EUS-guided coil and glue injection versus endoscopic glue injection for gastric varices: International multicentre propensity-matched analysis.

BACKGROUND: Gastric varices (GVs) are conventionally managed with endoscopic cyanoacrylate (E-CYA) glue injection. Endoscopic ultrasound (EUS)-guided therapy using combination of coils and CYA glue (EUS-CG) is a relatively recent modality. There is limited data comparing the two techniques. METHODOLOGY: This international multicentre study included patients with GV undergoing endotherapy from two Indian and two Italian tertiary care centres. Patients undergoing EUS-CG were compared with propensity-matched E-CYA cases from a cohort of 218 patients. Procedural details such as amount of glue, number of coils used, number of sessions required for obliteration, bleeding after index procedure rates and need for re-intervention were noted. RESULTS: Of 276 patients, 58 (male 42, 72.4%; mean age-44.3 ± 12.1 years) underwent EUS-CG and were compared with 118 propensity-matched cases of E-CYA. In the EUS-CG arm, complete obliteration at 4 weeks was noted in 54 (93.1%) cases. Compared to the E-CYA cohort, EUS-CG arm showed significantly lower number of session (1.0 vs. 1.5; p < 0.0001) requirement, lower subsequent-bleeding episodes (13.8% vs. 39.1%; p < 0.0001) and lower re-intervention (12.1% vs. 50.4%; p < 0.001) rates. On multivariable regression analysis, size of the varix (aOR-1.17; CI 1.08-1.26) and technique of therapy (aOR-14.71; CI 4.32-50.0) were significant predictors of re-bleeding. A maximum GV size >17.5 mm had a 69% predictive accuracy for need for re-intervention. CONCLUSION: Endoscopic ultrasound-guided therapy of GV using coil and CYA glue is a safe technique with better efficacy and lower re-bleeding rates on follow-up compared to the conventional endoscopic CYA therapy.

Infection prevention and control for COVID-19 response in the Rohingya refugee camps in Bangladesh: an intra-action review.

BACKGROUND: Infection Prevention and Control (IPC) is critical in controlling the COVID-19 pandemic and is one of the pillars of the WHO COVID-19 Strategic Preparedness and Response Plan 2020. We conducted an Intra-Action Review (IAR) of IPC response efforts to the COVID-19 pandemic in Cox's Bazar, Bangladesh, to identify best practices, challenges, and recommendations for improvement of the current and future responses. METHODS: We conducted two meetings with 54 participants purposively selected from different organizations and agencies involved in the frontline implementation of IPC in Cox's Bazar district, Bangladesh. We used the IPC trigger questions from the WHO country COVID-19 IAR: trigger question database to guide the discussions. Meeting notes and transcripts were then analyzed manually using content analysis, and results were presented in text and quotes. RESULTS: Best practices included: assessments, a response plan, a working group, trainings, early case identification and isolation, hand hygiene in Health Facilities (HFs), monitoring and feedback, general masking in HFs, supportive supervision, design, infrastructure and environmental controls in Severe Acute Respiratory Infection Isolation and Treatment Centers (SARI ITCs) and HFs and waste management. Challenges included: frequent breakdown of incinerators, limited PPE supply, inconsistent adherence to IPC, lack of availability of uniforms for health workers, in particular cultural and gender appropriate uniforms and Personal Protective Equipment (PPE). Recommendations from the IAR were: (1) to promote the institutionalization of IPC, programs in HFs (2) establishment of IPC monitoring mechanisms in all HCFs, (3) strengthening IPC education and training in health care facilities, and (4) strengthen public health and social measures in communities. CONCLUSION: Establishing IPC programmes that include monitoring and continuous training are critical in promoting consistent and adaptive IPC practices. Response to a pandemic crisis combined with concurrent emergencies, such as protracted displacement of populations with many diverse actors, can only be successful with highly coordinated planning, leadership, resource mobilization, and close supervision.

Training nurse simulation educators at scale to improve maternal and newborn health: a case study from Bihar, India.

BACKGROUND: Simulation has been shown to improve clinical and behavioral skills of birth attendants in low-resource settings at a low scale. Populous, low-resource settings such as Bihar, India, require large cadres of simulation educators to improve maternal and newborn health. It's unknown if simulation facilitation skills can be adopted through a train of trainers' cascade. To fill this gap, we designed a study to evaluate the simulation and debrief knowledge, attitudes and skills of a third generation of 701 simulation educators in Bihar, India. In addition, we assessed the physical infrastructure where simulation takes place in 40 primary healthcare facilities in Bihar, India. METHODS: We performed a 1 year before-after intervention study to assess the simulation facilitation strengths and weaknesses of a cadre of 701 nurses in Bihar, India. The data included 701 pre-post knowledge and attitudes self-assessments; videos of simulations and associated debriefs conducted by 701 providers at 40 primary healthcare centers. RESULTS: We observed a statistically significant difference in knowledge and attitude scores before and after the 4-day PRONTO simulation educator training. The average number of participants in a simulation video was 5 participants (range 3-8). The average length of simulation videos was 10:21 minutes. The simulation educators under study, covered behavioral in 90% of debriefs and cognitive objectives were discussed in all debriefs. CONCLUSION: This is the first study assessing the simulation and debrief facilitation knowledge and skills of a cadre of 701 nurses in a low-resource setting. Simulation was implemented by local nurses at 353 primary healthcare centers in Bihar, India. Primary healthcare centers have the physical infrastructure to conduct simulation training. Some simulation skills such as communication via whiteboard were widely adopted. Advanced skills such as eliciting constructive feedback without judgment require practice.

Providing HIV-related services in China for men who have sex with men.

PROBLEM: In China, human immunodeficiency virus (HIV) care provided by community-based organizations and the public sector are not well integrated. APPROACH: A community-based organization and experts from the Guangzhou Center for Disease Control and Prevention developed internet-based services for men who have sex with men, in Guangzhou, China. The internet services were linked to clinical services offering HIV testing and care. LOCAL SETTING: The expanding HIV epidemic among men who have sex with men is a public health problem in China. HIV control and prevention measures are implemented primarily through the public system. Only a limited number of community organizations are involved in providing HIV services. RELEVANT CHANGES: The programme integrated community and public sector HIV services including health education, online HIV risk assessment, on-site HIV counselling and testing, partner notification, psychosocial care and support, counting of CD4+ T-lymphocytes and treatment guidance. LESSONS LEARNT: The internet can facilitate HIV prevention among a subset of men who have sex with men by enhancing awareness, service uptake, retention in care and adherence to treatment. Collaboration between the public sector and the community group promoted acceptance by the target population. Task sharing by community groups can increase access of this high-risk group to available HIV-related services.

Simulation and nurse-mentoring in a statewide nurse mentoring program in Bihar, India: diagnosis of postpartum hemorrhage and intrapartum asphyxia.

Background: Mentoring programs that include simulation, bedside mentoring, and didactic components are becoming increasingly popular to improve quality. These programs are designed with little evidence to inform the optimal composition of mentoring activities that would yield the greatest impact on provider skills and patient outcomes. We examined the association of number of maternal and neonatal emergency simulations performed with the diagnosis of postpartum hemorrhage (PPH) and intrapartum asphyxia in real patients. Methods: We used a prospective cohort and births were compared between- and within-facility over time. Setting included 320 public facilities in the state of Bihar, India May 2015 - 2017. The participants were deliveries and livebirths. The interventions carried out were mobile nurse-mentoring program with simulations, teamwork and communication activities, didactic teaching, demonstrations of clinical procedures and bedside mentoring including conducting deliveries. Nurse mentor pairs visited each facility for one week, covering four facilities over a four-week period, for seven to nine consecutive months. The outcome measures were diagnosis of PPH and intrapartum asphyxia. Results:Relative to the bottom one-third facilities that performed the fewest maternal simulations, facilities in the middle one-third group diagnosed 26% (incidence rate ratio [IRR] = 1.26, 95% confidence interval [CI]: 1.00, 1.59) more cases of PPH in real patients. Similarly, facilities in the middle one-third group, diagnosed 25% (IRR = 1.25, 95% CI: 1.04, 1.50) more cases of intrapartum asphyxia relative to the bottom third group that did the fewest neonatal simulations. Facilities in the top one-third group (i.e., performed the most simulations) did not have a significant difference in diagnosis of both outcomes, relative to the bottom one-third group. Results:Relative to the bottom one-third facilities that performed the fewest maternal simulations, facilities in the middle one-third group diagnosed 26% (incidence rate ratio [IRR] = 1.26, 95% confidence interval [CI]: 1.00, 1.59) more cases of PPH in real patients. Similarly, facilities in the middle one-third group, diagnosed 25% (IRR = 1.25, 95% CI: 1.04, 1.50) more cases of intrapartum asphyxia relative to the bottom third group that did the fewest neonatal simulations. Facilities in the top one-third group (i.e., performed the most simulations) did not have a significant difference in diagnosis of both outcomes, relative to the bottom one-third group. Conclusions: Findings suggest a complex relationship between performing simulations and opportunities for direct practice with patients, and there may be an optimal balance in performing the two that would maximize diagnosis of PPH and intrapartum asphyxia.

Increases in diagnosis and management of obstetric and neonatal complications in district hospitals during a high intensity nurse-mentoring program in Bihar, India.

Maternal and neonatal mortality in Bihar, India was far higher than the aspirational levels set out by the Sustainable Development Goals. Provider training programs have been implemented in many low-resource settings to improve obstetric and neonatal outcomes. This longitudinal investigation assessed diagnoses and management of postpartum hemorrhage (PPH), hypertensive disorders of pregnancy, birth asphyxia (BA), and low birth weight (LBW), as part of the CARE's AMANAT program in 22 District Hospitals in Bihar, between 2015 and 2017. Physicians and nurse mentors conducted clinical instruction, simulations and teamwork and communication activities, infrastructure and management support, and data collection for 6 consecutive months. Analysis of diagnosis included 11,259 non-referred and management included 11,800 total (non-referred and referred) admissions that were observed. Data were analyzed using the chi-square test for trend. PPH was diagnosed in 3.7% with no significant trend but diagnosis of hypertensive disorders increased from 1.0% to 1.7%, (ptrend = 0.04), over the 6 months. BA was diagnosed in 5.8% with no significant trend but LBW diagnoses increased from 11% to 16% (ptrend<0.01). Among PPH patients, 96% received fluids, 85% received uterotonics and 11% received Tranexamic Acid (TXA). There was a significant positive trend in the number of patients receiving TXA for PPH (6% to 13.8%, ptrend = 0.03). Of all neonates with BA, there were statistically significant increases in the proportion who were initially warmed, dried, and stimulated (78% to 94%, ptrend = 0.02), received airway suction (80% to 93%, ptrend = 0.03), and supplemental oxygen without positive pressure ventilation (73% to 86%, ptrend = 0.05). Diagnoses of hypertensive disorders and LBW as well as initial management of BA increased during the AMANAT program. However, underdiagnoses of PPH and hypertensive disorders relative to population levels remain critical barriers to improving maternal morbidity and mortality.

Using a mobile nurse mentoring and training program to address a health workforce capacity crisis in Bihar, India: Impact on essential intrapartum and newborn care practices.

BACKGROUND: To address a health workforce capacity crisis, in coordination with the Government of Bihar, CARE India implemented an on-the-job, on-site nurse mentoring and training intervention named - Apatkalin Matritva evam Navjat Tatparta (AMANAT, translated Emergency Maternal and Neonatal Care Preparedness) - in public facilities in Bihar. AMANAT was rolled-out in a phased manner to provide hands-on training and mentoring for nurses and doctors offering emergency obstetric and newborn care (EmONC) services. This study examines the impact of the AMANAT intervention on nurse-mentees' competency to provide such services in Bihar, India during 2015-2017. METHODS: We used data from three AMANAT implementation phases, each covering 80 public facilities offering basic EmONC services. Before and after the intervention, CARE India administered knowledge assessments to nurse-mentees; ascertained infection control practices at the facility level; and used direct observation of deliveries to assess nurse-mentees' practices. We examined changes in nurse-mentees' knowledge scores using χ2 tests for proportions and t tests for means; and estimated proportions and corresponding 95% confidence intervals for routine performance of infection control measures, essential intrapartum and newborn services. We fitted linear regression models to explore the impact of the intervention on nurse-mentees' knowledge and practices after adjusting for potential confounders. RESULTS: On average, nurse-mentees answered correctly 38% of questions at baseline and 68% of questions at endline (P < 0.001). All nine infection control measures assessed were significantly more prevalent at endline (range 28.8%-86.8%) than baseline. We documented statistically significant improvements in 18 of 22 intrapartum and 9 of 13 newborn care practices (P < 0.05). After controlling for potential confounders, we found that the AMANAT intervention led to significant improvements in nurse-mentees' knowledge (30.1%), facility-level infection control (30.8%), intrapartum (29.4%) and newborn management (24.2%) practices (all P < 0.05). Endline scores ranged between 56.8% and 72.8% of maximum scores for all outcomes. CONCLUSION: The AMANAT intervention had significant results in a health workforce capacity crisis situation, when a large number of auxiliary nurse-midwives were expected to provide services for which they lacked the necessary skills. Gaps in intrapartum and newborn care knowledge and practice still exist in Bihar and should be addressed through future mentoring and training interventions. STUDY REGISTRATION: ClinicalTrials.gov number NCT02726230.

Simulation and team training embedded nurse mentoring programme and improvement in intrapartum and newborn care in a low-resource setting in Bihar, India.

BACKGROUND: Improvement of the quality of maternal and child health care remains a focus in India. Working with the Government of Bihar, CARE-India facilitated a comprehensive set of quality of care improvement initiatives. PRONTO's simulation and team-training was incorporated into the large-scale Apatkaleen Matritva evam Navjat Tatparta (AMANAT)nurse-mentoring program of the Government of Bihar supported by CARE-India to improve maternal and child health outcomes. Along-with the AMANAT program, the PRONTO components provided training on nontechnical and technical competencies for managing a variety of obstetric and neonatal conditions, as a team. This study assessed the effectiveness of nurse-mentoring including simulations on intrapartum and newborn care practices in 320 basic emergency obstetric and neonatal care (BEmONC) facilities. METHODS: Deliveries were observed to obtain specific information on evidence-based practice (EBP) indicators before and after the intervention. Intrapartum and newborn care composite scores - were calculated using those EBP indicators. A web-based routine monitoring system provided total training days, weeks and days/week of training and counts of simulation and teamwork-communication activities. Multilevel linear regression was used to examine the exposure-outcome associations. RESULTS: The final analysis included 668 normal spontaneous vaginal deliveries (NSVDs) from 289 public health facilities in Bihar. Facility-level intrapartum and newborn scores improved by 37 and 26-percentage points, respectively, from baseline to endline. Compared to the bottom one-third facilities that performed fewest NSVD simulations, the top one-third had 6 (95% confidence interval (CI) = 1-12) percentage points higher intrapartum score. Similar comparison using maternal complication simulations yielded 7 (95% CI = 1-12) percentage point higher scores. The highest newborn scores were observed in the middle one-third of facilities relative to the bottom one-third that did the fewest NSVD simulations (5, 95% CI: 1-10). CONCLUSIONS: Findings suggest significant overall improvement in intrapartum and newborn care practices after the AMANAT nurse-mentoring program in public sector BEmONC facilities. Simulation and team-training likely contributed towards the overall improvement, especially for intrapartum care. STUDY REGISTRATION: ClinicalTrials.gov number NCT02726230.

Synthesizing evidences for policy translation: a public health discourse on rotavirus vaccine in India.

The debate on the relevance of rotavirus vaccine to immunization program in India, where 27 million children are born every year, rages on. We synthesized the issues raised during these debates and reviewed the current literature to identify themes that could inform public health policy decision. The paradigm we used integrated disease burden data, host and environmental factors, vaccine efficacy, immunization program issues, and economic considerations. Our synthesis reveals that substantive country specific information on disease burden and economic impact of rotavirus illness in India is constrained by lack of public discussion and qualitative studies on mothers' perceptions of the vaccine in concern. The need to improve the performance of current immunization program against six major vaccine preventable diseases (tuberculosis, diphtheria, tetanus, pertussis, polio, and measles) is often cited as a priority over introduction of rotavirus vaccine. Health in India being a state subject, we emphasize that the states which are in a position to reap the benefit of rotavirus vaccine, due to their good immunization program performance, should not be restrained from doing so. Meanwhile, the poorly performing states should step up their vaccination program and increase immunization coverage. Scientific, ethical and societal concerns captured through multiple sources indicate that the introduction of rotavirus vaccine would be a good investment for India.