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.

Region-specific improvisation on WHO case definition and environmental risk factors associated with dengue: a case-control analysis from Kerala, India.

BACKGROUND: Region-specific variations may occur in symptomatic manifestations that need to be addressed by dynamic case definitions. Environmental risk factors for dengue also vary widely across geographic settings. Our aim was to study the test positivity rate of the World Health Organization (WHO) 2009 probable dengue case definition and to suggest region-specific improvisations to it. The study also analyses the sociodemographic and environmental risk factors of dengue fever in South Kerala, India. METHODS: A case-control study was conducted in South Kerala from 2017 to 2019. Dengue reverse transcription polymerase chain reaction (RT-PCR)-positive and RT-PCR-negative 'probable dengue' patients were compared to identify significant symptoms for a modified definition of dengue. A group of afebrile community controls was compared with RT-PCR-positive dengue cases to study the environmental and behavioural risk factors. RESULTS: Arthralgia, palmar erythema and rashes have high discriminatory power (odds ratio [OR] >3) for identifying dengue. Redness of eyes, altered consciousness, abdominal distension and chills were found to moderately discriminate (OR 2-3) dengue. The adjusted analysis showed the presence of mosquito breeding sites (indoor p=0.02, outdoor p=0.03), solid waste dumping (p<0.001) and open water drainage in the compound (p=0.007) as significant predictors. CONCLUSIONS: Regional modifications should be considered when using the WHO definition in endemic settings. Control of mosquito breeding at the household level is the key towards dengue prevention.

Mucormycosis in COVID-19 patients: predisposing factors, prevention and management.

India is considered the diabetes capital of the world and has the highest burden of mucormycosis. Bacterial, viral and fungal co-infections are increasingly being reported in severe acute respiratory syndrome virus 2 (SARSCoV-2) infected patients. India is one of the worst affected countries during the second wave of the COVID-19 pandemic. This combination of diabetes mellitus, COVID-19 and mucormycosis has led to the drastic upsurge of COVID-19-associated mucormycosis (CAM) in India. Immunosuppression, iron disequilibrium, endothelial injury, ketoacidosis and hypoxia are some of the other COVID-19-related risk factors for CAM. There has been an increase in the proportion of mucormycosis affecting paranasal sinuses and central nervous system (CNS) in CAM compared to pre-COVID-19 literature due to the SARSCoV-2-related pathophysiological mechanisms, complications and treatment strategies. CAM is a medical and surgical emergency, and it can present with non-specific symptoms and signs initially resulting in diagnostic delay. High index of suspicion and regular screening for features of CAM are of paramount importance to prevent lethal consequences. Rapid action with a tripod approach consisting of withdrawal of immunomodulators, early antifungal therapy and extensive surgical debridement is considered the best possible treatment model. We review the published data to give a detailed account of the predisposing factors and their mechanisms, diagnostic work-up, treatment modalities and prevention strategies of CAM with special emphasis on CNS mucormycosis.

Strategies and challenges in Kerala's response to the initial phase of COVID-19 pandemic: a qualitative descriptive study.

OBJECTIVE: To understand the structures and strategies that helped Kerala in fighting the COVID-19 pandemic, the challenges faced by the state and how it was tackled. DESIGN: Qualitative descriptive study using focus group discussions and in-depth interviews. SETTING: State of Kerala, India. PARTICIPANTS: 29 participants: four focus group discussions and eight in-depth interviews. Participants were chosen purposively based on their involvement in decision-making and implementation of COVID-19 control activities, from the department of health and family welfare, police, revenue, local self-government and community-based organisations. Districts, panchayats (local bodies) and primary health centres (PHCs) were selected based on epidemiological features of the area like the intensity of disease transmission and preventive/containment activities carried out in that particular area to capture the wide range of activities undertaken in the state. RESULTS: The study identified five major themes that can inform best practices viz social capital, robust public health system, participation and volunteerism, health system preparedness, and challenges. This study was a real-time exploration of the intricacies of COVID-19 management in a low/middle-income country and the model can serve as an example for other states and nations to emulate or adjust accordingly. CONCLUSION: The study shows the impact of synergy of these themes towards more effective solutions; however, further research is much needed in examining the relationship between these factors and their relevance in policy decisions.

Social, health system and clinical determinants of fever mortality during an outbreak of dengue fever in Kerala, India.

BACKGROUND AND OBJECTIVES: The morbidity and mortality spectrum of the south Indian state of Kerala is dominated by chronic non-communicable diseases, yet febrile illnesses because of neglected tropical diseases and emerging viral infections are often reported. As fever deaths are mostly avoidable, understanding the determinants of mortality is essential for implementing preventive measures. METHODS: A case-control study was done during an ongoing dengue outbreak in Thiruvananthapuram district, Kerala during 2017-18. Cases included all fever deaths from the line list of Integrated Disease Surveillance Program (IDSP). Data were obtained from hospital case records and by interviewing patients or care givers. The theoretical model for determinants of mortality was constructed at three levels namely sociodemographic factors, access to health care and health seeking behavior, and clinical determinants. RESULTS: This study confirmed association of mortality with age above 40 years (P = 0.010, OR = 3.48), being heavy built (P = 0.029, OR = 13.25), clinical symptoms of breathlessness (P < 0.001, OR = 24.89), restlessness (P < 0.001, OR = 97.26), clinical signs of drowsiness (P = 0.024, OR = 7.97), hypotension (P < 0.001, OR = 42.22), complications such as ARDS (P = 0.047, OR = 171.56), and myocarditis (P = 0.012, OR = 16.59). A low occupation status of semiskilled work or less (P = 0.012, OR = 0.30), choosing a nearby hospital for treatment (P = 0.018, OR = 0.48) and shortening the time gap between onset of symptom and final diagnosis (P = 0.044, OR = 0.72) was found to be protective. CONCLUSION: Along with biological and clinical factors, distal determinants like social factors, health seeking behavior, and health system factors are associated with fever mortality.