Decision Analysis in SHared decision making for Thromboprophylaxis during Pregnancy (DASH-TOP): a sequential explanatory mixed-methods pilot study.

OBJECTIVES: To gain insight into formal methods of integrating patient preferences and clinical evidence to inform treatment decisions, we explored patients' experience with a personalised decision analysis intervention, for prophylactic low-molecular-weight heparin (LMWH) in the antenatal period. DESIGN: Mixed-methods explanatory sequential pilot study. SETTING: Hospitals in Canada (n=1) and Spain (n=4 sites). Due to the COVID-19 pandemic, we conducted part of the study virtually. PARTICIPANTS: 15 individuals with a prior venous thromboembolism who were pregnant or planning pregnancy and had been referred for counselling regarding LMWH. INTERVENTION: A shared decision-making intervention that included three components: (1) direct choice exercise; (2) preference elicitation exercises and (3) personalised decision analysis. MAIN OUTCOME MEASURES: Participants completed a self-administered questionnaire to evaluate decision quality (decisional conflict, self-efficacy and satisfaction). Semistructured interviews were then conducted to explore their experience and perceptions of the decision-making process. RESULTS: Participants in the study appreciated the opportunity to use an evidence-based decision support tool that considered their personal values and preferences and reported feeling more prepared for their consultation. However, there were mixed reactions to the standard gamble and personalised treatment recommendation. Some participants could not understand how to complete the standard gamble exercises, and others highlighted the need for more informative ways of presenting results of the decision analysis. CONCLUSION: Our results highlight the challenges and opportunities for those who wish to incorporate decision analysis to support shared decision-making for clinical decisions.

Valuing tacit nursing knowledge during the COVID-19 pandemic.

Public health nurses in Ontario, Canada, support the healthy growth and development of children across the province through a variety of programs including home visits for pregnant individuals and families with young children. During the COVID-19 global pandemic the needs of families increased while access to health and social services decreased. During this time, home visiting teams closely involved in supporting families also experienced staff redeployment to support pandemic efforts (e.g., case and contact management, vaccinations) and changes to the nature of home visiting work, including shifts to remote or virtual service delivery. To support nursing practice in this new and evolving context, a framework for capturing and sharing the tacit or how-to knowledge of public health nurses was developed. A valuing of this type of knowledge for informing future public health nursing practice - well beyond the pandemic response - was recognized as a pandemic silver lining when reflecting on two years of supporting home visiting teams in our province.

COVID-19 in one region of New Zealand: a descriptive epidemiological study.

OBJECTIVE: To describe the epidemiology of COVID-19 in one region of New Zealand in the context of the national lockdown and provide a reference for comparing infection dynamics and control measures between SARS-Cov-2 strains.  Methods: Epidemiological linking and analysis of COVID-19 cases and their close contacts residing in the geographical area served by the Southern District Health Board (SDHB).  Results: From 13 March to 5 April 5 2020, 186 cases were laboratory-confirmed with wild-type Sars-Cov-2 in SDHB. Overall, 35·1% of cases were attributable to household transmission, 27·0% to non-household, 25·4% to overseas travel and 12·4% had no known epidemiological links. The highest secondary attack rate was observed in households during lockdown (15·3%, 95%CI 10·4-21·5). The mean serial interval in 50 exclusive infector-infectee pairs was 4·0 days (95%CI 3·2-4·7days), and the mean incubation period was 3.4 days (95%CI 2·7-4·2). CONCLUSIONS: The SARS-CoV-2 incubation period may be shorter than early estimates that were limited by uncertainties in exposure history or small sample sizes. IMPLICATIONS FOR PUBLIC HEALTH: The continuation of household transmission during lockdown highlights the need for effective home-based quarantine guidance. Our findings of a short incubation period highlight the need to contact trace and isolate as rapidly as possible.

Prenatal distress, access to services, and birth outcomes during the COVID-19 pandemic: Findings from a longitudinal study.

BACKGROUND/AIMS: During the COVID-19 pandemic, pregnant people have experienced disruptions to prenatal care, as well elevated rates of mental health problems and distress. The current longitudinal study aims to understand how different forms of prenatal distress (mental health problems, COVID-19 stressful experiences, and access to prenatal services) impact infant birth outcomes during the pandemic. METHODS: Participants were 265 pregnant individuals from Ontario, Canada. Maternal depression, pregnancy-related anxiety, COVID-related stressors (i.e., financial difficulties, social isolation), and disruptions to prenatal and health services were assessed during pregnancy. Delivery experiences and birth outcomes were assessed in the early postpartum period. Associations between pregnancy stressors and birth outcomes were assessed using path analyses. RESULTS: Participants reported experiencing substantial changes to their prenatal care due to COVID-19; 23.0 % had prenatal appointments cancelled, 47.9 % had difficulty accessing prenatal classes, and 60.8 % reported changes to their birth plans. Results of path analyses showed a unique effect of pregnancy-related anxiety during the pandemic on lower birth weight, younger gestational age at birth, and more infant birth problems. Further, multi-group path analysis revealed these effects were more pronounced in male infants. CONCLUSIONS: Findings demonstrate that pregnant individuals in Ontario, Canada have experienced considerable disruptions to services during pregnancy. In addition, pregnancy-related anxiety was uniquely linked to elevated risk for adverse birth outcomes, which more heavily impacted male infants. These findings underscore the need for additional mental health support and access to services for pregnant people and their infants, to reduce long-term adverse maternal and fetal health outcomes.

Exploring the context, role and impact of public health nursing during COVID-19: A multiple case study protocol.

AIM: The purpose of this study is to: (a) describe public health nursing roles over the course of the COVID-19 pandemic in Ontario, Canada; (b) describe the contextual factors that influence public health nursing role implementation; and (c) describe nurses' perceived impact of their roles on client outcomes and professional/personal nursing practice. DESIGN: Descriptive multiple case study. METHODS: Recruitment of public health nurses (PHNs), working in direct service or administrative leadership positions, in an Ontario public health unit will be conducted through purposive and snowball sampling. Nursing roles will be compared and contrasted across three cases differentiated by geographic setting: urban, urban-rural, northern. In each geographic case, a priori estimates of sample size will include 10 PHNs providing direct care and at least five nurses in an administrative leadership role; with an overall estimated study sample size of 45 individuals. Demographic data will be collected using an online anonymous survey. Individual semi-structured interviews with PHNs, and focus groups with nursing administrators will be conducted via telephone and audio-recorded. Individual interviews and focus groups will be transcribed verbatim. Reflexive thematic analysis will be used to generate emergent themes in each case and cross-case synthesis will be used to compare and contrast patterns across geographic cases. DISCUSSION: Expected findings will provide an in-depth analysis of the rapidly evolving roles and functions of PHNs throughout the COVID-19 pandemic and their impact on individuals, families and communities. As well, findings will provide a new understanding about the contextual barriers and facilitators of PHN role implementation in their working environments. IMPACT: Study findings can support decision-making in relation to funding, resource allocation and supportive work structures and processes at a public health system and/or individual public health organization level.

Characterization of the First SARS-CoV-2 Isolates from Aotearoa New Zealand as Part of a Rapid Response to the COVID-19 Pandemic.

SARS-CoV-2, the virus responsible for the COVID-19 pandemic, has wreaked havoc across the globe for the last two years. More than 300 million cases and over 5 million deaths later, we continue battling the first real pandemic of the 21st century. SARS-CoV-2 spread quickly, reaching most countries within the first half of 2020, and New Zealand was not an exception. Here, we describe the first isolation and characterization of SARS-CoV-2 variants during the initial virus outbreak in New Zealand. Patient-derived nasopharyngeal samples were used to inoculate Vero cells and, three to four days later, a cytopathic effect was observed in seven viral cultures. Viral growth kinetics was characterized using Vero and VeroE6/TMPRSS2 cells. The identity of the viruses was verified by RT-qPCR, Western blot, indirect immunofluorescence assays, and electron microscopy. Whole-genome sequences were analyzed using two different yet complementary deep sequencing platforms (MiSeq/Illumina and Ion PGM™/Ion Torrent™), classifying the viruses as SARS-CoV-2 B.55, B.31, B.1, or B.1.369 based on the Pango Lineage nomenclature. All seven SARS-CoV-2 isolates were susceptible to remdesivir (EC50 values from 0.83 to 2.42 µM) and ß-D-N4-hydroxycytidine (molnupiravir, EC50 values from 0.96 to 1.15 µM) but not to favipiravir (>10 µM). Interestingly, four SARS-CoV-2 isolates, carrying the D614G substitution originally associated with increased transmissibility, were more susceptible (2.4-fold) to a commercial monoclonal antibody targeting the spike glycoprotein than the wild-type viruses. Altogether, this seminal work allowed for early access to SARS-CoV-2 isolates in New Zealand, paving the way for numerous clinical and scientific research projects in the country, including the development and validation of diagnostic assays, antiviral strategies, and a national COVID-19 vaccine development program.

Politicians: please work together to minimise the spread of COVID-19

If the virus spreads further throughout our communities, and authorities ask people to limit social contact and self-isolate, cooperation with these necessary measures will play a crucial role in minimising COVID-19's spread and protecting the most vulnerable among us. Teams of infectious disease, public health and primary care experts are advising the Government on the best way to deal with this threat.

Coping strategies mediate the associations between COVID-19 experiences and mental health outcomes in pregnancy.

The COVID-19 pandemic has resulted in elevated mental health problems for pregnant women. Effective coping strategies likely reduce the impact of COVID-19 on mental health. This study aimed to (1) understand how COVID-19 stressors are related to different coping strategies and (2) identify whether coping strategies act as mechanisms accounting for the associations between COVID-19 stressful experiences and mental health problems in pregnancy. Participants were 304 pregnant women from Ontario, Canada. Depression, anxiety, insomnia, and perceived stress were assessed using validated measures. COVID-related stressors (i.e., financial difficulties, social isolation), subjective negative impact of COVID-19, and coping strategies used in response to COVID-19 were assessed by questionnaires. Results indicated that the subjective negative impact of COVID-19 was associated with more dysfunctional coping and less emotion-focused coping, whereas specific COVID-19 stressors, namely financial difficulties and social isolation, were associated with more dysfunctional coping and problem-focused coping. Dysfunctional coping was linked to elevated mental health problems and emotion-focused coping was linked to less mental health problems. Dysfunctional coping and emotion-focused coping partially mediated the effects of specific COVID-19 stressors on mental health outcomes. Findings indicate that coping is one pathway through which the COVID-19 pandemic impacts mental health in pregnancy. Supports and interventions for pregnant women during the pandemic should focus on bolstering coping skills, in order to minimize the mental health consequences of COVID-19.

SARS-CoV-2 antibodies in the Southern Region of New Zealand, 2020.

During New Zealand's first outbreak in early 2020 the Southern Region had the highest per capita SARS-CoV-2 infection rate. Polymerase chain reaction (PCR) testing was initially limited by a narrow case definition and limited laboratory capacity, and cases may have been missed. Our objectives were to evaluate the Abbott SARS-CoV-2 IgG nucleocapsid assay, alongside spike-based assays, and to determine the frequency of antibodies among PCR-confirmed and probable cases, and higher risk individuals in the Southern Region of New Zealand. Pre-pandemic sera (n=300) were used to establish assay specificity and sera from PCR-confirmed SARS-CoV-2 patients (n=78) to establish sensitivity. For prevalence analysis, all samples (n=1214) were tested on the Abbott assay, and all PCR-confirmed cases (n=78), probable cases (n=9), and higher risk individuals with 'grey-zone' (n=14) or positive results (n=11) were tested on four additional SARS-CoV-2 serological assays. The median time from infection onset to serum collection for PCR-confirmed cases was 14 weeks (range 11-17 weeks). The Abbott assay demonstrated a specificity of 99.7% (95% CI 98.2-99.99%) and a sensitivity of 76.9% (95% CI 66.0-85.7%). Spike-based assays demonstrated superior sensitivity ranging 89.7-94.9%. Nine previously undiagnosed sero-positive individuals were identified, and all had epidemiological risk factors. Spike-based assays demonstrated higher sensitivity than the Abbott IgG assay, likely due to temporal differences in antibody persistence. No unexpected SARS-CoV-2 infections were found in the Southern Region of New Zealand, supporting the elimination status of the country at the time this study was conducted.

Comprehensive analysis of SARS-CoV-2 antibody dynamics in New Zealand.

OBJECTIVES: Circulating antibodies are important markers of previous infection and immunity. Questions remain with respect to the durability and functionality of SARS-CoV-2 antibodies. This study explored antibody responses in recovered COVID-19 patients in a setting where the probability of re-exposure is effectively nil, owing to New Zealand's successful elimination strategy. METHODS: A triplex bead-based assay that detects antibody isotype (IgG, IgM and IgA) and subclass (IgG1, IgG2, IgG3 and IgG4) responses against Nucleocapsid (N) protein, the receptor binding domain (RBD) and Spike (S) protein of SARS-CoV-2 was developed. After establishing baseline levels with pre-pandemic control sera (n = 113), samples from PCR-confirmed COVID-19 patients with mild-moderate disease (n = 189) collected up to 8 months post-infection were examined. The relationship between antigen-specific antibodies and neutralising antibodies (NAbs) was explored with a surrogate neutralisation assay that quantifies inhibition of the RBD/hACE-2 interaction. RESULTS: While most individuals had broad isotype and subclass responses to each antigen shortly after infection, only RBD and S protein IgG, as well as NAbs, were relatively stable over the study period, with 99%, 96% and 90% of samples, respectively, having responses over baseline 4-8 months post-infection. Anti-RBD antibodies were strongly correlated with NAbs at all time points (Pearson's r ≥ 0.87), and feasibility of using finger prick sampling to accurately measure anti-RBD IgG was demonstrated. CONCLUSION: Antibodies to SARS-CoV-2 persist for up to 8 months following mild-to-moderate infection. This robust response can be attributed to the initial exposure without immune boosting given the lack of community transmission in our setting.

COVID-19 and mental health during pregnancy: The importance of cognitive appraisal and social support.

BACKGROUND: Pregnancy is a period of elevated risk for mental health difficulties, which are likely exacerbated by the COVID-19 pandemic. This study aims to understand the impact of COVID-19 on mental health and identify risk and protective factors during pregnancy. METHODS: Participants were 303 pregnant individuals from Ontario, Canada. Depression, anxiety and insomnia were measured using validated questionnaires. COVID-related experiences (i.e., financial difficulties, relationship conflict, social isolation) were assessed in relation to mental health. Social support and cognitive appraisal of the pandemic were examined as protective factors. RESULTS: 57% of the sample reported clinically elevated depression, >30% reported elevated worries, and 19% reported elevated insomnia. Depression (t = 25.14, p < .0001) and anxiety (t = 17.21, p < .0001) levels were higher than non-COVID pregnant samples. Social isolation, financial trouble, relationship difficulties and threat of COVID-19 were associated with mental health. Social support (rrange -.24 to -.38, p <.01) was associated with lower mental health problems and negative cognitive appraisal (rrange .20 to .33, p <.01) was linked to more mental health problems. Furthermore, social support and cognitive appraisal interacted (ß = -.92, SE = .41, p < .05), such that higher social support acted as a protective factor, particularly for those who appraise the impact of COVID-19 to be more negative. CONCLUSIONS: Findings underscore the need to address the high rates of mental health during pregnancy and outline potential targets (cognitive appraisal and social support) to protect pregnant people from experiencing mental health problems during the COVID-19 pandemic.

Recognising and responding to intimate partner violence using telehealth: Practical guidance for nurses and midwives.

AIMS: To synthesise the current, global evidence-informed guidance that supports nurses and midwives to recognise and respond to intimate partner violence (IPV), and how these practices can be translated from face-to-face encounters to care that is delivered through telehealth. BACKGROUND: COVID-19-related social and physical distancing measures increase the risk for individuals who are socially isolated with partners who perpetuate violence. Providing support through telehealth is one strategy that can mitigate the pandemic of IPV, while helping patients and providers stay safe from COVID-19. DESIGN AND METHODS: In this discursive paper, we describe how practical guidance for safely recognising and responding to IPV in telehealth encounters was developed. The ADAPT-ITT (Assessment, Decisions, Administration, Production, Topical Experts, Integration, Testing, Training) framework was used to guide the novel identification and adaptation of evidence-informed guidance. We focused on the first six stages of the ADAPT-ITT framework. CONCLUSIONS: This paper fills a gap in available guidance, specifically for IPV recognition and response via telehealth. We present strategies for prioritising safety and promoting privacy while initiating, managing or terminating a telehealth encounter with patients who may be at risk for or experiencing IPV. Strategies for assessment, planning and intervention are also summarised. System-level responses, such as increasing equitable access to telecommunication technology, are also discussed. RELEVANCE TO CLINICAL PRACTICE: Integrating innovative IPV-focused practices into telehealth care is an important opportunity for nurses and midwives during the current global COVID-19 pandemic. There are also implications for future secondary outbreaks, natural disasters or other physically isolating events, for improving healthcare efficiency, and for addressing the needs of vulnerable populations with limited access to health care.