Clinico-epidemiological profile of COVID-19 patients admitted during third wave of pandemic in a tertiary care hospital in New Delhi, India.

Even nearly two years after the first reported case, the novel coronavirus (SARS-CoV-2) continues to ebb and flow around the world. A retrospective cohort study was carried out to determine the clinico-epidemiological profile and outcome of the cases. The study analyzed secondary data from 827 patients who presented to our center with COVID-19-related illnesses between December 15, 2021, and February 15, 2022 (third wave in India). There was a significant difference in the vaccination status of patients treated at home and those admitted, with 87.9% having received two doses compared to 74% in the second group being unvaccinated. Patients who were isolated at home recovered at a rate of 99.4%, while hospitalized patients died at a rate of 26.5%. Vaccination reduces the severity of COVID-19; however, constant vigilance for new variants, precautionary measures, and increased vaccination drives are critical moving forward.   *Other members of the Safdarjung Hospital COVID-19 working group: B. Lal (Medicine), Harish Sachdeva (Anaesthesiology), Santvana Kohli (Anaesthesiology), Amandeep Jaswal (Anaesthesiology), Sumitra Bachani (Obstetrics and Gynecology), Ajay Kumar (Pediatrics), Rohit Kumar (Pulmonary Medicine), Vidya Sagar Chaturvedi (Surgery), Vinod Chaitanya (Medicine).

Severity and mortality associated with COVID-19 among children hospitalised in tertiary care centres in India: a cohort study

Background It is critical to identify high-risk groups among children with COVID-19 from low-income and middle-income countries (LMICs) to facilitate the optimum use of health system resources. The study aims to describe the severity and mortality of different clinical phenotypes of COVID-19 in a large cohort of children admitted to tertiary care hospitals in India, Methods Children aged 0-19 years with evidence of SARS-CoV-2 infection (real time polymerase chain reaction or rapid antigen test positive) or exposure (anti-SARS-CoV-2 antibody, or history of contact with SARS-CoV-2) were enrolled in the study, between January 2021 and March 2022 across five tertiary hospitals in India.. All study participants enrolled prospectively and retrospectively were followed up for three months after discharge. COVID-19 was classified into severe (Multisystem Inflammatory Syndrome in Children (MIS-C), severe acute COVID-19, ‘unclassified') or non-severe disease. The mortality rates were estimated in different phenotypes. Findings Among 2468 eligible children enrolled, 2148 were hospitalised Signs of illness were present in 1688 (79%) children with 1090 (65%) having severe disease. High mortality was reported in MIS-C (18·6%), severe acute COVID-19 (13·3%) and the unclassified severe COVID-19 disease (12·3%). Mortality remained high (17·5%) when modified MIS-C criteria was used. Non-severe COVID-19 disease had 14·1% mortality when associated with comorbidity. Interpretation Our findings have important public health implications for low resource settings. The high mortality underscores the need for better preparedness for timely diagnosis and management of COVID-19. Children with associated comorbidity or coinfections are a vulnerable group and need special attention. MIS-C requires context specific diagnostic criteria for low resource settings. It is important to evaluate the clinical, epidemiological and health system-related risk factors associated with severe COVID-19 and mortality in children from LMICs. Funding Department of Biotechnology, Govt of India and Department of Maternal, Child and Adolescent Health and Aging, WHO, Geneva.

Multimodal analysis of the COVID-19-associated mucormycosis outbreak in Delhi, India indicates the convergence of clinical and environmental risk factors.

BACKGROUND: The aetiology of the major outbreak of COVID-19-associated mucormycosis (CAM) in India in spring 2021 remains incompletely understood. Herein, we provide a multifaceted and multi-institutional analysis of clinical, pathogen-related, environmental and healthcare-related factors during CAM outbreak in the metropolitan New Delhi area. METHODS: We reviewed medical records of all patients diagnosed with biopsy-proven CAM (n = 50) at 7 hospitals in the New Delhi, and NCR area in April-June 2021. Two multivariate logistic regression models were used to compare clinical characteristics of CAM cases with COVID-19-hospitalised contemporary patients as controls (n = 69). Additionally, meteorological parameters and mould spore concentrations in outdoor air were analysed. Selected hospital fomites were cultured. Mucorales isolates from CAM patients were analysed by ITS sequencing and whole-genome sequencing (WGS). RESULTS: Independent risk factors for CAM identified by multivariate analysis were previously or newly diagnosed diabetes mellitus, active cancer and severe COVID-19 infection. Supplemental oxygen, remdesivir therapy and ICU admission for COVID-19 were associated with reduced CAM risk. The CAM incidence peak was preceded by an uptick in environmental spore concentrations in the preceding 3-4 weeks that correlated with increasing temperature, high evaporation and decreasing relative humidity. Rhizopus was the most common genus isolated, but we also identified two cases of the uncommon Mucorales, Lichtheimia ornata. WGS found no clonal population of patient isolates. No Mucorales were cultured from hospital fomites. CONCLUSIONS: An intersection of host and environmental factors contributed to the emergence of CAM. Surrogates of access to advanced COVID-19 treatment were associated with lower CAM risk.

Effect of COVID-19 vaccination status on outcome of adult patients admitted at a tertiary care centre in India.

COVID-19 vaccination was initially started in India on 16th January 2021 after approval from national authorities. This study was carried out to assess the effect of vaccination status on the severity and clinical outcome among patients infected with COVID-19. The study included all adult COVID-19 patients admitted to our hospital from 1st April to 30th June 2021. A total of 819 patients were enrolled in the study out of which only 183 (22.3%) were vaccinated. The study documented a statistically significant reduction in the severity of illness among the vaccinated (single/double dose) (33% severe COVID-19) against the unvaccinated (43% severe COVID-19) groups; along with a reduction in mortality. On univariate and multivariate analysis, age, severity of illness and lack of COVID-19 vaccination status were associated with a statistically significant increased mortality. To conclude, this study demonstrates the role of vaccination in decreasing the severity and mortality of COVID-19 infection.

Preeclampsia in COVID-19: A Masquerading Errant-An Exploration of Foeto-Maternal Outcome from a Tertiary Care Hospital In India.

Background: COVID-19 pandemic has shown that the multisystem involvement in COVID-infected patients is beyond the usual clinical manifestations of other respiratory viral illnesses. This study aims to evaluate the upshots of COVID-19 in women with preeclampsia. Methodology: This descriptive study was conducted in department of Obstetrics & Gynaecology at VMMC & Safdarjung Hospital (May-November 2020), wherein a retrospective review of the medical records of laboratory confirmed SARS CoV2-positive pregnant women (as per ICMR), with preeclampsia (as defined by ACOG guidelines), was done in the dedicated COVID labour ward. Primary outcome was incidence of preeclampsia in SARS CoV2 positive gravid females. Secondary outcomes were socio-demographic and maternal characteristics, severity of COVID-19 and foeto-maternal outcome. Results: During these 7 months, 38/302 (12.58%) SARS COV2-positive women presented with pre-eclampsia, either before or at the time of admission; amongst them 47.37% were primigravida. Severe preeclampsia was chronicled in 65.71% women. Around 20% women had severe COVID-19. All women with severe COVID19 required ICU stay, 5 requiring intubation. Three of these patients succumbed to their illness. Out of the 40 babies born to these women (including 2 twin pregnancies), 36.84% were premature deliveries. Seventeen (42.50%) babies had low birth weight. Although 82.50% were live births, five (12.50%) were intrauterine demise and 2 were early neonatal deaths. Conclusion: Gravid women with preeclampsia infected with SARS CoV2 have comparative more severe illness, requiring more intensive care requirement and high maternal and neonatal morbidity.

Stillbirth in COVID-19 Affected Pregnancies: A Double Whammy for the Mother.

Introduction Pregnant women represent a high-risk group especially during the COVID-19 pandemic, suffering at the expense of pandemic restrictions and landing up in adverse maternofetal outcomes including stillbirth. Fetal demise along with COVID-19 disease acts as a double blow to these mothers. Literature is still limited on its impact on maternofetal outcomes. Methods A prospective, observational study was conducted in a tertiary care hospital in Delhi, India from April 15, 2020 to April 14, 2021, wherein all pregnant mothers with SARS-CoV-2 infection in the hospital who delivered a stillborn baby were enrolled and analyzed for incidence of stillbirth. These women were evaluated for risk factors and causes for stillbirth. Results Out of 15859 deliveries in the institute, there were 330 viable births among COVID-19 affected pregnancies. The incidence of stillbirth was 7.2% (24/330). The institutional delivery rate fell by 43% during the pandemic. The majority of cases were unbooked, from rural areas and of low socioeconomic status (p<0.01). The most significant risk factor and cause for stillbirth was an associated comorbidity (75%, p<0.001), notably severe forms of hypertensive disorders of pregnancy (HDP, 41.6%, p=0.002), followed by preterm labour (58.3%) and preterm premature rupture of membranes (PPROM, 29.1%, p<0.001). HDP remained the main cause of macerated stillbirths while maternal fever (50%, p<0.001) was the main cause of fresh stillbirth. Major modifiable factors were lack of awareness of when to seek care (83.3%), financial reasons (75%), commutation problems (87.5%), distance to hospitals (50%) and delayed referral (41.6%). Conclusion Improved policy-making, with an emphasis on telemedicine, COVID-19 preparedness alongside amped up vaccination and healthcare workers training will help reduce adverse maternofetal outcomes.

Management of bronchial asthma in 2021.

To The Editor, The Global Initiative for Asthma (GINA) 2021 update was published on the 28th of April, 2021. There are significant changes, including treatment of mild asthma, the role of azithromycin, treatment of asthma in COVID-19 times, and role of biologics...

SARS COV 2 positive healthcare workers in obstetrics and gynaecology- Save the saviour study.

Context: Health-care workers (HCWs), being the front-line warriors, have been at increased risk for COVID-19 throughout the pandemic. However, the current extent of SARS-CoV-2 transmission and associated risk factors is still unclear in low- and middle-income countries, like India, especially in the department of obstetrics and gynaecology, which propelled this study. Aims: (i) Frequency of infection among HCWs among OBGYN department and cycle threshold value (Ctv) of SARS-COV-2 on RT-PCR. (ii) Clinical presentation, assessment of risk factors, and its impact on HCWs. Settings and Design: This was a prospective study conducted at the Department of Obstetrics and Gynaecology, VMMC and Safdarjung Hospital, New Delhi for the duration of 6 months. Methods and Material: All SARS-CoV-2-positive HCWs in the department were interviewed verbatim after recovery, through a self-formulated, validated questionnaire, and answers recorded on pre-designed proforma. Statistical Analysis Used: Categorical variables were presented as number and percentage (%), whereas continuous variables as mean ± standard deviation (SD) and median values. Data were transferred on Microsoft Excel spreadsheet and analysed using SPSS v 27.0. Results: Amongst 727 HCWs working in the department, 350 RT-PCR tests were performed, and 110 tested positive (prevalence of 15.13%). Mean Ctv of RT-PCR was 28.03. Most HCWs were symptomatic (n = 94) with mild infection; working as nursing officers (40%). Majority of them acquired virus while working in non-COVID wards (76%). Noncompliance with IPC practices (40%) and lack of social distancing (34.5%) were key risk factors. Conclusion: Adept knowledge of the risk factors and IPC practices can aid in averting casualties due to SARS-COV-2 amongst the HCWs.

A systematic review and metanalysis of diagnostic yield of BAL for detection of SARS-CoV-2.

BACKGROUND: The gold standard for diagnosing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is microbiological confirmation by reverse transcriptase-polymerase chain reaction (RT-PCR)1 most commonly done using oropharyngeal (OP) and nasopharyngeal swabs (NP). But in suspected cases, where these samples are false-negative, bronchoalveolar lavage (BAL) may prove diagnostic. OBJECTIVES: Hence, the diagnostic yield of BAL for detection of SARS-CoV-2 in cases of non-diagnostic upper respiratory tract samples is reviewed. METHODS: Databases such as MEDLINE, Scopus, and Google Scholar were searched using a systematic search strategy. The current study has been in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and has been registered with the International Prospective Registry of Systematic Reviews (CRD42020224088). RESULTS: 911 records were identified at initial database extraction, of which 317 duplicates were removed and, 596 records were screened for inclusion eligibility. We included total 19 studies in the systematic review, and 17 were included in metanalysis. The pooled estimate of SARS-CoV-2 positivity in BAL was 11% (95%CI: 0.01-0.24). A sensitivity analysis also showed that the results appear to be robust and minimal risk of bias amongst the studies. CONCLUSION: The current study demonstrates that BAL can be used to diagnose additional cases primary disease and superadded infections in patients with severe COVID-19 lower respiratory tract infection.

Severe Acute Respiratory Syndrome Coronavirus 2 and Dengue Virus Co-infection: Indian Perspectives.

Severe acute respiratory syndrome Coronavirus 2 (SARS CoV-2) and Dengue virus (DENV) Coinfection can be a pertinent issue in a country like India, where Dengue is endemic, and Coronavirus disease 19 (COVID-19) is also reported from all states of the country. The coinfection of these viruses has already been reported in different dengue-endemic countries like Singapore, Thailand, and Bangladesh. The outcome and the dynamics of each of the diseases may be altered in the presence of coinfection. We highlighted the critical characteristic similarities and differences between COVID-19 and Dengue infection & the specific point, which may challenge diagnosing and managing these coinfections. COVID-19 and Dengue coinfection can be deadly in combination with an atypical presentation, providing diagnostic and therapeutic challenges. A high index of suspicion, early recognition of symptoms, and warning signs are vital to prevent double jeopardy.

Mortality among adult hospitalized patients during the first wave and second wave of COVID-19 pandemic at a tertiary care center in India.

The similarities and differences between the mortality patterns of the two waves in India remain largely unknown. This was a retrospective study of medical records conducted in the COVID data center of our hospital This study analyzed data of patients who died in the month of August, 2020 to October 2020 (one month before and after the peak of first wave i.e., 16th September, 2020) and April 2021 to June 2021 (one month before and after the peak of second wave i.e., 6th May, 2021), corresponding to an equal part of the pandemic during first (2020) and second (2021) wave. Out of 1893 patients in the study, 764 patients were admitted during the first wave and 1129 patients during the second wave of pandemic. In total, 420 patients died during the entire study period. Of those, 147 (35%) deaths occurred during the first wave and 273 (65%) during the second wave, reflecting a case fatality rate (CFR) of 19.2% during the first wave and a CFR of 24.18%. There were no significant differences in the age group, gender, presenting complaints, duration of stay and comorbidities. However, the deceased COVID-19 patients had an increase in case fatality rate, average duration of symptoms from onset to hospital admission (DOSHA) and a major shift from MODS to ARDS being the cause of death during the second wave of pandemic. This study demonstrates increased CFR, average DOSHA and a paradigm shift to ARDS as cause of mortality during the second peak of the pandemic. It is necessary to remain vigilant of newer COVID-19 variants of concern, follow COVID-19 appropriate behaviors and keep emphasizing on care of high-risk groups including patients with comorbidities and elderly population to prevent mortality.

A Prospective Study of Specialized Coagulation Parameters in Admitted COVID-19 Patients and Their Correlation With Acute Respiratory Distress Syndrome and Outcome.

Background Acute respiratory distress syndrome (ARDS) is a frequent complication of COVID-19 and is associated with a component of thrombo-inflammation and cytokine storm. COVID-19 also affects the hemostatic system causing multiple coagulation abnormalities that is a cause of concern and needs to be addressed.  Objective We aimed to assess coagulation parameters of COVID-19 patients and identify whether they could be used as potential prognostic biomarkers to predict ARDS and immediate outcomes. Methods This was a prospective study done on 68 patients at four serial time points. Patients between 18-85 years admitted to the hospital as in-patients and ICU with a confirmed diagnosis of COVID-19 by RT-PCR were included. Exclusion criteria included pregnancy, patients below and above the mentioned age, previously known coagulopathy, systemic anticoagulants or anti-platelet therapy or vitamin K antagonists and moribund patients. Patients were divided into three categories based on SOFA score at admission, presence (group 1) or absence (group 2) of ARDS and outcome (dead or alive). Routine and specialized coagulation tests were performed on patients' platelet-poor plasma at the time of study inclusion (day 0), days 3, 7 and at discharge on STAR Max®3 (Diagnostica Stago France) automated coagulation analyzer and included prothrombin time (PT), international normalized ratio (INR) (STA® -NeoPTimal), activated partial thromboplastin time (APTT) (STA® -Cephascreen), fibrinogen (STA® Liquid Fib), D-dimer (STA® LiatestD- Dimer), Protein C (STA Stachrom® Protein C), Protein S (STA® Latest Free Protein S) and Antithrombin (STA® Chrom ATIII). ELISA did testing for tissue plasminogen activator (Asserachrom® tPA) as per the manufacturer's protocol. Results Sixty-eight patients, including 43 (63%) males and 25 (37%) females, with a median age of 48 years (IQR 20-85), were recruited in this study. The incidence of ARDS was 34%, with a mortality of 13%. History of contact with a COVID-19 case was present in 71% (48/68) of the patients. Fever was the most common presenting symptom in 84% (57/68) of the patients. The most common comorbidities were hypertension and diabetes mellitus (DM) in 22% (15/68) and 21% (14/68) of the patients. DM (p=0.07) and chronic obstructive pulmonary disease (COPD) (p=0.03) were significantly associated with ARDS. DM (p=0.02), hypertension (p=0.01), and COPD (p=0.02) were also significantly associated with mortality. APTT was markedly prolonged among non-survivors at day 0 (D0) and D7 (p=0.03, p=0.02). D-Dimer was elevated in 38/68 (56%) patients at D0. D-Dimer levels were significantly higher in non-survivors (p<0.001), in ARDS patients (p=0.001) and patients with higher SOFA scores (p=0.001). ROC curve showed that D-dimer cut-off > 2.13 (AUC of 0.86) and >0.85 (AUC of 0.74) predicts mortality and ARDS, respectively. Among the natural anticoagulants, protein C was significantly associated with a high SOFA score at D0 and D3 (p=0.04).  Conclusion Diabetes mellitus, hypertension and COPD were associated with poor outcomes. D-dimer levels must be monitored in COVID patients due to their association with ARDS and mortality. We observed that the levels of natural anticoagulants fell during the illness, making them prone to coagulopathies; however, none were seen in this study. Elevated tPA levels were also found in our patients; fibrinolytic therapy may benefit COVID-19 patients suffering from ARDS.