India Field Epidemiology Training Program Response to COVID-19 Pandemic, 2020-2021.

The India Field Epidemiology Training Program (FETP) has played a critical role in India's response to the ongoing COVID-19 pandemic. During March 2020-June 2021, a total of 123 FETP officers from across 3 training hubs were deployed in support of India's efforts to combat COVID-19. FETP officers have successfully mitigated the effect of COVID-19 on persons in India by conducting cluster outbreak investigations, performing surveillance system evaluations, and developing infection prevention and control tools and guidelines. This report discusses the successes of select COVID-19 pandemic response activities undertaken by current India FETP officers and proposes a pathway to augmenting India's pandemic preparedness and response efforts through expansion of this network and a strengthened frontline public health workforce.

Measles outbreak among children ≤15 years old, Jaintia Hills District, Meghalaya, India, 2017.

BACKGROUND: Of 1115 measles outbreaks during 2015 in India, 61,255 suspected measles cases were reported. In 2016, a measles outbreak was reported at East and West Jaintia Hills districts in Meghalaya State, India. OBJECTIVES: The outbreak was investigated to describe the epidemiology, estimate vaccination coverage and vaccine effectiveness (VE), determine risk factors for the disease, and recommend control and prevention measures. METHODS: A measles case was defined as new-onset fever with maculopapular rash occurring between May 1, 2016, and January 21, 2017, in a resident of East and West Jaintia Hills. Cases were identified by active and passive surveillance. Serum and urine samples were collected from cases with laboratory diagnosis for confirmation. A retrospective cohort study was conducted to estimate vaccination coverage, VE, and risk factors for the disease. RESULTS: We identified 382 cases (51% female). The attack rate was 24% with three deaths. The case fatality rate was <1%. The median age was 4 years (range: 3 months-12 years). Among children 12-60 months, 128 (56%) received measles-containing-vaccine first-dose (MCV1), 85 (37%) received measles-containing-vaccine second-dose (MCV2), and 80 (35%) received Vitamin A. VE for MCV1 was 78% and for MCV2 94%. Being unvaccinated for MCV1 (relative risk [RR] = 9.7, 95% confidence interval [CI] = 4.6-20.5) and MCV2 (RR = 17.4, 95% CI = 4.3-69.4) were both strongly associated with illness. CONCLUSIONS: Poor vaccination coverage led to the measles outbreak in East and West Jaintia Hills districts of Meghalaya. Strengthening the routine immunization systems and improving Vitamin A uptake is essential to prevent further outbreaks.

Public health surveillance during Simhastha Kumbh, a religious mass gathering in Ujjain district, Madhya Pradesh, India, 2016.

A daily surveillance for disease detection and response at the Simhastha Kumbh Mela, in Ujjain, Madhya Pradesh, April-May 2016, was established. Existing weekly reporting of the Integrated Disease Surveillance Programme (IDSP) was modified to report 17 diseases or events from 22 public hospitals and three private hospitals in Ujjain. Water samples were also tested for fecal contamination in areas reporting diarrhea. We identified 56,600 ill persons (92% from government hospitals and 8% from private hospitals): 33% had fever, 28% acute respiratory infection, and 26% acute diarrheal diseases. There were 15 deaths (12 injury and 3 drowning). We detected two diarrhea outbreaks (Mahakaal Zone with 9 cases and Dutta Akhara Zone with 42 cases). Among 26 water samples, eight showed fecal contamination. This was a large implementation of daily disease surveillance in a religious mass gathering in India by IDSP. We recommended laboratory confirmation for diseases and similar daily surveillance in future mass gatherings in India.

Mumps outbreak investigation in Jaisalmer, Rajasthan, India, June-September 2016.

Mumps, a vaccine-preventable disease, cause inflammation of salivary glands and may cause severe complications, such as encephalitis, meningitis, deafness, and orchitis/oophoritis. In India, mumps vaccine is not included in the universal immunization program and during 2009 to 2014, 72 outbreaks with greater than 1500 cases were reported. In August 2016, a suspected mumps outbreak was reported in Jaisalmer block, Rajasthan. We investigated to confirm the etiology, describe the epidemiology, and recommend prevention and control measures. We defined a case as swelling in the parotid region in a Jaisalmer block resident between 23 June 2016 and 10 September 2016. We searched for cases in health facilities and house-to-house in affected villages and hamlets. We tested blood samples of cases for mumps immunoglobulin M (IgM) enzyme-linked immunosorbent assay (ELISA). We found 162 cases (60% males) with a median age of 9.4 years (range: 7 month-38 years) and 65 (40%) were females. Symptoms included fever (70%) and bilateral swelling in neck (65%). None of them were vaccinated against mumps. Most (84%) cases were school-going children (3-16 years old). The overall attack rate was 2%. Village A, with two hamlets, had the highest attack rate (hamlet 1 = 13% and hamlet 2 = 12%). School A of village A, hamlet 1, which accommodated 200 children in two classrooms, had an attack rate of 55%. Of 18 blood samples from cases, 11 tested positive for mumps IgM ELISA. This was a confirmed mumps outbreak in Jaisalmer block that disproportionately affected school-going children. We recommended continued surveillance, 5-day absence from school, and vaccination.

Quantifying the influence of climate, host and change in land-use patterns on occurrence of Crimean Congo Hemorrhagic Fever (CCHF) and development of spatial risk map for India.

Crimean Congo Hemorrhagic Fever (CCHF), is an emerging zoonosis globally and in India. The present study focused on identifying the risk factors for occurrence of CCHF in the Indian state of Gujarat and development of risk map for India. The past CCHF outbreaks in India were collated for the analyses. Influence of land use change and climatic factors in determining the occurrence of CCHF in Gujarat was assessed using Bayesian spatial models. Change in maximum temperature in affected districts was analysed to identify the significant change points over 110 years. Risk map was developed for Gujarat using Bayesian Additive Regression Trees (BART) model with remotely sensed environmental variables and host (livestock and human) factors. We found the change in land use patterns and maximum temperature in affected districts to be contributing to the occurrence of CCHF in Gujarat. Spatial risk map developed using CCHF occurrence data for Gujarat identified density of buffalo, minimum land surface temperature and elevation as risk determinants. Further, spatial risk map for the occurrence of CCHF in India was developed using selected variables. Overall, we found that combination of factors such as change in land-use patterns, maximum temperature, buffalo density, day time minimum land surface temperature and elevation led to the emergence and further spread of the disease in India. Mitigation measures for CCHF in India could be designed considering disease epidemiology and initiation of surveillance strategies based on the risk map developed in this study.

Experience of setting up of Control room for COVID-19 at NCDC, New Delhi.

Significant public health events of the 21st century include epidemic prone diseases such as severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), influenza A (H1N1), Ebola virus disease, and coronavirus (SARS-COV-2). Preparedness as well as risk mitigation strategies play an integral role for the success of responses to such health emergencies. An extraordinary cluster of cases of respiratory disease of unknown cause triggered a series of events that constituted a public health risk across the globe through international spread from China and was declared a Public Health Emergency of International Concern (PHEIC) on 30 January, 2020 by the World Health Organization (WHO). To monitor implementation of activities in order to contain the local transmission of COVID-2019 in India, a control room was established at the National Centre for Disease Control (NCDC), New Delhi on 23rd January, 2020 under the Integrated Disease Surveillance Project (IDSP). The main objectives of the control room were to alleviate the concerns and address queries of passengers arriving from the affected countries and also to provide the general public information regarding the measures to be taken as well as the contact details of the respected district health authorities for further necessary action. A total of 183 hunting lines were established at the NCDC, Noida, TB Centre, and the National Health Authority (NHA) Hyderabad and Bengaluru by March 2020. A total of 79,013 calls, 1,04,779 emails, and 1,787 international calls were received w.e.f. 23 January to 30 March, 2020 at the NCDC control room. The NHA Bengaluru and Hyderabad Control room received 3,52,176 calls w.e.f. 15 March to 30 March and TB Noida control room received 55,018 calls w.e.f. 16 March to 30 March, 2020. This prompt action of the center to set up a control room at the NCDC gave the states enough grace period to train their staff and start their individual help lines for addressing people's queries and allay fears.

Seroprevalence of antibodies to SARS-CoV-2 and predictors of seropositivity among employees of a teaching hospital in New Delhi, India.

OBJECTIVE: Healthcare workers (HCWs) are at a high risk of contracting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) due to the increased likelihood of clinical exposure during patient management. The study objective was to determine the seroprevalence of antibodies to SARS-CoV-2 and its predictors among hospital employees. METHODS: The cross-sectional study was conducted at a teaching hospital from August 2020 to September 2020 among 1,401 employees, including 1,217 HCWs, in New Delhi, India. The serum samples were examined for immunoglobulin G (IgG) antibodies to SARS-CoV-2 using the COVID Kavach-Anti-SARS-CoV-2 IgG Antibody Detection enzyme-linked immunosorbent assay kit. Data were collected electronically using the EpiCollect mobile platform. A p < 0.05 was considered to indicate statistical significance. RESULTS: A total of 169 participants (12.1%) had detectable IgG antibodies to SARS-CoV-2. The highest seropositivity rate was observed in the administrative staff (20.1%), while it was lowest among medical doctors (5.5%, p < 0.001). Male sex and ever having lived in a containment zone were independently associated with past infection with SARS-CoV-2. CONCLUSION: The seroprevalence of SARS-CoV-2 infection in health workers may be lower than in the general population in New Delhi. However, nonpharmaceutical interventions were not associated with a reduction in the risk of acquisition of SARS-CoV-2.

Seroprevalence of anti-SARS-CoV-2 antibodies in Indore, Madhya Pradesh: A community-based cross-sectional study, August 2020.

BACKGROUND: In India, laboratory diagnosis of SARS - CoV-2 infection has been mostly based on real-time reverse transcriptase-polymerase chain reaction (RT-PCR). Studies have shown that Viral titres peak within the first week of symptoms but may decline later hampering RT-PCR-based diagnostic strategies. Exact estimate is difficult under high-risk screening strategy with evidences of having large number of asymptomatic cases. This has prompted a call for adoption of antibody testing as potential source of data. MATERIALS AND METHODS: A cross-sectional study with a sample size of 7000 was conducted for 15 days including all the 85 wards under Indore Municipal Corporation. Stratified Random Sampling was used to collect the samples. Trained teams collected basic sociodemographic information and serum samples which were tested for the presence of specific antibodies to COVID-19 using ICMR-Kavach IgG ELISA kits. The data collected was compiled and analysed using appropriate statistical software. RESULTS: Overall weighted seroprevalence of the study population was found to be 7.75%. The prevalence in males and females was comparable (7.91% vs 7.57%). Highest seropositivity (10.04%) was seen among individuals aged more than 60 years. Total number of infections in the population were estimated to be 2,03,160. Overall Case Infection Ratio was found to be 27.43. CONCLUSION: The current seroprevalence study provides information on proportion of the population exposed, but the correlation between presence and absence of antibodies is not a marker of total or partial immunity. It must also be noted that more than 90 percent of the population is still susceptible for COVID-19 infection. Hence, non-pharmaceutical interventions like respiratory hygiene, physical distancing, hand sanitization, usage of personal protective equipment such as masks and implementation of public health measures need to be continued.

Disease surveillance during a large religious mass gathering in India: The Prayagraj Kumbh 2019 experience.

BACKGROUND: Mass gathering (MG) events are associated with public health risks. During the period January 14 to March 4, 2019, Kumbh Mela in Prayagraj, India was attended by an estimated 120 million visitors. An onsite disease surveillance was established to identify and respond to disease outbreaks. METHODS: A health coordination committee was established for planning. Disease surveillance was prioritized and risk assessment was done to identify diseases/conditions based on epidemic potential, severity of illness, and reporting requirement under the International Health Regulations (IHR) of 2005. A daily indicator and event-based disease surveillance was planned. The indicator-based surveillance (IBS) manually and electronically recorded data from patient hospital visits and collected MG area water testing data to assess trends. The event-based surveillance (EBS) helped identify outbreak signals based on pre-identified event triggers from the media, private health facilities, and the food safety department. Epidemic intelligence was used to analyse the data and events to detect signals, verify alerts, and initiate the response. RESULTS: At Kumbh Mela, disease surveillance was established for 22 acute diseases/syndromes. Sixty-five health facilities reported 156 154 illnesses (21% of a total 738 526 hospital encounters). Among the reported illnesses, 95% (n = 148 834) were communicable diseases such as acute respiratory illness (n = 52 504, 5%), acute fever (n = 41 957, 28%), and skin infections (n = 27 094, 18%). The remaining 5% (n = 7300) were non-communicable diseases (injuries n = 6601, 90%; hypothermia n = 224, 3%; burns n = 210, 3%). Water samples tested inadequate for residual chlorine in 20% of samples (102/521). The incident command centre generated 12 early warning signals from IBS and EBS: acute diarrheal disease (n = 8, 66%), vector-borne disease (n = 2, 16%), vaccine-preventable disease (n = 1, 8%), and thermal event (n = 1, 8%). There were two outbreaks (acute gastroenteritis and chickenpox) that were investigated and controlled. CONCLUSIONS: This onsite disease surveillance imparted a public health legacy by successfully implementing an epidemic intelligence enabled system for early disease detection and response to monitor public health risks. Acute respiratory illnesses emerged as a leading cause of morbidity among visitors. Future MG events should include disease surveillance as part of planning and augment capacity for acute respiratory illness diagnosis and management.

A study of the impact of tuberculosis on the quality of life and the effect after treatment with DOTS.

A prospective study was conducted on 90 patients of tuberculosis at 2 directly observed treatment short course (DOTS) cum microscopy centers in an urban area of Delhi. The WHOQOL-BREF (Hindi) questionnaire was used to assess the QOL at the onset of treatment, after 3 months of treatment under DOTS, and at completion of treatment. Patients with tuberculosis had significantly lower mean scores than controls for overall QOL. The most affected domains were physical and psychological. Women scored significantly better than men in the physical and environmental domains. Overall QOL scores were lowest for category II and significantly lower for the psychological and social domains. The mean scores after treatment were significantly lower than controls for overall QOL, the social and environmental domains. The DOTS regimen improves the QOL and its domains; however, they remain significantly affected compared to the healthy controls.

Assessment of mental health status of senior secondary school children in Delhi.

BACKGROUND: Schoolchildren undergo rapid mental, emotional, and social changes and are susceptible to psychiatric disorders. OBJECTIVES: This study aimed to assess the mental health status and some determinants in senior secondary school children in Delhi. METHODOLOGY: A cross-sectional study was carried out on a sample of 458 children, selected by 2-stage sampling. Goldberg's General Health Questionnaire containing 60 items (GHQ-60) was used for assessment of mental health. RESULTS: GHQ was administered to 239 boys and 219 girls in the age group of 15 to 20 years. Of 458 students, 113 (24.7%) had a score>or=16, the cutoff score, indicating mental morbidity among them. Among boys and girls, 28.5% and 20.5%, respectively, had some component of mental morbidity. Morbidity was significantly higher in children hailing from nuclear families and among children who had either failed or those who had scored highest in the class. CONCLUSION: Mental health needs of schoolchildren need to be addressed by the school health services.

Meso level multi-disciplinary approach for reduction of pre-treatment loss to follow-up in Revised National Tuberculosis Control Program, Delhi, India.

BACKGROUND: Universal access to tuberculosis (TB) care services emphasizes early detection and initiation of treatment for all pulmonary TB patients. Pre-treatment loss to follow-up patients needs to be actively tracked and treated to break the chain of transmission in the community. OBJECTIVES: MATERIALS AND METHODS: A questionnaire based cross sectional study of a sample of 340 patients who were pre-treatment loss to follow-up was conducted from November 2011 to March 2012 in Delhi. Qualitative study involved focused group discussions with paramedical providers using a topic outline guide, patients were interviewed using semi-structured questionnaire and brainstorming of program managers to elicit reasons, suggestions and health seeking behavior among those who were pre-treatment loss to follow-up. RESULTS: Preference for private practitioners (64.4%), lack of trust in government health system (26.7%), inconvenient time of Directly Observed Treatment (DOT) centre (18.5%) and wrong patient address (14%) were the main reasons for pre-treatment loss to follow-up. Paramedical provider's opinion elicited in focused group discussion was that there is an increased tendency of pre-treatment loss to follow-up in drug addicts and home-less patients. Brainstorming with program managers revealed that a lack of trust in allopathic system of medicine and human resource constraints were the leading causes of pre-treatment loss to follow-up. A Meso level multi disciplinary model with community participation through Resident Welfare Associations (RWAs) has been designed based on the above findings. The model suggests mutual collaboration between government and non government agencies for promotion of International Standards of TB care in private clinics, de addiction services and social welfare schemes through RWAs. CONCLUSION: There is a need for Advocacy Communication and Social Mobilization on a large scale. Collaboration with Resident Welfare Associations (RWAs) and with practitioners from alternate systems of medicine should be encouraged.

Universal access to DOTS in Delhi Prisons: Where do we stand?

BACKGROUND: Universal access implies that all tuberculosis (TB) patients in the community should have access to early, good quality diagnosis and treatment services that are affordable and convenient to the patient in time, place, and person. To achieve universal access, all affected vulnerable and marginalized population like prison inmates should have access to TB diagnostic and treatment services. OBJECTIVES: To assess the TB control activities in prisons of Delhi, the capital of India, and to suggest interventions for strengthening the program based on the observations. MATERIALS AND METHODS: Study was conducted at Tihar Prison, Delhi. TB case notification data from the Revised National TB Control Program (RNTCP) between 2008 and 2012 and log process framework were used to assess various parameters. RESULTS: Mean number of patients initiated on TB treatment was 120.6 annually between 2008 and 2012. The RNTCP has been implemented in Delhi Prisons since 2002; however, gaps were identified in human resource, training needs, case finding, diagnostic and treatment services, and supervision on situational analysis. Coordination between prison authorities and RNTCP authorities in relation to initial screening and discharge process appeared to be weak. CONCLUSION AND RECOMMENDATIONS: Because of the restricted access, vulnerability of the prison population, increase in drug-resistant TB, the TB control activities in the prison require restructuring. Initial screening for early diagnosis and treatment and "Discharge planning" needs to be devised so that there is sufficient time before release or transfer of individuals from prison. This needs strong commitment from the prison health authorities and RNTCP staff.

Treatment pathways of extrapulmonary patients diagnosed at a tertiary care hospital in Delhi, India.

BACKGROUND: In order to put extrapulmonary tuberculosis patients early on treatment, it is important to study pathways, which these patients adopt in for seeking treatment. MATERIALS AND METHODS: In order to study the treatment pathways of extrapulmonary patients and assess appropriate points for intervention, a cross-sectional study was conducted in chest clinic of a tertiary care hospital in Delhi. RESULTS: Factors associated with longer paths included reason for going to first health facility (nearness and known provider), availing more than one health facilities, presenting symptoms of fever, joint pain, nodular skin swelling and skin lesion. Self-referral to the chest clinic was associated with shorter paths. Lower level of education, occupation, non-serious perception of the disease and visiting five health facilities were significantly associated with patient delay of more than 3.5 weeks. Symptoms of fever, joint pain and skin lesion, visiting private health facility first, availing more than two health facilities and travelling distance of more than 100 km to reach chest clinic were significantly associated with the health facility delay of more than 4.5 weeks. CONCLUSIONS: Increasing public awareness, training of private practitioners and capacity building of government facilities will help in reducing delay.