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.

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, IFNß) 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, IFNß, 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, IFNß, 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.

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.

"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.

Promoting health economic evaluation studies in the AYUSH system of medicine: the need of the hour.

The double burden of communicable and noncommunicable diseases is a major threat to the Indian public health system. AYUSH, an acronym for Ayurveda, Yoga and Naturopathy, Unani, Siddha, Sowa-Rigpa, and Homeopathy, represents the Indian system of medicine recognized by the Government of India. Mainstreaming of AYUSH is one of the key strategies of the Indian government for tackling increasing disease burden through initiatives such as AYUSH wellness centers, telemedicine, and quality control measures for medications in the AYUSH system of medicine. Such investment of resources in health systems may require economic evaluations. However, such evaluations are lacking in the AYUSH system, except for a few in homeopathy and yoga. In the absence of evidence from economic evaluations, researchers and decision makers are guided mostly by clinical efficacy while formulating healthcare strategies. In view of the increasing use of AYUSH across the country, economic evaluations of the AYUSH system are the need of the hour to aid healthcare decision making.

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.

Dengue fever in a municipality of West Bengal, India, 2015: An outbreak investigation.

BACKGROUND: In November 2015, death due to fever and increased number of fever cases were reported from Baranagar Municipality of North 24 Parganas district of West Bengal. OBJECTIVES: The episode was investigated with the objective to (1) confirm the existence of an outbreak, (2) describe it in terms of time, place, and person, (3) determine the cause of outbreak, and (4) recommend control measures. METHODS: Monthly incidence of dengue from 2012 to 2014 was calculated and compared with 2015 to confirm the outbreak. We used Integrated Disease Surveillance Programme definition and searched for suspect dengue cases going door-to-door in ward number one of Baranagar Municipality. Active case search was done in health facilities also. Information on date of onset, symptoms, sociodemographic, serological reports, and clinical outcome for suspected and confirmed dengue cases was collected. Blood specimens were collected for NS1 ELISA/monoclonal IgM antibody capture-ELISA test. Environmental and entomological surveys were done. RESULTS: Six hundred and seventy-one dengue cases (Overall attack rate = 3/1000), two deaths (Case fatality = 3/1000) were reported during September 14, 2015, till December 12, 2015. Out of 34 wards, attack rate was highest in ward number 1 (0.7%) and was 3 per 1000 among females. All age groups were affected. Thirty-two percent required hospitalization. NS1 ELISA was positive for 612 cases. Out of interviewed 31 dengue cases, 94% had headache, 90% had myalgia, followed by arthralgia, rash, and retro-orbital pain. Only in ward number 1, house index was >5%. CONCLUSION: We confirmed dengue outbreak. All age groups got affected. Deaths occurred in this outbreak. Potential breeding sources were present in ward number 1.

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.

Adverse events in India's Ayush interventions for cervical and lumbar spondylosis: a systematic review.

INTRODUCTION: Low back and neck pain are common musculoskeletal disorders with multiple treatment options. India's traditional medical systems, known as Ayush (Ayurveda, Yoga and Naturopathy, Unani, Siddha, Sowa-Rigpa and Homoeopathy) offer range of interventions and are widely used. In view of limited documentation of adverse events following Ayush interventions for lumbar and cervical spondylosis, we synthesized evidence and estimated proportion of studies reporting adverse events. METHODS: We systematically searched all published documents from biomedical and multidisciplinary abstract and citation databases and Ayush-specific repositories from their inception to April 2021. We selected studies as per inclusion criteria and extracted information, adhering to PRISMA guidelines. We systematically reviewed the qualitative evidence form the selected studies. RESULTS: Majority (94%) of the selected 113 studies were interventional studies and included 77 (68.1%) journal articles and 35 (31%) academic dissertations. Among the Ayush systems, considerable proportion was from Ayurveda (32.7%), followed by Siddha (24.8%), Yoga (22.1%), Unani (15.9%) and Homoeopathy (4.4%). Almost three-fourths of the studies were on lumbar spondylosis (65%; n = 74), followed by cervical spondylosis (31%; n = 35), and the remaining four included both. Thirteen percent of the 113 studies described adverse events [Yoga = 9.7%; Unani = 1.8% and Homoeopathy = 1.8%]. More adverse events were reported among the studies on lumbar (9.7%) than cervical spondylosis (2.7%). The nature of interventions were non-pharmacological (10.6%; n = 12), pharmacological (n = 2; 1.8%) or combined (n = 1; 0.9%). CONCLUSIONS: Only one in eight studies reported any adverse event following Ayush interventions for cervical and lumbar spondylosis. There could be certain degree of underreporting of adverse events and requires further exploration. PROSPERO Registration ID CRD42020167433.

Public health preparedness, syndromic surveillance, and response during the largest religious gathering at the Catholic pilgrimage center of Velankanni in South India: 2016.

Background: The dynamicity and mobility of the population in a mass gathering setting pose a challenge to traditional disease surveillance methods and strain the local health services. Velankanni is one of the most sacred Christian pilgrimage places located in Nagapattinam, Tamil Nadu, India. We participated in the Velankanni festival to describe the public health preparedness, surveillance, and response activities carried out during the festival. Methods: This was a cross-sectional study. We reviewed the national and international guidelines and published literature and discussed with the key stakeholders. We developed a checklist to observe public health preparedness activities. We facilitated the staff and monitored the activities by the implementers. We established the syndromic surveillance in the designated locations of the event and used tracker software to capture the data. Emergency medical teams were formed with trained health personnel to respond to medical emergencies. Results: The team monitored all the public health activities. There are 59 primary care public health facilities and nine ambulatory Mobile Medical Units, with 160 medical officers available at the site. Of the 16,169 persons who attended the medical camps, 9863 (61%) were males and 8408 (52%) were aged 15-44. Acute diarrheal disease was the most frequent of the reported syndromes, followed by injuries, acute febrile illness, and animal bites. Conclusions: There was no outbreak of any disease either identified or reported. Our findings suggest that risk assessments should be used, and establishing an Incident Command Center is vital for executing command and control mechanisms during mass gatherings.

Process evaluation of a complex, multilevel, multicomponent scheme for the prevention and control of non-communicable diseases in Tamil Nadu, India: A mixed-methods protocol.

Background: Non-communicable diseases (NCDs) are the leading cause of morbidity and mortality in India, necessitating development of multilevel and multicomponent interventions. Makkalai Thedi Maruthuvam (MTM) is a complex multilevel, multicomponent intervention developed and implemented by the south Indian State of Tamil Nadu. The scheme aims to deliver services for preventing and controlling diabetes, and hypertension at doorstep. This paper describes the protocol for planning and conducting the process evaluation of the MTM scheme. Methods and analysis: The process evaluation uses mixed methods (secondary data analysis, key informant interviews, in-depth interviews, conceptual content analysis of documents, facility-based survey and non-participant observation) to evaluate the implementation of the MTM scheme. The broad evaluation questions addressed the fidelity, contexts, mechanisms of impact and challenges encountered by the scheme using the Consolidated Framework for Implementation Research (CFIR) framework. The specific evaluation questions addressed selected inputs and processes identified as critical to implementation by the stakeholders. The CFIR framework will guide the thematic analysis of the qualitative interviews to explore the adaptations and deviations introduced during implementation in various contexts. The quantitative data on the indicators developed for the specific evaluation questions will be cleaned and descriptively analysed.

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.

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.