Chlamydia trachomatis is the most common cause of curable bacterial sexually transmitted infection (STI) worldwide. It manifests primarily as urethritis in males and endocervicitis in females. Untreated chlamydial infection in man can cause epididymitis and proctitis. Though most women with Chlamydia infection are asymptomatic or have minimal symptoms, some develop salpingitis, endometritis, pelvic inflammatory disease (PID), ectopic pregnancy and tubal factor infertility. It is associated with an increased risk for the transmission or acquisition of HIV and is also attributed to be a risk factor for the development of cervical carcinoma. Early diagnosis and treatment of infected individuals is required to prevent the spread of the disease and severe sequelae. Traditionally, tissue culture was considered the gold standard for the diagnosis. However, with the availability of newer diagnostic techniques particularly molecular methods which are not only highly sensitive and specific but are cost-effective also, the diagnosis has became fast and easy. The purpose of this review is to study the various aspects of genital C. trachomatis infection. Also the advances related to the clinical picture, various diagnostic modalities, prevention, treatment, drug resistance and control measures will be dealt with.
Chlamydia trachomatis; epidemiology; genetics; immunology; treatment
Tropical pulmonary eosinophilia (TPE) is a syndrome of wheezing, fever and eosiniphilia seen predominantly in the Indian subcontinent and other tropical areas. Its etiological link with Wuchereria bancrofti and Brugia malayi has been well established. The pathogenesis is due to an exaggerated immune response to the filarial antigens which includes type I, type III and type IV reactions with eosinophils playing a pivotal role. Peripheral blood eosinophilia is usually striking with levels over 3000/μl being common. High serum levels of IgE and filarial-specific IgE and IgG are also found. The pathology may vary from an acute eosinophilic alveolitis to histiocytic infiltration depending on the stage of the disease. While earlier studies had suggested that the disease runs a benign course, more recent work has shown that untreated TPE could result in a fair degree of respiratory morbidity. Pulmonary function tests may show a mixed restrictive and obstructive abnormality with a reduction in diffusion capacity. The bronchoalveolar lavage (BAL) eosinophil count has a negative correlation with the diffusion capacity. Treatment consists of diethylcarbamazine (DEC) for at least three weeks. Despite treatment with DEC, about 20 per cent of patients may relapse. Steroids have shown to have a beneficial effect but the exact dose and duration is yet to be confirmed by randomized controlled trials. A specific and easily available marker is required for TPE in order to distinguish it from other parasitic and non-parasitic causes of pulmonary eosinophilia.
Cough; DEC; fibrosis; filarial antigen; microfilariae; tropical pulmonary eosinophilia; wheezing
Background & objectives:
Children with sickle cell disease require more frequent hospital care and younger children (<5 yr of age) are more vulnerable to mortality. There are limited data on the events leading to hospitalizations and death in younger children with sickle cell disease from India. This study was, therefore, undertaken to evaluate the morbidity pattern in hospitalized under five children with sickle cell disease in a tertiary care hospital in Maharashtra, India.
This was a prospective observational study carried out from July 2007 to June 2009. Hospitalized children below five years of age with sickle cell disease were enrolled for the study and evaluated for morbid event/s leading to hospitalization. Haematological indices were noted at baseline (most recent past when patient was not acutely sick) and at the time of hospitalization.
Eighty five children with sickle cell disease were hospitalized during the study period. Hospitalization with acute febrile illness (31%) was the most common morbid event followed by severe anaemia (30%) and acute painful events (20%). Majority (62%) of the events occurred between August and October. Forty five patients had foetal haemoglobin (HbF) more than 20 per cent (26.80±4.81%) and morbidity was significantly less in these patients.
Interpretation & conclusion:
Acute febrile illness was the most common morbid event followed by severe anaemia and acute painful event hospitalized children with sickle cell disease. There was significant seasonal variation with maximum events occurring in the monsoon season.
Bacteraemia; children; haemoglobin; infection; morbidity; sickle cell disease
Background & objectives:
Survival pattern among children infected with the human immune deficiency virus (HIV) follows a bimodel distribution. Some children survive beyond 9 years age and are known as long term survivers (LTS) while others had a more rapid course to death during the first few years of life. In the LTS group of children, two sub-populations have emerged, the long term non-progressors (LTNP) who have remained asymptomatic over a period of years and those who have survived despite clinical and laboratory evidence of disease progression, the long term progressors (LTP). The aim of the present study was to determine the factors influencing the conversion of LTNPs to LTPs in a group of perinatally HIV infected children who were followed up for five years.
A total of 26 HIV seropositive paediatric patients were monitored from 2006 to 2011 with CD4 cell counts, onset of clinical manifestations, body weight, biochemical, haematological and immunological parameters. Statistical analyses, both qualitative and quantitative, were used to determine the degree of conversion of non-progressors to progressors.
All 26 (13 female and 13 male) perinatally HIV infected children, born during1991-1996 were healthy until 2006. But by 2011, 18 were placed in progressors group with antiretroviral therapy (ART), while six remained in non progressors group and two died. As per the Kaplan-Meier survival analysis, AIDS free median survival period (years) in LTP group (CD4 count) of the cohort was 10±0.66 (<200; P=<0.05); 11±0.61 (200-350, P=<0.05), 12±0.18 (>350, P=<0.05). Intercurrent and opportunistic infections (OIs) were observed in LTPs only. The incidence of OI in LTPs was higher when compared to general paediatric population.
Interpretation & conclusions:
Our findings show that CD4 counts and OIs play an important role in influencing the survival chances of perinatally HIV infected children.
AIDS; HIV; LTNPs; LTP; paediatric; progressors
Background & objectives:
Non-detection of hepatitis B virus (HBV) envelope protein (hepatitis B surface antigen, HBsAg) in a chronically HBV infected individual has been described as occult infection. One possible reason for this phenotype is alteration in large (L-HBsAg) to small (S-HBsAg) envelope protein ratio associated with reduced or non secretion of HBsAg. This results in quantitative levels of serum HBsAg below the detection limit of enzyme immunoassays. Genotype D of HBV has a characteristic 33 nucleotide (nt) deletion upstream of the pre-S2/S promoter. This deletion may reduce HBsAg secretion in occult infection patients infected with genotype D HBV. Additional deletions in the pre-S2/S promoter may further aggravate reduced HBsAg secretion in patients infected with genotype D HBV. Thus, the aim of the present study was to determine the role of genotype D specific 33nt deletion and additional pre-S2/S promoter deletions in causing reduced or no secretion of HBsAg, in occult infection. Since these deletions overlap virus polymerase, their effect on virus replication was also investigated.
We examined the in vitro expression of HBsAg, ratio of cure and ‘e’ antigen (HBcAg/HBeAg), their secretion and virus replication, using overlength 1.3 mer/1.86 mer genotype A replicons, and genotype D replicons with and without additional pre-S2/S promoter deletions from cases of occult infection.
Genotype D replicon showed a decrease in HBsAg secretion compared to the wild-type genotype A. Genotype D replicons carrying additional pre-S2/S promoter deletions, showed further reduction in HBsAg secretion, demonstrated presence of intracellular HBcAg/HBeAg, virus replication intermediates and ‘e’ antigen secretion.
Interpretation & conclusions:
The characteristic 33 nt deletion of genotype D HBV reduces HBsAg secretion. Additional pre-S2/S promoter deletions may further diminish HBsAg secretion, leading to occult infection. Pre-S2/S promoter deletions do not affect HBV replication.
Genotypes; HBV; occult; pre-S2/S; promoter mutants; surface antigen (HBsAg)
Background & objectives:
Janani Suraksha Yojana (JSY), a conditional cash transfer scheme introduced to improve the institutional delivery rates and thereby reduce the maternal and infant mortality was implemented in all States and Union Territories of India from 2007. The present study was carried out to identify the beneficiary level factors of utilization of JSY scheme in urban slums and resettlement colonies of trans-Yamuna area of Delhi.
A cross-sectional community based survey was done of mothers of infants in the selected areas of the two districts by stratified random sampling on a population proportionate basis. Socio-demographic factors, antenatal services availed and distance of nearest health facility were studied. Outcome variable, a beneficiary, was a woman who had ever interacted with the ASHA of her area during the antenatal period of previous pregnancy and had child birth in an institution. Descriptive tables were drawn; univariate analysis followed by multiple logistic regression was applied for identifying the predictors for availing the benefits.
Of the 469 mothers interviewed, 333 (71%) had institutional delivery, 128 (27.3%) had benefited from JSY scheme and 68 (14.5%) had received cash benefits of JSY. Belonging to Hindu religion and having had more than 6 antenatal check ups were the significant predictors of availing the benefits of JSY.
There is a need to improve the awareness among urban slum population about the utilization of JSY scheme. Targeting difficult to access areas with special measures and encouraging more antenatal visits were essential, prerequisites to improve the impact of JSY.
ASHA; cash incentives; determinants; Janani Suraksha Yojana; institutional delivery; maternal mortality
Background & objectives:
Environmental factors including weather variables may play a significant role in the transmission of dengue. This study investigated the effect of seasonal variation on the abundance of Aedes aegypti and Ae. albopictus larvae and explored the impact of weather variability on dengue transmission in Sisaket, Thailand.
The monthly mosquito larval surveys were carried out in urban and rural areas in Sisaket, Thailand from January to December 2010. Data on monthly-reported cases of dengue fever over the period 2004-2010 were obtained from the Ministry of Public Health. Weather data over the same period were obtained from the Thai Meteorological Department. Chi-square test was used to find the differences relating to seasonal variability, areas of study, and mosquito species factors using entomological survey data. Time series Poisson regression analysis was performed using data on monthly weather variables and dengue cases.
There were more Ae. aegypti larvae per household than Ae. albopictus larvae in the winter and rainy seasons. More Aedes larvae per household were found in the rainy season than in the winter and summer seasons. Relative humidity at a lag of one month and rainy days in the current month were significant predictors of dengue incidence in Sisaket.
Interpretation & conclusions:
Increased rain during the current month and less humidity during the previous month might trigger a higher incidence of dengue epidemic in Sisaket. The present findings suggest that the dengue incidence corresponds with the number of Aedes larvae. The seasonal patterns of dengue outbreaks coincide with the rainy season.
Aedes aegypti; Ae. albopictus; dengue; season; transmission prediction; weather
Background & objectives:
Bacterial vaginosis (BV) is highly prevalent among women in reproductive age group. Little information exists on routine vaginal pH measurement in women with BV. We undertook this study to assess the utility of vaginal pH determination for initial evaluation of bacterial vaginosis.
In this cross-sectional study vaginal swabs were collected from women with complaints of white discharge, back ache and pain abdomen attending a government hospital and a community health clinic, and subjected to vaginal pH determination, Gram stain, wet mount and whiff test. Nugent score and Amsel criteria were used for BV confirmation.
Of the 270 women included in the analysis, 154 had BV based on Nugents’ score. The mean vaginal pH in women with BV measured by pH strips and pH glove was 5 and 4.9, respectively. The vaginal pH was significantly higher in women with BV. Vaginal discharge was prevalent in 84.8 per cent women, however, only 56.8 per cent of these actually had BV by Nugent score (NS). Presence of clue cells and positive whiff test were significant for BV. Vaginal pH >4.5 by pH strips and pH Glove had a sensitivity of 72 and 79 per cent and specificity of 60 and 53 per cent, respectively to detect BV. Among the combination criteria, clue cells and glove pH >4.5 had highest sensitivity and specificity to detect BV.
Interpretation & conclusions:
Vaginal pH determination is relatively sensitive, but less specific in detecting women with BV. Inclusion of whiff test along with pH test reduced the sensitivity, but improved specificity. Both, the pH strip and pH glove are equally suitable for screening women with BV on outpatient basis.
Amsel criteria; bacterial vaginosis; Nugent score; pH test; whiff test
The World Food Summit in 1996 provided a comprehensive definition for food security which brings into focus the linkage between food, nutrition and health. India has been self sufficient in food production since seventies and low household hunger rates. India compares well with developing countries with similar health profile in terms of infant mortality rate (IMR) and under five mortality rate (U5 MR). India fares poorly when underweight in under five children is used as an indicator for food insecurity with rates comparable to that of Subsaharan Africa. If wasting [low body mass index (BMI) for age in children and low BMI in adults] which is closely related to adequacy of current food intake is used as an indictor for the assessment of household food security, India fares better. The nineties witnessed the emergence of dual nutrition burden with persistent inadequate dietary intake and undernutrition on one side and low physical activity / food intake above requirements and overnutrition on the other side. Body size and physical activity levels are two major determinants of human nutrient requirements. The revised recommended dietary allowances (RDA) for Indians takes cognisance of the current body weight and physical activity while computing the energy and nutrient requirements. As both under- and overnutrition are associated with health hazards, perhaps time has come for use of normal BMI as an indicator for food security.
Food insecurity outcome indicators; food security; hunger; nutrition security; under five mortality; undernutrition
Food and nutrition security are intimately interconnected, since only a food based approach can help in overcoming malnutrition in an economically and socially sustainable manner. Food production provides the base for food security as it is a key determinant of food availability. This paper deals with different aspects of ensuring high productivity and production without associated ecological harm for ensuring adequate food availability. By mainstreaming ecological considerations in technology development and dissemination, we can enter an era of evergreen revolution and sustainable food and nutrition security. Public policy support is crucial for enabling this.
Food availability; food production; sustainable food security
The past seven decades have seen remarkable shifts in the nutritional scenario in India. Even up to the 1950s severe forms of malnutrition such as kwashiorkar and pellagra were endemic. As nutritionists were finding home-grown and common-sense solutions for these widespread problems, the population was burgeoning and food was scarce. The threat of widespread household food insecurity and chronic undernutrition was very real. Then came the Green Revolution. Shortages of food grains disappeared within less than a decade and India became self-sufficient in food grain production. But more insidious problems arising from this revolution were looming, and cropping patterns giving low priority to coarse grains and pulses, and monocropping led to depletion of soil nutrients and ‘Green Revolution fatigue’. With improved household food security and better access to health care, clinical manifestations of severe malnutrition virtually disappeared. But the decline in chronic undernutrition and “hidden hunger” from micronutrient deficiencies was slow. On the cusp of the new century, an added factor appeared on the nutritional scene in India. With steady urban migration, upward mobility out of poverty, and an increasingly sedentary lifestyle because of improvements in technology and transport, obesity rates began to increase, resulting in a dual burden. Measured in terms of its performance in meeting its Millennium Development Goals, India has fallen short. Despite its continuing high levels of poverty and illiteracy, India has a huge demographic potential in the form of a young population. This advantage must be leveraged by investing in nutrition education, household access to nutritious diets, sanitary environment and a health-promoting lifestyle. This requires co-operation from all the stakeholders, including governments, non government organizations, scientists and the people at large.
Dual nutrition burden; green revolution; micronutrients; nutrition; supplementation
Rising food costs can have major impact on vulnerable households, pushing those least able to cope further into poverty and hunger. On the other hand, provided appropriate policies and infrastructure are in place, higher agricultural prices can also raise farmers’ incomes and rural wages, improve rural economies and stimulate investment for longer-term economic growth. High food prices since 2007 have had both short-term impacts and long-term consequences, both good and bad. This article reviews the evidence of how rising costs have affected global food security since the food price crisis of 2007-2008, and their impact on different categories of households and countries. In light of recent studies, we know more about how households, and countries, cope or not with food price shocks but a number of contentious issues remain. These include the adequacy of current estimates and the interpretation of national and household food and nutrition security indicators. India is a particularly important country in this regard, given the high number of food insecure, the relative weight of India in global estimates of food and nutrition insecurity, and the puzzles that remain concerning the country's reported declining per capita calorie consumption. Competing explanations for what is behind it are not in agreement, but these all point to the importance of policy and programme innovation and greater investment necessary to reach the achievable goal of food and nutrition security for all.
Food costs; food security; India
The National Prophylaxis Programme against Nutritional Blindness due to vitamin A deficiency (NPPNB due to VAD) was started in 1970 with the specific aim of preventing nutritional blindness due to keratomalacia. The Programme was launched as an urgent remedial measure to combat the unacceptably high magnitude of xerophthalmic blindness in the country seen in the 1950s and 1960s. Clinical VAD has declined drastically during the last 40 years. Also, indicators of child health have shown substantial gains in different States in the country. The prevalence of severe undernutrition has come down significantly. Immunization coverage for measles and other vaccine preventable diseases has improved from 5-7 per cent in early seventies to currently 60-90 per cent, in different States. Similarly, there has been a significant improvement in the overall dietary intake of young children. There has been virtual disappearance of keratomalacia, and a sharp decline in the prevalence of Bitot spots. Prophylactic mega dose administration of vitamin A is primarily advocated because of the claim of 23 per cent reduction in childhood mortality. However, benefits on this scale have been found only in areas with rudimentary health care facilities where clinical deficiency is common, and there is substantial heterogeneity, especially with inclusion of all trials. There is an urgent need for adopting a targeted rather than universal prophylactic mega dose vitamin A supplementation in preschool children. This approach is justified on the basis of currently available evidence documenting a substantial decline in VAD prevalence, substantial heterogeneity and uncertainty about mortality effects in present era with improved health care, and resource constraints with competing priorities.
Massive dose; serum retinol; supplementation; VAD; vitamin A
Iodine deficiency disorders (IDD) constitute the single largest cause of preventable brain damage worldwide. Majority of consequences of IDD are invisible and irreversible but at the same time these are preventable. In India, the entire population is prone to IDD due to deficiency of iodine in the soil of the subcontinent and consequently the food derived from it. To combat the risk of IDD, salt is fortified with iodine. However, an estimated 350 million people do not consume adequately iodized salt and, therefore, are at risk for IDD. Of the 325 districts surveyed in India so far, 263 are IDD-endemic. The current household level iodized salt coverage in India is 91 per cent with 71 per cent households consuming adequately iodized salt. The IDD control goal in India was to reduce the prevalence of IDD below 10 per cent in the entire country by 2012. What is required is a “mission approach” with greater coordination amongst all stakeholders of IDD control efforts in India. Mainstreaming of IDD control in policy making, devising State specific action plans to control IDD, strict implementation of Food Safety and Standards (FSS) Act, 2006, addressing inequities in iodized salt coverage (rural-urban, socio-economic), providing iodized salt in Public Distribution System, strengthening monitoring and evaluation of IDD programme and ensuring sustainability of IDD control activities are essential to achieve sustainable elimination of IDD in India.
India; iodine deficiency disorders; iodized salt; National Iodine Deficiency Disorders Control Programme; sustainable elimination