Available online 5 October 2022, 105318

ABSTRACTBackground

Seasonal outbreaks of infectious conjunctivitis remain a public health issue. Determination of outbreak etiologies in the context of a worldwide pandemic may provide useful information to guide public health strategies. The aim of this study was to identify pathogens associated with outpatient infectious conjunctivitis during the COVID-19 Delta surge.

Methods

This prospective study was conducted from April 2021 to September 2021. All outpatients presenting to the Aravind Eye Center (Madurai, India) with signs and symptoms consistent with acute infectious conjunctivitis were eligible. Three swabs were obtained from each participant: one from each conjunctiva and one from the anterior nares. Samples were processed for metagenomic RNA deep sequencing (RNA-seq).

Results

Samples from 106 study participants were sequenced. The most common presenting symptoms were tearing (86%) and itching (71%). Preauricular lymphadenopathy was present in 38% of participants. 20% of participants had close contacts with similar symptoms. Systemic symptoms such as coughing, runny nose, vomiting or diarrhea were uncommonly reported. 60% of all participants used some medicated eye drops upon enrollment. 75% of study participants demonstrated infection with human adenovirus D (HAdV-D). 11% of conjunctivitis was associated with SARS-CoV-2. 15% had no definitive pathogen detected. 8% of all participants had codetection of more than one pathogen on RNA-seq.

Conclusions

During the COVID-19 Delta surge in India, HAdV-D was the most common pathogen associated with infectious conjunctivitis. SARS-CoV-2 was the second most common etiology. Seasonal surveillance may be necessary for the determination of emerging and reemerging pathogens responsible for infectious conjunctivitis.

Section snippetsINTRODUCTION

Worldwide epidemics of infectious conjunctivitis occur regularly1,2. Episodes of infectious conjunctivitis continued despite the widespread implementation of nonpharmaceutical interventions designed to mitigate the COVID-19 pandemic, such as mask-wearing, hand-washing, and social distancing. We know infectious conjunctivitis etiology varies by location and season3. Pathogens driving infectious conjunctivitis during a COVID-19 pandemic have not been studied in a prospective manner.

As worldwide

MATERIALS & METHODS

This study adhered to the tenets of the Declaration of Helsinki. The Institutional Review Board of the University of California, San Francisco and Aravind Eye Hospital in Madurai, India, approved the study. Informed written consent was obtained from all patients. Guardians were consented for all children. Children older than 18 years of age provided assent. Conjunctival swabs were obtained from patients who presented to the Aravind Eye Hospital in Madurai, India from April 1 to May 1,2021 and

RESULTS

The highly contagious Delta variant of SARS-CoV-2 surged in southern India in the spring of 20215. Peak numbers necessitated a cessation of elective clinical visits from May 10, 2021 through May 24, 2021. Elective clinical study participation stopped on May 1, 2021 and resumed June 1, 2021. During this time period of sample collection, 106 patients were consented for study participation (Figure 1).

Demographics of infectious conjunctivitis study participants are summarized in Table 1. The mean

DISCUSSION

The overall effects of the novel COVID-19 pandemic on the frequency, etiologies, and geographic variability of worldwide, recurrent, and seasonal conjunctivitis epidemics are unknown. With the onset of the COVID-19 pandemic, circulation of other respiratory viruses, in many countries decreased early on6.7. As respiratory viruses are also common etiologies of infectious conjunctivitis, there was some suggestion of decreased rates of infectious conjunctivitis during the early pandemic8.9.

LIMITATIONS

54% of all participants were using an antibacterial drop at the time of sample collection. This may be the reason why no bacterial conjunctivitis pathogens were identified. However, this also emphasizes the overuse of topical antibiotics for infectious conjunctivitis which may be predominantly viral in etiology. Additionally, the pathogens identified on the clinical swabs are suggestive for symptom causality, however comparative control swabs from unaffected patients were not obtained so an

CONCLUSIONS

This study emphasizes the importance of repeated regional and seasonal surveillance of causes of infectious diseases. The unbiased nature of deep sequencing allows for the detection of unanticipated pathogens and unexpected co-infections. RNA sequencing may be a useful diagnostic tool for the comprehensive surveillance of all viruses, including the RNA virus SARS-CoV-2, that can cause conjunctivitis.

FUNDING

Research reported in this manuscript was supported by the National Eye Institute of the National Institutes of Health under Award Number R01EY032041 (T.D.), a Research to Prevent Blindness Unrestricted Grant, and the Peierls Foundation. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Nonauthor contribution

Seasonal Conjunctivitis Outbreak Reporting for Prevention and Improved Outcomes (SCORPIO) Study Group

Aravind Eye Hospital, Madurai, India – Lalitha Prajna, N. Venkatesh Prajna, Ramesh Gunasekaran, Sankalp Singh Sharma, Vishnu Teja; B.P Koirala Lions Center for Ophthalmic Studies, Kathmandu, Nepal – Meenu Chaudhary, Sanjeeta Sitaula; Centre de Recherche en Sante de Nouna, Nouna, Burkina Faso – Ali Sié, Boubacar Coulibaly, Mamadou Bountogo; Chulalongkorn University, Bangkok, Thailand – Thanapong

Uncited References

[13]

Declaration of Competing Interest

None

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