An outbreak of acute hemorrhagic conjunctivitis due to Coxsackievirus A24 in a residential school, Naharlagun, Arunachal Pradesh: July 2023.

PURPOSE: An acute conjunctivitis outbreak was investigated at a residential school in Naharlagun, Arunachal Pradesh, Northeast India, in July 2023. We aimed to identify the etiological agent and assess any complications in follow-up cases. METHODS: We used a structured questionnaire to record clinical findings and followed up with cases one-month post-conjunctivitis. Sixty-one cases were examined and eight conjunctival and oropharyngeal swab samples were collected after obtaining informed consent from guardians/school authorities. We screened for 33 viral and bacterial pathogens using an IVD-approved Real-time PCR assay. Further, the samples were subjected to nucleic acid sequencing. RESULTS: Among 465 screened students and staff, 80 individuals (approximately 17.2%) showed acute hemorrhagic conjunctivitis symptoms among which 61 cases were available for clinical examination. We identified the Enterovirus responsible by targeted sequencing using next-generation sequencing. The etiological agent was found to be Coxsackievirus A24, a member of Enterovirus C, in seven out of eight samples subjected to sequencing. Common symptoms included conjunctival hyperemia and foreign body sensation (100%), bilateral eye involvement (73.8%), eye pain (70%), watery discharge (49.2%), and eyelid swelling (38%). Only 6.5% had purulent discharge. Most cases resolved within 5-6 days, with only 9.8% reporting abdominal symptoms post-conjunctivitis. No serious complications occurred within one month. Throat swabs aided in diagnosing enterovirus infections alongside eye swabs. CONCLUSIONS: The outbreak of acute conjunctivitis was caused by Coxsackievirus A24, a member of Enterovirus C. Cases resolved spontaneously within 6-7 days, with no severe complications. Collecting oropharyngeal swabs alongside conjunctival swabs could improve enteroviral conjunctivitis diagnosis.

Norovirus gastroenteritis in children under-five years hospitalized for diarrhea in two cities of northeast India: A retrospective study.

PURPOSE: Norovirus gastroenteritis, known to cause 'winter vomiting disease' is increasingly being identified as a major cause of viral gastroenteritis worldwide. The impact and prevalence of this viral disease are lacking in many parts of India including northeast India. This study aimed to determine the prevalence and association of norovirus gastroenteritis among under-five-year-old hospitalized children in two cities in northeast India (Dibrugarh in Assam & Dimapur in Nagaland). MATERIALS AND METHODS: A retrospective analysis of 407 randomly selected diarrheal stool samples was conducted using a commercial multiplex probed-based real-time RT-PCR assay capable of detecting six-viral gastroenteritis pathogens including Norovirus GI, Norovirus GII, Rotavirus, Human Adenovirus, Human Astrovirus, and Sapovirus. RESULTS: Results showed that norovirus was detected in 18.4% of the samples (75/407; 95% CI: 14.8%-22.5%), with norovirus genogroup II being the predominant group in 97.3% of norovirus cases. A significant association of norovirus diarrhea was found with seasonality, with higher prevalence in colder months compared to warmer months (22.4% vs 9.1%, p-value:0.002). Additionally, 66.7% (50/75) of cases of norovirus gastroenteritis had reported vomiting as the major symptom and had a shorter duration of diarrhea (p-value 0.03). Co-infections with other viral pathogens were seen in 45.9% (187/407) of the cases. The detection of rotavirus was 67.1% (273/407), human adenovirus (45.9%; 187/407), sapovirus and astrovirus (5.9%, 24/407 each), and norovirus GI (0.5%, 2/407) among the cases. CONCLUSION: This study reports the prevalence of norovirus gastroenteritis in northeast India and further highlights that norovirus gastroenteritis is responsible for substantial cases of hospitalization of under-five years children in the region.

Airway Microbiology in Children with Cystic Fibrosis: A Prospective Cohort Study from Northern India.

OBJECTIVE: The objective of this study is to find the organism profile and antimicrobial susceptibility patterns in children with cystic fibrosis (CF). DESIGN: Prospective cohort study. SETTING: Hospital-based study. INTERVENTION: Sputum cultures/throat swabs were collected from the study population. Relevant details like anthropometry, systemic examination findings and investigations were entered in a pre-designed format. Sputum culture was subjected to microbiological analysis at the hospital microbiology laboratory. MAIN OUTCOME MEASURE: Prevalence of positive sputum/cough swab culture in CF patients, their organism profile and antibiotic sensitivity. RESULTS: A total of 63 patients were enrolled in the study. A total of 136 organisms were grown in our study population. Thirteen different organisms were isolated, which included five gram-positive bacteria, six gram-negative bacteria, eight Candida spp. and one filamentous. Antibiotic sensitivity profile of the Pseudomonas aeruginosa showed excellent sensitivity to all the aminoglycosides, piperacillin-tazobacteum and polymixin, similarly methicillin-sensitive Staphylococcus aureus, methicillin-resistant S. aureus and Enterococcus spp. were uniformly sensitive to vancomycin, linezolid and teicoplanin. Fungal isolates showed 100% sensitivity to all the antifungals tested including azoles and amphotericin B. CONCLUSION: We observed 61% of culture positivity for different organisms in our study. Staphylococcus aureus and P. aeruginosa were the most frequently isolated organisms. Pseudomonas aeruginosa isolates were largely sensitive to aminoglycosides, carbapenems and polymixin. We found an unusually higher incidence of enterococcal infection in our study cohort with few vancomycin-resistant isolates.

Haemophilus influenzae and SARS-CoV-2: Is there a role for investigation?

During the current pandemic of COVID-19, the authors observed that during screening test for SARS-CoV-2 targeting the E-gene by qRT-PCR, few nasopharyngeal/oropharyngeal samples showed amplification signals at late cycle threshold (CT-value) > 35 despite being negative for other confirmatory target genes. Thirty such samples (taken as cases) showing detectable CT of > 35 cycle in E-gene which were negative for other target genes of SARS-CoV-2 and 30 samples with undetectable fluorescence in E-gene were taken as controls for investigation. An in-vitro diagnostic approved commercial qRT-PCR multiplex kit detecting 33 respiratory pathogens which can also detect Haemophilus influenzae was used for screening the samples. It was observed that out of the 30 samples showing detectable CT> 35 in E-gene, 11 samples were positive for Haemophilus influenzae whereas in the controls only three samples were positive for H. influenzae (p-value: 0.03) which was statistically significant. Further, the probes and primers were screened against H. influenzae for matches in the genome. It was observed that all primers and probes for the E-gene of SARS-CoV-2 had over 13 bp long sequences matching 100% with multiple sites across the H. influenzae genome. This qRT-PCR primer & probes are being used extensively across India, and laboratories using them should be aware of the cross-reactivity of primers & probes with the H. influenzae genome. Further, the authors observed that 95.9% (5415/5642) of COVID-19 positive cases detected in their laboratory were asymptomatic at the time of collection of samples. This warrants further investigations.

TSP-based PCR for rapid identification of L and S type strains of SARS-CoV-2.

BACKGROUND: In the initial few months of the COVID-19 pandemic, two distinct strains of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) were identified (L and S strain) based on a tightly linked SNP between two widely separated nucleotides at location 8782 (ORF1ab T8517C) and position 28,144 (ORF8: C251T, codon S84L). MATERIALS AND METHODS: A Type Specific Primer based one step RT-PCR (TSP-PCR) test to distinguish the L and S type strains of SARS-CoV-2 without the need for viral genome sequencing, was developed. The study also analyzed 18,221 whole genome sequences (WGS) available up to April 2020 to know the prevalence of L and S type of strains. Phylogenetic and recombination analysis of SARS-CoV-2 genome with nearest animal and human coronaviruses were analyzed using MEGA X and SimPlot version 3.5.1 software respectively. RESULTS: The rapid TSP-PCR distinguished the L and S type strains of SARS-CoV-2 by amplifying a specific 326 bp and 256 bp fragment of the L and S type strain respectively. The test was used to analyzed 120 random SARS-CoV-2 positive samples from Assam, India among which 118 were found to be of L-type strains only. On analysis of 18,221 WGS, it was found that L type was the predominant strain with an overall prevalence ∼90%. However, pockets of high prevalence of S-type strains (>35%) were still in circulation in Washington region in April 2020. The study did not detect any significant recombination events between closely related coronavirus and SARS-CoV-2. CONCLUSION: TSP-based PCR for identification of circulating strains of SARS-CoV-2, will add in rapid identification of strains of COVID-19 pandemic to understand the spread of the virus, its transmissibility and adaptation into human population. Though, the S-type strains have decreased drastically across the globe since April 2020, the role of TSP-PCR in geographical niches where such strains are still prevalent may help in rapidly distinguishing the strains and study its evolution.

Knowledge, Attitude, and Behavioural Response of Corporate Employees in India towards Influenza: A Questionnaire Based Study.

OBJECTIVE: Understanding about influenza would be helpful in adapting preventive measures like social distancing, seeking medical attention and getting vaccinated. The objective of this study was to evaluate knowledge, attitude and practices (KAP) towards influenza among Indian corporate employees and assessment of their awareness through a questionnaire-based survey. METHODS: Indian corporate employees of either gender (≥18 years) were provided with a self-administered questionnaire with domains namely knowledge (21 questions), attitude (6 questions), and practices (6 questions). RESULTS: Overall, 500 corporate employees completed the survey from four zones. Total of 50.8% respondents had low level of knowledge of influenza, 34% had moderate knowledge, and 15.2% had high knowledge of influenza. Attitude domain revealed that 66% respondents were quiet concerned and 24% were extremely concerned regarding influenza. The practice domain demonstrated that 57.8% respondents took high level of precautions while 36.6% took moderate level precautions for the prevention of infection. CONCLUSIONS: Knowledge and attitude regarding importance of vaccine against influenza is not adequate. This study emphasizes the need for effective awareness programs for the management of influenza.

Influenza Illness in Pregnant Indian Women: A Cross-Sectional Study.

Data about burden of influenza in pregnancy in India are scant. In order to assess the contribution of influenza to acute respiratory illness (ARI) in pregnancy, 266 north Indian pregnant females with febrile ARI were studied from December 2014 to May 2015. Twin nasopharyngeal/oropharyngeal swabs were obtained and tested for influenza viruses by RT-PCR. Fifty (18.8%) patients tested positive for influenza (A/H1N1pdm09 in 41, A/H3N2 in 8, and influenza B Yamagata in 1). Rigors, headache, and a family history of ARI were significantly more frequent in influenza positive patients. Oseltamivir and supportive therapy were administered to all confirmed cases. Nine influenza positive cases needed hospitalization for their respiratory illness, and 5 developed respiratory failure. Of these, 4 (3 in third trimester) succumbed to their illness. We conclude that influenza viruses are a cause of significant morbidity and mortality among pregnant females with ARI in north India. As such, appropriate preventive strategies of influenza vaccination and early initiation of antiviral therapy during illness are stressed.

Poor uptake of influenza vaccination in pregnancy in northern India.

OBJECTIVE: To study the uptake of influenza vaccination among pregnant women in northern India and physicians' beliefs and practices regarding vaccination. METHODS: A questionnaire-based survey was undertaken between October 2012 and April 2013. Pregnant women attending an obstetric hospital in Srinagar, India, and healthcare personnel were asked to participate. RESULTS: Among 1000 women aged 18-41 years (13.6% first trimester, 26.8% second trimester), none had been offered or received influenza vaccination. Only 9 (10.0%) of 90 obstetricians surveyed had been vaccinated for influenza in the past 5 years, although 81 (90.0%) believed that influenza could have severe consequences for themselves and their patients. The reasons cited for non-vaccination included poor knowledge about availability of vaccine and concerns about its efficacy. Sixty-six (73.3%) obstetricians believed that vaccine adverse effects are under-reported, and 79 (87.8%) believed that vaccination programs are motivated by profit. Eighty-four (93.3%) obstetricians wished to undergo vaccination in the coming flu season. CONCLUSION: Influenza vaccination among pregnant women in northern India is nonexistent. Poor uptake is rooted in misperceptions about vaccine availability, efficacy, and safety among treating physicians, few of whom are vaccinated.

Knowledge, attitude, and practices about the seasonal influenza vaccination among healthcare workers in Srinagar, India.

BACKGROUND: Healthcare workers (HCWs) universally have a poor uptake of influenza vaccination. However, no data are available from India. OBJECTIVE: To explore knowledge, attitudes, and practices associated with influenza vaccination in HCWs in a temperate climate area in northern India. PATIENTS AND METHODS: A self-administered questionnaire was offered to all HCWs in three major hospitals of Srinagar and information sought on motivations, perceptions, preferences and practices regarding influenza vaccination. RESULTS: Of the 1750 questionnaires received, 1421 (81%) were returned. Only 62 (4·4%) HCWs had ever received influenza vaccination even as 1348 (95%) believed that influenza poses adverse potential consequences for themselves or their contacts; 1144 (81%) were aware of a vaccine against influenza and 830 (58%) of its local availability. Reasons cited by 1359 participants for not being vaccinated included ignorance about vaccine availability (435; 32%), skepticism about efficacy (248; 18%), busy schedule (166; 12%), fear of side effects (70; 4%), and a perception of not being-at-risk (82; 6%). Sixty-one percent (865) believed that vaccine programs are motivated by profit. Eighty-eight percent opined for mandatory vaccination for HCWs caring for the high-risk patients, as a part of 'employee health program'. Most of the participants intended to get vaccinated in the current year even as 684 (48%) held that vaccines could cause unknown illness and 444 (31%) believed their adverse effects to be underreported. CONCLUSION: Influenza vaccination coverage among HCWs is dismally low in Srinagar; poor knowledge of vaccine availability and misperceptions about vaccine effectiveness, fear of adverse effects and obliviousness to being-at-risk being important barriers. Multifaceted, adaptable measures need to be invoked urgently to increase the coverage.

An outbreak of influenza B in an isolated nomadic community in Jammu & Kashmir, India.

BACKGROUND & OBJECTIVES: Community outbreaks of disease amongst nomadic populations generally remain undocumented. Following a reported increase in acute respiratory tract infections (ARI) in May 2011 in a nomadic population of Sangerwini in Jammu & Kashmir, India, we examined the patients with ARI symptoms and their nasal swabs were tested for influenza virus. METHODS: Patients with ARI (n=526) were screened from May 14 to 23, 2011 and nasopharyngeal swabs collected from 84 with Influenza like illness (ILI) for bacterial cultures and influenza virus testing. Samples were tested for influenza A and influenza B by real time (RT)-PCR. RESULTS: Twelve (14.3%) of the 84 patients tested positive for influenza B, compared to only one (0.9%) of 108 patients with ILI in a parallel survey performed in Srinagar during the same period, suggesting a localized outbreak in the isolated nomadic community. All presented with respiratory symptoms of less than seven days. Familial clustering was seen in 40 per cent (25% of influenza B positives). Average daytime temperatures ranged from 15-16 ° C compared to 22 ° C in Srinagar. Four patients developed pneumonia whereas others ran a mild course with a total recovery with oseltamivir and symptomatic therapy. INTERPRETATION & CONCLUSION: Our report of confirmed influenza B in this underprivileged nomadic population argues for routine surveillance with efforts to improve vaccination and infection control practices.

Pandemic and seasonal influenza viruses among patients with acute respiratory illness in Kashmir (India).

BACKGROUND: With the emergence of pandemic influenza A (2009A/H1N1) virus in India, we sought to determine the prevalence and clinical presentations of seasonal and pandemic influenza viruses among acute respiratory illness (ARI) patients from Srinagar, a temperate climate area in northern India, during the peak winter season. METHODS: Combined throat and nasal swabs, obtained from 194 (108 male) presenting with ARI from January to March 2010 (Week 53-week 10), were tested by RT-PCR for influenza A and B, including 2009A/H1N1 viruses. HA1 gene of selected 2009A/H1N1-positive samples was sequenced, and phylogenetic analysis was carried out. RESULTS: Twenty-one (10·8%, age 15-80 years, median age 40 years) patients tested positive for influenza viruses: 13 (62%) for 2009A/H1N1 virus, 6 (28·5%) for seasonal influenza A (H3N2), and 2 (9·5%) for influenza B. Twelve of the 13 patients with 2009A/H1N1 presented with febrile ARI, and eight had associated comorbidities. All of the patients recovered. Phylogenetic analysis of HA gene (n = 8) revealed that all strains from Srinagar clustered in 2009A/H1N1 clade seven along with the other 2009A/H1N1 strains from India. Amino acid substitutions in the HA protein defining clade seven (P83S, S203T, and I321V) were found in almost all isolates from Srinagar. CONCLUSIONS: Both seasonal and 2009A/H1N1 viruses appear to be associated with ARI in Srinagar. The 2009A/H1N1 in Srinagar is genetically similar to globally circulating clade 7 strains, with unique signature sequences in the HA gene. Further investigations into ascertain the role of these mutations in possible alteration of the virulence and transmissibility of the virus are needed.