Satellite Epidemic of Covid-19 Associated Mucormycosis in India: A Multi-Site Observational Study.

BACKGROUND: Sudden upsurge in cases of COVID-19 Associated Mucormycosis (CAM) following the second wave of the COVID-19 pandemic was recorded in India. This study describes the clinical characteristics, management and outcomes of CAM cases, and factors associated with mortality. METHODS: Microbiologically confirmed CAM cases were enrolled from April 2021 to September 2021 from ten diverse geographical locations in India. Data were collected using a structured questionnaire and entered into a web portal designed specifically for this investigation. Bivariate analyses and logistic regression were conducted using R version 4.0.2. RESULTS: A total of 336 CAM patients were enrolled; the majority were male (n = 232, 69.1%), literate (n = 261, 77.7%), and employed (n = 224, 66.7%). The commonest presenting symptoms in our cohort of patients were oro-facial and ophthalmological in nature. The median (Interquartile Range; IQR) interval between COVID diagnosis and admission due to mucormycosis was 31 (18, 47) days, whereas the median duration of symptoms of CAM before hospitalization was 10 (5, 20) days. All CAM cases received antifungal treatment, and debridement (either surgical or endoscopic or both) was carried out in the majority of them (326, 97.02%). Twenty-three (6.9%) of the enrolled CAM cases expired. The odds of death in CAM patients increased with an increase in HbA1c level (aOR: 1.34, 95%CI: 1.05, 1.72) following adjustment for age, gender, education and employment status. CONCLUSION: A longer vigil of around 4-6 weeks post-COVID-19 diagnosis is suggested for earlier diagnosis of CAM. Better glycemic control may avert mortality in admitted CAM cases.

A case control investigation of COVID-19 associated mucormycosis in India.

BACKGROUND: Increased occurrence of mucormycosis during the second wave of COVID-19 pandemic in early 2021 in India prompted us to undertake a multi-site case-control investigation. The objectives were to examine the monthly trend of COVID-19 Associated Mucormycosis (CAM) cases among in-patients and to identify factors associated with development of CAM. METHODS: Eleven study sites were involved across India; archived records since 1st January 2021 till 30th September 2021 were used for trend analysis. The cases and controls were enrolled during 15th June 2021 to 30th September 2021. Data were collected using a semi-structured questionnaire. Among 1211 enrolled participants, 336 were CAM cases and 875 were COVID-19 positive non-mucormycosis controls. RESULTS: CAM-case admissions reached their peak in May 2021 like a satellite epidemic after a month of in-patient admission peak recorded due to COVID-19. The odds of developing CAM increased with the history of working in a dusty environment (adjusted odds ratio; aOR 3.24, 95% CI 1.34, 7.82), diabetes mellitus (aOR: 31.83, 95% CI 13.96, 72.63), longer duration of hospital stay (aOR: 1.06, 95% CI 1.02, 1.11) and use of methylprednisolone (aOR: 2.71, 95% CI 1.37, 5.37) following adjustment for age, gender, occupation, education, type of houses used for living, requirement of ventilatory support and route of steroid administration. Higher proportion of CAM cases required supplemental oxygen compared to the controls; use of non-rebreather mask (NRBM) was associated as a protective factor against mucormycosis compared to face masks (aOR: 0.18, 95% CI 0.08, 0.41). Genomic sequencing of archived respiratory samples revealed similar occurrences of Delta and Delta derivates of SARS-CoV-2 infection in both cases and controls. CONCLUSIONS: Appropriate management of hyperglycemia, judicious use of steroids and use of NRBM during oxygen supplementation among COVID-19 patients have the potential to reduce the risk of occurrence of mucormycosis. Avoiding exposure to dusty environment would add to such prevention efforts.

SARS-CoV-2 re-infection: development of an epidemiological definition from India.

The current investigation was conducted with the objective to develop an epidemiological case definition of possible severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) re-infection and assess its magnitude in India. The epidemiological case definition for SARS-CoV-2 re-infection was developed from literature review of data on viral kinetics. For achieving second objective, the individuals who satisfied the developed case definition for SARS-CoV-2 re-infection were contacted telephonically. Taking available evidence into consideration, re-infection with SARS-CoV-2 in our study was defined as any individual who tested positive for SARS-CoV-2 on two separate occasions by either molecular tests or rapid antigen test at an interval of at least 102 days with one negative molecular test in between. In this archive based, telephonic survey, 58 out of 1300 individuals (4.5%) fulfilled the above-mentioned definition; 38 individuals could be contacted with healthcare workers (HCWs) accounting for 31.6% of the cases. A large proportion of participants was asymptomatic and had higher Ct value during the first episode. While SARS-CoV-2 re-infection is still a rare phenomenon, there is a need for epidemiological definition of re-infection for establishing surveillance systems and this study contributes to such a goal.Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) re-infection is an emerging concern and there is a need to define it. Therefore, working epidemiological case definition for re-infection was developed and its magnitude was explored via archive-based, telephonic survey. Re-infection with SARS-CoV-2 was defined as two positive tests at an interval of at least 102 days with one interim negative test. Thirty-eight of the 58 eligible patients could be contacted with 12 (31.6%) being HCWs. Majority of the participants were asymptomatic and had higher Ct value during their first episode. To conclude, a working epidemiological case definition of SARS-CoV-2 re-infection is important to strengthen surveillance. The present investigation contributes to this goal and records reinfection in 4.5% of SARS-CoV-2 infected individuals in India.

Internet Addiction, Sleep Quality and Depressive Symptoms Amongst Medical Students in Delhi, India.

Today, the internet has become an important element in people's lives, and owing to internet access becoming widespread, it has resulted in internet addiction. It is a major concern amongst medical students aiming to develop into health professionals. The implications of this addiction as well as its association with sleep and depression affects their studies, impacts their career goals and has detrimental consequences for society as a whole. The objectives of this study were to assess the proportion of medical undergraduate students and interns with internet addiction (IA), depressive symptoms and poor sleep quality and to study the association of IA with sleep quality and depressive symptoms. A cross-sectional questionnaire-based study was carried out in a medical college in Delhi. Universal sample consisting of all the medical students from first to final year (n = 185) and interns (n = 37) enrolled during the time of the study were included. Sleep quality, internet addiction and depressive symptoms in these students was assessed using Pittsburgh Sleep Quality Index (PSQI) Young's Internet Addiction Test (YIAT) and Patient Health Questionnaire-9 (PHQ) respectively. The average YIAT score was 33.16 ± 15.68. Overall 18%, 59.9%, 46.8% of students scored above validated cutoff scores for internet addiction, poor sleep quality and depression respectively. Prevalence of IA among males and females were 20.4% and 12.9% respectively. Significant correlations were found between potential IA, sleep quality and depression (p < 0.001). The study concluded a strong correlation between IA, disturbed sleep quality and depression. Identifying medical students with potential IA is important because this addiction often coexists with other psychological problems. Thus timely remedial actions and tailored interventions are required to combat IA among medical students.

Healthcare workers & SARS-CoV-2 infection in India: A case-control investigation in the time of COVID-19.

BACKGROUND & OBJECTIVES: Healthcare workers (HCWs) are at an elevated risk of contracting COVID-19. While intense occupational exposure associated with aerosol-generating procedures underlines the necessity of using personal protective equipment (PPE) by HCWs, high-transmission efficiency of the causative agent [severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)] could also lead to infections beyond such settings. Hydroxychloroquine (HCQ), a repurposed antimalarial drug, was empirically recommended as prophylaxis by the National COVID-19 Task Force in India to cover such added risk. Against this background, the current investigation was carried out to identify the factors associated with SARS-CoV-2 infection among HCWs in the country. METHODS: A case-control design was adopted and participants were randomly drawn from the countrywide COVID-19 testing data portal maintained by the ICMR. The test results and contact details of HCWs, diagnosed as positive (cases) or negative (controls) for SARS-CoV-2 using real-time reverse transcription-polymerase chain reaction (qRT-PCR), were available from this database. A 20-item brief-questionnaire elicited information on place of work, procedures conducted and use of PPE. RESULTS: Compared to controls, cases were slightly older (34.7 vs. 33.5 yr) and had more males (58 vs. 50%). In multivariate analyses, HCWs performing endotracheal intubation had higher odds of being SARS-CoV-2 infected [adjusted odds ratio (AOR): 4.33, 95% confidence interval (CI): 1.16-16.07]. Consumption of four or more maintenance doses of HCQ was associated with a significant decline in the odds of getting infected (AOR: 0.44; 95% CI: 0.22-0.88); a dose-response relationship existed between frequency of exposure to HCQ and such reductions (χ[2] for trend=48.88; P <0.001). In addition, the use of PPE was independently associated with the reduction in odds of getting infected with SARS-CoV-2. INTERPRETATIONS & CONCLUSIONS: Until results of clinical trials for HCQ prophylaxis become available, this study provides actionable information for policymakers to protect HCWs at the forefront of COVID-19 response. The public health message of sustained intake of HCQ prophylaxis as well as appropriate PPE use need to be considered in conjunction with risk homoeostasis operating at individual levels.

Are they there yet? Linkage of patients with tuberculosis to services for tobacco cessation and alcohol abuse - a mixed methods study from Karnataka, India.

BACKGROUND: Tobacco use and alcohol abuse are associated with higher risk of tuberculosis (TB) infection, progression to active TB and adverse treatment outcomes among patients with TB. Revised National Tuberculosis Control Programme (RNTCP) treatment guidelines (2016) require the documentation of tobacco and alcohol use among patients with TB and their linkage to tobacco and alcohol abuse treatment services. This study aimed to assess the extent of documentation of tobacco and alcohol usage data in the TB treatment card and to explore in-depth, the operational issues involved in linkage. METHODS: A convergent parallel mixed methods study was conducted. All new TB treatment cards of adult patients registered under RNTCP between January and June 2017 in Dakshina Kannada district were reviewed to assess documentation. Document review was done to understand the process of linkage (directing patients to tobacco and alcohol abuse treatment services). In-depth interview of health care providers (n = 7) and patients with TB (n = 5) explored into their perspectives on linkage. RESULTS: Among 413 treatment cards reviewed, tobacco use was documented in 322 (78%), of whom 86 (21%) were documented as current tobacco users. Sixteen (19%) out of these 86 patients were linked to tobacco cessation services. Alcohol usage status was documented in 319 (77%) cards of whom 71(17%) were documented as alcohol users. Eleven (16%) out of these 71 patients were linked to alcohol abuse treatment services. The questions in the treatment card lacked clarity. Guidelines on eliciting history of substance abuse and criteria for linkage were not detailed. Perceived enablers for linkage included family support, will power of the patients and fear of complications. Challenges included patient's lack of motivation, financial and time constraints, inadequate guidelines and lack of co-ordination mechanisms between TB programme and tobacco/alcohol abuse treatment services. CONCLUSION: Documentation was good but not universally done. Clear operational guidelines on linkage and treatment guidelines for health care providers to appropriately manage the patients with comorbidities are lacking. Lack of coordination between the TB treatment programme and tobacco cessation as well as alcohol treatment services was considered a major challenge in effective implementation of the linkage services.

Beliefs Supporting Violence, Attitudes and Aggressive Behavior Among School Adolescents in Rural Delhi.

Violence and aggression amongst adolescents is increasing across the globe. However, the research on adolescent violence in India is limited. The present study was undertaken to study aggressive beliefs, attitudes, behavior rural schools in north district of Delhi. It was a cross-sectional study conducted among adolescents studying in grade VIII-X in three rural schools in Delhi, selected by non-probability sampling. The data was collected using a questionnaire adapted from CDC Compendium of tools measuring aggression. Out of the total 270 adolescents, there were 119 boys (44.1%) and 151 (55.9%) girls. The mean score of beliefs, attitude aggressive behaviour for private co-ed school was highest while all girls' school had lowest (p < 0.001). Being male (p < 0.001), studying in private co-ed school (p < 0.001) and having attitude towards violence (p = 0.02) contributed significantly to total aggression score. The study highlighted that type of school, gender and attitudes influence adolescents' behavior towards aggression.

Formulation of Research Question - Stepwise Approach.

Formulation of research question (RQ) is an essentiality before starting any research. It aims to explore an existing uncertainty in an area of concern and points to a need for deliberate investigation. It is, therefore, pertinent to formulate a good RQ. The present paper aims to discuss the process of formulation of RQ with stepwise approach. The characteristics of good RQ are expressed by acronym "FINERMAPS" expanded as feasible, interesting, novel, ethical, relevant, manageable, appropriate, potential value, publishability, and systematic. A RQ can address different formats depending on the aspect to be evaluated. Based on this, there can be different types of RQ such as based on the existence of the phenomenon, description and classification, composition, relationship, comparative, and causality. To develop a RQ, one needs to begin by identifying the subject of interest and then do preliminary research on that subject. The researcher then defines what still needs to be known in that particular subject and assesses the implied questions. After narrowing the focus and scope of the research subject, researcher frames a RQ and then evaluates it. Thus, conception to formulation of RQ is very systematic process and has to be performed meticulously as research guided by such question can have wider impact in the field of social and health research by leading to formulation of policies for the benefit of larger population.

Awareness About Anti-Smoking Related Laws and Legislation Among General Population in Slums of Delhi, India.

Introduction: Almost 40% of Delhi's population lives in slums and is vulnerable to tobacco use. It is therefore important to assess their opinion and ensure compliance to antismoking legislation. The present study was undertaken to assess the awareness of the general public residing in slums in Delhi regarding the smoke-free initiative of 2009, 3 years after intensive implementation. Methods: It was a cross-sectional study conducted among participants selected by cluster sampling from the slums in six districts of Delhi using a pretested semistructured questionnaire. A total of 708 slum dwellers were interviewed. Results: Out of the total, only 16.1% (n = 114) of the participants had heard of The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003 (COTPA), though, they were aware about some of the provisions of the COTPA. Majority (n = 529; 74.7%) perceived the smoke-free zones as the places where smoking forms of tobacco are banned. Regarding the awareness about the places designated as smoke-free zones, 82.1% (n = 581) of the respondents named educational institutions. About 61% of the people interviewed reported to have seen people smoking at public places on the day of interview while only 21.5% reported to have seen any one getting punished for smoking. Conclusions: Awareness about COTPA was low. The study respondents perceived that no action was being taken against persons acting in violation of the law. Thus, there is a need for stricter implementation of COTPA and increased spreading of awareness among the general public. Implications: While awareness about antismoking legislation among general population (particularly slums) has been studied world over, this has not been the case in India. The study depicts opinion of one of the susceptible populations regarding tobacco control legislation, which has hitherto not been studied in the Indian context. This study has an important implication as it highlights the need for stringent enforcement of antismoking legislation for tobacco control.

Preventive Health Practices among Doctors in Delhi.

INTRODUCTION: With times, increasing attention is being given to doctor's own health as it is known to influence their patient care. Little is known about preventive health practices among them. OBJECTIVE: To assess preventive health practices among doctors in Delhi. MATERIAL AND METHODS: It was a cross-sectional study undertaken amongst the doctors working in selected hospitals, dispensaries and private clinics in Delhi. A self-administered questionnaire containing items for assessment of preventive health and self-care practices was used to collect the data. RESULTS: Out of the total 160 participants, there were 118 males (73.8%) and 42 (26.2%) females. The mean age of the participants was 29.9±7.4 years. There were 55 doctors (34.4%) who were suffering from chronic diseases like vision problems, dental problems, hypertension and diabetes. Nearly half of the doctors (n=74; 46.2%) did not have any for health insurance. Majority of the doctors (n=65; 40.6%) were obese. The knowledge regarding preventive health guidelines regarding all of the tests asked for, was low among the study participants. As far as preventive health practices were concerned, only 8.8% (14) had checked their blood pressure according to recommended guidelines while none of them had their lipid profile done. While there were 9 female doctors (21.4%) who had done their self breast examination in last six months, there was only 1 participant who had undergone pap test. With respect to self-care practices when the physicians last fell ill, majority had self-managed themselves (n=108; 67.5%). CONCLUSION: Preventive health care practices among the doctors are low. There an urgent need for them to follow good health care practices which they in turn can advocate to their patients.

Perception about use of comics in medical and nursing education among students in health professions' schools in New Delhi.

Background: Graphic narratives can give medical and nursing students a broader concept of health and illness. However, graphic texts are not yet integrated into medical education in India. The present study was undertaken to assess the perception of medical and nursing undergraduate students about the use of comics in health professions' education. Methods: This study was an institution-based cross-sectional study conducted among 130 medical and 108 nursing students of a medical and nursing college, respectively, in Central Delhi. A pretested self-administered questionnaire containing items to assess knowledge and perception about graphic medicine in medical education was used for data collection. Data were analyzed using SPSS 16.0. Results: The mean age of students was 20.82 ± 1.51 years. Out of the 238 students, only 21.8% had heard about graphic medicine. However, 76.9% (n = 183) of students agreed that comics should be used in health professions' education. When asked about the subjects in which comic strips can be useful, the majority of medical students wanted them to be used in teaching community medicine (n = 95; 73.1%), while nursing students more often indicated their use in anatomy (n = 59; 54.6%). Overall large proportion of both nursing and medical students opined that comics aid in better understanding (58.8%) and memorization of concepts and content (57.6%). The majority of respondents felt that comic designing requires expertise (67.6%). Students also stated that comic strips on communicable diseases and reproductive and child health could be developed and used in teaching the subject of community medicine/public health. Discussion: Majority of students felt that comics should be used in medical education in India, preferably for teaching community medicine. Further, maternal and child health are important topics that can be taught using comics in public health. There is a need to explore ways for integrating graphic medicine into health professions' education.

Workplace violence against resident doctors in a tertiary care hospital in Delhi.

BACKGROUND: Healthcare workers particularly doctors are at high risk of being victims of verbal and physical violence perpetrated by patients or their relatives. There is a paucity of studies on work-related violence against doctors in India. We aimed to assess the exposure of workplace violence among doctors, its consequences among those who experienced it and its perceived risk factors. METHODS: This study was done among doctors working in a tertiary care hospital in Delhi. Data were collected by using a self-administered questionnaire containing items for assessment of workplace violence against doctors, its consequences among those who were assaulted, reporting mechanisms and perceived risk factors. RESULTS: Of the 169 respondents, 104 (61.4%) were men. The mean (SD) age of the study group was 28.6 (4.2) years. Sixty-nine doctors (40.8%) reported being exposed to violence at their workplace in the past 12 months. However, there was no gender-wise difference in the exposure to violence (p=0.86). The point of delivery of emergency services was reported as the most common place for experiencing violence. Verbal abuse was the most common form of violence reported (n=52; 75.4%). Anger, frustration and irritability were the most common symptoms experienced by the doctors who were subjected to violence at the workplace. Only 44.2% of doctors reported the event to the authorities. 'Poor communication skills' was considered to be the most common physician factor responsible for workplace violence against doctors. CONCLUSIONS: A large proportion of doctors are victims of violence by their patients or relatives. Violence is being under-reported. There is a need to encourage reporting of violence and prepare healthcare facilities to tackle this emerging issue for the safety of physicians.