Determinants of depression in Indian tribal adults: Evidence from the Longitudinal Ageing Study in India Wave-I survey.

BACKGROUND OBJECTIVES: The tribal populations are vulnerable to mental health issues owing to various reasons. However, limited research has been conducted to assess depression and related determinants among tribal adults aged ≥45 yr (45 years and older). The present study aimed to assess the prevalence and sociodemographic and health determinants of depressive symptoms among the scheduled tribe (ST) population aged ≥45 yr in India. METHODS: The present study analyzed the Wave I data of the Longitudinal Ageing Study in India conducted between April 2017 to December 2018. The outcome variables in the present study were self-reported depressive symptoms. Two internationally recognised tools, the Centre for Epidemiologic Studies Depression scale (CES-D) and Composite International Diagnostic Interview-Short Form (CIDI-SF), were used to obtain the data, however, only the CES-D data are utilized in this study. The present study focused on 12,215 ST individuals aged ≥45 yr from whom information about depressive symptoms was collected and analyzed. RESULTS: Nearly 25 per cent ST population aged 45 yr or older experienced depressive symptoms. The likelihood of experiencing depressive symptoms among the ST population aged ≥45 yr was negatively associated with 10 or more years of education and living with children and others and positively associated with experiencing multiple morbidity conditions. INTERPRETATION CONCLUSIONS: Given the substantial burden of depression among the adult ST population, the present study lays emphasis on raising the awareness about depressive symptoms and strengthen the availability of mental health services among the ST community through intensive campaigns and engagement of ST individuals along with other key stakeholders. Higher education, living with spouse and children and a physically active lifestyle can play a crucial role in limiting depressive symptoms among the tribal adults (≥45 yr). It is paramount to regularly screen depressive symptoms and conduct more microlevel studies to evaluate socioeconomic and health determinants of depressive symptoms among ST communities living in different geographic regions.

Epidemiological investigation of viral hepatitis E outbreak in two colocated training centers.

Background: A high number of jaundice cases were reported from two colocated training centers in North India. This outbreak was investigated to describe the epidemiology, identify risk factors, and recommend preventive and control measures. Methods: Initial line list was prepared, and case definition was defined as "the presence of icterus or passage of yellow-colored urine with fever/anorexia/vomiting/abdominal pain in a resident of Military Station A between 03/04/2016 to 06/06/2016". Case search was conducted through surveillance. An unmatched 1:1 case-control study was conducted to evaluate the associated risk factors. All cases were tested for hepatitis markers. Environmental investigation of food and water sources was conducted to identify the source of infection. Results: Of 172 cases, all were males from two co-located military training centers (attack rate, 4.7%). Clinical features included icterus (100%), yellowish discoloration of urine (98.9%), anorexia (97.22%), fever (80%), nausea/vomiting (56%), and abdominal pain (52.77%). Only one case (0.6%) had complication of fulminant hepatitis, and there were no deaths (CFR = 0%). Consumption of juice with ice from juice shops was significantly associated with illness (Odds Ratio-14.3 [95%CI 7.4-27.6]). Of 172 cases, 167 (97.1%) tested anti-HEV-IgM positive. Juice shops in training centers were using ice made from contaminated water with positive coliform test. All other water samples tested satisfactory. No cross-contamination of water pipelines with sewage was observed. Conclusion: Epidemiological evidence concludes that a large viral hepatitis E outbreak was likely caused by consumption of juice with contaminated ice. Early stoppage of contaminated ice usage led to timely control of the outbreak.

Improved detection of Shigella using Escherichia coli medium enrichment: Polymerase chain reaction from stool samples.

Laboratory diagnosis of shigellosis using conventional culture technique is limited by lower sensitivity and higher turnaround time. Here, we have evaluated the role of polymerase chain reaction from stool samples after enrichment in Escherichia coli medium for detection of Shigellae. The technique not only increased the sensitivity but also decreased the turnaround time.

The 2002 Chandigarh cholera outbreak revisited: utility of MALDI-TOF as a molecular epidemiology tool.

UNLABELLED: In July 2002, an outbreak of cholera occurred in north India with two separate geographical foci. Pulsed field gel electrophoresis (PFGE) was previously used in typing a representative sample of these isolates. This study evaluates the usefulness of MALDI-TOF as an epidemiological tool for typing Vibrio cholerae isolates in comparison with PFGE and Amplified fragment length polymorphisms (AFLP). Forty-six isolates of V. cholerae isolated from stool of patients affected in the July 2002 outbreak were typed using MALDI-TOF. To validate its utility, clinical and environmental isolates previously characterized by PFGE and AFLP were included for dendrogram analysis. All 46 isolates were correctly identified by MALDI-TOF to species level. Two distinct clades appeared on dendrogram using MALDI-TOF corresponding to the two geographical foci of the outbreak. For the study of evolution of organisms from environment, AFLP was superior as it clearly demarcated clinical and environmental isolates. The outbreak was not due to a single clone but due to multiple clones circulating simultaneously, as was seen with PFGE also. SIGNIFICANCE AND IMPACT OF THE STUDY: MALDI-TOF appears to be a highly discriminatory, cost-effective and rapid epidemiological typing technique that can be used in the investigation of cholera outbreaks.

Free living amoebae in water sources of critical units in a tertiary care hospital in India.

BACKGROUND: Isolation of free-living amoebae (FLA) is reported sparsely from water taps, ventilators, air conditioners, haemodialysis units and dental irrigation systems of hospitals worldwide. Their prevalence in hospital environment especially in wards having immunocompromised patients may pose a risk to this group of susceptible population as they may cause disease themselves or may carry pathogens inside them. No study from India has performed such surveillance. OBJECTIVE: To evaluate extent of FLA contamination in water sources of bone marrow transplant (BMT) intensive care unit (ICU), transplant ICU, haemodialysis unit and high dependency unit in a tertiary care hospital in India. MATERIALS AND METHODS: A total of hundred samples including fifty each of tap water samples and swabs from mouth of taps used for drinking, bathing and hand washing purposes in these units were collected according to standard procedure. Samples were inoculated onto non-nutrient agar plates at room temperature followed by morphological confirmation. Molecular identification including polymerase chain reaction (PCR) and sequencing was performed in culture positive samples. RESULTS: Four tap water samples and ten swab samples showed growth of trophozoites and cyst formation. Morphologically, four amoebae resembled Acanthamoeba spp. which was further confirmed by PCR and sequencing showed them to be of T3 and T4 genotypes. CONCLUSION: The presence of these FLA in hospital water sources emphasises the urgent need of implementing effective preventive measures. Further studies are required to estimate the true prevalence of FLA in Indian hospitals by taking larger number of samples.

Utility of whole-cell repetitive extragenic palindromic sequence-based PCR (REP-PCR) for the rapid detection of nosocomial outbreaks of multidrug resistant organisms: experience at a tertiary care center in North India.

BACKGROUND: There is a huge need to develop molecular typing methods which are simple to perform, rapid and cost effective to confirm clonality of nosocomial isolates in outbreak situations. OBJECTIVES: The aim of the study was to investigate a hospital outbreak of multi-drug resistant (MDR) Klebsiellapneumoniae septicemia in a paediatric surgery intensive care unit (PSICU) using a repetitive extragenic palindromic polymerase chain reaction (REP-PCR). MATERIALS AND METHODS: MDR Klebsiella pneumoniae isolates from an outbreak of nosocomial sepsis were typed byREP-PCR using consensus primers. Isolates from different intensive care units (ICUs) but with similar antibiogram were also genotyped for comparison. RESULTS AND CONCLUSION: A cluster of twelve MDR K Pneumoniae septicemia cases was identified at the PSICU by genotyping using REP-PCR. Surveillance cultures failed to pick up any source of infection. REP-PCR was found to be a rapid and simple tool for investigation outbreaks in hospitals. Due to early detection we could initiate infection control practices with focus on hand washing and prevent the further transmission of the organism.

Pyonephrosis due to Chryseobacterium gleum: a first case report.

Chryseobacterium spp are widely distributed in nature but data of their isolation from clinical samples is scanty. Here, we report the first case of AmpC producing C. gleum causing pyonephrosis in a patient having bilateral nephrolithiasis on double J (DJ) stent. The present isolate was resistant to vancomycin, erythromycin, clindamycin, carbapenems and ciprofloxacin and susceptible to tetracycline and minocycline. The patient was treated with tetracycline and recovered without the need for removal of the DJ stent. The environmental surveillance carried out to trace the nosocomial origin of the isolate was negative. Since antimicrobial susceptibility of this isolate is different from previous reports, we emphasise that in vitro susceptibility testing should be sought to choose optimal antimicrobial agents for these Nonfermentative Gram-Negative Bacilli (NFGNBs) with different susceptibility patterns.

Mandatory public reporting of healthcare-associated infections in developed countries: how can developing countries follow?

The threat posed by increased transmission of drug-resistant pathogens within healthcare settings and from healthcare settings to the community is very real and alarming. Although the developed world has taken strong steps to curb this menace, there has been little pressure on developing countries to take any corrective action. If the reporting of alarming rates of healthcare-associated infections (HCAIs) from hospitals in India and many other developing countries was made mandatory, it would help to force stakeholders (e.g. healthcare workers, legislators, administrators and policy makers in hospitals) to acknowledge and tackle the problem. This would introduce quality control in a long neglected area of health care, and enable patient empowerment which is practically non-existent in India. Healthcare institutions should commit towards enforcing 'zero tolerance' towards lapses in prevention of HCAIs. Public pressure would force the Indian Government to acknowledge the problem, and to allocate more funds to improve resources and infrastructure; this could substantially elevate the standard of health care given to the average Indian. Despite the numerous challenges, overall public benchmarking of HCAIs is a commendable goal that would go a long way towards tackling this menace in developing countries such as India.

Point prevalence surveys of healthcare-associated infections and use of indwelling devices and antimicrobials over three years in a tertiary care hospital in India.

Few hospitals in India perform regular surveillance for healthcare-associated infections (HAIs) and use of indwelling devices and antimicrobials. The aim of this study was to conduct two one-day point prevalence surveys of HAIs and use of indwelling devices and antimicrobials in a large 1800-bed tertiary care hospital in India. The overall prevalence of HAIs was 7%, and surgical site infections were the most common (33%). Indwelling devices were present in 497 (27%) patients, and 915 (50%) patients were receiving antimicrobials. This study helped to generate robust baseline data on the prevalence of HAIs and use of indwelling devices and antimicrobials in the study hospital.

Molecular characterization of Shiga-toxigenic Escherichia coli isolated from diverse sources from India by multi-locus variable number tandem repeat analysis (MLVA).

In a first study from India, a diverse collection of 140 environmental and clinical non-O157 Shiga-toxigenic Escherichia coli strains from a large geographical area in north India was typed by multi-locus variable number tandem repeat analysis (MLVA). The distribution of major virulence genes stx1, stx2 and eae was found to be 78%, 70% and 10%, respectively; 15 isolates were enterohaemorrhagic E. coli (stx1 +/stx2 + and eae +). By MLVA analysis, 44 different alleles were obtained. Dendrogram analysis revealed 104 different genotypes and 19 MLVA-type complexes divided into two main lineages, i.e. mutton and animal stool. Human isolates presented a statistically significant greater odds ratio for clustering with mutton samples compared to animal stool isolates. Five human isolates clustered with animal stool strains suggesting that some of the human infections may be from cattle, perhaps through milk, contact or the environment. Further epidemiological studies are required to explore these sources in context with occurrence of human cases.

Comparing hand hygiene measures in a neonatal ICU: a randomized crossover trial.

OBJECTIVE: To compare plain soap, alcohol hand rub and iodophors as hand hygiene measures in a neonatal intensive care unit (NICU). DESIGN: Randomized, crossover, three-armed, controlled trial with blinded outcome measurement. SETTING: Level III NICU. PARTICIPANTS: 35 NICU nurses. INTERVENTION: Participants were assigned to plain soap hand washing, alcohol hand rub and povidone-iodine hand scrub by a random cross-over design. Interventions were preceded by 14-day neutral periods. Cultures from hands were taken before and after each hand-hygiene use, prior to 5 patient-care activities. MAIN OUTCOME MEASURE: The primary outcome was mean post-hygiene colony forming unit count (CFU-C). RESULTS: There were differences between soap, alcohol and povidone groups vis a vis posthygiene CFUC [median: 60, 8 and 10.5, respectively (P<0.001)], absolute reduction in CFU-C [median: 15, 100 and 40, respectively (P<0.001)], percent reduction in CFUC [median: 33.3, 92 and 87, respectively (P<0.001)] and proportion with low CFU-C [47%, 71% and 72%, respectively (P<0.001)]. Alcohol [Adjusted OR 3.2 (95% CI 1.9, 5.3)], povidone-iodine [AOR 3.1 (95% CI 1.8, 5.3)] and high prehygiene CFU-C (>300) [AOR 0.18 (95% CI 0.1, 0.3)] were independently associated with low CFU-C. CONCLUSION: After a 2 minute hand wash at entry into NICU, alcohol hand rub and povidone-iodine scrub are superior to plain soap hand wash for subsequent decontamination of hands of nurses working in NICU.

Detection of Shiga toxin variants among Shiga toxin-forming Escherichia coli isolates from animal stool, meat and human stool samples in India.

AIM: To study the prevalence and distribution of various variants in the stx gene of Shiga toxin-producing Escherichia coli (STEC) isolated from diverse environmental sources (animal stool, meat) and human illness, from a large geographic area in India, and to understand the association between variants, serotype distribution and human disease. METHODS AND RESULTS: A surveillance for STEC was conducted in the semi-urban and rural areas of Punjab, Himachal, Haryana and Chandigarh. Shiga toxin-producing Escherichia coli isolates (80 animal stool, 39 meat, 21 human stool from diarrhoea and HUS cases) were characterized for stx variants by PCR. Shiga-like toxin (Stx) was detected using Ridascreen-EIA assay. Variant stx2c was the most common (25·1%), followed by stx1d (13%), stx1c (10·7%) and stx2d (9·2%), whereas stx2e, stx2f and stx2g were absent. Only 8/21 (38%) human isolates harboured stx variants, of which stx2c and stx2d were found in 2 and 1 isolates, respectively. The low frequency of carriage of these potentially more pathogenic variants may explain the low severity of human illness seen in India. Shiga-like toxin was detected in only 42 of the isolates positive for the stx genes probably due to the low levels of toxins produced. Serogroup distribution was found to be diverse, suggesting the lack of any predominant circulating type. CONCLUSIONS: The presence of stx variants 1c, 1d, 2c and stx2d in diverse environmental and human sources in India was demonstrated. The prevalence of the most common subtype stx2c found in this study in animal isolates may pose a threat to the public health. We report the subtyping of human STEC isolates and report the presence of stx1d subtype for the first time from India. SIGNIFICANCE AND IMPACT OF THE STUDY: We demonstrated the presence of potentially pathogenic subtypes in the environmental specimens which may act as a reservoir for human infections. Serogroups new to India were also reported.

Viability kinetics, induction, resuscitation and quantitative real-time polymerase chain reaction analyses of viable but nonculturable Vibrio cholerae O1 in freshwater microcosm.

AIM: To study the induction of a viable but nonculturable (VBNC) state in Vibrio cholerae O1 in freshwater, in response to cold temperatures (4°C) and starvation. METHODS AND RESULTS: Vibrio cholerae O1 cells were inoculated in freshwater microcosm and incubated at 4°C. The cells became coccoid, rugose and subsequently nonculturable by day 16 on tryptic soy agar (TSA) and by day 23 on TSA-SP, while 87 and 65% of the cells retained their membrane integrity, respectively. Viable cells were observed until day 30 using direct fluorescent antibody-direct viable count method. In vitro resuscitation was demonstrated by temperature upshift. Utilizing 16S rRNA as an endogenous control, the DNA pol II (27·43-fold), fliG (12·44-fold), ABC transporter (27·11-fold), relA (60·76-fold) and flaC (15·29-fold) were significantly up-regulated in VBNC cells, while the expression of fadL-3 was comparable. The expression of DNA pol II, fliG, ABC transporter, relA and flaC was 3·3, 1·1, 5·9, 5·8 and 1·2-fold, respectively, for resuscitated cells. VBNC cells were found to be virulent, as ctxA and tcpA were expressed. CONCLUSIONS: Vibrio cholerae undergoes both phenotypic alteration and genotypic modulation to protect itself from stress in freshwater. SIGNIFICANCE AND IMPACT OF THE STUDY: Induction and resuscitation of the VBNC state in freshwater is important for an understanding of the epidemiology of cholera in the freshwater environment.

Environmental and epidemiological surveillance of Vibrio cholerae in a cholera-endemic region in India with freshwater environs.

AIM: To conduct epidemiological and ecological surveillance of cholera in freshwater environments. METHODS AND RESULTS: A freshwater region of India was surveyed between April 2007 and December 2008. Vibrio cholerae was isolated from 59·5% of water and plankton samples (n = 357) and 35·5% of stool samples (n = 290). Isolation from water was dependent on air (r = 0·44) and water temperatures (r = 0·49) (P < 0·01) but was independent of rainfall (r = 0·15), chlorophyll a (r = 0·18), salinity (r = 0·2) or pH (r = 0·2) (P > 0·05). Isolation from plankton was dependent on temperature of air (r = 0·45), water temperature (r = 0·44), chlorophyll a concentration (r = 0·42), pH (r = 0·23) and salinity (r = 0·39) (P < 0·01). Cholera cases correlated with rainfall (r = 0·82, P < 0·01) and chlorophyll a concentration (r = 0·42, P < 0·05), but not with air temperature (r = 0·3, P = 0·37). Vibrio cholerae O1 possessed ctxB, ctxA, rstR and tcpA (ElTor), toxR, toxT, rtxA, rtxC, mshA and hylA. Among non-O1-non-O139, the distribution of virulence-associated and regulatory protein genes was heterogeneous with - 0·7, 2·2, 94·77, 97·76, 99·25, 100 and 100% isolates being positive for tcpA, toxT, rtxA, rtxC, hylA, toxR and mshA, respectively. Two-thirds of non-O1-non-O139 isolates exhibited antibiotic resistance to various antibiotics that did not correlate with geographical site or time of origin for the isolates. RAPD and AFLP showed V. cholerae to be a diverse bacterium. AFLP demonstrated separate lineages for non-O1-non-O139 and O1 isolates. CONCLUSION: Environmental parameters played a significant role in the emergence and spread of cholera and the abundance of V. cholerae. But based on virulence gene profiling and genetic fingerprinting, the possibility of origin of toxigenic isolates from nontoxigenic environmental isolates seems unlikely in freshwater environs of India. SIGNIFICANCE AND IMPACT OF THE STUDY: This study explains the ecology, epidemiology and seasonality of cholera in freshwater environs.