Current burden on healthcare systems in low- and middle-income countries: recommendations for emergency care of COVID-19

Field based research in the era of the pandemic in resource limited settings: challenges and lessons for the future

The coronavirus pandemic that began in December 2019, has had an unprecedented impact on the global economy, health systems and infrastructure, in addition to being responsible for significant mortality and morbidity worldwide. The "new normal" has brought along, unforeseen challenges for the scientific community, owing to obstructions in conducting field-based research in lieu of minimizing exposure through in-person contact. This has had greater ramifications for the LMICs, adding to the already existing concerns. As a response to COVID-19 related movement restrictions, public health researchers across countries had to switch to remote data collections methods. However, impediments like lack of awareness and skepticism among participants, dependence on paper-based prescriptions, dearth of digitized patient records, gaps in connectivity, reliance on smart phones, concerns with participant privacy at home and greater loss to follow-up act as hurdles to carrying out a research study virtually, especially in resource-limited settings. Promoting health literacy through science communication, ensuring digitization of health records in hospitals, and employing measures to encourage research participation among the general public are some steps to tackle barriers to remote research in the long term. COVID-19 may not be a health emergency anymore, but we are not immune to future pandemics. A more holistic approach to research by turning obstacles into opportunities will not just ensure a more comprehensive public health response in the coming time, but also bolster the existing infrastructure for a stronger healthcare system for countries.

A Study on Community needs, perceptions and demand regarding the use of the health services during COVID-19 pandemic in district Kathua, J and K

Introduction

The impact of the COVID-19 pandemic on essential health services is a source of great concern. Health gains made during the last 2-3 decades have been halted due to shifting of resources to fight the COVID-19 pandemic.

Aim and Objective

This study was conducted to identify community needs, demands, and perceptions regarding the effectiveness of using health services during the pandemic.

Methodology

This was a qualitative study which was conducted through focus group discussions. The participants comprised of three groups: community leaders, healthcare providers, and field workers. Discussion among the participants was conducted using the standardized World Health Organization community assessment tool.

Result

In our study, it was reported that most of the essential health services were disrupted due to COVID-19 pandemic. The barriers to accessing essential health services have been exacerbated and the provision of community-based services is effected due to this. In regard to COVID-19 vaccination also, there remain individuals who are reluctant to be vaccinated.

Conclusion

Our study shows that the community faced barriers in accessing and using health services during the pandemic. To ensure the public's access to health services and strengthen healthcare preparedness strategies like health budget allocation, manpower, infrastructure, trainings, integration with primary healthcare, etc., need to be carried out during and after the pandemic. Thus, participation and inter-sectoral coordination across levels are required to overcome these barriers.

When healers get wounded! Moral injury in healthcare providers during the COVID-19 pandemic in Pakistan

Introduction

Moral injury (MI) is a multi-faceted and multidimensional phenomenon. Occupational MI has been studied mainly among military personnel and first responders and is linked to mental health problems. MI encompasses negative moral emotions such as shame, guilt, and anger leading to distress, and impairment in social and occupational functioning. The COVID-19 pandemic predisposed healthcare providers to moral dilemmas, potentially morally injurious events (PMIEs), and MI. We aimed to assess the prevalence and predictors of MI in healthcare providers during the COVID-19 pandemic in Pakistan.

Materials and methods

This cross-sectional study was conducted in July-October 2021 among physician/clinician staff working at teaching hospitals in Lahore. The Moral Injury Symptoms Scale-Health Professionals (MISS-HP) was used to collect data. SPSS 26 was used for data analysis applying Wilcoxon Mann-Whitney U and Kruskal-Wallis tests on non-normally distributed data at α = 0.05. Predictors of MI were ascertained through Binary Logistic Regression analysis.

Results

Four hundred and twenty physicians responded to the questionnaires. The Median (IQR) MI scores were 37(28-47). Guilt, moral concerns, and shame were higher-scoring MI dimensions. 40.8% (n = 171) suffered from clinically significant distress and impaired functioning while 14.3% (n = 60) from severe distress. Gender, department, and history of psychiatric illness predicted higher levels of distress which were 1.9 times higher in females than males and 2.5 times higher with a history of psychiatric illness. Working on the front lines did not predict MI.

Conclusion

Our findings highlight the substantial burden of MI in our sample during COVID-19, having implications for healthcare providers' well-being, healthcare quality, and service delivery. This calls for concerted efforts from all stakeholders to better prepare for future disasters through effective human-resource policies, pre-trauma exposure soft-skills training, effective teamwork and communication strategies; self-stewardship and resilience modules, and mental health support for healthcare providers. The dimensional construct of MI may vary across cultures; hence we recommend further cross-cultural research on MI in healthcare providers, particularly in the context of public health disasters.

The association between preoperative COVID-19-positivity and acute postoperative complication risk among patients undergoing orthopedic surgery

Aims

This study aimed to investigate the risk of postoperative complications in COVID-19-positive patients undergoing common orthopaedic procedures.

Methods

Using the National Surgical Quality Improvement Programme (NSQIP) database, patients who underwent common orthopaedic surgery procedures from 1 January to 31 December 2021 were extracted. Patient preoperative COVID-19 status, demographics, comorbidities, type of surgery, and postoperative complications were analyzed. Propensity score matching was conducted between COVID-19-positive and -negative patients. Multivariable regression was then performed to identify both patient and provider risk factors independently associated with the occurrence of 30-day postoperative adverse events.

Results

Of 194,121 included patients, 740 (0.38%) were identified to be COVID-19-positive. Comparison of comorbidities demonstrated that COVID-19-positive patients had higher rates of diabetes, heart failure, and pulmonary disease. After propensity matching and controlling for all preoperative variables, multivariable analysis found that COVID-19-positive patients were at increased risk of several postoperative complications, including: any adverse event, major adverse event, minor adverse event, death, venous thromboembolism, and pneumonia. COVID-19-positive patients undergoing hip/knee arthroplasty and trauma surgery were at increased risk of 30-day adverse events.

Conclusion

COVID-19-positive patients undergoing orthopaedic surgery had increased odds of many 30-day postoperative complications, with hip/knee arthroplasty and trauma surgery being the most high-risk procedures. These data reinforce prior literature demonstrating increased risk of venous thromboembolic events in the acute postoperative period. Clinicians caring for patients undergoing orthopaedic procedures should be mindful of these increased risks, and attempt to improve patient care during the ongoing global pandemic.

The COVID-19 Pandemic and Coronary Heart Disease: the Next Surge

PURPOSE OF REVIEW

In this narrative review, we highlight different ways in which the COVID-19 pandemic has impacted coronary heart disease (CHD) burden and how a surge in morbidity and mortality may be expected in the near future. We also discuss potential solutions, and the direction subsequent research and corrective actions should take.

RECENT FINDINGS

COVID-19 has been implicated in the development and worsening of CHD via acute and chronic mechanisms in the form of plaque rupture, destabilization, and sustenance of a chronic inflammatory state leading to long COVID syndrome and increased rates of myocardial infarction. However, indirectly the pandemic is likely to further escalate the CHD burden through poor health behaviors such as tobacco consumption, reduced physical activity, economic devastation and its associated sequelae, and regular cardiac care interruptions and delays. COVID-19 has increased the total CHD burden and will require extensive resource allocation and multifaceted strategies to curb future rise.

Development of a Manual for Disaster Medical Support Using Korean Medicine for Disaster Survivors

Objective: Disasters adversely affect the mental health of disaster survivors, leading to depression, anxiety, and stress-related disorders. Survivors complain of not only psychological symptoms but also physical symptoms such as insomnia, pain, and fatigue. Providing immediate and effective psychological support to all survivors is difficult because human and physical medical resources are limited. Therefore, the authors developed a manual for disaster medical support using Korean medicine (KM) for disaster survivors to provide prompt, effective, and long-term support that supplement existing psychological support. Methods: In this article, the authors introduce KM treatment protocols, which are unique elements of the manual. In addition, the authors have developed a step-by-step treatment protocol based on the stage and condition of survivors, as well as separate treatment protocols for psychological and physical symptoms. Results: The interventions include ear acupuncture, acupuncture, herbal medicine, breathing relaxation, stabilization techniques, emotional freedom technique, and self-care methods such as acupressure, exercise, and walking meditation. This manual has been certified as an official procedure of the Korean Society of Oriental Neuropsychiatry. Conclusions: The authors believe that this manual will enable KM doctors to be effectively utilized as medical resources at disaster sites. Furthermore, this manual would provide a good model that can be extended to countries that wish to use integrative medicine for disaster support to implement the commitments of the Declaration of Astana.

Marching Ahead through the Pandemic: Continuing Anesthesia Services in COVID Era—Our Experience from a Tertiary Care Cancer Centre

Introduction This paper aims to provide an overview of the administrative and clinical preparations done in a tertiary care cancer hospital in continuing operation theatre (OT) services through the COVID pandemic.

Methods Retrospective data collection, data for the past 1.5 years (COVID period) March 2020 to August 2021 were compared to surgical output for a similar duration of time before the COVID era (September 2018–February 2020).

Results A total of 1,022 surgeries were done under anesthesia in the COVID period as against 1,710 surgeries done in a similar time frame in the pre-COVID era. Overall, we saw a 40%drop in the total number of cases. Thorax, abdominal, and miscellaneous surgeries (soft tissue sarcomas, urology, and gyneconcology) saw a maximum fall in numbers; however, head and neck cases saw an increase in numbers during the pandemic. Surgical morbidity and mortality were similar in the COVID and pre-COVID era. No cases of severe COVID infection were reported among the healthcare staff working in OT.

Discussion We could successfully continue our anesthesia services with minimal risk to healthcare staff throughout the pandemic by adopting major guidelines in a pragmatic and practical approach with minor changes to suit our setup.

Proposing a New Conceptual Syndemic Framework for COVID-19 Vaccine Hesitancy: A Narrative Review

BACKGROUND

Discussions regarding syndemics have dominated research in recent years. Vaccine hesitancy has also been propelled to the forefront. In this narrative review, we aim to frame a novel syndemic framework to understand the interaction between vaccine hesitancy, COVID-19, and negative health outcomes.

METHODS

A non-systematic electronic search was conducted in PubMed and Google Scholar. Search criteria were limited to articles published between November 2019 and June 2022. Articles related to the COVID-19 syndemic and vaccine hesitancy were included.

RESULTS

Our review revealed that the adherence to COVID-19 regulations-although they were effective in preventing COVID-19 transmission, cases, and deaths-created a dynamically unstable 'vicious cycle' between undesirable health, economic, and social outcomes. The "accumulation" of complex stressors decreased individuals' cognitive flexibility and hindered them from making decisions and getting vaccinated. Furthermore, it increased individuals' risk of acquiring COVID-19, losing their employment, increasing poverty, and decreasing healthcare utilization. We illustrated how the amalgamation of sociodemographic and contextual factors associated with COVID-19 might impact people's vaccine decisions, making them more hesitant toward COVID-19 vaccination. Failing to receive vaccinations increases the chances of COVID-19 transmission, hospitalization, and other negative health outcomes.

CONCLUSIONS

Understanding the interaction between these factors is essential to provide policymakers with inspiration to set appropriate interventions for promoting COVID-19 vaccination acceptance to decrease the overall burden of pandemics.

Survival analysis of patients with COVID-19 admitted at six hospitals in Uganda in 2021: a cohort study

Background

Assessing factors associated with mortality among COVID-19 patients could guide in developing context relevant interventions to mitigate the risk. The study aimed to describe mortality and associated factors among COVID-19 patients admitted at six health facilities in Uganda.

Methods

We reviewed medical records of patients admitted with COVID-19 between January 1st 2021 and December 31st 2021 in six hospitals in Uganda. Using Stata version 17.0, Kaplan Meier and Cox regression analyses were performed to describe the time to death and estimate associations between various exposures and time to death. Finally, accelerated failure time (AFT) models with a lognormal distribution were used to estimate corresponding survival time ratios.

Results

Out of the 1040 study participants, 234 (22.5%: 95%CI 12.9 to 36.2%) died. The mortality rate was 30.7 deaths per 1000 person days, 95% CI (26.9 to 35.0). The median survival time was 33 days, IQR (9–82). Factors associated with time to COVID-19 death included; age ≥ 60 years [adjusted hazard ratio (aHR) = 2.4, 95% CI: [1.7, 3.4]], having malaria test at admission [aHR = 2.0, 95% CI:[1.0, 3.9]], a COVID-19 severity score of severe/critical [aHR = 6.7, 95% CI:[1.5, 29.1]] and admission to a public hospital [aHR = 0.4, 95% CI:[0.3, 0.6]]. The survival time of patients aged 60 years or more is estimated to be 63% shorter than that of patients aged less than 60 years [adjusted time ratio (aTR) 0.37, 95% CI 0.24, 0.56]. The survival time of patients admitted in public hospitals was 2.5 times that of patients admitted in private hospitals [aTR 2.5 to 95%CI 1.6, 3.9]. Finally, patients with a severe or critical COVID-19 severity score had 87% shorter survival time than those with a mild score [aTR 0.13, 95% CI 0.03, 0.56].

Conclusion

In-hospital mortality among COVID-19 patients was high. Factors associated with shorter survival; age ≥ 60 years, a COVID-19 severity score of severe or critical, and having malaria at admission. We therefore recommend close monitoring of COVID-19 patients that are elderly and also screening for malaria in COVID-19 admitted patients.

Clinical Manifestations of COVID-19 Patients with Comorbid and Non-comorbid at Dr. Soetomo Hospital, Surabaya

Background : Covid-19 has been declared a global health emergency. Reports of thousands of cases with morbidity and mortality continue to increase every day. The clinical course of patients with comorbidities influences the prognosis and progression of the covid-19 disease. Hypertension is the most common cormorbidity of covid-19 patients with long hospitalizations. Objective : This study aimed to determine the clinical differences between covid-19 patients cormobid and non cormobid . Methods : The study was conducted retrospectively through samples of medical records of inpatients for the period June 1, 2021 – August 31, 2021. The samples were divided into comorbid and non-cormobid groups; each totaling 130 medical records. The sample of the comorbid group was selected by simple random; while the non-cormobid group with the matching process. Data were analyzed using t-test and Wilcoxon. Results : The most common kormobid is hypertension with clinical manifestations of cough, fever, headache, runny nose, painful swallowing, anosmia, shortness of breath, nausea, vomiting and diarrhea. The average length of stay for patients with comorbidities was 21 days and without comorbidities 14 days. The test results showed that there were clinical differences between patients with comorbid and non-cormobid patients with p value = 0.0000 (p>0.05) and there was a difference in length of stay with p-value = 0.001 (p>0.05). Conclusion : The clinical difference between covid-19 patients comorbid and non cormobid lies in the symptoms of headache with a longer duration of treatment, which is 22 days. More intensive treatment and care is needed for covid-19 patients with comorbid hypertension. Keywords : clinical manifestation; covid-19; comorbid; length of treatment.

Machine Learning-Based COVID-19 Patients Triage Algorithm Using Patient-Generated Health Data from Nationwide Multicenter Database

Introduction

A prompt severity assessment model of patients with confirmed infectious diseases could enable efficient diagnosis while alleviating burden on the medical system. This study aims to develop a SARS-CoV-2 severity assessment model and establish a medical system that allows patients to check the severity of their cases and informs them to visit the appropriate clinic center on the basis of past treatment data of other patients with similar severity levels.

Methods

This paper provides the development processes of a severity assessment model using machine learning techniques and its application on SARS-CoV-2-infected patients. The proposed model is trained on a nationwide data set provided by a Korean government agency and only requires patients’ basic personal data, allowing them to judge the severity of their own cases. After modeling, the boosting-based decision tree model was selected as the classifier while mortality rate was interpreted as the probability score. The data set was collected from all Korean citizens with confirmed COVID-19 between February 2020 and July 2021 (N = 149,471).

Results

The experiments achieved high model performance with an approximate precision of 0.923 and area under the curve of receiver operating characteristic (AUROC) score of 0.950 [95% tolerance interval (TI) 0.940–0.958, 95% confidence interval (CI) 0.949–0.950]. Moreover, our experiments identified the most important variables affecting the severity in the model via sensitivity analysis.

Conclusion

A prompt severity assessment model for managing infectious people has been attained through using a nationwide data set. It has demonstrated its superior performance by surpassing that of conventional risk assessments. With the model’s high performance and easily accessible features, the triage algorithm is expected to be particularly useful when patients monitor their health status by themselves through smartphone applications.

Perceived COVID-19 vaccine effectiveness, acceptance, and drivers of vaccination decision-making among the general adult population: A global survey of 20 countries

Background

Mass vaccination campaigns have significantly reduced the COVID-19 burden. However, vaccine hesitancy has posed significant global concerns. The purpose of this study was to determine the characteristics that influence perceptions of COVID-19 vaccine efficacy, acceptability, hesitancy and decision making to take vaccine among general adult populations in a variety of socioeconomic and cultural contexts.

Methods

Using a snowball sampling approach, we conducted an online cross-sectional study in 20 countries across four continents from February to May 2021.

Results

A total of 10,477 participants were included in the analyses with a mean age of 36±14.3 years. The findings revealed the prevalence of perceptions towards COVID-19 vaccine’s effectiveness (78.8%), acceptance (81.8%), hesitancy (47.2%), and drivers of vaccination decision-making (convenience [73.3%], health providers’ advice [81.8%], and costs [57.0%]). The county-wise distribution included effectiveness (67.8–95.9%; 67.8% in Egypt to 95.9% in Malaysia), acceptance (64.7–96.0%; 64.7% in Australia to 96.0% in Malaysia), hesitancy (31.5–86.0%; 31.5% in Egypt to 86.0% in Vietnam), convenience (49.7–95.7%; 49.7% in Austria to 95.7% in Malaysia), advice (66.1–97.3%; 66.1% in Austria to 97.3% in Malaysia), and costs (16.0–91.3%; 16.0% in Vietnam to 91.3% in Malaysia). In multivariable regression analysis, several socio-demographic characteristics were identified as associated factors of outcome variables including, i) vaccine effectiveness: younger age, male, urban residence, higher education, and higher income; ii) acceptance: younger age, male, urban residence, higher education, married, and higher income; and iii) hesitancy: male, higher education, employed, unmarried, and lower income. Likewise, the factors associated with vaccination decision-making including i) convenience: younger age, urban residence, higher education, married, and lower income; ii) advice: younger age, urban residence, higher education, unemployed/student, married, and medium income; and iii) costs: younger age, higher education, unemployed/student, and lower income.

Conclusions

Most participants believed that vaccination would effectively control and prevent COVID-19, and they would take vaccinations upon availability. Determinant factors found in this study are critical and should be considered as essential elements in developing COVID-19 vaccination campaigns to boost vaccination uptake in the populations.

This large-scale multi-country study explores perceived COVID-19 vaccine effectiveness, acceptability, and hesitancy rates and their related factors among the general adult populations from 20 countries. We found that a considerable proportion of the participants has an intention to receive the COVID-19 vaccine. However, more than half still expressed their hesitancy to receive the vaccines. Countries where the majority of respondents responded that they would accept COVID-19 vaccination included Malaysia (96.0%), Bangladesh (93.6%), and Iraq (91.8%). The majority of the participants from Vietnam (86.0%) and Turkey (74.7%) expressed hesitance to receive COVID-19 vaccine. Perceived vaccine effectiveness ranged from 67.8% in Egypt to 95.9% in Malaysia. The participants believed that convenience, health providers’ advice, and costs of vaccines are important for people to decide whether to accept COVID-19 vaccines. Country of residence, age, sex, level of education, area of residence, marital status, and family economic status were significantly associated with tendency to undergo COVID-19 vaccination and the perception that COVID-19 vaccine decision-making is influenced by convenience. The findings of this study provide useful guidance for tailored interventions to enhance the acceptance of COVID-19 vaccine. Promotional program addressed on detected socioeconomic factors is warranted.

Inequalities in the prevalence of cardiovascular disease risk factors in Brazilian slum populations: A cross-sectional study

BACKGROUND

Social and environmental risk factors in informal settlements and slums may contribute to increased risk of cardiovascular disease (CVD). This study assesses the socioeconomic inequalities in CVD risk factors in Brazil comparing slum and non-slum populations.

METHODS

Responses from 94,114 individuals from the 2019 Brazilian National Health Survey were analysed. The United Nations Human Settlements Programme definition of a slum was used to identify slum inhabitants. Six behavioural risk factors, four metabolic risk factors and doctor-diagnosed CVD were analysed using Poisson regression models adjusting for socioeconomic characteristics.

RESULTS

Compared to urban non-slum inhabitants, slum inhabitants were more likely to: have low (less than five days per week) consumption of fruits (APR: 1.04, 95%CI 1.01-1.07) or vegetables (APR: 1.08, 95%CI 1.05-1.12); drink four or more alcoholic drinks per day (APR: 1.05, 95%CI 1.03-1.06); and be physically active less than 150 minutes per week (APR: 1.03, 95%CI 1.01-1.04). There were no differences in the likelihoods of doctor-diagnosed metabolic risk factors or CVD between the two groups in adjusted models. There was a higher likelihood of behavioural and metabolic risk factors among those with lower education, with lower incomes, and the non-White population.

CONCLUSIONS

Brazilians living in slums are at higher risk of behavioural risk factors for CVD, suggesting local environments might impact access to and uptake of healthy behaviours.

Safety and efficacy of hydroxychloroquine for treatment of non-severe COVID-19 among adults in Uganda: a randomized open label phase II clinical trial

Background

Several repurposed drugs such as hydroxychloroquine (HCQ) have been investigated for treatment of COVID-19, but none was confirmed to be efficacious. While in vitro studies have demonstrated antiviral properties of HCQ, data from clinical trials were conflicting regarding its benefit for COVID-19 treatment. Drugs that limit viral replication may be beneficial in the earlier course of the disease thus slowing progression to severe and critical illness.

Design

We conducted a randomized open label Phase II clinical trial from October–December 2020.

Methods

Patients diagnosed with COVID-19 using RT-PCR were included in the study if they were 18 years and above and had a diagnosis of COVID-19 made in the last 3 days. Patients were randomized in blocks, to receive either HCQ 400 mg twice a day for the first day followed by 200 mg twice daily for the next 4 days plus standard of care (SOC) treatment or SOC treatment alone. SARS COV-2 viral load (CT values) from RT-PCR testing of samples collected using nasal/orapharyngeal swabs was performed at baseline, day 2, 4, 6, 8 and 10. The primary outcome was median time from randomization to SARS COV-2 viral clearance by day 6.

Results

Of the 105 participants enrolled, 55 were assigned to the intervention group (HCQ plus SOC) and 50 to the control group (SOC only). Baseline characteristics were similar across treatment arms. Viral clearance did not differ by treatment arm, 20 and 19 participants respectively had SARS COV-2 viral load clearance by day 6 with no significant difference, median (IQR) number of days to viral load clearance between the two groups was 4(3–4) vs 4(2–4): p = 0.457. There were no significant differences in secondary outcomes (symptom resolution and adverse events) between the intervention group and the control group. There were no significant differences in specific adverse events such as elevated alkaline phosphatase, prolonged QTc interval on ECG, among patients in the intervention group as compared to the control group.

Conclusion

Our results show that HCQ 400 mg twice a day for the first day followed by 200 mg twice daily for the next 4 days was safe but not associated with reduction in viral clearance or symptom resolution among adults with COVID-19 in Uganda.

Trial registration: NCT04860284.

Strategies for the prevention, diagnosis and treatment of COPD in low- and middle- income countries: the importance of primary care

INTRODUCTION

Low- and middle-income countries (LMICs) bear a high proportion of the global morbidity and mortality caused by COPD. Increased exposure to risk factors throughout life (e.g. malnutrition, indoor and outdoor air pollution, and smoking) is associated with higher COPD prevalence in LMICs and the lack of treatment availability increases avoidable harm.

AREAS COVERED

This review covers the epidemiology and burden of COPD in LMICs, and challenges and recommendations related to health-care systems, prevention, diagnosis, and treatment. Main challenges are related to under-resourced health-care systems (such as limited availability of spirometry, rehabilitation, and medicines). Lack of policy and practical local guidelines on COPD diagnosis and management further contribute to the low diagnostic and treatment rates. In the absence of, or limited number of respiratory specialists, primary care practitioners (general practitioners, nurses, pharmacists, physiotherapists, and community health workers) play an even more pivotal role in COPD management in LMICs.

EXPERT OPINION

Raising awareness on COPD, educating health-care workers, patients, and communities on cost-effective preventive measures as well as improving availability, affordability and proper use of diagnostic and pharmacological and non-pharmacologic treatment in primary care are the key interventions needed to improve COPD prevention, diagnosis, and care in LMICs.

Enablers and hindrances to health promotion and disease prevention practices among healthcare workers in Nelson Mandela Bay Municipality, South Africa

Health promotion (HP) and disease prevention (DP) practices among healthcare workers (HCWs) are key to achieving universal health coverage. This study identified HP and DP enablers and hindrances and compared them at different healthcare levels in Nelson Mandela Bay Municipality, South Africa. An exploratory cross-sectional study using a structured questionnaire was conducted among HCWs (n = 501) from 23 hospitals. Bivariate and multinomial regression were used to analyze the data. The highest number of participants (70.46%; n = 353) were from tertiary hospitals. Thirteen and Eight categories of enablers and hindrances respectively were identified. Of these, eleven enablers and six hindrances of HP and DP were associated with tertiary hospitals; no enabler was identified at both primary and secondary while one hindrance was associated with primary level of health care. Collaboration among disciplines and organizations (Coeff: 2.16, 95% CI: 1.28-3.66) and programme planning (Coeff: 0.375, 95% CI: 0.23-0.62) were the predictors of HP and DP among medical doctors, while staff induction training (Coeff: 0.62, 95% CI: 0.40-0.95) and performance appraisal (Coeff: 1.86, 95% CI: 1.16-2.98) were the enablers among allied health workers. On the other hand, 'facility promoting treatment more than prevention' (Coeff: 2.03, 95% CI: 1.30-3.14) and 'practice guidelines incorporating HP' (Coeff: 2.79, 95% CI: 1.66-4.70) were the predictors of HP and DP hindrances among medical doctors and allied health workers respectively. Our work indicates the need for an operational strategy designed considering enabling and hindering factors to HP and DP practices for empowering HCWs and enhancing health outcomes.

Managing COVID-19 infection in a Young Acute Myeloid Leukemia Patient Successfully With Antiviral and Granulocyte Colony Stimulating Factor: Playing on a Sticky Wicket

The COVID-19 pandemic has drastically affected healthcare systems throughout the world. Though all domains of healthcare are busy battling this deadly pandemic, oncology care has taken a drastic hit due to cancer patients being immunocompromised and predisposed to acquire COVID-19 infection. Patients suffering from acute myeloid leukemia are at greater risk of acquiring Severe Acute Respiratory Syndrome Coronavirus 2(SARS CoV 2) infection along with developing complications related to COVID-19 due to the immunosuppression caused by the malignancy, as well as the high-intensity chemotherapy provided in acute myeloid leukemia. We report a case of 28-year-old male who was a known case of acute myeloid leukemia diagnosed three months ago, presented with high-grade fever with cough and breathlessness. Nasopharyngeal swab of the patient for SARS CoV2 by reverse transcriptase-polymerase chain reaction turned out to be positive. The patient was managed successfully with steroids, remdesavir, granulocyte colony-stimulating factor, and other supportive measures, and was discharged in a stable condition.

Assessing national cervical cancer screening guidelines: Results from an HIV testing clinic also screening for cervical cancer and HPV in Soweto, South Africa

OBJECTIVE

A screening centre in Soweto, South Africa (SA), investigated high-risk human papillomavirus (HR-HPV), HIV, cervical cancer risk amongst women.

METHODS

This cross-sectional study (June 2018-March 2019) describes screening results (Roche Linear Array HPV test and Pap smear liquid based cytology) and history of screening (known HIV status, antiretroviral therapy [ART] use, previous Pap smears). Data were stratified by age group (18-29, 30+ years), HIV status, Pap smear results and tested for statistical significance.

RESULTS

Of 280 women, 20.4% were HIV-positive, 18.2% had abnormal Pap smears, 41.8% had HR-HPV. Of older women, 48.2% (n = 78/162) had never had a Pap smear. Of younger women, 89.0% (n = 105/118) never had a Pap smear, but had significantly more low-grade squamous intraepithelial lesions (LSIL) and other HR-HPV infection than older women (12.7%[n = 15/118] vs 4.9%[n = 8/162], p = 0.0193; and 49.2%[n = 58/118] vs 29.0%[n = 47/162], p = 0.0006; respectively). HIV-positive women had more abnormal cytology results and infection with other HR-HPV types or co-infection with other HR-HPV type(s)/HPV-16 compared to HIV-negative women (35.1%[n = 20/57] vs 13.9%[n = 31/223], p = 0.0002; 56.1%[n = 32/57] vs 32.7%[n = 73/223], p = 0.001; and 12.3%[n = 7/57] vs 4.9%[n = 11/223], p = 0.044; respectively). Of 57 HIV-positive women, 45.6% (n = 26) already knew their HIV status; of which 69.2% were on ART and 34.6% never had a Pap smear.

CONCLUSION

South African women have high rates of HIV, Pap smear abnormalities and HR-HPV, with low cervical cancer screening coverage. SA cervical cancer screening policy excludes (undiagnosed) HIV-positive and HIV-negative women <30 years, both populations found to have high prevalence of HR-HPV. HPV-based primary screening from 25 years could improve outcomes.

Comparative analysis of N95 respirators fit testing with commercially available and in house reagent

Background

Due to COVID-19, thousands of healthcare workers have been affected and have lost their lives in the line of duty. For the protection of healthcare workers, WHO and CDC have made standard guidelines and requirements for PPE use. N95 masks are amongst the most readily used PPE by healthcare professionals and it is highly recommended by OSHA that every make and model of N95 should go through a fit test at least once in a year.

Method

A total of 30 randomly selected healthcare professionals (who were a regular user of N95 respiratory masks) were subjected to assess in-house (saccharin sodium benzoate) reagent for use for standard qualitative fit testing in our hospital. Threshold testing with the in-house reagent at three different concentrations was performed prior to establish participants' sensitivity to the reagent. After successful completion of threshold testing, fit test was performed on participants wearing an N95 mask.

Results

All the participants included in the study passed the sensitivity testing with three concentrations of the reagents, while it was concluded that the concentration of the in-house reagent that was well suited for the sensitivity testing was a concentration of 1g/dl saccharin with 10g/dl sodium benzoate. For fit testing 12g/dl was found to be more appropriate.

Discussion

Our study provided a low cost solution to ensure safety of healthcare workers who are regular users of N95 masks following guidelines implemented by OSHA and CDC.

Conclusion

The in-house test solution prepared was found to be equally sensitive to its commercially available counterpart.