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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Coverage and Effectiveness of Influenza and Pneumococcal Immunization in Autoimmune Inflammatory Rheumatic Disease Patients: A Cross-sectional Study
Correspondence Address :
Dr. Jawad Iqbal Rather,
Senior Resident, Department of Nephrology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar-190011, Jammu and Kashmir, India.
E-mail: jawadiqbal93@gmail.com
Introduction: Patients with Autoimmune Inflammatory Rheumatic Disease (AIIRD) are at an increased risk of developing infectious diseases. Vaccination is recommended for these patients by various societies as a preventive strategy. Despite this, the coverage of vaccination is exceedingly low, especially in developing countries.
Aim: To estimate the coverage of pneumococcal and influenza vaccinations, as well as Vaccine Effectiveness (VE).
Materials and Methods: This was a cross-sectional study conducted over a duration of one year, from December 2021 to December 2022, in the Department of Internal Medicine and Allied Specialties at the Sher-I-Kashmir Institute of Medical Sciences (SKIMS), Srinagar, Jammu and Kashmir, India. All consenting AIIRD patients aged over 18 years were enrolled in the outpatient department of Internal Medicine and Allied Specialties at SKIMS, Srinagar, Jammu and Kashmir, India. A history of seasonal influenza and pneumococcal vaccinations was obtained. The coverage of vaccination was determined, and patients were followed-up over a period of one year to assess VE. The Chi-square test was used for comparing categorical values, with a p-value of <0.05 considered significant.
Results: This study included 438 patients, of which 348 (79.5%) were females and 90 (20.5%) were males. The mean age of the study population was 38±11.8 years. Out of 438 patients, only 100 (22.8%) were vaccinated against influenza, while a total of 90 (20.5%) patients had received one or more doses of pneumococcal vaccines. The incidence of symptomatic influenza and pneumococcal pneumonia was higher in the unvaccinated groups. Both vaccines were found to be safe and effective, with a VE of 73.21% for the influenza vaccine and 65.26% for the pneumococcal vaccine.
Conclusion: Present study reveals an overall low coverage of these vaccinations among patients with AIIRD in the region, which needs to be addressed. The findings indicate that influenza and pneumococcal vaccines are safe and effective for patients with AIIRD.
Infection, Respiratory tract, Symptoms
Patients with AIIRD have an increased susceptibility to infections, largely stemming from both the immune system compromise associated with the disease and the use of immunosuppressive medications. Given this heightened risk, vaccination plays a crucial role in their overall healthcare management. Patients with AIIRD face a higher risk of morbidity and mortality from vaccine-preventable diseases, such as influenza and Streptococcus pneumoniae, compared to the general population (1),(2),(3),(4),(5). Most leading medical societies, including the American College of Rheumatology and the European League against Rheumatism, recommend vaccinations against these diseases for patients with AIIRD (6),(7),(8),(9),(10),(11).
Vaccinations, which may be either inactivated or live based on the indication, are required for patients with AIIRD who are either planning to start or are currently undergoing immunosuppression. Inactivated vaccines include Pneumococcal, seasonal influenza, Hepatitis A and B, meningococcus, Haemophilus influenzae, and the recombinant Zoster vaccine, among others. Live, attenuated vaccines include Zoster Vaccine Live (ZVL), Measles, Mumps and Rubella (MMR), yellow fever, and others. To ensure maximum protection, it is recommended that vaccinations be administered several weeks before initiating immunosuppressive therapy. This strategy enhances the probability of eliciting a protective immune response, especially in the case of rituximab, which significantly diminishes humoral immunity (12).
Administering vaccinations before the initiation of immunosuppressive therapy not only allows for the use of necessary live vaccines, which are typically contraindicated once immunosuppression has begun, but also ensures the completion of any required series of inactivated (non live) vaccines prior to starting immunosuppressive medications. Live vaccines should ideally be given at least four weeks before beginning immunosuppression to mitigate the risk of disseminated disease associated with live vaccines (13). In the majority of AIIRD patients who are on conventional synthetic Disease-Modifying Antirheumatic Drugs (DMARDs), most biologics, and glucocorticoids, vaccinations are anticipated to provide sufficient protection. However, it is worth noting that the immune response to some vaccines may be somewhat diminished (14).
While there exists a theoretical risk that the immune response triggered by vaccination could lead to exacerbations of autoimmune diseases, the available evidence, though limited, indicates that vaccine administration does not increase disease activity in patients with AIIRD (15),(16),(17),(18),(19). Despite these recommendations, the rate of vaccine uptake remains low among patients with AIIRD (20),(21),(22),(23). For instance, a large multinational cohort study involving 3,920 patients with rheumatoid arthritis revealed that more than half of the patients had never been vaccinated against pneumococcal disease or influenza, and less than a third were appropriately vaccinated (20). The primary reason cited by patients for not getting vaccinated was the lack of a recommendation from their healthcare provider (21). In a study that included 310 physicians, including internal medicine specialists, rheumatologists, and primary care physicians, it was found that only 53.9% were aware of vaccine schedules, and only 53.2% recommended vaccines to their patients (24). The coverage of vaccination, which is an important preventive measure for patients with AIIRD, is largely unknown in our patient population. In this context, the study aimed at addressing the knowledge gap regarding the coverage and efficacy of influenza and pneumococcal vaccination in patients with AIIRD. The primary objective of the present study was to estimate the coverage of pneumococcal and influenza vaccinations. The secondary objective was to confirm Vaccine Effectiveness (VE).
This was a cross-sectional observational study conducted over a duration of one year, from December 2021 to December 2022, in the Department of Internal Medicine and Allied Specialties at the Sher-I-Kashmir Institute of Medical Sciences (SKIMS), Srinagar, Jammu and Kashmir, India. The study was approved by the Institutional Ethics Committee (IEC number RP 248/2021). As per the institutional protocol, every participant received both verbal and written information about the study before consenting to participate. Consecutive patients with AIIRD who visited the outpatient department of Medicine and Allied Specialties at our institute were included.
Inclusion criteria: Adult AIIRD patients visiting the outpatient clinic of the Department of Internal Medicine and Allied Specialties who consented to participate were included in the study.
Exclusion criteria: Patients aged less than 18 years and patients who did not provide consent were excluded from the study.
Sample size: Consecutive patients with AIIRD who visited the outpatient department of Medicine and Allied Specialties at the institute were included in the study.
Study Procedure
Demographic and clinical details were recorded, which included age, clinical diagnosis, and vaccination status regarding the influenza vaccine and pneumococcal vaccine. Data were collected during patient interviews and from clinical files. All participants were followed over a duration of one year to monitor the development of symptoms consistent with Influenza Like Illness (ILI), as defined by the World Health Organisation (WHO) (25). Patients who developed symptoms of lower respiratory tract infections or were admitted with pneumonia (CURB 65 ≥ 2) (26) were subjected to testing for pneumococcal pneumonia using a urinary test for pneumococcal antigen. To test for influenza, throat and nasal swabs were collected in viral transport medium (Hi-mediaTM) and were processed immediately (within 3-4 hours) at the influenza laboratory of the Sher-I-Kashmir Institute of Medical Sciences. Samples were analysed using real-time Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) (Applied Biosystems) following the Centers for Disease Control (CDC) protocol. Samples were further subtyped for influenza A and influenza B.
Vaccine Effectiveness (VE) was estimated using the formula (27).
VE= Incidence of a disease in unvaccinated - Incidence of a disease in vaccinated/ Incidence of a disease in unvaccinated
Statistical Analysis
The data recorded on the proforma was compiled in a spreadsheet (WPS Office 2020) and exported to the data editor of the Statistical Package for Social Sciences (SPSS, Version 21.0, IBM SPSS, Armonk, New York, USA). Continuous variables were expressed as mean±SD, and categorical variables were expressed as frequencies and percentages. Data was presented in tabulated form. The Chi-square test was applied for the comparison of categorical variables. A two-tailed p-value was used to calculate statistical significance, with a value of <0.05 considered significant.
The study included 438 patients, of which 348 (79.5%) were females and 90 (20.5%) were males. The mean age of the study population was 38±11.8 years. The majority of patients, 122 (27.9%), belonged to the age group of 31-40 years. The most common AIIRD was rheumatoid arthritis, affecting 320 patients (73.1%), followed by systemic lupus erythematosus, which affected 74 patients (16.9%). Demographic data, underlying AIIRD, and co-morbid conditions are shown in (Table/Fig 1).
Regarding the treatment of the underlying rheumatologic disorder, 427 patients (97.5%) had a history of steroid exposure, and 345 patients (78.8%) had been exposed to DMARDs. Out of the 438 patients, only 100 (22.8%) were vaccinated against influenza, while a total of 90 (20.5%) patients had received one or more doses of pneumococcal vaccines. Among those vaccinated, 84 patients (92.6%) were vaccinated on the recommendation of a physician, while six patients (7.4%) opted for vaccination on their own (Table/Fig 2).
Nineteen patients (4.3%) developed Influenza A, while 22 patients (5.0%) developed Influenza B. The estimated VE was 81.3% for Influenza A and 66.11% for Influenza B. The seasonal influenza vaccine significantly reduced the incidence of symptomatic influenza, with an overall VE of 73.21%.
A total of 36 patients (8.2%) developed pneumococcal pneumonia. The pneumococcal vaccine reduced the incidence of pneumococcal pneumonia; however, it did not reach statistical significance (Table/Fig 3). The VE for pneumococcal pneumonia was 65.26%.
A total of 438 patients were included in this study, out of which 348 (79.5%) were females, resulting in a female-to-male ratio of 3.9. The female predominance in AIIRD is well known and may be attributed to various genetic, epigenetic, hormonal, and environmental factors (28). The most prevalent disease was rheumatoid arthritis (73.1%), followed by SLE (16.9%). Out of 438 patients, only 100 (22.8%) were vaccinated against influenza, while only 90 (20.5%) were vaccinated against pneumococcus. These numbers reflect the overall poor coverage of vaccinations among patients with AIIRD in our region. Likely causes include a lack of awareness, vaccine hesitancy among patients in general, and the cost of vaccines, particularly for patients with limited financial resources. Additionally, a low enthusiasm among treating physicians regarding prescribing vaccines and a failure to counsel patients about the benefits of vaccination may also contribute to such poor coverage.
In a research study led by Jiang Y et al., in China, which focused on the knowledge, attitudes, and practices concerning vaccination among patients with rheumatic diseases, it was discovered that only one out of 235 patients had received the influenza vaccine, and none had been vaccinated against pneumococcus. A mere 3.8% had received a doctor's recommendation for influenza or pneumococcal vaccines. The primary reasons cited for not getting vaccinated were the perception of vaccines as “unnecessary” and “troublesome to take” (29). Similarly, in a previously cited study (24), it was found that only 53.9% of physicians out of 310 knew about vaccine schedules, and only 53.2% recommended vaccines to their patients. In another study that included 222 AIIRD patients, it was observed that 68.5% of patients were vaccinated against influenza and 34.7% against Streptococcus pneumoniae (30).
Out of 100 patients vaccinated with the influenza vaccine, three patients developed influenza (A and/or B) during follow-up. Statistical analysis revealed a significant difference (p-value: 0.012) between the incidence of influenza in vaccinated and unvaccinated patients, suggesting that the influenza vaccine has significant overall protective efficacy against influenza A and B in patients with AIIRD. The estimated VE was 81.3% for influenza A and 66.11% for influenza B, respectively. A study conducted by Rose A et al., on 122 subjects demonstrated that the vaccine efficacy against influenza A was 62% (31). A regional study conducted by Mir H et al., on VE against influenza-related acute respiratory infections revealed a VE against influenza A/H1N1 of 55% (32). The comparatively higher VE in present study can be attributed to the COVID-19 pandemic during the study period, which witnessed a lockdown and the implementation of COVID-19 appropriate behaviour (wearing masks, maintaining social distancing, using hand sanitizers, frequent hand washing, avoiding crowded places, etc.), leading to an overall decrease in the transmission of respiratory/airborne infections. The VE against influenza B in present study was in agreement with a study conducted by Skowronski DM et al., on 683 patients, which revealed a VE of 69% (57-77) against influenza B (33).
Among 90 patients vaccinated with the pneumococcal vaccine, three developed pneumococcal pneumonia, whereas among 348 unvaccinated patients, 33 developed pneumococcal pneumonia. Statistical analysis revealed a p-value of 0.058, suggesting that pneumococcal vaccination has a protective (but not statistically significant) role against pneumococcal pneumonia in patients with AIIRD. The VE turned out to be 65.26%. This suggests that vaccinated patients with AIIRD have a 65.26% lower chance of developing pneumococcal pneumonia. Similar findings were noted in a population-based study on elderly patients conducted by Vila-Corcoles A et al., which reported a VE of 66% (34).
The findings of present study reveal a considerably low rate of vaccination in patients with AIIRD. These patients are at high-risk of infection due to the underlying disease and immunosuppressive therapies. This calls for increased awareness among both physicians and patients. Moreover, both influenza and pneumococcal vaccines are safe and effective in patients with AIIRD, which should help to alleviate the phenomenon of vaccine hesitancy.
Limitation(s)
The limitations of present study include its observational nature, which makes it prone to biases and confounding factors. Matching for baseline characteristics was not performed, which may have confounded the results. Additionally, being a hospital-based study, it is susceptible to referral and selection biases. Nevertheless, present study demonstrates the safety and efficacy of vaccination in patients with AIIRD.
The present study revealed an overall low coverage of vaccinations among patients with AIIRD in the region, which needs to be addressed. It is crucial to raise awareness among both physicians and patients regarding these vaccinations. This will ensure that more patients can avail themselves of the protective benefits of these vaccines. Present study also indicates that the Influenza and Pneumococcal vaccines are safe and effective for patients with AIIRD. These vaccines represent an important public health measure in preventing respiratory infections among patients with AIIRD, similar to their benefits for the general population and other patients.
DOI: 10.7860/JCDR/2024/74384.20330
Date of Submission: Jul 20, 2024
Date of Peer Review: Sep 04, 2024
Date of Acceptance: Oct 03, 2024
Date of Publishing: Nov 01, 2024
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jul 20, 2024
• Manual Googling: Sep 09, 2024
• iThenticate Software: Oct 02, 2024 (14%)
ETYMOLOGY: Author Origin
EMENDATIONS: 7
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