CLUSTER-RANDOMIZED TRIAL COMPARING TWO SARS-CoV-2 TESTING MODELS IN AFRICA

Background: Most programs use a screen and test strategy to identify SARS-CoV-2 infection, but this strategy does not identify individuals with asymptomatic infection. We determined the SARS-CoV-2 case detection rates in a test-all model compared to the standard screen-and-test model in Kenya and Cameroon. Method(s): A cluster-randomized trial was conducted in 20 health facilities between May-October 2022. In each country, 5 facilities were randomized to test all (testing offered regardless of screening outcome) or screen and test (testing offered if screened positive) arms. Additional staff were hired to support implementation of the two models in Kenya (K) and the test all model in Cameroon (C). Clients age>2 years attending HIV, TB and MNCH clinics were tested using SARS-CoV-2 rapid antigen tests. We estimated case detection rates (CDR) with facility level weighted averages and used a weighted t-test with robust standard errors for between arm comparison. Result(s): Overall, 80,828 attendee visits were reported in the test-all arm (63,492 C and 17,336 K) and 71,254 attendee visits were reported in the screenand- test arm (56,589 C and 14,665 K). In the test-all arm, 42,325 (52.4%) were screened for COVID-19 symptoms (46.7% C and 73.2% K) and 21,536 (26.6%) were tested (29.2% C and 17.4% in Kenya) with a positivity rate of 1.4% (2.0% C and 1.1% K). In the screen-and-test arm, 48,314 (67.8%) were screened (72.8% C and 48.6% K), and 3,629 (7.5%) were eligible for testing (8.2% C and 3.7% K) - of those, 2,139 (58.9%) were tested (57.1% C and 82.4% K) with a positivity rate of 4.1% (3.4% C and 10% K). The estimated CDR was 3.59 (95% CI:1.55-5.64) per 1,000 attendee visits in the test-all arm and 1.46 (95% CI:0.60-2.32) per 1,000 attendee visits in the screen-and-test arm. Compared to the screen-and-test arm, the test-all arm had significantly higher COVID-19 CDR in MNCH clinics (3.57 vs.1.29, p=0.034). There were no significant differences in COVID-19 CDR between the two arms in HIV (4.20 vs.1.98, p=0.174) and TB (10.33 vs. 5.03, p=0.283) clinics, though the number of SARS-CoV-2 infections was small. Conclusion(s): The test-all arm identified more SARS-CoV-2 cases than the routine screen-and-test model, despite overall low testing coverage. The test-all model should be considered in future epidemics to improve early detection of SARS-CoV-2 infection among vulnerable populations, but effective implementation requires additional human resources to manage the clinic volumes. COVID-19 Case Detection Rates Per 1,000 Attendees: Comparison of Screen-and- Test and Test-All Arms.

Acute motor and sensory axonal neuropathy in a patient with undiagnosed mixed connective tissue disease

Case Report: Acute motor and sensory axonal neuropathy (AMSAN) syndrome is a rare subtype of Guillain-Barre syndrome (GBS) with poor recovery [1]. While respiratory and gastrointestinal infections may precipitate AMSAN, an underlying autoimmune disorder is seldom reported in literature. We herein report the complex case of a patient with undiagnosed, asymptomatic mixed connective tissue disease (MCTD) who developed AMSAN syndrome. Case: A 44-year-old Asian male without medical history presented with progressively worsening weakness of both upper and lower extremities and inability to perform daily activities. His symptoms started 12 weeks prior with difficulty standing from a seated position. He felt subjectively better for some time until a week prior, when he became bedbound. He had diarrhea 6 months ago, with 5-6 loose bowel movements a day for a few weeks. Vital signs on admission was normal. On neurological examination, he was alert and oriented, with bilateral upper and lower extremity flaccid paralysis, diffuse muscle atrophy, bilateral hand and foot drop, negative Hoover sign, diffuse areflexia, and intact sensation. Cerebrospinal fluid (CSF) analysis showed WBC 0 and protein level 136. MRI cervical, thoracic, and lumbar spine were normal. EMG revealed sensory involvement with positive sharp waves in proximal muscles along with fibrillations. Intravenous immunoglobulin (IVIG) was initiated at 0.4 mg/kg for 5 days. Infectious workup for COVID-19, stool culture, HIV, TB, RPR and campylobacter jejuni antibody (Ab), was negative. ANA was positive in a speckled pattern with titres 1:1280, with a positive RNP Ab, SS-A, and RF IgM, IgG and IgA. Rest of the autoimmune workup (anti-dsDNA, anti-CCP, SS-B, aldolase, anti-Jo-1, anti-Scl-70, p-ANCA, c-ANCA, anti-GM1, anti-GQ1b, and anti-GD1a ganglioside Ab) was negative. The myositis specific 11 Ab panel was negative. Despite IVIG therapy, he developed dysphagia, respiratory distress, with a negative inspiratory force of -0, requiring intubation. He had a tracheostomy and PEG tube placed and remains quadraplegic nearly 120 days later. Discussion(s): The authors report a unique case of a patient who became progressively weak over 3 months, leading to complete quadriplegia. Interestingly, this is more consistent with chronic inflammatory demyelinating poly-neuropathy (CIDP), as AMSAN typically develops over a short period of 2 to 4 weeks [2]. Despite having negative anti-GM1 and anti-GD1a Ab (in which positive Ab are pathognomonic but not always present in AMSAN syndrome), the patient had weakness that began in the lower extremities, progressing to paralysis, along with albuminocytological dissociation on CSF analysis, pointing to a GBS diagnosis [3]. He had sensory involvement in the EMG, thus making the diagnosis as AMSAN. He had an undiagnosed, asymptomatic autoimmune process most consistent with MCTD. Whether the two disease processes are related to each other is a concept that has not yet been investigated. Pediatric Clinical Case Reports Concurrent Session Saturday February 4, 2023 1:00 PM Copyright © 2023 Southern Society for Clinical Investigation.

A LESSON ON ANCHORING BIAS DURING A PANDEMIC: A CASE PRESENTATION

SESSION TITLE: Cases of Overdose, OTC, and Illegal Drug Critical Cases Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Anchoring bias is a cognitive bias where one relies too heavily on initial information early on in the decision making process, affecting subsequent decisions due to future arguments being discussed in relation to the "anchor. Overemphasis on COVID-19 due to the pandemic has impacted the timely diagnosis and treatment of other diseases. CASE PRESENTATION: A 39-year-old man with a past medical history of COVID 19 in 12/2020 presents to the ED with increasing weakness, chest pain, recurrent fevers, diarrhea, and cough. CXR revealed bilateral infiltrates suggestive of pneumonia/pulmonary edema. Patient was empirically started on ceftriaxone. CT chest was suspicious of COVID-19;however repeat testing was negative. Diarrhea did not improve. Patient later admitted to recent travel to Jamaica. Ova and parasite, C-difficile, and stool culture were negative. On hospital day 8, the patient was intubated and placed on mechanical ventilation for worsening hypoxic respiratory failure Infectious disease was consulted for recurrent fevers of unknown origin and diarrhea with recent travel. Testing for typhoid fever, hantavirus, malaria, HIV, zika virus, chikungunya, dengue, and yellow fever were performed. Consent was obtained for HIV testing. HIV antibody tests were positive, CD4 count of 7, and viral load greater than 900k. Since a new diagnosis of AIDS with a CD4 count of 7 was obtained, the patient was subsequently tested for opportunistic infections such as TB. TB sputum PCR testing was positive but AFB smear was negative for TB. Antiretroviral and tuberculosis treatments were initiated. DISCUSSION: Anchoring bias can delay critical diagnoses and impede patient care if it is not recognized. According to Watson et. al, one way physicians circumvent the thought of pretest probability when ordering tests based on patient history and the subsequent list of differential diagnoses is anchoring bias. Bypassing the pretest probability also alters the sensitivity and specificity of testing because results that do not confirm or rule out a top differential diagnosis are thought to be inaccurate and are then repeated attributing the initial result to a bad specimen or an improper collection of the specimen. CONCLUSIONS: The case presented exemplifies clearly the concept of anchoring bias. Upon initial presentation, the patient had nonspecific symptoms such as weakness, chest pain, recurrent fevers, diarrhea, and cough, all of which can be symptoms of COVID 19 in the setting of a global pandemic. It is clear that the initial diagnosis based on these symptoms was COVID 19. When initial testing was negative, anchoring bias still played a role in the decision to test the patient once again, despite the first negative test. Repeat testing still did not support the diagnosis of COVID 19, which expanded the differential diagnosis and ultimately led to the correct diagnosis of AIDS with concomitant TB infection. Reference #1: Saposnik, et. Al. Cognitive Biases Associated with Medical Decisions: A Systematic Review. BMC Med Inform Decis Mak. 2016 Nov. 3. PMID: 27809908 Reference #2: Harada, et. al. COVID Blindness: Delayed Diagnosis of Aseptic Meningitis in the COVID-19 Era. Eur J Case Rep Intern Med. 2020 Oct 23. PMID: 33194872. Reference #3: Singh, et. al. The Global Burden of Diagnostic Errors in Primary Care. BMJ Qual Saf. 2016 Aug 16. PMID: 27530239. DISCLOSURES: No relevant relationships by Sagar Bhula

TULAREMIA PRESENTING AS LARGE GI ULCERATION AND HEMORRHAGE

SESSION TITLE: Critical Care Infections SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 09:15 am - 10:15 am INTRODUCTION: Francisella tularensis is a zoonotic disease by an aerobic, gram negative coccobacillus. It is transmitted by exposure to infected animal or vectors in individuals who landscape or camp. Common symptoms are fever, chills, anorexia, and headache. Abdominal tularemia can present with abdominal pain, emesis, diarrhea, and rarely intestinal ulceration and hemorrhage. It is treated with aminoglycosides, fluoroquinolones and tetracycline. CASE PRESENTATION: 38-year-old male presented with fever, cough, anorexia, and black stool for 5 days. Patient worked as a landscaper. He has no pets, travel history or sick contacts. He does not take any medications at home. Physical exam was significant for sinus tachycardia and rhonchi of right upper lobe. Significant labs include WBC of 9.8 with 41% bands, hemoglobin 15.5, sodium 125, procalcitonin 27.3, and lactic acid 1.8. COVID-19, MRSA, Legionella and Pneumococcal urine antigen were negative. CTA chest revealed mass-like opacity in right upper lobe with multiple bilateral pulmonary nodules. Lower respiratory culture showed Candida albicans. Patient was empirically started on ceftriaxone and azithromycin. He was transferred to intensive care for worsening respiratory status and was placed on non-invasive ventilation on hospital day 1. Antibiotics were broadened to ceftaroline and levofloxacin due to suspicion of tularemia. Amphotericin B was added. Labs for Histoplasma, Blastomyces, TB, Leptospira, and HIV were negative. Patient then suffered a cardiac arrest on hospital day 2 after having large brown secretions pouring from his mouth. Cardiopulmonary resuscitation was initiated and patient was intubated and started on vasopressors with return of spontaneous circulation. Massive blood transfusion protocol was initiated. Emergent bedside upper endoscopy showed large blood clot adherent to duodenal ulcer. Interventional radiology planned on performing gastric duodenal artery embolization. However, patient suffered two more cardiac arrest with resuscitation efforts terminated per family request. Karius Digital Culture later was positive for Francisella tularensis. Autopsy revealed diffuse alveolar hemorrhage, hilar lymphadenopathy, and perforated duodenal ulceration with large adherent clot. DISCUSSION: Gastrointestinal tularemia is rare and usually from drinking contaminated water or oral inoculation of bacteria. Intestinal tract involvement can present with mesenteric lymphadenopathy and ulcerative lesions resulting in gastrointestinal bleeding with case fatality rate of 50%. Even though this is noted in the literature, to our knowledge no case reports have been published. CONCLUSIONS: Careful history taking and early identification of risk factors are important when severe tularemia infection is suspected such as in individuals with extensive outdoor activities. Treatment should be empirically initiated in high risk patients. Reference #1: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4585636/ Reference #2: https://casereports.bmj.com/content/2017/bcr-2017-22125. Reference #3: Altman GB, Wachs JE. Tularemia: A pathogen in nature and a biological weapon. Aaohn Journal. 2002 Aug;50(8):373-9. DISCLOSURES: No relevant relationships by Maria Haider Baig

A CHALLENGING CASE OF MYCOBACTERIUM TB-INDUCED HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS

SESSION TITLE: Challenging Cases of Hemophagocytic Lymphohistiocytosis SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of excessive immune activation in response to a variety of insults including malignant, autoimmune and infectious processes. The most common infectious trigger is a viral infection, but other pathogens have also been implicated including Mycobacterium tuberculosis (MTB) CASE PRESENTATION: 62-year-old male from Bangladesh presented due to lethargy, weakness, and anorexia for several weeks. He also reported fevers, diarrhea, and unintentional weight loss. On examination, he appeared acutely ill with diffuse bibasilar crackles on lung exam. Labs showed platelets of 132, ESR 45 mm/hr, CRP 9.6mg/dL, ferritin 1,765ng/mL and transaminitis. A viral panel was positive for Rhinovirus. Computed tomography (CT) of the chest showed diffuse bilateral ground-glass opacities and he was started on antibiotics for pneumonia. On day 3, his respiratory status worsened and he was emergently intubated. He underwent bronchoscopy and bronchoalveolar lavage (BAL) and started on high-dose steroids for possible hypersensitivity pneumonitis. On day 5, he was extubated to nasal cannula, however, his condition worsened despite treatment. Extensive infectious workup, including HIV, Covid and P jirovecii PCR, sputum, and blood cultures, and preliminary AFB smear were negative. Subsequent labs noted rising ferritin levels (4,164 ng/mL), high triglycerides, pancytopenia and transaminitis. Calculated H score was 211 which gave a 93-96% probability of HLH. Initiation of Etoposide was discussed but family deferred. He was later transferred to another facility. On follow-up, IL-2 receptor antibodies were elevated, bone marrow biopsy showed hemophagocytosis and necrotizing granulomas. He was intubated for worsening hypoxemia. Repeat bronchoscopy and BAL analysis showed many acid-fast bacilli. Anti TB treatment (ATT) was deferred due to his critical state. He further declined and eventually expired. DISCUSSION: The exact mechanism for which MTB triggers HLH is unclear, however, it is thought that MTB serves as an obligate intracellular pathogen after phagocytosis by phagocytic cells to induce TH1-mediated cytotoxicity, activating macrophages and NK cells, further releasing a large quantity of cytokines and chemokines. The lack of specific clinical signs, low sensitivity for acid-fast staining, and time-consuming culture make the diagnosis of TB-HLH difficult. However, the use of NAATs has improved the yield of sputum testing. Exceedingly high ferritin levels should serve as a red flag in cases of undetermined diagnosis. Moreso, Cytopenias, elevated LFTs, and coagulation dysfunction are other clues that a diagnosis of HLH should be on the differential. It is believed that early and effective ATT is the key to preventing HLH in TB patients. CONCLUSIONS: It is paramount to both recognize the features of TB as well as HLH as early diagnosis and treatment favor better outcomes. Reference #1: Padhi S, Ravichandran K, Sahoo J, Varghese RG, Basheer A. Hemophagocytic Lymphohistiocytosis: An Unusual Complication in Disseminated Mycobacterium Tuberculosis. Lung India (2015) 32(6):593–601. doi: 10.4103/0970-2113.168100 Reference #2: Dalugama, C., Gawarammana, I.B. Fever with pancytopenia: unusual presentation of extrapulmonary tuberculosis: a case report. J Med Case Reports 12, 58 (2018). https://doi.org/10.1186/s13256-018-1596-0 Reference #3: O M P Jolobe, Timely recognition of hematophagocytosis attributable to coexistence of lymphoma and tuberculosis, QJM: An International Journal of Medicine, Volume 112, Issue 4, April 2019, Page 315, https://doi.org/10.1093/qjmed/hcy198 DISCLOSURES: No relevant relationships by Katherine Acosta No relevant relationships by Chika Winifred Akabusi No relevant relationships by Uma Medapati No relevant relationships by Hector Ojeda-Martinez No relevant relationships by Busala Oke No relevant relationships by Mar o Torres

COVID19 case detection in symptomatic and asymptomatic individuals in Zambia, May- October 2021

Introduction/ Background: Rapid, scalable point-of-care COVID-19 testing at community-level may hold the key towards diagnosis and control in resource-limited settings. Our initial door-to-door symptom-based strategy yielded low COVID-19 cases. We therefore investigated COVID19 case detection using a strategy of community hubs in a peri-urban community (~27,000) with high TB/HIV prevalence in Zambia. Methods: COVID19 screening was delivered using “community hubs”, walk-in testing locations staffed by 2 Community Health Workers serving 3000 to 4000 people. Between May-October 2021 4 hubs were operated in high-risk transmission hotspots changing location weekly. All persons attending the hubs were offered COVID-19 testing (Panbio-AgRDT and a PCR (Cepheid-Xpert-Xpress TM or VitaPCRTM RT-PCR assay (Credo Diagnostics Biomedical, Singapore), depending on availability) and symptoms screening;TB/HIV screening and testing;counselling and linkage to routine care. Qualitative methods included: mystery shoppers, focus group discussions with different groups and observations. Results: Over 6 months, 2956 people were screened at the hubs, 1724 (58%) males with median age 30 years. Prevalence of COVID19 suggestive symptoms was 18.3% (540/2956). A total of 2938 antigen tests were done and 168 (5.7%) were positive. For PCR testing, by Xpert Xpress 370/1270 (29.1%) were positive and 113/951 (11.9%) by VitaPCR;157 (5.3%) were positive on both. Test positivity was strongly associated with being symptomatic (p<0.001). Antigen test positivity rate was 1.6% in asymptomatic versus 24.2% in symptomatic;for Xpert-Xpress 20.6% versus 46.5% and for Vita PCR 4.2% versus 30.4% respectively. Qualitative results are available. Impact: This study aims to generate and evaluate models of community-based COVID-19 services to improve the trace-screen-test- isolate cascade and management by overcoming barriers, reducing stigma, and enabling communities to access rapid-testing. Rapid dissemination of key findings will mitigate the impact of the SARS-CoV2 epidemic and to help increase the knowledge. Conclusion: Delivering COVID-19 case-finding using mobile community hubs is feasible and acceptable and contributed towards the district and national COVID19 response in Zambia. Symptomatic persons have a significant higher chance of being detected with SARS-COV-2.

DIABETIC KETOACIDOSIS IN A NEW ONSET ELDERLY TYPE 1 DIABETES AFTER SARS-CoV-2 VACCINATION: ASSOCIATION OR COINCIDENCE?

Introduction In the era of the COVID-19 pandemic, several cases of new onset diabetes associated with COVID-19 have been reoprted. Additionally, patients with diabetes, a high-risk population, are prioritised for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. The vaccine against the (SARS-CoV-2) could represent a new environmental trigger for autoimmune disorders such as Graves' disease, immune thrombotic thrombocytopenia, autoimmune liver diseases, Guillain-Barré syndrome, systemic lupus erythematosus and type 1 diabetes. case We report a case of diabetic ketoacidosis in a new onset Type 1 diabetes in an elderly female following SARSCoV- 2 vaccination. A 69-year-old female with a history of treated TB abdomen in 2015 with no history of diabetes received her second dose of SARS-CoV-2 vaccination (COMIRNATY) on 21st August 2021. Two weeks following vaccination, she developed osmotic symptoms, reduce appetite and lethargy. Her random blood glucose (RBS) was 41 mmol/L, serum ketone 4.4 mmol/L, pH of 7.29 mmHg, bicarbonate 12.5 mmol/L and serum osmolarity of 298 mOsm/kg. She was treated for DKA with intravenous insulin infusion and hydration with resolution of DKA within 12 hours. Anti-Glutamic Acid Decarboxylase and anti-Islet Cells antibodies were positive with low fasting C-peptide of 102 pmol/L. She was discharged well with basal bolus insulin. Four months later, HbA1c reduced from 15.6% to 7.7% with a random C-peptide of 152 pmol/L. Conclusion The occurrence of hyperglycaemia crisis following SARSCoV- 2 vaccine in patients with pre-existing diabetes is known but the occurrence of new onset autoimmune diabetes following vaccination is rare. Further studies are needed to better understand the underlying pathogenesis of autoimmune diabetes following SARS-CoV-2 vaccine.

A peculiar presentation of stroke in young patients

Introduction: Young patients presenting with stroke to the emergency department (ED) is more uncommon. Atypical presentations of stroke in young patients presenting to ED include loss of consciousness, headache, vomiting, and blurring of vision. Young patients may present with stroke of infective causes which include bacterial, viral, fungal, and parasitic origin. Case discussion: A 24-year-old male presented to the ED in semiconscious state with decreased responsiveness along with complaints of fever since 2days and giddiness since 2days, followed by two episodes of vomiting and loss of consciousness. His vital data are blood pressure of 90/60mm Hg, and on examination, Glasgow Coma Scale (GCS) was E3V2M2, pupils are 1mm sluggishly reacting to light and showing upbeat and downbeat nystagmus on both sides, horizontal gaze palsy was present on the right side, all four limbs are in paraplegia and hyperreflexive to deep tendon reflexes, and ankle clonus is present. In view of poor GCS, the patient was intubated in the ED. The patient had a history of right maxillary fungal sinusitis 7 years back for which Functional Endoscopic Sinus Surgery (FESS) was done. The patient denied COVID infection and immunization. Neuroimaging and magnetic resonance imaging (MRI) brain plain with contrast revealed right maxillary fungal sinusitis extending up to the base of the skull with bilateral pontine and cerebellar infarcts, and there was complete occlusion of basilar artery occlusion. The patient was shifted to the intensive care unit (ICU);on further evaluation, the patient's serum homocysteine, protein C, and protein S were normal. Carotid Doppler was normal. Infective workup was done for TB and herpes simplex virus (HSV), bacterial workup was done, and then fungal workup was done for KOH mount, and tissue fungal smear revealed Aspergillus which was managed with antifungals like liposomal amphotericin B and voriconazole;FESS was done during hospitalization. The patient improved clinically and was discharged to the rehabilitation center. Conclusion: In this case, the cause of stroke was an improperly treated fungal sinusitis which invaded the basilar artery. Being an emergency physician, we should have high index of suspicion in the case of young patients presenting with stroke to ED;we need to consider their past history which gives clue toward the diagnosis of infective causes besides routine workup.

CLUSTER RCT of A MID-LEVEL MANAGER INTERVENTION to PROMOTE IPT UPTAKE in UGANDA

Background: Despite longstanding guidelines endorsing isoniazid preventive therapy (IPT) for persons with HIV, uptake is low across sub-Saharan Africa. Mid-level health managers oversee IPT programs nationally;interventions aimed at this group have not been tested. Methods: We conducted a cluster randomized trial in Uganda among district-level health managers from 2017-2021. The unit of randomization was groups of 4-7 managers. Our intervention convened managers into mini-collaboratives facilitated by Ugandan TB/HIV experts and provided business leadership/management training, SMS platform access, and data feedback. The primary outcome was IPT initiation rates among adults with HIV in health facilities overseen by participants over 2 years (2019-2021). We compared incidence rates using cluster-level targeted minimum loss-based estimation. We conducted pre-specified analyses that excluded Q3-2019 to understand intervention effects independent of a national "100-day push" of IPT tied to a financial contingency during Q3-2019. Qualitative interviews were analyzed to ascertain mechanisms of intervention action. Results: Managers from 82/82 eligible districts (61% of Uganda's 135 districts) were enrolled and randomized: 43 districts to intervention, 39 to control. After one year, in 5-point-Likert quantitative surveys, intervention-group managers demonstrated greater increases in familiarity with IPT (by +0.47 points (95%CI:0.14-0.80)) and knowledge of IPT efficacy (+0.59 points (95%CI:0.06-1.12)) as compared to control. Intervention-group managers reported improved within-district communication and inter-district collaboration and feeling empowered to better manage frontline providers, in contrast to control, in qualitative interviews. Over two years, the IPT initiation rate was 0.74 vs. 0.65 starts/person-year in intervention vs control: incidence rate ratio (IRR)=1.14 (95%CI:0.88-1.46;p=0.16). Excluding Q3-2019, IPT initiation was higher in intervention vs control: 0.32 vs. 0.25 starts/person-year (IRR=1.27, 95%CI:1.00-1.61, p=0.03;Figure). Conclusion: Though overall IPT initiation rates were not significantly higher with the mid-level manager intervention in this cluster randomized trial, rates were significantly higher compared to control when excluding the massive MoH-led "100-day IPT push" in both arms. The higher rates were sustained during the COVID-19 pandemic, suggesting benefits of targeted leadership and management training for mid-level health managers.