Baseline findings of a multicentric ambispective cohort study (2021-2022) among hospitalised mucormycosis patients in India

In India, the incidence of mucormycosis reached high levels during 2021-2022, coinciding with the COVID-19 pandemic. In response to this, we established a multicentric ambispective cohort of patients hospitalised with mucormycosis across India. In this paper, we report their baseline profile, clinical characteristics and outcomes at discharge. Patients hospitalized for mucormycosis during March-July 2021 were included. Mucormycosis was diagnosed based on mycological confirmation on direct microscopy (KOH/Calcofluor white stain), culture, histopathology, or supportive evidence from endoscopy or imaging. After consent, trained data collectors used medical records and telephonic interviews to capture data in a pre-tested structured questionnaire. At baseline, we recruited 686 patients from 26 study hospitals, of whom 72.3% were males, 78% had a prior history of diabetes, 53.2% had a history of corticosteroid treatment, and 80% were associated with COVID-19. Pain, numbness or swelling of the face were the commonest symptoms (73.3%). Liposomal Amphotericin B was the commonest drug formulation used (67.1%), and endoscopic sinus surgery was the most common surgical procedure (73.6%). At discharge, the disease was stable in 43.3%, in regression for 29.9% but 9.6% died during hospitalization. Among survivors, commonly reported disabilities included facial disfigurement (18.4%) and difficulties in chewing/swallowing (17.8%). Though the risk of mortality was only 1 in 10, the disability due to the disease was very high. This cohort study could enhance our understanding of the disease's clinical progression and help frame standard treatment guidelines.

Characterization of IL-10 Family of Cytokines in Acute and Convalescent COVID-19 Individuals

Cytokines are major players in orchestrating inflammation, disease pathogenesis, and severity during COVID-19. Members of the interleukin (IL)-10 family of cytokines play important roles in regulating immune responses to various inflammatory and infectious diseases. However, the role of the IL-10 family of cytokines in COVID-19 remains elusive. Hence, we determined the plasma levels of the IL-10 family of cytokines (IL-10, IL-19, IL-20, IL-22, and IL-24) in 7 groups of COVID-19 individuals, based on days since real-time reverse transcriptase-polymerase chain reaction confirmation of SARS-CoV-2 infection. Our data show that the levels of IL-10, IL-19, IL-20, IL-22, and IL-24 cytokines decreased from days 15-30 to days 61-90 and plateaued thereafter. Severe COVID-19 patients exhibit increased plasma levels of IL-10, IL-19, IL-20, IL-22, and IL-24 compared to mild patients. Thus, our study provides evidence of alterations in the plasma levels of the IL-10 family of cytokines in convalescent COVID-19 individuals.

Factors associated with unexplained sudden deaths among adults aged 18-45 years in India - A multicentric matched case-control study

BACKGROUND OBJECTIVES

In view of anecdotal reports of sudden unexplained deaths in India's apparently healthy young adults, linking to coronavirus disease 2019 (COVID-19) infection or vaccination, we determined the factors associated with such deaths in individuals aged 18-45 years through a multicentric matched case-control study.

METHODS

This study was conducted through participation of 47 tertiary care hospitals across India. Cases were apparently healthy individuals aged 18-45 years without any known co-morbidity, who suddenly (<24 h of hospitalization or seen apparently healthy 24 h before death) died of unexplained causes during 1 st October 2021-31 st March 2023. Four controls were included per case matched for age, gender and neighborhood. We interviewed/perused records to collect data on COVID-19 vaccination/infection and post-COVID-19 conditions, family history of sudden death, smoking, recreational drug use, alcohol frequency and binge drinking and vigorous-intensity physical activity two days before death/interviews. We developed regression models considering COVID-19 vaccination ≤42 days before outcome, any vaccine received anytime and vaccine doses to compute an adjusted matched odds ratio (aOR) with 95 per cent confidence interval (CI).

RESULTS

Seven hundred twenty nine cases and 2916 controls were included in the analysis. Receipt of at least one dose of COVID-19 vaccine lowered the odds [aOR (95% CI)] for unexplained sudden death [0.58 (0.37, 0.92)], whereas past COVID-19 hospitalization [3.8 (1.36, 10.61)], family history of sudden death [2.53 (1.52, 4.21)], binge drinking 48 h before death/interview [5.29 (2.57, 10.89)], use of recreational drug/substance [2.92 (1.1, 7.71)] and performing vigorous-intensity physical activity 48 h before death/interview [3.7 (1.36, 10.05)] were positively associated. Two doses lowered the odds of unexplained sudden death [0.51 (0.28, 0.91)], whereas single dose did not.

INTERPRETATION CONCLUSIONS

COVID-19 vaccination did not increase the risk of unexplained sudden death among young adults in India. Past COVID-19 hospitalization, family history of sudden death and certain lifestyle behaviors increased the likelihood of unexplained sudden death.

Presence of heavy metals in over the counter teeth whitening products- An evaluative study

Background

Dentistry plays a crucial role in shaping the facial aesthetics of a person and thus boosts self-esteem. Tooth discolouration is one of the significant cosmetic problems and hence, many teeth whitening products are widely used for discolouration. However, these products may have heavy metals or chemicals that can affect the tooth and other organs.

Aim

The aim is to estimate the amount of heavy metals present in teeth whitening products available for purchase over-the-counter in the pharmacies.

Materials and Method

A cross-sectional study of teeth whitening products available Over the Counter (OTC) in pharmacies in Chennai and adjoining districts of Tamil Nadu was conducted during the period from December 2019 to February 2020. The Flame Atomic Absorption Spectrometry (FAAS) method was used to measure the heavy metals such as inorganic lead, chromium, cobalt, arsenic, cadmium, nickel and mercury in the products.

Results

We collected 39 products and finalized nine for analysis. These products were available as tablet (n = 1), liquids (n = 2) and powders (n = 6). All products were mentioned as herbal or natural. Three products contained inorganic lead levels in parts per million (ppm) of 759 (product 2); 39.4 (product 3) and 28.1 (product 7), way above the permitted levels. None of the other heavy metals were detected from these products.

Conclusion

After analysis with the FAAS method, inorganic lead over and above the permissible levels was observed. Dental professionals and community need to be aware of the availability of such products and its detrimental effects on oral and general health.

Health-related quality of life and associated factors among COVID-19 individuals managed with indian traditional medicine: A cross-sectional study from south India

Introduction

Coronavirus disease-2019 (COVID-19) had a multidimensional impact on human life. It affects the health-related quality of life (HRQoL) which is a perceived measure of physical and mental health. We estimated the EuroQol utility value for COVID-19 and the associated factors for those managed at Siddha COVID care centres in Tamil Nadu.

Methods

A cross-sectional study was conducted by a telephonic interview of 2000 randomly selected COVID-19 adults tested positive during June 2020 to Jan 2021. We collected sociodemographic, clinical and EQ-5D-5L profile. Mean EQ-5D-5L summary utility values and EQ-VAS scores were estimated. Multivariate regression was used to examine the factors associated with EQ-5D-5L. Study protocol was approved by the Institutional ethics committee of Government Siddha Medical College, Chennai (GSMC-CH-3401/ME-2/050/2021). The committee waived the written informed consent considering the pandemic situation of emerging infectious diseases.

Results

We interviewed 1047 participants. Of the total 68% were males with the median age (IQR) of 38 (29-51) years. The mean EQ-5D-5L utility score and EQ-VAS scores are 0.98 ± 0.05 and 92.14 ± 0.39 respectively. COVID-19 asymptomatic group reported a mean utility score of 0.99 ± 0.03 which is relatively more than the symptomatic group (0.97 ± 0.06),. EQ-VAS score was also reported high among the asymptomatic (95.45 ± 5.95) than the symptomatic (91.40 ± 8.69COVID-19.

Conclusion

The severity of illness and the comorbidity are significantly associated with a low HRQoL of COVID-19 patients.

Syndromic surveillance system during mass gathering of Panchkroshi Yatra festival, Ujjain, Madhya Pradesh, India

Background

The health implications surrounding a mass gathering pose significant challenges to public health officials. The use of syndromic surveillance provides an ideal method for achieving the public health goals and objectives at such events. In the absence of published reports of systematic documentation of public health preparedness in mass gatherings in the local context, we describe the public health preparedness and demonstrate the operational feasibility of a tablet-based participatory syndromic surveillance among pilgrims during the annual ritual circumambulation- Panchkroshi Yatra.

Methods

A real-time surveillance system was established from 2017-2019 to capture all the health consultations done at the designated points (medical camps) in the Panchkroshi yatra area of the city Ujjain in Madhya Pradesh. We also surveyed a subset of pilgrims in 2017 to gauge satisfaction with the public health measures such as sanitation, water, safety, food, and cleanliness.

Results

In 2019, injuries were reported in the highest proportion (16.7%; 794/4744); most numbers of fever cases (10.6%; 598/5600) were reported in 2018, while 2017 saw the highest number of patient presentations of abdominal pain (7.73%; 498/6435).

Conclusion

Public health and safety measures were satisfactory except for the need for setting up urinals along the fixed route of the circumambulation. A systematic data collection of selected symptoms among yatris and their surveillance through tablet could be established during the panchkroshi yatra, which can complement the existing surveillance for detecting early warning signals. We recommend the implementation of such tablet-based surveillance during such mass gathering events.

Litchi consumption and missed meals continue to be associated with acute encephalopathy syndrome among children: an investigation of the 2019 outbreak in Muzaffarpur district, Bihar, India

BACKGROUND

Muzaffarpur district in Bihar State of India recorded a resurgence of acute encephalopathy syndrome (AES) cases in the summer of 2019 after no reported outbreak in 3 y. Earlier studies generated evidence that litchi consumption and missing the previous evening's meal were associated with AES. We investigated the recent outbreak to understand the risk factors associated with AES.

METHODS

We conducted a matched case-control study by comparing AES cases with healthy controls from case-households and the neighborhood community for risk factors like missing evening meal and litchi consumption before onset of AES.

RESULTS

We recruited 61 cases and 239 controls. Compared with the community controls, case-patients were five times more likely to have reported eating litchi in the 7 d preceding the onset of illness (adjusted OR [AOR]=5.1; 95% CI 1.3 to 19) and skipping the previous evening's meal (AOR=5.2; 95% CI 1.4 to 20). Compared with household controls, case-patients were five times more likely to be children aged <5 y (AOR=5.3; 95% CI 1.3 to 22) and seven times more likely to have skipped the previous evening's meal (AOR=7.4; 95% CI 1.7 to 34).

CONCLUSIONS

Skipping the previous evening's meal and litchi consumption were significantly associated with AES among children in Muzaffarpur and adjoining districts of Bihar.

Restoration of dendritic cell homeostasis and Type I/Type III interferon levels in convalescent COVID-19 individuals

Background

Plasmacytoid and myeloid dendritic cells play a vital role in the protection against viral infections. In COVID-19, there is an impairment of dendritic cell (DC) function and interferon secretion which has been correlated with disease severity.

Results

In this study, we described the frequency of DC subsets and the plasma levels of Type I (IFNα, IFNβ) and Type III Interferons (IFNλ1), IFNλ2) and IFNλ3) in seven groups of COVID-19 individuals, classified based on days since RT-PCR confirmation of SARS-CoV2 infection. Our data shows that the frequencies of pDC and mDC increase from Days 15–30 to Days 61–90 and plateau thereafter. Similarly, the levels of IFNα, IFNβ, IFNλ1, IFNλ2 and IFNλ3 increase from Days 15–30 to Days 61–90 and plateau thereafter. COVID-19 patients with severe disease exhibit diminished frequencies of pDC and mDC and decreased levels of IFNα, IFNβ, IFNλ1, IFNλ2 and IFNλ3. Finally, the percentages of DC subsets positively correlated with the levels of Type I and Type III IFNs.

Conclusion

Thus, our study provides evidence of restoration of homeostatic levels in DC subset frequencies and circulating levels of Type I and Type III IFNs in convalescent COVID-19 individuals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12865-022-00526-z.

"Design and implementation challenges of massive open online course on research methods for Indian medical postgraduates and teachers -descriptive analysis of inaugural cycle"

BACKGROUND

In view of the growing popularity, reach and access for Massive Open Online Courses (MOOCs), India's apex body for medical education, the National Medical Commission (NMC) mandated uniform foundational course on research methods for the medical post graduates (PGs) and faculty members of the medical institutions under NMC as MOOC. This course is a pioneering effort in the field of India's PG medical education. NMC entrusted Indian Council of Medical Research (ICMR)-National Institute of Epidemiology (NIE) to design and offer the MOOC, named as Basic Course in Biomedical Research (BCBR). We describe the experience of designing and that of implementation challenges in the inaugural cycle of the course.

METHODS

The course objective was to inculcate the fundamental concepts in research methods covering epidemiology and biostatistics in the form of video lectures, resource materials, discussion forum, assignments, feedback and a final proctored examination. The course was delivered over 16 weeks through MOOCs platform under the Indian Ministry of Education. We reviewed records, documents and faculty notes and described the course conceptualization, development, design and implementation process. We abstracted information from course portal on enrolment profile of the participants, self-reported course feedback (structured and open-ended on format, lectures and quality of contents), examination registration form, scores obtained in the assignments/examination and that of the participant queries. We described quantitative data using descriptive statistics. We presented the thematic analysis of qualitative data from open-ended questions in the feedback system and that of email interactions.

RESULTS

The inaugural cycle (September-December 2019) was taken by 24,385 participants. Majority, 15,879 (65%) were from medical background. 13,242 (54%) were medical postgraduates and 2637 (11%) were medical teachers. Among the enrolled, 14,720 (60%) cleared the assignments. A total of 11,392 (47%), 8,205 (62%) medical PGs and 896 (34%) faculty members successfully completed the course. Feedback from 1305 (5%) participants had mean score of 4.5/5 (±0.7) for quality of teaching. We faced challenges in customizing the course for medical participants, unawareness among target group, digital illiteracy and the ongoing pandemic.

CONCLUSIONS

During the inaugural cycle of the online Basic Course in Biomedical Research course, nearly half of the enrolled participants successfully completed and received the certificate. India's MOOC for enhancing research capabilities of future medical researchers encountered successes and challenges. Lessons learnt from the inaugural cycle will guide future directions and to address larger issues in terms of sustainability and replication by stakeholders in medical education in India or elsewhere.

AYUSH digital initiatives: Harnessing the power of digital technology for India's traditional medical systems

The incorporation of digital technologies is recognized as one of the inevitable factors to achieve better health care services. Recently, Indian Ministry of AYUSH (MoA) embraced digitalization extensively for development, education and research in AYUSH. In this context, we describe India's digital initiatives for AYUSH systems of medicine for information, research, and academia at various levels. We reviewed the websites and documents available from the MoA and its research councils/institutes along with the plan documents. We described the identified digital initiatives under categories of (1) Health information system (2) Research database/library (3) Academic (4) Information Education and Communication (IEC). We specified the purpose and target group of the identified digital initiatives. We identified 19 key digital initiatives. The AYUSH hospital management information system (A-HMIS), National AYUSH Morbidity and Standardized Terminologies Electronic Portal (NAMASTE), AYUSH Suraksha, e-Aushadhi, e-Charak, Triskandha Kosha, SiddAR APP were categorized under health information system. The Traditional Knowledge Digital Library (TKDL), AYUSH research portal, DHARA, e-CHLAS, Research Management Information system (RMIS), e-Granthasamuccaya and AYUSH Sanjivani App were categorized under research database/library. The Ayurveda e-learning and Ayurvedic Inheritance of India were categorized as the academic initiatives. The Siddha-NIS App, Yoga locator, and Naturopathy-NIN App were categorized as Information, education and communication (IEC) initiatives. The digital initiatives from the MoA were a key to reform the traditional systems of medicines and could improve the education, quality of research and accessibility of the AYUSH healthcare services.

Characterization of memory T cell subsets and common γ-chain cytokines in convalescent COVID-19 individuals

T cells are thought to be an important correlates of protection against SARS‐CoV2 infection. However, the composition of T cell subsets in convalescent individuals of SARS‐CoV2 infection has not been well studied. The authors determined the lymphocyte absolute counts, the frequency of memory T cell subsets, and the plasma levels of common γ−chain in 7 groups of COVID‐19 individuals, based on days since RT‐PCR confirmation of SARS‐CoV‐2 infection. The data show that both absolute counts and frequencies of lymphocytes as well as, the frequencies of CD4⁺ central and effector memory cells increased, and the frequencies of CD4⁺ naïve T cells, transitional memory, stem cell memory T cells, and regulatory cells decreased from Days 15–30 to Days 61–90 and plateaued thereafter. In addition, the frequencies of CD8⁺ central memory, effector, and terminal effector memory T cells increased, and the frequencies of CD8⁺ naïve cells, transitional memory, and stem cell memory T cells decreased from Days 15–30 to Days 61–90 and plateaued thereafter. The plasma levels of IL‐2, IL‐7, IL‐15, and IL‐21—common γc cytokines started decreasing from Days 15–30 till Days 151–180. Severe COVID‐19 patients exhibit decreased levels of lymphocyte counts and frequencies, higher frequencies of naïve cells, regulatory T cells, lower frequencies of central memory, effector memory, and stem cell memory, and elevated plasma levels of IL‐2, IL‐7, IL‐15, and IL‐21. Finally, there was a significant correlation between memory T cell subsets and common γc cytokines. Thus, the study provides evidence of alterations in lymphocyte counts, memory T cell subset frequencies, and common γ−chain cytokines in convalescent COVID‐19 individuals.

Seroprevalence of IgG antibodies against SARS-CoV-2 in India, March 2020 to August 2021: a systematic review and meta-analysis

INTRODUCTION

India experienced 2 waves of COVID-19 pandemic caused by SARS-CoV-2 and reported the second highest caseload globally. Seroepidemiologic studies were done to track the course of the pandemic. We systematically reviewed and synthesized the seroprevalence of SARS-CoV-2 in the Indian population.

METHODS

We included studies reporting seroprevalence of IgG antibodies against SARS-CoV-2 from March 1, 2020 to August 11, 2021 and excluded studies done only among patients with COVID-19 and vaccinated individuals. We searched published databases, preprint servers, and government documents using a combination of keywords and medical subheading (MeSH) terms of "Seroprevalence AND SARS-CoV-2 AND India". We assessed risk of bias using the Newcastle-Ottawa scale, the appraisal tool for cross-sectional studies (AXIS), the Joanna Briggs Institute (JBI) critical appraisal tool, and WHO's statement on the Reporting of Seroepidemiological Studies for SARS-CoV-2 (ROSES-S). We calculated pooled seroprevalence along with 95% Confidence Intervals (CI) during the first (March 2020 to February 2021) and second wave (March to August 2021). We also estimated seroprevalence by selected demographic characteristics.

RESULTS

We identified 3821 studies and included 53 studies with 905379 participants after excluding duplicates, screening of titles and abstracts and full-text screening. Of the 53, 20 studies were of good quality. Some of the reviewed studies did not report adequate information on study methods (sampling = 24% (13/53); laboratory = 83% [44/53]). Studies of 'poor' quality had more than one of the following issues: unjustified sample size, nonrepresentative sample, nonclassification of nonrespondents, results unadjusted for demographics and methods insufficiently explained to enable replication. Overall pooled seroprevalence was 20.7% in the first (95% CI = 16.1 to 25.3) and 69.2% (95% CI = 64.5 to 73.8) in the second wave. Seroprevalence did not differ by age in first wave, whereas in the second, it increased with age. Seroprevalence was slightly higher among women in the second wave. In both the waves, the estimate was higher in urban than in rural areas.

CONCLUSION

Seroprevalence increased by 3-fold between the 2 waves of the pandemic in India. Our review highlights the need for designing and reporting studies using standard protocols.

Transdisciplinarity of India's master's level public health programmes: evidence from admission criteria of the programmes offered since 1995

INTRODUCTION

In the Indian subcontinent, Master's-level Public Health (MlPH) programmes attract graduates of diverse academic disciplines from health and non-health sciences alike. Considering the current and futuristic importance of the public health cadre, we described them and reviewed their transdisciplinarity status based on MlPH admissibility criteria 1995 to 2021.

METHODS

Using a search strategy, we abstracted information available in the public domain on MlPH programmes and their admissibility criteria. We categorized the admission criteria based on specified disciplines into Health science, Non-health science and Non-health non-science categories. We described the MlPH programmes by location, type of institution, course duration, curriculum, pedagogical methods, specializations offered, and nature of admission criteria statements. We calculated descriptive statistics for eligible educational qualifications for MlPH admission.

RESULTS

Overall, 76 Indian institutions (Medical colleges-21 and Non-medical coleges-55) offered 92 MlPH programmes (Private-58 and Public-34). We included 89 for review. These programmes represent a 51% increase (n = 47) from 2016 to 2021. They are mostly concentrated in 21 Indian provinces. These programmes stated that they admit candidates of but not limited to "graduation in any life sciences", "3-year bachelor's degree in any discipline", "graduation from any Indian universities", and "graduation in any discipline". Among the health science disciplines, Modern medicine (n = 89; 100%), Occupational therapy (n = 57; 64%) is the least eligible. Among the non-health science disciplines, life sciences and behavioural sciences (n = 53; 59%) and non-health non-science disciplines, humanities and social sciences (n = 62; 72%) are the topmost eligible disciplines for admission in the MPH programmes.

CONCLUSION

Our review suggests that India's MlPH programmes are less transdisciplinary. Relatively, non-medical institutions offer admission to various academic disciplines than the medical institutions in their MlPH programmes. India's Master's level public health programmes could be more inclusive by opening to graduates from trans-disciplinary backgrounds.

Determinants of severity among hospitalised COVID-19 patients: Hospital-based case-control study, India, 2020

Background

Risk factors for the development of severe COVID-19 disease and death have been widely reported across several studies. Knowledge about the determinants of severe disease and mortality in the Indian context can guide early clinical management.

Methods

We conducted a hospital-based case control study across nine sites in India to identify the determinants of severe and critical COVID-19 disease.

Findings

We identified age above 60 years, duration before admission >5 days, chronic kidney disease, leucocytosis, prothrombin time > 14 sec, serum ferritin >250 ng/mL, d-dimer >0.5 ng/mL, pro-calcitonin >0.15 μg/L, fibrin degradation products >5 μg/mL, C-reactive protein >5 mg/L, lactate dehydrogenase >150 U/L, interleukin-6 >25 pg/mL, NLR ≥3, and deranged liver function, renal function and serum electrolytes as significant factors associated with severe COVID-19 disease.

Interpretation

We have identified a set of parameters that can help in characterising severe COVID-19 cases in India. These parameters are part of routinely available investigations within Indian hospital settings, both public and private. Study findings have the potential to inform clinical management protocols and identify patients at high risk of severe outcomes at an early stage.

COVID-19 testing, timeliness and positivity from ICMR's laboratory surveillance network in India: Profile of 176 million individuals tested and 188 million tests, March 2020 to January 2021

Background

The Indian Council of Medical Research set up a pan-national laboratory network to diagnose and monitor Coronavirus disease 2019 (COVID-19). Based on these data, we describe the epidemiology of the pandemic at national and sub-national levels and the performance of the laboratory network.

Methods

We included surveillance data for individuals tested and the number of tests from March 2020 to January 2021. We calculated the incidence of COVID-19 by age, gender and state and tests per 100,000 population, the proportion of symptomatic individuals among those tested, the proportion of repeat tests and test positivity. We computed median (Interquartile range—IQR) days needed for selected surveillance activities to describe timeliness.

Results

The analysis included 176 million individuals and 188 million tests. The overall incidence of COVID-19 was 0.8%, and 12,584 persons per 100,000 population were tested. 6.1% of individuals tested returned a positive result. Ten of the 37 Indian States and Union Territories accounted for about 75.6% of the total cases. Daily testing scaled up from 40,000 initially to nearly one million in March 2021. The median duration between symptom onset and sample collection was two (IQR = 0,3) days, median duration between both sample collection and testing and between testing and data entry were less than or equal to one day. Missing or invalid entries ranged from 0.01% for age to 0.7% for test outcome.

Conclusion

The laboratory network set-up by ICMR was scaled up massively over a short period, which enabled testing a large section of the population. Although all states and territories were affected, most cases were concentrated in a few large states. Timeliness between the various surveillance activities was acceptable, indicating good responsiveness of the surveillance system.

Outbreak of ceftriaxone-resistant Salmonella enterica serotype Typhi-Tiruchirappalli, Tamil Nadu, India, June 2018

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Surveillance detected ceftriaxone-resistant Salmonella enterica serotype Typhi

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Investigation revealed illness associated with eating in a restaurant

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Illness likely due to contaminated food and use of unchlorinated water

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Investigation highlights the value of surveillance in detecting emerging pathogens

•

Timely and detailed investigations and strengthening of food safety are required

Objectives

In May 2018, a laboratory network for antimicrobial resistance (AMR) surveillance in Tamil Nadu, India, detected a cluster of Salmonella enterica serotype Typhi (S. Typhi) isolates resistant to ceftriaxone. We investigated to describe the epidemiology and identify risk factors for the outbreak.

Methods

We conducted unmatched case-control studies. We defined a case as illness (fever with abdominal pain, diarrhea or vomiting) in a person with blood culture-confirmed ceftriaxone-resistant S. Typhi isolated between January 1 and July 4, 2018 in Tiruchirappalli, Tamil Nadu. We interviewed cases using a semi-structured questionnaire to identify common exposures to food, water and places visited.

Results

We identified 7 cases (5 men) during March 25–June 8, 2018, median age 23 years (range: 12–42); all were hospitalized, none died. Eating at Restaurant A (odds ratio [OR]=22) and chicken gravy (OR=16) was associated with illness. Of the 10 workers at Restaurant A, stool culture from 8 did not detect S. Typhi; 2 did not consent to provide samples. Five water samples around the restaurant showed low or no residual chlorine content.

Conclusions

The investigation highlights the value of AMR surveillance in detecting emerging pathogens and the need for timely investigations, along with strengthening food safety.

Low risk of relapse and deformity among leprosy patients who completed multi-drug therapy regimen from 2005 to 2010: A cohort study from four districts in South India

Introduction

Relapse of leprosy among patients released from treatment (RFT) is an indicator of the success of anti-leprosy treatment. Due to inadequate follow-up, relapse in leprosy patients after RFT is not systematically documented in India. Relapsed leprosy patients pose a risk in the transmission of leprosy bacilli. We determined the incidence of relapse and deformity among the patients RFT from the leprosy control programme in four districts in South India.

Methods

We conducted two follow-up surveys in 2012 and 2014 among the leprosy patients RFT between 2005 and 2010. We assessed them for any symptoms or signs of relapse, persistence and deformity. We collected slit skin samples (SSS) for smear examination. We calculated overall incidence of relapse and deformity per 1000 person-years (PY) with 95% confidence intervals (CI) and cumulative risk of relapse.

Results

Overall, we identified 69 relapse events, 58 and 11, during the first and second follow-up surveys, respectively. The incidence of relapse was 5.42 per 1000 PY, which declined over the years after RFT. The cumulative risk of relapse was 2.24%. The rate of deformity among the relapsed patients was 30.9%. The overall incidence of deformity was 1.65 per 1000 person years. The duration of M. leprae detection in smears ranged between 2.38 and 7.67 years.

Conclusions

Low relapse and deformity rates in leprosy RFT patients are indicative of treatment effectiveness. However, a higher proportion of detection of deformity among relapsed cases is a cause for concern. Periodic follow-up of RFT patients for up to 3 years to detect relapses early and ensure appropriate treatment will minimize the development of deformity among relapsed patients.

India achieved leprosy elimination (<1 case/10000 population) in 2005. However, it remains a country with a high burden of leprosy (120,334 cases in 2017–18), with an annual detection of more than 10000 new cases, including children, indicating widespread active transmission. In addition to the untreated leprosy cases, even patients who relapse after release from leprosy treatment play a significant role in disease transmission. Early detection and management of leprosy relapse cases will minimize the disease transmission and might prevent leprosy-associated deformity. Leprosy management services are primarily provided by the government healthcare system in India and supported by several major non-governmental charitable organizations. The burden of leprosy relapse in India cannot be measured since there is no provision to follow-up the patients who complete multi-drug treatment (MDT) in the national leprosy program. We report the incidence of leprosy relapse among the patients who completed leprosy treatment from the national leprosy control program in four districts in South India. The report also highlights the effectiveness of MDT in program settings, the lower risk of developing deformity after treatment completion, and the need to incorporate an appropriately designed follow-up strategy.

Epidemiology of hospital-based COVID- 19 cluster in a tertiary care cancer hospital, Chennai, India 2020

Objectives

To identify risk factors associated with Coronavirus disease 2019 (COVID-19) in a Tertiary care cancer hospital-based cluster and recommend control measures.

Methods

We conducted tracing and confirmation among hospital and community contacts. We telephonically interviewed and abstracted information from hospital records and registers. We described the cluster by time, place and person. We conducted unmatched case-control study to compare risk factors and computed Odds Ratio (OR) and 95% confidence interval.

Results

We confirmed COVID-19 in 21 of 1478 tested (1.4%). Secondary attack (%) of COVID-19 among 824 contacts was higher among in-patients of block A (18), household contacts (3.4), housekeeping staff (3.3) and nurses (1.7). The cluster started on April 22 with two successive peaks five days apart and lasted until May 8. Being male, patients aged >33 years [OR = 30·7; 95% CI = 3·6 to 264], having hypertension [OR = 4·3; 95% CI = 1·1 to 16·7] or diabetes [OR = 3·8; 95% CI = 1·0 to 14·1] were associated with COVID-19. Mask compliance was poor (20%) among hospital workers.

Discussion

We recommended screening of all patients for diabetes and hypertension and isolation/testing of anyone with influenza-like illness for preventing COVID-19 clusters in hospital settings.

Secondary attack rate of COVID-19 among contacts and risk factors, Tamil Nadu, March-May 2020: a retrospective cohort study

OBJECTIVE

To describe the characteristics of contacts of patients with COVID-19 case in terms of time, place and person, to calculate the secondary attack rate (SAR) and factors associated with COVID-19 infection among contacts.

DESIGN

A retrospective cohort study SETTING AND PARTICIPANTS: Contacts of cases identified by the health department from 14 March 2020to 30 May 2020, in 9 of 38 administrative districts of Tamil Nadu. Significant proportion of cases attended a religious congregation.

OUTCOME MEASURE

Attack rate among the contacts and factors associated with COVID-19 positivity.

RESULTS

We listed 15 702 contacts of 931 primary cases. Of the contacts, 89% (n: 14 002) were tested for COVID-19. The overall SAR was 4% (599/14 002), with higher among the household contacts (13%) than the community contacts (1%). SAR among the contacts of primary cases with congregation exposure were 5 times higher than the contacts of non-congregation primary cases (10% vs 2%). Being a household contact of a primary case with congregation exposure had a fourfold increased risk of getting COVID-19 (relative risk (RR): 16.4; 95% CI: 13 to 20) than contact of primary case without congregation exposure. Among the symptomatic primary cases, household contacts of congregation primaries had higher RR than household contacts of other cases ((RR: 25.3; 95% CI: 10.2 to 63) vs (RR: 14.6; 95% CI: 5.7 to 37.7)). Among asymptomatic primary case, RR was increased among household contacts (RR: 16.5; 95% CI: 13.2 to 20.7) of congregation primaries compared with others.

CONCLUSION

Our study showed an increase in disease transmission among household contacts than community contacts. Also, symptomatic primary cases and primary cases with exposure to the congregation had more secondary cases than others.

Dynamic alterations in monocyte numbers, subset frequencies and activation markers in acute and convalescent COVID-19 individuals

Monocytes are thought to play an important role in host defence and pathogenesis of COVID-19. However, a comprehensive examination of monocyte numbers and function has not been performed longitudinally in acute and convalescent COVID-19. We examined the absolute counts of monocytes, the frequency of monocyte subsets, the plasma levels of monocyte activation markers using flowcytometry and ELISA in seven groups of COVID-19 individuals, classified based on days since RT-PCR confirmation of SARS-CoV2 infection. Our data shows that the absolute counts of total monocytes and the frequencies of intermediate and non-classical monocytes increases from Days 15-30 to Days 61-90 and plateau thereafter. In contrast, the frequency of classical monocytes decreases from Days 15-30 till Days 121-150. The plasma levels of sCD14, CRP, sCD163 and sTissue Factor (sTF)-all decrease from Days 15-30 till Days 151-180. COVID-19 patients with severe disease exhibit higher levels of monocyte counts and higher frequencies of classical monocytes and lower frequencies of intermediate and non-classical monocytes and elevated plasma levels of sCD14, CRP, sCD163 and sTF in comparison with mild disease. Thus, our study provides evidence of dynamic alterations in monocyte counts, subset frequencies and activation status in acute and convalescent COVID-19 individuals.

Recovery of Memory B-cell Subsets and Persistence of Antibodies in Convalescent COVID-19 Patients

It is essential to examine the longevity of the defensive immune response engendered by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. We examined the SARS-CoV-2-specific antibody responses and ex vivo memory B-cell subsets in seven groups of individuals with COVID-19 classified based on days since reverse-transcription polymerase chain reaction confirmation of SARS-CoV-2 infection. Our data showed that the levels of IgG and neutralizing antibodies started increasing from days 15 to 30 to days 61 to 90, and plateaued thereafter. The frequencies of naive B cells and atypical memory B cells decreased from days 15 to 30 to days 61 to 90, and plateaued thereafter. In contrast, the frequencies of immature B cells, classical memory B cells, activated memory B cells, and plasma cells increased from days 15 to 30 to days 61 to 90, and plateaued thereafter. Patients with severe COVID-19 exhibited increased frequencies of naive cells, atypical memory B cells, and activated memory B cells, and lower frequencies of immature B cells, central memory B cells, and plasma cells when compared with patients with mild COVID-19. Therefore, our data suggest modifications in memory B-cell subset frequencies and persistence of humoral immunity in convalescent individuals with COVID-19.

Secular trends of grossly underreported snakebite burden in India, 2009-2018: analysis of data from India's National Health Profile

BACKGROUND

India's National Health Profile (NHP) documents snakebite cases and deaths based on hospital-based reports, hence underrepresenting the actual burden. We describe secular trends of NHP data using population denominators for 2009-2018.

METHODS

We abstracted the data on snakebite cases and deaths and calculated incidence and case fatality rate (CFR) by gender and by states using population denominators. We estimated the change in incidence and CFR over time by using a Poisson regression model. We computed the incidence rate ratio (IRR) and 95% confidence interval (CI) using Stata 14.0.

RESULTS

The incidence of snakebites ranged from 89 to 141 per million population and without any specific pattern during 2009-2018 as per NHP reports. The incidence increased by 3% per year (IRR 1.03 [95% CI 0.99 to 1.07]). The incidence was higher among males (range 97-163) than females (range 71-115) and there was no difference in trends by gender (IRR 1.07 [95% CI 0.37 to 3.12]). The CFR was 5-13 deaths per 1000 cases, with an annual decline of 12% (IRR 0.88 [95% CI 0.85 to 0.92]). The CFR did not differ by gender (male 5-12, female 6-13; IRR 0.48 [95% CI 0.20 to 1.17]).

CONCLUSION

India's NHP snakebite data, representing an underestimate of the actual burden, suggests no specific secular trend and points to areas documenting consistent and significant burden.

Cost-effectiveness of surgical mask, N-95 respirator, hand-hygiene and surgical mask with hand hygiene in the prevention of COVID-19: Cost effectiveness analysis from Indian context

INTRODUCTION

In the absence of specific treatment, preventive strategies are of paramount importance in management of coronavirus disease 2019(COVID-19) pandemic. We estimated cost-effectiveness of non-pharmacological interventions such as hand-hygiene, surgical-mask N-95 respirators and surgical mask in general population.

METHODS

We performed a decision tree and markov-model based economic evaluation. We estimated total costs and outcomes from public payer's perspective, based on information available through systematic literature search on relative intervention effect during early pandemic phase. We estimated outcomes as number COVID-19 prevented and Quality Adjusted life year (QALY) over one-year time-horizon with one-day cycle-length. Incremental cost effectiveness ratios (ICER) was calculated multiple sensitivity analyses were applied to assess parameter uncertainty.

RESULTS

Use of surgical mask with hand hygiene, fit tested N-95 respirator, surgical-mask, non-fit tested N-95 and hand-hygiene interventions prevented additional 1139, 1124, 1121, 1043 and 975 COVID-19 cases per-million as compared to using none. Additional costs incurred (in billion) were ₹29.78 ($0.40), ₹148.09 ($1.99), ₹72.51 ($0.98), ₹26.84 ($0.36) and ₹2.48 ($0.03) as well as additional QALYs gained were 357.4, 353.01, 327.95, 351.52 and 307.04 for surgical mask with hand hygiene, fit-tested N-95, non-fit-tested N-95, surgical mask and hand-hygiene respectively. ICERs with surgical with hand hygiene, hand-hygiene alone, surgical-mask alone, N-95 respirator fit and non-fit test were 83.32($1.12), 8.07($0.11), 76.36($1.03), 419.51($5.65) and 221.10 ($2.98) million ₹ ($)/QALY respectively. Results were robust on uncertainty analysis.

DISCUSSION

Among the non-pharmacological interventions to be considered for preventing spread of COVID-19, hand hygiene was cost-effective and avoidance of use of surgical masks and respirators by the general public could save resources.

Self-reported and clinically identified loss of smell and taste among persons tested for COVID-19 in Chennai, southern India, July-August 2020: A cross sectional study

Background

Early detection of symptoms of loss of smell and taste lately added for Coronavirus disease 2019 (COVID-19) has the potential for improving pandemic response. In the Indian context, we compared proportion experiencing new loss of smell or taste among COVID-19 positive and negative individuals in Chennai city, Southern India.

Methods

We did an analytical cross-sectional study among individuals aged 18–80 years undergoing testing at COVID-19 sample collection centres. We ascertained loss of smell and taste using standardised self-reporting and clinical examination procedures. We administered Sino Nasal Outcome (SNOT 22) questionnaire for comprehensive understanding of these symptoms. We compared proportion having symptoms between COVID-19 positive and negative persons. We compared the two assessment methods to compute diagnostic validity indicators.

Results

Of the 277 participants, 169 (61%) were men and mean age of 40.7 years [SD = 13.3]. Fifty eight (21%) had COVID-19 and 12 (36%) of them were asymptomatic. Predominantly reported symptoms were fever (30%), headache (18%) and cough (18%). Self-reported or clinically identified new loss of smell or taste was higher among COVID-19 positive (n = 13; 22%) than negative persons (n = 23; 11%) [p = 0.02]. Sensitivity was higher for self-reported or clinically identified loss of smell (17.2%) than that of loss of taste (6.9%). Negative predictive value for loss of smell or taste, self-reported or clinically identified was 81%. Likelihood ratio of positive test was 2.13.

Conclusion

Loss of smell or taste are predominantly reported by COVID-19 confirmed individuals. Objective and subjective assessments of smell and taste may be required to identify those requiring COVID-19 testing.

Potential for establishing an injury surveillance system in India: a review of data sources and reporting systems

Background

Unintentional injuries account for 10% of deaths worldwide; the majority due to road traffic injuries, falls, drowning, poisoning and burns. Effective surveillance systems provide evidence for informed injury prevention and treatment and improve recovery outcomes. Our objectives were to review existing sources of unintentional injury data, and quality of the data on the burden, distribution, risk factors and trends of unintentional injuries in India and to describe strengths and limitations of health facility-based data for potential use in injury surveillance systems.

Methods

We searched national and international organisations’ websites to identify unintentional injury-related mortality and morbidity data sources in India. We reviewed and evaluated data collection methods for surveillance attributes recommended by World Health Organization (WHO). We visited health facilities at all levels from public and private sectors, emergency transport centres, insurance offices and police stations in settings reporting significant number of injuries. In these sites, we interviewed key stakeholders using an explorative approach on current data collection processes and challenges to establishing an injury surveillance system based on WHO guidelines.

Results

Major gaps were highlighted in injury mortality and morbidity data in India, including ill-defined causes of injury deaths and lack of standardisation in classification and coding. Site visits revealed that reporting standards of injuries varied, with issues around clarity of definitions, accountability, time points and lack of reporter/coder training. Major challenges were lack of dedicated staff and training.

Conclusions

There is an important need to build human resource capacity, integrate data sources, standardise and streamline data collected, ensure accountability and capitalise on digital health information systems including insurance databases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-09992-9.

An outbreak of bilateral photokeratitis and eyelid erythema following exposure to an artificial source of ultraviolet radiation, Tamil Nadu, India, 2018

Metal halide lights (MHLs) emit ultraviolet radiation (UVR) and should be used with enclosed fixtures. We investigated a cluster of blurred vision in a locality in South India reported among light music event attendees to identify risk factors.

METHODS

We searched for attendees with any eye-related symptoms by door-to-door. We described cases by time, place, and person and inspected the environment to generate a hypothesis. We followed-up the cohort of the attendees to examine the hypothesis of exposure to MHL as the cause of the outbreak. We computed relative risk (RR) and 95% confidence interval (CI) by comparing attack rates among attendees by seating location and duration of exposure.

RESULTS

Of the total 500 attendees, we could interview 319 (64%) and 89% (284/319) attendees developed bilateral photokeratitis (median age = 24 years [range: 2-80 years]). Attack rate was higher among female (92% [172/189]) than male (85% [110/130]). Attack rate among those seated within 12 meters from dais was higher (95% [241/253]) than the rest (65% [43/66]; RR = 1.5; 95% CI = 1.2, 1.7) and attack rate was higher among those continuously exposed to MHL (97% [268/277]) than others (38% [16/42]; RR = 2.5; 95% CI = 1.7, 3.7). The duration of exposure was associated with increased risk of bilateral photokeratitis (χ2 test for linear trend = 74; P < 0.00001). During the environmental inspection, we identified the use of MHL with a broken outer envelope.

CONCLUSIONS

Photokeratitis was associated with exposure to UVR from MHL with a broken outer envelope. We recommended the usage of MHL along with enclosed fixtures.

Entry and initial spread of COVID-19 in India: Epidemiological analysis of media surveillance data, India, 2020

Background

India reported first laboratory-confirmed case of coronavirus disease 2019 (COVID-19) on 30 January from Kerala. Media surveillance is useful to capture unstructured information about outbreaks. We established media surveillance and described the characteristics of the COVID-19 cases, clusters, deaths by time, place, and person during January–March 2020 in India.

Methods

The media surveillance team of ICMR-National Institute of Epidemiology abstracted data from public domains of India's Central and State health ministries, online news and social media platforms for the period of January 31 to March 26, 2020. We collected data on person (socio-demographics, circumstances of travel/contact, clinical and laboratory), time (date/period of reported exposures; laboratory confirmation and death) and place (location). We drew epidemic curve, described frequencies of cases by age and gender. We described available details for identified clusters.

Results

As of March 26, 2020, India reported 694 (Foreigners = 45, 6%) confirmed COVID-19 cases (Attack rate = 0.5 per million population) and 17 deaths (Fatality = 2.5%) from 21 States and 6 Union Territories. The cases were higher among 20–59 years of age (60 of 85) and male gender (65 of 107). Median age at death was 68 years (Range: 38–85 years). We identified 13 clusters with a total of 63 cases and four deaths among the first 200 cases.

Conclusion

Surveillance of media sources was useful in characterizing the epidemic in the early phase. Hence, media surveillance should be integrated in the routine surveillance systems to map the events specially in context of new disease outbreaks.

Association between exposure to artificial sources of ultraviolet radiation and ocular diseases: a systematic review protocol

OBJECTIVE

The objective of this review will be to determine the association between exposure to artificial sources of ultraviolet radiation and ocular diseases.

INTRODUCTION

Numerous studies have established the association between natural ultraviolet radiation and ocular diseases in humans. However, the evidence of the association between artificial sources of ultraviolet radiation and ocular diseases has not been reviewed.

INCLUSION CRITERIA

The proposed review will include studies with participants of any age and sex, and documented exposure to artificial sources of ultraviolet radiation and incidence of ocular diseases.

METHODS

Databases including PubMed and Embase will be searched. Study selection and full-text screening will be done by two independent reviewers. The search results will be presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram. Critical appraisal of the eligible studies for methodological quality will be conducted using JBI checklists. All studies, regardless of their methodological quality, will undergo data extraction and synthesis using standardized data extraction tools. Quantitative papers will, where possible, be pooled in statistical meta-analysis. Heterogeneity will be assessed statistically using the standard χ, and also explored using relevant subgroup analyses based on the different quantitative study designs included in this review. Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42019129372.

Unanticipated challenges: Institutional anonymity vs child health

The case study presented by the researcher reflects on a dilemma faced during her public health research in a setting in South India. Her case prompts discussions around the public health context, ethical dilemmas therein, research challenges and relevance to other situations in public health research.

Concepts of body constitution in traditional Siddha texts: A literature review

Analysis of body constitution has been in practice in most complementary and alternative systems of medicine. Siddha system of medicine practiced in South India consists of fundamental classical literature that stress on the importance of tri-humoral makeup of individuals. Guidance has been given in the classics for identifying specific types of body constitution, various dietary recommendations and disease susceptibility. In validating such important traditional fundamental aspects, analytical systematic literature framework is the first robust step. The present study has been conducted to provide an updated integrative framework of information about body constitution given in various Siddha literatures in quantitative systematic method by using Whittemore and Knafl's five stage approach. This descriptive account may be useful to construct a suitable questionnaire for Siddha based udaliyal assessment.

Use of systematic epidemiological methods in outbreak investigations from India, 2008-2016: A systematic review

Background

In the absence of a comprehensive review, we conducted a systematic review on the use of systematic approach in outbreak investigation using reports from India.

Objectives

The primary objective was to estimate the proportion of outbreak reports from India during 2008–16, that reported the steps in outbreak investigation. The secondary objectives were to (1) describe the outbreak reports by selected characteristics (source, investigating agency, disease, time, place and person) (2) estimate the proportion of outbreaks that conducted analytical and additional studies.

Methods

We searched eight electronic databases and grey literature for outbreak investigation reports among humans at community settings from India during 2008–2016. We developed a check-list based on the 10-steps approach used by Field Epidemiology Training Programme (FETP) of ICMR-National Institute of Epidemiology (ICMR-NIE), Chennai, India. This checklist was used to independently screen and extract data on general characteristics of the outbreak investigation reports and the steps completed. We adopted The Joanna Briggs Institute (JBI) check list for prevalence studies to examine the credibility and consistency. The protocol was registered at Prospero (CRD42017065038). We calculated proportion of reports that followed the steps in their investigation and descriptive statistics on selected characteristics.

Results

Of 10,657 articles screened, 136 articles were included for the review. Completion of the ten steps in the outbreak investigations was seen in 16% of reports. The highest level of completion was for drawing conclusion in outbreak investigation (98%) and the lowest completion (29%) was for developing a case definition by time, place and person followed by conducting an analytic study (24%).

Conclusions

Outbreak reports from India either lacked application of systematic steps for investigation or failed to report the actual procedures followed. We recommend improving systematic investigation of outbreaks through training and supervision of outbreak response teams and encouraging publications.

•

Systematic review of outbreak investigation reports from India (2008–16) for application of systematic approach documented poor application of use of methods used or reporting of recommended steps.

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Defining of a case by time, place and person and conducting an analytic study were the least reported steps.

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There is a need to strengthen the quality and transparency of outbreak investigations while reporting.

Cholera outbreak linked with lack of safe water supply following a tropical cyclone in Pondicherry, India, 2012

In the aftermath of a severe cyclonic storm on 7 January 2012, a cluster of acute diarrhoea cases was reported from two localities in Pondicherry, Southern India. We investigated the outbreak to identify causes and recommend control measures. We defined a case as occurrence of diarrhoea of more than three loose stools per day with or without vomiting in a resident of affected areas during 6-18 January 2012. We used active (door-to-door survey) and stimulated passive (healthy facility-based) surveillance to identify cases. We described the outbreak by time, place, and person. We compared the case-patients with up to three controls without any apparent signs and symptoms of diarrhoea and matched for age, gender, and neighbourhood. We calculated matched odds ratio (MOR), 95% confidence intervals (CI), and population attributable fractions (PAF). We collected rectal swabs and water samples for laboratory diagnosis and tested water samples for microbiological quality. We identified 921 cases and one death among 8,367 residents (attack rate: 11%, case-fatality: 0.1%). The attack rate was the highest among persons of 50 years and above (14%) and females (12%). The outbreak started on 6 January and peaked on the 9th and lasted till 14 January. Cases were clustered around two major leakages in water supply system. Nine of the 16 stool samples yielded V. cholerae O1 Ogawa. We identified that consumption of water from the public distribution system (MOR=37, 95% CI 4.9-285, PAF: 97%), drinking unboiled water (MOR=35, 95% CI 4.5-269, PAF: 97%), and a common latrine used by two or more households (MOR=2.7, 95% CI 1.3-5.6) were independently associated with cholera. Epidemiological evidence suggested that this outbreak was due to ingestion of water contaminated by drainage following rains during cyclone. We recommended repair of the water supply lines, cleaning-up of the drains, handwashing, and drinking of boiled water.