Effectiveness of early awake self proning strategy in non-intubated patients with COVID-19 hypoxemia: An open-labelled randomized clinical trial from Jodhpur, India.

Awake self-proning is being used widely as respiratory support in COVID-19 hypoxemia, in resource limited settings. We aimed to investigate the effectiveness of early awake self-proning in preventing mortality and need for intubation in adults with moderate COVID-19 hypoxemia. In this randomized clinical trial with intention-to-treat analysis, we enrolled eligible adults with COVID-19 hypoxemia (SpO2 <94%), requiring supplemental oxygen via nasal prongs or facemask from a tertiary-care setting in Jodhpur, India between June 15 to December 24, 2020. Awake proning comprised of 4-hour cycles with prone position maintained 2 h per cycle. The control group did not maintain any specific position. All participants received standard care. The primary outcomes were 30-day mortality and requirement for mechanical ventilation. Of 502 participants included, mean (SD) age was 59.7 (12.7) years with 124 women (24.6%); 257 were randomized to awake-proning, 245 to control group and all 502 were included for follow-up mortality analysis. Mortality at follow-up was 16.3% in the awake-prone and 15.1% in the control group [OR:1.10 (0.68-1.78), p=0.703). Requirement of mechanical ventilation was 10% in both groups (p=0.974). Survival time (in days) was not significantly different between the groups [Log-rank test, HR: 1.08 (95% CI, 0.70-1.68), p=0.726]. Likewise, time to intubation was comparable (Log-rank test, HR: 0.93 (95% CI, 0.56-1.70), p=0.974). Hence, awake self-proning did not improve survival or requirement of mechanical-ventilation in non-intubated patients with mild to moderate COVID-19 hypoxemia. Trial Registration: Clinical trial registry of India, ID: CTRI/2020/06/025804. ***************************************************************   *Appendix Authors list  Deepak Kumar1, Gopal Krishna Bohra1, Nishant Kumar Chauhan2, Nikhil Kothari3, Vijaya Lakshmi Nag4 Sanjeev Misra5  1Department of Internal Medicine; 2Department of Pulmonary Medicine; 3Department of Anaesthesiology and Critical Care; 4Department of Microbiology; 5Department of Surgical Oncology, All India Institute of Medical Sciences, Jodhpur, India.

Adherence to healthy behavioral practices promotes COVID 19 preventive behavior among chronic disease patients: A cross-sectional study from urban Rajasthan, India.

Background: The coronavirus disease-19 (COVID-19) pandemic has led to unprecedented morbidity and mortality across the world. Chronic disease patients of urban poor neighbourhoods are one of the most vulnerable population subgroups as the number of cases and deaths increase exponentially in India. The study aims to explore the factors associated with desirable health behaviours among chronic disease patients availing care from a primary health facility and examine their association with the COVID-19 preventive behaviour. Material and Methods: A cross-sectional study was conducted among chronic disease patients attending a health centre in an urban area of Jodhpur, Rajasthan. A interviewer administered semi-structured questionnaire was pilot tested and validated prior to initiation of data collection. A total of 520 patients were enrolled for the study. Results: Poor adherence to health behaviour was observed among a majority of the respondents (infrequent physical activity: 72.0%, one or less fruit serving per day: 96.5%, one or less vegetable serving per day: 88.8%). A factor analysis revealed three domains of COVID-19 preventive behaviour: sanitisation, preventive hygiene and social distancing. Multiple regression revealed respondents opting for COVID-19 screening and those with lower salt intake followed the overall and individual COVID-19 preventive behaviour. Conclusion: The health behaviour assessment and inter-personal counselling by the health care providers at the primary health facilities may contribute to the increasing adherence for the COVID-19 preventive behaviour among chronic disease patients.

Anti-SARS-CoV-2 IgG status among frontline health workers involved in COVID-19 survey at Jodhpur, Rajasthan, India.

Background: Asymptomatic carriers are responsible for the consistent spread of coronavirus disease 2019 (COVID-19) in the community. The Government of India has deputed house-to-house survey teams to aid in identifying asymptomatic individuals and their susceptible contacts. We selected door-to-door survey teams of a COVID-19 red zone in western India and determined their infectioncontrol practices and anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) immunoglobin G (IgG) status. Materials and Methods: This single-day prospective cross-sectional study was conducted by the Department of Microbiology of a tertiary care hospital of Jodhpur, in collaboration with the Rajasthan State Health Services. Participants were asked to fill out a questionnaire regarding personal protective equipment (PPE) use after written informed consent. Venous blood samples were collected and Kavach enzyme-linked immunosorbent assay (ELISA) (J Mitra and Co.) was performed to determine anti-SARS-CoV-2 IgG status. Results: Out of the total 39 participants, IgG antibody was detected in four. Of them, three reported mild symptoms in the past. Out of two previously real-time polymerase chain reaction (RT-PCR) SARS-CoV-2-positive participants, only one had detectable IgG antibodies (Ab) in serum. Cloth mask was used by 24, N95 mask by 11, and surgical masks by four. Conclusion: Anti-SARS-CoV-2 IgG Abs were detected among four members of house-to-house COVID-19 survey teams in Jodhpur. Most of the team members used cloth masks, whereas the Government of India guidelines has recommended triple-layered surgical masks as minimum essential PPE for healthcare workers in India. More such studies should be conducted to ascertain infection prevention and control practices among such vulnerable frontline workers in our country.

Emerging and re-emerging viral infections in India.

The number of outbreaks have progressively increased since many years in India. In this era of globalization and rapid international travel, any infectious disease in one country can become a potential threat to the entire globe. Outbreaks of Nipah, Zika, Crimean-Congo Haemorrhagic Fever and Kyasanur Forest Disease have been reported since a decade and now we are facing COVID-19 pandemic. One of the challenges in the prevention of these outbreaks is that as the cases decrease, the felt need declines, the public demand decreases and the mitigation responses get overshadowed by the need of emergency responses elsewhere. The One Health approach is a movement to promote alliance between medicine field, veterinary medicine and environmental sciences to upgrade the health of humans, animals, and ecosystem. The data in this article is compiled from different websites and publications of World Health Organization (WHO), Centre for Disease Control and Prevention (CDC), Integrated Disease Surveillance Programme (IDSP), grey literature and media. There is an urgent need for better surveillance and disease burden assessments in the country and to gain detailed insights into vector biology, factors of environment influencing the diseases, mapping of endemic areas, strengthen intersectoral coordination, infection control practices, and ensure use of Personal Protective Equipment's (PPE) and availability of drugs and vaccines to handle the outbreaks in a better way.

Awareness, Attitude, and Acceptability of Healthcare Workers About COVID-19 Vaccination in Western India

Introduction In the coronavirus disease 2019 (COVID-19) pandemic, healthcare workers (HCWs) are at the frontline around the world and categorized as a priority group for COVID-19 vaccines. Our study aimed to find out the COVID-19 vaccine awareness, attitude, and acceptance in HCWs in western India. Methods A cross-sectional study was carried out between January 14 and January 28, 2021, at a tertiary care hospital located in western India. Data were collected anonymously using Google Forms. Descriptive statistics were used to determine the sociodemographic variables. The knowledge and attitude of HCWs were analyzed using mean and SD. Multivariate analysis was done to find out the association between participants’ attitudes with demographic characteristics. Results Of the total health care workers, 498 answered the survey. The mean age of participants was 29.8 years (SD 6.4), and 354 (71.1%) were male. Among the respondents, 445 (89.4%) would accept a COVID-19 vaccine when available. Four-hundred seventy-six (476) HCWs (95.6%) had excellent knowledge regarding COVID-19 and COVID-19-appropriate behavior. The majority of the subjects (399) had a neutral attitude toward COVID-19 vaccination. Health care professionals (doctors and nurses) had higher acceptance for vaccination against COVID-19 than non-professionals. Conclusions The higher rates of COVID-19 vaccine acceptability and the excellent knowledge among HCWs will directly enhance the level and acceptability of vaccine among the general population and will definitely help in reducing the mortality and morbidity related to COVID-19.

Enabling Readiness of a School to Reopen During a Pandemic - A Field Experience.

Modeling studies indicate that the closure of schools during the coronavirus disease (COVID-19) pandemic may not be well grounded for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, as evidences indicate that children are less affected by this virus, and the clinical attack rates in the 0-19 age group are low. Experts also opine that school closures might have negative effects on the scholastic abilities of children and also an adverse impact on the economy and health care system, considering the responsibilities conferred upon the parents. Also, in a developing country like India, it is difficult for the rural population to afford distance online learning, which brings into importance the reopening of schools in a safe environment to avoid adversities such as increased drop-outs in the upcoming academic year, loss of in-person benefits such as mid-day meal scheme. This study highlights a field experience in relation to readiness assessment of a rural school in the Jodhpur district of Rajasthan, India, for a safe reopening to accept students in a safe and conducive atmosphere, which shall help prevent transmission of the virus in the schools among the children. In this regard, an indigenous readiness checklist has been developed to achieve the purpose, which assesses the readiness in 3 domains: (1) procedural readiness; (2) supplies, sanitation, and infrastructure-related; and (3) education and training.

COVID-19 seropositivity among non-medical frontline office staff from two cities in Rajasthan, India.

AIMS: The indigenously developed Indian Council of Medical Research (ICMR)-NIV COVID Kavach IgG enzyme linked immunosorbent assay (ELISA) has been recommended for seroprevalence among vulnerable populations in India, which provided essential services throughout the lockdown. The staff working in the High Court was one such group. We compared anti-SARS-CoV-2 IgG seropositivity among the staff of Jodhpur and Jaipur High Courts, Rajasthan, India. METHODS: Asymptomatic judiciary staff of Jodhpur and Jaipur benches of High Courts were enrolled after informed written consent. A questionnaire was filled and 3-5 ml venous blood was collected from participants. The ICMR-NIV COVID Kavach IgG ELISA and EUROIMMUN IgG ELISA were used for detection of Anti-SARS-CoV-2 IgG antibodies. RESULTS: A total of 63 samples (41 from Jodhpur and 22 from Jaipur) were collected between 28th July to 4th August 2020. The overall anti-SARS-CoV-2 IgG seroprevalence was found to be 6.35%. Seropositivity was higher among the staff from Jaipur (13.64%) as compared to Jodhpur (2.44%). The Kavach ELISA results were in complete agreement with EUROIMMUN ELISA. The infection control measures were deemed effective. CONCLUSION: Seroprevalence among the staff of Jodhpur High Court was found to be lower than Jaipur, reflecting higher susceptibility to COVID-19 in the former. Many offices worldwide are closed till mid 2020 but need to come up with pre-emptive policies eventually. This study may help to anticipate the possible challenges when other government/private offices start functioning. The infection control practices of one workplace may help formulate guidelines for other offices.

Analysis of Facility and Home Isolation Strategies in COVID 19 Pandemic: Evidences from Jodhpur, India.

PURPOSE: Jodhpur administration directed its efforts to control and mitigate COVID 19 infection by implementing and monitoring facility isolation (FI) and home isolation (HI) measures. This study is conducted with a hypothesis that there is no difference in the quality of life and cost-effectiveness of mildly symptomatic or asymptomatic patients in HI and FI. PATIENTS AND METHODS: A mixed-method study was conducted in Jodhpur in September 2020. The purposive sampling technique was used and data from 120 individuals admitted in HI and FI were collected. The information about the status and functioning of isolation facilities was collected from various sources. Multi-stakeholder interactions with 15 personnel engaged in managing isolation facilities were done. EQ-5D version (EQ-5D-5L) which consists of the EQ-5D descriptive system and the EQ visual analog scale (EQ-VAS) was used to assess health-related quality of life. RESULTS: The strength of HI strategy is demonstrated by its ability to provide psychological and social support with minimal logistic requirements but the issue of sufficient household infrastructure, adequate family and societal support for implementing this strategy is of concern. The strength of FI strategy includes its ability to provide support to patients who have issues of sufficient household infrastructure, adequate family and societal support, but this strategy poses a threat of increasing human resource constraints and financial load on the health system. The respondents from HI obtained a mean EQ-5D index score of 0.90 and a mean VAS score of 85, whereas it was 0.80 and 78.5, respectively, for FI. The cost estimated for home isolation was Rs 549 (7.43 US $) per person, whereas it was Rs 2440 (33.02 US $) for facility Isolation. CONCLUSION: Though HI seems advantageous in terms of a better quality of life and cost-saving over FI, both the strategies are context-specific having their own trade-offs.

Trends of Epidemiological and Demographic Indicators of COVID-19 in India.

INTRODUCTION: This study was planned to assess the trends of epidemiological indicators and demographic determinants related to the COVID-19 in India. METHODOLOGY: This was a descriptive analysis of the COVID-19 cases and their outcomes between 1st March to 31st May 2020 in India. Unpaired t-test and ANOVA were used to determine the statistical differences. Linear regression models were prepared to estimate the effect of testing on the fatalities. The Infection Fatality Rate (IFR)/Case Fatality Rate (CFR), doubling time, and Basic Reproduction Number (R0) per week were calculated. RESULTS: Two-thirds of the cases were between 21-50 years of age, while three-fourth of deaths were among people above 50-years of age. The mean age of people infected with COVID-19 was declining throughout the study period. The mean age of infected males and females was significantly different. The male-female ratio of both infection and deaths due to COVID-19 was near about 2:1. IFR/CFR was 3.31 (95% CI = 3.13-3.50) in April, which reduced to 2.84 (95% CI = 2.77-2.92) in May. An incremental trend was observed in the recovery rates (9.42% to 48.18%), tests conducted / million population (12 / million to 2708 / million) and doubling time (3.59 to 17.71 days). The number of tests was significantly influencing the fatalities (ß = 0.016, 95% CI = 0.012-0.020). The overall R0 was found to be 1.72. CONCLUSIONS: Public health interventions were likely effective in containing the spread of COVID-19. There is a need to further improve the testing capacity. The high-risk category of individuals being prioritized for hospital admission should be redefined to include individuals older than 50 years.

COVID-19 vaccine hesitancy among medical students in India.

The coronavirus disease 2019 (COVID-19) vaccine was launched in India on 16 January 2021, prioritising health care workers which included medical students. We aimed to assess vaccine hesitancy and factors related to it among medical students in India. An online questionnaire was filled by 1068 medical students across 22 states and union territories of India from 2 February to 7 March 2021. Vaccine hesitancy was found among 10.6%. Concern regarding vaccine safety and efficacy, lack of awareness regarding their eligibility for vaccination and lack of trust in government agencies predicted COVID-19 vaccine hesitancy among medical students. On the other hand, the presence of risk perception regarding themselves being affected with COVID-19 reduced vaccine hesitancy as well as hesitancy in participating in COVID-19 vaccine trials. Vaccine-hesitant students were more likely to derive information from social media and less likely from teachers at their medical colleges. Choosing between the two available vaccines (Covishield and Covaxin) was considered important by medical students both for themselves and for their future patients. Covishield was preferred to Covaxin by students. Majority of those willing to take the COVID-19 vaccine felt that it was important for them to resume their clinical posting, face-to-face classes and get their personal life back on track. Around three-fourths medical students viewed that COVID-19 vaccine should be made mandatory for both health care workers and international travellers. Prior adult vaccination did not have an effect on COVID-19 vaccine hesitancy. Targeted awareness campaigns, regulatory oversight of vaccine trials and public release of safety and efficacy data and trust building activities could further reduce COVID-19 vaccine hesitancy among medical students.

Viral Ribonucleic Acid Shedding and Transmission Potential of Asymptomatic and Paucisymptomatic Coronavirus Disease 2019 Patients.

We studied the pattern and duration of viral ribonucleic acid (RNA) shedding in 32 asymptomatic and 11 paucisymptomatic coronavirus disease 2019 cases. Viral RNA shedding in exhaled breath progressively diminished and became negative after 6 days of a positive reverse-transcription polymerase chain reaction test. Therefore, the duration of isolation can be minimized to 6 days.

Tobacco, alcohol use and other risk factors for developing symptomatic COVID-19 vs asymptomatic SARS-CoV-2 infection: a case-control study from western Rajasthan, India.

BACKGROUND: Understanding risk factors of symptomatic coronavirus disease 2019 (COVID-19) vis-à-vis asymptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, severe disease and death is important. METHODS: An unmatched case-control study was conducted through telephonic interviews among individuals who tested positive for SARS-CoV-2 in Jodhpur, India from 23 March to 20 July 2020. Contact history, comorbidities and tobacco and alcohol use were elicited using standard tools. RESULTS: Among 911 SARS-CoV-2-infected individuals, 47.5% were symptomatic, 14.1% had severe COVID-19 and 41 (4.5%) died. Older age, working outside the home, cardiac and respiratory comorbidity and alcohol use were found to increase the risk of symptomatic disease as compared with asymptomatic infection. Current tobacco smoking (odds ratio [OR] 0.46 [95% confidence interval {CI} 0.26 to 0.78]) but not smokeless tobacco use (OR 0.81 [95% CI 0.55 to 1.19]) appeared to reduce the risk of symptomatic disease. Age ≥60 y and renal comorbidity were significantly associated with severe COVID-19. Age ≥60 y and respiratory and cardiac comorbidity were found to predispose to mortality. CONCLUSIONS: The apparent reduced risk of symptomatic COVID-19 among tobacco smokers could be due to residual confounding owing to unknown factors, while acknowledging the limitation of recall bias. Cross-protection afforded by frequent upper respiratory tract infection among tobacco smokers could explain why a similar association was not found for smokeless tobacco use, thereby being more plausible than the 'nicotinic hypothesis'. Those with comorbidities and age ≥60 y should be prioritized for hospital admission.

Swift contact tracing can prevent transmission-Case report of an early COVID-19 positive case.

This is a case study of a positive COVID-19 case who was diagnosed and isolated early on in the infection. However, her seventeen close contacts who were quarantined and under observation remained negative indicating no viable chain of transmission despite high-risk contact. We further discuss the importance of effective contact tracing coupled with strict isolation or quarantine in breaking the chain of transmission.

Dynamics of SARS-CoV-2 Transmission Among Indian Nationals Evacuated From Iran.

OBJECTIVE: During the coronavirus disease (COVID-19) pandemic, Indian nationals evacuated from Iran were quarantined at Jaisalmer, Rajasthan. We wished to study the transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in this closed population. METHODS: A basic susceptible, exposed, infected, and removed (SEIR) compartmental model was developed using the daily stepwise approach in Microsoft Excel. An advanced model using standard differential equations in Python software version 3.6 was used to estimate R0 based on model fit to actual data. RESULTS: Forty-eight SARS-CoV-2 infections were found among the 474 quarantined individuals. Out of these, 44 (92%) were asymptomatic. R0 for the overall duration was found to be 2.29 (95% CI: 1.84-2.78). Male gender and age ≥ 60 years were associated with SARS-CoV-2 infection (RR = 4.33, 95% CI: 2.07-9.05 and 5.32, 95% CI: 3.13-9.04, respectively). Isolation of infected individuals and stricter quarantine of remaining individuals reduced the R0 from 2.41 initially to 1.17 subsequently. CONCLUSION: R0 value was found comparable to the earlier studies indicating similar transmission dynamics among quarantined individuals in India. Universal testing and prompt isolation of infected individuals reduced the transmission of SARS-CoV-2. Smaller group sizes should be preferred to large groups during facility-based quarantine in evacuation situations. The role of asymptomatic individuals appears to be strong in SARS-CoV-2 transmission within closed populations.

Transmission Dynamics of the COVID-19 Epidemic at the District Level in India: Prospective Observational Study.

BACKGROUND: On March 9, 2020, the first COVID-19 case was reported in Jodhpur, Rajasthan, in the northwestern part of India. Understanding the epidemiology of COVID-19 at a local level is becoming increasingly important to guide measures to control the pandemic. OBJECTIVE: The aim of this study was to estimate the serial interval and basic reproduction number (R0) to understand the transmission dynamics of the COVID-19 outbreak at a district level. We used standard mathematical modeling approaches to assess the utility of these factors in determining the effectiveness of COVID-19 responses and projecting the size of the epidemic. METHODS: Contact tracing of individuals infected with SARS-CoV-2 was performed to obtain the serial intervals. The median and 95th percentile values of the SARS-CoV-2 serial interval were obtained from the best fits with the weibull, log-normal, log-logistic, gamma, and generalized gamma distributions. Aggregate and instantaneous R0 values were derived with different methods using the EarlyR and EpiEstim packages in R software. RESULTS: The median and 95th percentile values of the serial interval were 5.23 days (95% CI 4.72-5.79) and 13.20 days (95% CI 10.90-18.18), respectively. R0 during the first 30 days of the outbreak was 1.62 (95% CI 1.07-2.17), which subsequently decreased to 1.15 (95% CI 1.09-1.21). The peak instantaneous R0 values obtained using a Poisson process developed by Jombert et al were 6.53 (95% CI 2.12-13.38) and 3.43 (95% CI 1.71-5.74) for sliding time windows of 7 and 14 days, respectively. The peak R0 values obtained using the method by Wallinga and Teunis were 2.96 (95% CI 2.52-3.36) and 2.92 (95% CI 2.65-3.22) for sliding time windows of 7 and 14 days, respectively. R0 values of 1.21 (95% CI 1.09-1.34) and 1.12 (95% CI 1.03-1.21) for the 7- and 14-day sliding time windows, respectively, were obtained on July 6, 2020, using method by Jombert et al. Using the method by Wallinga and Teunis, values of 0.32 (95% CI 0.27-0.36) and 0.61 (95% CI 0.58-0.63) were obtained for the 7- and 14-day sliding time windows, respectively. The projection of cases over the next month was 2131 (95% CI 1799-2462). Reductions of transmission by 25% and 50% corresponding to reasonable and aggressive control measures could lead to 58.7% and 84.0% reductions in epidemic size, respectively. CONCLUSIONS: The projected transmission reductions indicate that strengthening control measures could lead to proportionate reductions of the size of the COVID-19 epidemic. Time-dependent instantaneous R0 estimation based on the process by Jombart et al was found to be better suited for guiding COVID-19 response at the district level than overall R0 or instantaneous R0 estimation by the Wallinga and Teunis method. A data-driven approach at the local level is proposed to be useful in guiding public health strategy and surge capacity planning.