The burden of dengue and force of infection among children in Kerala, India; seroprevalence estimates from Government of Kerala-WHO Dengue study.

Background: Dengue shows high geographic heterogeneity within and across endemic countries. In the context of increasing burden and predicted outbreaks due to climate change, understanding the heterogeneity will enable us to develop region specific targeted interventions, including vaccination. World Health Organisation (WHO) suggests standard methodologies to study the burden and heterogeneity at national and subnational levels. Regional studies with robust and standard methodology to capture heterogeneity are scarce. We estimated the seroprevalence of dengue in children aged 9-12 years and the force of infection in Kerala, India, from where Zika cases also have been reported recently. Methods: We conducted a school-based cross-sectional survey in 38 clusters; selected by stratified random sampling, representing rural, urban, high burden and low-burden administrative units. Validation of Indirect IgG ELISA was done by Plaque Reduction Neutralization Test (PRNT90) using the local isolates of all four serotypes. Force of infection (FOI) was estimated using the WHO-FOI calculator. We conducted a follow-up survey among a subsample of seronegative children, to estimate the rate of sero-conversion. Results: Among 5236 children tested, 1521 were positive for anti-dengue IgG antibody. The overall seroprevalence in the state was 29% (95% CI 24.1-33.9). The validity corrected seroprevalence was 30.9% in the overall sample, 46.9% in Thiruvananthapuram, 26.9% in Kozhikkode and 24.9% in Kollam. Age-specific seroprevalence increased with age; 25.7% at 9 years, 29.5% at 10 years, 30.9% at 11 years and 33.9% at 12 years. Seroprevalence varied widely across clusters (16.1%-71.4%). The estimated force of infection was 3.3/100 person-years and the seroconversion rate was 4.8/100 person-years. 90% of children who tested positive were not aware of dengue infection. All the four serotypes were identified in PRNT and 40% of positive samples had antibodies against multiple serotypes. Interpretation: The study validates the WHO methodology for dengue serosurveys and confirms its feasibility in a community setting. The overall seroprevalence in the 9-12 year age group is low to moderate in Kerala; there are regional variations; high burden and low burden clusters co-exist in the same districts. The actual burden of dengue exceeds the reported numbers. Heterogeneity in prevalence, the high proportion of inapparent dengue and the hyperendemic situation suggest the need for region-specific and targeted interventions, including vaccination. Funding: World Health Organization.

Institutional quarantine centres as a strategy in control of COVID-19 outbreak: An evolving model from Kerala, India.

BACKGROUND: Institutional quarantine centres were set up in all districts in Kerala as a novel strategy in the fight against novel COVID-19 virus. These were meant for returnees from affected areas, for whom home quarantine was not possible due to lack of facilities. This research aims to evaluate facilities and services of Institutional quarantine centres in Thiruvananthapuram district, Kerala state and to study profile of persons under quarantine in these centres. METHODS: A cross-sectional study was conducted to evaluate institutional quarantine centres established in Thiruvananthapuram district of Kerala in April 2020. Evaluation was done using a checklist based on standard operating procedures for functioning of centres issued by Health department. Inspection of facilities and registers was done. Details of a subset of inmates were collected by telephonic interviews using a semi-structured questionnaire. RESULTS: Two (0.41%) inmates in the centre turned positive on testing while in quarantine. Both of them were foreign returnees and were asymptomatic. There was not a single case of transmission of infection between inmates or to staff and volunteers. The adherence to infection control practices was satisfactory in all centres. One third of inmates were from listed highly affected countries and were mandatorily quarantined. CONCLUSION: Institutional quarantine centres were functioning effectively to provide quarantine facilities for high-risk individuals and thereby controlling the spread of COVID-19. Selection of facilities, staffing pattern and day to day functioning of these centres is a model which can be replicated at other COVID-19 affected areas.

The Conundrum of Ventricular Dilatations Following Decompressive Craniectomy: Is Ventriculoperitoneal Shunt, The Only Panacea?

INTRODUCTION: Ventriculomegaly and hydrocephalus (HCP) are sometimes a bewildering sequela of decompressive craniectomy (DC). The distinguishing criteria between both are less well defined. Majority of the studies quoted in the literature have defined HCP radiologically, rather than considering the clinical status of the patient. Accordingly, these patients have been treated with permanent cerebrospinal fluid (CSF) diversion procedures. We hypothesize that asymptomatic ventriculomegaly following DC should undergo aspiration with cranioplasty and be followed up regularly. MATERIALS AND METHODS: All patients with post-DC who were scheduled for cranioplasty and satisfied the radiological criteria for HCP were included. These patients were categorized into two groups. Group 1 included ventriculomegaly with clinical signs attributable to HCP and Group 2 constituted ventriculomegaly but no clinical signs attributable to HCP. All patients in Group 1 underwent ventriculoperitoneal shunt followed by cranioplasty, whereas all patients in Group 2 underwent cranioplasty along with simultaneous ventriculostomy and temporary aspiration of the lateral ventricle. All patients were regularly followed as the outpatient basis. RESULTS: There were 21 patients who developed ventriculomegaly following DC. There were 10 patients in Group 1 and 11 patients in Group 2. The average duration of follow-up was from 6 months to 2 years. Two patients in the shunt group - (group 1) had over drainage and required revision. One patient in aspiration group - (group 2) required permanent CSF diversion. CONCLUSIONS: Cranioplasty with aspiration is a viable option in selected group of patients in whom there is ventriculomegaly but no signs or symptoms attributable to HCP.

Benign cephalic histiocytosis.

A one and a half year old girl born of a non-consanguineous marriage presented with multiple asymptomatic erythematous to hyperpigmented and skin colored papules on both cheeks slowly increasing in number of 1 year duration. On the basis of clinical, histopathological, and immunohistochemistry findings, a diagnosis of benign cephalic histiocytosis was made.

Controlling oxygenation during initiation of cardiopulmonary bypass: can it improve immediate postoperative outcomes in cyanotic children undergoing cardiac surgery? A prospective randomized study.

OBJECTIVE: Cardiopulmonary bypass (CPB) initiated with high oxygen levels may expose cyanotic children to reoxygenation injury. The ideal method of initiation of bypass to prevent this phenomenon still remains largely unproven. This study tested the hypothesis that controlling oxygenation during initiation of CPB improves early postoperative outcomes. METHODS: Thirty-one cyanotic children were randomized to two treatment arms of the study. In group A (intervention), CPB was initiated with fraction of inspired oxygen (Fio 2) 0.21, and after one minute of full bypass, Fio 2 was increased at increments of 0.1 per minute to reach 0.6. In group B (hyperoxemic), CPB was initiated using Fio 2 >0.6. Aortic cross clamp time (minutes), CPB time (minutes), creatine phosphokinase-MB (CPK-MB) levels (U/L), lactate levels (mmol/L), duration of ventilator support (hours), inotropic support (hours), and intensive care unit (ICU) stay (hours) as well as hospital mortality were measured. RESULTS: Levels of CPK-MB (group A mean = 59.6 U/L, 95% confidence interval [CI]: 45.9-73.3; group B mean = 82.6 U/L, 95% CI: 66.1-99.1, P = .016) and ventilation time (group A median = 16.5 hours; interquartile range [IQR] = 11.25-23; group B median = 27.5 hours; IQR = 17-54, P = .045) were significantly lower in the intervention group. Other parameters showed no significant differences: CPB time (group A median = 71.5 minutes, IQR = 64-100; group B median = 95.5 minutes, IQR = 58-145, P = .71), cross clamp time (group A mean = 59.2 minutes, 95% CI: 47.6-70.8; group B mean = 66.57 minutes, 95% CI: 47.6-88.5, P =.57), lactate levels (mmol/L; group A median = 1.8, IQR = 1.48-2.59; group B median = 2.1, IQR = 1.29-2.62, P = 1), inotropic support (group A median = 47.5 hours, IQR = 36-73.75; group B median = 59.5 hours, IQR = 41.75-92.5, P = .27), ICU stay (group A median = 59.5 hours, IQR = 48.25-118.5; group B median = 85 hours, IQR = 47.75-137.50, P = .21), and mortality (group A n = 2, group B n = 2). CONCLUSION: A controlled oxygenation protocol was associated with significantly lower postoperative CPK-MB levels. Evaluation of other end points including ventilation times requires a study with larger sample size for validation.