Extent of disability among paediatric Japanese encephalitis survivors and predictors of poor outcome: a retrospective cohort study in North India.

OBJECTIVE: To determine the Japanese encephalitis (JE)-associated long-term functional and neurological outcomes, the extent of reduced social participation and predictors of poor outcomes among paediatric JE survivors. DESIGN: A retrospective cohort study. SETTING: Laboratory-confirmed JE-positive paediatric cases (<16 years of age) hospitalised at the paediatric ward of Baba Raghav Das Medical College, Gorakhpur, India, between 1 January 2017 and 31 December 2017, were followed up after 6-12 months of hospital discharge. PARTICIPANTS: 126 patients were included in the study; median age was 7.5 years (range: 1.5-15 years), and 74 (58.73%) were male. OUTCOME MEASURES: Functional outcome defined by Liverpool Outcome Score (LOS) dichotomised into poor (LOS=1-2) and good (LOS=3-5) outcome groups compared for demographic, clinical and biochemical parameters for prognostic factors of poor outcomes. Social participation of patients scaled on Child and Adolescent Scale of Participation score 2-5. RESULTS: About 94 of 126 (74.6%) children developed neurological sequelae at different levels of severity. Age-expected social participation was compromised in 90 out of 118 children. In multivariate logistic regression analysis, a combination of parameters, JE unvaccinated status (OR: 61.03, 95% CI (14.10 to 264); p<0.001), low Glasgow Coma Score (GCS) at admission (≤8) (OR: 8.6, 95% CI (1.3 to 57.1); p=0.026), malnutrition (OR: 13.56, 95% CI (2.77 to 66.46); p=0.001) and requirement of endotracheal intubation (OR: 5.43, 95% CI (1.20 to 24.44); p=0.027) statistically significantly predicted the poor outcome with 77.8% sensitivity and 94.6% specificity. The goodness-of-fit test showed that the model fit well (Hosmer-Lemeshow goodness-of-fit test) (χ 2=3.13, p=0.988), and area under the receiver operating characteristic curve was 0.950. CONCLUSION: This study estimates the burden of JE-presenting post-discharge deaths (15.4%) and disability (63.08%). Those who did not receive JE vaccine, were suffering from malnutrition, had GCS ≤8 at admission and required endotracheal intubation had poorer outcomes.

Evidence-Based Health Behavior Interventions for Cholera: Lessons from an Outbreak Investigation in India.

In rural India, since 2014, the Swachh Bharat Abhiyan (Clean India Mission) has ensured construction of more than 100 million toilets and is now focusing on reinforcement of sanitation behaviors. We report a cholera outbreak in a remote village in western India where open defecation was implicated in causation. A water pipeline was damaged in the vicinity of a stream flowing from a site of open defecation. Despite the availability of a toilet facility in the majority of households (75%), open defecation was widely practiced (62.8%). Many reported not washing hands with soap and water before eating (78.5%) and after defecation (61.1%). The study emphasizes the need for focused health behavior studies and evidence-based interventions to reduce the occurrence of cholera outbreaks. This could be the last lap in the path toward achieving the United Nations Sustainable Development Goal 6, which aims to "ensure availability and sustainable management of water and sanitation for all."

Declining trends in Hepatitis A seroprevalence over the past two decades, 1998-2017, in Pune, Western India.

Reduction in seroprevalence of Hepatitis A virus (HAV) is known to be associated with improvements in socioeconomic conditions of the community. National Institute of Virology, Pune has been studying seroprevalence of hepatitis viruses in Pune region over the past four decades. In total, 1438 samples were collected from urban general (UGEN), urban lower socioeconomic stratum (ULSES) and rural (RURAL) populations of the Pune district. Based on estimates in previous studies, subjects were enrolled from age groups '6-10', '15-25' and '40 + ' years. HAV seroprevalence in younger population showed a significant decline. A significant decline in HAV seroprevalence in '15-25' years age group in UGEN (from 85.9% to 73.9%; OR = 0.46, 95% CI: 0.25-0.86) and RURAL (from 98.6% to 91.4%; OR = 0.15, 95% CI: 0.05-0.45) populations suggested that the trend probably started more than a decade ago. Seroprevalence of HAV among ULSES '6-10' children was found to be significantly higher (70.4%) than that among the RURAL children (44.2%; OR = 3.0, 95%CI: 1.7-5.2) and UGEN children (40.4%; OR = 3.5, 95%CI: 1.8-6.7). In view of increasing rates of urbanisation in India, ULSES population needs special consideration while designing future studies and viral hepatitis vaccination/elimination strategies. Our findings call for robust population-based studies that consider heterogeneity within populations and dynamics of socio-economic parameters in various regions of a country.

Effectiveness of Presumptive Treatment of Acute Febrile Illness With Doxycycline or Azithromycin in Preventing Acute Encephalitis Syndrome in Gorakhpur, India: A Cohort Study.

OBJECTIVE: To estimate effectiveness of presumptive doxycycline or azithromycin treatment in preventing progression of Acute Febrile Illness to Acute Encephalitis Syndrome in Gorakhpur. STUDY DESIGN: Prospective cohort study. STUDY SETTING: Primary healthcare centers and Community healthcare centers of Gorakhpur district, Uttar Pradesh. PARTICIPANTS: Children aged 1 year to less than 15 years with fever of 3 days to less than 15 days duration attending three selected peripheral health facilities in Gorakhpur during August to October, 2018. PROCEDURE: 35 medical officers in three selected Primary Healthcare Centers/Community Healthcare centers were sensitized on the treatment strategy. After sensitization, study participants were enrolled and information about prescription of doxycycline or azithromycin was collected. Participants were telephonically followed-up to know their progression status from AFI to AES. MAIN OUTCOME MEASURE: Incidence of acute encephalitis syndrome among acute failure illness patients who received presumptive doxycycline or azithromycin treatment and those who did not receive this treatment. RESULTS: Of the enrolled 930 AFI patients, 801 (86%) were prescribed doxycycline or azithromycin and 725 (78%) could be telephonically followed-up. Progression to acute encephalitis syndrome was seen in 6 of the 621 patients who received presumptive treatment, and 5 of the 104 who did not receive the treatment. The relative risk of developing acute encephalitis syndrome among acute febrile illness patients who were prescribed presumptive treatment with doxycycline or azithromycin was 0.20 (95% CI: 0.06-0.65). The effectiveness of presumptive treatment with doxycycline or azithromycin strategy was 79.9% (95% CI: 35.4-94). CONCLUSIONS: PDA treatment to children presenting with fever in peripheral health facilities of the study blocks in Gorakhpur during August-November, 2018 had good effectiveness in preventing progression of acute febrile illness to acute encephalitis syndrome.

Study of a hepatitis E virus outbreak involving drinking water and sewage contamination in Shimla, India, 2015-2016.

BACKGROUND: Hepatitis E, caused by hepatitis E virus (HEV), accounts for 50% of acute hepatitis cases in India. We report an outbreak of hepatitis E in Shimla, India, in 2015-2016. METHODS: ICMR-National Institute of Virology (NIV), Pune, received two batches of water samples from Shimla in January 2016 to test for the presence of enterically transmitted hepatitis viruses. Subsequently, 57 icterus patients were tested for various markers of hepatotropic viruses, i.e. anti-HEV IgM/IgG, anti-hepatitis A virus (anti-HAV) IgM/IgG antibodies and HEV RNA. Water samples were screened for HEV and HAV RNA followed by phylogenetic analysis. RESULTS: Overall, 48/57 patients availing municipal water had evidence of HEV infection, detected by serology and RT-PCR. All the water samples tested positive for HEV and HAV RNA, while the patients were negative for anti-HAV IgM antibody, indicating no recent HAV infection. Phylogenetic analysis confirmed the aetiological agent of the current outbreak to be HEV genotype 1. CONCLUSIONS: Serology and RT-PCR confirmed HEV as the aetiology of the outbreak. The absence of new cases of hepatitis A, despite the presence of HAV in the water supply, could be due to previously acquired immunity. Sewage contamination of water leading to faecal-oral transmission of HEV still remains a concern, thus emphasising the need for a vaccination/control strategy.

Seroprevalence and incidence of primary dengue infections among children in a rural region of Maharashtra, Western India.

BACKGROUND: Dengue infections have become a huge threat to public health systems in developing countries. Data on seroprevalence and incidence of dengue infections are lacking from rural regions of India. The objective of present study was to investigate the seroprevalence and incidence of dengue infection utilizing repeated serosurveys from a rural region of Maharashtra, Western India. METHODS: In the present study, 819 children between ages 5 to 15 years from 21 villages in Pune District of Maharashtra, India were sampled in 2014 and 2016. The sera were tested for the presence of dengue specific IgG using an indirect IgG ELISA kit. RESULTS: Overall seroprevalence of dengue was 15.3% (95% confidence intervals (CI) 12.9-17.8%) in 2014 and 20.5% (95% CI 17.8-23.4%) in 2016. Among the 694 children who were seronegative at baseline (2014), 78 seroconverted. Overall incidence rate of primary dengue was 54.2 infections/1000 children years (95% CI 43.0-67.3). Incidence of primary dengue infection was higher in children from urbanized villages compared to rural villages (Incidence rate ratio (IRR) 2.6 (95% CI 1.3-5.2)). In rural villages, incidence of primary dengue infection was higher in children aged 10 years or above as compared to those aged below 10 years (IRR 9.75 (95% CI 1.21-77.9). CONCLUSIONS: The study provides the incidence rates of primary dengue infections from a rural region of India. More multi centric studies investigating the incidence of dengue will provide accurate estimate of incidence of dengue and help formulate well directed policies. The results also suggest that urbanization and transitions in demographic settings might favour dengue outbreaks in rural regions and these regions need to be targeted for vector control measures.

Risk Factors for Acquiring Scrub Typhus among Children in Deoria and Gorakhpur Districts, Uttar Pradesh, India, 2017.

Scrub typhus is associated with outbreaks of acute encephalitis syndrome in Uttar Pradesh, India. A case-control study indicated that children residing, playing, or visiting fields; living with firewood stored indoors; handling cattle fodder; and practicing open defecation were at increased risk for scrub typhus. Communication messages should focus on changing these behaviors.

Bacteriological Study Among Influenza-like Illness Cases in a Community Setting in Pune, India.

Influenza-like illness (ILI) and acute respiratory infection (ARI) are common presentations during winter, and indiscriminate antibiotic use contributes significantly to the emerging post-antibiotic era. Although viral agents causing ILI are predominant, they are indistinguishable from the bacterial agents based on the clinical features alone. The present study was aimed at determining the bacterial agents associated with ILI and their susceptibility pattern during a study done in a community setting in Pune during a surveillance of ILI between March 2013 to November 2016. Throat swabs from 512 suspected ILI cases were processed, and organisms were identified by the standard conventional method. An antimicrobial susceptibility testing was done as per the Clinical Laboratory Standard Institute (CLSI) guidelines. The patients comprised 238 males and 274 females with the majority (38.7%) in the age group of ≤10 years. Bacteria could be isolated from 9.8 % of the patients. The predominant bacteria included beta-hemolytic Streptococcus (42%) followed by group G Streptococcus (30%) and group A Streptococcus (20%). All organisms were sensitive to Penicillin except two isolates of Staphylococcus aureus (50%). Tetracycline (98.8%) and ciprofloxacin (87%) were the next most effective drugs. Overall resistance was observed for erythromycin (37%) and co-trimoxazole (32%).

Chickenpox and measles clusters among college students in Pune, Maharashtra.

Chickenpox and measles, both vaccine preventable febrile rash illnesses, present in a comparatively severe form among young adults/adults than among children. Immunity levels against chickenpox are not known in India and those against measles have been found variable across the country. Places where students or adults/young adults from various parts of the country come together pose a peculiar challenge in preventive policy making regarding these diseases. In this article, we present findings from parallel outbreaks of the two diseases in a graduate/postgraduate institute in the city of Pune. A team from National Institute of Virology [Pune] investigated outbreak of febrile rash illness in a premier graduate institute and found that it was a case of two parallel outbreaks of chickenpox and measles. In this outbreak chickenpox cases did not present with greater severity but measles cases were severe. The concerned institute hosts more than 800 students and 300 staff including faculty. These outbreaks were contained because of the alert physician in the institute; but it also highlights a need for uniform policies across such educational institutions in the country.

Emergence of Crimean-Congo hemorrhagic fever in Amreli District of Gujarat State, India, June to July 2013.

Crimean-Congo hemorrhagic fever virus (CCHFV) etiology was detected in a family cluster (nine cases, including two deaths) in the village of Karyana, Amreli District, and also a fatal case in the village of Undra, Patan District, in Gujarat State, India. Anti-CCHFV IgG antibodies were detected in domestic animals from Karyana and adjoining villages. Hyalomma ticks from households were found to be positive for CCHF viral RNA. This confirms the emergence of CCHFV in new areas and the wide spread of this disease in Gujarat State.

Burden of seasonal and pandemic influenza-associated hospitalization during and after 2009 A(H1N1)pdm09 pandemic in a rural community in India.

BACKGROUND: Influenza is vaccine-preventable; however, the burden of severe influenza in India remains unknown. We conducted a population-based study to estimate the incidence of laboratory confirmed influenza-associated hospitalizations in a rural community in western India. METHODS: We conducted active surveillance for hospitalized patients with acute medical illnesses or acute chronic disease exacerbations in Pune during pandemic and post pandemic periods (May 2009-April 2011). Nasal and throat swabs were tested for influenza viruses. A community health utilization survey estimated the proportion of residents hospitalized with respiratory illness at non-study facilities and was used to adjust incidence estimates from facility-based surveillance. RESULTS: Among 9,426 hospitalizations, 3,391 (36%) patients were enrolled; 665 of 3,179 (20.9%) tested positive for influenza. Of 665 influenza positives, 340 (51%) were pandemic A(H1N1)pdm09 and 327 (49%) were seasonal, including A/H3 (16%), A/H1 (3%) and influenza B (30%). The proportion of patients with influenza peaked during August 2009 (39%) and 2010 (42%). The adjusted annual incidence of influenza hospitalizations was 46.8/10,000 during pandemic and 40.5/10,000 during post-pandemic period with comparable incidence of A(H1N1)pdm09 during both periods (18.8 and 20.3, respectively). The incidence of both pH1N1 and seasonal hospitalized influenza disease was highest in the 5-29 year olds. CONCLUSIONS: We document the previously unrecognized burden of influenza hospitalization in a rural community following the emergence of influenza A(H1N1)pdm09 viruses in India. During peak periods of influenza activity circulation i.e during the monsoon period, 20% of all hospital admissions in the community had influenza positivity. These findings can inform development of influenza prevention and control strategies in India.

Performance of case definitions used for influenza surveillance among hospitalized patients in a rural area of India.

OBJECTIVE: To assess case definitions for influenza in a rural community in India. METHODS: Residents of the study area who were hospitalized for any acute medical condition for at least one night between May 2009 and April 2011 were enrolled. Respiratory specimens were collected and tested for influenza viruses in a reverse-transcription polymerase chain reaction (PCR). The PCR results were taken as the "gold standard" in evaluating the performance of several case definitions. FINDINGS: Of the 3179 patients included in the final analysis, 21% (665) were PCR-positive for influenza virus, 96% reported fever and 4% reported shortness of breath. The World Health Organization (WHO) case definition for severe acute respiratory illness had a sensitivity of 11% among patients aged < 5 years and of 3% among older patients. When shortness of breath was excluded from the definition, sensitivities increased (to 69% and 70%, respectively) and corresponding specificities of 43% and 53% were recorded. Among patients aged ≥ 5 years, WHO's definition of a case of influenza-like illness had a sensitivity of 70% and a specificity of 53%. The addition of "cough and reported or measured fever" increased sensitivity to 80% but decreased specificity to 42%. CONCLUSION: The inclusion of shortness of breath in WHO's case definition for severe acute respiratory illness may grossly underestimate the burden posed by influenza in hospitals. The exclusion of shortness of breath from this definition or, alternatively, the inclusion of "cough and measured or reported fever" may improve estimates of the burden.