Tuberculosis infection prevention and control in rural Papua New Guinea: an evaluation using the infection prevention and control assessment framework.

BACKGROUND: Papua New Guinea (PNG) is one of the 14 countries categorised as having a triple burden of tuberculosis (TB), multidrug-resistant TB (MDR TB), and TB-human immunodeficiency virus (HIV) co-infections. TB infection prevention and control (TB-IPC) guidelines were introduced in 2011 by the National Health Department of PNG. This study assesses the implementation of this policy in a sample of district hospitals in two regions of PNG. METHODS: The implementation of TB-IPC policy was assessed using a survey method based on the World Health Organization (WHO) IPC assessment framework (IPCAF) to implement the WHO's IPC core components. The study included facility assessment at ten district hospitals and validation observations of TB-IPC practices. RESULTS: Overall, implementation of IPC and TB-IPC guidelines was inadequate in participating facilities. Though 80% of facilities had an IPC program, many needed more clearly defined IPC objectives, budget allocation, and yearly work plans. In addition, they did not include senior facility managers in the IPC committee. 80% (n = 8 of 10) of hospitals had no IPC training and education; 90% had no IPC committee to support the IPC team; 70% had no surveillance protocols to monitor infections, and only 20% used multimodal strategies for IPC activities. Similarly, 70% of facilities had a TB-IPC program without a proper budget and did not include facility managers in the TB-IPC team; 80% indicated that patient flow poses a risk of TB transmission; 70% had poor ventilation systems; 90% had inadequate isolation rooms; and though 80% have personal protective equipment available, frequent shortages were reported. CONCLUSIONS: The WHO-recommended TB-IPC policy is not effectively implemented in most of the participating district hospitals. Improvements in implementing and disseminating TB-IPC guidelines, monitoring TB-IPC practices, and systematic healthcare worker training are essential to improve TB-IPC guidelines' operationalisation in health settings to reduce TB prevalence in PNG.

The clinical and epidemiological characteristics of a series of patients living with HIV admitted for COVID-19 in a district hospital.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic continues to evolve. Globally, COVID-19 continues to strain even the most resilient healthcare systems, with Omicron being the latest variant. We made a thorough search for literature describing the effects of the COVID-19 in a high human immunodeficiency virus (HIV)/tuberculosis (TB) burden district-level hospital setting. We found scanty literature. METHODS: A retrospective observational study was conducted at Khayelitsha District Hospital in Cape Town, South Africa (SA) over the period March 2020-December 2021. We included confirmed COVID-19 cases with HIV infection aged from 18 years and above. Analysis was performed to identify predictors of mortality or hospital discharge among people living with HIV (PLWH). Predictors investigated include CD4 count, antiretroviral therapy (ART), TB, non-communicable diseases, haematological, and biochemical parameters. FINDINGS: This cohort of PLWH with SARS-CoV-2 infection had a median (IQR) age of 46 (37-54) years, male sex distribution of 29.1%, and a median (IQR) CD4 count of 267 (141-457) cells/mm3. Of 255 patients, 195 (76%) patients were discharged, 60 (24%) patients died. One hundred and sixty-nine patients (88%) were on ART with 73(28%) patients having acquired immunodeficiency syndrome (AIDS). After multivariable analysis, smoking (risk ratio [RR]: 2.86 (1.75-4.69)), neutrophilia [RR]: 1.024 (1.01-1.03), and glycated haemoglobin A1 (HbA1c) [RR]: 1.01 (1.007-1.01) were associated with mortality. CONCLUSION: The district hospital had a high COVID-19 mortality rate among PLWH. Easy-to-access biomarkers such as CRP, neutrophilia, and HbA1c may play a significant role in informing clinical management to prevent high mortality due to COVID-19 in PLWH at the district-level hospitals.

High anti-SARS-CoV-2 seroprevalence among unvaccinated mother-child pairs from a rural setting of north-eastern Tanzania during the second wave of COVID-19.

Background: The reported infection rates, and the burden of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in low- and middle-income countries, including sub-Saharan Africa, are relatively low compared to Europe and America, partly due to limited testing capabilities. Unlike many countries, in Tanzania, neither mass screening nor restrictive measures such as lockdowns have been implemented to date. The prevalence of SARS-CoV-2 infection in rural mainland Tanzania is largely unknown. Methods: Between April and October 2021, we conducted a cross-sectional study to assess anti-SARS-CoV-2 seroprevalence among mother-child pairs (n=634 children, n=518 mothers) in a rural setting of north-eastern Tanzania. Findings: We found a very high prevalence of anti-SARS-CoV-2 antibody titres with seroprevalence rates ranging from 29% among mothers and 40% among children, with a dynamic peak in seropositivity incidence at the end of July/early in August being revealed. Significant differences in age, socioeconomic status and body composition were associated with seropositivity in mothers and children. No significant associations were observed between seropositivity and comorbidities, including anaemia, diabetes, malaria, and HIV. Interpretations: The SARS-CoV-2 transmission in a rural region of Tanzania during 2021 was high, indicating a much higher infection rate in rural Tanzania compared to that reported in the UK and USA during the same period. Ongoing immune surveillance may be vital to monitoring the burden of viral infection in rural settings without access to molecular genotyping where a load of communicable diseases may mask COVID-19. Surveillance could be implemented in tandem with the intensification of vaccination strategies.

Primary hip and knee arthroplasty at district level is safe and may reduce the burden on tertiary care in a low-income setting.

BACKGROUND: Arthroplasty procedures in low-income countries are mostly performed at tertiary centers, with waiting lists exceeding 12 to 24 months. Recently, this is further exacerbated by the impact of the Covid Pandemic on elective surgeries. Providing arthroplasty services at other levels of healthcare aims to offset this burden, however there is a marked paucity of literature regarding surgical outcomes. This study aims to provide evidence on the safety of arthroplasty at district level. METHODS: Retrospective review of consecutive hip and knee primary arthroplasty cases performed at a District Hospital (DH), and a Tertiary Academic Hospital (TH) in Cape Town, South Africa between 1st January 2015 and 31st December 2018. Patient demographics, hospital length of stay, surgery related readmissions, reoperations, post-operative complications, and mortality rates were compared between cohorts. RESULTS: Seven hundred and ninety-five primary arthroplasty surgeries were performed at TH level and 228 at DH level. The average hospital stay was 5.2 ± 2.0 days at DH level and 7.6 ± 7.1 days for TH (p < 0.05). Readmissions within 3 months post-surgery of 1.75% (4 patients) for district and 4.40% (35) for tertiary level (p < 0.05). Reoperation rate of 1 in every 100 patients at the DH and 8.3 in every 100 patients at the TH (p < 0.05). Death rate was 0.4% vs 0.6% at district and tertiary hospitals respectively (p > 0.05). Periprosthetic joint infection (PJI) rate was 0.43% at DH and 2.26% at TH. The percentage of hip dislocation requiring revision was 0% at district and 0.37% at tertiary level. During the study period, 228 patients received their arthroplasty surgery at the DH; these patients would otherwise have remained on the TH waiting list. CONCLUSIONS: Hip and Knee Arthroplasty at District health care level is safe and; for the reason that the DH feeds into the TH; providing arthroplasty at district level may help ease the pressure on arthroplasty services at tertiary care facilities in a Southern African context. Adequately trained surgeons should be encouraged to perform these procedures in district hospitals provided there is appropriate patient selection and adherence to strict theatre operating procedures. LEVEL OF EVIDENCE: Level III Retrospective cohort study.

COVID-19 and diabetic ketoacidosis: A case series at an urban district hospital in South Africa.

BACKGROUND:  Coronavirus disease 2019 (COVID-19) is associated with an increased prevalence and mortality from diabetic ketoacidosis (DKA) globally. With limited access to specialised care, most patients with DKA in South Africa are managed at district hospital level. This study describes the profile of patients admitted to a district hospital in South Africa with DKA and COVID-19 and examines associated risk factors encountered. METHODS:  This was a case series of all patients presenting to a district hospital with DKA and COVID-19 infection between July 2020 and July 2021. Data extracted included patients' demographic profiles, biochemical results, comorbidities and clinical outcomes. RESULTS:  The median age of the 10 patients admitted during the study period was 39 years old (±12), six of whom were male. The hemoglobin A1c (HbA1c) values on admission ranged from 9.7 to 13.8. Five of the patients had pre-existing type 2 diabetes mellitus (DM). Four of the known DM patients were on metformin only, and one was on biphasic insulin. Three patients had other pre-existing comorbidities, two patients with hypertension and one with human immunodeficiency virus (HIV). Three patients demised, two of whom were hypoxic on admission. CONCLUSION:  Diabetic ketoacidosis appears more commonly in COVID-19 infected patients with type 2 DM and at a young age. Suboptimal glycaemic control was associated with DKA, and hypoxia was a strong predictor for mortality. Treatment inertia was evident in the known DM group, who were on monotherapy despite persistent hyperglycaemia. Greater vigilance is required to detect ketosis in type 2 DM and intensify therapy to improve glycaemic control.

Patterns of RT-PCR Test Conversion and Implications on Time of Discharge in a District Hospital and a COVID-19 Care Centre in Pali, Rajasthan, India.

Introduction Although coronavirus disease 2019 (COVID-19) first appeared in 2019, the symptoms are similar to common viral illnesses, and if undiagnosed or there is a delay in treatment, it may prove fatal because of the virus's propensity to attack the respiratory and cardiovascular system. The antigenic conversion status of reverse transcription-polymerase chain reaction (RT-PCR) was an important criterion for discharge among the COVID-19 patients of the two hospitals in the study. Aim The aim of the study was to assess the time taken to antigenic conversion from positive to negative in RT-PCR test for COVID-19 done on patients admitted to the two hospitals where the study took place. Materials and methods A prospective cross-sectional study with repeated sampling for antigenic conversion by RT-PCR was done on 117 patients of different age groups admitted to Bangur Hospital and Agarsen Bhavan in Pali, Rajasthan, India, from April 27 to June 30, 2020. Pharyngeal and nasal swabs were analyzed by real-time RT-PCR for COVID-19 infection. The patients' first positive sample was taken as "zero sample". If the repeat sample taken on the fifth day was positive, sampling was repeated after 48 hours on consecutive days 7, 9, 11, 13, and 15 of admission till the RT-PCR test returned negative. Results Among the 117 patients, 92 (78.63%) were treated as mild, 10 (8.54%) were moderately severe, and 15 (12.82%) were very severe requiring ICU care. The median rate of conversion of RT-PCR test (positive to negative) from the day of admission was quite variable as five patients converted to negative by RT-PCR test on day seven of admission, one on day eight of admission, 26 on day nine, 30 on day 10, five on day 11, 13 on day 12, 10 on day 13, 11 on day 14, five on day 15, six on day 16, three on day 17, and one on day 18 of admission. Conclusion The study proved that follow-up of patients, prompt and comprehensive treatment, and repeated sampling ensures fast recovery with implications on time to discharge of such patients in a pandemic. The study justified and heralds the message that the inherent immunity of an individual corresponds to the time taken to conversion from positive to negative in the RT-PCR test.

A Single-Center Audit of Symptomatic Breast Cancer Patient Referrals During COVID-19 Pandemic Restrictions.

Background Recommendations to balance cancer care with patient and hospital staff safety have been issued to hospitals during the coronavirus disease (COVID-19) pandemic. Concerns have been raised that service restrictions could jeopardize effective cancer management. Thus, this study aimed to conduct an audit to verify this proposition. Methods We conducted an audit comparing two-week wait (2ww) breast cancer referrals in our center between May and July 2019 and 2020. The primary endpoints were changes in the overall referral rates, differences in the waiting time, and breast cancer diagnosis rates between the two cohorts. Group differences were evaluated using the chi-square test (χ2). A p-value of <0.05 at 95% CI was considered significant. Results The 2ww referrals decreased by 442 (28.3%) in 2020 (2019 N=1564 vs. 2020, N=1122). Referrals in 2020 were associated with a higher rate of two-week specialist consultation than referrals in 2019 (p<0.05). The 2020 patient cohort was associated with a higher rate of breast cancer diagnosis than the 2019 cohort (6.9% vs. 4.9%, p<0.05). Of the 521 patients who had telephone consultations, 29.2% were discharged, and 367 (70.4%) had post-telephone one-stop clinic visits, of which 9.0% had breast cancer. Conclusions The audit provided evidence of effective breast cancer services during the COVID-19 pandemic restrictions. The study results could inform patients and the general public at large that the waiting time and breast cancer diagnosis are not compromised during COVID-19 pandemic management. The high rates of post-telephone one-stop clinic visits and cancer diagnosis may indicate weakness in triage and difficulties in diagnosing nonspecific presentation of cancer over the telephone.

Ventilators are not the answer in Africa.

The treatment of severely ill coronavirus disease 2019 (COVID-19) patients has brought the worldwide shortage of oxygen and ventilator-related resources to public attention. Ventilators are considered as the vital equipment needed to manage these patients, who account for 3% - 5% of patients with Covid-19. Most patients need oxygen and supportive therapy. In Africa, the shortage of oxygen is even more severe and needs equipment that is simpler to use than a ventilator. Different models of generating oxygen locally at hospitals, including at provincial and district levels, are required. In some countries, hospitals have established small oxygen production plants to supply themselves and neighbouring hospitals. Oxygen concentrators have also been explored but require dependable power supply and are influenced by local factors such as ambient temperature and humidity. By attaching a reservoir tank, the effect of short power outages or high demands can be smoothed over. The local and regional energy unleashed in the citizens to respond to the COVID-19 pandemic should now be directed towards developing appropriate infrastructure for oxygen and critical care. This infrastructure is education and technology intensive, requiring investment in these areas.

Emergency centre reorganization in preparation to the COVID-19 pandemic: A district hospital's dynamic adaptation response.

The COVID-19 global pandemic forced healthcare facilities to put special isolation measures in place to limit nosocomial transmission. Cohorting is such a measure and refers to placing infected patients (or under investigation) together in a designated area. This report describes the physical reorganisation of the emergency centre at Khayelitsha Hospital, a district level hospital in Cape Town, South Africa in preparation to the COVID-19 pandemic. The preparation included the identification of a person under investigation (PUI) room, converting short stay wards into COVID-19 isolation areas, and relocating the paediatric section to an area outside the emergency centre. Finally, we had to divide the emergency centre into a respiratory and non-respiratory side by utilising part of the hospital's main reception. We are positive that the preparation and reorganization of the emergency centre will limit nosocomial transmission during the expected COVID-19 surge. Our experience in adapting to COVID-19 may have useful implications for ECs throughout South Africa and in low-and-middle income countries that are preparing for this pandemic.