Benefits of Tocilizumab in patients with a severe form of SARS-CoV-2 infection: Experience of the intensive care unit of the Mohammed VI university hospital, Oujda.

BACKGROUND: COVID-19 is a new disease that appeared in December 2019. Millions of people have been infected and died from this infection. Until today, the pathophysiology and treatment of this infection remain unknown, but a lot of studies are trying to solve the mystery. The trail of inflammation remains the most convincing, especially the Interleukin 6 (IL-6) which could play an important role in a reaction cascade leading to a cytokine storm. According to studies, although few in number, the Tociluzimab (TCZ), which is an anti-IL6, could prevent or even suppress this storm, leading to a less severe clinical state of the disease and a faster recovery. This could decrease the use of oxygen, avoid the risk of intubation and mortality. PATIENTS AND METHODS: This single-center retrospective observational case review brought together 557 COVID-19 seriously ill patients (pulmonary involvement> 25% + SatO2AA <90%) admitted to the intensive care unit of our university hospital from March 1st, 2020 to February 28th, 2021. They were divided into 2 groups a Tociluzimab group (TCZ group) and a Non Tociluzimab group (NON TCZ) to facilitate the comparison. The aim of the study was to compare the length of hospital stay, the use of mechanical ventilation and the mortality in the TCZ group versus the NON TCZ group. RESULTS: The average age of our patients was 62,05 years (±13.51) and 62.61 years (±16.33) respectively in the TCZ versus NON TCZ group. 76 (76%) were men while 24 were women (24%) in the TCZ group; and there was 313 (68.49%) men and 144 (31.51%) women in the NON TCZ group. Their average BMI was 28 kg/m2 (±4.52) in the TCZ group versus 27.89 kg/m2 (±4.73) in the NON TCZ group. Among them, the TCZ group included 38 (38%) diabetic patients, 38 hypertensive (38%), 12 heart disease (12%) and 2 chronic renal failure (2%), while the NON TCZ group regrouped 35 (7.65%) diabetics, 33 (7.22%) hypertensive, 12 heart disease (2.67%), and 5 chronic renal failure (1.09%) patients. The mean time to consultation of patients was almost similar in the two groups: 8.86 (±7,28) days for TCZ and 8.83 (±7,03) days for NON TCZ group. The mean length of ICU hospital stay was 9 days (4,94) for the TCZ group and 8,75 days (4,73) for the other one. The saturation at admission was at 74.92% (10.45) for the TCZ group ranging from 40% to 92%, and at 73,56% for the NON TCZ group. Lung damage from COVID-19 was extensive in 12%, severe in 32%, and critical in 56% of TCZ group enrolled cases. Meanwhile it was extensive in 23.63%, severe in 41,35%, and critical in 35,01% of the NON TCZ group. The biological findings found average of white blood cells at 12256/12082 e/mm3, lymphocytes at 761/842 e/mm3, CRP at 181/199 mg/L, ferritin at 1747/528 µg/L, and fibrinogen at 6.92/6.27 g/L for the TCZ group versus NON TCZ group. Medical care was based on isolation, oxygenotherapy, azithromycin, vitamin C, zinc, vitamin D, salicylic acid, dexamethasone followed with methylprednisolone, and anticoagulation for all hospitalized patients. The TCZ group received at least 1 course of Tociluzimab dosed at 400 mg (2 patients received 2 doses and 1 patient received 3 doses). The indication of a Tociluzimab course in our department was based on a set of arguments: an increase in oxygen requirements, a progression of lesions on chest-computed tomography and an increase in inflammation markers including IL-6, CRP, ferritin, fibrinogen, and a decrease in the percentage of lymphocytes. The invasive mechanical ventilation was indicated for 4 (4%) patients in the TCZ group versus 192 (42,01%) in the NON TCZ. Among the 100 patients included in our cohort in the TCZ group, 40% died in intensive care unit and 60% had a favorable evolution with a decrease of the biological markers of inflammation. However, in the NON TCZ group, 197 (43,10%) passed away. CONCLUSION: The use of Tociluzimab in ICU patients with severe COVID-19 pneumonia did not contribute to a significant difference in the reduction of hospital stay. However, the invasive mechanical ventilation was less needed in patients receiving Tociluzimab than the others. Moreover, there was a mortality benefit associated with the use of Tociluzimab, but only before 10 days of hospitalization.

Using the RE-AIM framework to evaluate the implementation of integrated community case management in Kenya.

AIM: To evaluate an integrated community case management programme for sick children aged 2 to 59 months in western Kenya using the Research, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework. METHODS: This was a prospective observational research project conducted between December 2013 and February 2016. Outcome variables were measured before, during and at end of implementation using a series of surveys as well as by looking at routine service statistics. RESULTS: A total of 2604 community health workers were trained in 245 community units. The average post-training knowledge level (73.5%) and retention rates (89.7) of trained community health workers was high. At the end of study, there was an increase in the proportion of children who received appropriate treatment for diarrhoea (49.2%), pneumonia (19.5%), malaria (16.4%) and vitamin A (51.5%) from baseline. Community health workers were able to assess, classify and treat sick children with a similar quality as that provided by facility-based healthcare workers (>85% concordance). CONCLUSION: Based on the RE-AIM metrics, our results demonstrate promising practical approaches and outcomes of a large-scale implementation of integrated community case management in western Kenya. The findings have important implications for future design and expansion of the programme in Kenya.

Community case management of lower chest indrawing pneumonia with oral amoxicillin in children in Kenya.

AIM: To determine the accuracy and effectiveness of community health workers (CHWs) when compared to trained nurses for management of pneumonia in Kenyan children. METHODS: In Homabay County in western Kenya, children 2-59 months of age with lower chest indrawing pneumonia were identified, classified and treated by CHWs with oral amoxicillin (90 mg/kg per day) for five days at home. Trained nurses visited the child within 24 hours to verify diagnosis; and on day 4 and 14 to assess treatment outcomes. RESULTS: CHWs identified 1906 children with lower chest indrawing pneumonia. There was an 88.7% concordance in classification and treatment for lower chest indrawing pneumonia by CHWs compared to nurses. Children with moderate malnutrition (OR 1.68; 95% CI: 1.22-2.30), comorbidities such as diarrhoea or malaria (OR 1.55; 95% CI: 1.32-1.81) or an additional day of delay in care seeking (OR 1.06; 95% CI: 1.02-1.10) were more likely to have an incorrect classification of lower chest indrawing by the CHW. Comorbidity (OR 1.66; 95% CI: 1.12-2.48) and fast breathing (OR 4.66; 95% CI: 1.26-17.27) were significantly associated with treatment failure on day 14. CONCLUSION: CHWs can correctly manage lower chest indrawing pneumonia even in high-mortality settings, such as western Kenya, in sub-Saharan Africa.

Perceived Quality of Care of Community Health Worker and Facility-Based Health Worker Management of Pneumonia in Children Under 5 Years in Western Kenya: A Cross-Sectional Multidimensional Study.

Integrated community case management (iCCM) programs that train lay community health workers (CHWs) in the diagnosis and treatment of diarrhea, malaria, and pneumonia have been increasingly adopted throughout sub-Saharan Africa to provide services in areas where accessibility to formal public sector health services is low. One important aspect of successful iCCM programs is the acceptability and utilization of services provided by CHWs. To understand community perceptions of the quality of care in an iCCM intervention in western Kenya, we used the Primary Care Assessment Survey to compare caregiver attitudes about the diagnosis and treatment of childhood pneumonia as provided by CHWs and facility-based health workers (FBHWs). Overall, caregivers rated CHWs more highly than FBHWs across a set of 10 domains that capture multiple dimensions of the care process. Caregivers perceived CHWs to provide higher quality care in terms of accessibility and patient relationship and equal quality care on clinical aspects. These results argue for the continued implementation and scale-up of iCCM programs as an acceptable intervention for increasing access to treatment of childhood pneumonia.