IJMSNR Second Issue Vol 1 Issue 2 - 31.12.2021

One Health Approach: The key to addressing pandemics and
other complex challenges of the 21st Century
The corona virus infectious disease or Covid 19 pandemic has been medicine, public health, environmental sciences, and a host of other
causing unprecedented loss of lives and livelihoods across the globe. disciplines to work together to improve the health of humans,
This is the third time a Beta coronavirus has crossed the animal- animals and the environment. The scope of one health includes areas
1Senior Resident, Department of Anesthesiology, Chettinad Hospital And Research Institute, Chennai, Tamilnadu, India. 2Assistant
human species barrier in the last 20 years resulting in a major such as climate change, biodiversity loss, food, and water security,
Professor, Department of Anesthesiology, Chettinad Hospital And Research Institute,
emerging Chennai, Tamilnadu,
and reemerging India. 3Professor
diseases, antimicrobial and HOD,
resistance etc.…
zoonotic outbreak [1]. The first was in 2002, when the SARS CoV-1
Department of Anesthesiology, Chettinad Hospital And Research Institute, Chennai, Tamilnadu, India.
virus caused an outbreak in China and second was in 2012 with the
MERS CoV causing an outbreak in the Middle East. The SARS CoV-
1 originated from bats and the MERS CoV originated from camels.
Covid 19 disease is a zoonotic infection caused by SARS CoV-2
virus, which originated in Wuhan city in China in December 2019,
which quickly spread across the world. The zoonotic source of SARS
CoV-2 is not known but is closely related to a group of SARS CoV
viruses found in bats a, humans and civets [2].
The complex challenges of the 21st century like climate change and
the recent disease outbreaks are evidence of increased human –
animal interactions and human influence which will continue to
increase, given the increasing human demand for space, food and
unbridled consumerism. They also are an indicator of the
interconnectedness of human and animal and environmental health.
Hippocrates, the great Greek physician in his book ‘On air, waters
and places’ had dwelled on the importance of relationship between Image source: https://www.who.int [4]
human health and the environment [3]. The ‘One Health’ approach
The key strategies of One health for the prevention and control of
recognizes this important relationship between human, animal and
zoonotic diseases are as follows [3, 5].
environmental health. In 2004, the wildlife conservative society with
a group of partner organizations launched the ‘the one world, one 1. Surveillance of disease or infections in wildlife, livestock and
health ‘initiative which was the primary step in the evolution of the human populations including environmental surveillance.
modern concept of One Health [3]. One health is defined by the One
Health High Level Expert Panel (OHLLEP) as “an integrated, 2. Minimizing human -animal interactions and spread of infections
unifying approach that aims to sustainably balance and optimize the from animals to humans – for example safe handling of livestock,
health of people, animals and ecosystems” [4]. pets and wildlife, livestock vaccinations etc...
The one health approach calls upon human medicine, veterinary 3. Reducing antimicrobial resistance through rational antibiotic use
in animals and livestock.
5.Addressing climate change at local, national, and international

levels.
Article Summary: Submitted: 22-October-2021 Revised: 06-November-2021 Accepted:
6. Promoting researchPublished: 31-December-2021
03-December-2021
collaborative
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brucellosis [8].
We are facing complex challenges with regard to climate change,

How to cite this article: Priyanka Raj C K. One Health Approach: The
emerging and reemerging diseases, food and water security. Isolated
key to addressing pandemics and other complex challenges of the 21st
Century. Int J Med Sci and Nurs Res 2021;1(2):1–2.
International Journal of Medical Sciences and Nursing Research 2021;1(2):1-2 Page No: 1
Priyanka Raj C K. One Health Approach: Key to addressing the pandemics and other complex challenges of the 21 st Century
4. Integrating and coordinating disease prevention, surveillance and 4. WHO: Tripartite and UNEP support OHHLEP’s definition
response across all sectors (animal husbandry, education, health, of “One Health”. Available from:
communications, agriculture etc.…) https://www.who.int/news/item/01-12-2021-tripartite-and-
5. Addressing climate change at local, national, and international levels. unep-support-ohhlep-s-definition-of-one-health [Accessed
on: 25th August 2021]
6. Promoting collaborative research 5. Hamida MG, Ba Abdullah MM. The SARS-CoV-2
outbreak from a one health perspective. One Health.
These strategies have been effective in controlling SARS CoV outbreak in
2020;10:100127. DOI:
2002 by banning of trade of civet cats [6]. One health strategies also helped
in reducing the MERS CoV case fatalities [7]. In Chad, simultaneous human https://doi.org/10.1016/j.onehlt.2020.100127
and animal vaccinations have proven effective against brucellosis [8]. 6. Parry J. WHO queries culling of civet cats. BMJ
2004;328(7432):128.
We are facing complex challenges with regard to climate change, emerging 7. Hemida MG, Alnaeem A. Someone health-based control
and reemerging diseases, food and water security and individual responses strategies for the middle east respiratory syndrome
are incapable of addressing these issues and the only way to deal with these coronavirus, One Health 2019;8:100102. PMID: 31485476
complex issues is to collaborate and coordinate our efforts across disciplines, 8. Roth J, Zinsstag J, Orkhon D, Chimed-Ochir G, Hutton G,
sectors and nations. Barriers to implementing One health do exist, but One Cosivi O, et al. Human health benefits from livestock
Health approach is the key to ensure sustainability and survivability of all
vaccination for brucellosis; case study. Bulletin WHO
life on planet earth.
2003;81:867-876.
References:
1. Schmiegea D, Arredondo AMP, Ntajal J, Paris JMG, Savi MK, Patel
K, et al. One Health in the context of coronavirus outbreaks: A Dr. C. K. Priyanka Raj,
systematic literature review. One Health. 2020;10:1-9. DOI:
https://doi.org/10.1016/j.onehlt.2020.100170
2. World Health Organization: WHO Coronavirus (COVID-19) Deputy Editor-In-Chief, IJMSNR,
Associate Professor.
Dashboard. Available from: https://covid19.who.int/ [Accessed on:
Department of Public Health and Epidemiology,
10 August 2021] College of Medicine and Health Sciences,
3. Katz DL, Elmore JG, Wild D, Lucan SC. Jekel’s Epidemiology, Sohar, National University of Science and Technology,
biostatistics, preventive medicine and public health. 4th edition Sultanate of Oman.
2014:364-377. Elsevier Saunders. ISBN-13: 978-1455706587
Email ID: priyankaraj@nu.edu.om and
DeputyEditor-in-chief@ijmsnr.com
Publish your research articles with

International Journal of Medical Sciences and Nursing Research
Website: http://ijmsnr.com/
Challenges met by Healthcare Professionals (Nurses) at
the time of Covid-19 Pandemic
Introduction: maintained as it highly affects the healthcare delivery system.

Professional training includes the hazards of disease, and its routes,
The fast-growing Covid-19 pandemic has a great health problem to routes of transmission, personal protection, prevention and control
1Senior Resident, Department of Anesthesiology, Chettinadmeasures
people in worldwide and has a major challenge for nurses and other will extend the knowledge and skill of nurses and nursing
Hospital And Research Institute, Chennai, Tamilnadu, India.
health care professionals as well Department
2Assistant Professor, as nursing of
students. Here, few students, who might be brought to the pandemic to support their
Anesthesiology, Chettinad Hospital And Research Institute, Chennai, Tamilnadu, India.
major challenges are listed
3Professor that Department
and HOD, the health care workers (HCW)
of Anesthesiology, colleagues
Chettinad whenResearch
Hospital And there areInstitute,
sufficient trained Tamilnadu,
Chennai, nurses can India.
have more
especially Nurses are faced and facing many problems in their day- advocate with patient and their relatives about patient care. [3]
to-day life.
Shortage of personal protection equipment:
Major Challenges are facing by the nurses:
There is a shortage of PPE in most hospitals and health centers in
Increased risk of infection among nurses: The reports India including face mask, gowns and respirators. Local product of
from across the world shows that the healthcare workers were face mask and other kits are reported to be of low quality which is
affected by Covid-19 outbreak in the early period. [1] It was not protective against infection. [3]
particularly nurses who took care of Covid-19 unit are getting
Long working hours:
infected or dying due to Covid-19 most of the hospitals and isolation
centres were overloaded by Covid cases which leads to nurses are Shortage of staff pattern results in long working hours and sometimes
susceptible to infection. But now this situation is changed in few double shift also some nurses care needs to do. [3]
hospitals because of awareness of Covid outbreaks.
Inadequate quarantine facilities:
Lack of awareness of Covid-19 among Healthcare
Workers: As this disease has spread suddenly the nurses were not In earlier period of this outbreaks the nurses are quarantined between
aware about this type of disease will go worst. But now nurses are 14 – 15 days after they completed one rotation of duty. But, later as
prepared in somewhat extent for future Covid out breaks. Now, a the cases increases the rules of quarantine period was reduced to 2 to
day’s most of the hospitals also prepared with adequate ICU and 3 days which is happened particularly the Urban Centre of Delhi and
emergency rooms. Few countries like Hong Kong, Taiwan, Mumbai. The rules of testing the health workers also changed which
Singapore are already learned the lessons well from SARS and H1N1 leads to increased incidence of infection among nurses. [4]
out breaks. The health care workers in those countries already aware
Mental Violence:
about these pandemic outbreaks. [2]
It will lead to inefficient care nurses facing mental violence can be in
Shortage of experienced nurses in Covid-19 unites: the form of threats, verbal abuse, hostility and possible source of
In most of the hospitals the nurse’s patient ratio need to be well violence includes patient, visitors and co-workers. [3, 5]
Article Summary: Submitted:26-October-2021 Revised:10-November-2021 Accepted:02-December-2021 Published:31-December-2021
Quick Response Code: This is an open access journal, and articles are distributed under the terms of the
Creative Commons Attribution-Non-Commercial-ShareAlike 4.0 International
Web Site License, which allows others to remix, tweak, and build upon the work
non-commercially, as long as appropriate credit is given and the new creations are
http://ijmsnr.com/ licensed under the identical terms.
How to cite this article: Senthilvel S. Challenges met by healthcare

professionals (Nurses) at the time of Covid-19 Pandemic. Int J Med Sci
and Nurs Res 2021;1(2):3–4.
Senthilvel S. Challenges met by healthcare professionals (Nurses) at the time of Covid-19 Pandemic
Lack of teamwork: 6. Alluhidan M, Tashkandi N, Alblowi F, Omer T, Alghaith T,

Alghodaier H, et al. Challenges and policy opportunities in
One of the highly sought-after tools in the field of human resource nursing in Saudi Arabia. Human Resources for Health
management in team work. Since there is lack of team work in Covid-19 2020;18:98. DOI: 10.1186/s12960-020-00535-2.
management working as a team will get and share innovative ideas to
tackle this Covid-19 pandemic.
Importance of nursing administration: Mrs. Sumathi Senthilvel,

M.Sc., (Nursing), RN., RM.,
The nursing service and administration is very important and essential in
Associate Editor, IJMSNR,
the COVID-19 care unit. In Saudi Arabia, the MOH has collaborated
Formerly Assistant Professor in Nursing,
with the private sector and planned to sector wise and nursing Department of Fundamental Nursing,
administration to strengthen in all the levels. [6] Amrita College of Nursing. Ponekkara, Kochi, Kerala.
Conclusion: Email ID: AssociateEditor@ijmsnr.com
Nurses are playing important role in the battle against COVID unit.
Nurses are facing challenges while working in COVID care unites as
mentioned like risk of infection, more working hours, lack of awareness
and etc. These challenges immediately need to meet which will be
improving efficient nursing care in COVID-19 pandemic. More training
programs and researchers are needed to the healthcare workers (Staff
Nurses) to prepare them for future pandemics.
References:
1. Lai X, Wang M, Qin D, Tan L, Ran L, Chen D, et. al. Coronavirus
Disease 2019 (Covid-2019) Infection Among Health Care Workers
and Implications for Prevention Measures in a Tertiary Hospital in
Wuhan, China. JAMA Netw Open 2020;3(5):e209666. DOI:
10.1001/jamanetworkopen.2020.9666.
2. Tripathi R, Alqahtani SS, Albarraq AA, Meraya AM, Tripathi P,
Banji D, et al. Awareness and preparedness of COVID-19
Outbreak Among Healthcare Workers and Other Residents of
South-West Saudi Arabia: A Cross-Sectional Survey. Front Public
Helath 2020;8:482. DOI: 10.3389/fpubh.2020.00482.
3. Challenges in Nursing: What Do Nursing Face on a Daily Basis
Available on: https://online.arbor.edu/news/challenges-in-nursing
[Last Accessed on 18 July 2021]
4. Nurses concerned of COVID-19 exposure, lack of quarantine
quarters. Available on:
https://www.breakingbelizenews.com/2020/08/08/nurses-
concerned-of-covid-19-exposure-lack-of-quarantine-quarters/
Last Accessed on 19 July 2021]
5. Chhugani M, James MM. Challenges faced by nurses in India-the
major workforce of the healthcare system. Nursing & Care Open
Access Journal 2017;2(4):112-114. DOI:
10.15406/ncoaj.2017.02.00045.

International Journal of Medical Sciences and Medical Research
A multivariate analysis approach on identifying of influencing factors
and the chance of development of diabetic eye disease among diabetes in
a diabetic Centre of Southwestern Malabar region of India
Amitha Prasad1, Senthilvel Vasudevan2
1Biostatistician
Technician, IQVIA, World Trade Center Kochi (Brigarde), 7 th floor, Tower A, Info Park SEZ, Info Park Phase-1 Campus,
Kakkanad, Kochi, Kerala, India. 2Assistant Professor of Statistics (Biostatistics and Epidemiology), Department of Pharmacy Practice, College
of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
Abstract
Background: Diabetic Retinopathy is a non-communicable disease and metabolic disorder. It is a public health problem in Worldwide. In
this paper, finding influencing factors and how much probability to development of DR among known T2DM patients.
Materials and Methods: This was a hospital-based cross-sectional and observational study among T2DM patients, with and without DR
in the diabetes clinic with sample of one hundred and fifty patients. Statistical analysis used chi-square and binary logistic regression analysis
was used to identify correlates of DR after controlling of confounders.
Results: In this present study, one hundred and fifty DM patients were included and in that, 39 (26%) patients had DR. Smoking habit was
strongly associated with development of DR (AOR=15.39, p=0.002), patients had history of hypertension was associated with DR
(AOR=1.10, p=0.016), medication, in that insulin users were strongly associated with DR (AOR=5.72, p=0.002), duration of diabetes mellitus
with >10 years was associated with DR (AOR=1.18, p=0.001), total cholesterol with abnormal was 5-fold more increase in risk with the
development of DR (AOR=5.86, p=0.065) but not significant, high hba1c with >6.5% was associated with the progression of DR (AOR=1.34,
p=0.035), and fasting blood sugar with abnormal was associated with the progression of DR (AOR=1.01, p=0.027) except age but, showed
positive association in bivariate with DR. The probability of developing DR in a known T2DM patient was 98%.
Conclusion: From this study, we revealed that influencing variables were hba1c, smoking habit, intake of tablet/insulin, duration of DM,
history of hypertension and fasting blood sugar. The chance/probability of developing retinopathy was very high among known diabetes
patients those who had longer duration of DM. Hence, we have recommended a periodic eye screening is mandatory in T2DM patients.
Keywords: diabetes mellitus, diabetic retinopathy, influencing factors, probability, multivariate analysis

Keywords:
non-commercially, as long as appropriate credit is given and the new creations
http://ijmsnr.com/ are licensed under the identical terms.
Corresponding Author: Dr. Senthilvel Vasudevan,

Assistant Professor of Statistics, Department of Pharmacy Practice,
College of Pharmacy, King Saud Bin Abdulaziz University for Health
Sciences, Riyadh, Saudi Arabia. Email ID: vasudevans@ksau-hs.edu.sa
Introduction
Diabetes Mellitus (DM) is called otherwise by the word “Diabetes”. DM is a non-communicable disease [1]. DM is the public health problem
in Worldwide. It is classified into two major types namely Type I DM, Type II DM [2]. Diabetic Retinopathy (DR) is a non-communicable
and metabolic disorder. It is the complication of DM. DR is also called as “eye threatening disease”. DR affects the minor blood vessels in
the retina. It is a public health problem in both developing and developing countries. Overall, in India there are 65 million people with DM,
and it would be projected to increase to 134 million in coming year 2045. [3] If the body glucose level is not maintaining correctly for a long
period, then it leads to last stage vision loss [4]. The prevalence of DR was 27% in between 2015 – 2019 based on Worldwide and in that
Proliferative DR (PDR) was 1.4% [5].
The prevalence of DR is more in male gender, urban area had more prevalence and 22.18% patients had DR. [6] Even though the literacy
rate is high in Kerala, but the prevalence of DM is 16.3% also very high and vision threatening was seen in 39.5% population. So many
studies were done with small sample size, and some studies were done with larger sample size. [7] DR progression was associated with older
age, male sex, hyperglycaemia (higher HbA1C) and with not smoking. [8] There was no separate paper related to find probability of
developing or progressing DR in DM patients. That’s why, we did this study with a reasonable sample size. The main aims of this study
was to identify the influencing factors of DR among T2DM patients and to estimate the probability of developing of DR among known
T2DM patients.
How to cite this article: Prasad A, Vasudevan S. A multivariate analysis approach on identifying of influencing factors and the
chance of development of diabetic eye disease among diabetes in a diabetic Centre of Southwestern Malabar region of India .
Int J Med Sci and Nurs Res 2021;1(2):5-9.
Prasad A et al. A multivariate analysis approach on influencing factors and the chance of development of diabetic eye disease
Materials and Methods: Statistical analysis: All data were entered and managed by using
Microsoft Excel 2010 [Microsoft Office 360, Microsoft Ltd., USA]
A hospital-based cross-sectional and observational study was conducted and data were analyzed by using SPSS 20.0 version for windows
with one hundred and fifty known DM patients by simple random [IBM SPSS Ltd., Chicago IL, USA].
sampling method were recruited and included in this study. Data were
collected from the Diabetic Centre patients in Amrita Institute of Descriptive Statistics: Quantitative variables were expressed as
Medical Sciences, Kochi, Kerala. This study was done in between mean and standard deviation, and qualitative variables were
February and March 2018. expressed as frequency, and proportions. Bivariate analysis: Chi-
Square test was used to compare dichotomous variables.
Selection of variables and allocation for the data analysis: In our Multivariate Logistic Regression (MLR) Analysis: Binary Logistic
present study, we have considered the variables as binary variables for Regression equation (Y = β0 + β1X1 + β2X2 + β3X3 + … … … + βnXn)
the purpose of data analysis. with backward conditional analysis was used to find the influencing
factors in the development of DR among known T2DM patients. [9]
Gender (X1): Male = 0, Female = 1, The statistically significant (p<0.05) variables were identified from
Age (X2): ≤50 years = 0, >50 years = 1, bivariate analysis and variables had p-value <0.20 were identified and
Educational status(X3): School = 0, College = 1, included in the final Binary Logistic Regression analysis. [10] The
Family history of Diabetes Mellitus (X4): No = 0, Yes = 1, level of significant was fixed as p<0.05.
Alcohol consumption (X5): No = 0, Yes = 1.
Smoking habit (X6): No = 0, Yes = 1, Ethical Consideration: This study was done with prior permissions
History of hypertension (X7): No = 0, Yes = 1, were obtained from both the institutions before conducted. Patients’
Medication (X8): Tablet Users = 0, Insulin Users = 1, data were obtained from the medical records and some information
Duration of Diabetes Mellitus (X9): <10 years = 0, ≥ 10 years = 1, from the patients directly. Patients’ data were confidential and
Body Mass Index classification (X10): Normal = 0, Over Weight = 1, preserved by the AIMS institutions, Kochi, Kerala. Ethical approval
Total cholesterol (X11): Normal = 0, Abnormal = 1, from the Institutional Review Board/Ethics Committee had been
HbA1C (X12): ≤ 6.5% = 0, > 6.5% = 1, and obtained and informed all the details about the study and had got the
Fasting blood sugar (X13): Normal = 0, Abnormal = 1 as shown in Table oral consents were taken from all participants at the time of study
– 1. period.
For the analysis, I have taken the variables were converted as binary Results:
variables. We have found the association between dichotomous variables
(gender, educational status, family history of DM, smoking habit, history In our present study, two hundred T2DM patients as per inclusion and
of hypertension, medication, BMI classification, total cholesterol, and exclusion criteria with aged thirty years and above were recruited and
fasting blood sugar) and found mean comparison between continuous included. In that, 39 (26%) patients had DR and 111 (74%) patients
variables (age, duration of diabetes mellitus, and hba1c), with and were not having DR. The average age of the participants was 58.2 ±
without variables by using Chi-Square test. 10.5 (31–87) years. The other variables were presented in Table – 1.
To find out the odds ratio (Probability of developing DR in a DM patient) In bivariate analysis, the variables duration of diabetes mellitus,
as follows: medication, duration of hypertension, smoking habit, HbA1C, and
FBS were showed statistically significant with and without DR with
Y = β0 + β1X1 + β2X2 + β3X3 + … + βiXi + … + βnXn … … … (1) p<0.05. So, these variables were influencing with the development
of DR among known T2DM patients.
Find the value of Y and substitute in eY, and then
In this study, we have used Binary Logistic Regression (BLR)
P Analysis with backward conditional analysis to predict the
------------ = eY … … … (2) influencing factor to develop the diabetic retinopathy among known
1–P T2DM patients. From the multivariate logistic regression analysis,
the results were obtained and in that, Hosmer-Lemeshow test was
and find the value of P. showed a goodness of fit with Chi-Square value of 2.891 and p-value
was 0.941 (p>0.05). Hence, we have concluded that the selection of
This P – value is the probability of developing DR in a DM patient. prediction variables was very much suitable to the final model binary
logistic regression model was a good fit and the substitute variables.
Inclusion Criteria: T2DM patients with aged ≥30 years those who have
been lived permanently in area in and around Kochi area. The history of hypertension wasn’t significant in the bivariate
analysis but included in the final BLR analysis. The history of
Exclusion Criteria: Patients those who had other chronic diseases and hypertension wasn’t significant in the bivariate analysis but included
other communicable and non-communicable diseases. in the final BLR analysis.
Table: 1 Distribution of basic and clinical characteristics of HbA1C, β-regression value = 0.218, [AOR:1.34; 95%CI: (1.02–
with and without Diabetic Retinopathy among Type 2 Diabetes 1.75); p=0.035], (p<0.05). 34% risk increase as shown in Table–2.
Mellitus patients Table – 2 List of predictor variables in the multivariate
logistic regression equation, β-Values, its significance,
Diabetic Retinopathy
Variables
No. of Patients odds ratios and 95% Confidence Interval
n (%) With DR Without DR
Gender (X1) Male 85 (56.7) 20 (23.5) 65 (76.5) Variables in the 95% CI
β
Female 65 (43.3) 19 (29.2) 46 (70.8) Multivariate Logistic OR Significance
Value Lower Upper
Age groups ≤ 50 34 (22.7) Regression Equation
60.38 9.06 Limit Limit
(in years) (X2) > 50 116 (77.3) 57.37 10.84 Age (X2) 0.458 0.97 >0.05, NS 0.92 1.03
Educational Status School 91 (60.7) 23 (25.3) 68 (74.7) Smoking habit (X6) 0.002 15.39 <0.01, HS 2.66 89.18
(X3)
College 59 (39.3) 16 (27.1) 43 (72.9) History of HTN (X7) 0.013 1.10 <0.05, S 1.02 1.18
Family History of Yes 47 (31.3) 9 (19.1) 38 (80.9) Medication (X8) 0.009 5.72 <0.01, HS 1.93 16.91
DM (X4) Duration of DM (X9) 0.085 1.18 <0.01, HS 1.07 1.31
No 103 (68.7) 30 (29.1) 73 (70.9) Total Cholesterol (X11) 0.001 5.86 >0.05, NS 0.90 38.41
Alcohol Yes 127 (84.7) 32 (25.2) 95 (74.8) HbA1C (X12) 0.218 1.34 <0.05, S 1.02 1.75
Consumption (X5)
No 23 (15.3) 7 (30.4) 16 (69.6) FBS (X13) 0.002 1.01 <0.05, S 1.00 1.02
Smoking Habit Yes 136 (90.7) 33 (24.3) 103 (75.7) Constant 1.486 0.72 <0.05, S
(X6) HTN - Hypertension; DM - Diabetes Mellitus; β - Regression Values; OR -
No 14 (9.3) 6 (42.9) 8 (57.1)
Odds Ratio; CI - Confidence Interval, HS- Highly Significant; S -
History of Yes 55 (36.7) 8 (14.5) 47 (85.5) Significant; NS - Not Significant
hypertension (X7) No 95 (63.3) 31 (32.6) 64 (67.4)
Medication (X8) Tablet Users
In bivariate analysis, the association between groups (with and
93 (62.0) 11 (11.8) 82 (88.2) without DR) and duration of DM was showed a highly statistically
Insulin Users 57 (16.0) 28 (49.1) 29 (50.9) significant with p-value<0.01 as shown in Figure–1.
Duration of DM < 10 years 64 (42.7) 16.62 7.57
Mean (SD) (X9) Figure:1 Relationship between with and without diabetes
≥ 10 years 86 (57.3) 10.21 6.65 and classifications of duration of diabetes mellitus
BMI 18.5 – 24.9
68 (45.3) 17 (24.6) 52 (75.4)
Classifications (Normal)
(X10) 25.0 – 29.9
82 (54.7) 22 (27.2) 59 (72.8)
(Over Weight)
Total Cholesterol Normal 123 (82.0) 36 (29.3) 87 (70.7) <10 years 14.30% 85.90%
(X11)
Abnormal 27 (18.0) 3 (11.1) 24 (88.9)
HbA1C (in %) ≤ 6.5 30 (20.0) 8.94 2.12
Mean (SD) (X12)
> 6.5 120 (80.0) 7.97 1.83
Fasting Blood Normal 14 (10.4) 2 (14.3) 12 (85.7) ≥ 10 years 34.90% 65.10%
Sugar~ (X13)
Abnormal 121 (89.6) 33 (27.3) 88 (72.7)
In the third step of backward elimination only, the variables smoking 0% 20% 40% 60% 80% 100% 120%
habit, β-regression value=0.002, Adjusted Odds Ratio, [AOR:15.39;
95%CI:(2.66–89.18); p=0.002], (p<0.05), was 15-times more risk than With DR Without DR
non-smokers. History of hypertension, β-regression value=0.013,
[AOR:1.10; 95%CI:(1.02–1.18); p=0.016], (p<0.05) with hypertension
10% increase in risk in the development of DR. Medication, β-regression The other variables like medication, duration of hypertension,
value=0.009, [AOR = 5.72; 95%CI:(1.93–16.91); p=0.002], (p<0.05). The smoking habit, HbA1C, and FBS were also showed statistically
risk was five times more in insulin users than tablet users. significant with and without DR with p<0.05. HbA1C in the
progression of DR. Next, to find the probability of the development
Duration of diabetes mellitus, β-regression value=0.085, [AOR:1.18; of DR in a DM patient. Here, we have taken clinical data of a DM
95%CI:(1.07–1.31); p=0.001], The risk was 18% more those who had DM patient with DR and in high and substitute in the equations (1) and
≥10 years (p<0.05). Total cholesterol, β-regression value=0.001, (2), the variables were as follows: smoking habit (X6) = yes = 1;
[AOR:5.86; 95%CI: (0.89–38.41); p=0.065], (p>0.05). The risk was 5- history of hypertension (X7) = yes = 1; medication (X8) = yes = 1;
times more in abnormal than normal but not significant. According to duration of diabetes mellitus (X9) = 20 years; hba1c (X12) = 7.2%;
fasting blood sugar (X13) = 190 mg/dL. Substitute in equation – 1, Duration of diabetes mellitus 10 years or longer was showed a
Hence, the binary logistic regression equation (1) became, significant factor in the development of DR in diabetes. Similar type
result was found by Roberts et. al., Kawasaki et. al. [17, 18] HbA1C was
Y = β0 + β1X1 + β2X2 + β3X3 + … … … + β13X13 ---------- (1) a risk factor and association with the development/progression of DR.
The same type of results was found by Song et al. [19] In this study, we
According to final multivariate logistic regression analysis, the above have got total cholesterol was a prominent risk factor with 5-fold with
equation was rewritten as follows, ie., modified (1) equation was, DR and it was an influencing with the development/progression of DR
but not showed any significant with DR in the multivariate analysis.
Y = β0 + β6X6 + β7X7 + β8X8 + β9X9 + β12X12 + β13X13
Y = 1.486 + (0.002) (1) + (0.013) (1) + (0.009) (1) + (0.085) (20) In a study by Abougalambou and Abougalambou. [20] have obtained
+ (0.218) (7.2) + (0.002) (190) fasting blood sugar was a risk factor in the progression of retinopathy.
Y = 4.160 Brambilla et al. has also arrived similar result in the study. [21] There
Therefore, eY = 64.072 and Substitute, the value of eY = 64.072 in was a positive correlation between DR and age with 60 years and above
the equation (2), We have got following, but, not showed any significant with DR development. But in a study
by Stratton et al. has determined the older age was associated with the
P progression of DR. [22]
------------ = eY ------------------ (2)
1–P Conclusion: From this study revealed that the influencing
variables were HbA1C, smoking habit, intake of tablet/insulin, duration
P of DM (longer years), history of hypertension and fasting blood sugar
------------ = 64.072 in a known T2DM patient. The chance/probability of developing
1–P retinopathy was very high among diabetes patients those who have had
longer duration of diabetes mellitus. Hence, we have to recommend to
P = 0.984 ~ 98% the diabetic/retinopathy patients to get health education and eye care
from their family physician/endocrinologist/authorized diabetic/retina
Hence, the probability of developing DR was P = 0.984 (Odds Ratio). Centre public health professionals. Moreover, the diabetic patients have
So, the probability of developing DR in a known T2DM patient was to go for a periodic eye screening once in six months to prevent from
estimated as 98%. the development of DR, or to avoid, or to retain in the same severity
stage or to rescue themselves from loss of eye sight.
Discussion:
Acknowledgement: The authors are thankful to the Medical-Director,
This is the study in Kerala related to find the influencing factors and Medical Superintend, Head of Retina Centre, and Head of the
probability to the progression of DR in diabetic patients. DR is one of Department of Biostatistics of Amrita Institute of Medical Sciences,
the public health problems in Worldwide. [3] DM patients have not Kochi, Kerala for their support and guidance to proceed the study.
controlled their blood glucose level over a period of time then, they
will have to effect by retinopathy. If not screened in time and not Authors’ contributions: AP, SV: Conception and Study design; AP:
properly controlled the risk factors then, it will affect the retina and it Acquisition of Data; AP, SV: Data processing, Analysis and
will cause to vision loss. In bi-variate analysis, duration of DM, Interpretation of Data; Both the authors – AP and SV were drafting the
medication, total cholesterol, HbA1C, fasting blood sugar were showed article, revising it for intellectual content; Both authors were checked
a significant with development of DR. But body mass index wasn’t and approved of the final version of the manuscript.
showed any significance with the progression of DR.
Here, AP – Amitha Prasad; SV – Senthilvel Vasudevan
In the final statistical model in the BLR analysis the variables HbA1C, Source of funding: None
FBS, smoking habit, intake of tablet/insulin, duration of DM and
history of hypertension were only showed a significant with the Conflict of interest: None
development of DR. In our present study, the newly diagnosed with
Type 2 DM patients, 26% had DR. After the multivariate analysis the
related factors, smoking was a prominent risk factor in the development References:
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Clinical Profile and Risk Assessment of Infections Among Diabetics
in a Community Health Hospital in Chennai: A Hospital Based
Descriptive and Cross-Sectional Study
Shalini Kaliaperumal1 , Ezhilan Naganathan2, Betty Chacko3
1, 2, 3 Department of Medicine, CSI Kalyani Multi-Speciality Hospital, Chennai, Tamil Nadu, India.
Abstract
Background: Incidence of diabetes mellitus continues to rise, common focus areas for diabetes control are blood glucose levels, diet, and
exercise. Controlling these factors are essential for a better quality of life in diabetes patients. Patients with diabetes have an increased risk
of asymptomatic bacteriuria and pyuria, cystitis, and, more important, serious upper urinary tract infection.
Materials and Methods: This was a hospital based descriptive and cross-sectional study which included 250 Study subjects who were
admitted in CSI Kalyani General hospital during the period from July 2017 to July 2018 and who has Diabetic as a comorbidity were
interviewed using structured protocol based proforma. Patient underwent routine clinical, pathological and biochemical investigations.
Results: In this study, 250 in-patients were included and analyzed. The prevalence of Infection in Diabetes mellitus was 65.6%. There is
no significant association between age, education, occupation, hba1c, duration and type of treatment and biochemical values. The commonest
organism in Urine sample among the study group was E.coli followed by Klebsiella. UTI is more common in females, respiratory infection
is more common in males and it was statistically significant (p<0.009) and (p<0.007) respectively.
Conclusion: From this study, we have concluded that patient with diabetes mellitus is at increased risk for common infections due to poor
glycemic control and obesity. Poor glycemic control suppresses the immunity and more prone for infection. Therefore, the challenges will
be to attain good glycemic control, change in lifestyle to maintain normal BMI. This will prevent the morbimortality, reduce the long-term
complication and maintenance to prolong the life without any sequele. More prospective case control studies on the management of infections
in DM patients are needed.
Keywords: type 2 diabetes mellitus, infections, clinical profile, hba1c, glycemic control
Corresponding Author: Dr. Shalini Kaliaperumal,

No.5, First Floor, Main Road, Manakula
Vinayagar Nagar, Pondicherry, India.
Email ID: shalinikaliaperumal@gmail.com Cell No: +91 96296 04933
Introduction
Diabetes is fast gaining the status of a potential epidemic in India with more than 62 million diabetic individuals currently diagnosed with
the disease. In 2000, India (31.7 million) topped the world with the highest number of people with diabetes mellitus followed by China (20.8
million) with the United States (17.7 million) in second and third place respectively. The prevalence of diabetes is predicted to double globally
from 171 million in 2000 to 366 million in 2030 with a maximum increase in India. It is predicted that by 2030 diabetes mellitus may afflict
up to 79.4 million individuals in India, while China (42.3 million) and the United States (30.3 million) will also see significant increases in
those affected by the disease. Indians are genetically predisposed to the development of coronary artery disease due to dyslipidemia and low
levels of high-density lipoproteins; these determinants make Indians more prone to development of the complications of diabetes at an early
age (20-40 years) compared with Caucasians (>50 years) and indicate that diabetes must be carefully screened and monitored regardless of
patient age within India. [1]
Diabetes mellitus (DM) is a common non communicable disease in India. The prevalence of type 2 DM is 11% in urban areas in comparison
to 3-9% in rural areas. Infections play a significant role in morbidity and mortality of diabetic patients. Studies revealed that defect in the
function of neutrophils, lymphocytes, and monocytes were the reason for increased infections in diabetics. Other reasons are low levels of
leukotriene B4, thromboxane B2, and prostaglandin E. Some studies showed decreased lymphocyte function in diabetics, and decreased
How to cite this article: Kaliaperumal S, Ezhilan N, Chacko B. Clinical Profile and Risk Assessment of Infections Among Diabetics in a
Community Health Hospital in Chennai: A Hospital Based Descriptive and Cross-Sectional Study. Int J Med Sci and Nurs Res 2021;1(2):10–
18.
Kaliaperumal S et al. Clinical Profile and Risk Assessment of Infections Among Diabetics
levels of phagocytosis in monocyte. There is also evidence that lacking. Therefore, the aim of this study was to explore this problem
improving glycemic status in diabetics, improves cellular immunity. [2] in our own setup. The main objectives are to study the epidemiology
of infections among diabetics; to assess the risk of infections among
Diabetes and related complications are associated with long-term diabetic patients; to study the clinical profile of infection among
damage and failure of various organ systems. Diabetes induces changes diabetic patients; and to study the common organisms isolated in
in the microvasculature, causing extracellular matrix protein synthesis, Urine, Sputum and Pus sample.
and capillary basement membrane thickening which are the pathognomic
features of diabetic microangiopathy. These changes in conjunction with Materials and Methods:
advanced glycation end products, oxidative stress, low grade
inflammation, and neovascularization of vasa vasorum can lead to macro We have done this hospital based descriptive cross-sectional study in
vascular complications. [3] A positive association between diabetes and CSI Kalyani Multi-specialty hospital, Chennai with a sample of 250
infection was previously the subject of debate in the literature , but recent patients in the study period of July 2017 – July 2018.
evidence suggests that bacterial infections are a relatively frequent Sample Size Calculation: The prevalence of Infections in diabetes
occurrence in diabetic patients and that there may be an associated mellitus is 30% [2, 10] We required 250 samples to estimate 30%
increase in morbidity and mortality .The weight of evidence suggests that prevalence of Infections in diabetic patients with the precision of 6%
patients with type 2 diabetes have an increased incidence of common and 95% confidence interval.
community acquired infections, including lower respiratory tract 2
infection, urinary tract infection (UTI), and skin and mucous membrane 𝑍(1−𝛼/2) ∗ p(1 − p)
N=
infections . There is also a substantially increased susceptibility to rare 𝑑2
but potentially fatal infections including necrotizing fasciitis and
p - Expected proportion; d – Precision; Z1-α/2 – Two-sided Z value
emphysematous pyelonephritis. [4] In patients with Diabetes mellitus,
for corresponding α; N – required sample size.
soft tissue and bone infection of the lower limbs is the most common
cause for hospital admission. The rate of lower extremity amputation The inclusion criteria were both male and female patients willing to
among diabetics is more than 40 times that of non-diabetics. [5] The risk participate, in-patients in all wards, CSI Kalyani Multi-speciality
of infection-related mortality is notably increased for diabetic adults Hospital with aged >12years and diabetes mellitus (both Type 1 & 2)
compared with those without diabetes, but only among people with as comorbidity and with some exclusion criteria of aged less ≤12
concurrent cardiovascular disease. [6] years, patient not willing for admission, non diabetic and patient not
willing to participate, GDM and OPD Patients with DM. [9]
Hepatitis C virus (HCV) infection may contribute to the development of
diabetes mellitus. This relationship has not been investigated at the 250 Study subjects, who are diabetic were included after obtaining
population level, and its biological mechanism remains unknown. [7] their written consent. Patients who were admitted in CSI Kalyani
Infections are widely considered to be a source of significant health care General hospital during the period of July 2017 to July 2018 and who
costs and to reduce quality of life among people with diabetes mellitus has Diabetic as a comorbidity were interviewed using structured
(DM). A recent review of higher-quality population-based protocol based proforma. Complete clinical examination was done.
epidemiological studies found clinically important (∼1.5–3.5 times Patient underwent routine clinical, pathological and biochemical
higher) infection risks associated with poorer DM control in some investigations such as Total count, differential, count, HbA1C, FBS,
studies (usually defined as a glycated hemoglobin [HbA1C] level >7–8% PPBS, S. Urea, S. Creatinine, SGOT, SGPT were done. Appropriate
[53 – 64 mmol/mol]). microbiological investigations such as Urine c/s, Sputum c/s, Blood
c/s, Pus c/s were done according to the clinical profile of the patients.
Preventing the development of diabetic complications such as infections, Other imaging methods were done such as Chest X ray, CT Chest,
kidney failure, and amputations involves proper glycemic control. CT Abdomen and CT Brain as required. Established diagnosis were
Addressing different aspects of diabetes control aid in the reduction of documented and results were tabulated. The data collected were
infection susceptibility. [8] Literature suggests maintaining causal blood entered and analysed by using SPSS for Windows Version 20. Mean
glucose levels below 200 mg/dL. Glucose levels above 200 mg/dL are and Standard deviation was used for normally distributed continuous
expected to pose an increased risk of infections. To assist in the data. The dichotomous data were expressed as number and
maintenance of proper perfusion through blood vessels, adherence to percentages. The association was found using Chi-Square test
standard of care is vital. The risk and burden of infection is more in case /Fisher’s Exact test wherever applicable. p-value was considered as
of diabetics than in case of non-diabetic individuals. There is also statistically significant
evidence of altered glycemic control in diabetic patients with infection Ethical Consideration: This study was done with prior permission
and Obesity as a risk of infection; the main of complications related with and approval from the institutional research and ethical committee
diabetes mellitus is due to impaired glucose tolerance and improper and with patients’ written consents and data were confidential.
glucose control, and it has also revealed that with good glycemic control
the number of complications has reduced, and also with good control of Results:
infection the glycemic control is also good. Maintaining a normal BMI This study was done among the Diabetic patients of age >12years
is also essential to reduce the risk of disease burden among Diabetes who are all treated as In-Patient during July 2017 to July 2018 in CSI
mellitus. Although DM is very common in south India, studies on type Kalyani Hospital, Chennai. A total of 250 patients were analyzed and
of infections in patients with DM from rural South Indian areas are their data were given in Table – 1.
Table – 1 Distribution of socio-demographic and clinical variables In this study group, the prevalence of diabetes mellitus is more in
the age group of 50 – 59 years (28%) followed by the age group 60
Number of – 69 years (23.6%), the youngest case recorded in the study is 30
Variables Patients Percentage years of age. In our study, both male and female nearly equal in
Gender this study. It was observed that predominant group in this study
Male 128 51.2 were in high school (41.2%) followed by middle school (21.6%).
Among this study group 17.6% of the people were illiterates.
Female 122 48.8 Majority of them in this study group were unemployed (48%).
Age (in years) Majority of study group were with the duration of 5.1 – 10 years
30 – 39 12 4.8 (31.6%) followed by 0.6 – 5.0 years (26%). In our present study,
40 – 49 47 18.8 54.8 % of diabetics were taking only OHA‘s predominantly
followed by 20.4 % of Diabetics were on Diet only. Among the
50 – 59 70 28.0
general symptoms majority of them had fever (42.4%) followed by
60 – 69 59 23.6 swelling of legs (9.6%). In the predominant group in this study had
70 – 79 43 17.2 systemic hypertension (45.6%) followed by CAD (25.6%) as a
>80 19 7.6 comorbidity.
Educational Status
It was observed that majority of Diabetics in this group had history
Illiterate 44 17.6 of UTI in the past (10.8%) followed by Respiratory infection in the
Primary 11 4.4 past (8.0%). In this study, predominant group were with the BMI
Middle school 54 21.6 of 25-29.9 (36%), pre-obese group followed by 18.5 – 22.9 (25%)
High school 103 41.2 Normal group according to Asian criteria of BMI. In this study
group, 33.4 % of them had Leukocytosis. In this, FBS>126 in 77.2
Diploma 28 11.2 % of study group, PPBS >140 in 88.4 % of study group, S. Urea
Graduate 10 4.0 elevated in 26.4 % of study group, S. Creatinine elevated in 17.6%
Postgraduate 0 0 of study group, SGOT >40 in 15.2 % of study group and SGPT >40
Employment Status in 14% of study group. It is observed that, 58.8 % of the study group
had HbA1C >8 followed by 19.6 % of the study group had HbA1C
Unemployed 119 47.6
6.1 to 7%. Predominant culture positivity was in Urine sample
Unskilled worker 12 4.8 (24%) followed by Sputum sample (14.4%). Among the urine
Semi-skilled worker 33 13.2 sample which had growth the commonest organism which was
Skilled worker 43 17.2 found as E.Coli (31.1%) followed by Klebsiella (6.6%). Among the
sputum sample the commonest organism was Klebsiella (32%).
Clerical/shop/farm 29 11.6
Second commonest was Mycobacterium Tuberculosis (14%)
Semi professional 14 5.6 detected by Gene Xpert method. Among the pus sample which had
Professional 0 0 growth, the commonest organism was found to be Staphylococcus
Duration of Diabetes Mellitus (in years) aureus (33.3%) and Pseudomonas (33.3%). Major microvascular
≤ 0.5 36 14.4 complication in this study was found to be diabetic nephropathy
(17.2%) followed by Diabetic Retinopathy (5.6%). Among the 250
0.6 – 5.0 65 26.0 study subjects it was observed that 65.6% of the Diabetics had
5.1 – 10.0 79 31.6 Infection and 34.4 % of the Diabetics had no infection. Among the
10.1 – 15.0 27 10.8 study subjects the commonest infection found was Urinary
15.1 – 20.0 28 11.2 infection (37.2%) followed by Respiratory infection (21.6%). 78.5
% of this study group had UTI, followed by Pyelonephritis (15.1
>20 15 6.0
%). It was significant that 61.6 % of them had Asymptomatic UTI
Types of treatment with diabetes mellitus and respiratory infections LRTI (13.6%) is more common.
OHA 137 54.8
Insulin 23 9.2 The commonest foot infections in this study group were found to be
Cellulitis (52.9%) followed by Diabetic foot ulcer (29.4%). Among
Diet only 51 20.4
the soft tissue infections, the commonest was found to be
Insulin & OHA 39 15.6 Candidiasis (25%). In our study the commonest TB manifestation
General symptoms in diabetes mellitus was found to be Pulmonary Tuberculosis (77.8%). Moreover,
Fever 106 42.4 Hepatitis B and Acute Gastroenteritis were distributed equal in
Swelling of legs 24 9.6 number (36.3%) as shown in Table–1. Infection was more common
in females (53.7%) and it was statistically significant (p=value
Fatigue 14 5.6 0.03). It was observed that infection is predominant among
Loss of appetitie 10 4.0 semiprofessional group (71.6%)
(Contd…)
Table – 1 Distribution of socio-demographic and clinical variables Positive Culture Sensitivity (Contd… Table-1)
(Contd… Table-1)
Urine 60 24.0
Comorbidities in Diabetes Mellitus Sputum 36 14.4
HTN 114 45.6 Pus 9 3.6
CAD 64 25.6 Blood 1 0.4
Organisms in Urine Sample
Anemia 30 12.0
E.Coli 38 31.1
Dyslipidemia 25 10.0
Klebsiella 8 6.6
CKD 23 9.2
Pseudomonas 4 3.3
CVA 20 8.0
Staph Epidermidis 3 2.5
Hypothyroid 14 5.6
Candida albicans 2 1.6
Others 52 20.8
Enterococcus 2 1.6
Past infection history in diabetes mellitus
Staph.aureus 2 1.6
UTI 27 10.8
Non albican candida 1 0.8
Respiratory infection 20 8.0
No growth 62 50.8
DM foot ulcer 18 7.2 Organisms in Sputum Sample
Body Mass Index in DM Klebsiella 16 32.0
<18.5 17 6.8 Mycobacterium Tuberculosis 7 14.0
18.5 – 22.9 62 24.8 Pseudomonas 6 12.0
23 – 24.9 41 16.4 Proteus Vulgaris 4 8.0
25 – 29.9 90 36.0 Staph aureus 3 6.0
≥30 40 16.0 Streptococcus 2 4.0
Total count in DM E.coli 2 4.0
Leukocytosis (>11000) 84 33.6 Citrobacter 1 2.0
Normal count (4000-11000) 149 59.6 Acinetobacter 1 2.0
Leukopenia (<4000) 16 6.4 No growth 8 16.0
Urine Pus cells in DM Organisms in Pus sample
<5 83 33.2 Staph Aureus 3 33.3
5 to 10 36 14.4 Pseudomonas 3 33.3
10 to 20 26 10.4 E.coli 1 11.1
20 to 30 21 8.4 MRSA 1 11.1
Numerous 22 8.8 No growth 1 11.1
Occasional 34 13.6 Micro Vascular Complications
None 28 11.2 Nephropathy 43 17.2
Biochemical values in DM Retinopathy 14 5.6
Neuropathy 9 3.6
FBS >126 193 77.2
Infection in Diabetes Mellitus
PPBS >140 221 88.4
Yes 164 65.6
S. Urea > 40 66 26.4
No 86 34.4
S. Creat >1.3 44 17.6
Type of infections in Diabetes Mellitus
SGOT > 40 38 15.2
Urinary 93 37.2
SGPT > 40 35 14.0
Respiratory 54 21.6
HbA1C
Foot infections 20 8.0
4 to 6% 13 5.2
Skin and soft tissue 15 6.0
6.1 to 7% 49 19.6 Tuberculosis 9 3.6
7.1 to 8% 41 16.4 Cholecystitis 2 0.8
>8% 147 58.8 Others 19 7.6
Table – 2 Association between with and without infection among It is observed that infection is more common in underweight group
diabetes patients (BMI<18.5) followed by obese group (BMI>30) and the test was
showed statistically highly significant (p-value<0.01) as shown in
Figure–1.
Figure: 1 Comparison of Body Mass Index and with Infection
In our present study, 68.2% of the Diabetics with Urinary symptoms

had positive urine culture and this was statistically significant (p-
value<0.001) as shown in Figure–2.
Figure: 2 Comparison of urinary symptoms with urine c/s
and unemployed (70.6%) and it not statistically significant with p-

value=0.418 (>0.05). In our study, infection is more common when the
duration of diabetes is 0.6 – 5 years (76.9%) followed by 15.1 – 20 years
(71.4%) and this was not statistically significant with p-value=0.070
(>0.05).
Infection is more common in diabetics who are only on diet and only on
OHA. Among the Diabetics who are only on diet, 68.6 % of them had
infection and Diabetics who are only on OHA, nearly 67.2 % of them
had infections. It was not statistically significant with p>0.05. Discussion:
It was not statistically significant with p>0.05. It is observed that Diabetes Mellitus [12] is a non-communicable disease and is one of
infection is more common in diabetics who had systemic hypertension the major disease burdens worldwide and also a leading cause for
as a comorbidity but this was not statistically significant (p>0.05). non-traumatic lower limb amputations, the association of the
However, Infection was less common in Dyslipidemia and CVA group Infection and diabetes mellitus is not a new entity it’s been known
and it was highly statistically significant (p<0.01). for quite some time for now, the recent studies also suggest the
increased
prevalence of infections among diabetics with, many research has also soft tissue infections (6.0%), Tuberculosis (3.6%) and
proved that glycemic control within appropriate normal limits will also help Cholecystitis (0.8%). Escherichia coli (31.1%) and Klebsiella (6.6%)
to reduce the morbimortality and long-term complications [14] of Diabetes were the commonest organisms isolated from urine sample.
mellitus. [11, 12] Physicians should be aware of risk factors and type of Klebsiella (32%) and Mycobacterium tuberculosis (14%) were the
infections present in patients with diabetes in order to provide proper care. commonest organism isolated from the sputum sample. In a
Prospective studies on the management of infections in patients with retrospective study was done by Bettegowde et al. from a rural
diabetes mellitus are needed. [13] Diabetic retinopathy is a major Tertiary care hospital of South Karnataka, out of 842 diabetics, 254
complication of DM. [15, 16] Diabetic neuropathy is also a complication of (30.1%) had infections. The commonest comorbidity was
DM and insulin complications in the long-term. [17, 18, 19, 20] Hypertension (62.99%). Common infections encountered were upper
respiratory tract infection (29.13%), urinary tract infection (26.77%),
Other type of infections is also happening to DM patients. [21] Complete Lower respiratory tract infection (15.74%), Tuberculosis (11.81%),
clinical examination was done. Patient underwent routine clinical, Skin and soft tissue infections (11.02%) and Foot infections (8.66%).
pathological and biochemical investigations such as Total count, Escherichia coli and Candida albicans were the common causative
differential, count, HbA1C, FBS, PPBS, S. Urea, S. Creatinine, SGOT, organisms of urinary tract infection. Staphylococcus aureus and
SGPT were done. Appropriate microbiological investigations [21, 22, 23] Mycobacterium tuberculosis were the most common microorganisms
such as Sputum c/s [24], Urine c/s [25, 26], Blood c/s, Pus c/s [26] were causing respiratory tract infections. [2]
done according to the clinical profile of the patients. Other imaging methods
were done such as Chest X ray, CT Chest, CT Abdomen and CT Brain as In my study urinary infection (37.2%), Respiratory infection (21.6%),
required. Established diagnosis were documented and results were tabulated foot infection (8.0%), Skin and soft tissue infection (6.0%),
as per results. [24, 26] Tuberculosis (3.6%) and Cholecystitis (0.8%). In Sow et al. study the
mean infections were the skin and soft tissues (54.91%), urogenital
In our study the number of male and female were equal. Mean age of study infections (16.18%), respiratory infections (14.45%), malaria
subject was 60 years. In my study, the maximum number of Diabetics with (3.46%), infections of the skin and soft tissues were dominated by the
infection were seen in 50 – 59 years’ age group (78.3%). This increase in diabetic foot (41.90%). [32] In our study positive correlation found
incidence of infection with age was observed in a study by Gillani et al. [27] between Asymptomatic UTI and Diabetic patients. Out of 77.4% of
However there was no statistical significance with age and infection in my Urinary tract infection, 66% of the Diabetics had an Asymptomatic
study. In my study the infection rate was higher among females (53.7%). UTI. Similarly, in Bissong et. al. study, it was observed that there
However, this was not statistically significant. UTI is more common in was a high prevalence of ASB in diabetics than in non-diabetics. [33]
females (36.9%) and this was statistically significant (p=0.009). Similarly,
in Al-Rubeaan et al study, the prevalence of UTI was more common in In my study the common organism isolated from urine sample was
diabetic females. [28] In my study Age, duration of diabetes and HbA1C did found to be E.coli (31.1%) followed by Klebsiella (6.6%). Similarly,
not influence the incidence of infection and there is no statistical in Aswani et al study, a total of 181 diabetics (83 males and 98
significance, while BMI above 30 kg/m2 increased the risk of infection and females) and 124 non-diabetic subjects (52 males and 72 females)
it is statistically significant (p<0.01). Similar statistical significance with culture positive UTI were studied. The isolation rate of
observed in Al-Rubeaan et al study. [28] In my study respiratory infection Escherichia coli (E. coli) from urine culture was higher (64.6 per cent)
is more common in males (23.4%) and it was statistically significant among diabetic patients followed by Klebsiella (12.1 per cent) and
(p=0.007). Similarly, in Dutt and Dabhi study, male patients and Enterococcus (9.9 per cent). [34] The present study revealed that
uncontrolled DM had higher prevalence on pneumonia associated with Klebsiella were the commonest organism isolated from Sputum
diabetes. [29] In this study it was also revealed that there was no significant sample. Similarly, in Saibal et al [35] study totally 47 diabetics and
statistical association between Education, Occupation, Type of treatment, 43 non-diabetic adult hospitalized patients with CAP were enrolled.
biochemical values and HbA1C with infections among diabetics. However, Klebsiella pneumoniae was the most frequent causative pathogen for
58.8% of them had HbA1C >8%, and infection is less common with HbA1C, CAP in diabetic patients, whereas Streptococcus pneumoniae was the
4 to 6% but it wasn’t statistically significant. In Critchley et al study, it was most frequent causative agent for non-diabetic patients. [36] In the
observed that long-term infection risk rose with increasing HbA1C for most present study the common organism isolated in Pus sample was
outcomes. Poor glycemic control was powerfully associated with serious Staphylococcus aureus (33.3%) and Pseudomonas (33.3%), which is
infections and should be a high priority. [30] In our study there was a similar to a study done by Banu et al. [37], prospective study done at
positive correlation that the risk of infection is high in diabetics who are on a tertiary care hospital, one hundred patients over the age of 18,
diet only (68.6%) and only on Oral hypoglycemic agents (67.2%). There having chronic diabetic foot ulcer, and attending the surgery
was a positive correlation observed that Diabetics who are on Insulin has outpatient department were included Staphylococcus aureus was the
good control of blood sugars and less prone to infection. But this was not predominant organism, followed by Pseudomonas aeruginosa. In
statistically significant with p>0.05. However, in a study by Ooi et al, it was my study there is a positive correlation that oral candidiasis is
statistically significant that Intensive insulin therapy and tight glycemic common in diabetics. Similarly, in a study done by Radmila R. et al
control were associated with a lower risk of infection. [31] Out of 250 study it was concluded that oral candidiasis is significantly more frequent
subjects, 164 diabetics had infections and 86 diabetic patients without in diabetic patients compared to the non-diabetic subjects. [32, 38,
infections. In our study, the prevalence of infections among Diabetics was 39] In our study the predominant comorbidity was systemic
65.6%. The predominant infections encountered were Urinary infection hypertension (45.6%) followed by CAD (25.6%), Dyslipidemia
(37.2%), Respiratory infection (21.6%), Foot infections (8.0%), Skin and (10%), CKD (9.2%), CVA (8%), NAFLD (7.6%) and PVD (0.8%).
Conclusion:
Acknowledgement: The authors thank the participants, members of the
The predominant microvascular complication among the study group was Diabetic screening for all adult patients who are all coming with
Diabetic Nephropathy (17.2%) followed by Diabetic Retinopathy (5.6%) infection is mandatory to reduce the mortality and morbidity
and Diabetic Neuropathy (3.6%). However in Behera et al study, there associated with it. Diabetic screening tests should be mandatory at
was high prevalence of vascular complications and infections in T2DM their first visit to the hospital above 30 years of age and then every 3
patients. Of the total patients, 56% had nephropathy, 20% neuropathy, years to reduce long term complication of Diabetes mellitus. Further
17.3% retinopathy, 31.3% CVD, 11.3% CAD, 4.6% acute metabolic studies are required to find out the morbimortality of infections
complications, 44% infections and 16.6% had NAFLD respectively. among diabetic patients.
Macrovascular events occurred earlier than microvascular complications.
[11] In our study, the prevalence of Herpes zoster was 6.3% and there Limitations:
was a positive correlation that Diabetes increases the risk of Herpes
zoster. Similarly, in a retrospective study was done by Guignard et al. As it is a hospital-based study, this cannot be extrapolated to the
[40], revealed that type II diabetes was associated with an increased risk general population. Patient who was not willing to participate in the
of developing HZ, which was particularly high in adults 65 years and study could not be included, thereby the exact prevalence of infection
older and moderately increased in adults under 65 years of age. in diabetics could not find out. As this study done only in inpatients
with diabetics, OP patients with diabetics and infection could not be
Conclusion: assessed. As it was a cross sectional study, the outcome after treating
infection could not be measured. The morbimortality of infection in
This study revealed that infection is more common in females rather than diabetics could not be assessed as there is no follow up in this study.
males. The risk of infection increases with the duration of diabetes.
Infection is predominant in Diabetics who are only on diet and only on
Authors Contributions: SK, EN, BC: Conception and
Oral hypoglycemic agents. Majority of them in this study group had
design.: Acquisition of Data. EN, BC: Analysis and Interpretation of
HbA1C >8% which highlights that the risk of increases with poor
data. All authors SK, EN, BC: Drafting the article, revising it for
glycemic control. Majority of the Diabetics had past history of Urinary
Intellectual content. All authors were checked and approved of the
tract and Respiratory tract infection. It is highlighted that infection rate
final version of the manuscript.
increases in Underweight (BMI<18.5) and Obese group BMI (>30).
Majority of them in this study had Systemic Hypertension and Coronary
Here, SK: Shalini Kaliaperumal; EN: Ezhilan Naganathan; and BC:
artery disease as a comorbidity.
Betty Chacko
The commonest microvascular complication in this study was Diabetic
Nephropathy followed by Diabetic Retinopathy. The commonest Source of funding: We didn’t get any types of financial
infection found was Urinary tract infection, Respiratory infection, Foot support from our parent institution and any other financial
infection, Skin and soft tissue infection, Tuberculosis and Cholecystitis. organization.
Urinary Tract Infection (UTI) is common in age group 60–69 years and
Respiratory infection is common in age group >80 years. UTI is more
common in females and Respiratory infection more common in males.
Conflict of Interest: The authors declared no conflict of interest
The commonest organism isolated in urine sample was E.coli followed
by Klebsiella. Abbreviations:
The commonest organism in sputum sample was Klebsiella followed by FBS - Fasting blood sugar
Mycobacterium tuberculosis. Hence good glycemic control, proper PPBS - Post prandial blood sugar
maintenance and maintaining an appropriate BMI especially in long
duration of diabetics is essential to reduce long term complications and BMI - Body mass index
infections. It is essential that appropriate screening measures should be OHA - Oral Hypoglycemic agent
initiated at an early stage.
UTI - Urinary tract infection
Recommendations: LRTI - Lower respiratory tract infection
This study is based on local small population and therefore has URTI - Upper respiratory tract infection
limitations, it is recommended that wider areas must be covered to find TB - Tuberculosis
out the incidence and prevalence of infections in diabetes mellitus. More
prolonged duration of study is needed to identify the wide spectrum of CAP - Community acquired pneumonia
diseases among the Diabetics. Infection, which has been demonstrated CAD - Coronary Artery disease
to be significantly associated with diabetics must therefore be identified
and treated at an early stage to reduce the consequence of both CKD - Chronic Kidney Disease
uncontrolled Diabetes and infections and to reduce the morbimortality. SHTN - Systemic hypertension
PVD - Peripheral vascular disease
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2008. Available from: https://e-
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Publish your research article with

Hidden Markov Model of Evaluation of Break-Even Point of HIV
patients: A Simulation Study
Mahalakshmi Rajendran1, Senthamarai Kannan Kaliyaperumal2 , Balasubramaniam Ramakrishnan3
1, 3 Research Scholar, Department of Statistics, Manonmaniam Sundaranar University, Abishekapatti, Tirunelveli, Tamil Nadu, India.
2Professor of Statistics, Department of Statistics, Manonmaniam Sundaranar University, Abishekapatti, Tirunelveli, Tamil Nadu, India.
.
Abstract
Background: The HIV virus carries projection of significant global population with specific estimations of the mathematical results of
evolutionary methods which was presented in Tree Hidden Markov model (HMM).
Materials and Methods: Hidden Markov models used to model the progression of the disease among HIV infected people. The author
predicts a Baum Welch Algorithm method through HMM that can assess an unknown state of transition.
Results: The Tree HMM model predicts the break down point starts once patient is infected with the HIV virus as it affects the immune
system. The immune system drops more quickly in the initial inter arrival time when compared with the later time interval. The HIV virus
length in the nth state within regrouping is uncertain to occur in each state of the given model. A simulation study was done to assess the
goodness of fit for the model.
Conclusion: The HIV virus length in the nth state within regrouping is uncertain to occur in each state of the given model. The inter arrival
censoring between each state is essential in each infected HIV patients. The outcome of this works states that health care expert can use this
model for effective patient cares.
Keywords: expectation, hidden markov model, human immunodeficiency virus, immune system, transition

Corresponding Author: Ms. Mahalakshmi Rajendran,

Research Scholar, Department of Statistics, Manonmaniam
Sundaranar University, Abishekapatti, Tirunelveli, Tamil Nadu, India.
Email ID: mahalakshmirajendran@gmail.com
Introduction
Twenty-Six million people in 2020 June, were assessing the human immunodeficiency virus (HIV) antiretroviral therapy when compared to
2019 end an estimation of 25.4 million, an estimated 2.4% of increase was observed. Awareness among pregnant and breastfeeding women
have been increased around 85% who have received ART living with HIV, this avoids HIV transmission to their newborns and also ensures
their protective health. The 69th World Wellbeing Gathering proposed a "Worldwide wellbeing area technique on HIV for 2016-2021”. [1]
The arrangement offered five vital headings, which are as per the following: data on designated activity of once pestilence and reaction,
counteraction, treatment, and care, and exploration. The impact of mediations on the administrations required, guaranteeing uniformity for
the populaces needing administrations, getting long haul subsidizing to pay the expenses of administrations, and speeding up the change to
a manageable future are immensely significant contemplations. [2] UNAIDS has set a 2030 cutoff time for the destruction of the HIV
pandemic, which will match with World Guides Day in 2014. As indicated by gauges, about 2.39 million individuals in India are tainted
with HIV, making it the third most crowded country on the planet. South India was the main region to be hit by the HIV pandemic since it
had the most noteworthy populace thickness at that point. [3]
Hidden Markov Model (HMM) is an extension of Markov model. Markov Model was named after Andrei Andreyevich Markov who lived
in the year (1856-1922). Markov Chain is a statistical model where the data describes in sequence form. HMM is an especially embedded
How to cite this article: Rajendran M, Kaliyaperumal SK, Ramakrishnan B. Hidden Markov Model of Evaluation of Break-Even Point of
HIV patients: A Simulation Study. Int J Med Sci and Nurs Res 2021;1(2):19-22
International Journal of Medical Sciences and Nursing Research 2021;1(2):19-22 Page No:19
Rajendran M et al. Hidden Markov Model of Evaluation of Break-Even Point of HIV patients
under the umbrella of stochastic process where each state holds the Figure–1 Hidden random variable shown with Tree HMM
Markov property. [4] The three main information to be observed in the
HIV affected immune system is the parameter space, state space and
state transition probability. [5]
Mathematical and Statistical models for infectious diseases commonly

in the process of looking forward in estimating the epidemic which helps
different public health sectors to plan optimally. Recent literature shows
large number of literatures on Mathematical Models for communicable
diseases. [6] A validated goodness of fit model (HMM) been used as an
investigative to expect the diseases progression outcomes in infected
cows. [7] Mathematical Modelling has been identified at the early stage
of HIV epidemiological research, also concluded that theoretical
research focuses on quantitative data on sequential changes in the
mathematical distribution of sexual partner change along with other
factors like variations in epidemiologic abundance in serum and
emissions. [8] Mathematical Modelling suggests the cost effectiveness
and time of HIV pandemic interventions, when given the right
information to experimental trials. As the HIV pandemic is being a silent
global threat since last four decades. [9] The HMM topology inference , 𝐸𝑥𝑝𝑒𝑐𝑡𝑒𝑑 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑡𝑟𝑎𝑛𝑠𝑖𝑡𝑖𝑜𝑛𝑠 𝑓𝑟𝑜𝑚 𝑠𝑡𝑎𝑡𝑒 𝑖 𝑡𝑜 𝑗
model denotes its graphical figures including the number of states with 𝑎𝑖𝑗 =
𝐸𝑥𝑝𝑒𝑐𝑡𝑒𝑑 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑡𝑟𝑎𝑛𝑠𝑖𝑡𝑖𝑜𝑛𝑠 𝑓𝑟𝑜𝑚 𝑠𝑡𝑎𝑡𝑒 𝑖
the association of symbols in each different state and state transitions
with non-zero probabilities. Assuming the HMM model always specify ∑𝑇𝑡=1 𝑝𝑡 (𝑖, 𝑗)
the states prior to the information received. [10] =
∑𝑇𝑡=1 𝛾𝑖 (𝑡)
The Baum Welch Algorithm was published by Baum LE and along with
coauthors who worked through his articles, even the name “Welch” ,
∑𝑇𝑡=1 𝛼𝑖 (𝑡)𝑎𝑖𝑗 𝑏𝑗 (𝑂𝑡+1 ) 𝛽𝑗 (𝑡 + 1)
𝑎𝑖𝑗 = … … … (1)
appears as the coauthor that have been worked in developing this Baum ∑𝑇𝑡=1 𝛼𝑖 (𝑡)𝛽𝑖 (𝑡)
Welch Algorithm. This algorithm was an example of Expectation
Maximization (EM) algorithm. Mathematical methods associate to the 𝑃𝑟(𝑖𝑗) = 𝑃𝑟(𝑆𝑡=𝑖, 𝑆𝑡+1=𝑗 /𝑂, 𝜇)
algorithm along with an explanation as how the Baum Welch Algorithm
fits the EM were also seen. [11 – 15] 𝑃𝑟(𝑆𝑡=𝑖, 𝑆𝑡+1=𝑗 /𝑂, 𝜇)
= … … … (2)
𝑃(𝑂/𝜇)
We assume that the human immune system gets affected with HIV in a
future state when the present state is already affected with HIV. The
𝛼𝑖 (𝑡)𝑎𝑖𝑗 𝑏𝑖𝑗𝑜𝑡 𝛽𝑗 (𝑡 + 1)
non-observable damage causing the immune system which leads to the = 𝑁 𝑁
∑𝑚=1 ∑𝑛=1 𝛼𝑚 (𝑡)𝑎𝑚𝑛 𝑏𝑚𝑛𝑜𝑡 𝛽𝑛 (𝑡
HMM is the one to observe in this article. When the human system gets + 1)
affected with HIV, it is represented by time t=1, which is the initial state
of the process. At every time interval the human system moves from the Equation (2) observes the probability of being at state 𝑖 at time 𝑡, and
current position to another position, i.e., t = (1, 2, 3, … …), the transition at state 𝑗 at time 𝑡 + 1, given the model 𝜇 and the observation 𝑂.
probabilities are independent of the time t. Then, define 𝛾𝑖 (𝑡) this is the probability of being at state 𝑖 at time 𝑡,
given the observation 𝑂 and the model 𝜇, as seen in equation (3),
Materials and Methods:
𝑁
𝑆𝑡=𝑖
𝛾𝑖 (𝑡) = 𝑃𝑟 ( , 𝜇) = ∑ 𝑃𝑟(𝑆𝑡=𝑖, 𝑆𝑡+1=𝑗 /𝑂, 𝜇) … … … (3)
Hidden Markov Model: [10] A continuous process to develop 𝑂
𝑗=1
model parameters in the transition state to explain the respective time
point in the infected patients. A Hidden Markov Model (HMM) is
usually represented by 𝐻𝑀𝑀: 𝜇 = (𝐴, 𝐵, 𝜋). This model tells us; the 𝑁
state transition probability, observational probability, probability of
= ∑ 𝑃𝑟(𝑖, 𝑗)
starting in a particular state. The Baum-Welch algorithm also known as
𝑗=1
EM-algorithm to emphasis on parameter estimation built on direct
numerical maximum likelihood estimation. To maximize and find the
posterior estimation of the hidden variables of HIV infected patients. The The above equation (3) holds because 𝛾𝑖 (𝑡) is the expected number of
estimation depends on the assumption of the independent observations transitions from state 𝑖 and 𝑝𝑡(𝑖, 𝑗) is the expected number of transitions
Tree HMM as seen in Figure-1. Transition variables defined as; from 𝑖to 𝑗. Given the above definitions we begin with an initial model
𝑝𝑡(𝑖, 𝑗), 1 ≤ 𝑡 ≤ 𝑇, 1 ≤ 𝑖, 𝑗 ≤ 𝑁 𝜇 and simply it for different states.
𝜋𝑖, = 𝑃𝑟𝑜𝑏𝑎𝑏𝑖𝑙𝑖𝑡𝑦 𝑜𝑓 𝑏𝑒𝑖𝑛𝑔 𝑎𝑡 𝑠𝑡𝑎𝑡𝑒 𝑖 𝑎𝑡 𝑡𝑖𝑚𝑒 𝑡 = 1; = 𝛾𝑖 (𝑡) The Tree HMM model predicts the break down point starts once
patient is infected with the HIV virus as it affects the immune
, 𝐸𝑥𝑝𝑒𝑐𝑡𝑒𝑑 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑡𝑟𝑎𝑛𝑠𝑖𝑡𝑖𝑜𝑛𝑠 𝑓𝑟𝑜𝑚 𝑠𝑡𝑎𝑡𝑒 𝑖 𝑡𝑜 𝑗 system. As the infected patient passes from one state to another the
𝑎𝑖𝑗 = likelihood of high risk is more in the HIV patient as observed in
𝐸𝑥𝑝𝑒𝑐𝑡𝑒𝑑 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑡𝑟𝑎𝑛𝑠𝑖𝑡𝑖𝑜𝑛𝑠 𝑓𝑟𝑜𝑚 𝑠𝑡𝑎𝑡𝑒 𝑖
Table-1 and Figure-2. The hidden nature of the virus is clearly
∑𝑇𝑡=1 𝑃𝑟(𝑖, 𝑗) observed in Table-1, stating the infected patient has a very less
= ……… (4) chance of survival as and when the time increases. The immune
∑𝑇𝑡=1 𝛾𝑖 (𝑡)
system drops more quickly in the initial inter arrival time when
compared with the later time interval. The model finally concludes
, 𝐸𝑥𝑝𝑒𝑐𝑡𝑒𝑑 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑡𝑟𝑎𝑛𝑠𝑖𝑡𝑖𝑜𝑛𝑠 𝑓𝑟𝑜𝑚 𝑖 𝑡𝑜 𝑗 𝑤𝑖𝑡ℎ 𝑛 𝑜𝑏𝑠𝑒𝑟𝑣𝑒𝑑
𝑏𝑖𝑗𝑛 = that, assessing the HIV patients at the initial time and state the
𝐸𝑥𝑝𝑒𝑐𝑡𝑒𝑑 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑡𝑟𝑎𝑛𝑠𝑖𝑡𝑖𝑜𝑛𝑠 𝑓𝑟𝑜𝑚 𝑖 𝑡𝑜 𝑗 likelihood of risk is less. As the time and state increases the
likelihood of risk increases compared to the previous state.
∑𝑡:𝑂𝑡=𝑛,1≤𝑡≤𝑇 𝑃𝑟(𝑖, 𝑗)
= ……… (5)
∑𝑇𝑡=1 𝑃𝑟(𝑖, 𝑗) Figure–2 Three states of HIV infected patient’s risk
Results and Discussion

The three states are defined as; First state the initial state of HIV infection
identified and under treatment (i.e., the person identified as HIV positive
starting from the initial time period); Second State identified as the person
infected under HIV after some period of initial time period; Third state
observes the later time period of the infected person (i.e., the HIV infected
persons are not aware of the diseases in them and identified it very lately).
A simulation study was done to assess the goodness of fit for the model.
The simulation was carried out using Mathcad Software and the graphical
representation was figured through Minitab software.
Table–1 HIV infected patients risk observed in the three states

as time increases
Time Per First State Second Third

Week State State
This simulation study attempts to make predictions of HIV patients
1 2 3 4
and assess the performance of the model. For this, the dataset had
2 1.5 1.5 2 taken from the World Health Organization Website. [2] The dataset
had categorized into three subparts and renamed by states. The
3 1.33 1 1.333 states are: S1 also known as the first state, is the initial state of HIV
infection identified and under treatment. In this way S2, second
4 1.25 0.75 1 state is the person infected under HIV; S3 is the state observes the
later time period of the infected person.
5 1.2 0.6 0.8
Using the three states, the risk for the patients in the above states in
6 1.16 0.5 0.667 every week was estimated and tabulated as shown in Table-1. The
same estimated values were visualized using a three-dimensional
7 1.14 0.429 0.571
graph as shown in Figure-2. Thus, the Hidden Markov Model was
8 1.12 0.375 0.5 trained and the prediction was made using the Baum Welch
Algorithm. [13, 14] The performance of the trained model was
9 1.11 0.333 0.444 assessed. The risk of the patients in the three states also discussed.
10 1.1 0.3 0.4 Conclusion

20 1.05 0.15 0.2
The HIV virus carries projection of significant global population
30 1.03 0.1 0.133 with specific estimations of the mathematical results of
evolutionary methods which was presented in Tree HMM model.
40 1.02 0.075 0.1 Our model assumes that the HIV infected patients are possibly of
high risk in after state one. This HIV infected patients are of a single
50 1.02 0.06 0.08 controlling strain in each state of the Tree HMM model. The HIV
virus length in the nth state within regrouping is uncertain to occur
in each state of the given model. The inter arrival censoring between 11. Rabiner LR. A tutorial on hidden Markov models and selected
each state is essential in each infected HIV patients. The outcome of applications in speech recognition. Proceedings of the IEEE
this works states that health care expert can use this model for effective 1989;77(2):257–286. DOI: 10.1109/5.18626
patient cares. 12. Baum LE. An Inequality and Associated Maximization
Technique in Statistical Estimation for Probabilistic Functions
Authors’ contributions: MR, SKK, BR: Conception and Study of Markov Processes. Inequalities and Maximization Technique
design; MR: Acquisition of Data; MR, SKK, BR: Data processing, 1972;3:1-8. Available from:
Analysis and Interpretation of Data; All authors MR, SKK, BR were https://files.library.northwestern.edu/public/Files/Baum.pdf
drafting the article, revising it for intellectual content; All authors were 13. Baum LE, and Eagon JA. An Inequality with Applications to
checked and approved of the final version of the manuscript. Statistical Estimation for Probabilistic Functions of Markov
Processes and to a Model for Ecology. Bulletin of the American
Here, MR – Mahalakshmi Rajendran; SKK – Senthamarai Kannan Mathematical Society 1967;73:360-363. DOI: 10.1090/S0002-
Kaliyaperumal, BR – Balasubramaniam Ramakrishnan 9904-1967-11751-8
14. Baum LE, and Petrie T. Statistical Inference for Probabilistic
Source of funding: None Functions of Finite State Markov Chains. The Annals of
Mathematical Statistics 1966;37:1554-1563.
Conflict of interest: None DOI: 10.1214/aoms/1177699147
15. Baum LE, and Sell GR. Growth Transformations for Functions
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227. Available from: https://msp.org/pjm/1968/27-2/pjm-v27-
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2021] Technique Occurring in the Statistical Analysis of Probabilistic
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[Accessed on: 05 August 2021]
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Mythreyee M. Declining trend of HIV infection among the rural
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PMID: 26878073

Determination of Hazard State of Non-Communicable Diseases Using
Semi-Markov Model
Balasubramaniam Ramakrishnan1, Senthamarai Kannan Kaliyaperumal2 , Mahalakshmi Rajendran3
1, 3 Research Scholar, Department of Statistics, Manonmaniam Sundaranar University, Abishekapatti, Tirunelveli, Tamil Nadu, India.
2Professor of Statistics, Department of Statistics, Manonmaniam Sundaranar University, Abishekapatti, Tirunelveli, Tamil Nadu, India.
.
Abstract
Background: The developed Semi-Markov model with Kumaraswamy Exponentiated Inverse Rayleigh distribution examined patients with
hypertension, heart diseases, smoking habits and Stroke, is measured from one state to another.
Materials and Methods: Patients with Non-Communicable disease described through Kumaraswamy Exponentiated Inverse Rayleigh
distribution.
Results: The estimated parameters of Semi-Markov model with this distribution predicted by the maximum likelihood estimation for each
successive state observed significant abnormality. The data noted predicts established model is a good fit for many attributes that prevailed
in studied data. The developed Semi-Markov model is a best fit for non-Communicable disease in the long run of patient’s data. Through
different Exponential family distribution, one can look at for further perfect fit of patient data, which is to be estimated.
Conclusion: This model can be an alternative method to estimate the effect of patient in survival analysis, where it will be effective in time
consumption in medical field.
Keywords: heart diseases, hypertension, Semi-Markov processes, smoking, stroke
Corresponding Author: Mr. Balasubramaniam Ramakrishnan,

Research Scholar, Department of Statistics, Manonmaniam
Sundaranar University, Abishekapatti, Tirunelveli, Tamil Nadu, India.
Email ID: bala.rcbe@gmail.com
Introduction
The World Health Organization (WHO) has predicted that Non-Communicable Diseases (NCDs) get about 40 million
individuals worldwide each year [1]. Four major syndromes, the essential focus of worldwide NCDs response has been; cancer,
chronic respiratory infections, diabetes and heart disease. The NCDs response also concentrates on four key risk issues;
harmful practice of liquor, physical lethargy, tobacco usage and unhealthy diet are the issues perceived by the WHO as
significant elements leading to NCDs. In this article, through Semi-Markov Process (SMP) the four major NCDs are depicted
with real-life data to find out the survival probability of patients.
Stroke in the human body immune system reveals the identical manner as a heart disease, but this stroke happens in brain
(blood flow gets interrupted) which lead to damage. Worldwide, heart diseases cause approximately one third deaths [2]. 15
million people worldwide suffer from stroke each year, with the amount of stroke deaths increases every year [3]. This stroke
could even raise for the next upcoming 20 years, specifically in the developing countries [4]. Examining effectiveness in human body and
health fitness is an urgent proposal to lesser the burden. Hypertension is a leading risk factor for cardiovascular disease, and randomized
cases have determined that antihypertensive drug therapy reduces risks of stroke, cardiovascular disease, heart failure and total mortality [5].
How to cite this article: Ramakrishnan B, Kaliyaperumal SK, Rajendran M. Determination of Hazard State of Non-
Communicable Diseases Using Semi-Markov Model. Int J Med Sci and Nurs Res 2021;1(2):23-28
Ramakrishnan B et al. Determination of Hazard State of Non-Communicable Diseases Using Semi-Markov Model
Some experimental investigations have showed that relationship of Transition probability, 𝑃𝑖𝑗 satisfy the conditions, as 𝑃𝑖𝑗 ≥ 0,
blood pressure to cardiovascular risk is not linear, with no better ∑ 𝑃𝑖𝑗 = 1 for all 𝑗. As the Marko process does not deal with the
devaluation in risk or perhaps indeed an extended risk identified with population sizes of region at time of the state transitions the random
low blood pressure. process, esteems the transition population size of region at
Getting blood pressure control (BP) in victims with hypertension reduces (𝑇𝑛+1 − 𝑇𝑛 ) in a SMP and distribution that satisfies:
the risk of stroke and ischemic heart disease [6, 7, 8]. Barriers to
hypertension control take place at the stages of the patient, physician and 𝑄𝑖𝑗 (𝑡) = 𝑃(𝑋𝑛+1 = 𝑗, 𝑇𝑛+1 − 𝑇𝑛 ≤ 𝑡⁄𝑋𝑛 = 𝑖) … … (2)
health system, and comprise inadequate approach to high-quality care,
physician and patient unwillingness to enhance therapy for
The Kumaraswamy Exponentiated Inverse Rayleigh (KEIR) [16]
uncontrollable BP (i.e., inertia), and treatment non-adherence [9]. The
probability density function (pdf) of population size of region time in
relative influence of these various obstacles is recognized and is not
a particular state ′i′ before passing to state ′j′ given in eqn. (2)
focused on by Joint national committee [10]. The increased incidence of (b−1)
hypertension is due to a combination of behavioral risk factors, age, and 2abαθ − θ2 aα −
θ aα
fij (t) = 3
(e x ) [1 − (e x2 ) ]
population expansion, including recurrent stress, being overweight, a x
lack of physical activity, hazardous alcohol use, and an unhealthful diet
[11]. x ≥ 0; a, b, α, θ > 0 … … (3)
The cumulative density function (CDF) 𝐹𝑖𝑗 (𝑡), along with

Materials and Methods:
corresponding survival function (SF) eqn. (4); of waiting time in state
𝑖, 𝑆𝑖 (𝑡) observed in eqn. (5)
Semi – Markov Model:
b
θ aα
− 2
This methodology used for the study are elucidated as follows. In 𝐹𝑖𝑗 (𝑡) = 1 − [1 − (e x ) ] … (4)
Stochastic process, the theory of Semi-Markov Model (SMP) is an area
which develops rapidly in the past few decades. The fact is that SMP Where 𝐹𝑖𝑗 is the historical frequency of transition from state𝑖 to
provide a natural useful model in real life systems of examining, standby state𝑗.
systems, stochastic mechanisms and many others. P. Levy the author
who individually and instantaneously introduced the SMP10. Derivation θ aα
b
− 2
of SMP starts from the Markov renewal process with special case of 2- 𝑆𝑖𝑗 (𝑡) = [1 − (e x ) ] … (5)
dimensional Markov sequence. SMP concept is a normal derivation from
the Markov chains [12].
A standardized regular Markov chain, with discrete set of states denotes; The parameters of the KEIR distribution are predicted through the
E= 0, 1, 2, 3… is simplified by a matrix 𝑄 = 𝑞𝑖𝑗 ; 𝑖, 𝑗 ∈ 𝐸 where; maximum likelihood estimation (MLE) method.
Log likelihood function is observed in eqn. (6)

𝑞𝑖𝑗 = −𝑞𝑖 = − ∑ 𝑞𝑖𝑗
𝑗∈𝐸, 𝑖≠𝑗 𝑙 = 𝑛𝑙𝑜𝑔(2) + 𝑛𝑙𝑜𝑔(𝑎) + 𝑛𝑙𝑜𝑔(𝑏) + 𝑛𝑙𝑜𝑔(𝛼) + 𝑛𝑙𝑜𝑔(𝜃)
𝑛
Markov chain derives; the 𝑖𝑡ℎ state

of a particular system having a − ∑ 𝑙𝑛𝑥𝑖3
random time 𝜃𝑖 distributed by the exponential family law with, 𝑖=1
𝑛 𝑛 𝜃𝑎𝛼
parameter 𝑞𝑖 and by the system passing the 𝑗𝑡ℎ state with a probability 𝑎𝛼𝜃
𝑞𝑖𝑗 −∑ + (𝑏 − 1) ∑ 𝑙𝑛 [1 − 𝑒 𝑥𝑖2 ] … (6)
𝑝𝑖𝑗 = 𝑖, 𝑗 ∈ 𝐸. 𝑥𝑖2
𝑞𝑖 𝑖−1 𝑖=1
The methods and designing of transition probabilities of SMP defined The MLE obtained by solving the above non-linear system of eqn.
as: Firstly, considering a model with 𝑘 states belonging to finite state (6). In eqn. (6) we do not have the exact solution, from the large
space 𝐸 = {1, 2, . . . , 𝑘}; where,(𝑋0 , 𝑋1 , 𝑋2 , . . . , 𝑋𝑛 ) ∈ 𝐸; be the sample property of ML Estimates; MLE 𝜃̂ can be treated as being
sequential states where the 𝑛 visits a random process, when (0 = 𝑇0 <
𝑇1 < . . . < 𝑇𝑛 ) are the sequential time to enter into each of these five approximately normal with mean 𝜃 and variance covariance
states. Therefore, the probability of n transitions from the first state to matrix equal to the inverse of the expected information matrix.
fifth state, denoted by 𝑖 𝑡𝑜 𝑗, the model fixed is been defined as in eqn.
(1). i.e., √𝑛(𝜃̂ − 𝜃) → 𝑁(0, 𝑛𝐼−1 (𝜃). 𝐼(𝜃)is the information matrix
then its inverse of matrix is 𝐼 −1 (𝜃) provides the variances and
𝑃𝑖𝑗 = 𝑃(𝑋𝑛+1 = 𝑗⁄𝑋𝑛 = 𝑖) … … (1) covariance’s.
̂), 𝛼̂ ± 𝑍𝛼 √𝐼𝛼𝛼 ̂), 𝑏̂ ± 𝑍𝛼 √𝐼𝑏𝑏

−1 ̂ The accompanying five state boundaries were set up for the model
𝑎̂ ± 𝑍𝛼 √𝐼𝑎𝑎
−1 (𝜃 −1 (𝜃 (𝜃 ), 𝜃̂ ± 𝑍𝛼 √𝐼𝜃𝜃
−1 ̂
(𝜃) … (7)
2 2 2 2 turn of events, as displayed in Figure-1, for the accompanying
reasons:
The significance providing by iterations as observed in equation (7), with
likelihood functions as the ideal solution to the parameters. S1: Patients Age and Gender
S2: Patients with Hypertension
Table-1, is a typical Markov chain state consistent to transition matrix 𝑃 S3: Patients with Heart Diseases
with the interactive population size of region transition probabilities S4: Patients with Smoking Habits
change from the first state observation, as observed in eqn. (3) S5: Patients with Stroke
1−𝑎 𝑏 𝛼 𝜃 Figure – 1 A five-state model data from the Hepatitis C

𝛼 1−𝑏 𝜃 𝑎 Prediction Dataset
𝑃𝑖𝑗 (𝑡) = [ ] … (8)
𝑏 𝜃 1−𝛼 𝑎
𝜃 𝛼 𝑏 1−𝜃
Table 1. The transitions between the phases of the process

occur at regular intervals.
Patients has Patients has Patients has Patients

Hypertension Heart Smoking Habits had a
Diseases Stroke
498 276 1674 249
214 36 214 66
36 138 138 27
214 138 1674 112 In the Assembled Realm, the Clinical Exploration Gathering
Malignancy Family Appraisal Exploration (MRC CFAS) is an
66 47 112 249 enormous size multi-focus longitudinal glance. [15]
The examinations, what began inside the late 1980s and covered a
specialist example of thirteen 004 individuals from the more
The rows of eqn. (8), signifies the present four states of the model use seasoned organization, transformed into intended to explore
withdrawal and renormalization, of Stroke processes and long-term dementia and intellectual decrease inside the matured people. The
process, the columns represent the four statuses (S2, S3, S4 and S5) on the realities have also been utilized to concentrate on various afflictions
state. The records in the first row access the probabilities of hypertension along with sadness [16] and actual debilitation [9], notwithstanding
will stay to stroke (1 – a) or leave (a), and thus move into the second state to view the solid energetic future [2] of the members. The meetings
b. Following the first row, the second row provides probability an with people have been acted in extra of 46 000 cases to far. There
individual in b will be in the next observation, having heart diseases in are more insights on the gander plan close by on the web
state (1 – b). The third row gives the probability of smoking habits (1 − (www.Cfas.Ac.United realm). To take a gander at getting more
𝛼) and forth state had a stroke process (1 − 𝜃). [13] seasoned inside the more established people, the creators utilized a
three-country variant with the conditions of "healthy," "records of
stroke," and "death." The conditions of "refreshing," "history of
Results and Discussion stroke," and "death toll" have been totally addressed through change
powers in a three-state model (country three).
For the taken dataset [14], with the utilization of information factors like
segment attributes and various sicknesses, the dataset might be used to In Figure–2, you could see an illustration of the multi-state model.
foresee whether a patient is probably going to experience the ill effects of It very well may be energizing to look how the amount of time that
stroke. Every section in the dataset contains data about the patient that is elapses following a stroke impacts the charge of downfall. We
pertinent to that segment. concentrate on a subset of the MRC CFAS data, explicitly records
from the Newcastle place. This data set may be known as the MRC
The accompanying five state boundaries were set up for the model turn of CFAS for the length of this paper. This subset conveys data on 2316
events, as displayed in Figure-1, for the accompanying reasons: individuals who had been 65 years or more established at the time
in their meeting, which occurred among 1991 and 2003. These The standard length of notice up spans changed into years, and the
individuals have been exposed to however much nine meetings middle wide assortment of meetings directed was with regards to
throughout which they have been mentioned on the off chance that member. Figure 2(c) portrays the circulation of time between the hour
they had a stroke for the explanation that their past visit, and their age of the last meeting and the hour of destruction or appropriate control,
at the hour of the meetings changed into noted. Even after the whichever happens first.
conviction of the subsequent period, the exact dates of death are all
things considered close by. At pattern, the people's stroke history Figure – 2(c) Unmistakable information on the time between
became explored, and they gave measurements on their age (A),
sexual orientation (G; 0 for women and 1 for folks), long periods of
the last meeting and either demise or control are likewise
tutoring (E; zero for under 10 years and 1 for a considerable length of accessible
time or extra), and smoking distinction at 60 years old years (S; zero
for non-smokers or ex-smokers and 1 for current individuals who
smoke). By characterizing smoking along these lines, it's miles less
potentially that people could give up due to disease.
After the age of 60, smoking conduct won't change. The yearly report
on smoking-related direct and perspectives distributed in 2005 [6]
saw that the people who smoke after the age of 65 years are the most
un-plausible of all to need to stop, and the individuals who do wish
to stop are significantly more liable to have accomplished so before
the age of 65 years. People contrasted in expressions of the number
of meetings they had and the measure of time they spent among
interviews. Figures 2(a) and a couple of 2(b) portray the wide
assortment of meetings finished through anyone, just as a dispersion
of the time of follow-up spans, separately.
Frequencies of change are summed up from the dataset. The answers for
Figure – 2(a) Unmistakable information on the quantity of the change probabilities μ_(ij) (t) at time t utilizing the calculation are
meetings per individual gotten with S5 states: T = 6178, progress likelihood matric as given in
Table-1.
Table-1 shows the recurrence dispersions of sets of progressive states

saw in the records test. These frequencies identify with the number of
times a person had an assertion in country I followed through an
assertion in country j for every one of the 2 states I and j and for the
entirety of individuals in the example. In light of the varieties inside the
states' definitions, there have been no advances from country 2 to
country 1. An assortment of likely detectable examples of follow-up for
each body inside the MRC CFAS longitudinal investigations have been
perceived inside the notice. A person can, as an occurrence, be in
advantageous wellbeing while the analyze begins off evolved however
at that point go through a stroke inside the next years and pass on or stay
alive while the examiner closures, or the individual in question can be
Figure – 2 (b) Unmistakable information on the length in superb wellness however at that point experience a stroke and either
among meetings pass on before the view closes or be legitimate controlled, depending on
the cases. Also, if an individual is accounted for to have had a stroke
toward the beginning of the exploration, it's miles conceivable that the
person might live to tell the story or pass on before the conviction of the
investigate.
Figure-3, 4, 5, 6 portray a graphical portrayal of those various examples,

which can be delegated free examples A–F. In styles A, B, E, and F, it
is recognized that a shift from country 1 to country 2 has taken region
sometime. In any case, on account of examples C and D, the ways of
life of oversight makes it hard to decide if or presently not this kind of
shift has occurred. As a final product, there are capacity results. It is
possible that an individual moved to realm 2 anyway became in no way,
shape or form reported on this nation because of restriction, or that a
Figure 3: Effect on Patients from State S1 to S2 Figure 4: Effect on Patients from State S1 to S3
At the time of the baseline study, the median age of the participants
was 74 years. According to the research design, people above the
age of 75 were over-sampled in order to obtain an equivalent number
of participants as those aged 65–74 years at the beginning of the
study. Circling back to every member was booked to happen about
like clockwork, as indicated by the review's plan. This present
person's specific season of death has been set up. To represent the
way that it is hard to build up the specific season of the progress
from condition 1 to state-2, the information is exposed to separating
on the left, right, and stretch tomahawks, individually. It is
conceivable that exchanges from state-1 to state-2 were happened
yet were not found preceding demise or right blue penciling toward
the finish of the subsequent period, yet this has not been shown.
Advances from state-1 to state-2 that happen before the review's
beginning date are left edited; else, they are left shortened. For the
situation that people are joined up with the exploration, advances
from state-1 to state-2 that happen before the review's beginning date
are left controlled. Prohibition from the examination might be set
off by the passing of a member before to the review's initiation.
Among the five provinces of SMP, the Stroke state S5 is viewed as

Figure 5: Effect on Patients from State S1 to S4 Figure 6: Effect on Patients from State S1 to S5
a retaining state; i.e., when a patient isn't truly in a functioning state,
she/he won't ever be in the others states and rather remains there
a person remained in realm 1 until the person passed on or the state until the end of time. The S5 state stroke is classified Danger state
turned out to be pleasantly blue-penciled. The estimated transition and the others states S1, S2, S3 and S4 moderate states.
intensities for the Semi Markov Model are mentioned in Table-2.
Conclusion
Table: 2. The estimated transition intensities for the Semi
Markov model The developed Semi-Markov model is a best fit for non-
Communicable disease in the long run of patient’s data. Through
different Exponential family distribution, one can look at for further
States Patients has Patients Patients Patients
perfect fit of patient data, which is to be estimated. There are many
at time Hypertension has Heart has had a more non-Communicable diseases which needs to be estimated in
𝑡𝑖𝑗 Diseases Smoking Stroke the goodness of fit in the future. This model can be an alternative
Habits method to estimate the effect of patient in survival analysis, where
State 1 0.485 0.435 0.439 0.354 it will be effective in time consumption in medical field.
State 2 0.208 0.056 0.056 0.095
Authors’ contributions:
State 3 0.035 0.217 0.037 0.038
State 4 0.207 0.217 0.439 0.159 BR, SKK, and MR: Conception and Study design; BR: Acquisition
of Data; BR, SKK, MR: Data processing, Analysis and
State 5 0.065 0.075 0.029 0.354 Interpretation of Data; All authors – BR, SKK, MR were drafting
the article, revising it for intellectual content; All authors were
The Semi Markov transitional probabilities through KEIR for the checked and approved of the final version of the manuscript.
effect of Patient’s with age and gender determined by Patient’s
Hypertension, Patient’s Heart Diseases, Patient’s Smoking Habits Here, BR – Balasubramaniam Ramakrishnan; SKK – Senthamarai
and Patient’s with stroke is examined. The threshold for each Kannan; MR – Mahalakshmi Rajendran
transition intensities are examined with the conditional probability
that the patient will not survive after the time. Among the four non-
Communicable diseases the hazard for the Patient’s having a Stroke Source of funding: None
is the first one to look for, as the survival of chance is minimal. The
Patient having Stroke the next hazard was heart disease, then with Conflict of interest: None
Hypertension and Smoking habits was found.
References: 15. Melzer D, McWilliams B, C. Brayne C, Johnson T, Bond J.

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JP, et al. Risks of untreated and treated isolated systolic
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August 2021]

Availability, Utilization of Iodized Salt, Status of Iodine Deficiency
Disorder and Level of Iodine Content at Households’ Salt among
Coastal Areas of Population in India
Senthilvel Vasudevan1 , Murugan Natesan2

1AssistantProfessor of Statistics, Department of Pharmacy Practice, College of Pharmacy, King Saud Bin Abdulaziz University for Health
Sciences, Riyadh, Saudi Arabia. 2Professor, Department of Community Medicine, Pondicherry Institute of Medical Sciences, Kalapet,
Pondicherry, India.
Abstract
Background: Iodine deficiency disorder is common public health problem in developed and developing countries. In Worldwide, nearly
1Senior 2Assistant Professor,
70% ofResident, Department
the households of Anesthesiology,
only using adequate iodizedChettinad Hospital
salt in their And
regular Research
food. Institute,
To estimate theChennai,
householdTamilnadu, India.prevalence
salt utilization, of goiter,
3
Department
status of iodine
of Anesthesiology,
deficiency disorder,
Chettinad
and toHospital
find theAnd
iodineResearch
level at Institute,
householdChennai,
level in the
Tamilnadu,
study areas.
India. Professor and HOD, Department of
Materials and Chettinad
Anesthesiology, Methods:Hospital
We haveAnddone a community-based
Research observational
Institute, Chennai, Tamilnadu,studyIndia.
on IDD in the coastal areas of Villupuram District, Tamil
Nadu with examined households salt in 1233 households in selected eight villages. All data were analyzed using Chi-Square test. p–
value<0.05 was considered as statistically significant.
Results: Totally 1233 households were recruited and incorporated in this study. Among 1233 households, male 385 (31.2%) and female
848 (68.8%). The male and female age-group was showed statistically highly significant association with p<0.01. Out of 1233 individuals,
141 (11.4%) were found as total goiter. The prevalence of goiter was 105 (12.4%) in female than male was 36 (9.4%) and no statistical
association between gender among goiter prevalence (p>0.05).
Conclusion: From our present study findings, we have concluded that majority of the study population was used iodized salt in their regular
food. But, very less adequately iodized salts were available nearby study areas. Nevertheless, majority of the households didn’t know about
the benefits about the usage of iodized salt. Health education is needed in to the shopkeepers and local vendors. This will be conducted by
non-Governmental organization, Government organization and other nearby medical colleges.
Keywords: household salt, utilization, iodine, iodine deficiency disorder, coastal areas
Article Summary: Submitted: 02-October-2021 Revised: 20-November-2021 Accepted: 10-December-2021 Published: 31-December-2021
are licensed under the identical terms.
http://ijmsnr.com/
Corresponding Author: Dr. Senthilvel Vasudevan,
Assistant Professor of Statistics, Department of Pharmacy Practice,
College of Pharmacy, King Saud Bin Abdulaziz University for Health
Sciences, Riyadh, Saudi Arabia. Email ID: vasudevans@ksau-hs.edu.sa
Introduction
Iodine is a very important vital micronutrient in human food in their routine life and it needs to produce thyroid hormones. It is needed in all
stages of life. [1] In Worldwide, nearly 70% of households only use adequate iodized salt in their daily food. [2, 3] Changes needed
immediately in the iodized salt coverage among countries. [4] India is the first nation to initiate salt with iodized salt but there are some big
problems in implementing it through the National programme. So, ensuring the availability of iodized salt, utilization through monitoring
systems. [5] In another one review on the National coalition for sustained optimal iodine intake by Yadav et al [6] has reported India could
achieve universal salt iodization by 2015.
Iodine deficiency in a household's salt is affecting a child's growth, intelligence quotient (IQ) level and in many ways. [7] The consumption
of iodine per day for up to 6 months, infants up to 1 years, up to 8 years, up to 13 years, up to 18 years and adults is 110, 130 mcg, 90 mcg,
120 mcg, 150 mcg and 150 mcg respectively. [8] Iodized salt coverage was very low in Tamil Nadu. [9] If the pregnant women don’t consume
the adequate level of iodine 250 g/per day [10] in their food as per WHO recommendation, then the fetal growth, child initial years’ growth,
child’s brain development would be affected severely. Iodine is an important micro nutrient in food to the human brain development and
reduce the abnormalities in the pregnant women, child bearing, enough children brain and IQ development. [25] We contacted this study to
find the iodine content of household salt, its availability and its effect in the study areas of Tamil Nadu. Our study is the first study in this
study area. Main objectives of the present study were to estimate the household salt utilization and availability of iodized salt, status of Iodine
How to cite this article: Vasudevan S, Natesan M. Availability, Utilization of Iodized Salt, Status of Iodine Deficiency Disorder and Level
of Iodine Content at Households’ Salt among Coastal Areas of Population in India. Int J Med Sci and Nurs Res 2021;1(2):29–37
Vasudevan S et al., Availability, Utilization of Iodized Salt, Status of Iodine Deficiency Disorder and Level of Iodine Content at Households’ Salt
Deficiency Disorder and among gender, and level of iodine content at Sciences, Rural Health Center, Anaichikuppam in Marakkanam.
households’ salt among coastal areas of population in Villupuram District, Development Block of Villupuram district, Tamil Nadu, India.
Tamil Nadu, India.
Inclusion Criteria: In our study, we have incorporated all residents
Materials and Methods: living in eight villages with one year and above aged ≥3 years.
Because, what type of difficulties or effects would happen to the
children with aged 3 or more. To be found by this study.
Study design, area and period of conducted this study: We have done
a community-based, cross sectional study in the area of Anaichikuppam, Exclusion Criteria: Children with aged <3 years and those who
Pondicherry Institute of Medical Science Rural Health Centre, were affected by chronic diseases and severe communicable
Marakkanam block of Villupuram district, Tamil Nadu. The data was diseases.
collected in the one-month period of February 2012.
Estimation of sample size for the study: As per existing literature
Allocation of households among study areas: We have collected by Roy et. al. [11] in his study he has found/explicated that the
information from 1233 households by using convenient sampling method households with adequately iodized salt of >15 ppm was 62.4%,
and included in our present study. In this present study, we have randomly statistical power 80%, allowable error 5% and level of significant
selected and included 8 villages out of 16 villages namely, Kil 95%, the required sample size with formula, required minimum
Pudhupattu, Koonimedu, Chettikuppam, Anumandai, Kil Pettai, sample size (N) = 4pq/d2 = 965 households. But we have included
Parichamedu, Alapakkam, and Orani as shown in Figure–1. 1233 households in our study. One responsible person from each
household was interviewed and recorded the usage of iodized salt in
Selection of study participants: We have recruited and included all their respective households. 1233 individuals available at the time
individuals those were living in the Pondicherry Institute of Medical of face-to-face survey in these households were examined for goiter.
Figure–1 Distribution of villages in the study area
About the questionnaire: The questionnaire was framed by the The level of iodine is adequate in the food salt then only all free from
faculties of the department and it had three parts. Part–A: Basic and some diseases like thyroid enlargement and goiter.
Socio-demographic characteristics: name of village, household
number, name of the family members, age, gender, religion, educational Data Management and Statistical Analysis Used: The data were
level, source of drinking water and the income of the family. Part–B: organized, compiled and formulated by Microsoft Excel 2010 [Office
Grading of Goiter: The goiter grading of all the individuals available 360, Microsoft Ltd., USA] and were analyzed by using statistical
in the household was recorded. The questionnaire was tested properly software SPSS 21.0 Version [IBM SPSS Ltd., USA]. The continuous
and discussed through presented that in front of the Department variables were expressed using descriptive statistics like mean, and
faculties and in the institutional research committee members and standard deviation and categorical variables were expressed using
corrected according to the comments. The examination was done frequency and proportions. To find the association between gender and
respondents stood in front of the examiner, who looked carefully at the goiter by using bi-variate analysis chi-square test. p<0.05 was fixed
neck for any sign of visible thyroid enlargement. as level of significant.
Grading of Goiter was graded according to the WHO classification Ethical consideration: Ethical approval was taken from the
as follows: Institutional Ethics Committee of Pondicherry Institute of Medical
Sciences, Pondicherry before conducting our study. Proper
Classification of Goiter grading of palpation [12] Grade: 0 No permission was obtained from the village administrative officer and
palpable or visible goiter; Grade-1: A goiter that is palpable but not village head to conduct our study. We have received written consent
visible when the neck is in the normal position; and Grade-2: A form each in-charge of the household in the study areas. We have
swelling in the neck that is clearly visible when the neck is in a normal explained in the local language TAMIL about the purpose of the study,
position and is consistent with an enlarged thyroid when the neck is its importance, potential risks and benefits of participating, procedure
palpated a thyroid gland will be considered goitrous when each lateral of maintaining confidentiality to all the study participants in this
lobe has a volume greater than the terminal phalanx of the thumbs of study. We didn’t get any type of financial from the parent institution
the subject being examined. Part-C: Iodine level of salt at household or from any type of financial institution and we didn’t give any
level: The household salts were tested for qualitatively on spot with incentives to the study participants. Anonymity and confidentiality
MBI kit provided by Government of India and United Nations were ensured throughout the study
Children’s Fund (UNICEF) [13, 14, and 15]. The iodine concentration
was recorded as 0, 7, 15, 30 ppm. Results:
Selection of participants: In the present study, we have approached In this present study, we have visited and planned to conduct the study
1356 households in the 8 selected villages, 1233 households were of totally 1356 households at the time of study period in the selected 8
recruited by face-to-face interviewed with pre-designed and pre-tested villages. But, totally 1233 households were selected from 8 villages.
questionnaire in the local language TAMIL. Totally, 25 under graduate Out of 1233 households, 135 (10.95%) households were from Kil
medical students those who were in the seventh semester were trained Pudhupattu, 422 (34.23%) Koonimedu, 86 (6.97%) Chettikuppam,
for two weeks by teaching staffs of Department of Community 233 (18.89%) Anumandai, 156 (12.65%) Kil Pettai, 118 (9.57%)
Medicine. Data were collected by trained students under the supervision Parichamedu, 37 (3.00%) Alapakkam, and 46 (3.74%) households
of the Department of Community Medicine faculties, post graduate from Orani were interviewed by house-to-house survey were
medical students, and with the help of interns and social workers of the randomly selected and included in our present study as shown in
RHC of PIMS. Study participants were the residents of the households Figure – 1. In that, 95 houses were locked due to unavailability of
those who were available using simple random sampling method at the individuals and 28 household’s in-charge refused to participate in our
time of survey. The response rate was 90.9%. study. So, finally we have selected and incorporated 1233 households
in our study. Hence, the non-response rate of our study was
Method of data collection: A house to house survey in the selected 2.2%. After this elimination of these, we have selected and included
villages was done in one-month period. The purpose of the study was 1233 households in our main study. From these households we have
elaborately explained to the study participants. The consenting interviewed 1233 individuals as shown Figure–2.
individuals were included in the study. The proper permission was
obtained from the respective village administration officers and Basic socio-demographic variables of the study population: Totally
authorities before conducting our study. Data were collected only from 1233 households were recruited and incorporated in this study. Out of
the head of the family of each house at the time of data collection by 1233 households, each one house, one responsible person (head of the
using a structured questionnaire. Socio-economic status was determined house) was selected and collected the data through
using the Modified B G Prasad classification of socio-economic status questionnaire. Among 1233 households, male 385 (31.2%) and
2013. The revised Prasad’s Classifications based on 2013 was Social female 848 (68.8%). In our present study, sex-ratio was 1:2.2. Most
Class–I: 5113 and above; Social Class–II: 2557 – 5112; Social Class– of the respondents were female gender and study participants were
III: 1533 – 2556; Social Class–IV: 767 – 1532; and Class–V: less than lying in the age-group in between 21–50 years and very few 20 (1.6%)
767. [16] Iodine level of salt: [17] By rapid kit testing, the level of in the age-group of 61 and above. The association between age-groups
Iodine ≥15 ppm then it is called adequately iodized salt and the level of and gender was shown statistically highly significant with p-value =
Iodine <15 ppm then it is inadequately iodized Salt. 0.006 (p<0.01).
In 1233 surveyed households, 975 (79.1%) were Hindus, 230 (18.7%) between gender among goiter prevalence Chi-Square value = 1.137
were Muslims, and 28 (2.3%) Christian. The water sources of the with p-value = 0.980 (>0.05) as shown in Table – 1.
households bore well, piped water (provided by metro water supply of
Tamilnadu), hand pump and mineral water. The major sources of Utilization of iodized salt in the study areas among households:
drinking water were well 567 (46.0%). According to socio-economic In 1233 households, majority 874 (70.9%) households hadn’t known
status, more than half of the households were under the middle class about the benefits about the usage of iodized salt in their regular food
and more than 1/4th of households was under the lower middle class. and 359 (29.1%) households responded to the perceived benefits of
Very few of the households were under the upper-class group as per using iodized salt. 238 (19.3%) of the households that used iodized
the Modified BG Prasad Classification 2013. salt was good for their health. 28 (2.3%) respondents felt that the
iodized salt is clean as compared to non-iodized salt. It was
Status of iodine deficiency disorder level among households: interesting to note that 15 (1.2%) respondents were aware of the
Among 1233 individuals were spot examined by MBI kit for iodine importance of iodized salt in brain development in children, and
deficiency disorder. Total goiter (Grades 1 & 2 combined) prevalence physical growth of children. Another 12 (1.0%) were answered its
(TGP) was 141 (11.4%). The prevalence of goiter was 12.4% in use is good during pregnancy in women. 8 (0.6%) were to prevent
females than male was 9.4%. But there was no statistical association illness, 6 (0.5%) were it added taste to their food,
Table: 1 Distribution of age-groups among gender for goiter examination (N=1233)
Gender
Total
Chi- Total Goiter Rate
N (%)
Male Female Square N (%)
Age – Groups 1233
385 (31.2%) 848 (68.8%) test value 141 (11.4)
(in years) (100%)
&
Goiter Goiter p - value (2) + (4)
n (%) n (%) (1) + (3)
36 (9.4%) 105 (12.4%)
(1) (3)
(2) (4)
≤ 10 10 (15.4) 1 (14.3) 55 (84.6) 6 (85.7) 65 (5.3) 7 (5.0)
11 – 20 36 (33.0) 4 (25.0) 73 (67.0) 12 (75.0) 109 (8.8) 16 (11.3)
21 – 30 110 (31.8) 8 (20.0) 236 (68.2) 32 (80.0) 346 (28.1) 40 (28.4)
18.087
31 – 40 134 (37.0) 11 (29.7) 228 (63.0) 26 (70.3) 0.006 362 (29.4) 37 (26.2)
p<0.01
41 – 50 55 (25.6) 7 (28.0) 160 (74.4) 18 (72.0) 215 (17.4) 25 (17.7)
51 – 60 32 (27.6) 5 (33.3) 84 (72.4) 10 (66.7) 116 (9.4) 15 (10.6)
61 and above 8 (40.0) 0 (0) 12 (60.0) 1 (100.0) 20 (1.6) 1 (0.7)
Figure: 2 Flowchart of the process of allocation of villages and households in the study area (N=1233)
1 (0.1%) were prevented anomaly, 1 (0.1%) were answered iodized adequate (15ppm and above) iodine salt as shown in Table – 2.
salt was useful to their children’s health, and 44 (3.6%) weren’t aware
about anything of iodized salt and its benefits. In our study, the Place of buying salts and types of salts among households:
overall adequately iodized (≥15 ppm) salt utilized by the households Total 1233 households, 540 (43.8%) were bought powered salt and the
was 26.0% [(320/1233) *100]. Most 960 (77.9%) of the respondents remaining 693 (56.2%) were bought crystalline salt. Hence, more than
did not know if there was any disadvantage in using iodized salt, 244 half of the study population bought crystalline salt. Out of 1233
(19.8%) of the 1233 respondents felt that use of iodized salt was of households, 858 (69.6%) purchased salt in local grocery stores. In
no disadvantage. 18 (1.5%) respondents felt that there was some that, 396 (45.2%) were purchased powered salt and in that, 90 (22.7%)
disadvantage in using iodized salt. The disadvantages as said by the were identified as adequate iodine (15ppm and above) salt. Among
households that 10 (0.8%) were high cost, followed by hypertension 858 households, 462 (54.8%) purchased crystalline salt and in that, 30
3 (0.2%), 1 (0.1%) diabetes mellitus, 1 (0.1%) kidney disease, and 2 (6.5%) were identified as adequate iodine (15ppm and above) salt.
(0.2%) were told the iodized salt caused obesity.
Out of 1233 households, 86 (7.0%) purchased salt in nearby village
Availability of types of salts in the study areas: markets. In that, 71 (82.6%) were purchased powered salt and in that,
Among 1233 households, 540 (43.8%) households were purchased 180 (25.4%) were identified as adequate iodine (15ppm and above)
powered salt and in that 159 (29.4%) households were identified as salt. Among 86 households, 15 (17.4%) were purchased crystalline
adequate (15ppm and above) iodine salt and 693 (56.2%) were salt and in that, 2 (13.3%) were identified as adequate iodine (15ppm
purchased crystalline salt and in that 161 (23.2%) were identified as and above) salt. Out of 1233 households, 160 (13.0%) were purchased
Table: 2 Distribution of place of buying salts and types of salts among households (N=1233)
Packed + Loose Crystalline

Packed Powered Salt
Salt Association Association
Total between
between
Adequately Packed Adequately
Iodine % Powered Salt iodine in
Adequately and Packed powered and
Adequately
Iodine % (159 + + Loose Packed + Total
Iodine %
Place of n (%) (15ppm and n (%) 161)/1233 Crystalline Loose
(15ppm and N (%)
buying salts above) salt Crystalline
540 693 above) = 26.0% salt
(43.8%) 159/540 (56.2%) Chi-Square 1233 (100.0)
161/693 = (2) + (4) Value and Chi-Square
(1) = 29.4% (3) 23.2%
Value and p-
p-value value
(2) (4)
(1) & (3) (2) & (4)
Local
Grocery 396 (45.2) 90 (22.7%) 462 (54.8) 30 (6.5%) 858 (69.6)
Store 14.0
Village
71 (82.6) 18 (25.4%) 15 (17.4) 2 (13.3%) 23.3 86 (7.0)
Market
236.86 168.25
Ambulant
0 (0) 0 (0%) 56 (100) 15 (26.8%) 26.8 56 (4.5)
Vendor 0.0001 0.0001
Public p<0.001 p<0.001

Distribution 11 (7.8) 11 (100%) 149 (92.2) 110 (73.8%) 75.6 160 (13.0)
System
Others
(Puducherry 62 (84.9) 40 (64.5%) 11 (15.1) 4 (36.4%) 60.3 73 (5.9)
Market)
salt through the public distribution system. In that, 11 (7.8%) were benefits of using iodized salt. But, a report of eight states in India
purchased powered salt and in that, 11 (100.0%) were identified as showed a high 45.1% of households avail of iodized salt by awareness
adequate iodine (15ppm and above) salt. Among 160 households, 149 of iodized salt than our present study. [23]
(92.2%) were purchased crystalline salt and in that, 110 (73.8%) were
identified as adequate iodine (15ppm and above) salt. The The availability and utilization of adequately iodized salt was
households’ members purchased salt from ambulant vendors and in mentioned as very low by Taiiku and Mazengia. [19] IDD is a major
other (Puducherry Market) places. Association between Packed problem in 130 countries. So, regular survey relates to the magnitude
Powered Salt and combined packed, loose Crystalline salt was showed of IDD, iodine and its benefits related information, education and
a significant association with Chi-Square Value = 236.86 and p-value communication (IEC) programs conducted and construct a related
= 0.0001 (<0.001) and Association between Adequately iodine in monitoring agency is needed to improve or ensure the iodized salt to
powered and combined packed, loose crystalline salt Chi-Square distribute to the affected communities/areas. [24] Iodine content is low
Value = 168.25 and p-value = 0.0001 were listed in the Table– in the diet salt will cause many problems like hypothyroidism, damage
2. Hence, out of 1233 households 320 (26.0%) were used iodized salt in brain development, mental effects, deaf and dump, psychological
in their regular food. problems, abortion, deficit in fetal growth and also fetal death in
pregnancy period in women. Due to IDD many problems have
Maintenance of salt containers, type of storage of salt, and places happened in pregnancy and in the child births in India. This will be
of storage in the households: Majority 1176 (95.4%) of the eradicated by fortified salt with iodine or double fortified salt with
households used containers with a lid for storing the salt. Whereas, 18 iodine and iron. [25] In our present study, adequately iodized salt (AIS)
(1.5%) used containers without lid and another 27 (2.2%) households utilized by the households of the study areas was 26.0%. But, a study
did not transfer the salt to any container, but stored it in its original in Northwest Ethiopia by Tariku and Mazengia have revealed that the
packet itself and others 12 (1.0%). ie., others meant 8 households utilization of very high adequate iodized salt was 63.3%. [19] Whereas,
were stored the salt in gunny bags and another 4 in paper to wrap the in another one study by Pandav et al. [26] has mentioned 71%
salt. Majority 1080 (87.6%) of the households were stored salt inside households consumed AIS (≥15 ppm) as their diet salt. In another one
the cabinets in their respective kitchen, another 47 (3.8%) stored on study in Bihar by Sankar et al. [27] have mentioned that 40.1%
top of the table, 76 (6.2%) households were stored above the stove, household salt was found as adequate salt. Moreover, as per UNICEF
and 30 (2.4%) were on the floor in the kitchen. Out of 1233 consultant report explicitly that consumption of edible salt with 0 ppm
households, 76 (6.2%) households knew that they weren’t using iodine was 34.5% in Tamil Nadu State as per NFHS III survey 2005-
iodized salt. Only 551 (44.7%) of the respondents knew that they were 06. [28] Whereas 88% of people took iodized salt in their daily diet.
using iodized salt. A significant 601 (48.7%) number of households [29] In the UNICEF report as per year 2006 – 07 had stated that 65.2%
weren’t aware of whether the salt used in their houses was iodized. and 58.2% in upper and lower Egypt respectively; but in year 2014 –
Among 1233 households, 106 (8.6%) households responded for “what 15 it was shown high 72.6% and 74.6% in upper and lower Egypt
reasons they didn’t use the iodized salt in their food?”. 60 (4.9%) of respectively. [30] So, the iodine content is varying from region to
the households responded the reason was rate of the iodized salt was region in India. [31]
more in cost wise; 34 (2.8%) were traditionally buying crystalline salt
from the ambulant vendor, and 12 (1.0%) were responded as not In a study, the level of iodine content was in packaged crushed, crystal
available in the local areas. ie., households’ members responded that salt, and loose crystal salts 31.4%, 58.6%, and 9.9% respectively. [23]
it is very difficult to buy iodized salt because grocery shops are far In our study, out of 1233 households, 693 (56.2%) households were
away from their residing place. bought packed and loose crystalline salts. In that, 66 (9.5%) were
packed and loose crystalline salts. Out of 66 salts, 10 (2.2%) were
packed crystalline salts bought from the local grocery store, in that 2
Discussion: (0.2%) loose crystalline salt, 56 (84.8%) were loose crystalline and it
was provided by a salt ambulant vendor. The adequate iodine content
IDD problems have become a public health problem on a World level. in packed powered salt 29.4%, and total packed, loose crystalline salt
[18] These IDD problems are present throughout the country India. In was 23.2%. To eliminate the iodine deficiency and to estimate the
our present study, female gender was more than male gender. Similar iodine nutrition among countries by conducting nationwide surveys.
type of results was revealed by Tariku and Mazengia conducted in [20] The main limitations of the study were those who were available
Northwest Ethiopia. [19] In this study, total goiter prevalence (TGP) in the household’s maximum women. Some households were closed
was 11.4%. In the year 1992 – 2002 the TGP was estimated in the due to working days.
rage of 17.6 – 18.2% by World Health Organization (WHO). [20] In
our study, 26% of a household's salt contained adequate iodine Conclusion:
content. Whereas, a study by Kapil in the year 2001 had mentioned
high, ie, adequate salt (≥15 ppm) was used in 35% of households in From our present study findings, we have concluded that the majority
Kanchipuram district. [21] Moreover, in another one study by Deepika of study population used iodized salt in their regular food. But, very
et. al. had shown very high adequate iodine content in 3/4th of less adequately iodized salts were available in the study
households’ salt in Prakasam district, Andhra Pradesh. [22] In our area. Nevertheless, the majority of households didn’t know about the
study, more than 1/3rd of households responded to the perceived benefits about usage of iodized diet salt. Health education is needed in
selling adequate iodized salt in nearby grocery 6. Yadav K, Chakrabarty A, Rah JH, Kumar R, Aguayo V, Ansari
stores/shops/malls/supermarkets and to improve knowledge about MA et al. The National Coalition for Sustained Optimal Iodine
iodized salt among shopkeepers and local salt vendors. Iodized salt intake (NSOI): a case study of a successful experience from India.
provided through the public delivery system to study rural areas. This Asia Pac J Clin Nutr 2014;23 Suppl 1:S38-S45. PMID: 25384725
will be done through health education in schools, colleges and 7. Kramer M, Kupka R, Subramanian SV, Vollmer S. Association
community level, by communication and information (ECI) would be between household unavailability of iodized salt and child growth:
conducted by Non-Governmental organizations, Government evidence from 89 demographic and health surveys. The American
organizations and other in and around medical colleges. Journal of Clinical Nutrition 2016;104(4):1093-1100. DOI:
https://doi.org/10.3945/ajcn.115.124719
Recommendations: Health education related to usage of iodized salt, 8. Iodine: Fact sheet for Consumers. National Institutes of Health
how to store the iodized salt in the household level, how to identify the Available on: https://ods.od.nih.gov/factsheets/Iodine-Consumer/
iodized salt in the grocery shops. In school level also the iodine related [Last Accessed on: 16th October 2020]
health study is needed in and around study areas. 9. Jagriti Chandra. Tamil Nadu ranks lowest in coverage of iodized
salt. The Hindu, New Delhi was published on 9th September 2019.
Acknowledgement: Authors are very much thankful to the Director- Available on: https://ods.od.nih.gov/factsheets/Iodine-Consumer/
Principal, Head of the Department and those who have involved in the [Last Accessed on: 16th October 2020]
study including teaching faculties, ANMs, staff nurses, Undergraduate 10. India Iodine Survey Report 2018 – 19. National Report. Nutrition
interns those who were posted in the rural health center, Post Graduates International;2019:22. New Delhi, India. Available on:
and other non-teaching staffs. https://www.ign.org/cm_data/2019-INDIA-IODINE-SURVEY-
2018-19_FINAL-REPORT.PDF
Authors’ Contributions: SV, MN: Study conception and design; SV: 11. Roy R, Chaturvedi M, Agrawal D and Ali H. Household use of
data collection, draft manuscript preparation. All authors reviewed the iodized salt in rural area. J Fam Med and Pri Care 2016;5(1):77-
results and approved the final version of the manuscript. 81. PMID: 27453848
12. World Health Organization. Goitre as a determinant of the
SV – Senthilvel Vasudevan and MN – Murugan Natesan prevalence and severity of iodine deficiency disorders in
populations. Vitamin and Mineral Nutrition information System:
Conflict of interest: The authors are not having any type of conflict Classification of goitre by palpation 2014:1-6. Available on:
of interest in the study. https://apps.who.int/iris/bitstream/handle/10665/133706/WHO_
NMH_NHD_EPG_14.5_eng.pdf;jsessionid=ED159EC9711529F
Source of funding: We didn’t get any kind of funding from the parent 527C648438D894D5C?sequence=1 [Last Accessed on: 22nd
institution or any other financial institutions or organizations. We September 2020]
didn’t give any incentives to the study participants. 13. Pandav CS, Arora NK, Krishnan A, Sankar R, Pandav S &
Karmarkar MG. Validation of spot-testing kits to determine
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One Health Approach: The key to addressing pandemics and

other complex challenges of the 21st Century

5.Addressing climate change at local, national, and international

Quick Response Code: This isThese

We are facing complex challenges with regard to climate change,

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Introduction: maintained as it highly affects the healthcare delivery system.

Article Summary: Submitted:26-October-2021 Revised:10-November-2021 Accepted:02-December-2021 Published:31-December-2021

How to cite this article: Senthilvel S. Challenges met by healthcare

Lack of teamwork: 6. Alluhidan M, Tashkandi N, Alblowi F, Omer T, Alghaith T,

Importance of nursing administration: Mrs. Sumathi Senthilvel,

Conclusion: Email ID: AssociateEditor@ijmsnr.com

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Article Summary: Submitted:02-October-2021 Revised:02-November-2021 Accepted:08-December-2021 Published:31-December-2021

Corresponding Author: Dr. Senthilvel Vasudevan,

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Article Summary: Submitted:04-October-2021 Revised:15-November-2021 Accepted:23-December-2021 Published:31-December-2021

Corresponding Author: Dr. Shalini Kaliaperumal,

Figure: 1 Comparison of Body Mass Index and with Infection

In our present study, 68.2% of the Diabetics with Urinary symptoms

Figure: 2 Comparison of urinary symptoms with urine c/s

and unemployed (70.6%) and it not statistically significant with p-

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Article Summary: Submitted:12-October-2021 Revised:16-November-2021 Accepted:24-December-2021 Published:31-December-2021

Corresponding Author: Ms. Mahalakshmi Rajendran,

Mathematical and Statistical models for infectious diseases commonly

Results and Discussion

Table–1 HIV infected patients risk observed in the three states

Time Per First State Second Third

10 1.1 0.3 0.4 Conclusion

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Keywords: heart diseases, hypertension, Semi-Markov processes, smoking, stroke

Article Summary: Submitted:11-October-2021 Revised:13-November-2021 Accepted:24-December-2021 Published:31-December-2021

Corresponding Author: Mr. Balasubramaniam Ramakrishnan,

The cumulative density function (CDF) 𝐹𝑖𝑗 (𝑡), along with

Log likelihood function is observed in eqn. (6)

Markov chain derives; the 𝑖𝑡ℎ state

̂), 𝛼̂ ± 𝑍𝛼 √𝐼𝛼𝛼 ̂), 𝑏̂ ± 𝑍𝛼 √𝐼𝑏𝑏

1−𝑎 𝑏 𝛼 𝜃 Figure – 1 A five-state model data from the Hepatitis C

Table 1. The transitions between the phases of the process

Patients has Patients has Patients has Patients

498 276 1674 249

Table-1 shows the recurrence dispersions of sets of progressive states

Figure-3, 4, 5, 6 portray a graphical portrayal of those various examples,

Among the five provinces of SMP, the Stroke state S5 is viewed as

References: 15. Melzer D, McWilliams B, C. Brayne C, Johnson T, Bond J.

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Senthilvel Vasudevan1 , Murugan Natesan2

Figure–1 Distribution of villages in the study area

Table: 1 Distribution of age-groups among gender for goiter examination (N=1233)

≤ 10 10 (15.4) 1 (14.3) 55 (84.6) 6 (85.7) 65 (5.3) 7 (5.0)

11 – 20 36 (33.0) 4 (25.0) 73 (67.0) 12 (75.0) 109 (8.8) 16 (11.3)

21 – 30 110 (31.8) 8 (20.0) 236 (68.2) 32 (80.0) 346 (28.1) 40 (28.4)

41 – 50 55 (25.6) 7 (28.0) 160 (74.4) 18 (72.0) 215 (17.4) 25 (17.7)

51 – 60 32 (27.6) 5 (33.3) 84 (72.4) 10 (66.7) 116 (9.4) 15 (10.6)

61 and above 8 (40.0) 0 (0) 12 (60.0) 1 (100.0) 20 (1.6) 1 (0.7)

Packed + Loose Crystalline

Public p<0.001 p<0.001

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