Protocol for establishing a model for integrated influenza surveillance in Tamil Nadu, India

The potential for influenza viruses to cause public health emergencies is great. The World Health Organisation (WHO) in 2005 concluded that the world was unprepared to respond to an influenza pandemic. Available surveillance guidelines for pandemic influenza lack the specificity that would enable many countries to establish operational surveillance plans. A well-designed epidemiological and virological surveillance is required to strengthen a country's capacity for seasonal, novel, and pandemic influenza detection and prevention. Here, we describe the protocol to establish a novel mechanism for influenza and SARS-CoV-2 surveillance in the four identified districts of Tamil Nadu, India. This project will be carried out as an implementation research. Each district will identify one medical college and two primary health centres (PHCs) as sentinel sites for collecting severe acute respiratory infections (SARI) and influenza like illness (ILI) related information, respectively. For virological testing, 15 ILI and 10 SARI cases will be sampled and tested for influenza A, influenza B, and SARS-CoV-2 every week. Situation analysis using the WHO situation analysis tool will be done to identify the gaps and needs in the existing surveillance systems. Training for staff involved in disease surveillance will be given periodically. To enhance the reporting of ILI/SARI for sentinel surveillance, trained project staff will collect information from all ILI/SARI patients attending the sentinel sites using pre-tested tools. Using time, place, and person analysis, alerts for abnormal increases in cases will be generated and communicated to health authorities to initiate response activities. Advanced epidemiological analysis will be used to model influenza trends over time. Integrating virological and epidemiological surveillance data with advanced analysis and timely communication can enhance local preparedness for public health emergencies. Good quality surveillance data will facilitate an understanding outbreak severity and disease seasonality. Real-time data will help provide early warning signals for prevention and control of influenza and COVID-19 outbreaks. The implementation strategies found to be effective in this project can be scaled up to other parts of the country for replication and integration.

Kyasanur Forest Disease, is our surveillance system healthy to prevent a larger outbreak? A mixed-method study, Shivamogga, Karnataka, India: 2019

BACKGROUND

Kyasanur Forest disease (KFD) is a tick-borne zoonosis that is endemic in Karnataka. Against the backdrop of the recent geographical expansion of KFD, indicating the inadequacy of policy and surveillance systems, the present study was performed to evaluate the KFD surveillance system in Shivamogga.

METHODS

US Centers for Disease Control and Prevention guidelines for surveillance system evaluation were followed. Nine attributes of the system towards its objectives were evaluated in a mixed study in Shivamogga.

RESULTS

Two of three medical officers and four of six health staff at the institutions visited were found to be untrained in KFD surveillance. Integrated disease surveillance formats did not capture KFD data. Surveillance (tick, monkey, human) was mostly driven by the Health Department. Some of the critical findings of the evaluations were the absence of an animal and entomological surveillance line list, non-standardized reporting formats for human suspects, varying delays in the time-to-test across laboratories (2-16 days), and a lack of systematic data-sharing practices. Significant issues that emerged in the interview were deforestation with a change in ecosystem dynamics, limited diagnostic capacity, non-availability of point-of-care tests, outdated surveillance guidelines, a confusing surveillance perimeter (5 km), non-existing co-ownership among stakeholders, limited vaccine production capacity, and inadequate operational research.

CONCLUSIONS

The system should consider integrating a One Health approach with defined ownership of activities among stakeholders. Revision of the guidelines is mandatory.

The antianginal efficacy of isosorbide dinitrate therapy is maintained during diuretic treatment

OBJECTIVES

To determine whether the use of a diuretic would maintain the antianginal efficacy of isosorbide dinitrate during 1 week of therapy.

METHODS

During continuous therapy, organic nitrates have a reduction in antianginal effectiveness and cause fluid retention. The study was a randomized, double-blind, placebo-controlled crossover design examining the effect of 1 week of daily treatment with 50 mg hydrochlorothiazide/5 mg amiloride on the antianginal effectiveness of 30 mg isosorbide dinitrate administered every 6 hours. Exercise stress testing was performed before and 3 hours after administration of isosorbide dinitrate at the start and end of the placebo and diuretic treatment phases.

RESULTS

The time to onset of angina (475 +/- 35 versus 490 +/- 29 seconds, difference not significant) and to moderate angina after administration of isosorbide dinitrate (542 +/- 40 versus 566 +/- 37 seconds, difference not significant) were similar at the start and end of the diuretic phase of the study but were reduced at the end of the placebo phase (471 +/- 40 versus 410 +/- 40 seconds, p < 0.05 and 531 +/- 38 versus 466 +/- 39 seconds, p < 0.05, respectively). Total exercise time and time to onset of angina 3 hours after administration of isosorbide dinitrate were longer (p < 0.005) at the end of the diuretic phase compared with the end of the placebo phase. Patients gained weight during the placebo phase and lost weight during the diuretic phase of the study. The change in weight was inversely correlated to the change in total exercise time (r = -0.53, p < 0.05).

CONCLUSIONS

Patients using a diuretic with isosorbide dinitrate maintain an increased anginal threshold and total exercise time compared with placebo. Weight change is inversely related to exercise duration, and this result is consistent with fluid retention restoring cardiac preload during nitrate use. The increased anginal threshold during concurrent isosorbide dinitrate and diuretic use may be attributable to maintenance of the organic nitrate-induced reductions in cardiac preload.