 21% of all communicable diseases in India are related to unsafe water with diarrhoea alone causing more than 0.1 million deaths annually. The WHO drinking water surveillance parameters of quality, quantity, accessibility, affordability and continuity were assessed in one vulnerable ward of Ahmedabad—a fast growing city in Western India. Interviews with key informants of the ward office, health centre and water supply department, secondary analysis and mapping of field test reports and a questionnaire-based survey of different household types were conducted. We found that Ahmedabad Municipal Corporation (AMC) supplies water to the ward intermittently for two hours during the day. Housing society clusters supplement their AMC water supply with untested bore-well water. The water quality surveillance system is designed for a twenty-four-hour piped distribution of treated surface water. However, in order to maintain surveillance over an intermittent supply that includes ground water, the sampling process should include periodic surveys of water actually consumed by the citizens. The laboratory capacity of the Central Water Testing Laboratory should expand to include more refined tests for microbial and chemical contamination.

Organisational climate from view point of motivation in district hospital, India

Organisational Climate (OC) has been an important topic of research in Organisational Development. There are several frameworks and approaches to study OC. One such framework focuses on the effect of OC on motivation. Although studying OC from viewpoint of motivetion is an important one, there is very limited research in Indian public health system on assessing OC from the view point of motivation. The present study uses a comprehensive framework that focuses on assessing OC from the view point of motivation in a government district hospital. The overall objective of the study was to assess the OC of a District Hospital (DH) from the view point of motivation. A total of 66 staff (all from the same district hospital) participated in the study that included 12 Class I doctor specialists;14 Class II doctors and 40 Class III staff The data was collected using a validated instrument called Motivational Analysis of Climate (MAO-C). The instrument included six needs or motives and twelve dimensions of organisational climate that were ranked by individuals according to their perception. Based on the ranks, final scores were calculated that reflected the dominant climate (highest score for a particular motive) and backup climates (second highest score for a particular motive). Also a combination of the two motives, dominant and back up motives or climates indicated a particular OC. According to the study, the dominant climate in the organisation was that for Dependency motive while the backup climate for the organisation was for Control motive. According to the literature, both Dependency and Control motives are dysfunctional climates. A high dependency motive indicates that the overall organisational climate is characterized by no initiatives by the people and the employees always look for approval from their seniors;assistance of others in developing oneself;a need to check with others who are more knowledgeable. Similarly high score for control motive indicates that order is maintained in organisation;indicates display of personal power;a desire to stay informed and an urge to monitor events and to take corrective action when needed. When the two motives are combined, the study indicates a dependency-control climate profile which means that the organisational practices are similar to government offices, where subordinates have no say in decision making and they have to follow the established rules of the organisation. Such organisations have clearly laid communication channels controlled from higher authority indicating typical characteristics of a beaurocratic organisation.

Laboratory Capacity for Surveillance of Infectious Diseases in Gujarat: Quantity, Quality, Effects and Way Forward

Background: India carries one of the largest burdens of infectious diseases in the world. To estimate this, laboratory confirmation is vital. We estimated the lab capacity and effectiveness in the state of Gujarat for Enteric Fever, Infectious Hepatitis, and Dengue. Methods: We estimated the number of labs in the state through telephonic surveys and physical screening of a representative sample of labs. We created four levels of tests, Level-0 being no test and 3 being the best confirmatory test available in the state. For the profusion of rapid diagnostic test kits (RDTKs), we constructed Effective Diagnostic Scores (EDS) calculated from their sensitivity and specificity at disease prevalences specified in the literature. Tests with EDS > 0.51 were level-2 tests, and EDS Results: Our analysis showed that there are 4293 labs in the state (1765 public and 2528 private), 7/100,000 population. However, only 2878 labs contributed to a total pooled Effective Lab Diagnostic Score (ELDS) of 6776 in the state. Strikingly, 94% of the lab effectiveness lay in RDTs (level-2 and 1 tests) which are essentially screening tests. Ninety-six percent of the overall lab effectiveness of Gujarat existed in private and only 4% in public labs. Contrarily, the level-3 confirmatory testing effectiveness, through ELISA and culture constituted only 4% of private and 36% of public lab effectiveness. More than half of the private lab effectiveness was located in eight Tier 1 cities. Level-3 confirmatory testing effectiveness was present only in Tier 1 and 2 towns. Hepatitis B testing contributed 34% of the total ELDS, followed by Dengue (30%), Enteric Fever (26%) and Hepatitis A and E (10%). Conclusion: Our study has established that the capacity and effectiveness of the lab network in Gujarat lie predominantly in RDTKs. We need to adapt our systems to capture this data in a manner that will allow us to monitor the burdens of these diseases.

Community Based Survey Methodology for Maternal Healthcare Utilization: Gujarat, India

Background: About 60% of institutional births occur in the private sector in Gujarat due to limited availability of obstetricians in the government. Chiranjeevi Yojana (CY), a voucher-like program initiated in 2007, accredits private obstetricians who are reimbursed by the state government to provide free delivery care to eligible women i.e. below poverty line and tribal. One million women have delivered under the CY program yet there are no large community based studies of the program. Methodology of a prospective community study is described here. Methods/Designs: A prospective cohort study was done in 142 villages across 3 districts in Gujarat between July, 2013 and November, 2014. A detailed survey was done by trained researchers to ascertain maternal healthcare information including antenatal, intra-partum and post-partum care, place of delivery, birth outcomes, out of pocket expenses etc. Results: 54,955 households were surveyed. 73% of all households had poverty documentation. 4274 mothers who delivered in the study period were included. Discussion: This paper is description of the methodology of a large community based survey and household and individual level characteristics. The survey was nested in a larger project to evaluate the CY program in the state of Gujarat.

社区参与眼部保健:与社区合作并服务社区

社区参与的保健系统是初级卫生保健的基本要素,也是1978年《阿拉木图宣言》的核心内容,其指出“公民有权力和义务参与个人或集体的医疗保健”。世界上至少有一半人群无法享有全面的卫生保健服务,而社区的参与将会改变这一现状。而社区是由一群不同特征的人组成,他们处于不同生活环境或者不同地理位置,通过一些社会纽带,共同的观念联系在一起。

Knowledge,attitude,beliefs and practices in HIV/AIDS in India:identifying the gender and rural-urban differences

Objective:To promote the use of preventive measures and raise awareness regarding HIV/AIDS in India.Methods:Data from the population-based NFHS-3 survey 2005-06 was used.In this study,information collected on 87 961 women aged 15-49 years and 44 717 men aged 15-54 years was used in the final analysis.The data collected was stratified by gender and place of residence. Analyses of the variables related to the outcomes i.e.knowledge,attitude,belief and practices, was conducted using Chi-square test to calculate significant differences among proportions of categorical variables.Results:We found that knowledge of HIV transmission and prevention was low among women and rural residents.Most of the respondents had a non-discriminatory attitude towards HIV positives and majority agreed that children should be educated on HIV/ AIDS.The use of condoms and proportion of respondents who had undergone HIV testing was found to be significantly low.We found a significant gap in the beliefs regarding ways to avoid HIV.Conclusions:There are significant gender and urban-rural differentials in India in terms of knowledge,attitude,beliefs and practices in HIV/AIDS.Information dissemination in India should be designed in a way that not only raises the level of awareness but also result in behavioral change.

Are High School Students Ready to Stop the Bleed from Injuries? Needs Assessment in a Low Resource Country

Background: Life-threatening bleeding is a major cause of trauma-related deaths. Stop the Bleed—Active bleeding control (ABC) program in Hyderabad recently showed that lay first responders can be effectively trained. However, the willingness of high school students to train in bleeding control is unknown. We report Stop the Bleed training needs assessment from high schools in India and estimate the potential multiplier effect. Methods: A cross-sectional survey was conducted from 12 randomly selected schools in Hyderabad. The study was to understand current knowledge, skills and willingness to get trained and respond to life-threatening bleeding from injuries. 107 Participants (35 Teachers and 72 students) were purposively selected for telephonic interviews with a structured questionnaire. Results: Response rate was 93% overall. 80% of participants have never been trained in bleeding control. 84% reported willingness to be trained, train others and help bleeding victims. All the teachers reported that stop the bleed training would be useful in high schools. 70.6% of teachers recommended that training could start from middle school (10 to 15 years), 47% preferred the online training mode. Only 20% of participants had prior training in lifesaving first aid and 32% did not know the number of emergency medical services (EMS). Each trained participant has the potential to train 3 to 4 people at the household level and perhaps more at the community level. Conclusion: The surveyed schools in Hyderabad do not have the knowledge, skills, or training curriculum in Stop the Bleed. Students and teachers are willing to be trained and train others, with great potential for a “multiplier-effect” in the community.

Mass drug administration for lymphatic filariasis elimination in a coastal state of India: a study on barriers to coverage and compliance

Background:Lymphatic filariasis is targeted for elimination in India through mass drug administration(MDA)with diethylcarbamazine(DEC)combined with albendazole(ABZ).For the strategy to be effective,>65%of those living in endemic areas must be covered by and compliant to MDA.Post the MDA 2011 campaign in the endemic district of Odisha,we conducted a survey to assess:(i)the filariasis knowledge in the community,(ii)the coverage and compliance of MDA from the community perspective,and(iii)factors affecting compliance,as well as the operational issues involved in carrying out MDA activities from the drug distributor’s perspective.Methods:A sample of 691 participants-both male and female,aged two years or above-were selected through multistage stratified sampling and interviewed using a semi-structured questionnaire.Additionally,drug distributors and the medical officers in charge of the MDA were also interviewed to understand some of the operational issues encountered during MDA.Results:Ninety-nine percent of the study participants received DEC and ABZ tablets during MDA,of which only just above a quarter actually consumed the drugs.The cause of non-compliance was mostly due to fear of side effects,lack of awareness of the benefits of MDA,and non-attendance of health staff in the villages.Lack of adequate training of drug distributors and poor health communication activities before the MDA campaign commenced and the absence of follow-up by health workers following MDA were a few of the operational difficulties encountered during the MDA campaign.Conclusion:Currently MDA is restricted to the distribution of drugs only and the key issues of implementation in compliance,health education,managing side effects,and logistics are not given enough attention.It is therefore essential to address the issues linked to low compliance to make the program more efficient and achieve the goal of filariasis elimination.

Disconnect between primary care and cancer follow-up care: An exploratory study from Odisha, India

Objective:There has been a steady increase in the demand for cancer follow-up care in India.Compared with Western countries,there is little evidence on the capacity of the Indian primary care workforce to accommodate such tasks.We explored the perceptions of oncologists,general practitioners,and patients with regard to the involvement of primary care in cancer follow-up care.Methods:We undertook semistructured focus-group discussions with eight oncologists,nine general practitioners,and 17 cancer patients to gain an understanding of their perceived roles and responsibilities with regard to primary care in delivering follow-up care and the potential concerns.Data from the focus groups were transcribed verbatim,translated,and analyzed with use of a the-matic approach.Results:Most general practitioners felt that their job is to see‘normal’patients,and cancer patients were exceptions to routine care.Oncologists were apprehensive with regard to the com-petence of general practitioners and patient trust.Patients consult oncologists for cancer follow-up care as they perceive it to be very specialized.Patients expressed difficulty in accessing follow-up care and want specialized oncological care by trained personnel in their vicinity.Conclusion:Despite the growing number of cancer survivors,we found a disconnect between primary care and cancer follow-up care.