Examining the Association of Air Quality on Covid-19 Patient Outcomes Using Area Level Data from the Electronic Health Record

Background: Within the coronavirus 2019 (COVID-19) pandemic, literature has found worsened patient outcomes and increased virus transmissibility associated with reduced air quality. This factor, a structural social determinant of health (SDOH), has shown great promise as a link between air quality and patient outcomes during the COVID-19 pandemic. Researching SDOH within our patient populations is often difficult and limited by poor documentation or extensive questionnaires or surveys. The use of demographic data derived from the electronic health record (EHR) to more accurately represent SDOH holds great promise. The use of area-level determinants of health outcomes has been shown to serve as a good surrogate for individual exposures. We posit that an area level measure of air quality, the county-level Air Quality Index (AQI), will be associated with disease worsening in intensive care unit (ICU) patients being treated for COVID-19. Method(s): We will calculate AQI using a combination of open-source records available via the United States Environmental Protection Agency (EPA) and manual calculations using geospatial informatics systems (GIS) methods. Subjects will be identified as adult (> 18 years) patients admitted to Vanderbilt University Medical Center's ICUs between January 1, 2020, and March 31, 2022 with a positive SARS-CoV-2 laboratory analysis result. We will exclude patients without a home address listed. Patient demographic and hospital data from ICU admission to 28 days following admission will include: age, sex, home address, race, insurance type, primary language, employment status, highest level of education, and hospital course data. Together these will be collated to produce our primary outcome variable of WHO Clinical Progression Scale score. These validated scores range from 0 (uninfected) to 10 (dead) to track clinically meaningful progression of COVID-19 infected patients. Our AQI variable will be obtained from the EPA available county-level monitoring station spatial data combined with open-source state/county center point spatial data. These data contain historic cataloguing to determine air quality at both specific time points and averages over time. Where a county's average yearly AQI is not available due to lack of a monitoring station, we will use spatial data tools to calculate an average based on data from nearby stations. We will utilize yearly averages of AQI in the year prior to COVID-19 diagnosis to describe overall impact of air quality on patients' respiratory outcomes as opposed to single day exposures. Linkage of patient data to AQI database will be performed using patient addresses. Discussion(s): By combining area level data with electronic health record (EHR) data, we will be positioned to understand the contribution of environmental and social determinants of health on patient outcomes. Our long-term goal is to elucidate which social and environmental determinants of health are associated with worse outcomes from COVID-19 and other respiratory viruses, using data extracted from the EHR.

Modeling anticipated changes in numbers of SARS-CoV-2 infections within communities due to immunization campaigns

Background: As SARS-CoV-2 spread in early 2020, uncertainty about the scope, duration, and impact of the unfolding outbreaks caused numerous countries to interrupt many routine activities, including health services. Because immunization is an essential health service, modeling changes in SARS-CoV-2 infections among communities and health workers due to different vaccination activities was undertaken to understand the risks and to inform approaches to resume services.

COVID-19 Vaccine Safety Surveillance and Causality Assessment of Adverse Events Following Immunisation: Lessons from South Africa

Introduction: The South African Health Products Regulatory Authority (SAHPRA) utilises various AEFI reporting tools to monitor vaccine safety in the country. In 2020, SAHPRA in collaboration with the National Department of Health's (NDoH) Expanded Programme on Immunisation (EPI), joined the African Union Smart Safety Surveillance programme, as one of four pilot countries, to introduce an electronic adverse event following immunisation (AEFI) reporting system (Med Safety App) for healthcare professionals and consumers [1]. On 17/05/2021, the NDoH introduced its national COVID-19 vaccination programme. SAHPRA launched a microsite during 2021, to provide feedback to the public on AEFI with the COVID-19 vaccines. Objective(s): To provide an overview of COVID-19 vaccine safety surveillance and describe causality assessment outcomes for serious AEFI reported during the first year of COVID-19 vaccine administration. Method(s): All severe and/or serious AEFI are investigated by provincial EPI surveillance teams, followed by causality assessment conducted by the National Immunisation Safety Expert Committee (NISEC), using the World Health Organization (WHO) methodology [2]. Causality assessment outcomes are classified based on the final diagnoses determined during the assessment by NISEC according to WHO categories, seriousness, Medical Dictionary for Regulatory Activities (MedDRA) system organ class and patient demographics. Data were collected retrospectively from the SAHPRA COVID-19 AEFI microsite and the EPI national AEFI database. Result(s): By 01/04/2022, 33,063,221 COVID-19 vaccine doses had been administered, with 5 815 spontaneous AEFI reports (0.0173%) submitted. Of these, 2,571 (0.008%) were reported as serious. Spontaneous reporting of AEFI increased significantly compared to pre-COVID-19 vaccine introduction. The most frequently reported AEFIs were side effects already listed in the product information. No safety concerns were raised based on causality assessment outcomes for 273 serious cases analysed by 01/04/2022. Over two thirds of these cases were classified as coincidental (70.7%) as cardiac-, respiratory- or vascular disorders (MedDRA system organ class), with 12.1% classified as vaccine product related (see table below). The presentation will include all causality assessments conducted up to 31/08/2022, and more detailed information about causality assessed cases will be available in the public domain at the time of the conference and will be included in the presentation. Conclusion(s): Vaccine safety surveillance and monitoring trends of reported AEFI are vital measures to ensure that the benefits of immunisation are maintained in the interest of public health and efficient vaccination programmes. Transparent communication with the public is important to maintain public confidence in vaccines and prevent all AEFI being misinterpreted as caused by the vaccine.

COVID-19 Vaccine Safety Surveillance and Causality Assessment of Adverse Events Following Immunisation: Lessons from South Africa: An International Journal of Medical Toxicology and Drug Experience

Introduction: The South African Health Products Regulatory Authority (SAHPRA) utilises various AEFI reporting tools to monitor vaccine safety in the country. In 2020, SAHPRA in collaboration with the National Department of Health's (NDoH) Expanded Programme on Immunisation (EPI), joined the African Union Smart Safety Surveillance programme, as one of four pilot countries, to introduce an electronic adverse event following immunisation (AEFI) reporting system (Med Safety App) for healthcare professionals and consumers [1]. On 17/05/2021, the NDoH introduced its national COVID-19 vaccination programme. SAHPRA launched a microsite during 2021, to provide feedback to the public on AEFI with the COVID-19 vaccines. Objective: To provide an overview of COVID-19 vaccine safety surveillance and describe causality assessment outcomes for serious AEFI reported during the first year of COVID-19 vaccine administration. Methods: All severe and/or serious AEFI are investigated by provincial EPI surveillance teams, followed by causality assessment conducted by the National Immunisation Safety Expert Committee (NISEC), using the World Health Organization (WHO) methodology [2]. Causality assessment outcomes are classified based on the final diagnoses determined during the assessment by NISEC according to WHO categories, seriousness, Medical Dictionary for Regulatory Activities (MedDRA) system organ class and patient demographics. Data were collected retrospectively from the SAHPRA COVID-19 AEFI microsite and the EPI national AEFI database. Results: By 01/04/2022, 33,063,221 COVID-19 vaccine doses had been administered, with 5 815 spontaneous AEFI reports (0.0173%) submitted. Of these, 2,571 (0.008%) were reported as serious. Spontaneous reporting of AEFI increased significantly compared to pre-COVID-19 vaccine introduction. The most frequently reported AEFIs were side effects already listed in the product information. No safety concerns were raised based on causality assessment outcomes for 273 serious cases analysed by 01/04/2022. Over two thirds of these cases were classified as coincidental (70.7%) as cardiac-, respiratory- or vascular disorders (MedDRA system organ class), with 12.1% classified as vaccine product related (see table below). The presentation will include all causality assessments conducted up to 31/08/2022, and more detailed information about causality assessed cases will be available in the public domain at the time of the conference and will be included in the presentation. Conclusion: Vaccine safety surveillance and monitoring trends of reported AEFI are vital measures to ensure that the benefits of immunisation are maintained in the interest of public health and efficient vaccination programmes. Transparent communication with the public is important to maintain public confidence in vaccines and prevent all AEFI being misinterpreted as caused by the vaccine.

Re-Engineering of Undergraduate Analogue Electronics Laboratories during Covid-19

The coronavirus pandemic that spread throughout the world during 2020 and 2021 caused enormous upheavals in workplaces and educational settings. Most educational establishments were forced to rapidly switch to online methods of course delivery and student assessment, which presented a challenge to programmes with practical laboratories and project-based learning. This paper presents the approaches that were taken to mitigate the effects of Covid-19 on the practical laboratories for two analogue circuit design modules at University College Cork (UCC). The practical learning outcomes for these modules were facilitated by use of ADALM2000 Active Learning Modules combined with small modifications to make the best use of the kits. © 2022 IEEE.

Establishing a national SARS-CoV-2 surveillance network across South Africa to support wastewaterbased genomic and epidemiological monitoring of the COVID pandemic, 2020-2021

Introduction/ Background: Findings from wastewater-based epidemiology (WBE) surveillance of SARS-CoV-2 are increasingly used to monitor the epidemiology of SARS-CoV-2. We report on the findings from the South African Collaboration COVID-19 Environmental Surveillance System (SACCESS) laboratories and compare these with clinically obtained data. Methods: Wastewater grab or passive samples and underwent concentration, RNA extraction, reverse-transcriptasepolymerase chain reaction (RT-PCR) detection and quantification of SARS-CoV-2. Following whole genome amplicon-based sequencing, nonsynonymous mutations in the spike protein specific to variants of concern (VOCs) were identified. Quantitative RNA concentrations in genome copies/mL and the read-frequencies of lineagespecific single nucleotide polymorphisms (SNPs) in the spike protein of SARS-CoV-2 were plotted alongside official case load and SARS-Cov-2 lineage distribution by epidemiological week (provided by NICD SARS-CoV-2 epidemiology team and the Centre for Respiratory Diseases and Meningitis of the NICD). Results: Results from 95 wastewater treatment plants (WWTPs) across 9 provinces and all eight metropolitan areas of South Africa were collected weekly, biweekly or monthly from June 2020-October 2021 illustrate that increases and decreases in SARSCoV- 2 concentrations at all sites corresponded to metro-specific timing of the peak and post-peak decline in clinical cases. Increases in SARS-CoV-2 concentrations consistently preceded increases in clinical cases. In 18 WWTPs genomic analysis detected SNPs corresponding to prevalent VOCs and documented the change from beta to delta variant over the third SARS-CoV-2 wave. Impact: Without sufficient evidence that WBE findings correspond with clinical epidemiology and genomic results, public health authorities are often reluctant to use these data to guide decision making. Our findings illustrated that WBE monitoring of SARS-CoV-2 and detection of SNPs specific to SARS-CoV-2 variants correspond with clinical epidemiology and genomic findings. Conclusion: Wastewater based epidemiology including genotyping should be integrated into SARS-CoV-2 surveillance networks to support decision-making regarding public health interventions to contain SARS-CoV-2. Additional analyses to support interpretation of quantitative and genomic results should be done.

COVID-19 response in South African communities: Screening, testing, tracing and movement modelling.

In South Africa (SA), the first case of COVID-19 was reported on 5 March 2020 from a traveller who had returned from Italy. Increases in COVID-19 cases and deaths necessitated the design and implementation of community screening, testing, and tracing as a control strategy. The SA government's plans to implement community-based screening, testing, contact tracing and movement modelling during the early phases of the COVID-19 pandemic presented both opportunities and challenges. In this article, we present our experiences, opportunities and lessons for community-based COVID-19 response, anchoring these efforts in the primary healthcare system.

The impact of implementing the SNIS recommendations for the care of COVID-19 patients undergoing emergent mechanical thrombectomy

Objective: To determine how implementation of Society for Neurointerventional Surgery (SNIS) guidelines affected outcomes for ischemic stroke patients. Background: SNIS issued guidelines for patient management during the coronavirus disease 2019 (COVID-19) pandemic. Recommendations include intubating COVID-19 positive and unknown COVID-19 status patients prior to endovascular thrombectomy, cohorting by COVID-19 status, early discharge, and postponing elective cases. Design/Methods: This was a retrospective cohort study comparing ischemic stroke patients treated with thrombectomy during the COVID-19 pandemic peak (4/1/20-6/30/20) to those treated in 2019 (4/1/19-6/30/19). Statistical tests used for analysis included Kruskal-Wallis, chisquared and Fisher's exact test. Results: There were 112 ischemic stroke patients treated with thrombectomy: 55 (49%) in 2019 and 57 (51%) during the COVID-19 peak. There were no differences in thrombectomy among all ischemic stroke admissions in 2019 vs. the COVID-19 peak (22% vs. 24%, p=0.67). COVID- 19 testing was performed in 29 (51%) patients;none were positive. The median age was 68 in 2019 and 69 during the COVID-19 peak, p=0.28;other characteristics were similar. Compared to 2019, a significantly higher proportion of patients were intubated during the COVID-19 peak (96% vs. 45%, p<0.0001). The median days to extubation was 2 days for both groups, p=0.31. The proportion of patients re-intubated was 2% in 2019 vs. 5% during the COVID-19 peak, p=0.95. The median time to groin puncture was significantly shorter in 2019 than during the COVID-19 peak, 38 vs 43 minutes, p=0.002. The TICI score and mRS were similar between groups, p=0.26 and p=0.84, respectively. Conclusions: After implementing SNIS guidelines, including pre-treatment intubation, we observed a statistically significant but not clinically meaningful increased time to groin puncture, which did not negatively impact outcomes. These results suggest hospitals who manage patients efficiently can implement safe management practices in response to COVID-19 without impacting outcomes. We recommend following SNIS guidelines to prevent the spread of COVID-19.

The impact of COVID-19 on the volume of stroke admissions at a comprehensive stroke center

Objective: To determine how coronavirus disease 2019 (COVID-19) impacted stroke patient admission volumes. Background: To prevent the spread of COVID-19 social distancing guidelines were implemented and many institutions postponed elective procedures. Delayed hospital admission has been reported due to fear of infection. Design/Methods: This retrospective cohort study compared stroke patients admitted to a comprehensive stroke center during the COVID-19 pandemic 4/1/20-6/30/20 "COVID-19 peak" to patients admitted 4/1/19-6/30/19 "2019". Characteristics and outcomes were compared using chi-squared, Fisher's exact, and the Kruskal-Wallis test. Results: There were 651 stroke admissions: 341 (52%) in 2019, 310 (48%) during the COVID-19 peak;overall a 9% decrease. The median number of admissions per day was 4 in 2019 and 3 during the COVID-19 peak, p=0.21. The proportion of patients by stroke type was not significantly different in 2019 compared to the COVID-19 peak: Ischemic stroke (75% vs. 76%, p=0.69);hemorrhagic stroke (16% vs. 18%, p=0.39);transient ischemic attacks (11% vs. 7%, p=0.10). The median age was 70 years in both 2019 and during the COVID-19 peak, p=0.64;other demographic characteristics were comparable. The time from onset to arrival was 273 minutes in 2019 vs. 263 minutes during COVID-19 peak, p=0.46;24% were transfers in 2019 vs. 23% during the COVID-19 peak (p=0.72). The median length of stay (4 days, p=0.52) and the median discharge mRS (3, p=0.31) was identical in 2019 compared to the COVID-19 peak. Of the 113 patients tested for COVID-19, 4% were positive. Conclusions: Although many centers have reported a significant decrease in stroke patient admissions, the COVID-19 pandemic did not significantly affect patient volume or the time from onset to arrival at our institution. As the pandemic continues, it is important for hospitals to be informed that COVID-19 may not impact stroke volume, so providers are prepared to manage both stroke and COVID-19 patients efficiently.

Asymptomatic COVID-19 in South Africa - implications for the control of transmission.

Asymptomatic COVID-19 may contribute significantly to the pandemic trajectory based on global biological, epidemiological and modelling evidence. A retrospective analysis was done to determine the proportion of asymptomatic COVID-19 in the workplace during the lockdown period from 27 March to 31 May 2020. We found that nearly 45% of cases were asymptomatic at the time of the first test. This high proportion of asymptomatic COVID-19 cases has implications for interventions, such as enforcing quarantine of all close contacts of COVID-19 cases regardless of symptoms.

Le COVID-19 a symptomatique pourrait contribuer significativement à la trajectoire de la pandémie en se basant sur des preuves mondiales, biologique et épidémiologiques, et en modélisant les preuves. Une analyse rétrospective a été réalisée afin de décrire la proportion d'infections asymptomatiques de SARS-CoV-2 parmi les clusters essentiels sur les lieux de travail en Afrique du Sud où des investigations de flambée ont été réalisées durant la période de confinement très restrictive du 27 mars au 31 mai 2020. Près de 45% des cas étaient asymptomatique lors du premier test. Cette proportion élevée des cas de COVID-19 asymptomatiques a des implications en ce qui concerne les interventions nonpharmaceutique comme le renforcement de la quarantaine de tous les contacts étroits des cas de SARS-CoV-2 sans tenir compte des symptômes.

The impact of implementing the snis recommendations for the care of emergent neurointerventional patients in the setting of COVID-19 on patients undergoing mechanical thrombectomy

Introduction: As a result of the novel coronavirus 2019 (COVID-19) pandemic, the Society for Neurointerventional Surgery (SNIS) issued guidelines for patient management during COVID-19. Specifically, they suggested intubating COVID-19 positive or those with unknown COVID-19 status prior to emergent endovascular thrombectomy, cohorting by COVID-19 status, early ICU discharge, and postponing elective cases. We sought to determine how the implementation of SNIS guidelines affected outcomes for patients with ischemic stroke. Methods: This was a retrospective cohort study comparing ischemic stroke patients who were treated with thrombectomy admitted during the COVID-19 pandemic 4/1/20-6/30/20 “COVID-19 peak” to patients admitted 4/1/19-6/30/19 “2019”. Statistical tests used for analysis included Kruskal- Wallis, chi-squared and Fisher's exact test. Results: The proportion of patients treated with thrombectomy was not significantly different, 23% in 2019 vs. 24% during the COVID-19 peak, p=0.67. There were 112 patients treated with thrombectomy: 57 (51%) in 2019, 55 (49%) during the COVID-19 peak. No patients treated with thrombectomy were positive for COVID-19, but 27 (49%) were tested. The median age was 69 for those treated in 2019 and 69 for those during the COVID-19 peak, p=0.44. Patients were similar in sex, race, and comorbidities. The time from onset to arrival was also statistically similar, p=0.19. In 2019, 16% received tPA compared to 9% during the COVID-19 peak, p=0.28. The median time to groin puncture was significantly shorter in 2019, 38 minutes, than during the COVID-19 peak, 44 minutes, p=0.01. The recanalization rate and mRS were similar between groups, p=0.06, and p=0.91, respectively. Conclusions: After implementing the SNIS guidelines, including pre-treatment intubation, we observed a significantly longer time to groin puncture. Anecdotally, the increased observed was remarkably small given the changes to care and did not negatively impact patient outcomes. This suggests that hospitals managing patients efficiently can implement changes in response to COVID- 19 and continue high level of care without impacting outcomes. Therefore, we recommend following the SNIS guidelines to prevent the spread of COVID-19.

Transitioning to online teaching: a phenomenological analysis of social work educator perspectives

Online education in social work has been proliferating and is now ubiquitous due to COVID-19. To optimize instructor pedagogical wisdom and ensure student benefit, critical reflection is needed on the transition to online education. Prior to the pandemic, 17 social work educators were interviewed about their perspectives on the transition from teaching on-the-ground classes to online. This interpretative phenomenological study identified three themes that influenced the educator’s experience: personal qualities, pedagogical beliefs, and macro and institutional factors. It is this unique mix of each participants’ pedagogical beliefs, personal qualities, and macro or institutional factors which influenced the individual educator’s experience of satisfaction. Each educator’s perspective of online teaching is arrived at through calculations of costs and benefits as they balance their own and their students’ needs within the demands and supports of their respective institutions. These perspectives can be characterized by one of four standpoints: mutual benefit, compromised learning, instructor reservations, and incompatibility. Implications include enhancing social work educators’ critical reflexivity while navigating the evolving technological context and providing administrators with points of intervention to support instructors and develop online delivery modes. © 2021 Informa UK Limited, trading as Taylor & Francis Group.

Increased care at discharge from COVID-19: The association between pre-admission frailty and increased care needs after hospital discharge; a multicentre European observational cohort study.

BACKGROUND: The COVID-19 pandemic has placed significant pressure on health and social care. Survivors of COVID-19 may be left with substantial functional deficits requiring ongoing care. We aimed to determine whether pre-admission frailty was associated with increased care needs at discharge for patients admitted to hospital with COVID-19. METHODS: Patients were included if aged over 18 years old and admitted to hospital with COVID-19 between 27 February and 10 June 2020. The Clinical Frailty Scale (CFS) was used to assess pre-admission frailty status. Admission and discharge care levels were recorded. Data were analysed using a mixed-effects logistic regression adjusted for age, sex, smoking status, comorbidities, and admission CRP as a marker of severity of disease. RESULTS: Thirteen hospitals included patients: 1671 patients were screened, and 840 were excluded including, 521 patients who died before discharge (31.1%). Of the 831 patients who were discharged, the median age was 71 years (IQR, 58-81 years) and 369 (44.4%) were women. The median length of hospital stay was 12 days (IQR 6-24). Using the CFS, 438 (47.0%) were living with frailty (≥ CFS 5), and 193 (23.2%) required an increase in the level of care provided. Multivariable analysis showed that frailty was associated with an increase in care needs compared to patients without frailty (CFS 1-3). The adjusted odds ratios (aOR) were as follows: CFS 4, 1.99 (0.97-4.11); CFS 5, 3.77 (1.94-7.32); CFS 6, 4.04 (2.09-7.82); CFS 7, 2.16 (1.12-4.20); and CFS 8, 3.19 (1.06-9.56). CONCLUSIONS: Around a quarter of patients admitted with COVID-19 had increased care needs at discharge. Pre-admission frailty was strongly associated with the need for an increased level of care at discharge. Our results have implications for service planning and public health policy as well as a person's functional outcome, suggesting that frailty screening should be utilised for predictive modelling and early individualised discharge planning.

Nosocomial COVID-19 infection: examining the risk of mortality. The COPE-Nosocomial Study (COVID in Older PEople).

BACKGROUND: Hospital admissions for non-coronavirus disease 2019 (COVID-19) pathology have decreased significantly. It is believed that this may be due to public anxiety about acquiring COVID-19 infection in hospital and the subsequent risk of mortality. AIM: To identify patients who acquire COVID-19 in hospital (nosocomial COVID-19 infection (NC)) and their risk of mortality compared to those with community-acquired COVID-19 (CAC) infection. METHODS: The COPE-Nosocomial Study was an observational cohort study. The primary outcome was the time to all-cause mortality (estimated with an adjusted hazard ratio (aHR)), and secondary outcomes were day 7 mortality and the time-to-discharge. A mixed-effects multivariable Cox's proportional hazards model was used, adjusted for demographics and comorbidities. FINDINGS: The study included 1564 patients from 10 hospital sites throughout the UK, and one in Italy, and collected outcomes on patients admitted up to April 28th, 2020. In all, 12.5% of COVID-19 infections were acquired in hospital; 425 (27.2%) patients with COVID died. The median survival time in NC patients was 14 days compared with 10 days in CAC patients. In the primary analysis, NC infection was associated with lower mortality rate (aHR: 0.71; 95% confidence interval (CI): 0.51-0.98). Secondary outcomes found no difference in day 7 mortality (adjusted odds ratio: 0.79; 95% CI: 0.47-1.31), but NC patients required longer time in hospital during convalescence (aHR: 0.49, 95% CI: 0.37-0.66). CONCLUSION: The minority of COVID-19 cases were the result of NC transmission. No COVID-19 infection comes without risk, but patients with NC had a lower risk of mortality compared to CAC infection; however, caution should be taken when interpreting this finding.