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It is unclear why the severity of influenza varies in healthy adults or why the burden of severe influenza shifts to young adults when pandemic strains emerge. One possibility is that cross-protective T cell responses wane in this age group in the absence of recent infection. We therefore compared the acute cellular immune response in previously healthy adults with severe versus mild pandemic H1N1 infection. 49 previously healthy adults admitted to the National Hospital of Tropical Diseases, Viet Nam with RT-PCR-confirmed 2009 H1N1 infection were prospectively enrolled. 39 recovered quickly whereas 10 developed severe symptoms requiring supplemental oxygen and prolonged hospitalization. Peripheral blood lymphocyte subset counts and activation (HLADR, CD38) and differentiation (CD27, CD28) marker expression were determined on days 0, 2, 5, 10, 14 and 28 by flow cytometry. NK, CD4 and CD8 lymphopenia developed in 100%, 90% and 60% of severe cases versus 13% (p<0.001), 28%, (p = 0.001) and 18% (p = 0.014) of mild cases. CD4 and NK counts normalized following recovery. B cell counts were not significantly associated with severity. CD8 activation peaked 6-8 days after mild influenza onset, when 13% (6-22%) were HLADR+CD38+, and was accompanied by a significant loss of resting/CD27+CD28+ cells without accumulation of CD27+CD28- or CD27-CD28- cells. In severe influenza CD8 activation peaked more than 9 days post-onset, and/or was excessive (30-90% HLADR+CD38+) in association with accumulation of CD27+CD28- cells and maintenance of CD8 counts. Severe influenza is associated with transient T and NK cell deficiency. CD8 phenotype changes during mild influenza are consistent with a rapidly resolving memory response whereas in severe influenza activation is either delayed or excessive, and partially differentiated cells accumulate within blood indicating that recruitment of effector cells to the lung could be impaired.

In this study, we present a multi-objective optimization framework formulated as mixed-integer second-order cone programming (MISOCP) to restore electricity distribution systems following fault clearance. The proposed model incorporated two objective functions: Minimizing the total unserved load while considering load prioritization and reducing the frequency of switching actions of sectionalizing devices. The model's constraints included preserving the radial configuration of the reconfigured distribution grid, power flow equations, PV models of distributed energy resources, voltage-dependent load models, node voltage limits, and branch power flow limits. The presented optimization framework was converted from the optimization model formulated as mixed-integer nonlinear programming (MINLP), achieved through the reformulation of nodal power balance equations as second-order cone constraints and the approximate formulation of the voltage-dependent load models for conic solvers. Pareto optimal solutions were then achieved through a heuristic approach. The proposed optimization framework was validated on the enhanced IEEE 33-node test feeder and a Vietnamese real 190-bus distribution grid, utilizing the CPLEX solver under the GAMS programming language. We also explored various fault location scenarios across the distribution grid and evaluated the influence of the different objective functions, as well as two load models, on the optimization outcomes.

The integration of artificial intelligence (AI) into healthcare systems within low-middle income countries (LMICs) has emerged as a central focus for various initiatives aiming to improve healthcare access and delivery quality. In contrast to high-income countries (HICs), which often possess the resources and infrastructure to adopt innovative healthcare technologies, LMICs confront resource limitations such as insufficient funding, outdated infrastructure, limited digital data, and a shortage of technical expertise. Consequently, many algorithms initially trained on data from non-LMIC settings are now being employed in LMIC contexts. However, the effectiveness of these systems in LMICs can be compromised when the unique local contexts and requirements are not adequately considered. In this study, we evaluate the feasibility of utilizing models developed in the United Kingdom (a HIC) within hospitals in Vietnam (a LMIC). Consequently, we present and discuss practical methodologies aimed at improving model performance, emphasizing the critical importance of tailoring solutions to the distinct healthcare systems found in LMICs. Our findings emphasize the necessity for collaborative initiatives and solutions that are sensitive to the local context in order to effectively tackle the healthcare challenges that are unique to these regions. The integration of AI into healthcare systems in low-middle income countries faces significant challenges. Here, authors show that AI models developed in high income countries can be adapted for LMICs using methods like missing feature imputation and transfer learning.

  Abbreviations: HAI, healthcare-associated infection; ICU, intensive care unit; PPS, point prevalence survey; STGs, standard treatment guidelines; VINARES, Viet Nam Resistance; WHO, World Health Organization Provenance: Not commissioned; externally peer reviewed. Traditional HAI risks are recorded, as well as those specific to the Vietnamese healthcare system, for example, the hands-on involvement of family in patient care, the large numbers of staff and students accessing the ICU, and the high prevalence of tetanus patients requiring extended periods of invasive mechanical ventilation. GARP, Global Antibiotic Resistance Partnership; LiU, Linköping University; OUCRU, Oxford University Clinical Research Unit; UK NEQAS, United Kingdom National External Quality Assessment Service.

Abstract Background Ventilator-associated pneumonia (VAP) is the commonest hospital-acquired infection (HAI) in intensive care. In Asia, VAP is increasingly caused by resistant gram-negative organisms. Despite the global antimicrobial resistance crisis, the epidemiology of VAP is poorly documented in Asia. Methods We systematically reviewed literature published on Ovid Medline, Embase Classic, and Embase from 1 January 1990 to 17 August 2017 to estimate incidence, prevalence, and etiology of VAP. We performed a meta-analysis to give pooled rates and rates by country income level. Results Pooled incidence density of VAP was high in lower- and upper-middle-income countries and lower in high-income countries (18.5, 15.2, and 9.0 per 1000 ventilator-days, respectively). Acinetobacter baumannii (n = 3687 [26%]) and Pseudomonas aeruginosa (n = 3176 [22%]) were leading causes of VAP; Staphylococcus aureus caused 14% (n = 1999). Carbapenem resistance was common (57.1%). Conclusions VAP remains a common cause of HAI, especially in low- and middle-income countries, and antibiotic resistance is high. Ventilator-associated pneumonia (VAP) is the commonest infection in intensive care. Our systematic review and meta-analysis found VAP incidence rates to be highest in low-income compared with high-income countries in Asia. Antimicrobial resistance rates are also alarmingly high.

Nursing professional is one of the most stressful jobs, particularly during the COVID-19 pandemic. When caring for COVID-19 patients, nurses face challenging conditions and limited resources, as well as the fear of infecting themselves and their families, putting them at risk for depression, anxiety, and insomnia. The purpose of this study was to determine the frequency, sources, and risk factors for occupational stress among clinical nurses caring for COVID-19 patients in a Vietnamese tertiary hospital. A cross-sectional survey was conducted among all clinical nurses (184 nurses) at a tertiary hospital in Vietnam from March 15 to April 15, 2021. A questionnaire was used for collecting data. Data analysis was done by descriptive statistics, bivariate and multivariate logistic regressions. Risk factors were identified by adjusted odds ratio with 95% confidence interval and P values less than 0.05. The survey was completed by 89.7% (165/184) of clinical nurses. Most participants were female (85.5%) and ≤ 40 years old (97.6%). Overall, participants reported a medium stress level with an Extended Nursing Stress Scale (ENSS) mean score of 1.79 points, and 32.1% had occupational stress. Prevalence of occupational stress among participants caring for COVID-19 patients (34.0%) was not statistically significant difference with that among those who did not (29.4%). Nurses' occupational stress in emergency and intensive care units (50.0%) was substantially higher than that in the other departments (11.7%). The most stressors for participants were difficulties connected to inadequate emotional preparedness, patients and families, and death and dying, with subscale mean scores of 1.97, 1.88, and 1.88 points, respectively. In multivariate analysis, working at an emergency and intensive care unit (OR 4.97), usually or more frequently feeling heavy duty for patients (OR 3.17), and income decrease (OR 3.03) were risk factors associated with occupational stress. One-third of clinical nurses at a tertiary hospital experienced occupational stress, with highest rate occurred at emergency and intensive care units. Nurses' working conditions at emergency and intensive care units should be essentially addressed to improve nurses' occupational stress.

Candidozyma auris is an emerging health threat, especially in healthcare settings due to its resistance to several classes of antifungals leading to high mortality. In Viet Nam, the burden of this fungal pathogen is unknown because of little available data. In this report, six cases with C. auris isolation between 2023 and 2024 at the National Hospital for Tropical Diseases, a tertiary referral hospital in northern Viet Nam, are described. Our findings highlight the first report of C. auris in the north of Viet Nam and underscore the importance of prevalence surveys in the future.

Vietnam is a lower middle-income country with no national surveillance system for hospital-acquired infections (HAIs). We assessed the prevalence of hospital-acquired infections and antimicrobial use in adult intensive care units (ICUs) across Vietnam. Monthly repeated point prevalence surveys were systematically conducted to assess HAI prevalence and antimicrobial use in 15 adult ICUs across Vietnam. Adults admitted to participating ICUs before 08:00 a.m. on the survey day were included. Among 3287 patients enrolled, the HAI prevalence was 29.5% (965/3266 patients, 21 missing). Pneumonia accounted for 79.4% (804/1012) of HAIs Most HAIs (84.5% [855/1012]) were acquired in the survey hospital with 42.5% (363/855) acquired prior to ICU admission and 57.5% (492/855) developed during ICU admission. In multivariate analysis, the strongest risk factors for HAI acquired in ICU were: intubation (OR 2.76), urinary catheter (OR 2.12), no involvement of a family member in patient care (OR 1.94), and surgery after admission (OR 1.66). 726 bacterial isolates were cultured from 622/1012 HAIs, most frequently Acinetobacter baumannii (177/726 [24.4%]), Pseudomonas aeruginosa (100/726 [13.8%]), and Klebsiella pneumoniae (84/726 [11.6%]), with carbapenem resistance rates of 89.2%, 55.7%, and 14.9% respectively. Antimicrobials were prescribed for 84.8% (2787/3287) patients, with 73.7% of patients receiving two or more. The most common antimicrobial groups were third generation cephalosporins, fluoroquinolones, and carbapenems (20.1%, 19.4%, and 14.1% of total antimicrobials, respectively). A high prevalence of HAIs was observed, mainly caused by Gram-negative bacteria with high carbapenem resistance rates. This in combination with a high rate of antimicrobial use illustrates the urgent need to improve rational antimicrobial use and infection control efforts.

Sedation assessment, spontaneous awakening and breathing trials are evidence-based practices which can minimise harm from ventilation and sedation of critically ill patients. There are known difficulties in implementing these processes which are likely to be exacerbated in low-resource settings. This study aimed to describe current delivery of these care processes in three intensive care units in Vietnam; identify barriers and facilitators to their delivery; and describe local capacity for improvement. We conducted a prospective rapid evaluation between 01/11/2021 and 31/12/2023 comprising registry-enabled measurement of daily care processes, process mapping, observations, focus group discussions, semi-structured interviews and a structured assessment of local capacity for improvement. Contextual determinants of care quality were analysed using the Consolidated Framework for Implementation Research. Organisational capacity for improvement was analysed using the Model for Understanding Success in Quality. Sedation was assessed qualitatively rather than using systematic tools. Spontaneous Awakening and Breathing Trials were both performed according to individual doctors' clinical judgement in a non-protocolised manner. Barriers to delivering these processes included the lack of locally-adapted protocols, perceived safety concerns exacerbated by staffing shortages and lack of familiarity due to confusing terminology. Facilitators to improvement included quality improvement champions, registry-enabled audit and feedback, training, and partnerships within and between hospitals. We identified opportunities to improve sedation and ventilation in the three study settings in Vietnam. The barriers to delivering the care processes we studied echoed those reported in high-income countries, but were exacerbated by local contextual factors such as staffing shortages and differences in professional roles. We developed recommendations for future improvement projects: implementing setting-adapted protocols, standardising terminology to improve documentation, engaging clinical staff with feedback, identifying champions, educate staff regarding the clinical processes and quality improvement and leverage existing internal expertise. These recommendations may have applicability to other care processes and/or settings.

Background: Catheter-associated urinary tract infections (CAUTIs) are among the most prevalent healthcare-associated infections (HAIs) globally, contributing to increased morbidity, prolonged hospital stays, and increased healthcare costs. Interventions that support prompt removal of the urinary catheter are evidence-based actions to effectively reduce CAUTI rates. 1 Objective: At the National Hospital of Tropical Disease (NHTD), catheter removal interventions in the intensive care unit (ICU) were implemented using quality improvement (QI) methodology to reduce CAUTI incidence and urinary catheter device utilization. Methods: Training was performed for ICU clinical staff with knowledge checks before and after the program. A bedside visual reminder of CAUTI risk and checklist to assess catheter need were implemented. Weekly compliance of provided visual reminders and checklists were measured using a simple audit tool. Device utilization ratios (DURs, ratios of device days to patient days), and CAUTI incidence rates (per 1,000 device days) were collected at baseline (July–September 2018) and quarterly thereafter until June 2019. Statistical significance was determined by an independent t test. Results: In the first quarter (October–December 2018), the CAUTI incidence rate decreased from 8.9 to 1.3 per 1,000 device days ( P = .036). The ICU staff trained in CAUTI prevention, mean knowledge scores before and after training increased from 68% to 87%. The DUR decreased slightly from 0.59 to 0.55 after the first-quarter training then steadily increased in the following quarter (0.60; January–March 2019) and after the intervention (0.54; April–June 2019). CAUTI incidence rates also increased but were still lower than at baseline: 4.8 and 6.3 per 1,000 days of device use. Compliance of reminders was 51% during the first quarter, increased slightly in the second quarter 62%, then decreased to 40% during the last quarter. The nurses’ adherence to the daily checklist remained stable (>75%). Conclusions: This CAUTI prevention project was the first use of quality improvement methodology to implement change at NHTD. A trend decrease in CAUTI was observed, though a greater decrease occurred at the beginning of the intervention. Limited compliance of daily reminders is likely reflected in no statistically significant decrease in DUR. Possibly, this quality improvement project raised awareness among clinicians to improve general CAUTI prevention practices in the ICU without decreasing DUR. Given limited compliance with reminder and checklists, the intervention will be revised during the next PDSA cycle to improve adherence. 1 Meddings J, Rogers MA, Krein SL, Fakih MG, Olmsted RN, Saint S. Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review. BMJ Qual Saf 2014;23:277–289. Funding: None Disclosures: None