Immediate cause and the role of multimorbidity in deaths associated with COVID 19 among hospitalized patients in a low resource district in Kerala India: A record-based case-control analysis.

Introduction: Multimorbidity is the coexistence of two or more chronic medical conditions in a person. The study aims to investigate the immediate cause of death and risk factors of mortality including multimorbidity among patients hospitalized with SARS CoV2 infection in Kasaragod district in Kerala, India. Methods: A record-based case-control study was done using the hospital records and follow-up surveillance system of SARS-COV 2 patients admitted in the Kasaragod district. SARS-COV 2 patients who had expired during the study period from June to December 2020 and reported as COVID-19 deaths (N = 226) were the cases, and an equal number of hospital controls were the study participants. Results: The mean (SD) age of the cases and controls were found to be 64.6 (14.2) years and 61.5 (13.4) years, respectively. Covid pneumonia alone was reported as the cause of death in more than half (52%) of the study participants. This was followed by cardiovascular events (8.5%) and acute kidney injury (6.5%). Among individual comorbidities among people who expired, diabetes mellitus (53%) was the most common, followed by hypertension (46%) and cardiovascular diseases (23%). More than 50% were found to have multimorbidity. Logistic regression showed chronic kidney disease (CKD) (Adjusted odds ratio (AOR) = 2.18 (1.24-3.83)) and malignancy (AOR = 3.05 (1.27-7.32)) to be significantly associated with mortality as individual determinants. Hypertension-diabetes mellitus [AOR = 1.68 (1.02-2.76), P = 0.043] and hypertension-CKD [AOR = 3.49 (1.01-12.01), P = 0.48] dyads were multimorbidities significantly associated with mortality. Conclusion: Combinations of hypertension with diabetes mellitus and CKD were found to be significant determinants for mortality in hospitalized COVID-19 patients. Uniformity in death certification is required to understand the causes and contributors to death in COVID-19.

Association of symptom characteristics and comorbid conditions with viral RNA positivity of Covid-19 patients in Kasaragod district in Kerala, India: A retrospective cohort study.

Background Symptoms of Covid-19 are known to be non-specific ranging from asymptomatic cases to severe illness affecting multiple organ systems. The duration of viral RNA positivity and transmission varies in individuals. We describe the association between symptom characteristics and comorbid conditions with viral RNA positivity of SARSCoV-2 affected individuals. Methods We conducted a record-based retrospective cohort study of 179 patients found to be positive for Covid-19 in Kasaragod district in Kerala. We included details of all patients found positive during the initial phases of the pandemic and recorded details regarding symptoms, duration of viral RNA positivity and the occurrence of transmission. The data were analysed using SPSS. Results Any symptom was present in 68%. Fever (43%) was the most common symptom while 50% had at least one respiratory symptom. Increased duration of viral RNA positivity was found to be associated with presence of comorbid conditions. The majority of individuals who transmitted disease (75%) had some symptom, predominantly a respiratory symptom. Conclusion Respiratory symptoms are seen in half of the patients and viral RNA positivity was for a longer duration in patients with comorbid conditions.

Psychological distress and burnout among healthcare worker during COVID-19 pandemic in India-A cross-sectional study.

BACKGROUND: COVID-19 has inundated the entire world disrupting the lives of millions of people. The pandemic has stressed the healthcare system of India impacting the psychological status and functioning of health care workers. The aim of this study is to determine the burnout levels and factors associated with the risk of psychological distress among healthcare workers (HCW) engaged in the management of COVID 19 in India. METHODS: A cross-sectional study was conducted from 1 September 2020 to 30 November 2020 by telephonic interviews using a web-based Google form. Health facilities and community centres from 12 cities located in 10 states were selected for data collection. Data on socio-demographic and occupation-related variables like age, sex, type of family, income, type of occupation, hours of work and income were obtained was obtained from 967 participants, including doctors, nurses, ambulance drivers, emergency response teams, lab personnel, and others directly involved in COVID 19 patient care. Levels of psychological distress was assessed by the General health Questionnaire -GHQ-5 and levels of burnout was assessed using the ICMR-NIOH Burnout questionnaire. Multivariable logistic regression analysis was performed to identify factors associated with the risk of psychological distress. The third quartile values of the three subscales of burnout viz EE, DP and PA were used to identify burnout profiles of the healthcare workers. RESULTS: Overall, 52.9% of the participants had the risk of psychological distress that needed further evaluation. Risk of psychological distress was significantly associated with longer hours of work (≥ 8 hours a day) (AOR = 2.38, 95% CI(1.66-3.41), income≥20000(AOR = 1.74, 95% CI, (1.16-2.6); screening of COVID-19 patients (AOR = 1.63 95% CI (1.09-2.46), contact tracing (AOR = 2.05, 95% CI (1.1-3.81), High Emotional exhaustion score (EE ≥16) (AOR = 4.41 95% CI (3.14-6.28) and High Depersonalisation score (DP≥7) (AOR = 1.79, 95% CI (1.28-2.51)). About 4.7% of the HCWs were overextended (EE>18); 6.5% were disengaged (DP>8) and 9.7% HCWs were showing signs of burnout (high on all three dimensions). CONCLUSION: The study has identified key factors that could have been likely triggers for psychological distress among healthcare workers who were engaged in management of COVID cases in India. The study also demonstrates the use of GHQ-5 and ICMR-NIOH Burnout questionnaire as important tools to identify persons at risk of psychological distress and occurrence of burnout symptoms respectively. The findings provide useful guide to planning interventions to mitigate mental health problems among HCW in future epidemic/pandemic scenarios in the country.

Quarantine practices and COVID-19 transmission in a low-resource setting: Experience of Kerala, India.

INTRODUCTION: Disease transmission patterns of COVID-19 have shown that masking, social distancing, contact tracing and quarantine measures are important strategies for reducing transmission. The effective implementation of quarantine is determined by the commitment of the people and monitoring by the State. The aim of the study was to find out the effectiveness of home quarantine practises and its role in determining SARS CoV2 transmission. METHODS: Record-based retrospective cohort study was conducted among expatriates of Kerala who were on quarantine at their homes and later tested positive for SARS -CoV-2. Quarantine practises were categorised as strict room quarantine, incomplete room quarantine, home quarantine and no quarantine. Risk of transmission was assessed using risk ratios. Multiple logistic regression analysis was performed to find out the determinants of SARS CoV2 transmission. RESULTS: The median (IQR) age and duration of quarantine of 95 study participants were found to be 35 (29, 44) years and 7 (3,13) days, respectively. Majority of the participants practised strict room quarantine (57%), whereas 11.6%, 16.8% and 14.7% practiced incomplete room, home and no quarantine, respectively. Home quarantine without room quarantine had 24 times odds for transmitting disease [OR (95%CI)): 24.14 (4.87--119.75), P < 0.001] and not being in quarantine for any duration before being diagnosed was found to be 14 times riskier when compared with strict room quarantine [OR (95%CI)): 14.44 (2.42-86.17), P = 0.003]. DISCUSSION: Low-resource settings successful in the initial phases of COVID-19 pandemic should make periodic revisions in the quarantine guidelines while continually promoting physical distancing strategies.