Clinical Characteristics of 100 Patients With COVID-19-Associated Mucormycosis From a Tertiary Care Center in North India.

Background Fungal infection in patients with coronavirus disease 2019 (COVID-19) has emerged as a new challenge in healthcare facilities. This study aimed to describe the demographic and clinical characteristics of COVID-19-associated mucormycosis (CAM). Methodology This retrospective, single-center case series included patients who were hospitalized and diagnosed with COVID-19 and mucormycosis at the All India Institute of Medical Sciences, Rishikesh (North India) from April 15, 2021, onwards and last followed up on June 30, 2021. Demographic, clinical, laboratory, radiological, microbiological, pathological, and outcome data were then collected and analyzed. Results Of the 100 consecutive inpatients with CAM, 95 (95%) had diabetes mellitus. At the onset of illness, the most common manifestations were facial swelling (85%), eye swelling (83%), headache (68%), pain around the eyeball (67%), malaise (57%), and fever (50%). The most common organ involved on examination was the nose and paranasal sinus (96%), followed by the orbit (83%), palate (19%), and cranial nerves (7%). Pulmonary involvement was seldom observed (1%). Predominant pathological findings were the presence of aseptate hyphae (75%), necrosis (75%), angioinvasion (36%), and perineural invasion (2.6%). During the last follow-up, 13 patients died, with 11 (84.6%) having severe COVID-19 and two (15.3%) having moderate COVID-19. Conclusions Steroid use and diabetes mellitus are the significant risk factors of CAM. Patients with CAM usually present with face/eye swelling with radiological involvement of the nose and sinus and may die because of severe COVID-19.

Mixed invasive fungal infections among COVID-19 patients.

Background and Purpose: The healthcare system in India collapsed during the second wave of the COVID-19 pandemic. A fungal epidemic was announced amid the pandemic with several cases of COVID-associated mucormycosis and pulmonary aspergillosis being reported. However, there is limited data regarding mixed fungal infections in COVID-19 patients. Therefore, we present a series of ten consecutive COVID-19 patients with mixed invasive fungal infections (MIFIs). Materials and Methods: Among COVID-19 patients hospitalized in May 2021 at a tertiary care center in North India, 10 cases of microbiologically confirmed COVID-19-associated mucormycosis-aspergillosis (CAMA) were evaluated. Results: All patients had diabetes and the majority of them were infected with severe COVID-19 pneumonia (6/10, 60%) either on admission or in the past month while two were each of moderate (20%) and mild (20%) categories of COVID-19; and were treated with steroid and cocktail therapy. The patients were managed with amphotericin-B along with surgical intervention. In total, 70% of all CAMA patients (Rhizopus arrhizus with Aspergillus flavus in seven and Aspergillus fumigatus complex in three patients) survived. Conclusion: The study findings reflected the critical importance of a high index of clinical suspicion and accurate microbiological diagnosis in managing invasive dual molds and better understanding of the risk and progression of MIFIs among COVID-19 patients. Careful scrutiny and identification of MIFIs play a key role in the implementation of effective management strategies.

Determinants of COVID-19 Vaccination Willingness among Health Care Workers: A Quick Online Survey in India.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has caused a large number of deaths along with severe socio-economic effects. The vaccine is considered to be the last hope to control viral transmission. This study aimed to explore the determinants of health care workers' (HCWs) willingness to take the COVID-19 vaccination. METHODS: A structured, pre-validated, and pre-tested questionnaire was administered online to 599 HCWs including physicians, residents, and nurses from different types of healthcare set-ups across India. Information was collected regarding vaccine acceptability, attitude toward vaccination, and reasons for hesitancy. The chi-square test, followed by multinomial regression analysis, was applied to determine the factors associated with HCWs' vaccination willingness. RESULTS: It was found that 73 % (n=437) of HCWs were willing to accept the vaccines, while 10.85% (n=65) refused and 16.2% (n=96) needed more time to decide. Gender (P<0.001), occupation (P=0.040), working as front-line workers (P=0.008), vaccine manufacturing country preferences (P<0.001), and perceived risk of catching COVID-19 in the next 6 months (P=0.005) had a significant association with intent to receive vaccination (the response were "yes" vs. "no" and "not sure"). The reasons for vaccine hesitancy were vaccine safety and efficacy concerns, antivaccine attitude and beliefs, personal choice, and not wanting to take a vaccine before others. CONCLUSION: The majority of HCWs agreed to take COVID-19 vaccines once available. Nevertheless, providing support to manage evolving vaccine environments will help change the perception of HCWs who refuse or are reluctant to take the vaccines.

COVID-19 vaccine acceptability, determinants of potential vaccination, and hesitancy in public: A call for effective health communication.

BACKGROUND: Coronavirus disease rapidly spreads across the entire world in < 2 months and gravely jeopardizes the regular human routine. The medical fraternity recommends a vaccine as one of the best solutions to save the universe. However, to be effective, the population should reflect an encouraging attitude to accept it. The study aimed to measure vaccine acceptability and reason for hesitancy among the public. MATERIALS AND METHODS: Eight hundred and forty one adults visiting a tertiary care hospital responded to a pretested validated questionnaire on vaccine acceptability and hesitancy. The Chi-square test and independent t-test, followed by multinomial logistic regression, were used to analyze the findings. RESULTS: Overall, 53.4% (n = 445) of participants interested to take vaccine, 27.2% (n = 229) were not sure, and the remaining 19.4% (n = 163) did not intent to vaccinate. Gender (P = 0.013), information on the vaccine (P = 0.022), chances to get coronavirus disease in the next 6 months (P < 0.001), awareness on India COVID-19 vaccine (P < 0.001), Indian manufacturing company of vaccine (P < 0.001), family history of the laboratory-confirmed case (P < 0.001), and health status (P = 0.011) found a significant association with intention to vaccination (a response "yes" vs. "no" and "not sure"). Reasons for vaccine hesitancy included specific antivaccine attitudes and beliefs, a concern of fear and phobia, lack of information, and safety issues on the vaccine. CONCLUSIONS: This institute-specific survey revealed that approximately every 4 in 8 people were not sure to take the vaccine, and one in five people refused to be vaccinated. The study recommends using target-based health education to understand and address vaccine-specific concerns to enhance vaccine coverage, and boost confidence among the population.

Antiviral Combination Clinically Better Than Standard Therapy in Severe but Not in Non-Severe COVID-19.

PURPOSE: Definitive antiviral treatment is not available for COVID-19 infection, with the exception of remdesivir, which still evokes many doubts. Various monotherapy or combination therapies with antivirals or other agents have been tried. The present study aims to evaluate the therapeutic potential of hydroxychloroquine and lopinavir-ritonavir in combination with ribavirin in mild-severe COVID-19. PATIENTS AND METHODS: A single-center, open-label, parallel-arm, stratified randomized controlled trial evaluated the therapeutic potential of combination antiviral therapies. Enrolled patients in the severe category were randomized into three groups: (A) standard treatment, (B) hydroxychloroquine+ribavirin+standard treatment, or (C) lopinavir+ritonavir+ribavirin+standard treatment; while the non-severe category comprised two groups: (A) standard treatment or (B) hydroxychloroquine+ribavirin. Combination antivirals were given for 10 days and followed for 28 days. The primary endpoints were safety, symptomatic and laboratory recovery of organ dysfunctions, and time to SARS-CoV-2 RT-PCR negative report. RESULTS: In total, 111 patients were randomized: 24, 23, and 24 in severe categories A, B, and C, respectively, and 20 in each of the non-severe groups. Two patients receiving ribavirin experienced drug induced liver injury, and another developed QT prolongation after hydroxychloroquine. In the severe category, 47.6%, 55%, and 30.09% in A, B, and C groups, respectively, showed symptomatic recovery, compared to 93.3% and 86.7% in A and B groups, respectively, in the non-severe category at 72 hours (P>0.05). CONCLUSION: Though the results failed to show statistical superiority of the antiviral combination therapies to that of the standard therapy in both the severe and non-severe categories in symptomatic adult patients of COVID-19 due to very small sized trial, clinically hydroxychloroquine+ribavirin therapy is showing better recovery by 7.4% than standard therapy in the former category. However, results do indicate the benefit of standard therapy in the non-severe category by 6.6%. Furthermore, the dose of ribavirin needs to be reconsidered in the Indian population.

Awareness, perception, and mitigating measures on COVID-19: Do we still need to educate our masses on COVID-19?

BACKGROUND: COVID-19 was declared an emergency of international concern by the World Health Organization in 2020. This study assesses patients' awareness, perception, and mitigating measures taken during the COVID-19 outbreak visiting an apex tertiary health-care center in North India. MATERIALS AND METHODS: A cross-sectional study was conducted between September 15, 2020, and November 15, 2020, in a tertiary care public hospital, North India, using a structured self-administered questionnaire. The survey included 809 patients using a consecutive sampling strategy. The self-structured and prevalidated questionnaire was used to collect information on study variables. Chi-square test and independent samples t-test, followed by binary and multivariate logistic regression, was used to determine the factors associated with awareness toward COVID-19. RESULTS: The mean age of participants was 32.41 (±11.24) years. Multivariate logistic regression shows that married participants (OR: 0.660, 95 % CI: 0.440-0.989, P= 0.044), reading books/magazine or attended institutional lectures (OR: 2.241, 95% CI: 1.545-3.249, P = 0.001), and watching television and radio (OR: 1.824, 95% CI: 1.283-2.592, P = 0.001) are significantly more aware than their counterparts. Participants with higher income group (>20,000 Indian rupee) significantly had higher awareness than participants having salary <10,000 rupees (OR: 0.280, 95% CI: 0.178-0.440, P = 0.001) or 10,001-20,000 rupees (OR: 0.481, 95% CI: 0.297-0.777, P = 0.003). Patients avoiding traveling across or abroad had significantly much reasonably good awareness than their counterparts (OR: 0.357, 95% CI: 0.139-0.918, P = 0.033). CONCLUSIONS: Participants demonstrated good awareness, encouraging perception, and complied with appropriate mitigating measures during the outbreak. Considering frequent waves and the pandemic's long duration, consistent reinforcement of government measures, including masks, maintaining social distance, and frequent handwashing, is much needed.

Is it time to consider shreds of epidemiological and environmental evidence associated with high transmission of COVID-19?

Novel coronavirus named COVID-19 that emerged in late December from Wuhan affected almost the entire globe. Recent studies provided new insight into the high transmission of the disease. This review explores the current evidence of epidemiological and environmental factors associated with high transmission of COVID-19. Even transmission and symptoms found among cats, dogs, ferrets, and tiger suggested low species barrier of the virus. The airborne transmission was found even up to 4 m, and fecal transmission with virus particles and RNA in sewage and wastewater suggests rethinking containment strategies. However, temperature, humidity, and pollution were also associated with transmission and mortality trends of COVID-19. To better mitigate and contain the current pandemic, it is a need of hours to consider the recent shreds of evidence to prevent further spread and require detailed investigations of these evidences by extensive epidemiological and meteorological studies.

Predictors of critical illness and mortality based on symptoms and initial physical examination for patients with SARS-CoV-2: A retrospective cohort study.

INTRODUCTION: An unidentified cluster of pneumonia was identified in Wuhan city of China in the last week of December 2019, named Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-COV-2). The current study explored the predictors associated with critical illness and mortality based on symptoms at the time of admission and initial physical examination findings in patients with SARS-CoV-2. MATERIAL AND METHODS: A total of 249 records of laboratory-confirmed SARS-COV-2 patients were analyzed. Demographic profile and findings of initial physical examination were collected and analyzed. Bivariate logistic and multivariable stepwise forward regression analysis was used to identify the predictors of critical illness and mortality. RESULTS: A total of 249 records of SARS-COV-2 patients were retrospectively studied, of whom 66 (26.5%) developed a critical illness, and 58 (23.29%) died. The mean age of patients was 45.15 (16.34) years; 171 (68.71%) were men. From 27 potential predictors for developing a critical illness, 15 were reported independent predictors for critical illness, and 13 were for increased risk of mortality. Stepwise forward regression reported dyspnea as a single strongest predictor (OR, 5.800, 95% CI-2.724-12.346; p = 0.001, R2 = 0.272) to develop critical illness. Likewise, the respiratory rate was alone reported as a strong predictor (OR, 1.381, 95% CI- 1.251-1.525; p = 0.000, R2 = 0.329) for mortality. CONCLUSIONS: Coronavirus disease is a new challenge to the medical fraternity, leading to significant morbidity and mortality. Knowledge of potential risk factors could help clinicians assess patients' risk with unfavourable outcomes and improve hospitalization decisions in the early stage.

Hematological profile and biochemical markers of COVID-19 non-survivors: A retrospective analysis.

BACKGROUND: Coronavirus disease is primarily transmitted through the respiratory route and bodily contact. The fatality in COVID-19 cases was alarming in the initial days. This study analyzes hematological and biochemical markers of COVID-19 non-survivors. MATERIAL AND METHODS: In this single-center study, records of 249 patients hospitalized with COVID-19 were studied for hematological profile and biochemical markers. Records of patients with laboratory-confirmed COVID-19 disease hospitalized between April 14, 2020, to August 15, 2020, were included in the analysis. RESULTS: Significantly, the disease mortality was associated with increased procalcitonin (P < 0.05), C-reactive protein (P < 0.05), aspartate transaminase (P < 0.05), serum potassium (P < 0.05), neutrophils count (P < 0.05), white blood cell count (P < 0.05), prothrombin time (P < 0.05) and activated prothrombin time (P < 0.05) in patients reported abnormal x-ray findings. Further, patients with abnormal radiological findings significantly showed a reduced level of lymphocyte counts (P < 0.05), oxygen saturation (P < 0.05), and partial oxygen pressure (P < 0.05). Reduced level of aspartate aminotransferase (P < 0.05), alanine aminotransferase (P < 0.05) and lactate dehydrogenase (P < 0.05) reported significant association with mortality among patients with COVID-19. CONCLUSIONS: The clinicians may consider the hematological and biochemical parameters in the patients with COVID-19 in future decision-making. These indicators might support clinical decisions to identify high fatality cases and poor diagnosis in the initial admission phase. In COVID-19 patients, we recommend close monitoring on procalcitonin, C-reactive protein, neutrophils count, and white blood cell count as a clinical indicator for potential progression to critical illness.

Non-COVID area of a tertiary care hospital: A major source of nosocomial COVID-19 transmission.

COVID-19 pandemic has spread to all corners of the world where infection control measures are being implemented. There is now a resurgence of the disease in health care facilities with documented in-hospital transmission and cases becoming positive in areas designated to cater for COVID-19 negative patients. We encountered such an event at our institution where fourteen patients (including health care workers) in the non-COVID zone were found to be COVID-19 positive. This highlights the loopholes in the system and the need for better and systematic infection control measures in hospitals that deal with infectious diseases with high infectivity. Findings also suggests the failure of government's criteria for suspected COVID-19 cases, and therefore needs a rethinking.