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English to Punjabi: Interview of a Medical Professional General field: Science
Source text - English India Alliance Fellow Spotlight: Dr Rahul Gajbhiye - National Institute For Research In Reproductive Health
"Immediately after the WHO declared COVID-19 as a pandemic, I conceptualized and implemented the National Registry of Pregnant women with COVID-19 in India (PregCovid registry) in partnership with the Government of Maharashtra and Municipal Corporation of Greater Mumbai. The PregCovid registry aims to study the impact of SARS-CoV-2 infection on pregnant, post-partum women, their new-borns and to determine mother-to-child transmission of SARS-CoV-2 infection in India. The standardized data generated from the PregCovid registry is useful for guiding the policy responses to the COVID-19 pandemic at various levels including, clinical management, the decision on vaccination of pregnant women." says Rahul Gajbhiye, this month's India Alliance Fellow in Spotlight. Read this interview to learn more about Rahul’s work on the National Registry of Pregnant Women with Covid in India (PregCovid registry), the role of India Alliance Fellowship in his career, endometriosis research, and more!
Let us begin by talking about your research. What are you currently working on, and what impact do you envision?
Through my current India Alliance Clinical and Public Health Intermediate Fellowship project “Endometriosis Clinical & Genetic Research in India” (ECGRI), I am addressing the burden of endometriosis at the national level and established a partnership with international experts to contribute to improving women’s health globally.
ECGRI is a large-scale, multi-site, case-control study covering representative Indian populations of eastern, north-eastern, northern, central, western, and southern geographical zones of India to investigate the clinical phenotypes and genetic risks associated with endometriosis. World Endometriosis Research Foundation Endometriosis Phenome and Biobanking Harmonisation Project (WERF- EPHect) standards are followed to ensure high standards of clinical data collection, sample processing, and storage. This National study will identify the clinical, epidemiological, environmental, and lifestyle risk factors associated with different endometriosis subtypes in Indian women. The study extends the discovery of genetic and environmental risk factors for endometriosis to the Indian population adding significantly to our understanding of the causes of this disease. The study will lead to the establishment of a biorepository for endometriosis with associated detailed clinical and genomic data. ECGRI will also help in educating and raising awareness about the disease in India (https://ecgri.in/education/). We are trying our best to achieve breakthroughs in the field of Endometriosis, which will eventually help in improving the lives of women across the world.
Immediately after the WHO declared COVID-19 as a pandemic, I conceptualized and implemented the National Registry of Pregnant women with COVID-19 in India (PregCovid registry) in partnership with the Government of Maharashtra and Municipal Corporation of Greater Mumbai. The PregCovid registry aims to study the impact of SARS-CoV-2 infection on pregnant, post-partum women, their new-borns and to determine mother-to-child transmission of SARS-CoV-2 infection in India. The standardized data generated from the PregCovid registry is useful for guiding the policy responses to the COVID-19 pandemic at various levels including, clinical management, the decision on vaccination of pregnant women.
As a clinician, I am providing clinical services through Andrology Clinic and investigating the spectrum and frequency of CFTR and non-CFTR gene mutations in Indian men with congenital absence of vas deferens (CAVD). This study would be useful for understanding the aetiology of CAVD, providing genetic counselling, and help in establishing a mutation panel for screening the men with CAVD and their female partners before undergoing intracytoplasmic sperm injection (ICSI) in India.
My research goals are also towards addressing the health issues of tribal, poor, vulnerable, and marginalized sections of society. Even though the highest number of deaths due to snakebites are reported from India, only a small proportion of snakebite cases are managed at health facilities as most of the patients go to traditional faith healers. Our earlier studies conducted through Model Rural Health Research Unit (MRHRU), Dahanu, Maharashtra demonstrated a higher burden of snakebites in tribal areas, no awareness, and prior training on the management of snakebites, and irrational use of the intradermal anti-venom test. Capacity building of Medical Officers and frontline health workers on the treatment of snakebites as per the standard treatment guidelines reduced the case fatality rate due to snakebite envenomation in Dahanu, Maharashtra. Based on this work, ICMR- National Task Force on snakebite recommended scaling up the study at the National level. In Phase I, we are implementing the study in Maharashtra and Odisha states. The study will help in reducing the mortality and morbidity due to snakebites. The evidence generated from the study may be useful to the Government of India, WHO, and other agencies for developing strategies to reduce the burden of mortality and morbidity associated with snakebite envenomation.
The Endometriosis Clinical and Genetic Research in India (ECGRI -https://ecgri.in) study is being implemented through 15 study sites in North, East, West, Northeast, central and southern India. Could you share your journey in this project with us, considering the challenges posed by the pandemic?
My India Alliance fellowship was activated in October 2019 and after obtaining all mandatory approvals including Health Ministry Screening Committee (HMSC), Ethics Committee approvals from all study sites, training of project staff, we launched the ECGRI study in January 2020. Soon after the study was initiated, the pandemic of COVID-19 started, and it was incredibly challenging to implement the study during the lockdown period. Additionally, some of the study sites were converted into dedicated COVID-19 hospitals. To convert this adversity into an opportunity, we developed the electronic database of ECGRI study for real-time data entry. We also developed endometriosis patient awareness brochures in English, Hindi, and other regional languages. The endometriosis patient awareness brochures are available to the health care providers and the general population (https:/ecgri.in/education/). Anticipating the impact of COVID-19 on the ECGRI study, we expanded our collaborative network and added additional collaborating centres to achieve the periodic targets of study participant recruitments. Currently, we have a total of 16 study sites in 11 cities representing the north, northeast, west, east, central, and south zone of India. COVID-19 pandemic posed several challenges for the recruitment of study participants, laboratory work. However, due to the staunch support and commitment of all collaborators, research staff, and ECGRI project staff, we could recruit more than 600 participants (endometriosis cases and hospital controls) during the past year of the pandemic period. Recently, efforts and contributions of the ECGRI study got global recognition in the 14th World Congress on Endometriosis.
What has been the impact of COVID-19 on pregnant and post-partum women? In your opinion, what needs to be done to mitigate the impact and meet the needs of pregnant and postpartum women?
There is evidence that pregnant women are at an increased risk for developing severe COVID-19 compared to non-pregnant women in different populations. Moreover, pregnant women with COVID-19 are at increased risk for preterm birth and might have an increased risk of other adverse pregnancy outcomes, as reported in several studies and systematic reviews. We recently published the impact of the second wave of COVID-19 on pregnant women and reported that a higher number of women with severe COVID-19 disease requiring ICU admissions, were admitted during the second wave as compared to the first wave at BYL Nair Hospital, Mumbai. The study reported higher pregnancy complications and maternal deaths during the second wave as compared to the first wave of the COVID-19 pandemic. Many deaths were due to COVID-19 pneumonia and respiratory failure. The highly virulent variant of concern B.1.617 is likely to be responsible for higher severe COVID-19 cases, ICU admissions, and mortality. However, we do not have genome sequencing data so the direct association could not be established.
Based on our experience with the PregCovid registry and the available literature, we suggest that pregnant women should continue to take precautions for reducing the risk of acquiring SARS-CoV-2 infection. Physical distancing, handwashing, wearing a mask should be promoted. The findings of our recently published study in the official journal of ACOG, Obstetrics & Gynaecology, as well as other publications from the PregCovid registry, suggest that pregnant women are more vulnerable to develop adverse outcomes, including severe COVID-19, pregnancy loss, and death due to COVID-19. The Ministry of Health and Family Welfare (MoHFW), Government of India has given the Operational Guidance for COVID-19 Vaccination of Pregnant Women. Pregnant women should be provided with information about the risks of SARS-CoV-2 infection in pregnancy, the benefits of vaccination, and the possible side effects of vaccination so that they can make an informed decision. With the availability of the vaccine and the recommendation of MoHFW, pregnant women should be considered for vaccination on high priority to rescue the damage done by COVID-19 on maternal and neonatal health in India.
Concerning your work on the impact of Covid-19 on pregnant women, have you come across any case studies that you feel are noteworthy? Can you share some brief highlights with us?
To date, more than 6000 pregnant and postpartum women with COVID-19 are registered in the PregCovid registry. We have come across several important case studies which are useful for the policymakers, health providers, and general population. Many pregnant women with COVID-19 had anxiety and stress. During the early phase of the pandemic, three women with COVID-19 were diagnosed with postpartum psychosis (PPP). Around 35 % of women with PPP pose a risk to their babies. Two women in our study required separation from their babies and one required supervision. This was the first documented case series on Post-Partum Psychosis in women with COVID-19. We also reported the first case of delirium in a pregnant woman with SARS-CoV-2 infection. Based on our study, we recommend the training of healthcare workers on early recognition and appropriate treatment of psychiatric emergencies in pregnancy and the post-partum period. Accurate information about COVID-19 as well as counselling should be provided to pregnant and postpartum women for reducing stress.
Another interesting case study was on co-infections of malaria, dengue in pregnant women with COVID-19. We reported an important observation that pregnant women with COVID-19 can have symptoms like dengue or malaria. Dengue and Malaria are endemic in several parts of India. Therefore, this observation is important for recommending physicians and obstetricians to be vigilant for the early identification of co-infections such as malaria and dengue with COVID-19.
Tuberculosis (TB) and COVID-19 affect the lungs and have similar risk factors. We, therefore, analysed the registry data at Nair Hospital and observed that six women had active Pulmonary TB. Based on the results, we recommended that pregnant women with symptomatic COVID‐19 should also be tested for TB, especially in countries with a high burden of TB. The infrastructure of the RNTCP can be utilized for the control of COVID‐19, and vice versa.
The impact of COVID-19 on multiple gestation pregnancy (MGP) was studied in our registry cohort. Higher risk of Preterm, Spontaneous abortions, PROM, Preeclampsia in women with MGP and COVID-19 was observed. MGP with COVID-19 needs special attention with a multidisciplinary team approach for both maternal and neonatal care. We analysed the impact of COVID-19 on pregnant women with Rheumatic heart disease (RHD) or Peripartum cardiomyopathy (PPCM). Preterm delivery, PPROM, low birth weight, and neonatal death were observed in women with COVID-19 and RHD/PPCM. The Healthcare system should be strengthened for the management of heart disease and COVID-19. Recently, we reported a neurological complication, Guillain-Barre Syndrome in the pregnant woman with COVID-19.
I received support from Dr Niraj Mahajan and the team at BYL Nair Hospital, Mumbai, Dr Rakesh Waghmare & MEDD team, and the PregCovid registry team at ICMR-NIRRH for implementation of the registry. We submitted the important findings and publications from the PregCovid registry to the Director-General, ICMR to facilitate the policy decision on vaccination of pregnant women in India.
What motivated you to be a physician-scientist?
I was born and brought up in a small town in the Vidarbha region (Pauni, Bhandara) in Maharashtra State, where I got first-hand experience on how the lack of medical services affected the lives of rural, tribal, and other marginalized sections of the society. Therefore, my primary aim to join Medicine was to serve the rural, tribal, and marginalized communities. Before joining post-graduation in Community Medicine at BJ Medical College, Pune, I served as a Medical Officer (MO) as a part of the Pre-PG MOship program of the Government of Maharashtra. While serving in the rural parts of the Pune district as a Medical officer in 2001, I noticed the high maternal mortality due to postpartum haemorrhage. In a primary health centre, I implemented the 'Condom tamponade method' for stabilizing postpartum haemorrhage, which saved the lives of many mothers. This experience completely changed my thinking about future career paths, and I got motivated to join ICMR-National Institute for Research in Reproductive Health Mumbai, India in the year 2003 and joined the path of physician-scientist. By combining clinical experience with investigative skills, medical graduates are in a unique position to address critical issues in medical care and public health.
Since 2003, I have been voluntarily providing mentoring support to medical undergraduates and postgraduates on opportunities in Medical Research to contribute to increasing the cadre of Physician-Scientists in India. If we want to make our Nation a global leader in Medical Research, we need to increase the cadre of Physician-Scientists to a level of at least 50% of its total scientific strength in all the institutions that have a mandate of Medical Research. I am happy that DBT/Wellcome Trust India Alliance, Department of Health Research, Indian Council of Medical Research, have initiated several schemes to attract medical graduates and postgraduates to join Medical Research in India.
How has the India Alliance (IA) fellowship helped you with your research goals so far? Could you share some tips for potential aspirants of the Clinical and Public Health Research fellowships?
In 2017, I was awarded an INSA Indo Australia ECMR post-doctoral fellowship under the mentorship of Professor Grant Montgomery at the Institute for Molecular Biosciences, the University of Queensland, Australia. During my tenure at the University of Queensland, Australia, I decided to explore the career path of Clinical and Genetic Epidemiology. On returning to India in 2018, I was exploring opportunities to conduct large-scale clinical and epidemiological studies in reproductive health. The IA fellowship came at the right time for achieving my dream. The entire process of fellowship application and selection helped me acquire several skills and visit several people whom otherwise I would not have had a chance to meet. Thus, the prestigious fellowship of India Alliance has opened new avenues for achieving my research goals in clinical and public health. It also gave me a platform to establish a national and international network of clinicians, scientists, and policymakers working on addressing the global burden of endometriosis. The generous funding and workforce support have helped me to pursue the ECGRI study and respond to the public health emergency of the COVID-19 pandemic to pay back to society and the country.
Any tips for potential aspirants of the Clinical and Public Health Research fellowship?
For potential aspirants, my advice would be to dream big and work honestly towards achieving your dream. Plan for a research project that has specific, quantifiable, feasible, relevant, concrete, and time-bound objectives. I recommend visiting the India Alliance website for videos and other materials, research profiles of previous IA fellows, and get inputs from mentors and collaborators for developing a good application. Start preparing early and dedicate a good amount of time to developing your application. Publish consistently from your MD or Ph.D. research work and document all important findings as quickly as possible.
What is one experience from your time as a clinical and public health researcher in India so far that has been especially memorable or useful for you?
During the year 2013, I was given the responsibility to establish Maharashtra’s first Model Rural Health Research Unit (MRHRU). It was a big challenge to acquire land, procure equipment, establish a research lab, liaison with the state health department, linked medical college, and initiate the research programs based on the local disease burden. I worked as a ‘foot soldier’ for the establishment of MRHRU, sacrificing my personal and family life to serve the tribal and marginalized communities. The first research project I implemented at MRHRU was on capacity building of the health system for snakebite management under the mentorship of Dr V M Katoch, Dr Kiran Katoch, Dr Himmatrao Bawaskar, and Dr Smita Mahale. The dedication and passion of our MRHRU and snakebite research team not only brought down the mortality due to snakebite envenomation in Dahanu, but also empowered the healthcare providers on clinical management and research. We were able to establish the infrastructure of MRHRU including a well-equipped laboratory, implemented research programs, published a policy document, research articles in high-impact factor journals, and simultaneously saved the lives of people. This is the most memorable experience in my life as a clinical and public health researcher in India.
Who are your role models when it comes to meaningful research in public health? How have they helped shape your interests and career?
My biggest role models are Mahatma Jyotiba Phule, Savitribai Phule, Shahuji Maharaj, Sayajirao Gaikwad, Thanthai Periyar, Dr Rakhamabai Raut, Dr B. R. Ambedkar, Mahatma Gandhi, Dr Yashavant Phule, Sir Joseph Bhore, Waldemar Haffkine, Dr Sushila Nayar, Dr. C. G. Pandit and others who contributed during their lifetime for the betterment of humanity and laid the foundations of public health in India.
My public health research career has been shaped by several extraordinary researchers who are my role models for doing meaningful research in public health. Two decades ago, when I was working as a medical officer at Primary Health Center in Pune District, Maharashtra, Dr Archana Patil and Dr Satish Pawar inspired and motivated me to choose the path of a physician-scientist. After joining ICMR-NIRRH in 2003, I found role models Dr N. K. Ganguli, Dr Chander Puri, and Late Dr Vrinda Khole who transformed me into a Physician-Scientist. I received mentoring support from Dr V M Katoch, Dr Kiran Katoch, and Dr Smita Mahale for establishing Model Rural Health Research Unit in Dahanu, Maharashtra, and received guidance for implementing public health research projects through MRHRU. I would not have achieved the research goal of reducing the case fatality rate due to snakebite envenomation in the tribal area of Dahanu, Maharashtra without the support of Dr Himmatrao Bawaskar. Dr V. M. Katoch and Dr Kiran Katoch have been a great inspiration as their vision and practical experience of public health has transformed public health research in India.
I am inspired by international role models Grant Montgomery, David Adamson, and Linda C. Giudice, who are providing mentoring support for the endometriosis research.
The most inspiring role model during the current COVID-19 pandemic is Dr Balram Bharagava, Secretary Department of Health Research and Director General, ICMR. Dr Bhargava’s vision, passion, and commitment to public health is a major source of inspiration to strive hard during the ongoing pandemic. The PregCovid registry is being implemented under the guidance and support of Dr Balram Bhargava, Dr Smita Mahale, and Dr Geetanjali Sachdeva.
I am also inspired by the work of Dr Yogesh Kalkonde, IA CPH fellow who left his lucrative career in the USA to serve the tribal and marginalized communities in India. ECGRI and other public health projects in my lab have extensively benefitted from his unconditional support and guidance.
My journey as a clinical and public health researcher would have been impossible without the support of excellent role models at home - which include my parents, my spouse, my sisters and brothers-in-law, my brother, and our two indomitable sons who constantly inspire me!
What are you most looking forward to once the COVID-19 pandemic is over?
Since I converted the adversity of COVID-19 into an opportunity, I could excel in my research goals even during the pandemic period. However, some of the aspects of the ECGRI study that required physical inspection and monitoring could not be undertaken. I would initiate physical monitoring and supervision as soon as the pandemic is over. I believe that personal interactions with collaborators and the research team increase the research output. After the pandemic is over, I plan to release the policy document based on the experience of the PregCovid registry. I would be initiating the capacity building of the health system on treatment of snakebite envenomation. This would be a priority, as this research goal could not be achieved during the pandemic period.
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