Breakthrough infection among healthcare personnel following exposure to COVID-19: Experience after one year of the world's largest vaccination drive.

Context: The COVID-19 vaccination drive globally was supposedly a game-changing event. However, the emerging variants of the virus and waning immunity over time posed new challenges for breakthrough infections. Standing at the frontline of defense against COVID-19, healthcare personnel (HCP) were vulnerable to such infections. Aims: This study estimates i) the vaccine breakthrough infections (VBI) among HCP following exposure to COVID-19 cases, and ii) the mean interval between the second dose of vaccine and laboratory-confirmed SARS-CoV-2 infection. Materials and Methods: A cross-sectional study was conducted including 385 HCP with a history of exposure to COVID-19 cases during January and February 2022. Demographic details and clinical and vaccination history were collected from the test forms and the Web-based hospital management system. Laboratory testing of COVID-19 was carried out by real-time RT-PCR test. Results: The majority of the HCP were males (262; 68.05%) and nurses (180; 46.75%) by occupation. Two doses of vaccines were received by 278 (87.7%) HCP. VBI was confirmed in 185 (66.55%) HCP. No significant difference in VBI between the COVAXIN and COVISHIELD recipients (P = 0.69) was observed. The interval between the second dose and confirmed SARS-CoV-2 infection was significantly higher (P < 0.00001) in COVAXIN recipients (median 228 days) than in COVISHIELD recipients (median 95 days). Conclusions: The incidence of VBI was very high among the HCP, but not statistically different among the COVAXIN and COVISHIELD-recipients. Waning immunity over time suggests boosting immunity with a third dose because of emerging variants.

Persistence of SARS-CoV-2 in COVID-19 patients during the second wave of the pandemic in India.

INTRODUCTION: India witnessed the catastrophic second wave of COVID-19 during the summer months of 2021. Many patients with non-resolution of symptoms admitted to dedicated COVID-19 treatment centers required prolonged inpatient care which led to the unavailability of beds for other COVID-19 patients. The objective of this study was to determine the duration of SARS-CoV-2 positivity in moderate and severe COVID-19 patients requiring long-term pulmonary care as well as to find out the association between different variables with the persistence of the virus. METHODOLOGY: A retrospective chart review of clinical and laboratory data of patients with moderate and severe COVID-19 between 1st April 2021 and 15th July 2021 admitted for more than 28 days and requiring long-term pulmonary care was carried out at National Cancer Institute, AIIMS, India. SARS-CoV-2 RNA was detected with real-time reverse transcriptase-polymerase chain reaction-based tests. Data from all consecutively included patients satisfying the selection criteria were presented temporally and analyzed by Fisher's exact test (p < 0.05). RESULTS: All 51 patients tested positive for SARS-CoV-2 RNA at the 5th week of initial laboratory confirmation of COVID-19. The majority of the patients (38; 74.5%) remained positive for viral RNA till the 6th week and the median duration of viral positivity was 45 days. The clinical presentation of SARI at admission was significantly higher among patients with viral persistence till the 6th week (p < 0.05). CONCLUSIONS: The median duration of the viral positivity was 45 days and SARI at admission was significantly associated with viral persistence till the 6th week.

Clinical features, demography, and predictors of outcomes of SARS-CoV-2 infection at a tertiary care hospital in India: A cohort study.

BACKGROUND: The "second wave" of the COVID-19 pandemic hit India from early April 2021 to June 2021. We describe the clinical features, treatment trends, and baseline laboratory parameters of a cohort of patients with SARS-CoV-2 infection and their association with the outcome. METHODS: This was a retrospective cohort study. Multivariate logistic regression models were fitted to identify clinical and biochemical predictors of developing hypoxia, deterioration during the hospital stay, and death. RESULTS: A total of 2080 patients were included. The case fatality rate was 19.5%. Among the survivors, the median duration of hospital stay was 8 (5-11) days. Out of 853 (42.3%%) of patients who had COVID-19 acute respiratory distress syndrome at presentation, 340 (39.9%) died. Patients aged >45 years had higher odds of death as compared to the 18-44 years age group. Vaccination reduced the odds of death by 40% (odds ratio [OR] [95% confidence interval [CI]]: 0.6 [0.4-0.9], P = 0.032). Patients with hyper inflammation at baseline as suggested by leukocytosis (OR [95% CI]: 2.1 [1.5-3.1], P < 0.001), raised d-dimer >500 mg/dL (OR [95% CI]: 3.2 [2.2-4.7], P < 0.001), and raised C-reactive peptide >0.5 mg/L (OR [95% CI]: 3.7 [2.2-13], P = 0.037) had higher odds of death. Patients who were admitted in the 2nd week had lower odds and those admitted in the 3rd week had higher odds of death. CONCLUSION: This study shows that vaccination status and early admission during the inflammatory phase can change the course of illness of these patients. Improving vaccination rates and early admission of patients with moderate and severe COVID-19 can improve the outcomes.

The Effectiveness of SARS-CoV-2 Vaccination in Preventing Severe Illness and Death - Real-world Data from a Cohort of Patients Hospitalized with COVID-19.

Background: While long-term studies on the correlates of protection, vaccine effectiveness, and enhanced surveillance are awaited for SARS-CoV-2 vaccine, studies on breakthrough infections help understand the nature and course of this illness among vaccinated individuals and guide in public health preparedness. This study aims to compare the differences in the hospitalization outcomes SARS-CoV-2 infection of fully vaccinated individuals with with those of unvaccinated and partially vaccinated individuals. Materials and Methods: Single institution observational cohort study. This study compared the differences in clinical, biochemical parameters and the hospitalization outcomes of 53 fully vaccinated individuals with those of unvaccinated (1464) and partially vaccinated (231) individuals, among a cohort of 2,080 individuals hospitalized with SARS-CoV-2 infection. Descriptive statistics and propensity-score weighted multivariate logistic regression analysis adjusting for clinical and laboratory parameters were used to compare the differences and to identify factors associated with outcomes. Results: Completing the course of vaccination protected individuals from developing severe COVID-19 as evidenced by lower proportions of those with hypoxia, abnormal levels of inflammatory markers, requiring ventilatory support, and death compared to unvaccinated and partially vaccinated individuals. There were no differences in these outcomes among patients who received either vaccine type approved in India. Conclusions: Efforts should be made to improve the vaccination rates as a timely measure to prepare for the upcoming waves of this highly transmissible pandemic. Vaccination rates of the communities may also guide in the planning of the health needs and appropriate use of medical resources.

Seroprevalence of antibodies to SARS-CoV-2 in healthcare workers & implications of infection control practice in India.

Background & objectives: Healthcare workers (HCWs) are considered to be at a high risk of contracting COVID-19 infection. Besides, control of nosocomial infections transmitted from HCWs to the patients is also a cause of concern. This study was undertaken to investigate the seroprevalence of antibodies against the SARS-CoV-2 virus among the hospital staff of a tertiary care health facility in north India. Methods: The HCWs were tested for SARS-CoV-2 serology (IgG+IgM) using chemiluminescence immunoassay between June 22 and July 24, 2020. Venous blood (2 ml) was collected and tested for SARS-CoV-2 IgG and IgM antibodies. Results: Of the 3739 HCWs tested, 487 (13%) were positive for total SARS-CoV-2 antibodies. The highest seroprevalence was observed in administrative staff (19.6%) and least in physicians (5.4%). The staff who used public (20%) and hospital transportation (16.9%) showed higher seroprevalence compared to staff using personal transportation (12.4%). No difference was observed between HCWs posted in COVID versus non-COVID areas. All seropositive symptomatic HCWs in our study (53.6%) had mild symptoms, and the remaining 46.4 per cent were asymptomatic. The antibody positivity rate progressively increased from 7.0 per cent in the first week to 18.6 per cent in the fourth week during the study. Interpretation & conclusions: The presence of antibodies to SARS-CoV-2 in a significant number of asymptomatic HCWs, association with the use of public transport, relatively lower seroprevalence compared with the non-HCWs and rising trend during the period of the study highlight the need for serosurveillance, creating awareness for infection control practices including social distancing and study of infection dynamics in the community for effective control of an infectious pandemic.

Psychometric analysis and construct validation of Health Professional Education in Patient Safety Survey in the Indian context.

Background Improving patient safety (PS) is critical to optimizing healthcare delivery. There is a need to develop curricula or incorporate PS concepts in health professionals' (HPs) education, in both theoretical and practical training. Consequently, there is a need to measure the perception of HPs regarding various PS competencies imparted to them during their training. The Health Professional Education in Patient Safety Survey (H-PEPSS) is a tool that measures HPs' self-reported PS competence and was designed to reflect six sociocultural areas central to PS. The tool has been validated in Canada but not in India. We did a confirmatory factor analysis (CFA) and psychometric validation of the H-PEPSS in the Indian context. Methods The sample comprised 240 HPs. We used the maximum likelihood estimation method on AMOS V20 (SPSS Inc.) to carry out a CFA of the tool. We used the normed fit index, Tucker-Lewis index, comparative fit index, standard root mean square residual, root mean square residual and root mean square error of approximation to evaluate the model fit. Internal consistency and reliability of the six factors of the model were examined using Cronbach's alpha. Convergent validity of the model was examined using average variance extracted and composite reliability. Discriminant validity was examined using the Fornell and Larcker criterion and the heterotrait-monotrait method. Results The results indicate a good fit. The H-PEPSS was found to be reliable and valid for assessing PS competencies among HPs. Comparison of the results with the results of the Canadian setting confirmed external validity. Conclusion The 16-item H-PEPSS has good psychometric properties for use in the Indian context. The 23-item HPEPSS was found to be reliable and valid for assessing PS.

Techno stress among medical freshmen: An exploratory study.

INTRODUCTION: Use of technology and ICT tools is ubiquitous among college students including medical students. However overuse or misuse may lead to many physical and psychological problems including the risk of harming professional standing in the long term. The purpose of this study was to explore techno stress among freshmen at a medical institute and to suggest measures to reduce problematic use of technology pertaining to internet. OBJECTIVES: (i) To explore the extent of technology use including internet among medical freshmen, (ii) To identify the content of usage (iii) To quantify the extent of techno stress and iv. To suggest measures to reduce problematic use of technology. MATERIALS AND METHODS: The sample comprised all the freshmen at a medical institute (n = 61). A semi structured questionnaire was used to collect socio demographic details of students and their patterns of technology usage. Perceived Stress Scale was used to measure stress. RESULTS: The mean age of the sample was 18.34 (±0.58) years comprising 68% males and 32% females. Students spent a mean time of 3.96 h/day on the technology tools (standard deviation = 4.99). Ninety-two percent of the students used technology for educational purposes followed by entertainment (89%), social networking (77.78%), watching films (70.37%), communication (66.67%) and watching pornography (46.3%). 11.47% had symptoms suggestive of problematic internet use. One percent had craving suggestive of addiction. All these had stress out of which 43% had high and 57% had moderate levels of stress. DISCUSSION: Considering the students' present usage of social media, it can serve as a potent academic tool. However, awareness is required to be raised with regard to its use as a medical professional. CONCLUSION: Use of technology is crucial in the current academic world and restrictions on usage may neither be practical nor feasible. However, understanding patterns of usage among students is a preliminary step that can enable educators and administrators to formulate guidelines to channelise their usage in more productive ways.

How to rapidly design and operationalise PPE donning and doffing areas for a COVID-19 care facility: quality improvement initiative.

INTRODUCTION: Effective implementation of standard precautions specific to COVID-19 is a challenge for hospitals within the existing constraints of time and resources. AIM: To rapidly design and operationalise personal protective equipment (PPE) donning and doffing areas required for a COVID-19 care facility. METHODS: Literature review was done to identify all issues pertaining to donning and doffing in terms of Donabedian's structure, process and outcome. Training on donning and doffing was given to hospital staff. Donning and doffing mock drills were held. 5S was used as a tool to set up donning and doffing areas. Instances of donning and doffing were observed for protocol deviations and errors. Plan-do-study-act cycles were conducted every alternate day for 4 weeks. The initiative was reported using Standards for QUality Improvement Reporting Excellence (SQUIRE) guidelines. RESULTS: Best practices in donning and doffing were described. Our study recommends a minimum area of 16 m2 each for donning and doffing rooms. Verbally assisted doffing was found most useful than visual prompts. DISCUSSION: Challenges included sustaining the structure and process of donning and doffing, varied supplies of PPE which altered sequencing of donning and/or doffing, and training non-healthcare workers such as plumbers, electricians and drivers who were required during emergencies in the facility. CONCLUSION: Our study used evidence-based literature and quality improvement (QI) tools to design and operationalise donning and doffing areas with focus on people, task and environment. Our QI will enable healthcare facilities to rapidly prototype donning and doffing areas in a systematic way.

Clinico-demographic profile & hospital outcomes of COVID-19 patients admitted at a tertiary care centre in north India.

BACKGROUND & OBJECTIVES: In December 2019, a novel coronavirus (SARS-CoV-2) emerged in China and rapidly spread globally including India. The characteristic clinical observations and outcomes of this disease (COVID-19) have been reported from different countries. The present study was aimed to describe the clinico-demographic characteristics and in-hospital outcomes of a group of COVID-19 patients in north India. METHODS: This was a prospective, single-centre collection of data regarding epidemiological, demographic, clinical and laboratory parameters, management and outcome of COVID-19 patients admitted in a tertiary care facility in north India. Patient outcomes were recorded as death, discharge and still admitted. RESULTS: Data of 144 patients with COVID-19 were recorded and analyzed. The mean age of the patients was 40.1±13.1 yr, with 93.1 per cent males, and included 10 (6.9%) foreign nationals. Domestic travel to or from affected States (77.1%) and close contact with COVID-19 patients in congregations (82.6%) constituted the most commonly documented exposure. Nine (6.3%) patients were smokers, with a median smoking index of 200. Comorbidities were present in 23 (15.9%) patients, of which diabetes mellitus (n=16; 11.1%) was the most common. A significant proportion of patients had no symptoms (n=64; 44.4%); among the symptomatic, cough (34.7%) was the most common symptom followed by fever (17.4%) and nasal symptoms (2.15%). Majority of the patients were managed with supportive treatment with hydroxychloroquine and azithromycin given on a case-to-case basis. Only five (3.5%) patients required oxygen supplementation, four (2.8%) patients had severe disease requiring intensive care, one required mechanical ventilation and mortality occurred in two (1.4%) patients. The time to reverse transcription-polymerase chain reaction (RT-PCR) negativity was 16-18 days. INTERPRETATION & CONCLUSIONS: In this single-centre study of 144 hospitalized patients with confirmed COVID-19 in north India, the characteristic findings included younger age, high proportion of asymptomatic patients, long time to PCR negativity and low need for intensive care unit care.

How much is adequate staffing for infection control? A deterministic approach through the lens of Workload Indicators of Staffing Need.

BACKGROUND: Staffing ratios based on hospital beds and norms do not adequately address the requirement of infection preventionists (IP) in hospitals. We, therefore, aimed to determine staffing of IP (nursing category) based on actual workload involved. METHODS: The study design was quantitative and longitudinal conducted for 1 year. The study was structured around the steps of the World Health Organization's Workload Indicators of Staffing Need (WISN). RESULTS: We identified infection control activities, support activities and additional activities to be performed by 4 IP with a total available working time of 6,132 hours for an annual workload of 6,238.25 (±372) hours in an acute care hospital with 182 beds and 69,331 annual admissions. Core infection control activities consumed 78% time. Support and additional activities consumed the remaining 22% time. Active surveillance required 44% time and education consumed 32% time. WISN ratio of available staff and required staff was 0.75. DISCUSSION: A WISN ratio less than 1 suggests inadequate staffing. Therefore, the WISN method recommends 4 IP instead of 3 based on existing workload. We compared our results with the existing quantification-based staffing studies. CONCLUSIONS: WISN is a valuable method to measure all infection control activities and translate workload into IP (nursing) full time equivalents.

Workload Indicators of Staffing Need as a tool to determine nurse staffing for a high volume academic Emergency Department: An observational study.

INTRODUCTION: Determination of staffing requirement for an Emergency Department (ED) is often difficult due to random arrivals of a complex mix of cases, fluctuating volumes and lengths of stay. Most staffing strategies are based on patient census, lengths of stay, patient dependency or patient classification systems. However, the actual quantity of workload is seldom employed as a basis to calculate staffing. AIM: The aim of this study was to determine the requirement of nurses for a high volume academic ED and to suggest measures to optimally schedule them. METHODOLOGY: Structured interviews were held with ED nurses to list their health service activities, support and additional activities. Time taken for the activities was calculated based on observations and interviews. Records were perused to obtain annual service statistics. Workload Indicators of Staffing Need (WISN) described by World Health Organization was utilized to analyze and determine staffing need. RESULTS: The study identified 34 health service activities, 21 support activities and 3 additional activities to be performed by 125 nurses with a total available working time of 187,250 h for an annual volume of 105,103 patients. The WISN ratio was 0.90 which indicates that the current staff strength was inadequate. The Emergency Department requires 13 more full time staff nurses for it to function optimally. In case of reallocation of certain relevant duties to phlebotomists or nursing assistants, the requirement of staff nurses is 102. Consequently, a skill mix ratio of 82% nurses to 18% nursing assistants and phlebotomists is suggested. DISCUSSION: The Workload Indicators of Staffing Need is a simple, easy to use method that can prospectively measure direct and indirect nursing activities and translate workload into nursing full time equivalents for the ED. This method is also useful to identify activities that do not require nursing professional skills and prescribe the skill mix of staff.

Patient safety at a public hospital in southern India: A hospital administration perspective using a mixed methods approach.

Background: Patient safety cannot be considered in isolation when organizational factors, both active and latent, influence patient outcomes. Methods: We did a cross-sectional mixed methods study using a convergent parallel design at a tertiary care public sector hospital in Hyderabad, Telangana (i) to qualitatively investigate the nature and determinants of patient safety incidents occurring in the hospital; (ii) to quantify the perception of hospital staff regarding factors affecting patient safety from an organizational perspective; and (iii) to triangulate the results to highlight areas in need of improvement. Results: The most common factors affecting patient safety were situational factors, working conditions and latent organizational factors including communication systems. Despite the relatively poor knowledge of paramedical staff regarding patient safety incidents, they perceived innovation and flexibility, outward focus, reflexivity, quality, pressure to produce, performance feedback and effort to be significantly higher compared to the heads of departments and clinical faculty. The strength of the dimensions: integration, involvement, training, welfare, supervisory support in the hospital was weak as perceived by all categories of staff. Conclusion: There is a need to build team work, improve trust and communication between various departments, invest more in training, and provide supervisory support along with structural and process improvements in issues such as drug procurement and developing patient-friendly physical environment.

Cost analysis of a disaster facility at an apex tertiary care trauma center of India.

INTRODUCTION: For the Commonwealth Games 2010, Jai Prakash Narayan Apex Trauma Centre (JPNATC) of India had been directed by the Director General Health Services and Ministry of Health and Family Welfare, Government of India, to set up a specialized unit for the definitive management of the injured/unwell athletes, officials, and related personnel coming for the Commonwealth Games in October 2010. The facility included a 20-bedded fully equipped ward, six ICU beds with ventilator capacity, one very very important person observation area, one perioperative management cubicle, and one fully modular and integrated operating room. OBJECTIVE: The objective of this study was to calculate the cost of disaster facility at JPNATC, All India Institute of Medical Sciences, New Delhi. METHODOLOGY: Traditional (average or gross) costing methodology was used to arrive at the cost for the provisioning of these services by this facility. RESULTS: The annual cost of providing services at disaster facility at JPNATC, New Delhi, was calculated to be INR 61,007,334.08 (US$ 983,989.258) while the per hour cost was calculated to be INR 7061.03 of the total cost toward the provisioning of services by disaster facility where 26% was the capital cost and 74% was the operating cost. Human resource caters to maximum chunk of the expenditures (47%). CONCLUSION: The results of this costing study will help in the future planning of resource allocation within the financial constraints (US$ 1 = INR 62 in the year 2013).