Zero Suicide Quality Improvement: Developmental and Pandemic-Related Patterns in Youth at Risk for Suicide Attempts

The Zero Suicide (ZS) approach to health system quality improvement (QI) aspires to reduce/eliminate suicides through enhancing risk detection and suicide prevention services. This first report from our randomized trial evaluating a stepped care for suicide prevention intervention within a health system conducting ZS-QI describes (1) our screening and case identification process, (2) variation among adolescents versus young adults, and (3) pandemic-related patterns during the first COVID-19 pandemic year. Between April 2017 and January 2021, youths aged 12-24 years with elevated suicide risk were identified through an electronic health record (EHR) case-finding algorithm followed by direct assessment screening to confirm risk. Eligible/enrolled youth were evaluated for suicidality, self-harm, and risk/protective factors. Case finding, screening, and enrollment yielded 301 participants showing suicide risk indicators: 97% past-year suicidal ideation, 83% past suicidal behavior;and 90% past non-suicidal self-injury (NSSI). Compared to young adults, adolescents reported more past-year suicide attempts (47% vs. 21%, p <.001) and NSSI (past 6 months, 64% vs. 39%, p <.001);less depression, anxiety, posttraumatic stress, and substance use;and greater social connectedness. Pandemic onset was associated with lower participation of racial-ethnic minority youths (18% vs. 33%, p <.015) and lower past-month suicidal ideation and behavior. Results support the value of EHR case-finding algorithms for identifying youths with potentially elevated risk who could benefit from suicide prevention services, which merit adaptation for adolescents versus young adults. Lower racial-ethnic minority participation after the COVID-19 pandemic onset underscores challenges for services to enhance health equity during a period with restricted in-person health care, social distancing, school closures, and diverse stresses.Copyright © 2023 Society of Clinical Child and Adolescent Psychology.

Tuberculosis (TB) Aftermath: study protocol for a hybrid type I effectiveness-implementation non-inferiority randomized trial in India comparing two active case finding (ACF) strategies among individuals treated for TB and their household contacts.

BACKGROUND: Approximately 7% of all reported tuberculosis (TB) cases each year are recurrent, occurring among people who have had TB in the recent or distant past. TB recurrence is particularly common in India, which has the largest TB burden worldwide. Although patients recently treated for TB are at high risk of developing TB again, evidence around effective active case finding (ACF) strategies in this population is scarce. We will conduct a hybrid type I effectiveness-implementation non-inferiority randomized trial to compare the effectiveness, cost-effectiveness, and feasibility of two ACF strategies among individuals who have completed TB treatment and their household contacts (HHCs). METHODS: We will enroll 1076 adults (≥ 18 years) who have completed TB treatment at a public TB unit (TU) in Pune, India, along with their HHCs (averaging two per patient, n = 2152). Participants will undergo symptom-based ACF by existing healthcare workers (HCWs) at 6-month intervals and will be randomized to either home-based ACF (HACF) or telephonic ACF (TACF). Symptomatic participants will undergo microbiologic testing through the program. Asymptomatic HHCs will be referred for TB preventive treatment (TPT) per national guidelines. The primary outcome is rate per 100 person-years of people diagnosed with new or recurrent TB by study arm, within 12 months following treatment completion. The secondary outcome is proportion of HHCs < 6 years, by study arm, initiated on TPT after ruling out TB disease. Study staff will collect socio-demographic and clinical data to identify risk factors for TB recurrence and will measure post-TB lung impairment. In both arms, an 18-month "mop-up" visit will be conducted to ascertain outcomes. We will use the RE-AIM framework to characterize implementation processes and explore acceptability through in-depth interviews with index patients, HHCs and HCWs (n = 100). Cost-effectiveness will be assessed by calculating the incremental cost per TB case detected within 12 months and projected for disability-adjusted life years averted based on modeled estimates of morbidity, mortality, and time with infectious TB. DISCUSSION: This novel trial will guide India's scale-up of post-treatment ACF and provide an evidence base for designing strategies to detect recurrent and new TB in other high burden settings. TRIAL REGISTRATION: NCT04333485 , registered April 3, 2020. CTRI/2020/05/025059 [Clinical Trials Registry of India], registered May 6 2020.

Scaling Up TB Screening and TB Preventive Treatment Globally: Key Actions and Healthcare Service Costs.

The 2018 United Nations High-Level Meeting on Tuberculosis (UNHLM) set targets for case detection and TB preventive treatment (TPT) by 2022. However, by the start of 2022, about 13.7 million TB patients still needed to be detected and treated, and 21.8 million household contacts needed to be given TPT globally. To inform future target setting, we examined how the 2018 UNHLM targets could have been achieved using WHO-recommended interventions for TB detection and TPT in 33 high-TB burden countries in the final year of the period covered by the UNHLM targets. We used OneHealth-TIME model outputs combined with the unit cost of interventions to derive the total costs of health services. Our model estimated that, in order to achieve UNHLM targets, >45 million people attending health facilities with symptoms would have needed to be evaluated for TB. An additional 23.1 million people with HIV, 19.4 million household TB contacts, and 303 million individuals from high-risk groups would have required systematic screening for TB. The estimated total costs amounted to ~USD 6.7 billion, of which ~15% was required for passive case finding, ~10% for screening people with HIV, ~4% for screening household contacts, ~65% for screening other risk groups, and ~6% for providing TPT to household contacts. Significant mobilization of additional domestic and international investments in TB healthcare services will be needed to reach such targets in the future.

HIV matters when diagnosing TB in young children: an ancillary analysis in children enrolled in the INPUT stepped wedge cluster randomized study.

BACKGROUND: Children under age five years, particularly those living with HIV (CLHIV), are at risk for rapid progression of tuberculosis (TB). We aimed to describe TB clinical presentations, diagnostic pathways and treatment outcomes in CLHIV compared to children without HIV in Cameroon and Kenya. METHODS: This sub-analysis of a cluster-randomized trial evaluating the integration of pediatric TB services from May 2019 to March 2021 enrolled children age < 5 years with TB. We estimated the HIV infection rate with 95% confidence interval (CI). We compared TB clinical presentations, diagnostic pathways and treatment outcomes in CLHIV and children without HIV. Finally, we investigated whether HIV infection was associated with a shorter time to TB diagnosis (≤ 3 months from symptoms onset) after adjusting for covariates. Univariable and multivariable logistic regression analysis were performed with adjusted odds ratios (AORs) presented as measures of the association of covariates with HIV status and with shorter time to TB diagnosis. RESULTS: We enrolled 157 children with TB (mean age was 1.5 years) and 22/157 (14.0% [9.0-20.4%]) were co-infected with HIV. CLHIV were more likely to initially present with acute malnutrition (AOR 3.16 [1.14-8.71], p = 0.027). Most TB diagnoses (140/157, 89%) were made clinically with pulmonary TB being the most common presentation; however, there was weak evidence of more frequent bacteriologic confirmation of TB in CLHIV, 18% vs. 9% (p = 0.067), due to the contribution of lateral-flow urine lipoarabinomannan to the diagnosis. HIV positivity (AOR: 6.10 [1.32-28.17], p = 0.021) was independently associated with a shorter time to TB diagnosis as well as fatigue (AOR: 6.58 [2.28-18.96], p = 0.0005), and existence of a household contact diagnosed with TB (AOR: 5.60 [1.58-19.83], p = 0.0075), whereas older age (AOR: 0.35 [0.15-0.85], p = 0.020 for age 2-5 years), night sweats (AOR: 0.24 [0.10-0.60], p = 0.0022) and acute malnutrition (AOR: 0.36 [0.14-0.92], p = 0.034) were associated with a delayed diagnosis. The case fatality rate was 9% (2/22) in CLHIV and 4% (6/135) in children without HIV, p = 0.31. CONCLUSIONS: These results altogether advocate for better integration of TB services into all pediatric entry points with a special focus on nutrition services, and illustrate the importance of non-sputum-based TB diagnostics especially in CLHIV. TRIAL REGISTRATION: NCT03862261, first registration 05/03/2019.

Applying the National Standards of Perioperative Care of Older People Undergoing Emergency Laparotomy (Nela)

Introduction There are well documented in-equalities for outcomes for surgical intervention associated with Age and Frailty including emergency laparotomy. NELA data has shown over half of such patients are over 65 years old about one fifth are over 80. These patients having significantly higher mortality, longer hospital stays and it has also shown frailty to be an independent marker of poor outcomes. Through application of key standards these outcomes have improved however input from "consultant geriatrician-led MDT" remains stubbornly low nationally. Aims To improve local Trust performance in meeting the NELA standard: "Peri-operative assessment by a member of the Geriatrician-Led MDT for frail (CFS 5+) patients 65 or older" to >80% (Green: >=80%, Amber: 50 - 79% Red: <50%) of estimated 100 patients per year. Methods 1. Proactive case finding with general surgical teams;2. Engagement with Emergency Surgical Committee and NELA leads;3. Improved our own electronic referral system;4. Assist in development of electronic booking system with emergency laparotomy cases Results We showed a significant improved in meeting the NELA standard from the red zone (Mean: 33% range 5% to 35%) into the amber with a of mean 60% (quartile range 52% to 78%) but still remains below our target with significant quarterly variation seen. All referrals and assessment remain post-intervention. Limitations in measures: Large variations in Frailty assessment and referral process (prospective Vs retrospective) Process rather than a Quality measure No balancing measures - Is there Reduced service elsewhere? Conclusions Following a number of change ideas and despite challenging COVID related staffing issues we showed that a combination of key stakeholder engagement, proactive case-finding and improved referral processes we have improved Geriatrician input in frail patients undergoing emergency laparotomy. We suspect due to the non-systematic assessment of frailty that we may be missing some patients and or seeing late in care pathway.

Relative role of border restrictions, case finding and contact tracing in controlling SARS-CoV-2 in the presence of undetected transmission: a mathematical modelling study.

BACKGROUND: Understanding the overall effectiveness of non-pharmaceutical interventions to control the COVID-19 pandemic and reduce the burden of disease is crucial for future pandemic planning. However, quantifying the effectiveness of specific control measures and the extent of missed infections, in the absence of early large-scale serological surveys or random community testing, has remained challenging. METHODS: Combining data on notified local COVID-19 cases with known and unknown sources of infections in Singapore with a branching process model, we reconstructed the incidence of missed infections during the early phase of the wild-type SARS-CoV-2 and Delta variant transmission. We then estimated the relative effectiveness of border control measures, case finding and contact tracing when there was no or low vaccine coverage in the population. We compared the risk of ICU admission and death between the wild-type SARS-CoV-2 and the Delta variant in notified cases and all infections. RESULTS: We estimated strict border control measures were associated with 0.2 (95% credible intervals, CrI 0.04-0.8) missed imported infections per notified case between July and December 2020, a decline from around 1 missed imported infection per notified case in the early phases of the pandemic. Contact tracing was estimated to identify 78% (95% CrI 62-93%) of the secondary infections generated by notified cases before the partial lockdown in Apr 2020, but this declined to 63% (95% CrI 56-71%) during the lockdown and rebounded to 78% (95% CrI 58-94%) during reopening in Jul 2020. The contribution of contact tracing towards overall outbreak control also hinges on ability to find cases with unknown sources of infection: 42% (95% CrI 12-84%) of such cases were found prior to the lockdown; 10% (95% CrI 7-15%) during the lockdown; 47% (95% CrI 17-85%) during reopening, due to increased testing capacity and health-seeking behaviour. We estimated around 63% (95% CrI 49-78%) of the wild-type SARS-CoV-2 infections were undetected during 2020 and around 70% (95% CrI 49-91%) for the Delta variant in 2021. CONCLUSIONS: Combining models with case linkage data enables evaluation of the effectiveness of different components of outbreak control measures, and provides more reliable situational awareness when some cases are missed. Using such approaches for early identification of the weakest link in containment efforts could help policy makers to better redirect limited resources to strengthen outbreak control.

Telemonitoring of the Continuum of Care of Hepatitis C During the COVID-19 Pandemic in Brazil.

Introduction: To accomplish elimination of hepatitis C virus (HCV) by 2030, as proposed by the World Health Organization, the Brazilian Ministry of Health outlined the Hepatitis C Elimination Plan, which provides coverage of all critical steps in the continuum of care (CoC) of hepatitis C. As expected, the advent of COVID-19 pandemic has disrupted the CoC of hepatitis C worldwide. The Brazilian Liver Institute launched a remote patient monitoring (RPM) program to assist the general population at risk in HCV testing and to provide linkage and retention to care for HCV-positive subjects. The RPM program was also designed to relink HCV-positive patients lost to follow-up during the COVID-19 pandemic due to their limited access to the health care system. Methods: The HCV telemonitoring number was highly advertised in Brazilian media. The RPM program was conducted by dedicated health care personnel trained to follow a predefined script designed to provide awareness, ensure consistent information for educational purposes, and recruit eligible participants to be tested for HCV. Results: From August 2020 to December 2021, 3,738 subjects entered in contact with RPM. There were 26,884 interactions (mean 7.2 interactions per participant), mostly by WhatsApp (78%). Twenty out of those 221 subjects (9%) who tested were HCV positive. Those subjects altogether with 128 other patients with HCV, tested elsewhere, were followed in the HCV CoC. Up to now, 94% of them were linked to care, 24% are undergoing treatment and 8% achieved sustained virological response (SVR). Conclusions: Our preliminary results showed that HCV CoC telemonitoring was a feasible and useful strategy to follow HCV at-risk subjects through all cascade of care until SVR during the COVID-19 health care disruption. It could be used beyond the defervescence of SARS-CoV-2 pandemic to ensure linkage to care of those HCV-positive patients.

Community-Based Approach to Assess Obstructive Respiratory Diseases and Risk in Urban African American Churches.

Asthma, and chronic obstructive pulmonary disease (COPD) are significant health problems that have disparate effects on many Americans. Misdiagnosis and underdiagnosis are common and lead to ineffective treatment and management. This study assessed the feasibility of applying a two-step case-finding technique to identify both COPD and adult asthma cases in urban African American churches. We established a community-based partnership, administered a cross-sectional survey in step one of the case-finding technique and performed spirometry testing in step two. A total of 219 surveys were completed. Provider-diagnosed asthma and COPD were reported in 26% (50/193) and 9.6% (18/187) of the sample. Probable asthma (13.9%), probable COPD (23.1%), and COPD high-risk groups (31.9%) were reported. It is feasible to establish active case-finding within the African American church community using a two-step approach to successfully identify adult asthma and COPD probable cases for early detection and treatment to reduce disparate respiratory health outcomes.

Effectiveness of Relink Initiatives to Re-Engage Diagnosed-but- Untreated Hcv-Positive Patients with Direct-Acting Antiviral Treatment

Background: Hepatitis C virus (HCV) infection is a major cause of chronic liver disease that can progress to cirrhosis and hepatocellular carcinoma. The WHO has identified HCV infection as a public health threat and set a global target for HCV elimination by 2030. Simple pangenotypic direct-acting antiviral regimens allow most patients to be cured with minimal pretreatment and on-treatment monitoring. To achieve the WHO goal, patients-including previously diagnosed HCV-positive patients who have been lost to follow-up- need to be linked to care. Studies report up to 60% of patients who test positive for HCV antibody are lost to follow-up and not treated. This loss has been further exacerbated by the COVID-19 pandemic, during which there was a reduction in treatment urgency, such that many patients put off receiving care. Here, we explore the effectiveness of care re-engagement programs for patients with HCV. Method(s): We assessed ReLink programs (sponsored by Gilead Sciences, Inc.), designed to identify and re-engage HCV-positive patients with medical care and start/restart HCV treatment. We evaluated these programs by analyzing the number of patients, steps in the care cascade where patients were lost to follow-up, and the efficacy of the engagement program (determined by number relinked and treated). Result(s): Six programs assessed 44,964 patient records, identifying 11,163 patients lost to follow-up and eligible for contact. Several common points in the care cascade were identified where patients were most frequently lost to follow- up, often after diagnosis but before start of treatment. The main reason for loss to follow-up was the inability to contact patients. Overall, 3726 patients were relinked with care, and 701 were treated (Table). Several key points were identified for improving patient engagement with care, including the use of electronic databases to identify patients lost to follow-up, securing reliable contact information for patients, and partnership with medical societies. Conclusion(s): Active case-finding, patient navigation, and care coordination in these programs led to increased engagement and treatment rates. Engaging HCV-positive patients with care is urgent, as many may already have developed more advanced liver disease. Adopting and adapting effective strategies from these programs may be a feasible way to improve patient outcomes and increase treatment numbers, thus contributing to meeting the WHO goal of HCV elimination. (Table Presented).

Key issues related to COVID-19 health care system: Lessons learnt from Thailand

Thailand is a high middle-income country with export-led economy based on trade and foreign direct investment. The COVID-19 pandemic has serious impact on health system, Thai economy and people due to unemployment in services and manufacturing sectors. First phase of the outbreak, Thai Government established the Centre for COVID-19 Situation Administration (CCSA) as special task force. Ministry of Public Health (MOPH) has formulated a management strategy focusing on comprehensive, proactive response by activating EOC (Emergency Operation Centre). Phase 2 was controlled by limited local transmission, emphasis on test, treat and immunization. Phase 3-4 were sustained local transmission and mitigation waves included patient care, prevention of large outbreak and vaccination. Five Key Lessons Learnt from Thailand's COVID-19 Response are 1) Invest in health facilities. Investment in healthcare infrastructure has prepared Thailand well for the pandemic. More than 1,000 public hospitals and 10,000 primary health care facilities provide medical and primary healthcare services and accommodate COVID-19 patients. 2) Universal health coverage (UHC). Since 2002, Thailand has achieved universal health coverage. During the outbreak, essential healthcare is provided to all infected people including foreigners without financial barriers. 3) The help of more than one million village health volunteers These volunteers who complemented primary healthcare services at community level undertook door-to-door visits for health education, active case finding, disease surveillance and quarantine. 4) Early action. Screening passengers from Wuhan, People's Republic of China (PRC) was initated within three days after PRC's announcement of cases of pneumonia. The first confirmed COVID-19 case outside PRC prompted strong public health measures and campaigns. A whole-of-government approach established the Center for COVID-19 Situation Administration (CCSA), chaired by the Prime Minister and top political leaders. 5) Nationwide public cooperation on effective social measures. Daily press conferences by CCSA's spokesperson and by MOPH executives/experts provided essential information to public. Conclusion(s): Strong, well-resourced and inclusive medical and public health systems, vaccination campaign and administrative systems has been integrated to fight the epidemic. A 'whole of society' approach means, 'Nobody is safe unless Everybody is safe'. We are strong, not because we are rich, because we fight and we do not give up.

Early Diagnosis of Coeliac Disease by Case-Finding at the Preventive Youth Health Care Centres in the Netherlands (Glutenscreen)

Introduction: Objectives: Coeliac disease (CD) occurs in 1% of the population, but is severely underdiagnosed. Secondary prevention by early diagnosis may be achieved by case-finding. Aims & Methods: To prospectively assess whether case-finding at the Preventive Youth Health Care Centres (YHCCs) in the Netherlands is a feasible and effective strategy for early CD-diagnosis. We analyzed data from the case-finding study GLUTENSCREEN from its start at 4th February 2019 till 4th January 2022 (with interruption of 5 months due to COVID19). Parents of all symptomatic children aged 1-4 years attending the YHCC in the Kennemerland-region for a regular visit, were asked if their child has >=1 CD-related symptoms. If so, a point-of-caretest (POCT) to assess CD-specific antibodies against tissue transglutaminase (TGA), was performed onsite the YHCCs. If the POCT was positive, the child was referred to our hospital for definitive diagnosis according to the ESPGHAN guideline. Result(s): 36.9% (5706/15466) of the children had >=1 CD-related symptoms. Parents of 3104 (54.4%) children gave informed consent for a POCT (47% female;median age 2.8years). In 61 children the POCT was positive: CD was confirmed in 55 children (2.0% of the tested children) and ruled out in 5 children. Of them two children had negative HLA-DQ2/8 and TGA (ELISAtest) and in 3 children with TGA <10xULN small bowel biopsies showed Marsh 0-1 lesions. From one child who was referred to the hospital, parents refused additional investigation. Conclusion(s): Case-finding for CD using a POCT is effective and feasible and it detects a high CD prevalence of 1.8%. Before implementation of the case-finding strategy cost-effectiveness and acceptability analyses are needed. .

Inequalities in Access to Care for the London Post Covid Syndrome Pathway for Children and Young People (Cyp)

Aims The London Post COVID Syndrome Pathway was set up in October in 2020 in order to meet the needs of children affected by persistent symptoms after SARS-CoV-2 infection. The UK CLoCk study (1), 11-17 years, showed high symptom prevalence, increasing from time of testing to 3 months (35.4% to 66.5% in SARS-CoV-2 positive cases and 8.3% to 53.3% in controls). ONS (2) data from a large, randomly selected population survey (April 2020 to August 2021) reported symptom prevalence 4-8 weeks after infection of 3.3% in primary aged children (vs 3.6% in negative controls) and 4.6% (vs 2.9%) in secondary aged. The Zoe Kings study (3) showed 1.8% of children had symptoms beyond 8 weeks after infection. The COVID pandemic has affected ethnic minorities and those in deprived communities the most. Here, we aimed to describe referral patterns and ascertain factors influencing inequalities in access to care. Methods We collected demographic and clinical data from our Post COVID clinics, from October 2020 to January 2022. Deprivation deciles were based on the Index of Multiple Deprivation (IMD 2019). Decile 1 represents the most deprived 10% (decile) in England and Decile 10 represents the least deprived 10%. Analyses were descriptive. Results A total of 86 patients were referred with persistent symptoms (median age 14, range 7-18). The female:male ratio was 1.5:1 (52:34). Ethnicity data was available for n=74. Of those 5% identified from Black backgrounds (expected 13.30%);9% Asian (vs 18.50%);12% Other Ethnic Groups (vs 3.40%), 7% Mixed Ethnic Groups (vs 5%) and 53% White (vs 59.80%). Median IMD score was 6, with mode =7 (London mean 3, mode =1). Conclusion Our data suggests children from more affluent (less deprived) areas are accessing the service, with an underrepresentation of males. A small number of patients were referred compared to those reporting persistent symptoms in national surveys. This may be due to a relatively lower number having impairment and/or a lack of awareness amongst professionals. Ethnicity data shows a lower number than expected Black (40% less) and Asian (50% less) backgrounds are accessing support. Since schools re-opened in September 2021 reduced school attendance has been reported for many children. Persistent symptoms are common post viral infection, and most children recover. However, for some these can be debilitating. If children have reduced school attendance due to persistent symptoms they need prompt access to care. Our study raises concern about access to Post COVID services for all children (particularly males and those from minority backgrounds), raising lack of awareness amongst GPs and schools as a possibility. Proactive case finding is needed, particularly in hardly-reached groups. NHS England has recommended a lead for supporting equality to help this and is in post. The numbers of children accessing care is smaller than the number reporting symptoms, an area that requires further study.

The existence of Dibates mellitus in cases of Tuberculois patients. Findings in a Tribal population from Nikshay Data base

Introduction: For more than 75,000 years, tuberculosis (TB) has plagued humans over the planet. It is the greatest cause of infectious disease-related death worldwide, surpassing out HIV, though COVID-19 may overtake it. Approximately 1,200,000 individuals died as a direct result of this disease, and an additional 250,000 people who were HIV-positive died as a result of it, according to WHO estimates for 2018. Only eight nations, India (28%) China (9%) Indonesia (8%), Pakistan 6%, Nigeria 4% and Bangladesh 4%, account for two thirds of the world's TB infections, according to the World Health Organization (WHO) (3 percent) Needless to highlight India remains the top contributor for the disease. While Diabetes mellitus (DM) is one of the most common chronic disorders in our society. and incidentally India had been time and again given the name of Diabetic Capital of World. Interestingly animal models have been used to examine how hyperglycaemia affects the immunological response to M. tuberculosis, but a definite answer has not yet been established. Its widely accepted that DM is a risk factor for TB. Various published evidence point out that, if a person has both tuberculosis and diabetes, the risk of death increases. TB treatment results are negatively correlated with diabetes. Diabetes patients have a mortality risk ratio that is higher than that of the general population, even after correcting for age and other relevant confounders. Keeping in view of these facts and the paucity of published evidence when it comes to tribal hinterlands of Jharkhand we decided to do a cross sectional observation analysis of the Data avaialbel in Nikshay portal. Nikshay portal is Methods: District of Pakur in Jharkahnd was chosen as it is one of the districts sharing border with West Bengal, Bihar and Bangladesh is nearby.We used data from the adult population obtained from Nikshay portal for one year 2021, and divided into two subgroups. We conducted univariate analysis to find association of DM presence with different sociodemographic variables using chi square and unpaired t-test/Mann Whitney test for non -parametric data. Multivariable logistic regression models were used to predict the association of DM presence with epidemiological factors. Data was analysed using JASP software and p value <0.05 was considered statistically significant. Results: Out of 1687 registered TB patients we found 29 who were having Diabetes as co morbidity, Majority of them were male, while 19 of them were referred from private facility, three of them died and two were lost to follow up. Other predictors were found which increased the chances of having DM along with TB were middle age, and sex. Conclusions: As has been reported by others as well the problem of co infection of TB with DM is a reality and growing. The two programs are now being run under different heads which need to change. As seen most of the diabetics were from Private facilities meaning we might be missing more. More active case findings needs to be done so that no case of DM with TB is missed. Screening for DM among TB patients should be compulsory and treatment of co-morbidity should be included in adult health programmes. No conflict of interest

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.

SERVICE DEVELOPMENT -NURSE LED MULTIAGENCY HEPATITIS C MOBILE COMMUNITY OUTREACH SCREEN TEST TREAT SERVICE

Introduction Delivery of the World Health Organisation elimination agenda for Hepatitis C Virus (HCV) requires active case finding, to engage hard to reach risk groups. Surrey is a relatively affluent part of the country, but contains pockets of significant unmet need, which are a barrier to the HCV care cascade. In 2020 the Surrey HCV Operational Delivery Network (ODN) piloted 'pop up clinics' for housed homeless populations during the COVID 19 pandemic. Based on this experience the ODN lead successfully bid for NHS England funding for a Mobile Outreach Van (MOV). Methods Detailed mapping of the ODN was undertaken jointly with the Hepatitis C Trust to identify potential locations to screen e.g., Opiate Substation Therapy dispensing pharmacies, and areas with high numbers of homeless people. MOV procurement and governance obtained in accordance with Trust policy. Individuals complete a brief liver health questionnaire including Blood Bourne Virus (BBV) risk factors. HCV screening is undertaken using Oraquick point of care testing. Those screening HCV Antibody positive (Ab +ve) receive a Clinical Nurse Specialist (CNS) assessment for therapy including a BBV screen HCV PCR and Fibro Scan. Hepatitis C Trust peer support is available to all individuals. Other significant findings prompt onward referral e.g., cirrhosis surveillance. Results First six months of operation the team have undertaken 50 testing days in 16 venues. 761 individuals have accepted HCV Ab screening. 40 (5.2%) tested HCV Ab +ve. 10 individuals confirmed viraemic and eligible for treatment. Another 7 individuals were re-engaged to undertake end of treatment or Sustained Virologic Response 12/48 PCR. In addition, 1 HCV Ab +ve (PCR negative), patient was diagnosed with Human Immunodeficiency Virus and referred to the local sexual health team. 16 individuals identified with advanced fibrosis or cirrhosis were referred to hospital for Hepatocellular Carcinoma surveillance. Patients engaged through the MOV service have received their treatment in the community via this service delivered by a CNS. Conclusions Nurse led MOV screen test treat model has proven to be safe and effective in engaging difficult to reach populations. Hepatitis C Trust peers accessibility help to address the anxiety/stigma surrounding HCV. MOV wider benefits include engagement with drug and alcohol services, and harm reduction. The next phase of implementation, the team plan to deliver needle exchange and naloxone in a partnership agreement with Surrey County Council.

SUCCESSFUL IMPLEMENTATION OF CASE FINDING FOR HEPATITIS C IN PEOPLE DETAINED IN POLICE CUSTODY

Introduction As part of the national Hepatitis C (HCV) elimination strategy, NHS England aims to eliminate HCV by 2025. As part of this programme, identifying undiagnosed cases through HCV testing is critical. Unfortunately, the global COVID 19 pandemic led to a reduction in HCV testing in England, potentially slowing progress towards elimination. To mitigate the impact of this, innovative ways of increasing HCV testing are required. Individuals detained in police custody have higher rates of injecting drug use than the general population and may therefore be at risk of HCV transmission. Police custody suites may therefore provide an opportunity to offer HCV testing to 'at risk' individuals. In collaboration with local police custody healthcare staff, we developed a pilot of HCV testing for individuals in police custody. Here we describe the outcomes of this pilot Methods Since 01/07/2021, all individuals presenting to Northumbria police custody suites who were reviewed by a healthcare professional were offered Dried Blood Spot test (DBS) for HCV Antibody/RNA, HIV and HBsAg. Individuals were excluded if they were <16 years of age or alleged perpetrators of sexual violence. The Newcastle HCV team were responsible for informing people of their results and establishing those with a positive HCV result on a treatment pathway. Results Of the 3116 people in police custody identified as eligible to be offered BBV testing (See figure 1), 193 accepted (6%). A total of 19 were HCV Ab positive (10% of total individuals tested) and of these 12 were HCV RNA detected (63.0% of HCV Ab positive and 6% of total individuals tested). No cases of HIV or hepatitis B were identified. 137 (71.0%) individuals were negative for all BBV's. Unfortunately, 37 (19%) samples could not be processed by the lab due to insufficient samples (19.0%). This was identified as a training issue and addressed by senior custody suite staff. of the 12 cases of active HCV identified, 5 have commenced HCV antiviral treatment, 6 are awaiting treatment and 1 person is awaiting retesting as the result was 'weak positive'. of the 7 individuals who were HCV Antibody positive but RNA negative, 3 had self-cleared, 3 were known to have received antiviral treatment and achieved a sustained virological response and 1 patient was currently on treatment. Conclusions The pilot demonstrated that HCV screening can successfully be implemented into the police custody suites, leading to a diagnosis of active HCV in 6%. Wider implementation of this strategy could help progress towards HCV elimination.

TWO-TIERED LIVER FIBROSIS ASSESSMENT IN PRIMARY CARE ANNUAL DIABETIC SCREENING - 3 YEAR FOLLOW UP

Introduction We previously presented the outcome of a pathway incorporating 2-tiered fibrosis assessment into annual diabetic reviews in primary care. This 3 year follow up study looks at: 1. Outcomes in patients referred into secondary care with moderate-advanced fibrosis Ongoing service delivery requirements after the first year of case finding Effectiveness of the pathway in detecting patients with advanced disease, by looking at the number of patients missed in the pathway presenting with advanced disease. Methods All patients aged >35 years with Type 2 Diabetes Mellitus (T2DM) attending annual review at two primary care practices in North East England between April 2018 and September 2019 (n=467) had a Fib-4 requested, followed by transient elastography (TE) if the Fib-4 was above the high sensitivity threshold. Those with a liver stiffness measurement (LSM) >8kPa were reviewed in secondary care. This pathway was continued in both practices after the end of the initial study period. We reviewed the outcomes of all patients referred to secondary care;the number of patients referred in the subsequent years with ongoing case-finding;and any patients missed from initial screening presenting with decompensated/ symptomatic disease. Results From the 467 patients in the initial study, 58 were referred for TE, 25 had a LSM>8kPa and 20 had advanced disease (on imaging/biopsy/endoscopy). 6/20 (30%) patients with advanced disease have died- 2/20 liver related deaths (hepatocellular carcinoma (HCC) and decompensated cirrhosis);1 patient diagnosed with HCC was treated with curative transarterial chemoembolisation;3 patients had varices on OGD (2 started on carvedilol for primary prophylaxis);12 remain under follow up. In all patients with LSM >8kPa (n=25): 8/25 (32%) died (3/8 from COVID-19);24% (6) LSM improved, 8% (2) LSM deteriorated;32% (8/25) lost weight. No patients missed by the pathway presented with decompensated disease. Serial FIB- 4 at annual screening 2019-2021: 4 patients new raised Fib-4 scores - 1 DNA, 1 TE is awaited, 1 LSM <8kPa (discharged), 1 advanced disease (LSM 17.1kPa). Conclusion Incorporation of a two-tiered liver fibrosis assessment into primary care annual diabetic screening significantly improves identification of advanced liver disease and no patients have presented with advanced disease out-with the pathway. It allows for early detection and interventions against the complications associated with advanced liver disease. Mortality in patients with advanced liver disease remains high. Referrals for TE and into secondary care dramatically reduce after the initial year of case finding.

Patient Navigators: an innovative approach to improve hepatitis c case finding leveraging existing human immunodeficiency virus service delivery models to reach last mile patients in Nasarawa State, Nigeria

Background and aims: The natural history of Hepatitis C Virus (HCV) demonstrates an asymptomatic disease that often leads to liver degeneration in approximately three decades. In HIV/HCV coinfection, liver degeneration is accelerated with decompensated cirrhosis occurring in less than two decades resulting in higher mortality rates. The asymptomatic nature of HCV, increased rate of disease progression in HIV, low awareness, and poor care seeking behaviour emphasizes the need to improve HCV case finding in People Living with HIV (PLHIV). In Nigeria, the Nasarawa State Government has committed to HCV elimination, with an initial focus on PLHIV, necessitating integration of services to screen ART patients for HCV. However, due to the COVID pandemic and the resultant scale-up of Differentiated Service Delivery (DSD) models within the HIV program, screening yield from facility-based case finding reduced significantly. To ensure last mile linkage to HCV screening, the Patient Navigator pilot was conducted from March-October 2021. This analysis aims to assess screening coverage before and during this pilot period. Method: One healthcare worker across three secondary facilities i.e., General Hospitals Keana, Awe, and Uke, labelled patient navigator (PN) was charged with the responsibility of identifying unscreened PLHIV using facility screening records and enrolment data. These PNs were HIV program defaulter trackers, consequently integrating this service within the HIV program. The PN employed strategic patient tracking approaches like phone calls, community engagements and peer group meetings. Using laboratory screening registers, screening progress was compared pre-intervention (July 2020 to February 2021) versus during the intervention (March to October 2021). Results: A total of 125, 560, and 923 were active on ART care as of January 2020 in General Hospitals Keana, Awe, and Uke respectively. Across sites, the first 4 months of the pre-intervention phase sawhigh screening numbers as all available patients presenting to facilities were screened. Subsequently, a decline in screening numbers across all facilities. However, the intervention phase demonstrated extended coverage, reaching the last mile patients leading to an increase in case finding by 18% in GH Keana, and 23% in GH Awe and GH Uke respectively. (Figure Presented) Conclusion: The use of patient navigators demonstrates the feasibility and cost-effectiveness of increasing case-finding through HCV/HIV program integration.

Hepatitis C virus (HCV) micro-elimination in the hospital setting: The results of the HCV Caserta hospital project.

BACKGROUND: In the present study we evaluated the efficacy of an innovative model of HCV micro-elimination in a hospital setting in an area of high HCV prevalence. PATIENTS AND METODS: Between January and December 2019, a prospective, interventional study for a program of HCV case-finding and linkage-to-care was performed in S. Anna and S. Sebastiano hospital of Caserta, in Campania, a region in southern Italy. All adult patients who were admitted to the Caserta hospital in the study period and resulted positive for anti-HCV were included in the study. The outcomes evaluated were the number of subjects resulting HCV-RNA-positive, those linked-to-care and treated with a DAA and the subjects whose anti-HCV-status was unknown. RESULTS: In the study period, 14,396 subjects, admitted to the hospital for different reasons, were tested for anti-HCV: 529 (3.7%) subjects resulted positive for anti-HCV. Of the 529 anti-HCV-positive subjects, 10 died during hospitalization and 243 were already treated with a DAA. The remaining 276 subjects were contacted and agreed to be evaluated. Of these 276 subjects, 68 patients resulted HCV- RNA-negative and 194 HCV-RNA-positive and 180 of these were treated with a DAA according to the international guidelines. DISCUSSION: A simple, rapid, inexpensive model of HCV micro-elimination in the hospital setting allowed us to find anti-HCV-positive subjects with unknown anti-HCV status or not linked to a clinical center.

INNOVATION to ACHIEVE the SECOND 95 AMIDST COVID-19 in KEY POPULATION in NIGERIA

Background: Key Populations (KP) makeup 3.4% of the general population, yet account for ∼32% of new HIV infections in Nigeria (NACA, 2017). With criminalizing laws, and ∼3000 active KPs hotspots in Lagos state alone, it is increasingly challenging for civil society organizations to reach these groups with the much needed HIV services. With the COVID-19 outbreak in the South-West region of Nigeria, Lagos state in early March, 2020 and attendant lockdown leading to restriction in movement, it became even more challenging to reach KP members with a complement of comprehensive HIV services. We describe our experience implementing innovatively evidence and community-based strategies to scale active HIV case-finding using a COVID-19 guided protocol during the 6-week lockdown in the state. Methods: We set up 22 Community ART (cART) teams split into an 8-person KP peer-led sub team comprising (community health worker, pharmacist, laboratory technician, four counselor testers, and a community mobilizer) that conducted HIV Testing Services (HTS) in 78 communities across 7 districts using the "moonlight testing" (nightly testing) approach. The teams were equipped with a line-list of index clients for elicitation of sexual and needle-sharing partners. Community engagement of gate keepers of pre-mapped KP communities was innovatively conducted, to seek approval, grant access and provide security during testing of elicited partners. Following an orientation on COVID-19 protocols for clients assessing services, index partners who accepted HTS were provided HIV prevention information, condom messaging, demonstration and distribution;those who tested positive were retested and provided with ART immediately. Results: Prior to the lockdown (February-March 2020), 8,831 clients were offered HIV testing services with 1,396 (positivity yield of 16%). Following the lockdown period which lasted for 6 weeks (March-May, 2020), HIV testing among key population increased by 38% (12, 159) with a 28% increase (1, 781) in HIV positives and 15% positivity yield. Conclusion: Despite the pre-existing challenges with KP access to comprehensive differentiated services worsened by current COVID-19 realities, peer-led cART showed significant promise in accelerating KP HIV case finding and sustaining community ART delivery.