Reliable epidemiological information on injury burden and pattern is essential to formulate effective injury control and prevention strategies. Injury surveillance systems are globally gaining ground as a tool for collecting such systematic data on injuries, but less so in low and middle income countries. This study describes the experience of setting up a District Level Hospital-Based Injury Surveillance System in India and the pattern of injuries encountered therein.

The Russell's viper is one of the most dangerous and commonly encountered vasculotoxic poisonous snakes in India that is responsible for most snakebite mortalities. Usually hemorrhagic stroke is the sequel of viper bite; however, ischemic stroke is increasingly recognized and reported in the literature. In rural areas, there is a need to keep the possibility of cerebral infarction as one of the differential diagnoses of neurological deterioration following Russell's viper's bite, as early identification of neurological complications can lead to a more effective treatment. In the present article, we discuss a case of a young male who was presented with both supra- and infratentorial infarcts.

Introduction: The present study was aimed to describe our experience with epidemiological characteristics, management options, and outcome of scorpion envenomation in children. Materials and Methods: The present retrospective study was conducted at Narayana Medical College and Hospital. The epidemiologic details including geographical locality of the event, age distribution, gender, and sting sites were noted in all hospitalized children with scorpion bite injury. Results: During the study period, a total 52 children were managed for scorpion sting. Mean age was 8.87 years. Male children were commoner victims of scorpion sting. Scorpion sting had bimodal pattern. Prazocin was used in 25 children. There was evidence of pulmonary edema in 23 cases. Seven patients required elective ventilation, and 5 of them could be weaned off within 72 hours. Mean hospital stay was 3.69 days. Two children expired in the present series. Conclusion: In present study, there was bimodal distribution of the scorpion sting cases, male children were more affected, and almost all of them improved with good outcome. We did not use anti-venin in the present study. The data from the study will serve not only to create heightened public awareness about scorpion envenomation but also to develop public awareness strategies and preventive measures.

Background Physician-coded verbal autopsy (PCVA) is the most widely used method to determine causes of death (CODs) in countries where medical certification of death is uncommon. Computer-coded verbal autopsy (CCVA) methods have been proposed as a faster and cheaper alternative to PCVA, though they have not been widely compared to PCVA or to each other. Methods We compared the performance of open-source random forest, open-source tariff method, InterVA-4, and the King-Lu method to PCVA on five datasets comprising over 24,000 verbal autopsies from low- and middle-income countries. Metrics to assess performance were positive predictive value and partial chance-corrected concordance at the individual level, and cause-specific mortality fraction accuracy and cause-specific mortality fraction error at the population level. Results The positive predictive value for the most probable COD predicted by the four CCVA methods averaged about 43% to 44% across the datasets. The average positive predictive value improved for the top three most probable CODs, with greater improvements for open-source random forest (69%) and open-source tariff method (68%) than for InterVA-4 (62%). The average partial chance-corrected concordance for the most probable COD predicted by the open-source random forest, open-source tariff method and InterVA-4 were 41%, 40% and 41%, respectively, with better results for the top three most probable CODs. Performance generally improved with larger datasets. At the population level, the King-Lu method had the highest average cause-specific mortality fraction accuracy across all five datasets (91%), followed by InterVA-4 (72% across three datasets), open-source random forest (71%) and open-source tariff method (54%). Conclusions On an individual level, no single method was able to replicate the physician assignment of COD more than about half the time. At the population level, the King-Lu method was the best method to estimate cause-specific mortality fractions, though it does not assign individual CODs. Future testing should focus on combining different computer-coded verbal autopsy tools, paired with PCVA strengths. This includes using open-source tools applied to larger and varied datasets (especially those including a random sample of deaths drawn from the population), so as to establish the performance for age- and sex-specific CODs.

The present article was aimed to study demographic and clinical pattern, periodicity and precipitating events for hypokalemic paralysis and to assess the response to treatment both during acute attacks and as prophylaxis in comparison with available literature. Forty patients with hypokalemic paralysis were admitted in Narayana Medical College and Hospital during the last two years, in all the medical units and neurology wards. Patients were assessed clinically, with symptomatology and precipitating factors were evaluated. There were total 40 patients in the present study. Younger more including male gender. Mean age was 30.95 years. Common precipitating factor were diarrhea, fever, strenuous activity, following dextrose administration, in patients with diabetic ketoacidosis, however in majority of the cases we could not identify the precipitating factors. Most common electrocardiographic change on ECG was U' wave (36 cases) followed by flat 'T' wave (14 patients) and ECG was normal in 4 patients. Hypokalemic paralysis was predominantly seen in younger males. Vomiting, diarrhea were important precipitating factors. The response to oral potassium chloride supplementation was good as only few patients requiring intravenous potassium chloride. The approach to hypokalemic paralysis patient includes a vigorous search for the underlying etiology and potassium replacement therapy.

Background Verbal autopsy (VA) has been proposed to determine the cause of death (COD) distributions in settings where most deaths occur without medical attention or certification. We develop performance criteria for VA-based COD systems and apply these to the Registrar General of India’s ongoing, nationally-representative Indian Million Death Study (MDS). Methods Performance criteria include a low ill-defined proportion of deaths before old age; reproducibility, including consistency of COD distributions with independent resampling; differences in COD distribution of hospital, home, urban or rural deaths; age-, sex- and time-specific plausibility of specific diseases; stability and repeatability of dual physician coding; and the ability of the mortality classification system to capture a wide range of conditions. Results The introduction of the MDS in India reduced the proportion of ill-defined deaths before age 70 years from 13% to 4%. The cause-specific mortality fractions (CSMFs) at ages 5 to 69 years for independently resampled deaths and the MDS were very similar across 19 disease categories. By contrast, CSMFs at these ages differed between hospital and home deaths and between urban and rural deaths. Thus, reliance mostly on urban or hospital data can distort national estimates of CODs. Age-, sex- and time-specific patterns for various diseases were plausible. Initial physician agreement on COD occurred about two-thirds of the time. The MDS COD classification system was able to capture more eligible records than alternative classification systems. By these metrics, the Indian MDS performs well for deaths prior to age 70 years. The key implication for low- and middle-income countries where medical certification of death remains uncommon is to implement COD surveys that randomly sample all deaths, use simple but high-quality field work with built-in resampling, and use electronic rather than paper systems to expedite field work and coding. Conclusions Simple criteria can evaluate the performance of VA-based COD systems. Despite the misclassification of VA, the MDS demonstrates that national surveys of CODs using VA are an order of magnitude better than the limited COD data previously available.

Objective: Snake bite remains major public health problem worldwide. We present our experience with cases of snake bites managed in our tertiary care teaching center of South India. Materials and Methods: The details of all patients with snake bite admitted to a tertiary teaching care hospital from 2010 to 2012 were retrospectively retrieved and reviewed. The details regarding age, gender, first aid received or not, time elapsed between the bite, emergency care management and ASV (Anti Snake Venom) administration, site of snake bite, clinical features at the time of presentation, local examination findings at the site of bite, duration of hospital stay, need for elective ventilation, details of investigations and outcome were reviewed. The data were analyzed in PSPP software (Free Software Foundation, Inc.) for window for statistical analysis, while standard deviation (SD) was applied for the continuous variables, and proportions were applied for the categorical variables. Results: Mean age was 38.4 ± 14.8 years (range 4-70 years). Majority [72 (82.8%)] were farmers. In 86.2% patients, the site of bite was in lower limbs. Snake could be identified in only 20 cases [Cobra-12 (60%), Krait-2 (10%), and Viper-6 (30%)]. Mean time to reach to hospital was 12.1 ± 21.4 hours (range 1-120 hours). Mean anti-venom therapy duration was 3.2 ± 2.0 days (range 1-14 days). Mean hospital stay was 4.7 ± 3.1 days (range 1-15 days). Majority (72.4%) made good recovery; mortality was in 4.6% cases, and 20 (23%) patients left against medical advice. Conclusions: This study identified major epidemiological and management variables related to snake bite. There is a need for a well-planned data collection and information dissemination system to avoid this potentially preventable disease.

OBJECTIVES We have herein reported our experience with the pattern of presentation of cases of acute organophosphorus (OP) poisoning cases in a tertiary care hospital. MATERIALS AND METHODS This retrospective study evaluated the hospital records of patients with acute OP poisoning. In a pre-structured proforma, data regarding age, sex, time elapsed after intake, circumstances of poisoning, duration of hospitalization, severity, complications, and outcome of the patients were recorded. The data were presented as mean ± standard deviation, entered in the open office datasheet, and analyzed with PSPP software. RESULTS A total 101 patients were included in the study. Young adult males were more commonly involved than females (M:F 2.5:1). The mean age of the patients was 28 years (range 2-72 years, SD ± 14.3 years). Mean time to receive treatment was 5.2 ± 7.4 (range 1-48 h). About 45.5% patients received first aid before coming to the hospital. The reason was suicide in 88.1% cases and accident in 12 (11.9%, all children). Seventy-nine patients received pralidoxime (PAM) and the mean duration was 1.7 ± 1.1 (range 1-4 days). Atropine was given in all patients. Mean duration was 5.1 ± 3.1 (range 1-19 days). Mean hospital stay was 7.5 ± 4.7 days (range 1-26 days). Mortality was 9.9% in the present series. CONCLUSION Although the present study contribute substantial information regarding the epidemiology and outcome of acute OP poisoning in a tertiary care teaching hospital at a district level, its relatively small sample size and the retrospective record-based nature are the major limitations of the present study. There is a further need for prospective studies to understand the underlying socio-economic factors responsible for acute OP poisoning in our population, and, accordingly, address the problems to reduce the incidence of acute OP poisoning cases.

OBJECTIVES This study was conducted to evaluate the performance of World Health Organisation (WHO) verbal autopsy tool in determining major causes of neonatal deaths. METHODS From a tertiary care hospital and a government multispecialty hospital, the attending paediatricians ascertained a clinical cause of death for 371 neonatal deaths. Trained field workers conducted verbal autopsy (VA) interviews. Two independent paediatricians, who had no access to the clinical information, assigned cause of death as per verbal autopsy. Analysis was based on 313 cases in which both clinical diagnosis and VA diagnosis was obtained. FINDINGS As per the clinical diagnosis, four most common causes of neonatal deaths were sepsis (29.1%), preterm birth (27.8%), birth asphyxia (27.2%), and congenital anomalies (11.5%). Cause specific mortality fractions by VA diagnosis were statistically similar to those obtained by clinical diagnosis except for birth asphyxia (16.3%). Diagnostic accuracy of verbal autopsy diagnosis against clinical diagnosis ranged from 78% to 92% in ascertaining different underlying causes of death. Area under the Receiver-Operator Characteristics curve (95% confidence interval) was 0.75 (0.69-0.80) for sepsis, 0.74 (0.68-0.80) for preterm birth, 0.73 (0.65-0.82) for congenital anomaly and 0.70 (0.64-0.75) for birth asphyxia. Kappa for all four causes was moderate (0.46-0.55). INTERPRETATION The WHO verbal autopsy tools can provide reasonably good estimates of predominant causes of neonatal deaths in countries where neonatal mortality is high. Caution is required to interpret cause specific mortality fraction (CSMF) for birth asphyxia by VA because it is likely to be an underestimate.

BACKGROUND:It is estimated that India has more deaths from rabies than any other country. However, existing estimates are indirect and rely on non-representative studies.METHODS AND PRINCIPAL FINDINGS:We examined rabies deaths in the ongoing Million Death Study (MDS), a representative survey of over 122,000 deaths in India that uses enhanced types of verbal autopsy. We estimated the age-specific mortality rates of symptomatically identifiable furious rabies and its geographic and demographic distributions. A total of 140 deaths in our sample were caused by rabies, suggesting that in 2005 there were 12,700 (99% CI 10,000 to 15,500) symptomatically identifiable furious rabies deaths in India. Most rabies deaths were in males (62%), in rural areas (91%), and in children below the age of 15 years (50%). The overall rabies mortality rate was 1.1 deaths per 100,000 population (99%CI 0.9 to 1.4). One third of the national rabies deaths were found in Uttar Pradesh (4,300) and nearly three quarters (8,900) were in 7 central and south-eastern states: Chhattisgarh, Uttar Pradesh, Odisha, Andhra Pradesh, Bihar, Assam, and Madhya Pradesh.CONCLUSIONS AND SIGNIFICANCE:Rabies remains an avoidable cause of death in India. As verbal autopsy is not likely to identify atypical or paralytic forms of rabies, our figure of 12,700 deaths due to classic and clinically identifiable furious rabies underestimates the total number of deaths due to this virus. The concentrated geographic distribution of rabies in India suggests that a significant reduction in the number of deaths or potentially even elimination of rabies deaths is possible.

OBJECTIVES:Differences in sexual networks probably explain the disparity in the scale of HIV epidemics in sub-Saharan Africa and India. HIV and sexually transmitted infection (STI) discordant couple studies provide insights into important aspects of these sexual networks. The authors quantify the role of male sexual behaviour in HIV transmission in married couples in India.METHODS:The authors analysed patterns of HIV and STI discordance in married couples from two community surveys in India: the National Family Health Study-3 for HIV-1 and the Centre for Global Health Research health check-up for HSV-2 and syphilis. A statistical model was used to estimate the fraction of infections introduced by each of the two partners.RESULTS:Only 0.8%, 16.0% and 3.5% of couples were infected (either partner or both) with HIV-1, HSV-2 and syphilis, respectively. A large proportion of infected couples were discordant (73.0%, 56.3% and 84.2% for HIV-1, HSV-2 and syphilis, respectively). This model estimated that, among couples with any STI, the male partner introduced the infection the majority of the time (HIV-1: 85.4%, HSV-2: 64.1%, syphilis: 75.0%).CONCLUSIONS:Male sexual activity outside of marriage appears to be a driving force for the Indian HIV/STI epidemic. Male client and female sex worker contacts should remain a primary target of the National AIDS Control Program in India.

A cross-sectional study was conducted in Chandigarh Union Territory to evaluate the performance of an audio-assisted confidential voting interview (AVI), for assessing the sexual behavior among young adults aged 20 - 34 years. Using systematic random sampling 625 males and 630 females were interviewed alternately, either by AVI or by face-to-face interview (FFI). More men revealed having sex with men in AVI (2.6%) than FFI (0.6%) (P 0.06). Women reported having sex with non-regular partners more often in AVI (4.8%) compared to FFI (0.3%) (P < 0.001). AVI performed better than FFI for eliciting sensitive sexual behaviors.

confidence interval, CI: 0.83–0.97); pre-gestational maternal illness, 0.75 (95% CI: 0.65–0.84); pregnancy-induced hypertension, 0.76 (95% CI: 0.69–0.81); antepartum haemorrhage, 0.76 (95% CI: 0.67–0.84) and obstetric complication, 0.82 (95% CI: 0.71–0.93). Conclusion The WHO verbal autopsy tool for stillbirth can provide reasonably good estimates of common underlying causes of stillbirth in resource-limited settings where a medically certified cause of stillbirth may not be available.

Heterosexual transmission of HIV in India is driven by the male use of female sex workers (FSW), but few studies have examined the factors associated with using FSW. This nationally representative study examined the prevalence and correlates of FSW use among 31,040 men aged 15-49 years in India in 2006. Nationally, about 4% of men used FSW in the previous year, representing about 8.5 million FSW clients. Unmarried men were far more likely than married men to use FSW overall (PR = 8.0), but less likely than married men to use FSW among those reporting at least one non-regular partner (PR = 0.8). More than half of all FSW clients were married. FSW use was higher among men in the high-HIV states than in the low-HIV states (PR = 2.7), and half of all FSW clients lived in the high-HIV states. The risk of FSW use rose sharply with increasing number of non-regular partners in the past year. Given the large number of men using FSW, interventions for the much smaller number of FSW remains the most efficient strategy for curbing heterosexual HIV transmission in India.

OBJECTIVE:To determine the rates of death and infection from HIV in India.DESIGN:Nationally representative survey of deaths.SETTING:1.1 million homes in India. Population 123,000 deaths at all ages from 2001 to 2003.MAIN OUTCOME MEASURES:HIV mortality and infection.RESULTS:HIV accounted for 8.1% (99% confidence interval 5.0% to 11.2%) of all deaths among adults aged 25-34 years. In this age group, about 40% of deaths from HIV were due to AIDS, 26% were due to tuberculosis, and the rest were attributable to other causes. Nationally, HIV infection accounted for about 100,000 (59,000 to 140,000) deaths or 3.2% (1.9% to 4.6%) of all deaths among people aged 15-59 years. Deaths from HIV were concentrated in the states and districts with higher HIV prevalence and in men. The mortality results imply an HIV prevalence at age 15-49 years of 0.26% (0.13% to 0.39%) in 2004, comparable to results from a 2005/6 household survey that tested for HIV (0.28%). Collectively, these data suggest that India had about 1.4-1.6 million HIV infected adults aged 15-49 years in 2004-6, about 40% lower than the official estimate of 2.3 million for 2006. All cause mortality increased in men aged 25-34 years between 1997 and 2002 in the states with higher HIV prevalence but declined after that. HIV prevalence in young pregnant women, a proxy measure of incidence in the general population, fell between 2000 and 2007. Thus, HIV mortality and prevalence may have fallen further since our study.CONCLUSION:HIV attributable death and infection in India is substantial, although it is lower than previously estimated.

India's HIV epidemic is of global interest. 2 years ago, we showed that HIV prevalence in young women declined by about a third between 2000 and 2004 in the southern states of Andhra Pradesh, Karnataka, Maharashtra, and Tamil Nadu.1Kumar R Jha P Arora P et al.Trends in HIV-1 in young adults in south India from 2000 to 2004: a prevalence study.Lancet. 2006; 367: 1164-1172Summary Full Text Full Text PDF PubMed Scopus (101) Google Scholar HIV prevalence at young ages (15–24 years) is a useful proxy for trends in HIV incidence. We now present trends up to 2007.Among 423 842 women aged 15–24 years tested nationally at antenatal clinics, prevalence declined by 54% (95% CI −45 to −63; p<0·0001) between 2000 and 2007 in south India, and there was no significant change in north India (3%, −47 to 53; p=0·73) where HIV is less prevalent (figure). Declines in south India were similar if we analysed individual age-groups, if we excluded Tamil Nadu, or restricted the analyses to each individual state or to the sites tested continuously for at least 4 years. Women who use antenatal clinics differ from those who do not in education, residence, and migration, but these demographic factors remained similar from year to year. More research is needed to understand why incidence has fallen in south India. The most probable reason is reduced contacts with female sex work by the husbands of tested women or increased condom use in sex work.Although useful for estimating trends in HIV incidence, data from antenatal clinics cannot estimate community prevalence reliably. The National Family Health Survey of 2005–06 (NFHS-3)2International Institute for Population Sciences and Macro InternationalNational Family Health Survey (NFHS-3), 2005–2006. India Volume I. IIPS, Mumbai2007Google Scholar yielded lower HIV prevalence nationally in adults (0·28%, 95% CI 0·25–0·31 at ages 15–49 years) than seen among women at antenatal clinics in our study (0·60%, 0·57–0·63 at ages 15–49 years). A study in one district3Dandona L Lakshmi V Sudha T Kumar GA Dandona R A population-based study of human immunodeficiency virus in south India reveals major differences from sentinel surveillance-based estimates.BMC Med. 2006; 4: 31Crossref PubMed Scopus (59) Google Scholar suggested that women with HIV were over-represented in public antenatal clinics, but we found that HIV infection was associated with lower use of public antenatal clinics within the NHFS-3. Among 8743 eligible women, survival analyses with Cox's regression of time since last antenatal clinic use yielded a hazard ratio for HIV of 0·44 (0·22–0·90; p=0·02), after adjustment for age and sampling unit.The halving of new infections in south India and the lack of demonstrable increases in the north would, at first glance, seem to be consistent with India's downward revision of HIV prevalence in 2006 from 5·1 million to 2·5 million (range 2·0–3·1 million). However, the revised prevalence estimates are based largely on "hybrid" analyses that combine antenatal clinic and NFHS-3 data, whereas earlier estimates were based on antenatal clinic data. The NFHS-3 has biases also, including the under-representation of high-risk groups.4Kumar R Jha P Arora P Dhingra N for the Indian Studies of HIV/AIDS Working GroupHIV-1 trends, risk factors and growth in India.in: National Commission on Macroeconomics and Health. Background papers: burden of disease in India. Ministry of Health and Family Welfare, New Delhi2005: 58-74https://www.who.int/macrohealth/action/NCMH_Burden%20of%20disease_(29%20Sep%202005).pdfGoogle ScholarIn conclusion, although the estimation of HIV trends is reasonably robust, we caution that prevalence estimates remain uncertain. Reliable estimation of prevalence requires combining various sources of data, including information on AIDS mortality.5Jha P Jacob B Gajalakshmi V et al.for the RGI-CGHR InvestigatorsA nationally representative case-control study of smoking and death in India.N Engl J Med. 2008; 358: 1137-1147Crossref PubMed Scopus (384) Google ScholarWe declare that we have no conflict of interest. India's HIV epidemic is of global interest. 2 years ago, we showed that HIV prevalence in young women declined by about a third between 2000 and 2004 in the southern states of Andhra Pradesh, Karnataka, Maharashtra, and Tamil Nadu.1Kumar R Jha P Arora P et al.Trends in HIV-1 in young adults in south India from 2000 to 2004: a prevalence study.Lancet. 2006; 367: 1164-1172Summary Full Text Full Text PDF PubMed Scopus (101) Google Scholar HIV prevalence at young ages (15–24 years) is a useful proxy for trends in HIV incidence. We now present trends up to 2007. Among 423 842 women aged 15–24 years tested nationally at antenatal clinics, prevalence declined by 54% (95% CI −45 to −63; p<0·0001) between 2000 and 2007 in south India, and there was no significant change in north India (3%, −47 to 53; p=0·73) where HIV is less prevalent (figure). Declines in south India were similar if we analysed individual age-groups, if we excluded Tamil Nadu, or restricted the analyses to each individual state or to the sites tested continuously for at least 4 years. Women who use antenatal clinics differ from those who do not in education, residence, and migration, but these demographic factors remained similar from year to year. More research is needed to understand why incidence has fallen in south India. The most probable reason is reduced contacts with female sex work by the husbands of tested women or increased condom use in sex work. Although useful for estimating trends in HIV incidence, data from antenatal clinics cannot estimate community prevalence reliably. The National Family Health Survey of 2005–06 (NFHS-3)2International Institute for Population Sciences and Macro InternationalNational Family Health Survey (NFHS-3), 2005–2006. India Volume I. IIPS, Mumbai2007Google Scholar yielded lower HIV prevalence nationally in adults (0·28%, 95% CI 0·25–0·31 at ages 15–49 years) than seen among women at antenatal clinics in our study (0·60%, 0·57–0·63 at ages 15–49 years). A study in one district3Dandona L Lakshmi V Sudha T Kumar GA Dandona R A population-based study of human immunodeficiency virus in south India reveals major differences from sentinel surveillance-based estimates.BMC Med. 2006; 4: 31Crossref PubMed Scopus (59) Google Scholar suggested that women with HIV were over-represented in public antenatal clinics, but we found that HIV infection was associated with lower use of public antenatal clinics within the NHFS-3. Among 8743 eligible women, survival analyses with Cox's regression of time since last antenatal clinic use yielded a hazard ratio for HIV of 0·44 (0·22–0·90; p=0·02), after adjustment for age and sampling unit. The halving of new infections in south India and the lack of demonstrable increases in the north would, at first glance, seem to be consistent with India's downward revision of HIV prevalence in 2006 from 5·1 million to 2·5 million (range 2·0–3·1 million). However, the revised prevalence estimates are based largely on "hybrid" analyses that combine antenatal clinic and NFHS-3 data, whereas earlier estimates were based on antenatal clinic data. The NFHS-3 has biases also, including the under-representation of high-risk groups.4Kumar R Jha P Arora P Dhingra N for the Indian Studies of HIV/AIDS Working GroupHIV-1 trends, risk factors and growth in India.in: National Commission on Macroeconomics and Health. Background papers: burden of disease in India. Ministry of Health and Family Welfare, New Delhi2005: 58-74https://www.who.int/macrohealth/action/NCMH_Burden%20of%20disease_(29%20Sep%202005).pdfGoogle Scholar In conclusion, although the estimation of HIV trends is reasonably robust, we caution that prevalence estimates remain uncertain. Reliable estimation of prevalence requires combining various sources of data, including information on AIDS mortality.5Jha P Jacob B Gajalakshmi V et al.for the RGI-CGHR InvestigatorsA nationally representative case-control study of smoking and death in India.N Engl J Med. 2008; 358: 1137-1147Crossref PubMed Scopus (384) Google Scholar We declare that we have no conflict of interest.

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.

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.

Introduction Diarrhoeal diseases are a major cause of hospitalizations and child deaths globally. Together they account for approximately one in six deaths among children younger than five years. 1 Of India's more than 2.3 million annual deaths among children, about 334 000 are attributable to diarrhoeal diseases.