Conclusions: We developed a novel, valid, and reliable tool to assess posterior circulation strokes. This can contribute to a more comprehensive estimation of posterior stroke and, additionally, due to its predictive properties, it can be used to more accurately select candidates for specific treatments.Background: Assessing the severity of posterior circulation strokes, due to the variety of symptoms, is a significant clinical problem. Current clinimetric scales show lower accuracy in the measurement of posterior stroke severity, compared with that of anterior strokes. The aim of the study was to design a validated tool, termed Adam’s Scale of Posterior Stroke (ASPOS), for better assessment and prediction of posterior stroke. Methods: This prospective, observational study involved 126 posterior circulation ischemic stroke subjects. Four researchers, previously trained in ASPOS, randomized the stroke severity using a novel tool and other appropriate stroke scales  to assess the psychometric properties, reliability, and validity of ASPOS and investigate its predictive value. Results: ASPOS reached a Cronbach’s alpha coefficient of 0.7449, indicating good internal consistency. The Bland–Altman analysis showed a good coefficient of repeatability (CR) of 0.46, a 95% confidence interval (CI) of 0.41–0.53, and excellent intraclass correlation coefficients or weighted kappa values (>0.90), reflecting high reliability and reproducibility. Highly significant correlations with other scales confirmed the construct and predictive validity of ASPOS. A total ASPOS score of three points indicated a significantly increased probability of severe stroke based on the NIHSS, compared to a total ASPOS of 1–2 points (odds ratio (OR) 141; 95% CI: 6.72–2977.66;  Posterior circulation strokes account for 20–40% of all ischemic strokes . CompareThe aim of the current study was to develop and validate a consolidated, reliable, and reproducible clinimetric tool  dedicated to exclusively assessing the severity of stroke in posterior circulation with additional predictive properties.This prospective and observational study was conducted from November 2019 to September 2020 in the Department of Neurology at University Hospital No. 1 in Bydgoszcz, Poland. This study included 126 patients who met the clinical and radiological criteria for the diagnosis of ischemic stroke in posterior circulation (onset within 24 h of admission).Both clinical and functional condition were assessed within 24 h after the onset of stroke using the NIHSS, Glasgow Coma Scale (GCS), IVBSS, Barthel Index, and modified Rankin Scale (mRS), all of which are relevant and common instruments for this purpose. Four researchers, including two physicians, one stroke research nurse, and a physiotherapist, performed the stroke subject evaluation; each had several years of experience working in the intensive stroke unit and had NIHSS assessment certification.On the first day of the stroke, three randomly selected investigators assessed each patient using ASPOS for estimation of the inter-rater reliability. The differences in the assessment did not exceed 2 h. One researcher, randomly selected each time, assessed the clinical and functional condition of stroke subjects with other available scales on the first day after the stroke to estimate the construct validity, and predictive validity was estimated on the 90th day after the stroke. Three hours after the ASPOS evaluation, one of the three previously randomly selected investigators was also selected at random for re-assessment by ASPOS (test–retest) to estimate the intra-rater reliability. The differences in the sum values of the ASPOS between two randomly selected researchers were used to assess the repeatability of the tool.The following exclusion criteria were used: lack of consent for the patient to participate in the study or inability to express it consciously . Furthermore, subjects underwent reperfusion therapy (thrombolysis and/or thrombectomy) due to the tendency for rapid and significant fluctuations in stroke severity.ASPOS  consistsThe study protocol was approved by the Bioethics Committee of the Nicolaus Copernicus University in Torun at Collegium Medicum of Ludwik Rydygier in Bydgoszcz (KB number 733/2019). All subjects read the study protocol and signed informed consent to participate in the study. The study was conducted according to the Declaration of Helsinki regarding research on humans.p < 0.05 was considered as the threshold for statistical significance.The statistical analysis of the collected data was performed with STATISTICA version 13.1 . Due to the incompatibility of feature distribution with normal distribution (Shapiro–Wilk test), nonparametric tests were used, i.e., the Mann–Whitney U test (assessment of the predictive relation between ASPOS and NIHSS), Spearman’s rank correlation test , intraclass correlation coefficient, and weighted Cohen’s kappa . The psychometric properties of the tool and repeatability were assessed by Cronbach’s alpha coefficient and Bland–Altman analysis, respectively. Logistic regression model and Kruskal–Wallis statistics were performed for the evaluation of the predictive values of ASPOS. The significance level of The general characteristics of the studied population are shown in The results of the inter-rater and intra-rater reliability are shown in p < 0.0001), Barthel Index , and mRS , indicating good construct validity (p < 0.0001) and a high correlation with IVBSS  were found. On the 90th day after the stroke, we revealed high correlations with NIHSS , Barthel Index , and mRS , indicating the high predictive validity of the tool , no case of NIHSS with at least six points was found. In the group with a total ASPOS score of three points , we reported five cases with an NIHSS total score of six points or more. In the ASPOS group with 4–11 points , 26 cases of NIHSS had six points or more. The Kruskal–Wallis test showed a significant difference between the above groups  (p = 0.0014).Using an NIHSS value of 6 as the cutoff for stroke severity and qualifying for a thrombectomy, we noted that, in the group with a total ASPOS score of 1 or 2 ( 0.0001) . LogistiWe developed a novel diagnostic tool, guided by three main assumptions, that may be useful in the assessment and prediction of posterior circulation stroke.First, we aimed for an ASPOS that would be simple, easy to complete, and understandable, such that, like NIHSS, it could be used not only by longtime neurologists but by other members of the stroke team, such as nurses or physical therapists. Limiting the components of the scale to the necessary minimum, a clear definition for individual scale components, clear rules for scoring the severity of individual items, and adopting general rules for assessment similar to those in NIHSS made it possible to achieve high reproducibility between examiners, which was reflected in the excellent ICC and κ values. Moreover, a high rate of repeatability was proven by the Bland–Altman analysis ,14. ThisSecondly, the scale was designed to meet the requirements of the International Quality of Life Assessment Project to obtain appropriate psychometric parameters . DespiteFinally, we devised a valid tool to accurately estimate the stroke severity based on the high correlations with other widely recognized scales used for this purpose. Significant dependencies on the first and 90th day after stroke demonstrated the construct and predictive validity of ASPOS. Moreover, it is more universal and can be used not only to assess the clinical condition, but also to reflect the functional status, reactivity and the degree of independence. Therefore, we hypothesize its particular usefulness for the proper and objective assessment of the subject’s condition during the diagnostic procedure in the emergency ward. Completing the questionnaire takes up to a minute and is a valuable supplement to gaps and deficiencies for certain clinical symptoms not included in the NIHSS, and fully reflects the actual and reliable stroke severity. Neurological examination of the patient is extended to include gait and swallowing assessments, which take a few more minutes, but provide information on key symptoms for posterior stroke, often overlooked in the initial diagnosis, which underestimates the patient’s condition and may delay or resign from extended vascular diagnosis. In our opinion, it is more appropriate to spend a few more minutes on a more reliable assessment of the patient, which will provide the basis for firm and quick diagnostic and therapeutic decisions than to observe the dynamics of symptoms for several minutes and wait for a significant deterioration, hesitating and delaying further treatment. In many cases only the neurological deterioration forces us to make faster decisions. Moreover, we hypothesize that additional time for a better assessment of stroke severity can ultimately shorten and accelerate diagnostic process and contribute to a faster initiation of reperfusion therapy.Our device might be used not only for the reliable assessment of posterior circulation strokes. Due to its predictive properties, we hypothesized its usefulness as a criterion for undertaking the qualification activities for mechanical thrombectomy. Two-thirds of our patients obtained a total value of ASPOS that did not exceed two points, which was also the median score. This was not related to the approach, even with the generally accepted limit of six points using NIHSS. It was revealed that the probability of achieving this limit was significantly increased after obtaining three points by ASPOS; it increased successively with each subsequent point. In our opinion, this dependence can be utilized, and the value of three points by ASPOS can be considered as a border value for the initial selection of patients for extended diagnostic procedures in the direction of detecting occlusion of large intracranial vessels. However, we realized that, due to the lower accuracy of NIHSS in posterior stroke, assuming a value of six points may be doubtful, but there is currently no better point of reference.It is not our intention to completely replace or abolish the NIHSS. When developing and presenting a new tool, we sought to draw attention to the possibility of its use as a realistic alternative or additional tool dedicated to posterior strokes for a better and more reliable measurement of specific symptoms compared to anterior stroke. ASPOS may support NIHSS in reducing and correcting the proven differences in prolonged diagnostic time and lower the quality of treatment in patients with posterior circulation stroke versus anterior circulation . HoweverThe authors are aware that the current study has some limitations. Due to a moderate sample size, further multicenter research on larger cohorts is needed to confirm our findings. Our analysis did not cover the entire cross section of posterior circulation stroke subjects. For formal and bioethical reasons, a large group of severe stroke subjects was procedurally excluded. In the next step, validation of ASPOS should be performed among stroke patients who undergo reperfusion therapy. A limitation of the tool is that one of the items did not obtain a satisfactorily high discriminant value. However, the overall reliability of the device is sufficient, which, in view of the large variety of clinical manifestations in this group of strokes, is an advantage of the scale.ASPOS is a novel, valid, and reliable diagnostic tool that can be used to assess posterior circulation strokes. It achieved appropriate psychometric features, high reproducibility, and easy performance, which makes it suitable for everyday practice in stroke units. It can contribute to a more comprehensive estimation of posterior stroke and, additionally, due to its predictive properties, it can be used to more accurately select candidates for specific treatment.


Primary care providers assume responsibility for patients with increasingly complex problems requiring interprofessional collaboration. Introducing interprofessional education in healthcare curricula prepares healthcare students for this reality. Solving simulation scenarios as an educational strategy is promoted to support interprofessional education in health care, and is mostly used in acute clinical situations. This paper aims to explore how healthcare students’ actions influence interprofessional collaboration and treatment plan identification when they solve common, sub-acute patient scenarios in primary care situations.Interaction analysis of video recordings from the simulation scenarios was performed with a focus on the students’ joint actions; specifically how these actions unfold and how productive the students were in terms of developing treatment plans.We found variation in the groups’ interactions, the paths they followed, and the quality of their knowledge output in their shared treatment plan. The groups with the capacity to collaborate and engage in sharing information, and explain and elaborate on concepts, were more successful in developing comprehensive treatment plans. Furthermore, these groups managed the duality of defining and solving the immediate problem and collaboratively preparing for future care.Analysis of the activities in our scenarios showed the students’ potential to practice interprofessional collaboration. Our study illustrates that simulation of sub-acute scenarios in primary care is an underexplored but suitable arena to train communication and teamwork in complex situations. The simulation scenarios are also feasible for use on-site in an educational facility or in practice with minimal equipment and resources. Primary care professionals assume responsibility for patients with increasingly complex problems. Shorter hospital stays and increased emphasis on home care and aging in place suggest that more people will require primary health care . To meetIPE implies that students from two or more professions engage in interactions to learn about, from, and with one another to improve collaboration and quality of care , 4. ReseHealthcare education programs may have different perspectives on learning and teaching, adding to the barriers of implementing IPE. Based on the definition of IPE, where learning “about, from and with” one another is the cornerstone, we adopted a socio-cultural perspective to understand interprofessional learning. Facilitating IPE requires effective teaching methods, and the use of simulation as an educational strategy is promoted to support IPE in healthcare education , 10.The use of simulation scenarios is recognized as a facilitator for active learning to develop clinical and collaborative skills in a safe environment in health care and healthcare education . SimulatShift of care and treatment from hospitals to primary care, increased prevalence of long-term conditions, and complex care requirements depend on collaboration between healthcare professionals in primary care who are more accustomed to collaborate within their profession, organization and sector . Thus, pExpanding simulation training to include common, sub-acute primary care scenarios offers the learners complex situations where they have time to assess, discuss, and collaborate to solve the problem. In particular, the development of shared treatment plans can work as a means to improve communication, coordination, and collaboration, consequently resulting in a more coherent plan for the patient . These sThis paper describes the analysis of healthcare students’ interactions while exploring common, sub-acute patient scenarios in primary care situations, and aims to explore how healthcare students’ actions influence interprofessional collaboration and treatment plan identification.shared knowledge objects are viewed as the materialization and co-creation of knowledge that represents the goal to be pursued (e.g. learning outcome) and the material outcome to be achieved through the activity (e.g. simulation) [productive interactions as verbal and non-verbal communicative exchanges between the participants leading to the co-construction of the shared knowledge objects [Active participation is understood as deliberate, joint, knowledge driven activities contributing to the shared goal [interaction trajectories are viewed as coherent sequences of productive interactions, which unfolds as moment-to-moment events over time [This study adopts a socio-cultural perspective where knowledge and learning are constructed and co-created in interactions between participants, environments and artefacts (tools and objects) in a social practice , 26, herulation) ;. We und objects . Active red goal . The intver time .We conducted an explorative, qualitative study with video recordings of healthcare students participating in primary care simulation scenarios. The unit of analysis in this study is the collaborative actions  in which the shared knowledge is produced. Such actions comprise speech, bodily behavior, artefacts, and environmental structures.We recruited 27 healthcare students close to graduation, 10 of which were medical students (MS), eight were master’s students in advanced geriatric nursing (AGN), and nine were bachelor’s students in nursing (NS). The students were allocated into 10 groups, and two groups participated in the simulation each day. Table The simulation took place at UiO:eColab, a research laboratory with two fully equipped healthcare offices/consultation rooms separated by a control room. We used a Laerdal SimMan® patient simulator . The patWe developed two simulations with common, sub-acute patient scenarios from primary care situations. The scenarios were developed based on the assumption that caring for patients with complex problems is often beyond the expertise of any single profession . The twoWe collected data during 5 days in April 2019. Video recording was chosen to enable repetitive viewings of the dialogue and interactions by the project group . DiscretWe used interaction analysis to guide our analysis of the data. Interaction analysis is a useful method to study the unfolding interactions in play during a social activity, including talk, non-verbal interactions, and material artefacts , 32. IniWe informed the students about voluntary participation, confidentiality, video recording and data storage, and that only the project group had access to the recorded material. We obtained informed consent after giving oral and written information. The Norwegian Centre for Research Data approved the study (project number 60867).The video recordings facilitated repeated review of the material, individually and in group work, by coauthors with different backgrounds, helping to ensure the legitimacy of our interpretations . The firspecific treatment plans and non-specific treatment plans. A specific treatment plan had relevant, clearly defined clinical problem(s) with defined, related actions and interventions. A non-specific treatment plan either had several unspecified clinical problems or lacked defined problems entirely, and the actions and interventions were non-specific or nonexistent. Table The analysis revealed that the content and structure of the treatment plans varied between the groups and was influenced by the interactions and communication between the students. This led us to divide the material into two groups: In the groups that engaged in productive interactions, and created a specific treatment plan, we observed a deliberate, collective strategy bringing multiple perspectives into the discussions. The interactions unfolded as coherent sequences where the students actively built on each other’s input in a joint effort. The students shared information and discussed, and their collaborative actions led to the emergence of new knowledge and progress of the shared treatment plan. In the groups that created non-specific treatment plans we observed circular discussions, with repetition of prior statements without clarifying the concepts. There were limited contributions and less active participation in the groups, which led to less development of shared knowledge, and ended with a non-specific treatment plan. We have selected unfolding interactions as examples from two groups that prepared a specific and non-specific treatment plan to illustrate the most typical interactions and co-creation activities observed in the simulations. In the following section, we present examples from Group 1 and Group 2 to help explain and visualize these interactions.Group 1 consists of an MS, AGN, and NS and they are simulating a scenario with pneumonia. At the beginning of the simulation, they are sitting by the table in the office, with the AGN in the middle. The medical record lies open in front of the MS and AGN. There is a notepad with notes on the table in front of the NS. Everybody is looking at the medical record.In the following excerpt, we meet Group 1 at the starting point of the planning phase Table . Before In the excerpt, we see that the MS starts with an open question about fluid intake (Section 1.1), inviting the other participants to contribute. The invitation is accepted, with both the NS and AGN contributing. The NS writes on the notepad and suggests writing their plan down (Section 1.8). The AGN reads the medication list and explains that the patient is on diuretics.The first notable finding in this excerpt is that this group’s interactions were aimed at creating a shared understanding from the start. By looking at the AGN and NS, talking in an open, questioning tone, the MS addresses both directly to assess their interpretation of the situation. The conversation between the participants is characterized by equal contribution, albeit in half sentences. Nevertheless, they elaborate spontaneously on one another’s input. The NS suggests writing down a plan in an attempt to structure the group’s knowledge. They continue to elaborate on one another’s suggestions, contributing to further clarification and specification of diagnostic tests and treatment.Leading up to the following excerpt, the group had been discussing pain medication, which led the NS to suggest monitoring the patient’s pain. Both the MS and AGN agreed to this suggestion, with the MS exclaiming that it was a very good idea. The discussion continues in Table As illustrated in this excerpt, MS actively addresses the AGN and invites the AGN to contribute in a friendly tone (Section 1.11). The AGN hesitates slightly and reaches for the forms. The AGN flips through the pile of forms and explains that registering delirium should be considered (Section 1.12). Then NS spots the form and points towards it (Section 1.16). The AGN confirms that the NS is correct in a cheerful tone (Section 1.17).The excerpt presented in Table So far, these short excerpts show Group 1’s attempts to gain knowledge by using artifacts, and that they continue to build on one another’s statements and suggestions in order to co-create a coherent treatment plan.Continuing the planning phase, the group has discussed the 4AT (a tool for delirium assessment) and National Early Warning Score (NEWS) forms. The MS expressed unfamiliarity with the 4AT and NEWS forms, and the AGN and NS both contributed in explaining the forms’ aims and usages. In the following excerpt Table  Group 1 This excerpt shows that the NS initiates the summarization of the treatment plan (Section 1.19). The NS summarizes in a clear, friendly tone, while actively pointing to the notes on the notepad (Section 1.21). The MS and AGN look attentive towards the NS and contribute with clear, confirmative sounds (Section 1.22). The NS appears unsure about the possibility of monitoring pain with the suggested form, hesitating and talking in a questioning tone while looking at the AGN (Section 1.26), prompting the AGN to explain (Section 1.27). After this excerpt, they continue to discuss different pain scales and then the NS continues to summarize the plan. The MS and AGN contribute with input to make the plan more specific.Here, the students attempt to construct an overview by summarizing their existing knowledge, initiated by the NS. Through the structuring and reframing of the proposed treatment plan, the group members collectively arrive at a better understanding of how to treat the patient. The way in which the students continuously dealt with uncertainty by explaining and elaborating upon the concepts in question during the planning shows that they are attentive towards one another and actively seeking joint knowledge. This example is illustrative of interactions that lead to a concrete and specific treatment plan.Group 2 has the same composition as Group 1, with an MS, AGN, and NS, and they are also simulating the scenario with pneumonia. At the beginning of the simulation, they are sitting by the table in the office, with the MS in the middle. The medical record lies open in front of the MS. A notepad with notes is on the table in front of the AGN. The AGN and NS look at the MS.In the excerpt presented below, we meet Group 2 approximately 1.5 min into the planning phase. Prior to this excerpt, the MS expressed an intention to admit the patient to hospital due to confusion. The MS also suggested administering intravenous fluids and bladder scan at the nursing home. The AGN contributed with agreement and repeated the MS’s statements. The NS said nothing except in a response to the MS about the amount of urine output. The planning continues in Table In this excerpt, the MS starts speaking hesitantly and suggests conferring with the hospital, since they are unsure of why the patient is disoriented (Sections 2.1 and 2.3). The AGN confirms the MS’s statements and agrees with the MS (Sections 2.4 and 2.6). Then, the AGN indicates the lack of information by waving a hand over the notes. The NS does not contribute with any relevant content.The excerpt above illustrates how the MS acknowledges their collective lack of knowledge as to why the patient is disoriented. At once, the AGN contributes with agreement and repetition of the MS’s statement. Thus, they have agreed on their mutual knowledge about the patient’s condition: the fact that they do not understand it. Voicing this collective uncertainty has the potential to strengthen the collaborative effort to explore the problem at hand. The excerpt also shows that they have the opportunity to utilize other resources to solve the problem by conferring with the hospital. However, when we observe the students’ subsequent actions, it is obvious that they do not act on their prior statements.Before the next excerpt, the MS talked about the operation wound and contacting the patient’s relatives. The AGN mostly replied in a confirming tone without further contribution. The NS went to the patient to perform a practical assignment (bladder scan). Then, the MS mentioned frequent monitoring at the nursing home in case admitting the patient to the hospital takes time, if they accept to admit him at all, still without any elaboration or contribution from the AGN or NS. Table This excerpt shows that the MS initially aims for a discussion with the AGN and NS by asking if there is anything they have not thought of. However, the MS quickly returns to the concept of admitting the patient to hospital yet again (Section 2.10). Then the MS changes direction towards making a plan if the patient is not admitted (Section 2.12). The AGN picks up this statement and hesitantly suggests waiting to make a plan until they know if the patient will be admitted (Section 2.13). Initially, the MS agrees, but then explains that they should have a tentative treatment plan prepared if fluids and pain relief improves the situation . The NS says nothing.In this excerpt, we see that the group seems inclined to return to possible hospital admittance as the main intervention for the patient. Although this concept repeatedly occurs in the simulation, they continue to add other potential interventions sporadically. The discussion, however, often stops at the point of mentioning an intervention, such as administering fluids, without further elaboration of why or how. In turn, they do not arrive at a mutual understanding of the concepts and the conversation circles back to the hospital. The talk is mostly driven by the MS, who appears unsure of what to do. They have not stated any tentative clinical problems for the patient, which consequently seems to make it difficult to refine, elaborate on, or conceptualize a treatment plan.Leading up to the following excerpt, the MS has talked about intravenous fluid, possible constipation, and optimizing pain medication. The AGN mentioned coughing, but the MS dismissed it because of clear lungs when auscultating. The MS commented on fluids again and monitoring fluid intake and output to optimize the patient, if not admitted. The MS then asked if anything had been forgotten, and the AGN mentioned nutrition. The discussion continues in Table This excerpt shows that the MS acknowledges the suggestion from the AGN regarding nutrition (Section 2.19). However, in the same section, the MS explains why it is important to clarify the patient’s condition first, because wound revision in the hospital requires fasting (Section 2.21). Thus, the MS rejects the contribution from the AGN due to the possible necessity for surgery. At this point, the MS starts to admit that hospitalization is uncertain (still Section 2.21), and is interrupted by the AGN who adds that everything depends on admittance or not (Section 2.22). The facilitator ends the simulation.The excerpt above illustrates that the group did not progress in their development of the treatment plan. They were not able to generate concrete ideas or further elaborate on the concepts they shared. Any attempt to start a joint discussion about the treatment plan and materialize these ideas is stopped by their inability to define the patient’s clinical problems. The planning phase goes around in circle, with wanting to confer with the hospital about the patient’s confusion, then admitting him without any clear indication as to why, then suggesting to make a tentative treatment plan in case he is not admitted, and then talking about admittance due to wound revision. The group seems to have knowledge of the situation in practice, but appears to have difficulties conceptualizing, elaborating on and refining a treatment plan.The interaction and co-creation process ranged from discussions, efforts to structure knowledge, and use of tools in Group 1, to repetition of prior statements without further elaboration in Group 2, as illustrated in Fig. In summary, we found variation in how the groups engaged in interactions, the paths they followed and the quality of their shared knowledge object, the treatment plan.The analysis showed that the development, content, and structure of the shared treatment plans were influenced by the interactions within the group. The groups that managed to engage in productive interactions in a coherent interaction trajectory developed a more comprehensive and specific treatment plan than the groups where the interactions were less productive.We identified that several productive interactions occurred during the collaborative work, exemplified by Group 1, such as joint discussion and elaboration of concepts. The students in Group 1 mediated their actions by utilizing the artefacts and tools available to them . ThroughIn contrast, Group 2 spent limited time in joint identification and discussion of concepts and were less productive in mediating the artefacts and tools available to them. Although talking in friendly tones, the verbal contributions were mainly confirming sounds or repetition of statements, instead of suggestions or elaborations. They had sporadic eye contact, but most of their gaze faced their notes or the medical chart. Consequently, they did not manage to utilize available productive resources to advance in their conceptualization of the treatment plan.Our results illustrates that the groups where the students participated actively in sharing knowledge, practice and experiences managed to engage in productive interactions and refine the treatment plan in a collaborative effort. ZPD can be seen as a process where the student’s performance is co-constructed in interaction and collaboration with others . The goaOur scenarios presented the students with sub-acute situations from a nursing home, and were not dependent on the students having advanced technical skills. However, we acknowledge that they might have perceived the scenarios as complex due to an atypical presentation of symptoms and lack of algorithms to follow. Still, since the simulation scenarios comprised common primary care situations and a slow pace, the students had time to assess, plan, and talk together to solve the problem. The scenarios seemed to facilitate the development of the students’ collaborative competencies, and expand their ZPD, as long as the student managed to make sense of the activities. Our study highlights the feasibility of sub-acute primary care simulation scenarios to teach communication and teamwork in situations where an accurate diagnosis and decisions about treatment may be difficult to make. After completing the simulation together, the students may be better prepared to participate and contribute in this type of scenario in the future. Through that process, the students ZPD will have been expanded. The next time the students participate in simulation, they should manage a higher level of difficulty, and further develop their ZPD.why is to look at the IPE definition where learning “about, with and from”, is a cornerstone. Still, healthcare students are educated in professional silos [about other professions and about their own role in the collaboration. We exposed the students to collaborative activities where they had to develop a shared treatment plan for the patient without providing instructions on how the task could be completed. Expansion of the students’ ZPD requires active participation and some students might not feel comfortable with active participation if they are insecure of how to participate. In our study, only seven of the 27 students had prior interprofessional simulation experience and we do not know which groups these students were allocated to. Neither do we know anything about their experience from clinical practice. Limited previous experience might have affected their ability and willingness to take an active part in the scenarios. In addition, the students had not met prior to the simulation activity. They did spent some time in informal conversation in the groups to get to know each other before the simulation started. Nevertheless, a failure in creating a specific treatment plan could be explained by the fact that the students had just met, and thus were a bit hesitant in their interactions.Our results revealed two distinct trajectories when developing a shared treatment plan. By contrasting two groups, we have illustrated how the co-construction process of shared knowledge can take different routes and lead to different results. Ideally, the groups should follow a coherent interaction trajectory, as seen illustrated in Group 1, where the elaboration on previous statements, use of available resources, and interactions created possibilities for the development of the shared knowledge object . Howeveral silos  and therfrom the other students, rather than contribute actively in learning in interaction with. This would limit their own contributions, but also the other students’ possibility to advance in their ZPD. Making the students feel safe and confident in the learning situation can foster confidence in the students own role and willingness to participate in a team [In our results, exemplified by Group 2, we saw that some students seemed to entrust identifying and generating knowledge to the medical student. It can be a complex task for students to know how to engage in interactions that lead to concrete ideas and to further elaborate on those ideas to develop a shared knowledge object . The stun a team , and conn a team . We beliAs we have sought to understand how to organize student activities supporting interprofessional learning, we found that productive interactions and coherent interaction trajectories are important aspects for training interprofessional collaboration. We have contrasted and compared two groups to visualize these interactions and trajectories. Our results indicate that the groups with coherent interaction trajectories managed the duality of defining and solving the immediate problem and preparing for future care in collaboration. Those groups with circular trajectories may miss important opportunities for interprofessional learning.When planning and implementing IPE, educators should have strategies available to prevent or detect the problems that the students encounter to help them move beyond circular trajectories during the simulation. Understanding the students’ current knowledge and capabilities, and discovering emerging problems, can help educators determine how to organize or change the simulation so that the students advance in their ZPD. Thus, educators, and especially the facilitators directly involved when the simulation is in progress, need to be flexible in their roles and adapt to the students’ needs . In retrAnother possibility is to present strategies for collaboration, interaction trajectories and shared knowledge development in the preparation and briefing sequences before the simulation scenarios or add an introductory IPE course before the simulations. This might better prepare the students for interprofessional collaboration as they are presented with strategies on how to collaborate.Reflecting on the simulation experience is seen as a cornerstone for students to reconstruct their experience into learning . As suchDespite IPE literature listing interprofessional collaboration and communication as competencies to achieve through IPE , it is lThere are several limitations to our study. We acknowledge that the students agreeing to participate might be the most receptive to IPE and simulation. Reasons given for not participating were lack of time, not granted leave of absence from clinical practice or work, or feeling uncomfortable with video recordings. We tried to avoid non-participation by emphasizing that the interactions between the participants were of interest and not their technical skills, and that only the project group would view the actual recordings. We also provided letters to deliver to leaders and educators to help the students get approved absence. The simulation was completed in 1 day, which also minimized absence from work or practice. Our study has a small sample size, as is typical of a qualitative study ; thus, oThere are also limitations when using video recordings, as the participants might change their behaviour due to the camera. However, in the research facilities where we conducted the simulations, the cameras and audio equipment were discretely placed in the ceiling, minimizing the interference. We used a patient simulator as the patient, which might induce lack of realism, as the simulator does not have facial expressions or the ability to respond. To enhance realism, the facilitators were present in the simulation room, acting as the patient’s voice and offering responses not available through the simulator. This in itself could also be a limitation to the realism of the situation. However, informal student feedback suggests that the facilitator added to the realism by acting as an older patient when communicating with them as the scenario played out. The students were not given any concrete tools on how to achieve interprofessional collaboration before the simulation, which might have limited their ability to maximize collaboration. We have suggested adding these strategies to the briefing or implementing an introductory IPE course.The present study of simulation in common, sub-acute patient scenarios in primary care situations illustrates that what seemed to characterize the groups engaging in productive interactions was a deliberate, collective strategy bringing multiple perspectives into the discussions in a coherent trajectory. For the students to actively participate and engage in productive interactions, and advance in their ZPD, they have to be able to make sense of the simulation. Use of in-scenario instructions might be a prudent way to help students to move out of non-productive trajectories and promote collaboration. Overall, the student activities in our scenarios show the potential for practicing interprofessional collaboration and adding simulations of sub-acute primary care scenarios as an area of importance in teaching communication and teamwork in complex situations. Therefore, we suggest that educators planning and developing interprofessional simulated scenarios should include common, sub-acute primary care situations. To further develop IPE strategies, research should expand on the interactions and collaborative efforts when people are learning through interprofessional simulation.


To describe how early case detection, testing and contact tracing measures were deployed by stakeholders in response to the COVID-19 outbreak in Ghana – using three outbreak scenarios.A descriptive assessment of three case studies of COVID-19 outbreaks within three settings that occurred in Ghana from March 13 till the end of June 2020.A construction camp, a factory and a training institution in Ghana.Staff of a construction camp, a factory, workers and students of a training institution.We described and compared the three COVID-19 outbreak scenarios in Ghana, highlighting identification and diagnosis of cases, testing, contact tracing and stakeholder engagement for each scenario. We also outlined the challenges and lessons learnt in the management of these scenarios.Approach used for diagnosis, testing, contact tracing and stakeholder engagement.Index cases of the training institution and construction camp were screened the same day of reporting symptoms, whiles the factory index case required a second visit before the screening. All index cases were tested with RT-PCR. The training institution followed and tested all contacts, and an enhanced contact tracing approach was conducted for staff of the other two sites. Multi-sectorial engagement and collaboration with stakeholders enabled effective handling of the outbreak response in all sites.Comparing all three settings, early diagnosis and prompt actions taken through multi-sectorial collaborations played a major role in controlling the outbreak. Engaging stakeholders in the COVID-19 response is an effective way to mitigate the challenges in responding to the pandemic.The COVID-19 outbreak response and writing workshop by the Ghana Field Epidemiology and Laboratory Training Programme (GFELTP) was supported with funding from President Malaria Initiative – CDC, and Korea International Cooperation Agency (on CDC CoAg 6NU2GGH001876) through AFENET Since the novel coronavirus 2019 (COVID -19), was identified in Wuhan City in the Hubei Province of China in December 20192Ghana recorded its first case on March 12, 2020 and total cases and deaths stood at over 17,000 and 100 respectively by the end of June 2020. 3Despite current limitations in knowledge of COVID_19 disease transmission, the disease certainly spreads from person to person, from respiratory droplets of both symptomatic and asymptomatic infected people, commonly through coughing and sneezing. Early diagnosis, complete contact listing, timely contact tracing and prompt isolation of cases are key to preventing transmission of outbreaks such as COVID-19. 6These measures help control sporadic cases and clusters and prevent community transmission through effective mechanisms for quarantine, isolation, treatment and monitoring of contacts and cases, and suppression of community infection transmission through context-appropriate measures.6Outbreak responses, including early diagnosis and contact tracing, affect the impact of outbreaks. Outbreaks usually affect individuals and communities. Therefore, an effective response involves both the community and other stakeholders.10Stakeholders in an outbreak become the link between the affected population and the response team. Their role also involves communicating the outlook of the outbreak to the population and demystifying rumours and fears due to the outbreak.Ghana developed documents for early identification of cases, prompt contact tracing and case management. These protocols were used in the training of health workers and health education. National laboratories were also equipped to test the virus using Reverse-Transcription Polymerase Chain Reaction (RT-PCR) tests. Health workers were trained for contact tracing of cases and data management systems that allow for tracking and decision-making. These measures evolved in different locations based on the spread, with Accra and Kumasi being the initial points of the outbreak.Similarly, the implementation of the protocols was based on specific considerations and the dynamics of the affected populations. Regular evaluation of all outbreak response strategies is important, particularly early diagnosis and contact tracing as the outbreak spreads. We examined how stakeholders deployed early case diagnosis and contact tracing measures during Ghana's COVID-19 response in three different settings.A descriptive assessment of three case studies of Ghana's early COVID-19 outbreaks in three settings from March 13 to June 30 2020.Three settings in Ghana, a country located in West Africa with 30 million people, were studied. Ghana recorded its first two cases of COVID-19 on March 12, 2020. Subsequently, the number of cases increased to over 17,000 as of the end of June 2020.The first of the three settings was a training institution in the Greater Accra Region, one of the largest in the country, and located within a district identified as a hotspot during the first two months of the outbreak. The institution has a population of over 20,000, consisting of staff and students. Facilities include academic faculties, residential facilities, commercial and recreational centres, and a hospital that serves both the institution and the district.The second set was a construction camp located in the Eastern Region of Ghana. The camp houses over 200 workers of a railway construction firm and is located in an isolated community, surrounded by small rural settlements. The workers share rooms, living areas and toilet facilities. They are served meals in a common dining area in batches and have recreational grounds for sports activities. Shuttle services are available to and from the construction sites and living quarters. The camp has a health post operated by a physician assistant who attends to minor ailments of workers.The third setting was a food processing factory located in a metropolitan area close to Ghana's capital. It has about 2,000 workers, including casual workers, who reside either within the metropolis or in the neighbouring districts. The factory provides shuttle services for workers to and from work, and a staff canteen serves them food. Minor ailments and injuries are managed at an onsite clinic managed by nurses and laboratory personnel under the supervision of an institutional physician.We described and compared three COVID-19 outbreak response scenarios in Ghana. Our description highlights identification and diagnosis of cases, testing, contact tracing and other containment measures and stakeholder engagement for each scenario. We also outlined overall challenges and lessons learnt in the management of these scenarios.We reviewed daily situational reports, interim and final reports and all documents about the outbreak in these three settings. These included community/ institutional reports, field epidemiology teams' reports, and reports from the health directorates.Relevant data were extracted from the routine COVID-19 surveillance data management system of the Ghana Health Service into Microsoft Excel for the three sites, cleaned and analysed descriptively and presented as a table.We obtained ethical clearance from the Ghana Health Service Ethics review committee (GHS-ERC 006/05/20). The Ghana Health Service  and the institutions concerned provided and gave permissions for the data to be used. Participants were assured of the confidentiality of the information shared. All information obtained was stored on password-protected computers.On March 13 2020, a day after Ghana recorded its first case of COVID-19, a 36-year old female student in a training institution who had returned from a trip abroad a week earlier reported to a private facility with a history of fever, cough, general weakness, runny nose, headache. Persons with a recent travel history to a country with reported cases of COVID-19, COVID-19 was suspected, a sample was taken for testing, and a diagnosis of COVID-19 was made on March 14, 2020. The case was isolated for management. A total of 96 contacts within and outside the campus were listed. Of these, 74 were students, and 72 of them underwent 14-days of mandatory quarantine on campus. Three of the quarantined contacts developed some mild cough, cold, and fever symptoms during the follow-up follow-up period, but all three tested negative for COVID-19. There were no major symptoms reported among the remaining contacts during this period. At the end of the 14-day quarantine period, 94 contacts tested negative and were discharged.The index case at the construction camp in the Eastern region was a 32-year-old male worker with a railway construction company. He reported to the camp's health post on March 30 2020, with a cough, fever and a recent history of travel outside the country. As the first suspected case reported in the region, immediate attention was given at all levels. The health directorate was informed, and samples were taken on March 30 2020, for testing. Results came out positive for COVID-19 on March 31 2020. The case was taken to the isolation centre for management. Subsequently, all 249 workers in the camp were listed as contacts due to the nature of the camp and the level of interaction among its occupants. Contacts were quarantined for 14 days and tested. In the following week, 15 new cases were recorded from the contacts tested.Testing of contacts continued, and the number of cases eventually increased to 69 by the third week. Identified contacts and asymptomatic cases were quarantined or isolated at the camp or designated quarantine/ isolation centres in the region. Daily charting of symptoms and signs was done for all cases and retested after 14 days. A case had to test negative twice before being discharged from the isolation centre. All confirmed cases were asymptomatic, and no death was recorded among them.The index case at the factory was a 48-year-old female worker who reported to the company's clinic on April 9, 2020, with cough, fever, chills, and body pains. Two weeks before presentation, she had been seen with symptoms of cough and unwellness and had been given some medications and discharged. On this second occasion, with a high index of suspicion of Covid-19, a sputum sample was taken on April 9, 2020, and tested. The positive result for COVID-19 was received on April 17, 2020. The case was taken to a designated isolation centre for management. Identified contacts of the index case at work were listed (160 workers) and tested while other employees of the company agreed to undergo voluntary testing (enhanced screening) for COVID-19 . Out of 1,138 employees whose samples were taken, 695 positive cases were recorded for COVID-19, 128. employees tested negative, while 315 did not receive their test results for more than three weeks. Case management teams were formed to handle disclosure of results to confirmed cases (most of whom were asymptomatic and managed at home), management plans and risk communication to primary contacts.The three case scenarios occurred early on during the outbreak in Ghana. Depending on the availability of test kits, nasopharyngeal, or oropharyngeal or sputum samples were taken. For all index cases, samples were taken immediately at the point of care and analysed using RT-PCR at the Virology Department of the Noguchi Memorial Institute for Medical Research (NMIMR).Testing for identified contacts for the construction camp case and the training institution also took place at NMIMR, with samples taken by Ghana Health Service (GHS) and the institutional health facility staff. However, the factory and construction camp advocated for and eventually had mass testing for many of its staff because they were concerned that routine daily interactions potentially would have brought the case into contact with a wider population of the staff. For factory contacts, some had their tests analysed at NMIMR while others were done at the Public Health Reference Laboratory (PHRL) of the GHS because of their large numbers and to avoid delays in getting results.The positivity rate after the initial testing was 61.1% . This resulted in many staff undergoing isolation, with a few (9) refusing to be isolated because they did not believe the results were truly positive. Turnaround time for test results for all index cases was two days but varied considerably for the tests for contacts. It was on average four days, ten days and two days for the construction camp, factory and training institution.Some factory contacts, especially on retesting, did not get their results and were eventually declared discharged when they remained asymptomatic after 14 days based on the revised national protocol. Testing was at no cost to cases and contacts by the national testing policy. The GHS team listed contacts from the airline the case used, household, faculty, and other contact points on campus for the academic institution. Contacts were then identified through phone calls and informed of the 14-day quarantine they were to undergo. Contacts from the airline and household were followed by GHS. At the same time, the GFELTP residents and supervisors were deployed as the contact tracing team responsible for the students and faculty contacts on campus. All the contacts were initially tested for COVID-19 and found to be negative for the infection. Student contacts were quarantined on campus to make follow up easier. This was made possible because the institution was closed as part of the national response to the outbreak. Faculty contacts chose to self-quarantine at home.All contacts were monitored daily with symptoms charting, given psychological support at least once a week, and provided with food and housekeeping supplies throughout their stay. At the end of the mandatory 14 days quarantine period, all contacts tested negative and were discharged to go home.The entire camp was quarantined since they were all listed as contacts, with the district surveillance team responsible for contact tracing. The identified contacts to the index case were quarantined for 14 days in the camp. Contacts were tested at the beginning of quarantine. Positive contacts were isolated in the camp's isolation centre set up by the construction firm. This centre was located on one side of the camp, where the movement was prohibited to prevent further contact.Contacts were monitored daily with symptoms charting for 14 days, tested after the quarantine, and discharged based on two negative test results. For the factory, primary contacts of the index case in her household were listed, identified and quarantined. Contacts were monitored daily with symptoms charting for 14 days, tested and discharged based on two negative test results.All household contacts tested negative. Contacts in the factory were identified and tested. The factory requested mass testing of all other workers based on the sensitivity of the work it does. Cases from among the staff found were identified, and their contacts were listed through phone interviews. Some cases, however, refused to accept their test results and so did not disclose their contacts. Those living outside the factory district were transferred to their districts of residence for contact tracing and follow up of their contacts. Contacts to cases in other districts were followed up, but only a few districts reported back on them. Contact tracing teams were formed to follow-up contacts of cases living in the factory district. Some contacts refused to cooperate with contact tracers making it difficult for an effective 14 day follow to be done.In addition to early diagnosis and contact tracing, other containment measures were in place in all three scenarios to make the response effective.Handwashing facilities and some alcohol-based sanitisers were provided at the training institution, at the entrance of the quarantine hostel. A “no mask no entry” policy was instituted to ensure that all contacts and staff were protected. Some detergents and PPEs were provided for workers for cleaning the hostel, and the place was fumigated before and after contacts occupied it. Hand sanitisers were provided for each contact during the period.For the camp, segregation of workers to different parts or zones based on their infection status  enabled the facility to be fumigated. There were training sessions for factory workers on the infection and management and containment protocols and appropriate PPEs. Workers were sensitised on what COVID-19 was, early signs and symptoms to report, how to prevent getting infected, and psychological support, especially for cases.For the factory, an infectious disease preparedness and response plan was developed. Handwashing facilities comprising running water, soap and hand dryers were provided at the entrances. The temperature of all persons entering the factory, including staff were taken daily. All workers needed to wear facemasks always when within the factory. A “no facemask, no entry” policy was instituted, and signage on the same was displayed around the facility. Floor markings were put in place within the production plant to ensure physical distancing. The number of persons per table at the canteen was reduced.Appropriate personal protective equipment (PPE) were provided and used by the staff of the factory clinic following training on how to use them. Work-related meetings were conducted virtually. A well-resourced room was designated as a holding centre for staff who may present with suspected symptoms of COVID-19.There was a collaboration between stakeholders in responding to these pockets of outbreaks. For the training institution, the facility authorities promptly notified the GHS, which kicked in the response immediately. Management of the institution was notified, and its emergency response team (ERT) was called to manage the response on the campus, also ably supported by the GFELTP team. The collaborative team worked with the institution management to provide boarding and lodging, education, psychological support, monitoring, testing and eventual discharge. The faculty leadership and school members from where the case index case originated were very supportive in providing sanitary and housekeeping logistics for the contacts while under quarantine on campus.Contacts to the index case who were living outside the campus were managed by the GHS directly. On average, all measures were instituted in less than a week.In the construction camp, the camp physician informed the district health directorate and right away, support was received from the regional health directorate to facilitate testing, contact tracing and data management. The human resource department of the construction firm was also pivotal in organising the affected workers throughout the process to undergo procedures, providing resources for infection prevention and control, and observing all protocols to reduce or avoid the spread of the infection in the camp. There were meetings between the facility management and the regional and health directorates to provide education, psychological support and monitoring. A GFELTP resident supported the district with contact tracing and all other containment processes. On average, all measures were instituted in less than a weekAt the factory, the management worked with the local government authority, the district health directorate, the regional health directorate and the public health directorate of the GHS. Specifically, The Deputy Director of Public Health (DDPH) for the region and the national Disease Surveillance Department of GHS was duly notified. In turn, they gave guidance to the district to help contain the infection. On their part, the factory made their facility available for test samples from workers and contacts to be taken there so that staff could easily commute to the testing site. Again, the team from GFELTP was very instrumental in providing human resources and other logistics to support testing and contact tracing. As part of the containment measures, the company had to operate at a limited capacity. Factory management had issues with this. This was partly due to delays in getting results from the laboratory to discharge those who potentially may have become negative to return to work. Some results took as long as three weeks. Whiles others were never returned. The team continued to facilitate improvement in turnaround time for test results by engaging the laboratories. Before the full reopening of the factory, a team from GHS, the local government office and field epidemiologists from the GFELTP conducted an assessment of the factory's preparedness for reopening. A report of the assessment was submitted to the regional health directorate and the local government office for approval to reopen.The team worked to support the factory to be ready to operate in a safe environment where all COVID-19 preventive protocols are in place and adhered to. Management were cooperative in getting all the required measures in place. On average, it took more than a week for measures to be put in place.We set out to examine how early case diagnosis, testing and contact tracing measures were deployed in response to COVID-19 outbreaks in three different settings in Ghana through collaboration between stakeholders.Early diagnosis, including testing, contact tracing and stakeholder engagement, proved to be important for managing these three cases of COVID-19 outbreak. Spread was reduced as there were no new cases beyond the primary contacts. Swift and prompt identification of contacts and contact tracing in COVID-19 response is essential due to the novelty of the disease and the new information obtained about it daily.6As a global pandemic, initial COVID-19 cases reported in countries were associated with a history of travel to another country. However, community or vertical transmission becomes inevitable when the country cannot contain imported cases due to the nature of the spread. In the case of the three scenarios described, two had travel history, making it easy to suspect COVID-19 on presentation with symptoms. However, in the case of the factory scenario, the patient had no travel history. Thus, though she presented with symptoms, COVID-19 was suspected only at the second visit, delaying diagnosis. Delay in diagnosis leads to further spread of the disease. There is a need to sensitise health workers on the possibility of community spread a disease or a pandemic starts immediately. This can lead to alertness and a high index of suspicion of cases.The laboratory plays a major role in responding to outbreaks. In the case of COVID-19, the laboratory's role in diagnosing cases cannot be overemphasised. This is because the standard for diagnosing a suspected case was a positive laboratory test result. In all three cases, laboratory testing of samples was a vital step in managing the situation.The turnaround time for all three cases scenarios ranged between 2 and 10 days and even in some cases, no results were obtained. There is a strong need to consider laboratory capacity when planning outbreak response strategies. In the factory, mass testing was a step towards curtailing the outbreak. However, due to the laboratory challenges, some results were not received. A longer turnaround time implies the potential spread of the disease since individuals whose samples were taken continue to go about their daily lives while waiting for their results. Lapses of this nature tend to impact the containment of the outbreak negatively. Positive cases never get to know their status, leading to further spread of the disease to their contacts.Again, suspected cases begin to agitate and feel uneasy waiting for their test results. Delay in response from laboratories and long turnaround time lead to delay in containing outbreaks and difficulty in managing the situation.Completeness and promptness of contact listing, identification and tracking and tracing of contacts of cases in COVID-19 response help in containing its spread. Ideally, contacts of a case should be identified and contacted 24 hours after case results have been declared.Finding secondary contacts was difficult due to the attitude of some of the primary contacts turned cases. One way to complete the process of identifying, tracking and tracing contacts could be through intense education on the essence of contact identification, quarantine, isolation, and other measures taken after testing. This can improve the willingness of contacts to be traced, quarantined or isolated.Stakeholder engagenment was a major feature in handling the outbreak in all three settings. Multi-sectorial engagement and collaboration with stakeholders is required to deal effectively with contact tracing and outbreak response. There was full support from the institutional management in the institution and at the construction camp while there were some hitches with support in the factory. This explains why contact tracing was effectively done in the two settings and not the latter. Given the role of local authorities in outbreak response, focus must be placed on building their capacity through education, training and constant communication using the right channels.The multi-sectorial team overseeing an outbreak reponse, needs to be managed daily by experts for an effective outcome.A major key for mitigating a pandemic is the implementation of a coordinated response which focuses on public health messaging and maintenance of situational awareness15Community understanding of COVID-19 is key to getting the exposed population to cooperate with the response team. In all three cases, education of cases, contacts and stakeholders ensured their cooperation throughout the outbreak period. . Approaches such as adopting a single channel of communication to the workers helped them feel secure and helped deal with issues of stigma. Also, engaging professional counsellors and psychologists to talk to cases and contacts allayed their fearsOne lesson learnt from the three settings was the effectiveness of protocols in confined settings. All protocols were fully observed in the construction camp and institution where people were camped and could easily be enforced. In a setting where people had no restrictions, enforcement of protocols was challenging. Confined settings were therefore found to help in enforcing protocols to curb the outbreak. A similar situation was seen in China, where strict confinement measures were instituted to help contain the outbreak. The rate of spread was seen to drop drastically.In addition, approaches used in each of the settings had to be modified based on the institution's set up and way of operation. Each setting has its unique practices, policies and process in place. Again, the educational and socioeconomic status can provide insight into disease transmission within and out of the workplace and further insight into how the outbreak can be successfully handled.18Recovery strategies are best adopted based on the location of the outbreak. What worked perfectly in an academic institution may not necessarily work in a factory or a construction camp. Therefore, there is the need to have flexible approaches that are modifiable based on the location, setting, and nature of place the outbreak.From the three scenarios, the need for an emergency response plan and a team to implement it to be in place before the outbreak occurs is highlighted. Periodic simulation exercises can be done to test the readiness and capacity of the institution to deal with the situation. This is in line with the WHO policy for getting workplaces prepared in the face of COVID-19.19Tackling epidemics in this 21st century requires a multisectorial approach that incorporates the whole society. This is because, gradually, many diverse factors, including social, medical and economic are drivers of epidemics.20Prompt identification of cases leads to an early response with appropriate measures to curtail an outbreak.Long turnaround time for test results negatively impact outbreak containment measures.Laboratory capacity needs to be critically considered in situations of mass testing, with considerationPrompt and sustained stakeholder engagement and cooperation are important for quick response to the outbreak situation.Enforcement of restrictions and adherence to preventive protocols are essential to the containment of the outbreakIn every outbreak, a clear communication channel regarded by all stakeholders is essential for risk communication.An understanding of the context-specific issues in the application of epidemiological systems and protocols is very important for successful outbreak managementOne limitation of the study is possible recall bias as field notes were used, and in the heat of the outbreak, it is possible some facts were missed. We contacted stakeholders in the various settings for clarification and additional information during this write-up to address the gaps.Comparing all three settings, early diagnosis and prompt actions taken through multi-sectorial collaborations played a major role in controlling the outbreak. Early diagnosis, including prompt testing and release of results, identification, tracing and following up of cases and contacts, is essential in mitigating outbreaks. While there could be challenges due to the extent of the outbreak, the multi-sectoral stakeholder engagement approach involving cases, contacts, their communities, management of institutions and health workers is key to effective implementation of all outbreak response activities.


Foreign body aspiration is common in the pediatric age group, especially in males. Despite the high frequency of this potentially life-threatening event, it is not always easy to recognize it given the high variability of the clinical presentation and the potential of “pauci-symptomatic” inhalation. Moreover, a variable latency of the onset of symptoms since the moment of aspiration may be possible determining difficulties in the identification of the inhalation on an anamnestic basis. We describe the case of a 19-month-old boy who accessed the emergency room initially for a head trauma. The clinical evaluation, however, revealed an unexplained serious respiratory distress needing tracheal intubation. After our evaluation, we hypothesized that the severe respiratory distress determined an altered state of consciousness with following head trauma. The radiological findings raised the suspicion of foreign body aspiration for the presence of an atelectasis of the entire left lung. The computed tomography showed an abrupt interruption of the main bronchus at 12 mm from the hull. The following bronchoscopy identified an almond of 2 cm. We will review the literature to underline the diagnostic issues behind foreign body aspiration in children by highlighting the diagnostic clues that are helpful for emergency clinicians in the management of this condition. Foreign body aspiration (FBA) is a frequent problem in the pediatric age, being one of the most common causes of morbidity and mortality, especially in children under 3 years of age . The cliA 19-month-old boy was admitted to the Emergency Department because he fell from his baby feeding highchair. This fall occurred in apparent well-being, without the presence of anticipatory signs or symptoms. First, he fell on his gluteus and then he banged his head (occiput) on the ground. He presented with vomiting (three episodes) and he was very irritable. His respiratory rate and heart rate were >60 breaths and >150 beats per minute, while oxygen saturation was <80%. Upon physical examination, the child was hydrated and conscious, but irritable. More importantly, we noted subcostal retractions, and, at the auscultation, decreased breath sounds in the left basal part of chest. The patient was ventilated with an AMBU balloon connected to an oxygen source and monitored with a pulse oximeter. Despite our intervention, oxygen saturation fell below 70% and the more we ventilated, the more the saturation dropped down. The lung ultrasound  showed tThe patient had never consumed almonds or other nuts before and in this circumstance ingested the almond by chance.The baby had a progressive clinical improvement, and after 24 h, he was extubated and discharged from intensive care to be admitted to the general pediatrics ward for a few days with gradual and a total respiratory function recovery.FBA is a life-threatening condition for young patients. FBA is common especially between 1 and 3 years of age and our patient fell within this age range. Accordingly, Midulla et al. examined 70 patients undergoing bronchoscopy for FBA and found that 63 (90%) patients were less than 3 years old and 6 (8.6%) were even less than 1 year old. The majority of these patients  were of the male gender [The higher incidence in the first years of life is probably related to the different behavior that children have in this period, as they are used to putting small objects into their mouths and they often cry and shout while parents try to feed them. Moreover, their molars are not yet developed, so they are not able to chew properly. Of note, an immature neuromuscular mechanism of airway protection represents a further contributing factor.It is also widely documented that aspiration of a foreign body is a very dangerous condition for the life of young patients. With the improvement of diagnostic and treatment techniques, the mortality rate has decreased remarkably . In factSeveral different aspirated foreign bodies have been reported, both organic and inorganic. The most common aspirated foreign body is food, especially dried nuts or melon and sunflower seeds. The latter is more frequent in Middle Eastern countries, while nuts or inorganic bodies, such as plastic pieces of toys or coins, are mostly seen in Western countries. These differences are probably related to different cultural habits . Other uOn the other hand, the localization in the left main bronchus as occurred in our case is less frequent compared to the localization in the right bronchus. Midulla et al., indeed, found that out of the 70 patients diagnosed with FBA, in 42 (60%), the foreign body was located in the right bronchial tree, in 23 (32.8%) the foreign body was located in the left bronchus, in three patients (4.3%) it involved the right and the left lung, and in two children (2.9%) the foreign body was located just below the vocal cords . It coulWhen the foreign body has a larger diameter, it is more likely to obstruct the higher portions of the airways such as the larynx or trachea, and in this case, the symptoms appear immediately after inhalation with signs of suffocation. In these cases, it is necessary to intervene quickly with first aid maneuvers. If the foreign body has a smaller diameter, then it is more likely to wedge in the more sloping portions of the bronchial tree and the most common symptoms and signs are coughing, localized wheezing and decreased localized breath sounds . NeverthIn general, symptoms can occur within 8 h of inhalation, as well as several days later, in some cases even after 180 days . We can In our case, the mother initially brought the patient to the emergency room for a head injury, without dwelling on the obvious respiratory issues. Furthermore, she reported no potential previous inhalation episodes, and only after the almond was found, she began to remember what may have happened. Due to an in-depth medical history, she informed us that the baby was likely to have inhaled the almond seven days earlier when he accidentally took the almond. The patient, in fact, had never consumed almonds or other nuts before.In this case, we faced a diagnostic challenge, as we were disoriented by the reported head trauma, and we found the presence of respiratory distress that could not be traced back to a definite cause. In the case of our baby, it is possible that we inadvertently excluded the left lung at the time of ventilation as we were unaware of the underlying cause. However, our management would not have contravened the American Heart Association’s Pediatric Advanced Life Support (PALS) guidelines, according to which in case of a history of certain inhalation and the child stops breathing, precise ventilation is required in order to engage the foreign object in the main bronchus and to be able to take advantage of the patency of the other bronchus for the cardiopulmonary resuscitation (CPR).In our case, the radiological examination was very suggestive, but the bronchoscopy was decisive for the diagnosis by allowing the identification and removal of the almond.Regarding the radiological presentation patterns occurring in case of FBA, there is current consensus on their variety, although some features have been encountered more frequently . Of the This case report allows us to underline that FBA often represents a major diagnostic challenge since its recognition is not always so immediate and can sometimes even be confused with other conditions, leading to a delay in diagnosis with potential unfavorable prognostic implications. For this reason, clinicians should always keep in mind FBA when facing unclear or persisting pulmonary symptoms .


Pastoralist community accounts for a significant portion of the population in Ethiopia. This community is different from majority of the country’s population. Access to TB prevention and control services is uneven in the country. The community TB program is designed to improve the access. Exploring the program performance from the perspectives of its implemters in a pastoral setting remains important.We conducted a qualitative study using an interpretive description method in the pastoralist community setting of Ethiopia. Study participants were recruited from geographically dispersed areas. We collected data through in-depth interview using semi-structured interview guides and audio recordings during February 01–30, 2020. The guides were developed in consultation with TB program experts and clinicians treating TB patients in the study area. Notes were taken at the interviews to enrich transcription of the data. Principal investigator conducted the interview. The subsequent interviews were informed by emerging ideas from forgoing interview transcriptions and continued until data saturation was achieved.One hundred and fifty six codes, nine categories and three themes emanated. The first theme was inadequate community TB performance and some of its codes include inadequate presumptive TB case identification and compromised directly observed treatment short course service delivery. The second theme was factors contributing to the program performance. Community factors, lack of physical access to health facilities and indirect non-medical cost were some categories under this theme. The final theme was suggested solutions; and its categories include a need for active community involvement and modification of service delivery approaches.Community TB performance was inadequate in the pastoralist community. Multifaceted factors contributed to the inadequate program performance. Socioeconomic and access related factors were major contributers. Aligning the program to the context of the pastoralist community setting is required to improve the performance. Tuberculosis (TB) have been declared to be a global public health emergency by the world health organization (WHO) nearly three decades ago in 1993. Human immunodeficiency virus (HIV) and the emergence of multidrug resistant TB (MDR TB) fuelled the pandemic and complicated its prevention and control efforts . HoweverPastoral communities of Ethiopia occupy 61 % of the total land mass and 97 % of Ethiopian pastoralists found in lowland areas of Afar, Somali, Oromiya, and Southern Nations Nationalities and peoples’ region. In spite pastoralareas have a significant role in the national economy, yet very little consideration was given to pastoral development and policy makers often neglect them, focusing on the interests of agriculture and urban people , 11. TheThis study was conducted in a pastoral community of the Borena zone in Ethiopia. Pastoralist community covers 12–15 % of the total population of the country , 14, 15.In this study, we used an interpretive description method which is one form of the generic qualitative research approaches , 18. ThiStudy participants were CHWs, called Health extension workers in Ethiopia. We recruited health posts haphazardly from geographically dispersed areas, in terms of distance and direction from the centre, of Borena zone. In the selected area, where there were more than one CHWs available, one with longer work experience was selected purposively for the interview. This approach is believed to facilitated unbiased selection of the study participants as the Borena zone is a homogeneously pastoral area with almost similar livelihood and health care access. In cases where two or more community health worker work in the same health post, one of them was interviewed. Among them, one with long work experience of the area was given priority to be interviewed for better information.Data were collected through in-depth interview using semi-structured interview guides Table  and audiData analysis was done concurrently with the data collection using a Microsoft office word processor . InterviTwenty two community health workers, also called health extension worker, who had three or more years of work experience at the time of interview were included in the study. The age range of the interviewee was between 20 and 30 years. Eight of them were trained to level four while the other were to level three .Community health workers are responsible to provide DOTs services at their respective HPs. Patients residing in the catchment area of the HP who are started on anti TB treatment in higher heath facilities such as health centre and hospitals are referred to their respective HPs for the treatment refilling and adherence monitoring. As per the national guidelines of the country, the drugs are given in the morning under the supervision of CHWs. In this study, many study participants witnessed the compromise in the DOTs service provision due to multiple reasons to be presented in the subsequent parts of the study. Examples of quotes that elaborate the theme and categories under it, taken from the statements of the study participants, are given below Table .Table 4From the total 156 significant information or codes identified, 125 were categorized under the five categories of this theme. The five categories, emerged under this theme and each of which contain a number of codes were community, physical access, CHWs, direct non medical cost and referral health facilities related factors. Study participants mentioned a lot of information corresponding to each category , lack of transport facility, difficult weather condition and hard to reach catchment population.A couple of codes emerged related to the CHWs from the analysis. One of them was the lack of commitment to the work by the CHWs. That is, some of the CHWs got disappointed with multiple challenges they have been facing and lack improvement in the situation, they tend to have minimal courage to work to achieve the intended goals of the program. Most CHWs do not have at least locally appropriate living room in the work area and daily travel from distant living area. Most of them are female and have their own children to care. Work overload is another repeatedly mentioned code under this category. They have to conduct community home visits and provide selected services at the HP including DOTs services which should be given on a daily basis. In such a pastoralist community, mothers have much responsibility to take care of their children besides the health service provision to community in a setting. The transport cost is one of the most frequently mentioned significant information under this category. In the community where health care seeking practice is low and lack of transportation facility. Unaffordable transport cost if they find one, is major problem contributing to poor performance of the community TB in the current study setting.Laboratory facility, long Lab test turnaround time and lack of appropriate health care provider in the referral health facilities are significant information mentioned in this category. These conditions are believed to discourage presumptive TB cases from accepting referrals from the CHWs.Community health workers are the actual implementors of the community TB program. Noticing solutions they suggest is important for the program. Under the theme of suggested solutions, two categories of significant information emerged. Each of the categories is presented as follows Table .Table 6Pastoral community has its own structural organization. For example, in the current study setting, the community have village specific community leaders and methods of communication. Local leaders are highly acceptable by the community members. Therefore, using Community own social structure helps to realize active involvement of the community members and hence important to communicate necessary health education messages. This community involvement can be extended to the level of starting home based TB treatment delivery with the close supervision of trained treatment supporters selected by the community.The other category, emerged under this theme, was the need for modification of community TB services approach. In this category, significant information repeatedly mentioned by the study participants includes further decentralization of the activities such as outreach services to be conducted on a regular basis in coordination with health centre staff and establishing TB sputum slide fixing at the HP. If appropriate capacity building training is given, CHWs can take samples and send the specimen for laboratory testing so that direct non-medical cost to patients could be averted and in turn, access to the service will be improved.The above five categories of codes are organized and finally three themes emerged from the analysis. The three themes, interplays between sub-themes and their implications were illustrated using a diagram Fig. .Fig. 1SDecentralizing health care services, through the implementation of health extension program, including community TB, was designed to improve access to the primary health care services. In this study, we explored the performance of the community TB, which is one of the packages decentralized to the CHWs in the pastoral community setting. The first theme emerged in this study was the low performance where CHWs’ contribution in presumptive TB case identification and DOTs provision is not achieving the goals. One indicator of the poor performance was inadequate presumptive TB case identification and referral which consistent with other study reports , 31. Ina Data collection by single experienced data collector and efforts made to increase trustworthiness of the analysis and hence of the result, such as members checking, validation of transcripts against audio-recordings and field notes by two independent experts, use of language spoken by the study participants and immediate transcription following the interview were some of the strengths of the study. In addition, participants from all levels of training as community health workers were selected to include all ranges of views. The sex difference between the interviewer and most of the interviewee could have biased the responses. But, the interviewer baracketed himself to minimize the potential bias.In this study, we found out that community TB performance is low in the pastoralist community. There are many factors contributing to the low performance and aligning the approach in the context of the pastoralist community setting is suggested as a solution to improve the performance. Therefore, designing and implementing context appropriate approaches such as patient centred and modified DOTs with community treatment supporters is required to achieve the intended goals of the END TB strategy in the pastoral community.