Situation Analysis of Early Implementation of Programmatic Management of Tuberculosis Preventive Treatment among Household Contacts of Pulmonary TB Patients in Delhi, India.

Tuberculosis Preventive Treatment (TPT) is a powerful tool for preventing the TB infection from developing into active TB disease, and has recently been expanded to all household contacts of TB cases in India. This study employs a mixed-methods approach to conduct a situational analysis of the initial phase of TPT implementation among household contacts of pulmonary TB patients in three districts of Delhi, India. It was completed using a checklist based assessments, care cascade data, and qualitative analysis. Our observations indicated that organizational structure and planning were established, but implementation of TPT was suboptimal with issues in drug availability and procurement, budget, human resources, and training. Awareness and motivation, and shorter regimen, telephonic assessment, and collaboration with NGOs emerged as enablers. Apprehension about taking TPT, erratic drug supply, long duration of treatment, side effects, overburden, large population, INH resistance, data entry issues, and private provider reluctance emerged as barriers. The study revealed potential solutions for optimizing TPT implementation. It is evident that, while progress has been made in TPT implementation, there is room for improvement and refinement across various domains.

Hypertension and its correlates among pregnant women consuming tobacco in India: Findings from the National Family health Survey-4.

Background: Hypertension (high blood pressure) during pregnancy has significant implications on maternal and perinatal morbidity and mortality. Tobacco use during pregnancy amplifies this burden and increases the risk of hypertensive disorders along with adverse birth outcomes. The current study aimed to evaluate the joint risk atpopulation-level of tobacco use and hypertension among pregnant women in India. Methodology: Data of 32,428 "currently pregnant" women aged 15-49 years was obtained from the National Family Health Survey (NFHS-4) 2015-16to estimate bivariate (tobacco user vs. non-user) and binomial logistic regression analysis in order to get odds ratios of having hypertension. The analysis included socio-demographic variables such as the respondent's age, type of residence, wealth index, and education status. Results: Prevalence of hypertension among pregnant tobacco users (7.5%) was significantly higher than that of non-users (6.1%). The unadjusted odds of having hypertension were 1.17 (95% CI: 1.02-1.35) times among tobacco users than non-users and increased with age (p < 0.001) and in rural areas (p = 0.02) after adjusting for other covariates. However, it varied inversely with education status (p > 0.05; NS) and wealth quintile (p = 0.01). Conclusion: The present study identifies the higher co-existence of hypertension among tobacco-using pregnant women and highlights the need for tobacco control/cessation and hypertension prevention and management during pregnancy considering socio-demographic disparities.

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.

Higher proinflammatory responses possibly contributing to suppressed cytotoxicity in patients with COVID-19 associated mucormycosis.

INTRODUCTION: COVID-19 Associated Mucormycosis (CAM), an opportunistic fungal infection, surged during the second wave of SARS Cov-2 pandemic. Since immune responses play an important role in controlling this infection in immunocompetent hosts, it is required to understand immune perturbations associated with this condition for devising immunotherapeutic strategies for its control. We conducted a study to determine different immune parameters altered in CAM cases as compared to COVID-19 patients without CAM. METHODOLOGY: Cytokine levels in serum samples of CAM cases (n = 29) and COVID-19 patients without CAM (n = 20) were determined using luminex assay. Flow cytometric assays were carried out in 20 CAM cases and 10 controls for determination of frequency of NK cells, DCs, phagocytes, T cells and their functionalities. The cytokine levels were analyzed for their association with each other as well as with T cell functionality. The immune parameters were also analyzed with respect to the known risk factors such as diabetes mellitus and steroid treatment. RESULTS: Significant reduction in frequencies of total and CD56 + CD16 + NK cells (cytotoxic subset) was noted in CAM cases. Degranulation responses indicative of cytotoxicity of T cell were significantly hampered in CAM cases as compared to the controls. Conversely, phagocytic functions showed no difference in CAM cases versus their controls except for migratory potential which was found to be enhanced in CAM cases. Levels of proinflammatory cytokines such as IFN-γ, IL-2, TNF-α, IL-17, IL-1ß, IL-18 and MCP-1 were significantly elevated in cases as compared to the control with IFN-γ and IL-18 levels correlating negatively with CD4 T cell cytotoxicity. Steroid administration was associated with higher frequency of CD56 + CD16- NK cells (cytokine producing subset) and higher MCP-1 levels. Whereas diabetic participants had higher phagocytic and chemotactic potential and had higher levels of IL-6, IL-17 and MCP-1. CONCLUSION: CAM cases differed from the controls in terms of higher titers of proinflammatory cytokines, reduced frequency of total and cytotoxic CD56 + CD16 + NK cell. They also had reduced T cell cytotoxicity correlating inversely with IFN-γ and IL-18 levels, possibly indicating induction of negative feedback mechanisms while diabetes mellitus or steroid administration did not affect the responses negatively.

Hypertension Control Cascade and Regional Performance in India: A Repeated Cross-Sectional Analysis (2015-2021).

Background The weak control cascade of hypertension from the time of screening till the attainment of optimal blood pressure (BP) control is a public health challenge, particularly in resource-limited settings. The study objectives were to (1) estimate the change in the rate of prevalence of hypertension, the yield of newly diagnosed cases, initiation of treatment, and attainment of BP control in the age group 15 to 49 years; (2) ascertain the magnitude and predictors of undiagnosed hypertension, lack of initiation of treatment, and poor control of those on antihypertensive therapy; and (3) estimate the regional variation and state-level performance of the hypertension control cascade in India. Methodology We analyzed demographic and health surveillance (DHS) data from India's National Family Health Survey Fifth Series (NFHS-5), 2019-2021, and NFHS-4 (2015-2016). The NFHS-5 sample comprised 695,707 women and 93,267 men in the age group of 15 to 49 years. Multiple logistic regressions were performed to find the associated predictors, and respective adjusted odds ratios (aORs) were reported. Results The prevalence of hypertension (cumulative previously diagnosed and new cases) among individuals aged 15 to 49 years was 22.8% (22.6%, 23.1%; n = 172,532), out of which 52.06% were newly diagnosed cases. In contrast, in NFHS-4, the prevalence of hypertension among individuals aged 15 to 49 years was 20.4% (20.2%, 20.6%; n = 153,384), of which 41.65% were newly diagnosed cases. In NFHS-5, 40.7% (39.8% and 41.6%) of the previously diagnosed cases were on BP-lowering medications compared to 32.6% (31.8%, 33.6%) in NFHS-4. Furthermore, in NFHS-5, controlled BP was observed in 73.7% (72.7% and 74.7%) of the patients on BP-lowering medication compared to 80.8% (80.0%, 81.6%) in NFHS-4. Females compared to males (aOR = 0·72 and 0·007), residents of rural areas (aOR = 0·82 and 0·004), and those belonging to the socially disadvantaged groups were not initiated on treatment despite awareness of their hypertension status indicative of poor treatment-seeking behavior. Furthermore, increasing age (aOR = 0·49, P < 0·001), higher body mass index (aOR = 0·51, P < 0·001), and greater waist-to-hip ratio (aOR = 0·78, P = 0·047) were associated with uncontrolled hypertension in patients on antihypertensive drug therapy. Conclusions Hypertension control cascade in India is largely ineffectual although screening yield and initiation of antihypertensive treatment have improved in NFHS-5 compared to NFHS-4. Identification of high-risk groups for opportunistic screening, implementing community-based screening, strengthening primary care, and sensitizing associated practitioners are urgently warranted.

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.

Job satisfaction among medical officers working in Delhi.

Background: Satisfied human resource is an essential asset for high productivity, efficiency, and quality of care in a healthcare organization. Job satisfaction among healthcare professionals assumes further significance for the purpose of maximization of human resource potential in the context of the shortage of manpower in the health sector in India. Objectives: The objective of the study was to assess the job satisfaction among medical officers (MOs) working in Delhi and to study the factors influencing the satisfaction level amongst them. Material and Methods: It was a cross-sectional study conducted amongst selected MOs (by convenience) in all the districts of Delhi. A structured, self-administered questionnaire was used to collect data from the participants. Results: A total of 115 MOs completed the questionnaire. There were 61 (53%) female doctors and 54 (47%) male doctors. The mean age of the study participants was 38.28 ± 7.37 years. The experience of the study group ranged between 1 and 28 years (9.59 ± 6.47 years). Of the total, 59.1% of participants were found to be satisfied with their job. The most common reason given for satisfaction with job was the timing of their job that suits them. The reason given for not being satisfied with job was salary not at par with work pressure. A significantly higher proportion of male participants considered "lack of accommodation" (P < 0.03) and "frequent detailment" (P < 0.031) are big problems faced in their jobs as compared with the female participants. Only 37 (32.2%) participants felt that the MO is able to give enough time to patients for clinical assessment in Out Patient Department. Conclusions: Although majority (59%) of the study group was satisfied with their job, there were numerous problems faced by the doctors at their workplace. Low pay was one of the important reasons cited for being dissatisfied. There is an urgent need to address all the factors affecting job satisfaction through proper planning and implementing relevant human resource policies for improvement in the work environment at public health institutions.

Determinants of severity among hospitalised COVID-19 patients: Hospital-based case-control study, India, 2020.

BACKGROUND: Risk factors for the development of severe COVID-19 disease and death have been widely reported across several studies. Knowledge about the determinants of severe disease and mortality in the Indian context can guide early clinical management. METHODS: We conducted a hospital-based case control study across nine sites in India to identify the determinants of severe and critical COVID-19 disease. FINDINGS: We identified age above 60 years, duration before admission >5 days, chronic kidney disease, leucocytosis, prothrombin time > 14 sec, serum ferritin >250 ng/mL, d-dimer >0.5 ng/mL, pro-calcitonin >0.15 µg/L, fibrin degradation products >5 µg/mL, C-reactive protein >5 mg/L, lactate dehydrogenase >150 U/L, interleukin-6 >25 pg/mL, NLR ≥3, and deranged liver function, renal function and serum electrolytes as significant factors associated with severe COVID-19 disease. INTERPRETATION: We have identified a set of parameters that can help in characterising severe COVID-19 cases in India. These parameters are part of routinely available investigations within Indian hospital settings, both public and private. Study findings have the potential to inform clinical management protocols and identify patients at high risk of severe outcomes at an early stage.

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.

Opportunistic screening for diabetes mellitus and hypertension in primary care settings in Karnataka, India: a few steps forward but still some way to go.

Background: Opportunistic screening for individuals aged ≥30 years at all levels of healthcare for early detection of diabetes mellitus (DM) and hypertension (HTN) is an integral strategy under the national program to control non-communicable diseases. There has been no systematic assessment of the screening process in primary care settings since its launch. The objective was to determine the number and proportion eligible for screening, number screened, diagnosed and treated for DM and HTN among persons aged ≥30 years in two selected primary health centres (PHCs) in Dakshina Kannada district, Karnataka, India during March-May 2019 and to explore the enablers and barriers in the implementation of screening from the perspective of the health care providers (HCPs) and beneficiaries . Methods: This was a sequential explanatory mixed-methods study with a quantitative (cohort design) and a descriptive qualitative component (in-depth interviews and focus group discussions) with HCPs and persons seeking care. Those that were not known DM/HTN and not screened for DM/HTN in one year were used to estimate persons eligible for screening. Results: Of 2697 persons, 512 (19%) were eligible for DM screening, 401 (78%) were screened; 88/401 (22%) were diagnosed and 67/88 (76%) were initiated on treatment. Of 2697, 337 (13%) were eligible for HTN screening, 327 (97%) were screened, 55 (17%) were diagnosed with HTN; of those diagnosed, 44/55 (80%) were initiated on treatment.  The documentation changes helped in identifying the eligible population. Patient willingness to undergo screening and recognition of relevance of screening were screening enablers.  Overworked staff, logistical and documentation issues, inadequate training were the barriers. Conclusion: Nearly 19% were eligible for DM screening and 13% were eligible for HTN screening. The yield of screening was high. We noted several enablers and barriers. The barriers require urgent attention to reduce the gaps in delivery and uptake of services.

Tobacco Use Among the Youth in India: Evidence From Global Adult Tobacco Survey-2 (2016-2017).

BACKGROUND: Worldwide, tobacco use is a serious public health concern affecting the youth. A vast majority of tobacco users start using tobacco well before the age of 18 years which has enormous psychosocial and health effects. OBJECTIVES: To estimate the prevalence of individual forms of tobacco usage among youth aged 15 to 24 years and to assess the association of sociodemographic factors with tobacco use. METHODS: The source of data was a cross-sectional GATS-2 survey in India (analysed using SPSSv17.0) which used a multistage, geographically stratified cluster sampling method. Bivariate analysis was done for evaluation of the possible association of tobacco use with sociodemographic factors. Multivariable logistic regression analysis was conducted to determine the relative strength of association between those factors and tobacco use. RESULTS: There were 13 329 respondents (44.9% males and 55.1% females) aged 15 to 24 years. Overall, 11.9% of respondents were using tobacco. The prevalence of smoke and smokeless tobacco usage was 5% and 10.9%, respectively, whereas 2% of respondents reported dual usage. The odds of using any form of tobacco were significantly higher among respondents aged 20 to 24 years (odds ratio [OR]: 2 [1.76-2.77]) who were primarily residing in rural areas (adjusted odds ratio [aOR]: 1.36 [1.2-1.54]) and were unmarried (aOR: 1.56 [1.37-1.88]). The odds of using any form of tobacco were significantly lower among females (aOR: 0.21 [0.19-0.24]), literate individuals (aOR: 0.33 [0.29-0.37]), and those who were unemployed/students/homemakers (aOR: 0.44 [0.39-0.50]). CONCLUSIONS: The overall tobacco usage of 11.9% among young people in the age group of 15 to 24 years is a matter of concern. The study identified several sociodemographic factors significantly associated with tobacco use, implying the need for designing interventions considering social vulnerabilities of youth.

"YES it's the Perfect Time to Quit": Fueling Tobacco Cessation in India during COVID-19 Pandemic.

Entire world is battling the Novel Coronavirus Disease (COVID-19) pandemic. India too, has undertaken stringent containment measures to combat this disease. The country is in a state of national lockdown, which has inadvertently led more than a quarter of the Indian population to not use tobacco. This paper discusses the opportunity that surfaces with unavailability of tobacco products, and advocates the need for escalation of tobacco cessation services as well as strategic management of stress to stay tobacco-free.

Quit attempts among tobacco users identified in the Tamil Nadu Tobacco Survey of 2015/2016: a 3 year follow-up mixed methods study.

OBJECTIVES: To determine current tobacco use in 2018/2019, quit attempts made and to explore the enablers and barriers in quitting tobacco among tobacco users identified in the Tamil Nadu Tobacco Survey (TNTS) in 2015/2016. SETTING: TNTS was conducted in 2015/2016 throughout the state of Tamil Nadu (TN) in India covering 111 363 individuals. Tobacco prevalence was found to be 5.2% (n=5208). PARTICIPANTS: All tobacco users in 11 districts of TN identified by TNTS (n=2909) were tracked after 3 years by telephone. In-depth interviews (n=26) were conducted in a subsample to understand the enablers and barriers in quitting. PRIMARY AND SECONDARY OUTCOMES: Current tobacco use status, any quit attempt and successful quit rate were the primary outcomes, while barriers and enablers in quitting were considered as secondary outcomes. RESULTS: Among the 2909 tobacco users identified in TNTS 2015/2016, only 724 (24.9%) could be contacted by telephone, of which 555 (76.7%) consented. Of those who consented, 210 (37.8%) were currently not using tobacco (ie, successfully quit) and 337 (60.7%) continued to use any form of tobacco. Of current tobacco users, 115 (34.1%) have never made any attempt to quit and 193 (57.3.8%) have made an attempt to quit. Those using smoking form of tobacco products (adjusted relative risk (aRR)=1.2, 95% CI: 1.1 to 1.4) and exposure to smoke at home (aRR=1.2, 95% CI: 1.1 to 1.3) were found to be positively associated with continued tobacco use (failed or no quit attempt). Support from family and perceived health benefits are key enablers, while peer influence, high dependence and lack of professional help are some of the barriers to quitting. CONCLUSION: Two-thirds of the tobacco users continue to use tobacco in the last 3 years. While tobacco users are well aware of the ill-effects of tobacco, various intrinsic and extrinsic factors play a major role as a facilitator and lack of the same act as a barrier to quit.