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India introduced BBV152/Covaxin and AZD1222/Covishield vaccines in January 2021. We estimated the effectiveness of these vaccines against severe COVID-19 among individuals aged ≥45 years.We did a multi-centric, hospital-based, case-control study between May and July 2021. Cases were severe COVID-19 patients, and controls were COVID-19 negative individuals from 11 hospitals. Vaccine effectiveness (VE) was estimated for complete (2 doses ≥ 14 days) and partial (1 dose ≥ 21 days) vaccination; interval between two vaccine doses and vaccination against the Delta variant. We used the random effects logistic regression model to calculate the adjusted odds ratios (aOR) with a 95% confidence interval (CI) after adjusting for relevant known confounders.We enrolled 1143 cases and 2541 control patients. The VE of complete vaccination was 85% (95% CI: 79-89%) with AZD1222/Covishield and 71% (95% CI: 57-81%) with BBV152/Covaxin. The VE was highest for 6-8 weeks between two doses of AZD1222/Covishield (94%, 95% CI: 86-97%) and BBV152/Covaxin (93%, 95% CI: 34-99%). The VE estimates were similar against the Delta strain and sub-lineages.BBV152/Covaxin and AZD1222/Covishield were effective against severe COVID-19 among the Indian population during the period of dominance of the highly transmissible Delta variant in the second wave of the pandemic. An escalation of two-dose coverage with COVID-19 vaccines is critical to reduce severe COVID-19 and further mitigate the pandemic in the country.

Objectives In May 2018, a laboratory network for antimicrobial resistance (AMR) surveillance in Tamil Nadu, India, detected a cluster of Salmonella enterica serotype Typhi (S. Typhi) isolates resistant to ceftriaxone. We investigated to describe the epidemiology and identify risk factors for the outbreak. Methods We conducted unmatched case-control studies. We defined a case as illness (fever with abdominal pain, diarrhea or vomiting) in a person with blood culture-confirmed ceftriaxone-resistant S. Typhi isolated between January 1 and July 4, 2018 in Tiruchirappalli, Tamil Nadu. We interviewed cases using a semi-structured questionnaire to identify common exposures to food, water and places visited. Results We identified 7 cases (5 men) during March 25–June 8, 2018, median age 23 years (range: 12–42); all were hospitalized, none died. Eating at Restaurant A (odds ratio [OR]=22) and chicken gravy (OR=16) was associated with illness. Of the 10 workers at Restaurant A, stool culture from 8 did not detect S. Typhi; 2 did not consent to provide samples. Five water samples around the restaurant showed low or no residual chlorine content. Conclusions The investigation highlights the value of AMR surveillance in detecting emerging pathogens and the need for timely investigations, along with strengthening food safety.

BACKGROUND: The first national severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) serosurvey in India, done in May-June, 2020, among adults aged 18 years or older from 21 states, found a SARS-CoV-2 IgG antibody seroprevalence of 0·73% (95% CI 0·34-1·13). We aimed to assess the more recent nationwide seroprevalence in the general population in India. METHODS: We did a second household serosurvey among individuals aged 10 years or older in the same 700 villages or wards within 70 districts in India that were included in the first serosurvey. Individuals aged younger than 10 years and households that did not respond at the time of survey were excluded. Participants were interviewed to collect information on sociodemographics, symptoms suggestive of COVID-19, exposure history to laboratory-confirmed COVID-19 cases, and history of COVID-19 illness. 3-5 mL of venous blood was collected from each participant and blood samples were tested using the Abbott SARS-CoV-2 IgG assay. Seroprevalence was estimated after applying the sampling weights and adjusting for clustering and assay characteristics. We randomly selected one adult serum sample from each household to compare the seroprevalence among adults between the two serosurveys. FINDINGS: Between Aug 18 and Sept 20, 2020, we enrolled and collected serum samples from 29 082 individuals from 15 613 households. The weighted and adjusted seroprevalence of SARS-CoV-2 IgG antibodies in individuals aged 10 years or older was 6·6% (95% CI 5·8-7·4). Among 15 084 randomly selected adults (one per household), the weighted and adjusted seroprevalence was 7·1% (6·2-8·2). Seroprevalence was similar across age groups, sexes, and occupations. Seroprevalence was highest in urban slum areas followed by urban non-slum and rural areas. We estimated a cumulative 74·3 million infections in the country by Aug 18, 2020, with 26-32 infections for every reported COVID-19 case. INTERPRETATION: Approximately one in 15 individuals aged 10 years or older in India had SARS-CoV-2 infection by Aug 18, 2020. The adult seroprevalence increased approximately tenfold between May and August, 2020. Lower infection-to-case ratio in August than in May reflects a substantial increase in testing across the country. FUNDING: Indian Council of Medical Research.

Background The Indian government provides for free/subsidized services in public hospitals and conditional cash transfer (CCT) schemes for delivery care. Our objectives were to estimate the proportion of women reporting out-of-pocket expenditure (OOPE) for delivery care at home and public hospitals, magnitude of components of OOPE for public hospitals by wealth status, and to determine the factors associated with OOPE for delivery care at home and public hospitals in South 24 Parganas district. Methods We did a community based cross-sectional analytical study among women who delivered between November 2016 to March 2017. We calculated median (Inter-Quartile Range) direct and indirect expenditures. We did multiple logistic regression to calculate odds ratios (95% confidence interval). Results All women reported OOPE for delivery care. Median OOPE was INR 865 (IQR: 520,1700) at public hospital and INR 1700 (IQR: 550,2300) at home. Among public hospital deliveries, majority of OOPE was due to indirect expenditure, 35.8% due to wage loss. Poorest women had the highest median gross OOPE. The middle-income group had the highest median percentage of reduction in OOPE for home delivery after receiving government subsidy. OOPE was most likely for a male child (OR 4.8, 95% CI 1.1–2.0) for home delivery and for caesarian section (OR 56.8, 95% CI 13.6–237) among the public hospital deliveries. Conclusions Women incurred OOPE for delivery care at home and public hospitals despite free/subsidized care. Augmenting the package of delivery-related CCT schemes and increase in universal health insurance coverage for economically poor households can reduce the financial burden of delivery care in the district.

Background: Large data on the clinical characteristics and outcome of COVID-19 in the Indian population are scarce. We analyzed the factors associated with mortality in a cohort of moderately ill COVID-19 patients enrolled in a multicentre randomized trial on convalescent plasma. Methods: Demographic, clinical, laboratory, treatment, and outcome data were extracted from electronic records. Factors associated with mortality were explored using univariate and multivariable Cox regression analysis and expressed as hazard ratio (HR) with 95% confidence intervals (CI). Findings: The mean (SD) age of the cohort (n=451) was 51±12·4 years; 76·7% were male. Admission SOFA score was 2·4±1·1. Non-invasive ventilation, invasive ventilation and vasopressor therapy were required in 98·9%, 8·4% and 4·0% respectively. The 28 day all-cause mortality was 14·4%. Median time from symptom onset to hospital admission was similar (p=1.0) in survivors (4 days; IQR 3-7) and non survivors (4 days; IQR 3-6). Patients with two or more co-morbidities had 2·25 (95%CI:1·17–4·32, p=0·014) times risk of death. When compared with survivors, admission IL-6 levels were higher (p 10 (9·38, 3·67-24·0,p 1·0mg/l (2·51,1·14-5·51,p=0·022), ferritin>500ng/ml (2·66,1·46-4·85,p=0·001) and LDH≥450 IU/L (2·96,1·61-5·45,p=0·001) were significantly associated with death. Interpretation: In this cohort of moderately ill COVID-19 patients, severity of illness, underlying co-morbidities and higher levels of inflammatory markers were significantly associated with death. Trial Registration: The trial protocol was registered with the Clinical Trial Registry of India (CTRI/2020/04/024775). Funding: This study was funded by Indian Council of Medical Research, an autonomous government funded medical research council. Declaration of Interests: No other author has any competing financial or non-financial interest. Ethics Approval Statement: Ethical approval was obtained from the ICMR Central Ethics Committee on Human Research 326 (CECHR-002/2020) as well as from the Institutional Review Boards (IRB) /Institutional Ethics 327 Committees of all the participating hospitals.

Background: Repeated cross-sectional serosurveys in the same geographic area establish the trend of the evolving pandemic. We present the findings of the third round of a national serosurvey to estimate the seroprevalence of SARS-CoV-2 infection among the general population and health care workers of India. Methods: We conducted the third population-based serosurvey between Dec 18, 2020 and Jan 6, 2021 in the same 700 villages or wards from 70 districts in 21 states across India, which were selected for the first and second serosurveys. We enrolled from each district, at least 400 individuals aged ≥ 10 years from general population and 100 HCWs from sub-district level public health facilities. Serum samples from general population were tested for the presence of IgG antibodies against nucleocapsid (N) and spike protein (S1-RBD) of SARS-CoV-2 using the Abbott and Siemens assays respectively, whereas sera from HCWs were tested for anti-S1-RBD. For general population, sera positive for either of the antibodies were considered positive, while sera positive for anti-S1-RBD were considered as positive for HCW. Weighted seroprevalence estimates were adjusted for sensitivity and specificity of respective assays. Findings: Of the 28,598 sera from general population, 4585 (16%) had IgG antibodies against N, 6647 (23.2%) against S1-RBD and 7436 (26%) against either. The weighted and assay characteristic adjusted seroprevalence against either of the antibodies was 24.1 (95%CI: 23.0% to 25.3%). Seroprevalence was lower in rural areas (21.4%, 95% CI: 20.3% to 22.6%) compared to urban non-slum (29.4%, 95% CI: 26.9% - 32.1%) and slum areas (34.6%, 95% CI: 31.0% to 38.3%). Among 7385 HCWs, the seroprevalence of anti-S1-RBD IgG antibodies was 25.6% (95% CI: 23.5% to 27.8%). Interpretation: Nearly one in four individuals aged 10 years or older from general population as well as HCWs were exposed to SARS-CoV-2 by December 2020 amounting to 271 million infections in India. Funding Statement: Indian Council of Medical Research Declaration of Interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare no competing interests Ethics Approval Statement: The project was approved by Institutional Human Ethics Committee at ICMR-National Institute of Epidemiology.

Background: India introduced BBV152/Covaxin and AZD1222/Covishield vaccines from January 2021. We estimated effectiveness of these vaccines against severe Coronavirus disease 2019 (COVID-19) among individuals aged >=45 years. Methods: We did a multi-centric, hospital-based, case–control study between May and July 2021. Cases were severe COVID-19 patients and controls were COVID-19 negative individuals from 11 hospitals. Vaccine effectiveness (VE) was estimated for full (2 doses ≥14days) and partial (1 dose ≥21 days) vaccination; duration between two vaccine doses and against the Delta variant. We used a random effects logistic regression model to calculate adjusted odds ratios (aOR) with 95% CI after adjusting for relevant known confounders. Findings: We enrolled 1,143 cases and 2,541 controls. The VE of full vaccination was 80% (95% CI: 73%-86%) with AZD1222/Covishield and 69% (95% CI: 54%-79%) with BBV152/Covaxin. The VE was highest for a gap of 6-8 weeks between two doses of AZD1222/Covishield (92%, 95% CI: 82%-96%) and BBV152/Covaxin (92%, 95% CI: 26%-99%). The VE estimates were similar against the Delta strain and sub-lineages. Interpretation: BBV152/Covaxin and AZD1222/Covishield were effective against severe COVID-19 among the Indian population during the period of dominance of highly transmissible Delta variant in second wave of pandemic. An escalation of two-dose coverage with COVID-19 vaccines is critical to control the pandemic in the country. Funding Information: Indian Council of Medical Research Declaration of Interests: None to declare. Ethics Approval Statement: We obtained written informed consent from all the participants or their legally authorized representatives. Study procedures were approved by the Institutional Human Ethics Committees of all participating institutions.

Introduction: The EQ-5D-5L questionnaire is a tool that is a very generic and preference-based instrument to describe the health-related quality of life. We have generated the stratified index utility value for the Tamil Nadu population and compared the utility values based on socio-demographic and clinical characteristics. Methods: We conducted a community-based analytical cross-sectional study using telephonic interviews from November 2020 till December 2020 among individuals aged 18 years and above who were infected by the coronavirus confirmed with an RT-PCR within 30 days in Tamil Nadu State. EQ-5D-5L profile, socio-demographic and clinical characteristics of the study participants were collected and analyzed. Results: We interviewed 372 participants, with 57.5% were males, and their mean age was 44.5 ± 15.3 years. About 40% of participants reported as having comorbidities, such as diabetes (19.4%), hypertension (12.4%), heart disease (2.4%), kidney disease (0.8%) and others. The mean EQ-5D utility score was 0.925 ± 0.150, and the mean EQ-VAS was 90.68 ± 11.81. Overall, men had a higher utility value (0.938 ± 0.130) than women, (0.907 ± 0.170). Individuals with comorbidities, requiring longer hospitalization were having lower utility scores than their counterparts. Conclusion: We report the EQ-5D-5L utility values for the COVID-19 illness. These values would help to estimate quality-adjusted life years in health economic evaluation studies.

Background: India witnessed a severe second wave of COVID-19 during March and June 2021. We did the fourth nationwide serosurvey to estimate prevalence of SARS-CoV-2 antibodies in the general population aged >=6 years and health care workers (HCWs). Methods: We did a cross-sectional study between 14 June and 6 July 2021 in 700 clusters in the same 70 districts across 21 states/Union Territory. From each district, a minimum of 400 individuals aged >=6 years from general population and 100 HCWs from the district public health facilities were included. The serum samples were tested for the presence of IgG antibodies against S1-RBD and nucleocapsid protein of SARS-CoV-2 using chemiluminescence immunoassay. We estimated the weighted and test adjusted seroprevalence of IgG antibodies against S1-RBD and/or nucleocapsid protein along with 95% CI. Findings: Of the 28,975 sera tested, the weighted and test adjusted prevalence of IgG antibodies against S1-RBD and/or nucleocapsid protein among the general population aged >=6 years was 67.6% (95% CI: 66.4 – 68.7). The seroprevalence increased with age and was not different in rural and urban areas. Compared to unvaccinated adults (62.3%, 95% CI: 60.9 – 63.7), seroprevalence was significantly higher among individuals who received one (81.0%, 95% CI: 79.6 - 82.3) and two doses (89.8%, 95% CI: 88.4 - 91.1). The seroprevalence of IgG antibodies among 7,252 health care workers was 85.2% (95% CI: 83.5 - 86.7). Interpretation: Nearly one third of the population is still seronegative. It is necessary to accelerate the coverage of COVID-19 vaccination among adults and continue adherence to non-pharmaceutical interventions. Funding: Indian Council of Medical Research. Declaration of Interest: None to declare. Ethical Approval: The Institutional Human Ethics Committee of the ICMR National Institute of Epidemiology, Chennai approved the study protocol.

Background: The first round of national serosurvey in India was conducted in May-June 2020 among adults from 21 States. The second serosurvey was conducted in August-September 2020 to estimate the nationwide seroprevalence for SARS-CoV-2 infection in the general population aged ten years and above. Methods: The household serosurvey was conducted among individuals aged ten years and above in the same 700 villages and wards from 70 districts selected during the first serosurvey. Blood samples were tested using the Abbott SARS-CoV-2 IgG assay. Seroprevalence was estimated after applying the sampling weights and adjusting for clustering and assay characteristics. In order to compare the adult seroprevalence between the two surveys, we randomly selected one adult serum sample from each household. Findings: The weighted and adjusted prevalence of infection among 29,082 individuals aged ten years and above was 6·6% (95% CI: 5·8% - 7·4%). The seroprevalence among adults was 7·1% (95% CI: 6·2% – 8·2%). Seroprevalence was similar across age groups, sex, and occupation. Seroprevalence was highest in urban slum areas followed by urban non-slum and rural areas. We estimated a cumulative 74·3 million infections in the country, with 26 – 32 infections for every reported COVID-19 case by August 2020. Interpretation: Nearly one in 15 individuals aged ten years and above had SARS-CoV-2 infection by August 2020. The adult seroprevalence increased ten times between May and August 2020. Lower infection to case ratio in August compared to May reflects a substantial increase in testing across the country. Funding: The study was funded by the Indian Council of Medical Research, New Delhi, India. The study sponsor was involved in reviewing the study design, writing of the manuscript and the decision to submit the paper for publication. Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: The authors obtained written informed consent from individuals aged 18 years and older. We obtained assent from children aged between 10–17 years, and written informed consent from their parents or guardians prior to the survey. The Central Ethics Committee of Health Research of Indian Council of Medical Research and the Institutional Human Ethics Committee of ICMR-National Institute of Epidemiology, Chennai approved the study protocol.

Background/objectives Young women are more vulnerable to sexually transmitted infections (STIs). Our objectives were to estimate the prevalence of sexual behaviours and condom use by types of partner, and determine the factors associated with condom use during last sex among 18–24-year-old young women of Tura town in Meghalaya. Methods We did a cross-sectional survey among 250 young women using colour-coded audio computer assisted self-interview system for data collection. Multiple logistic regression analysis was used to estimate adjusted odds ratio to determine the factors independently associated with condom use. Results Ever having sex was reported by 61% women. In all, 20% were married, and 18% had a boyfriend. Pre-marital sex was reported by 54% women. Thirteen percent of 92 women reported ever practicing anal sex. Prevalence of condom use during last sex was 32% with husband and 38% with boyfriend. Age between 18 and 20 years, students, teachers, and knowledge on HIV prevention were significantly associated with condom use during last sex with husband. Conclusions Young urban women in this area need comprehensive sexual education and awareness on modes of transmission of STIs, including HIV. Prevention messages targeting young individuals should include information on risk of early sexual debut, pre-marital sex, and unsafe sex.

Background/objectives Snakebite envenomings are an important but neglected public health problem. Our objectives were to describe the clinico-epidemiological profile and management practices of snakebite cases in Himachal Pradesh, India. Methods We did a cross-sectional analysis of data extracted from the records of snakebite cases (2008–2012) in Zonal Hospital, Solan, Himachal Pradesh. We estimated time trends, age/sex distribution of cases, and distribution of bites by colour of snake. We categorised the clinical manifestations into syndromes. Cases with locally toxic, haemotoxic or neurotoxic manifestations were classified as poisonous bites. Amongst the poisonous cases, we analysed trends in use of vials of antisnake venom (ASV) and its clinical outcomes and financial implications. Results Of the total 497 snakebites reported during 5 years, cases increased from 77/55,784 (0.14%) total hospital admissions in 2008 to 110/68,770 (0.16%) in 2012, 73% occurred in rainy season (July–September), and 266 (54%) amongst females. Colour of snake was recorded in 159 (32%) of which 122 (77%) were green. In all, 171 (34%) were poisonous out of which 96 (56%) were haemotoxic. Cases of poisonous bites decreased from 42 (2008) to 17 (2012). Out of 25 referred envenomings, 2 (8%) were given ASV at peripheral institutes. Use of ASV vials decreased from 747 (2008) to 71 (2012), with a corresponding reduction of 73% in the expenditure on ASV per cured patient. Cure rate remained above 70%. Five (3%) poisonous snakebite cases died. Conclusions Effective management of snakebites would include appropriate ASV use and production of monovalent antitoxin as per predominance of specific species of snakes.

Malnutrition is a strong predictor of poor outcomes in people living with HIV (PLHIV). Drug users are at increased risk of malnutrition regardless of whether or not they are infected with HIV. Little data exists on the nutritional status of drug users (with or without HIV infection) in India.We describe and compare the nutrition and metabolic status of 107 HIV-positive and 193 HIV-negative male clients of a community-based drop-in center for injection drug users in Chennai, India. Measures of nutrition and metabolic status include body composition, dietary intake, food insecurity, and serum lipid levels.We found poor overall nutritional status in both the HIV-positive and HIV-negative clients, with HIV-positive men faring worse on some parameters. Both groups had extremely low percent body fat, but levels in HIV-positive participants were significantly lower (6.5% versus 7.9%, p=.01). HIV-positive men also had significantly lower total caloric and fat intakes compared to HIV-negative men. A considerable proportion (70%) of both HIV-positive and HIV-negative drug users were food insecure. HDL cholesterol levels were significantly lower and below normal range in the HIV-positive compared to HIV-negative men.The high levels of food insecurity and poor nutritional status in this population, regardless of HIV status, indicates critical need for intervention. Improving nutritional status in those who are infected with HIV prior to initiation of antiretroviral treatment may help patients to reap the full benefits of therapy.