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Indian Journal of Community Medicine

Vol. 28, No. 1 (2003-01 - 2003-03)

Editorial

Surveillance of HIV/AIDS Epidemic in India

HIV/AIDS pandemic is posing serious challenges the world over Number of people living with HIV/AIDS (Dec. 2002) are estimated to be 42 millions. Sub-Saharan-Africa is worst affected as it is home for 29.4 million of HIV/AIDS, South and South East Asia contributed 6.0 million and share of India alone in this continent is 4.0 million, which is next only to Sub Saharan Africa.. Therefore, the threat of HIV/AIDS looms large over India; necessitating adequate and effective response tomeet this unabated scourge1.

The activities of screening of blood for HIV commenced in India way back in 1985 at National AIDS Research Institute, Pune and Christian Medical College, Vellore. During this phase of restricted surveillance the purpose was to validate the presence of HIV infection in India First HIV positive was detected in 1986 from commercial sex workers in Madras. Soon, thereafter, HIV reporting system was set up under the aegis of ICMR with sero-surveillance and reference centres spread over throughout the country with a view to identify the geographical spread of HIV infection and determining the major modes of HIV transmission. Most of these testing centres were located in Medical Colleges and activities of screening were confined to high risk and institutional population. This activity indicated that HIV was widespread in the country and every state reported the presence of HIV infection bythe end of year 19972,3 .

The distribution and spread was not uniform and was highly uneven.. The Maharashtra, Tamil Nadu, Andhra Pradesh, Karnataka and Manipur experienced heavy burden of HIV The 1998 estimates of HIV sero prevalence in the adult population of India was about 0.7% .The cumulative rate for HIV tests performed in the country, including both high risk and low risk groups, has shown a slow pattern of increase from 1% in 1992 to 2.3% of tests in 1998. The cumulative sero-positivity rate acquired alarming epidemic proportion of 2.46% by the year 1999 and it provided a clue of rising trend of HIV in India2,3, not obeying to the command of all appropriate measures undertaken through Phase 1 of National AIDS Control Programme .The predominant mode of transmission in India happened to be unprotected hetero-sexual intercourse (83.88%). Hitherto for the serosurveillance activity was limited to bigger cities and metropolitan areas and it was not population based surveillance and could not be considered as an epidemiological surveillance by any stretch of imagination, but nevertheless it provided some useful information for action during phase I of National Programme of HIV and AIDS. By and large the activities during this phase were highly centralised in terms of planning and implementation of the programme.

Though the sentinel surveillance commenced at 55 sentinel sites in 19944. During the year 1998, a bold step was undertaken by NACO to initiate nationwide HIV sentinel surveillance activities and the task was entrusted to nodal agency (National Institute of Health and Family Welfare, New Delhi). A test run sentinel surveillance from Feb. to March 1998 was undertaken by 154 sites, mostly urban in character5.The objectives of sentinel surveillance during this phase were to monitor trends of HIV infection in the country as also to determine burden of HIV infection and geographical variations. During August to Oct. 1998 over 180 sentinel sites representing all states and union territories in the country were covered for sentinel surveillance. For monitoring trends of HIV epidemic in India strategy of unlinked, anonymous surveillance was adopted covering high risk population (attendees of STD clinics, injecting drug users, men having sex with men and commercial sex workers) who manifest high risk of contracting and spreading HIV infection and low risk population (pregnant women) representing general adult population Accordingly, STD clinics attendees and pregnant women seeking antenatal care through clinics were targeted for surveillance activity. Essentially it happened to be cross-sectional annual surveys to determine HIV prevalence, spread over three months (August to October every year)5,6.

For antenatal clinic sites a sample size of 400 consecutive women attending the antenatal clinic for the first time during the sampling period and similarly for STD clinic site 250 consecutive individuals presenting to STD clinic for the first time were chosen to complete the pre-determined sample size, if the quota was met before twelve weeks the sampling was stopped and if the sample size was not met during the predetermined twelve weeks period, that was no problem the sampling stopped .These rules of the surveillance wereviolated quite often byparticipatingsites.

Inclusion criteria were printed on all the request forms. Inclusion criteria stipulated that all new patients visiting STD clinics and suffering from one or other type of STD's where blood is drawn for VDRL testing and all pregnant women attending antenatal clinic to be tested only once during the round.

Designated regional co-ordinators of various Medical Colleges and regional research centres (Epidemiologists and Microbiologists) were made responsible to oversee the implementation (Operational aspects) of HIV sentinel surveillance to ensure quality aspects Generally two supervisory visits were ensured by regional co-ordinating experts to each site in their respective region. 25% of the sites were checked by NIHFW teams to enhance the quality of surveillance. However, in the year 2002 there was set back and the supervisory visits could not be ensured because of administrative reasons and the operation of surveillance was left unsupervised by external experts.

External quality assurance programme was introduced in the year 2001. All the samples tested positive in the laboratory were sent to designated reference laboratory for retesting and conformation and similarly 5% of negative samples were also sent for retesting.

Epidemiological sentinel surveillance, operation covered 180, 180, 232, and 320 sites in the years 1998, 99, 2000 and 2001 respectivelyinvarious parts of the country7-11.

On the basis of data of sentinel surveillance using certain assumptions and consistence methodology estimates of HIV infections in adult population (15-49 year age group) in the country have been worked out during 1998, 99, 2000 and 2001. The point estimates for these years were arrived at 3.50, 3 .70, 3.86 and 3.97 million respectively indicating rising trends. It is claimed that burden of new HIV infection is on the decline from 0.16 million (year 2000) to 0.11 (year 2001); however, it is to be interpreted with cautions. The HIV sentinel surveillance provides useful estimates of burden of HIV infection in the country as also its trends in various risk groups of population. There are wide regional variations of HIV prevalence7-11.

2001 census population of India was 1027 million and over half a billion in the age group of 15-49 years. The overall prevalence of HIV in adult population was less than 1% (approximately 0.8%) offers little indication of serious situation facing the country. An estimated 3.97 million people were living with HIV at the end of 2001, is the second highest figure in the world after Sub Saharan Africa11 . Based on the consistent high prevalence rates of three rounds of surveillance, 49 districts have been identified as high prevalence districts Prevalence among women attending antenatal clinics was higher than 1% in Andhra Pradesh, Karnataka, Maharashtra , Manipur, Nagaland and Tamil Nadu indicating that epidemic has shifted from high risk population to low risk or general population over a period of time. HIV Infection has crossed 2% in Mumbai, it is more than 1% in Hyderabad, Bangalore and Chennai and is below 1% in Calcutta, Ahmedabad and Delhi metropolitan area; further, the HIV infection is being propagating from high risk groups to low risk groups population. HIV infection among women, who are not sex workers was "disturbingly high" in India. Young girls were especially vulnerable to HIV. Around 50% of all HIV infections most of whom contract HIV before they are 20 years old10,11 .

Prevalence of HIV infection in age group 15-19 years in STD attendees and pregnant women in the states of Andhra Pradesh, Maharashtra, Tamil Nadu, Karnataka, Nagaland, Chhattisgarh, Punjab and MP indicates recency of infection affecting adolescent age group necessitating focussed response and intervention for adolescent health, accepting responsible sexual behaviour.

Based on the analysis of existing sentinel surveillance data, the states and union territories can be broadly classified into three groups.

Group I: High HIV prevalence states which include Maharashtra, Tamil Nadu, Karnataka, Andhra Pradesh and Manipur where HIV prevalence rates were 1 % or more in antenatal women.

Group II: Moderate prevalence states include Gujarat, Goa, Kerala, West Bengal and Nagaland where HIV prevalence rates were 5% or more among high HIV risk behaviour groups but below 1% in antenatal women.

Group III: Low prevalence states include the remaining states where HIV prevalence rates in any of the high risk behaviour groups were still less than 5% and as also HIV prevalence less than 1% in antenatal women.

Since the distribution of HIV in India is not uniform, the epidemic is focussed sharply in few states, with most of India having low rates of infection, therefore, differential strategies and responses are required for different regions.

To achieve zero level of growth of HIV/AIDS by 2007 appears to be a herculean task in view of rising trend and unabated spread of HIV to general population12. Fight against HIV/AIDS needs to be integrated with control of STDs, adolescent health, control of reproductive infections and tuberculosis through primary health care and augmenting facilities for treatment of RTIs and STIs in rural areas on sustained basis.

The HIV sentinel surveillance operation and implementation were planned centrally and NACO selected these sentinel sites arbitrarily, not based on evidence of past track records (STD sites). Quality of surveillance of STD clinics attached with Medical Colleges was optimal but most of these sites did not achieve the desired target of 250 samples as most of the clients sought services from established private practitioners of those towns. At times, the STD clinics were established on adhoc basis and functioned only during the specified period of surveillance (August to October every year) and thereafter these were shut down.. Many of the STD clinics started special recruitment drives to complete the quota of fixed sample which violated the intents of surveillance. Consecutive sampling was not followed. At times, the authorities had to extend the time to complete the sample size. Most attendees of STD clinics were men. To obviate the problem of adequate coverage and to complete the desired sample size the modus operandi of sentinel surveillance was changed in the year 2001. To enrol the female clients it was resolved that from year 2001 onwards the STD sites would collect consecutive samples from two sources i.e. 150 samples from Skin and V.D. clinics (STD clinic) and 100 samples from Obstetric and Gynaecology clinic of the same hospital from OPD. With these modifications though the sample size was achieved but it had adverse effects on prevalence rates as many non-STD women were recruited to complete the sample size only. Therefore, the prevalence rates of year 2001 and 2002 in high risk groups should be interpreted cautiously in view of inclusion of 100 females from the OPD of Obst. and Gynae. The participating sites were not clear of the specified objectives of surveillance and were not imparted adequate training. State run STD clinics had poor infrastructure and best practices of waste disposal, personal protection, safe disposal of needles and syringes were seldom followed.

Most antenatal clinics could achieve the desired sample size but practice of consecutive sampling was not followed by them. Accounts of total antenatal attendees was not maintained properly. During the round of annual survey new registers for antenatals were started and all those antenatals whose blood samples were collected were registered in this register with a motive to show full coverage (100% coverage). In many of the antenatal clinics the routine VDRL testing was absent and they resorted to VDRL testing only during the period of surveillance.

One of the basic tenet of surveillance was data collection for action; however, HIV surveillance was driven by collection of data only as there was no action on that data. It was expected that the participating sites would build up the counselling and awareness generation activities to focus on behaviour changes as also establish best practices in the clinic and hospital and sustain these on endurable basis, but these were conspicuous by their absence. Similarly, condom promotion programme in STD clinics was seldom undertaken. There was hardly any feed back to participating sites by the State or Nodal agency or even by NACO. Wisdom prevailed only once, when the State level Assistant Project

Directors could interact with the State Co-ordinators at Delhi; to understand the problems and arrive at some solution. Summary sheet on prevalence of HIV infections, site or centre-wise as brought out by NACO and NIHFW gives erroneous impressions on prevalence as the sample size for many of the sentinel sites appears to be too inadequate to draw valid conclusion7-11. Zone-wise/ region-wise results on prevalence seems to be more appropriate for planning and implementation strategies. Almost all the participating sites were located in urban areas only and the clients or attendees most probably were urban in most settings. Thus, the data of HIV sentinel surveillance does not unfold the true picture of prevalence of HIV in rural areas.

Antenatal clinics and post partum centres tend to function under different administrative control and there is not much cohesion or co-ordination among these centres to accomplish the task of surveillance. Moreover, the sentinel surveillance programme is run as crash programme without much thought of pre-planning and sustained quality services for antenatals and STD clients. All good/best practices initiated/carried out during sentinel surveillance period come to halt or vanish once the period of surveillance is over. Most STD clinics are established on an adhoc arrangement to tide over the period of surveillance. STD clinics and antenatal clinics are located in urban settings and in Government set up, their utilization is sub-optimal, barring some metropolitan cities which are heavily used and sometime the situation runs out of control. Refusal rates in sentinel surveillance site is not recorded.

Since blood bank screening for HIV has become mandatory and is making substantial progress, anonymous and unlinked screening of voluntary blood donors can provide useful information on prevalence of HIV in population of young adults. Since there is no cure for HIV/AIDS efforts have largely been focussed on prevention, raising awareness for behaviour change targeting high risk groups and general population (focus on adolescents) Behaviour surveillance activities have become essential.

Behavioural surveillance surveys initiated in 1995 (Preventive indicators surveys)13,14 and repeated in year 2001-2002 highlight important facets of the country's bid to curtail the epidemic15. General population survey in India during 1996 revealed that percentage of adult population (15-49 years) who could cite at least two acceptable means of prevention against HIV infection in urban areas of Delhi, West Bengal, Maharashtra and Tamil Nadu was of the level of 57.2, 54.4, 55.1 and 77.3 respectively while for rural domain in these respective states the levels were low and discouraging at 43.6, 13.4, 27.5, 63.8 respectively14 .Men had better knowledge while female lagged much behind because of poor access to media and least exposure to outside world. Similarly, the condom use rate in most recent sexual act with non-regular sexual partner/partners in urban settings of Maharashtra, Tamil Nadu, Delhi and West Bengal was 62.2, 77.8, 28.6 and 19.4 respectively while rural domain within these states manifested low level of condom use rate at 9.1, 8.6, 25 and 10% respectively. National Family Health Survey I and II data revealed very low use rate of condom, 2.4 and 3.1% respectively as contraceptive16. NFHS II data indicates that only 4 out of 10 ever married women in India have heard of AIDS and there was low level of knowledge among rural women, illiterate women and women belonging to scheduled caste and tribes. Television was the most important source of information followed by radio and peer groups and friends16.

Behavioural surveillance survey undertaken in year 2001 in India in general population, commercial sex workers and men having sex with men unfolds mixed picture of success and failures. Country-wide, awareness of HIV/AIDS is high as 76% of adult Indians (aged 15-49) and almost same proportion of adult population were aware that consistent and correct use of condom helps in prevention of transmission of HIV/AIDS. More than half of the respondents in the country (57%) were aware that having one faithful and uninfected sex partner could prevent transmission of HIV/AIDS15,16.

But in general, awareness and knowledge of HIV/AIDS remain weak in rural ,areas and among women. More than 80% of urban men recognized the protective value of consistent condom use, compared to just 43% of rural women. As against 55.5% of men, 38.3% of women could cite two cardinal methods of prevention of HIV namely uninfected faithful sex partner and consistent condom use. Sex with non-regular partner in the last 12 months was prevalent to the extent of 7% in urban and 6 .3% in rural areas and condom use rate with such kind of risky sexual relationship was 62.4% in urban areas and 42.9% in rural areas. This is the "bridge population" which connect high risk and low risk populations. The larger the size of "bridge population" the greater the risk of transmission into general population15,16.

High level of awareness and knowledge about HIV/AIDS and evidence of high condom use among vulnerable population in state that have mounted consistent prevention efforts, was obvious in the state of Maharashtra which is home to a long-standing, generalized epidemic. Behaviour change in high group such as female sex workers, their clients and injecting drug users was obvious as 66%, 77% and 52% of them respectively consistently used condoms which is quite encouraging figure. Thus the targeted interventions have paid dividends. Similarly, in Gujarat focussed programmes have helped ensure that some three quarters of female sex workers used condoms, the last time they had sex with commercial or casual partner. But the state also reminds that HIV/AIDS responses have to reach the wider rural population if the epidemic is to be kept under check. Kerala where intervention for general and marginalized populations have taken place together, they have helped keeping HIV prevalence low. The survey goes to show that significant proportion of men who have sex with men in India also have sex with women (almost 31 % had sex with female partners in a six month recall period) and many (36% during a month's recall) have sex with commercial male partners, hitherto hidden facet of epidemic. Condom use rates were distressingly low in men having sex with men (39%), this points for further urgent action. Thus a major challenge for India is to rapidly expand the coverage of groups at high risk (vulnerable population) and provide intervention such as peer counselling, condom promotion, treatment of STIs and enabling environments. Besides this, the bigger challenge is that the response reaches young, illitrate population and rural community especially women

AIDS Cases Surveillance:

The AIDS cases surveillance is done with a view to ensure reporting of AIDS cases as per standard AIDS case definition by specified institutions and trained physicians (PRAM) to capture the disease burden and opportunistic infection and subsequently, strategy of management of such cases.

The number of AIDS cases reported in India upto Dec. 2002 (over 42000) represent only a small fraction of the actual AIDS cases. The reported AIDS cases do not tell anything about the magnitude of the problem because of under reporting by states and lack of diagnostic skills. Epidemiological analysis of reported AIDS cases reveal that disease is affecting mainly the people in sexually active and economically productive age group of 15-49. Common in men than women, the ratio being 3:1. The majority of patients (89%) are in the age group 15-44. The predominant mode of transmission of infection in AIDS patients was through heterosexual contact (80.86%), followed by blood transfusion (5.52%), IDU (5.30%), perinatal transmission (0.72%) and others (7.60%). The major opportunistic infection in the AIDS patients was tuberculosis indicating a possibility of a dual epidemic of TB and HIV in the country. Nearly 60% of the AIDS cases are reported to be opportunistic TB infection cases. Treatment of TB among the HIV infected persons is a new challenge to the National TB Control Programme.

AIDS case surveillance data can supplement the HIV surveillance data in monitoring the epidemic and could contribute to the planning of Hospital and home/community based care for AIDS patients under the programme.

During the year 2002, efforts have been made to launch community based studies on prevalence of sexually transmitted diseases (STD) in urban and rural areas of India. The study is under progress. The overall objectives envisaged for such a study were to determine the prevalence, knowledge, risk and health seeking behaviour of the community in the context of sexually transmitted diseases in the country. Focus of this study is adult population between 15-49 years of age. Nationwide about 17000 adults would be selected in different parts/regions of the country from identified primary sampling units(PSU)

From each PSU, 100 individuals (50 male and 50 female) will be selected and subjected to interviews, clinical examination and collection of samples for laboratory testing, right at the village level, which is a challenging situation indeed. The laboratory tests would be conducted for T. Pallidum, Tnchomoniasis, Candidasis, HIV, HSV2 and HPV, dysplasia, chlamydia plus Neisseria gonerrhoea and bacterial vaginosis. The results of this community based study are keenly awaited. However, it is felt that success rate of such survey is limited, because of limited coverage of desired sample size and difficult to ensure the random sample, apart from many operational problems of organizing camps for such surveys in rural and urban slum population. Such like studies are fraught with severe limitations; because of ill-designed and ambitious model for community based STD survey, hence it needs to be rethought.

It is imperative to intensify and improve the quality of surveillance for effective HIV/AIDS response. Surveillance data as well as behavioural research provides vital information to design a sound and comprehensive HIV/AIDS programme and effective response18.

Sentinel surveillance data is also reproduced for ready reference*. (below)

References:

  1. World Health Organization. AIDS epidemicUpdate-December 2002. Geneva: WHO: 2002 Dec. Reference Number: ISBN 92 9173 253 2 Available from: URL: http://www.who.int/hiv/pub/ epidemiology/epi2002/en
  2. Ministry of Health and Family Welfare (Govt. of India). Agenda Notes Sixth Conference of CentralCouncil of Health and Family Welfare. 1999 Feb16-18; New Delhi,India.
  3. National AIDS Control Organisation NACO NACPII1999-2004. Specialists training reference module NACO; New Delhi.
  4. National AIDS Control Organisation (MOH&FW, GOI), India country scenario update, 1994. New Delhi, NACO, 1994 Sept.
  5. National Institute of Health and Family Welfare, GOIOrientation workshop for specialists from regionalco-ordinating centers. National annual sentinel surveillance for HIV. Introductory document. 1998 Jan19-21 : New Delhi, NIHFW.
  6. National AIDS Control Organisation (MOH&FW, GOI). Training module on the sentinel surveillance ofHIVinfection. New Delhi, NACO, 1993, June.
  7. NIHFW Annual sentinel surveillance for HIV infection -A country report on monitoring of surveillance activities and supervisory visits of HIV infections in thecountry 1998, Jan. 19-21, New Delhi NIHFW.
  8. National AIDS Control Organisation (MOH&FW, GOI). Report on round 2000 HIV prevalence levels, state-wise. New Delhi NACO, 2000
  9. NIHFW (GOI). Executive summary -Annual sentinel surveillance for HIV infection 2000. New Delhi: NIHFW, 2000.
  10. National AIDS Control Organisation (MOH&FW, GOI). HIV sentinel surveillance round 2001. New Delhi: NACO; 2001
  11. NIHFW (GOI). Executive summary -annual sentinel surveillance for HIV infection 2001. New Delhi: NIHFW; 2001.
  12. Govt. of India National Health Policy – 2002. New Delhi: GOI; 2002. Available from URL: www.mohfw.nic.in
  13. World Health Organisation. Global programme on AIDS - Evaluation of a National AIDS Programme: Amethods package Prevention of HIV infection. Geneva: WHO: 1994.
  14. National AIDS Control Organization. Prevention Indicator Survey (PSI) 1996. New Delhi: NACO; 1996
  15. National AIDS Control Organization. Nation-wide Behavioural Surveillance of General and High Risk Groups 2001-2002. Conducted by ORG-MARG. New Delhi: NACO; 2002. Available From: URL: www. Naco.nic.in/nacp/bssl.pdf
  16. International Institute of Population Sciences (IIPS). India - National Family Health Survey (NFHS 2) - Key findings. Mumbai: IIPS, 1998-99
  17. Ministry of Health and Family Welfare (Govt. of India). National Population Policy – 2000. New Delhi: MOH&FW, 2000 Available from URL: http: //www.populationcommission.nic.in
  18. Heidi J, Larson, Jai Parkash Narain. Beyond 2000 Responding to HIV/AIDS in the new millennium. NewDelhi (India): South-East Asia regional office, WHO. Report No. SEA/AIDS/I 22.
  19. NACO (MOH&FW, GOI) Guidelines for AIDS case surveillance. New Delhi: 1993, MOH&FW.

Indian Journal of Community Medicine Vol XXVIII, No 1, Jan –Mar., 2003

*SENTINEL SURVEILLANCE FOR HIV INFECTION 1998-2001

Sr. no. Name of State/Union Territory Sites HIIV Prevelance
1998 2000 2001
1 Andhra Pradesh STD 23.1 30.0 26.60
    ANC 2.25 2.60 1.50
2 Arunchal Pradesh STD 0.0 0.10 0.0
    ANC 0.4 0.0 0.0
3 Assam STD 1.74 0.61 1.49
    ANC 0.0 0.0 0.0
4 Bihar STD 1.35 0.50 1.20
    ANC 0.0 0.10 0.13
5 Delhi STD 1.6 3.26 4.65
    ANC 0.25 0.25 0.13
    IDU - 5.00 -
6 Goa STD 19.50 12.02 15.00
    ANC 1.23 1.17 0.50
    CSW - 53.20 50.79
7 Gujurat STD 2.54 4.65 4.14
    ANC 0.00 0.5 0.50
8 Haryana STD 2.60 2.75 1.08
    ANC 0.00 0.00 0.41
9 Himachal Pradesh STD 0.39 0.4 0.26
    ANC 0.36 0.89 0.13
10 Jammu and Kashmir STD - 0.40 0.80
    ANC - 0.112 0.25
11 Karnataka STD 16.41 12.80 16.40
    ANC 1.75 1.68 1.13
    IDU - 4.23 2.00
12 Kerala STD 2.6 5.20 6.42
    ANC 0.1 0.00 0.08
13 Madhya Pradesh STD 2.59 1.60 2.69
    ANC 0.47 0.12 0.25
14 Maharashtra STD 16.00 18.40 9.2
    ANC 2.37 1.12 1.75
    IDU - - 41.38
    MSM - - 23.60
    CSW - - 52.26
15 Manipur STD 4.15 11.60 10.50
    ANC 0.75 0.75 1.75
    IDU 70.73 64.34 56.26
16 Meghalaya STD - 0.00 0.00
    ANC 0.13 - 0.00
17 Mizoram IDU - 1.41 1.39
    STD 1.49 2.00 2.20
    ANC 0.48 0.37 0.33
18 Nagaland IDU 1.0 9.61 2.00
    STD 11.1 6.90 7.40
    ANC 0.7 1.35 1.25
19 Orissa IDU 13.2 7.03 5.50
    STD 1.5 2.60 0.80
20 Punjab ANC 0.00 0.27 0.25
    STD 1.8 0.80 1.61
21 Rajasthan ANC 0.00 0.00 0.40
    STD 5.22 2.84 4.00
22 Sikkim ANC - 0.25 0.00
    STD - 0.00 0.00
23 Tamil Nadu ANC 0.13 0.00 0.00
    STD 16.0 16.80 12.60
    ANC 1.0 1.00 1.13
    IDU - 26.70 24.56
24 Tripura MSM - 4.00 2.40
    STD - 1.34 3.20
25 Uttar Pradesh IDU - 0.0 0.25
    STD - 0.0 0.0
26 West Bengal ANC 1.60 1.80 0.90
    STD 0.24 0.12 0.00
    ANC 2.0 1.96 0.60
27 A&N Islands IDU 0.62 0.50 0.13
    STD - - 0.00
28 Chandigarh ANC - 1.2 1.20
    STD - 0.25 0.26
29 D&N Haveli ANC 2.95 3.35 3.78
30 Daman & Diu ANC 0.47 0.80 0.00
    STD - 0.00 0.25
31 Lakshdweep ANC - 0.00 -
    STD 0.13 0.00 0.25
32 Pondicherry ANC 0.65 0.00 0.00
    STD 7.2 4.1 0.00
    ANC 0.5 0.25 0.25

Sunder Lal - Prof & Head Deptt of SPMPt BDS PGIMS, Rohtak

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