A Quality Improvement Initiative to Reduce Prescription Error in a Pediatrics Outpatient Department at a Secondary-Level Community Hospital.

Background Medication errors are common, especially by new trainees in primary care settings. Our study aimed at reducing the rate of prescription error in the pediatric outpatient department (OPD) of a secondary healthcare center in suburban north India using a quality improvement methodology. Methods Based on a survey and focused group discussion (FGD) involving all stakeholders, the identified problems and difficulties faced during outpatient prescriptions, interventions, and outcome parameters were drafted. The primary outcome measure was the prescription error rate evaluated by a senior resident (SR) of pediatrics, and the secondary outcome measures included the frequency of antibiotic prescriptions and investigations. Intervention Two cycles of Plan-Do-Study-Act (PDSA) were conducted on accessible drug formularies and standard treatment protocols for common pediatric conditions. Results The mean baseline prescription error was 72.2% (95% confidence interval (CI): 63.2-81.1). After the implementation of the first PDSA cycle, the mean error rate was 46.5% (95% CI: 36.6-56.5). There were eight consecutive points of prescription error below the control limit (63.2% and 81.1%) of the baseline. The PDSA-2 cycle showed the same shift to below the control limit (36.6% and 56.5%). The mean error rate found at the end of the PDSA-2 cycle was 22.5% (95% CI 15.7-29.5). There was no clinically significant difference in the number of investigations or antibiotics prescribed. Conclusion The application of standardized drug formularies and standard treatment protocols (STPs) can help reduce prescription errors, especially in a primary care setting. Expansion of such techniques to other centers could be particularly useful.

Long-Term Kinetics of SARS-CoV-2 Neutralizing and Anti-Receptor Binding Domain Antibodies among Laboratory-Confirmed COVID-19 Cases in Delhi National Capital Region, India: A Prospective, One-Year Follow-Up Study.

Background: This study was conducted with the objective of measuring the neutralizing and anti-receptor binding domain antibody levels against SARS-CoV-2 among laboratory-confirmed COVID-19 cases and exploring its long-term kinetics over a period of 1 year. Methods: One hundred laboratory-confirmed COVID-19 cases were recruited. Serum samples of the participants were collected within three months from the date of the positive COVID-19 report. The participants were prospectively followed up every three months for symptoms and the collection of blood samples for three additional rounds. The presence of anti-SARS-CoV-2 antibodies (IgA, IgG, and IgM antibodies), anti-receptor binding domain antibodies (anti-RBD), and neutralizing antibodies were measured. Findings: Median plaque reduction neutralization test (PRNT) titers showed a rising trend in the first three rounds of follow-up. The quantitative anti-receptor binding domain ELISA (QRBD) values showed a declining trend in the initial three rounds. However, both the PRNT titers and QRBD values showed significantly higher values for the fourth round of follow-up. Total antibody (WANTAI) levels showed an increasing trend in the initial three rounds (statistically significant). Interpretation: Neutralizing antibodies showed an increasing trend. The anti-receptor binding domain antibodies showed a decreasing trend. Neutralizing antibodies and anti-RBD antibodies persisted in the majority.

Anti-SARS-CoV-2 antibody kinetics up to 6 months of follow-up: Result from a nation-wide population-based, age stratified sero-epidemiological prospective cohort study in India.

Repeated serological testing tells about the change in the overall infection in a community. This study aimed to evaluate changes in antibody prevalence and kinetics in a closed cohort over six months in different sub-populations in India. The study included 10,000 participants from rural and urban areas in five states and measured SARS-CoV-2 antibodies in serum in three follow-up rounds. The overall seroprevalence increased from 73.9% in round one to 90.7% in round two and 92.9% in round three. Among seropositive rural participants in round one, 98.2% remained positive in round two, and this percentage remained stable in urban and tribal areas in round three. The results showed high antibody prevalence that increased over time and was not different based on area, age group, or sex. Vaccinated individuals had higher antibody prevalence, and nearly all participants had antibody positivity for up to six months.

Cell-Mediated Immunity (CMI) for SARS-CoV-2 Infection Among the General Population of North India: A Cross-Sectional Analysis From a Sub-sample of a Large Sero-Epidemiological Study.

Background Cell-mediated immunity (CMI), or specifically T-cell-mediated immunity, is proven to remain largely preserved against the variants of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), including Omicron. The persistence of cell-mediated immune response in individuals longitudinally followed up for an extended period remains largely unelucidated. To address this, the current study was planned to study whether the effect of cell-mediated immunity persists after an extended period of convalescence or vaccination. Methods Whole blood specimens of 150 selected participants were collected and tested for Anti-SARS-CoV-2 Interferon-gamma (IFN-γ) response. Ex vivo SARS-CoV-2-specific interferon-gamma Enzyme-linked Immunospot (IFN-γ ELISpot) assay was carried out to determine the levels of virus-specific IFN-γ producing cells in individual samples. Findings Out of all the samples tested for anti-SARS-CoV-2 T-cell-mediated IFN-γ response, 78.4% of samples were positive. The median (interquartile range) spots forming units (SFU) per million levels of SARS-CoV-2-specific IFN-γ producing cells of the vaccinated and diagnosed participants was 336 (138-474) while those who were vaccinated but did not have the disease diagnosis was 18 (0-102); the difference between the groups was statistically significant. Since almost all the participants were vaccinated, a similar pattern of significance was observed when the diagnosed and the never-diagnosed participants were compared, irrespective of their vaccination status. Interpretations Cell-mediated immunity against SARS-CoV-2 persisted, irrespective of age and sex of the participant, for more than six months of previous exposure. Participants who had a history of diagnosed COVID-19 infection had better T-cell response compared to those who had never been diagnosed, in spite of being vaccinated.

Effect of Structured Yoga Program on Stress and Well-being Among Frontline Healthcare Workers During COVID-19 Pandemic.

CONTEXT: Frontline healthcare workers are at risk of developing psychological distress during a pandemic. Yoga, a form of mind-body medicine can reduce body stress and increases well-being. AIMS: To assess the effect of yoga on the stress and well-being of healthcare workers during the COVID-19 pandemic. SETTINGS AND DESIGN: This single-arm pre-post study was conducted among frontline health workers (support staff, paramedics, and medics) posted at a secondary care hospital in a North Indian district. METHODS AND MATERIALS: Basic demographic details, blood pressure, anthropometric variables like height, weight, and biochemical variables like glycosylated hemoglobin (Hb1Ac), fasting and post-prandial blood sugar, lipid profile, serum cortisol, and C-reactive protein were measured. Stress levels were assessed using the depression anxiety and stress scale (DASS)-21 while well-being was assessed using the World Health Organization (WHO)-5 well-being scale. Twelve weeks of supervised yoga session was provided for 1 hour per session, 3 times per week. STATISTICAL ANALYSIS: The mean value was compared from baseline to post-intervention with paired t-test/Wilcoxon signed rank test. RESULT: A total of 89 participants were enrolled, 53 (59.5%) being male. Two-thirds of the participants were aged 20-39 years. During follow-up, 80 participants completed 12 weeks of yoga sessions. Post-intervention DASS-21 score decreased and WHO-5 increased significantly. The glycosylated hemoglobin (HbA1c) level and cholesterol-HDL ratio decreased significantly. Other variables didn't change significantly. No adverse effects were reported by the participants. CONCLUSION: Supervised structured yoga sessions helped decrease stress, depression, and anxiety and improved well-being. Therefore, it can be a feasible strategy to manage workplace-related stress and phycological morbidities.

Prevalence of Anemia Among the Elderly in India: Evidence From a Systematic Review and Meta-Analysis of Cross-Sectional Studies.

Anemia is a leading cause of increased morbidity and mortality among the elderly population. In spite of numerous interventions and strategies rolled out to tackle the growing burden of anemia, lesser importance is being given to this age group. There is a lack of data on the national level burden of anemia among elderly persons (≥ 60 years) in India. We aimed at estimating the prevalence of anemia among elderly persons (≥ 60 years) in India by conducting a systematic review and meta-analysis. We searched PubMed, Embase, Cochrane Library, Google Scholar, and IndMed, and included cross-sectional studies reporting data on the prevalence of anemia among elderly persons in India and used random effects model to estimate pooled point prevalence with 95% confidence interval (CI), To explore the heterogeneity further, we did sub-group analyses based on zonal divisions of India (region), rural or urban, study setting, method of hemoglobin estimation and sampling strategy. Out of 22 studies, one study was of high quality of bias, 11 of moderate, and 10 were of low quality of bias. The pooled estimate of anemia was 68.3% (95%CI: 60.7 to 75.9), I2 = 99.0%, and Q=2079.2 (p-value <0.001). The pooled prevalence of anemia among the elderly in India was found to be high and necessary actions need to be taken at the policy level to achieve "active and healthy ageing".

A Time and Motion Study of Community Health Workers in Rural Area of Ballabgarh, Haryana.

Introduction: Health workforce is the important pillar of health system in India. Efficient utilization of scarce community-level human resources in health care is critical to ensure optimum care in a community. Objective: To describe the time utilization pattern of health workers (HWs) during field activity at the primary healthcare level and to study the facilitators and barriers in efficient time utilization. Methods: A mixed-method study with a time and motion approach was carried out in the rural areas of Ballabgarh block of Haryana. Time and motion approach was continuous, direct, synchronous and both active and passive method of time logging was adapted. Electronic Geo-Positioning System based mobile, timestamp application and the digital stopwatch were used to capture time utilization. The quality of the data collected in the daily work plan during the household (HH) visits was assessed using semi-structured interview schedule. In-depth interview with the HWs was carried out to understand the facilitating factors and barriers in their efficient functioning. Results: Proportion of HH s covered in data collection for time and motion patterns was 36% out of the total number of HH s in the SCs. The completeness of work plan was 74.8%. The average number of HHs covered per day by an HW was 38. Mean (standard deviation [SD]) time duration spent in each HH in completing the work plan was 2.9 (0.8) minutes. Mean (SD) total distance travelled by HW per day was 1845.1 (974.2) metres. Mean (SD) time duration spent idle in the field was 22.7 (13.0) minutes. Proportion of effective time utilised in the field was 54.3%. Several enabling factors and barriers were identified at personal, community, and health system level. Conclusion: Only half of the allotted time was effectively utilized by the HWs for house visit in the community. Planning the beat schedule as per the feasibility and ensuring quality of HH visits using information technology is critical for providing primary healthcare at village level.

Test concordance and diagnostic accuracy of three serological assays for detection of anti-SARS-CoV-2 antibody: result from a population-based sero-epidemiological study in Delhi.

BACKGROUND: Several methodological tests are available to detect SARS-CoV-2 antibody. Tests are mostly used in the aid of diagnosis or for serological assessment. No tests are fully confirmatory and have variable level of diagnostic ability. We aimed at assessing agreement with three serological tests: quantitative anti receptor binding domain ELISA (Q-RBD), qualitative ELISA (WANTAI SARS-CoV-2 Ab) and qualitative chemiluminescence assay (CLIA). METHODS: This study was a part of a large population based sero-epidemiological cohort study. Participants aged 1 year or older were included from 25 randomly selected clusters each in Delhi urban (urban resettlement colony of South Delhi district) and Delhi rural (villages in Faridabad district, Haryana). Three type of tests were applied to all the baseline blood samples. Result of the three tests were evaluated by estimating the total agreement and kappa value. RESULTS: Total 3491 blood samples collected from March to September, 2021, out of which 1700 (48.7%) from urban and 1791 (51.3%) from rural. Overall 44.1% of participants were male. The proportion of sero-positivity were 78.1%, 75.2% and 31.8% by Wantai, QRBD and CLIA tests respectively. The total agreement between Wantai and QRBD was 94.5%, 53.1% between Wantai and CLIA, and 56.8% between QRBD and CLIA. The kappa value between these three tests were 0.84 (95% CI 0.80-0.87), 0.22 (95% CI 0.19-0.24) and 0.26 (95% CI 0.23-0.28). CONCLUSIONS: There was strong concordance between Wantai and QRBD test. Agreement between CLIA with other two tests was low. Wantai and QRBD tests measuring the antibody to same S protein can be used with high agreement based on the relevant scenario.

A qualitative study regarding menstrual hygiene in a rural community of Haryana, India.

INTRODUCTION: Adolescent girls face challenges in menstrual hygiene in routine patterns which impacts their education and health. A qualitative study was undertaken to assess the knowledge and practices regarding menstruation in a rural community of Haryana and to identify the barriers to menstrual hygiene. METHODOLOGY: The study was conducted in the month of September 2019 among various stakeholders i.e. adolescent females, adolescent males, Accredited Social Health Activist (ASHA) workers, Anganwadi workers, school teachers and Medical Officers. The stakeholders were mapped with the help of a Multi-Purpose Health Worker and ASHA of the village. Interview guides for focus group discussion (FGD) and in-depth interview (IDI) were prepared from previous literature to understand menstrual health management among the stakeholders. RESULTS: After IDI and FGD, we found that there is a barrier to accessibility of regular sanitary pads, a lack of education on menstrual hygiene among adolescent girls. School absenteeism was a concern due to the unavailability of mechanisms for the disposal of sanitary pads in school and poor maintenance of toilets. CONCLUSION: Proper implementation of the Adolescent Reproductive Sexual Health program and Menstrual health education can improve the use and reduce stigma and ignorance. Free uninterrupted supply of sanitary pads through school and Anganwadi will help improving accessibility and separate toilets for girls would lead to a reduction in absenteeism.

Serological prevalence of SARS-CoV-2 antibody among children and young age group (between 2 and 17 years) in India: An interim result from a large multicentric population-based seroepidemiological study.

Background: Estimating seroepidemiolgical prevalence of SARS-CoV-2 antibody is an essential public health strategy. There is insufficient evidence of prevalence among those belonging to young age population in India. Objective: To compare the SARS-CoV-2 seropositivity rate between children and adults in selected sites from India. Materials and Methods: This was a multicentric population-based seroepidemiological study conducted in selected urban and rural areas of five sites selected from four states (Delhi, Odisha, Uttar Pradesh, Tripura) of India. Participants aged ≥1 year were included from different clusters of each area. Total serum antibody against SARS-CoV-2 virus was assessed qualitatively by using a standard enzyme-linked immunosorbent assay (ELISA) kit. Results: Data collection period was from 15 March 2021 to 10 June 2021. Total available data was of 4509 participants, of whom 700 were <18 years of age and 3809 were ≥18 years of age. The site-wise number of available data among those aged 2-17 years was 92, 189, 165, 146 and 108 for the sites of Delhi urban, Delhi rural, Bhubaneswar rural, Gorakhpur rural and Agartala rural area, respectively. The seroprevalence was 55.7% in the <18 years age group and 63.5% in the ≥18 years age group. The prevalence among female children was 58% and among male children was 53%. Conclusion: SARS-CoV-2 seropositivity rate among children was high and comparable to that of the adult population. Hence, it is unlikely that any future third wave by prevailing SARS-CoV-2 variant would disproportionately infect children 2 years or older.

Antibody Response to SARS-CoV-2 among COVID-19 Confirmed Cases and Correlates with Neutralizing Assay in a Subgroup of Patients in Delhi National Capital Region, India.

Background: The plaque reduction neutralization test (PRNT) is the gold standard to detect the neutralizing capacity of serum antibodies. Neutralizing antibodies confer protection against further infection. The present study measured the antibody level against SARS-CoV-2 among laboratory-confirmed COVID-19 cases and evaluated whether the presence of anti-SARS-CoV-2 antibodies indicates virus neutralizing capacity. Methods: One hundred COVID-19 confirmed cases were recruited. Their sociodemographic details and history of COVID-19 vaccination, contact with positive COVID-19 cases, and symptoms were ascertained using a self-developed semi-structured interview schedule. Serum samples of the participants were collected within three months from the date of the positive report of COVID-19. The presence of anti-SARS-CoV-2 antibodies (IgA, IgG and IgM antibodies), receptor binding domain antibodies (anti-RBD), and neutralizing antibodies were measured. Findings: Almost all the participants had anti-SARS-CoV-2 antibodies (IgA, IgG and IgM) (99%) and anti-RBD IgG antibodies (97%). However, only 69% had neutralizing antibodies against SARS-CoV-2. Anti-RBD antibody levels were significantly higher among participants having neutralizing antibodies compared with those who did not. Interpretation: The present study highlights that the presence of antibodies against SARS-CoV-2, or the presence of anti-RBD antibodies does not necessarily imply the presence of neutralizing antibodies.

Gestational Diabetes Mellitus Among Pregnant Women Attending Ante-natal Clinic at a Secondary Care Health Facility in Haryana, India.

INTRODUCTION: Gestational diabetes has serious health effects during pregnancy and childbirth. We estimated the occurrence of gestational diabetes mellitus (GDM) among pregnant women in a secondary care hospital in Haryana. METHODS: It was a hospital-based cross-sectional study, done in an ante-natal clinic (ANC) at a sub-district hospital (SDH), Faridabad district of Haryana, India. Eligible pregnant women attending the ANC clinic were recruited. An oral glucose tolerance test (OGTT) with 75 g of glucose was done with a collection of blood for fasting blood sugar (FBS) and two-hour post-OGTT blood glucose. A pre-tested semi-structured interview schedule was administered. Both the modified International Association of the Diabetes and Pregnancy Study Groups criteria (IADPSGC) and the Diabetes in Pregnancy Study Group of India (DIPSI) criteria were used. Data were presented as percentages, means, standard deviation, and 95% confidence interval (CI). Bi-variable and multi-variable logistic regressions were done. The level of significance was set at 0.05. RESULTS: Of the 623 eligible participants, 66.1% were within the 20-25 age group. The GDM was found in 14.1% (95%CI: 11.5-17.1) participants as per modified IADPSG criteria and 6.7% (95%CI: 4.9-9.0) participants as per DIPSI criteria, respectively. Increasing age [adjusted odds ratio (AOR): 1.24 (95% CI: 1.05-1.47), p=0.008] and increasing years of schooling [AOR: 1.19 (1.01-1.41), p=0.032] were significantly associated with GDM by DIPSI criteria. Family history of DM was also found to have an increased odds with GDM using modified IADPSG criteria [AOR 2.87 (95% CI: 1.09-7.54), p=0.032].  Conclusion: Considerable proportion of pregnant women were found to have GDM in a Sub-district hospital at Ballabgarh in north India. The study highlighted the need and generated evidence about the feasibility of GDM screening utilizing routine staff in a secondary care facility.

Effect of Structured Yoga Program on Stress and Professional Quality of Life Among Nursing Staff in a Tertiary Care Hospital of Delhi-A Small Scale Phase-II Trial.

BACKGROUND: Nursing staff suffer from various level of stress and burnout. We aimed to assess the effect of 12 weeks of structured yoga on stress and the professional quality of life among nursing staff. DESIGN AND METHOD: An open-label, phase-II randomized clinical trial was undertaken considering a sample size of convenience was done. In service nursing staff were randomized (1:1) to intervention group and wait-list control group. Primary outcome was perceived stress which was measured by Perceived Stress Scale (PSS). Secondary measures were professional quality measured by Professional Quality of Life (ProQOL) scale, blood pressure, serum cortisol, and high-sensitive C-reactive protein. Both the per-protocol and intention to treat analysis was done. RESULTS: Total 113 participants were allocated to intervention group (n = 58, mean = 35 years, SD = 7.9 years) and wait-list control group (n = 55, mean = 32.5 years, SD = 6.8 years). After 12 weeks, 19 participants of intervention group and 32 participants of wait-list control group were included in the per-protocol analysis. Follow-up mean PSS score was 15.4 (95% CI 12.6-18.2, SD 5.8) in intervention group, 20.7 (95% CI 19.7-21.7, SD 2.8) in wait-list control group (p-value < 0.0001). The other parameters didn't differ between the groups and from baseline to end line too. CONCLUSIONS AND RELEVANCE: The finding showed supervised structured yoga may be efficacious to reduce stress. Studies with larger sample size are needed to confirm the findings. TRIAL REGISTRATION: It was approved by the Institute Ethics Committee (Reference no: IECPG-543/20.12.2017, RT-57/31.01.2018) and was registered prospectively in the Clinical Trial Registry of India prospectively (No. CTRI/2018/02/012206).

Effect of Community-Based Structured Yoga Program on Hba1c Level among Type 2 Diabetes Mellitus Patients: An Interventional Study.

CONTEXT: In view of the rising burden of type 2 diabetes mellitus (DM) cases in India, there is an urgent need for an effective, low-cost, sustainable intervention controlling diabetes thus preventing complications. AIMS: This study aimed to assess the effect of structured yoga programs on diabetes. SUBJECTS AND METHODS: This was a community-based interventional study that was conducted in an urban resettlement colony of Delhi, India. Known diabetes patients with glycated hemoglobin (Hb1Ac) ≥6.5% were enrolled from 12 randomly selected blocks of the community with a sample size of 192 in each intervention and wait-listed control arm. The intervention was structured yoga of 50 min daily, 2 consecutive weeks in a nearby park and health center followed by twice a week home practice up to the 3rd month. The primary outcome measure was HbA1c% and secondary outcome measures were lipid profile and fasting blood glucose. STATISTICAL ANALYSIS USED: Aper-protocol analysis was done. Mean, standard deviation (SD), and 95% confidence interval were estimated. The level of significance was considered for 0.05. RESULTS: There was a significant decrease of Hb1Ac (0.5%, SD = 1.5, P = 0.02), total cholesterol (11.7 mg/dl, SD = 40.5, P < 0.01), and low-density lipoprotein (3.2 mg/dl, SD = 37.4, P < 0.01) from baseline to end line in the intervention group. These changes in intervention group were also significantly different from the change in the wait-listed control group. The other variables did not change significantly. CONCLUSIONS: It revealed that structured yoga program improved glycemic outcome and lipid profile of individuals in a community-based setting. Yoga can be a feasible strategy to control hyperglycemia, lipid levels, and can help better control type 2 DM.