Knowledge, attitudes, and practices of vaccinators about expanded programs on immunization: a cross-sectional study

Introduction

The periodic evaluation of knowledge, attitudes, and practices (KAP) of healthcare workers, including vaccinators, concerning expanded programs on immunization (EPI) is very crucial for a better healthcare system. This study was carried out to assess the KAP of vaccinators about the EPI, including cold storage of vaccines and their practices related to vaccine cold chain management.

Method

A cross-sectional study was conducted from January 2022 to June 2022 among registered vaccinators in the twin cities (Islamabad and Rawalpindi) of Pakistan. A structured self-administered questionnaire (English and Urdu) was developed as per the Pakistan national EPI policy and strategic guidelines 2022 and World Health Organization (WHO) guidelines, as well as from earlier studies (Cronbach's alpha value of 0.734). The final questionnaire consisted of closed-ended questions in four sections, including sociodemographic information, knowledge (with dichotomous variables of yes/no), attitudes (with a 5-point Likert scale ranging from strongly agree to strongly disagree), and handling of vaccines and cold chain management. Completed questionnaires were entered into Microsoft Excel and then imported into SPSS version 25 for statistical analysis.

Results

A total of 186 vaccinators completely filled out their questionnaires, with a 97.9% response rate. More than half of the participants (57.5%) had no training related to EPI. Most of the respondents had a moderate to poor level of knowledge regarding EPI. The overall attitude was positive, and 57% of the participants strongly agreed that the national immunization programs can significantly contribute to the decrease in morbidity and mortality rates among children. In the current study, participants showed good practices toward EPI, vaccine storage, and cold chain management. The majority (93.5%) of the participants checked the expiry of vaccines at regular intervals to maintain the first expiry first out (FEFO) in their healthcare setting.

Discussion

In conclusion, most of the vaccinators had moderate to poor knowledge, a positive attitude, and good practices toward EPI, vaccine cold storage, and cold chain management. Lack of training among vaccinators on EPI was also observed. These findings have suggested that continuous training, education, and regular supervision of vaccinators in EPI are important for maximum immunization effectiveness and coverage.

An established abdominal wall multidisciplinary team improves patient care and aids surgical decision making with complex ventral hernia patients

INTRODUCTION

Abdominal wall reconstruction (AWR) is an emerging subspecialty within general surgery. The practice of multidisciplinary team (MDT) meetings to aid decision making and improve patient care has been demonstrated, with widespread acceptance. This study presents our initial experience of over 150 cases of complex hernia patients discussed in a newly established MDT setting.

METHODS

From February 2020 to July 2022 (30-month period), abdominal wall MDTs were held bimonthly. Key stakeholders included upper and lower gastrointestinal surgeons, a gastrointestinal specialist radiologist, a plastic surgeon, a high-risk anaesthetist and two junior doctors integrated into the AWR clinical team. Meetings were held online, where patient history, past medical and surgical history, hernia characteristics and up-to-date computed tomography scans were discussed.

RESULTS

Some 156 patients were discussed over 18 meetings within the above period. Ninety-five (61%) patients were recommended for surgery, and 61 (39%) patients were recommended for conservative management or referred elsewhere. Seventy-eight (82%) patients were directly waitlisted, whereas seventeen (18%) required preoperative optimisation: three (18%) for smoking cessation, eleven (65%) for weight-loss management and three (18%) for specialist diabetic assessment and management. In total, 92 (59%) patients (including operative and nonoperative management) have been discharged to primary care.

DISCUSSION

A multidisciplinary forum for complex abdominal wall patients is a safe process that facilitates decision making, promotes education and improves patient care. As the AWR subspecialty evolves, our view is that the "complex hernia MDT" will become commonplace. We present our experience and share advice for others planning to establish an AWR centre.

Zika Virus from the Perspective of Observational Studies: a Review

Background: Since 1952 when Zika Virus (ZIKV): a Flavivirus, was first discovered in humans, it has not received enough scientific research compared to some of the other members of the family Flaviviridae; like Dengue Virus (DENV). However, this has not stopped the virus from infecting the human population globally. In particular, the global spread of ZIKV has led to a surge in observational studies. Methods: Regarding recently published ZIKV-related literature, we are not aware of any reviews strictly focusing on ZIKV from the perspective of observational studies. Therefore, we reviewed recently published observational studies exploring the global spread of ZIKV and its association with Congenital ZIKV Infection (CZI) and clinical manifesta­tions in adults. Online databases including google scholar, PubMed and Elsevier were used for retrieving relevant stud­ies. Results: ZIKV cases have been reported in different parts of the world, with certain regions reporting more cases than the rest, like Brazil. ZIKV causes a wide spectrum of diseases and disorders including microcephaly, developmental disorders, and Guillain-Barre syndrome to name a few. Furthermore, CZI in neonates mainly manifests into neurologi­cal disorders and diseases, whereas ZIKV in adults’ targets various organs. Conclusion: ZIKV poses a serious threat to human population and observational studies provide a different perspective on the damaging capabilities of ZIKV in real-life settings. Moreover, there are gaps in the literature regarding ZIKV-related-complications that future experimental studies need to address. These complications include in-utero transmis­sion, Guillain-Barre syndrome, cross-reactivity, sexual transmission, along with its persistence in the male reproductive tract.

Expression Profiles of Hepatic Immune Response Genes in HEV Infection

Hepatitis E is a liver inflammation caused by infection with the hepatitis E virus (HEV). Every year, there are an estimated 20 million HEV infections worldwide, leading to an estimated 3.3 million symptomatic cases of hepatitis E. HEV viral load has been studied about the disease progression; however, hepatic the host gene expression against HEV infection remains unknown. Methods: We identified the expression profiles of hepatic immune response genes in HEV infections. Fresh blood samples were collected from all the study subjects (130 patients and 124 controls) in 3ml EDTA vacutainers. HEV viral load was determined by a real-time PCR. The total RNA was isolated from the blood using the TRIZOL method. The expression of theCCL2, CCL5, CXCL10, CXCL16, TNF, IFNGR1, and SAMSN1 genes was studied in the blood of 130 HEV patients and 124 controls using a real-time PCR. Results: Gene expression profiles indicate high levels of CCL2, CCL5, CXCL10, CXCL16, TNF, IFNGR1, and SAMSN1 genes that might lead to the recruitment of leukocytes and infected cell apoptosis. Conclusion: Our study demonstrated distinct differences in the expression profiles of host immune response-related genes of HEV infections and provided valuable insight into the potential impact of these genes on disease progression.

Recent Developments in Oral Delivery of Vaccines Using Nanocarriers

As oral administration of vaccines is the preferred route due to its high patient compliance and ability to stimulate both cellular and humoral immune responses, it is also associated with several challenges that include denaturation of vaccine components in the acidic environment of the stomach, degradation from proteolytic enzymes, and poor absorption through the intestinal membrane. To achieve effective delivery of such biomolecules, there is a need to investigate novel strategies of formulation development that can overcome the barriers associated with conventional vaccine delivery systems. Nanoparticles are advanced drug delivery carriers that provide target-oriented delivery by encapsulating vaccine components within them, thus making them stable against unfavorable conditions. This review provides a detailed overview of the different types of nanocarriers and various approaches that can enhance oral vaccine delivery.

How reconfiguration of a minor injuries unit has affected service delivery during the COVID-19 pandemic: a retrospective analysis

INTRODUCTION

Redeployment of orthopaedic consultants to a minor injuries unit (MIU) during the COVID-19 pandemic provided a unique opportunity to assess the impact of early senior specialist input on patient management.

METHODS

Patient demographics, diagnosis, location of injury and disposal method were compared between three 7-day periods: during the April 2020 COVID-19 lockdown (period A), one month prior to period A (period B) and one year prior to period A (period C). Orthopaedic consultants staffed the MIU during period A, and emergency nurse practitioners staffed the MIU during periods B and C.

RESULTS

Period A witnessed higher injury severity either due to modified activities or altered healthcare-seeking behaviour during lockdown. For fractures, compared with periods B and C, period A saw a lower rate of referral to fracture clinic (41% vs 100% vs 86%, p<0.001) and higher rate of discharge (38% vs 0% vs 9%, p<0.001). The median time to fracture clinic was also longer (15 days vs 6 days vs 10 days, p<0.001), indicating earlier institution of definitive care. There were no other significant differences between periods with radiology alerts and complaints received remaining largely unchanged.

CONCLUSION

Early senior orthopaedic input in the patient journey from MIU had clear benefits, this being most true for fracture diagnoses. Earlier definitive management planning was observed as lower rates of fracture clinic referral, higher rates of discharge and deferred first fracture clinic reviews. This study highlights the benefits of greater partnership between MIU and orthopaedics. As the pandemic subsides and redeployed staff return to normal duties, a modification of this model could be utilised to ensure this partnership is sustainable.

A case report of dengue shock syndrome complicated with multiorgan failure and hepatitis E virus superinfection

Dengue fever is a vector borne viral disease. It is more prevalent in Southeast Asia. The main symptoms include myalgia, nausea, vomiting and rash, hence, subsequently lead to dengue hemorrhagic fever and dengue shock syndrome. In the current report, we are presenting a case of a 50-year-old female patient who was presented in hospital with the symptoms of fever, vomiting, abdominal pain, productive cough and sore throat. Her serology came positive for dengue NSP1, and she was shifted to intensive care unit because of her aggravating condition. On day 4, the hepatitis E virus infection also was detected and she died after developing hepatic shock and multiorgan failure. This report states the superinfection of hepatitis E and dengue virus and highlights the significance of its early detection for better clinical management.

The importance of right heart function in heart failure with preserved ejection fraction

Funding Acknowledgements

Type of funding sources: None.

Background

Heart failure (HF) is a complex clinical syndrome that is a frequent cause of morbidity and mortality. Although half of patients with HF have a preserved ejection fraction (HFpEF), the majority of studies have examined the prognostic impact of left heart parameters instead of the right. We thus evaluated associations of right heart hemodynamics and echocardiographic measures with outcomes in HFpEF subjects.

Purpose

To perform long-term mortality analysis of patients with decompensated HFpEF using strain imaging and right heart catheterization hemodynamics.

Methods

This was a retrospective cross-sectional study which included patients hospitalized for acute heart failure exacerbation as the primary admitting diagnosis based on clinical and laboratory parameters as determined by the primary medical team. Patients included were only those with HFpEF and with available echocardiographic and right heart catheterization (RHC) hemodynamic data done during the index admission. 2D strain analysis software was used to automatically calculate right ventricular free wall strain (RVFWS), fractional area change (FAC), and left ventricular global longitudinal strain (LVGLS). Demographic and clinical parameters were obtained including RHC hemodynamics. The outcome of interest was long term 6-year all-cause mortality. Right and left ventricular echocardiographic strain and hemodynamic parameters were compared between patients with mortality and those who survived using independent T tests and non-parametric methods as appropriate. Multivariable logistic regression was used to identify echocardiographic and hemodynamic factors independently associated with all-cause mortality. Results From a total of 100 patients, 47% were Caucasian and 53% were female. The mean age was 67.4 ± 14.3. There was an 18% long term all cause mortality rate. Of the right sided echocardiographic strain parameters, only RVFWS was statistically significantly lower among those who died (12.0 vs 15.7 p = 0.038). Meanwhile, 4 chamber LVGLS was significantly lower (13.8 vs 15.1 p = 0.016) and mean right atrial (RA) pressure was higher (13.6 vs 10.7 p = 0.076) although this did not reach statistical significance. Looking at echocardiographic strain and hemodynamic parameters as predictors of mortality, after adjusting for age, gender and race accounting for the major differences in these parameters between the survival groups, only RVFWS (OR 1.90, 95% CI 1.12-3.28; p = 0.02) and RA pressure (OR 1.85, 95% CI 1.12-3.28; p = 0.016) remained independently associated with long term all-cause mortality with C statistic of 0.751 for the overall predictive model.

Conclusion

Among patients with HFpEF admitted for acute heart failure exacerbation, baseline RVFWS and RA hemodynamic pressure measurements were independently associated with long term all-cause mortality. This suggests that right heart diagnostic parameters may hold more prognostic utility in HFpEF. Abstract Figure.  Abstract Figure.

Delayed admissions and efficacy of steroid use in patients with critical and severe COVID-19: an apprehensive approach

BACKGROUND

Inadvertent delays in access to appropriate therapeutic interventions in high-risk group coronavirus disease 2019 (COVID-19) patients contribute to mortality in patients with severe/critical disease presentation.

OBJECTIVES

The aim of this study was to determine the effect of timely admission to the hospital on mortality of patients with severe/critical COVID-19. Another secondary aspect of this study was to observe the efficacy of time-dependent use of corticosteroids on mortality of critical/severe COVID-19 patients.

METHODS

Clinical data of 659 patients with severe/critical COVID-19, admitted to four major tertiary care hospitals from the Islamabad-Rawalpindi region of Pakistan was retrospectively collected from a period February-August 2020. Multivariate logistic regression analysis was carried out to determine the predictors of mortality in severe/critical COVID-19 patients.

RESULTS

Out of a total of 659 patients, 469 (71.2%) patients died. Age > 60 years, presence of hypertension, heart disease and kidney disease along with late admission (>5 days) were significant predictors of mortality in patients with severe/critical COVID-19.

CONCLUSIONS

The study highlights the importance of well-timed provision of appropriate medical interventions control COVID-19-associated mortality.

Public health workers' knowledge, attitude and practice regarding COVID-19: the impact of Field Epidemiology Training Program in the Eastern Mediterranean Region

BACKGROUND

This study aimed to compare knowledge, attitude and practice (KAP) regarding COVID-19 between public health workers (PHWs) attended field epidemiology training program (FETP-trained) and those who did not attend FETP (non-FETP trained).

METHODS

Multi-country cross-sectional survey was conducted among PHWs who participated in COVID-19 pandemic in 10 countries at EMR. Online questionnaire that included demographic information, KAP regarding COVID-19 pandemic was distributed among HCWs. Scoring system was used to quantify the answers, bivariate and Multivariate analysis performed to compare FETP-trained with non-FETP trained PHWs.

RESULTS

Overall, 1337 PHWs participated, with 835 (62.4%) < 40 years of age, and 851 (63.6%) males. Of them, 423 (31.6%) had FETP, including that 189 (44.7%) had advanced level, 155 (36.6%) intermediate and 79 (18.7%) basic level training. Compared with non-FETP trained, FETP trained were older, having higher KAP scores. FETP participation was low in infection control, and PH laboratories. KAP mean scores for intermediate level attendees are comparable to advanced level.

CONCLUSIONS

FETP-trained are having better KAP than non-FETP PHWs. Expanding the intermediate level, maintain the Rapid Response training and introduce the laboratory component are recommended to maximize the benefit from FETP. Infection control, antimicrobial resistance and coordination are areas where training should include.

Presenting characteristics, comorbidities, and outcomes among COVID-19 patients hospitalized in twin cities of Pakistan

Background

COVID-19 became a pandemic rapidly after its emergence in December 2019. It belongs to the coronavirus family of viruses, which have struck a few times before in history. Data based on previous research regarding etiology and epidemiology of other viruses from this family helped played a vital role in formulating prevention and precaution strategies during the initial stages of this pandemic. Data related to COVID-19 in Pakistan were not initially documented on a large scale. In addition, due to a weak health care system and low economic conditions, Pakistan’s population, in general, already suffers from many comorbidities, which can severely affect the outcome of patients infected with COVID-19.

Objective

COVID-19 infections are coupled with a manifestation of various notable outcomes that can be documented and characterized clinically. The aim of this study was to examine these clinical manifestations, which can serve as indicators for early detection as well as severity prognosis for COVID-19 infections, especially in high-risk groups.

Methods

A retrospective observational study involving abstraction of demographic features, presenting symptoms, and adverse clinical outcomes for 1812 patients with COVID-19 was conducted. Patients were admitted to the four major hospitals in the Rawalpindi-Islamabad region of Pakistan, and the study was conducted from February to August 2020. Multivariate regression analysis was carried out to identify significant indicators of COVID-19 severity, intensive care unit (ICU) admission, ventilator aid, and mortality. The study not only relates COVID-19 infection with comorbidities, but also examines other related factors, such as age and gender.

Results

This study identified fever (1592/1812, 87.9%), cough (1433/1812, 79.1%), and shortness of breath (998/1812, 55.1%) at the time of hospital admission as the most prevalent symptoms for patients with COVID-19. These symptoms were common but not conclusive of the outcome of infection. Out of 1812 patients, 24.4% (n=443) required ICU admission and 21.5% (n=390) required ventilator aid at some point of disease progression during their stay at the hospital; 25.9% (n=469) of the patients died. Further analysis revealed the relationship of the presented symptoms and comorbidities with the progression of disease severity in these patients. Older adult patients with comorbidities, such as hypertension, diabetes, chronic kidney disease, and asthma, were significantly affected in higher proportions, resulting in requirement of ICU admission and ventilator aid in some cases and, in many cases, even mortality.

Conclusions

Older adult patients with comorbidities, such as hypertension, diabetes, asthma, chronic obstructive pulmonary disorder, and chronic kidney disease, are at increased risk of developing severe COVID-19 infections, with an increased likelihood of adverse clinical outcomes.

Mental health impacts of COVID-19 on healthcare workers in the Eastern Mediterranean Region: a multi-country study

Background

Healthcare workers (HCWs) fighting against the COVID-19 pandemic are under incredible pressure, which puts them at risk of developing mental health problems. This study aimed to determine the prevalence of depression, anxiety, and stress among HCWs responding to COVID-19 and its associated factors.

Methods

A multi-country cross-sectional study was conducted during July–August 2020 among HCWs responding to COVID-19 in nine Eastern Mediterranean Region (EMR) countries. Data were collected using an online questionnaire administered using KoBo Toolbox. Mental problems were assessed using the Depression, Anxiety, and Stress Scale (DASS-21).

Results

A total of 1448 HCWs from nine EMR countries participated in this study. About 51.2% were male and 52.7% aged ≤ 30 years. Of all HCWs, 57.5% had depression, 42.0% had stress, and 59.1% had anxiety. Considering the severity, 19.2%, 16.1%, 26.6% of patients had severe to extremely severe depression, stress, and anxiety, respectively. Depression, stress, anxiety, and distress scores were significantly associated with participants’ residency, having children, preexisting psychiatric illness, and being isolated for COVID-19. Furthermore, females, those working in a teaching hospital, and specialists had significantly higher depression and stress scores. Married status, current smoking, diabetes mellitus, having a friend who died with COVID-19, and high COVID-19 worry scores were significantly associated with higher distress scores.

Conclusions

Mental problems were prevalent among HCWs responding to COVID-19 in EMR. Therefore, special interventions to promote mental well-being among HCWs responding to COVID-19 need to be immediately implemented.

Risk Factors of COVID-19 Critical Outcomes in the Eastern Mediterranean Region: A Multicountry Retrospective Study

BACKGROUND

The establishment of empirical evidence in the Eastern Mediterranean Region (EMR) necessitates the implementation of wide-scale studies to describe the demographic, clinical features, and severity profile of COVID-19 patients.

OBJECTIVE

This study aimed to assess the patterns of COVID-19 severity and mortality in seven countries and to determine the risk factors of COVID-19 severity and mortality.

METHODS

This multi-country study was based on a retrospective review of medical records of hospitalized patients confirmed to have COVID-19. This study included data from Iraq, Pakistan, Sudan, Somalia, Morocco, Egypt, and Yemen. All demographic and clinical data were extracted from hospital records (paper files) by trained data collectors.

RESULTS

A total of 4141 patients were included in this study from seven countries. Comorbidities were reported by nearly half of the patients, with hypertension (HT) (24.7%) and diabetes (22.7%) being the most common. Older age, diabetes mellitus, hypertension, and heart diseases were significantly associated with COVID-19 severity and mortality. Ever smoking and renal diseases were significantly associated with severity but not mortality, while male gender, respiratory diseases, and malignancy were significantly associated with mortality but not severity.

CONCLUSIONS

The study confirmed the role of comorbidities and demographic features on the severity and mortality of COVID-19. Understanding the contributing factors ensures attentive care and informs clinical management of patients with poorer prognoses in the early stages of diseases.

Epstein - Barr virus epidemiology in HIV infected transsexuals

OBJECTIVE

To molecularly characterise the relationship between Epstein-Barr virus (EBV) genotypes and Pashtun ethnicity.

METHODS

The cross-sectional study was conducted from November 2018 to December 2019 after approval from the Gomal University, Dera Ismail Khan, Pakistan, and comprised blood samples from transgender sex workers who were seropositive for human immunodeficiency virus-1 and seronegative for human immunodeficiency virus residing in two cities of Khyber Pakhtunkhwa province and Islamabad, the federal capital. Formalin-fixed paraffin-embedded (FFPE). Samples were collected from the partner institute along with the patients data, but without any follow-up from the study subjects which was purely on the basis of physical availability. β-globin gene and EBER-1(EBV encoded small RNA-1) were amplified for qualitative assessment and existence of Epstein-Barr virus. Characterisation of EBNA-2 (EBV Nuclear Antigen-2 was done through nested polymerase chain reaction.

RESULTS

Of the 80 subjects, 40(50%) each were seropositive and seronegative individuals. The overall mean age was 28±6.917 years. Among the seropositive group, 38(95%) were homosexual and 2(5%) were heterosexual. Among the seropositive group, 16(40%) had Epstein-Barr virus genotype 1 and 6(15%) had genotype 2, while co-infections were found in 2(5%) subjects. In the seronegative group, 36(90%) subjects had Epstein-Barr virus genotype 1, while there was no case of genotype 2 or co-infection. EBV-2 genotypes with HIV seropositivity showed strong association (p=0.005). Amplification for the EBER-1 gene was done in all the 80(100%) samples.

CONCLUSIONS

Epstein-Barr virus EBV genotype 1 was found to be the most frequent type, while genotype 2 and co-infections were detected in only seropositive samples.

Risk Factors of COVID-19 Critical Outcomes in the Eastern Mediterranean Region: Multicountry Retrospective Study (Preprint).. [DOI: 10.2196/preprints.32831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

BACKGROUND

The establishment of empirical evidence in the Eastern Mediterranean Region necessitates the implementation of wide-scale studies to describe the demographic, clinical features, and severity profile of patients with COVID-19.

OBJECTIVE

This study aims to assess the patterns of COVID-19 severity and mortality in seven countries, and to determine the risk factors of COVID-19 severity and mortality.

METHODS

This multicountry study was based on a retrospective review of medical records of hospitalized patients confirmed to have COVID-19. This study includes data from Iraq, Pakistan, Sudan, Somalia, Morocco, Egypt, and Yemen. All demographic and clinical data were extracted from hospital records (paper files) by trained data collectors.

RESULTS

A total of 4141 patients were included in this study from seven countries. Comorbidities were reported by nearly half of the patients, with hypertension (n=1021, 24.7%) and diabetes (n=939, 22.7%) being the most common. Older age, diabetes mellitus, hypertension, and heart diseases were significantly associated with COVID-19 severity and mortality. Ever smoking and renal diseases were significantly associated with severity but not mortality, while male gender, respiratory diseases, and malignancy were significantly associated with mortality but not severity.

CONCLUSIONS

The study confirms the role of comorbidities and demographic features on the severity and mortality of COVID-19. Understanding the contributing factors ensures attentive care and informs clinical management of patients with poorer prognoses in the early stages of diseases.

An Overview of the Treatment Options Used for the Management of COVID-19 in Pakistan: Retrospective Observational Study

BACKGROUND

Since the first reports of COVID-19 infection, the foremost requirement has been to identify a treatment regimen that not only fights the causative agent but also controls the associated complications of the infection. Due to the time-consuming process of drug discovery, physicians have used readily available drugs and therapies for treatment of infections to minimize the death toll.

OBJECTIVE

The aim of this study is to provide a snapshot analysis of the major drugs used in a cohort of 1562 Pakistani patients during the period from May to July 2020, when the first wave of COVID-19 peaked in Pakistan.

METHODS

A retrospective observational study was performed to provide an overview of the major drugs used in a cohort of 1562 patients with COVID-19 admitted to the four major tertiary-care hospitals in the Rawalpindi-Islamabad region of Pakistan during the peak of the first wave of COVID-19 in the country (May-July 2020).

RESULTS

Antibiotics were the most common choice out of all the therapies employed, and they were used as first line of treatment for COVID-19. Azithromycin was the most prescribed drug for treatment. No monthly trend was observed in the choice of antibiotics, and these drugs appeared to be a random but favored choice throughout the months of the study. It was also noted that even antibiotics used for multidrug resistant infections were prescribed irrespective of the severity or progression of the infection. The results of the analysis are alarming, as this approach may lead to antibiotic resistance and complications in immunocompromised patients with COVID-19. A total of 1562 patients (1064 male, 68.1%, and 498 female, 31.9%) with a mean age of 47.35 years (SD 17.03) were included in the study. The highest frequency of patient hospitalizations occurred in June (846/1562, 54.2%).

CONCLUSIONS

Guidelines for a targeted treatment regime are needed to control related complications and to limit the misuse of antibiotics in the management of COVID-19.

Pakistan's Response to COVID-19: Overcoming National and International Hypes to Fight the Pandemic

The COVID-19 outbreak started as pneumonia in December 2019 in Wuhan, China. The subsequent pandemic was declared as the sixth public health emergency of international concern on January 30, 2020, by the World Health Organization. Pakistan could be a potential hotspot for COVID-19 owing to its high population of 204.65 million and its struggling health care and economic systems. Pakistan was able to tackle the challenge with relatively mild repercussions. The present analysis has been conducted to highlight the situation of the disease in Pakistan in 2020 and the measures taken by various stakeholders coupled with support from the community to abate the risk of catastrophic spread of the virus.

Notes From the Field: The Combined Effects of Tocilizumab and Remdesivir in a Patient With Severe COVID-19 and Cytokine Release Syndrome

SARS-CoV-2 is known to cause severe bilateral pneumonia and acute respiratory distress syndrome or COVID-19 in patients, which can be debilitating and even fatal. With no drugs or vaccines available yet, a wide range of treatment regimens used are being repurposed. The need of the hour is to analyze various currently available regimens and devise a treatment plan that is most effective for COVID-19. Here we describe the case of a 68-year-old man with hypertension and diabetes, exhibiting symptoms of cough and shortness of breath, who presented at the emergency department of our hospital. Chest computed tomography revealed bilateral ground glass opacities that were indicative of COVID-19, and a computed tomography score of 24 was indicative of severe pulmonary pneumonia. He tested positive for COVID-19. His treatment regimen included the use of convalescent plasma, oxygen therapy, steroids, high-dose antibiotics, broad-spectrum antiviral remdesivir, and anti–interleukin-6 monoclonal antibody (Tocilizumab) at various stages of the disease. Oxygen supplementation was required at the time of admission. The patient initially developed a cytokine release storm, and oxygen supplementation was initiated to manage his condition. Supportive care and multiple treatment regimens were used to successfully recover the patient’s health. With a rapid increase in number of confirmed cases worldwide, COVID-19 has become a major challenge to our health care system. With no available vaccines currently, the establishment of a combination of therapeutic drugs that effectively reduce disease progression is of utmost importance.

A200 VEDOLIZUMAB IS AN EFFECTIVE TREATMENT OPTION FOR NON INFLAMMATORY BOWEL DISEASE RELATED ENTEROPATHY

Background

Vedolizumab is an α4β7 integrin antagonist which inhibits intestinal T-cell translocation by blocking integrin interactions with mucosal vascular addressin cell adhesion molecule 1, reducing lymphocyte mediated inflammation. Its gut selective mode of action and safety profile have lead to reports of off-label use of vedolizumab for non-IBD related inflammatory intestinal disorders.

Aims

We conducted a literature review to assess clinical, endoscopic and histologic improvement in patients treated with Vedolizumab for non-IBD enteropathies refractory to conventional therapy.

Methods

EMBASE, Medline, Clinicaltrials.gov and Cochrane CENTRAL were searched on September 12, 2019 for case studies, case series and cohort studies without language restriction yielding 356 studies with 164 duplicates, 74 non-applicable studies, leaving 118 studies. After full text review, 98 studies were excluded, leaving 20 included studies.

Results

65% of patients (51/79) achieved clinical response. 40.5% (15/37) of patients experienced endoscopic improvement and 33% (17/51) of patients experienced histologic improvement. The duration of treatment varied from patients receiving only induction doses to up to 70 months for maintenance therapy. There were four reported cases of withdrawal due to adverse events from Vedolizumab.

Conclusions

In a treatment refractory population, over 60% of patients reported to have a clinical response and one-third endoscopic/histologic response, indicating that Vedolizumab is a viable option for patients with refractory non-IBD enteropathy.

Funding Agencies

None

A234 CLINICAL, ENDOSCOPIC AND HISTOLOGICAL IMPROVEMENT IN COMMON VARIABLE IMMUNODEFICIENCY DISEASE ASSOCIATED ENTEROPATHY WITH VEDOLIZUMAB

Background

Common variable immune deficiency (CVID) can be associated with autoimmune manifestations including enteric inflammation and diarrhea. Systemic immunosuppression used in patients with inflammatory bowel disease (IBD) may be associated with increased risk of infection in CVID.

Aims

We report a patient with CVID associated intestinal enteropathy who underwent clinical, endoscopic and histological improvement after treatment with vedolizumab (IgG1 monoclonal antibody to α4β7 integrin), as well as a concurrent systematic review (SR) of the literature.

Methods

Case report and systematic literature review. We searched EMBASE, Medline, Cochrane CENTRAL, clinialtrials.gov, and the International Clinical Trials Registry Platform without language restriction using key words to identify patients with CVID associated enteropathy treated with vedolizumab. Clinical, endoscopic and histological outcomes were extracted and safety data.

Results

A 32-year-old male presented with weight loss, anemia and hypoalbuminemia on a background of chronic diarrhea and recurrent sinus infections. Serology and genetic testing was not consistent with celiac disease. Pan-endoscopy showed complete villous atrophy in the duodenum and biopsies showed and intraepithelial lymphocytosis (IEL) in the duodenum and terminal ileum. CT abdomen showed pan-enteritis with extensive mesenteric lymphadenopathy which were reactive on lymph node excision, as well as bronchiectasis. Pneumococcal vaccination challenge to assess humoral response confirmed CVID. After suboptimal response with steroids and mercaptopurine, treatment was initiated with vedolizumab 300mg IV at weeks 0, 2, and 6, then 8 weekly. This led to normalization of stool frequency, weight gain as well as endoscopic and histological resolution within 6 months of treatment. The SR yielded 101 studies of which 3 case series were identified reporting a total of 7 patients with CVID. In 5 cases there was clinical improvement, 4 reported endoscopic improvement and 3 patients had histologic improvement. No safety concerns associated with vedolizumab were reported.

Conclusions

Vedolizumab, a selective leucocyte inhibitor to the gut, was able to induce either clinical, endoscopic or histological improvement in 8 published cases in the worldwide literature. Prospective studies are needed to determine whether this treatment could be included in the therapeutic armamentarium for this orphan indication.

Funding Agencies

None

Unraveling the molecular mechanism governing the tissue specific expression of IFNλR1

The functional receptor for type III interferons (IFNs) is a heterodimer of IFNLR1 and IL10R2. IFNLR1 is expressed in a highly tissue specific manner, with epithelial and liver tissue as the prime expressing tissues in humans. However, knowledge about the molecular pathways responsible for regulating the expression of IFNLR1 is yet unknown. In this study, various bioinformatics tools were used to predict the scores of signal peptides of IFNλR1 and IFNαR1, which was considered as an important difference in the expression of both receptors or participation in regulating the IFNLR1 gene. In silico study revealed that the signal peptide of IFNαR1 had more potential than the signal peptide of IFNλR1 but changing the signal peptide of wild type IFNλR1 with the signal peptide of IFNαR1 in wet lab had barely shown any differences. Selective expression of IFNλR1 was considered to be a plus point towards the targeted anti-viral activity of IFNλs but artificial control on its expression will surely make IFNλs a better drug with enhanced activity. The results of this study may help us in contributing some understanding towards the mechanisms involved in the selective expression of IFNLR1 and exceptionalities involved.

Identification of essential regulatory elements responsible for the explicit expression of IL-28Rα and their effect on critical SNPs using in-Silico methods

IL-28Rα and IL10Rβ collectively construct a fully functional hetero-dimeric receptor for type III interferons (IFNs). IL-28Rα is the private chain for type III IFNs since their involvement in any other pathway has not been reported yet and they are highly expressed in response to certain viral attack or cancers. IL-28Rα is specific in their expression pattern and it expresses within few cell types only. The regulatory mechanisms governing the expression of IL-28Rα at the molecular level are not completely known yet and need to be scrutinized at primary levels. In the present study, various in-silico techniques were applied and it was observed that AP1-2, STAT 1-6, P-53, LyF-1 (lymphoid transcription factor), c-Jun, PU.1, CREB (cAMP response element-binding), PLAG (pleotropic adenoma gene), MYOD (myoblast determination protein 1), NOFL and KLFS as transcription factors that are selected with preference. Interestingly AP-2, c-Jun, LyF-1, STAT, NF-Y and P53 have also been reported in literature recently as some of the key regulatory elements as well. Based on the fact that interlinking between different interferon stimulation genes (ISGs) is also not very clear and induction of one type of interferon can affect the efficacy of the other, we found that IFN-λ4 induction can increase the expression of IL-28Rα, similar to IFN-λ3 but contrary to type I IFNs, which has either no effect on the expression of IL-28Rα or can down regulate its expression at higher concentrations (data not published).

Transcriptome analysis reveals a classical interferon signature induced by IFNλ4 in human primary cells

The IFNL4 gene is negatively associated with spontaneous and treatment-induced clearance of hepatitis C virus infection. The activity of IFNλ4 has an important causal role in the pathogenesis, but the molecular details are not fully understood. One possible reason for the detrimental effect of IFNλ4 could be a tissue-specific regulation of an unknown subset of genes. To address both tissue and subtype specificity in the interferon response, we treated primary human hepatocytes and airway epithelial cells with IFNα, IFNλ3 or IFNλ4 and assessed interferon mediated gene regulation using transcriptome sequencing. Our data show a surprisingly similar response to all three subtypes of interferon. We also addressed the tissue specificity of the response, and identified a subset of tissue-specific genes. However, the interferon response is robust in both tissues with the majority of the identified genes being regulated in hepatocytes as well as airway epithelial cells. Thus we provide an in-depth analysis of the liver interferon response seen over an array of interferon subtypes and compare it to the response in the lung epithelium.

Body mass index, waist circumference, hip circumference, waist-hip-ratio and waist-height-ratio: which is the better discriminator of prevalent screen-detected diabetes in a Cameroonian population?

BACKGROUND

The link between measures of adiposity and prevalent screen-detected diabetes (SDM) in Africa has been less well investigated. We assessed and compared the strength of association and discriminatory capability of measures of adiposity including body mass index (BMI), waist circumference (WC), hip circumference (HC), waist-hip-ratio (WHR) and waist-height-ratio (WHtR) for prevalent SDM risk in a sub-Saharan African population.

METHODS

Participants were 8663 adults free of diagnosed type 2 diabetes, who took part in the nationally representative Cameroon Burden of Diabetes (CAMBoD) 2006 survey. Logistic regression models were used to compute the odd ratio (OR) and 95% confidence interval (95%CI) for a standard deviation (SD) higher level of BMI (7.3), WC (12.5), HC (11.7), WHR (0.19) and WHtR (0.08) with prevalent SDM risk. Assessment and comparison of discrimination used C-statistic and relative integrated discrimination improvement (RIDI, %).

RESULTS

The adjusted OR and 95%CI for prevalent SDM with each SD higher adipometric variable were: 1.05 (0.98-1.13) for BMI, 1.30 (1.16-1.46) for WC, 1.18 (1.05-1.34) for HC, 1.05 (1.00-1.16) for WHR and 1.26 (1.11-1.39) for WHtR. C-statistic comparisons and RIDI analyses showed a trend toward a significant superiority of WC over other adipometric variables in multivariable models. Combining adiposity variables did not improve discrimination beyond multivariable models with WC alone.

CONCLUSION

WC was the best predictors and to some extent WHtR of prevalent SDM in this population, while BMI and WHR were less effective.

Interferon lambda 4 signals via the IFNλ receptor to regulate antiviral activity against HCV and coronaviruses

The IFNL4 gene is a recently discovered type III interferon, which in a significant fraction of the human population harbours a frameshift mutation abolishing the IFNλ4 ORF. The expression of IFNλ4 is correlated with both poor spontaneous clearance of hepatitis C virus (HCV) and poor response to treatment with type I interferon. Here, we show that the IFNL4 gene encodes an active type III interferon, named IFNλ4, which signals through the IFNλR1 and IL-10R2 receptor chains. Recombinant IFNλ4 is antiviral against both HCV and coronaviruses at levels comparable to IFNλ3. However, the secretion of IFNλ4 is impaired compared to that of IFNλ3, and this impairment is not due to a weak signal peptide, which was previously believed. We found that IFNλ4 gets N-linked glycosylated and that this glycosylation is required for secretion. Nevertheless, this glycosylation is not required for activity. Together, these findings result in the paradox that IFNλ4 is strongly antiviral but a disadvantage during HCV infection.

Over expression of a synthetic gene encoding interferon lambda using relative synonymous codon usage bias in Escherichia coli

Interferon Lambda (IFN-λ) is a type III interferon which belongs to a novel family of cytokines and possesses antiviral and antitumor properties. It is unique in its own class of cytokines; because of the specificity towards its heterodimer receptors and its structural similarities with cytokines of other classes. This renders IFN-λ a better choice for the treatment against many diseases including viral hepatitis and human coronavirus (HCoV-EMC). The present study describes a computational approach known as relative synonymous codon usage (RSCU); used to enhance the expression of IFN-λ protein in a eukaryotic expression system. Manually designed and commercially synthesized IFN-λ gene was cloned into pET-22b expression plasmid under the control of inducible T7-lac promoter. Maximum levels of IFN-λ expression was observed with 0.4 mM IPTG in transformed E. coli incubated for 4 hours in LB medium. Higher concentrations of IPTG had no or negative effect on the expression of IFN-λ. This synthetically over expressed IFN-λ can be tested as a targeted treatment option for viral hepatitis after purification.

Prevalence of human immunodeficiency virus infection among transgender men in Rawalpindi (Pakistan)

Background

Transgender males are at high risk for sexually transmitted diseases including AIDS caused by the notorious Human Immunodeficiency Virus (HIV), yet little consideration is given by the policy makers, researchers and non-governmental organizations (NGOs) towards this sensitive issue in Pakistan.

Methods

In this study, we have investigated the prevalence of HIV infection among 306 transgender males with a median age of 29 years (range 15–64 years) residing in Rawalpindi, Pakistan. Rapid HIV antibody-screening methods including the strip test and Enzyme Linked Immuno-absorbent tests were employed to detect HIV antibodies among the subjects. For further confirmation, Polymerase Chain Reaction (PCR) was carried out. Statistical analytical techniques utilized included logistic regression and chi-square.

Results

HIV-1 was found to be the predominant viral subtype. PCR confirmed 21.6% (Confidence Interval 0.17-0.26) of the respondents were reported being HIV positive. 15.7% of the transgender men who shave at home and 13.7% of the transgender men who were educated below 5th grade were found to have HIV.

Conclusion

This study shows a very high prevalence of HIV among transgender males. Unawareness among these individuals about the ramifications of this infection owes largely to lack of education. The spread rate is alarming and HIV epidemic is imminent if awareness is not widespread.

Crystal structure of picolinic acid hydrazide, C6H7N3O

C6H7N3O, monoclinic, C12/c1 (no. 15), a = 19.222(2) Å, b = 3.8987(4) Å, c = 18.115(2) Å, β = 107.095(2)°, V = 1297.6 Å3, Z = 8, Rgt(F) = 0.038, wRref(F2) = 0.122, T = 293 K.

Synthesis and structure determination of some oxadiazole-2-thione and triazole-3-thione galactosides

The syntheses of 5-pyridyl-3(beta-D-galactopyranosyl)-1,3,4-oxadiazole-2-thiones 3a-3c and 5-pyridyl-2(beta-D-galactopyranosyl)-4-benzyl-1,2, 4-triazole-3-thiones 6a-6c are reported. The existence of N-galactosides--not S-galactosides--was proven by IR and 15N NMR spectroscopy. The structures of the final products and the intermediates were elucidated by IR, 1H, 13C and 15N NMR spectroscopy and mass spectrometry.