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Hernandez SE, Solomon D, Moon J, Parmasad V, Wiegmann D, Bennett NT, Ferren RS, Fitzsimmons AJ, Lepak AJ, O'Horo JC, Pop-Vicas AE, Schulz LT, Safdar N. Understanding clinical implementation coordinators' experiences in deploying evidence-based interventions. Am J Health Syst Pharm 2024; 81:120-128. [PMID: 37897218 DOI: 10.1093/ajhp/zxad272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Indexed: 10/29/2023] Open
Abstract
PURPOSE The fluoroquinolone restriction for the prevention of Clostridioides difficile infection (FIRST) trial is a multisite clinical study in which sites carry out a preauthorization process via electronic health record-based best-practice alert (BPA) to optimize the use of fluoroquinolone antibiotics in acute care settings. Our research team worked closely with clinical implementation coordinators to facilitate the dissemination and implementation of this evidence-based intervention. Clinical implementation coordinators within the antibiotic stewardship team (AST) played a pivotal role in the implementation process; however, considerable research is needed to further understand their role. In this study, we aimed to (1) describe the roles and responsibilities of clinical implementation coordinators within ASTs and (2) identify facilitators and barriers coordinators experienced within the implementation process. METHODS We conducted a directed content analysis of semistructured interviews, implementation diaries, and check-in meetings utilizing the conceptual framework of middle managers' roles in innovation implementation in healthcare from Urquhart et al. RESULTS Clinical implementation coordinators performed a variety of roles vital to the implementation's success, including gathering and compiling information for BPA design, preparing staff, organizing meetings, connecting relevant stakeholders, evaluating clinical efficacy, and participating in the innovation as clinicians. Coordinators identified organizational staffing models and COVID-19 interruptions as the main barriers. Facilitators included AST empowerment, positive relationships with staff and oversight/governance committees, and using diverse implementation strategies. CONCLUSION When implementing healthcare innovations, clinical implementation coordinators facilitated the implementation process through their roles and responsibilities and acted as strategic partners in improving the adoption and sustainability of a fluoroquinolone preauthorization protocol.
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Affiliation(s)
- Sara E Hernandez
- School of Pharmacy, University of Wisconsin-Madison, Madison, WI, USA
| | - Demetrius Solomon
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Jukrin Moon
- School of Pharmacy, University of Wisconsin-Madison, Madison, WI, USA
| | - Vishala Parmasad
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Douglas Wiegmann
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Nick T Bennett
- Antimicrobial Stewardship Program, Saint Luke's Health System, Kansas City, MO, USA
| | - Ryan S Ferren
- University of Texas Medical Branch, Galveston, TX, USA
| | - Alec J Fitzsimmons
- Department of Medical Research, Gundersen Health System, La Crosse, WI, USA
| | - Alexander J Lepak
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - John C O'Horo
- Mayo Foundation for Medical Education and Research, Rochester, MN, USA
| | - Aurora E Pop-Vicas
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Lucas T Schulz
- Department of Pharmacy, University of Wisconsin Health, Madison, WI, USA
| | - Nasia Safdar
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
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Keating JA, Parmasad V, McKinley L, Safdar N. Integrating infection control and environmental management work systems to prevent Clostridioides difficile infection. Am J Infect Control 2023; 51:1444-1448. [PMID: 37329984 PMCID: PMC10773464 DOI: 10.1016/j.ajic.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/04/2023] [Accepted: 06/05/2023] [Indexed: 06/19/2023]
Abstract
Effective infection prevention and control within health care settings requires collaboration and coordination between infection control and environmental management teams. However, the work systems of these teams can be difficult to integrate despite their shared goals. We provide results from a qualitative study of Clostridioides difficile infection prevention in Veterans Affairs facilities regarding challenges in coordination between these teams and opportunities to improve coordination and maximize infection prevention activities.
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Affiliation(s)
- Julie A Keating
- William S. Middleton Memorial Veterans Hospital, Madison, WI; Division of Infectious Disease, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI
| | - Vishala Parmasad
- Division of Infectious Disease, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI
| | - Linda McKinley
- William S. Middleton Memorial Veterans Hospital, Madison, WI
| | - Nasia Safdar
- William S. Middleton Memorial Veterans Hospital, Madison, WI; Division of Infectious Disease, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI.
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Parmasad V, Keating J, McKinley L, Evans C, Rubin M, Voils C, Safdar N. Frontline perspectives of C. difficile infection prevention practice implementation within veterans affairs health care facilities: A qualitative study. Am J Infect Control 2023; 51:1124-1131. [PMID: 36977453 DOI: 10.1016/j.ajic.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 03/17/2023] [Accepted: 03/19/2023] [Indexed: 03/28/2023]
Abstract
BACKGROUND In 2012, the veteran's affairs (VA) multidrug-resistant organism (MDRO) Program Office launched a national Clostridioides difficile Infection (CDI) Prevention Initiative to address CDI as the most common cause of healthcare associated infections, mandating use of a VA CDI Bundle of prevention practices in inpatient facilities. We draw upon frontline worker perspectives to explore work system barriers and facilitators to the sustained implementation of the VA CDI Bundle using the systems engineering initiative for patient safety (SEIPS) framework. METHODS We interviewed 29 key stakeholders at 4 participating sites between October 2019-July 2021. Participants included infection prevention and control (IPC) leaders, nurses, physicians, and environmental management staff. Interviews were analyzed to identify themes and perceptions of facilitators and barriers to CDI prevention. RESULTS IPC leadership was most likely to know of the specific VA CDI Bundle components. Other participants demonstrated general knowledge of CDI prevention practices, with role-based variation in the depth of awareness of specific practices. Facilitators included leadership support, mandated CDI training and prevention practices, and readily available training from multiple sources. Barriers included limits to communication about facility or unit-level CDI rates, ambiguous communications about CDI prevention practice updates and VA mandates, and role-hierarchies that may limit team members' clinical contributions. DISCUSSION Recommendations include improving centrally-mandated clarity about and standardization of CDI prevention policies, including testing. Regular IPC training updates for all clinical stakeholders are also recommended. CONCLUSIONS A work system analysis using SEIPS identified barriers and facilitators to CDI prevention practices that could be addressed both nationally at the system level and locally at the facility level, specifically in the areas of communication and coordination.
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Affiliation(s)
- Vishala Parmasad
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI; William S. Middleton Memorial Veterans Hospital, Madison, WI.
| | - Julie Keating
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI; William S. Middleton Memorial Veterans Hospital, Madison, WI
| | - Linda McKinley
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI; William S. Middleton Memorial Veterans Hospital, Madison, WI
| | - Charlesnika Evans
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. Veterans Affairs Hospital, Hines
| | - Michael Rubin
- IDEAS 2.0 Center, George E. Whalen VA Medical Center, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT
| | - Corrine Voils
- William S. Middleton Memorial Veterans Hospital, Madison, WI; Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Nasia Safdar
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI; William S. Middleton Memorial Veterans Hospital, Madison, WI
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Carayon P, Thuemling T, Parmasad V, Bao S, O'Horo J, Bennett NT, Safdar N. Implementation of An Antibiotic Stewardship Intervention to Reduce Prescription of Fluoroquinolones: A Human Factors Analysis in Two Intensive Care Units. J Patient Saf Risk Manag 2022; 26:161-171. [PMID: 35146329 DOI: 10.1177/25160435211025417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Antibiotic use is often the target of interventions in health care organizations that aim to decrease healthcare-associated infections (HAI) such as Clostridioides difficile (CDI); this is particularly important for fluoroquinolones (FQ), which are frequently used in critical care settings. In this study, using a multiple case study research approach, we conduct an in-depth analysis of an intervention aimed at limiting ICU prescriber access to FQ in two ICUs of two hospitals. The data collection and analysis were guided by a human factors engineering approach based on the SEIPS (Systems Engineering Initiative for Patient Safety) model and evidence-based implementation principles. Our results show some differences in the implementation of the FQ intervention between the two ICUs, such as level and method of FQ restriction, and training and communication with physicians and pharmacists. In both ICUs, several organizational learning mechanisms helped to quickly identify problems with the intervention and ensure that changes were made in a just-in-time manner (e.g. just-in-time training, removal of FQ in order set for pneumonia). Despite their organizational differences, both sites developed strategies to successfully implement the FQ intervention.
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Affiliation(s)
- Pascale Carayon
- Department of Industrial and Systems Engineering, Wisconsin Institute for Healthcare Systems Engineering; University of Wisconsin-Madison
| | - Teresa Thuemling
- Wisconsin Institute for Healthcare Systems Engineering; University of Wisconsin-Madison
| | | | - Songtao Bao
- School of Journalism and Mass Communication; University of Wisconsin-Madison
| | | | | | - Nasia Safdar
- Department of Medicine; University of Wisconsin-Madison
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Parmasad V, Keating JA, Carayon P, Safdar N. Physical distancing for care delivery in health care settings: Considerations and consequences. Am J Infect Control 2021; 49:1085-1088. [PMID: 33359551 PMCID: PMC7759337 DOI: 10.1016/j.ajic.2020.12.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 12/20/2020] [Accepted: 12/21/2020] [Indexed: 11/25/2022]
Abstract
As health care systems explore new ways of delivering care for patients with and without COVID-19, they must consider how to maintain physical distancing among health care workers and patients. Physical distancing in high complexity systems such as health care is particularly challenging and may benefit from a human factors and systems engineering perspective. We discuss challenges to implementing and maintaining physical distancing in health care settings and present possible solutions from a human factors and systems engineering perspective.
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Affiliation(s)
- Vishala Parmasad
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI
| | - Julie A Keating
- William S. Middleton Memorial Veterans Hospital, Madison, WI
| | - Pascale Carayon
- Wisconsin Institute for Healthcare Systems Engineering, University of Wisconsin-Madison, Madison, WI; Department of Industrial and Systems Engineering, College of Engineering, University of Wisconsin-Madison, Madison, WI
| | - Nasia Safdar
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI; William S. Middleton Memorial Veterans Hospital, Madison, WI.
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Safdar N, Parmasad V, Brown R, Carayon P, Lepak A, O'Horo JC, Schulz L. Decreasing ICU-associated Clostridioides difficile infection through fluoroquinolone restriction, the FIRST trial: a study protocol. BMJ Open 2021; 11:e046480. [PMID: 34187821 PMCID: PMC8245435 DOI: 10.1136/bmjopen-2020-046480] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 06/16/2021] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Clostridioides difficile infection (CDI) is one of the most common healthcare-associated infections in the USA, having high incidence in intensive care units (ICU). Antibiotic use increases risk of CDI, with fluoroquinolones (FQs) particularly implicated. In healthcare settings, antibiotic stewardship (AS) and infection control interventions are effective in CDI control, but there is little evidence regarding the most effective AS interventions. Preprescription authorisation (PPA) restricting FQs is a potentially promising AS intervention to reduce CDI. The FQ Restriction for the Prevention of CDI (FIRST) trial will evaluate the effectiveness of an FQ PPA intervention in reducing CDI rates in adult ICUs compared with preintervention care, and evaluate implementation effectiveness using a human-factors and systems engineering model. METHODS AND ANALYSIS This is a multisite, stepped-wedge, cluster, effectiveness-implementation clinical trial. The trial will take place in 12 adult medical-surgical ICUs with ≥10 beds, using Epic as electronic health record (EHR) and pre-existing AS programmes. Sites will receive facilitated implementation support over the 15-month trial period, succeeded by 9 months of follow-up. The intervention comprises a clinical decision support system for FQ PPA, integrated into the site EHRs. Each ICU will be considered a single site and all ICU admissions included in the analysis. Clinical data will be extracted from EHRs throughout the trial and compared with the corresponding pretrial period, which will constitute the baseline for statistical analysis. Outcomes will include ICU-onset CDI rates, FQ days of therapy (DOT), alternative antibiotic DOT, average length of stay and hospital mortality. The study team will also collect implementation data to assess implementation effectiveness using the Systems Engineering Initiative for Patient Safety model. ETHICS AND DISSEMINATION The trial was approved by the Institutional Review Board at the University of Wisconsin-Madison (2018-0852-CP015). Results will be made available to participating sites, funders, infectious disease societies, critical care societies and other researchers. TRIAL REGISTRATION NUMBER NCT03848689.
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Affiliation(s)
- Nasia Safdar
- Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Vishala Parmasad
- Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Roger Brown
- School of Nursing, University of Wisconsin-Madison Graduate School, Madison, Wisconsin, USA
| | - Pascale Carayon
- Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Alexander Lepak
- Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | | | - Lucas Schulz
- Pharmacy, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
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Musuuza JS, Watson L, Parmasad V, Putman-Buehler N, Christensen L, Safdar N. Prevalence and outcomes of co-infection and superinfection with SARS-CoV-2 and other pathogens: A systematic review and meta-analysis. PLoS One 2021; 16:e0251170. [PMID: 33956882 PMCID: PMC8101968 DOI: 10.1371/journal.pone.0251170] [Citation(s) in RCA: 265] [Impact Index Per Article: 88.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 04/21/2021] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION The recovery of other pathogens in patients with SARS-CoV-2 infection has been reported, either at the time of a SARS-CoV-2 infection diagnosis (co-infection) or subsequently (superinfection). However, data on the prevalence, microbiology, and outcomes of co-infection and superinfection are limited. The purpose of this study was to examine the occurrence of co-infections and superinfections and their outcomes among patients with SARS-CoV-2 infection. PATIENTS AND METHODS We searched literature databases for studies published from October 1, 2019, through February 8, 2021. We included studies that reported clinical features and outcomes of co-infection or superinfection of SARS-CoV-2 and other pathogens in hospitalized and non-hospitalized patients. We followed PRISMA guidelines, and we registered the protocol with PROSPERO as: CRD42020189763. RESULTS Of 6639 articles screened, 118 were included in the random effects meta-analysis. The pooled prevalence of co-infection was 19% (95% confidence interval [CI]: 14%-25%, I2 = 98%) and that of superinfection was 24% (95% CI: 19%-30%). Pooled prevalence of pathogen type stratified by co- or superinfection were: viral co-infections, 10% (95% CI: 6%-14%); viral superinfections, 4% (95% CI: 0%-10%); bacterial co-infections, 8% (95% CI: 5%-11%); bacterial superinfections, 20% (95% CI: 13%-28%); fungal co-infections, 4% (95% CI: 2%-7%); and fungal superinfections, 8% (95% CI: 4%-13%). Patients with a co-infection or superinfection had higher odds of dying than those who only had SARS-CoV-2 infection (odds ratio = 3.31, 95% CI: 1.82-5.99). Compared to those with co-infections, patients with superinfections had a higher prevalence of mechanical ventilation (45% [95% CI: 33%-58%] vs. 10% [95% CI: 5%-16%]), but patients with co-infections had a greater average length of hospital stay than those with superinfections (mean = 29.0 days, standard deviation [SD] = 6.7 vs. mean = 16 days, SD = 6.2, respectively). CONCLUSIONS Our study showed that as many as 19% of patients with COVID-19 have co-infections and 24% have superinfections. The presence of either co-infection or superinfection was associated with poor outcomes, including increased mortality. Our findings support the need for diagnostic testing to identify and treat co-occurring respiratory infections among patients with SARS-CoV-2 infection.
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Affiliation(s)
- Jackson S. Musuuza
- Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States of America
- William S. Middleton Memorial Veterans Hospital, Madison, WI, United States of America
| | - Lauren Watson
- Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States of America
| | - Vishala Parmasad
- Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States of America
| | - Nathan Putman-Buehler
- Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States of America
| | - Leslie Christensen
- Ebling Library for the Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States of America
| | - Nasia Safdar
- Division of Infectious Disease, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States of America
- William S. Middleton Memorial Veterans Hospital, Madison, WI, United States of America
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Mohan S, Dharamraj K, Dindial R, Mathur D, Parmasad V, Ramdhanie J, Matthew J, Pinto Pereira LM. Physician behaviour for antimicrobial prescribing for paediatric upper respiratory tract infections: a survey in general practice in Trinidad, West Indies. Ann Clin Microbiol Antimicrob 2004; 3:11. [PMID: 15196306 PMCID: PMC441403 DOI: 10.1186/1476-0711-3-11] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2004] [Accepted: 06/14/2004] [Indexed: 12/01/2022] Open
Abstract
Background Upper respiratory tract infections (URTIs) are among the most frequent reasons for physician office visits in paediatrics. Despite their predominant viral aetiology, URTIs continue to be treated with antimicrobials. We explored general practitioners' (GPs) prescribing behaviour for antimicrobials in children (≤ 16 years) with URTIs in Trinidad, using the guidelines from the Centers for Disease Control and Prevention (CDC) as a reference. Methods A cross-sectional study was conducted on 92 consenting GPs from the 109 contacted in Central and East Trinidad, between January to June 2003. Using a pilot-tested questionnaire, GPs identified the 5 most frequent URTIs they see in office and reported on their antimicrobial prescribing practices for these URTIs to trained research students. Results The 5 most frequent URTIs presenting in children in general practice, are the common cold, pharyngitis, tonsillitis, sinusitis and acute otitis media (AOM) in rank order. GPs prescribe at least 25 different antibiotics for these URTIs with significant associations for amoxicillin, co-amoxiclav, cefaclor, cefuroxime, erythromycin, clarithromycin and azithromycin (p < 0.001). Amoxicillin alone or with clavulanate was the most frequently prescribed antibiotic for all URTIs. Prescribing variations from the CDC recommendations were observed for all URTIs except for AOM (50%), the most common condition for antibiotics. Doctors practicing for >30 years were more likely to prescribe antibiotics for the common cold (p = 0.014). Severity (95.7%) and duration of illness (82.5%) influenced doctors' prescribing and over prescribing in general practice was attributed to parent demands (75%) and concern for secondary bacterial infections (70%). Physicians do not request laboratory investigations primarily because they are unnecessary (86%) and the waiting time for results is too long (51%). Conclusions Antibiotics are over prescribed for paediatric URTIs in Trinidad and amoxicillin with co-amoxiclav were preferentially prescribed. Except for AOM, GPs' prescribing varied from the CDC guidelines for drug and duration. Physicians recognise antibiotics are overused and consider parents expecting antibiotics and a concern for secondary bacterial infections are prescribing pressures. Guidelines to manage URTIs, ongoing surveillance programs for antibiotic resistance, public health education on non-antibiotic strategies, and postgraduate education for rational pharmacotherapy in general practice would decrease inappropriate antibiotic use in URTIs.
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Affiliation(s)
- Shaun Mohan
- Faculty of Medical Sciences, University of The West Indies, St. Augustine, Trinidad, Trinidad and Tobago
| | - Kavita Dharamraj
- Faculty of Medical Sciences, University of The West Indies, St. Augustine, Trinidad, Trinidad and Tobago
| | - Ria Dindial
- Faculty of Medical Sciences, University of The West Indies, St. Augustine, Trinidad, Trinidad and Tobago
| | - Deepti Mathur
- Faculty of Medical Sciences, University of The West Indies, St. Augustine, Trinidad, Trinidad and Tobago
| | - Vishala Parmasad
- Faculty of Medical Sciences, University of The West Indies, St. Augustine, Trinidad, Trinidad and Tobago
| | - Joseph Ramdhanie
- Faculty of Medical Sciences, University of The West Indies, St. Augustine, Trinidad, Trinidad and Tobago
| | - Jason Matthew
- Faculty of Medical Sciences, University of The West Indies, St. Augustine, Trinidad, Trinidad and Tobago
| | - Lexley M Pinto Pereira
- Faculty of Medical Sciences, University of The West Indies, St. Augustine, Trinidad, Trinidad and Tobago
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