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Print ISSN: 0976-3325
Electronic ISSN: 2229–6816 NATIONAL JOURNAL OF COMMUNITY MEDICINE
Official Journal of the National Association of Community Medicine
Electronic ISSN: 2229–6816
EDITORIAL BOARD
Editor Emeritus:
Dr. R. K. Bansal
Chief Editor
Dr. S. L. Kantharia
Joint Editor
Dr. A. B. Pawar
Executive Editor
Dr. Prakash Patel
Guest Editor
Dr. Manoj Kumar Bansal
Members
Dr. Anupam Verma, Surat
Dr. J. K. Kosambiya, Surat
Dr. A. M. Kadri, Rajkot
Dr. N. B. Dholakia, Gandhinagar
Dr. Girish Thakar, Surat
Dr. Mohua Moitra, Surat
Dr. Rachna Prasad, Surat
Dr. Deepak Saxena, Surat
Dr. Sunil Nayak, Surat
Dr. Naresh Godara, Surat
Ms. Swati Patel, Surat
All the views expressed in the articles are the personal views of the authors and should not be
considered as the official views of the National Journal of Community Medicine or the Association.
The Journal retains the copyrights of all material published in the issue. However, reproduction of the
published material in part or total in any form is permissible with due acknowledgement of the
source as per ethical norms.
The journal is archived in IndMEDICA, CAB Abstract, Index Copernicus International, DOAJ, Open J-Gate
and Global Health.
ADDRESS FOR CORRESPONDENCE
The Executive Editor, National Journal of Community Medicine
Department of Community Medicine, Surat Municipal Inst. of Medical Education & Research
Opp. Bombay Market, Umarwada, Surat- 395 010
Mobile: 094260 39663
Website: www.njcmindia.org Email: [email protected]
Publisher:
Dr. Priyanka Patel,
C-104, Teaching Staff Quarters, SMIMER Campus,
Opp. Bombay Market, Umarwada, Surat – 395010.
Email: [email protected]
NATIONAL JOURNAL OF COMMUNITY MEDICINE 2011 Vol 2 Issue 1
Electronic ISSN: 2229–6816 NATIONAL JOURNAL OF COMMUNITY MEDICINE
Volume 1, Issue 2, Pages 1 – 174, January - June 2011
TABLE OF CONTENT
Page
EDITORIAL
the Growing Challenge of Coronary Heart Disease in South Asia- Implications for the Community and
Health System
Manoj Kumar Bansal .................................................................................................................................................
1-3
ORIGINAL ARTICLE
Knowledge Attitude and Practices for Antenatal Care and Delivery of the Mothers of Tea Garden in
Jalpaiguri and Darjeeling Districts, West Bengal
Prabir Kumar Manna, Debasis De, Debidas Ghosh ........................................................................................
4-8
Certain Modifiable Risk Factors in Essential Hypertension: A Case-Control Study
Sunil M Sagare, S S Rajderkar, B S Girigosavi ..................................................................................................
9-13
Assessment of Nutritional Status of Rural Early Adolescent School Girls in Dantan-II Block, Paschim
Medinipur District, West Bengal
Soumyajit Maiti, Kauhik Chattterjee, Kazi Monjur Ali, Debidas Ghosh Shyamapada Paul......................
14-18
Study of Socio-Demographic Profile of Burn Cases Admitted in Shri Chhatrapati Shivaji Maharaj
General Hospital, Solapur
Haralkar Santosh Jagannath, Tapare Vinay S, Rayate Madhavi V ................................................................
19-23
Profile of Pediatric Malignancy: A Three Year Study
Bhalodia Jignasa N, Patel Mandakini M ...........................................................................................................
24-27
A Study To Assess the Unmet Needs of Family Planning in Gwalior District and To Study the Factors
that Helps in Determining It
Srivastava Dhiraj Kumar, Gautam Pramod, Gautam Roli, Gour Neeraj, Bansal Manoj .............................
28-31
A Study on Coverage Utilization and Quality of Maternal Care Services
Neeraj Agarwal, Abhiruchi Galhotra, H M Swami .........................................................................................
32-36
Study of Satisfaction of Patients Admitted in a Tertiary Care Hospital in Nagpur
M V Kulkarni, S Dasgupta, A R Deoke, Nayse ................................................................................................
37-39
Missed Opportunities of Janani Suraksha Yojana Benefits Among the Beneficiaries in Slum Areas
Wadgave Hanmanta Vishwanath, Gajannan M Jatti, Upendra Tannu ........................................................
40-42
Prevalence and Epidemiological Correlates of Hypertension Among Labour Population
S E Mahmood, Anurag Srivastava, V P Shrotriya, Iram Shaifali, Payal Mishra ..........................................
43-48
Cervical Pap Smear Study and Its Utility in Cancer Screening to Specify the Strategy for Cervical Cancer
Control
49-51
Mandakini M Patel, Amrish N Pandya, Jigna Modi .......................................................................................
Knowledge of Tuberculosis and Its Management Practices Amongst Postgraduate Medical Students in
Pune City
Rahul R Bogam, Sunil M Sagare ........................................................................................................................
52-59
Study on Work Related Factors of Agate Grinders in Shakarpura-Khambat, Gujarat
Deepak B Sharma, Tushar A Patel .....................................................................................................................
60-63
Electronic ISSN: 2229–6816 Seroprevalence of Leptospirosis in South Gujarat Region by Evaluating the Two Rapid Commercial
Diagnostic Kits Against the Mat Test for Detection of Antibodies To Leptospira Interrogans
Tanvi Panwala, Summaiya Mulla, Parul Patel .................................................................................................
64-70
Combined Use of Metoclopramide and Glycopyrrolate as a Prophylactic Antiemetic in Elective
Cesarean Section Under Spinal Anesthesia
Dinesh Thakur, Mihir Goswami, Himanshu Shah ..........................................................................................
71-74
General Anaesthesia Control Mode versus Local Anaesthesia With Intravenous Sedation for Day Care
Laparoscopic Tubal Ligation
Dinesh Thakur, Mihir Goswami, Himanshu Shah ..........................................................................................
75-77
Epidemiological Correlates of Contraceptive Prevalence in Married Women of Reproductive Age Group
in Rural Area
Sujata K. Murarkar, S. G. Soundale ...................................................................................................................
78-81
Screening for Pre-Malignant Conditions in the Oral Cavity of Chronic Tobacco Chewers
Priyanka Mahawar, Shweta Anand, Umesh Sinha, Madhav Bansal, Sanjay Dixit .....................................
82-85
Adolescence Awareness: A Better Tool to Combat HIV/AIDS
Anurag Srivastava, Syed Esam Mahmood, Payal Mishra, V P Shrotriya, Iram Shaifali ............................
86-90
Epidemiological Profile of Enteric Fever Cases Admitted in Scsmgh, Solapur
Malangori A.Parande, C. G. Patil, Madhavi V Rayate, Mehboob U Lukde .................................................
91-95
Study of Prevalence of Diarrhoeal Diseases Amongst Under Five Population
Shailesh Sutariya, Nitiben Talsania, Chintul Shah ..........................................................................................
96-99
An Interventional Study (Calcium Supplementation & Health Education) on Premenstrual Syndrome Effect on Premenstrual and Menstrual Symptoms
Shailesh Sutariya, Nitiben Talsania, Chintul Shah, Mitesh Patel...................................................................
100-104
Contraceptive Knowledge, Attitude and Practices in Mothers of Infant: A Cross-Sectional Study
Priyanka Mahawar, Shweta Anand, Deepa Raghunath, Sanjay Dixit ..........................................................
105-107
Outbreak Investigation of Cholera in Bharuch City
Navneet G. Padhiyar, Jivraj Damor ...................................................................................................................
108-110
Comparative Study of Selected Parameters of Gender Discrimination in Rural versus Urban Population
of Ahmedabad, Gujarat
Rashmi Sharma, S Mukherjee ............................................................................................................................. 111-115
A Study on Occupational Pain Among Dentists of Surat City
Sumit Moradia, Prakash Patel ............................................................................................................................
116-118
Epidemiology of Disability in Incident Leprosy Patients At Supervisory Urban Leprosy Unit of Nagpur
City
L B Chavan, Prakash Patel .................................................................................................................................. 119-122
Correlates of Hypertension Among the Bank Employees of Surat City of Gujarat
Ashwinkumar M Undhad, P J Bharodiya, Rupalben P. Somani ...................................................................
123-125
Microalbuminuria in Diabetic Patients: Prevalence and Putative Risk Factors
Deepak Parchwani, S.P. Singh ............................................................................................................................
126-129
Clinical and Socio-Demographic Profile of Patients Registered at ART Centre, SMIMER, Surat
Hitenkumar P Sonani, Ashwinkumar M Undhad, Ghanshyambhai T Savani ............................................
130-132
Epidemiological Factors Associated With Hypertension Among Tribal Population in Gujarat
Bhadresh Mandani, Bhavesh Vaghani, Manishkumar Gorasiya, Parul Patel ..............................................
133-135
Electronic ISSN: 2229–6816 Histological Grading of Oral Cancer: A Comparison of Different Systems and their Relation to Lymph
Node Metastasis
Doshi Neena P, Shah Siddharth A, Patel Keyuri B, Jhabuawala Munira F ..................................................
136-142
Nutritional Status and Dietary Pattern of Underfive Children in Urban Slum Area
Narkhede Vinod, Likhar Swarnakanta, Pitale Smita, Durge Pushpa ...........................................................
143-148
CASE REPORT
A Report of Two Cases: Post Flood Autopsy Findings in Urban Patients with an Unusual Presentation
of Leptospirosis with Hemorrhagic Pneumonia in Government Medical College, Surat
Mandakini M Patel, Bhavna Gamit, R D Patel, Rahul Modi ..........................................................................
149-151
A Case of Malignant Low Grade Endometrial Stromal Sarcoma and Review of the Literature
Amrish N Pandya, Arpita Nishal, Hemali Tailor ............................................................................................
152-154
A Case of Invasive Micro Papillary Carcinoma of the Breast With Literature Review
Amrish N Pandya, Arpita Nishal, Hemali Tailor ............................................................................................
155-157
SPECIAL ARTICLE
Census 2011: Important Health Related Messages
Rashmi Sharma, Ajesh Desai ..............................................................................................................................
158-160
SHORT COMMUNICATION
Evaluation of Pre-Test and Post-Test Knowledge Questionnaire after Intensive ICTC Team Training
among Health Care Workers
Vaibhav Gharat, Bipin Vasava, Sushil Patel, Rupani Mihir, Bhautik Modi .................................................
161-162
ORIGINAL ARTICLE
Male Child Preference for the First Child Decreasing among Women in Surat City
Thakkar Dhwanee, Viradiya Hiral, Shaikh Nawal, Bansal RK, Shah Dhara, Shah Shashank ..............................
163-165
A Study of 100 Cases of Brachial Plexus
Ojaswini Malukar, Ajay Rathva .........................................................................................................................
166-170
Female Foeticide Perceptions and Practices among Women in Surat City
Shaikh Nawal, Viradiya Hiral, Thakkar Dhwanee, Bansal RK, Shah Dhara, Shah Shashank ...................
171-174
INSTRUCTION FOR AUTHORS
Electronic ISSN: 2229–6816 National Journal of Community Medicine is Online……..
All full text articles can be downloaded ……
www.njcmindia.org
ISSN: 0976 3325
. Editorial .
THE GROWING CHALLENGE OF CORONARY HEART DISEASE IN SOUTH ASIAIMPLICATIONS FOR THE COMMUNITY AND HEALTH SYSTEM
Manoj Kumar Bansal MD, DM (Cardiology)
Cardiovascular diseases are major causes of
mortality and disease in the Indian
subcontinent, causing more than 25% of deaths.
The epidemic of cardiovascular diseases
(coronary artery disease and stroke) in India is
advancing rapidly and there has been a
dramatic rise in the prevalence of Coronary
Artery Disease in India which is further
projected to rise substantially. It is predicted that
India will be host to more than half the cases of
heart disease in the world within the next 15
years. Apart from the high burden of
cardiovascular diseases, what is even more
distressing is the fact that they affect the
productive workforce aged 35–65 years.
Coronary artery disease catches Indians young
and they manifest coronary heart diseases 5–10
years earlier than in other populations around
the world. The mean age for first presentation of
acute myocardial infarction in Indians is 53
years. In India about 50% of the CHD-related
deaths occur in people younger than 70 years
compared with 22% in the West. Such
premature coronary artery disease can have
devastating consequences for an individual, the
family, and society. Between the years 1990 and
2020, CHD is anticipated to increase by 120% for
women and 137% for men in developing
countries as compared to 30%–60% in developed
countries. In developed nations the rise in the
burden of CVD occurred over several decades
due to a long period of epidemiological
transition. In India, perhaps because of the rapid
pace of economic development, epidemiological
changes have spanned a much shorter time.
Quantification of the exact disease burden
cannot be done in India since there are relatively
few mortality studies from India, as there is no
uniform completion of death certificates and no
centralized registry for cardiovascular diseases.
However the WHO and the World Bank
estimate
that
deaths
attributable
to
cardiovascular diseases have increased in
parallel with the expanding population in India,
and that cardiovascular diseases now accounts
for a large proportion of disability adjusted life
years(DALY) lost. Wasir et al reported an
increasing trend and significant burden of CHD
NATIONAL JOURNAL OF COMMUNITY MEDICINE 2011 Volume 2 Issue 1
cases in the cardiology out-patient department
and medical admissions to a Delhi-based
tertiary care hospital. From 1966 to 1970, CHD
was present in 18.4% of all heart diseases cases
seen at the All India Institute of Medical
Sciences, Delhi. This changed to 16.5% in the
period of 1971–75, 15.2% in 1976–80 and 19.7%
in 1981–85. In the same years, the proportion of
CHD cases in hospital admissions increased
from 20.8% to 21.0%, 20.3% and 23.9%,
respectively. Pooled data from the states of
Assam, Madhya Pradesh, Punjab, Kerala, and
Karnataka reveals that as proportion of all
cardiac admissions to various government
hospitals, CHD increased from 14% in 1970 to
19% in 1985. At Vellore (South India),
admissions due to CHD in a non-government
hospital steadily increased from 4% in 1960 to
33% in 1989, indicating increasing burden on the
healthcare system. The prevalence of CAD in
urban India is about double the rate in rural
India and about 4-fold higher than in the U.S.
The rates appear to be higher in south India
with Kerala having a prevalence of 13% in urban
areas and 7% in rural areas.
In India, the economic impact of the increase in
cardiovascular diseases was estimated at 9
billion dollars in national income from
premature deaths due to heart disease, stroke
and diabetes in 2005 alone, with the projected
estimates of 237 billion dollars by 2015. The outof-pocket health expenses incurred by
households increased from 31.6 per cent in 1995
to 47.3 per cent in 2004. Modelling studies have
estimated that if non-communicable diseases
(NCDs) were completely eliminated, the
estimated GDP in a year would have been 4-10
per cent higher.
The INTERHEART study has brought a lot of
clarity in our understanding of multiple well
established physiological and behavioral risk
factors for incident myocardial infarction. This
study was an international casecontrol study,
carried out in 52 countries involving15152
cases of incident acute myocardial infarction
(AMI) and 14820 controls and estimated the
hazard ratios and population-attributable
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ISSN: 0976 3325
fractions for multiple risk factors for incident
myocardial infarction in several regions of the
world. It was revealed that abnormal lipids,
smoking, hypertension, diabetes, abdominal
obesity,
psychosocial
stress,
decreased
consumption of fruits and
vegetables,
moderate
consumption
of
alcohol, and
physical activity accounted for most of the
risk of myocardial infarction worldwide.
Collectively, these nine risk factors accounted
for 90 per cent of the population attributable
risk (PAR) in men and 94 per cent in women.
The risk of heart attacks imposed by these risk
factors was similar in both sexes, for all the
population\groups studied at all ages in all
regions emphasizing the role of environmental
origin of cardiovascular risk factors for all the
ethnicities of the world. The effect of the risk
factors is particularly striking in young men
(PAR about 93%) and women (about 96%),
indicating that most premature myocardial
infarction is preventable. Worldwide, the two
most important risk factors are smoking and
abnormal lipids. Together they account for
about two-thirds of the PAR of an acute
myocardial infarction. Psychosocial factors,
abdominal obesity, diabetes, and hypertension
were the next most important risk factors in men
and women, but their relative effect varied in
different regions of the world. The usual
measure of obesity (body-mass index) showed a
modest relation with acute myocardial
infarction but was not significant when
abdominal obesity was included in the analysis.
The South Asian component of this study
confirmed that deaths due to acute
myocardial infarction in south Asians occur at
5-10 years earlier than western population. This
higher risk for premature coronary artery disease
is largely determined by the higher levels of
risk factors and the nine conventional risk
factors
(abnormal
lipids,
smoking,
hypertension, diabetes, abdominal obesity,
psychosocial factors, consumption of fruits &
vegetables, alcohol and regular physical
activity) collectively explain 86 per cent of the
AMI risk in south Asians. In South Asians too,
abnormal Apo-B/ApoA-1 ratio and smoking
are the most important risk factors. Low
education level is associated with increased
risk of AMI worldwide. Protective lifestyle
factors such as leisure time physical activity and
regular intake of fruits and vegetables are
markedly lower among south Asians than
western population, while harmful risk factors
such as elevated ApoB/Apo A-1 ratio are
higher in south Asians. South Asians have
significantly higher population attributable risk
associated with waist-hip ratio. South Asians
have higher level of risk factors in both cases
and controls under the age of sixty.
Even though coronary heart disease is a huge
public health challenge for developing
countries in South Asia especially India, it has
attracted less comment and little public health
response. The community and the policy
makers need to realize the importance of
formulating ‘Healthy-Heart policy’ and setting
into place primordial prevention strategies
which focus on the population at large. Stricter
regulations against tobacco use, increase in
prices of tobacco products and aggressive
media campaign could perhaps decrease the
use of tobacco in populations. Decrease in
tobacco use will also lead to a reduction in a
whole host of other non-communicable
diseases. Community Health education
programs to encourage dietary changes and
increasing the amount of physical activity are
needed. Curricula in schools and colleges
should also highlight the concept of healthy
heart diet and regular physical activity. Since
women are the often neglected sufferers of
coronary heart disease, both health care
providers and the community need to be made
aware of the same. South Asian countries need
to develop their own guidelines for the early
identification of individuals at risk of
cardiovascular
disease.
Innovative
cost
effective strategies focusing on optimal
delivery of cardiovascular care within existing
public health framework need to be developed.
REFERENCES
1.
Reddy KS, Yusuf S. Emerging epidemic of
cardiovascular disease in developing countries.
Circulation.1998;97:596-601.
2.
Bansal M. Premature coronary artery disease in
Indians. Ind Res Comm.2009;3(1):61-63.
3.
Prabhakaran D, Yusuf S. Cardiovascular disease in
India: Lessons learnt & challenges ahead. Indian J
Med Res.2010; 132(5):529-30.
4.
Sharma M, Ganguly NK. Premature coronary artery
disease in Indians and its associated risk factors.
Vascular Health and Risk Management.2005;1(3):217225.
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5.
Vamadevan SA, Prabhakaran D. Coronary artery
disease in Indians: Implications of the INTERHEART
study. Indian J Med Res.2010; 132(5):561-66.
6.
Wasir HS, Kumar MV, Reddy KS Cardiovascular
disease in India: The magnitude of problem and the
changing pattern. In: Wasir HS.Editor. Preventive
Cardiology: an introduction. New Delhi: Vikas
Publishing House, 1991;40–54.
About the Guest Editor
Dr. Manoj Kumar Bansal, a leading and distinguished cardiologist, is a full time consultant with the
B&M Patel Cardiac Centre, attached to P S Medical College, Karamsad. He specializes in trans-radial
primary angioplasty and the catheter based treatment of mitral and aortic stenosis (balloon
valvuloplasty).Besides catering to the urban areas, the centre is actively engaged in the extension of
specialized cardiac services to the rural population. He has over 25 publications in peer reviewed
indexed journals to his credit.
3
ISSN: 0976 3325
Original Article .
KNOWLEDGE ATTITUDE AND PRACTICES FOR ANTENATAL CARE AND DELIVERY OF
THE MOTHERS OF TEA GARDEN IN JALPAIGURI AND DARJEELING DISTRICTS, WEST
BENGAL
Prabir Kumar Manna1, Debasis De2 and Debidas Ghosh3
1Lecture,
Department of Physiology, Siliguri College, Siliguri, Darjeeling, West Bengal 2Research
Scholar,
& Head, Department of Bio-Medical Laboratory Science & Management.(UGC
Innovative Department), Vidyasagar University, Midnapore-721 102 ,West Bengal.
3Professor
Correspondence:
Prof. Debidas Ghosh, Professor & Head,
Department of Bio-Medical Laboratory Science & Management (UGC Innovative Department),
Vidyasagar University, Midnapore-721 102, West Bengal
Email: - [email protected] Phone:- (+91)9232690993.
ABSTRACT
The present study aimed to access the influence of socioeconomic factors on antenatal care and
delivery practices of the mother of North Bengal. A community based study was carried out among
1772 families of the 7 blocks of the two districts. Various socio economic factors were considered for
the antenatal care and delivery practices. We also tried to find out the relationship between antenatal
check up with perinatal mortality. The study shows that the muslim mothers, Scheduled tribe
mothers, non -educated and mothers with higher age group are less interested about ANC. Family
income 2000/- month showing 62.42% ANC coverage. We found that only 7.11% mother used Govt.
hospital and 2.65% used private clinic. The mother with medical problems and obstetric problems has
high ANC coverage. So, socioeconomic factors significantly influence the antenatal coverage and
delivery practices. Hence initiative may be taken at Government and non government levels to raise
knowledge, attitude and practices for the improvement of antenatal care and delivery practices of the
mother at these zones.
Key words: Mother, Antenatal care, Delivery, Perinatal mortality, North Bengal
INTRODUCTION
The National Population Policy (NPP) proposes
a reduction in the infant mortality rate to 30 per
1000, and of maternal mortality rate to 100 per
100000 by the year 2010.1 The goal is to reduce
infant mortality by nearly 60 (from about 72 per
1000 in 1996 to 30 per 1000 in 2010) in a span of
about 14 years considering that it took almost 20
years for the infant mortality rate to decline
from about 125 per 1000 in 1978 to 72 per 1000 in
1996.
On the positive side, the basic institutional
mechanism for achieving lower infant mortality
levels is already in place. The ICDS (Integrated
Child Development Services), instituted in the
mid- 1970's, has proven effective in reducing
infant mortality in the areas where it has
operated. The program offers supplementary
nutrition and basic health care to children less
than 3 years of age, pregnant women, and
mothers of young children. In the mid-1990's,
the ICDS program to all Community
Development Blocks and Urban Slums, and
funding to ICDS was increased substantially.
Although the program serves 22 million women
and children, a large percentage of women and
children eligible to receive ICDS services do not
receive them.2 Expanding the coverage to
include more beneficiaries is clearly necessary if
rapid reductions in infant and child mortality
are to be effected over the next decade.
The ICDS program has the potential for greatly
expanding the distribution of folic acid and iron
supplements to pregnant women who suffer
from nutritional anaemia. .According to NFHS,
only about 50% of women received folic
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ISSN: 0976 3325
acid/iron supplements during pregnancy for
India as a whole, and the percentage receiving
these supplements was lower still in Rajasthan,
Uttar Pradesh., Bihar and Nagaland i.e. less than
30%. 3 A study shows that in West Bengal 67.5 %
mother have 3 or more ANC visit, 97% got TT-1,
91.4% got TT-2 or booster, 87.3% got Iron and
Folic Acid (IFA) and 61.6% received 3 ANC, IFA
and TT-2. 4 Another study in rural North zone
showed that 78.6% visited health centre for
antenatal care but 35% received 3 antenatal
cares.5 Reductions in maternal mortality will
also require a rapid expansion of antenatal and
obstetric services for pregnant women,
particularly in rural areas where only a minority
of births are supervised by trained health
personnel.
services. Understanding of the knowledge and
practices of the community regarding maternity
care during pregnancy, delivery is required for
program implementation. Common people of
North Bengal are generally tea garden workers
and farmers. Most of them are illiterate and
poor. We do not have information about the
ANC of the mothers of the two districts of North
Bengal.
Therefore, the present study was
carried out to evaluate the socio-demographic
correlates and barriers of maternal health-care
utilization among married women aged 18-42
years living in seven blocks of Jalpaiguri and
Darjeeling districts.
Non-utilization or under-utilization of maternal
health-care services, especially among the rural
poor and urban slum population are high due to
either lack of awareness or access to health-care
The study was conducted in the seven blocks of
two districts of North Bengal (Darjeeling and
Jalpaiguri) in the period of March 2007 to
August 2008.
MATERIAL AND METHODS
Table 1: The role of different character in ANC coverage
Character
Age
Religion
Caste
Education level
of mother
Education level
of father
Occupation
Family Income
18-25
26-33
>33
Hindu
Muslim
Gen
SC
ST
Illiterate
Primary
above
Illiterate
Primary
above
Farmer
Garden
worker
1200/month
2000/month
Total
636
712
424
1158
614
840
533
399
673
782
317
723
646
403
530
1242
Ante natal care
Fully
Partially
N0 (%)
N0 (%)
437(68.71)
145(22.80)
368951.69)
217(30.48)
177(41.75)
126(29.72)
793(68.48)
202(17.44)
189(30.78)
286(46.58)
512(60.95)
220(26.19)
316(58.29)
117(21.95)
154(38.60)
151(37.84)
305(45.32)
250(37.15)
419(53.58)
202(25.83)
258(81.39)
36(11.36)
352(48.69)
225(31.12)
371(57.43)
184(28.48)
259(64.27)
79(19.60)
308(58.11)
112(22.13)
674(54.27)
376(30.27)
Not
N0 (%)
54(8.50)
127(17.73)
121(28.53)
163(14.08)
239(38.94)
108(12.86)
100(18.76)
94(23.56)
118(17.53)
161(20.59)
23(7.29)
146(20.19)
91(14.09)
65(16.13)
110(20.75)
192(15.46)
1160
612
600(51.72)
382(62.42)
225(19.40)
77(12.58)
Four blocks of Darjeeling district (Kharibari-214,
Naxalbari-263, Matigara-318, Phansidewa-244)
and three blocks of Jalpaiguri (Malbazar-210,
Haldibari-284 and Dhupguri-239) were selected
by random selection method.1772 families of
two districts were considered randomly for data
collection. The mothers were interviewed using
a pre-structured interview schedule including
335(28.88)
153(25.00)
p-value
χ2=104.95
p<∞
χ2=312.61
p<∞
χ 2=67.94
p<∞
χ2=128.65
p<∞
χ2=32.59
p< ∞
χ2=18.38
p< ∞
χ2=21.37
p< ∞
details of ANC, socio-demographic profile,
delivery practices and infant mortality to assess
the antenatal care and delivery practices of the
mothers. We also tried to find out the reasons
for perinatal mortality.
OBSERVATIONS
5
ISSN: 0976 3325
Table-1 showing the age, religion, caste,
education, occupation and income wise
distribution of mothers and their ante natal care.
Table shows that mothers of 18-25 years of age
have taken more ante natal care. Mother belongs
to Hindu religion, general caste, highly
educated, farmers and higher income group also
taken more antenatal care than the other group.
Higher age group, Muslims, Scheduled tribes,
illiterate and poor economic group mothers
have taken less ante natal care. All the variables
have significant relationship with the antenatal
care.
Table-2 shows the status of antenatal care of the
mothers. We found that 67.95% mothers used
garden hospital and 22.29% mothers used local
PHC. Only 2.65% mothers used private clinics.
Table-3 represent that the mothers come to the
health centers or hospitals for ANC mostly
because they found some problems during early
pregnancy. Delivery place, delivery type,
Doctor, Postnatal visit etc plays some role in
having ANC. All the variables have significant
relationship with the ante natal care coverage of
the mothers.
Table 2: The percentage distribution of ANC
receiving place and TT schedule
ANC place/ TT Characteristics
Place where ANC taken
Garden hospital
Local PHC
Government hospital
Private clinic
Tetanus Toxoid Schedule
TT-1
TT2/Booster
None
No (%)
983(67.95)
323(22.29)
103(7.11)
38(2.65)
409(23.08)
1038(58.58)
325(18.34)
Table 3: Relationship of different variables with antenatal care
Variables
Medical problems
Yes
No
Obstetric problems
Yes
No
Delivery place
Home
Garden/Local Hospital
Delivery type
Vaginal
Caesarean
Done by
Doctor/Nurse
Dhai
Breast feeding within 24 hour
Yes
No
Postnatal visit
Yes
No
Total
Ante natal care
Yes (%)
No (%)
p-value
961
755
826(85.95)
601(79.60)
135(14.05)
154(20.40)
χ 2=12.17
p< ∞
496
1220
456(91.94)
969(79.43)
40(8.06)
251(20.57)
χ 2=39.18
p< ∞
1054
662
816(77.42)
607(91.69)
238(22.58)
55(8.31)
χ 2=58.50
p< ∞
1452
264
1217(83.82)
206(78.03)
235(16.18)
58(21.97)
χ 2=5.28
p<0.02
712
1004
614(86.24)
809(80.58)
98(13.76)
195(19.42)
χ 2=9.42
p<0.002
667
1049
629(94.30)
794(75.69)
38(5.70)
253(24.31)
χ 2=98.58
p< ∞
421
1295
408(96.91)
1015(78.38)
13(3.09)
280(21.62)
χ 2=77.08
p< ∞
Table-4 shows the perinatal death rate in
relation to antenatal care taken by the mothers.
It clearly shows that the perinatal death rate is
very much related to the antenatal care. Our
study shows that the mothers who have taken
less than two antenatal cares are having
perinatal death rate of 82.40, but the mothers
with two and more antenatal care are having
less perinatal death rate (67.07).
Table – 5 Represents the delivery places of the
poor economic people, Muslims, scheduled
castes and tribes. The mothers of Joint family
and illiterate mothers do not like to go to
hospital for delivery.
We found that the socio economic characters
play some role in delivery practices of the
mothers of our study area. Economy, religion
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ISSN: 0976 3325
family and education of the mother significantly
related to the delivery practices of the mothers.
We also found that caste does not play any role
with the delivery practices of the mothers.
Table 4: Relationship of Antenatal Checkup
with Perinatal Mortality
No
of
ANC
>2
<2
No of
live birth
1968
1784
No of
perinatal
death
132
147
Perinatal
death rate
67.07/1000
82.40/1000
DISCUSSION
Antenatal care is most important health care for
the maintenances of sound health of pregnant
mother and intrauterine baby. Poor antenatal
care may results severe health problems of both
the mother and prenatal baby 6. In the survey
zone, the overall antenatal care level is poor,
may be due to economical factor 7 geographical
barriers as primary health center are located far
way from their villages. The level is
comparatively less in Muslim than Hindu 8
which may be due to low educational level 9,10
social customs 11 and wrong ideas as proposed
by others. The previous facts have been
supported here by the results of this report
where home delivery of the pregnant mother is
comparatively less in educated family than the
illiterate or low educated family. Similarly the
antenatal care of mother is also high in nuclear
family. Economical status of the family is also
one of the factors of antenatal and intra natal
care of the mother which has been reflected here
as proposed by others 7.
Table 5: Socio economic characters in delivery pattern
Character
Economy
Very lower
lower
Religion
Hindu
Muslim
Caste
Gen
SC
ST
Family
Joint
Nuclear
Education of Mother
Illiterate
Primary
above
Hospital delivery
No (%)
Home delivery
No (%)
Total
p-value
402(35.96)
260(43.48)
716(64.04)
338(56.52)
1118
598
χ 2=9.30
p<0.002
489(42.20)
173(29.62)
643(56.80)
411(70.38)
1132
584
X2=29.90
p< ∞
335(41.36)
209(40.04)
118(30.13)
475(58.64)
313(59.96)
266(69.27)
810
522
384
X2=0.27
P<0.8720
314(32.81)
348(45.85)
643(67.19)
411(54.15)
957
759
X2=30.37
p< ∞
241(37.48)
319(41.43)
102(33.66)
402(62.52)
451(58.57)
201(66.34)
643
770
303
X2=6.06
P<0.0484
CONCLUSION
From above discussion it may be cleared that
antenatal care and delivery practices of the
mother in tea garden areas of North Bengal is
very poor. Social educational and economical
features are responsible for such results. Steps
may be adopted at Government and non
government levels to raise knowledge, attitude
and practices for the improvement of antenatal
care and delivery practices at this zone to
develop as sound health for future generation.
RECOMMENDATIONS
1.
2.
3.
The economic status, education of the
families must be improved.
Parents will be acknowledged about the
values of ante natal care.
Health worker need to identify the pregnant
mother and to give reminder before a
particular dose of ante natal care.
ACKNOWLEDGEMENTS
Authors would like to express their grateful
thanks to the local people, panchayet members,
health centers, tea garden managers of the study
area.
7
ISSN: 0976 3325
REFERENCES
1.
2.
3.
4.
5.
6.
7.
1.National Family Health Survey-India 1992-93. 1995.
Bombay: International Institute of Poulation Studies.
2.Eighth Five Year Plan 1992-97. Volumes I & II. New
Delhi: Government of India, Planning Commission.
National Family Health Survey-India 1998-99. 2003.
Bombay: International Institute of Population Studies.
Singh P, Yadav RJ. Antenatal care of pregnant woman
in India, Ind J Community Med. 2000;25:112-7
Singh A, Arora AK. The changing profile of pregnant
women and quality antenatal care in rural North India.
Ind J Community Med .2007; 32:135-136
Coria-Soto IL, Bobadilla JL, Notzon F. The effectiveness
ANC in preventing intrauterine growth retardation and
low birth weight due to preterm delivery. International J
Quality Health Care. 1996, 8:13-20.
N Taguchi. M Kawabata. M Mackawa, T Marua,
Aditiawarman LD. Influence of economic background
and antenatal care programme on maternal mortality in
Surabaya, Indonesia. Tropical Medicine and International
Health, 2003,8: 847-852.
8.
Salam A, Siddiqui SA, Socioeconomic inequalities in
use of delivery care services in India. J. Obsetet. Gynecol
India. 2006, 56:123-127.
9.
El-gilany AH. Falure to register for antenatal care at
local primary health care Center. Annals of Soudi
Medition, 2000,20:229-232.
10. Woolett A, Dosanjh- Matwala N, Pregnency and
antenatal care: attitudes and experiences of Asian
women. Child Care Health and Development. 2006, 16:6378.
11. Rezeberga D, Lazdane G, Gilbert G, Donders G. The
impact of social factors on attendance of antenatal care
services and the subsequent effect on mothers health,
measured during the year of economic transition in
Latvia. Eur. Clinics. Obslet. Gynocal, 2007, 3:47-51.
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ISSN: 0976 3325
Original Article .
CERTAIN MODIFIABLE RISK FACTORS IN ESSENTIAL HYPERTENSION: A CASECONTROL STUDY
Sunil M. Sagare1, S. S. Rajderkar2 B. S. Girigosavi3
1Lecturer,
Dept. of Community Medicine, Bharati Vidyapeeth Deemed University Medical College,
Pune, 2Dean, Govt. Medical College, Miraj, 3Taluka Health Officer, Kavathemahankal, Maharashtra.
Correspondence:
Dr. Sunil M. Sagare
Dhankawadi, Pune - 411043
Mobile – 09503218928, 09420123602
Email - [email protected]
ABSTRACT
Essential hypertension accounts for 90% of all cases of hypertension. Though it is a one of major risk
factors for cardiovascular diseases, it is a condition with its own risk factors. Overall prevalence of
hypertension is increasing over the years in India (from 3.57% in 1977 to 20-30% after 1995).
Considering the public health importance of ‘Essential Hypertension’ the present study was
conducted. The objective was to study role of certain risk factors in essential hypertension. A case
control study was conducted in rural township of Tasgaon; in Sangli district of Maharashtra during
2001-2002, to study role of certain modifiable risk factors in essential hypertension in 21-60 years age
group. 165 cases of essential hypertension were selected by systematic random sampling from two
private hospitals & O.P.D. of RHTC, Tasgaon and 330, age & sex matched controls were selected in
the ratio of 1:2. A significant association was found between essential hypertension and various risk
factors including smoking, its frequency and duration, alcoholic status, leisure time physical
inactivity, restless sleep, BMI, mental stress, mixed diet and salt intake. Smoking of more than 10
cigarettes or bidi had 3.23 times risk of developing hypertension than smoking up to 10 cigarettes or
bidi.
Keywords: Hypertension, Risk factors, Leisure time physical activity, Restless sleep
INTRODUCTION
Hypertension is prevalent all over the world.
Usually it is readily detectable, easily treatable
condition and if left untreated may leads to
serious
complications.
In
considerable
proportion of cases the disease tends to be
asymptomatic for prolonged time, hence also
labeled as ‘Silent Killer’1. Essential hypertension
is the most prevalent form of hypertension
accounting for 90% of all cases of hypertension2.
High blood pressure is a major risk factor for
stroke, CHD, heart or kidney failure2.
Hypertension is also considered as an ‘Iceberg’
disease’ because unknown morbidity far
exceeds the known morbidity2. It ranked fourth
in the world by prevalence3.
In India, impact of hypertension was perhaps
not fully regarded due to high incidence of
communicable diseases. Now, as communicable
diseases are getting controlled and life
expectancy has increased, its importance as a
public health problem is now being felt .Studies
revealed vast range of risk factors in relation to
essential hypertension ranging from genetic
factors to lifestyle. However these studies were
mainly descriptive or cross sectional barring few
being analytical. Substantial research has been
carried out in the natural history of
hypertension as well as measures for treatment
and control. These studies led to concept of
evolution of risk factors. Few case control
studies have been carried out on cardiovascular
diseases in relation with various risk factors but
seldom on hypertension as a separate entity in
Maharashtra state. No such study exists in
Sangli district of Maharashtra state. Hence the
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study was carried out in a rural township of
Tasgaon in Sangli district.
A case control study was carried out in rural
township of Tasgaon in Sangli district of
Western Maharashtra from Jan 2001 to June
2002.
Study population: Comprised of known cases of
essential hypertension of both sexes in the age
group of 21-60 years and matching controls from
same town.
Sample size: Desired sample size of 165 was
calculated by standard sample size formula for
case
control
studies9.
(Prevalence
of
hypertension (P0) = 0.15% and Risk ratio (RR) =
0.346)
Selection of cases and controls and collection
of information: Cases were selected from two
private hospitals and OPD attending of RHTC,
Tasgaon, in age group of 21-60 years by
systematic random sampling. Controls were
selected from neighboring houses of cases and
from general population. Controls were
matched for age (±2 years), sex and parity in
case of females. As Case: Control proportion
taken as 1:2, the study population comprised of
495 subjects with 165 cases and 330 controls
fulfilling inclusion criteria.
Relevant information was collected in
predesigned and pretested questionnaire. 24
hours recall and stock inventory method was
used for measurement of calorie, fat and salt
intake individually. Salt intake score was
prepared specially for the study to measure ‘Salt
intake per day’. Mental stress score was also
prepared to measure the strength of mental
stress with help of 51 common stressful life
events12.
Measurements and definitions used in study:
1. Blood Pressure Measurements: Blood
pressure readings were taken by single
observer for every individual with same
sphygmomanometer throughout the study
as per gaudiness10. After taking informed
consent from participants total 3 readings
were performed on each participant at 10
minutes interval in sitting position. Actual
blood pressure readings were noted of all.
Mean of three readings of systolic blood
pressure (SBP) and diastolic blood pressure
(DBP) are considered as representing blood
pressure of participants. When SBP and DBP
fall into different categories, the higher
category
was
selected
to
classify
individual’s blood pressure. The readings
are made of the close 2mm of Hg. mark on
the scale. Hypertension is considered
according to criteria as SBP of 140 mm Hg or
greater, DBP of 90 mm Hg or greater or
taking antihypertensive medication.
2. Height, Weight and BMI Recording:
a) Height: The subject was asked to stand with
the back against the wall and heels touching
the ground, arms on the side and eyes in
front parallel to ground. Reading coinciding
the occipital edge was noted in cm. with the
help of standard measuring tape.
b) Weight: Weight of all subjects with
minimum clothes on the body was recorded
in kilograms with the help of standard ISI
marked weighing machine which was
adjusted to ‘zero’ weight while measuring it.
c) Body Mass Index (BMI) 2: Calculated by
formula, BMI = Weight (Kg) / Height2 (m)
The same single tape and weighing machine
was used by a single person throughout the
study. The weighing machine was
standardized from time to time with the
help of standard weight. Subjects were
classified according to BMI ≤ 25 as normal
and >25 as overweight and obese.
3. Definitions:
a) Smoker: A person who has been smoking at
least a bidi or cigarette or any other form for
at least six months from study period.
b) Alcoholic: A person who has been taking
alcohol at least 30 ml. per day for at least six
months from study period.
c) Vegetarian: Defined as a person who drives
his food from fruits, vegetable, wheat, rice,
pulses, milk and milk products.
d) Mixed Diet: A person who consumes eggs
and meat in addition to vegetarian diet.
e) Leisure time physical activity11: Activity
undertaken in the individual’s discretionary
free time. It includes exercise and sports.
Data analysis: Association between selected
variables was tested for significance by using
Chi-square test. Odds ratio and its confidence
intervals were calculated wherever required.
RESULTS
A total of 495 individuals were studied
comprising 165 cases and 330 controls .Sex wise
distribution revealed 93(56%) males and 72(44%)
females in cases and 186(56%) males and
144(44%) females in controls. Two matched
controls for age and sex (and parity in case of
females) were taken for each case, so percentage
of controls comes to same as cases in their
respective age group.
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Forty-one (44.09%) amongst cases and fifty
(26.88%) amongst controls were smokers.
Among smokers, twenty-eight (68.29%) cases
and twenty (40%) controls were smoking more
than 10 cigarettes or bidi per day. Twenty-five
(60.98%) cases and nineteen (38%) controls were
smoking for 5 years and above.
Table 1: Age and sex wise distribution of cases and controls
Age wise
Male
Female
distribution
Cases (%)
Controls (%)
Cases (%)
Controls (%)
in years
8 (5.55)
4 (5.55)
12 (6.45)
21-30
6 (6.45)
16 (11.11)
8 (11.11)
44 (23.66)
22 (23.66)
31-40
40 (27.78)
20 (27.78)
60 (32.26)
30 (32.26)
41-50
80 (55.56)
40 (55.56)
70 (37.63)
35 (37.63)
51-60
Total
93 (100)
186 (100)
72 (100)
144 (100)
Thirty-seven (39.78%) cases and fifty-one
(27.42%) controls were found alcoholic. Among
alcoholics, seventeen (45.95%) cases and twenty-
Total
Cases (%)
Controls (%)
10 (6.06)
30 (18.18)
50 (30.3)
75 (45.46)
165 (100)
20 (6.06)
60 (18.18)
100 (30.3)
150 (45.46)
330 (100)
one (41.18%) controls were consuming alcohol
for 5 years and above.
Table 2: Distribution of cases and controls according to smoking and alcohol habit
Risk Factor
Case (%)
Control (%)
χ2
P
OR (95% CI)
*Smoking
a) Status
Smoker
41(44.09)
50(26.88)
8.35
0.003
2.14 (1.28-3.59)
Non smoker
52(55.91)
136(73.12)
b) No. of Cigarette or Bidi
Smoking/ day
> 10
28(68.3)
20(40)
7.23
0.007
3.23 (1.37-7.59)
≤ 10
13(31.7)
30(60)
c) Duration of Smoking
> 5 years
25(60.98)
19(38)
4.76
0.029
2.54 (1.09-5.91)
≤ 5 years
16(39.02)
31(62)
Alcohol Status*
Alcoholic
37(39.78)
51(27.42)
4.39
0.036
1.74 (1.03-2.95)
Non- alcoholic
56(60.22)
135(72.58)
Duration of Alcohol
Consumption
> 5 years
17(45.95)
21(41.18)
0.198
0.655
1.21 (0.52-2.85)
≤ 5 years
20(54.05)
30(58.82)
* Only males in present study were found to be smoker and alcoholic in both the groups
Maximum numbers of participants were not
doing leisure time physical activity. Leisure time
physical activity was considerably more in
controls i.e. 46 (13.94%) controls compared to
ten (6.06%) cases.
Distribution of participants was comparable in
both the groups considering duration of sleep.
i.e. 83 (50.3%) cases and 146 (44.24%) controls
were taking sleep of 8 hours or less. However
restless sleep was observed more in cases i.e.
39(23.63%) cases compared to 50(15.15%)
controls. BMI <25 was found in majority of
participants; i.e. in 134(81.22%) cases and 302
(91.51%) controls. BMI ≥ 25 was found more in
cases i.e.31 (18.78%) cases compared to
28(8.49%) controls.
More or less stress was observed in most of
participants. More stress (Score >200) was
observed in 15(9.1%) cases and 12(3.64%)
controls; however less stress (Score 41 to 200)
was observed in majority of cases and controls,
i.e. 133 (80.6%) cases and 253 (76.67%) controls
No person from both groups had predominantly
non-vegetarian dietary pattern. 94 (56.96%)
cases and 225(68.18%) controls were exclusively
vegetarians.
Definitely higher and higher salt consumption
was observed more in cases; i.e. 65(39.4%) cases
compared to 79(23.94%) controls. Higher salt
11
ISSN: 0976 3325
consumption (between 5 -7 grams) was
observed in 60 (36.36%) cases and 73 (22.13%)
controls and definitely higher consumption (>7
grams) was observed only in 5 (3.03%) cases and
6 (1.81%) controls. Optimum salt consumption
(up to 5 grams) was observed in 100 (60.61%)
cases and 251(76.06%) controls.
DISCUSSION
Amongst 165 cases, it was observed that number
of cases increasing with increasing age i.e. 10
cases (6.06%) comprising of 6 males (6.45%) and
4 females (5.55%) in age group 21-30 years to 75
cases (45.46%) comprising of 35 males (37.63%)
and 40 females (55.56%) were in the age group
of 51-60 years. It has already been proved that
the prevalence of hypertension increases with
age in both genders. This can be due to natural
aging process and also response to cumulative
environmental factors. Similar pattern was also
found by Gujrathi V.V.et al (1988)4.
Table 3: Distribution of cases and controls according to other risk factors
Risk Factor
Case (%)
Control (%)
χ2
P
Leisure Time Physical Activity
No
155(93.94)
284(86.06)
6.805
0.009
Yes
10(6.06)
46(13.94)
Sleep
a) Duration of Sleep
≤ 8 hours
83(50.3)
146(44.24)
1.625
0.202
> 8 hours
82(49.7)
184(55.76)
b) Nature of Sleep
Restless
39(23.64)
50(15.15)
5.37
0.02
Calm
126(76.36)
280(84.85)
BMI
> 25
31(18.79)
28(8.48)
11.12
0.0008
≤ 25
134(81.21)
302(91.52)
Mental Stress Score
> 40 (Stress)
148(89.7)
265(80.3)
7.02
0.008
≤ 40 (No stress)
17(10.3)
65(19.7)
Dietary Pattern
Mixed Diet
71(43.03)
105(31.82)
6.03
0.014
Vegetarian
94(56.97)
225(68.18)
Salt intake
> 5 grams (Higher)
65(39.4)
79(23.94)
12.73
0.0003
≤ 5 grams (Optimum)
100(60.61)
251(76.06)
The present study found statistically significant
association between hypertension and habit of
cigarette or bidi smoking. (P= 0.003). Significant
association of hypertension was also observed
with smoking more than 10 cigarettes or bidis
per day (P= 0.007) and smoking habit of more
than 5 years (P=0.029). Odds ratio for smokers,
smoking more than 10 cigarettes and smoking
habit for more than 5 years were found to be
2.14, 3.23 and 2.55 respectively, indicating risk of
hypertension is strongly related to habit of
smoking, number of cigarettes or bidi smoked
and duration in years of smoking.
It is known fact that smoking for prolonged
duration over a period of time builds itself up to
a threshold level, initiating vascular changes in
blood vessels ultimately resulting into
hypertension. Significant association between
smoking habit and hypertension in present
OR (95% CI)
2.51 (1.25-5.01)
1.27 (0.877-1.854)
1.73 (1.088-2.76)
2.49 (1.457-4.270)
2.13 (1.218-3.742)
1.61 (1.10-2.376)
2.06 (1.386-3.075)
study correlates with findings by Gopinath N. et
al (1994)5 and Gupta R. et al (1997) 7.
Clear cut dose response relation was observed in
present study and the findings are supported by
findings of Sally E., Mc. Nagny et al (1997)13
who found increasing risk of hypertension with
number of cigarettes smoked. Gupta R. et al
(1997)7 also found that both moderate and heavy
smokers have greater hypertension prevalence
and prevalence was greater in long term
smokers from rural as well as urban areas.
Statistically significant association was found
between hypertension and alcohol (P = 0.036).
Odds ratio of 1.74 revealed that 1.74 times risk of
developing risk among alcoholics than nonalcoholics. Gujrathi V. V. et al (1988)4 and
Gopinath N. et al (1994)5 confirmed relationship
of high blood pressure to alcohol use. Jiang He
(1997)8 too mentioned about an association of
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alcohol consumption and blood pressure levels
in more than 60 population studies worldwide.
Risk of developing hypertension was found to
be marginally more (OR= 1.21) among alcohol
consumers with duration of 5 years or more.
However no significant association was revealed
between hypertension and duration of alcohol
consumption (P=0.20) in present study.
between hypertension and leisure time physical
inactivity (P=0.009). Odds ratio was found to be
2.51 indicating that with absence of leisure time
physical activity there is more than twice the
risk of hypertension when compared with
positive leisure time physical activity. In
support to present study, Dr. Anil Pahwa
(2000)14 mentioned that long term aerobic
exercise regimens have beneficial effects upon
systolic blood pressure.
Restless sleep was associated with hypertension
and the difference was significant statistically
(P=0.02). OR=1.73 indicates that, with restless
sleep there is 1.73 times more risk of
hypertension when compared with calm sleep.
Statistically significant association has been
observed between hypertension and BMI with
cut off point of 25 (P=0.0008). Odds ratio for
BMI > 25 was found to be 2.49, indicating 2.49
times more risk of developing hypertension in
overweight and obese persons. Present study
findings are supported by N. K. Goel et al
(1996)6 and S. Mishra et al (1997)15 who quoted
findings of Manitoba Cohort study followed for
26 years in which BMI was a significant
predictor of cardiovascular diseases including
hypertension. More or less stress was observed
in most of cases and controls and this was found
significantly associated with development of
hypertension (P= 0.008). Odds ratio of 2.13
clearly specifies more than twice the risk of
developing hypertension with exposure to stress
of varying degrees. I. J. Perry et al (1994)16
observed similar finding that factors inducing
psychological stress contribute to development
of
hypertension.
Statistically
significant
association was observed between dietary habits
and hypertension (P=0.014). The Odds ratio of
1.96 was indicative of nearly two times higher
risk of hypertension in persons with mixed
dietary pattern as compared to vegetarians.
Among dietary factors higher salt consumption
was also found to be significantly associated
with hypertension (P= 0.0003). Twice the risk of
developing
hypertension
(OR=2.06)
was
observed among persons consuming more than
5 grams of salt per day. The present study
finding are similar to those of Goel N.K. and P.
Kaur (1994)6 and supported by findings of Paul
Elliot et al (1996)17 in ‘Intersalt’ study.
CONCLUSIONS
Summarily present study found smoking, its
frequency and duration, alcohol consumption,
leisure time physical inactivity, restless sleep,
BMI, mental stress, mixed diet and salt intake as
risk factors for essential hypertension among
age group of 21-60 years.
REFERENCES
1. Kulkarni A.T.: ‘Hypertension – A Silent Killer’. Indian
Medical Gazette.1998 March:73-76
2. Park K.: ‘Text book of Preventive and Social Medicine’.
16th edition, M. S. Banarsidas Bhanot Publishers,
Jabalpur. 2000: 277-80, 297
3. The World Health Report 1998 – WHO, Geneva, 1998
4. Gujarathi V.V. et al: ‘A Study of Prevalence of
Hypertension and Diabetes Mellitus Amongst
Government Gazetted Officers in Aurangabad City in
India’. Indian Journal of
Preventive and Social
Medicine.1998;19(3):79-85
5. Gopinath N. et al ‘Epidemiological Study of
Hypertension in Young (15-24years) Delhi Urban
Population’ Indian Journal Med. Res.1994 January:32-37
6. Goel N. K. and Kaur P.: ‘Role of Various Risk Factors in
The Epidemiology of Hypertension in a Rural
Community of Varanasi District’. Indian Journal of
Public Health. 1996 September;40(3):71-76
7. Gupta R. et al: ‘Correlation of Smoking, Blood Pressure
Levels and Hypertension Prevalence in Urban and Rural
Subjects’. JAPI.1997; 45(12): 919-22
8. Jiang He and Paul Whelton: ‘Epidemiology and
Prevention of Essential Hypertension, Part I’. Medical
Clinics of North America.1997 Sept; 81(5):1077-1112
9. Raymond S. Greenberg and Michel A. Ibrahim. ‘Oxford
Textbook of Public Health’. 1st Indian Edition, Vol. III;
Bombay Oxford University Press.1987: 130-31.
10. ‘The Sixth Report of The Joint National Committee on
Prevention, Detection, Evaluation and Treatment of
High Blood Pressure’. Arch. Intern. Med. Nov-24, 1997;
Vol.157: 2413-46.
11. ‘Obesity: Preventing and Managing Global Epidemic’,
Technical Report Series No.894, WHO Geneva, 1997
12. Gurmeet Singh et al: ‘Presumptive Stressful Life Events
Scale (PSLES) - A New Stressful Life Events Scale for Use
in India’. Indian Journal of Psychiatry.1984; 26(2):107-14
13. Sally E., Mc Nagny et al: ‘Cigarette Smoking and Severe
Uncontrolled Hypertension in Inner-city African
Americans’. Am. J. Medicine. August 1997; Vol.103:12133.
14. Dr. Anil Pahwa: ‘Exercise and Health Benefits’. Current
Medical Journal North Zone. Jan.2002; 20(10):37-42
15. S. Mishra, H. S. Wasir: ‘Obesity As a Risk Factor for
Coronary Artery Disease’. JAPI.1997; 45(7):555-58
16. J. Perry et al: ‘Environmental Factors in the Development
of
Hypertension’.
British
Medical
Bulletin.
1994;50(2):246-55.
17. Paul Elliott et al; ‘Intersalt Revisited: Further Analysis of
24 Hour Sodium Excretion and Blood Pressure Within
and Across Population.’ BMJ. May 1996; Vol.312:1249-5.
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Original Article .
ASSESSMENT OF NUTRITIONAL STATUS OF RURAL EARLY ADOLESCENT SCHOOL
GIRLS IN DANTAN-II BLOCK, PASCHIM MEDINIPUR DISTRICT, WEST BENGAL
Soumyajit Maiti1, Kauhik Chattterjee1, Kazi Monjur Ali1, Debidas Ghosh2 Shyamapada Paul3
Department of Bio-Medical Laboratory Science and Management (U.G.C Innovative Department)
of Nutrition & Dietetics, Vidyasagar University, Midnapore – 721 102, West Bengal
3Rural Research Institute of Physiology & Applied Nutrition (RRIPAN), Gitanjali, Vidyasagar Road,
Midnapore – 721 101, West Bengal.
1
2Department
Correspondence:
Prof. Debidas Ghosh,
Professor & Head, Bio-Medical Laboratory Science and Management,
Vidyasagar University, Midnapore – 721 102, West Bengal, India.
E-mail: [email protected]
ABSTRACT
A study was conducted to ascertain the growth and nutritional status of adolescent school girls in
rural area. Present study was conducted among adolescent girls studying in 5th to 8th standard (age
group of 10 to 14 years) of eighteen government approved school in Dantan-II block, Paschim
Medinipur district, West Bengal. Physical growths of total of 3611 girls were assessed through
anthropometry. Data on weights and heights of girls were collected using standardized techniques.
The extent of malnutrition of adolescent girls was evaluated by well-to-do Indian and NCHS median
value. The results revealed that the weights and heights of these girls were below those of standard
value. As regards weight for age index, only 28.2% subjects were in the normal category and the
percentage of subjects suffering from Grade I (25.7%), Grade II (30.4%), Grade III (13.7%) and Grade
IV (1.9%) malnutrition was quite prevalent in present study. With respect to height for age index,
65.2% of the subjects were in the normal category, 32.6% had mild retardation and about 2.2% had
poor status. The present study revealed that different grades of malnutrition are widely prevalent
among the girls in our study area. All these observations suggest that school going early adolescent
girls need better nutrition to combat the problem of under nutrition. Further studies should be made
to identify the factors responsible for it.
Key words: Nutritional Status, Anthropometry, Adolescent Girls, Dantan-II block
INTRODUCTION
Adolescence is an important stage of growth
and development in the lifespan. Unique
changes that occur in an individual during this
period are accompanied by progressive
achievement of biological maturity.1 This period
is very crucial since these are the formative
years in the life of an individual when major
physical, psychological and behavioural changes
take place.2 Adolescent may represent a window
of opportunity to prepare nutritionally for a
healthy adult life.3
Adolescent girls, constituting nearly one tenth of
Indian population, form a crucial segment of the
society.4 The girls constitute a more vulnerable
group especially in the developing countries
where they are traditionally married at an early
age and are exposed to greater risk of
reproductive morbidity and mortality. In
general adolescent girls are the worst sufferers
of the ravages of various forms of malnutrition
because of their increased nutritional needs and
low social power.5 Early adolescence is a period
of rapid growth and maturation in human
development. The nutritional status of
adolescent girls, the future mothers, contributes
significantly to the nutritional status of the
community.6 Under-nutrition among adolescent
girls is a major public health problem leading on
impaired growth.7 Nutritional deficiencies has
far reaching consequences, especially in
14
ISSN: 0976 3325
adolescent girls. If their nutritional needs are not
met, they are likely to give birth to
undernourished children, thus transmitting
undernutrition to future generations.8 Previous
study showed that girls from disadvantaged
backgrounds have poor nutritional status.5,9
Their weights and heights are lower than the
well-to-do Indian counterparts.10
This age group needs special attention because
of the turmoil of adolescence which they face
due to the different stages of development that
they undergo, different circumstances that they
come across, their different needs and diverse
problems. Rural adolescent girls have been
considered a low risk group for poor health and
nutrition.2 Despite all these important
considerations, adolescent girls did not receive
adequate attention in rural areas in our country,
and only recently few studies have been carried
out in this population group.2,5,6 It is well
established that nutritional status is a major
determinant of the health and well-being among
adolescent and there is no doubt regarding the
importance of the study of nutritional status.11
Nutritional status was evaluated using
anthropometric indicators recommended by
WHO Expert Committee.12
Keeping in view, the present study has been
elucidated to assess the nutritional status of
rural school going adolescent girls in Dantan-II
block, Paschim Medinipur, West Bengal.
METHODOLOGY
Study Area:
The present study was carried out in Dantan-II
block which consist of remote villages situated
around 216 km away from Kolkata, the
provincial capital of West Bengal and 60 km
from district head quarter. In Datan-II block,
there were 18 Govt. approved secondary schools
among them two are girl schools and rest are coed schools. All school girls were included in the
present study. The period of the study was 200910 academic session. The study was crosssectional in nature and the subjects were
selected through random sampling procedure.
Study Participants:
The study was conducted among adolescent
school girl (10-14yrs) of Dantan-II block and
girls were living in and around the school.
Selected girls were studying in 5th, 6th, 7th and 8th
standards formed part of the study. Total 4143
girls were enrolled in 2009-10 academic session
and 3611 girls were measured. The participation
rate was over 85%.
Age estimation
Assessment of age is most essential for
conducting growth studies. The accurate age of
the adolescent girls was recorded from the
school registration books.
Measurements
Height
Height in centimetres was marked on a wall
with the help of a measuring tape. All girls were
measured against the wall without foot wear
and with heels together and their heads
positioned so that the line of vision was
perpendicular to the body. A glass scale was
brought down to the topmost point on the head.
The height was recorded to the nearest 1 cm.
Weight
A bathroom scale was used. It was calibrated
against known weights regularly. The zero error
was checked for and removed if present, every
day. The clothes of the girls were not removed
as adequate privacy was not available. Their
weight was recorded to the nearest 500 grams.
Statistical Analysis:
The physical growth data obtained from the
different age groups of girls were compared
with WHO recommended anthropometric
indicators and with those of the well-to-do
Indian girls.13 Nutritional status of different age
groups of girls were categorized as per Indian
Academy of Paediatrics classification using
weight for age and Vishveshswara Rao’s
classification using height for age as indicators.14
Statistical calculations were performed using
standard methods.
Ethical consideration:
Permission for the study was obtained from the
school authorities prior to commencement.
RESULTS
Distribution of subjects:
Table 1 focused the age and class wise
distribution of the study subjects. Among all the
subjects, maximum (26.47%) were studying in
5th standard and minimum (23.62%) in 8th
standard.
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Table 1: Details age and class wise distribution
of the adolescent girls
Characteristics
No. of Girls
(n=3611)
Percentage
817
771
767
878
378
22.63
21.35
21.24
24.34
10.47
956
905
897
853
26.47
25.06
24.84
23.62
Age (in year)
10
11
12
13
14
Standard
5th
6th
7th
8th
Mean age of girls: 12
Table 2 executes the age wise mean weight
which was compared with standard references
data. The mean weights of the girls ranged from
24.49 ± 4.48 to 35.73 ± 6.36 kg between the ages
10 to 14 years. But the observed data were much
lower than well-to-do Indian children data and
median value of NCHS data. The mean weights
were 70-76% of those of the well-to-do Indian
children and 71-75% of NCHS median for 10-14
years. At 10 years of age mean weight (75.35%)
were closer to NCHS median value.
Table 3 presents the comparison of mean height
of the subject with standard data. The mean
heights of the girls were between 134.0±7.682
and 147.7±4.091 cm. The data on scrutiny
revealed progressive body growth pattern of the
children with increasing age. But the observed
data were much inferior to well-to-do Indian
children data and NCHS reference data. The
mean height was 92-94% of those of the well-todo Indian children and 90-94% of NCHS median
for 10-14 years. The average height of the
subjects was found to be less than the NCHS
standard being 90% to 94% for 10 to 14 years
girls. Similarly, the mean height of 10 years
(94.33%) was closer to NCHS median value.
Table 2: Age-wise mean body weight (kg) of the adolescent girls in comparison to well-to-do Indian
children and NCHS data (N=3611)
Age (Years)
N
Weight Mean
(kg) ± SD
10
11
12
13
14
817
771
767
878
378
24.49 ±4.48
27.59 ± 5.33
30.25 ± 5.56
33.83 ± 5.56
35.73 ± 6.36
Well-to-do
Indian
children
weight (kg)
33.58
37.17
42.97
44.45
46.70
% of wellto-do
Indian
children
72.93
74.22
70.39
76.10
76.50
NCHS
Standard
(Median
value)
32.5
37.0
41.5
46.1
50.3
% of NCHS
standard
75.35
74.56
72.89
73.38
71.03
Table 3: Age-wise mean height (cm) of the adolescent girls in comparison to well-to-do Indian
children and NCHS data (N=3611)
Age (Years)
N
Height Mean
(cm) ±SD
10
11
12
13
14
817
771
767
878
378
130.47 ± 8.4
136.56 ± 8.65
139.52 ± 9.14
143.66 ± 8.5
145.47 ± 6.07
Well-to-do
Indian children
weight (kg)
138.9
145.0
150.98
153.44
155.04
In order to determine the gradation of
nutritional status (Table 4), weight for age index
showed that overall normal category was 28.2%
where the rest of the children had varying
degrees of malnutrition. The percentage of
children in the normal category was between
18.5% and 34.2% in the age group of 10 to 14
years. The weight for age anthropometric index
showed the lowest percentage (18.5%) of normal
% of well-todo Indian
children
93.93
94.17
92.40
93.62
93.82
NCHS
Standard
(Median value)
138.3
144.8
151.5
157.1
160.4
% of
NCHS
standard
94.33
94.30
92.09
91.44
90.69
at 14 years and height percentage (34.2) at 11
years of age. Overall higher percentages of
malnutrition were grade II (30.4%).
Using the height for age index, 48.4-73.2% girls
in various age groups were in the normal
category with the lowest percentage at 14 years.
About 23.6-50.8% of girls had mild retardation
and 0.8-3.2% of girl had poor nutritional status
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ISSN: 0976 3325
with respect to height for age index. The results
of the present study revealed that about 71.8%
of the subjects as per weight for age criterion
and 34.8% of the subjects as per height for age
criterion were suffering from various degrees of
malnutrition.
girl at adolescent stage is high throughout the
country and also in the state of West Bengal.
DISCUSSION
Adolescence is an important stage of growth
and development that requires increased
nutrition and adolescent anthropometry varies
significantly worldwide.12,15 Growth and
development is closely linked to the diet they
receive during childhood and adolescence.3
Undernutrition among adolescent girls is a
serious public health problem internationally,
especially in developing countries.18 The
magnitude the problem of malnutrition amongst
Based on the results of the study, it appears that
children had shown reduced growth in
comparison to NCHS median value and well-todo Indian children. In the present study, the
mean weights of girls were 76 to 79% and the
mean heights were 95 to 97% of those of the
well-to-do Indian children. The study revealed
that the mean weight and height of girls were
less as compared to the NCHS standards.
Table 4: Gradation of nutritional status of adolescent girls on the basis of nutritional indices
Nutritional grades
10 yrs
(n=817)
11yrs
(n=771)
12 yrs
(n=767)
13 yrs
(n=878)
14 yrs
(n=378)
Weight for age a
Normal
259(31.7) 264(34.2) 208(27.11) 218(24.82) 70(18.5)
Grade I
208(25.5) 110(14.3) 211(27.5) 299(34.05) 101(26.7)
Grade II
302(37.0) 282(36.5) 172(22.42) 222(25.28) 121(32.0)
Grade III
41(5.0)
110(14.3) 149(19.42) 128(14.57) 68(18.0)
Grade IV
7(0.8)
5(0.64)
27(3.5)
11(1.25)
18(4.8)
Height for Age b
530(60.4) 183(48.4)
Normal
598(73.2) 549(71.2) 493(64.3)
Mild retardation
193(23.6) 212(27.5) 255(33.2)
326(37.1) 192(50.8)
Poor
26(3.2)
10(1.3)
19(2.5)
22(2.5)
3(0.8)
Figures in parentheses denote percentages.
aIndian Academy of Paediatrics Classification. bVishveshwara Rao’s Classification.
The results of the present study are in
concurrence with the study of Goyel who
reported mean weight were 75-79% and height
were 95-96% of the well-to-do Indian children of
10-15 years age school girls of Jaipur.10 Kalhan
assessed the nutritional status of adolescent
school girls of Haryana.7 Their average weight,
height were 22.3% and 14.9% of the
corresponding estimated reference values. In the
present study, the weights and heights of the
girls were below those of the well-to-do Indian
girls. In another study, nutritional status of
adolescent girls aged 10-18 years belonging to
scheduled caste communities in rural Rajasthan
was assessed. It was found that the values for
height and weight of the adolescent girls were
below the well-to-do group study data19. The
girls of the present study exhibited better height
profiles as compared to their weights in respect
to median value of NCHS. Their weights were
much below those of the well-to-do Indian girls.
Total
(n=3611)
1019(28.2)
929(25.7)
1099(30.4)
496(13.7)
68(1.9)
2353(65.2)
1178(32.6)
80(2.2)
In the present study, the nutritional status of
early adolescent girls was evaluated using
Indian
Academy
of
Paediatrics
and
Vishveshwara Rao’s classification. Nutritional
status of the early adolescent girls were revealed
high incidence of under-nutrition. A large
percentage of subjects were found to be
suffering from different grades of malnutrition.
This reflects the both acute and chronic undernutrition among the subjects. The frequency of
grade II malnutrition of girls of the present
study was more than those reported in an earlier
study on school girls which had reported
26.1%.10 This may be due to, the present study
subject covered rural sectors. However, both
studies found similar rates of normal grade and
grade III malnutrition.
Prevalence of malnutrition in the present study
appeared to be distinctively higher than the
earlier studies among adolescent at Kolkata15
(30.61%) and Bangladeshi girls (16%) studied by
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ISSN: 0976 3325
al.16.
Ahmed et
Overall prevalence was more or
less same with that of a rural community of
Gosaba Block (66%). This could be due to better
literacy rate in these two areas. Kapoor & Aneja
reported 35.5% of adolescent girls (11-18 years)
of Delhi to be undernourished (W/H² less than
the 5th percentile of reference standard)17.
Anthropometric data and the extent of
malnutrition in the girls of present study had
revealed a dismal picture. Girls of the present
study suffer from various degrees of
malnutrition. This problem is widely prevalent
in the rural communities of almost all state of
India2. This disadvantaged group tend to have
high rates of growth retardation and prevalence
of chronic under-nutrition during the adolescent
period.
These percentages of malnourished adolescent
girls are quite alarming and steps need to be
taken to improve their nutritional status. Hence,
efforts are needed to use the school system
favourably for improving the nutritional status
of girls. This has earlier been suggested by
Gopalan (1974)20. In future, studies should be
done on adolescent girls in rural sectors for to
identify the factors responsible for this problem,
which may in turn help to adopt and implement
the proper strategies for upliftment of whole
community.
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
RECOMMENDATIONS
The present study findings amply reveal that
adolescent girls in rural sectors suffer different
grades of malnutrition. Considering the results
of this study, it is suggested that a
comprehensive strategy should be implemented
in disadvantaged groups of our country in order
to prevent adolescent girl undernourishment.
AKNOWLEDGEMENT
The author is extremely thankful to authorities
of Indian Red Cross Society (Paschim Medinipur
district branch) for financial assistance. We are
gratefully acknowledged the various school
authorities for granting permission to carry out
the study. We also acknowledged the assistance
rendered by Mr. A Nayak and Mr. H. Satpati.
The authors are further indebted to the girls of
various schools who participated in the study.
13.
14.
15.
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17.
18.
19.
20.
Tanner JM. Growth at adolescence (2nd ed.) Oxford:
Blackwell Scientific Publications, 1992.
Patil SN, Wasnik V, Wadke R. Health problems
amongst adolescent girls in rural areas of Ratnagiri
district of Maharashtra, India. J of Clinical and
Diagnostic Research, 2009; Oct; 3: 1784-1790.
Kaur TJ, Kochar GK, Agarwal T. Impact of nutrition
education on nutrient adequacy of adolescent girls.
Stud Home Comm Sci, 2007; 1:51-55.
Government of India. Report of the working group on
adolescents for the Tenth Five-Year Plan. Planning
Commission, 2001; 1-3.
Choudhary S, Mishra CP, Shukla KP. Correlates of
nutritional status of adolescent girls in the rural area of
Varanasi. The Internet J of Nutr and Wellness, 2009;
7(2).
Venkaiah K, Damayanti K, Nayak MU, Vijayaraghavan
K. Diet and nutritional status of rural adolescents in
India. European J of Clinical Nutr, 2002; 56: 1119–1125.
Kalhan M, Vashisht BM, kumar V, Sharma S.
Nutritional status of adolescent girls of rural Haryana.
The Internet J of Epidemiology, 2010; 8 (1).
Mulugeta A, Hagos F, Stoecker B, Kruseman G,
Linderhof V, Abraha Z, et al. Nutritional status of
adolescent girls from rural communities of Tigray,
Northern Ethiopia. Ethiop J Health Dev, 2009; 23:5-11.
Ghosh B, Paul SP. Studies on the growth and
nutritional status of the rural children of primary age
group of Kharagpur. Ind J Physiol & Allied Sci, 1991;
45:145-155.
Goyle A. Nutritional status of girls studying in a
government school in Jaipur city as determined by
anthropometry. Anthropologist, 2009; 11: 225-227.
National Family Health Survey (NFHS 2). Chhattisgarh
(1998-1999). Mumbai; International Institute of
Population Sciences, 2002.
World Health Organization. Physical status: The use
and interpretation of anthropometry. Technical report
series. Geneva; WHO, 1995; Report No.:854.
Vijaya RK, Singh D, Swaminathan MC. Heights and
weights of well nourished Indian school children. Ind J
Med Res, 1971; 59: 648-654.
Gopaldas T, Sheshadri S. Nutrition: Monitoring and
Assessment. New Delhi: Oxford University Press, 1987;
P. 185.
Mukhopadhyay A, Bhadra M, Bose K. Anthropometric
assessment of nutritional status of adolescents of
Kolkata, West Bengal. J Hum Ecol, 2005; 18: 213-216.
Ahmed F, Zareen M, Khan MR, Banu CP, Haq MN,
Jackson AA. Dietary patterns, nutrient intake and
growth of adolescent school girls in urban Bangladesh.
Pub Health Nutr, 1998;1: 83-92.
Kapoor G, Aneja S. Nutritional disorders in adolescent
girls. Indian Pediatr, 1992; 29:969-73.
Rahmathullah L, Underwood BA, Thulasiraj RD,
Milton RC, Ramaswamy K, Rahmathullah R, Babu G.
Reduced mortality among children in Southern India
receiving a small weekly dose of vitamin A. N Engl J
Med, 1990; 323: 929-935.
Chaturvedi S, Kapil U, Bhanthi T, Gnanasekaran N,
Pandey RM. Nutritional status of married adolescent
girls in rural Rajasthan. Indian J Pediatr. 1994;61:695701.
Gopalan C. Delivery of Health services-need for second
front. Swasth Hind, 1974; June: 187.
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Original Article .
STUDY OF SOCIO-DEMOGRAPHIC PROFILE OF BURN CASES ADMITTED IN SHRI
CHHATRAPATI SHIVAJI MAHARAJ GENERAL HOSPITAL, SOLAPUR
Haralkar Santosh Jagannath1, Tapare Vinay S2, Rayate Madhavi V3
1Assistant Professor 2Associate Professor, Dept. of PSM, Dr. V.M. Govt. Medical College, Solapur,
Maharashtra 3Professor and Head, Dept. of Community Medicine, K. V. Institute of Medical Sciences,
Maduranthagam, Tamilnadu
Correspondence:
Dr. Haralkar S.J.,
Assistant Professor, Department of PSM,
Dr. V. M. Govt. Medical College, Solapur-413003 (Maharashtra State)
E-mail: [email protected], [email protected] Mobile: 9923002702
ABSTRACT
The problem of burn in developing countries like India is more due to various socio-cultural factors
present in the country. The study was aimed to find the distribution, determinants, outcome and
psychological effect of burns. The present hospital based descriptive study was carried out in surgery
ward of Shri Chhatrapati Shivaji Maharaj, General Hospital Solapur, to know socio – demographic
profile, duration of stay and outcome of burn. All cases of burns admitted in Hospital during study
period (September 2000 to August 2001) were the study subjects. More than half were in the age
group between 21 and 40 years. More than two third were females. Rural patients outnumbered
urban patients. Majority of patients were unemployed and among unemployed majority of patients
were housewives. 40% patients were literate. Majority of the cases were from class IV (Upper Lower)
socioeconomic group. Majority of patients (37.78%) were admitted during winter season. Maximum
number of burns occurred between 5pm and 11 pm. Majority of burns (97.56%) took place at home.
79.33% of burns were accidental. 36% patients had hospital stay less than one day. Among 450 cases,
65.78% died, 16.44% were discharged against medical advice
Key words – Socio-demographic profile, burn cases, hospital stay, outcome.
INTRODUCTION
Man has invented fire since times immortal. The
use of fire in various aspects has not only added
to his comforts but also added to his miseries by
increasing risk of burns. Since ages, man has
paid the price for his comforts in terms of
thermal injuries. Carelessness which leads to
accidents contributes to occurrence of thermal
injuries. Annually about 2 million people suffer
from various modes of burn injuries worldwide
of whom more than a lakh die (1). In India about
60,000 people suffer from burns annually, more
than 50,000 are treated in hospitals and about
10,000 succumb to thermal injury (2). Exact figure
is likely to be even higher, considering the
poverty, illiteracy, poor standards of safety at
home and in the industry and the social and
cultural peculiarity etc. Thus the burn ‘disease’
is endemic in our country. This is a great strain
on the already scarce health resources of
developing countries especially India.
The problem of burn in developing countries
like India is more due to various socio-cultural
factors present in the country. Some of these
factors may be dowry , use of crackers in festival
like Diwali, poor housing conditions , poor
maintainance of electric appliances , custom of
wearing sarees or dupatta , illiteracy , ignorance
and poverty. Mortality due to burn injuries is
higher in developing countries as compared to
developed countries because of lack of
awareness among people and lack of availability
of health care services. The developing countries
also differ from developed countries with
respect to sex of people affected, place of injury
etc. Females are more affected in developing
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countries than developed countries and
domestic burns are more in developing
countries while non-domestic burns are more in
developed country. The ultimate goal is to help
the patient to return to his/her natural lifestyle
and lead as normal life as possible, so that he /
she is not a burden on his / her family.
Several studies on epidemiology of burns are
done in different countries and in India. Most of
the
studies
have
included
different
epidemiological factors such as age, sex,
occupation, place of burns, cause of burns etc. in
their study. Although flame, scald, chemical ,
electricity seem to be the direct causes of burns,
underlying social factors like interpersonal
relationship in the family , mental stress,
negligence, male dominance, female battering
by in-laws is rarely considered in any of the
studies. Hence this descriptive hospital based
study was planned with a purpose to know the
magnitude and socio- cultural factors of the
problem of burns so that a sound prevention
programme can be suggested, planned and
implemented.
MATERIALS AND METHODS
The present hospital based descriptive study
was carried out in surgery ward of Shri.
Chhatrapati Shivaji Maharaj, General Hospital
Solapur, to know socio – demographic profile,
duration of stay and outcome of burn.
All cases of burns admitted in Surgery Ward of
Shri. Chhatrapati Shivaji Maharaj General
Hospital, Solapur during study period
(September 2000 to August 2001) were the study
subjects. Minor cases of burns managed in
casualty and O.P.D were not included in this
study.
Variables studied are age, sex, place of
residence, occupation, education, socioeconomic
status, marital status, type of clothes, season,
time of occurrence and place of burn.
OBSERVATIONS
Majority of cases (55.78%) were in the age group
between 21 and 40 years which is peak
productive period. Among 450 cases, 67.78%
were females and 32.22% were males. Rural
patients (52.44%) outnumbered urban patients
(47.56%) but not statistically significant. Majority
of patients (81.33%) were unemployed and
among unemployed majority of patients
(57.65%) were housewives. Among 450 patients,
40% patients were literate and 60% were
illiterate. Majority of the cases (43.33%) were
from class IV (Upper Lower) socioeconomic
group followed by 36.67% from class III (Lower
Middle) socio-economic group. Among 450
cases, majority of cases (95.73%) were married.
Maximum number of patients (74.22%) had
mixed type of cloths at the time of injury.
Majority of patients (37.78%) were admitted
during winter season (October to January) and
less number of patients (30.44%) were admitted
during rainy season (June to September).
Maximum number of burns (37.78%) occurred
between 5pm and 11 pm while minimum
number of burns (8.67%) occurred between 11
pm and 5 am when most of the people are
sleeping. Majority of burns (97.56%) took place
at home and 2.44% at work place. 79.33% of
burns were accidental, 17.11% were suicidal and
homicidal burns accounted for 3.56%.36%
patients had hospital stay less than one day,
33.33% patients had hospital stay between 1 – 7
days and 30.67% patients had hospital stay more
than 7 days. 6.89% patients had psychiatric
problems after burn injury. Among 450 cases,
65.78% died, 16.44% were discharged against
medical advice, 13.78% were discharged with
complete cure and 4% were discharged with
residual functional disability.
DISCUSSION
In this study it is observed that majority of cases
were in the age group between 21 and 40 years
which is statistically significant (P<0.001). Our
observations are consistent with studies
conduced by B. P. Sarma and N. Sarma (1994) (3),
maximum no. of patients were in the age group
between 21 – 40 years. In studies conducted by
Mural Turegan et al and C. N. Malla et al (4, 5)
which showed that maximum no. of patients
were in the age group 21 – 30 years.
Among 450 cases, 67.78% were females and
32.22% were males. Several studies (6,7,8,9,10,11,12)
support our observation that overall females
burnt are more than males. No. of females burnt
is more than males. This may be due to gender
difference, socio-cultural factors and dowry
problems. Secondly most of the women are
housewives and they come more in contact with
fire.
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Rural patients (52.44%) outnumbered urban
patients (47.56%) but not statistically significant
(P>0.05). The present study findings are similar
to the findings of L. M. Bariar et al (13) (1994)
who found that out of 400, 222 (55.5%) were
form rural and 178 (44.5%) were from urban
area. Studies conducted by E. Fernandes –
Morales et al and Dalbir Singh et al (10,12) showed
that the cases were predominantly from urban
areas in contrast to present study findings. Rural
patients outnumber urban patients, may be
because of style of living and low socio –
economic status. Use of shegadi, chulha,
kerosene pressure stove etc. for cooking is more
seen in rural area than in urban areas.
Table No. 1 Socio-demographic profile of burn cases
Variables
Age in years
No. of patients (n=450)
X2 value
0-20
129
P<0.001
21-40
251
> 41
70
Sex
Male
145 (32.22%)
Female
305 (67.78%)
Residence
Urban
214
P>0.05
Rural
236
Occupation
Employed
84 (18.66%)
Unemployed
366 (81.33%)
Education
Literate
180
P<0.01
Illiterate
270
SES
Class II (Upper middle)
17
P<0.01, X2 applied
Class III (Lower middle)
165
in lower (IV&V
Class IV (Upper lower)
195
pooled) & middle
Class V ( Lower lower)
73
(II&III pooled) SES
Marital status*
Married
359 (95.73%)
Unmarried
16 (4.27%)
Type of clothes
Cotton
38
P<0.001
Synthetic
78
Mixed
334
Season
Summer (Feb. to May)
143
P>0.05
Rainy (June to Sept)
137
Winter (Oct. to Jan.)
170
Time of
5 am to 11 am
109
P<0.001
occurrence
11 am to 5 pm
132
5 pm to 11 pm
170
11 pm to 5am
39
Place of burn
Home
439 (97.55%)
Work place
11 (2.44%)
Nature of burn
Accidental
357
P<0.001
Suicidal
77
Homicidal
16
Hospital stay
<1 day
162
P>0.05
1-7 day
150
>7 day
138
Psychiatric
Delirium
16 (3.55%)
problems after
Anxiety
8 (1.77%)
burn
Depression
7 (1.55%)
Outcome
Complete cure
62 (13.78%)
Residual functional disability
18 (4%)
Expired
296 (65.78%)
AMA discharge
74 (16.44%)
*-Unmarried males below the age of 21 years and un – married females below the age of 18 years are
not considered.
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Majority of patients (81.33%) were unemployed
and among unemployed majority of patients
(57.65%) were housewives. The present study
findings are similar to the findings of M.
Subramanyam (14) (1996) who found that
majority of patients i.e. 47.4% were housewives
and housemaids. Burns are more common in
housewives than other occupation because
housewives are more exposed to injury prone
environment while cooking. Cooking at floor
level, use of kerosene pressure stove, wearing of
loose clothes such as sarees, dupattas makes
them more prone for burn injuries.
Among 450 patients, 40% patients were literate
and 60% were illiterate. The burn cases were
more in illiterate than literate which is
statistically significant (P<0.01). The present
study findings are slightly different from the
findings of V. Jayaraman et al (15) (1993) who
found that 50% of the cases were illiterate. D.
Marsh et al (11) (1996) in their study found that
majority of patients were young uneducated
housewives. Burns are more common in
illiterate people because illiteracy is usually
associated with ignorance, low socioeconomic
status and lack of knowledge about preventive
measures.
Majority of the cases (43.33%) were from class IV
(Upper Lower) socioeconomic group followed
by 36.67% from class III (Lower Middle) socioeconomic group. When class IV and V are
pooled as lower socioeconomic status and II
and III as middle socioeconomic status, a
significant association is found between socioeconomic status and burn (P < 0.01). Several
other studies (7, 14, 16) also support the finding that
burn cases are more in lower socioeconomic
group. The low socioeconomic status usually
goes parallel with poor standard of living
making persons more prone for burn injury.
Among 450 cases, majority of cases (95.73%)
were married. Several studies (7,12,13,14) support
our finding that married people predominate
over unmarried in burn patients. The higher
frequency among married people may be due to
the fact that kitchen is the place where most
accidents occurred. Married females are more
affected. This may be because of the fact that
majority of the married females are working in
kitchen and majority of burns occur at kitchen.
The other factors which make Indian females
more prone for burn injury are their low status,
gender inequality and social evils like dowry.
Maximum number of patients (74.22%) had
mixed type of cloths at the time of injury which
is statistically highly significant (P<0.001). The
present study findings are similar to the
findings of U. U. Lade (17) (1997) who found that
maximum no. of patients i.e. 65% worn mixed
type of clothes followed by synthetic (25%) and
cotton (8.33%).
Majority of patients (37.78%) were admitted
during winter season (October to January) and
less number of patients (30.44%) were admitted
during rainy season (June to September). This
increase in the number of patients in winter
season is not statistically significant (P > 0.05).
Similar findings were observed in the study of
D. J. Barilla and R. Goode (18) (1996) conducted in
USA that fatal fires were common during winter
months i.e. from December to February.
Increased no. of cases during winter season in
our study can be explained on the grounds that
people come in contact with warm items like
camp fire during winter season and festival like
Diwali where there is lot of fire work also comes
during winter months.
Maximum number of burns (37.78%) occurred
between 5 pm and 11 pm which is highly
significant (P<0.001) while minimum number of
burns (8.67%) occurred between 11 pm and 5 am
when most of the people are sleeping. It is clear
that one is busy during evening hours in
cooking and a mistake with fire in hurry can
result in burns. Only 8.67% of burns occurred at
night between 11 pm to 5 am when most of the
people are sleeping. In contrast to our findings,
some studies (7,14) found that maximum no. of
burns took place between 6 am and 2 pm.
Although the timings are different in these
studies they also coincide with cooking hours.
Majority of burns (97.56%) took place at home
and 2.44% at work place. The present study
could be compared with the findings of other
studies (8,15,7,19,20,21) which support our finding
that majority of burns occur at home. This may
be because of less no. of industries in and
outside Solapur city and there might be proper
arrangement to avoid the accidents due to burn
at the place of work. Secondly the burn victims
are mainly housewives who work in home in
poor housing conditions.
Maximum no. of burns (79.33%) were accidental
which is statistically significant followed by
suicidal (17.11%) and homicidal burns (3.56%).
From several studies (15,7,13, 21) it is observed that
accidental burns are more common followed by
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ISSN: 0976 3325
suicidal and homicidal burns. Accidental burns
are common, may be because of ignorance, poor
standards of safety measures, cooking at floor
level and wearing of sarees or dupatta.
36% patients had hospital stay less than one day,
33.33% patients had hospital stay between 1 – 7
days and 30.67% patients had hospital stay more
than 7 days. The present study findings are
slightly different from the findings of K.K.
Ghuliani et al (8) (1988) who found that out of
300, 17(5.66%) patients had hospital stay less
than one day, 154 (51.33%) patients had hospital
stay between 1 – 7 days and 129 (43%) patients
had hospital stay more than 7 days.
6.89% patients had psychiatric problems after
burn injury. Psycho- social studies in relation to
burns have been sporadic in India and have
been relatively narrow in focus. The ICMR
collaborative study on burn injury (1977)
assessed that about one sixth of the survivors
from burn injuries suffer from psychiatric
symptoms (22).
Among 450 cases, 65.78% died, 16.44% were
discharged against medical advice, 13.78% were
discharged with complete cure and 4% were
discharged with residual functional disability.
Different findings are observed in the study of
L.M. Bariar et al (13) (1994) who found that 41%
patients were discharged, 39.5% patients
expired and 19.5% left against medical advice.
The present study findings are different from
the findings of S. Al- shlash et al (21) (1996) who
found that 68.74% patients were discharged
with complete cure, 10.80% were discharged
with residual functional disability , 7.36%
expired and 13.10% were discharged against
medical advice.
REFERENCES
1.
2.
Lynch J.B. ,Stephen R. Lewis : Symposium on treatment
of burns, Vol.5.
S.P. Patankar : Clinical and histological overview of
burn wound healing, Dissertation submitted for M.S.
(General Surgery), 1997.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
B. P. Sarma and N. Sarma : Epidemiology, morbidity,
mortality and treatment of burn injuries – a study in a
peripheral industrial hospital , Burns , 20(3), June 1994,
253 – 5.
Murat Turegan et al : The last 10 years in a burn centre
in Ankara, Turkey : An analysis of 5264 cases, Burns,
23(7/8), 584 – 90.
C. N. Malla et al: Analytical study of burns in Kashmir,
Burns 9(3), 1983, 180 – 3.
E. H. Liu et al : A 3 year prospective audit of burns
patients treated at the Western Regional Hospital of
Nepal, Burns , 24(2), March 1988, 129 – 33.
M. Gupta et al : Burn epidemiology: The Pink City
scence, Burns, 19(1) , Feb 1993, 47 – 51.
K. K Ghuliani et al: An epidemiological study of burn
injury, Indian Journal of Public Health; 32(1), Jan March 1988, 24 – 30.
Punit Kumar Aggarwal and Siti Roy Chowdhury :
Statistical analysis of burns in West Bengal, Indian
Journal of Burns, 2 (1). April. 1994, 24 – 30.
Dalbir Singh et al: Burn mortality in Chandigarh Zone ;
25 years autopsy experience form a tertiary care
hospital of India, Burns, 24(2), March 1998, 150 – 6.
D. Marsh et al : Epidemiology of adults hospitalized
with burns in Karachi , Pakistan, Burns, 22 (3), 1996, 225
– 9.
E. Fernandez – Morales et al : Epidemiology of burns in
Malaga, Spain, Burns 23(4) , 1997, 323 – 32.
L. M. Bariar : Review of 400 cases of burns at Aligarh,
Indian Journal of Burns, 2(1) , April 1994, 35 – 40.
M.Subramanyam : Epidemiology of burns in a district
hospital in Western India, Burns , 22(6), 1996,439 – 42.
V. Jayaraman et al : Burns in Madras , India ; An
analysis of 1368 patients in 1 year, Burns, 19(4) , Aug
1993, 339 – 344.
Stuart P. Pegg et at : Epidemiology of burns attending a
casualty department in Brisbane, Burns , 9(6), 1983, 416
– 21.
U.U. Lade : An epidemiology and management of
burns and scalds in Pediatric group (0 – 12years),
Dissertation submitted for M.S. (General Surgery),
1997.
D.J. Barillo and R. Goode : Fire fatality study
:demographics of fire victims ,Burns , 22(2) , 1996, 8588.
E. Danaf : Burn variables influencing survival a study
of 144 patients ,Burns, 21(7) , Nov. 1995, 517 – 20.
D. Duggan and S. Quine : Burn injuries and
characteristics of burn patients in New South Wales,
Australia, Burns, 21 (2), 1995, 83 – 9.
S. Al-Shlash et al : Eight years experience of a regional
burns unit in Saudi Arabia : Clinical and
epidemiological aspect ; Burns , 22(5) , 1996, 376 – 80.
Rajiv K. Sing: Psychiatric problems in burn patients,
Indian Journal of Burns, 1(1), April 1993, 71 – 3.
23
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Original Article .
PROFILE OF PEDIATRIC MALIGNANCY: A THREE YEAR STUDY
Bhalodia Jignasa N1, Patel Mandakini M2
1Associate
Professor, Department of Pathology, G.M.E.R.S. Medical College, Sola, Ahmedabad,
Gujarat
Professor, Department of Pathology, Govt. Medical College & New Civil
Hospital, Surat, Gujarat.
2Additional
Correspondence:
Dr.Bhalodia Jignasa N.
B-37, Marutinandan Vihar Bunglows, Nr. Aarohi villa, S.P. Ring road, Bopal, Ahmedabad - 380058.
E-mail : [email protected]
Mobile: 9925594684
ABSTRACT
The objective of this study was to find out the profile of childhood cancers in South Gujarat region,
during November 2002 to October 2005. Between November 2002 to October 2005 data was analyzed
for the malignancies occurring in the age group 0-14 years. Data was categorized according to
incidence of pediatric malignancies in different age groups, sex and types of tumors. All the children
below 15 years with confirmed diagnosis of cancer by means of histological or cytological
examinations were included in this study. Total 2150 patients were diagnosed as having malignancies
in our hospital out of which 43 were pediatric tumors. Overall incidence of pediatric tumor was 2%.
The peak incidence of pediatric tumors (44.18%) was found in children below five year of age. Males
were affected more than females. Among hematological malignancies most common was acute
lymphoblastic leukemia. The pattern of childhood tumors shows wide variation among the age
groups. Acute lymphoblastic leukemia, lymphoma and CNS tumors are most common tumors in this
age group.
Key words: Pediatric malignancy, cancer profile, incidence, south Gujarat region
INTRODUCTION
Incidence of pediatric tumors is on rise all over
the world.1 Malignant neoplasms are rare in
children, yet it is an important cause of
childhood mortality in many of the
economically developed nations of the world.2,3
Malignancy is the second most common cause of
childhood death in developed world, accounting
for 10%-12.3% of all childhood deaths.1,2 It is
second major cause of childhood mortality after
accidents in U.S.A.4,5 In developing countries
like India childhood mortality is still due to
malnutrition and infections, but pediatric
tumors are also rising in number.1
Childhood cancers are unique in the sense that
they arise from embryonal cells, respond to
treatment rapidly and the survival has
improved dramatically over the last two
decades due to aggressive combine modality
management.2 Because of the major advances in
diagnosis, multi-modality therapy, development
of rational use of combination chemotherapy
and improved supportive care, the cure rate in
childhood cancer has increased tremendously
and over 60% of all childhood cancers are now
curable.6 Seven out of ten children with cancer
in the resource-rich countries are cured, with a
five-year survival for certain cancers for
example, Hodgkin’s disease and retinoblastoma,
now 95%.7
Good- quality population level statistics on the
occurrence of cancer at young age have been
more difficult to obtain than in adults.8 Serious
under reporting, even in western countries, has
been documented.8 Appropriate management of
pediatric
tumors
requires
complete
epidemiological data of pediatric tumors in
different geographical areas. As hospital
registries are the only available source of
information for assessing the disease pattern in
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ISSN: 0976 3325
community, 1
so we conducted this study to find
out the profile of childhood cancer in South
Gujarat region.
We used three years hospital records in this
retrospective study from November 2002 to
October 2005. All children with cancer, aged 014 years diagnosed by means of histological and
cytological examination during that period were
included in the study. Patients from South
Gujarat region attend this Government hospital
for better care and cure.
The system of classification by site was devised
primarily for cancers in adults are less useful for
studying the types of childhood tumors that can
arise at diverse sites. National Cancer Institute,
US has classified childhood cancers according to
SEER (Surveillance, Epidemiology and End
Results) programme data, which is a
modification of ICCC (International childhood
cancer classification).9 We classified our tumors
according to this criteria.
The profile of childhood cancer was studied
focusing on the prevalence of tumors according
to age, sex and type of tumors.
RESULTS
In our hospital during period of three years 2150
patients were diagnosed as having malignancies
out of which 43 cases were of pediatric age
group. The pediatric malignant tumor comprises
2% of all malignancies. Males are affected
(58.14%) than females (41.86%) with male to
female ratio of 1.38:1.
Tumors were arranged according to their
incidence in 0-4 years (44.18%), 5-9 years
(25.58%) and 10-14 years (30.24%). The incidence
of tumor varied among different age groups.
The highest incidence was seen in 0-4 years of
age group and lowest incidence is seen in 5-9
years of age group.
It was observed that hematological malignancies
were more common (60.47%) than the nonhematological malignancies (39.53%). Acute
lymphoblastic leukemia is most common
hematological malignancy. It account for 39.53%
of total malignancies, 65.38% of total
hematological malignancies and 89.47% of acute
leukemia. Peak incidence of acute leukemia
occurs in 0-6 years of age group. Among
hematological malignancies acute lymphoblastic
leukemia is followed by Hodgkins disease
(13.90%), acute myeloid leukemia (4.65%) and
non-Hodgkins
lymphoma
(2.32%).
Most
common nonhematological malignancy is
Wilm’s tumor (9.30%) followed by sympathetic
nervous system tumors (neuroblastomas and
gangioneuroblastomas) (6.97%).
Table 1: Incidence of pediatric malignancies according to sex in our study and other studies
Gender
Gurney et al11
Yeole et al10
Male
Female
M:F ratio
54.10%
45.90%
1.17:1
61.20%
38.80%
1.57:1
DISCUSSION
In our study pediatric tumors constituted 2% of
all malignancies. It is lower then other studies
(3.4%) in Rathi et al.1, (4.5%) in Kusumakumary
et al.2 and (3.3%) in Yeole et al.10. But according
to Arora et al.7 incidence of cancer in India is 1.64.8%, so our finding falls in this range. Our
incidence is lower than England (0.5%) 7 and
(0.8%) in U.S.A.8. This is related to population
structure (33% of the population in India is less
than 15 years of age compared to 18% in
England). Children form a larger part of the
population in a developing country where the
life expectancy is lower than in the developed
world.8 The international comparison of cancer
Vineeta Joshi et
al12
1.58:1
Present study
58.14%
41.86%
1.38:1
frequency and incidence are potentially biased
by variability in diagnosis, classification and
differential access to medical care and
incomplete registration.2
Following table shows incidence of pediatric
malignancies according to sex in present study
and other studies.
In all three studies the incidence of malignancies
is higher in male than in female. Male and
female ratio in present study is 1.38:1 which is
almost comparable with both Yeole et al10 and
Vineeta Joshi et al12 studies. The ratio is slightly
higher than Gurney et al study 11, which was
conducted in USA. Male predominance is a
salient feature of the childhood tumors. Sex ratio
varies with site. The male excess is particularly
25
ISSN: 0976 3325
seen in neoplasms of lymphoid origin e.g. ALL,
NHL and HD which represent over two third of
all tumors. Environmental factors like exposure
to carcinogens at work or smoking habits may
be contributing to excess of cancers in adult
males but such an explanation cannot account
for the excess of cases seen in male children.
Genetic difference in immune function may be
responsible for the increased incidence of
lymphoid tumors in males. The female excess
seen in germ cell tumors may be due to earlier
development of ovarian tumors than testicular
tumors, but no convincing explanation is given
for increased incidence of sacrococcygeal
teratomas in girls.2
Male preponderance in our country could be
also as a result of our cultural factors wherein
boys get more attention and are brought to
hospital more often for management.10 The
following table shows comparison of prevalence
of childhood malignancy according to age in
different studies.
It shows that the incidence is more in 0-4 years
of age group. The majority of acute
lymphoblastic leukemia and embryonal tumors
(neuroblastoma,
hepatoblastoma,
nephroblastoma, retinoblastoma, rhabdomyosarcoma
and medulloblstoma) occurs in children less
than five years of age. Peak age of acute
lymphoid leukemia occurs at 2 years of age.10, 11
In present study total cases of acute
lymphoblastic leukemia is 17. Out of that 70.58%
cases were from child below 5 years of age
group, so highest incidence of malignancy was
in age group of 0-5 years age group.
Table 2: Prevalence of childhood malignancies
according to age in present study and Yeole, et
al10 study and Jabeen et al8 study
Age in
years
0-4
5-9
10-14
Yeole et
al.10
36%
32%
32%
Jabeen et
al.8
30.9%
31.4%
37.7%
Present
study
44.18%
25.58%
30.24%
Table 3: Relative frequencies (%) of different pediatric malignancies in 2 developed countries, India
and few canters from India.
Tumor
Leukemia
Lymphoma
CNS Tumors
Neuroblastoma
Wilm’s tumor
Bone tumors
Soft tissue tumors
Other
U.S.A.12
UK12
India1
Mumbai10
Delhi6
Gujarat12
Kerala2
30.1
12.3
19.1
8.1
6.5
4.8
6.3
10.1
20.4
8.7
16.6
7.5
5.4
4.8
8.5
16
32
14.08
18.21
4.21
4.94
7.66
5.49
18.35
32.8
12.65
17.6
5.25
3.85
4.3
19
28.8
11.5
21.0
4.1
3.3
3.3
3.8
11.8
39.9
15.25
8.3
4.47
4.86
7.34
1.15
9.52
30.0
10
19.3
5.1
5.4
5.4
6.6
13.8
Leukemias are the commonest form of
childhood malignancies and together with
lymphoma,
constitute
35-55%
of
all
malignancies in different regions. In present
study, lymphoma and leukemia together
constitute 60.45% of malignancies. Among
leukemias, most common are acute leukemias,
75-80% being ALL and 20-25% ANLL.10 In
present study ALL constitute 89% of total
leukemias and ANLL is 11% of leukemias. CNS
tumors constitute about 18-20% of malignant
neoplasms in pediatric age group. In present
study, incidence of pediatric CNS tumor is
6.97%, which is almost comparable with Parikh
BJ et al study which is carried out at GCRI,
Ahmedbad, Gujarat.12 But incidence is lower in
our study than other studies done out of
Present
study
44.18
16.27
6.97
6.97
9.30
2.32
2.32
11.67
Gujarat. Incidence of Wilm’s tumor is slightly
higher (9.30%) than that of other studies.
Incidence of neuroblastoma, bone tumors, soft
tissue tumors and other malignancies is
comparable with different studies. Pediatric
solid tumors show wide incidence variation
among the age groups. Frequency of Wilm’s
tumor, Yolk sac tumor and PNET is high in 0-4
years of age group. In children of 5-9 years CNS
tumors and neuroblastoma is common.
Hodgkins disease is more in children more than
10 years. It is a known fact that certain
childhood malignancies are more prevalent in
younger children under 5 years, while others
mostly occur in an older age group.13
CONCLUSION
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ISSN: 0976 3325
Pediatric tumors are a special entity with
different genetic, environmental factors playing
a role in their etiology. The growth potential and
response to treatment is also different from
those of adult tumors. Children in developing
nation are increasingly affected by malignancy
in addition to rampant malnutrition and
infection, but dedicated registry maintenance of
pediatric tumors is lacking. As many of common
childhood malignancies are curable there is need
to have a dedicated pediatric cancer registry for
assessing the magnitude of problem in our
country as pediatric tumors show wide variation
across centers.
REFERENCES
1.
2.
3.
Rathi A.K., Kumar S., Ashu A., Singh K. and Bahadur
A.K. Epidemiology of pediatric tumors at a teriary care
centre. Indian J Med Paediatr Oncol. 2007; 28(2): 33-5.
Kusumakumary P., Rojomon Jacob, Jothirmayi R, Nair
M.K. Profile of pediatric malignancies: A ten year
study. Indian Pediatrics 2000; 37: 1234-8.
Kusumakumari P. Childhood malignancies. Ind. J. Med
and Ped. Oncol. 1996; 17: 168-77.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Advani S.H. Chemotherapy of childhood tumors. Ind. J.
Med and Ped. Oncol. 1995; 16: 142-3.
Young J.L., Ries L. G., Silverberg E., Horm J. W., Miller
R. W. Cancer incidence, survival and mortality for
children younger than age 15 years. Cancer 1986;
58:598-602.
Arya L. S. Childhood cancer-challenges and
opportunities. Indian J. of Pediatrics. 2003; 70:159-62.
Arora R.S., Eden TOB, Kapoor G. Epidemiology of
childhood cancer in India. Indian J. of Cancer. 2009;
46(4): 264-73.
Jabeen S., Haque M, Islam M.J., Talukder M.H. Profile
of pediatric malignancies: A five year study. J Dhaka
Med Coll. 2010; 19(1): 33-8.
http;//seer.cancer.gov/iccc/seericcc.html
Yeole B.B., Advani S.H., Sunny L. Epidemiological
features of childhood cancers in greater Mumbai. Ind.
Pediatrics. 2001; 38: 1270-7.
Gurney J.G., Severson R., Devis S, Robinson L.L.
Incidence of cancer in children in United States. Cancer
1995; 75(8): 2186-95.
Joshi V., Kumar A. Pediatric Hemato-oncology in India.
Epidemiologic Differences. M.B. Agrawal. Hematology
Today, 2004.
Chaudhuri K., Shinha A., Hati G.C., Karmakar R,
Banerjee A. Childhood malignancies at BS medical
college: a ten year study. Ind. J. Pathol microbial. 2003;
46(2): 194-6.
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Original Article .
A STUDY TO ASSESS THE UNMET NEEDS OF FAMILY PLANNING IN GWALIOR DISTRICT
AND TO STUDY THE FACTORS THAT HELPS IN DETERMINING IT
Srivastava Dhiraj Kumar1, Gautam Pramod2, Gautam Roli3, Gour Neeraj4, Bansal Manoj5
Lecturer, Department of Community Medicine, UP Rural Institute of Medical Sciences & Research
Post Graduate Resident, Department of Community Medicine, 3Former Post Graduate
Resident, Department of Obstetrics & Gynaecology, 4Assistant Professor, Department of Community
Medicine, G.R Medical College, Gwalior 5Assistant professor, Department of Community Medicine,
Govt. Medical College, Sagar.
1
2Former
Correspondence:
Dr. Dhiraj Kumar Srivastava
C/o Mr. RK Srivastava, H. No. 1532, Near Ebnezer School,
Bhagat Singh Nagar, Bhind Road, Gola Ka Mandir, Gwalior (MP)-474005
E-mail: [email protected] Mobile No: 09893071022, 09027156756
ABSTRACT
While real progress has been made in improving access to family planning globally, the unmet needs
continue to grow. So the present study was designed to determine the percentage of unmet needs of
family planning in Gwalior district and to study the various co-relative factors responsible for the
unmet need for family planning. The present study was a Cross Sectional Descriptive study carried
out from Jan 2007 to July 2007. 520 married women were interviewed using a pre designed, pre tested
structured proforma. The district was divided into urban and rural areas. The rural area was further
divided into four blocks. From each block one PHC and five Sub Centers under the respective PHC
were selected randomly. From each Sub Centre 11 married women were selected. The Urban area was
divided into four divisions and from each division five wards were selected randomly. From each
ward 20 married women were selected. Proportion, Chi square test and ODDs ratio were applied to
interpret the result. The unmet need of family planning in Gwalior district was 21.70%. It was higher
in rural area and women of the age group of 15-19 years. The unmet needs were also higher among
women who did not have any media exposure or did not discuss about family planning with their
husbands. The present study concludes that Family Planning services should be specifically directed
toward the married women of the age group of 20 years or less.
Key Words: Unmet needs, Family Planning, Contraceptive Methods
INTRODUCTION
While real progress has been made in improving
access to family planning globally, the unmet
needs of family planning – that is, the number of
individuals who would like to use family
planning methods but do not have access to a
full range of modern contraceptives and
information continues to grow.
In the developing world limited access to family
planning results in high rate of unintended
pregnancies, millions of unsafe abortions &
thousands of maternal deaths. Limited access to
family planning is also a leading cause of infant
death in developing countries.
In developing countries as a whole, excluding
China, about 20 per cent of married women of
reproductive age have unmet need for family
planning. In total, more than 100 million
sexually active women in developing countries
would like to adopt some measures of family
planning.1 Because of the large population of
Asia, however, by far the greatest number of
women with unmet needs live in this region.
India has the most unmet need for family
planning, at about 31 million.1
The findings of National Family Health Survey
(NFHS) I and II carried out in 1992-93 and 199899 respectively have revealed that for a large
28
ISSN: 0976 3325
proportion of our population, the need for
family planning services is not met with despite
the existence of National Policy of Family
Planning since 1983. However, the analysis of
recent findings of NFHS -III does reveal that the
unmet need of family planning has declined
from 15.8% in NFHS -II to 13.2% in NFHS -III.1
have an unmet need for family planning. The
level of unmet need in Madhya Pradesh is same
as the level for India as a whole. A
comprehensive study of unmet need in the state
is highly desirable in order to develop a locally
relevant and suitable strategy to overcome the
problems of unmet need on priority basis.
Unmet needs for family planning signify the gap
between the reproductive intentions of couples
and their actual contraceptive behaviour. If
measured accurately, it can indicate the
potential demand for family planning services
and its likely impact on fertility, if the demand is
met effectively.
The present study was undertaken with the
following objectives:
According to NFHS -II (1998-99), 16% of
currently married women in Madhya Pradesh
•
To determine the percentage of unmet need
for family planning in Gwalior district.
•
To study the various co-relative factors
responsible for the unmet need of family
planning.
Table –I: Shows the socio- demographic profile and unmet need of study participants.
Socio- demographic
parameters
Age of participant
·
15-19 years
·
20-24 years
·
25-29 years
·
30-34 years
·
35-39 years
·
40-44 years
·
45-49 years
Educational Qualification
·
Illiterate
·
Up to 5th std.
·
Up to 12th std.
·
Graduate
·
Post Graduate
Occupation
·
Housewife
·
Working
Religion
·
Hindu
·
Muslim
·
Sikh
·
Others
Socio- Economic Class
·
Class-I
·
Class-II
·
Class-III
·
Class-IV
·
Class-V
Urban
Total
Unmet
(N=300)
needs
(N=46)
Rural
Total
Unmet
(N=220)
needs
(N=67)
Total
Total
Unmet
(N=520)
needs
(N=113)
12
61
59
68
51
40
21
5
7
5
10
7
7
5
21
53
49
41
29
17
10
17
13
10
9
9
5
4
33
114
108
109
80
57
31
22
20
15
19
16
12
9
36
61
89
73
41
15
12
9
8
2
79
64
42
33
2
35
17
9
6
0
115
125
131
106
43
50
29
18
14
2
221
79
41
5
217
3
67
0
438
82
108
5
159
92
46
3
19
24
3
0
148
59
13
0
39
26
2
0
307
151
59
3
58
50
5
0
81
69
59
63
28
18
13
9
5
1
93
57
38
19
13
33
19
9
5
1
174
126
97
82
41
51
32
18
10
2
The present study was a Cross-Sectional
Descriptive study carried out from January 2007
to July 2007 by the staff and students of the
Deptt. of Community Medicine, G.R Medical
College, Gwalior. The study was carried on
married women of reproductive age group (age
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ISSN: 0976 3325
15 to 49 years) in Gwalior district. A sample of
520 was calculated using 16.2% prevalence of
unmet need for family planning among married
women in Madhya Pradesh (NFHS-II, 1998-99)
and a relative precision of 20% with 95%
confidence interval.
The study was carried out in both rural and
urban area of Gwalior district. Multistage
stratified sampling method was used to select
the requisite sample. In the first step, Gwalior
district was divided into urban & rural area. In
the second step, urban area was divided into 3
divisions, namely- Lashkar, Morar& Hazira.
Similarly, the rural area was divided into 4
blocks, namely- Morar, Ghatigaon, Bhitarwar &
Dabra. In the third step, five wards from each
division of urban area and one PHC from each
block of rural area were selected randomly.
From each PHC five sub-centres were selected.
From each urban ward 20 married women and
from each sub-centre 11 married women of the
age group 15-49 years were selected and
interviewed through house to house survey
method. To ensure active support &
participation of the subject, the aims of the study
were explained to them and verbal consent was
sought out. The data was collected regarding
socio-demographic profile, age of marriage and
consummation, number of children ever born,
child loss etc. The subjects were also interviewed
about their knowledge of contraceptive
methods, past and current use of contraceptives
and their intention to use contraceptives in
future. The data collected was analyzed using
suitable statistical software. Proportion, chisquare test and ODDs ratio were applied to
interpret the result.
RESULTS
Out of total 520 participants 300 participants
belonged to urban area and 220 participants
belonged to rural areas (Table-I).
Table-II: Shows the relationship between the unmet needs and number of child born and child loss
Number of children
0
2-Jan
4-Mar
>4
Total
P value
Child living
Total number
Unmet needs
41
12
286
51
146
32
47
18
520
113
P=0.077 df=3 X2=6.82
Child loss
Total number
Unmet needs
415
81
71
21
33
11
2
0
520
113
P=0.23 df=3 X2 = 4.31
There was no statistically significant difference
in the demand for family planning among
women who had a child loss compared to the
women who did not have a child loss (Table-II).
Majority of women had discussed about family
planning with their husbands and were aware of
their husband views on family planning (TableIV and Table-V).
However there was a statistically significant
difference in the demand for family planning
among women who did not have media
exposure compared to those who had it (TableIII).
Table-IV: Distribution of women who had
discussion on family planning with their
husband.
Table-III: Showing the distribution
participant according to media exposure
of
Total
Unmet
P Value
number
needs
Yes
425
78
0.002446
(X2= 9.18
No
95
35
Df=2)
Total
520
113
Odds ratio: 2.01(1.27 to 3.17 at 95%CI)
Response
s
Yes
Total
Unmet
Total
number
needs
416
72(14.7%) 488(100%)
(85.2%)
No
104(71.7%) 41(28.2%) 145(100%)
Odds ratio: 2.27 (1.46 to 3.58 at 95% CI)
DISCUSSION:
The present study had calculated the total
unmet needs for family planning in Gwalior
district to be 21.70% which is similar to the value
found by Andurkar SP et al (20.54%).(2) However
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ISSN: 0976 3325
the rates are higher than the rates reported in
NFHS-III (13.2%). It was found in the present
study that unmet needs for family planning
were more among residents of rural area
(30.45%) than urban area (15.53%)
The highest percentage of unmet needs for
family planning was noted in the age group 1519 years (66.66%). Various researchers like
Kumari C (3) & Chandhick N et al (4) also noted
that the use of contraceptive measure was least
among the similar age group. This can be
attributed to the fact that the young couples do
not have sufficient knowledge of various
contraceptive methods available or they have
fear of the side effects of the contraceptive
methods. Also, it was noted in the study that
Muslim population had least usage of
contraceptive methods than any other religion
and thus had maximum unmet need for family
planning. Studies carried out in different parts
of the country by various researchers like
Diwedi SN et al (5) also reported that the use of
any contraceptive method is least among
Muslims than any other religion. This is
probably due to religious beliefs prevailing
among Muslim community.
Table-V: Distribution of women according to
the views of their husband on family planning.
Approves
Disapproves
Do not know
Total
number
383(84.9)
86 (74.7)
51 (75%)
Unmet
needs
68 (15.1)
29 (25.3)
16(25%)
Total
451(100)
115(100)
67(100)
It was found in the present study that women
with 4 or more living children are more
susceptible for adoption of any contraceptive
measures than any other women. A longitudinal
study carried out in Central India by Roy TK et
al(6) also noted similar findings. Similarly
women with the loss of 3-4 children are also
prone to adopt any contraceptive measure. Roy
TK et al (6) found it to be a key factor for women
intending to use any contraceptive methods.
The present study noted that women who had
exposure to any form of mass media
communications had less unmet needs of family
planning than women who had no media
exposure or very little media exposure (OR2.0074, 95%, CI-1.27 to 3.169). Epidemiological
studies carried out by Diwedi SN et al
found similar results.
(5)
also
The present study noted that women who had
discussion with their husbands on family
planning were more likely to use any
contraceptive methods than women who did not
discuss (OR-2.27, 95%, CI-1.46 to 3.58)
It was noted in the present study that women
whose husbands approved the use of
contraceptive methods were having less unmet
needs for family planning than women whose
husbands disapproved or were unaware of their
husband’s view. This difference was statistically
significant.
CONCLUSION:
The present study concluded that the percentage
of unmet need for family planning is maximum
in the young sexually active women below the
age of 20 years that are residing in rural India.
Family Planning measures should be specifically
directed toward this group of women if India
has to make any progress in controlling its
population.
The study also concludes that women who have
completed their families are more susceptible to
adoption of permanent contraceptive methods
and this facility should be provided to them.
REFERENCES:
1.
2.
3.
4.
5.
6.
Kishore J. National Health Programs of India, 7th
edition, Century Publication New Delhi; 2007: p93-197.
Andurkar SP, Yadav VB, Dalvi SD. Study of unment
need for family planning among married women of
reproductive age in urban health central field practice
area of Govt. Medical College, Aurangabad. Indian J
Public Health.2006; 50:45-6.
Kumari C. Contraceptive practices of women living in
rural areas of Bihar. Br J Fam Plann. 1998 ;24:75-7.
Chandhick N, Dhillon BS, Kambo I, Saxena NC.
Contraceptive knowledge, practices and utilization of
services in the rural areas of India (an ICMR task force
study). Indian J Med Sci. 2003;57:303-10.
Dwivedi SN, Sundaram KR. Epidemiological models
and related simulation results for understanding of
contraceptive adoption in India. Int J Epidemiol. 2000
;29:300-7.
Roy TK, Ram F, Nangia P, Saha U, Khan N. Can
women's childbearing and contraceptive intentions
predict contraceptive demand? Findings from a
longitudinal study in Central India. Int Fam Plan
Perspect. 2003;29:25-31.
31
ISSN: 0976 3325
Original Article .
A STUDY ON COVERAGE UTILIZATION AND QUALITY OF MATERNAL CARE SERVICES
Neeraj Agarwal1, Abhiruchi Galhotra2, H M Swami3
1Associate
Professor, 2Assistant Professor, Department of Community Medicine, Govt. Medical
College, Chandigarh 3Medical Superintendent, Gian Sagar Medical college, Chandigarh.
Correspondence:
Dr. Abhiruchi Galhotra
Assistant Professor, Department Of Community Medicine
Government Medical College, Sector 32-A, Chandigarh
E-mail: [email protected] Mobile: 09646121541
ABSTRACT
The objectives of the study were yo assess the utilization of various maternal services and to
compare the quality of services provided by doctors and health workers in terms of components and
advice received by pregnant women during antenatal period. It was a Cross-sectional Study
conducted in a village on the border of Chandigarh (U.T.) and Mohali (Punjab). All the women who
had delivered in the past three years in the village Palsora were included in the study. 92.4% of the
pregnancies were registered, 53.2% of which received antenatal care by a Doctor and 46.8% by a
health worker. The measuring of blood pressure was significantly higher by the doctor than the
health workers who recorded weight more significantly. The advice provided by doctors was
significantly higher than health workers regarding diet, danger signs, newborn care, family planning
and natal care.
Key words: Antenatal care (ANC), Health worker (HW), Reproductive and child health, (RCH),
Postnatal Care (PNC)
INTRODUCTION
The National Population Policy 2000 (NPP-2000)
envisages the goal of 100 percent registration of
pregnancy, 80 percent institutional deliveries
and 100 percent deliveries to be conducted by
trained staff/birth attendant by the year 20101.
Reproductive & child health programme2
recommends that as a part of antenatal Care,
women should get registered & receive at least
three antenatal checkups which include weight
and height measurement, blood pressure
records, abdominal examination along with
General Physical Examination (GPE) and
investigations to detect any complication. It also
includes provision of two doses of tetanus
toxoid vaccine, 100 tablets of Iron and Folic Acid
(IFA) prophylactically to prevent anemia,
dietary advice, intranatal and postnatal care
which includes, new born care, family planning
etc. The reproductive age group (15-45 years)
owing to their vulnerability deserves special
attention.
Because of the universality of
marriage & social pressure to bear children
early, women are subjected to added risk of
morbidity & higher mortality3. With a paradigm
shift in approach from “Top Down” to “Grass
root level Micro planning” in the Reproductive
& Child Health Programme2, it is imperative to
assess the felt needs of the population for
providing the appropriate and optimum range
of maternal health services. Hence the present
study was carried out to know the prevalence of
utilization of antenatal services and to compare
the quality of services provided by doctors and
health workers.
The study was carried out in village PALSORA,
with a population of approximately 3500. This
village is a part of field practice area of Rural
Health Training Center (RHTC) of Department
of Community Medicine, Govt. Medical College
& Hospital, Sector-32, Chandigarh and is
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ISSN: 0976 3325
situated at the border of Chandigarh and Mohali
.The respondents were all the mothers who had
given a birth in the preceding three years (i.e.
birth in the period from September 2002 to
September 2005).
A predesigned pretested questionnaire was used
to collect the desired information about
utilization of the specific components of
antenatal and postnatal care.
OBSERVATION AND DISCUSSIONS
Of the 307 women who had delivered a child in
the past three years, majority were Hindus
(73.3%), in the age group of 20 – 34 years
(86.3%), and illiterate (46.6%). Birth order was 1
& 2-3 in 35.2% and 55.0% respectively.
Table 1: Antenatal Care Indicators
Antenatal Care Indicators
Present Study
% of women who received at least one Antenatal checkup
% of women who received at least 3 Antenatal checkup
% of women who received Antenatal checkup in first trimester
% of women who received 2 or more Tetanus toxoid
% of women who received 100 IFA tablets
92.4% i.e. 283, of the women who delivered
during the study period, had received antenatal
checkups during their pregnancy. As per the
NFHS-24 data, only 65.4% of the women in India
received at least one antenatal check up. This is
in comparison to a study by Sinha Babu et al5
92.2
77.2
30.0
90.6
53.1
NFHS-II
PUNJAB INDIA
74
65.4
57
43.8
42.6
33
89.9
66.8
64.2
47.5
(99.2%), where as in a study by Bartati Banerjee6,
the utilization of antenatal services was 64.25%.
The registration of antenatal cases was 57.2% in
a study by Ranjan Das7 et al, whereas it was 95%
in a study by Sunder Lal8 et al.
Table 2: Appropriateness of Physical Examination by Provider
Component
Weight measurement x 3
Blood Pressure exam. x 3
Abdominal Examination x 3
All (N=237)
No. (%)
153 (64.1)
105 (44.3)
152 (64.1)
Doctor (N=126)
No. (%)
74 (58.7)
74 (58.7)
83 (65.9)
A total of 237 (77.2%) mothers received 3 or
more Antenatal Checkups during their
pregnancy. According to NFHS-24 only 43.8% of
the women received at least three antenatal
checkups (Table 1). Ranjan Das7 et al reported
three or more antenatal visits in 62% of the
registered cases whereas it was 27.7% in a study
by Sunder Lal8 et al. In a study by Agarwal9 et al
23% of the registered antenatal women had
three to four visits. In the present study, out of
the 237 mothers who received three or more
Antenatal checkup’s, 126 (53.2 %) mothers
received antenatal Care by Doctors & 105
(46.8%) mothers received antenatal care by a
health worker i.e. ANM etc. The data collected
from these mothers was used for analysis for
quality of care (Fig. 1).
The ANC visits for 3 or more time was 81.9% for
doctor as a provider as compared to 82.0% in
Health Worker (N=105)
No (%)
79 (75.2)
30 (28.6)
70 (66.7)
p- value
0.008 (S)
0.0000 (S)
0.89 (NS)
case of health worker. In General Physical
Examination (GPE), doctors had measured
blood pressure in 58.7% pregnant mothers,
which is significantly higher (p<0.0001) than
health workers. But weight measurement by
health workers was significantly (p=. 008)
higher than doctors. Abdominal examination
was done by both in two out of three women
(Table 2). The advice provided by doctors was
significantly higher than HW regarding diet
(p=.0001), danger signs (p=.0001), newborn care
(p=.0001), family planning (p=.0001) & natal
care (p=.0001).
In the present study, 90.6% of the pregnant
females had received two doses of tetanus
toxoid, 66.8% of mothers had received two doses
of Tetanus toxoid according to NFHS- 24, and
where as in a study by R.Talwar10 only 54.6%
had received tetanus toxoid. In another study by
33
ISSN: 0976 3325
Lal8
Das7
Sunder
et al and by Ranjan
et al two
doses of tetanus toxoid were received in 94.8%
and 93.2% mothers.
mothers received 100 IFA tablets as per NFHS –
24. In a study by Sunder Lal8 et al, 100 tablets of
IFA were given in 5.8% women. A similar study
by Ranjan Das7 et al showed IFA consumption
of 1.7% for more than 100 tablets.
Though IFA was given to majority of the women
in the present study, but only 53.1% had
received it for three months. 47.5% of the
Table 3: Quality of ANC in Term of Advice by Provider
Component
Doctor
No
124
112
107
73
112
124
120
100
79
60
Diet advice
Danger Sign
New Born Care
Family Planning Advice
Delivery Care Advice
TT Immunization
IFA given
IFA Consumption
Quantity (100 tablet of IFA)
Delivery at Hospital
Health Worker
No
%
75
71.4
33
31.4
39
37.1
29
27.6
37
35.2
101
96.2
99
94.3
80
80.8
67
67.7
32
30.5
%
98.4
88.9
84.9
57.9
88.9
98.4
95.2
83.3
65.8
47.6
The Institutional deliveries were more in cases,
where ANC was provided by a doctor (47.6% Vs
30.5%), (Table 3). One third (34.6%) of births in
p-value
0.0001(S)
0.0001(S)
0.0001(S)
0.0001(S)
0.0001(S)
0.29(NS)
0.35(NS)
0.5(NS)
0.86(NS)
0.008(S)
this area took place in health facilities and twothird were home deliveries.
Live birth in last three years
307
Received Antenatal Care
283 (92.2%)
Antenatal Visits
3 or more
237, 77.2%
Less than 3
46, 15%
Ante Natal Care Provider
Doctors
126
Health Workers
105
Others (Included)
06
Analysis for ANC Quality
Figure 1 Flow chart of analysis for quality of care.
34
ISSN: 0976 3325
The proportion of births occurring in health
facilities is higher for mothers with birth order
one (44.4%) than mother with birth order 4 or
more (16.7%). The reason for non-institutional
delivery in majority was that institutional
delivery was not considered necessary by
respondents (67.2%). Studies by Sunder Lal et al
and Ranjan Das et al reported institutional
deliveries in 14.2% and 10.7% respectively.
Based on mother's reports, 6.2% (19) of infants
born in this area in the past three years were
delivered by caesarian section.
About three-fourth (74%) of non-institutional
births were followed by a check-up within two
months of delivery (Table 4). Among births that
were followed by a check-up, around 80%
check-ups took place shortly after birth (72%
within two days & 7% within a week). The
likelihood of a birth being followed by a
postpartum check-up was higher for literate
mothers than illiterate mothers and for mothers
who had got antenatal check-up thrice.
In the postnatal component, abdominal
examination, advice regarding family planning,
breast feeding and baby care was provided in
76%, 29.8%, 71% and 59% respectively (Table 4).
Table 4: PNC of Non-Institutional Delivery
(N=204)
Post-natal
Care No.
% Punjab India
Availed
Total PNC Given
151
74
20.0
17
With in 2 day
108 71.5
28
14
With in a Week
10
6.6
56
31
After one week
33
21.9
16
55
Component of PNC CARE (n=151)
Abdominal
115 76.2
86
38
Examination.
Family
Planning 45
29.8
35
27
Advice.
Breast
Feeding 101 70.9
65
43
Advice
Baby Care Advice
89
58.9
58
46
CONCLUSIONS
Majority of the women in the present study
were illiterate Hindus in the age group of 20-34
years, with a birth order of 2-3in 55%. 92.4% of
the pregnancies were registered, 53.2% of which
received antenatal care by a doctor and 46.8% by
a health worker. As far as the quality of
antenatal care, as provided by either a doctor or
a health worker, it was observed that
measurement of blood pressure during
antenatal checkup was significantly higher in
case of doctor as a provider, whereas weight
measurement was significantly higher where
health worker was the antenatal provider.
Regarding quality of antenatal care in terms of
advice by the provider, it was observed that
antenatal, intranatal and postnatal advice given
by doctor, as antenatal provider was
significantly higher than a health care worker.
Institutional deliveries were more in cases
where a doctor (47.6%vs.30.5%) had provided
antenatal care. Both doctor and health worker
had provided tetanus toxoid and IFA tablets to
approximately 95% of mothers.
Antenatal care services have traditionally been
and still continue to be one of the most sought
services at the subcentre level. The RCH2
approach places special emphasis on clientoriented, need-based, high quality integrated
services. Inbuilt mechanisms for assessment of
quality of ANC coverage have been developed
and incorporated into the routine reporting
system. But these reports are not always reliable.
Accountability at all levels should be ensured
and random crosschecking by independent
institutions be encouraged.
RECOMMENDATIONS
There should be provision for improvement of
competence; confidence and motivation of
ANM’s, health workers to ensure full range of
antenatal care activities specified under
NRHM11 programme. Attention should also be
given to regular and sustained contact between
health workers and antenatal mothers
particularly through home visits to develop
mutual confidence and thereby help remove
prevailing misconceptions of mothers, women
and other barriers of utilization of antenatal care
services.
Awareness should be generated amongst the
community members by holding mothers’
meeting and extensive IEC programme inviting
opinions and suggestions from the clients and
encouraging enhanced community participation
for bringing about a quantitative and qualitative
change in the coverage of reproductive health
programme; Support should also be obtained
from local NGO’s.
35
ISSN: 0976 3325
Last, but not the least the present study
emphasizes the need for training and retraining
of health functionaries, who by working at grass
root levels can do a lot in improving the quality
of antenatal services.
REFRERENCES
1.
2.
3.
4.
5.
Govt. of India. National Population Policy 2000.
Department of Family Welfare, Ministry of Health and
Family Welfare, GOI, New Delhi.
J. Kishore. Reproductive and Child Health Program-II,
National Health Programs of India. Fifth EditionCentury Publications, New Delhi, 2005. p21-78.
K. Park. Demography and family planning. Park’s Text
Book of Preventive and Social Medicine. Eighteenth
Edition. Banarsidas Bhanot Publishers, Jabalpur. 2005.
p349-382.
International Institute for Population Sciences (UPS)
and ORS Marco. National Family Health Survey
(NFHS-2) 1998-99 Mumbai UPS 2000.
Sinhababu A; Sinha Mahapatra B; Das D; Mundle M;
Soren A.B; Panja T.K. A Study on Utilization and
Quality of coverage of Antenatal Care Services at
Subcentre level. Indian Journal of Public Health 2006;
31 (1): 49-52.
6.
Banerjee Bratati. A Qualitative Analysis of Maternal &
child Health Services of an Urban Health Center by
assessing Client Perception in terms of Awareness
satisfaction & Service Utilization. Indian Journal of
community medicine 2003; 28(4): 153-156.
7.
Das Ranjan, Amir Ali, Nath Papri. Utilization and
coverage of services by women of Jawan Block in
Aligarh. Indian Journal of Community Medicine 2001;
26(2): 94-100.
8.
Lal S. Kapoors; Vashist B M, Punia M.S. Coverage &
Quality of Maternal & Child Health Services at
Subcentre level. Indian Journal of Community
Medicine 2001; 26(1): 16-20.
9.
Aggrawal O.P, Kumar R; Gupta A, et al. Utilization of
antenatal care services in Periurban Area of East Delhi.
Indian Journal of Community Medicine 1997; 22:29-32.
10. Talwar R, Chitkara A, Khokhar A.,Rasania S. K,
Sachdeva T.R. Determinants of utilization of antenatal
care services amongst attendees in a Public Sector
Hospital in Delhi. Health and Population Perspectives
and Issues 2005; 28 (3): 154-163.
11. www.mohfw.nic.in/NRHM.htm
36
ISSN: 0976 3325
Original Article .
STUDY OF SATISFACTION OF PATIENTS ADMITTED IN A TERTIARY CARE HOSPITAL IN
NAGPUR
M V Kulkarni1, S Dasgupta2, A R Deoke1, Nayse3
1Associate
Professor, Department of Community Medicine, 2Dean, 3Statistician, Department of
Community Medicine, NKP Salve Institute of Medical Sciences, Nagpur, Maharastra
Correspondence:
Dr. M. V. Kulkarni,
Plot no. 9, Vasudhashri, Radhakrisnna Society,
Manish Nagar, Somalwada, Nagpur.440015. Maharashtra
Email: [email protected] Mobile: 9922949668
ABSTRACT
The study was conducted with an objective to study satisfaction of patients admitted in a tertiary care
hospital regarding behavior of hospital staff, cleanliness, and hospital services. Hospital based cross
sectional study was carried out among indoor patients from Lata Mangeshkar Hospital which is a
tertiary care hospital attached to NKPSIMS, Nagpur. Indoor `patients (n=907) discharged during the
study period of four months from February 2008 to May 2008 were interviewed on the day of
discharge and pre-designed proforma was filled. Data was analyzed by using Epi- info statistical
software. Level of satisfaction among patients was found to be better with behavior of doctors
(87.76%) as compared to behavior of nurses and Class III & Class IV workers (70.01%, 59.09%
respectively) and statistically it was found to be highly significant (P<0.0001). Dissatisfaction was
found to be more with cleanliness in toilets (56.01%) as compared to the other hospital areas which
was also statistically highly significant (P<0.0001). Approximately only half of the patients were
satisfied with quality of food available in the hospital and 16.98% patients reported availability of
insufficient quantity of drinking water. Most of the patients (75%) were satisfied with overall services
available in the hospital.
Keywords: Patient satisfaction, behavior, cleanliness
INTRODUCTION
Health care scenario is fast changing all over the
world1. Patient satisfaction is one of the
established yardsticks to measure success of the
services being provided in the hospitals2.
Improved socioeconomic status and easier
access to medical care has led to high
expectations and demands from consumers of
hospital services3. For health care organization
to be successful monitoring of customer’s
perception is a simple but important strategy to
assess and improve their performance 4, 5.
A patient is the ultimate consumer of the
hospital. He is the person in distress. He expects
from hospital comfort, care and cure2.Patient
forms certain expectations prior to visit. Once
the patient come to the hospital and experience
the facilities, they may become either satisfied or
dissatisfied. Human satisfaction is a complex
concept that is related to a number of factors
including lifestyle, past experiences, future
expectations and the value of both individual
and society 1.The goal of any service
organization is creation of satisfaction among
customers.
Very few studies carried out in India for
measuring satisfaction of patient with hospital
services. The purpose of present study is to
carry out evaluation of hospital services by
getting feedback from indoor patients.
AIMS AND OBJECTIVES
1.
To study satisfaction of patients admitted in
Lata mangeshkar Hospital regarding
37
ISSN: 0976 3325
2.
3.
behavior of medical, nursing and supportive
staff
To study satisfaction of admitted patients
regarding cleanliness in the hospital as well
as food and drinking water facility available
in the hospital
To study satisfaction of the patients
regarding services provided in the hospital
A hospital based cross sectional study was
carried out in Lata Mangeshkar hospital, which
is a 585 bedded tertiary care hospital attached to
NKP Salve institute of Medical Sciences,
Nagpur, Maharashtra. The study was conducted
from February 2010 to May 2010 among patients
admitted in all wards of Lata Mangeshkar
hospital with a minimum hospital stay of 2 days.
All the patients (n=907) discharged during the
study period were included in the study but
patients admitted ICU and casualty were
excluded from the study.
On the day of the discharge, after taking
informed consent the patients were interviewed.
For pediatric patients, attendants of patients
were interviewed. A predesigned pretested
“Indoor Patient Feedback Form” was filled up.
A scoring system was used for finding
satisfaction of the patient, with a minimum score
of 1 and maximum score of 10. Depending on
the score given by the patient, satisfaction was
divided into 3 levels i. e. poor, average and
satisfactory. The data was analyzed by using
Epi-Info statistical software by calculating
proportions and chisquare test.
RESULTS
Patients were more satisfied with behavior of
doctors (87.76 %) as compared to the behavior of
nurses and Class III & Class IV workers (70.01%,
59.09% respectively). It was found to be
statistically significant (P<0.0001).Better level of
education among doctors may be the reason for
present study finding.
Table 1: Satisfaction of the patients regarding behavior of hospital staff
Behavior of hospital staff
Poor
Average
Satisfactory
Total
Doctors (%)
27 (2.98)
84 (9.26)
796 (87.76)
907 (100)
Nurses (%)
45 (4.96)
227 (25.03)
635 (70.01)
907 (100)
Class III & Class IV Workers (%)
99 (10.92)
272 (29.99)
536 (59.09)
907 (100)
Table 2: Satisfaction of the patient regarding cleanliness in the hospital
Cleanliness in hospital
Poor
Average
Satisfactory
Total
Patient area (%)
63 (6.95)
226 (24.92)
618 (68.13)
907 (100)
Patient’s level of satisfaction was found to be
better regarding cleanliness in patients’ area,
wards and hospital campus (68.13%, 61.85% and
65.93% respectively). But dissatisfaction was
found to be more regarding the cleanliness in
toilets (56.01 %) which were statistically
significant. (P<0.0001).In Most of the places
toilet is neglected area in the cleanliness.
51.93% were unsatisfied with quality of food
and 16.98% patients were unsatisfied with
availability of drinking water in the hospital.
The study was carried out during summer
season. That may be the reason for
unavailability of water.
Wards (%)
65 (7.17)
281 (30.98)
561 (61.85)
907 (100)
Toilets (%)
172 (18.96)
336 (37.05)
399 (43.99)
907 (100)
Hospital Campus (%)
73 (8.05)
236 (26.02)
598 (65.93)
907 (100)
Table 3: Satisfaction of patients regarding
quality of food and availability of drinking
water in the hospital
Food and
Quality
Availability of
drinking water
of food
drinking water
Satisfactory
436 (48.1)
753 (83.02)
Unsatisfactory
471 (51.9)
154 (16.98)
Total
907 (100)
907 (100)
th
Most of the patients’ i.e.3/4 patients were
satisfied with the services available in the
hospital. Maximum numbers of patients coming
to the hospital are from low socio-economic
status so their expectations from hospital
services may be low.
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ISSN: 0976 3325
Table 4: Satisfaction of the patients regarding
hospital services
Hospital Services
Poor
Average
Satisfactory
Total
Number of patients (%)
36 (3.97)
190 (20.95)
681 (75.08)
907 (100)
DISCUSSION
In this study, patients were more satisfied with
behavior of doctors (87.8%). Arpita Bhattacharya
et al4 also reported 98.2% patients were satisfied
with behavior of doctors which is similar with
the present study. Most of the patients were
satisfied with cleanliness in the wards. Few
authors1,4 have findings similar to the present
study. Waseem Qureshi et al6 reported 12%
patients were dissatisfied with cleanliness in
toilets which is comparable with the present
study (18.96%). In present study, half of the
patients were dissatisfied with quality of food
available in the hospital which is in contrast to
the findings of Arpita Bhattacharya et al4 and
Aarti et al1 who found 0.8% and 19.8% patients
dissatisfied with quality of food.
Overall level satisfaction of the patients
regarding hospital services was found to be
good (75.08%). In a study conducted in Srinagar
Waseem Qureshi et al 6 reported only 6.7%
patients were poorly satisfied with hospital
services .In a study carried out in Ethiopia, Bima
Abdosh7 reported 54.1 % patients were satisfied
with services in the hospital. R Kumari et al 8
found unsatisfactory availability of drinking
water (45.7%) and toilet facilities (37.4%) as well
as the cleanliness of the toilets (27.3%) in a study
conducted in Lucknow.
were dissatisfied with quality of food and few
patients with availability of drinking water in
the hospital. 3/4th of admitted patients during
the study period were satisfied with services
available in the hospital.
RECOMMENDATIONS
There is a scope for improving services in the
hospital. Behavior of hospital staff should be
improved by conducting special sessions for
behavior change communication. Emphasis
should be given to improve cleanliness in the
hospital especially in the toilets. Sufficient
quantity of water should be made available at
any time throughout the year.
LIMITATIONS OF THE STUDY
This is just a part of baseline study, which was
carried out for evaluating hospital services .A
continuous ongoing study is required for getting
definitive results.
BIBILIOGRAPHY
1.
2.
3.
4.
5.
CONCLUSIONS
Assessing satisfaction of patients is simple and
cost effective way for evaluation of hospital
services. The findings of the present study
carried out for assessing satisfaction of indoor
patients admitted in Lata Mangeshkar Hospital
reveal patients were more satisfied with
behavior of doctors. Most of the patients were
satisfied regarding cleanliness in the patient
area, wards and hospital campus but
dissatisfaction was found to be more regarding
cleanliness in the toilets. Half of the patients
6.
7.
8.
Aarti Verma,R. K. Sarma.Evaluation of the exit
proformas in use at special wards of public sector
tertiary care center. Journal of Academy of hospital
administration 2000; Vol 12, No.1 (2000-01 –2000-06)
Talluru Sreenivas, G.Prasad. Patient satisfaction –A
comparative study. Journal of Academy of hospital
administration 2003; Vol 15, No.2 (2003-07 –2003-12)
Reena
Kumar.
Medical
documentation-Patient
satisfaction document. Journal of Academy of hospital
administration 2003; Vol 15, No.1 (2003-01-2003-06)
Arpita
bhattacharya,
Prema
Menon,
Vipin
Koushal,KLN Rao. Study of patient satisfaction in a
Tertiary referral hospital. Journal of Academy of
hospital administration 2003; Vol 15, No. 1 (2003-012003-06)
Singh Brijender, Sarma R. K, Sharma D. K.,Singh
VijenderAryaand Sanjay Deepak Assessment of
hospital services by consumers: A study from NDDTC,
AIIMS, Ghaziabad. Medico legal update2005; Vol 5, No
1 (2005-01 -2005-03)
Waseem Qureshi, Nazir khan, Ajaz Naik. A case study
on patient satisfaction in SMHS hospital, Srinagar. JK
Practitioner2005; Vol 12, No.3: 154-155.
Bima Abdosh.The quality of hospital services in eastern
Ethiopia: Patient’s perspective. Ethiop.J.health Dev
2006; 20(3): 199-200.
Ranjeeta Kumari, MZ Idris, Vidya Bhushan, Anish
Khanna, Monika Agarwal, SK Singh. Study on patient
satisfaction in the government allopathic health
facilities of Lucknow district, India IJCM 2009; Volume:
34(1): 35-42.
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ISSN: 0976 3325
Original Article .
MISSED OPPORTUNITIES OF JANANI SURAKSHA YOJANA BENEFITS AMONG THE
BENEFICIARIES IN SLUM AREAS
Wadgave Hanmanta Vishwanath1, Gajannan M Jatti2, Upendra Tannu3
1Medical
Officer, Primary Health Centre, Valsang, Solapur 2Lecturer, Dept. of P&SM, Govt. Medical
College, Miraj, Pin-416410, Sangli, Maharashtra 3Volunteers Coordinator, Sure Start Project, Solapur
Correspondence:
Dr.Wadgave Hanmanta Vishwanath
Primary Health Centre Valsang, South Solapur, Dist. Solapur – 413228.
Email: [email protected], [email protected] Mob: + 91 9405844323
ABSTRACT
In 2005, with the goal of reducing the numbers of maternal and neonatal deaths, the Government of
India launched Janani Suraksha Yojana (JSY), a conditional cash transfer scheme, to incentivize
women to give birth in a health facility. But still the beneficiaries are missing the opportunities of JSY
benefit due to various reasons. The objectives of the study were to explore the reasons of Missed
opportunities of Janani Suraksha Yojana benefits among the beneficiaries and to suggest few
recommendations depending upon the study results. It was a community based cross sectional study
Conducted from Jan 2009 to Dec 2009 among 3212 women. The sample was collected by trained social
workers in house to house activity. Out of 3212 women 360 (11.20%) were eligible for getting the
benefit of Janani Suraksha Yojana. Among the 360 only 118 (32.78%) women got the benefit of JSY
while, 242 (67.22%) missed the opportunity of getting JSY benefit due to Lack of information of JSY in
37.19% women followed by difficulty in getting the documents and card was not-filled in time by
ANM were the common causes in 25.62% and 15.29% women respectively. finding shows the poor
IEC efforts in the implementation of JSY, divulging most of the poor eligible women from their rights
of JSY benefits. Hence, continuous IEC activity with active involvement of health service provider like
ANM, MPW is needed.
Key Words: Missed opportunities, JSY, slum, beneficiaries, Knowledge
INTRODUCTION
The state of maternal, newborn, and child health
in India is of global importance; in 2005, more
than 78 000 (20%) of 387 200 maternal deaths, 1
and more than 1 million (31%) of 3·4 million
neonatal deaths occurred in India. The maternal
mortality ratio declined from about 520 per 100
000 live births in 1990 to nearly 290 per 100 000
in 2005 and the neonatal mortality rate
decreased from 54 per 1000 live births in 1990 to
38 per 1000 in 2005. Despite this progress, the
numbers of maternal and neonatal deaths
remained high. In April, 2005, in response to the
slow and varied progress in improvement of
maternal and neonatal health, the Government
of India launched Janani Suraksha Yojana (JSY;
translated as safe motherhood scheme)—a
national conditional cash transfer scheme to
incentivize women of low socioeconomic status
to give birth in a health facility. The ultimate
goal of the programme is to reduce the number
of maternal and neonatal deaths2. JSY had an
great impact in reducing maternal and newborn
health morbidities and mortalities.3,4
Even though JSY scheme is approaching
towards the fulfillment of the goal of JSY still
further review is needed on its various aspects.5
So an effort is tried to explore the reasons of not
getting the JSY benefit in urban slum areas.
Study type- Community based cross sectional
study. Study period: Jan 2009 to Dec. 2009.
Sample size: 3212 women delivered in the
period during Jan 2008 to Dec. 2008 were
included in the study. Study area: As the basic
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ISSN: 0976 3325
objective of JSY scheme was focusing on
vulnerable and women of lower socioeconomic
status. It was decided to cover the slum areas of
Solapur, Western Maharashtra. List of registered
slums was taken from Municipal Corporation
office. Total 127 registered slums were there in
Solapur, covering a population about 3-4 Lakh.
50% of the slums were selected by lottery
method for the study purpose covering
population of 1.75 lakh from 60 slums. Listing of
all deliveries occurred during Jan 2008 to Dec.
2008 was done by Social workers with the help
of Anganwadi Workers. House to house activity
was conducted with pre-tested and pre-deigned
Performa. Every woman was taken for the study
but the detail aspects of JSY were interviewed
with woman who was eligible for JSY benefit.
The data was analyzed by using SPSS software
and the findings were presented into
percentages.
Eligibility Criteria for JSY. 2
1.
Women must be below poverty Line or
Belongs to SC/ST
2. Should undergo at least three ANC visits.
3. Age should be above 19 years.
4. First or second child only
Eligible Woman: Woman who fulfills the above
criteria
RESULTS
Out of 3212 women 360 (11.20%) were eligible
for getting the benefit of Janani Suraksha
Yojana. Among the 360 only 118 (32.78%)
women got the benefit of JSY while, 242 (67.22%)
missed the opportunity of getting JSY benefit.
Common reasons for not getting the benefit
were lack of information of JSY( 37.19%)
followed by difficulty in getting the documents
in time (25.62%) and not-filled in time by ANM
(15.29%) (Table 1).
Table 1: Reasons of not getting the benefit of JSY among the eligible Women
Sr. No.
1
2
3
4
5
6
7
8
9
Total
Reasons
Lack of Information about JSY
Document were not available
JSY Form was not filled
JSY Information was received very late
Check up in private hospital so refused (by Health
worker) to give JSY
Home Delivery
Delivery outside the area
Ignored as it is difficult to get any money in govt.
sector
Refused to mention the reason
25.35% women who delivered in private
hospital received the JSY benefit while, 34.60%
women got the benefit delivered in govt.
Number
90
62
37
22
14
%
37.19
25.62
15.29
9.09
5.79
5
4
2
2.07
1.65
0.82
6
242
2.48
100.00
hospital but findings were not statistically
significant. (χ2 =1.98; P >0.05) as shown in table
2.
Table 2: Comparison of JSY utilization in the eligible women delivered in Private & Govt. Hospitals
Type of Hospital
Private
Govt.
Total
DF=1, χ2 =1.98; P > 0.05
JSY Status
JSY Benefit Received (%)
JSY Benefit not Received (%)
18 (25.35)
53 (74.65)
100 (34.60)
189 (65.40)
118 (32.78)
242 (67.22)
DISCUSSION
In the present study only 32.78% eligible women
got the assistance of JSY scheme in the delivery.
But the Converge evaluation Survey of
Total
71
289
360
Maharashtra 6 2009, found that only 17.1 women
got the assistance of JSY scheme. The findings
were lower than the present study. But the
awareness of JSY Scheme was found in 52.1% of
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ISSN: 0976 3325
the women interviewed which was higher than
the present study as 37.19% women were not
aware of JSY scheme so missed from the benefit
of JSY Scheme. 29.5% of women who delivered
in private hospital received assistance of JSY
was the finding noted in the 2009 coverage
evaluation survey. 6 Which was similar to
present study (25.35%).
form filled at right time & also not helped
the beneficiary for getting the certificates
(documents) fulfilled at right time.
ACKNOWLEDGEMENT
We are thankful to Dr. Shahikant Ahankari,
President, HALO Medical Foundation, Anadur
for providing us the social workers for survey.
CONCLUSIONS
Lack of JSY information, difficulty in getting the
documents fulfilled & filling the form at proper
time were three common reasons in not getting
the benefit of JSY. The % of beneficiaries (Who
Got JSY benefit) was more in the women
received ANC care / Delivery done in Govt.
Hospitals.
RECOMMENDATIONS
REFERENCES
1.
2.
3.
1. Intensive IEC activity should be conducted
at individual level, family level &
community level.
2. Flexibility in documents should be there as
Caste certificate like document are very
difficult to get in short period of time.
3. Private
hospitals
should
be
made
mandatory to display the information of JSY
& taking the form of JSY filled in correct
time.
4. Health service provider should be made
accountable if he/she not given the
information at right time, not taken JSY
4.
5.
6.
Hogan MC, Foreman KJ, Naghavi M, et al. Maternal
mortality for 181 countries, 1980–2008: a systematic
analysis of progress towards Millennium Development
Goal 5. Lancet 2010; 375: 1609–23.
Government of India, Ministry of Health and Family
Welfare, Maternal Health Division, New Delhi. Janani
Suraksha Yojana: features & frequently asked questions
and answers. http://mohfw. nic.in/dofw% 20website
/JSY_ features_ FAQ _ Nov _2006.htm (assessed
Feburwary 5, 2011).
Lim SS, Dandona L, Hoisington JA, James SL, Hogan
MC, Gakidou E. India's Janani Suraksha Yojana, a
conditional cash transfer programme to increase births
in health facilities: an impact evaluation. Lancet 2010;
375: 2009-2023.
Khan, M.E., Hazra, A. and Bhatnagar, I. 2010. Impact of
Janani Suraksha Yojana (JSY) on selected family health
behaviors in rural Uttar Pradesh. Journal of family
welfare, 56.
Abhijit Das, Deepa Rao b, Amy Hagopian. India's
Janani Suraksha Yojana: further review needed. Lancet
2011; 377: 295-296.
Government of India, Ministry of Health and Family
Welfare, Maharashtra Fac tsheet.2009 Coverage
Evaluation Survey.
www.unicef.org/india/Maharashtra_Fact_Sheet.pdf
(assessed on Feb 5, 2011).
42
ISSN: 0976 3325
Original Article .
PREVALENCE AND EPIDEMIOLOGICAL CORRELATES OF HYPERTENSION AMONG
LABOUR POPULATION
S E Mahmood1, Anurag Srivastava2, V P Shrotriya3, Iram Shaifali4, Payal Mishra5
1Assistant Professor, Department of Community Medicine, Rohilkhand Medical College and
Hospital, Bareilly (UP) 2Associate Professor, 3Professor, Department of Community Medicine, Shri
Ram Murti Smarak Institute of Medical Sciences, Bareilly (UP) 4Resident, Department of
Pharmacology, Rohilkhand Medical College and Hospital, Bareilly (UP) 5Assistant
Professor/Statistician, Department of Community Medicine, Shri Ram Murti Smarak Institute of
Medical Sciences, Bareilly (U.P.)
Correspondence:
Dr. Syed Esam Mahmood,
Assistant Professor, Department of Community Medicine,
Rohilkhand Medical College and Hospital, Bareilly (U.P.),
E-mail: [email protected] Mobile: 8127537806
ABSTRACT
The average prevalence of hypertension in India is 25% in urban and 10% in rural inhabitants.
Prevalence of hypertension has been found to increase in traditional populations undergoing
modernization. There is a strong correlation between changing lifestyle factors and increase in
hypertension. The objectives of the study were to find out Prevalence of hypertension and
identification of associated risk factors amongst labour population of District Bareilly. The cross
sectional field study involved 185 respondents, aged 18 years and above using simple random
sampling technique. A study instrument which included behavioral risk factor questionnaire
(Tobacco use, alcohol consumption and type of diet) and physical measurements of height, weight,
waist circumference, hip circumference and blood pressure was used to collect data. Chi- square test
and regression analysis were used to analyze data. The overall prevalence of hypertension was found
to be 10.81%. Prevalence of hypertension was significantly higher among individuals, aged 40 years
and above, with high body mass index and increased waist hip ratio, (P<.05). There is an increase in
cases of hypertension amongst labour population of District Bareilly. Weight reduction may lead to
decrease in blood pressure of an individual.
Key words: Prevalence, Hypertension, Risk factors, Lifestyle modifications
INTRODUCTION
Hypertension is the commonest cardiovascular
disorder affecting about 20% adult populations
worldwide. It is an important risk factor for
cardiovascular mortality. (1)
Reports suggest
that the prevalence of hypertension is rapidly
increasing in developing countries and is one of
the leading causes of death and disability in
developing countries. (2) Cardiovascular diseases
are projected to cause 4.6 million deaths in India
by 2020. (3)
The prevalence of hypertension in India is
reported as ranging from 10 to 30.9 %. (4) The
average prevalence of hypertension in India is
25% in urban and 10% in rural inhabitants. (5)
There is a strong correlation between changing
lifestyle factors and increase in hypertension.
The rural populations being the marginalized
and vulnerable communities in India face
considerable disparity as compared to urban
populations in terms of health facilities,
education and economic pursuits. (6) Prevalence
of hypertension has been found to increase in
rural populations undergoing modernization.
Recently, a study conducted among labour
population of Gujarat reported prevalence of
hypertension to be 16.9% as per WHO criteria. (7)
The prevalence will increase even further unless
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ISSN: 0976 3325
broad and effective preventive measures are
implemented. Epidemiological studies to assess
the prevalence of hypertension are essential to
plan preventive strategies and promote the
health of these populations.
Though several studies have been carried out
among the general population in India but very
few studies have been conducted among labour
population. Non exposure to risk factors like
physical inactivity and obesity might be
prevalent among the labourers but exposure to
risk factors like smoking and alcohol
consumption are on the rise in lower
socioeconomic strata.
The literature on prevalence and risk factors of
hypertension among labourers in Bareilly was
scarce, thereby the present study was
undertaken to find out prevalence of
hypertension and to identify the risk factors
associated amongst rural labour population
aged 18 years and above of Bhojipura Block,
district Bareilly.
The cross sectional study was carried out in
labour population of Bhojipura Block of Bareilly
district, Uttar Pradesh. Simple random sampling
was used to select the study subjects. Adults of
age 18 years and above in the selected
households were surveyed and comprised the
study unit in the present study. A total of 185
individuals participated in the study. Those
adults who were non cooperative or refused to
provide the necessary information were not
included in the study. Those individuals who
were absent on two repeated visits were
excluded from the study. Pregnant women were
also excluded from the study.
A structured pretested and predesigned
questionnaire was used to assess study subjects’
self-reported behavioral and lifestyle risk factors
(Smoked and smokeless tobacco use, alcohol
consumption and type of diet) for hypertension,
the measurement of subject’s blood pressure
and anthropometrical parameters.
Modified Prasad's classification was applied to
measure the individual’s socioeconomic status.
(8)
Following Operational Definitions were put to
use in the present study:
1.
Current smoking- someone who at the time
of survey, smoked in any form either daily
or occasionally for last 6 months.
2.
Current smokeless tobacco use- reported
consumption of smokeless tobacco in any
form at the time of the survey either daily or
occasionally for last 6 months.
3. Current drinker-Those who consumed 30
ml. or more of any type of alcohol per day
for last 6 months preceding the survey.
4. Hypertension- means systolic BP ≥
140mmHg and/or mean diastolic BP ≥
90mmHg or history of anti hypertensive
treatment fifteen days before the survey.
5. Overweight/obesity- body mass index level
of ≥ 25 Kg/m2 and ≥ 30 Kg/m2 respectively.
For
physical
examination,
standardized
calibrated
mercury
column
type
sphygmomanometer; stethoscope, common
weighing machine and measuring tape were
used.
During the course of the interview, two
measurements of blood pressure on each study
participant
with
a
mercury
column
sphygmomanometer were made using a
standardized technique 30 minutes apart in
sitting position. Blood pressure measurements
were made on the left arm of each study subject,
using a cuff of appropriate size at the level of the
heart. In case where the two readings differed
by over 10 mm of Hg, a third reading was
obtained, and the three measurements were
averaged. The pressures at which sound
appeared and disappeared were taken as
systolic blood pressure (SBP) and diastolic blood
pressure (DBP) respectively.
Blood pressure was classified as normal (SBP
<120 and DBP <80 mmHg), pre-hypertension
(SBP = 120-139 and/or DBP = 80-89 mmHg),
stage I hypertension (SBP = 140-159 and/or DBP
= 90-99 mmHg), and stage II hypertension (SBP
> 160 and/or DBP > 100 mmHg) as per US
Seventh Joint National Committee on Detection,
Evaluation and Treatment of Hypertension (JNC
VII) criteria. (9)
Body weight was measured (to the nearest
0.5kg) with the subject standing motionless on
the weighing scale, feet about 15cm apart and
weight equally distributed on each leg. Subjects
were instructed to wear minimum outwear (as
culturally appropriate) and no footwear while
there weight was being measured.
Height was measured (to the nearest 0.5cm)
with the subject standing in an erect position
against a vertical surface, and the head
positioned so that the top of the external
auditory meatus was level with the inferior
margin of the bony orbit (Frankfurt’s plain).
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ISSN: 0976 3325
Body Mass Index was calculated as weight in
kilograms divided by weight in meters squared.
Based on their BMI, individuals were classified
into four groups: thin (BMI <18.5), normal
(BMI=18.5-24.9), overweight (BMI = 25.0-29.9)
and obese (BMI > 30.0) as per WHO. (10)
Waist circumference was measured with a
standard measuring tape, while subjects were
lightly clothed, at a level midway between the
lower margin of the last rib and iliac crest in
centimeters (to the nearest 0.1cm). Waist
circumference (WC) cut-offs were taken as 90
cms for males and 80 cms for females to define
abdominal obesity using South Asia Pacific
Guidelines. (11)
Hip circumference (HC) was measured at the
maximum circumference over the buttocks in
centimeters (to the nearest 0.1cm) with the
subject in standing position.
Waist hip ratio was calculated as waist
circumference divided by hip circumference.
The cut-off used for the waist-hip ratio (WHR)
for males was 0.9 and for females it was 0.8 to
define obesity. (11)
Data entry and statistical analysis were
performed using the Microsoft Excel and SPSS
windows version 14.0 software. Tests of
significance like Pearson’s Chi- square test and
F-test were applied to find out the results. P
values <0.05 were considered significant for the
identified risk factors and outcome variables.
Univariate logistic regression analysis was done
using systolic and diastolic blood pressure as the
dependent variable and the various risk factors
identified as independent variables.
significance like Pearson’s Chi- square test and
F-test were applied to find out the results. P
values <0.05 were considered significant for the
identified risk factors and outcome variables.
Univariate logistic regression analysis was done
using systolic and diastolic blood pressure as the
dependent variable and the various risk factors
identified
as
independent
variables.
Multivariate logistic regression analysis was
done using systolic and diastolic blood pressure
as the dependent variable and the risk factors
identified significant in univariate analysis as
independent variables.
RESULT
Out of 185 respondents studied, 47 (25.40%)
respondents were found pre hypertensive and
20 (10.81%) were found hypertensive (Table 1).
Table 1: Gender wise distribution of respondents according to their blood pressures measured as per
JNC-VII criteria report
Gender
(n=185 )
Male (n=86)
Female (n=99)
Total
Chi-Square (df)
Normal
(%)
Pre Hypertension
(%)
Stage I Hypertension
(%)
Stage II Hypertension
(%)
2(2.32%)
7(7.07%)
9(4.86%)
5(5.81%)
(6.06%)
11(5.94%)
55(63.95%)
24(27.90%)
63(63.63%)
23(23.23%)
118(63.78%)
47(25.40%)
2.531(3) P Value 0.470
Table 2: Age wise distribution of individuals identified with hypertension
Age group
Mean SBP (mmHg)
Mean
± SD
(years)
18-30
117.93
31-40
122.42
41-50
120.48
51-60
129.53
>60
130.00
Total
120.53
F –value
5.000
P-value
0.001
The overall, mean blood pressures were 120.53 ±
13.40 / 78.75 ± 8.63mm Hg respectively. The
12.821
12.321
11.932
15.533
11.282
13.402
Mean DBP (mmHg)
Mean
± SD
77.00
80.32
77.81
85.06
85.00
78.75
8.267
6.775
7.718
10.176
6.686
8.637
6.358
0.000
mean systolic as well as diastolic blood
pressures were found to steadily increase with
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ISSN: 0976 3325
age, being lowest in age group 18-30 years
(117.93 ± 12.82/ 77.00 ± 8.26) and highest in age
group 51-60 years (130.00 ± 11.28/85.00 ± 6.68)
(Table 2).
The proportion of hypertension also showed an
increasing trend with age. Prevalence of
hypertension was significantly (P <0.05) higher
among individuals aged 40 years and above
(20.0%) as compared to those aged below 40
years (7.4%). Though the proportion of
hypertension was higher among females
(13.13%) as compared to males (8.13%), it was
not statistically significant (P >0.05). Similarly
the differences observed in the subjects
belonging to the lower socioeconomic class
(11.53%) as compared to the lower-middle
socioeconomic class (6.89%), and between
illiterate respondents (11.17%) as compared to
the literate ones (0.0%) were insignificant (P
>0.05) (Table 3).
Table 3: Hypertension in relation to socio-demographic characteristics
Socio demographic Characteristics
No. Studied
Age group (years)
18-30
31-40
41-50
51-60
> 60
Gender
Males
Females
Socio-economic class
Lower
Lower-middle
Educational status
Illiterate
Read and write
Less than primary school
Primary school completed
Total (n=185)
No. of Hypertensive
Chi-Square(df),
P-value
116
19
21
17
12
7 (6.03%)
3 (15.78%)
2 (9.52%)
4 (23.52%)
4 (33.33%)
12.434 (4)
0.014
86
99
7 (8.13%)
13 (13.13%)
1.189 (1)
0.275
156
29
18 (11.53%)
2 (6.89%)
0.546 (1)
0.460
179
1
4
1
20 (11.17%)
0 (0.0%)
0 (0.0%)
0 (0.0%)
0.752 (3)
0.861
Although a higher proportion of respondents
(14.45%) with a smoking habit were found
hypertensive as compared to those who did not
smoke (7.84%), difference was not statistically
significant (P >0.05). Similarly the prevalence of
hypertension did not differ significantly
between smokeless tobacco users (14.49%) and
non smokeless tobacco users (8.62%), and
between alcoholics (12.69%) and non-alcoholics
(9.83%). Also the prevalence of hypertension did
not differ significantly between non vegetarians
(11.23%) and vegetarians (0.0%) (Table 4).
Significant differences (P <0.05) in the
prevalence of hypertension were seen between
respondents with a high BMI (18.75%) as
compared to those with a normal or low BMI
(10.05%), and among respondents with a high
waist hip ratio (19.04% men and 14.94% women)
as compared to those with a normal or low waist
hip ratio (4.61% men and 0.0% women) (Table
4).
Age, body mass index and waist hip ratio were
found significant on univariate analysis. Age
and waist hip ratio were found to be significant
predictors to hypertension in the study
population in the multivariate model (Table 5).
DISCUSSION
The prevalence of hypertension has been
increasing in India. The average prevalence of
hypertension in India is 25% in urban and 10%
in rural inhabitants. (5) Factors which are
attributable to these changes are rapid
urbanization, lifestyle changes, and dietary
changes and increased life expectancy. (12)
The overall prevalence of hypertension was
found to be 10.81% in the present study. Similar
prevalence of hypertension (16.9 per cent) has
also been reported in the study conducted
among labour population of Gujarat. (7) A higher
prevalence (20.6%) was reported in the study
conducted among adult population at rural
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ISSN: 0976 3325
Wardha.
This is probably because our study
was carried among labourers belonging to low
socioeconomic strata while the Wardha study
had a mix of subjects with all different
(13)
professions from the general population. The
prevalence of pre-hypertension (25.40%) in the
present study is similar to the trends reported
worldwide. (2)
Table 4: Hypertension in relation to modifiable risk factors:
Risk factors
No. Studied
Smoking habit
Present
Absent
Smokeless tobacco use:
Present
Absent
Alcohol consumption
Present
Absent
Type of diet
Vegetarian
Non Vegetarian
Body mass index:
<18.5
18.5-24.9
25-30
>30
Increased Waist hip ratio:
Men ( >0.9)
Women (>.08)
Men ( <0.9)
Women (<.08)
Total (n=185)
No. of Hypertensive
Chi-Square (df)
P-value
83
102
12 (14.45%)
8 (7.84%)
2.077 (1)
0.150
69
116
10 (14.49%)
10 (8.62%)
1.547 (1)
0.214
63
122
8 (12.69%)
12 (9.83%)
0.353 (1)
0.552
7
178
0 (0.0%)
20 (11.23%)
0.882 (1)
0.348
57
112
15
1
5 (8.77%)
12(10.71%)
2(13.33%)
1 (100.0%)
8.596 (3)
0.035
21
87
65
12
4 (19.04%)
13 (14.94%)
3 (4.61%)
0 (0.0%)
4.422 (1)
0.035
The proportion of hypertension was found to
increase steadily with the increase in age. These
findings are coherent with study carried in rural
Wardha (13). Such changes of blood pressure
with age might be due to changes in vascular
system i.e. atherosclerotic changes in blood
vessels.
Although the proportion of hypertension was
higher among females as compared to males but
the difference was not statistically significant.
Similar observations were reported in the
Gujarat study (7).
Table 5: Multivariate logistic regression analysis of predictors of hypertension in the total study
sample modify
Predictor
Age (< 40 yrs=1, >40 yrs=2)
Body mass index (High=1, Normal=2)
Waist hip ratio (Increased=1, Normal=2)
The percentage of hypertensives among the
illiterate respondents was observed higher as
compared to the literate ones. However there
was no significant association with education in
the present study. Obviously the level of
education is related to the protection of
hypertension. Education was found to be
β coeff.
Odd’s ratio
95% CI
P-value
1.182
-0.269
1.456
3.262
0.764
4.290
1.231-8.644
0.341-1.713
1.204-16.706
0.017
0.514
0.029
significantly associated to hypertension in the
Wardha study (13).
Socioeconomic status was not significantly
associated with hypertension in our study. This
is in contrast to the WHO report which says that
societies that are in transitional stage of
economic and epidemiological change have
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ISSN: 0976 3325
higher prevalence of hypertension among upper
socioeconomic groups.(1) This is possibly
because most of our respondents belonged to
lower income class.
BMI more than or equal to 25 was found to be
significantly associated with hypertension.
Similar findings were observed by a cross
sectional study conducted among laborers in
Madhya Pradesh. (6)
High proportions of respondents with a higher
waist hip ratio were found hypertensive. Similar
observations were reported in a study
conducted in rural Wardha (13).
85% of
hypertensives had a waist-hip ratio equal to or
more than the cut-off point, i.e. 0.8 for females
and 0.9 for males. Central obesity indicated by
increased waist-hip ratio has been positively
correlated with high blood pressure in several
populations. (1)
Type of diet (vegetarian verses non-vegetarian)
was not found to be significant associated to
hypertension in this study. Diet and nutrition
have been linked to high blood pressure.
Composite diets have been demonstrated to
reduce the risk of hypertension.(14, 15)
pressure of an individual. This study also
emphasizes the need for epidemiological studies
among labour populations as presently there is
an increase in cases of hypertension among
them.
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
In our study, a higher proportion of smokers
were found hypertensive as compared to non
smokers. However there was no significant
association with smoking in our study. This
result is not consistent with that of the Gujarat
study, i.e. smokers have a significantly higher
BP than non-smokers (7).
10.
Smokeless tobacco use was not significantly
associated with hypertension prevalence. This
finding in our study did not match with the
finding of a study conducted amongst rural
population of Maharashtra (16).
13.
We did not find any relationship between
alcohol consumption and hypertension. Possibly
majority of our respondents did not consume
alcohol. Alcohol consumption has been
consistently related to high blood pressure in
cross-sectional
as
well
as
prospective
observational studies in several populations.(1)
Moderate alcohol consumption was agreed to be
an important lifestyle measure recommended to
lower blood pressure (17).
Hypertension control. Technical Report Series: World
Health Organization; 1996. Report No.: 862.
Kearney PM, Whelton M, Reynolds K, Muntner P,
Whelton PK, He J. Global burden of hypertension:
analysis of worldwide data. Lancet 2005; 365: 217-23.
Rodgers A, Lawes C, MacMahon S. Reducing the global
burden of blood pressure related cardiovascular
disease. J Hypertens 2000; 18:S3-6.
Padmavati S. A meta-analysis-National Heart Institute,
New Delhi. Ind Heart J 2002; 54:99-102
Gupta R. Trends in hypertension epidemiology in
India. Journal of Human Hypertension 2004; 18:73–78
Kapoor S, Tyagi R, Saluja K, Chaturvedi A and Kapoor
AK. Emerging health threats among a primitive tribal
group of Central India. Journal of Public Health and
Epidemiology April 2010; 2(2):13-19
Tiwari RR. Hypertension and epidemiological factors
among tribal labour population in Gujarat. Indian
Journal of Public Health 2008; 52(3):144-146
Agarwal AK. Social classification: The need to update
in the present scenario. Indian J Community Med 2008;
33:50-1
JNC VII Express: Prevention, detection, evaluation and
treatment
of
high
blood
pressure.
In:
http://www.nhlbi.nih.gov/guidelines /hypertension/
th
11.
12.
14.
15.
16.
17.
express.pdf; 2003. Accessed on 15 November 2009.
Physical status: The use and interpretation of
anthropometry. Technical report series. Geneva: World
Health Organization; 1995. Report No.: 854.
Webb G. Nutrition: A health promotion approach.
2002:186.
Pradeepa R, Mohan V. Hypertension & prehypertension in developing countries. Indian J Med Res
December 2008; 128: 688-690.
Deshmukh PR, Gupta SS, Dongre AR, Bharambe MS,
Maliye C, Kaur S, Garg BS. Relationship of
anthropometric indicators with blood pressure levels in
rural Wardha. Indian J Med Res2006; 123: 657-664.
Sacks FM, Rosner B, Kass EH. Blood pressure in
vegetarians. Am. J. Epidemiol. 1974; 100: 390-398.
Reddy K S, Katan M B. Diet, nutrition and the
prevention of hypertension and cardiovascular
diseases. Public Health Nutrition 2004; 7(1A):167–186.
Agrawal VK, Bhalwar R, Basannar DR. Prevalence and
determinants of Hypertension in a rural community.
MJAFI 2008; 64: 21-25.
Chalmers J et al. World Health OrganizationInternational society of hypertension Guidelines for the
Management of Hypertension. J Hypertens 1999;
17:151-185.
Weight reduction may lead to decrease in blood
48
ISSN: 0976 3325
Original Article .
CERVICAL PAP SMEAR STUDY AND ITS UTILITY IN CANCER SCREENING, TO SPECIFY
THE STRATEGY FOR CERVICAL CANCER CONTROL
Mandakini M Patel1, Amrish N Pandya1, Jigna Modi2
1Associate
Professor, 2Assistant professor, Department of Pathology, Government Medical College,
Surat, 395001, Gujarat, India
Correspondence:
Dr. Mandakini M. Patel
303 / Karuna flats, Ravishankar Sankul,
Bhatar Char Rasta, Surat-395007, Gujarat, India
Email: [email protected], [email protected] Mobile: 098256 41338
ABSTRACT
The study was conducted to explore various lesions of Uterine cervix [inflammatory and growth], to
find out target age group in which screening efforts can be concentrated for early detection as well as
reduction of the incidence of cervical cancer, in our set up. Patients in the age group 15-50 and 50-78
years with various complaints were screened during June 2006 to December 2007. Total 995 patients
were studied. Slides were fixed in 95% ethyl alcohol and stained with Pap stain. Slides were reported
according to The 2001 Bethesda System, by cytopathologists. Out of 995 patients studied, 940 showed
inflammation and other benign lesions. 55 patients showed premalignant and malignant lesions.
Premalignant lesions were present in 30-50 year of age group.
Keywords: Cervical cancer, Screening, Bathesda system, Pap smear, strategy
INTRODUCTION
MATERIAL AND METHOD
Cancer of uterine cervix is a leading cause of
mortality and morbidity among women worldwide. In developing countries it is the most
common gynecological cancer and one of the
leading causes of cancer death among women.
The retrospective study was carried out at
Government Medical College and New Civil
hospital, Surat during June 2006 to December
2007, total 995 patients were screened.
Nearly 4 lacs new cases of cervical cancers are
diagnosed annually worldwide and 80% of them
are diagnosed in the developing countries.
There are 1.7 million cases in the developing
world and as many as 5-13 millions women
have precancerous lesions1, 3
According to National Cancer Registry Program
of India, cancers of uterine cervix and breast are
leading malignancies seen in Indian women2.
Cervical cancers can be prevented through early
detection using several screening techniques.
Cervical smear is a sensitive test for early
screening of the cervical lesion and most widely
used system for describing PAP smear result is
TBS [2001, The Bethesda System].4
The patients were in the age range of 15-50 and
50-78 years, having complaints like vaginal
discharge, bleeding per vagina or something
coming out per vagina. History and symptoms
along with parity were recorded.
Smears were taken by trained technician using
modified Ayres wooden spatula which was
inserted and rotated 3600 over cervix. Both
ectocervix and endocervix were sampled. Slides
were prepared, labeled, fixed in 95% ethyl
alcohol immediately and subsequently stained
by Pap stain. After staining, slides were
mounted with DPX (distrene dibutyl phthalate
xylene), screened and reported by two
cytopathologists according to The 2001 Bethesda
system.
49
ISSN: 0976 3325
RESULTS
Amongst the 995 cervico-vaginal smears studied
during June 2006 to December 2007 on patients,
ranging from 20 to 50 years and above age, 572
(57.4%) showed inflammatory lesion, 22(2.2%)
showed atrophy, 41 (4.1%) showed ASCUS,
1(0.1%) showed HSIL, 7(0.7%) showed SCC, 28
(2.8%) showed metaplasia, 4(0.4%) had
Radiation changes, 119(11.9%)were inadequate
and 195(19.5%) didn't show any remarkable
pathology.
ASCUS has 4.1 % while AGUS has 0.5%
incidence. Ratio of inflammation and other
lesions to premalignant and malignant ones was
940: 55 [94.5% and 5.5%].
Table 1: Relation of age with various nonneoplastic and neoplastic pathology of cervix
Age group (years )
NRP
Inadequate
Inflammatory
Atrophy
Metaplasia
Radiation changes
ASCUS
AGUS
LSIL
HSIL
SCC
Total
15-30
83
60
244
0
13
0
7
0
0
0
0
407
DISCUSSION
With the changes in the life styles and
demographic profiles in developing countries,
non-communicable diseases are emerging as an
important health problem which demand
appropriate control program before they assume
epidemic propagation. Cancer has been a major
cause of morbidity and mortality.
According to National Cancer Registry Program
of India, cancers of uterine cervix and breast are
the leading malignancies seen in females of
India. There should be an effective mass
screening program aimed at specific age group
for detecting precancerous condition before they
progress to invasive cancers.1, 3, 5
Our study showed that there were 94.5% benign
and inflammatory and 5.5% were premalignant
and malignant lesion, out of which
premalignant lesions 83.6% that were ASCUS
and AGUS. ASCUS progresses to LSIL, HSIL
AND
SCC.
AGUS
progresses
to
adenocarcinoma. 1, 6, 7
ASCUS was found to be highest in age group 3150 years in the other study. ASCUS is to be
labeled as ASCUS–reactive and ASCUS–SIL
which on biopsy turned out to be 83.6% positive
for LSIL or HSIL. 4,6, 8 As percentage of ASCUS
reported in other studies correlated with our
31-40
68
40
248
4
7
0
8
4
0
1
3
383
41-50
33
13
52
8
4
3
16
1
1
0
1
132
50-78
11
6
28
10
4
1
10
0
0
0
3
73
Total (%)
195 (19.6)
119 (11.99)
572 (57.48)
22 (2.2)
28 (2.81)
4 (0.4)
41 (4.12)
5 (0.5)
1 (0.1)
1(0.1)
7 (0.7)
995
findings,1,6, 9 we should advocates PAP smear
study and follow up at 31 years and above.
There are various screening test for cervical
cancer like Pap smear, liquid Pap cytology,
automated cervical screening techniques, visual
inspection of cervix after Lugol's Iodine and
acetic
acid
application,
speculoscopy,
cervicography.
Out of all these, exfoliative cytology has been
regarded as the gold standard for cervical
screening programs.10
the role of HPV in
development of cervical cancer is proved
beyond doubt. If Pap screening is associated
with HPV-DNA testing than we can increase the
sensitivity. World Health Organization (1992)
recommended screening every woman once in
her lifetime at 40 years, 9 our results do not agree
with it as the incidence of ASCUS is also high
during 31-40 years. So if you catch them early at
30 years of age then you can prevent further
development of cancer. The American Cancer
Society recommends that all women should
begin cervical cancer screening after 3 years of
beginning coitus. It is also recommended every
1-2 years, women who have crossed the age of
30 years and have had 3 consecutive normal Pap
results may be screened after 2-3 years.
CONCLUSION
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ISSN: 0976 3325
Pap smear examination is widely accepted
screening method. In countries like India with
predominant rural population is having low
socio-economic status, marriage at an early age
and poor medical facility. It is a major challenge
to formulate a screening program that is easily
available, within existing resources, to a large
section of society. It is also important to set clear
and realistic long term goals.
We can develop a cost effective screening
method by training medical and paramedical
staff at primary health centre level. PAP smear
examination should begin at 30 years.It should
be subsequently followed with HPV-DNA
testing at higher centres.
Abbreviations used:
ASCUS: Atypical cells of undetermined
significance
AGUS: Atypical glandular cells of undetermined
significance
TBS: The Bathesda System Papanicolau
HSIL: High grade squamous intra epithelial
lesion
SCC: Squamous cell carcinoma
LSIL: Low grade squamous intra epithelial
lesion
HPV-DNA: Human papilloma virusdeoxyribonucleic acid
NRP: No Remarkable Pathology
REFERENCES
1.
Rejendra A Kalkar, Yogesh Kulkarini. Screening for
cervical cancer: an overview. Obstet Gynecol India vol.
56 no. 2: March / April 2006.
2.
National Cancer Regitry Program. Annual Report. IC
New Delhi; 1990-1996.
3.
Mohammed Shaoaib Khan, Fohadiya Yasin Raja at el.
Pap smear Screening for Precancerous conditions of
the cervical cancers. Pak J. Med. Res.; vol. 44 no. 3,
2005:111-3.
4.
The 2001 Bethesda System; Terminology for reporting
results of cervical cytology. JMA 287, 2114, 2002.
5.
Bishop A. Shessis TS. Cervical dysplasia treatment: Key
issues for developing countries. Bull Pan Am Health
Organ 1996; 30:378-86.
6.
Amne E. Radar, Peter G. Rose at el. Atypical Squamous
cells of undetermined significance in women over 55.
Actacytologica; vol. 43, no. 3: 1999: 357-61.
7.
Izabela T. Burja, Sophie K. Thompson. Atypical
glandular cells of undetermined significance on cervical
smears. Acta cytologica; vol.43, no. 3: 1999: 357-56.
8.
Shazli N. Malik, Edward J. Wilkinson at el. Do
Qualifiers of ASCUS distinguish between low and high
risk patients? Acta cytologica; vol.43, no. 3: 1999: 37680.
9.
A Juneja, A Sehgal, S Sharma at el. cervical cancer
screening in India: Strategies revisited; Ind vol. 61, no
Indian J Med Sci, 2007: 34-47.
10. Cheryl L R, Clair W M, Kevin R et al. prevention of
cervical cancer. Critical review in Oncology /
Hematology; 2000: 33: 169-185.
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Original Article .
KNOWLEDGE OF TUBERCULOSIS AND ITS MANAGEMENT PRACTICES AMONGST
POSTGRADUATE MEDICAL STUDENTS IN PUNE CITY
Rahul R Bogam1, Sunil M Sagare2
1Tutor, 2
Assistant Professor, Department of Community Medicine, Bharati Vidyapeeth Deemed
University Medical College, Pune.
Correspondence:
Dr Rahul Ramesh Bogam
Amit Apartment B/7
Sasanenagar, Opp.Suryamukhi Ganesh Mandir
Hadapsar, Pune – 411028 Maharashtra
Email - [email protected], [email protected], Mobile No. – 09975718466
ABSTRACT
The study was aimed to assess the pre and post training knowledge of tuberculosis and its
management amongst newly admitted postgraduate students in medical college and hospital. India
accounts for nearly one fifth of global burden of tuberculosis. Every year approximately 1.8 million
persons develop tuberculosis. Postgraduate students are many times the first contact of patients in
teaching as well as secondary and tertiary care hospitals. Considering this fact, the current study was
conducted to assess pre and post training knowledge about basic facts of tuberculosis and its
management practices. All newly admitted postgraduate students attended RNTCP training and
completed pre test and post test questionnaires. Each completed questionnaire was assigned marking
system. The data was analysed using paired t test. Significant improvement in knowledge was found
after RNTCP Training (Pre test mean marks: 10.25, post test mean marks: 14.36, t=8.43, df=35, p=0).
The education of postgraduate students on guidelines for detection and early management of TB is
crucial for further improvement in national tuberculosis control strategies. RNTCP training should be
a part of regular activity of all medical colleges and hospitals.
Keywords: RNTCP, Pre test and post test, Methodologies, Post graduate medical students
INTRODUCTION
India is the highest TB burden country in the
world and accounts for nearly one fifth (20%) of
global burden of tuberculosis1. Every year
approximately 1.8 million persons develop
tuberculosis of which about 8, 000, 00 are
infectious and until recently 3, 70, 000 cases died
of it annually-1000 every day. In India, today
two deaths occur every three minutes from
tuberculosis but these deaths can be prevented.
With proper care and treatment, TB patients can
be cured.2
The National Tuberculosis Control Programme
(NTCP) was reviewed in India in 1992 and
Revised
National
Tuberculosis
Control
Programme (RNTCP) was drawn and formally
launched in March 1997 with phased coverage
in various states throughout India.3
The postgraduate students are many times a
first contact physician of patients in teaching
hospital as well as secondary and tertiary care
hospital and needs to be oriented towards
RNTCP policies and strategies in order to
reduce TB burden.
The present study attempts to understand the
knowledge and management practices of newly
admitted postgraduate students pertaining to
tuberculosis before and after RNTCP training.
OBJECTIVE
To assess pre and post training knowledge and
management practices of newly admitted
52
ISSN: 0976 3325
postgrad
duate
stu
udents
p
pertaining
tubercullosis, as enviisaged underr RNTCP.
to
MATER
RIAL AND METHODS
M
The sttudy was conducted amongst 36
postgrad
duate studeents. All were
w
first year
studentss enrolled for variouss discipliness of
Bharati Vidyapeeth
V
Deemed Un
niversity Med
dical
College and hospittal Pune. RNTCP
R
Train
ning
was org
ganized as a part of routtinely schedu
uled
program
mme activity
y of collegee and hosp
pital.
Training
g faculty waas chosen from people who
w
underweent training
g at Nation
nal Tubercullosis
Institutee (NTI), Bang
galore.
The prretested selff administeered structu
ured
all
question
nnaires
weere
distrib
buted
to
participaants. Particcipants werre allowed 20
minutess to completee questionnaaire under strict
s
supervission. Modullar Training was condu
ucted
by
t
trained
f
facilitators
subsequen
ntly.
Methodo
ologies like role play, demonstrattion,
socratic method of
o commun
nication, grroup
discussion, question
n-answer seessions, possters,
printed handouts, film
f
show, setting
s
up novel
n
examplees etc. weree incorporaated in train
ning
program
mme. At the end of train
ning program
mme,
the sam
me questionnaaires were distributed
d
to
o all
participants and responsses collecteed. The
marrking system
m for each co
omplete quesstion was
assiigned. The data was eentered in Microsoft
M
office excel sheet and analy
yzed using paired
p
‘t’
testt.
RES
SULTS
Of 36 newly admitted
a
po
ostgraduate students,
s
tweelve were fro
om Paediatriic and six were
w
from
Miccrobiology departmentt. Three students
participated fro
om Obstetriccs and Gyna
aecology,
Orthopaedics and Dermaatology dep
partment
each
h. Two stud
dents each w
were from Pathology
P
and
d
Commu
unity
Med
dicine
dep
partment.
Dep
partment
of
Pulm
monary
Medicine,
M
Oto
orhinolaryng
geology and Psychiatry sent one
stud
dent each forr participatio
on.
ble1: Mean marks
m
of partticipants
Tab
Mean
n
mark
ks
(out of 20)
Pre test
t
10.255
Postttest
14.366
S.D.
t
value
df
pvalue
3.45
2.94
8.43
35
0
Figure 1:
1 Question wise
w mean marks
m
in pre teest & post teest
* Statistiically significcant differen
nce was obserrved.
NATIONAL JOURNAL
J
OF COMMUNITY MEDICIN
NE 2011 Volume 2 Issu
ue 1
53
ISSN: 0976 3325
Table 2: Number of participants with correct responses in pre test and post test (n=36)
Pre test (%)
28(77.78)
Post test (%)
32(88.89)
t value
1.78
p-value
0.08
32(88.89)
34(94.44)
0.57
0.57
14(38.89)
32(88.89)
5.92
<0.001
What are five components of DOTS:¶
3(8.33)
10(27.77)
2.22
0.03
5.
Indications for sputum examinations:
2(5.55)
4(11.11)
0.53
0.60
a)
b)
c)
A person with cough of 2 weeks or more
HIV positive patient with cough of any duration
Suspected/confirmed extra pulmonary TB with cough of
any duration
Contacts of smear positive TB patient*
15(41.66)
18(50)
0
1
28(77.77)
31(86.11)
1.78
0.08
19(52.77)
35(97.22)
4.78
<0.001
1.
Tick the correct statement:
a)
b)
c)
TB Kills more adults in India than any other disease
TB Kills less adults in India than any other disease
TB is one of the leading infectious causes of deaths in
India*
All of the above
d)
2.
Most common symptom of pulmonary
tuberculosis is:
a)
b)
Heamoptysis
Persistent cough of 2 weeks or more than 2 weeks with or
without expectoration*
Fever
Weight loss
c)
d)
3.
The objectives of RNTCP are to achieve and
maintain:
a)
Cure rate of at least 60% among newly detected smear
positive TB cases and case detection of at least 50% of
expected new smear positive PTB cases in a community
positive TB cases and case detection of atleast 80% of
expected new smear positive PTB cases in a community*
b)
c)
d)
4.
d)
6.
A TB suspect with two -ve smears should be
subjected to:
a)
b)
Chest X-ray
If cough persists despite 10-14 days of a general
antibiotic, a chest X-ray is taken
If cough persists despite 10-14 days of a general
antibiotic, should have a repeat 2 smear examinations
performed*
Should be given 10-14 days of ciprofloxacin
c)
d)
7.
In Ziehl-Neelsen staining following reagent is
not used:
a)
b)
c)
d)
Carbol fuchsin
Sulphuric acid
Methylene blue
Carbolic acid*
8.
No of sputum samples required for diagnosis
of smear positive cases are:
a)
b)
c)
One
Two*
Three
54
ISSN: 0976 3325
d)
Four
9.
Under RNTCP ‘New Case’ is defined as: a TB
patient who has never had treatment for TB
or has taken anti-TB drugs
a)
b)
c)
d)
Less than 1month*
Less than 2 months
Less than 6 months
None of the above
10. Family member can be DOT provider:
a)
b)
b)
c)
d)
b)
c)
d)
0.009
17(47.22)
30(83.33)
3.99
0.0003
22(61.11)
28(77.77)
2.24
0.03
20(55.55)
31(86.11)
3.67
0.0008
20(55.55)
23(63.89)
0.90
0.37
15(41.66)
18(50)
0.70
0.49
15(41.66)
17(47.22)
0.90
0.37
25(69.44)
36(100)
3.92
0.0003
32(88.89)
34(94.44)
1
0.32
TB bacilli are resistant to Isoniazid & Rifampicin with or
without resistance to others*
Resistant to Isoniazid only
Resistant to Rifampicin only
All of the above
17. Best method of prevention of TB is:
a)
2.75
Give INH for 6 months to child < 6 years who are
contacts of TB patient after ruling out active TB
contacts of TB patient irrespective of BCG status after
ruling out active TB*
contacts of TB patient, then do PPD test
All contacts of positive TB case receive 6 months of INH
16. Multi-Drug resistant tuberculosis (MDR-TB)
is defined as:
a)
25(69.44)
2,4,6 months*
2,6 months
2,3,5,7 months
2,3,4,6,8 months
15. RNTCP policy on chemoprophylaxis is:
a)
18(50)
Rifampicin
Streptomycin*
Isoniazid
Pyrazinamide
14. The follow up sputum smear examination for
New Case of TB will be done at:
a)
b)
c)
d)
p-value
2(HRZE)3/4(HR)3*
2(SHRZE)3/1(HRZE)3/5(HRE)3
2(HRZ)3/2(HR)3
None of the above
13. Contraindicated anti-TB drug in pregnancy
a)
b)
c)
d)
t value
Less expensive
Few adverse reactions
Less effective than daily regimen*
Reduction in total quantity of drug consumed
12. Treatment regimen for smear positive case in
RNTCP:
a)
b)
c)
d)
Post test (%)
True
False*
11. False statement about Intermittent regimen
of DOTS:
a)
b)
c)
d)
Pre test (%)
Active diagnosis of sputum positive case
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ISSN: 0976 3325
b)
c)
d)
18. Effective drug in TB-HIV confection to reduce
mortality:
a)
b)
c)
d)
t value
p-value
10(27.77)
29(80.55)
4.44
<0.001
21(58.33)
29(80.55)
2.47
0.02
5(13.88)
25(69.44)
5.65
<0.001
Rifampicin
Streptomycin
Isoniazid
Ethambutol*
20. In RNTCP, ACSM stands for:
a)
b)
c)
Post test (%)
Azithromycin
Cotrimoxazole*
Ciprofloxacin
Ethambutol
19. All are bactericidal drugs except:
a)
b)
c)
d)
Pre test (%)
Passive diagnosis of sputum positive
Early diagnosis and treatment of sputum positive case*
Treatment of Mountoux positive case.
Advocacy, Communication and Social Mobilization*
Advocacy, Communication and Social Motivation
Adherence, Communication and Social Mobilization
None of the above
d)
df = 35, ¶ Open ended question, * Correct response
DISCUSSION
RNTCP Training of postgraduate medical
students is a routine activity at Bharati
Vidyapeeth Deemed University Medical College
and Hospital, in addition to that of faculty
members, interns and paramedical staff of the
college. All training programmes are being
conducted by trained facilitators including City
Tuberculosis
Officer,
Pune
Municipal
Corporation forming RNTCP Core Committee
of the institute.
RNTCP Training principally focused on
essential components of RNTCP like burden of
tuberculosis,
pathogenesis
of
TB,
symptamatology, diagnosis and treatment
services, Advocacy, Communication and Social
Mobilization (ACSM) and recent updates in
RNTCP.
A modified questionnaire was used based upon
the one designed by National Tuberculosis
Institute (NTI), Bangalore for medical officer’s
training. The questionnaire contained a set of 20
questions of which 19 were closed ended and
one was open ended. Each completed question
was assigned one mark for correct response and
zero mark for incorrect response. For one open
ended question about DOTS components, one
mark is given for responding three or more
components and zero mark is given for
responding less than three components.
Of 38 medical postgraduate students, two were
excluded from study since they did not attend
sessions fully.
The pre test and post test mean marks of
participants were worked out. Mean pre test
marks were 10.25 and the post test marks were
14.36 showing that the training did help in
improving knowledge (Table 1). The difference
was found to be significant statistically. (t=8.43,
df=35 p=0)
The questions were grouped under four broad
categories: RNTCP objectives and DOTS
components, Diagnosis, Treatment services and
ACSM.
A) RNTCP objectives and DOTS components:
Despite
RNTCP
being
part
of
their
undergraduate
studies,
only
14(38.89%)
participants
correctly
specified
RNTCP
objectives (Q.No. 3) in pretraining phase. In post
training phase, 32 (88.89%) participants could
state correct response. Statistically significant
difference was observed in pretest (0.39) and
post test (0.89) mean marks (t =5.92, df = 35, p
<0.001). Similarly highly significant difference in
pre test (0.08) and post test (0.28) mean marks
(t=2.22, df =35, p=0.03) was observed for DOTS
components.
In addition to Power Point Presentation (PPP),
group discussion as well as various examples
were set up to explain RNTCP objective and
DOTS components. These could be the possible
56
ISSN: 0976 3325
reasons for showing statistically significant
difference in pre test and post test mean marks.
knowledge and attitudes of nurses regarding
HIV/AIDS.
Vijayaprasad Gopichandran et al6 used Power
Point Presentation as a tool to provide TB
education amongst high school children and
found it to be effective.
C) Treatment services:
B) Diagnosis:
All definitions of treatment outcome under
RNTCP were explained during role play. Each
actor in role play was labelled as a patient with
specific treatment outcome. Eighteen (50%)
participants in pre test and 25(69.44%)
participants in post test defined ‘New Case’
(Q.No.9) correctly. The difference in mean
marks of pre test (0.47) and post test (0.69) was
found to be statistically significant. (t=2.75,
df=35, p=0.009).
Twenty five (69.44%) participants defined Multi
Drug
Resistant
tuberculosis
(MDR-TB)
(Q.No.16) precisely in pretesting. After training,
all 36 (100%) participants could define it rightly
i.e. resistance of TB bacilli to Isoniazid and
Rifampicin with or without resistance to other
drugs. Statistically significant difference was
observed in mean pre test (0.69) and post test (1)
marks (t=3.92, df= 35, p= 0.0003). Role play,
performed during training period highlighted
the concept of MDR-TB.
Recent RNTCP guidelines8 states collection of
two sputum samples for diagnosis of smear
positive TB case (Q.No.8). Nineteen (52.77%)
participants felt that three sputum samples are
essential for diagnosis of smear positive case as
revealed during pretesting session. At the end of
session, significant increase in knowledge was
observed (pre test mean marks=0.53& post test
mean marks=0.97) with correct response given
by 35(97.22%) participants (t=4.78, df=35, p
<0.001).
The topic was more stressed during role play
and group discussion including demonstration
on ‘How to yield good quality sputum sample
from patient’.
Statistically significant difference was revealed
for the questions related to ‘Diagnosis’. The
difference could have been observed due to
combined use of methodologies like role play,
group discussion, demonstration, display of
posters etc.
Stewart KE et al.7 reported that workshop
including role playing exercises and questionanswer sessions resulted in improved
It has been proved that Intermittent regimen of
DOTS is equally effective as daily regimen8
(Q.No.11). Twenty two (61.11%) participants
gave the correct response in pre test and the
same was increased to 78% in post test (t=2.24,
df=35, p=0.03).
Printed Handouts containing comparative
features of daily regimen and intermittent
regimen were distributed to participants. In a
study6 of similar nature, printed handouts were
used as a education tool to educate participants
about tuberculosis.
RNTCP guidelines emphasize that family
member cannot give DOTS (Q.No.10). During
pretesting, eighteen (50%) participants thought
that family member can be a DOT provider. One
film was shown related to it. During post
testing, thirty (83.33%) participants realized that
DOTS should not be given by family member.
The difference was found to be statistically
significant (t=3.99, df=35, p=0.0003).
Audio-visual mode of health education session
was used as a simple educational intervention
on the knowledge and awareness of TB amongst
high
school
children
by
Vijayaprasad
Gopichandran et al.6
Amongst all first line anti TB drugs (Q.No.19),
Ethambutol is bacteriostatic drug while other
drugs are bactericidal. During pretesting,
21(58.33%) participants and during post testing
29(80.55%) participants correctly stated that
Ethambutol is a bacteriostatic drug. The
difference was found to be statistically
significant. (t= 2.47, df=35, p=0.018)
Cotrimoxazole is an effective drug to reduce
mortality amongst HIV infected TB patients
(Q.No.18). Ten participants (27.77%) could
specify Cotrimoxazole as a correct option (pre
test mean marks = 0.28). Sixteen participants
(44.44%) preferred to choose Ciprofloxacin and
two participants (5.55%) selected Ofloxacin and
Azithromycin as an effective drug to reduce
mortality in TB-HIV coinfection. Six participants
(16.67%) were unaware of it and gave no
response. After training more than two third of
participants 29(80.55%) correctly mentioned
Cotrimoxazole as an effective drug to reduce
mortality among HIV infected TB patients. (Post
test mean marks =0.64). Statistically significant
57
ISSN: 0976 3325
difference was revealed in mean marks of pre
test and post test (t=4.44, p < 0.001). This topic
was stressed more during group discussion and
role play. Adeline Nyamathi, Manju Vatsa et al.9
found significant improvement of HIV
knowledge of nurses from pre test to post test by
using teaching strategies like role play, small
group sessions and lectures with discussion.
Before training 20(55.55%) participants were
aware about treatment regimen for new smear
positive
case
under
RNTCP
i.e.
2(HRZE)3/4(HR)3.(Q.No.12).Less than one third
of participants had no idea about treatment
regimen. Eight (22.22%) participants selected
other options. Facilitators showed all patient
wise boxes to participants and explained all
treatment categories rather than explaining it
therotically.After
training
31(86.11%)
participants stated correct treatment strategy for
new smear positive case.
The difference in mean marks of pre test (0.58)
and post test (0.86) was found to be statistically
significant. (t=3.67, df=35, p= 0.0008)
In a KAP survey, A Vijaya Raman, VK Chadha
et al.4 found 9 (60%) had knowledge of NTP
regimen amongst 15 allopathic doctors
surveyed. Incorporation of ‘Role Play’ and
‘Demonstration’ method might be attributed to
statistically significant difference in mean marks
of pre test and post test for questions mentioned
in category of ‘Treatment Services’.
D) Advocacy, Communication and Social
Mobilization (ACSM):
The intensification of ACSM activities is an
essential component of RNTCP (Q.No.20).In
pretraining phase, 5(13.88%) of participants
stated the full form of ACSM correctly while in
post training phase nearly two third (69.44%) of
participants were able to give the full form of
ACSM accurately. The difference was
statistically significant (t= 5.65, df=35, p <0.001)
The
present
study showed
significant
improvement in participant’s knowledge of
tuberculosis and its management practices from
pre test to post test. The study carried out in
public health workers and DOTS workers by PS
Wu, Pesus Chou et al.5 also found statistically
significant
improvement
in
knowledge
regarding tuberculosis from pre test to post test.
The topics pertaining to questions for which
statistically significant difference was seen in
mean marks of participants were covered within
first 90 minutes of training session. This together
with
methodologies
like
role
play,
demonstration,
Socratic
method
of
communication, printed handouts, film show
setting up novel examples, group discussion,
question-answer session, posters might be
reasons for significant increase in knowledge of
participants in post test. Participants were
encouraged to ask questions and efforts were
done to establish ‘two way communication’.
Novel examples were used to make point across
during training.
Even though the post test score was found more
for questions related to most common symptom
of pulmonary tuberculosis, correct statement
regarding
TB,
indications
of
sputum
examination, management of smear negative TB,
ZN staining, contraindicated anti TB drug in
pregnancy, follow up sputum examinations,
best method of prevention of TB and RNTCP
policy on chemoprophylaxis etc, the difference
was not significant statistically.
Clinical practice paradigms are often ingrained
in physicians during their post graduate
training. Education of postgraduate students on
guidelines for detection and early management
of tuberculosis is crucial for further
improvements in national tuberculosis control
strategies.
CONCLUSION AND RECOMMENDATIONS
The study revealed inadequacies in the
knowledge
of
tuberculosis
amongst
postgraduate students. Their ability to diagnose
and manage tuberculosis infection has
important public health implications.
‘RNTCP Training’ should be the part of regular
activity of all medical colleges and hospitals.
Didactic lecture for delivering information need
to be replaced by methodologies like role play,
demonstration, questionanswer session,
Socratic method of communication, setting up
various examples film show, printed handouts,
Posters, Group Discussion etc, for better
understanding. More studies are needed to
assess the knowledge of postgraduate students
on tuberculosis and its management practices
especially in reference to RNTCP.
ACKNOWLEDGEMENT
58
ISSN: 0976 3325
We heartily acknowledge the cooperation and
support of Dr. Narendra Thakur, City
Tuberculosis
Officer,
Pune
Municipal
Corporation, to Dr. Chougule S. G., Medical
Officer (RNTCP) and Dr. Medha Bargage,
Associate Professor, Department of Pulmonary
Medicine,
Bharati
Vidyapeeth
Deemed
University Medical College and Hospital, Pune.
We express our reverential gratitude to Dr. M. P.
Dandare, Professor and Head, Department of
Community Medicine, Bharati Vidyapeeth
Deemed University Medical College, Pune for
guidance in the preparation of this paper.
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Park.K. Textbook of Preventive and Social Medicine,
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Sunderlal.Textbook of Community Medicine, 2nd ed.
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A Vijaya Raman, VK Chadha et al. A study of
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PS Wu, Pesus Chou, et al. Assessment of Changes in
Knowledge and Stigmatization Following Tuberculosis
Training Workshop in Taiwan. J formos Med Assoc
2009; 108:377-85.
Vijayaprasad Gopichandran et al. Impact of a simple
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59
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Original Article .
STUDY ON WORK RELATED FACTORS OF AGATE GRINDERS IN SHAKARPURAKHAMBAT, GUJARAT
Deepak B Sharma1, Tushar A Patel1
1Assistant
Professor, Department of Community Medicine, Pramukh Swami Medical College,
Karamsad, Anand
Correspondence
Dr. Deepak. B. Sharma
Department of Community Medicine,
Pramukh Swami Medical College, Karamsad, Anand
Email: [email protected], Mobile: 09427409354
ABSTRACT
Decorative carving of agate stone is a traditional household industry localized in the Khambhat area
of Gujarat. The following study analyses the i) age and sex distribution of agate workers ii) factors
behind opting for this job and iii) adoption of preventive measures. It was a cross sectional study
involving 98 agate workers in Shakarpura engaged in grinding work. The data was analysed in terms
of percentage, mean, S.D, mode, etc. All the agate workers had opted this work because of family
constraints. 97(99%) opted this job because of comparative good wages with less hard work than
other jobs.15.4% were using the preventive measures. KAP gap of 84.6% was found. It was also
revealed that 53.0% were not using the devices because they find it cumbersome to use, difficulty in
breathing and because of addiction to various tobacco products.
Keywords: Agate, Khambat, Cumbersome, Debts, Preventive measures
INTRODUCTION
Agate is a hard, semiprecious stone, a variety of
chalcedony, with striped or clouded coloring
and containing high amount of free silica
(>60%). It is used to make cheap jewelry and
various articles of decoration. Dust is generated
mainly during the grinding process. Grinding of
the stones is carried out indoors or under open
shade, on electric emery. Dust generated during
grinding pervades the work environment as
well as the community .1
The problem of silicosis is much more severe in
the unorganized sector of industries like slate
pencil cutting, stone cutting and agate industry.
The flaw here is that most industries belonging
to the unorganized sector do not fall under the
purview of the statutory tools such as the
Factories Act aimed to protect the health and
safety of the working population. Moreover, the
employers lack the will to provide safe working
environment for the workers. It is probably
economic compulsions that the workers choose
to work in hazardous environments and are
subjected to exploitation.2
The workers working in agate industry are in
debt trap. The workers are not free to change
either the job or employer till they fully repay
the debt. The workers are scared of the
employers because of dire consequences they
may face. If the workers die, the family members
are asked to repay the debt. Under these
circumstances, the family is compelled to work
under the same employer.3
This study was conducted with the objective to
study the factors related to working in agate
grinding home based working units and
adoption of preventive measures. Total agate
grinders in Shakarpura village in Khambat are
around 200. For the study half of them i.e. 100
worker were interviewed. Two persons were
excluded from the study due to poor response.
Information was collected by interview method
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in a pre-designed proforma. The analysis is done
by EPI-info package and the results were
interpreted in terms of %, mean, S.D, median.
RESULTS
Table 1 describes the age & sex wise distribution
of agate workers. Out of 98 workers 66.3% were
males and 33.7 % were females. Maximum
workers were from the age groups 30-50 in both
male (70.8%) and female (74.0%).
Figure 1 illustrates the distribution of agate
workers according to reasons behind opting this
work. Out of 98 workers, all had opted for this
job because of family constraints. 97(99%) opted
this job because of comparative good wages
with less hard work than other jobs. 90(91.8 %)
found that there is lack of opportunity in the
area. Further 71(72.4%) said that they don’t
know other work and 50(50.5%) said that
compulsion because of debts from the lender.
Table 1: Age & sex wise distribution of agate
workers
Age
Male (%)
Female (%)
Total (%)
15-20
1(1.5)
1(3.1)
2(2.1)
20-25
5(7.7)
4(12.5)
9(9.3)
25-30
9(13.8)
1(3.1)
10(10.3)
30-35
15(23.1)
5(15.6)
20(20.6)
35-40
12(18.5)
9(28.1)
21(21.6)
40-45
9(13.8)
10(30.3)
19(19.4)
45-50
10(15.4)
0(0.0)
10(10.3)
50-55
0(0.0)
2(6.3)
2(2.1)
55-60
2(3.1)
1(3.1)
3(3.1)
>60
2(3.1)
0(0.0)
2(2.1)
Total
65(100.0)
33(100.0)
98(100.0)
Mean age-35.94 years, S.D-8.91 years, Median35years, Mode- 40 years
Compulsion because of debts from the
lender
50
Family constraints
98
No other job in the community
90
%
Doesn’t know other work
71
Good daily wages as compared to other
labourer job without much hard work
99
0
20
40
60
80
100
120
Figure 1: Reasons behind opting for Grinding Work
Figure 2 and 3 highlights the usage of
preventive measures and reasons for not using
face masks respectively.
Out of 98 agate workers only 15.4% were
wearing mask as a preventive measure and
14.28% using wet method to prevent spillage of
dust in the environment. KAP gap of 84.6% is
found. 53.0% were not using the devices because
they find it cumbersome to use, difficulty in
breathing and because of addiction to various
tobacco products.
Not using
84.6
Face mask
15.4
Wet method
14.28
0
10
20
%
30
40
50
60
70
80
90
Figure 2: Adoption of Preventive measures
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Cumbersome, Dusts deposit over the nose
, Difficulty in breathing &…
21.7
Cumbersome & Difficulty in breathing
15.7
Cumbersome, Difficulty in
breathing, Addiction/eating problem
Cumbersome & Dusts deposit over the
nose
53
%
6
Dusts deposit over the nose
3.6
0
10
20
30
40
50
60
Figure 3: Reasons for not using Face mask
DISCUSSION
The study showed that the ratio of male and
female workers was 2:1 and maximum workers
were from the age 30-45 yrs.
This study also showed that the workers opted
this job because of family constraints,
comparative good wages with less hard work
than other jobs, lack of opportunity in the area
and compulsion because of debts from the
lender. PUCL (Peoples Union for Civil Liberties)
Bulletin had also emphasized the same facts.3
A large KAP gap in using preventive measures
was found. Very few 15 (15.4%) workers were
using the face mask and wet methods 14
(14.28%). According to Prevention and control
exchange, there is a worldwide need to
effectively apply existing knowledge into
appropriate preventive strategies in the
workplace.4
Dust control measures remain the single most
potent strategy for the prevention of silicosis.
Saiyed (1999) in an article in the ICMR Bulletin
has said that there is no silicosis without dust
exposure, and the dust levels in the work
environment correlate well with the incidence as
well as the severity of the disease. Therefore,
elimination or suppression of dust in the work
environment is the key in the control of silicosis.
Each industry has its unique work process and
therefore it is not possible to have a single
prescription appropriate to all.5 In the same
study, it was however emphasized that the
personal protective equipments such as masks
should be prescribed only when all available
dust control measures have failed. In fact, the
dust masks are of little value when the dust
concentrations are high as the dust particles will
clog the pores in the filter resulting in a choking
sensation and discontinuance of the use of
masks by workers. Moreover, the masks are not
suited for hot and humid climate.5
The agate workers in Shakarpura are working
mostly in household units. When no other
preventive measure is available to the agate
workers, it is better to have the cheapest one as
the costlier one can’t be installed by the agate
workers themselves and the employers are also
not interested in getting these machines for their
employees. Pre-placement examination is again
a very big question in such an unorganized
sector of work.
Lakho et.al (2008) in his Cost Benefit Analysis
study showed that if dust control devices are
installed in all the agate-grinding facilities of
Khambhat, not only the prevalence of Silicosis
and TB can be reduced, but in the long run there
are financial benefits also.6
Very little can be done once the disease has set
in and therefore, prevention is most important,
pre - placement & periodic health examinations
of the worker are important. Dust control is the
most important engineering procedure to reduce
risk. If a significant number of workers develop
silicosis within 20 – 25 years of first
employment, the dust control measures should
be suitably revised.7
CONCLUSIONS
The study highlights that there is a need to
increase the receptivity of the preventive
measures like use of wet methods and dust
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control measures (face mask) when hardly
anything can be done else using these methods .
The devices developed by the NIOH for the
reduction of dusts in the environment needs to
be installed, lest we want to safeguard the lives
of agate workers as the silica filled dust is the
real killer in Shakarpura-Khambat.
2.
3.
4.
ACKNOWLEDGEMENT
We would like to acknowledge Departmental
Head- Dr Vasudev Rawal for guidance and
support to conduct the study. Agate workers
responsive behavior needs to be acknowledged
without which the study would not have been in
this shape.
REFERENCES
1.
Saiyed HN. Silicosis among children in the agate
industry, In: J. Pronczuk de Garbino, Editor-in-Chief,
5.
6.
7.
Children’s health and the environment: a global
perspective, a resource manual for the health sector.
Section VI; Case Studies, 2004. p 277-281.
Kulkarni GK. Prevention and control of silicosis: A
national challenge. Indian Journal of Occupational and
Environmental Medicine. December 2007; 11(3).
Silicosis - A Death Trap for Agate Workers in Gujarat.
PUCL Bulletin 2008 March; XXVIII(03).
Prevention and control exchange: Hazard prevention
and control in the work environment: airborne dust,
Occupational and environmental health. Department of
protection of the human environment, Executive
summary, World Health Organization, Geneva, August
1999.
Saiyed HN. Silicosis - An Uncommonly Diagnosed
Common Occupational Disease. ICMR Bulletin
September 1999; Vol 29, No 9.
Lakho J, Bhagia H, Sadhu G. Cost-benefit analysis of
installing dust control devices in the agate industry,
Khambhat (Gujarat), Indian Journal of Occupational
and Environmental Medicine - 2008; Volume 12 - Issue
3, 128-131.
Vaz LS, Jindal AK & Dudeja P. Organ /System Diseases
Peculiar to Occupational Settings. In: Rajwir Bhalwar,
Chief editor, Textbook on Public health and
Community Medicine, Section 11: 225; p-1275.
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Original Article .
SEROPREVALENCE OF LEPTOSPIROSIS IN SOUTH GUJARAT REGION BY EVALUATING
THE TWO RAPID COMMERCIAL DIAGNOSTIC KITS AGAINST THE MAT TEST FOR
DETECTION OF ANTIBODIES TO LEPTOSPIRA INTERROGANS
Tanvi Panwala1 Summaiya Mulla2 Parul Patel3
1Assistant
Surat
Professor 2Professor & Head, Department of Microbiology, Government Medical College,
Department of Microbiology, GMERS, Sola, Ahmedabad
3Tutor,
Correspondence:
Dr. Tanvi Panwala
E-7, Vigneshawar Estate,
Nanpura, Timaliyavad, Surat-395001
E-mail : [email protected], Mobile no. : 98258-31144
ABSTRACT
The study was conducted to evaluate the two rapid tests for the serologic diagnosis of leptospirosis
namely Microplate Immunoglobulin M(IgM)-Enzyme Linked Immunosorbent Assay(ELISA) and IgM
Rapid Leptocheck WB and the performance of each assay compared with that of the current standard,
the microscopic agglutination test (MAT). The panels of 188 sera from 130 cases of leptospirosis from
three different geographical locations were tested as well as 310 sera from healthy individual or
individual with other infectious disease other than leptospirosis. Acute phase sera from cases (n=130)
were collected <14 days after the onset of symptoms and convalescent phase sera (n=58) were
collected ≥14 days after the onset of symptoms. By traditional method (two-by-two) contingency
table, the sensitivity, specificity, PPV(Positive predictive value), NPV(Negative predictive value),
Efficiency of test and (Kappa) value for agreement (with MAT) for the Rapid Leptocheck WB were
98.36%, 86.95%, 86.95%, 98.36%, 92.37% and 0.81 in acute phase of disease. Corresponding values for
IgM ELISA were 96.82%, 88.05%, 88.40%, 96.72%, 91.53% and 0.88 respectively. The sensitivity,
specificity, PPV(Positive predictive value), NPV(Negative predictive value), Efficiency of test and
(Kappa) value for agreement (with MAT) for the Rapid Leptocheck WB were 87.87%, 88%, 90.82%,
84.61%,86.20% and 0.85 in convalescent phase of the disease. Corresponding values for IgM ELISA
were 91.42%, 95.65%, 96.96%, 88%, 93.10% and 0.81 respectively. These values for the 2 tests were
comparable, indicating that there was no difference in their efficacies. The second-generation assay
included in study (Leptocheck and ELISA) showed significantly higher sensitivity with early acute
phase sera than the reference or first generation method (MAT) while retaining high specificity and
should greatly improve the rapid detection of leptospirosis in the field.
KEY WORDS: Leptospirosis, MAT test, IgM ELISA test, IgM Rapid Leptocheck test.
INTRODUCTION
Leptospirosis is a zoonosis caused by
spirochetes of the genus Leptospira, which has a
worldwide distribution1. Humans become
infected through contact with contaminated
animal urine, tissues, or water2 The clinical
presentation is difficult to distinguish from
dengue, malaria, influenza, and many other
diseases characterized by fever, headache, and
myalgia3. Although the patient's exposure
history may assist in narrowing the differential
diagnosis, a rapid and simple test with high
sensitivity and specificity would be useful for
early diagnosis and treatment and for public
health surveillance4. Definitive laboratory
diagnosis of leptospirosis requires detection of
the organism in a clinical specimen or a fourfold
or greater rise in microscopic agglutination test
(MAT) titer in the setting of an appropriate
clinical syndrome.
The most frequently used diagnostic approach
for leptospirosis has been that of serology. The
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MAT is the serological test used in reference
laboratories, because of its high degree of
sensitivity and specificity5. However, the MAT
is a complex test that requires a large panel of
live-cell suspensions to provide adequate
coverage of the antigenic diversity represented
in a given testing area. Moreover, antibody
levels detectable by MAT usually do not appear
before day 6 or 7 after development of
symptoms; they usually peak by the fourth
week, but detectable titers may persist for years6,
7, 8. Hence, interpretation of the results is
difficult without paired specimens collected at
the appropriate times; therefore, results are
usually not available quickly enough to be
useful for patient management.
Several alternatives to the MAT have been
developed; those available commercially include
an Immunoglobulin M (IgM) Enzyme-Linked
Immunosorbent Assay (ELISA)9, an IgM
dipstick assay (LDS)10, an IgM dot-ELISA
dipstick test (DST)11, and the indirect
heamagglutination
assay (IHA)12. Reported
evaluations suggest that some of these assays
are highly sensitive and specific12, 13, 14, 15, 16, 17, 18,
but they have not been systematically compared
to each other and to the MAT. This study was
designed to determine the performance of these
serologic assays in detecting Leptospira-specific
antibodies and to compare results obtained with
each system to those obtained with the MAT.
This information should assist diagnostic
laboratories, especially those without the
capacity to maintain the MAT, to select a
suitable assay for screening serum samples from
suspected cases of leptospirosis.
Case sera: The study was conducted at new civil
hospital, Surat, India, a tertiary health centre in
South Gujarat during the period May 2007 to
July 2008. All suspected cases of Leptospirosis
attending the outpatient department of these
hospitals during the study period were
included. A total of 188 sera from 130 cases were
included in the study, the panel of case sera (188
specimens) consisted of 130 acute phase sera
(obtained <14 days after the onset of illness) and
58 convalescent phase sera (obtained 14 to 28
days after the onset of illness). Paired sera were
available for 58 cases. Samples were from
different geographic location namely, 76 cases
were from Surat district, 18 cases were from
Valsad district and 36 cases were from Navasari
district. Control sera: A total of 310 control
specimen were collected which includes 50
healthy donors, 100 were from individuals
known to have disease other than leptospirosis
and 160 healthy control from different
geographic locations. Information helpful in the
interpretation of results such as agent or disease
specific finding and place of residence was
obtained.
Criteria for clinical suspicion of leptospirosis:
Acute febrile illness with headache, myalgia and
prostration associated with any of the following:
•
•
•
•
•
Conjuctival suffusion
Meningeal irritation
Anuria or oliguria and/or proteinuria
Jaundice
Hemorrhages (from the intestines; lung
bleeding is notorious in some areas)
• Cardiac arrhythmia or failure
• Skin rash and a history of exposure to
infected animals or an environment
contaminated with animal urine.
• Other common symptoms include nausea,
vomiting, abdominal pain, diarrhea &
arthralgia.
MAT test: The MAT test was performed using
standard
procedure19.
Live
leptospira
(representing 11 serovars belonging to 11
serogroup) cultured in EMJH (EllinghausenMcCullough- Johnson-Harris) media to detect
agglutination antibodies from patient sera. Live
leptospira cell suspension were added to serially
diluted serum specimens in 96 well flat
bottomed microtiter plates and incubated at
370C for 2 hours. Agglutination was examined
by dark field microscopy at a magnification of
100X. The reported titer was calculated as the
reciprocal of the highest dilution that
agglutinated at least 50% of the cells for each
serovar.A MAT test is considered borderline at
titre of >80 and positive at titre of >200 for single
samples. Serogroup included in the antigen
panel are as follows:
Australis (Australis), Autumnalis (Bangkinang),
Ballum
(Ballum),
Sejroe
(Hardjo),
Grippotyphosa
(Grippotyphosa),
Canicola
(Canicola), Hebdomadis (Hebdomadis), Pomona
(Pomona),
Semeranga
(Patoc1),
Pyrogen
(Pyrogen),
Icterohaemorrhagiae
(Icterohaemorrhagiae).
IgM ELISA test: The ELISA was carried out as
per the manufacturer’s instruction. ELISA kit
was obtained from Serion verion ELISA (classic
leptospira IgM). Serum antibodies of the IgM
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class, when present, combine with leptospira
antigen attached to the polystyrene surface of
the microwell test strips. Residual serum is
removed by washing and peroxidase conjugated
antihuman IgG, IgA, IgM is added.
The
microwells are washed and substrate system,
para-nitrophenyl-phosphate is added.
The
substrate is hydrolysed by enzyme, and
chromogen changes to yellow coloured. Case
and control sera (10µL) were diluted 1:100 and
tested according to the manufacturer’s
instruction. The result is read with a dual
wavelength spectrophotometer at 405nm and a
background of 620nm. The colour intensity is
directly related to the concentration of
Leptospira IgM antibodies in the test sample.
Each set of tests is run with a positive control,
negative control and cut-off calibrator in
duplicate. The test is valid when the absorbance
reading of the above meets the specification of
the Serion ELISA instruction. The results were
interpreted according to the manufacturer’s
recommendation.
Specimens
having
an
absorbent ratio greater than that of cutoff
calibrator were defined as positive.
Calculation for Serion ELISA classic leptospira
IgM:
•
Serion units of <15 gives a negative result
interpreted as no evidence of recent
infection.
• A Serion unit of 15-20 is a low positive or
borderline result and may suggest a recent
infection.
• Serion units of >20 is a positive result
suggestive of a recent or current infection.
Samples giving borderline results should be
tested in parallel with a further sample taken
from the patient 1-2 weeks later.
Rapid Leptocheck Test: Case and control sera
(10µL) were used and tested according to the
manufacturer’s instruction. It utilizes the
principle of immunochromatography, a unique
two-site immunoassay on a membrane. As the
test sample flow through the membrane
assembly of the test device, the anti-human IgM
colloidal gold conjugate forms a complex with
IgM antibodies in the sample. This complex
moves further on the membrane to the test
window ‘T’ where it is immobilized by the
broadly reactive leptospira genus specific
antigen coated on the membrane, leading to the
formation of a red to deep purple coloured band
at the test region. ‘T’ which confirms a positive
test result. Absence of this coloured band in test
region ‘T’ indicates a negative test result. The
unreacted conjugate and the unbound complex
if any move further on the membrane and are
subsequently immobilized by the anti-rabbit
antibodies, coated on the control window “C” of
the membrane assembly, forming a red to deep
purple coloured band. The control band shows
to validate the test result.
Criteria for laboratory confirmation: The
suspected patients fulfilling any of the following
criteria were considered as a case of
leptospirosis:(1) isolation of leptospira from
clinical specimen (2) Seroconversion in IgM
ELISA and MAT test from seronegative to a titre
of at least 100, (3) Fourfold or greater increase in
MAT or ELISA titre between acute and
convalescent phase serum specimens obtained 2
weeks apart and studied at the same laboratory
(4) a titre of >100 in IgM ELISA or >200 in MAT
if only a single sample was available.
DATA ANALYSIS
Sensitivity, specificity, positive predictive
values(PPV), negative predictive values(NPV),
Kappa value were calculated based on MAT
cutoff of >80 dilution , using standard equations:
•
•
•
•
•
% sensitivity =true positive / (true positive
+ false negative) × 100.
% specificity = true negative/ (false positive
+ true negative) × 100.
PPV (Positive predictive value) = true
positive/all positive test.
NPV (Negative predictive value) = true
negative/ all negative test.
Efficiency of test= (true positive +true
negative)/total samples
RESULTS
The
sensitivity,
specificity,
PPV(Positive
predictive value), NPV(Negative predictive
value), Efficiency of test and (Kappa) value for
agreement (with MAT) for the Rapid
Leptocheck WB were 98.36%, 86.95%, 86.95%,
98.36%,92.37% and 0.88 in acute phase of
disease. Corresponding values for IgM ELISA
were 96.82%, 88.05%, 88.40%, 96.72%, 91.53%
and 0.88 respectively. These values for the 2
tests were comparable, indicating that there was
no difference in their efficacies.
The
sensitivity,
specificity,
PPV(Positive
predictive value), NPV(Negative predictive
value), Efficiency of test and (Kappa) value for
agreement (with MAT) for the Rapid
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Leptocheck WB were 87.87%, 88%, 90.82%,
84.61%,86.20% and 0.85 in convalescent phase of
the disease. Corresponding values for IgM
ELISA were 91.42%, 95.65%, 96.96%, 88%,
93.10% and 0.81 respectively. So, the changes in
the values of these tests, depending on the stage
of the disease are shown in table-1 and chart- 1&
2 below.
Table 1: Comparison of two rapid tests in acute and convalescent phase
Tests
Leptocheck
WB
IgM ELISA
Phases
Acute Phase
(< 14 days)
Convalescent phase
(14-28 days)
Acute Phase
(< 14 days)
Convalescent phase
(14-28 days)
Sensitivity
98.36%
Specificity
86.95%
PPV
86.95%
NPV
98.36%
Efficiency
92.37%
87.87%
88.00%
90.62%
84.61%
6.20%
96.82%
88.05%
88.40%
96.72%
91.53%
91.42%
95.62%
96.96%
88.00%
93.10%
The sensitivity of the MAT for diagnosis of
leptospirosis was also tested which showed
sensitivity of 44.61% during 1st week and 60.38%
during second to fourth week. These values
were lower than the corresponding values for
the Leptocheck WB and IgM ELISA.
DISCUSSION
Leptospirosis is an acute febrile disease, widely
recognized as being emergent or re-emergent in
tropical and subtropical regions, the disease is
endemic and exposure to infection is
widespread. In temperate climates, the disease is
primarily one of occupational, recreational
expose. Leptospirosis is frequently underdiagnosed, because of the non-specific
symptoms early in the disease and the difficulty
of performing the culture.
In leptospirosis, antibodies begin to appear
within a few days of onset of symptoms and in a
significant proportion of patients the antibodies
persist in detectable quantities for several
months (Silva et al, 1995). As has been
described, genus specific antibodies appear
earlier than the serovar specific microscopic
agglutinating antibodies. At this earlier stage of
the disease, genus-specific tests, especially IgM
immunoassays, are expected to be positive
though more serovar specific tests such as MAT
may not be able to detect the presence of
antibodies owing to nil or low immune response
(Christie, 1980). From the clinical point of view,
the ability to detect the infection early in the
course of the disease is of extreme importance
for initiating appropriate treatment to avoid
serious complications. In this context, the genus
specific IgM immunoassays would be of great
use for detecting leptospirosis at an early stage
of the disease.
One of the drawbacks of IgM immunoassays
and Rapid Leptocheck WB is their inability to
give any information about the infecting
serovars. But such information is mainly of
epidemiological importance, as differentiation
between the infecting serovars does not affect
the clinical course of management.
The
usefulness of these rapid genus-specific
immunoassays is at the peripheral level, where
the only information required is whether or not
a patient has a leptospiral infection.
The sensitivities of both rapid Leptocheck WB
and IgM ELISA are at acceptable levels even
during the first week of illness when the IgM
antibodies start to appear. This indicates that
the assays are highly responsive to even low
levels of IgM antibodies. As the tests have high
PPV during all stages of the disease, these tests
are useful for screening. Since these tests detect
IgM antibodies, which persist for a shorter
period than IgG antibodies, their NPV begin to
decline after 1 month of infection. Because of
this, these tests will have only limited usefulness
in epidemiological studies on prevalence of
infection among a population.
As MAT detects both IgM and IgG antibodies, it
is difficult to differentiate between current
clinical infection and past exposure to leptospira
using a single MAT. In this regard there is a
need to define criteria for a positive MAT when
MAT is used alone for serodiagnosis of
leptospirosis. Based on our criteria, MAT on a
single sample had shown only 44.61% sensitivity
during the acute phase (0 to 14 days) of illness.
This comparatively >1:80 cut-off value was used
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because the study was conducted in an endemic
zone with high seroprevalence among the
healthy population. The sensitivity of MAT rose
to 60.38% during the convalescent phase (14 to
28 days) of disease. Some of the patients who
had negative MAT results during the first weeks
of disease and they became positive by
seroconversion and showed rising titres when
another sample obtained 14 days after the onset
of illness was examined.
Therefore, this test is a useful tool for
epidemiological purpose.
• We observed that more patients were male
in our study. Almost are working class
male farm workers.
• We observed that there were 71 (seventy
one) i.e. more number of cases in the age
group of 20-39 years. This reflects as they
are active earning adult age groups and
from history majority of these had
occupational history as farmer.
Among the 100 serum samples from patients
with disease other than leptospirosis (malaria,
dengue, hepatitis, typhoid, HIV). There were no
false positive reactions observed with
Leptocheck WB or IgM ELISA. It may be due to
we used limited numbers diseased groups. We
did not observe any significant difference in the
cross-reactivity rate in different disease by
ELISA & Leptocheck WB. None of the sera from
the above groups of patients had given
significant titres by MAT. However, low titres
by MAT (1:20-1:40) were obtained for some of
the patients, which reflects that it may be IgG
antibody.
Table 2: Results of our study in comparison with other studies
Test
Results
Rapid test
Leptocheck or
Dipstick
Sensitivity
Specificity
PPV
NPV
Sensitivity
Specificity
PPV
NPV
IgM ELISA
WYsekhar EH
Soo4, 8
83.3%
93.8%
95.29%
79%
54.2%
96.9%
96.3%
58.5%
Our study was compared with other studies
(table- 2), our study sensitivity for rapid test is
94.68 % which is comparable to the other two
studies (WY Sekhar, EH, Soo20, P. Vijayachari et
al21). It is slightly higher than the other two
studies which may be due to the difference in
test as they have used Dipstick as a rapid
method
which
is
based
on
immunochromatography principal, and in our
study we have used Leptocheck WB (lateral
flow method).
The specificity of P. Vijayachari et al21 & W.Y.
Sekhar EH Soo20 ranges from 88% to 94%. In
our study, it was 87.23% which correlates well
with their studies.
In case of IgM ELISA, the sensitivity of WY
Sekhar study was very low, which may be due
to difference in kit mode. They have used
PanBio for their study, where as we have used
Serion Virion IgM ELISA which was evaluated
according to Indian geographical areas.
SC Sehgal, PV
Vijaychari4, 2
78.7%
88.3%
91.0%
73.4%
78.5%
87.6%
90.5%
73%
Present study
93.81%
86.81%
88.34%
92.94%
93.81%
90.10%
91.00%
93.81%
The sensitivity of P. Vijayachari study was also
slightly lower than our study but it is
comparable. The specificity of two studies
correlates well with our study.
The agreement between Rapid test with MAT
and IgM ELISA with MAT test were 80% and
84% respectively which are comparable to SC
Sehgal, P. Vijayachari et al study.
Additionally one of the major limitations for any
evaluation of assays for serologic diagnosis of
leptospirosis is the paucity of cases confirmed
by culture. As a result, findings from new
serologic assays are comparable with those from
cases that are primarily defined by another
serologic assay. Consequently, there are very
few reports of sensitivity and specificity of the
MAT, because it is the gold standard against
which other assays are usually compared.
CONCLUSION
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This study was conducted at New Civil
Hospital, Surat during the period May 2007 to
July 2008. There were 130 clinically suspected
cases from different regions of South Gujarat.
Majority of patients were young adults. There
was male preponderance, and majorities were
farm workers.
The Rapid Leptocheck WB test is easy to
perform and it requires only a single dilution
and does not require any special equipment.
The kit reagents have a long shelf-life even at
room temperature. The test has good sensitivity
(98.36%) and specificity (86.95%) in acute phase
and sensitivity of 87.87% and specificity of 88%
in convalescent phase considering MAT as Gold
Standard. So, it is now the test of choice for the
diagnosis of current leptospirosis, and for
routine use at the peripheral level in developing
countries. IgM ELISA is also very good test for
early detection of leptospiral infection which has
good sensitivity (96.82%) and specificity
(88.05%) in acute phase and sensitivity of 91.42%
and specificity of 95.62% in convalescent phase
considering MAT as Gold standard. The
limitation of this test includes its ability to give
information about the infecting serovar because
of these both are genus-specific nature.
Therefore MAT test is a useful tool for
epidemiological purpose.
The microscopic agglutination test (MAT)
(WOLFF, 1954) is still the ‘corner-stone’ of
leptospirosis diagnosis. However, the test has
many disadvantages. Considerable laboratory
infrastructure and skilled manpower are
required for performing MAT. Many strains of
leptospires have to be maintained in the
laboratory for use as antigens in the test.
Standardisation of the test can detect both IgM
and IgG antibodies, but it may fail to
demonstrate low levels of IgM antibodies
during the early stage of the disease. The value
of MAT lies in its ability to recognize the
infecting serogroup, especially in repeat sample
collected 10-14 days after the first specimen.
Therefore, this test is a useful tool for
epidemiological purposes.
So, the second-generation assay included in our
study (Leptocheck and ELISA) showed
significantly higher sensitivity with early acute
phase sera than the reference or first generation
method (MAT) while retaining high specificity
and should greatly improve the rapid detection
of leptospirosis in the field.
REFERENCE
1. World Health Organization. 1999. Leptospirosis
worldwide, 1999. Wkly. Epidemiol. Rec. 74:237-242.
2. Levett, P. N. 2001. Leptospirosis. Clin. Microbiol. Rev.
14:296-326.
3. Tappero, J. W., D. A. Ashford, and B. A. Perkins. 2000.
Leptospira species (leptospirosis), p. 2495-2501. In G. L.
Mandell, J. E. Bennett, and R. Dolin (ed.), Principles and
practice of infectious diseases, 5th ed. Churchill
Livingstone, Philadelphia, Page.34
4. Perkins, B. A. 1998. Epidemic leptospirosis associated
with pulmonary hemorrhage in Nicaragua, other recent
outbreaks, and diagnostic testing: issues and
opportunities, p. 159-167. In W. M. Scheld, W. A. Craig,
and J. M. Hughes (ed.), Emerging infections 2. American
Society for Microbiology, Washington, D.C.25
5. Cole, J. R., C. R. Sulzer, and A. R. Pursell. 1973.
Improved microtechnique for the leptospiral microscopic
agglutination test. Appl. Microbiol. 25:976-980.
6. Adler, B., S. Faine. 1978. The antibodies involved in the
human immune response to leptospiral infection. J. Med.
Microbiol. 11:387-400.
7. Cumberland, P. C., C. O. R. Everard, J. G. Wheeler, and
P. N. Levett. 2001. Persistence of anti-leptospiral IgM,
IgG and agglutinating antibodies in patients presenting
with acute febrile illness in Barbados 1979-1989. Eur. J.
Epidemiol. 17:601-608.
8. Terpstra, W. J., G. S. Ligthart, and G. J. Schoone. 1985.
ELISA for the detection of specific IgM and IgG in
human leptospirosis. J. Gen. Microbiol. 131:377-385.
9. Winslow, W. E., D. J. Merry, M. L. Pirc, and P. L. Devine.
1997. Evaluation of a commercial enzyme-linked
immunosorbent assay for detection of immunoglobulin
M antibody in diagnosis of human leptospiral infection.
J. Clin. Microbiol. 35:1938-1942.
10. Gussenhoven, G. C., M. A. W. G. van der Hoorn, M. G.
A. Goris, W. J. Terpstra, R. A. Hartskeerl, B. W. Mol, C.
W. Van Ingen, and H. L. Smits. 1997. LEPTO dipstick, a
dipstick assay for detection of Leptospira-specific
immunoglobulin M antibodies in human sera. J. Clin.
Microbiol. 35:92-97.
11. Levett, P. N., S. L. Branch, C. U. Whittington, C. N.
Edwards, and H. Paxton. 2001. Two methods for rapid
serological diagnosis of acute leptospirosis. Clin. Diagn.
Lab. Immunol. 8:349-351.
12. Levett, P. N., and C. U. Whittington. 1998. Evaluation of
the indirect hemagglutination assay for diagnosis of
acute leptospirosis. J. Clin. Microbiol. 36:11-14.
13. Outbreak of leptospirosis among triathlon participants
and community residents in Springfield, Illinois, 1998.
Clin. Infect. Dis. 34:1593-1599.
14. Brandão, A. P., E. D. Camargo, E. D. da Silva, M. V.
Silva, and R. V. Abrão. 1998. Macroscopic agglutination
test for rapid diagnosis of human leptospirosis. J. Clin.
Microbiol. 36:3138-3142.
15. Cinco, M., D. Balanzin, and E. Banfi. 1992. Evaluation of
an immunoenzymatic test (ELISA) for the diagnosis of
leptospirosis in Italy. Eur. J. Epidemiol. 8:677-682.
16. Ribeiro, M. A., C. C. Souza, and S. H. P. Almeida. 1995.
Dot-ELISA for human leptospirosis employing
immunodominant antigen. J. Trop. Med. Hyg. 98:452456.
17. Silva, M V, PM Nakamura, E D Camargo, L Batista, A J
Vaz, E C Romero, A P Brandão. Immunodiagnosis of
human leptospirosis by dot-ELISA for the detection of
IgM, IgG, and IgA antibodies. Am. J. Trop Med Hyg
1997;56:650-655.
18. Yersin, C., P. Bovet, H. L. Smits, and P. Perolat. 1999.
Field evaluation of a one-step dipstick assay for the
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diagnosis of human leptospirosis in the Seychelles. Trop.
Med. Int. Health 4:38-45.
19. Vijayachari P, Suganan AP, Sehgal SC. Role of
microscopic agglutination test (MAT) as a diagnostic tool
during acute stage of leptospirosis in low and high
endemic areas. Indian J Med Res 2001;114: 99-106.
20. WY Sekhar, E H Soo, V Gopalkrishnan, S Devi.
Leptospirosis in Kuala Lumpur and the Comparitive
Evaluation on of two Rapid Commercial Diagnostic Kits
Against the MAT test for the Detection of antibodies to
leptospira Interrogans. Singapore Med J 2000; 41(8):373
21. Sehgal SC, Vijaychari P, Sharma S, Sugunan AP.
Leptodipstick –A rapid and simple method for
serodiagnosis of leptospirosis in acute stage. Trans Soc
Trop Hyg 1999; 93:1-4.
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Original Article .
COMBINED USE OF METOCLOPRAMIDE AND GLYCOPYRROLATE AS A PROPHYLACTIC
ANTIEMETIC IN ELECTIVE CESAREAN SECTION UNDER SPINAL ANESTHESIA
Dinesh Thakur1, Mihir Goswami2, Himanshu Shah3
1Assistant
Professor, Department of Anesthesiology, 2Associate Professor, Department of Community
Medicine, 3Professor and Head, Department of Anesthesiology, Kesar SAL Medical College and
Research Institute, Ahmedabad
Correspondence:
Dr Mihir Goswami,
1, Sunrise Bunglows, Behind Pratik Mall,
Near City Pulse Cinema, Kudasan, Gandhinagar
Mobile: 99243 01414
ABSTRACTS
Objective: To compare the combined effect of two traditional antiemetic drugs (metoclopramide and
glycopyrrolate) against published data of effect of single antiemetic drug for prevention of nausea
and vomiting in women undergoing lower section caesarean section under spinal anaesthesia
Methods: Seventy eight full term parturient women undergoing lower segment cesarean section
under spinal anaesthesia(using 5% lignocaine) were injected metoclopramide 10mg & glycopyrrolate
0.2mg intravenously at the time of abdominal incision. The frequency of nausea and vomiting and
Apgar scores of neonates were noted. Results: Incidence of nausea was noted in 3.84% during
operative and post operative period. No incidence of vomiting and any other adverse effects were
observed. Apgar scores were >8 in all neonates at one and five minutes. Conclusion: Incidence of
vomiting is low (zero case) in current study group compared to groups(data from published research)
with either metoclopramide or glycopyrrolate or ondansetron but observed differences are
statistically insignificant, however the upper class interval limit of Z value falling above significance
level (>1.96) in all groups suggesting that it might significant and required further studies to prove or
disprove significantly lower incidences of nausea and vomiting if combine use of two drugs
(glycopyrrolate plus metoclopramide) as a prophylactic antiemetic in elective cesarean section under
spinal anesthesia.
Key Words: nausea, vomiting, spinal anaesthesia, cesarean section, metoclopramide, glycopyrrolate
INTRODUCTION
The incidences of emetic symptoms are high
during the pregnancy because of increased
concentration of progesterone in the system.
Progesterone decreases gastrointestinal motility
and reduces lower oesophageal pressure. These
physiological and anatomical changes may
predispose the pregnant women to develop
emetic tendency.
Intra-operative emetic symptoms during
abdominal surgery under regional anesthesia
have a multi-factorial origin and factors such as
psychological
changes
(anxiety),
arterial
hypotension, hypo-perfusion of the central
nervous system, abrupt visceral movements,
and concomitant opiate administration1 may
have an influence on them. Additionally, there is
a higher predisposition to intra operative nausea
vomiting among patients at the end of their
pregnancies, as a consequence of increased
intra-abdominal pressure.
The reported incidence of nausea and vomiting
during cesarean section performed under
regional anaesthesia varies from 50% to 80%
when no prophylactic antiemetic is given.2-8
A number of treatments have been introduced
in order to reduce post operative nausea and
vomiting (PONV), such as 5-HT3 antagonists
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ISSN: 0976 3325
(ondansetron and granisetron), dopamine
receptor antagonists, and antihistamine drugs.
However, each of these treatments is associated
with critical limiting factors, namely cost with 5HT3 antagonists, extrapyramidal symptoms
with dopamine receptor antagonists, excessive
sedation and tachycardia with antihistamine
drugs.9-11
Almost all previous researches on PONV
prevention were using single prophylactic
antiemetic drug. The purpose of present study
was to compare the combined effect of two
traditional antiemetic drug i.e. metoclopramide
and glycopyrrolate against published research
data of single antiemetic drug for prevention of
nausea and vomiting in women undergoing
cesarean section under spinal anaesthesia.
Seventy eight full term parturient women of
ASA I & II (American Society of Anesthesiology
Grade I & II), aged between 19 and 35 years
scheduled for elective lower segment cesarean
section under spinal anaesthesia were subjects of
the study. Patients with preeclampsia, arterial
hypertension,
chronic
utero-placental
insufficiency, history of acid peptic disease or
fasting for less than 6 hours were excluded. The
study period was between January 2010 and
December 2010.
Each patient received 20 ml per kilogram of
lactated Ringer’s solution before administration
of spinal anaesthesia to prevent hypotension. All
patients received oxygen via a face mask at a
flow rate of 3 liters per minutes since induction
of spinal anaesthesia. Patients were positioned
in the right/left lateral decubitus or sitting
position and a 22 gauge spinal needle was
introduced through mid line approach at the
L3–L4 inter-space. Patients received 2 ml of 5%
lignocaine (hyperbaric) subarachnoid injection
and turned in supine position with left uterine
displacement to avoid aorto-caval compression.
Surgery was started when a sensory block up to
T5 dermatome was obtained. Each patient
received 10 mg of metoclopramide and 0.2 mg of
glycopyrrolate intravenously when surgery
started.
Hypotension was defined as a reduction of more
than 20% from baseline pressure or if systolic
blood pressure was less than 90 mmHg and
managed with bolus intravenous
lactated
Ringer’s solution and ephedrine in 10-mg
increments.
Each patient was observed and asked for the
intra-operative occurrence of nausea and
vomiting. Apgar scores were obtained at 1 and 5
minutes. Each patient remained in the recovery
room for 4 hours and was observed by the
nursing staff for the postoperative occurrence of
nausea and vomiting.
Results are analyzed manually by suitable
statistical tests.
OBSERVATIONS AND RESULTS
Incidence of nausea was noted in 3(3.84%) of
total 78 studied subjects during operative/postoperative period. No incidence of vomiting was
observed.
Noticeable
side
effects
of
metoclopramide and glycopyrrolate were not
found in any studied subjects. Apgar scores
were >8 in all neonates at one and five minutes.
Table 1: Published researches showing effect of antiemetic drugs during operative and post operative
period of cesarean section under spinal anaesthesia in American Society of Anesthesiology grade I &
II full term parturient women
Antiemetic drugs Æ
Observation
Nausea (%)
Vomiting (%)
Biswas et
al12
(n=20)
4(20)
2(10)
Metoclopramide (10mg)
Ali Shahriari
Garcia-Migual
at al13
FJ at al14
(n=40)
(n=48)
21(52.5)
3(6.25)
0
1(2.08)
DISCUSSION
Great care had been taken to design
methodology such a way that made possible to
compare findings with previous researches.
Ondansetron(4mg)
A K Pan
Garcia-Migual
at al8
FJ at al14
(n=20)
(n=49)
2(10)
4(8.16)
1(5)
0
Present study found no side effects of
combination of metoclopramide (10mg) and
glycopyrrolate (0.2mg) on parturient women
and neonates. The Apgar scores were acceptable
72
ISSN: 0976 3325
range of 8-10 at one and five minutes suggesting
safety of drugs. Similar drug safety of
Metoclopramide was observed by Lussos SA at
al3, Biswas et al12 and Ali Shahriari at al 13.
Similarly, Biswas et al12 and Ure D at al15 found
that Glycopyrrolate was safe to neonates and no
adverse effects found in patients.
Study
results
were
compared
with
Glycopyrrolate alone shows lower in incidence
of nausea and vomiting but statistically
insignificant at 95% significance level (Table 2).
Table 2: Comparison of antiemetic effect of metoclopramide plus glycopyrrolate to glycopyrrolate
alone during operative and post operative period of cesarean section under spinal anaesthesia in
American Society of Anesthesiology grade I & II full term parturient women
Observation
Nausea
Vomiting
Metoclopramide(10mg) +
Glycopyrrolate(0.2mg)
% (n=78)
3.84
0
Glycopyrrolate
(0.2mg)12
% (n=20)
10
5
Z value
(Class Interval)
at 95% CL
0.87 (-1.08, 2.83)
1.02 (-0.93, 2.98)
P value
(95% C.L.)
0.38
0.30
Table 3: Comparison of antiemetic effect of metoclopramide plus glycopyrrolate to metoclopramide
alone during operative and post operative period of cesarean section under spinal anaesthesia in
American Society of Anesthesiology grade I & II full term parturient women
Observation
Metoclopramide(10mg) +
Metoclopramide
Z value
P value
(10mg)
(Class Interval)
(95% C.L.)
% (n=78)
% (n=108)*
at 95% CL
Nausea
3.84
25.92
4.65 (2.67, 6.61)
<0.001
Vomiting
0
2.77
1.75 (-0.020, 3.70)
0.08
*combine data, incorporated from studies by Biswas et al12, Ali Shahriari 13 & Garcia-Migual FJ at al14
Study
results
were
compared
with
Metoclopramide alone shows lower in incidence
of nausea and vomiting but the incidence of
vomiting is statistically insignificant at 95%
confidence limits (Table 3).
Table 4: Comparison of antiemetic effect of metoclopramide plus glycopyrrolate to ondansetron
during operative and post operative period of cesarean section under spinal anaesthesia in American
Society of Anesthesiology grade I & II full term parturient women
Observation
Metoclopramide(10mg) + Ondansetron(4mg)
Z value
% (n=69)#
(Class Interval)
% (n=78)
at 95% CL
Nausea
3.84
8.69
1.20 (-0.75, 3.16)
Vomiting
0
1.44
1.00 (-0.95, 2.96)
# combined data, incorporated from studies by A K Pan at al8 & Garcia-Migual FJ at al14
Study results were compared with ondansetron
shows lower in incidence of nausea and
vomiting in current study group but statistically
insignificant at 95% confidence limits (Table 4).
Although, incidence of nausea was low and
statistically significant (p <0.001) when study
group compared to group with metoclopramide
alone drug (Table 3) have comparatively
moderate value as nausea is discomfort, not
complication. Again, nausea is a subjective
sensation
which
comparisons.
interfering
P value
(95% C.L.)
0.22
0.31
in
valid
CONCLUSION AND RECOMMENDATION:
Incidence of vomiting is low (zero case) in
current study group compared to groups with
either metoclopramide or glycopyrrolate or
ondansetron. However, observed differences are
statistically insignificant, the upper class interval
limit of Z value falling at significant level (>1.96)
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ISSN: 0976 3325
in all groups. It suggest, observed lower
incidence of nausea and vomiting in current
study group (glycopyrrolate + metoclopramide)
may be significant in future studies or if sample
size increased. So we recommended further
studies to prove or disprove our findings of
lower incidences of nausea and vomiting if
combine two drugs (glycopyrrolate plus
metoclopramide) as a prophylactic antiemetic in
elective cesarean section under spinal
anesthesia.
8.
9.
10.
11.
REFERENCES:
1.
2.
3.
4.
5.
6.
7.
Kestin IG. Spinal anaesthesia in obstetrics. Br J Anesth
1991;66:596-607.
Kovac AL. Prevention and treatment of postoperative
nausea and vomiting, Drugs 2000; 59: 213-43.
Lussos SA, Bader AM, Thornhill ML, Datta S. The
antiemetic efficacy and safety of prophylactic
metoclopramide for elective caesarean section delivery
during spinal anaesthesia. Reg Anesth 1992; 17: 126-30.
Pan PH, Moore CH. Intraoperative antiemetic efficacy
of prophylactic ondansetron versus droperidol for
cesarean section patients under epidural anesthesia.
Anesth Analg 1996;83:982-6
Kang YG, Abouelish E, Caritis S. Prophylactic
intravenous ephedrine infusion during spinal
anesthesia for cesarean section. Anesth Analg
1982;61:839-42.
Santos A, Datta S. Prophylactic use of droperidol for
control of nausea and vomiting during spinal
anaesthesia for caesarean delivery. Anesth Analg 1984;
63: 85-87.
Chestnut DH, Vandewalker GE, Qwen CI et al.
Administration of metoclopramide for prevention of
nausea and vomiting during epidural anaesthesia for
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elective caesarean delivery.Anesthesiology 1987; 66:
563-566.
A K Pan, A Rudra. Prophylactic single dose
intravenous administration of ondansetron in the
prevention of postoperative emetic symptoms during
spinal anaesthesia for caesarean delivery. Indian J.
Anaesth.2003;47(3):178-180.
Gan TJ. Postoperative nausea and vomiting-can it be
eliminated? JAMA 2002; 287: 1233-6.
Domino KB, Anderson EA, Polissar NL, Posner KL.
Comparative efficacy and safety of ondansetron,
droperidol, and metoclopramide for preventing
postoperative nausea and vomiting: a meta-analysis.
Anesth Analg 1999; 88: 1370-9.
Fujji Y, Tanaka H, Kobayashi N. Prevention of nausea
and vomiting after middle ear surgery: granisetron
versus ramosetron, Laryngoscope 1999; 109: 1988-90.
B N Biswas, A Rudra, S K Das, S Nath at al. A
Comparative Study of Glycopyrrolate, Dexamethasone
and Metoclopramide in Control of Post-Operative
Nausea and Vomiting after Spinal Anaesthesia for
Caesarean Delivery. Indian J. Anaesth. 2003; 47 (3) :
198-200.
Ali Shahriari, K Maryam, M H Heidari. Prevention of
nausea and vomiting in caesarean section under spinal
anaesthesia with midazolam or metoclopramide?
Journal of the Pakistan Medical Association
2009;43:756-759.
García-Miguel FJ, Montaño E, Martín-Vicente V,
Fuentes AL, Alsina FJ, San José JA: Prophylaxis Against
Intraoperative Nausea And Vomiting During Spinal
Anesthesia For Cesarean Section. A Comparative Study
Of Ondansetron Versus Metoclopramide. The Internet
Journal
of
Anesthesiology
2000;
Vol4N2:
http://www.ispub.com/journals/IJA/Vol4N2/nvpo.h
tm; Published April 1, 2000; Last Updated April 1,
2000.accessed on 1st March 2011.
Ure D, James KS, McNeill M, Booth JV. Glycopyrrolate
reduces nausea during spinal anaesthesia for caesarean
section without affecting neonatal outcome. Br J
Anaesth.1999;82(2):277-9.
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Original Article .
GENERAL ANAESTHESIA CONTROL MODE VERSUS LOCAL ANAESTHESIA WITH
INTRAVENOUS SEDATION FOR DAY CARE LAPAROSCOPIC TUBAL LIGATION
Dinesh Thakur1, Mihir Goswami2, Himanshu Shah3
1Assistant
Professor, Department of Anaesthesiology, 2Associate Professor, Department of
Community Medicine, 3Professor & Head, Department of Anaesthesiology, Kesar SAL Medical
College & Research Institute, Ahmedabad
Correspondence:
Dr Mihir Goswami,
1, Sunrise Bunglows, Behind Pratik Mall,
Near City Pulse Cinema, Kudasan, Gandhinagar
Email: [email protected], Mobile: 99243 01414
ABSTRACT
Comparative study has been undertaken to evaluate the anaesthetic techniques either by General
anaesthesia with control mode (GA) or Local anaesthesia with intravenous sedation (LA) in
laparoscopic tubal ligation in 60 female patients in the age group of 20 to 30 years. All were American
Society of Anaesthesiology grade 1 & divided equally into two Groups of 30 each. Group with GA has
longer induction to skin incision time (p< 0.001) and higher incidence of post operative nausea and
vomiting than Group with LA (p<0.001).
KEY WORDS: Anaesthesia, intravenous sedation, Laparoscopic tubal ligation
INTRODUCTION
At present, tubal ligation by laparoscopic
method is most common procedure and has
advantages in high success rate and early return
to normal activity, so appropriate anaesthetic
technique should be chosen. The General
Anaesthesia (GA) with control is associated with
side effects like nauseas and vomiting. Although
the quality provides by Local Anaesthesia (LA)
with sedation is unsatisfactory due to
discomfort and contraction abdominal muscles,
it offers the advantage of patient being awake,
oriented, breathe spontaneously and avoiding
the need of keeping patient in post anaesthesia
recovery room for more time.
The objective of study was to determine either
GA with control or LA with IV sedation
anaesthetic technique is better for laparoscopic
tubal ligation.
Sixty female patients of American Society of
Anaesthesiology grade I, aged between 20 and
30 years were randomly taken for laparoscopic
tubal ligation. They were further divided into
two groups of 30 each. The study was
undertaken between January 2009 and
December 2010 at Kesar SAL Medical College,
Ahmedabad, India. Anaesthetic technique was
GA with control mode in group I, and LA with
IV sedations was in group II. All patients were
fasting overnight and pre-medicated with
Fentanyl 1 µg/kg and Metoclopramide 10 mg,
30 minute before induction of Anaesthesia.
During operation, ECG special lead–II, oxygen
saturation, Non Invasive Blood Pressure
monitoring was observed. In group I, GA was
given with IV propofol-3mg/kg, Scoline
1mg/kg and intubated with appropriate size of
endotracheal cuff tube (Portex) and maintained
on Halothen (0.5% to 1%), oxygen and Nitrous
Oxide & put on control mode. In group II,
patients received IV Midazolam
0.07mg/kg,
Ketamine 0.5 mg/kg. The incision site was
infiltrated with LA 10 ml of 1.5% Lignocaine
with Adrenaline (1:20, 1000). Induction to
incision time, volume of CO2 insufflates, intra
abdominal pressure apart from vital signs were
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ISSN: 0976 3325
noted. The duration of surgery, recovery time,
intra-operative and postoperative complications
were also recorded. Appropriate statistical test
applied and “p” value <0.05 was considered as
significant.
OBSERVATIONS
The incidence of intra-operative bradycardia
was 16.7% in group I and 10% in Group II and
statistically insignificant. The changes in SpO2
during
procedure
and
recovery
were
comparable in both the groups. The incidence of
postoperative nausea and vomiting were more
in Group with GA than Group with LA (Table
2). Postoperative analgesia required in group
with GA only. The induction to skin incision
time was more in Group with GA than Group
with LA (Table3).
16
14
12
10
8
6
4
2
0
Volume of CO2
Group I GA with Control
Maximum Abdominal
Pressure
Group II LA with Sedation
Figure 1: Comparison of Volume of CO2 & Maximum Abdominal Pressure
Table 1: Comparison of Pulse Rate between Two Groups at Different Time Intervals Intra-operatively
Time Interval
Group with GA
Mean±SD
5 Minutes
85.63±9.63
15 Minutes
79.03±10.94
25 Minutes
80.05±14.70
35 Minutes
95.60±24.57
P Significant < 0.05
Table 2: Comparison of complications between
the two studied groups
Complication
Group I
GA with
Control
Nausea
6(20%)
Vomiting
10(33.3%)
Group II
LA with
Sedation
1(3.3%)
2(6.6%)
P value
0.001
0.001
DISCUSSION & CONCLUSION:
Tubal ligation can be performed under LA with
sedation1 and its effectiveness has been
debated.2 Though, GA has been recommended
for tubal ligation to reduce the complication3 but
Group with LA P Value
Mean±SD
96.43±9.61
0.001*
95.53±14.37
0.001*
92.57±12.90
0.015*
96.00±10.44
0.980
*Significant Value
it may not be safe technique due to its
complications.4, 5 High induction to skin incision
time in Group I with GA than Group II with LA
was attributed to time required for induction of
GA and insertion of endo-trachial cuff tube and
it was similar to Swann et al.6
The decrease in heart rate in Group I with GA
can be attributed to Propofol which blunts the
pressure response to surgical stimulus and
causes reduction in blood pressure without
compensatory increase in heart rate.7,8 The
higher incidence of postoperative nausea and
vomiting in GA is more in gynaecological
procedures as earlier studies. 9 Bordahl et al10
have reported a higher incidence of abdominal
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ISSN: 0976 3325
pain in GA than LA with I.V. sedation.
Comparative study undertaken suggests that
longer induction to skin incision time and
higher incidences of post operative nausea and
vomiting in group I with GA makes LA with I.V.
sedation is choice of anaesthesia technique for
laparoscopic tubal ligation.
Table 3: Comparison of induction time & duration of surgery in studied groups
Group
Group I
GA with Control±SD (Minute)
5.13±0.93)
21.53±5.56
Induction Time
Duration of Surgery
Induction time: from giving I.V. drug to skin incision
REFERENCES:
1. Cruiksahnk DP, Laube DW, DeBacker LJ. Intraperitoneal
ligation anaesthesia for postpartum tubal ligation. Obstet
Gynecol 1973; 42: 127-30
2. Practice Guidelines for obstetrical Anaesthesia: a report
by the American Society of Anaesthesiologist’s Task
Force on Obstetrical Anaesthesia. Anaesthesiology 1999;
90: 600-11
3. Peterson HB, Hulka JF, Spicelmen FJ et al. Local Vs
General Anaesthesia for laparoscopic sterilization: A
randomized study. Obstet Gynecol 1987; 70: 903-8
4. Case fatality: Peterson HB, destefano F, Greenspan JP,
Ory HW. Mortality risk associated with tubal
sterilization in United States hospitals Am J Obstet
Gynecol 1982; 143: 125-9
5. Perterson HB, DeStefano F, Gubin GL, et al, Deaths
attributable to tubal sterilization in the United States,
1977 to 1981. Am J Obstet Gynecol 1983; 146: 131-6
Group II
LA with Sedation±SD (Minute)
3.01± 1.86
21.56±6.63
P Value
0.001
0.983
6. Swan DG, Spens H, Edward SA, Chestnut RJ.
Anaesthesia for Gyhaecological laparoscopy – A
comparison between the LMA and Endotracheal tube.
Anaesthesia 1993; 48: 431-34
7. Short CE, Bufalari A. Propofol Anaesthesia. Vet Clin
North Am Small Anim Prct 1999; 29: 474-78
8. Reves JG, Glass PSA, Lubrasky DA, McEvoy MD,
Martinez-Ruiz R. Intravenous anaesthesia. In Miller RD,
editor. Miller’s Aneaesthesia. Philadelphia: Churchill
Livingstone 2010: 725
9. Chui PT, Gin T, Oh TE. Anaesthesia for Laproscopic
general surgery. Anaesth Intensive Care 1993; 21: 163171
10. Bordahl PE, Reader JC, Nordentoft J et al. Laproscopic
sterilization under local or general anaesthesia? A
randomized study. Obstet Gyne col 1993; 81: 137-141.
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Original Article .
EPIDEMIOLOGICAL CORRELATES OF CONTRACEPTIVE PREVALENCE IN MARRIED
WOMEN OF REPRODUCTIVE AGE GROUP IN RURAL AREA
Sujata K. Murarkar1, S. G. Soundale2
1Lecturer,
Pune, 2Ex. Head of the Department of PSM, S.R.T. R. Medical College,Ambajogai, Maharashtra
Correspondence:
Dr. Sujata K. Murarkar
B-5, Flat no. 11, Morya Residency, Phase III,
Pashan-sus road, Pashan, Pune-411021.
E-mail - [email protected] , Mobile – 09011090147
ABSTRACT
In spite of availability of a wide range of contraceptives and mass media campaigns population
control is a distant dream to achieve. It is pertinent to identify the factors responsible for poor
contraceptive acceptance. The study was conducted to find out contraceptive prevalence in married
women of reproductive age group and to study epidemiological correlates affecting contraceptive
practices. A cross-sectional population based study covered 512 married women in reproductive age
group in the village Chanai, Taluka- Ambajogai, Dist.-Breed. They were interviewed by predesigned
and pretested questionnaire. Out of 512 married women 48.63% were contraceptive acceptors.
Contraceptive acceptance was more in women who are graduate and above(82.76%), women from
nuclear family (58.79%), Upper middle socioeconomic class (79.62%).Contraceptive acceptance was
lowest in agricultural laborer(38.87%) .A significant association was found between contraceptive
acceptance and literacy status, occupation, type of family, socioeconomic status and age at marriage.
Keywords: Contraceptive acceptance, literacy status, type of family, age at marriage
INTRODUCTION
India was the first country in the world to
formulate the National Family Planning
Programme in the year 1952 with the objective
of ‘reducing the birth rate of the extent
necessary to stabilize the population at a level
consistent with requirement of national
economy’.1
India adds about 10 lakh persons to its
population every fortnight and adds about one
Australia every eight month. By 2045 or earlier,
India would overtake China as the world’s most
populous Nation.2
The extent of acceptance of contraceptive
methods still varies within societies and also
among different castes and religious groups.
The factors responsible for such varied picture
operate at the individual, family and community
level with their root in the socioeconomic and
cultural milieu of Indian society.1In spite of
availability of a wide range of contraceptives
and mass media campaigns and information,
education and communication programmes, the
population control remains a distant dream to
achieve. It is pertinent to identify the factors
responsible for poor acceptance of family
planning programme in different socio-cultural
and socioeconomic groups.3
Women need the ability to decide when to start
and finish childbearing, how long to wait after
the birth of one child before becoming pregnant
with the next and how many children to have.4
Considering the above facts, the present study
was conducted with the objectives to find out
contraceptive prevalence in married women of
reproductive age group and to study
epidemiological
correlates
affecting
contraceptive practices at Chanai, a field
practice area of S. R. T. R. Medical College,
Ambajogai.
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c)
A Cross sectional study was conducted in rural
area to find out the epidemiological correlates of
contraceptive prevalence in married women of
reproductive age group i.e. 15 to 49 years.
Study Period: The study was conducted from
September 2005 to August 2006.
Study area: Village chanai was selected by
random sampling method from the field
practice area of Department of Preventive and
Social Medicine, Swami Ramanand Teerth Rural
Medical College and Hospital, Ambajogai in
district Beed.
Study participants: All the married women in
the age group of 15-49 years at the time of
interview were included in the study. Pregnant,
widowed, divorced and non cooperative women
were excluded from the study.
Data collection and analysis:
All married women in the reproductive age
group were interviewed by house to house visits
with the help of predesigned and pretested
proforma.
Association
between
selected
epidemiological correlates was tested for
significance by using Chi-square test
Some definitions used in the present study:
1.
Literacy
status5:
a) Illiterate: A person who could not read
or write. This category also includes
those who could only sign or reproduce
same writing mechanically without
meaning.
b) Primary: Those who had studied up to
4th standard.
2.
Secondary: Those who had studied
from 5th to 10th standard.
d) Higher secondary: A person who had
obtained higher secondary school
certificate from any educational board.
e) Graduate: A person who had obtained
graduate degree from any university.
Occupation definitions:
a) Housewives: All elderly women who
were engaged in household duties s
were considered as housewives.
b) Agricultural laborer: A person involved
in the agriculture, working in her own
land or in somebody else’s land, for cash
kind or share of crop.
c) Business: Any well or semi established
organized business owned by an
individual irrespective of its size and
category, if it was meant for profit.
d) Employed: All salaried class persons
employed
in
Government,
semi
government or private organization
were considered as employed.
e) Others:
Persons
having
other
occupational activities not covered
under that mentioned above were
accounted under this column.
RESULTS AND DISCUSSION
Out of 512 married women, nearly half of
women were contraceptive acceptors i.e.
249(48.63%) and remaining half were non
acceptors of contraceptives i.e. 263(51.37%).
Maximum contraceptive acceptance (i.e. 65%)
was observed in 35-39 and 40-44 years of age
group followed by 30-34 and 25-29 years of age
group i.e. 60% and 48.58% respectively.
Table1: Distribution of married women in reproductive age group according to contraceptive use
Age group (in yrs.)
15 – 19
20 – 24
25 – 29
30 – 34
35 – 39
40 – 44
45 – 49
Total
Acceptors (%)
5 (23.80)
23 (24.41)
51 (48.58)
51 (60)
66 (65.34)
41 (65.08)
12 (27.90)
249 (48.63)
Out of 512 married women, 205(40.03%) were
illiterate and 307(59.97%) were literates. Among
illiterate women; contraceptive acceptors were
Non-acceptors (%)
16 (76.20)
71 (75.53)
54 (51.42)
34 (40)
35 (34.66)
22 (34.92)
31 (72.10)
263 (51.37)
Total (%)
21 (100)
94 (100)
105 (100)
85 (100)
101 (100)
63 (100)
43 (100)
512 (100)
less i.e.71 (34.63%) as compared to 134(65.37%)
non acceptors.
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In contrast, contraceptive acceptors were more
among literate women and the prevalence of
acceptors rises with level of educational status
i.e. from 48.83% at primary level of education to
82.76% at graduation and above level.
Highly significant difference was observed
between educational status and prevalence of
contraceptive acceptors (χ2 =21.15, df= 4, and
p<0.001).
Due to education women exposed to the outside
world, want to be gainfully employed and don’t
want to be tied down to household chores.
These might be some possible reasons for
significant difference and prompt them to look
for contraception. Similar high prevalence of
contraceptive acceptance was observed by K.C.
Bhuyan (1980)7, M. Bhattacharya et al (1984)8,
A.K. Sharma et al (1997)3 and A. Kansal et al
(2005)1.
Table 2: Distribution of contraceptive acceptors & non- acceptors as per various epidemiological
correlates
Epidemiological correlates
Acceptors
(%)
Non-acceptors
(%)
Total (%)
χ2
df
Literacy status
Illiterate
71(34.63)
134 (65.37)
205 (100)
21.15
4
Primary
21 (48.83)
22 (51.17)
43(100)
Secondary
109 (53.97)
93 (46.03)
202 (100)
Higher secondary
23 (69.70)
10 (30.30)
33 (100)
Graduate& above
24 (82.76)
5 (17.24)
29 (100)
Occupation
Housewife
157 (55.09)
128 (44.91)
285 (100)
14.04
2*
Agricultural laborer
82 (38.87)
129 (61.13)
211 (100)
Employed
6(75)
2(25)
8(100)
Business
4 (50)
4 (50)
8(100)
Type of family
Nuclear
174 (58.79)
122 (41.2)
296 (100)
31.73
2
Joint
54 (31.77)
116 (68.23)
170 (100)
Three generation
21(45.66)
25 (54.24)
46(100)
Socio-economic status6
Upper (≥ 2701)
17(56.67)
13(43.33)
30 (100)
25.28
4
Upper Middle (1350-2700)
43 (79.62)
11(20.38)
54(100)
Middle (810-1349)
20 (46.51)
23(53.49)
43(100)
Upper Lower (405-809)
57 (43.19)
75(56.81)
132 (100)
Lower (< 405)
112 (44.27)
141(55.73)
253(100)
Age at marriage (yrs.)
10 – 15
0(0.00)
46(100)
46(100)
25.90
1**
16 – 20
133(46.02)
156(53.98)
289(100)
21 – 25
109(65.67)
57(34.33)
166(100)
26 – 30
7 (63.63)
4(36.37)
11(100)
* Employed & business put together.
** Figures in the age group of 10-20 & 21-30 were pooled together for application of χ2 test.
Lowest prevalence of contraceptive acceptance
was observed among agricultural labourers
(38.87%) as compared to other occupations
including housewives.
between occupation of married women and
contraceptive acceptance (χ2=14.04, df=2,
p<0.001).
P-value
< 0.001
< 0.001
< 0.001
< 0.01
< 0.001
In support to present study findings, A. S.
Chandra Mouli, Sheila Mouli (1981)9 in their
study found, 26.90% of the respondents
accepting family planning were agricultural
labourers in a village of Bangalore.
Maximum contraceptive acceptance was seen in
women from nuclear family i.e. 174(58.79%) out
of 296. Out of 46 women from three generation
family and out of 170 women from joint family,
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i.e. 21(45.66%) and 54 (31.77%) respectively were
contraceptive acceptors.
Statistically significant association was revealed
between prevalence of contraceptive acceptance
and type of family (χ2=31.73, df=2, p<0.001).
The low acceptance among joint family may be
due to the fact that in a joint family couple is not
bothered about the economic burden of
supporting children because the head of the
family is supposed to care for all his dependents
and not just his own children. Secondly, the wife
in a joint family obtains a higher position in her
husband’s family only after the birth of child. So
in a joint family the women feels encouraged to
produce more children. Thirdly, some couples in
joint family may not have power to take
decision.
increased from 33% to 52% as the wives’ age at
marriage increased from less than 13 years to 18
years and above respectively. It seems that age
at marriage plays an important role in
acceptance of contraceptive method
CONCLUSIONS
1.
2.
3.
Contraceptive acceptance was highest from
upper middle class i.e.43 (79.62%) out of 54
women followed by upper class i.e. 17(56.67%)
out of 30 women and lowest in women from
upper lower class i.e.57 (43.19%) out of 132
women.
In present study contraceptive acceptance was
found 46.51% (i.e.20 out of 43) among women in
middle socioeconomic status. Similarly A.K.
Sharma et al (1997)3 revealed that 41.3% women
were belonged to middle income group in their
study on pattern of contraceptive use by
residents of village in south Delhi.
The present study found statistically significant
difference between socioeconomic status and
prevalence
of
contraceptive
acceptance
(χ2=25.28, df=4, p<0.01). Percentage of
acceptance of contraceptive methods increases
steadily with increasing age at marriage,
maximum being in the age group of 21–25 years
i.e. 109 (65.67%) out of 166, followed by 26-30
years i.e. 7 (63.63%)out of 11 and 133 (46.02%)
out of 289 women in 16-20 years of age group .
Statistically significant association was observed
between age at marriage and prevalence of
contraceptive acceptance (χ2=25.90, df=1,
p<0.001).
N. Audinarayana
influence of age
family planning
percentage of
(1986)10 in his study on the
at marriage on fertility and
behavior observed that the
family planning adopters
Contraceptive prevalence rate in the
present study was observed to be
48.63%.
The findings indicate that literacy status
of female exerted a strong influence on
contraceptive acceptance. It could be
accelerated by conducting and exposing
all segments of the population to
educational programmes on family
planning.
The findings support the contention that
there is still a need to intensify
information,
education
and
communication activities and motivate
the population to practice contraception
REFERENCES
1.
A.Kansal et al. Epidemiological correlates of
contraceptive prevalence in rural population of
Dehradun district”. Indian Journal of Community
Medicine. 2005; 30 (2): 60-62.
2.
J. Kishore: National Health Programmes of India: New
Delhi, Century publication (2005) 5th Edition.
3.
A. K. Sharma et al: “Pattern of contraceptive use by
residents of a village in south Delhi”. Indian Journal of
Public Health, 1997; 41(3).
4.
ICRW: “The Impact of Unmet Family Planning Needs
on Women’s Health”. Information Bulletin, December,
(2004).
5.
Kuppuswami B: Manual of socioeconomic scale (urban)
Manasayan, 32, NetajiSubhashMarg, Delhi, (1981).
6.
Prasad BG. Changes proposed in social classification of
Indian families. Journal of Indian Medical Association
1970; 55 (16): 198-199.
7.
K.C.Bhuyan. Some aspects of the family planning
programme in rural Bangladesh – A case study. The
Journal of Family Welfare 1980; 17(1):3-15.
8.
M. Bhattacharya et al. Socio economic correlates of
fertility and contraceptive practices amongst target
couples of a rural community. The Journal of Family
Welfare 1984; 28(3):139-146.
9.
A. S. Chandra Mouli, Sheila Mouli: “Adopters and non
adopters of family planning in an Indian village-A case
study”. The Journal of Family Welfare 1981; 27(3): 3038.
10. N. Audinarayana. The influence of age at marriage on
fertility and family planning behaviour; a cross cultural
study. The Journal of Family Welfare 1986; 33(1):56-62.
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Original Article .
SCREENING FOR PRE-MALIGNANT CONDITIONS IN THE ORAL CAVITY OF CHRONIC
TOBACCO CHEWERS
Priyanka Mahawar1, Shweta Anand2, Umesh Sinha3, Madhav Bansal3, Sanjay Dixit4
1Assistant
Professor, Department of Community Medicine, Sri Aurobindo Institute of Medical
Sciences, Indore (MP) 2Assistant Professor, Department of Pediatrics, Chirayu Medical College &
Hospitals, Bhopal (MP), 3Department of Community Medicine, Sri Aurobindo Institute of Medical
Sciences, Indore (MP) 4Professor and Head, Department of Community Medicine, M.G.M. Medical
College, Indore
Correspondence:
Dr. Priyanka Mahawar
Sri Aurobindo Institute of Medical Sciences, Indore.
ABSTRACT
Oral cancer is a major health problem in tobacco users all over the world. It is one of the ten most
common cancers in the world. Oral cancer is almost always preceded by some type of precancerous
lesion. The precancerous lesions can be detected upto 15years, prior to their change to an invasive
carcinoma. It usually affects between the ages of 15 and 40 years. It may be triggered by factors like
frequency and duration of tobacco consumption, alcohol, poor oral hygiene etc. This study was
conducted primarily to screen chronic tobacco chewers for the presence of oral pre-malignant
conditions and secondly to educate them about the hazards of tobacco and motivate them to quit the
habit. This was a cross sectional study conducted at Badi gawaltoli area of Indore. Tobacco chewers
using tobacco for more than 5yrs were included in the study. Chronic tobacco chewers were screened
for oral pre-malignant lesions followed by an educational intervention about the harmful effects of
tobacco. Two follow ups were made to motivate them to quit the habit and to get treatment for their
lesions. An open ended semi-structured questionnaire was administered to chronic tobacco chewers
to assess their habit of tobacco chewing, smoking, their knowledge regarding lesions in their mouth,
hazards of tobacco and any cessation efforts. Among the 80 identified chronic tobacco chewers, 60
were males and 20 were females. Lesions such as leukoplakia, erythroplakia and oral sub-mucosal
fibrosis were found in 10 females (50%) and 24 males (40%).
Key words: tobacco chewers, oral malignant condition, screening
INTRODUCTION
Oral cancer is the most common cancer in India
and according to Dr Geoff Craig “People are
dying of oral cancer because of ignorance”.
Oral cancer is almost always preceded by some
type of precancerous lesion.The precancerous
lesions can be detected for upto 15years, prior to
their change to an invasive carcinoma. It usually
affects between the ages of 15 and 40 years. It
may be triggered by factors like frequency and
duration of tobacco consumption, smoking etc.
The term leukoplakia is defined by the WHO as
an “a white patch or plaque that cannot be
scraped off and cannot be characterized
clinically or pathologically as any other
disease”.1 Approximately 3% of the world’s
population have leukoplakic lesions, and
somewhere between 5% and 25% of these
lesions are pre-malignant. Buccal mucosa and
oral commisures are the most common sites.
It has two clinical types:Homogenous - presents with a smooth or
wrinkled white patches. It is less often
associated with malignancy.
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Nodular - presents as white patches or nodule
on erythematous base. It has higher incidence of
malignant transformation.2
Use of tobacco is associated with more mortality
and morbidity than any other personal,
environmental or occupational exposure.
Smokeless tobacco has 100 times higher
concentration of carcinogens than cigarettes.
Each year about 5,75,000 new cases and
50,20,000 deaths occur worldwide.1.8 Billion
cases present worldwide.One out of every five
death is due to tobacco.3
Oral cancer is a major problem in India also. Dr
Surendra Shastri head of preventive oncology at
Tata Memorial Hospital gave us a stunning
information that "There are about 7,00,000 new
cases of cancers ever year in India out of which
tobacco related cancers are about 3,00,000,
cancer of uteri are 1,00,000 and 80,000 breast
cancer. Cost of treatment of oral cancer is about
3.5 lakh. Every 2 seconds a child in Mumbai
tries tobacco. This can be completely prevented
by simple changes in lifestyle and regular
screening and even have health benefits that
reach beyond cancer. About 2000 deaths a day
in India is tobacco related."
Total economic cost of treating tobacco related
diseases is more than the revenue generated
from the tobacco.
Common form of tobacco consumption in India:
−
−
Gutka is a mixture of betel nut and chewing
tobacco. It is extremely addictive and is
apparently targeted at youngsters.
Quid is the mixture of tobacco and lime and
extensively consumed in India.
Be it in the form of Gutka, Quid, snuff or misri
and so on, the tobacco when kept in mouth
leaches out carcinogens, which act on the
mucosa causing precancerous lesions, which
lead to cancer.
METHODOLOGY
The present study was conducted in Indore
(Madhya Pradesh) with the objectives to screen
chronic tobacco chewers for the presence of oral
pre-malignant conditions and to educate them
about the hazards of tobacco and motivate them
to quit the habit. Badi gwaltoli slum was chosen
by lottery random sampling .Cases were
defined as those chewing tobacco for past 5
continuous years. 80 chronic tobacco chewers
were identified. An open ended semi-structured
questionnaire was administered to chronic
tobacco chewers to assess their habit of tobacco
chewing, smoking, their knowledge regarding
lesions in their mouth, hazards of tobacco and
any cessation efforts.
Oral inspection and examination of oral cavity
for pre-malignant lesions such as leukoplakia,
erythroplakia and oral sub-mucosal fibrosis was
done under aseptic conditions using gloves and
disposable tongue depressor.
Individuals were simultaneously educated
about the hazards of tobacco consumption with
the help of posters and photographs and were
motivated to give up the habit. The education
included
the
association
of
tobacco
consumption with different types of cancer,
control measures and healthy lifestyle.
Individuals were referred to cessation clinics to
help them give up the habit. Individuals who
were found to have any of the pre-malignant
lesions in the oral cavity were referred to
Maharaja yashwant rao hospital for further
diagnosis and management of the lesions.
Two follow up visits were done at an interval of
10 days, to enquire about the efforts made for
cessation of the habit and to see the compliance
to the referral. Individuals who did not go for
checkup to hospital were motivated again and
asked for the reasons of non compliance.
RESULTS
The total number of cases identified in the study
was 80 and 75% of it were males. 53% of the
male tobacco chewers in study area were found
to start the habit of tobacco chewing around the
age of 10-17 yrs. Surprisingly, 9% of male child
initiated this habit before even attaining age of
ten years. However 13 out of 20 females i.e. 65%
initiated tobacco chewing in the age group of
10-17yrs. Stress either due to economical or
family problems and influence of friends and
family members were most important initiating
factor in both the sexes.
Betel nut with tobacco was found to be most
commonly used in the study population. Betel
nut contains an alkaloid known as Arecoline
which is carcinogenic. Consequently, the
proportion of individuals with lesions in this
category (using beetle nut with tobacco) was
highest. In our study the presence of lesions was
found to be less if tobacco is chewed alone. On
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examination the presence of pre-malignant
lesions was six times more common in those
individuals who were chewing tobacco for more
than ten years
in between teeth and lips. Table 1 shows that the
chances of oral lesions was found to be more
with >5 times/day use of tobacco (p value
0.0003, df 5)
Table 1: Distribution of cases according to
frequency of consumption of tobacco
History of smoking and alcoholism was not
found to be significantly associated with the
presence of pre-malignant lesions. In the study
population, 87% of males and 85% of females
were found to have cessation trials before
screening and educational intervention .65% of
females and 46% of males were found to have
tried for cessation at least one time before the
screening and educational intervention. 88% of
study population who tried fo cessation suffer
from various withdrawal symptoms like
irritability, headache, constipation, confusion
and tremors during cessation trials. Inspite of
fore-knowledge about the health hazards of
tobacco consumption in 85% of females and 95%
of males ( Fig 1); they were still chewing
tobacco. After the screening and educational
intervention, it was found that there was a
slight increase in the number of people going to
hospitals for treatment of lesions and cessation
clinics for quitting the habit.
Frequency of
Consumption
Lesions
Absent
Total
13
Lesions
Present
(%)
1 (7%)
Less than 5
times
5-10 times
10-15 times
15-20 times
20-25 times
More than 25
times
Total
12
14
3
2
2
11 (47%)
3 (18%)
12 (80%)
5 (71%)
2 (50%)
23
17
15
7
4
46
34(42%)
80
14
Lesions were found mainly in those who keep
the quid in their mouth for too much time.
Significant association was found between the
place where quid is kept and lesion appearance.
Lesions were more in persons who keep quid in
buccal cavity as compared to those who keep it
Female
Male
No
15%
Yes
85%
No
5%
Yes
95%
Fig 1: Awareness about the hazards of tobacco
DISCUSSION
The present study shows that in Badi gawaltoli
community, the oral pre-malignant lesions is
almost present in one out of every three persons
who are using tobacco for more than five years.
This was screening program based on clinical
examination carried out by pre-final students
(and not by experienced surgeons). Therefore,
false positive and false negative cases are likely
to occur and this fact needs to be taken into
account while drawing any conclusions.
Many studies have reported the relationship
between frequency of tobacco consumption and
presence of oral pre-malignant lesions, duration
of tobacco consumption and development of
lesions, effect of betel nut on the development of
submucosal fibrosis in tobacco chewers. The
findings of this study corroborate with findings
of these studies. The lesions were more common
in those with a history of more frequent and
longer duration of tobacco use and use of beetle
nut along with tobacco.
40% of the males and 50% of the females
chewing tobacco are having pre-malignant
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ISSN: 0976 3325
lesions and it is comparable with studies
conducted at Naiga on community (Mumbai)4
where 45.6% males and 57.98% females found to
be having oral pre-malignant lesions.
Among the factors studied, habit of smoking
and alcohol consumption are not so important
influencing factors in the development of
lesions, which is not similar to the observation
of P.C.Gupta.et.al (Gandhinagar).5
The lesions were found to be more common in
those chewing betel nut along with tobacco
(57%). The use of betel nut increases the friction
over oral mucosa resulting in mechanical
trauma to oral cavity. The betel nut also releases
Arecoline which is carcinogenic. A similar
finding was observed in the study conducted by
Dr.Daftary.et.al (Tata research foundation,
Mumbai) 6 in which 45% of those who were
chewing tobacco along with beetle nut were
found to have lesions.
The individuals with lesions were referred to
the MY hospital for further diagnosis and
management. But only few went to the hospital.
The reasons for not being able to visit the
hospital were lack of time, not considering the
problem as serious, loss of wages etc. The
present study also highlights initiation of
tobacco use in childhood which increases the
duration of exposure to carcinogenic substances
in tobacco and therefore increases the risk of
development cancer in early productive part of
life. It is very important to have effective
preventive strategies to halt this problem. We
can prevent this problem either by strong
campaign or health education about the hazards
of tobacco use or any oral lesions and also by
including them in educational curriculum for
school going children and by implementing a
task force comprising of dentists, counselors
and psychiatrist.
REFRENCES
1. KB Bhargava, SK Bhargava and TM Shah. Textbook of
Ear Nose and Throat diseases 7th Edition; pp 230-231.
2. www.mayoclinic.com (accessed on Feb. 2011)
3. David M Burns. Nicotine addiction 17thedition; p 45-46.
4. KS Talole, SS Bansode, MB Patki. Prevalence of Oral
Precancerous Lesions in Tobacco of Naigaon, Mumbai.
Indian Journal of Community Medicine. 2006; 31 (4): 10-2.
5. Datta K, Saha R K, Chakrabarti R N,P.C.gupta. A simple
risk estimates study for oral cavity cancer: practical
approach in Indian context. Journal of Indian Medical
Association. 1997; 95(3): 70-1.
6. DK Daftary, RB Bhonsle, RB Murti. An oral lesion in
tobacco-lime users in Maharashtra, India. Journal of Oral
Pathology & Medicine. 1979; 8 (1): 47–52.
85
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Original Article .
ADOLESCENCE AWARENESS: A BETTER TOOL TO COMBAT HIV/AIDS
Anurag Srivastava1, Syed Esam Mahmood2, Payal Mishra3, V P Shrotriya4, Iram Shaifali5
1Associate
Professor, Department of Community Medicine, Shri Ram Murti Smarak Institute of
Medical Sciences, Bareilly (U.P.) 2Assistant Professor, Department of community medicine,
Rohilkhand Medical College and Hospital, Bareilly (U.P.) 3Assistant Professor/Statistician 4Professor,
Department of Community Medicine, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly
(U.P.) 5Resident, Department of Pharmacology, Rohilkhand Medical College and Hospital, Bareilly
(U.P.)
Correspondence:
Dr. Anurag Srivastava,
Associate Professor, Department of Community Medicine,
Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly (U.P.)
ABSTRACT
Adolescents are exposed to the risk of being victims of HIV/AIDS, mostly because of a low level of
awareness of HIV/AIDS and inadequate access to HIV prevention and treatment services. School
education has been described as a ‘social vaccine’, and it can serve as a powerful preventive tool. The
objective is to assess awareness of HIV/AIDS amongst adolescents of District Bareilly. The crosssectional study involved 341 students, aged 11-19 years. A study instrument was used to assess study
subjects’ level of awareness regarding modes of transmission, preventive and curative measures of
HIV/AIDS and the attitude towards PLWHA. Chi- square test was used to analyze data. The
awareness regarding modes of transmission, methods of prevention and treatment was found to be
significantly higher among boys as compared to girls (P <.001). There is a low level of awareness of
HIV/AIDS amongst adolescents of District Bareilly. The challenge lies in developing programmes to
spread awareness and to induce behavioral changes among them.
Key words: Awareness, HIV/AIDS, adolescents
INTRODUCTION
The Acquired Immune Deficiency Syndrome
(AIDS) caused by Human Immuno-deficiency
Virus (HIV) remains the most serious of
infectious disease challenges to public health.
The United Nations adopted to halt and reverse
the spread of HIV/AIDS as one of its
Millennium Development Goals. The estimated
number of persons living with HIV and deaths
due to AIDS worldwide in 2007 was 33.2 million
and 2.1 million respectively. Nearly ninety five
percent of the global total, live in the developing
world. Approximately 3.7 million people in
India were living with HIV in 2006. India’s
epidemic continues to affect large numbers of
people, mostly because of a low level of
awareness of HIV/AIDS and inadequate access
to HIV prevention and treatment services. (1)
HIV/AIDS is mainly affecting the young adults
in the age group of 15–24 years thus retarding
the economic growth of the country.
Adolescents aged 10-19 years of age accounting
for nearly 23% of the population of India are
exposed to the risk of being victims of
HIV/AIDS. (2)
This is the time when they get interested in
sexual relationships. Immature reproductive
tracts make them more susceptible to
HIV/AIDS. Discussing sex has also been a taboo
among them. With the influence of media and
the breakdown of traditional family structures,
and in the absence of organized institutions for
imparting sex education, they tend to learn
about sexual and reproductive health from
unreliable sources resulting in perpetuation of
myths regarding safe sex and reproductive
health.
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Studies conducted in urban and rural parts of
India have shown low levels of awareness
among school going adolescents. (3, 4) Majority
of them study in the secondary school level. (5)
The challenge lies in developing programmes to
spread awareness and to induce behavioral
changes among them. The School Adolescent
Education Programme has been focused to
create awareness of HIV/AIDS and to inform
adolescents, about the dangerous consequences
of unsafe sex and encouraging them to use
condoms.
Researches carried worldwide have shown that
participating in schooling is a critical factor in
protecting young people, and especially girls,
from HIV infection. (1) Thus, school education
has been described as a ‘social vaccine’, and it
can serve as a powerful preventive tool. There is
further evidence that HIV and AIDS education
does not result in an earlier age of sexual debut,
and in fact it may delay the initiation of sexual
activity and encouraging protective behavior
upon sexual initiation. (2)
Offering HIV/AIDS awareness education and
training to these school going students as well to
their parents and teachers is a major challenge.
As children are valuable resources for the future
of a country, they should be equipped with
ample amount of information so as to take
decisions about sexuality and protect themselves
and their counterparts from the disease. Hence
the present study was undertaken to assess the
level of awareness regarding preventive and
curative measures of HIV/AIDS among
secondary school students of Bhojipura Block,
district Bareilly .
The cross sectional study was carried out among
secondary school students of Bhojipura Block of
Bareilly district, Uttar Pradesh over a period of
three months ( December 2010 to February
2011). Adolescents of age 11-19 years in the
selected schools were surveyed and comprised
the study unit in the present study.
A total of 341 students of 9th, 10th, 11th and 12th
standard participated in the study. The response
rate of students was 100 percent. A structured
pretested and predesigned questionnaire
consisting of close ended questions was used to
assess study subjects’ level of awareness
regarding modes of transmission, preventive
and curative measures of HIV/AIDS and the
attitude towards PLWHA. Written consent was
obtained from the principals of the respective
schools after explaining to them the purpose of
the study.
Table 1: Age and gender wise distribution of
study subjects
Age (years)
<15
15-18
>18
Total
Male
No. (%)
27 (7.9)
196 (57.5)
9 (2.6)
232 (68.0)
Female
No. (%)
11 (3.2)
96 (28.2)
2 (0.6)
109 (32.0)
Total
No. (%)
38 (11.1)
292 (85.6)
11 (3.2)
341 (100)
significance like Pearson’s Chi- square test were
applied to find out the results. P values <0.05
were considered significant for outcome
variables.
Table 2: Distribution of respondents according to source of information regarding HIV/AIDS
Source of
Information
Television
Radio
Newspaper
Road side play
NGO
Friend
Male
(n=232)
No. (%)
134 (39.3)
109 (32.0)
75 (22.0)
49 (14.4)
39 (11.4)
85 (24.9)
RESULT
Out of 341 respondents studied, 232 (68.0%)
respondents were males and 109 (32.0%) were
Female
(n=109)
No. (%)
69 (20.2)
51 (15.0)
30 (8.8)
3 (0.9)
12 (3.5)
23 (6.7)
Total
(n=341)
No. (%)
203 (59.5)
160 (46.9)
105 (30.8)
52 (15.2)
51 (15.0)
108 (31.7)
females. Overall, 38 (11.1%) respondents were
less than 15 years, 292 (85.6%) respondents were
between 15-18 years and 11 (3.2%) respondents
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were above 18 years of age. The mean age was
15.9 ± 1.5 years (Table 1).
All the students had heard about HIV/AIDS.
Two hundred and three (59.5%) students had
heard about HIV/AIDS from television while
160 (46.9%) mentioned radio as main source of
information to them (Table 2).
The awareness regarding modes of transmission
(unprotected sexual intercourse, infected blood
transfusion, sharing of needles and syringes and
vertical transmission of HIV from infected
mother to baby) was found to be significantly
higher (P <0.05) among boys as compared to
girls. Only 26.1% of the students could name
homosexual intercourse as a mode of
transmission (Table 3).
Table 3: Distribution of respondents according to awareness regarding modes of transmission of
HIV/AIDS
Modes of Transmission
Unprotected sexual intercourse
Homosexual intercourse
Infected Blood transfusion
Sharing needles/syringes/blades
HIV infected Mother to baby
No. of aware students (%)
Male (n=232) Female
(n=109)
190 (55.9)
70 (20.5)
71 (20.8)
18 (5.3)
179 (52.5)
68 (19.9)
194 (56.9)
68 (19.9)
134 (39.3)
51 (15.0)
Total
(n=341)
261 (76.5)
89 (26.1)
247 (72.4)
262 (76.8)
185 (54.3)
Chi-Square
(df)
P-value
12.79 (1)
7.633 (1)
8.102 (1)
18.787 (1)
3.595 (1)
<0.05
<0.05
<0.05
<0.05
>0.05
Nearly one-fifth of the students had a false notion that mosquito bite could transmit the disease
(Table 4).
Table 4: Distribution of respondents according to myths regarding HIV/AIDS
Myths
Mosquito bite can spread HIV/AIDS
HIV/AIDS can spread through kissing
HIV/AIDS can spread through
touching an infected person
HIV/AIDS can spread through sweat
working together
Sharing same clothes can spread
HIV/AIDS
Eating together can spread HIV/AIDS
Living together can spread HIV/AIDS
common / public toilet
No. of students with ‘Yes’
Responses (%)
Male
Female
Total
(n=232)
(n=109)
(n=341)
51 (15.0)
19 (5.6)
70 (20.5)
48 (14.1)
11 (3.2)
59 (17.3)
36 (10.6)
11 (3.2)
47 (13.8)
Chi-Square
(df)
Pvalue
0.942 (1)
5.82 (1)
11.226 (1)
>0.05
<0.05
<0.05
51 (15.0)
20 (5.9)
16 (4.7)
13 (3.8)
67 (19.6)
33 (9.7)
2.506 (1)
0.927 (1)
>0.05
>0.05
33 (9.4)
15 (4.4)
47 (13.8)
0.013 (1)
>0.05
42 (12.3)
39 (11.4)
29 (8.5)
20 (5.9)
13 (3.8)
10 (2.9)
62 (18.2)
52 (15.2)
39 (11.4)
5.669 1)
11.177 (1)
0.81 (1)
<0.05
<0.05
>0.05
The awareness regarding methods of prevention
of HIV/AIDS was also significantly higher (P
<.001) among boys as compared to girls. Only
19.1% girls and 59.5% boys had knowledge
about condoms as means of protection while
12.0% girls and 47.5% boys stated that
HIV/AIDS can be prevented by having a single
sexual partner (Table 5).
Only 39.6% students knew the difference
between HIV and AIDS. Nearly half of the
students thought that HIV/AIDS can be cured.
Less than half of the students thought that
PLWHA should be socially supported,
sympathized and cared (Table 6).
Table 5: Distribution of respondents according to awareness regarding methods of prevention of
HIV/AIDS
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Methods of Prevention
Using condom during each
intercourse
Not having sex with prostitute
Having a single sexual partner
Abstaining from homosexual
intercourse
Screening of blood prior to transfusion
Using sterilized/disposable syringes
Screening of pregnant mother for HIV
No. of aware students (%)
Male
Female
Total
(n=232)
(n=109)
(n=341)
203 (59.5) 65 (19.1) 268 (78.6)
Chi-Square
(df)
P-value
34.229 (1)
<0.001
116 (34.0)
162 (47.5)
76 (22.4)
27 (7.9)
41 (12.0)
12 (3.5)
143 (41.9)
203 (59.5)
88 (25.9)
19.386 (1)
31.941 (1)
18.322 (1)
<0.001
<0.001
<0.001
178 (52.2)
179 (52.5)
105
(30.8)
69 (20.2)
56 (16.4)
37 (10.9)
247 (72.4)
235 (68.9)
142 (41.6)
6.690 (1)
23.005 (1)
3.906 (1)
>0.001
<0.001
>0.001
Table 6: Attitude of respondents towards people with HIV/AIDS
Responses (Yes)
Male (%)
(n=232)
Total (%)
(n=341)
104 (30.5)
Female
(%)
(n=109)
31 (9.1)
135 (39.6)
ChiSquare
(df),
15.834 (1)
Awareness regarding the difference
between HIV +ive and AIDS?
Awareness regarding the symptoms of
AIDS?
Knowledge about HIV/AIDS being cured
PLWHA should be kept separate, isolated
from others
PLWHA should be socially supported,
sympathized and cared
105 (30.8)
<0.001
28 (8.2)
133 (39.0)
13.049(1)
0.001
106 (31.1)
84 (24.7)
69 (20.2)
48 (14.1)
175 (51.3)
132 (38.8)
12.359 (1)
9.130 (1)
>0.001
>0.001
113 (33.2)
47 (13.8)
160 (47.1)
2.602 (1)
>0.001
DISCUSSION
In the present study all the students had heard
about HIV/AIDS which is similar to the
observations of a study carried out by Goyal R C
et al where study group was rural population. (3)
However this was much higher than finding of
Ghosh Satyajeet et al (4). This may be because of
intensified IEC campaign in last 8-10 years In
our study a higher proportion of students
mentioned television (59.5%) and radio (46.9%)
as main sources of information to them. These
observations
show
the
strength
and
effectiveness of media as source of information
and very poor effort by health personnel which
requires being strongly motivated. Similar
findings were observed by R Amalraj Edwin (5)
and Poddar A K et al (6). This is comparable to
the Delhi study where majority of the students
had heard about HIV/AIDS from television and
radio. (7)
The awareness regarding modes of transmission
and methods of prevention of HIV/AIDS was
found to be significantly higher among boys as
compared to girls. Thus adolescent girls lacked
awareness regarding HIV/AIDS. This is
compatible to the findings reported in the
Pvalue
studies conducted among secondary school
students of Kolkata (8) and Maharashtra (9)
respectively. Sunder N et al (10) conducted a
survey in 7 urban colleges and found that 59%
females indicating that HIV transmission could
be prevented by using condom. This difference
is probably because our study has been
conducted in rural areas in Bareilly and Sunder
N conducted this study in urban colleges. About
prevention through condom our finding are
supported by Francis P T et al(11) who observed
that 79% students thought that use of condom
decrease the risk of getting AIDS .
Our study revealed that 20.5% of the students
believed that mosquito bite could transmit the
disease while 18.2% students thought that it
could spread by sharing meals. Similar findings
have been reported in the study conducted
among school adolescents of Gujarat. (12) Studies
of Sunder N et al (10) and Francis P T (11) also
strengthen these facts.
In the current study 59.5% students stated that
HIV/AIDS can be prevented by having a single
sexual partner. This is similar to the
observations reported among school adolescents
of Gujarat. (12)
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Only 39.6% students in our study knew that HIV
and AIDS are not synonymous. This is in
conformity to findings (35%) reported in a study
among school adolescents of Gujarat. (12) Nearly
half of the students thought that HIV/AIDS can
be cured. A study carried among adolescent
girls of rural areas of Jammu also found similar
observations. (13) Less than half of the students
thought that PLWHA should be socially
supported, sympathized and cared. Favorable
attitudes towards PLWHA were also found
among senior secondary school children of
Delhi. (7)
REFERENCES
1.
2.
3.
4.
Impact of social exposure is clearly visible in all
areas of awareness among males in comparison
to females.IEC programs should be undertaken
with regard to HIV/AIDS, safe sex and
avoidance of high risk behavior in schools to
increase the awareness of adolescents especially
for females as they are less aware as well as
more vulnerable. Significant improvement
between pre-test and post-test knowledge levels
after health education regarding HIV/AIDS has
been reported. (14, 15)
5.
RECOMMENDATIONS
9.
After this study following recommendations are
relevant for the improvement of HIV/AIDS
related awareness in adolescent population:
1.
2.
3.
4.
The reproductive health education should
be part of curriculum in all schools. These
should be classroom based education
programme on AIDS/ HIV, beginning from
secondary classes onwards and a class
teacher should be properly trained for
educating the students effectively.
Seminars, talks and debates to be organized
in different cross sections during school age.
Exhibition of cartoons, photos and painting
competition on AIDS related theme.
To promote students for active participation
in AIDS awareness campaigns as Red
Ribbon Express and World AIDS Day
programmes.
6.
7.
8.
10.
11.
12.
13.
14.
15.
UNAIDS. Report on the global AIDS epidemic.
UNAID: Geneva; 2007.
UNAIDS (1997) Impact of HIV and Sexual Health
Education on the Sexual Behaviour of Young People: A
Review Update. UNAIDS, Geneva.
Goyal R C: Community based study on demographic:
Health and psychological profile and needs of the
people living with HIV/ AIDS in rural ares of Ahmad
Nagar district in Maharastra. Indian Journal Of Medical
Reserch, 2003, 22(1) 49-53.
Ghosh Satyajit, Chowhhury S, Gill J S: Knowledge of
HIV/ AIDS/ STDs and high risk sexual practices in
two slumsof south Delhi. HIV/AIDS research in India,
123-125, 1997.
R Amalraj Edwin, Chandrasekharan Nirimala Solomon
Sunithi, Ganapathy, P Sambandam Raja: First year
medical student’s AIDS knowledge and attitude. IJCM,
1995 20(4) 52-53.
Poddar A K Poddar Saha D, Mandal R N: Perception
about AIDS among residents of Calcutta slum IJPH
1996, 40(1) 15-17.
Lal P, Nath A, Badhan S, Ingle GK. A study of
awareness about HIV/AIDS among senior secondary
school children of Delhi. Indian Journal of Community
Medicine 2008; 33 (3):190-192.
Chakrovarty A, Nandy S, Roy R, Sengupta B, Chatterjee
S, and Chaudhari RN. A study of awareness on
HIV/AIDS among higher secondary school students in
central Kolkata. Indian Journal of Community Medicine
2007; 32(3):228-229.
Khadilkar HA, Warkari PD, Yadav VB, Soundale SG.
Impact of health education on knowledge about
HIV/AIDS among students of social sciences. Indian
Journal of Community Medicine 2005; 30 (4):150.
Lal Sunder, Malik J S, Vashisht Singh B M, Punia M S
Jam R B: General population survey in rural area to
generate prevention indicators for HIV/AIDS control.
Indian J of Community Medicine 1998:23(2) 50-55.
Francis P T, Gill J S, Chowdhury: Knowledge, beliefs
and attitudes regarding AIDS/STDS and human
sexuality among senior secondary students on Delhi.
HIV AIDS research in India 1992, 162-165.
Singh A and Jain S. Awareness of HIV/AIDS among
school adolescents in Banaskantha district of Gujarat.
Health and Population: Perspectives and Issues 2009; 32
(2):59-65,
Mahajan P and Sharma N. Awareness Level of
Adolescent
Girls
Regarding
HIV/AIDS
(A
Comparative Study of Rural and Urban Areas of
Jammu) J. Hum. Ecol. 2005, 17(4):313-314.
MHRD (2004) Selected Educational Statistics 2003-04.
Ministry of Human Resource Development, Govt. of
India.
M Baldo. AIDS and school children. Indian Journal of
Medical Sciences1999; 53(12): 556-559.
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Original Article .
EPIDEMIOLOGICAL PROFILE OF ENTERIC FEVER CASES ADMITTED IN SCSMGH,
SOLAPUR
Malangori A.Parande1, C. G. Patil2, Madhavi V Rayate3, Mehboob U Lukde4
1Assistant
Professor, Department of P.S.M., B.J.M.C., Pune 2Professor, Department of Community
Medicine, K.I.M.S., Karad 3Professor, Department of Community Medicine, K. V. Institute of Medical
Sciences, Maduranthagam, Tamilnadu 4Medical Officers, PHC-Kashti, Tal-Shrigondha, DistAhmadnagar.
Correspondence:
Dr. Parande Malangori Abdulgani,
462/ C-2, Greenland Complex, Salisbury Park, Gultekdi,
Pune-411037, State: Maharashtra
Mobile: 09850131337, 09881947880
ABSTRACT
Enteric fever, though occurs in all parts of the world, is a serious public - health problem in
developing countries. It is one of the important cause of morbidity in India due to high rates of
complications and hospitalization. This disease mainly affects the older children and young adults. So
it’s important to know the socio-demographic and other epidemiologic factors of the disease. The
study was conducted with objectives to study socio-demographic and some of the epidemiologic
features of enteric fever cases and also to study duration of hospital stay, outcome and mortality
among enteric fever cases. A hospital based cross-sectional descriptive study was conducted in
Solapur City from January 2002 to December 2002. All proved cases of enteric fever admitted in
medicine and pediatric ward of SCSMGH, Solapur were the study subjects. There were total 172
cases of enteric fever admitted during this period. Out of 172 enteric fever cases, majority (40.70%)
were in the age group between 11-20 years. Males outnumbered the females giving M:F ratio of 1.6:1.
A significant association was found between literacy status, socioeconomic status, levels of personal
hygiene and occurrence of enteric fever. The overall duration of hospital stay ranged from 2 to 35
days with mean 7.91 days and S.D. 5.45 days. Fatality rate observed in this study was 1.74%. Thus
present study found majority of patients in 11-20 years (school children and adolescents) age group.
There was significant association of literacy status, socioeconomic status and personal hygiene with
development of enteric fever.
Key words: -Enteric fever, Personal hygiene, Duration of hospital stay, Outcome
INTRODUCTION
Enteric fever though occurs in all parts of the
world, is a serious public - health problem in
developing countries. The disease has been
virtually eliminated from the industrialized
world because of the provisioning of clean water
and good sewage systems. But the under developed and the developing countries
continues to face the brunt. According to an
estimate of US Centers for Disease Control and
Prevention, there are 21.6 million typhoid cases
annually, with the annual incidence varying
from 100 to 1000 cases per 100,000 populations.
The incidence is highest in the age group of 5 19 years but population based studies from
South Asia suggest that the incidence is highest
in children aged less than 5 years, with higher
rates of complications and hospitalization.
Enteric fevers are not notifiable diseases
throughout India and hence the correct
incidence is not known. Limited studies in the
country reveal more than three lac cases and
more than 650 deaths (approx.) annually in our
country1. 1% of children between 0-17 yrs suffer
per year. In year 2005 there were 6, 53,580
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deaths2.
enteric fever cases & 417
Resistant to
antibiotics is one of the serious obstacles in
control of enteric fever. Its danger doesn’t end
when symptoms disappear as patient may turn
into carrier state which may be a chronic one in
which condition the person is excreting the
bacilli for several years3.
OBJECTIVES
i) To study sociodemographic and some of the
epidemiologic features of enteric fever cases
ii) To study duration of hospital stay, outcome
and mortality among enteric fever cases.
A hospital based cross-sectional descriptive
study was conducted in Solapur City to study
epidemiological features of enteric fever cases,
from January 2002 to December 2002 after
obtaining ethical Committee clearance.
Selection of cases: All proved cases of enteric
fever admitted in medicine and pediatric ward
of SCSMGH, Solapur were the study subjects.
The cases of enteric fever treated on OPD basis
were not included in this study. There were total
172 cases of enteric fever admitted during this
period. The information was collected in a
predesigned and pretested proforma which
included sociodemographic data, duration of
stay, family background, outcome etc. The
interviews of 1
the patients and their relatives (in case of
children below 12 years) taken at the time of
hospital visit and at time of discharge after
taking their informed consent.
Some definitions used in the study
1) Criteria for labeling the case as an enteric
fever
i) Suggestive clinical picture &
ii) Blood culture positive for Salmonella typhi
and/ or Salmonella paratyphi organisms. &/or
iii) Widal test +ve as per following criteria3, 4
a) Titre of TO 1: 100 or more and/or TH 1:
200 or more.
b) A rise in titre which is atleast four fold.
2)
Education2, 5
Illiterate – A person who could not read or
write. This category also included those who
could only sign or reproduce some writing
mechanically without any meaning.
Literate – Those who had taken formal
education. This category was further subdivided
into Primary, High school, S.S.C., H.S.C,
Graduate and above. This category also
included those who could read or write with
meaning but had not taken any formal
education in school and were included in
Primary group of education. The children below
7 years were not considered while taking
education history. In this study, there were 7
children below 7 years of age who were
excluded while considering literacy status.
3) Socioeconomic status6, 7, 8
Socioeconomic status as suggested by B.G.
Prasad was adopted and modified as per All
India Consumer Price Index (AICPI) of 1st March
2002.
4) Duration of hospital stay- time interval
between date of admission and discharge and
was grouped as- < 7 days, 7-13 days, 14-28 days,
> 28 days.
5) Personal hygiene2 - includes daily bathing,
clothing, washing hands with soap and water
before meals and after toilet, care of nails and
feet, care of teeth (oral hygiene), spitting,
coughing, sneezing, sleep and personal
appearance. Personal hygiene was graded as –
Good- if 7-10 factors present., Average – if 3-6
factors present., Poor- if < 3 factors present
6) Environmental history
i) Type of house9 - Kaccha / Pacca
ii) Overcrowding2 -as per persons per room
criteria
iii) Storage of drinking water- hygienic/
unhygienic
iv) Storage of cooked food10 - hygienic/
unhygienic
v) Method of waste disposal- sanitary /
insanitary
7) Outcome of patient was recorded as recovery
and discharge, absconded, discharge against
medical advice and death.
RESULTS
Total no. of proved enteric fever cases admitted
during the study period were 172. Age wise
distribution showed that maximum no. of
patients i.e.70 (40.70%) were in 11-20 years age
group. More than two third of patients i.e.118
(68.60%) were 0-20 years age group (i.e. children
and adolescents). Out of 172 cases, 107(62.21%)
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patients were males and 65(37.79%) were
females. Male to female ratio was 1.6: 1.
Area wise distribution of cases showed that
92(53.48%) patients were from rural area and
80(46.52%) were from urban area. Religion wise
distribution showed that majority of the patients
105(61.04%) were Hindus, 44(25.58%) were
Muslims and 23(13.38%) belonged to other
religions like Christians, Jain etc.
educational status
Educational status
No. of patients (%)
Illiterate
82(49.70)
Primary
25(15.15)
High school
22(13.33)
S.S.C.
15(9.09)
Higher secondary school
11(6.67)
Graduate and higher
10(6.06)
Total
165*(100.00)
x2=28.04, df=4,p< 0.001(highly significant)
*- 7 children were below 7 years of age so were not
considered when analyzing literacy status.
Distribution of literacy status and enteric fever
cases (Table no.1) showed that as literacy status
increased, risk of getting enteric fever infection
decreased
and
was
found
statistically
significant.
Table 2: Levels of personal hygiene and enteric
fever
Levels of personal hygiene
Total No (%)
Good
12 (6.98)
Average
47 (27.32)
Poor
113 (65.70)
Total
172 (100.00)
x2=91.76, df=2,p< 0.001(highly significant)
Distribution of cases according to socioeconomic
status showed that out of 172 cases, more than
half patients 94(54.65%) were from class
IV(upper lower) socioeconomic status followed
by V(lower lower)47(27.33%) according to
modified B.G. Prasad classification. Only 1.16%
patients belonged to class I (upper)
socioeconomic status. When class IV and V were
pooled as lower socioeconomic status and class
I,II and III as upper and middle socioeconomic
status, a significant association was found
between socioeconomic status and enteric
fever.(x2 =70.348, df=2,p< 0.001)
Out of 172 respondents, (Table no. 2) 2/3rd
113(65.70%) patients had poor personal hygiene
and only 12(6.98%) had good hygiene. As
standard of personal hygiene were increased ,
there were less chances of enteric fever disease
and was found statistically significant(p<0.001).
housing conditions
Housing condition
1) Type of house
Kaccha
Pacca
2) Storage of drinking water
Unhygienic
Hygienic
3) Storage of cooked food
Unhygienic
Hygienic
4) Overcrowding
Present
Absent
5) Waste disposal
Insanitary
Sanitary
Total
Patients (%)
137(79.65)
35(20.35)
124(72.09)
48(27.91)
94(54.65)
78(45.35)
121(70.35)
51(29.65)
117(68.02)
55(31.98)
172(100.00)
The distribution of enteric fever patients
according to housing conditions (Table no.3)
showed that majority 137(79.65%)had Kaccha
house. Around 3/4th of the cases 124(72.09%)
had unhygienic way of storage of drinking
water. Out of 172 cases, more than half of
patients 94(54.65%) had unhygienic way of
storage of food. Overcrowding was present in
121(70.35%) cases and insanitary way of waste
disposal was present in 117(68.02%) of cases.
duration of hospital stay
Duration of hospital stay
< 7 days
7 to 13 days
14 to 28 days
>28 days
Total
Mean+ S.D.
Patients (%)
84(48.84)
68(39.53)
18(10.47)
2(1.16)
172(100.00)
7.91+ 5.45
The mean duration of hospital stay for enteric
fever patient (Table no.4) was 7.91 with
Standard Deviation 5.45 days and range was 235 days.
Out of 172 respondents, 151(87.79%) were
responded very well to treatment and
recovered.
However
7(4.07%)
patients
absconded and 11(6.40%) were given discharge
against medical advice. Their status about the
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disease outcome could not be assessed. Three
patients were died giving fatality rate of 1.74%.
DISCUSSION
Out of 172 enteric fever cases, majority (40.70%)
were in the age group between 11-20 years. The
possible causes for enteric fever being common
in this age group include their mobility,
consumption of unhygienic food and water in
schools and colleges. These observations were
consistent with various studies11, 12
Males outnumbered the females giving M:F
ratio of 1.6:1.This might be due to our cultural
background where male is more likely to report
to hospital, at same time more likely to contract
infection outside the house. This finding was
comparable with the studies of S.C. Sood and
P.N. Taneja13 and S.N. Khosla et al14.
associated with lack of clean and safe water.
More than half of respondents (54.65%) had
unhygienic storage of cooked food. This was
consistent with findings Gasem MH et
al17.Insanitary waste disposal was seen in more
than 2/3rd of cases (68.02%).Several studies11, 17
support this finding.
The overall duration of hospital stay ranged
from 2 to 35 days with mean 7.91 days and S.D.
5.45 days. The present study findings were more
or less comparable with the findings of other
studies13, 14. The longer duration of stay in some
patients may be due to development of
complications or patient may be reported late
when
the
complications
were
already
developed. Fatality rate observed in this study
was 1.74%. Dr. Amit Kulkarani12 in a hospital
study found that mortality was 4%.
Among 172 patients, 49.70% were illiterate and
50.30% were literate. A significant association
was found between literacy status and
occurrence of enteric fever (p< 0.001). Enteric
fever was more common among illiterate and
low educational status people as is usually
associated with ignorance, poverty and poor
personal hygiene. This observation was
consistent with study done by S.Bhatti et al15.
CONCLUSION
The present study found a significant
association between socioeconomic status and
enteric fever (p<0.001). Several studies13, 15, 16
also support the finding that enteric fever was
more common in lower socioeconomic group.
The low socioeconomic status usually goes
parallel with poor standard of living and poor
personal hygiene making persons more prone
for enteric fever.
RECOMMENDATIONS
Around 2/3rd of cases (65.70%) had poor
personal hygiene. As standards of personal
hygiene increased, risk of enteric fever
decreased and is found to be statistically
significant (p<0.001). Several studies support
this finding13, 15, 16, 17.
In housing conditions, more than 3/4th patients
(79.65%) had Kaccha house. A study done by
Gasem MH et al17 also had similar observation.
Poor housing condition is associated with
increased fly population and in turn enteric
fever.
Majority (72.09%) had unhygienic storage of
drinking water. The study conducted by S.
Bhatti et al15 also found that enteric fever was
Thus present study found majority of patients in
11-20 years (school children and adolescents)
age group. There was significant association of
literacy status, socioeconomic status and
personal hygiene with development of enteric
fever.
1) The specific age group like school going
children and adolescents should be identified as
high risk group and imparted health education
towards prevention of enteric fever.
2) Improving educational status of people and in
cases of children, educational status of parents
especially mothers should be increased through
adult education classes.
3) Sanitation should be improved by protection
and purification of drinking water supplies,
provision of basic sanitation and promotion of
food and personal hygiene. These measures
should be followed by health education.
REFERENCES
1. Textbook of Public health and Community Medicine, By
Department of Community Medicine, Armed Forces
Medical College, Pune in collaboration with World
Health Organization, , India Office, New Delhi, first
edition, 2009.,1132-1134.
2. K. Park: Park’s Textbook of P.& S.M. , 20TH edition,
Banarsidas Bhanot Publisher, Jabalpur, Feb 2009, 206209,416, 658,599.
3. Ananthnarayan R. and Jayaram Panikar C.K. : Textbook
of Microbiology, 4th edition, 1992, 279-89
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4. K.K. Samal and C.S. Sahu: Malaria and Widal reaction,
J.A.P.I., 39(10), 1991, 74-76
5. Kuppuswami B: Manual of Socioeconomic scale (Urban),
Manasayan, 32, Netaji Subhash Marg, New Delhi, 1981,
6.
6. Letter from office of Assistant Labour Commissioner,
Solapur, issued to Solapur Janata Sahakari Bank, Letter
no. ACL/index/2845, Assistant Labour Commissioner,
dated 1-3-2002.
7. P. Kumar: Social Classification- Need for constant
updating, Ind. J of Comm. Medicine, XVIIII, 1993, 60-61.
8. Prasad B.G.: Changes proposed in the social
classification of Indian families. JIMA, 55(16), 1970, 198199.
9. 9) Ghosh R.N.: Housing, Town and Village planning,
Mannual of Prev and Social Medicine, First edition,
1981.7
10. WHO Geneva (1980): The treatment and prevention of
acute diarrhea- Practical guidelines, 2nd edition.
11. H.N. Mangal et al: Prevalence of enteric fever in Jaipur,
Ind J. of Med. Res., 55(3), Mar 1967, 219-223.
12. Dr. Amit Kulkarani: Study of clinical features of enteric
fever , Dissertation submitted for
M.D.(General
Medicine), to Pune University, December 1999.
13. S.C. Sood and P.N. Taneja: Typhoid fever, Clinical
picture and diagnosis, Ind J of Child Health, 10(2), Feb
1961, 69-76.
14. S.N. Khosla et al: Incidence of carrier state in treated
patients of typhoid fever, J.A.P.I.,43(3), 1995, 189-190.
15. S.Bhatti et al: Enteric fever in adult patients at Akuh,
1998-2001: Epidemiology, Clinical features , lab
diagnosis and antibiotic susceptibility patterns, Q
Pakistan J of Med SC, Apr- Jun 2002.
16. ICMR bulletin: Typhoid fever: The changing trends,
22(5), May 1992, 57-63.
17. Gasem MH et al: Poor food hygiene, housing as risk
factors for typhoid fever in Semarang, Indonesia, Trop
Med Int Health, 6(6), June 2002, 484-90.
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Original Article.
STUDY OF PREVALENCE OF DIARRHOEAL DISEASES AMONGST UNDER FIVE
POPULATION
Shailesh Sutariya1, Nitiben Talsania2, Chintul Shah3
1Mobile
Health Unit Coordinator, Commissionerate of Health, MS & ME, Gandhinagar 2Professor,
Professor, Department of Community Medicine, B.J. Medical College, Ahmadabad.
3Assitant
Correspondent:
Dr. Shailesh Sutariya
Mobile Health Unit Coordinator, Commissionerate of Health, MS & ME, Gandhinagar
ABSTARCT
Acute diarrheal disease with its accompanying dehydration has remained a challenging problem to
the medical profession and the community in the third world countries especially in the age below
five years. The current study was conducted to study the prevalence of diarrheal diseases amongst
under five population and the seasonal distribution of diarrheal diseases amongst under five
population. It was a longitudinal study conducted among 2408 children under 5 yrs age group
including 541 infants. Maximum cases of diarrhea (81.89%) were in infants. 90.60% episodes of
diarrhea were treated at home with ORS and/or home available fluids. About half of the diarrheal
episodes 2798 (46.39%) were occurred in monsoon season.
Key words: Acute diarrheal disease, under five child, infant, ORS
INTRODUCTION
Acute diarrheal disease with its accompanying
dehydration has remained a challenging
problem to the medical profession and the
community in the third world countries
especially in the age below five years.1 The
WHO estimates that four million children under
the age of five die each year in the world from
diarrhea mainly in developing countries. The
current global cholera epidemic can only be
resolved through the introduction of safe
drinking water supplies and appropriate levels
of hygiene. These diseases are usually caused by
water-borne pathogens such as salmonella, E.
coli, shigella and enteroviruses.2
“The diseases associated with water are heavily
contaminated in the developing world”
comments Dr. Kreisel. “They hit hardest the
poorest urban and rural households of the poor
countries. Nearly half of the populations in
developing countries suffer from health
problems directly linked to insufficient or
contaminated water”.3
In hospitals up to a third of total pediatric
admissions are due to diarrheal diseases and up
to 17% of all deaths in indoor pediatric patients
are diarrhea related.4 The household surveys
carried out during 1994-95 showed that in under
five year children diarrhea episodes were
1,92,943 and morbidity rate was 1.7 episodes per
year per child.5
The present study was carried out during
October 2001 to October 2002 in Dhinoj,
Mervada, Sunsar, Chaveli, and Railwaypura
villages of Dhinoj PHC. Out of 13 villages in
Dhinoj PHC, 5 villages were selected by
systematic random sampling method (38.76%).
Every third village was selected. Children below
five years were selected. A house to house
survey was done in families having one or more
children below 5 years of age. The selected
families were visited for three reasons
throughout the year to elicit information
regarding occurrence of diarrhea (recall period
being 12 months), etiological causes and types of
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treatment, and agencies providing treatment of
diarrhea. Mothers were specifically interviewed
to elicit feeding/weaning practices during
diarrhea.
A longitudinal study was planned to find out
etiological causes and health seeking behavior
for
diarrheal
diseases
and
laboratory
investigations of selected stool samples. The
stool samples were examined microscopically by
concentration technique for presence of Ova,
cysts, cells of parasites in a private laboratory.
RESULTS
Table 1 shows no. of children affected by
diarrheal diseases. Among infants 2110(34.99%)
were diarrheal episodes followed by children in
the age group 1-5, 3921(65.01%). Maximum
cases of diarrhea (81.89%) were in infants which
was statistically significant. (X2= 26.75, df= 1, p<
0.001).
Table 1: Village wise Distribution of Diarrheal
Episodes In Children Under 5 Years
Name of
Age Groups
Village
0-1 yr
1-5 yrs
Total
Dhinoj
705 (11.7) 1209 (20.0) 1914 (31.7)
Railwaypura 201 (3.3)
355 (5.9)
556 (9.2)
Sunsar
845 (14.0) 1392 (23.1) 2237 (37.1)
Chaveli
151 (2.5)
315 (5.2)
466 (7.7)
Mervada
208 (3.5) 650 (10.8) 858 (14.2)
Total
2110 (35.0) 3921 (65.0) 6031 (100)
Table 2: Number of Cases and Episodes of Diarrhea Treated Among Under 5 Children
Sr. No.
1
2
3
Total
1
2
3
Particular
Total no. of Children
Total no. of Children affected
No. of diarrhea episodes per child/year
Total no. of diarrhea episodes
Treated at home with home available fluids
and ORS
Need to consult Doctor
Hospitalized
Table 2 shows that out of total 6031 episodes,
5464 (90.60%) episodes of diarrhea were treated
at home with ORS and/or home available fluids.
PHC staff created good rapport with
community. Information, Education and
Communication activities were done by BEICO
and MO. Out of 6031 (100%) episodes of
diarrhea, 5464 (90.6%) episodes were effectively
0-11months
541 (22.47)
443 (18.39)
4.76
2110 (34.99)
1861 (30.85)
217 (3.59)
32 (0.55)
Age Group (%)
1-5 Yrs
Total
1867 (77.53)
2408 (100)
1320 (54.82)
1763 (73.21)
2.97
3.42
3921 (65.01)
6031 (100)
3603 (59.74)
5464 (90.60)
310 (5.14)
8 (0.13)
527 (8.74)
40 (0.66)
controlled by ORS & home available fluids only.
217 (3.59%) episodes in infants and 310 (5.14%)
episodes in children of 1-5 yr age group
required to consult doctors for treatment. 32
(0.55%) episodes in infants and 8 (0.13%)
episodes in children of 1-5 yr age group
required hospitalization.
Table 3: Seasonal Distribution of Episodes of Diarrhea
Sr.
No.
1
2
3
4
5
Village
Dhinoj
Railwaypura
Sunsar
Chaveli
Mervada
Total
Total Episodes (Cases)
1914 (559)
556(163)
2237 (654)
466 (136)
858 (251)
6031 (1763)
It was observed that about half of the diarrheal
episodes 2798 (46.39%) were occurred in
monsoon season; summer season accounted
Winter
317 (93)
92 (27)
413 (121)
83 (24)
142 (41)
1047 (306)
Season
Summer
699 (204)
203 (59)
797 (233)
174 (51)
313 (92)
2186 (639)
Monsoon
898 (262)
261 (77)
1027 (300)
209 (61)
403 (118)
2798 (818)
2186 (36.25%) episodes and winter season 1047
(17.36%) episodes. Episodes of diarrhea were
increasing season wise. There were 208.8% more
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episodes of diarrhea in summer than winter,
128% more episodes in monsoon than summer
and 374.2% more in monsoon than winter.
Episodes of diarrhea were less in the Chaveli
village and more in Sunsar out of selected five
villages.
Table 4: Micro-organism found in Stool Sample
Taken in Diarrhea
Organism
E. histolytica
A.Lumbricoides (Round Worm)
A. Duodenale (Hook Worm)
T. trichura (Whip Worm)
E. Vermicularis (Thread Worm)
V. Cholerae
Prevalence
5.8
4.7
3.9
1.2
0.4
00
Maximum prevalence rate was noted for E.
histolytica followed by A. lumbricoides and A.
duodenale.
DISCUSSION
Out of 2408 children in five villages, 541 were
infants and 1867 were in 1-5 yrs age group. Out
of 541 infants, diarrheal diseases affected 443
infants (81.88%) and out of 1967 children of 1-5
yr age group, diarrheal diseases affect 1320
(70.70%) children. In 0-11 yr age groups, no. of
diarrheal episodes per child per year was 4.76
which was higher than 2.97 that was observed in
1-5 years age group which is similar with the
study of Dr. C. Shiva Ram on diarrheal diseases
in rural Karnataka6 and with Sircar B.K. study in
Calcutta.7
Out of 2408 children, diarrheal diseases affected
1763 children (73.21%). In study period total
6031 episode were observed and found that
90.6% cases treated at home with HAF and ORS.
In study of Dr. C. Shiva Ram this figure was 85%
which is an identical finding observed in studies
in other parts of India. 527 (8.74%) children need
to consult doctor. There were 40(0.66%) cases
with severe dehydration or associated with
other diseases and need hospitalization. The
need for hospitalization of infants was higher
32(0.55%) in comparison to 1-5 yr age group
children 8(0.13%). It was observed in this study
that most of mothers did not consider diarrhea
to be dangerous and try to use home remedies.
Dr. Rita and Paramjit in Varanasi found same
results but mothers did not use home remedies.8
Village wise distribution of diarrhea episodes
shows poor health situation of Sunsar village
which account for more than one-third diarrheal
episodes. Reasons behind this was that no
pipeline water supply and use of pond water
without any treatment, low literacy status,
scattered houses, distance from health facility;
so less utilization of health facility, low socioeconomic status, malnutrition among children
and women.
It was observed that about half of the diarrheal
episodes 2798(46.39%) were occurred in
monsoon season; followed by summer season
accounting 2186(36.25%) episodes and later on
winter season 1047 (17.36%) episodes. There
were 208.8% more episodes of diarrhea in
summer than winter, 128% more episodes in
monsoon than summer and 374.2% more in
monsoon than winter. This results correlate with
studies of S. Villa and others in seasonal
diarrheal morbidity among Mexican children.9
This study compare well with Dr. C.P.Mishra et
al, observed maximum prevalence in rainy
season (32.99%) followed by summer month
(12.93%). Least number of such cases (8.64%)
was reported during winter months.10
Laboratory report of stool sample suggested that
there were large number of worm infestation
cases. Most common cause was poor hygiene.
Children were playing in and with soil. Most of
the times bare footed and no hand washing
before meal and after defecation. E. histolytica
was found in 5.8% of stool samples. Eggs of
roundworm were present in 4.7% cases and
pathogen was found in 16% cases. These
findings were similar to the results of M.
Mahajan et al study.11
CONCLUSION AND RECOMMENDATIONS
Out of 541 infants diarrheal diseases affected 443
infants (81.88%) and 1320 (70.70%) from 1967
children of 1-5 yr age group. In 0-11 months age
group, number of diarrheal episodes per child
per year was 4.76 which was higher than 2.97,
that was observed in 1-5 yrs age group. Half of
the diarrheal episodes 2798 (39%) were occurred
in monsoon season, 2186 (36.25%) episodes in
summer and 1047 (17.36%) in winter. 5464
(90.60%) episodes were treated at home, 527
(8.24%) need to consult doctor and 40 (0.66%)
children were hospitalized. More than half
children utilized subcenters and ORS depot. 371
(21.05%) treated by private practitioner.
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Diarrhea can be prevented by breastfeeding, by
immunizing all children against measles, by
using sanitary latrines, by keeping food and
clean water and by washing hands before
touching food. When a breastfed child has
diarrhea, it is important to continue
breastfeeding. A child with diarrhea needs food.
Trained help is needed if diarrhea is more
serious than usual.
REFERENCES
1.
2.
3.
P. Mohapatra et al, Diarrhoea, A raid on under five
children. Indian Journal of Preventive and Social
Medicine, Vol. 22,3-4,1991.
http://www.who.int/abotwho/en/preventing/diarrh
oeal.htm
WHO issues drinking water guidelines for the 1990s,
Indian Journal of Community Medicine, Vol. XVIII No.
4, 1993.
4.
5.
UNICEF (1989), The state of world report, 1989.
WHO (1999), Health situation in the South East Asia
region 1994-97.
6.
Dr. C. Shivram, Diarrhoeal Diseases in children a
survey in the rural area of Bellary District. IJPSM
Vol.23, No. 2.
7.
B.K.Sircar, M.R. Maha, Effectiveness of oral rehydration
salt solution in reduction of death during cholera
epidemic, Indian Journal of public health, Vol. XXXIV,
No. 1, Jan-March, 1990.
8.
Rita B. P. Kaur. Epidemiological correlates of diarrhoea
in a rural area of Varanasi, Rita B. & P. Kaur. IJCM Vol.
XIV No. 2.
9.
S. Villa, H. Guiscafre et al Seasonal diarrhoeal mortality
among Mexican children, bulletin of WHO, 1999, Pg 77.
10. C.P.Mishra. A study on some diarrhoea related
practices in urban Mirzapur, IJPH, Vol. XXXIV No.1.
11. Mahajan, M. Mathur et al, Prevalence of intestinal
parasitic infection in east Delhi, Indian Journal of
Community Medicine, Vol- XVIII, No. 4, 1993.
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Original Article.
AN INTERVENTIONAL STUDY (CALCIUM SUPPLEMENTATION & HEALTH EDUCATION)
ON PREMENSTRUAL SYNDROME - EFFECT ON PREMENSTRUAL AND MENSTRUAL
SYMPTOMS
Shailesh Sutariya1, Nitiben Talsania2, Chintul Shah3, Mitesh Patel3
1Mobile
Health Unit Coordinator, Commissionerate of Health, MS & ME, Gandhinagar 2Professor,
Professor, Department of Community Medicine, B.J. Medical College, Ahmadabad
3Assitant
Correspondent:
Dr. Shailesh Sutariya
Mobile Health Unit Coordinator, Commissionerate of Health, MS & ME, Gandhinagar
ABSTRACT
The study was conducted to study the effect of calcium supplementation on Premenstrual and
Menstrual Symptoms. It was a one year follow-up prospective, randomized controlled interventional
study. After the initial 2-cycle screening phase, a total of 215 healthy premenopausal women were
enrolled in the study group calcium supplementation(500 BD) of the trial and 140 subjects either the
relatives or neighbors of the study population were enrolled as control group health, nutrition,
hygiene education of the trial. By the second and third treatment months, all symptoms except for
fatigue and insomnia showed a significant response to calcium. For the symptom of low backache, the
mean screening score was significantly higher than the control group score (0.82±0.74 vs
0.69±0.66,p=0.033) and became significantly lower than the control group score by the end of third
treatment cycle. (0.30±0.45 vs 0.49±0.59,p<0.01). Nearly half (55%) of the women in the study group
reported ≥50% improvement and one-third (30%) of the women in study group reported ≥75%
improvement. Significantly lower symptoms score was detected in the urban sites during the first
treatment phase with calcium and during the final treatment phase
Keywords: Premanstrual Syndrom, calcium supplement, intervention, health education
INTRODUCTION
The premenstrual syndrome may be defined as
the cyclic recurrence, during the luteal phase of
the menstrual cycle of a combination of physical,
psychological, and/or behavioral changes of
enough severity to deteriorate interpersonal
relationships and/or interfere with normal
activities 1. Premenstrual syndrome may affect
30-40% of the female population, and has been
implicated in work absenteeism, criminal
behavior, marital discord, and billions of dollars
worth of business loss. The literature
surrounding
premenstrual
syndrome
is
voluminous, and undoubtedly the variability in
case definition, the paucity of controlled studies,
and
the
uncertainty
with
regard
to
pathophysilogic mechanism contribute to the
current confusion and poor success in treating
Subjects with premenstrual syndrome. 2-5
MATERIALS & METHODS
Study Design: 1-year follow-up study: A
prospective,
randomized
controlled
interventional study. In these there are 3 phases.
(1) Diagnostic or identification phase (PMS)
(2) Intervention by calcium carbonate or
Gluconate 500 mg 1BD for 3 cycles, or service for
a specific period. (Health, Nutrition, Hygiene
education)
(3) Assessment phase for results. Premenstrual
symptoms scored on 17 parameters.
Study Area: Urban & Rural Communities
Community based study was planned and
carried out in urban field practice area
kalapinagar, Babausingh ni Chali, b/h. Parag
School & Mali no kuvo attached with UHTC
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Mala, community Medicine Dept, B. J. Medical
College, Ahmedabad and subcenters of Adalaj
PHC, District, Gandhinagar namely Uvarsad,
Por, Chandkheda, PTC College & Pre PTC
college Adalaj Proper, and Zundal which has
been adopted as rural field practice area for
UG/PG training of this department.
Study Population
Subjects:
Healthy,
Premenstrual
women
between the age of 15 and 45 years were
interviewed and inquired about complains
regarding premenstrual syndrome between Oct
2004 to Dec 2004, on the basis of following
criteria, symptoms occurring during the luteal
phase of the menstrual cycle that regressed
rapidly after the onset of menstruation, and that
were severe enough to disrupt social and work
activities with regular menstruation. The
primary outcome measure in the study was the
symptom complex score, which was calculated
as the average of the 17 daily individual
symptoms ratings. 6.
active mental illness, pregnancy or breastfeeding & use of oral contraceptives.
Written informed consent was obtained from all
study participants approved by the institutional
ethics committee review board chaired by the
superintendent of New Civil Hospital,
Ahmedabad in August 2004.
Sampling Design
Each subject was required to keep a daily diary
of 17 symptoms associated with PMS for the
five-month study period, beginning on the first
day of menses. After the initial 2-cycle screening
phase, a total of 215 healthy premenopausal
women who met all inclusion / Exclusion
criteria were enrolled in the study group
calcium supplementation(500 BD) of the trial
and 140 subjects either the relatives or neighbors
of the study population were enrolled as control
group health, nutrition, hygiene education of the
trial.
Sample Size
RESULTS
Sample size requirements were determined size
of 215 (treatment group). Four hundred women
were screened. Three hundred fifty five patients
were enrolled in the study, 215 met criteria for
efficacy analysis. 140 patients not included in
study failed to meet criteria. In addition, one
more of the following symptoms must have
been present during the luteal phase for a
woman to qualify- mood swings, depressionsadness,
tension-irritability,
anxietynervousness, anger-aggression-short temper or
crying spells.
Analysis of the data indicated that 63 % of the
patients in the study group were between 16-35
years of age and rest above 35, while in the
control group 56% of the patients were in the
age group 16-35 and the rest above it.
Inclusion Criteria
(1) General good health as determined by
history and routine physical examination
(height, weight)
(2) Non-pregnant
(3) Regular menstrual cycle of 23 to 28 days as
documented in the daily diaries.
(4) Discontinuance of the use of analgesics for
the duration of study,
(5) The requirement that the diagnosis of PMS
be prospectively documented for 2 menstrual
cycles with the daily self- rating scale (The PMS
Diary), a validated self-assessment daily diary.
Specific Exclusion Criteria: included a history
of renal disease, hepatic diseases, digitalis
therapy, significant gynecologic abnormality
Table 1: Demographic data of study population
(Mean ± SE)
Particular
Age (yrs)
Weight (kg)
Height (cm)
Cycle
length (d)
Bleeding
length (d)
Onset
of
PMS
(Days
before
menses)
Study
group
22.7 ±6.7
55.8±15.1
150.8±6.8
29.3±2.8
Control
group
22.9±6.7
55.9±15.3
150.4 ±6.7
28.8±2.6
Total
22.8±6.0
55.9±15.1
150.6±6.0
29.1±2.7
5.1±1.3
5.2±1.2
5.2±0.3
7.3±3.0
6.2± 3.0
6.5±3.0
Majority of subjects both in the study and
control group were hindus. 39% subjects of the
study group were literate, while 68% had less
then 10 years of schooling. The marital status of
the subjects of the study group indicated that
96% of them were married, while in the control
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group 94% were married.
House wives
accounted for 93% and 90% in the study and the
control groups respectively. The socio economic
analysis indicated that 67% of the study group
and 62% in the control group belonged to lower
socioeconomic class.
Following these criteria, the postmenstrual
phase was defined as days 5-10; the
premenstrual phase was defined as the six days
before menses (days 23-28).
Table 2: Mean symptom complex scores for calcium and health education groups by specific
treatment cycle and menstrual phase.
Group
Mean
screening
No. of
Study
215
participants
Control
140
Luteal
Study
0.90 ± 0.52
Control
0.92 ± 0.55
Menstrual
Study
0.82 ± 0.54
Control
0.81 ± 0.52
* P< 0.05, Data are presented as Mean ± SE.
First
treatment
215
135
0.58 ± 0.51
0.66 ± 0.49
0.60 ± 0.53
0.59 ± 0.50
Significant difference were found between
groups for the mean screening of the luteal (p=.
659), Menstrual (p= .818), or inter Menstrual
phase (P=. 726) of the cycle. The baseline luteal
Second
treatment
210
138
0.48 ± 0.46*
0.61 ± 0.48
0.53 ± 0.47
0.59 ± 0.53
Third
treatment
212
138
0.43* ±0.40*
0.60 ± 0.52
0.47 ± 0.44
0.52 ± 0.52
mean symptom complex scores were 0.90 ± 0.52
for the calcium treatment group and 0.92 ± 0.55
for the control group.
Table 3: Calcium treatment on 4 symptoms factor scores
Factor & symptoms
Group
Luteal phase symptom
factor score
Mean
Third
screening
treatment
0.99 ± 0.59
0.46 ± 0.47*
1.04 ± 0.66
0.65 ± 0.64
Menstrual phase
symptom factor score
Mean
Third
screening
treatment
0.77 ± 0.62
0.40 ± 0.52
0.80 ± 0.62
0.48 ± 0.62
Study
Symptom factor 1:Negative
Control
Effect
Mood Swings, Depression,
Tension, Anxiety, Anger,
Crying Spells
Study
0.96 ± 0.58
0.51 ± 0.46* 0.93 ± 0.60
0.59 ± 0.63
Symptom factor 2: Water
Control
0.97 ± 0.60
0.69 ± 0.58
0.92 ± 0.57
0.63 ± 0.52
retention,
Swelling of extremities,
Tenderness of breasts,
Abdominal bloating,
Headache, Fatigue
Study
0.97 ± 0.76
0.45 ± 0.63+ 0.78 ± 0.68
Symptom factor 3: Food
0.40 ± 0.63
Control
1.02 ± 0.76
Cravings,
0.60 ± 0.75
0.73 ± 0.64
0.42 ± 0.62
Increased or Decreased
appetite, Craving for sweets
or salts
Study
0.74 ± 0.63
0.30 ± 0.40* 0.94 ± 0.65
0.52 ± 0.62
Symptom factor 4: Pain
Control
0.69 ± 0.58
0.50 ± 0.52
0.87 ± 0.60
0.58 ± 0.62
Lower abdominal cramping,
Generalized aches and pains,
Low Backache
* P< 0.001, + P< 0.05, Data are presented as mean ± SE
.
During the treatment cycle a significantly lower
third treatment cycles during the luteal phase
symptom complex score was observed in the
(p<0.05, p, 0.001). The luteal phase symptom
calcium treated group for both the second and
complex score by the third calcium treatment
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was 0.43± 0.40 compared with the control
symptom complex scores of the 0.60 ± 52. The
luteal mean symptom complex score values for
the study group were lower for the treatment
cycles compared with the symptom complex
score values during screening and these mean
symptom
complex
scores
progressively
decreased for each treatment group. By the third
treatment cycle calcium effectively reduced the
symptom complex score by 48% compared with
the control effect of 30%. This significant
calcium effect was not detected in the first
treatment cycle.
As noted with mean symptom complex score, a
significant calcium effect on all 4-symptom
factors was observed during the luteal phase of
the menstrual cycle. No significant effect was
noted during the menstrual or intermenstrual
phase of the cycle for the symptom factors.
Three of the four symptom factors (Symptom
factor 1, symptom factor 2, symptom factor 4)
were observed to have significantly lower
symptom factors score by the second treatment
month.
There were significantly lower symptom score
for all 4 factors (negative affect, symptom factor
1(p<0.001); water retention symptom factor 2
(P<0.001); food graving, symptom factors
3(P<0.05) and pain, symptom factors 4(P<0.001);
by the third calcium treatment cycle compared
with first.
By the third treatment cycle the negative effect
symptom factors was reduced by 45% for study
compared with 28% for control group, the water
retention symptom factors was reduced by the
36% for study compared to 20% for control.
Table 4: Differences between treatment group during luteal phase for individual symptom complex
scores
Symptoms
Mood swings
Depression-sadness
Tension-irritability
Anxiety-nervousness
Anger-short temper
Crying spells
Swelling of extremities
Tenderness-breast fullness
Abdominal bloating
Abdominal cramping
Aches and pains
Low Backache
Headaches
Fatigue
Appetite increased/decreased
Craving sweets or salts
Insomnia
Baseline
Mean symptom complex score
Study
Control
P Value
group
group
1.06 ± 0.70
1.11 ± 0.77
P = .484
0.94 ± 0.66
0.95 ± 0.75
P = .809
1.31± 0.68
1.39 ± 0.71
P = .331
0.98 ± 0.77
1.03 ± 0.83
P = .359
1.14 ± 0.68
1.20 ± 0.77
P = .470
0.51 ± 0.58
0.56 ± 0.65
P = .237
0.77 ± 0.75
0.74 ± 0.72
P = .701
1.10 ± 0.85
1.18 ± 0.82
P = .228
1.12 ± 0.72
1.12 ± 0.75
P = .818
0.70 ± 0.66
0.73 ± 0.68
P = .741
0.70 ± 0.68
0.66 ± 0.63
P = .469
0.82 ± 0.74
0.69 ± 0.66
P = .033
0.73 ± 0.66
0.76 ± 0.66
P = .445
1.09 ± 0.72
1.05 ± 0.72
P = .573
0.97 ± 0.78
1.03 ± 0.77
P = .483
0.97 ± .80
1.02 ± 0.79
P = .597
0.36 ± 0.55
0.38 ± 0.59
P = .469
All 17 individual symptoms were analyzed to
determine differences between treatment groups
during the luteal phase of the menstrual cycle
with the exception of low backache, no
significant differences were found in treatment
groups in individual symptoms score during the
mean screening. Within the first treatment for
the individual symptoms of generalized aches
and pains to prove significantly from control. By
the second and third treatment months, all
symptoms except for fatigue and insomnia
showed a significant response to calcium (as
Third treatment cycle
Mean symptom complex score
Study
Control
P Value
group
group
0.50 ± 0.58
0.70 ± 0.75
P =. 002
0.43 ± 0.55
0.58 ± 0.74
P =. 011
0.62 ± 0.58
0.84 ± 0.77
P<. 001
0.45 ± 0.58
0.66 ± 0.77
P<. 001
0.53 ± 0.57
0.74 ± 0.77
P =. 001
0.23 ± 0.40
0.37 ± 0.57
P =. 002
0.40 ± 0.57
0.56 ± 0.70
P =. 007
0.59 ± 0.67
0.84 ± 0.77
P<. 001
0.55 ± 0.63
0.81 ± 0.77
P<. 001
0.29 ± 0.44
0.50 ± 0.59
P<. 001
0.31 ± 0.49
0.49 ± 0.60
P<. 001
0.30 ± 0.45
0.49 ± 0.59
P<. 001
0.40 ± 0.52
0.52 ± 0.58
P =.033
0.60 ± 0.66
0.71 ± 0.73
P=.0135
0.46 ± 0.65
0.61 ± 0.76
P =.025
0.43 ± 0.64
0.60 ± 0.78
P =. 010
0.15 ± 0.35
0.19 ± 0.41
P =. 213
shown in table IV) for the symptom of low
backache the mean screening score was
significantly higher than the control group score
(0.82±0.74 vs 0.69±0.66,p=0.033) and became
significantly lower than the control group score
by the end of third treatment cycle. (0.30±0.45 vs
0.49±0.59,p<0.01).
The percent change
characterized into 4
improvement. b) <50%
improvement d) ≥75%
from baseline was
groups: a) negative
improvement. c) ≥50%
improvement. Nearly
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half (55%) of the women in the study group
reported ≥50% improvement and one-third
(30%) of the women in study group reported
≥75% improvement.
Table 5: Percentage improvement in all 17
symptoms of women in study group
Symptoms
Negative improvement
More than 50% improvement in
all the 17 symptoms
More than 75% improvement in
all the 17 symptoms
Total
women in
study group
No.
%
17
8
118
55
60
29
215
100
When we analyzed the differences urban versus
rural sites (Kalapinagar Vs Adalaj), significantly
lower symptoms score was detected in the
urban sites during the first treatment phase with
calcium and during the final treatment phase
(data not shown). This may be due to more
awareness, follow-up and motivation treated by
own medical social workers in their urban
health training center and its field practice area
viz. Kalapinagar, Babu sing ni chali, b/h parag
school, and mali no kuvo survey.
COMMENTS AND DISCUSSION:
PMS afflicts millions of premenopausal women
and has been described as one of the most
common disorders in women. Despite its
overwhelming
prevalence,
clinical
investigations exploring its patho-physiologic
features have been disappointing. Few
therapeutic modalities have proved consistently
effective.
This
study
has
found
that
calcium
supplementation effectively alleviates the luteal
phase symptoms of PMS. Calcium treatment
resulted in an approximately 50% reduction in
total mean symptom scores with a significant
benefit on symptoms such as depression, Mood
swings, Headache, and irritability and breast
engorgement. The findings in this community
based randomized control trial both in urban &
rural area of Ahmedabad and Gandhinagar
districts respectively are consistent with an
earlier trial reporting a significant benefit. With
the use of calcium therapy in women with PMS,
calcium was not found effective during the
menstrual or intermenstrual phase of the cycle.
Calcium therapy is inexpensive does not result
in bone loss is effective in mood and depression
as well as own all 4 symptoms complex and did
not result in significant non-compliance due to
adverse effects. Calcium supplementation may
act by replanting an underlying physiologic
deficit suppressing parathyroid hormone
secretion,
and
ultimately
reducing
neuromuscular
irritability
and
vascular
reactivity.
Should PMS prove to be an indicator of low
calcium status that encourages premonopausal
women to increase their calcium intake, the
public health benefit in areas such as
osteoporosis; risk reduction could be significant.
Further investigation into adequate close and
duration of therapy may provide further
benefits for women with PMS. In the study by
Kendall & schnurr7. A positive effect of B6 (150mg/ daily) for 2 months treatment period was
seen on premenstrual autonomic reactions, such
as dizziness & nausea, and on behavior change.
BIBLIOGRAPHY
1.
2
3
4
5
6
7
Robert F.Casper, Margaret T. Hearn, The effect of
hysterectomy and bilateral oophorectomy in women
with severe premenstrual syndrome; American journal
of Obstet Gynecol,volume 162;1990: page105-109.
Susan Thys-Jacobs, MD, Paul Starkey, MD, “Calcium
carbonate and the premenstrual syndrome: Effects on
premenstrual and menstrual symptoms ” Am. J.
Ob/Gy Vol 179 No 2,1998, Page 444- 453.
Monika Malhotra, “premenstrual syndrome” Obs. &
Gynae. Vol VIII No 3: March 2003 Page: 125-128
Robert L. Reid, S.S.C. Yen, “premenstrual syndrome”
Am. J. Obstet. Gynecol Vol 139 No 1 Page 85-97.
Pradeep Agarwal, S. G. Malik, V.Padubidri “Psychiatric
morbidity in patients suffering from menstrual
disturbances” Indian F. psychiat (1989) 31(2) Page: 173176.
P.Casson,D.A. Van Vugt, and R.L. Reid, “Lasting
response to ovariectomy in severe intractable
premenstrual syndrome.”; American journal of Obstet
Gynecol,volume 162;1990: page99-105.
Kendall K, Schnurr P. “The effect of vitamin B6
supplementation on premenstrual symptoms.” Obstet
Gynecol 1987;70:145-9.
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Original Article.
CONTRACEPTIVE KNOWLEDGE, ATTITUDE AND PRACTICES IN MOTHERS OF INFANT: A
CROSS-SECTIONAL STUDY
Priyanka Mahawar1, Shweta Anand2, Deepa Raghunath3, Sanjay Dixit4
1Assistant
Professor, Department of Community Medicine, Sri Aurobindo Institute of Medical
sciences, Indore (M.P.) 2Assistant Professor, Department of Pediatrics, Chirayu Medical College &
Hospitals, Bhopal.(M.P.) 3Assistant Professor, 4Professor & Head, Department of Community
Medicine, M.G.M. Medical College, Indore.
Correspondence:
Dr. Shweta Anand
Assistant Professor, Department of Pediatrics,
Chirayu Medical College & Hospitals, Bhopal.(M.P.)
ABSTRACT
A cross-sectional study regarding knowledge, attitude & practices of family planning was conducted
in an immunization center of Indore district. All the females coming to immunization center for
vaccinating their infants were interviewed using a pretested, semi structured Performa during a fixed
study period. The performa included details like socio demographic features, questions related to
knowledge, attitude and practices (KAP) regarding contraceptive use. Results showed poor
contraceptive knowledge amongst females. 18% KAP Gap was found in total subjects. Maximum
KAP Gap was found in the 19-21year age group. The KAP Gap was not significantly more in Muslim
women as compare to Hindu women. The KAP Gap was more in Housewives than other occupations.
Knowledge of various family planning methods should be provided to all the females coming to
health center.
Key words: Knowledge, Attitude, Practices, family planning.
INTRODUCTION
family1
India is the pioneer country in the world to
launch a nation wide family planning
program in the year 1952, and during the third
5-year plan it was declared “The very centre of
planned development”. In April 1976, the
country framed its first “National population
policy” which is now running under RCH
(Reproductive and child Health) program, so
that each and every couple of India get aware
of the need of the family planning methods.
Family planning through contraception tries to
achieve two main objectives; firstly, to have
only the desired number of children and
secondly, to have these children by proper
spacing of pregnancies.2 A number of K.A.P.
survey has been carried out covering different
population groups. In their study among rural
Rajputs found that raise in education besides
providing knowledge and the contraceptive
methods helps in improving acceptance of
family control devices.3 There are also other
studies carried out in this sphere.4,5,6
The need of contraceptive practices in order to
control population explosion lies in the
following point:•To avoid unwanted births
•To regulate intervals between pregnancies
•To control the time at which births occur in
relation to age of the parent
• To determine the number of children in
But inspite of availability of sterilization
facilities and contraceptive measures free of
cost by Government of India, couples are not
adopting them. Therefore it is important to
stimulate social change and motivating them.
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Present Cross sectional study was conducted in
Chacha Nehru Bal Chikitsalaya(C.N.B.C.),
Maharaja Yashwant Rao Hospital campus,
Indore to assess the Knowledge, Attitude and
Practices of different family planning methods
in women with children less than one year of
age and to find the reasons behind it. All the
women with children less than 1 year of age
coming to immunization center for vaccination
during study period of 1st November 2009 to 30th
January 2010 were included in the study. A total
of 53 females attended the immunization clinic
but only 50 gave consent for the study. A
Pretested, semi structured questionnaire was
prepared for the interview. This questionnaire
was administered to women coming to C.N.B.C.
during the study period regarding the age, sex,
occupation and their socioeconomic status is
calculated by Modified Prasad's Scale.7
The data was entered in Microsoft excel
spreadsheet and was analyzed using SPSS
software and Chi Square test was applied
wherever necessary.
RESULT
Socio-Demographic Profile
38% women were in the age group 22-24
years.78% of respondents were Hindu by
religion.90%
of
the
respondents
were
housewives. 74% of the respondents were in
social Class II. 30% of the respondents were
having more than two children.
Knowledge
Figure 1 shows that 98% of the subjects had
heard about oral contraceptive pills and 88% of
the subjects had heard about Cu-T but none of
them had complete knowledge about any family
planning method. 88% women had Television as
their source of knowledge and less than 50%
women said that their Doctor provided them
knowledge.
54 % women did not have any knowledge about
I-pill (emergency contraceptive pill) .Out of 23
women having knowledge about i-pill; 86%
women had T.V. as their source of knowledge.
Only 60 % women were aware about the
contraceptive
property
of
exclusive
breastfeeding.62 % women thought that family
planning methods should be used by women
with children less than 1 year of age.
No. of female METHODOLOGY
50
40
30
20
10
0
37
44
49
43
29
35
Figure 1: Knowledge regarding each family
planning method
Attitude
98% women felt that exclusive breastfeeding
should be done for 6 months.46% women
thought that OCPs should be used within 6
months after child birth.58% women felt that
Cu-T should be inserted in post delivery period.
96% women thought that there should be a
difference of minimum 3 yrs between two
children.86% women agreed that permanent
sterilization should be done after two
children.46% women think they can use i pill as
a regular family planning method.
Practice
40% women had used family planning method
in past.26% were using family planning method
at present out of which only 1 women was using
Condom, 10 were using Cu-T and 2 had adopted
permanent method i.e. tubectomy. Only 1
women in this study, had used I-pill in past on
the advice of her mother.
KAP Gap
18% KAP Gap was found in total subjects.
Maximum KAP Gap was found in the 19-21year
age group. The KAP Gap was not significantly
more in Muslim women as compare to Hindu
women. The KAP Gap was more in Housewives
than other occupations.
Reasons for KAP gap
The following reasons were found in this study
for KAP GAP:−
They were afraid of the various side effects.
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−
−
−
−
Husbands did not want that they should use
any family planning method.
Due to hesitation.
Elderly people in the family not permit
them.
Women think that due to tubectomy their
body weakens affecting their household
work.
DISCUSSIONS
Present study was conducted in females having
at least one child less than a year. This group of
females are in utmost need of using
contraceptive devices and also most receptive to
family planning. But only 62% females were
adopting family planning method. According to
National Family Health Survey 56 % of ever
married Indian women is using family
planning8.None of the female had complete
basic knowledge regarding family planning
methods. Also television was their chief source
of information. Reddy et al in 2003 stated that
the major source of knowledge about Family
Planning methods for the study population was
magazines (64%) followed by personal relations
i.e. spouse, friends and relatives (62%), mass
media (54%) and health personnel (34%)(9.The
role of health care providers in providing
contraception knowledge should be emphasized
as it’s a two way communication process.
Most of the female’s attitude towards use of
family planning method was satisfactory. But
most of them said that they act according to
their spouse’s or in law’s decision. They have no
choice related to child birth.
20% of females were using CuT, 2 adopted
permanent method. Use of modern methods of
contraception has increased in past few years.8
This reflects that couples are adaptive to newer
and better methods of contraception.
Maximum KAP gap was seen in younger age
group females. Though the age of marriage has
increased8; still a substantial population is
exposed to early marriage.
The study reveals good knowledge and
favorable attitude towards family planning. The
knowledge of family planning is widespread
among the respondents and they are aware of
least one method of contraception but practice of
using
contraception
is
poor.
Good
communication skills and behavior change is
required to bridge this gap.
REFRENCES
1. Park J.E.Park’s Textbook of Preventive & Social
Medicine, 20th edition 2009 p421.
2. Dabral S, Malik SL. Demographic Study of Gujjars of
Delhi: IV. KAP of Family Planning. J. Hum. Ecol. 2004;
16(4):231-237.
3. Gautam AC, Seth PK. Appraisal of the knowledge,
attitude and practices (KAP) of family control devises
among rural Rajputs and Scheduled caste of Hatwar area
of Bilaspur district, Himachal Pradesh. 2001;
Anthropologist, 4(4):289-292.
4. Takkar N, Goel P, Saha PK, Dua D. Contraceptive
practices and awareness of emergency contraception in
educated working women. Indian J Med Sci [Serial
online] 2005 [cited 2007 Apr 4], 59:143-149. Available
from:
http://www.indianjmedsci.org/text
asp?
2005/59/4/143/16119.
5. Amonker RG, Brinker GD. The level of development
and knowledge, attitude and practice of family planning
in India. Social Development Issues. 2000; 23(2).
Available from: http://www.iucisd.org.
6. Rao AAK. Client Demand Approach (CDA) in the
Revised Family Welfare Programame - A Feasibility
Study. Regional Health Forum WHO South-East Asia
Region. 2005; 5(2).
7. Prasad BG. Changes proposed in Social classification of
Indian families. J Indian Med Assoc 1970;55:198-9.
8. Key Indicators for Urban Poor in Madhya Pradesh from
NFHS-3 and NFHS-2. :www.uhrc.in.2006:1-2 (assessed
on jan 2011).
9. Rajesh Reddy S, K.C.Premarajan, K.A.Narayan, Akshaya
Kumar Mishra ; Rapid appraisal of knowledge, attitude
and practices related to family planning methods among
men within 5 years of married life Indian J. Prev. Soc.
Med Vol 34 No.1&2 page 63-66.
107
ISSN: 0976 3325
Original Article.
OUTBREAK INVESTIGATION OF CHOLERA IN BHARUCH CITY
Navneet G. Padhiyar1, Jivraj Damor2
1Assistant
Professor, 2Associate Professor, P.S.M. Department Govt. Medical College, Vadodara
Correspondence:
Dr. Jivraj Damor
D/27, Akanksha Duplex, Laxmipura road Gorwa Vadodara - 390016
ABSTRACT
Introduction: Cholera is an acute diarrhoeal disease, present in India since ancient times. Cholera
epidemic was reported in June 2009 in Bharuch city, Gujarat.
Aim: To find out the cause of cholera epidemic and to suggest preventive and control measure.
Study design: Cross sectional study. Person from high risk area were interviewed
Results: Contamination of drinking water with sewage water was found to be the cause of this
epidemic.
Key words: cholera, drinking water, sewage system.
INTRODUCTION
An outbreak is the occurrence of cases of an
illness, specific heath related behaviour or other
event, clearly in excess of normal expectancy in
a community in a specific time period. An
outbreak is limited or localized to a village,
town or closed institution. All efforts should be
made to investigate such outbreaks at the
earliest to prevent further spread.
Epidemiological studies have shown that
cholera is responsible for about 5 – 10 % of all
acute diarhhoea cases in non epidemic
situation1.
Cholera is a severe bacterial infection caused by
the bacteria Vibrio cholerae, which primarily
affects the small intestine and the main
symptoms include production of profuse watery
diarrhoea and vomiting.
Transmission is primarily by the acquisition of
the pathogen through contaminated drinking
water or infected food. The severity of the
diarrhoea and associated vomiting can lead to
rapid
dehydration
(hypohydration)
and
electrolyte loss. If these are not replaced then
death may follow.
The primary symptoms of cholera are profuse
diarrhoea, severe dehydration and abdominal
pain. Cholera may also cause vomiting. These
symptoms start suddenly, usually one to five
days after infection, and are the result of a toxin
produced by the vibrio cholerae bacterium that
compels profuse amounts of fluid from the
blood supply into the small and large intestines.
People infected with cholera suffer acute
diarrhoea. This highly liquid diarrhoea,
colloquially referred to as "rice-water stool" is
loaded with bacteria that can infect water used
by other people.7 Cholera is transmitted through
ingestion of water contaminated with the
cholera bacterium, usually from faeces or other
effluent. The source of the contamination is
typically other cholera patients when their
untreated diarrhoea discharge is allowed to get
into waterways or into groundwater or drinking
water supplies.
An area is declared free of cholera when twice
the incubation period i.e. 10 days has elapsed
since the death, recovery or isolation of the last
case2.
Date of Investigation:- 17 -06-09
Total population of Bharuch city is 1, 80,000
Symptoms of cholera:NATIONAL JOURNAL OF COMMUNITY MEDICINE 2011 Volume 2 Issue 1
•
First case of cholera reported on 27/05/09
108
ISSN: 0976 3325
•
Total 16 confirmed cases of cholera as on 1706-09. Of which 2 cases are from Asa village,
Taluka Jaghadiya. The remaining cases
reside in urban area of Bharuch.
•
•
•
Table 1: Age and gender wise distribution of
cases reported
Age (Years)
1 -5
5 -15
15-60
>=60
Total
Male
0
0
5
0
5
Female
1
1
6
3
11
Total
1
1
11
3
16
•
Majority of the cases are in the age group of
15-60 years. There is no preponderance of
cases in extremes of age.
•
There is no clustering of cases by time and
cases have appeared as sporadic events over
a period of time which suggests a
continuous exposure rather than a point
source. Further the cases have appeared in
more than one area suggesting a diffuse
source of infection rather than a single
source.
•
Six cases are from Ektanagar area of
Bharuch. First case of cholera was also from
this area on 27-5-09. Total population in
Ekatanagar area is around 4000. Remaining
cases were from different areas of Bharuch.
Line listing of all cases is attached herewith.
High risk geographical area - Ektanagar:•
•
Leakage in water supply pipes has led to
contamination of drinking water with
sewage. There is blocked sewerage system.
Breeding places of mosquito and housefly
were evident. Source of drinking water is
piped water supply by municipality.
Residents from this area complained of bad
odor from water on the day of visit.
Out of 91 water samples 50 found positive
while 41 found negative for Chlorine as
reported by ADHO Bharuch.
At present tap water supply was stopped
and alternate supply by tanker twice a day
was established which was inadequate.
Removal of garbage has been undertaken
yet not complete.
Chlorine tablets were distributed only once
initially.
Repairing of 75 leakages in water supply
line out of 88 leakages found.
Microbiological aspects: •
Two-stool samples from the patients
admitted at civil Hospital, Bharuch on the
day of visit were taken and then processed
at Department of Microbiology, Medical
College, Vadodara, for cholera.
Conclusion and Recommendation:•
•
•
•
•
•
•
•
Description of Control measure taken: •
From all these observations it is concluded
that
cholera
outbreak
is
due
to
contamination of drinking water due to
leakage in water supply system.
Affected person had not consumed outside
food during 2 days prior to illness which
suggests that infection is water borne.
It is recommended in present situation that
water supply should be safe and
chlorinated. In affected area frequency of
water supply by tanker should be in
proportion of population.
Distribution of chlorine tablet and educating
people how to use should be continued.
Prophylaxis with Doxycycline should be
given to family contacts and in neighboring
houses when warranted.
IEC: -Health education to people regarding
water safety and personal hygiene should be
taken up including not eating street food.
Boiling
of
drinking
water
before
consumption wherever feasible. IEC can be
through
newspaper,
local
television
channels, distribution of pamphlets.
Local health authorities should take up
measures to destroy unsafe street food and
check water quality in ice factories also.
Assessment and evaluation of water supply
system to look for leakages and clearing up
of blocked sewage lines should be taken up
on an urgent basis. Long term plans for
replacement of water pipes and sewage
system where required is advocated3.
REFERENCE
1.
Fricker, J., Children in the tropics 1993 No. 204.
109
ISSN: 0976 3325
2.
3.
4.
WHO (1994), Weekly Epidemiological Record No 3, 29
January 1994.
WHO (1994), Health situation in the South East Asia
Region 1994 - 1997 Regional office for SEAR, New
Delhi.
Pike J (23-10-2007) “Cholera – Biological Weapons”
Weapons of Mass destruction, Global secutiry.com
5.
6.
7.
www.who.int/cholera/countries.
www.worldwaterday.org/wwday/2001/disease/chole
ra.html
“The origin of quarantine” Clinical infectious disease”
35 (9) 1071 -2.
110
ISSN: 0976 3325
Original Article.
COMPARATIVE STUDY OF SELECTED PARAMETERS OF GENDER DISCRIMINATION IN
RURAL VERSUS URBAN POPULATION OF AHMEDABAD, GUJARAT
Rashmi Sharma1, S Mukherjee2
1Assistant
2Dean,
Professor, Community Medicine Department, GMERS Medical College, Sola, Ahmadabad
Gujarat Adani Institute of Medical Sciences, Bhuj, Gujarat.
Correspondence:
Dr. Rashmi Sharma,
Assistant Professor, Community Medicine Department
GMERS Medical College, Sola, Ahmadabad
ABSTRACT
It was a population based cross sectional study done with the objective of comparing some
parameters (attitude & practice) of gender discrimination (GD) in rural and urban areas of
Ahmedabad district. A population of 963 (446 urban & 517 rural) showed alarmingly adverse sex
ratio (SR) as low as 562 among urban preschoolers. GD was prevalent in both study areas but
manifested differently. Preference of male child by both partners an indicator of gender
discrimination was seen in both areas, It correlated with female literacy, their low mean age at
marriage and first conception. While urban areas showed more adverse sex ratio coupled with
awareness and use of Ultrasonography (USG) for sex determination and poor employment status,
rural areas exhibited (along with adverse sex ratio) poor literacy and employment status of females
and poor contraceptive use.
Key words: Gender discrimination, sex ratio, rural and urban areas
INTRODUCTION
“Biggest disease today is not leprosy or
tuberculosis, but rather the feeling of being
unwanted” (Mother Teresa).
“You can tell the condition of a nation by
looking at the status of its women” (Pandit
Jawaharlal Nehru).
‘Women’s rights are the edifice on which human
rights stand’ (Dr APJ Abdul Kalam).
Above statements by great human beings find
an echo in a comment by United Nations that
discrimination against girls anywhere in the
world is a social ill and violation of human
rights which must be stopped.1 Gender describes
the socially construed roles, activities and
responsibilities assigned to women and men in a
given culture, location or time. Gender is
defined as a social construct of the set of
qualities and behaviors expected from male and
female2. While an individual’s sex does not
change, gender roles are socially determined
and change over the time period. A child’s sex is
determined before birth but gender is learned3.
The
word
discrimination
means
treat
differently and gender discrimination (GD)
means relatively different treatment to the
persons (by society) on the basis of gender.
Females in our society meet inferior treatment
and this discrimination is widely prevalent in all
areas including health care and in both rural and
urban areas. It reflects through many direct and
indirect parameters. “Son preference affects all
aspects of women’s life, including child care,
health education, employment, because she is
discriminated sine the moment she is born and
sometimes even before if sex selection
procedures are available”. 4
Sex Ratio (number of females per 1000 males)
and preference of male child are two indicators
from Gujarat which reflect the GD situation in
the state. Data from Census 2001 depicts a
decline in overall sex ratio from 934 (1991) to 920
(2001) and more so for urban areas (from 907 in
1991 to 880 in 2001). This decline is more
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pronounced in children up to 6 years of age (45
points from 928 in 1991 to 883 in 2001) against
the drop of 18 points (from 945 in 1991 to 927 in
2001) for entire nation5. The proportion of
couples in Gujarat who currently have 2 sons or
1 son and 1 daughter and do not want any more
children varied between 90 – 95 percent while
this proportion for couples with 2 daughters
was only 49 percent6. We believe that GD is
prevalent in both rural and urban areas of
Gujarat but manifests differently. Therefore this
study was conducted to document the gender
discrimination and compare rural and urban
differences reflected by various parameters.
A population based cross sectional study was
carried by trained medical social workers under
the direct supervision of us (RS) with the help of
structured questionnaire using interview and
observation technique during October to
November 2006 in the catchments areas of rural
health training center (Santej) and urban health
training center (Sanand) of the institute. A
house-to-house visit to cover 100 eligible
couples (married couples with the age of female
partner ranging between 15 and 44 years) each
from both areas was carried out through
stratified sampling. Sample of 100 couples for
each area (total 200) was considered adequate
for the logistic reasons. In order to ensure the
fair representation of entire study area, each
area was divided into 4 quadrants and 25
eligible couples from each quadrant were taken
and first house was selected randomly, if last
house had more than one eligible couple than all
couples from that house were covered. Verbal
consent was obtained from all the respondents
prior to interview. Subjects were explained
objectives of the study and assured of
confidentiality. Data was analyzed in EpiInfo
and wherever found necessary tests of
significance such as chi square for qualitative
and Z test for quantitative data were applied to
check the statistical validity of observed
differences.
RESULTS
Populations of 446 from urban and 517 from
rural areas were covered which yielded 101
(urban) and 104 (rural) eligible couples (against
the sample size determined as 100 from each
area) from 107 and 120 families respectively.
Based on mean family size, families were
slightly larger in rural (4.3) than urban areas
(4.2). Eligible couple rates were high in urban
(226.5/ 1000) than in rural (201.2/ 1000) areas.
Overall unfavorable sex ratio was observed in
both study areas. It was alarmingly adverse
among urban under fives (562.5) and favorable
for > 45 years in both areas (table 1).
Table 1: Sex ratio (SR) as per the age of study
subjects (N=963)
Age
Rural
Urban
(Years)
Number
SR
Number
SR
0–5
53
1028.3
50
562.5
6 – 15
112
836.1
113
1017.9
16 – 45
279
910.1
240
983.5
> 45
73
1085.7
43
1263.2
Total
517
446
SR = number of females per 1000 males
Literacy status of female partners amongst these
couples was significantly high in urban than
rural areas (X2 = 49.6; df = 3; p < 0.001). Higher
education too was more in urban areas (table 2).
Table 2: Education status (percentage) of
studied women
Education Status
Illiterate
Up to primary
Up to SSC
SSC & above
Rural (104)
42.9
18.1
12.4
26.7
Urban (101)
9.1
11.5
19.2
60.4
Very few women (5.0% in urban & 10.6% in
rural) were employed. However, rural females
were engaged in menial jobs, while in urban
areas they were engaged in other jobs as well.
Ages at marriage, first conception & first
delivery for females were low in general but all
three were significantly low in rural areas (p <
0.01) (table 3).
Contraceptive use is largely perceived as
responsibility of females while the decision in
this regard is largely taken by male partners or
even other family members such as mother in
law. Ever Contraceptive use rate which is based
on contraceptive use by either of the partner and
includes of past and/ or current use was
significantly high (P < 0.001) in urban (68%)
than rural (55%) areas. Dominant reason for
poor contraceptive use in rural areas was
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ISSN: 0976 3325
“husbands don’t want it”. Ultrasonography
(USG) is a common test performed during
pregnancy for sex determination of fetus. Based
on the recall, more women in urban (29)
underwent USG than in rural areas (19) and the
difference was statistically significant (p <0.05).
When asked about the indication for USG,
majority women in both areas mentioned
“advice of doctor”, while 5 and 4 women from
urban and rural areas respectively confessed of
undergoing it for sex determination of fetus.
USG rates rose with education of women in both
areas. Male child preference (son syndrome) was
there and was more in female partners from
rural (50 %) than urban areas (41.5 %).
Table 3: Some parameters showing gender discrimination in rural and urban areas
Parameters
Age at marriage
Age at first delivery
Age at first conception
No. of live birth
Rural (N = 104)
Mean
SD
17.7
2.8
18.6
5
18.3
4.9
2.2
1.3
More females in urban areas were either unclear
or not particular (or diplomatic?) about gender
of child (25.7 % compared to 11.5 % in rural
areas). Large numbers of male partners (more in
rural) were unavailable during the survey.
However, their preference for male child too
was high in both areas but was even higher in
urban areas
Table 4: Preference child’s gender (percent) by
female partner
Sex
Male
Female
Any one
Not replied
Percent response
Rural (104)
Urban (101)
50
41.5
35.6
32.6
11.5
25.7
2.8
0
DISCUSSION
In the absence of any recognizable pressure,
studies world over suggest a SR (number of
females per 1000 males) at birth as a biological
constant with a value of about 943 – 945 females
per 1000 males7.
SR in our study was
alarmingly low (562) for urban preschool
children (table 1). It is an accepted fact that the
impact of differential sex selective undercount,
age reporting and migration is negligible in this
age group and the SR here are principally
influenced by sex ratio at birth and to some
extent on sex selective mortality in this age
group. Higher SR favoring elderly females seen
in both areas (table 1) are due to the excess male
mortality in this age group as a result of
occupational exposure in males, longer life
Urban (N = 101)
Mean
SD
19.6
2.8
20.1
4.1
20.6
4.3
1.9
1.1
Statistical analysis
Z Value
Interpretation
3.2
Significant
2.3
Significant
3.7
Significant
0.53
Significant
expectancy for females and cardiac and
respiratory diseases which affect more males
(missing males!). Current adverse sex ratio
among under-fives if remain unchecked, will
take little time to show its impact in higher age
groups, as it has cumulative effect. Adverse SR
has been linked with low status of women in
communities which in turn is determined by her
position in industry, occupation, economy,
education and decision making power in the
family7.
Female literacy as well as the
proportion of women with high education was
high in urban areas in the present study.
Education especially female education is a major
factor influencing health. It leads to better
utilization of health care and greater
community/ political participation8. Because of
low literacy only 5 to 10 percent women in this
study were employed. Though female
employment rate was high in rural areas, they
were engaged mainly in unskilled job but in
urban areas due to better education were
engaged in variety of jobs. Literacy status does
not seem to be beneficial for improving sex
ratios in this study as there were stronger factors
other than literacy in causation of decline in
female population. Despite the fact that
proportion of women with higher education was
high in urban areas, the adverse sex ratio was
more in urban areas. Pre-conception and preNatal Diagnostic Techniques (Regulation and
Prevention of Misuse) act has not worked as a
deterrent. Improvement in literacy and
subsequent
improved
education
and
employment opportunities will take time to
develop the favorable attitude and reflect in
practice. Mean age at marriage, first conception
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ISSN: 0976 3325
and first delivery all three were significantly low
in rural areas, which deprive these women from
educational and job opportunities. More number
of live births in rural areas shows highunregulated fertility and poor contraceptive use.
Contraceptive use was significantly low (p <
0.001) amongst rural couples (55.0%). Dominant
reason for non use of contraceptive was
husband do not want in rural and no need
perception in urban areas. Contraceptive use
depends upon education, attitude and
availability of services8. Desire of male child
was more in rural indicates prevailing gender
discrimination. Male child preference was more
overtly prevalent in rural females though the
difference was statistically not significant (P >
0.05), but literate women in urban areas are
sometimes diplomatic in stating as aware of the
current facts. Renu from Chandigarh had four
abortions in five years says that according to her
husband having a son is more important than
having a child9.
Five women in rural and 4 in urban in this study
underwent USG for sex determination but under
reporting cannot be ruled out and it was
observed elsewhere10 that USG rate rose with
education of women. Here 13 percent women
had undergone sex determination and there
were two female feticides. It also revealed the
fact that despite the ban on sex determination
the practice still continues in north India
through private clinics10. Son syndrome is a
reflection on the low status of females in our
society. Important reason for this are social
responsibilities perceived to be undertaken by
males such as propagation of family name,
support in the old age, perform cremation and
dowry11. Ironically, USG which is one of the
most beneficial diagnostic tools to monitor fetal
health but in connivance of some of the doctors
is widely misused in sex determination leading
to female feticide leading to the skewed SR in
children.
CONCLUSION
Historically India had a deficit of women
compared to most other countries. Until the
1980s, women and girls were dying either of
neglect or were killed soon after they were born
(infanticide). Today, thanks to ‘advances’ in
medical technology, they are now eliminated
while still in the womb. Female feticide has
become an organized crime and the ultrasound
machine has turned into an instrument of
murder. This study explores GD as prevalent in
both areas and is evident by alarmingly low sex
ratio (SR) among urban under fives (562), high
USG rates in urban especially in educated ones.
Low education and high dropouts (female), poor
quality/ quantity jobs, low contraceptive uses
reveal
gender
discrimination
in
rural
population. Main causes of non-use of
contraceptive – “husbands do not want or
“desire for son” summarizes the scene in rural
and urban areas respectively. More women and
men everywhere preferred male children.
RECOMMENDATIONS
• Gender discrimination is deep-rooted so
women
empowerment
through
better
education, employment opportunities and
reservation at various places only, in long
term can eliminate this problem.
• Intensive
and
sustained
Information,
Education
and
Communication
(IEC)
campaign to masses through all channels with
the incorporation of rural and urban specific
messages.
• Monitoring of sex ratio at birth through civil
registration system must be intensified.
Complete registration of births and deaths
especially of girls, pregnancy and abortion
should be pivotal function of village/ nagar
panchyats to safeguard against the evil
practice of feticide.
• Implementation of PNDT act should be more
meaningful and realistic. As such the legal
measures can play limited role in correcting
this imbalance and discrimination. Still the
persons whether from community or amongst
care providers once found guilty should be
severely punished.
• Removal of GD cannot be achieved by the
health department alone, therefore, each one
from the society such as parents, teachers,
social scientists, doctors, lawyers, journalists,
political and religious leaders within their
own domain have to play a role to curb this
practice.
REFERENCE
1. UNICEF. United Nations Children fund, Website:
http://www.unicef.org. 2007.
2. NACO. Quest on HIV & AIDS. Hand book for young
people NACO: 13 -14.New Delhi.2004.
3. Kishore J. Gender: The Vanishing Girl Child New Delhi:
Century Publications. 2005.
4. WHO. World Health Organization. Women’s health in a
social context in the western Pacific Region. WHO.1997.
114
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5. Census of India. Registrar General of India (RGI) at
www.censusindia.net. 2001.
6. NFHS 3. NFHS 3 Fact Sheet Gujarat Provisional Data,
Ministry of Health & Family Welfare, Government of
India, New Delhi.2005-06.
7. Haldar A. Skewed Sex Ratio. Indian J Med Res. 2006;
5916: 583-584.
8. Khokhar A, Garg S & Bharti N. Determinates of Reason
of School Drop outs Amongst Dwellers of an Urban
Slum of Delhi, Indian Journal of Community Medicine
2005; 30 (3): 92.
9. Aravanudar Gita. Disappearing daughters: the tragedy
of female feticide. New Delhi, Penguin.2007.
10. Singh AJ, Arora K. Status of sex determination tests in
North Indian Villages, Indian Journal of Community
Medicine 2006; 31(1): 43.
11. Vadera BN, Joshi UK, Unadakat SV, Yadav BS & Yadav
Sudha. Study on Knowledge, Attitude and Practices
Regarding Gender Preference and Female feticide
among pregnant women. Indian Journal of Community
Medicine 2007; 32 (4): 300.
115
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Original Article.
A STUDY ON OCCUPATIONAL PAIN AMONG DENTISTS OF SURAT CITY
Sumit Moradia1, Prakash Patel2
1Consulting
Dental Surgeon, Surat 2Assistant Professor, Department of Community Medicine,
SMIMER, Surat
Correspondence:
Dr. Prakash Patel
Assistant Professor, Department of Community Medicine, SMIMER, Surat
Mobile: 9426039663
ABSTRACT
This study has been conducted to measure prevalence of pain related to dental work among dentists
in Surat city and to identify the aggravating and relieving factors associated with the pain. In this
cross sectional study, 77 randomly selected dentists were interviewed. Prevalence of pain was 63.6
percent. Back was the commonest site for pain. Prolong sitting was reported to be the most common
aggravating factor for pain while correcting working post relieve pain in most. Most of the dentists
did not take any treatment for pain which may adversely affect the condition and increases the
severity of the pain. Regular daily exercise as well as physiotherapy are helpful to relieve pain but
very few doing it regularly. Some dentists took pain killers while very few consulted orthopedic
surgeons for treatments.
Keywords: Musculo-skeleton pain, dentist, exercise, posture
INTRODUCTION
A wide variety of deleterious work
environmental factors are proved to affect the
physical health of dentists or even aggravate
their preexisting disorders.1-3 Studies have
shown that dentists report more frequent and
worse
health
problems3
particularly
musculoskeletal pain.4
There is increasing
evidence that unique working conditions in
dentistry can significantly affect the health of
dentists.
Musculoskeletal pain, particularly back pain,
has been found to be a major health problem for
dental practitioners. 4-6
Dentists commonly experience musculoskeletal
pain during the course of their careers. While
the occasional backache or neck-ache is not a
cause for alarm, if regular pain or discomfort is
ignored, the cumulative physiological damage
can lead to an injury or a career-ending
disability. The dentists are at high risk of neck
and back problems due to the limited work area
and impaired vision associated with the oral
cavity. These working restrictions frequently
cause a clinician to assume stressful body
positions to achieve good access and visibility
inside the oral cavity. Furthermore, dental
procedures are usually long and require much
more concentration during work. Back pain is
one of the most common and troublesome of
complaints; its exact causes are legion and an
exact diagnosis is often difficult.7
Some investigations have shown that the
prevalence and location of pain and other
symptoms may be influenced by posture and
work habits, as well as other demographic
factors.6
Several dental procedures require the dentist to
assume and maintain positions that may have
potential
disadvantages
for
their
musculoskeletal system.8 Their work with
patients is often performed with their arms
abducted and unsupported and the cervical
spine flexed forward and rotated lead to high
prevalence of pain in back, neck and shoulder
region.5, 9
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The study has been conducted to measure
prevalence of pain related to dental work among
dentists in Surat city and to identify the
aggravating and relieving factors associated
with the pain.
METHODOLOGY
The study was conducted in Surat city in the
month of January 2011. Taking a population of
400 dentists as registered to local Indian Dental
Association branch and prevalence of 80% of
neck/back/shoulder pain among dentists6 the
sample size was found to be 67 (using Epi-info
2002 software). For the calculation confidential
limit of 95% and allowable error of 10% was
considered.
Considering certain non response, 80 dentists
were randomly selected from register of IDA.
All selected dentists were contacted and
explained about the study details. Informed
verbal consent was sought from all dentists and
personnel interview was conducted for those
who agreed for participation. A pretested precoded questioner was used to record
information obtained during interaction with
participants.
The data was analyzed using Epi Info 2002
software (Database and statistics software for
public health professionals. July 2002). Statistical
significance was said to be established when p
value is < 0.05 at 95% confidence interval.
the rest, pain was started after completing their
graduation.
Table 1: Profile of dentist participated in the
study
No of dentists (%)
Gender
Female
Male
Age group (years)
<30
>30 - 40
>40
Weight (Kg)
<=50
>50 - 60
>60 - 70
>70
Experience (years)
<=5
>10
>5 - 10
Presence of pain
Yes
No
23 (29.9)
54 (70.1)
55 (71.4)
18 (23.4)
4 (5.2)
11 (14.3)
25 (32.5)
27 (35.1)
14 (18.2)
45 (58.4)
7 (9.1)
25 (32.5)
49 (63.6)
28 (36.4)
Table 2: Distribution of pain according to site of
pain among dentists (n=49)
Site of pain
Neck pain
Back pain
Shoulder pain
Pain in wrist
Pain in leg
No. of Dentist (%)
21 (42.9)
37 (75.5)
11 (22.5)
1 (2.04)
1 (2.04)
OBSERVATION AND DISCUSSION
Out of selected 80 dentists 77 dentists agreed to
participate in the study. Profile of the study
participants is described in table 1.
Mean age of participants was 29.4 years (SD
6.38). Mean weight of participants is 62.3 kg (SD
10.6). Current study revealed that 49 (63.6%)
dentists had at least one kind of occupational
pain either neck or back or shoulder or
combination of it.
Back, neck and shoulder are most common sites
of pain reported by 75.5%, 42.9% and 22.5%
dentists respectively. Occurrence of pain at these
sites was reported by many studies in the past.
10, 6 Forty seven (95.9%) dentists out of 49 had got
pain after starting dentistry (Table 2). Only two
participating dentist reported that the pain was
started during their under graduate study. For
Five dentists stated that they were feeling
continuous pain during the whole day while
remaining 89.8% had intermittent pain which
was precipitated and or aggravated by certain
factors. Prolong sitting posture was the most
common factor (95.9%) which aggravate the
pain.
On asking to describe severity of their pain, 21
(40.8%) dentist categories their pain in to mild
category as pain didn’t demand change in their
working posture. 22 (44.9%) dentist classify their
pain in to moderate category as the pain made
them to change posture while working. The
remaining 7 (12.2%) categories their pain in to
severe pain as it compelled them to take rest in
between.
Certain factors help the participants to relieve
their pain which includes correct posture
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(46.9%), pause for few minutes (32.7%), muscle
relaxing exercise (24.5%), analgesic drugs
(10.2%), and complete rest for a day (4.1%), etc
(Table 3). Similar to this study, a study in
Glasgow also found that improving or
correcting posture can definitely help to relieve
the pain.11
1.
2.
3.
Table 3: Factors aggravating or relieving pain
(n=49)
Factors
Pain aggravating factors
Prolong sitting
Rotation
Lifting Heavy object
Driving
Trauma
Pain relieving factors
Correct posture
Pause in working
Exercise
Analgesic drug
Short sitting
Ortho belt
Rest
Dentist should avoid working in bent
position. Straight posture helps to prevent
development of pain as it maintains the
normal “s” shape of spinal cord and reduces
stress on intervertebral discs.
Education of correct posture should be part
of under graduate dental education.
Dentists should be encouraged to take
regular breaks.
Dentist should do regular exercise especially
relaxation exercise during their practice
No. of Dentist (%)
47 (95.9)
7 (14.3)
5 (10.2)
2 (4.1)
1 (2.0)
23 (46.9)
16 (32.7)
12 (24.5)
5 (10.2)
1 (2.0)
1 (2.0)
2 (4.1)
Only few dentist remained absent in their
clinical work due to pain. Three dentists
remained absent for one day and 5 for more
than 2 days.
Medical treatment and physiotherapy exercise
play important role in management of musculoskeleton pain. Among the 49 study participants,
49% had never taken any treatment of their
work related pain (table 4), which reveled
ignorance in the participants. Ignorance of pain
in early stage and continuous exposure to
aggravating factor ultimately convert mild and
moderate pain in to sever disabling pain.
Regular exercise was found to be effective in
preventing and relieving dental work related
pain.12
Table 4: Measures taken by study participants to
relieve pain (n=49)
Treatment
No treatment
Drugs
Exercise
Physiotherapy
Other
4.
No. of Dentist (%)
24 (49.0)
8 (16.3)
15 (30.6)
13 (26.5)
6 (12.2)
ACKNOWLEDGEMENT:
We are grateful to Dr Paresh Moradia, Secretary,
Surat IDA Branch and the department of
Community Medicine of SMIMER for providing
guidance and technical support. At last, special
thanks are due to participating dentist for
encouraging response and sparing their
valuable time for the study.
REFERENCES
1. Myers HL, Myers LB (2004) ‘It’s difficult being a dentist’:
stress and health in the general dental practitioner.Br
Dent J 197, 89–93.
2. Puriene A, Janulyte V, Musteikyte M, Bendinskaite
R(2007) General health of dentists. Literature review.
3. Szymanska J (2002) Disorders of the musculoskeletal
system among dentists from the aspect of ergonomics
and prophylaxis. Ann Agric Environ Med 9, 169–73.
4. Shugars D, Miller D, Williams D, Fishburne C, Srickland
D. Musculoskeletal pain among general dentists. General
Dentistry 1987;4:272-6.
5. Murtomaa H. Work related complaints of dentists and
dental assistants. Int Arch Occup Environ Health
1982;50: 231-6.
6. Marshall ED, Duncombe LM, Robinson RQ, Kilbreath
SL. Musculoskeletal symptoms in New South Wales
dentists. Aust Dent J 1997;42:240-246.
7. McRea R. Clinical orthopedic examination. 3rd edition.
Churchill Livingstone, Longman Group, London, UK.
1990.
8. Powell M, Smith JW. Occupational stress in dentistry:
The postural component. Ergonomics 1964 (Suppl): 337340.
9. Shugars DA, Williams D, Cline SJ, Fishburne C.
Musculoskeletal back pain among dentists. General
Dentistry 1984; 32: 481-85.
10. Khalid A. Al Wzaan et al.. Back & Neck Problems
Among Dentists and Dental Auxiliaries The Journal of
Contemporary Dental Practice, Volume 2, No. 3,
Summer Issue, 2001)
11. Students of university of Glasgow dental school, a study
on back pain, 0105932c & 0105741c elective report 2005).
12. Shrestha BP, Singh GK, Niraula SR, Work Related
Complaints among Dentists, J Nepal Med Assoc
2008;47(170):77-81).
RECOMMENDATION
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Original Article.
EPIDEMIOLOGY OF DISABILITY IN INCIDENT LEPROSY PATIENTS AT SUPERVISORY
URBAN LEPROSY UNIT OF NAGPUR CITY
L B Chavan1, Prakash Patel2
1State Epidemiologist, Gujarat State AIDS Control Society, Ahmedabad 2Assistant Professor,
Department of Community Medicine, Surat Municipal Institute of Medical Education and Research,
Surat.
Correspondence:
Dr. Prakash B Patel,
Surat Municipal Institute of Medical Education and Research, Surat, Gujarat, India – 395010
Phone: +91 9426039663
ABSTRACT
Leprosy is a chronic infectious disease caused by Mycobacterium Leprae, affecting mainly peripheral
nerves and skin. Disabilities and deformities are major concerns as it triggers social, economic and
psychosocial problems of leprosy patients. In the study, 105 incident leprosy patients registered in a
randomly selected Supervisory Urban Leprosy Unit during year 2004-05 were interviewed. Disability
was graded as per WHO-2 point scale. There were 52 male and 53 female with median age of 26
years. The WHO grade -II disability was 12.38 % and it was significantly higher among manual
workers and housewives (76.92%, P<0.05). Hands and feet disabilities were found in 38.10 % while
nobody had eye related disability. Subjects with delayed diagnosis beyond 12 months had
significantly higher grade-2 disabilities than diagnosed earlier (P<0.05). Disability rate was also
higher in Multi-Bacillary leprosy patients (P<0.001). Ulcer was the most common type of grade-II
deformity (61.54 %) which was significantly higher in females (P<0.05). Prevalence of disability was
found higher in study area than national average. Awareness about Prevention Of Deformities (POD),
early diagnosis (<12 months) and treatment are recommended to avert visible deformities and hence
social stigma in leprosy patients.
Key Words: Leprosy, Deformity, Epidemiology, Disability
INTRODUCTION
Leprosy is a chronic infectious granulomatous
disease caused by Mycobacterium Leprae,
affecting mainly peripheral nerves and skin. As
a single disease entity, leprosy is one of the
foremost causes of deformities and crippling.
The deformities may result due to the disease
process (e.g. loss of eye brows, other facial
deformities), or those resulting from paralysis of
some muscle due to damage to peripheral nerve
trunk
(e.g.
claw-hand,
foot-drop,
lagophthalmos), or those resulting from injuries
or infection to hands or feet (e.g. scar
contractures of figures, mutilation of hands and
feet, corneal ulceration).1
The present MDT regimen used for treating
leprosy was introduced in the early 1980’s, since
than the prevalence has drops down
significantly. In Nagpur, since introduction of
M.D.T. in July 1988 – 89 during phased manner,
the Prevalence Rate has reduced from 82 per
10,000 in 1988-89 to 2.8 per 10,000 populations
on 1st April 2003. The proportion of cases with
visible deformity (grade- 2) was 1.8% in India
and 1.53% in Maharashtra state.2
However, social stigma remains a major
obstacle to self-reporting and early treatment.
Patients are compelled to hide their condition
and avoid diagnosis, allowing a completely
curable disease to worsen to the point of
disfigurement. This study was conducted to
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explore various epidemiological factors of
deformities associated with leprosy in Nagpur
city.
OBJECTIVE
1) To study the prevalence of disabilities as
per the WHO definition in newly detected
leprosy patients.
2) To study selected epidemiological factors of
disabilities in newly detected leprosy
patients in Nagpur city.
METHODOLOGY
Study was carried out in Supervisory Urban
Leprosy Unit (SULU)-II allotted randomly out
of three SULUs in the Nagpur city. This SULU
covers 8 Urban Leprosy Centers and having
population of 443,042 (Census-2001).
The study was conducted for the period from
April 2004 to March 2005. All new cases of
leprosy registered under the SULU during this
period were taken in to the study. Detailed
addresses were obtained from their respective
urban leprosy center with the help of Non
Medical Assistant. House to house visit was
carried out to collect data from leprosy patients.
Pre tested Performa was used to collect data.
Personal interview of each case was carried out
within one month of registration. Two rounds of
home visits were carried out at each family to
have maximum coverage. A thorough clinical
examination of the leprosy cases were done
with the help of Female Social Worker. All type
of disability related to leprosy were recorded.
Disability grading was done as per WHO-2
point scale. The observations were analyzed
using Epi-info 2002 software.
RESULTS
Under the eight urban leprosy centers of
Supervisory Urban Leprosy Unit -II, total 119
new cases of leprosy were registered during the
period April 2004 to March 2005. Out of which,
we are able to contact 105 patients which were
finally analyzed. The data obtained was
analyzed using different variables.
Table 1: Distribution of leprosy cases according to age, sex and type of leprosy
Age in
years
<15
16 – 30
31 – 45
46 – 60
> 60
Total
Type of leprosy
Male
6
11
6
4
1
28
PB
Female
9
10
5
4
1
29
Total (%)
15 (26.32)
21 (36.84)
11 (19.30)
8 (14.04)
2 (3.50)
57 (54.29)
Overall 75(71.44%) cases were between the age
group of 16-60 years, which is economically
productive age group. The average age of
disease onset was 32.81 (SD 9.65) years ranging
from 5 years to 80 years. The median age of
leprosy was 26 years. Leprosy cases are almost
equally distributed in both the genders. Leprosy
cases
were
clinically
classified
into
Paucibacillary and Multibacillary leprosy
according to WHO study group on
chemotherapy of leprosy 1993. (3) Table 1
reveals that PB cases reported higher in newly
registered patients.
The disability rate found to be 38.10 % for
Hands and Feet. Eye disability was not found in
any Leprosy patient. The WHO grade –2
Male
2
11
2
4
5
24
MB
Female
2
9
6
3
4
24
Total (%)
11 (20.76)
19 (35.84)
11 (20.76)
7 (13.21)
5 (9.43)
53 (50.47)
Total (%)
19 (18.10)
41 (39.05)
19 (18.10)
15 (14.29)
11 (10.46)
105 (100)
disabilities among incident leprosy patients was
12.39%. Disability rate was more in MultiBacillary leprosy patients than in PauciBacillary (P<0.001).
Table 2: Distribution of leprosy cases according
to WHO grading of disability 3
Grade of
Total
disability for
PB (%)
MB (%)
(%)
limbs
Grade – 0
46(80.7)
19(39.6)
65(61.9)
Grade – 1
10(17.5)
17(35.4)
27(25.7)
Grade – 2
1(1.7)
12(25.0)
13(12.4)
Total
57 (54.3) 48 (45.7) 105 (100)
(Grade 0 Vs Grade 1 & 2) P<0.001
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Average delay in diagnosis of leprosy cases was
11.15 months, (range 0 to 66 months). The
median delay in diagnosis of leprosy cases was
11 months. Subjects with delayed diagnosis
beyond 12 months had significantly excess
grade-2 disabilities than diagnosed within12
months (P<0.05).
Table 3: Leprosy cases according to Delay in diagnosis and disability grading
Delay in diagnosis*
Disability Grading
Total (%)
Grade-1 (%)
Grade-2 (%)
Less than or equal to 12 months
21 (77.8)
4 (30.8)
25 (62.5)
More than 12 months.
6 (22.2)
9 (69.2)
15 (37.5)
Total
27 (67.5)
13 (32.5)
40 (100)
P<0.05 (*Delay in diagnosis (10): period between awareness of first sign/symptom to the start of
MDT)
A grade-II disability among Manual workers
and Housewives out of total was 76.92%, which
is significantly greater than others (P<0.05). The
odds in favor of Grade-2 disabilities are 3.49
times high among Manual workers and
Housewives as compared to others.
Most common type of grade-II deformity was
Ulcer (61.53 %). Ulcer deformity was
significantly higher in females than males
(P<0.05).
Table 4: Leprosy cases according to type of
Grade II deformity and Gender
Type of
Male
Female
deformity
(%)
(%)
Ulcer
1 (20.0)
7 (87.5)
Clawed finger/s
2 (40.0)
1 (12.5)
Clawed hand
1 (20.0) 0
Clawed hand
1 (20.0) 0
and Ulcer
Total deformities 5 (46.2)
8 (53.8)
(Ulcer Vs Non ulcer deformity P<0.05)
Total
(%)
8(61.5)
3(23.1)
1(7.7)
1(7.7)
13(100)
Table 5: Leprosy cases according to occupation and Grade –2 disabilities
Occupation
Grade- 2
disabilities (%)
10 (76.92)
3 (23.08)
Grade -1 or Grade 0 disabilities (%)
37 (41.11)
53 (58.89)
Leprosy
cases (%)
47 (45.63)
56 (44.37)
Manual workers and Housewives
Others with small-scale business, private
job, students, and unemployed and in
government job sectors.
Total
13 (100)
90 (100)
103* (100)
(Housewives & Manual workers Vs Rest of all disability P<0.05)
OR: 3.49 (95% CI 1.23-8.46)
* Occupation data was not available for 2 patients
DISCUSSION
The average age of onset of disease reported by
Kaur S et al (1982) 4 and Atsuro Tsutsumi et al
(2003) 5 was 35.07 years and 36.4 years
respectively, which is slightly higher than
present study.
Similar to current study findings of almost
equal males: female ratio, Stella, Van M Beer et
al (1999) 6, Mathew VG et al (2002) 7 and
Chaturvedi RM et al (1988) 8 had also reported
similar male: female ration.
Higher PB:MB ratio was observed in the present
study which is higher than Kyaw Tin study 9,
may be because of intensive case findings
activities during the survey period giving
predominance of PB cases than MB type.
Current study find 12.39% grade-2 disability
rate which is much greater than national and
state average. The incidence and number of
deformities or disabilities increases as the
disease lasts longer. Nerve thickening has often
been associated with deformities, which is more
common in MB patients in the present study1.
Longer delay in diagnosis, average 11.15
months as found in the current study indicates
poor IEC activities and or poor accessibility of
MDT services. 10, 11 Delay diagnosed patients
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present with higher rate of disability and it may
be the reason for significantly higher rate of
grade 2 disability in patient diagnosed after 12
months of onset of symptoms.
Deformities and disabilities are more commonly
found among manual workers, since they are
more frequently exposed to injuries and thus
infection to leprosy1. It may be true for
Housewives as minor scratches and injuries are
often neglected and /or not taken care of by
these workers and housewives leading to
disabilities.
Higher rate of ulcer in female may be due to
inadequate care of anesthetic hands and feet by
patient and /or lack of knowledge, awareness
and health education regarding protection of
anesthetic limbs from constant injury during
cooking, washing and further household work,
mostly neglected by females resulting in ulcer.12,
services, regular conduit of IEC in urban
slum areas recommended.
REFERENCES
1.
2.
3.
4.
5.
13
6.
CONCLUSION
7.
1.
2.
3.
4.
Prevalence of disability was found higher
in study area than national average is of
great concern.
Deformities found more among Manual
Workers and Housewives. Awareness
about Prevention Of Deformities (POD) to
this Target group in Nagpur city was
recommended as well a large-scale
prospective epidemiological study to find
out causes and progress of risk factors.
Disability bears stigmatizing psychological
impact on patients and society, so early
diagnosis within 12 months and prompt
and adequate treatment will help to avert
the visible deformities and hence social
stigma in leprosy patients.
As longer delay in diagnosis indicates poor
IEC activities and /or poor access to MDT
8.
9.
10.
11.
12.
13.
Yawalkar SJ (2002). Leprosy for Medical Practioners
and paramedical workers. 7th edn, Novartis foundation
for sustainable development, Basle, Switzerland, p13.
Garg BS, Deshmukh PR (2004). Progress Towards
leprosy elimination in Maharashtra state and Reflection
from Leprosy Elimination Monitoring, 2003. J
Mahatma Gandhi Inst Med Sci, 9(1), 5-9.
Government of India (1999). Learning material on
leprosy for capacity building of medical officers
working in hospital/ PHC/CHC/ Dispensaries.
Director General of Health Services, Ministry of Health
and family welfare (leprosy-Division), Govt Of Ind and
ILEP, New Delhi. pp 4-11.
Kaur S (1982). Endemicity of leprosy in union territory
of Chandigarh and surrounding state. Lepr. In India;
54: 428.
Tsutsumi A, Izutsu T, Islam A, et al (2004). Depressive
status of leprosy patients in Bangladesh: Association
with self perception of stigma. Lepr. Rev. 75(1):57-66.
Stella M. Van Beers, Mohammad Hatta and Paul R.
Klaster et al (1999). Patient contact is the major
determinant in incident leprosy implication for future
contact. Int J Lepr Other Mycobact Dis. 67(2):119-28.
Mathew VG, Roberts H (2002). Epidemiological
assessment of mono lesion leprosy cases. Lepr. Rev.
73(3):172-78.
Chaturvedi RM (1988). Epidemiological study of
leprosy in Malwani Suburb of Bombay. Lepr. Rev.
59(2): 113-20.
Tin
K
(1999).
Population
screening
and
chemoprophylaxis for household contacts of leprosy
patients in the republic of the Marshall Island. Int J
Lepr Other Mycobact Dis. 67(4 Suppl):S26-9.
Government of India (2002). NLEP information system:
Addl. Annex 14; Indian Second National Leprosy
Elimination Report 2002. Director General of Health
Services, Ministry Of Health and Family Welfare, Govt
Of Ind and WHO, New Delhi. pp 83-91.
Government of India (2002). Leprosy Elimination
Monitoring in Maharashtra. Director General of Health
Services, Ministry Of Health and Family Welfare, Govt
Of Ind and WHO, New Delhi. pp xiii, ii, 36.
Kaur H and Ramesh V (1994). Social problems of
women leprosy patients: A study conducted at 2 urban
Leprosy centers in Delhi. Lepr Rev. 65(4):361-75.
LEPRA (2002). Report of the international leprosy
association, technical forum. Lepr Rev. 73(2 suppl);
345-552.
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Original Article.
CORRELATES OF HYPERTENSION AMONG THE BANK EMPLOYEES OF SURAT CITY OF
GUJARAT
Ashwinkumar M Undhad1, P J Bharodiya1, Rupalben P. Sonani1
1Ex-intern,
Surat Municipal Institute of Medical Education & Research, Surat
Correspondence
Dr. Ashwinkumar M Undhad
ABSTRACT
Hypertension is becoming a public health emergency worldwide, especially in the developing
countries. The job of bank employees is both sedentary in nature and accompanies high levels of
mental stress, thereby at a higher risk of developing hypertension. The present cross-sectional study
was conducted to find out the prevalence and the determinants of hypertension among bank
employees of Surat city. Prevalence of hypertension was found to be 69.5%. Hypertension was
significantly associated with age 45 years or more, alcohol intake, waist circumference, body mass
index and diabetes.
Keywords: Hypertension, Body Mass Index, risk factor, correlates, diabetes, alcohol intake
INTRODUCTION
Hypertension is becoming a public health
emergency worldwide, especially in developing
countries, where studies projected an increase
by 80% in the number of hypertensive by the
year 20251. Hypertension is directly responsible
for 57% of all stroke deaths and 24% of all
coronary heart disease deaths in India2.
Hypertension is a controllable disease and a
small decline of 2mmHg population-wide in BP
can prevent 151,000 stroke cases. The prevalence
of hypertension has increased by 30 times
among the urban population over a period of 55
years and about 10 times among the rural
population over a period of 36 years3.
Many studies have shown that physical
inactivity is a significant risk factor of
hypertension. Also there are evidences that long
term mental stress is associated with
hypertension but more research is needed in this
area4. The job of bank employees is both
sedentary in nature and accompanies high
mental stress also. In India very few studies
have been conducted among bank employees
who are at a high risk of being hypertensive.
The present study was conducted to find out the
prevalence and risk factors of hypertension
among bank employees of Surat city of Gujarat.
METHODOLOGY
A cross-sectional study was conducted in the
seven purposively selected banks (nonprobability sampling), of Surat city. The total
number of employees (both officer and clerical
grade) was 218. Out of this 18 employees could
not be contacted in the two visits that we made
to the banks. Thus the total sample size covered
was 200. The period of the study was five
months, from July 2007 to November 2007.
Written permission from the managers of the
respective banks and verbal consent from the
respondents was taken for the study after
explaining about the study procedure, including
fasting plasma glucose estimation.
Information
regarding
their
biosocial
characteristics and their type of diet was
recorded in a predesigned and pretested
schedule. Also their weight, height, blood
pressure was measured and recorded. Blood
pressure was measured using a mercury
sphygmomanometer with the patient in sitting
position. Phase I (appearance of sound) was
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taken as systolic blood pressure and phase IV
(disappearance of sound) was taken as diastolic
blood pressure. Two readings were taken 2
minutes apart and the average was calculated.
As per JNC VI criteria for measuring blood
pressure, the subjects should not have had tea,
coffee etc. at least 30 minutes before the blood
pressure is taken. This is a limitation of our
study as it was not possible for us to ascertain it.
Subjects having Systolic Blood Pressure ³140 mm
Hg and/or Diastolic Blood Pressure ³90 mm Hg
or on anti-hypertensive medications were
classified as hypertensive (JNC-VI)5. For
classifying obesity, Body Mass Index (BMI) ³30
kg/m2 was considered obese) and Waist
circumference (for males ³102 cm and for
females ³88 cm was classified as obese)6
Classification of diabetes was done on the basis
of WHO (1999) criteria, according to which FPG
³126mg/dl, 110-126 mg/dl and <110 mg/dl are
categorized as diabetic, impaired fasting
glycemic and normoglycemic respectively7.
Those on hypoglycemic drugs/insulin were also
classified as diabetic.
Data was analyzed using the software SPSS 11.5
for Windows. The prevalence rates are given as
percentages and 95% confidence intervals were
estimated. Discrete data was analyzed using
Pearson.s Chi-square test for difference in
proportions. Two-tailed p-values less than 0.05
were considered significant.
RESULTS
The study subjects consist of 176 males (88.0%)
and 24 females (12.0%) with mean age of 46.4
years (25-59 years).
Table 1: Association of hypertension with certain biosocial characteristics and risk factors (n=200)
Biosocial characteristics/risk factors
Age
Less than 45 yrs
45 yrs or more
Sex
Male
Female
Occupational Grade
Clerical
Officer
Type of diet
Vegetarian
Non-vegetarian
Smoking
Never used
Ever used
Alcohol
Never used
Ever used
Body Mass Index
<30 kg/m2
³30 kg/m2
Waist circumference
Obese
Non-obese
Diabetes status
Diabetic
Non-diabetic
*Significant
Subjects (%)
Hypertensive (%)
X2 Value
p-value
62 (31.0)
138 (69.0)
29 (46.8)
110 (79.7)
21.89
<0.05*
176 (88.0)
24 (12.0)
125 (71.0)
14 (58.3)
1.60
>0.05
68 (34.0)
132 (66.0)
44 (64.7)
95 (72.0)
1.12
>0.05
172 (86.0)
28 (14.0)
118 (68.6)
21 (75.0)
0.47
>0.05
149 (74.5)
51 (25.5)
112 (69.1)
27 (71.1)
0.05
>0.05
129 (64.5)
71 (35.5)
104 (65.4)
35 (85.4)
6.12
<0.05*
172 (86.0)
28 (14.0)
112 (65.1)
27 (96.4)
11.14
<0.05*
61 (30.5)
139 (69.5)
88 (63.3)
51 (83.6)
8.24
<0.05*
40 (20.0)
160 (80.0)
33 (82.5)
106 (66.3)
3.99
<0.05*
Prevalence of hypertension was 69.5% (95% CI:
63.12% to 75.88%) and was much higher when
compared to that from various studies
conducted among the urban population
throughout India3,8. Higher mean age of our
study group as compared to the general
population, .white-collar hypertension and not
being able to ascertain about subjects intake of
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ISSN: 0976 3325
tea, coffee etc. 30 minutes prior to measuring
blood pressure could also have slightly
overestimated the prevalence.
Table 1 shows the association of certain biosocial
characteristics
and
risk
factors
with
hypertension.
Among
the
biosocial
characteristics
studied,
prevalence
of
hypertension was significantly higher (79.7%) in
the bank employees of age 45 years or more as
compared to the prevalence (46.8%) among
those less than 45 years of age. WHO (1978)
reported that blood pressure rises with age in
both men and women. Studies conducted
among the general population in India also
report that increasing age is associated with
hypertension.9,10 Sex, occupational grade, and
type of family of the subjects were not
significantly associated with prevalence of
hypertension. Hypertension Study Group (2001)
have also reported that there was no significant
difference between the mean systolic blood
pressures of men and women.11
According to WHO (1996), alcohol consumption
has been consistently related to high blood
pressure in cross-sectional as well as prospective
observational studies in several populations. We
also found the similar association.
Type of diet (vegetarian vs. non-vegetarian) and
smoking (ever-smokers vs. never-smokers) was
not significantly associated with hypertension
prevalence. This is in contrast to the finding of
Chennai Urban Population Study by Shanthirani
CS et al.10 There was a significant difference
between the prevalence of hypertension in
subjects with BMI ³30 kg/m2 (96.4%) and those
with BMI <30 kg/m2 (65.1%). Hypertension
Study Group (2001) also observed that a higher
BMI was associated with increased risk of
hypertension.11 In Chennai urban population
study, Shanthirani CS et. al observed that the
mean
BMI
among
hypertensive
was
significantly
higher
than
among
nonhypertensives.10 In our study when obesity was
classified by waist circumference, hypertension
prevalence among obese was significantly more
(83.6%) than the prevalence among the nonobese
(63.3%). In Chennai Urban Population Study by
Shanthirani CS et. al mean waist circumference
was significantly higher among hypertensive as
compared to that among non-hypertensives.10
According to WHO (1996), central obesity
indicated by an increased waist-hip ratio or
increased waist circumference has been
positively correlated with high blood pressure
in several populations. Among the diabetics,
prevalence of hypertension was significantly
more as had been reported by other studies.10, 11
This study highlights the burden of
hypertension among the bank employees. As
hypertension and diabetes was associated in our
study group, it hints at the possibility of higher
prevalence of .syndrome X among the bank
employees. This possibly puts them at a high
risk of coronary heart disease. Studies on noncommunicable diseases, focused on such highrisk occupational groups are rarely reported in
our country and more of such studies are
needed. Special programmes, integrating
preventive and curative care for bank employees
are required urgently.
REFERENCES
1.
Kearney PM, Whelton M, Reynolds K, Muntner P,
Whelton PK, He J. Global burden of hypertension:
analysis of worldwide data. Lancet 2005; 365:217-223.
2.
Rodgers A, Lawes C, MacMahon S. Reducing the global
burden of blood pressure related cardiovascular
disease. J Hypertens. 2000; 18 (Su.pl 1); S3-S6.
3.
Gupta R. Meta-analysis of prevalence of hypertension
in India. Indian Heart Journal. 1997; 49:43-48
4.
Chantal G, Chantal B, Gilles RD et. al; Effects of job
strain on blood pressure: A prospective study of male
and female white-collar workers. American Journal of
Public Health 2006 August; 96:8:1436-1443
5.
The sixth report of the Joint National Committee on
prevention, detection, evaluation and treatment of high
blood pressure (Nov. 1997), National Institute of
Health, National Heart, Lung and Blood Institute,
National High Blood Pressure Education Program,
Publication no. 98-4080.
6.
World Health Organization, Technical Report Series,
No. 916; WHO 2003.
7.
World Health Organization. Definition, diagnosis and
classification of diabetes mellitus; its risks and
complication; Report of a WHO consultation 1999.
8.
Gupta R, Gupta VP, Sarna M, Bhatnagar S et al.
Prevalence of Coronary heart disease and risk factors in
an urban Indian population: Jaipur Heart Watch-2,
Indian Heart Journal 2002; 54:1:59-66.
9.
Joshi PP, Kate SK, Shegokar V. Blood Pressure trends
and lifestyle risk factors in rural India. J Asso Phy Ind
1993; 41:9:579-819.
10. Shanthirani CS, Pradeepa R, Deepa R, Premalatha G,
Saroja R, Mohan V. Prevalence and risk factors of
hypertension in a selected South Indian population.the
Chennai Urban Population Study. J Assoc Physicians
India 2003; 51:20-27.
11. Hypertension Study Group. Prevalence, awareness,
treatment and control of hypertension among elderly in
Bangladesh and India. WHO Bulletin 2001;79:490-500.
125
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Original Article.
MICROALBUMINURIA IN DIABETIC PATIENTS: PREVALENCE AND PUTATIVE RISK
FACTORS
Deepak Parchwani1, S.P. Singh2
1Associate
Professor, Department of Biochemistry, Gujarat Adani Institute of Medical Sciences, Bhuj,
Gujarat 2Professor, Department of Biochemistry, M.L.B. Medical college, Jhansi, Uttar Pradesh
Correspondence:
Dr Deepak Parchwani
H/No-B/17, New G. K. General Hospital,
Gujarat Adani Institute of Medical Sciences , Bhuj (Guj)
E-mail: [email protected], [email protected] Phone: 7600024672, 9426857672
ABSTRACT
Microalbuminuria refers to the excretion of albumin in the urine at a rate that exceeds normal limits
but is less than the detection level for traditional dipstick methods and is considered as a marker of
diabetic nephropathy. The current study was conducted to establish the prevalence of elevated
urinary albumin levels (microalbuminuria) in a sequential sample of diabetic patients attending
hospital diabetic clinics and to determine its relationship with known and putative risk factors, to
identify micro- and normoalbuminuric patients in this sample for subsequent comparison of clinical
characteristics of the micro- and normoalbuminuric patients identified and to ascertain relationship of
serum angiotensin converting enzyme (ACE) activity with diabetic incipient nephropathy. This crosssectional analytical study was conducted at Gujarat Adani Institute of Medical Sciences
Bhuj(Gujarat).Patients having clinical albuminuria and with other causes of proteinuria were
excluded. Data was analyzed by SPSS software. Microalbuminuria was observed in 34.48% in patients
with type 1 and 28.33% in patients with type 2 diabetes mellitus respectively. There was no
statistically significant difference in the frequency of microalbuminuria between type 1 and type 2
diabetes mellitus patients. Having the condition was significantly associated with advanced age, poor
glycaemic control, dyslipidemia (with respect to total cholesterol, triglycerides and LDL-C), smoking,
body mass index and coexisting hypertension. The duration of diabetes was a significant correlate in
type 1 DM subjects only. No significant association with gender, HDL-C levels, age at onset of DM,
mode of treatment, socio-economic status and other lifestyle variations was found. All clinical and
biochemical parameters in patient with microalbuminuria was more adversely affected than patients
with normoalbuminuria. Serum angiotensin converting enzyme (ACE) levels were significantly
elevated (P<0.001) in both of the diabetic groups, moreover, its levels were higher in subjects with
microalbuminuria than in those without this complication (P<0.05).
Key words: Microalbuminuria, diabetes Mellitus, angiotensin converting enzyme activity,
dyslipidemia.
INTRODUCTION
Diabetic nephropathy is the chief cause of
morbidity and premature mortality in patient
with diabetes mellitus.This complication is first
manifested as an increase in urinary albumin
excretion (microalbuminaria) which progresses
to overt abluminuria and then to renal failure.1
Microalbuminuria is usually absent at diagnosis
of type 1 diabetes mellitus but may be present
at diagnosis of type 2 diabetes Mellitus 1 , partly
because
diagnosis
is
often
delayed.
Microalbuminuria is also considered to be a
predictor for cardiovascular disease both among
diabetic and non-diabetic subjects, as the
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ISSN: 0976 3325
presence of microalbuminuria is more reflective
of diffuse generalized vasculopathy
and
endothelial dysfunction, which in large arterial
beds hypothetically leads to atherosclerosis and
in the microcirculation ,may precede or
contribute to development of insulin resistance.2
Recent statistics from the World Health
Organization (WHO) project an increase in the
prevalence of diabetes worldwide particularly in
developing countries3 .Currently, India leads the
world with the largest number of diabetic
subjects and this is expected to further rise in the
coming years3 .Hence studies on diabetes related
complications are essential to assess the burden
of diabetes. Thus in this study an attempt has
been made to define more precisely the (a)
prevalence of microalbuminuria in an
unselected population of diabetes mellitus (b) to
evaluate
possible
relationship
among
microalbuminuria,
serum
angiotensin
converting enzyme and lipid parameters.
MATERIAL AND METHOD
The study was conducted on 180 diabetic
patients attending diabetic outdoor of Gujarat
Adani
Institute
of
Medical
Sciences,
Bhuj(Gujarat). These were compared with 50
healthy control.
Exclusion Criteria
1) Patients with overt diabetic nephropathy
(urinary albumin excretion rate > 0.5 gm/day)
and / or deranged renal function or other renal
disease.
2) Patients having history of cardiovascular
disease.
3) Urinary tract infection or recent illness.
4) Pregnant and lactating females.
Selected patients were divided into 3 groups
according to serum lipid profile. (NCEP
Classificaton)4
1) Good Metabolic Control: was defined as
when serum cholesterol was < 200 mg/dl or
serum triglyceride level < 150 mg/dl or
serum LDL level < 120 mg/dl.
2) Fair Metabolic Control: was defined as when
serum cholesterol was between 200 – 240
mg/dl or serum triglyceride level between
150 –200 mg/dl or serum LDL level between
120 –150 mg/dl.
3) Poor Metabolic Control: was defined as when
serum cholesterol was >240 mg/dl or serum
triglyceride level > 200 mg/dl or serum LDL
level > 150 mg/dl.
Venous blood was collected from subjects after
overnight fast and was subjected for following
estimations.
1. Plasma sugar by Trindel method.5
2. Serum Cholesterol by modified Roeschlau’s
method.6
3. Serum triglyceride by McGrowan method.7
4. HDL – C by Bursteim et al method.8
5. LDL – C was calculated by Friedewald’s
formula. 9
6. Microalbuminuria by Micral method.10
7. Serum angiotensin converting enzyme
activity by Cushman and Cheung method ,
modified by Letreut et al(1979).11
8. Glycosylated hemoglobin lon exchange Resin
method.12
RESULTS
Table 1. presents the clinical and biochemical
characteristics of control, normoalbuminuric
and microalbuminuric subjects and showed that
the 180 diabetic patients studied included 101
males and 79 females. Overall 54 had
microalbuminuria
(30%).
Prevalence
of
microalbuminuria among males was 31.25% and
among females was 28.57%. Thus present study
shows that prevalence of microalbuminuria
across the gender were not statistically
significant.
Patients with microalbuminuria had higher BMI
compared to normoalbuminuric subjects. (26.40
± 3.21 Vs 23.21 ± 2.68) (P < 0.05). Patients with
microalbuminuria had higher duration of
diabetes compared to normoalbuminuric
subjects (P < 0.001_. The prevalence of
microalbuminuria significantly increased with
diabetes duration.
Glycated hemoglobin (HbAlC) and mean age
was significantly higher in microalbuminuric
subjects compared to normoalbuminuric ones.
There was a very strong increse (P < 0.01) at the
level of angiotensin converting enzyme activity
in both of the diabetic groups. ACE activity
levels were also significantly higher in diabetic
patients with microalbuminuria than in
normoalbuminuric diabetic subjects (P < 0.05).
Table 2 shows the increased prevalence of
microalbuminuria with increasing dyslipidemia.
However no significant difference between
prevalence of microalbuminuria with respect to
metabolic control of HDL - C was found.
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ISSN: 0976 3325
Table 1: Characteristics of control and diabetic (normoalbuminuric and microalbuminuric) subjects
(Mean ± SD)
Parameters
Control
subjects
50
27/23
39.24 ± 10.20
22.0 ± 1.04
5.20 ± 1.40
170.40 ± 34.46
96.45 ± 14.34
52.96 ± 6.78
98.46 ± 18.49
17.46 ± 2.41
Normoalbuminuric
subjects
126
72/54
40.10 ± 12.00
6.2 ± 4.0
23.2 ± 2.68
7.98 ± 1.96
200.20 ± 26.47
164.40 ± 49.03
45.70 ± 7.46
125.50 ± 24.38
40.80 ± 3.96 +
Microalbumiburic
subject
54
29/25
45.70 ± 14.00*
9.0 ± 6.8 **
26.40 ± 3.21 *
9.01 ± 2.20 **+
227.26 ± 33.81 *
228.30 ± 56.06
45.42 ± 6.42
142.60 ± 36.48
46.42 3.71 * +
N
Male / Female
Age in years
Duration of Diabetic (years)
BMI (Kg/m2)
HbA1C (%)
Serum Cholesterol (mg/dl)
Serum Triglyceride (mg/dl)
HDL – C (mg/dl)
LDL –C (mg/dl)
Serum Angiotensin Converting enzyme
(SACE) (U/L)
* P < 0.05 Vs normoalbuminuric Subjects, ** P < 0.001 Vs normoalbuminuric Subjects
*+ P < 0.001 Vs Control Subjects.
Table 2: Prevalence of microalbuminuria according to levels of serum cholesterol, triglyceride, HDLC and LDL–C.
Good control
Fair control
Serum Cholesterol (mg/dl)
< 200
200 – 240
Microalbuminuria Cases (%)
8
30
Serum Triglyceride (mg/dl)
< 150
150-200
22
26
LDL –C (mg/dl)
< 120
120-150
15
25
HDL – C (mg/dl)
> 45
35 – 45
25
32
* P < 0.05 Vs Fair Control, ** P = ns Vs Fair Control or Good Control
DISCUSSION
Various epidemiological and cross sectional
studies have reported marked variation in the
prevalence of microalbuminuria.13 Earlier
studies on Asia Immigrant Indians and native
Indians have suggested a high prevalence of
microalbuminuria.14 Gupta et al reported a
prevalence of 26.6% in 65 type 2 north Indian
non-proteinric patients,14 while John et al
reported a prevalence of 19.7% from a tertiary
hospital in vellore, south India.13 Studies in the
white UK population revealed a prevalence of
microalbuminuria of 7% - 9%.14
This variation in prevalence can be attributed to
factor such as difference in populations, in the
defination of microalbuminuria, method of
urine collection, etc. However this could also
reflects true differences in the ethnic
susceptibility to nephropathy. In the present
study the prevalence of microalbuminuria
across the genders were not statistically
Poor control
> 240
60*
> 200
48 % *
> 150
62*
< 35 **
37
different. Earlier studied have reported an
increased prevalence of microalbuminuria in
men compared with women.1
The casual risk factors for microalbuminuria are
raised blood pressure, poor glycemic control,
older age, duration of diabetes, male sex and pre
existing retinopathy. Microalbuminuria has also
been reported to be associated with generalized
vascular disease.2 In our study we observed that
the
microalbuminuria
patients
had
a
significantly
higher
serum
angiotensin
converting
enzyme
activity
than
normoalbuminuric and control subjects which
supports the hypothesis that microalbuminuria
reflects more of a generalized vascular damage
than of diabetic glomerolopathy and ACE
activity has an essential role in the development
of complications in diabetes.In conclusion,
Microalbuminuria in diabetes, which represents
an earlier phase in the development of clinical
nephropathy, is associated with many
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ISSN: 0976 3325
potentially modifiable risk factors. In estimating
diabetic nephropathy risk, AER is most
important and should be done frequently but
there are gains to be made in predictive
precision by considering family history,
smoking habits, glycemia, B.P.,BMI lipid levels
and ACE activity. Early screening for incipient
diabetic
nephropathy
and
aggressive
management of these risk factors is important in
optimising the renal outcome of patients with
diabetes mellitus.
5.
6.
7.
8.
9.
10.
BIBLIOGRAPHY
1.
2.
3.
4.
Broch – Johnsen, K., Kreiner, S. Proteinuria : Value as
predictor of cardiovascular mortality in type 1 diabetes
mellitus. Br. Med. J. 2005,294;1651- 1654.
Deckert, T., Feldt – Rasmussen, B., Jensen.
T.Albuminuria reflects widespread vascular damage :
the steno hypothesis. Diabetologia.1989,32;219 –226.
Wang, J.J., And Sarah, X.Salutary effect of pigment
epithelium derived factor in diabetic nephropathy.
Diabetes.2006,55;1678 – 1685.
National Cholesterol Education Program. (1993).
Second report of the expert panel on detection,
Evalution & treatment of high blood cholesterol in
adults. NHI publication no. 93 –3096.
11.
12.
13.
14.
Trinder P. Enzymatic analysis of plasma glucose. Ann.
Clin. Biochem.1969, 6;24-26
Roeschlau, P., Bernt, E., Gruber, W.A. Enzymatic
analysis of total cholesterol. Clin. Chem. Clin. Biochem.
1974,12; 226 – 228.
Mcgowan, M.W., Fossati, P., Prencipe, L.Enzymatic
analysis of plasma triglyceride. Clin. Chem. 1982,28;
2077 – 2078.
Burstein, M. , Scholnic, H.R., Morfin, R. Enzymatic
analysis of plasma HDL- C. J. lipid. Res. 1970,24;204 –
206.
Friedwald, W.Y., Levy R.I., Fredrickson, D.S.
Estimation of concentration of LDL – C in plasma
without use of the preparative ultracentrifuge. Clin.
Chem.1972, 18; 499 – 501.
Mogensen, C., Viberti, G., Peheim, E., Kutter, D., et al.
Evaluation of the micral test , an immunologic rapid
test for the detection of microalbuminuria. Diabetes.
Care. 1997, 20;1642- 1646.
Cushman, D.W., And Cheung, H.S. Modified by
LETREUT, A., DELBARY, M. Spectrophotometric assay
of angiotensin converting enzyme. Biochem. pharmacol
.1979, 20;1637 – 1648.
Trivell, L.A. And Lai, H.T. Estimation of HbAIC by lon
–exchange resin method.1971, 284;353 – 354.
Allawi, J., Rao P.V., Gilbert, R. Microalbuminuria in
non- insulin – dependent diabetes : Its prevalence in
Indian compared with Europid patients. Br. Med. J.
1988, 296;462 – 464.
Gupta, D. K, Verma, L.K., Dash, S.C. Prevalence of
microalbuminuria in diabetes : a study from north
India. Diabetes. Res. Clin. Pract. 1991,12;125 – 128.
129
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Original Article.
CLINICAL AND SOCIO-DEMOGRAPHIC PROFILE OF PATIENTS REGISTERED AT ART
CENTRE, SMIMER, SURAT
Hitenkumar P Sonani1, Ashwinkumar M Undhad1, Ghanshyambhai T Savani2
1Ex-intern, 2Volunteer,
Department of Community Medicine, Surat Municipal Institute of Medical
Education and Research, Surat.
Correspondence:
Dr. Hitenkumar P Sonani
ABSTARCT
The current study was conducted to understand the clinical and socio-demographic profile of patients
attending ART centre of SMIMER. All HIV positive patient came to ART centre, SMIMER were
included in the study. Total 2357 patients were registered at ART centre of SMIMER during the study
period with an average of 181 newly registered patients every month. Most of the patient were
between 20 years to 50years of age, 37% were female, 73% were married and 25% were illiterate. At
the time of registration 20% patient were in WHO stage 3 & 4 of AIDS while 56% had CD4 less than
250 cells/mm3.
Keywords: ART, HIV, AIDS, CD4, WHO Staging of AIDS
INTRODUCTION
Human immunodeficiency virus (HIV) infection
and Acquired Immuno-Deficiency Syndrome
(AIDS) is threatening the survival of many
nations. According to the National AIDS Control
Organization [NACO] HIV prevalence in India
is 0.36%1 and people living with HIV are around
2.47 million.2 The prevalence rate of HIV among
adults in Gujarat is 0.38%.3
Though, antiretroviral therapy (ART) does not
cure HIV/AIDS, but effective ART regimens
inhibit the efficient replication of the HIV virus,
and reduce viremia to undetectable levels. This
leads to slowing of disease progression and
fewer opportunistic infections and helps people
lead more productive lives, with perceptibly
reduced stigma and discrimination. Successes
achieved by ART in terms of delaying the onset
of AIDS have transformed the common
perception about HIV from being a “virtual
death sentence” to a “chronic manageable
illness”.
Appropriate management of OIs is as important
as antiretroviral therapy (ART) in preventing
mortality and morbidity among HIV-infected
persons. The incidence of OI depends on the
level of immunosuppression (occurring at CD4
cell counts of < 200/mm3 or total lymphocyte
count <1200/mm3), and on the endemic
prevalence of the causative agent.
The Government of India launched the free ART
programme on 1 April 2004,since than more and
more patients are put on ART treatment with
rapid expansion of the programme.4
The current study was conducted to understand
the clinical and socio-demographic profile of
patients attending ART centre of SMIMER.
METHODOLOGY
This was a cross sectional study conducted at
ART centre in SMIMER hospital which is a
tertiary care medical college hospital providing
almost all type of speciality care. Surat city and
surrounding districts are main catchment area of
the hospital. Patients taking services at the
hospital are mostly from the poor social
economic class. In SMIMER hospital the ART
centre is started on 18th January 2010 and
registration of patient started on 21st January
2010. All HIV positive patient came to ART
centre, SMIMER were included in the study. The
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patient’s data available at ART centre are used
for the study.
RESULTS
Total 2357 patients were registered at ART
centre of SMIMER from 20th January 2010 to
10th February 2011. By average, 181 patients
newly registered in every month. And
accodingly around 9 new patients registered
every working day at the centre.
Results shows that maximum number of
patients that is registered were in the month
March 2010(518) and after that in February
2010(511). And minimum number of patients
were registered in January 2010 and in January
2011.
600
No. of Patient
500
511
518
400
300
176
200
148
100
0
136
114
47
113
135
106
111
116
98
28
Fig 1: Month wise registration of patients at ART centre
From May’10 to Dec’10, number of newly
registred patients were almost steady and
ranges between 100 to 150 patients per month.
The ART centre in SMIMER was started on 18th
January. And patients that are taking treatment
in other ART centre in Surat were transferred in
SMIMER as per conviniency of patients. This
may be the reason for peaks in Feb’10 and
March’10. After regestring maximum patients in
first two months, in flow of patients was steady
in every month.
Table 1 shows certain demographic and social
indicators of patient registred to ART centre.
Most of the patient were between 20 years to
50years of age which is economically and social
most productive age group. Out of total 862
female patients, maximum 344(39.9%) were
from age group of 20 to 30 years. Total 9
transgender were registered during study
period. Similar study was done at District
Government Wenlock hospital, one of the
teaching hospitals attach to Kasturba Medical
College Manglore, India5.
Table 1: Socio-demographic information of
patients attending ART centre, SMIMER
Soci-demographic
Indicators
Age
<20 years
20-50 years
>50 years
Gender
Male
Female
TG
Marital Status
Unmarried
Married
Divorced
Separated
Widow
Live-in Relations
Education
Illiterate
Up to primary
Up to Secondary
Graduate & Above
No. of Patient
(n=2354)
Percent
age
122
2101
131
5.2
89.3
5.6
1483
862
9
63.0
36.6
0.4
212
1727
59
58
296
2
9.0
73.4
2.5
2.5
12.6
0.1
582
971
726
71
24.7
41.2
30.8
3.0
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Result of this study shows 64.4% of patients
were male, which is consistent with results of
our study which shows 63% of male patients.
This is similar to the findings in a study
conducted in the Udupi District by Kumar A et
al 6 Similar observation was made by Sarna A et
al7 and Cauldbeck et al8 in Banglore, where
majority of the attendees were male(84%).
Estimated Adult HIV prevalence in India in 2007
is 0.34% (0.25% - 0.43%) & estimated HIV
prevalence among males (0.40%) continues to be
higher than among females (0.27%).3 This might
be the reason of higher registration of male
Table 2: Clinical profile of patients attending
ART centre, SMIMER
Clinical Indicators
Patient
%
WHO staging of AIDS (n=2327)
Stage 1
1411
60.6
Stage 2
440
18.9
Stage 3
343
14.7
Stage 4
133
5.7
CD4 count at the time of registration (n=2290)
≤50 cells/mm3
176
7.7
51-150 cells/mm3
563
24.6
151-250 cells/mm3
538
23.5
251-350 cells/mm3
371
16.2
>350 cells/mm3
642
28.0
Past history of Tuberculosis (n=2333)
Yes
182
7.8
No
2151
92.2
Mobility status on registration (n=2325)
Ambulatory
194
8.3
Bed-ridden
41
1.8
Working
2090
89.9
Most of the patients registered were married.
Around 9% of patients were unmarried. This
indicates high-risk behaviour of person in the
community. Educational status revealed that
most of the patients were having belov primary
education. These findings are similar to the
study conduicted by Jayaram S et al9 and to the
study conducted by Safren SA et al 10 However
Cauldbeck et al observed no trends for
education
level
with
respect
to
the
seropositivity.8
Clinical profile of the patients at the time of
registration at ART centre was depicted in Table
2. More than two third patients came to avail
ART during the first and second stage of the
disease which is a sign of quality referral from
ICTC centre and might be due to impact of large
scale IEC campaigning at state and national
level. However around one fifth PLHA came
late in the course of disease which could affect
effectiveness of ART drugs and treatment
outcome.
CD4 count is one of most reliable investigation
for clinical staging of PLHA and used to make
decision on treatment initiation along with OIs.
55.8% patient were came to centre with CD4
count less than 250 which need to be put on
treatment according to national guideline.
Around 8% patients were having past history of
tuberculosis. These patients were at high risk of
recurrence of tuberculosis.
90% patients came to centre in physically
working condition. Early registration at ART
centre will help the clinicians to initiation of
ART at optimal time which will help to improve
quality and longevity of life of a patient.
REFERENCES
1.
www.mohfw.nic.in/NFHS-3
HIV
Prevalence.ppt
accessed on 27/10/2010]
2. www.unicef.org/india/children_2358.htm [accessed on
27/10/2010].
3. HIV Sentinel Surveillance and HIV Estimation 2007: A
Technical Brief; NACO; MOHFW; 23-24
4. Antiretroviral Therapy Guidelines for HIV-infected
Adults and Adolescents Including Post-exposure
Prophylaxis; May 2007;2).
5. Sanjeev Badiger, Rekha Thapar, Prasanna mithra P,
Ganesh Kumar, Animesh Jain, Unnikrishna Bhaskaran,
Jayaram Subramanya;A profile of patients attending an
Anti Retroviral Therapy (ART) centre at a tertiary care
hospital in South India; Australasian Medical Journal
(Online) AMJ 2010, 3, 6, 344-348.
6. Kumar A, Kumar P, Gupta M, Kamath A, Maheshwari
A, Singh S. Profile of Clients Tested HIV positive in a
Voluntary Counseling and Testing Center of a District
Hospital,Udupi, South Kannada. Indian Journal of
Community Medicine 2008;33(3):156-9.
7. Sarna A, Pujari S, Sengar AK, Garg R, Gupta I, Van Dam
J. Adherence to antiretroviral therapy & its determinants
amongst HIV patients in India. Indian J Med Res
2008;127,28-36
8. Cauldbeck MB, O'Connor C, O'Connor MB, Saunders JA,
Rao B, Mallesh VG, et al. Adherence to anti-retroviral
therapy among HIV patients in Bangalore. India AIDS
Research and Therapy 2009, 6:7.
9. Jayaram S, Shenoy S , Unnikrishnan B, Ramapuram J,
Rao M. Profile of attendees in Voluntary Counseling and
Testing Centers of a Medical College Hospital in Coastal
Karnataka. Indian Journal of Community Medicine
2008;33:43-6.
10. Safren SA, Kumarasamy N, James R, Raminani S,
Solomon S, Mayer KH. ART adherence, demographic
variables and CD4 outcome among HIV-positive
patients on antiretroviral therapy in Chennai, India.
AIDS Care 2005; 17(7): 853-862.
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Original Article.
EPIDEMIOLOGICAL FACTORS ASSOCIATED WITH HYPERTENSION AMONG TRIBAL
POPULATION IN GUJARAT
Bhadresh Mandani1, Bhavesh Vaghani2, Manishkumar Gorasiya2, Parul Patel3
1Voluntary Research Assistant, University of Chicago, USA, 2Volunteer, USA, 3Assistant Professor, U.
N. Mehta Cardiology Institute & Research Centre, Ahmedabad
Correspondence:
Dr. Bhadresh Mandani Email: [email protected]
ABSTRACT
Cardiovascular diseases are recognized as major public health problems by WHO. Very few studies
have been carried out among tribal population in India. A cross sectional study was carried out in
2005 to find out the magnitude of hypertension among 154 tribal adult of South Gujarat. WHO
classification of hypertension was taken as operational criteria and data was collected in predesigned, pretested schedule. Blood pressure measurement was done twice on each subject using
mercury sphygmomanometer. Overall magnitude of hypertension was found to be 16.9%, and only
smoking was found to have significantly associated with it.
Keywords: Hypertension, tribal population, risk factor
INTRODUCTION
METHODOLOGY
World is in the stage of epidemiological
transition and the non-communicable diseases
are overtaking the communicable diseases. This
phenomenon is not only seen in developed
countries but is also evident in the developing
countries like India. Among the major noncommunicable diseases, cardiovascular diseases
are recognized as major public health problems
by WHO.1 Though several studies have been
carried out among different population with
sedentary lifestyle to assess the risk factors for
NCD, but very few studies have been carried out
among tribal population especially in India. One
argument towards this can be non exposure to
risk factors like decreased physical activity and
obesity among the tribal by virtue of their
lifestyle but other side of the coin suggests that
the risk factors like smoking and alcohol
consumption is increasing among the lower
socio-economic strata.
The present cross-sectional study was carried
out in 2005 among different tribes of Surat
region of Gujarat. The selected villages have
about 30,000 tribal population; mostly being
engaged in labour farm work. From the
sampling frame of labour population aged 20
years and above, 154 study subjects were
included by simple sampling random technique
in the present study. Pre-designed, pre-tested
schedule was used to collect data regarding
demographic characteristics and different risk
factors like smoking and alcohol.
With this background the present study was
carried out to find out the prevalence of
hypertension as well as different cardiovascular
risk factors and to assess association of different
risk factors with hypertension if any.
For the present study all those who have smoked
at least one cigarette or bidi in the last onemonth period were considered as current
smoker while those who have left smoking since
≥1 year were considered as ex-smokers. For the
purpose of ever smokers the current smokers
and ex-smokers were added together. Similarly
those who reported to have taken alcohol at least
once in last one month were considered as
current alcohol users. This was followed by
measurement of blood pressure, height and
weight. Two blood pressure readings were
obtained on left arm after the subject had rested
for at least 5 minutes in a seated position using
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mercury sphygmomanometer, 10 minutes apart.
Finally average of two readings was taken. SBP ≥
140 mm Hg and/or DBP ≥ 90 mm Hg and/or
treatment with anti-hypertensive medication
were labeled as hypertensive.2 Subjects having
hypertension were referred to nearby Primary
Health Centre for further management. Body
weight was measured on the weighing scale,
wearing minimum outerwear (as culturally
appropriate) and without any footwear. Height
was measured using a non-stretchable tape with
the subject in an erect position against a vertical
surface, with the head positioned so that the top
of the external auditory meatus was level with
the inferior margin of the bony orbit. Body mass
index was calculated by dividing the weight in
kilograms with the square of height measured in
meters. WHO classification of obesity was used
for the categorization.3 Percentages was
calculated and chi-square test was done using
Epi Info software.
OBSERVATIONS AND DISCUSSION
Out of 154 subjects, 59.1% were male while
40.9% were female. Majority of the study
subjects belonged to less than 25 years of age.
Overall magnitude of hypertension was found to
be 16.9%.
38.5% of the subjects were ever smokers while
only 5.5% have taken alcohol. Only 9 (5.4%)
subjects were overweight-pre-obese. The mean
BMI for the females was found to be 19.3 ± 3.5
kg/m2. The distribution of hypertension
according to the risk factors is shown in Table 1.
Except for smoking all other factors were found
to be non-significant.
Table 1: Distribution of hypertension according to different risk factors
Risk Factors
Age (in years)
<45
≥45
Sex
Male
Female
Smoking history
*Ever smokers
Never Smokers
Alcohol use
*Present
Absent
Body mass index
Overweight-pre-obese
Non-obese
* Included only males
Number
Hypertensive
No (%)
132
22
χ2;
df;
p-value
23 (17.4)
3 (13.6)
0.017;
1;
>0.05
91
63
15 (16.5)
11 (17.5)
0.025,
1,
>0.05
35
56
9 (25.7)
6 (10.7)
3.52;
1;
<0.05
5
86
1 (20.0)
13 (15.1)
0.407;
1;
>0.05
9
145
26 (17.9)
-
-
-
In the present study the overall magnitude of
hypertension was found to be 16.9%. However a
study among tribal “Oraon” population of
Orissa
revealed
lower
prevalence
of
hypertension (4.6/1000 population).4 Similar
finding (prevalence 5.8%) was also noted by
Chadha SL et al5 among Gujaratis residing in
Delhi. In contrast a study among primitive tribes
of Orissa reported prevalence of hypertension
among males and females as 31.8% and 42.2%,
respectively6. Recent studies have shown that
Asian Indians are particularly susceptible to
non-communicable diseases.
Comparison with studies shows that there is a
clear increase in magnitude of hypertension in
urban Indians from 6.2% in 1970 to 26.9% in
2000.7,8 This can be attributed to the
epidemiological
transition
and
changing
lifestyles.
Although the magnitude of hypertension is age
related, being highest in those over 50 years of
age9,10 but the non-significant association of age
with hypertension in present study can be
attributed to comparatively young age group of
study population; mean age being 31.7±10.1
years. All the hypertensive subjects were nonobese and this could be due to very low
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magnitude of obese in the study population.
However the mean BMI of the females was
similar to that reported in NFHS survey data
while the proportion of those females having
BMI<18.5 kg/m2 was found to be 38.1% which
was lower than 47.7% as reported in NFHS
survey.
Magnitude of smoking is higher in this study
and smoking has been found a significant factor
for the occurrence of hypertension. There is a
plethora of studies suggesting the tobacco
smoking as an important and independent risk
factor for hypertension and cardiovascular
diseases.11
Thus to summarize, this study reveals that the
magnitude of hypertension in the tribal
population is comparable to the magnitude
found in the other Indian studies. It is likely that
a systematic and larger study may give better
understanding of the prevalence and the
underlying
risk
factors
among
these
populations.
REFERENCES
1.
2.
Integrated NCD management and prevention. In the
official website of WHO. http:// www.who.int
WHO. Epidemiology and prevention of Cardiovascular
diseases in elderly people. WHO Technical Report
Series No. 853, World Health Organization, Geneva,
1995.
3.
WHO. Obesity: Preventing and managing the global
epidemic. WHO Technical Report Series No. 894, World
Health Organization, Geneva, 2000.
4.
Dash SC, Sundaram KR, Swain PK. Blood pressure
profile, urinary sodium and body weight in the ‘Oraon’
rural and urban tribal community. J Assoc Physicians
India. 1994; 42: 878-80.
5.
Chadha SL, Gopinath N, Ramachandran K.
Epidemiological study of coronary heart disease in
Gujaratis in Delhi (India). Ind J Med Res 1992, 96:115121.
6.
Kerketta AS, Bulliyya G, Babu BV, Mohapatra SS,
Nayak RN. Health status of the elderly population
among four primitive tribes of Orissa, India: A clinicoepidemiological study. Zeitschrift für Gerontologie und
Geriatrie. Published online on 10 April 2008.
http://www.springerlink.com/
content/6g424u36581868wq/ last visited on 10th July
2008.
7.
Malhotra SL. Studies in arterial blood pressure in the
North and South India with reference to dietary factors
in its causation. J Assoc Physicians India 1971; 19:211224.
8.
Chadha SL, Radhakrishnan S, Ramachandran K, Kaul
U, Gopinath N. Epidemiological study of coronary
heart disease in urban population of Delhi. Indian J
Med Res 1990; 92: 424-30.
9.
Anand MP. Epidemiology of hypertension. In: Anand
MP, Billimoria AR, editors. Hypertension: an
international monograph. New Delhi. Indian J Clin
Practice 2001:10-25.
10. Singh RB, Suh IL, Singh VP et al. Hypertension and
stroke in Asia: prevalence, control and strategies in
developing countries for prevention. J Hum Hypertens
2000; 14: 749-763.
11. Noel H. Essential hypertension: evaluation and
treatment. J Am Acad Nurse Pract 1994; 6: 421- 435.
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Original Article.
HISTOLOGICAL GRADING OF ORAL CANCER: A COMPARISON OF DIFFERENT SYSTEMS
AND THEIR RELATION TO LYMPH NODE METASTASIS
Doshi Neena P1, Shah Siddharth A2, Patel Keyuri B1, Jhabuawala Munira F3
1MD
Pathology, Department of Pathology, 2MS ENT, Department of ENT, 3DCP, Department of
Pathology, Shree Krishna Hospital and Pramukh Swami Medical College, Karamsad, Anand-388 325,
Gujarat, India.
Correspondence:
Dr. Neena Doshi,
47 Gulmohar Park, Near Akota Garden,
Akota, Vadodara-390 020, Gujarat, India.
E mail: [email protected]
ABSTRACT
Oral squamous cell carcinoma has a great predisposition to produce metastasis in lymph nodes. In
clinical practice, the treatment plan and prognosis of oral squamous cell carcinoma is mainly based on
the primary tumor, regional lymph node metastasis, and distant metastasis (TNM) staging system.
However, this system does not provide any information on the biological characteristics and thus an
aggressive clinical behavior of the tumor. The aim of this study was to assess some indicative
histological parameters that would assist in the prognosis of these lesions. All cases of oral squamous
cell carcinoma's treated with wide excision of growth with radical neck dissection, registered between
2006 – 2009 in the Department of Pathology, Shree Krishna Hospital, Karamsad were studied
retrospectively. Surgical specimens of 31 metastasizing tumors were compared with 26 tumors which
did not metastasize. Each case was graded according to: Broders' classification in the whole thickness
of tumor, Anneroth’s multifactorial grading system and Bryne’s deep invasive cell grading system.
Bryne’s score showed an Odds ratio of 2.12, 95% C.I. (1.41, 3.18). The predictive value of the score is
73.7%. Bryne’s deep invasive cell score showed significant relation with lymph node metastasis.
Other grading methods failed to show any relation with metastasis. Bryne’s deep invasive cell
grading system in appropriate biopsy specimens would be of great value in predicting lymph node
metastasis and treatment results of oral squamous cell carcinoma.
Keywords · Bryne’s grading system, grading systems, metastasis, oral SCC
INTRODUCTION
Oral cancer represents the third most common
form of malignancy in the developing countries,
whilst in the developed countries it is the eighth
most common form of cancer.[1] Oral squamous
cell carcinoma (SCC) is the most frequent
malignancy in the mouth, accounting to 95% of
all oral malignant lesions.[2] The most affected
sites are the tongue, inferior lips and floor of the
mouth. The typical demographic profile of oral
SCC is one of a man in the fifth to eighth
decades of life, who is a tobacco chewer and/or
a smoker. In India, where tobacco chewing is
used with betel nuts and reverse smoking
(placing the lit end in the mouth) is practiced,
there is a striking incidence of oral cancer.[3] Less
than 10% of cases arise in women. [4]
Oral squamous cell carcinoma has a great
predisposition to produce metastasis in lymph
nodes. In clinical practice, the treatment plan
and prognosis of oral squamous cell carcinoma
is mainly based on the TNM (primary tumor,
regional lymph node metastasis, and distant
metastasis) staging system. The most recent
staging system is the AJCC TNM staging system
(2002).[5] Staging is assessed by clinical methods
with the aid of imaging techniques and Fine
Needle Aspiration Cytology (FNAC). Staging
aids in planning the course of management.
However, TNM system does not provide any
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information on the biological characteristics and
thus an aggressive clinical behavior of the
tumor. The aim of this study was to assess some
indicative histological parameters that would
assist in the prognosis of these lesions and in the
correct choice of therapy.
A retrospective study of all cases of oral SCC's
treated with wide excision of growth with
radical neck dissection, registered between 2006
– 2009 in Department of Pathology of Shree
Krishna Hospital, Karamsad for whom adequate
histologic material was available, was
undertaken. The lesions that were primary
tumor arising intra-orally, were included. The
tumors that originated from the tongue, floor of
the mouth, cheek, gingiva, palate, or retromolar
trigone, were included. The tumors arising from
the vermilion border of the lip, and the
pharyngeal complex were excluded because
these sites are not from the oral cavity proper.
To achieve a more homogenous sample
material, some cases were excluded from the
study. Tumors that involved the mandibular
bone, overlying skin, resection specimens
following radiotherapy/chemotherapy, which
reduce the bulk of tumor and obscure the cell
morphology, and recurrent tumors; were all
excluded from the study. General information
including age, and sex were registered. The size
of the primary tumor was noted and categorized
into T1 to T3 (T4 tumors were excluded from the
study), according to AJCC TNM stage for oral
cavity and lip cancer. Number of involved
nodes, and size of involved lymph nodes was
noted, and categorized into NX to N3.[5]
All the samples were fixed in 10% formalin,
embedded in paraffin, and stained with
Haemotoxylin and Eosin stain. The cases were
reviewed and grouped into two categories based
on lymph node metastasis into metastatic and
non-metastatic. Cases in both the groups were
graded according to the:
1.
Broder’s (1920) classification:
Accordingly, tumors were graded on the
basis of degree of differentiation and
keratinization of tumor cells into
Grade I: Well differentiated tumors – 75-100% of
cells are differentiated
Grade II: Moderately differentiated tumors – 5075% of cells are differentiated
Grade III: Poorly differentiated tumors – 25-50%
of cells are differentiated
Grade IV: Anaplastic tumor – 0-25% of cells are
differentiated
2.
Anneroth’s et al
grading system:
(1987)
multifactorial
According to this system, three parameters
reflecting tumor cell features including
keratinization, nuclear pleomorphism, and
mitoses were evaluated in the whole thickness
of the tumor and each scored from 1-4 (Table 1).
Pattern of invasion, stage of invasion, and
lymphoplasmacytic infiltration representing
tumor-host relationship were graded in the most
invasive margins and scored from 1-4. Then the
sum of scores were grouped as follows: 6-12
grade I, 13-18 grade II, 19-24 grade III, and the
results were compared in the metastasizing and
non-metastasizing groups.
3.
Bryne’s et al (1992) deep invasive cell
grading system:
According to this system, number of mitosis and
stage of invasion was omitted from the
Anneroth’s grading system, while the rest of the
4 parameters mentioned above were measured
in the deepest invasive margins, and not in the
whole thickness of the tumor, and graded
similarly. The sum of scores were grouped as
follows: 4-8 grade I, 9-12 grade II, 13-16 grade
III, and the results were compared in the
metastasizing and non-metastasizing groups.
In cases where opinion of the two authors
differed, the disagreement was resolved by
consensus after joint review using a
multiheaded microscope, and reviewed by the
third author. The results of the three grading
systems in each of the two groups (metastatic
and non-metastatic) were analyzed by logistic
regression.
RESULTS
Reviewing a total of 111 cases of oral SCC
reported during the study period between 2006
– 2009 and excluding all unsuitable cases
mentioned before, 57 cases of oral SCC treated
with radical surgery and neck dissection
remained for final analysis. Males comprised of
42 cases (73.7%) with a male/female ratio of
2.8:1. 31 patients (54.4%) had lymph node
metastasis and 26 cases (45.6%) were free of
metastasis.
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Table 1: Anneroth’s et al (1987) multifactorial grading system for oral SCC’s
Morphologic parameter
POINTS
Number of mitosis/hpf
Pattern of invasion
0-1
Pushing, welldelineated
infiltrating borders
2
20-50% cells
keratinized
Moderately
abundant nuclear
pleomorphism
2-3
Infiltrating, solid
cords, bands and/or
strands
Stage of invasion
Carcinoma-in-situ
and/or questionable
invasion
Distinct invasion,
but involving lamina
propria only
Invasion below lamina
propria adjacent to
muscles, salivary gland
tissues, and periosteum
Lymphoplasmacytic
infiltration
Marked
Moderate
Slight
Degree of keratinization
Nuclear pleomorphism
1
>50% cells
keratinized
Little nuclear
pleomorphism
3
5-20% cells keratinized
4
0-5% cells keratinized
Abundant nuclear
pleomorphism
Extreme nuclear
pleomorphism
4-5
Small groups or cords
of infiltrating cells
>5
Marked and widespread cellular
dissemination in small
groups and/or in
single cells
Extensive and deep
invasion replacing
most of the stromal
tissue and infiltrating
jaw bone
None
Males in the metastatic group comprised of 20
cases with a male/female ratio of 1.8:1, while
males in the non-metastatic group comprised of
22 cases with a male/female ratio of 5.5:1.
Higher incidence of metastatic cancer in females
is due to presentation with late nodal stage.
Fig. 1 (40x view) Nuclear pleomorphism, Score 4
(extreme)
Fig. 1 (05x view) Degree of keratinization, Score
1 (highly keratinized)
The mean age distribution was 47.7 with a range
of 27 to 75 years. The mean age in males was
47.9 compared with 46.9 years in females. The
mean age in males with metastasis was 46.5
compared with 48 years in females. The mean
age in males with absence of metastasis was 49.2
compared with 44 years in females. There was
no statistical relation of age with lymph node
metastasis.
Fig. 2 (05x view) Pattern of invasion, Score 1
(pushing borders)
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in the metastatic group, 03 were T1 tumors, 22
were T2, and 06 were T3; while of the 26 cases
analyzed in non-metastatic group, 17 were T1,
07 were T2, and 02 were T3. There was no
statistical relation of tumor size with lymph
node metastasis.
Table 2: A summary table of data showing
tumors in the study as graded by Broders’
classification
(small groups and cords of infiltrating cells)
(marked and widespread cellular dissemination)
Broders’
classification
Metastatic
group
No. (%)
Welldifferentiated
Moderatelydifferentiated
Poorlydifferentiated
Anaplastic
14 (45.2)
Nonmetastatic
group
No. (%)
16 (61.5)
14 (45.2)
10 (38.5)
02 (06.5)
00 (00.0)
01 (03.2)
00 (00.0)
Total
31 (100.0)
26 (100.0)
Total
No.
(%)
30
(52.6)
24
(42.1)
02
(03.5)
01
(01.8)
57
(100.0)
The relation between Broders' classification and
lymph node metastasis is shown in Table 2.
With regard to Broders’ classification, of the 31
cases analyzed in the metastatic group, 14 were
well-differentiated (Grade I), 14 moderately
differentiated (Grade II), 2 poorly differentiated
(Grade III) and 1 anaplastic (Grade IV); while of
the 26 cases analyzed in non-metastatic group,
16 were well-differentiated (Grade I), and 10
moderately differentiated (Grade II). Statistical
analysis failed to detect any relationship
between Broders' grades and lymph node
metastasis.
tumors in the study as graded by Anneroth
multifactorial grading system
Fig. 4 (10x view) Lymphoplasmacytic
infiltration, Score 1 (marked)
The greatest diameters of tumors ranged from 1
to 5.5 cm with an average of 2.9 cm. With regard
to primary tumor size, of the 31 cases analyzed
Anneroth
multifactori
al grading
system
Grade-I
Grade-II
Grade-III
Total
Metastatic
group
No. (%)
11 (35.9)
18 (58.1)
02 (06.5)
31 (100.0)
Nonmetastati
c group
No. (%)
19 (73.1)
07 (26.9)
00 (00.0)
26 (100.0)
Total
No. (%)
30 (52.6)
15 (26.3)
02 (03.5)
57 (100)
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With regard to Anneroth multifactorial grading
system, of the 31 cases analyzed in the
metastatic group, 11 were Grade-I, 18 were
Grade-II and 02 Grade-III; while of the 26 cases
analyzed in non-metastatic group, 19 were
Grade I, and 07 Grade II (Table 3). Statistical
analysis failed to relate this grading method
with lymph node metastasis.
tumors in the study as graded by Bryne’s deep
invasive cell grading system
Bryne’s
deep
invasive
cell
grading
system
Grade-I
Grade-II
Grade-III
Total
Metastatic
group
No. (%)
Nonmetastatic
group
No. (%)
Total
No. (%)
10 (32.3)
16 (51.6)
05 (16.1)
31 (100.0)
23 (88.5)
03 (11.5)
00 (00.0)
26 (100.0)
33 (57.9)
19 (33.3)
05 (08.8)
57 (100.0)
With regard to Bryne’s deep invasive cell
grading, of the 31 cases in the metastasizing
group, 10 cases were grouped in grade I, 16 in
Grade II and 5 in Grade III; while of 26 cases in
the non-metastasizing group, 23 were grade I
tumors, and 03 were grade II (Table 4). Bryne’s
score was the only significant predictor of
metastasis in our study with Odds ratio of 2.12,
and 95% Confidence Interval C.I. (1.41, 3.18).
The predictive value of the score is 73.7%.
DISCUSSION
Oral cancer is the commonest cancer in India,
accounting for 50-70% of total cancer
mortality.[3] In our study on 57 oral SCC’s,
males comprised of 73.7% of cases. S P
Khandekar et al (3) in their study on 80 cases of
oral cancer, showed a prevalence of cancer in
61.25% of males and I. Yazdi et al in their study
on 48 cases of tongue SCC showed male
prevalence of 60.4% (6). High proportion of cases
among males may be due to high prevalence of
tobacco consumption habits in them, coupled
with smoking whereas in our society females
less commonly indulge in tobacco smoking.
The current TNM classification is the widely
used system for predicting the clinical result of
oral SCC. In our study, T1 tumors lacking
metastasis, showed statistical significance.
However, a significant percentage (35%) of
patients with early stages of SCC (T1-T2) had
shown a poor prognosis despite the small size of
the tumor. Bundgaard et al demonstrated that
up to 25% of patients with T1 could show poor
prognosis at follow-up (9). Thus, the TNM
system
includes
acceptable
prognostic
parameters but the biological properties of the
tumor cannot be predicted.
In the past, several investigators conducted
studies on oral SCC's, correlating histologic
malignancy grading with different clinical
parameters such as clinical staging, recurrence
and prognosis.
AC Broders’ in 1920 initiated a quantitative
grading system for the cancer of the lip. Broders’
suggested that the grading of the tumors should
be according to the differentiation of tumor cells.
This system had four grades, of which grade 1
and 2 were relatively differentiated tumors, and
grades 3 and 4 were not very well differentiated
tumors. Despite the widespread use of this
system, or slight modifications of it, there has
generally only been a limited relationship with
the grading and the outcome of treatment and
survival of the patient. The suggested reason for
such a poor correlation with the grading and
prognosis, is the relative heterogeneity of the
cell population present in the tumors. In our
study, and I. Yazdi et al (6) in their study, failed
to observe any relationship between Broders'
system of grading and lymph node metastasis.
Due to poor relationship between Broders’
grading and patient survival, need for new
system of grading was felt. It was recognized by
many authors including Jakobsson, Eneroth,
Moberger etc., that observing a number of
factors in the biopsy along with cellular
differentiation might give a better prognostic
indicator of oral SCC. They also recognized that
not only tumor cells, but also the reaction of the
host to the tumor, needs to be graded to give
more prognostic information. Jacobsson et al
(1973) multifactorial grading system was based
on
structure,
differentiation,
nuclear
pleomorphism, mitosis, mode of invasion, stage
of
invasion,
vascular
invasion,
and
lymphoplasmacytic
infiltration.
After
Jacobsson, many other researchers modified or
developed new system based on the Jacobssons’
grading system. These include Fisher (1975),
Lund (1975), Willen (1975), Anneroth and
Hansen (1984), Crissman (1980 & 1984).
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In a comprehensive review of the above
mentioned grading systems used in oral SCC’s,
Anneroth et al (1987) modified the existing
multifactorial grading systems in use and
proposed a new grading system. Unlike the
previous systems where a number of parameters
overlapped each other, this system reduced the
number of parameters to be studied to
keratinization, nuclear pleomorphism, mitoses,
pattern of invasion, stage of invasion, and
lymphoplasmacytic infiltration. Dilana Duarte
Lima Dantas et al (2) in their study on 16 cases of
squamous cell carcinoma of the tongue, and I.
Yazdi et al (6) in their study found no correlation
between the Anneroth’s histological scores of
malignancy and the prognosis. In our study
also, we failed to observe any relationship
between Anneroth’s multifactorial grading
system and lymph node metastasis.
Anneroth and other multifactorial grading
systems used the entire tumor cell population in
a biopsy, to obtain a final grading of the tumor.
Bryne et al (1989) recognized the fact that there
are heterogeneous tumor cell populations in
malignancies, and observed that the cells in the
deep invasive margin tend to be less
differentiated than the cells in the superficial
part of the tumor. Bryne et al in 1992 modified
the grading system used by Anneroth. In
Bryne’s system, only the cells at the deep
invasive margin of the tumor were graded. They
also omitted stage of invasion and mitotic count
from Anneroth’s grading system, since their
omission increased the reproducibility of the
grading system. Also the validity of the mitotic
count as a marker of prognosis remains
controversial due to tumor heterogeneity, interobserver disagreement, variations in the size of
the high power field in different microscopes
and a too low mitotic count in the deep invasive
parts of the tumor as compared with more solid
tumor areas of tumors (6). In our study the
statistical relationship between Bryne’s deep
invasive cell grading system with lymph node
metastasis was significant. I. Yazdi et al (6) in
their study showed significant statistical
differences (p=0.05) between Bryne’s grading
system and lymph node metastasis.
information on the biological characteristic and
aggressive clinical behavior of oral SCC. The
first and most widely practiced grading system
for oral SCC was developed by AC Broder. Since
then a multitude of multifactorial grading
systems have developed. Jacobsson and
Anneroth grading system, are still sometimes
used and studied (1,7, 8,9,10). However, the most
recent of these multifactorial grading systems
developed by Bryne et al (1992), which analyses
four factors of the carcinoma in its invasive front
is most reproducible but less popularly used.
We found a significant positive trend between
Bryne’s deep invasive cell grading system with
lymph node metastasis; while all the other
grading systems, especially the most popularly
used Broder’s classification failed to show any
statistical significance to lymph node metastasis.
In conclusion, we believe that Bryne’s grading of
the invasive parts of oral SCC could be taken as
a valuable predictive factor in lymph node
metastasis. The clinical value of this system can
be increased if larger pieces of biopsies are taken
from the tumor. Generally, in the oral cavity,
there are no contraindications for the removal of
biopsies measuring 15´ 5´ 5 mm from
representative areas. In most cases, this would
be sufficient for invasive cell grading (6). There
could be scope of further improving the clinical
value of this histological grading system by
including new immunohistochemical markers
like expression of vascular endothelial growth
factor-C (VEGF-C) (9) and Ki-67 (1) that take into
account the biological behavior of the tumor.
REFERENCES
1.
2.
3.
4.
CONCLUSION
5.
A significant percentage of patients with early
stages of SCC have a poor prognosis despite the
small size of the tumor (9). Hence TNM staging
system used in clinical practice does not provide
6.
Vijay R Tumuluri. A retrospective Analysis of Cell
Proliferation in Human Oral Squamous Cell
Carcinoma. A thesis submitted to Queen Elizebeth
Research Institute for Mothers and Infants, The
University of Sydney; Nov 1998.
Dilana Duarte Lima Dantas et al. Clinical-pathological
parameters in squamous cell carcinoma of the tongue.
Braz Dent J 2003;14:1:22-25.
SP Khandelkarl, PS Bagdey. Oral cancer and some
epidemiological factors : A Hospital based study.
Indian Journal Of Community Medicine 2006;31:3:157162.
Kenneth D McClatchey, Richard J. Zarbo. The Jaws and
Oral Cavity. Sternberg’s Diagnostic Surgical Pathology
2004;2:884-915.
Juan Rosai. American Joint Committee on Cancer
(AJCC) Staging of Oral cavity and lip; 2002. Rosai and
Ackerman’s Surgical Pathology, 9th Edn 2004 Appendix
C:2:2804-2806.
Yazdi DMD, M. Khalili DMD. Grading of Oral Cancer:
Comparison of Different Systems with Respect to
Lymph Node Metastasis in Tongue SCC.
141
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7.
8.
Kat, Keizo. A Study of Prognostic Factor of Oral
Squamous Cell Carcinoma. Examination of Histologic
Grading of Malignancy by Anneroth Classification.
Acta Scholae Medicinalis Universitatis in Gifu
2001;49:3:63-67.
Y. Okada, I. Mataga. An analysis of cervical lymph
nodes metastasis in oral squamous cell carcinoma:
Relationship between grade of histopathological
malignancy and lymph nodes metastasis. International
journal of oral and maxillofacial surgery, 2003;32:3:284288.
9.
M.F. Muñoz-Guerra. Early stage oral cancer: prognosis
with regard to histological grading, intratumoral
lymphangiogenesis, and the expression of vascular
endothelial growth factor-C (VEGF-C). Rev Esp Cirug
Oral y Maxilofac 2006;28:1:25-40.
10. Kazunari Karakida. Examination of Factors Predicting
Occult Metastasis of the Cervical Lymph Nodes in T1
and T2 Tongue Carcinoma. Tokai J Exp Clin Med
2002;27:3:65-71.
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Original Article.
NUTRITIONAL STATUS AND DIETARY PATTERN OF UNDERFIVE CHILDREN IN URBAN
SLUM AREA
Narkhede Vinod1, Likhar Swarnakanta1, Pitale Smita2, Durge Pushpa2
1Department of Community Medicine, Peoples College of
Medical Sciences & Research Centre,
Bhopal 2Department of Community Medicine, NKP Salve Institute of Medical Sciences & Research
Centre, NAGPUR
Correspondence:
Dr. Vinod narkhede,
Assistant Professor, Department of Community Medicine, PCMS & RC, PCMS Campus,
Bhanpur Road, Bhanpur, Bhopal- 462037, Madhya Pradesh, India.
ABSTRACT
Nutrition of pre-school children (0-5 years age group) is of paramount importance because the
foundation for lifetime health, strength and intellectual vitality is laid during this period. The study
was aimed to assess the nutritional status and dietary pattern of children below five years of age. It
was a community based cross-sectional study in children below five years of age from Urban slum,
Nagpur. A house-to-house survey was done. By systematic random sampling 434 children below five
years of age were included in the study. Every child was subjected to anthropometric measurements
using standard technique. Dietary survey was done in 20% subsample. 52.23 % were suffering from
various grades of malnutrition. 32.18 % children were in grade I, 16.09 % in grade II, 3.46 % in grade
III and 0.5 % in grade IV malnutrition. The mean calorie intake of children in the age group 2-3 years
was 842.6 Kcal, 3-4 years was 956.12 Kcal and 4-5 years was 1096.24 Kcal respectively. Nutritional
rehabilitation centers should be started in the community and linked with health centers to treat less
severely affected undernourished children.
Key words: Malnutrition, under five children, urban slum
INTRODUCTION
The nutritional status of a community
particularly of its vulnerable groups comprising
of children, expectant mother and lactating
mothers has been recognized as an important
indicator, of national development in turn
depends on social development indices. The
‘Nutrition’ emerges as an important prerequisite
for national development.5
In the present context malnutrition is
synonymous with protein-energy malnutrition,
which signifies an imbalance between the supply
of protein and energy and the body’s demand
for them to ensure optimal growth and function.
This imbalance includes both inadequate and
excessive energy intake; the former leading to
malnutrition in the form of wasting, stunting
and underweight, and the latter resulting in
overweight and obesity.
A number of studies carried out during
emergency and non-emergency situations have
demonstrated the association between increased
mortality
and
increasing
severity
of
anthropometric deficits. Data from six
longitudinal studies on the association between
anthropometric status and mortality of children
aged 6-59 months revealed a strong association
between the severity of weight-for-age deficits
and mortality rates. Indeed, out of the 11.6
million deaths among under-five children in
1995 in developing countries, it has been
estimated that 6.3 million—or 54% of young
child
mortality—were
associated
with
malnutrition, the majority of which is due to the
potentiating
effect
of
mild-to-moderate
malnutrition as opposed to severe malnutrition.9
There is strong evidence that poor growth or
smaller size is associated with impaired
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development, and a number of studies have also
demonstrated a relationship between growth
status and school performance and intellectual
achievement. However, this cannot be regarded
as a simple causal relationship because of the
complex environmental or socioeconomic factors
that affect both growth and development.
The present study is carried out to find out the
pattern of malnutrition in under five and dietary
factors, so that actions may be taken in future to
control malnutrition in community.
AIMS AND OBJECTIVES
To assess the nutritional status of under five
children.
To assess the dietary pattern and its correlation
of with nutritional status.
The present community based cross-sectional
study was conducted in children below five
years of age from Urban health centre, Jaitala,
Nagpur under the administrative control of
Department of Preventive and Social Medicine,
NKP Salve Institute of Medical Sciences and
Research Centre, Nagpur. The total population
of the area was 16042. Study was conducted
from April 2005 to July 2006.
Study subjects consisted of children below five
years of age. Total 1827 children were registered
in 0-5 years age group. A list of household was
prepared having the study subjects and 434
children’s were included in the study. A pilot
study was conducted in 60 children below 5
years of age of all age group to test the feasibility
of the survey and test proforma.
The optimal sample size of 434 study subjects
was calculated on the basis of 48% prevalence of
undernourished children found in pilot survey.
n = 4pq/L2
where p = positive character, q = 100-p, L=
allowable error 10% of ‘p’
A house-to-house survey was done. By
systematic random sampling 434 children below
five years of age were included in the study.
Every attempt was made to cover maximum
number of children by giving 3 visits to them.
Total 404 children were included in the study.
The information obtained from child’s mother
was filled in the proforma. After obtaining
preliminary information at child’s home, they
were called at urban health centre along with
their mother. Every child was subjected to
anthropometric measurements. A diet survey
was done in 40% subsample of children in 2-5
years age group. 0-2 year children were not
included for dietary survey as most of the
children were breast fed upto 2 years of age and
their mothers were not able to give the quantity
of breast milk fed to them.
Anthropometric measurements taken were
weight, height, mid arm circumference, head
circumference, chest circumference as per
following technique.
Weight
Weight of under five children was measured by
children weighing machine (< 2 years) and adult
weighing machine (> 2 years) with minimum
clothing over body and without shoes. The
machine was regularly checked. Method
employed for weighing was near accuracy of
100grams.
Height / Length
Height was measured by making child, after
removing the shoes, to stand on a flat surface
with feet parallel and with heels, buttocks,
shoulders and back of head touching upright the
wall. The head were held comfortably erect, with
the lower border of the orbit in the same
horizontal plane as the external auditory meatus.
The arms were made to hang at sides in natural
manner. Measurement was done with the help
of fibre glass measuring tape.
For infants and children below five years of age,
who could not stand, length was measured by
making child laid on flat surface, head
positioned firmly against the fixed hardboard,
with the eyes looking vertically. The knees
extended, by applying firm pressure and feet are
flexed at right angles to the lower legs on the
board. Length was measured between the two
boards to the nearest accuracy 0.1cm.
Diet Survey
Diet survey was done in 40% subsample. Dietary
intake was assessed by oral questionnaire (24
hours recall method) and weighment of raw
food method. Energy and protein intake was
calculated using food composition table given in
the “Nutritive value of Indian food stuffs” by
Gopalan.3
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Statistical Analysis
Data was analyzed on Epi-Info Software 3.2
version. Chi square test is used to test the
significance.
OBSERVATIONS AND DISCUSSION
As per table No. 1 it was observed that out of 404
children studied 206 (51.0 percent) were males
and 198 (49.0 percent) were females.
Table 1: Distribution of Children according to
Age and Sex (n = 404)
Age Group Number of Children Total (%)
(Month)
Male (%) Female (%)
0-3
22 (5.4)
13 (3.2)
35 (8.6)
4-6
09 (2.2)
19 (4.7)
28 (6.9)
7-9
19 (4.7)
16 (4.0)
35 (8.6)
10-12
16 (4.0)
16 (4.0)
32 (8.0)
13-18
23 (5.7)
19 (4.7)
42 (10.4)
19-24
24 (5.9)
23 (5.7)
47 (11.6)
25-30
20 (5.0)
19 (4.7)
39 (9.7)
31-36
17 (4.2)
14 (3.5)
31 (7.7)
37-42
13 (3.2)
12 (3.0)
25 (6.2)
43-48
12 (3.0)
22 (5.4)
34 (8.4)
49-54
15 (3.7)
11 (2.7)
26 (6.4)
55-60
16 (4.0)
14 (3.5)
30 (7.5)
Total
206 (51.0) 198 (49.0) 404 (100)
Majority of children belong to 0-12 months age
group (32.1 %), followed by 13-24 months (22.0
%), 25-36 months (17.4 %), 37-48 months (14.6 %)
and 49-60 months (13.9 %).
Table 2: Distribution of Children according to
Per-capita Monthly Income (n = 404)
Per-capita
Percentage
Number of
Monthly
Children
(%)
Income (Rs)
≥ 3000
4
1.0
1500-2999
10
2.5
900-1499
37
9.1
450-899
240
59.4
<450
113
28.0
Total
404
100
Classification according to Prasad’s Socioeconomic Scale
As per table No. 2 it was found that majority of
children’ family were having per-capita monthly
income less than Rupees 900 i.e. 59.4 percent had
per-capita monthly income between Rupees 450899 and 28.0 percent had less than Rupees 450.
Table 3: Distribution of children according to
child feeding practices (n = 404)
Children
68
37
404
253
Percentage
16.83
9.16
100
71.87*
Prelacteals fed
Colostrum not fed
Breast feeding
Weaning at 4-6
months
* Weaning was yet to start in 52 children
As per table No. 3 it was observed that 68 (16.83
percent) children were given prelacteals.
Maximum numbers of children were given
Jaggery water (67.65 percent) followed by 23.53
percent given honey and 8.82 were given ghutti
as first fed.
Out of 404 children, 37 children’s mother did not
fed colostrums to their children. The main
reason for not giving colostrum was advised by
grandmother of the baby. Breast feeding was
given to 100 percent children. In general mothers
fed breast milk to their children upto 1 to 2 years
of age. Only 3 children’s mother breast-fed till
the age of 3 years.
Maximum number of women started weaning at
4-6 months of age (62.62 percent), followed by 79 months of age (20.54 percent), 10-12 months of
age (3.22 percent), in 0.74 percent children
weaning started after 12 months and in 12.87
percent children weaning was not started.
In general weaning was started with rice and dal
water in majority of cases, few children were
given daliya, khichadi and fruit juice as weaning
food.
As per table No. 4 it was observed that
according to Indian Academy of Pediatrics
(1972) classification out of 404 children studied,
47.77 percent were normal and 52.23percent
were suffering from various grades of
undernutrition. 32.18 percent children were in
grade I, 16.09 percent in grade II, 3.46 percent in
grade III and 0.5 percent in grade IV
undernutrition8.
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Table 4: Distribution of children according to various grades of nutritional status Age and Sex wise
(I.A.P. Classification) (n = 404).
Age
Group
In months
0-3
4-6
7-9
10-12
13-18
19-24
25-30
31-36
37-42
43-48
49-54
55-60
Total
Total
Normal
M
F
19
12
8
15
13
11
4
4
8
7
11
7
9
9
6
4
9
6
5
5
5
3
5
8
102
91
193(47.77)
I
M
F
1
1
1
3
5
3
9
7
9
2
11
8
9
7
5
5
4
5
4
10
6
7
6
2
70
60
130(32.18)
Grades of Under Nutrition
II
III
M
F
M
F
1
1
1
1
2
3
3
2
4
8
2
2
1
7
1
1
2
2
6
4
1
2
6
1
1
2
1
2
4
4
1
26
39
8
6
65(16.09)
14(3.46)
Age group wise prevalence of undernutrition
was highest in 13-24 months age group (13.86
percent), followed by 0-12 months (10.9 percent),
25-36 months (10.4 percent), 49-60 months (8.66
percent) and 37-48 months (8.41 percent). In age
group of 0-12 months and 25-36 months
prevalence was almost equal i.e. 10.9% and
10.4% respectively. On comparing prevalence of
IV
M
F
1
1
2
02(0.5)
Total no. of
Children
(%)
35 (8.7)
28 (6.9)
35 (8.7)
32 (7.9)
42 (10.4)
47 (11.6)
39 (9.7)
31 (7.7)
25 (6.2)
34 (8.4)
26 (6.4)
30 (7.4)
404
404 (100)
undernutrition in 0-6 months age group with 760 months age group it was observed that
former group had a better nutritional status as
compared to later group. The difference was
statistically significant (χ2 =43.07, df=1,
p<0.0001). Probably indicating faulty weaning
practices and dietary habits.
Table 5: Mean daily intake of foodstuffs among 2-5 years children
Food
Stuff
Cereals
Pulses & Legumes
Leafy Vegetable
Other Vegetable
Milk and Milk product
Oil & fat
Sugar and jaggery
2-3 yrs
(gm/day)
123.8
24.2
5
5
90
10
20
RDA
(gm/day)
175
35
40
20
300
15
30
Sex wise prevalence of undernutrition was
slightly higher in females (26.49 percent) as
compared to males (25.74 percent), however no
significant difference was observed. Grade IV
undernutrition was found only in female (0.5
percent) children.
In India, as per NNMB the prevalence of grade I,
II, III and IV undernutrition was 36.6, 19.7, 4.4
and 0.7 percent respectively among 6-60 months
children from rural area. In Maharashtra, as per
NNMB the prevalence of grade I, II, III and IV
undernutrition was 39.0, 21.2, 4.8 and 0.6 percent
%
Deficit
29.26
30.86
87.5
75
70
33.33
33.33
3-5 yrs
(gm/day)
158.8
28.9
7.4
8
80
22
32
RDA
(gm/day)
270
35
50
30
250
25
40
% Deficit
41.19
17.43
85.2
73.33
68
12
20
respectively among 6-60 months children from
rural area.7
Undernutrition is a very complex entity.
Purchasing power, socio-economic factors,
cultural factors, urban rural settings and many
similar factors plays role in its etiology, hence
observations of various authors vary.
As per Table No. 5 it was observed that the diet
of the children were predominantly cereal and
pulses based like wheat, rice and pulses. The
diet was deficient in green leafy vegetables,
other vegetables, milk and milk products. The
children were given mainly two meals, lunch
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and dinner. All the foodstuffs were less than the
recommended dietary allowances by ICMR.6
The major dietary sources of energy were
observed to be mainly cereals, sugar, and oil.
The children were consuming toast and biscuit
with morning tea. Some people used cow’s milk
for making tea and children were given tea,
many children were consuming tea without
milk.
As per table No. 6 it was observed that the mean
protein intake of children in the age group 2-3
years was 20.92 gm, 3-4 years was 23.12 gm and
4-5 years was 24.98 gm. Pulses and cereals were
the main sources of protein. Protein deficit was
16-18 percent less than the recommended daily
allowance by Indian Council of Medical
Research 1990.6
Table 6: Mean Protein & Calorie Intake of Children in the age group of 2 – 5 Years.
Age Group
in Years
(n)
2-3 (28)
3-4 (25)
4-5 (27)
Proteins (gms)
Mean intake of
RDA
study Population
20.92
25
23.12
28
24.98
30
The mean calorie intake of children in the age
group 2-3 years was 842.6 Kcal, 3-4 years was
956.12 Kcal and 4-5 years was 1096.24 Kcal
respectively. Cereals were the main sources of
calories. The mean intake of calories was less
(35-40 percent) than the recommended daily
allowance by Indian Council of Medical
Research 1990.
Almost all children had protein and calorie
deficit as compared to RDA recommended by
ICMR. The percent of deficit for calories was
% Deficit
16.32
17.41
16.73
Calories (Kcal)
Mean intake of study
RDA
Population
842.6
1400
956.12
1560
1096.24
1690
%
Deficit
39.81
38.71
35.13
more than the protein deficit, thus indicating the
widespread prevalence of malnutrition among
these children is largely conditioned by low
calorie intake and protein gap. This may be
because of low purchasing power of parents.
Agrawal K et al (2001)2 mentioned that the mean
value of intake of calorie in the age group of 2-3,
3-4 and 4-5 was 1017.2 kcal, 1126.6 kcal and
1100.3 kcal respectively and protein was 25.9g,
28.7g and 28.2g respectively.
Table 7: Association of Per Capita Monthly Income and Nutritional Status (n = 404)
Per Capita Monthly
Income (In INR)
≥ 3000
1500-2999
900-1499
450-899
<450
Total
(χ2 =5.24, df=3, p-0.15).
Nutritional Status
Normal (%)
Malnourished (%)
2 (50.00)
2 (50.00)
4 (40.00)
6 (60.00)
24 (64.86)
13 (35.14)
108 (45.00)
132 (55.00)
55 (48.67)
58 (51.33)
193 (47.77)
211 (52.23)
Goyle A et al (2004)4 stated that the mean intake
of energy, protein of the age group 2-3 years and
3-4 years was 777 ± 158.95 kcal, 22.7 ± 5.9 gm and
787 ± 170.7 kcal, 23.7 ± 7.7 gm respectively. The
mean intake of energy was below the
recommended daily allowances not for the
protein for both age group.
As per table No. 7 it was observed that
prevalence of undernutrition was higher in
Total (%)
04 (100)
10 (100)
37 (100)
240 (100)
113 (100)
404 (100)
children from low income group (Rs 450-899 and
<450) as compared to higher income group
(1500-2999 and >3000), however the association
was not found significant (χ2 =5.24, df=3, p>0.1).
Dhakal MM et al (2005)2 mentioned that the
burden of malnourishment still haunts the poor
with 82.75% children from low income group i.e.
IV & V by Prasad Scale.
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In the present study the association between per
capita monthly income and nutritional status
was not found significant as the number of
children from high per capita income were few
as compared to the children from low per capita
income.
RECOMMENDATIONS
Based
on
study
findings
recommendations are suggested.
following
1.
The families from community should be
encouraged for home-based activities for
alternative source of income, which will help
in improving their purchasing power.
2.
As low birth weight of child had significant
effect on malnutrition, more emphasis
should be given on nutritional education
during pregnancy including knowledge
about breast feeding practices especially
exclusive breast feeding for 4-6 months,
proper and adequate weaning, breast
feeding for 2-3 years.
3.
Nutritional rehabilitation centers should be
started in the community and person from
the community is identified and linked with
health centers to treat less severely affected
undernourished children.
BIBLIOGRAPHY
1. Agrawal K, Kushwah A, Kushwah HS, Agarwal R and
Rajput LP. Dietary analysis and assessment of nutritional
status of pre-school children of urban and rural
population. The Indian Journal of Nutrition and Dietetics
2001; 38: 231-235.
2. Dhakal MM, Rai A, Singh CM and Mohapatra SC. Health
impact assessment: a futuristic approach in under-five
care. Indian Journal of Preventive and Social Medicine
2005; 36(3&4): 114-120.
3. Gopalan C, Ramasastri BV, Balasubramanian SC.
Nutritive value of Indian foods. NIN, Indian Council of
Medical research, Hyderabad 1995.
4. Goyle A, Vyas S, Jain P, Shekhawat N and Saraf H.
Nutrient intake of children residing in Squatter
settlements on pavements and along roadsides in Jaipur
city. Journal of Human Ecology 2004; 15(2): 143-146.
5. Gupta SP. Nutrition –an Indian experience. Indian
journal of Public Health 1999; 43: 11-16.
6. ICMR. Recommended dietary intake for Indians, New
Delhi 1990.
7. NNMB. Diet and Nutritional status of rural population.
NNMB Technical Report No. 21, 2002.
8. Nutrition subcommittee of the Indian Academy of
Pediatrics. Indian Pediatrics 1972; 9: 360-364.
9. http://whqlidoc.who.int/hq/1997/WHO_NUT_97.4
pdf.
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Case Report .
A REPORT OF TWO CASES: POST FLOOD AUTOPSY FINDINGS IN URBAN
PATIENTS WITH AN UNUSUAL PRESENTATION OF LEPTOSPIROSIS WITH
HEMORRHAGIC PNEUMONIA IN GOVERNMENT MEDICAL COLLEGE,
SURAT
Mandakini M Patel1, Bhavna Gamit2, R D Patel3, Rahul Modi2
1Additional
Professor, 2Assistant Professor, 3Professor and Head, Department of Pathology,
Government Medical College, Majura gate, Surat, 395001, Gujarat, India
Correspondence:
Dr.Mandakini.M.Patel,
303 / Karuna flats, Ravishankar Sankul, Bhatar Char Rasta,
Surat-395007, Gujarat, India
Email: [email protected], [email protected], Mobile: 098256 41338
ABSTRACT
South Gujarat is endemic zone for leptospirosis in paddy workers but recently we have post flood
plenty of urban patients who were presented with high grade fever, dyspnea & haemoptysis with
rapid deterioration. Clinicians were suspecting an outbreak of Hantavirus or leptospirosis. Both our
patients were serologically negative for leptospirosis ante mortem, but alveolar hemorrhage & raised
urea was the only finding. Both our patient rapidly deteriorated.
We performed autopsy & took post mortem samples for serologically & HP Examination of tissue.
Serological finding showed one patient positive for PCR and second was positive for Leptocheck and
IgM ELISA.
On HP examination we observed massive intra-alveolar hemorrhage, interstitial nephritis, vasculitis
in spleen and kidney, myocarditis & hemorrhage in various organs like heart, suprarenal gland, and
subarachnoid space in both our patient. Levaditi’s stain was also performed but results were not
conclusive. IHC for kidney tissue was not possible due to lack of facility. Extensive hemorrhage in
lung was the cause of death in both patients. Follow up autopsy studies of 30 patients were showing
same histopathological findings.
Key words: Leptospirosis, hemorrhagic pneumonia.
INTRODUCTION
Leptospirosis is worldwide sporadic zoonotic
disease, caused by a pathogenic species of the
genus leptospira interrogans; most common in
humid subtropical & tropical region.1 Species
has several serological variants (the serovar).
The serovar distribution varies with the
geographical region. Recently genus leptospira
is classified into 13 species1, 2 based on shared
antigen.
Leptospirosis is considered a protean disease in
reference to variety of signs & symptoms and
rarely an unusual presentation in course of its
biphasic illness.2 Human is the end host for
leptospirosis, it spreads by intact skin, rarely by
nosocomial route.
We report two autopsy cases of leptospirosis
with hemorrhagic pneumonia.
CASE REPORT
Both the patients were young male (18 &
17years respectively) from city area with history
of exposure of flood water. Initial presentation
was mild fever with myalgia & cough. Both
patients had blood in sputum, rapidly
deteriorating to ARDS, pulmonary hemorrhage
& death. Ante mortem laboratory investigation
showed WBC count 18,600 and 13,600/cmm
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with neutrophilia, platelet count was markedly
reduced 11,000 & 81,000/cmm respectively.
Peripheral Smear for Malaria Parasite was
negative & prothrombin time was normal. Liver
function tests showed no significant change in
enzyme but showed direct bilirubin 1.9mg/dl &
2.00mg/dl respectively. Kidney function tests
showed normal creatinine level but increase in
urea level 113mg/dl & 59mg/dl respectively.
Both patients were serologically negative for
IgM antibody for leptospirosis ante mortem..
We are having two patients from urban
population with clinical presentation of
weakness, fever & myalgia rapidly progressing
to acute respiratory distress, hemoptysis & rapid
deterioration.
Post mortem serological tests were performed
for hanta virus in first patient at NIV Pune
which was negative. Serological test for
leptospirosis also was negative, but PCR for
leptospirosis was positive. In second patient
IgM rapid leptocheck & lepto IgM ELISA were
positive. MAT & PCR were negative.
Histopathological findings of both cases showed
interstitial and alveolar hemorrhage of lung in
addition one case showed feature of pneumonia.
Vasculitis is appreciated in spleen and kidney in
one case. Hemorrhage in heart wall, suprarenal
gland and subarachnoid space was also noticed.
Figure 1: Photo micrograph showing intraalveolar hemorrhage in lung. (H&E x 100)
DISCUSSION
South Gujarat, have the epidemic of
leptospirosis, in monsoon season, in paddy
workers of field, during July to September. Most
of the patients have specific pathological
presentation, in the form of multi organ
involvement. Liver was the most commonly
involved organ with jaundice, pruritus & tender
hepatomegaly. Second common organ involved
is kidney with manifestation of oliguria &
azotemia. The third organ involved is lung with
sudden onset of breathlessness & hemoptysis.3
Figure 2: Photomicrograph showing Vasculitis
in spleen.(H&E x 200)
Figure
3:
Photo
micrograph
showing
subarachnoid hemorrhage in brain. (H&E x 100)
Leptospirosis is presently came to international
attention as a infectious disease having biphasic
clinical
spectrum showing influenza like
infection which rapidly progress to fulminant
fatal disease characterized by jaundice, renal
failure, hemorrhage & shock.4
Both our patient when admitted, had history of
exposure to flood water, having fever &
myalgia, with rapid conversion to ARDS &
pulmonary
hemorrhage.
Pulmonary
manifestation were reported to be less
prominent in leptospirosis.5 The epidemic of
leptospirosis following heavy monsoon flood in
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Mumbai in year 2000 with prominent
pulmonary hemorrhage was observed.4
A case was also reported from Brazil who had
history of swimming through flood water,
presented to hospital with mild symptom,
developed
hemoptysis
&
pulmonary
hemorrhage within 3 days.4 When severe
pulmonary hemorrhage occur, differential
diagnosis was kept as falciparum malaria,
septicemia, DIC & hanta virus infection with
pulmonary syndrome.4, 5
Leptospirosis is identified directly from infected
tissue by dark field microscopy, fluorescent
antibody assay, blood culture, C.S.F., urine or
affected organ may yield positive result.
Serological identification is more useful
clinically; include Latex test, Elisa test & dipstick
test. MAT uses a battery of antigen from
common (frequently locally endemic) leptospira
serovar available at reference laboratory such as
center for disease control & prevention (CDC).
Positive result is defined as a 4- fold rise in titer
between acute & convalescent specimen.
Additional diagnostic test for leptospirosis is
polymerase chain reaction (PCR). Our both
patient were negative for ante mortem
serological test but one showed positive PCR1, 3,
5, 6. We also performed Levaditi’s stain in tissue
which was negative. IHC for kidney tissue was
not possible due to lack of facility.
We have, further, 30 more autopsy cases from
urban area having history of exposure to flood
water, with similar clinical, autopsy and
histopathological findings. Laboratory diagnosis
of leptospirosis takes long culture time, low
recovery rate, low sensitivity of acute serological
ABBREVIATIONS
CDC: Centre for Disease Control
IHC: Immunohistochemistry
HP: Histopathology
IgM: Immunoglobulin M
ELISA: Enzyme Linked Immunosorbent Assay
PCR: Polymerase Chain Reaction
NIV: National Institute of Virology
ARDS: Acute Respiratory Distress Syndrome
REFERANCE
1. Peter Speelman, Leptospirosis. In: Kasper et al.
Harrison’s Principles of Internal Medicine, 16th Ed. New
York, McGraw-Hill; 2005. pp. 988-91.
2. AM Bal. Unusual clinical manifestation of leptospirosis. J
Post grad Med 2005; 51:179-83.
3. AM Clerke, AC Leuva, C Joshi, and SV Trivedi. Clinical
profile of leptospirosis in south Gujarat. J Post grad Med
2002; 48:117-8.
4. Spichler A., Moock M, Chapola E.G. & Vinetz. Weil’s
disease:
an
unusually
fulminant
Presantation
characterized by pulmonary hemorrhage and shock.
Braz J Infect Dis 2005; Aug; 9(4):336-40.
5. SA Divate, R Chaturvedi, NN Jadhav, P Vaideeswar.
Leptospirosis associated with diffuse Alveolar
hemorrhage. J Post grad Med 2002; 48:131-2.
6. HP Salkade, S Divate, JR Deshpande, V Kawishwar, R
Chaturvedi, BM Kandalkar, P Vaideeswar. A study of
autopsy findings in 62 cases of leptospirosis in a
metropolitan city in India. J Post grad Med 2005; 51:16973.
7. ND Pai, PM Adhikari. Hemorrhagic pneumonitis: A rare
presentation of leptospirosis. J Post grad Med 2001;
47:35-6.
test. So it should not be the basis on which
treatment is initiated. When there is history of
exposure empiric therapy should be started.
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Case Report .
A CASE OF MALIGNANT LOW GRADE ENDOMETRIAL STROMAL SARCOMA AND
REVIEW OF THE LITERATURE
Amrish N Pandya1, Arpita Nishal2, Hemali Tailor3
1Associate
Professor, 2Associate professor (IHBT), 3Assistant Professor, Department of Pathology,
Government medical college and new civil hospital, Surat
Correspondence:
Dr. Amrish N Pandya
702 /B, Amrutdhara Aptts, Opp. St. Xavier’s School,
Ghod Dod Road, Surat-396001
ABSTRACT
Low grade endometrial stromal sarcoma is a rare pelvic malignancy that arises from the
endometrium. This article describes the morphological features of one such tumour discovered as
finding in a hysterectomy specimen of a 32 year lady with a clinical diagnosis of dysfunctional uterine
bleeding with multiple fibroids. Morphological and immunohistochemical evaluations were
performed and a final diagnosis of low grade endometrial stromal sarcoma was given. This report is
aimed to present a case of endometrial stromal tumor because of its rare existence and difficulties in
establishing histological diagnosis.
Keywords: uterine sarcoma, low grade endometrial stromal sarcoma
INTRODUCTION
Uterine mesenchymal tumors pose many
problems to the surgical pathologist in
prediction of their biological behavior, i.e.
whether benign, low malignant potential or
frankly
malignant.
Differentiation
of
endometrial stromal and smooth muscle tumors
can be done in most instances by routine light
microscopic examination, has not been a subject
of discussion in the literature. However, highly
cellular leiomyomas can be misinterpreted as
endometrial stromal tumors and vice versa. The
morphological features of one such lesion, a low
grade endometrial stromal sarcoma is presented.
Endometrial stromal sarcomas (ESS) are rare
neoplasms, comprising approximately 0.2% of
all uterine malignancies. 1 The tumors are
composed
of
cells
resembling
normal
endometrial stroma. Endometrial stromal
tumours are divided into three types on the basis
of mitotic activity, vascular invasion and
observed differences in prognosis. The
endometrial stromal nodule is a lesion confined
to the uterus, with pushing margins, less than
three mitosis per ten high power fields and
absence of lymphatic or vascular spread. The
disease usually has good prognosis with no
reported recurrences or deaths following
surgical removal of the tumor. Low grade ESS is
defined as infiltrative stromal tumor show less
than ten mitosis per ten high power fields,
frequently extending into and growing within
large vascular spaces. It has a five year survival
rate of 100%. 2 High grades ESS is characterized
by more than ten mitosis per ten high power
fields. It is a highly lethal neoplasm with a
aggressive clinical course and a five year
survival of 55%.2 ESS occur primarily in the
perimenopausal age group, between 45 and 50
years with about one-third being in post
menopausal age group.3,4,5
CASE REPORT
A 32 year old woman presented with
menorrhagia and dysmenorrhoea of four months
duration. She underwent hysterectomy for bulky
uterus with suspicion of multiple fibroids from
clinical examination.
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positive (Fig.2), CD34 negative, EMA negative,
CK negative, ER (Fig.3) and PR (Fig.4) positive.
The conclusion was that it was ESS of low grade
malignancy.
Fig 1: H & E stain. (400x)
Fig.3 ER positive (DAB chromogen, 400x)
Fig.2 CD 10 positive. (DAB chromogen, 400x)
On gross examination the uterus with cervix
measured 13x10x6 cms. Cut section showed the
endometrial cavity filled with multiple nodular
fleshy growths with areas of hemorrhage, largest
nodule measuring 3x3cms.
Tumor was
infiltrating more than half of myometrial
thickness and extending approximately 3-4 mm
from the serosa. Histologically, the sections from
various parts of nodule show densely cellular
tumor made up of round/oval/oblong uniform
cells (resembling endometrial stromal cells) with
scanty cytoplasm. (fig.1) Cells are arranged in
diffuse sheets, at places intersecting and
anastomosing cords arranged around spiral
arteriole. 6-8 mitotic figures were seen per ten
high power fields in the mitotically active areas
of the tumor. Irregular shaped, tongue shaped,
and circumscribed nests of tumor cells are seen
infiltrating the bundles of myometrium. Foci of
necrosis and hemorrhage were also seen. The
immunohistochemical study showed CD 10
Fig. 4 PR positive (DAB chromogen, 400x)
DISCUSSION
Endometrial sarcoma constitutes 15 to 25% of
uterine sarcomas. These tumors are seen most
commonly in older postmenopausal women.
However women in the reproductive ages may
be affected. 6 LGESS have typically a mitotic
count of 5 and less than 10 hpf with minimal
atypia in the cells. Some tumors may be positive
for estrogen and progesterone receptors which
may affect treatment modalities.7 Patients with
LGESS typically present with abnormal vaginal
bleeding, pelvic and abdominal pain. In some
cases it might be without any complaints. 8 Most
tumors grow through the intramural sections of
the uterus rather than intra cavitary, hence
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making
it
difficult
histopathology diagnosis.
for
preoperative
Patients most commonly undergo surgery with
the presumptive diagnosis of uterine fibroid or
pelvic mass. Olive et al. emphasized the
presence of large thick-walled muscular vessels
as a feature that serves to distinguish a highly
cellular
leiomyomas
from
a
stromal
proliferation. 10 Immunohistochemistry is helpful
to differentiate both neoplasms. The addition of
new immunohistochemical markers such as hcaldesmon and CD10 may solve the diagnostic
problems. CD10, expressed by lymphoid cell
precursors, is a cell-surface neutral endo
peptidase and it stains endometrial stroma in the
uterus but not glands. Strong and diffuse CD10
staining was observed in ESN and LGESS
whereas most leiomyomas were negative.
Between EST and leiomyomas, correct
classification is important due to the differences
in clinical behavior and treatment.
LGESS usually behaves in an indolent clinical
fashion; however recurrences and distant
metastases can occur. Prolonged survival as well
as cure is common despite the development of
recurrent or metastatic disease. 5
The mitotic count is an important independent
prognostic factor for these tumors. 5 In addition,
it has been suggested that early tumor stage, low
myometrial invasion, and low mitotic count are
REFERENCES
1.
Koss LG, Spiro RH. Brunschwing A. Endometrial
stromal sarcoma. Surg Gynecol Obstet.1965; 121: 531-7.
2.
Norris HJ, Taylor HB. Mesenchymal tumours of the
uterus: A clinical and pathological study of 53
endometrial stromal tumours. Cancer. 1966; 19: 755-66.
3.
Larson B, Silfersward C, Nilsson B, Pettersson F.
Endometrial stromal sarcoma of the uterus: A clinical
and histopathological study. The radiumhemmet series
1936-1981. Eur J Obstet Gynecol Reprod Biol 1990; 35:
239-49.
4.
Mansi JL, Ramachandra S, Wiltshaw E Fisher C. Case
Report: endometrial stromal sarcomas. Gynecol Oncol
1990; 36: 113-8.
5.
Gadducci A, Sartori E, Landoni F, et al. Endometrial
stromal sarcoma: analysis of treatment failures and
survival. Gynecol Oncol 1996; 63: 247-53.
6.
Bohr L, Thomsen CF. Low-grade stromal sarcoma: a
benign appearing malignant uterine tumor; a review of
current literature. Differential diagnostic problems
illustrated by four cases. Eur J Obstet Gynecol Reprod
Biol 1991; 39:63-9.
7.
Katz L, Merino MJ, Sakamoto H, Schwartz PE.
Endometrial stromal sarcoma: a clinicopathologic study
of 11 cases with determination of estrogen and
progestin receptor levels in three tumors. Gynecol
Oncol 1987; 26(1): 87-97.
8.
Fekete PS, Vellios F. The clinical and histologic
spectrum of endometrial stromal neoplasms: a report of
41 cases. Int. J. Gynecol Pathol 1984; 3:198-212.
9.
Bodner K, Bodner-Adler B, Obermair A, Windbichler G,
Petru E, Mayerhofer S. Prognostic parameters in
endometrial stromal sarcoma: A clinicopathologic study
in 31 patients. Gynecol Oncol 2001; 81(2):160-5.
10. Olive E, Clement PB, Young RH. Endometrial stromal
tumors. An update on a group of tumors with a protean
phenotype. Adv Anat Pathol 2000; 7: 257-8.
associated with a lengthened overall survival in
patients with endometrial stromal sarcomas. 9
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Case Report .
A CASE OF INVASIVE MICRO PAPILLARY CARCINOMA OF THE BREAST WITH
LITERATURE REVIEW
Amrish N Pandya1, Arpita Nishal2, Hemali Tailor3
1Associate
Professor, 2Associate professor (IHBT), 3Assistant Professor, Department of Pathology,
Government medical college and new civil hospital, Surat
Correspondence:
Dr. Amrish N Pandya
702 /B, Amrutdhara Aptts, Opp. St. Xavier’s School,
Ghod Dod Road, Surat-396001
ABSTRACT
Invasive micro papillary carcinoma has been recognized as rare but distinctive variant of carcinoma
in various anatomic sites, including breast, urinary bladder, lung and major salivary glands. The
tumor is characterized by nested pattern of eosinophilic tumor cells arranged in a solid, morular,
tubular patterns. Most often this growth pattern is mixed with conventional carcinoma or other
variants. Patients have typically high-stage disease at presentation and a poor clinical outcome
compared with that of patients with conventional carcinoma arising in the same organ site.
We report a case of 65 year old woman with painful lump in right breast, admitted to the surgical
ward of our institute, diagnosed as invasive micro papillary carcinoma of the breast
histopathologically and immunohistochemically.
Keywords: Breast, micro papillary carcinoma, invasive
INTRODUCTION
Invasive micro papillary carcinoma of the breast
has been recently described as a poorly
recognized aggressive and a rare variant (<3%)
of infiltrating duct carcinoma. It is definitively
associated with lymphatic invasion and a high
incidence of nodal metastases. 1, 2
and nipple. On the cut surface of the breast
there was a 2.5cmx2cm ill-circumscribed mass
lesion, 3 cm away from nipple, with extensive
fibrosis.
Required sections from the mass, lymph nodes
and margins were taken, processed and stained
with H & E stain as well as underwent
Immunohistochemistry procedures.
A 65 year old woman presented with a painful
lump in the right breast since last two months.
Physical examination revealed a discrete mass
in central location of the right breast. A
diagnosis of mammary carcinoma was made on
Fine needle aspiration cytology. The patient
underwent a right modified radical mastectomy
with axillary dissection.
On low power microscopic examination the
tumor was constituted of abundant invasive
epithelial nests, small syncytial groups, cohesive
tumor cell clusters surrounded by clear spaces
and the stroma surrounding the clear spaces
had a fine reticular to collagenous structure. The
cell clusters mainly had round pattern while
some of them had serrated peripheral borders.
Some of the group has central lumen. There was
no desmoplasia around epithelial cell nests.
The mastectomy specimen was sent to the
surgical pathology laboratory of our institute.
On gross examination, the specimen measured
30cmx25cmx5cm with 27cmx12cm epidermis
On high power microscopic examination, the
epithelial cells were cuboidal to columnar with
variable amount of cytoplasm that ranges from
finely granular to densely eosinophilic in nature
CASE REPORT
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(Fig. 1). Myoepithelial cells were not seen at the
periphery of cell clusters.
DISCUSSION
Invasive micro papillary carcinoma of the breast
has been recently described as a poorly
recognized aggressive and a rare variant 1, 2.
Invasive papillary cancers were first described
by Fisher et al, who recognized several subtypes
in their review of 1603 patients tumors from the
National Surgical Adjuvant Breast Project
(protocol 4) 3. The patterns that termed
exfoliative were thought clinically as with poor
prognosis. In 1993 Siriaunkgu and Tavassoli
from the Armed Forces Institute of Pathology
described the first series of this tumor which
they called as invasive micro papillary
carcinoma. They noted that this pattern is a
different entity from metastatic papillary
carcinoma and tubular carcinoma 4.
Fig. 1: Cuboidal to columnar epithelial cells
with variable amounts of cytoplasm that ranges
from finely granular to densely eosinophilic
(H&EX400)
Histological grading and mitotic index were
fairly high and pleomorphism was present.
Total 8 lymph nodes were identified, 3 lymph
nodes showing metastases and the remaining
showed features of sinus histiocytosis.
Fig. 3: HER-2/neu positivity
The tumor is best characterized by a nested
pattern of eosinophilic tumor cells arranged in a
solid, morular and tubular pattern. The tumor
cells have intermediate to high grade nuclei and
individual groups have a clear space separating
them from the surrounding stroma. These
spaces are not lined by endothelial cells and this
is most likely shrinkage artifact. 4, 6
Fig. 2: Estrogen receptor positivity
Immunohistochemistry for estrogen receptor
(ER) (Fig.2) and progesterone receptor (PR), cerbB-2 was performed (fig.3). Both ER and PR
immunoexpressions were positive in 70% of the
tumor cells. C-erbB-2 was (+++) positive in
cytoplasmic membrane of the tumor cells.
The intraductal component that accompanies
these tumors often has a micro papillary pattern
in which intermediate to high grade nuclei and
necrosis typically present. It has been further
defined by electron microscopic analyses, which
showed microvilli on the external surfaces of
cell clusters. 1
IMPC has a high % of estrogen receptor and
progesterone receptor positivity (90% and 70%)
and nearly doubles the expected percentage of
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HER-2/neu positivity
(60%). 2, 6, 7
ER positivity has traditionally been associated
with better differentiated tumors would appear
to be an exception to these general rules.
Expression of acid mucins and surface linear
staining with epithelial membrane antigen
antibody was also described. The clinical
significance and role of prognostic markers in
IMPC are not fully described. It has been shown
that prognostic factors in IMPC of the breast are
the grade and extensive lymphatic invasion 2.
Other factors such as ER and PR status, HER2/neu protein over expression and p53
deletions have also been studied. It appears that
the presence or absence of these markers in
IMPC generally mimic that of the usual breast
cancer in terms of predicting patient prognosis.
2, 8, and 9 It has also been found that pure IMPC
was associated with high-grade histology,
metastases to regional lymph nodes, a high
mitotic index and c-erbB-2 immune positivity. 9,
10 In this case HER-2/neu immunoexpressions
was positive in 60% of the tumor cells. Survival
rates were similar to those of other patients with
equivalent numbers of lymph node metastases. 9
In terms of the differential diagnosis of IMPC of
the breast, other primary breast tumors, such as
the rare invasive papillary carcinoma and
colloidal carcinoma, must be considered.
Invasive papillary carcinoma is Histologically
distinguishable from invasive micro papillary
by its lack of clear spaces surrounding tumor
clusters, truly papillary architectures and
typically low nuclear grade. 6
The distinction from pure colloid carcinoma is
especially relevant because mucin secretion is
an occasional, albeit usually minor, feature of
IMPC of the breast. The large extracellular
mucin pools of colloid carcinoma are infrequent
in IMPC. 6
Metastatic tumors especially ovarian serous
papillary adenocarcinoma, micro papillary
variant of transitional cell carcinoma of the
bladder must also be considered in the
differential diagnosis. 8 Both of these tumors
may exactly mimic the histological appearance
of primary IMPC of the breast.
A thorough and accurate clinical history and the
presence of associated duct carcinoma in situ
will aid in the correct diagnosis of primary
IMPC of the breast. The observation of a
papillary pattern in intramammary lymphatic
tumor emboli or lymph node metastases should
prompt a search for even a small amount of
IMPC differentiation in the primary tumor.
Identification of this entity as a distinct variant
of breast cancer seems prudent because of the
predilection of IMPC for lymphatic invasion
and lymph node spread.
REFERENCES
1.
Luna-More S, Gonzalez B, Acedo C, Rodrigo l, Luna C.
Invasive micropapillary carcinoma of the breast: A new
special type of invasive mammary carcinoma. Pathol
Res Pract 1994; 190:668-74.
2.
Luna-More S, de los Santos F, Breton JJ, Canadas MA.
Estrogen and progesterone receptors, c-erbB-2, p53,
and Bcl-2 in thirty-three invasive micropapillary breast
carcinoma. Pathol Res Pract 1996; 192:27-32.
3.
Fisher ER, Costantino J, Fisher B, et al. Pathologic
finding from the National Surgical Adjuvant Breast
and Bowel Project Investigators. Cancer 1993; 71:214150.
4.
Siriaunkgul S, Tavassoli FA. Invasive micropapillary
carcinoma of the breast. Mod Pathol 1993: 660-62.
5.
Petersen JL. Breast carcinomas with an unexpected
inside-out growth pattern: rotation of polarization
associated with angioinvasion. Pathol Res Pract 1993;
189:780-84.
6.
Walsh MM, Bleiweiss IJ. Invasive micropapillary
carcinoma of the breast: eighty cases of an
underrecognized entity. Hum Pathol 2001; 32:583-9.
7.
Gong Y, Sun X, Huo L, Wiley EL, Rao MS. Expression
of cell adhesion molecules, CD44s and e-cadherin, and
micro vessel density in invasive micropapillary
carcinoma of the breast. Histopathol 2005; 46:24-30
8.
Amin MB, Ro JY, el-Sharkawy T, et al. Micropapillary
variant of transitional cell carcinoma of the urinary
bladder. Histologic pattern resembling ovarian
papillary serous carcinoma. Am J Surg Pathol 1994;
18:1224-32.
9.
Paterakos M, Watkin WG, Edgerton SM, Moore DH
2nd, Thor AD. Invasive micro papillary carcinoma of
the breast: a prognostic study. Hum Pathol 1999;
30:1459-63.
10. Pettinato G, Manivel CJ, Panico L, Sparano L, Petrella
G. Invasive micropapillary carcinoma of the breast:
clinicopathologic study of 62 cases of a poorly
recognized variant with highly aggressive behavior.
Am J Clin Pathol 2004; 121:857-66.
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Special Article .
CENSUS 2011: IMPORTANT HEALTH RELATED MESSAGES
Rashmi Sharma1, Ajesh Desai2
1Assistant
professor, Community Medicine department 2Professor & Head, Obstetrics & Gynecology
Department, GMERS Medical College, SG Highways, Sola Ahmadabad 380060,
Correspondence:
Dr. Rashmi Sharma,
Assistant professor, Community Medicine department,
GMERS Medical College, SG Highways, Sola Ahmadabad 380060,
E mail: [email protected]
ABSTRACT
Census is a massive exercise which aims to the mass enumeration along with collection of certain vital
information of the target population. In most of the countries, it is done at the interval of 10 years.
Data thus collected is of vital importance to see the impact of strategies undertaken in last 10 years
and also for the planning and redesigning the strategies or the future.
Recently released data for Census 2011 for India contains ample of information which can be
segregated right up to a village. In this article attempt has been made to track and analyze some
important health related indicators such as population growth, rural urban ratio, sex ratios and
literacy status (with gender specificity) and the change of these indicators since earlier census
undertaken in 2001.
Key words: Census 2011, sex ratio, decadal growth rate, literacy status
Census is the mass enumeration of the entire
population of a defined geographical area at a
particular point of time. Census operations in
India probably largest of its kind in the world
began since 1865. First two censuses in 1865 &
1872 were conducted in non synchronous
manner in different parts of country. From 1881
onwards, censuses are being undertaken
uninterruptedly. Census done every tenth year
gathers many social, political, economic and
health indicators which are crucial for future
planning and also for evaluating the
interventions carried in the past. The provisional
data of Census 2011 has been just released and it
brings out several important health related
information especially when this data is
compared and analyzed with data of previous
census.
Some of the important findings of Census 2011
are as follows.
1.
Decline in population growth rate:
Decadal growth rate is the rate of addition of
new persons in the population since last
census. This growth rate has been on decline
since 1971. Compared to earlier declines in
decadal growth rates from 24.8% (1961 – 71)
to 24.6% (1971 – 81), 23.87% (1981 – 1991)
and 21.54% (1991 – 2001), this time the
decline is very evident as the decadal
growth rate is 17.64% during 2001 – 2011.
Annual exponential growth rate too has
decreased from 1.97% during 1991 – 2001 to
1.64% in 2001 – 2011. The dent of 4 points in
decadal growth rate (from 21.54 to 17.64) in
decadal growth rate has shown a visible
reduction in growth rates of so called
BIMARU states. The decadal growth rates
for 2001 – 2011 for states like UP, Madhya
Pradesh, Haryana and Uttarakhand now
stand within the range of 19 – 20%. It will be
interesting to know that Kerala recorded a
decadal growth rate of only 4.86% which is
at par with developed countries. At the
same time Nagaland is the only state which
has shown a marginal negative growth rate
of 0.47% in this decade which is seen in
some developed or eastern European
countries which are heading towards
population stabilization. It is indeed a good
sign that ever increasing population of our
158
ISSN: 0976 3325
country is now showing some sign of de
acceleration of population growth. In
accordance to this decline in growth rate, it
is the first time that our country reported
smaller increase in absolute addition of new
persons (18.1 crores during 2001 – 2011 than
18.2 crores during 1991 – 2001). This is
despite the fact that the base population in
2001 was much higher (102.8 crores) than in
1991 (84.6 crores). Proportion of 0 – 6 years
population to total population – another
indicator of recent fertility has also
decreased since 2001 (15.9%) and now
stands at 13.2%.
2.
Ever increasing population and rural urban
difference:
Due to continuous increase in population
since 1911, the population density (number
of persons per square kilometer) is on
regular increase. It was 274 in 1991,
increased to 324 in 2001 and is now 382 in
2011. Within the country it shows wide
diversity in small states and union territories
such as Delhi recorded highest population
density of 11297 while the Arunachal
Pradesh had the lowest (17). Increasing
population along with migration of people
to urban areas in quest of jobs results the
tilting of urban rural balance. Urbanization
is on increase. In 2001 census, the urban
population was 27.8%. Growth in the two
segments has also been different. While the
rural population during 1991 – 2001 grew at
the rate of 17.9% the urban population
during grew faster at the rate of 31.2 %.
Census 2011 places the proportion of urban
population at 38.7%.
3.
Improvement in Literacy:
Improvement in literacy in general and in
women in particular has important bearings
on health as a literate/ educated person is
more amenable for health education and is
more likely to avail health services. Literacy
is a proportion calculated in the population
(> 6 years of age) for the persons who are
able to read and write. Literacy rate is
increased from 65.4% in 2001 to 74% in 2011.
The gains have been more impressive in
women (54.2% in 2001 to 65.5% in 2011) than
men (75.9% in 2001 to 82.1% in 2011).
Overall improvement in literacy reduces the
gender gap as well. In the Kerala where the
overall literacy is 93.9% the difference in
male and female literacy is also less being
only 4% as the literacy in male and females
are 96.0% and 92.0% respectively. An
indication of great strides being made in
educating women perhaps could be the
reason leading to decrease in proportion of
0 - 6 to total population to 13.2%, indicative
of decrease in fertility in last 6 years.
4.
Sex ratio in total and 0 – 6 years
population:
Sex ratio is the number of females per 1000
males. Biologically this ratio should always
be more than 1000, however, it depends up
on selective migration 9both inter and intra
country), female feticide and differential
health and social care norms (discriminating
female population) and as a result this ratio
is mostly adverse (being less than 1000). This
ratio is calculated for total population, 0 – 6
years age population (referred as child sex
ratio). Child sex ratio depends up on the
selective
contraceptive
use;
sex
determination followed by female feticide
but is largely uninfluenced by migration.
The total sex ratio is the end product of
migration, differential care and also the
fertility experiences. In terms of total sex
ratio the country is showing a progressive
improvement from 927 (1991) to 933 (2001)
to 940 (2011). Still the Kerala is the only large
state in the country which has a sex ratio of
more than 1000 (1084). A disturbing trend
observed at the same time is the declining
child sex ratio. It was 945 (1991) and
decreased to 927 (2001) and 914 (2011). This
is an area of concern because despite the
campaigns by governments to save the girl
child and rigorous implementation of PNDT
act.
Worst culprits are northern belt
comprising of Punjab (846), Haryana (830),
Delhi (866), J & K (859) and Chandigarh
(867) followed by the states of Uttarakhand,
Gujarat
(886
each),
Rajasthan
and
Maharashtra (883 each). Jhajjar (774 females)
and Mahendragarh (778 females) two
districts from Haryana have the distinction
of recording lowest child sex ratio in the
country. In fact within these 2 districts, there
are villages which have the child sex ratio as
low as 500. As mentioned earlier this
adverse sex ratio in 0 – 6 years cannot be
attributed to the migration and solely
depends up on the fertility pattern of the
community in last 6 years. It is worth noting
here that the small states such as North
Eastern states and so called “BIMARU states
159
ISSN: 0976 3325
showed a favorable sex ratio in this
population. As a whole the diverse trends in
sex ratio where the total sex ratio is
improving but the 0 – 6 years sex ratio is
decreasing is a challenge to all governmental
agencies, social scientists, demographers,
NGOs and the civil society. It may be noted
that if a decline continues in the sex ratio of
0 – 6 years, soon it will start reflecting in
overall sex ratio and it will be impossible to
sustain or improve overall sex ratio. At the
same time it is interesting to see that Gujarat
has shown opposite trends. It showed a
marginal increase in sex ratio in 0 – 6 years
from 883 (2001) to 886 (2011) while showed a
decline in overall sex ratio from 920 (2001) to
918 (2011); both opposite to national trends.
Finally a paradox is seen with this census data
where we see that the some of the states from
Western India performing well on economic
development or education do not do so well in
area of health. It only emphasizes the need to
share the fruits of development with the entire
population and thereafter these developments
should also reflect in the health improvement of
people as well.
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ISSN: 0976 3325
Short Communication.
EVALUATION OF PRE-TEST AND POST-TEST KNOWLEDGE QUESTIONNAIRE AFTER
INTENSIVE ICTC TEAM TRAINING AMONG HEALTH CARE WORKERS
Vaibhav Gharat1, Bipin Vasava2, Sushil Patel1, Rupani Mihir1, Bhautik Modi1
1Resident, 2Assistant
Professor, Dept. of Community Medicine, SMIMER, Surat
Correspondence:
Dr. Vaibhav Gharat
Keywords: HIV/AIDS, ICTC team training, health care workers
INTRODUCTION
It is estimated that 2.5 million new HIV
infections occurred worldwide in 20071 and
primary prevention remains a key intervention
for mitigating the HIV/AIDS epidemic. With the
expansion of service delivery network Primary
Health Care level staff come across the issue
related to HIV. Gujarat State AIDS Control
Society (GSACS) has developed an intensive 3
days training schedule for developing and fine
tuning the counseling skills of the medical
officers, counselors, laboratory technician and
staff nurses in the form of ICTC team training so
as to produce skilled personnel who can identify
their clients problems, are well informed and
can provide high quality HIV related services.
The training was conducted in four batches in
which total of 134 participants were present.
There were 20 questions in the questionnaire
and each question was given one mark for
correct response or reply. So there were
maximum 20 marks in each questionnaire. On
applying the paired T-test on the overall training
results, mean value for pre-test and post-test
were 66.6 and 121.0 respectively which came out
to be statistically significant (p <0.000001).
We tried to measure the improvement in all
responses after training by comparing the posttest responses with pre-test responses and the
results are shown in table 1. It is apparent from
table 1 that after training, there is an
improvement in each part and it is also
statistically significant.
METHODOLOGY
Presentation, group work, role play, group
exercise,
hands
on
trainings,
games,
demonstration and presentation by participants
were main tools to impart training among the
participants. Faculties of department of
community medicine were actively involved in 3
days training programme. Trainings were
conducted in four different batches. All the
faculties and tools were kept similar for all four
batches. A pretested questioner was used to
before and after training to measure effect of
training on HIV related knowledge of
participants. Two tailed t test was used establish
statistical significance among pre and post
training score.
RESULTS AND DISCUSSION
CONCLUSION
Tools used to impart trainings are very effective
and can significantly improve knowledge of
health care workers. This type of team training
of medical and paramedical personnel of PHCs
and CHCs together helps to improve their skills
in a sustainable manner. Different issues from
different health centres about HIV counseling
are raised and solved satisfactorily. So this type
of training should be organized on regular basis
for efficient working of ICTC and NACP III.
RECOMMENDATIONS
This type of training should be conducted
annually for all health care workers providing
services related to HIV/AIDS.
161
ISSN: 0976 3325
Table 1: Pre training and post training score of correct answer
NO
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
QUESTION
Causes of HIV transmission
Three causes through which HIV does not transmit
Name the period between HIV infection and
detection of antibody
Can anyone transmit HIV in others immediately
after becoming HIV infective (true/false)
Name any two test which can detect HIV infection
Is newborn baby born to a HIV positive mother
have antibody at the time of birth (true/ false)
Why HIV counseling is so important?
Counseling related case problem
What are the risky behaviors behaviors
Which matters should be kept in mind before HIV
testing
Signs of good listener during counseling
Types of question asked during counseling session
Will you ask about past sexual history during
counseling
Fours things should be explained to the client while
giving HIV negative report
Fours things should be explained to the client while
giving HIV positive report
Counseling related case problem
Mention three self care strategies during counseling
Knowledge about Post exposure prophylaxis
HIV and breast feeding
Universal precaution should be taken ONLY with
HIV positive patients (true /false)
REFERENCE
1.
2.
UNAIDS: AIDS Epidemic Update December 2007. Geneva: UNAIDS; 2007.
Joanna
Orne-Gliemann,
Patrice
T
Tchendjou, Marija Miric, Mukta Gadgil,
Maia Butsashvili, Fred Eboko, Eddy PerezThen, Shrinivas Darak, Sanjeevani Kulkarni,
George Kamkamidze, Eric Balestre, Annabel
Desgrées
du
Loû
and
Francois
Dabis.Couple-oriented
prenatal
HIV
3.
PRETEST
(n=134)
130 (97)
113 (84)
119 (89)
POSTTEST
(n=134)
134 (100)
132 (99)
133 (99)
%
Increase
3
15
10
Sig.(2tailed)
(T-test)
0.00001
0.00001
0.00001
55 (41)
113 (84)
43
0.00001
108 (81)
70 (52)
134 (100)
116 (87)
19
39
0.00001
0.00001
23 (17)
120 (90)
57 (42)
17 (13)
130 (97)
132 (99)
98 (73)
127 (95)
80
9
31
82
0.00001
0.00001
0.00001
0.00001
14 (10)
28 (21)
97 (72)
129 (96)
92 (69)
120 (90)
86
48
18
0.00001
0.00001
0.00001
35 (26)
131 (99)
73
0.00001
27 (20)
133 (99)
79
0.00001
91 (68)
19 (14)
21 (16)
79 (59)
83 (62)
117 (87)
88 (66)
123 (92)
118 (88)
121 (90)
19
52
76
29
28
0.00001
0.00001
0.00001
0.00001
0.00001
counseling for HIV primary prevention: an
acceptability study. BMC Public Health
2010, 10:197.
DeAnne K. Hilfinger Messias, Linda
Moneyham, Medha Vyavaharkar, Carolyn
Murdaugh,
and
Kenneth
D.
Phillips.Embodied
Work:
Insider
Perspectives on the Work of HIV/AIDS
Peer Counselors. Health Care Women Int.
2009 July; 30(7): 572–594.
162
ISSN: 0976 3325 Original Article .
MALE CHILD PREFERENCE FOR THE FIRST CHILD DECREASING AMONG WOMEN IN
SURAT CITY
Thakkar Dhwanee1, Viradiya Hiral2, Shaikh Nawal3, Bansal RK4, Shah Dhara3, Shah Shashank3
1Resident,
Department of Paediatrics 2Resident, Department of Obstetrics & Gynaecology 3Ex-Intern,
Department of Community Medicine 4Professor & Head, Department of Community Medicine, Surat
Municipal Institute of medical Education & Research, Surat, India
Correspondence:
Dr. R. K. Bansal
Professor & Head, Department of Community Medicine,
Surat Municipal Institute of medical Education & Research, Surat, India
ABSTRACT
The systematic undervaluation of women is quite visible in our country through adverse sex ration at
birth for girls. The present study attempts to address the desired gender preferences of the first child
of couples in Surat city. Randomly selected 270 women were interviewed using a semi structured
questioner. It was observed that just below two-thirds (63%) of the respondents had expressed their
contentment with either gender choice. Of the remaining the majority had expressed their desire for a
male child (22.2%) followed by a female child (14.4%). ‘Ensuring continuation of family name’ was
the most cited reason for preferring male as a first child while ‘females are considered as the ‘Laxmi’
of the house’ was the most common reason for favouring female as first child. However, Nearly all of
the respondents (98.9%) profess that boys and girls should be given equal rights. At the minimum the
study revealed that the people of Surat city are becoming sensitive towards the issue of male child
reference or at least adopting a politically correct attitude in public settings.
Keywords: Gender, female foeticide, India
INTRODUCTION
The systematic undervaluation of women is
quite visible in our country in terms of lower
status of girl child; unwantedness; practices as
dowry; lower social status of parents of brides;
lifelong responsibility of parents even after
marriage; fear of sexual exploitation and abuse;
disdain upon arrival of girl child and have been
amply documented by various researchers.1-4
The sex ratio at birth favours females; lower
female mortality throughout entire lifespan
given equal medical care5 ; additionally men’s
propensity to risk behaviours and violence
increases premature mortality6, contrary to
higher female mortality in the Indian scenario1.
Employing life tables of gender-neutral
countries, the population sex ratio is calculated
at between 97.9 and 100.37. Throughout the rest
of the world, women outnumber men by 3-5%
so where have our women gone1? Should we
NATIONAL JOURNAL OF COMMUNITY MEDICINE 2011 Volume 2 Issue 1.
label the distorted sex ratio deficits of 2001
Census data resulting from systematic girl child
discrimination/ killings, especially in the belt
extending from northwest of India to parts of
Rajasthan, Gujarat and Maharashtra8 as
annihilation? Recent newspaper reportings and
raids have clearly brought out the rampant
misuse of sonography for prenatal sex
determination and the need to sensitise the
community on the vital issue of skewed sex
ration and its consequent social impacts. The
present study attempts to address the desired
gender preferences of the first child of couples in
Surat city.
This study comprises of face to face interviews
using a semi-structured interview schedule
containing both, qualitative and the quantitative
163
ISSN: 0976 3325 variables, among 270 randomly selected families
residing in Adajan Patia; Nanpura; Ghod Dod;
Citylight; Sarthana Jakatnaka; Umarwada;
Sagrampura; Bhatar; Rustampura; Athwalines;
Parle Point; Palanpur Patia; Majuragate; Ring
Road; Ugat; Bhesan; Katargam; Ved Road;
Varachha; Singanpore; Amroli of Surat city of
South Gujarat with their informed consent from
29th March 2007 to 15th May 2007. The first part
of the study aims to explore whether gender
bias exists in our society in the form of the
desired gender of the first child by the couples
and the reasons for the same. Once the reasons
for the gender bias of the first child are revealed
and compared to their contextual background,
this issue could be explored in a better manner
and possible remedial solutions could be
contemplated.
Table 1: Reasons for preferring a boy as the desired first child (n=60)
Reason(s) preferring a boy as the desired first child
Son serves as a support of the family in all situations
Family tension decreases if the first child is a boy
A son is a great financial help to his parents
Boys enjoy freedom to do anything according their will
Ensuring continuation of family name
Ensuring continuation of family traditions and customs
A son is a matter of respect for the mother in the family
A boy stands good position in our society
For families desiring a single child, a boy is always preferred
A male child helps in having a small and happy family
We feel good and delighted
Women face ruthless and insulting experiences in life
No reason given
No.
9
2
4
1
17
5
1
1
3
1
2
6
8
%
15
3.3
6.7
1.7
28.3
8.3
1.7
1.7
5
1.7
3.3
10
13.3
Table 2- Reasons for no gender preference desire for the first child (n=171)
Reason(s) for no gender preference desire for the first child
In today’s era, both boys and girls can progress equally
Gender contemplation leads to unnecessary doubts & tensions
Gender does not matter to us
Gender does not matter for first child
For parents all children are equal
Irrespective of gender of the education of a child is important
Gender of the child is God’s gift to us
We don’t have a say in God’s orders
We should not oppose God’s power with science & technology
Foetus is a living thing. So it should not be killed
First Child’s gender is immaterial owing to fertility concerns
Having a child is more important than gender issues
Child is our second existence irrespective of the gender
Both girls & boys help parents so this issue is unimportant
In times of need a girl also helps & rescues her parent’s
No reason
No.
38
2
12
24
31
2
34
5
1
1
4
9
2
2
1
13
%
22.2
1.2
7.0
14.0
18.1
1.2
19.8
2.9
0.8
0.8
2.3
5.3
1.2
1.2
0.8
7.6
Table 3: Reasons for preferring a girl as the desired first child (n=55)
Reason(s) for female gender preference
Females are considered as the ‘Laxmi’ of the house
Dikari Vahal No Dariyo
Female are more sensitive and caring towards parents
Daughter can help her mother in her household work
Girl makes home environment more lively
Daughter teaches us how to behave with a daughter-in-law
Female joins two families
Girls are equal to boys in present times
What females can do, males cannot always do so
Sons give more importance to their wives after marriage
At least one daughter is must for a family
As I am a female, why should I prefer a male child!
No reason
No.
15
6
10
1
2
2
3
5
2
2
2
2
5
%
27.2
10.9
18.2
1.8
3.6
3.6
5.5
9.1
3.6
3.6
3.6
3.6
9.1
164
ISSN: 0976 3325 OBSERVATIONS
It was observed that just below two-thirds (63%)
of the respondents had expressed their
contentment with either gender choice. Of the
remaining the majority had expressed their
desire for a male child (22.2%) followed by a
female child (14.4%). The reasons listed for the
gender preferences or neutrality are listed in
tables 1 to 3.
DISCUSSION
An estimated 80 million females are
consequently missing in India and China alone1.
The deficit of women in India and the possible
factors responsible for it have aroused attention
among demographers, social scientists and
women activists who have tried to understand
the phenomenon in terms of under-enumeration
of women in the census counts, sex-selective
migration, and sex ratio at birth, as well as sex
differentials in mortality.
The tables of this study reveal quite a rosy
picture as compared to earlier times when male
child preferences were very strongly expressed18. Yet its hard to be believed. If gender neutrality
does indeed prevail then why aren’t girls
visible1? Why are they missing1? Or perhaps this
gender neutrality is a recent phenomenom?
Time would tell. However, this does bring home
one fact that the government activities are
indeed sensitizing the people on this issue. The
subsequent tables highlight the reasons for no
gender preference for the first child or for male
child preference or for female child perference.
It is heartenening to note that there are also
respondents who opine a preference for a female
child for reasons as considering a female child as
the “Laxmi” of the house. The males gender
increases substantially (44-4%) in subsequent
children mainly for reasons such as continuation
of family name (32.5%) and for completion of
family (22.5%).
However those couples harbouring no gender
preferences and those preferring a second girl
child mainly due toi their feeling that a female
child as the “Laxmi” of the house is indeed a
welcome finding given the current gender ratio
disparity in our country. What is particularly
interesting is that oparents are quite relaxed
about the gender of their second child once their
first child is a male child. The continuation of
family name emerges as the main reason as to
why our society gives more importance to boys
over girls, as cited by 112 out of 270
respondents.
At the same time nearly all of the respondents
(98.9%) profess that boys and girls should be
given equal rights. These findings alongwith
publicised stringent govt. punitive sanctions on
prenatal sex determination and female foeticide
are indeed sensitizing our populace and are
signalling the ushering in of times when the
govt. would not tolerate such attitudes. The
statements and campaigns of the Govt. of
Gujarat, on “Beti Bachao Andolan” speak
volumes about their commitment for the
abatement of female foeticide. The social
sanctions on “save the girl child” are very
significant
such
as
the
historic
and
unprecedented gathering of the Patidar society
to vow to stop female foeticide. The gigantic
numbers of the people who participated in this
event itself is mind boggling. At the minimum it
is safe to say that the people of Surat city are
becoming sensitive towards the issue of male
child reference or at least adopting a politically
correct attitude in public settings. With the
forthcoming harsher govt. legislations on
prenatal sex determinations coupled with
intensive IEC campaigns it is quite possible that
we would witness better gender ratio in our next
census.
REFERENCES
1. Hesketh T, Xing ZW. Abnormal sex ratios in human
populations: Causes and consequences. Proc Natl Acad
Sci USA 2006 September 5; 103 (36): 13271– 13275.
2. Leone T, Matthews Z, Dalla-Zuanna G. Impact and
determinats of gender preference for children in Nepal.
International Family Planning Perspectives 2003; 29: 69–
75.
3. Kumari R. Rural female adolescence: Indian scenario.
Soc Change. 1995; 25 (2-3): 177- 88.
4. Mahalingam R, Jackson B. Idealized cultural beliefs
about gender: implications for mental health. Soc
Psychiatry Psychiatr Epidemiol. 2007; 42:1012–1023.
5. Sen AK. Missing women. Br. Med. J. 1992; 304: 586– 587
6. Waldron I. Recent trends in sex mortality ratios for
adults in developed countries. Soc. Sci. Med. 1993; 36:
451- 462.
7. Coale A. Excess female mortality and the balance of the
sexes in the population: an estimate of the number of
missing females. Popul. Dev. Rev. 1991; 3: 518.
8. Arnold F, Kishor S, Roy TK. Sex-selective abortions in
India. Population Development Review 2002; 28: 759–
785.
165
A STUDY OF 100 CASES OF BRACHIAL PLEXUS
Ojaswini Malukar1, Ajay Rathva1
1Department
of Anatomy Medical College & Hospital, GMERS, Gotri, Vadodara, India
Correspondence:
Dr Ojaswini Malukar, Associate Professor,
Department of Anatomy, Medical College & Hospital, GMERS, Gotri, Vadodara, India
ABSTRACT
Brachial Plexus innervates the upper limb. As it is the point of formation of many nerves, variations
are common. The presence of anatomical variations of the peripheral nervous system is often used to
explain unexpected clinical signs and symptoms. Therefore it is of importance to anatomists,
radiologists, anesthesiologists and surgeons. The current research work was aimed to study common
and anomalous variations of brachial plexsus and communication between its branches. The present
study was done on 50 cadavers to study 100 brachial plexuses, 50 each of right and left upper limbs.
10 cases showed absence of musculocutaneous nerve and 8 cases of communication between
musculocutaneous and median nerve. 18% of cases showed significant variations which can have
bearing on surgical procedures.
Key-words: Brachial plexus, Anatomical variations, Peripheral nerves.
INTRODUCTION
All nerve plexuses are formed only by the
ventral rami, and never by the dorsal rami.1,2,3
They supply the limbs. The plexus formation is
physiological or functional adaptation, and is
perhaps the result of the following special
features in the limbs:
1. Overlapping of dermatomes
2. Overlapping of myotomes;
3. Composite nature of muscles;
4. Possible migration of muscles from the
trunk to the limbs; and
5. Linkage of the opposite groups of muscles
in the spinal cord for reciprocal innervation.
The brachial plexus supplies the upper limb,
and is formed by the ventral rami of lower
nerve (C5, C6, C7, C8, T1). It consists of roots,
trunks, divisions and cords. (Figure-1)
Knowledge of variations in anatomy is
important
to
anatomists,
radiologists,
anesthesiologists and surgeons, and has gained
more importance due to the wide use and
reliance on computer imaging in diagnostic
medicine. Also, presence of anatomic variations
of the peripheral nervous system is often used to
explain unexpected clinical signs and symptoms
of nerve palsy syndrome and vascular problems.
Fig 1: Brachial Plexus
The C5 and C6 fuse to form the upper trunk, the
C7 continues as the middle trunk and the C8
and T1 join to form the lower trunk. Each trunk,
soon after its formation, divides into anterior
and posterior divisions. The anterior divisions of
the upper and middle trunks form the lateral
cord, the anterior division of the lower trunk
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ISSN: 0976 3325 continues as the medial cord and the posterior
divisions of all three form the posterior cord.
The cords then give rise to various branches that
form the peripheral nerves of the upper limb.
The anterior divisions supply the flexor
compartments of upper limb and the posterior
divisions, the extensor compartments. Since the
brachial plexus is a complex structure,
variations in formation of roots, trunks,
divisions and cords are common. The present
study deals with some of the common variations
and some hitherto unknown variations of the
brachial plexus.4,5
Absence of musculocutaneous nerve in 10 cases.
In those cases median nerve supplies
coracobrachialis, biceps brachii and brachialis,
and turns into lateral cutaneous nerve of
forearm. (Figure – 3)
7,8,9
This study was conducted on 50 cadavers (100
upper limb specimens) from the dissection
laboratory with an age range of 50 – 80 years.
The dissection was performed in dissection
laboratories of Smt. N.H.L. Municipal Medical
College, Ahmedabad, B.J. Medical College,
Ahmedabad and Baroda Medical College,
Vadodara from August 2006 to August 2008.
Dissection was done according to Cunningham's
Manual of practical Anatomy, Fifteenth edition.6
Dissection of front and back of arm, cubital
fossa, flexor and extensor compartment of
forearm and palm and dorsum of hand was
done to trace all the branches of Brachial plexus
upto their innervations in all cases.
RESULTS
Fig 3: Absence of musculocutaneous nerve
Table 1: Cases with absence of MCN
Absence of MCN
Cases
%
Right
7
14%
Left
3
6%
Bilateral
2
4%
In present study, 8 cases of communication
between MCN and MN.10,11 In those cases
anastamotic branch was observed running from
the MCN towards the MN, after piercing the
caracobrachialis muscle. (Figure – 4).
One case of fusion of lateral cord and medial
cord, anterior to axillary artery found on left
side. Branches of both the cords are normal.
(Figure – 2)
Fig 4: Communication between MN and MCN
Fig 2: Lateral and Medial cord fusion
In two cases all the three cords were lying lateral
to the axillary artery which has surgical
importance in shoulder surgeries.
167
ISSN: 0976 3325 In present study MCN pierces coracobrachialis
muscle at various levels from the point of
coracoid process. (Figure-5).
Table 2: Cases with communication between
MCN and MN
Communication
between MCN and
MN
Cases
Percentage
Right
Left
Bilateral
1
2%
7
14%
2
4%
Mean distance of MCN piercing coracobrachialis
muscle from the coracoid process on right side is
56.2 ± 12.4 mm and on left side is 55.9 ± 13.3
min. mean difference between right and left side
is not statistically significant. (Z = 0.11, P >
0.05).
Fig :5 MCN Pierces CB at distance from Cor.Pr
Table 3: Distance of MCN piercing CB from Cor.
Pr.
MCN pierces
CB Distance
from Cor. Pr.
in (mm)
31 – 40
41 – 50
51 – 60
61 – 70
71 – 80
81 – 90
Total cases
Right
side
%
3
10
18
5
5
2
43
6
20
36
10
10
4
Left
side
%
5
10
19
5
5
3
47
10
20
38
10
10
6
In present study formation of Median nerve by
MRM and LRM at various level from the
coracoid process. (Figure-6)
Fig:6 Formation of MN at distance from Cor.Pr
Table 4: Distance of formation of MN by LRM
and MRM from Cor. Pr.
Formation
of Right
MN by LRM side
and MRM and
distance from
the Cor. Pr. in
(mm)
31 – 40
5
41 – 50
10
51 – 60
10
61 – 70
20
71 – 80
5
Total cases
50
%
Left
side
%
10
20
20
40
10
5
10
10
20
5
50
10
20
20
40
10
On both side formation of MN by LRM and
MRM and the mean distance from the coracoid
process is 57 ± 11.8 mm. In present study no
variation or communication between other
branches of brachial plexus is seen.
DISCUSSION
In present study, 10 cases of absence of
musculocutaneous nerve is found, here median
nerve takes over supply of Biceps brachi,
coracobrachialis
and
brachialis
muscle.
Aberrations were more on right side (7 cases)
than left side (3 cases) while 2 cases had
bilateral variation.
Le Minor (1990)12
reported Types I – V
regarding variant communications between the
musculocutaneous and median nerve.
Type – I
:There are no connecting fibers
between the musculocutaneous and
Median nerve.
168
ISSN: 0976 3325 Type – II
:Although, some fibres of medial root
of median nerve unite with the
lateral root of median nerve and
form the main trunk of median
nerve, remaining medial root fibers
run in the musculocutaneous nerve
leaving it after a distance to join the
main trunk of median nerve.
Type – III :The lateral root of the median nerve
from the lateral cord runs in the
musculocutaneous nerve and leaves
it after a distance to join the main
trunk of the median nerve.
Type – IV :The fibres of the musculocutaneous
nerve unite with the lateral root of
the median nerve.
After some
distance,
the
musculocutaneous
nerve arises from the median nerve.
Type – V :The musculocutaneous nerve is
absent.
The
fibers
of
musculocutaneous nerve run within
the median nerve along its course.
In present study, 8 cases of communication
between musculocutaneous and median nerve
found. In those cases anastomotic branch was
observed running from the musculocutaneous
nerve towards the median nerve after piercing
the coracobrachialis muscle. In all cases it
presented the Le Minor type 2A pattern, which
is also the most common.2 Aberrations are more
on the left side (7 cases). In 2 cases it presents
bilaterally.
Knowledge
of
various
communications between MCN and MN may
prove valuable in traumatology of the shoulder
joint, as well as in relation to repair operations.
13 Cases of communication between the median
nerve and musculocutaneous nerve or median
nerve and ulnar nerve have been reported
(Srinivasan and Rhodes, 1981; Venieratos and
Anangostopoulou, 1998; Gumusburun and
Adiguzel, 2000; Choi et al 2002). These variation
are not rare, and it is possible that the combined
lesion of the musculocutaneous and part of
median nerve would occur in injury of the
lateral cord. Lesions of the communicating nerve
may give rise to patterns of weakness that may
impose difficulty in diagnosis. Clinical
implication of this could be that injury of
musculocutaneous and median nerve may lead
to unexpected presentation of weakness of
forearm
flexors
and
thenar
muscles.
(Sunderland, 1978).
Communication between the musculocutaneous
and median nerve may prove valuable in
traumatology of shoulder.
In man, the forelimb muscles develop from the
mesenchyme of the para-axial mesoderm during
5th week of embryonic life (Larsen, 1997). The
axons of spinal nerves grows distally to reach
the limb bud mesenchyme. The peripheral
processes of the motor and sensory neutrons
grow in the mesenchyme, in different directions
( Brown et al 1991; Williams et al 1995).
Although it is unclear why neuronal processes
assemble to form a mixed nerve, in this complex
developmental event, there are multiple
possibilities for the route taken by developing
axons and thus for their arrival at the main
trunk.14
Once formed, any developmental differences
would obviously persists postnatally (Brown et
al 1991). As the guidence of the developing
axons is regulated by expression of
chemoattractants and chemorepulsants in a
highly co-ordinated site specific fashion any
alterations in signaling between mesenchymal
cells and neuronal growth cones can lead to
significant variations (Sanes et al 2000).
Alternatively the variation could arise from
circulatory factors at the time of fusion of the
brachial plexus cords (Kosugi et al 1986).
In present study, MCN pierces coracobrachialis
muscle at various level from the point of
coracoid process. The mean distance on right
side is 56.2 ± 12.4 mm and on left side is 55.9 ±
13.3 mm.
In present study, formation of median nerve by
LRM ant. MRM at various level from the
coracoid process, in front of the axillary artery
and mean measurement is 57 ± 11.8 mm from
the coracoid process
CONCLUSION
1.
2.
3.
The knowledge of variation in the formation
of brachial plexus is very useful for
neurosurgeons for treating tumours of nerve
sheaths
such
as
schwannomas,
neurofibroma and non neuronal tumors like
lipoma.
Orthopedic treatments of the cervical spine
also need a thorough knowledge of the
normal and abnormal formation of brachial
plexus.
Keeping in mind the variations in anatomy
and the level of penetration are important
while performing neurolization of the
brachial
plexus
lesions,
shoulder
arthroscopy by anterior glenohumoral
169
ISSN: 0976 3325 4.
5.
portal
and
shoulder
reconstructive
surgery.13
During surgical procedures of the axilla and
the shoulder, a surgeon is exposed to the
topographical anatomy of the neural
structures and awareness of such variations
may be of immense clinical help.
Knowledge of such anomalies are also
important during treatment of fractures.
Knowledge of variation is of immense
importance during surgical exploration of
axilla and arm region, during nerve block,
during internal fixation of humeral fracture
from common anterior approach to avoid
injury to these nerves.
3.
4.
5.
6.
7.
8.
9.
ACKNOWLEDGEMENTS
I thank Dr B D Trivedi, Prof. & H.O.D, Smt. N H
L MMC, Ahmedabad for guiding us in this
study.
10.
11.
12.
REFERENCES
1.
2.
B.D. Chaurasia's Text Book of Human Anatomy –
(Upper limb and thorax ) – (Head and Neck and Brain),
vol.1 and vol.3
Essentials of Human Anatomy (Superior and Inferior
Extremities), Part-III. A.K.Datta, Third Edition. Current
Books International, Calcutta
13.
14.
Gray's Anatomy : 40th edition, Anatomical basis of
clinical practice.
Kerr AT (1918) : The brachial plexus of nerve in man
the variation in its formation and brnches. American
Journal of Anatomy : 23 : 285 – 295.
Leffert, R.D. (1985) : Anatomy of brachial plexus In :
Brachial plexus injuries. Churchill Livingstone. New
York, p.384.
Cunningham's Text Book – Manual of practical
Anatomy, Fifteenth edition.
Gumsburun E ; Adiguzd, E. (2000) : A variation of the
brachial plexus characterized by the absence of the
musculocutaneous nerve : Case report. Surgical and
Radiologic Anatomy. 22 : 63 – 65.
Rao, P.V.V.P. and Chaudhary S.C. (2001) : Absence of
musculocutaneous nerve : two case reports. Clinical
Anatomy, 14: 31 – 35.
Sud, M and Sharma, A. (2000) : Absence of
musculocutaneous nerve and the innervation of
coracobrachialis. Biceps brachii and brachialis from the
median nerve. Journal of the anatomical society of
India. 49 (2) : 176 – 177.
Chauhan, R and Roy, T.S. (2002) : Communication
between the median and musculocutaneous nerve : A
case report, Journal of Anatomical Society of India. 51
(1) : 72 – 75.
Choi, D : Rodriguez – Nicdenfuhr, M: Vazquez
Le Minor, J.M. (1992) : A rare variant of the median
and musculocutaneous nerve in man. Archieves
Anatomy Histology Embryology. 73 : 33 – 42.
Haeri, G.B. and Wiley, A.M. (1982) : Shoulder
impingement syndrome, results of operative release.
Clinical Orthopaedic. 168 : 128 – 132.
Williams PL : Nervous system. In : Gray's Anatomy.
Churchill Livingstone. New York, 1995 : 1267 – 1272.
170
FEMALE FOETICIDE PERCEPTIONS AND PRACTICES AMONG WOMEN IN SURAT CITY
Shaikh Nawal1, Viradiya Hiral2, Thakkar Dhwanee3, Bansal RK4, Shah Dhara1, Shah Shashank1
1Ex-Intern,
Department of Community Medicine 2Resident, Department of Obstetrics & Gynaecology
Department of Paediatrics 4Professor & Head, Department of Community Medicine, Surat
Municipal Institute of medical Education & Research, Surat, India
3Resident,
Correspondence:
Dr. R. K. Bansal
Professor & Head, Department of Community Medicine,
Surat Municipal Institute of medical Education & Research, Surat, India
ABSTRACT
Female foeticide besides skewed sex ratio and its attendant social evils has grave ethical undertones,
especially for medical professionals and our commitment to save lives. Randomly selected 270
women were interviewed using a semi-structured interview schedule to explore the female foeticide
perceptions and practices among couples in Surat city. Only 148 (51.9%) of the women were aware of
the fact that 3 female children killed every minute in India. Prenatal sex determination among their
relatives and neighbours were reported by 80% respondent, though they themselves had never
resorted to it. Could this figure influence the proxy rates for community behaviour, perhaps, this
needs indepth exploration. Supporting to this fact, 25.9% respoindents reported of ever been
pressurized by their family members to undergo prenatal sex diagnosis of their foetus. Encouragingly
90% respondents had opined that that repeated prenatal sex diagnosis and abortions are detrimental
to the mental and physical health of a woman and is wholly preventable. Stricter laws and honest
enforcement of these laws were the commonest suggestions by respondent to prevent female foeticide
in society.
Keywords: female foeticide, Gender, Sex ratio
INTRODUCTION
Numerous studies have amply documented a
tradition of systematic undervaluation of
women is our country 1-2. The male child
preference is invariably expressed in various
forms of female foeticide and infanticide
subsequent to the misuse of sonography for
prenatal sex determination. It is indeed
saddening that while browsing newspapers one
can sometimes come across news articles about
such activities and about raids by Govt. officials
against sonography clinics. The higher female
mortality in Indian scenario1 is amply brought
out in the distorted sex ratio deficits of 2001
Census data due to systematic girl child
discrimination/ killings, especially in the belt
extending from northwest of India to parts of
Rajasthan, Gujarat and Maharashtra3 and has
even been labelled as annihilation? Female
foeticide besides skewed sex ratio and its
attendant social evils has grave ethical
undertones, especially for medical professionals
and our commitment to save lives. Arguably, it
could perhaps be compared to the Holocaust, in
any case such a scenario is simply not acceptable
in a civilized society. Yet, on the other hand this
problem is not there among the tribal or the so
called backward communities. The Govt. of
Gujarat has launched various welfare schemes
in line with its firm commitment to deter female
foeticide. The present study attempts to explore
the female foeticide perceptions and practices
among couples in Surat city.
This study comprises of face to face interviews
among 270 randomly selected families residing
in Adajan Patia; Nanpura; Ghod Dod; Citylight;
Sarthana Jakatnaka; Umarwada; Sagrampura;
171
ISSN: 0976 3325 Bhatar; Rustampura; Athwalines; Parle Point;
Palanpur Patia; Majuragate; Ring Road; Ugat;
Bhesan; Katargam; Ved Road; Varachha;
Singanpore; Amroli of Surat, a city in south
Gujarat which lies on the west coast of India.
Informed consent has been obtained from all of
the respondents. A semi-structured interview
schedule was utilised for this purpose. The
study period was spread over 29th March 2007 to
15th May 2007. Both the qualitative and the
quantitative data has been analysed manually.
OBSERVATIONS
It was observed that only 148 (51.9%) of the
women were aware of the fact that 3 female
children killed every minute in India. When
inquired as to whom they thought is responsible
for female foeticide in terms of doer or seeker or
both? The maximum number of respondents 227
(84.1%) had opined of the concept of shared
responsibility of both in the context of female
foeticide, followed by the seeker 22 (8.1%) and
the doer 21 (7.8%). When asked about the
various Govt. of Gujarat schemes 109 (40.4), 72
(26.7), 66(22.4) and 52(19.3) of the respondents
were aware of the Kanya Kelavni Yojna, Janani
Suraksha Yojna, Narmada Vikas Bond and
Chiranjivi Yojna, highlighting the fact that the
awareness about the government run schemes
needs to be strengthened upon, as their
awareness levels are quite low.
28.6%
Marriage problem for male will arise
4.1%
Polyandry will start
2.8%
Imbalance will be harmful in both the ways
28.3%
It will lead to social, economical and mental problem
12.8%
Number of rape cases and other crime will increase
Population will decrease
4.1%
Female foeticide will decrease
3.8%
0.7%
It will be easy for government to run a country
3.4%
Value of women will increase
11.4%
No answer
0%
5%
10%
15%
20%
25%
30%
35%
Fig 1: Effects of Decrease in Number of Females than Males as stated by respondents
Figure 1 reveals that the respondents are quite
aware of the problems that could potentially
occur in case of a scenario of deficit of females in
our country consequent to gender selective
abortions. The respondents had opined that the
issue of prenatal sex determination assumes
more importance in case the previous two
children are girls and in such an instance of the
total respondents only 13 (5%) had stated that
they would resort to this technique, with the
majority 227 (84%) being against this practice. 30
(11%) had firmly stated that they would not opt
for the thrid child. This finding is encouraging
given that during 1800, the British Government
found that there were no daughters in a village
in the Eastern Uttar Pradesh region of India.4
Fortunately, we are not coming across such
instances lately. These opinions could imply that
our society is now more comfortable with the
concept of having girl children or that
respondents are hesitant to acknowledge their
desire for sons and are not forthcoming with an
honest answer to this sensitive and ethical isssue
consequent to governmental and societal strong
sanctions. It needs mention that Baru (1993)5 had
documented the association between sex
determination tests and subsequent selective
foeticide.
Interestingly 80% of the repondents had
reported of prenatal sex determination among
their relatives and neighbours, though they
themselves had never resorted to it. Could this
figure influence the proxy rates for community
behaviour, perhaps, this needs indepth
172
ISSN: 0976 3325 exploration. 15% of the respondents had
ackonwledged that they had ever undergone an
abortion, however not even in a single instance
was this preceded by the reports of a girl child
and interestingly 85.4% of the respoindents gave
no reason for undergoing the abortion. The vast
majority (85%) of the respondents had opined
that the practice of female foeticide is commoner
today as compared to the period twenty years
ago and they attributed this to easy access to
ultrasonography and chronic villa biopsy,
making it easy for couples to get rid of girl child.
Table 1: Suggestions to Prevent Prenatal Sex Determination & Female Foeticide and Violence (n=277)
Suggestions
Legal punishments & deterrence
Strict enforcement of law
Making newer laws
Stricter laws
Creating greater awareness of existing laws
Govt. should frame suitable laws against dowry
Give equal status to men & women
Increase awareness of these issues among women
Free education to women
Increase opportunities for employment of women
Frame and ensure equal rights for girls & boys
Give women appropriate positions in governance
Ensure reservation for women
Ensure protection to women
Increase female educational attainments
Steps & measures to curb violence against women
Economic encouragements for birth of female child
Doctors guilty of sex determination should be hanged
Prenatal sex determination test should be banned
Invent sonography machines unable to detect foetus gender
Governmental laws and campaigns are good enough
Spreading public awareness by religious leaders
Spreading awareness that child is god’s gift
Government should stop taking bribes in such issues
Everyone should understand such issues in terms of humanity
No suggestions given
An encouraging finding is that 90% respondents
had opined that that repeated prenatal sex
diagnosis and abortions are detrimental to the
mental and physical health of a woman and is
wholly preventable. This finding is offset with
25.9% respoindents reporting of ever been
pressurized by their family members to undergo
prenatal sex diagnosis of their foetus. 3.7 percent
of the women had reported that after the birth of
a daughter when they became pregnant again,
they had been pressurized by the elders in the
family to undergo abortion once the sex
selective tests had determined that their foetus
was a girl. 92.2% respondents believed that
sonography plays an imporatant role in female
foeticide. 12.6% respondents had opined that the
PNDT Act in the present set up will not be able
No.
17
42
10
47
3
2
7
2
3
6
6
2
3
3
8
2
2
2
15
2
7
18
2
2
3
64
%
6.1
15.2
3.6
16.9
1.1
0.7
2.5
0.7
1.1
2.2
2.2
0.7
1.1
1.1
2.9
0.7
0.7
0.7
5.4
0.7
2.5
6.5
0.7
0.7
1.1
23.1
to keep a check on the cases of abortion based on
prenatal sex diagnosis.
Table 1 reveals the multitude of reasons given
by the respondents which they feel would help
in dealing with this ghastly crime such as
stricter laws and enforcement and are self
explanatory.
DISCUSSION
Sex-selective abortions have negated reductions
in female mortality though improved care with
an estimated 80 million missing females in India
and China. The missing millions6 has grave
antisocial consequences of large cohorts of
surplus
marriageable
males
.7-8
Govt.
commitments alone are often inadequate; it
173
ISSN: 0976 3325 needs to be ensured that the citizens
comprehend
the
government’s
infallible
commitment, through laws and enforcement,
forbidding infanticide, abandonment, and
neglect of female children. Societies need to
proscribe families who indulge in any of these,
gender discriminatory, antisocial activities.
The strong son preference is strongly entrenched
in India mind set and needs strong deterrence to
prevent female foeticide.9 It is heartening that
the Central and the State Governments have
indeed responded by formulating appropriate
remedial laws and enforcing stringent
regulation of these laws in an attempt to reduce
the sex selection and selective foeticide and
infanticide. However, recent studies have
pointed out that sex selection techniques are still
being practiced with impunity.10
REFERENCES
9. Hesketh T, Xing ZW. Abnormal sex ratios in human
populations: Causes and consequences. Proc Natl Acad
Sci USA 2006 September 5; 103 (36): 13271– 13275.
10. Leone T, Matthews Z, Dalla-Zuanna G. Impact and
determinats of gender preference for children in Nepal.
International Family Planning Perspectives 2003; 29: 69–
75.
785.
12. Sharma et al, 2007 Sharma BR, Gupta N, Relhan N.
Misuse of prenatal diagnostic technology for sex-selected
abortions and its consequences in India. Public Health
2007; 121(11):854-60.
13. Baru RV. Reproductive technologies and the private
sector- implications for women's health. Health Millions
1993; 1 (1): 6-8.
14. Fathalla M. The missing millions. People Planet. 1998; 7
(3): 10-1.
15. Dandona R., Dandona L., Kumar G. A., Gutierrez J. P.,
McPherson S., Samuels F., Bertozzi S. M. Demography
and sex work characteristics of female sex workers in
India. BMC Int. Health Hum. Rights 2006; 6: 5.
16. Hudson V, Den Boer A. A surplus of men, a deficit of
peace: security and sex ratios in Asia's largest states. Int.
Secur. 2002; 26: 5– 38.
785.
18. Jha P, Kumar R, Vasa P, Dhingra N, Thiruchelvam D,
Moineddin R. Low female[corrected]-to-male [corrected]
sex ratio of children born in India: national survey of 1.1
million households. Lancet 2006; 367: 211– 218.
174
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Citing a journal:
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Singh SS, Vijayachari P, Sinha A, et al. Clinico-epidemiological study of hospitalized cases of severe
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tropical medicine and parasitology, 2000 Sep 18-22; Oxford. Cheshire: Complete Congress Services Ltd; 2000. p.
139
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