Identification of hot-spots of Water borne diseases and Water based vector borne

diseases in slums of Bhubaneswar City

Abstract:
Background: Like any other fastest growing cities in third world countries slums are becoming dominant type of human settlement
in Bhubaneswar, craving their way into the fabric of the main city. An estimated 0.3 million (BMC, 2008) people reside in the slums
of the City of Temple, which is almost one third of its total population size. Due to high population density, overcrowding, lack of
safe water and sanitation slums are productive breeding grounds for several communicable diseases majority of which are water
and vector borne in nature. Seasonal outbreaks of such diseases are common phenomenon in slums. Available surveillance system
does not help much in prediction of those epidemics. Eventually Health services providers are grappling with management of such
outbreaks. Current study was an effort to find out the hot-spots (significant clusters) of those diseases across Bhubaneswar slums
based on two years of data collected from the OPD registers of urban slums health centers. The identified outbreak pattern would
help the concerned authority to design control measures in advance. The study also aimed to demonstrate how such value additions
in the existing surveillance system can make management of outbreaks more effective.
Methods: Pure Spatial and Space-time cluster identification was done for water borne diseases using spatial and space-time scan
statistics, where as for water based vector borne diseases only pure spatial clusters were identified. Data of new cases over the year
2011-2012 were taken from the OPD registers of the urban slum health centers located within the slums. The discrete Poisson
model for spatial and space-time scan statistics was chosen for detecting high risk clusters (hot-spot)
Results: Total 9 spatial clusters and 6 space time clusters were identified in case of water borne diseases with varying radios and
significance. Further scanning revealed that diarrhea hot spots are located in northern part where as dysentery hotspots are located
in the southern part of the city. Only three spatial clusters were found in case of water based vector borne diseases. Those again
coincided with three clusters of water borne diseases. The overlapping suggests that poor environmental sanitation and socioeconomy in slums mediate risk factors for both types of diseases.
Conclusions: Water borne diseases like diarrhea and dysentery and water based vector borne diseases like malaria, fileria etc. have
spatial and spatio-temporal clusters. It indicates the need to address prevention and control measures in those identified hotspots.
Sndromic surveillance system as depicted in the study can be adopted for the slums of entire city .It can predict outbreaks in
advance and can help them manage effectively.
Key wards | Water borne disease; water based vector borne diseases; spatial cluster; spatiotemporal cluster; urban slums;
Syndromic survelliance

Introduction

population in the city due to vast devastation caused by

super cyclone. It led to huge in-migration from rural

According to Census 2011, Odisha is one of the top five

hinterlands, other parts of states and even outside of

states with 23.1% of its urban households located in the

the states in search of employment mainly in the

slums. In the state capital Bhubaneswar total 0.3 million

construction sector. The city has total 377 slums out of

population reside in slums across Bhubaneswar

which only 99 slums are authorized (BMC, 2008). Most

Municipal Corporation (BMC) area and its out growth.

of the slums are located encroaching unutilized govt.

The last decade has seen a prolific growth of slum

land / railway land which were temporarily vacant. Low

1

income group people reside in those areas in poor living

current study was confined within 168 slums where

condition devoid of basic services and amenities .With

HUP has its presence. In such epidemiological studies

the proliferation of slums the city started getting its

clusters of disease occurrence and their statistical

share of challenges in terms of complex disease

significance etc. are determined by applying certain

etiologies and risk factors. Absence of proper

mathematical (discrete Poisson distribution model was

infrastructure, especially primary health care services

used in current study) model.

for urban poor is making the health outcomes more

comprising of cases along with its time of diagnosis,

skewed. Slum areas are witnessing seasonal outbreaks

place of occurrence, geo location and population size

of diarrhea and malaria. Bhubaneswar Municipal

of those places of occurrences over a significant period

Corporation with the support from National Rural

of time is a prerequisite for this kind of study. In present

Health Mission (NRHM) and in collaboration with eleven

study the supply of data was one of the major

local NGOs is running urban slum health centers located

hindrances. Often existing surveillance system provides

within the slums. These centers render basic health care

the data of cases over a considerable period of time.

services to the urban poor. However seasonal outbreaks

Mainly Census or other type of survey is the source of

of water borne and water based vector borne diseases

population data of particular geographical units (in

in slums has evolved as perpetual public health

present case it was slum). It was difficult to extract slum

challenges for the city. Chief Municipal Medical Officer

specific case data from existing surveillance system.

of

Hospital

Getting slum population data over a regular interval of

approached Population Foundation of India seeking

time was also difficult as census has recently started

support in mapping the spatial outbreak pattern of the

capturing slum data. To overcome this constrains only

water borne disease

in slums of the city. This is how

HUP intervention slums were opted. In those slums

the idea of undertaking the current study was

population survey in two consecutive years (2011 &

germinated.

2012) was conducted as a part of HUP intervention. The

Bhubaneswar

Municipal

Corporation

A robust database

outpatient registers of the all five urban slum health

Despite clear dissimilarity of the etiologic agents water
centers serving those slums were the sources of cases
based vector borne diseases (mainly malaria, fileriasis)
and their place of occurrence, date of diagnosis, age,
and water borne diseases( diarrhea, dysentery, typhoid
gender etc. The corresponding time interval was kept
etc.) both seem to share common risk factors which are
largely mediated by poor environmental sanitation
infrastructure and socioeconomic condition. In this
pioneering study these two type of diseases were
considered for identification of their hot spots.
Ideally

such

spatiotemporal

studies

should

be

from 1st January 2011 to 31st December 2012.

Objectives:
1. To identify significant high risk clusters of
occurrence of water borne and water based
vector borne diseases across slums of
Bhubaneswar

undertaken in all the slums in the cities. However

2

2. To demonstrate how existing surveillance

system can be upgraded for effective
management of outbreak which is otherwise a
perpetual challenge for health service provides.

centers were started functioning since last quarter of

2010, rest were from 1st quarter of 2011. To keep
symetry only case data of complete 2011 and 2012
were screend and considered for the current study.

Methods

Screening of OPD registers revealed five types of water

borne diseases and two types of vector borne disease
were predominantly diagnosed in the year 2011 and
2012. In current study only those diseases were
included. Following table depicts the classification of
diseases

Study area

As mentioned in the previous section current study was

confined within 168 slums across 24 municipal wards of
Bhubaneswar city. Out of those slums 142 were
coterminous with the catchment areas of five urban
slums health centers (Fig: 1). However there was no
designated urban slums health centers for remaining 26
slums located across ward no 1,2,7 and 8 and they were

Type of diseases
Waterborne diseases(WBD)

Name of diseases
Diarrhea
Dysentery
Cholera
Typhoid
Hepatitis A,D/Jaundice
Water based vector borne Malaria
diseases(WBVB)
Filaria
Table 1| Disease categorization

While creating the database all the new cases were

captured to represent the incidence only for the
corresponding diseases. Once the database was ready
all the cases without the information of patients
residing area/slum were excluded.

Analytical and modeling technique:

Incidence analysis
Figure 1| Ward map showing study area

dependent on the health centers located at adjacent

ward number 9( Fig:9) Each urban slum health centers is
supposed to cater 25,000 slum populations.
Data Sources
The study was conducted by using primary and
secondary data. The disesas case data were obtained
by screening OPD registers of five urban slums health
cneters along with date of diagnosis, age , gender and
habitual location of patients. Survey conducted by HUP
was the source of population data for the identified
habitual locations. Gramin GPS tracker was used to
record latitude and longitude of all the identified
locations. Out of five some of the urban slum health

Incidence of water borne diseases and water based

vector borne diseases were plotted against covariates
like age group and sex. Also an age -sex composite
distribution of the diseases were analyzed and
presented with pyramid. MS Excel and SPSS v16 were
used for incidence analysis
Cluster Analysis
A retrospective purely spatial and space-time scan
statistic was applied to detect high risk clusters
[vulnerable pockets] of waterborne diseases and water
based vector borne diseases by using SaTScan
software (version 9.2) with a discrete Poisson model.
The Poisson distribution model is used to describe
3

discrete quantitative data such as counts (incidence of

diseases) in which population size (say N) is large, the
probability of an individual event (occurrence of
diseases per 100,000 populations, say p) is small but
expected number of events Np is moderate. SaTScan
uses a Poisson-based model, where the number of
events in a geographical area is Poisson-distributed,
according to a known underlying population at risk. The
distribution formula says = = =
/! where
k= actual case of
occurrence and
=
expected
number
of
occurrence.

and shape, jointly covering the entire study region,

where each cylinder reflects a possible cluster.
The cylindrical window moves over space and time
scanning for an elevated risk within the space-time
window as compared to outside the window.

In case of spatial
scan statistics it
imposes a circular
window on the
map. The window
is
in
turn
Figure 2| Illustration of scan window
centered around
each of several
possible centroids positioned throughout the study
region. For each centroid, the radius of the window
varies continuously in size from zero to some upper
limit. In present study it was taken 50% of the
population at risk to avoid any pre selection bias. In this
way, the circular window is flexible both in location and
size. In total, the method creates an infinite number of
distinct geographical circles, with different sets of
neighboring census areas within them, and each being a
possible candidate for a cluster. The set of centroids
used is defined either in a special grid file, or they are
taken to be identical to the different census locations as
specified in the coordinates file. The latter option
ensures that each census area is a potential cluster in
itself.
The space-time scan statistic is defined by a cylindrical
window with a circular geographic base and with height
corresponding to time. The base is defined exactly as for
the purely spatial scan statistic, while the height reflects
the time period of potential clusters. The cylindrical
window is then moved in space and time, so that for
each possible geographical location and size, it also
visits each possible time period. In effect, we obtain an
infinite number of overlapping cylinders of different size

Under null hypothesis and when there are no

covariates, the expected number of cases () in each
area is proportional to the population size or person
year of that area.

The null hypothesis assumes that incidences of diseases

are randomly distributed. The alternative hypothesis for
each scanning window is that there is an elevated risk
inside the window as compared to outside.
Hypothesis:
H0: The incidence rate is the same over the study area
(homogeneous or relative risk =1)
Ha: The rate is higher in A (Fig:2)

The difference of the incidence inside and outside each

window was calculated by the log likelihood ratio (LLR).
L0 = Likelihood under the null hypothesis
La = Likelihood under the alternative hypothesis
LLR= La / L0
According to the Kulldorffs scan statistics if K be the
total number of incidence of diseases in the study area
and k be the observed number of incidence in within
the circular/ cylindrical window and
be the
covariates adjusted expected number of incidence in
the window under null hypothesis. Let the number of
diseases incidences in the study area follow Poisson
distribution then

LLR= La / L0

Since the analysis is conditioned on the total number of

cases observed, K- is the expected number of cases
outside the window. I() is an indicator function. When
SatScanTM is set to scan only for clusters with high rates,
4

I() =1 when the window has more cases than expected

under null hypothesis, and 0 otherwise.

Type of diseases

Name
of
diseases
Waterborne
Diarrhea
diseases(WBD)
Dysentery
Cholera
Typhoid
Hepatitis
A,D/Jaundice
Water based vector Malaria
borne diseases(WBVB) Filaria

Significant results (based on Monte Carlo simulation)

from these were defined as a cluster. Among the
statistically significant clusters, the cluster with the
maximum LLR indicates one that is least likely to have
occurred by chance which is thus the most likely cluster.
Secondary clusters were those in rank order after the
most likely cluster, based on their likelihood ratio test
statistic. The relative risk of each cluster is the ratio of
the estimated risk within the cluster to that outside the
cluster (Kulldorff.M, 2013)

No of case
identified
1864
605
0
1
5
56
5

Table 2| Distribution of reported cases

Age groups have been found one of the deciding factors

in terms of both waterborne and water based vector
borne diseases. Following table depicts the distribution
of diseases according to age groups.

SaTScanTM adjusts for the underlying spatial in

homogeneity of a background population. It can also
adjust for any number of categorical covariates
provided by the user, as well as for temporal trends,
known space-time clusters and missing data. It is
possible to scan multiple data sets simultaneously to
look for clusters that occur in one or more of them.
Though covariates like age and sex were an integral part
of the database yet those were not incorporated in the
model to keep the output simple.

Age groups
0-1
1-5
5-15
15-25
25-35
35-45
45-55
55-65
65
Missing vale
Total

Result

WBD
132
508
499
352
429
244
130
82
94
6
2476

WBVBD
0
3
7
17
15
12
4
3
0
0
61

Table 3 | Age wise distribution of disease distribution

After doing all adjustments for the study duration,

habitual residence of patients total 2476 cases of
waterborne diseases were identified to be used in the
model and total 61 cases of water based vector borne
diseases were identified. In case of water borne
diseases Diarrhea occupies the top slot with 74
%(n=2476) identified cases followed by Dysentery.
Whereas in case of water based vector borne diseases

In both the category of diseases number of female

patients was found more than the number of male
patients.

Malaria was the majority with 92% identified cases

(n=61)
Sex
Female
Male

Count
1380
1096

WBD
%
56
44

N
2476

Count
33
28

WBVBD
%
59
41

N
61

Table 4| Sex wise diseases incidence distribution

>65
38
55-65
38
45-55
55
35-45
110
25-35
148
15-25
130
5-15 254
1-5 241
0-1
79
400

200

56
44
75
134
281
222
245
267

Female
Male

53
0

200

400

Figure 3| Age-sex distribution of WBD cases

Cluster detected
With a purely spatial scanning considering all the water
borne diseases together nine clusters with elevated risk
were detected.(Fig:5) Out of nine three were found
statistically insignificant(p>.000001). The primary
cluster of water borne disease was found on the
northern part of city across ward number 9 with radios
of 0.12 km. Three adjacent slums come under this
cluster comprising three adjacent slums. The log
likelihood ratio was found 868.79 (p<.000001). The
maximum likelihood ratio indicates this cluster is less
likely to be formed by chance and also the value of
relative risk (RR=9.5) signifies how intense the cluster
was. All the clusters were plotted by ArcView GIS 3.2
and presented in map
With the same data set however space-time scan
statistics detects 6 significant clusters (Fig:6), where the
centroid of primary cluster got slightly shifted from the
primary cluster identified in previous case(Fig:5). While
Panda Park was the centriod of the primary cluster in
previous case, HKNagar evolved as the centriod in
present case. The radius of primary cluster this time is
bigger covering .37 km and containing five adjacent
slums and cluster lasted only for 2012. The relative risk
was found slightly lower than the previous case
(RR=8.65). Since the different water borne diseases

>65
55-65
2
45-55
1
35-45
4
25-35-9
15-25 7
5-15
3
1-5
2
0-1
10

0
1
3
8
Female

6
10

Male

4
1
0
0

10

20

Figure 4| Age-sex distribution of WBVBD

have different etiological agents with the segregation of

disease clustering pattern gets totally changed. While
the northern part of the city was identified with the
primary clusters of diarrhea (Fig: 7), slums of the
southern part were more prone to dysentery (Fig:8).
Despite clear dissimilarity of the etiologic agents water
based vector borne diseases (mainly malaria, filarial)
and water borne diseases( diarrhea, dysentery, typhoid
etc.) both seems to share common risk factors which
are largely mediated by poor environmental sanitation
infrastructure and socioeconomic condition. Pure
spatial scan statistics identified three clusters of Water
based vector borne diseases two of which coincides
with the same geographical area having indentified with
clusters of water borne disease(Fig:9 & 7 ) No space
time clusters of water based vector borne diseases were
identified based on available data.

Figure 5| Spatial cluster of water borne disease

Following table depicts the details of nine spatial clusters identified

Raious(km)

Location

85.798745

0.12

868.797479

20.282232

85.805044

212.570223

JanataNagar

20.301508

85.81132

0.083

80.893849

JayadevNagarBasti

20.247004

85.840296

0.49

59.511693

KapileswarBhoiSahi

20.230106

85.830032

55.259999

NilachakraNagar

20.302421

85.817028

48.486951

pvalue
1.00E17
1.00E17
1.00E17
1.00E17
1.00E17
1.00E17

KapileswarBasti

20.229712

85.816737

7.15407

0.024

13

3.66

3.55

3.57

GangaNagar

20.262421

85.815095

1.964492

0.975

14

7.84

1.79

1.79

Balitotasahi

20.280774

85.814593

1.683479

0.992

42

31.27

1.34

1.35

Cluster

Location ID

Long

Lat

PandaPark

20.32587

Mundasahi

LLR

Observed

Expected

OR

RR

714

101.25

7.05

9.5

343

92.53

3.71

4.14

252

103.23

2.44

2.6

81

18.04

4.49

4.61

40

4.12

9.7

9.84

285

153.68

1.85

1.97

Table 5| Detail of the nine clusters of water borne diseases

Kapileswar Bhoisahi ranked 5 th based on its LLR score. It is one of the significant secondary clusters of water borne
diseases. However its relative risk (RR=9.84) is higher than even primary clusters (9.5). This signifies the intensity of this
cluster and

Figure 6| Space time cluster of Water borne diseases

Following table depicts the detail of space time clusters with end and beginning time of the clusters
Clust
er

Location ID

HKNagar

Mundasahi

JanataNagar
JayadevNagarBa
sti
NilachakraNaga
r
KapileswarBhoi
Sahi

4
5
6

Lat
20.3280
91
20.2822
32
20.3015
08
20.2470
04
20.3024
21
20.2301
06

Long
85.7995
36
85.8050
44
85.8113
2
85.8402
96
85.8170
28
85.8300
32

Radios(k
m)
0.37
0
0.083
0.49
0
0

Start date
01/01/20
12
01/01/20
12
01/01/20
11
01/01/20
11
01/01/20
11
01/01/20
11

End date
31/12/20
12
31/12/20
12
31/12/20
11
31/12/20
11
31/12/20
11
31/12/20
11

No
location
5
1
2
2
1
1

LLR
781.1711
55
165.7162
53
102.3506
78
91.73251
1
85.69790
2
70.22669
6

pvalue
1.00E17
1.00E17
1.00E17
1.00E17
1.00E17
1.00E17

observ
ed

expect
ed

OR

RR

689

106.69

6.46

8.56

214

46.33

4.62

4.96

252

90.4

2.79

2.99

79

10.52

7.51

7.72

193

64.9

35

1.84

2.97
19.0
6

3.14
19.3
2

Table 6| Details of the six space-time clusters of water borne diseases

The primary space- time cluster was found existing within 2012 only and it was found comprising 5 locations with HK
Nagar being the centriod. Out of five locations one is Panda Park the centroid of the primary cluster detected in purely
8

spatial scanning. Cluster 2 in rank of log likelihood ratio was also found to exist within 2012. However remaining four
secondary clusters duration were confined within 2011. The 4th secondary cluster with Jaydevnagar basti as its centroid
demands special attention apart from primary clusters as it spreads over .49 km area containing two adjacent slums
having relative risks RR= 7.72 which is at per the primary cluster. Despite relatively low LLR score 6th cluster again
demands special attention as it RR= 19.3 is even greater than the primary cluster.

Figure 7 | Space time clusters of Dirrhea

Following table depicts the detail of four identified hot-spots of diarrhea

CLUST
ER

LOC_ID

HKNagar

Mundasahi

JanataNagar
NilachakraN
agar

LATITU
DE
20.3280
91
20.2822
32
20.3015
08
20.3024
21

LONGIT
UDE
85.7995
36
85.8050
44
85.8113
2
85.8170
28

RADI
US

START
END
No of
DATE
DATE
LOC
LLR
01/01/20 31/12/2
643.568
0.37 12
012
5
378
01/01/20 31/12/2
212.545
0 12
012
1
714
01/01/20 31/12/2
147.396
0.083 11
011
2
683
01/01/20 31/12/2
80.9430
0 11
011
1
53
Table 7| Detail of four Diarrhea clusters

p
VALUE
1.00E17
1.00E17
1.00E17
1.00E17

OBSERV
ED

EXPECT
ED

544

80.27

211

34.86

246

68.02

159

48.83

OR
6.7
8
6.0
5
3.6
2
3.2
6

RR
9.1
6
6.7
4.0
1
3.4
7

All the four clusters are found significant however geographically located in the northern side of the city. The primary
cluster which comprises five locations and with radius 0.37 km began in 2012 and ended in the same year. One of the
secondary clusters was also confined within 2012. Remaining two clusters were started on 2011 and ended in the same
year. Since the time precision was taken only year this scan statistics does not show any intermediate clusters
When dysentry cases are scanned seperately the primary clusters appeared in the southern part of the city with
relativly bigger radius of 1.94 km , while Samantrapur Basti remained the centriod of the clsuter it spread across 7 other
location. This cluster was bengan in 2011 and it implies that that year southern part of the city has come acrros certain
out breaks of dysentry. Other two secondary clusters how ever coincide with the cluster centriod of dirrhoea and the

clusters began only in 2012. Following map shows the location of the identified clusters of dysentry along with the
detail description of the clusters their likelihood ratio, p-value; ods ratio and relative risks.

Figure 8| Location of the clusters of the dysentery in Bhubaneswar slums

Following table is presenting the details of the identified hotspots of the dysentery across slums of Bhubaneswar.
LOC_ID
SamantrapurBa
sti

LATITUD
E
20.22952
8

PandaPark
NilachakraNaga
r

20.32587
20.30242
1

LONGITU
DE
85.83999
8
85.79874
5
85.81702
8

RADIU
S
1.94
0.12
0

START
DATE
01/01/201
1
01/01/201
2
01/01/201
2

END DATE
31/12/20
11
31/12/20
12
31/12/20
12

NUMBER
LOC
8
3
1

LLR
187.0721
89
163.1254
82
15.04009
9

OBSERVE
D

EXPECTE
D

1.00E-17

113

9.39

OR
12.0
3

1.00E-17
0.000016
7

117

12.96

9.03

RR
14.5
7
10.9
5

51

21.69

2.35

2.48

P VALUE

Table 8| Detail of the dysentery clusters

In case of water based vector borne diseases small numbers of cases were obtained from OPD registers and that too of
Malaria and Fileria. No space time clusters were identified with the data however three pure spatial clusters were
detected in the study area. Out of three only the primary clusters with LLR value 31.24 were found statistically
significant. Though first secondary cluster with its centroid located at Kapileswar Bhoi Sahi was found statistically
insignificant ( p>.00001) yet its maximum relative risks (RR=10.29) demands special attention. All three clusters have
been found to share same geographic location with previously identified hot-spots of water borne diseases. Following
table represents the detail of the clusters for water based vector borne diseases.
CLUSTER

LOC ID

LATITUDE

LONGITUDE

RADIUS

No of LOC

LLR

p VALUE

OBSERVED

EXPECTED

OD

RR

Mundasahi

20.282232

85.805044

31.241963

4.88E-15

32

6.84

4.68

8.73

kapileswarBhoiSahi

20.230106

85.830032

4.222975

0.059

0.31

9.83

10.29

GangaNagar

20.262421

85.815095

1.072667

0.831

0.58

3.45

3.53

Table 9| Detail of the clusters of water based vector borne diseases

10

Figure 9| Location of clusters of vector borne diseases

Figure 10| Common hot spots

11

Overlapping of the hot spots of water borne diseases

and water based vector borne disease proves that slums
are having common risk factors which are mainly
mediated by poor environmental sanitation and socio
economic condition.

Conclusion
Current study was an effort to demonstrate such
surveillance system can be helpful in various ways from
planning for preventive measures, management of
outbreaks to policy formation. Continuous surveillance
system can validate the identified clusters and further
longitudinal studies can be undertaken there for
identification of causal factors.
In case of space time scan statistics the precision time
was taken one year (2011-12) due to paucity and poor
quality of data. Once active or syndromic surveillance
system is in place clustering pattern in month, weak and
even day basis is possible. Managing outbreaks can be
more effectively with that prediction.
Current study reveals that northern part of the city is
more prone do diarrhea while in southern part a large
cluster of dysentery was indentified. Secondary
information also suggests the yearly outbreaks of water
borne diseases in southern part. Sources from Public
Health Engineering department suggest it is because of
the land formation of the area. Laterite soil is
predominant in this area which is porous in nature.
Eventually it leads to subsurface water contamination.
High prevalence of using of dug well in this area also
may be another reason. All the facts demand further
integration. Laboratory test can confirm if different
etymological agents
are really active in different
geographical area.
In the current study no covariates like age, sex, socio
economy etc was considered while modeling.
Incorporation of such covariates can give us more
robust information helpful for preventive measures and
policy formation.

In conclusion water borne diseases like diarrhea and

dysentery and water based vector borne diseases like
malaria; fileriosis etc. have special and spatiotemporal
clusters. With proper data the seasonal nature of the
outbreaks can be identified and prevention and control
measures can be designed.
Limitation
The prime limiting factor of this current study was
availability and quality of data. Since it was difficult to
extract slum specific data from the existing surveillance
system case dada was obtained from OPD registers of
urban slums health centers. While the study was
undertaken most of the centers were only two years old
in their operation. However such study demands data of
comparatively longer periods for trend analysis.
Data quality was another constraint and several
adjustments had to make. Still some bias like chances of
over reporting or under reporting cannot be ruled out.
The study lacks in comprehensiveness as it was confined
only in HUP intervention areas.
Another limitation of this current study lies in the
nature of circular scan statistics, which does not allow
for irregular geographic shapes.
As there is no consensus and optimal maximum- size of
the spatial cluster size setting in current study
recommended value of 50% of the population at risk in
scanning window was used to avoid pre-selection bias.
However bigger clusters often identifies area with
comparatively lower relative risk. But from policy
makers point of view identification of those clusters are
essential than the smaller clusters with elevated risks.
Proximity of health center or disperse community can
be another confounding factor in terms of case

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reporting. To keep the study simple no further

adjustment were made.
Acknowledgement
We would like to thanks all the HUP partner NGOs
managing urban slum health centers in collaboration
with NRHM and Bhubaneswar Municipal Corporation,
for sharing their OPD registers of two consecutive years.
Dr. Dinabandhu Sahoo, Joint Director NUHM( Tech) and
former Chief Municipal Medical Municipal Officer
deserves special thanks as without his instigation this
study would not have been materialized. We would
also like to thank Mr. Ratikanta Behera who with his
team did the most tedious part of the study by
screening case by case form OPD register and made the
essential database for this study.
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