Revised ISHAM-ABPA working group clinical practice guidelines for diagnosing, classifying and treating allergic bronchopulmonary aspergillosis/mycoses.

BACKGROUND: The International Society for Human and Animal Mycology (ISHAM) working group proposed recommendations for managing allergic bronchopulmonary aspergillosis (ABPA) a decade ago. There is a need to update these recommendations due to advances in diagnostics and therapeutics. METHODS: An international expert group was convened to develop guidelines for managing ABPA (caused by Aspergillus spp.) and allergic bronchopulmonary mycosis (ABPM; caused by fungi other than Aspergillus spp.) in adults and children using a modified Delphi method (two online rounds and one in-person meeting). We defined consensus as ≥70% agreement or disagreement. The terms "recommend" and "suggest" are used when the consensus was ≥70% and <70%, respectively. RESULTS: We recommend screening for A. fumigatus sensitisation using fungus-specific IgE in all newly diagnosed asthmatic adults at tertiary care but only difficult-to-treat asthmatic children. We recommend diagnosing ABPA in those with predisposing conditions or compatible clinico-radiological presentation, with a mandatory demonstration of fungal sensitisation and serum total IgE ≥500 IU·mL-1 and two of the following: fungal-specific IgG, peripheral blood eosinophilia or suggestive imaging. ABPM is considered in those with an ABPA-like presentation but normal A. fumigatus-IgE. Additionally, diagnosing ABPM requires repeated growth of the causative fungus from sputum. We do not routinely recommend treating asymptomatic ABPA patients. We recommend oral prednisolone or itraconazole monotherapy for treating acute ABPA (newly diagnosed or exacerbation), with prednisolone and itraconazole combination only for treating recurrent ABPA exacerbations. We have devised an objective multidimensional criterion to assess treatment response. CONCLUSION: We have framed consensus guidelines for diagnosing, classifying and treating ABPA/M for patient care and research.

Incidence and prevalence of chronic pulmonary aspergillosis in patients with post-tuberculosis lung abnormality: Results from a community survey in North India.

BACKGROUND: Post-tuberculosis lung abnormality (PTLA) is the most common risk factor for developing chronic pulmonary aspergillosis (CPA). However, the prevalence and incidence of CPA in PTLA patients in India remain unknown. OBJECTIVES: We aimed to ascertain the incidence and prevalence of CPA in subjects with PTLA. METHODS: We identified a cohort of pulmonary tuberculosis who completed anti-tuberculosis therapy (ATT) before November 2019 from the records of the 12 tuberculosis treatment centers attached to the national program. We recorded the clinical and demographic details. We performed computed tomography (CT) of the chest and estimated serum A. fumigatus-specific IgG. We categorised subjects as PTLA with or without CPA using a composite of clinical, radiological, and microbiological features. We resurveyed the subjects at 6 months (or earlier) for the presence of new symptoms. We calculated the prevalence and the incidence rate (per 100-person years) of CPA. RESULTS: We included 117 subjects with PTLA, with a median of 3 years after ATT completion. Eleven subjects had CPA in the initial survey, and one additional case developed CPA during the second survey. The prevalence of CPA in PTLA subjects was 10.3% (12/117). The total observation period was 286.7 person-years. The median (interquartile range) time to develop CPA after ATT completion was 12.5 (5-36.7) months. We found the CPA incidence rate (95% confidence interval) of 4.2 (1.8-6.5) per 100-person years. CONCLUSION: Chronic pulmonary aspergillosis complicates 10% of PTLA subjects after successful outcomes with ATT. Four new CPA cases may develop per 100-persons years of observation after ATT completion. We suggest screening patients with PTLA who develop new symptoms for CPA.

Risk factors for pulmonary mucormycosis in subjects with diabetes mellitus-A case-control study.

BACKGROUND: Factors associated with pulmonary mucormycosis (PM) among subjects with diabetes mellitus (DM) remain unclear. Following the coronavirus disease (COVID-19)-associated mucormycosis outbreak in India, specific environmental exposures (especially cattle dung exposure) were proposed as possible aetiology. We hypothesized that environmental factors are associated with PM. We compared subjects with DM with (cases) and without PM (controls). METHODS: In this case-control study, for each PM case, we included five unmatched diabetic controls (hospital [n = 2], community [n = 3]) without PM. We collected information on demography, COVID-19 infection, glycated haemoglobin% (HbA1c), the type of house (pucca vs. kutcha) where the participants reside, and other environmental factors. The primary exposure tested was cattle dung exposure (CDE; using cattle dung cakes as fuel or cattle handling). We performed a multivariate logistic regression to explore factors associated with PM and report the association as an adjusted odds ratio (OR) with 95% confidence intervals (CI). RESULTS: We enrolled 39 PM cases and 199 controls (hospital [n = 80], community [n = 119]). CDE (OR 0.68, 95% CI [0.14-3.31]; p = 0.63) was not associated with increased PM in DM. We found male sex (OR 4.07, 95% CI [1.16-14.31]), higher HbA1c (OR 1.51, 95% CI [1.18-16.32]), COVID-19 (OR 28.25, 95% CI [7.02-113.6]) and residence at kutcha house (OR 4.84, 95% CI [1.33-17.52]) associated with PM. CONCLUSION: Cattle dung exposure was not associated with PM in subjects with DM. Instead, male sex, poor glycaemic control, COVID-19 and the type of housing were associated with pulmonary mucormycosis.

Effectiveness of indigenous ready-to-use therapeutic food in community-based management of uncomplicated severe acute malnutrition: a randomized controlled trial from India.

A randomized controlled trial was conducted in Chandigarh, India (2011), to determine the effectiveness of indigenous ready-to-use therapeutic food (RUTF) in community-based management of uncomplicated severe acute malnutrition (SAM). Intervention was through outpatient therapeutic program site (OTP). Study and control group children (6 months-5 years) were followed up weekly for 12 weeks, in OTP and at home. All children received supplementary nutrition through anganwadis under integrated child development scheme. Study children, in addition, received therapeutic dose of RUTF in OTP. Primary outcome, 115% of baseline weight, was attained in 6 of 13 (46.2%) and 1 of 13 (7.7%) children among study and control group, respectively [odds ratio: 10.28, 95% confidence interval (CI): 1.02-103.95]. Compared with control group, addition of RUTF in study group resulted in average additional increase in weight by 13 g/kg of baseline weight/week/child (95% CI: 2-23). Indigenous RUTF was effective in community-based management of uncomplicated SAM.

Prevalence of Aspergillus Sensitization and Allergic Bronchopulmonary Aspergillosis in Adults With Bronchial Asthma: A Systematic Review of Global Data.

BACKGROUND: The prevalence of allergic bronchopulmonary aspergillosis (ABPA) in asthmatic patients remains unclear and is likely different across geographic locales. OBJECTIVE: To systematically review the literature for estimating the prevalence of Aspergillus sensitization (AS) and ABPA in adults with bronchial asthma. METHODS: We searched the PubMed and Embase databases for studies reporting the prevalence of AS or ABPA in at least 50 asthmatic subjects. The primary outcome was to assess the prevalence of ABPA. The secondary outcome was to evaluate the prevalence of AS in asthma and that of ABPA in asthma with AS. We pooled the prevalence estimates using a random-effects model and examined the factors influencing the prevalence using multivariate meta-regression. RESULTS: Of the 11,801 records retrieved, 86 studies with 25,770 asthmatic subjects met the inclusion criteria. Most of the studies were from tertiary care centers. The pooled prevalence of ABPA in asthma (47 studies; 9822 asthmatic subjects) was 11.3% (95% CI, 8.7-14.2). The pooled prevalence of AS in asthma (73 studies; 23,003 asthmatic subjects) was 25.1% (95% CI, 20.5-30.0), whereas the prevalence of ABPA in AS (36 studies; 2954 asthmatic subjects) was 37.0% (95% CI, 27.9-46.6). Multivariate meta-regression identified studies published from India (odds ratio, 1.11; 95% CI, 1.01-1.23) as the only factor associated with higher ABPA prevalence. There was presence of significant statistical heterogeneity and publication bias. CONCLUSIONS: We found a high prevalence of ABPA in adult asthmatic subjects, underscoring the need for screening for ABPA in all asthmatic subjects seeking tertiary care.

Prevalence of Aspergillus sensitization and Allergic Bronchopulmonary Aspergillosis in bronchial asthma: A systematic review of Indian studies.

Background: The prevalence of allergic bronchopulmonary aspergillosis (ABPA) in Indian asthmatic patients remains unknown. We systematically reviewed the literature for estimating the prevalence of Aspergillus sensitization (AS) and ABPA in Indian subjects with bronchial asthma. Methods: We searched the PubMed and Embase databases for studies from India reporting the prevalence of AS or ABPA in at least 50 asthmatics. The primary outcome of our study was to assess the prevalence of ABPA. The secondary outcomes were to evaluate the prevalence of AS in asthma and ABPA in Aspergillus-sensitized asthma. We pooled the prevalence estimates using a random effects model and examined the factors influencing the prevalence using multivariate meta-regression. Results: Of the 8,383 records retrieved, 34 studies with 14,580 asthmatics met the inclusion criteria. All the studies were from tertiary centers. The pooled prevalence of ABPA in asthmatics (26 studies; 5,554 asthmatics) was 16.2% [95% confidence interval (CI), 12.5-20.4]. The pooled prevalence of AS in asthma (29 studies; 13,405 asthmatics) was 30.9% (95% CI, 25.3-36.6), while the prevalence of ABPA in AS (20 studies; 1,493 asthmatics) was 48.2% (95% CI, 39.6-56.8). Meta-regression identified studies published after 2009 (OR 1.14; 95% CI, 1.02-1.28) and studies with severe asthmatics (OR 1.12; 95% CI, 1.00-1.26) as the only factors associated with higher ABPA prevalence. Conclusions: There is a high prevalence of ABPA in Indian asthmatic subjects at tertiary centers, underscoring the need for screening all asthmatic subjects in special asthma and chest clinics for ABPA.

Aspergillus Sensitization and Allergic Bronchopulmonary Aspergillosis in Asthmatic Children: A Systematic Review and Meta-Analysis.

Background: The prevalence of aspergillus sensitization (AS) and allergic bronchopulmonary aspergillosis (ABPA) in asthmatic children remains unclear. Objective: To systematically review the literature to estimate the prevalence of AS and ABPA in children with bronchial asthma. Methods: We searched the PubMed and Embase databases for studies reporting the prevalence of AS or ABPA in pediatric asthma. The primary outcome was to assess the prevalence of AS, while the secondary outcome was to evaluate the prevalence of ABPA. We pooled the prevalence estimates using a random effects model. We also calculated the heterogeneity and publication bias. Results: Of the 11,695 records retrieved, 16 studies with 2468 asthmatic children met the inclusion criteria. Most studies were published from tertiary centers. The pooled prevalence of AS in asthma (15 studies; 2361 subjects) was 16.1% (95% confidence intervals [CI], 9.3-24.3). The prevalence of AS was significantly higher in prospective studies, studies from India, and those from developing countries. The pooled prevalence of ABPA in asthma (5 studies; 505 children) was 9.9% (95% CI, 0.81-27.6). There was significant heterogeneity and publication bias for both outcomes. Conclusions: We found a high prevalence of AS and ABPA in asthmatic children. There is a need for community-based studies from different ethnicities using a standard methodology to ascertain the true prevalence of AS and ABPA in pediatric asthma.

Outcomes and Challenges in the Programmatic Implementation of Tuberculosis Preventive Therapy among Household Contacts of Pulmonary TB Patients: A Mixed-Methods Study from a Rural District of Karnataka, India.

The National TB Elimination Programme (NTEP) of India is implementing tuberculosis preventive treatment (TPT) for all household contacts (HHCs) of pulmonary tuberculosis patients (index patients) aged <5 years and those HHCs aged >5 years with TB infection (TBI). We conducted an explanatory mixed-methods study among index patients registered in the Kolar district, Karnataka during April-December 2022, to assess the TPT cascade and explore the early implementation challenges for TPT provision. Of the 301 index patients, contact tracing home visits were made in 247 (82.1%) instances; a major challenge was index patients' resistance to home visits fearing stigma, especially among those receiving care from the private sector. Of the 838 HHCs, 765 (91.3%) were screened for TB; the challenges included a lack of clarity on HHC definition and the non-availability of HHCs during house visits. Only 400 (57.8%) of the 692 eligible HHCs underwent an IGRA test for TBI; the challenges included a shortage of IGRA testing logistics and the perceived low risk among HHCs. As HHCs were unaware of their IGRA results, a number of HHCs actually eligible for TPT could not be determined. Among the 83 HHCs advised of the TPT, 81 (98%) initiated treatment, of whom 63 (77%) completed treatment. Though TPT initiation and completion rates are appreciable, the NTEP needs to urgently address the challenges in contact identification and IGRA testing.

Test and Treat Model for Tuberculosis Preventive Treatment among Household Contacts of Pulmonary Tuberculosis Patients in Selected Districts of Maharashtra: A Mixed-Methods Study on Care Cascade, Timeliness, and Early Implementation Challenges.

Tuberculosis preventive treatment (TPT) is an important intervention in preventing infection and reducing TB incidence among household contacts (HHCs). A mixed-methods study was conducted to assess the "Test and Treat" model of TPT care cascade among HHCs aged ≥5 years of pulmonary tuberculosis (PTB) patients (bacteriologically/clinically confirmed) being provided TPT care under Project Axshya Plus implemented in Maharashtra (India). A quantitative phase cohort study based on record review and qualitative interviews to understand the challenges and solutions in the TPT care cascade were used. Of the total 4181 index patients, 14,172 HHCs were screened, of whom 36 (0.3%) HHCs were diagnosed with tuberculosis. Among 14,133 eligible HHCs, 10,777 (76.3%) underwent an IGRA test. Of them, 2468 (22.9%) tested positive for IGRA and were suggested for chest X-ray. Of the eligible 2353 HHCs, 2159 (91.7%) were started on TPT, of whom 1958 (90.6%) completed the treatment. The median time between treatment initiation of index PTB patient and (a) HHC screening was 31 days; (b) TPT initiation was 64 days. The challenges in and suggested solutions for improving the TPT care cascade linked to subthemes were tuberculosis infection testing, chest X-ray, human resources, awareness and engagement, accessibility to healthcare facilities, TPT drugs, follow-up, and assessment. A systematic monitoring and time-based evaluation of TPT cascade care delivery followed by prompt corrective actions/interventions could be a crucial strategy for its effective implementation and for the prevention of tuberculosis.

Outbreak investigation of acute watery diarrhea in a village of North India: timely action saved lives.

INTRODUCTION: Outbreaks of acute watery diarrhoea are common in developing countries having poor access to safe drinking water and sanitation. An outbreak of acute watery diarrhoea in a village in North India was investigated with the aim to initiate and recommend necessary actions to control it. METHODOLOGY: A house to house survey using a specially designed case record form was conducted covering all the households. Stool samples of some of the affected individuals and twenty water samples during and after the outbreak from various sites were collected for laboratory analysis. RESULTS: Out of 624 inhabitants surveyed, 118 were found to be suffering from acute watery diarrhoea (Overall attack rate of 18.9%) with two suspected deaths following diarrhoea. Males and females were affected equally and the age group of 15-44 years was affected predominantly. A peculiar epidemic curve with single peak was noted. One of the stool samples collected during the outbreak grew Vibrio Cholera O1(Ogawa) and twelve out of the twenty water samples including the samples from both the tube wells had high coliform counts indicating fecal contamination. Chlorine levels in all the water samples were found to be inadequate. CONCLUSIONS: Local cultural practices such as indiscriminate defecation in public places, using tullu pumps to extract water from the public supply line, poor engineering design and maintenance of the water supply system having leakages at many sites along with inadequate chlorination of the supply water from the tube wells were the risk factors that could have contributed to this outbreak.

Perception of Global Participants of ITEC Nations on Country's Preparedness and Response to COVID-19 Pandemic.

Background: The Coronavirus disease 2019 (COVID-19) pandemic has exposed the public health preparedness and response system across the world. The current study was conducted to gauge the perception of public health professionals of Indian Technical and Economic Cooperation (ITEC) countries regarding the preparedness and responses of their countries in mitigating the COVID-19 pandemic. Methodology: Three capacity-building programs, namely "Managing COVID-19 Pandemic-Experience and Best practices of India" were conducted by PGIMER, Chandigarh, for public health professionals from ITEC countries from April to May 2021 in which 97 participants from 13 countries have participated. The tools used in the study were adapted from WHO's COVID-19 Strategic Preparedness and Response (SPRP), Monitoring and Evaluation Framework, interim guidelines for Critical preparedness, readiness and response actions for COVID-19, and a strategic framework for emergency preparedness, and finalized using Delphi technique. The overall preparedness of managing COVID-19 was rated using five-point Likert scale, whereas the overall score for the country in combating the COVID-19 pandemic was assessed using 10 point scale. Results: We found that the perception of public health professionals to government response regarding COVID-19 for fostering improvement on COVID-19 situation was "moderate" with respect to transmission and surveillance mechanism, uniform reporting mechanism, and availability of adequate personal protective equipment (PPE) for health workers. However, the participants rated government response as "poor" in the availability of multisectoral national operational plan, human resource capacity, availability of trained rapid response team (RRT), preparedness in prevention and clinical management, training of healthcare workers, communication and community engagement strategies, facilities to test samples of patients, and transparent governance and administration. Conclusion: A poor level of preparedness of countries in diverse domains of managing the COVID-19 pandemic was observed. As the global threat of COVID-19 is still looming, great efforts on building a robust preparedness and response system for COVID-19 and similar pandemics are urgently required.

Theoretical constructs of smoking cessation among current tobacco smokers in India: a secondary analysis of Global Adult Tobacco Survey-2 (2016-2017).

BACKGROUND: Quitting tobacco smoking is a complex process, and the transtheoretical model describes the various stages of behaviour change that smokers experience to stop smoking. Predictors of intention to quit and stage of behavioural change could assist policy-makers in establishing tailor-made strategies to offer support. OBJECTIVE: In the current study, we analysed the determinants of cessation among 9499 current smokers of India recorded during the second Global Adult Tobacco Survey (2016-2017). METHODS: Bivariate analysis, multivariate analysis (binary logistic regression was performed for past quit attempts and intention to quit smoking in the future; multinomial logistic regression to understand predictors of various stages of change determining cessation behaviour of current smokers) was undertaken. RESULTS: The majority of the smokers was men (91.0%), in 25-44 years age group, (42.3%), daily wagers (37.4%) and resided in the rural area (73.3%), with bidi being the most commonly smoked product (72%). Nearly 72% tried to quit without any assistance with 36.6% (precontemplation), 27% (contemplation), 28% (preparation (or action)) and 8.1% in (relapse) stage. Men ((1.049); 95% CI 1.047 to 1.051), the primary (1.192; 95% CI 1.190 to 1.193) as well as higher education, being married (1.231; 95% CI 1.229 to 1.234) and urban residence (1.167; 95% CI 1.1.65 to 1.168) were found to be associated with higher prevalence of previous quit attempts. The regression modelling found out that intent to quit reduced with increasing age and was similarly prevalent with any level of education. CONCLUSION: Understanding stages of behavioural change could assist the stakeholders in developing individualised interventions along with the development of intensive cessation protocols in clinical and public health settings.

A Mixed Methods Evaluation of Adolescent Friendly Health Clinic Under National Adolescent Health Program, Puducherry, India.

OBJECTIVES: To assess the awareness and utilization of Adolescent Friendly Health Clinic (AFHC) services among school going adolescents (14-19 y) and to explore the forces 'for' and 'against' the utilization of AFHC services in Puducherry, India. METHODS: This mixed-methods study was conducted in two primary health centres. Record review assessed the utilization of AFHC service. Survey assessed the awareness on AFHC services and self-reported illnesses and their treatment seeking behavior. Group interviews were conducted with adolescent girls, boys and healthcare providers. A summative content analysis was done to organize the 'for' and 'against' forces for service utilization. RESULTS: Of the 311 adolescents, less than 50% were aware of the services available at AFHC. Utilization of Weekly Iron and Folic Acid Supplementation was good. Only 2-10% of adolescents consulted the outpatient services of the Primary Health Centre for the treatment of their health problems. The authors found low utilization of AFHC services (15% among girls, zero among boys). One of the reasons for low utilization was poor awareness. Though free sanitary napkins motivated the girls to avail the services, boys considered the AFHC as a girl's clinic. Healthcare providers suggested that building rapport and trust with adolescents and their parents, involving school teachers and ensuring privacy in the clinic would increase the utilization. CONCLUSIONS: There is a huge gap between the awareness and utilization of AFHC services. The reasons for non-utilization were poor awareness and misconceptions about the clinic. Training of health staffs on communication skills, and supportive supervision could improve the utilization.

Are people at high risk for diabetes visiting health facility for confirmation of diagnosis? A population-based study from rural India.

BACKGROUND: India is witnessing a rising burden of type 2 diabetes mellitus. India's National Programme for Prevention and Control of Diabetes, Cancer, Cardiovascular diseases and Stroke recommends population-based screening and referral to primary health centre for diagnosis confirmation and treatment initiation. However, little is known about uptake of confirmatory tests among screen positives. OBJECTIVE: To estimate the uptake of confirmatory tests and identify the reasons for not undergoing confirmation by those at high risk for developing diabetes. METHODS: We analysed data collected under project UDAY, a comprehensive diabetes and hypertension prevention and management programme, being implemented in rural Andhra Pradesh, India. Under UDAY, population-based screening for diabetes was carried out by project health workers using a diabetes risk score and capillary blood glucose test. Participants at high risk for diabetes were asked to undergo confirmatory tests. On follow-up visit, health workers assessed if the participant had undergone confirmation and ask for reasons if not so. RESULTS: Of the 35,475 eligible adults screened between April 2015 and August 2016, 10,960 (31%) were determined to be at high risk. Among those at high risk, 9670 (88%) were followed up, and of those, only 616 (6%) underwent confirmation. Of those who underwent confirmation, 'lack of symptoms of diabetes warranting visit to health facility' (52%) and 'being at high risk was not necessary enough to visit' (41%) were the most commonly reported reasons for non-confirmation. Inconvenient facility time (4.4%), no nearby facility (3.2%), un-affordability (2.2%) and long waiting time (1.6%) were the common health system-related factors that affected the uptake of the confirmatory test. CONCLUSION: Confirmation of diabetes was abysmally low in the study population. Low uptake of the confirmatory test might be due to low 'risk perception'. The uptake can be increased by improving the population risk perception through individual and/or community-focused risk communication interventions.