Biomedical subjects
Prabhat Jha
Publications and source records attributed to Prabhat Jha.
Body mass index, sexual behaviour, and sexually transmitted infections: an analysis using the NHANES 1999-2000 data.
BACKGROUND: Factors determining human sexual behaviour are not completely understood, but are important in the context of sexually transmitted disease epidemiology and prevention. Being obese is commonly associated with a reduced physical attractiveness but the associations between body mass index, sexual behaviour and the risk of acquiring sexually transmitted infections has never been studied. METHODS: The National Health and Nutrition Examination Survey (NHANES) files of 1999-2000 were used. Linear regression was used to relate the reported number of sex partners in the last year and lifetime to Body Mass Index (BMI). Logistic regression was used to relate Herpes Simplex Virus type II (HSV-2) antibodies to BMI and other variables. RESULTS: Data on 979 men and 1250 women were available for analysis. Obese (mean number of partners for men:1.12, women: 0.93) and overweight (mean for men: 1.38, women: 1.03) individuals reported fewer partners than individuals of normal BMI (mean for men: 2.00, women: 1.15) in the last year (p < .0.01 & p < 0.05 for men, p < 0.05 & n.s. for women). The same relationship held for lifetime partners in men (mean 11.94, 18.80, and 22.08 for obese, overweight and normal BMI respectively (p < 0.05 & n.s. for obese and overweight vs normal respectively), but not in women (mean 7.96, 4.77, and 5.24 respectively). HSV-2 antibodies were significantly correlated with the number of lifetime partners in both men and women, with the odds of being HSV-2 positive increasing by 0.6% (p < 0.01) and 2.7% (p < 0.01) for men and women respectively. HSV-2 antibodies increased with age, even after adjustment for lifetime partners (p < 0.01). Being obese (HSV-2 prevalence 15.9 and 34.9% for men and women respectively) or overweight (HSV-2 prevalence 16.7 and 29.3 for men and women respectively) was not associated with HSV-2 antibodies (HSV-2 prevalence for normal BMI: 15.6 and 23.2% respectively), independent of whether the association was adjusted for life time sexual partners or not. There was evidence of substantial misreporting of sexual behaviour. CONCLUSION: Obese and overweight individuals, especially men, self report fewer sex partners than individuals of normal weight, but surprisingly this is not reflected in their risk of HSV-2 infection. HSV-2 antibodies provide information not contained in self-reported number of partners and may better estimate sexual risk than self-reported behaviour.
Social inequalities in male mortality, and in male mortality from smoking: indirect estimation from national death rates in England and Wales, Poland, and North America.
BACKGROUND: There are substantial social inequalities in adult male mortality in many countries. Smoking is often more prevalent among men of lower social class, education, or income. The contribution of smoking to these social inequalities in mortality remains uncertain. METHODS: The contribution of smoking to adult mortality in a population can be estimated indirectly from disease-specific death rates in that population (using absolute lung cancer rates to indicate proportions due to smoking of mortality from certain other diseases). We applied these methods to 1996 death rates at ages 35-69 years in men in three different social strata in four countries, based on a total of 0.6 million deaths. The highest and lowest social strata were based on social class (professional vs unskilled manual) in England and Wales, neighbourhood income (top vs bottom quintile) in urban Canada, and completed years of education (more than vs less than 12 years) in the USA and Poland. RESULTS: In each country, there was about a two-fold difference between the highest and the lowest social strata in overall risks of dying among men aged 35-69 years (England and Wales 21%vs 43%, USA 20%vs 37%, Canada 21%vs 34%, Poland 26%vs 50%: four-country mean 22%vs 41%, four-country mean absolute difference 19%). More than half of this difference in mortality between the top and bottom social strata involved differences in risks of being killed at age 35-69 years by smoking (England and Wales 4%vs 19%, USA 4%vs 15%, Canada 6%vs 13%, Poland 5%vs 22%: four-country mean 5%vs 17%, four-country mean absolute difference 12%). Smoking-attributed mortality accounted for nearly half of total male mortality in the lowest social stratum of each country. CONCLUSION: In these populations, most, but not all, of the substantial social inequalities in adult male mortality during the 1990s were due to the effects of smoking. Widespread cessation of smoking could eventually halve the absolute differences between these social strata in the risk of premature death.
Trends in HIV-1 in young adults in south India from 2000 to 2004: a prevalence study.
BACKGROUND: Major increases in HIV-1 prevalence in India have been predicted. Incident infections need to be tracked to understand the epidemic's course, especially in some southern states of India where the epidemic is more advanced. To estimate incidence, we investigated the prevalence of HIV-1 in young people attending antenatal and sexually transmitted infection (STI) clinics in India. METHODS: We analysed unlinked, anonymous HIV-1 prevalence data from 294 050 women attending 216 antenatal clinics and 58 790 men attending 132 STI clinics in 2000-04. Southern and northern states were analysed separately. FINDINGS: The age-standardised HIV-1 prevalence in women aged 15-24 years in southern states fell from 1.7% to 1.1% in 2000-04 (relative reduction 35%; p(trend)<0.0001, yearly reduction 11%), but did not fall significantly in women aged 25-34 years. Reductions in women aged 15-24 years were seen in key demographic groups and were similar in sites tested continuously or in all sites. Prevalence in the north was about a fifth of that in the south, with no significant decreases (or increases) in 2000-04. Prevalence fell in men aged 20-29 years attending STI clinics in the south (p(trend)<0.0001), including those with ulcerative STIs (p(trend)=0.0008), but reductions were more modest in their northern counterparts. INTERPRETATION: A reduction of more than a third in HIV-1 prevalence in 2000-04 in young women in south India seems realistic, and is not easily attributable to bias or to mortality. This fall is probably due to rising condom use by men and female sex workers in south India, and thus reduced transmission to wives. Expansion of peer-based condom and education programmes for sex workers remains a top priority to control HIV-1 in India.
Advancement of global health: key messages from the Disease Control Priorities Project.
The Disease Control Priorities Project (DCPP), a joint project of the Fogarty International Center of the US National Institutes of Health, the WHO, and The World Bank, was launched in 2001 to identify policy changes and intervention strategies for the health problems of low-income and middle-income countries. Nearly 500 experts worldwide compiled and reviewed the scientific research on a broad range of diseases and conditions, the results of which are published this week. A major product of DCPP, Disease Control Priorities in Developing Countries, 2nd edition (DCP2), focuses on the assessment of the cost-effectiveness of health-improving strategies (or interventions) for the conditions responsible for the greatest burden of disease. DCP2 also examines crosscutting issues crucial to the delivery of quality health services, including the organisation, financial support, and capacity of health systems. Here, we summarise the key messages of the project.
Low female[corrected]-to-male [corrected] sex ratio of children born in India: national survey of 1.1 million households.
BACKGROUND: Fewer girls than boys are born in India. Various hypotheses have been proposed to explain this low sex ratio. Our aim was to ascertain the contribution of prenatal sex determination and selective abortion as measured by previous birth sex. METHODS: We analysed data obtained for the Special Fertility and Mortality Survey undertaken in 1998. Ever-married women living in 1.1 million households in 6671 nationally-representative units were asked questions about their fertility history and children born in 1997. FINDINGS: For the 133 738 births studied for 1997, the adjusted sex ratio for the second birth when the preceding child was a girl was 759 per 1000 males (99% CI 731-787). The adjusted sex ratio for the third child was 719 (675-762) if the previous two children were girls. By contrast, adjusted sex ratios for second or third births if the previous children were boys were about equal (1102 and 1176, respectively). Mothers with grade 10 or higher education had a significantly lower adjusted sex ratio (683, 610-756) than did illiterate mothers (869, 820-917). Stillbirths and neonatal deaths were more commonly male, and the numbers of stillbirths were fewer than the numbers of missing births, suggesting that female infanticide does not account for the difference. INTERPRETATION: Prenatal sex determination followed by selective abortion of female fetuses is the most plausible explanation for the low sex ratio at birth in India. Women most clearly at risk are those who already have one or two female children. Based on conservative assumptions, the practice accounts for about 0.5 million missing female births yearly, translating over the past 2 decades into the abortion of some 10 million female fetuses.
Better health statistics are possible.
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Reducing the burden of smoking world-wide: effectiveness of interventions and their coverage.
Cigarette smoking and other tobacco use imposes a huge and growing public health burden globally. Currently, approximately 5 million people are killed annually by tobacco use; by 2030, estimates based on current trends indicate that this number will increase to 10 million, with 70% of deaths occurring in low- and middle-income countries. Numerous studies from high-income countries, and a growing number from low- and middle-income countries, provide strong evidence that tobacco tax increases, dissemination of information about health risks from smoking, restrictions on smoking in public places and in work-places, comprehensive bans on advertising and promotion and increased access to cessation therapies are all effective in reducing tobacco use and its consequences. Despite this evidence, tobacco control policies have been unevenly applied--due partly to political constraints. This paper provides a summary of these issues, beginning with an overview of trends in global tobacco use and its consequences and followed by a review of the evidence on the effectiveness of tobacco control policies in reducing tobacco use. A description of the types and comprehensiveness of policies currently in place and a discussion of some of the factors correlated with the strength and comprehensive of these policies follows.
Prospective study of one million deaths in India: rationale, design, and validation results.
BACKGROUND: Over 75% of the annual estimated 9.5 million deaths in India occur in the home, and the large majority of these do not have a certified cause. India and other developing countries urgently need reliable quantification of the causes of death. They also need better epidemiological evidence about the relevance of physical (such as blood pressure and obesity), behavioral (such as smoking, alcohol, HIV-1 risk taking, and immunization history), and biological (such as blood lipids and gene polymorphisms) measurements to the development of disease in individuals or disease rates in populations. We report here on the rationale, design, and implementation of the world's largest prospective study of the causes and correlates of mortality. METHODS AND FINDINGS: We will monitor nearly 14 million people in 2.4 million nationally representative Indian households (6.3 million people in 1.1 million households in the 1998-2003 sample frame and 7.6 million people in 1.3 million households in the 2004-2014 sample frame) for vital status and, if dead, the causes of death through a well-validated verbal autopsy (VA) instrument. About 300,000 deaths from 1998-2003 and some 700,000 deaths from 2004-2014 are expected; of these about 850,000 will be coded by two physicians to provide causes of death by gender, age, socioeconomic status, and geographical region. Pilot studies will evaluate the addition of physical and biological measurements, specifically dried blood spots. Preliminary results from over 35,000 deaths suggest that VA can ascertain the leading causes of death, reduce the misclassification of causes, and derive the probable underlying cause of death when it has not been reported. VA yields broad classification of the underlying causes in about 90% of deaths before age 70. In old age, however, the proportion of classifiable deaths is lower. By tracking underlying demographic denominators, the study permits quantification of absolute mortality rates. Household case-control, proportional mortality, and nested case-control methods permit quantification of risk factors. CONCLUSIONS: This study will reliably document not only the underlying cause of child and adult deaths but also key risk factors (behavioral, physical, environmental, and eventually, genetic). It offers a globally replicable model for reliably estimating cause-specific mortality using VA and strengthens India's flagship mortality monitoring system. Despite the misclassification that is still expected, the new cause-of-death data will be substantially better than that available previously.
Sample registration of vital events with verbal autopsy: a renewed commitment to measuring and monitoring vital statistics.
Registration of births, recording deaths by age, sex and cause, and calculating mortality levels and differentials are fundamental to evidence-based health policy, monitoring and evaluation. Yet few of the countries with the greatest need for these data have functioning systems to produce them despite legislation providing for the establishment and maintenance of vital registration. Sample vital registration (SVR), when applied in conjunction with validated verbal autopsy procedures and implemented in a nationally representative sample of population clusters represents an affordable, cost-effective, and sustainable short- and medium-term solution to this problem. SVR complements other information sources by producing age-, sex-, and cause-specific mortality data that are more complete and continuous than those currently available. The tools and methods employed in an SVR system, however, are imperfect and require rigorous validation and continuous quality assurance; sampling strategies for SVR are also still evolving. Nonetheless, interest in establishing SVR is rapidly growing in Africa and Asia. Better systems for reporting and recording data on vital events will be sustainable only if developed hand-in-hand with existing health information strategies at the national and district levels; governance structures; and agendas for social research and development monitoring. If the global community wishes to have mortality measurements 5 or 10 years hence, the foundation stones of SVR must be laid today.
Smoking and premature mortality: reflections on the contributions of Sir Richard Doll.
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Does use of tobacco or alcohol contribute to impoverishment from hospitalization costs in India?
The study investigates the association between tobacco and alcohol use, and the potential risk of impoverishment from borrowing and distress selling of assets for meeting costs of hospitalization in India. Data from the fifty-second round of the National Sample Survey, a representative survey of 120,942 households across India, were used to investigate the likelihood and the levels of borrowing and distress selling of assets to cover hospitalization expenditures among regular users of tobacco and/or alcohol, non-users from households where there was use, and non-users from households with no use. The data were analyzed by bivariate comparisons and multivariate logistic and ordinary least square regression. The study found a higher risk of borrowing/distress selling during hospitalization for individuals who use tobacco (OR 1.35, p<0.05), who were non-users but belong to households that use tobacco (OR 1.38, p<0.05), and non-users from households that use both tobacco and alcohol (OR 1.51, p<0.05), even after controlling for socio-economic and demographic factors. The same groups also met a higher percentage of hospitalization expenditures through borrowing/distress selling of assets. The adjusted population-attributable risk proportion of borrowing/distress selling to meet hospital expenditures for tobacco and alcohol use was 16%. The study suggests that there is an association between use of tobacco and alcohol, and impoverishment through borrowing and distress selling of assets due to costs of hospitalization. While reduction of poverty is the overarching goal of developing countries and multilateral development organizations, very little is mentioned about control of tobacco and alcohol in the framework of development. It might be necessary to include strategies for control of tobacco and alcohol in the larger framework of poverty reduction.
India's HIV-1 epidemic.
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Evidence for global health.
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Weapons of mass salvation: Canada's role in improving the health of the global poor.
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Household tobacco and alcohol use, and child health: an exploratory study from India.
The study uses data from the National Family Health Survey-II, a nationally representative survey from India of 92,486 households, to investigate the association between household tobacco and alcohol use, and child health. The study findings show that children from households that use tobacco or alcohol were less likely to be immunized, more likely to have acute respiratory tract infection, more likely to be malnourished, and more likely to die before first birthday, even after controlling for other socio-economic and demographic characteristics. Policies and programs for child survival may also need to incorporate strategies to control household tobacco and alcohol use in addition to other ongoing interventions.
Smoking and mortality from tuberculosis and other diseases in India: retrospective study of 43000 adult male deaths and 35000 controls.
BACKGROUND: In India most adult deaths involve vascular disease, pulmonary tuberculosis, or other respiratory disease, and men have smoked cigarettes or bidis (which resemble small cigarettes) for several decades. The study objective was to assess age-specific mortality from smoking among men (since few women smoke) in urban and in rural India. METHODS: We did a case-control study of the smoking habits of 27000 urban and 16000 rural men who had died in the state of Tamil Nadu, southern India, from medical causes (ie, any cause other than accident, homicide, or suicide), and of 20000 urban and 15000 rural male controls. The main analyses are of mortality at ages 25-69 years. FINDINGS: In the urban study area, the death rates from medical causes of ever smokers were double those of never smokers (standardised risk ratio at ages 25-69 years 2.1 [95% CI 2.0-2.2]). The risks were substantial both for cigarette smoking (the main urban habit) and for bidi smoking. Of this excess mortality among smokers, a third involved respiratory disease, chiefly tuberculosis (4.5 [4.0-5.0], smoking-attributed fraction 61%), a third involved vascular disease (1.8 [1.7-1.9], smoking-attributed fraction 24%), 11% involved cancer (2.1 [1.9-2.4], smoking-attributed fraction 32%), chiefly of the respiratory or upper digestive tracts, and 14% involved alcoholism or cirrhosis (3.3 [2.9-3.8], not attributed to smoking). Among ever smokers, the absolute excess mortality from tuberculosis was substantial throughout the age range 25-69 years. (A separate survey of 250000 men living in the urban study area found that ever smokers are three times as likely as never smokers to report a history of tuberculosis, corresponding to a higher rate of progression of chronic subclinical infection to clinical disease.) The proportional excesses of respiratory, vascular, and neoplastic mortality at ages 25-69 years among ever smokers in the urban study area were replicated, each with similarly narrow CI for the risk ratio, in the rural study area (where bidi smoking predominated), and are taken to be largely or wholly causal. For urban and for rural death from medical causes at older ages (> or =70 years), the standardised risk ratio was 1.3. INTERPRETATION: Smoking, which increases the incidence of clinical tuberculosis, is a cause of half the male tuberculosis deaths in India, and of a quarter of all male deaths in middle age (plus smaller fractions of the deaths at other ages). At current death rates, about a quarter of cigarette or bidi smokers would be killed by tobacco at ages 25-69 years, those killed at these ages losing about 20 years of life expectancy. Overall, smoking currently causes about 700000 deaths per year in India, chiefly from respiratory or vascular disease: about 550000 men aged 25-69 years, about 110000 older men, and much smaller numbers of women (since few women smoke).
Mother-to-child HIV transmission and ARVs.
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