The Impact of the COVID-19 Pandemic on the Incidence of Herpes Zoster: A Narrative Literature Review.

Coronavirus disease 2019 (COVID-19) has had a broad impact on health services and health outcomes. During the pandemic, there were numerous reports of herpes zoster (HZ) in people with COVID-19 and in COVID-19 vaccine recipients. The aim of this review is to elucidate the global effects of the COVID-19 pandemic on HZ. It is postulated that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection produces an immunosuppressive state that favours varicella zoster virus (VZV) reactivation. Three large cohort studies (a multinational study and studies from the USA and Spain) that excluded individuals vaccinated against HZ reported significantly increased risk of HZ following COVID-19 infection, especially in people aged ≥ 50 years. In contrast, a large study from Israel that did not consider HZ vaccination status reported no such increase. Cases of HZ following COVID-19 vaccination have been reported and may be the result of attenuated cell-mediated immunity. This phenomenon appears to vary by vaccine type. Some (but not all) large analyses have reported a significant positive relationship between receipt of mRNA vaccines for COVID-19 and development of HZ. These include analyses of health records databases in Israel and Hong Kong and of spontaneous case reports in the US Vaccine Adverse Event Reporting System (VAERS) database. Routine vaccinations, including shingles vaccine programmes, were disrupted by the COVID-19 pandemic. It is estimated that missed shingles vaccinations may have resulted in 63,117 avoidable HZ cases in the USA. Now that the World Health Organization has declared an end to the COVID-19 pandemic as a health emergency and routine vaccination services have resumed, there is a need to increase awareness of HZ and HZ vaccination.Graphical abstract available for this article.

Knowledge, attitude, and practice toward herpes zoster (HZ) and HZ vaccination: Concept elicitation findings from a multi-country study in the Asia Pacific.

Herpes zoster (HZ) is a prevalent disease characterized by a painful rash. A multi­country study was conducted to elicit public and physician knowledge, attitude, and practice (KAP) toward HZ disease and vaccination for the assessment of local factors influencing HZ vaccine perceptions in four Asian-Pacific countries/territories One-to-one qualitative interviews were conducted in 2022, among the public (people aged ≥ 50 years, adults with parents aged ≥ 50 years, zoster vaccine live-vaccinated individuals aged ≥ 50 years in Republic of Korea, and HZ patients; n = 78) and physicians (general practitioners and specialists; n = 24). Themes surrounding KAP toward HZ and HZ vaccination were summarized using a thematic analysis. A substantial knowledge gap related to HZ was observed among the public, including its causes, long-term impacts, and the at-risk population. There was a low perceived risk of HZ and low general awareness of HZ vaccine availability, although country/territory-specific differences existed. Fear of HZ-associated pain contributed toward vaccination intent among HZ patients and adults with parents aged ≥ 50 years. HZ-naïve adults who were encouraged to receive the vaccine by others were not motivated to do so due to optimism bias. Physicians were perceived to be a reliable source of information. However, physicians did not always proactively discuss HZ vaccination due to time constraints and a perceived need to prioritize other vaccinations including influenza and pneumococcal vaccines. Initiatives are needed to improve public awareness of HZ and its complications, in terms of overall impact on individuals and society, and highlight the important role of physicians in recommending vaccination.

Co-administration of the adjuvanted recombinant zoster vaccine with other adult vaccines: An overview.

BACKGROUND: The adjuvanted recombinant zoster vaccine (RZV; Shingrix®, GSK) is a subunit vaccine that has been approved for the prevention of herpes zoster in adults. Co-administration of two vaccines in a single visit is a strategy to improve overall vaccine coverage. OBJECTIVES: This review aims to consolidate available clinical data on RZV co-administration, providing an overview of safety, reactogenicity and immunogenicity. METHODS: RZV co-administration data were obtained from five randomised, open-label, phase III clinical trials with similar study designs. The co-administered vaccines included: quadrivalent seasonal inactivated influenza vaccine (IIV4; NCT01954251), 23-valent pneumococcal polysaccharide vaccine (PPSV23; NCT02045836), reduced-antigen-content diphtheria-tetanus-acellular pertussis vaccine (Tdap; NCT02052596), 13-valent pneumococcal conjugate vaccine (PCV13; NCT03439657) and COVID-19 mRNA-1273 booster (NCT05047770). Eligible participants were healthy adults aged ≥50 years. RESULTS: A total of 3,974 participants were vaccinated (co-administration: 1,973; sequential: 2,001) across the five trials. Vaccine response rates to RZV were similar for co-administration (range: 95.8-99.1 %) and sequential groups (range: 95.1-99.1 %). Immune responses to RZV and the other vaccines (with the exception of pertactin) were non-inferior when the vaccines were co-administered compared with sequentially administered. Overall incidences of solicited local and general adverse events (AEs), unsolicited AEs, serious AEs or potential immune-mediated diseases were similar after co-administration or sequential administration. Myalgia was the most common solicited systemic AE (co-administration: 38-64 %; sequential: 30-59 %). Shivering and fever were more common after co-administration (16 % and 21 %, respectively) than after sequential administration (both 7 %) of RZV and PPSV23. CONCLUSIONS: Co-administration of RZV with routine vaccines does not significantly alter the reactogenicity, immunogenicity or safety of RZV or the co-administered vaccine. Healthcare practitioners should consider routine co-administration of RZV with other adult vaccines to improve vaccination coverage.

Herpes Zoster Recurrence: A Narrative Review of the Literature.

INTRODUCTION: Herpes zoster (HZ; shingles) is a painful, cutaneous disease caused by reactivation of the varicella zoster virus, which causes varicella (chickenpox) typically during childhood. The considerable healthcare burden of HZ is relatively well documented, with approximately one in three individuals experiencing at least one episode during their lifetime, debilitating symptoms including neuropathic pain, and complications such as post-herpetic neuralgia, vision loss, and rarely, stroke, and increased severity in immunocompromised individuals. However, we are not aware of a comprehensive review of literature specifically examining the burden of HZ recurrence. METHODS: We conducted a PubMed search (1 January 2003-2 February 2023) to assess available literature on the incidence, risk factors, and clinical features of HZ recurrence. RESULTS: The incidence of HZ recurrence reported by the studies identified was wide ranging. Studies in general populations of immunocompetent or immunocompetent/immunosuppressed (mixed) populations with an initial HZ episode estimate that approximately 1.2-9.6% of individuals may experience HZ recurrence, with an incidence rate of 1.7-16.6 cases per 1000 person-years. HZ recurrence was reported in 0.0-18.2% of immunocompromised individuals with HZ, with an incidence rate of 17.0-55 cases per 1000 person-years. Incidence rates varied according to study design, follow-up, and study populations. Recognized risk factors for HZ recurrence include immunocompromised status, female sex, family history, and comorbidities such as diabetes. Other factors that may predispose individuals to recurrence include long-lasting pain after the initial HZ episode and the presence of herpes zoster ophthalmicus. DISCUSSION: Our review underlines that following an initial HZ episode, individuals remain at risk of HZ recurrence, adding to the disease burden in a population. As HZ is preventable by vaccination, national HZ vaccination recommendations should include the need for and timing of vaccination in both immunocompetent and immunocompromised individuals who have a history of HZ.

Herpes zoster (HZ), also known as shingles, results from the same virus that causes chickenpox in childhood. In shingles, the chickenpox virus is reactivated, most commonly causing a painful skin rash. About one in three people have shingles at least once in their lifetime. Neuralgia (a burning, stabbing, and sometimes severe pain along a nerve pathway) may continue for months after the initial rash. Shingles may lead to loss of vision and rarely stroke. Shingles is more severe in people with weakened immunity. We reviewed published information on shingles recurrence (i.e., a second, third, or later episode of shingles), as we were not aware of a broad review of information specifically on recurrence. We focused on the rate of recurrence and factors that increase the risk of recurrence. Overall, in around one-tenth of individuals who experience shingles, the disease may reoccur after complete resolution. The rate of recurrence varied on the basis of how the studies were carried out and the type of patients included in the studies. Well-known factors that increase the risk of shingles recurrence are reduced immunity, female sex, family history, and other conditions (e.g., diabetes). Other factors that may increase the risk of shingles recurrence include pain that lasts for a long time after the first episode of shingles and having herpes zoster ophthalmicus, which leads to eye complications. Our review summarizes available data. As shingles is preventable by vaccination, strategies to prevent this disease should include those who have a history of shingles.

Effectiveness and safety of recombinant zoster vaccine: A review of real-world evidence.

The recombinant zoster vaccine (RZV) was licensed in the US for prevention of herpes zoster (HZ) in 2017. We conducted a literature search (January 1, 2017-August 1, 2023) using PubMed, Embase, and Scopus to consolidate the real-world evidence related to RZV. Overall, RZV effectiveness against HZ was high across the studied populations in real-world settings, including adults aged ≥ 50 years and patients aged ≥ 18 years with immunodeficiency or immunosuppression. Effectiveness was higher with two doses versus one dose, especially in elderly people and immunocompromised individuals. The safety profile of RZV was broadly consistent with that established in clinical trials. RZV does not appear to increase the risk of disease flares in patients with immune-mediated diseases. Approximately two-thirds of individuals received a second RZV dose within 2-6 months after the first dose. Collectively, RZV effectiveness against HZ was high, and these real-world studies reaffirm its favorable benefit-risk profile.

What is the context?Herpes zoster is a common and painful rash that develops following reactivation of latent (meaning silent or dormant) varicella zoster virus, which is the virus that causes the common childhood illness chickenpox. The recombinant zoster vaccine (RZV) was first approved for the prevention of herpes zoster in the USA and Canada in 2017 and has since been approved in the European Union and various other countries. The approval was based on the results of large clinical trials. Since its launch over 5 years ago, evidence for RZV use in real-world settings has been collected; the benefits of real-world studies include large sample sizes, more diverse populations, and the ability to identify rare side effects.What is new?We provide a review of real-world studies, which have shown that RZV is effective across the studied populations, including in adults aged 50 years and above and in patients with immunodeficiencies (i.e., those who have a decreased ability to fight infections or other diseases) or receiving immunosuppressive therapies (treatments that lower the activity of the body's immune system). The safety profile of RZV in real-world studies was generally consistent with that seen in clinical trials.What is the impact?These studies show the effectiveness and well-tolerated safety profile of RZV in real-world settings.

Increased Risk of Herpes Zoster in Adults ≥50 Years Old Diagnosed With COVID-19 in the United States.

Background: Case reports have described herpes zoster (HZ) in patients with coronavirus disease 2019 (COVID-19). However, this constitutes low-quality evidence for an association. We therefore performed a retrospective cohort study to assess the risk of developing HZ following a COVID-19 diagnosis. Methods: We compared the HZ incidence in ≥50-year-olds diagnosed with COVID-19 vs those never diagnosed with COVID-19. We used data from the US MarketScan Commercial Claims and Encounters and Medicare Supplemental (3/2020-2/2021) and Optum Clinformatics Data Mart (3-12/2020) databases. Individuals with COVID-19 were exact-matched 1:4 to those without COVID-19 by age, sex, presence of HZ risk factors, and health care cost level. Adjusted incidence rate ratios (aIRRs) were estimated by Poisson regression. Results: A total of 394 677 individuals ≥50 years old with COVID-19 were matched with 1 577 346 individuals without COVID-19. Mean follow-up time after COVID-19 diagnosis and baseline characteristics were balanced between cohorts. Individuals diagnosed with COVID-19 had a 15% higher HZ risk than those without COVID-19 (aIRR, 1.15; 95% CI, 1.07-1.24; P < .001). The increased HZ risk was more pronounced (21%) following COVID-19 hospitalization (aIRR, 1.21; 95% CI, 1.03-1.41; P = .02). Conclusions: We found that COVID-19 diagnosis in ≥50-year-olds was associated with a significantly increased risk of developing HZ, highlighting the relevance of maintaining HZ vaccination.

Diphtheria-tetanus-pertussis (DTP) vaccination: understanding the perspectives and expectations of parents and healthcare professionals in France and India.

Diphtheria-tetanus-pertussis (DTP) combination vaccines are a cornerstone of infant vaccinations worldwide. DTP vaccine acceptance could be impacted by sub-optimal relationships between parents and healthcare professionals (HCPs). This survey, conducted in France and India between 14/2/2020 and 26/3/2020, aimed to understand perspectives and expectations of parents and HCPs toward DTP vaccination. Participants were parents (parents/guardians of ≤3-year-old children; France: n = 1002, India: n = 1021) and HCPs (general practitioners/pediatricians initiating DTP vaccination; France: n = 300; India: n = 300) who chose to take part. A representative sample of parents was achieved via quotas and random iterative weighting to match key demographics of the target population. In India, only parents from socio-economic classes A/B/C and private HCPs were included. Whilst DTP vaccine acceptance was high among parents in France (85%) and India (98%), French HCPs overestimated parental acceptance (99% thought parents were very/fairly accepting). The proportions of parents reporting that the HCP is someone they trust versus the proportions of HCPs wanting to be seen as trusted were discrepant in France (76% versus 90%) but not India (83% versus 85%). Some surveyed parents indicated that, ideally, they would like some input in vaccine brand decisions alongside HCPs, an opinion shared by some HCPs. In France, short-term experience post-vaccination was more important to parents than HCPs, for whom long-term protection was more important. In India, these aspects were equally important to both. Increased awareness of parents' priorities and concerns regarding DTP vaccination can support HCPs in their discussions with parents and help build trust, which may impact vaccine acceptance.

Herpes zoster in outpatient departments of healthcare centers in India: a review of literature.

In India, although incidence of Herpes zoster has not been assessed, regional cases have been reported. We revisited the peer-reviewed literature on clinical cases of HZ to depict the trends in population characteristics, disease presentation, and predisposing factors for the disease in India. Systematically conducted literature search yielded 27 studies, published between January 2011 and May 2020, reporting 3124 HZ clinical cases, with high proportions in older adults (>50 years of age: 15.0-81.3%). Thoracic dermatome was consistently reported as the most frequent site affected by HZ (38.9-71.0%). Post-herpetic neuralgia and secondary bacterial infections were the two most frequent complications (10.2-54.7% and 3.5-21.0%, respectively). Despite the paucity of data and gaps in the reporting of HZ cases, available evidence indicate that the disease causes an important burden to older adults in India, suggesting that preventive strategies, along with recommendations to healthcare practitioners, can help mitigate the burden of HZ.

PLAIN LANGUAGE SUMMARYWhat is the context?Herpes zoster is caused by reactivation of the varicella virus in sensory gangila usually during older age.The most common complication involve skin and neurological disorders, such as post herpetic neuralgia.Herpes zoster can impact quality of life for months or even years (especially for those >50 years of age).In India, there is a lack of population-based studies on herpes zoster to reflect burden of disease. What is new?We reviewed the literature on clinical cases of herpes zoster in India from last decade and found that:High propotions of older adults (>50 years of age) are reported to have the disease.Thoracic dermatomes and post herpetic neuralgia are common clinical presentation and complication.Post herpetic neuralgia is observed more frequently in older patients.What is the impact?Our review highlights sigificant number of cases of herpes zoster are reported and the disease causes a substantial burden to older adults in India.In view of the growing elderly population in India, the finding of greater proportion of cases in >50 years of age holds importance.Implementation of preventive strategies along with guidance to healthcare pracitioners can help prevent the disease and complications in vulnerable population.

A practitioner's guide to the recombinant zoster vaccine: review of national vaccination recommendations.

INTRODUCTION: The adjuvanted recombinant zoster vaccine (RZV) is currently licensed in over 30 countries for the prevention of herpes zoster (HZ) in adults aged ≥50 years. We conducted a review of available national guidelines or recommendations on RZV use to identify the similarities and differences and highlight any potential gaps. AREAS COVERED: National recommendations from ten countries (Austria, Canada, the Czech Republic, Germany, Ireland, Italy, Spain, the Netherlands, the UK and the USA) are summarized under the following seven topics: HZ vaccine preference, age group recommendations, considerations prior to vaccination, dose schedule, co-administration with other vaccines, vaccination of special populations, and vaccine safety profile. In seven of these countries, RZV is the preferred or the only recommended HZ vaccine. There were some differences in age group recommendations, reflecting evaluations dependent on public funding. There were also differences with respect to use in immunocompromised and other special populations. EXPERT OPINION: The high efficacy and anticipated public health impact of RZV led to expanded national recommendations for RZV vaccination compared to previous HZ recommendation in many countries. Possible areas that could be considered in future revisions of national recommendations, including use in immunocompromised adults ≥18 years, are also highlighted.

PLAIN LANGUAGE SUMMARYThe varicella-zoster virus causes chickenpox, usually in childhood. After the chickenpox episode, the virus remains in the body in a latent state and can reactivate later in life, causing herpes zoster, or shingles. Adults over 50 years of age or those who have a weakened immune system are more vulnerable to developing herpes zoster. Herpes zoster appears as a painful localized skin rash. While live attenuated vaccines against herpes zoster have existed for many years, a recombinant vaccine against herpes zoster (RZV) has recently become available in several countries. Guidelines issued by national health authorities or vaccination committees provide healthcare professionals with information on practical aspects of vaccination. However, given the novelty of the RZV vaccine, we identified such guidelines in only ten countries (Austria, Canada, the Czech Republic, Germany, Ireland, Italy, Spain, the Netherlands, the United Kingdom, and the United States of America). We summarized these national RZV recommendations, focusing on herpes zoster vaccine preference, the age at which RZV is recommended, considerations before vaccination, vaccination schedule, the possibility of administering RZV together with other vaccines, vaccinating vulnerable populations and the safety of RZV. While national recommendations varied, most guidelines indicate that RZV is the preferred herpes zoster vaccine due to its high and persistent efficacy and as it can be administered to vulnerable populations who are at increased risk of herpes zoster and its complications. Recommendations have noted that side effects are common with RZV, however, most are of mild-moderate intensity and temporary (see also Figure 1).

Can COVID-19 Increase the Risk of Herpes Zoster? A Narrative Review.

Herpes zoster (HZ) is associated with substantial morbidity. It is caused by reactivation of the latent varicella zoster virus (VZV) following decline in cell-mediated immunity, which is commonly age-related, but also occurs in individuals with immunosuppressive diseases and/or treatment. Since coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, has been associated with T cell immune dysfunction and there have been reports of HZ in COVID-19 patients, we have performed a review of available literature on whether COVID-19 could trigger HZ. We identified 27 cases of HZ following COVID-19, which most frequently occurred within 1-2 weeks of COVID-19, and the majority of cases had typical presentation. Atypical presentations of HZ were noted especially in patients with lymphopenia. It has been hypothesized that VZV reactivation occurs as a consequence of T cell dysfunction (including lymphopenia and lymphocyte exhaustion) in COVID-19 patients. Based on current evidence, which is limited to case reports and case series, it is not possible to determine whether COVID-19 increases the risk of HZ. Practitioners should be aware of the possible increased risk of HZ during the pandemic period and consider timely therapeutic and preventive measures against it.

Towards adult vaccination in India: a narrative literature review.

Despite vast improvements in childhood vaccination coverage in India, adult vaccination coverage is negligible. Our aim was, therefore, to create awareness about the importance of adult immunization. Although the true burden of vaccine-preventable diseases (VPDs) among Indian adults is unknown, adults are particularly vulnerable during outbreaks, due to a lack of immunization, waning immunity, age-related factors (e.g. chronic conditions and immunosenescence), and epidemiological shift. There are no national adult immunization guidelines in India, and although several medical societies have published adult immunization guidelines, these vary, making it unclear who should receive which vaccines (based on age, underlying conditions, etc.). Other barriers to adult immunization include vaccine hesitancy, missed opportunities, and cost. Steps to improve adult vaccination could include: adoption of national guidelines, education of healthcare providers and the public, and promotion of life-course immunization. Improving adult vaccine coverage could help reduce the burden of VPDs, particularly among older adults.

Hexavalent Vaccines in India: Current Status.

Hexavalent vaccines containing diphtheria, tetanus, pertussis, Haemophilus influenzae type b, poliomyelitis, and hepatitis B virus antigens have the potential to be used for the primary series in India (6, 10, 14 weeks of age) and the toddler booster dose. Three hexavalent vaccines are available in India: DTwP-Hib/HepB-IPV (wP-hexa), DTaP-IPV-HB-PRP~T(2aP-hexa), and DTaP-HBV-IPV/Hib (3aP-hexa). In the three published phase-3 Indian studies, pertussis 'vaccine response' rates 1 month after a 6-10-14-week primary series were 68.4-75.7% for wP-hexa, 93.8-99.3% for 2aP-hexa, and 97.0-100% for 3aP-hexa; seroprotection rates for the other five antigens were 88.2-100%, 49.6-100%, and 98.6-100%, respectively. Studies outside India show: good immunogenicity/safety after boosting dosing; immune persistence to age 4.5 years (2aP-hexa), 7-9 years (3aP-hexa) (all antigens), and 9-10 and 14-15 years, respectively (hepatitis B); and successful co-administration with other vaccines. Hexavalent vaccines could reduce the number of injections, simplify vaccination schedules, and improve compliance.

Epidemiology of rotavirus gastroenteritis and need of high rotavirus vaccine coverage with early completion of vaccination schedule for protection against rotavirus diarrhea in India: A narrative review.

Rotavirus is a leading cause of severe pediatric diarrhea worldwide, with about 199,000 childhood deaths in 2015, of which 90% in low-income countries. India alone accounts for 22% of the global rotavirus gastroenteritis (RVGE)-related deaths among children below 5 years of age. The World Health Organization recommends introducing rotavirus vaccines (RVVs) as a priority in developing countries where high rates of RVGE are observed. To have the desired impact, RVV should be administered the earliest possible, ideally before the first episode of RVGE. In India, four RVVs are available for use in infants ≥6 weeks of age: the single-strain, two-dose, live-attenuated human RVV Rotarix; the five-strain, three-dose, human-bovine reassortant RVV Rotateq; the single-strain, three-dose, naturally reassortant human-bovine RVV Rotavac; and the five-strain, three-dose, human-bovine RVV Rotasiil; all of them proven to be efficacious and well tolerated. Whereas Rotarix and Rotateq have shown high efficacy/effectiveness against severe RVGE in developed countries (≥90%), they have been observed to be lower in developing countries (~40%-70%). Rotavac and Rotasiil have shown similar efficacy in low-income settings, but further studies are needed to assess their effectiveness. Rotarix and Rotateq have not shown increased intussusception (IS) risk in clinical trials. Postmarketing surveillances were able to show a very tiny increased risk of IS after the first dose of vaccine, but the extensive benefits of rotavirus vaccination far outweigh the low-level risk of IS. In India, where the disease is a major problem and occurs in very early months of life, RVVs should have high coverage and vaccination schedule should be completed as early as possible (≥6 weeks of age) to maximize the vaccine impact.

A New Combined Vaccine Against Measles, Mumps, Rubella and Varicella in India.

A quadrivalent MMRV (measles-mumps-rubella-varicella) combination vaccine has recently been launched in India. This vaccine is highly immunogenic, with seroconversion rates against all antigens reaching 96.6-100% at 42 to 56 days after the second vaccine dose in unvaccinated children or in those previously vaccinated with MMR+/-V. Two doses efficacy, against all varicella is 94.1% and effectiveness reaches 91%. The most frequent solicited local adverse event after MMRV vaccine is redness, and fever is the most common solicited general symptom. Higher rates of fever and febrile convulsions compared to MMR+/-V have been reported when used as first dose but not when used as the second of a measles containing vaccine, irrespective of age of the second dose.

A Questionnaire-Based Survey of Indian ENT Surgeons to Estimate Clinic Prevalence of Acute Otitis Media, Diagnostic Practices, and Management Strategies.

Acute otitis media (AOM) is common in Indian children, but there is limited published information on its clinic prevalence, clinicians' diagnostic practices, and their management strategies. We approached 649 ear-nose-throat (ENT) surgeons to assess these aspects of AOM. We conducted the survey between May 2010 and February 2011 with the same set of ENT surgeons practising across India, once each during summer, monsoon and winter, using a validated 36-item questionnaire to record their reflective recall. 78 % (506/649) of approached ENT surgeons responded. The clinic prevalence of AOM was 43 % with peaks reported in July and December. 96 % (486/506) of the surgeons used otoscopy to diagnose AOM. 86 % (435/506) prescribed analgesics, and 89 % (449/506) prescribed decongestants. 98 % (495/506) treated AOM with an antibiotic at initial consultation: amoxicillin/clavulanic acid 78 % (395/506), amoxicillin 29 % (144/506), cefpodoxime 29 % (149/506), cefixime 28 % (141/506) and azithromycin 27 % (134/506). Amoxicillin/clavulanic acid 32 % (162/506) and cefpodoxime 27% (137/506) were mostly prescribed for relapse. The average reported duration of initial antibiotic therapy was 7 days and for relapse was 9 days. The reported clinic prevalence of AOM was higher (43 %) than anticipated (about 10 %) in ENT practice. Almost all the ENT surgeons used an otoscope to diagnose AOM. Amoxicillin/clavulanic acid was the preferred antibiotic for treating AOM either initially or for relapse. Most surgeons also used analgesics and decongestants for symptomatic relief.

Time to sputum conversion in smear positive pulmonary TB patients on category I DOTS and factors delaying it.

BACKGROUND: Sputum smear positive pulmonary tuberculosis patients expel infectious viable bacilli for a period following commencement of treatment. Patients on Directly Observed Treatment Shortcourse (DOTS) receive intermittent therapy with multidrug regimen. AIMS: To determine the time to sputum smear and culture conversion following initiation of DOTS treatment and study the factors that influence it. METHODS: A prospective study was undertaken at a tertiary care teaching hospital in Mumbai over a one year period on a cohort of 71 sputum smear positive patients on Category I DOTS treatment. Patients were followed up weekly for upto 20 weeks or until they underwent smear and culture conversion whichever was earlier. At each follow up, specimens were collected and processed for microscopy and culture using standard protocol. RESULTS: 60/71 [84.55%] patients completed the study. 56/60 [93.3%] patients underwent sputum smear and culture conversion. The median time to smear and culture conversion was end of 5th week [day 35] and 6 1/2 weeks [day 45] respectively. Univariate and stepwise regression analysis showed that patients who had cavitatory disease, high pretreatment smear grade and a past history of tuberculosis were more likely to undergo delayed or nonconversion [P < 0.05]. CONCLUSION: The time to sputum smear and culture conversion under DOTS is similar to previous antituberculosis regimens. Since viable bacilli continue to be expelled for upto two months, infection control measures should be maintained for such time. Patients with cavitatory disease, high pretreatment smear grade or a past history of tuberculosis need to be monitored more closely.

Incremental yield in sputum smear positivity by examining a second early morning sputum specimen in follow-up patients on DOTS: 7 year analysis of RNTCP laboratory register.

BACKGROUND: Patients receiving DOTS undergo periodic follow-up sputum examination, which aids in monitoring response to treatment. Continued or new smear positivity at follow up examination entails extension of intensive phase or change in treatment category and the need for culture and drug susceptibility test. SETTING: Tuberculosis microscopy centre at a tertiary care teaching hospital, Mumbai, India. OBJECTIVE: To determine the incremental yield in sputum smear positivity by examining a second early morning sputum specimen in follow-up patients on DOTS. DESIGN: Retrospective analysis of follow up sputum microscopy results recorded in tuberculosis laboratory register for the period 2002-2008. RESULTS: During the study period, 5015 follow-up patients submitted two early morning sputum specimens, of which 501(9.99%) patients were detected to be smear-positive. Out of smear positive patients under study, 324 patients had both specimens positive, 79 patients had only first specimen positive and 98 patients had only second specimen positive. The incremental yield was 1.95% of total and 19.5% of smear positives. CONCLUSION: Discordant smears were present in nearly a third of patients detected smear positive during follow-up. More than half of these patients were detected only by examining second specimen. The incremental yield by examining the second early morning specimen was 1.95% of total and 19.5% of smear positive specimens. It is important to detect each possible smear positive follow-up patient as they are likely to benefit from altered treatment. The inclusion of a second early morning sputum specimen examination is essential to maximize their detection.