All the King's Horses and All the King's Men: Falling Into Moral Injury, During the COVID-19 Pandemic

Health care providers who experienced giving care or abbreviating those services, during the COVID-19 pandemic, risked experiencing a sense of moral injury. Moral injury is a term to describe incidents where a health care provider knows the right thing to do, but constraints make it exceedingly difficult or impossible to execute the right course of action. These incidents likely also were present for sonographers and vascular technologists, and it is vital that these compromises for patients are recognized, and healing strategies offered to those suffering from moral injury. Some suggestions for treatment of moral injury are to recognize these experiences, seek solutions, provide empathy for patients and resources for health care providers. It may also be beneficial to allow employees and employers to forgive the mistakes made during the pandemic and focus on solutions to prevent future incidents of moral injury.Copyright © The Author(s) 2023.

The COVID-19 Pandemic Experience for Patients with Central Nervous System (CNS) Tumors: Differences in Patient- Reported Outcomes (PROs) and Practice Recommendations

Background/Purpose: The COVID-19 pandemic and associated mitigation procedures have significantly altered daily life in ways that may disproportionately affect patients with CNS tumors. This study aimed to explore differences in symptom burden and interference, mood disturbance, and health-related quality of life in the CNS tumor patient population during the COVID-19 pandemic, compared to a normative sample of pre-pandemic data. Method(s): Data from the Neuro-Oncology Branch (NOB) Natural History Study, including demographic and clinical data, as well as PROs including PROMIS Anxiety and Depression Short-Forms, EQ- 5D-3L, MDASI-Brain Tumor/Spine Tumor, and NeuroQOL-Cognition Function, were collected and compared across groups ('NOB normative sample' and 'COVID year' patients) using one-sample proportion tests. Result(s): 178 COVID year CNS tumor patients (55% male, 82% Caucasian, median age 45 years) were compared with 678 NOB normative sample patients with similar demographic and clinical characteristics. Symptom burden remained comparably high during the COVID year compared to the NOB normative sample with the most common moderate-severe symptoms being fatigue (31% vs. 35%), difficulty remembering (28% vs. 24%), drowsiness (22% vs. 25%), disturbed sleep (20% vs. 22%), and distress (20% for both). However, a significantly greater proportion of COVID year assessments endorsed moderate-severe depression on the PROMIS compared to the NOB normative sample (17% vs. 12%, p = 0.023, Cohen's h = 0.22) and moderate-severe depression/anxiety on the EQ-5D-3L was also more prevalent (53% vs. 43%, p = 0.009, Cohen's h = 0.28). There were no other significant differences in PROs between groups. Conclusions and Implications: These findings demonstrated that while objective symptom burden for CNS tumor patients was unchanged, there was an increase in depression reported during the COVID-19 pandemic. Future work should investigate potential pandemic-era interventions for screening, targeting, and improving both mood disturbance and other disease-specific symptoms to improve symptom burden and quality of life.

Selected Women's Health Disparities

The National Institutes of Health defines health disparities as "differences in incidence, prevalence, mortality, and burden of disease and other adverse health conditions that exist among specific population groups in the United States." There are measurable differences such as education, income, and location that tend to exist between races/ethnicities, sexual identities, and age groups associated with variations in health outcomes. Cardiovascular disease, COVID-19, cancer, and reproductive health are among the conditions that have been identified as having higher morbidity and mortality among women than men. Access to adequate healthcare, access to support services, or a female's genetic makeup further contribute to health disparities. Copyright © 2022, Jobson Publishing Corporation. All rights reserved.

Assessment of a Student-Run Free Gender-Affirming Care Clinic's Transition to Telehealth.

Background: Transgender and Gender-Nonconforming (TGNC) people continue to experience severe health discrimination and limited access to care. Methods: Using survey data collected during August-September, 2020, we report on our findings regarding volunteer provider and patient satisfaction with a student-run free gender-affirming care telehealth clinic at the University of North Carolina at Chapel Hill School of Medicine. Results: We find that patients report overall excellent experiences with telehealth care, primarily due to decreased transportation burden, more efficient use of time, and more frequent communication with student volunteer providers. Conclusion: Our findings show that telehealth is a viable option for student-run clinics in the TGNC community.

Severe Acute Respiratory Syndrome Coronavirus 2 Infection and Pregnancy in Sub-Saharan Africa: A 6-Country Retrospective Cohort Analysis.

BACKGROUND: Few data are available on COVID-19 outcomes among pregnant women in sub-Saharan Africa (SSA), where high-risk comorbidities are prevalent. We investigated the impact of pregnancy on SARS-CoV-2 infection and of SARS-CoV-2 infection on pregnancy to generate evidence for health policy and clinical practice. METHODS: We conducted a 6-country retrospective cohort study among hospitalized women of childbearing age between 1 March 2020 and 31 March 2021. Exposures were (1) pregnancy and (2) a positive SARS-CoV-2 RT-PCR test. The primary outcome for both analyses was intensive care unit (ICU) admission. Secondary outcomes included supplemental oxygen requirement, mechanical ventilation, adverse birth outcomes, and in-hospital mortality. We used log-binomial regression to estimate the effect between pregnancy and SARS-CoV-2 infection. Factors associated with mortality were evaluated using competing-risk proportional subdistribution hazards models. RESULTS: Our analyses included 1315 hospitalized women: 510 pregnant women with SARS-CoV-2, 403 nonpregnant women with SARS-CoV-2, and 402 pregnant women without SARS-CoV-2 infection. Among women with SARS-CoV-2 infection, pregnancy was associated with increased risk for ICU admission (adjusted risk ratio [aRR]: 2.38; 95% CI: 1.42-4.01), oxygen supplementation (aRR: 1.86; 95% CI: 1.44-2.42), and hazard of in-hospital death (adjusted sub-hazard ratio [aSHR]: 2.00; 95% CI: 1.08-3.70). Among pregnant women, SARS-CoV-2 infection increased the risk of ICU admission (aRR: 2.0; 95% CI: 1.20-3.35), oxygen supplementation (aRR: 1.57; 95% CI: 1.17-2.11), and hazard of in-hospital death (aSHR: 5.03; 95% CI: 1.79-14.13). CONCLUSIONS: Among hospitalized women in SSA, both SARS-CoV-2 infection and pregnancy independently increased risks of ICU admission, oxygen supplementation, and death. These data support international recommendations to prioritize COVID-19 vaccination among pregnant women.

Epidemiology of Candidemia Rates during COVID-19 and Comparison of Outcomes in Candidemia between COVID-19 and Non-COVID-19 Patients

Background. Fungemia is associated with high rates of morbidity, mortality and increase in length of hospital stay. Several studies have recognized increased rates of candidemia since the COVID-19 pandemic. Methods. A retrospective cohort study was conducted at a tertiary healthcare system in Detroit, Michigan to evaluate the impact of the COVID-19 pandemic on incidence of candidemia. The "pre COVID-19" timeframe was defined as January - May 2019 while the "during COVID-19" timeframe was January - May 2020. To compare incidence and patient characteristics between cohorts, t-tests and chi-square analysis was used. Additional sub-analysis was performed in candidemia patients during COVID-19 timeframe comparing outcomes of patients based on COVID-19 status. A Fisher Exact and Satterthwaite Test were used for analysis of categorical and continuous variables, respectively. Results. Overall, 46 cases of candidemia were identified in both the pre COVID-19 and during COVID-19 periods. Pre COVID-19, the average number of cases was 3.0 ± 1.2 per month. The incidence more than doubled during COVID-19 to 6.2 ± 4.2 cases per month (p = 0.14) (Figure 1). No significant differences in patient demographics were detected between cohorts, however, patients in the COVID-19 cohort had higher rates of corticosteroid use, mechanical ventilation and vasopressors (Table 1). In the 2020 period, 31 patients developed candidemia and 12 (38.7%) patients tested SARS-CoV-2 positive. On average, COVID-19 patients developed candidemia 12.1 days from admission, compared to 17.8 days in the COVID-19 negative cohort (p = 0.340). Additionally, COVID-19 patients with candidemia coinfection were significantly more likely to expire;83.3% (n=10) COVID-19 patients expired compared to 36.8 (n=7) in the COVID-19 negative cohort (p = 0.025) (Table 2). Conclusion. The prevalence of fungemia markedly increased during the COVID-19 surge. Increased use of corticosteroids and broad spectrum antimicrobials, prolonged use of central venous catheters and prolonged ICU length of stay likely contributed to this increase. Patients who developed candidemia co-infection with COVID-19 were found to have poorer outcomes as compared to those who were SARS-CoV-2 negative or untested.

Outbreak of Multidrug-resistant Pseudomonas aeruginosa in a Tertiary Healthcare System in Detroit

Background. Pseudomonas aeruginosa is one of the most common causes of healthcare-associated infections in critically ill patients and those with suboptimal immunity. However, the development of multidrug resistant Pseudomonas aeruginosa (MDR Pa) creates an even great disease burden and threat to both the hospital and local community health. The purpose of this study is to illustrate a descriptive analysis of a cluster of MDR Pseudomonas, during a local surge of SARS-CoV-2 (COVID 19) pandemic. The goal is to shed more light on the troublesome parallel during outbreaks, such as COVID-19 and consequential secondary outcomes. Methods. From November 2020 through February 2021, 16 patients exposed to the intensive care units of a tertiary healthcare system were infected or colonized with a multidrug-resistant strain of P. aeruginosa (Figure 1). Outbreak investigation was conducted via retrospective chart review of the first eight cases and prospective analysis of the latter eight cases. The isolates collected prospectively were analyzed for taxonomic identification, antimicrobial resistance profile, and phylogenetic analysis. Clinical characteristics of all patients were collected, and epidemiological investigation was carried out. MDR is defined as resistance to at least four classes of antibiotics: third-generation cephalosporins, fluoroquinolones, aminoglycosides, and carbapenems. Results. Of the 16 cases of MDR Pa infections, seven died within five months (Table 1). Antimicrobial resistance gene profiling detected blaOXA and blaPAO betalactamase genes in all the samples. One sample contained an additional blaVIM resistance gene, although this patient was colonized and not actively infected. The analysis suggests existence of two clusters demonstrating relatedness and possible horizontal transmission. Timing of this cluster of cases coincides with surge of COVID-19 cases. This highlights the importance of infection control measures and antimicrobial stewardship. Conclusion. Since early 2017 studies show there is a growing prevalence worldwide in transferable resistance, particularly for β-lactamases and carbapenemases, MDR Pseudomonas. This study emphasizes an irony paralleled during a pandemic, the needed efforts to prevent unintentional lapses in patient safety.

Evaluating participant and coordinator satisfaction with telephone assessments

BACKGROUND: In response to the COVID-19 pandemic, the Alzheimer's Disease Research Center (ADRC) at the Icahn School of Medicine at Mount Sinai began conducting evaluations for the National Alzheimer's Coordinating Center Uniform Data Set (NACC UDS) by telephone in March 2020. The ADRC designed a survey to evaluate participant and research coordinator satisfaction with telephone evaluations. METHOD: Following UDS evaluations, participants rated their satisfaction on 5 items: voice quality on telephone, respect for privacy, degree of comfort using the telephone, and confidence that the information collected was accurate. Coordinators were asked to gauge their satisfaction on similar items. To calculate satisfaction scores, responses were assigned values: "Very" = 3, "Fairly" = 2, and "Not at all" = 1. Maximum satisfaction score was 15 for participants and 18 for coordinators. RESULT: Data was available for 130 participants evaluated by telephone between March 2020 and January 2021. Of these, 68.5% were female, 53.7% were white, with an average age of 76.4 and 16 years of education. 74% of participants had a Global Clinical Dementia Rating (CDR) score of 0;22% CDR 0.5;4% CDR 1. Participants with CDR >1 were evaluated by caregiver interviews without testing, and those with CDR=1 were offered testing at the discretion of their family and examiners. Average total satisfaction rating was 14.2/15 for participants and 16.8/18 for coordinators. 98% of participants felt their privacy was "very" respected (mean 2.98/3). When looking at global CDR scores, 89.6% of participants with CDR=0 and 88.2% with CDR ≥0.5 were "very" confident in the accuracy of the information collected. In contrast, coordinators were "very" confident in the accuracy of their evaluation 84.4% of the time when participants had a CDR=0 and 67.7% of the time when participants had a CDR ≥0.5. CONCLUSION: Overall satisfaction with telephone evaluations was high, but participant and coordinator confidence in the accuracy of assessments varied, with coordinator satisfaction lower for more cognitively impaired participants. Future work will analyze satisfaction with ongoing remote assessments and evaluate the impact of additional demographic and diagnostic variables. © 2021 the Alzheimer's Association.

Assessment of Clinical Outcomes Among Children and Adolescents Hospitalized With COVID-19 in 6 Sub-Saharan African Countries.

IMPORTANCE: Little is known about COVID-19 outcomes among children and adolescents in sub-Saharan Africa, where preexisting comorbidities are prevalent. OBJECTIVE: To assess the clinical outcomes and factors associated with outcomes among children and adolescents hospitalized with COVID-19 in 6 countries in sub-Saharan Africa. DESIGN, SETTING, AND PARTICIPANTS: This cohort study was a retrospective record review of data from 25 hospitals in the Democratic Republic of the Congo, Ghana, Kenya, Nigeria, South Africa, and Uganda from March 1 to December 31, 2020, and included 469 hospitalized patients aged 0 to 19 years with SARS-CoV-2 infection. EXPOSURES: Age, sex, preexisting comorbidities, and region of residence. MAIN OUTCOMES AND MEASURES: An ordinal primary outcome scale was used comprising 5 categories: (1) hospitalization without oxygen supplementation, (2) hospitalization with oxygen supplementation, (3) ICU admission, (4) invasive mechanical ventilation, and (5) death. The secondary outcome was length of hospital stay. RESULTS: Among 469 hospitalized children and adolescents, the median age was 5.9 years (IQR, 1.6-11.1 years); 245 patients (52.4%) were male, and 115 (24.5%) had comorbidities. A total of 39 patients (8.3%) were from central Africa, 172 (36.7%) from eastern Africa, 208 (44.3%) from southern Africa, and 50 (10.7%) from western Africa. Eighteen patients had suspected (n = 6) or confirmed (n = 12) multisystem inflammatory syndrome in children. Thirty-nine patients (8.3%) died, including 22 of 69 patients (31.9%) who required intensive care unit admission and 4 of 18 patients (22.2%) with suspected or confirmed multisystem inflammatory syndrome in children. Among 468 patients, 418 (89.3%) were discharged, and 16 (3.4%) remained hospitalized. The likelihood of outcomes with higher vs lower severity among children younger than 1 year expressed as adjusted odds ratio (aOR) was 4.89 (95% CI, 1.44-16.61) times higher than that of adolescents aged 15 to 19 years. The presence of hypertension (aOR, 5.91; 95% CI, 1.89-18.50), chronic lung disease (aOR, 2.97; 95% CI, 1.65-5.37), or a hematological disorder (aOR, 3.10; 95% CI, 1.04-9.24) was associated with severe outcomes. Age younger than 1 year (adjusted subdistribution hazard ratio [asHR], 0.48; 95% CI, 0.27-0.87), the presence of 1 comorbidity (asHR, 0.54; 95% CI, 0.40-0.72), and the presence of 2 or more comorbidities (asHR, 0.26; 95% CI, 0.18-0.38) were associated with reduced rates of hospital discharge. CONCLUSIONS AND RELEVANCE: In this cohort study of children and adolescents hospitalized with COVID-19 in sub-Saharan Africa, high rates of morbidity and mortality were observed among infants and patients with noncommunicable disease comorbidities, suggesting that COVID-19 vaccination and therapeutic interventions are needed for young populations in this region.

The Critical Need for Pooled Data on Coronavirus Disease 2019 in African Children: An AFREhealth Call for Action Through Multicountry Research Collaboration.

Globally, there are prevailing knowledge gaps in the epidemiology, clinical manifestations, and outcomes of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among children and adolescents; and these gaps are especially wide in African countries. The availability of robust age-disaggregated data is a critical first step in improving knowledge on disease burden and manifestations of coronavirus disease 2019 (COVID-19) among children. Furthermore, it is essential to improve understanding of SARS-CoV-2 interactions with comorbidities and coinfections such as human immunodeficiency virus (HIV), tuberculosis, malaria, sickle cell disease, and malnutrition, which are highly prevalent among children in sub-Saharan Africa. The African Forum for Research and Education in Health (AFREhealth) COVID-19 Research Collaboration on Children and Adolescents is conducting studies across Western, Central, Eastern, and Southern Africa to address existing knowledge gaps. This consortium is expected to generate key evidence to inform clinical practice and public health policy-making for COVID-19 while concurrently addressing other major diseases affecting children in African countries.

SARS-CoV-2 Infection in Health Care Personnel and Their Household Contacts at a Tertiary Academic Medical Center: Protocol for a Longitudinal Cohort Study.

BACKGROUND: Health care personnel (HCP) are at high risk for exposure to the SARS-CoV-2 virus. While personal protective equipment (PPE) may mitigate this risk, prospective data collection on its use and other risk factors for seroconversion in this population is needed. OBJECTIVE: The primary objectives of this study are to (1) determine the incidence of, and risk factors for, SARS-CoV-2 infection among HCP at a tertiary care medical center and (2) actively monitor PPE use, interactions between study participants via electronic sensors, secondary cases in households, and participant mental health and well-being. METHODS: To achieve these objectives, we designed a prospective, observational study of SARS-CoV-2 infection among HCP and their household contacts at an academic tertiary care medical center in North Carolina, USA. Enrolled HCP completed frequent surveys on symptoms and work activities and provided serum and nasal samples for SARS-CoV-2 testing every 2 weeks. Additionally, interactions between participants and their movement within the clinical environment were captured with a smartphone app and Bluetooth sensors. Finally, a subset of participants' households was randomly selected every 2 weeks for further investigation, and enrolled households provided serum and nasal samples via at-home collection kits. RESULTS: As of December 31, 2020, 211 HCP and 53 household participants have been enrolled. Recruitment and follow-up are ongoing and expected to continue through September 2021. CONCLUSIONS: Much remains to be learned regarding the risk of SARS-CoV-2 infection among HCP and their household contacts. Through the use of a multifaceted prospective study design and a well-characterized cohort, we will collect critical information regarding SARS-CoV-2 transmission risks in the health care setting and its linkage to the community. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/25410.

O12.6 Minority HIV/AIDS Research Initiative: Advancing HIV Prevention and Treatment Through Data-Informed Research, Community-Informed Practices and Innovative Intervention Strategies

Black/African American (Black thereafter) and Hispanic/Latino (Latinx thereafter) communities bear disproportionate burden of HIV infections in the U.S. These communities also tend to be disproportionately affected by social and structural determinants of health that hamper access to and engagement in HIV prevention and care services. Public health research efforts must advance HIV prevention and care through biomedical and structural interventions tailored to the needs of and culturally acceptable for the affected communities.The CDC Minority HIV Research Initiative (MARI) was established in 2003 to build capacity for HIV epidemiologic and prevention research in mostly Black and Latinx communities and among historically underrepresented early-career scientists working in highly affected communities. The MARI program supports the goal of promoting health equity and reducing HIV-related health disparities.From 2007–2020, 11 MARI investigators have developed HIV prevention interventions in highly affected communities. The interventions developed by seven MARI investigators will be discussed. Best practices about the recruitment and engagement of communities of color using evidence-based online recruitment campaigns, establishing community and scientific advisory boards, engaging community members in all stages of HIV research, and integration of mobile technologies to sustain HIV prevention and care interventions during the COVID-19 pandemic will be illustrated. We will also highlight the accomplishments of MARI investigators building successful partnerships with local health departments and community-based organizations to promote disseminations of findings and sustainability of interventions tailored to their communities. Lastly, we describe why initiatives like MARI that support the development of innovative and effective interventions to reduce HIV disparities in communities of color are essential to ending the HIV epidemic in the U.S.Ensuring the communities’ engagement in HIV policy changes and intervention development are crucial to intervention uptake and sustainability. As such, MARI research initiative is filling gaps in how we address HIV in racial/ethnic and sexual minority communities.

Protective population behavior change in outbreaks of emerging infectious disease.

BACKGROUND: During outbreaks of emerging and re-emerging infections, the lack of effective drugs and vaccines increases reliance on non-pharmacologic public health interventions and behavior change to limit human-to-human transmission. Interventions that increase the speed with which infected individuals remove themselves from the susceptible population are paramount, particularly isolation and hospitalization. Ebola virus disease (EVD), Severe Acute Respiratory Syndrome (SARS), and Middle East Respiratory Syndrome (MERS) are zoonotic viruses that have caused significant recent outbreaks with sustained human-to-human transmission. METHODS: This investigation quantified changing mean removal rates (MRR) and days from symptom onset to hospitalization (DSOH) of infected individuals from the population in seven different outbreaks of EVD, SARS, and MERS, to test for statistically significant differences in these metrics between outbreaks. RESULTS: We found that epidemic week and viral serial interval were correlated with the speed with which populations developed and maintained health behaviors in each outbreak. CONCLUSIONS: These findings highlight intrinsic population-level changes in isolation rates in multiple epidemics of three zoonotic infections with established human-to-human transmission and significant morbidity and mortality. These data are particularly useful for disease modelers seeking to forecast the spread of emerging pathogens.

SARS-CoV-2 seropositivity after infection and antibody response to mRNA-based vaccination (preprint)

The effect of SARS-CoV-2 infection on response to mRNA-based SARS-CoV-2 vaccines is not well-described. We assessed longitudinal SARS-CoV-2-specific antibody responses pre- and post-vaccination among individuals with and without prior infection. The antibody response to the first vaccine dose was almost two-fold higher in individuals who were seropositive before vaccination compared to those who were seronegative, suggesting that prior infection primes the immune response to the first dose of mRNA-based vaccine.

Protective Population Behavior Change in Outbreaks of Emerging Infectious Disease (preprint)

During outbreaks of emerging infections, the lack of effective drugs and vaccines increases reliance on non-pharmacologic public health interventions and behavior change to limit human-to-human transmission. Interventions that increase the speed with which infected individuals remove themselves from the susceptible population are paramount, particularly isolation and hospitalization. Ebola virus disease (EVD), Severe Acute Respiratory Syndrome (SARS), and Middle East Respiratory Syndrome (MERS) are zoonotic viruses that have caused significant recent outbreaks with sustained human-to-human transmission. This investigation quantified changing mean removal rates (MRR) and days from symptom onset to hospitalization (DSOH) of infected individuals from the population in seven different outbreaks of EVD, SARS, and MERS, to test for statistically significant differences in these metrics between outbreaks. We found that epidemic week and viral serial interval were correlated with the speed with which populations developed and maintained health behaviors in each outbreak.