Rajesh Kumar

Background: Hypertension, a leading cause of cardiovascular disease, is a significant public health challenge, with urban India reporting prevalence rates up to 40%. Excessive salt intake, averaging 8 to 11 g/day in India, far exceeds the World Health Organization–recommended limit of 5 g/day and is a key modifiable risk factor. While 24-hour urine collection is the gold standard for measuring 24-hour urinary excreted salt levels, its practicality in large-scale studies is limited, necessitating alternative methods such as spot urine sampling and dietary recall. Objective: This study aimed to address current knowledge gaps by evaluating 24-hour urinary excretory salt levels across age groups and comparing the gold standard of 24-hour urinary salt excretion with estimates from spot urine samples and 24-hour dietary recalls among adolescents and their parents in Chandigarh, India. Methods: A cross-sectional survey was conducted among 462 adolescents and 395 parents from public schools in Chandigarh, part of a cluster randomized controlled trial focused on reducing chronic disease risk factors. Twenty-four–hour urinary excreted salt levels were measured via 24-hour urine collection, spot urine samples were analyzed with the Kawasaki, Tanaka, and INTERSALT equations, and 2 nonconsecutive 24-hour dietary recalls using a correction factor of 0.9. Bland-Altman plots were used to assess agreement between methods. Results: The mean 24-hour urinary excreted salt levels measured via 24-hour urine samples were 6.95 g/day (SD 0.24; 95% CI 6.48‐7.42) for adolescents and 7.73 g/day (SD 0.3; 95% CI 7.18‐8.28) for parents. Spot urine estimates showed variability, with the INTERSALT equation with potassium yielding the closest results to 24-hour measurements for parents (mean 8.12, SD 0.4 g/d; 95% CI 7.36‐8.95) and adolescents (mean 7.97, SD 0.4 g/day; 95% CI 7.16‐8.77). Dietary recall underestimated 24-hour urinary excreted salt levels for both groups (mean 4.15, SD 0.08 g/day for adolescents and mean 3.62, SD 0.08 g/day for parents). Conclusions: Spot urine sampling, particularly the INTERSALT with potassium equation, offers a feasible alternative to 24-hour urine collection for estimating population-level 24-hour urinary excreted salt levels among adolescents and adults in resource-limited settings. Dietary recall alone significantly underestimates intake and should be supplemented with objective measures. These findings support the use of tailored estimation methods based on age for improved hypertension management strategies in India.

Introduction: High-quality anthropometric data is essential to creating effective nutrition policy, but there’s limited evidence on the quality of data from population-based household surveys in India, particularly at the sub-national level. Methods: We compared survey procedures implemented by the National Family Health Survey (NFHS), rounds 1, 2, 3, 4, and 5, and the Comprehensive National Nutrition Survey (CNNS). We conducted a disaggregated analysis at the state level to observe quality performance for height-for-age (HAZ), weight-for-age (WAZ), and weight-for-height (WHZ) z-scores for children under five years. Nine data quality parameters, guided by WHO-UNICEF guidelines, were assessed: completeness of birth date and anthropometric measurement, sex ratio, age-heaping, position mismatch, digit preferences, implausible values, z-score distribution and growth faltering graphs. Results: Survey methods improved over time, including enhanced training, increased use of computer-assisted devices, and real-time supervision. Consequently, from 1992 to 2020, there were improvements in anthropometric data quality, including more balanced age and sex distribution, increased completeness of birth date (from 53% to 95%) and anthropometric measures (from 60% to 91%), and decreased rounding of measurements. Steady albeit small improvements were observed in the standard deviation of HAZ (from 1.9 to 1.8) and WHZ (from 1.5 to 1.3). Implausible HAZ values were reduced from 5% to 2%. Data quality varied across states but generally showed a positive trend. Conclusions: Anthropometric data quality in Indian population-level surveys shows satisfactory progress, reflecting global advancement. However, gaps persist, particularly in errors in birth date and height and weight measurement. Continued efforts are needed to further enhance data quality through improved survey planning, training, data collection, real-time supervision, analysis, and reporting, together with the strengthening of administrative data and civil records. High implausible values, especially in surveys with otherwise strong data quality, likely reflect, at least in part, underlying population inequities.

Background: The global surge in ultra-processed food (UPF) consumption is a major public health challenge, particularly among adolescents. UPFs, characterised by high energy density, added sugars, fats and sodium, and low essential nutrients, are linked to poor diet quality and heightened risks of obesity, diabetes and all-cause mortality. Despite growing concerns, there is limited evidence on school-based interventions targeting UPF reduction in low- and middle-income countries (LMICs) like India. Methods: A cluster-randomised controlled trial was conducted across 12 public schools in Chandigarh, India, targeting Grade 8 adolescents and their parents. The intervention was structured around the PRECEDE–PROCEED (Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation-Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development) Model and comprised 11 sessions for adolescents delivered over 6 months. Additionally, a single educational session was conducted for parents to enhance their awareness of reducing UPF consumption and encouraging healthier dietary behaviours. Dietary intake data were collected at baseline and endline using two non-consecutive 24-hour dietary recalls. Foods were categorised into four groups based on the extent and purpose of industrial processing using NOVA food classification. Energy levels were estimated using Prospective Urban Rural Epidemiology (PURE) study data. The intervention’s effectiveness was evaluated using a difference-in-difference (DiD) analytical approach. Findings: The intervention significantly reduced UPF energy intake among adolescents by 1062 Kcal/day (95% CI −2100 to –67) and processed food by 274 Kcal/day (95% CI −526 to –23). However, no significant changes were observed in minimally processed food consumption. Among parents, the intervention had no significant impact on energy intake for any of the NOVA classified food categories. Process evaluation highlighted high participant engagement and feasibility of the intervention in school settings. Conclusion: This study demonstrates the potential of school-based behavioural interventions to reduce UPF consumption among Indian adolescents, addressing a critical gap in public health research and practice in LMICs. Trial registration number: CTRI/2019/09/021452.

The significant genetic diversity among Group A Streptococcal (GAS) strains isolated from various geographical regions presents serious challenges for treatment and vaccine development strategies

Background: Context-specific policies on social determinants of health (SDH) have been advocated to achieve health equity goals. Therefore, we reviewed the policies and assessed the progress achieved in health equity in India. Methods: A logical framework with qualitative and quantitative approaches was used to review the contents of policies identified from government websites, and data from the budget and national sample surveys were used to assess inputs and equity outcomes. Results: India has formulated several rights-based equity-oriented policies and increased financial allocations to the social sector. Civil participation has increased especially among the marginalized population. The Right to Education Act has made education free and compulsory for children. Initiatives on poverty alleviation have led to improvements in living conditions. The National Food Security Act provides subsidized food grains to about 2/3rds of the country's 1.4 billion population. However, undernutrition remains a major issue. Infant Mortality Rate (IMR) has declined from 58 in 2004-05 to 30 per thousand live births in 2019-21, and the gap in IMR has narrowed down between states, various socioeconomic groups, and urban and rural populations. Conclusions: Although policy initiatives have improved SDH to some extent but inequity in socio-economic, rural-urban, gender, wealth, and caste groups persists in India.

We report process evaluation findings from the ‘SMART Eating’ intervention trial, which significantly improved fat, sugar and salt (FSS), and fruits and vegetables (FVs) intake among adults. Intervention used information technology [short message service (SMS), WhatsApp and website] and interpersonal communication (distribution of SMART Eating kit) and pamphlet for comparison group. Guided by UK Medical Research Council’s framework, using embedded mixed-methods design, continuous process evaluation documented fidelity, dose, reach, acceptability and mechanisms. Intervention was implemented as intended, with high reach (91%) in both groups: ‘comparison group’ (n = 366): inadequate use of pamphlets (46%); ‘intervention group’ (n = 366): with timely remedial measures to remove implementation/usage barriers, dose of SMS (93%), WhatsApp (89%) and ‘SMART Eating’ kit (100%) was adequate, but website usage was low (50%); compliance was evident from participants’ interactions with the implementor and observations on kit usage. All these might have improved attitude, social influence, self-efficacy and household behaviours, which, in turn, mediated intervention’s effect on improving FSS and FV intake. Among poor performers, lack of effect on FV intake was perceived to be related to high cost/pesticides use and FSS intake was related to lack of family support. Low website usage, challenges with WhatsApp messaging and contextual factors (cost, pesticides abuse and family support) need to be considered while designing similar future interventions.

Background: Molecular techniques can enhance the power of epidemiological investigations for tracing HIV transmission networks. This information could be useful for developing strategies for prevention of HIV transmission. Hence, we carried out to a study on the transmission patterns among newly diagnosed HIV cases among High-Risk Groups (HRGs) of North-West India using phylogenomic methods. Methods: Phylogenomic analysis was carried out among 37 randomly selected samples of recently infected HRGs identified through Recent Infections Testing Algorithm (RITA) using Limiting Antigen Avidity Assay. Amplification of the reverse transcriptase region of pol gene (540 base pairs) and sequencing was done. Reference sequences were extracted from HIV Los Alamos database. Sequences aligned by Clustal W and HIV-1 subtype were determined on the basis of phylogenomic analysis of the pol sequence. Phylogenetic trees were constructed using the MEGA (version 11.0). Results: The phylogeny clearly depicts that the study isolates RTFSWCHD and RTFSWPB007 cluster with and are related to the Indian reference sequences AY746371 and EU683781 and a Nepalese sequence KX430115.The other study isolates (RTFSWCHD001, RTFSWPB005, RTFSWCHD002, RTFSWPB006, RTFSWHR008, RTFSWHR 009) clustered uniquely among themselves without any interlinking with other references. One study isolate (RTFSWHP004) clustered closely with Zimbabwian isolate AY998351. The phylogeny shows that the study isolate MSMCHD005 clades separately with the Indian references (DQ838761, EU683781and AY746371), but is also very closely related to the references from China (HG421606, JQ658754), Nepal(JN023039) and Myanmar (N223216, JN223183, KC913773). Other study isolates (MSMCHD003, MSMHP007, MSMCHD004, MSMPB001, MSMPB002, and MSMHR006) are highly interrelated among themselves and form a separate unique clade together. The evolutionary tree shows that all the sequences from current study formed a monophyletic lineage, i.e., sequences from India clustered together more than with sequences from any other country. The study sequences showed relatedness only to the Nepal references KX430115 and JN023035. The South African, UK, Norway, China, and Myanmar references are grouped into aseparate clade. Conclusion: Molecular epidemiologic methods were able to reveal transmission networks; hence, phylogenomic methods can be used in HIV Sentinel Surveillance to monitor transmission networks.

Background & objectives: HIV sentinel surveillance (HSS) among antenatal women in India has been used to track the epidemic for many years. However, reliable tracking at the local level is not possible as ANC sentinel sites are limited in number and cover a smaller sample size at each site. Prevention of parent-to-child-transmission (PPTCT) programme data has a potential advantage due to better geographical coverage, which could provide more precise HIV case estimates; therefore, we compared HSS ANC data with PPTCT programme data for HIV tracking. Methods: Out of the 499 surveillance sites, where HSS and PPTCT programme was being conducted in 2015, 210 sites (140 urban and 70 rural) were selected using a stratified random sampling method. HSS (n=72,981) and PPTCT (n=112,832) data records were linked confidentially. The sociodemographic characteristics of HSS and PPTCT attendees were compared. HIV prevalence from HSS ANC was compared with the PPTCT programme data using Chi-square test. State- and site-level correlation of HIV prevalence was also done. Concordance between HSS and PPTCT HIV positivity was estimated using kappa statistics. Results: The age distribution of HSS and PPTCT attendees was similar (range: 23 to 27 yr); however, HSS ANC participants were better educated, whereas PPTCT recorded a higher proportion of homemakers. The correlation of HIV prevalence between HSS and PPTCT was high (r=0.9) at the State level and moderate at the site level (r=0.7). The HIV positivity agreement between HSS ANC and PPTCT was good (kappa=0.633). A similar prevalence was reported across 26 States, whereas PPTCT had a significantly lower prevalence than HSS in three States where PPTCT coverage was low. Overall HIV prevalence was 0.31 per cent in HSS and 0.22 per cent in PPTCT (P<0.001). Interpretation & conclusions: High-quality PPTCT programme data can provide reliable HIV trends in India. An operational framework for PPTCT-based surveillance should be pilot-tested in a phased manner before replacing HSS with PPTCT.

Transgender women globally are disproportionately burdened by HIV. Co-occurring epidemics of adverse psychosocial exposures accelerate HIV sexual risk, including among transgender women; however, studies using additive models fail to examine synergies among psychosocial conditions that define a syndemic. We examined the impact of synergistic interactions among 4 psychosocial exposures on condomless anal sex (CAS) among transgender women in India. A national probability-based sample of 4,607 HIV-negative transgender women completed the Indian Integrated Biological and Behavioural Surveillance survey, 2014−2015. We used linear probability regression and logistic regression to assess 2-, 3-, and 4-way interactions among 4 psychosocial exposures (physical violence, sexual violence, drug use, and alcohol use) on CAS. Overall, 27.3% reported physical and 22.3% sexual violence victimization (39.2% either physical or sexual violence), one-third (33.9%) reported frequent alcohol use and 11.5% illicit drug use. Physical violence was associated with twofold higher odds of CAS in the main effects model. Statistically significant two- and three-way interactions were identified, on both the multiplicative and the additive scales, between physical violence and drug use; physical and sexual violence; physical violence, sexual violence, and alcohol use; and physical violence, alcohol use and drug use. Physical and sexual violence victimization, and alcohol and drug use are highly prevalent and synergistically interact to increase CAS among HIV-negative transgender women in India. Targeted and integrated multilevel initiatives to improve the assessment of psychosocial comorbidities, to combat systemic transphobic violence, and to provide tailored, trauma-informed alcohol and substance use treatment services may reduce HIV risk among transgender women.