Trends of humoral immune responses to heterologous antigenic exposure due to vaccination & omicron SARS-CoV-2 infection: Implications for boosting

Background & objectives: Vaccination and natural infection can both augment the immune responses against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), but how omicron infection has affected the vaccine-induced and hybrid immunity is not well studied in Indian population. The present study was aimed to assess the durability and change in responses of humoral immunity with age, prior natural infection, vaccine type and duration with a minimum gap of six months post-two doses with either ChAdOx1 nCov-19 or BBV152 prior- and post-emergence of the omicron variant. Methods: A total of 1300 participants were included in this observational study between November 2021 and May 2022. Participants had completed at least six months after vaccination (2 doses) with either ChAdOx1 nCoV-19 or an inactivated whole virus vaccine BBV152. They were grouped according to their age (? or ?60 yr) and prior exposure of SARS-CoV-2 infection. Five hundred and sixteen of these participants were followed up after emergence of the Omicron variant. The main outcome was durability and augmentation of the humoral immune response as determined by anti-receptor-binding domain (RBD) immunoglobulin G (IgG) concentrations, anti-nucleocapsid antibodies and anti-omicron RBD antibodies. Live virus neutralization assay was conducted for neutralizing antibodies against four variants – ancestral, delta and omicron and omicron sublineage BA.5. Results: Before the omicron surge, serum anti-RBD IgG antibodies were detected in 87 per cent participants after a median gap of eight months from the second vaccine dose, with a median titre of 114 [interquartile range (IQR) 32, 302] BAU/ml. The levels increased to 594 (252, 1230) BAU/ml post- omicron surge (P<0.001) with 97 per cent participants having detectable antibodies, although only 40 had symptomatic infection during the omicron surge irrespective of vaccine type and previous history of infection. Those with prior natural infection and vaccination had higher anti-RBD IgG titre at baseline, which increased further [352 (IQR 131, 869) to 816 (IQR 383, 2001) BAU/ml] (P<0.001). The antibody levels remained elevated after a mean time gap of 10 months, although there was a decline of 41 per cent. The geometric mean titre was 452.54, 172.80, 83.1 and 76.99 against the ancestral, delta, omicron and omicron BA.5 variants in the live virus neutralization assay. Interpretation & conclusions: Anti-RBD IgG antibodies were detected in 85 per cent of participants after a median gap of eight months following the second vaccine dose. Omicron infection probably resulted in a substantial proportion of asymptomatic infection in the first four months in our study population and boosted the vaccine-induced humoral immune response, which declined but still remained durable over 10 months

Assessing contrast sensitivity change in retinal diseases with use of yellow-amber NoIR glasses

Purpose: The purpose of this study was to assess change of contrast sensitivity (CS) in subjects having retinal diseases with yellow?amber no infrared (NoIR) glasses used as low vision aid (LVA). Methods: We examined CS in 82 low vision (LV) subjects having retinal diseases with Pelli Robson Chart at 1 m distance before and after wearing yellow?amber NoIR glasses. We also found type of retinal affection and macular optical coherence tomography (OCT) features. Results: The distance and near best?corrected visual acuity (BCVA) was, respectively, 0.68 ± 0.17 (median = 0.70) and 0.72 ± 0.25 (median = 0.70) logmar units. The pre?LVA CS was 0.52 ± 0.29 (median = 0.3) and post? LVA was 0.52 ± 0.28 (median = 0.45) logunits (mean reduction = ?0.002 ± 0.24; Median reduction = 0; P = 0.909). The pre?LVA and post?LVA CS showed a negative correlation with logmar distance BCVA [r = ?0.090; P = 0.317 and r = ?0.152; P = 0.090 respectively]. The pre?LVA and post?LVA CS showed a negative correlation with logmar near BCVA [r = ?0.114; P = 0.207 and r = ?0.054; P = 0.549 respectively]. The CS did not improve in subjects having macular degeneration, pathological myopia, hereditary maculopathy, and diabetic retinopathy. The macular OCT features like fluid, exudates, scars, drusens, traction, and hole did not significantly influence CS both at pre?LVA and post?LVA stage. Conclusion: This is the first study with yellow?amber NoIR glasses which blocks “both ultraviolet and infrared light.” The subjects having macular degeneration, pathological myopia, hereditary maculopathy, and diabetic retinopathy did not improve in CS with filters. The correlation values showed that filters may improve CS in subjects having good baseline BCVA.

Text messaging improves diabetes-related knowledge of patients in India: A quasi-experimental study

Background. Diabetes-related health education promotes patient efficacy for diabetes self-management. However, sub-optimal knowledge of diabetes in people with diabetes is recognized as a challenge in overcrowded public health facilities in India. We aimed to determine the effect of health education through mobile phone text messages (short messaging service [SMS]) on diabetes-related knowledge of patients with diabetes. Methods. From February 2016 to February 2017, we recruited adult patients with diabetes for this quasi-experimental study done in the outpatient setting of a major tertiary care government hospital in Delhi, India. Participants in the intervention group received a text message on diabetes self-care practices every alternate day for 90 days. We evaluated the patients’ knowledge of diabetes using the Spoken Knowledge in Low Literacy in Diabetes (SKILL-D) questionnaire and a self-designed diabetes knowledge questionnaire. Results. We enrolled 190 men and 160 women, of whom 52 (13.7%) were lost to follow-up. At baseline, mean diabetes knowledge scores were higher in the intervention group compared to the control group. After the intervention period of 3 months, the diabetes knowledge scores for SKILL-D and the patient diabetes knowledge questionnaire showed a statistically significant increase in the intervention group (mean difference 0.7 and 0.5, respectively; p<0.001, but there was no increase in the control group). Conclusion. The use of mobile phone technology for diabetes-related health education through mobile text-message (SMS) technology is an effective method for health promotion.

Ethical issues in expanding latent TB management in high burden countries

Global efforts are being made to eliminate tuberculosis (TB) as a public health problem by 2030. These efforts are being thwarted by the challenge of effective management to minimise the progression of latent TB infection (LTBI) to TB, thereby interrupting the chain of transmission. Approximately 5%–10% LTBI cases eventually develop TB in their lifetime with the risk being higher in children, people living with HIV/AIDS (PLHIV), undernourished people, and patients with diabetes, chronic kidney disease, silicosis, and other comorbid conditions. Apart from operational barriers, complex ethical issues govern decision-making processes in either retaining current LTBI management practices or advocating implementation of the latest World Health Organization guidelines, which suggest extending treatment to vulnerable groups who have a higher risk of progression to TB. Newer LTBI treatment regimens have a diminished risk of toxicity that allays threats to patient safety. Public health justification for treating LTBI can also override patient autonomy, but the lack of a patient-centred approach is associated with poor adherence and treatment outcomes. Cost-effectiveness studies need to evaluate the gains and losses accruing from funding treatment of LTBI versus similar costs in nutritional interventions for managing undernutrition. Similarly, the impact of diverting resources available for management of the existing active TB control programmes to expanding LTBI treatment also needs to be assessed. In conclusion, a comprehensive LTBI treatment strategy built on the basis of high-quality evidence is the best way forward for resolving the ethical considerations at the heart of LTBI management in the developing world. Keywords: Tuberculosis; India; Latent TB; Medical ethics

Under-recognised ethical dilemmas of diabetes care in resource-poor settings

Ineffective diabetes management results in suboptimal glycaemic control and adverse health outcomes. In resource-poor settings, a combination of high burden of medication nonadherence in patients and therapeutic inertia amongst clinicians is largely attributed to the failure to achieve glycaemic targets in diabetic populations. The potential health risks from intensification of medical therapy for aggressive lowering of glucose levels in Type 2 diabetes patients represents an ethical dilemma between averting risk from overtreatment and preventing future harm from raised blood glucose levels. However, the ethical dilemmas experienced by clinicians in most of the developing world when contemplating prescription of additional oral hypoglycaemic agents or initiating insulin have received little attention from the medical community. Such ethical dilemmas unique to resource-poor settings often emerge from poor availability of drugs, diagnostics and physician consultation time for diabetic patients. Furthermore, existing evidence-based guidelines for diabetes management assume a standard of care which is lacking in such settings. This often compels the developing world clinicians when confronted with such diabetes-related ethical dilemmas to rely solely on their clinical judgement which could be ethically unjust and medically prone to error. Newer research needs to generate evidence to develop best practice guidelines for optimal therapeutic outcomes, while acknowledging the reality of limited healthcare services available in resource-poor settings.

Surrogacy and women's right to health in India: Issues and perspective.

The human body is a wonderful machine. The future of child birth in the form of test tube babies, surrogate motherhood through new reproductive and cloning technology will introduce undreamt of possibilities in the sexual arena. Surrogacy is a method of assisted reproduction whereby a woman agrees to become pregnant for the purpose of gestating and giving birth to a child for others to raise. In some jurisdictions the possibility of surrogacy has been allowed and the intended parents may be recognized as the legal parents from birth. Commercial surrogacy, or "Womb for rent", is a growing business in India. In our rapidly globalizing world, the growth of reproductive tourism is a fairly recent phenomenon. Surrogacy business is exploiting poor women in country like India already having with an alarmingly high maternal death rate. This paper talks about paternity issues and women's right to health in context of surrogacy. Government must seriously consider enacting a law to regulate surrogacy in India in order to protect and guide couples going in for such an option. Without a foolproof legal framework, patients will invariably be misled and the surrogates exploited.

Psychosocial effect and economic burden on parents of children with locomotor disability.

Objective. To assess the social and financial burden on parents of children with locomotor disability. Methods. A cross-sectional study was conducted in the Institute for Physically Handicapped (IPH), Delhi, where parents of 100 locomotor disabled children of age group 6 to 15 years were interviewed to estimate the socioeconomic burden of caregiving their children. Results. The study observed that the parents of the disabled children were severely burdened in terms of financial burden and mental health. Conclusions. There is an urgent need for support activities for such families at a national level in order to curb the huge economic and social burden of care-giving. Counselling should be an integral part of rehabilitat ion for such families.

Should there be mandatory testing for HIV prior to marriage in India?

The National AIDS Prevention and Control Policy of the government of India states that testing for HIV infection should be voluntary in nature. But from time to time various state governments and the central government have announced their intent of introducing mandatory premarital testing. Though this intent has not yet been translated into action, we present our case against the adoption of such a policy by discussing various social and medical issues. These include the limited population that such a policy would target given the early age of marriage in India; issues related to its implementation considering the low marriage registration rates in India; potential of stigma and discrimination associated with it; issues with defining boundaries and the role of the state; limitations related to the HIV test itself in context of the policy, including the window period and the positive predictive value of the test; its limited impact in population groups at a high risk for HIV infection; its limited role in changing unsafe behaviours; its limited potential to enhance the empowerment of women; its conflict with existing human rights; and the adverse experience of other countries with a similar policy.

Changing profile of disease contributing to mortality in a resettlement colony of Delhi.

BACKGROUND: The past decade has seen a decline in the disability-adjusted life years (DALYs) contributed by communicable diseases while lifestyle changes and rapid urbanization have led to an increase in DALYs contributed by non-communicable diseases. We studied the causes of death in a low socioeconomic area over 11 years to help identify changes in the pattern of disease. METHODS: We did this study in Gokulpuri, a resettlement colony in East Delhi. All deaths occurring from 1994 to 2004 were analysed using a verbal autopsy questionnaire completed by trained health workers during their home visits in the area. RESULTS: A total of 515 deaths occurred during the period; 340 in men (66%) and 175 in women (34%). The six commonest causes of death were tuberculosis (24.8%), chronic obstructive pulmonary disease (11.6%), pneumonia (8.7%), accidents and poisoning (8.6 %), coronary heart disease (8.2%) and cancer (4.6%). The age-specific mortality rate was highest among people > 45 years of age. The cause-specific mortality rate due to communicable diseases showed a decline while that due to non-communicable diseases showed a rising trend in all age groups. CONCLUSION: Our study shows the coexistence of communicable and non-communicable diseases in a low socioeconomic area with a rising trend in non-communicable diseases. Surveillance for risk factors of non-communicable diseases should be done even in predominantly low socioeconomic areas. The coexistence of communicable and non-communicable diseases and the increase in non-communicable diseases among the economically deprived sections of our society suggest the need to re-prioritize components of healthcare among these sections.

Drug use among juveniles in conflict with the law.

OBJECTIVE: To study the pattern of drug use, reasons for initiation and the perception about the effects of using drugs, among juveniles in conflict with law. METHODS: A qualitative study was conducted at Prayas Observation Home for boys, New Delhi. Eight key informant interviews were conducted to find the prevalence of prior drug use among boys. Five focus group discussions were conducted with 34 children using a topic outline guide. RESULTS: The study showed that drug use was related to other criminal activities. Peer group and media were the most important influences for initiation of drug use. All kinds of drugs could easily be procured by children and there was a gradual progression from non-use to tobacco and alcohol use, to marijuana and ultimately to other drugs. Knowledge about medical and social mal-effects of consuming drugs did not seem to effect either the consumption of drugs or the desire to leave this habit. CONCLUSION: Results of the study demonstrate an urgent need for taking stringent measures in order to curb drug use among adolescents.

Knowledge and attitude towards tuberculosis in a slum community of Delhi.

A cross-sectional study was conducted among 208 adults (114 males and 94 females) aged 16-70 years, selected by systematic random sampling method in Lok Nayak Colony, Delhi to assess the knowledge and attitude towards tuberculosis (TB). Literacy rate was 28.4%. Only 174 (83.6%) heard of tuberculosis mainly from neighbours (64.9%) and friends (62.1%). Only 2.3% knew that TB was caused by a germ. Literates were more aware than illiterates regarding some signs and symptoms of TB i.e breathlessness (p=0.002), low grade fever (p=0.02), loss of appetite (p<0.001) and factors favouring TB e.g. overcrowding (56.4%) and poor diet (45.4%). Only 12.6% knew about the duration of treatment for 6-8 months and 1.7% knew about preventive role of BCG. Tendency to discriminate TB patients was evident from the findings e.g 71% respondents agreed upon isolating TB patients from the family, 74.1% on avoiding the patient in food sharing, on quitting job by the patient (33%), prohibiting marriage of the patient (27.6%), shunning him from attending social functions (18%), etc. Extensive health education directing towards attitudinal change by community involvement is needed to create awareness and remove myths about TB in such colonies.