Determinants of severity among hospitalised COVID-19 patients: Hospital-based case-control study, India, 2020

Background

Risk factors for the development of severe COVID-19 disease and death have been widely reported across several studies. Knowledge about the determinants of severe disease and mortality in the Indian context can guide early clinical management.

Methods

We conducted a hospital-based case control study across nine sites in India to identify the determinants of severe and critical COVID-19 disease.

Findings

We identified age above 60 years, duration before admission >5 days, chronic kidney disease, leucocytosis, prothrombin time > 14 sec, serum ferritin >250 ng/mL, d-dimer >0.5 ng/mL, pro-calcitonin >0.15 μg/L, fibrin degradation products >5 μg/mL, C-reactive protein >5 mg/L, lactate dehydrogenase >150 U/L, interleukin-6 >25 pg/mL, NLR ≥3, and deranged liver function, renal function and serum electrolytes as significant factors associated with severe COVID-19 disease.

Interpretation

We have identified a set of parameters that can help in characterising severe COVID-19 cases in India. These parameters are part of routinely available investigations within Indian hospital settings, both public and private. Study findings have the potential to inform clinical management protocols and identify patients at high risk of severe outcomes at an early stage.

980Quantifying inadvertent data-duplication- findings from validation of antenatal-registration and HIV-testing data-sets from an Indian state

Background

India plans elimination of HIV-Mother-to-Child-Transmission in 2020. Targets include >95% coverage of Antenatal-care (ANC) and HIV-testing. In 2015-16, while 43% of the estimated Indian pregnant-women (PW) received HIV-tests, one state reported >95% testing. Indian public-health-care is a three-tiered system from primary-level sub-centres (population-5000) to tertiary-level hospitals. ANC involves multiple-visits per pregnancy at different care-levels and data are aggregated in the Health-Management-Information-System (HMIS) at all levels. We validated (public and private-sector data from this state, for duplication in ANC registration and HIV-testing using mixed methods.

Methods

In the absence of guidelines for assessing aggregate-data duplication, we used mixed-methods, including surveys among 9845 PW and providers from 240 facilities in 10/36 representative districts; in-depth-interviews; case-studies and analysis of HMIS and HIV-program data (April 2015-Mar 2017). Interviews and case-studies highlighted inadvertent duplicate data-capture. Surveys quantified levels of duplication and adjustment factors (public and private-sector) were developed.

Results

Twenty-four% PW, visited multiple facilities for ANC, while 81% providers reported all the PW coming to their facilities as new ANC registrations (irrespective of lower-tier registration); identifying a minimum duplication of 19% (24%*81%) in ANC coverage. Twenty-nine% and 28% PW from public and private-facilities reported >1 HIV-test; while 75% and 36% reported visiting another public-facility where HIV test was likely to be reported again. Minimum duplication of 22% and 10% in HIV testing was noted in public and private-sectors respectively.

Conclusions

We report methods to quantify repeat HIV-testing and duplicate-reporting, due to inherent processes in ANC in public-healthcare in India. Modification of data-capture was recommended and adopted across India.

Key messages

Assessing duplication in aggregate health data is key to developing robust datasets for disease elimination

SARS-CoV-2 seroprevalence among the general population and healthcare workers in India, December 2020-January 2021

BACKGROUND

Earlier serosurveys in India revealed seroprevalence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) of 0.73% in May-June 2020 and 7.1% in August-September 2020. A third serosurvey was conducted between December 2020 and January 2021 to estimate the seroprevalence of SARS-CoV-2 infection among the general population and healthcare workers (HCWs) in India.

METHODS

The third serosurvey was conducted in the same 70 districts as the first and second serosurveys. For each district, at least 400 individuals aged ≥10 years from the general population and 100 HCWs from subdistrict-level health facilities were enrolled. Serum samples from the general population were tested for the presence of immunoglobulin G (IgG) antibodies against the nucleocapsid (N) and spike (S1-RBD) proteins of SARS-CoV-2, whereas serum samples from HCWs were tested for anti-S1-RBD. Weighted seroprevalence adjusted for assay characteristics was estimated.

RESULTS

Of the 28,598 serum samples from the general population, 4585 (16%) had IgG antibodies against the N protein, 6647 (23.2%) had IgG antibodies against the S1-RBD protein, and 7436 (26%) had IgG antibodies against either the N protein or the S1-RBD protein. Weighted and assay-characteristic-adjusted seroprevalence against either of the antibodies was 24.1% [95% confidence interval (CI) 23.0-25.3%]. Among 7385 HCWs, the seroprevalence of anti-S1-RBD IgG antibodies was 25.6% (95% CI 23.5-27.8%).

CONCLUSIONS

Nearly one in four individuals aged ≥10 years from the general population as well as HCWs in India had been exposed to SARS-CoV-2 by December 2020.

Findings from the 2017 HIV estimation round & trend analysis of key indicators 2010-2017: Evidence for prioritising HIV/AIDS programme in India

Background & objectives:

The National AIDS Control Organisation (NACO) and the ICMR-National Institute of Medical Statistics, the nodal agency for conducting HIV estimations in India, have been generating HIV estimates regularly since 2003. The objective of this study was to describe India's biennial HIV estimation 2017 process, data inputs, tool, methodology and epidemiological assumptions used to generate the HIV estimates and trends of key indicators for 2010-2017 at national and State/Union Territory levels.

Methods:

Demographic Projection (DemProj) and AIDS Impact Modules (AIM) of Spectrum 5.63 software recommended by the United Nations Programme on HIV and AIDS Global Reference Group on HIV Estimates, Modelling and Projections, were used for generating HIV estimations on key indicators. HIV sentinel surveillance, epidemiological and programme data were entered into Estimation Projection Package (EPP), and curve fitting was done using EPP classic model. Finally, calibration was done using the State HIV prevalence of two rounds of National Family Health Survey (NFHS) -3 and -4 and Integrated Biological and Behavioural Surveillance (IBBS), 2014-2015.

Results:

The national adult prevalence of HIV was estimated to be 0.22 per cent in 2017. Mizoram, Manipur and Nagaland had the highest prevalence over one per cent. An estimated 2.1 million people were living with HIV in 2017, with Maharashtra estimated to have the highest number. Of the 88 thousand annual new HIV infections estimated nationally in 2017, Telangana accounted for the largest share. HIV incidence was found to be higher among key population groups, especially people who inject drugs. The annual AIDS-related deaths were estimated to be 69 thousand nationally. For all indicators, geographic variation in levels and trends between States existed.

Interpretation & conclusions:

With a slow decline in annual new HIV infections by only 27 per cent from 2010 to 2017 against the national target of 75 per cent by 2020, the national target to end AIDS by 2030 may be missed; although at the sub-national level some States have made better progress to reduce new HIV infection. It calls for reinforcement of HIV prevention, diagnosis and treatment efforts by geographical regions and population groups.

Unsterile injection equipment associated with HIV outbreak and an extremely high prevalence of HCV-A case-control investigation from Unnao, India

The integrated counseling and testing center (ICTC) located in the district hospital, Unnao in the northern state of Uttar Pradesh (UP), India witnessed an increased detection of HIV among its attendees in July 2017. Subsequently, health camps were organized by the UP State AIDS Control Society in the villages and townships contributing to such detection. We conducted a case-control study to identify factors associated with this increased detection; 33 cases and 125 controls were enrolled. Cases were individuals, detected HIV sero-reactive during November 2017-April 2018 from three locations namely Premganj, Karimuddinpur and Chakmeerapur in the Bangarmau block of the district of Unnao. Controls hailed from the same geographical setting and tested HIV sero-nonreactive either in health camps or at ICTC centers from where the cases were detected. Misclassification bias was avoided by confirming HIV sero-status of both cases as well as controls prior to final analysis. Study participants were interviewed on various risk practices and invasive treatment procedures. They were also tested for HIV and other bio-markers reflecting unsafe injecting and sexual exposures such as hepatitis B surface antigen (HBsAg), anti-HCV antibody (HCV Ab), anti-herpes simplex-2 Immunoglobulin G (HSV-2 IgG) and rapid plasma regain (RPR) test for syphilis. Secondary data analysis on three time points during 2015 through 2018 revealed a rising trend of HIV among attendees of the ICTCs (ICTC-Hasanganj, ICTC-Unnao district hospital and ICTC- Nawabganj) catering to the entire district of Unnao. While there was a seven fold rise of HIV among ICTC attendees of Hasanganj (χ² value for trend 23.83; p < 0.001), the rise in Unnao district hospital was twofold (χ² value for trend 4.37; p < 0.05) and was tenfold at ICTC-Nawabganj (χ² value for trend 5.23; p < 0.05) indicating risk of infection prevailing throughout the district. Primary data was generated through interviews and laboratory investigations as mentioned above. The median age of cases and controls was 50 year (minimum 18 –maximum 68; IQR 31–57) and 38 year (minimum 18 –maximum 78; IQR 29–50) respectively. Thirty six percent of the cases and 47% of controls were male. A significantly higher proportion of cases (85%) had HCV Ab compared to controls (56%; OR 4.4, 95% CI 1.5–12.1); none reported injection drug use. However, cases and controls did not differ significantly regarding presence of HSV-2 IgG (6% versus 8% respectively). Neither any significant difference existed between cases and controls in terms of receiving blood transfusion, undergoing invasive surgical procedures, tattooing, tonsuring of head or skin piercing. In multivariate logistic regression model, ‘unsafe injection exposure during treatment-seeking’(AOR 6.61, 95% CI 1.80–24.18) and ‘receipt of intramuscular injection in last five years’ (AOR 7.20, 95% CI 1.48–34.88) were independently associated with HIV sero-reactive status. The monophyletic clustering of HIV sequences from 14 cases (HIV-1 pol gene amplified) indicated a common ancestry. Availability of auto-disabled syringes and needles, empowerment of the local communities and effective regulatory practices across care settings would serve as important intervention measures in this context.

Sustained progress, but no room for complacency: Results of 2015 HIV estimations in India

Background & objectives:

Evidence-based planning has been the cornerstone of India's response to HIV/AIDS. Here we describe the process, method and tools used for generating the 2015 HIV estimates and provide a summary of the main results.

Methods:

Spectrum software supported by the UNAIDS was used to produce HIV estimates for India as a whole and its States/Union Territories. This tool takes into consideration the size and HIV prevalence of defined population groups and programme data to estimate HIV prevalence, incidence and mortality over time as well as treatment needs.

Results:

India's national adult prevalence of HIV was 0.26 per cent in 2015. Of the 2.1 million people living with HIV/AIDS, the largest numbers were in Andhra Pradesh, Maharashtra and Karnataka. New HIV infections were an estimated 86,000 in 2015, reflecting a decline by around 32 per cent from 2007. The declining trend in incidence was mirrored in most States, though an increasing trend was detected in Assam, Chandigarh, Chhattisgarh, Gujarat, Sikkim, Tripura and Uttar Pradesh. AIDS-related deaths were estimated to be 67,600 in 2015, reflecting a 54 per cent decline from 2007. There were variations in the rate and trend of decline across India for this indicator also.

Interpretation & conclusions:

While key indicators measured through Spectrum modelling confirm success of the National AIDS Control Programme, there is no room for complacency as rising incidence trends in some geographical areas and population pockets remain the cause of concern. Progress achieved so far in responding to HIV/AIDS needs to be sustained to end the HIV epidemic.

Survival of Children Living with Human Immunodeficiency Virus on Antiretroviral Therapy in Andhra Pradesh, India

OBJECTIVE

To assess the survival probability and associated factors among children living with human immunodeficiency virus (CLHIV) receiving antiretroviral therapy (ART) in India.

METHODS

The data on 5874 children (55% boys) from one of the high HIV burden states of India from the cohort were analyzed. Data were extracted from the computerized management information system of the National AIDS Control Organization (NACO). Children were eligible for inclusion if they had started ART during 2007-2013, and had at least one potential follow-up. Kaplan Meier survival and Cox proportional hazards models were used to measure survival probability.

RESULTS

The baseline median (IQR) CD4 count at the start of antiretroviral therapy was 244 (153, 398). Overall, the mortality was 30 per 1000 child years; 39 in the <5 year age group and 25 in 5-9 year age group. Mortality was highest among infants (86 per 1000 child years). Those with CD4 count ≤ 200 were six times more likely to die (adjusted HR: 6.3, 95% CI 3.5, 11.4) as compared to those with a CD4 count of ≥350/mm3.

CONCLUSION

Mortality rates among CLHIV is significantly higher among children less than five years when the CD4 count at the start of ART is above 200. Additionally, lower CD4 count, HIV clinical staging IV, and lack of functional status seems to be associated with high mortality in children who are on ART.

Predictors of bisexual behaviour among MSM attending intervention sites may help in prevention interventions for this bridge to the heterosexual epidemic in India: data from HIV sentinel surveillance

Background

Indian cultural tradition demanding marriage, many MSM howsoever they self-identify are likely to be married or have sex with women. To consolidate India's HIV prevention gains, it is important to understand and address the interaction between the MSM and heterosexual epidemics in India and create specific interventions for bisexual MSM. The challenge is to identify and intervene this hard to reach population. Data from HIV Sentinel Surveillance 2011 among MSM in four Indian states were analyzed to assess predictors and prevalence of bisexual behaviour in MSM.

Methods

Between March-May 2011, 4682 men (15–49 years) who had anal/oral sex with a male partner in the past month, attending intervention sites and consenting for an un-linked anonymous survey answered an 11- item questionnaire and provided blood for HIV test by finger stick at 19 designated surveillance sites.

Results

Of 4682 MSM tested overall, 5% were illiterate, 51% reported only receptive anal intercourse, 21% only penetrative and 28% both. 36% MSM had ever received money for sex. Overall 6.8% were HIV infected. 44% MSM were bisexual in the last six months. On multivariate analysis, ‘being bisexual’ was found to be independently associated with ‘older age’: 26–30 years [AOR = 3.1, 95% CI(2.7, 3.7)], >30 years [AOR = 6.5, 95% CI(5.5, 7.7)]; ‘reporting penetrative behaviour alone’ with other men [AOR = 5.8, 95% CI(4.8, 7.0), p<0.01] and ‘reporting both penetrative and receptive behaviour’ [AOR = 2.7, 95% CI(2.3, 3.1) p<0.01]. Those who both paid and received money for sex [AOR = 0.49, 95% CI (0.38, 0.62)] were significantly less likely to be bisexual.

Conclusions

A substantial proportion of men receiving services from Targeted Intervention programs are bisexual and the easy opportunity for intervention in this setting should be capitalised upon. Focusing on older MSM, as well as MSM who show penetrative behaviour with other men, could help in reaching this population.

Initial virologic response and HIV drug resistance among HIV-infected individuals initiating first-line antiretroviral therapy at 2 clinics in Chennai and Mumbai, India

Human immunodeficiency virus drug resistance (HIVDR) in cohorts of patients initiating antiretroviral therapy (ART) at clinics in Chennai and Mumbai, India, was assessed following World Health Organization (WHO) guidelines. Twelve months after ART initiation, 75% and 64.6% of participants at the Chennai and Mumbai clinics, respectively, achieved viral load suppression of <1000 copies/mL (HIVDR prevention). HIVDR at initiation of ART (P <.05) and 12-month CD4 cell counts <200 cells/μL (P <.05) were associated with HIVDR at 12 months. HIVDR prevention exceeded WHO guidelines (≥ 70%) at the Chennai clinic but was below the target in Mumbai due to high rates of loss to follow-up. Findings highlight the need for defaulter tracing and scale-up of routine viral load testing to identify patients failing first-line ART.

Estimate of HIV prevalence and number of people living with HIV in India 2008-2009

OBJECTIVES

To update the estimation of the adult HIV prevalence and number of people living with HIV (PLHIV) in India for the year 2008-2009 with the combination of improved data and methods.

DESIGN

Based on HIV sentinel surveillance (HSS) data and a set of epidemiological assumptions, estimates of HIV prevalence and burden in India have been derived.

SETTING

HSS sites spread over all the States of India.

PARTICIPANTS

Secondary data from HSS sites which include attendees of antenatal clinics and sites under targeted interventions of high-risk groups, namely, female sex workers (FSW), intravenous drug users (IDU) and men having sex with men (MSM).

PRIMARY AND SECONDARY OUTCOME MEASURES

Estimates of adult HIV prevalence and PLHIV in India and its states.

RESULTS

The adult HIV prevalence in India has declined to an estimated 0.31% (0.25-0.39%) in 2009 against 0.36% (0.29-0.45%) in 2006. Among the high prevalence states, the HIV prevalence has declined in Tamil Nadu to 0.33% in 2009 and other states show either a plateau or a slightly declining trend over the time period 2006-2009. There are states in the low prevalence states where the adult HIV prevalence has risen over the last 4 years. The estimated number of PLHIV in India is 2.4 million (1.93-3.04 million) in 2009. Of which, 39% are women, children under 15 years of age account for 4.4% of all infections, while people aged 15-49 years account for 82.4% of all infections.

CONCLUSIONS

The estimated adult prevalence has declined in few states, a plateau or a slightly declining trend over the time. In future, efforts may be made to examine the implications of the emerging trend of the HIV prevalence on the recent infections in the study population.

National estimate of HIV seroprevalence among tuberculosis patients in India

The national estimate for human immunodeficiency virus (HIV) prevalence among tuberculosis (TB) patients in India has previously been estimated indirectly from global data. To derive an improved national estimate from local data, we correlated district-level HIV surveillance data from antenatal clinics and TB diagnostic centres, and applied this correlation to state-level HIV prevalence estimates for the antenatal population. We estimate that among the 1.96 million incident TB cases in 2007, 4.85% (95%CI 4.12-5.73) or 95 240 (95%CI 80 730-112 478) were HIV-infected. With these estimates from local data, the national programme can better plan TB-HIV collaborative activities and monitor efforts to detect HIV infection in this large population.

Process of estimating the number of people living with HIV in India

This article attempts to appraise the methodology of estimating the people living with AIDS in India. In this estimation, the primary demographic data were obtained from Registrar General of India and Sample Registration System. HIV prevalence data was drawn from HIV Sentinel Surveillance conducted at 704 sites in 2005. The HIV prevalence at each site was estimated using the formula p +/- 1.645O(pq/n), where p represents the proportion of HIV positives and n the number of attendees at the site. Statewise prevalence for each risk group was estimated with the help of the formula giving 90% confidence internal for median prevalence as Median of the proportion positive +/- 1.645 x 1.2533O(pq/n), where 1.2533 was the adjustment for large variations involved. If the estimated median prevalence comes out to be zero, it was replaced by the actual prevalence of the low prevalent states for each risk group. In case of general population, the urban-rural ratio came out to be 1:1 in case of high prevalence states and 2.4:1 in case of other states. Having adjusted for age, the sex differential was 1.2:1 in gereralised epidemic states, 2:1 in concentrated epidemic states and 3:1 in low epidemic states. Overall additions were made for FSW by applying to them the HIV prevalence observed in FSWsites under TI. Prevalence in child population was done by applying the GFR to the women with HIV and then multiplying it by 0.3 (percentage infected).

Serious underreporting of visceral leishmaniasis through passive case reporting in Bihar, India

OBJECTIVES

Visceral leishmaniasis (VL) is a major public health problem in Bihar, India. Unfortunately, accurate data on the incidence or prevalence of the disease are not available. This longitudinal study was undertaken to determine the incidence of VL in a Community Development Block area of the state of Bihar. Survey results were compared with official reports of the disease to assess the extent of underreporting by the Government health system.

METHODS

Three health subcentre areas in Kanti Block, consisting of 14 villages with a total population of 26 444, were selected. Active surveillance was performed every month from January 2001 to December 2003 by house to house survey to detect cases of fever for more than 15 days. Patients clinically suspected of suffering from VL were subjected to parasitological examination for confirmation. Analysis of records of the reporting agencies in the district was undertaken to compare and assess the extent of underreporting.

RESULTS

A total of 202 cases of VL were identified in 3 years giving an average annual incidence rate of 2.49/1000 population (95% CI = 2.15-2.83). As identification data of patients was not available with the official reporting agencies for 2001 and 2002, extent of underreporting could be assessed for 2003 only. In the study population, 65 cases of VL were detected during 2003 providing an annual incidence rate of 2.36/1000 population. Only eight (12.30%) cases were reported officially, resulting in underreporting by a factor of 8.13. In 2003, the official incidence rate of VL for Kanti Block was 0.31/1000 against the actual rate of 2.36/1000. As the constraints for official reporting at the block and the district levels are similar, the underreporting at district level was also assumed to be similar. This finding has significance in the preparation for elimination programme.

The changing survival scenario in gangrenous sigmoid volvulus: a four-decade study

There is a suspicion that mortality in gangrenous sigmoid volvulus has considerably declined over the recent years. This study was aimed to assess if this is a genuine trend, applicable to the patients, of this study too, and to identify factors responsible for the change, if any. Seventy-eight patients operated for gangrenous sigmoid volvulus, in the last four decades of the just gone century, were analysed. Nine clinical parameters were studied to identify factors responsible for mortality and to see if there was a change in clinical presentation in the later decades. Mortality in the 4 studied decades varied between 15.4% and 65%. Differences were significant (p<0.05) only between the decades of the seventies and eighties and between bunched pre 1980 (48%) and post 1980 (20%) decades. A sea change in survival scene occurred at the end of the decade of the seventies. The change was not accompanied by a concomitant improvement in clinical presentation (p>0.05). Two facts which could explain improved survivals in the post. 1980 period were, the increased recognition of gangrene extending beyond the area of constriction and improved survival after primary anastomoses (p<0.05). These indicated a more accurate assessment of viability and the distance between the cut bowel ends, a stricter selection of cases for primary anastomosis and using Hartmann operation in doubtful situations. Mortality in gangrenous sigmoid volvulus, without knotting in the Indian population has genuinely declined from over 50% in an earlier time to 20% in the later 20 years of the last century, the watershed in the changed scenario being the year 1980.

Study on the anatomical dimensions of the human sigmoid colon

Although the sigmoid colon is commonly afflicted with disease, studies on its anatomical dimensions are scarce. It is suspected that dimensions of the sigmoid colon change with age. This study documents data on the anatomical measurements of the sigmoid colon in 70 Indian subjects (51 live and 19 cadavers). Seven parameters of sigmoid colon anatomy measured included length and width of the sigmoid colon and mesocolon at specific points. Three mesocolic indices (width to length ratios) were calculated. Comparisons of measurements in the live and cadaver subjects and in the two sexes were made. The relationship of change in parameters with age was assessed. Appropriate statistical methods were used and the differences were considered significant at P < or = 0.05. The study showed wide ranging variations in the values of various measured parameters of the sigmoid colon. Seven patterns of the shape of the sigmoid loop were identified. In the commonest pattern the sigmoid mesocolon was vertically longer than wide (dolichomesocolic), the sigmoid loop having its maximum convexity located just a little proximal to the apex. Patterns where the width of the mesocolon was greater than the vertical length (brachymesocolic) were also observed. The gender analysis showed that the sigmoid mesocolon of the female was brachymesocolic (wider than long), whereas that of the male was dolichomesocolic (longer than wide). This might explain the higher incidence of sigmoid volvulus in the male. This study also showed that the measurements of the sigmoid colon and its mesocolon do not change significantly within the age range of 16-60 years in the two sexes. Also noteworthy is the observation that in the cadaver the sigmoid colon shows considerable shrinkage, particularly of its mesocolon; consequently the data from cadaver subjects, though valuable for anthropometric use, have limitations when used for clinical applications.

Gangrenous sigmoid volvulus: a clinical study of 76 patients

BACKGROUND AND AIMS

This study investigated the clinical picture of gangrenous sigmoid volvulus presented by Indian patients to describe the various patterns of gangrene and to identify the risk factors leading to the very high mortality from this disease.

PATIENTS AND METHODS

A structured protocol including nine parameters was used to study risk factors in 76 patients treated at two major teaching hospitals in India. The clinical picture of patients at the two hospitals did not differ significantly.

RESULTS

Contrary to expectations, we found gangrene in 26% of cases extending beyond the area of constriction into the rectum/descending colon. This extension was sometimes patchy and had an ill defined line of demarcation, which may lead to an error in judgment and cause a failure of anastomosis, which can be fatal. Risk factors were age over 60 years, the presence of shock on admission and a history of previous episodes of volvulus.

CONCLUSION

This study identified three risks for survival. It is suggested that all patients with nongangrenous sigmoid volvulus undergo a recurrence-prevention procedure immediately or electively. We also found that extension of gangrene beyond the confines of the constriction is not uncommon, calling for caution on the part of the treating surgeon.

Significance of Cryptosporidium in acute diarrhoea in North-Eastern India

In a hospital-based study, stool samples from 2095 patients of all ages were examined for different fungal, protozoal and bacterial enteropathogens over a period of 2 years (July 1994-June 1996). Cryptosporidium was detected in 151 specimens (7.2%) and was the third commonest pathogen found. The highest prevalence of this organism was in the group aged 16-45 years and during the rainy months (July-Oct.). Diarrhoea caused by the protozoon was of mild to moderate severity and features of dysentery were absent. Amongst other enteropathogens, Candida albicans was the most frequently isolated, followed by enteropathogenic and enterotoxigenic Escherichia coli, Salmonella spp., Campylobacter jejuni, Entamoeba histolytica, Giardia duodenalis (lamblia), Shigella spp., Vibrio cholerae and Aeromonas spp.