The COVID-19 Pandemic Identifies Significant Global Inequities in Hemodialysis Care in Low and Lower-Middle Income Countries-An ISN/DOPPS Survey

INTRODUCTION It is unknown how the COVID-19 pandemic has affected the care of vulnerable chronic hemodialysis (HD) patients across regions, particularly in low and lower-middle income countries (LLMICs). We aimed to identify global inequities in HD care delivery during the COVID-19 pandemic. METHODS The ISN and the Dialysis Outcomes and Practice Patterns Study (DOPPS) conducted a global online survey of HD units between March and November, 2020, to ascertain practice patterns and access to resources relevant to HD care during the COVID-19 pandemic. Responses were categorized according to World Bank income classification for comparisons. RESULTS Surveys were returned from 412 facilities in 78 countries: 15 (4%) in low-income countries (LICs), 111 (27%) in lower-middle income countries (LMICs), 145 (35%) in upper-middle income countries (UMICs), and 141 (34%) in high-income countries (HICs). Respondents reported that diagnostic tests for SARS-CoV-2 were unavailable or of limited availability in LICs (72%) and LMICs (68%) as compared with UMICs (33%) and HICs (20%). The number of patients who missed HD treatments was reported to have increased during the COVID-19 pandemic in LICs (64%) and LMICs (67%) as compared with UMICs (31%) and HICs (6%). Limited access to HD, intensive care unit (ICU) care, and mechanical ventilation among hospitalized patients on chronic dialysis with COVID-19 were also reportedly higher in LICs and LMICs as compared with UMICs and HICs. Staff in LLMICs reported less routine testing for SARS-CoV-2 when asymptomatic as compared with UMICs and HICs-14% in LICs and 11% in LMICs, compared with 26% and 28% in UMICs and HICs, respectively. Severe shortages of personal protective equipment (PPE) were reported by the respondents from LICs and LMICs compared with UMICs and HICs, especially with respect to the use of the N95 particulate-air respirator masks. CONCLUSION Striking global inequities were identified in the care of chronic HD patients during the pandemic. Urgent action is required to address these inequities which disproportionately affect LLMIC settings thereby exacerbating pre-existing vulnerabilities that may contribute to poorer outcomes

The global impact of the Coronavirus 2019 pandemic on in-centre haemodialysis services: an International Society of Nephrology -Dialysis Outcomes Practice Patterns Study survey

Introduction To assess the impact of the COVID-19 pandemic impact on haemodialysis centres, The Dialysis Outcomes and Practice Patterns Study and International Society of Nephrology (ISN) collaborated on a web-survey of centres. Methods A combined approach of random sampling and open invitation was used between March 2020 and March 2021. Responses were obtained from 412 centres in 78 countries and all 10 ISN regions. Results In 8 regions, rates of SARS-CoV-2 infection were <20% in most centres, but in North East Asia and Newly Independent States and Russia rates were ≥20% and ≥30%, respectively. Mortality was ≥10% in most centres in 8 regions, though lower in North America and Caribbean and North East Asia. Diagnostic testing was not available in 33%, 37%, and 61% of centres in Latin America, Africa, and East and Central Europe, respectively. Surgical masks were widely available, but severe shortages of particulate-air filter masks were reported in Latin America (18%) and Africa (30%). Rates of infection in staff ranged from 0% in 90% of centres in North East Asia to ≥50% in 63% of centres in the Middle East and 68% of centres in Newly Independent States and Russia. In most centres <10% of staff died, but in Africa and South Asia 2% and 6% of centres reported ≥50% mortality, respectively. Conclusion There has been wide global variation in SARS-CoV-2 infection rates amongst haemodialysis patients and staff, PPE availability, and testing, and the ways in which services have been redesigned in response to the pandemic

An ISN-DOPPS Survey of the Global Impact of the COVID-19 Pandemic on Peritoneal Dialysis Services

INTRODUCTION Home dialysis may minimize SARS-CoV2 exposure risks compared to center-based dialysis. We explored how the pandemic may have introduced challenges related to peritoneal dialysis (PD) supply availability, routine patient care, and how facility practices changed during this time. METHODS The PD/Dialysis Outcomes and Practice Patterns Study (PDOPPS/DOPPS) and International Society of Nephrology (ISN) administered a web-based survey from November 2020 to March 2021. Medical director responses were compared across 10 ISN regions. RESULTS One hundered sixy-five PD facilities in 51 countries returned surveys. During the initial COVID-19 wave, the reported frequency of in-person patient visits decreased in 9 of 10 ISN regions. Before the pandemic, most facilities required a mask during PD exchanges which continued over the course of the pandemic. Although most facilities in different regions did not report PD supply disruptions, sites in Africa and South Asia reported major disruptions. Reductions in laparoscopic surgical procedures for PD catheters were reported by facilities in 9 of 10 regions whereas nonsurgical percutaneous procedures increased in facilities in 6 regions. Training of new PD patients declined in facilities in each region. Increased use of remote technology by patients to communicate with clinics was observed in all regions compared to prepandemic levels. CONCLUSION Marked within-region and across-region variability was noted in PD facility burden, clinical practice, and adaptation to the COVID-19 pandemic. This study highlights opportunities to improve routine PD care, adapt to the ongoing pandemic, and increase preparedness for potential future interruptions in PD care

Establishment of a high-dependency unit in Malawi.

Adults admitted to hospital with critical illness are vulnerable and at high risk of morbidity and mortality, especially in sub-Saharan African settings where resources are severely limited. As life expectancy increases, patient demographics and healthcare needs are increasingly complex and require integrated approaches. Patient outcomes could be improved by increased critical care provision that standardises healthcare delivery, provides specialist staff and enhanced patient monitoring and facilitates some treatment modalities for organ support. In Malawi, we established a new high-dependency unit within Queen Elizabeth Central Hospital, a tertiary referral centre serving the country's Southern region. This unit was designed in partnership with managers, clinicians, nurses and patients to address their needs. In this practice piece, we describe a participatory approach to design and implement a sustainable high-dependency unit for a low-income sub-Saharan African setting. This included: prospective agreement on remit, alignment with existing services, refurbishment of a dedicated physical space, recruitment and training of specialist nurses, development of context-sensitive clinical standard operating procedures, purchase of appropriate and durable equipment and creation of digital clinical information systems. As the global COVID-19 pandemic unfolded, we accelerated unit opening in anticipation of increased clinical requirement and describe how the high-dependency unit responded to this demand

A comparison of four epidemic waves of COVID-19 in Malawi; an observational cohort study

Background: Compared to the abundance of clinical and genomic information available on patients hospitalised with COVID-19 disease from high-income countries, there is a paucity of data from low-income countries. Our aim was to explore the relationship between viral lineage and patient outcome. Methods: We enrolled a prospective observational cohort of adult patients hospitalised with PCR-confirmed COVID-19 disease between July 2020 and March 2022 from Blantyre, Malawi, covering four waves of SARS-CoV-2 infections. Clinical and diagnostic data were collected using an adapted ISARIC clinical characterization protocol for COVID-19. SARS-CoV-2 isolates were sequenced using the MinION™ in Blantyre. Results: We enrolled 314 patients, good quality sequencing data was available for 55 patients. The sequencing data showed that 8 of 11 participants recruited in wave one had B.1 infections, 6/6 in wave two had Beta, 25/26 in wave three had Delta and 11/12 in wave four had Omicron. Patients infected during the Delta and Omicron waves reported fewer underlying chronic conditions and a shorter time to presentation. Significantly fewer patients required oxygen (22.7% [17/75] vs. 58.6% [140/239], p &lt; 0.001) and steroids (38.7% [29/75] vs. 70.3% [167/239], p &lt; 0.001) in the Omicron wave compared with the other waves. Multivariable logistic-regression demonstrated a trend toward increased mortality in the Delta wave (OR 4.99 [95% CI 1.0–25.0 p = 0.05) compared to the first wave of infection. Conclusions: Our data show that each wave of patients hospitalised with SARS-CoV-2 was infected with a distinct viral variant. The clinical data suggests that patients with severe COVID-19 disease were more likely to die during the Delta wave

Distinct clinical and immunological profiles of patients with evidence of SARS-CoV-2 infection in sub-Saharan Africa

Clinical management of COVID-19 in resource-poor settings has distinct challenges and detailed patient characterisation is needed. Here, the authors describe the clinical and immunological profiles of patients at a hospital in Malawi with confirmed and suspected COVID-19

Distinct clinical and immunological profiles of patients with evidence of SARS-CoV-2 infection in sub-Saharan Africa

Although the COVID-19 pandemic has left no country untouched there has been limited research to understand clinical and immunological responses in African populations. Here we characterise patients hospitalised with suspected (PCR-negative/IgG-positive) or confirmed (PCR-positive) COVID-19, and healthy community controls (PCR-negative/IgG-negative). PCR-positive COVID-19 participants were more likely to receive dexamethasone and a beta-lactam antibiotic, and survive to hospital discharge than PCR-negative/IgG-positive and PCR-negative/IgG-negative participants. PCR-negative/IgG-positive participants exhibited a nasal and systemic cytokine signature analogous to PCR-positive COVID-19 participants, predominated by chemokines and neutrophils and distinct from PCR-negative/IgG-negative participants. PCR-negative/IgG-positive participants had increased propensity for Staphylococcus aureus and Streptococcus pneumoniae colonisation. PCR-negative/IgG-positive individuals with high COVID-19 clinical suspicion had inflammatory profiles analogous to PCR-confirmed disease and potentially represent a target population for COVID-19 treatment strategies

Access to continued professional education among health workers in Blantyre, Malawi

Objective: To describe the current status of continued professional development (CPD) of healthcare personnel within the Ministry of Health (MoH) health centres in Blantyre, Malawi Design: A cross-sectional descriptive study utilizing an interviewer-administered questionnaire. Subjects: Healthcare workers in public health centers in Blantyre District, Malawi. Results: Fifty-seven healthcare workers participated of whom 47 (82.5%) were nurses, 8 (14.0%) were either medical assistants or clinical officers, and one laboratory technician and a dental therapist. At the time of the study, 50(87.7%) were prescribers and 54 (94.7%) had ever issued a prescription for medications. Participation in workshops and seminars within the past 12 months was reported by 54 (94.7%) of the participants and 49 (86.0%) reported that their health facilities had clinical hand-over meetings. All participants indicated desire to receive professional journals for free while only 35 (61.4%) were willing to pay for a journal subscription. Current personal and institutional subscription to a journal was low, at 2 (3.5%) each. About 30% had been trained to conduct research and 23 (40.1%) had ever conducted research with only 3 (5.3%) ever written a journal or newsletter article. 47.4% had access to a working phone at work and only 3 (5.3%) had access to internet facilities at all. Only 21% were satisfied with their own knowledge on health matters. Conclusions: Healthcare professionals in Blantyre\'s DHO zone are using mostly clinical hand-over meetings, seminars and workshops for their CPD. There is need to improve access to relevant professional journals. The regulatory or licensing boards for healthcare professional in Malawi should seriously consider mandatory CPD credits for re-registration Key Words: Malawi, continued professional development African Health Sciences Vol.4(3) 2004: 182-18

Access to continued professional education among health workers in Blantyre, Malawi

Objective: To describe the current status of continued professional development (CPD) of healthcare personnel within the Ministry of Health (MoH) health centres in Blantyre, Malawi Design: A cross-sectional descriptive study utilizing an interviewer-administered questionnaire. Subjects: Healthcare workers in public health centers in Blantyre District, Malawi. Results: Fifty-seven healthcare workers participated of whom 47 (82.5%) were nurses, 8 (14.0%) were either medical assistants or clinical officers, and one laboratory technician and a dental therapist. At the time of the study, 50(87.7%) were prescribers and 54 (94.7%) had ever issued a prescription for medications. Participation in workshops and seminars within the past 12 months was reported by 54 (94.7%) of the participants and 49 (86.0%) reported that their health facilities had clinical hand-over meetings. All participants indicated desire to receive professional journals for free while only 35 (61.4%) were willing to pay for a journal subscription. Current personal and institutional subscription to a journal was low, at 2 (3.5%) each. About 30% had been trained to conduct research and 23 (40.1%) had ever conducted research with only 3 (5.3%) ever written a journal or newsletter article. 47.4% had access to a working phone at work and only 3 (5.3%) had access to internet facilities at all. Only 21% were satisfied with their own knowledge on health matters. Conclusions: Healthcare professionals in Blantyre\'s DHO zone are using mostly clinical hand-over meetings, seminars and workshops for their CPD. There is need to improve access to relevant professional journals. The regulatory or licensing boards for healthcare professional in Malawi should seriously consider mandatory CPD credits for re-registration Key Words: Malawi, continued professional development African Health Sciences Vol.4(3) 2004: 182-18