Challenges in the Implementation of Human Papillomavirus Self-Sampling for Cervical Cancer Screening in India: A Systematic Review.

PURPOSE: In the light of WHO's call for elimination of cervical cancer, primary human papillomavirus (HPV) screening through self-collection is a powerful tool that can improve screening coverage. Challenges encountered during implementation of the program are unique to each country. We conducted this systematic review to list the challenges in implementing primary HPV screening through self-sampling in Indian context. METHODS: A literature search was performed in PubMed, Embase, and Google Scholar since their inception till July 2022 for peer-reviewed articles published in the English. Non-Indian studies and those which did not mention implementation challenges were excluded. Articles were screened and reviewed independently by two authors. The results were discussed using a narrative synthesis. RESULTS: All the eight original articles included in the review were of cross-sectional design. The challenges identified in these studies were grouped into beneficiary, health care provider, and health system perspectives. Beneficiary-related issues outnumbered other challenges in all the studies which included misconceptions and fear, lack of motivation, low self-efficacy in collection leading to poor sample quality, low socioeconomic status leading to lack of privacy, and refusal for screening and further treatment. CONCLUSION: This review highlights the challenges for the implementation of HPV self-sampling in India. Future programs should incorporate context-specific solutions for the success of primary HPV screening and cervical cancer elimination.

Feasibility of Training Community Health Workers in the Detection of Oral Cancer.

Importance: Visual screening for oral cancer has been found to be useful in a large randomized clinical trial in Kerala, India, showing substantial reduction in mortality. To address the shortage of medical personnel in resource-deficient regions, using the services of community health workers has been proposed as a strategy to fill the gap in human resources in health care. Objective: To assess the feasibility of community health workers in screening and early detection of oral cancer using a mobile application capturing system. Design, Setting, and Participants: A cross-sectional study using a household sample was conducted in 10 areas of Gautam Budhnagar district, Uttar Pradesh, India, from January 31, 2020, to March 31, 2021, to assess the feasibility of identification of oral lesions by community health workers using a mobile phone application compared with diagnosis by trained dentists in a screening clinic. Men and women aged 30 years or older as well as tobacco users younger than 30 years were eligible for screening. Interventions: Screening by trained community health workers vs dentists. Results: A total of 1200 participants were screened by the community health workers during their home visits; of these, 1018 participants (526 [51.7%] men; mean [SD] age, 35 [16] years) were also referred and screened by the dentists a clinic. There was near-perfect agreement (κ = 0.9) between the findings of the community health workers and the dentists in identifying the positive or negative cases with overall sensitivity of 96.69% (95% CI, 94.15%-98.33%) and specificity of identification of 98.69% (95% CI, 97.52%-99.40%). Conclusions and Relevance: In this cross-sectional study, trained community health workers were able after initial supervision by qualified dentists to perform oral cancer screening programs. These findings suggest that community health workers can perform this screening in resource-constrained settings.

Advanced virtual mentoring of dentists in oral cancer screening and tobacco cessation - An interventional study.

Context: Oral cancer is the third common cancer in India. Its mortality can be reduced through early detection and tobacco cessation ideally by dentists owing to their forte of work. Aim: This study was conducted to discuss effectiveness of an advanced tele-mentoring programme in oral cancer screening and tobacco cessation for dentists across India. Settings and Design: Online, interventional study. Methods and Material: The 14-week long training programme with 52 participants/spokes from across India had weekly hour-long online sessions comprising of an expert-led didactic and case discussions by spokes. Online evaluation (pre- and post-training, post-session), weekly and post-one-year feedback were conducted. Successful spokes attended a hands-on workshop subsequently. Statistical Analysis Used: One and independent sample t-tests determined the significance of the evaluation scores of the participants. Findings on attitudes and practice-related questions are presented as simple percentages. Results: A notable increase in the overall and per-session mean knowledge score, and confidence in oral cancer screening was observed. Many participants started these services at their clinics, thereby reducing further referrals, and were also motivated to spread community awareness about the same. Conclusion: This tele-mentoring programme, based on the novel Extension for Community Healthcare Outcomes model, is the first oral cancer screening training programme for dentists. This model-comprising of expert didacts, case discussions, and significant spoke-expert interaction-is a promising best-practices tool for reducing the disparity in knowledge and skills regarding oral cancer prevention among dentists across different locations. This would enable these most appropriate healthcare providers to contribute toward the overall goal of oral cancer prevention.

Use of cauliflower mosaic virus DNA markers to assess the potential for pathogen transmission from physicians' white coats.

In an observational study, the sleeves and pockets of physicians' white coats often directly or indirectly contacted patients and environmental surfaces. DNA markers on the sleeves or pockets were frequently transferred to surfaces and patients. These findings suggest that contaminated white coats have the potential to contribute to pathogen transmission.

Barriers and facilitators in implementing population based common cancer screening through community health workers.

Population based cancer screening was initiated in India in 2016 owing to an increased burden of cancers. A feasibility health system study was done by utilising community health workers (CHWs) to conduct the cancer screening. The current study is a qualitative study to elicit the barriers and facilitators in implementing population based cancer screening through CHWs. The study was conducted at three subcentres of Dholai block of Cachar district, Assam, India and Cachar Cancer Hospital and Research Center, Silchar. The participants of the study were CHWs, master trainer nurses and women from community. Three focus group discussions (FGDs) and one in-depth interview (IDI) were conducted at the provider level and seven IDIs of women from the community. The FGDs and IDIs were audio recorded after taking verbal consent from the participants. The verbatims were prepared following translation and transcription and data analysis using ATLAS ti ver 8. The major barrier faced by the community was a lack of motivation to get screened which stemmed from various factors such as personal beliefs, attitudes and fear. The major facilitators were accessibility of tests, family support and CHWs as screening service providers. The major barriers for CHWs were difficulty in motivating the community, lack of support from supervisors and lack of motivation to work. The major facilitators were convenience of screening during home visits, empowerment, skill enhancement and teamwork. Population based cancer screening was a new concept for the community under study. Cancer screening by CHWs was well accepted by the community. Awareness generation among the community was a major factor in improving screening coverage. The study highlights that training and motivation of CHWs can improve the uptake of cancer screening services. CHWs felt empowered with the new skills imparted and were able to carry out screening.

Scalable in-hospital decontamination of N95 filtering face-piece respirator with a peracetic acid room disinfection system.

BACKGROUND: Critical shortages of personal protective equipment, especially N95 respirators, during the coronavirus disease 2019 (COVID-19) pandemic continues to be a source of concern. Novel methods of N95 filtering face-piece respirator decontamination that can be scaled-up for in-hospital use can help address this concern and keep healthcare workers (HCWs) safe. METHODS: A multidisciplinary pragmatic study was conducted to evaluate the use of an ultrasonic room high-level disinfection system (HLDS) that generates aerosolized peracetic acid (PAA) and hydrogen peroxide for decontamination of large numbers of N95 respirators. A cycle duration that consistently achieved disinfection of N95 respirators (defined as ≥6 log10 reductions in bacteriophage MS2 and Geobacillus stearothermophilus spores inoculated onto respirators) was identified. The treated masks were assessed for changes to their hydrophobicity, material structure, strap elasticity, and filtration efficiency. PAA and hydrogen peroxide off-gassing from treated masks were also assessed. RESULTS: The PAA room HLDS was effective for disinfection of bacteriophage MS2 and G. stearothermophilus spores on respirators in a 2,447 cubic-foot (69.6 cubic-meter) room with an aerosol deployment time of 16 minutes and a dwell time of 32 minutes. The total cycle time was 1 hour and 16 minutes. After 5 treatment cycles, no adverse effects were detected on filtration efficiency, structural integrity, or strap elasticity. There was no detectable off-gassing of PAA and hydrogen peroxide from the treated masks at 20 and 60 minutes after the disinfection cycle, respectively. CONCLUSION: The PAA room disinfection system provides a rapidly scalable solution for in-hospital decontamination of large numbers of N95 respirators during the COVID-19 pandemic.

Capacity building of primary care physicians of the tea garden hospitals in Dibrugarh, Assam: A demonstration project.

BACKGROUND: The three most commonly occurring cancers in India are those of the breast, uterine cervix, and lip or oral cavity, together accounting for approximately 34% of all cancers. All the three cancers are amenable to prevention, early detection, and treatment through which the morbidity and mortality due to these cancers can be reduced. This pilot study was conducted to assess the operational feasibility of the national cancer screening guidelines. METHOD: This study was conducted in the Dibrugarh district of Assam in seven tea garden hospitals which serve as the primary health centers for the tea estate population in the Northeast region of India. The study intervention was a three-day training package designed to train primary care physicians in population-based screening for oral, breast, and cervical cancers. Knowledge evaluation and skill assessment were performed with a validated questionnaire and checklist, respectively. RESULTS: Pre and posttraining knowledge assessment showed significant gain in the knowledge levels of the participants in all topics. The greatest knowledge increase was seen in breast cancer (96.3%), followed by cervical cancer (57.5%), oral cancer (35.5%) and general cancer-related information (16.7%). The skill assessment done for each participant individually at the end of the training indicated a need for retraining all participants in breast cancer screening. CONCLUSION: The learnings from this study will be of great help in scaling up the capacity building programme for cancer screening when the nation-wide population-based cancer screening programme will be rolled out in the country.

Effectiveness of Ultraviolet-C Light and a High-Level Disinfection Cabinet for Decontamination of N95 Respirators.

BACKGROUND: Shortages of personal protective equipment (PPE) including N95 respirators are an urgent concern in the setting of the global COVID-19 pandemic. Decontamination of PPE could be useful to maintain adequate supplies, but there is uncertainty regarding the efficacy of decontamination technologies. METHODS: A modification of the American Society for Testing and Materials standard quantitative carrier disk test method (ASTM E-2197-11) was used to examine the effectiveness of 3 methods, including ultraviolet-C (UV-C) light, a high-level disinfection cabinet that generates aerosolized peracetic acid and hydrogen peroxide, and dry heat at 70°C for 30 minutes. We assessed the decontamination of 3 commercial N95 respirators inoculated with methicillin-resistant Staphylococcus aureus (MRSA) and bacteriophages MS2 and Phi6; the latter is an enveloped RNA virus used as a surrogate for coronaviruses. Three and 6 log10 reductions on respirators were considered effective for decontamination and disinfection, respectively. RESULTS: UV-C administered as a 1-minute cycle in a UV-C box or a 30-minute cycle by a room decontamination device reduced contamination but did not meet criteria for decontamination of the viruses from all sites on the N95s. The high-level disinfection cabinet was effective for decontamination of the N95s and achieved disinfection with an extended 31-minute cycle. Dry heat at 70°C for 30 minutes was not effective for decontamination of the bacteriophages. CONCLUSIONS: UV-C could be useful to reduce contamination on N95 respirators. However, the UV-C technologies studied did not meet pre-established criteria for decontamination under the test conditions used. The high-level disinfection cabinet was more effective and met criteria for disinfection with an extended cycle.

Evaluation of the potential for electronic thermometers to contribute to spread of healthcare-associated pathogens.

In a point-prevalence culture survey, 24 of 300 (8%) handles of electronic thermometers in 3 hospitals were contaminated with 1 or more potential pathogens. A DNA marker inoculated onto the handles of electronic thermometers in hospital and long-term care facility settings spread to surfaces in patient rooms, to other types of portable equipment, and to patients' hands. Our findings suggest that effective strategies are needed to reduce the risk for pathogen transmission by electronic thermometers.

Evaluation of an automated ultraviolet-C light disinfection device and patient hand hygiene for reduction of pathogen transfer from interactive touchscreen computer kiosks.

Touchscreens are a potential source of pathogen transmission. In our facility, patients and visitors rarely perform hand hygiene after using interactive touchscreen computer kiosks. An automated ultraviolet-C touchscreen disinfection device was effective in reducing bacteriophage MS2, bacteriophage ϕX174, methicillin-resistant Staphylococcus aureus, and Clostridium difficile spores inoculated onto a touchscreen. In simulations, an automated ultraviolet-C touchscreen disinfection device alone or in combination with hand hygiene reduced transfer of the viruses from contaminated touchscreens to fingertips.

Herpes Zoster in the Older Adult.

Herpes zoster (HZ) is the result of reactivation of latent varicella zoster virus (VZV) and occurs most frequently in older adults. Classically, HZ presents as a unilateral, selflimited, dermatomal rash. Postherpetic neuralgia (PHN) is a common sequela, presenting as severe pain that persists after the rash has resolved. In the elderly, PHN can be debilitating and requires a prompt diagnosis, treatment with antivirals, and adequate pain control. A longer-term pain management strategy is required if PHN occurs. A modestly effective vaccine exists and is recommended for older individuals.

Contaminated Portable Equipment Is a Potential Vector for Dissemination of Pathogens in the Intensive Care Unit.

A DNA marker inoculated onto shared portable equipment in surgical and medical intensive care units disseminated widely to surfaces in patient rooms and provider work areas and to other types of portable equipment. These results demonstrate the potential for contaminated portable equipment to serve as a vector for dissemination of pathogens. Infect Control Hosp Epidemiol 2017;38:1247-1249.

Evaluation of Viral Surrogate Markers for Study of Pathogen Dissemination During Simulations of Patient Care.

During patient care simulations, cauliflower mosaic virus DNA and bacteriophage MS2 performed similarly as surrogate markers of pathogen dissemination. These markers disseminated to the environment in a manner similar to Clostridium difficile spores but were more frequently detected on skin and clothing of personnel after personal protective equipment removal.

Dissemination of a nonpathogenic viral DNA surrogate marker from high-touch surfaces in rooms of long-term care facility residents.

A nonpathogenic DNA marker inoculated onto the television remote controls in rooms of 2 ambulatory long-term care facility (LTCF) residents disseminated to the hands of the LTCF residents, to high-touch surfaces in the room and on the ward, and to shared portable equipment. These findings suggest that contaminated high-touch surfaces in rooms of ambulatory LTCF residents are a potential source for widespread dissemination of pathogens.

Do medical students receive training in correct use of personal protective equipment?

BACKGROUND: Healthcare personnel often use incorrect technique for donning and doffing of personal protective equipment (PPE). OBJECTIVE: We tested the hypothesis that medical students receive insufficient training on correct methods for donning and doffing PPE. METHODS: We conducted a cross-sectional survey of medical students on clinical rotations at two teaching hospitals to determine the type of training they received in PPE technique. The students performed simulations of contaminated PPE removal with fluorescent lotion on gloves and were assessed for correct PPE technique and skin and/or clothing contamination. To obtain additional information on PPE training during medical education, residents, fellows, and attending physicians completed written questionnaires on PPE training received during medical school and on knowledge of PPE protocols recommended by the Centers for Disease Control and Prevention. RESULTS: Of 27 medical students surveyed, only 11 (41%) reported receiving PPE training, and none had received training requiring demonstration of proficiency. During simulations, 25 of 27 (92.5%) students had one or more lapses in technique and 12 (44%) contaminated their skin with fluorescent lotion. For 100 residents, fellows and attending physicians representing 67 different medical schools, only 53% reported receiving training in use of PPE and only 39% selected correct donning and doffing sequence. CONCLUSIONS: Our findings suggest that there is a need for development of effective strategies to train medical students in correct use of PPE. ABBREVIATIONS: PPE: Personal protective equipment; MRSA: Methicillin-resistant Staphylococcus aureus; SARS: Severe acute respiratory syndrome; MERS: Middle East respiratory syndrome; WHO: World Health Organization; CDC: Centers for Disease Control and Prevention; OSCE: Objective structured clinical examination.

Are health care personnel trained in correct use of personal protective equipment?

Effective use of personal protective equipment (PPE) is essential to protect personnel and patients in health care settings. However, in a survey of 222 health care personnel, PPE training was often suboptimal with no requirement for demonstration of proficiency. Fourteen percent of physicians reported no previous training in use of PPE.

Spontaneous coronary dissection in polycystic kidney disease.

We report a case of a 46-year-old woman with hypertension and autosomal dominant polycystic kidney disease who presented with chest pain and was found to have spontaneous coronary artery dissection (SCAD) on diagnostic catheterization. We review the pathogenesis, management and prognosis of SCAD. We conclude that in patients with polycystic kidney disease who present with angina pectoris and positive cardiac biomarkers, coronary artery dissection should be considered.

Subtyping clinical specimens of influenza A virus by use of a simple method to amplify RNA targets.

This work presents the clinical application of a robust and unique approach for RNA amplification, called a simple method for amplifying RNA targets (SMART), for the detection and identification of subtypes of H1N1 pandemic, H1N1 seasonal, and H3N2 seasonal influenza virus. While all the existing amplification techniques rely on the diffusion of two molecules to complex RNA structures, the SMART achieves fast and efficient amplification via single-molecule diffusion. The SMART utilizes amplifiable single-stranded DNA (ssDNA) probes, which serve as reporter molecules for capturing specific viral RNA (vRNA) sequences and are subsequently separated on a microfluidic chip under zero-flow conditions. The probe amplification and detection are performed using an isothermal (41°C) amplification scheme via a modified version of nucleic acid sequence-based amplification (NASBA). In our study, 116 consecutive, deidentified, clinical nasopharyngeal swab samples were analyzed independently in a blinded fashion using the SMART, reverse transcription-PCR (RT-PCR), antigen (Ag) testing, and viral culture. The SMART was shown to have a limit of detection (LOD) of approximately 10(5) vRNA copies/ml, corresponding with a time-to-positivity (TTP) value of 70 min for real-time detection. The SMART correctly detected influenza virus in 98.3% of the samples with a subtyping accuracy of 95.7%. This work demonstrates that the SMART represents a highly accurate diagnostic platform for the detection and subtyping of influenza virus in clinical specimens and offers significant advantages over the current commercially available diagnostic tools.