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.

Nipah outbreak in North Kerala - What worked? Insights for future response and recovery based on examination of various existing frameworks.

Asia Pacific region has been witnessing numerous public health emergencies in recent years with the Nipah outbreak in North Kerala (2018), India, needs special mention. Threats posed and experiences gained have compelled health systems to draft frameworks nationally and internationally for preparedness, outbreak response, and recovery. Our failure to obtain comprehensive guiding frameworks for application in the Indian context for Ebola, Severe Acute Respiratory Syndrome, Influenza A (H1N1), and Nipah outbreaks led us to the search outside India for frameworks that have worked in the past. A thorough review of the WHO, Centers for Disease Control and Prevention, and Malaysian framework was done to identify explicit components and replicable objectives to the national context. In the absence of a specific framework, Nipah recovery and response experience that worked in Kerala outbreak (2018) was compared against novel H1N1 (2015) guidelines at national level. This article provides the groundwork and insights as a value addition toward an India-specific framework of action for response and recovery for Nipah outbreaks in future.

Identifying core competency areas to assess communication skills among interns at a tertiary teaching hospital in southern India.

BACKGROUND.: We aimed to develop a teaching-learning and evaluation programme on communication skills for interns. Core competency areas for focused communication skills training and assessment were identified to achieve the obective. We then assessed the identified competencies among interns using objective structured clinical examination (OSCE), before the start of internship. METHODS.: Five core areas for focused training and evaluation were identified on the basis of responses of practising physicians in local settings. OSCE stations were developed for evaluation based on the identified competency areas. A pre-test OSCE was administered to 30 interns. RESULTS.: Five core areas selected for training and evaluation were: (i) communicating with a parent resistant to immunization; (ii) interacting with a patient who has psychosomatic complaints; (iii) explaining risks and procedures; (iv) breaking bad news; and (v) communicating with patients and bystanders in a casualty setting. Thirty of 160 interns were selected to participate in the OSCE before the training (pre-test). The lowest score was for breaking bad news. Scores indicated that explaining risks and procedures, communicating in a busy casualty setting and dealing with psychosomatic complaints were areas that required extensive training and practice. CONCLUSIONS.: We were able to identify core competency areas for focused training and evaluation of communication skills suited to the local context and used OSCE to evaluate the skills before the start of internship.

Nipah Virus Outbreak in Kerala State, India Amidst of COVID-19 Pandemic.

We report here a Nipah virus (NiV) outbreak in Kozhikode district of Kerala state, India, which had caused fatal encephalitis in a 12-year-old boy and the outbreak response, which led to the successful containment of the disease and the related investigations. Quantitative real-time reverse transcription (RT)-PCR, ELISA-based antibody detection, and whole genome sequencing (WGS) were performed to confirm the NiV infection. Contacts of the index case were traced and isolated based on risk categorization. Bats from the areas near the epicenter of the outbreak were sampled for throat swabs, rectal swabs, and blood samples for NiV screening by real-time RT-PCR and anti-NiV bat immunoglobulin G (IgG) ELISA. A plaque reduction neutralization test was performed for the detection of neutralizing antibodies. Nipah viral RNA could be detected from blood, bronchial wash, endotracheal (ET) secretion, and cerebrospinal fluid (CSF) and anti-NiV immunoglobulin M (IgM) antibodies from the serum sample of the index case. Rapid establishment of an onsite NiV diagnostic facility and contact tracing helped in quick containment of the outbreak. NiV sequences retrieved from the clinical specimen of the index case formed a sub-cluster with the earlier reported Nipah I genotype sequences from India with more than 95% similarity. Anti-NiV IgG positivity could be detected in 21% of Pteropus medius (P. medius) and 37.73% of Rousettus leschenaultia (R. leschenaultia). Neutralizing antibodies against NiV could be detected in P. medius. Stringent surveillance and awareness campaigns need to be implemented in the area to reduce human-bat interactions and minimize spillover events, which can lead to sporadic outbreaks of NiV.

Unintentional injuries among children admitted in a tertiary care hospital in North Kerala.

World Health Organization global disease update (2004) points out injuries as the sixth leading cause of morbidity and mortality in childhood. A descriptive hospital based study was conducted to find out the common types of unintentional injuries among children admitted for management of unintentional injuries in Pediatric Surgery department and Intensive Care Unit of a tertiary care hospital of North Kerala and to find out the contributing risk factors. A total of 400 children admitted during the study period of 6 months of 2009 constituted the study population. Mechanical injuries comprising of Road traffic accidents and accidental fall were the major cause of unintentional injuries (36%), followed by Poisoning (22.3%). A higher proportion of unintentional injuries were noted to occur among children of younger mothers, overactive child, children belonging to extended or joint families, child left alone or with friends, pre-school children, male child and from urban dwellings. The study highlights the need to identify the different types of unintentional injuries and the risk factors of childhood injuries which require hospitalisation. Identification of risk factors will help to formulate strategies aimed at risk reduction and prevention of childhood injuries.

Replicating the Kerala State's Successful COVID-19 Containment Model: Insights on What Worked.

Although Kerala was the first state in India to report COVID cases, it was well prepared drawing on its past experience in managing effectively the Nipah outbreak and Kerala floods. It knew and initiated the measures required for containment because of its prior experience with mobilizing community-based groups, involvement of local-self government in decentralized planning, and participation in the containment and relief measure as well as a system-ready health system and infrastructure. The measures taken to "flatten the curve" that is unique to Kerala and the determinants of success are described in detail as "what worked" using the framework we developed post the Nipah outbreak containment experience. These are being shared with the hope that the insights these measures undertaken by the state provide can be used elsewhere to translate and replicate components that work.

Disability with Persistent Pain Following an Epidemic of Chikungunya in Rural South India.

OBJECTIVE: We investigated the effects of chronic rheumatic and musculoskeletal symptoms on the functional status of people affected by the chikungunya (CKG) epidemic in the Calicut District, Kerala, South India in 2009. METHODS: A cross-sectional house-to-house survey was conducted 18 months after the CKG epidemic to assess functional status of individuals with post-epidemic persistent pain. All respondents over age 15 years with persistent pain fitting the epidemiological case definition were included. Participants' functional status was assessed using the Health Assessment Questionnaire-Disability Index (HAQ-DI). Factors affecting severity of HAQ-DI were analyzed by ordinal regression. RESULTS: Of 3869 subjects interviewed, 1195 (34.3%) had a positive history of CHIKV virus infection (epidemiological or confirmed); 36.28% (624/1720) of CKG-affected individuals had persistent pain 18 months post epidemic. Mean age of those affected was 48.22 ± 15.6 years; 23.2% had no disability, while 16.2% had moderate to severe disability on the HAQ-DI. Significant factors affecting severity of disability on HAQ-DI included previous rheumatic musculoskeletal disease (OR 2.27), joint and soft-tissue involvement (OR 3.74), only joint involvement (OR 2.14), female sex (OR 1.44), diet (OR 4.73), and history of joint swelling (OR 1.72). CONCLUSION: Persistence of pain noted in post-CKG disease resulted in significantly deteriorated functional status of those affected.

Prevalence and Risk Factors of Hypertension among Male Occupational Bus Drivers in North Kerala, South India: A Cross-Sectional Study.

Background. Hypertension is a leading cause of morbidity and mortality worldwide. We aimed to evaluate the prevalence of hypertension in a population of male bus drivers in North Kerala, India. Methods. The study population included male bus drivers of Corporation Bus stand Kozhikode, Kerala. Blood pressure, height, and weight of subjects were measured, and relevance was obtained using a structured questionnaire. Results. Age varied from 21 to 60 years (mean 36.5 ± 8.4). Among 179 bus drivers studied, 16.8% (30/179) had normal BP, 41.9% (75/179) had prehypertension, and 41.3% (74/179) had hypertension. Isolated systolic HTN was seen in 6.70% (12/179) individuals. Out of 74 hypertensives, 9 (12.1%) were aware of their hypertension, while 3 (4.0%) were medicated and only 1 (1.3%) had BP adequately controlled. Age > 35 years (P = 0.015), BMI ≥ 23 kg/m(2) (P = 0.007), supporting more than four family members (P = 0.011), and taking main meals from restaurants on most working days (P = 0.017) were independently associated with HTN in binary logistic regression. Conclusion. Prevalence of hypertension was high among bus drivers. Age > 35 years, elevated BMI, supporting a large family, and dietary habits associated with the job showed significant association with hypertension. Primary and secondary prevention strategies need to be emphasized in this occupational group.

Prevalence and factors related to rheumatic musculoskeletal disorders in rural south India: WHO-ILAR-COPCORD-BJD India Calicut study.

AIMS: To assess the prevalence and factors related to rheumatic musculoskeletal disorders (RMSD) in a rural population of south India. METHODS: The cross-sectional study included all individuals, 15 years and above, in a rural unit of Calicut District in North Kerala. Data were collected using the validated World Health Organization - International League of Associations for Rheumatology - Community Oriented Program for the Control of Rheumatic Diseases - Bhigwan model questionnaire by trained volunteers. In Phase 1 details of demographic characteristics, major co-morbidities and perceived musculoskeletal aches and pains were elicited. Phases 2 and 3 further evaluated and diagnosed the subjects. Predictors for RMSD were assessed using binary logistic regression analysis. RESULTS: There were 4999 individuals in the study. The prevalence of RMSD was 24.9% (95% CI 23.73; 26.12%). Females constituted 50.7% of the population; 5.1% of the respondents were illiterate; 80.9% belonged to low-income groups. Diabetes mellitus and hypertension affected 4.1% and 5.4% of the subjects respectively. The predictors for RMSD in the population were female sex, age, illiteracy, married status, low-income group, vegetarian diet, current alcohol consumption, current tobacco use, history of injury or accidents, diabetes and hypertension. Symptom-related ill-defined rheumatism (10.39%) followed by osteoarthritis (3.85%) were the most prevalent in the Phase 3 rheumatological evaluation. CONCLUSION: There is an urgent need to introduce lifestyle modifications in high-risk groups and start rehabilitation for those affected. Community rheumatology in primary health care settings in rural areas needs to be strengthened by introducing national programs addressing RMSD at the grassroots level.