WHO South-East Asia Journal of Public Health

ISSN 2224-3151
WHO South-East Asia Journal of Public Health
Volume 1, Issue 2, April–June 2012, 125-226
Volume 1, Issue 2, April–June 2012, 125-226
Editorial
Role of modern technology in public health:
opportunities and challenges
Jai P Narain & Roderico Ofrin
125
Perspective
Malaria control in India: has sub-optimal
rationing of effective interventions compromised
programme efficiency?
Habib H Farooqui, Mohammad A Hussain,
Sanjay Zodpey,
128
Original Research
Abuse against women in pregnancy: a populationbased study from Eastern India
Bontha V Babu, & Shantanu K Kar
133
Prognostic indicators in patients with snakebite:
analysis of two-year data from a township
hospital in central Myanmar
Myo-Khin, Theingi-Nyunt,
Nyan-Tun-Oo, Ye-Hla
144
Initiating tobacco cessation services in India:
challenges and opportunities
Cherian Varghese, Jagdish Kaur, Nimesh G
Desai, Pratima Murthy, Savita Malhotra,
Subbakrishna D K, Vinayak M Prasad,
Vineet G Munish
159
Betel quid chewing and its risk factors in
Bangladeshi adults
Meerjady S Flora, Christopher GN MascieTaylor, Mahmudur Rahman
169
Injection practices in India
IPEN Study Group
189
Policy and practice
Funding health promotion and disease prevention
programmes: an innovative financing experience
from Thailand
Supreda Adulyanon
201
WHO
South-East Asia
Journal of
Public Health
Review
Nipah virus outbreaks in Bangladesh: a deadly
infectious disease
Mahmudur Rahman, Apurba Chakraborty208
Report from the field
Early detection of chronic diseases and their risk
factors: a women empowerment model from
Kerala, India
Safraj Shahul Hameed
213
Commentary
Hospital or home? Scripting a high point in the
history of TB care and control
Mukund Uplekar & Mario Raviglione
220
Voices
Mobile phones for community health workers of
Bihar empower adolescent girls
Derek Treatman, Mohini Bhavsar, Vikram
Kumar & Neal Lesh
224
Recent WHO publications
226
WHO South-East Asia Journal of Public Health
Performance of cause-specific childhood
mortality surveillance by health workers using a
short verbal autopsy tool
Rakesh Kumar, Suresh K Kapoor,
Anand Krishnan
151
Antibiogram of S. enterica serovar Typhi and
S. enterica serovar Paratyphi A: a multi-centre
study from India
Indian Network for Surveillance of
Antimicrobial Resistance Group
182
Volume 1, Issue 2, April–June 2012, 125-226
Inside
ISSN 2224315-1
World Health House
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New Delhi-110002, India
www.searo.who.int/who-seajph
www.searo.who.int/who-seajph
cover - initial pages.indd 1
05-Jun-2012 2:34:31 PM
WHO South-East Asia
Journal of Public Health
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cover - initial pages.indd 2
WHO South-East Asia Journal of Public Health
Volume 1, Issue 2, April–June 2012, 125-226
Advisory Board
Samlee Plianbangchang
(Chair)
Richard Horton
Hooman Momen
David Sanders
Fran Baum
Lalit M Nath
Chitr Sitthi-amorn
Editorial Board
Poonam K Singh
(Chair)
Sattar Yoosuf
Nyoman Kumara Rai
Jai P Narain
Sangay Thinley
Athula Kahandaliyanage
Quazi Munirul Islam
Nata Menabde
Maureen E Birmingham
Mahmudur Rahman
Chencho Dorji
Hasbullah Thabrany
Nay Soe Maung
Suniti Acharya
Rohini de A Seneviratne
Phitaya Charupoonphol
Mariam Cleason
Kenneth Earhart
Jacques Jeugmans
Editorial Team
Jai P Narain
(Chief Editor)
Anchalee Chamchuklin
(Coordinator)
Rajesh Bhatia
(Associate Editor)
Jitendra Tuli
(Copy Editor)
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Rajesh Kumar
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05-Jun-2012 2:34:33 PM
WHO South-East Asia Journal of Public Health
Volume 1, Issue 2, April–June 2012, 125-226
Contents
Editorial
Role of modern technology in public health: opportunities and challenges
Jai P Narain & Roderico Ofrin
125
Perspective
Malaria control in India: has sub-optimal rationing of effective interventions compromised
programme efficiency?
Habib H Farooqui, Mohammad A Hussain, Sanjay Zodpey,
128
Original Research
Abuse against women in pregnancy: a population-based study from Eastern India
Bontha V Babu, & Shantanu K Kar
133
Prognostic indicators in patients with snakebite: analysis of two-year data from a township hospital
in central Myanmar
Myo-Khin, Theingi-Nyunt, Nyan-Tun-Oo, Ye-Hla
144
Performance of cause-specific childhood mortality surveillance by health workers using a short
verbal autopsy tool
Rakesh Kumar, Suresh K Kapoor, Anand Krishnan
151
Initiating tobacco cessation services in India: challenges and opportunities
Cherian Varghese, Jagdish Kaur, Nimesh G Desai, Pratima Murthy, Savita Malhotra,
Subbakrishna D K, Vinayak M Prasad, Vineet G Munish
159
Betel quid chewing and its risk factors in Bangladeshi adults
Meerjady S Flora, Christopher GN Mascie-Taylor, Mahmudur Rahman
169
Antibiogram of S. enterica serovar Typhi and S. enterica serovar Paratyphi A: a multi-centre
study from India
Indian Network for Surveillance of Antimicrobial Resistance Group
182
Injection practices in India
IPEN Study Group
189
Policy and practice
Funding health promotion and disease prevention programmes: an innovative financing
experience from Thailand
Supreda Adulyanon
201
Review
Nipah virus outbreaks in Bangladesh: a deadly infectious disease
Mahmudur Rahman, Apurba Chakraborty
208
i
Book 1.indb 1
05-Jun-2012 2:35:51 PM
Report from the field
Early detection of chronic diseases and their risk factors: a women empowerment model
from Kerala, India
Safraj Shahul Hameed
213
Commentary
Hospital or home? Scripting a high point in the history of TB care and control
Mukund Uplekar & Mario Raviglione
220
Voices
Mobile phones for community health workers of Bihar empower adolescent girls
Derek Treatman, Mohini Bhavsar, Vikram Kumar & Neal Lesh
224
Recent WHO publications
226
ii
Book 1.indb 2
05-Jun-2012 2:35:54 PM
Editorial
Role of modern technology in public health:
opportunities and challenges
Jai P Naraina & Roderico Ofrinb
During the past two decades, the world has seen
profound changes in technology development,
heralding an information age.1 As a result of
the information and communication boom, a
combination of new technologies is being used
to obtain, disseminate and share information
as never before. Moreover, social media has
also become a powerful tool to share ideas
and solutions in almost all spheres of daily
life. This also offers great opportunities to
bring about better health to populations at
large in a different way. An important question
however is: how can modern technology be
deployed to improve quality of health delivery
at a lower cost? What are the challenges and
opportunities that lie ahead?
It is due to today’s internet connectivity
and (smart) mobile phone penetration,
more than air travel, that the world is now
literally a global village. With information
and communication devices available even
in remote villages, there is a potential that
these technologies could revolutionize health
service delivery and act as a “game changer”
for an efficient and people-centered health
care system in the 21st century. For example,
an early warning system during emergencies
via short text messaging, or even availability
of mobile phones in remote villages can be
used to call for help in the event of a difficult
labour thereby preventing maternal or infant
mortality. Mobile phones which are now
virtually ubiquitous with 700 million users in
India alone are being used to track distribution
of bed nets by malaria programmes. In the
global adult tobacco surveys, handheld devices
or PDAs# are used by health care workers to
collect and collate survey data, and to transfer
data to a central location in no time; such
a facility can be used in other similar field
surveys without use of the printed forms.
Satellite connectivity helps greatly in distance
learning, and in transmission of data as well
as information pertaining to early warning of
unusual health events.
Similarly, text messaging information
on new cases of influenza from hospital
settings as a part of online surveillance or
alerting patients with diabetes or stroke
through messages regarding their medicine
Former Director, Department of Sustainable Development and Healthy Environments, World Health Organization, Regional Office
for South-East Asia, New Delhi, India.
Regional Adviser Emergency and Humanitarian Action, World Health Organization, Regional Office for South-East Asia, New Delhi,
India.
#
Personal Digital Assistants
Correspondence to who-seajph@searo.who.int
a
b
WHO South-East Asia Journal of Public Health 2012;1(2):125-127
Book 1.indb 125
125
05-Jun-2012 2:35:54 PM
Role of modern technology in public health
intake; conducting information-sharing
sessions through videoconferencing and
teleconferencing thereby reducing the number
of face-to-face interactions/meetings; using
email for fast and non-bureaucratic means
of communication; risk mapping through
the use of geographic information system
and geographic positioning system; social
networking such as Facebook and Twitter for
news gathering, updating of an emergency
or an outbreak; and carrying out clinical or
bedside e-consultations regarding patients in
remote or rural sites as a part of telemedicine
are some of the applications where modern
technology can modernize health care and
bring in efficiency and quality. Dissemination
of technical information is another example.
While many scientific journals are presently
facing a cost crunch in publishing hard copies,
the trend is now moving towards free online
or web publishing.
Given these advances, a global consultation
on eHealth was organized by WHO in 2004
which recommended that WHO should
support information for health promotion and
awareness, health and biomedical research and
e-learning; information for health information
system including disease surveillance; and
information for health care delivery including
diagnostics, treatment and consultation 2.
Then, in May 2005, the World Health Assembly
discussed the topic in the context of health and
passed a resolution on eHealth using Member
States to create long-term strategies, develop
necessary infrastructure and collaborate with
private and non-profit sectors3. During 20052006, WHO undertook a global survey on
e-Health to obtain baseline data on the current
status of eHealth, which indicated that after
a slow start in the 1990s there is growing
momentum for eHealth uptake by countries
which is very likely to continue, particularly
in developing countries.4
126
Book 1.indb 126
Jai P Narain et al.
These are just some examples where
technology can be used. But technology is
growing rapidly and it is often difficult to keep
pace with it. Internet and social media use is
growing in various countries in the South-East
Asia Region.5 However, despite the improved
access to such technologies public health and
clinical health services are not dominant in
their content and/or applications.
There are many barriers and challenges
to the rapid use of modern technology and in
the implementation of various initiatives and
specific World Health Assembly resolutions.
In many countries, the infrastructure or
connectivity does not exist. There are
also concerns that investing in the use of
modern technology comes at a high initial
cost compared to basic health needs and
other competing priorities. Demonstrating
the cost-effectiveness of modern technology
in promoting health is therefore a priority.
Creative ways of investing and cost sharing
should be discussed so that the information
highway has health as one of its main
applications. Building capacity of health care
workers through training is also urgently
needed. There are also issues that have
legal, security, accountability and ethical
implications. For example, those related to
the uniformity in legal standards, especially
those that are in place in developing countries
regarding the security and safety of medical
information. There are concerns also that
the rapid developments and penetration of
technology is further causing a digital divide
between “haves” and “have nots”, causing
further disparities in society and along the
social gradient.
Nevertheless, technology must be used
appropriately. Whether technology can be of
benefit or harm will depend largely on the
way it is used. The potential applications of
information/communication technology for
WHO South-East Asia Journal of Public Health 2012;1(2):125-127
05-Jun-2012 2:35:54 PM
Jai P Narain et al.
health to strengthen health systems and
improve efficiency, safety and quality of health
care are truly enormous. As recognized by
the World Health Assembly, all countries must
use the opportunities to build or strengthen
basic eHealth systems as a part of health
programmes thereby improving health
services. While governments have a key role
in pushing the agenda, it will be important to
strengthen collaboration with international
and nongovernmental organizations, the
private sector and other key stakeholders.
Member States can also learn from success
and failures of other countries and partners
in order to move forward in this area. Based
on evidence, it is clear that enhancing use of
modern technology is an excellent investment
for the future.
WHO South-East Asia Journal of Public Health 2012;1(2):125-127
Book 1.indb 127
Role of modern technology in public health
References
1. Blaya J, Fraser H, Holt B. eHealth technologies show
promise in developing countries. Health Affairs. 2010;
29(2): 244-251.
2. World Health Organization. eHealth for health
care delivery: strategy 2004-2007. Geneva: WHO,
2004.
3. World Health Assembly. eHealth. Resolution
WHA58.28. Geneva: WHO, 2005.
4. World Health Organization. Building foundations
for eHealth: progress of Member States: report of
the WHO Global Observatory for eHealth. Geneva:
WHO, 2006.
5. Internet world statistics: usage and population
statistics. http://www.internetworldstats.com/asia.
htm - accessed on 23 February 2012.
127
05-Jun-2012 2:35:54 PM
Perspective
Malaria control in India: has sub-optimal rationing
of effective interventions compromised programme
efficiency?
Habib H Farooquia, Mohammad A Hussainb, Sanjay Zodpeya,c
Despite more than five decades of intensive
control efforts, malaria is still a challenge to
the Indian health system.1 1.6 million cases
and around 1000 deaths were reported in
2010 as per National Malaria programme.2
These estimates of malaria burden, however,
are uncertain. Incidence gaps have been
identified.3,4 Lack of accurate estimates for
population at risk is one of the elementary
problems in defining intervention strategies
against malaria. The Government of India
has recognized these facts while updating
operational guidelines for malaria control.5
There is evidence of the decreasing trend
in cases over the past few years. However,
recent estimates of malaria deaths made by
independent researchers have raised questions
on progress of the malaria control programme.3
Increasing the pace of malaria control in
India requires a meticulous assessment of
malaria control interventions in terms of
operational feasibility, cost-effectiveness,
net-effectiveness and rationing of various
interventions.
Epidemiologically, malaria is extremely
complex; it is a focal disease the distribution
of which is influenced by a multitude of
factors related to human, mosquito and
parasite population, as well as to the
environment. The emergence, transmission
and sustainability of malaria depends largely
upon the interaction between and among
these factors. Epidemiological reasoning
and mathematical modelling has shown that
the key to malaria control lies in reservoir
reduction and vector control. As per the
classic Ross–Macdonald mathematical model,
the efficiency with which an arthropod vector
transmits a pathogen, known as vectorial
capacity, depends on the density of the vector
species, number of susceptible host species,
the probability that a vector, having acquired
the pathogen, will live long enough to transmit
the pathogen, which is a combination of its
daily survival probability and the extrinsic
incubation period.6 Thus, the interventions
that reduce the host-vector contact (e.g. bed
nets) target reduction of host species. Those
that target adult vectors [e.g. the application
of dichlorodiphenyltrichloroethane (DDT) to
the walls of dwellings] influence the probability
of vector survival. Finally, vectoral capacity
is also affected by vector competence, which
is the chance that when a vector feeds on
an infected host it will actually acquire the
pathogen and support its development to
the infectious stage. This is affected by
Indian Institute of Public Health, Delhi, India.
Indian Institute of Public Health, 2nd & 3rd Floor, JSS Software Technology Park, E1/1, Infocity Road, Patia, Bhubaneswar751024, Odisha, India.
c
Public Health Foundation of India, New Delhi, India.
Correspondence to Mohammad A Hussain (email: akhtar.hussain@iiphb.org)
a
b
128
Book 1.indb 128
WHO South-East Asia Journal of Public Health 2012;1(2):128-132
05-Jun-2012 2:35:54 PM
Habib H Farooqui et al.
Malaria control in India: has sub-optimal rationing of effective interventions
compromised programme efficiency?
intrinsic properties of the vector and by
the density of the pathogen in the infected
host. Interventions like mass drug treatment
and schemes for the genetic modification of
vectors target vector competence.
Control strategies for vector-borne
infectious diseases can target the reservoir,
the pathogenic microorganism, the vector,
the human host, or combinations of these
elements.6 Traditionally, reservoir reduction
has been achieved through early case
detection and prompt treatment (EDPT)
and vector control through indoor residual
insecticide spray (IRS) with insecticides that
reduce the daily survival rate of the mosquito
whereas the insecticide-treated mosquito nets
(ITN) reduce the human biting rate of the
mosquito and its daily survival rate. However,
critical prerequisites to have positive effects of
IRS would depend on walls of dwellings being
sprayable, mosquitoes resting indoors and
sensitvity to insecticide. Similarly, the ITNs
require a consistent use by humans whenever
there is a chance of a human-mosquito contact.
The adoption of newer methods of malaria
diagnosis (rapid diagnostic kits) and treatment
(artemisin-based combination therapy) as well
as preventive instruments like long-lasting
insecticidal nets (LLIN)/insecticide-treated
bednets (ITNs) have improved the efficiency
of malaria control programmes. All these
present-day antimalarial interventions help
in reducing the endemicity by reducing the
human infectivity through early and effective
treatment and reduction in vectorial capacity
through mosquito control measures.7 However,
operationalization of these strategies has been
a story of success and failures during different
phases of malaria control in India.
The cost of scaling up and maintaining
of the existing level of coverage of essential
interventions has been a challenge. Despite
a considerable increase in the past few
years, global funding for malaria control still
WHO South-East Asia Journal of Public Health 2012;1(2):128-132
Book 1.indb 129
falls short of the estimated requirements
to provide complete intervention coverage
to those at risk in endemic regions. 8 The
current international funding for malaria
control represents approximately 20% of the
estimated total need for a gradual scale-up of
interventions for controlling malaria.8 National
government spending also falls short in many
countries including India.9 Thus, there is a
need for effective and efficient utilization of
all available resources. There is a growing
body of evidence on best practices and costeffectiveness of malaria control interventions
across the globe, which can serve as guidance
for financial decision-making.10 It is important
to ask whether interventions currently in
practice are being appropriately used and
what is the most cost-effective way to scale up
activities to the levels needed? In particular,
which prevention or treatment strategies,
and what combination, are most effective
and where?
An analysis of the budget documents
of National Vector-borne Disease Control
Programme (NVBDCP) in India has shown
that financial allocations have been scaled up
from Indian Rupees (INR) 1370 million during
the Tenth Five Year Plan (2002-2007) to INR
3190.2 million for the Eleventh Five Year Plan
(2007-2012).11 The actual expenditure has also
increased. However, the allocative efficiency
of the programme is compromised as a result
of inappropriate financing at geographical,
operational and technical levels. In terms of
geographical distribution, five states (Orissa,
Chhattisgarh, Madhya Pradesh, Jharkhand
and West Bengal) accounted for 60% malaria
cases and 75% falciparum malaria cases in
2002-2003. However, the financial allocations
represented only 41.5% of the total funds.
Micro-stratification of risk areas for better
targeting of interventions is very poor in
India. Also, it is found that malaria is most
common in areas where reliable data are least
129
05-Jun-2012 2:35:54 PM
Malaria control in India: has sub-optimal rationing of effective interventions
compromised programme efficiency?
available so exact numbers are not easy to
determine.3 This in turn affects the optimum
allocative efficiency. The estimated number
of cases used for policy planning are basically
generated from routine reporting of malaria
data. However, independent researchers have
reported that 86% deaths due to malaria are
not recorded in any formal government health
system, indicating that deaths from malaria
are predominantly unnoticed by the existing
health-reporting system.3 Besides this, the
health management information system in
India has not been found fit for the recording
of malaria morbidity and mortality.12
Some malaria control intervention are
technically more efficient than others; for
instance, it has been argued that early diagnosis
and treatment through rapid diagnostic kits
and artemisin-based combination therapies
offer much higher net effectiveness over
residual insecticidal sprays on the basis of
operational feasibility. Estimates have revealed
that during the Eleventh Five Year Plan the
contribution for drugs and diagnostics has
increased from 8.3% to 15.5% and from 0.7%
to 6.3% respectively. Similarly, allocation for
LLINs has been increased from 0% to 7.5%,
highlighting the fact that programme is
moving in the direction of improved technical
efficiency. However, there is slight reduction
in the budgetary allocation for bednets (ITN)
from 5.2% to 3.4%. Also, it has been argued
that the production and availability of LLNs
is compromised in the country. It was also
observed that the insecticide spraying budget
has reduced from 52.5% to 28.1%. Such
reduction may result in poor efficiency as
it is well recognized that incremental costeffectiveness of preventive measures are a
good bargain.
In the context of operational efficiency
and programme management, increasing the
investment in training, and monitoring and
evaluation to 3.2% and 3.5% respectively,
130
Book 1.indb 130
Habib H Farooqui et al.
offers positive synergies with intervention
efficiencies. However, the financial allocation
for behaviour change communication at
8.46% may result in reduced programme
efficiency as it has poor net effectiveness
and is prone to potential leakages. Similarly,
the operational cost at 39.1% of total budget
also raises concerns on efficiency. The
programme does not conform to evidencebased recommendations on financial allocation
for drugs, diagnostics, LLINs, ITNs and
spraying, etc.
Allocative efficiency of funding can be
enhanced by prioritizing financial allocation
to key interventions on the basis of their net
effectiveness and operational feasibility. This
will ensure enhanced technical efficiency of the
programme along with reduced operational
costs. Financial allocation for interventions
based on early diagnosis and treatment should
be prioritized over IRS and ITNs/LLIN. With
85% of Indian population residing in high and
low malaria-risk areas, the coverage scale of
preventive intervention appears to be limited
to less than 30% of population at risk.13
Evidence suggests that both interventions are
effective in reducing malaria, as compared
with active case detection and treatment.
However, ITNs are effective than IRS in
averting malaria cases. However, in terms of
efficiency of interventions the evidence from
African countries has shown that in a very
low-income country, the cost-effectiveness
per DALY averted ranges from US$ 19 to US$
85 for ITNs (nets plus insecticide), US$ 32
to US$ 58 for residual spraying (two rounds
per year) and US$ 1 to US$ 8 for casemanagement improvements.14 The health
outcome measured in a randomized cluster
trial in India has shown that the mean cost
per case averted for ITNs was statistically
significantly lower (US$ 52) than IRS (US$
87).15 High coverage with artemisinin-based
combination treatments was found to be
WHO South-East Asia Journal of Public Health 2012;1(2):128-132
05-Jun-2012 2:35:54 PM
Habib H Farooqui et al.
Malaria control in India: has sub-optimal rationing of effective interventions
compromised programme efficiency?
the most cost-effective strategy for control
of malaria recently.16 However, it has been
argued that treatment alone can achieve less
than half the total benefit obtainable through a
combination of interventions, hence, scaling up
the use of ITNs or IRS with insecticides is also
critical. An assessment of cost-effectivenss
and cost-benefit implications of increasing the
coverage of all interventions (comprehensive),
prevention (bednets and indoor spraying)
and improved case management, found
that increasing the coverage of improved
case management is the most economically
attractive strategy for the Asia-Pacific
region. The cost per DALY averted in malaria
case management strategies is US$ 88 as
compared with US$ 1722 and US$ 1567
through strategies like spraying and bednets,
and comprehensive strategies involving
all interventions respectively (Personal
Communication: Swarup Sarkar, GFATM and
Ross Mcloed, Asian Development Bank). There
are very limited cost-effective analysis studies
available on environment-friendly antimalarial
measures, i.e. biolarvicide, Gambusia fish and
Bacillus thuriengesis var israelis etc. in the
Indian context. Hence, more effort should
be made to find out the feasibility of these
interventions to enable decisions on whether
to advocate these environment-friendly
initiatives on long-term basis on a large scale.
There is also the need for conducting a costeffective analysis of various control measures
initiated under the national malaria control
programme.
The choice of intervention should not be
one over another, rather it should be a rational
mix that can offer a comprehensive control
strategy inclusive of all interventions, and is
focussed on regional programme requirements
based on disease epidemiology. A decade ago
the way to decide on interventions was to look
for disease burden and its epidemiological
WHO South-East Asia Journal of Public Health 2012;1(2):128-132
Book 1.indb 131
manifestations in terms of mortality, morbidity
and DALYs lost.17 However in the current
senario different malario-metric indices like
the Plasmodium falciparum parasite rate
(PfPR), entomological inoculation rate (EIR)
within the limits of Plasmodium falciparum
transmission (PfEIR), Pf annual parasite
incidence (PfAPI), basic reproductive number
for malaria under malaria control (PfRc)
should be taken under consideration while
allocating resources. The Malaria Atlas
Project (MAP) could be of great help while
considering the above matrices.18 Information
obtained from the National Anti-Malaria
Management Information System (NAMMIS)
could be of important, provided the validity
of the reporting system is justified. Evidence
from developing countries on best practices
and cost-effectiveness of malaria control
interventions can serve as guidance for
financial decision-making. However, care
must be taken when comparing the costeffectiveness of prevention and treatmentbased interventions, as the denominator
populations at risk may not be directly
comparable due to differences in age, location
or exposure to malaria.10 Similarly, valuable
insights from economic analysis, mathematic
models such as decision-tree models and
probabilistic sensitivity analysis models can
be considered for rational resource allocation
by donors and domestic health budgets and
for the selection of optimal packages of
interventions by malaria control programmes.
The model described by Ross and Macdonald
can be a good starting point for identifying
the epidemiological rationale and the utility
of various interventions across different
situations, and it should be complemented
by a cost-effectiveness analysis and financial
analysis to serve as guidance for policy
decisions.
131
05-Jun-2012 2:35:54 PM
Malaria control in India: has sub-optimal rationing of effective interventions
compromised programme efficiency?
References
1. National Vector Borne Disease Control Programme.
Director General Health Services. Ministry of Health
and Family Welfare. Malaria.. http://nvbdcp.gov.in/
malaria-new.html - accessed 2 May 2012.
2. National Vector Borne Disease Control Programme.
Director General Health Services. Ministry of Health
and Family Welfare. Malaria. http://nvbdcp.gov.in/
Doc/mal-situation-March12.pdf - accessed 15 May
2012.
3. Dhingra N, Jha P, Sharma VP, Cohen AA, Jotkar
RM, Rodriguez PS, et al. Adult and child malaria
mortality in India: a nationally representative
mortality survey. Lancet. 2010 Nov 20; 376(9754):
1768-1774.
4. Hay SI, Gething PW, Snow RW. India’s invisible
malaria burden. Lancet. 2010; 376(9754):17161717.
5. Government of India. Operational manual for
implementation of malaria programme 2009. New
Delhi: Ministry of Health and Family Welfare, 2009.
http://nvbdcp.gov.in/Doc/Malaria-OperationalManual-2009.pdf - accessed 2 May 2012.
6. Klempner MS, Unnasch TR and Hu LT. Taking a bite
out of vector-transmitted infectious diseases. N Engl
J Med. 2007; 356(25): 2567-2569.
7. Mendis K, Rietveld A, Warsame M, Bosman
A, Greenwood B, Wernsdorfer WH. From malaria
control to eradication: The WHO perspective. Trop
Med Int Health. 2009; 14(7): 802-9.
8. Kiszewski A, Johns B, Schapira A, Delacollette C,
Crowell V, Tan-Torres T, et al. Estimated global
resources needed to attain international malaria
control goals. Bull World Health Organ. 2007; 85:
623–30. 9. Snow RW, Guerra CA, Mutheu JJ, Hay SI. International
funding for malaria control in relation to populations
132
Book 1.indb 132
Habib H Farooqui et al.
at risk of stable plasmodium falciparum transmission.
PLoS Med. 2008; 5(7): e142. 10. White MT, Conteh T, Cibulskis R, Ghani AC. Costs and
cost-effectiveness of malaria control interventions - a
systematic review. Malar J. 2011;10:337. 11. Government of India. Working group on communicable
and non-communicable diseases for the eleventh five
year plan: report. New Delhi: Director General Health
Services, 2006.
12. Dash AP. Estimation of true malaria burden in India:
a profile of National Institute of Malaria Research.
2nd edn. New Delhi: National Institute of Malaria
Research, 2009.
13. World Health Organization. World malaria report
2010. Geneva: WHO, 2010.
14. Breman JG, Mills A, Snow RW, Mulligan JA, Lengeler
C, Mendis K, et al. Conquering malaria: disease
control priorities in developing countries. 2nd edn.
New York: Oxford University Press, 2006.
15. Bhatia MR, Fox-Rushby J, Mills A. Cost-effectiveness
of malaria control interventions when malaria
mortality is low: insecticide-treated nets versus inhouse residual spraying in India. Soc Sci Med. 2004;
59: 525-539.
16. Morel CM, Lauer JA, Evans .DB. Achieving the
millennium development goals for health. Costeffectiveness analysis of strategies to combat malaria
in developing countries. BMJ. 2005; 331:12991302B.
17. World Health Organization. Roll back malaria:
framework for monitoring progress and evaluation
outcomes and impact. Geneva: WHO, 2000.
18. The Malaria Atlas Project aims to disseminate free,
accurate and up-to-date information on malaria
and associated topics, organised on a geographical
basis. http://www.map.ox.ac.uk/ - accessed 2 May,
2012.
WHO South-East Asia Journal of Public Health 2012;1(2):128-132
05-Jun-2012 2:35:54 PM
Original Research
Abuse against women in pregnancy: a population-based
study from Eastern India
Bontha V Babua,b & Shantanu K Kara
Background: Violence against women is widely recognized as an important public health problem.
However, the magnitude of the problem among pregnant women is not well known in several parts
of India. Hence, the prevalence and characteristics associated with various forms of domestic
violence against women in pregnancy were studied in Eastern India.
Methods: A population-based cross-sectional sample survey covering married women with a
history of at least one full-term pregnancy (n 1525) was carried out in the Orissa, West Bengal and
Jharkhand states of India. Interviews were conducted using a pre-piloted structured questionnaire
to inquire about physical, psychological and sexual domestic violence. Data on socioeconomic
characteristics and behaviours were also collected. The association of independent variables with
domestic violence were examined by using logistic regression models.
Results: The prevalence of physical, psychological and sexual domestic violence during a recent
pregnancy was found to be 7.1%, 30.6% and 10.4% respectively, and the lifetime prevalence
during all pregnancies was 8.3%, 33.4% and 12.6% respectively. Urban living, higher maternal
age and husbands’ alcoholism were the factors associated with domestic violence in pregnancy.
Women belonging to lower social groups were less likely to have physical domestic violence. Factors
such as higher prevalence of undesirable behaviours like denying adequate rest and diet, demand
for more sex, not providing antenatal care and pressure for male child were also associated with
domestic violence in pregnancy.
Conclusions: Considerable proportions of women experience some type of domestic violence during
pregnancy. Health-care providers should be able to recognize and respond to pregnant women’s
victimization and refer them for appropriate support and care.
Key words: Violence, pregnancy, retrospective, cross-sectional, survey, India.
Introduction
Violence against women is widely recognized
as an important public health problem. A
substantial number of women across several
countries have reported abuse by intimate
partner at some point in their lives. 1-3
Estimates of domestic violence prevalence
vary widely from 18% to 70% in India.
Differences in study methodology may account
for such large variations. It is also realized that
the magnitude of the problem has not been
studied very well in several parts of India.4
Prevalence of domestic violence in pregnancy,
which is a serious concern in both developing
Regional Medical Research Centre, Indian Council of Medical Research, Bhubaneswar-751 023, Orissa, India.
Indian Council of Medical Research, New Delhi-110 029, India.
Correspondence to Bontha V Babu (email: babubontha@gmail.com)
a
b
WHO South-East Asia Journal of Public Health 2012;1(2):133-143
Book 1.indb 133
133
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Abuse against women in pregnancy: a population-based study from Eastern India
and developed countries, is reported to be
33%.5 The occurrence of domestic violence
across women’s life-course is not inevitable
but it can be a normalized behaviour in certain
social circumstances.6
There is some support to the argument
that prevalence of domestic violence decreases
during pregnancy.7 It seems that domestic
violence is not initiated during pregnancy.
However, whether pregnancy is a risk factor or
a protective factor for women against domestic
violence is inconclusive.8 In several countries
including India, pregnant women retain the
privileged public position. Cultural norms may
play an important role in affecting the degree
to which women are protected from domestic
violence at family level. Regardless of these
issues, several pregnant women do report a
history of domestic violence. They should be
identified as high-risk group for developing
preventive interventions in view of severe
health consequences.6,9,10 These consequences
include a general loss of interest on the part
of the mother in her or her baby’s health,
both during the pregnancy and after the child
is born.11 In addition, women subjected to
several abusive behaviours during pregnancy
may lack emotional support of their partners
during pregnancy. Many women have no
access to health care during pregnancy and
this proportion is high among women who
experience domestic violence.12,13 Pregnant
women who experience domestic violence
have been found to have higher risks of
obstetric and other complications to mother
and foetus/child that warrant antenatal
care.6 The desire for male child is rampant in
Indian communities14 and exerting pressure
on women for bearing a male child is very
common. It is established that violence and
abuse against pregnant women affects not
only the health and well-being of the mother,
but also that of the foetus and the child.6,10
134
Book 1.indb 134
Bontha V Babu et al.
There is paucity of data on domestic
violence during pregnancy in India. A
population-based study undertaken across the
country reported the prevalence of physical
domestic violence to be 18%.15 In addition,
some clinic-based studies revealed that 22%
to 48% of women report physical domestic
violence during pregnancy.16-19 These studies
have reported the prevalence of psychological
and sexual domestic violence to be 29%
and 6% respectively. 19 We hypothesized
that domestic violence is a wide-spread
phenomenon, however, its prevalence may
vary across Indian states. These variations
may occur within the population due to
differences in socioeconomic characteristics
such as habitation (rural or urban residence),
age, religion and caste affiliation, education,
occupation and income. Hence, this study
was conducted to determine the prevalence
and associated characteristics of women with
various forms of domestic violence during
pregnancy.
Methods
A population-based study was undertaken in
three eastern states of India. The population
of the selected states, i.e. Orissa, West
Bengal, and Jharkhand, was 31.7 million,
80.2 million and 26.9 million, respectively in
the year 2001.20 This cross-sectional study
was carried out in 2004-2005. Quantitative
data were collected through interviews using
a structured questionnaire. The questionnaire
contained items on socioeconomic data and
domestic violence experience. To assess
domestic violence exposure, women were
asked several questions on various behaviours
related to violence. Questions were posed
to get women’s experience to a specific act
of violence during their pregnancy. These
behaviours and corresponding questions have
been identified, based on previous studies in
other settings. A multiphase process was used
WHO South-East Asia Journal of Public Health 2012;1(2):133-143
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Bontha V Babu et al.
Abuse against women in pregnancy: a population-based study from Eastern India
to develop these questionnaires to ensure
that they were culturally and linguistically
appropriate. Later the questionnaires were
piloted to check appropriateness, clarity and
flow of questions, but villages where pilots
were conducted, were not included in the
study. The other details of the questionnaire
and the interviews are available elsewhere.4
Interviews were conducted by women
investigators after obtaining consent from
women respondents.
The sample size was calculated based on
the estimate of domestic violence prevalence
from the sampled states.20 The multistage
sampling strategy was used. This is described
in detail elsewhere.4 Briefly, from each state,
four districts were selected from different
corners of the state. Out of these four districts,
two each were allocated to draw rural and
urban samples. From each district chosen for
a rural sample, two blocks (administrative
units in the district) were randomly selected.
From each block, two villages were randomly
selected. From each district allocated for an
urban sample, an urban area (a city or a
town) was selected and in this area, eight
pockets comprising people belonging to
different socioeconomic strata (high-income
groups, middle-income groups, low-income
groups and slums) were identified. A married
woman up to the age of 50 years was sampled
from each selected household. Initially, 1753
women were contacted; however, 35 women
refused to participate, yielding a refusal rate
of 2%. Of 1718 women, 1525 women who
were chosen for the study had at least one
full-term pregnancy. Only women with fullterm pregnancy were included in the study
to examine the association between domestic
violence and pregnancy outcome. Complete
data were available on all 1525 women
included in the analysis.
WHO South-East Asia Journal of Public Health 2012;1(2):133-143
Book 1.indb 135
Study variables
Independent variables
Data were collected on a number of
characteristics of women that were expected
to have association with domestic violence.
The community-level variables included in
the study were the state of residence (Orissa,
West Bengal or Jharkhand), area of residence
(rural or urban), religion (Hindu, Muslim,
Christian or any other religion) and social
group (scheduled tribe, scheduled caste,
backward caste or general caste). The other
independent variables were age and education,
which were categorized into illiterate (those
who can neither read nor write), functional
literate (those who can read or write, but did
not have formal schooling), school education
(1-10 years of schooling), and college or
higher education (those having more than 10
years of education). The occupation of the
participant was recorded and categorized into
housewives, salaried jobs (those in permanent
or temporary jobs with fixed monthly salary),
farming and small business (those engaged
in agriculture-related activity and small
businesses) and labourer (daily-waged skilled
and unskilled labourers). The monthly income
of the family was calculated during data
analysis, based on the information collected
on income of all members as well as from
common sources of the family. The income
details were collected in Indian rupees. One
rupee was equivalent to 0.02 United States
dollar. The information on parity was also
recorded. The husband’s habit of drinking
alcohol was also noted.
Outcome variables
The three principle domestic violence outcome
variables considered in our analysis were:
(i) physical domestic violence; (ii) psychological
domestic violence; and (iii) sexual domestic
violence. These variables were identified from
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Abuse against women in pregnancy: a population-based study from Eastern India
the responses to a set of questions that were
asked for each of the outcome variables.
If a woman (as a victim) gave a positive
response to any of the questions in a set,
it was considered as presence of domestic
violence for that category. These questions
are described in detail elsewhere.4 In addition,
experiences of women for other behaviours
namely change in sexual activity, availability
of rest and diet, seeking of antenatal care
and exposure to demand for male child by
the family were also investigated. For change
in sexual activity, the respondent was asked
about the frequency of sexual activity during
pregnancy. For availability of rest and diet,
she was asked whether adequate food and
rest were given during pregnancy. For these
two questions, the respondent was given three
options – as usual, decreased or increased
during pregnancy. For seeking antenatal care,
respondents were asked whether or not they
visited any health facility during pregnancy
for check-up. Respondents were specifically
probed to know whether the woman was
pressurized by her husband or other family
members for delivering a male child.
Statistical analysis
The association of independent variables
with different types of domestic violence
were examined by using multivariate
procedures. Binary domestic violence variables
(experienced domestic violence or did not
experience domestic violence) were modelled
with multivariate logistic regression as a
function of each independent variable. The
independent variables were categorized
into different groups as described earlier.
Multiple logistic regression models were run
by backward step-wise elimination procedure.
The fit of the logistic regression models was
checked by applying the Hosmer-Lemeshow
Goodness of Fit tests. A p value of less than
0.05 was considered as the minimum level for
statistical significance.
136
Book 1.indb 136
Bontha V Babu et al.
Results
The prevalence of physical, psychological and
sexual domestic violence during the recent
pregnancy was found to be 7.1% (95%
confidence interval (CI): 5.9%-8.4%), 30.6%
(95% CI: 28.3%-32.9%) and 10.4% (95%
CI: 8.9%-12.0%) (Table 1). The lifetime
prevalence of physical domestic violence during
pregnancy was 8.3% (95% CI: 7.5%-9.2%),
psychological domestic violence was 33.4%
(95% CI: 31.9%-34.9%) and sexual domestic
violence was 12.6% (95% CI: 11.5%-13.6%).
The variability in domestic violence during
pregnancy was very small across the states.
The association of women’s characteristics
with three forms of domestic violence during
pregnancy was presented in terms of adjusted
odds ratios (AORs) (Table 2). With regard to
physical domestic violence, urban residence,
older age, salaried job and husband’s alcoholism
emerged as the risk factors, whereas women’s
affiliation to lower social group, higher levels of
education and family income were protective
against physical domestic violence. Religion
was not included in the model.
Women who lived in urban areas, were
older in age, belonged to backward castes and
scheduled tribes, were multiparous and those
whose husbands were alcoholics, were found
to be more likely to experience psychological
domestic violence. However, some variables,
i.e. belonging to scheduled castes and having
higher education, emerged as significant
protective factors against psychological
domestic violence.
The regression analysis for sexual domestic
violence revealed that five of the nine variables
had significant association. Urban residence,
higher age of women, multiparity and
husband’s alcoholism were found to be the
risk factors. And women with higher levels
of education were found to be less likely to
experience sexual domestic violence during
pregnancy.
WHO South-East Asia Journal of Public Health 2012;1(2):133-143
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Bontha V Babu et al.
Abuse against women in pregnancy: a population-based study from Eastern India
Table 3 presents the prevalence of abusive
behaviours against women by their partners. It
is expected that there is decreased demand for
sex by the husband when his wife is pregnant.
About 85% (95% CI: 83.1%-87.5%) women
who have not experienced any sort of domestic
violence reported that the frequency of sexual
activity decreased during pregnancy, whereas
only 52% (95% CI: 47.7%-56.5%) women
who had experienced domestic violence
reported decreased frequency of sexual
activity in pregnancy. Those who were exposed
to sexual abuse had low level of sexual activity
in pregnancy (23.3%; 95% CI: 16.7%29.9%). Overall, 67.2% women reported that
frequency of sexual activity decreased during
pregnancy, about 25% women said that there
was no change, and 7.4% said that there was
no sexual intercourse during pregnancy. A
very small proportion (0.9%) of women said
that there was increase in the frequency of
sexual activity during pregnancy.
With regard to allowing women to take
adequate rest and diet, about 19% women
reported that diet and rest increased during
pregnancy, and the same proportion (19%) of
women reported that diet and rest decreased,
while 62.6% women said that there was
no change in the provision of diet and rest.
However, a higher number of women who
had faced domestic violence during their
pregnancy said that there was decrease
in the adequate amount of rest and diet
(26.7%; 95% CI: 22.8%-30.6%), compared
to women who had not experienced any
domestic violence (15.1%; 95% CI: 12.9%17.3%). Overall 20% women did not receive
antenatal care. This proportion was higher
(29%; 95% CI: 25.0%-33.0%) among women
who experienced domestic violence than those
who had not experienced domestic violence
during pregnancy (15.6%; 95% CI: 13.4%17.8%).
WHO South-East Asia Journal of Public Health 2012;1(2):133-143
Book 1.indb 137
About 18% women expressed that they
faced pressure from family for having a male
child. The pressure for having a male child was
higher (25%; 95% CI: 21.1%-28.7%) among
those women who had experienced domestic
violence, compared with those who had not
experienced domestic violence (15%; 95%
CI: 12.8%-17.2%).
Discussion
This population-based study revealed that
a considerable proportion of women had
experienced some type of domestic violence
during their pregnancy. These findings are
similar to those of some hospital-based
studies conducted in India.16-19 The prevalence
of domestic violence among ever married
women in this region was found to be 56%.4
The prevalence of domestic violence during
pregnancy was lower than that of domestic
violence during the lifetime (physical domestic
violence - 7.1% vs 16.1%; psychological
domestic violence - 7.1% vs 16.1%; and
sexual domestic violence - 10.4% vs. 25.4%
respectively). Considerable variation in the
prevalence of lifetime and during-pregnancy
domestic violence has been reported. With
regard to the perpetrators of violence, usually
husbands are the perpetrators, followed by
very few cases of perpetration by husbands’
parents and kins.4
Pregnant women were also victimised by
abusive behaviours and by lack of emotional
support. These behaviours were faced more
frequently by women who experienced
domestic violence. Usually, the men who
perpetrate violence tend to hold conventional
gender role attitudes, expecting women
to take sole responsibility for household
chores. Also, the inability to perform routine
household tasks due to physical exhaustion
and reduced mobility due to pregnancy
frequently resulted in violence. 21 Women
137
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Abuse against women in pregnancy: a population-based study from Eastern India
who experienced domestic violence reported
lower utilization of antenatal care. Association
between domestic violence and delayed and
failed antenatal care-seeking was reported by
previous studies also.12,13 Similarly, exerting
pressure for male child was noticed more
frequently among women who faced domestic
violence. It is to be noted that this type of
behaviour is a form of psychological domestic
violence women experience. These abusive
behaviours are also a risk factor for domestic
violence during pregnancy. These behaviours
had a positive association with all the three
forms of domestic violence.
Living in urban areas was found to be a
risk factor than living in rural areas. Other
studies from developing nations support this
finding.22,23 The urban social environment
can be more stressful and alienating than
rural areas. These conditions may influence
spousal relations.23 Women from the higher
age groups were at a higher risk of all forms
of domestic violence during pregnancy12,24.
Multiparity is usually correlated with higher
maternal age. However, some studies have
found that younger pregnant women are
more likely to have been exposed to domestic
violence than older pregnant women.13,25,26
Alcohol consumption is positively associated
with domestic violence during pregnancy and
also with lifetime domestic violence in several
communities.27-29 In India, alcoholism is usually
a cause of spousal conflict, as women questions
husband’s habit of alcohol consumption.
They try to stop him from taking alcohol and
squandering money on it. Domestic violence
is a consequence of this type of conflict, as
men take it as challenge to their authority.
This phenomenon goes on in several Indian
households on a regular basis.
Higher levels of education and family
income were found to be protective factors
against risk of domestic violence during
pregnancy. Educational attainment has
138
Book 1.indb 138
Bontha V Babu et al.
repeatedly been found to reduce the likelihood
of domestic violence even in developed
communities.30 Women with education are
typically more autonomous and possess
the resources and skills necessary to better
recognize and terminate a potentially abusive
relationship.
Though this study has identified some
risk factors and protective factors with regard
to domestic violence during pregnancy, it
is important not to assume that any group
or individual is especially at a low risk. In
addition, the limitation of the study is the
cross-sectional design itself, which does not
allow for establishing a cause-and-effect
relationship. Hence, the associations observed
during regression analyses could be the
function of some prior cause. However, study
results provide vital information to develop
policies and interventions for preventing
domestic violence in pregnancy. Women
should have access to information on the
health hazards of domestic violence during
pregnancy and sources of help.
A higher prevalence of domestic violence
in pregnancy has public health implications.
Health-care providers should have a role in
preventing domestic violence during pregnancy
and its health consequences. Hence, healthcare providers should be trained to recognize
and respond to violence during pregnancy
and refer women for appropriate support and
care, if required. Further research is needed
on the feasibility and benefits of universal
screening for domestic violence in pregnancy,
particularly for encouraging the utilization of
antenatal care services to prevent the health
consequences of domestic violence.
Acknowledgements
This study received financial and technical
support from the Indian Council of Medical
Research (ICMR), New Delhi, India.
WHO South-East Asia Journal of Public Health 2012;1(2):133-143
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Bontha V Babu et al.
Abuse against women in pregnancy: a population-based study from Eastern India
Table 1: Prevalence of domestic violence per 100 women during
pregnancy in Eastern India
Type of domestic
violence
Number of women
State
Orissa
West Bengal
Jharkhand
All
410
657
458
1525
8.0
(5.4-10.6)
5.8
(4.0-7.6)
8.3
(5.8-10.8)
7.1
(5.9-8.4)
Psychological
29.3
(24.9-33.7)
28.6
(25.1-32.1)
34.7
(30.3-39.1)
30.6
(28.3-32.9)
Sexual
13.9
(10.5-17.2)
7.3
(5.3-9.3)
11.8
(8.9-14.7)
10.4
(8.9-12.0)
1039
1524
1264
3827
9.7
(7.9-11.5)
6.9
(5.6-8.2)
8.9
(7.3-10.6)
8.3
(7.5-9.2)
Psychological
31.6
(28.8-34.4)
31.2
(28.9-33.5)
37.5
(34.7-40.3)
33.4
(31.9-34.9)
Sexual
16.7
(14.4-19.0)
9.2
(7.7-10.6)
13.2
(11.3-15.2)
12.6
(11.5-13.6)
In most recent pregnancy
Physical
In all pregnancies during the lifetime
Number of pregnancies
Physical
Figures in parenthesis are 95% confidence intervals
WHO South-East Asia Journal of Public Health 2012;1(2):133-143
Book 1.indb 139
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Abuse against women in pregnancy: a population-based study from Eastern India
Bontha V Babu et al.
Table 2: Association of socioeconomic variables of women with the prevalence of
domestic violence in Eastern India
Adjusted odds ratio (95% confidence intervals)
Characteristics
N
Physical violence
Psychological
violence
Sexual violence
Habitat
Rural
1037
Reference
Reference
Reference
452
2.37 (1.37-4.11)
1.81 (1.33-2.46)
1.58 (1.02-2.43)
<20 years
180
Reference
Reference
Reference
20-29 years
971
1.99 (0.71-5.59)
1.81 (1.15-2.83)
1.48 (0.70-2.16)
30 years and above
374
3.22 (1.09-9.50)
1.36 (0.83-2.25)
2.24 (1.01-4.97)
Urban
Age group
Caste category
General castes
716
Reference
Reference
Reference
Backward castes
337
0.89 (0.51-1.55)
1.33 (0.97-1.81)
0.92 (0.41-2.07)
Scheduled castes
341
0.43 (0.22-0.84)
0.62 (0.44-0.88)
0.97 (0.42-2.20)
Scheduled tribes
131
0.85 (0.39-1.89)
1.15 (0.73-1.80)
1.64 (0.71-3.78)
Education
Illiterate
482
Reference
Reference
Reference
Functional literate
122
0.49 (0.20-1.20)
0.76 (0.48-1.20)
0.60 (0.29-1.24)
School education
718
0.53 (0.31-0.88)
0.71 (0.53-0.95)
0.80 (0.54-1.20)
College education and above
203
0.04 (0.01-0.46)
0.23 (0.14-0.40)
0.25 (0.10-0.63)
Occupation
Housewife
1216
Reference
Reference
Reference
180
0.77 (0.39-1.52)
0.99 (0.40-2.47)
1.33 (0.27-6.49)
Farming/small business
81
0.44 (0.15-1.36)
1.14 (0.42-3.14)
1.83 (0.37-10.02)
Salaried job
48
9.16 (1.41-59.36)
0.66 (0.24-1.86)
2.48 (0.41-14.95)
<2000
639
Reference
Reference
Reference
2001-4000
463
4001-6000
126
1.03 (0.64-1.66)
0.18 (0.04-0.82)
6001-8000
93
Labourer
Family income per month
(Indian rupees)
8001-10000
>10000
64
140
0.62 (0.21-01.82)
0.29 (0.03-2.45)
0.11 (0.01-1.10)
0.64 (0.33-123)
0.42 (0.14-1.28)
0.65 (0.34-1.25)
0.43 (0.14-1.32)
1.06 (0.51-2.18)
0.64 (0.19-2.20)
1.14 (0.55-2.39)
0.59 (0.17-1.99)
0.89 (0.40-1.97)
0.84 (0.19-3.74)
Parity
One
371
Reference
Reference
Reference
Two
514
0.83 (0.37-1.88)
1.36 (0.95-1.95)
0.92 (0.50-1.72)
More than two
640
1.52 (0.72-3.24)
2.07 (1.45-2.96)
2.04 (1.14-3.63)
Husband’s alcoholism
No
Yes
1162
Reference
Reference
Reference
363
7.84 (4.93-12.48)
3.59 (2.76-4.67)
4.97 (3.47-7.10)
Religion was not included in any of the logistic regression models.
Occupation and income were not included in the model for psychosocial domestic violence. Caste, occupation and
income were not included in the model for sexual violence
140
Book 1.indb 140
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Bontha V Babu et al.
Abuse against women in pregnancy: a population-based study from Eastern India
Table 3: Prevalence of selected behaviours against women during recent
pregnancy, by type of domestic violence in Eastern India (data in percentage)
Type of domestic violence
Behaviours
Number of pregnant
Physical
109
Psychological
467
Sexual
Any
None
159
490
1035
women
Sexual activity
•
•
As usual
Increased
67.0
46.3
76.1
46.9
13.9
(58.1-75.9)
(41.8-50.8)
(69.4-82.7)
(42.5-51.3)
(11.8-16.0)
1.1
0.6
1.0
0.5
0.9
(-0.9-2.7)
•
Decreased
(0.1-2.0)
(-0.6-1.8)
(0.1-1.9)
(0.1-0.9)
32.0
52.7
23.3
52.1
85.3
(23.2-40.8)
(48.2-57.2)
(16.7-29.9)
(47.7-56.5)
(83.1-87.5)
Rest and diet
•
•
•
As usual
Increased
Decreased
65.1
66.6
57.9
65.1
61.4
(56.1-79.1)
(62.3-70.9)
(50.2-65.6)
(60.9-69.3)
(58.4-64.4)
3.7
7.9
4.4
8.2
23.5
(0.1-7.3)
(5.4-10.3)
(1.3-7.5)
(5.8-10.6)
(20.9-26.1)
31.2
25.5
37.7
26.7
15.1
(21.5-29.5)
(30.1-45.3)
(22.8-30.6)
(12.9-17.3)
46.8
30.0
37.1
29.0
15.6
(37.4-56.2)
(25.8-34.2)
(29.6-44.6)
(25.0-30.0)
(13.4-17.8)
34.9
25.9
27.7
24.9
15.0
(25.9-43.9)
(21.9-29.9)
(20.7-34.7)
(21.1-28.7)
(12.8-17.2)
(22.5-39.9)
Not received
antenatal care
Pressure for male
child
Figures in parenthesis are 95% confidence levels
WHO South-East Asia Journal of Public Health 2012;1(2):133-143
Book 1.indb 141
141
05-Jun-2012 2:35:55 PM
Abuse against women in pregnancy: a population-based study from Eastern India
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Health and Domestic Violence against Women. Initial
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2. Campbell JC. Health consequences of intimate partner
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7. Castro R, Peek-Asa C, Ruiz A. Violence against
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9. Ellsberg M, Jansen HA, Heise L, Watts CH, GarciaMoreno C. Intimate partner violence and women’s
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5;371(9619):1165-72.
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partner violence victimization prior to and during
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11. Newberger EH, Barkan SE, Lieberman ES, McCormick
MC, Yllo K, Gary LT, Schechter S. Abuse of pregnant
women and adverse birth outcome. Current
knowledge and implications for practice. JAMA 1992
May 6;267(17):2370-2.
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12. Perales MT, Cripe SM, Lam N, Sanchez SE, Sanchez
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in Lima, Peru. Violence Against.Women 2009
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Saltzman LE. Pregnancy intendedness and physical
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14. Clark S. Son preference and sex composition
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15. Peedicayil A, Sadowski LS, Jeyaseelan L, Shankar V,
Jain D, Suresh S, Bangdiwala SI. Spousal physical
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16. Purwar MB, Jeyaseelan L, Varhadpande U, Motghare
V, Pimplakute S. Survey of physical abuse during
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The prevalence of domestic violence in antenatal
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21. Bacchus L, Mezey G, Bewley S. A qualitative
exploration of the nature of domestic violence
in pregnancy. Violence Against.Women 2006
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22. Hindin MJ, Adair LS. Who’s at risk? Factors associated
with intimate partner violence in the Philippines. Soc.
Sci.Med. 2002 Oct;55(8):1385-99.
23. Klomegah RY. Intimate Partner Violence (IPV) in
Zambia: An Examination of Risk Factors and Gender
Perceptions. Journal of Comparative Family Studies
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24. Hedin LW, Janson PO. Domestic violence during
pregnancy. The prevalence of physical injuries,
substance use, abortions and miscarriages. Acta
Obstet.Gynecol.Scand. 2000 Aug;79(8):625-30.
25. Martin SL, Mackie L, Kupper LL, Buescher PA, Moracco
KE. Physical abuse of women before, during, and after
pregnancy. JAMA 2001 Mar 28;285(12):1581-4.
26. Hedin LW, Grimstad H, Moller A, Schei B, Janson
PO. Prevalence of physical and sexual abuse before
and during pregnancy among Swedish couples. Acta
Obstet.Gynecol.Scand. 1999 Apr;78(4):310-5.
27. Jeyaseelan L, Sadowski LS, Kumar S, Hassan F,
Ramiro L, Vizcarra B. World studies of abuse in the
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family environment--risk factors for physical intimate
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28. Krishnan S. Gender, caste, and economic inequalities
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Women Int. 2005 Jan;26(1):87-99.
29. Jasinski JL. Pregnancy and domestic violence: a
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143
05-Jun-2012 2:35:55 PM
Original research
Prognostic indicators in patients with snakebite:
analysis of two-year data from a township hospital in
central Myanmar
Myo-Khina, Theingi-Nyuntb, Nyan-Tun-Ooc, Ye-Hlad
Background: Rural people seek medical treatment for snakebite at peripheral health care facilities.
Hence, identification of the characteristics, which can be used at peripheral levels of health care
as reliable predictors of mortality, are required.
Methods: Hospital records of 101 patients (70 males and 31 females) with age ranging from 3
to 80 years, admitted to Nahtogyi township hospital in central Myanmar during January 2005 to
December 2006 were reviewed retrospectively. Binary logistic regression was used for estimating
odds ratio (OR) and 95% Confidence Interval (CI) for various prognostic indicators of mortality.
Results: Almost all snakebites were on extremities; more in legs (62%) than hands (37%). Most
(52.5%) bites occurred in the morning (4 am to noon). Mean (SD) time for bite-to-hospital and
bite-to-injection of anti-snake venom (ASV) was 134.6 (78.6) and 167 (187.8) minutes respectively.
Eleven cases (10.9%) had died. Case fatality ratio (CFR) was significantly higher in 39 patients
with un-clotted blood as compared to 62 patients with clotted blood (25.6% vs 1.6%, p <0.0005).
Significantly higher CFR was observed in 49 patients who received ASV in >2 hours after the bite
compared to 52 cases who received ASV within two hours (9.9% vs 0.9%, p <0.0001). Odds
ratio of fatality were higher among those who had urine output of <400 ml in the first 24 hours
(OR 26.4; 95% CI 2.4 to 288.3), un-clotted blood (OR 4.6; 95% CI 0.3 to 66.7), bite-to-injection
time of >2 hours (OR 4; 95% CI 0.1 to 219.8) bite-to-hospital time of >2 hours (OR 3.1; 95%CI
0.1 to 136.3) and bites in the morning (OR 2; 95% CI 0.3 to 16.0).
Conclusions: Clinical parameters could be used by healthcare providers to identify snakebite
patients for referral, who may have fatal outcome.
Key Words: Snakebite, urine output, anti-snake venom, prognosis, predictors, Myanmar.
Introduction
Snakebite, an important cause of death in
agriculture workers of developing countries, is
a priority health problem for rural populations.
Recent studies show that most of the
snakebites occur in South Asia, South-East
Asia and Sub-Saharan Africa.1 About 5 million
cases occur annually throughout the world
leading to 125 000 deaths.2
Department of Medical Research (Lower Myanmar), Yangon, Myanmar.
Mandalay Teaching Hospital, Mandalay, Myanmar.
Natogyi Township Hospital, Mandalay Division, Myanmar.
d
Department of Medical Research (Central Myanmar), Nay Pyi Taw, Myanmar.
Correspondence to Myo-Khin (khinm@mptmail.net.mm)
a
b
c
144
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WHO South-East Asia Journal of Public Health 2012;1(2):144-150
05-Jun-2012 2:35:55 PM
Myo-Khin et al.
In Myanmar, snakebite cases occur in
almost all the regions especially in Mandalay,
Bago, Sagaing, Ayeyarwady and Yangon
Divisions.3 It has been reported that 10 000
cases of snakebite occur annually with more
than 1000 deaths.4 Seventy percent of the
bites are caused by Russell’s vipers (Daboia
russelli siamensis). Therefore, mortality from
snakebite is quite high (10%) in Myanmar.5
A prospective study on 500 snakebite victims
revealed that the mortality could be as high as
50% in cases with severe envenomation.6
Most of the snakebite patients are from
rural populations living in villages and working
on agricultural land. Once bitten by snakes,
they seek medical treatment at rural health
centres or township health care facilities.
However, apart from simple clotting test and
urinary examination, many of the facilities
have limited laboratory and clinical capabilities
required for care of critically ill patients with
multi-organ dysfunction as a complication
of snakebite. Thus, it is important that the
health care providers should be able to identify
patients with snakebites at high risk of fatal
complications so as to be able to refer them
to a hospital with more facilities.
The availability of complete clinical records
of all snakebite patients at a township hospital
prompted us to study prognostic indicators
keeping in view relative interdependence
or interaction of various factors that could
determine morbidity and mortality. The
specific aim of the study was to identify simple
healthcare-related clinical characteristics, for
use at peripheral levels of health care, that can
serve as reliable predictors of mortality.
Methods
This retrospective study was carried out
using hospital records. The hospital records
of all snakebite cases admitted to Nahtoogyi
township hospital, Mandalay Division, during
WHO South-East Asia Journal of Public Health 2012;1(2):144-150
Book 1.indb 145
Prognostic indicators in patients with snakebite
the period of January 2005 to December 2006,
were reviewed. The clinical outcome was
listed as survived or died. Those classified as
absconded, discharged on request, left against
advice, referred to the tertiary centre were
followed up in 2008 to classify them as alive
or dead.
Descriptive characteristics of the patients
and the snakebite event such as gender, age,
time of bite, site of bite, bite-to-hospital time
were recorded. Clinical data such as biteto-injection time of antisnake venom (ASV),
urine output on first day, clotting time, unclotted to clotted time interval, initial and
total anti-venom doses administered were
also noted. Signs and symptoms such as
hypotension, tachycardia, swelling, vomiting,
epigastric pain, and renal angle pain were also
documented. Majority of hospitals in Myanmar
used Mono-specific Liquid Equine Russell’s
Viper Anti-Venom in liquid form (Myanmar
Pharmaceutical Factory, Yangon, Myanmar).
Statistical analysis
MINTAB Statistical Software, Release 14 for
Windows, Minitab Inc. USA was used for
data entry and analysis. Following univariate
analyses, comparison of the descriptive features
and clinical data between survivors and nonsurvivors were done using ‘t’ test and chi-square
test as appropriate. Bite-to-hospital interval and
bite-to-injection of ASV interval, urine output
in first 24 hours, clotting status, were further
categorized as binary variables. Binary logistic
regression models were constructed and the
most significant model with the highest number
of concordant and discordant pairs was selected
and odds ratios (OR) and 95% Confidence
Interval (CI) were calculated.
Results
One-hundred-and-one snakebite cases were
admitted to the hospital during the two-year
145
05-Jun-2012 2:35:56 PM
Prognostic indicators in patients with snakebite
Myo-Khin et al.
study period. The age of the victims ranged
from 3 to 80 years with a mean (SD) of 32.3
(15.5) years. Males predominated with a ratio
of 2.2: 1. The number of snakebite cases was
highest in 21-30 years age group (34, 33.7%),
followed by 13-20 years (19, 18.8%), 31-40
years (16, 15.8%), > 50 years (14, 13.9%),
and 41-50 years age group (13, 12.9%).
Lowest numbers of cases were in children
under 12 years of age (5, 5%).
Snakebite occurred throughout the year
but high peaks were observed in October and
January. Very low occurrences were observed
in February to April. More than half (52.5%)
of the bites occurred in the morning (4 am
to noon), followed by afternoon (noon to 6
pm) (28.7%) and evening hours (6 pm to
midnight) (18.8%). Most of the patients who
died (72.7%) were bitten in the morning.
Almost all bites were on extremities; legs were
the more common site (62%) as compared to
the hands (37%).
The time to reach the hospital ranged from
20 minutes to 7.5 hours with a mean (SD) of
134.6 (78.6) minutes (median 120 minutes).
Among them, 79 (78.2%), 47 (46.5%) and 19
patients (18.8%) failed to reach the hospital
within one, two, and three hours of snakebite.
About a third (32%) of the cases had swelling
at bite site, 31% complained of epigastric
pain with or without vomiting and 5% had
renal angle pain. Only a few (6%) presented
with hypotension (blood pressure less than
90/60 mmHg) and or tachycardia (heart rate
more than 100/minute). Although, mean (SD)
urine output during the first 24 hours was
794.4 (576.6) ml (median 600 ml), 28 cases
(28%) passed less than 400 ml of urine in the
first 24 hours. Thirty-nine cases (38.6%) had
‘non-clotted’ coagulation status. A significantly
higher mortality was observed in cases with
‘non-clotted’ coagulation status as compared
to those with ‘clotted’ blood status (25.6% vs
1.6%, p <0.0001).
The mean (SD) bite-to-injection time
of the initial dose of ASV was 167 (187.8)
minutes (range 20 to 1560 minutes; median
120 minutes). ASV was administered to 22, 30
and 26 cases within one, two, and three hours
respectively and 23 cases failed to receive ASV
within three hours. The initial amount of ASV
received was 20 ml in 51 cases (51%), 40 ml
in 35 (35%), 10 ml in 14 (14%) and 50 ml
in one case (1%). On an average (SD), 25.6
(11.3) ml of ASV was given initially; median
dose being 20 ml. Seven cases received ASV
at the village-based primary health care centre
before they were referred to the hospital.
During the course of the treatment up
to 120 ml of ASV was given at the hospital.
On average (SD), 43.9 (39.0) ml of ASV was
used per snakebite case (median 40 ml).
A significantly larger amount of ASV (almost
three times) was used in ‘non-clotted’ cases
as compared to ‘clotted’ cases (Table 1). Also,
a significantly larger amount of ASV per case
Table 1: Amount of anti-snake venom (ASV) used in relation to
the coagulation status
Coagulation status (number)
Mean
Standard
Deviation
Non-clotted (39)
Clotted (62)
70.8
26.9
27.8
18.3
All cases (101)
43.9
39.0
146
Book 1.indb 146
Total amount of ASV used (ml) per case
p
<0.001
WHO South-East Asia Journal of Public Health 2012;1(2):144-150
05-Jun-2012 2:35:56 PM
Myo-Khin et al.
Prognostic indicators in patients with snakebite
was used in those who died as compared
to those who survived (7.5% vs 4.0%,
p <0.002). Among 39 cases with ‘non-clotted’
blood status, 32 cases reverted to ‘clotted’
stage following ASV therapy. The median
clotting time on hospital admission was 540
minutes (range - 60 to 1110 minutes).
Eighty-six patients recovered and were
discharged from the hospital. The average
(SD) duration of stay in hospital was 6.9 (3.2)
days with a range of 1 to 21 days and a median
of 7 days. Some of the patients (6) had to
be referred for further management. Among
them, three patients died and three survived.
One patient, who had absconded from the
hospital, was later confirmed to be alive and
well. One patient who left against advice was
later confirmed as died. Thus a total of 11 cases
had died and 90 cases survived. Although a
higher case fatality ratio (CFR) was observed
in males (11.4%) than females (9.7%), the
difference was not statistically significant.
Higher CFR was also observed in children under
5 years of age (20%) as compared to older
children and adults (Table 2).
Binary logistic regression models were
constructed and the final model revealed that
the odds of fatality were higher in urine output
less than 400 ml in first 24 hours (OR 26.4;
95% CI 2.4 to 288.3), ‘un-clotted’ blood status
(OR 4.6; 95% CI 0.3 to 66.7), bite-to-injection
time of >2 hours (OR 4; 95% CI 0.1 to 219.8),
bite-to-hospital time of >2 hours (OR 3.1;
95%CI 0.1 to 136.3), and bite in the morning
time (OR 2; 95% CI 0.3 to 16.0).
Discussion
In Myanmar, viper snake bites are estimated
to be 7000 to 8000 per year with over 500
deaths. Although there is no doubt that the
disease course may be fulminant and lethal,
recognition of predictor signs with prompt
necessary action could reduce the mortality.
The regression model we constructed in this
study for the first time indicates that oligurea,
‘un-coagulable blood status’ on admission to
the hospital, delayed bite-to-injection time,
delayed bite-to-hospital interval, and morning
bites have association with increased mortality
for snakebite in Myanmar though only oligurea
was found to be statistically significantly
associated with mortality. The importance
of these factors as major determinants of
mortality in viper bite has been studied from
various aspects using different types and
levels of scientific evidence. Our model also
reveals the importance of these predictors by
providing the degree of statistical significance
of each factor. Other factors such as the length
of snake, characteristic of snakes which are
Table 2: Case fatality ratio from snakebite by age group in a township
hospital of Central Myanmar
Age group (years)
<12
13-20
21-30
31-40
41-50
>51
All
Number of
cases
5
19
34
16
13
14
101
WHO South-East Asia Journal of Public Health 2012;1(2):144-150
Book 1.indb 147
Died
Case Fatality Ratio (%)
1
20.0
3
3
2
1
1
11
15.8
8.8
12.5
7.7
7.1
10.9
147
05-Jun-2012 2:35:56 PM
Prognostic indicators in patients with snakebite
beyond control have been studied previously
by others.7
Haemostatic disturbances are known to be
the pathological mechanism causing fulminant
disease in viper bite, and bleeding tendency
is well recognized as an indicator of greater
risk of death. 6,8,9 The present study also
indicates blood incoagulopathy as a predictor
of mortality.
The importance of bite-to-injection time
is also well known as a significant factor
influencing mortality. A study from Nepal
showed that the delay in receiving treatment
was significantly longer for victims with
a fatal outcome.10 The optimum time for
administration of ASV has been previously
suggested as “as soon as possible” or within
4 hours. Bite-to-injection time of less than
4 hours is associated with rapid recovery of
renal function.11 Although we were not able to
determine the renal function of our patients,
we found that bite-to-injection time of more
than two hours could increase the mortality by
four times than those who receive ASV within
two hours. Our findings indicate that a delay
of even two hours in neutralizing the action
of venom would be enough to do pathological
damage and increase the mortality.
Viper bites is one of the most common
causes of acute renal failure in hospital practice
in Myanmar.12 It has been demonstrated by
in-vitro and in-vivo studies that viper venom
has direct nephrotoxic effect in addition to
causing renal impairment through disturbed
blood coagulation mechanism.13,14,15 Oliguria
as evidence of renal function impairment has
been pointed out but opinion differs as to when
it should become a deciding factor in clinical
management.16 We found that urine output
of less than 400 ml in the first 24 hours is
a strong predictor (26 times higher risk) of
mortality.
148
Book 1.indb 148
Myo-Khin et al.
A recent paper shows the value of low dose
dopamine-high dose furosemide regimen in
the management of acute renal failure and
suggests that this regimen may abort onset
of acute renal failure if given early and should
therefore be considered when a warning red
flag such as oliguria or albuminuria signals
impending renal failure.17 Albuminuria which is
easy to perform has also been shown to be a
sign of renal impairment but it may sometimes
be a late sign. 14,15 Detection of urinary
N-acetyl-beta-D-glucosaminidase (NAG) may
be an early indicator of renal damage in viper
envenomation but it is not practical to do this
test in township or most other hospitals.18
Numerous studies and guidelines have
discussed the quantity of ASV to be given
in viper bite. It is generally agreed that this
should neutralize the average quantity of
venom injected by the viper at one bite.
Based on studies of the average quantity of
venom injected by Russell’s viper (given as
63mg) and the neutralization capacity of ASV
produced by Myanmar Pharmaceutical Factory
(MPF) (given as 2 mg per ml) it has been
recommended that the standard dose of ASV
should be 40 ml for patients with systematic
envenomation but with no complications.19
This ASV dose regimen was used at our study
hospital during the study period, and served
as a basis for our analysis.
Regarding the seasonal pattern of
snakebite, the present study is one of many
other studies that have shown the importance
of season in snakebite problem in Myanmar.
However, the morbidity pattern of the present
study differs from previous findings where
highest incidence of snakebite was found
during the harvesting season from October
to December. 20 This might be due to the
difference in study area; the present study
focused on data from central Myanmar where
WHO South-East Asia Journal of Public Health 2012;1(2):144-150
05-Jun-2012 2:35:56 PM
Myo-Khin et al.
paddy as well as other crops are planted as
compared to the data from lower Myanmar
which has mainly paddy plantations. In the
study township, in addition to rice, green peas
and sesame were cultivated during the months
of May, June and July. The paddy harvesting
season is during September and October. In
addition to the peaks in snakebite morbidity
during the sowing and harvesting seasons, a
third peak was observed during the months of
December and January when sunflower and
groundnuts were cultivated. The only period
of the year where cultivation work is not
done is between the months of February and
April. This period coincided with a decreased
snakebite morbidity observed in the present
study.
Male predomination in this study was
similar to the findings of previous studies.20,21,22
This risk is associated with greater number of
outdoor activities of males than their female
counterparts. Although the CFR of 10.9% is
higher than our previous findings from central
Myanmar;21 it is in agreement with other
previous reports from Myanmar.3,5
The present study has some limitations.
It was focused mainly on the predictors of
mortality based on retrospective analysis
of a small number of medical records from
a township hospital. It will be interesting
to carry out a larger clinical auditing study
prospectively to identify imperfections in the
management of snakebite at the peripheral
level where manpower and laboratory facilities
are inadequate.
In conclusion, snakebites are still a
common medical emergency encountered
in township hospitals, especially in rural
areas. Timely treatment is the mainstay for
reduction of mortality. Recognition of predictor
signs is essential for clinical management
and early referral which could lead to a
significant decrease in mortality. Our study
has established the validity of some of the
predictors being used in Myanmar which will
help in deciding clinical management options
including ASV dose and onward referral to
tertiary centers.
Acknowledgements
It has been documented that longer
snakes cause more severe envenoming and
more extensive swelling than the snakes
with shorter length.7 In the present study,
the length of the snake was not documented.
Hence, length of the snake as a predictor
of fatality should be investigated in future
studies.
We are most grateful to Dr Aung-Than-Ba-Tu,
former Director-General, Department of
Medical Research for his encouragement,
valuable advice and inputs to the study as
well as in writing this report.
Regarding hypotension, a significant
rise of blood cortisol in patients with unclotted blood has been reported.23 In a large
study carried out in India, hypotension was
identified as a large (22 times) predictor of
mortality.24 However, relatively few cases had
presented with hypotension in the present
study, therefore, its significance could not be
assessed.
1. Kasturiratne A, Wickremasinghe AR, de Silva N,
Gunawardena NK, Pathmeswar A, et al. The global
burden of snakebite: a literature analysis and
modelling based regional estimates of envenoming
and deaths. PLoS Medicine. 2008: 5(11): e218e220.
WHO South-East Asia Journal of Public Health 2012;1(2):144-150
Book 1.indb 149
Prognostic indicators in patients with snakebite
References
2. Chippaux J. Estimating the global burden of snakebite
can help to improve management. PLoS Medicine.
2008: 5(11): e221 –e222.
149
05-Jun-2012 2:35:56 PM
Prognostic indicators in patients with snakebite
3. Thein-Hlaing. Epidemiology of snake Bite in Burma.
Dissertation submitted for Diploma of Preventive &
Tropical Medicine. Burma: Institute of Medicine I,
1970.
4. Min-Swe. Epidemiology of snakebite in Burma with
special reference to Gyobingauk Township. M.Med.Sc
Thesis . Yangon: Institute of Medicine I, 1977.
5. Chippaux J. Snake-bites: appraisal of the global
situation. Bulletin of the World Health Organization.
1998; 76(5): 515-524.
6. Maung-Maung-Aye. Snake-bite-clinical features and
treatment: 23rd Burma Medical Conference Abstract.
Burma, 1976..
7. Tun-Pe, Ba-Aye, Aye-Aye-Myint, Tin-Nu-Swe,
Warell DA. Bites by Russell’s vipers (Daboia russelli
siamensis) in Myanmar: effect of the snake’s length
and recent feeding on venom antigenaemia and
severity of envenoming. Trans R Soc trop Med Hyg.
1991; 85(6): 804-8.
8. Than-Than, Hutton RA, Myint-Lwin, Khin-Ei-Han,
Soe-Soe, Tin-Nu-Swe, Phillips RE, Warrell DA.
Haemostatic disturbances in patients bitten by
Russell’s viper (Vipera russelli siamensis) in Burma.
Br J Haematol. 1988; 69(4): 513-20.
9. Bandyopadhyay SK, Ghosh S, Bandyopadhyay R,
Dutta A. Prognostic factors in haemotoxic viper bite:
analysis of data from a referral hospital. J Indian Med
Assoc. 2009; 107(1): 12-3.
function abnormalities following bites by Russell’s
vipers (Daboia russelii siamensis) in Myanmar. Trans
R Soc Trop Med Hyg. 1991; 85(3): 404-9.
15. Win-Aung, Khin-Pa-Pa-Kyaw, Baby-Hla, Saw-SandarAye, Saw-Phone-Naing, Aye-Kyaw, Tin-Nu-Swe. Trans
Renal involvement in Russell’s viper bite patients
without disseminated intravascular coagulation. Trans
R Soc Trop Med Hyg. 1998; 92(3): 322-4.
16. Tin-Maung-Han, Zaw-Win-Htut, Ne-Win, Zar-Ni-Soe,
Thet-Thet-Naing. Preliminary report: Experiences
of viper bite management in medical unit III of
Mandalay General Hospital. Myanmar J Current
Medical Practice. 2009; 13: 5-13.
17. Tin-Maung-Han, Zaw-Win-Htut, Kaung-Nyunt-Zan,
Zar-Ni-Soe, Thet-Thet-Naing, Nwe-Ni-Hla-Maung.
Low-dose dopamine, high-dose furosemide regime
in acute renal failure due to viper bites: Medical unit
III experience. Myanmar J Current Medical Practice.
2009; 13: 14-19.
18. Win-Aung, Aye-Kyaw, Tin-Win, San-Kun, Thin-ThinHlaing. Urinary NAG as an early indicator of renal
damage in Russell’s viper bite envenomation. Trans
R Soc Trop Med Hyg. 1996; 90(2): 169-72.
19. Tun-Pe, Khin-Aung-Cho. Amount of venom injected
by Russell’s viper (V. russelii). Toxicon. 1986; 24:
730-733.
20. Tin-Nu-Swe. Snakebite and renal function. MD Thesis.
South Wales: University of New, 1994.
10. Ko Ko Naing. A study of peritoneal dialysis in acute
renal failure patients due to russell’s viper bite.
M.Med.Sc (Internal Medicine) Dissertation. Mandalay:
University of Medicine, 2004.
21. Myo-Khin, Ye-Hla, Theingi-Nyunt, Soe-Win-Oo.
Retrospective study of snakebites from selected
hospitals in central Myanmar. Myanmar Journal of
Current Medical Practice. 2009; 14: 8-13.
11. Sharma SK, Chappuis F, Jha N, Bovier PA, Loutan L,
Koirala S. Impact of snake bites and determinants
of fatal outcomes in southeastern Nepal. Am J Trop
Med Hyg. 2004; 71: 234-238.
22. Aye-Aye-Myint, Tun-Pe, Tin-Zar-Maw. An epidemiological study of snakebite and venomous snake
survey in Myanmar. In: World Health Organization,
Regional Office for South-East Asia. Management of
snakebite and research. New Delhi: WHO-SEARO,
2002. pp 12-16.
12. Warrell DA. Snake venoms in science and clinical
medicine. 1. Russell’s viper: biology, venom and
treatment of bites. Trans R Soc Trop Med Hyg. 1989;
83(6): 732-40.
13. Soe-Soe, Than-Than, Khin-Ei-Han. The nephrotoxic
action of Russell’s viper (Vipera ruselli) venom.
Toxicon. 1990; 28(5): 461-7.
14. Thein-Than, Tin-Tun, Hla-Pe, Phillips RE, Myint-Lwin,
Tin-Nu-Swe, Warrell DA. Development of renal
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Myo-Khin et al.
23. Tin-Nu-Swe, Myo-Khin, Maung-Maung-Thwin,
Saw-Naing. Acute changes in serum cortisol levels
following Russel’s viper bites in Myanmar. Southeast
Asian J Trop Med Public Health. 1997; 28(2): 399403.
24. Athappan G, Balaji MV, Navaneethan U. Acute renal
failure in snake envenomation: a large prospective
study. Saudi J Kidney Dis Transpl, 2008; 19(3):
404-10.
WHO South-East Asia Journal of Public Health 2012;1(2):144-150
05-Jun-2012 2:35:56 PM
Original Research
Performance of cause-specific childhood mortality
surveillance by health workers using a short verbal
autopsy tool
Rakesh Kumara, Suresh K Kapoorb, Anand Krishnana
Background: The routine use of verbal autopsy in health-care delivery settings has been limited.
Hence, the performance of neonatal and postneonatal verbal autopsy (VA) tools developed at the
Comprehensive Rural Health Services Project (CRHSP), Ballabgarh (India), were assessed.
Methods: Short VA tools developed by CRHSP were filled by health workers during their routine
house visits while standard VA tools of the International Network of Field Sites with continuous
Demographic Evaluation (INDEPTH) were filled by trained research workers for all 143 under-fivechildren deaths that occurred in 2008. The level of agreement in the cause of death assigned by the
two VA tools was assessed by kappa and by comparison of the cause-specific mortality fractions.
Results: Among 65 neonatal deaths, the cause specific mortality fraction (CSMF) was 43.1% and
40% for low birthweight, 15.4% and 26.2% for birth asphyxia, and 7.7% and 10.8% for pneumonia
by INDEPTH and CRHSP VA tools respectively. In 78 deaths among 29-days to <5-year olds, the
CSMF was 29.4% and 26.9% for diarrhoea, and 16.6% each for pneumonia using the INDEPTH
and CRHSP VA tools respectively. Kappa for most causes of death was more than 0.8, except for
birth asphyxia, which had a kappa of 0.678.
Conclusions: Short VA tools have a satisfactory performance in field settings, which can be used
routinely by health workers for filling the gaps in the cause-of-death information in places where
medical certification of cause of death is deficient.
Key words: Verbal autopsy, neonatal, mortality, child, India.
Introduction
Child mortality is a global priority as enunciated
by the Millennium Development Goals (MDGs).
The target is to reduce the under-five-child
mortality by two thirds in each country. Though
child deaths are declining the world over,
the rate of decline is not enough to achieve
the target by 2015.1,2 India has made some
progress in reducing child mortality but it is
still far from achieving the MDG. Also, there is
large regional variability in childhood morbidity
and mortality rates.3
Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India.
Professor Emeritus, Department of Community Health, St. Stephen’s Hospital, New Delhi, India.
Correspondence to Rakesh Kumar (email: babluaiims@gmail.com)
a
b
WHO South-East Asia Journal of Public Health 2012;1(2):151-158
Book 1.indb 151
151
05-Jun-2012 2:35:56 PM
Performance of short verbal autopsy tool
The information on the distribution and
trends of the causes of childhood mortality
is important to develop effective health
policies and for evaluating existing health
programmes addressing the issue of childhood
mortality. However, this information is lacking
in many developing countries. There is
considerable lacuna in vital registration as
well as in reporting of the cause of death.4
The vital registration system in India has been
estimated to complete in only be 50% of all
deaths.5 Reliable, medically certified causeof-death data are available only in 14.5% of
all registered deaths.5,6
In places where the system of medical
certification of cause of death is deficient,
verbal autopsy (VA) is an alternative method
to ascertain the cause of death. Verbal autopsy
is based on the assumption that most causes of
death have distinct symptom complexes that
can be recognized, remembered and reported
by the lay respondents. Various VA tools
have been used in different settings to obtain
cause-of-death data. The VA tool developed
by the International Network of Field Sites
with continuous Demographic Evaluation
(INDEPTH) is one such standard tool that
is used by many demographic surveillance
sites. The INDEPTH VA tools have separate
questionnaires for neonatal (0-28 days) and
postneonatal (29 days - 12 years) mortality.
The factors that may affect the validity of
a VA include questionnaire design, type of
interviewers and respondents, recall period,
cause-of-death ascertainment mechanisms
and cause-of-death classification.7
Verbal autopsies for childhood deaths
have been used in research settings, 8,9
and in surveys on a large sample of the
population.10,11 Various verbal autopsy tools
for childhood mortality have been validated in
different settings,12-17 but the focus has largely
been on methodological issues.18-20 Most of
the available VA tools require specialized
152
Book 1.indb 152
Rakesh Kumar et al.
training and need longer time to complete
the interview. Consequently the use of verbal
autopsy under routine health-care delivery
settings has been limited.
A shorter VA tool that takes less time and
requires less intense training was developed
at the Comprehensive Rural Health Services
Project (CRHSP), Ballabgarh (India) in 2002,
which was revised in 2007. Keeping in mind the
information needed for ascertaining the causes
of death, verbal autopsy tools were designed
separately for neonatal (0-28 days) and postneonatal (29 days – <5 years) deaths. While
the experience with these tools has been
encouraging, the performance of the tools has
never been examined. This study was done
with the objective of comparing the causespecific mortality fraction and agreement
between CRHSP and INDEPTH VA tools for
major causes of childhood mortality.
Methods
This study was carried out from January to
December 2008 in the Intensive Field Practice
Area of CRHSP, Ballabgarh, which is a field
practice area of the All India Institute of
Medical Sciences (AIIMS), New Delhi, India, as
well as an INDEPTH Health and Demographic
Surveillance site. It covers a population of
about 86 000 in 28 villages through its two
primary health centres (PHCs). Around 2000
live births occur in this area in one year.
Health workers make house-to-house visits to
provide basic health services. All deaths are
routinely reported and verbal autopsies are
done by health workers. Assignment of the
cause of death is done by the Medical Officer
of the PHC.
Verbal autopsy
The CRHSP neonatal and post-neonatal VA
tools are used for deaths in the age groups
0 to 28 days, and 29 days to <5 years,
WHO South-East Asia Journal of Public Health 2012;1(2):151-158
05-Jun-2012 2:35:56 PM
Rakesh Kumar et al.
respectively. These tools have seven sections
comprising identification detail; narrative
regarding the events leading to death; specific
questions on symptoms and signs; history of
immunization; treatment; and past diseases
in the deceased or other family members. The
neonatal VA tool, besides an open narrative
section, has 52 close-ended questions without
having any filter questions, whereas the postneonatal tool, in addition, has questions on
nutrition history, and five modules with one
filter question in each. In the 5 modules the
number of items range from 5 to 11. The
CRHSP tools require minimal training and take
approximately 20 minutes to complete.
The INDEPTH neonatal and post-neonatal
VA tools are used for all deaths in the age
groups of 0 to 28 days, and 29 days to 12
years, respectively. These tools have seven
sections comprising background detail of
the deceased; background information of
the interview; information regarding the
informant; open narrative section; signs and
symptoms during neonatal period; accidents
and injuries; and treatment history. It takes
approximately 60 minutes to complete an
INDEPTH VA tool.
The INDEPTH VA tools were translated into
the local dialect and pretested at Ballabgarh
in a non-project village. Subsequently,
independent back-translation of the tools was
done. The CRHSP VA tools were developed by
modifying the earlier versions of the VA tools.
An open narrative section was added. These
tools were already being used for routine
mortality surveillance in the CRHSP area.
Field research assistants were recruited
and trained for three days to administer the
INDEPTH VA tools. The assistants were female
lay workers with previous experience in data
collection for health-related projects. They
were trained in the interview technique, as
well as on the causes of death. Health workers
WHO South-East Asia Journal of Public Health 2012;1(2):151-158
Book 1.indb 153
Performance of short verbal autopsy tool
and health supervisors were trained for a day
on administering the CRHSP VA tools. Their
training was shorter as they were already
using these tools.
All deaths that took place in the intensive
field practice area of CRHSP, Ballabgarh,
among under-five-children during January to
December 2008 were included in the study.
The verbal autopsy using both tools (CRHSP
and INDEPTH) was conducted for all deaths.
As a first step, the CRHSP VA tools were
filled by health workers. A time gap was kept
between the filling of forms and the date of
death (over two weeks but not exceeding
six weeks for CRHSP VA tools). After a gap
of two weeks and within three months of
the death, the same families were visited by
field research assistants who completed the
translated INDEPTH VA tool. Field supervisors
verified the details in the INDEPTH VA tool. In
the case of the CRHSP VA tool, details were
verified by health supervisors after visiting
the household. They also checked the forms
for completeness.
Assigning the cause of death
Cause of death assignment for the INDEPTH VA
tool was done by the medical officer in-charge
of the primary health centre. For the CRHSP
VA tool, this function was performed by one of
the investigators (RK). Subsequently, causes
of death were coded as per the International
Statistical Classification of Diseases 10 th
Revision (ICD-10). Medical officers working
in PHCs have public health qualifications,
and their course work includes ICD coding.
During their postgraduation they would also
have gained some hands-on experience on
assigning the cause of death and coding the
diagnoses. Only one physician was used for
the purpose of assigning the cause of death,
as use of multiple coders does not have any
added benefit.21
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05-Jun-2012 2:35:56 PM
Performance of short verbal autopsy tool
Statistical analysis
Data were entered into Microsoft Excel 2007
and analysed by using the SPSS version 17.0.
The cause-specific mortality fractions (CSMF)
were calculated as per the ICD-10 codes.
The CSMFs were compared for the CRHSP
and INDEPTH VA tools. The performance of
CRHSP VA tools was considered satisfactory if
the CSMF estimate using the CRHSP VA tools
was within 20% of the CSMF obtained by the
INDEPTH VA tools.13 The chance-corrected
concordance was also estimated for various
causes of childhood mortality using Cohen’s
kappa. A kappa value of more than 0.75 was
considered as “excellent”, 0.40 to 0.75 “as fair
to good” and below 0.40 as “poor.”
Ethical issues
Approval from the AIIMS Ethics Committee
was obtained before the start of the study.
Field workers and assistants were trained in
interview techniques, so as to minimize the
trauma to the respondent when discussing
the death of a loved one. Written informed
consent was taken from all interviewees before
administration of the INDEPTH VA tools. The
CRHSP VA tools were already being used as a
routine surveillance activity; hence, consent
was not taken for it. Information gathered
from interviewees was kept confidential.
Results
One hundred and forty three deaths occurred
among under-five-children in the CRHSP
population during 2008. Sixty five deaths
occurred in the neonatal period (0-28 days);
60% of these deaths were in the early
neonatal period (0-7 days). Seventy eight
deaths occurred in the period from 29-days
to <5 years; 58% of these deaths were
between 29 days to <1 year. Most neonates
died in hospital (56%) or on way to hospital
(38%), whereas only 22% of the 29-days to
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Book 1.indb 154
Rakesh Kumar et al.
<5 year-olds died at hospital and 65% died at
home. There were more males (58%) among
neonatal deaths compared to the 29-days to
<5 year-olds (50%). The number of deaths
for which a specific cause could be assigned
was found to be greater in the case of CRHSP
VA tools as compared with the INDEPTH
VA tools (Table 1). There was not much
misclassification in ascertainment of the cause
of death as the chance-corrected concordance
for major causes of death was “fair to good”
or “excellent” (Table 2).
Low birthweight was the most common
cause of death in both early and late neonatal
period. The CSMF of low birthweight and
prematurity by INDEPTH and CRHSP VA
tools was 46.2% and 41.1% respectively,
in the early neonatal period, and 38.4% by
both tools in the late neonatal period. Birth
asphyxia was another common cause of death
in the early neonatal period, using both the
VA tools, with a CSMF of 25.6% and 38.5%,
respectively; however it was a less common
cause of death in the late neonatal period with
a CSMF of 0% and 7.7% respectively, using
the INDEPTH and CRHSP VA tools. The CSMF
of pneumonia in the early neonatal period was
5.1% according to both tools, and 11.5% and
19.2% in the late neonatal period, using the
INDEPTH and CRHSP VA tools respectively.
The CSMF of congenital malformation was
7.7% according to both tools in the early
neonatal period, and 7.7% and 3.8% in the
late neonatal period, using the INDEPTH and
CRHSP VA tools respectively.
Diarrhoea was the most common cause
of death among 29-days to <5 year-olds
(Table 1). In children aged 29-days to <1 year,
diarrhoea was the cause of death in 42.2%
and 37.7% children, according to the INDEPTH
and CRHSP VA tools respectively; however in
children aged 1 year to <5 years, diarrhoea
was the cause of death in 12.1% children,
using both tools. Among children of 1 year
WHO South-East Asia Journal of Public Health 2012;1(2):151-158
05-Jun-2012 2:35:56 PM
Rakesh Kumar et al.
Performance of short verbal autopsy tool
Table 1: Cause-specific mortality fractions in less-than-five-year old children by
INDEPTH and CRHSP verbal autopsy tools
Cause-specific mortality fraction (%)
0 - 28 days
N=65
Cause of death (ICD codes)
INDEPTH
29 days to <5 years
N=78
CRHSP
INDEPTH
CRHSP
Low birthweight (P07.0- P07.3)
43.1
40.0
0
0
Birth asphyxia (P21.9)
15.4
26.2
0
0
0
0
29.4
26.9
7.7
10.8
16.6
16.6
0
0
6.4
6.4
6.2
4.6
6.4
6.4
Protein-energy malnutrition (E40-E46)
0
0
5.1
7.7
Other infectious diseases (A00- B99 except A09)
0
0
3.8
5.1
7.7
6.2
2.5
2.5
0
0
1.2
2.5
1.4
1.4
5.6
5.4
18.5
10.8
23.0
20.5
Diarrhoea (A09)
Pneumonia (J18)
Neurological disorder (G00-G99)
External injury (S00-Y98)
Congenital malformation (Q00-Q99)
Malignant neoplasm (C00-D48)
Others
Unclassified (R00-R99)
CRHSP = Comprehensive Rural Health Service Project, IDEPTH = International Network of Field Sites with continuous Demographic Evaluation
Table 2: Level of agreement between INDEPTH and CRHSP verbal autopsy tools
for various causes of death among under-five children
Age group
0 - 28 days
N=65
Cause of death
29 days - <5 years
N=78
n
Kappa (SE)
n
Kappa (SE)
Low birthweight (P07.0- P07.3)
28
0.878 (0.109)
0
-
Birth asphyxia (P21.9)
10
0.678 (0.118)
0
-
Pneumonia (J18)
5
0.817 (0.125)
13
0.833 (0.081)
Diarrhoea (A09)
0
-
23
0.916 (0.048)
Congenital malformation (Q00-Q99)
4
0.881 (0.118)
2
1.000
Malignant neoplasm (C00-D48)
0
-
2
0.795 (0.200)
Protein-energy malnutrition (E40-E46)
0
-
4
0.712 (0.157)
Neurological disorder (G00-G99)
0
-
5
0.795 (0.200)
External injury (S00-Y98)
5
0.849 (0.148)
5
1.000
SE=Standard Error, CRHSP=Comprehensive Rural Health Service Project, IDEPTH = International Network of Field Sites with continuous Demographic
Evaluation
WHO South-East Asia Journal of Public Health 2012;1(2):151-158
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Performance of short verbal autopsy tool
to <5 years in age, external injury was the
common cause of death, with CSMF according
to both tools being 15.2%. Pneumonia was
another common cause of death in this
age group with 17.7% and 22.2% deaths
respectively, using the INDEPTH and CRHSP
VA tools. Neurological disorders and proteinenergy malnutrition were the other important
causes of death in this age group.
Discussion
The ideal mortality measurement should
be routine, reproducible, low cost and
sustainable. Use of short verbal autopsy tools
to generate cause-specific mortality fractions
at the local level can help in better planning
of health-care services as health workers who
used short verbal autopsy tools had a “fair to
good” level of agreement in causes of deaths,
as compared with those arrived at by the
INDEPTH tools (Table 2). A study in the CRHSP
area had reported earlier that the performance
of verbal autopsy tools by health-care workers
in routine health-care delivery settings was
good for adult deaths.22
In the neonatal age group, low birthweight
and prematurity was the most common
cause of mortality. It had a CSMF of 40%,
using the CRHSP VA tool, which is within the
acceptable limit (20%) of CSMF, according to
the INDEPTH VA tool. Low birthweight as a
cause of death was more common than other
studies conducted in a similar setting8 or
elsewhere,23,24 which reported a CSMF in the
range of 10-30%. Misclassification of cases of
sepsis or pneumonia as low birth-weight may
be the reason for a higher CSMF in this study,
as in this study the CSMF of pneumonia or
sepsis was quite low in comparison with other
studies.8,23-24 Most babies born prematurely
or with a low birthweight are likely to die
from sepsis or pneumonia, but this study
underestimated pneumonia as a cause of
156
Book 1.indb 156
Rakesh Kumar et al.
death in many neonates. It is important to
decide a priori, how to classify deaths in the
neonatal period. Should prematurity or low
birthweight be considered an “underlying
cause” or a “risk factor” as many premature
or low-birth-weight babies may die due to
other causes such as pneumonia, diarrhoea
or sepsis?
Birth asphyxia was another common cause
of death in this study, though the CRHSP VA
tool diagnosed it as a cause of death more
commonly (26.2%) than the INDEPTH VA tool
(15.4%). The reason for this large difference
could be more unclassified deaths in the case
of the INDEPTH VA tool. The narrative section
plays a major role in assignment of the cause
of death for birth asphyxia. It is possible that
health-care workers were able to extract more
information on events surrounding birth. They
had worked in the area for a longer period
and had a better rapport with the informants.
The CSMF of birth asphyxia was similar to
that reported globally or from the South-East
Asia Region,23,24 though a study in northern
India had found a much lower CSMF of birth
asphyxia.8 The CSMF of perinatal conditions in
the neonatal period was found to be 71% in a
large sample survey in India.25 The CSMF of
congenital malformations was similar in both
CRHSP VA and INDEPTH VA tools and was
consistent throughout the study.8,23-24
In the age group of 29 days to <5 years,
diarrhoea and pneumonia were the two most
common causes of death. The CSMF for these
common causes of death by the CRHSP VA
tool was within the acceptable limit (20%)
of the CSMF, using the INDEPTH VA tool. The
CSMFs during infancy obtained in this study,
was similar to other studies.23,25 However, in
the post-infancy period, the CSMF of diarrhoea
was much lower in this study. Injuries were a
common cause of death in this study; similar
results have been found elsewhere.25
WHO South-East Asia Journal of Public Health 2012;1(2):151-158
05-Jun-2012 2:35:56 PM
Rakesh Kumar et al.
The chance-corrected concordance
between CRHSP and INDEPTH VA tools was
excellent for most causes of death except
for birth asphyxia. Very few studies have
presented results in terms of kappa; though
some authors argue that it could be a better
method.7 The chance-corrected concordance
was better for pneumonia than a study
conducted in Kenya.10 The performance of
the CRHSP VA tool for birth asphyxia and
low birthweight in the neonatal period was
similar to other studies; 13,14 however, the
performance in these studies was measured
in terms of validity. In contrast to the other
studies, the performance of the 29 days to
<5 year VA tool was better for diarrhoea and
pneumonia.13,15,18
In all cases, the CRHSP VA tools were
administered before the INDEPTH VA tool. A
gap of two to six weeks is too short to forget
the elements of earlier interview, yet any
longer gap would affect the quality of recall.
The INDEPTH tool is more detailed. It was also
felt that there is more chance of it influencing
recall than the CRHSP tool. Also, the CRHSP
tool is filled routinely, a practice that was not
interfered with in the study protocol, whereas
the INDEPTH tool was filled in the research
mode. It would have been ideal to validate the
VA instruments against medical certification;
however preponderance of home deaths
precluded this option. Attempts were made to
retrieve the medical records of the deceased
in case of hospital deaths, but these records
could not be traced in most cases as these are
usually destroyed after the death of the child.
Records could not be retrieved from hospitals
also, as deaths had occurred in hospitals that
were spread across a wide geographic area.
Moreover, selective admission to hospitals in
a rural area may bias the validation of a tool
that is used in a field setting.
Overall, in the 29 days to <5 year period,
the CSMFs by CRHSP VA tool were within the
WHO South-East Asia Journal of Public Health 2012;1(2):151-158
Book 1.indb 157
Performance of short verbal autopsy tool
20% limit of the CSMF by the INDEPTH VA
tool for most causes of deaths. However, in
neonatal deaths, most CSMFs by the CRHSP
VA tool were not found to be within the 20%
limit of the CSMF by the INDEPTH VA tool. The
smaller number of deaths in the neonatal age
group could probably be the reason for this
difference. Many factors including the design,
type of interviewers and respondents, the
recall period, cause-of-death ascertainment
mechanisms and cause-of-death classification
affect the performance of VA tools.
It can be concluded that despite the
limitations mentioned above, the CRHSP
VA tools performed satisfactorily in the field
setting. The use of CRHSP tool takes less time
to complete the forms, requires less intense
training, and provides data that are useful
for priority setting. Hence, the use of short
VA tool by health workers can fill the gaps in
cause-specific childhood mortality information
in places where medical certification of cause
of death is deficient.
Acknowledgements
The Comprehensive Rural Health Service
Project at Ballabgarh is a member of the
INDEPTH network and acknowledges its
contribution in strengthening demographic
surveillance activities.
References
1. Murray CJL, Laakso T, Shibuya K, Hill K, Lopez AD.
Can we achieve Millennium Development Goal 4? New
analysis of country trends and forecasts of under-5
mortality to 2015. Lancet. 2007;370(9592):10401054.
2. Rajaratnam JK, Marcus JR, Flaxman AD, Wang
H, Levin-Rector A, Dwyer L, et al. Neonatal,
postneonatal, childhood, and under-5 mortality for
187 countries, 1970-2010: a systematic analysis of
progress towards Millennium Development Goal 4.
Lancet. 2010;375(9730):1988-2008.
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3. Hazarika I. India at the crossroads of millennium
development goals 4 and 5. Asia Pac J Public
Health. 2011, Apr 13. http://www.ncbi.nlm.nih.gov/
pubmed/21490106 - accessed 6 January 2012.
4. Jha P. Reliable mortality data: a powerful tool for
public health. Natl Med J India. 2001;14(3):129131.
5. Mortality statistics in India. 2006: status of
mortality statistics reporting in India: a report.
New Delhi: Ministry of Health, Directorate General
of Health Services, 2007. http://cbhidghs.nic.in/
writereaddata/mainlinkfile/File976.pdf. - accessed
6 January 2012.
6. Registrar General of India. Compendium of India’s
fertility and mortality indicators 1971- 1999. New
Delhi: Office of Registrar General of India, 2001.
7. Fottrell E, Byass P. Verbal autopsy: methods in
transition. Epidemiol Rev. 2010;32(1):38-55.
8. Baqui AH, Darmstadt GL, Williams EK, Kumar V,
Kiran TU, Panwar D, et al. Rates, timing and causes
of neonatal deaths in rural India: implications for
neonatal health programmes. Bull World Health
Organ. 2006;84(9):706-713.
9. Etard JF, Le Hesran JY, Diallo A, Diallo JP, Ndiaye JL,
Delaunay V. Childhood mortality and probable causes
of death using verbal autopsy in Niakhar, Senegal,
1989-2000. Int J Epidemiol. 2004;33(6):12861292.
10. Jha P, Gajalakshmi V, Gupta PC, Kumar R, Mony P,
Dhingra N, et al. Prospective study of one million
deaths in India: rationale, design, and validation
results. PLoS Med. 2006;3(2):e18.
11. Baqui AH, Black RE, Arifeen SE, Hill K, Mitra SN, al
Sabir A. Causes of childhood deaths in Bangladesh:
results of a nationwide verbal autopsy study. Bull
World Health Organ. 1998;76(2):161-171.
12. Benara SK, Singh P. Validity of causes of infant death
by verbal autopsy. Indian J Pediatr. 1999;66(5):
647-650.
13. Setel PW, Whiting DR, Hemed Y, Chandramohan D,
Wolfson LJ, Alberti KGMM, et al. Validity of verbal
autopsy procedures for determining cause of death
in Tanzania. Trop Med Int Health. 2006;11(5): 681696.
14. Marsh DR, Sadruddin S, Fikree FF, Krishnan C,
Darmstadt GL. Validation of verbal autopsy to
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determine the cause of 137 neonatal deaths in
Karachi, Pakistan. Paediatr Perinat Epidemiol. 2003;
17(2):132-142.
15. Kalter HD, Gray RH, Black RE, Gultiano SA. Validation
of postmortem interviews to ascertain selected
causes of death in children. Int J Epidemiol. 1990;
19(2):380-386.
16. Setel PW, Rao C, Hemed Y, Whiting DR, Yang
G, Chandramohan D, et al. Core verbal autopsy
procedures with comparative validation results from
two countries. PLoS Med. 2006;3(8):e268.
17. Mobley CC, Boerma JT, Titus S, Lohrke B, Shangula
K, Black RE. Validation study of a verbal autopsy
method for causes of childhood mortality in Namibia.
J Trop Pediatr. 1996;42(6):365-369.
18. Maude GH, Ross DA. The effect of different sensitivity,
specificity and cause-specific mortality fractions
on the estimation of differences in cause-specific
mortality rates in children from studies using verbal
autopsies. Int J Epidemiol. 1997;26(5):1097-1106.
19. Quigley MA, Armstrong Schellenberg JR, Snow RW.
Algorithms for verbal autopsies: a validation study
in Kenyan children. Bull World Health Organ. 1996;
74(2):147-154.
20. King G, Lu Y, Shibuya K. Designing verbal autopsy
studies. Popul Health Metr. 2010;8:19.
21. Joshi R, Lopez AD, MacMahon S, Reddy S, Dandona
R, Dandona L, et al. Verbal autopsy coding: are
multiple coders better than one? Bull World Health
Organ. 2009;87(1):51-57.
22. Krishnan A, Kumar R, Nongkynrih B, Misra P,
Srivastava R, Kapoor SK. Adult mortality surveillance
by routine health workers using a short verbal autopsy
tool in rural north India. J Epidemiol Community
Health. 2011 Mar 3. http://www.ncbi.nlm.nih.gov/
pubmed/21372064- accessed 6 January 2012.
23. Mathers CD, Boerma T, Ma Fat D. Global and regional
causes of death. Br Med Bull. 2009;92:7-32.
24. Lawn JE, Cousens SN, Wilczynska K. Estimating the
causes of four million neonatal deaths in the year
2000: statistical annex - the World Health Report
2005. Geneva: World Health Organization, 2005.
25. Registrar General of India. Report on cause of death
in India 2001-2003. New Delhi: Office of Registrar
General Office of India, 2009.
WHO South-East Asia Journal of Public Health 2012;1(2):151-158
05-Jun-2012 2:35:57 PM
Original research
Initiating tobacco cessation services in India:
challenges and opportunities
Cherian Varghesea, Jagdish Kaurb, Nimesh G Desaic, Pratima Murthyd, Savita Malhotrae,
Subbakrishna D Kd, Vinayak M Prasadf, Vineet G Munishg
Background: Tobacco use contributes significantly to the diseases burden in India. Very few
tobacco users spontaneously quit. Therefore, beginning 2002, a network of 19 tobacco cessation
clinics (TCCs) was set up over a period of time to study the feasibility of establishing tobacco
cessation services.
Methods: Review of the process and operational aspects of setting up TCCs was carried out by
evaluation of the records of TCCs in India. Baseline and follow-up information was recorded on a
pre-designed form.
Results: During a five-year period, 34 741 subjects attended the TCCs. Baseline information
was recorded in 23 320 cases. The clients were predominantly (92.5%) above 20 years, married
(74.1%) and males (92.2%). All of them received simple tips for quitting tobacco; 68.9% received
behavioural counselling for relapse prevention and 31% were prescribed adjunct medication.
At six-week follow-up, 3255 (14%) of the tobacco users had quit and 5187 (22%) had reduced
tobacco use by more than 50%. Data for three, three-monthly follow-ups was available for 12 813
patients. In this group, 26% had either quit or significantly reduced tobacco use at first follow-up
(three-months), 21% at the second (six-months) and 18% at the third follow-up (nine-months)
had done so.
Conclusions: It is feasible to set up effective tobacco cessation clinics in developing countries.
Integration of these services into the health care delivery system still remains a challenge.
Key words: Tobacco cessation, health services, behaviour counselling, nicotine replacement
therapy, India
Introduction
Tobacco use is a major modifiable risk factor
for health globally. In the South-East Asia
Region (SEAR), smoking prevalence ranges
from 29.8% to 63.1% among men and 0.4%
to 15% among women. The practice of tobacco
chewing also needs attention. Smokeless
tobacco use ranges from 1.3% to 38% among
World Health Organization Regional Office for the Western Pacific, Manila, Philippines.
Directorate General of CGHS, Ministry of Health and Family Welfare, Government of India, New Delhi, India.
Institute of Human Behaviour and Allied Sciences, Delhi, India.
d
National Institute of Mental Health and Neuro Sciences, Bangalore, India.
e
Post Graduate Institute of Medical Education and Research, Chandigarh, India.
f
Tobacco Free Initiative, World Health Organization, Geneva, Switzerland.
g
World Health Organization Country Office for India, New Delhi.
Correspondence to Pratima Murthy (pratimamurthy@gmail.com)
a
b
c
WHO South-East Asia Journal of Public Health 2012;1(2):159-168
Book 1.indb 159
159
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Initiating tobacco cessation services in India
men and 4.6% to 27.9% among women.1
India has a huge burden of tobacco-related
morbidity, disability and mortality.2-3 Nearly
one-third to more than half of those above
15 years use some form of tobacco.2,4-7 The
Global Adult Tobacco Survey (GATS) in 2010
revealed that 47.9% of males and 20.3%
of females, constituting 34.6% of the adult
population, used tobacco in one or the other
form in India.8
The WHO Framework Convention on
To b a c c o C o n t r o l ( F C TC ) r e c o m m e n d s
comprehensive policies for tobacco control,
including cessation or treatment of tobacco
dependence. Offer to help quit tobacco use is
one of the six strategies for tobacco control
advocated by WHO under MPOWER and
technical guidelines for tobacco cessation
have also been developed for different levels
of health care providers. However, despite
the enormous health burden resulting from
tobacco use, there were no organized tobacco
cessation services in India until 2001.
Global support for tobacco control policies
and national data on mortality and morbidity
related to tobacco use began to have its impact
on policy and programming for tobacco control
in India.9 In 2002, formal tobacco cessation
facilities were set up for the first time. The
purpose of the tobacco cessation clinics was
to develop simple intervention models for
tobacco cessation for smokers and smokeless
tobacco users, to generate experience in the
delivery of these interventions that can be
applied in the primary care setting, and finally,
to study the feasibility of implementing these
interventions and their acceptability in general
primary health care settings.
Methods
The first formal tobacco cessation clinics
were set up in 2002, as a joint initiative of
the Ministry of Health and Family Welfare,
160
Book 1.indb 160
Cherian Varghese et al.
Government of India and the World Health
Organization’s Country Office for India.
Principal investigators from selected tertiary
level health facilities were trained in tobacco
cessation services in Thailand. Thirteen
tobacco cessation clinics (TCC) were set up
in psychiatry (3), cancer (5), surgical (2),
cardiology (1), chest diseases (1) as well as
in a nongovernment organizational setting (1).
The TCCs were subsequently expanded to five
more Regional Cancer Centres (RCC) in 2005.
Another TCC has more recently been added in
a general hospital setting.
The space for the TCCs was provided in the
existing facilities. At a consultative meeting,
organized by the Ministry of Health & Family
Welfare, guidelines for assessment and
intervention were evolved by consensus. The
concept and operational plan was prepared
by technical experts from three premier
institutions, i.e. The Institute of Human
Behaviour and Allied Sciences, Delhi, the
National Institute of Mental Health and Neuro
Sciences, Bangalore, and the Post- Graduate
Institute of Medical Research, Chandigarh,
supported by the WHO Country office, for
India.
The staff involved in running the centerseither a psychologist, social worker or medical
officer- was trained in a two-day workshop on
psychosocial and pharmacological approaches
to cessation. A similar workshop was held
during the expansion phase. All investigators
and staff were brought together annually for a
review of the work and to enhance their skills
in specific areas as per the need. Each clinic
was supported with two personnel, a computer
and a carbon monoxide monitor. The tobacco
cessation approach followed at the tobacco
cessation clinics is outlined in Table 1.
A brief intake form with minimum baseline
information on socio-demographic information,
duration and type of tobacco use and the type of
WHO South-East Asia Journal of Public Health 2012;1(2):159-168
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Cherian Varghese et al.
Initiating tobacco cessation services in India
Table 1: Tobacco cessation approach
Component
Description
Motivation
Enhancing knowledge of dangers of continuing tobacco use and
benefits of quitting
Encouragement to quit with simple tips to deal with withdrawal
Handouts with information on tobacco dependence and cessation
Behaviour counselling
Focused on relapse prevention measures such as recognizing and
coping with internal and external triggers for tobacco use.
Medication
Included bupropion and nicotine chewing gums (gums were not
available in India in the first few years of initiation of the TCCs). tobacco cessation intervention was developed
and used in all the TCCs. Active efforts were
made to recruit tobacco users for cessation at
the TCCs through liaison with other medical
services, community participation in camps and
awareness programmes, referral by doctors,
friends and relatives or by self-referral. All the
TCCs maintained follow-up information for six
weeks and some also maintained longer-term
follow-up information.
Results
During the first five years of the setting up of
the TCCs, 34 741 cases were registered across
18 TCCs. Baseline information was recorded
for 23 320 cases.
Socio-demographic
characteristics
Most of the clients were married (74.1%),
males (92.2%), and above 21 years (82.5%).
Nearly half of the respondents had more than
10 years of education. Median monthly income
was 3000. Women who sought treatment
at the TCCs were comparatively older than
the men, less educated and with lower
monthly income levels. Students constituted
a very small proportion of the TCC clients
(Table 2).
WHO South-East Asia Journal of Public Health 2012;1(2):159-168
Book 1.indb 161
Tobacco use pattern
A majority of those accessing tobacco
intervention services were chewers (65.5%).
Smokeless tobacco use was significantly
associated with income below 1500 per month
and education below 10 years (p<0.001).
Women accessing services were more likely
than men to use smokeless tobacco (83.5% and
64% respectively). Self-report of alcohol use
among the smokers was relatively low (18%),
almost exclusively a male phenomenon. None
of the tobacco chewers reported concomitant
alcohol use.
Types of intervention
All cessation service seekers were provided
motivation and simple tips on how to quit
tobacco. Behaviour counselling (BC) as the
primary strategy for cessation was provided
to 16 070(68.9%) subjects. In addition to
behaviour counselling, 4713(20.2%) received
medication (mostly bupropion), 2362(10.1%)
received nicotine replacement therapy
(NRT) and a few (175; 0.8%) got both NRT
and medication. At the time of this study,
varenicline was not available as a treatment
option.
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Initiating tobacco cessation services in India
Cherian Varghese et al.
Table 2: Profile of clients attending tobacco cessation clinics and
six-week tobacco quit rates
Total
6 week quit rates
N=23,320
Males
N=21,500
n (%)
n (%)
n (%)
n (%)
n (%)
< 20
1759 (7.5)
1686 (7.8)
73 (4.0)
282 (16.0)
270 (16.0)
12 (6.4)
21-40
13267 (56.9)
12289 (57.2)
978 (53.7)
1833 (13.8)
1733 (14.1)
100 (10.2)
> 40
8289 (35.6)
7520 (35.0)
769 (42.3)
1140 (13.8)
1072(14.3)
68 (8.8)
0
2127 (9.1)
1713 (8.0)
414 (22.8)
254 (11.9)
219 (12.8)
35 (8.5)
1 to 5
2605 (11.2)
2216 (10.3)
389 (21.4)
353 (13.6)
324 (14.6)
29 (7.5)
6 to 10
7487 (32.1)
6879 (32.0)
608 (33.4)
1047 (14.0)
977 (14.2)
70 (11.5)
> 10
11076 (47.5)
10668 (49.7)
408 (22.4)
1599 (14.4)
1553 (14.6)
46 (11.3)
17274 (74.1)
15752 (73.2)
1522 (83.6)
2364 (13.7)
838 (15.0)
21 (11.8)
5760 (24.7)
5582 (26.0)
178 (9.8)
859 (14.9)
2212 (14.0)
152 (10.0)
286 (1.2)
166 (0.8)
120 (6.6)
32 (11.1)
25 ( 15.1)
7 (6.9)
10933(46.9)
10383 (48.3)
530 (29.0)
1765 (16.2)
1720 (16.6)
45 (8.5)
Semi-skilled/
unskilled
1830 (7.8)
1634 (7.6)
43 (2.4)
201 (11.0)
195 (10.9)
6 (14.0)
Student
1662 (7.2)
1787 (8.3)
28 (1.5)
215 (12.9)
212 (13.0)
3 (10.7)
Others/not
classified
8895 (38.1)
7696 (35.8)
1219 (67.1)
1074 (12.0)
948 (12.3)
126 (10.3)
<1500
4209 (21.5)
3761 (20.4)
448 (41.6)
899 (13.7)
779 (14.2)
120 (10.9)
1500 to 3000
5502 (28.2)
5215 (28.3)
287 (26.7)
652 (13.9)
637 (13.9)
15 (5.9)
> 3000
9823 (50.3)
9482 (51.3)
341 (31.7)
1681 (14.4)
1640 (14.6)
41 (9.6)
6809 (29.2)
6549 (30.4)
260 (14.3)
830 (12.2)
798 (12.2)
32 (12.3)
15271 (65.5)
13751 (64.0)
1520 (83.5)
2309 (15.1)
2165 (15.7)
144 (9.5)
1240 (5.3)
1200 (5.6)
40 (2.2)
116 (9.4)
112 ( 9.3)
4 (10.0)
16070 (68.9)
14803 (68.9)
1267 (69.6)
2007 (12.5)
1893 (12.8)
114 (9.0)
7250 (31.1)
6697 (31.1)
553 (30.4)
1248 (17.2)
1182 (17.6)
66 (11.9)
Characteristics
Females
N= 1820
Total
Males
Females
N=10471
N=9875
N=596
Age in years
Education in
years
Marital status
Married
Single
Widowed/
separated
Occupation
Professional/semiprofessional
Monthly income
Type of tobacco
use
Smoking
Smokeless
Both
Type of
Intervention*
BC alone
BC+ Medication
* BC= behavioural counselling *both categories included motivation
162
Book 1.indb 162
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Cherian Varghese et al.
Outcome at six weeks
Information on six-week outcome was
available for 10 471 subjects (44.9% of
the entire group). Of them, 3255 (31.1%)
had quit, 5187 (49.5%) reported significant
improvement (reduced intake by 50% or
more compared to baseline) and 2029 (8.7%)
reported ‘no change’. Considering those lost
to follow-up as ‘not improved’, the improved
group was 36% (14% quitters and 22% who
had reduced use by 50% or more).
Among men, factors associated with
improved outcome at six weeks included a
younger age, use of smokeless tobacco, and
combined pharmacological and behavioural
interventions. Among women, while outcome
in general was poorer than men, combined
use of pharmacotherapy and behavioural
counselling was associated with a better
outcome and lack of education with a poorer
outcome.
of population growth, the absolute number
of deaths in this age group is rising by about
3% per year.10 As per GATS India, five in
ten current smokers and users of smokeless
tobacco planned to quit or at least thought of
quitting.8 In this scenario, it became important
for India to institute a tobacco control
programme, including expansion of facilities
for tobacco cessation.
A major lesson from the study is that
it is possible to establish effective tobacco
cessation services in diverse health settings
with optimal use of existing infrastructure
and minimal support. It is also evident that
follow-up is a very important component of
care to ensure better outcome. There is a need
to build awareness regarding the availability
and benefits of tobacco cessation services.
Educating the community about the benefits
of tobacco cessation interventions is likely
to improve retention in tobacco cessation
programmes.
Discussion
Several predictors of tobacco cessation
have been described in earlier studies
including intention to quit, recent episode
of quitting, longer duration of recent quit,
negative attitudes to smoking and a younger
age.11,12 It has also been suggested that
stopping tobacco use before the age of 40
years may be critical to improve health.11 In
our experience, help is sought usually in the
fourth decade, when many tobacco-related
health problems may have already occurred.
Nevertheless, our findings that younger people
are more likely to be retained in treatment
and have better outcomes, is an indicator
to provide outreach to tobacco users at an
early stage. The feasibility of using innovative
technology such as mobile phones or quit
tobacco helplines could be explored to improve
access by youth and in hard-to-reach cases.
In 2010, smoking is expected to have caused
about 930 000 adult deaths in India. Because
Healthcare givers at all levels of the
healthcare delivery system must be trained
Longer-term outcome
Only some of the TCCs maintained longerterm follow-up data. Three-monthly follow-up
data (for nine months) was available for 12
813 clients. In this group, 26% were in the
improved category at the first follow-up (three
months), 21% at the second follow-up (6
months) and 18% at the third follow-up (nine
months). What is striking is that of those who
remained in follow-up, a significant number
moved from the ‘no-change’ to the ‘improved’
category over a period of time. This indicates
the need for retaining people in follow-up
for chronic, relapsing conditions like tobacco
dependence, in order to improve longer-term
outcome.
WHO South-East Asia Journal of Public Health 2012;1(2):159-168
Book 1.indb 163
Initiating tobacco cessation services in India
163
05-Jun-2012 2:35:57 PM
Initiating tobacco cessation services in India
in tobacco dependence treatment including
behaviour counselling and pharmacotherapy.
We found that physicians, in general, lacked
knowledge of tobacco cessation protocols and
felt uncomfortable or at a loss in their ability
to handle needs of their patients for tobacco
cessation. Data from the Indian Global Health
Professionals Students Survey (GHPSS)
between 2005-2008 among dental, medical,
nursing and pharmacy students, showed high
prevalence of tobacco use and a general lack of
training among health professionals in patient
cessation counselling techniques.13 Dental
professionals also need to be aggressively
involved in smokeless tobacco cessation.14
Education of health professionals is needed
to occur both within the governmental health
systems as well as in the private sector. It
is important to ask every patient visiting
any health facility about tobacco use as it
has been observed that few physicians ask
their patients about tobacco use.15 Educating
physicians in asking and assessing tobacco
use among patients as well as training them
in tobacco cessation on a wider scale is an
urgent need. In this regard, several resources
have been developed by the Ministry of Health
& Family Welfare, Government of India and
the WHO Country office for India. These
resources include a training manual for tobacco
cessation developed under the cancer control
programme, a manual for dentists, a training
module for doctors; these can also be used
for training in tobacco cessation.16-18 ‘National
Guidelines for Tobacco Dependence Treatment’
have also been developed which need to be
widely disseminated.19 More detailed manuals
on tobacco cessation for both doctors and
nurses and other professionals have also been
developed for the SEA Region.20,21
There has not been much research on
tobacco dependence treatment or cessation in
so far as smokeless tobacco is concerned. The
Indian experience of offering cessation services
164
Book 1.indb 164
Cherian Varghese et al.
to smokers as well as to smokeless tobacco
users, especially the chewers, is unique. GATS
India has also revealed that 26% of the adult
population in India uses smokeless tobacco.8
Considering that only about 1% of smokeless
tobacco users report having spontaneously
quit,8 it is very important to address smokeless
tobacco cessation in India.
Tobacco chewing is more prevalent among
Indian women as compared to smoking; in
some parts of India it is as high as 57%.22
A significant problem of tobacco use among
students is recently coming to light,23 and a
shift of use to younger persons is expected.24
In a study from a TCC at Chandigarh, 92% of
subjects were in the 10-19 years age range
and a majority (68.2%) had started tobacco
use under peer pressure.25 The lower socioeconomic stratum is underrepresented among
our treatment seekers. These groups would
benefit more from cost-effective interventions
at the community level.
Studies in western settings,11 as well as the
present study indicate improved quit rates with
the addition of pharmacotherapy to behaviour
counselling. Our experience also suggests
a better outcome with the combination of
these two approaches. Similar encouraging
results have been reported with the combined
approaches in a chest diseases tobacco
cessation setting in India.26 The evidence for
combined efficacy of pharmacotherapy and
behavioural counselling in enhancing rates of
tobacco cessation is now available.27-29
Taking into consideration the high
prevalence of tobacco use in India, community
cessation intervention programmes should be
integrated in the primary health care delivery
services within a proper monitoring and
evaluation framework. A study from Thailand
reports benefits from a community pharmacistbased smoking cessation programme.30
WHO South-East Asia Journal of Public Health 2012;1(2):159-168
05-Jun-2012 2:35:57 PM
Cherian Varghese et al.
The data collected during the preliminary
phase of establishment of the TCCs is
extremely basic but provides some valuable
insights into the kind of populations that have
accessed tobacco cessation services. The
sample is heterogeneous from diverse clinical
settings and population groups. Although staff
delivering the services received brief training in
tobacco cessation intervention, there is likely
to have been a great amount of variability
in counselling depending on the staff’s
background, training and treatment setting.
Despite these limitations, the establishment of
the TCCs has been the first step in providing
formal tobacco cessation services in India. In
a country where use of tobacco is widespread,
it is critical to establish the evidence for
achievement of effective tobacco cessation
by use of behavioural counselling and optimal
pharmacotherapy. Extending tobacco cessation
services to rural populations, given the higher
prevalence of tobacco use in rural populations,
is imperative. Behaviour counselling is
applicable and acceptable in rural settings,
where access to pharmacotherapy may be
limited. Studies from India have shown that
health education and community awareness
has helped in tobacco cessation.31,32
The existing TCCs are not sufficiently
equipped to take care of any population-based
cessation scale-up programme. It would be
critical to build cessation capacity in the
medical and dental college hospitals, both to
provide the needed training to the students
and also to cater to the cessation needs of
the population. In low-resource settings,
with limited access to pharmacotherapy,
there is also a need to evaluate cost-effective
behavioural interventions, particularly for
smokeless forms of tobacco use, for further
expansion of tobacco cessation activities.33
The Government of India initiated the
National Tobacco Control Programme in 200708. Taking into account the widespread use
WHO South-East Asia Journal of Public Health 2012;1(2):159-168
Book 1.indb 165
Initiating tobacco cessation services in India
of tobacco and need for assisting tobacco
users to quit, provision was made to establish
tobacco cessation facilities at the district
hospital level. This was a major step forward in
establishing tobacco cessation facilities as near
the community as possible. A psychologist and
a social worker are provided at the District
Tobacco Control Cell to undertake tobacco
cessation activities. The Government of India
has decided to make most of the TCCs selfsufficient and continue their activities in a
sustainable manner from 2010-11 onwards.
The focus of these RCTCs would be to build
capacity of the states in tobacco cessation by
conducting training of health professionals and
also to focus on setting up cessation facilities
in medical and dental institutions. National
Guidelines for Tobacco Dependence Treatment
have taken care of smokeless tobacco
cessation along with the focus on smoking
cessation. Training modules for doctors
and health workers were also developed in
2010-11 emphasizing the “brief advice” for
tobacco cessation. For the first time, tobacco
cessation was also incorporated in the training
modules of doctors under the Revised National
Tuberculosis Control Programme (RNTCP).
All medical and dental colleges, general
hospitals and tuberculosis hospitals have
been encouraged to set up tobacco cessation
facilities as part of care giving, using existing
infrastructure and resources to make these
sustainable.
To conclude, tobacco cessation services
established in selected tertiary level centres
in India were well received and short-term
outcome of subjects seeking help was
encouraging. However, tobacco cessation
activities clearly need to be up-scaled, and
the public better informed of the availability
and relevance of such interventions. Younger
persons using tobacco, women users, rural
populations and the economically underprivileged need to be more actively targeted.
165
05-Jun-2012 2:35:57 PM
Initiating tobacco cessation services in India
Tobacco cessation must be offered more widely
in medical settings in both urban and rural
areas. The integration of tobacco cessation
with existing national health programmes
is a cost-effective strategy to widen the
cessation services for effective outreach at
the community level. The use of innovative
technologies like mobile phones and setting
up quit-lines can give a major impetus to the
ongoing efforts of the Government of India
for providing cessation facilities to a larger
population, especially in the remote and rural
areas. A clear and definite need for welldesigned studies to examine the longer-term
impact of tobacco cessation interventions in
low-and middle-income settings is important
for further expansion of these services.
Mizoram (Jane R Ralte), Regional Cancer
Center, Thiruvananthapuram (Jayakrishnan
R), Tata Memorial Hospital, Mumbai (Surendra
Shastri), Vallabhbhai Patel Chest Institute,
New Delhi (Raj Kumar), Ministry of Health
and Family Welfare, Government of India,
WHO Country Office for India., and the staff of
TCC IHBAS and NIMHANS. We also gratefully
acknowledge the active role played by the
subsequent co-ordinators of the various TCCs
towards tobacco control and cessation.
Acknowledgements
2. Rani M, Bonu S, Jha P, Nguyen SN, Jamjoum L.
Tobacco use in India: prevalence and predictors of
smoking and chewing in a national cross sectional
household survey. Tobacco Control. 2003; 12:
8-15.
We acknowledge the contribution of Acharya
Harihar Regional Cancer Center, Cuttack
(UR Parija), Bhagwan Mahaveer Cancer
Hospital, Jaipur (Vivek Sharma, Rahman
AU), B Barooah Cancer Institute, Assam
(Joydeep Das), Cancer Institute, Chennai
(Rohini Prem Kumari, E Vidhubala), Chatrapati
Shahuji Maharaj Medical University, Lucknow
(Ramakant B), Chittaranjan National Cancer
Institute, Kolkata (Utpal Sanyal), Institute
of Behavior and Allied Sciences, New Delhi
(SN Gupta, Uday Singh, Deepak Kumar,
Rupali Shivalkar), Indira Gandhi Institute of
Cardiology, Patna (Mahabir Das), Jawaharlal
Nehru Cancer Hospital and Research Center,
Bhopal (Dilip Kumar Kar), MNJ Institute
of Oncology and Regional Cancer Center,
Hyderabad (BN Rao), National Institute of
Mental Health and Neuro Sciences (Issac M,
Benegal V), Bangalore, National Organization
for Tobacco Eradication, Goa (Shekhar Salkar),
Post Graduate Institute of Medical Research,
Chandigarh (Anil Malhotra), Pramukhswami
Medical College and Shree Krishna Hospital,
Gujarat (Girish Mishra), Regional Cancer Center,
166
Book 1.indb 166
Cherian Varghese et al.
References
1. World Health Organization, Regional Office for
South-East Asia. Tobacco free initiative. http://
www.searo.who.int/en/section2666.htm - accessed
2 May 2012.
3. Srivastava A, Pal H, Dwivedi SN, Pandey A, Pandey
JN. National household survey of drug and alcohol
abuse in India. New Delhi. Ministry of Social Justice
and Empowerment, and UN Office on Drugs and
Crime, Regional Office for South Asia, 2004.
4. Gupta PC, Mehta HC. Cohort study of all-cause
mortality among tobacco users in Mumbai, India.
Bulletin of the World Health Organization. 2000;
78:16-30.
5. Gajalakshmi V, Peto R, Kanaka TS, Jha P. Smoking
and mortality from tuberculosis and other diseases
in India: a retrospective study of 43,000 adult male
deaths and 35000 controls. Lancet. 2003; 362:
507-515.
6. Gupta P, Ray C. Smokeless tobacco and health in
India and South Asia. Respirology. 2003; 8: 419431.
7. Rastogi T, Jha P, Reddy KS, Prabhakaran D,
Spiegelman D, Stampfer MJ, Willett C, Ascherio.
A bidi and cigarette smoking and risk of acute
myocardial infarction among males in urban India.
Tobacco Control. 2005;14: 356-358.
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8. Global Adult Tobacco Survey. GATS India report 20092010. Mumbai: International Institute for Population
Sciences (IIPS) and New Delhi: Ministry of Health
and Family Welfare, 2010.
9. Reddy KS, Gupta PC. Report on tobacco control
in India. New Delhi: Ministry of Health and Family
Welfare, 2005.
10. Jha P, Jacob B, Gajalakshmi V, Gupta PC, Dhingra
N, Kumar R, et al. A nationally representative case–
control study of smoking and death in India. New
England Journal of Medicine. 2008; 358:1137-114.
11. Aveyard P, West W. Managing smoking cessation.
British Medical Journal. 2007; 335:37-41
12. Hyland A, Borland R, Li Q, Yong HH, McNeill A, Fong
GT, et al. Individual-level predictors of cessation
behaviors among participants in the international
tobacco control (ITC) four country survey. Tob
Control. 2006; 15(suppl_3): 83-94.
13. Sinha DN, Singh G, Gupta PC, Pednekar M, Warrn CW,
Asma S, Lee J. Linking India Global Health Professions
Student Survey data to the World Health Organization
Framework Convention on Tobacco Control. Indian J
Cancer. 2010; 47: 30-34.
14. Saddichha S, Rekha DP, Patil BK, Murthy P, Benegal V,
Isaac M. Knowledge, attitude and practices of Indian
dental surgeons towards tobacco control: advances
towards prevention. Asian Pacific J Cancer Prev.
2010; 11: 939-942.
15. Nichter M. Introducing tobacco cessation in developing
countries: an overview of project quit tobacco
international. Tob Control. 2006; 15: i12-i17.
16. Directorate General of Health Services. Manuals
for training in cancer control. Manual on tobacco
cessation. Ministry of Health and family welfare, Govt.
of India. New Delhi 2005.
17. Shah M, Ray CS, Arora M. Helping your patients
remain tobacco free: quick reference guide for
dentists. New Delhi: Ministry of Health and Family
Welfare, 2006. http://www.whoindia.org/LinkFiles/
Oral_Health_tobacco_cessation.pdf - accessed 2
May 2012.
18. Directorate General of Health Services. Training
manual for doctors. New Delhi: Ministry of Health and
Family Welfare, 2011. (http://www.whoindia.org/
LinkFiles/Tobacco_Free_Initiative_Training_Manual_
for_Doctors_-_Tobacco_Control_.pdf - accessed 2
May 2012).
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19. Directorate General of Health Services. Tobacco
dependence treatment guidelines. New Delhi:
Ministry of Health and Family Welfare, 2011. http://
whoindia.org/LinkFiles/Tobacco_Free_Initiative_
Tobacco_Dependence_Treatment_Guidelines.pdf accessed 2 May 2012.
20. World Health Organization, Regional Office for SouthEast Asia. Helping people quit tobacco- a manual
for doctors and dentists. New Delhi: WHO-SEARO,
2010.
21. World Health Organization Regional Office for SouthEast Asia. Tobacco cessation- a manual for nurses,
health workers and other health professionals. New
Delhi: WHO-SEARO, 2010.
22. Gupta PC. Survey of socio-demographic characteristics
of tobacco use among 99,598 individuals in Bombay,
India using hand held computers. Tobacco Control.
2002; 11: 82-83.
23. Sinha DN, Gupta PC, Pednekar MS, Jones JT, Warren
CW. Tobacco use among school personnel in Bihar,
India. Tobacco Control. 2002;11: 82-83.
24. Reddy S, Perry CL, Stigler MH, Arora MS. Differences
in tobacco use among young people in urban India
by sex, socioeconomic status, age and school grade:
assessment of baseline survey data. The Lancet.
2006; 367: 589-594.
25. Malhotra S, Malhotra A, Kakkar N, Das PP, Singh J.
The clinical and demographic profile of Nicotine users
among Children and Adolescents. German Journal of
Psychiatry. 2008; pp 14-18.
26. Kumar R, Kushwah AS, Gopal C, Mahakund SP,
Vijayan VK. Smoking cessation interventions and
continuous abstinence rate at one year. The Indian
Journal of Chest Diseases & Allied Sciences. 2007;
49: 201-208.
27. Stead L, McNeill A, Shahab L, West R. Rapid review of
brief interventions and referral for smoking cessation.
London: NICE, November 2005.
28. Lancaster T, Stead LF. Individual behavioural
counselling for smoking cessation. Cochrane
Database Syst Rev. 2005;(2).
29. Wu P, Wilson K, Dimoulas P, Mills E. Effectiveness of
smoking cessation therapies: a systematic review and
meta-analysis. BMC Public Health. 2006; 6: 300.
30. Thavorn K, Chaiyakunapruk N. A cost-effectiveness
analysis of a community pharmacist-based smoking
cessation programme in Thailand. Tob Control.
2008;17: 177-182.
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31. Anantha N, Nandakumar A, Vishwanath N, Venkatesh
T, Pallad YG, Manjunath P, et al. Efficacy of an antitobacco community education program in India.
Cancer Causes Control. 1995; 6:119-129.
Cherian Varghese et al.
33. Murthy P, Sadichha S. Tobacco cessation services
in India: recent developments and the need for
expansion. Indian J Cancer. 2010; 47 (Suppl 1):
69-74.
32. Gupta PC, Aghi MB, Bhonsle RB, Murti PR, Mehta FS,
Mehta CR, Pindborg JJ. An intervention study
of tobacco chewing and smoking habits for primary
prevention of oral cancer among 12,212 Indian
villagers. IARC SciPubl. 1986; 74: 307-18.
168
Book 1.indb 168
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05-Jun-2012 2:35:57 PM
Original research
Betel quid chewing and its risk factors in
Bangladeshi adults
Meerjady S Floraa, Christopher GN Mascie-Taylorb, Mahmudur Rahmanc
Background: Despite its ill effects, betel quid chewing is a common practice in the South-East
Asia Region. However, so far no large-scale study had been conducted, hence, this study was
aimed at estimating the extent of betel quid chewing and its association with socio-demographic
factors in Bangladeshi adults.
Methods: The data of a cross-sectional sample survey, involving 15 155 and 15 719 adults from
rural and urban areas of Bangladesh respectively, were analyzed. Data were collected on betel quid
chewing and socio-demographic characteristics by interview method using a pre-tested structured
questionnaire. Anthropometric measurements were done following standard protocols.
Results: Overall 31% of the study samples chewed betel quid regularly. Prevalence was two times
higher in rural (43.2%) compared to the urban areas (19.1%). Betel quid use was more common
among Hindus (41.4%), farmers (55.3%), and people in the 40-year or more (63.9%) age group;
and the habit was less common in unmarried (1.6%) and educated persons (19.6%). Ex-smokers
(73.8%) and current smokers (37.3%) were more likely to use betel quid than never smokers
(25.6%). The frequency of betel quid chewing was 5.15 times a day which varied significantly with
age, locality, religion and occupation. Three-fourths of the betel quid users chewed tobacco with
it which was not influenced by socio-economic variables. On average, 2.29 Takas (USD 0.03) was
spent a day on betel quid chewing.
Conclusions: Betel quid chewing was found to be a common habit in Bangladesh. Mature adults
(40+years) of low socio-economic status, i.e., rural residents, farmers and the illiterate are more
likely to chew betel quid.
Keywords: Betel quid, areca nut, adults, risk factors, smoking, Bangladesh.
Introduction
Betel quid, the leaf of Piper betle vine, is
usually taken with aqueous calcium hydroxide
paste (slaked lime), pieces of areca nut
(supari) and some other ingredients, which
vary with individual taste and region. After
introduction, tobacco soon became the
most commonly used ingredient with the
betel quid.1 Betel quid chewing is a popular
National Institute of Preventive and Social Medicine, Dhaka -1212, Bangladesh.
Department of Biological Anthropology, University of Cambridge, Cambridge, United Kingdom.
Institute of Epidemiology, Diseases Control and Research, Dhaka, Bangladesh.
Correspondence to author Meerjady S Flora (e-mail: meerflora@yahoo.com)
a
b
c
WHO South-East Asia Journal of Public Health 2012;1(2):169-181
Book 1.indb 169
169
05-Jun-2012 2:35:58 PM
Betel quid chewing in Bangladeshi adults
traditional activity that is integrated into social
and cultural practices and ceremonies.2 It is
a cheaper pleasure, affordable by the least
advantaged members of the community. The
habit has been prevailing for at least 2000
years throughout South Asia, South-East Asia
and the South Pacific.3 It is the fourth most
commonly used psychoactive substance in the
world after caffeine, alcohol and nicotine.4
Areca nut is often chewed in a betel quid.
It is regarded by many people in South Asia
as good for health. It is used as an astringent,
mouth freshener, a taste enhancer, purgative,
intoxicant, for impotence and gynaecological
problems, parasitic intestinal infection and
for indigestion and prevention of pregnancyrelated morning sickness. It is also used
as a mildly euphoric stimulant because it
contains relatively high levels of psychoactive
alkaloids. Chewing increases the capacity to
work, causes a hot sensation in the body and
heightens alertness. It is used among the poor
to avoid boredom and to suppress hunger.
A study in the UK reported that 42% of South
Asian immigrants (from Bangladesh) chewed
areca nut because it gave them a refreshing
feeling and 35% used it because of its good
taste, 29% used it as a snack and others used
it because it helped to relieve stress and was
believed to strengthen the teeth and gums.5
It is estimated that 600 million people use
betel nut globally.1 The habit of betel quid
chewing has been reported in many countries
including Pakistan, Sri Lanka, Bangladesh,
Thailand, Cambodia, Malaysia, Indonesia,
China, Taiwan, Papua New Guinea, several
Pacific Islands, and migrant populations in
places like South Africa, Eastern Africa, North
America, UK, and Australia.4 In Thailand, a
decline has been recorded, while in Taiwan
an increase in consumption was noticed,
especially among children and youths.4 The
per capita consumption of betel quid in Taiwan
has increased from 1.4 kg in 1981 to 7.5 kg
170
Book 1.indb 170
Meerjady S Flora et al.
in 1996. In 2001, 14.4% of adult males and
1.5% of adult females were current betel
nut chewers.6 Betel quid chewing is socially
acceptable in all sections of society, in all age
groups, and among women; although in most
countries it is more often confined to the older
age groups.2,4 Blue collar workers and the rural
poor had a higher chewing rate. Education and
income were inversely correlated with betel
quid use.6 In Pakistan, at least one chewable
product of betel, areca and tobacco are used
daily by 40% of the adolescents and adults.7
Bangladeshis traditionally, for a long time,
have been chewing betel quid as a popular
habit. A study, done on a limited sample,
reported that 30% of the adults were using
betel nut regularly.8 However, large-scale
studies have not been conducted to find out
the extent of this habit in Bangladesh. This
study was aimed to determine the magnitude
of betel quid chewing and its association with
locality, sex, education, occupation, smoking
and other characteristics since betel quid,
even without tobacco, was recently classified
as a human carcinogen by the International
Agency for Research on Cancer (IARC).
Case-control studies from India, Pakistan
and Taiwan reported an independent effect of
betel quid as a risk factor for oral cancer. It
had increased relative risks for pre-cancers;
and dose-response trends were also noticed
for both frequency and duration of betel quid
use.9 People using betel quid without tobacco
were 9.9 times more likely to develop oral
cancer than non-users after adjustment for
other covariates.10
Methods
Cross-sectional sample surveys were conducted
in 15 155 rural and 15 719 urban adults to
find out the extent of betel quid chewing in
Bangladesh. These surveys were conducted
in Mirpur, an area in the capital city Dhaka
and the rural Kaliganj sub-district which is
WHO South-East Asia Journal of Public Health 2012;1(2):169-181
05-Jun-2012 2:35:58 PM
Meerjady S Flora et al.
approximately 42 km from the capital. These
areas are representative of the general urban
and rural populations of Bangladesh. The
distribution of age and other background
characteristics of this sample appear to
reflect the profile of the adult Bangladeshi
population.11,12 These areas were chosen to
assess whether betel quid chewing differed
markedly between rural and urban areas,
independent of the variation in socioeconomic
characteristics. At 99% confidence level with
5% relative precision, and assumed prevalence
of betel quid chewing to be 30.3%,8 estimated
sample size was 6108 individuals for each sex
in each area. Considering non-response rate
and missing data the targeted sample size was
rounded to 15 000 in each area.
To select the sample households, the
interviewers’ chose a specific place (usually
the central point) as a start point for the
survey and sampled every second household
in the urban or rural areas. The direction for
the survey in the locality was chosen entirely
by chance (toss of a coin). Only households
having at least one male and one female
respondent over 18 years of age were included
in the survey provided respondents agreed to
participate in the study. The exclusion criteria
were those who were extremely ill, mentally
handicapped or unwilling to participate.
However, all households agreed to participate
in the study. Although equal representation
of both sexes was targeted, about 54% were
females in each survey.
Four teams comprising one male and
one female interviewer were recruited from
the local community. These teams were
intensively trained. Male household members
were interviewed by male interviewers and
female interviewers collected data from the
female members. A pre-tested structured
questionnaire printed in Bangla was used for
data collection. Verbal consent was obtained
from every respondent. Interviews were
WHO South-East Asia Journal of Public Health 2012;1(2):169-181
Book 1.indb 171
Betel quid chewing in Bangladeshi adults
conducted in private. Ethical approval was
obtained from the Ethical Committee of the
National Institute of Preventive and Social
Medicine.
The socio-demographic data included age,
sex, marital status, educational attainment,
religion, and main occupation. The betel quid
chewing data covered prevalence and its cost.
Betel quid users were defined as those who
took betel leaf with areca nut and lime (with
or without tobacco) daily at the time of the
data collection. Tobacco is chewed as part
of a mixture with betel nut in two different
forms, zarda and tobacco leaf. Zarda is a
commercially prepared moist or dry chewed
tobacco mixed with a variety of colourings,
spices and essences while tobacco is used as
dried, whole leaf after chopping it up. Current
smokers were defined as those who smoked
daily at the time of the data collection; ever
smokers as those who had smoked at some
time in their life either daily or occasionally;
the past smoker category included those
who had stopped smoking before the data
collection period but used to smoke daily in
the past, and occasional smokers were those
who smoked occasionally.
The analyses were carried out using the
Statistical Package for Social Sciences (SPSS)
version 14.0. Prevalence was weighted to
account for the age distribution, sex and
locality stratification. Distribution of the
data was checked and where necessary, log
transformation was done to normalize the data
before statistical analyses. Statistical tests
used to determine the association between
exposure and outcome variables included χ2
test, independent sample t-test and ANOVA.
To test the statistical significance, p value level
of <0.05 was considered but due to the large
sample size a more stringent cut-off of p<0.01
or less was usually used. In addition, as a
number of statistical tests were conducted,
the Bonferroni correction (α/K, where α is the
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05-Jun-2012 2:35:58 PM
Betel quid chewing in Bangladeshi adults
p value & K is the number of tests used) was
used. Effects of exposure variables were also
assessed after adjusting for other variables
by multivariate analyses. In addition to Odds
Ratio (OR), 95% confidence intervals of
different estimates were also estimated.
Results
Overall 31% (95% CI: 30.99 to 31.01) of the
study sample was found to be using betel
quid but there was significant heterogeneity
in relation to the socio-demographic variables
(Table 1). Rural residents (43.2%) were twice
as likely to chew betel quid as their urban
counterparts (19.1%), (p <0.001). The
chewing rate was two percent higher among
females (31.8%) than males (29.8%).
Betel quid chewing increased significantly
from younger to older age groups peaking
in the 50-69 year age groups. More Hindus
chewed betel quid compared to other religious
groups. Unmarried respondents used betel
quid least of all (OR 0.44; 95% CI: 0.34 to
0.56). Betel quid use decreased with increase
in educational attainment. Farmers were more
likely to chew betel quid (OR 1.23; 95% CI:
1.05 to 1.43). A sequential binary logistic
regression model was significant (p<0.001).
The model was very good both in classifying
regular betel quid chewers (70.8%) and nonchewers (85.8%). Forward logistic regression
indicated that age group was the best predictor
of betel quid chewing.
Betel quid use was more common among
the past smokers (73.8%) and current
smokers (37.3%) than the never (25.6%) and
occasional smokers (9.7%). After controlling
for the socio-demographic variables, past
smokers were three times (OR 3.09; 95% CI:
2.71 to 3.53) and current smokers were 1.3
times (OR 1.30; 95% CI: 1.17 to 1.44) more
likely to use betel quid. Significant associations
of betel quid use were found neither with
172
Book 1.indb 172
Meerjady S Flora et al.
general obesity nor central obesity after
controlling for the socio-demographic variables
(Table 2).
Regular chewers took betel quid on average
5.15 times a day but there was variation by
locality, occupation, religion and age (Table 3).
Urban respondents and Muslims chewed
betel quid more frequently. Businessmen
took it significantly more frequently than
the non-paid, farmers and servicemen or
professionals. The frequency of betel quid
chewing increased with age peaking in the
50-59 year age group. Multiple regression
models did not show any effect of sex, marital
status and education on the frequency of betel
quid use after controlling for other variables.
Although the model was significant (p<0.001)
it could only explain 1.4% of the variation in
betel quid chewing.
More than three-quarters of the betel
quid users chewed tobacco with it. There
was no significant difference in relation to
socio-demographic status except for religion;
Christians were more likely to take tobacco
with betel quid (Table 4).
On an average, betel quid users spent 2.29
Takas (range <1-101 Takas) on betel quid and
chewing tobacco. Table 5 shows that the mean
expenditure varied markedly by the sociodemographic variables. Significant differences
were found in expenditures by marital status,
educational levels, religion and occupations.
Multiple regression analyses controlling for
other socio-demographic variables did not find
any association with education and marital
status. Only 18.2% of the variation could
be explained in multiple regressions. Males,
urban users, businessmen, and Muslims spent
more money on betel quid chewing. Those in
the 30-39 and 40-49 year age groups spent
more than younger persons (<20 year age
group).
WHO South-East Asia Journal of Public Health 2012;1(2):169-181
05-Jun-2012 2:35:58 PM
Meerjady S Flora et al.
Betel quid chewing in Bangladeshi adults
Table 1: Betel quid chewing in relation to the socio-demographic
characteristics in Bangladesh
Adjusted for
Betel quid
Characteristics
N
chewing
Socio-demographic
p-value**
variablesˇ
n (%)
OR
95% CI
<0.001
0.58
0.54 to 0.62
<0.001
1.20
1.04 to 1.37
Area
Rural*
15 155
6546 (43.2)
Urban
15 716
3009 (19.1)
Male*
13 588
4055 (29.8)
Female
17 283
5500 (31.8)
<20*
3654
30 (0.8)
20-29
10 033
674 (6.7)
5.04
3.46 to 7.36
30-39
6502
2025 (31.1)
22.72
15.56 to 33.17
40-49
4887
2842 (58.2)
66.49
45.49 to 97.19
Sex
Age (years)
50-59
2914
2003 (68.7)
96.90
65.90 to 142.48
60-69
1822
1254 (68.8)
81.86
55.22 to 121.35
70 +
1059
727 (24.90
63.54
43.02 to 96.82
28 834
8768 (30.4)
1639
678 (41.4)
0.87
0.76 to 0.99
393
108 (27.5)
0.57
0.43 to 0.75
0.44
0.34 to 0.56
1.05
0.91 to 1.21
0.64
0.59 to 0.69
0.34
0.32 to 0.38
0.17
0.15 to 0.20
0.27
0.12 to 0.64
<0.001
Religion
Islam*
Hindu
Christian
<0.001
Marital status
Married*
23 685
8586 (36.3)
Unmarried
5819
91 (1.6)
Widow/ divorced
1366
878 (64.3)
No schooling*
8669
5195 (59.9)
1-5 yrs of schooling
6547
2274 (34.7)
10 498
1707 (16.3)
5134
374 (7.3)
15 380
5504 (35.8)
2138
6 (0.3)
<0.001
Educational status
6-10 yrs of schooling
Higher secondary +
<0.001
Occupation
Non-paid*
Students
Manual labourer
640
270 (42.2)
1.29
1.03 to 1.62
3290
1818 (55.3)
1.23
1.05 to 1.43
993
215 (21.7)
1.09
0.83 to 1.28
Business
3152
1003 (31.8)
1.15
0.99 to 1.34
Service
4485
617 (13.8)
0.73
0.63 to 0.85
Farmer
Skilled labourer
<0.001
* Reference Group, OR- Odds Ratio, CI-Confidence Interval, **p-value by χ2-test.
ˇAdjusted for socio-demographic variables shown in the table.
WHO South-East Asia Journal of Public Health 2012;1(2):169-181
Book 1.indb 173
173
05-Jun-2012 2:35:58 PM
Betel quid chewing in Bangladeshi adults
Meerjady S Flora et al.
Table 2: Association of betel quid chewing with smoking, body mass index, and
central obesity in Bangladesh
Adjusted for
Betel quid
chewing
Characteristics
N
Unadjusted
p-value**
%
Socio-demographic
variablesˇ
OR
95% CI
OR
95% CI
Smoking
Never*
5441
25.6
144
9.7
Occasional
Past
1866
73.8
Current
2096
37.3
0.31
<0.001
0.26 to 0 .37
1.03
0.83 to 1.28
8.18
7.44 to 8.98
3.09
2.71 to 3.53
1.73
1.62 to 1.84
1.30
1.17 to 1.44
Body mass index
CED III*
423
7.2
CED II
464
7.9
0.79
0.66 to 0.93
1.28
1.01 to 1.61
CED I
1038
17.7
0.61
0.52 to 0.71
1.23
1.00 to 1.50
Normal
3260
55.6
774
11.5
Overweight
<0.001
0.43
0.38 to 0.50
1.12
0.93 to 1.34
0.50
0.42 to 0.58
1.17
0.95 to 1.44
1.13
1.02 to 1.24
1.02
0.90 to 1.16
1.26
1.12 to 1.42
1.02
0.87 to 1.20
Waist circumference
Normal*
4775
81.5
High
646
11.0
Very High
441
7.5
<0.001
* Reference group, CED- Chronic energy deficiency, OR- Odds Ratio, CI-Confidence Interval,
**p-value by χ2-test, ˇadjusted for locality, age, sex, education, occupation, religion and marital status.
174
Book 1.indb 174
WHO South-East Asia Journal of Public Health 2012;1(2):169-181
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Meerjady S Flora et al.
Betel quid chewing in Bangladeshi adults
Table 3: Frequency of betel quid chewing per day in relation to the
socio-demographic characteristics in Bangladesh
Adjusted for
Characteristics
N
Mean†
SD
p-value
Socio-demographic variables
β
F-value
p-value
Area
Rural*
6545
5.02
4.27
Urban
3006
5.44
4.27
<0.001^
.029
23.3
<0.001
NS^
-.007
0.3
NS
10.2
<0.001
18.9
<0.001
0.5
NS
4.0
NS
5.1
<0.001
Sex
Male*
4051
5.21
4.63
Female
5500
5.11
4.00
<20*
30
4.14
3.63
20-29
674
4.50
4.59
.044
30-39
2025
5.04
4.67
.093
40-49
2841
5.29
4.32
.115
50-59
2002
5.31
3.96
.119
60-69
1253
5.26
4.21
.118
726
4.99
3.52
8764
5.21
4.34
Hindu
678
4.55
3.52
Christian
108
4.52
2.94
8582
5.15
4.29
Age in Years
70 +
<0.001ˇ
.101
Religion
Islam*
-.057
<0.001ˇ
-.057
NSˇ
-.009
Marital status
Married*
Unmarried
91
4.55
7.52
878
5.17
3.89
No schooling*
5194
5.10
4.02
1-5 yrs of schooling
2273
5.25
4.30
6-10 yrs of schooling
1706
5.22
5.03
373
4.89
3.87
5503
5.10
3.99
Widow/ divorced
.011
Educational status
Higher secondary +
.010
.000
NSˇ
-.040
Occupation
Non-paid*
Students
Manual labourer
Farmer
Skilled labourer
Business
Service/ professionals
6
3.80
1.94
-.109
270
5.22
3.90
.003
1817
5.07
4.22
-.003
215
5.07
5.22
-.006
1003
5.67
5.40
.044
615
5.00
4.14
<0.001ˇ
-.012
*Reference Group, †Geometric mean, SD- Standard deviation, p-value by ^t-test, ˇone-way ANOVA, NS- Not
significant
WHO South-East Asia Journal of Public Health 2012;1(2):169-181
Book 1.indb 175
175
05-Jun-2012 2:35:58 PM
Betel quid chewing in Bangladeshi adults
Meerjady S Flora et al.
Table 4: Chewing tobacco use among the betel quid users in relation to the sociodemographic characteristics in Bangladesh
Chewing tobacco use
Characteristics
No
N
Yes
%
N
p-value*
%
Area
Rural
Urban
1501
22.9
5040
77.1
736
24.5
2269
75.5
904
22.3
3143
77.7
1333
24.2
4166
75.8
NS
Sex
Male
Female
NS
Age (years)
10
33.3
20
66.7
20-29
<20
149
22.1
524
77.9
30-39
478
23.6
1546
76.4
40-49
645
22.7
2194
77.3
50-59
486
24.3
1516
75.7
60-69
305
24.3
948
75.7
70 +
164
22.6
561
77.4
Islam
2008
22.9
6752
77.1
Hindu
209
30.9
468
69.1
20
18.5
88
81.5
2024
23.6
6553
76.4
13
14.3
78
85.7
200
22.8
678
77.2
NS
Religion
Christian
<0.001
Marital status
Married
Unmarried
Widow/ divorced
NS
Educational status
No schooling
1247
24.0
3943
76.0
1-5 yrs of schooling
517
22.8
1755
77.2
6-10 yrs of schooling
388
22.7
1318
77.3
82
22.0
291
78.0
Non-paid
1360
24.7
4142
75.3
Students
1
16.7
5
83.3
Higher secondary +
NS
Occupation
Manual labourer
66
24.6
202
75.4
371
20.4
1466
79.6
54
25.1
161
74.9
Business
221
22.1
781
77.9
Service/ professionals
147
23.9
468
76.1
Farmer
Skilled labourer
NS
*p-value by χ2-test, NS- Not significant.
176
Book 1.indb 176
WHO South-East Asia Journal of Public Health 2012;1(2):169-181
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Meerjady S Flora et al.
Betel quid chewing in Bangladeshi adults
Table 5: Daily expenditure (in Taka) on betel quid in relation to the
socio-demographic characteristics in Bangladesh
Characteristics
Mean†
SD
p-value
Adjusted for
Socio-demographic variables
β
Area
Rural*
1.93
3.33
Urban
3.36
3.30
Sex
Male*
2.73
4.00
2.02
2.64
2.62
4.18
20-29
2.28
4.17
.047
30-39
2.39
4.26
.061
40-49
2.36
2.87
.064
50-59
2.28
2.82
.049
60-69
2.19
3.32
.037
70 +
2.01
2.19
Religion
Islam*
2.35
3.39
Hindu
1.82
2.61
Christian
1.42
1.40
Marital status
Married*
2.30
3.33
Unmarried
2.82
7.79
Widow/ divorced
2.15
2.37
Educational status
No schooling*
2.09
2.96
1-5 yrs of schooling
2.35
3.51
.010
6-10 yrs of schooling
2.74
4.07
.017
Higher secondary +
Female
Age(years)
<20*
F-value
p-value
<0.001^
.225
900.0
<0.001
<0.001^
-.145
92.7
<0.001
3.3
0.003
19.3
<0.001
2.0
NS
2.1
NS
10.0
<0.001
<0.001ˇ
.010
-.056
<0.001ˇ
-.127
.059
0.001ˇ
.013
3.18
2.63
Occupation
Non-paid*
2.02
2.75
Students
2.29
1.75
-.098
Manual labourer
3.21
2.96
.036
Farmer
2.17
3.12
-.024
Skilled labourer
3.18
4.22
.042
Business
3.36
5.06
.068
Service/ professionals
3.35
3.31
<0.001ˇ
<0.001ˇ
-.018
.032
*Reference group, †Geometric mean, SD- Standard deviation, p-value by ^t-test, ˇone-way ANOVA,
NS- Not significant
WHO South-East Asia Journal of Public Health 2012;1(2):169-181
Book 1.indb 177
177
05-Jun-2012 2:35:58 PM
Betel quid chewing in Bangladeshi adults
Discussion
Despite betel quid chewing being a risk factor
for oral cancer, it is a popular habit in South
Asia, South-East Asia and the South Pacific.2,3
The prevalence of 31% estimated in this
study is similar to the earlier report of 30.3%
prevalence by Rahman et al.8 Prevalence of
betel quid chewing in Bangladesh lies in the
middle of the 20%-40% prevalence found in
India, Pakistan and Nepal over the last two
decades7 and in the South Asian immigrants
to the UK, where 42% of adults used betel
quid.1
Adding tobacco with betel quid is a common
practice in the South-East Asian countries.4 In
the current study, three-quarters of the betel
quid chewers added tobacco which is slightly
lower than the report (85.2%) by Rahman
et al. 8 In the current sample betel quid
chewing frequency was 5.15 times per day,
on average. These rates are much lower than
Pakistan where the mean frequency of betel
quid chewing varied from 6.5 to 11 in different
ethnic groups. 7 In the Solomon Islands,
subjects who chewed higher amounts of betel
quid per day (>5) showed significantly higher
risks of oral and pharyngeal cancer than those
who chewed less quids (<5).13 The cessation
rates of betel quid chewing were associated
with the decreasing daily consumption of betel
quid. Hence, reduction of the daily amount,
in a betel quid cessation programme, could be
associated with future stopping habit.14
Several factors influence betel quid
chewing, including ethnicity, demographic
and psychosocial factors, its accessibility and
public policy. Personal habits are dictated by
different social and cultural behaviours in both
sexes.13 Four factors form the foundation for
the popularity of betel quid chewing: Social
acceptability, religious beliefs, perceived
health benefits and addiction.5
178
Book 1.indb 178
Meerjady S Flora et al.
As there are no social restrictions, betel
quid chewing, with added tobacco, has been
a traditional practice for a long time among
Bangladeshi women. There was no sexdifference in betel quid chewing in the current
study although Rahman et al8 found that
females used betel quid in higher proportions
(34.6%) than males (26%); this might
reflect sampling differences between the two
surveys. In Karachi, an equal percentage
(30%) of men and women chewed betel quid,1
while in Taiwan more males than females used
it (14.4% versus 1.5% respectively)6 but in
Cambodia, females (32.6%) outnumbered
males (0.8%) in betel quid chewing and in
Mumbai ( India) 37.8% of men and 29.7% of
women used betel quid.4 Even if women had
a lower chewing behaviour, they were less
likely to stop chewing than men. As regard to
whether betel quid chewing cessation has an
association with sex, ethnicity and type of quid,
male chewer’s are the major focus in betel
quid chewing prevention programmes.14
No sex difference was found in frequency
of betel quid chewing; the overall mean was
5.21 times/day which is slightly lower than
the mean of 5.88 found by Khan et al.16 This
study also found that a high proportion of
male (77.7%) and female (75.8%) betel
quid chewers also took tobacco which is in
agreement with the finding of Rahman et al 8
where the male and female who were taking
tobacco with betel quid were 80.3% and
88.1% respectively. Males spent 7.3 times
more than females (6.38 and 0.87 Takas,
respectively) which is much greater than the
difference found by the Bangladesh Bureau of
Statistics study (5.25 and 2.62 Takas by males
and females, respectively).17
The findings of the current study were in
agreement with Rahman et al,8 in showing that
the proportion of betel quid chewers increased
with age and more than 50% of the middle-to
elderly-aged persons took betel quid, which
WHO South-East Asia Journal of Public Health 2012;1(2):169-181
05-Jun-2012 2:35:59 PM
Meerjady S Flora et al.
was very high in comparison to Taiwan, where
only 20% used it.6 Rahman et al did not find
any difference in chewing tobacco among
betel quid users in different age groups, which
is consistent with the current data.8 The
frequency of betel quid chewing increased with
age and remained similar in the middle-and
elderly-age groups.
Urban residents were less likely to use
betel quid than in the rural areas (19.1%
versus 43.2%), but their frequency of chewing
was higher (5.44 and 5.02 times/day for
urban and rural areas respectively). Rahman
et al and Wen et al also found a lower usage
in urban than rural areas in Bangladesh 8
and Taiwan6 respectively. Rahman et al also
showed that the prevalence of betel quid use
decreased with improving socio-economic
class of urban residents.8 The current study,
however, showed no significant difference
in tobacco chewing between urban and
rural betel quid users (75.5% and 77.1%
respectively) after adjusting for the other
socio-demographic variables. No locality
differences in chewing tobacco were found
among males in a Bangladeshi study16 or in
an Indian study involving both sexes.18
Educational attainment was inversely
associated with betel quid use in the current
study which is consistent with the findings of
a Taiwanese study.6 Education always plays a
vital role in the health status of a country and
also in the development of health behaviour
of an individual.19 Our study also showed that
manual labourers and farmers were more
likely to chew betel quid. However, business
persons also used betel quid frequently. Thus,
male manual labourers appear to be the
occupational group most at risk for the hazards
of betel quid chewing as they are more likely
to chew tobacco than other occupations.
Another important finding is that betel quid
chewing is closely associated with religion.
WHO South-East Asia Journal of Public Health 2012;1(2):169-181
Book 1.indb 179
Betel quid chewing in Bangladeshi adults
A study from Leicester, UK, reported that areca
nut chewing was most common among first
generation Asian immigrants with the highest
prevalence among Jains (28%) and Muslims
(23%) followed by Hindus (18%). In second
generation Asian immigrants, this practice was
highest among Muslims (17%) followed by
Hindus (13%) and Jains (12%).20 Our study
revealed that Hindus were more likely to chew
betel quid with tobacco. Betel quid is regarded
by many Indians as a fruit of divine origin. It is
considered an auspicious ingredient in Hinduism
and is used along with betel leaf in religious
ceremonies, important social gatherings and
weddings and when honouring individuals.5
Seventh-Day Adventists in Solomon Islands
were less likely to be betel quid chewers. This
might be explained by the code of abstinence
from betel quid use recommended by the
Seventh-Day Adventists.21
When betel quid with tobacco is consumed
with alcohol and smoking, relative risk
increases elevenfold.22 We found a significant
association between smoking and betel quid
use. Betel quid use rate was higher among
current smokers than among never smokers
but the rate was highest among ex-smokers.
Probably smoking quitters took betel quid
as a means of quitting tobacco smoking.
Therefore, betel quid chewing should not be
considered as an isolated issue, but should
always be coupled with issues related to
tobacco smoking. Effective policies in smoking
prevention and smoking cessation may
substantially reduce betel quid use. Reducing
cigarette smoking served as an important
first step in reducing betel quid chewing in
Taiwan,6 thus, incorporating betel quid into
tobacco control may provide a new paradigm
to slow down the drastic increase in betel
quid use in Bangladesh also. We did not find
any association of betel quid with general or
central obesity although a study in Taiwanese
men found independent association with
general and central obesity.23
179
05-Jun-2012 2:35:59 PM
Betel quid chewing in Bangladeshi adults
In conclusion, betel quid chewing was
found to be a common habit in Bangladesh.
Mature adults (40+years) of low socioeconomic status, i.e., rural residents, farmers
and illiterate are more likely to chew betel
quid. An anti-betel quid chewing programme
is urgently warranted for current chewers.
Education about betel quid chewing should be
emphasized in the public prevention education.
Regular screening for betel quid chewing may
help prevent excess deaths in the future. As
the habit is rooted in Bangladeshi tradition
and culture, anthropological studies are
indicated for designing appropriate educational
campaigns.
Acknowledgements
The surveys were conducted with support
from the Department for International
Development (DfID), United Kingdom. We
gratefully acknowledge the financial support of
the Board of Graduate Studies, the University
of Cambridge, the British Federation of Women
Graduates Charitable Foundation, the Charles
Wallace Bangladesh Trust, and Churchill
College, University of Cambridge.
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3. Mack TM. The new Pan-Asian paan problem. Lancet.
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Prev Policy. 2006; 26: 10-15.
8. Rahman M, Rahman M, Flora MS, Akter SFU, Hossain
S, Mascie-Taylor CGN. Behavioural risk factors of
non-communicable diseases in Bangladesh. Dhaka:
National Institute of Preventive and Social Medicine,
2006.
9. Jacob BJ, Straif K, Thomas G, Ramadas K, Mathew
B, Zhang ZF, et al. Betel quid without tobacco as a
risk factor for oral pre-cancers. Oral Oncol. 2004;
40: 697-704.
10. Merchant A, Husain SSM, Hosain M, Fikree FF, Pitiphat
W, Siddiqui AR, et al. Paan without tobacco: an
independent risk factor for oral cancer. Int J Cancer.
2000; 86: 128-131.
11. Bangladesh Bureau of Statistics. 2004 Statistical
pocket book of Bangladesh. Dhaka: Bangladesh
Bureau of Statistics, 2006.
12. Bangladesh Bureau of Statistics. Report on sample
vital registration system 2003. Dhaka: Bangladesh
Bureau of Statistics, 2006.
13. Lumukana R, King T. Smoking and chewing habits
of oral cancer patients in the Solomon Islands. Pac
Health Dialog. 2003; 10: 41–44.
14. Yap SF, Ho PS, Kuo HC, Yang YH. Comparing factors
affecting commencement and cessation of betel quid
chewing behavior in Taiwanese Adults. BMC Public
Health. 2008; 8: 199.
15. Lin CF, Wang JD, Chen PH, Chang SJ, Yang YH, Ko
YC. Predictors of betel quid chewing behavior and
cessation patterns in Taiwan Aborigines. BMC Public
Health. 2006; 6: 271.
WHO South-East Asia Journal of Public Health 2012;1(2):169-181
05-Jun-2012 2:35:59 PM
Meerjady S Flora et al.
16. Khan MMH, Aklimunnessa K, Kabir MA, Kabir M, Mori
M. Tobacco consumption and its association with illicit
drug use among men in Bangladesh. Addiction.2006;
101: 1178-1186.
17. Bangladesh Bureau of Statistics (BBS). Report of
survey on prevalence of morbidity, treatment status,
treatment expenditures, fertility, immunization and
smoking, July 1997. Dhaka: BBS, 1999.
18. Rani M, Bonu S, Jha P, Nguyen SN, Jamjoum L.
Tobacco use in India: prevalence and predictors of
smoking and chewing in a national cross-sectional
household survey. Tob Control. 2003; 12: e4-e11.
19. Fagerstrom K. The epidemiology of smoking. Health
consequences and benefits of cessation. Drugs. 2002;
62 (Suppl): S1-S9.
Betel quid chewing in Bangladeshi adults
21. Tovosia S, Chen PH, Ko AM, Tu HP, Tsai PC, Ko YC.
Prevalence and associated factors of betel quid use
in the Solomon Islands: a hyperendemic area for oral
and pharyngeal cancer. Am J Trop Med Hyg. 2007;
77: 586–590.
22. S u b a p r i ya R , T h a n g a v e l u A , M a t h a va n B ,
Ramachandran CR, Nagini S. Assessment of
risk factors for oral squamous cell carcinoma in
Chidambaram, Southern India: a case-control study.
Eur J Cancer Prev. 2007; 16: 251–256.
23. Lin WY, Pi-Sunyer FX, Liu CS, Li TC, Li CI, Huang
CY, et al. Betel nut chewing is strongly associated
with general and central obesity in Chinese male
middle-aged adults. Obesity (Silver Spring). 2009;
17: 1247–1254.
20. Vora AR, Yeoman CM, Hayter JP. Alcohol, Tobacco
and paan use and understanding of oral cancer risk
among Asian males in Leicester. Br Dent J. 2000;
188: 444–451.
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Original research
Antibiogram of S. enterica serovar Typhi and S. enterica
serovar Paratyphi A: a multi-centre study from India
Indian Network for Surveillance of Antimicrobial Resistance Groupa
Background: Enteric fever continues to be a public health problem in many countries including
India. Emergence of the multidrug resistant strains of S. enterica serovar Typhi may render treatment
with antibiotics ineffective. A multi-centre surveillance study was, therefore, conducted in India
to monitor the time trends in antibiotic susceptibility patterns of S. enterica serovar Typhi and S.
enterica serovar Paratyphi A in India.
Methods: All S. enterica serovar Typhi and S. enterica serovar Paratyphi A strains isolated from
January 2008 to December 2010 in the 15 participating centres were included in the study. Each
centre compiled their data in a predefined template which included data of the antimicrobial
susceptibility pattern, location of the patient and specimen type. The data in the submitted templates
was collated and analysed using a common protocol.
Results: A total of 3275 isolates of Salmonellae causing enteric fever were included in the study.
There were 2511 S. enterica serovar Typhi and 764 S. enterica serovar Paratyphi A strains during
the three-year study period. Resistance to nalidixic acid was seen in 83% of the S. enterica serovar
Typhi and 93% of S. enterica serovar Paratyphi A strains. Majority of the strains were susceptible
to third generation cephalosporins.
Conclusions: Enteric fever in India is caused by S. enterica serovar Typhi and S. enterica serovar
Paratyphi A. Nalidixic acid resistance is high among both S. enterica serovar Typhi and S. enterica
serovar Paratyphi A. Susceptibility to ampicillin, chloramphenicol and cotrimoxazole is high. Third
generation cephalosporins continue to remain susceptible.
Key words: S. enterica serovar Typhi , S. enterica serovar Paratyphi A, antibiotics, India
Introduction
Enteric fever continues to remain a public
health problem in many countries. In 2000,
typhoid fever caused an estimated 21.7 million
illnesses and 217 000 deaths, and paratyphoid
fever caused an estimated 5.4 million illnesses
worldwide.1 In Asia, Crump et al reported a
crude incidence of typhoid as 274 per 100 000
persons.1 Salmonella enterica serotype Typhi
and Salmonella enterica serotype Paratyphi A
are the main causes of enteric fever in India;
S. enterica serovar Typhi being predominant.2
In 1999, Sinha et al found the incidence rate to
be 9.8 per 1000 person years in an urban slum
of North India.3 However, in 2008, Ochlai et al
who conducted their surveillance in an urban
Indian Network for Surveillance of Antimicrobial Resistance
Correspondence to Sangeeta Joshi (email: sangeetajo@yahoo.com, insar_india@yahoogroups.com)
a
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05-Jun-2012 2:35:59 PM
Indian Network for Surveillance of
Antimicrobial Resistance Group
slum in Kolkata in eastern India, reported an
incidence of 214.2 per 100 000/year.4
After the first reported outbreak of
chloramphenicol resistant S. enterica serovar
Typhi in 1972, there has been a steady
increase in the number of multidrug resistant
(MDR) strains of S. enterica serovar Typhi –
resistance to ampicillin, chloramphenicol and
trimethoprim- sulphamethoxazole - over the
next two decades. With the increasing use of
Antibiogram of S. typhi and S. paratyphi A in India
fluoroquinolones in the 1990s for treatment
of enteric fever, there was a gradual decrease
in MDR of S. enterica serovar Typhi with
emergence of nalidixic acid resistant strains.
A network of microbiology laboratories
(Indian Network for Surveillance of
Antimicrobial Resistance) at premier medical
colleges and hospitals in India was formed with
support from the World Health Organization
(Figure 1). The network aims to monitor and
Figure 1: INSAR sites India (alphabetically as per institutional name)
The sites marked with a red dot indicates those centres whose data is included in the study. All India Institute of Medical
Sciences (AIIMS) - New Delhi, Apollo Health City - Hyderabad, BJ medical college (BJMC) - Pune, Chacha Nehru Bal Chikitsalaya
(CNBC) - New Delhi, Choithram Hospital and Research Centre - Indore , Christian Medical College (CMC) - Vellore, Fortis
Hospital - Mohali, Global Hospitals - Hyderabad, Government Medical College & Hospital (GMC) - Chandigarh, Government
medical college (GMC) - Aurangabad, Gujarat Cancer and research Institute (GCRI) - Ahmedabad, Indraprastha Apollo
Hospital - New Delhi, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) - Puducherry Manipal
Hospital - Bangalore, PD Hinduja National Hospital & MRC (PDNH) - Mumbai, Postgraduate Institute of Medical Education
& Research (PGIMER) - Chandigarh, Regional institute of medical sciences (RIMS) - Imphal, Sanjay Gandhi Postgraduate
Institute of Medical Sciences (SGPGI) - Lucknow, Stanley medical college (SMC) - Chennai.
WHO South-East Asia Journal of Public Health 2012;1(2):182-188
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Antibiogram of S. typhi and S. paratyphi A in India
review the antimicrobial resistance problem
in India. Initially, few organisms of public
health importance were chosen for monitoring
the prevalence and antimicrobial resistance
patterns. Therefore, S. enterica serovar Typhi
and S. enterica serovar Paratyphi A were
chosen from amongst the Gram negative
organisms. All participating laboratories
shared their antimicrobial susceptibility data
and provided technical support to other
members. This study provides a national
level understanding of the emerging trends of
antimicrobial resistance among clinical isolates
of S. enterica serovar Typhi and S. enterica
serovar Paratyphi A and provides a platform
for initiating epidemiological studies of enteric
fever.
Methods
This study was conducted over three
years (January 2008 to December 2010)
retrospectively. Each centre compiled their
susceptibility data for S. enterica serovar Typhi
and S. enterica serovar Paratyphi A isolates
for the study period in a defined template.
The data collection template included patient’s
location, source / specimen of isolation and
the antibiotic susceptibility profiles. Blood
cultures were done by the conventional
microbiological techniques or automated
systems in the participating centres. The
identification of Salmonellae was done by the
standard biochemical tests and confirmation
was done by serotyping.5
The antibiotic susceptibility testing was
performed at different study sites by the Kirby
Bauer’s’ disc diffusion technique and / or by
MIC testing, using CLSI recommendations.6
One laboratory used the BSAC guidelines for
antimicrobial testing and interpretations.7 The
antibiotics tested included ampicillin (10μg),
co-trimoxazole (1.25/23.75 μg), ciprofloxacin
(5 μg), nalidixic acid (30 μg), ceftriaxone
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Indian Network for Surveillance of
Antimicrobial Resistance Group
(30 μg), and chloramphenicol(30 μg). Inoculum
was prepared by making a direct saline
suspension of isolated colonies selected from
an 18- to 24-hour blood agar plate. Turbidity
of the suspension was adjusted to achieve
a turbidity equivalent to a 0.5 McFarland
standard and five disks were applied on a
100mm Mueller Hinton agar plate as per
CLSI guidelines / BSAC. E. coli ATCC 25922
was used as the quality control strain for disc
diffusion.
Results
A total of 3275 isolates of Salmonellae causing
enteric fever were included in the study. There
were 2511 S. enterica serovar Typhi strains
(430 in 2008, 694 in 2009 and 1387 in 2010)
and 764 S. enterica serovar Paratyphi A strains
(311, 217 and 236 in 2008, 2009 and 2010
respectively) during the study period. These
strains were isolated predominantly from
blood culture. Few isolates from pus (3), stool
(14) and urine (8) also were also included in
the study.
The antibiotic susceptibility (by CLSI
guidelines) for S. enterica serovar Typhi
and S. enterica serovar Paratyphi A isolates
for the study period are shown in Table 1
and Table 2. Nalidixic acid resistance was
high in both S. enterica serovar Typhi and
S. enterica serovar Paratyphi A, being 82%
and 93% respectively during the three-year
period. Third generation cephalosporins were
100% susceptible in 2008. Resistance to
third generation cephalosporins was seen in
3% of strains of S. enterica serovar Typhi in
2009 and in 1% S. enterica serovar Paratyphi
A in 2010. Multidrug resistance (MDR) to
ampicillin, chloramphenicol and cotrimoxazole
in S. enterica serovar Typhi was observed in
less than 5% isolates. The antibiogram for
the isolates reported by BSAC guidelines is
summarized in Table 3.
WHO South-East Asia Journal of Public Health 2012;1(2):182-188
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Indian Network for Surveillance of
Antimicrobial Resistance Group
Antibiogram of S. typhi and S. paratyphi A in India
Table 1: Antibiogram of S. enterica serovar Typhi. (% susceptible)
Year
N
Amp
Chl
Sxt
Ctri
Cip
NA
2008
430
95
96
96
100
99
23
2009
694
96
97
95
97
75
22
2010
1387
89
95
94
100
59
8.3
Amp-Ampicillin, Chl- Chloramphenicol, Sxt- Cotrimoxazole, Ctri – Ceftriaxone, Cip- Ciprofloxacin, NA- Nalidixic acid
Table 2: Antibiogram of S. enterica serovar Paratyphi A. (% susceptible)
Year
N
Amp
Chl
Sxt
Ctri
Cip
NA
2008
311
99
99
100
100
100
12
2009
217
91
100
91
100
85
2.9
2010
236
95
100
97
99
71
7.2
Amp-Ampicillin, Chl- Chloramphenicol, Sxt- Cotrimoxazole, Ctri – Ceftriaxone, Cip- Ciprofloxacin, NA- Nalidixic acid
Table 3: Antibiogram of S. enterica serovar Typhi and S. enterica serovar
Paratyphi A by BSAC guidelines (% susceptible)
Year
Isolate
N
Amp
Chl
Sxt
Ctri
Cip
NA
2009
S. enterica
serovar
Typhi
43
88
100
100
100
79
77
2010
S. enterica
serovar
Typhi
55
85
100
100
100
13
9
2009
S. enterica
serovar
Paratyphi A
22
68
100
100
100
14
9
2010
S. enterica
serovar
Paratyphi A
18
33
56
44
100
17
17
Amp-Ampicillin, Chl- Chloramphenicol, Sxt- Cotrimoxazole, Ctri – Ceftriaxone, Cip- Ciprofloxacin, NA- Nalidixic acid
WHO South-East Asia Journal of Public Health 2012;1(2):182-188
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Antibiogram of S. typhi and S. paratyphi A in India
Discussion
Enteric fever continues to remain an important
infection in endemic countries and to travelers
to these areas. As observed in the present
study, enteric fever in India is mainly caused
by S. enterica serovar Typhi and S. enterica
serovar Paratyphi A. Nalidixic acid resistance
is high among both S. enterica serovar
Typhi and S. enterica serovar Paratyphi A.
Susceptibility to ampicillin, chloramphenicol
and cotrimoxazole - traditional first line drugs
for enteric fever treatment is good. Third
generation cephalosporins continue to remain
susceptible and are a useful choice for the
treatment of enteric fever. The major strength
of the study is that it had representations
from 15 centres which used similar protocols
for data collection. However, one limitation of
this study is the fact that there was inadequate
representation from eastern India.
In a study of six years (2000 to 2006)
from north India, there were a predominance
of S. enterica serovar Typhi (62%) , followed
by 38% S. enterica serovar Paratyphi A.8 The
study highlighted the emergence of S. enterica
serovar Paratyphi A as the predominant
serotype in 2003-2004 with resurgence of
S. enterica serovar Typhi in the subsequent
period in their study. MDR S. enterica serovar
Typhi was 10.69% while 13.13% were MDR
S. enterica serovar Paratyphi A. Another
study from north India also reported high
proportion of S. enterica serovar Paratyphi
A with nalidixic acid resistance (92.5%).9
Interestingly, 90% of their isolates were
sensitive to chloramphenicol. Another study
from a tertiary care hospital in Delhi from 1999
to 2004, revealed a gradual decrease in MDR
S. enterica serovar Typhi,10 However, MDR S.
enterica serovar Paratyphi A increased from
3.5% in 1999 to 11.6% in 2004. The proportion
of S. enterica serovar Paratyphi A rose from
20.3% in 1999 to 30.3% in 2004. The gradual
increase in prevalence of S. enterica serovar
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Indian Network for Surveillance of
Antimicrobial Resistance Group
Paratyphi A over the years could probably be
due to the introduction of monovalent vaccine
effective against S. enterica serovar Typhi only
gradually replacing the bivalent TA vaccine.11
A recent study from eastern India showed
multidrug resistance in 11.9% and 15.6%
of S. enterica serovar Typhi and S. enterica
serovar Paratyphi A isolates respectively.2
The percentage of S. enterica serovar Typhi
isolations were more than S. enterica serovar
Paratyphi A. Similarly, we also had a larger
number of S. enterica serovar Typhi isolates
(77%) than S. enterica serovar Paratyphi A
(23%).
Ray et al found that nalidixic acid
(NA) susceptibility was a good marker
for fluoroquinolone susceptibility but NA
resistance had a poor predictive value for
ciprofloxacin resistance.12 They suggested
that NA resistant isolates should be tested for
ciprofloxacin MIC before deciding a change in
therapeutic regimen. Nalidixic acid resistant
isolates of S. enterica serovar Typhi and
S. enterica serovar Paratyphi A had higher
MIC’s to fluoroquinolones as compared to
the nalidixic acid susceptible ones.13 In a
study from Puducherry, south India, there
was a high rate of ciprofloxacin resistance
(8%) observed in S. enterica serovar Typhi,
with 78% isolates being NA resistant.14 They
also reported a high rate of MDR S. enterica
serovar Typhi (22%). Chitnis et al reported
a gradually increasing MIC to ciprofloxacin
from <=0.125 mg/L to > 1mg/L among the
isolates of S. enterica serovar Typhi over the
years 1988 to 2005.15 Concurrently MDR,
which was seen in upto 90% isolates in
1990-91 had declined to 5.6% in 2005. In
view of the increasing MIC’s of ciprofloxacin,
there has been a suggestion to relook at
the breakpoints and the zone diameters for
reporting ciprofloxacin for Salmonella.16 As
per BSAC guidelines 2011 for ciprofloxacin for
Salmonella, it is recommended that isolates
WHO South-East Asia Journal of Public Health 2012;1(2):182-188
05-Jun-2012 2:36:00 PM
Indian Network for Surveillance of
Antimicrobial Resistance Group
with MIC > 0.06 mg/L should be reported
as resistant. In the present study, MIC >
0.125mg/L was interpreted as intermediate
susceptible/ resistant for the isolates reported
by one laboratory as per BSAC guidelines
2010.7
In the present study, S. enterica
serovar Typhi susceptibility to ampicillin,
chloramphenicol and cotrimoxazole was 93%,
96% and 95% respectively. This is similar
to a study done in south India where there
was a significant increase in sensitivity to
chloramphenicol (86%), ampicillin (84%) and
cotrimoxazole (88%). MDR was seen in 12%
cases in the same study.17 There is a marked
reduction in the reduction of MDR isolates as
compared to studies in early 2000.10 The high
prevalence of MDR among Salmonella species
had led to fluoroquinolones assuming a
primary role in the therapy. Some investigators
have noted increases in the prevalence of
S. enterica serovar Typhi and S. enterica
serovar Paratyphi A strains susceptible to
traditional first-line antimicrobials coinciding
with a switch to fluoroquinolones for the
management of enteric fever.18
Azithromycin has been seen to be efficacious
for the treatment of typhoid fever;19 however,
there are reports of emergence of resistance
to azithromycin.20 There are sporadic reports
of third generation cephalosporin resistance
in Salmonella. Gokul et al. reported an ACC-1
AmpC β- lactamase producing S. enterica
serovar Typhi.21 However, third generation
cephalosporins still continue to be a good
option for the treatment of enteric fever.
To conclude, this study demonstrates the
re-emergence of susceptibility to ampicillin,
chloramphenicol and cotrimoxazole in
Salmonella enterica serovar Typhi, a decline in
MDR strains and a high resistance to nalidixic
acid in India. Third generation cephalosporins
seem to be effective therapeutic options.
WHO South-East Asia Journal of Public Health 2012;1(2):182-188
Book 1.indb 187
Antibiogram of S. typhi and S. paratyphi A in India
Acknowledgement
This work and the INSAR group are supported
by the World Health Organization.
Indian Network
for Surveillance of
Antimicrobial Resistance
(INSAR) (alphabetically as
per institutional name)
a
All India Institute of Medical Sciences
(AIIMS), New Delhi – Arti Kapil
Apollo Health City, Hyderabad - Ratna Rao
BJ medical college (BJMC), Pune - Anju
Kagal
Chacha Nehru Bal Chikitsalaya (CNBC), New
Delhi - Vikas Manchanda
Choithram Hospital and Research Centre,
Indore - DS Chitnis
Christian Medical College (CMC), Vellore Veeraraghavan Balaji
Fortis Hospital, Mohali - Anita Sharma
Global Hospitals, Hyderabad - Ranganathan
N Iyer
Government Medical College & Hospital
(GMC), Chandigarh - Varsha Gupta
Indraprastha Apollo Hospital, New Delhi Raman Sardana
Jawaharlal Institute of Postgraduate Medical
Education and Research (JIPMER),
Puducherry - BN Harish
Manipal Hospital, Bangalore - Sangeeta
Joshi
PD Hinduja National Hospital & MRC
(PDNH), Mumbai - Camilla Rodrigues
Postgraduate Institute of Medical Education
& Research (PGIMER), Chandigarh Pallab Ray and Vikas Gautam
Sanjay Gandhi Postgraduate Institute of
Medical Sciences (SGPGI), Lucknow - TN
Dhole
187
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Antibiogram of S. typhi and S. paratyphi A in India
References
1. Crump JA, Luby SP, Mintz ED. The global burden of
typhoid fever. Bull World Health Organ. 2004; 82:
346-53.
2. Bhattacharya SS, Das U, Choudhury BK. Occurrence
and antibiogram of Salmonella Typhi and S. Paratyphi
A isolated from Rourkela, Orissa. Indian J Med Res.
2011; 133: 431-3.
3. Sinha A, Sazawal S, Kumar R, Sood S, Reddaiah VP,
Singh B, et al. Typhoid fever in children aged less
than 5 years. Lancet. 1999; 354: 734-37.
4. Ochiai RL, Acosta CJ, Danovaro-Holliday MC, Baiqing
D, Bhattacharya SK, Agtini MD, et al. A study of
typhoid fever in five Asian countries: disease burden
and implications for control. Bull World Health Organ.
2008; 86: 260-68.
5. Collee JG, Marmion BP, Fraser AG, Simmons A, eds.
Mackie & McCartney Practical medical Microbiology.
14th edn. London: Churchill Livingstone, 1996
6. Clinical and Laboratory Standards Institute.
Performance standards for antimicrobial susceptibility
testing; Eighteenth Informational supplement.
CLSI document M100-S18. Wayne PA: Clinical and
Laboratory Standards Institute, 2008.
7. British Society for Antimicrobial Chemotherapy
(BSAC). Susceptibility testing: breakpoints. 2012
http://www.bsac.org.uk/Susceptibility+Testing/
Breakpoints - accessed 03 May 2012.
8. Verma S, Thakur S, Kanga A, Singh G, Gupta P.
Emerging Salmonella paratyphi A enteric fever and
changing trends in antimicrobial resistance pattern
of Salmonella in Shimla. Indian J Med Microbiol.
2010; 28: 51-3.
9. Gupta V, Kaur J, Chander J. An increase in enteric
fever cases due to Salmonella paratyphi A in and
around Chandigarh. Indian J Med Res. 2009; 129:
95-8.
10. Mohanty S, Renuka K, Sood S, Das BK, Kapil A.
Antibiogram pattern and seasonality of Salmonella
serotypes in a North Indian tertiary care hospital.
Epidemiol Infect. 2006; 134: 961-6.
Indian Network for Surveillance of
Antimicrobial Resistance Group
12. Ray P, Sharma J, Marak RS, Garg RK. Predictive
efficacy of nalidixic acid resistance as a marker of
fluoroquinolone resistance in Salmonella enterica var
Typhi. Indian J Med Res. 2006; 124: 105-8.
13. Joshi S, Amarnath SK. Fluoroquinolone resistance
in Salmonella typhi and Salmonella paratyphi A in
Bangalore India. Trans R Soc Trop Med Hyg. 2007;
101: 308-10.
14. Menezes GA, Harish BN, Khan MA, Goessens WH,
Hays JP. Antimicrobial resistance trends in blood
culture positive Salmonella Typhi isolates from
Pondicherry, India, 2005-2009. Clin Microbiol Infect.
2012 Mar; 18(3): 239-45.
15. Chitnis S, Chitnis V, Hemvani N, Chitnis DS.
Ciprofloxacin therapy for typhoid fever needs
reconsideration. J Infect Chemother. 2006; 12:
402-4.
16. Rodrigues C, Kumar NJ, Lalwani J, Mehta A.
Ciprofloxacin breakpoints in enteric fever- time
to revise our susceptibility criteria. Indian J Med
Microbiol. 2008; 26:91.
17. Krishnan P. Stalin M, Balasubramanian S. Changing
trends in antimicrobial resistance of Salmonella
enterica serovar typhi and Salmonella enterica
serovar paratyphi A in Chennai. Indian J Pathol
Microbiol. 2009; 52: 505-8.
18. Maskey AP, Basnyat B, Thwaites GE, Campbell JI,
Farrar JJ, Zimmerman MD. Emerging trends in enteric
fever in Nepal: 9124 cases confirmed by blood culture
1993–2003. Trans R Soc Trop Med Hyg. 2008; 102:
91–5.
19. Aggarwal A, Ghosh A, Gomber S, Mitra M, Parikh AO.
Efficacy and safety of azithromycin for uncomplicated
typhoid fever: an open label non-comparative study.
Indian Pediatr. 2011; 48(7): 553-6
20. Reddy S, Rangaiah J, Addiman S, Wareham D, Wilson
P, Sefton A. Epidemiology, antibiotic trends and the
cost of enteric fever in East London, 2005-2010.
Travel Med Infect Dis. 2011; 9(4): 206-12.
21. Gokul BN, Menezes GA, Harish BN. ACC-1 betaLactamase-producing Salmonella enterica Serovar
Typhi, India. Emerg Infect Dis. 2010; 16: 1170-1.
11. Padmapriya V, Kenneth J, Amarnath SK. Reemergence of Salmonella paratyphi A: a shift in
immunity? Natl Med J India. 2003;16: 47-8.
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Original research
Injection practices in India
IPEN Study Groupa
Background: About 16 billion injections are administered each year worldwide, and at least half
of them are unsafe. India contributes 25% to 30% of the global injection load. A majority of
curative injections are unnecessary. The present study was undertaken to assess the burden
of injections and prevalent injection practices in India.
Methods: A nationwide population-based cluster survey (1200 clusters; 24 021 subjects) at
household level; along with observations, interview of prescribers (2402), and exit interview of
the patients (12 012) at health facility level in the selected clusters was carried out - using
probability proportionate to size (PPS) technique. Observations at health facility included generic
observation (3592), observation of injection process (17 844), and observation of prescriber-client
interaction (24 030).
Results: The frequency of injections was 2.9 (95%CI: 2.8-3.2) per person/year. Of the total
injections, 62.9% (95%CI: 60.7-65.0) were unsafe. Injections administered for curative purpose
constituted 82.5% and a large majorly of these were prescribed for common symptoms like
fever/cough/diarrhoea. Use of glass syringes was consistently associated with potential risk of
blood-borne viral transmission. Satisfactory disposal of injection waste was observed at 61.3%
(95%CI: 58.2-64.3) of the health facilities, and at 50.9% (95%CI: 46.7-55.2) of the immunization
clinics. Significant differences were observed in the injection prescription pattern in public and
private facilities, and in rural and urban areas.
Conclusions: Three billion injections were estimated to be administered annually in India; of
them 1.89 billion were unsafe. Evidence suggests that the micro-level leadership for reducing
injection overuse and making injections safer lies with the prescriber.
Key words: Injection, safety, practices, waste, rational use, India.
Introduction
Injections are among the most commonly
used medical procedures with an estimated 16
billion administrations each year worldwide.
An overwhelming majority (90%-95%) of
these injections are administered for curative
purposes.1 Estimates suggest that at least 50%
of the world’s injections administered each
year are unsafe, particularly in developing
countries. Moreover, a majority of the curative
injections have been judged to be unnecessary.
People residing in developing regions receive
1.5 to 11.3 injections per person/year and up
to 75% of them are given with unsterilized,
reused equipments – the reuse being highest
in South-East Asia Region.2,3
The INCLEN Trust International, F-1/5, 2nd Floor, Okhla Industrial Area, Phase-I, New Delhi 110020, India.
Correspondence to Narendra K Arora (email: nkarora@inclentrust.org)
a
WHO South-East Asia Journal of Public Health 2012;1(2):189-200
Book 1.indb 189
189
05-Jun-2012 2:36:00 PM
Injection practices in India
A safe injection does no harm to the
recipient, does not expose the healthcare
worker to any risk, and does not result in
waste that puts the community at risk.4
Faults in injection practices coupled with
overuse of injections may expose all of them to
several harms including life-threatening bloodborne viral (BBV) infections. Global estimates
arrived at by using mathematical models have
suggested that unsafe injections account for
32% of new hepatitis B virus (HBV) infections,
40% of new hepatitis C virus (HCV) infections
and 5% of new HIV infections. This will pose
a burden of 9.2 million disability adjusted life
years (DALYs) between 2000 and 2030.5 In
the developing countries, inadequate supplies
and improper waste disposal has led to largescale reuse of injection equipment without
sterilization. In addition, the improperly
disposed chlorinated plastic and sharps pose
a threat to the environment.
Anecdotal evidence suggests that the
overuse of injections is increasing.4 In India,
studies documenting such changes are not
available. However, broad trends can be
observed from small studies indicating a rise
from 1.2 injections/person/year in 1987 to
2.46 injections/person/year in 2001.6-7 A high
proportion of injections given in India might
be unsafe, mainly due to reuse of needles/
syringes - which are also scavenged for resale,
to confound the situation. The popularity
of curative injections remains high due to
various factors influencing the behaviour of
prescribers/injection givers as well as clients.
A large proportion of these injections are
unnecessary.4,8-9 While addressing the need for
a countrywide evidence on prevalent injection
practices, the present study was undertaken
in 2003-2004 to assess: the frequency of
injections; proportion of unsafe injections; and
injection-related waste disposal in government
and private health facilities, and in rural and
urban areas of India.
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Book 1.indb 190
IPEN Study Group
Methods
Study design
A nationwide population-based cluster
survey (1200 clusters; 24 021 subjects) at
the household level along with observations,
interview of prescribers (2402), and exit
interview of the patients (12 012) at health
facility level in the selected clusters was
carried out, using probability proportionate to
size (PPS) technique. Observations at health
facility included generic observations (3592),
observation of injection administrations
(17 844), and observation of prescriber-client
interactions (24 030). The whole country
was demarcated into 15 zones on the basis
of socio-cultural and geographic factors. The
sampling universe was a zone and each zone
comprised of either a single state or a group
of two to five small states (Figure 1). The
clusters were drawn separately for urban and
rural areas. The details of the sample size and
plan are given in Table 1.
The survey commenced at a randomly
selected household. Household members
were listed and one individual was randomly
selected and interviewed. Consecutive
households were covered until 20 clients
were interviewed. One government and one
private health facility located in or nearest to
the cluster were selected. If more than one
private health facility existed in the cluster, the
one which was reported to administer more
injections was selected. For the immunization
clinic, a nearby out-reach area/sub-centre/
dispensary where routine immunization was
done was selected. Exit interviews were
conducted to neutralize Hawthorn effect
during direct observations. Five consecutive
patients coming out of both the public and
private health facilities were interviewed
among those who agreed to participate.
WHO South-East Asia Journal of Public Health 2012;1(2):189-200
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IPEN Study Group
Injection practices in India
Figure 1: Number of injections per person/year according to study zones
Zone 1
2.9
Zone 2
Zone 7
2.5
3.3
Zone 5
Zone 3
2.4
2.7
Zone 6
Zone 9
3.2
2.3
Zone 4
1.8
1.8
Zone 8
2.9
Zone 11
2.9
Zone 12
5.2
Zone 13
Zone 10
All India 2.9
4.1
Zone 15
3.2
Zone 14
5.6
Study tools
The draft instruments were developed by a
multidisciplinary central coordinating team,
with inputs from programme managers in
the Ministry of Health and Family Welfare,
Government of India. The instruments,
consisting of a mix of structured close-ended
and semi-structured open-ended questions,
were validated and piloted at eight sites across
the country, and were finalized during the
national protocol finalization workshop.
WHO South-East Asia Journal of Public Health 2012;1(2):189-200
Book 1.indb 191
The factors that make an injection safe
were studied in detail by senior investigators
through direct observation of the injection
administration. These were grouped under
factors associated with injection equipment
and its sterilization; and those associated with
the technique of administering an injection.
A checklist for safe/unsafe injections was
developed for this assessment. This checklist
was based on various criteria suggested by
the World Health Organization (WHO).10 An
injection was classified as unsafe if: it had
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05-Jun-2012 2:36:01 PM
Injection practices in India
IPEN Study Group
Table 1: Sample plan of the study for interviews and observations
Zonal sample
Total sample size
No. of
zones
Proposed
Covered
No. of
Clusters
Sample
per cluster
Sample
per zone
80
(Rural-40,
Urban-40)
20
1600
15
24000
24021
Generic observation
80
(Rural-40,
Urban-40)
3
(Government-1,
Private-1,
Immunization
clinic-1)
240
15
3600
3592
Observation of injection
process
80
(Rural-40,
Urban-40)
15
(Government-5,
Private-5,
Immunization
clinic-5)
1200
15
18000
17844
Observation of clientprescriber interaction
80
(Rural-40,
Urban-40)
30
(Government-10,
Private-10)
1600
15
24000
24030
Exit interview of patients
80
(Rural-40,
Urban-40)
10
(Government-5,
Private-5)
800
15
12000
12012
Prescriber's interview
80
(Rural-40
Urban-40)
2
(Government-1,
Private-1)
160
15
2400
2402
Community Level
Community survey
Health Facility Level
potential to transmit blood-borne viruses
(being given using inadequately sterilized
syringe/ needle and or syringe/ needle were
reused for another patient) and/or it was
administered using faulty technique (and could
cause local infection and or reaction).
Quality assurance
A uniform understanding of the study protocol,
methods and instruments among the senior
investigators and research associates was
assured through a national protocol finalization
workshop followed by 15 zonal workshops.
Members of the Central Coordinating Team
made quality assurance visits to 150 clusters
(12.5%) covering all 15 zones. All Intelligent
Character Recognition (ICR) sheets were
screened for completeness and appropriate
192
Book 1.indb 192
coding of responses. Range checks and
logical runs were incorporated in the data
management software to minimize errors.
Data analysis
Intelligent Character Recognition sheets were
filled by the senior investigators, for each
unit of community-based survey and facilitybased observations and interviews, on a daily
basis during data collection phase. The data
were scanned and directly transferred to the
computers from the ICR sheets using ABBYY
Form Processing Solutions (Form Reader 4.0).
Recognized data were first transferred to Excel
spreadsheets for data cleaning. The survey
feature of ‘STATA release 7.0’ was used for
analysis of the whole data set. Magnitude of
injections, proportion of unsafe injections,
WHO South-East Asia Journal of Public Health 2012;1(2):189-200
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IPEN Study Group
awareness and perceptions regarding injection
practices and inappropriate disposal of sharps
waste were calculated for the individual
zones and thereafter for the whole country
by imputing weights for the population.
The zone-wise estimates of urban and rural
population were used according to the 2001
census. For health facility-based data, allIndia estimates were derived by applying
weightage for proportion of injections given
at different health facilities (as determined
during community survey).
Ethical issues
A prior written consent was obtained from all
study participants. The consent forms were
prepared in local languages and one copy was
given to the interviewees for their records. For
those unable to read, a person not connected
with the study read out the consent form and
assured that the contents were made explicitly
clear.
Results
Based on the data obtained from the survey,
we estimate that in the over one billion
population of India, three billion injections
were administered annually. Of these, 2.49
billion injections were given for curative
purposes and 1.89 billion injections were
unsafe. The private sector was contributing
2.1 billion injections to the total injections and
1.26 billion to the unsafe injections.
Frequency of injections
In the three months recall, 27.1% (95%CI:
25.9-28.3) of the subjects in the community
survey reported to have received injection(s).
The number of injections received per
person-year was estimated to be 2.9 (95%
CI: 2.8-3.2) (Figure 1). The frequency of
injections was almost twice among infants
(5.6; 95%CI: 5.0-6.2) as compared to older
WHO South-East Asia Journal of Public Health 2012;1(2):189-200
Book 1.indb 193
Injection practices in India
subjects (2.8; 95%CI: 2.6-3). Of all the
injections, 17.5% (95%CI: 16.0-18.9) were
for vaccination. Among infants, injections for
vaccination were 63.2% (95%CI: 56.8-69.6)
compared to 12.2% (95% CI: 10.9-13.4)
among older subjects. More than three fourths
(77.0%; 95%CI: 75.1-79.0) of curative
injections were prescribed in the private
facilities. Among preventive injections, two
third injections (66%; 95%CI: 62.5-69.6)
were given in the government sector.
Prescription pattern
On direct observation, 44.1% (95%CI: 42.945.6) of all outpatient clients were prescribed
injections. A larger proportion of clients in the
private health facilities received injections
45.9% (95% CI: 44.2-47.7) as compared to
those attending government health facilities
38.5% (95%CI: 36.7-40.3). Non-formal
prescribers were giving 12% to 15% more
injections as compared to allopathic doctors.
A similar trend was seen with exit interviews
where nearly half of the respondents (48.1%;
95%CI: 46.3-49.9) had received injections,
with a higher proportion in private facilities
(50.6%; 95%CI: 48.5-52.7) as compared to
government facilities (40.7%; 95%CI: 38.642.9).
Exit interviews revealed that the highest
proportion of injection prescriptions were
seen at the clinics of non-formal prescribers
(57.5%), followed by Indigenous Systems of
Medicine (ISM) (52.6%) and allopathic clinics
(42.6%). This trend of prescribing injections,
as assessed through direct observation
of the client-prescriber interaction, was
similar to that obtained from exit interviews
(52.3%, 48.2% and 40.5% respectively).
Exit interviews (51.1%; 95%CI: 48.9-53.3)
as well as community survey (51.7%;
95%CI: 49.8-53.7) indicated that over half
of the curative injections were prescribed for
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05-Jun-2012 2:36:01 PM
Injection practices in India
IPEN Study Group
Unsafe injections
symptoms of fever/cough/diarrhoea. A vast
majority of prescribers (88.6%; 95%CI: 86.890.5) was of the opinion that injections gave
psychological relief to the patients as they
insisted on injections. Notwithstanding these
perceptions, direct observations revealed that
most of the times (70.6%), doctors took a
decision about the prescription and the clients
accepted it. Enquiries with clients underscored
this, where a large proportion of clients 44.1%
(95% CI: 42.7-45.6) accepted the doctor’s
decision to administer injections even when
these were perceived to be unnecessary. When
clients who were insisting on an injection were
questioned about why they prefer to receive
injections, 73.8% (95%CI: 72.5-75.1) cited
certain benefits of the injections over oral
medicines (e.g. quick relief, more effective
method of illness treatment).
Of all the injections administered in India,
one third (31.6%) carried a potential risk
of transmitting BBV. Unsafe injection due
to faulty technique was observed in 53.1%
of the observed administrations. Together,
these two factors made nearly two third
(62.9%) of the injections unsafe (Table 2). The
proportion of unsafe injections was highest
at the immunization clinics (74.0%) followed
by government (68.7%) and private (59.9%)
health facilities (Table 3).
The type of injection equipment (glass or
plastic syringe) had a profound effect on the
safety of injections, be it potential risk of BBV
transmission; faulty injection technique or the
overall unsafe injections (Table 2). Regression
analysis showed that there was a linear but
Table 2: Characteristics of unsafe injections in India (data in percent)
Characteristics
Injections carrying risk of blood
borne virus transmission
Faulty technique
Overall
Overall unsafe
injections
Unsafe injections
with plastic syringe
Unsafe injections
with glass syringe
31.6
18.2
70.7
(29.4-33.7)
(16.3-20.1)
(67.2-74.3)
53.1
46.2
73
(50.8-55.4)
(43.5-48.9)
(69.9-76.1)
62.9
53.3
90.8
(60.7-65.0)
(50.6-55.9)
(88.8-92.8)
Figures in parentheses show 95% confidence interval.
Table 3: Unsafe injections according to type of health facility and syringe use in
India (data in percent)
Injections carrying risk of
blood-borne virus transmission
Type of health
facility
Overall
unsafe
injections
Injections
with plastic
syringe
Overall
With plastic
syringe
With glass
Syringe
Government health
facilities
68.7
(66.1-71.3)
62.7
(59.8-65.5)
35.4
(32.7-38.1)
18.5
(15.7-21.3)
63.7
(59.1-68.3)
Private health
facilities
59.9
(56.9-62.8)
80.7
(78.2-83.2)
30.1
(27.3-32.9)
18.1
(15.8-20.5)
80.1
(74.7-85.5)
Immunization
clinics
74.0
(71.4-76.6)
52.3
(49.1-55.5)
33.5
(30.5-36.5)
18.0
(14.9-21.1)
50.5
(45.8-55.2)
All India
62.9
(60.7-65.1)
74.6
(72.6-76.6)
31.6
(29.4-33.7)
18.2
(16.3-20.1)
70.7
(67.2-74.3)
Figures in parentheses show 95% confidence interval.
194
Book 1.indb 194
WHO South-East Asia Journal of Public Health 2012;1(2):189-200
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IPEN Study Group
Injection practices in India
inverse relationship between the quantum
of plastic syringe use in a zone and overall
prevalence of unsafe injection as well as
potential risk of BBV transmission irrespective
of the type of health facility.
In multivariate logistic analysis, use of
glass syringes consistently emerged as the
most important factor behind unsafe injections
(OR 8.4); for risk of BBV transmission (OR
12.2); and for unsafe injection due to faulty
techniques (OR 3.0). The likelihood of unsafe
injection was marginally lower in urban
areas as compared to rural areas. The risk of
unsafe injection when administered at nonallopathic health facilities (ISM and non-formal
prescribers) was over one and a half times as
compared to that with allopathic prescribers
(Table 4).
Written guidelines for sterilization were
available at only 10.1% (95% CI: 8.8-11.4)
of all health facilities across the country.
More than half of the prescribers (55.6%;
95%CI: 51.7-59.5) reported an incorrect
sterilization process. Sterilization equipment
was available at 84.2% (95%CI: 81.4-87.1)
of the government health facilities, 76.9%
(95%CI: 73.9-80.0) of the immunization
clinics and 57.7% (95%CI: 54.1-61.3) of
private health facilities. Over three fourths
(75.9%; 95%CI: 72.7-79.0) of the available
sterilization equipment were functional.
The guidelines for waste disposal were
available at only 14.2% (95%CI: 12.6-15.7)
of the health facilities. Satisfactory facilitylevel disposal of injection waste was observed
at 61.3% (95%CI: 58.2-64.3) of the health
facilities; immunization clinics being the worst
performers at 50.9%. Satisfactory terminal
disposal was observed in less than half of the
health facilities (44.8%; 95%CI: 41.9-47.7);
41.55% in private health facilities. A marked
difference existed between the observed
status and prescribers’ perception about waste
disposal at the health facility as well as at the
terminal levels (Table 5). Direct observation at
health facilities documented that the selling of
Table 4: Risk of unsafe injections in India
(multivariate logistic regression analysis)
Model
Model 1
Model 2
Independent
variables
Blood-borne virus
transmission
Overall
Faulty technique
OR (95% CI)
p
OR (95% CI)
p
OR (95%
CI)
p
8.4 (6.4-10.9)
<0.001
12.2 (9.7-15.5)
<0.001
3.0 (2.5-3.6)
<0.001
Urban area
0.7 (0.6-0.8)
<0.001
0.9 (0.7-1.1)
0.2
0.7 (0.6-0.8)
<0.001
Private health
facility
0.9 (0.8-1.1)
0.2
1.3 (1.1-1.6)
<0.001
0.9 (0.8-1.1)
0.4
Immunization
clinic
1.1 (0.9-1.3)
0.1
0.6 (0.5-0.8)
<0.001
1.3 (1.3-1.5)
<0.001
Glass syringe
8.6 (6.4-11.4)
<0.001
12.5 (9.8-15.8)
<0.001
3.0 (2.4-3.7)
<0.001
Urban area
0.8 (0.6-0.9)
<0.001
1.0 (0.8-1.3)
0.9
0.7 (0.6-0.9)
<0.001
ISM practitioner
1.5 (1.1-1.9)
<0.001
1.7 (1.2-2.3)
<0.001
1.3 (0.99-1.7)
0.05
Informally trained
practitioner
1.6 (1.1-2.3)
0.01
1.9 (1.4-2.7)
<0.001
1.4 (0.98-1.9)
0.07
Glass syringe
ISM – Indian system of medicine
WHO South-East Asia Journal of Public Health 2012;1(2):189-200
Book 1.indb 195
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05-Jun-2012 2:36:01 PM
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IPEN Study Group
Table 5: Satisfactory injection-related waste disposal in India: direct observation
versus prescriber’s perception (data in percent)
Level of waste
disposal
Government health facility
Private health facility
Immunization
clinic
Direct
observation
Prescriber’s
perception
Direct
observation
Prescriber’s
perception
Direct
observation
Health facilitylevel disposal
60.5
(56.7-64.2)
90.1
(87.8-92.5)
62.3
(58.6-65.9)
86.4
(83.9-88.9)
50.9
(46.7-55.2)
Terminal
disposal
53.5
(49.8-57.2)
69.6
(66.1-73.0)
41.5
(37.9-45.2)
57.9
(54.2-61.6)
49.1
(45.3-52.9)
Figures in parentheses show 95% confidence interval.
used plastic syringes/needles to retail scrap
dealers was more in private health facilities
(15.2%; 95%CI: 12.3-17.9) as compared to
that from government health facilities (3.2%;
95%CI: 1.9-4.5).
Rural- urban differentials
Client-prescriber interactions demonstrated
that the proportion of prescriptions with
injection was higher in rural areas (46.6%;
95%CI: 44.8-48.4) as compared to urban
areas (37.6%; 95%CI: 35.1-39.9). This
difference was maintained when data was
stratified according to the type of health
facilities and type of health providers. The
proportion of injections carrying risk of spread
of BBV transmission was also higher in villages
(33.4%; 95%CI: 30.4-36.5) as compared to
urban areas (26.6%; 95%CI: 23.2-30.1).
Availability and functional status of sterilization
equipment was similar in the two areas.
Disposal of injection-related waste at health
facility level was better in urban areas (69.6%;
95%CI: 66.0-73.1) as compared to their rural
counterparts (57.9%; 95%CI: 53.8-62.0).
Similarly, terminal disposal was better in urban
health facilities (51.2%; 95%CI: 46.9-55.5)
as compared to health facilities in rural areas
(42.2%; 95%CI: 38.5-45.9).
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Book 1.indb 196
Discussion
An overwhelming majority of injections in our
study were given for therapeutic reasons.
However, their proportionate share seems to
be a little lower in India (82.7%) as compared
to the global data (95%). 4 The overall
frequency of injections in our nationwide
data was 2.9 injections per person/year. This
is almost double of the average estimate for
developing countries (1.5),2 though half of
what has been observed in Cambodia (5.9).11
Estimates of injections per person/year in
developing countries vary from 1.5 to 11.3.2,3
If we apply our data to total population, around
3 billion injections are administered annually
in India; of which nearly 2.5 billion are curative
injections, and roughly 2 billion injections are
unsafe. Barring vaccines, the major share is
borne by the private sector. Another indicator
of the injection frequency in our data was that
every second exit interviewee in the study
had received injections. A similar trend has
been reported from Cambodia where 47% of
the total prescriptions included a therapeutic
injection or infusion.11
Of the total quantum of injections, around
two third were found to be unsafe, which is on a
higher side from the developing world estimate
of nearly 50% injections being unsafe.2 Reuse
WHO South-East Asia Journal of Public Health 2012;1(2):189-200
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IPEN Study Group
of syringes, with or without sterilization is
a serious problem across countries in the
developing regions, being highest in SouthEast Asia. Injections administered with
unsterilized, reused equipment constitute
1.2% to 75.0%.3,5 Smaller studies from India
have also reported widely prevalent reuse of
syringes.12,13 The worrisome part was that this
was highest at immunization clinics where
74.0% of the injections were either carrying
a potential risk of BBV transmission or were
administered with faulty technique. There
was a wide gap between observed status and
prescribers’ perception on waste disposal.
The situation of terminal disposal of injection
waste was worse. Rural-urban differences
on injection safety may be explained by the
higher use of glass syringes in rural areas,
variations in the profile of prescribers, and
training of the injection givers. Although basic
issues related to the burden of injection, safety
and waste disposal broadly remain the same
for rural and urban areas, management of
injection-related waste in remote villages and
outreach clinics is going to pose a significant
challenge logistically.
The main area of limitation in this study
was that of the observations at health
facility level. Hawthorn effect was likely
to influence the injection prescribing and
injection administering practices, resulting
into underestimation of unsafe and irrational
injections. The quantum of this error could not
be estimated, although direction was possible
to assess. To neutralize this, exit interviews of
a separate group of clients coming out of the
same health facilities were also conducted.
An appropriate and systematic global
response to the threat of unsafe injections has
been slow to emerge.14 The goal is not only
to make the injection practices safe but also
to reduce the overall quantum of injections
administered to people by modifying the
WHO South-East Asia Journal of Public Health 2012;1(2):189-200
Book 1.indb 197
Injection practices in India
prescription practices – both in public and
private sectors. We also need to include a
large constituency of non-formal prescribers
in our scope since they contribute a sizeable
proportion of injection prescriptions.15 Starting
from the formulation of a National Safe
Injection Policy, these efforts would include
behaviour change among health workers and
clients; provision of uninterrupted supply of
safe injection equipment; and establishment
and maintenance of injection-related waste
disposal mechanisms. India has recently
seen substantive progress in some of these
areas.16 Professional bodies have formulated
their policies and plan of action, and a large
nationwide grid of Model Injection Centres
was established by the INCLEN Programme
Evaluation Network, as a follow up to this
study.17-19
One of the most positive translational
developments prompted by this study has been
the minimization of glass syringe usage. With
extra effort and patience required to properly
sterilize the glass syringes, particularly in
crowded out- patient settings, most of the
injections administered through glass syringes
were unsafe. The government’s response to
this evidence has been quick. As a policy, the
Auto-Disable (AD) syringes are now being
used universally in the national immunization
programme and their uninterrupted supply is
assured. In addition, it has also been made
mandatory for all states to use AD syringes in
all government hospitals and health centres.
However, much needs to be done in several
domains of injection safety - specifically in: (a)
inducing and sustaining a culture of rational
use of injections among prescribers through
advocacy, communication and training; and
(b) terminal disposal of injection-related
waste. In this regard, the disposal of plastic
waste is a big challenge in rural areas because
of the economic viability of the rather unclear
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05-Jun-2012 2:36:01 PM
Injection practices in India
system of collection and terminal disposal of
such waste in primary care settings.
Community survey as well as exit interviews
indicated that over half of the curative injections
were prescribed for common symptoms, e.g.
fever, cough, or diarrhoea. This enforces the
assertions made in reports from India and
Bangladesh that most injections in healthcare
settings are unnecessary.20,21 In the present
study, a huge majority of prescribers was of
the opinion that clients insist for injections
since it gave them psychological relief.
However, the evidence generated through
direct observation was contrary to these
perceptions. In most instances, doctors took a
decision about the prescription and the clients
accepted it. Enquiries with clients revealed that
a large proportion of clients accept the doctor’s
decision to administer injections even when
these were perceived to be unnecessary.
The biggest irony is that a widely practiced
health care intervention which has benefited
the people so extensively in the last century is
also turning into a health hazard and a threat
to community health. Excessive recourse
of prescribers to injections, when equally
effective oral formulations are available
or the medication is not required at all, is
constantly aggravating this threat. It is not a
question of onus, but the evidence suggests
that the micro-level leadership for creating a
professional as well as social milieu favourable
to rational use of injections lies with the
prescribers, particularly in the private sector
which has an overwhelming influence over the
huge domain of non-formal prescribers.
Acknowledgements
We thank the Ministry of Health and Family
Welfare, Government of India and The World
Bank for their financial support for this
study.
198
Book 1.indb 198
IPEN Study Group
IPEN Study Group
a
Manuscript Writing Team: Sanjay Chaturvedi,
Narendra K Arora, M Lakshman, RM Pandey.
Central Coordinating Team: Kalyan K Ganguly,
Kiran Goswami, Moumita Biswas, S Rema
Devi, Sneh Rewal, S Vivek Adhish, Thomas
Mathew. Extended Central Coordinating
Team: B Mallikarjun, Faruque U Ahmed,
Sanjay P Zodpey, SL Chadha, RN Basu,
Sheffali Gulati, Shitanshu Uppal, TD Sharma,
SK Pradhan, Deoki Nandan, Sandip K Ray,
Sunita Shanbhag, Pankaj Hari, Vibhor Krishna,
Kailash C Malhotra, Harish Pemde, Tanu
Singhal, Abdul Rauf, Naveet Wig, Hemant
Kumar, Vaishali Deshmukh, Manoja Das. Team
of Investigators: Zone 1 (Punjab, Chandigarh,
Delhi, Haryana, Himachal Pradesh, Jammu
& Kashmir): Zonal Coordinator- Rajesh
Kumar; Investigators- Muneer A Masoodi,
Safoora Bilques, Tejbir Singh, SS Deepti, O
Raj Goldi, Kanwaljit Singh, Jasleem Kaur,
Vikrant Prabhakar, S Bandyopadhyay, Sonu
Goel, Jay Kishore, Sanjay Atri, KC Sharma,
Manoj Bhardwaj, Ashwini Goel, Purshottam
Zone 2 (Uttar Pradesh, Uttaranchal): Zonal
Coordinator- Amarjeet Singh, JS Thakur and
RC Ahuja; Investigators- Vinod K Srivastava,
AK Shrivastava, VK Srivastav, Uday Mohan,
Ramesh Chandra, Yogesh Saxena, Deoki
Nandan, SP Agnihotri, BB Maheshwari, SK
Misra, SC Gupta, SN Bhargawa, SC Mohapatra,
VM Gupta, Ramesh Chandra, SD Kandpal, Azra
Ahmed, S Manazir Ali, GK Gupta, Sangeeta
Kansal. Zone 3 (Bihar, Jharkhand): Zonal
Coordinator- SP Srivastava; Investigators- RRP
Singh, NP Verma, Mala Sinha, Manju Prasad,
Ashok Kumar, HK Das, Amita Varma, Kalpana
Das, Arbind Kumar, Manish Kumar, RK Sinha,
KK Sinha, Arun K Sharma, JP Mishra, Vivek
Kashyap, SK Singh, CS Sharma, B Kishore
Singh, KN Acharya, SN Sharma. Zone 4 (West
Bengal, Andaman & Nicobar Islands): Zonal
Coordinator- Sandip K Ray; InvestigatorsJayasri M Ghosh, Sarmila Mallik, Shyama
WHO South-East Asia Journal of Public Health 2012;1(2):189-200
05-Jun-2012 2:36:01 PM
IPEN Study Group
P Mitra, Biswajit Biswas, Samir Das Gupta,
Rabindra Nath Sinha, Palash Das, Ramaprasad
Roy, Asoke Mondal, Prasanta Ray Karmakar,
Dipak Pal, NC Mondal, Madhumita Dobe,
Ashok K Mallick, RN Mandal, Suprakas Hazra,
Nabendu Chaudhuri, Nabanita Bhattacharyya,
Bansi B Mukhopadhyay, Bijoy Mukherjee.
Zone 5 (Assam, Arunachal Pradesh, Sikkim,
Meghalaya): Zonal Coordinator- Faruque
U Ahmed; Investigators- Alak Barua, SD
Kakoty, P K Dutta, Bobyjeet Goswami, Giriraj
Kurse, SP Sinha, Ganesh C Baruah, Bijit
Bhattacharya, PK Bordoloi, Saurabh Borkatoki,
Jugadhar Changmai, PJ Bhuyan, Chiranjeeb
Kakoty, Aloka Bhattacharjee, Ajmal Hussain,
Abdul Kalam Ajad, Saumyendra Nath Sarma,
Minakshi Borah, C Danaila, BB Rai. Zone 6
(Manipur, Tripura, Mizoram, Nagaland): Zonal
Coordinator- E Yaima Singh; Investigators- L
Usharani Devi, AK Brogen, T Gambir Singh, K
Robindro Singh, Thoiba Henba, A Naranbabu
Singh, Kumini Kathipri, L Yanthan, Tiasnup,
Limatula, K Zoramthanga, B Lalduhawma,
F Lallianhlira, Vanlalrengpuia, Tapan K Das,
S Deb Barman, Pranab Chatterjee, Jayanta
K Das, Saroj K Das, Kamal Reang. Zone 7
(Rajasthan): Zonal Coordinator- BSTomar;
Investigators- Suresh C Gaur, SC Gupta,
SL Agarwal, MC Poonia, BL Gupta, Suman
Bhansali, Rajendra Tater, SL Solanki, SR
Negi, Anoop Tankha, JS Broca, Pavitra Mohan,
Sanjna Mohan, Narendra Gupta, Veena
Dwivedi, Kanhaiya Lal, Sanwaria, Tej Ram Jat,
Mahesh Panpalia, RP Yadav, Gaurav Bhargava,
SL Nepalia. Zone 8 (Gujarat, Diu, Daman):
Zonal Coordinator- BR Vyas; Investigators- KN
Pandya, Deepak Pande, Ratan K Srivastava,
Naresh Godara, Nipin Bagla, Arvind Panwar,
Yogesh Parikh, Umesh Patel, Hiren Deshi,
Sunil Panjwani, PV Kotecha, VS Majumdar,
Sangeeta Patel, JR Damar, Chetana Shah,
Hemant JS, BS Bhavsar, Geeta Kedia, Kamlesh
Shah, Kinjal Baxi. Zone 9 (Madhya Pradesh,
Chattisgarh): Zonal Coordinator- SS Bhambal;
Investigators- AK Upadhyay, RKS Kushawaha,
WHO South-East Asia Journal of Public Health 2012;1(2):189-200
Book 1.indb 199
Injection practices in India
UK Dube, Pradeep Tiwari, BL Sharma, R
Kathal, Vijay Tiwari, Raj Kumar Raj, Prakash
Pradhan, Basant Kumar Kashyap, Babu Lal
Kashyap, Rajendra Shukla, Ashok Mishra,
Subodh Mishra, N Gandhi, M Toppo, DK Pal,
PK Kasar, S Nandeshwar, R Kakkar. Zone 10
(Orissa): Zonal Coordinator- Bhagwati C Das;
Investigators- GS Patnaik, MK Panigrahi, G
Banalata Devi, BK Behera, Nutan Panda, T
Karuna, DM Satapathy, P Bharati, T Sahu,
Archana Patnaik, JM Das, NC Sahani, OP
Panigrahi, HP Acharya, SK Misra, AKMisra, B
Mahapatra, K Misra. Zone 11 (Maharashtra,
Goa): Zonal Coordinator- AK Niswade;
Investigators- Sanjay P Zodpey, Suresh N
Ughade, Abhay Gaidhane, SG Deshpande,
AV Saoji, SZ Quazi, Unmesh Korde, Violet M
Desa, Leena Rasal, Trupti N Bodhare, Lalit R
Sankhe, Nishikant Rahate, Ranjit Mankeshwar,
Sudhir Makrikar, DL Ingole, PA Bhuyar, JS
Bhawalkar, BS Kamlapurkar, Dilip D Motghare,
AMA Ferrira. Zone 12 (Andhra Pradesh):
Zonal Coordinator- S Narasimha Reddy;
Investigators- M Ram Prasad, C Bala Krishna,
KVS Murthy, KAK Reddy, G Subrahmanyam,
B Prithviraj, Venugopal Reddy, G Kasiram, A
Sanjeeva Rao, G Krishnababu, R Sambasiva
Rao, V Subramanyam, C Niranjan Paul, N
Ananthaiah Chetty, A Sreedevi, G Ravi Prabhu,
V Chandrasekhar, TSR Sai, GSS Ganesh Babu,
R Nageswara Rao. Zone 13 (Karnataka): Zonal
Coordinator- B Mallikarjun; InvestigatorsKapate Rajashekar, BN Patil, TPrabhushetty,
Shrishail Ghooli, Shivananda, Shivaprasad,
GB Belvadi, HM Vishwanath Kumar, SC
Mogali, Asha Benakappa, RS Phaneendra
Rao, Ramachandra Kamath, Vinod Batt,
Avinash Shetty, AS Akki, KA Masaki, VD
Patil, AS Wantamutte, NS Mahantshetti,
Suresh Sommannavar. Zone 14 (Tamil Nadu,
Pondicherry): Zonal Coordinator- Manjula
Datta; Investigators- R. Sathianathan, S Shaffi
Ahmed, RK Padmanabhan, Edwin Amalraj,
KR John, NC Appavoo, VM Soma Sundaram,
TSathyaprakash, R Meera, G Sugunadevi,
199
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Injection practices in India
K Bhuvaneswari, M Seetharaman, PAT
Jagadeeswari, KM Maithreyi, V Dhanalakshmi,
S Vijayalakshmi, C Indira Priyadarsini, K
Muthulakshmi, R Napoleon, P Gnanaguru.
Zone 15 (Kerala, Lakshwadeep): Zonal
Coordinator- S Rema Devi; Investigators- C
Nirmala, V Suja, K Sasikala, T Unnikrishnan, M
Ramla Beegum, Thomas Bina, T Jayakrishnan,
T Hymavathi, KR Leela Itty Amma, PK
Accamma, Lucy Rapheal, Nileena Koshy, G
Syamala Kumari, A Sobha.
IPEN Study Group
1198: unnecessary therapeutic injections are a major
risk factor. Epidemiol Infection. 2000;125:367-75.
10. World Health Organization. Tool for the assessment
of injection safety. Geneva: WHO, 2001.
11. Vong S, Perz JF, Sok S, Som S, Goldstein S, Hutin Y,
Tulloch J. Rapid assessment of injection practices in
Cambodia, 2002. BMC Public Health. 2005;5:56.
12. Kermode M, Holmes W, Langkham B, Thomas MS,
Gifford S. Safer injections, fewer infections: injection
safety in rural north India. Trop Med Int Health.
2005;10:423-32.
13. Pandit NB, Choudhary SK. Unsafe injection practices in
Gujarat, India. Singapore Med J. 2008;49:936-9.
References
1. World Bank, Safe Injection Global Network (SIGN).
Injection Safety. http://siteresources.worldbank.
org/INTPHAAG/Resources/AAGInjectionSafety9-03.
pdf – accessed on 15 July 2010.
2. Simonsen L, Kane A, Lloyd J, Zaffran M, Kane
M. Unsafe injections in the developing world and
transmission of blood-borne pathogens: a review.
Bull WHO. 1999;77:789-800.
3. Hutin YJF, Hauri AM, Armstrong GL. Use of injections
in health care settings worldwide, 2000: literature
and regional estimates. BMJ. 2003;327:1075-77.
4. World Health Organization. Safe Injection Global
Network (SIGN) initial meeting report, October 4-5,
1999, WHO headquarters, Geneva, Switzerland.
Geneva: WHO, 2000.
5. Hauri AM, Armstrong GL, Hutin YJF. The global
burden of disease attributable to contaminated
injections given in health care settings. Int J STD
AIDS. 2004;15:7-16.
6. Trisha G. Drug prescription and self-medication
in India: an exploratory survey. Soc Sci Med.
1987;25:307-18.
7. Anand K, Pandav CS, Kapoor SK. Injection use in a
village in north India. Natl Med J India. 2001;14:14344.
8. Lakshman M, Nichter M. Contamination of medicine
injection paraphernalia used by registered medical
practitioners in south India: an ethnographic study.
Soc Sci Med. 2000;51:11-28.
14. Kermode M. Unsafe injections in low-income country
health settings: need for injection safety promotion
to prevent the spread of blood-borne viruses. Health
Promot Int. 2004;19:95-103.
15. Kermode M, Muani V. Injection practices in the formal
& informal healthcare sectors in rural north India.
Indian J Med Res. 2006;124:513-20.
16. Hutin YJF. Acting upon evidence: progress towards
the elimination of unsafe injection practices in India.
Indian Pediatr. 2005;42:111-3.
17. Indian Medical Association. Policy on safe injections
in health care settings: ‘safe injections, safe
life’. -http://www.imanational.com/Projects1.asp
–accessed on 10 March 2005.
18. Indian Academy of Pediatrics. IAP workshop on safe
injection practices: recommendations and IAP plan
of action. Indian Pediatr. 2005;42:155-61.
19. IndiaCLEN Program Evaluation Network. Model
Injection Centres: a program to improve injection
practices in the country (2005-2008). (http://
w w w. i p e n . o r g . i n / i n d e x . p h p ? o p t i o n = c o m _
content&task=view&id=58&Itemid – accessed 25
April 2012).
20. Kaipilyawar SB. History, magnitude and rationality
of injection use - a compilation. J Indian Med Assoc.
2005;103:206-8.
21. Chowdhury Azad AK, Roy T, Faroque ABM, Bachar SC,
Asaduzzaman M, Nasrin N, et al. A comprehensive
situation assessment of injection practices in primary
health care hospitals in Bangladesh. BMC Public
Health. 2011;11:779.
9. Singh J, Bhatia R, Patnaik SK, Khare S, Bora D, Jain
DC, Sokhey J. Community studies on hepatitis B in
Rajahmundry town of Andhra Pradesh, India, 1997-
200
Book 1.indb 200
WHO South-East Asia Journal of Public Health 2012;1(2):189-200
05-Jun-2012 2:36:02 PM
Policy and practice
Funding health promotion and disease prevention
programmes: an innovative financing experience from
Thailand
Supreda Adulyanona
Abstract: Sustainable sources of funding for health programmes have been explored by many
countries. In Thailand, the Health Promotion Foundation (ThaiHealth) was established in 2001 as
an innovative state agency for funding health promotion from the 2% surcharge on alcohol and
tobacco excise tax.
ThaiHealth is governed by a Board chaired by the Prime Minister. It is not part of the conventional
health services. ThaiHealth explicitly pursues a “socio-cultural” rather than a ”biomedical model”
of health. It has fostered strategic partnerships with government, private sector, nongovernmental
organizations, and communities to implement health promotion plans. In 2010, its budget was
3700 million bahts (119 million US dollars).
Since ThaiHealth plays a catalytic, coordinating, empowering and enabling role, its impact can only
be assessed “collectively” with all partner organizations. ThaiHealth contributed to development of
several policies that led to enactment of laws and building the capacity of organizations, communities
and individuals in planning and carrying out health promotion activities. The “Collective impact”
includes decline in smoking among the more-than-15-year-olds from 25.47% in 2001 to 20.7%
in 2009; harmful alcohol drinkers from 9.1% in 2004 to 7.3% in 2009; death rate from vehicle
accidents from 22.9 per 100 000 in 2003 to 16.82 per 100 000 in 2010.
The main factors leading to achievements of ThaiHealth are: flexibility, financial security and
effective strategy. However, inadequate understanding among public and stakeholders about the
philosophy, governance and operation of ThaiHealth is reckoned as a huge challenge.
Key words: Financing, health promotion, disease control, smoking, alcohol, Thailand.
Introduction
From “Health for All” to “Ottawa Charter”,
“Jakarta Declaration” and “Bangkok Charter”,
the concept of health promotion is shaping
the service-based health education model
into a socio-cultural model. The focus of
contemporary health promotion is on broader
social determinants of health. It requires
“movements” to create and coordinate health
promotion initiatives in health and related
sectors for healthy behaviours, healthy
policies, healthy environments and healthy
systems.1
Thai Health Promotion Foundation, 979/116-120 S. M. Tower, Paholyothin Road, Samsen Nai, Payathai, Bangkok 10400 Thailand.
Correspondence to Supreda Adulyanon (email: supreda@thaihealth.or.th)
a
WHO South-East Asia Journal of Public Health 2012;1(2):201-207
Book 1.indb 201
201
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Funding health promotion and disease prevention programmes: an
innovative financing experience from Thailand
Globally, noncommunicable diseases
(NCDs) have emerged as the leading cause of
disease burden. Several developing countries
are also experiencing a rise in NCDs. Health
promotion, having its focus on healthoriented approaches, can be used as a tool
for preventing NCDs by diminishing the impact
of major risk factors such as tobacco, alcohol,
dietary imbalances, and physical inactivity.2
In spite of the increasing need, health
promotion is conventionally given low priority
in most countries, particularly in comparison
with curative services. Therefore, instead of
having health promotion budgets completely
within the health ministry, innovative sources of
predictable and sustainable funding for health
promotion especially for NCDs prevention were
explored and implemented by many countries
during the past decades.3-5
The need for innovative
health promotion financing
system in Thailand
Thailand has transformed into a middle-income
country. Consequently, the Thai burden of
diseases has been gradually shifting to NCDs,
injuries and mental illnesses.6 The transition
to unhealthy lifestyles and health risks has
been found to be linked with urbanization,
internal migration and changes in social
environment.7
In the light of the rising burden of NCDs,
greater need for health promotion was
felt in Thailand. Innovative exploration for
health promotion financing started from the
tobacco control drive. From 1988 to 1993,
Thailand succeeded in developing of policies
and enacting laws for tobacco control. The
advocacy for tax increase on tobacco for health
reasons was successful in 1994. However,
even though the revenue gained from tobacco
excise tax increased, the financial support
from the government for tobacco control was
202
Book 1.indb 202
Supreda Adulyanon
not only limited, but also showed a declining
trend.
In 1995, the movement for sustainable
finance for tobacco control led to a study
on ”health financing model from dedicated
excise tax under the control of an autonomous
agency established by the State”. After a long
process of national policy development, the
Thai Parliament enacted the Health Promotion
Foundation Act in 2001to establish Health
Promotion Office as a state agency. This
agency is not part of the Ministry of Public
Health but is under the direct supervision of
the Prime Minister. It funds health promotionrelated activities from the 2% surcharge
on alcohol and tobacco excise tax. The
“surcharge” requires the tobacco and alcohol
industries to pay 2% “additional tax” on top
of the excise tax. The Thai Health Foundation
(ThaiHealth) is the first organization of its kind
in Asia that is apparently one of the outcomes
of the health care reforms in Thailand.8 The
Thai experience of setting up and operating
the health promotion foundation, and the
lessons learned from innovative funding of
health promotion in Thailand could be useful
to other countries.
The Thai Health Promotion
Foundation: governance,
mission and strategy 9, 10
The Health Promotion Foundation Act provides
ThaiHealth with considerable autonomy as
well as annual revenue, derived from the 2%
additional excise tax on tobacco and alcohol.
In 2010, the budget of ThaiHealth was 3700
million bahts (119 million US dollars).
ThaiHealth is governed by a Board of
Governance as well as an Evaluation Board.
It also uses a series of expert advisory
committees. The Board of Governance has a
multi-sectoral structure. It is chaired by the
Prime Minister with Minister of Public Health
WHO South-East Asia Journal of Public Health 2012;1(2):201-207
05-Jun-2012 2:36:02 PM
Supreda Adulyanon
Funding health promotion and disease prevention programmes: an
innovative financing experience from Thailand
as the first Vice-Chairman and an independent
expert as the Second Vice-Chairman. Board
members comprise representatives from nine
ministries and eight independent experts
from various disciplines. Under the policy
direction of the Board of Governance, health
promotion implementation is executed by
the Health Promotion Office, through a wide
variety of networks and partners who develop
and carry out a range of programmes and
projects, to achieve the heath targets. The
Board of Evaluation has seven members who
are selected from experts in health promotion,
finance and evaluation. The responsibility of
the Board of Evaluation is to execute overall
performance evaluation of ThaiHealth leading
to transparency and efficiency. According to
the Act, ThaiHealth has to report annually
to the Cabinet as well as to both houses of
Parliament.
Adopt i ng the comprehensi ve WH O
paradigm of health, ThaiHealth explicitly
pursues a ”socio-cultural” rather than the
”biomedical model” of health. This funding
strategy was designed to financially support
major strategic health promotion activities,
particularly in the areas that are considered
to be ”hard-to-reach” by the conventional
health system.
The mission of ThaiHealth, recently
rephrased in 2011, is “to inspire, motivate,
coordinate and empower individuals and
organizations in all sectors for the enhancement
of health promotive capability as well as
healthy society and environment”. 11 With
its supporting role, rather than replacing
the existing bodies, and positioning itself
as a catalyst rather than an implementer,
ThaiHealth has fostered strategic partnerships
with various sectors including government,
private sector, nongovernmental organizations
(NGOs) and communities. These partnerships
are the key mechanism for driving health
promotion implementation synchronously.
WHO South-East Asia Journal of Public Health 2012;1(2):201-207
Book 1.indb 203
The missions of ThaiHealth were
implemented through the master plan which
currently comprises 14 plans. The plans
were organized on issue-based, settingbased and system-based approaches. The
issue-based plans include Tobacco Control;
Alcohol Control; Traffic Injuries and Disaster
Management; Physical Exercise and Sports
for Health; Healthy Food and Diet; and
Health Risk Factors Control. The settingbased plans cover Health of Disadvantaged
Groups; Health Promotion in Community;
Children, Youth and Family Health; and Health
Promotion in Organizations. Health system
based plans comprise Social Marketing and
Communication; Health Promotion through
Health Service Systems; and Supportive
Systems and Mechanisms. Most ThaiHealth
plans were proactively implemented through
strategic partners rather than by funding
project proposals. However, a plan for
promoting open grants and innovative projects
was specifically organized as a channel to open
up opportunities for all.
ThaiHealth’s strategy has employed the
concept of “Triangle that Moves the Mountain”,
proposed by Professor (Dr) Prawase Wasi.12 To
move the immovable “mountain”, symbolised
for the extreme difficulty encountered in
bringing about social change, this strategy
indicates that strengthening the three
interconnected angles of the triangle or sectors
is necessary. Creating relevant knowledge
that provides evidenced-based action and
policy, facilitating social movement to raise
public awareness and action, and fortifying
the political authority’s involvement, must
be connected together in order to effectively
generate the holistic ability to solve difficult
social and health problems.13
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Funding health promotion and disease prevention programmes: an
innovative financing experience from Thailand
ThaiHealth’s contribution
to advancement of health
promotion
The International Network of Health Promotion
Foundations (INHPF) has indicated general
advantages of health promotion foundations.14
ThaiHealth provides a dedicated infrastructure
for health promotion, offering several
advantages. It is able to: (i) Ensure a
cohesive and focused approach to health
promotion; (ii) Advocate for health promotion
to government; (iii) Conduct trials, plan
and implement long-term and innovative
programmes; (iv) Secure funding for health
promotion initiatives from political and
other uncertainty; (v) Work flexibly and
collaboratively across a range of sectors;
(vi) Collect, collate and transfer knowledge
on effective health promotion; and (vii) React
quickly to emerging needs of current health
issues.
Supreda Adulyanon
Five years after its establishment, the
Evaluation Board of ThaiHealth initiated a
review to assess the progress in relation to
its legislative mandate and direction. This
assessment was based on available data and
reports as well as on the stakeholders’ opinion.
The reviewers led by Addy Carroll reported
several key achievements of ThaiHealth
(Box 1).15 The review also recommended some
major strategic and executive improvements
that later became the focus of ThaiHealth such
as: (i) Improving the evaluation of effectiveness
of health promotion at project, programme,
strategic and overall organizational levels;
(ii) Be more proactive in prioritizing more-atrisk or disadvantaged population groups and
targeting health inequalities; (iii) Enhance
partnership involvement with the local
government; (iv) To more strategically discern
plans for funding expansion; (v) Build and
strengthen the capacity of staff, partners and
related personnel.
Box 1: Major achievements of the Thai Health Promotion Foundation
Brought together many units in society including public, private and community
groups to mobilize energy and resources.
Played a proactive role in advocating for policy and environmental change to
improve health.
Filled a void in dissemination of health information to the public.
Created notable awareness about health and healthy behaviour among people.
Mobilized and coordinated existing groups.
Built capacity of many to promote health, e.g. teachers, doctors, nurses, community
health workers.
Placed health promotion on the community agenda - increased community
understanding of the need to take care of own health through healthy lifestyles.
Rapidly enhanced its profile and built good relationships with the media and
key organizations that enabled ThaiHealth to be a powerful voice for health in
Thailand.
Used resources to raise awareness and on issues that had not been given
prominence earlier, e.g. reduction of alcohol consumption.
Established strong mass-media campaigns that were both proactive and
aggressive.
204
Book 1.indb 204
WHO South-East Asia Journal of Public Health 2012;1(2):201-207
05-Jun-2012 2:36:02 PM
Supreda Adulyanon
Funding health promotion and disease prevention programmes: an
innovative financing experience from Thailand
In 2011, The Evaluation Board of
ThaiHealth, supported by the World Health
Organizations Regional Office for South-East
Asia, again commissioned a Ten Year Review
of ThaiHealth by an international committee
chaired by Dr Rhonda Galbally – the founding
Chief Executive Officer of VicHealth. The
review team included international experts
from WHO, World Bank, and Rockefeller
Foundation. The aim is to assess the degree
to which ThaiHealth has reached maturity
that both enables it to withstand external
contextual factors, while remaining open and
relevant in the face of changing need and
expectations. The final report of this review
will be released in 2012.
“Collective outcomes
and impacts” of health
promotion in Thailand
Since ThaiHealth plays a catalytic, coordinating,
empowering and enabling role, attribution
cannot be given for any achievement to
ThaiHealth alone without recognizing the
contribution of its partners and other
organizations. The so-called “collective
impact” approach is one of the core values
of the foundation. Some examples of recent
“collective” achievements are mentioned below,
including tobacco and alcohol control.10
Tobacco control
There has clearly been an expansion in the
number of active tobacco control partners
including newly established institutions, i.e.
Tobacco Control Research and Knowledge
Management Centre and The National Quitline.
The National Tobacco Control Committee has
made continuous progress in many legislative
missions, i.e. increasing the ban on smoking
in public places including pubs and bars,
open-air markets and restaurants; increasing
the number of pictorial warnings on cigarette
WHO South-East Asia Journal of Public Health 2012;1(2):201-207
Book 1.indb 205
packs; requirement for tobacco companies
to identify tobacco ingredients (substances
that cause cancer) on the packs; not allowing
companies to put messages such as “lowtar” or “light” on the packs; and banning any
advertisement at the point of sale, etc. The nosmoking campaigns were active nationwide as
well as among many specific groups of people
creating the no-smoking- in-public culture,
particularly in urban areas.
As far as outcomes are concerned, the
decreasing trend in smoking is continuing in
Thailand since 1992. In 2009, the smoking
rate among the population aged more than 15
years old was 20.7% compared with 25.5% in
2001.16 It is noted that due to increase in the
tobacco excise tax from 75% in 2001 to 85%
in 2009, the income of ThaiHealth increased
despite the declining trend in smoking rate.
Alcohol control
Alcohol consumption has increased significantly
in Thailand. The recorded per capita adult
consumption rose from 0.26 litres in 1961
to 8.47 litres of pure alcohol in 2001.17 A
strategy similar to the tobacco control strategy
has been employed in solving the problem of
harmful use of alcohol by ThaiHealth since
2002. The three focal points of the “Triangle
that moves the mountain” - the National
Committee on Alcohol Control, the Centre for
Alcohol Studies, and the Stopdrink Network,
were the key generators of policy, knowledge
and social mobilization. The sample of national
policies were released including the Alcohol
Control Act, the first comprehensive law on
alcohol control in Thailand. The Centre for
Alcohol Studies concluded that the number of
national alcohol policies in Thailand rose from
one policy per eight years between 1950-2001
to two policies per year during 2003-2008.
Mass campaigns and community mobilizations
have moved the whole nation.13, 18
205
05-Jun-2012 2:36:02 PM
Funding health promotion and disease prevention programmes: an
innovative financing experience from Thailand
Recently, the Health Examination Survey,
the most comprehensive health survey in
Thailand, showed that the rate of harmful
alcohol drinkers decreased from 9.1% in 2004
to 7.3% in 2009 - a reduction of nearly 20%.19
This declining trend was supported by the Thai
household expenditure for alcohol consumption
that recorded a historic decline of 0.7% and
10.4% in 2009 and 2010 respectively, whereas
an increasing trend had been noticed earlier
for many decades.20
The other examples of major policy
developments include: liability to damage caused
by unsafe product act; child toy control system;
television programme rating; establishment of
(independent) public broadcasting television
from earmarked tobacco and alcohol excise
tax; prohibition on speaking on mobile phone
while driving without aid accessory; safe and
clean internet café policy; and FDA prohibition
of adding sugar into instant milk powder, etc.
Other health outcomes observed in recent years
included decline in the number of deaths from
vehicle accidents from 22.9 per 100 000 in 2003
to 16.82 per 100 000 in 2010. 21 The number of
Thai people who exercised regularly increased
from 29.0% in 2003 to 29.6% in 2007. 22
R e c e n t l y, t h e i n i t i a l r e p o r t o f a
comprehensive economics research by the
Health Innovation and Technology Assessment
Programme (HITAP)`, Ministry of Public
Health, on “the willingness to pay”, covering
from 7311 households and derived by stratified
three-stage sampling nationwide, showed that
the amount of money that people are willing
to pay for the five major plans of ThaiHealth
(physical activity, tobacco control, road safety,
food and nutrition, and alcohol control) ranged
from 2.75 to 1.35 times the actual budget of
ThaiHealth in these plans. 23
During the first decade, ThaiHealth
significantly extended its areas of interests, in
part due to the demands for effective policies
206
Book 1.indb 206
Supreda Adulyanon
and programmes to respond to emerging health
problems across Thailand. For the ThaiHealth’s
vision of the next decade, globalization and
its complex implications for public health in
Thailand was recognized as an important health
determinant. Thus, international collaboration
in health promotion became more crucial
to diminish the negative consequences of
globalization in ThaiHealth’s long-term plans.11
One of the major international missions of
ThaiHealth is to be the resource organization
for establishment of the Health Promotion
Foundation in the other countries. ThaiHealth’s
engagement with the International Network in
Health Promotion (INHPF) provides a collective
global, regional and national advocacy for
innovative health promotion financing. 24
Lessons learned
The three main factors leading to ThaiHealth’s
early achievements in the health promotion
arena are - flexibility, financial security, and
effective strategy. The (public) autonomous
status allows ThaiHealth to facilitate and
coordinate with partners in various sectors.
The funding mechanism, from a dedicated
source (2% surcharge on tobacco and
alcohol), could ensure financial security.
Finally, ThaiHealth’s “Triangle that moves the
mountain” strategy with a complementary and
coordinating role, rather than that of replacing
existing structure/agencies and capacity, is
widely and positively accepted.
A big challenge for ThaiHealth, which
is a very new concept of health promotion
financing, is lack of public and stakeholders’
understanding of its philosophy, governance
and operation. It faces inevitable threats such as
securing political support to counter opposition
from some industries and businesses. Critically,
ThaiHealth is still on a learning curve as far
as innovative health promotion management
is concerned. Hence, capacity building of
health promotion managers, advocates and
WHO South-East Asia Journal of Public Health 2012;1(2):201-207
05-Jun-2012 2:36:02 PM
Supreda Adulyanon
Funding health promotion and disease prevention programmes: an
innovative financing experience from Thailand
experts, as well as its operational aspects need
continuous improvement.11
13. Thamarangsi T. The “triangle that moves the
mountain” and Thai alcohol policy development: four
case studies. Contemporary Drug Problems. 2009;
36 (1-2): 245.
References
14. International Network of Health Promotion Foundation.
Building sustainable health promotion infrastructure
and capacity at all levels is fundamental to closing
the implementation gap. Proceeding of the 7th Global
Conference on Health Promotion, 26-30 October,
Nairobi, Kenya, 2009. West Perth, 2009.
1. World Health Organization. Preventing chronic
diseases: a vital investment: WHO global report.
Geneva: World Health Organization, 2005.
2. World Health Organization. Global NCD Network: a
new network to combat noncommunicable diseases:
Conceptual Framework. Geneva: WHO, 2009.
3. Prakongsai P, Bundhamcharoen K, Tisayatikom K,
Tangcharoensathien V. Financing health promotion
in South East Asia- does it match with current and
future challenges? Nonthaburi: International Health
Policy Program (IHPP), 2008.
4. Tangcharoensathien V, Prakongsai P, Limwattananon
S, Buasai S. Innovative financing of health promotion.
International Encyclopedia of Public Health. 2008;
3: 624-638.
5. Vathesatogkit P, Tan YL, Ritthipakdee B. Vathesatogkit P,
Tan YL, Ritthipakdee B. Lessons learned in establishing
a health promotion fund. Bangkok: Southeast Asia
Tobacco Control Alliance (SEATCA), 2011.
6. B u n d h a m c h a r o e n K , O d t o n P, P h u l ke r d S,
Tangcharoensathien V. Burden of disease in Thailand:
changes in health gap between 1999 and 2004.
Nonthaburi: International Health Policy Program
(IHPP), 2005.
7. Phoolcharoen W, Ungchusak K, Sittitrai W, Brown T.
Thailand: lessons from a strong national response to
HIV/AIDS. AIDS. 1998; 12: S123–135.
8. Siwaraksa P. The birth of ThaiHealth fund. Bangkok:
Thai Health Promotion Foundation, 2002.
9. Thai Health Promotion Foundation. Health Promotion
Foundation Act, B.E. 2544 (2001). Bangkok, 2001.
10. Thai Health Promotion Foundation. The annual
report 2001-2010. Bangkok: Thai Health Promotion
Foundation, 2001
11. Thai Health Promotion Foundation. The 10 year
direction, goal and strategy of Thai Health Promotion
Foundation (2012- 2021). Bangkok: Thai Health
Promotion Foundation, 2011.
12. Wasi P. “Triangle that moves the mountain” and
health systems reform movement in Thailand. Human
Resources for Health Development Journal. 2000;
4(2):106-10.
WHO South-East Asia Journal of Public Health 2012;1(2):201-207
Book 1.indb 207
15. Caroll A, Wood L, Tantives S. Many things to many
people: a review of ThaiHealth. Bangkok: World
Health Organization and Thai Health Promotion
Foundation, 2007.
16. Pitayarungsarit S, Iam-anan P. Summary of the
tobacco control situation (in Thailand), 2011. Tobacco
Control Research and Knowledge Management
Center, Bangkok, 2011.
17. World Health Organization. Adult per capita
consumption of alcohol. Geneva: WHO, 2005.
18. Adulyanon S. Alcohol policy in Thailand. The Globe.
2007; 1&2: 19.
19. The National Health Examination Survey Office.
The report of the 4th Health Examination Survey,
2008-2009. Nonthaburi: Health System Research
Institute, 2010.
20. Office of the National Economic and Social
Development Board. The annual survey of National
Account Department. Office of the National Economic
and Social Development Board, 2008-2010.
21. National Center of Road Safety. The annual report
of road safety in Thailand. Bangkok: Department of
Disaster Prevention and Mitigation, 2010.
22. National Statistics Office. The report of the survey of
physical activity behavior in Thai population, 2007.
Bangkok: National Statistics Office, 2008.
23. Terawattananon Y, Leerahawarong P, Tavornchareonsupt M, Praditsittikorn N, Kumpang R,
Rattanawipapong W, et al. Initial report of the
evaluation of willingness to pay of households for
health promotion measures of Thai Health Promotion
Foundation. Nonthaburi: Ministry of Public Health,
2011.
24. International Network of Health Promotion Foundation.
http://www.hpfoundations.net/ - accessed 1 May
2012.
207
05-Jun-2012 2:36:02 PM
Review
Nipah virus outbreaks in Bangladesh: a deadly
infectious disease
Mahmudur Rahmana, Apurba Chakrabortya
Abstract: During 2001-2011, multidisciplinary teams from the Institute of Epidemiology,
Disease Control and Research (IEDCR) and International Centre for Diarrhoeal Disease Research,
Bangladesh(icddr,b) identified sporadic cases and 11 outbreaks of Nipah encephalitis. Three
outbreaks were detected through sentinel surveillance; others were identified through event-based
surveillance. A total of 196 cases of Nipah encephalitis, in outbreaks, clusters and as isolated cases
were detected from 20 districts of Bangladesh; out of them 150 (77%) cases died. Drinking raw
date palm sap and contact with a case were identified as the major risk factors for acquiring the
disease. Combination of surveillance systems and multidisciplinary outbreak investigations can be
an effective strategy not only for detection of emerging infectious diseases but also for identification
of novel characteristics and risk factors for these diseases in resource- poor settings.
Keywords: Nipah virus, outbreak, surveillance, transmission, communicable disease,
Bangladesh.
Introduction
Nipah is a recently detected viral zoonotic
disease caused by Nipah virus originating from
a new genus - the Henipa virus.1, 2 Pteropus
bats are the zoonotic host of the virus and
pigs are the likely amplifying host.2, 3 The
virus was first identified in Nipah village of
Malaysia in 1998,2, 4 since then three other
countries have reported human cases of Nipah
virus infection, including Bangladesh.5-7 The
Institute of Epidemiology, Disease Control and
Research (IEDCR), a government mandated
institute, conducted disease surveillance and
outbreak investigations for Nipah encephalitis
in Bangladesh. We present a review of the
methods used for detecting these cases and
their novel characteristics and risk factors
through outbreak investigations during 20012011.
Methods
We reviewed IEDCR strategies and guidelines
from its records to explore the mechanism for
detection of Nipah cases and clusters. We also
reviewed the method of hospital-based Nipah
surveillance jointly conducted by IEDCR and
the International Centre for Diarrhoeal Disease
Research, Bangladesh (icddr,b). Outbreak
investigation reports were studied to identify
the sources of information through which
these outbreaks were detected. The Nipah
surveillance database was used to describe
the demographic and clinical characteristics of
the identified Nipah cases. Published reports
Institute of Epidemiology, Disease Control and Research, Mohakhali, Dhaka-1212, Bangladesh.
Correspondence to Mahmudur Rahman (email: director@iedcr.org)
a
208
Book 1.indb 208
WHO South-East Asia Journal of Public Health 2012;1(2):208-212
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Mahmudur Rahman et al.
on Nipah encephalitis in Bangladesh and
unpublished outbreak investigation reports
were reviewed to identify the risk factors for
Nipah encephalitis in Bangladesh.
Results
To detect disease outbreaks, IEDCR conducts
both ‘event-based surveillance’ and ‘surveillance
for specific disease or conditions’. Up to April
2010, as part of the event-based surveillance,
IEDCR conducted unstructured monitoring of
newspapers and television channels for reports
of suspected disease outbreaks. In April 2010,
IEDCR started a more structured surveillance
of suspected disease outbreak reports in
10 national newspapers and eight national
television channels. Any reported cluster or
outbreak of known illness and even report
of a single death from unknown disease is
captured through this surveillance method. In
addition to the media surveillance, IEDCR has
two hotline numbers for healthcare providers
to report disease outbreaks. Through district
and sub-district rapid response teams, IEDCR
verifies the existence of any outbreak and
conducts investigation.
To identify outbreaks of encephalitis
through enhanced surveillance networks and
to identify risk factors for transmission of
Nipah encephalitis, IEDCR in collaboration
with the International Centre for Diarrhoeal
Disease Research, Bangladesh (icddr,b)
has been conducting surveillance for Nipah
encephalitis in Bangladesh since 2006.
Initially, this surveillance programme started
in 10 hospitals. Currently, the surveillance is
functioning in five hospitals in northwestern
and central Bangladesh. Clinicians of sentinel
hospitals identify and list all encephalitis cases
presenting in the surveillance hospitals. A
case of encephalitis is defined as any person
with history of acute onset of fever or axillary
temperature of >38.50C and evidence of acute
WHO South-East Asia Journal of Public Health 2012;1(2):208-212
Book 1.indb 209
Nipah virus outbreaks in Bangladesh
brain pathology manifested by altered mental
status or new onset of seizure or neurological
deficit. Any cluster of encephalitis cases,
defined by two encephalitis cases within 21
days of each other and within half an hour
walking distance from each other, identified
through the sentinel hospitals are investigated
by a trained team of epidemiologists from
IEDCR and icddr,b.
As part of the cluster investigation the
IEDCR and icddr,b team conducts search for
encephalitis cases in the community adjacent
to the cluster and carries out epidemiological
research to identify risk factors. In case of
outbreaks of encephalitis that are detected
through event-based surveillance or sentinel
surveillance, a team of epidemiologists,
veterinarians and anthropologists conduct
outbreak investigations. These investigations
include identification of alive or deceased
human cases suspected of having Nipah
encepahlitis, identification of possible animal
sources of the infection, assessment of
environmental contamination, and study of
possible behavioural factors contributing to
the outbreak and case control study to identify
possible risk factors. For each case of Nipah
encephalitis, four age-matched neighbourhood
controls are selected for case control study.
Exposure histories of both cases and controls
within 30 days prior to the onset of illness are
collected.
In case of any encephalitis cluster or
outbreak, investigation teams collect blood
from the suspected encephalitis cases and
samples are sent to IEDCR. Initially, samples
were sent to Centers for Disease Control
and Prevention, USA (CDC) for testing. Later
in 2007, a Nipah laboratory was set up at
IEDCR for safe specimen handling and testing.
Virologists of IEDCR conduct enzyme-linked
immunosorbent assay to identify IgM and IgG
antibodies against Nipah virus.
209
05-Jun-2012 2:36:02 PM
Nipah virus outbreaks in Bangladesh
Mahmudur Rahman et al.
days). In the course of illness, 123 (63%)
Nipah encephalitis cases developed acute
respiratory distress syndrome (Table 1).
In Bangladesh, Nipah outbreak was first
confirmed in 2003, when a team from Centers
for Disease Control and Prevention, Atlanta,
USA (CDC), icddr,b and the Government of
Bangladesh retrospectively investigated two
outbreaks of suspected encephalitis with human
deaths which had occurred in Meherpur district
in 2001 and in Naogaon in 2003.7 Including
these two, 11 outbreaks of Nipah encephalitis
have been detected in Bangladesh since
2001. Five of these outbreaks were detected
from newspaper reports of human deaths
from unknown illness, three were reported
by sentinel hospitals, one was reported from
a private hospital and others were reported
by the civil surgeon of a district. During this
period, 196 cases of Nipah encephalitis were
detected from 20 districts of Bangladesh in
outbreaks, clusters and as isolated cases; out
of these 150 (77%) cases died.
Drinking raw date palm sap collected during
winter months, which is a delicacy in rural
Bangladesh, was first identified as a risk factor
for Nipah infection in an outbreak in Tangail in
2005.8 This has also been identified as a risk
factor in three more outbreaks so far. Several
sporadic cases have also reported history of
drinking raw date palm sap within 30 days
before the onset of illness. Close contacts with
a sick person or his/her secretions and contact
with sick animals were the other two risk
factors identified through case control studies
in different outbreak investigations (Table 2).
The Nipah cases were mostly distributed
in the northwestern and central part of
Bangladesh. Outbreaks occurred during
December to May, which coincides with the
winter season in Bangladesh. Cases were
distributed in all age groups. Median age was
25 years (range: 0.5-75 years) and 124 (63%)
cases were males. Median duration from onset
of illness to death was six days (range: 1-47
Discussion
Pteropus bats were found to be positive
for Nipah antibodies in different outbreak
areas.7 A zoonotic investigation team of icddr,b
identified the way bats contaminate the shaved
surface of the date palm trees (from where the
sap is collected) using infrared camera.9
A combination of an ‘event-based’ and
‘sentinel’ surveillance system has been
a successful strategy in Bangladesh for
detecting recurrent outbreaks of Nipah
Table 1: Clinical characteristics of Nipah cases in Bangladesh
Clinical characteristic
Fever
196 (100)
Altered mental status
169 (86)
Sever weakness/lethargy
142 (72)
Headache
131 (67)
Acute respiratory distress syndrome
123 (63)
Cough
108 (55)
Vomiting
105 (54)
Myalgia
81 (41)
Convulsions
59 (30)
210
Book 1.indb 210
Number (%)
WHO South-East Asia Journal of Public Health 2012;1(2):208-212
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Mahmudur Rahman et al.
Nipah virus outbreaks in Bangladesh
Table 2: Risk factors identified through case control studies in
Nipah outbreaks of Bangladesh
Odds
Ratio
District
Risk factors
2001
Meherpur
Contact with a sick cow7
7.9
2.2 - 27.7
-
Caring or living with a case7
4.8
1.23 - 18.8
-
6.1
1.3 - 27.8
0.007
8.2
21.4
1.25 - ∞
2.78 - 966.1
-
2003
Naogaon
Close proximity with pig herds10
2004
Rajbari
Climbing trees
Contact with Nipah patient13
2004
Faridpur
Touching a Nipah patient14
5.6
1.79 - 17.24
0.003
2005
Tangail
Drinking raw date palm juice8
7.9
1.6 - 38
<0.01
2007
Thakurgaon
Remaining in the same room with
Nipah patient16
Undefined
-
<0.001
2007
Kushtia
Physical contact with a Nipah
patient15
Undefined
-
<0.001
2008
Manikganj and Drinking raw date palm juice
Rajbari
18
2.2 - ∞
<0.005
2010
Faridpur
Drinking raw date palm juice
-
-
-
2011
Lalmonirhat
Drinking raw date palm juice
17
4 - 70
≤0.001
13
encephalitis. Multidisciplinary collaborative
investigation of the outbreaks identified the
clinical characteristics, risk factors and mode
of transmission of this highly fatal zoonotic
disease.
Over 50 species of Pteropus bats, the
natural reservoir of Nipah virus, live in South
and South-East Asian countries. 10 After
the large outbreak of Nipah encephalitis
in Malaysia, only three outbreaks have
been reported from countries other than
Bangladesh, one in Singapore and two
in India. 5, 6 Therefore, it is important to
know whether specific environmental or
host factors are responsible for recurrent
transmission of Nipah virus to humans in
Bangladesh or whether virus detections are
the result of an efficient surveillance system.
Although Bangladesh, like many other lowincome countries, lacks an integrated disease
surveillance system, the combination of event-
WHO South-East Asia Journal of Public Health 2012;1(2):208-212
Book 1.indb 211
95%
Confidence
Interval
p
Year
based surveillance system with a sentinel
surveillance system for encephalitis has
possibly increased the likelihood of identifying
Nipah cases in Bangladesh in comparison to
some other countries in the region, which lack
a strong surveillance for encephalitis.
While more than 95% of the Nipah cases in
Malaysia had a history of contact with pigs,11
in only one of the 11 Bangladeshi outbreaks a
close proximity to pig herds was identified as
a risk factor. Identification of the drinking of
raw date palm sap, a unique cultural practice
in rural Bangladesh12 and possibly in the
neighbouring Indian states, as a risk factor for
acquiring Nipah infection in Bangladesh and the
validation of the plausibility of contamination
of date palm sap with Nipah virus from
Pteropus bats through separate zoonotic
investigation highlights the importance of a
multidisciplinary approach in investigating
outbreaks of zoonotic diseases.9
211
05-Jun-2012 2:36:03 PM
Nipah virus outbreaks in Bangladesh
Nipah outbreaks in Bangladesh have
presented some features distinctly different
than the outbreak in Malaysia. In Bangladesh,
a higher proportion of Nipah cases suffered
from respiratory symptoms than in Malaysia.4
Also, the case fatality ratio was higher in
Bangladesh, which may be related to the lack
of access of Bangladeshi cases to intensive
care facilities.4 Like in other diseases caused
by paramyxoviruses, such as measles,
mumps, respiratory syncytial virus infection,
parainfluenza, person-to-person transmission
was a common mode of transmission in
Bangladeshi Nipah cases, but this mode
of transmission was not common in Nipah
encephalitis cases in Malaysia. Therefore,
future investigations should focus on exploring
the reasons for variable presentation and
different modes of transmission of Nipah virus
in different settings.
To conclude, Nipah encephalitis, a fatal
zoonotic disease, recurrently claims lives in
Bangladesh following the initial reports of
outbreaks in other countries. A combination of
event-based and sentinel surveillance systems
is an innovative strategy to detect encephalitis
outbreaks which has been successful in
detecting Nipah outbreaks in Bangladesh.
Multidisciplinary outbreak investigations
can be an important tool in exploring novel
characteristics and risk factors of emerging
infectious zoonotic diseases in resource-poor
settings.
References
1. Chua KB. Nipah virus outbreak in Malaysia. J Clin
Virol. 2003;26:265-75.
2. Chua KB, Bellini WJ, Rota PA, et al. Nipah virus: a
recently emergent deadly paramyxovirus. Science.
2000;288:1432-5.
3. Epstein JH, Field HE, Luby S, Pulliam JR and Daszak
P. Nipah virus: impact, origins, and causes of
emergence. Curr Infect Dis Rep. 2006;8:59-65.
212
Book 1.indb 212
Mahmudur Rahman et al.
4. Goh KJ, Tan CT, Chew NK, et al. Clinical features
of Nipah virus encephalitis among pig farmers in
Malaysia. N Engl J Med. 2000;342:1229-35.
5. Paton NI, Leo YS, Zaki SR, et al. Outbreak of Nipahvirus infection among abattoir workers in Singapore.
Lancet. 1999;354:1253-6.
6. Harit AK, Ichhpujani RL, Gupta S, et al. Nipah/Hendra
virus outbreak in Siliguri, West Bengal, India in 2001.
Indian J Med Res. 2006;123:553-60.
7. Hsu VP, Hossain MJ, Parashar UD, et al. Nipah virus
encephalitis reemergence, Bangladesh. Emerg Infect
Dis. 2004;10:2082-7.
8. Luby SP, Rahman M, Hossain MJ, et al. Foodborne
transmission of Nipah virus, Bangladesh. Emerg
Infect Dis. 2006;12:1888-94.
9. Khan MS, Hossain J, Gurley ES, Nahar N, Sultana R
and Luby SP. Use of infrared camera to understand
bats’ access to date palm sap: implications for
preventing Nipah virus transmission. Ecohealth.
2010;7:517-25.
10. Luby SP, Gurley ES and Hossain MJ. Transmission
of human infection with Nipah virus. Clin Infect Dis.
2009;49:1743-8.
11. Parashar UD, Sunn LM, Ong F, et al. Case-control
study of risk factors for human infection with a new
zoonotic paramyxovirus, Nipah virus, during a 19981999 outbreak of severe encephalitis in Malaysia. J
Infect Dis. 2000;181:1755-9.
12. Rahman MA, Hossain MJ, Sultana S, et al. Date Palm
Sap Linked to Nipah Virus Outbreak in Bangladesh,
2008. Vector Borne Zoonotic Dis. 2012;12(1):6572.
13. Montgomery JM, Hossain MJ, Gurley E, et al. Risk
factors for Nipah virus encephalitis in Bangladesh.
Emerg Infect Dis. 2008;14:1526-32.
14. Gurley ES, Montgomery JM, Hossain MJ, et al. Personto-person transmission of Nipah virus in a Bangladeshi
community. Emerg Infect Dis. 2007;13:1031-7.
15. Homaira N, Rahman M, Hossain MJ, et al. Cluster of
Nipah virus infection, Kushtia District, Bangladesh,
2007. PLoS One. 2010;5:e13570.
16. Homaira N, Rahman M, Hossain MJ, et al. Nipah
virus outbreak with person-to-person transmission
in a district of Bangladesh, 2007. Epidemiol Infect;
138:1630-6.
WHO South-East Asia Journal of Public Health 2012;1(2):208-212
05-Jun-2012 2:36:03 PM
Report from the field
Early detection of chronic diseases and their risk
factors: a women empowerment model from Kerala,
India
Safraj Shahul Hameeda
Identification of risk factors through screening is an important tool in the fight against chronic
diseases. We have used a unique model, named Saantwanam (to console) in Malayalam language,
for health screening in Kerala, India.
Under the Saantwanam programme, government selects suitable women care-givers who are
trained and equipped by a nongovernmental organization through loans from a public sector bank.
After training, care-givers deliver screening services by measuring the weight and height, and
blood pressure, glucose and cholesterol levels of people concerned in their local communities at
a reasonable fee-for-service that provides a source of income to them. All care-givers are trained
to counsel on healthy living, i.e. appropriate diet, exercise and unhealthy habits such as tobacco
consumption. When cases are detected they are referred to local physicians and later on followed
up by care-givers at their residence.
In the last five years, the Saantwanam programme has screened more than 300 000 people for
various diseases and risk factors. They have been counselled to avail of health-care services. The
Saantwanam model does not cause additional expenditure to the government for early detection of
chronic diseases and their risk factors. Moreover, it ensures that the care-givers are rewarded for
their effort. However, before large-scale implementation of this model, measurement of baseline
risk factors in a sample population should be done so that their impact can be measured at a later
date. The cost-effectiveness of the model also needs to be determined.
Key words: Health, screening, chronic diseases, empowerment, women, India.
Introduction
Recent studies report that chronic diseases
have displaced communicable diseases as
the leading cause of death and disability
in India.1, 2 Chronic diseases are estimated
to have caused a cumulative loss of 16.68
billion rupees to the Indian Gross Domestic
Product (GDP) between 2005 and 2016.3 Large
financial costs pose significant difficulties for
assessment of the prevalence, and provision
of treatment services for chronic diseases
in a large developing country like India.
Identification of risk factors through screening
is an important tool in the fight against chronic
diseases.
Health Action by People, 7/1724, Temple Road, Kochulloor, Trivandrum, Kerala 695011, India.
Correspondence to Safraj Shahul Hameed (email: Safraj@gmail.com)
a
WHO South-East Asia Journal of Public Health 2012;1(2):213-219
Book 1.indb 213
213
05-Jun-2012 2:36:03 PM
Early detection of chronic diseases and their risk factors
Among the Indian states, Kerala is at the
most advanced stage of an epidemiologic
transition that has brought about a dramatic
change in the disease profile. Kerala, with a
population of over 31 million in 2000 has the
longest life expectancy and the lowest infant
mortality rate in India.4, 5 The Kerala model of
development, characterized by a high level
of human development and a low level of
economic growth, has been much discussed
in academic circles, most notably by Amartya
Sen.6, 7
Now lifestyle diseases are the major cause
of death in Kerala. The burden of deaths from
cardiovascular diseases now exceeds that of
industrialized countries.8 However, necessary
reorientation of a public health strategy that
focuses on chronic diseases has not yet taken
place. This has resulted in high prevalence
of many chronic diseases and risk factors in
Kerala.9-11 Therefore, a unique public-private
partnership model of health screening,
which relies on entrepreneurship, has been
developed in Kerala.
Saantwanam, a home-based
health screening programme
Saantwanam means ”console” in Malayalam,
the local language in Kerala. Saantwanam was
conceived by Health Action by People (HAP),
a nongovernmental organization (NGO) based
in Kerala, which is devoted to public health
research.12 The Saantwanam programme is
run in partnership with the State Bank of India,
the largest public sector bank in India, and
Kudumbashree, the poverty alleviation wing
of Kerala government.13
The aims of the Saantwanam programme
are to: (1) identify adults with one or more risk
factors for chronic diseases and refer them to
physicians for advice; (2) help patients with
risk factors or disease to monitor their condition
regularly, and help reduce complications;
214
Book 1.indb 214
Safraj Shahul Hameed
and (3) provide health education to people.
These aims are achieved through creation
of a network of “home care-givers” – young
educated women, who are trained in the
science of health screening. Trained “home
care-givers” reach out to every home in
their locality where individuals are screened
for the presence of major risk factors and
diseases. Those who have risk factors or are
already suffering from diseases and are under
treatment are monitored regularly to assess
the progress of treatment. These services are
provided for a fee at an affordable cost. Thus
a member of the Saantwanam programme or
“care-givers” involved in household screening
and monitoring earns a decent income by
providing the envisaged services.
Kudumbashree, a government of Kerala
enterprise, is entrusted with the task of
identifying and selecting deserving candidates
from among the eligible population using the
following eligibility criteria. The “care-giver”
candidate shall (i) ideally belong to a belowpoverty line family; (ii) be nominated by the
”local self government” and Kudumbashree;
(iii) have a minimum of high school education;
(iv) have a valid two-wheeler driving licence or
would obtain one after completing the training;
and (v) undergo a one-week residential
training in health-screening methods.
A five-day training programme for selected
candidates is organized by HAP. The training
provided by epidemiologists and physicians
consists of theory and practice sessions.
Screening methods and common disease
conditions in Kerala are taught during
the theory sessions. Practical training on
measurement techniques and safe handling
and disposal of waste are also provided.
A certificate of successful completion of
training is provided along with an instruction
booklet.
WHO South-East Asia Journal of Public Health 2012;1(2):213-219
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Safraj Shahul Hameed
After completing the training the care-givers
who possess a two-wheeler driving licence
are provided assistance by Kudumbashree
to obtain bank loans and other financial
subsidies. On receipt of application, the State
Bank of India provides collateral-free loans up
to Indian rupees 50 000 (US$1250). Once the
necessary financial assistance is secured the
amount is used for obtaining the necessary
equipment (see Box 1).
The success of the programme depends on
access to the services. Mobility and outreach are
ensured through the provision of a motor bike/
scooter and a mobile telephone. All equipment
used in the Saantwanam programme conforms
to the standards recommended by the World
Health Organization.
Methods
The care-givers of the Saantwanam
programme, at the household level, measure
and take readings for height, weight, body
mass index (BMI), body fat, blood pressure,
blood glucose, cholesterol, triglycerides, urine
sugar and albumin. All measurements are
carried out using standardized methods for
which care-givers are trained. The equipment
is also standardized and calibrated periodically.
Early detection of chronic diseases and their risk factors
Height is measured using a custom-built
anthropometric rod that can be easily carried
by the care-giver. The subjects are asked
to stand close to the wall and their height
measured using the adjustable anthropometric
rod. The BMI is calculated from the height and
the weight measurements using a calibrated
electronic weighing machine. The blood
pressure is measured after making the subject
sit down, and the procedure is carried out in a
standardized manner that is explained to caregivers during their initial training. Random
capillary-blood-glucose level is measured
using the standardized glucometer and a
repeat test is advised for those showing high
values. All subjects with higher-than-normal
values are advised to consult physicians of
their choice in public or private sector. All initial
tests including lipid measurements are done
at random; subsequent tests, if required, are
carried out after fasting. Sterilized, disposable
needles and swabs are used for finger-prick
blood collection. Care-givers provide the test
results in a standardized form with indicated
healthy ranges.
Care-givers are required to visit the
households in their area at least once a month.
All data collected by care-givers are transferred
Box 1: Equipment used by Saantwanam care-givers in Kerala, India
Abbott optium sensor glucometer
Omron digital blood pressure monitor
Roche Accutrend GCT machines for cholesterol and triglycerides
Omron body fat monitor
Tanita weighing balance
Anthropometric rod
Electronic calculator
Nokia mobile telephone
Glucose strips, swabs and lancets
Two-wheeler (motorcycle or scooter)
WHO South-East Asia Journal of Public Health 2012;1(2):213-219
Book 1.indb 215
215
05-Jun-2012 2:36:03 PM
Early detection of chronic diseases and their risk factors
to HAP where they are stored and analysed.
Care-givers also have telephonic access to
physicians involved with the programme. Any
doubts and concerns that the subjects might
have during the screening are addressed by
connecting the patient to the physician over
the mobile phone. As mobile phones are part
of a corporate user group, the care-givers do
not incur any expenses for calls within the
network.
The cost of equipment and training material
is estimated at US$ 1250 per care-giver. The
equipment is purchased and distributed
by HAP directly from the manufacturers.
The equipment is also warranted by the
manufacturer. The breakdown time is limited
to one working day since HAP provides
replacements. All consumables are bought
by HAP directly from the manufacturers.
These are provided to care-givers at prices
significantly lower than the prevailing market
price. The consumables are couriered to caregivers within a day of receiving the order.
After completing six months the caregivers
are required to pay a fee of US$ 12.50 per
Safraj Shahul Hameed
month to HAP for covering the administrative
costs. Caregivers charge a reasonable fee for
service, which is a source of some revenue
for them. At the same time, this model makes
the services affordable to the public. The
fees charged for services by care-givers is
presented in Table 1.
Results
The project was launched on 8 October 2005.
Out of the 561 participants who attended a
series of 13 training programmes conducted till
May 2008, 239 were inducted as Saantwanam
care-givers. Fifty-nine care-givers have since
discontinued. The Saantwanam programme
currently covers both urban and rural areas
in all districts of Kerala. More than 300 000
people have been screened so far for diabetes,
hypertension and hyper cholesterolemia as
part of the programme. If family members
are also included more than one million adults
have been exposed to individual-level health
education provided by the care-givers since
the start of the programme. The number of
tests done and the revenue generated as
Table 1: Fees charged by Saantwanam care-givers for their
services in Kerala, India
Measurements
Fee (US currency)*
Blood glucose
62 cents
Blood pressure
25 cents
Body mass index
25 cents
Serum cholesterol
1.5 dollars
Triglycerides
1.5 dollar
Urine sugar and albumin
13 cents
*One US$ = 40 Indian rupees
216
Book 1.indb 216
WHO South-East Asia Journal of Public Health 2012;1(2):213-219
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Safraj Shahul Hameed
Early detection of chronic diseases and their risk factors
part of the programme is shown in Table 2.
About 50 000 new cases of diabetes were
detected and referred to local physicians. It
is important that the quality of diagnosis and
care provided by care-givers is monitored
regularly. Five supervisors conduct spot
checks and households are also contacted to
provide feedback on programmes. Moreover,
regular re-training programmes are conducted
to ensure that care-givers’ knowledge and
skills remain current and relevant.
followed up in the community by care-givers
and their routine blood tests are carried out at
their residence. The care-givers being part of
local women’s self-help groups regularly meet
with the local government officials to discuss
health-related issues in the community. As
a result of these discussions, screenings
of people in marginalized communities
undertaken by care-givers, are now subsidized
by the panchayat - an elected body of
local self-governance. The project is now
considered by local governments as part of
the health system, thus, ensuring long-term
sustainability.
Discussion
Community participation is the hallmark
of the Saantwanam programme right from
the selection of care-givers. The training
component is supported by the government
of Kerala. Care-givers are then deployed in
their own communities. All care-givers are
trained to provide counselling on healthy living
that includes appropriate diet and exercise
as well as unhealthy habits including tobacco
consumption. When cases are detected they
are referred to local physicians. Patients
diagnosed with hypertension/diabetes are
Community-based health programmes
have been shown to increase awareness,
help identify patients at high risk, as well as
community-based interventions, and increase
adherence to chronic disease screening. A
large-scale multipronged diabetes awareness
programme provided through community
involvement as part of the Prevention
Awareness Counselling and Evaluation
(PACE) project in Chennai, reported that such
programmes are effective in heightening the
Table 2: Number of tests performed and sales revenue generated by
Saantwanam care-givers from 2005-2011 in Kerala, India
Measurement
Blood glucose
Number of tests*
Sales revenue
(US dollars)**
332400
207750
30500
45750
Blood pressure
500000
125000
Body mass index (BMI)
300000
50000
Cholesterol
*Blood glucose and cholesterol measurements calculated from the number of glucose and cholesterol strips bought
by care-givers and blood pressure and BMI based on the data provided by care-givers
** Sale revenue refers to the fee-for-service received by care-givers.
WHO South-East Asia Journal of Public Health 2012;1(2):213-219
Book 1.indb 217
217
05-Jun-2012 2:36:03 PM
Early detection of chronic diseases and their risk factors
awareness among many different segments
of the population.14 A study from the United
States of America reported that communitybased screening can be used as a method for
identifying the high percentage of patients
at risk for diabetes or with undiagnosed
diabetes in an inner-city immigrant/mixedethnic population. 15 The Bootheel Heart
Health Project reported that even with modest
resources, community-based interventions
show promise in reducing self-reported risk
for cardiovascular disease within a relatively
brief period. 16 A qualitative study done
on why community health workers called
“promotoras” increased adherence to chronic
disease screening among women along the
United States-Mexico border, reported that
community health workers can play a crucial
role in the health care team, and that both
clients and clinicians recommended working
with them to increase adherence to chronic
disease screening.17
The Saantwanam programme holds
opportunity for scaling up and there is scope
for further improvement. Health education
using books, pamphlets, posters and video
are planned for the coming year. However,
before any large-scale implementation,
the baseline risk factors in the population
should be measured so that their impact
can be assessed at a later date. One of the
limitations of this project is that we did not
have the baseline data on risk factors. The
selection of suitable candidates is important
for the success of the programme. Most caregivers who discontinued working, reported on
subsequent interviews that they were not clear
about the type of work involved. The nature of
the work involved should be explained clearly
at the time of selection. The use of portable
electronic equipment instead of paper forms
could facilitate the capture and storage of
patient data by making the process easier
and safer.
218
Book 1.indb 218
Safraj Shahul Hameed
There is a definite potential to include
more diagnostic tests and services like first
aid, wound dressing and cancer screening,
etc. Incorporation of WHO Package of essential
noncommunicable disease interventions (WHOPEN) protocols in the training programmes
can help assess the risk of death from
cardiovascular diseases in 10 years.18 These
protocols have been developed taking into
consideration limitations in low-resource
settings where even referrals can be very
difficult and delayed due to lack of transport
and accessibility. Suitably trained caregivers might be able to prevent or manage
noncommunicable NCDs locally and at the
first-contact point with the patient.
Organizations and individuals in other parts
of the world can use this model with suitable
variations to provide health-screening services
and to generate employment for women. This
model involves no additional expenditure
to the government while at the same time
ensuring that the individuals involved are
rewarded for their effort.
References
1. Gupta R, Joshi P, Mohan V, Reddy KS, Yusuf S.
Epidemiology and causation of coronary heart disease
and stroke in India. Heart. 2008; 94: 16-26.
2. Joshi R, Cardona M, Iyengar S, et al. Chronic disease
now a leading cause of death in rural India: mortality
data form the Andhra Pradesh rural health initiative.
Int J Epidemiol. 2006; 35: 1522-9.
3. Abegunde DO, Mathers CD, Adam T, Ortegon M,
Strong K. The burden and costs of chronic diseases
in low income and middle income countries. Lancet.
2007; 370: 1929-38.
4. Registrar General of India. SRS analytical studies,
Report 1 of 2005. SRS based abridged life tables
1998-2002. New Delhi: Registrar General of India,
2005.
WHO South-East Asia Journal of Public Health 2012;1(2):213-219
05-Jun-2012 2:36:03 PM
Safraj Shahul Hameed
5. Registrar General of India. Sample registration
system 2006. http://www.censusindia.net - accessed
on 5 April 2008.
6. Dreze J, Sen A. India: economic development and
social opportunity. New Delhi: Oxford University
Press, 1995.
7. Sen A. Development as freedom. New Delhi: Oxford
University Press, 2000.
8. Soman CR, Kutty VR, Safraj S, Vijayakumar K,
Rajamohanan K, Ajayan K. All cause mortality and
cardiovascular mortality in Kerala state of India.
Results from a 5 year follow up of 161942 rural
community dwelling adults. Asia Pac J Public Health. 2011: 23:896-903.
9. Joseph A, Kutty VR, Soman CR. High risk for coronary
heart diseases in Thiruvanthapuram city: A study of
serum lipids and other risk factors. Indian Heart J.
2000;52(1);29-35.
10. Kutty VR, Soman CR, Joseph A, Pisahrody R,
Vijayakumar K. Type 2 diabetes in Southern Kerala;
variation I n Prevalence among geographic divisions
within a region. Natl Med J India. 2000: 13(6);
287-92.
11. Kutty VR, Soman CR, Joseph A, Kumar KV, Pisharody
R. Random capillary blood sugar and coronary risk
factors in a south Kerala population. J Cardiovasc
Risk. 2002: 9(6); 361-67.
12. Health action by people. www.hapindia.org - accessed
on 10 June 2008.
WHO South-East Asia Journal of Public Health 2012;1(2):213-219
Book 1.indb 219
Early detection of chronic diseases and their risk factors
13. Kudumbashree. www.Kudumbashree.org - accessed
on 10 June 2008.
14. Somannavar S, Lanthorn H, Deepa M, Pradeepa
R, Rema M, Mohan V. Increased awareness about
diabetes and its complications in a whole city:
effectiveness of the “prevention, awareness,
counselling and evaluation. [PACE] Diabetes Project
[PACE-6]. J Assoc Physicians India. 2008; 56; 497502.
15. Grant T, Soriano Y, Marantz PR, Nelson I, Williams
E, Ramirez D, et al. Community-based screening for
cardiovascular disease and diabetes using HbA1c.
American Journal of Preventive Medicine. 2004; 26:
271-275.
16. Brownson RC, Smith CA, Pratt M, Mack NE, JacksonThompson J, Dean CG, Dabney S, Wilkerson
JC. Preventing cardiovascular disease through
community-based risk reduction: the Bootheel Heart
Health Project. American Journal of Public Health.
1996: 86: 206-213.
17. Reinschmidt KM, Hunter JB, Fernández ML, Lacy
CR. Understanding the success of promotoras in
increasing chronic disease screening. Journal of
Health Care for the Poor and Underserved. 2006;
17: 256-264.
18. World Health Organization. Package of essential
noncommunicable (PEN) disease interventions
for primary health care in low resource settings.
Geneva: WHO, 2010. http://whqlibdoc.who.int/
publications/2010/9789241598996_eng.pdf accessed 22 February 2012
219
05-Jun-2012 2:36:03 PM
Commentary
Hospital or home? Scripting a high point in the history
of TB care and control
Mukund Uplekar & Mario Raviglionea
“A concurrent comparison of home and
sanatorium treatment of pulmonary
tuberculosis in South India” – popularly
referred to as the Madras Study, revolutionized
the public health approach to tackling TB.1
It “liberated” treatment of TB, which was
confined to sanatoria and hospitals, to health
centres and homes, making it available to
the masses who needed it most. The study is
unique in many respects. The 93-page long
article with an appendix of ten radiographs
of patients treated in the “home” series of
the study covered only two of the seven
key objectives! The study helped initiate a
lasting and what later proved to be a highly
productive collaboration among the Indian
Council of Medical Research (ICMR), the British
Medical Research Council (MRC) and the
World Health Organization (WHO). The MRC
seconded Dr Wallace Fox, who coordinated
the study, to WHO. The study engaged 100
staff – 40 from Madras government and 60
employed by the ICMR. Distinctively, it began
with setting up of a Centre specifically for the
study – Tuberculosis Chemotherapy Centre,
which successfully completed the study and
continued to exist thereafter, albeit with a
different name – the Tuberculosis Research
Centre, to produce some more landmark
studies especially chemotherapy trials, which
also informed subsequent global TB control
policies.
What prompted setting up this landmark
study? The provision of TB care at that
time was largely restricted to TB specialists
who managed their patients in specialized
hospital units and sanatoria. Hospitalization
also facilitated treatment supervision and
patient follow-up. The specialist physicians
often doubted the feasibility and effectiveness
of ambulatory treatment as it would not
guarantee treatment adherence, allow disease
transmission to the households and the
community, and potentially increase the risk
of development of drug-resistance. However,
providing hospitalized treatment to all the
TB patients was beyond the capacity of most
resource-poor countries which carried a high
burden of the disease. At the time of the study,
India had an estimated 1.5 million infectious
TB cases and only 23 000 TB beds in sanatoria
and hospitals. A majority of these facilities
were run by private entities and mainly served
the rich patients who could afford them.
Early anti-tuberculosis drugs producing good
results had arrived, and a policy decision
choosing between home-based treatment and
hospital-based treatment had to be taken.
Dr C. G. Pandit, the then Director of ICMR,
had emphasized “....in a country where for a
long time to come adequate facilities for the
isolation and treatment of the active case of
tuberculosis is not practicable, the importance
of providing adequate treatment in the
a
Stop TB Department, World Health Organization, Geneva, Switzerland
Correspondence to Mukund Uplekar (email: uplekarm@who.int)
220
Book 1.indb 220
WHO South-East Asia Journal of Public Health 2012;1(2):220-223
05-Jun-2012 2:36:03 PM
Mukund Uplekar et al.
patients’ homes cannot be overemphasized.
There is reason to believe that by a controlled
use of chemotherapeutic agents, it may be
possible to evolve a method of treatment
under home conditions which can break the
chain of person to person infection and render
an infectious person non-infectious. The study
has now been undertaken…”.2 And indeed
the study did transform forever, the way TB
was treated worldwide. Isn’t it an irony that
similar questions are being posed today for
the treatment of multidrug-resistant and
extensively drug-resistant TB?3
The study compared the effect of standard
TB treatment at that time – isoniazid (INH)
and para-amino salicylic acid (PAS) for a period
of 12 months – in two groups of patients in
a controlled clinical trial. One group was
treated under good conditions in a sanatorium
according to the existing standards and the
other under ordinary conditions at homes
of the patients. The sanatorium-treated
patients, despite prompt nursing care, good
accommodation, adequate bed rest, and
balanced diet, did not fare any better than
the patients treated in their own, overcrowded
homes, had limited rest and a poor diet.
Importantly, in spite of random allocation,
the home series had more severe disease
than the sanatorium series. It is worthwhile
mentioning some other momentous findings
of the study1
(1)quiescence of the disease at one year
and relapses in the subsequent four years
showed no differences between home and
sanatorium patients;4
(2)a five-year follow up of close family
contacts did not show any special risk for
contacts of patients treated in homes;5
(3)treatment in sanatorium was no safeguard
against irregularity of drug intake. A
significant unexpected finding was that
sanatorium treatment posed greater
WHO South-East Asia Journal of Public Health 2012;1(2):220-223
Book 1.indb 221
Home or hospital: a high point in history of TB
social problems such as difficulties in
making patients stay for a long period and
disruption of family life.
The interim findings of the study were
immediately reviewed in the seventh report
(1960) of the WHO expert committee on TB.
The committee noted that countries with
a large TB problem and limited resources
should use their scarce resources for setting
up programmes supporting domiciliary use
of anti-TB drugs rather than for construction
of hospitals. However, it was only after all
the results of the follow-up of patients were
available, that the WHO expert committee,
in its eighth report in 1964, recommended
unambiguously that “all financial resources
and manpower available for TB control in
developing countries be confined to organizing
efficient ambulatory services and not to
constructing new beds. TB beds, where they
already exist, should be integrated into the
ambulatory and domiciliary services so as to
ensure their most rational use”. The global
uptake of WHO recommendations was not
as swift as expected. Seven years later, Dr
Halfdan Mahler, pointed out in his article - the
tuberculosis programmes in the developing
countries - another public health classic, the
incorrect advice that developing countries
continued to receive “in recent months”,
including “it is bad public health practice
to treat a case of infectious tuberculosis at
home”.6 In fact, hospitalization of TB patients,
for the initial two months or longer remained
a common practice in most African countries
until recently. Probably because the study
was a demonstration in an Indian setting,
its findings were eventually taken up more
quickly in Asian countries. More recently,
a WHO-assisted multi-country project and
other studies have demonstrated feasibility,
effectiveness and cost-effectiveness of
community-based TB care in Africa.7,8
221
05-Jun-2012 2:36:03 PM
Home or hospital: a high point in history of TB
This truly remarkable study sowed the
seeds for the DOTS strategy launched by
WHO in the mid-1990s which reactivated the
dormant and disappearing TB programmes.
A critical demonstration of this study was
that although irregular drug intake was
significantly more among home-treated
patients, hospitalization was not a guarantee
for regular drug intake unless the patient
was actually seen swallowing every dose.
Without labelling it, the study prompted the
need for what became known as “directly
observed treatment (DOT)” decades later.
In fact, it was also Dr Wallace Fox who
first discussed in-depth the need for direct
observation of treatment in another article.9
Summarising the experiences in diverse nontuberculous conditions including rheumatic
fever, myxoedema, epilepsy and leprosy, he
observed that self-administration of drugs
presents problems in tuberculosis also, and
more importantly, “these problems are not
confined to ‘underdeveloped’ countries”.
In order to investigate the ideal form of
chemotherapy for the home treatment of
pulmonary TB, he pointed out the need
to “investigate regimens given daily or
intermittently under direct observation”. DOT
incorporating Dr Fox’s own words “direct
observation” thus became the central plank
of the five-point DOTS strategy that promoted
globally close supervision of treatment as a
means to ensure cure. Key components of
subsequent global TB control strategies have
been alluded by listing some of the essential
requirements of a domiciliary TB diagnosis
and treatment programme in the concluding
statement: “…..adequate supply of antituberculosis drugs, enough staff, including
a public health nurse and a social worker,
transport, a small number of hospital beds
for special cases, an efficient appointment
system, a system of surprise checks on the
cooperation of the patients in taking their
medicines, reliable smear examination of
222
Book 1.indb 222
Mukund Uplekar et al.
sputum for tubercle bacilli, and a welfare fund
for especially needy patients”.
The issue of community-based versus
hospital-based care has again come into sharp
focus in scaling up programmatic management
of drug-resistant TB (PMDT). Albeit based on
limited evidence yet, WHO guidelines on PMDT
suggest that community-based care provided
by trained lay and community health workers
can achieve comparable results and may help
in decreasing nosocomial spread of drugresistant disease.3,10,11 WHO now promotes
a comprehensive approach to TB care and
control: the Stop TB Strategy.12 This approach,
built on the DOTS strategy, emphasizes
patient-centred care. It recommends that
patient supervision should be humane and
integrate personal support and counselling.
The Stop TB Strategy also underscores the
importance of community engagement in
TB care.13 This is a call to communities to
contribute to their own health in the spirit of
the Alma-Ata Declaration of Health for All. It
supports patient participation in communitybased and home-based care schemes. The
rights-based approach guarantees costeffective access to care while safeguarding
patients in their own community.14 This policy
recommendation would not have been possible
without a clear demonstration that ambulatory
care is as safe and effective as the hospitalbased care.
In conclusion, the Madras study1 is among
the most influential in the history of TB
care and control. Together with subsequent
chemotherapy trials, also conducted at the
then Tuberculosis Chemotherapy Centre, it
proved that modern chemotherapy regimens
cured virtually all TB cases. Those who still
doubt domiciliary treatment of multidrug
resistant TB will likely be contradicted by
the evidence that is now accumulating. The
Madras study will always inspire and inform
WHO South-East Asia Journal of Public Health 2012;1(2):220-223
05-Jun-2012 2:36:03 PM
Mukund Uplekar et al.
policies that advocate reaching patients where
they are and caring for them.
References
1. Tuberculosis Chemotherapy Centre, Madras. A
concurrent comparison of home and sanatorium
treatment of pulmonary tuberculosis in South India.
Bull World Health Organ. 1959; 21(1): 51-144.
2. Pandit CG. Research in tuberculosis in India. Ind J
Tub. 1956; 4(1): 3-6.
3. World Health Organization. Guidelines for the
programmatic management of drug-resistant
tuberculosis. Geneva: WHO, 2008.
4. Dawson JJY. A five-year study of patients with
pulmonary tuberculosis in a concurrent comparison
of home and sanatorium treatment for one year with
isoniazid plus PAS. Bull World Health Organ. 1966;
34: 533-551.
5. Andrews RH. Prevalence of tuberculosis among close
family contacts of tuberculosis patients in South
India, and influence of segregation of the patient
on the early attack rate. Bull World Health Organ.
1960; 23: 463-510.
6. Mahler H. The tuberculosis programme in the
developing countries. Bull Int Union Tuberc. 1966;
37: 77-82.
Home or hospital: a high point in history of TB
8. Floyd K, Wilkinson D, Gilks CF. Comparison of cost
effectiveness of directly observed treatment (DOT)
and conventionally delivered treatment for TB:
experience from rural South Africa. British Medical
Journal. 1997; 315: 1407-1411.
9. Wallace Fox. The problem of self-administration
of drugs; with particular reference to pulmonary
tuberculosis. Tubercle. 1958; 39: 269-274.
10. Mitnick C, Bayona J, Palacios E, Shin S, Furin J,
Alcántara F, et al. Community-based therapy for
multidrug-resistant tuberculosis in Lima, Peru. NEJM.
2003; 348(2): 119–128.
11. Heller T, Lessells RJ, Wallrauch CG, Bärnighausen
T, Cooke GS, Mhlongo L, et al. Community-based
treatment for multidrug-resistant tuberculosis in rural
KwaZulu-Natal, South Africa. Int J Tuberc Lung Dis.
2010; 14(4): 420-6.
12. Raviglione MC and Uplekar MW. WHO’s new Stop TB
Strategy. The Lancet. 2006; 367: 952-55.
13. Getahun H, Raviglione M. Transforming the global
tuberculosis response through effective engagement
of civil society organizations: the role of the World
Health Organization. Bull World Health Organ. 2011;
89: 616-618.
14. World Health Organization. A human rights approach
to tuberculosis. Geneva: WHO, 2001.
7. World Health Organization. Community contribution
to TB care: practice and policy. Geneva: WHO,
2003.
WHO South-East Asia Journal of Public Health 2012;1(2):220-223
Book 1.indb 223
223
05-Jun-2012 2:36:04 PM
Voices
Mobile phones for community health workers of Bihar
empower adolescent girls
Derek Treatmana, Mohini Bhavsara, Vikram Kumara & Neal Lesha
Ruby, a 16-year-old girl who has recently
entered puberty, sits next to an Accredited
Social Health Activist (ASHA), named Sangeeta,
who lives in Ruby’s village Kalua in Bihar and
provides basic health services and education
as a volunteer for India’s National Rural Health
Mission (NRHM). Sangeeta had recently
finished a three-day training on using a new
mobile phone application called CommCare as
a job-aid tool for counselling adolescent girls
and women on menstrual hygiene, sexually
transmitted diseases, and family planning
methods.
Ruby gives her name, age, and a few
other personal details for Sangeeta’s record.
Sangeeta then begins the first lesson on
menstrual hygiene. Played through the mobile
Ruby (right) voices her opinions on community outreach
after hearing health messages played from the mobile
phone of her ASHA (left). Photo by Derek Treatman
phone’s loudspeaker, Ruby hears general
information and a few common myths about
menstruation from recorded audio messages
on the phone.
“Some people believe that during a
woman’s menstrual period she is impure
and is unfit to do common household chores
or cook. Would you agree or disagree?” the
phone asks.
“Disagree!” Ruby says with conviction.
Sangeeta smiles and records the answer
in the phone, which then responds, “That
is absolutely correct! A woman’s menstrual
cycle is a natural physiological process
signifying maturation of reproductive organs,”
and continues to say that women need not
consider themselves impure.
Ruby has previously received education
on topics like reproductive health, which
today is uncommon for a young woman of
her socioeconomic status in Bihar. Although
these topics are far from breaching the
school curriculum here, programmes run by
local nongovernmental organizations (NGOs)
enable women like Ruby to attend a few
days of formal instruction to get the basic
information they need to make choices about
their health, their families, and their future.
Dimagi, Inc., 585 Massachusetts Ave, Suite 3, Cambridge, MA 02139, USA
Correspondence to Vikram Kumar (email: information@dimagi.com)
a
224
Book 1.indb 224
WHO South-East Asia Journal of Public Health 2012;1(2):224-226
05-Jun-2012 2:36:04 PM
Derek Treatman et al.
Although Ruby has already learned about
female anatomy and menstruation, she
explains that there is something new that
she heard today from Sangeeta’s mobile
application.
“When a girl begins to menstruate,
she needs to think about the possibility of
pregnancy and using contraceptives, that she
must not become pregnant because her pelvis
is not strong enough. Adolescent girls who
become pregnant can sometimes die or have
a miscarriage,” Ruby explains.
Through a mobile phone, this instruction
can be given informally in one’s own home,
and personally, by a local health worker
whom one knows and trusts. Information
can also be given in a series of staggered,
short lessons, allowing a health worker to
focus on one topic at a time. Group training
and classroom instruction, although highly
beneficial, condenses a lot of information into
a very short amount of time but does not
allow the same level of intimacy or individual
engagement.
Ruby continues, “I know that this
information is important. My friends who are
younger and those older, if they don’t know, I
will explain it to them. They are embarrassed
and say, ‘how could I possibly speak to my
mother?’ or ‘how could I ask my auntie?’ But
I can explain it to them.”
Ruby’s home is just off a national highway
that runs between Delhi and Kolkata, which
means she has easy access to things like
school and the local health centre. After
school she travels by bicycle to nearby villages
further into the interior of Bihar to tutor girls
her age that don’t have access to any formal
education.
WHO South-East Asia Journal of Public Health 2012;1(2):224-226
Book 1.indb 225
Mobile phones for community health workers
“People don’t know anything there,” she
says. “They don’t have books, or training, or
anything. If I don’t give them coaching, how
will they learn?” Ruby speaks with a sense of
urgency and responsibility perhaps uncommon
for someone her age. We are delighted when
she suggests using mobile phones to spread
these messages further into the interior. She
has echoed the very cause which brought us
to India in the first place, and we are humbled
to hear her say it.
Ruby has told her father that she will not
marry until she is 21 years old, that for now
she wants to study. Never before in a village of
Northern India have we encountered such an
emphatic and candid young woman; one who
takes such sensitive information to heart and
acts upon it, for herself and others. Sangeeta
explains that she was married when she was
15 years old and had her third child by the
time she was 20. As a growing, young woman,
Ruby has turned to Sangeeta today as at many
other times, for advice and support on matters
such as marriage.
Working in rural health development
programmes in India, it is easy to mistake
adolescent girls as helpless or disempowered.
As outsiders in a villager’s home, women
are often reserved and make infrequent eye
contact. The sensitive topics of this intervention
make conversation even more difficult, but
Ruby reminds us not to generalize. She is the
outspoken voice of impoverished adolescent
girls who lack education but know of its
importance. Unafraid to seek this knowledge
on her own, she has become an advocate
for young women in her village and others
around it.
225
05-Jun-2012 2:36:04 PM
Recent WHO publications
Strategic Framework for Elimination of Human Rabies
Transmitted by Dogs in the South-East Asia Region
Publisher: World Health Organization, Regional Office for South-East Asia. New Delhi: 2012. 59 pages. ISBN: 9789290224174
Dog bites are the primary
and techniques have been developed in recent years
source of human infec-
to improve dog vaccination coverage, dog population
tion in rabies-endemic
management and accessibility of modern rabies vac-
countries and account for
cines. Considering the importance of consolidating
96% of rabies cases in the
achievements in rabies control in Member countries,
South-East Asia Region.
the WHO Regional Office for South-East Asia has
Elimination of human
developed a regional strategy for elimination of hu-
rabies is dependent on
man rabies transmitted by dogs in the Region. The
elimination of dog rabies.
strategy aims to eliminate human rabies through
Some countries have a
progressive control of dog rabies and human rabies
comprehensive rabies
prophylaxis in rabies-endemic countries and to
control programme but it
maintain the rabies free status in rabies-free areas
is a neglected area in others. New innovative tools
of the South-East Asia Region by 2020.
Quality Assurance in Bacteriology and Immunology
Third Edition
Publisher: World Health Organization, Regional Office for South-East Asia. New Delhi: 2012.
182 pages. ISBN: 9789290224150
There is an increasing
by international laboratories. The International
dependence on clini-
Standards Organization (ISO) has provided several
cal and public health
guidelines and standards for achieving quality in
laboratories for better
laboratory results.
patient management
and also for preventing
the spread of emerging
pathogens.
With rapid
and significant growth
of laboratories at all levels of health care, it has
become mandatory to
check results to make them reliable and cost-effective, as well as comparable with those obtained
226
Book 1.indb 226
These guidelines dwell upon the basic con-
cepts of quality assurance in microbiology and also
describe essential practices and steps of ensuring
quality in various activities that a microbiology
laboratory is expected to undertake in its support
to primary health care system in a biosafe environment and in accordance with ISO. Following these
guidelines will help in delivery of reliable, costeffective and timely laboratory results and support
clinical and public health actions.
WHO South-East Asia Journal of Public Health 2012;1(2):224-226
05-Jun-2012 2:36:07 PM
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Volume 1, Issue 2, April–June 2012, 125-226
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ISSN 2224-3151
WHO South-East Asia Journal of Public Health
Volume 1, Issue 2, April–June 2012, 125-226
Volume 1, Issue 2, April–June 2012, 125-226
Editorial
Role of modern technology in public health:
opportunities and challenges
Jai P Narain & Roderico Ofrin
125
Perspective
Malaria control in India: has sub-optimal
rationing of effective interventions compromised
programme efficiency?
Habib H Farooqui, Mohammad A Hussain,
Sanjay Zodpey,
128
Original Research
Abuse against women in pregnancy: a populationbased study from Eastern India
Bontha V Babu, & Shantanu K Kar
133
Prognostic indicators in patients with snakebite:
analysis of two-year data from a township
hospital in central Myanmar
Myo-Khin, Theingi-Nyunt,
Nyan-Tun-Oo, Ye-Hla
144
Initiating tobacco cessation services in India:
challenges and opportunities
Cherian Varghese, Jagdish Kaur, Nimesh G
Desai, Pratima Murthy, Savita Malhotra,
Subbakrishna D K, Vinayak M Prasad,
Vineet G Munish
159
Betel quid chewing and its risk factors in
Bangladeshi adults
Meerjady S Flora, Christopher GN MascieTaylor, Mahmudur Rahman
169
Injection practices in India
IPEN Study Group
189
Policy and practice
Funding health promotion and disease prevention
programmes: an innovative financing experience
from Thailand
Supreda Adulyanon
201
WHO
South-East Asia
Journal of
Public Health
Review
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infectious disease
Mahmudur Rahman, Apurba Chakraborty208
Report from the field
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Commentary
Hospital or home? Scripting a high point in the
history of TB care and control
Mukund Uplekar & Mario Raviglione
220
Voices
Mobile phones for community health workers of
Bihar empower adolescent girls
Derek Treatman, Mohini Bhavsar, Vikram
Kumar & Neal Lesh
224
Recent WHO publications
226
WHO South-East Asia Journal of Public Health
Performance of cause-specific childhood
mortality surveillance by health workers using a
short verbal autopsy tool
Rakesh Kumar, Suresh K Kapoor,
Anand Krishnan
151
Antibiogram of S. enterica serovar Typhi and
S. enterica serovar Paratyphi A: a multi-centre
study from India
Indian Network for Surveillance of
Antimicrobial Resistance Group
182
Volume 1, Issue 2, April–June 2012, 125-226
Inside
ISSN 2224315-1
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