Global Health Crisis, Global Health Response: How Global Health Experiences Prepared North American Physicians for the COVID-19 Pandemic.

The COVID-19 pandemic plunged hospital systems into resource-deprived conditions unprecedented since the 1918 flu pandemic. It brought forward concerns around ethical management of scarcity, racism and distributive justice, cross-disciplinary collaboration, provider wellness, and other difficult themes. We, a group of medical educators and global health educators and clinicians, use the education literature to argue that experience gained through global health activities has greatly contributed to the effectiveness of the COVID-19 pandemic response in North American institutions. Support for global health educational activities is a valuable component of medical training, as they build skills and perspectives that are critical to responding to a pandemic or other health system cataclysm. We frame our argument as consideration of three questions that required rapid, effective responses in our home institutions during the pandemic: How can our health system function with new limitations on essential resources? How do we work at high intensity and volume, on a new disease, within new and evolving systems, while still providing high-quality, patient-centered care? And, how do we help personnel manage an unprecedented level of morbidity and mortality, disproportionately affecting the poor and marginalized, including moral difficulties of perceived care rationing?

Pursuit to Post: Ethical issues of social media use by international medical volunteers.

Medical volunteers from high-income countries seek short-term global health experiences in low- and middle-income countries to learn and practice medicine, complete service-learning projects, conduct research, and burnish their curricula vitae. The uniqueness and poignancy of these global health experiences frequently compel medical volunteers to not only capture visual reminders of their experience but to share them online through social media. Prioritizing image creation and sharing, which center on the volunteer's priorities over patient-centered priorities, risks failing to acknowledge the ethical issues inherent in power imbalances between the medical volunteers, patients, hosts, organizational partners and others, and bypasses the values of the host community. Using social media as an example of an emerging ethical challenge in the context of short-term experiences in global health, the authors examine potential consequences for patients, host communities, and international partnerships and discuss important pre-posting considerations.

Correction: Documenting Social Media Engagement as Scholarship: A New Model for Assessing Academic Accomplishment for the Health Professions.

[This corrects the article DOI: 10.2196/25070.].

Documenting Social Media Engagement as Scholarship: A New Model for Assessing Academic Accomplishment for the Health Professions.

BACKGROUND: The traditional model of promotion and tenure in the health professions relies heavily on formal scholarship through teaching, research, and service. Institutions consider how much weight to give activities in each of these areas and determine a threshold for advancement. With the emergence of social media, scholars can engage wider audiences in creative ways and have a broader impact. Conventional metrics like the h-index do not account for social media impact. Social media engagement is poorly represented in most curricula vitae (CV) and therefore is undervalued in promotion and tenure reviews. OBJECTIVE: The objective was to develop crowdsourced guidelines for documenting social media scholarship. These guidelines aimed to provide a structure for documenting a scholar's general impact on social media, as well as methods of documenting individual social media contributions exemplifying innovation, education, mentorship, advocacy, and dissemination. METHODS: To create unifying guidelines, we created a crowdsourced process that capitalized on the strengths of social media and generated a case example of successful use of the medium for academic collaboration. The primary author created a draft of the guidelines and then sought input from users on Twitter via a publicly accessible Google Document. There was no limitation on who could provide input and the work was done in a democratic, collaborative fashion. Contributors edited the draft over a period of 1 week (September 12-18, 2020). The primary and secondary authors then revised the draft to make it more concise. The guidelines and manuscript were then distributed to the contributors for edits and adopted by the group. All contributors were given the opportunity to serve as coauthors on the publication and were told upfront that authorship would depend on whether they were able to document the ways in which they met the 4 International Committee of Medical Journal Editors authorship criteria. RESULTS: We developed 2 sets of guidelines: Guidelines for Listing All Social Media Scholarship Under Public Scholarship (in Research/Scholarship Section of CV) and Guidelines for Listing Social Media Scholarship Under Research, Teaching, and Service Sections of CV. Institutions can choose which set fits their existing CV format. CONCLUSIONS: With more uniformity, scholars can better represent the full scope and impact of their work. These guidelines are not intended to dictate how individual institutions should weigh social media contributions within promotion and tenure cases. Instead, by providing an initial set of guidelines, we hope to provide scholars and their institutions with a common format and language to document social media scholarship.

Importance of authorship and inappropriate authorship assignment in paediatric research in low- and middle-income countries.

OBJECTIVE: To understand the importance of authorship and authorship position, and gauge perceptions of inappropriate authorship assignment, among authors publishing paediatric research conducted in low- and middle-income countries (LMICs). METHODS: We conducted a cross-sectional, mixed-methods study using an online survey of both corresponding and randomly selected, non-corresponding authors who published research conducted in LMICs from 2006 to 2015 in the top four paediatric journals by Eigenfactor score. We used chi-square tests to compare responses by authors living in LMICs to authors living in high-income countries (HICs). We analysed qualitative responses using thematic analysis. RESULTS: Of 1420 potential respondents, 19.6% (n = 279) completed the survey. 57% (n = 159) lived in LMICs and 43% (n = 120) in HICs. LMIC authors more commonly perceived first authorship as most important for their academic advancement than HIC authors (74.2% vs. 60.8%, P = 0.017), while HIC authors reported last authorship as most important (25.1% vs. 38.3%, P = 0.018). 65% (n = 181) of respondents believed that their collaborators had been inappropriately assigned authorship positions (no difference in LMIC and HIC responses) and 32.6% (n = 91) reported personally accepting inappropriate authorship positions (more common in HIC respondents, P = 0.005). In qualitative data, respondents questioned the applicability of standard authorship guidelines for collaborative research conducted in LMICs. CONCLUSIONS: LMIC and HIC authors held different perceptions about the importance of authorship position. Reported inappropriate authorship assignment was common among both LMIC and HIC respondents. Alternatives to standard authorship criteria for research conducted in LMICs merit further studies.

OBJECTIF: Comprendre l'importance de la paternité d'auteur et de la position de l'auteur, et évaluer les perceptions de l'attribution inappropriée de la paternité d'auteur parmi les auteurs qui publient des recherches pédiatriques menées dans des pays à revenu faible ou intermédiaire (PRFI). MÉTHODES: Nous avons mené une étude transversale à méthodes mixtes avec un sondage en ligne auprès d'auteurs de correspondance et sélectionnés au hasard, d'auteurs not de correspondance, ayant publié des recherches menées dans des PRFIde 2006 à 2015 dans les quatre revues pédiatriques les mieux classées par le score d'Eigenfactor. Nous avons utilisé des tests de chi carré pour comparer les réponses des auteurs des PRFI à ceux des aux auteurs des pays à revenu élevé (PRE). Nous avons analysé les réponses qualitatives à l'aide d'une analyse thématique. RÉSULTATS: Sur 1.420 répondants potentiels, 19,6% (n = 279) ont répondu au sondage. 57% (n = 159) vivaient dans des PRFI et 43% (n = 120) dans des PRE. Les auteurs des PRFI estimaient plus souvent que la position de premier auteur était le plus important pour leur avancement universitaire que les auteurs des PRE (74,2% contre 60,8%, P = 0,017), tandis que les auteurs desPRE ont déclaré que le dernier auteur était le plus important (25,1% contre 38,3%, P = 0,018). 65% (n = 181) des répondants estimaient que des positions d'auteur avaient été attribués de manière inappropriée à leurs collaborateurs (aucune différence entre les réponses des PRFI et des PRE) et 32,6% (n = 91) ont déclaré avoir personnellement accepté des positions d'auteurs inappropriées (plus fréquents chez les répondants desPRE, P = 0,005). En ce qui concerne les données qualitatives, les répondants se sont interrogés sur l'applicabilité des directives standards en matière de paternité d'auteur pour la recherche collaborative menée dans les PRFI. CONCLUSIONS: Les auteurs des PRFI et desPREont des perceptions différentes sur l'importance de la position de l'auteur. L'attribution inappropriée de laposition d'auteur signalée était fréquente chez les répondants des PRFI et des PRE. Les alternatives aux critères standards de la paternité d'auteur pour les recherches menées dans les PRFI méritent d'être approfondies.

Outcomes of empiric treatment for pediatric tuberculosis, Kampala, Uganda, 2010-2015.

BACKGROUND: Childhood tuberculosis (TB) diagnoses often lack microbiologic confirmation and require empiric treatment. Barriers to empiric treatment include concern for poor outcomes and adverse effects. We thus determined the outcomes of empiric TB treatment from a retrospective cohort of children at a national referral hospital in Kampala, Uganda from 2010 to 2015. METHODS: Children were diagnosed clinically and followed through treatment. Demographics, clinical data, outcome and any adverse events were extracted from patient charts. A favorable outcome was defined as a child completing treatment with clinical improvement. We performed logistic regression to assess factors associated with loss to follow up and death. RESULTS: Of 516 children, median age was 36 months (IQR 15-73), 55% (95% CI 51-60%) were male, and HIV prevalence was 6% (95% CI 4-9%). The majority (n = 422, 82, 95% CI 78-85%) had a favorable outcome, with no adverse events that required treatment discontinuation. The most common unfavorable outcomes were loss to follow-up (57/94, 61%) and death (35/94, 37%; overall mortality 7%). In regression analysis, loss to follow up was associated with age 10-14 years (OR 2.38, 95% CI 1.15-4.93, p = 0.02), HIV positivity (OR 3.35, 95% CI 1.41-7.92, p = 0.01), hospitalization (OR 4.14, 95% CI 2.08-8.25, p < 0.001), and living outside of Kampala (OR 2.64, 95% CI 1.47-4.71, p = 0.001). Death was associated with hospitalization (OR 4.57, 95% CI 2.0-10.46, p < 0.001), severe malnutrition (OR 2.98, 95% CI 1.07-8.27, p = 0.04), baseline hepatomegaly (OR 4.11, 95% CI 2.09-8.09, p < 0.001), and living outside of Kampala (OR 2.41, 95% CI 1.17-4.96, p = 0.02). CONCLUSIONS: Empiric treatment of child TB was effective and safe, but treatment success remained below the 90% target. Addressing co-morbidities and improving retention in care may reduce unfavorable outcomes.

Debriefing Trainees After Global Health Experiences: An Expert Consensus Delphi Study.

BACKGROUND: Global health (GH) opportunities in pediatric residencies are prevalent. Debriefing trainees after a GH experience is a tool to optimize educational processing, identify post-return stressors, and facilitate coping skills; however, there are no consensus recommendations for debriefing in this context. OBJECTIVE: Our objective was to develop structure and content guidelines for standardized debriefing of residents returning from short-term clinical GH rotations abroad. METHODS: Through a modified Delphi methodology, we developed a standardized consensus-based debriefing tool. Eleven pediatric GH education experts were recruited. Experts were individuals with leadership experience in GH education who demonstrated academic engagement by either primary or senior authorship of a publication or relevant presentation at a conference. The expert panel (EP) completed 4 surveys that were amended after each round based on qualitative data, which was assessed for emergent themes. In the final round, the EP rated each consensus recommendation in importance using a 4-point Likert scale. RESULTS: Ten of the 11 panelists completed all study rounds. The EP achieved consensus that residents should complete post-return debriefing and rated 32 consensus recommendations in importance. Twelve recommendations were deemed "essential"; these debriefing recommendations focused on timing and preparation, reflection and feedback, trainee well-being and coping skills, ethical concerns, and the need to provide mental health support and resources for trainees with psychological distress. CONCLUSIONS: According to GH experts, all residents who participate in GH experiences should participate in a post-return debrief. Thirty-two consensus recommendations regarding content, timing, structure, and actions for post-return debriefing were formulated.

The Senior Resident-Fellow Dynamic on Pediatric Hospital Medicine Teams: A Qualitative Study.

BACKGROUND AND OBJECTIVES: With the Accreditation Council for Graduate Medical Education accreditation in place for pediatric hospital medicine (PHM) fellowships, fellows are playing a larger role in resident education. However, the impact of PHM fellows on pediatric residency training is not well described. We aimed to identify the factors that affect the dynamic between senior residents and fellows working together on PHM teams. METHODS: In this qualitative study, we used purposive sampling and interviewed 15 senior residents and 8 PHM fellows between April and September 2020. We created a conceptual framework for the senior resident-fellow dynamic to develop the interview guide. Using verbatim transcripts uploaded into Dedoose software, 2 authors coded responses and identified themes using directed content analysis. RESULTS: Twelve themes emerged as factors that impact the senior resident-fellow dynamic and fell into 6 categories: Team organization, role clarity, teaching, fellow approachability, decision-making, and attending involvement. Both senior residents and PHM fellows described an optimal dynamic in which a hierarchal approach to team structure, teaching, and decision-making is counterbalanced by fellow approachability. Role uncertainty, especially with increased attending involvement, led to conflict between residents and fellows. CONCLUSIONS: This study demonstrated that a structured hierarchy surrounding supervision, decision-making, and teaching promoted level-appropriate autonomy for both senior residents and fellows. These findings can be used to design an intervention, such as a leadership curriculum for fellows and senior residents, to target behaviors that facilitate a stepwise approach to supervision and patient care.

Viral Coinfections in Kawasaki Disease: A Meta-analysis.

CONTEXT: Viral infections are suspected triggers in Kawasaki disease (KD); however, a specific viral trigger has not been identified. OBJECTIVES: In children with KD, to identify (1) overall prevalence of viral infections; (2) prevalence of specific viruses; and (3) whether viral positivity was associated with coronary artery aneurysms (CAAs) or refractoriness to intravenous immunoglobin (IVIG). DATA SOURCES: We searched Embase, Medline, and Cochrane databases and gray literature. STUDY SELECTION: Eligible studies were conducted between 1999 and 2019, and included children diagnosed with KD who underwent viral testing. DATA EXTRACTION: Two investigators independently reviewed full-text articles to confirm eligibility, extract data, appraise for bias, and assess evidence quality for outcomes using the Grading of Recommendations Assessment Development and Evaluation criteria. We defined viral positivity as number of children with a positive viral test divided by total tested. Secondary outcomes were CAA (z score ≥2.5) and IVIG refractoriness (fever ≥36 hours after IVIG). RESULTS: Of 3189 unique articles identified, 54 full-text articles were reviewed, and 18 observational studies were included. Viral positivity weighted mean prevalence was 30% (95% confidence interval [CI], 14-51) and varied from 5% to 66%, with significant between-study heterogeneity. Individual virus positivity was highest for rhinovirus (19%), adenovirus (10%), and coronavirus (7%). Odds of CAA (odds ratio, 1.08; 95% CI, 0.75-1.56) or IVIG refractoriness (odds ratio, 0.88; 95% CI, 0.58-1.35) did not differ on the basis of viral status. LIMITATIONS: Low or very low evidence quality. CONCLUSIONS: Viral infection was common with KD but without a predominant virus. Viral positivity was not associated with CAAs or IVIG refractoriness.

Determinants of retention in care of newborns diagnosed with sickle cell disease in Liberia: Results from a mixed-methods study of caregivers.

High-income nations have established that early diagnosis and preventive treatment reduces early deaths in sickle cell disease (SCD). However, in low-/middle-income countries where SCD is common, attrition from clinical care is common. Reasons for poor retention in care are multi-factorial and poorly understood. The objective of this study was to identify factors that influence caregiver decision-making around chronic health care needs of a child with SCD. We conducted an exploratory sequential mixed methods study of caregivers of children diagnosed with SCD during a newborn screening program in Liberia. Caregivers completed questionnaires and semi-structured interviews designed to identify drivers of health decision-making. Interviews were digitally recorded, transcribed, coded, and analyzed using semi-structured thematic analysis to identify themes. Data integration occurred by using quantitative results to expand and clarify the qualitative themes. Twenty-six caregivers participated in the study. The mean age of the child at the interview was 43.7 months. Five themes influencing health decisions were identified: grief, the importance of support networks, stigma, perceived benefits, and the burden of chronic disease. The five themes crossed multiple domains of a socioecological model and identified complex interactions between family, community, social and cultural norms, and organizational structures. This study highlights the importance of community awareness of SCD and appropriate health communication by healthcare workers. Healthcare decision-making is multifactorial and complex. These results provide a framework for improving retention in care. In a low-resource country such as Liberia, much can be done by leveraging existing resources and cultural practices.

Realizing the Promise of Dolutegravir in Effectively Treating Children and Adolescents Living With HIV in Real-world Settings in 6 Countries in Eastern and Southern Africa.

BACKGROUND: Despite encouraging results from clinical trials and in high-income countries, large-scale data on the effectiveness and safety of dolutegravir (DTG) in children and adolescents living with HIV (CALHIV) are lacking in low- and middle-income countries (LMICs). METHODS: Retrospective analysis was performed among CALHIV 0-19 years old and weighing greater than or equal to 20 kg who received DTG from 2017 to 2020 at sites in Botswana, Eswatini, Lesotho, Malawi, Tanzania and Uganda to determine effectiveness, safety and predictors of viral load suppression (VLS) among CALHIV using DTG, including through single drug substitutions (SDS). RESULTS: Among 9419 CALHIV using DTG, 7898 had a documented post-DTG VL, and VLS post-DTG was 93.4% (7378/7898). VLS for antiretroviral therapy (ART) initiations was 92.4% (246/263), and VLS was maintained for the ART-experienced [92.9% (7026/7560) pre- vs. 93.5% (7071/7560) post-DTG; P = 0.14). Among previously unsuppressed, 79.8% (426/534) achieved VLS with DTG. Only 5 patients reported a Grade 3 or 4 adverse event (0.057 per 100 patient-years) requiring DTG discontinuation. History of protease inhibitor-based ART [odds ratio (OR) = 1.53; 95% confidence interval (CI): 1.16-2.03], care in Tanzania (OR = 5.45; 95% CI: 3.41-8.70), and being 15-19 years old (OR = 1.31; 95% CI: 1.03-1.65) were associated with gain of VLS post-DTG. Predictors of VLS on DTG included VLS before DTG (OR = 3.87; 95% CI: 3.03-4.95) and using the once-daily, single tab tenofovir-lamivudine-DTG regimen (OR = 1.78; 95% CI: 1.43-2.22). SDS maintained VLS [95.9% (2032/2120) pre- vs. 95.0% (2014/2120) post-SDS with DTG; P = 0.19], and 83.0% (73/88) of unsuppressed gained VLS using SDS with DTG. CONCLUSIONS: We found DTG to be highly effective and safe within our cohort of CALHIV in LMICs. These findings can empower clinicians to prescribe DTG confidently to eligible CALHIV.

Risk factors and prognostic significance of platelet count abnormalities in children with HIV infection on antiretroviral therapy.

OBJECTIVES: To establish the incidence, risk factors and correlation with survival of thrombocytopenia and thrombocytosis (T/T) among children with HIV infection (CWH). DESIGN: A retrospective nested case control study of patients 0-18 years in five Baylor International Pediatric AIDS Initiative (BIPAI) centers in sub-Sahara Africa, 2004-2014. METHODS: Clinical and laboratory variables including complete blood counts (CBC) were extracted from the BIPAI electronic medical record system. Incident cases of T/T were identified and frequency-matched on follow-up time with controls with normal platelets. We calculated the prevalence and incidence density of T/T and used conditional logistic regression to evaluate their association with selected clinical variables. We constructed Kaplan-Meier curves and a Cox proportional hazards model to evaluate the impact of T/T on survival. RESULTS: Two thousand, one hundred and nine children were sampled. The incidence density of thrombocytopenia was 1 per 57.9 (95% confidence interval [CI] 50.3-66.8) CWH-years. Thrombocytopenia was higher in children with WHO Stage III/IV, lower in children on zidovudine, and had no association with use of lamivudine or nevirapine, CD4 + suppression, age, and nutrition status. Thrombocytopenia was independently associated with 2.2-fold higher mortality (95% CI 1.62-3.08). The incidence density of thrombocytosis was 1 per 11.4 (95% CI 10.7-12.1) CWH-years. Thrombocytosis was associated with higher CD4 + cell count, younger age, and use of lamivudine or nevirapine, and did not impact survival. CONCLUSIONS: Platelet count is a clinically valuable biomarker of HIV clinical progression and mortality. Laboratory studies are necessary to elucidate the mechanisms of T/T.

Qualitative Study of Barriers and Facilitators to Care Among Children in Immigrant Families.

OBJECTIVES: Children in immigrant families comprise ∼25% of US children and live in families with high levels of poverty and food insecurity. Studies suggest a decline in public benefit enrollment among children in immigrant families. We aimed to explore perspectives on barriers and facilitators in accessing care among immigrant caregivers of hospitalized children. METHODS: With a general qualitative descriptive design, we developed a semistructured interview guide using an iterative process informed by literature and content expertise. Using purposive sampling, we recruited immigrant caregivers of hospitalized children in March 2020 and conducted interviews in English or Spanish. Interviews were recorded, transcribed, and translated to English. Three authors coded transcripts using Dedoose and identified themes via thematic analysis. RESULTS: Analysis of 12 caregiver interviews revealed barriers and facilitators in accessing healthcare and public benefit use. Barriers included healthcare system barriers, immigration-related fear, and racism and discrimination. Within healthcare system barriers, subthemes included language barriers, cost, complexity of resource application, and lack of guidance on available benefits. Within immigration-related fear, subthemes included fear of familial separation, fear of deportation, fear that benefit use affects immigration status, and provider distrust. Healthcare system facilitators of resource use included recruiting diverse workforces, utilizing language interpretation, guidance on benefit enrollment, legal services, and mental health services. Participants also recommended hospital partnership with trusted information sources, including media stations and low-cost clinics. CONCLUSIONS: Immigrant caregivers of hospitalized children identified barriers and facilitators in access to care. Further research is needed to assess the efficacy of caregiver-suggested interventions.

Perceived roles, benefits and barriers of virtual global health partnership initiatives: a cross-sectional exploratory study.

BACKGROUND: Virtual global health partnership initiatives (VGHPIs) evolved rapidly during the COVID-19 pandemic to ensure partnership continuity. However the current landscape for VGHPI use and preference is unknown. This study aimed to increase understanding of GH partners' perspectives on VGHPIs. METHODS: From 15 October to 30 November 2020, An online, international survey was conducted using snowball sampling to document pandemic-related changes in partnership activities, preferences for VGHPIs, and perceived acceptability and barriers. The survey underwent iterative development within a diverse author group, representing academic and clinical institutions, and the non-profit sector. Participants from their professional global health networks were invited, including focal points for global health partnerships while excluding trainees and respondents from the European Economic Area. Analysis stratified responses by country income classification and partnership type. Authors used descriptive statistics to characterize responses, defining statistical significance as α = 0.05. RESULTS: A total of 128 respondents described 219 partnerships. 152/219 (69%) partnerships were transnational, 157/219 (72%) were of > 5 years duration, and 127/219 (60%) included bidirectional site visits. High-income country (HIC) partners sent significantly more learners to low- to middle-income country (LMIC) partner sites (p < 0.01). Participants commented on pandemic-related disruptions affecting 217/219 (99%) partnerships; 195/217 (90%) were disruption to activities; 122/217 (56%) to communication; 73/217 (34%) to access to professional support; and 72/217 (33%) to funding. Respondents indicated that VGHPIs would be important to 206/219 (94%) of their partnerships moving forward. There were overall differences in resource availability, technological capacity, and VGHPI preferences between LMIC and HIC respondents, with a statistically significant difference in VGHPI acceptability (p < 0.001). There was no significant difference between groups regarding VGHPIs' perceived barriers. CONCLUSIONS: The pandemic disrupted essential partnership elements, compounding differences between LMIC and HIC partners in their resources and preferences for partnership activities. VGHPIs have the potential to bridge new and existing gaps and maximize gains, bi-directionality, and equity in partnerships during and after COVID-19.

Achieving Antiretroviral Therapy Uptake and Viral Suppression Among Children and Adolescents Living With HIV in the UNAIDS 90-90-90 Era Across Six Countries in Eastern and Southern Africa-Lessons From the BIPAI Network.

BACKGROUND: Although achievements have been made globally since the UNAIDS 90-90-90 targets were announced, paediatric data remain sparse. We describe achievements toward antiretroviral therapy (ART) uptake and viral load (VL) suppression, existing gaps, and potential best practices among children and adolescents living with HIV (CALHIV) across 6 Eastern and Southern African countries. SETTING: Baylor College of Medicine International Paediatric AIDS Initiative Network sites in Botswana, Eswatini, Lesotho, Malawi, Tanzania, and Uganda. METHODS: We performed retrospective data analysis among CALHIV ages 0-19 years between 2014 and 2019. RESULTS: A total of 25,370 CALHIV received care, 85.8% (21,773/25,370) received ART, 84.4% (18,376/21,773) had documented VL results, and 74.6% (13,715/18,376) had VL < 1000 cps/mL. By 2019, the pooled proportion of CALHIV receiving ART and having viral suppression increased to 99.8% [95% confidence interval (CI): 98.1 to 100.0] and 89.8% (95 CI: 88.2 to 91.5) respectively. Lower rates of viral suppression and higher lost to follow-up (LTFU) were seen in the 0-4-year and 15-19-year cohorts. CALHIV on ART not achieving viral suppression were younger, received care in Malawi or Mbeya, had a history of tuberculosis, lower rates of integrase-strand inhibitor-based ART, and were on ART for shorter durations. Best practices reported included adopting universal ART, ART optimization with protease inhibitor-based and/or dolutegravir-based regimens, peer-supported activities, child/adolescent friendly services, community-supported activities, and technology-driven quality improvement activities and digital solutions. CONCLUSIONS: High rates of CALHIV receiving ART and having viral suppression can be achieved in settings in Eastern and Southern Africa through using pediatric best practices. Increased efforts must be made to address LTFU and to support under-fives and adolescents.

Virtual global health in graduate medical education: a systematic review.

Objectives: To synthesize recent virtual global health education activities for graduate medical trainees, document gaps in the literature, suggest future study, and inform best practice recommendations for global health educators. Methods: We systematically reviewed articles published on virtual global health education activities from 2012-2021 by searching MEDLINE, EMBASE, Cochrane Library, ERIC, Scopus, Web of Science, and ProQuest Dissertations & Theses A&I. We performed bibliography review and search of conference and organization websites. We included articles about primarily virtual activities targeting for health professional trainees. We collected and qualitatively analyzed descriptive data about activity type, evaluation, audience, and drivers or barriers. Heterogeneity of included articles did not lend to formal quality evaluation. Results: Forty articles describing 69 virtual activities met inclusion criteria. 55% of countries hosting activities were high-income countries. Most activities targeted students (57%), with the majority (53%) targeting trainees in both low- to middle- and high-income settings. Common activity drivers were course content, organization, peer interactions, and online flexibility. Common challenges included student engagement, technology, the internet, time zones, and scheduling. Articles reported unanticipated benefits of activities, including wide reach; real-world impact; improved partnerships; and identification of global health practice gaps. Conclusions: This is the first review to synthesize virtual global health education activities for graduate medical trainees. Our review identified important drivers and challenges to these activities, the need for future study on activity preferences, and considerations for learners and educators in low- to middle-income countries. These findings may guide global health educators in their planning and implementation of virtual activities.

Risk factors and prognostic significance of anemia in children with HIV infection on antiretroviral therapy.

OBJECTIVES: To establish the incidence, risk factors and prognostic effect of anemia in children living with HIV (CLWH). DESIGN: Retrospective nested case-control study of patients 0-18 years in five centers in sub-Saharan Africa, 2004-2014. METHODS: Incident cases of anemia were identified from electronic records and matched with CLWH without anemia. We calculated the incidence density of anemia and used conditional logistic regression to evaluate its association with risk factors, stratified by severity and type of anemia. We used a Cox proportional hazards model to evaluate the impact of anemia on survival. RESULTS: Two thousand, one hundred and thirty-seven children were sampled. The incidence density of anemia was 1 per 6.6 CLWH-years. Anemia was moderate in 31.8% and severe in 17.3% of anemia cases, which had 10-year mortality hazards of 3.4 and 4.5, respectively. Microcytic anemia (36% cases) was associated with 2.3-fold hazard of 10-year mortality, and with malnutrition and CD4 + suppression. Normocytic anemia (50.5% cases) was associated with 2.6-fold hazards of 10-year mortality, and with more severe malnutrition, CD4 + suppression, and WHO stage, but inversely associated with lamivudine and nevirapine therapy. Macrocytic anemia (13.5% cases) was neither associated with higher 10-year mortality nor with severe malnutrition or CD4 + suppression but was associated with WHO stage II/III and negatively associated with lamivudine therapy. CONCLUSION: This large multicountry study of CLWH found a high incidence density of anemia. Higher severity, normocytic and microcytic types of anemia were independently associated with long-term mortality. Laboratory studies are needed to decipher the mechanisms of anemia and how it impacts mortality in CLWH.

Public Benefit Use and Social Needs in Hospitalized Children With Undocumented Parents.

BACKGROUND AND OBJECTIVES: Studies supporta recent decline in public benefit enrollment among immigrant families. We aimed to describe health and resource use, barriers to use, and immigration-related fear in families with undocumented parents compared with families without undocumented parents. We also aimed to assess associations with discontinuation of public benefits and fear of deportation. METHODS: We assessed immigration concerns and enrollment in Medicaid, Supplemental Nutrition Assistance Program (SNAP), and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) with an 89-item anonymous, cross-sectional survey of English- and Spanish-speaking caregivers of hospitalized children. Multivariable logistic regression was used to assess associations with discontinuation of public benefits and fear of deportation. RESULTS: Of 527 families approached, 399 enrolled (105 with 1 or more undocumented parent, 275 with no undocumented parent, and 19 with undisclosed immigration status). Compared with families without undocumented parents, families with undocumented parents had higher levels of poverty and food insecurity. Controlling for perceived eligibility, public benefit use was similar across groups. Of families with undocumented parents, 29% reported public benefit discontinuation because of immigration concerns, and 71% reported fear of deportation. Having an undocumented parent was associated with public benefit disenrollment (odds ratio: 46.7; 95% confidence interval: 5.9-370.4) and fear of deportation (odds ratio: 24.3; 95% confidence interval: 9.6-61.9). CONCLUSIONS: Although families with undocumented parents had higher levels of poverty and food insecurity compared with families without undocumented parents, public benefit use was similar between groups. Immigration-related fear may be a barrier to public benefit use in this population.

Development of the Association of Pediatric Program Directors Global Educator Scholarship-Expanding Bidirectional Efforts in Global Health Education.

BACKGROUND: The Board of the Association of Pediatric Program Directors (APPD) partnered with the APPD Global Health Learning Community (GHLC) to establish the APPD Global Pediatric Educator Scholarship. This award seeks to recognize pediatric educators who demonstrate leadership in improving pediatric education in low- and middle-income countries, and provide them with career development opportunities by attending the APPD Spring meeting. Two educators per year have been awarded the scholarship since 2017. AWARD EVALUATION: The authors sent survey questions via email and obtained responses from 6 (100%) of the scholarship awardees, 8 (75%) APPD GHLC leadership individuals, and 4 (67%) APPD Board members. Three authors analyzed the responses with consensus achieved on themes. RESULTS: Awardees noted learning about educational strategies, academic opportunities through networking, and context for stronger bilateral exchange with partners. APPD leaders noted an expansion of the organization's mission to include global presence. Challenges included program visibility, sustainable funding, and logistics. Suggestions included better incorporation of awardees into APPD membership, longitudinal mentorship, targeted conference navigation, and visits to local academic institutions. CONCLUSIONS: The APPD Global Educator Scholarship is a replicable model of organizational global outreach that expands the concept of bidirectional exchange to include career sponsorship for global partners.

Inpatient Food Insecurity in Caregivers of Hospitalized Pediatric Patients: A Mixed Methods Study.

BACKGROUND AND OBJECTIVE: Among US households with children, 14% are food insecure. Household food insecurity (FI) is associated with poorer health outcomes and increased hospital admissions. There is less known about caregivers' ability to obtain adequate food during hospitalization (inpatient FI). METHODS: We conducted a mixed methods study of primary caregivers of hospitalized children 0 to 18 years. A modified US Household Food Security Survey was used to identify inpatient FI. Associated factors were identified using logistic regression adjusted for covariables. Caregiver semistructured interviews were conducted to elicit perceptions on food accessibility and effects of and solutions for inpatient FI. RESULTS: The prevalence of inpatient FI was 43%. Household FI was present in 38% of families. Inpatient FI was associated with household FI (P < .01). In multivariable analysis, odds of inpatient FI were increased among caregivers with annual household income <$30,000 (adjusted odds ratio [aOR] 2.14), public transportation use (aOR 6.33), living >30 miles from the hospital (aOR 2.80), self-rated fair/poor health (aOR 3.31), maternity leave (aOR 4.75), and past/current Supplemental Nutrition Assistance Program benefit utilization (aOR 2.52). Qualitative analysis identified barriers to food access, such as lack of affordable options, and found that caregivers made sacrifices for their hospitalized child, including skipping meals. Caregivers viewed their presence at their child's bedside and personal nourishment as important factors affecting their child's care. CONCLUSIONS: Inpatient FI may affect a significant proportion of hospitalized children's caregivers. Pediatric hospitals should ensure that caregivers have access to food in order to fully engage in their child's care.