Clinical profile of hospitalized COVID-19 patients in first & second wave of the pandemic: Insights from an Indian registry based observational study

Clinico-Epidemiological Characteristics of Healthcare Workers with SARS-CoV-2 Infection during the First and Second Waves in a Teaching Hospital from Eastern India: A Comparative Analysis

In this retrospective observational study, we have performed a comparative analysis of the demographic, clinical and epidemiological characteristics of the HCWs affected with SARS-CoV-2 infection during first two waves in India. The overall prevalence of SARS-CoV-2 infection among HCWs was found to be 15.24% (14.20-16.33) and 23.38% (22.14-25.65) during first and second waves respectively. The second wave showed an adjusted odds ratio of 0.04(0.02-0.07) and 2.09(1.49-2.93) for hospitalization and being symptomatic, respectively. We detected significantly higher level of C-reactive protein (CRP) among admitted HCWs during the second wave (5.10 -14.60 mg/dl) as compared to the first wave (2.00 - 2.80 mg/dl). Our study found the relative risk of SARS-CoV-2 reinfection among HCWs during the second wave to be 0.68 [0.57-0.82, p < 0.001)]. Although, the prevalence of SARS CoV-2 infection and risk of being symptomatic was higher during second wave, the risk of hospitalization was less when compared with the first wave.

Influence of COVID-19 pandemic in India on coronary artery disease clinical presentation, angiography, interventions and in-hospital outcomes: a single centre prospective registry-based observational study

OBJECTIVE

The study examined the influence of the COVID-19 pandemic in India on variation in clinical features, management and in-hospital outcomes in patients undergoing percutaneous coronary intervention (PCI).

DESIGN

Prospective registry-based observational study.

SETTING

A tertiary care hospital in India participant in the American College of Cardiology CathPCI Registry.

PARTICIPANTS

7089 successive patients who underwent PCI from April 2018 to March 2023 were enrolled (men 5627, women 1462). Details of risk factors, clinical presentation, coronary angiography, coronary interventions, clinical management and in-hospital outcomes were recorded. Annual data were classified into specific COVID-19 periods according to Government of India guidelines as pre-COVID-19 (April 2018 to March 2019, n=1563; April 2019 to March 2020, n=1594), COVID-19 (April 2020 to March 2020, n=1206; April 2021 to March 2022, n=1223) and post-COVID-19 (April 2022 to March 2023, n=1503).

RESULTS

Compared with the patients in pre-COVID-19 and post-COVID-19 periods, during the first COVID-19 year, patients had more hypertension, non-ST elevation myocardial infarction (NSTEMI), lower left ventricular ejection fraction (LVEF) and multivessel coronary artery disease (CAD). In the second COVID-19 year, patients had more STEMI, lower LVEF, multivessel CAD, primary PCI, multiple stents and more vasopressor and mechanical support. There were 99 (1.4%) in-hospital deaths which in the successive years were 1.2%, 1.4%, 0.8%, 2.4% and 1.3%, respectively (p=0.019). Compared with the baseline year, deaths were slightly lower in the first COVID-19-year (age-sex adjusted OR 0.68, 95% CI 0.31 to 1.47) but significantly more in the second COVID-19-year (OR 1.97, 95% CI 1.10 to 3.54). This variation attenuated following adjustment for clinical presentation, extent of CAD, in-hospital treatment and duration of hospitalisation.

CONCLUSIONS

In-hospital mortality among patients with CAD undergoing PCI was significantly higher in the second year of the COVID-19 pandemic in India and could be one of the reasons for excess deaths in the country. These patients had more severe CAD, lower LVEF, and more vasopressor and mechanical support and duration of hospitalisation.

Analyzing the Outcomes of COVID-19 Infection on Patients With Comorbidities: Insights From Hospital-Based Study

Introduction COVID-19 exhibits a broad spectrum of clinical manifestations, ranging from asymptomatic or mild cases to severe respiratory distress and, in some instances, fatal outcomes. The pre-existing inflammatory state in the patient prior to exposure to COVID-19, which could be because of any etiology or comorbidity, has been associated with prolonged morbidity, and adverse outcomes like increased mortality have been found. This study endeavors to investigate the principal risk factors linked to the morbidity and mortality of COVID-19, such as age, gender, and co-morbidities such as hypertension, diabetes mellitus, and others. Material and methods Patient demographic data like age, gender, and co-morbidities like diabetes mellitus, hypertension, respiratory illness, and coronary artery diseases, cerebrovascular accident was observed. The patient clinical profile, hematological, inflammatory markers at the time of admission, and outcome were noticed. Patients were divided into two groups - patients with comorbidity and those without comorbidity. Results In each cohort of COVID-19 patients, comprising those with and without comorbidities, there were 145 participants. The mean age of patients without comorbidities was found to be 49.97 years, whereas the mean age of those with comorbidities was 64.35 years. Within the comorbidity group, males formed the majority, accounting for 77.2% of the cohort; in the group without comorbidity also males predominated, representing 68.3% of the participants. Hypertension was the most common co-morbidity (89.7%), followed by diabetes mellitus (39.3%), and ischemic heart disease (8.3%). The multivariate logistic regression analysis for prediction of mortality showed hypothyroidism with odds ratio (OR) of 336.26 and confidence intervals (CI) (1.19-9477.13), ischemic heart disease with OR of 320.94 (CI 3.19-3237.4) and presence greater than two co-morbidities with OR of 42.14 (CI 1.34-1325.76). Cox regression analysis showed a statistically significant hazard ratio of 0.294 in patients with greater than two co-morbidities. Conclusion Hypothyroidism, ischemic heart disease, and the presence of multiple comorbid conditions were associated with the severity of COVID-19 illness and mortality.

A Comparative Study of Deaths Due to the COVID-19 Pandemic During the First and Second Waves in a Tertiary Care Center of a Rural Area in South India

Background The coronavirus disease 2019 (COVID-19) pandemic affected life and livelihood worldwide, including India, with over five million deaths recorded over two years. In the present study, our objective was to analyze the COVID-19 deaths during the first and second waves in relation to demographic factors and comorbid conditions. Methods This was a hospital-based, retrospective comparative study of COVID-19 deaths that occurred in our hospital during the first and second waves of the COVID-19 pandemic. A total of 210 (6.69%) deaths recorded during both waves of the pandemic were analyzed. Microsoft Excel sheets (Microsoft Corporation, Redmond, WA, USA) were used to collect data from the medical records section, and the data were compiled. Descriptive statistics were used and analyzed using SPSS version 21 (IBM Corp., Armonk, NY, USA). Results Out of 3136 inpatients, mortality was 6.69% (n=210). Out of 210 deaths recorded in the study, 34 (2.25%) and 176 (10.7%) were during the first and second waves of the pandemic, respectively. The most common age group affected during the two waves was 50-75 years (67.6% & 47.7%; n=23 & n=84). People from urban (52.9%; n=18) and rural (67%; n=118) backgrounds were affected more during the first and second waves, respectively. Males were affected more (72.8%; n=153) in both waves. Age group (P=0.009) and locality (P=0.026) were statistically significant factors associated with mortality in the two COVID-19 waves. The time interval from admission in the hospital to death was less than seven days in both waves (70.5% & 69.8%; n=24 & n=123). A large number of subjects died after 48 hours of admission during both waves (70% (n=24 & n=124) in each wave). More than half of the subjects who died (52.9% (n=18) & 59% (n=104)) had comorbid conditions in both waves. Diabetes mellitus (17.6%; n=6) and hypertension (23.5%; n=8) were the most common comorbid conditions during the first wave of the pandemic while diabetes mellitus (30.6%; n=54) alone was the most common during the second wave. Conclusion The findings of this study stress the importance of considering demographic factors and geographic locations in understanding the impact of COVID-19, providing valuable inputs for public health interventions and resource allocation in response to similar pandemics.

COVID-19 in Pakistan: A national analysis of five pandemic waves

OBJECTIVES

The COVID-19 pandemic showed distinct waves where cases ebbed and flowed. While each country had slight, nuanced differences, lessons from each wave with country-specific details provides important lessons for prevention, understanding medical outcomes and the role of vaccines. This paper compares key characteristics from the five different COVID-19 waves in Pakistan.

METHODS

Data was sourced from daily national situation reports (Sitreps) prepared by the National Emergency Operations Centre (NEOC) in Islamabad. We use specific criteria to define COVID-19 waves. The start of each COVID-19 wave is marked by the day of the lowest number of daily cases preceding a sustained increase, while the end is the day with the lowest number of cases following a 7-days decline, which should be lower than the 7 days following it. Key variables such as COVID-19 tests, cases, and deaths with their rates of change to the peak and then to the trough are used to draw descriptive comparisons. Additionally, a linear regression model estimates daily new COVID-19 deaths in Pakistan.

RESULTS

Pakistan saw five distinct waves, each of which displayed the typical topology of a complete infectious disease epidemic. The time from wave-start to peak became progressively shorter, and from wave-peak to trough, progressively longer. Each wave appears to also be getting shorter, except for wave 4, which lasted longer than wave 3. A one percent increase in vaccinations decreased deaths by 0.38% (95% CI: -0.67, -0.08) in wave 5 and the association is statistically significant.

CONCLUSION

Each wave displayed distinct characteristics that must be interpreted in the context of the level of response and the variant driving the epidemic. Key indicators suggest that COVID-19 preventive measures kept pace with the disease. Waves 1 and 2 were mainly about prevention and learning how to clinically manage patients. Vaccination started late during wave 3 and its impact on hospitalizations and deaths became visible in wave 5. The impact of highly virulent strains Alpha/B.1.1.7 and Delta/B.1.617.2 variants during wave 3 and milder but more infectious Omicron/B.1.1.529 during wave 5 are apparent.

Clinical characteristics and predictors of COVID-19 in a community sample from urban areas of Chennai, Southern India

In early 2020, with the arrival of the first case of COVID-19 in India, the laboratory at The Tamil Nadu Dr. MGR Medical University was recognized as a national testing site and received samples from two zones of Greater Chennai Corporation. This descriptive study analyzed the testing outcomes, along with demographics, self-reported symptoms, potential exposure to COVID-19 that were recorded in Sample Report Forms between June and September 2020. Nasopharygeal/oropharyngeal swabs were tested for SARS CoV-2 by RT-PCR Test. Of the 18,082 samples that were tested, 18% (3267) received a COVID-19 positive RT-PCR result for COVID-19. Among the COVID-19 positives, 40.9% (1336) were females (p < 0.000). Individuals in the age groups 21-30 and 31-40 years included the largest number (767, 23.48% each) of COVID-19 positive cases. The largest number of cases were from those who were classified as Severe Acute Respiratory Illness (SARI) or Influenza Like Illness (ILI) (1657, 50.7%) followed by those who reported direct contact with a COVID-19 lab confirmed case (1163, 35.6%). Among those with symptoms, 1791 (28.9%) tested COVID-19 positive compared to 1476 who were COVID-19 positive and asymptomatic (p < 0.001). Main symptoms were cough (32.1%), fever (48.3%), body ache (21.04%) and sore throat (30.60%). In multivariable analysis, history of SARI/ILI, contact with a confirmed case and having fever, cough and sore throat were the main predictors of being COVID-19 positive. Therefore, clinical and demographic characteristics correlated with COVID-19 positivity. And classification of patients based on self-reported symptoms and risk categories offers a model to prioritize testing and vaccination efforts.

Clinical and Epidemiological Characteristics of Hospitalized COVID-19 Patients in an Isolation Centre in South-West Nigeria

INTRODUCTION

The clinical presentation of coronavirus disease 2019 (COVID-19) can vary widely, and while the primary infection involves the respiratory system, other organs can also be affected. This study presents the clinical and epidemiological characteristics of hospitalized COVID-19 patients in a tertiary hospital in Ado Ekiti, South-West Nigeria.

MATERIALS AND METHODS

This is a retrospective study involving COVID-19 patients admitted to the isolation ward between August 2020 and January 2021. The data used for this study was obtained from the patient's medical record, which includes demographic characteristics, clinical presentation, baseline co-morbidities, and laboratory investigations.

RESULTS

The average age of the patients was 60.3 years, and more than two-thirds were male. The most common symptoms were fever, shortness of breath, cough, and tiredness. Comorbidities identified among the patients included diabetes mellitus, heart disease, obesity, and chronic kidney disease. The most common radiological findings were bilateral homogeneous patchy opacities and peripheral fluffy infiltrates. The overall mortality rate was 21.9%, with 13 deaths in patients with severe disease. Age and duration of admission were found to be significant predictors of death.

CONCLUSION

The results of this study provide valuable insights into the clinical presentation of COVID-19 in Nigeria and may guide future management strategies for similar infections.

Evaluation of a Hospitalized Pediatric COVID-19 Cohort from Indian National Clinical Registry of COVID-19

OBJECTIVE

To evaluate the factors associated with mortality of a multicentric cohort of hospitalized COVID-19 patients, 0-18 y old, from 42 centers across India.

METHODS

The National Clinical Registry for COVID-19 (NCRC) is an on-going prospective data collection platform enrolling COVID-19 patients diagnosed by real-time PCR or rapid antigen test. The data are collected in prestructured e-capture forms. The sociodemographic, clinical, laboratory, and hospital outcome data from 1st September 2020 to 20th February 2022 were analyzed.

RESULTS

Of the 1244 enrolled hospitalized COVID-19 patients aged 0-18 y, 98 and 124 were infants and neonates, respectively. Only 68.6% children were symptomatic at admission, with fever being the most common symptom. Diarrhea, rash, and neurological symptoms were also noted. At least 1 comorbidity was present in 260 (21%) children. The in-hospital mortality rate was 6.2% (n = 67), the highest in infants (12.5%). Altered sensorium (aOR: 6.8, CI: 1.9, 24.6), WHO ordinal scale ≥ 4 at admission (aOR: 19.6, CI: 8.0, 47.8), and malignancy (aOR: 8.9, 95% CI: 2.4, 32.3) were associated with higher odds of death. Malnutrition did not affect the outcome. Mortality rates were similar across the three waves of the pandemic, though a significant shift towards the under-five group was observed in the third wave.

CONCLUSION

This multicentric cohort of admitted Indian children showed that the COVID-19 was milder in children than adults, and the pattern was consistent across all waves of the pandemic.

Post COVID sequelae among COVID-19 survivors: insights from the Indian National Clinical Registry for COVID-19

INTRODUCTION

The effects of COVID-19 infection persist beyond the active phase. Comprehensive description and analysis of the post COVID sequelae in various population groups are critical to minimise the long-term morbidity and mortality associated with COVID-19. This analysis was conducted with an objective to estimate the frequency of post COVID sequelae and subsequently, design a framework for holistic management of post COVID morbidities.

METHODS

Follow-up data collected as part of a registry-based observational study in 31 hospitals across India since September 2020-October 2022 were used for analysis. All consenting hospitalised patients with COVID-19 are telephonically followed up for up to 1 year post-discharge, using a prestructured form focused on symptom reporting.

RESULTS

Dyspnoea, fatigue and mental health issues were reported among 18.6%, 10.5% and 9.3% of the 8042 participants at first follow-up of 30-60 days post-discharge, respectively, which reduced to 11.9%, 6.6% and 9%, respectively, at 1-year follow-up in 2192 participants. Patients who died within 90 days post-discharge were significantly older (adjusted OR (aOR): 1.02, 95% CI: 1.01, 1.03), with at least one comorbidity (aOR: 1.76, 95% CI: 1.31, 2.35), and a higher proportion had required intensive care unit admission during the initial hospitalisation due to COVID-19 (aOR: 1.49, 95% CI: 1.08, 2.06) and were discharged at WHO ordinal scale 6-7 (aOR: 49.13 95% CI: 25.43, 94.92). Anti-SARS-CoV-2 vaccination (at least one dose) was protective against such post-discharge mortality (aOR: 0.19, 95% CI: 0.01, 0.03).

CONCLUSION

Hospitalised patients with COVID-19 experience a variety of long-term sequelae after discharge from hospitals which persists although in reduced proportions until 12 months post-discharge. Developing a holistic management framework with engagement of care outreach workers as well as teleconsultation is a way forward in effective management of post COVID morbidities as well as reducing mortality.

Epidemiology, clinical presentation and treatment outcomes in patients with COVID-19 in an ambulatory setting: a cross sectional study during the massive SARS-CoV-2 wave in India

The COVID-19 pandemic, caused by SARS-CoV-2, has profoundly affected developing countries like India. This retrospective cross-sectional analysis investigated epidemiological, clinical characteristics, treatment strategies, and outcomes for hospitalized COVID-19 patients during the Massive SARS-CoV-2 Wave in India. Among 233 patients, the median age was 47.33 years, mostly male. Hospital stays averaged 8.4 days. Common symptoms include fever (88.41%), dry cough (56.2%), myalgia (44.20%), and shortness of breath (22.8%). The most common comorbidities were diabetes mellitus (52%) and hypertension (47.2%). Elevated biomarkers include D-dimer (24.4%), CRP (32.1%), ferritin (26.60%), and others. Prescription analysis revealed that antibiotics (42.6%), Antivirals (37%), anthelmintics (20.30%), vitamins and nutritional supplements (20.71%) and glucocorticoids (12.8%) were the most commonly prescribed. Oxygen therapy was needed by 19.31% of patients in the moderate and severe categories within 24 hours of admission. The mortality rate was 8.58%. The surge led to increased hospitalizations and mortality, particularly among young adults. Diabetes and hypertension were correlated with mortality. Irregular use of drugs lacking evidence, like antibiotics and anthelmintics, vitamins and nutritional supplements, was observed in COVID-19 management. This study underscores the impact of the pandemic in India and highlights the need for evidence-based treatments.

Assessment of lung involvement using HRCT among vaccinated and non-vaccinated elderly COVID-19 patients admitted in a designated hospital, Tamil Nadu - A retrospective study

Introduction

The COVID-19 pandemic is considered one of the most devastating situations globally, the worst affected were the senior citizens. A number of initiatives were carried out to control the COVID-19 pandemic; one such important measure is the development of COVID-19 vaccines to prevent the disease. But the continuous emergence of new SARS-COV2 variants (antigenic drift) and its demographic variation in virulence makes the vaccine's efficacy questionable. This study is intended to evaluate the association between the degree of lung involvement and the effectiveness of vaccination against the disease in cases admitted to a designated hospital in Tamil Nadu.

Materials and Methods

A hospital records-based-retrospective research was conducted among COVID-19 patients admitted from the 1st of April 2021 to the 31st of May 2021, and information was gathered regarding their vaccination status, comorbid conditions, and CT severity score (CTSS) in the HRCT lung report. A consecutive sampling technique was used to choose the study participants; about 120 participants were included in the study. The Chi-square test and Fisher's extract test were used to evaluate the hypothesis. The relationship between a dependent variable and independent factors was estimated using multiple linear regression.

Results

Among 120 participants, about 60.2% were males and 39.8% were females. Vaccination status and comorbid conditions had a significant association with severe lung involvement in COVID-19 patients.

Conclusion

Non-vaccinated patients had severe lung involvement based on the HRCT lung scan findings than the vaccinated patients. To reduce mortality, it is essential to ensure universal coverage of COVID-19 vaccination.

Impact of COVID-19 on healthcare system in India: A systematic review

Despite an extensive healthcare system in India, the COVID-19 Pandemic created havoc upon the existing Indian healthcare system by disrupting the supply of essential healthcare services to patients. It has also highlighted the significant-quality discrepancies of healthcare facilities between the rural-urban areas and between public and private healthcare providers. The not so advanced healthcare system of India was exposed through the lack of oxygen and essential drugs required for the treatment of COVID-19. Additionally, during the pandemic period there was a drastic decline in seeking non-COVID-19 disease related healthcare services. The objective of this systematic review is to determine whether COVID-19 has impacted the healthcare system in India.

A single-centred retrospective observational analysis on mortality trends during the COVID-19 pandemic

BACKGROUND

South Africa experienced high mortality during the COVID-19 pandemic. Resources were limited, particularly at the district hospital (DH) level. Overwhelmed healthcare facilities and a lack of research at a primary care level made the management of patients with COVID-19 challenging. The objective of this study was to describe the in-hospital mortality trends among individuals with COVID-19 at a DH in South Africa.

METHODS

Retrospective observational analysis of all adults who demised in hospital from COVID-19 between 01 March 2020 and 31 August 2021 at a DH in South Africa. Variables analysed included: background history, clinical presentation, investigations and management.

RESULTS

Of the 328 participants who demised in hospital, 60.1% were female, 66.5% were older than 60 and 59.6% were of black African descent. Hypertension and diabetes mellitus were the most common comorbidities (61.3% and 47.6%, respectively). The most common symptoms were dyspnoea (83.8%) and cough (70.1%). 'Ground-glass' features on admission chest X-rays were visible in 90.0% of participants, and 82.8% had arterial oxygen saturations less than 95% on admission. Renal impairment was the most common complication present on admission (63.7%). The median duration of admission before death was four days (interquartile range [IQR]: 1.5-8). The overall crude fatality rate was 15.3%, with the highest crude fatality rate found in wave two (33.0%).

CONCLUSION

Older participants with uncontrolled comorbidities were most likely to demise from COVID-19. Wave two (characterised by the 'Beta' variant) had the highest mortality rate.Contribution: This study provides insight into the risk factors associated with death in a resource-constrained environment.

An in-depth appraisal of clinico-biochemical and radiological findings of COVID-19 patients during the COVID-19 pandemic in a dedicated COVID Care Hospital in Eastern India and its outcome in relation to the COVAXIN vaccination status: A 2-year study

Introduction

COVID-19 pandemic hit Odisha province from April 2020 to December 2020, then from April 2021 to August 2021 and from February 2022 to April 2022 as the first, second, and third waves, respectively, with the most severe form witnessed during the second wave. Kalinga Institute of Medical Sciences hospital in Odisha was declared a Dedicated COVID Hospital (DCH) during those three waves and witnessed 9485 cases of admissions among which there were 1214 deaths. COVAXIN vaccination of the vulnerable population was launched in February 2021 onwards. This study has been done to know the clinic-biochemical profiles, radiologic findings of COVID-19 admitted patients, the predictors of mortality in the second wave, and clinical outcomes in the three waves in relation to COVAXIN vaccination status.

Material and Methods

This was a serial three-round retrospective study from the electronic medical records using multistage random sampling where we collected and critically analyzed the demographic, and all the relevant possible health data of the cases that consist of 514 cases admitted in three waves. The data from death certificates among the 555 cases in the second wave have been analyzed to conclude predictors of mortality.

Results

Mortality increased with age, male gender, comorbidities, and raised C-reactive protein level. High NL ratio, extent of pulmonary involvement. There was a wide variation in incidence and spectrum of illness starting from 79% incidence of mild symptomatic in the initial and third wave, but remained in the range of 35-65% in the second wave, respectively, and the most noticeable symptomatic illness was that of the upper respiratory tract. In fulminant cases, the mode of presentations was severe pneumonia and acute respiratory distress syndrome. Males were more sufferers than females. Children had better outcomes compared to adults. COVID-associated coagulopathy had a normal platelet count. Subsequently, in 2021 year onwards vaccination of the vulnerable population was launched in a phased manner that changed the dynamics of the disease outcome by better survival chances despite intercurrent COVID infection by induction of herd immunity. On the contrary, there was a higher prevalence of serious illness among non-vaccinated individuals. While the cases continued during the second wave of the pandemic, long COVID became a clinical entity of symptomatic that persisted or recurred among the COVID illness recovered cases after reverse transcriptase polymerase chain reaction results for COVID-19 became negative. The symptoms consisted of fatigue, cough, dyspnea as pulmonary manifestations and extra-pulmonary involvement of the cardiac, renal, and central nervous systems and the pulmonary imaging features consisted of interstitial pneumonia, consolidation, cavity pattern, and prone to microbial infection. These events lead to morbidity and admission. Coinciding with the vaccination of all population of Odisha province with the first dose of the vaccine by around the period of the first quarter of 2022, there was a new variant named Omicron responsible in the third wave, in which the majority of the admitted cases had.mild upper respiratory illness. This was not as lethal as its predecessors due to its lower propensity to invade the lungs and blood vessels.

Conclusion

Immune dysregulation plays a central role in the pathogenesis of the manifestations. Vaccine-induced protection and the induction of herd immunity played a proactive role in the waning of the severity of clinical presentations.

Reinfection of COVID-19 among doctors at a tertiary care centre in Northern India: A report from a resource-limited setting

Background and Aims

There is an increasing recognition of reinfection in coronavirus disease 2019 (COVID-19). We studied the reinfection of COVID-19 disease among doctors at a tertiary care centre in Northern India.

Methods

All COVID-19 patients readmitted for COVID-19 disease after any duration with at least a positive Real time- polymerase chain reaction (RT-PCR) for severe acute respiratory syndrome coronavirus 2 were included. Their clinical profile, vaccination status, outcome and Centre for disease control (CDC), Atlanta, USA reinfection criteria screening were recorded.

Results

A total of 57 (0.53%) doctors were identified and 56 of them satisfied the CDC criteria. It included 13 (20.3%) females and 89.3% of cases were from clinical specialities; 98.2% of individuals had the first infection in 2020 and mean duration between 2 infections was 156.29 ± 76.02 (35-298) days. Duration between two episodes of the disease with more than 90 days apart was in 80.3% cases. One (1.8%) patient developed severe disease and two (3.6%) cases were of moderate severity. Symptoms were similar in both infections except significantly higher number of extra-respiratory complaints (2.2% vs. 9.1%). There were 37.5% cases who had received first dose of vaccination of any duration at the time of second infection. Nine (16.1%) and four (7.1%) patients with more than 4 weeks after the first and second dose of vaccination developed the second infection, respectively.

Conclusion

Majority of reinfection were symptomatic and developed after 90 days and so majority followed CDC criteria. Breakthrough infections among vaccinated healthcare worker are real, and with sustained exposure to the virus, they should continue to use precaution including hand hygiene and mask in order to prevent reinfection.

Clinical Characteristics and Outcomes of Patients with Acute Respiratory Failure Due to SARS-CoV-2 Interstitial Pneumonia Treated with CPAP in a Medical Intermediate Care Setting: A Retrospective Observational Study on Comparison of Four Waves

BACKGROUND

In COVID-19 patients non-invasive-positive-pressure-ventilation (NIPPV) has held a challenging role to reduce mortality and the need for invasive mechanical ventilation (IMV). The aim of this study was to compare the characteristics of patients admitted to a Medical Intermediate Care Unit for acute respiratory failure due to SARS-CoV-2 pneumonia throughout four pandemic waves.

METHODS

The clinical data of 300 COVID-19 patients treated with continuous positive airway pressure (CPAP) were retrospectively analysed, from March-2020 to April-2022.

RESULTS

Non-survivors were older and more comorbid, whereas patients transferred to ICU were younger and had fewer pathologies. Patients were older (from 65 (29-91) years in I wave to 77 (32-94) in IV, p < 0.001) and with more comorbidities (from Charlson's Comorbidity Index = 3 (0-12) in I to 6 (1-12) in IV, p < 0.001). No statistical difference was found for in-hospital mortality (33.0%, 35.8%, 29.6% and 45.9% in I, II, III and IV, p = 0.216), although ICU-transfers rate decreased from 22.0% to 1.4%.

CONCLUSIONS

COVID-19 patients have become progressively older and with more comorbidities even in critical care area; from risk class analyses by age and comorbidity burden, in-hospital mortality rates remain high and are thus consistent over four waves while ICU-transfers have significantly reduced. Epidemiological changes need to be considered to improve the appropriateness of care.

Epidemiology, Clinical Profile, Intensive Care Needs and Outcome in Children with SARS-CoV-2 Infection Admitted to a Tertiary Hospital During the First and Second Waves of the COVID-19 Pandemic in India

OBJECTIVES

To compare the epidemiological, clinical profile, intensive care needs and outcome of children hospitalized with SARS-CoV-2 infection during the first and second waves of the pandemic.

METHODS

This was a retrospective study of all children between 1 mo and 14 y, admitted to a dedicated COVID-19 hospital (DCH) during the first (1st June to 31st December 2020) and second waves (1st March to 30th June 2021).

RESULTS

Of 217 children, 104 (48%) and 113 (52%) were admitted during the first and second waves respectively. One hundred fifty-two (70%) had incidentally detected SARS-CoV-2 infection, while 65 (30%) had symptomatic COVID-19. Comorbidities were noted in 137 (63%) children. Fifty-nine (27%) and 66 (30%) children required high-dependency unit (HDU) and ICU care respectively. Severity of infection and ICU needs were similar during both waves. High-flow oxygen (n = 5, 2%), noninvasive ventilation [CPAP (n = 34, 16%) and BiPAP (n = 8, 5%)] and invasive ventilation (n = 45, 21%) were respiratory support therapies needed. NIV use was more during the second wave (26% vs. 13%; p = 0.02). The median (IQR) length (days) of DCH stay among survivors was longer during the first wave [8 (6-10) vs. 5.5 (3-8); p = 0.0001].

CONCLUSIONS

Disease severity, associated comorbidities, PICU and organ support need and mortality were similar in the first and second waves of the pandemic. Children admitted during the second wave were younger, had higher proportion of NIV use and shorter length of COVID-19 hospital stay.

Assessing the Clinical Characteristics and Management of COVID-19 among Pediatric Patients in Ghana: Findings and Implications

There is an increasing focus across countries on researching the management of children admitted to hospital with COVID-19. This stems from an increasing prevalence due to new variants, combined with concerns with the overuse of antimicrobials driving up resistance rates. Standard treatment guidelines (STGs) have been produced in Ghana to improve their care. Consequently, there is a need to document the clinical characteristics of children diagnosed and admitted with COVID-19 to our hospital in Ghana, factors influencing compliance to the STG and treatment outcomes. In all, 201 patients were surveyed between March 2020 and December 2021, with males accounting for 51.7% of surveyed children. Those aged between 6 and 10 years were the largest group (44.8%). Nasal congestion and fever were some of the commonest presenting complaints, while pneumonia was the commonest (80.6%) COVID-19 complication. In all, 80.0% of all admissions were discharged with no untreated complications, with a 10.9% mortality rate. A combination of azithromycin and hydroxychloroquine (41.29%) was the most prescribed antimicrobial regimen. Compliance to the STG was variable (68.2% compliance). Increased compliance was associated with a sore throat as a presenting symptom. Mortality increased following transfer to the ICU. However, current recommendations to prescribe antimicrobials without demonstrable bacterial or fungal infections needs changing to reduce future resistance. These are areas to address in the future.

Clinical Profile of COVID-19 Patients Admitted at a Private Hospital During Three Surges in Mandalay, Myanmar

Introduction During the coronavirus disease 2019 (COVID-19) pandemic, private hospitals in Mandalay started to manage COVID-19 infections according to national treatment guidelines since February 2021. Variations of clinical characteristics and their outcomes in different surges could be evaluated in the private hospital. This study aimed to assess the clinical profile and outcomes of COVID-19 patients admitted at a private hospital during three surges in Mandalay. Methods This study is a retrospective record review of the case series of COVID-19 patients admitted at City Hospital, Mandalay. The study was conducted from January to December 2022. All of the hospital records of COVID-19 patients admitted during the second wave from February 2020 to 26 May 2021, the third wave from 27 May 2021 to 27 January 2022, and the fourth wave from 28 January to April 2022 were included in the study. Results A total of 1606 admitted cases were included in the study. The mean with standard deviation (SD) of age was 55.7±18.5, and males were 778 (48.4%). The mean duration of hospital stay in days was 10.8±5.94, 10.6±6.11, and 7.3±2.88 in second, third, and fourth waves, respectively. The mean duration of hospital stay was shortened in the fourth wave. Comorbid conditions with hypertension and/or diabetes diseases were mostly observed in three waves of COVID-19 infection. Fever was the most presented symptom in three waves. Cough, sore throat, and rhinorrhea were observed more in the fourth wave compared with previous waves. Complication with pneumonia (71.3%), liver dysfunction (21.0%), acute respiratory distress syndrome (10.0%), thrombocytopenia (6.2%), acute kidney injury (5.5%), bleeding (3.9%), and pulmonary embolism (2.9%) were investigated. Antiviral treatment such as remdesivir or molnupiravir was used more in the patients of third and fourth waves than those of the second wave. Oxygen therapy (59.9%), prone position (35.5%), non-invasive ventilation (9.5%), invasive ventilation (0.5%), inotropes (4.6%), and renal replacement therapy (1.1%) were recorded in serious cases. Only 7.9% and 9.4% died in the hospital in second and third waves. No mortality was observed in the fourth wave. Conclusions The study recommended that COVID-19 patients with comorbid conditions of hypertension or diabetes and ages 65 and older should be taken with intensive care support at the hospital. This study also concluded that a private hospital in Mandalay could tackle with COVID-19 severe cases in line with national treatment guidelines since the second wave and could provide better management in the fourth wave. Antiviral treatment should be used in severe COVID-19 cases for further emergency management. In conclusion, private hospital involvement in the COVID-19 pandemic is supportive of the healthcare provision in Myanmar in an emergency situation.

Efficacy of integrated tele yoga intervention on physiological and psychological variables in asymptomatic COVID-19 positive patients: A Randomized Control Trial

BACKGROUND

A study was conducted on asymptomatic COVID-19 positive patients admitted in a COVID-19 hospital in Indore, India during first wave of the pandemic. The objective of the study was to assess the efficacy of an integrated tele-yoga intervention as an adjunct to conventional management on physiological, psychological and mindfulness variables.

METHODS

In a confirmatory randomized control trial, 60 asymptomatic COVID-19 patients in hospital confinement were randomly allocated to experimental and control groups (n=30). The tele-yoga intervention included breathing exercise, pranayama and meditation and delivered over 30 minutes for 7 days to the experimental group while, the control group continued treatment as usual. Assessment of physiological variables & psychological variables was carried out before intervention and on day seven immediately after intervention. Data was analyzed using SPSS (V.16.0).

RESULTS

Mann Whitney U test shows that there was a statistically significant difference between groups regarding all variables (p<0.001). The physiological and psychological variables which included Oxygen Saturation (2.07%), Heart Rate (8.21%), Respiratory Rate (10.04%), Systolic Blood Pressure (6.14%), Diastolic Blood Pressure (8.38%), Visual Analog Scale for Stress (62.78 %), Covid-19 Peritraumatic Distress Index (68.44 %), and State Mindful Attention Awareness Scale (72.72 %) showed significant changes in the experimental group compared to control group.

CONCLUSION

The results of this study suggest that integrated tele-yoga might have therapeutic benefits in improving physiological, psychological, and mindfulness variables in asymptomatic COVID- 19 patients.

[COVID 19 - Hospital Admission in the First and Second Wave in Germany]

PURPOSE

 We analyzed patients' characteristics and hospital admission in Germany's first and second COVID 19 wave.

METHODS

 We include all patients hospitalized with the proven diagnosis COVID 19 admitted to the HELIOS Hospital Krefeld, Germany, in the first wave (n = 84; from 11.03.2020-30.06.2020) and the second wave (n = 344; from 01.07.2020-31.01.2021).

RESULTS

 Patients' age, gender and comorbidities were similar with the exception of venous thrombosis in medical history which was more frequent in the first wave (6 % vs 0.3 %, p = p = 0,001). At admission, there were no differences in the results of the initial lab values (c-reactive protein, leucocytes) and blood gas analyses between both groups. Treatment differed in the application of dexamethasone and anticoagulation. In the first wave, nobody received dexamethasone. However, this changed to 52.6 % of patients in the second wave for a mean length of 3.6 ± 4.1 days. Anticoagulation with double standard prophylaxis (2 × 40 mg low molecular heparin, subcutaneous) was applied in 7.1 % of patients in the first wave but 30.2 % (p = 0.002) in the second wave. In the first wave more thromboembolic events were diagnosed after admission (19.0 % vs 7.0 %, p = 0.001). In-hospital death was 26.2 % in the first wave and 15.4 % in the second wave (p = 0.0234). Most deaths were attributed to acute respiratory distress syndrome (ARDS).

CONCLUSION

 Patients' characteristics did not vary in Germany's first and second COVID 19 wave, but anticoagulation and dexamethasone were applied more frequently in the second wave. In addition, there were fewer thromboembolic complications in the second wave.

Retrospective study of comparison of clinical severity and outcome of hospitalised COVID-19 patients during the first and second waves of the pandemic in India

OBJECTIVES

To compare the clinical severity and outcome of hospitalised patients during the two waves of the COVID-19 pandemic in India.

SETTING

A tertiary care referral hospital in South India.

PARTICIPANTS

Symptomatic SARS CoV-2 reverse transcriptase PCR positive patients presenting to the emergency department during the two waves were recruited. The first wave spanned between April and December 2020 and the second wave between April and May 2021.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome of interest was mortality. Secondary outcomes included illness severity at presentation, need for oxygen therapy, non-invasive ventilation (NIV) and hospital or intensive care unit admission.

RESULTS

The mean (SD) age of the 4971 hospitalised patients in the first wave was similar to the 2293 patients in the second wave (52.5±15.4 vs 52.1±15.1 years, p=0.37). When compared with the first wave, during the second wave, a higher proportion of patients presented with critical illness (11% vs 1.1%, p<0.001) and needed supplemental oxygen therapy (n=2092: 42.1% vs n=1459: 63.6%; p<0.001), NIV (n=643; 12.9% vs n=709; 30.9%; p<0.001) or inotropes/vasoactive drugs (n=108; 2.2% vs n=77: 3.4%; p=0.004). Mortality was higher during the second wave (19.2% vs 9.3%; p<0.001). On multivariable regression analysis, age >60 years (risk ratio, RR 2.80; 95% CI 2.12 to 3.70), D-dimer >1000 ng/mL (RR 1.34; 95% CI 1.15 to 1.55), treatment with supplemental oxygen (RR 14.6; 95% CI 8.98 to 23.6) and presentation during the second wave (RR 1.40; 95% CI 1.21 to 1.62) were independently associated with mortality.

CONCLUSION

The second wave of the COVID-19 pandemic in India appeared to be associated with more severe presentation and higher mortality when compared with the first wave. Increasing age, elevated D-dimer levels and treatment with supplemental oxygen were independent predictors of mortality.

A case control investigation of COVID-19 associated mucormycosis in India

Background

Increased occurrence of mucormycosis during the second wave of COVID-19 pandemic in early 2021 in India prompted us to undertake a multi-site case–control investigation. The objectives were to examine the monthly trend of COVID-19 Associated Mucormycosis (CAM) cases among in-patients and to identify factors associated with development of CAM.

Methods

Eleven study sites were involved across India; archived records since 1st January 2021 till 30th September 2021 were used for trend analysis. The cases and controls were enrolled during 15th June 2021 to 30th September 2021. Data were collected using a semi-structured questionnaire. Among 1211 enrolled participants, 336 were CAM cases and 875 were COVID-19 positive non-mucormycosis controls.

Results

CAM-case admissions reached their peak in May 2021 like a satellite epidemic after a month of in-patient admission peak recorded due to COVID-19. The odds of developing CAM increased with the history of working in a dusty environment (adjusted odds ratio; aOR 3.24, 95% CI 1.34, 7.82), diabetes mellitus (aOR: 31.83, 95% CI 13.96, 72.63), longer duration of hospital stay (aOR: 1.06, 95% CI 1.02, 1.11) and use of methylprednisolone (aOR: 2.71, 95% CI 1.37, 5.37) following adjustment for age, gender, occupation, education, type of houses used for living, requirement of ventilatory support and route of steroid administration. Higher proportion of CAM cases required supplemental oxygen compared to the controls; use of non-rebreather mask (NRBM) was associated as a protective factor against mucormycosis compared to face masks (aOR: 0.18, 95% CI 0.08, 0.41). Genomic sequencing of archived respiratory samples revealed similar occurrences of Delta and Delta derivates of SARS-CoV-2 infection in both cases and controls.

Conclusions

Appropriate management of hyperglycemia, judicious use of steroids and use of NRBM during oxygen supplementation among COVID-19 patients have the potential to reduce the risk of occurrence of mucormycosis. Avoiding exposure to dusty environment would add to such prevention efforts.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07844-y.

Seroprevalence of SARS-CoV-2-specific anti-spike IgM, IgG, and anti-nucleocapsid IgG antibodies during the second wave of the pandemic: A population-based cross-sectional survey across Kashmir, India

Background

Within Kashmir, which is one of the topographically distinct areas in the Himalayan belt of India, a total of 2,236 cumulative deaths occurred by the end of the second wave. We aimed to conduct this population-based study in the age group of 7 years and above to estimate the seropositivity and its attributes in Kashmir valley.

Methods

We conducted a community-based household-level cross-sectional study, with a multistage, population-stratified, probability-proportionate-to-size, cluster sampling method to select 400 participants from each of the 10 districts of Kashmir. We also selected a quota of healthcare workers, police personnel, and antenatal women from each of the districts. Households were selected from each cluster and all family members with age 7 years or more were invited to participate. Information was collected through a standardized questionnaire and entered into Epicollect 5 software. Trained healthcare personnel were assigned for collecting venous blood samples from each of the participants which were transferred and processed for immunological testing. Testing was done for the presence of SARS-CoV-2-specific anti-spike IgM, IgG antibodies, and anti-nucleocapsid IgG antibodies. Weighted seropositivity was estimated along with the adjustment done for the sensitivity and specificity of the test used.

Findings

The data were collected from a total of 4,229 participants from the general population within the 10 districts of Kashmir. Our results showed that 84.84% (95% CI 84.51-85.18%) of the participants were seropositive in the weighted imputed data among the general population. In multiple logistic regression, the variables significantly affecting the seroprevalence were the age group 45-59 years (odds ratio of 0.73; 95% CI 0.67-0.78), self-reported history of comorbidity (odds ratio of 1.47; 95% CI 1.33-1.61), and positive vaccination history (odds ratio of 0.85; 95% CI 0.79-0.90) for anti-nucleocapsid IgG antibodies. The entire assessed variables showed a significant role during multiple logistic regression analysis for affecting IgM anti-spike antibodies with an odds ratio of 1.45 (95% CI 1.32-1.57) for age more than 60 years, 1.21 (95% CI 1.15-1.27) for the female gender, 0.87 (95% CI 0.82-0.92) for urban residents, 0.86 (95% CI 0.76-0.92) for self-reported comorbidity, and an odds ratio of 1.16 (95% CI 1.08-1.24) for a positive history of vaccination. The estimated infection fatality ratio was 0.033% (95% CI: 0.034-0.032%) between 22 May and 31 July 2021 against the seropositivity for IgM antibodies.

Interpretation

During the second wave of the SARS-CoV-2 pandemic, 84.84% (95% CI 84.51-85.18%) of participants from this population-based cross-sectional sample were seropositive against SARS-CoV-2. Despite a comparatively lower number of cases reported and lower vaccination coverage in the region, our study found such high seropositivity across all age groups, which indicates the higher number of subclinical and less severe unnoticed caseload in the community.

Comparison of COVID-19 Infection in Children During the First and Second Wave

Concerns have been raised in the media that 'the third wave' will severely affect children. Here, an experience of SARS-CoV-2 infection in children is reported. Of the 8,626 SARS-CoV-2 RT-PCR tests performed in children (0-17 y) from March 2020 to July 2021 at the authors' institute, 1470 (17%) were positive, [711/4821 (14.7%) during the first wave (July 2020 to January 2021), and 759/3583 (21.2%) during the second wave (February 2021 to July 2021)]. The children in both waves were similar in presentation (74.1% mildly symptomatic versus 80.2% mildly symptomatic; rest asymptomatic). None of them had COVID pneumonia. Five children died (0.3%), all of a serious primary non-COVID disease. Seventy-three cases of MIS-C during August 2020 to July 2021, with low mortality (2.7%) were also identified. The similarity in COVID-19 infection in children between the first and the second waves seems to suggest that the likelihood of the 'third wave' hitting children hard is low.

Clinical-epidemiologic variation in patients treated in the first and second wave of COVID-19 in Lambayeque, Peru: A cluster analysis

OBJECTIVES

To identify differences in the clinical and epidemiologic characteristics of patients during the first and second waves of the COVID-19 pandemic at the EsSalud Lambayeque health care network, Peru.

METHODS

An analytical cross-sectional study of 53,912 patients enrolled during the first and second waves of COVID-19 was conducted. Cluster analysis based on clustering large applications (CLARA) was applied to clinical-epidemiologic data presented at the time of care. The two pandemic waves were compared using clinical-epidemiologic data from epidemiologic surveillance.

RESULTS

Cluster analysis identified four COVID-19 groups with a characteristic pattern. Cluster 1 included the largest number of participants in both waves, and the participants were predominantly female. Cluster 2 included patients with gastrointestinal, respiratory, and systemic symptoms. Cluster 3 was the "severe" cluster, characterized by older adults and patients with dyspnea or comorbidities (cardiovascular, diabetes, obesity). Cluster 4 included asymptomatic, pregnant, and less severe patients. We found differences in all clinical-epidemiologic characteristics according to the cluster to which they belonged.

CONCLUSION

Using cluster analysis, we identified characteristic patterns in each group. Respiratory, gastrointestinal, dyspnea, anosmia, and ageusia symptoms were higher in the second COVID-19 wave than the first COVID-19 wave.

Characteristics and Management of Children With Suspected COVID-19 Admitted to Hospitals in India: Implications for Future Care

Introduction: There is a growing focus on researching the management of children with COVID-19 admitted to hospital, especially among developing countries with new variants alongside concerns with the overuse of antibiotics. Patient care can be improved with guidelines, but concerns with the continued imprudent prescribing of antimicrobials, including antibiotics, antivirals, and antimalarials.

Objective: Consequently, a need to document the current management of children with COVID-19 across India. Key outcome measures included the percentage of prescribed antimicrobials, adherence to current guidelines, and mortality.

Methodology: A point prevalence study using specially developed report forms among 30 hospitals in India.

Results: The majority of admitted children were aged between 11 and 18 years (70%) and boys (65.8%). Reasons for admission included respiratory distress, breathing difficulties, and prolonged fever. 75.3% were prescribed antibiotics typically empirically (68.3% overall), with most on the Watch list (76.7%). There were no differences in antibiotic prescribing whether hospitals followed guidelines or not. There was also appreciable prescribing of antimalarials (21.4% of children), antivirals (15.2%), and antiparasitic medicines (27.2%) despite limited evidence. The majority of children (92.2%) made a full recovery.

Conclusion: It was encouraging to see low hospitalization rates. However, concerns about high empiric use of antibiotics and high use of antimalarials, antivirals, and antiparasitic medicines exist. These can be addressed by instigating appropriate stewardship programs.

Clinical Profile and Short-Term Outcome of Children with Acute SARS-CoV-2 Infection During the First and Second Waves of the Pandemic

OBJECTIVES

To compare the clinical profile and short-term outcome of children admitted with acute SARS-CoV-2 infection during the first and second waves of the Coronavirus Disease (COVID-19).

METHODS

This retrospective study was conducted in a tertiary care setting. A retrospective medical record review of all pediatric patients admitted with confirmed SARS-CoV-2 infection between March 2020 and September 2021 was conducted. Patients' demographic data, pre-existing comorbidities, mode of presentation, and clinical course in the hospital were noted. The outcome measures were in-hospital mortality, need for intensive care, and invasive mechanical ventilation, duration of ICU, and hospital stay.

RESULTS

One thousand and twenty-four children were recruited, 592 of the first wave and 432 of the second wave. In the second wave, more children were admitted with respiratory distress (OR = 3.38) and neurological manifestations (OR = 4.61). There was a higher requirement of intensive care (OR = 4.2) and invasive mechanical ventilation (OR = 4.17). In-hospital mortality of the second wave was also increased (1.4% vs. 0.1%), but the difference was not statistically significant. Children with neurological comorbidities (OR = 8.73), malnutrition (OR = 3.01), and preterm babies (OR = 6.8) were associated with severe COVID.

CONCLUSION

The clinical profile of the second wave of COVID-19 in children was different from the first wave, with more respiratory distress and neurological manifestations at presentation. In the second wave, a significant increase in the incidence of severe infections requiring ICU care was observed.

Co-Infections, Secondary Infections, and Antimicrobial Use in Patients Hospitalized with COVID-19 during the First Five Waves of the Pandemic in Pakistan; Findings and Implications

Background: COVID-19 patients are typically prescribed antibiotics empirically despite concerns. There is a need to evaluate antibiotic use among hospitalized COVID-19 patients during successive pandemic waves in Pakistan alongside co-infection rates. Methods: A retrospective review of patient records among five tertiary care hospitals during successive waves was conducted. Data were collected from confirmed COVID-19 patients during the first five waves. Results: 3221 patients were included. The majority were male (51.53%), residents from urban areas (56.35%) and aged >50 years (52.06%). Cough, fever and a sore throat were the clinical symptoms in 20.39%, 12.97% and 9.50% of patients, respectively. A total of 23.62% of COVID-19 patients presented with typically mild disease and 45.48% presented with moderate disease. A high prevalence of antibiotic prescribing (89.69%), averaging 1.66 antibiotics per patient despite there only being 1.14% bacterial co-infections and 3.14% secondary infections, was found. Antibiotic use significantly increased with increasing severity, elevated WBCs and CRP levels, a need for oxygen and admittance to the ICU; however, this decreased significantly after the second wave (p < 0.001). Commonly prescribed antibiotics were piperacillin plus an enzyme inhibitor (20.66%), azithromycin (17.37%) and meropenem (15.45%). Common pathogens were Staphylococcus aureus (24.19%) and Streptococcus pneumoniae (20.96%). The majority of the prescribed antibiotics (93.35%) were from the WHO’s “Watch” category. Conclusions: Excessive prescribing of antibiotics is still occurring among COVID-19 patients in Pakistan; however, rates are reducing. Urgent measures are needed for further reductions.

'Imperfect but useful': pandemic response in the Global South can benefit from greater use of mathematical modelling

Mathematical modelling has been a helpful resource for planning public health responses to COVID-19. However, there is a need to improve the accessibility of models built within country contexts in the Global South. Immediately following the overwhelming 'second wave' of COVID-19 in India, we developed a user-friendly, web-based modelling simulator in partnership with the public health experts and health administrators for subnational planning. The purpose was to help policy-makers and programme officials at the state and district levels, to construct model-based scenarios for a possible third wave. Here, we describe our experiences of developing and deploying the simulator and propose the following recommendations for future such initiatives: early preparation will be the key for pandemic management planning, including establishment of networks with potential simulator users. Ideally, this preparedness should be conducted during 'peace time', and coordinated by agencies such as WHO. Second, flexible modelling frameworks will be needed, to respond rapidly to future emergencies as the precise nature of any pandemic is impossible to predict. Modelling resources will, therefore, need to be rapidly adaptable to respond as soon as a novel pathogen emerges. Third, limitations of modelling must be communicated clearly and consistently to end users. Finally, systematic mechanisms are required for monitoring the use of models in decision making, which will help in providing modelling support to those local authorities who may benefit most from it. Overall, these lessons from India can be relevant for other countries in the South-Asian-Region, to incorporate modelling resources into their pandemic preparedness planning.

Use of COVID-19 Test Positivity Rate, Epidemiological, and Clinical Tools for Guiding Targeted Public Health Interventions

India experienced a second wave of COVID-19 infection with an unprecedented upsurge in the number of cases. We have analyzed the effect of different restrictive measures implemented in six Indian states. Further, based on available national and international data on disease transmission and clinical presentation, we have proposed a decision-making matrix for planning adequate resources to combat the future waves of COVID-19. We conclude that pragmatic and well calibrated localized restrictions, tailored as per specific needs may achieve a decline in disease transmission comparable to drastic steps like national lockdowns. Additionally, we have underscored the critical need for countries to generate local epidemiological, clinical and laboratory data alongwith community perception and uptake of various non-pharmaceutical interventions, for effective planning and policy making.

Characterizing the third wave of COVID-19: An analysis from the National Clinical Registry of COVID-19

Background & objectives

Data from the National Clinical Registry for COVID-19 (NCRC) were analyzed with an aim to describe the clinical characteristics, course and outcomes of patients hospitalized with COVID-19 in the third wave of the pandemic and compare them with patients admitted earlier.

Methods

The NCRC, launched in September 2020, is a multicentre observational initiative, which provided the platform for the current investigation. Demographic, clinical, treatment and outcome data of hospitalized COVID-19 patients were captured in an electronic data portal from 38 hospitals across India. Patients enrolled during December 16, 2021 to January 17, 2022 were considered representative of the third wave of COVID-19 and compared with those registered during November 15 to December 15, 2021, representative of the tail end of the second wave.

Results

Between November 15, 2021 and January 17, 2022, 3230 patients were recruited in NCRC. Patients admitted in the third wave were significantly younger than those admitted earlier (46.7±20.5 vs. 54.6±18 yr). The patients admitted in the third wave had a lower requirement of drugs including steroids, interleukin (IL)-6 inhibitors and remdesivir as well as lower oxygen supplementation and mechanical ventilation. They had improved hospital outcomes with significantly lower in-hospital mortality (11.2 vs. 15.1%). The outcomes were better among the fully vaccinated when compared to the unvaccinated or partially vaccinated.

Interpretation & conclusions

The pattern of illness and outcomes were observed to be different in the third wave compared to the last wave. Hospitalized patients were younger with fewer comorbidities, decreased symptoms and improved outcomes, with fully vaccinated patients faring better than the unvaccinated and partially vaccinated ones.

Potential long-term effects of SARS-CoV-2 infection on the pulmonary vasculature: a global perspective

The lungs are the primary target of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, with severe hypoxia being the cause of death in the most critical cases. Coronavirus disease 2019 (COVID-19) is extremely heterogeneous in terms of severity, clinical phenotype and, importantly, global distribution. Although the majority of affected patients recover from the acute infection, many continue to suffer from late sequelae affecting various organs, including the lungs. The role of the pulmonary vascular system during the acute and chronic stages of COVID-19 has not been adequately studied. A thorough understanding of the origins and dynamic behaviour of the SARS-CoV-2 virus and the potential causes of heterogeneity in COVID-19 is essential for anticipating and treating the disease, in both the acute and the chronic stages, including the development of chronic pulmonary hypertension. Both COVID-19 and chronic pulmonary hypertension have assumed global dimensions, with potential complex interactions. In this Review, we present an update on the origins and behaviour of the SARS-CoV-2 virus and discuss the potential causes of the heterogeneity of COVID-19. In addition, we summarize the pathobiology of COVID-19, with an emphasis on the role of the pulmonary vasculature, both in the acute stage and in terms of the potential for developing chronic pulmonary hypertension. We hope that the information presented in this Review will help in the development of strategies for the prevention and treatment of the continuing COVID-19 pandemic.

In this Review, the authors discuss the potential causes of the heterogeneity of COVID-19 and summarize the pathobiology of the disease, with an emphasis on the role of the pulmonary vasculature in the acute stage and the potential for developing chronic pulmonary hypertension.

A thorough understanding of the dynamic behaviour of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is essential to understanding its heterogeneous effects on the pulmonary vasculature in patients with coronavirus disease 2019 (COVID-19).

The severity and clinical phenotype of COVID-19 are influenced by host factors, including socioeconomic factors and genetics.

Silent hypoxia is a major and independent cause of lung damage in COVID-19; the use of modern imaging techniques is proving to be very valuable in identifying silent hypoxia.

The pulmonary vascular system has a major role in the pathobiology of COVID-19.

Both COVID-19 and chronic pulmonary hypertension are global diseases with a complex interaction.

Emerging SARS-CoV-2 variants can potentially break set epidemiological barriers in COVID-19

Young age, female sex, absence of comorbidities, and prior infection or vaccination are known epidemiological barriers for contracting the new infection and/or increased disease severity. Demographic trends from the recent coronavirus disease 2019 waves, which are believed to be driven by newer severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) variants, indicate that the aforementioned epidemiological barriers are being breached and a larger number of younger and healthy individuals are developing severe disease. The new SARS‐CoV‐2 variants have key mutations that can induce significant changes in the virus‐host interactions. Recent studies report that, some of these mutations, singly or in a group, enhance key mechanisms, such as binding of the receptor‐binding domain (RBD) of the viral spike protein with the angiotensin‐converting enzyme 2 (ACE2) receptor in the host‐cells, increase the glycosylation of spike protein at the antigenic sites, and enhance the proteolytic cleavage of the spike protein, thus leading to improved host‐cell entry and the replication of the virus. The putative changes in the virus–host interactions imparted by the mutations in the RBD sequence can potentially be the reason behind the breach of the observed epidemiological barriers. Susceptibility for contracting SARS‐CoV‐2 infection and the disease outcomes are known to be influenced by host‐cell expressions of ACE2 and other proteases. The new variants can act more efficiently, and even with the lesser availability of the viral entry‐receptor and the associated proteases, can have more efficient host‐cell entry and greater replication resulting in high viral loads and prolonged viral shedding, widespread tissue‐injury, and severe inflammation leading to increased transmissibility and lethality. Furthermore, the accumulating evidence shows that multiple new variants have reduced neutralization by both, natural and vaccine‐acquired antibodies, indicating that repeated and vaccine breakthrough infections may arise as serious health concerns in the ongoing pandemic.

Emerging SARS‐CoV‐2 variants:

Harbor key mutations altering the virus‐host interactions.

Show more efficient host‐cell entry and greater replication resulting in higher viral loads, prolonged viral shedding, and greater tissue injury.

Show reduced neutralization by natural and vaccine acquired antibodies.

Causing symptomatic illness in increasing number of young, women, and healthy individuals.

The Dominance of Severe Acute Respiratory Syndrome Coronavirus 2 B.1.617 and Its Sublineages and Associations with Mortality during the COVID-19 Pandemic in India between 2020 and 2021

As the COVD-19 pandemic spreads, several new severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) variants with various mutations across the genome have arisen, and they appear to be the greater risk to global public health. In this study, we have performed molecular characterization of SARS-COV-2 circulating in India between January 2020 and May 2021. Phylogenetic analysis of the SARS-COV-2 reported in the first and second waves of the outbreak showed the evolutionary hierarchy of SARS-COV-2 that was dispersed across the evolutionary tree of SARS-COV-2 with six major next strain clades: 19A (5.3%), 20A (29.9%), 20B (24.9%), 20I-Alpha, V1 (7.4%), 21A-Delta (17.2%), and 21B-Kappa (12.7%). Among the observed clades, 21A-Delta and 21B-Kappa belonging to the B.1.617 and its sublineages are the two notable clades that dominated approximately 78% of the total SARS-COV-2 genomes reported during April and May 2021. This study has also established a link between different SARS-COV-2 variants and risk of mortality during the COVID-19 epidemic using multivariable logistic regression model for patient-level data. The estimated model demonstrates that the risk of mortality of the COVID 19 patients infected by variant B.1.617 and/or its sublineages is much higher than the other preexisting SARS-COV-2 variants, especially among individuals over 45 years of age, regardless of gender. Considering the transmissibility of the B.1.617 and its sublineages and its potential impact to the public health, real-time analysis of COVID-19 cases coupled with stringent genomics surveillance are promising tools to develop and adapt stringent measures to contain and reduce the impact of SARS-COV-2.

Differences in age distribution in first and second waves of COVID-19 in eastern Uttar Pradesh, India

Comparison of first and second waves of Coronavirus disease (COVID-19) showed varied differences including the peak and time distribution. Contrary to published reports of comparing two waves in India wherein the younger age group was affected more in the second wave in India; a secondary data analysis of around 0.5 million real-time reverse transcription-polymerase chain reaction tests conducted in COVID-19 diagnostic laboratory in eastern Uttar Pradesh, India showed an increase in positivity rate in older age groups in the second wave. The positivity rate among symptomatic cases was found to be three times higher in second wave compare to the first wave. Higher positivity rates were seen across older age groups, with a shift of 11 years in the mean age of positivity in the second wave compared to the first.