Addressing vaccine hesitancy during the COVID-19 pandemic: Learning from the past and moving forward

Excerpt@#Anong hirap ang kailangan niyong maranasan para kayo ay magpabakuna na? How much suffering are you willing to risk experiencing to persuade you to go for COVID-19 vaccination? @*@#Working at a COVID-19 Referral Center, we probably saw a lot more critically ill COVID-19 patients than in other hospitals in the Philippines. During the height of the Delta surge in 2021, our intensive care units (ICUs) for adults and pediatric critical COVID-19 were always full with a long waiting line. The typical medical history of the patients would be a senior retiree, usually a Lolo (grandfather) or a Lola (grandmother), who needed urgent support to be hooked to a mechanical ventilator because they could not breathe on their own anymore. When asked about their COVID-19 vaccination status, Lolo and Lola were often not vaccinated. Other times, the patient may not yet be old enough to be considered a Lolo or Lola but may have illnesses like heart failure, diabetes, hypertension, or on dialysis. They too were often not vaccinated. And occasionally, we admitted small children who would seemingly be out of place in the sea of adult patients in the Emergency Room. One would think that because the very young have not yet been allowed to get vaccinated, the people around them would strive to be vaccinated to protect these little ones. On the contrary, though, we saw many young patients whose exposures to COVID-19 came from their unvaccinated parents. This heartbreaking situation continued despite the intensive COVID-19 vaccination program of our government. When one thinks about it, it is possible that some of the many deaths and sufferings of patients and the anguish of grieving families, as well as the lonely exits of beloved ones dying alone amidst CPR machines and teams, may have been avoided had unvaccinated patients opted to be vaccinated. Now over 2 ½ years into the pandemic with many cases said to be mild, we continue to have a continuous flow of admissions for COVID-19 which fall into the moderate, severe, and even critical COVID-19, and some of them are because they have remained unvaccinated. Where and how can we improve the situation?

When the choices we make will affect others

@#“Is it my problem if my father-in-law does not want to get vaccinated?” All of us must have encountered scenarios like the above. We have all met individuals who refused or hesitate to get vaccinated for COVID-19. They could be from our family members, our colleagues, our friends, our employees, our neighbors, our school, or communities, from anywhere! We do not need to look far. What will we do? Or how should we approach these situations? For more than a year now, we have been witnessing the unfolding of the roll out of the “biggest” vaccine drives in history. Furthermore, this COVID-19 pandemic challenged every individual to make a personal stand about accepting and even promoting vaccination. This issue of the Acta Medica Philippina includes two contributions that give us different perspectives on the phenomenon called “Vaccine Hesitancy.” Vaccine hesitancy is reluctance or refusal to get vaccinated even with the availability of vaccines. While vaccine hesitancy is observed across the world, our issue looks specifically at the factors which contribute to the unique experiences in the Southeast Asian region and even more specifically to our country. These discussions will lead to a better understanding of drivers, both barriers and enablers to vaccine acceptance and uptake. This timely sharing of information comes at that crucial period when the vaccine hesitancy rates are high in our country despite efforts of our government to persuade as many individuals as possible to come for their COVID-19 booster vaccines. The World Health Organization (WHO) released guidance for countries and governments on how they can improve the vaccine uptake of their constituents.1 In addition to addressing the need for up-to-date information campaigns, governments and other “actors” who play major roles in the implementation of the vaccination program, especially during the current pandemic, need to listen and attune themselves to the main drivers of vaccine acceptance versus hesitancy. These are: 1) providing an enabling environment, 2) social influences; and 3) motivation. The paper of Hartigan-Go and group shows vaccine hesitancy research and how this information may be used to strategize vaccine education and communication campaigns to increase vaccine uptake.2 The invited essay is a discussion on how the traumatic experience we all witnessed in recent national history with another novel vaccine is an important driver negatively affecting behavior toward vaccination campaigns; and how can we move forward from there.3 We hope these contributions will help us all appreciate and respect the complexity of behavior related to vaccination, persuade our countrymen towards action that will help us achieve our desired goals for more, and work towards attaining our goal of better health for all.

The impact of the Implementation of a Surgical Antibiotic Use Guideline in the Practice of Antibiotic Use in the Department of Surgery, Philippine General Hospital

@#Objective. This study aimed to assess compliance with current best practice guidelines on the use of antibiotics in the Department of Surgery in the Philippine General Hospital and to determine the impact of the dissemination of an institution-based guideline on compliance and on patient outcomes. Methods. Two antibiotic use surveys were performed 4 weeks before and 4 weeks after the implementation and dissemination of the PGH Surgical Antibiotic Use Guidelines in the Department of Surgery. The medical records of eligible patients were reviewed regarding patient and case characteristics, details on the administration of antibiotics and the collection of specimen for culture studies. Data relating to the occurrence of surgical site infection within 30 days of the operation was extracted. Compliance with antibiotic use guidelines was assessed for each case. The compliance rates in the pre- and post-intervention periods were compared. Results. The study included a total of 477 patients, 213 in the pre-implementation and 264 in the post-implementation period. Compared with the pre-intervention period, rates of compliance with guidelines improved for all parameters in the post-implementation period except for correct dosing. The greatest improvement was seen in the selection of the recommended drug, and proper duration. There was modest improvement in the timing of the preoperative drug administration. There was poor compliance with recommendations for appropriate specimen collection for culture studies, with marked improvement in collection in the pediatric group post-intervention. Overall, the in-hospital SSI rate was reduced from 6.8% to 1.1%, while there was little change in the 30-day SSI rate, post-intervention. Conclusion. A simple intervention to raise awareness of institutional guidelines on antibiotic use in the surgical setting lead to a modest improvement on overall compliance, although rates of total compliance with all relevant guidance on antibiotic use, choice, dose, timing and duration remained low. The impact on surgical site infection rates based on such compliance was modest.

Validation of snort-spit saliva in detecting COVID-19 using RT-PCR and Rapid Antigen Detection Test

@#Objective. To determine the diagnostic accuracy of self-collected snorted and spit saliva in detecting COVID-19 using RT-PCR (ssRT-PCR) and lateral flow antigen test (ssLFA) versus nasopharyngeal swab RT-PCR (npRT-PCR). Methods. One hundred ninety-seven symptomatic subjects for COVID-19 testing in a tertiary hospital underwent snort-spit saliva self-collection for RT-PCR and antigen testing and nasopharyngeal swab for RT-PCR as reference. Positivity rates, agreement, sensitivity, specificity, and likelihood ratios were estimated. Results. Estimated prevalence of COVID-19 using npRT-PCR was 9% (exact 95% CI of 5.5% - 14.1%). A higher positivity rate of 13% in the ssRT-PCR assay suggested possible higher viral RNA in the snort-spit samples. There was 92.9% agreement between ssRT-PCR and npRT-PCR (exact 95% CI of 88.4% to 96.1%; Cohen’s Kappa of 0.6435). If npRT-PCR will be assumed as reference standard, the estimated Sensitivity was 83.3% (exact 95% CI of 60.8% to 94.2%), Specificity 93.9% (exact 95% CI of 89.3% to 96.5%), Positive predictive value of 57.7% (exact 95% CI of 38.9% to 74.5%), Negative predictive value of 98.2% (exact 95% CI of 95% to 99.4%), positive likelihood ratio of 3.65 (95% CI of 7.37 to 24.9), negative likelihood ratio of 0.178 (95% CI of 0.063 to 0.499). There was 84.84% agreement (95% exact CI of 79.1% to 89.5%; Cohen’s Kappa of 0.2356) between ssLFAvs npRT-PCR, sensitivity of 38.9% (exact 95% CI of 20.3% to 61.4%), specificity of 89.4% (exact 95% CI of 84.1% to 93.1%), PPV of 26.9% (95% CI of 13.7% to 46.1%), NPV of 93.6% (exact 95% CI of 88.8% to 96.4%), LR+ of 3.67 (95% CI of 1.79 - 7.51), LR – of 0.68 (95% CI of 0.47 - 0.99). Conclusion. Our data showed that snort-spit saliva RT-PCR testing had acceptable diagnostic performance characteristics and can potentially be used as an alternative to the standard nasopharyngeal/oropharyngeal swab RT-PCR test for COVID-19 in certain situations. However, our data also showed that snort-spit saliva antigen testing using lateral flow assay did not offer acceptable performance.

Evaluation of tuberculosis infection control strategies at the Philippine General Hospital

@#<p style="text-align: justify;"><strong>BACKGROUND:</strong> Nosocomial TB transmission adversely affects inpatients and healthcare workers (HCWs). HCWs have a higher risk of tuberculosis and MDR-TB compared to the general population. Nosocomial TB outbreaks have occurred among patients with HIV/AIDS. Hospitals need to examine TB infection control measures in order to address this growing concern.</p><p style="text-align: justify;"><strong>OBJECTIVE:</strong> This study aimed to evaluate the TB infection control strategies in the adult service wards of the Philippine General Hospital (PGH).</p><p style="text-align: justify;"><strong>METHODS:</strong> This descriptive study was conducted on adult inpatients with bacteriologically-confirmed PTB admitted in April-August 2016. A data collection tool based on Center for Disease Control (CDC) guidelines was utilized for chart review. Baseline characteristics, diagnosis, treatment, and isolation intervals were obtained and compared between areas. In-hospital TB infection control practices were reviewed using the CDC TB Risk Assessment Worksheet with data from the TB-DOTS, UP Health Service, PGH Hospital Infection Control Unit, and PGH Department of Laboratories.</p><p style="text-align: justify;"><strong>RESULTS:</strong> Of the 95 patients with bacteriologically-confirmed PTB, data from 72 medical records were available and included in the analysis. Majority were Medicine patients (55.6%) with a diagnosis of pneumonia (52.8%). Only 61.1% were PTB suspects on admission. The mean diagnosis interval was 5.82 days±5.473, the mean treatment interval was 0.77 days±2.941, and the mean isolation interval was 8.23 days±6.372. Only 41.7% were successfully isolated. The most common reasons for isolation failure/delay were lack of vacancy (ER, Medicine wards) and lack of isolation room (Surgical wards). Treatment initiation rate was 66.7% while TB-DOTS inpatient referral rate was 55.6%. The hospital is classified as having potential ongoing transmission of PTB.</p><p style="text-align: justify;"><strong>CONCLUSION:</strong> In this study, TB treatment was promptly started but there were delays in diagnosis and isolation. Gaps included 1) lack of recognition of a PTB case, 2) limited isolation rooms, and 3) inadequate utilization of TB-DOTS. TB infection control measures need to be strengthened in order to prevent nosocomial transmission of PTB.</p>

Effect of a multifaceted intervention on hand hygiene compliance among healthcare workers at the medicine wards and ICU in a tertiary hospital setting

@#<p style="text-align: justify;"><strong>BACKGROUND:</strong> While hand hygiene is recognized as the cornerstone for reducing risk for nosocomial infections, compliance in our institution remains low. Previously identified barriers include poor access to hand hygiene products, lack of reminders, and poor knowledge on indications.</p><p style="text-align: justify;"><strong>METHODS:</strong> At the medical wards and ICU of a tertiary hospital, a group of medical students, residents, and nurses was exposed to interventions addressing the identified barriers. Alcohol handrub was provided at each bedside, visual reminders were placed at critical locations, and commonly missed opportunities were reinforced at the start of the study. Hand hygiene compliance was covertly evaluated after two weeks and compared against that of an unexposed group.</p><p style="text-align: justify;"><strong>RESULTS:</strong> 664 and 727 hand hygiene opportunities were observed in the unexposed and exposed groups, respectively. Compliance was higher in the exposed group (32.60% vs. 16.26%, p <0.05), which by subset analysis was consistent for the different healthcare worker designations and locations evaluated. Nurses had the highest compliance rate in both groups.</p><p style="text-align: justify;"><strong>CONCLUSIONS:</strong> These results suggest the efficacy of the employed interventions in improving hand hygiene compliance in this setting. Hand hygiene opportunities identified to be most frequently missed in this observation can guide future intervention efforts in our institution.</p>

Barriers to hand hygiene compliance in the medicine wards and intensive care unit of a tertiary teaching hospital in the Philippines

@#<p style="text-align: justify;"><strong>INTRODUCTION:</strong> Healthcare associated infections (HCAI) continue to be major problems in our institution. Studies have shown that hand hygiene remain to be the primary measure that prevents HCAI. This study aimed to measure hand hygiene compliance rate and determine factors affecting compliance.</p><p style="text-align: justify;"><strong>METHODS:</strong> Healthcare workers in the medicine wards and intesive care units (ICU) were directly observed for compliance to the World Health Organization hand hygiene guidelines. In a month period, subjects were selected by convenience sampling. Factors affecting hand hygiene compliance was investigated. Survey of infrastructure and hand hygiene products was concurrently done. Thereafter, self-administered survey was distributed to assess knowledge, attitudes and perceptions toward hand hygiene.</p><p style="text-align: justify;"><strong>RESULTS:</strong> Overall hand hygiene compliance was 11%. Compliance was less likely for doctors, in the ward, and before patient contact. On the other hand, compliance was likely among nurses, in the ICU, before aseptic procedure, after exposure to body fluid, and after patient contact. Demand for hand hygiene was high with mean of 35 (SD=nine) opportunities per hour of patient care. Hand hygiene products are less available in the wards than in the ICU. Sinks are not in convenient locations. Hand hygiene posters were either not visible or lacking. Majority of the survey respondents know at most only two of the five hand hygiene indications.</p><p style="text-align: justify;"><strong>DISCUSSION:</strong> Access to hand hygiene products, training and education, and reminders in the workplace are among the basic requirements in the implementation of hand hygiene programs. With problems related to these three components, hand hygiene compliance is expected to be low.</p><p style="text-align: justify;"><strong>CONCLUSION: </strong>Low compliance to hand hygiene was associated with professional status, location and indication. Barriers to hand hygiene include inadequate and inaccessible sinks and hand hygiene products in the ward, high demand for hand hygiene, poor knowledge of hand hygiene, and lack of reminders in the workplace.</p>

Barriers to hand hygiene compliance in the medicine wards and intensive care unit of a tertiary teaching hospital in the Philippines

INTRODUCTION: Healthcare associated infections (HCAI) continue to be major problems in our institution. Studies have shown that hand hygiene remain to be the primary measure that prevents HCAI. This study aimed to measure hand hygiene compliance rate and determine factors affecting compliance.METHODS: Healthcare workers in the medicine wards and intesive care units (ICU) were directly observed for compliance to the World Health Organization hand hygiene guidelines. In a month period, subjects were selected by convenience sampling. Factors affecting hand hygiene compliance was investigated. Survey of infrastructure and hand hygiene products was concurrently done. Thereafter, self-administered survey was distributed to assess knowledge, attitudes and perceptions toward hand hygiene.RESULTS: Overall hand hygiene compliance was 11%. Compliance was less likely for doctors, in the ward, and before patient contact. On the other hand, compliance was likely among nurses, in the ICU, before aseptic procedure, after exposure to body fluid, and after patient contact. Demand for hand hygiene was high with mean of 35 (SD=nine) opportunities per hour of patient care. Hand hygiene products are less available in the wards than in the ICU. Sinks are not in convenient locations. Hand hygiene posters were either not visible or lacking. Majority of the survey respondents know at most only two of the five hand hygiene indications.DISCUSSION: Access to hand hygiene products, training and education, and reminders in the workplace are among the basic requirements in the implementation of hand hygiene programs. With problems related to these three components, hand hygiene compliance is expected to be low.CONCLUSION: Low compliance to hand hygiene was associated with professional status, location and indication. Barriers to hand hygiene include inadequate and inaccessible sinks and hand hygiene products in the ward, high demand for hand hygiene, poor knowledge of hand hygiene, and lack of reminders in the workplace.