[Show abstract][Hide abstract] ABSTRACT: Multi drug-resistant (MDR) typhoid in India is an escalating problem. MDR isolates of Salmonella Typhi are on rise and are becoming a challenge for timely and appropriate treatment. Occurrence of per cent sensitive (%S), per cent resistant (%R) and per cent intermediate (%I) isolates may vary geographically and treatment decided on the basis of only one of these three subpopulations may lead to selection of inappropriate drug for treatment and thus treatment failure. Determination of sensitivity index (SI) of antimicrobial agents, instead of %S or %R subpopulations, may give clearer insight regarding selection of appropriate antimicrobial for treatment of typhoid. In present work, the data of sensitivity testing were analysed and interpreted both in terms of SI as well as %S, %I and %R.
A total of 205 isolates of Salmonella Typhi were collected during June 2000 and August 2002 from a network of five institutes- Lady Hardinge Medical College (LHMC, N=110), Ram Manohar Lohia Hospital (RML, N=14), Majeedia Hospital (MH, N=48), Lal's Pathology Lab (LAL, N=28) and All India Institute of Medical Sciences (AIIMS, N=5) on nutrient agar slopes. Of these, 142 isolates were subjected to phage typing and biotyping at National Salmonella Phage Typing Centre, New Delhi. Five isolates resistant to 3-7 and one isolate susceptible to all of total 12 antimicrobial tested were subjected to plasmid analysis. SI for various antimicrobials was determined as the ratio of %S and %R values derived form %RIS analysis using WHONET5.
18 (8.7%) isolates were susceptible to all tested antimicrobials and 124 (60%) were MDR. Of the 142 isolates, 103 were phage type E1 and biotype I. SI of antimicrobials rather than individual %S or %R or %I population presents a better criterion for interpretation of sensitivity testing data as well as selection of the most appropriate antimicrobial for timely treatment. Presence of 140, 48 and 23 Kb size plasmids in all 5 MDR isolates and none in susceptible isolate was observed.
Re-emergence of chloramphenicol sensitivity in Salmonella typhi was observed in the present study. Interpretation in terms of SI criteria warrants that reintroduction of chloramphenicol at present for treatment of typhoid may rebound resistance. Current empiric therapy used for treatment of typhoid may soon become ineffective. SI being a ratio will not only eliminate geographical variation of %RIS data but also its interpretation. SI can provide guidelines for clinicians in remote areas where facilities for sensitivity testing are not available.
The Indian Journal of Medical Research 03/2005; 121(3):185-93. · 1.40 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The treatment guidelines are generally decided on the basis of either percent resistant (%R) or percent sensitive (%S) bacterial population tested with a given antimicrobial that vary geographically and represent only a part of total bacterial population existing in response to the antimicrobial used. The isolates with intermediate sensitivity (%I) are either not reported or clubbed with resistant isolates though the two may differ in clinical response. Sensitivity Index (SI) of an antimicrobial is sensitive to change in any of the three co-existing bacterial population and may be a better criterion for rational use of antimicrobial.
Indian Journal of Medical Microbiology 04/2004; 22(2):107-11. · 0.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We have conducted a study to analyze monitoring of the cold chain of 674 OPV field samples collected at four different levels of vaccine distribution viz., immunization clinics, district stores, hospitals and Primary Health Centers (PHC) from states of Uttar Pradesh, Madhya Pradesh, and Delhi. The study design included: collection and scoring of vaccine vial monitor (VVM) status of the samples and testing for total oral polio virus concentration (TOPV) by standard WHO protocol. Ten samples each were exposed to 25 degrees C and 37 degrees C, and 10 samples as controls were kept at -20 degrees C. VVM were scored daily till they attained grade 4 and each sample was subsequently subjected to potency testing for individual polio serotypes 1, 2 and 3, and TOPV. Of the 674 samples tested it was observed that: samples from immunization clinics and district stores had an acceptable VVM score of grade 1 and 2; however the probable risk that a sub potent vaccine could have been administered was 2.15%. In 2.5% samples received from district stores vaccine had a VVM score of grade 3 (i.e., discard point), although vaccine when tested was found to be potent (i.e., leading to the vaccine wastage). With exposure to higher temperatures, VVM changed score to grade 2 and 3 when the vaccine was kept at 25 degrees C/37 degrees C, and the titres of individual serotypes 1, 2 and 3 and TOPV were beyond the acceptable limits. Important observations at the different levels of vaccine distribution network and correlation of VVM and potency status of OPV are discussed in the paper which will be of help to the EPI program managers at different transit levels.
[Show abstract][Hide abstract] ABSTRACT: To discover the cause of acute renal failure in 36 children aged 2 months to 6 years who were admitted to two hospitals in Delhi between 1 April and 9 June 1998.
Data were collected from hospital records, parents and doctors of the patients, and district health officials. Further information was obtained from house visits and community surveys; blood and stool samples were collected from other ill children, healthy family members and community contacts. Samples of drinking-water and water from a tube-well were tested for coliform organisms.
Most of the children (26/36) were from the Gurgaon district in Haryana or had visited Gurgaon town for treatment of a minor illness. Acute renal failure developed after an episode of acute febrile illness with or without watery diarrhoea or mild respiratory symptoms for which the children had been treated with unknown medicines by private medical practitioners. On admission to hospital the children were not dehydrated. Median blood urea concentration was 150 mg/dl (range 79-311 mg/dl) and median serum creatinine concentration was 5.6 mg/dl (range 2.6-10.8 mg/dl). Kidney biopsy showed acute tubular necrosis. Thirty-three children were known to have died despite being treated with peritoneal dialysis and supportive therapy.
Cough expectorant manufactured by a company in Gurgaon was found to be contaminated with diethylene glycol (17.5% v/v), but a sample of acetaminophen manufactured by the same company tested negative for contamination when gas-liquid chromatography was used. Thus, poisoning with diethylene glycol seems to be the cause of acute renal failure in these children.
Bulletin of the World Health Organisation 02/2001; 79(2):88-95. DOI:10.1590/S0042-96862001000200002 · 5.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Most outbreaks of viral hepatitis in India are caused by hepatitis E. This report describes an outbreak of hepatitis B in a rural population in Haryana state in 1997. At least 54 cases of jaundice occurred in Dhottar village (population 3096) during a period of 8 months; 18 (33.3%) of them died. Virtually all fatal cases were adults and tested positive for HBsAg (other markers not done). About 88% (21/24) of surviving cases had acute or persistent HBV/HCV infections; 54% (13/24) had acute hepatitis B. Many other villages reported sporadic cases and deaths. Data were pooled from these villages for analysis of risk factors. Acute hepatitis B cases had received injections before illness more frequently (11/19) than those found negative for acute or persistent HBV/HCV infections (3/17) (P = 0.01). Although a few cases had other risk factors, these were equally prevalent in two groups. The results linked the outbreak to the use of unnecessary therapeutic injections.
Epidemiology and Infection 01/2001; 125(3):693-9. DOI:10.1017/S0950268800004684 · 2.54 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In Rajahmundry town in India, 234 community cases of jaundice were interviewed for risk factors of viral hepatitis B and tested for markers of hepatitis A-E. About 41% and 1.7% of them were positive for anti-HBc and anti-HCV respectively. Of 83 cases who were tested within 3 months of onset of jaundice, 5 (6%), 11 (13.3%), 1 (1.2%), 5 (6%) and 16 (19.3%) were found to have acute viral hepatitis A-E, respectively. The aetiology of the remaining 60% (50/83) of cases of jaundice could not be established. Thirty-one percent (26/83) were already positive for anti-HBc before they developed jaundice. History of therapeutic injections before the onset of jaundice was significantly higher in cases of hepatitis B (P = 0.01) or B-D (P = 0.04) than in cases of hepatitis A and E together. Other potential risk factors of hepatitis B transmission were equally prevalent in two groups. Subsequent studies showed that the majority of injections given were unnecessary (74%, 95% CI 66-82%) and were administered by both qualified and unqualified doctors.
Epidemiology and Infection 11/2000; 125(2):367-75. · 2.54 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To find out prevalence of HBsAg in general population, especially in under-five children.
Bangalore and Rajahmundry towns in southern India.
Localities were chosen as the sampling units in each town. About 10-20 households were randomly selected from each locality. Only the youngest but apparently healthy person present in the household was interviewed for age, sex and history of jaundice any time in life. Mothers were interviewed to collect data for children below 15 years of age. Blood samples were collected from these persons on filter paper strips (18-mm diameter disc, Whatman filter paper No. 3) by finger prick method. The samples were tested for HBsAg by Micro ELISA (Ortho-Clinical Diagnostics).
Overall, 3.3% (95% CI, 2.0-4.5) of 737 persons in Rajahmundry and 4.2% (95% CI, 2.8-5.5) of 816 persons in Bangalore were found carriers of HBsAg. Age-specific or sex specific carrier rates were similar in Rajahmundry as well as in Bangalore. Most of the carriers (96%) denied having jaundice ever in life.
The results from this community based study are in agreement with the historical data from hospital based studies that about 3-5% of persons may be carriers of HBsAg and that the pool of chronic carriers of hepatitis B virus in India is built up in childhood and is then maintained in older children and adults. The results highlight the need of completing hepatitis B immunization during the infancy.
Indian pediatrics 03/2000; 37(2):149-52. · 1.04 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In Rajahmundry town in India, 234 community cases of jaundice were interviewed for risk factors of viral hepatitis B and tested for markers of hepatitis AE, respectively. The aetiology of the remaining 60% (50/83) of cases of jaundice could not be established. Thirty-one percent (26/83) were already positive for anti-HBc before they developed jaundice. History of therapeutic injections before the onset of jaundice was significantly higher in cases of hepatitis B (P = 0·01) or B82%) and were administered by both qualified and unqualified doctors.
Epidemiology and Infection 01/2000; 125(2):367-375. DOI:10.1017/S0950268899003854 · 2.54 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To describe the epidemiological characteristics of poliomyelitis in Delhi in 1997 after four consecutive statewide immunization campaigns with oral polio vaccine (OPV).
Stool samples were collected from 158 cases of acute flaccid paralysis (AFP) along with their age, sex, residential address, immunization history and dates of onset of paralysis, reporting and investigation. The samples were processed for isolation of polioviruses. In addition, historical data on vaccination coverage surveys and OPV testing were reviewed. These data were analyzed to understand the epidemiological patterns of poliomyelitis in Delhi.
Of 158 cases of AFP, about 23% were investigated within 2 days of onset of paralysis. Two samples each were collected from 97 (61%) cases, and one each from the remaining cases. Detection of 158 cases of AFP gave an incidence of 1.34 per 100,000 population. About 36% (57/158) of AFP cases excreted poliovirus, mostly (53/158) wild poliovirus. Of the wild poliovirus isolates, 72% (38/53) and 25% (13/53) were serotypes P1 and P3 respectively; 2 isolates were P2. Almost 95% (146/154) of AFP cases and all the laboratory confirmed cases (excreting wild poliovirus) occurred in children below 5 years of age. Only one-third of AFP (55/158) or laboratory confirmed cases (18/53) had received 3 or more doses of OPV before onset of paralysis. About one-fourth of cases in both the categories were totally unvaccinated. AFP cases occurred round the year but peaked in November-December. Peaks were always observed during July-August in the past. The cases were widely scattered without any obvious clustering in any locality.
Poliomyelitis has declined substantially in Delhi. The study underscores the need for further efforts to improve vaccine coverage levels, AFP surveillance, and cold chain maintenance to achieve the complete interruption of transmission.
Indian pediatrics 01/2000; 36(12):1211-9. · 1.04 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To describe outbreaks of measles which affected many districts in Uttar Pradesh (UP) during 1996.
The state of Uttar Pradesh, India.
The reported data on measles morbidity, mortality and vaccine coverage from 1991 through 1996 were reviewed. Reported vaccine coverage levels were compared with the results of coverage surveys carried out in UP from 1992 through 1996. Line lists on measles cases were analyzed to ascertain the age, immunization status, geographical distribution, and age and sex-specific fatality ratios during the outbreaks. A community survey was organized in 7 affected villages to estimate vaccine effectiveness.
Fifty one of 68 districts in UP reported 6922 measles cases and 281 deaths in 1996. The majority of cases and deaths occurred in June and July which are usually low transmission months. Overall cases fatality ratio (CFR) was 4.1%. CFRs were significantly higher in females and young children. The median age of cases was found to be below 5 years. There was heavy clustering of cases and deaths in rural areas. About 85% of the cases and virtually all the measles associated deaths occurred in unvaccinated children. Published documents on statewide coverage surveys revealed that the measles vaccine coverage levels ranged between 26% and 36% during 1992-96. Large gaps were found between reported coverage and survey results. Nevertheless, epidemiological studies indicated a vaccine effectiveness of more than 90%.
The outbreaks occurred due to poor vaccine coverage levels and an inefficient surveillance system which failed to generate early warning signals. The study highlights the urgent need to raise the vaccine coverage levels rapidly in all districts to achieve measles control and prevent future outbreaks in UP.
Indian pediatrics 04/1999; 36(3):249-56. · 1.04 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To find out the patterns of and the factors, if any, affecting the transplacental transfer of measles antibody.
Comparison of measles antibody titres in mothers with titres in cord blood samples.
Maternal and cord blood samples from 174 full-term pregnant women of middle socio-economic status were tested for hemagglutination inhibition (HI) antibody against measles in Delhi during October 1993 to January 1995. None of the mothers had been immunized against measles.
Antibody were undetectable in both maternal and cord samples in only 4 (2.3%) pairs. Mean maternal titre was found to be 2.94 Log2. Transplacental concentration and dilution were respectively observed in 34% and 26% of the samples. Cord titres were more often higher than the maternal values only if the maternal values were low. Overall, cord/maternal ratio of mean titre (Log2) was found to be 1.06. Although the age of the mother and parity had had no significant bearing on the transplacental transfer of measles antibody, cord titres were significantly more often higher than the maternal values as the birth weight increased (Chi-square for linear trend = 5.4; p = 0.02).
The study failed to show appreciable concentration of measles antibodies across the placenta.
Indian pediatrics 01/1999; 35(12):1187-91. · 1.04 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This paper describes the epidemiology of measles in a medium size town (population 240,000) in India where vaccine coverage levels have remained constant at around 70 per cent in the past 7 years. A retrospective community survey covering 4023 children under 10 years old detected 252 cases of measles in the previous year. This gave an annual incidence of 6.3 per cent (95 per cent CI 5.5-7). About half of the cases occurred in vaccinated children. Only 5 per cent of the cases occurred in children below 9 months of age. This age is appropriate for routine measles immunization. Despite modest coverage levels with only 54 per cent effective vaccine (estimated by a screening method), there was a modest upward shift in the age distribution of measles cases; the median age was more than 48 months.
Journal of Tropical Pediatrics 01/1999; 44(6):369-71. · 1.26 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In India, virtually all outbreaks of viral hepatitis are considered to be due to faeco-orally transmitted hepatitis E virus. Recently, a cluster of 15 cases of viral hepatitis B was found in three villages in Gujarat State. The cases were epidemiologically linked to the use of inadequately sterilized needles and syringes by a local unqualified medical practitioner. The outbreak evolved slowly over a period of 3 months and was marked by a high case fatality rate (46.7%), probably because of concurrent infection with hepatitis D virus (HDV) or sexually transmitted infections. But for the many fatalities within 2-3 weeks of the onset of illness, the outbreak would have gone unnoticed. The findings emphasize the importance of inadequately sterilized needles and syringes in the transmission of viral hepatitis B in India, the need to strengthen the routine surveillance system, and to organize an education campaign targeting all health care workers including private practitioners, especially those working in rural areas, as well as the public at large, to take all possible measures to prevent this often fatal infection.
Bulletin of the World Health Organisation 02/1998; 76(1):93-8. · 5.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Maternal blood-cord samples from 171 women of middle socio-economic status who had been administered at least two doses of tetanus toxoid (TT), were assayed for tetanus antitoxins by passive haemagglutination (PHA) test. All the mother as well as cord samples had antitoxin titres > or = 0.015IU/ml, the generally accepted minimal protective level; 98 per cent of the mothers and 97 per cent of the newborns had levels > or = 0.125IU/ml. Transplacental dilution was observed in 45 per cent of the samples; the cord/maternal antitoxin ratio (C/M) of geometric mean titre (GMT) was found to be 0.72. The C/M ratio was not affected by the maternal age, parity, birth weight, and number of TT doses administered to mother. The study showed that tetanus antitoxins were diluted on the fetal side of circulation, but the protective levels of antitoxins were achieved in all the newborns as the mothers had received at least two doses of TT before delivery.
[Show abstract][Hide abstract] ABSTRACT: The study was carried out to evaluate the efficacy of IPV in neonates and to study the additive effect of IPV or OPV at birth on seroconversion with three subsequent doses of OPV. Addition of IPV or OPV at birth to the conventional OPV schedule resulted in significantly higher seroconversion rates than in the controls, who received three doses of OPV. Three doses of IPV beginning from birth resulted in significantly better seroconversion rates than in the control group. Children receiving 3 doses of IPV showed significantly greater seroconversion rates against type III polio virus than those receiving IPV/OPV at birth followed by 3 doses of OPV. The difference in the seroconversion rates against the other virus types was not significant.
A significantly greater number of children who received some vaccine at birth (IPV or OPV) were protected against poliomyelitis by 6 weeks age as compared to those who received no immunization at birth. The study recommends that seroconversion rates following three doses of IPV are satisfactory. Addition of IPV or OPV at birth to the conventional schedule markedly increases the seroconversion rates. Immunization can be started at birth to ensure early protection against poliomyelitis.
The Indian Journal of Pediatrics 07/1997; 64(4):511-5. DOI:10.1007/BF02737758 · 0.87 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Virologic surveillance of poliomyelitis to monitor the transmission of wild polio virus in the community. STUDY AREA: All major hospitals of Delhi and surrounding area.
Stool samples were collected from 1221 cases of acute flaccid paralysis during 1992-1994 and were subjected to virus isolation on RD and HEp2 cell line. Viruses isolated were analyzed further by microneutralization test using polio and nonpolio antisera. The polio isolates were further characterized as vaccine or wild type using ELISA and probe technology.
Out of the 1221 cases tested, virus was isolated in 57.4%. Among the virus positive cases, polio was isolated in 57% and in 43% non polio entero viruses were detected. The most prevalent was polio virus type 1. Most of the strains were wild type.
Wild polio virus was prevailing in the community under study between the years 1992-1994.
Indian pediatrics 10/1996; 33(9):746-50. · 1.04 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Blood samples from 171 full-term pregnant women (aged 18-38 years) of middle socioeconomic status from Delhi were tested for diphtheria antitoxins by indirect hemagglutination (IHA) test. History of primary immunization/clinical diphtheria during childhood was not ascertainable, but none had been revaccinated against diphtheria at any time. About 94% women had very high antitoxin titers (> or = 0.125 IU/ ml); none had antitoxin titer less than 0.015 IU/ml, the minimum protective level. The titers were uniformly high in all age groups. However, women having 2 or more children had significantly higher antitoxin titers than those having no or one child (p < 0.01). The results from this study and historical data on diphtheria in Delhi are compatible with continued transmission of C. diphtheriae in recent times in Delhi which is of sufficient magnitude to boost the antitoxin levels in adults, especially mothers having two or more children. The study highlights the need of increasing the immunization coverage with DPT among children to reduce the transmission of Corynebacterium diphtheriae.
The Southeast Asian journal of tropical medicine and public health 06/1996; 27(2):274-8. · 0.72 Impact Factor