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Introduction: Healthcare workers (HCWs) are at higher risk of getting infected with COVID-19 infection due to their close proximity to COVID-19-positive patients. We studied the risk stratification and positivity rate in HCWs at risk of getting COVID-19 infection as well as the possible factors responsible for their being at risk of COVID-19 infection during the study period. Material and Methods: This prospective study was conducted after approval by the institutional ethics committee. The data regarding demographic variables, risk stratification, COVID-19 (reverse-transcription polymerase chain reaction) report, and possible sources of exposure for HCWs were recorded in a proforma by personal/telephonic interviews as well as from hospital records from March 2020 to June 2021. The data generated were entered into Microsoft Excel® software and analyzed using percentages, proportions, and Chi-square tests for qualitative variables. Results: COVID-19 infection's positivity rate was 19.5% among high-risk and 0.6% among low-risk HCW contacts. HCWs working in non-COVID-19 areas (67.9%) were more at risk than those working in COVID-19 areas (32.1%). In contrast, the COVID-19 positivity rate was significantly higher among high-risk contact HCWs from COVID-19 areas (34.2%) than in non-COVID-19 areas (12.6%). The maximum COVID-19 positivity rate was seen in high-risk contacts with body fluid exposure (21%), performing aerosol-generating procedures (20%), and close exposure in operation theaters (18%). Conclusions: Risk stratification is an important tool to contain infection among HCWs who had unprotected close contact with a COVID-19-positive case. With appropriate contact tracing, we were able to avoid over- and under-quarantine, save many man-hours as well as contain the spread of infection. HCWs should not only wear appropriate personal protective equipment (PPE) during work hours but should also practice mask-wearing and social distancing while they are in the community. [ABSTRACT FROM AUTHOR]

Since the COVID-19 pandemic, the world began a frantic search for possible prophylactic 11 options. We conducted a study to assess the role of hydroxychloroquine for COVID-19 12 prophylaxis in health-care workers. The study was a prospective cohort with four arms (high, 13 medium, low dose, and control) of HCQ prophylaxis. Participants were grouped as per their 14 opting for any one arm on a voluntary basis as per institute policy. The outcomes studied 15 were COVID-19 positivity by RT-PCR and its severity assessed by WHO COVID-19 16 severity scale. Total 486 participants were enrolled, of which 29 (6%) opted for low dose, 2 17 (<1%) medium dose, and none for high dose HCQ while 455 (93.6%) were in the control 18 arm. Of the 164 participants who underwent RT-PCR, 96 (58.2%) tested positive. Out of 19 these 96 positive cases, 79 [82.3%]) were ambulatory and were managed conservatively at 20 home. Only 17.7% participants, all from the control group, required hospitalization with the 21 mild-moderate disease. None of the participants had severe disease, COVID-related 22 complications, ICU stay, or death. The difference in the outcome was statistically 23 insignificant (p value >0.05). This single-centre study demonstrated that HCQ prophylaxis in 24 healthcare workers does not cause a significant reduction in COVID-19 as well as mitigating 25 its severity in those infected. At present, most of the trials have not shown any benefit. 26 Though COVID-19 vaccines have reduced the need for prophylaxis, the search for a safe and 27 reasonable chemoprophylaxis should continue until a large population of individuals gets 28 vaccinated, especially in underdeveloped countries. [ABSTRACT FROM AUTHOR]

A Primary Healthcare-System-Strengthening Project (PSSP) is implemented by the Ministry of Health, Sri Lanka, with funding support from the World Bank for providing quality care through primary medical care institutions (PMCIs). We used an explanatory mixed-methods study to assess progress and challenges in human resources, drug availability, laboratory services and the health management information system (HMIS) at PMCIs. We conducted a checklist-based assessment followed by in-depth interviews of healthcare workers in one PMCI each in all nine provinces. All PMCIs had medical/nursing officers, but data entry operators (44%) and laboratory technicians (33%) were mostly not available. Existing staff were assigned additional responsibilities in PSSP, decreasing their motivation and efficiency. While 11/18 (61%) essential drugs were available in all PMCIs, buffer stocks were not maintained in >50% due to poor supply chain management and storage infrastructure. Only 6/14 (43%) essential laboratory investigations were available in >50% of PMCIs, non-availability was due to shortages of reagents/consumables and lack of sample collection–transportation system. The HMIS was installed in PMCIs but its usage was sub-optimal due to perceived lack of utility, few trained operators and poor internet connectivity. The PSSP needs to address these bottlenecks as a priority to ensure sustainability and successful scale-up. [ABSTRACT FROM AUTHOR]

Background: Coronavirus disease-2019 (COVID-19) pandemic has been a cause of significant mental health disturbances in medical health personnel. However, 18 months into the pandemic, healthcare workers (HCWs) have become accustomed to the heightened stress and anxiety that comes with caring for COVID patients. Through this study, we aim to measure depression, anxiety, stress, and insomnia in doctors with the help of validated scales. Materials and methods: This was a cross-sectional study with an online survey design conducted among doctors from major hospitals in New Delhi. The questionnaire included participant demographics, including designation, specialty, marital status, and living arrangements. This was followed by questions from the validated depression, anxiety, stress scale (DASS-21), and insomnia severity index (ISI). Depression, anxiety, stress, and insomnia scores were calculated for each participant, and the data were analyzed statistically. Results: The mean scores of the whole study population showed no depression, moderate anxiety, mild stress, and subthreshold insomnia. Female doctors exhibited more psychological issues (mild depression and stress, moderate anxiety, but only subthreshold insomnia) as compared to males (mild anxiety, but no depression, stress, and insomnia). Junior doctors also had higher depression, anxiety, and stress scores than senior doctors. Similarly, single doctors, those living alone, and those not having kids had higher DASS and insomnia scores. Discussion: HCWs have been under tremendous mental stress during this pandemic which is influenced by multiple factors. Female sex, junior doctors, working on the frontline, not being in a relationship, and living alone may be some of the factors recognized in our study and corroborated by many authors, which may increase the chances of depression, anxiety, and stress in them. HCWs need regular counseling, time off for rejuvenation, and social support to overcome this hurdle. [ABSTRACT FROM AUTHOR]

Background: Isoniazid preventive therapy (IPT) has been shown to reduce the risk of tuberculosis (TB) among people living with HIV (PLHIV). In 2017, India began a nationwide roll-out of IPT, but there is a lack of evidence on the implementation and the challenges. Objectives: Among PLHIV newly initiated on antiretroviral therapy (ART) from January 2017 to June 2018, to: (i) assess the proportion who started and completed IPT and (ii) explore reasons for non-initiation and non-completion from health-care providers' and patients' perspectives. Methods: An explanatory mixed-methods study was conducted in two selected districts of Karnataka, South India. A quantitative phase (cohort analysis of routinely collected program data) was followed by a qualitative phase involving thematic analysis of in-depth interviews with providers (n = 22) and patients (n = 8). Results: Of the 4020 included PLHIV, 3780 (94%) were eligible for IPT, of whom, 1496 (40%, 95% CI: 38%-41%) were initiated on IPT. Among those initiated, 423 (28.3%) were still on IPT at the time of analysis. Among 1073 patients with declared IPT outcomes 870 (81%, 95% CI: 79%-83%) had completed the six-month course of IPT. The main reason for IPT non-initiation and non-completion was frequent drug stock-outs. This required health-care providers to restrict IPT initiation in selected patient subgroups and earmark six-monthly courses for each patient to ensure that, once started, treatment was not interrupted. The other reasons for non-completion were adverse drug effects and loss to follow-up. Conclusion: The combined picture of 'low IPT initiation and high completion' seen in our study mirrors findings from other countries. Drug stock-out was the key challenge, which obliged health-care providers to prioritize 'IPT completion' over 'IPT initiation'. There is an urgent need to improve the procurement and supply chain management of isoniazid. [ABSTRACT FROM AUTHOR]

Objective: We assessed uptake of isoniazid preventive therapy (IPT) among child contacts of smear-positive tuberculosis (TB) patients and its implementation challenges from healthcare providers' and parents' perspectives in Bhopal, India.Methods: A mixed-method study design: quantitative phase (review of programme records and house-to-house survey of smear-positive TB patients) followed by qualitative phase (interviews of healthcare providers and parents).Results: Of 59 child contacts (<6 years) of 129 index patients, 51 were contacted. Among them, 19 of 51 (37%) were screened for TB and one had TB. Only 11 of 50 (22%) children were started and 10 of 50 (20%) completed IPT. Content analysis of interviews revealed lack of awareness, risk perception among parents, cumbersome screening process, isoniazid stock-outs, inadequate knowledge among healthcare providers and poor programmatic monitoring as main barriers to IPT implementation.Conclusion: National TB programme should counsel parents, train healthcare providers, simplify screening procedures, ensure regular drug supply and introduce an indicator to strengthen monitoring and uptake of IPT. [ABSTRACT FROM AUTHOR]

Background: In India, a new care package consisting of (i) daily regimen with fixed-dose combination drugs, collected once-a-month and self-administered by the patient, (ii) 'one stop service' at antiretroviral treatment (ART) centre for both HIV and tuberculosis (TB) treatment and (iii) technology-enabled adherence support (99DOTS, which required patients to give a missed phone call after consuming drugs) was piloted for treatment of TB among HIV-infected TB patients. Conventional care included intermittent regimen (drugs consumed thrice-weekly) delivered under direct observation of treatment supporter and the patients needing to visit TB and HIV care facilities, separately for treatment. Objective: To assess the effect of new care package on TB treatment outcomes among HIV-TB patients registered during January–December 2016, as compared to conventional care and explore the implementation challenges. Methods: A mixed-methods study was conducted in four districts of Karnataka, India where new care package was piloted in few ART centres while the rest provided conventional care. Quantitative component involved a secondary cohort analysis of routine programme data. Adjusted relative risk(aRR) was calculated using Poisson regression to measure association between new care package and unsuccessful treatment outcome. We conducted in-depth interviews with healthcare providers and patients to understand the challenges. Results: Unsuccessful TB treatment outcomes (death, loss to follow-up and failure) were higher in new care package (n = 871) compared to conventional care (n = 961) (30.5% vs 23.4%; P value<0.001) and aRR was 1.3(95% CI: 1.1–1.7). Key challenges included patients' inability to give missed call, increased work load for ART staff, reduced patient–provider interaction, deficiencies in training and lack of role clarity among providers and reduced involvement of TB program staff. Conclusion: With new care package, TB treatment outcomes did not improve as expected and conversely declined compared to conventional care. TB and HIV programs need to address the operational challenges to improve the outcomes. [ABSTRACT FROM AUTHOR]

Background: The national tuberculosis (TB) programme in India recommends screening all pregnant women for TB, but this is rarely implemented. We carried out systematic TB screening among women attending the antenatal clinic of a tertiary care hospital in Puducherry, South India, during February to April 2018. Objective: To assess the number screened and number (proportion) with presumptive and active TB, and understand potential implementation from the healthcare providers' perspective. Methods: We conducted a mixed-methods study. The quantitative phase was a cross-sectional study including 4203 pregnant women. Data were captured using a structured proforma. Any of the following symptoms constituted 'presumptive TB': any cough, haemoptysis, fever, weight loss, night sweats, neck swellings, joint pains, neck stiffness and disorientation. Those screening positive were referred for investigations and evaluation by a chest physician. The qualitative phase involved seven one-to-one interviews with healthcare providers. Manual thematic analysis was performed to generate themes. Results: Among 4203 women (two HIV-positive) screened, 77 (1.8%) had presumptive TB. Cough was the predominant symptom (n = 75). Only 12 women could produce a sputum sample, of whom one (0.02%) was diagnosed with active TB by the Xpert MTB/RIF assay. Challenges cited by healthcare providers were lack of awareness among clients and providers, high case load, lack of dedicated staff, perception that TB screening is a low-yield, low-priority activity and losses in the referral process. Suggested solutions were providing dedicated staff and space for screening, educating women to self-report using posters and videos, and creating a one-stop care provision. Conclusions: The TB yield among pregnant women was very low, calling into question the value of systematic screening in a low-HIV setting. However, the findings may not be generalizable. Evidence is urgently needed from primary and secondary care facilities. The challenges and solutions identified may help in optimizing the screening process. [ABSTRACT FROM AUTHOR]

REFERENCES 1 Sureka B, Tak V, Nag VL, Rani R, Garg MK, Misra S. Suraksha Chakra: A new scoring system to protect the healthcare workers from COVID. Such basic points need to be taken into consideration when designing hospital wards, catering not only to COVID patients but also to non-COVID patients. Einstein archives 29-041 Sureka I et al. i [[1]] modelled a suraksha chakra (safety circle) by designing a new scoring system to protect healthcare workers from COVID. [Extracted from the article]

Background: Motivated human resource is the key to improve health system performance and retention of health workers. There is scanty literature on measuring motivation of health workers in India. Thus, the objective of this study was to measure and identify important aspects of health workers' motivation in North India.Methods: A mixed method study design was adopted. Under the quantitative component, we interviewed randomly selected 62 community health workers (CHWs) in 18 sub-centres in two blocks of District Ambala, Haryana, India using a structured motivation scale. In-depth interviews were also carried out with 18 CHWs to explore the sources of motivation.Results: The age of respondents and training in the past 12 months were found to be significantly associated with motivation. Job burnout, poor personal health, job insecurity and less career development opportunities were the individual level de-motivators, whereas not being able to fulfil family roles and poor supportive supervision were identified as environmental factors for poor motivation. Love for work, and financial incentives were individual level motivators, while community support and recognition, organizational commitment and pride, regular training were identified as environmental level motivators.Conclusion: Non-financial motivators such as interpersonal relations, family support, skill and career development opportunities require more attention. Regular need-based training is essential to maintain high levels of motivation. [ABSTRACT FROM AUTHOR]

Consent is a legal requirement of medical practice and not a procedural formality. Getting a mere signature on a form is no consent. If a patient is rushed into signing consent, without giving sufficient information, the consent may be invalid, despite the signature. Often medical professionals either ignore or are ignorant of the requirements of a valid consent and its legal implications. Instances where either consent was not taken or when an invalid consent was obtained have been a subject matter of judicial scrutiny in several medical malpractice cases. This article highlights the essential principles of consent and the Indian law related to it along with some citations, so that medical practitioners are not only able to safeguard themselves against litigations and unnecessary harassment but can act rightfully. [ABSTRACT FROM AUTHOR]

Background We have conducted 23 operational research (OR) courses since 2009, based on 'The Union/ Médecins Sans Frontières (MSF)' model, now popularly known as SORT-IT (Structured Operational Research and Training Initiative) model - wherein participants are mentored through the whole research process from protocol development (module 1) to data analysis (module 2) to publication (module 3) over a period of 9-12 months. We have faced a number of challenges including shortage of time, especially for data analysis and interpretation, and a heavy mentorship burden on limited numbers of experienced facilitators. To address these challenges, we have made several modifications to the structure of the OR course. In this article, we describe the revised structure and our experience (successes and challenges) of implementing it in Asia in 2013. Findings The key changes introduced included extending the duration of the course modules (by a day each in module 1 and 2 and by three days in module 3), increasing the numbers of facilitators and standardizing milestones related to data entry and analysis. We successfully implemented this revised structure in the second Asian OR Course held in Nepal in 2013. Eleven of twelve participants successfully completed all the milestones and submitted 13 scientific manuscripts (two participants completed two projects) to international peer-reviewed journals. Though, this posed two challenges - increased costs and increased time away for faculty and participants. Conclusions The revised structure of 'The Union/MSF' model of OR capacity building addressed previous issues of insufficient time and overburdened mentors and we intend to continue with this model for future courses. [ABSTRACT FROM AUTHOR]

Risk factors and outcome among COVID-19 exposed and quarantined healthcare workers: A study on the status of existing practices of standard precautions. Dear Editor, Kumar et al. analyze risk factors and outcome among Covid-19 exposed and quarantined healthcare workers. [Extracted from the article]

During war, sharp high-speed missiles have been driven inside the brain; however, in civilian practice it is rare to see such episodes. An approximately 10-cm long nail was driven inside the brain in an attempt to commit suicide by a schizophrenic patient. The case is being reported for its rarity in civilian practice and as a case of clinical interest. After investigating the patient by plain X-rays and a CT scan, he was operated by a neurosurgical team and the nail was successfully removed. In post-operative phase, patient was given medical and psychiatric care along with psychological counseling. The patient made good uneventful recovery in the post-operative phase. [ABSTRACT FROM AUTHOR]

Background: The Global Fund encourages operational research (OR) in all its grants; however very few reports describe this aspect. In India, Project Axshya was supported by a Global Fund grant to improve the reach and visibility of the government Tuberculosis (TB) services among marginalised and vulnerable communities. OR was incorporated to build research capacity of professionals working with the national TB programme and to generate evidence to inform policies and practices. Objectives: To describe how Project Axshya facilitated building OR capacity within the country, helped in addressing several TB control priority research questions, documented project activities and their outcomes, and influenced policy and practice. Methods: From September 2010 to September 2016, three key OR-related activities were implemented. First, practical output-oriented modular training courses were conducted (n = 3) to build research capacity of personnel involved in the TB programme, co-facilitated by The Union, in collaboration with the national TB programme, WHO country office and CDC, Atlanta. Second, two large-scale Knowledge, Attitude and Practice (KAP) surveys were conducted at baseline and mid-project to assess the changes pertaining to TB knowledge, attitudes and practices among the general population, TB patients and health care providers over the project period. Third, studies were conducted to describe the project's core activities and outcomes. Results: In the training courses, 44 participant teams were supported to develop research protocols on topics of national priority, resulting in 28 peer-reviewed scientific publications. The KAP surveys and description of project activities resulted in 14 peer-reviewed publications. Of the published papers at least 12 have influenced change in policy or practice. Conclusions: OR within a Global Fund supported TB project has resulted in building OR capacity, facilitating research in areas of national priority and influencing policy and practice. We believe this experience will provide guidance for undertaking OR in Global Fund projects. [ABSTRACT FROM AUTHOR]

Background:Severe acute malnutrition (SAM) is the most serious form of malnutrition affecting children under-five and is associated with many infectious diseases including Tuberculosis (TB). In India, nutritional rehabilitation centres (NRCs) have been recently established for the management of SAM including TB. The National TB Programme (NTP) in India has introduced a revised algorithm for diagnosing paediatric TB. We aimed to examine whether NRCs adhered to these guidelines in diagnosing TB among SAM children. Methods:A cross-sectional study involving review of records of all SAM children identified by health workers during 2012 in six tehsils (sub-districts) with NRCs (population: 1.8 million) of Karnataka, India. Results:Of 1927 identified SAM children, 1632 (85%) reached NRCs. Of them, 1173 (72%) were evaluated for TB and 19(2%) were diagnosed as TB. Of 1173, diagnostic algorithm was followed in 460 (37%). Among remaining 763 not evaluated as per algorithm, tuberculin skin test alone was conducted in 307 (41%), chest radiography alone in 99 (13%) and no investigations in 337 (45%). The yield of TB was higher among children evaluated as per algorithm (4%) as compared to those who were not (0.3%) (OR: 15.3 [95%CI: 3.5-66.3]). Several operational challenges including non-availability of a full-time paediatrician, non-functioning X-ray machine due to frequent power cuts, use of tuberculin with suboptimal strength and difficulties in adhering to a complex diagnostic algorithm were observed. Conclusion:This study showed that TB screening in NRCs was sub-optimal in Karnataka. Some children did not reach the NRC, while many of those who did were either not or sub-optimally evaluated for TB. This study pointed to a number of operational issues that need to be addressed if this collaborative strategy is to identify more TB cases amongst malnourished children in India. [ABSTRACT FROM AUTHOR]