The burden of COVID-19 infection in a rural Tamil Nadu community.

BACKGROUND: There have been over 30 million cases of COVID-19 in India and over 430,000 deaths. Transmission rates vary from region to region, and are influenced by many factors including population susceptibility, travel and uptake of preventive measures. To date there have been relatively few studies examining the impact of the pandemic in lower income, rural regions of India. We report on a study examining COVID-19 burden in a rural community in Tamil Nadu. METHODS: The study was undertaken in a population of approximately 130,000 people, served by the Rural Unit of Health and Social Affairs (RUHSA), a community health center of CMC, Vellore. We established and evaluated a COVID-19 PCR-testing programme for symptomatic patients-testing was offered to 350 individuals, and household members of test-positive cases were offered antibody testing. We also undertook two COVID-19 seroprevalence surveys in the same community, amongst 701 randomly-selected individuals. RESULTS: There were 182 positive tests in the symptomatic population (52.0%). Factors associated with test-positivity were older age, male gender, higher socioeconomic status (SES, as determined by occupation, education and housing), a history of diabetes, contact with a confirmed/suspected case and attending a gathering (such as a religious ceremony, festival or extended family gathering). Amongst test-positive cases, 3 (1.6%) died and 16 (8.8%) suffered a severe illness. Amongst 129 household contacts 40 (31.0%) tested positive. The two seroprevalence surveys showed positivity rates of 2.2% (July/Aug 2020) and 22.0% (Nov 2020). 40 tested positive (31.0%, 95% CI: 23.02 - 38.98). Our estimated infection-to-case ratio was 31.7. CONCLUSIONS: A simple approach using community health workers and a community-based testing clinic can readily identify significant numbers of COVID-19 infections in Indian rural population. There appear, however, to be low rates of death and severe illness, although vulnerable groups may be under-represented in our sample. It's vital these lower income, rural populations aren't overlooked in ongoing pandemic monitoring and vaccine roll-out in India.

A science-based response to COVID-19.

The COVID-19 pandemic behaves like many other viruses spread through respiratory routes. This is generally a mild disease for those aged less than 50 years. A complete and prolonged lockdown will reduce COVID-19 mortality but simultaneously lead to a graver public health, social, and economic disaster. The focus has to be based on the reality that exists in an area.

Study to Test and Operationalize Preventive Approaches for CKD of Undetermined Etiology in Andhra Pradesh, India.

INTRODUCTION: High prevalence of chronic kidney disease (CKD) not associated with known risk factors has been reported from coastal districts of Andhra Pradesh. The Study to Test and Operationalize Preventive Approaches for Chronic Kidney Disease of Undetermined Etiology in Andhra Pradesh (STOP CKDu AP) aims to ascertain the burden (prevalence and incidence) of CKD, the risk factor profile, and the community perceptions about the disease in the Uddanam area of Andhra Pradesh. METHODS: Study participants will be sampled from the Uddanam area using multistage cluster random sampling. Information will be collected on the demographic profile, occupational history, and presence of conventional as well as nonconventional risk factors. Glomerular filtration rate (GFR) will be estimated using the Chronic Kidney Disease Epidemiology Collaboration equation, and proteinuria will be measured. All abnormal values will be confirmed by repeat testing after 3 months. Cases of CKD not associated with identified etiologies will be identified. Biospecimens will be stored to explore future hypotheses. The entire cohort will be followed up every 6 months to determine the incidence of CKD and to identify risk factors for decline in kidney function. Qualitative studies will be performed to understand the community perceptions and expectations with respect to the interventions. IMPLICATIONS: CKD is an important public health challenge in low- and middle-income countries. This study will establish the prevalence and determine the incidence of CKD not associated with known risk factors in a reported high-burden region, and will provide insights to help design targeted health systems responses. The findings will contribute to the policy development to tackle CKD in the region and will permit international comparisons with other regions with similar high prevalence.

Prevalence and Visual Outcomes of Cataract Surgery in Rural South India: A Cross-Sectional Study.

PURPOSE: To determine the prevalence of cataract surgery and postoperative vision-related outcomes, especially with respect to sex, socioeconomic status (SES) and site of first contact with eye care, in a rural area of South India. METHODS: In a population-based cross-sectional survey of 5530 individuals aged 50 years or older from 10 villages selected by cluster sampling, individuals who had undergone cataract surgery in one or both eyes were identified. Consenting participants were administered a questionnaire, underwent vision assessment and ophthalmic examination. Outcomes were classified as good if visual acuity of the operated eye was 6/18 or better, fair if worse than 6/18 but better than or equal to 6/60, and poor if worse than 6/60. RESULTS: Prevalence of cataract surgery in this age group (771 persons) was 13.9% (95% confidence interval, CI, 13.0-14.9%). In the 1112 eyes of 749 persons studied, at presentation, 53.1% (95% CI 50.1-56.1%) of operated eyes had good, 38.1% (95% CI 35.2-41.0%) had fair, and 8.8% (95% CI 7.1-10.5%) had poor outcomes. With pinhole, 75.2% (95% CI 72.6-77.8%) had good, 17.2% (95% CI 14.9-19.5%) had fair, and 7.4% (95% CI 5.8-9.0%) had poor outcomes. In 76.3% of eyes with fair and poor presenting outcomes we detected an avoidable cause for the suboptimal visual acuity. Place of surgery and duration since surgery of 3 years or more were risk factors for blindness, while SES, sex and site of first eye care contact were not. CONCLUSION: The high prevalence of avoidable causes of visual impairment in this rural setting indicates the scope for preventive strategies.

Rotavirus and other Diarrheal Disease in a Birth Cohort from Southern Indian Community.

OBJECTIVE: To describe the incidence, severity and etiology of diarrheal disease in infants and young children residing in an urban slum community in Southern India. SETTING: Three contiguous urban slums in Vellore, Tamil Nadu. PARTICIPANTS: 452 children participating in a birth cohort study on diarrheal disease; 373 completed three years of follow-up. OUTCOME MEASURES: Diarrheal incidence (obtained by twice-weekly home visits) and severity (assessed by the Vesikari scoring system), and etiological agents associated with diarrhea (through examination of stool specimens by bacteriologic culture, rotavirus enzyme immunoassay, PCR for norovirus and microscopy for parasites). RESULTS: A total of 1856 diarrheal episodes were reported in 373 children. The overall incidence rate of diarrhea was 1.66 episodes per child year for three years, with 2.76 episodes per child year in infancy. The incidence peaked during the months of July and August. Severe diarrhea formed 8% of the total episodes. Rotavirus was the most common pathogen detected, being identified in 18% of episodes. Good hygiene status resulted in 33% protection against moderate-to-severe diarrhea. CONCLUSIONS: This study highlights the burden of diarrheal disease and the important etiological agents of childhood diarrhea in Southern India. Promotion of hygienic behavior through health education may help reduce diarrheal incidence in this and similar communities.

Maternal periodontal disease as a significant risk factor for low birth weight in pregnant women attending a secondary care hospital in South India: a case-control study.

CONTEXT: Periodontal disease (PD) is a common infection in the community; however, its relationship with low birth weight (LBW) has not been well-established. AIMS: The aim was to determine the association between maternal PD and LBW. SETTINGS AND DESIGN: A case-control (1:1) study. MATERIALS AND METHODS: The study population comprised of women who delivered at the hospital during the study period (September 2011 to February 2012).Women between 18 and 35 years of age, who delivered singleton, live infants during study period with at least 18 teeth were enrolled. Those with pregnancy induced hypertension, gestational diabetes, blood-borne viral infections, periodontal treatment within the past 6 months and valvular heart disease were excluded. Control population was parity matched to the cases. STATISTICAL ANALYSIS USED: Chi-square test, t-test and univariant and multivariant logistic regression were used to analyze various study findings, and level of significance was set at 5% (P<0.05). RESULTS: PD was independently associated with LBW (odds ratio: 4.94, 95% confidence interval: 1.03-23.65, P=0.045). Additionally, conventional risk factors such as maternal height (P=0.029), secondary schooling (<8 years of schooling) (P=0.001), socio-economic status (P=0.046), type of family (joint) (P=0.008), number of ante-natal visits (P=0.028) and gestational age at birth (<37 weeks) (P=0.045) showed significant association with LBW. CONCLUSIONS: There seems to be an association between PD and LBW independent of conventional risk factors. Women who had PD were 5 times more likely to deliver LBW infants.

Prevalence of porcine cysticercosis in Vellore, South India.

BACKGROUND: Porcine cysticercosis is acquired by pigs through consumption of human faeces containing Taenia solium ova and indicates the presence of active transmission of the parasite between pigs and humans. METHODS: The prevalence of porcine cysticercosis was assessed by an antigen ELISA and enzyme linked immunoelectrotransfer blot (EITB) for antibodies in rural and urban areas of southern India. RESULTS: Of the 112 porcine blood samples, 13 (11.6%) were positive for cysticercal antigens and the free-range pigs were 3.6 times more likely to be infected than the slaughtered pigs and 67 (59.8 %) tested positive for serum antibodies indicating high exposure to T. solium eggs. CONCLUSION: The high prevalence of porcine cysticercosis recorded in the study areas mandates public health measures, which includes meat inspection.

Changes in knowledge and practices related to taeniasis/cysticercosis after health education in a south Indian community.

A health education programme for taeniasis/cysticercosis was implemented and evaluated among schoolchildren and the general community in a rural block in southern India, an area that is endemic for cysticercosis. The baseline survey among 831 participants from three randomly selected villages showed poor knowledge regarding the spread of taeniasis and neurocysticercosis. There was also a lack of adequate hygiene and sanitation practices. Health education was given in these villages and in the schools located in these villages regarding the lifecycle of the pork tapeworm, spread of taeniasis and cysticercosis, and prevention of these conditions. The post-intervention test conducted 6 months later among 1060 participants revealed a 46% increase in the overall score of knowledge and practices. Awareness about the mode of spread of taeniasis and cysticercosis improved by almost 3 times and the reported practice of washing hands with soap and water before eating improved by 4.8 times and after using the toilet by 3.6 times. One person who reported the passage of tapeworm segments was confirmed to be a carrier of Taenia solium and was treated. The health education given on prevention of taeniasis and cysticercosis was useful in improving the knowledge and practices of the community and also in diagnosing taeniasis through self-reporting.

Risk factors for acquiring Strongyloides stercoralis infection among patients attending a tertiary hospital in south India.

PURPOSE: Strongyloides stercoralis causes persistent and fatal disseminated infections in immunocompromised hosts. In this study, we aimed to determine the risk factors for acquiring strongyloidiasis and the associated morbidity in south India. MATERIALS AND METHODS: The study was carried out in two parts. This included a 6-month chart review of cases with strongyloidiasis and randomly selected controls conducted to determine the association with immunocompromised states. Secondly, a cross-sectional study was conducted to investigate hyperinfection in human immunodeficiency virus (HIV)-infected adults where the stool and sputum samples were examined by microscopy for Strongyloides larvae. RESULTS: In the chart review, 118 cases were compared with 240 controls. A higher proportion of patients on corticosteroids [8 (53.3%)] and with HIV infection [3 (60%)] had the risk of acquiring strongyloidiasis than not, although the difference was not statistically significant in this population. In the cross-sectional study, 14/239 HIV-positive individuals had Strongyloides larvae in the stool samples but none had Strongyloides detectable in their sputum samples. The CD4 cell counts were significantly lower in cases with Strongyloides compared with HIV-infected individuals with no parasites in their stool samples (P < 0.001). CONCLUSIONS: In this setting, strongyloidiasis was seen more often in patients on corticosteroid therapy and with HIV infection. In HIV, an association with lower CD4 counts indicates the need for inclusion of Strongyloides as an opportunistic parasite. Gram negative sepsis was an important complication of strongyloidiasis hyperinfection in both HIV and steroid therapy. Further prospective studies on the risk of developing complicated Strongyloides infection are required.

Pilot randomized trial of nutritional supplementation in patients with tuberculosis and HIV-tuberculosis coinfection receiving directly observed short-course chemotherapy for tuberculosis.

OBJECTIVE: To investigate the effects of nutritional supplementation on the outcome and nutritional status of south Indian patients with tuberculosis (TB) with and without human immunodeficiency virus (HIV) coinfection on anti-tuberculous therapy. METHOD: Randomized controlled trial on the effect of a locally prepared cereal-lentil mixture providing 930 kcal and a multivitamin micronutrient supplement during anti-tuberculous therapy in 81 newly diagnosed TB alone and 22 TB-HIV-coinfected patients, among whom 51 received and 52 did not receive the supplement. The primary outcome evaluated at completion of TB therapy was outcome of TB treatment, as classified by the national programme. Secondary outcomes were body composition, compliance and condition on follow-up 1 year after cessation of TB therapy and supplementation. RESULTS: There was no significant difference in TB outcomes at the end of treatment, but HIV-TB coinfected individuals had four times greater odds of poor outcome than those with TB alone. Among patients with TB, 1/35 (2.9%) supplemented and 5/42(12%) of those not supplemented had poor outcomes, while among TB-HIV-coinfected individuals, 4/13 (31%) supplemented and 3/7 (42.8%) non-supplemented patients had poor outcomes at the end of treatment, and the differences were more marked after 1 year of follow-up. Although there was some trend of benefit for both TB alone and TB-HIV coinfection, the results were not statistically significant at the end of TB treatment, possibly because of limited sample size. CONCLUSION: Nutritional supplements in patients are a potentially feasible, low-cost intervention, which could impact patients with TB and TB-HIV. The public health importance of these diseases in resource-limited settings suggests the need for large, multi-centre randomized control trials on nutritional supplementation.

Relative seroprevalence of cysticercus antigens and antibodies and antibodies to Taenia ova in a population sample in south India suggests immunity against neurocysticercosis.

We evaluated the exposure of a community in Vellore district of south India to Taenia solium infection and its relationship to the prevalence of neurocysticercosis (NCC) causing active epilepsy. Seroprevalence of Taenia cysticercus antigens and antibodies were determined in 1064 randomly chosen asymptomatic individuals, antibodies to T. solium ova in 197 selected sera, and prevalence of taeniasis by a coproantigen test in 729 stool samples. The prevalence of NCC causing active epilepsy in Vellore district was determined in a population of 50 617. Coproantigens were detected in 0.8% (6 samples), Taenia cysticercus antigens in 4.5% (48 sera) and cysticercus IgG antibodies in 15.9% (169 sera) of the population. Cysticercus antibodies were directed against relatively low molecular weight cyst glycoprotein antigens in 14.9% (158 sera) of the population. IgG antibodies to Taenia ova were found in 81 (41.1%) of the selected samples. Prevalence of NCC causing active epilepsy was 1.3 per 1000 population. These results show high exposure of the population to the parasite and a relatively high prevalence of active infections (4.5% antigen positives) but a low prevalence of NCC causing active epilepsy (0.13%). These findings may indicate that the population is protected against developing neurocysticercosis. IgG antibodies directed against Taenia ova and low molecular weight cyst antigens may contribute to protection.

Congenital rubella syndrome and rubella in Vellore, South India.

Rubella, a mild, vaccine-preventable disease, can manifest as congenital rubella syndrome (CRS), a devastating disease of the fetus. To emphasize the inadequacy of the existing rubella vaccination programme in India, we evaluated epidemiological evidence of rubella virus activity with data available from a tertiary-care centre. The proportion of suspected CRS cases that were laboratory confirmed increased from 4% in 2000 to 11% in 2008. During the same period, 329 clinically suspected postnatal rubella cases were tested of which 65 (20%) were laboratory confirmed. Of women (n=770) of childbearing age, 12·5% were susceptible to rubella.

Long-term clinical evaluation of asymptomatic subjects positive for circulating Taenia solium antigens.

Although presence of cysticercal antigens in serum is presumed to indicate active cysticercosis not all positive persons are symptomatic. The significance of a positive antigen test in asymptomatic individuals, in predicting development of symptomatic cysticercosis on long-term follow up, is unknown. Forty two of 48 persons from Vellore district, India who were positive for circulating serum cysticercal antigens were followed up for four to five years. None of them developed clinical evidence of neurocysticercosis or subcutaneous cysts. We conclude that asymptomatic individuals with circulating cysticercal antigens have a low risk of developing symptomatic cysticercosis within four to five years.

Detecting spatial clusters of Taenia solium infections in a rural block in South India.

Neurocysticercosis (NCC) is a major cause of seizures/epilepsy in countries endemic for the disease. The objectives of this study were to spatially map the burden of active epilepsy (AE), NCC, taeniasis, seroprevalence for cysticercal antibodies and positivity to circulating cysticercal antigens in Kaniyambadi block (approximately 100 villages comprising 100 000 population) of Vellore district and to detect spatial clusters of AE, NCC, taeniasis and seroprevalence. Using geographic information system (GIS) techniques, all 21 study villages with over 8000 houses (population of 38 105) were mapped. Clustering of different indices of Taenia solium infection was determined using a spatial scan statistic (SaTScan). There was a primary spatial cluster of AE with a log likelihood ratio (LLR) of 10.8 and relative risk (RR) of 22.4; however, no significant clustering for NCC was detected. Five significant spatial clusters of seropositivity for cysticercal antibodies, two clusters of seropositivity for cysticercal antigens and one for taeniasis were detected (LLR of 8.35 and RR of 36.67). Our study has demonstrated the use of GIS methods in mapping and identifying 'hot spots' of various indices of T. solium infection in humans. This spatial analysis has identified pockets with high transmission rates so that preventive measures could be focused on an intensive scale.

The clinical significance of MIB-1 labeling index in pituitary adenomas.

Pituitary adenomas are unique in several ways--they are rarely malignant and yet can be invasive of several compartments. Recurrences in tumors with bland histological features that have been radically excised are a reason for frustration faced by endocrinologists and neurosurgeons in treatment of pituitary adenomas. Several attempts have therefore been made to determine the growth potential of pituitary adenomas. The aim of the present study was to define the biological significance of the MIB-1 labelling index (MIB-1 LI) in pituitary adenomas. The study included 159 cases of surgically treated pituitary adenoma seen in a single institution. MIB-1 LI was not found to be related to age or gender. The mean MIB-1 LI for clinically functional adenomas was marginally higher than that for clinically non-functional adenomas. There was a significant difference in the MIB-1 LI for tumors with a maximum diameter of more than 4 cm at a MIB-1 LI of ≥2%, however this difference was not statistically significant at a higher MIB-1 LI cut off value of >3%. The mean MIB-1 LI was significantly higher in tumors causing hydrocephalus and in those with cavernous sinus invasion and not when invasion was defined as invasion by tumor in any direction. We conclude that large pituitary macroadenomas, tumors filling the third ventricle causing hydrocephalus and tumors with true cavernous sinus invasions are more likely to have a higher proliferation index. Close follow up of tumors showing these imaging features would be recommended.

Mortality patterns and the effect of socioeconomic factors on mortality in rural Tamil Nadu, south India: a community-based cohort study.

The importance of mortality data for assessing the health status of any population and for planning disease control and health promotional interventions is well established. A population-based cohort study was conducted in Kaniyambadi Block, a rural block in North Arcot District in Tamil Nadu, India, with a population of approximately 120,000 people living in 88 villages. The mortality rates, patterns and effect of socioeconomic factors on mortality were studied. The overall incidence of mortality in the study cohort was 7.3/1000 person-years, with higher rates of mortality among men than women. People with low socioeconomic status (SES) had almost two-fold higher mortality rates across all age groups compared with people with high SES. Deaths due to injuries and other external causes contributed 23.0% of all deaths, among which the low socioeconomic group had 56% excess cause-specific mortality compared with the high socioeconomic group. Standardised mortality ratios indicated that the low socioeconomic group had 25% excess mortality compared with the overall standard mortality. This study clearly shows that the low SES group had a significantly higher incidence of mortality due to all causes and among all age groups.

Infant morbidity in an Indian slum birth cohort.

OBJECTIVE: To establish incidence rates, clinic referrals, hospitalisations, mortality rates and baseline determinants of morbidity among infants in an Indian slum. DESIGN: A community-based birth cohort with twice-weekly surveillance. SETTING: Vellore, South India. SUBJECTS: 452 newborns recruited over 18 months, followed through infancy. MAIN OUTCOME MEASURES: Incidence rates of gastrointestinal illness, respiratory illness, undifferentiated fever, other infections and non-infectious morbidity; rates of community-based diagnoses, clinic visits and hospitalisation; and rate ratios of baseline factors for morbidity. RESULTS: Infants experienced 12 episodes (95% confidence interval (CI) 11 to 13) of illness, spending about one fifth of their infancy with an illness. Respiratory and gastrointestinal symptoms were most common with incidence rates (95% CI) of 7.4 (6.9 to 7.9) and 3.6 (3.3 to 3.9) episodes per child-year. Factors independently associated with a higher incidence of respiratory and gastrointestinal illness were age (3-5 months), male sex, cold/wet season and household involved in beedi work. The rate (95% CI) of hospitalisation, mainly for respiratory and gastrointestinal illness, was 0.28 (0.22 to 0.35) per child-year. CONCLUSIONS: The morbidity burden due to respiratory and gastrointestinal illness is high in a South Indian urban slum, with children ill for approximately one fifth of infancy, mainly with respiratory and gastrointestinal illnesses. The risk factors identified were younger age, male sex, cold/wet season and household involvement in beedi work.

Seroprevalence of Taenia solium antibodies in Vellore district, south India.

Although Taenia solium neurocysticercosis is the cause of almost one-third of epilepsy in Vellore district, south India, the level of exposure to T. solium in the district is not known. This study determined the seroprevalence of cysticercus antibodies in seizure-free, study subjects aged 2-60 years from urban and rural areas of Vellore district. Cysticercus antibodies, as determined by immunoblots, were noted in 15.9% of 1063 people and were significantly higher in the rural population (17.7%) compared with the urban population (6.0%). Twenty-four percent of the rural population and 12% of the urban population ate pork. One-third of all households in the district had one or more members seropositive for cysticercus antibodies. The high index of exposure to T. solium in south India calls for improved animal husbandry and sanitation.

Polymerase chain reaction in the detection of an 'outbreak' of asymptomatic viral infections in a community birth cohort in south India.

Asymptomatic enteric infections are important where sequelae or protection from subsequent illness is an outcome measure. The use of reverse transcription-polymerase chain reaction (RT-PCR) to identify asymptomatic enteric infections in a birth cohort followed for rotaviral infections in a south Indian urban slum is reported. Of 1191 non-diarrhoeal samples from 371 children collected in May-June 2003, 22 (1.9%) were positive by ELISA. A total of 147 (40.6%) of 362 samples tested by VP6 RT-PCR were positive. In those samples that could be typed, a high diversity of G types including G1, G2, G4, G8, G9 and G10, and a high proportion (34.4%) of mixed infections were detected. Noroviruses were identified in 6/28 (21.4%) samples tested. The identification of infections undetectable by conventional techniques indicates the importance of the use of sensitive diagnostic techniques in research studies. Asymptomatically infected children may also act as a source of infection for other susceptible hosts.