Violence and Abuse: A Pandemic Within a Pandemic.

INTRODUCTION: During the COVID-19 pandemic, as society struggled with increasing disease burden, economic hardships, and with disease morbidity and mortality, governments and institutions began implementing stay-at-home or shelter-in-place orders to help stop the spread of the virus. Although well-intentioned, one unintended adverse consequence was an increase in violence, abuse, and neglect. METHODS: We reviewed the literature on the effect the pandemic had on domestic violence, child and elder abuse and neglect, human trafficking, and gun violence. In this paper we explore common themes and causes of this violence and offer suggestions to help mitigate risk during ongoing and future pandemics. Just as these forms of violence primarily target at-risk, vulnerable populations, so did pandemic-related violence target marginalized populations including women, children, Blacks, and those with lower socioeconomic status. This became, and remains, a public health crisis within a crisis. In early 2021, the American College of Emergency Physicians (ACEP) Public Health and Injury Committee was tasked with reviewing the impact the pandemic had on violence and abuse as the result of a resolution passed at the 2020 ACEP Council meeting. CONCLUSION: Measures meant to help control the spread of the COVID-19 pandemic had many unintended consequences and placed people at risk for violence. Emergency departments (ED), although stressed and strained during the pandemic, remain a safety net for survivors of violence. As we move out of this pandemic, hospitals and EDs need to focus on steps that can be taken to ensure they preserve and expand their ability to assist victims should another pandemic or global health crisis develop.

WHO O2CoV2: oxygen requirements and respiratory support in patients with COVID-19 in low-and-middle income countries-protocol for a multicountry, prospective, observational cohort study.

INTRODUCTION: SARS-CoV-2 has been identified as the cause of the disease officially named COVID-19, primarily a respiratory illness. COVID-19 was characterised as a pandemic on 11 March 2020. It has been estimated that approximately 20% of people with COVID-19 require oxygen therapy. Oxygen has been listed on the WHO Model List of Essential Medicines List and Essential Medicines List for Children for almost two decades. The COVID-19 pandemic has highlighted, more than ever, the acute need for scale-up of oxygen therapy. Detailed data on the use of oxygen therapy in low-and-middle income countries at the patient and facility level are needed to target interventions better globally. METHODS AND ANALYSIS: We aim to describe the requirements and use of oxygen at the facility and patient level of approximately 4500 patients with COVID-19 in 30 countries. Our objectives are specifically to characterise type and duration of different modalities of oxygen therapy delivered to patients; describe demographics and outcomes of hospitalised patients with COVID-19; and describe facility-level oxygen production and support. Primary analyses will be descriptive in nature. Respiratory support transitions will be described in Sankey plots, and Kaplan-Meier models will be used to estimate probability of each transition. A multistate model will be used to study the course of hospital stay of the study population, evaluating transitions of escalating respiratory support transitions to the absorbing states. ETHICS AND DISSEMINATION: WHO Ad Hoc COVID-19 Research Ethics Review Committee (ERC) has approved this global protocol. When this protocol is adopted at specific country sites, national ERCs may make require adjustments in accordance with their respective national research ethics guidelines. Dissemination of this protocol and global findings will be open access through peer-reviewed scientific journals, study website, press and online media. TRIAL REGISTRATION NUMBER: NCT04918875.

Severity and outcomes of Omicron variant of SARS-CoV-2 compared to Delta variant and severity of Omicron sublineages: a systematic review and metanalysis.

OBJECTIVES: To compare severity and clinical outcomes from Omicron as compared with the Delta variant and to compare outcomes between Omicron sublineages. METHODS: We searched the WHO COVID-19 Research database for studies that compared clinical outcomes for patients with Omicron variant and the Delta variant, and separately Omicron sublineages BA.1 and BA.2. A random-effects meta-analysis was used to pool estimates of relative risk (RR) between variants and sublineages. Heterogeneity between studies was assessed using the I2 index. Risk of bias was assessed using the tool developed by the Clinical Advances through Research and Information Translation team. RESULTS: Our search identified 1494 studies and 42 met the inclusion criteria. Eleven studies were published as preprints. Of the 42 studies, 29 adjusted for vaccination status; 12 had no adjustment; and for 1, the adjustment was unclear. Three of the included studies compared the sublineages of Omicron BA.1 versus BA.2. As compared with Delta, individuals infected with Omicron had 61% lower risk of death (RR 0.39, 95% CI 0.33 to 0.46) and 56% lower risk of hospitalisation (RR 0.44, 95% CI 0.34 to 0.56). Omicron was similarly associated with lower risk of intensive care unit (ICU) admission, oxygen therapy, and non-invasive and invasive ventilation. The pooled risk ratio for the outcome of hospitalisation when comparing sublineages BA.1 versus BA.2 was 0.55 (95% 0.23 to 1.30). DISCUSSION: Omicron variant was associated with lower risk of hospitalisation, ICU admission, oxygen therapy, ventilation and death as compared with Delta. There was no difference in the risk of hospitalisation between Omicron sublineages BA.1 and BA.2. PROSPERO REGISTRATION NUMBER: CRD42022310880.

Emergency care interventions for paediatric severe acute respiratory infections in low- and middle-income countries: A systematic review and narrative synthesis.

Background: Severe acute respiratory infections (SARIs) are the leading cause of paediatric death globally, particularly in low- and middle-income countries (LMICs). Given the potential rapid clinical decompensation and high mortality rate from SARIs, interventions that facilitate the early care are critical to improving patient outcomes. Through this systematic review, we aimed to evaluate the impact of emergency care interventions on improving clinical outcomes of paediatric patients with SARIs in LMICs. Methods: We searched PubMed, Global Health, and Global Index Medicus for peer-reviewed clinical trials or studies with comparator groups published before November 2020. We included all studies which evaluated acute and emergency care interventions on clinical outcomes for children (29 days to 19 years) with SARIs conducted in LMICs. Due to observed heterogeneity of interventions and outcomes, we performed narrative synthesis. We assessed bias using the Risk of Bias 2 and Risk of Bias in Non-Randomized Studies of Interventions tools. Results: We screened 20 583, 99 of which met the inclusion criteria. Conditions studied included pneumonia or acute lower respiratory infection (61.6%) and bronchiolitis (29.3%). Studies evaluated medications (80.8%), respiratory support (14.1%), and supportive care (5%). We found the strongest evidence of benefit for decreasing risk of death for respiratory support interventions. Results were inconclusive on the utility of continuous positive airway pressure (CPAP). We found mixed results for interventions for bronchiolitis, but a possible benefit for hypertonic nebulised saline to decrease hospital length of stay. Early use of adjuvant treatments such as Vitamin A, D, and zinc for pneumonia and bronchiolitis did not appear to have convincing evidence of benefit on clinical outcomes. Conclusions: Despite the high global burden of SARI in paediatric populations, few emergency care (EC) interventions have high quality evidence for benefit on clinical outcomes in LMICs. Respiratory support interventions have the strongest evidence for benefit. Further research on the use of CPAP in diverse settings is needed, as is a stronger evidence base for EC interventions for children with SARI, including metrics on the timing of interventions. Registration: PROSPERO (CRD42020216117).

Emergency unit assessment of seven tertiary hospitals in Nepal using the WHO tool: a cross-sectional study.

BACKGROUND: In 2021, the Nepal national emergency care system's assessment (ECSA) identified 39 activities and 11 facility-specific goals to improve care. To support implementation of the ECSA facility-based goals, this pilot study used the World Health Organization's (WHO) Hospital Emergency Unit Assessment Tool (HEAT) to evaluate key functions of emergency care at tertiary hospitals in Kathmandu, Nepal. METHODS: This cross-sectional study used the standardized HEAT assessment tool. Data on facility characteristics, human resources, clinical services, and signal functions were gathered via key informant interviews conducted by trained study personnel. Seven tertiary referral centers in the Kathmandu valley were selected for pilot evaluation including governmental, academic, and private hospitals. Descriptive statistics were generated, and comparative analyses were conducted. RESULTS: All facilities had continuous emergency care services but differed in the extent of availability of each item surveyed. Academic institutions had the highest rating with greater availability of consulting services and capacity to perform specific signal functions including breathing interventions and sepsis care. Private institutions had the highest infrastructure availability and diagnostic testing capacity. Across all facilities, common barriers included lack of training of key emergency procedures, written protocols, point-of-care testing, and ancillary patient services. CONCLUSION: This pilot assessment demonstrates that the current emergency care capacity at representative tertiary referral hospitals in Kathmandu, Nepal is variable with some consistent barriers which preclude meeting the ECSA goals. The results can be used to inform emergency care development within Nepal and demonstrate that the WHO HEAT assessment is feasible and may be instructive in systematically advancing emergency care delivery at the national level if implemented more broadly.

A systematic review of acute and emergency care interventions for adolescents and adults with severe acute respiratory infections including COVID-19 in low- and middle-income countries.

Background: Severe acute respiratory infections (SARIs) remain a leading cause of death globally, particularly in low- and middle-income countries (LMICs). Early intervention is critical, considering the potential for rapid decompensation in patients with SARIs. We aimed to evaluate the impact of acute and emergency care interventions on improving clinical outcomes in patients >10 years old with SARIs in LMICs. Methods: A systematic literature search was performed in PubMed, Global Health, and Global Index Medicus databases to identify peer-reviewed studies containing SARI, LMICs, and emergency care interventions. Studies published prior to November 2020 focusing on patients >10 years old were included. A narrative synthesis was performed due to the heterogeneity of identified articles. Risk of bias was assessed using the Risk of Bias 2 and Risk of Bias In Non-Randomized Studies of Interventions tools. Results: 20 223 studies were screened and 58 met the inclusion criteria. Thirty-four studies focused on coronavirus-2019 (COVID-19), 15 on pneumonia, seven on influenza, one study on severe acute respiratory syndrome, and one on undifferentiated SARI. Few COVID-19 studies found a benefit of the tested intervention on clinical status, mortality, or hospital length-of-stay. Little to no benefit was found for azithromycin, convalescent plasma, or zinc, and potential harm was found for hydroxychloroquine/chloroquine. There was mixed evidence for immunomodulators, traditional Chinese medicine, and corticosteroids among COVID-19 studies, with notable confounding due to a lack of consistency of control group treatments. Neuraminidase inhibitor antivirals for influenza had the highest quality of evidence for shortening symptom duration and decreasing disease severity. Conclusions: We found few interventions for SARIs in LMICs with have high-quality evidence for improving clinical outcomes. None of the included studies evaluated non-pharmacologic interventions or were conducted in low-income countries. Further studies evaluating the impact of antivirals, immunomodulators, corticosteroids, and non-pharmacologic interventions for SARIs in LMICs are urgently needed. Registration: PROSPERO registration number: CRD42020216117.

Introduction.

Since its inception, the World Health Organization's Emergency Medical Teams (EMT) Initiative has strived to save lives, preserve health, and alleviate suffering through inclusiveness, transparency, global cohesion, and regional adaptation of quality standards and methodology.1 The mission of the Global EMT Initiative is to enhance the surge capacity of countries through the promotion of rapid mobilization and efficient coordination of both national and international medical teams and health care workforce to reduce loss of life and prevent long-term disability because of disasters, outbreaks, and other emergencies.1Over the past decade, four EMT Global Meetings have been held and serve as a platform to foster collaboration and support among the global EMT community, which consists of clinicians and non-clinical providers, Member States, and partners. The gatherings in Geneva, Panama, Hong Kong, and Bangkok created momentum for the development of a global network and proved vital in guiding the direction of the initiative.Under the leadership of the EMT Strategic Advisory Group, the 2022 EMT Global Meeting in Yerevan convened over 500 participants from 110 countries and organizations. The event provided the network an opportunity to define a longer EMT strategy - EMT 2030 - which serves to strengthen national EMT and rapid response capacities as part of the global health emergency preparedness, response, and resilience (HEPR) architecture outlined by the 75th World Health Assembly in May 2022.2One of the four core objectives of the EMT 2030 strategy is to Strengthen information systems, evidence, and research. To further this objective, for the first time in 2022, the EMT secretariat introduced a research program into the EMT Global Meeting.The overall aim of research among EMTs is to support improvement of care provided to populations affected by emergencies, and therefore further the mission and vision of the EMT initiative. Even though the adoption of an experience-based strategy has had a positive impact in the past years, there is a need for an evidence-based generalizable guidance, aiming to increase predictability of response, strengthen advanced planning, and facilitate early actions. To this end, since late 2021, the EMT Secretariat has begun compiling a Global EMT Research Agenda, including documenting innovative solutions and products, deployments of national and international teams, and lessons learned from responses. The Secretariat also launched new platforms for advocacy and information exchange among the EMT Network.The 2022 EMT Global Meeting abstracts highlight the vast number of accomplishments that the EMT Network can and has already accomplished. From documenting the process of developing teams to modeling impact of effective responses, to demonstrating regional and sub-regional enhancements in knowledge sharing and after-action reviews of responses, there has been a wealth of experience presented in Yerevan. It is our pleasure to present them here.We look forward to strengthening the evidence base for EMT preparedness and response, with many of these abstracts developed further into manuscripts and more research to come.

A clinical case definition of post-COVID-19 condition by a Delphi consensus.

People with COVID-19 might have sustained postinfection sequelae. Known by a variety of names, including long COVID or long-haul COVID, and listed in the ICD-10 classification as post-COVID-19 condition since September, 2020, this occurrence is variable in its expression and its impact. The absence of a globally standardised and agreed-upon definition hampers progress in characterisation of its epidemiology and the development of candidate treatments. In a WHO-led Delphi process, we engaged with an international panel of 265 patients, clinicians, researchers, and WHO staff to develop a consensus definition for this condition. 14 domains and 45 items were evaluated in two rounds of the Delphi process to create a final consensus definition for adults: post-COVID-19 condition occurs in individuals with a history of probable or confirmed SARS-CoV-2 infection, usually 3 months from the onset, with symptoms that last for at least 2 months and cannot be explained by an alternative diagnosis. Common symptoms include, but are not limited to, fatigue, shortness of breath, and cognitive dysfunction, and generally have an impact on everyday functioning. Symptoms might be new onset following initial recovery from an acute COVID-19 episode or persist from the initial illness. Symptoms might also fluctuate or relapse over time. A separate definition might be applicable for children. Although the consensus definition is likely to change as knowledge increases, this common framework provides a foundation for ongoing and future studies of epidemiology, risk factors, clinical characteristics, and therapy.

The effects of mobile health on emergency care in low- and middle-income countries: A systematic review and narrative synthesis.

BACKGROUND: In resource-constrained settings, mobile health (mHealth) has varied applications. While there is strong evidence for its use in chronic disease management, the applications of mHealth for management of acute illness in low- and middle-income countries (LMICs) are not as well described. This review systematically explores current available evidence on the effectiveness of mHealth interventions at improving health outcomes in emergency care settings in LMICs. METHODS: A systematic search of the literature was performed in accordance with PRISMA guidelines, utilizing seven electronic databases and manual searches to identify peer-reviewed literature containing each of three search elements: mHealth, emergency care (EC), and LMICs. Articles quality was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. RESULTS: After removing duplicates, 6498 studies met initial search criteria; 108 were eligible for full text review and 46 met criteria for inclusion. Thirty-six pertained to routine emergency care, and 10 involved complex humanitarian emergencies. Based on the GRADE criteria, 15 studies were rated as "Very Low" quality, 24 as "Low" quality, 6 as "Moderate" quality, and 1 as "High" quality. Eight studied data collection, 9 studied decision support, 15 studied direct patient care, and 14 studied health training. All 46 studies reported positive impacts of mHealth on EC in LMICs. CONCLUSIONS: Mobile health interventions can be effective in improving provider-focused and patient-centered outcomes in both routine and complex EC settings. Future investigations focusing on patient-centered outcomes are needed to further validate these findings.

Injection Drug Use-Associated Candidemia: Incidence, Clinical Features, and Outcomes, East Tennessee, 2014-2018.

BACKGROUND: Injection drug use (IDU) is an established but uncommon risk factor for candidemia. Surveillance for candidemia is conducted in East Tennessee, an area heavily impacted by the opioid crisis and IDU. We evaluated IDU-associated candidemia to characterize the epidemiology and estimate the burden. METHODS: We assessed the proportion of candidemia cases related to IDU during January 1, 2014-September 30, 2018, estimated candidemia incidence in the overall population and among persons who inject drugs (PWID), and reviewed medical records to compare clinical features and outcomes among IDU-associated and non-IDU candidemia cases. RESULTS: The proportion of IDU-associated candidemia cases in East Tennessee increased from 6.1% in 2014 to 14.5% in 2018. Overall candidemia incidence in East Tennessee was 13.5/100 000, and incidence among PWID was 402-1895/100 000. Injection drug use-associated cases were younger (median age, 34.5 vs 60 years) and more frequently had endocarditis (39% vs 3%). All-cause 30-day mortality was 8% among IDU-associated cases versus 25% among non-IDU cases. CONCLUSIONS: A growing proportion of candidemia in East Tennessee is associated with IDU, posing an additional burden from the opioid crisis. The lower mortality among IDU-associated cases likely reflects in part the younger demographic; however, Candida endocarditis seen among approximately 40% underscores the seriousness of the infection and need for prevention.

Leveraging the COVID-19 response to improve emergency care systems in the Eastern Mediterranean Region.

The COVID-19 pandemic began as a cluster of reported cases of acute respiratory illness in China on 31 December 2019 and went on to spread with exponential growth across the globe. By the time it was characterized as a global pandemic on 11 March 2020, 17 of 22 countries in the Eastern Mediterranean Region (EMR) had reports of infected persons. EMR countries are particularly susceptible to such outbreaks due to the presence of globally interconnected markets; complex emergencies in more than half of the countries; religious mass gatherings that draw tens of millions of pilgrims annually; and variation in emergency care systems capacity and health systems performance within and between countries.

Lessons learned from an under-reported mumps epidemic among Rohingya refugees in Cox's Bazar District, Bangladesh.

BACKGROUND: In 2018, a large mumps epidemic coincided with an outbreak of diphtheria in refugee camps established in Bangladesh for the Rohingya people. These refugees did not receive a mumps-containing vaccine. METHODS: Cases of mumps were reported to the WHO's Early Warning, Alert and Response System (EWARS) during the Rohingya refugee crisis. The authors present amalgamated epidemiological data of a major, previously under-reported, mumps epidemic. RESULTS: In total, 19 215 mumps cases across a total of 218 facilities were reported to EWARS during 2018. The attack rate was 2.1% of the whole population. Of these cases, 7687 (40%) were in children aged <5 y. Mumps was more commonly seen among males than females. CONCLUSION: Detailed reporting of outbreaks of all vaccine-preventable diseases is essential to ensure appropriate vaccination decisions can be made in future humanitarian crises.

Remote Supervision in Short-Term Global Health Experiences.

The global health development community is increasingly examining the phenomenon of short-term experiences in global health (STEGH), with an aim to mitigate the negative impacts of such activities on host communities. Appropriate supervision is one strategy, but various barriers (e.g., institutional requirements) limit the availability of qualified supervisors. Remote supervision represents one potential model to provide supervision that may mitigate the negative impacts of STEGH. This paper reports observed outcomes from a description of a pilot remote supervision program employed in a global health program for Canadian undergraduate students. Benefits for learners included greater confidence and independence, greater perceived effectiveness in conducting their project abroad, and reassurance of remote support from their supervisor, supplemented with day-to-day guidance from the local partner. Host communities reported greater trust in the bidirectional nature of partnership with the visiting institution, empowerment through directing students' work, and improved alignment of projects with community needs. Finally, faculty noted that remote supervision provided greater flexibility and freedom when compared to traditional in-person supervision, allowing them to maintain professional duties at home. Collectively, this pilot suggests that remote supervision demonstrates a potential solution to mitigating the harms of STEGHs undertaken by learners by providing adequate and appropriate remote supervision.

Which Burn Outcomes Do Patients Anticipate as Most Likely to Be Important.

Burn therapies should focus on achieving outcomes that are most important to patients. The authors wanted to discover which outcomes newly burned patients would anticipate as most important to them and explored the association between demographic/burn characteristics and patient preferences. The authors surveyed 753 of 776 patients seen by our burn service from 2008 to 2013 during the initial encounter. Patients were asked to rate the anticipated importance of several burn outcomes including cosmetic appearance, resumption of normal function, and the lack of pain/itching on a four-item Likert scale (not important, somewhat important, important, and extremely important). The association between demographic and burn characteristics with patient's views on the importance of various outcomes was explored with χ and nonparametric tests. Patient mean (SD) age was 30 (22) years, 58% were males, 69% were white. Overall, function was extremely important to 96% of patients, lack of pain/itching was extremely important to 85% of patients, and cosmesis was extremely important to 59% of patients. Cosmesis was extremely important to more females than males (69 vs 52%; P < .001) and the mean age of patients in whom cosmesis was extremely important was lower than those in whom it was not (25 vs 40; P < .001). Cosmesis was more commonly extremely important in patients with head/neck than extremity burns (67 vs 57%; P < .001). Levels of importance for function and lack of pain/itching did not differ by gender, age, TBSA, or burn location. Thus, return to normal function and lack of pain and itching appear to be more commonly very important to burn patient than the cosmetic appearance of their burns. Cosmesis was of greater importance to younger patients, female patients, and those with head/neck burns.

Infrared Thermal Imaging Has the Potential to Reduce Unnecessary Surgery and Delays to Necessary Surgery in Burn Patients.

Clinical distinction between superficial and deep burns is problematic. The authors determined whether an infrared thermal imaging (IRTI) camera could predict burn depth. Burn depth was assessed by an experienced surgeon, and the burns were imaged with a portable, lightweight IRTI camera that measures heat emission from the skin using long infrared wavelengths (7.5-13 µm). Burns were considered "deep" if they were surgically excised and confirmed to be of full thickness on microscopic evaluation or if they did not heal spontaneously within 21 days of injury. All other burns were considered "nondeep." There were 39 burns that had both days 1 and 2 IRTI measurements and available outcome. Of these, 16 were "deep" burns and 23 were "nondeep." The mean temperatures of "nondeep" burns between days 1 and 2 increased from 30.6 ± 2.7 to 32.1 ± 3.0°C (difference of 1.5 ± 2.3°C). The mean temperatures of "deep" burns decreased from 32.3 ± 2.0 to 30.8 ± 1.3°C (difference of -1.5 ± 2.0°C) between days 1 and 2. Any decrease in temperatures between days 1 and 2 was predictive of a deep wound, and any increase between days 1 and 2 was predictive of a nondeep burn. Using the ultimate burn depth as the criterion standard, the overall accuracy of IRTI was considerably higher than that of clinical assessment; 87.2% (95% CI: 71.8-95.2) vs 54.1% (95% CI: 37.1-70.2). Any decrease in temperatures between days 1 and 2 was predictive of a deep wound. Our results suggest that thermography using IRTI is more accurate than clinical examination in predicting burn depth and could potentially reduce unnecessary surgery as well as reduce delays to surgery when necessary.

Tc-99m mebrofenin hepatobiliary scan in obstructive hepatobiliary disease: determining causes with early and late delayed imaging.

Hepatobiliary radionuclide imaging is typically performed to detect cholecystitis. Infrequently, imaging reveals an obstructive pattern. Although delayed hepatobiliary imaging is commonly used to differentiate between intrahepatic (IH) and extrahepatic (EH) obstruction in the newborn; there is room to clarify the use of delayed imaging in the adult population. A retrospective review was performed of adult patients demonstrating a complete obstructive pattern on initial Tc-99m mebrofenin hepatobiliary imaging. Delayed imaging was divided into early delayed (ED) (<10 h) and late delayed (LD) (≥10 h) imaging. Two physicians qualified the presence of intestinal radiotracer (negative, low to high) on delayed images. Determination of EH or IH pathology was obtained from chart review. A total of 24 patients demonstrated an obstructive pattern using delayed Tc-99m mebrofenin hepatobiliary imaging, with delayed imaging ranging from 4 to 30 h. EH pathologies (choledocholithiasis, stricture, other) represented 63% of cases (n = 15), IH pathologies (cirrhosis, hepatitis, other) represented 33% cases (n = 8) and 1 case was indeterminate. 67% of EH cases showed intestinal activity on delayed imaging (67% on ED and 67% on LD imaging), whereas 63% of IH cases showed intestinal activity on delayed imaging (67% on ED imaging and 60% on LD imaging). The presence of intestinal activity on the both the early and delayed images did not differentiate between the IH and EH pathology groups. Subdividing the groups into ED imaging and LD imaging was also not predictive of determining location of obstructive pattern on the initial 1 h of imaging. This data suggests that delayed hepatobiliary scintigraphy has little or no role in determining the cause of obstructive pathology.