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INDIAN JOURNAL OF PUBLIC HEALTH
(Quarterly Journal of Indian Public Health Association)

Journal Advisory Committee Dr. Deoki Nandan Dr. Sandip Kumar Ray Dr. Ranadeb Biswas Dr. F. U. Ahmed Dr. J. Ravi Kumar Mrs. Shuva Kumari
Vol. 52 No.3 July - September 2008
Editorial Board
Chief Editor Dr. V. K. Srivastava Editor Dr. Samir Dasgupta Associate Editor Dr. R. N. Chaudhuri Dr. Sanjay Chaturvedi Joint Editor Dr. D. K. Raut Dr. A. B. Biswas Assistant Editor Dr. Kaushik Mishra Dr. Prabir Kumar Sen Managing Editor Dr. Dilip Kumar Das Assistant Managing Editor Dr. Rabindra Nath Sinha Members Dr. D.H. Ashwath Narayana Dr. (Lt.Col.) Atul Kotwal Dr. B. M. Vashisht Dr. N. K. Goel Dr. Prasant Kr. Saboth Dr. D. M. Satpathy Dr. Chitra Chatterjee Dr. Rabindra Nath Roy Dr. Ashok Kr. Mallick Dr. Kunal Kanti Majumdar Secretary General (Ex-officio) Dr. (Mrs.) Madhumita Dobe
Indian Journal of Public Health is published quarterly by Indian Public Health Association. Manuscripts and correspondence should be addresed to : Managing Editor, Indian Journal of Public Health, 110 Chittaranjan Avenue (3rd floor), Kolkata-700073, West Bengal. Manuscripts, written in English, should be submitted in triplicate. One copy must also be submitted in electronic format to: ijph2005@yahoo.com, ijph@iphaonline.org Papers submitted to the journal must be accompanied by a Certificate signed by all authors. Editorial Office: 110, Chittaranjan Avenue, Kolkata - 700 073 Phone : 32913895 (033) E-mail: ijph2005@yahoo.com / ijph@iphaonline.org
Indian Journal of Public Health Contents

Vol.52 No.3 July - September 2008
115 Editorial Injury: the most Underappreciated and Unattended Pandemic Sanjay Chaturvedi Original Article Prevalence of Risk Factors for Non-Communicable Disease in a Rural Area of Faridabad District of Haryana A. Krishnan, B. Shah, Vivek Lal, D. K. Shukla, Eldho Paul, S. K. Kapoor Epidemiology of Disability in a Rural Community of Karnataka K. S. Ganesh, A. Das, J. S. Shashi Elimination of Iodine Deficiency Disorders Current Status in Purba Medinipur District of West Bengal, India A. B. Biswas, I. Chakraborty, D. K. Das, A. Chakraborty, D. Ray, K. Mitra Special Article Integrated Diseases Surveillance Project (IDSP) Through a Consultants Lens K. Suresh Short Communication Hypertension and Epidemiological Factors among Tribal Labour Population in Gujarat Rajnarayan R Tiwari Respiratory Morbidity among Street Sweepers Working at Hanumannagar Zone of Nagpur Municipal Corporation, Maharashtra Sabde Yogesh D, Sanjay P Zodpey Needle Sticks Injury among Nurses Involved in Patient Care: A study in Two Medical College Hospitals of West Bengal G. K. Joardar, C. Chatterjee, S.K.Sadhukhan, M.Chakraborty, P Das, A.Mandal . Dietary Profile of Sportswomen Participating in Team Games at State/National Level Ritu Jain, S. Puri, N. Saini Perception Regarding Quality of Services in Urban ICDS Blocks in Delhi A. Davey, S. Davey, U. Datta A Study on Delivery and Newborn Care Practices in a Rural Block of West Bengal P Das, S. Ghosh, M. Ghosh, A. Mandal . Hospitalisation due to Infectious and Parasitic Diseases in District Civil Hospital, Belgaum, Karnataka A. C. Naik, S. Bhat, S. D. Kholkute Review Article Homelessness: A Hidden Public Health Problem S. Patra, K. Anand Letter to the Editor: HIV/ AIDS Awareness through Mass Media the Measurement of Efforts Made in an Urban Area of India Hem Chandra, K. Jamaluddin, L. Masih, K. Faiyaz, N. Agarwal, D. Kumar Undernutrition in 5-10 Year Olds: Experiences from a PHC in Pondicherry S. Sarkar, S. Ananthakrishnan
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Editorial Injury: the most Underappreciated and Unattended Pandemic

Injury accounts for 9% of global mortality and 12% of the global burden of disease in terms of disability adjusted life years (DALY) lost. They figure in the leading causes of death throughout the world and yet remain the most underappreciated pandemic. Every year, an estimated 5 million people die from injury1. Road traffic injury (RTI) alone accounts for 25% of mortality and 22% of DALY lost. Ranked 9th in terms of worldwide burden, they are projected to ascend to 3rd rank by 20202. In many parts of the world, injury related database is thin and the real load may be heavier than the estimates. For every injury related mortality, several thousand more require hospital treatment and suffer with impairments, frequently with disabling consequences. Injury affects the productive work force, youth and school-going children the most. It follows the inverted U-shaped curve with age. Almost 50% of injury related mortality is borne by 15-44 years age group. Under-five children account for 25% of drowning deaths and over 15% of fire-related deaths. Males bear the major brunt in all ages, gender difference being the highest in 15-44 years age group. Mortality from RTI and interpersonal violence is about 3 times higher among males than that in females. Reducing the burden of injury is going to be one of the main challenges for public health in this century. In terms of cost, RTI alone accounts for 1-2% of the gross national product to most of the countries. For the low and middle-income countries (LMICs), this exceeds the total developmental aid received by them. Assessment of direct and indirect costs of injury involves complex methods that are seldom free of limitations and compromises. What generates a great deal of discussion is the economic quantization of human life. Putting monetary values on pain, suffering and death is ethically unacceptable to many. The burden of injury related mortality and morbidity is comparatively very high in low and middleincome countries (LMICs). Over 90% of this burden is borne by such countries. Recent evidence suggests that victims of life-threatening but salvageable injury have six times higher probability of death in a low-income setting3. South-East Asia (SEA) alone bears 31% of the worlds burden of injury and 27% of injury related mortality. Thousands of children saved from infectious and nutritional diseases are killed or crippled by injury in this region. RTI is the biggest culprit in most of these countries - total regional share in the global burden of RTI being 34%4. It is also estimated that SEA region accounts for 57% of the global burden of burn injury and 53% of burn mortality 1. In Bangladesh and Maldives, drowning is the commonest cause of accidental deaths. India specific information base on injury is also very weak and the published data is hard to come by. The latest published review on RTI in India has estimated 2-5 million hospitalizations and over 100,000 deaths in 2005. RTI alone accounts for 1030% of all hospitalizations, being highest in the state of Tamilnadu and lowest in Nagaland5. If we take a stock of our response to this ongoing pandemic, the situation looks scary. Let us start with info-capture and surveillance. In the absence of a trauma registry system, the injury related information is not uniformly or systematically captured, analysed or disseminated in several South Asian countries, including India. Even in the tertiary care facilities where there are functioning medical record divisions the distal recording units, like emergency rooms, are unable to optimally utilise the provisions provided in Chapters XIX & XX of ICD-10 6 for coding and classification of injury. Several circumstantial attributes, which are essential for subsequent coding and classification, are not optimally captured in the distal recording units. Besides the 3 character alpha-numeric core code, which is mandatory for any international reporting, Chapter XX a newer feature of ICD 10, provides an additional e-code for all cases of injury7. This code is about the external cause of injury, and is a significant information for injury surveillance. No proximal data management facility can generate this e-code once the required information is lost at the distal capture unit. This is a huge gap in the injury surveillance process, right at the data-generation level. The initial step in this direction would be to develop sentinel units for injury surveillance in most of the tertiary and
Indian Journal of Public Health Vol.52 No.3 July - September, 2008
Editorial: Injury: the most Underappreciated and Unattended Pandemic
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secondary care hospitals before going for the goal of establishing the National Trauma Registry of India. Certain short term activities can be identified and operationalized, e.g.: framing the case definitions; development of data collection tool; development of data capture process, protocol, and infrastructure; and identification and training of stakeholders. The long term activities would constitute: quality assurance mechanisms; evaluation; knowledge transfer and collaboration. The next or parallel step should be to initiate and sustain a population-based programme on injury prevention. Advocacy starts with identification of stakeholders. A felt need for such a programme is to be created so that the programme gains widest possible acceptance and support. The conceptual framework of a National Injury Prevention Programme must be inclusive in character to accommodate all the significant actors and agencies. This collaborative network should be most visible at the district and sub-district levels. Governments which improve the organization of injury prevention services benefit from reduced injury related burden, as compared to similarly resourced governments which do not. With improved and systematic response towards injury prevention, the range of reduction in the mortality alone will bear incremental rewards. Benefit in terms of DALY saved will go manifold. Such a national response to the problem of injury is yet to materialize in many developing countries. The rationale to initiate a population-based national programme on injury prevention is quite strong and visible. It just needs to be effectively advocated.
References:
1. WHO. The injury chart book: a graphical overview of the global burden of injuries. Geneva: WHO; 2002. WHO. World report on road traffic injury prevention. Geneva: WHO; 2004. Rivara FP Mock C. The 1,000,000 lives campaign , (editorial). Inj Prev. 2005;11:321-3. WHO-SEARO. Strategic plan for injury prevention and control in South-East Asia. New Delhi: WHO-SEARO; 2002. Gururaj G. Road traffic deaths, injuries and disabilities in India: current scenario. Natl Med J India 2008;21:1420. WHO. International statistical classification of diseases and related health problems tenth revision (ICD-10). vol. 1. Geneva: WHO; 1992. WHO. Foundations and fundamentals of injury prevention and control, and safety promotion (section 1, lesson 1). In: TEACH VIP [CD-ROM]. Geneva: WHO; 2005.
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Sanjay Chaturvedi
Associate Editor, IJPH & Professor of Community Medicine, University College of Medical Sciences and GTB Hospital, Delhi E-mail: cvsanjay@hotmail.com
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Original article Prevalence of Risk Factors for Non-Communicable Disease in a Rural Area of Faridabad District of Haryana
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A. Krishnan1, B. Shah2, Vivek Lal3, D. K. Shukla4, Eldho Paul5, S. K. Kapoor6 Abstract
Background & Objectives: To estimate the prevalence and levels of common risk factors for noncommunicable disease in a rural population of Haryana. Methods: The study involved a survey of 1359 male and 1469 female respondents, aged 15-64 years. Multistage sampling was used for recruitment (PHCs/ sub-centres/ villages). All households in the selected villages were covered, with one male and one female interviewed in alternate household. WHO STEP- wise tool was used as the study instrument which included behavioural risk factor questionnaire and physical measurements of height, weight, waist circumference and blood pressure. The age adjusting was done using rural Faridabad data from Census 2001. Results: The age adjusted prevalence of daily smoked tobacco was 41% for men and 13% for women. Daily smokeless tobacco use was 7.1% and 1.2% for men and women respectively. The prevalence of current alcohol consumption was 24.6% among men and none of the women reported consuming alcohol. The mean number of servings of fruits and vegetables per day was 3.7 for men and 2.7 for women. The percentage of people undertaking at least 150 minutes of physical activity in a week was 77.8% for men and 54.5% for women. Among men 9.0 % had BMI > 25.0 compared to 15.2% among women. The prevalence of measured hypertension, i.e. >140 SBP and/or >90 DBP or on antihypertensive drugs was 10.7% among men and 7.9% among women. Conclusion: The study showed a high burden of tobacco use and alcohol use among men, inactivity and overweight among women and low fruit and vegetable consumption among both sexes in rural areas. Key words : Alcohol, BMI, Hypertension, Physical inactivity, Risk factors, Rural, Tobacco.
Introduction
Non- communicable diseases (NCDs) contributed 60% of deaths and 43% of global burden of disease in the year 2002, and by 2020, are projected to account for 73% of deaths and 60% of disease burden1. Clearly, NCDs can no longer be regarded as a problem confined to the developed countries and urban society. Affluence, progressive ageing of population, improving socio-economic conditions and changed life styles have caused an increase in non-communicable diseases and these are spreading to rural areas as well and these need to be documented to dispel myths that NCDs
are a problem only in urban areas. Together NCDs (cardio-vascular diseases, cancer, chronic obstructive pulmonary diseases and diabetes) accounted for 42.7% of deaths in 2000 in India2. These are linked by common risk factors related to lifestyle like tobacco use, unhealthy diet, physical inactivity, obesity, high blood pressure, raised cholesterol and glucose levels. These risk factors are measurable and largely modifiable and thus continuing surveillance of the levels and patterns of risk factors is of fundamental importance to planning and evaluating preventive activities in the control of NCDs.
1Associate Professor, Centre for Community Medicine, AIIMS, New Delhi; 2Senior Deputy Director General (NCDs), Division of Non Communicable Diseases, ICMR, New Delhi; 3Junior Resident, Centre for Community Medicine, AIIMS; 4Deputy Director General, Division of Non Communicable Diseases, ICMR; 5Statistical Assistant, Centre for community medicine, AIIMS; 6 Professor Emeritus, Community Health Departt, St Stephens Hospital, Delhi. *Corresponding author: kanandiyer@yahoo.com
Krishnan A et al: Risk Factors for Non-Communicable Diseases in Haryana
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An integrated approach to risk factor surveillance is vital for NCD control. Surveillance of NCD risk factors as currently practiced in India has largely focused on separate risk factors like tobacco, alcohol or diet. Very few studies have been undertaken to assess physical activity. There is a felt need to have a comprehensive look at the NCD risk factors using standard methodology to ensure comparability. Such tools have recently been developed by WHO and are being used by health planners to generate evidence for advocacy. Comprehensive Rural Health Services Project (CRHSP), Ballabgarh run by All India Institute of Medical Sciences (AIIMS) was among the sites where it was pilot tested and later became a part of the multicentric surveillance site coordinated by Indian Council of Medical Research (ICMR). As part of this we studied a rural population of Haryana for prevalence of common risk factors of NCDs using WHO STEPS approach. We report the results of this survey here.
followed as per STEPs protocol for anthropometric and blood pressure measurements. The height was measured using adult portable stadiometer to the nearest 0.1 cm. SECA digital weighing scales were used to measure weight of the individuals and was recorded in kilograms up to 0.1 kg. A SECA constant tension tape was used to measure Waist circumference to the nearest 0.1 cm. The blood pressure was measured using OMRON digital automatic blood pressure monitor. All measurements were done at domiciliary level. Three male and three female workers were trained by a team of ICMR and were regularly supervised by the investigators and ICMR team. Definitions: (Source- WHO STEPS manual3) Current daily smokers were defined as those who were currently smoking cigarettes, bidis or hookah daily. Current daily smokeless tobacco users were defined as those who were currently using chewable tobacco products, gutka, naswar, khaini or zarda paan daily. Current alcohol drinkers were defined as those who reported to consuming alcohol within the past one year. One standard drink was equivalent to consuming one standard bottle of regular beer (285 ml), one single measure of spirits (30 ml) or one medium size glass of wine (120 ml). One serving of vegetable was considered to be 1 cup of raw green leafy vegetables, cup of other vegetables (cooked or chopped raw) or cup of vegetable juice. One serving of fruit was considered to be 1 medium size piece of apple, banana or orange, cup of chopped, cooked, canned fruit or cup of fruit juice, not artificially flavoured. Physical inactivity was defined as less than 10 minutes of activity at a stretch, during leisure, work or transport. Body mass index (BMI) was calculated by dividing the weight (in kilograms) by square of height (in meters). Overweight was defined as BMI 25 and < 30 Obesity was defined as BMI 30 Hypertension was defined as BP 140/ 90 or currently on antihypertensive drugs.
Material and methods

We conducted a survey in the rural area of Ballabgarh, in Faridabad district of Haryana from April 2003 to January 2004. A total of 2500 participants were aimed at, with 250 in each age (15-24, 25-34, 35-44, 45-54 and 55-64) and sex group. Multistage sampling was used for the purpose of recruitment. Two PHCs were selected randomly from among a total of 5 PHCs in the block. Thereafter, one sub-center in each PHC was selected randomly. One village was randomly selected from the list of villages in the sub-center. If the village was small, an additional village was selected from the same sub-center. All the households in the selected villages were covered, with one male and one female being interviewed in alternate households. The selection of the male/female was from the list of eligible in that house and was done in a random manner. If need be, the household was revisited a second time at least one of which was on a different day/time. The WHO STEP-wise tool was used and the behavioural risk factor Questionnaire was suitably modified and translated in local language. It included questions on socio-demographic status, data on tobacco and alcohol use, measures of dietary habits and physical inactivity. Standard procedure was
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Ethical clearance for the study was obtained from AIIMS. Written informed consent was obtained from each participant. The results of the measurement were provided to the respondents and all case needing referral were referred to the Civil Hospital at Ballabgarh to consult a physician. Data were entered simultaneously. An independent data entry operator did the reentry of 10 percent data and these were validated. The data was analyzed using SPSS for windows (version 10.0). The age standardized percentages for the target age group were computed using rural Faridabad data from Census 2001.
Results
A total of 1359 men and 1469 women were included in the survey. Among the men, majority were unskilled or landless labourers (23.95%). Of the women, 96% were housewives. About 38% of the men had studied up to high school, as against 11.1% who had never been to school. Majority of women had never attended school (56.6%), while only 10% had studied beyond 8th standard.
highest in 45-54 years age group, whereas smokeless tobacco in the forms of khaini, gutka, snuff and chewed tobacco was most prevalent in 25-34 years age group. There was a steep rise in daily smoking of tobacco after 24 years of age from 9.4% in 15- 24 years age group to 46.6% in 25- 34 years age group. Thereafter there was a gradual rise to a peak of 72.2% at 45-54 years age group. The prevalence then showed a decline in the later age group. For women both smoked and smokeless tobacco use was more common in the older age group of 55-64 years. The median age for starting to smoke among men was 20.0 yrs (IQR 17.0-25.0), while the median duration of smoking was 20.0 yrs (IQR 10.0-29.4). The median age for starting to smoke among women was 31.0 yrs (IQR 25.0-40.0), while the median duration of smoking was 12.9 yrs (IQR 5.0-22.0). Smoking tobacco in the form of bidis was the most common with the mean number of bidis smoked per day among men being 6.1 and among women being 0.7. Khaini was the commonest form in which smokeless tobacco was consumed, among both men and women. None of the women reported consuming alcohol. The prevalence of ever alcohol consumption among men was 29.0% and that of current alcohol consumption was 24.6%. The difference between the two was maximum at the age of 55-64 years. The prevalence was highest in the 35-44 years age group. The current alcohol consumers comprised 84.8% of
Tobacco & alcohol use (Table 1)

The age-adjusted prevalence of daily smoked and smokeless tobacco use in men was 41.0% and 7.1% respectively. The same for women was 13.0% and 1.2% respectively. For men, smoked tobacco use was
Table 1. Prevalence of tobacco use and alcohol use by age & sex
Age in years Daily smoked tobacco use (n=1359) 15-24 25-34 35-44 45-54 55-64 Age adjusted prevalence** 9.4% 46.6% 63.8% 72.2% 67.4% 41.0% (38.4-43.7) Men Daily smokeless tobacco use (n=1359) 6.5% 10.1% 6.8% 4.9% 4.3% 7.1% (5.8-8.6) Daily smoked tobacco use (n=1469) 0.4% 7.3% 18.2% 34.5% 38.7% 13.0% (11.3-14.8) Women Daily smokeless tobacco use (n=1469) 0.4% 0.2% 1.7% 1.8% 4.9% 1.2% (0.6-1.8) Ever alcohol consumption (n=1359) 10.0% 32.8% 47.5% 44.1% 36.2% 29.0% (26.5-31.4) Men* Current alcohol consumption (n=1359) 9.4% 29.7% 41.5% 34.8% 20.2% 24.6% (22.3-27.0)
* None of the women reported alcohol consumption, **95% Cl values in parenthesis

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Table 2. Pattern of physical inactivity by domains

Age in years Leisure (n=1359) 79.2% 89.7% 87.5% 87.0% 90.4% 85.2% (83.1-86.9) Men Work (n=1359) 71.4% 50.9% 43.8% 49.1% 58.5% 57.2% (54.4-59.8) Transport (n=1359) 15.5% 21.0% 20.0% 19.3% 23.2% 18.8% (16.7-20.9) Leisure (n=1469) 95.4% 99.5% 97.3% 97.0% 98.4% 97.3% (96.3-98.0) Women Work (n=1469) 74.1% 55.5% 39.7% 57.1% 71.8% 59.9% (57.4-62.4) Transport (n=1469) 54.9% 41.1% 30.6% 41.1% 67.5% 45.7% (43.1-48.2)
15-24 25-34 35-44 45-54 55-64 Age adjusted Total (95% Cl)
those who had ever consumed alcohol. The mean number of drinks consumed in the past 7 days was 12.0 (95% CI 9.2- 14.9). This was highest in the age group 45- 54 yrs. A total of 4.6% men consumed, more than or equal to 5 drinks on any day, in the last week. Men were consuming more fruits and vegetables than women in any age group. The mean number of servings of fruits and vegetables per day was 3.7 (95%CI 3.6-3.8) for men and for women, it was 2.7 (95% CI 2.6-2.8). The proportion of men consuming >5 servings of fruits and vegetables per day was 6.6%, while only 1.8% women reported to consuming this much amount. Across the age groups, mean number of servings of fruits and vegetables consumed per day were similar. The mean number of days in a week when fruits were consumed was 2.05 (95% CI 1.93-2.16) for men and for women was 1.46 (95% CI 1.36-1.56).
Physical inactivity (Table 2)

The physical inactivity was highest during leisure time and was least during transport from one place to another for both men and women. The percentage of people undertaking at least 150 minutes of physical activity in a week was lesser for women (54.5%) than for men (77.8%) among all age groups. Such level of physical activity was highest in the age group 35-44 years (81.9% and 72.9% for men and women respectively) and lowest in 55-64 years age group (70.2% and 37.9% for men and women respectively). The mean duration of physical activity in minutes for all male subjects for a week was 1103.6 (95%CI 1068.5-1192.7) and 781.4 (95%CI 730.9-832.0) for all women. This was more in the age group 35-44 years for both men and women.
Table 3. Distribution BMI & waist circumference by age & sex

Age in years Mean BMI (95%CI) 15-24 25-34 35-44 45-54 55-64 Age adjusted mean 19.7(19.4-20.0) 20.7(20.4-21.0) 21.0(20.6-21.4) 21.0(20.5-21.6) 20.7(19.9-21.5) 20.4(20.2-20.6) Men (n=1359) Mean waist circumference (95%CI) 72.2(71.5-72.9) 77.8(76.9-78.8) 81.5(80.2-82.7) 82.6(80.9-84.3) 82.3(79.9-84.7) 77.4(76.9-77.9) Women (n=1362) Mean BMI Mean waist (95%CI) circumference (95%CI) 19.6(19.3-19.8) 20.3(20.0-20.7) 22.0(21.5-22.5) 22.9(22.2-23.6) 22.421.5-23.3) 21.0(20.7-21.2) 68.7(68.0-69.4) 71.9(71.0-72.9) 77.4(76.0-78.7) 81.1(79.2-83.0) 83.4(81.2-85.7) 74.3(73.7-74.9)
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Table 4 . Prevalence of thinness, overweight and obesity in the study subjects

Age Group BMI<18.5 (%) 15-24 25-34 35-44 45-54 55-64 36.3 21.9 25.8 25.6 33.0 Male (n=1359) BMI BMI 18.5-24.9 25.0<30.0 (%) (%) 59.8 69.5 61.3 59.5 51.0 61.9 (59.6-64.8) 2.9 7.5 10.6 13.0 13.8 7.5 (6.1-9.0) BMI 30 (%) 1.0 1.2 2.3 1.9 2.1 1.5 (1.1-2.6) BMI<18.5 (%) 37.2 32.8 22.2 16.8 24.2 29.1 (26.2-31.3) Female (n=1362) BMI BMI 18.5-24.9 25.0<30.0 (%) (%) 57.5 56.3% 54.7% 52.7% 48.4 55.8 (52.9-58.3) 5.3 9.7% 17.9% 21.6% 19.4 12.1 (10.7-14.2) BM 30.0 (%) 0 1.2% 5.2% 9.0% 8.1 3.1 (2.4-4.3)
Age adjusted 29.1 prevalence* (26.0-30.9)
* 95% Cl values in parenthesis
Anthropometry (Table 3 & 4)

A total of 107 women were found to be pregnant and these were excluded for anthropometric examinations. Both mean BMI and waist circumference was highest in 45-54 years age group for men. For women, the mean waist circumference was highest in 55-64 years, while mean BMI was highest in 45-54 years age group. There was an increase in BMI among
women as compared to men after 25-34 years of age group and thereafter for all age groups; obesity was more common in women. Across all age groups overweight was more common among women than men. The prevalence of underweight was similar for both men and women. After 35 years of age overweight and obesity combined was more than thinness among women while thinness was consistently more prevalent than overweight and obesity combined, for all age
Table 5. Distribution of mean systolic & diastolic BP & % hypertensive by age & sex
Age in years Mean systolic BP (95% CI) 120.6 (119.6-121.6) 118.5 (117.2-119.7) 118.5 (116.7-120.4) 123.0 (120.4-125.5) 127.0 (122.4-131.6) 120.4 (119.6-121.1) Men Mean diastolic BP (95% CI) 70.4 (69.7-71.2) 72.8 (71.8-73.8) 75.6 (74.4-76.9) 78.1 (76.3-79.8) 76.2 (73.7-78.8) 73.4 (72.8-73.9) % Hypertensive (140/90 or on antihypertensive) 4.9 7.1 12.6 21.9 30.1 Mean systolic BP (95% CI) 110.2 (109.2-111.2) 109.0 (107.8-110.1) 111.9 (110.3-113.6) 121.6 (118.6-124.6) 131.2 (127.3-135.1) 113.3 (112.5-114.1) Women Mean diastolic BP (95% CI) 66.4 (65.6-67.1) 68.4 (67.4-69.4) 71.4 (70.2-72.6) 75.5 (73.7-77.3) 76.1 (74.2-78.0) 69.8 (69.3-70.3) % Hypertensive (140/90 or on antihypertensive) 1.5 2.9 7.3 22.4 30.9
15-24 25-34 35-44 45-54 55-64 Age adjusted mean
10.7 (9.0-12.4)
7.9 (6.6-9.4)
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groups among men. A total of 2.2% of men had waist circumference 102 cm, which was most commonly seen in the 55-64 years age. This was against the cutoff for women of 88 cm which was seen in 13.2%. Again it was more common in the 54-65 years age group.
2.8% among men and women respectively. Similar to our study, others have also found that khaini and bidis to be the commonest form of tobacco use 4-6. The difference between ever use and current use was small, suggesting that tobacco use once initiated, is continued and quitting of tobacco use is infrequent. The steep rise in alcohol consumption from 9.4% in 15-24 years age group to 29.7% in 25-34 years age group could be due to the economic independence gained during this time in life. The consumption rose to a peak of 41.5% in 35-44 years age group, and gradually declined thereafter. Most of the men who reported to having consumed alcohol ever in life, had also done so in the last one year indicating that few people quit alcohol. Our prevalence rates were similar to that of NFHS 2 for Haryana5 (20.7% for men and 0.1% for women) but lower than a previous study conducted in Punjab, which reported a prevalence of 58.3%7 for men and 1.5% for women. In our study, women did not report to consuming alcohol- a finding that has also been shown by other studies 8,9. Our study showed that women have a poorer dietary pattern than men for all the age groups, which may be a reflection of their poor social status10,11. It is ironical that a low vegetable consumption is prevalent in a predominantly vegetarian community. Developing countries are undergoing various types of transitionsepidemiological, socio-economic, demographic and nutritional. Earlier developing countries had a high prevalence of under-nutrition, but this era of transition has also brought a double burden of under-nutrition and over-nutrition in these countries12. Recent data from NFHS 2 identified a significant proportion of Indian women as overweight, coexisting with high rates of malnutrition. However, the survey was confined only to married women in reproductive age group and showed a prevalence rate of 2.2% for women aged 15-49 years using BMI>30.0. The only representative surveys are the ones conducted by the Food and Nutrition Board (i.e. District Nutrition Profiles survey) 13, which have reported prevalence of 0.3% and 0.7% in rural men and women respectively, using a BMI cutoff of >30.0. The present study showed that 1.5% men and 3.1% women have obesity. Our study draws attention to the fact that there exists a pool of women who were overweight in rural areas. Our study showed that physical inactivity was more common among women across all domains. Maximum physical inactivity was during leisure time while most men were physically active during transport. This could be due to the fact that in rural areas bicycles or walking are the still the usual mode of transport.
Blood pressure (Table 5)

The prevalence of selfreported hypertension was 3.5% in men and 6.8% in women, whereas the prevalence of hypertension (defined as BP 140/90 or currently on antihypertensive drugs) was 10.7% in men and 7.9% in women. The mean systolic and diastolic blood pressure among men was 120.4 mmHg and 73.4 mmHg respectively. The same among women were 113.3 mmHg and 69.8 mmHg respectively. There was a sharp increase in prevalence of hypertension among women after 35-44 years age group. The huge male and female difference in younger age groups disappeared post menopause. The prevalence of selfreported diabetes was 0.7% among men and 0.5% among women and showed an increasing trend with age.
Discussion
Our study presents the burden of major NCD risk factors, in a rural area, using WHO STEPS approach. This is among the first sites to use this comprehensive approach to measure the NCD risk factor burden. It was not the purpose of this survey to compare this burden with other risk factor specific surveys done by different people at different places at different times etc. However, some limited comparison from other surveys would be meaningful to get an insight into the burden at national level. Tobacco use in India is high and there are considerable differences in the types and methods by which it is used. A prevalence of 41% of daily smokers among men was similar to that reported by NFHS 2 for Haryana (40.6%)5, but in women our finding of 13% is much higher than that of NFHS 2 (3.6%). The prevalence of ever smokers in NFHS 2 was 42.4% and 3.8% for men and women respectively. A survey of tobacco use in Karnataka and Uttar Pradesh (UP) found the prevalence of ever smoking in Karnataka to be 33.1% among rural men and 0.6% among rural women4. The prevalence of current smoking was 31.2% and 0.6% among rural men and women respectively. In UP the prevalence of ever smoking , was 28.3% among rural men and 2.9% among women. Current smoking showed a prevalence of 28.2% and
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Physical activity measurement at community level is difficult with the existing instruments and therefore these results would need to be interpreted with caution. However it does appear that contrary to general impression, physical inactivity is an emerging cause of concern in rural areas of India. Our findings show a high burden of hypertension among elderly population. Men had a higher prevalence than women in all age categories. Our finding of 10.7% prevalence of hypertension in men and 7.9% in women is lower than that observed in other studies14. In a population-based survey carried out during 1994-1995 in Raipur Rani block in the state of Haryana, 4.5% were found to be hypertensive15. Women had significantly higher prevalence of hypertension than men (5.8% vs 3.0%). This is contrary to our finding of lower prevalence of hypertension in women as compared to men across all age groups.
2.
Ghaffar Abdul, Reddy K. Srinath, Singhi Monica. Burden of non- communicable diseases in South Asia. BMJ. 2004; 328:807-810. WHO. STEPS: A Framework- The WHO STEPwise approach to surveillance of noncommunicable diseases (STEPS).WHO. 2002. Chaudhry K. Prevalence of tobacco use in Karnataka and Uttar Pradesh, India. Report. 2001. International Institute for Population Sciences (IIPS) and ORC Macro, India: National Family Health Survey (NFHS-2), 1998-1999, Mumbai, India: IIPS. 2000. Sinha Dhirendra N, Gupta Prakash C, Pednekar Mangesh S. Tobacco use in a rural area of Bihar, India. Indian Journal of Community Medicine. 2003 Oct.-Dec; 28 (4): 167-70 Mohan D, Sharma HK, Sundaram KR, Neki JS. Pattern of alcohol consumption in rural Punjab men. Indian Journal of Medical Research. 1980; 72:702-711. Sethi BB, Trivedi JK. Drug abuse in a rural population. Indian Journal of Psychiatry. 1979; 21: 211. Singh RB, Bajaj Sarita, Niaz Mohammad A, Rastogi Shanty S, Moshiri M. Prevalence of type 2 diabetes mellitus and risk of hypertension and coronary artery disease in rural and urban population with low rates of obesity. International Journal of Cardiology. 1998;66: 65-72.
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6.
Conclusion
Our study confirms the high burden of NCD risk factors in rural areas and reiterates the need to address these issues comprehensively as a part of NCD prevention and control strategy. STEPwise approach of WHO offers an entry point for low and middle income countries to initiate NCD surveillance, as it allows for the development of a flexible, increasingly comprehensive and complex surveillance system depending on local needs and resources3. Further surveys are recommended based on this approach to ensure data comparability over time and between different sites. It is also important to study trends of various risk factors and Ballabgarh offers a sentinel site for such activity to be conducted in future.
7.
8.
9.
Acknowledgement
This work presents the results of one of the five sites of the multi-site initiative of ICMR and the authors acknowledge the contribution of investigators of the other four sites ( Dr. JC Mahanta, Dr. Thankappan, Dr. V Mohan and Dr. Prashant Joshi) in its planning and design. We also acknowledge the technical guidance provided by WHO - particularly Dr. Cherian Varghese ( WHO India), Dr. Jerzy Leowski WHO/ SEARO) and Dr. Ruth Bonita ( formerly with WHO/ HQ) and ICMR - Dr. Prashant Mathur and Dr. Geeta Menon.
10. United Nations Population Fund. The state of world population 1997: the right to choose: reproductive rights and reproductive health. New York; UNFPA. 1997. 11. Anandalakshamy S. The Girl Child and the Family. Department of Women and Child Development, Ministry of HRD; Government of India, Delhi. 1994. 12. Kapoor SK, Anand K. Nutritional transition: a public health challenge in developing countries. Journal of Epidemiology and Community Health. 2002; 56:804-805. 13. Government of India; Department of Women and Child Development, Ministry of Human Resources. India Nutrition Profile. New Delhi; GOI. 1998.
References
1. WHO. The World Health Report 2002- Reducing risks, promoting healthy life. Geneva. WHO. 2002.
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14. Gupta R, Gupta HP Keswani P Gupta VP Gupta , , , KD. Coronary heart disease and coronary risk factor prevalence in rural Rajasthan. J Assoc Physicians India. 1994;42:24-6.
15. Malhotra P Kumari S, Kumar R, Jain S, Sharma , BK. Prevalence and determinants of hypertension in an un-industrialised rural population of North India. J Hum Hypertens. 1999 Jul; 13(7):467-72.
53rd Annual National Conference of IPHA

Organized by Department of Community Medicine Kempegowda Institute of Medical Sciences (KIMS), Bangalore - 560 070 Theme Dates : : Changing Public Health Scenario in the 21st century 8th January, 2009 (Thursday) 9th -11th January, 2009 (Friday, Saturday& Sunday) Preconference CME Conference
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Only A/c Payee Demand Draft will be accepted, cheques will not be accepted. Demand Draft shall be in the name of 53rd National Conference of IPHA, payable at Bangalore. Please write your name, place, IPHA membership number (for members) and mobile number on the reverse of the bank draft. Category IPHA member 1 Non-member Retired member1 IPHA member PG1& 2 & UG/ Interns 3 PG student (Non-member) 2 Foreign delegates 4 Institutional delegates2 Before 31-10-2008 Rs. 1500 Rs. 2300 Rs. 1000 Rs. 800 Rs. 1000 US$ 100 2000 (18000 for 10 Delegates) Rs 1000 Rs 300 01-11-2008 to15-12-2008 Rs. 1800 Rs. 2600 Rs. 1300 Rs. 1100 Rs. 1400 US$ 125 Rs. 2500 ( 24000 for 10 delegates) Rs 1500 Rs 500 Spot 5 Rs. 2300 Rs. 3100 Rs. 1800 Rs. 1800 Rs. 2000 US$150 Rs. 3000 (29000 for 10 delegates) Rs 2000 Rs 700
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Quote IPHA membership number. Recommendation letter from Head of Department / Head of Institution is compulsory. Recommendation letter from Head of Department and only for those whose papers are accepted for presentation. Or equivalent Indian currency. Conference kit will be provided subject to availability. Conference kit will not be provided. : Dr. B G Parasuramalu, Professor & Head Organizing Secretary - 53rd Annual National Conference of IPHA, Department of Community Medicine, Kempegowda Institute of Medical Sciences (KIMS), BSK 2nd Stage, Bangalore - 560070. (M) 0-99860-03467 Email: iphacon09@kimsbangalore.edu.in Websites: www.iphaonline.org ; www.kimscommunitymedicine.org
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Original Article Epidemiology of Disability in a Rural Community of Karnataka

*K. S. Ganesh1, A. Das 2, J. S. Shashi 3 Abstract
Objectives: To determine the prevalence and pattern of disability in all age groups in a rural community of Karnataka. Methods: A community-based cross-sectional study was conducted during January-December 2004 among 1000 study subjects of all age groups selected randomly from four villages under rural field practice area of a teaching institution. Subjects were interviewed and examined using a predesigned schedule. Percentage prevalence, chi square test and multiple logistic regression analysis were used for statistical analysis. Results: The prevalence of disability was found to be 6.3%. Both physical and mental disabilities are of great concrn in this area. 80% of the disabled had multiple disabilities. Knowledge and occupation plays a major role as determinants of disability. Chronic medical conditions are also more common among disabled. Key words: Disability, Epidemiology, Cross-sectional, Determinants.
Introduction
Disability is one of the major public health problems of the developing countries, though the data collected do not reflect the full extent of disability prevalence1, 2, 3. This limitation results from the conceptual framework adopted, the scope and coverage of surveys undertaken, the definitions, classifications and the methodology used for the collection of data on disability. In India, the implementation of the strategy for people with disabilities as stated in the disability act 1995 is being vigorously perused by the Ministry of Social Welfare and all other concerned ministries4. Therefore it is appropriate time to take stock of the situation of the disabled population in the country specially in rural sector where around 80% of the disabled persons reside. Besides, prevalence studies will be useful tool for developing community based rehabilitation programmes for disabled. In view of the above context, the present study was conducted to determine the prevalence and pattern of disability in all age groups in a rural community of Karnataka.
Materials and Methods

This was a community-based cross sectional study carried out over a period of 1 year from January to December 2004. The study was conducted at the rural field practice area of a teaching institution, which covers a population of 45 000 spread over 11 villages of a Taluk in Karnataka State of India. Four villages namely Kotemattu, Yenegudda, Kidiyoor and Kadekar were selected randomly for the present study. The population covered by these four villages was 16,298. Sample size was estimated for infinite population by using the formula 4pq/d2, where prevalence was taken as 10%1. Required precision of the estimate (d) was set at 20%. Using the above formula, the sample size was estimated to be 900. After adding non-response rate of 10%, an additional 100 subjects were included. Thus 1000 subjects in all the age group were selected for this study. Probability proportional to sampling technique was used to select the study sample from each village. In each of the four centers, all family folders were arranged in a serial order. Then, the first folder was
1Assistant Professor, Community Medicine, Kasturba Medical College, Mangalore, Karnataka; 2Professor, Community Medicine, KS Hegde Medical College, Mangalore, Karnataka; 3Assistant Professor, Community Medicine, KMC, Manipal, Karnataka. *Corresponding author: sssgan@yahoo.com.
Ganesh KS et al: Disability in a Rural Area of Karnataka
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selected randomly from the random number table and the names of the eligible candidates from that household noted down. Similarly, the next folder was randomly picked up and the names of all the eligible candidates of that household listed. This procedure was repeated till the desired number of eligible persons was achieved from each centre. Although households were taken as cluster, the design effect would be minimal considering the disability characteristics that are different for members of the household. So, we analysed the data taking individual as sampling unit. The study was conducted by making house-to-house visits, interviewing and examining all the individuals in the family selected with pre-tested questionnaire. Informed verbal consent was obtained from all respondents. If a designated person could not be contacted or not cooperative during three separate visits, then the subject was considered as nonrespondent. The demographic and other variables recorded were age, sex, socio-economic status, marital status, family type, literacy and occupation. Considering the fact that the age, education and occupation are important determinants of disability, we analysed the data after sub categorization of each of these variables. Socioeconomic status was assessed by modified Uday Parik scale. Disability was assessed as per the criteria laid down by WHO5. Mental disability was assessed by Indian Disability Evaluation and Assessment Scale (IDEAS) developed by the Rehabilitation Committee of Indian Psychiatric Society6. Disability below the age of 5 years was assessed based on the instrument designed on the lines of questionnaire taken from Action Aid India7. Chronic medical conditions were assessed based on the previous diagnosis. The data collected was tabulated and analyzed by using the Statistical Package for Social Sciences (SPSS) version 11.5 for windows. Chi square test was carried out to test the differences between proportions. To determine the independent effect of various factors on disability, Multiple Logistic Regression was performed.
Table 1: Prevalence of disability according to socio-demographic variables (n=954)

Variables Gender Male Female Age group (years) <5 5-14 15-59 60 Total Prevalence 2, p Subjects No (%) 472 482 72 122 635 125 24 (5.1) 36 (7.5) 0 1( 0.8) 30 (4.7) 29 (21.5) 34 (7.5) 26 (5.3) 0 45 (8.5) 15 (3.5) 16 (7.7) 44 (5.9) 2.3 0.1
74.2 0.001*
Socio-economic status Low 456 Middle 486 High 12 Marital Status Ever married Never married Family Type Nuclear Joint/extended 527 427 208 746
1.8 0.2 10.1 0.001* 0.9 0.3
Literacy (years of schooling) Illiterate 84 1-4 118 5-10 522 > 10 125 Occupation Unemployed Housewife Unskilled Skilled Students Professional 104 231 311 40 161 21
19 (22.6) 16 (13.6) 23(4.4) 52.4 1(0.8) < 0.001* 30 (28.8) 17 (7.4) 10 (3.2) 1 (2.5) 1 (0.6) 74.8 0 < .0001*
Results
Of the 1000 subjects enrolled into the study, 954 subjects were available for the final analysis (response rate 95%). Among them 472 (49.5%) subjects were males, 635 (67.5%) belonged to the age group of 15 59 years,
* P value less than 0.05 is considered as significant. 105 (10.6%) subjects are below 7 years. Total number of disabled among 7 years and above was 59. 86 (8.7%) subjects are below 6 years. Total number of disabled among 6 years and above was 59.
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870 (92%) were literate, 746 (78.2%) belonged to joint/ extended family. About half of the study population belonged to the middle socio-economic status (51%), while only 1.3% (12) belonged to high socio-economic status. 55.2% of the study subjects were ever married. By occupation, 32.6% were unskilled workers/farmers/ petty business people; only 4.2% were skilled workers and 2.2% professionals. Others were housewife (24.2%), students (16.9%) and unemployed (10.9%). The overall prevalence of disability was found to be 6.3% (60/954). The most common type of disability among the disabled was mental disability (22/60) followed by loco motor (17/60), hearing (13/60), speech (12/60) and visual (10/60) disability. 80% (48) of the disabled had single disability and the rest 20% had multiple disabilities. The prevalence of disability among the elderly group (>60 years) was very high (21.5%). As the age advances, the prevalence increased significantly (2=74.26, p=0.001).The present study showed that 40% (24) of the disabled were males and 60% (36) were females. The prevalence of disability was marginally higher among low socioeconomic and nuclear family group. Among ever married group, the prevalence was two and half times more than never married group and the difference was found to be significant (2=10.11, p=0.001). Nearly one quarter of illiterates (22.6%) were disabled and those with education level of above 10th standard had very low prevalence. As literacy level increased, the prevalence declined significantly (2=52.4, p= <0.001). Also, the prevalence of disability among the unemployed was very high (28.8%). The difference in prevalence of disability between different occupation groups was found to be statistically significant (2=78.846, p= <0.0001). The present study revealed that half of the disabled were unemployed, 28.3% were housewife and 16.7% were unskilled workers, farmers and people with petty business (Table 1). Majority of the disabled had joint pain and backache (35, 58.3%). Hypertension was present in 30% (18) followed by asthma/COPD in 15% (9), diabetes mellitus and fits in 10% (6) and heart problems in 5% (3) of the disabled. Multiple logistic regression analysis revealed that illiteracy, primary schooling and unemployment had independent significant association with the disability (Table 2).
Table 2: Correlates of disability: Multiple Logistic Regression analysis

Variables Gender Male Female Age group (years) < 45 45-59 60 Marital status Never married Ever married Odds ratio adjusted 1.9 0.8 2.3 1.5 95% CI P value
0.8-4.4 0.3-2.7 0.8-6.1 0.5-4.7 0.8-47.3 3.0-221.1 3.3-269.2 1.8-138.2 0.1-8.9 0.1-10.7 0.02-6.4
0.1 0.8 0.1 0.5 0.1 0.003* 0.002* 0.012* 0.9 0.8 0.5
Literacy (Years of schooling) > 10 5-10 5.9 1-4 25.7 Illiterate 29.9 Occupation Professional & Skilled Unemployed Housewife Unskilled Students 15.9 0.9 1.3 0.3
* P value < 0.05 is considered as significant; 105 (10.6) subjects are below 7 years; 86 (8.7%) subjects are below 6 years
Discussion
Well documented studies to determine the prevalence and its epidemiological features are few. Some studies had taken only the physical disability and some others mental disability. Also, the data collected by health workers could not detect mild degrees of disability because of their limited knowledge and lack of training. As our study illustrates, both physical and mental disabilities are of great concern in this area. Also, knowledge and occupation plays a major role as determinants of disability. Chronic medical
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conditions are also more common among disabled. World Health Organization estimates that 10% of the worlds population has some form of disability1. In contrast, recent National Sample Survey Organization report2 and Census data 20013 revealed prevalence as 2%.The present study showed a higher prevalence of disability in comparison to prevalence in general. This is because of detection of even mild degrees of disability in our study. As per population data provided by United Nations Population Fund (UNFPA) Geneva 1995, the prevalence in India was 4.6%4. Higher prevalence of mental disability and the proportion of people with multiple disabilities were observed because of detection of even mild mental disability in our study in contrast to other studies2,3,8,9. The prevalence was more common among geriatric age group. Our study findings are consistent with the results of other studies2, 3,10. Marginally higher prevalence of disability among females in contrast to other studies might be due to favorable sex ratio in this area 3, 10 . The present study showed that 75% of the disabled were married and 25% of them were unmarried in contradiction to other studies 8,3. In India, about 92% of the disabled lived with their spouse and/ or other members in the family. But in the present study, 26.7% of the disabled belonged to nuclear family. Others (73.3%) belonged to joint/extended family. In view of the above, the disabled in this part of the country are well placed as far as the family life is concerned. Disabled in this area are better educated when compared to the disabled people of other areas3,8. Various studies have shown that the prevalence of disabilities is found to be significantly high among the individuals suffering from chronic medical conditions11,12. It was observed by univariate analysis that the age group, marital status, literacy, and occupation had significant association with the disability. Age, education and occupation all might act as confounders in association of exposure variables of the study with disability. The adjusted Odds Ratio (OR) for illiteracy and primary schooling (1-4) revealed that the chance of disability was 30 and 25.7 times respectively as compared to those with education of above 10 th standard. Similarly adjusted OR for unemployment was
15.91 as compared to professionals and skilled. Thus Multiple Logistic Regression analysis after accounting for confounding factors showed that illiteracy; primary schooling (1-4) and unemployment were considered as significant factors in association with the disability. Considering the fact that the population in this study had a very high literacy rate and favorable sex ratio, it is unlikely that the results are generalisable to similar settings. We could not interview the nonrespondents because of their non-cooperation and nonavailability during our field visits. Since the proportion of non-respondents was very small in our study population, we expect only a minimal effect on our prevalence estimate. There may have been recall bias. Pure tone audiometry was not used while assessing hearing disability due to feasibility constraints. In view of the above findings it is concluded that the disabled in this area need community assistance. There is an ample scope for community based rehabilitation of the disabled also.
References
1. World Health Organization .Training in the community for people with disabilities. WHO: Geneva; 1989. National Sample Survey Organization. A report on disabled persons. Department of Statistics, Government of India: New Delhi; 2003. Census of India 2001. Data on disability. Office of the Registrar general India. (Serial online) 9 August 2004. Available from: URL: www.censusindia.net/disability/disability_ mapgallery.html. Sharma AK, Praveen V. Community Based Rehabilitation in Primary Health Care System. Indian Journal of Community Medicine 2002; 117: 139-142. World Health Organization. International Classification of Functioning, Disability and Health: A manual of classification relating to the consequences of disease. WHO: Geneva; 2001. Govt. of India. Guidelines for evaluation and assessment of mental illness and procedure for certification. Ministry of Social Justice and empowerment, Government of India. New Delhi, 2002.
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3.
4.
5.
6.
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7.
Thomas M, Pruthvish S. Identification and needs assessment of beneficiaries in community based rehabilitation initiatives. Action Aid India, Bangalore, 1993. Noveymony MA, Raj SS. A study in the family and socio-economic conditions of the persons with disabilities in Vallioor Panchayat Union. Asian Pacific Disability Rehabilitation Journal 2003; 5(1): 14-20. Kishore MT. Psychiatric diagnosis in persons with intellectual disability in India. Journal of Intellectual Disability Research Jan.2004; 48(1): 19-24.
10. Alan MJ, Branch LG. The Framingham Disability Study. American Journal of Public Health 1981; 71(11): 1211-1216. 11. Joshi K, Kumar R, Avasti A. Morbidity profile and its relationship with disability and psychological distress among elderly people in northern states. Int. Journal of epidemiology Dec. 2003; 32(6): 978-987. 12. Dey AB, Shubha S, Kalpana MN, Jhingan HP . Evaluation of the health and functional status of older Indians as a preclude to the development of a health programme. The National Medical Journal of India 2001; 14(3): 135-138.
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We are happy to announce that the IPHA BHABAN is now ready for use. Memebers are welcome to stay at the Bhaban during their official and unofficial visits to Kolkata. The location is very close to the airport and to the Government and Non government offices at Salt Lake. It is also away from the traffic snarls and pollution. We request all members to solicit utilization of the Bhaban and spread the message to all concerned. Type of rooms AC Non AC Dormitory For members Rs. 200 per bed Rs. 150 per bed Rs. 100 per bed For non members Rs. 400 per bed Rs. 300 per bed Rs. 150 per bed Members staying for IPHA Work No charge ,, ,,
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Original Article Elimination of Iodine Deficiency Disorders Current Status in Purba Medinipur District of West Bengal, India
A. B. Biswas1, I. Chakraborty2, *D. K. Das3, A. Chakraborty4, D. Ray5, K. Mitra6 Abstract
Background and Objectives: Towards sustainable elimination of iodine deficiency disorders (IDD), the existing programme needs to be monitored through recommended methods and indicators. Thus, we conducted the study to assess the current status of IDD in Purba Medinipur district, West Bengal. Methods: It was a community based cross-sectional study; undertaken from October 2006 - April 2007. 2400 school children, aged 8-10 years were selected by 30 cluster sampling technique. Indicators recommended by the WHO/UNICEF/ICCIDD were used. Subjects were clinically examined by standard palpation technique for goitre, urinary iodine excretion was estimated by wet digestion method and salt samples were tested by spot iodine testing kit. Results: The total goitre rate (TGR) was 19.7% (95% Cl = 18.1 21.3 %) with grade I and grade II (visible goitre) being 16.7% and 3% respectively. Goitre prevalence did not differ by age but significant difference was observed in respect of sex. Median urinary iodine excretion level was 11.5 mcg/dL and none had value less than 5 mcg/dL. Only 50.4% of the salt samples tested were adequately iodised ( 15 ppm). Conclusion: The district is in a phase of transition from iodine deficiency to iodine sufficiency as evident from the high goitre prevalence (19.7%) and median urinary iodine excretion (11.5mcg/dL) within optimum limit. But, salt iodisation level far below the recommended goal highlights the need for intensified efforts towards successful transition. Key Words: Iodine deficiency, Goitre, IDD, Urinary iodine, Iodised salt
Introduction:
Iodine deficiency disorders (IDD), spectrum of health consequences due to iodine deficiency are still major public health problems in many countries. One of the most common preventable causes of mental retardation in the world today is iodine deficiency1, 2. An estimated 1571 million people worldwide lives in iodine-deficient environment, and is at risk of IDD3. In India, about 167 million people are estimated to be at risk for IDD, of which 54 million have goitre and over 8 million have neurological deficits 4. Earlier 275 districts in the country have been surveyed for IDD and 235 districts have been found to be endemic5. For prevention and control of IDD iodisation of salt is widely recognised as the most effective and
1Professor, 3Associate
sustainable long-term public health measure6 and is being implemented in many countries. In India, compulsory salt iodisation was initiated in 1998 but it was revoked in 2000. However, the government of India from 15th August 2005 has once again imposed the ban on sale and production of non-iodised salt. Besides this, since 1992, IDD control programme has been in operation in all the states of India, including West Bengal with the aim of eliminating IDD as a public health problem. However, International Council for the Control of Iodine Deficiency Disorders (ICCIDD), WHO and UNICEF recommend the progress of such programme in any country needs to be monitored using quantifiable indicators 7. The indicators include: 1. Proportion of households consuming effectively iodised salt (>90%);
Community Medicine, B. S. Medical College, Bankura, 2Professor, Biochemistry, Medical College, Kolkata; Professor, 4Demonstrator, Community Medicine, R. G. Kar Medical College, Kolkata; 5Assistant Professor, Biochemistry, Medical College, Kolkata; 6 Health and HIV specialist, UNICEF, Kolkata, West Bengal. *Corresponding Author: dilip_shampa@hotmail.com, drdilipkumardas@gmail.com
Biswas AB et al: IDD in Purba Medinipur, West Bengal
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2. Urinary iodine: proportion below 100 mcg/lt (<50%) and proportion below 50 mcg/lt (<20%) and 3. Thyroid size: proportion of school children 6-12 years age with enlarged thyroid, by palpation or ultrasound (<5%). Using these indicators and prescribed methodologies by WHO, UNICEF and ICCIDD; during the recent years, studies had been done in six districts (Malda, Birbhum, Dakshin Dinajpur, North 24 Parganas, Purulia and Howrah) of the state 8-13. These studies have reported mild to moderate goitre prevalence in the surveyed districts and variable proportion of adequately iodised salts. In this context, it was decided to have more objective and scientifically valid data in other districts of the state. We thus conducted the present study to assess the status of IDD in Purba Medinipur district of West Bengal with the following objectives: to find out the prevalence of goitre among school children aged 8 to10 years in Purba Medinipur district, to determine the status of urinary iodine excretion (UIE) levels of school children aged 8 to 10 years in the district and to assess iodine content of salts at the household level in the district.
Multistage cluster sampling methodology was followed for selecting the study population. We enlisted all the rural & urban population units in the district with their respective population. The 30 clusters i.e. population units (villages/urban wards) to be surveyed were selected using probability proportional to size (PPS) sampling method. In each identified cluster all the primary schools were enlisted and simple random sampling was used to select one school for detailed survey. From the sampling frame of all children between 8-10 years of the selected school, 80 children were selected following simple random sampling technique for inclusion in the study. If the sample could not be covered in the school, adjoining school was included to complete the sample of the cluster. Thus a total of 2400 school children were included in the study. Prior intimation was given to the identified school authority one week before the survey to ensure attendance of students. The schoolteachers and children were also briefed about the activities to be undertaken during the survey. A pre-designed pretested schedule was used for data collection. Investigators comprised of faculty members from the Department of Community Medicine, R. G. Kar Medical College, Kolkata and Depar tment of Biochemistry, Medical College, Kolkata, West Bengal. An initial training was imparted to minimise inter observer variation during the survey. Assessment of goitre: The size of the thyroid was determined clinically by standard palpation method and grading of goitre was done according to the criteria recommended by the joint WHO/UNICEF/ICCIDD (Grade 0: No palpable or visible goitre. Grade I: A mass in the neck that is consistent with an enlarged thyroid that is palpable but not visible when the neck is in normal position. It moves upwards in the neck as the subject swallows. Grade II: A swelling in the neck that is visible when the neck is in a normal position and is consistent with an enlarged thyroid when the neck is palpated) 7, 14. Goitre grades I and II together considered as the Total Goitre Rate (TGR). Estimation of urinary iodine excretion level: The recommended sample size for collection of biological specimens, such as urine, is 300 (i.e. 10 children x 30 clusters) 14. Considering 20% dropout/wastage, final sample size of urine samples was decided to be 360
Materials and Methods

It was a cross-sectional, school-based study conducted during October 2006 to April 2007 in Purba Medinipur district, West Bengal. The study population was school children of 8-10 years of age. We included this age group because of their combined high vulnerability to disease, easy accessibility & representative ness of their age group in the community. This age group are recommended for assessment of IDD7. No previous data was available on prevalence of goitre in Purba Medinipur district. Thus, the sample size of children to be surveyed was based on the assumed goitre prevalence rate of 50%, 95% confidence interval (CI), a design effect of 3 and a relative precision of 10%. Using these parameters a sample size of 1200 was obtained. But as our intention was to assess the degree of severity also, we decided to double the calculated sample size; thus the final sample size was 2400 children in the age group of 8 10 years i.e. 80 per cluster in a 30 cluster sampling technique7.
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(i.e. 12 children x 30 clusters). In the present study, systematic random selection was used to select 12 children from each school for urine collection, among those who were clinically examined. Thus, 360 casual on the spot urine samples (0.5 to 1.0 ml) were collected in wide-mouthed screw capped plastic bottles (one drop of toluene was added to inhibit bacterial growth and to minimise odour) and stored in a refrigerator at 4oC until analysis. Six urine samples were wasted and finally 354 samples were available for analysis. The Urinary Iodine Excretion (UIE) level was measured by wet digestion method15. The result was expressed as mcg iodine/dL urine. Assessment of iodine content of salt: In each cluster, all the study children were asked to bring about 20 gm of salt which were routinely being consumed in their respective families. In the present study, Iodine content of 2400 salt samples was estimated using spot iodine testing kit. The data entry and analysis was done at R.G.Kar Medical College, Kolkata. We entered the data in Microsoft Excel and analysed accordingly to find out the outcome variables.
Prevalence of goitre: Table 1 depicts the prevalence of goitre in Purba Medinipur district. Overall total goitre prevalence rate (TGR) was 19.7% (95% Cl =18.1 21.3 %), of which16.7% and 3.0% was grade I and grade II (visible goitre) respectively. Goitre prevalence among girls (22.4%) and boys (16.7%) was significantly different (2 = 12.55, d.f. = 1, p=0.0003). Overall age specific goitre prevalence among 8, 9 and 10 years old children were17.5%, 20.3% and 21.4% respectively; the difference was not statistically significant (2 =3.99, d.f. = 2, p=0.136). Urinary iodine excretion level: We analysed 354 urine samples for urinary iodine excretion (UIE) levels. Urinary iodine excretion levels for 83 (23.4%) of the children were in the mild range (5 9.9 mcg/ dL) of iodine deficiency. No children had UIE value in the moderate or severe range of iodine deficiency. 76.6% children had urinary iodine above the recommended level of 10 mcg/dL (Table 2). The median UIE level was 11.5mcg/dL (range = 7.5 18 mcg/dL). Iodine content of salts: In the present study, 2400 salt samples were tested with spot iodine testing kit. It was revealed that salt with nil iodine content was consumed by 17.7% of the beneficiaries and another 32% consumed salt with iodine content of <15 ppm. Half of the households (50.4%) had adequate iodine content of 15 ppm (Table 3).
Results:
Characteristics of the study population: Of 2400 study children, 47.5% (1139) were males and 52.5% (1261) females. About 33.5% (805), 32.7% (785), 33.8% (810) of them belonged to eight, nine and ten years of age respectively. Most of the children were from rural area (93.3%, 2240/2400) and Hindu by religion (79%, 1896/2400).
Table 1: Goitre prevalence by age and sex in Purba Medinipur district, West Bengal (n=2400)
Age (Years) Male(n=1139) Goitre Grade I II TGR No. (%) 49 57 59 165 5 4 16 25 54 (13.2) 61(17.2) 75 (20.1) 190 (16.7)* Female(n=1261) Goitre Grade I II TGR No. (%) 77 84 74 235 10 87 (22.0) 14 98 (22.8) 24 98 (22.5) 48 283 (22.4)* Combined(n=2400) Goitre Grade I II TGR No. (%) 126 141 133 400 15 141(17.5)** 18 159(20.3)** 40 173(21.4)** 73 473(19.7)
8 (n=805) 9 (n=785) 10 (n=810) All (n=2400)
* 2 = 12.55, d.f. = 1, p=0.0003
** 2 = 3.99, d.f. = 2, p= 0.136
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Table 2: Urinary Iodine Excretion levels in the study population in Purba Medinipur district, West Bengal (n = 354)
Urinary Iodine Excretion levels (mcg/dL) < 5.0 5.0 9.9 10 Number 0 83 271 Percentage 0 23.4 76.6
Table 3: Iodine content of salts at household level in Purba Medinipur district, West Bengal (n = 2400)
Iodine content of salts (ppm) Nil < 15 15 Number Percentage 424 767 1209 17.7 31.9 50.4
recommended level of 10 mcg/dL. Overall, 76.6% of the children had UIE levels in the ranges of optimal iodine nutrition ( 10 mcg/dL), and none had concentrations <5 mcg/dL. These results indicate that current iodine deficiency does not exist in Purba Medinipur district. Similar median values of urinary iodine in the desirable range of 10 mcg/dL were also observed by most of the studies in other districts of West Bengal 8-11, 13 and also other states 17- 22. However, median urinary iodine values less than the recommended level was reported from three districts in other states (Lakhimpur Kheri and Mainpuri in Uttar Pradesh and Gaya in Bihar) 16 and also from Purulia district of West Bengal 12. Analysis of the urinary iodine excretion in the present study indicated inadequate intake of iodine by a substantial proportion of children, which was not at all unexpected as analysis of salt samples also revealed around 50% of the children consumed noniodised/inadequately iodised salt. We found, only 50.4% of the children were consuming adequately iodised salt ( 15 ppm), which is far below the recommended goal of > 90% coverage 7. Compared to this, less proportion was found in Birbhum (37.2%) and Purulia (33.4%) district 9, 12, but much higher proportion was reported from other districts viz. 67.4%, 70%, 80% and 85% in Dakshin Dinajpur, North 24 Parganas, Howrah and Malda respectively 10, 11, 13, 8. For monitoring progress towards elimination of IDD, the recommended parameters are to be interpreted cautiously. There may be discrepancies between urinary iodine concentrations and prevalence of goitre, because urinary iodine excretion level reflects the current iodine status, while the prevalence of goitre indicates the long-term iodine status in a population23. Findings of high TGR and optimal urinary iodine excretion have been reported in most of the earlier studies in India 8-11, 13, 17 - 22 reflecting a transition from iodine deficient to iodine sufficient state. Observation in Purba Medinipur corroborates with most of the other districts in the state. However, consumption of iodine from sources other than iodised salts needs also to be studied.
Discussion:
In the present study, an overall goitre prevalence rate of 19.7% was found, signifying that the district Purba Medinipur is mildly endemic for iodine deficiency. However, recent studies in six other districts of the state viz. Malda, Birbhum, Dakshin Dinajpur, North 24 Parganas, Purulia and Howrah using standard methodology, as has been followed in the present one, revealed prevalence of 11.3%, 12.6%, 18.6%, 20.1%, 25.9% and 13.7% of goitre respectively8-13. But less than 5% TGR was found in 9 out of 15 districts studied in 11 states by an Indian Council of Medical Research (ICMR) study 16. Urinary iodine concentrations are the most reliable indicator of IDD. The WHO/UNICEF/ICCIDD have also recommended that no iodine deficiency be indicated in a population when median urinary excretion level is 10 mcg/dL or more i.e. more than 50% of the urine samples have UIE level of 10 mcg/ dL and not more than 20% of the samples have UIE level of less than 5 mcg/dL7. In Purba Medinipur district, we found a desirable value for both these two indicators. Median UIE level (11.5 mcg/dL) was more than the minimum
Conclusion:
High TGR of 19.7% indicates that the Purba Medinipur district is mildly endemic for IDD. But, median urinary iodine (11.5 mcg/dL) reflects no
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existence of current iodine deficiency. Interpreting these two indicators together, it may be concluded that the district Purba Medinipur is in a state of transition from iodine deficiency to iodine sufficiency. However, adequately iodised salt consumption at the household level (50.4%) is far below the recommended goal of >90%. Towards sustainable elimination of IDD, awareness generation for both sale and consumption of iodised salt, regular monitoring at household and retailer level through involvement of different sectors need to be strengthened.
5. 6.
WHO. Eliminations of iodine deficiency disorders in South East Asia, SEA/NUT/138, 1997, 1-8. Manner VMG. Control of iodine deficiency disorders by iodination of salt: strategy for developing countries. In: Hetzel BS, Dunn JT, Stanbury JB, eds.The prevention and control of iodine deficiency disorders. Amsterdam, Elsevier, 1987: 111- 125. Joint WHO/UNICEF/ICCIDD Consultation: Indicators for assessing iodine deficiency disorders and their control programmes, Geneva, WHO, 1992. Biswas AB, Chakraborty I, Das DK, Biswas S, Nandy S. and Mitra J. Iodine deficiency disorders among school children of Malda, West Bengal, India. J Health Popul Nutr 2002 Jun; 20 (2): 180183. Biswas AB, Chakraborty I, Das DK, Roy RN, Mukhopadhaya S and Chatterjee S. Iodine deficiency disorders among school children of Birbhum, West Bengal. Current Science 2004; 87 (1): 78 - 80.
7.
Acknowledgements
We acknowledge the support and cooperation of the district authorities, Department of Health and Family Welfare as well as Department of Primary Education, Purba Medinipur district, West Bengal. The school authorities and children of the surveyed schools deserve special mention for their help and much needed cooperation during actual conduct of the study. We express our sincere gratitude to the Department of Health and Family Welfare, Government of West Bengal and UNICEF, Kolkata, West Bengal for their financial and other support to carry out the study smoothly. 8.
9.
References :
1. Hetzel BS. S.O.S. for a billion the nature and magnitude of the iodine deficiency disorders. In: Hetzel BS, Pandav CS, Eds. S.O.S. for a billion. The conquest of iodine deficiency disorders. Delhi, Oxford University Press; 1996, pp 3 -29. Kapil U. Goitre in India and its prevalence. Journal of Medical Sciences and Family Planning, 1998, 46 50. United Nations Childrens Fund. The state of the worlds children: focus on nutrition. New York, Oxford University Press; 1998, pp 15 20. Ramji S. Iodine deficiency disorders epidemiology, clinical profile and diagnosis. In: Nutrition in children - developing country concern; Editors: H. P. S. Sachdev, Panna Choudhury, Department of Paediatrics, Moulana Azad Medical College, New Delhi, 1995, 245 254.
10. Das DK, Chakraborty I, Biswas AB, Sarkar GN, Shrivastava P and Sen S. Iodine deficiency , disorders among school children of Dakshin Dinajpur district, West Bengal. Indian Journal of Public Health, April-June 2005; 49(2): 68-72. 11. Sen TK, Biswas AB, Chakrabarty I, Das DK, Ramakrishnan R, Manickam P, Hutin Y. Persistence of Iodine Deficiency in Gangetic Flood-Prone Area, West Bengal, India. Asia Pacific Journal of Clinical Nutrition 2006; 15(4): 528 -532 12. Biswas AB, Chakraborty I, Das DK, Roy RN, Ray S and Kunti SK. Assessment of iodine deficiency disorders in Purulia district, West Bengal, India. Journal of Tropical Paediatrics 2006; 52 (4): 288 - 292. 13. Das DK, Chakraborty I, Biswas AB, Saha I, Majumder P and Saha S. Assessment of iodine deficiency disorders in Howrah district, West Bengal, India. (Personal Communication). 14. Kumar S. Indicators to monitor progress of National Iodine Deficiency Disorders Control
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Programme (NIDDCP) and some observation on iodised salt in West Bengal. Indian Journal of Public Health 1995; 39 (4): 141-147. 15. Dunn JT, Crutchfield HE, Gutekunst R and Dunn D. Methods for measuring iodine in urine. A joint publication of WHO/UNICEF/ICCIDD, 1993, 1823. 16. Toteja GS, Singh P Dhilon BS and Saxena BN. , Micronutrient deficiency disorders in 16 districts of India: part 1 report of an ICMR task force study district nutrition project. ICMR; New Delhi, 2001, pp 1- 22. 17. Kapil U. Editorial: Current status of Iodine Deficiency Disorders Control Programme, Indian Paediatrics 1998; 35: 831-836. 18. Sohal KS, Sharma TD, Kapil U, Tandon M. Assessment of iodine deficiency in district Hamirpur, Himachal Pradesh. Indian Paediatr1998; 35:1008-1011.
19. Bhardwaj AK, Kapil U. Assessment of iodine deficiency in district Bikaner, Rajasthan. Indian J Matern Child Hlth 1997; 8:18-20. 20. Sohal KS, Sharma TD, Kapil U, Tandon M. Current status of prevalence of goitre and iodine content of salt consumed in district Solan, Himachal Pradesh. Indian Paediatr1999; 36:1253-1256. 21. Kapil U, Sohal KS, Sharma TD, Tandon M and Pathak P. Assessment of iodine deficiency disorders using the 30 cluster approach in district Kangra, Himachal Pradesh. Journal of Tropical Pediatrics, October 2000: 264 266. 22. Kapil U, Sethi V, Goindi G, Pathak F, Singh P . Elimination of iodine deficiency disorders in Delhi. Ind. J Paediatr 2004; 71 (3): 211 212. 23. Sebotsa MLD, Dannhauser A, Jooste PL, and Joubert G. Prevalence of goitre and urinary iodine status of primary school children in Lesotho. Bulletin of the World Health Organiztion 2003; 81 (1): 28 34.
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Notice for 53rd Annual Central Council Meeting

The 53rd Annual Central Council Meeting of the IPHA will be held on 8th January, 2009 at 6 PM at Meeting Hall of Kempegowda Institute of Medical Sciences (New Campus), Banashankari 2nd stage, Bangalore -560 070. (Please reconfirm the exact venue and time from the organizers of the conference) Sd/Dr. Madhumita Dobe Secretary General, IPHA
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Special Article Integrated Diseases Surveillance Project (IDSP) Through a Consultants Lens
*K. Suresh1, Summary
India has long experienced one of the highest burdens of infectious diseases in the world, fueled by factors including a large population, high poverty levels, poor sanitation, and problems with access to health care and preventive services. It has traditionally been difficult to monitor disease burden and trends in India, even more difficult to detect, diagnose, and control outbreaks until they had become quite large. In an effort to improve the surveillance and response infrastructure in the country, in November 2004 the Integrated Disease Surveillance Project (IDSP) was initiated with funding from the World Bank. Given the surveillance challenges in India, the project seeks to accomplish its goals through, having a small list of priority conditions, many of which are syndrome-based at community and sub center level and easily recognizable at the out patients and inpatients care of facilities at lowest levels of the health care system, a simplified battery of laboratory tests and rapid test kits, and reporting of largely aggregate data rather than individual case reporting. The project also includes activities that are relatively high technology, such as computerization, electronic data transmission, and video conferencing links for communication and training. The project is planned to be implemented all over the country in a phased manner with a stress on 14 focus states for intensive follow-up to demonstrate successful implementation of IDSP. The National Institute of Communicable Diseases chosen to provide national leadership may have to immediately address five issues. First, promote surveillance through major hospitals (both in public and private sector) and active surveillance through health system staff and community, second, build capacity for data collation, analysis, interpretation to recognize warning signal of outbreak, and institute public health action, third, develop a system which allows availability of quality test kits at district and state laboratories and /or culture facilities at identified laboratories and a national training program to build capacities for performing testing and obtaining high quality results, fourth, there must be a process established by which an appropriate quality assurance program can be implemented and fifth, encourage use of IT infrastructure for data transmission, analysis, routine communication (E-mail etc) and videoconferencing for troubleshooting, consultations and epidemiological investigations. These five activities must be addressed at the national level and cannot be left up to individual states/districts. Keywords: Surveillance, syndrome case, probable case, laboratory confirmed case, epidemic, public health action, rapid test kits.
Introduction
Three years of implementation of IDSP has taught many lessons. In the course of implementation, a few
1Public
practical modifications have been affected. This article looks at the implementation challenges of each of the activities originally planned under IDSP and the changes that occurred over this period as observed by
Health (Child) Consultant, New Delhi. *Correspondence: ksuresh@airtelmail.in, ksuresh.20@gmail.com
Suresh K: Integrated Disease Suveillance Project
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the consultant in the course of his association with the project since March 2006. Administrative Structure of IDSP: In January 2007 the project was restructured to provide nearly half of the total credit (SDR 21.53 million) for urgent financing requested by Government of India (GOI) for Avian Influenza pandemic prevention and control. The realization of operational ease has led to relocating the administrative unit located in the ministry of health and family welfare (under a Joint secretary) to National Institute of Communicable Diseases (NICD) under the leader ship of its Director in 2006-07. This arrangement facilitated utilizing the services of about half dozen officers (epidemiologists, microbiologists and statistical officers) to support dedicated National Program Officer in ensuring enhanced technical support, improved states oversight and trouble shooting. Under the project surveillance units have been established at national, state and district levels in 23 states covered under first two phases and the process is underway in phase III states. The operational manuals have been prepared and to a large extent the planned training of the health staff has been completed in these 23 states. An effort to enhance coordination with national disease control programs has begun with rationalization of fever reporting forms with the National Vector Borne Diseases Control program. The project depended on state for technical human resources {complimenting only information technology (IT) and support staff on contractual basis}. Lack of ownership and quick turn over of the state staff was a challenge and hindering the pace of the progress of the project during first three years. Making IDSP as part of National Rural Health Mission has the biggest gain of 2007-08, leading to creation of 766 dedicated professional positions (Epidemiologist, Microbiologists, and Entomologists) under NRHM at central, state and district level. While it created a good opportunity for the professionals (especially Public Health /Epidemilogists), recruitment of qualified people and their orientation for the project activities is going to be challenge for the coming years. Project Implementation: Project implementation has been lagging by about a year. Third
phase states started activities only in later part of 200708. Training of phase I districts have been completed and those in phase II are near completion. Supplies of phase one is complete and that for phase II and III is decentralized. Adaptation of information technologies is taking shape, Call Center 24x7 (unique NO: 1075) is functional since beginning of 2008 and videoconferencing with most of the state headquarters is established. However the electronic online data entry, analysis and transmission have not yet begun. Establish and operate a Central Surveillance Unit (CSU): Central Surveillance Unit will support and complement the state surveillance units (SSUs): Central surveillance unit by now is well established and supported by dedicated NICD officers to the state for periodical visits. Most states were visited 1-2 times as against expected quarterly visits. The quality of review, trouble shooting and facilitating action needs to be improved. Prepare national guidelines for disease surveillance, select priority conditions for surveillance, and standard case definitions for each of them and methods for surveillance: This task was completed in 2006, but some implementation hurdles like difficulty in collecting passive surveillance data, desegregation of data by age and gender were noted. Revision of syndromic (S) and probable (P) forms by including only select priority specific conditions and eliminating desegregation of data by age and gender recently would facilitate surveillance. Coordinate timely transport of specimens to the regional, national and international laboratories: This task is happening as it used to before IDSP through NICD Microbiology section Analyze data, identify epidemiological trends and prepare national epidemiological situation reports: The data is being received from about 250 districts of phase I &II states and periodical analysis is being done since third quar ter of 2007-08. The first national epidemiological annual report (2006) is ready and the one for 2007 is getting ready. Coordinate Quality Assurance Surveys: Base line quality of laboratories has been completed and internal quality standards along with waste management guideline have been shared. The quality of training by
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master training institutes has been evaluated externally and suitable actions being taken on the recommendations. The key recommendations include more hands on training particularly in filing up the forms of reporting, better participatory teaching approaches, more exposure to real field situations and better involvement of the microbiologists/laboratory technicians. Integrate and strengthen disease surveillance at State and Districts level:
their districts, only about half of them are sending weekly summaries to the CSU. However large numbers of districts are sending weekly reports directly to the CSU also. iv Train state and district level staff; All the states in phase I have completed the training as per their PIP whereas most in phase II are nearing completion of training of staff as envisaged in PIP All the states had initially given high priority to . rural health staff @ one worker per sub-center and @ one doctor per PHC because of administrative convenience and no efforts were made to train hospital and dispensary doctors, nurses and pharmacists. Therefore the district, sub-district and major hospital surveillance is not really established. Realizing the limitation States like Tamil Nadu, Gujarat and Karnataka were able to complete the training of all the staff involved in surveillance activities in 2007 and demonstrate the utility. All states by now have realized the need for training of staff involved in IDSP from hospitals, doctors, pharmacists and laboratory technicians and male health workers in sub center and are planning for the same in the 2008 activities. v) Implement periodical non-communicable disease surveys/and or their risk factors
A. State-level:
i) Establish state surveillance unit (SSU): Each State will establish a SSU headed by technical officer, supported by 3 technical consultants (training, finance and procurement ) and 4 support staff from project (data entry operators-2, office assistant and accountant).
All the states in phase I and II have already established the SSUs and most in phase III also have established the SSUs. The major hurdle has been the continuity in the State technical officers. As it is a senior level post quick turn over is seen due to superannuation / promotion. It is also a fact that this level officer has many other responsibilities and hence not able to give more than 20-25% of his/her time for IDSP As far as . the contractual posts are concerned majority of them are filled up in Phase I and II but there is big turn over due to temporary nature of the post and low pay package. It has been very difficult to get public health consultant and the financial consultants at state level. ii) The emphasis is on integration of disease surveillance activities, laboratory coordination, and involvement of private sector, non governmental organizations (NGOs) and community.
The project has envisaged periodical household surveys by states (one third of states each year by rotation) once in 3-4 years. The surveys would capture behavioral variables (like smoking, alcohol consumption etc) to mount national/state specific advocacy and behavior change communication strategies. Negotiations between NICD and Indian Council of Medical Research (ICMR) took longer time than expected and the actual survey was delayed and likely to be completed by September 2008 for the first generation of 8 states. vi) Support districts in data analysis, transport specimens, and outbreak investigations.
Most of the state level officers are struggling in settling their own house (Govt. set up) right, attention to surveillance activities; laboratory coordination and involvement of private sector etc are not getting priority. iii) SSU will prepare and send weekly/monthly summaries of the disease situation to CSU.
While most SSUs in phase I & II have been able to send monthly collated surveillance information from
The SSUs have been supporting outbreak investigations and specimen transportations. However, SSUs are still not in a position to support data analysis as the requisite software is not yet developed by the National Informatics Center (NIC). vi) Oversee the implementation of IDSP monitor , quality of laboratory services etc.
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Due to quick turn over of both the regular state surveillance officer (SSO) and the contractual technical staff the mechanism of oversight and monitoring of the laboratory services is poor.
iii)
Train sub-district health staff
District level:
i) Establish district surveillance unit (DSU): Each State will establish a DSU in each district headed by medical graduate with a background of Public health, supported by one microbiologist and 4 support staff from project (data entry operators2, office assistant and accountant).The emphasis is on integration of disease surveillance activities, laboratory coordination, and involvement of private sector, NGOs and community.
Training of the health staff at the primary health center (PHC)s and sub-centers has been completed in phase I & near completion in phase II. The staff (doctors, pharmacists and lab technicians etc) at the district and sub-district hospitals was taken up in late 2007 and being intensified in 2008. iv) Initiate investigation of suspected cases/outbreaks & institute public health action.
All the states in Phase I &II and some in phase III have established DSU by now. District Vector Borne Diseases control Medical officers or a Deputy Chief Medical (Additional /Assistant) officer of Health at the District Chief Medical office (District Health and Family Welfare Office) has been given additional responsibility of IDSP This again is an impediment for the progress . of the project as the officer is able to give about one thirds of his time only. It is also a fact that most of these officers do not have public health background. Lack of qualified microbiologists at the district level (except in Karnataka and Maharashtra) has left the oversight and coordination responsibility of laboratories loose. One thirds of the district are able to involve private sector that too on a small scale. Majority of the districts surveillance units with medical colleges have not been able to negotiate with them for a productive partnership for surveillance and improved diagnostic capabilities. Integrating the surveillance at the district level is a distant dream due to different developmental status of vertical programs like national vector borne disease control program (NVBDCP), national tuberculosis control program ( NTCP) etc. ii) Analyzing the sur veillance data from the peripheral institutes and providing feedback.
Investigation of suspected cases and out breaks has been initiated in majority of the districts. Identifying the outbreak from routine reporting (based on alert of more than expected cases) and taking investigation is still wanting. On outbreak investigation public health action is invariably taken. v) Support for collection and transport specimens to laboratory networks
The specimen collection and transportation in a district is mainly done by the district staff. vi) Responding promptly to the information provided by the community.
The system of recording the community information and responding is yet to be developed.
Community Level:
i) Notify the nearest health facility of a disease or health condition selected
There is no official formalization of community reporting, though sometimes community does report to the nearest PHC. Use of call center is limited to health staff only. ii) Support health workers during outbreak investigations
Most communities do support during outbreak investigations for fear of spread of disease. iii) Community mobilization and empowerment for community par ticipation in containment measures.
Most of the districts are able to input the data online. Analyzing surveillance data and feedback during monthly meetings and on visit to the peripheral units has started in states like Gujarat, Tami Nadu, Karnataka, Uttarkhand.
Community mobilization and empowerment of community participation for containment measure is still a distant dream.
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Strengthen data quality, analysis and links to action: i) Real-time on-line entry, management and analysis of surveillance data using computers, internet and www:
Real-time on line entry of data at the district level is happening in phase I & II districts. Collation, analysis using computers and internet is waiting for the development of appropriate software. ii) Email services between CSU, SSU, DSU and laboratories and other stakeholders
E-mail services between CSU, SSU and DSU are established but need to stabilize. The laboratories and other stakeholders (medical colleges) are yet have similar facilities. iii) Rapid dissemination of health alerts to public, health staff and civil societies
Rapid dissemination of health alerts to public health staff and civil societies is being developed, through 24X7 call ser vice center (1075). Videoconferencing facilities are established in state headquarters and the CSU is interacting with states periodically. Converting state units as teaching ends is under consideration. iv) Quality assurance sur veys of laboratory information
purchased within the country. As would be expected in a country of great diversity, there is also great diversity of capability and capacity in laboratory services. States like Maharashtra and Karnataka have capability and have already embarked on building laboratory capacity for IDSP Where laboratory services . exist, there is a need to improve quality and to address fundamental problems in the system related to procurement and subsequent distribution of supplies. In general, limited testing should be offered at the district level. Peripheral health centers and sub-centers are often performing microscopy (AFB and malaria) should be left at that level. At the district level, testing of human specimens should be limited to those tests for which high quality rapid assays are available (e.g., dengue, leptospirosis). Presently, culture should be limited to those laboratories designated as state laboratories or facilities where there is a very clear demonstration of sufficient volume of specimens to retain the necessary skills. A process for quality assurance needs to be established at each site identified for laboratory strengthening. 1. The upgrading of laboratories at the state and district level to improve laboratory support for providing on time and reliable confirmation of suspected cases, monitoring drug resistance The introduction of quality assurance system for laboratories: Establishing External Quality Assurance System (EQAS):
2. 3.
The mechanisms of quality assurance and control of laboratory information is being developed. Improve laboratory Support: Currently, laboratory capacity in India for diagnosis of infectious diseases is fragmented with some capacity at the National Institutes of Communicable Diseases, at the Indian Council for Medical Research and at Medical Colleges around the country. Presently, laboratory services exist in a number of categorical programs with limited coordination and, compounding the problem, there is no apparent perceived need for coordination or leadership at the national level. There is no focal point within this mixture of laboratories to ensure services are available where needed and assure quality of testing. For example, there is no place that assures quality of rapid diagnostic kits
IDSP had envisaged 4 levels of laboratories namely: L1 = Peripheral laboratories that will have diagnostic facilities for Malaria, TB, Typhoid and chlorination of well water and fecal contamination of water, L2= District Public health laboratories will carry out tests for Malaria, TB, Typhoid and chlorination of well water and fecal contamination of water primarily to confirm results from L1, and for quality control. They would also have oversight responsibility of L1 laboratories. L3= Regional/State laboratories will carry out all tests to confirm L1 and L2 results and for some state specific diseases (e.g. Leptospirosis, KFD, Anthrax etc). They would also have culture facilities for bacteria and viruses along with drug sensitivity studies. L4= Central and L4 reference laboratories for routine work and specific outbreak investigations.
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Based on three years experience and challenges in establishing the Public Health laboratories it is now agreed that under IDSP apart from state Public Health Laboratories and specialized laboratories (L3&L4) only 50 District laboratories (2 per focus state and 1 in rest of the states each)will be strengthened to take up Public Health laboratories responsibilities. Revised laboratory strengthening plan of action under IDSP is addressing the regional and referral laboratories. In the first phase, states used the money for renovating and minor additions to physical structure of all laboratories in the districts. It was observed that most of the money was distributed (based on average per unit) without considering the needs of individual laboratories. Vertical programs like NVBDCP and NTCP had supported L1 laboratories up gradation in entire country in last few years. Therefore from 2006 no money is released for renovation unless a definite need is ascertained. Training for Disease Surveillance and Action: The project aims to train both in formal and informal sector for disease surveillance, specific training for disease control, and special training of state/district surveillance officers in epidemiology and specialized training in laboratory work, data management and communications. In addition to the routine program trainings as listed above, the training under IDSP has to cater to larger need of epidemiologists and Microbiologists able to organize and oversee IDSP activities at state and district level. This would involve training epidemiologist and microbiologists and rapid response team members at the SSU and DSU. Two weeks Field Epidemiology training has been field tested in 2007. It is decided to train the Microbiologist and a lab. technician from each of the 50 identified laboratories in quality assurance and specific disease tests. The challenge now is to take to scale both the training. With GOI sanctioning of 766 posts of epidemiologists, Microbiologists and Entomologists, on one side there is good opportunity for public health qualified professionals, on the other it is going to become a challenge. NICD need to identify some more regional institutions to take up 2 weeks field epidemiology training in addition to the training of trainers (TOTs) they are already handling.
Way Forward: Infrastructure strengthening: Despite recent improvements, obtaining information regularly from the larger public hospitals and private sector from the urban areas still remains a challenge for the IDSP The . initiative started to rationalize the weekly reporting forms needs to be implemented to reduce the burden of nonspecific conditions on the surveillance system. More importantly, the ability to analyze and act on the information being generated is critically lacking especially at the district level. Frequent turn-over of state and district surveillance officers also slowed down the effective implementation of surveillance activities. To address this, a specialized cadre of epidemiologists - which was not originally envisaged under the project - has been strongly recommended by the Bank as well as Centre for Disease Control (CDC) teams that recently reviewed the project. Similarly, due to limited availability of microbiologists, the original plan for laboratory strengthening has been revised focusing on making 50 public health laboratories functional and link each district to such labs. The GOI has created positions of epidemiologists, Microbiologist and entomologists under the National Rural Health Mission (NRHM). The challenge is to fill in these posts urgently with motivated people and arrange for their induction training with necessary field epidemiology and microbiology training. Scaling down the laboratory strengthening component to make 50 public health laboratories functional during the next 6 months appears to be doable task. Piloting of disease surveillance in 4 metro cities needs acceleration to provide lessons for scaling-up urban surveillance in other cities. I. Outbreak response: 1. The enhanced reporting and investigation of outbreaks by IDSP is an important accomplishment of the project, and warrants recognition. However it will be important to further strengthen IDSP capacity for early outbreak detection by emphasis on prompt outbreak reporting to the district surveillance officer. Special emphasis is required on seeking such information from the health providers and different options such as giving mobile telephones to the sub center (SC) reporting units should be explored.
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2.
In addition to enhancing detection and prompt reporting of outbreaks, determining the quality of outbreak investigations should be an essential evaluation component of the project. This will require expanded and standardized recording of information about outbreaks investigated: the number of cases and deaths, causative agent, timeliness of detection and response, results of systematic investigation, including epidemiologic characterization and determination of source(s), and public health response. In some states, it will also be important to improve coordination between IDSP and epidemiology cells/response units. IDSP should invest substantial efforts to assure the proposed Call Center is effectively implemented. This will require strategic marketing of the system to the providers and health personnel in the area covered by the call center. It will also require links to SSU (DSU) for promptly evaluating the information, and giving feedback to the provider (e.g. expedited access to reference diagnostic tests, information about clinical presentation of rare conditions, access to limited therapye.g. diphtheria anti-toxin) and initiating appropriate actions. Information from calls should be routed simultaneously, not sequentially, to relevant SSU (for follow-up) and CSU (for information and to recognize cross-state outbreaks). Media scanning can detect possible outbreaks, as well as identify rumors which need addressing. Although it can be the responsibility of an SSU to systematically monitor local newspapers, web pages, etc, media scanning can also be done by a contracted service. The benefit of a contracted service is systematic, prompt scanning which is not contingent on public health personnel; also, any items noticed can be routed immediately to the appropriate (and possibly multiple) district, state, or national units. Conditions to be reported under IDSP IDSP should continue to refine strategies for improving the interpretability of data by emphasizing a) reporting units/data sources most likely to provide usable and impor tant
information, b) enhancing specificity of case definitions, c) encouraging laboratory confirmation and laboratory repor ting and d) encouraging consistency in reporting 2. Continued collection of S form data from subcenters reinforces community engagement with IDSP so that outbreaks at the village level will be recognized and reported through IDSP reporting channels; for a single SC data collection burden is not too high, and the proposed revision of S form to eliminate age and sex breakdown of cases will further minimize burden. However, other reporting units (PHCs, hospitals, private hospitals, medical colleges, ID hospitals) should report a revised list of conditions using more specific case definitions. Revision of P form may consider dropping non-specific and high volume conditions e.g. fever, ARI Acute Gastroenteritis (leaving cholera) etc. as they create a large burden of data collection on the system, but the data are difficult if not impossible to interpret.
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III. Strengthen laboratory diagnosis of cases 1

1. Doctors in Hospitals with large load of outpatients do not generally demand for investigations to arrive at a diagnosis. The states need to promote utilization of existing laboratory investigations routinely and also make efforts to improve diagnostic capabilities in these facilities. Routine specimen transportation (from outbreaks and hospitals) to the laboratories both in public and private sector system (especially L3, L4 and L5) needs streamlining. Keeping vigilance on the quality of investigations in these laboratories by external quality assurance mechanism is equally important. Promote reporting of laboratory confirmed data using laboratory investigations reporting forms (Lto L5 forms). Line listing of cases with positive laboratory tests, and adding a column for type of specimen {a cerebrospinal fluid (CSF) or blood culture result is quite different from sputum} will improve the utilization. IDSP should consider
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collecting reports of positive tests for Hib, rotavirus, pneumococcus, and other salmonella species. 5. At the present, linkage of reports from clinical and laboratory sources is not feasible (outside of the individual patient record), so one may need to accept some degree of duplication in order to have information on the number of laboratory confirmed cases. Continue to implement initiatives such as urban surveillance and sentinel ID hospitals to target large and strategically located hospitals for special attention as reporting units. These sources are likely to draw more severely ill patients from a large population, thus efficiently providing sentinel information about a large area. In addition, they are likely to have, or can be supported to have, better laboratory and clinical diagnostic facilities. Targeting reporting units such as strategic hospitals and laboratories is a reasonable priority in all sites, but it may be particularly important in states that are less advanced in their IDSP activities, so that at least some surveillance information is available for these areas.
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Rapid completion of the network (both for data transmission and for videoconferencing) is urgently needed; getting the districts operational will be critical to realize the full impact for IDSP Videoconferencing should . be viewed as an essential public health tool for surveillance and for outbreak management. Once the system is operational at districts, there will be even greater oppor tunities for frequent communication without difficult travel.
IV. Sentinel Reporting Units 1.
References:
1. Integrated Diseases Surveillance Project, Project Implementation Plan 2004-09, GOI, MOH &FW (Department of Health) Nirman Bhavan New Delhi 110001. Project appraisal Document, June 7 2004 The World Bank, New Delhi-11003 Integrated Disease Surveillance Program Annual report- NICD 2007 Integrated Disease Surveillance Program Annual report- Commissioner HFW&ME Gujarat 2007 IDSP Aid Memoirs, the World Bank, New Delhi November 2006 & May 2007. IDSP Mid-Term Evaluation, the World Bank, New Delhi November 2007.
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Indian Public Health Association

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Notice for 53rd Annual General Body Meeting

The 53rd Annual general Body Meeting of the IPHA will be held on 9th January, 2009 at 6 PM at Kuvempu Kalakshetra Auditorium, KIMS Hospital Campus, K.R.Road, V.Puram, Bangalore - 560 004. (Please reconfirm the exact venue and time from the organizers of the conference). Sd/Dr. Madhumita Dobe Secretary General, IPHA
144
Short Communication Hypertension and Epidemiological Factors among Tribal Labour Population in Gujarat
*
Rajnarayan R Tiwari1 Summary
A cross sectional study was carried out in 2005 to find out the magnitude of hypertension among 154 tribal labourers of Gujarat belonging to Naika, Rathwa and Damor tribes. WHO classification of hypertension was taken as operational criteria and data was collected in pre-designed, pretested schedule. Blood pressure measurement was done twice on each subject using mercury sphygmomanometer. Overall magnitude of hypertension was found to be 16.9%, and only smoking was found to have significantly associated with it. World is in the stage of epidemiological transition and the non-communicable diseases are overtaking the communicable diseases. This phenomenon is not only seen in developed countries but is also evident in the developing countries like India. Among the major non-communicable diseases, cardiovascular diseases are recognized as major public health problems by WHO1. Though several studies have been carried out among the workers with sedentary lifestyle to assess the risk factors for NCD, but very few studies have been carried out among labour population especially in India. One argument towards this can be non exposure to risk factors like decreased physical activity and obesity among the labourers by virtue of their occupation but other side of the coin suggests that the risk factors like smoking and alcohol consumption is increasing among the lower socio-economic strata. With this background the present study was carried out to find out the prevalence of hypertension as well as different cardiovascular risk factors and to assess association of different risk factors with hypertension if any. The present cross-sectional study was carried out in 2005 among the labourers of different tribes of Chhotaudepur region of Gujarat. The selected villages have about 30,000 tribal population; mostly being engaged in labour work. From the sampling frame of labour population aged 20 years and above, 154 study subjects were included by simple sampling random technique in the present study. Pre-designed, pre-tested schedule was used to collect data regarding demographic characteristics and different risk factors like smoking and alcohol. For the present study all those who have smoked at least one cigarette or bidi in the last one-month period were considered as current smoker while those who have left smoking since 1 year were considered as ex-smokers. For the purpose of ever smokers the current smokers and ex-smokers were added together. Similarly those who reported to have taken alcohol at least once in last one month were considered as current alcohol users. This was followed by measurement of blood pressure, height and weight. Two blood pressure readings were obtained on left arm after the subject had rested for at least 5 minutes in a seated position using mercury sphygmomanometer, 10 minutes apart. Finally average of two readings was taken. SBP 140 mm Hg and/or DBP 90 mm Hg and/or treatment with anti-hypertensive medication were labeled as hypertensive2. Subjects having hypertension were refereed to the Primary Health Centre of Chhotaudepur for fur ther management. Body weight was measured on the weighing scale, wearing minimum outerwear (as culturally appropriate) and without any footwear. Height was measured using a non-stretchable tape with
1Scientist C, Occupational Medicine Division, National Institute of Occupational Health, Ahmedabad, Gujarat. *Corresponding author: rajtiwari2810@yahoo.co.in.
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Table 1: Distribution of hypertension according to different risk factors

Risk Factors Age (in years) <45 45 Sex Male Female Smoking history *Ever smokers Never Smokers Alcohol use *Present Absent Number Hypertensives No (%) 23 (17.4) 3 (13.6) 15 (16.5) 11 (17.5) 9 (25.7) 6 (10.7) 1 (20.0) 13 (15.1) 26 (17.9) 2;df, p-value
132 22 91 63 35 56 5 86
0.017; 1; >0.05
0.025,1, >0.05
3.52; 1; <0.05
0.407; 1;>0.05
However a study among tribal Oraon population of Orissa revealed lower prevalence of hypertension (4.6/1000 population)4. Similar finding (prevalence 5.8%) was also noted by Chadha SL et al5 among Gujaratis residing in Delhi. In contrast a study among primitive tribes of Orissa reported prevalence of hypertension among males and females as 31.8% and 42.2%, respectively6. Recent studies have shown that Asian Indians are particularly susceptible to non-communicable diseases. Comparison with studies shows that there is a clear increase in magnitude of hypertension in urban Indians from 6.2% in 1970 to 26.9% in 20007, 8. This can be attributed to the epidemiological transition and changing lifestyles.
Body mass index Overweight-pre-obese 9 Non-obese 145 * Included only males
the subject in an erect position against a vertical surface, with the head positioned so that the top of the external auditory meatus was level with the inferior margin of the bony orbit. Body mass index was calculated by dividing the weight in kilograms with the square of height measured in meters. WHO classification of obesity was used for the categorization3. Percentages were calculated and chi-square test was done using Epi Info software. Out of 154 subjects, 59.1% were male while 40.9% were female. Majority of the study subjects belonged to less than 25 years of age. Overall magnitude of hypertension was found to be 16.9%. 38.5% of the subjects were ever smokers while only 5.5% have taken alcohol. Only 9 (5.4%) subjects were overweight-pre-obese. The mean BMI for the females was found to be 19.3 3.5 kg/m2. The distribution of hypertension according to the risk factors is shown in Table 1. Except for smoking all other factors were found to be non-significant. In the present study the overall magnitude of hypertension was found to be 16.9%.
Although the magnitude of hypertension is age related, being highest in those over 50 years of age9,10, but the non-significant association of age with hypertension in present study can be attributed to comparatively young age group of study population; mean age being 31.710.1 years. All the hypertensive subjects were non-obese and this could be due to very low magnitude of obese in the study population. However the mean BMI of the females was similar to that reported in NFHS survey data while the proportion of those females having BMI<18.5 kg/m2 was found to be 38.1% which was lower than 47.7% as reported in NFHS survey. Magnitude of smoking is higher in this study and smoking has been found a significant factor for the occurrence of hypertension. There is a plethora of studies suggesting the tobacco smoking as an important and independent risk factor for hypertension and cardiovascular diseases11. Thus to summarize, this study reveals that the magnitude of hypertension in the tribal labour workers is comparable to the magnitude found in the other Indian studies. It is likely that a systematic and larger study may give better understanding of the prevalence and the underlying risk factors among these workers.
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References:
1. 2. Integrated NCD management and prevention. In the official website of WHO. http:// www.who.int WHO. Epidemiology and prevention of Cardiovascular diseases in elderly people. WHO Technical Report Series No. 853, World Health Organization, Geneva, 1995. WHO. Obesity: Preventing and managing the global epidemic. WHO Technical Report Series No. 894, World Health Organization, Geneva, 2000. Dash SC, Sundaram KR, Swain PK. Blood pressure profile, urinary sodium and body weight in the Oraon rural and urban tribal community. J Assoc Physicians India. 1994; 42: 878-80. Chadha SL, Gopinath N, Ramachandran K. Epidemiological study of coronary heart disease in Gujaratis in Delhi (India). Ind J Med Res 1992, 96:115-121. Kerketta AS, Bulliyya G, Babu BV, Mohapatra SS, Nayak RN. Health status of the elderly population among four primitive tribes of Orissa, India: A clinico-epidemiological study. Zeitschrift 7.
fr Gerontologie und Geriatrie. Published online on 10 April 2008. http://www.springerlink.com/ content/6g424u36581868wq/ last visited on 10th July 2008. Malhotra SL. Studies in arterial blood pressure in the North and South India with reference to dietary factors in its causation. J Assoc Physicians India 1971; 19:211-224. Chadha SL, Radhakrishnan S, Ramachandran K, Kaul U, Gopinath N. Epidemiological study of coronary heart disease in urban population of Delhi. Indian J Med Res 1990; 92: 424-30. Anand MP Epidemiology of hypertension. In: . Anand MP Billimoria AR, editors. Hypertension: , an international monograph. New Delhi. Indian J Clin Practice 2001:10-25.
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10. Singh RB, Suh IL, Singh VP et al. Hypertension and stroke in Asia: prevalence, control and strategies in developing countries for prevention. J Hum Hypertens 2000; 14: 749-763. 11. Noel H. Essential hypertension: evaluation and treatment. J Am Acad Nurse Pract 1994; 6: 421435.
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147
Short communication Respiratory Morbidity among Street Sweepers Working at Hanumannagar Zone of Nagpur Municipal Corporation, Maharashtra
*Sabde Yogesh D1, Sanjay P Zodpey1 Summary
Due to the occupational exposure street sweepers are very much vulnerable to develop the chronic diseases of respiratory system. Therefore this study was undertaken to find out the proportion of chronic respiratory morbidity among the street sweepers and the role of various associated risk factors. The study included two groups: study group i.e. street sweepers and comparison group (Class IV workers working in the office buildings). Various risk factors studied were age, sex, socioeconomic status, length of service, smoking habit, type of house, area of residence, cooking fuel and pets. Proportion of chronic respiratory morbidity (chronic bronchitis, asthma and bronchiectasis) was higher (8.1%) among street sweepers compared to comparison group (2.1%), the difference being statistically significant. Unconditional multivariate logistic regression revealed that risk of having chronic respiratory morbidity among street sweepers was 4.24 (95 % CI of OR = 1.24 to 14.50) times higher than that in the comparison group and the risk increased significantly with increasing length of service (OR = 1.75, 95 % CI = 1.09 to 2.81). Street sweepers are exposed to significantly more amount of dust, microorganisms, toxins and vehicle exhaust than the recommended norms1-3. Due to this occupational exposure they are very much vulnerable to develop the chronic diseases of respiratory system such as chronic bronchitis, asthma, etc. The problem is further compounded by various socioeconomic factors like habit of smoking, poor housing conditions, etc4-8. Therefore a need was felt to study the proportion of chronic respiratory morbidity and the role of various risk factors contributing to chronic respiratory morbidity in this occupational group. The present study was designed as a crosssectional study with a comparison group. The study group comprised of all the street sweepers working in Hanumannagar Zone of Nagpur Municipal Corporation (N=273). The comparison group included all the class IV workers working in the office buildings of Nagpur Municipal Corporation, Nagpur (N =142). The study was undertaken during November 2003 to January 2005. Pretested proforma was used to record the necessary information such as socio-demographic factors, occupational history, past and present medical history & findings of clinical examination. Standard clinical methods were used and opinion was sought from specialists of Government Medical College Nagpur to confirm the diagnosis. International Classification of Diseases version 10 (ICD 10) was used to make the final diagnoses e.g. Chronic bronchitis (ICD No. J44) defined as presence of a chronic productive cough on most of the days for three months, in each of the two successive years, in patient in whom other causes of chronic cough have been excluded (Other causes of chronic cough were excluded by sputum microscopy and chest X-ray). As occupational exposure to dust is known to cause chronic respiratory morbidity like chronic bronchitis, bronchial asthma and bronchiectasis, the
1Department of Preventive and Social Medicine, Government Medical College and Hospital, Nagpur, Maharashtra, India. Corresponding author: ysabde@yahoo.com
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Table 1 shows the distribution of various respiratory morbid ICD code Morbid Street Comparison conditions among the subjects. It Conditions sweepers group P value was observed that the proportion (n=273) (n=142) of chronic bronchitis was No. (%) No. (%) significantly more (p = 0.0346) among street sweepers (5.9%) as J41 Chronic bronchitis 16 (5.9) 2 (1.4) 0.0346* compared to the comparison J45 Bronchial asthma 5 (1.8) 1 (0.7) 0.3613 group (1.4%). The other chronic respiratory morbidity included J00 URI 20 (7.3) 10 (7) 0.9156 bronchial asthma and J49 Bronchiectasis 1 (0.4) 0 0.5214 bronchiectasis. While considering chronic respiratory morbidity * Statistically significant collectively, it was found that the proportion was more among street effect of various risk factors on the occurrence of sweepers (8.1%) than the comparison group (2.1%), chronic respiratory morbidity was studied in detail. the difference being significant statistically (p = 0.0157). Bivariate analysis was initially done to study the effect of various risk factors associated with respiratory None of the 273 street sweepers was using protective morbidity, viz. age, sex, socioeconomic status, devices like masks, goggles, etc. while working. occupation, length of service, smoking habit, house, Proportion of chronic respiratory morbidity area of residence, cooking fuel and pets. The chi-square increased with increase in age and length of service. (2) test was applied to test the significance. In the This increase was statistically significant when chi second step, unconditional multiple logistic regression (MLR) analysis was carried out to estimate the adjusted odds Table 2: Distribution of chronic respiratory morbidity ratios (OR) for the abovementioned risk according to age and length of service factors for chronic respiratory morbidity. Street sweepers Comparison group The Full Model of MLR comprised of all (n=273) (n=142) the risk factors included in the study. Of Subjects Morbidity Subjects Morbidity these, the factors significant at = 0.25 No. (%) No (%) were identified and included in the Final Model 1. The factors which were significant in Final Model 1 at = 0.05 Age group (years) 20 - 29 19 0 13 0 were then included in Final Model 2 and 30 - 39 104 6 (5.8) 35 1 (2.9) again tested at = 0.05. The factors thus identified were considered to be the 40 - 49 114 11 (9.6) 69 2 (2.9) significant risk factors. STATA version 8 50 36 5 (13.9) 25 0 was used for the analysis of the data. Length of Service (years) There were a total of 273 street 0-9 80 3 (3.8) 42 0 sweepers working in Hanumannagar 10 - 19 103 7 (6.8) 48 1 (2.1) Zone of Nagpur Municipal Corporation, Nagpur and 142 class IV employees 20 - 29 78 11 (14.1) 45 2 (4.4) (comparison group) working in office 30 12 1 (8.3) 7 0 buildings of Nagpur Municipal Corporation, Nagpur. All of them 2 test for linear trend p < 0.05
Table 1: Distribution of respiratory morbid conditions among the study subjects
participated in the study.
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square test for linear trend was applied (p<0.05) (Table 2). In full model of unconditional multiple logistic regression analysis (MLR), it was found that the occupation as street sweeper was significantly associated with the proportion of chronic respiratory morbidity (p = 0.019). None of the other hypothesized risk factors were found to be significant at (level of significance) = 0.05. However to include the marginally significant risk factors in the final reduced model, we identified the risk factors having p value less than 0.25 in full model of MLR. These factors were lower socioeconomic status (p = 0.204), occupation as street sweeper (p = 0.019), increasing length of service (p = 0.156), and smoking habit (p= 0.152). In the final model of multiple logistic regression analysis it was observed that the p value was significant for two factors viz. occupation as street sweeper (p = 0.021) and increasing length of service (p = 0.021). The Odds Ratio for occupation as street sweeper was 4.24 (95% CI = 1.24 to 14.50) and that for increasing length of service was 1.75 (95% CI = 1.09 to 2.81). Thus the findings of the present study revealed that the proportion of chronic respiratory morbidity (chronic bronchitis, bronchial asthma and bronchiectasis) was significantly higher among street sweepers than the comparison group subjects. The higher proportion of chronic respiratory morbidity among the street sweepers having longer length of their service as a street sweeper could be because of the increasing duration of occupational exposure. These results indicated a duration response relationship between the occupational exposure and the outcome as chronic respiratory morbidity. These findings were supported by the fact that none of the street sweepers used masks during sweeping. These findings were in agreement with the study conducted among Danish Waste Collectors, where the propor tion of chronic bronchitis (7.8%) was significantly more than that among park workers4. Raaschou-Nielsen O et al also found a significantly higher proportion of chronic bronchitis and asthma in Copenhagen Street Cleaners compared with Cemetery Workers5. Nagraj C et al at Bangalore7 and Diggikar
UA at Pune 8 also detected higher proportion of respiratory morbidities among the street sweepers. Thus it is recommended to use protective devices for these street workers to ward off respiratory morbidity.
References:
1. Krajewski JA, Tarkowski S, Cyprowski M, Szarapinska-Kwaszewska J, Dudkiewicz B. Occupational exposure to organic dust associated with municipal waste collection and management. Int J Occup Med Environ Health 2002; 15(3):289301. Heederik D, Douwes J. Towards an occupational exposure limit for endotoxins. Ann Agric Environ Med 1997;4:1719 Wilkins K. Gaseous organic emissions from various types of household waste. Ann Agric Environ Med 1997; 4:8789. Hansen J, Ivens UI, Breum NO, Nielsen M, Wrtz H, Poulsen OM et al. Respiratory symptoms among Danish waste collectors. Ann Agric Environ Med 1997; 4: 6974. Raaschou-Nielsen O, Nielsen ML, Gehl J. Trafficrelated air pollution: exposure and health effects in Copenhagen street cleaners and cemetery workers. Arch Environ Health 1995; 50(3):20713. Meer G, Kerkhof M, Kromhout H, Schouten JP , and Heederik D. Interaction of atopy and smoking on respiratory effects of occupational dust exposure: a general population-based study. Environ Health 2004; 3:6. Nagaraj C, Shivram C, Jayanthkumar K, Murthy NNS. A study of morbidity and mortality profile of sweepers working under Banglore City Corporation. Ind J of Occup and Environ Med 2004; 8(2):11-16. Diggikar UA. Health status of street sweepers with reference to lung function tests [Dissertation]. Pune University; 2004.
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Short Communication Needle Sticks Injury among Nurses Involved in Patient Care: A study in Two Medical College Hospitals of West Bengal
*G. K. Joardar1, C. Chatterjee2, S.K.Sadhukhan3, M.Chakraborty4, P. Das5, A.Mandal6 Summary
A hospital-based retrospective study on a sample of 228 nurses involved in patient care, in two medical college hospitals of West Bengal, showed that 61.4% of them sustained at least one Needle Stick Injury (NSI) in last 12 months. The risk of such injuries per 1000 nurses per year was found to be 3,280. Out of the most recent injuries among 140 nurses, 92.9% remained unreported to appropriate authorities; in 52.9% events hand gloves were worn by the nurses; only 5% of those nurses received hepatitis B vaccine, 2.1% hepatitis B immunoglobulin and none of them received post exposure prophylaxis for HIV. The health care workers who deal with patients, especially who are exposed to blood, body fluids and potentially contaminated instruments or wastes, are at high risk of contracting serious blood-borne infections like hepatitis B (HBV) , hepatitis C (HCV) and HIV through occupational injuries during their professional activities1 - 5. Percutaneous injury is the most common method of exposure to blood borne pathogens6. In the USA approximately 6,00,000 to 8,00,000 needle stick injuries occur annually among the health care workers, and as a result more than 1000 of them contract hepatitis C or HIV. The most affected category of health care workers is the nurses who are involved in 42% to 74% of the reported needlestick injuries1. This hospital-based retrospective study was conducted among the nurses involved in patient care to quantify the incidence and risk of needle stick injuries during patient care in the hospital setting and to asses certain aspects of their practice profiles during and after such events. The study places were North Bengal Medical College & Hospital, located in a rural area of Darjeeling district and the city-based N.R.S. Medical College & Hospital, Kolkata, West Bengal. The study period was from May 2004 to April 2005. Upon approval by the administration and getting lists of total 725 such nurses from the nurses authorities, one-third of the nurse population was selected for the study. With a random start, every third subject from the list was selected by systematic random sampling technique. Thus a total of 228 nurses comprised the sample size. The inclusion criterion was to work in hospital setting uninterruptedly for last 12 months. After review of literatures on similar studies and getting inputs from experts in epidemiological studies the draft questionnaire was prepared. The final questionnaire for data collection was prepared after the draft questionnaire was pre-tested among the student nurses. The nurses themselves reported data on their experience in the last 12 months period. In case of multiple injuries, the detail information about the most recent injury was elicited. The anonymity of the respondents was ensured. The data analysis was done using suitable descriptive statistics (rates, ratio and proportion). The risk of needle stick injury per 1000 nurses per year was calculated as follows: The cumulative incidence of needlestick injuries among all nurses in last 12 months total number of nurses studied x 1000.
1Associate Professor, 5Assistant Professor, Community Medicine, 6Principal, NRS Medical College, 2Assistant Professor, Community Medicine, Medical College, Kolkata, 3Assistant Professor, MCH, All India Institute of Hygiene & Public Health, Kolkata, 4Professor, Community Medicine, North Bengal Medical College, Darjeeling. *Corresponding author: gkjoardar@rediffmail.com.
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Table 1: Profiles of the most recent needle stick injuries and certain aspects of practice among the nurses experiencing the injuries (n=140)
Profile Character of injury Puncture, drew blood Puncture, did not draw blood Devices involved Disposable needles Reusable needles Suture Needles Reporting of injuries Reported Not reported Practice during the procedure Used gloves Hand washing after the injure Washed hands with soap & water Received post-exposure prophylaxis Hepatitis B vaccine Hepatitis B immunoglobulin Anti Retroviral Therapy for HIV Tests done on source patients For HIV For Hepatitis B For Hepatitis C Tests done on nurses themselves For HIV For Hepatitis B For Hepatitis C No. (%) 118 (84.3) 12 (15.7) 75 (53.6) 29 (20.7) 36 (25.7) 10 (7.1) 130 (92.9) 74 (52.9) 129 (92.1) 7 (5.0) 3 (2.1) 0 8 (5.7) 8 (5.7) 0 3 (2.1) 5(3.6) 0
of NSI per 1000 nurses per year came to 3,280. Table no. 1 shows that out of 140 most recent injuries all were puncture in nature and 84.3% of them drew blood; 53.6% were associated with disposable needle & syringe devices; 20.7% were associated with reusable needles and 25.7% with suture needles. It was revealed that 92.3% of those injuries were not reported to the appropriate authorities. Regarding the reasons of non-reporting, it was revealed that in more than half of the events the nurses had not enough time; and in almost one-third of the events they were unaware of the reporting procedure. Regarding certain aspects of their practice profiles it was observed that out of those 140 nurses (with their recent injuries), 52.9% had worn gloves in their hands during the procedures involved; 92.1% had their hands washed with soap and water after the events; only 5% of them received hepatitis-B vaccine and 2.1% hepatitis-B immunoglobulin. Regarding post-injury laboratory testing, as far as the knowledge of the injured nurses, only 5.7% of the source patients were tested for both HIV and hepatitis-B, and none for hepatitisC. Only 3.6% of those nurses were tested for hepatitisB and two were tested positive (HBsAg +ve); 2.1% for HIV - all of them found non-reactive; and none were tested for hepatitis-C. The injured nurses had no knowledge regarding the test results of the source patients. Similar studies in different areas of the world showed variations in the proportions of health care workers sustaining needle stick injuries during patient care in the hospital settings. A study in the USA showed that at least one needle stick injury occurred among 27.5% nurses in last one year1. A study in three tertiary care hospitals in south India showed that 75% of the health care workers sustained at least one injury in last 12 months 7 . Chaudhary and Agarwal from Lucknow (India) observed that 53% of health care workers experienced at least one injury within 0 - 6 years period 8. Regarding the risk of needlestick injuries per 1000 nurse per year, the present study observed much higher value of 3280 compared to 448 as observed by Jennifer M. Lee et al1. Compared to 92% non-reporting of injuries (to appropriate authorities), 70% to 78% non-reporting were observed among nurses in the USA, where reporting of all such events is a national mandate1.
Regarding specific protection against hepatitis B infection, it was observed that only 21.1% (n=48) of the nurses were fully immunized with hepatitis B vaccine. Out of the total 228 nurses studied, 61.4% (140) experienced at least one needle stick injury in the last 12 months. The frequency distribution of the injuries showed that 21.1%, 15.8%, 9.6%, 9.2% and 5.7% of those nurses sustained 1-3, 4-6, 7-9, 10-12 and 13 to 15 injuries, respectively, in the last 12 months. The cumulative incidence of the needle injury events during the last 12 months was 748; and the risk
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The source analysis in a study among 380 health care workers who sustained needle stick injuries (in a tertiary care hospital in Mumbai) observed that 6.1%, 3.9% and 3.2% of the sources were positive for hepatitis-B, HIV and hepatitis-C, respectively 6. A similar study, among 38 health care workers in Mumbai observed that 26.3% of the sources tested positive for HIV and 10.5% positive for hepatitis B 9. A study conducted in Lucknow observed that out of the 79 health care workers who sustained needle stick injuries, none received post exposure prophylaxis (PEP) for HIV 8. The nurses involved in patient care in the hospital settings are at great risk of sustaining needle stick injuries and acquiring dreaded blood borne infections like HIV, hepatitis-B and hepatitis-C as a consequence of their occupational exposures. There is lots of scope in improving their awareness and practices as how to minimize this risk and adverse consequences of such injuries through appropriate IEC activities (including in-service training), strict adherence to universal safety precautions and universal immunization for them with appropriate vaccine(s) like hepatitis-B vaccine.
2.
Anthony S. Fauci, H. Clifford Lane. Human Immunodeficiency Virus Disease: AIDS & Related Disorders. Harrisons Principles of Internal Medicine; Mc Graw Hill, 2005; 16th edition: 1076-1139. Reproductive & Child Health, Module for Medical Officers (Primary Health Care) MO (PHC), Integrated Skill Development Training, National Institute of Health & Family Welfare, Munirka, New Delhi. November, 2002: 489-516. Park K. Parks Text Book of Preventive & Social Medicine; M/s Banarasidas Bhanot, Jabalpur (India), 2005; 18th edition: 167 175 and 271 281. Physicians Guide, HIV/AIDS Prevention & Awareness (2006); National AIDS Control Organization, William J. Clinton Foundation HIV/ AIDS Initiative in association with Indian Medical Association: 45-66 and 111-142. Mehta A, Rodrigus C, Ghag S, Bavi P Shenai S, , Dastur F. Needle stick injuries in a tertiary care centre in Mumbai, India. Journal of Hospital Infection 2003; 60 (4): 368-373. Tetali S, Chaudhary P L. Occupational exposure to sharps and splash: Risk among health care providers in three tertiary care hospitals in south India. Indian Journal of Occupational & Environmental Medicine 2006; 10: 35-40. Chaudhary R, Agarwal P Prevalence of Needle . Stick injury (NSI) and its knowledge among health care workers in a tertiary care hospital in north India. Int Conf AIDS 2004 Jul 11-16; 15: abstract no. ThPeC7488. Rele M, Mathur M, turbadkar D. Risk of needlestick injuries in health care workers A report. Indian Journal of Medical Microbiology 2002; 20 (4): 206-207.
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Acknowledgement
The authors acknowledge their thankfulness to authorities of North Bengal Medical College & Hospital, Sushrutanagar, Darjeeling and N.R.S. Medical College & Hospital, Kolkata for their support and help
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8.
References:
1. Jennifer M. Lee, Marc F.Botteman, L ars Nicklasson et al. Needle stick injury in acute care nurses caring for patients with diabetes mellitus. Current Medical Research & Opinion 2005; 21(5): 741-747. 9.
153
Short Communication Dietary Profile of Sportswomen Participating in Team Games at State/National Level
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Ritu Jain1, S. Puri2, N. Saini3 Summary
A cross sectional study was conducted to assess dietary profile of 100 Delhi based national / state level sportswomen, aged 18 25 years, participating in team games volleyball, hockey, football and kabaddi. Mean energy intake was found to be 1471 + 479 Kcal. Only 24 percent of the sports women met the recommendations of 60 65 energy percent from carbohydrates and 87 percent were consuming more than 25 energy percent from fat. The mean macronutrients and micronutrient intakes of all the subjects were much lower than the recommendations. Improper food choices were also observed in majority. It becomes necessary to generate awareness among sports personnel regarding proper nutrition practices. The equation for success in sports is complex. Proper nutrition forms the foundation for physical performance as it provides both the fuel for biologic work and chemicals for extracting and using potential energy contained within this fuel. Food also provides essential elements for the synthesis of new tissues and the repair of existing cells. Nutrition thus plays an important role in attaining a high level of achievement in sports. Importance of nutrition in sports should reach all sports personnel to maximise their performance1. In recent times there has been a great emphasis on various aspects of nutrition for sportsmen but a very little attention has been paid to sportswomen. This is largely due to lack of opportunities for women in athletic participation and lack of interest and expertise in this area. The available research findings do not provide adequate information regarding diet pattern and nutritional profile of Indian sportspersons, and especially of sportswomen. Moreover, there is paucity of data on nutrition education interventions among Indian sportsmen2. With the Commonwealth Games in 2010 being held in New Delhi, it is important to meet the gap in nutrition research in sportswomen and formulate plans for nutrition intervention. In this perspective, the present study was undertaken in an attempt to study the dietary profile of sports women participating in team games at state or national level. We planned a cross-sectional descriptive study during September 2006 to February 2007. The sample consisted of 100 college sports women participating in different team games hockey, football, volleyball and kabaddi at state or national level. Players between 18-25 years of age, having training period of atleast one year, playing at state or national level, bonafide students of Delhi University Colleges and willing to participate in the study were purposively selected for ease in follow up from Sports Authority of India training centers where camps and practice sessions were organized on regular basis. A pre-tested structured questionnaire was used to gather information on lifestyle patterns, health status and dietary habits. Dietary assessment was done using 24hour dietary recall and food frequency questionnaire. The subjects were asked to report the food intake over the past 24 hours, which included the foods consumed as well as the quantity in household measures. The household measures were then converted to raw food amounts based on the values given by Raina et al3. The energy, macronutrients and micronutrients
1Research Nutritionist, Public Health Nutrition and Development Centre, 2Reader, Department of Foods and Nutrition, Institute of Home Economics, University of Delhi; 3Senior Lecturer, Physical Education, Institute of Home Economics, University of Delhi. *Corresponding author: jainritu84@gmail.com
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contents were then calculated based on Nutritive Value of Indian foods4. Physical activity profile of the subjects was studied by means of 24-hour activity record method. The total daily energy expenditure was calculated using Satyanarayan codes5 that involves estimation of energy expenditure of 9 groups of activities. 24-hour activity record and 24-hour dietary recall were done for the same day to find out the energy balance. The data collected was subjected to qualitative and quantitative analysis using a statistical package for social sciences (SPSS, Version 9.0). Percentages and frequencies of distribution were calculated for the general information, lifestyle related information, health profile and dietary patterns. The mean and standard deviations were calculated for energy intakes and intake of other nutrients.
It was observed that the mean energy, protein, fat, carbohydrate and micronutrients intakes of all the respondents were found to be much lower when compared with NIN recommendation 6. Mean vitamin C and calcium intakes of majority of subjects were higher than the ICMR7 recommendations for normal adult female but were lower than the values given by Rao8 for Indian sports people. We tried to further categorize the intakes into the levels of macronutrient adequacy. It was found that 74 percent subjects met the protein recommendations of 10 15 energy percent. For 15% subjects protein constituted >15 energy percent and the rest (11%) < 10 energy percent. However, only 24 percent of the sports women met the recommendations of 60 65 energy percent from carbohydrates with 71 percent consuming less than 60 energy percent from carbohydrates. Correspondingly, 87 percent of the respondents were consuming more than 25 energy percent from fat, while only 7% subjects met the recommendations of 20 25 energy percent from fat. Data also revealed that 67 percent, 87 percent and 99 percent of the subjects had their intakes of thiamin, riboflavin and niacin respectively lower than one-third of recommended values. Further analysis revealed that 95 percent of subjects used to eat chapatti daily. Items like rice (57%), paranthas (49%), biscuits (50%) and bread (43%) were consumed frequently. Protein foods consumed included pulses, animal foods and milk and milk products like curd paneer etc. Pulses either whole or washed constituted an integral part of their daily meal. All subjects reported to be consuming vegetables and fruits daily including a variety of these foods in their menu i.e. green leafy vegetables (67%), root vegetables (65%), other vegetables (62%) and seasonal fruits and vegetables (72%). Ghee, butter and refined oil were also used daily. Almost all the subjects took one or the other beverage to rehydrate themselves after their practice as well as competitions. Most frequently consumed beverages by the subjects include tea/ coffee, juices and aerated drinks. 51 percent of the respondents never took aerated drinks as they provide only empty calories. 47 percent of the subjects never took any sports drink for rehydration. Energy expenditure for most of the players exceeded their intake thus putting them into negative energy balance.
Results
Of 100 subjects enrolled, 60 percent were national level players. Even though participating in sports, 22 percent of the subjects did not perceive themselves as fit. Around 60 percent of subjects skipped atleast one of the meals and 40 percent subjects reported changes in their menstrual cycle that could be due to arduous exercise training. Table 1 depicts the mean intakes of different nutrients by the study sportswomen.
Table 1: Mean intakes of various nutrients by the sports women (n=100)

Nutrient Energy (kcal) Protein (g) Fat (g) Carbohydrate (g) Calcium (g) Iron (mg) Thiamin (mg) Riboflavin (mg) Niacin (mg) Vitamin C (mg) Vitamin A (mcg) Mean + SD (Range) 1471 479 (629-3429) 46.1 16.3 (15.9-114.4) 50.820.4 (14.9-127.8) 207.668.8 (82.9-455.7) 609.8246.3 (166.2-1271.4) 10.13.9 (3.3-26.4) 1.130.43 (0.36-2.52) 1.020.44 (0.20-2.49) 8.283.28 (3.33-22.40) 76.9669.95 (7.20-326.05) 487.33488.79 (72.28-1211.93)
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The findings revealed that many of the subjects were initiated into sports in their early childhood even though it may not be the same sport that they are pursuing at present. Only 44 percent of the subjects enrolled for the study have regular meals. In fact 20 percent of respondents had less than three meals a day; 31 percent of them skipped breakfast. They repor ted that these three meals included the refreshment provided to them by the camp organizers. It was found that the dietary energy was being derived from fat rather than from carbohydrate as fried snacks and namkeens was consumed frequently. Faulty food choices, preference for junk foods could be the reason and therefore counseling for proper food choices at low cost becomes imperative. Since most of the subjects have reported sub optimal energy intakes, their menstrual irregularities could be addressed if their energy intakes were improved in the future as regular menstruation helps to maintain bone mineral density9 and thus women who do not menstruate regularly may have a higher risk for the development of a stress fracture. Decreasing the amount of training or increasing energy intake and body weight restores regular menstrual cycles10. Thus in order to maximize the physical performance, it is imperative to develop information booklets for these players to generate awareness regarding proper nutrition practices. Information could also be elaborated with special reference to the particular game keeping cost factor in mind.
References:
1. Meti R, Sarawathi G. Impact of nutrition education and carbohydrate supplementation on performance of high school football players. Ind J Nutr Dietet 2002; 43: 197 206. Kelkar G, Subhadra K, Chengappa RK. Nutrition knowledge, attitude and practices of competitive Indian sportsmen. Ind J Nutr Dietet 2005; 43: 293 303. Raina U et al. Basic food preparation-a complete manual. Third Edition. Orient Longman 2002. Gopalan C, Ramasastri BV and Balasubramanian SC. Nutritive value of Indian foods. Indian Council of Medical Research. Reprint 2004. Satyanarayana K, Venkataramana Y, Someswara Rao M, Anuradha A and Narasinga Rao BS. Quantitative assessment of physical activity and energy expenditure pattern among rural working women. In: Update Growth, pp 197-205 [K.N. Agarwal and B.D. Bhatia, editors]. Varanasi, India: Banaras Hindu University. 1988. NIN / ICMR Recommended dietary intakes for Indian sports men and women, 1985. Indian Council of Medical Research. Nutrient Requirements and Recommended Dietary Allowances for Indians, 1990. Rao BSN. Nutrient requirements of sportsperson and athletes. Proc Nutr Soc India, 1996; 43: 79103. Cann C, Martin M, Genant H, Jaffe R. Decreased spinal mineral content in amenorrheic women. JAMA 1984; 251:626.
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Acknowledgements
With a deep sense of gratitude, the author wishes to express sincere thanks to lecturers in physical education of the selected colleges, statistician and the respondents for their cooperation in completion of the work. The author is also grateful to Dr. Sheila Vir, Director, Centre for Public Health Nutrition, New Delhi for her encouragement and useful discussions during the course of preparation of this paper.
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10. Nelson M, Fisher E, Catsos P Meredith C, Turksoy , R, Evans W. Diet and bone status in amenorrheic runners. Am. J Clin Nutr, 1986; 43: 910.
156
Short Communication Perception Regarding Quality of Services in Urban ICDS Blocks in Delhi
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A. Davey1, S. Davey2, U. Datta3 Summary
The good quality of the services is an important determinant for acceptance of a programme in a community. It not only enhances the credibility of a worker at the ground level but also generate the demand for the services. In this paper perception for the quality of the services was assessed through the exit interview of the beneficiaries at the Anganwadi centres (AWCs). 200 beneficiaries were included from 20 AWCs in a period of one and half month. 52.5% respondents were dissatisfied for the services provided from the AWC for one or more reason. The most common reason mentioned was the not easy accessibility of the AWC and less space available at the AWC (68.6%), followed by the poor quality of the food distributed (66.7%) and irregular pre school education (57.1%) from AWCs. Integrated Child Development Services (ICDS) scheme, recognized as the worlds most unique largest community based outreach system for women and child development, had been launched in 1975 in only 33 blocks on experimental basis. With immense success in the initial years it was periodically expanded to the extent that in the Tenth Five Year Plan ICDS scheme was universalized in the whole country1. But merely increasing the infrastructure/ availability of the services does not increase the utilization of the services from the centre. It depends on many factors and one of them is clients satisfaction. For clients satisfaction critical factor is the quality of services. Client rated quality as very good when they found three elements viz Doctors, Facilities and Workers to be of good quality2. The good quality of the services is necessary for acceptability of a programme in a community as it determines how beneficiaries would perceive about the services and make further demand. Though AWCs have long standing reputation among community by its existence but how far it is successful to satisfy the expectations of the end users through its services is not clear. Therefore, the present study was undertaken to assess perception of the beneficiaries for the quality of the services provided from AWCs. The cross-sectional community based study was conducted during July-August 2004, among 200 women respondents selected through stratified random sampling technique. In Delhi total 28 ICDS blocks are existing, 5 in rural areas and remaining in urban slums of nine districts. The study blocks running in the urban areas are divided into four geographical zones by arbitrary lines. From each zone one ICDS block was selected randomly and five anganwadi centers were selected from each block by systemic random selection technique, thus a total of 20 AWCs were included. At each AWC, every third respondents was interviewed in depth at the exit by open-ended interview schedule, till they make sub sample size of 10. Thus, total sample size of the respondents was 200. Respondents were comprised of pregnant women, lactating mothers and mothers of the children registered with the anganwadi centers. Respondent women were interviewed to ascertain their opinion on various aspects like approachability of AWC, utilization of services by the beneficiaries and their satisfaction towards services of the AWCs. Out of 200 respondents interviewed, 72.5% (145) were mothers of the children, 16.5% (33) pregnant women and 11% (22) lactating women. Out of 145
1Senior Resident in Subharti Medical College, Meerut; 2Medical Officer, Government of Uttar Pradesh. 3Reader, Education and Training Department, NIHFW, New Delhi *Corresponding author: anu_davey@yahoo.co.in
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children (for whom mothers are taken as respondents), 28.3% (41) were in the age group of less than 3 years and 71.7% (104) in the age group of 3-6 years. Overall, 44% respondents (88) were illiterate and 56% (112) were literate. Majority of the respondents (70%) were staying in the area since more than 5 years. When beneficiaries were asked about how they came to know about the AWC running in their areas, 37.5% said by themselves, 23% said from their mother in law, 20% from neighbors, 12% by helpers and 2.5% by ANM. Only 5% women came to know about the AWCs through AWWs, indicating their poor approachability in the community. 89% of the respondents had mentioned that AWW had visited them in last one year. 51.7% respondents said that their frequency for visit was once in 3 months. Reasons for visit were reported to be polio vaccination (69%), immunization services (51.7%); health education (11.8%); nutrition services (11.2%) and pre-school education was the least common reason (1.1%) mentioned by the respondents. Overall drive against Polio might have influenced the worker to go house to house. Pre school education could be the neglected component of the services delivered from AWC, so did the respondents mention it as the least common reason. Regarding utilization of services for the children all the mothers mentioned that they received supplementary nutrition from the AWCs. 56.6% mothers told growth monitoring was done of their children in last 6 months. Only 15.9 % had utilized services for immunization purposes from the AWCs. However, Benjamin et al3 reported growth monitoring was rare phenomena in Ludhiana district and Sharma A et al in the national evaluation of the ICDS services had observed that 36.3% of the AWWs were not able to monitor growth of the children4. For the 104 children of the preschool age group, only 42.3% mothers mentioned about utilization of services for preschool education from the AWCs, but not regularly. Irregular services of pre school education could be due to secondary emphasis for the monitoring of the AWW performance as primary importance is given to their growth monitoring activities and supplementary nutrition distribution and may be due to non availability of space and lack of education and
teaching aids at the AWC. Roy S et al had also concluded in their interventional study that lack of conceptual curiosity and skills of the AWWs also limit play way activities at the AWCs 5. 94.5 % of the pregnant and lactating women were mainly utilizing the services for the supplementary nutrition. Only 23.6% women told they were given health and nutrition education and 5.5% utilized AWCs for immunization services. None of pregnant and lactating women had ever received tablet iron and folic acid from the AWCs in last one year and had never been provided antenatal or postnatal care. Benjamin et al had also observed less dispensing of Iron and Folic Acid to the pregnant and lactating women by the AWWs in the Ludhiana district 3. 47.5% (95) of the respondents were satisfied with the services provided from the AWCs. Rest of the 105 dissatisfied beneficiaries (52.5%) had mentioned various reasons (Table 1); the most common reason being non-accessibility of the AWCs and inadequate space to run AWCs (68.6%). Other studies6, 7 also reported distance/unapproachable state as reasons for non-utilization of services. Further analysis revealed that, 22 of 70 (31.4%) dissatisfied respondents due to poor quality of food and 20 of 72 (27.8%) dissatisfied respondents due non
Table 1: Distribution of the respondents by their satisfaction for services provided from AWC (n=200)
Variables Satisfied with the services Yes No Reasons for non satisfaction Non-accessibility Less space at AWC Poor quality of food Irregular pre school education No frequent change in recipe No immunization at center Numbers (%) 95 (47.5) 105 (52.5) 72 (68.6) 72 (68.6) 70 (66.7) 60 (57.1) 45 (42.9) 45 (42.9)
accessibility, were satisfied with the overall functioning of the AWCs; however all the mothers, who were not satisfied with the pre school services, were also not
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satisfied with the services of AWCs. The findings of the present study also indicated that clients satisfaction about quality influenced the acceptance and utilization of services. Therefore, function of the AWWs should not be restricted to the distributing of supplementary nutrition to beneficiaries only, but need to focus to raise satisfaction level of the end users by developing good rapport through periodic survey and delivering optimum level of services.
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Sharma A. National consultation to review the existing guidelines in ICDS scheme in the field of Health and Nutrition. Indian Pediatrics 2001; 38:721-731. Roy S, Parmar P; Sundram. Impact of the intervention programme on the knowledge, content and skills of AWW and selected conceptual skills for the pre school, Indian Journal of Maternal and Child Health 1994 Jan-March; 5 (1): 20-22. Agnihotri S P Pandy D N, Nandan D. The impact , of Rural Health Services in Agra. Indian Journal of Public Health 1984; 28 (1): 25-29. Jain M, Nandan D, Misra S.K. Qualitative assessment of health seeking behaviour and perception regarding quality of health care services among rural community of district Agra. Indian Journal of Community Medicine 2006; 31 (3): 140-143.
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References:
1. 2. 3. Govt. of India. Nutrition and Food, Tenth Five Year Plan, 2002; p 341-346. State of Indias Health. Voluntary Health Association of India, 1992; pp 53-57. Benzamin AI, Panda P and Zachariah P Maternal . and Child Health Services in Dehlon block of Ludhiana district: Results of the ICDS evaluation survey. Health and Population: Perspective and Issues, 1994; 17(1-2): 67-85. 6.
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Attention All the newly enrolled Life Members of Indian Public Health Association
Dear Sir / Madam You are aware that the 53rd All India Annual Conference of IPHA is going to be held from 9th to 11th January 2009 at Kempegowda Institute of Medical Sciences (KIMS), Bangalore 560070, Karnataka. During the conference Life Membership Certificate (MIPHA Scroll) will be distributed. In case, you are unable to attend the conference at Bangalore, the Certificate will be sent to you. The certificate can also be collected from the HQ Secretariat at Kolkata personally or through your authorized representative.
Sd/Dr. Madhumita Dobe Secretary General, IPHA
159
Short Communication A Study on Delivery and Newborn Care Practices in a Rural Block of West Bengal
*P. Das1, S. Ghosh2, M. Ghosh3, A. Mandal4 Summary
A cross-sectional study was conducted in a rural block of the State of West Bengal to generate area specific data on the proportion of home deliveries and certain newborn care practices prevalent in that area. The study was done through house-to-house survey among 165 mothers who delivered in last six months. 83.6% deliveries were conducted at home and untrained persons attended 36.3% deliveries. Bath within 24 hours of delivery was given to 17.58% newborns. Birthweight was not recorded in 38.18%. High proportion of newborns, 78.5%, was given prelacteal feeding. The health system should urgently address the deficiencies in the delivery and newborn care practices in the study area. A good number of neonatal morbidity and mortality is attributed to improper delivery and newborn care practices1. Neonatal care practices depend on the knowledge, attitude and practice of the community as well as the availability and accessibility of the services. Several interventions have been adopted to address the unmet needs for Basic Reproductive and Child Health Services, supplies and infrastructures since 19722. In spite of all this, neonatal morbidity and mortality are considerably high in our country and neonatal mortality accounts for two-third of the infant deaths. 40 70% of neonatal deaths are seen during 1st week of life and majority occurs at home. Presently in our country only 34% births occur in health institution3 and 42% deliveries are assisted by skilled attendants4. There are considerable local variations in delivery and newborn care practices adopted by the community and interventions must take into account the prevailing practices in the area. It is highly relevant to generate area specific data regarding some of the key delivery and newborn care practices at the community level to initiate appropriate intervention. The present study was conducted in a rural block of West Bengal to assess the proportion of home deliveries, to identify the different categories of care providers and to find out the prevailing practices regarding some essential components of newborn care.
1Assistant
The study was conducted in Basirhat 1 block of North-24 Parganas district of West Bengal. The block had 19 subcenters and have a population of 1, 59,000. The respondents were mothers, who delivered live babies in the last six months (January to June 2005). Sample size was estimated to be 144 to provide coverage estimate at 95% confidence level and 8% error margin at 40% previous coverage level. Singlestage random sampling was used for selection of the mothers. All 19 subcentres were taken and from each sub-centre 10 mothers were selected randomly. 25 mothers denied providing information. Finally 165 mothers were studied. Majority of the deliveries, 138 (83.6%), were conducted at home. Only 26 (15.8%) deliveries took place at government health facilities (Table 1). Similar high proportion of home deliveries were observed in other studies like one in Jamnagar, Gujrat5. More than one-third of the deliveries (36.3%) were conducted by untrained persons. Untrained dais attended 31.5% deliveries and 4.8% deliveries were by friends, relatives and unqualified practitioners. Skilled birth attendance was available in only 14% deliveries (nurse 10.4% and doctors 3.6%) (Table 1). 17.6% newborns were given bath within 24 hours of delivery. Bath-after-delivery was found higher (32.0%) in a study in Egypt6. Birth-weight was not
Professor, 3Ex-Professor, Community Medicine, 2Assistant Professor, Psychiatry, 4Principal, N R S Medical College, Kolkata, West Bengal. *Corresponding author: palash_kal@yahoo.co.in
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Table 1: Place of delivery and assistance during delivery (n=165)

Factors Place of delivery Home Health Centre Hospital Nursing Home Provider Type: Doctor Nurse Trained Dai Untrained Dai Others Number 138 4 22 1 6 17 62 52 8 (%) (83.6) (2.4) (13.4) (0.6) (3.6) (10.4) (49.7) (31.5) (4.8)
practiced (98.79%) among the study population. Breast-feeding was initiated within half-an-hour in 42.4% infants. In 25.5%, it was initiated between halfan-hour to one hour and in 32.1% beyond one hour. The practice of prelacteal feeding was found to be highly prevalent (78.2%). Varieties of prelacteal feed observed, such as plain water (17.6%), sugar water (9.8%) and honey (51.1%). Honey was found predominant prelacteal food in another study done at hilly district of North India6 (46.14%) but sugar water was found to be dominant prelacteal food in Egypt study6. The present study identified several deficiencies in delivery and newborn care practices in the study area. The health system must urgently address the issues by adopting appropriate behaviour change communication strategies.
recorded in 63 (38.2%) newborns. This was similar (33.33%) to study done in Jamnagar district of Gujrat5 but very high in comparison to the study result (4.0%) obtained from a hilly district of North India7. Among 102 (61.8%) newborns where birth weights were recorded, 19 (18.6%) were low birth weight (Table 2).
References:
1. Reproductive and Child Health Module for Health Workers Female (ANM). National Institute of Health and Family Welfare, New Delhi, 2000. National Population Policy, 2000. Ministry of Health and Family Welfare, Govt. of India, Nirman Bhavan, New Delhi. National Family Health Survey (NFHS-2), Key findings, 1998-99. International Institute of Population Science, Deonar, Bombay, 2001, 134. The state of the World Children 2004. UNICEF , New York, USA. Suda Yadav, BS Yadav, SS Nagar, A Study on Neonatal Mortality in Jamnagar District of Gujrat, Indian Journal of Community Medicine 1998; 23 (3):130-135. Home Neonatal Care Practices in Rural Egypt during 1st Week of Life Md. H. Hussein et al http:/ /www.gfmer.ch/ IAMANEH_ISMANEH_Cairo_ 2006 Anmol K Gupta, Rajesh K Sood, Ajay Vatsayan, Dineswas K Dhadwal, Surender K Ahluwalia, Rajesh K Sharma; Breast Feeding Practices in Rural and Urban Communities in a Hilly District of North India, Indian Journal of Community Medicine 1997; 22 (1) : 33-37.
Table 2: Newborn care practices: Bathafter-delivery and birth weight (n=165)

Practices Bath-after-Delivery Bath given Bath not given Do not know Birth Weight LBW Normal Total Birth Weight not taken Initiation of breast feeding Within hour - 1 hour After 1 hour Prelacteal feeding Honey Sugar water Plain water Total Number (%) 29 (17.6) 32 (80.0) 14 (2.4) 19 (18.6) 83 (81.4) 102 (61.8) 63 (38.2) 70 (42.4) 42 (25.5) 53 (32.1) 84 (51.1) 16 (9.8) 29 (17.6) 129 (78.2)
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Newborn feeding practices were studied and it was found that breast-feeding was almost universally
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Short communication Hospitalisation due to Infectious and Parasitic Diseases in District Civil Hospital, Belgaum, Karnataka
*A. C. Naik1, S. Bhat1, S. D. Kholkute1 Summary
To assess the burden of infectious and parasitic diseases on hospital services at District Civil Hospital (DCH) Belgaum, a retrospective study was carried out using discharge records concerning 8506 inpatients due to infectious and parasitic diseases among 95655 patients admitted for all causes during the reference period 2000-2003. Out of the 21 causes of infectious and parasitic diseases, only 5 contributed maximally towards hospital admission. The most frequent cause was intestinal infections (44.0%) followed by tuberculosis (35.4%). 57.5% of these admissions were from the productive age group of 20-54 years. Tuberculosis is the most important disease in terms of hospital bed days (59.7%). Tuberculosis and intestinal infectious diseases represent more than three-fourth of the overall burden in terms of hospital bed days. Hospital discharge records are important source of data which can provide important information and serve as an essential tool for decision making. Furthermore it is an indicator of early warning signal for impending health problems1. In District Civil Hospital (DCH), Belgaum, diagnoses are coded as per International Classification of Diseases, 10th Revision (ICD-10). As per World Health Organization (WHO) there are 21 classifications under certain infectious and parasitic diseases 2. Infectious diseases caused by pathogenic bacteria, viruses and protozoa are the most common and wide spread health risk associated with drinking water3. In New Zealand, rates of some infectious diseases continue to remain high for a developed country and there are also large inequities in the distribution of this burden4. Globally waterborne and sanitation-related infections are one of the major contributors to diseases burden and mortality5. Infectious diseases kill more than 11 million people a year and diminish the lives of countless others6. Virtually all deaths due to infectious diseases occur in low-and middle-income countries. This study attempts to find out the distribution of hospitalisation due to infectious and parasitic diseases. This is a retrospective study carried out at DCH, Belgaum based on ICD-10 diagnosed codes devised by WHO. DCH is a major government multi-specialty hospital in Belgaum district having 740 beds and is attached to a medical college. The hospital also has a outpatient department (approximately 377000 consultations annually) and a community health department. Out of 95655 patients admitted during the four years reference period (2000-2003), 8506 patients admitted were due to infectious and parasitic diseases. Data was collected during 2005-06 and analysis made using Statistical Package for Social Sciences (SPSS) version 13.0 software. If any patient was readmitted after discharge this was considered as a new patient. The multiple co-infected patients are included in the frequency distribution based on the primary infection and not counted in other co-infection categories. From discharge certificates two things were noted e.g. frequency of admissions due to the condition, and duration of the service provided (expressed in days of hospital stay). Out of 95655 admissions, 8506 patients were admitted due to infectious and parasitic diseases. The admissions by age showed that proportion of
1Regional Medical Research Centre, Indian Council of Medical Research, Nehru Nagar, Belgaum, Karnataka. *Corresponding author: ashokcnaik@yahoo.com
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Table 1: Different parameters for the five leading causes of admissions in District Civil Hospital, Belgaum.
Causes Admissions No (%) Bed days No (%) 18904 (21.2) 53354 (59.7) 6572 (7.6) 3623 (4.1) 2176 (2.4) 4746 (5.3) 89375 (100.0) ALOS(days) 5 18 13 10 8 8 11 Deaths No (%) 48 (1.3) 312 (10.4) 238 (47.5) 53 (13.9) 10 (3.6) 38 (6.4) 699 (8.2) PMR (%) 6.9 44.6 34.0 7.6 1.4 5.4 100.0
Intestinal Infectious Diseases (A00A09) 3740 (44.0) Tuberculosis (A15A19) 3013 (35.4) Other Bacterial Diseases (A30A49) 501 (5.9) HIV diseases (B20B24) 380 (4.5) Protozoal Diseases (B50B64) 280 (3.3) Other Infectious Diseases* 592 (7.0) Total 8506 (100.0)
*Other Infectious Diseases=A20A28, A50B19, B25B49, B65B99. ALOS=Average length of stay. admissions below 5 years of the children constituted 12.7%. Most productive age group (20-54 years) constituted the maximum (57.5%) number of patients. Although male admissions are more in all the 5 infectious diseases, in case of tuberculosis and intestinal infections, a statistically significant difference between male and female admissions was observed (p<0.001). Among the 21 classification of infectious and parasitic diseases, only five contributed towards 93% of burden on hospital services namely intestinal infections, tuberculosis, other bacterial diseases (Septicemia, Leprosy, Tetanus, etc), HIV and protozoal diseases. Intestinal infectious diseases contributed maximum of 44% with proportional mortality rate (PMR) of 6.9%. Diarrhea, gastroenteritis and fever (96%) were more commonly reported among the 9 categories of intestinal infectious diseases in the DCH. Tuberculosis with 35.4% of admissions with a PMR of 44.6% was the second highest. Even though contribution from other bacterial diseases was only 5.9%, but PMR was considerably high (34%). Percentage of admissions due to HIV was only 4.5%; however PMR was 7.6%. Protozoal diseases contributed least (3.3%) compared to the above four categories of infectious diseases with PMR of 1.4% (Table-1). Malaria (85.7%) was more commonly reported among 11 categories of protozoal diseases and in 3.1% cases HIV-TB co-infection was found. Considering the number of bed days occupied disease wise, tuberculosis was the major contributor with 59.7% and average length of stay (ALOS) per patient was 18 days. The next category was the
PMR=Proportional mortality rate;
intestinal infections with 21.2% of bed days occupied with ALOS of 5 days. Other bacterial diseases (Septicemia, Leprosy, Tetanus, etc) also contributed a significant number of bed days with 7.6% and high ALOS of 13 days. HIV patients occupied 4.1% of bed days with ALOS of 10 days. The total number of children below 5 years admitted was 1084. The highest number of admissions was due to intestinal infectious diseases (72%) with PMR 10.1%. The admission for tuberculosis was 10.4% with PMR of 11.2%. In case of children, other bacterial conditions also contributed 10.1% and PMR was very high with 70.9% compared to other infectious diseases. Although hospital data has some limitations, but it provide important information for planning, evaluation of hospital services and epidemiological studies. Using the percentage of hospital bed days (related to both frequency of admission and duration of stay) as a proxy of a conditions relative burden on hospital services, childhood diseases as a whole account for less than 15% of the total burden. In a similar study conducted in Uganda, it was observed to be more than one-fourth of the total burden1. However the study referred above was carried out after a war and famine while the present study was conducted in normal situation. The present study reveals that the total load in all age groups of intestinal infectious diseases was 44% where as in case of children below 5 years this was higher (72% of 1084 admissions). These diseases are
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caused by contamination of human/animal feces and pathogenic microorganisms in drinking water. Infectious diseases caused by pathogenic bacteria, viruses, and protozoa are the most common. There is an urgent need to control this disease to reduce the hospital burden. The ALOS for TB patients was 18 days in DCH, Belgaum compared to 57 days in Lacor Hospital, Uganda and 86 days in Russia1, 7. However study undertaken in USA has found ALOS for TB patients is 14 days8 which is comparable to our results. The huge difference between Uganda and Russian studies compared to Indian and USA studies could be treatment policy for TB patients. TB patients require labor intensive care and a high volume of laboratory, radiology and ancillary services. In other words, the burden of TB in terms of use of hospital services is much higher than its burden in terms of number of admissions. It is expected that the burden of TB shall be reduced in future as DOTS strategy is being implemented in Belgaum district since 2002. The percentage of admissions due to HIV was only 4.5% of the total admissions. Further, HIV patients ALOS was 10 days compared to tuberculosis (18 days) and other bacterial diseases (13 days). The interesting observation in the present study is HIV-TB co-infected patients admission was 3.1% of the infectious and parasitic diseases which is comparable to the hospital data from USA (3.2%)8. Thus, the present study clearly suggests that intestinal infectious diseases and tuberculosis cause maximum burden on hospital services at DCH, Belgaum which can be reduced by proper and timely interventions. Burden of intestinal infections can be reduced by providing potable water and proper sanitary measures. The integration of preventive and curative care, implementing health education programs, improving the accessibility of health facilities and the availability of effective treatment, are also crucial for controlling infectious diseases. Burden of TB on hospital services can also be considerably reduced by proper awareness about DOTS (Directly Observed Treatment Short-course).
Acknowledgments
We wish to thank District Surgeon and Mr. Keshav Rao of district civil hospital, Belgaum for permitting to utilize the data. We thank Mr. Vinayak Upadhya and Mr. Shankar V. Belchad for support in data entry.
References:
1. Accorsi S, Fabiani M, Lukwiya M, Onek PA, Mattei PD, Declich S. The Increasing Burden of Infectious Diseases on Hospital Services at St. Marys Hospital Lacor, Gulu, Uganda. Am. J. Trop. Hyg. 2001; 64(3, 4): 154-158. World Health Organization. International Statistical Classification of Diseases and Related Health Problems, tenth revision (ICD-10). Geneva: World Health Organization, 1994. World Health Organization. Report on Infectious Diseases. World Health Organization, 1999. http:/ /www.who.int/infectious-disease-report (Accessed on 06/03/2007). Clair FM, Martin T, Michael B. A re-appraisal of the burden of infectious disease in New Zealand: aggregate estimates of morbidity and mortality. NZMA 2002; 115:1-8. Hunter PR. Climate change and waterborne and vector-borne diseases. Journal of Applied Microbiology 2003; 94:37S-46S. Disease Control Priorities Project. Infectious diseases. Changes in Individual Behavior Could Limit the Spread of Infectious Diseases. Disease Control Priorities Project, 2006. http:// www.dcp2.org (Accessed on 08/03/2007). Marx FM, Atun RA, Jakubowiak, Mckee M, Coker RJ. Reform of tuberculosis control and DOTS within Russian public health system: an ecological study. European Journal of Public Health 2006; 17 (no.1):98-103. Hansel NN, Merriman B, Haponic EF, Diette GB. Hospitalization for Tuberculosis in the United States in 2000: Predictors of In-Hospital Mortality. Chest 2004; 126: 1079-1086.
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Review Article Homelessness: A Hidden Public Health Problem

*S. Patra1, K. Anand1 Summary:
Homelessness is a problem, which affects not only the people who are homeless but the whole society. This problem is not well recognized among the public health professionals. This paper attempts to discuss the issues in the context of homelessness starting from the definition used to methodology of estimation of their numbers as well as their health problems and health care needs. There is lack of data on the health problems of homelessness from India. There is no special health or social programmes or services for this subsection of the society. The existing number of shelters is inadequate and as there are multiple barriers, which prevent them to have proper access to the existing health care system. With the changing social and economic scenario, homelessness is likely to increase. We need to recognize homelessness as a public health problem and attempt to target this group for special care in order to promote equity in health system. Key words: Homeless, shelter, census, barriers
Introduction
Homelessness has major public health implications for not only those affected but also for the general population. Homeless people are potential reservoirs of infectious diseases like tuberculosis, AIDS etc. Homelessness among youth leads to increased crime and substance use related disorders and is of public concern. Health in homelessness state is compromised by physical environment including hazards of street life, poor nutrition, lack of facilities to maintain personal hygiene1 and increased risk of infectious diseases through crowding, negligence towards disease and enforced lifestyle2. Initial health impairments and disabilities can lead to homelessness and a vicious cycle of deprivation. However, homelessness is not recognized as a public health problem. An inadequate information base has affected the public health response to homelessness. Health care providers need to acknowledge that there are an unknown, but large, number of persons who become homeless as a result of a residual impairment and disability and also as being victim of social and economic inequity.
1Centre
This paper tries to review issues related to homelessness in general and specifically in the Indian context. We did a review of literature by searching through electronic database like Pubmed and Indmed and google. Key words used for search were homeless people, health problems, causes, and health systems in different combinations. We also did manual search for articles published in un-indexed journals, and reviewed different research articles both published as well as unpublished.
Definition of Homelessness
There is wide variation in the definition of homelessness, between studies, between countries, and often definition has been affected by services and social support provided to them. A wider definition of homelessness is the absence of a personal, permanent, adequate dwelling. Homeless Assistance Act of 19873 of USA defined homeless to mean: An individual who lacks a fixed, regular, and adequate night-time residence; or who has a primary night-time residence that is a supervised
for community Medicine, All India Institute of Medical Sciences, New Delhi. *Corresponding Author: somadattap@gmail.com
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publicly or privately operated shelter designed to provide temporary living accommodations or a public or private place not designed for, or ordinarily used as, regular sleeping accommodations for human beings. The Census of India (2001) uses the notion of houseless population, defined as persons who are not living in census houses but are in houseless households. Houseless household, as the name suggests is an oxymoron, has been defined as those who do not live in buildings or census houses but live in the open on roadside, pavements, in hume pipes, under flyovers and staircases, or in open in places of worship, railway platforms etc. are to be treated as houseless household 4. A uniform definition of homelessness is essential in order to have recognition of the condition and policy towards homelessness. Counting the Homeless By very nature of their mode of living it is very difficult to enumerate the homeless. Some strategies for enumerating are: one-night counts or point in time; extrapolations from partial counts; windshield street surveys; adaptations of area probability designs; service-based designs5. In India the method adopted was point in time estimation. Enumeration of the houseless households was done on the night of 28th February, 2001 when the enumerators on basis of pre identified areas visited places of worships, railway platforms, and flyovers etc where such households were generally found. There are 447,552 houseless households consisting of 1,943,476 persons in the country4. Point-in-time counts method attempts to count all the people who are homeless on a given day or during a given week. There are many people who experience homelessness at a particular point of time but do not remain homeless. Another important methodological issue is regardless of the time period over which the study was conducted, many people will not be counted because they are not in places researchers can easily find. Due to both these reasons, magnitude of the problem of the homelessness is likely to be unreliable by point in time method. Capture-recapture methods overcome problems of ascertainment by calculating the size of the
unobserved population and completeness of survey. The plant-capture method was used to estimate the number of homeless people in southern Manhattan as part of the 1990 US decennial census6 and to estimate number of street children in Brazil7. Underestimation was to the tune of 63% in Brazil.
Identifying people who are at risk of homelessness

There are a certain subgroups of persons who are of high risk for becoming homeless. These include persons who live in poverty, have mental disability, victimized persons (domestic violence), persons with drug and alcohol addiction or health problems, and persons who lack sufficient social support 8. Other persons at risk are single women with young children and unskilled workers9 and people who are victims of natural disaster, racial discrimination, or those released from prison. In pediatric homeless population, we find 90% of street children are working children who live with their families. Remaining 10% are abandoned and neglected children with no family ties10. Insufficient research has been done to look for the factors compelling children to make street, their home. In a study, in India, it was found that the most common reason for running away from home was; beating by parents or relatives, followed by a desire for economic independence, both parents dead, argument with parent etc11. Health problems of homeless people Studies on health of homeless have found that there are high prevalence of premature death and diseases like respiratory tract disease, sexually transmitted diseases and chronic diseases12-21 (Table 1). In Baltimore study2 average number of problems per person in men were 8.3 and in women it was 9.2. Chronic diseases often go unrecognized and untreated21. Even if the condition is detected and treated, lack of compliance and consistent follow-up often results in disease progression, disability, morbidity, and premature death 22. Besides physical health problems, mental health problems, substance use disorders and behavioral problems23-31 are also very high among this subsection of the society (Table 2). This section clearly highlights that there is
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Table 1: Summary of selected studies on health problems of homeless

Domain Authors/ Reference Year Place of Study Major Findings
Premature-death MMWR12 MMWR13 Hibbs et al14 1987 1991 1994 1997 2000 Atlanta San Francisco Philadelphia Boston Toronto Median age at death: black men 43, white men 53 years Average age at death was 41 years Age-adjusted mortality rate 4 times that of general population Average age at death : 47 years Mortality rate ratios were 8.3 for men aged 18 to 24 years, 3.7 for aged 25 to 44 years, and 2.3 for aged 45 to 64 years higher compared to general population AIDS was the leading cause of death among persons 25 to 44 years of age Health problems of women were leucorrhoea, menstrual irregularities, infertility and STDs and 3/4th of this illness was uncared for. 90% of married homeless men visited Commercial Sex Workers, but 3.3% consistently used condoms. Prevalences were 1.8% for HIV, 30.6% for previous hepatitis B infection, 3.3% for acute infection by hepatitis B virus, and 5.7% for syphilis. Consistent use of condoms was referred to by 21.3% and injecting drugs by 3% of them. Pneumonia and influenza, were found to cause death in homeless persons 25 and 30 percent of population were reported to be infected with TB, chronic diseases 40% reported at least one chronic health problem Heart disease and cancer were the leading causes of death among persons 45 to 64 years of age health problems and pressure to fulfill needs like obtaining food, clothing and shelter as well as lack of self-esteem and feelings of worthlessness. External barriers include unavailable or fragmented health care services, and prejudices and frustrations on part of health care professionals8. One-fifth of homeless adults who had not obtained needed medical care stated that this was due to inability to pay for medical services33.
Hwang et al15 Hwang et al16
Sexual Health Hwang et al15 Ray Sk etal17 1997 2001 Boston Kolkata, India
Talukdar A et al18 2007 Brito VO et al19 2007
Kolkata, India Sao Paulo, Brazil
Respiratory Problems Hwang et al15 WHO20 Ropers R etal21 Hwang et al16 1997 1999 1987 1997 Boston London, San Franscico US Boston
little data from India on health problems of homeless. The data are mainly from the western world especially US for many of the health conditions.
Barriers to health care seeking

Homeless people are also plagued by multiple internal and external barriers to obtain effective primary care32. Internal barriers include denial of
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Table-2: Summary of selected studies on psychosocial and behavioral aspects of homeless

Domain Authors/ Reference Year Place of Study Major Findings
Substance use disorder and high-risk behavior Shaffer D et al23 1984 New York MMWR13 1991 San Francisco UNDP24 2002 14 states of India
Kramer CB et al25 Violence Hwang et al15 Kramer CB et al25
2008
Seattle
70% of the runaways were using illegal drugs Drugs or alcohol were detected in 78% of the study population. Out of all substance dependents about 1/4th was homeless. Ahmedabad (83%), Hyderabad (65%), Mumbai (54%) and Delhi (39%) reported a higher prevalence More abuse of alcohol (80.6% vs 12.8% and drug (59.4% vs 12.8%) compared to domicile population. Homicide, injuries, and poisoning were the leading causes of death among persons 18 to 24 years of age. Homeless people have more severe injuries(13.9% vs 2.0%, P < .001), assault by burning (17.8% vs 11.2%, p < .001) 26.9% of study children reported to experience physical abuse. Incidence of involuntary sex among homeless young people is considerably higher than in the general population Housing is associated with lower rates of sexual assault among women Sixty percent of the sample reported sexual abuse. Dissociative behavior is widespread among these youth and may pose a serious mental health concern Major mental illnesses were present among 42% of men and 48.7% of women 35.5% of the adolescent met lifetime criteria for Post Traumatic Stress Disorder. Significant correlates were age of adolescent, being female, having experienced serious physical abuse and/or sexual abuse etc. their age and developmental stage. These include lack of knowledge of clinic sites, fear of not being taken seriously and fears of police or social services involvement36. Available health care facilities: In India we have only shelters for homeless people. In Delhi, the capital of India, there is a total of 22 temporary and 12 permanent shelters with a capacity of 400034. By any estimate over 1 lakh people
1997 2008
Boston Seattle
Physical Abuse and Victimization Banerjee SR26 2001 Rosenthal D et al27 Kushel MB et al28 2003 2003
Calcutta, India Australia San Franssico Texas Seattle Baltimore USA
Rew L et al29 2003 Mental Health Problems Tyler et al (30) 2004 William R Breakey (2)1989 Whitbeck LB et al (31) 2007
Homeless people frequently lack identification or other documentation to prove indigent status in order to qualify for free or reduced services in mainstream health care settings. For this reason even if needed they are denied treatment under national programmes like RNTCP (Revised National Tuberculosis Control Programme). Similar reasons were also found by Heath Need Assessment Survey team of Aashray Adhikar Abhyan 34. Often the homeless people are denied services because of their appearance35. Homeless adolescents confront further hurdles stemming from
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are homeless in Delhi. In June 2000, Ashray Adhikar Abhiyan (a NGO) counted 52,765 homeless people, in cer tain areas of Delhi alone. Even Delhi Development Authority (DDA) admits that at least 1% of the population is homeless, i.e. 1.4 lakh at present37. More or less the shelters just provide physical protection and are not linked to any health intervention programs of the government. In one survey undertaken by Aashray Adhikar Abhyan, Institute of Human Behaviour and Allied Sciences34 it was found that homeless population considered visit or these places unfruitful for want of proper identity document and lack of support to guide them through cumbersome procedure, many feared past hostile experiences of discrimination and neglect. The issue of homelessness and health system has not been addressed at all in India. Thus, at this stage we have to learn from the experience of other countries. The Health Care for the Homeless (HCH), program USA 38 emphasizes a multi-disciplinary approach to deliver services, combining aggressive street outreach with primary care, mental health and substance abuse services. In Philadelphia and New York City a pilot project has started with aim to identify neighbourhoods from where a disproportionate number of homeless come and focus on activities like job training, health care services, drug and alcohol treatment etc39.
we do not have any proper existing health care services and programmes for homeless, all that we have are mostly supported by voluntary organizations. Recommendations In view of all these conditions, we suggest that 1. There is urgent need of proper definition and development of proper methodology to have a proper estimate of their number. 2. A national study to provide reliable data on health problems and health care needs of homeless people. An attitude of dignity is essential when working with people, who are homeless. Provide motivational training to health providers (Health Workers, Medical Officers, and Supervisors) to be more sensitive towards this group. Development of guideline to have a programme, which should be accessible (outreach services), affordable (free), comprehensive (both curative and preventive component). It should include mental health and substance abuse problems. This programmes should also have preventive component like screening for acute and chronic health problems, immunization and special services for women including family planning, antenatal and perinatal care. The National Urban Health Mission40 should look in to these aspects and identifying and caring for homeless could be one of the activities based incentives identified for the Urban Social Health Activist (USHA). Linking the programme with programmes like National Rural Employment Guarantee (NREG) Act41 which for rural area provides employment opportunities. Effort should be taken to see that homeless people can also avail this opportunity and its counterpart in urban area needs to be implemented. Public health professionals also need to focus into those social and economic issues, which are compelling people to lead a life of homeless. They also need to focus on operational aspects of certain programmes (eg, RNTCP) which need to be modified to include this particular group and also to have effective control on the disease.
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Conclusion
In conclusion high mortality and morbidity rate among homeless population are caused by preventable and treatable conditions but health care providers need to be aware of the unique difficulties faced by this subsection. There is need to improve accessibility and availability of health services in order to serve homeless population. Medical care facilities for the homeless are inadequate for a number of reasons: first, the magnitude of homelessness, is under defined. Second there is lack of studies on health problems of homeless people in India. Third, the shortage of facilities and the legal complications to provide them treatment. Fourth, behavior of the homeless and the inability of the providers to deal with such people. Fifth, in India 5.
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Letter to the Editor HIV/ AIDS Awareness through Mass Media the Measurement of Efforts Made in an Urban Area of India
Dear Editor, Growing threat of HIV/AIDS to the people has become a great concern of India and other developing countries. The awareness of HIV/AIDS is the prevention of the infection/ disease. Mass media such as Television, Radio, Print Media, Hoardings, role plays etc. are the first source of information and most effective modes of communication between the media and the general population where as health care providers are less source of information1. It has been proved by many studies that the main source of information for AIDS awareness in the student is mass media 2-5 . National AIDS Control Organization (NACO) in collaboration with WHO and other international agencies is dedicated and made many efforts to develop the awareness among the people but still prevalence is growing day by day. In view of above, Hospital Administration, Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS) and Uttar Pradesh Hospital and Health Administration Reforms Society (UPHHAR), Lucknow, Uttar Pradesh, India intended to conduct a study of efforts made by the government, NACO, NGOs etc to develop the awareness through mass media for urban population of Lucknow, Uttar Pradesh, during November December 2005. The objectives were to find out the level of efforts made through the mass media to develop the awareness of HIV / AIDS amongst the general population by Best Media Practices and to find out the level of contribution made by hospital and the public places for HIV/AIDS awareness. Seven newspapers were considered; out of which 3 were English daily editions, 3 Hindi daily editions and 1 Urdu daily edition, all widely circulated in the city of Lucknow. All these were scanned thoroughly for a period of one month (8th November 2005 to 8th December 2005) for the contents such as: general health awareness, awareness about HIV / AIDS, health seminars / programmes, central government health programmes and miscellaneous (these include articles on rallys, road shows, surveys, camps, etc.) Of 143 contents of different health related issues 52 (27%) were on HIDS/ HIV awareness. It indicates that newspaper print media is contributing reasonably adequate for HIV/AIDS awareness. Six major pre-identified routes, which connect the city to the railway stations, airport, bus stands covering approx. 50 km. length network were covered to study informative hoarding, banners & posters displayed providing information about HIV/AIDS. The study revealed that only 5% (7 out of 132) contribution is made by the hoarding/ banner on road for HIV/ AIDS awareness in comparison to other health related matters. Out of the five hospitals visited, only two hospitals were found to be actively involved in HIV/AIDS awareness through posters/ banners etc. This was quite an astonishing revelation because hospitals are the main places where considerable amount of awareness can be generated through posters, banners and hoardings. Only 04% (2 out of 48) efforts have been made by the hospitals to develop the AIDS/ HIV awareness in comparison to other health matters. On the primary channel of All India Radio, 6 programs on AIDS were broadcasted in the month of November 2005. In addition to this there was one phone in program on AIDS. 4 programs on AIDS were telecasted by Doordarshan and only 1 on general health including Kalyani I & II programs. Traveling through various routes in Lucknow revealed the fact that very few banners / hoardings are devoted for the purpose of spreading AIDS awareness. Out of the 6 routes covered (approx. 50 km. network area) only 4 hoardings of AIDS were found. The number of healthcare hoardings was unexpectedly low. There is an urgent need to significantly scale-up public health interventions in relation to HIV/AIDS awareness that work (both in terms of coverage and quality) to make a meaningful impact. While NGOs and community-based organizations have a critical role to play in implementing these interventions amongst the various population groups, the government must shoulder the overall responsibility for planning, coordinating, mobilizing, and facilitating the various HIV/AIDS prevention, care, and treatment services in the country. References: 1. Ndlovu RJ, Sihlangu RH. Preferred source of information on AIDS awareness among high school students from selected school in Zimbabwe: Journal of Advance Nursing, 1992 April; 17 (4): 507- 13. 2. Anochie L, Ikpeme E. AIDS awareness and knowledge among primary school children in Port Harcourt Metropolis: Niger Journal of Medicine, 2003 Jan Mar; 12 (1); 27-31.
Chandra H et al: HIV/ AIDS Awareness through Mass Media
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3.
4. 5.
Maswanya E et al. Knowledge and attitude towards AIDS among female college student in Nagasaki, Japan, Health Education, Res. 2000 Feb; 15 (1): 511. Lihiri s et al. Women in 13 states have little knowledge of AIDS: National Family Health Survey Bulletin 1995 Oct; (2): 1-4. Carducci A et al. AIDS related information, attitude and behaviors among Italian male young people:
European Journal of Epidemiology 1995 Feb; 11 (1): 23-31. Hem Chandra, K. Jamaluddin, L. Masih, K. Faiyaz, N. Agarwal, D. Kumar Hospital Administration, Sanjay Gandhi Post Graduate Institute of Medical Sciences and Uttar Pradesh Hospital and Health Administration Reforms Society, Lucknow, Uttar Pradesh, India
Undernutrition in 5-10 Year Olds: Experiences from a PHC in Pondicherry

Dear Editor, Child health care in India focuses on the under-fives under national programmes of ICDS and CSSM. Launch of RCH programme in 1997, drew attention to the needs of adolescents (10-19 years) also. But there remains a gap in delivering health care to 5-10 years old children. This age group is supposed to be addressed by the school health programme, which in India is very inadequate, without follow-up or accountability. The total number of children observed was 518. This being a primary care centre, most children in both age groups had minor ailments. We observed that a higher proportion (58%) of 5-10 year old children were malnourished as compared to under-fives (50%), though not statistically significant. However, significantly greater proportion of children in 5-10 years had severe malnutrition i.e., < 60% of the expected weight for age (2 = 10.94, p = 0.00094). The deprivation in nutrition will have longterm implications such as poorer work capacity and reproductive performance in adulthood2. But, this population is not representative of the children in the community as this was hospital based. So, this study needs to be extended to the community to assess the overall scenario. We recommend continuum of care from under-five through 5-10 years to the adolescents by strengthening the school health services.
Table 1: Undernutrition in 5-10 year olds as compared to under-fives

Age groups F M Total F M Total >80% % of expected weight for age 71-80% 61-70% <60% 16(10.1) 38(17.1) 54(14.2) 14(19.4) 16(24.2) 30(21.7) 3(1.9) 5(2.3) 8(2.1) 7(9.7) 5(7.6) 12(8.7) Total 158 222 380 72 66 138
<5 yrs
78(49.4) 61(38.6) 111(50) 68(30.6) 189(49.8) 129(33.9) 31(43.1) 27(40.9) 58(42.1) 20(27.8) 18(27.3) 38(27.5)
5-10 yrs
Figures in parentheses are row percentages

In the union territory of Pondicherry, one of the top achievers of human development in the country having low infant and child mortality rates 1 we compared the nutritional status of 5-10 year old children with underfives attending out patient clinic of Primary Health Centre (PHC), Mettupalayam, in Pondicherry town. Weight for age was used to measure undernutrition. Weights of all children less than 10 years was measured by the physicians using a baby weighing machine (pan type) for infants and a personal weighing scale for others in the months of August and September 2007. Each child was considered once in spite of multiple visits. According to IAP classification, underweight was measured as percentage of the median of NCHS standard. References: 1. 2. Profile of the Union Territory of Pondicherry. http:// ncw.nic.in/pdfreports/Gender%20 Profile Pondicherry.pdf (last accessed on 8.5.08) Kliegman: Nelson textbook of pediatrics, 18th ed. Saunders: Philadelphia; 2007. p 228. S. Sarkar1, S. Ananthakrishnan2
1Dept.
of Community Medicine, 2Dept. of Paediatrics; PKMC&RI, Puducherry, India Correspondence: sarkarsonaligh@gmail.com

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INDIAN JOURNAL OF PUBLIC HEALTH

(Quarterly Journal of Indian Public Health Association)

Vol. 52 No.3 July - September 2008

Indian Journal of Public Health Contents

Editorial Injury: the most Underappreciated and Unattended Pandemic

Indian Journal of Public Health Vol.52 No.3 July - September, 2008

Editorial: Injury: the most Underappreciated and Unattended Pandemic

Indian Journal of Public Health Vol.52 No.3 July - September, 2008

A. Krishnan1, B. Shah2, Vivek Lal3, D. K. Shukla4, Eldho Paul5, S. K. Kapoor6 Abstract

Indian Journal of Public Health Vol.52 No.3 July - September, 2008

Krishnan A et al: Risk Factors for Non-Communicable Diseases in Haryana

Material and methods

Indian Journal of Public Health Vol.52 No.3 July - September, 2008

Krishnan A et al: Risk Factors for Non-Communicable Diseases in Haryana

Tobacco & alcohol use (Table 1)

* None of the women reported alcohol consumption, **95% Cl values in parenthesis

Krishnan A et al: Risk Factors for Non-Communicable Diseases in Haryana

Table 2. Pattern of physical inactivity by domains

Physical inactivity (Table 2)

Table 3. Distribution BMI & waist circumference by age & sex

Indian Journal of Public Health Vol.52 No.3 July - September, 2008

Krishnan A et al: Risk Factors for Non-Communicable Diseases in Haryana

Table 4 . Prevalence of thinness, overweight and obesity in the study subjects

Age adjusted 29.1 prevalence* (26.0-30.9)

* 95% Cl values in parenthesis

Anthropometry (Table 3 & 4)

15-24 25-34 35-44 45-54 55-64 Age adjusted mean

Indian Journal of Public Health Vol.52 No.3 July - September, 2008

Krishnan A et al: Risk Factors for Non-Communicable Diseases in Haryana

Blood pressure (Table 5)

Indian Journal of Public Health Vol.52 No.3 July - September, 2008

Krishnan A et al: Risk Factors for Non-Communicable Diseases in Haryana

Indian Journal of Public Health Vol.52 No.3 July - September, 2008

Krishnan A et al: Risk Factors for Non-Communicable Diseases in Haryana

53rd Annual National Conference of IPHA

Kempegowda Institute of Medical Sciences (KIMS), Bangalore. Registration fees

Accompanying person 6 (Spouse & Children only) Pre-conference CME 1. 2. 3. 4. 5. 6.

Indian Journal of Public Health Vol.52 No.3 July - September, 2008

Original Article Epidemiology of Disability in a Rural Community of Karnataka

Materials and Methods

Indian Journal of Public Health Vol.52 No.3 July - September, 2008

Ganesh KS et al: Disability in a Rural Area of Karnataka

Table 1: Prevalence of disability according to socio-demographic variables (n=954)

1.8 0.2 10.1 0.001* 0.9 0.3

Indian Journal of Public Health Vol.52 No.3 July - September, 2008

Ganesh KS et al: Disability in a Rural Area of Karnataka

Table 2: Correlates of disability: Multiple Logistic Regression analysis

Indian Journal of Public Health Vol.52 No.3 July - September, 2008

Ganesh KS et al: Disability in a Rural Area of Karnataka

Indian Journal of Public Health Vol.52 No.3 July - September, 2008

Ganesh KS et al: Disability in a Rural Area of Karnataka

For booking rooms / seminar hall please contact:

Indian Journal of Public Health Vol.52 No.3 July - September, 2008

Indian Journal of Public Health Vol.52 No.3 July - September, 2008

Biswas AB et al: IDD in Purba Medinipur, West Bengal

Materials and Methods

Indian Journal of Public Health Vol.52 No.3 July - September, 2008

Biswas AB et al: IDD in Purba Medinipur, West Bengal

8 (n=805) 9 (n=785) 10 (n=810) All (n=2400)

* 2 = 12.55, d.f. = 1, p=0.0003

** 2 = 3.99, d.f. = 2, p= 0.136

Indian Journal of Public Health Vol.52 No.3 July - September, 2008

Biswas AB et al: IDD in Purba Medinipur, West Bengal