Emphasis of Diversity, Equity, and Inclusion on US Adult Infectious Disease Fellowship Program Websites in the Era of Virtual Recruitment

Women and underrepresented-in-medicine applicants value a climate for diversity when selecting graduate medical education training programs. Climate may not be accurately represented during virtual recruitment. Optimizing program websites may help overcome this barrier. We reviewed websites for adult infectious disease fellowships that participated in the 2022 National Resident Matching Program for emphasis on diversity, equity, and inclusion (DEI). Fewer than half expressed DEI language in their mission statement or had a dedicated DEI statement or webpage. Programs should consider emphasizing their commitment to DEI prominently on their websites, which may help recruit candidates from diverse backgrounds.

Risk factors for mortality among hospitalized COVID-19 patients in Northern Ethiopia: A retrospective analysis

Background

COVID-19 is a deadly pandemic caused by an RNA virus that belongs to the family of CORONA virus. To counter the COVID-19 pandemic in resource limited settings, it is essential to identify the risk factors of COVID-19 mortality. This study was conducted to identify the social and clinical determinants of mortality in COVID-19 patients hospitalized in four treatment centers of Tigray, Northern Ethiopia.

Methods

We reviewed data from 6,637 COVID-19 positive cases that were reported from May 7, 2020 to October 28, 2020. Among these, 925 were admitted to the treatment centers because of their severity and retrospectively analyzed. The data were entered into STATA 16 version for analysis. The descriptive analysis such as median, interquartile range, frequency distribution and percentage were used. Binary logistic regression model was fitted to identify the potential risk factors of mortality of COVID-19 patients. The adjusted odds ratio (AOR) with 95% confidence interval was used to determine the magnitude of the association between the outcome and predictor variables.

Results

The median age of the patients was 30 years (IQR, 25–44) and about 70% were male patients. The patients in the non-survivor group were much older than those in the survivor group (median 57.5 years versus 30 years, p-value < 0.001). The overall case fatality rate was 6.1% (95% CI: 4.5% - 7.6%) and was increased to 40.3% (95% CI: 32.2% - 48.4%) among patients with critical and severe illness. The proportions of severe and critical illness in the non-survivor group were significantly higher than those in the survivor group (19.6% versus 5.1% for severe illness and 80.4% versus 4.5% for critical illness, all p-value < 0.001). One or more pre-existing comorbidities were present in 12.5% of the patients: cardiovascular diseases (42.2%), diabetes mellitus (25.0%) and respiratory diseases (16.4%) being the most common comorbidities. The comorbidity rate in the non-survivor group (44.6%) was higher than in the survivor group (10.5%). The results from the multivariable binary regression showed that the odds of mortality was higher for patients who had cardiovascular diseases (AOR = 2.49, 95% CI: 1.03–6.03), shortness of breath (AOR = 9.71, 95% CI: 4.73–19.93) and body weakness (AOR = 3.04, 95% CI: 1.50–6.18). Moreover, the estimated odds of mortality significantly increased with patient’s age.

Conclusions

Age, cardiovascular diseases, shortness of breath and body weakness were the predictors for mortality of COVID-19 patients. Knowledge of these could lead to better identification of high risk COVID-19 patients and thus allow prioritization to prevent mortality.

The impact of war on the health system of the Tigray region in Ethiopia: an assessment

The war in Tigray region of Ethiopia that started in November 2020 and is still ongoing has brought enormous damage to the health system. This analysis provides an assessment of the health system before and during the war. Evidence of damage was compiled from November 2020 to June 2021 from various reports by the interim government of Tigray, and also by international non-governmental organisations. Comparison was made with data from the prewar calendar year. Six months into the war, only 27.5% of hospitals, 17.5% of health centres, 11% of ambulances and none of the 712 health posts were functional. As of June 2021, the population in need of emergency food assistance in Tigray increased from less than one million to over 5.2 million. While the prewar performance of antenatal care, supervised delivery, postnatal care and children vaccination was 94%, 73%, 63% and 73%, respectively, but none of the services were likely to be delivered in the first 90 days of the war. These data indicate a widespread destruction of livelihoods and a collapse of the healthcare system. The widespread use of hunger and rape during the brutal war and the targeting of healthcare facilities seem to be key components of the war. To avert worsening conditions, an immediate intervention is needed to deliver food and supplies and rehabilitate the healthcare delivery system and infrastructure.

Utilizing the SEIPS model to guide hand hygiene interventions at a tertiary hospital in Ethiopia

We aimed to apply the Systems Engineering Initiative for Patient Safety (SEIPS) model to increase effectiveness and sustainability of the World Health Organization's (WHOs) hand hygiene (HH) guidelines within healthcare systems. Our cross-sectional, mixed-methods study took place at Jimma University Medical Center (JUMC), a tertiary care hospital in Jimma, Ethiopia, between November 2018 and August 2020 and consisted of three phases: baseline assessment, intervention, and follow-up assessment. We conducted questionnaires addressing HH knowledge and attitudes, interviews to identify HH barriers and facilitators within the SEIPS framework, and observations at the WHO's 5 moments of HH amongst healthcare workers (HCWs) at JUMC. We then implemented HH interventions based on WHO guidelines and results from our baseline assessment. Follow-up HH observations were conducted months later during the Covid-19 pandemic. 250 HCWs completed questionnaires with an average knowledge score of 61.4% and attitude scores indicating agreement that HH promotes patient safety. Interview participants cited multiple barriers to HH including shortages and location of HH materials, inadequate training, minimal Infection Prevention Control team presence, and high workload. We found an overall baseline HH compliance rate of 9.4% and a follow-up compliance rate of 72.1%. Drastically higher follow-up compared to baseline compliance rates were likely impacted by our HH interventions and Covid-19. HCWs showed motivation for patient safety despite low HH knowledge. Utilizing the SEIPS model helped identify institution-specific barriers that informed targeted interventions beyond WHO guidelines aimed at increasing effectiveness and sustainability of HH efforts.

Early estimates of COVID-19 infections in small, medium and large population clusters

INTRODUCTION

Since its emergence in late December 2019, COVID-19 has rapidly developed into a pandemic in mid of March with many countries suffering heavy human loss and declaring emergency conditions to contain its spread. The impact of the disease, while it has been relatively low in the sub-Saharan Africa (SSA) as of May 2020, is feared to be potentially devastating given the less developed and fragmented healthcare system in the continent. In addition, most emergency measures practised may not be effective due to their limited affordability as well as the communal way people in SSA live in relative isolation in clusters of large as well as smaller population centres.

METHODS

To address the acute need for estimates of the potential impacts of the disease once it sweeps through the African region, we developed a process-based model with key parameters obtained from recent studies, taking local context into consideration. We further used the model to estimate the number of infections within a year of sustained local transmissions under scenarios that cover different population sizes, urban status, effectiveness and coverage of social distancing, contact tracing and usage of cloth face mask.

RESULTS

We showed that when implemented early, 50% coverage of contact tracing and face mask, with 33% effective social distancing policies can bringing the epidemic to a manageable level for all population sizes and settings we assessed. Relaxing of social distancing in urban settings from 33% to 25% could be matched by introduction and maintenance of face mask use at 43%.

CONCLUSIONS

In SSA countries with limited healthcare workforce, hospital resources and intensive care units, a robust system of social distancing, contact tracing and face mask use could yield in outcomes that prevent several millions of infections and thousands of deaths across the continent.

Hepatitis C virologic response in hepatitis B and C coinfected persons treated with directly acting antiviral agents: Results from ERCHIVES

BACKGROUND

There are scant data regarding hepatitis C (HCV) virologic response to directly acting antiviral agents (DAAs) in chronic hepatitis B (HBV) and HCV coinfected persons. HCV treatment response in those with spontaneously cleared HBV infection is unknown.

METHODS

All HCV infected persons treated with a DAA regimen in ERCHIVES were identified and categorized into HBV/HCV-coinfected (HBsAg, HBV DNA or both positive), HCV-monoinfected, and resolved HBV (isolated HBcAb+). SVR rates were determined and compared for all groups. Logistic regression model was used to determine factors associated with SVR.

RESULTS

Among 115 HCV/HBV-coinfected, 38,570 HCV-monoinfected persons, and 13,096 persons with resolved HBV, 31.6% of HCV/HBV-coinfected, 24.6% of HCV-monoinfected and 26.4% with resolved HBV had cirrhosis at baseline. SVR was achieved in 90.4% of HCV/HBV-coinfected, 83.4% of HCV-monoinfected and 84.5% of those with resolved HBV infection (P = 0.04 HCV/HBV vs. HCV monoinfected). In a logistic regression model, those with HCV/HBV were more likely to achieve SVR compared with HCV monoinfected (OR 2.25, 95% CI 1.17, 4.31). For HCV/HBV coinfected, the SVR rates dropped numerically with increasing severity of liver fibrosis (P-value non-significant). Factors associated with a lower likelihood of attaining SVR included cirrhosis at baseline (OR 0.85, 95% CI 0.80, 0.92), diabetes (OR 0.93, 95% CI 0.87, 0.99) and higher pre-treatment HCV RNA (OR 0.86, 95% CI 0.84, 0.87).

CONCLUSION

HBV/HCV-coinfected persons have higher overall SVR rates with newer DAA regimens. Though not statistically significant, the virologic response is graded, with decreasing SVR rates with increasing degree of liver fibrosis as determined by the FIB-4 scores.

285. Fibrosis Progression and Clinical Outcomes in HCV/HBV Coinfected Persons in the ERCHIVES Cohort

Background

Progression of liver disease and clinical outcomes in HCV/HBV coinfected persons and how they differ from HCV monoinfected persons and HCV infected persons with resolved HBV infection are not well characterized. We compared incidence of cirrhosis, hepatic decompensation and overall mortality in these three groups.

Methods

Using the Electronically Retrieved Cohort of HCV-infected Veterans (ERCHIVES), we identified those with HCV infection only, HCV/HBV coinfection (HbsAg or HBV DNA or both positive) or HCV with resolved HBV (HbcAb+ in absence of HbsAg or HBV DNA positivity). We excluded those with HIV coinfection or hepatocellular carcinoma at or before baseline, and those who received any HCV or HBV treatment. Incident rates (95% CI) were determined for cirrhosis, first hepatic decompensation event and overall mortality in the three groups.

Results

We identified 60,368 HCV monoinfected (Gp A), 151 HCV/HBV coinfected (Gp B) and 19,802 HCV infected with resolved HBV infection (Gp C). Mean age was 61.0, 60.9, and 63.0 years in the three groups and 96.5%, 96.0%, and 97.9% were males. Median baseline FIB-4 index was 2.0, 2.2, and 2.1, respectively. Incident cirrhosis (among those without cirrhosis at baseline) was increased 2- to 2.5-fold in HCV/HBV coinfected persons with baseline FIB-4 of 1.46–3.25. Hepatic decompensation and mortality were also increased several-fold in the HCV/HBV coinfected who had minimal or mild/moderate fibrosis at baseline. However, among those with cirrhosis at baseline, the difference was small among HCV/HBV coinfected and the other groups.

Conclusion

HCV/HBV coinfected persons with minimal or mild/moderate fibrosis at baseline have a much higher risk of developing cirrhosis, hepatic decompensation and mortality. However, once cirrhosis has is established, the difference is diminished. This underscores the need to intervene early when HCV/HBV coinfected persons still have minimal or mild/moderate fibrosis.

Disclosures

All authors: No reported disclosures.

294. Hepatitis C Virologic Response in Hepatitis B and C Coinfected Persons Treated with Directly Acting Antiviral Agents: Results from ERCHIVES

Background

Methods

Results

Conclusion

Disclosures

Evaluating antibiotic stewardship in a tertiary care hospital in Kerala, India: a qualitative interview study

OBJECTIVES

To determine what barriers and facilitators to antibiotic stewardship exist within a healthcare facility.

SETTING

1300-bed tertiary care private hospital located in the state of Kerala, India.

PARTICIPANTS

31 semistructured interviews and 4 focus groups with hospital staff ranging from physicians, nurses, pharmacists and a clinical microbiologist.

RESULTS

Key facilitators of antibiotic stewardship (AS) at the hospital included a dedicated committee overseeing appropriate inpatient antibiotic use, a prompt microbiology laboratory, a high level of AS understanding among staff, established guidelines for empiric prescribing and an easily accessible antibiogram. We identified the following barriers: limited access to clinical pharmacists, physician immunity to change regarding stewardship policies, infrequent antibiotic de-escalation, high physician workload, an incomplete electronic medical record (EMR), inadequate AS programme (ASP) physical visibility and high antibiotic use in the community.

CONCLUSIONS

Opportunities for improvement at this institution include increasing accessibility to clinical pharmacists, implementing strategies to overcome physician immunity to change and establishing a more accessible and complete EMR. Our findings are likely to be of use to institutions developing ASPs in lower resource settings.

454. Barriers and Facilitators to Control of Hospital Acquired Infections in Jimma, Ethiopia

Background

Given the complex, interdisciplinary nature of infection prevention, a systems approach may be useful to promote and sustain effective infection prevention practices. The Systems Engineering Initiative for Patient Safety (SEIPS) model provides a framework that can be used to identify barriers and facilitators of infection control practices and evaluate interactions between structures, processes, and outcomes.

Methods

A qualitative study was done to evaluate barriers and facilitators to implementation of effective infection control practices at Jimma University Hospital in Jimma, Ethiopia. Twenty-two semi-structured interviews of hospital employees, selected by convenience sampling, were conducted to assess the five components of SEIPS framework: person, physical environment, tasks, organization and tools. The interviews were transcribed, coded for themes, and analyzed using the software Dedoose.

Results

The primary facilitators to effective infection control were identified at the task, organization, and person level. Prominent themes included a manageable workload, a management system supportive of institutional feedback, sufficient budget, and positive individual attitude toward improving infection control. The primary barriers to effective infection control were found to be at the technology and tools, person, and organization levels. The major themes within these levels include poor supply chain management leading to personal protective equipment (PPE) shortages, an inconsistent and incomplete training program for employees, a lack of infection control policies, a lack of involvement of environmental services, and a nurse rotation program that increases unit staff turnover

Conclusion

To address the identified barriers, possible interventions to consider should include: developing infection control policies and protocols, using these to implement a regular staff training program, incorporation of environmental services to the healthcare team, identify and train infection control team member to manage the PPE supply chain, and establishing an HAI surveillance program to better identify current risk areas as well as track progress.

Disclosures

All authors: No reported disclosures.

Barriers and facilitators to infection control at a hospital in northern India: a qualitative study

Background

Hospital acquired infections occur at higher rates in low- and middle-income countries, like India, than in high-income countries. Effective implementation of infection control practices is crucial to reducing the transmission of hospital acquired infections at hospitals worldwide. Yet, no comprehensive assessments of the barriers to sustained, successful implementation of hospital interventions have been performed in Indian healthcare settings to date. The Systems Engineering Initiative for Patient Safety (SEIPS) model examines problems through the lens of interactions between people and systems. It is a natural fit for investigating the behavioral and systematic components of infection control practices.

Methods

We conducted a qualitative study to assess the facilitators and barriers to infection control practices at a 1250 bed tertiary care hospital in Haryana, northern India. Twenty semi-structured interviews of nurses and physicians, selected by convenience sampling, were conducted in English using an interview guide based on the SEIPS model. All interview data was subsequently transcribed and coded for themes.

Results

Person, task, and organizational level factors were the primary barriers and facilitators to infection control at this hospital. Major barriers included a high rate of nursing staff turnover, time spent training new staff, limitations in language competency, and heavy clinical workloads. A well developed infection control team and an institutional climate that prioritizes infection control were major facilitators.

Conclusions

Institutional support is critical to the effective implementation of infection control practices. Prioritizing resources to recruit and retain trained, experienced nursing staff is also essential.

Electronic supplementary material

The online version of this article (doi:10.1186/s13756-017-0189-9) contains supplementary material, which is available to authorized users.