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Background: Healthcare-associated bloodstream infections (BSI) threaten patient safety and are the third most common healthcare-associated infection (HAI) in low- and middle-income countries. An intensive-care-unit (ICU) based HAI surveillance network recording BSIs was started in India in 2017. We evaluated this surveillance network's ability to detect BSI to identify best practices, challenges, and opportunities in its implementation., Methods: We conducted a mixed-methods descriptive study from January to May 2022 using the CDC guidelines for evaluation. We focused on hospitals reporting BSI surveillance data to the HAI network from May 2017 to December 2021, and collected data through interviews, surveys, record reviews, and site visits. We integrated quantitative and qualitative results and present mixed methods interpretation., Results: The HAI surveillance network included 39 hospitals across 22 states of India. We conducted 13 interviews, four site visits, and one focus-group discussion and collected 50 survey responses. Respondents included network coordinators, surveillance staff, data entry operators, and ICU physicians. Among surveyed staff, 83% rated the case definitions simple to use. Case definitions were correctly applied in 280/284 (98%) case reports. Among 21 site records reviewed, 24% reported using paper-based forms for laboratory reporting. Interviewees reported challenges, including funding, limited human resources, lack of digitalization, variable blood culture practices, and inconsistent information sharing., Conclusion: Implementing a standardized HAI surveillance network reporting BSIs in India has been successful, and the case definitions developed were simple. Allocating personnel, digitalizing medical records, improving culturing practices, establishing feedback mechanisms, and funding commitment are crucial for its sustainability., Competing Interests: Declarations. Ethics approval and consent to participate: We conducted this study as part of the monitoring and evaluation of a national public health surveillance project titled “Capacity Building and Strengthening of Hospital Infection Control to Detect and Prevent Antimicrobial Resistance in India”. The project received ethical approval (IEC/NP-386/10.09.2015) from the Institutional Ethics Committee, All India Institute of Medical Sciences (AIIMS), New Delhi, and approval from the Health Ministry Screening Committee (HMSC), India. We obtained permission from the HAI surveillance network’s program coordinators before reaching out to network sites, and study participants provided consent via email for interviews, FGD, and surveys. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests. Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the U.S. CDC or the U.S. Department of Health and Human Services., (© 2024. The Author(s).)

Objective: Kyasanur Forest Disease (KFD) is a viral zoonosis reported from Karnataka, India. We investigated cases in the Shivamogga district, Karnataka, to describe the epidemiology and identify risk factors in the affected block in 2022., Methods: A case was defined as a laboratory-confirmed KFD-positive resident of Shivamogga from 1 January-31 May 2022. We extracted the records of KFD cases from district surveillance. We conducted a 1:3 case-control study in the Thirthahalli block. We enrolled laboratory-confirmed KFD-positive Thirthahalli residents from January to May 2022 as cases, and residents without "fever with myalgia" as controls. We reported adjusted odds ratios (aOR) with 95% confidence intervals (CI)., Results: Shivamogga reported 35 cases, with a median age of 46 (4-75) years, of which 51% were men, and one death. Among 25 cases and 90 controls, knowledge of avoiding recent monkey death sites was low (cases = 0%, controls = 11%). Monkey death sites within 500 m [aOR = 8.6 (1.8-41.9)] and household tick exposure [aOR = 3.7 (1.3-10.7)] were independent risk factors., Conclusion: This was a laboratory-confirmed cluster of KFD cases in Thirthahalli, with residence near a monkey death site and household tick exposure considered significant risk factors. We recommend evaluating monkey carcass disposal procedures and increasing awareness of tick protective measures., Competing Interests: The authors declare that they do not have any conflicts of interest., (Copyright © 2024 Vedachalam, Rajput, Choudhary, Narayanaswamy, Chandra, D. M., Rajagopal and Dikid.)

Background: Of the 43 mpox cases reported by the WHO in South East Asia between January 2022 and March 2023, 24 (56%) were from India., Objectives: We describe the clinical and epidemiological profile of cases identified through India's hospital case-based surveillance., Materials and Methods: We identified mpox cases as a positive result for mpox virus polymerase-chain-reaction assay, reported through surveillance from July 1, 2022 to January 7, 2023. Cases and clinicians were interviewed, and data were abstracted from the medical records. We conducted contact tracing among family, close social networks, and healthcare personnel staff for the first 17 cases. We collected the data on sociodemographics, clinical findings, and behavior, and described data using summary statistics., Results: We identified 24 laboratory-confirmed cases (42% females, median age 30 years, range 22-38), including one death (case fatality rate 4.2%). We collected clinical and behavioural data from 21 of 24 cases. All had rashes with vesicles and genital lesions; 7 (33%) reported genital lesions as the first symptom; and 3 (13%) reported complications. Among the 21 cases, all were sexually active, none self-identified as men having sex with men (MSM), and 6 (29%) reported multiple sex partners. We identified 51 contacts of the first 17 reported cases, none reported symptoms suggestive of mpox., Conclusion: The clinical and behavioral characteristics of mpox cases in India are consistent with the global 2022 outbreak, with the exception that no cases in India reported MSM. Most were sexually active young adult economic migrants and developed genital lesions., (Copyright © 2024 Copyright: © 2024 Indian Journal of Public Health.)

The present work was carried out during the emergence of Delta Variant of Concern (VoC) and aimed to study the change in SARS CoV-2 viral load in Covishield vaccinated asymptomatic/mildly symptomatic health-care workers (HCWs) to find out the optimum isolation period. The SARS CoV-2 viral load was carried out in sequential samples of 55 eligible HCWs which included unvaccinated (UnV; n = 11), single-dose vaccinated (SDV, n = 20) and double-dose vaccinated [DDV, n = 24; short-interval (<6 weeks)] subjects. The mean load of envelope (E) gene on day 5 in SDV [0.42 × 10 5 copies/reaction] was significantly lower as compared to DDV [6.3 × 10 5 copies/reaction, P = 0.005] and UnV [6.6 × 10 5 copies/reaction, P = 0.001] groups. The rate of decline of SARS CoV-2 viral load in the initial 5 days of PCR positivity was significantly higher in SDV as compared to that in DDV (Mean log decline 0.39 vs. 0.19; P < 0.001). This was possibly due to interference of adenoviral immunity of first dose of adenovirus-vectored vaccine in double-dose vaccinated HCWs who had received vaccines within a shorter interval (<6 weeks)., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: India accounted for 6% of global burden of malaria with 95% population residing in malaria endemic areas. However, Punjab is in the malaria elimination phase with annual parasite incidence (API) <1/1000 population., Objectives: We evaluated malaria surveillance system in Punjab using CDC's updated guidelines for evaluating public health surveillance systems to provide recommendations for strengthening the existing system and to overcome the challenges in the path of malaria free Punjab., Methods: We chose two districts of Punjab, Amritsar (lowest API) and Mansa (highest API), interviewed stakeholders, and performed a retrospective desk review. We evaluated the overall usefulness of the system and assessed seven attributes at state, district, health facility, and village level during July-August 2020., Results: In Punjab, there was progressive decline in the malaria cases from 2,955 cases in 2009 to 1,140 in 2019 and no malaria deaths since 2011. Regarding various attributes, overall score for flexibility was good (85.9%); average for simplicity (77%), acceptability (74%), data quality (74%), and timeliness (70%); and poor for representativeness (59%) and stability (57%)., Conclusions: Malaria surveillance system was useful in analyzing the trends of morbidity and mortality and for generating data to drive policy decisions. To improve stability, representativeness, and acceptability, surveillance staff should not be engaged in supplemental work, and reports from private sector must be ensured. Supportive supervision and regular trainings should be carried out regarding reporting formats, guidelines, and timely epidemiological investigations to improve timeliness, data quality, and simplicity., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Indian Journal of Community Medicine.)

Background: Muzaffarpur district in Bihar State of India recorded a resurgence of acute encephalopathy syndrome (AES) cases in the summer of 2019 after no reported outbreak in 3 y. Earlier studies generated evidence that litchi consumption and missing the previous evening's meal were associated with AES. We investigated the recent outbreak to understand the risk factors associated with AES., Methods: We conducted a matched case-control study by comparing AES cases with healthy controls from case-households and the neighborhood community for risk factors like missing evening meal and litchi consumption before onset of AES., Results: We recruited 61 cases and 239 controls. Compared with the community controls, case-patients were five times more likely to have reported eating litchi in the 7 d preceding the onset of illness (adjusted OR [AOR]=5.1; 95% CI 1.3 to 19) and skipping the previous evening's meal (AOR=5.2; 95% CI 1.4 to 20). Compared with household controls, case-patients were five times more likely to be children aged <5 y (AOR=5.3; 95% CI 1.3 to 22) and seven times more likely to have skipped the previous evening's meal (AOR=7.4; 95% CI 1.7 to 34)., Conclusions: Skipping the previous evening's meal and litchi consumption were significantly associated with AES among children in Muzaffarpur and adjoining districts of Bihar., (© The Author(s) 2022. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.)

Introduction: Scrub typhus is one of the most underreported and fatal illnesses accounting for 23% of all febrile illness. Rajasthan reported cases during 2018-2019 in state reporting system but did not report any case to central Integrated Disease Surveillance Programme (IDSP) unit. We evaluated the Scrub typhus surveillance system in Alwar district, Rajasthan, with the objective of describing and evaluating the system and providing evidence-based recommendations to identify gaps., Material and Methods: In cross-sectional study, we reviewed records and conducted key informant interviews at district- and block-level health facilities. Using US Centers for Disease Control guidelines, we evaluated the system by framing indicators for selected attributes for a defined reference period. Overall performance was ranked as outstanding (90-100%), excellent (80-89%), very good (70-79%), good (60-69%), and poor (<60%)., Results: Line list of confirmed cases was sent from district to block level for additional active case search (ACS) to implement control measures. We conducted 26 key informant interviews and reviewed records and calculated simplicity as 79%, flexibility 100%, data quality 46%, acceptability 92%, representativeness 48%, timeliness 43%, and stability 79%., Conclusions: Epidemiological surveillance (active and passive) is a core intervention under scrub typhus surveillance system. Lab reports were incompletely uploaded on IDSP portal. Surveillance reports should be updated after each ACS. Reporting format under IDSP should be uploaded timely, and lab reports from state should be sent within 48 hours of diagnosis so that case investigation is not delayed., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Indian Journal of Community Medicine.)

We initiated an epidemiological investigation following the death of a previously healthy 17 year-old boy with neuro-melioidosis. A case was defined as a culture-confirmed melioidosis patient from Udupi district admitted to hospital A from January 2013-July 2018. For the case control study, we enrolled a subset of cases admitted to hospital A from January 2017- July 2018. A control was resident of Udupi district admitted to hospital A in July 2018 with a non-infectious condition. Using a matched case-control design, we compared each case to 3 controls using age and sex groups. We assessed for risk factors related to water storage, activities of daily living, injuries and environmental exposures (three months prior to hospitalization), using conditional regression analysis. We identified 50 cases with case fatality rate 16%. Uncontrolled diabetes mellitus was present in 84% cases and 66% of cases occurred between May and October (rainy season). Percutaneous inoculation through exposure to stagnant water and injury leading to breakage in the skin were identified as an important mode of transmission. We used these findings to develop a surveillance case definition and initiated training of the district laboratory for melioidosis diagnosis., Competing Interests: The authors have declared that no competing interests exist., (Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.)

The India Field Epidemiology Training Program (FETP) has played a critical role in India's response to the ongoing COVID-19 pandemic. During March 2020-June 2021, a total of 123 FETP officers from across 3 training hubs were deployed in support of India's efforts to combat COVID-19. FETP officers have successfully mitigated the effect of COVID-19 on persons in India by conducting cluster outbreak investigations, performing surveillance system evaluations, and developing infection prevention and control tools and guidelines. This report discusses the successes of select COVID-19 pandemic response activities undertaken by current India FETP officers and proposes a pathway to augmenting India's pandemic preparedness and response efforts through expansion of this network and a strengthened frontline public health workforce.

India started Point of entry (PoE) surveillance at Mumbai International Airport, screening passengers returning from coronavirus disease (COVID-19)-affected countries using infrared thermometers. We evaluated in July 2020 for March 1-22 with the Centers for Disease Control and Prevention evaluation framework. We conducted key informant interviews, reviewed passenger self-reporting forms (SRFs) (randomly selected) and relevant Airport Health Organization and Integrated Disease Surveillance Programme (IDSP) records. Of screened 165,882 passengers, three suspects were detected and all were reverse transcription-polymerase chain reaction negative. Passengers under-quarantine line-listing not available in paper-based PoE system, eight written complaints: 6/8 SRF filling inconvenience, 3/8 no SRF filling inflight announcements, and standing in long queues for their submission. Outside staff deployed 128/150 (85.3%), and staff: passenger ratio was 1:300. IDSP reported 59 COVID-19 confirmed cases against zero detected at PoE. It was simple, timely, flexible, and useful in providing information to IDSP but missed cases at PoE and had poor stability. We recommended dedicated workforce and data integration with IDSP., Competing Interests: None

Delhi, the national capital of India, experienced multiple severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks in 2020 and reached population seropositivity of >50% by 2021. During April 2021, the city became overwhelmed by COVID-19 cases and fatalities, as a new variant, B.1.617.2 (Delta), replaced B.1.1.7 (Alpha). A Bayesian model explains the growth advantage of Delta through a combination of increased transmissibility and reduced sensitivity to immune responses generated against earlier variants (median estimates: 1.5-fold greater transmissibility and 20% reduction in sensitivity). Seropositivity of an employee and family cohort increased from 42% to 87.5% between March and July 2021, with 27% reinfections, as judged by increased antibody concentration after a previous decline. The likely high transmissibility and partial evasion of immunity by the Delta variant contributed to an overwhelming surge in Delhi.

Background: Mortality rates provide an opportunity to identify and act on the health system intervention for preventing deaths. Hence, it is essential to appreciate the influence of age structure while reporting mortality for a better summary of the magnitude of the epidemic., Objectives: We described and compared the pattern of COVID-19 mortality standardized by age between selected states and India from January to November 2020., Methods: We initially estimated the Indian population for 2020 using the decadal growth rate from the previous census (2011). This was followed by estimations of crude and age-adjusted mortality rate per million for India and the selected states. We used this information to perform indirect-standardization and derive the age-standardized mortality rates for the states for comparison. In addition, we derived a ratio for age-standardized mortality to compare across age groups within the state. We extracted information regarding COVID-19 deaths from the Integrated Disease Surveillance Programme special surveillance portal up to November 16, 2020., Results: The crude mortality rate of India stands at 88.9 per million population (118,883/1,337,328,910). Age-adjusted mortality rate (per-million) was highest for Delhi (300.5) and lowest for Kerala (35.9). The age-standardized mortality rate (per million) for India is (<15 years = 1.6, 15-29 years = 6.3, 30-44 years = 35.9, 45-59 years = 198.8, 60-74 years = 571.2, ≥75 years = 931.6). The ratios for age-standardized mortality increase proportionately from 45 to 59 years age group across all the states., Conclusion: There is high COVID-19 mortality not only among the elderly ages, but we also identified heavy impact of COVID-19 on the working population. Therefore, we recommend further evaluation of age-adjusted mortality for all States and inclusion of variables like gender, socio-economic status for standardization while identifying at-risk populations and implementing priority public health actions., Competing Interests: There are no conflicts of interest., (© 2021 The Authors.)

We report a diphtheria outbreak mostly among children (median 12 years; range 4-26 years) of a religious minority in urban India. Case-fatality rate (15%, 19/124) was higher among unimmunized patients (relative risk 4.1, 95% CI 1.5-11.7). We recommend mandating and integrating immunization into school health programs to prevent reemergence.

Background: A foodborne disease outbreak among wedding attendees from Makunsar village, Palghar district, Maharashtra state, India, was reported on February 18, 2018., Objectives: The outbreak investigation was conducted to find out the epidemiology of the outbreak and to identify the etiologic agent and risk factors., Methods: A case-control study was carried out, where cases (patients), controls, and food handlers were interviewed and leftover foods were collected for culture. A case was defined as a person having vomiting or diarrhea (i.e., ≥3 loose stools within 24 h) who attended the wedding ceremony at Makunsar village, Palghar district, Maharashtra, on February 18, 2018. Attack rate and odds ratio (OR) were calculated with 95% confidence intervals (CIs)., Results: Out of 75 cases, 63% were female. Altogether, forty-two (56%) cases were hospitalized, and later on, all of them were discharged from hospital without any mortality. About 93%, 68%, 43%, and 41% of the cases reported with vomiting, nausea, abdominal pain, and diarrhea, respectively. The median incubation period was found to be 4 h (range: 2-8 h). Eating gaajar halwa (carrot pudding) was significantly associated with illness (OR: 12.8; 95% CI: 3.5-46). Gaajar halwa is prepared with khoa, a perishable milk product. The gaajar halwa culture yielded no growth., Conclusion: The case-patients' clinical presentation and incubation period were consistent with enterotoxin-producing Staphylococcus aureus as the probable etiologic agent. The epidemiologic investigation identified the probable etiologic agent and food source in a low-resource community setting. Community food handlers were educated on food preparation hygiene and safe storage measures to prevent future outbreaks., Competing Interests: None

Background: Two suspected shellfish poisoning events were reported in Cuddalore District in Tamil Nadu, India, between January and April 2015., Objectives: The study was conducted to confirm the outbreaks and to identify the source and risk factors., Methods: For both outbreaks, a case was defined as a person with nausea, vomiting, or dizziness. Sociodemographic details and symptoms were noted down. Data were also collected in a standard 3-day food frequency questionnaire, along with a collection of clam samples. A case-control study was initiated in the April outbreak. Stool samples were collected from cases, and clam vendors were interviewed., Results: In an outbreak that happened in January, all the twenty people reported to be consumed clams were diagnosed as cases (100% attack rate, 100% exposure rate). In the April outbreak, we identified 199 cases (95% attack rate). In both outbreaks, the clams were identified as genus Meretrix meretrix. The most common reported symptoms were dizziness and vomiting. The clams heated and consumed within 30-60 min. No heavy metals or chemicals were detected in the clams, but assays for testing shellfish toxins were unavailable. All 64 selected cases reported clam consumption (100% exposure rate) as did 11 controls (17% exposure rate). Illness was associated with a history of eating of clams (odds ratio = 314, 95% confidence interval = 39-512). Of the six stool samples tested, all were culture negative for Salmonella, Shigella, and Vibrio cholerae. The water at both sites was contaminated with garbage and sewage., Conclusion: Coordinated and timely efforts by a multidisciplinary team of epidemiologists, marine biologists, and food safety officers led to the outbreaks' containment., Competing Interests: None

Background: In December 2018, an acute gastroenteritis outbreak was reported from Faridpur-Gujjran village, Patiala district, Punjab, India., Objective: The objective of this study was to describe the epidemiology and risk factors of the outbreak and recommend prevention measures., Methods: We conducted a descriptive study and a retrospective cohort study in the village. We defined a case as vomiting or ≥3 loose feces in 24 h plus abdominal pain and/or fever in a resident of the village during December 23-28, 2018. To find cases, we conducted a house-to-house survey; to identify risk factors, we conducted a retrospective cohort study. Fecal specimens were tested for enteric pathogens; water samples were tested for fecal contamination. We also interviewed food handlers. We compared attack rates by level of exposure. From the cohort study, we calculated risk ratios with 95% confidence intervals., Results: From the 261 residents of the village, we identified 116 cases (attack rate 44%) and no deaths. The median age of affected persons was 27.5 years (range 0.5-80 years). The illness was associated with eating in a community kitchen of a temple during December 23-24, 2018. Eating mixed vegetables was associated with illness. We found no pathogens in fecal specimens. All three water samples showed coliform contamination. Cooked food had been left at room temperature before serving., Conclusion: Improper storage practices might have led to microbial proliferation of the food served. Our findings will help guide the enforcement of food safety policies for community kitchens., Competing Interests: None

Background: On May 23, 2017, the health authorities in Longding district, Arunachal Pradesh, India, reported four suspected measles-related deaths in Konsa village, a remote village on the Indo-Myanmar border., Objective: We investigated to describe the epidemiology of the outbreak and identify associated risk factors., Methods: We defined a measles case as fever and maculopapular rash with cough, coryza, or conjunctivitis in a village of Longding district resident from March 1 to June 18, 2017. In Konsa village, we conducted a retrospective cohort study of children ≤5 years. We calculated attack rate (AR), case fatality rate (CFR), measles-containing vaccine first dose (MCV1) and Vitamin A coverage, risk ratio (RR), and vaccine efficacy. We collected samples for laboratory confirmation. We conducted a routine immunization system evaluation at multiple levels of Longding district., Results: We identified 75 suspected cases (56% females) for a Konsa village-specific AR of 86% (75/87) among children ≤5 years; the median age was 36 months; CFR was 7% (5/75); all deaths unvaccinated; none received Vitamin A. Coverage for MCV1 was 9.2% (6/65) and Vitamin A 4.6% (3/65). No MCV1 (RR = 7.3, 95% confidence interval [CI] = 1.3-53) and participation in a recent local festival (RR = 5.3, 95% CI = 1.5-18.5) were associated with illness. MCV vaccine efficacy was 100%. Of 17 cases, 13 tested positive for measles. The local health facility had neither staff nor immunization microplans., Conclusions: This outbreak was likely due to low MCV1 and Vitamin A coverage due to poor health-care access. The investigation led to a district measles catch-up campaign and resumption of regular immunization., Competing Interests: None

Background: Acute diarrheal disease (ADD) outbreaks frequently occur in the Gangetic plains of Uttar Pradesh, India. In August 2017, Muzaffarpur village, Uttar Pradesh, reported an ADD outbreak., Objectives: Outbreak investigation was conducted to find out the epidemiology and to identify the risk factors., Methods: A 1:1 area-matched case-control study was conducted. Suspected ADD case was defined as ≥3 loose stools or vomiting within 24 h in a Muzaffarpur resident between August 7 and September 9, 2017. A control was defined as an absence of loose stools and vomiting in a resident between August 7 and September 9, 2017. A matched odds ratio (mOR) with 95% confidence intervals (CIs) was calculated. Drinking water was assessed to test for the presence of any contamination. Stool specimens were tested for Vibrio cholerae, and water samples were also tested for any fecal contamination and residual chlorine., Results: Among 70 cases (female = 60%; median age = 12 years, range = 3 months-70 years), two cases died and 35 cases were hospitalized. Area-A in Muzaffarpur had the highest attack rate (8%). The index case washed soiled clothes at well - A1 1 week before other cases occurred. Among 67 case-control pairs, water consumption from well-A1 (mOR: 43.00; 95% CI: 2.60-709.88) and not washing hands with soap (mOR: 2.87; 95% CI: 1.28-6.42) were associated with illness. All seven stool specimens tested negative for V. cholerae. All six water samples, including one from well-A1, tested positive for fecal contamination with <0.2 ppm of residual chlorine., Conclusion: This outbreak was associated with consumption of contaminated well water and hand hygiene. We recommended safe water provision, covering wells, handwashing with soap, access to toilets, and improved laboratory capacity for testing diarrheal pathogens., Competing Interests: None

Background: Mass gathering (MG) events are associated with public health risks. During the period January 14 to March 4, 2019, Kumbh Mela in Prayagraj, India was attended by an estimated 120 million visitors. An onsite disease surveillance was established to identify and respond to disease outbreaks., Methods: A health coordination committee was established for planning. Disease surveillance was prioritized and risk assessment was done to identify diseases/conditions based on epidemic potential, severity of illness, and reporting requirement under the International Health Regulations (IHR) of 2005. A daily indicator and event-based disease surveillance was planned. The indicator-based surveillance (IBS) manually and electronically recorded data from patient hospital visits and collected MG area water testing data to assess trends. The event-based surveillance (EBS) helped identify outbreak signals based on pre-identified event triggers from the media, private health facilities, and the food safety department. Epidemic intelligence was used to analyse the data and events to detect signals, verify alerts, and initiate the response., Results: At Kumbh Mela, disease surveillance was established for 22 acute diseases/syndromes. Sixty-five health facilities reported 156 154 illnesses (21% of a total 738 526 hospital encounters). Among the reported illnesses, 95% (n = 148 834) were communicable diseases such as acute respiratory illness (n = 52 504, 5%), acute fever (n = 41 957, 28%), and skin infections (n = 27 094, 18%). The remaining 5% (n = 7300) were non-communicable diseases (injuries n = 6601, 90%; hypothermia n = 224, 3%; burns n = 210, 3%). Water samples tested inadequate for residual chlorine in 20% of samples (102/521). The incident command centre generated 12 early warning signals from IBS and EBS: acute diarrheal disease (n = 8, 66%), vector-borne disease (n = 2, 16%), vaccine-preventable disease (n = 1, 8%), and thermal event (n = 1, 8%). There were two outbreaks (acute gastroenteritis and chickenpox) that were investigated and controlled., Conclusions: This onsite disease surveillance imparted a public health legacy by successfully implementing an epidemic intelligence enabled system for early disease detection and response to monitor public health risks. Acute respiratory illnesses emerged as a leading cause of morbidity among visitors. Future MG events should include disease surveillance as part of planning and augment capacity for acute respiratory illness diagnosis and management., (Copyright © 2020 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: In the Gangetic plains of India, including Delhi, cholera is endemic. On 10 May 2018, staff at the north Delhi district surveillance unit identified a laboratory-confirmed cholera outbreak when five people tested positive for Vibrio cholerae O1 Ogawa serotype in Bhadola. We investigated to identify risk factors and recommend prevention measures., Methods: We defined a case as ≥3 loose stools within 24 h in a Bhadola resident during 1 April-29 May 2018. We searched for cases house-to-house. In a 1 : 1 unmatched case control study, a control was defined as an absence of loose stools in a Bhadola resident during 1 April-29 May 2018. We selected cases and controls randomly. We tested stool samples for Vibrio cholerae by culture. We tested drinking water for fecal contamination. Using multivariable logistic regression we calculated adjusted ORs (aORs) with 95% CIs., Results: We identified 129 cases; the median age was 14.5 y, 52% were females, 27% were hospitalized and there were no deaths. Symptoms were abdominal pain (54%), vomiting (44%) and fever (29%). Among 90 cases and controls, the odds of illness were higher for drinking untreated municipal water (aOR=2.3; 95% CI 1.0 to 6.2) and not knowing about diarrhea transmission (aOR=4.9; 95% CI 1.0 to 21.1). Of 12 stool samples, 6 (50%) tested positive for Vibrio cholerae O1 Ogawa serotype. Of 15 water samples, 8 (53%) showed growth of fecal coliforms., Conclusions: This laboratory-confirmed cholera outbreak associated with drinking untreated municipal water and lack of knowledge of diarrhea transmission triggered public health action in Bhadola, Delhi., (© The Author(s) 2020. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.)

Background: A cluster of 15 acute skin and soft tissue infections (SSTIs), including two cases of necrotizing fasciitis, reported in July 2018 from Kalwala village, led us to investigate and describe their epidemiology and to provide recommendations., Methods: Cases, defined as localized painful swelling and redness in Kalwala residents from 1 December 2017 to 20 August 2018, were identified from hospital records and house-to-house surveys. We conducted an unmatched case-control study to identify risk factors for severity. We cultured wound samples and environmental samples from wound-dressing stations., Results: We identified 36 cases (median age: 55 [range 17-80] y; 78% male), village attack rate 1% (36/4337) and no deaths. In 34 cases (94%), lower limbs were involved. Lymphatic filariasis (LF) was a common predisposing condition (67%). Comorbidities (diabetes or hypertension) (OR=9; 95% CI 2.0 to 41.1), poor limb hygiene (OR=16; 95% CI 2.8 to 95.3) and poor health-seeking behavior (OR=5; 95% CI 1.6 to 30.8) were associated with severity. All seven wound samples and 8/11 samples from wound-dressing stations showed atypical polymicrobial growth (Pseudomonas, Proteus, Klebsiella, Escherichia coli and Clostridium)., Conclusion: The outbreak of SSTIs among older males with LF was due to secondary bacterial infections and severity was associated with comorbidities, poor hygiene and health-seeking behavior, and likely contamination during wound-dressing. The LF elimination program managers was alerted, programmatic interventions were scaled up, home/facility-based morbidity and comorbidity management was facilitated and the outbreak was rapidly contained., (© The Author(s) 2020. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.)

Background: As of May 4, 2020, India has reported 42,836 confirmed cases and 1,389 deaths from COVID-19. India's multipronged response included nonpharmacological interventions (NPIs) like intensive case-based surveillance, expanding testing capacity, social distancing, health promotion, and progressive travel restrictions leading to a complete halt of international and domestic movements (lockdown)., Objectives: We studied the impact of NPI on transmission dynamics of COVID-19 epidemic in India and estimated the minimum level of herd immunity required to halt it., Methods: We plotted time distribution, estimated basic (R 0 ) and time-dependent effective (R t ) reproduction numbers using software R, and calculated doubling time, the growth rate for confirmed cases from January 30 to May 4, 2020. Herd immunity was estimated using the latest R t value., Results: Time distribution showed a propagated epidemic with subexponential growth. Average growth rate, 21% in the beginning, reduced to 6% after an extended lockdown (May 3). Based on early transmission dynamics, R 0 was 2.38 (95% confidence interval [CI] =1.79-3.07). Early, unmitigated R t = 2.51 (95% CI = 2.05-3.14) (March 15) reduced to 1.28 (95% CI = 1.22-1.32) and was 1.83 (95% CI = 1.71-1.93) at the end of lockdown Phase 1 (April 14) and 2 (May 3), respectively. Similarly, average early doubling time (4.3 days) (standard deviation [SD] = 1.86) increased to 5.4 days (SD = 1.03) and 10.9 days (SD = 2.19). Estimated minimum 621 million recoveries are required to halt COVID-19 spread if R t remains below 2., Conclusion: India's early response, especially stringent lockdown, has slowed COVID-19 epidemic. Increased testing, intensive case-based surveillance and containment efforts, modulated movement restrictions while protecting the vulnerable population, and continuous monitoring of transmission dynamics should be a way forward in the absence of effective treatment, vaccine, and undetermined postinfection immunity., Competing Interests: None

Background: In 2016, India reported 709 acute diarrheal disease (ADD) outbreaks (> 25% of all outbreaks). Tribal populations are at higher risk with 27% not having accessibility to safe drinking water and 75% households not having toilets. On June 26, 2017 Pedda-Gujjul-Thanda, a tribal village reported an acute diarrheal disease (ADD) outbreak. We investigated to describe the epidemiology, identify risk factors, and provide evidence-based recommendations., Methods: We defined a case as ≥3 loose stools within 24 h in Pedda-Gujjul-Thanda residents from June 24-30, 2017. We identified cases by reviewing hospital records and house-to-house survey. We conducted a retrospective cohort study and collected stool samples for culture. We assessed drinking water supply and sanitation practices and tested water samples for faecal-contamination., Results: We identified 191 cases (65% females) with median age 36 years (range 4-80 years) and no deaths. The attack-rate (AR) was 37% (191/512). Downhill colonies (located on slope of hilly terrains of the village) reported higher ARs (56%[136/243], p < 0.001) than others (20%[55/269]). Symptoms included diarrhea (100%), fever (17%), vomiting (16%) and abdominal pain (13%). Drinking water from five shallow bore-wells located in downhill colonies was significantly associated with illness (RR = 4.6, 95%CI = 3.4-6.1 and population attributable fraction 61%). In multi-variate analysis, drinking water from the shallow bore-wells located in downhill colonies (aOR = 7.9, [95% CI =4.7-13.2]), illiteracy (aOR =6, [95% CI = 3.6-10.1]), good hand-washing practice (aOR = 0.4, [95%CI = 0.2-0.7]) and household water treatment (aOR = 0.3, [95%CI = 0.2-0.5]) were significantly associated with illness. Two stool cultures were negative for Vibrio cholerae. Heavy rainfall was reported from June 22-24. Five of six water samples collected from shallow bore-wells located in downhill colonies were positive for faecal contamination., Conclusion: An ADD outbreak with high attack rate in a remote tribal village was associated with drinking water from shallow downhill bore-wells, likely contaminated via runoff from open defecation areas after heavy rains. Based on our recommendations, immediate public health actions including repair of leakages at contaminated water sources and alternative supply of purified canned drinking water to families, and as long-term public health measures construction of house-hold latrines and piped-water supply initiated.

Competing Interests: None

Background: Multidrug-resistant tuberculosis (MDR-TB) is a major public health challenge in India. It is associated with poor treatment outcomes, multiple adverse effects to treatment and involves enormous social and economic losses. The objective of the study was to ascertain the epidemiological and behavioural correlates contributing to drug resistance among patients admitted in a tertiary hospital in Delhi with drug-resistant TB (DR-TB)., Methodology: A descriptive cross-sectional study was carried out during the period of July-November 2013 at the Rajan Babu Institute of Pulmonary Medicine and Tuberculosis (RBIPMT), Delhi. All patients admitted with DR-TB for treatment were interviewed regarding social, demographic, and treatment aspects, using a semi-structured questionnaire. Their medical records were also reviewed., Results: A total of 250 patients were included in the study; 198 (79.2%) with multidrug-resistant (MDR-TB) and 52 (20.8%) with extensively drug-resistant TB (XDR-TB). Of these, 66% patients were male and 46% came from poor socioeconomic background. All the patients had history of receiving anti-tubercular treatment (a mean of 2.3 times, range 1-6 times) before the current diagnosis of DR-TB. While 81 (32%) took treatment from private practitioner during the first episode of TB, 146 (58%) received treatment exclusively at government health facilities. Almost 87% of DR-TB patients were previously treated with category-II under RNTCP. Irregularity of treatment was reported by 88 (35%) patients., Conclusion: The study explores the epidemiological and behavioural correlates among the patients with drug-resistant TB. History of previous treatments for TB was a common feature among all the enrolled patients. The fact that more than half of DR-TB patients received anti-tubercular treatment exclusively in government facilities is a matter of concern. There is an urgent need to ensure treatment adherence through improved quality in service delivery in public sector and strong linkage with the private sector. Health education and patient counseling is needed to address personal level risk factors and to ensure treatment adherence., (Copyright © 2018 Tuberculosis Association of India. Published by Elsevier B.V. All rights reserved.)

Purpose: Profile of maternal deaths in selected districts of four Indian states was studied to examine the regional differences in non-biological causal factors (socioeconomic and sociocultural) in maternal mortality and to examine the method and completeness of implementation of Maternal and Perinatal Death Inquiry and Response (MAPEDIR) process., Methods: An integrated qualitative and quantitative method was used to study the MAPEDIR process in selected districts of four states in India, through the use of standardized questionnaire for key informant interviews, participant observation checklist, analysis of verbal autopsy questionnaire, and maternal death reports., Results: A comparison of Profile's maternal deaths investigated showed that women died between 25 and 27 years of age. Half of the women died at home because of inability to afford transport (Delay II) and treatment costs. One third of the deaths had occurred in a health facility (Delay III) because of lack of specialists, equipments or blood. Two thirds of the delays (Delay I) were in seeking medical care. Review of the implementation process of MAPEDIR highlighted that the social audit review model is a unique field based collaborative initiative comprising of stakeholders from various sector in order to improve maternal health programming by reducing maternal mortality., Conclusions: MAPEDIR has been able to identify socio-cultural, economic and health care systems related determinants of maternal deaths. Standardization the mechanism for information data sharing at district, sub-district and village level can maximize the use of available evidence for advocacy and policy shifts by developing policies and interventions suited to local needs.