Clinico-epidemiological presentations and management of Nipah virus infection during the outbreak in Kozhikode district, Kerala state, India 2023.

India experienced its sixth Nipah virus (NiV) outbreak in September 2023 in the Kozhikode district of Kerala state. The NiV is primarily transmitted by spillover events from infected bats followed by human-to-human transmission. The clinical specimens were screened using real-time RT-PCR, and positive specimens were further characterized using next-generation sequencing. We describe here an in-depth clinical presentation and management of NiV-confirmed cases and outbreak containment activities. The current outbreak reported a total of six cases with two deaths, with a case fatality ratio of 33.33%. The cases had a mixed presentation of acute respiratory distress syndrome and encephalitis syndrome. Fever was a persistent presentation in all the cases. The Nipah viral RNA was detected in clinical specimens until the post-onset day of illness (POD) 14, with viral load in the range of 1.7-3.3 × 104 viral RNA copies/mL. The genomic analysis showed that the sequences from the current outbreak clustered into the Indian clade similar to the 2018 and 2019 outbreaks. This study highlights the vigilance of the health system to detect and effectively manage the clustering of cases with clinical presentations similar to NiV, which led to early detection and containment activities.

Alternate Biochemical Markers in Organophosphate Poisoning.

In India, organophosphates are the most widely used pesticides for suicide by poisoning. Early recognition of the diagnosis and its severity will help in achieving a better outcome. In poisoning by organophosphorus compounds, serum acetylcholinesterase (AChE) and pseudocholinesterase are currently widely accepted as biochemical markers for estimating the severity. A wide array of alternate, cheap, and easily available markers are explored in this review and using a combination of these markers may be better in terms of early identification of severe poisoning. In peripheral centers without access to costly investigations, these cheap markers may help in guiding an early referral to higher centers for severely poisoned patients. A comprehensive study comparing all these different markers has not been done so far, thereby emphasizing the need for the same. This review identified various new, cheaper, and easily available biochemical markers as having the potential to act as surrogates for assessing the severity of organophosphate poisoning, and there is a scope for future studies to understand its utility.

Need for social work interventions in the emergency department.

This paper reports findings from a qualitative study conducted on the Need for Social work interventions in the Emergency Department (ED) at a large tertiary care center in India. The emergency department is an important social work intervention point for individuals with various psychiatric, medical, and social needs who have little or no additional interaction with social services. Social workers are specially trained to understand the impact of social factors on health outcomes and provide interventions that address social barriers to improving health and accessing community resources; social workers are well prepared to provide services in the emergency department. However, limited research is available to understand the impact of psychosocial services in the emergency department. We aimed to identify areas which require integrated social work services and coordination to address the psychosocial issues within the ED. Interviews with 10 healthcare workers are analyzed thematically. Recurring themes throughout the interviews confirm the need for providing social work interventions to ensure the medical, psychological, and social care needs in the emergency department.

Performance & clinical utility of oropharyngeal versus nasopharyngeal swabs in COVID-19.

Background & objectives: The oropharyngeal (OP) and nasopharyngeal (NP) swab samples are the most recommended clinical specimens for detecting SARS-CoV-2 in an individual through the quantitative real-time reverse-transcriptase-polymerase chain reaction (rRT-PCR) method. The primary objective of this study was to compare the performance of NP and OP swabs for the diagnosis of COVID-19 among 2250 concomitant samples (1125 NP + 1125 OP) using rRT-PCR test. Methods: This study was conducted at a tertiary care hospital in southern India. The study compared the specificity and efficacy of the two samples (NP & OP swabs) in 1125 individuals suspected having COVID-19 infection. The rRT-PCR values from all the samples were compared based on gender, age group and viral load. The differences between unmatched proportion and matched proportion were analysed. Agreement between the two methods was assessed using Kappa statistic. Absolute sensitivity, specificity, positive and negative predictive values (PPV and NPV) for OP and NP swabs were analysed. Results: The study identified a fair degree of agreement between OP and NP swabs in diagnosis of COVID-19 (kappa = 0.275, P <0.001). There was also a fair degree of agreement between NP and OP swabs irrespective of gender, age or duration of symptoms. NP swabs had better sensitivity and NPV as compared to OP swabs, however, specificity and PPV were 100 per cent for both. Interpretation & conclusions: The present study showed that both OP and NP swabs had similar sensitivity and specificity for predicting the presence of SARS-CoV-2.

Psychosocial Effects of Isolation on Nipah Virus Infection Suspects during an Outbreak.

BACKGROUND AND METHODOLOGY: Nipah Virus (NiV) belonging to the genus Henipavirus is a biosafety level 4 pathogen with high human to human transmission. Nipah Virus outbreak of 2018 in Kozhikode, Kerala has evoked immense panic and fear in the system. Other viral infections with similar transmission pattern (Ebola, SARS, MERS or COVID 19) also identified with the negative impacts of isolation. This retrospective observational study was planned during November -December 2018 to understand the psychosocial effects among the subjects in Nipah isolation facility. The symptoms of Post-traumatic stress disorder (PTSD) were assessed using the Impact of Events Scale-Revised version (IES-R). RESULTS AND CONCLUSIONS: Of the 81 subjects, 73 could be contacted with a response rate of 90.12%. The mean age was 38 years (SD = 15.43) and 13.7% were health care workers. 63% of the subjects experienced fear of death during isolation stay and 12.3% of the subjects had lost their relatives or friends to Nipah infection. The mean IES score obtained was 10.78 (SD: 9.679, range 0-49) and 5 subjects had above the cut off 22. Nipah outbreak had evoked significant psychological disturbances in subjects who remained in isolation with its negative impacts.

Experiential learnings from the Nipah virus outbreaks in Kerala towards containment of infectious public health emergencies in India.

Nipah virus (NiV) outbreak occurred in Kozhikode district, Kerala, India in 2018 with a case fatality rate of 91% (21/23). In 2019, a single case with full recovery occurred in Ernakulam district. We described the response and control measures by the Indian Council of Medical Research and Kerala State Government for the 2019 NiV outbreak. The establishment of Point of Care assays and monoclonal antibodies administration facility for early diagnosis, response and treatment, intensified contact tracing activities, bio-risk management and hospital infection control training of healthcare workers contributed to effective control and containment of NiV outbreak in Ernakulam.

COVID-19: Striking a Balance between Health Care Provider Safety and Patient Care in the Indian Hospital Settings.

BACKGROUND: The COVID-19 pandemic has taken its toll on the health care systems all over the world. The global shortage of resources has adversely affected the safety of healthcare personnel as well patients. This has forced the health care facilities to adopt various measures and improvisation in infection control practices, in addition to those in personnel protective equipments (PPEs) adapting to their need and their resources. OBJECTIVES: To review the literature on the infection control practices in health care facilities against COVID-19 and put forward practical solutions, in addition to personnel protective equipments that may be adopted for health care personnel and patient safety in the Indian setting. CONCLUSIONS: We are now amidst of COVID-19 pandemic and we need to focus on 'Risk reduction as much as possible'. The facilities and resources should transform to meet the challenges within the shortest time frame. The concept of patient care needs to balance with the safety of the healthcare, patient and society. This is achievable only by a combination of engineering controls, administrative controls and PPEs. It involves a lot of committed team work while managing an outbreak like COVID - 19 attached with a lot of social stigma.

Adaptive Immune Responses in Humans During Nipah Virus Acute and Convalescent Phases of Infection.

BACKGROUND: Nipah virus (NiV) is 1 of 10 potential causes of imminent public health emergencies of international concern. We investigated the NiV outbreak that occurred in May 2018 in Kerala, India. Here we describe the longitudinal characteristics of cell-mediated and humoral immune responses to NiV infection during the acute and convalescent phases in 2 human survivors. METHODS: Serial blood samples were obtained from the only 2 survivors of the NiV outbreak in Kerala. We used flow cytometry to determine the absolute T-lymphocyte and B-lymphocyte counts and the phenotypes of both T and B cells. We also detected and quantitated the humoral immune response to NiV by virus-specific immunoglobulin M (IgM) and immunoglobulin G (IgG) enzyme-linked immunosorbent assay. RESULTS: Absolute numbers of T lymphocytes remained within normal limits throughout the period of illness studied in both survivors. However, a marked elevation of activated CD8 T cells was observed in both cases. More than 30% of total CD8 T cells expressed Ki67, indicating active proliferation. Proliferating (Ki-67+) CD8 T cells expressed high levels of granzyme B and PD-1, consistent with the profile of acute effector cells. Total B-lymphocyte, activated B-cell, and plasmablast counts were also elevated in NiV survivors. These individuals developed detectable NiV-specific IgM and IgG antibodies within a week of disease onset. Clearance of NiV RNA from blood preceded the appearance of virus-specific IgG and coincided with the peak of activated CD8 T cells. CONCLUSIONS: We describe for the first time longitudinal kinetic data on the activation status of human B- and T-cell populations during acute NiV infection. While marked CD8 T-cell activation was observed with effector characteristics, activated CD4 T cells were less prominent.

Nipah Virus Sequences from Humans and Bats during Nipah Outbreak, Kerala, India, 2018.

We retrieved Nipah virus (NiV) sequences from 4 human and 3 fruit bat (Pteropus medius) samples from a 2018 outbreak in Kerala, India. Phylogenetic analysis demonstrated that NiV from humans was 96.15% similar to a Bangladesh strain but 99.7%-100% similar to virus from Pteropus spp. bats, indicating bats were the source of the outbreak.

Infections among Contacts of Patients with Nipah Virus, India.

We conducted a serosurvey of 155 healthcare workers and 124 household and community members who had close contact with 18 patients who had laboratory-confirmed Nipah virus infections in Kerala, India. We detected 3 subclinical infections; 2 persons had IgM and IgG and 1 only IgM against Nipah virus.

Incidence and Spectrum of Opportunistic Infections Among HIV Infected Patients Attending Government Medical College, Kozhikode.

BACKGROUND: People with advanced human immunodeficiency virus (HIV ) infections are vulnerable to opportunistic infections because of a weakened immune system. Early diagnosis of Opportunistic infections and prompt treatment definitely contributes to increased life expectancy among infected patients and delays the progression to AIDS. AIMS AND OBJECTIVES: are to study the incidence, clinical spectrum and outcome of opportunistic infections and relation between opportunistic infections and CD4 count. MATERIAL AND METHODS: The study was carried out in the Anti Retroviral Treatment (ART ) clinic and medical wards of Government Medical College, Kozhikode. The study period was from January 2012 to January 2013 till 100 opportunistic infections are identified in newly diagnosed retro positive patients. This was a clinical observational study. 424 newly diagnosed retro positive patients were screened to identify 100 patients having opportunistic infections and they were studied in detail. RESULTS: Out of the 100 patients, 71 were males and 29 were females.67% were in the age group of 30-49 years. The most common symptom of presentation was weight loss (77%) followed by fever (67%) and mucocutaneous lesions (60%). The commonest opportunistic infection detected was candidiasis (52%) followed by tuberculosis (50%).Majority of the patients had a CD4 count between 50-200/ microL. Out of the 100 patients 19 patients expired. Among them 10 patients had disseminated tuberculosis. Incidence of opportunistic infection was 23.59/100 person years. CONCLUSIONS: This study demonstrates that Oral candidiasis is the commonest opportunistic infection in HIV patients and Tuberculosis is the second most common. The incidence of opportunistic infection is higher in the older age groups, males and patients with lowCD4 count.

Cerebral Venous Thrombosis after Intravenous Immunoglobulin Therapy in Immune Thrombocytopenic Purpura.

A common misconception is that immune thrombocytopenic purpura (ITP) causes only bleeding diathesis. From this case vignette of a young male with ITP who had cerebral venous thrombosis, we highlight the importance of considering venous thrombosis in such patients when they present with focal cerebral signs.

Correlation of periodontal inflamed surface area with glycated hemoglobin, interleukin-6 and lipoprotein(a) in type 2 diabetes with retinopathy.

BACKGROUND: The two-way relationship between periodontitis and type 2 diabetes mellitus (T2DM) is well established. Prolonged hyperglycemia contributes to increased periodontal destruction and severe periodontitis, accentuating diabetic complications. An inflammatory link exists between diabetic retinopathy (DR) and periodontitis, but the studies regarding this association and the role of lipoprotein(a) [Lp(a)] and interleukin-6 (IL-6) in these conditions are scarce in the literature. AIM: To determine the correlation of periodontal inflamed surface area (PISA) with glycated Hb (HbA1c), serum IL-6 and Lp(a) in T2DM subjects with retinopathy. METHODS: This cross-sectional study comprised 40 T2DM subjects with DR and 40 T2DM subjects without DR. All subjects were assessed for periodontal parameters [bleeding on probing (BOP), probing pocket depth, clinical attachment loss (CAL), oral hygiene index-simplified, plaque index (PI) and PISA], and systemic parameters [HbA1c, fasting plasma glucose and postprandial plasma glucose, fasting lipid profile, serum IL-6 and serum Lp(a)]. RESULTS: The proportion of periodontitis in T2DM with and without DR was 47.5% and 27.5% respectively. Severity of periodontitis, CAL, PISA, IL-6 and Lp(a) were higher in T2DM with DR group compared to T2DM without DR group. Sig-nificant difference was observed in the mean percentage of sites with BOP between T2DM with DR (69%) and T2DM without DR (41%), but there was no significant difference in PI (P > 0.05). HbA1c was positively correlated with CAL (r = 0.351, P = 0.001), and PISA (r = 0.393, P ≤ 0.001) in study subjects. A positive correlation was found between PISA and IL-6 (r = 0.651, P < 0.0001); PISA and Lp(a) (r = 0.59, P < 0.001); CAL and IL-6 (r = 0.527, P < 0.0001) and CAL and Lp(a) (r = 0.631, P < 0.001) among study subjects. CONCLUSION: Despite both groups having poor glycemic control and comparable plaque scores, the periodontal parameters were higher in DR as compared to T2DM without DR. Since a bidirectional link exists between periodontitis and DM, the presence of DR may have contributed to the severity of periodontal destruction and periodontitis may have influenced the progression of DR.

Temporal Trends in SARS-CoV-2 Antibody Levels Among COVID-19 Patients in Kerala During the First Wave and Pre-vaccination Period.

BACKGROUND: The SARS-CoV-2 virus interacts with host cells through the S1 domain of its spike protein. This study measures the IgG immune response to this domain in COVID-19 patients from Kerala, India, and explores its association with various health factors. METHODS: A cohort of 258 COVID-19 patients was analyzed for IgG antibodies targeting the S1 spike protein domain. The temporal pattern of the IgG response and its correlation with hospitalization needs, intensive care, and pre-existing conditions such as diabetes, hypertension, and coronary artery disease were assessed. RESULTS: A significant IgG response (76.4%) was detected, indicating robust immune activation post-infection. The IgG levels peaked between two to four and four to eight weeks post-infection, with a notable increase at 12 weeks, hinting at possible secondary exposure or an immune memory response. No correlation was found between IgG levels and the presence of diabetes mellitus, hypertension, or coronary artery disease. However, higher IgG responses correlated with the severity of the infection, as seen in patients requiring hospitalization or intensive care. CONCLUSIONS: The IgG response to the S1 spike protein domain serves as a potential marker of immune activation in COVID-19. It reflects the body's defense mechanism against the virus and may predict disease severity and outcomes. The findings suggest that IgG levels could be indicative of the viral load, inflammatory response, and possibly the likelihood of protection against reinfection.

Proportional relationship between periodontal inflamed surface area, clinical attachment loss, and glycated hemoglobin level in patients with type 2 diabetes mellitus on insulin therapy and on oral antidiabetic therapy.

BACKGROUND: Treatment of diabetes includes oral antidiabetic drugs (OAD), insulin, or their combinations. Insulin can achieve faster glycemic control and have anabolic action on bone. This study was undertaken to assess the prevalence and severity of periodontitis, and to estimate the proportional relationship between periodontal inflamed surface area, clinical attachment loss, and glycated hemoglobin (HbA1c) level in patients with type 2 diabetes (T2DM) on OAD therapy and on insulin therapy. METHODS: This cross-sectional study comprised 130 patients with T2DM on OAD therapy (OAD group) and 130 patients with T2DM on insulin therapy (INSULIN group). All patients were assessed for sociodemographic, behavioral characteristics, clinical history, periodontal parameters (bleeding on probing, probing depth, clinical attachment loss [Clinical AL], Oral Hygiene Index-simplified, plaque index, and periodontal inflamed surface area [PISA]), and biochemical variables (HbA1c, fasting plasma glucose, postprandial plasma glucose). RESULTS: Prevalence, extent, and severity of periodontitis and PISA were lower in the INSULIN group as compared with the OAD group. A proportional relationship was observed between HbA1c and PISA and between HbA1c and Clinical AL. A unit increase in HbA1c is associated with an increase in PISA of 130.47 mm2 and an increase in Clinical AL of 0.182 mm. CONCLUSION: A proportional relationship was observed between PISA, clinical attachment loss, and HbA1c level in patients with type 2 diabetes mellitus on insulin therapy and OAD therapy. Despite comparable oral hygiene status and glycemic control between the two groups, the periodontal parameters were lesser in the INSULIN group as compared with the OAD group.

Proportion and severity of periodontitis and correlation of periodontal inflamed surface area with glycemic status in patients with type 2 diabetic neuropathy with and without diabetic foot.

BACKGROUND: The association between diabetic neuropathy with and without diabetic foot and periodontitis remains unaddressed in the literature. The present study was conducted to evaluate the frequency of patients with periodontitis and its severity, and to correlate clinical attachment loss (AL) and periodontal inflamed surface area (PISA) with HbA1c in Type 2 Diabetic Neuropathy (T2DN) patients with and without diabetic foot. METHODS: In this cross-sectional study 310 patients with type 2 diabetic neuropathy (T2DN) were randomly selected, and the study comprised of 120 patients with T2DN with diabetic foot and 155 patients with T2DN without diabetic foot. All patients were assessed for periodontal parameters (bleeding on probing, probing depth, clinical AL, oral hygiene index-simplified), plaque index, and PISA) and systemic parameters (HbA1c, fasting blood glucose, post prandial blood glucose, urinary albumin creatine ratio, erythrocyte sedimentation rate, and high-sensitivity C-reactive protein).Unpaired t-test and Chi-Square test were used to analyze quantitative data and qualitative data, respectively. RESULTS: The frequency of patients with periodontitis in patients with T2DN with and without diabetic foot was 91.7% and 88.4%, respectively. The severity of periodontitis, PISA, and clinical AL were higher in the diabetic foot group. Clinical AL and PISA were significantly related with HbA1c in patients with T2DN with and without diabetic foot. CONCLUSIONS: Percentage of patients with periodontitis and the severity of periodontal destruction were high in type 2 diabetic neuropathy with diabetic foot. A significant correlation of PISA, clinical AL with glycemic status was found in patients with T2DN with and without diabetic foot.

A fulminant pneumonia due to Mycoplasma pneumoniae - Case report and literature review.

Fulminant pneumonia due to Mycoplasma pneumoniae [MP] is quite rare even though there is a high prevalence of Mycoplasma species infection in the general population. We report a case of an atypical pneumonia with Acute Respiratory Distress Syndrome (ARDS) due to Mycoplasma pneumoniae in a young female and the clinical challenges encountered along with the current literature review.

Genomic surveillance of SARS-CoV-2 by sequencing the RBD region using Sanger sequencing from North Kerala.

Next Generation Sequencing (NGS) is the gold standard for the detection of new variants of SARS-CoV-2 including those which have immune escape properties, high infectivity, and variable severity. This test is helpful in genomic surveillance, for planning appropriate and timely public health interventions. But labs with NGS facilities are not available in small or medium research settings due to the high cost of setting up such a facility. Transportation of samples from many places to few centers for NGS testing also produces delays due to transportation and sample overload leading in turn to delays in patient management and community interventions. This becomes more important for patients traveling from hotspot regions or those suspected of harboring a new variant. Another major issue is the high cost of NGS-based tests. Thus, it may not be a good option for an economically viable surveillance program requiring immediate result generation and patient follow-up. The current study used a cost-effective facility which can be set up in a common research lab and which is replicable in similar centers with expertise in Sanger nucleotide sequencing. More samples can be processed at a time and can generate the results in a maximum of 2 days (1 day for a 24 h working lab). We analyzed the nucleotide sequence of the Receptor Binding Domain (RBD) region of SARS-CoV-2 by the Sanger sequencing using in-house developed methods. The SARS-CoV-2 variant surveillance was done during the period of March 2021 to May 2022 in the Northern region of Kerala, a state in India with a population of 36.4 million, for implementing appropriate timely interventions. Our findings broadly agree with those from elsewhere in India and other countries during the period.