Impact of the Covid-19 Pandemic on Malaria Services in Uganda: A Time Series Analysis

Background: Pregnancy is both a risk factor for P. falciparum infection and development of severe malaria and, in Uganda, its control relies heavily in the administration of intermittent preventive treatment with sulfadoxinepyrimethamine (SP-IPTp) during antenatal care visits (ANC). COVID-19 pandemic severely impacted health systems globally. This study aims to assess trends in delivering malaria in pregnancy related healthcare services before and during Covid-19 in thirty health facilities in Northern Uganda. Method(s): Interrupted time series study comparing two periods: I) pre- Covid-19 (January 2018 to February 2020) and II) Covid-19 (from March 2020 to December 2021) period. Data were sourced from the District Health Information Management System II (DHIMS2) routinely collected indicators. Comparisons between the two periods were computed with a jointpoint regression model and Annual Average Percentage Changes (AAPC) were calculated. Result(s): The study involved data collected by 30 health facilities, 30 health facilities in Northern Uganda - including one hospital - with a catchment area of 506,276 inhabitants and an estimated number of pregnancies ranging from 21,440 to 23,315. Covid cumulative cases and deaths for Oyam districs are reported in Figure 1. As shown in Figure 2, during COVID period we found a significant reduction in the number of women accessing to at least 4 antenatal care (ANC) visits and taking at least three doses of intermittent preventive treatment (IPT) with sulfadoxine-pyrimethamine. The total number of pregnant women receiving Artemether-Lumefantrine for nonsevere malaria or being hospitalized for severe malaria, along with the total number of institutional deliveries and stillbirths followed kept following the trend recorded prior to the pandemic. Conclusion(s): The present study shows that, despite the international call for prioritization of maternal and reproductive health service delivery during COVID-19 pandemic, in Uganda, the essential care for malaria in pregnancy have been disrupted. This is concerning, as the failure to increase the delivery of SP-IPTp may impact malaria-related mortality.

Anemia as a Predictor of Poor Clinical Outcome in Patients Admitted for Covid-19

Background: In respiratory infections, anemia is both a consequence of acute inflammation [1] and a predictor [2] of poor clinical outcomes. There are few studies investigating the role of anemia in COVID-19, suggesting a potential role in predicting disease severity [3, 4]. In this study, we aimed to assess the association between the presence of anemia at admission and incidence of severe disease and death in patients hospitalized for COVID-19. Method(s): Data from all adult patients admitted for COVID-19 in University Hospital P. Giaccone (Palermo) and University Hospital of Bari, Italy, were retrospectively collected from 1st of September 2020 and 31 August 2022. The association between anemia (defined as Hb < 13 g/dl and < 12 g/dl in males and females, respectively), in-hospital mortality and severe COVID-19 was tested using a Cox's regression analysis. Severe COVID-19 forms were defined as admission to intensive or sub-intensive care unit or a qSOFAscore >=2 or CURB65scores >=3. P values were calculated using the Student's T-test for continuous variables and the Mantel-Haenszel Chi-square test for categorical ones. The association between anemia and the mortality was made using a Cox's regression analysis, adjusted, in two models, for the potential confounders and using a propensity score. Result(s): Among the 1562 patients included in the analysis, prevalence of anemia was 45.1% (95%CI 43-48%), and as shown in Table 1, were significantly older (p< 0.0001), reported more co- morbidities, and presented higher baseline levels of procalcitonin, CRP, ferritin and IL-6. As shown in Figure 1, patients with anemia reported a higher crude higher incidence of mortality compared to patients without this condition (Figure 1). Overall, the crude incidence of mortality was about four times higher in patients with anemia compared to those without. After adjusting for 17 potential confounders, the presence of anemia significantly increased the risk of death (HR=2.68;95%CI: 1.59-4.52) and of risk of severe COVID-19 (OR=2.31;95%CI: 1.65-3.24) (Table 2). The propensity score analysis substantially confirmed these analyses. Conclusion(s): Our study provides evidence that, in patients hospitalized for COVID-19, anemia is both associated with a more pronounced baseline proinflammatory profile and higher incidence of in-hospital mortality and severe disease.

Bamlanivimab and Etesevimab administered in an outpatient setting for SARS-CoV-2 infection.

The early administration of anti-SARS-CoV-2 monoclonal antibodies (mAb) could decrease the risk of severe disease and the need of inpatients care. Herein, our clinical experience with Bamlanivimab/Etesevimab for the treatment of early SARS-CoV-2 infection through an outpatient service was described. Patients with confirmed COVID-19 were selected by General Practitioners (GPs) if eligible to mAb administration, according to manufacturer and AIFA (Agenzia-Italiana-del-Farmaco) criteria. If suitability was confirmed by the Multidisciplinary Team, the patient was evaluated within the next 48-72 hours. Then, all patients underwent a medical evaluation, followed by mAb infusion or hospitalization if the medical condition had worsened. Overall, from March 29th to June 4th, 2021, 106 patients with confirmed COVID-19 were identified by GPs; 26 were considered not eligible and then excluded, while 9 refused treatment. Among the 71 remaining, 6 were not treated because of worsening of symptoms soon after selection. Finally, 65 received mAb therapy. All treated patients survived. However, 2/65 developed adverse events (allergic reaction and atrial fibrillation, respectively) and 6/65 needed hospitalization. By performing univariate logistic regression analysis, diabetes was the only risk factor for hospitalization after mAb administration [aOR = 9.34, 95%CI = 1.31-66.49, p= .026]. Importantly, subjects who worsened awaiting mAb were more frequently obese (OR = 16.66, 95%CI = 1.80-153.9, p= .013) and received home corticosteroid therapy for COVID-19 (OR = 14.11, 95%CI = 1.53-129.6, p= .019). Establishing a network among GPs and COVID units could be an effective strategy to provide mAb treatment to patients with early SARS-CoV-2 infection to reduce hospitalizations and pressure on healthcare systems.

Peculiar clinical presentation of COVID-19 and predictors of mortality in the elderly: A multicentre retrospective cohort study.

BACKGROUND: The spectrum of COVID-19 clinical manifestations is not yet known. In the elderly, mortality and extrapulmonary involvement appears more frequent than expected. METHODS: A multicentre-retrospective-case-series study of COVID-19 patients, aged ≥65 years, hospitalised between March 1 and June 15, 2020. Patients were classified at admission into 3 groups based on their Clinical Frailty Scale (CFS) score: 1-3 (group A), 4-6 (group B) and 7-9 (group C). RESULTS: Of the 206 patients in the study, 60 (29%) were assigned to group A, 60 (29%) to B and 86 (42%) to C. Significantly more frequent in group C than in B or A were: mental confusion (respectively 65%, 33%, 7%; P < 0.001), kidney failure (39%, 22%, 20%; P = 0.019), dehydration syndrome (55%, 27%, 13%; P < 0.001), electrolyte imbalance (54%, 32%, 25%; P = 0.001), and diabetic decompensation (22%, 12%, 7%; P = 0.026). Crude mortality was 27%. By multivariate logistic regression model independent predictors of death were male sex (adjusted odds ratio (aOR) = 2.87,95%CI = 1.15-7.18), CFS 7-9 (aOR = 9.97,95%CI = 1.82-52.99), dehydration at admission (aOR = 4.27,95%CI = 1.72-10.57) and non-invasive/invasive ventilation (aOR = 4.88,95%CI = 1.94-12.26). CONCLUSIONS: Elderly patients with a high CFS showed frequent extrapulmonary signs at admission, even in the absence of lung involvement. These findings, along with a high CFS, predicted a significant risk of mortality.

Beyond the comfort zone: Child neuropsychiatry residents in COVID-19 units

During the first months of 2020, the SARS-CoV-2 pandemic has rapidly caused an unprecedented health emergency. In the North of Italy, one of the first and most dramatically hit hotspots, residents and experienced doctors with various professional competencies have been hired. The recruitment has also been on a voluntary basis. In the present work, we describe the experience of a group of Child Neuropsychiatry residents from the University of Pavia who volunteered in COVID-19 units, mainly focusing on tasks regarding communication and relation. A focus group with the young doctors involved in the experience revealed some general themes shared by all the participants: 1) dealing with death, 2) professional identity, 3) the importance of communication. These themes could provide an insight for the clinical and policy plans for the involvement of doctors with different specializations in similar future events, as well as for a remodeling of the educational program for resident doctors. (PsycInfo Database Record (c) 2021 APA, all rights reserved) Abstract (Italian) Nei primi mesi del 2020 la pandemia causata dal SARS-CoV-2 ha provocato un'emergenza sanitaria globale senza precedenti. Nel Nord Italia, una delle zone piu precocemente e piu gravemente colpite, e stato necessario il reclutamento di medici in formazione e specialisti con competenze diverse. Tale reclutamento e avvenuto anche su base volontaria. Descriviamo l'esperienza di un gruppo di medici in formazione in Neuropsichiatria Infantile dell'Universita di Pavia che ha effettuato una frequenza volontaria in reparti COVID della provincia di Pavia, dedicandosi principalmente alla comunicazione e alla relazione. Da un focus group con i giovani medici coinvolti sono emersi alcuni temi generali condivisi da tutti: 1) fare i conti con la morte, 2) l'identita professionale, 3) l'importanza della comunicazione. Questi temi potrebbero servire da spunto di riflessione per la gestione futura di eventuali ulteriori emergenze, nonche per rimodulare l'offerta formativa dei medici in formazione specialistica. (PsycInfo Database Record (c) 2021 APA, all rights reserved)

Tocilizumab and corticosteroids for covid-19 treatment in elderly patients

Background. The mortality rate for coronavirus disease-19 (COVID-19) increases with age. Some anti-inflammatory drugs such as tocilizumab or steroids have been proposed for the treatment of severe disease;however, few data are available in the elderly. Methods. A retrospective case-series of patients hospitalized between March 1st and June 15th, 2020 with confirmed COVID-19 by RT-PCR testing on throat/nasopharyngeal swabs and age ≥ 65 years was analysed. Patients were retrospectively divided into three groups according to the chosen treatment [standard of care (SOC), tocilizumab or corticosteroids] and patient characteristics and occurrence of adverse events were compared among groups. Results. Overall, 206 patients were included, 148 treated with standard of care, 42 with steroids and 16 with tocilizumab. Patients treated with steroids or Tocilizumab presented more frequently with fever (p =.003), dyspnea (p <.001), bilateral opacities/infiltrates at chest X-ray (p =.026) or CT-scan (p =.020), and more frequently required non-invasive/invasive ventilation (p <.001). Crude mortality was 27%, without differences among groups (p =.074). No specific adverse events were observed during/after the administration of steroids or tocilizumab;however, a trend towards an increased risk of secondary infections was described compared to SOC (p =.097). At multivariate logistic regression, only tocilizumab administration was an independent predictor of secondary infections (aOR = 6.72, 95% CI = 1.43-31.39, p =.015). Conclusions. Tocilizumab and corticosteroid could have a possible role for severe form of pneumonia in course of COVID-19 also in elderly patients, even if great attention to the monitoring of infectious complications should be paid in this special population.