Mahesh Moorthy

An evaluation of saliva as an alternative to plasma for the detection of hepatitis C virus antibodies.

PURPOSE Seroepidemiological studies on the prevalence of Hepatitis C virus (HCV) in India have been hampered by reluctance of subjects to provide blood samples for testing. We evaluated the use of saliva as an alternate specimen to blood for the detection of antibodies to HCV. METHODS Chronic liver disease (CLD) patients attending the liver clinic were recruited for this study. A saliva and plasma sample (sample pair) was collected from each patient included in the study. Saliva samples were collected using a commercially available collection device--OmniSal. Sample pairs were tested with an in-use ELISA for the detection of antibodies to HCV (HCV-Ab), with a minor modification in the manufacturers protocol while testing saliva. The cut-off absorbance value for declaring a sample as positive was determined by receiver operating curve (ROC) analysis. HCV-Ab positivity in saliva was compared with that in plasma as well as with viral load in plasma and infecting genotype of the virus. Sensitivity, specificity, positive and negative predictive values, and correlation coefficients were calculated using Medcalc statistical software. RESULTS The optimal accuracy indices were: sensitivity-81.6%; specificity-92.5%; PPV-85.1% and NPV-90.5%. No correlation was found between salivary positivity and HCV viral load in plasma or infecting genotype. CONCLUSIONS The accuracy indices indicate that the assay must be optimized further before it can be recommended for routine use in epidemiological surveys for HCV-Ab.

Pandemic (H1N1) 2009 virus infection during pregnancy in South India

To assess the clinical profile of pregnant/puerperal women from a semi‐urban Indian population who were infected with pandemic (H1N1) 2009 virus (P[H1N1]2009v) and to evaluate their outcome.

Cardiac manifestations in patients with pandemic (H1N1) 2009 virus infection needing intensive care

PURPOSE To characterize the cardiac manifestations in severe pandemic (H1N1) 2009 virus [P(H1N1)2009v] infection. MATERIALS AND METHODS Adult patients admitted to the intensive care unit were recruited. Patients with an elevated troponin I (>1.5 ng/mL) and those requiring vasoactive agents had an echocardiogram. Myocardial injury was defined as elevated troponin I. Patients with reduced ejection fraction lower than 50% were diagnosed as having left ventricular systolic dysfunction. Myocarditis was presumed when myocardial injury was associated with global myocardial dysfunction. Myocardial injury and dysfunction were correlated with mortality and expressed as odds ratio (OR) with 95% confidence intervals (CI). RESULTS Thirty-seven patients presented at 6.4 (SD 3.2) days of illness. Four patients had valvular heart disease and 1 preexisting ischemic heart disease. Seventeen (46%) patients had evidence of myocardial injury. Twenty of 28 patients in whom an echocardiogram was clinically indicated had left ventricular systolic dysfunction. Of these, 14 patients were diagnosed as having myocarditis, and most of them (12 patients) developed it early. Myocarditis was associated with longer duration of vasoactive agents (OR 1.46, 95% CI 1.06-2.02) and mortality. Patients with elevated troponin I had an increased risk of death (OR 8.7, 95% CI 1.5-60). A higher mortality was observed in patients with left ventricular systolic dysfunction (OR 9.6, 95% CI 1.7-58) compared with those in whom an echocardiogram was normal or not indicated. CONCLUSION In our cohort of severe P(H1N1)2009v infection, myocardial injury and dysfunction was frequent and associated with high mortality.

Evaluation of a rapid immunochromatographic device for the detection of IgM & IgG antibodies to Dengue viruses (DENV) in a tertiary care hospital in South India.

This study has evaluated the performance of a rapid immunochromatographic test (ICT) device in detecting antibodies to Dengue virus (DENV) in a tertiary hospital in South India. Sera from hospital attendees, with requests for DENV antibody testing, were tested with the Panbio Dengue Duo Cassette and a reference antibody capture assay for the detection of IgM (Dengue IgM capture ELISA-National Institute of Virology, India) and IgG (Dengue IgG capture ELISA-Panbio Diagnostics Inc., Australia) antibodies. The ICT results were compared with results of antibody capture tests for the detection of the IgM and IgG antibodies, respectively. Accuracy indices for IgM and IgG detection, respectively were -- sensitivity 81.8% and 87.5%, specificity 75.0%, and 66.6%, positive predictive value (PPV) 61.0% and 72.9% and negative predictive value (NPV) 89.6% and 83.9%. The device performs poorly in detection of IgM and IgG antibodies to DENVs and is not recommended for use as a stand-alone diagnostic test.

Clinical Profile and Predictors of Mortality of Severe Pandemic (H1N1) 2009 Virus Infection Needing Intensive Care: A Multi-Centre Prospective Study from South India.

Background: This multi-center study from India details the profile and outcomes of patients admitted to the intensive care unit (ICU) with pandemic Influenza A (H1N1) 2009 virus [P(H1N1)2009v] infection. Materials and Methods: Over 4 months, adult patients diagnosed to have P(H1N1)2009v infection by real-time RT-PCR of respiratory specimens and requiring ICU admission were followed up until death or hospital discharge. Sequential organ failure assessment (SOFA) scores were calculated daily. Results: Of the 1902 patients screened, 464 (24.4%) tested positive for P(H1N1)2009v; 106 (22.8%) patients aged 35±11.9 (mean±SD) years required ICU admission 5.8±2.7 days after onset of illness. Common symptoms were fever (96.2%), cough (88.7%), and breathlessness (85.9%). The admission APACHE-II and SOFA scores were 14.4±6.5 and 5.5±3.1, respectively. Ninety-six (90.6%) patients required ventilation for 10.1±7.5 days. Of these, 34/96 (35.4%) were non-invasively ventilated; 16/34 were weaned successfully whilst 18/34 required intubation. Sixteen patients (15.1%) needed dialysis. The duration of hospitalization was 14.0±8.0 days. Hospital mortality was 49%. Mortality in pregnant/puerperal women was 52.6% (10/19). Patients requiring invasive ventilation at admission had a higher mortality than those managed with non-invasive ventilation and those not requiring ventilation (44/62 vs. 8/44, P<0.001). Need for dialysis was independently associated with mortality (P=0.019). Although admission APACHE-II and SOFA scores were significantly (P<0.02) higher in non-survivors compared with survivors on univariate analysis, individually, neither were predictive on multivariate analysis. Conclusions: In our setting, a high mortality was observed in patients admitted to ICU with severe P(H1N1)2009v infection. The need for invasive ventilation and dialysis were associated with a poor outcome.

Deviations in influenza seasonality: odd coincidence or obscure consequence?

In temperate regions, influenza typically arrives with the onset of colder weather. Seasonal waves travel over large spaces covering many climatic zones in a relatively short period of time. The precise mechanism for this striking seasonal pattern is still not well understood, and the interplay of factors that influence the spread of infection and the emergence of new strains is largely unknown. The study of influenza seasonality has been fraught with problems. One of these is the ever-shifting description of illness resulting from influenza and the use of both the historical definitions and new definitions based on actual isolation of the virus. The compilation of records describing influenza oscillations on a local and global scale is massive, but the value of these data is a function of the definitions used. In this review, we argue that observations of both seasonality and deviation from the expected pattern stem from the nature of this disease. Heterogeneity in seasonal patterns may arise from differences in the behaviour of specific strains, the emergence of a novel strain, or cross-protection from previously observed strains. Most likely, the seasonal patterns emerge from interactions of individual factors behaving as coupled resonators. We emphasize that both seasonality and deviations from it may merely be reflections of our inability to disentangle signal from noise, because of ambiguity in measurement and/or terminology. We conclude the review with suggestions for new promising and realistic directions with tangible consequences for the modelling of complex influenza dynamics in order to effectively control infection.

2009 Pandemic influenza in India

Pandemic-09-H1N1 virus caused the pandemic starting in the second quarter of 2009. The world was prepared to face the pandemic since it was anticipated for over one decade. Most countries, including India, had made detailed pandemic preparedness plans well ahead of its actual occurrence. The infection rapidly spread to the whole country within 2-3 months. The national tactics were to slow down its importation through international air travelers and to slow down its spread in cities and major towns. More than 75% of all infected persons were urban dwellers, suggesting that efforts were concentrated in urban communities. In general the illness of pandemic influenza has been similar to endemic/seasonal influenza; however, there is insufficient epidemiological and clinical data on the latter. We hope that the unprecedented experience of managing the pandemic will encourage the Government of India to plan to confront endemic/seasonal influenza more systematically. The pandemic seems to have reached a peak in September/October and has been on the decline since then.

Estimation of the Burden of Pandemic(H1N1)2009 in Developing Countries: Experience from a Tertiary Care Center in South India

Background The burden of the pandemic (H1N1) 2009 influenza might be underestimated if detection of the virus is mandated to diagnose infection. Using an alternate approach, we propose that a much higher pandemic burden was experienced in our institution. Methodology/Principal Findings Consecutive patients (n = 2588) presenting to our hospital with influenza like illness (ILI) or severe acute respiratory infection (SARI) during a 1-year period (May 2009–April 2010) were prospectively recruited and tested for influenza A by real-time RT-PCR. Analysis of weekly trends showed an 11-fold increase in patients presenting with ILI/SARI during the peak pandemic period when compared with the pre-pandemic period and a significant (P<0.001) increase in SARI admissions during the pandemic period (30±15.9 admissions/week) when compared with pre-pandemic (7±2.5) and post-pandemic periods (5±3.8). However, Influenza A was detected in less than one-third of patients with ILI/SARI [699 (27.0%)]; a majority of these (557/699, 79.7%) were Pandemic (H1N1)2009 virus [A/H1N1/09]. An A/H1N1/09 positive test was correlated with shorter symptom duration prior to presentation (p = 0.03). More ILI cases tested positive for A/H1N1/09 when compared with SARI (27.4% vs. 14.6%, P = 0.037). When the entire study population was considered, A/H1N1/09 positivity was associated with lower risk of hospitalization (p<0.0001) and ICU admission (p = 0.013) suggesting mild self-limiting illness in a majority. Conclusion/Significance Analysis of weekly trends of ILI/SARI suggest a higher burden of the pandemic attributable to A/H1N1/09 than estimates assessed by a positive PCR test alone. The study highlights methodological consideration in the estimation of burden of pandemic influenza in developing countries using hospital-based data that may help assess the impact of future outbreaks of respiratory illnesses.

Risk of pandemic (H1N1) 2009 virus infection among healthcare workers caring for critically ill patients with pandemic (H1N1) 2009 virus infection

laparoscopygrouphadpreoperative chemotherapy. Data onpreoperative albumin, smoking history and diabetes were not collected. All patients but one were followed up at 30 days (one patient lost to follow-up because of a change in general practitioner). Surveillance was performed on one patient who remained an inpatient at 30 days, by reviewing the case notes and drug charts and scrutinising for evidence of SSI. PDS was performed at 4–6 weeks; an outpatient appointment with a consultant surgeonwas made by checking the clinic entry for documented evidence of infection. The two patients readmitted within the 30 day period had case notes and drug charts scrutinised for evidence of infection. When three patients were discharged home prior to 30 days post surgery and had not had an outpatient appointment, PDS was performed by contacting their general practitioners by telephone and asking whether they had prescribed antibiotics for SSI. Our case–control audit demonstrates that the SSI rates in our department are not significantly different for robotic, laparoscopic surgery (3.8%) compared with conventional laparoscopic abdominal surgery (8.7%), although too few patients were assessed to confirm any real difference and the surveillance is ongoing. We conclude that it is important to collate the PDS data on SSI when a new procedure is introduced to an institution to ensure that quality indicators such as SSI are kept under review.

Experience with a fourth generation human immunodeficiency virus serological assay at a tertiary care centre in south India

VDRL and TPHA test was 1.3% (2/150). This is lower than the prevalence rates reported in studies carried out in Delhi (6.09%),[2] Germany (3.3%) and Bangladesh (23%).[3] The possible explanation for this could be the difference in the subgroup of population studied and the diagnostic tests employed. In addition, region, gender, ethnic factors and socioeconomic factors which inß uence the development of sexual behaviour do play a big role in the prevalence of syphilis.