Olfactory Performance in Post Mild-to-Moderate Acute Covid-19 across 2 Years

Background: Previous longitudinal studies (n=6) of objective olfaction performance post-acute COVID-19 have a maximum follow-up of 6-month and do not often test biomarkers. Although olfactory dysfunction appears to improve within two months of symptom onset, 4/6 longitudinal studies show persistent olfactory impairment. Method(s): PCR-confirmed COVID-19 patients in the prospective ADAPT cohort (Sydney, Australia) were assessed across 18 acute symptoms and hospitalization status: 40% mild, 50% moderate, 10% severe/hospitalised - none deceased). Blood samples were taken 2 (N=179), 4 (N=148) and 12-month (N=118) post-diagnosis. The NIH Odor Identification Test (OIT) and the Cogstate brief cognitive battery were performed. 58 also had an olfaction test at 24-month. The OIT raw data were transformed into demographically-corrected T-scores. OIT's attrition was completely random and only initial age (40+/-15 versus 47+/-15) differed between patients lost to follow-up and those in the study at 24-month. We tested peripheral neurobiomarkers (NFL, GFAP, S100B, GM-CSF) and immune markers (Interleukin-IL panel: 1-beta, 1Ralpha, 4, 5, 6, 8, 10, 12p40, 12p70, 13, and MCP-1, TNF-alpha and INF-gamma), analyzed as Log transformed and elevated/normal range using published references. Our previous analyses had shown no relationship with the kynurenine pathway, but an association of impaired olfaction and impaired cognition at 2-month only. Linear mixed effect regressions with time effect (months) tested olfaction trajectories (random subject effect) and their association with the biomarkers (main and time interaction). Result(s): At 2 months post-diagnosis 30% had impaired olfaction and those who had acute severe disease were more likely to be impaired (54% versus 26%, p=.009). 21%, 31% and 37% had impaired olfaction at 4, 12 and 24-months. Olfactory performance declined over time (p< .0001), which was dependent on the initial performance (Fig 1). Neurobiomarkers were within the normal range. IFN-gamma, IL-1Ralpha, IL-13 and TNF-alpha increased across time, p< .03-p< .0005. TNF-alpha and IFN-gamma showed a time covariance with poorer olfaction performance. Conclusion(s): Post-acute mild to moderate COVID-19 is associated with a declining olfactory performance up to 2-yr post-diagnosis, especially when initially impaired with the provisio of attrition although random. Olfactory performance decline may be mediated by upregulated immune parameters which are distinct from those driving cognitive changes. (Figure Presented).

Post-Covid Cognitive Impairment Mri Brain Scan Abnormalities: A Potential Biomarker

Background: Post-acute sequelae of SARS-COV-2 infection (PASC) is associated with cognitive impairment (CI) with unclear pathogenesis though blood brain barrier (BBB) impairment and excitotoxic injury appear significant. Post-acute sequelae of SARS-COV-2 infection (PASC) is associated with cognitive impairment (CI) with unclear pathogenesis though blood brain barrier (BBB) impairment and excitotoxic injury appear significant. We hypothesized that PASC CI patients would have brain inflammation and BBB disruption using advanced MR imaging. Method(s): In this prospective longitudinal study, 14 patients with PASC CI (mild and non-hospitalised) were enrolled (mean age of 45;10 F and 4 M) and 10 sex and age matched healthy controls. 13 had a follow up MR at 9-12 months (mean 10 months). All participants underwent DCE perfusion (an index of BBB integrity with Ktrans as the measurement), Diffusion Tensor Imaging (DTI) and single voxel MR spectroscopy (MRS) of the frontal cortex/white matter and the brainstem in addition to brain anatomical MRI. Between group analyses were used to determine which MRI outcomes were significantly different from controls in patients with PASC CI. Result(s): The PASCI CI group showed significantly increased (ie BBB impairment) Ktrans, and increased region (Frontal white matter and Brain Stem)-specific areas in the brain (p=< 0.005), reduction in NAA (ie neuronal injury) and mild reduction of Glx (ie excitotoxicity) in the frontal white matter and brain stem (p=0.004), and reduction in white matter integrity (increased diffusivity -greater radial and mean diffusivity). Increased Ktrans was correlated with increased both radial and mean diffusivity (r=0.9) in all tested brain regions. Ktrans significantly improved in the follow up MR (p= 002596 Z=-2.794872) with no difference between subjects and controls indicating BBB normalisation (p= 0.442418, z= -0.144841). White matter integrity also improved especially in the fractional anisotropy values in the executive networks (p=< 0.00045). MRS showed significant improvement in the NAA in the frontal white matter but Glx remain high as compared to the controls (p=0.0006). Conclusion(s): PASC CI was characterised by reversible diffuse BBB impairment, neuronal/axonal and excitotoxic injury. BBB impairment was associated with white matter disruption. These are suggestive biomarkers for the presence, severity and prognosis of PASC CI. Such biomarkers could underpin appropriate trial design and timing of intervention.

Grieving during Covid-19: Exploring the Lived Experiences of People Bereaved during the First Two Waves of the Pandemic

Introduction The COVID-19 pandemic has had a huge impact on all aspects of life. The high number of deaths and bereavements increased demand on already stretched services, whilst the unique circumstances caused by enforced social distancing meant that people bereaved at this time faced many additional challenges and potentially problematic grief trajectories. Aims To explore in depth people's lived experiences of bereavement during the Covid-19 pandemic, their adaptation and coping during this time, and the effect of informal and formal sources of bereavement support . Methods Semi-structured longitudinal telephone interviews were conducted with people bereaved during the first 10 months of the pandemic (March to December 2020), purposively sampled from a cohort of survey participants. Interview transcripts were analysed thematically. Results 24 participants (19 female;5 men) took part in a first interview and 15 in a follow up interview, approximately four months later. Five major themes were identified: End of life experiences;Funerals and memorialisation;Grieving and psychological impacts;Coping and adaptation and Sources of support. Many challenges relating to the pandemic context were identified, including restrictions to end of life and memorialisation arrangements, dealing with personal affairs, and lack of support. Such experiences negatively impacted individual grieving and wellbeing, in particular feelings of isolation and guilt surrounding lack of contact with the deceased. Participants experienced difficulties accessing services, and sometimes received support that was not appropriate for their particular situations and needs. Despite these difficulties, some people demonstrated remarkable resilience, and ability to cope and find meaning. Conclusions People bereaved in the COVID-19 pandemic have navigated grief and bereavement through exceptionally challenging circumstances, often lacking the informal and formal support needed to help them cope. Impact These insights can be used to help improve the care and support provided to bereaved people throughout their bereavement journeys.

What should good bereavement service support look like? Findings from pre-pandemic workshop discussions interpreted in the context of the Covid-19 pandemic

introduction: There has been a lack of consistency in approaches to bereavement support provision and evaluation. As part of a study which identified outcomes for adult bereavement support services in palliative care, we conducted stakeholder workshops with people from professional and lived experience backgrounds, providing a view on what support interventions should look like. aims: The aims of this first workshop were to gather stakeholder views on the purpose, impacts and outcomes of bereavement service support. In this paper we summarise these findings and consider their relevance to bereavement support during and following the Covid-19 pandemic. Methods: Stakeholders were divided into three groups and asked to consider how support services should help bereaved service users and what good bereavement service support looks like. Key themes were identified from the written and verbal content of the workshop.Findings: Three main themes emerged from the data;informal support and self¬management;the aims and purpose of bereavement service support and the timing, accessibility and quality of support. conclusion: Workshop findings align with public health models of bereavement care and recent service standards, identifying core support functions and aspirations for bereavement services. Finding the best mechanisms and modalities for meeting these, in the context of the late/post-pandemic period, presents both challenges and opportunities. © 2022, Cruse Bereavement Care. All rights reserved.

Impacts of COVID-19 on food banks

This study investigated how food banks in the USA were affected by the initial stages of the COVID-19 pandemic. Results revealed that interest in food banks in mid-2020 was better predicted by unemployment than by COVID-19 cases. It was also found that food distribution at banks increased by an average of 44%;wait times also increased at most food banks.

The role of altruism vs self-interest in COVID-19 vaccination uptake in the United Kingdom.

OBJECTIVES: The aim of the present study was to explore self-interest, kin altruism and non-kin altruism reasons that influence people to vaccinate against COVID-19. STUDY DESIGN: This was a cross-sectional study using a fully repeated measures design. METHODS: Participants (N = 178) answered questions on perceived threat and likelihood of infection, vaccination status and opinion on mandatory vaccination. Participants also rated a set of statements that asked how likely these would influence them and others to vaccinate against COVID-19. Statements reflected self-interest, kin altruism or non-kin altruism. RESULTS: Just more than half of the sample (50.8%) reported the likelihood of infection as somewhat or extremely likely, and almost three-fourths (74.2%) reported that COVID-19 posed a minor or moderate threat to their physical health. Almost three-fourths (74.3%) of the sample were vaccinated, with just more than half (56.2%) in favour of mandatory vaccination. A 2 (self/other) × 3 (self-interest/kin altruism/non-kin altruism) fully repeated measures analysis of variance showed that kin-altruistic reasons were rated most highly, regardless of whether this was regarding oneself or others. Participants rated others as having greater self-interest reasons for vaccination compared with oneself, whereas non-kin altruism reasons for vaccination were rated higher for oneself, compared with others. CONCLUSION: Highlighting the benefits of vaccination for close relatives and vulnerable others in the population would be a useful strategy for government to use when urging the public to vaccinate against COVID-19.

LEVELS OF GRIEF, SUPPORT NEEDS AND RISK FACTORS AMONG PEOPLE BEREAVED DURING THE COVID-19 PANDEMIC: BASELINE RESULTS FROM A LONGITUDINAL UK ONLINE SURVEY

Background The COVID-19 pandemic has had a detrimental impact on millions of people's experiences of bereavement. Traumatic end-of-life experiences and disruptions to support networks increase chances of poor bereavement outcomes. Aim To examine grief and support needs, and identify associated risk factors. Methods Mixed-methods survey of people bereaved in the UK from March 2020-January 2021, disseminated via media, social media, national associations, community/charitable organisations. Practical and emotional support needs were assessed in 13 domains, and grief intensity using the Adult Attitude to Grief (AAG) scale, which calculates an overall index of vulnerability (IOV) (range 0-36). Results 711 participants, mean age 49.5 (SD 12.9);88.6% female;95.3% white. Mean age of deceased 72.2 (SD 16.1);58% died in hospital;44% from COVID-19. Mean IOV was 20.41 (95% CI = 20.06 to 20.77), i.e. high vulnerability in grief overall. 28.2% exhibited extreme levels of vulnerability (i.e., IOV ≥ 24). In six support domains, all relating to psycho- emotional support, 50% to 60% of respondents reported high/fairly high levels of need. Increased levels of perceived support from health professionals led to significantly (P < 0.001) lower levels of grief and support need (small/medium effect, P < 0.001). Bereaved participants who were socially isolated/lonely experienced higher levels of grief and support needs than those who were not (P < 0.001). Grief and support needs were much higher for close family members compared with other groups (P < 0.05). Levels of grief and support needs were slightly higher for COVID deaths compared with non-COVID (P < 0.01), although this was not significant in a mixed model. Conclusions People bereaved during the pandemic experience high levels of grief and emotional support needs, with social isolation/loneliness and death of a close family member particular risk factors. Healthcare professionals' support is associated with better bereavement experiences.

Hyperinflammatory ARDS Is Characterized by Interferon-High, Neutrophil-Predominant Inflammation in the Lower Respiratory Tract

Background: Latent class analyses in patients with acute respiratory distress syndrome (ARDS) have identified “hyper-inflammatory” and “hypo-inflammatory” phenotypes with divergent clinical outcomes and treatment responses. ARDS phenotypes are defined using plasma biomarkers and clinical variables. It is currently unknown if these phenotypes have distinct pulmonary biology and if pre-clinical models of disease replicate the biology of either phenotype. Methods: 45 subjects with ARDS (Berlin Definition) and 5 mechanically ventilated controls were selected from cohorts of mechanically ventilated patients at UCSF and ZSFG. Patients with COVID-19 were excluded from this analysis. A 3-variable classifier model (plasma IL-8, protein C, and bicarbonate;Sinha 2020) was used to assign ARDS phenotypes. Tracheal aspirate (TA) RNA was analyzed using established bulk and single-cell sequencing pipelines (Langelier 2018, Sarma 2021). Differentially expressed (DE) genes were analyzed using Ingenuity Pathway Analysis (IPA). Microbial community composition was analyzed with vegan. Fgsea was used to test for enrichment of gene sets from experimental ARDS models in genes that were differentially expressed between each phenotype and mechanically ventilated controls. Results: Bulk RNA sequencing (RNAseq) was available from 29 subjects with hypoinflammatory ARDS and 10 subjects with hyperinflammatory ARDS. 2,777 genes were differentially expressed between ARDS phenotypes. IPA identified several candidate upstream regulators of gene expression in hyperinflammatory ARDS including IL6, TNF, IL17C, and interferons (Figure 1A). 2,953 genes were differentially expressed between hyperinflammatory ARDS and 5 ventilated controls;in contrast, only 243 genes were differentially expressed between hypoinflammatory ARDS and controls, suggesting gene expression in the hypoinflammatory phenotype was more heterogeneous. Gene sets from experimental models of acute lung injury were enriched in hyperinflammatory ARDS but not in hypoinflammatory ARDS (Figure 1B). Single cell RNA sequencing (scRNAseq) was available from 6 additional subjects with ARDS, of whom 3 had hyperinflammatory ARDS. 14,843 cells passed quality control filters. Hyperinflammatory ARDS subjects had a markedly higher burden of neutrophils (Figure 1C), including a cluster of stressed neutrophils expressing heat shock protein RNA that was not present in hypoinflammatory ARDS. Expression of a Th1 signature was higher in T cells from hyperinflammatory ARDS. Differential expression analysis in macrophages identified increased expression of genes associated with mortality in a previous study of ARDS patients (Morell 2019). Conclusions: The respiratory tract biology of ARDS phenotypes is distinct. Hyperinflammatory ARDS is characterized by neutrophilic inflammation with distinct immune cell polarization. Transcriptomic profiling identifies candidate preclinical disease models that replicate gene expression observed in hyperinflammatory ARDS.

“Empty and Lost”: The Challenges of Being Bereaved During the COVID-19 Pandemic

Background/aims: The COVID-19 pandemic has resulted in millions of deaths worldwide, whilst also causing severe disruption to end-of-life, grieving and coping processes. We examine bereavement experiences during the pandemic and relate our findings to the constructs of lossoriented and restoration- oriented coping, described in Stroebe and Schut's Dual Process Model (DPM). Methods: Two independent UK-wide surveys were disseminated online, including via social media and community/charitable organizations. They captured adult experiences of bereavement (to all causes of death) from March 2020 to January 2021. Free-text data were analyzed thematically. Results: Free-text comments were provided by 881 participants. Six main themes were identified: troubled and traumatic deaths;disrupted mourning, memorialization and death administration;mass bereavement, media/societal responses and the ongoing threat of the virus;grieving and coping (alone and with others);workplace and employment difficulties;and accessing support via health and social care. Examples of loss-oriented stressors included being unable to visit or say goodbye, the sudden and traumatic nature of many deaths, and restricted funeral and memorialization practices. Reactions included feelings of guilt and anger, and problems accepting the death and starting to grieve. Examples of restoration-oriented stressors and reactions comprised stressful deathrelated administration and severely curtailed social networks, support systems and social/recreational activities, which impacted peoples' ability to cope. Conclusions: These results demonstrate the exceptionally difficult sets of experiences associated with pandemic bereavement, defined by significant disruption to end of life, death and mourning practices, as well as usual coping mechanisms and formal or informal bereavement support. The DPM provides a useful framework for conceptualizing the additional challenges associated with pandemic bereavement and their impact on grieving and mental health.

Inequalities in Access to Bereavement Support Before and During COVID-19: Findings from Voluntary and Community Sector Bereavement Services in the UK

Background/aims: The COVID-19 pandemic has resulted in global mass bereavement;in the UK alone there have been 140,000 deaths to date, with a disproportionate impact on Black, Asian or minoritized ethnic (BME) communities. Voluntary and community sector (VCS) bereavement services including hospices play an important role in bereavement support. We aimed to determine services' perspectives on access to their support. Methods: Cross-sectional online survey of VCS bereavement services in the UK, open March-May 2021, disseminated via national organisations, associations and networks and social media. Results: 147 organisations participated;53% served specific counties or smaller regions;16% were UK-wide. 36% were hospice or palliative care services, 15% national bereavement charities or NGOs;12% local bereavement charities. 67.3% reported there were groups with unmet needs not accessing their services before the pandemic;most frequently reported were people from BME communities (49%), sexual minority groups (26.5%), deprived communities (24.5%) and men (23.8%). 50% of services reported that, in the year before COVID-19, <5% of clients were from BME communities;25% did not collect this data and 25% reported >5% BME clients. Compared with before the pandemic, 3.4% of services were seeing more people from BME groups, 52% were seeing the same proportion, 6.1% were seeing fewer and 38% didn't know/didn't collect this data. Conclusions: For over two thirds of VCS bereavement services in the UK, there are known inequities in who accesses support, with people from BME groups most likely to be recognised as needing support but not Paediatric Palliative Care Commissioners (n=2) Gender Female:Male 2:0 accessing services. During the pandemic, the proportion of BME clients did not increase, despite these communities being disproportionately affected by COVID-19. More attention needs to be paid to assessing and meeting unmet needs for formal bereavement support among disadvantaged groups and routinely collecting client data to help determine and ensure equity. (Table Presented).

The Impact of COVID-19 on the Provision of Voluntary and Community Sector Bereavement Services: A Cross-Sectional Survey from the UK

Background/aims: During the COVID-19 pandemic, voluntary and community sector (VCS) bereavement services including hospices have played a central role in supporting the bereaved. We aimed to describe the impact of the pandemic on these services to inform service development and policy. Methods: Cross-sectional online survey of VCS bereavement services in the UK, open March-May 2021, disseminated via national organisations, associations and networks, and social media. Results: 147 organisations participated;53% were regional, 16% UK-wide. 36% were hospice or palliative care services, 15% national bereavement charities or NGOs;12% local bereavement charities. During the pandemic referrals increased for 46% of organisations and decreased for 35%. 40.3% reported a current waiting list >3 weeks. 78.2% had changed services due to Covid;51.7% introduced new services. There had been a significant reduction in provision of all face-toface support including peer group meetings (50% to 4.1%, OR 0.04), facilitated group meetings (78% to 11%, OR 0.04), 1:1 support (87% to 27%, OR 0.06) and specialist intervention (44% to 16%, OR 0.25). Online and telephone provision saw major increases, particularly online 1:1 support (8.8% to 83%, OR 50.3), facilitated group meetings (4.1% to 56%, OR 30.48) and specialist intervention (3.4% to 36%, OR 16.01). Challenges included staff/volunteers providing support from home (69/64%), emotional impact on staff/volunteers (67/41%), increased pressure on staff due to client volume (41%) and complexity of needs (44%), implementing staff training (60%) and financial challenges (53%). 93% reported positive changes/opportunities during the pandemic, e.g., new coordination initiatives (47%). Conclusions: UK bereavement services rapidly transformed during the pandemic, despite significant challenges. To ensure positive changes and innovations are retained, the experiences and acceptability of new and adapted services among clients and staff require further investigation.

Grief, Support Needs and Associated Factors Among People Bereaved During the COVID-19 Pandemic: Baseline Results from a Longitudinal UK Online Survey

Background/aims: The COVID-19 pandemic has had a detrimental impact on millions of people's experiences of bereavement. Traumatic end-of-life experiences and disruptions to support networks increase chances of poor bereavement outcomes. We aimed to examine grief and support needs, and identify associated risk factors. Methods: Mixed-methods survey of people bereaved in the UK from Mar 2020-Jan 2021, disseminated via media, social media, national associations, community/charitable organisations. Practical and emotional support needs were assessed in 13 domains, and grief intensity using the Adult Attitude to Grief (AAG) scale, which calculates an overall index of vulnerability (IOV) (range 0-36). Results: 711 participants, mean age 49.5 (SD 12.9);88.6% female;95.3% white. Mean age of deceased 72.2 (SD 16.1);58% died in hospital;44% from COVID-19. Mean IOV was 20.41 (95% CI = 20.06 to 20.77), i.e., high vulnerability in grief overall. 28.2% exhibited extreme levels of vulnerability (i.e., IOV ≥ 24). In six support domains, all relating to psycho-emotional support, 50% to 60% of respondents reported high/fairly high levels of need. Increased levels of perceived support from health professionals led to significantly (P < 0.001) lower levels of grief and support need (small/medium effect, P < 0.001). Bereaved participants who were socially isolated/lonely experienced higher levels of grief and support needs than those who were not (P < 0.001). Grief and support needs were much higher for close family members compared with other groups (P < 0.05). Levels of grief and support needs were slightly higher for COVID-19 deaths compared with non- COVID-19 (P < 0.01), although this was not significant in a mixed model. Conclusions: People bereaved during the pandemic experience high levels of grief and emotional support needs, with social isolation/loneliness and death of a close family member particular risk factors. Healthcare professionals' support is associated with better bereavement experiences.

The Grief and Support Needs of Children and Young People Bereaved During the COVID-19 Pandemic: Parental Views From a UK National Survey

Background/aims: During the COVID-19 pandemic, many children and young people have experienced the death of close family members, whilst also facing unprecedented disruption to their lives. This study aimed to investigate the bereavement experiences and support needs from the perspective of their parents or guardians. Methods: We analysed cross-sectional free-text data from a survey of adults bereaved in the UK during the pandemic. Participants were recruited via media, social media, national associations and community/ charitable organisations. Thematic analysis was conducted on parent/ guardian responses to a question on the bereavement experiences and support needs of their children. Results: Free-text responses from 106 participants were included. Three main themes were identified: the pandemic-related challenges and struggles experienced by children and young people;family support and coping;and support from schools and services. Pandemic specific challenges include the impacts of being separated from the relative prior to their death, isolation from peers and other family members and disruption to daily routines and wider support networks. Examples were given of effective family coping and communication, but also difficulties relating to parental grief and children's existing mental health problems. The important role of schools and bereavement organisations in providing specialist support was demonstrated, but there was evidence of unmet need and lack of access to specialist grief or mental health support. Conclusions: Children and young people have faced additional strains and challenges associated with pandemic bereavement. We recommend initiatives that facilitate open and supportive communication within family and school settings, adequate resourcing of school and community- based specialist services and increased information and signposting to the support that is available.

QUINOLINIC ACID IS A BIOMARKER of COVID-19-ASSOCIATED COGNITIVE IMPAIRMENT

Background: COVID-19 infection-associated cognitive and olfaction impairments have an unclear pathogenesis, possibly related to systemic disease severity, hypoxia, or illness-associated anxiety and depression. A biomarker for these neurocognitive changes is lacking. The kynurenine pathway (KP) is an interferon stimulated myeloid cell mediated tryptophan degradation pathway important in immune tolerance, neurotoxicity and vascular injury, that is dysregulated in COVID-19. We hypothesized that neurocognitive impairments were associated with an activated KP. Methods: The current analysis includes COVID-19 patients as part of the ADAPT study, a prospective cohort (St Vincent's Hospital Sydney, Australia). Disease severity was assessed with 18 acute symptoms and hospitalization status. Blood samples were taken 2 months (N=136) and 4 months (N=121) post diagnosis along with cognitive (Cogstate Computerized Battery, CBB;NIH toolbox Odor Identification Test, OIT) and mental health screenings (DMI-10;IESR, SPHERE-34 Psychological subscale grouped into a composite score). KP metabolites (PIC, QUIN, 3HK, 3HAA, AA, KYN, TRP, log for analyses except for TRP) were measured by GC-MS and uHPLC. The CBB and OIT data were demographically-corrected. CBB follow-up data was also corrected for practice effect. Linear mixed effect regression models with time effect (days post diagnosis) tested whether cognition, and olfaction were associated the KP (main and time interaction);while correcting for disease severity, mental health and comorbidities. Results: 136 patients: mean age=46±15;40% females;90% English speaking background;disease severity: 40% mild, 50% moderate, 10% severe/hospitalised;34% treated comorbidities. At 2 months post diagnosis, 16% had cognitive impairment, and 25% had impaired olfaction. Cognitive impairment was more common in those with anosmia (p=.05). At 4 months, 23% had cognition impairment and 20% had impaired olfaction. QUIN (p=.001), 3HAA (p<.0001) increased over the study period, while TRP decreased (p=.02). QUIN level associated with poorer cognitive scores (p=.0007;QUIN (nM) between 800-1000 was most predictive). There was no time∗QUIN interaction. QUIN association to cognition persisted when severe cases were excluded (p<.005). Conclusion: COVID-19 is associated with KP activation, and the latter with cognitive impairment. QUIN was the only biomarker associated with cognitive impairment, and may be useful in monitoring and elucidating COVID-19 neuropathogenesis and treatment.

Halting Epidemics at the Outset: Community-Based Surveillance (CBS) in an Epidemic Preparedness Model for Early Detection and Early Action

Purpose: An innovative epidemic preparedness model establishing an SMS real-time community-based surveillance (CBS) system enables earlier detection and earlier action to control outbreaks at the outset. Methods & Materials: The One Health preparedness program has been piloted in 5 countries: Guinea, Indonesia, Kenya, Sierra Leone and Uganda, since 2019. A tiered model building on a foundation of volunteer skill-building, community health and epidemic awareness activities, building trust and motivating communities, and establishing connections with local health and veterinary authorities. CBS extends on that foundation establishing a simple, low-cost, real-time system for community volunteers to identify and notify of potentially serious health events triggering investigation and response by local authorities. Communities are prepared to take immediate actions to halt the spread. Materials and methodology are standardised: mobile phone SMS to signal alerts, Kobo application to log and monitor alerts, training packages, and job aids. Results: Volunteers and communities have successfully raised CBS alerts, taken action, and controlled outbreaks of measles, polio, acute watery diarrhoea, anthrax and rabies which minimised the spread and impact. To be effective CBS must achieve timely notification of alerts, accuracy to minimise needless investigation, action must be taken, and volunteers must remain engaged. Results from July 2020 – March 2021 show successful rapid notification: 76% of alerts were communicated to authorities within 24hrs. Volunteers accurately recognised the key signs for 77% of alerts. Owing to the relationships with local Government an average of 75% of alerts were investigated, although human health alerts have higher investigation rates than animal alerts. Volunteer reliability fluctuates from 44% to 88% across the 5 countries. Positive predictive value for human alerts is high in most countries;63% of alerts overall were confirmed positive as epidemic diseases. This established CBS system has readily incorporated detection of COVID-19 and been rapidly scaled-up during Ebola high-alert demonstrating agility for detection of emerging threats. Conclusion: Communities themselves have the potential to identify and combat epidemic threats. Preparedness programs which engage communities, build skills, establish simple and effective surveillance mechanisms and connect with local service providers, can control outbreaks at the outset and communities can enjoy greater resilience.

The impact of virtual and face to face patient consultations in MSK clinics on clinician perception of clinician consistency

Keywords: Clinician consistency;Clinician perception;Therapeutic alliance Purpose: Best practice guidance acknowledges that clinician consistency has a positive impact on therapeutic alliance (TA) and patient clinical outcome. With the rapid implementation of virtual consultations throughout the Covid-19 pandemic, developing and maintaining TA through clinician consistency has been a new challenge for clinicians. Purpose: While face to face assessment and treatment of MSK patients was limited due to Covid-19 social restrictions, this provided the opportunity to complete a Quality Improvement (QI) project with the purpose of exploring the impact of virtual consultations on clinician consistency and hence TA, develop clinical and operational pathways to support clinician consistency and engrain some lessons learnt when returning to a “Back to Better” model of MSK working post Covid-19. Methods: To establish a baseline perception of clinician consistency with the use of virtual patient consultations, a survey was sent to all clinical and administrative staff. The Model of Improvement methodology was utilised and two cycles completed whereby the survey was repeated six-weekly to inform iteration of the next cycle. The key interventions within these two cycles to enhance clinician consistency, were to devise and implement clinical and operational pathways. This included a standardised process of clinician documentation for the administrative staff to identify a specific timeframe for patient follow up, stipulating the appropriate clinician to ensure “Making Every Contact Count” (MECC) principles and enhancing patient choice on the consultation type i.e. virtual or face to face. Results: After 2 cycles (12 weeks) of using enhanced clinical and operational pathways to support clinician consistency, the clinician surveys demonstrated that 23% of clinical staff perceived an improvement in clinician consistency. Additionally, there was a 29% reduction in negative impact of cross reviews on personal workload, with a 33% increase in appropriate use of cross reviews as clinically indicated. This resulted in a 20% reduction in negative impact on quality of patient care. Conclusion(s): This Quality Improvement project has highlighted that utilising virtual consultations can negatively impact clinicians perception of clinician consistency. However, through installing clinical and operational pathways to enhance clinician consistency, while maintaining MECC principles, positive impact on clinician perception can be demonstrated within 12 weeks. Impact: This Quality Improvement project on clinician consistency has impacted clinical and operational pathways to ensure appropriate use of clinician consistency. This has a positive impact not only on clinician perception but also on creating a therapeutic alliance between therapist and patient. With these clinical and operational pathways now embedded in our clinical practice, the Croydon MSK department is moving towards “blended” clinics where all patients have the choice of consultation type whether that is telephone, video or face to face. This encourages patient choice and engagement throughout their MSK pathway. Funding acknowledgements: No funding required.