Incorporating COVID-19 into Acute Febrile Illness Surveillance Systems, Belize, Kenya, Ethiopia, Peru, and Liberia, 2020-2021.

Existing acute febrile illness (AFI) surveillance systems can be leveraged to identify and characterize emerging pathogens, such as SARS-CoV-2, which causes COVID-19. The US Centers for Disease Control and Prevention collaborated with ministries of health and implementing partners in Belize, Ethiopia, Kenya, Liberia, and Peru to adapt AFI surveillance systems to generate COVID-19 response information. Staff at sentinel sites collected epidemiologic data from persons meeting AFI criteria and specimens for SARS-CoV-2 testing. A total of 5,501 patients with AFI were enrolled during March 2020-October 2021; >69% underwent SARS-CoV-2 testing. Percentage positivity for SARS-CoV-2 ranged from 4% (87/2,151, Kenya) to 19% (22/115, Ethiopia). We show SARS-CoV-2 testing was successfully integrated into AFI surveillance in 5 low- to middle-income countries to detect COVID-19 within AFI care-seeking populations. AFI surveillance systems can be used to build capacity to detect and respond to both emerging and endemic infectious disease threats.

Evaluating the Clinical Impact of a Novel Pediatric Emergency Medicine Curriculum on Asthma Outcomes in Belize.

BACKGROUND: Respiratory-related complaints prompt most pediatric visits to Karl Heusner Memorial Hospital Authority's (KHMHA) Emergency Department (ED) in Belize. We developed and taught a novel pediatric respiratory emergencies module for generalist practitioners there. We assessed the curriculum's clinical impact on pediatric asthma emergency management. OBJECTIVE: This study assesses the clinical impact of a pediatric emergency medicine curriculum on management of pediatric asthma emergencies at KHMHA in Belize City, Belize. METHODS: We conducted a randomized chart review of pediatric (aged 2-16 y) visits for asthma-related diagnosis at the KHMHA ED between 2015 and 2018 to assess the training module's clinical impact. Primary outcomes included time to albuterol and steroids. Secondary outcomes included clinical scoring tool (Pediatric Respiratory Assessment Measure [PRAM]) usage, ED length of stay, usage of chest radiography, return visit within 7 days, and hospital admission rates. Kaplan-Meier survival analysis and Cox proportional hazard regression were used. RESULTS: Two hundred eighty-three pediatric asthma-related diagnoses met our inclusion criteria. The patients treated by trained and untrained physician groups were demographically and clinically similar. The time to albuterol was significantly faster in the trained (intervention) group compared with the untrained (control) physician group when evaluating baseline of the group posttraining (P < 0.05). However, the time to steroids did not reach statistical significance posttraining (P = 0.93). The PRAM score utilization significantly increased among both control group and intervention group. The untrained physician group was more likely to use chest radiography or admit patients. The trained physician group had higher return visit rates within 7 days and shorter ED length of stay, but this did not reach statistical significance. CONCLUSIONS: The curriculum positively impacted clinical outcomes leading to earlier albuterol administration, increased PRAM score use, obtaining less chest radiographs, and decreased admission rates. The timeliness of systemic steroid administration was unaffected.

Epidemiological and Clinical Characteristics of Acute Dengue Virus Infections Detected through Acute Febrile Illness Surveillance, Belize 2020.

The Acute Febrile Illness (AFI) Surveillance Network in Belize is a country-wide active surveillance program aimed at diagnosing vector-borne, respiratory, and enteric pathogens among patients presenting to 11 participating hospitals and clinics with new onset fever. This study describes the epidemiology of dengue virus (DENV) infections in Belize diagnosed through AFI surveillance in 2020. Of the 894 patients enrolled and PCR-tested for DENV in this period, 44 DENV-positive cases (5%) were identified. All four DENV serotypes were detected, with two cases testing positive for DENV serotype 4, which is the first report of this serotype in Belize since 2004. The majority of DENV cases (66%) were diagnosed in the Belize District, which contains the largest urban center in the country (Belize City). Positive cases were detected between January 2020 and September 2020, with the majority (89%) diagnosed during the dry season between January and April, unlike years prior when cases were more often diagnosed during the wet season. Clinical signs and symptoms varied slightly between DENV serotypes. Active surveillance of DENV among AFI cases provides insight into the epidemiologic and clinical characteristics of DENV in Belize. This information is important for informing public health interventions to mitigate DENV transmission.

A Pediatric Emergency Medicine Refresher Course for Generalist Healthcare Providers in Belize: Respiratory Emergencies.

Audience and type of curriculum: This is a refresher curriculum utilizing multiple methods of education to augment the skills of generalist healthcare providers in low- and middle-income countries (LMICs) in the identification and stabilization of pediatric respiratory emergencies. Our audience of implementation was Belizean generalist providers. Length of curriculum: Nine hours. Introduction: In the pediatric population, early recognition and stabilization can improve patient outcomes. Compared with many Western systems that rely on specialists and even subspecialists, in many lower-resource settings, generalists provide most emergency medical care. The purpose of this module is to present a curriculum focused on the identification and stabilization of common pediatric respiratory emergencies for general practitioners (physicians and nurses) working in the acute care setting. Our aim is to provide a care framework and refresher training for the management of pediatric respiratory emergencies for providers who may regularly see the acutely ill pediatric patient but who may not have had recent or any extensive teaching in the management of acute pediatric airway management, bronchiolitis, pneumonia, and asthma. Educational Goals: This curriculum presents a refresher course in recognizing and stabilizing pediatric acute respiratory complaints for generalist healthcare providers practicing in LMICs. Our goal is to implement this curriculum in the small LMIC of Belize. This module focuses on common respiratory complaints, including asthma, bronchiolitis, pneumonia and acute airway management. Educational Methods: The educational strategies used in this curriculum include didactic lectures, medical simulation, small-group sessions, and a skills lab. Research Methods: We scored written pretests before and posttests after intervention and retested participants to evaluate for knowledge retention. Participants provided qualitative feedback on the module. Results: We taught 26 providers. Twenty-one providers completed the posttest and eight completed the retest. The mean test scores improved from 8.3 ± 2.8 in the pretest to 9.7 ± 1.3 to the posttest (mean difference = 1.4; P = 0.027). The mean test score at pretest was 8.0 ± 4.0, which increased to 9.9 ± 2.5 at retest four months later (mean difference = 1.9, P = 0.049). Fifteen (71.4%) participants found the course "extremely useful," and 28 (28.5%) participants "very useful." Discussion: This curriculum is an effective and well-received training tool for Belizean generalist providers. Although limited by sample size and 20% attrition for the retest, there was a statistically significant improvement in test performance. We believe that our pilot in Belize shows that this type of refresher course could be useful for teaching generalist providers in LMICs to optimize care of the acutely ill pediatric patient with respiratory ailment. Evaluation of other modules in this curriculum, application of the curriculum in other locations, and measuring clinical patient outcomes will be included in future investigations. Topics: Medical simulation, rapid cycle deliberate practice (RCDP), Belize, bronchiolitis, pneumonia, asthma, airway, respiratory distress, low- and middle-income country (LMIC), collaboration, global health.

Assessment of Attitudes Toward the Emergency Triage System in Belize.

Objective. Triage in resource-limited settings (RLS) improves outcomes. Emergency Triage Assessment and Treatment (ETAT) is a simple triage algorithm that improves assessment and initial management of children in RLS. In Belize, pediatric triage varies with setting, from a 5-level Emergency Severity Index (ESI) used at the National Referral Hospital to a lack of triage at government health centers (GHC). Most data on ETAT implementation are in settings where no triage system existed; data on how to integrate ETAT into existing, heterogeneous triage systems are lacking. The aim of this study is to explore health care providers' (HCPs) attitudes toward the current triage system prior to national pediatric triage process implementation. Methods. A qualitative study was performed via convenience sampling of HCPs who participated in an ETAT training course using focus groups immediately and 1 year after an initial ETAT training. Focus groups were digitally recorded and transcribed. Three coders analyzed all transcripts to identify emerging themes. Constant comparison analysis was performed until achieving thematic saturation. Results. The following principal themes emerged: (1) importance of triage education and implementation to standardize and improve communication; (2) major limitations of ESI include its complexity, lack of pediatric-specific criteria, and dependence on equipment not consistently available; and (3) desire to implement a simple, low-resource pediatric-specific triage system. Conclusions. Participants believe triage education and process implementation is essential to improve communication and pediatric emergency care. Simple, low-resource pediatric-specific triage systems, like ETAT, may improve utilization by providing faster recognition and improved care for acutely ill children.

Developing an Accident and Emergency HIV Testing Program in Belize City: Recommendations from Key Stakeholders.

With the ultimate goal of developing an accident and emergency (A&E) department HIV testing program in Belize City, Belize, we sought input from key stakeholders on program components and potential facilitators and barriers to HIV testing in emergency care. We conducted semistructured interviews among 4 key stakeholder groups at Karl Heusner Memorial Hospital Authority (KHMHA) in Belize City: (1) 20 A&E patients, (2) 5 A&E physicians, (3) 5 A&E nurses, and (4) 5 KHMHA administrators. We performed a qualitative content analysis of the interview transcripts and isolated important themes. Major themes included: (1) Patient selection: patients preferred to test all A&E patients. All other stakeholder groups preferred testing specific patient groups. (2) Training: Specific training should be completed for staff. (3) Confidentiality: integral for testing. (4) Facilitators and barriers: facilitators included respectful relationships, privacy, resources, coordination, and education. Barriers included stigmatization, patient willingness, inadequate resources, privacy, and testing biases.

International Emergency Psychiatry Challenges: Disaster Medicine, War, Human Trafficking, Displaced Persons.

Mental health disorders are a major cause of morbidity and a growing burden in low-income and middle-income countries; but there is little existing literature on the detailed epidemiology, diagnosis, and treatment in low-resource settings. Special situations with vulnerable populations, such as those created by international humanitarian emergencies, refugees or internally displaced people, and victims of human trafficking, are increasing in prevalence. These victims are often resettled in developed countries and come to the emergency department seeking care. To better care for these populations, knowledge of specialized psychosocial and cultural considerations should inform the comprehensive psychiatric assessment and treatment plan.

Global Health and Emergency Care: Overcoming Clinical Research Barriers.

OBJECTIVES: There are many barriers impeding the conduct of high-quality emergency care research, particularly in low- and middle-income countries. Several of these barriers were originally outlined in 2013 as part of the Academic Emergency Medicine Global Health and Emergency Care Consensus Conference. This paper seeks to establish a broader consensus on the barriers to emergency care research globally and proposes a comprehensive array of new recommendations to overcome these barriers. METHODS: An electronic survey was conducted of a purposive sample of global emergency medicine research experts from around the world to describe the major challenges and solutions to conducting emergency care research in low-resource settings and rank them by importance. The Global Emergency Medicine Think Tank Clinical Research Working Group at the Society for Academic Emergency Medicine 2016 Annual Meeting utilized a modified Delphi technique for consensus-based decision making to categorize and expand upon these barriers and develop a comprehensive array of proposed solutions. RESULTS: The working group identified four broad categories of barriers to conducting emergency care research globally, including 1) the limited availability of research personnel, particularly those with prior research training; 2) logistic barriers and lack of standardization of data collection; 3) ethical barriers to conducting research in resource-limited settings, particularly when no local institutional review board is available; and 4) the relative dearth of funding for global emergency care research. Proposed solutions included building a diverse and interdisciplinary research team structured to promote mentorship of junior researchers, utilizing local research assistants or technologic tools such as telemedicine for language translation, making use of new tools such as mobile health (mHealth) to standardize and streamline data collection, identifying alternatives to local institutional review board approval and the use of community consent when appropriate, and increased advocacy for global emergency care research funding. CONCLUSIONS: Significant barriers to the conduct of high-quality global emergency care research persist, and innovative strategies need to be adopted to promote and grow the field of global emergency care research. This paper provides a global consensus on the most important barriers identified, as well as recommendations for cost-effective strategies for overcoming these barriers with the overall goal of promoting high-quality research and improving emergency care worldwide.

Reconstitution in vitro of MSP-based filopodium extension in nematode sperm.

The major sperm protein (MSP) motility system in nematode sperm is best known for propelling the movement of mature sperm, where it has taken over the role usually played by actin in amoeboid cell motility. However, MSP filaments also drive the extension of filopodia, transient organelles composed of a core bundle of MSP filaments, that form in the late in sperm development but are not found on crawling cells. We have reconstituted filopodial extension in vitro whereby thin bundles of MSP filaments, each enveloped by a membrane sheath at their growing end, elongated at rates up to 17 microm/min. These bundles often exceeded 500 microm in length but were comprised of filaments only 1 microm long. The reconstituted filopodia assembled in the same cell-free sperm extracts that produced MSP fibers, robust meshworks of filaments that exhibit the same organization and dynamics as the lamellipodial filament system that propels sperm movement. The filopodia and fibers that assembled in vitro both had a membranous structure at their growing end, shared four MSP accessory proteins, and responded identically to agents that alter MSP-based motility by modulating protein phosphorylation. However, filopodia grew three- to four-fold faster than fibers. The reconstitution of filopodial extension shows that, like the actin cytoskeleton, MSP filaments can adopt two architectures, bundles and meshworks, each capable of pushing against membranes to generate protrusion. The reconstitution of both forms of motility in the same in vitro system provides a promising avenue for understanding how the forces for membrane protrusion are produced.