Results of Serosurveillance and Forecasting the Third Wave of COVID-19 in an Industrial District in India.

Prevalence of immunoglobulin G (IgG) severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies in the industrial district of East Singhbhum (Jharkhand, India) from July, August, November, and December 2020 and January 2021 after the first wave and in July 2021 after the second wave of coronavirus disease 2021 (COVID-19) infections may be utilized to find the possibility of a third wave of COVID-19 infections. Based on the trend of the loss of protective IgG antibodies after the first wave and the seropositivity of 75% in the district in July 2021, simple forecasting and proportional estimates of the seropositivity in the next eight months and the estimated maximum number of the cases was done. We also considered the seropositivity without vaccination in July 2021 (63%). Additionally, the trend of the weekly RT-PCR and rapid antigen testing for SARS-CoV-2 may also preemptively predict an imminent wave. Based on the East Singhbhum population and the vaccination coverage with at least one dose till July 2021 (Covishield or Covaxin), it is estimated that a 4-5% monthly vaccination coverage rate of new individuals will not allow the seropositivity to fall below 50% and hold at bay a major wave. Vaccination coverage of 3% or less would allow a continuous drop in acquired immunity in the district and can potentially cause a rise in cases, making the community susceptible to a future surge of infections. A 3-5% vaccination rate of new individuals is unlikely to see a drop in the community seropositivity below 50% and the number of new cases of COVID-19 infections going above 478 to 712 per month at least till March 2022. The assumptions are based on presuming that there will be no new mutant of SARS-CoV-2 that escapes the immunity provided by previous infection or vaccination over the next eight months. However, currently, there is no evidence to speculate on any new variant of concern causing a major wave globally. The B.1.617.2 (delta) variant was first identified in October 2020 and there was a lag of six months to the second surge of COVID-19 infections in East Singhbhum, primarily caused by this variant. Additionally, 3% and above, with a rising weekly trend of reverse transcription-polymerase chain reaction (RT-PCR) positivity for SARS-CoV-2 can provide at least four to eight weeks advance warning before the peak of the wave if an imminent future wave is impending.

Serosurveillance of Health Care Workers in a COVID Hospital: Immune Response, and Its Longevity.

OBJECTIVE: We aimed to study the seroprevalence of coronavirus disease 2019 (COVID-19) and sustainability of the immune response in health care workers (HCWs). A cross-sectional study was conducted between October 7 and November 30, 2020, in a multi-specialty hospital in Eastern India designated as COVID hospital during this pandemic. Study participants included 2,110 HCWs, including those who have recovered from COVID infection. METHOD: HCWs were required to complete a questionnaire and give written consent to participate in the study. Their venous blood sample was collected for serum analysis of IgG antibodies to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by chemiluminescent immunoassay. RESULTS: Positive IgG antibodies were seen in 924 participants with a point prevalence of 43.79%. Slightly higher reactivity was seen in males. History of COVID-19 infection was noted in 10.9%, with the highest antibody response in 81% cases. A maximum of 87.9% reactivity was seen in the first two months, and a significant fall was noted in the fourth month, with reactivity seen in only 50% of the study participants. CONCLUSION: SARS-CoV-2 infection is associated with a variable immune response in the infected population. The declining trend of the antibodies correlates with short-lived protective immunity and the possibility of re-infection. Further studies are needed to explore the probable reasons for varied seroprevalence.

Prolonged Oxygen Therapy Post COVID-19 Infection: Factors Leading to the Risk of Poor Outcome.

BACKGROUND: Coronavirus disease 2019 (COVID-19) infection is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a single-stranded ribonucleic acid (RNA) ß-coronavirus. Prolonged duration of symptoms, ill health, disability, and need for hospitalisation are all well-known features of severe COVID-19 disease. OBJECTIVE: To describe the epidemiological, clinical and imaging characteristics of hospitalised patients of COVID-19 who required prolonged oxygen therapy after testing negative for SARS-CoV-2 and attempt to determine the associated factors leading to delayed recovery, failure to wean, and mortality. MATERIAL AND METHOD: Prospective observational study from 9th September to 6th November 2020 in a tertiary care COVID hospital of Jharkhand. Included COVID-19-infected patients requiring oxygen to maintain a saturation of ≥95% after testing reverse transcription polymerase chain reaction (RT-PCR) negative. Patients were classified as Group I, those who could be weaned off oxygen, and Group II, those who could not be weaned off oxygen during their stay in the isolation ward. A detailed assessment for outcome in these two groups related to age, gender, presence or absence of co-morbidities, nature of co-morbidities and findings of high-resolution CT (HRCT) thorax was done to ascertain risk factors for failure to wean and adverse outcomes. RESULTS: During the study period, 93 patients suffering from moderate to severe COVID-19 infection, could not be discharged from the hospital and were admitted to the post-COVID isolation ward after testing RT-PCR negative, due to breathlessness and need for oxygen therapy, with a male predominance, M:F ratio of 2.2:1. Of these 93 patients, 51 could be weaned off oxygen in the isolation ward. The mean and median age of patients who could be successfully weaned was 58.5±14.3 years and 60 years respectively, compared to a mean age of 64±12.4 years and a median age of 67 years for patients who could not be weaned off oxygen during the isolation period. Patients aged ≥60 years were at risk for prolonged requirement of oxygen compared to those <50 years of age, relative risk (RR) 1.43 (95%CI 0.9-2, p=0.051). Failure to wean in <50 years was noted in presence of co-morbidities, RR 4 (95%CI 1.5-10.6, p=0.005). Multivariable logistic regression analysis calculated an odds ratio (OR) of 12.22 (95%CI 2.4-61.5, p<0.002) in patients of coronary artery disease (CAD), and 3.34 (95%CI 1.01-10.9, p<0.046) in patients of diabetes, for failure to wean with delayed recovery in patients aged 50 years and more, having multiple co-morbidities. Presence of ≥three co-morbid conditions was associated with increased risk of critical care unit (CCU) admissions (RR 2.1, p=0.02), failure to wean (RR 1.79, p<0.006), and death (p=0.02). Elderly male patients (mean age of 81.3±7.2years) with CAD and multiple comorbidities were at a high risk of mortality (p=0.01). CONCLUSION:  Patients ≥50 years of age having ≥three co-morbidities are at increased risk of prolonged hospitalisation and oxygen therapy in moderate to severe COVID-19 infection, precluding their discharge even after they test negative for SARS-CoV-2. Elderly male patients of COVID-19 with CAD and multiple comorbidities are at a high risk of mortality.

A Prospective Study on Rapidly Declining SARS-CoV-2 IgG Antibodies Within One to Three Months of Testing IgG Positive: Can It Lead to Potential Reinfections?

Background COVID-19 immunoglobulin G (IgG) antibodies have been considered to provide protective immunity and its immunoassays have been widely used for serosurveillance. In our serosurveillance on an industrial workforce of randomly selected 3296 subjects, COVID-19 IgG antibody positivity was reported in 7.37% (243) subjects. However, when 30 days later, eight of the 243 COVID-19 IgG antibody-positive individuals complained of symptoms suggestive of COVID-19 infection and were confirmed as COVID-19 infection by reverse transcription-polymerase chain reaction (RT-PCR), their COVID-19 IgG antibodies were retested. Seven of the eight previously IgG positive individuals had lost their protective antibodies. Methods Subsequently, a prospective clinical trial was planned by repeating the test for IgG antibodies on the remaining earlier positive 235 individuals at 45-65 days after their initial test. Only 201 of the 235 individuals consented and participated in the non-randomized single-arm observational trial. Results Only 28.36% (57/201) retained their IgG antibodies and 70.15% (141/201) had lost their IgG antibodies. Three cases reported equivocal results on retesting. Conclusions Our findings show that the protective COVID-19 IgG antibodies rapidly decline over one to three months. Further studies are needed with a quantitative assay over a period with neutralizing antibodies to establish if its decay can potentially lead to reinfections. Rapidly decaying protective IgG antibodies would impact herd immunity and vaccine durability. It is critical for the potential vaccines to generate both protective T- and B-cell immune responses in a sustained manner.

Integrated clinical care pathway for managing necrotising soft tissue infections.

BACKGROUND: Necrotising soft tissue infections (NSTI) are relatively common infections with high morbidity and mortality rate, as they often present late in their course. Quick and aggressive surgical treatment improves survival and decreases hospital stay. MATERIALS AND METHODS: All patients with NSTI managed at our centre from June 2007 to January 2009 were included in this prospective study. We evaluated various parameters like age, co-morbidities, biochemical parameters, time interval between admission and first operative intervention, against duration of hospital stay and out come of the case. RESULTS: Fifty-four patients with NSTI were admitted and treated during the study period. Male to female ratio was 6:1. Mean time interval between admission and operative intervention was 6 hours. Mean period of hospitalisation was 53 days and we had limb salvage rate of 100% and one mortality (1.85%). Diabetes mellitus was the most common co-morbid condition and Staphylococcus aureus the most common isolate. Presence of leucocytosis, hyponatraemia, hypoalbuminaemia, anaemia and deranged renal functions were found to be poor prognostic factors. CONCLUSION: Late and varied presentation is the rule rather than exception with NSTI. Early recognition of the condition, with emergency operative intervention and repeated debridement by a dedicated surgical team, is the key to patient survival and limb salvage.

The Challenge of Enterocutaneous Fistulae.

During a period of six years, 17 cases of enterocutaneous fistulae arising from the small intestine were managed. Majority of the fistulae, (76%) resulted from surgical complications. There were 6 females and 11 male patients. The mean age of the patients was 40 years. In 9/17 patients (52%) the fistulae arose from the proximal small gut (duodenum and jejunum) and in the remaining 48% from the ileum. Octreotide was used in 11/17 patients (64%). Enteral nutrition was used in 9/17 patients (52%) while re-feed from the proximal gut fistulae was used in 4/9 patients (44%) to maintain the nutrition of the patients. Only one fistula (6%) closed spontaneously. There were 2 deaths (12%) in this study. 14/17 patients (82%) required surgical intervention at some stage for successful closure of intestinal fistula. Aggressive surgical treatment with judicious use of octreotide, nutritional support, stoma care and control of sepsis significantly improves the outcome of small intestinal fistulae.

Intestinal lipoma: a rare cause of lower gastrointestinal haemorrhage.

Lower gastrointestinal bleeding from submucosal lipomas of the intestine is very rare. We report our experience with 3-patients presenting with lower gastrointestinal haemorrhage who were detected to have no cause other than intestinal lipomas. In two of these patients, the lipoma was in the small intestine and presented with chronic blood loss or recurrent episodes of bleeding. The third patient presented with massive haematochyzia and had a number of lipomas in the cecum and right colon. The diagnosis was established by laparotomy and intraoperative enteroscopy in 2 cases, and by colonoscopy and laparotomy in the third. Surgical excision of the lipoma led to cure in all the patients. We conclude that when laparotomy and intraoperative enteroscopy fail to show any cause for bleeding other than an innocuous-looking lipoma, it should be excised. The literature has been reviewed.

IS PROPHYLACTIC USE OF OCTREOTIDE BENEFICIAL IN PREVENTING COMPLICATIONS AFTER PANCREATIC SURGERY?

Major complications following pancreatic surgery are related to the digestive exocrine secretions of the gland. Octreotide, a potent inhibitor of the pancreatic secretions may be of value in reducing the complication rate, particularly fistula formation and possibly the mortality after pancreatic surgery. Between Jan 97 and Jun 99, 19 patients who underwent pancreatic surgery were given perioperative Octreotide in a dose of 100 micrograms eight hourly for 7 days starting from the morning of the surgery. The post operative complications were compared with the results of 17 patients who underwent similar pancreatic surgery between Jan 94 to Dec 96 and who were not given perioperative Octreotide. The surgeries conducted in the Octreotide group were pancreatico-duodenectomy 6, lateral pancraetico-jejunostomy 7, pancreatic biopsy 4 and surgery for pancreatic trauma 2. In the non Octreotide group the surgeries done were pancreatico-duodenectomy 7, lateral pancreatico-jejunostomy 6, pancreatic biopsy 3 and surgery for pancreatic trauma 2. Only 1 out of 19 patients in the Octreotide group developed pancreatic fistula. This was after a pancreaticoduodenectomy and closed spontaneously after 7 days. In the non Octreotide group 5 out of 17 patients developed pancreatic fistula. Of these 5, 1 patient died while in remaining 4 the mean fistula closure time was 23 days. Octreotide reduces the incidence of pancreatic fistula after pancreatic surgeries. However, a larger prospective study is required to convincingly prove the efficacy of Octreotide in prevention of pancreatic fistula after pancreatic surgery.

USE OF ANORECTAL MANOMETRY FOR OBJECTIVE ASSESSMENT OF ANORECTAL FUNCTION AFTER POUCH ILEOANAL ANASTOMOSIS.

Sixteen patients of ulcerative colitis and two of familial adenomatous polyposis were subjected to anorectal manometry, a minimal of three months after Pouch Ileo-Anal Anastomosis and closure of ileostomy. Using a perfusion catheter the parameters measured were resting anal pressure (RAP), maximum squeeze pressure (MSP), pouch volume and compliance at maximum tolerated volume. Subjective evaluation included anal continence and frequency of stools. The subjective functional results after surgery were then correlated with the objective findings of manometry. 4/18 patients (22%) had nocturnal incontinence only, while one patient (5%) had incontinence both by day and night. Frequency of stools was < 8/day in 10/18 patients (55%). Only 1/5 patients (20%) with incontinence had anal sphincter pressures greater than the controls while only 3/13 continent patients (22%) had anal sphincter pressures less than the controls. The study shows that low anal sphincter pressures are associated with post-operative incontinence and that there is a correlation between decreased frequency of stools and increased pouch volume as well as pouch compliance.