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.

Impact of COVID-19 on utilization of maternal and child health services in India: Health management information system data analysis

Background/Objectives

Studies globally have documented the impact of COVID 19 on maternal and newborn health services. This study assesses the impact of COVID-19 on essential maternal and child health (MCH) services in India based on the national Health Management Information System (HMIS).

Methods

Present retrospective study used secondary data analysis upon the routinely collected data accessed from Health Management Information System. Microdata on maternal and newborn indicators was extracted for all states between April and June during 2019, 2020 and 2021. Relative change for each indicator were taken into consideration for the year 2020 and 2021; with respect to the outcomes in 2019.

Results

Compared to 2019, antenatal care registrations saw a decline in all states for both periods in 2020 and 2021 except for Sikkim, Telangana, Maharashtra and Andhra Pradesh. Similarly, the relative changes in 2019 pertaining to the proportion of pregnant women provided with emergency obstetric care for pregnancy complications registered a decline in all states except for Himachal Pradesh, Telangana and Arunachal Pradesh. There was a decreasing trend noted in institutional deliveries in 2020 and 2021 among all major states. However, an increasing trend was seen in the number of immunization sessions held among all major states.

Conclusion

The study demonstrates a disruption in service delivery during the lockdown period in the first wave and the peak of the second wave. Further qualitative studies need to be undertaken to generate evidence for maintaining continuum of care during a pandemic situation.

Expedited diagnosis of pediatric tuberculosis using Truenat MTB-Rif Dx and GeneXpert MTB/RIF

Rapid, cost-effective, and sensitive diagnostic assays are essential for global tuberculosis (TB) control, especially in high TB burden, resource-limited settings. The current study was designed to evaluate diagnostic accuracy of Truenat MTB-Rif Dx (MolBio) in children less than 18 years of age, with symptoms suggestive of TB. Gastric aspirate, induced sputum, and broncho-alveolar lavage samples were subjected simultaneously to AFB-smear, GeneXpert MTB/RIF, liquid culture (MGIT-960) and Truenat MTB-Rif Dx. The index-test results were evaluated against microbiological reference standards (MRS). Truenat MTB-Rif Dx had a sensitivity of 57.1%, specificity of 92% against MRS. The sensitivity and specificity of the Truenat MTB-RIF Dx compared with liquid culture was 58.7% and 87.5% while GeneXpert MTB/RIF was 56% and 91.4%. The performance of both GeneXpert MTB/RIF and Truenat MTB-Rif Dx are comparable. Result of our study demonstrates that Truenat MTB-Rif can aid in early and efficient diagnosis of TB in children.

Analysis of a Targeted Intervention Programme on the Risk Behaviours of Injecting Drug Users in India: Evidence From the National Integrated Biological and Behavioural Surveillance Survey

Objectives

This study provides insights on the impact of a targeted intervention (TI) programme on behaviour change among injecting drug users (IDUs) in India.

Methods

This paper examined the data from the Integrated Biological and Behavioural Surveillance 2014–2015 for IDUs in India. Logistic regression was performed to understand the factors (TI programme services) that affected injecting risk behaviours by adjusting for covariates. Propensity score matching was conducted to understand the impact of the TI programme on using new needles/syringes and sharing needles/syringes in the most recent injecting episode by accounting for the covariates that predicted receiving the intervention.

Results

Participants who received new needles and syringes from peer educators or outreach workers were 1.3 times (adjusted odds ratio, 1.29; 95% confidence interval [CI], 1.09 to 1.53) more likely to use new needles/syringes during most recent injecting episode than participants who did not receive needles/syringes. The matched-samples estimate (i.e., average treatment effect on treated) of using new needles in the most recent injecting episode showed a 2.8% (95% CI, 0.0 to 5.6) increase in the use of new needles and a 6.5% (95% CI, −9.7 to −3.3) decrease in needle sharing in the most recent injecting episode in participants who received new needles/syringes. There was a 2.2% (95% CI, −3.8 to −0.6) decrease in needle sharing in the most recent injecting episode among participants who were referred to other services (integrated counselling and testing centre, detox centres, etc.).

Conclusions

The TI programme proved to be effective for behaviour change among IDUs, as substantiated by the use of new needles/syringes and sharing of needles/syringes.

Multicentric validation of indigenous molecular test Truenat™ MTB for detection of Mycobacterium tuberculosis in sputum samples from presumptive pulmonary tuberculosis patients in comparison with reference standards

Background & objectives:

Early case detection is essential to interrupt transmission and to prevent further spread of tuberculosis (TB) in high endemic settings. Nucleic acid amplification tests (NAATs) with visual read-outs are ideal as point-of-care tests. Truenat™ MTB is an indigenous chip-based NAAT for detection of Mycobacterium tuberculosis, which involves extraction of DNA and real-time polymerase chain reaction (PCR) using portable, automated, battery-operated instruments. The current multicentric study was aimed to evaluate Truenat for detection of MTB in sputum samples obtained from patients with presumptive pulmonary TB with reference to culture as gold standard and Xpert as a comparator.

Methods:

The study was conducted at four sites, namely ICMR-National Institute for Research in Tuberculosis, Chennai; All India Institute of Medical Sciences, New Delhi; ICMR-National JALMA Institute for Leprosy and Other Mycobacterial Diseases, Agra; and National Institute of TB and Respiratory Diseases, New Delhi. Patients suspected to have TB were screened for eligibility. Two sputum samples were collected from each patient. Tests included smear, Xpert and Truenat directly from the sputum sample and culture by Lowenstein-Jensen (L-J) medium and MGIT960 from decontaminated pellets. Sample used for Truenat assay was coded. Resolution of Truenat false positives was done using an in-house PCR with TRC₄ primers.

Results:

The study enrolled 2419 presumptive TB patients after screening 2465 patients, and 3541 sputum samples were collected from the enrolled patients. Results of 2623 samples were available for analysis. Truenat showed a positivity rate of 48.5 per cent as compared to 37.0 per cent by Xpert. The sensitivities of Truenat and Xpert were was 88.3 and 79.7 per cent, respectively in comparison with culture.

Interpretation & conclusions:

Truenat MTB identified more positives among culture-confirmed samples than Xpert and had higher sensitivity. In addition, other advantageous operational features of Truenat MTB were identified which would be useful in field settings.

Validation of an indigenous assay for rapid molecular detection of rifampicin resistance in presumptive multidrug-resistant pulmonary tuberculosis patients

Background & objectives:

There is a need for an affordable, easy, high-sensitivity test usable at the peripheral health facility for diagnosis of drug-resistant (DR) tuberculosis (TB) to interrupt disease transmission. Nucleic acid amplification tests (NAATs) for early detection of DR-TB are ideal to bring testing near to the patient. Truenat™ MTB (Mycobacterium tuberculosis) and Truenat™ MTB-RIF (rifampicin) is an indigenous chip-based real-time polymerase chain reaction (PCR) based test for detection of multidrug-resistant (MDR) TB. The test involves extraction of DNA using automated, battery operated Trueprep instrument and real-time PCR performed on the Truelab analyzer. We report here multicentric validation of Truenat MTB-RIF for detection of DR-TB in suspected DR-TB patients.

Methods:

Consecutive patients aged 18-65 yr, with symptoms suggestive of TB and with a history of previous treatment, reporting to the National TB Elimination Programme (NTEP) clinics under four national institutes, namely AIIMS (All India Institute of Medical Sciences, New Delhi), NITRD (National Institute of Tuberculosis and Respiratory Diseases, New Delhi), NIRT (National Institute for Research in Tuberculosis, Chennai) and ICMR-National JALMA Institute for Leprosy and other Mycobacterial Diseases, Agra, were included in the study. Two sputum samples (one spot and one morning) were collected from each patient, after obtaining informed written consent. The samples were subjected to smear, GeneXpert and MGIT 960 culture (and drug susceptibility testing to RIF) (surrogate for MDR-TB) to serve as reference tests. The samples were coded to ensure blinding and subjected to Truenat MTB-RIF. Truenat MTB-RIF Version 1.5 was used for testing 1084 samples for RIF resistance, while Version 2.0 was used to test another 1201 samples.

Results:

Truenat MTB-RIF Version 1.5 in comparison with comprehensive laboratory reference standards yielded sensitivity and specificity of 76.2 and 94.7 per cent, respectively for the detection of RIF resistance in 1084 samples, collected across four sites. Based on the analysis of discordant samples, Version 2.0 of Truenat was developed by the manufacturer and this was further tested on additional 1201 samples, yielding a sensitivity of 87.5 per cent and specificity of 99.5 per cent.

Interpretation & conclusions:

Multicentric trial of Truenat™ MTB-RIF demonstrated a great potential of this point of care NAAT for detection of MDR-TB. The test would be useful in limited resource settings and inaccessible areas without need for any additional infrastructure.

Letter on: “An analysis of deficiencies in the data of interventional drug trials registered with Clinical Trials Registry – India”

An article published in this journal analyses the deficiencies in the data of interventional drug trials registered with Clinical Trials Registry - India. We wish to rebut some of the inferences and highlight the pitfalls of a purely automated analysis of registry data as posited by the authors.

Clinical Trials Registry - India: A decadal perspective

OBJECTIVE:

To present a descriptive analysis of the clinical studies registered in the Clinical Trials Registry – India (CTRI) and deduce its impact.

METHODS:

We searched the CTRI database for all registered clinical studies from July 20, 2007 to May 31, 2018. Extracted data were analyzed in three time periods i.e., Periods 1, 2, and 3 based on the major activities and milestones of the CTRI. In addition, comparative registrations of the various Primary Registries of the WHO were compiled and registration policy of Indian journals with regard to trial registration assessed.

RESULTS:

A total of 20,160 clinical studies were submitted to the CTRI in the designated study period. Of the registered 14,341 clinical studies, 10,485 (76.3%) were interventional trials which were either regulatory (n = 2004), academic non-regulatory (n = 3855), or those conducted as part of PG thesis (n = 4626) trials. Regulatory trials registration numbers varied according to the Indian regulatory scenario. PG thesis trial registrations showed a steep rise, although unlike regulatory trials, these were mostly retrospective registrations. CTRI registration numbers were comparable to that in other Primary Registries. Instructions to authors of 48% indexed Indian journals made a mention of trial registration.

CONCLUSIONS:

The CTRI has a strong global presence and has enhanced the transparency of regulatory trials as well as academic research particularly thesis-based work. The latter is expected to help improve standard of research and prevent repetitive research. Additional support from Indian journal editors by strict implementation of prospective registration is crucial for increasing compliance by researchers.

Exploring the bio-behavioural link between stress, allostatic load & micronutrient status: A cross-sectional study among adolescent boys

Background & objectives:

Allostatic load (AL) is a cumulative measure of physiological deregulation and is influenced by multiple factors including nutrition. The objectives of the study were to assess AL among adolescent boys (15-19 yr) and delineate its association with psychological stress and micronutrient status.

Methods:

A cross-sectional, school-based study was conducted among 370 adolescent boys of five higher secondary schools from Hyderabad, India. Perceived stress, adolescent life event stress (ALES), psychological morbidity and coping were measured. Biomarkers of AL included dehydroepiandrosterone sulphate, 12-h urinary cortisol, interleukin-6, C-reactive protein, lipid profile, body mass index and blood pressure. Micronutrient status with respect to iron (haemoglobin, ferritin, hepcidin, soluble transferrin receptor), folate, vitamins B12, C and A were analyzed in a sub-sample of 146 boys. AL score ≥3 was calculated from eight biomarkers.

Results:

Fourteen per cent participants had no AL but 34.3 per cent had AL score of ≥ 3. Unadjusted means of ALES scores were significantly different (P = 0.045) among participants with low [mean, 95% confidence interval (CI): 580, 531-629] and high (663, 605-721) AL. After controlling for confounders, the means were significantly different for controllable life event sub-scale of ALES (P = 0.048). Adjusted hepcidin concentrations were significantly higher among participants with high AL (means, 95% CI, 27.2, 24.0-30.8 for high AL; 22.1, 20.2-24.2 μg/l for low AL, P = 0.014).

Interpretation & conclusions:

Build-up of AL was found in adolescent boys and was positively associated with life event stress. Iron nutrition and stress exhibited a positive association through hepcidin. The study provides a link between iron nutrition, physiological deregulation and stress.