The Impact of COVID-19 Response on Infection Prevention Programs and Practices in Southeastern United States

Background. Early assessments of COVID19 preparedness reported resource shortages, use of crisis capacity strategies, variations in testing, personal protective equipment (PPE), and policies in US hospitals. One year later, we performed a follow-up survey to assess changes in infection prevention practice and policies in our diverse network of community and academic hospitals. Methods. This was a cross-sectional electronic survey of infection preventionists in 58 hospitals within the Duke Infection Control Outreach Network (community) and Duke/UNC Health systems (academic) in April-May 2021 to follow-up our initial survey from April 2020. The follow-up survey included 26 questions related to resource availability, crisis capacity strategies, procedures, changes to PPE and testing, and staffing challenges. Results. We received 54 responses (response rate, 93%). Facilities reported significantly fewer PPE and resource shortages in the follow-up survey compared to our initial survey (Figure 1, P< 0.05). Only 32% of respondents were still reprocessing N95 respirators (compared to 73% in initial survey, P< 0.05). All hospitals performed universal masking, universal symptom screening on entry, and 30% required eye protection. In 2020, most hospitals suspended elective surgical procedures in March-April, and restarted in May-June. Approximately 92% reported in-house testing for SARS-COV-2 by April 2020, at least a third of which had a weekly capacity of >100 tests. Almost 80% performed universal pre-operative testing, while 61% performed universal preadmission testing for SARS-COV-2. Almost all hospitals switched from test-based to time-based strategy for discontinuing isolation precautions, majority in August-September 2020. Twenty-five percent hospitals reported infection prevention furloughs, staffing cuts, and or reassignments, while 81% reported increased use of agency nursing during the pandemic. Conclusion. Our follow-up survey reveals improvement in resource availability, evolution of PPE guidance, increase in testing capacity, and burdensome staffing changes. Our serial surveys suggest increasing uniformity in infection prevention policies, but also highlight the increase in staff turnover and infection prevention staffing shortages.

Longitudinal antibody dynamics in children infected with SARS-CoV-2 through 6 months post-infection

Background. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection elicits antibodies (Abs) that bind several viral proteins such as the spike entry protein and the abundant nucleocapsid (N) protein. We examined convalescent sera collected through 6 months (~24wks) post-SARS-CoV-2 infection in children to evaluate changes in neutralization potency and N-binding. Methods. Outpatient, hospitalized, and community recruited volunteers < 18 years with COVID-19 were enrolled in a longitudinal study at Seattle Children's Hospital. Analysis includes symptomatic and asymptomatic children with laboratory-confirmed SARS-CoV-2 infection who provided blood samples at approximately 4wks (range: 2-18wks, IQR:4-8wks) and 24 wks (range: 23-35wks, IQR:25-27wks) after diagnosis. We measured neutralizing Ab using an in-house pseudoneutralization assay and anti-N binding Ab using the Abbott Architect assay. Results. Of 32 children enrolled between April 2020 and January 2021, 27 had no underlying immunocompromised state and 25 of these 27 children had symptomatic disease. Ten of 27 had a > 2-fold decrease neutralization titers between 4 and 24wks (most were < 10-fold);12 had < 2-fold change;and 5 had neutralization titers that increased > 2-fold over time (Fig. 1A). All but one of these 27 children had detectable neutralizing activity at 24wks. Anti-N Abs were assessed for 25 children at 4wks and 17 children at 24wks (data pending for 14 samples);all children with paired samples had a > 1.75-fold Abbott index reduction at 24wks, and 5 children had no detectable anti-N Abs by 24wks (Fig. 2A). An additional 5 children with symptomatic disease had complicating immunosuppression or multiple blood transfusions;2 had decreasing neutralizing titers, 2 increased, and 1 had no change (Fig. 1B). Anti-N Abs were undetectable for one child by 24wks (data pending for 4 samples) (Fig. 2B). No participants received COVID-19 vaccine. Conclusion. We show neutralizing Abs wane to a small degree over 24wks post-SARS-CoV-2 infection and remain detectable in most children. In contrast, anti-N Abs decreased, becoming undetectable in some children by 24wks. These findings add to understanding of the natural history of SARS-CoV-2 immunity in children.

Redirecting a global health surgical program to remote support during a pandemic: the IVU virtual visiting professorship program

INTRODUCTION AND OBJECTIVE: Global health surgical programs generally provide support through hands on surgical workshops. The COVID-19 pandemic has significantly impacted domestic and international travel, virtually eliminating the ability of such programs to provide in person care. International Volunteers in Urology (IVU) has developed a virtual visiting professorship (VVP) program out of necessity to redirect in person support to virtual support. METHODS: The VVP program was established in February 2020 when the decision was being made to suspend surgical mission trips. The program consists of hour long lectures provided to established international sites at which IVU has previously held global health surgical workshops on topics requested by those sites after solicitation by IVU. Lecturers are IVU volunteers. We report the experience of the IVU VVP program from February 2020 through January 2021. We evaluated the number and timing of VVPs, as well as topics, locations served, and volunteers engaged. We also report the results of a basic survey from participants evaluating the program. RESULTS: 42 lectures have been given over 12 months. Topics included those in General Urology (n=9), Oncology (n=20), Female Urology (n=2), Reconstruction (n=2), and Pediatrics (n=9). Lectures have been given to sites in 11 countries outside of the US, mainly in Africa, with 10 lectures given to the Pan-African Urological Surgeon's Association. A total of 2,149 persons registered for the VVPs;1,094 (51%) participated. While participation initially was proportionate to the number lectures given, there has been some decrease since September 2020 (Figure 1). The lectures have been given by 31 IVU volunteers, of which for 12 (39%), the VVP was their first experience with IVU. Participants ranked presentations on Likert Scale (0 poor-100 excellent) a median of 98. CONCLUSIONS: The COVID-19 pandemic has required global health surgical programs to significantly rethink their support of others. IVU has created a well-received VVP program that enables remote education during a time when it has been necessary for more selfisolation. Such a program enables maintained connectivity in this altered landscape of global health programs and has increased IVU participation.

Early perceptions of COVID-19 significantly differed between low-/lower-middle income countries and high-income countries

INTRODUCTION AND OBJECTIVE: While the response of certain countries to the COVID-19 pandemic was well publicized, the response of others, particularly less resourced, was not. We compared the personal response of individuals in low-/lower-middle income countries (LLMIC) to high-income countries (HIC) and what they witnessed by their establishments. METHODS: In May 2020, a survey was emailed to surgeons associated with the International Volunteering in Urology program. Responding participants were grouped into LLMIC or HIC. The survey questioned patient care and operating practice during the pandemic and personal attitudes regarding COVID-19, including personal risk of contraction and transmission. Results were compared by student's t-test, Mann-Whitney U, or chi-square test with p<0.05 being significant. RESULTS: 103 surveys were sent with 40 responses: 17 from LLMIC and 23 from HIC. The groups did not differ for age (p=0.13) or having children (p=0.06). Significantly more LLMIC respondents were male (p=0.03). HICs reported higher rates of COVID testing (83% vs. 6%;p<0.001). Groups had similar reports of operating per normal routine, having cared for or operated on COVID positive patients, and having personal patients die from COVID (p>0.05). Groups similarly had hospital guidelines on the care of COVID patients (p>0.05). Despite significantly more HICs performing telemedicine (87% vs. 18% p=0.0007), groups did not differ regarding working remotely (p=0.24). LLMICs expressed stronger concern regarding personal and family risk of contracting COVID, as well as being a possible vector of transmission (Figure 1). A Likert scale ranking of the pandemic (1 being unremarkable and 100 the worst seen) did not significantly differ between LLMIC and HIC (median 72.5 vs. 88.0;p=0.11). CONCLUSIONS: Early in the pandemic, there were significant differences in attitudes regarding personal risk of COVID-19 upon survey of LLMIC and HIC surgeons despite seemingly little difference in impact on clinical practice. This may come from LLMICs having more personal experience with prior pandemics. Follow-up studies are needed to evaluate if attitudes have changed as the pandemic has progressed.

Binding signatures and cross-reactivity in the SARS-CoV-2 immune response

Background: Mounting evidence indicates that antibodies generated during SARS-CoV-2 infection are correlates of protection. Antibodies targeting Spike (S) on the viral surface have been shown to neutralize the virus. However, the full repertoire of neutralizing and non-neutralizing antibodies against SARSCoV-2, as well as cross-reactivity between SARS-CoV-2 and other circulating (CoVs), remains unclear. We sought to profile the complete repertoire of linear CoV epitopes targeted by the humoral immune response in patients with and without COVID-19 from Seattle, WA. Methods: To map the linear epitope profiles in patients, we developed a comprehensive pan-CoV phage display library composed of 39 amino acid peptides covering the complete genomes of SARS-CoV-2 and the six other CoVs known to infect humans. Using samples from patients with confirmed COVID-19 and with no known SARS-CoV-2 exposure, we immunoprecipitated antibodies against CoV peptides, deep sequenced the co-immunoprecipitated phage, and applied a customized computational pipeline to define SARS-CoV-2 and crossreactive epitopes. Results: The dominant immune responses to SARS-CoV-2 were targeted to regions spanning S, Nucleocapsid (N), and ORF1ab. We identified 17 epitopes within S that were present in two or more individuals, spanning both the S1 and S2 subunits, with some detected in > 75% of individuals. The most commonly mapped S epitope (S- residues 1121-1159) was a region just upstream of the second heptad repeat. We identified nine epitopes within N that were reactive in at least two individuals, four of which were present in at least 35% of patients. The two most prominent N epitopes were derived from the RNA binding domain (N residues 141-179 and 161-199). Epitopes isolated from ORF1ab were the most variable across patients. Of the 46 unique ORF1ab epitopes we identified, only five were present in two or more individuals, suggesting that ORF1ab responses are individual-specific. We also found a high degree of variation in the total number of epitopes targeted by individuals (ranging from 2 to 25). Finally, we identified four unique cross-reactive sequences that were bound by antibodies in SARS-CoV-2 unexposed individuals. Conclusion: Our study comprehensively defined the linear epitope profiles of a population of COVID-19 and SARS-CoV-2 unexposed patients. Epitope maps and functional characterization of SARS-CoV-2 antibodies will be critical for the development of a broad repertoire of COVID-19 treatments and vaccine strategies.

SARS-CoV-2 preparedness among community hospitals in Southeastern United States

Background: The SARS-CoV-2 pandemic has placed a tremendous strain on the U.S. healthcare system leading to personal protective equipment (PPE) and resource shortages. Hospitals have developed contingency and crisis capacity strategies to optimize the use of resources, but, to date, community hospital preparedness has not been described. Methods: We performed a cross-sectional survey of infection preventionists in 60 community hospitals within the Duke Infection Control Outreach Network between April 22 and May 7, 2020 using Qualtrics. The survey included 13 questions related to resource availability, crisis capacity strategies and approaches to testing. Results: We received 50 responses during the study period with a response rate of 83%. Community hospitals reported varying degrees of PPE shortages (Table 1);80% of community hospitals were implementing strategies to extend and reuse N95 respirators, Powered Air-Purifying Respirators, face shields and face masks. Over 70% of facilities reported reprocessing N95 respirators (Figure 1). Almost all facilities reported universal masking at time of this survey with 90% performing daily employee screening at point of entry. Additionally, 8% of facilities restarted elective procedures at the time of this survey, but only 54% of facilities reported that they were performing preoperative testing for SARS-CoV-2. Thirty-seven percent of facilities performed one SARS-CoV-2 test before discharging an asymptomatic patient to skilled nursing facility, while 43% of facilities performed 2 tests. Conclusion: Our findings reveal differences in resource availability, crisis capacity strategies and testing approaches used by community hospitals in preparation for the SARSCOV- 2 pandemic. Lack of harmonization in approaches may be in part due to differences in state guidelines and decentralized federal approach to SARS-CoV-2 preparedness. (Table Presented).