Creating and sustaining a digital community of practice for quality improvement in South-East Asia during the COVID-19 pandemic.

INTRODUCTION: Ensuring quality of care in Low and Middle Income countries (LMICs) is challenging. Despite the implementation of various quality improvement (QI) initiatives in public and private sectors, the sustenance of improvements continues to be a major challenge. A team of healthcare professionals in India developed a digital community of practice (dCoP) focusing on QI which now has global footprints. METHODOLOGY: The dCoP was conceptualised as a multitiered structure and is operational online at www.nqocncop.org from August 2020 onwards. The platform hosts various activities related to the quality of care, including the development of new products, and involves different cadres of healthcare professionals from primary to tertiary care settings. The platform uses tracking indicators, including the cost of sustaining the dCoP to monitor the performance of the dCoP. RESULT: Since its launch in 2020, dCoP has conducted over 130 activities using 13 tools with 25 940 registration and 13 681 participants. From April 2021, it has expanded to countries across the South-East Asia region and currently has participants from 53 countries across five continents. It has developed 20 products in four thematic areas for a targeted audience. dCoP is supporting mentoring of healthcare professionals from five countries in the South-East Asia region in their improvement journey. Acquiring new knowledge and improvement in their daily clinical practice has been reported by 93% and 80% of participants, respectively. The dCoP and its partners have facilitated the publication of nearly 40 articles in international journals. CONCLUSION: This dCoP platform has become a repository of knowledge for healthcare professionals in the South-East Asia region. The current paper summarises the journey of this innovative dCoP in an LMIC setting for a wider global audience.

Improved immune response from biodegradable polymer particles entrapping tetanus toxoid by use of different immunization protocol and adjuvants.

Poly lactide-co-glycolide (PLGA) and polylactide (PLA) particles entrapping immunoreactive tetanus toxoid (TT) were prepared using the solvent evaporation method. The effect of different formulation parameters such as polymer hydrophobicity, particle size and use of additional adjuvants on the generation of immune responses in experimental animals was evaluated. Immune responses from hydrophobic polymer particles were better than those from hydrophilic polymer. Immunization with physical mixtures of different size particles resulted in further improvement in anti-TT antibody titers in Wistar rats. Physical mixture of nano and microparticles resulted in early as well as high antibody titers in experimental animals. Immunization with polymer particles encapsulating stabilized TT elicited anti-TT antibody titers, which persisted for more than 5 months and were higher than those obtained with saline TT. However, antibody responses generated by single point immunization of either particles or physical mixture of particles were lower than the conventional two doses of alum-adsorbed TT. Immunization with nanoparticles along with alum resulted in very high and early immune response: high anti-TT antibody titers were detected as early as 15 days post-immunization. Use of a squalene emulsion along with the particles during immunization enhanced the level of anti-TT antibody titers considerably. Single point immunization with admixtures of PLA microparticles and alum resulted in antibody response very close to that achieved by two injections of alum-adsorbed TT; the antibody titers were more than 50 microg/ml over a period of 6 months. These results indicated that the judicious choice of polymer and particles size, protecting the immunoreactivity of the entrapped antigen and the appropriate design of immunization protocol along with suitable adjuvant can lead to the generation of long lasting immune response from single dose vaccine formulation using polymer particles.

Potentiation of immune response from polymer-entrapped antigen: toward development of single dose tetanus toxoid vaccine.

Poly(lactide) (PLA) polymer particles entrapping immunoreactive tetanus toxoid (TT) were used for generation of immune response using single point immunization. Immunization with different sizes of polymer particles encapsulating immunoreactive TT elicited anti-TT antibody titers that persisted for more than 5 months. However, antibody response generated by single point immunization of either nanoparticles or microparticles were lower than the conventional two doses of alum adsorbed TT. To overcome this limitation, alum was used with particles that improved anti-TT antibody response. Immunization with nanoparticles along with alum resulted in very high and early immune response: high anti-TT antibody titers were detected as early as 15 days postimmunization. However anti-TT antibody titers declined rapidly with time. Immunization with admixture of microparticles and alum elicited higher antibody titers than the particles alone and the antibody titers were high particularly during the later part of the postimmunization period. Single point immunization with admixture of PLA microparticles and alum resulted in an antibody response very close to that achieved by two injection of alum-adsorbed TT. Physical mixture of both a nano- and microparticles along with alum resulted in sustained anti-TT antibody response from very early days of postimmunization until 150 days. The antibody titers were maintained around 50 microg/ml for more than 5 months. These results indicated that immune response from polymer particles can be further improved by use of additional adjuvant. Furthermore, using various size particles or physical mixture of different size particles along with alum, it is possible to modulate the kinetics of immune response using polymer particles based immunization.