Immunogenicity of measles-rubella vaccine administered under India’s Universal Immunization Programme in the context of measles rubella elimination goal: A longitudinal study

Background & objectives: There is a paucity of data regarding immunogenicity of recently introduced measles–rubella (MR) vaccine in Indian children, in which the first dose is administered below one year of age. This study was undertaken to assess the immunogenicity against rubella and measles 4-6 wk after one and two doses of MR vaccine administered under India’s Universal Immunization Programme (UIP). Methods: In this longitudinal study, 100 consecutive healthy infants (9-12 months) of either gender attending the immunization clinic of a tertiary care government hospital affiliated to a medical college of Delhi for the first dose of routine MR vaccination were enrolled. MR vaccine (0.5 ml, subcutaneous) was administered to the enrolled participants (1st dose at 9-12 months and 2nd dose at 15-24 months). On each follow up (4-6 wk post-vaccination), 2 ml of venous blood sample was collected to estimate the antibody titres against measles and rubella using quantitative ELISA kits. Seroprotection (>10 IU/ml for measles and >10 WHO U/ml for rubella) and antibody titres were evaluated after each dose. Results: The seroprotection rate against rubella was 97.5 and 100 per cent and against measles was 88.7 per cent and 100 per cent 4-6 wk after the first and second doses, respectively. The mean (standard deviation) titres against rubella and measles increased significantly (P<0.001) after the second dose in comparison to the levels after the first dose by about 100 per cent and 20 per cent, respectively. Interpretation & conclusions: MR vaccine administered below one year of age under the UIP resulted in seroprotection against rubella and measles in a large majority of children. Furthermore, its second dose resulted in seroprotection of all children. The current MR vaccination strategy of two doses, out of which the first is to be given to infants below one year of age, appears robust and justifiable among Indian children.

Corneal manifestations and treatment among patients with COVID-19-associated rhino-orbito-cerebral mucormycosis

Purpose: TO report the corneal manifestations in patients with COVID?19?associated rhino?orbito?cerebral mucormycosis (ROCM). Methods: This study was a retrospective, observational, and record?based analysis of patients of ROCM with corneal involvement. Results: A total of 220 patients were diagnosed with ROCM over a period of 3 months. Thirty?two patients had developed corneal manifestations. The mean age at diagnosis was 52.84 ± 12.8 years. The associated risk factors were systemic mucormycosis, uncontrolled diabetes, recent COVID?19 infection, and injudicious use of systemic steroids. Twenty?nine patients were known diabetics, 32 had recent COVID?19 infection, and 13 gave a history of injudicious use of steroids. The right eye (RE) was affected in nine patients, the left eye (LE) in 20 patients, and both eyes in three patients. Nine patients had a round?oval corneal ulcer. One patient each had a perforated corneal ulcer with uveal prolapse, sealed perforated corneal ulcer, spontaneously healed limbal perforation, diffuse corneal haze with hyphemia, panophthalmitis, diffuse corneal stromal abscess, limbal ischemia, anterior uveitis with posterior synechiae, inferior corneal facet, and filamentary keratitis. Three patients each had a corneal melt and inferior conjunctival xerosis with chemosis. Orbital exenteration was performed in six patients. Five patients with corneal ulcers healed. Topical eye drops of amphotericin (0.5 mg/ ml) cycloplegic, antiglaucoma medications, and lubricant eye drops were started along with systemic antifungals. Conclusion: Central corneal ulcer was the most common manifestation of mucormycosis. A concentration as low as 0.5 mg/ml of amphotericin eye drops was effective in the treatment.

Aetiology of hospital-acquired diarrhoea in under-five children from an urban hospital in East Delhi, India

Background & objectives: Majority of the studies of hospital-acquired diarrhoea conducted in Western countries have focused on the detection of Clostridium difficile in stool samples. Limited Asian and Indian literature is available on hospital-acquired diarrhoea. This study was aimed to describe the aetiological profile for hospital-acquired diarrhoea in children aged below five years. Methods: One hundred children aged one month to five years who developed diarrhoea (?3 loose stools for >12 h) after hospitalization for at least 72 h were enrolled. Children who were prescribed purgatives or undergoing procedures such as enema and endoscopy or those with underlying chronic gastrointestinal disorders such as celiac disease and inflammatory bowel disease were excluded from the study. Stool samples from the enrolled children were subjected to routine microscopic examination, modified Ziel- Nielson (ZN) staining for Cryptosporidium and culture for various enteropathogens. Multiplex PCR was used to identify the strains of diarrhoeagenic Escherichia coli. Rotavirus detection was done using rapid antigen kit. Toxins (A and B) of C. difficile were detected using enzyme immunoassay. Results: Of the 100 samples of hospital-acquired diarrhoea analysed, diarrhoeagenic E. coli (DEC) was found to be the most common organism, detected in 37 per cent of cases (enteropathogenic E. coli-18%, enterotoxigenic E. coli-8%, enteroaggregative E. coli-4% and mixed infections-7%). Cryptosporidium was detected in 10 per cent of cases. Rotavirus was detected in six per cent and C. difficile in four per cent of cases. Interpretation & conclusions: The findings of this study suggest that the aetiological profile of hospital- acquired diarrhoea appears to be similar to that of community-acquired diarrhoea, with DEC and Cryptosporidium being the most common causes. The efforts for the prevention and management of hospital-acquired diarrhoea should, thus, be directed towards these organisms.

Multiple nodules accompanied by pulmonary nocardiosis in a patient with systemic lupus erythematosus

Background:A retrospective case series study was done onforearm diaphyseal fracture in adolescents treated with TENS (titanium elastic nailing system).Purpose of the study was analysis of functional outcome of TENS in forearm diaphyseal fractures in children between 12-18 year age group. Methods:We retrospectively evaluated 30 patients operated by same senior surgeon during the period from March 2014 to February 2015 with closed diaphyseal forearm fractures in age group 12–18 years treated with TENS in whom closed reduction could not be achieved. Nail diameter taken as 33-40% of narrowest diameter of diaphysys were introduced proximally in ulna and distally in radius under image intensifier in closed manner. Postoperatively, patients encouraged for active shoulder, elbow and finger movements and suture removal done after 2 weeks. Patients were followed up for minimum period of one year.Results:In terms of union and range of motion using Anderson et al criteria 24 patients had excellent results, 4 patients had satisfactory results and one patienthad poor result having non-union of ulna. Two patients had superficial infection at the nail entry site which eventually resolved. One patient lost for follow up.Conclusions:We conclude that TENS in both bone forearm fractures in adolescent age group interms of union and range of motion is a minimally invasive and effective method of fixation.

Molecular detection of Plasmodium falciparum and Plasmodium vivax prevalence in North Indian population

Currently, malaria ranks as the 5th major cause of death in developing countries. There are six human malarial parasites species, with Plasmodium falciparum (Pf) and P. vivax (Pv) being the most predominant. This study enrolled 165 outpatients of a tertiary care hospital of the northeast district of Delhi. Blood samples were taken and were examined for malaria by slide microscopy and rapid malarial antigen detection test. DNA extraction was done and PCR was performed for genus as well as species identification. A total of 60 (36.36%) malaria positive samples were identified among a total of 165 samples collected. P. vivax and P. falciparum were found to be present in 51.66 and 13.33% samples, respectively and 18.33% samples were positive for both the species on the basis of PCR analysis. The present study suggests that while the traditional methods for diagnosis of malarial infection are gold standard they will not be able to detect mixed infections with low parasite count

Serum Interleukin-6 Levels in Children with Febrile Seizures

Objectives: To compare levels of Interleukin-6 (IL-6) in children with febrile seizures andfebrile controls. Methods: Study conducted in a tertiary-care hospital in Northern India fromNovember 2013 to April 2015, enrolling 160 children (80 each with febrile seizures and febrilecontrols), aged 6 – 60 months. Serum IL-6 estimated by ELISA method. Iron study done asper standard technique. All the cases of febrile seizure were followed up at 1 week, 3 monthsand 6 months for recurrence of seizures. Results: The mean serum IL-6 levels in childrenwith febrile seizures was 62.0 (63.9) pg/mL and febrile controls was 86.9 (70.6) pg/mL(P=0.025). Conclusion: Serum IL-6 levels were significantly lower in children with febrileseizures as compared to febrile controls.

Application of a stool antigen test to evaluate the burden of Helicobacter pylori infection in dyspepsia patients.

Helicobacter pylori (HP) is causally associated with peptic ulcer disease and gastric carcinoma. Determination of the prevalence of HP infection in dyspepsia patients’ in particular geographical area is imperative for the appropriate management of dyspepsia. HP antigen detection in stool is a noninvasive diagnostic test of HP infection. This prospective study was conducted to find out the prevalence of HP infection based on stool antigen testing in dyspeptic patients who had also undergone upper gastrointestinal (GI) endoscopy. This study highlights the high prevalence of HP infection in dyspeptic Indian patients, particularly males, and emphasizes the growing importance of the bacterium causing infection among children. We also found HP stool antigen testing to be superior to upper GI endoscopy for detecting HP infection. Hence, we recommend initial testing for HP stool antigen in dyspeptic patients before initiating treatment and before carrying out any invasive procedure such as endoscopy.

Fatal Superadded Nocardia Infection in a Case of Pulmonary Aspergillosis.

Pulmonary nocardiosis is a severe opportunistic infection in which chronic lung disease along with long term steroid therapy is the most significant predisposing factor. Demonstration of Nocardia in even potentially contaminated sample like sputum, warrant strong warning signal of association of the organism with the clinical condition because Nocardia are rarely encountered as laboratory contaminants. Immediate initiation of appropriate treatment is absolutely essential since any delay in diagnosis or treatment may prove detrimental to the extent of complete fatal outcome.

Comparative efficacy of continuous and pulse dose terbinafifine regimes in toenail dermatophytosis: A randomized double-blind trial.

Introduction: Dermatophytes are the most frequently implicated agents in toenail onychomycosis and oral terbinafi ne has shown the best cure rates in this condition. The pharmacokinetics of terbinafi ne favors its effi cacy in pulse dosing. Objectives: To compare the effi cacy of terbinafi ne in continuous and pulse dosing schedules in the treatment of toenail dermatophytosis. Methods: Seventy-six patients of potassium hydroxide (KOH) and culture positive dermatophyte toenail onychomycosis were randomly allocated to two treatment groups receiving either continuous terbinafi ne 250 mg daily for 12 weeks or 3 pulses of terbinafi ne (each of 500mg daily for a week) repeated every 4 weeks. Patients were followed up at 4, 8 and12 weeks during treatment and post-treatment at 24 weeks. At each visit, a KOH mount and culture were performed. In each patient, improvement in a target nail was assessed using a clinical score; total scores for all nails and global assessments by physician and patient were also recorded. Mycological, clinical and complete cure rates, clinical effectivity and treatment failure rates were then compared. Results: The declines in target nail and total scores from baseline were signifi cant at each follow-up visit in both the treatment groups. However, the inter-group difference was statistically insignifi cant. The same was true for global assessment indices, clinical effectivity as well as clinical, mycological, and complete cure rates. Limitations: The short follow-up in our study may have led to lower cure rates being recorded. Conclusion: Terbinafi ne in pulse dosing is as effective as continuous dosing in the treatment of dermatophyte toenail onychomycosis.

Vaccines for fungal infections

High morbidity and mortality caused by mycotic infections has been a cause for concern. Trials for various vaccines against fungal pathogens have not been approved by the US Food and Drugs Administration because of the high cost of production and lack of a single suitable candidate. Most fungal infections require cell-mediated immunity for their clearance. This has been the basis for the development of various vaccines. We discuss the various trials of candidate vaccines, the protective efficacy as well as their shortcomings. Recent research suggests that a universal vaccine can be prepared which may be effective against most fungal pathogens.

Cryptosporidium in Children with Diarrhea: A Hospital-based Study.

Objective: To estimate the proportionate contribution of Cryptosporidium to diarrhea in under-five children, and to study its demographic and clinical associates Methods: We collected stool specimens from children (age <5 yrs) suffering from diarrhea. The specimen was examined on the same day by Kinyoun’s acid-fast staining for the presence of Cryptosporidium parvum oocyst; rest of the sample was preserved for later cryptosporidium antigen detection by commercially available ELISA kit. Results: Out of 175 children with diarrhea, 48 (27.4%) had Cryptosporidium antigen in their stool specimen. Gender, history of contact with domestic animal, hydration status, breastfeeding and nutritional status were not significantly associated with cryptosporidium infection in children with diarrhea. Conclusion: Cryptosporidium is present in a significant portion of children suffering from diarrhea in our setting. Antigen detection has much higher isolation rate than acid-fast staining.

Immune response to second dose of MMR vaccine in Indian children.

Background & objectives: MMR vaccine in a two dose schedule has successfully eliminated measles, mumps and rubella from many developed countries. In India, it is not a part of national immunization programme but is included in the State immunization programme of Delhi as a single dose between 15-18 months. This prospective study was carried out to assess the extent of seroprotection against these three diseases in immunized children and to study the immune response to a second dose of MMR. Methods: Consecutive children aged 4-6 yr, attending the immunization clinic of a tertiary care hospital in Delhi for routine DT vaccination, were enrolled. Second dose of MMR was given and pre- and post-vaccination antibody levels were compared. Results: The pre-vaccination percentage seropositivity observed in the 103 children recruited, was 20.4 per cent for measles, 87.4 per cent for mumps and 75.7 per cent for rubella. Amongst the 84 children who were followed up after the second dose, the percentage seroprotection for measles rose from 21.4 (18/84) to 72.6 per cent (61/84) and 100 per cent became seroprotected to mumps and rubella. Interpretation & conclusions: The percentage of children protected against measles was found to be alarmingly low which needs to be investigated. Though the observed protection against mumps and rubella was adequate, its durability was not known. The need for re-appraisal of the current MMR immunization policy is called for by carrying out longitudinal studies on a larger sample.

Single Dose Azithromycin Versus Ciprofloxacin for Cholera in Children: A Randomized Controlled Trial.

Objective: To compare the clinical and bacteriological success of single dose treatment with azithromycin and ciprofloxacin in children with cholera. Design: Randomized, open labelled, clinical controlled trial. Setting: Tertiary care hospital. Participants: 180 children between 2-12 years, having watery diarrhea for ≤24 hr and severe dehydration, who tested positive for Vibrio cholerae by hanging drop examination or culture of stool. Intervention: Azithromycin 20 mg/kg single dose (n=91) or Ciprofloxacin 20 mg/kg single dose (n=89). Dehydration was managed according to WHO guidelines. Main outcome measures: Clinical success (resolution of diarrhea within 24 hr) and bacteriological success (cessation of excretion of Vibrio cholerae by day 3). Secondary outcome variables included duration of diarrhea, duration of excretion of Vibrio cholerae in stool, fluid requirement, and proportion of children with clinical or bacteriological relapse. Results: The rate of clinical success was 94.5% (86/91) in children treated with Azithromycin and 70.7% (63/89) in those treated with Ciprofloxacin [RR (95% CI)=1.34 (1.16- 1.54); P<0.001]. Bacteriological success was documented in 100% (91/91) children in Azithromycin group compared to 95.5% (85/89) in Ciprofloxacin group [RR (95% CI)=1.05 (1.00-1.10); P=0.06]. Patients treated with Azithromycin had a shorter duration of diarrhea [mean(SD) 54.6 (18.6) vs 71.5 (29.6) h; mean difference (95% CI) 16.9 (9.6–24.2); P<0.001] and lesser duration of excretion of Vibrio cholerae [mean(SD) 34.6 (16.3) vs 52.1 (29.2) h; mean difference (95% CI) 17.5 (0.2–24.7), P<0.001] in children treated with Azithromycin vs Ciprofloxacin. The amount of intravenous fluid requirement was significantly less among subjects who received Azithromycin as compared to those who received Ciprofloxacin [mean(SD) 4704.7(2188.4) vs 3491.1(1520.5) mL; Mean difference (95% CI) 1213(645.3–1781.9); P<0.001]. Proportion of children with bacteriological relapse was comparable in two groups [6.7% (6/89) vs 2.2% (2/91); RR (95% CI) 0.95 (0.89–1.01); P=0.16]. None of the children in either group had a clinical relapse. Conclusion: Single dose azithromycin is superior to ciprofloxacin for treating cholera in children.

Serological profile of HSV-2 in patients attending STI clinic: Evaluation of diagnostic utility of HSV-2 IgM detection.

Objective: The present study was done to evaluate the serological profile of herpes simplex virus-2 (HSV-2) among patients attending sexually transmitted infections (STI) clinic and to determine the utility of detecting HSV-2 IgM antibodies in such patients. A correlation of HSV-2 infection with other STI including HIV has also been attempted. Materials and Methods: Hundred consecutive patients who attended STI clinic, with one or more of the complaints as enunciated by WHO in syndromic approach for the diagnosis of STI, were included as subjects. All subjects were screened for common STI by standard laboratory procedures/ commercially available kits. HSV-1 and HSV-2 IgM antibody was detected by commercially available enzyme immuno assay kit in all patient's sera. Sera were also tested for other STI, namely HIV, Hepatitis B virus, Hepatitis C virus and Treponema pallidum. Antigen detection for Chlamydia trachomatis was done in genital swabs of all patients by Bio-Rad Chlamydia Microplate EIA 31189 (United States) kit. Results: Thirty patients were found to have genital herpes. In 17/30 (56.6%) patients, HSV-2 serology was found to correlate with the clinical diagnosis. The coexistence of other infection in HSV-2 seropositive patients was detected in 8/30 patients. None of the patients having concomitant infections were clinically diagnosed accurately. Sensitivity, specificity, positive predictive value and negative predictive value of IgM antibodies for the diagnosis of genital herpes was 73.91%, 90.91%, 70.83% and 92.91% respectively. Conclusion: HSV-2 IgM detection could only be used as a supportive test for the diagnosis of genital herpes . It needs to be emphasized that the sensitivity and positive predictive value scores are pointers for further improvement in the commercial assay systems and a large sample size may determine the broader utility of such systems.

Pattern of Candida isolates in hospitalized children.

Nosocomial candidemia is the 4(th) most common pathogen in blood stream infection. Emergence of non-albicans Candida species with often intrinsically resistance fluconazole pattern may lead to difficulty in management of septicemia. Although the present study isolated 80% of non albicans candida species with C.tropicalis as the most common (35%) species, 96% of our Candida species isolated were sensitive to fluconazole. The probable causes of low resistance pattern to fluconazole in our institute are discussed. It is however necessary to identify the complete clinical response to the given treatment. Therefore, appropriate identification of species with susceptibility testing would be advisable before start of anti-fungals. This would prevent emergence of fluconazole resistance.

Trend of antibiotic resistance of Vibrio cholerae strains from East Delhi.

BACKGROUND & OBJECTIVE: Epidemics of cholera caused by toxigenic Vibrio cholerae O1 and O139 (Bengal strain) represent a major public health problem in most developing countries. In view of the reported shift in epidemiology and pattern of antibiotic resistance in this was study carried out to assess the development of resistance to essential drugs like fluoroquinolones during treatment of cholera and cholera like cases in Delhi. METHODS: Faecal specimens collected from 1184 patients with cholera and cholera like illness between 2001-2006 admitted to Guru Teg Bahadur hospital, East Delhi were subjected to culture isolation. Antimicrobial susceptibility testing of V. cholerae isolates was done by disc diffusion method. RESULTS: Of the 1184 faecal samples examined, 670 (56.6%) were positive for V. cholera from 2001- 2006. V. cholerae El Tor Ogawa (54.6%) was more common than serotype Inaba (32.5%). During 2004-2006 V. cholerae Inaba emerged as the predominant serotype. Resistance to nalidixic acid, furazolidone and co-trimoxazole was constantly high (100%). Multiple antibiotic resistance (MAR) V. cholerae O1 Inaba isolates exhibited increased resistance to ciprofloxacin with MIC >4 microg/ml, but largely all remained susceptible to other antibiotics like, gentamicin, tetracycline and chloramphenicol. INTERPRETATION & CONCLUSION: V. cholerae have a permanent existence in the environment and during the quiescent period, their survival in water bodies allows dissipation of resistance patterns to different serotypes or strains of V. cholerae O1 and therefore there is need for constant observation.

Fecal occult blood screening in children with severe malnutrition.

We screened 50 consecutive severely malnourished children for evidence of gastrointestinal tract blood loss. Malnutrition was graded as per WHO recommendations. Gastrointestinal blood loss was detected using fecal occult blood test (FOBT) kit. Thirty (60%) of the study population were documented to be FOBT positive. This simple and rapid test is recommended as a routine screening procedure among severely malnourished children for the detection and timely treatment of occult blood loss, contributing to anemia and related complications.

Cytomegalovirus and rubella infection in children and pregnant mothers--a hospital based study.

Cytomegaloviruses (CMV) are ubiquitous and species-specific. Humans are believed to be the only reservoir of this virus and transmission occurs by direct or indirect person-to-person contact. Vertical transmission can lead to serious congenital infections. Rubella virus causes serious disease after vertical transmission but mostly remain subclinical or cause a trivial infection that may remain unrecognized. The objective of our study was to find the prevalence of CMV and rubella infection in the vulnerable section of our population attending GTB hospital. GroupI included pregnant women with bad obstetric history (BOH) (n=1115); GroupII normal pregnant women (n=500); Group III pediatric age group (n==585) and Group IV others with varied illness (n=100). Serologically IgM antibodies against CMV and rubella were detected using commercially available Elisa kit. The percentage prevalence in groupI was (11%) and (3.6%); groupII was (4%) and (0); groupIII was (12%) and (3%); group IV was (5%) and (1%) against CMV and rubella respectively. No apparent seasonal variation was observed in the pattern of infection. Also, overall infection rates were at a much lower rate as compared to other studies. Therefore the detection of IgM antibodies in early pregnancy is an important tool to identify active infection and to provide obstetric management to avoid the risk of congenital transmission of infection. This in turn may lead to a rethinking of current immunization strategies and appropriate modifications for the prevention of vertical infection.

Mycological profile of infectious Keratitis from Delhi.

BACKGROUND & OBJECTIVE: Corneal blindness is a major health problem worldwide and infectious keratitis is one of the predominant causes. The incidence of fungal keratitis has increased over the last few years. Though a few studies have been carried out on mycotic keratitis from north and other parts of India, there are none from Delhi. Keeping this in mind, this study was conducted to evaluate the frequency of positive fungal cultures in infectious keratitis and of the various fungal species identified as aetiologic agents in patients attending a tertiary care hospital in East Delhi. METHODS: Corneal scrapings from 346 patients of corneal ulcer with suspected fungal aetiology were subjected to direct examination by 10 per cent KOH mount, Gram stain and culture. The results were examined retrospectively and analyzed. RESULTS: Of the 346 patients of corneal ulcer investigated, in 77 (22.25%) cases fungal aetiology was identified. Males were more commonly affected and were mostly in the age group of 31-40 yr. It was seen that trauma was the most common predisposing factor especially in the agriculturists and the farmers. Aspergillus flavus was the most common fungus isolated in 31.16 per cent cases, followed by A. fumigatus (16.88%) and Fusarium spp. (7.79%). Yeasts were also isolated in 21.62 per cent cases. Both yeasts and mycelial fungi were isolated in 6.5 per cent of cases. INTERPRETATION & CONCLUSION: Because of serious consequences of infectious keratitis, it is important to know the exact aetiology of corneal ulcer to institute appropriate therapy in time. Laboratory confirmation should be undertaken and fungal infection should be ruled out before prescribing corticosteroids and antibacterial antibiotics.