C. P. Girish Kumar

Assessment of the scale, coverage and outcomes of the Avahan HIV prevention program for female sex workers in Tamil Nadu, India: is there evidence of an effect?

BackgroundAvahan, the India AIDS Initiative, a large-scale HIV prevention program, using peer-mediated approaches and STI services, was implemented for high-risk groups for HIV in six states in India. This paper describes the assessment of the program among female sex workers (FSWs) in the southern state of Tamil Nadu.MethodsAn analytical framework based on the Avahan impact evaluation design was used. Routine program monitoring data, two rounds of cross-sectional biological and behavioural surveys among FSWs in 2006 (Round 1) and 2009 (Round 2) and quality assessments of clinical services for sexually transmitted infections (STIs) were used to assess trends in coverage, condom use and prevalence of STIs, HIV and their association with program exposure. Logistic regression analysis was used to examine trends in intermediate outcomes and their associations with intervention exposure.ResultsThe Avahan program in Tamil Nadu was scaled up and achieved monthly reported coverage of 79% within four years of implementation. The cross-sectional survey data showed an increasing proportion of FSWs being reached by Avahan, 54% in Round 1 and 86% in Round 2 [AOR=4.7;p=0.001]. Quality assessments of STI clinical services showed consistent improvement in quality scores (3.0 in 2005 to 4.5 in 2008). Condom distribution by the program rose to cover all estimated commercial sex acts. Reported consistent condom use increased between Round 1 and Round 2 with occasional (72% to 93%; AOR=5.5; p=0.001) and regular clients (68% to 89%; AOR=4.3; p=0.001) while reactive syphilis serology declined significantly (9.7% to 2.2% AOR=0.2; p=0.001). HIV prevalence remained stable at 6.1% between rounds. There was a strong association between Avahan exposure and consistent condom use with commercial clients; however no association was seen with declines in STIs.ConclusionsThe Avahan program in Tamil Nadu achieved high coverage of FSWs, resulting in outcomes of improved condom use, declining syphilis and stabilizing HIV prevalence. These expected outcomes following the program logic model and declining HIV prevalence among general population groups suggest potential impact of high risk group interventions on HIV epidemic in Tamil Nadu.

Expanded Indian national rotavirus surveillance network in the context of rotavirus vaccine introduction

ObjectiveTo extend a nation-wide rotavirus surveillance network in India, and to generate geographically representative data on rotaviral disease burden and prevalent strains.DesignHospital-based surveillance.SettingA comprehensive multicenter, multi-state hospital based surveillance network was established in a phased manner involving 28 hospital sites across 17 states and two union territories in India.PatientsCases of acute diarrhea among children below 5 years of age admitted in the participating hospitals.ResultsDuring the 28-month study period between September 2012 and December 2014, 11898 children were enrolled and stool samples from 10207 children admitted with acute diarrhea were tested; 39.6% were positive for rotavirus. Highest positivity was seen in Tanda (60.4%) and Bhubaneswar (60.4%) followed by Midnapore (59.5%). Rotavirus infection was seen more among children aged below 2 years with highest (46.7%) positivity in the age group of 12-23 months. Cooler months of September–February accounted for most of the rotavirus-associated gastroenteritis, with highest prevalence seen during December–February (56.4%). 64% of rotavirus-infected children had severe to very severe disease. G1 P[8] was the predominant rotavirus strain (62.7%) during the surveillance period.ConclusionsThe surveillance data highlights the high rotaviral disease burden in India. The network will continue to be a platform for monitoring the impact of the vaccine.

Acute encephalitis syndrome in Gorakhpur, Uttar Pradesh, India – Role of scrub typhus

With reference to the recent communication to this Journal by Ranjan and colleagues, it is notable that outbreaks of acute encephalitis syndrome (AES) with high fatality have been occurring in Gorakhpur division, Uttar Pradesh, India since several years. These outbreaks occur during rainy season, peak during AugusteSeptember and predominantly affect children aged 14 years. Annually, approximately 1500e2000 AES patients get admitted to BRD Medical College (BRDMC), Gorakhpur the only tertiary care hospital in the region, with a case-fatality of 20e25%. In the past, AES patients have been investigated for viral and non-viral etiologies including Japanese encephalitis (JE), herpes simplex, enteroviruses, Chandipura, measles, mumps, dengue, varicella, Parvovirus, West Nile, malaria, and typhoid. 4 However, except for a small contribution (<10%) from JE, the etiology of AES has largely remained unknown. We investigated AES patients to explore role of scrub typhus (ST). We enrolled 370 AES patients (defined as acute onset of fever and change in mental status and/or new onset of seizures, excluding simple febrile seizures) and 109 patients of acute febrile illness (AFI; defined as fever of 2 weeks duration, without localizable signs) admitted at BRDMC during SeptembereOctober 2015 (Table 1). Blood samples were collected from these patients (1 ml in EDTA, 2 ml in plain tube without anticoagulant for serum). EDTA blood was centrifuged; buffy coat was applied on four spots of Whatman FTA classic card (GE Healthcare, UK) and air-dried. DNA was extracted from one spot using Qiagen protocol. A quantitative real-time PCR for 47 kDa gene was performed using primers, probes and protocol described by Jiang et al. and validated by Kim et al. A cycle threshold value 38 was considered positive. All samples were tested in duplicate and ST positives were repeat-tested. DNA quality and sample integrity was tested by performing RNase P qPCR. Sera were tested for IgM antibodies against Orientia tsutsugamushi (OT) using commercial ELISA (Scrub Typhus Detect, InBios International Inc., Seattle, USA). In the absence of any data about

Scrub Typhus as a Cause of Acute Encephalitis Syndrome, Gorakhpur, Uttar Pradesh, India

Outbreaks of acute encephalitis syndrome (AES) have been occurring in Gorakhpur Division, Uttar Pradesh, India, for several years. In 2016, we conducted a case–control study. Our findings revealed a high proportion of AES cases with Orientia tsutsugamushi IgM and IgG, indicating that scrub typhus is a cause of AES.

Scrub Typhus as an Etiology of Acute Febrile Illness in Gorakhpur, Uttar Pradesh, India, 2016

Seasonal outbreaks of acute encephalitis syndrome (AES) with high mortality occur every year in Gorakhpur region of Uttar Pradesh, India. Earlier studies indicated the role of scrub typhus as the important etiology of AES in the region. AES cases were hospitalized late in the course of their illness. We established surveillance for acute febrile illness (AFI) (fever ≥ 4 days duration) in peripheral health facilities in Gorakhpur district to understand the relative contribution of scrub typhus. Of the 224 patients enrolled during the 3-month period corresponding to the peak of AES cases in the region, about one-fifth had immunoglobulin M (IgM) antibodies against Orientia tsutsugamushi. Dengue and leptospira accounted for 8% and 3% of febrile illness cases. Treating patients with AFI attending the peripheral health facilities with doxycycline could prevent development of AES and thereby reduce deaths due to AES in Gorakhpur region.

Profile and trends of rotavirus gastroenteritis in under-five children in India (2012-2014): Preliminary report of the Indian national rotavirus surveillance network

ObjectiveTo estimate the burden of rotavirus-associated gastroenteritis in India.MethodsHospital-based surveillance network was established, with clinical evaluation and laboratory testing for rotavirus among children aged below 5 years hospitalized with acute gastroenteritis.ResultsBetween September 2012 and December 2014, stool samples from 10207 children were tested and rotavirus was detected in 39.6% of cases. Infections were more commonly seen among younger children (<2 years). Detection rates were higher during cooler months of September–February. Among rotavirus infected-children, 64.0% had severe or very severe disease. G1P[8] was the predominant rotavirus genotype (62.7%) observed during the surveillance period.ConclusionsSurveillance data highlights the high rotavirus disease burden and emphasizes the need for close monitoring to reduce morbidity and mortality associated with rotavirus gastroenteritis in India.

Intussusception hospitalizations before rotavirus vaccine introduction: Retrospective data from two referral hospitals in Tamil Nadu, India

Background The indigenous oral rotavirus vaccine Rotavac® was introduced into the public immunization system in India in 2016 and will be expanded in phases. This data will describe the epidemiology of intussusception in India in absence of rotavirus vaccination and will help in setting up or designing a safety monitoring system. Methods Medical records of intussusception cases between 2013 and 2016 in two major referral hospitals in Tamil Nadu, India were reviewed, and data on clinical presentation and management and outcome were collated. Results A total of 284 cases of intussusception were diagnosed and managed at the two centers of which 280/284 could be classified as level 1 by the Brighton criteria. Median age at presentation was 8 months (Inter Quartile Range, IQR 6–17.2) with a male to female ratio of 2.1:1. Over half (57.7%) required surgical intervention while the rest underwent non-surgical or conservative management. Conclusions Retrospective data from referral hospitals is sufficient to classify cases of intussusception by the Brighton criteria. These baseline data will be useful for monitoring when rotavirus vaccination is introduced.

Interpretation of rotavirus-positivity patterns across India

ObjectiveTo analyze variation in rotavirus-positivity using simple alternative statistical measures.MethodsHospital-based rotavirus surveillance among children admitted with acute gastroenteritis between 2005 and 2009. Prevalence, adjusted proportions and symmetrized index were calculated.ResultsRotavirus prevalence was 40% (range 37% - 44%). Adjusted proportion analysis revealed higher level of deviation from annual prevalence in seasons (December–February and September–November); age groups (<12 months and 12-23 months) and regions (East and South). Analysis of symmetrized index revealed higher estimates of variation in all years, except in 2006.ConclusionProposed statistical measures are useful as refined measures to study extent of disease spread in surveillance programmes, aiding evaluation of the load and pattern of disease burden in different regions over time.