scholarly journals Exit strategies: optimising feasible surveillance for detection, elimination and ongoing prevention of COVID-19 community transmission

2020 ◽  
Author(s):  
Kamalini Lokuge ◽  
Emily Banks ◽  
Stephanie Davis ◽  
Leslee Roberts ◽  
Tatum Street ◽  
...  
Keyword(s):  
Primary Care ◽  
Early Detection ◽  
Number System ◽  
Contact Tracing ◽  
Successful Implementation ◽  
Surveillance Strategy ◽  
Transmission Chain ◽  
Containment Measures ◽  
Community Transmission

BackgroundFollowing successful implementation of strong containment measures by the community, Australia is now close to the point of eliminating detectable community transmission of COVID-19. We aimed to develop an efficient, rapid and scalable surveillance strategy for detecting all remaining COVID-19 community transmission through exhaustive identification of every active transmission chain. We also identified measures to enable early detection and effective management of any reintroduction of transmission once containment measures are lifted to ensure strong containment measures do not need to be reinstated.MethodsWe compared efficiency and sensitivity to detect community transmission chains through testing of: hospital cases; primary care fever and cough patients; or asymptomatic community members, using surveillance evaluation methods and mathematical modelling, varying testing capacities and prevalence of COVID-19 and non-COVID-19 fever and cough, and the reproduction number. System requirements for increasing testing to allow exhaustive identification of all transmission chains, and then enable complete follow-up of all cases and contacts within each chain, were assessed per million population.FindingsAssuming 20% of cases are asymptomatic and all symptomatic COVID-19 cases present to primary care, with high transmission (R=2.2) there are a median of 13 unrecognised community cases (5 infectious) when a transmission chain is identified through hospital surveillance versus 3 unrecognised cases (1 infectious) through primary care surveillance. 3 unrecognised community upstream community cases themselves are estimated to generate a further 22-33 contacts requiring follow-up. The unrecognised community cases rise to 5 if only 50% of symptomatic cases present to primary care. Screening for asymptomatic disease in the community cannot exhaustively identify all transmission under any of the scenarios assessed. The additional capacity required to screen all fever and cough primary care patients would be approximately 2,000 tests/million population per week using 1/16 pooling of samples.InterpretationScreening all syndromic fever and cough primary care presentations, in combination with exhaustive and meticulous case and contact identification and management, enables appropriate early detection and elimination of community transmission of COVID-19. If testing capacity is limited, interventions such as pooling allow increased case detection, even given reduced test sensitivity. Wider identification and testing of all upstream contacts, (i.e. potential sources of infection for identified cases, and their related transmission chains) is critical, and to be done exhaustively requires more resources than downstream contact tracing. The most important factor in determining the performance of such a surveillance system is community participation in screening and follow up, and as such, appropriate community engagement, messaging and support to encourage presentation and compliance is essential. We provide operational guidance on implementing such a system.FundingNo specific funding was received for this project, beyond the salary support the authors receive from their institutions and elsewhere. Professor Banks is supported by the National Health and Medical Research Council of Australia (Principal Research Fellowship 1136128).

scholarly journals Exit strategies: optimising feasible surveillance for detection, elimination, and ongoing prevention of COVID-19 community transmission

BMC Medicine ◽  
2021 ◽  
Vol 19 (1) ◽  
Author(s):  
K. Lokuge ◽  
E. Banks ◽  
S. Davis ◽  
L. Roberts ◽  
T. Street ◽  
...  
Keyword(s):  
Early Detection ◽  
Respiratory Symptoms ◽  
Respiratory Illness ◽  
Reproductive Number ◽  
Surveillance Strategy ◽  
Transmission Chain ◽  
Containment Measures ◽  
Testing Uptake ◽  
Community Transmission

Abstract Background Following implementation of strong containment measures, several countries and regions have low detectable community transmission of COVID-19. We developed an efficient, rapid, and scalable surveillance strategy to detect remaining COVID-19 community cases through exhaustive identification of every active transmission chain. We identified measures to enable early detection and effective management of any reintroduction of transmission once containment measures are lifted to ensure strong containment measures do not require reinstatement. Methods We compared efficiency and sensitivity to detect community transmission chains through testing of the following: hospital cases; fever, cough and/or ARI testing at community/primary care; and asymptomatic testing; using surveillance evaluation methods and mathematical modelling, varying testing capacities, reproductive number (R) and weekly cumulative incidence of COVID-19 and non-COVID-19 respiratory symptoms using data from Australia. We assessed system requirements to identify all transmission chains and follow up all cases and primary contacts within each chain, per million population. Results Assuming 20% of cases are asymptomatic and 30% of symptomatic COVID-19 cases present for testing, with R = 2.2, a median of 14 unrecognised community cases (8 infectious) occur when a transmission chain is identified through hospital surveillance versus 7 unrecognised cases (4 infectious) through community-based surveillance. The 7 unrecognised community upstream cases are estimated to generate a further 55–77 primary contacts requiring follow-up. The unrecognised community cases rise to 10 if 50% of cases are asymptomatic. Screening asymptomatic community members cannot exhaustively identify all cases under any of the scenarios assessed. The most important determinant of testing requirements for symptomatic screening is levels of non-COVID-19 respiratory illness. If 4% of the community have respiratory symptoms, and 1% of those with symptoms have COVID-19, exhaustive symptomatic screening requires approximately 11,600 tests/million population using 1/4 pooling, with 98% of cases detected (2% missed), given 99.9% sensitivity. Even with a drop in sensitivity to 70%, pooling was more effective at detecting cases than individual testing under all scenarios examined. Conclusions Screening all acute respiratory disease in the community, in combination with exhaustive and meticulous case and contact identification and management, enables appropriate early detection and elimination of COVID-19 community transmission. An important component is identification, testing, and management of all contacts, including upstream contacts (i.e. potential sources of infection for identified cases, and their related transmission chains). Pooling allows increased case detection when testing capacity is limited, even given reduced test sensitivity. Critical to the effectiveness of all aspects of surveillance is appropriate community engagement, messaging to optimise testing uptake and compliance with other measures.

scholarly journals Containment of COVID-19 cases among healthcare workers: The role of surveillance, early detection, and outbreak management

2020 ◽  
Vol 41 (7) ◽  
pp. 765-771 ◽  
Author(s):  
Liang En Wee ◽  
Xiang Ying Jean Sim ◽  
Edwin Philip Conceicao ◽  
May Kyawt Aung ◽  
Jia Qing Goh ◽  
...  
Keyword(s):  
Early Detection ◽  
Healthcare Workers ◽  
Respiratory Illness ◽  
Individual Responsibility ◽  
Surveillance Period ◽  
Surveillance Strategy ◽  
Outbreak Management ◽  
Containment Measures ◽  
Community Transmission ◽  
Healthcare Associated

AbstractObjective:Staff surveillance is crucial during the containment phase of a pandemic to help reduce potential healthcare-associated transmission and sustain good staff morale. During an outbreak of SARS-COV-2 with community transmission, our institution used an integrated strategy for early detection and containment of COVID-19 cases among healthcare workers (HCWs).Methods:Our strategy comprised 3 key components: (1) enforcing reporting of HCWs with acute respiratory illness (ARI) to our institution’s staff clinic for monitoring; (2) conducting ongoing syndromic surveillance to obtain early warning of potential clusters of COVID-19; and (3) outbreak investigation and management.Results:Over a 16-week surveillance period, we detected 14 cases of COVID-19 among HCWs with ARI symptoms. Two of the cases were linked epidemiologically and thus constituted a COVID-19 cluster with intrahospital HCW–HCW transmission; we also detected 1 family cluster and 2 clusters among HCWs who shared accommodation. No transmission to HCWs or patients was detected after containment measures were instituted. Early detection minimized the number of HCWs requiring quarantine, hence preserving continuity of service during an ongoing pandemic.Conclusions:An integrated surveillance strategy, outbreak management, and encouraging individual responsibility were successful in early detection of clusters of COVID-19 among HCWs. With ongoing local transmission, vigilance must be maintained for intrahospital spread in nonclinical areas where social mingling of HCWs occurs. Because most individuals with COVID-19 have mild symptoms, addressing presenteeism is crucial to minimize potential staff and patient exposure.

scholarly journals Uncovering two phases of early intercontinental COVID-19 transmission dynamics

2020 ◽  
Vol 27 (8) ◽  
Author(s):  
Jing Yang ◽  
Juan Li ◽  
Shengjie Lai ◽  
Corrine W Ruktanonchai ◽  
Weijia Xing ◽  
...  
Keyword(s):  
Phylogenetic Analyses ◽  
International Travel ◽  
Contact Tracing ◽  
Genetic Sequencing ◽  
Response Strategies ◽  
The World ◽  
Containment Measures ◽  
The Usa ◽  
Community Transmission ◽  
Two Phases

Abstract Background The COVID-19 pandemic has posed an ongoing global crisis, but how the virus spread across the world remains poorly understood. This is of vital importance for informing current and future pandemic response strategies. Methods We performed two independent analyses, travel network-based epidemiological modelling and Bayesian phylogeographic inference, to investigate the intercontinental spread of COVID-19. Results Both approaches revealed two distinct phases of COVID-19 spread by the end of March 2020. In the first phase, COVID-19 largely circulated in China during mid-to-late January 2020 and was interrupted by containment measures in China. In the second and predominant phase extending from late February to mid-March, unrestricted movements between countries outside of China facilitated intercontinental spread, with Europe as a major source. Phylogenetic analyses also revealed that the dominant strains circulating in the USA were introduced from Europe. However, stringent restrictions on international travel across the world since late March have substantially reduced intercontinental transmission. Conclusions Our analyses highlight that heterogeneities in international travel have shaped the spatiotemporal characteristics of the pandemic. Unrestricted travel caused a large number of COVID-19 exportations from Europe to other continents between late February and mid-March, which facilitated the COVID-19 pandemic. Targeted restrictions on international travel from countries with widespread community transmission, together with improved capacity in testing, genetic sequencing and contact tracing, can inform timely strategies for mitigating and containing ongoing and future waves of COVID-19 pandemic.

The role of primary care in early detection and follow-up of cancer

2013 ◽  
Vol 11 (1) ◽  
pp. 38-48 ◽  
Author(s):  
Jon D. Emery ◽  
Katie Shaw ◽  
Briony Williams ◽  
Danielle Mazza ◽  
Julia Fallon-Ferguson ◽  
...  
Keyword(s):  
Primary Care ◽  
Early Detection

Primary care vs. oncology-driven surveillance following adjuvant chemotherapy in resected pancreas cancer.

2017 ◽  
Vol 35 (15_suppl) ◽  
pp. e18163-e18163
Author(s):  
Haider Samawi ◽  
Yaling Yin ◽  
Howard John Lim ◽  
Daniel John Renouf ◽  
Winson Y. Cheung
Keyword(s):  
Primary Care ◽  
Primary Care Physicians ◽  
Pancreas Cancer ◽  
Surveillance Strategy ◽  
Free Survival ◽  
Clinical Assessments ◽  
Imaging Results ◽  
Significant Difference ◽  
To Receive

e18163 Background: No standard surveillance strategy exists following resection of pancreas cancer. Our aims were to describe patterns of surveillance and to evaluate their impact on outcomes. Methods: Patients who received at least one cycle of adjuvant gemcitabine or 5-fluorouracil monotherapy at any 1 of 5 cancer centers in British Columbia from 2004 to 2015 were included. Surveillance was divided into two groups: discharged to primary care physicians (PCP) or follow up with oncologists (ONC) that included regular clinical assessments, laboratory testing and/or imaging. Results: We identified 147 patients. Median age at diagnosis was 64 (range 38-85) years and 48% were men. More patients were followed by ONC than PCP (66% vs. 44%). ONC were more likely to follow patients with T3/4 (78% vs. 62%, P = 0.03), while all other prognostic factors were balanced between the two groups. At the time of analysis, 68% of patients had a documented recurrence and 59% died. The median overall survival (OS) was 2.82 (95% CI 2.17-3.32) years in the ONC group and 3.35 (95% CI 2.85-5.06) years in the PCP group while the median relapse free survival (RFS) was 1.4 (95% CI 1.37-1.77) and 2.4 (95% CI 2.07-4.59) years, respectively. On multivariate analysis, there was no significant difference in OS between ONC and PCP-driven surveillance (HR 1.23; 95% CI 0.74-2.04, P = 0.4); however, RFS favored the PCP group (HR 1.62; 95% CI 1.01-2.56, P = 0.04, for oncology). On recurrence, 51% of patients received chemotherapy where the most common first line regimens were FOLFIRINOX (21%) and Gemcitabine/Nab-paclitaxel (20%). Patients followed by ONC were more likely to receive chemotherapy on recurrence than those followed by PCP (58% vs. 34%, respectively, P = 0.03), however, there was no difference in survival after recurrence between PCP & ONC (recurrence to death, 5.7 vs 8.9 months, respectively (P = 0.21). Conclusions: Surveillance tests and imaging performed by ONC detected recurrences earlier and correlated with a higher likelihood of aggressive therapy when compared to follow up by PCPs, but this did not result in OS differences. PCPs may have a larger role in the follow up care of selected patients with resected pancreas cancer.

scholarly journals Evaluation and Follow-Up of Infectious Tuberculosis at the University of Ottawa

1995 ◽  
Vol 6 (5) ◽  
pp. 239-243 ◽  
Author(s):  
Ziad A Memish ◽  
Raymonde Hickey ◽  
Ian Gemmill
Keyword(s):  
Early Detection ◽  
Skin Testing ◽  
Health Department ◽  
Contact Tracing ◽  
X Ray ◽  
Purified Protein Derivative ◽  
Chest X Ray ◽  
The University ◽  
Isoniazid Prophylaxis

A case of active infectious pulmonary tuberculosis (tb) in a recent immigrant to Canada was identified at the University of Ottawa. The student was attending classes regularly and coughing for six months before the diagnosis of infectious pulmonarytbwas made. Investigation carried out by the Ottawa-Carleton Health Department identified 871 student contacts. Of the 871 contacts, 773 (89%) were available for testing and follow-up. Initial skin testing with purified protein derivative (ppd) was positive in 149 contacts. Of the 602 contacts testing negative initially 399 (66%) returned for 12-week retesting. Eleven skin test converters were identified. All 160 contacts with positiveppdhad negative chest x-ray and were given isoniazid prophylaxis for six months. The estimated cost of the process of contact tracing, testing, follow-up and treatment was $34,036. Although pre-immigration screening policies fortbdo exist, additional pre- and postimmigration measures could help in the early detection of activetband the prevention of its spread.

scholarly journals Pharmacist-Physician Interprofessional Collaboration to Promote Early Detection of Cognitive Impairment: Increasing Diagnosis Rate

2021 ◽  
Vol 12 ◽  
Author(s):  
Hernán Ramos ◽  
Juan Pardo ◽  
Rafael Sánchez ◽  
Esteve Puchades ◽  
Jordi Pérez-Tur ◽  
...  
Keyword(s):  
Primary Care ◽  
Cognitive Impairment ◽  
Early Detection ◽  
Clinical Diagnosis ◽  
General Practitioners ◽  
Interprofessional Collaboration ◽  
Community Pharmacists ◽  
Cognitive Test ◽  
Community Pharmacies

The increased pressure on primary care makes it important for other health care providers, such as community pharmacists, to collaborate with general practitioners in activities related to chronic disease care. Therefore, the objective of the present project was to develop a protocol of action that allows close pharmacist-physician collaboration to carry out a coordinated action for very early detection of cognitive impairment (CI).Methods: A comparative study to promote early detection of CI was conducted in 19 community pharmacies divided into two groups: one group with interprofessional collaboration (IPC) and one group without interprofessional collaboration (NonIPC). IPC was defined as an interactive procedure involving all pharmacists, general practitioners and neurologists. A total of 281 subjects with subjective memory complaints were recruited. Three tests were used in the community pharmacies to detect possible CI: Memory Impairment Screening, Short Portable Mental State Questionnaire, and Semantic Verbal Fluency. Individuals with at least one positive cognitive test compatible with CI, were referred to primary care, and when appropriate, to the neurology service. Finally, we evaluated the differences in clinical and diagnostic follow-up in both groups after six months.Results: The NonIPC study group included 38 subjects compatible with CI referred to primary care (27.54%). Ten were further referred to a neurology department (7.25%) and four of them (2.90%) obtained a confirmed clinical diagnosis of CI. In contrast, in the IPC group, 46 subjects (32.17%) showed results compatible with CI and were referred to primary care. Of these, 21 (14.68%) were subsequently referred to a neurology service, while the remaining 25 were followed up by primary care. Nineteen individuals out of those referred to a neurology service obtained a confirmed clinical diagnosis of CI (13.29%). The percentage of subjects in the NonIPC group referred to neurology and the percentage of subjects diagnosed with CI, was significantly lower in comparison to the IPC group (p-value = 0.0233; p-value = 0.0007, respectively).Conclusions: The creation of IPC teams involving community pharmacists, general practitioners, and neurologists allow for increased detection of patients with CI or undiagnosed dementia and facilitates their clinical follow-up. This opens the possibility of diagnosis in patients in the very early stages of dementia, which can have positive implications to improve the prognosis and delay the evolution of the disease.

Depression screening optimization in an academic rural setting

2015 ◽  
Vol 28 (7) ◽  
pp. 709-725 ◽  
Author(s):  
Sohaib Aleem ◽  
William C Torrey ◽  
Mathew S Duncan ◽  
Shoshana J Hort ◽  
John N Mecchella
Keyword(s):  
Primary Care ◽  
Process Improvement ◽  
Performance Metrics ◽  
Critical Role ◽  
Data Entry ◽  
Rural Setting ◽  
Depression Screening ◽  
Successful Implementation ◽  
Content Type

Purpose – Primary care plays a critical role in screening and management of depression. The purpose of this paper is to focus on leveraging the electronic health record (EHR) as well as work flow redesign to improve the efficiency and reliability of the process of depression screening in two adult primary care clinics of a rural academic institution in USA. Design/methodology/approach – The authors utilized various process improvement tools from lean six sigma methodology including project charter, swim lane process maps, critical to quality tree, process control charts, fishbone diagrams, frequency impact matrix, mistake proofing and monitoring plan in Define-Measure-Analyze-Improve-Control format. Interventions included change in depression screening tool, optimization of data entry in EHR. EHR data entry optimization; follow up of positive screen, staff training and EHR redesign. Findings – Depression screening rate for office-based primary care visits improved from 17.0 percent at baseline to 75.9 percent in the post-intervention control phase (p < 0.001). Follow up of positive depression screen with Patient History Questionnaire-9 data collection remained above 90 percent. Duplication of depression screening increased from 0.6 percent initially to 11.7 percent and then decreased to 4.7 percent after optimization of data entry by patients and flow staff. Research limitations/implications – Impact of interventions on clinical outcomes could not be evaluated. Originality/value – Successful implementation, sustainability and revision of a process improvement initiative to facilitate screening, follow up and management of depression in primary care requires accounting for voice of the process (performance metrics), system limitations and voice of the customer (staff and patients) to overcome various system, customer and human resource constraints.

scholarly journals Vertical Program of Screenings and Check-ups in the Russian Federation: Design, Implementation and Lessons Learnt

2021 ◽  
Author(s):  
Igor Sheiman ◽  
Sergey Shishkin ◽  
Svetlana Sazhina
Keyword(s):  
Primary Care ◽  
Russian Federation ◽  
Large Scale ◽  
Primary Care Providers ◽  
Successful Implementation ◽  
Care Providers ◽  
Local Conditions ◽  
Design And Implementation ◽  
The Russian Federation

Abstract Background. The Russian Federation has introduced a vertical large-scale program of ‘dispensarization’ (Program) that includes health check-ups and screenings for the entire adult population. It is expected to improve the results of medical interventions and ensure health gains at a relatively low cost. The major research question: Does the design and implementation of the program meet the expectations? Methods. We analyze regulatory acts and the literature on the design and the outcomes of the Program. Physicians’ surveys and interviews are conducted to understand the capacity of primary care providers to meet the requirements of the Program, as well as the link between the early identification of new illnesses and their follow-up management, administration of the program, the barriers to its successful implementation. Results. There is a substantial progress of the coverage of the population and increase in the number of identified illnesses. Some specific instruments of the Program implementation work well, others require more careful design and additional integrative and managerial activities. The capacity of primary care providers does not allow to provide high quality preventive services, as well as to ensure a continuum of preventive and curative work. The pattern of the Program administration facilitates its nation-wide implementation according to the unified rules, but makes it more difficult to account for the local conditions and limits the autonomy of professionals to choose specific population risk groups and a list of services. The interaction of providers in preventive activities is inadequate. Conclusion The expectations of the Program are too high due to the inconsistency in its design and implementation. The major lesson learnt is that the program like this should meet the capacity of primary care and be designed as a complex of interrelated activities to identify illnesses and provide their follow-up management.

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