What Does a Systems Approach to Quality Improvement Look Like in Practice?

Universally improving healthcare systems is difficult to achieve in practice with organisations implementing a range of quality improvement (QI) approaches, in varying and changing contexts, and efforts ranging from project-based improvements to whole system change. This study aimed to identify how organisations overcome the challenges to improving the quality of the services they deliver. Drawing on the eight challenges from the ‘Quality and Safety in Europe by Research (QUASER) hospital guide, we assessed eight cases reported by the UK-based regulator Care Quality Commission as improving their performance. A thematic analysis of these secondary data established that all eight challenges had been addressed or considered in varying degrees. Education and physical and technological challenges seemed less prominent than developments made to address other challenges such as developing leadership, structure, and culture to support improving quality. This paper relies on the analysis of secondary case data and one framework to assess improvement efforts. Further research is required to consider other models and frameworks and to collate longitudinal data to capture the dynamics and increasing the maturity of improving healthcare systems in practice.

A Prospective Study of Clinical, Epidemiological and Serologic Status Features in a Paediatric Pcr Sars-Cov-2 Positive Population

Background:Although most cases of SARS-CoV-2 infection in pediatric population are asymptomatic or mild, severe cases may occur in a small percentage. Unlike other respiratory infections, children usually develop it from infected adults. Percentage of seroconversión and outcome of antibodies after infection anti-SAR-CoV-2 in children are still poorly understood and may be different from adults. The first aim was to describe clinical and epidemiological characteristics of pediatric patients diagnosed of SARS-CoV-2 infection in the second epidemic wave in two tertiary hospitals in Madrid, Spain and to determine the proportion of seronegative by comparing 3 serological techniques. As secondary aim it was proposed to determine the proportion of seronegative by comparing 3 serological techniques, seroconversion associated variables and the way of infection among the family members. Methods:Multicenter prospective observational study in two university hospitals of the Community of Madrid, between September and November 2020, of COVID-19 infection confirmed by PCR in the Emergency Department. A retrospective data collection was performed at 4-8 weeks after diagnosis on an outpatient basis, using a clinical-epidemiological questionnaire. At this time blood samples were collected to analyse the humoral response by 3 different serological assays.The quantitative variables are expressed as medians (interquartile range (IQR) 25-75).Univariate analysis of possible factors associated with seropositivity absence was performed.Results: One hundred and eleven patients (58 girls) were included with a median days of 37 (IQR: 34-44) between diagnosis and serologic test performed.Median age was 88 (IQR: 24-149) months. Parents were from abroad in 62 cases (50% from South and Central America).Ninety eight children were symptomatic, 17 children were diagnosed by epidemiological screening, 4 of whom subsequently developed symptoms.Eight of them needing admission with a median length of stay 2 days (IQR: 2-4), none of them in PICU.Underlying conditions were found in 33 patients, mainly recurrent bronchitis.Most frequent symptoms (70%) were low-grade fever (37-38ºC) or fever (≥ 38ºC), rhinorrhea 44%, cough 31.5%, headache 29.7%, weakness 27%, diarrhea 19.8%, abdominal pain and vomiting 26%, anosmia 16.2% (median 10 days; IQR: 6-30). Infection was interpreted as a secondary case in 56 patients, being a relative the index case in 96.4%. Seronegativity was observed in 19 patients in any of the 3 serological techniques (17.1%; 95% CI: 10.6-25.4), this proportion was higher among children aged 2-to 10-year-old age (16 of 45; 35%, p <0.05).In univariate analysis a lower proportion of seroconversion was found in those children in whom COVID-19 confirmation is not documented among household contacts (15/29; 51.7%; p <0.05). Conclusions: Our results confirm the mild clinical picture in children during the second epidemic wave, and that in most cases, children are not the index case in the family. Likewise, in children the proportion in whom seroconversion is not detected is high, and seems higher than that reported in adults. In our series, an association of seronegativity was seen in the 2 to 10 year-old age group and when there was no documentation of COVID-19 in any household contact.

Transmission of SARS-CoV-2 into and within immigrant households: nationwide registry study from Norway

BackgroundMinority groups and immigrants have been hit disproportionally hard by COVID-19 in many developed countries, including Norway.MethodsUsing individual-level registry data of all Norwegian residents, we compared infections across all multiperson households. A household with at least one member born abroad was defined as an immigrant household. In households where at least one person tested positive for SARS-CoV-2 from 1 August 2020 to 1 May 2021, we calculated secondary attack rates (SARs) as the per cent of other household members testing positive within 14 days. Logistic regression was used to adjust for sex, age, household composition and geography.ResultsAmong all multiperson households in Norway (n=1 422 411), at least one member had been infected in 3.7% of the 343 017 immigrant households and 1.4% in the 1 079 394 households with only Norwegian-born members. SARs were higher in immigrant (32%) than Norwegian-born households (20%). SARs differed considerably by region, and were particularly high in households from West Asia, Eastern Europe, Africa and Eastern Europe, also after adjustment for sex and age of the secondary case, household composition and geography.ConclusionSARS-CoV-2 is more frequently introduced into multiperson immigrant households than into households with only Norwegian-born members, and transmission within the household occurs more frequently in immigrant households. The results are likely related to living conditions, family composition or differences in social interaction, emphasising the need to prevent introduction of SARS-CoV-2 into these vulnerable households.

Can Africa achieve herd immunity?

The World Health Organization described herd immunity, also known as population immunity, as the indirect fortification from an infectious disease that happens when a population is immune either through vaccination or immunity developed through previous exposure to infection. The emergence of COVID-19 vaccine is a step towards the achievement of herd immunity. Over one billion people across the globe have been vaccinated and Africa recorded only 2%. The objective of this article was to develop a forecast of the number of people to be vaccinated to achieve herd immunity in the 13 WHO-identified priority African countries for COVID-19. Herd immunity is achieved when one infected person in a population causes less than one secondary case on average, corresponding to the effective basic reproduction number (R0). Vaccine delivery and distribution infrastructure including the cold chain remains weak. Vaccine hesitancy is also one of the limiting factors that may hinder herd immunity in Africa. In order to achieve herd immunity globally, African countries should not be excluded in fair and equal distribution of vaccines. Relevant stakeholders should foster commitment as well as community sensitization on COVID-19 vaccines and integration of COVID-19 vaccines in existing healthcare services.

Extranodal natural killer/T-cell lymphoma of the breast: a retrospective clinicopathological analysis of a consecutive 11-year case series

Background Extranodal NK/T-cell lymphoma of the breast (ENKTL-Breast) is rarely detected in clinical practice, and its clinicopathological features remain unclear. Results A consecutive 11-year (2010–2020) ENKTL-Breast case series was retrospectively analyzed. Eight cases of ENKTL-Breast were selected, with three primary and five secondary lesions, accounting for 3.5% (8/228) of all breast lymphomas. All patients were female with a median age of 46 years. Lesions presented as solid breast masses (8/8, 100%) and were usually located in the upper outer quadrant of the breast (7/8, 87.5%). B-symptoms were observed in seven (7/8, 87.5%) cases. Two primary ENKTL-Breast cases showed concomitant diseases (IgA nephropathy and chronic active hepatitis B). Histological and immunohistochemical features of ENKTL-Breast were similar to those of ENKTL at other sites. T-cell receptor rearrangement revealed clonality in all examined primary cases (2/2, 100%), but only in one secondary case (1/5, 20%). The disease progressed rapidly in two primary cases and both patients died within 3 and 9 months. For secondary cases, the disease manifested as a disseminated disease, with a median survival time of 6 months. Conclusions Our data suggested that ENKTL-Breast clinically mimics breast cancer to some extent, though B-symptoms might serve as a distinguishing factor. ENKTL-Breast is highly aggressive and patients with this disease exhibit a short survival time. Primary ENKTL-Breast tends to originate from activated cytotoxic T-cells, and immune-related diseases may be involved in its pathogenesis and development.

373. Household transmission of SARS-CoV-2 B.1.1.7 lineage –2 U.S. States, 2021

Background In December 2020, B.1.1.7 lineage of SARS-CoV-2 was first detected in the United States and has since become the dominant lineage. Previous investigations involving B.1.1.7 suggested higher rates of transmission relative to non-B.1.1.7 lineages. We conducted a household transmission investigation to determine the secondary infection rates (SIR) of B.1.1.7 and non-B.1.1.7 SARS-CoV-2 lineages. Methods From January–April 2021, we enrolled members of households in San Diego County, CA, and Denver, CO metropolitan area (Tri-County), with a confirmed SARS-CoV-2 infection in a household member with illness onset date in the previous 10 days. CDC investigators visited households at enrollment and 14 days later at closeout to obtain demographic and clinical data and nasopharyngeal (NP) samples on all consenting household members. Interim visits, with collection of NP swabs, occurred if a participant became symptomatic during follow-up. NP samples were tested for SARS-CoV-2 using TaqPath™ RT-PCR test, where failure to amplify the spike protein results in S-Gene target failure (SGTF) may indicate B.1.1.7 lineage. Demographic characteristics and SIR were compared among SGTF and non-SGTF households using two-sided p-values with chi-square tests; 95% confidence intervals (CI) were calculated with Wilson score intervals. Results 552 persons from 151 households were enrolled. 91 (60%) households were classified as SGTF, 57 (38%) non-SGTF, and 3 (2%) indeterminant. SGTF and non-SGTF households had similar sex distribution (49% female and 52% female, respectively; P=0.54) and age (median 30 years, interquartile range (IQR 14–47) and 31 years (IQR 15–45), respectively). Hispanic people accounted for 24% and 32% of enrolled members of SGTF and non-SGTF households, respectively (p=0.04). At least one secondary case occurred in 61% of SGTF and 58% of non-SGTF households (P=0.66). SIR was 52% (95%[CI] 46%-59%) for SGTF and 45% (95% CI 37%-53%) for non-SGTF households (P=0.18). Conclusion SIRs were high in both SGTF and non-SGTF households; our findings did not support an increase in SIR for SGTF relative to non-SGTF households in this setting. Sequence confirmed SARS-CoV-2 samples will provide further information on lineage specific SIRs. Disclosures All Authors: No reported disclosures

Transmission of SARS-CoV-2 in Norwegian schools: A population-wide register-based cohort study on characteristics of the index case and secondary attack rates

Objectives: To assess transmission of SARS-CoV-2 in schools mainly kept open during the COVID-19 pandemic. Design: Population-wide register-based cohort study. Setting: Primary and lower secondary schools in Norway have been open during the academic year 2020/2021 with strict infection prevention and control (IPC) measures in place. All identified contacts including student and staff members were urged to get tested following a positive SARS-CoV-2 case in a school. Participants: All students and educational staff in Norwegian primary and lower secondary schools from August 2020 to June 2021. Main outcome measures: Overall secondary attack rate (SAR14) was operationalized as the number of secondary cases (among students and/or staff) in the school by 14 days after the index case, divided by the number of students and staff members in the school. Moreover, we calculated SAR14-to-students, denoting transmission from all index cases to students only, SAR14-to-school staff, denoting transmission from all index cases to staff members only. We also calculated these measures in stratified samples consisting of student index cases or school staff index cases. Results: From August 2020 to June 2021 there were 4,078 index cases, 79% were students and 21% were school staff. In the majority (55%) of schools with an index case, no secondary cases were observed by 14 days, and in 16% of the schools there were only one secondary case within 14 days. Overall SAR14 was found to be 0.33% (95%CI 0.32-0.33). Staff-to-staff transmission (SAR14 0.45%, 95%CI 0.40-0.52) was found to be slightly more common than student-to-student (SAR14 0.33%, 95%CI 0.32-0.34) and student-to-staff (SAR14 0.28%, 95%CI 0.25-0.30) transmission. Conclusions: Our results confirm that schools have not been an important arena of transmission of SARS-CoV-2 in Norway and therefore support that schools can be kept open with IPC measures in place.

Secondary transmission of SARS-CoV-2 in educational settings in Northern Italy from September 2020 to April 2021: a population-based study

Background: We aimed to quantify the risk of transmission of SARS-CoV-2 in the school setting by type of school, characteristics of the index case and calendar period in the Reggio Emilia province (RE), Italy, from school reopening in September 2020 until the beginning of April 2021. The secondary aim was to estimate the promptness of contact tracing. Methods: A population-based analysis of surveillance data of all COVID-19 cases occurring in RE, Italy, from September 1, 2020, to April 4th, 2021, for which a school contact and/or exposure was suspected. Indicator of the delay in contact tracing was computed as the time elapsed since positivity of the index case and the date on which the swab for classmates was scheduled (or most were scheduled). Results: Overall, 30,426 and 13,571 contacts among classmates and teachers/staff, respectively, were identified and received recommendation for testing; 43,414 (98.7%) performed the test. Secondary transmission occurred in about 40% of the investigated classes, and the overall secondary case attack rate was 4%, slightly higher when the index case was a teacher, but with almost no differences by type of school and stable during the study period. Promptness of contact tracing increased during the study period, reducing the time from index case identification and testing of contacts from 7 to 3 days, as well the ability to identify possible source of infection in the index case (from 42% in September/October, to 22% in November, to 50% in December-April). Conclusions: Despite the spread of the Alpha variant during the study period in RE, the secondary case attack rate remained stable from school reopening in September 2020 until the beginning of April 2021.

Transmission of SARS-CoV-2 from pre and asymptomatic infected individuals. A systematic review

Background The transmission role of SARS-Cov-2 infected persons who develop symptoms post testing (pre symptomatics) or not at all throughout the course of positivity (asymptomatics) is unknown. We carried out a systematic review of available evidence to determine whether they were infectious or not and if so for how long and their probable contribution to the pandemic spread of SARS-CoV-2. Methods We searched LitCovid, medRxiv, Google Scholar and the WHO Covid-19 databases and reference lists of included studies. Search terms were COVID-19, SARS-CoV-2, transmission, asymptomatic, presymptomatic and appropriate synonyms. Searches were carried out to 31 March 2021. We included studies on people exposed to SARS CoV-2 within 2-14 days (incubation time) of close contact or suspected community or institutional exposure to index asymptomatic (at the time of observation) infected individuals, as defined in the study. We included studies with a proven or hypothesised chain of transmission with secondary case infected based on fulfilling a confirmed or probable case definition and confirmation of infectiousness and transmission outcome based either on serial PCR cycle threshold readings or viral culture or gene sequencing or any combination thereof and adequate follow up. We assessed the reliability of symptom and sign survey compatible with contemporary knowledge and extracted documentation of the likelihood of transmission, presence of replicating virus and/or documentation of phylodynamics (genetic sequence lineage) and/or adequate follow-up and reporting of symptoms and signs. We wrote to all included studies corresponding authors to request further details and assessed likelihood of transmission using adapted causality criteria. Results We included 18 studies from a variety of settings. Because of the current lack of standardized methodology and clear reporting criteria there was substantial methodological variation in transmission studies. Asymptomatic prevalence at the time of initial testing varied from 12.5% to 100% and of these 6% to 100% were pre-symptomatic cases, depending on the setting and the methods of case ascertainment and the population. Nursing/care home facilities reported high rates of presymptomatic: 50% - 100% (n=3 studies). Fifteen studies were classified as high risk and three studies at moderate risk of symptom ascertainment bias. In practice, this assessment means that high-risk studies may be less likely to distinguish between pre-symptomatic and asymptomatic cases. Six of the asymptomatic studies and four presymptomatic studies reported growing infectious virus although the data was too sparse to determine duration of infectiousness. Three studies were judged as providing possible and three of probable/likely evidence of asymptomatic transmission of SARs-CoV-2. Five studies provided evidence of possible and two of probable/likely presymptomatic transmission of SARs-CoV-2. Author response rate was 100%. Conclusions Reliable studies included here provide probable evidence of transmission of SARS-CoV-2 from presymptomatic and asymptomatic individuals. Single point in time estimates and binary PCR testing alone cannot provide reliable information on symptom status and information on infectivity. The number of studies and asymptomatic and presymptomatic cases eligible for inclusion was low, with more data and international standardisation of methods needed to further reduce uncertainty.

Characteristics of Three Person-to-Person Transmission Clusters of Severe Fever with Thrombocytopenia Syndrome in Southeastern China

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease worldwide. It can be transmitted from person to person, and the fatality rate is very high. During this study, three SFTS clusters including 12 associated cases were identified in three counties in Zhejiang Province from 2018 to 2020. The median age of the three index patients was 70 years, and that of secondary case patients was 59 years. Of note, the mortality rate of the index patients was 100%. The mortality rate of secondary case patients was 11%. The total secondary attack rate (SAR) was 30% (9/30). The SARs of cluster A, cluster B, and cluster C were 38% (3/8), 21% (3/14), and 38% (3/8), respectively. Additionally, the interval from onset to diagnosis was 4 days. The intervals from disease onset to confirmation of the index cases and secondary cases were 7 days and 4 days, respectively. All secondary case patients had a history of close contact with blood or body fluids of the index patients. These results indicate that SFTS patients should not be discharged until recovery. When SFTS patients die, the corpses should be transferred directly from the hospital to the crematorium for cremation by persons wearing proper protective equipment to prevent virus transmission.