Role of the primary care safety net in pandemic influenza

Trends in decision-making by primary care physicians regarding common infectious complaints

BACKGROUND

Primary care physicians played an important role in the global response during the COVID-19 pandemic, but with the absence of laboratory and diagnostics services, the move to telehealth and the focus on respiratory assessment, they faced increased uncertainty when making clinical decisions.

OBJECTIVES

This paper aims to examine the impact of the pandemic on decisions made by primary care physicians, as measured by referrals to chest X-ray and laboratory tests and by prescriptions of antibiotics.

METHODS

We conducted a retrospective study of all visits recorded with fever or cough, presenting to 209 community clinics in Southern Israel during the years 2018-2022. We describe changes in outcome rates across time and use multivariate generalised linear mixed effects model to compare the odds of referrals and prescriptions between periods, while accounting for gender, age, clinic sector, visit type, diagnosis, and season.

RESULTS

In total, 609,823 visits to primary care physicians complied with the cohort definitions. Social restrictions were associated with a decline in all measured outcomes for primary care physician decisions, most prominently among ages 20-59, for throat culture referral during the first lockdown (OR = 0.46) and for cephalosporine prescription during the second lockdown (OR = 0.55). This trend persisted following the cancellation of the restrictions.

CONCLUSIONS

Despite higher uncertainty during the COVID-19 social restrictions, the overall course of clinical decision-making processes was maintained, and was associated with a reduction in the use of auxiliary resources, which can improve the quality of patient care by lowering costs and supporting prevention of future antibiotics resistance.

Association between characteristics of employing healthcare facilities and healthcare worker infection rates and psychosocial experiences during the COVID-19 pandemic

BACKGROUND

Healthcare facility characteristics, such as ownership, size, and location, have been associated with patient outcomes. However, it is not known whether the outcomes of healthcare workers are associated with the characteristics of their employing healthcare facilities, particularly during the COVID-19 pandemic.

METHODS

This was an analysis of a nationwide registry of healthcare workers (the Healthcare Worker Exposure Response and Outcomes (HERO) registry). Participants were surveyed on their personal, employment, and medical characteristics, as well as our primary study outcomes of COVID-19 infection, access to personal protective equipment, and burnout. Participants from healthcare sites with at least ten respondents were included, and these sites were linked to American Hospital Association data to extract information about sites, including number of beds, teaching status, urban/rural location, and for-profit status. Generalized estimating equations were used to estimate linear regression models for the unadjusted and adjusted associations between healthcare facility characteristics and outcomes.

RESULTS

A total of 8,941 healthcare workers from 97 clinical sites were included in the study. After adjustment for participant demographics, healthcare role, and medical comorbidities, facility for-profit status was associated with greater odds of COVID-19 diagnosis (aOR 1.76, 95% CI 1.02-3.03, p = .042). Micropolitan location was associated with decreased odds of COVID-19 infection after adjustment (aOR = 0.42, 95% CI 0.24, 0.71, p = .002. For-profit facility status was associated with decreased odds of burnout after adjustment (aOR = 0.53, 95% CI 0.29-0.98), p = .044).

CONCLUSIONS

For-profit status of employing healthcare facilities was associated with greater odds of COVID-19 diagnosis but decreased odds of burnout after adjustment for demographics, healthcare role, and medical comorbidities. Future research to understand the relationship between facility ownership status and healthcare outcomes is needed to promote wellbeing in the healthcare workforce.

TRIAL REGISTRATION

The registry was prospectively registered: ClinicalTrials.gov Identifier (trial registration number) NCT04342806, submitted April 8, 2020.

The roles and challenges of the primary health care systems in epidemic management: a scoping review

BACKGROUND AND AIM

During the early stage of pandemics, primary health care (PHC) is the first point of contact with the health system for people. This study aimed to find the leading roles and challenges of the PHC system in dealing with the outbreak of infectious diseases.

METHODS

The current scoping review was conducted in 2022 using the Arkesy and O'Malley framework. A bibliographic search was conducted in PubMed, Web of Science, and Scopus databases. Following a Google Scholar search, a manual search in some journals, reference checks for articles, and a review of organizational reports, websites, and other sources of information were also conducted. Data were analyzed using the content-analysis method.

FINDINGS

Finally, 65 documents (42 articles and 23 reports, books, and news) were included in the study. Initially, 626 codes were extracted, and 132 final codes were categorized into eight main themes and 44 sub-themes. The main themes for the roles of PHC included: service provision, education and knowledge, surveillance, access, coordination and communication, management and leadership, infrastructure change and rapid preparation, and patient and community management. Regarding the challenges faced by PHC in the epidemic of infectious diseases, 24 key challenges were identified and categorized into four major areas.

CONCLUSIONS

Based on the results of the present study, there is a need for further studies to formulate and theorize the specific roles of PHC in managing infectious disease epidemics. The results of this study can be utilized by researchers and officials to inform their efforts in addressing this purpose.

Learning from intersectoral initiatives to respond to the needs of refugees, asylum seekers, and migrants without status in the context of COVID-19 in Quebec and Ontario: a qualitative multiple case study protocol

BACKGROUND

Refugees, asylum seekers, and migrants without status experience precarious living and working conditions that disproportionately expose them to coronavirus disease 2019 (COVID-19). In the two most populous Canadian provinces (Quebec and Ontario), to reduce the vulnerability factors experienced by the most marginalized migrants, the public and community sectors engage in joint coordination efforts called intersectoral collaboration. This collaboration ensures holistic care provisioning, inclusive of psychosocial support, assistance to address food security, and educational and employment assistance. This research project explores how community and public sectors collaborated on intersectoral initiatives during the COVID-19 pandemic to support refugees, asylum seekers, and migrants without status in the cities of Montreal, Sherbrooke, and Toronto, and generates lessons for a sustainable response to the heterogeneous needs of these migrants.

METHODS

This theory-informed participatory research is co-created with socioculturally diverse research partners (refugees, asylum seekers and migrants without status, employees of community organizations, and employees of public organizations). We will utilize Mirzoev and Kane's framework on health systems' responsiveness to guide the four phases of a qualitative multiple case study (a case being an intersectoral initiative). These phases will include (1) building an inventory of intersectoral initiatives developed during the pandemic, (2) organizing a deliberative workshop with representatives of the study population, community, and public sector respondents to select and validate the intersectoral initiatives, (3) interviews (n = 80) with community and public sector frontline workers and managers, municipal/regional/provincial policymakers, and employees of philanthropic foundations, and (4) focus groups (n = 80) with refugees, asylum seekers, and migrants without status. Qualitative data will be analyzed using thematic analysis. The findings will be used to develop discussion forums to spur cross-learning among service providers.

DISCUSSION

This research will highlight the experiences of community and public organizations in their ability to offer responsive services for refugees, asylum seekers, and migrants without status in the context of a pandemic. We will draw lessons learnt from the promising practices developed in the context of COVID-19, to improve services beyond times of crisis. Lastly, we will reflect upon our participatory approach-particularly in relation to the engagement of refugees and asylum seekers in the governance of our research.

The impact of the COVID-19 pandemic on primary care physicians and nurses in Nova Scotia: a qualitative exploratory study

BACKGROUND

The COVID-19 pandemic has brought immense disruption worldwide, dramatically altering the ways we live, work and learn on a day-to-day basis; however, few studies have investigated this from the perspective of primary care providers. In this study, we sought to explore the experiences of primary care providers in the province of Nova Scotia, with the intention of understanding the impact of the COVID-19 pandemic on primary care providers' ability to provide care, their information pathways, and the personal and professional impact of the pandemic.

METHODS

We conducted an exploratory qualitative research study involving semistructured interviews conducted via Zoom videoconferencing or telephone with primary care providers (physicians, nurse practitioners and family practice nurses) who self-identified as working in primary health care in Nova Scotia from June 2020 to April 2021. We performed a thematic analysis involving coding and classifying data according to themes. Emergent themes were then interpreted by seeking commonalties, divergence, relationships and overarching patterns in the data.

RESULTS

Twenty-four primary care providers were interviewed. Subsequent analysis identified 4 interrelated themes within the data: disruption to work-life balance, disruptions to "non-COVID-19" patient care, impact of provincial and centralized policies, and filtering and processing an influx of information.

INTERPRETATION

Our findings showed that managing a crisis of this magnitude requires coordination and new ways of working, balancing professional and personal life, and adapting to already implemented changes (i.e., virtual care). A specific primary care pandemic response plan is essential to mitigate the impact of future health care crises.

Building a Data Bridge: Policies, Structures, and Governance Integrating Primary Care Into the Public Health Response to COVID-19

PURPOSE

The effective integration of primary care into public health responses to the COVID-19 pandemic, particularly through data sharing, has received some attention in the literature. However, the specific policies and structures that facilitate this integration are understudied. This paper describes the experiences of clinicians and administrators in Alberta, Canada as they built a data bridge between primary care and public health to improve the province's community-based response to the pandemic.

METHODS

Fifty-seven semistructured qualitative interviews were conducted with a range of primary care and public health stakeholders working inside the Calgary Health Zone. Interpretive description was used to analyze the interviews.

RESULTS

SARS-CoV-2 test results produced by the local public laboratory were, initially, only available to central public health clinicians and not independent primary care physicians. This enabled centrally managed contact tracing but meant primary care physicians were unaware of their patients' COVID-19 status and unable to offer in-community follow-up care. Stakeholders from both central public health and independent primary care were able to leverage a policy commitment to the Patient Medical Home (PMH) care model, and a range of existing organizational structures, and governance arrangements to create a data bridge that would span the gap.

CONCLUSIONS

Primary care systems looking to draw lessons from the data bridge's construction may consider ways to: leverage care model commitments to integration and adjust or create organization and governance structures which actively draw together primary care and non-primary care stakeholders to work on common projects. Such policies and structures develop trusting relationships, open the possibility for champions to emerge, and create the spaces in which integrative improvisation can take place.

Effect of COVID-19 Pandemic on Maternal and Child Health Services and Strategies for Effective Service Implementation in Ethiopia

Introduction

The COVID-19 pandemic is a global burden to the Health sector of developing countries. However, the effect of COVID-19 on maternal and child health services is scarce and no evidence was documented in the Ethiopian context. Hence, this particular study aimed to examine the effect of the pAndemic and to identify effective strategies in Ethiopia.

Methods

Both quantitative and qualitative approaches were applied. For the qualitative, 74 study participants were considered. Study participants were selected purposively and interview guide was used to collect data. Finally audio records were transcribed verbatim, coded and analyzed thematically. For the quantitative, data were extracted from the DHIS2 reports to assess the trend over time.

Results

The qualitative findings indicated that the pandemic affected the MNCH services to be inaccessible and low quality. The trend analysis also showed that the COVID-19 has disrupted MNCH services particularly in the first two months Of the pandemic. Health workers also faced a scarcity of personal protective equipment, work overload and shortage Of resources during the pandemic. As a cope up strategy, the Health system at all levels has established a COVID-19 task force supported by a working guideline. There is also a media prevention program, establishment of quarantine at home, resource mobilization, active surveillance, availing extra ambulances and strong follow-up.

Conclusion

Multiple interventions applied to curb the pandemic have lowered MNCH service utilization. The low commitment of health workers, resources shortage and movement restrictions had a an impact on the uptake of MCH services. There should be a balance in resource utilization to COVID and other essential Health services and the government should avail the necessary supplies during the COVID era. Regionally tailored adaptive interventions are also required to improve MNCH service uptake. Extensive media advocacy and HEWs active involvement for community mobilization are also recommended.

Views from the trenches: California family physicians' challenges and resilience factors while providing patient care during the initial wave of COVID-19

This study examined challenges and factors promoting resilience among 20 California family physicians (FPs) during the first six months of the COVID-19 pandemic. A subset of academic, community, and resident FPs who responded to an online survey also participated in a semi-structured interview that explored concerns, moral distress, burnout, resource needs, support systems, coping strategies, and motivation to continue caring for patients. Thematic analysis was used to identify common themes in participant interviews. Interviewees demonstrated adaptability, resilience, and grit (i.e., commitment to completing a valued goal in the face of setbacks and adversity) despite challenges disrupting patient care, fears for family and self, and frustration due to the politicization of the pandemic. Factors promoting well-being and perseverance included professional and personal support, strong coping skills, and focusing on the meaning derived from practicing medicine. A service orientation that permeates family medicine philosophy and values motivated practitioners to continue to provide patient care while dealing with overwhelming personal and structural challenges. FPs drew strength from their internal coping skills, core family medicine values, and external support, notwithstanding demoralizing effects of mixed messages and politicization of the pandemic. FPs demonstrated resilience and grit in the face of challenges created by the COVID-19 pandemic. Ensuring adequate resources to promote a physically and psychologically healthy workforce while increasing access to care for all patients is crucial to prepare for the next healthcare crisis.

Health and Healthcare Variables Associated with Italy's Excess Mortality during the First Wave of the COVID-19 pandemic: An Ecological Study

Background

Healthcare factors have strongly influenced the propagation of COVID-19. This study aims to examine whether excess mortality during the first phase of the COVID-19 outbreak in Italy was associated with health, healthcare, demographic, and socioeconomic, provincial-level indicators.

Methods

This ecological study concerns the raw number of deaths reported from February 1 to April 30, 2020 and the mean number of deaths occurred during the same months from 2015 to 2019, per province. Information on socioeconomic factors and healthcare settings was extracted from updated databases on the Italian National Institute of Statistics (ISTAT) website. A multivariate model and four multilevel models were constructed to test the association between excess mortality and the analysed indicators across 107 Italian provinces.

Results

The hospitalization rate in long-term care wards and the cardiovascular disease mortality rate correlate positively with excess mortality (p <0.05), while higher densities of licensed physicians and of general practitioners are associated with lower excess mortality (p <0.05). After controlling for the COVID-19 cumulative incidence in each province, only the density of licensed physicians remains negatively associated with excess mortality (p <0.01).

Conclusion

Some health and healthcare variables (in particular, the density of physicians) are strongly associated with excess mortality during the first wave of the COVID-19 pandemic in Italy and should be targeted to increase the resilience of health systems.

Health-seeking behavior of COVID-19 cases during the first eight weeks of the outbreak in Singapore: differences between local community and imported cases and having visits to single or multiple healthcare providers

Background

COVID-19 is a novel pandemic affecting almost all countries leading to lockdowns worldwide. In Singapore, locally-acquired cases emerged after the first wave of imported cases, and these two groups of cases may have different health-seeking behavior affecting disease transmission. We investigated differences in health-seeking behavior between locally-acquired cases and imported cases, and within the locally-acquired cases, those who saw single versus multiple healthcare providers.

Methods

We conducted a retrospective study of 258 patients who were diagnosed with COVID-19 from 23 January to 17 March 2020. Variables related to health-seeking behavior included number of visits prior to hospitalization, timing of the first visit, duration from symptom onset to admission, and places where the cases had at least one visit.

Results

Locally-acquired cases had longer duration from onset of symptoms to hospital admission (median 6 days, interquartile range [IQR] 4–9) than imported cases (median 4 days, IQR 2–7) (p < 0.001). Singapore residents were more likely to have at least one visit to private clinics and/or government-subsidized public clinics than non-residents (84.0% vs. 58.7%, p < 0.001). Among locally-acquired cases, those who sought care from a single healthcare provider had fewer visits before their hospital admissions compared with those who went to multiple providers (median 2 vs. 3, p = 0.001).

Conclusion

Our study indicates the need to encourage individuals to seek medical attention early on in their patient journey, particularly from the same healthcare provider. This in turn, would facilitate early detection and isolation, hence limiting local transmission and enabling better control of the COVID-19 outbreak.

The Role of a Federally Qualified Health Center in Identification and Management of an Occupational COVID-19 Outbreak: Lessons for Future Infection Surveillance and Response

Federally Qualified Health Centers (FQHCs) have been essential in response to COVID-19 outbreaks among vulnerable populations. Our rural FQHC had a primary role in early detection of and response to a poultry plant-related outbreak at the outset of the pandemic that disproportionately and gravely affected the local Hispanic community. The health center activated a rapid local response that included the community's first mass testing event and first acute respiratory treatment clinic, both of which were central to abatement. Lessons learned from this experience provide important guidance for the potential role of FQHCs in infection outbreak preparedness in marginalized communities.

COVID-19 Vaccine Concerns and Acceptability by Language in a Marginalized Population in Rhode Island

INTRODUCTION

We need to understand the continued concerns and acceptability of COVID-19 vaccines within marginalized communities in the United States. Our study explores the concerns and acceptability of COVID-19 vaccines, by language group, at a Federally Qualified Health Center (FQHC) in Rhode Island.

METHODS

We conducted an exploratory, mixed data collection telephone survey in languages spoken in the community (Spanish, Cape Verdean (CV) Creole/Portuguese, and English). Participants were asked about their COVID-19 vaccination status, as well as vaccine concerns and acceptability via 9 closed-ended and 2 open-ended questions. Chi squared and multivariate analysis was used to compare concerns and acceptability across languages. Coding and immersion/crystallization techniques were used to identify qualitative data themes.

RESULTS

The overall response rate was 58%. Side effects were cited as the most frequent (66%) concern among all language groups. Concern about the speed of vaccine development, vaccine ingredients, and being in a research trial varied significantly by language. Qualitative findings included concerns about chronic medical conditions and generalized fear of vaccine safety. English speakers were the most likely to report concerns and CV Creole/Portuguese speakers were the least likely to report concerns about the vaccine. Spanish and CV Creole/Portuguese participants who were not yet vaccinated reported higher acceptability to receive the vaccine compared to English speakers, with odds ratios of 2.00 (95% CI: 1.00-4.00) and 1.27 (95% CI: 0.62-2.60), respectively.

CONCLUSION

To mitigate the effects of the COVID-19 pandemic and prepare for future pandemics, strategies must be based on understanding the beliefs and perceptions of marginalized communities.

Experiences made by family physicians managing patients with SARS-CoV-2 infection during spring 2020 - a cross-sectional analysis

BACKGROUND

In Germany, family physicians care for about 85% of the patients infected with SARS-CoV-2. The geographic distribution of the first wave in 2020 was heterogeneous, and each federal state experienced different percentages of patients that died from COVID-19. Each of the 16 federal states implemented its own regulation about medical care for SARS-CoV-2 infected patients. Against this background, the objective of this analysis was to gather experiences made by primary care physicians managing SARS-CoV-2 infected patients during the first wave in March 2020 and to clinically characterize these patients.

METHODS

In total, 5,632 physicians were invited to participate in an online questionnaire surveying routine data regarding the general care situation at the physician practice level and the care for patients infected with SARS-CoV-2. Bivariate and multivariate analyses were applied to characterize treatment experiences and to identify patient characteristics predicting the course of disease.

RESULTS

132 family physicians from all German federal states (except from Berlin) participated in this analysis (response rate 2.3%) and provided routine care data for 1,085 patients. Information from 373 of these patients were provided in greater detail. On average, each physician treated 8.5 patients infected with SARS-CoV-2. About 15% of the physicians used video consultations to communicate with their infected patients. More than 82% made positive experiences with the exceptional regulation to provide a certificate of incapacity to work by telephone. Half of the physicians faced equipment insufficiencies due to a lack of protective gear, and in 10% of the practices, the staff themselves acquired SARS-CoV-2 infection. Greater numbers of SARS-CoV-2 cases treated in a practice translated into higher odds for members of the practice to get infected (odds ratio (OR) 1.03, 95% CI [1.01;1.06]). Older persons, males and patients in rural areas had higher odds of a severe course of disease.

CONCLUSIONS

Our results show that a large percentage of primary care physicians additionally managed their COVID-19 patients remotely by telephone or video during the outbreak, while also being at a higher risk for SARS-CoV-2 infection. Further, the increased severity in rural areas underlines the importance of strong primary health care in order to enable hospitals to concentrate on critically ill patients.

Analysing the impact of COVID-19 on the mothers of Bangladesh: hearing the unheard

Aim

The purpose of this empirical study was to understand, explore and analyse how the COVID-19 pandemic has affected the mothers of our society, with particular emphasis on Bangladesh, which has so far been a relatively unexplored area.

Subject and methods

The study adopted qualitative and interpretative methods of social research, including content analysis and a perception study of 223 respondents through a semi-structured questionnaire survey, who were selected using purposive random sampling. The data obtained from the perception study was further complemented through phone interviews.

Results

The study found that the pandemic has not affected all mothers uniformly; rather, the intensity of its impact varied depending on factors such as the occupation of mothers and their husbands and their family pattern. Despite such variation, all mothers experienced a subsequent increase in workload, challenges while availing routine health facilities and higher levels of stress, anxiety, depression and certain behavioural changes.

Conclusion

However, the worst affected have been the mothers belonging to the lower socio-economic strata because the pandemic has made them and their husbands jobless, leading them towards an uncertain future.

Disaster Management in Rural and Remote Primary Health Care: A Scoping Review

OBJECTIVE

This scoping review aims to map the roles of rural and remote primary health care professionals (PHCPs) during disasters.

INTRODUCTION

Disasters can have catastrophic impacts on society and are broadly classified into natural events, man-made incidents, or a mixture of both. The PHCPs working in rural and remote communities face additional challenges when dealing with disasters and have significant roles during the Prevention, Preparedness, Response, and Recovery (PPRR) stages of disaster management.

METHODS

A Johanna Briggs Institute (JBI) scoping review methodology was utilized, and the search was conducted over seven electronic databases according to a priori protocol.

RESULTS

Forty-one papers were included and sixty-one roles were identified across the four stages of disaster management. The majority of disasters described within the literature were natural events and pandemics. Before a disaster occurs, PHCPs can build individual resilience through education. As recognized and respected leaders within their community, PHCPs are invaluable in assisting with disaster preparedness through being involved in organizations' planning policies and contributing to natural disaster and pandemic surveillance. Key roles during the response stage include accommodating patient surge, triage, maintaining the health of the remaining population, instituting infection control, and ensuring a team-based approach to mental health care during the disaster. In the aftermath and recovery stage, rural and remote PHCPs provide long-term follow up, assisting patients in accessing post-disaster support including delivery of mental health care.

CONCLUSION

Rural and remote PHCPs play significant roles within their community throughout the continuum of disaster management. As a consequence of their flexible scope of practice, PHCPs are well-placed to be involved during all stages of disaster, from building of community resilience and contributing to early alert of pandemics, to participating in the direct response when a disaster occurs and leading the way to recovery.

Empowering primary healthcare institutions against COVID-19 pandemic: A health system-based approach

Primary health care institutions (PHCIs) are an essential foundation for the national response to COVID-19 disease in India. With the soaring number of confirmed cases, the health system is currently under unprecedented stress. In this scenario, there is a pressing need for empowering PHCIs in COVID-19 preparedness and response. The World Health Organization's (WHO) "Health system building block" approach is a classic model, which can work as a road map for the national health system in the process of empowering PHCIs against COVID-19 as well as other upcoming global and regional public health emergencies.

Fighting against COVID-19: preparedness and implications on clinical practice in primary care in Shenzhen, China

Background

The new coronavirus pneumonia (NCP) caused by COVID-19 has affected more than 46 million people worldwide. In China, primary care has played a vital role during the COVID-19 outbreak, and it is important to examine the challenges faced by general practitioners (GPs). This study investigated the roles, preparedness and training needs of GPs in China in managing the NCP outbreak. Based on the outcomes of the study, we hope to take lessons and identify how GPs could be supported in delivering their gatekeeping roles and clinical duties in times of infectious disease outbreak.

Methods

An online survey on the official website of Shenzhen Continuing Education Center. It included questions on GPs’ demographics, their awareness of COVID-19 and their preparedness in managing suspected cases of NCP, as well as referrals and their training needs. Conditional multi-variate logistic models were used to investigate the relationships between GPs’ preparedness, situational confidence and anxiety.

Results

GPs’ clinical practice was significantly affected. GPs endeavoured to answer a flood of COVID-19-related enquiries, while undertaking community preventive tasks. In addition to in-person consultations, GP promoted COVID-19 awareness and education through telephone consultations, physical posters and social media. Overall GPs in Shenzhen felt well supported with adequate Personal Protective Equipment (PPE) and resources from secondary care services. Higher levels of self-perceived preparedness (OR = 2.19; 95%CI, 1.04–4.61), lower level of anxiety (OR = 0.56; 95%CI, 0.29–1.09) and fewer perceived family worries (OR = 0.37; 95%CI, 0.12–1.12) were associated with better confidence in coping at work.

Conclusions

Training and supporting GPs while reducing their (and their families’) anxiety increase their confidence in delivering the important roles of gatekeeping in face of major disease outbreaks.

Committing to Continuity: Primary Care Practices During COVID-19 in an Urban Brazilian Neighborhood

Decreased engagement in preventive services, including vaccination, during the COVID-19 pandemic represents a grave threat to global health. We use the case of the Bom Retiro Public Health Clinic in São Paulo, Brazil, to underscore how continuity of care is not only feasible, but a crucial part of health as a human right. The long-standing relationship between the clinic and neighborhood residents has facilitated ongoing management of physical and mental health conditions. Furthermore, we demonstrate how the clinic's history of confronting infectious diseases has equipped it to adapt preventive services to meet patients' needs during the pandemic. Our academic-community partnership used a multidisciplinary approach, relying on analysis of historical data, ethnographic data, and direct clinical experience. We identify specific prevention strategies alongside areas for improvement. We conclude that the clinic serves as a model for continuity of care in urban settings during a pandemic.

National primary care responses to COVID-19: a rapid review of the literature

OBJECTIVE

The aim of this review, conducted in April 2020, is to examine available national primary care guidelines for COVID-19 and to explore the ways in which these guidelines support primary care facilities in responding to the demands of the COVID-19 pandemic.

DESIGN

Rapid review and narrative synthesis.

DATA SOURCES

PubMed, Embase and Google, as well as the websites of relevant national health departments, were searched from 1 January 2020 to 24 April 2020.

ELIGIBILITY CRITERIA

Documents included must be issued by a national health authority, must be specific to COVID-19 care, directed at healthcare workers or managers, and must refer to the role of primary care in the COVID-19 response.

RESULTS

We identified 17 documents from 14 countries. An adapted framework on primary care challenges and responses to pandemic influenza framed our analysis. Guidelines generally reported on COVID-19 service delivery and mostly made specific recommendations for ensuring continued delivery of essential primary care services through telehealth or other virtual care modalities. Few offered guidance to support surveillance as a public health function. All offered guidance on implementing outbreak control measures, largely through flexible and coordinated organisational models with partners from various sectors. There was a lack of guidance to support supply chain management and practice resilience in primary care, and lack of personal protective equipment represents a serious threat to the provision of quality care during the pandemic.

CONCLUSIONS

Current national primary care guidelines for COVID-19 provide guidance on infection control and minimising the risk of spread in primary care practices, while supporting the use of new technology and coordinated partnerships. However, to ensure primary care practice resilience and quality of care are upheld, guidelines must offer recommendations on supply chain management and operational continuity, supported by adequate resources.

Convalescent Plasma Therapy for Management of COVID-19: Perspectives and Deployment in the Current Global Pandemic

The world is striving against the severe crisis of the COVID-19 pandemic. Healthcare professionals are struggling to treat their patients based on nonspecific therapies. Amidst this uncertainty, convalescent plasma therapy (CPT) has appeared to be an interim adjuvant therapy for severely ill patients of COVID-19 until long-term clinical trial treatment options are available. Considering the transfusion-related hazards, especially lung injuries and microbial transmission, where sensitivity is not ensured, rigorous trials should be conducted to determine this therapy's efficacy. Moreover, the ratio of recovered cases to plasma donors is not satisfying, which questioning this therapy's availability and accessibility. Although some countries are making the treatment free, the attributable cost mandates a justification for its suitability and sustainability. Our article aimed to review the published facts and findings of CPT's effectiveness in lowering the mortality rate of COVID-19. This pandemic showed that healthcare systems worldwide need core reform. A unified global collaboration must align and coordinate to face the current pandemic and enhance world readiness for future outbreaks based on health equity and equality.

The Role of Primary Care in a Pandemic: Reflections During the COVID-19 Pandemic in Canada

As COVID-19 cases began to rise in Ontario, Canada, in March 2020, increasing surge capacity in hospitals and intensive care units became a large focus of preparations. As part of these preparations, primary care physicians were ready to be redeployed to the hospitals. However, due to the effective implementation of community-wide public health measures, the hospital system was not overwhelmed. As Ontario prepares now for a potential second wave of COVID-19, primary care physicians have an opportunity to consider the full breadth and depth of scope for primary care during a pandemic. From planning to surveillance to vaccination, primary care physicians are positioned to play a unique and vital role in a pandemic. Nevertheless, there are specific barriers that will need to be overcome.

The Role of Family Physicians in a Pandemic: A Blueprint

Pandemics are a significant stress test for a country’s economic, political and health systems. An effective pandemic response demands a multi-pronged and multi-layered approach, comprising surveillance, containment, border control, as well as various social and community measures. In the wake of the novel coronavirus disease 2019 (COVID-19) pandemic, which has now infected more than 7 million people worldwide, strict quarantine measures are a commonplace, and a third of the world’s population have now gone into some form of lockdown. With the exception of border control, all these response measures involve the contributions of family physicians and general practitioners (GPs) in one way or another. Primary care physicians form and lead the primary care network, which in turn forms the backbone of any healthcare system. Being the first point of contact for a significant proportion of patients, primary care physicians play an essential strategic function in the fight against disease, both during peacetime and in the event of a public health crisis. In this commentary, we examine and propose some of the key roles that they play in a pandemic, drawing examples from the current COVID-19 pandemic and past experiences. COVID-19 has showed us that the world is grossly unprepared for a pandemic, both in terms of our global management and the structure of our current primary health care systems, and this should provide the impetus for us to improve.

Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study

BACKGROUND

While the COVID-19 pandemic will increase mortality due to the virus, it is also likely to increase mortality indirectly. In this study, we estimate the additional maternal and under-5 child deaths resulting from the potential disruption of health systems and decreased access to food.

METHODS

We modelled three scenarios in which the coverage of essential maternal and child health interventions is reduced by 9·8-51·9% and the prevalence of wasting is increased by 10-50%. Although our scenarios are hypothetical, we sought to reflect real-world possibilities, given emerging reports of the supply-side and demand-side effects of the pandemic. We used the Lives Saved Tool to estimate the additional maternal and under-5 child deaths under each scenario, in 118 low-income and middle-income countries. We estimated additional deaths for a single month and extrapolated for 3 months, 6 months, and 12 months.

FINDINGS

Our least severe scenario (coverage reductions of 9·8-18·5% and wasting increase of 10%) over 6 months would result in 253 500 additional child deaths and 12 200 additional maternal deaths. Our most severe scenario (coverage reductions of 39·3-51·9% and wasting increase of 50%) over 6 months would result in 1 157 000 additional child deaths and 56 700 additional maternal deaths. These additional deaths would represent an increase of 9·8-44·7% in under-5 child deaths per month, and an 8·3-38·6% increase in maternal deaths per month, across the 118 countries. Across our three scenarios, the reduced coverage of four childbirth interventions (parenteral administration of uterotonics, antibiotics, and anticonvulsants, and clean birth environments) would account for approximately 60% of additional maternal deaths. The increase in wasting prevalence would account for 18-23% of additional child deaths and reduced coverage of antibiotics for pneumonia and neonatal sepsis and of oral rehydration solution for diarrhoea would together account for around 41% of additional child deaths.

INTERPRETATION

Our estimates are based on tentative assumptions and represent a wide range of outcomes. Nonetheless, they show that, if routine health care is disrupted and access to food is decreased (as a result of unavoidable shocks, health system collapse, or intentional choices made in responding to the pandemic), the increase in child and maternal deaths will be devastating. We hope these numbers add context as policy makers establish guidelines and allocate resources in the days and months to come.

FUNDING

Bill & Melinda Gates Foundation, Global Affairs Canada.

Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study

BACKGROUND

While the COVID-19 pandemic will increase mortality due to the virus, it is also likely to increase mortality indirectly. In this study, we estimate the additional maternal and under-5 child deaths resulting from the potential disruption of health systems and decreased access to food.

METHODS

We modelled three scenarios in which the coverage of essential maternal and child health interventions is reduced by 9·8-51·9% and the prevalence of wasting is increased by 10-50%. Although our scenarios are hypothetical, we sought to reflect real-world possibilities, given emerging reports of the supply-side and demand-side effects of the pandemic. We used the Lives Saved Tool to estimate the additional maternal and under-5 child deaths under each scenario, in 118 low-income and middle-income countries. We estimated additional deaths for a single month and extrapolated for 3 months, 6 months, and 12 months.

FINDINGS

Our least severe scenario (coverage reductions of 9·8-18·5% and wasting increase of 10%) over 6 months would result in 253 500 additional child deaths and 12 200 additional maternal deaths. Our most severe scenario (coverage reductions of 39·3-51·9% and wasting increase of 50%) over 6 months would result in 1 157 000 additional child deaths and 56 700 additional maternal deaths. These additional deaths would represent an increase of 9·8-44·7% in under-5 child deaths per month, and an 8·3-38·6% increase in maternal deaths per month, across the 118 countries. Across our three scenarios, the reduced coverage of four childbirth interventions (parenteral administration of uterotonics, antibiotics, and anticonvulsants, and clean birth environments) would account for approximately 60% of additional maternal deaths. The increase in wasting prevalence would account for 18-23% of additional child deaths and reduced coverage of antibiotics for pneumonia and neonatal sepsis and of oral rehydration solution for diarrhoea would together account for around 41% of additional child deaths.

INTERPRETATION

Our estimates are based on tentative assumptions and represent a wide range of outcomes. Nonetheless, they show that, if routine health care is disrupted and access to food is decreased (as a result of unavoidable shocks, health system collapse, or intentional choices made in responding to the pandemic), the increase in child and maternal deaths will be devastating. We hope these numbers add context as policy makers establish guidelines and allocate resources in the days and months to come.

FUNDING

Bill & Melinda Gates Foundation, Global Affairs Canada.

Ebola, Zika, Corona…What Is Next for Our World?

In the past century, there have been several pandemics. Within the context of global health, these pandemics have often been viewed from the lens of determinants such as population, poverty, and pollution. With an ever-changing world and the COVID-19 pandemic, the current global determinants of public health need to be expanded. In this editorial, we explore and redefine the major determinants of global public health to prevent future pandemics. Policymakers and global leaders should keep at heart the determinants suggested hereby in any planning, implementation, and evaluation of efforts to improve global public health and prevent pandemics.

No-Notice Mystery Patient Drills to Assess Emergency Preparedness for Infectious Diseases at Community Health Centers in New York City, 2015-2016

Mystery patient drills using simulated patients have been used in hospitals to assess emergency preparedness for infectious diseases, but these drills have seldom been reported in primary care settings. We conducted three rounds of mystery patient drills designed to simulate either influenza-like illness (ILI) or measles at 41 community health centers in New York City from April 2015 through December 2016. Among 50 drills conducted, 49 successfully screened the patient–actor (defined as provision of a mask or referral to the medical team given concern of infection requiring potential isolation), with 35 (70%) drills completing screening without any challenges. In 47 drills, the patient was subsequently isolated (defined as placement in a closed room to limit transmission), with 29 (58%) drills completing isolation without any challenges. Patient–actors simulating ILI were more likely to be masked than those simulating measles (93% vs. 59%, p = 0.007). Median time to screening was 2 min (interquartile range [IQR] 2–6 min) and subsequently to isolation was 1 min (IQR 0–2 min). Approximately 95% of participants reported the drill was realistic and prepared them to deal with the hazards addressed. Qualitative analysis revealed recurring themes for strengths (e.g., established protocols, effective communication) and areas for improvement (e.g., hand hygiene, explaining isolation rationale). We conclude that mystery patient drills are an effective and feasible longitudinal collaboration between health departments and primary care clinics to assess and inform emergency preparedness for infectious diseases.

Primary Care Emergency Preparedness Network, New York City, 2015: Comparison of Member and Nonmember Sites

OBJECTIVES

To assess whether Primary Care Emergency Preparedness Network member sites reported indicators of preparedness for public health emergencies compared with nonmember sites. The network-a collaboration between government and New York City primary care associations-offers technical assistance to primary care sites to improve disaster preparedness and response.

METHODS

In 2015, we administered an online questionnaire to sites regarding facility characteristics and preparedness indicators. We estimated differences between members and nonmembers with natural logarithm-linked binomial models. Open-ended assessments identified preparedness gaps.

RESULTS

One hundred seven sites completed the survey (23.3% response rate); 47 (43.9%) were nonmembers and 60 (56.1%) were members. Members were more likely to have completed hazard vulnerability analysis (risk ratio [RR] = 1.94; 95% confidence interval [CI] = 1.28, 2.93), to have identified essential services for continuity of operations (RR = 1.39; 95% CI = 1.03, 1.86), to have memoranda of understanding with external partners (RR = 2.49; 95% CI = 1.42, 4.36), and to have completed point-of-dispensing training (RR = 4.23; 95% CI = 1.76, 10.14). Identified preparedness gaps were improved communication, resource availability, and train-the-trainer programs. Public Health Implications. Primary Care Emergency Preparedness Network membership is associated with improved public health emergency preparedness among primary care sites.

Pandemic Influenza Extension Areas in an Urban Pediatric Hospital

Introduction The 2009 H1N1 influenza pandemic created a surge of patients with low-acuity influenza-like-illness (ILI) to hospital Emergency Departments (EDs). The development and results of a tiered surge plan to care for these patients at a Pediatric Emergency Department (PED) were studied.

Hypothesis/Problem By providing standard assessment and treatment algorithms within physically separate ILI Extension Areas, it was hypothesized that patient care could be streamlined and the quality of care maintained.

Methods Hospital administrators created the tiered H1N1 surge plan within the framework of the existing emergency operations plan (EOP). After the initial expansion of space and staff utilization within the existing PED footprint, ILI Extension Areas were opened and staffed by non-ED physicians and nursing to provide care rapidly for ILI patients after Registered Nurse (RN) screening. Volumes, length of stay (LOS), left without being seen (LWBS) rates, patient satisfaction, and costs were tracked and measured.

Results Significantly elevated volumes of patients were seen in the months of September and October of 2009 (42.0% and 32.7% increase over 2008). During this time, 612 patients were triaged to the ILI Extension Areas. The LOS was similar to that experienced in prior years. The LWBS rates in September (4.8%) and October (3.4%) were slightly elevated over the 2009 yearly average (3.2%), but remained lower than during a prior, high-volume month. Satisfaction, measured as patients’ “likelihood to recommend,” remained within the range observed during other parts of the year. Cost estimates indicate favorable financial performance for the institution.

Conclusion The tiered surge response plan represented a success in managing large volumes of low-acuity patients during an extended period of time. This design can be utilized effectively in the future during times of patient surge.

Assessing Argentina's response to H1N1 in austral winter 2009: from presidential lethargy to local ingenuity

Argentina experienced a heavy burden of novel H1N1 influenza in austral winter 2009. In early July 2009, Argentina reported more than 1,500 cases and was confronting the highest per capita H1N1 mortality rate in the world. By September 2009, more than 500 people had died of H1N1 in Argentina. Unlike sister countries Chile and Mexico, Argentina's national authorities did not respond by implementing mitigation measures such as public gathering bans and school closures or by issuing broad-based messages about personal hygiene and disease prevention. Around the globe, many observers expressed dismay at this inaction. For example, The Economist scolded the country's leadership for its halting response and seeming apathy to an escalating health crisis. Why did Argentina, a middle-income country with a developed and, in many respects, sophisticated system of health and education, fall short in enacting a national pandemic plan during the 2009 H1N1 outbreak? What can we learn from Argentina's experiences about obstacles and opportunities during a pandemic crisis? This article, based on extensive qualitative research, including document capture, media analysis, and oral history interviews, assesses Argentina's mixed response to H1N1 during austral winter 2009, and adds to a growing body of studies focused on how governments and health systems in the Americas performed during the 2009-2010 H1N1 pandemic. When the first cases of novel H1N1 influenza were identified by the U.S. Centers for Disease Control and Prevention (CDC) in mid-April 2009, Argentina's national health ministry appeared to be prepared. Starting in 2002, primarily in response to the prospect of avian influenza, the health ministry had formulated a preparedness plan and, beginning in 2005, had conducted at least five pandemic simulation exercises. In April 2009, Argentina's health ministry activated its pandemic response plan, triggering the establishment of an executive-level situation room equipped with rapid communications and computer surveillance to track events as they unfolded. In addition, several expert committees were assembled to assess the situation and solicit input from health practitioners, academics, hospital staff, and allied professionals.

Protecting vulnerable populations from pandemic influenza in the United States: a strategic imperative

Protecting vulnerable populations from pandemic influenza is a strategic imperative. The US national strategy for pandemic influenza preparedness and response assigns roles to governments, businesses, civic and community-based organizations, individuals, and families. Because influenza is highly contagious, inadequate preparedness or untimely response in vulnerable populations increases the risk of infection for the general population. Recent public health emergencies have reinforced the importance of preparedness and the challenges of effective response among vulnerable populations. We explore definitions and determinants of vulnerable, at-risk, and special populations and highlight approaches for ensuring that pandemic influenza preparedness includes these populations and enables them to respond appropriately. We also provide an overview of population-specific and cross-cutting articles in this theme issue on influenza preparedness for vulnerable populations.