Primary series COVID-19 vaccine effectiveness among healthcare workers in Albania, February-December 2021.

Background: Healthcare workers have experienced high rates of morbidity and mortality from coronavirus disease 2019 (COVID-19). Methods: A prospective cohort study was conducted in three Albanian hospitals between 19 February and 14 December 2021. All participants underwent polymerase chain reaction (PCR) and serological testing at enrolment, regular serology throughout, and PCR testing when symptomatic.Vaccine effectiveness (VE) against COVID-19 and against all severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infections (symptomatic or asymptomatic) was estimated. VE was estimated using a Cox regression model, with vaccination status as a time-varying variable. Findings: In total, 1504 HCWs were enrolled in this study; 70% had evidence of prior SARS-CoV-2 infection. VE was 65.1% [95% confidence interval (CI) 37.7-80.5] against COVID-19, 58.2% (95% CI 15.7-79.3) among participants without prior SARS-CoV-2 infection, and 73.6% (95% CI 24.3-90.8) among participants with prior SARS-CoV-2 infection. For BNT162b2 alone, VE was 69.5% (95% CI 44.5-83.2). During the period when the Delta variant was predominant, VE was 67.1% (95% CI 38.3-82.5). VE against SARS-CoV-2 infection for the full study period was 36.9% (95% CI 15.8-52.7). Interpretation: This study found moderate primary series VE against COVID-19 among healthcare workers in Albania. These results support the continued promotion of COVID-19 vaccination in Albania, and highlight the benefits of vaccination in populations with high levels of prior infection.

Factors associated with receipt of COVID-19 vaccination and SARS-CoV-2 seropositivity among healthcare workers in Albania (February 2021-June 2022): secondary analysis of a prospective cohort study.

Background: Healthcare workers (HCWs) have been disproportionally affected by COVID-19. We investigated factors associated with two- and three-dose COVID-19 vaccine uptake and SARS-CoV-2 seropositivity among 1504 HCWs enrolled (19 February-7 May 2021) in a prospective COVID-19 vaccine effectiveness cohort in Albania through a secondary analysis. Methods: We collected sociodemographic, occupational, health, prior SARS-CoV-2 infection, and COVID-19 vaccination data from all HCWs at enrollment. Vaccination status was assessed weekly through June 2022. A serum sample was collected from all participants at enrollment and tested for anti-spike SARS-CoV-2 antibodies. We analyzed HCWs characteristics and outcomes using multivariable logistic regression. Findings: By 11 June 2022, 1337 (88.9%) HCWs had received two COVID-19 vaccine doses, of whom 255 (19.1%) received a booster. Factors significantly associated with receiving three doses (adjusted odds ratio (aOR), 95% CIs) were being ≥35 years (35-44 years: 1.76 (1.05-2.97); 45-54 years: 3.11 (1.92-5.05); ≥55 years: 3.38 (2.04-5.59)) and vaccinated against influenza (1.78; 1.20-2.64). Booster dose receipt was lower among females (0.58; 0.41-0.81), previously infected (0.67; 0.48-0.93), nurses and midwives (0.31; 0.22-0.45), and support staff (0.19; 0.11-0.32). Overall 1076 (72%) were SARS-CoV-2 seropositive at enrollment. Nurses and midwifes (1.45; 1.05-2.02), support staff (1.57; 1.03-2.41), and HCWs performing aerosol-generating procedures (AGPs) (1.40; 1.01-1.94) had higher odds of being seropositive, while smokers had reduced odds (0.55; 0.40-0.75). Interpretation: In a large cohort of Albanian HCWs, COVID-19 vaccine booster dose uptake was very low, particularly among younger, female, and non-physician HCWs, despite evidence demonstrating the added benefit of boosters in preventing infection and severe disease. Reasons behind these disparities should be explored to develop targeted strategies in order to promote uptake in this critical population. SARS-CoV-2 seroprevalence was higher among non-physicians and HCWs performing APGs. A better understanding of the factors contributing to these differences is needed to inform interventions that could reduce infections in the future. Funding: This study was funded by the Task Force for Global Health (US Centers for Disease Control (CDC) cooperative agreement # NU51IP000873) and the World Health Organization, Regional Office for Europe.

"No diversion": a qualitative study of emergency medicine leaders in Boston, MA, and the effects of a statewide diversion ban policy.

STUDY OBJECTIVE: We examine the attitudes of emergency department (ED) key informants about the perceived effects of a statewide ban on ambulance diversion on patients, providers, and working relationships in a large urban emergency medical system. METHODS: We performed a qualitative study to examine the effects of a diversion ban on Boston area hospitals. Key informants at each site completed semistructured interviews that explored relevant domains pre- and postban. Interviews were deidentified, transcribed, coded, and analyzed with grounded theory for emerging themes. We identified important themes focused on patient safety, quality of care, and relationships before and after implementation of the diversion ban. RESULTS: Nine of 9 eligible sites participated. Eighteen interviews were completed: 7 MD ED directors, 2 MD designees, and 9 registered nurse leaders. Although most participants had negative opinions about diversion, some had considered diversion a useful procedure. Key themes associated with diversion were adverse effects on patient care quality, patient satisfaction, and a source of conflict among ED staff and with emergency medical services (EMS). All key informants described some positive effect of the ban, including those who reported that the ban had no direct effect on their individual hospital. Although the period preceding the ban was reported to be a source of apprehension about its effects, most key informants believed the ban had improved quality of care and relationships between hospital staff and EMS. CONCLUSION: Key informants considered the diversion ban to have had a favorable effect on emergency medical care in Boston. These results may inform the discussion in other states considering a diversion ban.

Implementation of a rapid HIV testing programme favourably impacts provider opinions on emergency department HIV testing.

OBJECTIVE: To assess staff knowledge of Centers for Disease Control (CDC) guidelines, attitudes and barriers towards emergency department (ED) HIV testing before and after implementing an ED rapid HIV testing programme (EDRHTP). METHODS: We conducted a cross-sectional pre/post survey at an urban academic medical centre. In March 2009, ED registered nurses (RNs) and doctors (MDs) participated in an anonymous survey. An EDRHTP was established in September 2009, and in March 2011, the survey was redistributed to ED staff. Differences before and after programme implementation were assessed using χ(2) statistics or Fisher's exact test. RESULTS: Respondents reported greater familiarity with CDC guidelines after programme implementation (44% vs 59%, p=0.04) and more believed that HIV testing should be offered to all ED patients (44% vs 79%, p<0.0001). Prior to programme implementation, RNs and MDs differed in attitudes towards ED HIV testing across most questions, and differences disappeared post programme. CONCLUSIONS: Overall support for ED HIV testing increased after establishment of a rapid testing programme.

Psychosocial adjustment and mental health in former child soldiers--systematic review of the literature and recommendations for future research.

AIMS AND SCOPE: This article reviews the available quantitative research on psychosocial adjustment and mental health among children (age <18 years) associated with armed forces and armed groups (CAAFAG)--commonly referred to as child soldiers. METHODS: PRISMA standards for systematic reviews were used to search PubMed, PsycInfo, JSTOR, and Sociological Abstracts in February 2012 for all articles on former child soldiers and CAAFAG. Twenty-one quantitative studies from 10 countries were analyzed for author, year of publication, journal, objectives, design, selection population, setting, instruments, prevalence estimates, and associations with war experiences. Opinion pieces, editorials, and qualitative studies were deemed beyond the scope of this study. Quality of evidence was rated according to the systematic assessment of quality in observational research (SAQOR). FINDINGS: According to SAQOR criteria, among the available published studies, eight studies were of high quality, four were of moderate quality, and the remaining nine were of low quality. Common limitations were lack of validated mental health measures, unclear methodology including undefined sampling approaches, and failure to report missing data. Only five studies included a comparison group of youth not involved with armed forces/armed groups, and only five studies assessed mental health at more than one point in time. Across studies, a number of risk and protective factors were associated with postconflict psychosocial adjustment and social reintegration in CAAFAG. Abduction, age of conscription, exposure to violence, gender, and community stigma were associated with increased internalizing and externalizing mental health problems. Family acceptance, social support, and educational/economic opportunities were associated with improved psychosocial adjustment. CONCLUSIONS: Research on the social reintegration and psychosocial adjustment of former child soldiers is nascent. A number of gaps in the available literature warrant future study. Recommendations to bolster the evidence base on psychosocial adjustment in former child soldiers and other war-affected youth include more studies comprising longitudinal study designs, and validated cross-cultural instruments for assessing mental health, as well as more integrated community-based approaches to study design and research monitoring.

Impact of an emergency department closure on the local emergency medical services system.

BACKGROUND: On July 12, 2010, Boston Medical Center (BMC), the busiest emergency department (ED) in Massachusetts, with more than 100,000 adult patient visits per year, consolidated its two fully functional EDs into one. In preparation for this consolidation, BMC implemented systems changes to mitigate potential negative effects on both BMC and emergency medical services (EMS) providers, including Boston Emergency Medical Services (Boston EMS), the provider of 9-1-1 EMS to the City of Boston. OBJECTIVE: To examine the impact of the closure of an ED on an urban EMS system in a setting where ambulance diversion is not allowed. METHODS: We performed a before-and-after study that examined the effects of an ED closure on BMC and Boston EMS. We examined ED and Boston EMS volumes and ambulance turnaround intervals from June 1, 2010, to July 11, 2010 (preclosure) as compared with July 12, 2010, to August 26, 2010 (postclosure). Mean ED and Boston EMS volumes and Boston EMS turnaround intervals were calculated in four-hour shifts. We used multivariate analysis to analyze electronic medical systems data from BMC and Boston EMS and linear regression. We used autoregressive integrated moving average (ARIMA) models to determine the effect of the ED closure on turnaround intervals, ED volumes, and transport volumes. All analyses were adjusted for shift, ED volume, day of the week, and citywide EMS transport volumes. RESULTS: After ED closure, there was a statistically significant increase of 0.89 minutes (p = 0.02) in the mean EMS turnaround intervals. Additionally, the total ED volume decreased by 3.67 visits per shift (p < 0.001). The ratio of patients transported by Boston EMS to BMC remained unchanged (p = 0.11) for two weeks before and two weeks after the closure. CONCLUSIONS: The closure of one ED resulted in a statistically significant increase in turnaround intervals and a significant decrease in ED volume independent of EMS volumes. In the absence of ambulance diversion, ratios of EMS turnaround intervals and EMS volumes according to hospital destination can be used as alternatives to ambulance diversion times to examine the effects of system-level changes such as closure of an ED on an urban EMS system.

An automated procedure logging system improves resident documentation compliance.

OBJECTIVES: The purpose of this study was to determine the effect of an automated procedure logging (APL) system on the number of procedures logged by emergency medicine (EM) residents. Secondary objectives were to assess the APL's effect on completeness and accuracy of procedure logging and to measure resident compliance with the system. METHODS: This was a before-and-after study conducted at a university-affiliated, urban medical center, with an annual emergency department census of >130,000. The EM residency is a 4-year, Residency Review Committee (RRC)-accredited program with 12 residents per year. We developed software to electronically search and abstract resident procedures documented in the electronic medical record (EMR) and automatically export them into a Web-based residency management system. We compared the mean daily number of procedures logged for two 6-month periods: October 1, 2009, to March 31, 2010 (pre-APL), and October 1, 2010, to March 31, 2011 (post-APL), using a two-sample t-test. We also generated a random sample of 231 logged procedures from both the pre- and post-APL time periods to assess for completeness and accuracy of data transfer. Completeness and accuracy in the pre- and post-APL periods were compared using Fisher's exact test. Aggregate resident compliance with the system was also measured. RESULTS: The mean daily number of procedures logged increased by 168% (10.0 vs. 26.8, mean difference = 16.8, 95% confidence interval [CI] = 15.4 to 18.2, p < 0.001) after the implementation of APL. Procedures logged with the APL system were more complete (76% vs. 100%, p < 0.001) and more accurate (87% vs. 99%, p < 0.001). Most residents (42/48, 88%) used APL to log at least 90% of procedures. Only 4% of procedures eligible for automation were logged manually in the post-APL period. CONCLUSIONS: There was a significant increase in the daily mean number of procedures logged after the implementation of APL. Recorded data were more complete and more accurate during this time frame. This innovative system improved resident logging of required procedures and helped our assessment of Accreditation Council for Graduate Medical Education (ACGME) Patient Care and Practice-Based Learning Competencies for individual residents.

Understanding locally, culturally, and contextually relevant mental health problems among Rwandan children and adolescents affected by HIV/AIDS.

In assessing the mental health of HIV/AIDS-affected children and adolescents in Sub-Saharan Africa, researchers often employ mental health measures developed in other settings. However, measures derived from standard Western psychiatric criteria are frequently based on conceptual models of illness or terminology that may or may not be an appropriate for diverse populations. Understanding local perceptions of mental health problems can aid in the selection or creation of appropriate measures. This study used qualitative methodologies (Free Listing, Key Informant interviews, and Clinician Interviews) to understand local perceptions of mental health problems facing HIV/AIDS-affected youth in Rwinkwavu, Rwanda. Several syndrome terms were identified by participants: agahinda kenshi, kwiheba, guhangayika, ihahamuka, umushiha, and uburara. While these local syndromes share some similarities with Western mood, anxiety, and conduct disorders, they also contain important culture-specific features and gradations of severity. Our findings underscore the importance of understanding local manifestations of mental health syndromes when conducting mental health assessments and when planning interventions for HIV/AIDS-affected children and adolescents in diverse settings.

Prevalence and predictors of nasal and extranasal staphylococcal colonization in patients presenting to the emergency department.

STUDY OBJECTIVE: Methicillin-resistant Staphylococcus aureus (MRSA) is one of the most common causes of skin and soft tissue infections in patients presenting to the emergency department (ED). The prevalence of asymptomatic MRSA colonization in ED patients is less well described, particularly in the absence of a skin and soft tissue infection-related complaint. The goals of this study are to assess the prevalence of nasal and extranasal staphylococcal colonization in ED patients, evaluate risk factors, and molecularly characterize the strains. METHODS: We performed active surveillance for methicillin-susceptible S aureus (MSSA) and MRSA colonization in 400 subjects presenting to an urban ED. Risk factor assessment was performed and culture testing was conducted on anterior nares, oropharynx, palms, groin, perirectal area, wounds, and catheter insertion sites. Multiplex polymerase chain reaction was used to identify the USA300/400 clonal types. RESULTS: The prevalence of colonization with MSSA was 39% (95% confidence interval 34.2% to 44.0%), and prevalence of colonization with MRSA was 5% (95% confidence interval 3.1% to 7.6%). Among MRSA-colonized subjects, an extranasal site tested positive in 80% of subjects, and 45% had exclusive extranasal colonization. USA300 was identified in 55% of MRSA-colonized subjects. The main risk factors for MRSA colonization included HIV infection, diabetes, and participation in contact sports. CONCLUSION: The overall prevalence of MRSA colonization in this ED population was lower than that reported in other high-risk ambulatory care settings. However, extranasal colonization was present in more than half of MRSA-colonized subjects, and USA300 was the predominant clonal type.