Perinatal transmission of SARS-CoV-2 and transfer of maternal IgG/neutralizing anti-SARS-CoV-2 antibodies from mothers with asymptomatic infection during pregnancy.

PURPOSE: COVID-19 pandemic remains a serious public health threat worldwide. In view of the limited data on the risk of perinatal transmission of SARS-CoV-2 and transfer of maternal anti-SARS-CoV-2 antibodies, the present study was undertaken. METHODS: A prospective study including 57 pregnant women with a positive SARS-CoV-2 RNA test (SARS-CoV-2-RNA+) and 59 neonates born to them was conducted at Pune, India. 39 viral RNA negative (SARS-CoV-2-RNA-negative) pregnant women and their 39 neonates were included as controls. Neonatal nasal swab/cord blood samples were subjected to SARS-CoV-2 RNA detection by RT-PCR for investigation of perinatal transmission. Transfer of maternal antibodies was studied using ELISA and PRNT. RESULTS: 10/57 SARS-CoV-2-RNA+ mothers were symptomatic. The duration between COVID-19 diagnosis and delivery was ≤ 7 days for 82.4%. Perinatal transmission as evidenced by viral RNA in the neonatal nasal swab/cord blood (CB) was 3.6%. IgG-anti-SARS-CoV-2 positivity was 21.6%. Of the 39 neonates born to SARS-CoV-2-RNA-negative mothers, 20 (51%) and none, respectively, were positive for IgG-anti-SARS-CoV-2 and viral RNA. Preterm deliveries were higher in SARS-CoV-2-RNA+ (18.6%) than SARS-CoV-2 RNA-negative (0/39) mothers (p < 0.005). Respiratory distress at birth (< 4 h) was higher among neonates of SARS-CoV-2-RNA+ (20/59, 33.9%) than SARS-CoV-2-RNA-negative mothers (3/39, 7.7%; p < 0.001). ~ 75% IgG-positives exhibited neutralization potential with mean PRNT titers of 42.4 ± 24 (SARS-CoV-2-RNA+) and 72.3 ± 46.7 (SARS-CoV-2 RNA-negative); higher in the latter (p < 0.05). CONCLUSION: The rate of perinatal transmission was low. Transfer of maternal antibodies was lower among SARS-CoV-2-RNA+ mothers than SARS-CoV-2-RNA-negative mothers with subclinical infection during pregnancy. Presence of neutralizing antibodies in majority of IgG-positives suggests protection from SARS-CoV-2 in early life.

Quality improvement initiative 'S-A-F-H' to reduce healthcare-associated neonatal sepsis in a tertiary neonatal care unit.

BACKGROUND: Neonatal sepsis is a leading cause of morbidity and mortality among admitted neonates. Healthcare-associated infection (HAI) is a significant contributor in this cohort. LOCAL PROBLEM: In our unit, 16.1% of the admissions developed sepsis during their stay in the unit. METHOD: We formed a team of all stakeholders to address the issue. The problem was analysed using various tools, and the main contributing factor was low compliance with hand hygiene and handling of intravenous lines. INTERVENTIONS: The scrub the hub/aseptic non-touch technique/five moments of hand hygiene/hand hygiene (S-A-F-H) protocol was formulated as a quality improvement initiative, and various interventions were done to ensure compliance with hand hygiene, five moments of hand hygiene, aseptic non-touch technique. The data were collected and analysed regularly with the team members, and actions were planned accordingly. RESULTS: Over a few months, the team could reduce the incidence of HAI by 50%, which has been sustained for over a year. The improvement in compliance with the various aspects of S-A-F-H increased. CONCLUSIONS: Compliance with hand hygiene steps, five moments of hand hygiene and an aseptic non-touch technique using quality improvement methodology led to a reduction in neonatal sepsis incidence in the unit. Regular reinforcement is required to maintain awareness of asepsis practices and implementation in day-to-day care and to bring about behavioural changes.

Propranolol for infantile hemangioma (PINCH): an open-label trial to assess the efficacy of propranolol for treating infantile hemangiomas and for determining the decline in heart rate to predict response to propranolol.

BACKGROUND: Propranolol has emerged as front-line therapy for infantile hemangiomas (IHs). However, a well-defined protocol for administering and predicting response to propranolol is unavailable. METHODS: In this open-label trial, 31 children with IH (median age=5 mo; range,1 mo to 9 y) were administered propranolol (2 mg/kg/d) for a median duration of 28 weeks (12 to 50 wk). They were compared with 14 historical controls with IH who did not receive any treatment. An image-based scoring system was used to assess involution. RESULTS: Propranolol (28/31, 90.3%) produced better and faster response compared with control treatment (4/14, 28.6%). With propranolol, 65% to 80% involution was obtained in the first 8 weeks, with an additional 2% to 10% involution until 20 weeks. After 20 weeks, the changes in IH were insignificant. Response was more pronounced among infants ≤6 months of age who attained a peak involution score of 1.86, suggesting >80% involution of IH. The similar score in the cohort aged 6 to 36 months was 3.31. The heart rate (HR) decline after propranolol treatment was significantly higher among patients whose hemangioma responded to propranolol than in those who did not respond (P=0.0006). Decline in HR by >20%, 2 weeks after propranolol administration, was predictive of IH involution (relative risk=0.11; 95% confidence interval, 0.02-0.51; P=0.036). CONCLUSIONS: Propranolol is efficacious in patients with IH. The most pronounced response is seen in the first 8 weeks and in infants aged 6 months or younger. A decline in HR >20% is an early marker of response to propranolol.

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.

Improving donor human milk collection in a hospital without a human milk bank: a quality improvement initiative at an urban tertiary-care teaching hospital.

Feed intolerance and necrotising enterocolitis (NEC) are challenges while treating sick neonates. These can be reduced by giving human milk, but adequate availability of mother's own milk or pasteurised donor human milk (PDHM) is a challenge in neonatal setups, like ours, without an attached human milk bank. Hence, this quality improvement initiative was taken to improve donor human milk collection in our urban tertiary-care teaching hospital, to at least 500 mL per week in 4 weeks. After analysing the problem, our quality improvement team identified a shortage of human milk donation that was due to low awareness among the stakeholders and lack of a system to collect and store human milk and transport it to a milk bank. The team first established a system of supplies needed for milk collection, storage and transportation. It then tested change idea of information, education and counselling to increase milk donation. The team carried out a few plan-do-study-act cycles (individual and group counsellings, and usage of videos and information leaflets) to test the change ideas and adapted a few and abandoned some. During this journey, the milk collection increased to above the target amount. Various challenges were addressed, and there was a need for constant motivation of the stakeholders, especially the mothers, and now there is sustained milk donation in the setup. This is incorporated in the standard operating procedure and as a quality indicator of the unit for sustaining the changes in the unit. Our initiative can be replicated in other setups for increasing collection of donor human milk. Greater PDHM availability for sick neonates will, in effect, reduce NEC and feeding intolerance rates, leading to reduced hospital stay, morbidity, mortality and economic burden.

Development of a framework of intervention strategies for point of care quality improvement at different levels of healthcare delivery system in India: initial lessons.

BACKGROUND: Inadequate quality of care has been identified as one of the most significant challenges to achieving universal health coverage in low-income and middle-income countries. To address this WHO-SEARO, the point of care quality improvement (POCQI) method has been developed. This paper describes developing a dynamic framework for the implementation of POCQI across India from 2015 to 2020. METHODS: A total of 10 intervention strategies were designed as per the needs of the local health settings. These strategies were implemented across 10 states of India, using a modification of the 'translating research in practice' framework. Healthcare professionals and administrators were trained in POCQI using a combination of onsite and online training methods followed by coaching and mentoring support. The implementation strategy changed to a fully digital community of practice platform during the active phase of the COVID-19 pandemic. Dashboard process, outcome indicators and crude cost of implementation were collected and analysed across the implementation sites. RESULTS: Three implementation frameworks were evolved over the study period. The combined population benefitting from these interventions was 103 million. A pool of QI teams from 131 facilities successfully undertook 165 QI projects supported by a pool of 240 mentors over the study period. A total of 21 QI resources and 6 publications in peer-reviewed journals were also developed. The average cost of implementing POCQI initiatives for a target population of one million was US$ 3219. A total of 100 online activities were conducted over 6 months by the digital community of practice. The framework has recently extended digitally across the South-East Asian region. CONCLUSION: The development of an implementation framework for POCQI is an essential requirement for the initiative's successful country-wide scale. The implementation plan should be flexible to the healthcare system's needs, target population and the implementing agency's capacity and amenable to multiple iterative changes.

Establishment of nomograms and reference ranges for intra-cranial ventricular dimensions and ventriculo-hemispheric ratio in newborns by ultrasonography.

AIM: To establish normal ranges for the lateral, third, and fourth ventricular dimensions and the ventriculo-hemispheric ratio (VHR) in neonates using cranial ultrasonography. METHOD: Intra-cranial ventricles were assessed ultrasonographically using anterior fontanelle as acoustic window. Data were analyzed to determine correlation, coefficient of determination (R2), regression equations and plotted against gestational age (GA). RESULTS: Of total 1483 neonates (25-42 w GA), 372(25%) had GA < 34 weeks. GA strongly correlated with anterior horn width (AHW; 0.92), thalamo-occipital distance (TOD; 0.94), and third (0.78) and fourth (0.89) ventricular widths. The R2 values were 0.85, 0.88, 0.66 and 0.80, respectively. VHR had weak correlation (0.12, R(2)= 0.005) with GA and stayed constant (0.27-0.28) across GA. Nomograms of AHW, TOD, and third and fourth ventricular widths were constructed with respect to GA. CONCLUSION: Intra-cranial ventricles increase in size with GA but this increase is limited to only a few mm and is proportional to increment in brain tissue. Nomograms and regression equations of AHW, TOD and widths of third and fourth ventricles can assist in objectively assessing ventricular sizes. The almost uniform VHR can be used to screen ventricle size while suspecting hydrocephalus.