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Background. Trauma is the fourth burden of disease in South Africa (SA). The risk group is the same as that for HIV/AIDS. The Centers for Disease Control and the World Health Organization promulgated the opt-out testing system 10 years ago and several high- and lower-middle-income countries have adopted this approach. Objective. To review the feasibility of implementing the opt-out system in SA emergency departments. Methods. We examined the clinical, economic, practical and patient/provider perceptions concerning the scientific and ethical aspects of the opt-out concept. Results. Patients were generally positive about the opt-out system and the overall test rate and disease identification rates were better than with other systems. Although initial costs may increase, the long-term cost benefit and prevention of transmission, due to linking to care, make this option attractive. Conclusion. The opt-out option for patients presenting to emergency departments with an acute life-threatening illness or trauma, and for those in critically ill states in an intensive care unit, is justifiable based on international and regional practices. This also has the potential to advance early highly active antiretroviral therapy and reduce treatment costs and the disease-adjusted life years for HIV management and trauma critical care. SA should adopt an opt-out testing system instead of the current tedious opt-in system. [ABSTRACT FROM AUTHOR]

Introduction: With the emergence of new SARS-CoV-2 variants has come significant variations in disease manifestation, severity, and duration in non-hospitalized infected patients. To characterize symptom patterns and risk factors associated with symptom severity and duration, COVID-19 and influenza-like illness (ILI) outpatients and their contacts were enrolled at two sites in the United States of America and one site in Thailand., Methods: COVID-19 infection was confirmed at enrollment with a positive antigen or PCR test. Baseline demographics and medical histories were collected from participants at enrollment and daily self-reported symptom questionnaires were obtained to assess symptom severity and duration. Risk factors associated with symptom severity and duration were determined by multivariate logistic regression and Cox proportional hazards model., Results: Two hundred and forty one participants meeting the eligibility criteria were enrolled, including 174 confirmed COVID-19 cases (9% Delta and 90% Omicron), 33 ILI cases, and 34 healthy contacts. COVID-19 participants had a shorter median symptom duration of 9.0 (95% CI, 8.0-11.0) days than ILI participants. Infection with the Delta variant resulted in a longer symptom alleviation period compared to infection with the Omicron variant. The most commonly reported symptoms among COVID-19 participants were reported in the nasal and chest/respiratory domains of the FLU-PRO Plus. Participants infected with the Delta variant reported more symptoms overall, with significantly more symptoms affecting eyes and senses reported. 55% of SARS-CoV-2-positive participants reached a negative N1 Ct value by the day 14 study time point. No risk factors for moderate to severe symptoms were identified in this outpatient cohort. Male sex was associated with a shorter symptom duration., Conclusion: Symptom manifestation varied among Delta and Omicron variants. Few risk factors were identified for increased symptom severity or duration., Competing Interests: The authors have no competing interests., (Copyright: © 2025 Vashi et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Effective infection prevention and control (IPC) was central to keeping healthcare workers (HCWs) safe during the COVID-19 pandemic. However, as the pandemic continued, the maintenance of high-quality IPC practices waned, placing HCWs at increased risk of infection. A COVID-19 Safety Officer (SO) program was piloted by the United States Agency for International Development (USAID)-funded Reaching Impact, Saturation and Epidemic Control (RISE) project across two health facilities in Ethiopia, which trained clinical and non-clinical HCWs on IPC protocols to promote safe practices in patient care areas. We sought to evaluate the implementation and effectiveness of the SO program in improving IPC practices within the clinical setting., Methods: This is a post-implementation evaluation of the SO program, implemented in two hospitals in Ethiopia between May 2022 and December 2022. Participants completed a 4-day course on COVID-19 epidemiology, IPC, safety communication, and learning theory as a part of the Training of Trainers component ( n = 23), and were posted in clinical wards to provide staff training and support to maintain IPC protocols. The program was evaluated at 6 months using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Effectiveness was measured using direct observation of IPC practices across intervention sites. Implementation outcomes were measured using surveys and qualitative interviews to capture training cascade, knowledge, comfort, acceptability, and maintenance., Results: Participants were able to cascade training to an additional 167 clinical (67.6%) and 80 non-clinical (32.3%) staff across both sites. Direct observation of clinical staff at 6 months showed that 95% (59/62) wore at least a surgical mask with patients and were compliant with masking and/or distancing protocol. Clinical interviews revealed that SOs contributed to increased perceived comfort with screening and isolation procedures and environmental cleaning procedures., Conclusion: The SO training program was widely adopted, and effective in improving the implementation and comfort of maintaining IPC practices in clinical settings., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Woldeamanuel, Thumba, Gabul, Ahmed, Mekonnen, Tarekegn, Nhanala, Kent, Ashengo, Wu, Dagoye, Curless, Fisseha, Ayalew, Gebremichael and Hansoti.)

We present a case of mpox recurrence in a transgender woman with AIDS. Her recurrent lesions required several courses of antiviral therapy over a 5-month period and her monkeypox viral genome was subsequently noted to have tecovirimat resistance mutations. Interestingly, she developed a robust orthopoxvirus-specific T-cell response., Competing Interests: Potential conflicts of interest. All authors: No reported conflicts., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: Patients with suspected mpox presented to different venues for evaluation during the 2022 outbreak. We hypothesized that practice patterns may differ across venue of care., Methods: We conducted an observational study of patients undergoing mpox testing between 1 June 2022 and 15 December 2022. We assessed concomitant sexually transmitted infection (STI) testing, sexual history, and anogenital examination and a composite outcome of all 3, stratified by site. Venue of care was defined as ED (emergency department or urgent care), ID (infectious disease clinic), or PCP (primary care or other outpatient clinic)., Results: Of 276 patients included, more than half (62.7%) were evaluated in the ED. Sexual history, anogenital examination, and STI testing were documented as performed at a higher rate in ID clinic compared to ED or PCP settings. STIs were diagnosed in 20.4% of patients diagnosed with mpox; syphilis was the most common STI among patients diagnosed with mpox (17.5%). Patients evaluated in an ID clinic had higher odds ratio of completing all 3 measures (adjusted odds ratio, 3.6 [95% confidence interval, 1.4-9.3]) compared to PCP setting adjusted for age, gender, and men who have sex with men status. Cisgender men who have sex with men, transgender males, and transgender females had higher odds ratio of completing all 3 measures compared to cisgender females (adjusted odds ratio, 4.0 [95% confidence interval, 1.9-8.4]) adjusted for age and venue of care., Conclusions: Care varied across clinical sites. ID clinics performed a more thorough evaluation than other venues. Rates of STI coinfection were high. Syphilis was the most common STI. Efforts to standardize care are important to ensure optimal outcomes for patients., Competing Interests: Potential conflicts of interest. K.A.G. receives royalties from UpToDate, non-paid position at Pfizer, and personal consulting from Spark HealthCare, Premier HealthCare, Harrison Consulting and MedEd Learning. W.M.G. reports receiving honorarium from DKBmed; serving as a scientific advisor to Gilead Sciences, Inc; and owning stock in Abbott Laboratories, Danaher, Eli Lilly and Company, Iqvia, Johnson & Johnson, Stryker, UnitedHealth Group, and AstraZeneca Pharmaceuticals. M.M.H. receives royalties from UpToDate and BMJ publishing and has received consultant fees from Chembio, Cepheid, and Roche diagnostics. He has also received donations of test kits for research studies from Chembio, Cepheid, Roche diagnostics, and Hologic. All other authors report no potential conflicts., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: Since July 23, 2022, global mpox cases reached 92,546, with over 31,000 in the United States. Asymptomatic carriage is a critical mechanism influencing the global dissemination of mpox. Seroprevalence studies are crucial for determining the epidemic's true burden, but uncertainties persist in serologic assay performance and how smallpox vaccination may influence assay interpretation., Objectives: Our study aimed to assess the performance of several diagnostic assays among mpox-positive, vaccinated, and pre-outbreak negative control samples. This investigation sought to enhance our understanding and management of future mpox outbreaks., Study Design: Serum samples from 10 mpox-positive, five vaccinated uninfected, and 137 pre-outbreak controls were obtained for serological testing. The mpox-positive samples were obtained around 100 days post symptom onset, and vaccinated patients were sampled approximately 90 days post-vaccination. Multiple diagnostic assays were employed, including four commercial ELISAs (Abbexa, RayBioTech, FineTest, ProteoGenix) and a multiplex assay (MesoScale Diagnostics (MSD)) measuring five mpox and five smallpox antigens., Results: Three commercial ELISA kits had low specificity (<50 %). The Proteogenix ELISA targeting the E8L antigen had a 94 % sensitivity and 87 % specificity. The E8L antigen on the MSD assay exhibited the greatest distinction between exposure groups, with 98 % sensitivity and 93 % specificity., Conclusions: None of the assays could distinguish between mpox-positive and vaccinated samples. The MSD assay targeting the MPXV E8L antigen demonstrated the greatest differentiation between mpox-positive and pre-outbreak negative samples. Our findings underscore the imperative to identify sensitive and specific assays to monitor population-level mpox exposure and infection., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to declare., (Published by Elsevier B.V.)

Background The United States Agency for International Development (USAID) Reaching Impact, Saturation, and Epidemic Control (RISE) program funded Jhpiego to support the Government of Lesotho's COVID-19 response, including two national COVID-19 treatment centers. To evaluate the status of post-pandemic pediatric respiratory care in Lesotho, we analyzed pediatric treatment center data and healthcare worker (HCW) performance on pediatric COVID-19 training offered to HCWs at COVID-19 treatment centers. Methods We conducted a retrospective cohort study of patients 15 years of age or less hospitalized at two COVID-19 treatment centers in Lesotho from May 1, 2020, to April 30, 2022. Patient data were extracted from hospital files. We used the independent sample t-test, Mann-Whitney U test, or Fisher's exact test to evaluate associations between exposure variables and death. We also assessed differences between pre- and post-training examination scores of three one-day HCW training on pediatric COVID-19 using paired t-tests. Results Overall, <15-year-olds comprised 18/1,448 (1.2%) hospitalizations. Twenty-two percent (4/18) of children were hypoxemic (oxyhemoglobin saturation <94%) within the first 24 hours and 44% (8/18) at any point in the hospitalization. Oxygen utilization increased over the two-year period (p=0.004) and all eight children with hypoxemia received oxygen (p<0.001). Four of 18 (22%) patients died. For HCW training, pre- and post-training examinations were completed by 76/82 (92.7%) participants. The overall mean pretraining score was 44.6% (standard deviation (SD) 15.7%). Mean scores improved by an average of 32.2% (95% confidence interval (CI) 27.7%, 36.6%, p<0.001) on the same day post-training examination. Conclusions National COVID-19 treatment center data indicate a low burden of severe pediatric COVID-19 disease in Lesotho. However, recognized HCW knowledge gaps suggest deficiencies in identifying and referring severely ill children, which may detrimentally impact the ongoing post-pandemic care of children with severe lower respiratory infections., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. The Johns Hopkins School of Medicine Institutional Review Board issued approval IRB00279223. The Johns Hopkins School of Medicine Institutional Review Board (IRB00279223) and the Lesotho National Health Institutional Review Board (12-2021) approved this research. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: This report was made possible with support from the United States Agency for International Development (USAID)-funded RISE programme, under the terms of the cooperative agreement 7200AA19CA00003. The contents are the responsibility of the authors and do not necessarily reflect the views of USAID or the US government. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Joseph et al.)

Introduction: Worldwide, 3.7% (144.7 million) of people diagnosed with COVID-19 developed Post-COVID Conditions (PCC). Therefore, creating and implementing multidisciplinary rehabilitation clinics is important to address the needs of patients and improve overall recovery. This study was made possible with support from the United States Agency for International Development funded RISE program, under the terms of the cooperative agreement 7200AA19CA00003., Methods: This case study was conducted in Ecuador and describes the creation and implementation of 21 PCC rehabilitation clinics in primary healthcare centers and secondary level hospitals in 7 provinces across the country. Data was gathered for the identification of partnering health facilities and needs, for the evaluation of knowledge enhancement in health professionals after a specific training program, and for the measurement of key performance indicators. This article emphasizes the organization, educational strategies, and implementation of rehabilitation programs tailored specifically for the management of Post-COVID Conditions in Ecuador., Results: The implementation of PCC rehabilitation clinics involved a collaborative effort between the Ministry of Public Health (MOPH), the private sector and a non-governmental organization (Jhpiego). Twenty-one health facilities from the primary and secondary level of care were selected, and PCC rehabilitation implemented in 7 provinces of Ecuador. Additionally, 133 health providers were trained and a total of 13,846 patients treated, among whom 859 had a diagnosis of PCC. Medical doctors outperformed nurses in both pre- and post-tests scores. However, all healthcare professionals demonstrated comparable improvement in knowledge acquisition. Rehabilitation manuals were developed and adopted by the MOPH, rehabilitation equipment was donated and a mobile application, "RESPIRA", was developed and disseminated free of charge., Conclusion: The establishment of PCC rehabilitation clinics in Ecuador was successful in identifying patients in need of early rehabilitation. The insights of this study can serve as a guide for the development of similar initiatives in other countries. Tailored courses are essential to address disparities and ensure comprehensive skill development and promote equitable healthcare delivery.

Purpose: Intensive care units (ICUs) in low- and middle-income countries have high mortality rates, and clinical data are needed to guide quality improvement (QI) efforts. This study utilizes data from a validated ICU registry specially developed for resource-limited settings to identify evidence-based QI priorities for ICUs in Ethiopia., Materials and Methods: A retrospective cohort analysis of data from two tertiary referral hospital ICUs in Addis Ababa, Ethiopia from July 2021-June 2022 was conducted to describe casemix, complications and outcomes and identify features associated with ICU mortality., Results: Among 496 patients, ICU mortality was 35.3%. The most common reasons for ICU admission were respiratory failure (24.0%), major head injury (17.5%) and sepsis/septic shock (13.3%). Complications occurred in 41.0% of patients. ICU mortality was higher among patients with respiratory failure (46.2%), sepsis (66.7%) and vasopressor requirements (70.5%), those admitted from the hospital ward (64.7%), and those experiencing major complications in the ICU (62.3%)., Conclusions: In this study, ICU mortality was high, and complications were common and associated with increased mortality. ICU registries are invaluable tools to understand local casemix and clinical outcomes, especially in resource-limited settings. These findings provide a foundation for QI efforts and a baseline to evaluate their impact., Competing Interests: Declaration of competing interest None., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Syphilis diagnosis in the emergency department (ED) setting is often missed due to the lack of ED-specific testing strategies. We characterized ED patients with high-titer syphilis infections (HTSIs) with the goal of defining a screening strategy that most parsimoniously identifies undiagnosed, untreated syphilis infections., Methods: Unlinked, de-identified remnant serum samples from patients attending an urban ED, between 10 January and 9 February 2022, were tested using a three-tier testing algorithm, and sociodemographic variables were extracted from ED administrative database prior to testing. Patients who tested positive for treponemal antibodies in the first tier and positive at high titer (≥1:8) for nontreponemal antibodies in the second tier were classified as HTSI. Human immunodeficiency virus (HIV) status was determined with Bio-Rad enzyme-linked immunosorbent assay and confirmatory assays. Exact logistic regression and classification and regression tree (CART) analyses were performed to determine factors associated with HTSI and derive screening strategies., Results: Among 1951 unique patients tested, 23 (1.2% [95% confidence interval, .8%-1.8%]) had HTSI. Of those, 18 (78%) lacked a primary care physician, 5 (22%) were HIV positive, and 8 (35%) were women of reproductive age (18-49 years). CART analysis (area under the curve of 0.67) showed that using a screening strategy that measured syphilis antibodies in patients with HIV, without a primary care physician, and women of reproductive age would have identified most patients with HTSI (21/23 [91%])., Conclusions: We show a high prevalence of HTSI in an urban ED and propose a feasible, novel screening strategy to curtail community transmission and prevent long-term complications., Competing Interests: Potential conflicts of interest. All authors: No reported conflicts., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: We sought to understand the relative risk of COVID-19 infection and identify risk factors for infection to identify targets for mitigation among medical students., Methods: An observational cohort study of Johns Hopkins School of Medicine students was conducted from June 2020 to July 2021. Blood samples were collected and tested at three visits to assess for antibodies against SARS-CoV-2. Additionally, a questionnaire was administered at each visit to collect demographic information and assess potential social and behavioral risk factors., Results: 264 students enrolled in the study, and 38 participants completed all study requirements by study end. Roughly 6% of the first- and second-year classes had a reported positive COVID-19 test compared to 5% of third- and fourth-year students. By visit 3, 92% of medical students had detectable antibodies against COVID-19 compared to 4% during the study enrollment period. From study enrollment to visit 3, there was a 10-fold increase in the percentage of students reporting attending large social gatherings and dining in restaurants., Conclusions: Overall, few COVID-19 cases were found among medical students, even those on clinical rotations. As the study progressed, students reported engaging in higher-risk social behaviors in conjunction with increasing vaccination rates among students., (© 2024. The Author(s).)

Orthopoxvirus-specific T-cell responses were analyzed in 10 patients who had recovered from Mpox including 7 people with human immunodeficiency virus (PWH). Eight participants had detectable virus-specific T-cell responses, including a PWH who was not on antiretroviral therapy and a PWH on immunosuppressive therapy. These 2 participants had robust polyfunctional CD4+ T-cell responses to peptides from the 121L vaccinia virus (VACV) protein. T-cells from 4 of 5 HLA-A2-positive participants targeted at least 1 previously described HLA-A2-restricted VACV epitope, including an epitope targeted in 2 participants. These results advance our understanding of immunity in convalescent Mpox patients., Competing Interests: Potential conflicts of interest. All authors: No reported conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: During the 2022 mpox outbreak most patients were managed as outpatients, but some required hospitalization. Uncontrolled human immunodeficiency virus (HIV) has been identified as a risk factor for severe mpox., Methods: Patients with mpox diagnosed or treated within the Johns Hopkins Health System between 1 June and 15 December 2022 were included. The primary outcome of interest was risk of hospitalization. Demographic features, comorbid conditions, treatment, and clinical outcomes were determined., Results: A total of 353 patients were tested or treated for mpox; 100 had mpox diagnosed or treated (median age, 35.3 years; 97.0% male; 57.0% black and 10.0% Hispanic; 46.0% people with HIV [PWH]). Seventeen patients (17.0%) required hospitalization, 10 of whom were PWH. Age >40 years, race, ethnicity, HIV status, insurance status, and body mass index >30 (calculated as weight in kilograms divided by height in meters squared) were not associated with hospitalization. Eight of 9 patients (88.9%) with immunosuppression were hospitalized. Immunosuppression was associated with hospitalization in univariate (odds ratio, 69.3 [95% confidence interval, 7.8-619.7]) and adjusted analysis (adjusted odds ratio, 94.8 [8.5-1060.1]). Two patients (11.8%) who were hospitalized required intensive care unit admission and died; both had uncontrolled HIV infection and CD4 T-cell counts <50/µL. Median cycle threshold values for the first positive mpox virus sample did not differ between those who were hospitalized and those who were not., Conclusions: Immunosuppression was a significant risk factor for hospitalization with mpox. PWH with CD4 T-cell counts <50/µL are at high risk of death due to mpox infection. Patients who are immunosuppressed should be considered for early and aggressive treatment of mpox, given the increased risk of hospitalization., Competing Interests: Potential conflicts of interest. W. M. G reports receiving a honorarium from DKBmed; serving as a scientific advisor to Gilead Sciences; and owning stock in Abbott Laboratories, Danaher, Eli Lilly, Iqvia, Johnson & Johnson, Stryker, UnitedHealth Group, and AstraZeneca Pharmaceuticals. K. A. G. reports payment from the Aspen Institute, Teach For America, Premier, and UpToDate and reports a nonpaid position on the scientific advisory board for Pfizer. All other authors report no potential conflicts., (© The Author(s) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: The coronavirus 2019 (COVID-19) pandemic fundamentally changed how populations interface with the healthcare system. Despite historical spikes in US mortality during the pandemic, emergency department (ED) visits were paradoxically low. This is a concerning phenomenon that raises a red flag regarding access to care, especially among vulnerable populations. In this study we sought to understand how ED utilization evolved during the COVID-19 pandemic among traditionally understudied, low-income, racially diverse US- and foreign-born mothers., Methods: This is a secondary analysis of a pre-existing dataset of 3,073 participants enrolled in the Boston Birth Cohort at birth and followed prospectively. We obtained ED visit diagnoses from 2019 and 2020 via electronic health records, categorized according to the International Classification of Diseases, 10 th Revision, and compared them using graph plots, chi-square, and negative binomial regression., Results: The number of ED visits decreased by 29.1% ( P  < 0.001) from 2019 (1,376) to 2020 (976). However, visits for infectious and parasitic diseases, including COVID-19, increased by 90.6% (32:61) with COVID-19 accounting for 77% of those visits in 2020 (47/61). Mental health-related visits increased by 40.9% (44:62), with diagnoses of alcohol use disorder increasing by 183% (6:17). Regression analysis showed 50% less ED utilization among foreign- vs US-born participants; however, the increase in infectious diseases visits was greater among foreign-born compared to US-born mothers (185% vs 26%, P  = 0.01), while the increase in mental health diagnoses was greater among US-born mothers (69% vs -33%, P  = 0.10)., Conclusion: Despite a decrease in total ED visits during the pandemic, there was an increase in COVID-19- (immigrant > US born) and mental health- (US-born only) related visits. Our findings demonstrate that EDs remain a critical access point for care for minority populations and have implications for preparedness, resources, and services of EDs in urban settings to better address the needs of communities. However, alternative avenues for healthcare services for these populations, particularly during health crises, warrant further investigation., Competing Interests: Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. This work is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant numbers (UJ2MC31074, UT7MC45949), Autism Longitudinal Data Project. The Boston Birth Cohort (the parent study) is supported in part by the March of Dimes PERI grants (20-FY02-56 and 21-FY07-605); the National Institutes of Health (NIH) grants (2R01HD041702, R01HD086013, R01HD098232, R01ES031272, and R01ES031521; and the Hopkins Population Center Grant (P2CHD042854) from the National Institute of Child Health and Human Development. The information, content and/or conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred, by HRSA, HHS or the US government.

Background: We sought to understand the relative risk of COVID-19 infection and identify risk factors for infection to identify targets for mitigation among medical students., Methods: An observational cohort study of Johns Hopkins School of Medicine students was conducted from June 2020 to July 2021. Blood samples were collected and tested at three visits to assess for the presence of antibodies against SARS-CoV-2. Additionally, a questionnaire was administered at each visit to collect demographic information and assess potential social and behavioral risk factors., Results: 264 students enrolled in the study, and 38 participants completed all study requirements by study end. Roughly 6% of the first- and second-year classes had a reported positive COVID-19 test compared to 5% of third- and fourth-year students. By visit 3, 92% of medical students had detectable antibodies against COVID-19 compared to 4% during the study enrollment period. From study enrollment to visit 3, there was a 10-fold increase in the percentage of students reporting attending large social gatherings and dining in restaurants., Conclusions: Overall, few COVID-19 cases were found among medical students, even those on clinical rotations. As the study progressed, students reported engaging in higher-risk social behaviors in conjunction with increasing vaccination rates among students., Competing Interests: Competing interests: The authors declare that they have no competing interests.

HIV remains a threat to global public health, disproportionately affecting countries across Sub-Saharan Africa. Although treatment and access to care have improved, prevention remains critical to ending new HIV infections by 2030. A variety of prevention strategies exist, yet their effectiveness is difficult to measure and variable due to the nature of the interventions and vulnerability of the intervention during implementation. This systematic review of 51 studies synthesizes data on the implementation and evaluation of evidence-based HIV prevention interventions across Sub-Saharan Africa. Studies were included if they occurred between January 1, 2008, and December 31, 2019, inclusive in Sub-Saharan Africa, were written in English, implemented an HIV prevention intervention in the field, and had reportable results. Using a modified social-ecological model for HIV prevention, we divided studies into three categories: interventions targeting health systems (n = 16), communities (n = 8), and individuals (n = 27). Across all categories, the data emphasized preventing mother-to-child transmission (PMTCT), medical interventions, and psychosocial interventions. The most successful programs bundled several interventions that were integrated into the health system. There is a notable lack of interventions targeting key populations and there are significant rates of loss to follow up (LTFU) across many studies. This review provides insight into the prioritization of evidence-based HIV prevention interventions across Sub-Saharan Africa., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Long-term adherence to antiretroviral medication continues to present as a challenge along the continuum of the HIV care cascade. HIV interventions and support programs are significantly threatened in resource-limited settings by challenges in maintaining long-term follow-up for ART adherence. We sought to complete a systematic review to comprehensively examine ART adherence and retention in care interventions in Sub-Saharan Africa and to report on the implementation of interventions in real-world settings to inform future health investments in HIV care. Interventions were grouped according to their impact on individual, community, and health-systems levels. While a vast majority of studies evaluated a combination of interventions, those studies that incorporated the community as a resource were most successful. In addition, providing education and behavior reminders proved effective and should be accompanied by community and peer efforts for best results. Multi-level interventions, such as combining individual and community-level interventions showed promising results for long term ART adherence., (Copyright © 2022. Published by Elsevier Ltd.)

The clinical utility of point-of-care lung ultrasound (LUS) among hospitalized patients with COVID-19 is unclear., Design: Prospective cohort study., Setting: A large tertiary care center in Maryland, between April 2020 and September 2021., Patients: Hospitalized adults (≥ 18 yr old) with positive severe acute respiratory syndrome coronavirus 2 reverse transcriptase-polymerase chain reaction results., Interventions: None., Measurements and Main Results: All patients were scanned using a standardized protocol including 12 lung zones and followed to determine clinical outcomes until hospital discharge and vital status at 28 days. Ultrasounds were independently reviewed for lung and pleural line artifacts and abnormalities, and the mean LUS Score (mLUSS) (ranging from 0 to 3) across lung zones was determined. The primary outcome was time to ICU-level care, defined as high-flow oxygen, noninvasive, or invasive mechanical ventilation, within 28 days of the initial ultrasound. Cox proportional hazards regression models adjusted for age and sex were fit for mLUSS and each ultrasound covariate. A total of 264 participants were enrolled in the study; the median age was 61 years and 114 participants (43.2%) were female. The median mLUSS was 1.0 (interquartile range, 0.5-1.3). Following enrollment, 27 participants (10.0%) went on to require ICU-level care, and 14 (5.3%) subsequently died by 28 days. Each increase in mLUSS at enrollment was associated with disease progression to ICU-level care (adjusted hazard ratio [aHR], 3.61; 95% CI, 1.27-10.2) and 28-day mortality (aHR, 3.10; 95% CI, 1.29-7.50). Pleural line abnormalities were independently associated with disease progression to death (aHR, 20.93; CI, 3.33-131.30)., Conclusions: Participants with a mLUSS greater than or equal to 1 or pleural line changes on LUS had an increased likelihood of subsequent requirement of high-flow oxygen or greater. LUS is a promising tool for assessing risk of COVID-19 progression at the bedside., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Linkage to care (LTC) and initiation of antiretroviral therapy (ART) are key components in the longitudinal care cascade for people living with HIV. Many strategies to optimize these stages of HIV care have been implemented, though there is a paucity of analyses comparing the outcomes of these efforts in low- and middle-income countries. We conducted a systematic review of studies assessing interventions along all stages of the HIV care continuum published between 2008 and 2020. A comprehensive search strategy reviewed five electronic databases to capture studies assessing HIV testing, LTC, ART initiation, ART adherence, and viral suppression. Of the 388 articles that met the inclusion criteria, 78 described interventions for improving LTC/ART initiation. Efforts focused on empowering patients through integrative approaches generally yielded more substantive results compared to provider-initiated non-adaptive LTC interventions or cash incentives. Specifically, tailoring care and incorporating ART initiation into existing infrastructures, such as maternal clinics, had a high impact across settings. Moreover, strategies such as home-based HIV counseling and testing (HBHCT) appear to be most effective when implemented in tandem with other approaches including motivational counseling and point-of-care CD4 testing., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Influenza causes significant morbidity and mortality in the United States. Among patients infected with influenza, the presence of bacterial co-infection is associated with worse clinical outcomes; less is known regarding the clinical importance of viral co-infections. The objective of this study was to determine rates of viral co-infections in emergency department (ED) patients with confirmed influenza and association of co-infection with disease severity., Methods: Secondary analysis of a biorepository and clinical database from a parent study where rapid influenza testing was implemented in four U.S. academic EDs, during the 2014-2015 influenza season. Patients were systematically tested for influenza virus using a validated clinical decision guideline. Demographic and clinical data were extracted from medical records; nasopharyngeal specimens from influenza-positive patients were tested for viral co-infections (ePlex, Genmark Diagnostics). Patterns of viral co-infections were evaluated using chi-square analysis. The association of viral co-infection with hospital admission was assessed using univariate and multivariate regression., Results: The overall influenza A/B positivity rate was 18.1% (1071/5919). Of the 999 samples with ePlex results, the prevalence of viral co-infections was 7.9% (79/999). The most common viral co-infection was rhinovirus/enterovirus (RhV/EV), at 3.9% (39/999). The odds of hospital admission (OR 2.33, 95% CI: 1.01-5.34) increased significantly for those with viral co-infections (other than RhV/EV) versus those with influenza A infection only., Conclusion: Presence of viral co-infection (other than RhV/EV) in ED influenza A/B positive patients was independently associated with increased risk of hospital admission. Further research is needed to determine clinical utility of ED multiplex testing., (© 2022 The Authors. Influenza and Other Respiratory Viruses published by John Wiley & Sons Ltd.)

Introduction: Learning objectives (LOs) are a common tool used to define learning goals and guide curricula. As the field of global health has expanded, more rigorous and tailored approaches to effectively teach the next generation of the workforce are needed. The STAR project developed and utilized individualized LOs as the basis for on-the-job learning plans for senior global health leaders from low- and middle-income countries and from the US., Methods: We analyzed basic demographic information and LOs from 36 STAR fellows. Descriptive statistics provided an overview of the STAR fellows, competency areas and planned outputs of their LOs. We utilized qualitative thematic analysis to further explore the LOs themselves., Results: STAR fellows were based in the US and in low- and middle-income countries (LMICs). The majority had over 10 years of experience and at least one advanced degree. Fellows commonly worked on LOs related to capacity strengthening, communications, and development practice. Capacity strengthening LOs focused on mentorship, decision-making, and technical skills such as data analysis. Communications LOs focused on language skills, dissemination of information, and writing. Development practice LOs included gaining understanding of key stakeholders in global health and building effective partnerships and teams., Discussion: Our experience developing tailored LOs provided deeper understanding of diverse learning needs of global health leaders. While not representative of all global health learners, we captured priorities of senior US- and LMIC-based leaders and identified common themes for learning. Despite the labor required to tailor curricula in this way, more global health education programs can benefit by integrating similar processes., Competing Interests: The authors have declared that no competing interests exist.

Background: Delays in the implementation of evidence-based practices are significant and ubiquitous, compromising health outcomes. Resistance to change is a key factor in hindering adoption and integration of new evidence-based interventions. This study seeks to understand the impact of exposure to HIV testing within a research context on provider attitudes towards HIV counselling and testing (HCT) in emergency departments (ED)., Methods: This is a pre-and-post study design measuring the effect of a new ED-based HCT intervention, conducted by lay counsellors, on provider attitudes in Eastern Cape, South Africa. A validated, anonymized, 7-item survey was self-completed by routine care providers (physicians, nurses, and case managers). Questions were scored on a 5-point Likert scale with 5 consistently reflecting a positive attitude. Mean scores were calculated for each question and compared using a two-sample t-test to assess change in sample means for attitudes among providers surveyed before and after the intervention., Results: A total of 132 surveys were completed across three EDs. Majority of respondents were female (70.5%), 20-29 years old (37.9%), of African race (81.1%), nurses (39.4%), and practicing medicine for 0-4 years (37.9%). Pre-intervention, providers displayed a positive attitude towards 'the benefit of offering ED-based HCT to patients' (4.33), 'the ED offering HCT' (3.53), 'all ED patients receiving HCT' (3.42), 'concern about patient reaction to HCT' (3.26), and 'comfort with disclosing HCT results' (3.21); and a mildly negative attitude towards 'only high-risk ED patients receiving HCT' (2.68), and 'the burden of offering HCT in a clinical environment' (2.80). Post-intervention, provider attitudes improved significantly towards 'all ED patients receiving HCT' (3.86, p < 0.05), 'only high-risk ED patients receiving HCT' (2.30, p < 0.05), 'the burden of offering HCT in a clinical environment' (3.21, p < 0.05), and 'comfort with disclosing HCT results' (3.81, p < 0.05)., Conclusions: Controlled exposure to new practices with a structured implementation period can shift attitudes beginning a process of practice normalization. In our study, we observed improvements in provider attitudes regarding the benefits of HCT and the burden of offering HCT to all patients in the ED. Research activities may have a role in mitigating resistance to change and supporting intervention adoption., (© 2022. The Author(s).)

HIV/AIDS remains a looming presence in public health across the world, particularly in Sub-Saharan Africa. The HIV Care Cascade hinges on testing and knowledge of HIV status. Though significant advances have been made in diagnosing people living with HIV (PLHIV), limitations in understanding which strategies are best suited to certain regions or populations have contributed to the uneven distribution in the success of various HIV testing strategies. Here, we present a conceptual framework that outlines effective HIV testing strategies for four target groups. This framework is based on a systematic literature review of articles published from January 1st, 2008, to December 31st, 2019. The effectiveness of HIV testing strategies depends on various factors including the setting, type of test and service providers. Multiple strategies are needed to reach the UNAIDS target of 95% of individuals knowing their HIV status. Expansion of community-based approaches, self-testing and HIV testing services in antenatal care will further improve the state of HIV testing in Sub-Saharan Africa., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: To develop and implement a 'low-dose, high-frequency' (LDHF) advanced respiratory care training programme for COVID-19 care in Lesotho., Design: Prospective pretraining-post-training evaluation., Setting: Lesotho has limited capacity in advanced respiratory care., Participants: Physicians and nurses., Interventions: Due to limited participation in May-September 2020, the LDHF approach was modified into a traditional 1-day offsite training in November 2020 that reviewed respiratory anatomy and physiology, clinical principles for conventional oxygen, heated high-flow nasal cannula and non-invasive ventilation management. Basic mechanical ventilation principles were introduced., Outcome Measures: Participants completed a 20-question multiple choice examination immediately before and after the 1-day training. Paired t-tests were used to evaluate the difference in average participant pretraining and post-training examination scores., Results: Pretraining and post-training examinations were completed by 46/53 (86.7%) participants, of whom 93.4% (n=43) were nurses. The overall mean pretraining score was 44.8% (SD 12.4%). Mean scores improved by an average of 23.7 percentage points (95% CI 19.7 to 27.6, p<0.001) on the post-training examination to a mean score of 68.5% (SD 13.6%). Performance on basic and advanced respiratory categories also improved by 17.7 (95% CI 11.6 to 23.8) and 25.6 percentage points (95% CI 20.4 to 30.8) (p<0.001). Likewise, mean examination scores increased on the post-training test, compared with pretraining, for questions related to respiratory management (29.6 percentage points, 95% CI 24.1 to 35.0) and physiology (17.4 percentage points, 95% CI 12.0 to 22.8)., Conclusions: An LDHF training approach was not feasible during this early emergency period of the COVID-19 pandemic in Lesotho. Despite clear knowledge gains, the modest post-training examination scores coupled with limited physician engagement suggest healthcare workers require alternative educational strategies before higher advanced care like mechanical ventilation is implementable. Conventional and high-flow oxygen is better aligned with post-training healthcare worker knowledge levels and rapid implementation., Competing Interests: Competing interests: EDM declares other grants from The Bill & Melinda Gates Foundation, National Institutes of Health, Pfizer, The Save the Children Fund (UK) and US Centers for Disease Control; consulting fees from Aurum Institute; and unpaid committee participation with the Lifebox Foundation (UK) and WHO. The other authors declare no competing interests., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Electronic influenza surveillance systems aid in health surveillance and clinical decision-making within the emergency department (ED). While major advances have been made in integrating clinical decision-making tools within the electronic health record (EHR), tools for sharing surveillance data are often piecemeal, with the need for data downloads and manual uploads to shared servers, delaying time from data acquisition to end-user. Real-time surveillance can help both clinicians and public health professionals recognize circulating influenza earlier in the season and provide ongoing situational awareness., Methods: We created a prototype, cloud-based, real-time reporting system in two large, academically affiliated EDs that streamed continuous data on a web-based dashboard within hours of specimen collection during the influenza season. Data included influenza test results (positive or negative) coupled with test date, test instrument geolocation, and basic patient demographics. The system provided immediate reporting to frontline clinicians and to local, state, and federal health department partners., Results: We describe the process, infrastructure requirements, and challenges of developing and implementing the prototype system. Key process-related requirements for system development included merging data from the molecular test (GeneXpert) with the hospitals' EHRs, securing data, authorizing/authenticating users, and providing permissions for data access refining visualizations for end-users., Conclusion: In this case study, we effectively integrated multiple data systems at four distinct hospital EDs, relaying data in near real time to hospital-based staff and local and national public health entities, to provide laboratory-confirmed influenza test results during the 2014-2015 influenza season. Future innovations need to focus on integrating the dashboard within the EHR and clinical decision tools.

Background: South Africa (SA) faces a significant tuberculosis (TB) burden complicated by high rates of HIV-TB co-infection. In SA, emergency departments (EDs) play an important role in screening for TB., Objectives: To determine the prevalence of TB in the ED and the effectiveness of the World Health Organization (WHO) TB screening tool., Methods: This was a cross-sectional observational study, conducted in the ED at Livingstone Hospital, Port Elizabeth, from 4 June to 15 July 2018. All patients aged &gt;18 years and able to consent were administered the WHO TB screening questions and underwent a point-of-care HIV test and demographic data collection. Patients were followed up for 1 year and tracked in the National Health Laboratory Service database to determine TB status using laboratory testing., Results: Over the study period, 790 patients were enrolled. Overall, 121 patients (15.3%) were TB-positive, with 46 (38.0%) diagnosed after presenting to the ED and 75 (62.0%) with a previous TB history determined by self-report or confirmed laboratory testing. A greater proportion of the TB-positive patients were HIV-positive (49.6%) compared with the TB-negative population (24.8%). TB-positive individuals were more likely to present to the ED with a chief complaint of shortness of breath (SoB) (18.2%) compared with the TB-negative population (10.5%). Overall, the WHO TB screening tool had poor sensitivity (46.5%) and specificity (62.5%) for identifying TB-positive patients in the ED. A multiple logistic regression analysis, controlled for age and sex, showed HIV status (odds ratio (OR) 2.81; p&lt;0.001) and SoB (OR 2.19; p&lt;0.05) to be significant predictors of TB positivity. Adding positive HIV status and a presenting complaint of SoB increased sensitivity to 78.3%., Conclusions: EDs in SA face a high burden of TB. While WHO screening guidelines identify some of these patients, including routine HIV testing in the ED could significantly affect the number of TB diagnoses made.