Country data on AMR in India in the context of community-acquired respiratory tract infections: links between antibiotic susceptibility, local and international antibiotic prescribing guidelines, access to medicine and clinical outcome.

BACKGROUND: Antimicrobial resistance (AMR) is one of the biggest threats to global public health. Selection of resistant bacteria is driven by inappropriate use of antibiotics, amongst other factors. COVID-19 may have exacerbated AMR due to unnecessary antibiotic prescribing. Country-level knowledge is needed to understand options for action. OBJECTIVES: To review the current situation with respect to AMR in India and initiatives addressing it. Identifying areas where more information is required will provide a call to action to minimize further rises in AMR and to improve patient outcomes. METHODS: National AMR initiatives, antibiotic use and prescribing in India, and availability of susceptibility data, in particular for the key community-acquired respiratory tract infection (CA-RTI) pathogens (Streptococcus pneumoniae and Haemophilus influenzae) were identified. National and international antibiotic prescribing guidelines for specific CA-RTIs (community-acquired pneumonia, acute otitis media and acute bacterial rhinosinusitis) commonly used locally were also reviewed, plus local antibiotic availability. Insights from a local clinician and clinical microbiologist were sought to contextualize this information. CONCLUSIONS: Many initiatives have been launched since AMR was recognized as a national priority and organizations such as the Indian Academy of Paediatrics and the Global Antibiotic Resistance Partnership have worked to build awareness. The Indian Ministry of Health and Family Welfare published a 5 year national action plan on AMR. However, the burden of infectious disease and consumption of antibiotics in India is high. There have been national surveillance studies generating local data along with international studies such as Survey of Antibiotic Resistance (SOAR) and Antimicrobial Testing Leadership and Surveillance (ATLAS). For common RTIs, clinicians use a range of international and national guidelines. However, a more standardized inclusive approach to developing local guidelines, using up-to-date local surveillance data from community-acquired infections, could make guidelines more locally relevant. This would encourage more appropriate antibiotic prescribing and improve adherence. This would, in turn, potentially limit AMR development and improve patient outcomes.

Indian Academy of Pediatrics Consensus Statement on Diagnosis and Management of Bone and Joint Infections in Children.

JUSTIFICATION: Osteoarticular infections are fairly common in children but often these are associated with underdiagnosis, delayed diagnosis and improper management. This leads to an increased incidence of complications and poor outcomes. Given the paucity of standard protocols for the management of these children in the Indian context, Indian Academy of Pediatrics (IAP) has taken the initiative to formulate guidelines for the early diagnosis and rational management of bone and joint infections (BJIs). OBJECTIVES: To critically evaluate the current evidence and formulate consensus guidelines for the diagnosis and management of BJIs in children. PROCESS: A committee comprising of eminent national faculty from different parts of the country who are experts in the field of Pediatric Infectious Diseases, Pediatric Orthopedics and Musculoskeletal Radiology was constituted and duly approved by the IAP. On Jan 16, 2021, a virtual meeting was held and a detailed discussions were carried out regarding the need to formulate these guidelines. Subsequently, the expert group defined the key questions in the first stage followed by collection and review of scientific evidences including available national and international recommendations or guidelines. This was followed by detailed deliberation among group members and presentation of their recommendations. The same were finalized in an online meeting on Aug 01, 2021, and a consensus statement was developed and adopted by the group. STATEMENT: BJIs are medical emergencies that need early diagnosis and appropriate therapy to prevent long term sequelae like limb deformities. Bacterial infections like Staphylococcus aureus is the most common etiological agent. Nonspecific and subtle clinical manifestations make the diagnosis of pediatric BJIs more challenging. Diagnosis of BJIs is primarily clinical, supplemented by laboratory and radiological investigations. The choice of antibiotic(s), mode of administration and duration of therapy requires individualization depending upon the severity of infection, causative organism, regional sensitivity patterns, time elapsed between onset of symptoms and the child's presentation, age, risk factors and the clinical and laboratory response to treatment. There is paucity of appropriate guidelines regarding the diagnosis and management of BJIs in children in Indian context. Hence, the need for this expert consensus guidelines in Indian settings.

Indian Academy of Pediatrics (IAP) Advisory Committee on Vaccines and Immunization Practices (ACVIP): Recommended Immunization Schedule (2023) and Update on Immunization for Children Aged 0 Through 18 Years.

JUSTIFICATION: In view of new developments in vaccinology and the availability of new vaccines, there is a need to revise/review the existing immunization recommendations. PROCESS: The Advisory Committee on Vaccines and Immunization Practices (ACVIP) of Indian Academy of Pediatrics (IAP) had a physical meeting on March 25, 2023, at Vaccicon, Kolkata, followed by online meetings to discuss the updates and new recommendations. Opinion of each member was sought on the various recommendations and updates, following which an evidence-based consensus was reached. The contents were finalized on September 8, 2023, during the National Conference of Pediatric - Infectious Diseases (NCPID) at Aurangabad. An online meeting of all members was held on November 15, 2023 and the recommendations were finalized. Objectives: To review and revise the IAP immunization recommendations of 2020-21 and issue recommendations on existing and new vaccines. RECOMMENDATIONS: The major changes include recommendation of HPV vaccine for boys; a 2-dose schedule of 9vHPV for boys and girls aged 9-14 y; a dose of Td vaccine at 16-18 y; guidance for injectable polio vaccine (IPV) for those patients who are changing from National Immunization Program to IAP schedule.

Endemicity change of hepatitis A infection necessitates vaccination in food handlers: An Indian perspective.

In the last two decades, outbreaks due to the foodborne hepatitis A virus (HAV) have been frequently reported in India, with adolescents and adults primarily affected. In India, most food handlers are adolescents and young adults who might be exposed to unsatisfactory environmental conditions and poor water quality. This increases the risk of HAV infection and consequently compounds the risk of HAV transmission from food handlers to susceptible populations. Given the shift in hepatitis A endemicity from high to intermediate levels in India, implementing the vaccination of food handlers has become important as it can also contribute to the elimination of hepatitis A in India. This narrative review makes a case for hepatitis A immunization of food handlers in India considering the growing food industry, evolving food culture, and the substantial burden caused by hepatitis A outbreaks.

PLAIN LANGUAGE SUMMARYWhat is the context?Hepatitis A disease is a common form of viral hepatitis and is transmitted through contaminated food and water or through close contact with an infected person. The virus with stands high temperature and can survive on surfaces for long periods of time.In India, the burden of hepatitis A has shifted from children to adolescents and adults who are more culnerable to infection. They present a high risk of complications, often requiring hopitalization.The prevention of the disease has often bee neglected, inadequate safety measures for the preparation of food (via food handlers) is a known risk factor for the transmission of hepatitis A.What is new?Our review highlights the relationship between food handling and hepatitis A infection among adolescents and adults in Inida.The lack of knowledge of food safety regulations and hygiene measures among food handlers and the organizations that guide them may contribute to the spread of hepatitis A.What is the impact?Sanitation efforts, awareness and educational programs for food are needed to help reduce the transmission of hepatitis A virus and disease, yet these measures alone may not be sufficient.Vaccination among high-risk populations such as food handlers can prevent hepatitis A infection and its complications as well as transmission.

What is the true burden of diphtheria, tetanus, pertussis and poliovirus in children aged 3-18 years in Asia? A systematic literature review.

OBJECTIVES: In recent years, outbreaks and a rising incidence of diphtheria, tetanus, and pertussis have occurred in Asia, particularly in older children. METHODS: A systematic search of MEDLINE and Embase was conducted from January 2000 to October 2020 to identify the epidemiology of diphtheria, tetanus, pertussis, and poliomyelitis in children and adolescents (aged 3-18 years) in Asia. The results were then related to vaccination schedules, booster coverage rates, pertussis source of infection, and booster immunogenicity, as identified by a pragmatic review. The International Prospective Register of Systematic Reviews (PROSPERO) registration: #CRD42020222445. RESULTS: A total of 35 studies were included in this review. Limited data were reported on the epidemiology of diphtheria, tetanus, pertussis, and poliomyelitis. Data from studies reporting the incidence of diphtheria and pertussis exemplify the shift in epidemiology to older children/adolescents. Seroprevalence data suggest that immunity to pertussis and diphtheria is below the level of herd immunity in several Asian countries in this population. CONCLUSION: The true burden of diphtheria, pertussis, and tetanus in children aged 3-18 years in Asia is unknown because of weak or absent nationwide surveillance systems. The available evidence highlights the inadequacies in immunity, either by gaps in a recommendation or suboptimal booster coverage, supporting the public health need for booster vaccinations in this population.

A phase 4 study of the safety of the 13-valent pneumococcal conjugate vaccine in children 6 to 17 years of age in India.

PURPOSE: The 13-valent pneumococcal conjugate vaccine (PCV13) was recently approved in India for the prevention of pneumococcal disease in children aged 6 to 17 years based on global data as well as immunogenicity and safety findings from a phase 3 study. The current phase 4 study in India further evaluated the safety profile of PCV13 in this age group to support the positive benefit-risk profile of PCV13. METHODS: Healthy male and female children aged 6 to 17 years in India were administered a single intramuscular injection of PCV13. Through 7 days after PCV13 administration, local reactions and systemic events were recorded daily by caregivers in an electronic diary. Adverse events (AEs) were collected from the provision of informed consent through 28-42 days postvaccination. RESULTS: One hundred subjects enrolled in and completed the study. After PCV13 vaccination, 73.9% and 57.8% of subjects reported local reactions and systemic events, respectively. The majority of reactogenicity events were mild to moderate in severity, with injection site pain and fatigue the most frequently reported local reaction and systemic event, respectively. Six subjects reported 7 AEs, all of which were considered unrelated to PCV13. One subject reported a serious AE (acute hepatitis), which was considered unrelated to PCV13 and ultimately resolved. No subjects withdrew because of AEs, and there were no deaths. CONCLUSION: PCV13 vaccination was well tolerated with an acceptable safety profile in healthy subjects aged 6 to 17 years in India. This work further supports the safety profile of PCV13 for prevention of pneumococcal disease in this age group in India.

Indian Academy of Pediatrics Position Paper on Kawasaki Disease.

OBJECTIVE: To formulate practice guidelines on diagnosis and management of Kawasaki disease (KD) for Indian children. JUSTIFICATION: KD is a systemic vasculitis that predominantly affects infants and children less than 5 years of age. Coronary artery abnormalities (CAA) develop in around 15-25% of untreated children with KD. Coronary artery involvement can lead to long-term cardiovascular implications such as development of premature coronary artery disease. Diagnosis of KD is essentially clinical based on recognition of a constellation of characteristic symptoms and signs. Timely diagnosis and initiation of intravenous immunoglobulin (IVIG) therapy is known to produce five-fold reduction in the incidence of CAA. As there is no confirmatory laboratory test for KD, the diagnosis may be missed if one is not familiar with the nuances of clinical diagnosis. PROCESS: A committee was formed under the auspices of Indian Academy of Pediatrics in early 2018 for preparing guidelines on KD in Indian children. A meeting of the consultative committee was held in Mumbai, and a draft protocol was devised. All members scrutinized the recent publications on the subject and an attempt was made to arrive at a broad consensus. Published guidelines on the subject were also reviewed. RECOMMENDATIONS: The diagnosis is clinical and is aided by laboratory and 2D echocardiography. First line of therapy is IVIG, and should be started expeditiously once the diagnosis is made.