COVID-19 outbreak in Brazil: adherence to national preventive measures and impact on people's lives, an online survey.

BACKGROUND: The first case of COVID-19 infection was diagnosed in Brazil 26th February 2020. By March 16th, physical distancing and confinement measures were implemented by the Brazilian government. Little is known about how these measures were followed up by the Brazilian people and their impact on daily routine. METHODS: In early April 2020, using an online platform, we organized an online survey among adults living in Brazil about their COVID-19 preventive behavior and impact on their daily routine. RESULTS: Data from 23,896 respondents were analyzed (mean age: 47.4 years). Due to COVID-19 restrictions, half (51.1%) of the professionals reported working from home. Regular handwashing was practiced by 98.7% of participants; 92.6% reported adhering to the 1.5-2 m physical distancing rule, but only 45.5% wore a face mask when going outside. While 29.3% of respondents found it relatively easy to stay at home, indoor confinement was extremely difficult for 7.9% of participants. Moreover, 11% of participants were extremely worried about their health during the COVID-19 epidemic. Younger people, male, persons living in a rural area/village or popular neighbourhoods, students and workers reported less preventive behaviour. CONCLUSION: Restrictive measures markedly affected the daily and professional routines of Brazilians. Participants showed a satisfactory level of adherence to national COVID-19 prevention guidelines. Qualitative and follow-up studies are needed to monitor the impact of COVID-19 in the Brazilian society.

Impact of the COVID-19 Pandemic on the Medical Follow-up and Psychosocial Well-Being of People Living With HIV: A Cross-Sectional Survey.

BACKGROUND: Empirical data on the consequences of the novel coronavirus disease (COVID-19) pandemic on HIV care are lacking. We surveyed people living with HIV (PLWH) in different countries to investigate whether their medical follow-up and psychosocial well-being had been compromised due to COVID-19 and associated restrictions. METHODS: In April 2020, a cross-sectional survey among PLWH was conducted using a web-based multilingual questionnaire. The research tool assessed HIV follow-up, psychosocial well-being, COVID-19 (flu-like) symptoms and prevention measures. Consenting respondents provided answers anonymously. RESULTS: Three hundred seventeen PLWH were included (mean age 43.4 ± 11.7; 71.6% men); 60.3% of participants resided in Belgium and Brazil. One hundred forty (44.2%) reported experiencing a cold with at least one flu-like symptom since January 2020. Of the 18 who reported COVID-19 test results, 4 (22.2%) were positive. Seventy-four (23.3%) respondents screened positive for major depressive disorders, whereas 72 (22.7%) had generalized anxiety disorders. Fifty-six (17.7%) respondents reported difficulties in obtaining antiretroviral medications because of COVID-19-related measures. Adaptations of HIV care during the COVID-19 outbreak included greater quantities of antiretroviral refill in 67 (21.1%), phone consultations in 25 (7.9%), and new refill sites in 12 (3.9%). Factors associated with a reduced risk of experiencing flu-like symptoms included flu vaccination during the past 12 months (P = 0.005) and adaptations of HIV care during the COVID-19 pandemic (P = 0.010). CONCLUSION: COVID-19 and associated restrictive measures seem detrimental to the well-being and follow-up of PLWH. We recommend that health systems devise innovative approaches for antiretroviral provision and psychosocial support to PLWH during such outbreaks.

Introduction of a standardised protocol, including systematic use of tranexamic acid, for management of severe adult trauma patients in a low-resource setting: the MSF experience from Port-au-Prince, Haiti.

BACKGROUND: Bleeding is an important cause of death in trauma victims. In 2010, the CRASH-2 study, a multicentre randomized control trial on the effect of tranexamic acid (TXA) administration to trauma patients with suspected significant bleeding, reported a decreased mortality in randomized patients compared to placebo. Currently, no evidence on the use of TXA in humanitarian, low-resource settings is available. We aimed to measure the hospital outcomes of adult patients with severe traumatic bleeding in the Médecins Sans Frontières Tabarre Trauma Centre in Port-au-Prince, Haiti, before and after the implementation of a Massive Haemorrhage protocol including systematic early administration of TXA. METHODS: Patients admitted over comparable periods of four months (December2015- March2016 and December2016 - March2017) before and after the implementation of the Massive Haemorrhage protocol were investigated. Included patients had blunt or penetrating trauma, a South Africa Triage Score ≥ 7, were aged 18-65 years and were admitted within 3 h from the traumatic event. Measured outcomes were hospital mortality and early mortality rates, in-hospital time to discharge and time to discharge from intensive care unit. RESULTS: One-hundred and sixteen patients met inclusion criteria. Patients treated after the introduction of the Massive Haemorrhage protocol had about 70% less chance of death during hospitalization compared to the group "before" (adjusted odds ratio 0.3, 95%confidence interval 0.1-0.8). They also had a significantly shorter hospital length of stay (p = 0.02). CONCLUSIONS: Implementing a Massive Haemorrhage protocol including early administration of TXA was associated with the reduced mortality and hospital stay of severe adult blunt and penetrating trauma patients in a context with poor resources and limited availability of blood products.

The modified south African triage scale system for mortality prediction in resource-constrained emergency surgical centers: a retrospective cohort study.

BACKGROUND: The South African Triage Scale (SATS) was developed to facilitate patient triage in emergency departments (EDs) and is used by Médecins Sans Frontières (MSF) in low-resource environments. The aim was to determine if SATS data, reason for admission, and patient age can be used to develop and validate a model predicting the in-hospital risk of death in emergency surgical centers and to compare the model's discriminative power with that of the four SATS categories alone. METHODS: We used data from a cohort hospitalized at the Nap Kenbe Surgical Hospital in Haiti from January 2013 to June 2015. We based our analysis on a multivariate logistic regression of the probability of death. Age cutoff, reason for admission categorized into nine groups according to MSF classifications, and SATS triage category (red, orange, yellow, and green) were used as candidate parameters for the analysis of factors associated with mortality. Stepwise backward elimination was performed for the selection of risk factors with retention of predictors with P < 0.05, and bootstrapping was used for internal validation. The likelihood ratio test was used to compare the combined and restricted models. These models were also applied to data from a cohort of patients from the Kunduz Trauma Center, Afghanistan, to validate mortality prediction in an external trauma patients population. RESULTS: A total of 7618 consecutive hospitalized patients from the Nap Kenbe Hospital were analyzed. Variables independently associated with in-hospital mortality were age > 45 and < = 65 years (odds ratio, 2.04), age > 65 years (odds ratio, 5.15) and the red (odds ratio, 65.08), orange (odds ratio, 3.5), and non-trauma (odds ratio, 3.15) categories. The combined model had an area under the receiver operating characteristic curve (AUROC) of 0.8723 and an AUROC corrected for optimism of 0.8601. The AUROC of the model run on the external data-set was 0.8340. The likelihood ratio test was highly significant in favor of the combined model for both the original and external data-sets. CONCLUSIONS: SATS category, patient age, and reason for admission can be used to predict in-hospital mortality. This predictive model had good discriminative ability to identify ED patients at a high risk of death and performed better than the SATS alone.

Emergency department care for trauma patients in settings of active conflict versus urban violence: all of the same calibre?

BACKGROUND: Trauma is a leading cause of death and represents a major problem in developing countries where access to good quality emergency care is limited. Médecins Sans Frontières delivered a standard package of care in two trauma emergency departments (EDs) in different violence settings: Kunduz, Afghanistan, and Tabarre, Haiti. This study aims to assess whether this standard package resulted in similar performance in these very different contexts. METHODS: A cross-sectional study using routine programme data, comparing patient characteristics and outcomes in two EDs over the course of 2014. RESULTS: 31 158 patients presented to the EDs: 22 076 in Kunduz and 9082 in Tabarre. Patient characteristics, such as delay in presentation (29.6% over 24 h in Kunduz, compared to 8.4% in Tabarre), triage score, and morbidity pattern differed significantly between settings. Nevertheless, both EDs showed an excellent performance, demonstrating low proportions of mortality (0.1% for both settings) and left without being seen (1.3% for both settings), and acceptable triage performance. Physicians' maximum working capacity was exceeded in both centres, and mainly during rush hours. CONCLUSIONS: This study supports for the first time the plausibility of using the same ED package in different settings. Mapping of patient attendance is essential for planning of human resources needs.

Open Source Software For Patient Data Management In Critical Care.

We have previously developed a Patient Data Management System for Intensive Care based on Open Source Software. The aim of this work was to adapt this software to use in Emergency Departments in low resource environments. The new software includes facilities for utilization of the South African Triage Scale and prediction of mortality based on independent predictive factors derived from data from the Tabarre Emergency Trauma Center in Port au Prince, Haiti.

Saving life and limb: limb salvage using external fixation, a multi-centre review of orthopaedic surgical activities in Médecins Sans Frontières.

PURPOSE: While the orthopaedic management of open fractures has been well-documented in developed settings, limited evidence exists on the surgical outcomes of open fractures in terms of limb salvage in low- and middle-income countries. We therefore reviewed the Médecins Sans Frontières-Operational Centre Brussels (MSF-OCB) orthopaedic surgical activities in the aftermath of the 2010 Haiti earthquake and in three non-emergency projects to assess the limb salvage rates in humanitarian contexts in relation to surgical staff skills. METHODS: This was a descriptive retrospective cohort study conducted in the MSF-OCB surgical programmes in the Democratic Republic of Congo (DRC), Afghanistan, and Haiti. Routine programme data on surgical procedures were aggregated and analysed through summary statistics. RESULTS: In the emergency post-earthquake response in Haiti, 81% of open fracture cases were treated by amputation. In a non-emergency project in a conflict setting in DRC, relying on non-specialist surgeons receiving on-site supervision and training by experienced orthopaedic surgeons, amputation rates among open fractures decreased by 100 to 21% over seven years of operations. In two trauma centres in Afghanistan (national surgical staff supported from the outset by expatriate orthopaedic surgeons) and Haiti (national musculoskeletal surgeons trained in external fixation), amputation rates among long bone open fracture cases were stable at 20% and <10%, respectively. CONCLUSIONS: Introduction of and training on the proper use of external fixators reduced the amputation rate for open fractures and consequently increased the limb salvage rates in humanitarian contexts where surgical care was provided.