NATIONAL INSTITUTE OF EPIDEMIOLOGY (Indian Council of Medical Research)

Annual Report 2013-14

Second Main Road Tamil Nadu Housing Board, Ayapakkam Chennai - 600 077 Telephone : 26136204 / 26821600 Fax : 044-26820464 E-mail : [email protected] Web : www.nie.gov.in

Section No. TABLE OF CONTENTS Page no.

1.0 DISEASE SURVEILLANCE AND OUTBREAK RESPONSE

1.1 National hospital based Rotavirus surveillance network 1

1.2 Hospital based surveillance for Bacterial Meningitis 3

Data Management System for ICMR Antimicrobial Resistance 1.3 6 Surveillance Network

1.4 OUTBREAK INVESTIGATIONS 7

An outbreak of dengue fever in Demdema village of Rajganj block and 1.4.1 7 Siliguri municipal area, Jalpaiguri district, West Bengal 2013 Measles outbreak in Kilapudi village, Pallipattu, Tiruvallur, Tamilnadu, 1.4.2 8 India, 2014 An outbreak of scrub typhus in Senapati district, Manipur State, India, 1.4.3 9 2012 1.4.4 An outbreak of Hepatitis E in Solan Town, Himachal Pradesh, 2014 10 An outbreak of acute gastroenteritis in Molmigre village, Kherapara 1.4.5 10 PHC, West Garo Hills District, Meghalaya, 2013 Outbreak of Hepatitis-A at Kaliganj Block, Nadia District, West Bengal, 1.4.6 11 India, 2013 Combination of low vaccine coverage and effectiveness contributed 1.4.7 to measles outbreak in an urban area of Murshidabad District, West 12 Bengal, Eastern India, 2014 1.4.8 Cholera outbreak in Gotakhindaki, Bijapur District, Karnataka, 2013 13 Acute diarrhoeal disease outbreak in 15 Mile, Byrnihat, Ri-Bhoi District, 1.4.9 13 Meghalaya, 2013 Measles outbreak in Pimpalgaon (Baswant) village of Niphad Block of 1.4.10 14 Nashik District, Maharashtra, India, 2014 Outbreak of dengue fever in Siliguri Municipal Corporation, Darjeeling, 1.4.11 15 West Bengal, India, 2013 An outbreak of acute diarrhoeal disease in an urban locality of 1.4.12 16 Mubarakpur, Azamgarh District, Uttar Pradesh, India, 2013 Investigation of Hepatitis E outbreak in Chopadyachiwadi, Beed District, 1.4.13 17 Maharashtra, India 2013 Dengue outbreak investigation at Pudhukottai district, Tamil Nadu, 1.4.14 18 2012

2.0 LEPROSY 19

Multi-centric study of the ICMR task force on leprosy: ‘Socio-cultural 2.1 features and stigma of leprosy for treatment & control in general health 19 services in India: Cultural epidemiological study’ Occurrence of relapse, non-responsiveness to treatment in leprosy and 2.2 screening of M. leprae isolates for drug resistance using molecular and 22 mouse footpad techniques Endemicity of leprosy and utilization of health services in selected areas 2.3 25 of Uttar Pradesh, Chhattisgarh and Tamil Nadu WHO / TDR multi-centric trial on ‘Uniform MDT regimen for all types of 2.4 28 leprosy patients’ (CTRI/2012/05/002696)

3.0 HIV / AIDS 30

Mapping and Size Estimation of Hijras and other Transgender 3.1 30 Populations in states of India

Study to understand prevention of HIV and explore barriers for women: 3.2 A multi-stakeholder perspective on vaginal microbicides and other HIV 32 new prevention technologies (NPTs)

Comprehensive approach to condom promotion yields results among 3.3 long distance truckers who are clients of female sex workers in India: 33 The case of Avahan interventions Assessment of services for prevention and management of infertility in 3.4 35 the primary health care system in India

4.0 HEALTH SYSTEMS RESEARCH 37

Causes of referral out of female clients admitted in Comprehensive Emergency Obstetric and Neonatal Care (CEmONC) centres and 4.1 37 maternal and foetal outcomes: A cross sectional study, Tamil Nadu, India, 2012-13

Evaluation of hypertension management in the Non-Communicable 4.2 Disease program in Chennai, Theni and Villupuram districts : Tamil 39 Nadu Health Systems Project Coverage and effectiveness of Japanese Encephalitis vaccine, Gorakhpur, 4.3 44 Uttar Pradesh 5.0 PUBLIC HEATH TRAINING PROGRAMMES 46

5.1 The ICMR School of Public Health 46

5.1.1 Dissertation projects by MPH scholars, 2011-13 46 Estimation of injection safety practices in health care facilities and 5.1.1.1 awareness of safe injection among prescriber, provider and community 46 in Nicobar District, India, 2013 Status of Village Health Sanitation and Nutrition Committees in district 5.1.1.2 47 Chamba, Kangra and Una, Himachal Pradesh, 2013 The level of preparedness of households and associated factors for cyclone 5.1.1.3 disasters in rural communities of 3 coastal blocks of Cuddalore District, 47 Tamil Nadu Jan-March 2013 Infl uence of Social Risk Factors on Child Immunization in four tribal– 5.1.1.4 48 dominated states of North-east Adherence and factors associated with adherence in Diabetic treatment 5.1.1.5 among Patients attending public health care settings in Villupuram 48 District Tamil Nadu, January - March 2013 Utilization of services under Janani Shishu Suraksha Karyakram (JSSK) 5.1.1.6 for Institutional deliveries in Government Health facilities, Sirmaur 48 district, Himachal Pradesh, India, 2013 Prevalence of chronic complications of diabetes among type 2 diabetic 5.1.1.7 patients treated at primary health centers in Kanchipuram district of 49 Tamil Nadu, India-2013 Barriers to temporary modern contraceptive use among eligible couples 5.1.1.8 49 of Nongstoin Block, West Khasi Hills District, Meghalaya Factors associated with defi nite birth asphyxia among newborns of low- 5.1.1.9 risk antenatal mothers in Poonamallee Health Unit District, Tamil 49 Nadu, 2013: Hospital-based case-control study National Rural Health Mission’s Community-based monitoring of health 5.1.1.10 services and status of key health parameters at village level, Tamil 50 Nadu, 2013 Willingness for cervical cancer, breast cancer screening and associated 5.1.1.11 factors for not willing among women attending Primary health centres in 50 Villupuram district, Tamil Nadu, 2013 Awareness of cervical cancer and utilization of screening for cancer 5.1.1.12 cervix among female health care workers in Kancheepuram district of 50 Tamil Nadu State in India 2013 Comparison of knowledge and practice among the trained and not trained Auxiliary Nurse Midwife and Staff Nurse regarding 5.1.1.13 51 core skills of Skilled Birth Attendance in Birbhum district, West Bengal, India, 2012-2013 Burden of retinopathy amongst diabetic patients attending public health 5.1.1.14 51 facilities in Kancheepuram District, Tamil Nadu, India 2013

Process evaluation of Integrated Management of Neonatal and Childhood 5.1.1.15 52 Illnesses (IMNCI) Program in Thanjavur district, Tamil Nadu, 2013

Behavioural risk factors for Non Communicable diseases among 5.1.1.16 52 adolescents of rural areas, Kancheepuram district, Tamilnadu 2013. Newborn care practices among mothers and status of the Home Based 5.1.1.17 Postnatal Care (HBPNC) programme under National Rural Health 52 Mission in Mewat, Haryana, India, 2013 53 5.1.2 Field projects by scholars of MPH 5th cohort (2012-14)

5.2 Postgraduate Diploma in HIV Epidemiology 55

5.3 Centrally Coordinated Bioethics education in India 55

6.0 WORKSHOPS / TRAINING PROGRAMMES ORGANIZED 56

7.0 PUBLICATIONS 59

8.0 LIST OF STAFF MEMBERS 61 1. DISEASE SURVEILLANCE AND OUTBREAK RESPONSE

1.1 National Hospital Based Rotavirus Surveillance Network Project

Principal Investigator (NIE) Sanjay Mehendale (National Coordinator)

Co-Investigators (NIE) C. P. Girish Kumar, S. Venkatasubramanian Coordinating center- NIE; Referral centers- NIV, CMC, NICED, AIIMS ; Regional centers- Collaborating Institute/s NIE, RMRCs at Port Blair, Jabalpur, Dibrugarh, Belgaum, Bhubaneshwar& RMIMS Patna; Peripheral centers- ~30 hospital sites across the country

Funding Agency ICMR (extramural)

Total budget ~20 Crores (all centers for 4 years)

Start date Phase I – 2012; Phase II – 2013

Study Period 4 years

Background 2. To determine the age, seasonal distribution and outcomes of rotavirus- In India, an estimated 100,000 children die associated disease among the population each year because of rotavirus gastroenteritis. under surveillance, including monitoring A multicentric surveillance system in India was trends over time. established jointly in 2005 under the supervision of DG, ICMR, India and CDC, Atlanta. To strengthen 3. To investigate the molecular epidemiology this network the surveillance activities have been of rotavirus in India by typing the G and expanded in a phased manner, as recommended P type and characterization of untypeable by the National Technical Advisory Group on strains by sequencing. Immunizations. 4. To estimate the economic burden of Objectives rotavirus gastroenteritis seen at hospitals 1. To establish a national hospital based by standardized costing studies. surveillance to examine long term trends Methods and pattern of diarrhea attributable to rotavirus among children < 5 yr of age All children less than 5 years of age admitted with seen at in-patient facilities acute diarrhoea were enrolled after obtaining

ANNUAL REPORT 2013-14 1 informed and written consent from parents Bhubaneswar, one CRS under NIE Chennai / guardians. Clinical information and stool (Fig 1). specimens were obtained. The stool samples were A total of 5574 children were enrolled and 5311 stool tested for presence of rotavirus by ELISA. Rotavirus samples were collected in the study from September positive specimens were further characterized 2012 to March 2014. Out of 5574 enrolled, 47% to determine the G and P types using PCR based (2500/5311) of the stool samples were positive for assays. Lab QA/QC exercises were coordinated by rotavirus. The region wise rotavirus positivity CMC, Vellore. Data entry and validation were done rates are shown in fi gure 2. The distribution of using the online data entry module developed and major rotavirus genotypes viz. G1P[8], G2P[4], hosted on the NIE website. Data management for G9P[8], G12P[6], G12P[8] are shown in Figure 3. the project was done by NIE.

Current status The phase I of the surveillance was launched on 19th September 2012 in 8 Clinical Recruitment Sites (CRS) under CMC Vellore and one CRS under RMRC Port Blair. The phase II of the surveillance was launched in September 2013 in 4 CRS under NIV Pune, 4 CRS under AIIMS Delhi, 2 CRS under NICED Kolkata, 2 CRS under RMRC Dibrugarh and 2 CRS under RMRC Belgaum. The phase III is scheduled to be launched in July 2014 involving 2 CRS under RMRIMS Patna, 2 CRS under RMRCT Jabalpur, one CRS under RMRC Figure 2: Distribution of RV positivity by region

Figure 3: Major RV genotypes Figure 1: Rotavirus surveillance sites in different regions of India

ANNUAL REPORT 2013-14 2 1.2 Hospital based surveillance for Bacterial Meningitis

Principal Investigator (NIE) Sanjay Mehendale (National Coordinator)

Co-Investigators (NIE) Yuvaraj Jayaraman, R. Jayasri

Medical College, Thiruvananthapuram; Medical College, Alapuzha; Institute of Child Health, Chennai; Stanley Medical College, Chennai; Kilpauk Medical College, Chennai; Madurai Collaborating Institute/s Medical College, Madurai; Christian Medical College, Vellore; Kasturba Medical College, Manipal; Regional Medical Research Centre (ICMR), Bhubaneshwar; Chacha Nehru BalChikistalaya, New Delhi; Indira Gandhi Medical College, Shimla.

Funding Agency Ministry of Health and Family Welfare, Govt of India

Total budget 9,750, 000

Start date Mar 2012

Study Period 3 years

Status Ongoing

Background pneumoniae and N. meningitidis in India with the following objectives. In December 2011, pentavalent (DPT-Hep B - Hib) vaccine was introduced in the Universal Objectives Immunization Programme in Tamil Nadu and Kerala. Government of India will scale up the Primary Objectives coverage of pentavalent vaccine in other states 1. Establish a hospital based sentinel in a phased manner. An ongoing surveillance surveillance for bacterial meningitis in network is critical to monitor the changing trends children between 1 month and 59 months. in disease pattern following the introduction of pentavalent vaccine and to study the trends in 2. Determine trends of bacterial meningitis in resistance patterns of H. infl uenzae. This will children 1 month to 59 months of age at the ultimately help in formulation of a policy guideline surveillance sites. for management of the same. Hence the Ministry of Secondary Objectives: Health and Family Welfare, Government of India decided to initiate hospital based surveillance for 1. Determine the aetiological profi le and bacterial meningitis caused by H. Infl uenzae, S. invasive bacterial disease in children for

ANNUAL REPORT 2013-14 3 H. infl uenzae type b, S. pneumoniae, and N.  CSF isolates are being provided to the meningitidis reference lab. for serotyping

Methods  Assistance is provided in identifi cation The project is aimed to provide hospital based data of outbreaks, particularly meningococcal on bacterial meningitis caused by S. pneumoniae, outbreaks, where appropriate H. infl uenzae and N. meningitidis. Data on drug  On a quarterly basis, the sites’ meningitis resistance using MIC is being generated from all the surveillance sites. surveillance data is being shared with the Ministry of Health and ICMR. Use of uniform data forms has resulted in standardized reporting to Ministry of Health Current Status through ICMR on a regular basis. Since the initiation (1st March, 2012), the The sites selected to form this surveillance network project is functional in 11 sentinel sites (Fig. have the technical expertise to carry out Core 4; Table 1.). The 11th site New Delhi has been Surveillance for Bacterial Meningitis. ‘Core added in March 2013. A total of 7024 children Surveillance’ indicates the capacity to identify all were included as per protocol in the Bacterial suspect cases of meningitis and provide laboratory Meningitis surveillance for the period of two years support to perform a minimum of diagnostic tests (March’12 to February ’14), from 11 sentinel sites for case confi rmation including lumbar puncture and blood culture (Table 2.).

Various activities under core surveillance include:

 Meningitis surveillance is being conducted as a core site activity

 On an on-going basis, local data on suspected meningitis and the etiology of bacterial meningitis in children 1 month to 59 months of age is being collected

 Blood culture is performed to identify the causative bacteria

 Lumbar Puncture, microscopy, Figure 4 : Hospital based surveillance for bacterial Biochemistry Culture and Latex test are meningitis India Project Network with total number of also performed cases admitted in each Sentinel Site

ANNUAL REPORT 2013-14 4 Table 1- Number of Cases admitted in each Sentinel Site

No. of Cases S. No Sentinel Site Admitted 1 GMC, Trivandrum 1205 2 TDMC, Alleppey 399 3 ICH, Chennai 1960 4 SMC, Chennai 271 5 KMC, Chennai 361 6 MMC, Madurai 419 7 CMC, Vellore 510 8 KMC, Manipal 267 9 RMRC, Bhubaneshwar 815 10 CNBC, New Delhi 385 11 IGMC, Shimla 432 Total 7024

Table 2: Summary Results of the monthly consolidated report sent by sites (1st March 2012 – 28th February 2014)

Details N (%)

Total No. of inpatients in 11 sentinel sites 156154

Total admitted as in-patients with fever 49006 Proportion of Suspected Bacterial Meningitis cases among fever 7024(14.3) inpatients(n=49006) Proportion of LP done among the suspected cases (n=7024) 6262(89.1)

Proportion of Probable cases of Bacterial Meningitis (n=6262) 685 (10.9) Proportion of Confi rmed cases of Bacterial Meningitis (n=7024) (Either by 406 (5.8) Latex, or CSF Culture or Blood Culture). H. infl uenzaetype b(n=7024) 079 (1.13)

S. pneumoniae (n=7024) 313 (4.46)

N. meningitidis (n=7024) 014 (0.20)

ANNUAL REPORT 2013-14 5 Monitoring and Evaluation: All the sites are profi ciency panels were sent 6 times in the 2 year monitored for compliance in all aspects in the period to all sites. In general, all sentinel sites project. maintained satisfactory performance in most of the rounds. Quality Assurance – Reference laboratory (CMC, Vellore) has organized EQAS program and

1.3 Data Management System for ICMR Antimicrobial Resistance Surveillance Network

Principal Investigator (NIE) Tarun Bhatnagar

Co-Investigators (NIE) M Ravi

Funding Agency Department of Health Research

Total budget Nil

Start date Feb 2013

Study Period 1 year Data management program developed and handed over to Status Bioinformatics Division of ICMR

Background: which have already been already identifi ed. It is proposed that in addition to the clinical isolates As part of ICMR/ DHR response to rising and data captured by the Nodal Centres which are and almost unmanageable increase in essentially Tertiary Health Care Institutes; clinical anti-microbial resistance [AMR] among different isolates and data will also be obtained by country- microbes, ICMR/ DHR set up AMR Surveillance wide regional centers.Management of the data Network involving 6 nodal centers and phase-wise inclusion of other hospitals as regional centers generated through these surveillance networks attached to them. The focus of activities at the and its periodic analysis is a critical component. nodal centers of the AMR surveillance network Objectives will be dependent on the available local evidence including clinical data. The main network would 1. Develop web-based data management be an umbrella network effectively linking the system for nodal and regional centers of smaller networks built around the nodal centers ICMR-AMRSN

ANNUAL REPORT 2013-14 6 2. Establish effective operational linkages 1.4 OUTBREAK INVESTIGATIONS for data management between nodal 1.4.1 Outbreak of dengue fever in Demdema centers, regional centers, NIE-DMU and village of Rajganj block and Siliguri municipal ICMR area, Jalpaiguri district, West Bengal 2013

3. Establish data quality control and quality Dr. Santanu Sen, MPH 2012-14 assurance mechanisms We carried out an investigation from 9th August Current status to 23rd September 2013 to explore the outbreaks of dengue fever from Rajganj block and Siliguri Development of data entry formats, including paper- municipal areas of Jalpaiguri district, West Bengal. based and computer-based online data capture Of the 305 patients tested, 194 (63.6%) patients system with inputs from all nodal center PIs and ICMR were confi rmed to have acute dengue. Of the 194 (Fig: 5). The system has been refi ned over time patients with confi rmed dengue, 148 (76.3%) as per the evolving requirements of the data patients were NS-1 ELISA positive and the rest collection centers of AMRSN and is currently fully were MAC-ELISA positive. Of the 194 confi rmed functional. The program has been handed over to dengue patients, 115 (59.3%) patients were males the Bioinformatics Cell of ICMR that will manage and the median age was 24 years. Age group 15-19 years were worst affected in both areas. and maintain the system and coordinate data management for the network. The risk of transmission was higher in ward no. 42 of Siliguri municipal area than that in Demdema village. The most common manifestations included fever (100%), headache (60%), Myalgia (42%),

Figure 5. ICMR AMRSN Data Management System

ANNUAL REPORT 2013-14 7 Bone pain (21%), Retro-orbital pain (16%), Rash (4%) and bleeding manifestation (2%). One patient (0.38%) died. The vectors Aedes aegypti and Aedes albopictus were confi rmed to have caused the outbreak in Siliguri municipal areas and Demdema village respectively. There is reported evidence that dengue virus has broad circulation in any region, even by crossing country borders. Whether the outbreak arose from dengue importation or crossed into the village from a forest cycle is unknown.

control measures. Outbreak Investigation was initiated on 10th February2013 based on information received from surveillance medical offi cer, Chennai region. There was clustering of more than 10 cases in Kilapudi village with no recent change in surveillance system or migration of population. 36 cases were found by a door to door search for cases which was compared with NPSP data for that area. Outbreak was confi rmed by lab with 7 blood samples and 2 urine samples testing positive. Measles attack rate was highest among children below 2 years. Attack rate was high 1.4.2 Measles outbreak in Kilapudi village, among female children. The epicurve showed fi rst Pallipattu, Tiruvallur, Tamilnadu, India, 2014 case on 11th January 2014 and there was no case after 16th Feb. The pattern suggested possibility Dr. KST Suresh, MPH 2012-14 of a person to person transmission. Spot map About 100 cases of measles were reported in showed more cases among the hutments.In the Tiruvallur Health Unit District of Tamil Nadu study area, about 93% of children were vaccinated during 2013.We conducted measles outbreak with MCV 1st dose and 24% were vaccinated for Investigation in Kilapudi village Pallipattu block measles second dose. About 55% of children were with the following objectives: 1) To confi rm the administered Vitamin A during the past 6months. extent of Outbreak, 2) To describe the outbreak With a relative risk of 0.21 the vaccine effi cacy in Time, Place, Person 3) To generate and test the was found to be 79%. The focal measles outbreak hypothesis regarding the factors associated with in Kilapudi village of Tiruvallur district resulted the occurrence of the outbreak and 4)To facilitate from accumulation of susceptible children probably

ANNUAL REPORT 2013-14 8 measures. We identifi ed 71 cases (occurrence of high grade fever, with headache, muscle pain, nonproductive cough, and pain abdomen, with or without skin lesions amongst residents of Senapati District during August to December 2012 including 2 deaths. The disease mostly affected the age group of 15-29 years, but the attack rate was higher (2.5) in the age 60 years and above. Case fatality rate was 5%. The outbreak started in August, peaked in October and continued until December 2012. Two of the three cases tested positive for scrub typhus. We identifi ed that storage of fi re woods in and around the households (OR 2.9, 95% CI 1.33-78.8), vegetable plucking (OR 30.4, 95% CI 3.6-836.2), farming (OR 8.4, 95% CI 1.5-58.1), forest work (OR due to vaccine failure. It was recommended that 6.1,95% CI 6.1-1859.1) and defecating or urinating data on coverage should be examined and reasons in jungle or bushy areas (OR 10.8, 95% CI 1.8-96.2) for vaccine failure should be investigated. were associated with scrub typhus. Epidemiological 1.4.3 An outbreak of scrub typhus in Senapati evidence suggested that the outbreak of fever was district, Manipur State, India, 2012 due to scrub typhus. We recommend advocacy for proper and prompt treatment of suspected cases of Dr. Romila Devi, MPH 2012-14 scrub typhus, sensitization of all medical offi cers, mass awareness programme, health education and During the second half of 2012, clustering of fever establishment of surveillance system and facilities cases was reported in Senapati district of Manipur. for laboratory test for scrub typhus for its early We investigated the cases to confi rm the etiology, diagnosis and effective control. identify risk factors and recommend control

ANNUAL REPORT 2013-14 9 1.4.4 An outbreak of Hepatitis E in Solan contamination in water samples lifted from three Town, Himachal Pradesh, 2014 different places in the town (Coliform count>14 in 100ml water). The public water distribution supply Dr. Anadi Gupt, MPH 2012-14 system may have been the source of outbreak. We In March, 2014, cases of hepatitis were reported recommended that water must be protected and from Solan town in Himachal Pradesh, India. We drinking water to be chlorinated regularly. investigated this outbreak to identify the aetiology, 1.4.5 An outbreak of acute gastroenteritis in identify the source and propose recommendations. Molmigre village, Kherapara PHC, West Garo We identifi ed 51 cases (attack rate: 13 per 10000 Hills District, Meghalaya, 2013 population, no death) till 17thApril, 2014.Cases were defi ned as occurrence of acute Jaundice Dr. Bichitrani Marak, Dr. Gandira Marak, (yellow sclera/skin) and increased acute phase liver MPH 2012-14 enzymes in a resident of Solan Town, 1stJanuary, th 2014 onwards. Of the 10 sera tested, all tested On 6 August 2013, a clustering of diarrhea cases positive for IgM antibodies against hepatitis E virus was reported from Molmigre village, Kherapara and one serum tested positive for both Hepatitis Primary Health Centre, West Garo Hills District, E and A. The attack rate was highest among 10- Meghalaya, The cluster was investigated to 19 years old (16 per 10000). There were multiple identify the agents(s), source of infection and peaks in the epidemic curve pointing towards a make recommendations for control. A suspected persistent source epidemic. The incidence was case of acute gastroenteritis was defi ned as having highest in ward 1 (45 per 10000) out of the 13 wards > 3 watery stools with visible blood in stool in a st of the town. The public water distribution system resident of Molmigre village between 31 July th accessed water from three streams in the vicinity to 14 August, 2013. In total, 24 patients were of the town. There was evidence of recent faecal identifi ed among 146 residents (attack rate 16%). It

ANNUAL REPORT 2013-14 10 was high among age group 5-16 years (71%). Males hepatitis cases and intimated to district authorities. had a higher attack rate (21%). The case fatality They started providing primary control measures was 4%. The outbreak started on 31stJuly, 2013, and an outbreak investigation was initiated to peaked on 5thAugust and ended on 10thAugust, (1) confi rm existence of an outbreak, (2) confi rm 2013, suggesting person-to-person transmission. diagnosis, (3) identify source and risk factors, and Drinking water from the uncovered stored spring (4) initiate control measures. Observing the trend water on a funeral day was associated with an of Hepatitis-A from the previous two years (IDSP), increased likelihood of acute gastroenteritis [OR we noticed a sudden rise in the number of cases. 4.1(95%CI 1.1-20.5)]. Uncovered stored spring All (10) blood samples from suspected patients water might have been contaminated by the were anti-Hepatitis-A IgM positive. All cases were index case and the villagers who consumed the reported from six adjacent Gram Panchayats of contaminated water in the house of the index case three water-distribution areas. Among 1546 cases, on funeral day were affected. Sources of water no death was reported. Overall attack rate was supply must be protected and cleaned.Drinking 12/1000 population, higher in 0-9 and 10-19 yrs water needs to be chlorinated and/or boiled. (24.5/1000 and 37.3/1000 population respectively). Public Health Engineering Department found a 1.4.6 Outbreak of Hepatitis-A at Kaliganj breakage in main water supply line which was Block, Nadia District, West Bengal, India, repaired on 1st July. There was no second time 2013 chlorination at one distribution area. Analytical Dr. Nilanjan Dastidar, MPH 2012-14 study yielded using soap after defecation a signifi cant protective factor. The Hepatitis-A On 21st June, 2013, health authorities of Kaliganj outbreak was attributed to contaminated piped Block of Nadia district, West Bengal, received water supply. Probably residual chlorine in information on increasing number of acute affected areas was not suffi cient and not monitored

ANNUAL REPORT 2013-14 11 regularly. It was recommended to repair the broken pipe, increased amount of residual chlorine was ensured and increased awareness of use of soap after defecation and other hygienic practices were suggested.

coverage was 14%. Risk of measles was almost three times (RR:2.7; 95% CI:1.5-4.7) higher among the non-vaccinated than the vaccinated children. Overall vaccine effectiveness was 63% (95% CI: 34-69). The major reason for non-immunization was lack of awareness among mothers (80%). The measles outbreak in Dhuliyan municipality was due to low immunization coverage and poor 1.4.7 Outbreak in an urban area of vaccine effectiveness. We recommended special Murshidabad District, West Bengal, Eastern immunization campaign and health education to India, 2014 improve population awareness.

Dr. Atasi Mandal, MPH 2012-14

A cluster of measles cases and a death due to measles was reported in Dhuliyan municipality of Murshidabad district, West Bengal on 7thFebruary, 2014. We investigated the cluster to identify reasons and propose control measures. We identifi ed 227 cases and one death (Attack rate: 8.5%; Case fatality:0.4%). Attack rate was highest among children aged 12-24 months (26%) and there was no difference by gender (8%). The peak of the outbreak was in 2ndweek of February, 2014. The attack rate was highest in ward 14 (≥30/1000) wherethe vaccine coverage was <15%. The overall vaccine

ANNUAL REPORT 2013-14 12 1.4.8 Cholera outbreak in Gotakhindaki, Bijapur District, Karnataka, 2013

Dr. Kavita Dodamani, MPH 2012-14

On 12thAugust 2013, news papers and TV channels reported the occurrence of Acute Diarrhoeal Disease (ADD) cases in Gotakhindaki village of Bijapur District, Karnataka. We investigated the outbreak to confi rm it, describe with respect to time, place and person, identify the source of outbreak and formulate recommendations for control and preventive measures. There were 128 ADD cases (a resident/visitor of Gotakhindaki with history of passage of three or more loose or well water was the source of outbreak. Washing watery stools in the past 24 hours with or without with mud / water was signifi cantly associated with dehydration) which was an unusual increase in the the cases (OR=5.3, 95% CI =1.77- 16.78). Probably incidence during the month of July and August. V. the contaminated well water was the source of cholerae O1 Ogawa serotype was isolated from stool infection, due to Vibrio cholerae. We advocated samples. Attack rate was 6.7 percent. Case fatality Information, Education and communication rate was 0.2 percent (n=3). People of all age groups activities and ensured chlorinated water with were affected. The epicurve was of propagated the help of Gram Panchyat and Zillah Panchyat type. Among the 75 cases, 31(41%) of the cases had from nearby town which helped in the control of vomiting along with loose stools. We analysed 75 outbreak. cases and 75 controls to test whether contaminated 1.4.9 Acute diarrhoeal disease outbreak in 15 Mile, Byrnihat, Ri-Bhoi District, Meghalaya, 2013

Dr. Bibha Marak, MPH 2012-14

We investigated an outbreak of acute diarrhoeal disease in 15 Mile, Byrnihat in Ri-Bhoi district of Meghalaya. The objectives of the investigation were 1) to confi rm the existence of the outbreak, 2) to identify the source of the outbreak, 3) to initiate control measures and 4) to propose recommendations. There were 43 cases and 1 death which were clustered in one part of the village. All ages and both sexes were affected but females

ANNUAL REPORT 2013-14 13 of main source of drinking water which may have been contaminated by the index case. Regular chlorination of drinking water source, health education on hygienic practices like drinking boiled water and hand-washing with soap after defaecation may be effective in preventing such outbreaks.

1.4.10 Measles outbreak in Pimpalgaon (Baswant) village of Niphad Block of Nashik District, Maharashtra, India, 2014

Dr. MB Deshmukh, MPH 2012-14 were affected more. Attack rate was highest in the We received notifi cation of clustering of measles th age group of 0 -4 years (169/1000 population).Case cases on 5 April 2014 through the IDSP and NPSP fatality rate was 2.3%. Predominant symptoms in Nashik in Pimpalgaon (Baswant) village of included loose watery stool, vomiting, nausea, body Niphad block of Nashik district, Maharashtra. We ache and fever. Drinking unboiled well water (odds initiated outbreak investigation on the same day to ratio 5.06, 95% CI 2.2-11.1) and practice of hand confi rm the outbreak and the diagnosis, to describe washing after using toilet (OR 0.37, 95% CI 0.17- outbreak in respect to time, place, person and to 0.81) were associated with cases. No pathogens formulate recommendations for early control of the could be identifi ed from the stool samples sent outbreak. We defi ned a suspected measles case as for microbiological investigation. The outbreak an occurrence of fever with maculopapular (non may have been caused by faecal contamination vesicular) rash lasting for more than three days and cough or coryza (running nose) or conjunctivitis (red eyes) in the resident of Pimpalgoan (Baswant), Niphad Block, Nashik District, Maharashtra, India, 12thFebruary 2014 onwards. First case was reported on 18thMarch 2014 and the peak was reached on 26thMarch 2014, following which cases started decreasing and the last case was reported on 14thApril 2014. No case fatality was reported. Infection was likely transmitted by person to person contact (19 cases in fi ve houses). The outbreak spread from Samarthnagar area to Baradmatha area of the village. Samarthnagar was affected more than Baradmatha (p=0.03), median age of cases was 5 year (range 8 months -11 years). The

ANNUAL REPORT 2013-14 14 case reported on 9th July. In August after two cases age specifi c attack rates were signifi cantly different within second week we observed a rising trend. Till (p=0.003) and socially vulnerable groups were 30th September, 431 confi rmed cases were reported. more commonly affected. The vaccine effectiveness Vector control measures with Temephos and of measles vaccine in Pimpalgoan for the fi rst dose was 87% and for the second dose 91%. The nomadic Malathion were intensifi ed by mid of September. migratory population visiting outside this area By the end of September, a consistent decline in might have imported the measles outbreak. There reporting of cases was seen. Attack rates were is a need to protect high risk children in the high higher in male (203/ 100,000) and age group 15-45 risk areas through catch up rounds of measles. The years (238/ 100,000), one death was reported during reported coverage of measles immunization needs this period. Out of the 33 wards the attack rate was to be validated. Surveillance to identify new cases high in four wards. Predominant symptoms were must be strengthened. headache (98%), myalgia (90%) and arthralgia (58%). Small proportion of cases had rash (5%) and 1.4.11 Outbreak of dengue fever in Siliguri Municipal Corporation, Darjeeling, West Bengal, India, 2013

Dr. Jaybrata Deb, MPH 2012-14

In July and August 2013, 60 confi rmed cases of dengue were reported in Siliguri Municipal Corporation (SMC) of Darjeeling district. We investigated the outbreak to describe the cases in time, place and person and formulate recommendations for control. The confi rmed index

ANNUAL REPORT 2013-14 15 haemorrhagic manifestations (2%). Rain water disease was reported in an urban locality collection and discarded material constituted of Mubarakpur, Azamgarh District, Uttar 60% of breeding sites, and used tyres (10%). Pradesh, India. We investigated the cluster Environmental survey on 9th and 15th to identify the agents(s), source of infection September showed persistence of high vector to make recommendations for control. A indices. Strategies, like destruction of vector suspected case of diarrhoea was defi ned as breeding sites, did not have much impact in having more than three watery stools after vector control. There was reduction in reporting 18thAugust, 2013. In all, 369 case-patients were of cases after initiation of vector control by identifi ed among 97,000 residents (attack rate Temephos and Malathion. Effective vector 4%). All 7 stool samples and 4 vomitus samples control activities, training health workers in tested negative for Vibrio cholerae. The water identifying danger signs and prompt referral of public distribution system was found to which could prevent further outbreaks and bring down mortality were recommended.

1.4.12 An outbreak of acute diarrhoeal disease in an urban locality of Mubarakpur, Azamgarh District, Uttar Pradesh, India, 2013

Dr. Prashant Ranjan, MPH 2012-14

On 17thAugust 2013, an outbreak of diarrhoeal

ANNUAL REPORT 2013-14 16 be contaminated. The outbreak started on 17th August, peaked on 19th and ended on 21st August, 2013. Drinking water from the PDS was associated with an increased risk of diarrhoea (odds ratio: 6.5, 95% confi dence interval 2.7-16.3). The outbreak of diarrhoeal disease occurred due to contamination of the drinking water at various leakage points. It was recommended that authorities PDS need to enforce disinfection of drinking water at source and consider repair and re-laying of pipelines. the main village area (12.5%) was more than 1.4.13 Investigation of Hepatitis that in the hamlets of Chari Vasti (3.04%) and E outbreak in Chopadyachiwadi, Beed Ganesh Nagar (0.2%). The attack rate in 15 to District, Maharashtra, India 2013 49 years age group was high (9%). The attack rates of females (6.9%) and males (5.1%) was Dr. Nipte, MPH 2012-14 not signifi cantly different. Case fatality was Clusters of jaundice cases were reported in 1.2 percent. Samples from 7 case patients Chopadyachiwadi village, Beed district in were positive for hepatitis E IgM antibody. Maharashtra state of India on 29thJuly 2013. Environmental investigation confi rmed the sewage contamination of drinking water of We started the outbreak investigation on 30th hand pump 1. People drinking water from July 2013 to confi rm the outbreak, to fi nd its hand pump 1 had nearly eight times more cause, to describe the occurrence of cases by time, place & person, to identify the source of infection and to formulate recommendations for the control of outbreak. We used the operational case defi nition of acute hepatitis as an occurrence of acute onset of yellow eyes or dark urine with or without fever, fatigue, loss of appetite, loose motions, abdominal pain, nausea, vomiting and pruritus in a resident of Chopadyachiwadi village from 1st April 2013 onwards. A total of 82 cases of hepatitis were identifi ed in the village with the overall attack rate of 6%. The attack rate in

ANNUAL REPORT 2013-14 17 risk of developing hepatitis E compared to those declined. Highest attack rate was at Aranthangi who used other water sources (RR: 7.5, 95% CI: block followed by Thiruvarankulam. Overall attack 4.3 – 13.3) with a population attributable fraction rate was 215 per 100000 population. It was high (PAF) of 70%. Outbreak of hepatitis E resulted among infants (526) followed by children 1-5 years due to drinking water from hand pump 1 which was contaminated with feces. We recommended (344). Sex-wise incidence was similar. Case fatality temporary alternative water supply arrangement, ratio was 0.28%. It was relatively higher among 1-5 repair of blockages of hand pump 1, regular years age group (1.12%). Predominant symptoms chlorination of every drinking water source and were headache (90%) and Arthralgia (71%). periodic cleaning of sewage drainage system. Aedes indices were high. Among total containers 1.4.14 Dengue outbreak investigation at with larvae, 71% were water storage containers Pudhukottai district, Tamil Nadu, 2012 and rest were waste containers. Predominant mosquito species identifi ed were Aedes albopictus Dr. Meenachi, MPH 2012-14 and Aedes vittatus. The outbreak could have We investigated dengue fever outbreak at been due to improper water storage and waste Pudhukottai District following information from disposal. Rapid Response teams carried out anti- Tamil Nadu Public Health Offi cials towards end larval and anti-adult mosquito measures. Health of October 2012. The objectives were to confi rm education regarding Aedes breeding and symptoms existence of the outbreak, to describe the epidemic of dengue fever was given in public institutions. in time, place, person, to describe vector indices, breeding sites and species of Aedes mosquitoes. We Waste containers were removed in the campaign. confi rmed the outbreak. Cases started increasing We recommended refresher training to doctors since May 2012, dramatically increased since (including pediatricians) in clinical management of August, reached peak during October and then dengue fever and complications.

ANNUAL REPORT 2013-14 18 2. Leprosy

2.1 Multi-centric study of the ICMR task force on leprosy: ‘Socio-cultural features and stigma of leprosy for treatment & control in general health services in India: Cultural epidemiological study’

Principal Investigator (NIE) P. Manickam (PI cum Coordinator),

Thilakavathi Subramanian (NIE), VP Shetty (FMR), RK Co-Investigators Mutatkar (MAAS), PK Mohapatra (RMRCNE), VK Agrawal (RMCH), A Mahapatra (RMRCB) NIE-ICMR, Chennai, Tamil Nadu {co-ordinator} The Foundation for Medical Research (FMR), Mumbai, Maharashtra The Maharashtra Association of Anthropological Sciences (MAAS)-Centre for Health Research & Development (CHRD), Pune, Maharashtra Collaborating Institute/s Regional Medical Research Centre-North East (ICMR), Dibrugarh (RMRCNE), Assam Rohilkhand Medical College & Hospital (RMCH), Bareilly, Uttar Pradesh Regional Medical Research Centre (ICMR), Bhubaneswar (RMRCB), Odisha

Funding Agency ICMR (extramural)

Total budget Rs. 19,58,964

Start date January 2012

Study Period 2 years

Status Ongoing

Background effectiveness of current strategies of leprosy control. Leprosy-related stigma also remains a serious Although the overall prevalence in India is issue, contributing to a frequently overlooked less than 1 per 10,000 population, leprosy “hidden burden” of this neglected disease beyond continues to be a problem in some areas of the the standard epidemiological indicators. Such country. Notwithstanding accomplishments of questions are especially timely with the current the programme, questions remain about the integration of leprosy services in primary

ANNUAL REPORT 2013-14 19 healthcare, and the importance of maintaining the targeted sample size is 100 patients in these groups. capacity for diagnosis, access to effective treatment The family and community leaders are interviewed and disability care besides the impact of stigma, using topic guides on aspects of support, stigma both in the general population and in general features and community participation. Both health services. Research is needed to determine government and private health providers are whether and how social and cultural features of interviewed on integrated health services, care and leprosy affect access and the quality of clinical treatment-specifi c issues. services and leprosy control following change over to integrated services. In this context, NIE is Current status conducting and coordinating a multi-centric study All the participating centers have completed data that applies cultural epidemiological framework. collection (Tables 3 and 4). NIE conducted a Joint meeting to review and plan next steps at FMR, Objectives Mumbai, in January 2014. A new proposal for 1. Clarify relevance of socio-cultural features integrated analysis of qualitative and quantitative of experience and meaning of illness and data for possible funding is under consideration. the current impact of stigma between Each of the participating study sites has submitted leprosy and other health problems its report to ICMR. The joint report is being compiled. 2. Suggest strategies for improving patient- centered leprosy services

Methods

The study is being conducted in Tiruvannamalai district of Tamil Nadu (NIE), Karjat block of Raigad district (FMR) and Thane (Rural) [MAAS] from Maharashtra (FMR), Dibrugarh of Assam (RMRCNE), Bareilly district of Uttar Pradesh (RMCH) and Sonepur of Odisha (RMRCB) (Fig 4). Information is collected from patients, health staff (both health services and private sector) and community leaders and family members. The study gathers information on help-seeking and treatment experience, illness explanatory models, stigma and disease awareness from patients of leprosy and also from patients suffering fromTuberculosis, Malaria, and Skin diseases other than leprosy/ STD through in-depth interviews using Explanatory Model Interview Catalogue (EMIC) instrument. The Figure 4: Participating centers and study sites

ANNUAL REPORT 2013-14 20 Table 3: Number of patients interviewed by study sites and sampling conditions, Multi-centric socio-cultural epidemiological study of leprosy, 2012-14

Leprosy Non-leprosy Sites Total UT RFT TB Malaria Skin

Tiruvannamalai, Tamil Nadu 50 50 50 25 25 200

Karjat, Maharashtra 49 47 50 23 24 193

Thane rural, Maharashtra 50 50 50 25 25 200

Sonepur, Odisha 50 50 50 10 25 185

Dibrugarh, Assam 38 39 38 0 20 135

Bareilly, Uttar Pradesh 60 75 75 35 10 255

Total interviews 297 311 313 118 129 1168

Table 4: Number of stakeholders interviewed by study sites and category of stakeholders, Multi-centric socio-cultural epidemiological study of leprosy, 2012-14

NGO/ Govt. Family Community Sites private health Total members leaders providers staff

Tiruvannamalai, Tamil Nadu 24 24 2 19 69

Karjat, Maharashtra 2 21 9 16 48

Thane rural, Maharashtra 16 15 15 25 71

Sonepur, Odisha 22 26 11 25 84

Dibrugarh, Assam 11 0 0 14 25

Bareilly, Uttar Pradesh 60 0 20 20 100

Total interviews 135 86 57 119 397

ANNUAL REPORT 2013-14 21 2.2 Occurrence of relapse, non-responsiveness to treatment in leprosy and screening of M. leprae isolates for drug resistance using molecular and mouse footpad techniques

Principal Investigator (NIE) Sanjay Mehendale (National Coordinator)

Co-Investigators (NIE) Rajkumar Prabu, Joseph K. David, V.N.Mahalingam

Foundation for Medical Research, Mumbai National Institute of Epidemiology, Chennai Father Muller Medical College, Mangalore Collaborating Institute/s Blue Peter Health and Research Center (Lepra India), Hyderabad National JALMA Institute of Leprosy and Other Mycobacterial Diseases, Agra

Funding Agency ICMR (extramural)

Total budget 12,50,000/year

Start date March 2012

Study Period 3 years

Status Ongoing

Background Objectives

To effectively meet the challenges of containing the 1. Document and investigate the leprosy spread of leprosy, it is essential to keep a vigil on the cases with problem of recurrence of lesions magnitude of the problem of recurrence of lesions following release from treatment (RFT). and underlying causes especially among patients 2. Screen the M. leprae isolates for drug who have relapsed after treatment. This can only resistance using molecular and Mouse be effectively achieved by careful documentation footpad method (MFP). of as many problem cases as possible through an appropriate clinical, fi eld and laboratory support Methods system at many vulnerable settings. For a chronic Study design: Field, clinic and laboratory based disease like leprosy, drug resistance poses a multi -centric study addressing the issue of post serious threat following widespread and intensive MDT recurrence of lesions, relapse and occurrence chemotherapy intervention. of drug resistance in leprosy patients.

ANNUAL REPORT 2013-14 22 Study population: 1750 pauci-bacillary (PB) physical or psychological stress factors, and any and1750 multi-bacillary(MB) registered leprosy other illness in the past was also collected patients released from treatment (RFT) between New Patient recruitment: During the survey for April 2005 and March 2010. recruiting the RFT patients, voluntarily reporting Study area: Salem, Cuddalore and Coimbatore new leprosy patients were recruited. districts in Tamil Nadu, Chitoor district in Andhra Lab investigations: Slit skin smear (SSS) followed Pradesh by a biopsy (using local anesthesia) from an active Criteria for selection of patients: Patients or a newly developed lesion or from a site showing who have been released from treatment after the highest BI have been obtained. Studies are ongoing completion of a full course of WHO recommended to identify the cases of drug resistance. MDT from 2005 to 2010. Data analysis: Quantitative analysis of data Retrospective study: Information of all RFT using SPSS and other relevant statistical software cases from April 2005 to March 2010 available in will be performed registers of study centers was collected. Current status Prospective study: Paramedical workers The fi rst year data collection was completed in July examined all the available patients from the 2012 in all the four districts. The fi rst follow up line list of RFTs to identify cases with relapse / could not be started as per the schedule and was recurrence of lesion. started only in September 2013 and completed in At the time of examination of problem cases, February 2014 in three districts in Tamil Nadu. information on new skin and/or nerve lesions The fi rst follow up could not be initiated in Chittoor developed after RFT and /or persisting old active district in Andhra Pradesh due to prevailing lesions was also recorded using body chart along circumstances. The preliminary results are with details of treatment taken by the patients. summarized in the tables 5-7 below. The second Detailed history to include duration of symptoms, follow up is tobe initiated soon. history of reactions, family history, any known

Table 5: Enrolment status

Baseline 1st Follow-up Centers MB PB Total MB PB Total (%) Tamil Nadu Coimbatore 211 286 497 194 262 456 (92) Salem 258 298 556 232 277 509 (92) Cuddalore 134 274 408 121 256 377 (92) Andhra Pradesh Chitoor 303 419 722 - - - Total 907 1,278 2,183 547 795 1342 (92)*

ANNUAL REPORT 2013-14 23 (*Total attempted: 1461)

At the baseline we recruited 2,183 RFT patients from all four districts and 1,278 (59%) were from PB group. In the fi rst follow up we examined 1342 (92%) patients from three districts in Tamil Nadu.

Table 6: Description of all clinical fi ndingsin RFT Cases (n-1342)

Description Baseline 1st Follow Up

Recurrence / increase in size of lesion 30 2

New lesion 11 0

Persistence of active lesions 7 0

Reaction 5 1

Multiple problems (2 or more) 11 2

Total 64 (2.9%) 5 (0.37%)*

During the baseline recruitment we observed 64 (2.9) RFT cases with one or more clinical fi ndings, including 30 patients with recurrence/increase in the size of lesions. In the fi rst follow up fi ve RFT cases were having clinical fi ndings, among them two were having recurrence or increase in size of lesion.

Table 7: New case enrollment

1st year 2nd Year Centers MB PB Total MB PB Total

TN

Coimbatore 38 26 64 - 2 2

Salem 29 33 62 2 1 3

Cuddalore 10 16 26 - 4 4

AP

Chitoor 16 25 41 - - -

Total 93 (48%) 100 (52%) 193 2 (22%) 7 (78%) 9

ANNUAL REPORT 2013-14 24 In the fi rst year we recruited 93 and 100 new cases in MB and PB group who were diagnosed for the fi rst time during our visit to study centers. In the second year we recruited 2 MB and 7 PB new cases in three districts in Tamil Nadu.

2.3 Endemicity of leprosy and utilization of health services in selected areas of Uttar Pradesh, Chhattisgarh and Tamil Nadu

Principal Investigator (NIE) Sanjay Mehendale (National Coordinator)

Co-Investigators (NIE) Rajkumar Prabu, Joseph K. David, V.N. Mahalingam National JALMA Institute of Leprosy and Other Mycobacterial Diseases, Agra Collaborating Institute/s National Institute of Epidemiology, Chennai Regional Leprosy Training and Research Institute, Raipur

Funding Agency ICMR (extramural)

Total budget 12,50,000/year

Start date March 2012

Study Period 3 years

Status Ongoing

Background techniques can help in devising suitable methods for understanding the epidemiology of leprosy and In order to understand the reason for high identifying sources as well as causes of persisting burden of leprosy in some areas, it is necessary to foci of the disease. identify the natural reservoir(s) of M. leprae, the route of infection and the mode of transmission. Objectives The exact mode of transmission is not fully (1) Estimate the disease burden in selected known. During the last 20 years, rapid molecular districts of these states assays have been developed for detection of M. leprae directly from patient specimens. (2) Study the profi le of the disease. These assays have been primarily based on the amplifi cation of M. leprae specifi c sequences using (3) Identify sources of transmission by classical PCR and identifi cation of M.leprae DNA fragment. and molecular epidemiological methods In addition different genotyping methods are (4) Promote utilization of health services by being developed. These molecular biological leprosy patient and the community.

ANNUAL REPORT 2013-14 25 Methods in leprosy patients and their contacts are being studied. In the environment (soil and water) the Study area: This study is being carried out in presence of viable M. leprae, is being studied by selected districts of Uttar Pradesh, Tamil Nadu and RT-PCR.Information on utilization of health Chattisgarh to estimate actual burden of leprosy, services by leprosy patients, establishment of its clinical profi le, to understand the dynamics referral chains, usefulness of expert counselors, of transmission and to promote utilization of knowledge gaps and the impact of interventions health services. Six districts of (2each from Uttar has been collected and is being analyzed. Pradesh, Chhattisgarh and Tamil Nadu) have been chosen using the available NLEP data. In Tamil Current status Nadu the study is being conducted inThiruvallur and Kanchipuram districts. We completed data collection in Thiruvallur and Kanchipuram districts in Tamil Nadu. The Study population: Approximately one lakh Anganwadi workers examined 75,086 and 1,10,629 population of selected blocks in each district. participants in the 2 districts and identifi ed 1,669

Data Collection: Anganwadi workers of the and 1680 as having skin lesions suggestive of selected blocks of these districts were trained to leprosy in Thiruvallur and Kanchipuram districts identify the suspected leprosy cases using leprosy respectively (Table 8.). The paramedical workers photo fl ash cards. The suspected cases were then examined all these suspected cases and diagnosed examined by medical doctorswho confi rmed the 18 and 17 as leprosy. The medical doctor confi rmed diagnosis of leprosy. The confi rmed patients were all these cases and referred them to the nearest referred to the nearest public health facility for health facility in the respective districts for appropriate treatment. management.

We collected slit skin smear specimens from the The number of patients with PB leprosy was 14 confi rmed patients. Furthermore environmental in each of Thiruvallur and Kanchipuram districts samples such as water and soil samples in and (Table 9.). The cases with single lesion were more around households of the leprosy confi rmed in both the districts. Nerve involvement was also patients were collected.The investigation on observed in patients in both the districts and all of sources were focused on the nature of the contact them were from MB group. Grade 1 disability was and presentation of primary / secondary case. DNA observed in 4 and 2 MB patients in Thiruvallur fi ngerprints of M. leprae identifi ed and detected and Kanchipuram districts respectively.

ANNUAL REPORT 2013-14 26 Table 8: Population enumerated for estimating prevalence of leprosy, Thiruvallur and Kanchipuram districts, Tamil Nadu, India, 2013

Thiruvallur Kanchipuram 95,484 1,19,253 Total population enumerated Rural = 80,751 (84.57%) Rural = 95,145 (79.8%) Urban = 14,733 (15.43%) Urban = 24,108 (20.2%) 23,404 29,430 Number of households Rural = 19,793 Rural = 23,335 Urban = 3,611 Urban = 6,095 75,086 (78.63%) 1,10,629 (92.8%) Population available for Rural = 64,190 Rural = 87,334 examination Urban = 10, 896 Urban = 23,295 1669 (2.22%) 1680 (1.6%) Suspected cases Male = 912 (54.6%) Male = 875 (52.1%) Female = 757 (45.4%) Female = 805 (47.9%)

Confi rmed cases 18* 17#

*2.39/10,000 population examined by Anganwadi Workers #1.6/10,000 population examined by Anganwadi workers

Table 9: Clinical profi le of confi rmed cases of leprosy, Thiruvallur and Kanchipuram districts, Tamil Nadu, India, 2013

Profi le of confi rmed cases Thiruvallur District (n=18) Kanchipuram District (n=17) PB MB PB MB Cases confi rmed as leprosy 14 (77.8%) 4 (22.2%) 14 (82.4%) 3 (17.6%) No. of lesions Single 9 13 - 2 – 5 5 4 1 - > 5 - 3 Nerve involvement - 4 (22.2%) - 2 (11.8%) Disability Grade 1 4 (22.2%) - 2 Grade 2 - - - - No. SSS collected 14 4 13 3 No. SSS positive for M. leprae - 2 (11.1%) - 1 (5.9%)

ANNUAL REPORT 2013-14 27 Duration of disease 1 13 2 < 1 year 11 4 1 - 1 – 5 years > 5 years 2 - 1

2.4 WHO / TDR multi-centric trial on ‘Uniform MDT regimen for all types of leprosy patients’ (CTRI/2012/05/002696)

Principal Investigator (NIE) Sanjay Mehendale (International Trial Coordinator) Dr. K Katoch (Agra), Dr. M. Shivakumar (DFIT), Collaborators Dr. V Jadhav (Pune); Dr. K. Ramalingam (Tamil Nadu); Prof. J Shen (China) NJILOMD, Agra [Kanpur] DFIT, Chennai [Gaya and Rothas] Collaborating Institute/s NLEP-Maharashtra [Pune] NLEP-Tamil Nadu [Tiruvannamlai and Villupuram]

Funding Agency WHO/TDR and WHO India

Total budget INR11,28,102 (for fi nal follow-up)

Start date 2003

Study Period 2014

Status Ongoing

Background leprosy patients (Clinical Trials Registry of India: 2012/05/002696). Globally, leprosy treatment is currently offered through the general health services. There is a Objectives need for a simplifi ed treatment regimen that does Assess whether U-MDT results in maintaining not require skills to classify the disease and decide a maximum acceptable cumulative level of 5% the treatment accordingly. This will facilitate relapse rate at the end of 5 years. sustaining leprosy control activities through primary health care facilities. WHO-TDR supported Methods a multi-centric trial aimed at assessing effi cacy The open design trial requiring 2500 newly detected, of six-month multi-drug therapy (MDT) regimen previously untreated patients each in multi- currently recommended for multi-bacillary (MB) bacillary (MB) and pauci-bacillary (PB) groups patients as uniform MDT (U-MDT) for all types of is ongoing in six sites in India (Tiruvannamalai,

ANNUAL REPORT 2013-14 28 Villupuram, Pune, Agra, Gaya and Rohtas) and respectively and 17% had type I and 4% had type two sites in China (Guizhou and Yunnan). In the II reactions. In the PB group, the adverse events annual follow-up of enrolled patients, clinical reported were 3.3% new lesions, 5.3% neuritis, improvement (inactive, improved or static) is 6.8% type I reaction, and 0.5% type II reaction. Six recorded based on standardized clinical criteria. patients (MB=4, PB=2) had clinically confi rmed An individual, who after completion of treatment relapse that occurred between the fi rst and third develops one or more new skin patches consistent year of follow-up. The relapse rates among MB with leprosy, without evidence of reactions, is and PB patients were 0.069 per 100 PY and 0.021 considered to have relapsed. The rationale, per 100 PY (p=0.18) respectively. In summary, design and preliminary results had already been the interim fi ndings suggested that only few published (Axel et al, 2008). relapses occurred and the regimen was found to be Current status effective, acceptable & operationally convenient. The study enrolled 3392 patients during 2003- We observed improvement in clinical status of skin 2008. Of these, 38% were MB and 4% had grade 2 lesions in both types of leprosy patients. The UMDT disability. Of the 3130 who completed treatment, regimen was successful in preventing relapse to skin lesions were inactive in 42% of PB (n=798) and less than the pre-defi ned targeted relapse rates of 2 in 10% of MB (n=122) patients (χ = 353; p<0.001). 5% in 5years in a clinical trial scenario. However, At the end of fi ve years of follow-up, lesions were application of UMDT in the programme requires inactive in 91% in PB patients and 79% in the MB several practical considerations. group (χ2=72; p<0.001). Totally 1165 adverse events were reported and 48% were reported from MB We conducted a review meeting with leprosy experts group. In the MB group, 17% migrations and 8% on 7 February 2014, with the objective ofreviewing deaths were reported. In the PB group, migrations the reactions and relapses.It was concluded that were 29% and deaths 4.3%. In the MB group, no relapses were missed out and were not wrongly 11% and 12% developed new lesions and neuritis labeled as reactions.

ANNUAL REPORT 2013-14 29 3. HIV/AIDS

3.1 Mapping and Size Estimation of Hijras and other Transgender Populations in states of India

Principal Investigator (NIE) Thilakavathi Subramanian

Co-Investigators (NIE) V. Selvaraj, Dr. Sanjay Mehendale Centre for Sexuality and Health Research and Policy Collaborating Institute/s (C-SHaRP)

Funding Agency UNDP

Total budget 22, 997, 121

Start date 11 Dec 2012

Study Period 1 year

Status Completed

Rationale 2. Estimate the size of hijras and other male- to-female transgender people, in the same Hijrasand other TGs (MTF) have been recognized 17 states. as important core populations for whom appropriate HIV intervention programs need to be 3. Understand the social and sexual network developed. Mapping of sites (frequented by hijras dynamics / where they reside)is needed for identifi cation and establishment of project sites for HIV prevention Methods intervention. The size estimation of TG/Hijras will The study was conducted between December help the national program in decisions regarding 2012 and September 2013 in 17 states of India. the allocation of resources for the prevention Detailed listing of the sites up to the district intervention. level was done with the help of stakeholders, especially NGOs/CBOs working with sexual Objectives minorities. Participatory approaches using key 1. Map the areas in which hijras and other community informants (with Delphi consensus) male-to-female transgender people reside helped in site identifi cation.Nomination methods and/or where they can be potentially for size estimates were followed by site-visits for reached in 17 states of India verifi cation. Ten percent of the districts from each

ANNUAL REPORT 2013-14 30 state and a sub-sample of the mapped sites were the range of 53280-74297, with 21% TGs in rural randomly selected for validation, by an independent areas and the rest 79% in urban areas (Table 10.). team. Representatives from the community were Top fi ve states reporting the highest concentration involved at the planning and execution level. of TGs/Hijras were Maharashtra (10057), Uttar Results Pradesh (8001), Odisha (7854), West Bengal (6788) and Andhra Pradesh (5401) and they contributed A total of 5821 TG sites were mapped in the 17 study to 61% of total TG population. Of these 47% were states, with 1664 (28.6%) in rural areas and 4157 part of ‘gharanas’ (living in groups under ‘Gurus’). (71.4%) in urban areas. Top fi ve states reporting Among the estimated TG population in sex work the highest number of sites were Uttar Pradesh (825), West Bengal (752), Odisha (696), Tamil Nadu (62%), 72% were gharana based. Twenty-nine (649) and Maharashtra (586), comprising of about districts out of 466 districts in 17 states had more 60% of all sites. The total TG population (point than 400 TGs. Original estimates and estimation estimate) across the 17 states was 62137, with by validation teams yielded similar results.

Table 10: Total number of sites and size estimates of Hijras /TGs in 17 states of India

TG Identifi ed Size Estimate States Districts Sites Point Lower limit Upper limit Covered Mapped estimate 17 466 5,821 53,280 62, 137 74,297

Figure Map of India depicting the 17 states with TG sites

ANNUAL REPORT 2013-14 31 Conclusion

In 17 states of India, out of 466 districts, 29 districts had a point estimate of at least 400 TGs. In a phased manner, exclusive TG Targeted HIV interventions can be planned and implemented in sites reporting high number of TGs. In 11 states, 15 sites have been identifi ed for tracking HIV and risk behaviors of TGs through National Integrated Biological and Behavioural Surveillance of Department of AIDS Control, starting from 2013/14. 3.2 Study to understand prevention of HIV and explore barriers for women: A multi-stakeholder perspective on vaginal microbicides and other HIV new prevention technologies (NPTs)

Co-Principal Investigator (NIE) Thilakavathi Subramanian Co-Investigators (NIE) Sanjay Mehendale Collaborating Institute National AIDS Research Centre, Pune (Dr Seema Sahay) Funding Agency ICMR (extramural) Total budget Rs 923,024 Start date 11 Dec 2012 Study Period 1.5 year Status On-going

Rationale: Objectives Women in the general population often remain out of the purview of HIV prevention programs and 1. Explore knowledge, beliefs, attitudes, services which are mostly designed for high-risk need, experiences and concerns of women group populations. Availability and accessibility (high risk and general community) and to male condom is optimal; still usage has been other stakeholders towards existing HIV a challenge. This underscores women’s lack of prevention methods autonomy to negotiate for safer sex. Since for many 2. Explore partner’s perspective on potential women, it is not their behavior, but the behavior of use of vaginal microbicides and other their partners that makes them vulnerable to HIV new prevention technologies with specifi c infection, it is necessary to put control in the hands reference to couple dyad of women, while simultaneously being careful not to place undue burden and responsibility of protection 3. Understand needs and concerns of service on them. The vulnerability of women emphasizes providers for introduction of microbicides the need for new HIV prevention technologies that and other NPTs could be controlled and if not controlled, at least 4. Obtain multi-stakeholder insight into initiated by women.

ANNUAL REPORT 2013-14 32 the barriers and facilitators of access (2). Trained investigators conducted interviews and and potential usage of new prevention FGDs using guides. The interviews were recorded, technologies among women transcribed verbatim and translated in English for the purpose of analysis. Methods Using grounded theory approach, layers of The study sites are Chennai, Belgaum and Pune. data will be coded after constant reading and The lead Research organization is NARI, ICMR, comparisons. Multi-centric data will be analyzed Pune. The study is being conducted in Chennai and at NARI and report will be prepared. Data will Vellore districts of Tamil Nadu (One district each be analyzed using NUD*IST version 6.0 software from high and low HIV prevalent districts as per or Nvivo software. The quantitative data will be NACO guide lines). Qualitative data was collected analyzed in SPSS software using parametric and till data saturation was reached in each respondent non-parametric tests. category. The respondent categories include potential users, service providers, key infl uencers Current status and decision makers. The sample size for each site Data management is being done after the varies between 49 – 71. We conducted in-depth completion of data collection. interviews (81) and Focus Group Discussions (FGD) 3.3 Comprehensive approach to condom promotion yields results among long distance truckers who are clients of female sex workers in India: The case of Avahan interventions

Principal Investigator (NIE) Tarun Bhatnagar

National Institute of Medical Statistics, New Delhi (Damodar Sahu, Mandakranta Biswas, Arvind Pandey), Tata Institute of Collaborating Institute Social Sciences, Mumbai (Dipak Suryawanshi), London School of Hygiene and Tropical Medicine, London (Martine Collumbien)

Funding Agency Bill and Melinda Gates Foundation

Start date August 2011

Study Period 2 years Completed (Paper presented at 20th International AIDS Status Conference (AIDS 2014), Melbourne, July 2014

Background Methods As clients of female sex workers (FSW), truckers We analyzed data from 2009 cross-sectional are vulnerable to HIV and enhance the risk of survey for Integrated Behavioral and Biological transmission to their sex partners including Assessment. We created a composite variable, spouse. The Avahan interventions in India aimed ‘consistent condom use’, using six questions (‘every to mitigate such risks. time’ use with regular FSW AND ‘every time’ use

ANNUAL REPORT 2013-14 33 with occasional FSW AND used condom at last male partners and 56% (283/505) with all non- sexual intercourse with regular FSW AND used marital partners. In the last year, 43% (216) of condom at last sexual intercourse with occasional truckers were contacted by a peer educator, 38% FSW AND ‘every time’ use during anal sex with (191) participated in entertainment event, 35% FSWs AND not even one occasion when condom (178) visited the Avahan-branded “Khushi” clinic, was not used during anal or vaginal sex with a 30% (153) received counseling, 24% (121) received regular or occasional FSW). We used propensity condoms from peer educators, and 11% (57) score matching to estimate the impact of various attended training or meeting. Consistent condom Avahan intervention components on consistent use with FSWs was highest among truckers who condom use with FSWs by calculating the average attended trainings/meetings at 90%, 17.5% higher treatment amongst the treated (ATT). compared to the matched controls who did not Results attend (p=0.03; Table 11). Consistent condom use was also signifi cantly higher for truckers who Of 2085 truckers, we analyzed data from the received counseling (ATT=14%, p<0.01), were highest risk group of 505 (24%) who visited contacted by peer educator (ATT=13%, p=0.001), female sex workers in the last year. Prevalence participated in an entertainment event (ATT=12%, of consistent condom use by truckers was 75% p=0.001), visited “Khushi” clinic (ATT=11%, (379/505) with FSWs, 30% (44/145) with non-paid p=0.005) or received condoms (ATT=10%, p=0.02, non-marital female partners, 19% (14/73) with Table 11).

Table 11: Observed effect of Avahan interventions on consistent condom among long distance truckers who solicit female sex workers, IBBA-2, India (N=505)

Average Intervention component Consistent condom use (%) treatment effect for treated p-value (% exposed) Matched Treated (ATT %) untreated Contacted by peer educator (42.6%) 81.8 68.7 13.1 0.001 Attended entertainment event (37.7%) 81.6 69.4 12.2 0.001 Visited “Khushi” clinic (35.1%) 82.6 72.0 10.6 0.005 Received counseling (30.2%) 85.4 71.1 14.3 <0.01 Received condoms (23.9%) 83.3 73.3 10.0 0.02 Attend trainings/meetings (11.2%) 89.6 72.1 17.5 0.03

Conclusion All components of Avahan interventions among long distance truckers showed signifi cant impact on consistent condom use with FSWs. Ensuring sustainability of these interventions would be critical for HIV control among this key bridge population in India.

ANNUAL REPORT 2013-14 34 3.4 Assessment of services for prevention and management of infertility in the primary health care system in India

Principal Investigator (South Zone) Sanjay Mehendale

South zonal coordinator Thilakavathi Subramanian National Institute of Research in Reproductive Collaborating Institute Health, Mumbai (Sanjay Chauhan) Funding Agency UNFPA

Total budget Rs.512,760

Start date August 2012

Study Period March 2013

Status Completed

Rationale Specifi c Objectives

In India, there is lack of information on the 1. Assess knowledge and skills amongst availability, accessibility and utilization of providers at Sub centers (SCs), Primary prevention and management of facilities for Health Centers (PHCs), Community Health infertility – at different levels of health care in Centers (CHCs) and District Hospitals the public health care delivery systems. Recently (DHs) on prevention and treatment of NIRRH with WHO collaborating centres developed infertility. protocols for management of infertility; but this depends on the readiness of Primary health 2. Map readiness of sample facilities for care delivery system. Not much is known about providing services for prevention and available inputs, current management practices at treatment of infertility. different levels on primary care in public systems. 3. Make recommendations for designing Overall Objective appropriate programmatic interventions 1. Understand access and utilization of for addressing infertility. prevention and management services for infertility in the public health care delivery 4. Explore the social aspects of infertility system. including stigma and discrimination,

ANNUAL REPORT 2013-14 35 perceived causes of infertility among Results and conclusions couples in the study area; along with The districts chosen for the survey had high readiness of community for accessing prevalence of infertility as per DLHS 3. Infertility services for prevention and management of was perceived to be a problem in their area by infertility. majority of gynecologists and MOs and they

Methods reported that 5-6% of people visiting their facilities came with diffi culty in conceiving. This was a non-interventional, descriptive, cross The community had a perception of unavailability sectional survey of health facilities; carried out of infertility services at the public health facilities on the representative sample of facilities selected in their districts and thus often chose to visit the from six zones in the country (North, South, East, traditional healers or private practitioners. West, central & North-East). On consultation with UNFPA, 2 districts (with high prevalence rate) were While majority of staff at PHCs and sub-centres selected among each of the 6 zones from the DLHS- was in place, a number of key staff positions were 3 DataNIE was the South zone-study implementing lying vacant at CHCs. Less than 50% staff reported center. From South, 2 districts, namely, Nalgonda that they had received training on RTI/STI, IUCD from Andhra Pradesh and Kannur from Kerala were insertion and safe deliveries; none of them had selected. In these 2 districts, we visited 2 district received any in-service training on infertility. This hospitals, 4 community health centers, 8 primary is refl ected in inadequate knowledge on various aspects. health centers and 8 sub centers, interviewing 2 gynecologists, 1 general consultant, 1 Asst. surgeon None of the facilities had any IEC material on and 17 Medical Offi cers (MOs); 7 lab technicians, infertility and there were hardly any awareness 15 ANMs and 16 ASHAs. We also conducted 2 programs conducted in the community.Services Focus Group Discussion in each district; one under other national health programs on TB, RTI/ with married men (n= 10 – 12) and another with STI and safe deliveries were available at majority married women. There were checklists to be fi lled of health facilities but services for safe abortion for observing these health facilities. were not available at majority of CHCs and PHCs.

ANNUAL REPORT 2013-14 36 4. HEALTH SYSTEMS RESEARCH

4.1 Causes of referral out of female clients admitted in Comprehensive Emergency Obstetric and Neonatal Care (CEmONC) centres and maternal and foetal outcomes: A cross sectional study, Tamil Nadu, India, 2012-13

Principal Investigator (NIE) R. Ramakrishnan

Co-Investigators (NIE) R. Ezhil

Centre for Sexuality and Health Research and Policy Collaborating Institute/s (C-SHaRP)

Funding Agency Tamil Nadu Health Systems Project

Total budget 240,000

Start date May 2013

Study Period 1 year

Status Ongoing

Rationale headquarters and talukCEmONC centres (55) and referred out maternal clients from these centres Maternal mortality and neonatal mortality continue to be high in Tamil Nadu in spite of establishing during July 2012 to September 2012, in the state special care centres, namely, CEmONC centres. of Tamil Nadu, India were included in the study. An earlier evaluation of these centres revealed that We obtained the case sheets of all referred out these centres are referring out maternal clients to maternal clients of CEmONC centres, of Tamil other centres. The present study was initiated with Nadu state and collected outcome information of the following objectives. all maternal clients who were referred out from CEmONC centres during the period from July Objectives 2012 to September 2012 to tertiary care centres 1. To identify the reasons of referral out from such as Govt. Medical College and Hospital and CEmONC centres to other health facilities. District Govt. Hospital.

2. To identify the outcomes of referral out of Results maternal clients from CEmONC centres We received 1084 case sheet of maternal clients Methods referred out from 55 CEmONC centers to other A cross sectional study was conducted. All district health facilities from July 2012 to September 2012.

ANNUAL REPORT 2013-14 37 Out of 55 CEmONC centers, two centers had not was found to be 92%. In all, 6 (1.2%) mothers and reported any referred out cases during that period. 36(7%) babies died. Both mother and baby died Among the1084 case sheets, 960(89%) case sheets in 0.2% of referred out cases. It was observed were considered for data analysis. that there was a signifi cant (P<0.05) association The proportion of referred out maternal clients between type of CEmONC center and the delivery from district CEmONC centers was 52.3% and that outcome. All the six mothers died in this study from taluk CEmONC centers was 47.7%. About needed tertiary care. Again, four fi fth of the 50% of the maternal clients referred out were in babies died in this study for want of tertiary care. the age group 20-24 years. About three fourth of Out of 6 maternal deaths, 3 deaths were due to the maternal clients were in the gestational age maternal complication such as pregnancy induced of 33-40 weeks. The maternal mean gestational hypertension (1), previous LSCS(1) and premature age was 35 weeks and about 70% of the maternal rupture of membranes(1), the other 3 deaths were clients sought for antenatal care service in the due to other maternal complications. Out of 36 CEmONC centers. The proportion of Primipara child deaths, 4 deaths were associated with anti was 46 % and 17% had caesarean section in the partum hemorrhage and 8(22%) with pregnancy previous delivery. The proportion of hypertensives induced hypertension among their mothers. There among the maternal clients was 31% and 12% were 5 (14%) intrauterine deaths and 11(31%) due had hemoglobin level < 7 mg/dl. More than four to other complications. fi fth of maternal clients (82.2%) were referred to Conclusion medical college and hospital for further treatment and 13% of them were referred to district head Need for tertiary care was the major reason for quarter government hospital. The major reason referral out from CEmONC centres. Pregnancy for referring out of these maternal clients from Induced Hypertension and anemia were the main CEmONC centers was need for tertiary care (75%). clinical causes for referral out. Three fi fth of The main reason for referred out of maternal clients referred PIH cases actually reported in tertiary from CEmONC centres was pregnancy-induced care hospital for further treatment. There was no hypertension (21%). About one-fourth of referral major difference between normal and caesarean out cases was not directly related to pregnancy. pregnancy outcomes among referral out clients. Out of 960 study subjects, we could collect the Capacity building for doctors about obstetrical information on the outcomes of 535(55.7%) emergency management of Pregnancy induced individuals from 53 CEmONC centers. Nearly 84% hypertension might reduce the quantum of referral. were in the age group of 20-29 years. About 85% Referral system can be established to monitor the of the subjects were term pregnancy. Nearly half maternal clients. Middle level health managers of the pregnancy outcomes were normal delivery are needed to update information on maternal and about 46% women had caesarian section. The client events, especially for evaluating the ongoing delivery outcome for both mother and child alive projects.

ANNUAL REPORT 2013-14 38 4.2 Evaluation of hypertension management in the Non-Communicable Disease program in Chennai, Theni and Villupuramdistricts : Tamil Nadu Health Systems Project

Principal Investigator (NIE) Dr.Prabhdeep Kaur

Co-Investigators (NIE)

Collaborating Institute/s Government of Tamil Nadu

Funding Agency Tamil Nadu Health Systems Project

Total budget Rs 3,00,00,000

Start date July 2011

Study Period September 2014

Status Completed

Background pre and post intervention to assess the change in the treatment practices and self-management Government of Tamil Nadu has been implementing among patients with hypertension. The key community based and clinic based interventions objectives were to estimate the blood pressure for Non-Communicable diseases in 32 districts of control, level of adherence and self-management Tamil Nadu since 2012 through the World Bank practices among patients with hypertension in funded Tamil Nadu Health Systems Project the primary health centers/ government hospitals (TNHSP). Interventions include community based in Theni and Villupuram districts and the urban awareness to self help groups, awareness through PHC in Chennai. We also explored the prescription mass media and clinic based screening and practices for treatment of hypertension in the treatment for hypertension, diabetes, cancer cervix primary health centers/ government hospitals and cancer breast. Opportunistic screening is being in Theni and Villupuram districts and the urban offered in all Primary Health Centers (PHCs) and PHC in Chennai. hospitals for hypertension, diabetes, cancer cervix Methods and cancer breast for those visiting these facilities for any ailment or accompanying the patient. NIE We conducted pre intervention (Jan – May, has been working in collaboration with TNHSP, 2012) and post intervention (Jan-May, 2014) Govt. of Tamil Nadu for concurrent evaluation of cross sectional survey of the patients visiting the Non-Communicable Disease program. One of the selected primary health centers (PHC) and the components of the evaluation is patient surveys all the government hospitals in Villupuram and

ANNUAL REPORT 2013-14 39 Theni districts. We surveyed 18 urban PHC in up in Theni districts. Demographic characteristics Chennai where the interventions were initiated. of the population were similar at baseline and The patients in each health facility were recruited follow up in all the settings (Table 12 and 13.). consecutively starting from the fi rst hypertension There was decline in the Atenolol prescriptions patient reporting on the day of the survey. The in all the settings except urban PHC in Chennai. sample size for PHC was 180 from 15 PHC with There was increase in the Amlodipine prescriptions a cluster size of 12 patients. We included all the in the primary health centers of Villupuram and hospitals in Theni and Villupuram districts and Theni. the sample size was 32 per hospital. We used a semi-structured, interviewer administered There was increase in the proportion of patients questionnaire to collect data and the study was with comorbid diabetes taking treatment for approved by NIE Institutional Ethics Committee. hypertension in the primary health centers in We obtained informed consent from all the patients. Villupuram and Theni probably due to increased detection of diabetes in the screening program. Results Remarkable increase was observed in the proportion of patients who were counseled for dietary We surveyed 180 patients from PHCs in Villupuram changes and physical activity by the health staff and Theni and 216 in Chennai urban PHC at in all the settings. There was anincrease in the the baseline. During follow up, 185 patients at proportion of patients who reported having reduced Villupuram and Theni PHC and 200 in Chennai salt in the diet in all the settings. There was no urban PHC were surveyed. In the hospitals, we increase in the proportion of patients who started surveyed 339 patients at baseline, 350 at follow up walking regularly except in PHCs in Theni. There in Villupuram and 224 at baseline and 220 at follow was an increase in the awareness regarding target

Figure 5: Non-Communicable Disease clinic run by staff Figure 6: Patient exit interview being conducted by NIE staff at nurse in PHC in Villupuram, Tamil Nadu, 2014. a PHC in Villupuram district, Tamil Nadu, 2014.

ANNUAL REPORT 2013-14 40 organ complications of hypertension, however, Conclusion and Recommendations overall proportion of patients who had awareness was low. Two thirds or higher proportion of the We recommended that the training of doctors should be further strengthened with special focus patients continued to be from the nearby areas on case management to improve the prescription similar to the baseline with travel time less than practices for modifying dose or adding second 30 minutes. Majority of the patients got prescribed drug to achieve blood pressure control. NCD drugs from the pharmacy similar to the baseline. nurses should be periodically sensitized to sustain Proportion of patients who received one month the periodic counseling with a focus on physical drugs from the hospital pharmacy increased from activity, target organ complications and need nil to as high as 93% in Villupuram PHC with for long term adherence to drugs. Logistics and minimal change in the Chennai urban PHC (nil to planning should be improved to ensure availability 10%). There was an increase in the proportion of of adequate number of drugs so that the drugs can patients who achieved blood pressure control in all be prescribed for one month in all the settings. the settings. Improvement was higher in the PHCs Novel interventions might be developed to increase of Villupuram (38% vs. 47%) and Theni (29% vs. access to treatment for patients who are staying in 43%). the areas far away from PHC or hospitals.

Table 12: Summary of fi ndings in Primary health centers Villupuram, Theni and Chennai, 2011-14

Villupuram Theni Chennai Follow- Follow- Follow- Baseline Baseline Baseline up up up N=180 N=185 N=180 N=186 N=216 N=200 Demographic characteristics (%) Age >60 years 63 66 70 72 49 60 Females 63 67 57 59 79 71 Never attended school 56 57 40 61 34 41 Labourer (skilled/unskilled/ 35 39 38 39 16 10 agricultural) Drugs prescribed for hypertension (%)

Amlodipine 28 41 52 55 44 40

Atenolol 70 53 67 44 43 57

ANNUAL REPORT 2013-14 41 Enalapril 15 27 21 25 24 44 Co morbidities (%) Diabetes 26 34 28 36 58 44 Heart disease 5 9 11 1 7 11 Asthma/Respiratory diseases 8 10 5 3 6 13 Lifestyle modifi cations (%) Reduced fried snacks 47 34 53 44 45 40 Reduced salt intake 59 64 41 79 40 47 Started walking regularly 12 8 14 20 22 24 Counselling on Lifestyle modifi cation by government medical staff (%) Diet 54 84 62 83 57 70 Physical activity 7 34 9 67 13 56

Anti-hypertensive drug adherence for 36 42 47 70 67 63 previous 30 days (%)

Awareness of consequences of high BP (%) Kidney problem 8 15 7 20 2 20 Eye problem 4 26 11 20 3 22 Health system issues (%) Time to reach hospital >30 min 27 29 21 13 4 8 Getting medicines from hospital 86 88 95 96 96 76 pharmacy Advised by staff regarding prescribed 86 99 88 96 99 98 drug schedule

Anti-hypertensive drugs issued for 30 0 93 0 59 0 10 days (%)

Achieved BP control (Systolic <140mmHg,Diast <90 38 47 29 43 25 30 mmHg) (%)

ANNUAL REPORT 2013-14 42 Table 13: Summary of fi ndings in Government Hospitals, Villupuram and Theni, 2011-14

Villupuram Theni Baseline Follow-up Baseline Follow-up N=339 N=350 N=224 N=220 Demographic characteristics (%) Age >60 years 57 55 59 59 Females 54 64 60 62 Never attended school 41 50 47 52 Labourer (skilled/unskilled/ agricultural) 30 28 46 35 Drugs prescribed for hypertension (%) Amlodipine 52 52 57 56 Atenolol 47 36 52 46 Enalapril 25 29 27 45 Co morbidities (%) Diabetes 30 35 35 36 Heart disease 11 9 13 10 Asthma/Respiratory diseases 7 10 8 8 Lifestyle modifi cations (%) Reduced fried snacks 49 60 42 50 Reduced salt intake 47 69 37 62 Started walking regularly 13 12 20 13 Counselling on Lifestyle modifi cation by government

medical staff (%) Diet 58 72 51 82 Physical activity 9 42 13 58 Anti-hypertensive drug adherence for past 30 days (%) 40 49 50 82 Awareness of consequences of high BP (%) Kidney problem 11 19 13 9 Eye problem 15 19 9 25 Health system issues (%) Time to reach hospital more than 30 min 28 34 30 23 Getting medicines from hospital pharmacy 75 85 90 96

ANNUAL REPORT 2013-14 43 Advised by staff regarding prescribed drug 79 89 67 86 schedule Anti-hypertensive drugs issued for 30 days (%) 0 88 0 28 Achieved BP control 36 37 25 38 (Systolic <140mmHg,Diast <90 mmHg) (%)

4.3 Coverage and effectiveness of Japanese Encephalitis vaccine, Gorakhpur, Uttar Pradesh

Principal Investigator (NIE) Manoj Murhekar Co-Investigators (NIE) Prashant Ranjan, Sriram Selvaraju, Sanjay Mehendale Funding Agency ICMR (extramural) Start date Aug 2013 Study Period Mar 2014 Status Completed

Background 2. From each district, we sampled 40 clusters (villages/urban localities) using probability In the Gorakhpur division of Uttar Pradesh, JE proportional to size and selected 20 children from vaccine was introduced in the routine immunization each cluster. After obtaining the written informed programmein 2011, as a single dose strategy for consent, information about socio-demographic and children aged between 16-24 months, administered vaccination details was obtained from the mothers. along with DPT/OPV booster. We conducted a Information about vaccination status was collected study to estimate the coverage and effectiveness of based on the vaccination card and mother’s history the vaccine. if the child did not have the vaccination card. Objectives To estimate the effectiveness of JE vaccine, we conducted an un-matched case-control study. AES 1. To estimate coverage of JE vaccine case-patients, resident of Gorakhpur or Basti administered under the routine division aged between 24-54 months admitted immunization programme in Gorakhpur in the BRD Medical College, Gorakhpur, with 2. To estimate the effectiveness of JE vaccine laboratory confi rmed JE infection based on IgM antibodies in serum and/or cerebrospinal fl uid Methods were considered as cases and healthy children We did a cross sectional survey among children aged between 24-54 months were considered as aged 24-54 months to estimate the JE vaccine controls. The mothers of the cases and controls were coverage. We needed a sample size of 800 per interviewed using a semi-structured questionnaire district assuming the vaccination coverage of 20%, to collect information about socio-demographic absolute precision of + 4% and a design effect of characteristics and JE vaccination status after

ANNUAL REPORT 2013-14 44 obtaining written informed consent. Results

We surveyed 3200 children from four districts of Gorakhpur division. The coverage of JE vaccine in the division was 51% and ranged between 36% in Kushinagar to 66% in Gorakhpur district (Figure 2). The coverage was not different by gender or caste groups.

The common reasons cited by the mothers for non vaccination of their children included lack of information about the vaccination, and obstacles for vaccination such as place/timing of vaccination being inconvenient and mother being too busy or out of station. before the next transmission season beginning in We included 33 cases and 66 controls in the case- July/August as well as in view of high attack rates control study. About 76% of JE cases and 48% of among under-fi ve children, health authorities controls were aged >36 month. The cases and might consider conducting another mass JE controls were similar with respect to gender and vaccination campaign targeting children aged caste groups. 18% of cases and 53% controls had 1-5 years. It is also necessary to make mothers history of JE vaccination. On univariate analysis, aware about the need to administer two doses the JE cases as compared to healthy controls, were of JE vaccine, which are given free of cost in all more likely to be older (OR: 3.32, 95% CI: 1.31-8.42), the public health facilities in the division. Public unvaccinated (OR associated with vaccination: health managers in the division also need to be 0.2 0.07-0.54) and not have the vaccination card assured that the JE vaccine currently used in the (OR: 6.1, 95% CI: 2.22-16.77). The age and gender programme has acceptable effectiveness. adjusted odds ratio associated with JE vaccination was 0.16 (95% CI: 0.05-0.47). The effectiveness of the vaccine was 84% (95% CI: 53-95).

Conclusions The coverage of JE vaccine in the Gorakhpur division was low with only half of the eligible children in Gorakhpur division receiving one dose of the vaccine. The effectiveness of one-dose JE vaccination strategy with SA-14-14-2 strain was high and was comparable with studies conducted in Nepal and China. There is an urgent need to improve the coverage of JE vaccine in the division. In order to achieve high population immunity

ANNUAL REPORT 2013-14 45 5. PUBLIC HEATH TRAINING PROGRAMMES

5.1 The ICMR School of Public Health at the National Institute of Epidemiology has been conducting two-year Master of Public Health (Epidemiology and Health Systems) and one-year Post-Graduate Diploma in HIV Epidemiology courses. The highlights of these programmes during the year 2013-14 are as under: Master of Public Health (Epidemiology and Health Systems) • MPH course is in its sixth year.

• All 17 scholars of the fourth (2011) cohort graduated.

• 21 scholars of the fi fth (2012) cohort were in the process of data collection for their dissertation until March 2014.

• 11 scholars were admitted in the sixth cohort in July 2013 (2 Karnataka, 3 Maharashtra, 1 Mizoram, 1 Nagaland, 1 Odisha, 2 Tamil Nadu, 1 NIRT-ICMR, Chennai)

4TH COHORT OF MPH (2011-13) GRADUATED

5.1.1 Dissertation projects by MPH scholars, Dr. HM Siddaraju / Mentor: Dr. R 2011-13 Ramakrishnan, Scientist F

5.1.1.1 Estimation of injection safety practices In India, annually two third of the 3-6 billion in health care facilities and awareness of safe injections are administered in unsafe manner. injection among prescriber, provider and In Nicobar, prevalence of the Hepatitis B chronic community in Nicobar District, India, 2013 carrier is 22.2%. In Nicobarese tribe, unsafe

ANNUAL REPORT 2013-14 46 injection was a risk factor for HBV infection. among community regarding VHSNCs was low. Proportion of the population that received injection Lack of knowledge sharing between FHWs /AWWs in the past 3 months was 22% at the rate of 3 and the community was evident. Capacity building injections per capita per year. This community of VHSNC members, monitoring and supervision, based and facility based cross sectional survey was intersectoral convergence and sustained efforts for conducted to estimate prevalence of unsafe injection community participation are needed for the success practices in health care facility and awareness of of the VHSNC initiative of NRHM. safe injection among the people of Nicobar district. Proportion of individual receiving at least one 5.1.1.3 The level of preparedness of households injection in the past 3 months was 17.7% at the rate and associated factors for cyclone disasters of 2.1 injections per capita per year. Therapeutic in rural communities of 3 coastal blocks of injection was 79% (74.3-83.4). Over use of injection Cuddalore District, Tamil Nadu Jan-March and unsafe injection practices are prevalent in 2013 Nicobar district. Two third of the therapeutic Dr. T Senthilvel / Mentor: Dr. Thilakavathi injections were unnecessary and avoidable. This Subramanian, Scientist F can be reduced by interactional group discussion with prescriber and the community. Cuddalore is a coastal district of Tamil Nadu on Bay of Bengal and was classifi ed as “Wind very 5.1.1.2 Status of Village Health Sanitation and high damage risk zone-B” by Ministry of Urban Nutrition Committees in district Chamba, Development. The objectives of the study were to Kangra and Una, Himachal Pradesh, 2013 estimate the current level of disaster preparedness Dr. Shrikant Chavan / Mentor: Dr. Sanjay for cyclone and to determine the factors associated Mehendale, Director & Scientist G with the unpreparedness of the households in rural communities of the three coastal blocks of NRHM emphasises involvement of PRI and Cuddalore District. We conducted a cross sectional community in management of primary health study among 600 households. Nearly half of the programmes by the formation of VHSNC at the households were unprepared for cyclones. The revenue village level. We conducted this study in respondents who were unable to defi ne cyclone districts Chamba, Kangra and Una of Himachal and those who never received information on Pradesh to assess the structure of VHSNCs, preparedness for cyclones were more likely to be estimate awareness among their members and in unprepared for cyclones. Most of the respondents the community. We also determined the factors were unaware of spread of communicable diseases associated with the lack of awareness about during post cyclone period and their preventive VHSNCs among the members and community. measures. They were also unaware of availability We interviewed ten members including FHW, of alternate health facilities in the post cyclone AWW, PRI member from each of 40 VHSNCs and period. ten households from respected panchayats. We also performed records review. The structure of 5.1.1.4 Infl uence of Social Risk Factors on VHSNCs was not as per NRHM guidelines. Most Child Immunization in four tribal– dominated of the VHSNCs were non functional. Awareness states of North-east

ANNUAL REPORT 2013-14 47 Dr. Raja Dodum / Mentor: Dr. Tarun 5.1.1.6 Utilization of services under Janani Bhatnagar, Scientist C Shishu Suraksha Karyakram (JSSK) for Institutional deliveries in Government Child immunisation is determined by various social risk factors. This study was done in four Health facilities, Sirmaur district, Himachal tribal dominated states of India with an objective to Pradesh, India, 2013 determine factors infl uencing immunization status Dr. Uvi Tyagi / Mentor: Dr. Prabhdeep Kaur, of children aged 12-23 months. We analysed the pooled secondary data of 2006 NFHS-3 survey of Scientist C four north-eastern states. Home delivery, teenage Government of India launched Janani Shishu motherhood, ANC and religion were signifi cant Suraksha Karyakram (JSSK) scheme in June variables associated with incomplete immunization 2011 to eliminate the out of pocket expenses for coverage. The fi ndings suggest multiple approaches for improving children’s immunization and need families of pregnant women and sick newborns for further research. in government health facilities. We estimated the proportion of mothers who received JSSK benefi ts 5.1.1.5 Adherence and factors associated for different components in the facilities providing with adherence in Diabetic treatment among JSSK in Sirmaur district. We estimated out of Patients attending public health care settings pocket expenditure (OOP) if any and determined in Villupuram District Tamil Nadu, January the factors associated with not receiving benefi ts - March 2013 of JSSK scheme among mothers. We did cross Dr. Dhruba Mahajan / Mentor: Dr. R sectional survey among 156 women who delivered Ramakrishnan, Scientist F in the seven public sector facilities where JSSK was implemented in district Sirmaur, Himachal Tamil Nadu has started implementing preventive, Pradesh, India. 75 (48%) mothers received the curative management of diabetes in all districts. The full benefi ts of JSSK scheme. Overall, 133 (85%) objectives of the study were to estimate adherence mothers had OOPs during their delivery with among the diabetic patients to the anti diabetic median expenditure of 605 INR. The major areas medication and to determine the factors associated where OOP was incurred were consumables, with adherence in public health care settings. drugs and transport though large proportion got We did a cohort study among 166 patients≥30 reimbursed for transport. There was inadequate years, non pregnant and getting treatment for ≥3 awareness regarding benefi ts. There is need for months in same hospital. One third respondents cashless transport facility and adequate provision were non adherent to the diabetic drug treatment. of drugs and consumables. Low awareness need The lack of self awareness regarding regular to be addressed by educating the mothers in the follow up at hospital, not maintaining life style antenatal period. activities and lack of knowledge regarding drug benefi t were associated with non adherence. In 5.1.1.7 Prevalence of chronic complications order to improve adherence we recommend more of diabetes among type 2 diabetic patients comprehensive counseling services for attending treated at primary health centers in hospital, awareness on LSM and understanding of Kanchipuram district of Tamil Nadu, drug benefi t. India-2013

ANNUAL REPORT 2013-14 48 Dr. M Karthikeyan / Mentor: Dr. BN Murthy, determine the factors associated with non-use of Scientist G temporary modern methods of contraception among eligible couples. We conducted a case control study The major outcome of type 2 diabetes is its among 142 cases and 122 controls in Nongstoin chronic complications that causes prolonged block. We identifi ed lack of knowledge about hospitalization, disability and premature death, availability and misconceptions about methods of reducing the quality of life and imposing immense contraception as the major determinants of non- burden on the health care system. We did a hospital use of contraception. We also determined that based cross sectional study involving 12 study communication between couples and with other participants from each of the 16 selected PHCs. friends can have positive effects on contraceptive Prevalence of ischemic heart disease, stroke, CKD, use. Health workers need to inform couples about peripheral neuropathy were 7.81 (95% CI 4.02- the various methods available and the correct 11.60), 1.02 (95% CI-0.17-3.33), 10.4 (95% CI-4.68- way to use contraception. Reorientation of health 16.14) and 18.8 (95% CI-10.89-26.61). Prevalence workers may help to improve contraception use in of having atleast one complication was 32.8 (95% the region. CI- 26.20-39.90). Prevalence of hypertension and hyperlipidemia were 61.5 (95% CI-53.21- 69.70) 5.1.1.9 Factors associated with defi nite and 86% respectively. More than half had no birth asphyxia among newborns of low-risk knowledge on diabetic complications. Unemployed antenatal mothers in Poonamallee Health and those who were not aware about LSM were Unit District, Tamil Nadu, 2013: Hospital- statistically associated with having atleast one of based case-control study the complication. Routine screening and awareness Dr. E Sree Kalpana / Mentor: Dr. P Manickam, programs are needed at primary care level. Scientist C 5.1.1.8 Barriers to temporary modern We identifi ed that birth asphyxia was the leading contraceptive use among eligible couples of cause of infant deaths in Poonamallee health Nongstoin Block, West Khasi Hills District, unit district (HUD) of Tamil Nadu. Therefore, we Meghalaya conducted a hospital based case- control study to Dr. Rapborlang Laloo / Mentor: Dr. Tarun identify factors associated with birth asphyxia in Bhatnagar, Scientist C this setting. We interviewed 70 defi nite cases and 70 controls. We identifi ed that birth asphyxia was At 3.8, Meghalaya has one of the highest total fertility associated with incomplete ANC visits, prolonged rates in the country. The contraceptive prevalence labor pain, any oedema during labor, prolonged rate among currently married women age 15-49 straining and rupture of membranes by health is 24%. However knowledge about contraception staff. We recommended increasing compliance to among eligible couples is relatively high at 90% complete ANC, educating health workers to identify and sub centers and primary health centers have oedema at the time of admission for labour, and adequate human resource for satisfactory delivery prevent prolonged straining and artifi cial rupture of family planning services. Our objective was to of membranes.

ANNUAL REPORT 2013-14 49 5.1.1.10 National Rural Health Mission’s Cancer cervix is leading cause of cancer among rural Community-based monitoring of health women in India. The government of Tamil Nadu services and status of key health parameters has initiated an opportunistic screening program at village level, Tamil Nadu, 2013 for cancer cervix and cancer breast since 2011 in primary care settings. Our primary objective was Dr. Lalit Sarode / Mentor: Dr. P Manickam, to estimate the proportion of women willing for Scientist C cervical & breast cancer screening and to determine India’s National Rural Health Mission pilot- the factors associated with not willing. We did a tested Community-Based Monitoring (CBM) of cross sectional study among 240 women aged ≥ 30 years attending 16 PHCs (selected through health services through Village Health Sanitation, cluster sampling technique) in Villupuram District Nutrition Committees (VHSNC) with the aim to during 2013. Overall 29% were willing for cancer decentralize planning as per local needs. During cervix screening and 35% were willing for cancer 2007-2012, CBM was implemented in selected breast screening. We observed low acceptance of areas of Tamil Nadu and analysis of data from cancer screening among women attending PHCs in these areas indicates improvements in village Villupuram district. Lack of awareness of cancer health parameters. As a next logical step, we treatment & screening in PHCs was a risk factor conducted a cross- sectional survey to (1) compare for not willing for cancer screening. Family history status of village health parameters in CBM and of cancer was one of the key motivating factors non-CBM areas and determine the VHSNC related for screening acceptance. Awareness need to be factors that are associated with satisfactory village improved by using various media as well as through health parameters. Total score for village health community health workers. Community outreach parameter was higher in CBM compared to non- strategy might also improve the participation for CBM area (range 32-80 vs. 23-57, p<0.0001). cancer screening. Specifi cally, the service components of emergency 5.1.1.12 Awareness of cervical cancer and transportation, tuberculosis and preventive utilization of screening for cancer cervix services, maternity benefi t scheme, transparency among female health care workers in in services and social welfare societies were better Kancheepuram district of Tamil Nadu State in CBM areas (p<0.0001). VHNSC’s formation, in India 2013 their meetings, community needs assessment and Dr. D Bella Devaleenal / Mentor: Dr. Sanjay planning were signifi cantly associated with good Mehendale, Director & Scientist G panchayat category. Awareness in the community and health 5.1.1.11 Willingness for cervical cancer, breast professionals regarding early cancer detection is cancer screening and associated factors for vital. We did a cross sectional survey among female not willing among women attending Primary health care workers (FHCWs) in Kancheepuram district in Tamil Nadu to estimate the awareness of health centres in Villupuram district, Tamil cancer cervix and utilization of screening for cancer Nadu, 2013 cervix by them and to study the factors infl uencing Dr. M Senthil Kumar / Mentor: Dr. Prabhdeep the same. The study population included 132 Kaur, Scientist C female medical offi cers and staff nurses (Group I),

ANNUAL REPORT 2013-14 50 and 265 health nurses and ANMs (Group II) who practices. Most of the trained Staff Nurse had were ≥ 30 years of age working in Primary Health adequate knowledge and practices about normal centres and Government hospitals. Of all FHCWs, labour, management of complications of labour, 42% (56/132) in Group I and 6% (15/265) in Group PPH and Partograph ,active management of third II had adequate awareness. Of all, 13% (17/132) stage of labour, use of Magnesium sulphate during in Group I and 31% (82/265) in Group II had eclamptic convulsion, reparing of tears, providing undergone screening for cancer cervix at least once prophylactic eye care while one fourth of not trained (P value <0.001). Self- decision was the reason for undergoing routine screening in 82% (14/17) and had adequate knowledge and practices. Immediate 61% (50/82) in Group I and II respectively. There conduction of training for all not trained ANM and is a need for immediate interventions to improve Staff Nurse are needed. the awareness of cervical cancer and utilization of 5.1.1.14 Burden of retinopathy amongst cervical cancer screening among female health care diabetic patients attending public health workers. With more awareness and sensitization, facilities in Kancheepuram District, Tamil the female health care workers will be more Nadu, India 2013 willing to accept screening for cervical cancer and Dr. Tony Frederick / Mentor: Dr. J Yuvaraj, motivated to encourage the patients for the same. Scientist E 5.1.1.13 Comparison of knowledge and There is an increasing trend in the prevalence of practice among the trained and not trained Auxiliary Nurse Midwife and Staff Nurse diabetes and its related micro-vascular complication regarding core skills of Skilled Birth diabetic retinopathy (DR) in India. DR is one of the Attendance in Birbhum district ,West Bengal main causes for avoidable blindness in the working ,India,2012- 2013 age group. We investigated the independent associations between the stage of DR and possible Dr. Subhabrata Ghosh / Mentor: Dr. J Yuvaraj, risk factors among 270 diabetic patients attending Scientist E two rural public health facilities. The prevalence In India skilled birth attendance training program of diabetic retinopathy among them was 29.6%. for ANM/SN was launched in 2005 under NRHM to Factors associated with the presence and severity provide quality care for all during antenatal, labour of diabetic retinopathy were hypertension, longer and postnatal period and there by saving the life duration of diabetes, drug adherence, blood fasting of mothers and infants. We conducted a study in sugar > 130 mg dl and nephropathy. Direct and Birbhum district of West Bengal to describe and to indirect ophthalmoscopy can be used as an effective compare the knowledge and practice of core skills screening tool for early detection of DR and institute of SBA between trained and not trained ANM and control measures.There is a need for formulating Staff Nurse and to determine the factors associated effective strategies to prevent avoidable blindness with the practices.We interviewed 234 ANM and by 1) maintaining strict glycemic control, 2) 100 Staff Nurse working in Birbhum district. Most regular ophthalmic examinations, 3) behavior of the trained ANM had adequate knowledge and change communication, awareness and targeted practice about antenatal and postnatal care. Most intervention for strict adherence of drug and diet of the not trained had inadequate knowledge and control.

ANNUAL REPORT 2013-14 51 5.1.1.15 Process evaluation of Integrated inappropriate dietary practices (high fried food and Management of Neonatal and Childhood soft drinks consumption, low fruits and vegetable Illnesses (IMNCI) Program in Thanjavur consumption), higher level of experimentation district, Tamil Nadu, 2013 with alcohol and to a lesser extent smoking among adolescent boys. The study also showed high Dr. N Kalusivalingam / Mentor: Dr. R prevalence of under nutrition among adolescents. Ramakrishnan, Scientist F Child mortality is a sensitive indicator of a country’s 5.1.1.17 Newborn care practices among socio economic development. In Tamil Nadu mothers and status of the Home Based IMNCI training was initiated during 2007-08. Our Postnatal Care (HBPNC) programme under objectives were to describe the implementation of National Rural Health Mission in Mewat, Haryana, India, 2013 IMNCI program in Thanjavur district of Tamil Nadu and to evaluate the knowledge of IMNCI Dr. Latika Nath / Mentor: Dr. Prabhdeep trained health workers in case management. We Kaur, Scientist C conducted a cross sectional survey among the In India, the Home-Based Postnatal Newborn Village health nurses and Anganwadi workers in Care (HBPNC) programme by the Accredited four blocks in Thanjavur district. There were many Social Health Activists (ASHAs) under NRHM was vacancies in all categories of staff. There was a initiated in June 2011 to reduce neonatal mortality defi cit in the availability of logistics and drugs. Only which contributes to 68% of the infant mortality. less than half of VHNs and one fourth of AWWs Mewat district in Haryana has a high NMR of had the knowledge of all the danger signs. Our 47/1000 live births. We estimated the knowledge, recommendations were to provide necessary health attitude and practices and determined the factors workers and train those untrained, to conduct associated with unsafe newborn care practices refresher training and to provide continuous supply among mothers. We also estimated key indicators and replenishment of drugs and other logistics. with respect to trainings, knowledge, timeliness, 5.1.1.16 Behavioural risk factors for Non quality and documentation of ASHAs’ home Communicable diseases among adolescents visits. We did a cross-sectional survey among 320 of rural areas, Kancheepuram district, mothers in Mewat district and 61 ASHAs serving Tamilnadu 2013. in the selected subcentres. There were knowledge- practice gaps in adoption of safe practices even Dr. KR Ramaprasad / Mentor: Dr. BN Murthy, among mothers counseled by ASHAs. The poor Scientist G utilization of RCH services decreased opportunities Developing countries like India face a huge burden for ASHA-mother dialogue on adoption of safe of morbidity and premature mortality due to non- practices .There was no supervision of ASHAs communicable diseases. This study was done to home visits and documentation by ANMs .We determine prevalence of lifestyle associated risk recommend training of all ANMs, training of dais factors for non-communicable diseases among as ASHAs, innovative communication strategies 492 adolescents in the age group of 14 to 19 for advocating safe practices and improved years of rural areas of Kancheepuram district of responsiveness of the ‘102 referral services’ to Tamil Nadu.We documented high prevalence of newborn emergencies in the district.

ANNUAL REPORT 2013-14 52 5.1.2 Field projects by scholars of MPH 5th cohort (2012-14)

Secondary MPH scholar Program Evaluation NIE mentor Data Analysis

Dr. S. Meenachi Declining proportion of girls at Evaluation of ‘female foeticide prevention Dr. R Ramakrishnan, Sc. F birth at Cuddalore District, Tamil through scan centre audit’component of Nadu, India, 2001 to 2011- Cause RCH II programme at Cuddalore district, for concern Tamil Nadu, India, 2013

Dr. Kechongol Sophie Profi le of patients Registered at Program Evaluation of Measles Dr. Tarun Bhatnagar, Angami ART Centre of Kohima district, Immunization under Universal Sc. C Nagaland India, 2007-2012 Immunization Program in Kohima district, Nagaland Dr. Santanu Sen Epidemiological profi le of malaria Evaluation of malaria control programme Dr. MV Murhekar, Sc. F in East Singhbhum district, under the National Vector Borne Disease Jharkhand, 2010-12 Control Programme in Manoharpur block, West Singhbhum district, Jharkhand, India, 2013

Dr. K.S.T. Suresh Infant mortality rate in Program Evaluation of Infant death Dr. BN Murthy, Sc. G Tiruvallur, Tamilnadu, 2009-13 audit component of RCHP II, Tiruvallur, Tamilnadu, 2013 Dr. N Romila Devi Prevention of parent to child Evaluation of Prevention of Parent to Dr. J Yuvaraj, Sc. E transmission of HIV, Manipur, child transmission of HIV Programme, 2007-2011 Imphal East district,Manipur 2013

Dr. Anadi Gupt Clinico-epidemiological profi le Evaluation of Rashtriya Swasthya Dr. BN Murthy, Sc. G and management practices of Bima Yojana (RSBY) in District Solan, snake bite cases admitted at Zonal Himachal Pradesh, 2013 Hospital, District Solan, Himachal Pradesh, India, 2008-12

Dr. M. Anitha Secondary data analysis of 108 Evaluation of Emergency Ambulance Dr. SM Mehendale, emergency ambulance services, services - 108 for pregnancy, delivery & Sc. G Dindugul district, 2008 - 2013 postpartum care - RCH II in Dindigul district, Tamilnadu, 2013 Dr. Bichitrani Marak Prevention, management and Description and evaluation of prevention, Dr. CP Girish Kumar, control of sexually transmitted management and control of sexually Sc. C infection and reproductive tract transmitted infection/reproductive tract Dr. Tarun Bhatnagar, infection, sexually transmitted infection programme, District Hospital Sc. C infection clinic, District Hospital, West Garo Hills, Meghalaya, 2013 West Garo Hills, Meghalaya, India, 2008-12 Dr. Nilanjan Dastidar Analysis of Kala-azar Surveillance Evaluation of Kala-azar Elimination Dr. P Manickam, Data of Murshidabad District, Programof Murshidabad District, West Sc. C West Bengal, India, 2005-12 Bengal, India, 2013 Dr. Gandira Ch. Marak Malaria in East Garo Hills Evaluation of the Malaria control Dr. Prabhdeep Kaur, district, Meghalaya from 2008 to component of National Vector Borne Sc. C Disease Control Programme, East Garo 2012 Hills district, Meghalaya,2013

Dr. Atasi Mondal Surveillance data documents Refresher training and improved Dr. P Manickam, Sc. C higher occurrence of road traffi c logistics can increase the performance accidents and deaths among of community link workers in maternal younger age-group in fi ve blocks and child health services in Berhampur of Murshidabad district, West subdivision, Murshidabad district, West Bengal, India, 2008-12 Bengal, India, 2013

ANNUAL REPORT 2013-14 53 Dr. Kavita Profi le of Prevention of Evaluation of programme for Early Dr. Joseph K.David, Sc. C S. Dodamani Parent To Child Transmission Infant diagnosis of HIV, Bagalkote Dr. MV Murhekar, Sc. F of HIV in Bagalkote district, District, Karnataka, India, 2013 Karnataka, India, 2011-13

Dr. Bibha R. Marak Secondary data analysis Evaluation of Revised National Dr. Prabhdeep Kaur, of Revised National Tuberculosis Control Programme in Sc. C Tuberculosis Control East Garo Hills District, Meghalaya, Programme in East Garo 2013 Hills District, Meghalaya, 2008 -2012

Dr. MB Deshmukh Analysis of Integrated Assessment of Home Based Dr. Sanjay Mehendale, Sc. G Management of Care component of Integrated Neonatal and Childhood Management of Neonatal and IllnessesProgrammein rural Childhood Illnesses in Igatpuri area of Nashik District, block, Nashik district, Maharashtra, Maharashtra, India,2012 India,2013

Dr. Jaybrata Deb Analysis of surveillance data Evaluation of Kala-azar Elimination Dr. R Ramakrishnan, of Leishmaniasis (Kala-azar) Programme Darjeeling district, Sc. F in Darjeeling District, West West Bengal, India, 2013 Bengal, India, 2007-12

Dr. S. Babu Analysis of Chief ministers Evaluation of a Chief Ministers Dr. Thilakavathi Comprehensive Health Comprehensive Health Insurance Subramaniam, Sc. F Insurance Scheme, Scheme in Chennai and Dindigul Tamilnadu 2013 Districts 2013 Dr. Prashant Ranjan Changes in acute encephalitis Evaluation of Japanese Dr. MV Murhekar, Sc. F syndrome incidence after EncephalitisImmunization introduction of Japanese component of Universal encephalitis vaccine in a Immunization Program (UIP), region of India District Gorakhpur, Uttar Pradesh, India, 2013 Dr. Sampada Prevalence and determinants Evaluation of Intensifi ed TB Case Dr. Thilakavathi Dhayarkar of voluntary HIV testing fi nding component of HIV-TB Subramaniam, Sc. F & report collection among Collaborative Activities at National Dr. Sanjay female sex workers in three AIDS Research Institute, ART Mehendale, Sc. G HIV high prevalent states of center, Pune, Maharashtra, 2013 India- Analysis of Integrated Behavioral & Biological Assessment (IBBA) Round II 2009-10

Dr. DS Nipte Analysis of sex ratio at Evaluation of maternal health Dr. Sanjay birth in Beed District, component of Reproductive and Mehendale, Sc. G Maharashtra, India, 2008- Child Health (RCH) II program in 2013 Beed District, Maharashtra, India 2013

ANNUAL REPORT 2013-14 54 5.2 Postgraduate Diploma in HIV Medical Science and Technology (SCTIMST), Epidemiology Thiruvananthapuram, Kerala. The course, open for medical graduates only, is constituted of 30 The objective of the program is to develop a self credits involving classroom teaching at NIE sustaining institutionalized capacity of public health workers in applied HIV epidemiology and partner institutes and fi eld projects for HIV at fi eld level and competent in addressing HIV situation analysis, secondary data analysis, and public health needs and priorities effi ciently and evaluation of HIV-related surveillance system and effectively. It is expected that in the long term intervention program. PGDHE will lead to improved surveillance systems Second cohort of four scholars (2 West Bengal, 1 contributing to health system strengthening and Maharashtra, 1 Uttarakhand) admitted for the increased improved human resource capacity at the national level. The program is funded by Tamil course starting in July 2013 completed their course Nadu State AIDS Control Society with the support in June 2014. of CDC-Global AIDS Program, India. The funding for the course came to an end with The one-year postgraduate diploma program the second cohort. Hence, PGDHE program is no is affi liated to Sri ChitraTirunal Institute for longer offered by ICMR SPH at NIE.

5.3 Centrally Coordinated Bioethics education in India

Principal Investigator (NIE) Dr SM Mehendale & Dr R Ramakrishnan

Affi liations IGNOU and NIH

Funding Agency NIH, USA

Total budget $266,500

Start date May 2008

Study Period 6 years (after obtaining 1 year extension)

Status Ongoing

The grant was for conducting short-term bioethics education program and initiating Diploma program in Bioethics in collaboration with ‘Indira Gandhi National Open University (IGNOU). First batch of 50 students have completed the diploma and the second batch of 50 are currently doing the program. Virtual classes through internet and two face-to-face programs were conducted during the year 2013-14.

ANNUAL REPORT 2013-14 55 6.0 WORKSHOPS / TRAINING PROGRAMMES ORGANIZED

Basic Secondary Data Analysis Workshops for M&E assistants, Tamil Nadu State AIDS Control Society Dates: 16-17 Apr 2013 Participants: 20 M&E assistants from District AIDS Prevention Control Units of Tamil Nadu Funding agency: Tamil Nadu State AIDS Control Society Outcome: Training done for use of Excel software for analysis of HIV program data

Annual Internal Review Meeting (6thMay, 2014)

Outcome: Steps to improve the surveillance activity for Bacterial Meningitis were discussed and further corrective actions were suggested.

Hospital based sentinel surveillance for Bacterial Meningitis Investigators meeting (HBSSBM)and Experts meeting Date: 6- 7 May 2013 Participants: Investigators from 11 sentinel sites, coordinating sites and reference laboratory Annual Review Meeting of Expert Group site along with a representative from ICMR HQ (7thMay, 2014) participated. Experts from all over India joined the above group for the second day. Regional Training on Pre Surveillance Assessment (PSA) for Integrated Biological Funding agency: Ministry of Health and Family and Behavioral Surveillance (IBBS) Welfare.

ANNUAL REPORT 2013-14 56 Date: 4-5June 2013 Use of SPSS for data analysis Participants: Around 75 participants from WHO, Date: 18 – 20 December 2013 CDC, FHI 360, PHFI, NACO, NIE, TANSACS, Participants: 31 APSACS, KSACS, PACS, State Surveillance Funding agency: Participant funded Members (SST) and IMRB Outcome: Trained in statistical data analyses Funding agency: NACO using SPSS Outcome: The participants were trained on Basic Secondary Data Analysis Workshops protocol, guidelines of fi eld work, monitoring for ART data managers, Tamil Nadu State and evaluation of Pre Surveillance Assessment AIDS Control Society activities for IBBS 2014. Date: 27-28 Feb 2014 Participants: 20 district-level ART data managers from Tamil Nadu

Funding agency: Tamil Nadu State AIDS Control Society

Outcome: Training in use of Excel software for analysis of data from ART centres

BASIC Course in statistics Date: 24 – 28 June 2013 Participants: 44 Funding agency: Participant funded Outcome: Trained in basics of bio-statistics

Advanced course in statistics Date: 17 – 21 March 2014 Participants: 14 Funding agency: Participant funded Outcome: Trained in advanced statistical methodology like ANOVA,Survival analysis etc.

ANNUAL REPORT 2013-14 57 Pop Council, TANSACS, APSACS, KSACS, PACS, State Surveillance Members (SST) and IMRB research agency Funding agency: NACO Workshop on Analysis of Data from HIV/AIDS Surveillance/Programme for Maharashtra State AIDS Control Society Date: 10-14 March 2014 Participants: 25 participants, including data managers, M&E assistants and Program Offi cers Funding agency: Maharashtra State AIDS Control Society

Data management training workshop for ICMR Antimicrobial Resistance Surveillance Network Date: 26 March 2014 Participants: 17 participants from PGIMER, Chandigarh, AIIMS, New Delhi, ICMR, New Delhi, JIPMER, Pondicherry, and CMC, Vellore Funding agency: ICMR Outcome: Training of data managers in using

Outcome: Training in assessment of data quality, basic epidemiological analysis and preparing tables, graphs and EpiInfo maps

online data capture system and development of SOPs for data collection and validation. Regional Training of Trainers meeting (ToT) for Integrated Biological and Behavioral Surveillance (IBBS) Date: 31March to 5 April 2014 Participants: 70 participants from NIE, FHI 360,

ANNUAL REPORT 2013-14 58 7.0 PUBLICATIONS

Impact factor 1 Kaur, P, Chitra GA, Mehendale SM, Katoch VM. Perceptions of State Government 1.661 stakeholders & researchers regarding public health research priorities in India: An exploratory survey. IJMR. 2014 Feb; 139: 231-235 2 Ranjan P, Gore M, Selvaraju S, Kushwaha KP, Srivastava DK, Murhekar M. Changes 4.073 in acute encephalitis syndrome incidence after introduction of Japanese encephalitis vaccine in a region of India. J Infect. 2014 Mar;S0163-4453(14)00083-8 3 Ramachandran V, Kaur P, Kanagasabai K, Vadivoo S, Murhekar MV. Persistent 0.97 arthralgia among Chikungunya patients and associated risk factors in Chennai, South India.J Postgrad Med. 2014 Jan-Mar;60(1):3-6 4 *Alexander M, Mainkar M, Deshpande S, Chidrawar S, Sane S, Mehendale S. 3.073 Heterosexual Anal Sex among Female Sex Workers in High HIV Prevalence States of India: Need for Comprehensive Intervention. PLOS one. 2014 Feb;9(2):e88858 5 *Tilghman MW, Bhattacharya J, Deshpande S, Ghate M, Espitia S, Grant I, Marcotte 2.217 TD, Smith D, Mehendale S. Genetic attributes of blood-derived subtype-C HIV-1 tat and env in India and neurocognitive function. J Med Virol. 2014 Jan;86(1):88-96. 6 Ranjan A, Bhatnagar T. Estimation of under-reported visceral Leishmaniasis (Vl) cases in Bihar: a Bayesian approach. Ind J Com Heal.2013 Oct-Dec;25 (04):386-390 7 Mathai, A.K and Murthy B.N. Regression Model to Analyze Differential Response to - Treatment in Randomized Controlled Clinical Trial. J Math Syst Sci. 2013; 3(9): 419- 425. 8 Mathai, A.K and Murthy B.N. Some Practical Issues Related to Univariate Regression Analysis Prior to Multivariate Regression Analysis in Randomized Controlled Clinical Trials. J Math Syst Sci. 2013; 3(8): 371-380. 9 Singh, A and Murthy B.N. Lot Quality Assurance Sampling for Monitoring and - Evaluation of Immunization Coverage in District Solan, Himachal Pradesh, India, 2011. J Comm Med Heal Educ 2013, 4(1):1-3 10 Thilakavathi S, Lakshmi R, Santhakumar A Prabuddhagopal G, Boopathi K, Mathew 2.32 S, Rajat A, Girish Kumar CP et al. Increasing condom use and declining STI prevalence in high-risk MSM and TGs: evaluation of a large-scale prevention program in Tamil Nadu, India. BMC Pub Heal 2013 Sept;13:857. 11 Koli S, Pallipurath Radhakrishnan AN, Jacob M, Vadivoo S, Girish Kumar CP 1.096 Occurrence of hepatitis B virus genotype B and B+C mixed infections in Chennai, South India. Braz J Infect Dis. 2013 Sep-Oct;17(5):615-6.

ANNUAL REPORT 2013-14 59 12 Arima Y, Zu R, Murhekar M, Vong S, Shimada T. Human infections with avian - infl uenzaA(H7N9) virus in China: preliminary assessments of the age and sex distribution. Western Pacifi c Surveil Response J. 2013; 4(2):1-3

13 Murhekar M, Arima Y, Horby P, Vandemaele K, Vong S, Zijian F et al. Avian infl uenza - A(H7N9) and the closure of live bird markets. Western Pacifi c Surveill Response J. 2013; 4(2):1-5 14 Dagina R, Murhekar M, Rosewell A, Pavlin B. Event-based surveillance in Papua - New Guinea: strengthening an International Health Regulations (2005) core capacity. Western Pacifi c Surveill Response J. 2013; 4(3):1-3 15 Murhekar M, Dutta S, Ropa B, Dagina R, Posanai E. Vibrio cholerae antimicrobial - drug resistance, Papua New Guinea, 2009–2011. Western Pacifi c Surveill Response J. 2013; 4(3);1-5 16 Uthayakumaran N, Venkatasubramanian S. Multilevel Estimation of Outcome - Parameters in Surveillance Studies. Int J Stat and Analy. 2013;3(3):297-305

17 Uthayakumaran N, Venkatasubramanian S. Dual Circular Systematic Sampling - Methods for Disease Burden Estimation. Int J Stat and Analy. 2013;3(3):307-322

18 Thilakavathi, S, Mathai AK, Kumar N. Knowledge and practice of clinical ethics - among healthcare providers in a government hospital, Chennai. Indian J Med Ethics. 2013 Apr-Jun;10(2):96-100. 19 Senthilkumar B, Ramakrishnan R. Reducing average length of stay in critical care - unit. Retell. 2013;13(2);69-75

20 Chitra GA, Kaur P, Bhatnagar T, Manickam P, Murhekar MV. High prevalence of 1.094 household pesticides and their unsafe use in rural south India. Int J Occup Med and Environ Health. 2013;26(2):1-8 21 Bhatnagar T, Brown J, Saravanamurthy PS, Mohan Kumar R, Detels R. Color-Coded 3.312 Audio Computer-Assisted Self-Interviews (C-ACASI) for Poorly Educated Men and Women in a Semi-rural Area of South India: ‘‘Good, Scary and Thrilling’’. AIDS Behav. 2013 July;17(6):2260-8 22 *Pereira M, ShetaD,Shivahari V. Ghorpade, Gaikwad SN, Lokhande RM, Tripathy SP, 2.958 Mehendale SM. Anti-tuberculosis drug resistance in previously untreated pulmonary tuberculosis patients in pune, India. Int J Pharm Bio Sci 2013 July; 4(3): 579 – 585 23 *Sahay S, Nirmalkar A, Sane S, Verma A, Reddy S, Mehendale S. Correlates of Sex 0.919 Initiation among School Going Adolescents in Pune, India. Indian J Pediatrics. 2013 Oct; 80(10): 814-820

(*Publications based on research work carried out at NARI)

ANNUAL REPORT 2013-14 60 8.0 STAFF MEMBERS (AS ON MARCH 2014)

Sl.No. Name Designation 17 Mr. K. Boopathi Technical Assistant (Research) Group-A - Scientifi c Staff 18 Mr. M. Kirubanithy Technical Assistant 1 Dr. Sanjay M. Mehendale Director & Scientist-G 19 Ms. P. Jayasree Technical Assistant (Research) 2 Dr. B. Narasimha Murthy Scientist-G 20 Mr. T. Daniel Rajasekar Technical Assistant (Research) 3 Dr. M.V. Murhekar Scientist-F 21 Mr. V. Ramachandran Technical Assistant (Research) 4 Dr. R. Ramakrishnan Scientist-F 22 Mr. G. Elavarasu Technical Assistant (Research) 5 Dr. Thilakavathi Subramanian Scientist-F 23 Mr. M. GangadharaRao Technical Assistant (PMW) 6 Dr. VidyaRamachandran Scientist-F 24 Mr. S. Lucas Leonard Technical Assistant (PMW) 7 Mr. A. Elangovan Scientist-E 25 Ms. Mercy Mallika Technical Assistant (PMW) 8 Dr. J. Yuvaraj Scientist-E 26 Mr. M. Thiyagarajan Technical Assistant 9 Mr. J. Arockiasamy Scientist-D 27 Mr. A. Mohan Technical Assistant (PMW) 10 Dr. Joseph K. David Scientist-C 28 Mrs. M. Dhanalakshmi Technical Assistant 11 Dr. PrabhdeepKaur Scientist-C 29 Mrs. P. Kannaki Technical Assistant 12 Dr. C.P. Girish Kumar Scientist-C 30 Mrs. A. Tamilarasi Technical Assistant 13 Dr. TarunBhatnagar Scientist-C 31 Mrs. P. Shantha Technical Assistant 14 Dr. P. Manickam Scientist-C 32 Ms. P. Lourdu Stella Mary Technical Assistant 15 Dr. RajkumarPrabu Scientist-B 33 Mrs. R. Shanthi Technical Assistant 16 Dr. V. Selvaraj Scientist-B 34 Mrs. M.R. Santhi Technical Assistant Group-A - Technical Staff 35 Mrs. I. Kalaimani Technical Assistant 1 Mrs. R. Jayasri Technical Offi cer - B 36 Mr. P. Ashok Kumar Technical Assistant (PMW) Group-B - Technical Staff 37 Mr. R. Balasubramanian Technical Assistant (PMW) 1 Mr. N. Ramalingam Technical Offi cer - A 38 Mr. A. Jeya Kumar Technical Assistant (Research) 2 Dr. Vasna Joshua Technical Offi cer - A 39 Mr. S.A. Raveendra Technical Assistant 3 Dr. R. Ezhil Technical Offi cer - A 40 Mr. N. Vengatesan Technical Assistant 4 Mr. L. Sundaramoorthy Technical Offi cer - A 41 Mr. T. Karunakaran Technical Assistant(Laboratory) 5 Mr. C. Govindhasamy Technical Offi cer - A 42 Mr. A. Suresh T. A.(Health System Research) 6 Mr. K. Kanagasabai Technical Offi cer - A 43 Ms. R. Vijayaprabha Technical Assistant (Social Work) 7 Mr. B.K. Kirubakaran Technical Offi cer - A Group-C - Technical Staff 8 Mr. M. Ravi Technical Offi cer - A 1 Mr. R. Kadirvelu Technician - C (PMW) 9 Dr. S. Venkatasubramanian Technical Offi cer - A 2 Mr. Rakesh Kumar Yadav Technician - C (PMW) 10 Mr. V. Periannan Technical Offi cer - A 3 Mr. T. Ravichandran Technician - C (PMW) 11 Mrs. R. Sudha Technical Offi cer - A 4 Mr. M. JaggaBabu Technician - C (PMW) 12 Dr. N. Uthayakumaran Technical Offi cer - A 5 Mr. C. Sagayanathan Technician - C (PMW) 13 Mr. Rang LalMeena Technical Offi cer - A 6 Mr. R. Harikrishnan Technician - C (PMW) 14 Mr. S. Satish Asst.Library& InformationOffi cer 7 Mr. V. Ramesh Technician - C (PMW) 15 Mr. V.N. Mahalingam Technical Assistant (Research) 8 Mr. D. Augustine Technician - C (PMW) 16 Mr. P. Kamaraj Technical Assistant (Research) 9 Mr. T. SubbaRao Technician - C (PMW)

ANNUAL REPORT 2013-14 61 10 Mr. D. Murugan Technician - C (PMW) Group-C -Administrative Staff 11 Mr. R. Gopinath Technician - C (PMW) 1 Mrs. G. UmaiyaParvathy UDC 12 Mr. K. Satish Kumar Technician - C (PMW) 2 Mr.P. Raja UDC 3 Mr. Raj Kumar UDC 13 Mr. R. Ramakrishna Rao Technician - C (PMW) 4 Mr. R. Arumugam Stenographer 14 Mr. M. Anthony Doss Technician - C (PMW) 5 Mrs. R. Janaki Stenographer 15 Mr. C. Prabakaran Technician - C (PMW) 6 Mrs. K. Mahalakshmi Stenographer 16 Mr. P. Osoor Technician - C (PMW) 7 Mr. A. Subramani LDC 17 Mr. A. Gnanamurthy Technician - C 8 Mrs. P. Sharly Devi LDC 18 Mr. A. Thangavelu Technician - C 9 Mr. S. Suresh LDC 19 Mrs. Annamma Jose Technician - C 10 Mr. S. Yesudoss Staff Car Driver (Special Grade) 20 Mr. A. Krishna Kumar Technician - C 11 Mr. P. Baskaran Staff Car Driver (Grade-I) 21 Mr. M. Murali Mohan Technician - C 12 Mr. A. Mani Staff Car Driver (Grade-I) 22 Mr. K. Ramu Technician - C 13 Mr. S. Sittayya Staff Car Driver (Grade-I) 23 Mr. A. Kaleb Raja Kumar Technician - C 14 Mr. K. Paramasivam Staff Car Driver (Grade-I) 15 Mr. D. Anandaraj Staff Car Driver (Grade-I) 24 Mr. P. Ramu Technician - B 16 Mr. R. Ranganathan Staff Car Driver (Grade-II) 25 Mr. V.S. Ashok Kumar Technician - B 17 Mr. D. Justinraj Staff Car Driver (Grade-II) 26 Mr. R. Ravi Technician - B 18 Mr. E. Thiruppugazh Staff Car Driver (Grade-II) 27 Mr. M. Tamilmani Technician - B Supportive Staff 28 Mr. K..Damodaran Technician - B 1 Mr. K. Swaminathan Field Assistant 29 Mr. S. Baskaran Technician-A 2 Mr. A. Mani Field Assistant 30 Mr. D. Prabaharan Technician-A 3 Mr. L. KulBahadur K.C. Field Assistant 31 Mr. M. Saravanan Technician-A 4 Mr. P. Thulasi Attendant (Services) 32 Mr.A. ValliTheivanaiPangalan Technician-A 5 Mr. K. Loganathan Attendant (Services) 33 Mr. H. Dinesh Kumar Technician-A 6 Mr. K. Shanmugam Attendant (Services) Group-B -Administrative Staff 7 Mrs. A. Nirmala Attendant (Services) 8 Mr. M. Anbalagan Attendant (Services) 1 Mr. T. Jagan Assistant Accounts Offi cer 9 Mr. E. Gandhidoss Attendant (Services) 2 Mr. N.K.S. Brahaspathy Private Secretary 10 Mr. S. Sudandaraselvan Attendant (Services) 3 Mr. A. Murugarasan Private Secretary 11 Mr. M.R. Ravi Attendant (Services) 4 Mrs. D. Parvathi Section Offi cer 12 Mr. E. Anandan Attendant (Services) 5 Mrs. R. Udayalakshmi Section Offi cer 13 Mr. V.PenchalaNarasaiah Attendant (Services) 6 Mr. Michael Antony Joseph Section Offi cer 14 Mrs. S. Mallika Attendant (Services) 7 Mr. S. Kumaravel Assistant 15 Mrs. S. Sarada Attendant (Services) 8 Mrs. ShanthiBalasubramanian Assistant 16 Mrs. K. Kasthuri Attendant (Services) 9 Mrs. K. Pappu Assistant 17 Mr. N. Maharaja Attendant (Services) 10 Mrs. Uma Manoharan Personal Assistant 18 Mrs. S. Jamuna Attendant (Services) 11 Mrs. R. Alamelu Personal Assistant 19 Mr. A.S. Madhan Attendant (Services) 12 Mr.G.S. Munikrishna Gandhi Assistant 20 Mr. D. Mahendran Attendant (Services)

ANNUAL REPORT 2013-14 62