The Emergence of Candida auris is Not Associated with Changes in Antifungal Prescription at Hospitals

Purpose

This study describes the emergence of Candida auris in Hong Kong, focusing on the incidence and trends of different Candida species over time. Additionally, the study analyzes the relationship between C. auris and antifungal prescription, as well as the impact of outbreaks caused by C. auris.

Patients and Methods

Data were collected from 43 public hospitals across seven healthcare networks (A to G) in Hong Kong, including Candida species culture and antifungal prescription information. Among 150,267 patients with 206,405 hospitalization episodes, 371,653 specimens tested positive for Candida species. Trends in Candida species and antifungal prescription were analyzed before (period 1: 2015 1Q to 2019 1Q) and after (period 2: 2019 2Q to 2023 2Q) the emergence of C. auris in Hong Kong.

Results

Candida albicans was the most prevalent species, accounting for 57.1% (212,163/371,653) of isolations, followed by Candida glabrata (13.1%, 48,666), Candida tropicalis (9.2%, 34,261), and Candida parapsilosis (5.3%, 19,688). C. auris represented 2.0% of all Candida species isolations. Comparing period 2 to period 1, the trend of C. albicans remained stable, while C. glabrata, C. tropicalis, and C. parapsilosis demonstrated a slower increasing trend in period 2 than in period 1. Other species, including C. auris, exhibited a 1.1% faster increase in trend during period 2 compared to period 1. Network A, with the highest antifungal prescription, did not experience any outbreaks, while networks F and G had 40 hospital outbreaks due to C. auris in period 2. Throughout the study period, healthcare networks B to G had significantly lower antifungal prescription compared to network A, ranging from 54% to 78% less than that of network A.

Conclusion

There is no evidence showing correlation between the emergence of C. auris and antifungal prescription in Hong Kong. Proactive infection control measures should be implemented to prevent nosocomial transmission and outbreak of C. auris.

Epidemiology of multidrug-resistant organisms before and during COVID-19 in Hong Kong

Background

The coronavirus disease 2019 (COVID-19) has influenced antimicrobial consumption and incidence of multidrug-resistant organisms (MDROs). We aimed to study the epidemiology of MDROs before and during the COVID-19 pandemic in Hong Kong.

Methods

With the maintenance of infection control measures, we described the trend of MDRO infections, including methicillin-resistant Staphylococcus aureus (MRSA), carbapenem-resistant Acinetobacter species (CRA), and extended-spectrum-beta-lactamase-(ESBL)-producing Enterobacterales, in a healthcare region with 3100-bed before (1 January 2016 to 31 December 2019, period 1) and during COVID-19 (1 January 2020 to 30 September 2022, period 2), together with the antimicrobial consumption using piecewise Poisson regression. The epidemiological characteristics of newly diagnosed COVID-19 patients with or without MDRO infections were analyzed.

Results

Between period 1 and 2, we observed a significant increase in the trend of CRA infections (P<0.001), while there was no significant increase in the trend of MRSA (P=0.742) and ESBL-producing Enterobacterales (P=0.061) infections. Meanwhile, a significant increase in the trend of carbapenems (P<0.001), extended-spectrum beta-lactam-beta-lactamase inhibitor combinations (BLBI) (P=0.045), and fluoroquinolones (P=0.009) consumption was observed. The observed opportunity (23,540 ± 3703 vs 26,145 ± 2838, p=0.359) and compliance (81.6% ± 0.5% vs 80.1% ± 0.8%, P=0.209) of hand hygiene per year was maintained. In a multivariable model, older age, male sex, referral from residential care home for the elderly, presence of indwelling device, presence of endotracheal tube, and use of carbapenems, use of BLBI, use of proton pump inhibitors and history of hospitalization in the past 3 months were associated with higher risks of infections by MDROs among COVID-19 patients.

Conclusion

Infection control measures may control the surge of MDROs despite an increasing trend of antimicrobial consumption.

Emotional Eating as a Mediator in the Relationship between Dietary Restraint and Body Weight

This study aimed to assess the relationships between routine and compensatory restraints and body mass index (BMI), as well as to explore the mediating role of emotional and external eating in the relationships between routine and compensatory restraints and BMI. Chinese adults aged ≥18 years with different weight statuses were invited to fill out an online questionnaire. Routine and compensatory restraints and emotional and external eating were assessed using the validated 13-item Chinese version of the Weight-Related Eating Questionnaire. Mediation analyses tested the mediation effects of emotional and external eating on the relationship between routine and compensatory restraints and BMI. In total, 949 participants (26.4% male) responded to the survey (mean age = 33 years, standard deviation (SD) = 14, mean BMI = 22.0 kg/m², SD = 3.8). The mean routine restraint score was higher in the overweight/obese group (mean ± SD = 2.13 ± 0.76, p < 0.001) than in the normal weight (2.08 ± 0.89) and underweight (1.72 ± 0.94) groups. However, the normal weight group scored higher in compensatory restraint (2.88 ± 1.03, p = 0.021) than the overweight/obese (2.75 ± 0.93) and underweight (2.62 ± 1.04) groups. Routine restraint was related to higher BMI both directly (β = 0.07, p = 0.02) and indirectly through emotional eating (β = 0.04, 95% confidence interval (CI) = 0.03, 0.07). Compensatory restraint was only indirectly related to higher BMI through emotional eating (β = 0.04, 95% CI = 0.03, 0.07).

Control of Healthcare-Associated Carbapenem-Resistant Acinetobacter baumannii by Enhancement of Infection Control Measures

Antimicrobial stewardship and infection control measures are equally important in the control of antimicrobial-resistant organisms. We conducted a retrospective analysis of the incidence rate of hospital-onset carbapenem-resistant Acinetobacter baumannii (CRAB) infection (per 1000 patient days) in the Queen Mary Hospital, a 1700-bed, university-affiliated teaching hospital, from period 1 (1 January 2007 to 31 December 2013) to period 2 (1 January 2014 to 31 December 2019), where enhanced infection control measures, including directly observed hand hygiene before meal and medication rounds to conscious patients, and the priority use of single room isolation, were implemented during period 2. This study aimed to investigate the association between enhanced infection control measures and changes in the trend in the incidence rate of hospital-onset CRAB infection. Antimicrobial consumption (defined daily dose per 1000 patient days) was monitored. Interrupted time series, in particular segmented Poisson regression, was used. The hospital-onset CRAB infection increased by 21.3% per year [relative risk (RR): 1.213, 95% confidence interval (CI): 1.162−1.266, p < 0.001], whereas the consumption of the extended spectrum betalactam-betalactamase inhibitor (BLBI) combination and cephalosporins increased by 11.2% per year (RR: 1.112, 95% CI: 1.102−1.122, p < 0.001) and 4.2% per year (RR: 1.042, 95% CI: 1.028−1.056, p < 0.001), respectively, in period 1. With enhanced infection control measures, the hospital-onset CRAB infection decreased by 9.8% per year (RR: 0.902, 95% CI: 0.854−0.953, p < 0.001), whereas the consumption of the extended spectrum BLBI combination and cephalosporins increased by 3.8% per year (RR: 1.038, 95% CI: 1.033−1.044, p < 0.001) and 7.6% per year (RR: 1.076, 95% CI: 1.056−1.097, p < 0.001), respectively, in period 2. The consumption of carbapenems increased by 8.4% per year (RR: 1.84, 95% CI: 1.073−1.094, p < 0.001) in both period 1 and period 2. The control of healthcare-associated CRAB could be achieved by infection control measures with an emphasis on directly observed hand hygiene, despite an increasing trend of antimicrobial consumption.

Feasibility and Acceptability of an Online WhatsApp Support Group on Breastfeeding: Protocol for a Randomized Controlled Trial

Background

Mobile health, the use of mobile technology in delivering health care, has been found to be effective in changing health behaviors, including improving breastfeeding practices in postpartum women. With the widespread use of smartphones and instant messaging apps in Hong Kong, instant messaging groups could be a useful channel for delivering breastfeeding peer support.

Objective

The aim of this paper is to study the feasibility and acceptability of an online instant messaging peer support group by trained peer counselors on improving breastfeeding outcome in primiparous women in Hong Kong.

Methods

A two-arm, assessor-blind, randomized controlled feasibility study will be conducted on 40 primiparous women with the intention to breastfeed. Participants are recruited from the antenatal obstetrics and gynecology clinic of a public hospital in Hong Kong and randomly assigned at a 1:1 ratio to either intervention or control group. The intervention group receives peer support in an online instant messaging group with trained peer counselors on top of standard care, whereas the control group receives standard care. Breastfeeding outcome will be assessed for 6 months post partum or until weaned. The breastfeeding status, the proportion and duration of exclusive and any breastfeeding in each group, and the self-efficacy and attitude of participants will be assessed. The feasibility and acceptability of the study would also be assessed in preparation for a full randomized controlled trial.

Results

This study (protocol version 1 dated January 5, 2021) has been reviewed and approved by the institutional review board of the University of Hong Kong, Hospital Authority Hong Kong West Cluster (reference UW 21-039), on January 26, 2021. Data collection is ongoing and expected to be completed in December 2021. The findings will be updated on clinical trial registry and disseminated in peer-reviewed journals.

Conclusions

This study aims to assess the feasibility and effectiveness of an online instant messaging peer support group in improving the breastfeeding outcome of primiparous women in Hong Kong. Its findings could inform the feasibility of a full-scale trial with this intervention design.

Trial Registration

ClinicalTrials.gov NCT04826796; https://clinicaltrials.gov/ct2/show/NCT04826796

International Registered Report Identifier (IRRID)

DERR1-10.2196/32338

Evaluating online learning engagement of nursing students

BACKGROUND

Previous studies suggest that increased learning satisfaction may encourage learning engagement in an online learning environment.

OBJECTIVES

To evaluate the level of learning engagement and its relationship with students' perceived learning satisfaction in an online clinical nursing elective course.

DESIGN

A prospective interventional study.

SETTINGS

A nursing course was converted to an online format because of the coronavirus disease COVID pandemic.

PARTICIPANTS

Part-time post-registration nursing undergraduates enrolled in an elective online clinical course.

METHODS

Related teaching and learning strategies were deployed in the course using the Community of Inquiry framework. All students who completed the course were invited to complete an online survey that included a validated Online Student Engagement questionnaire (OSE). Pearson's correlations were used to determine the association between perceived learning satisfaction and learning engagement. A logistic regression model was used to explore the associations of gender, age, working experience and perceived learning satisfaction with higher learning engagement.

RESULTS

The questionnaires were completed by 56 of 68 students (82%). The Pearson's correlation coefficient between the mean perceived learning satisfaction and OSE scores was 0.75 (p < .001). Twenty-five students (45%) were identified as highly engaged, using a cut-off of ≥3.5 for the mean OSE score. The mean perceived learning satisfaction (SD) score differed significantly between highly engaged and not highly engaged students [4.02 (0.49) vs. 3.27 (0.62), p < .001]. The logistic regression model showed that a greater perceived learning satisfaction [adjusted odds ratio (OR): 17.2, 95% C.I.: 3.46-86.0, p = .001] was associated with an increased likelihood of higher learning engagement, and >1 year of working experience (adjusted OR: 0.11, 95% C.I.: 0.01-0.89, p = .0039) was associated with a decreased likelihood of higher learning engagement.

CONCLUSIONS

The study findings suggest that perceived learning satisfaction predicts learning engagement among nursing students in this online learning course.

Psychological Impact of the COVID-19 Pandemic on Licensed Full-Time Practicing Nurses Undertaking Part-Time Studies in Higher Education: A Cross-Sectional Study

Frontline nurses face an unpreceded situation with the coronavirus disease (COVID-19) pandemic, and many report suffering from physical and psychological stress. This online, cross-sectional survey used questionnaires, such as the Generalized Anxiety Disorder (GAD-7) questionnaire, the Patient Health Questionnaire (PHQ-2), the Connor–Davidson Resilience Scale, stress-related questions, and Brief Coping Orientation to Problems Experienced (Brief-COPE), to determine the psychological impact of COVID-19 on licensed full-time practicing nurses undertaking part-time studies in higher education. Recruitment commenced from August to September 2020; 385 students were approached, and 124 completed the survey (response rate: 32%). Most of the respondents were frontline nurses working in public sectors (89.5%), 29% of whom reported symptoms of depression, and 61.3% reported mild to severe levels of anxiety. The GAD-7 was significantly associated with the resilience score (β = −0.188; p = 0.008) and exhaustion (β = 0.612; p < 0.001). The PHQ-2 was significantly associated with ‘anxiety about infection’ (β = 0.071; p = 0.048). A lower anxiety level was significantly associated with a higher resilience level and a lower level of exhaustion, and a lower depression level was significantly associated with a lower anxiety about infection. Nursing programs incorporating resilience building may mitigate psychological distress of the study population.

Wuhan's experience in curbing the spread of coronavirus disease (COVID-19)

BACKGROUND

Since December 2019, coronavirus disease (COVID-19) has affected over 50 000 people in Wuhan, China. However, the number of daily infection cases, hospitalization rate, lag time from onset to diagnosis date and their associations with measures introduced to slow down the spread of COVID-19 have not been fully explored.

METHODS

This study recruited 6872 COVID-19 patients in the Wuchang district, Wuhan. All of the patients had an onset date from 21 December 2019 to 23 February 2020. The overall and weekly hospitalization rate and lag time from onset to diagnosis date were calculated. The number of daily infections was estimated by the back-projection method based on the number of daily onset cases. Their association with major government reactions and measures was analyzed narratively.

RESULTS

The overall hospitalization rate was 45.9% (95% CI 44.7 to 47.1%) and the mean lag time from onset to diagnosis was 11.1±7.4 d. The estimated infection curve was constructed for the period from 14 December 2019 to 23 February 2020. Raising public awareness regarding self-protecting and social distancing, as well as the provision of timely testing and inpatient services, were coincident with the decline in the daily number of infections.

CONCLUSION

Early public awareness, early identification and early quarantine, supported by appropriate infrastructure, are important elements for containing the spread of COVID-19 in the community.

Low awareness of high sodium intake among older Chinese people

Awareness is one of the first steps in a lifestyle modification process. Since older adults are at a higher risk of hypertension, maintaining low sodium intake is of utmost importance. Yet, it is uncertain if older adults have an awareness of their sodium intake. This study aimed to explore self-perceived sodium intake among older Chinese people and compare it with various measures of sodium intake. A cross-sectional study was conducted in Hong Kong in 2015. Data were collected from 24-h urinary sodium excretion (UNa24) measurements, dietary sodium intake by 24-h diet recalls and self-perceived salt intake levels among the older Hong Kong population. Kappa statistics and a paired t-test were used to compare the different measures. Fifty-nine participants provided complete 24-h urine samples. The mean (±SD) UNa24 of participants was 2846 ± 1253 mg, of which 74.6% exceeded the recommended daily sodium intake. About 87.8% of participants with UNa24 values >2000 mg perceived their sodium intake as too little or just right. The kappa statistic between UNa24 and self-perception was insignificantly different from zero (κ = -0.003, p-value = 0.909). The UNa24 estimates were significantly higher than those estimated from the 24-h diet recalls by 1203 mg (p-value <0.001). The findings imply that the low awareness of excessive sodium intake should be raised among older people to promote a healthy intake of sodium.

The Contribution of Sense of Community to the Association Between Age-Friendly Built Environment and Health in a High-Density City: A Cross-Sectional Study of Middle-Aged and Older Adults in Hong Kong

Sense of community may be shaped by the quality of the physical environment and has potential health implications. Based on a survey of 2,247 community-dwelling middle-aged and older adults living in Hong Kong, we tested the mediation effect of sense of community on the relationship between the quality of the built environment and physical and mental health using path analysis. The quality of the built environment was indicated by the age-friendliness of outdoor spaces and buildings. No direct association was found between the built environment and health outcomes, although age-friendly outdoor spaces were associated with better mental health. Sense of community mediated 14% of the total effect between outdoor spaces and mental health and 44.8% of the total effect between buildings and physical health, underscoring the importance of accommodating the social needs of middle-aged and older people in urban development in high-density cities.

Investigating Risk Factors for Falls among Community-Dwelling Older Adults According to WHO's Risk Factor Model for Falls

OBJECTIVES

The World Health Organization developed the Risk Factor Model for Falls to describe fall risks in a comprehensive manner. However, there was a lack of study adopting such framework in quantifying falls risk from different factors in a single model. Therefore, this study examined the risk factors from four domains in the Risk Factor Model for Falls among older adults.

DESIGN

Secondary data analysis of 10-year assessment records of the Minimum Data Set-Home Care instrument.

SETTING

Hong Kong.

PARTICIPANTS

89,100 community-dwelling adults aged 65 and over who first applied for publicly funded long-term care services from 2005 to 2014.

MEASUREMENTS

The Minimum Data Set-Home Care instrument was used to ascertain older adults' care needs and match them with appropriate services. Additionally, meteorological records from the same period were extracted from the Hong Kong Observatory. The logistic regression model was used to examine risk factors and their associations with falls.

RESULTS

In total 70 factors were included in the analysis, of which 37 were significantly associated with falls. Behavioral risk factors generally had greater odds ratios of falling, as compared with biological, socioeconomic, and environmental factors. Out of all significant factors, functional status, alcohol drinking, and locomotion outdoors had the largest odds ratios of falling.

CONCLUSION

Behavioral risk factors for falls are of remarkable influence yet are modifiable among older adults. Hence, falls prevention programs may need to prioritize addressing these factors.

The Prevalence and Negative Effects of Thoracic Hyperkyphosis on Chinese Community-Dwelling Older Adults in Wuhan, Hubei Province, China

BACKGROUND

Globally, 20% to 50% older adults have been found to have thoracic hyperkyphosis. Negative effects on physical performance have been reported. However, there has been a lack of research on the prevalence and negative effects of thoracic hyperkyphosis among Chinese community-dwelling elderly.

DESIGN

A cross-sectional study.

SETTING

The communities in Wuhan, China.

PARTICIPANTS

Three hundred and ninety-five Chinese community-dwelling older adults with thoracic hyperkyphosis.

MEASURES

Chinese community-dwelling older adults aged 60 or above lived in Wuhan, China from August to December 2018 were recruited for spine and physical performance assessments. The primary outcome was the prevalence of thoracic hyperkyphosis estimated according to the angle of kyphosis which was measured by manual inclinometers. The secondary outcomes were the effects of thoracic hyperkyphosis on physical performance measured by One-leg Standing Test (OLS), Timed Up AND Go Test (TUG), Chest Expansion Test (CE), Six Minutes Walking Test (6MWT), and Farsi Version of Functional Gait Assessment (FGA). The socio-demographic and health-related information were collected by a questionnaire.

RESULTS

Among 395 participants, the mean angle of kyphosis was 49.0° ± 10.5°, 75.2% of participants had the angle of kyphosis >40° (i.e., having thoracic kyperkyphosis). Compared with older adults having no thoracic hyperkyphosis, older adults with thoracic hyperkyphosis had increased risks performing impaired in OLS (OR=4.55, 95% CI 2.18-9.53, p<0.001), TUG (OR=6.08, 95% CI 2.57-14.40, p<0.001), CE (OR=3.23, 95% CI 1.63-6.38, p=0.001), 6MWT (OR=4.64, 95% CI 1.98-10.86, p<0.001), and FGA (OR=5.18, 95% CI 2.25-11.89, p<0.001) after controlling socio-demographic and health-related factors.

CONCLUSION

The thoracic hyperkyphosis had high prevalence and associated with impaired performance in balance, gait, and cardiopulmonary function tests among Chinese community-dwelling older adults, which calls for the future intervention.

Rapid Estimate of Inadequate Health Literacy (REIHL): development and validation of a practitioner-friendly health literacy screening tool for older adults

INTRODUCTION

This study aimed to develop and validate a brief practitioner-friendly health literacy screening tool, called Rapid Estimate of Inadequate Health Literacy (REIHL), that estimates patients' health literacy inadequacy in demanding clinical settings.

METHODS

This is a methodological study of 304 community-dwelling older adults recruited from one community health centre and five district elderly community centres. Logistic regression models were used to identify the coefficients of the REIHL score's significant factors. Receiver operating characteristic (ROC) curve analysis was then used to assess the REIHL's sensitivity and specificity. Path analysis was employed to examine the REIHL's criterion validity with the Chinese Health Literacy Scale for Chronic Care and concurrent validity with self-rated health scale and the Geriatric Depression Scale-15.

RESULTS

The REIHL has scores ranging from 0 to 23. It had 76.9% agreement with the Chinese Health Literacy Scale for Chronic Care. The area under the ROC curve for predicting health literacy inadequacy was 0.82 (95% confidence interval=0.78-0.87, P<0.001). The ROC curve of the REIHL showed that scores ≥11 had a sensitivity of 77.8% and specificity of 75.6% for predicting health literacy inadequacy. The path analysis model showed excellent fit (Chi squared [2, 304] 0.16, P=0.92, comparative fit index 1.00, root mean square error of approximation <0.001, 90% confidence interval=0.00-0.04), indicating that the REIHL has good criterion and concurrent validity.

CONCLUSION

The newly developed REIHL is a practical tool for estimating older adults' inadequate health literacy in clinical care settings.

Measurement properties of the chinese weinstein noise sensitivity scale

Context:

Noise sensitivity may mediate or moderate the influences of noise exposure on health, and it needs to be reliably evaluated. The 21-item Weinstein’s noise sensitivity scale (WNSS) has been the most popular scale for assessing noise sensitivity, but it is not yet available in traditional Chinese.

Aims:

This study aimed to conduct linguistic and psychometric performance of WNSS in Hong Kong (HK) Chinese.

Settings and Design:

A population-based telephone survey with 1-week follow-up.

Materials and Methods:

The HK Chinese WNSS was obtained after forward–backward translation from the original English version and cognitive debriefing in five Chinese adults. Its measurement properties were assessed in 569 Chinese adults aged 18 years or above.

Statistical Analysis Used:

The sample was randomly split into two halves. The first half was used to explore a scale structure of the WNSS by exploratory factor analysis (EFA) with the number of factors determined by the optimal comparison data technique and tested for being artifactual. The second half was used for confirmatory factor analysis. Convergent validity and test–retest validity were also assessed.

Results:

EFA identified two unipolar factors and removed three items poorly associated with the factors. The factors were likely artifactual and a unidimensional structure was assessed in CFA, which showed a satisfactory fit (root mean square error of approximation = 0.055; comparative fit index = 0.904; standardized root mean square residual = 0.061). The HK Chinese WNSS had good internal consistency (Cronbach’s α = 0.83) and test–retest reliability (intraclass correlation coefficient = 0.87). Furthermore, it confirmed the expected association with extraversion (r = −0.14, P < 0.001) and neuroticism (r = 0.28, P < 0.001).

Conclusion:

The 18-item HK Chinese WNSS was reliable and valid for assessing noise sensitivity in the Chinese population.

The challenge of patient empowerment in hand hygiene promotion in health care facilities in Hong Kong

Patient empowerment programs in hand hygiene were implemented in 2 extended-care hospitals. Of the 223 patients approached by the infection control nurses, 167 patients (74.9%) participated in the program. A positive response from the health care workers was reported in 70 (93.3%) of 75 patients who reminded health care workers to clean hands as part of the empowerment program. A significant increase in volume of alcohol-based handrub consumption was observed during the intervention period compared with baseline.

Preference of Food Saltiness and Willingness to Consume Low-Sodium Content Food in a Chinese Population

OBJECTIVE

To compare the preference of food saltiness and the willingness to consume low-sodium food among hypertensive older people, non-hypertensive older people and non-hypertensive young people in a Chinese population.

DESIGN

A cross-sectional study based on a quota sample. Three saltiness options (low-sodium, medium-sodium and high-sodium) of soup and bread were offered to each participant who rated the taste of each food on a 5-point Likert scale. Then, the participants rated their willingness to consume the low-sodium content foods on a 5-point Likert scale, given they were informed of the benefit of the low-sodium option. Generalised linear mixed model and multiple linear regression were used to analyse the data.

SETTING

Elderly centres and community centres in Hong Kong.

PARTICIPANTS

Sixty hypertensive older people, 49 non-hypertensive older people and 60 non-hypertensive young people were recruited from June to August 2014.

MEASUREMENTS

The tastiness score and the willingness score were the primary outcome measures. The Chinese Health Literacy Scale for Low Salt Consumption - Hong Kong population (CHLSalt-HK) was also assessed.

RESULTS

The tastiness rating of the high-sodium option of soup was significantly lower than the medium-sodium option (p<0.001), but there was no significant difference between the low-sodium and the medium-sodium options (p=0.204). For bread, tastiness rating of the low-sodium option and the high-sodium option were significantly lower than the medium-sodium option (p<0.001 for both options). The tastiness score of soup did not have significant difference across the groups (p=0.181), but that of bread from the hypertensive older adults (p=0.012) and the non-hypertensive older adults (p=0.006) was significantly higher than the non-hypertensive young adults. Higher willingness rating to consume the low-sodium option was significantly (p<0.001) associated with higher tastiness rating of the low-sodium option of soup and bread, and weakly associated with higher health literacy of low salt intake (soup: p=0.041; bread: p=0.024). Hypertensive older adults tended to be more willing to consume the low-sodium option than non-hypertensive older adults for soup (p=0.009), there was insignificant difference between non-hypertensive older adults and non-hypertensive young adults (p=0.156). For bread, there was insignificant difference in willingness rating to consume low-sodium option (p=0.375).

CONCLUSION

Older people are at a higher risk of hypertension, reduction of salt intake is important for them to reduce their risk of cardiovascular diseases. There is room for reducing the sodium content of soup, while the sodium in bread should be reduced progressively. Improving the taste of low-sodium food may help to promote reduction in dietary sodium intake.

Implementation of directly observed patient hand hygiene for hospitalized patients by hand hygiene ambassadors in Hong Kong

BACKGROUND

The importance of compliance with hand hygiene by patients is increasingly recognized to prevent health care-associated infections.

METHODS

This descriptive study observed the effects of an education campaign, targeted to increase patients' self-initiated hand hygiene, and a hand hygiene ambassador-initiated directly observed hand hygiene program on patients' hand hygiene compliance in a university-affiliated hospital.

RESULTS

The overall audited compliance of patients' self-initiated hand hygiene was only 37.5%, with a rate of 26.9% (112/416 episodes) before meals and medications, 27.5% (19/69 episodes) after using a urinal or bedpan, and 89.7% (87/97 episodes) after attending toilet facilities. Patients referred from a residential care home for older adults had significantly lower hand hygiene compliance (P = .007). Comparatively, the overall audited compliance of ambassador-initiated directly observed hand hygiene was 97.3% (428/440 episodes), which was significantly higher than patients' self-initiated hand hygiene via a patient education program (37.5%, 218/582 episodes, P < .001).

CONCLUSIONS

Directly observed hand hygiene can play an important role in improving compliance with hand hygiene by hospitalized patients.

The Effect of Telephone-Based Cognitive-Behavioral Therapy on Postnatal Depression: A Randomized Controlled Trial

BACKGROUND

Cognitive-behavioral therapy (CBT) is one of the most effective interventions for postnatal depression. However, few studies have evaluated the effect of CBT delivered via telephone for newborn mothers. The purpose of this study was to evaluate the efficacy of telephone-based CBT for postnatal depression at 6 weeks and 6 months postpartum.

METHODS

A multisite randomized controlled trial was conducted in the postnatal units at 3 regional hospitals in Hong Kong. A total of 397 women with an Edinburgh Postnatal Depression Scale (EPDS) score ≥10 on the second or third day postpartum were randomized to receive telephone-based CBT (n = 197) or standard care (n = 200). Primary outcome was the total EPDS score. A cutoff score of 9/10 on the EPDS was used to define women at risk of postnatal depression.

RESULTS

Telephone-based CBT was associated with significantly lower depressive symptoms compared with standard care, when assessed at 6 weeks postpartum in the subgroups of mothers with minor depression (EPDS 10-12; difference = 1.90, 95% CI: 0.72-3.08; p = 0.002) and major depression (EPDS ≥13; difference = 5.00, 95% CI: 3.12-6.88; p < 0.001). The effect was sustained at 6 months postpartum in the subgroup with minor depression (difference = 1.20, 95% CI: 0.09-2.32; p = 0.034) but not significant in the subgroup with major depression (difference = 1.69, 95% CI: -0.10-3.47; p = 0.064). The proportion of women who satisfied our definition of postnatal depression was significantly lower in the intervention group at 6 weeks (difference = 23.3%, 95% CI: 13.7-33.0%; p < 0.001) and 6 months postpartum (difference = 11.4%, 95% CI: 1.9-20.8%; p = 0.019).

CONCLUSIONS

Telephone-based CBT produced a significantly greater reduction in depressive symptoms than standard care during the postpartum period.

Use of fluoroquinolones is the single most important risk factor for the high bacterial load in patients with nasal and gastrointestinal colonization by multidrug-resistant Acinetobacter baumannii

Gastrointestinal colonization by carbapenem-resistant Acinetobacter baumannii (CRAB) and multidrug-resistant Acinetobacter baumannii (MRAB) provides an important reservoir for clinical infections and hospital outbreaks. We conducted a 7-month study in a 3200-bed healthcare network to investigate the prevalence of gastrointestinal colonization of CRAB and MRAB in Hong Kong. Between 1 June and 31 December 2014, a total of 17,760 fecal specimens from 9469 patients were screened. Testing showed that 340 (1.9%) specimens from 224 (2.6%) patients were CRAB-positive, which included 70 (0.39%) MRAB-positive specimens from 54 (0.57%) patients. The presence of wound or ulcer, use of broad-spectrum antibiotics in the preceding 6 months, and residence in elderly homes are independent risk factors for gastrointestinal colonization of CRAB. Quantitative bacterial counts in various body sites (rectal, nasal, axilla, wound, catheterized urine, if available) were performed in 33 (61.1%) of 54 MRAB patients. Ten (30.3%) and 8 (24.2%) patients had high bacterial load (defined as over 3 log10) in rectal and nasal swabs, with a median of 5.04 log10 cfu/ml of rectal swab and 4.89 log10 cfu/ml of nasal swab in saline diluent, respectively. Nine (81.8%) of 11 patients with wounds had high bacterial load in wound swabs, with a median of 5.62 log10 cfu/ml. Use of fluoroquinolones 6 months before admission was the only significant factor associated with high bacterial load in nasal and rectal swabs. With the implementation of directly observed hand hygiene before meals and medications to all conscious hospitalized patients, no hospital outbreaks were observed during our study period.

Development and Validation of Chinese Health Literacy Scale for Low Salt Consumption-Hong Kong Population (CHLSalt-HK)

Globally, sodium intake far exceeds the level recommended by the World Health Organization. Assessing health literacy related to salt consumption among older adults could guide the development of interventions that target their knowledge gaps, misconceptions, or poor dietary practices. This study aimed to develop and validate the Chinese Health Literacy Scale for Low Salt Consumption-Hong Kong population (CHLSalt-HK). Based on previous studies on salt intake and nutrition label reading in other countries, we developed similar questions that were appropriate for the Chinese population in Hong Kong. The questions covered the following eight broad areas: functional literacy (term recognition and nutrition label reading), knowledge of the salt content of foods, knowledge of the diseases related to high salt intake, knowledge of international standards, myths about salt intake, attitudes toward salt intake, salty food consumption practices, and nutrition label reading practices. Eight professionals, including doctors, nurses, and dietitians, provided feedback on the scale. The psychometric properties of the scale were assessed based on data collected from a convenience sample of 603 Chinese elderly adults recruited from Elderly Health Centres in Hong Kong. The 49-item CHLSalt-HK had a possible score range of 0 to 98, with a higher score indicating higher health literacy related to salt intake. The CHLSalt-HK had acceptable content validity; the item-level Content Validity Index ranged from 0.857 to 1.000, and the scale-level Content Validity Index was 0.994. Additionally, it had good internal consistency (Cronbach's alpha of 0.799) and good test-retest reliability (intraclass correlation coefficient of 0.846). The mean CHLSalt-HK score among those who were aware of the public education slogan about nutrition labels and sodium intake was higher by 3.928 points (95% confidence interval: 1.742 to 6.115) than that among those who were not aware of the slogan, which supports adequate discriminant validity. The validated CHLSalt-HK had acceptable content validity, acceptable construct validity, good internal consistency, good test-retest reliability, and adequate discriminant validity. The scale could be completed in 10-15 minutes and is easy to administer compared with the collection of biomarkers or food diaries. Further research should investigate its concurrent validity and predictive validity. The development of this scale supports the first step in salt intake reduction among older Chinese adults in Hong Kong by enabling the assessment of their health literacy related to salt consumption in health screenings or health assessments, and it can be used to evaluate salt reduction interventions.

Hand-touch contact assessment of high-touch and mutual-touch surfaces among healthcare workers, patients, and visitors

BACKGROUND

Unlike direct contact with patients' body, hand hygiene practice is often neglected by healthcare workers (HCWs) and visitors after contact with patients' environment. Contact with hospital environmental items may increase risk of pathogen transmission.

AIM

To enumerate the number of hand-touch contacts by patients, HCWs and visitors with any hospital environmental items.

METHODS

All contact-episodes between person and item were recorded by direct observation in a six-bed cubicle of acute wards for 33 working days. High-touch and mutual-touch items with high contact frequencies by HCWs, patients, and visitors were analysed.

FINDINGS

In total, 1107 person-episodes with 6144 contact-episodes were observed in 66 observation hours (average: 16.8 person-episodes and 93.1 contact-episodes per hour). Eight of the top 10 high-touch items, including bedside rails, bedside tables, patients' bodies, patients' files, linen, bed curtains, bed frames, and lockers were mutually touched by HCWs, patients, and visitors. Bedside rails topped the list with 13.6 contact-episodes per hour (mean), followed by bedside tables (12.3 contact-episodes per hour). Using patients' body contacts as a reference, it was found that medical staff and nursing staff contacted bedside tables [rate ratio (RR): 1.741, 1.427, respectively] and patients' files (RR: 1.358, 1.324, respectively) more than patients' bodies, and nursing staff also contacted bedside rails (RR: 1.490) more than patients' bodies.

CONCLUSION

Patients' surroundings may be links in the transmission of nosocomial infections because many are frequently touched and mutually contacted by HCWs, patients, and visitors. Therefore, the focus of hand hygiene education, environmental disinfection, and other system changes should be enhanced with respect to high-touch and mutual-touch items.

Minimal intervention for controlling nosocomial transmission of methicillin-resistant staphylococcus aureus in resource limited setting with high endemicity

OBJECTIVE

To control nosocomial transmission of methicillin-resistant Staphylococcus aureus (MRSA) in resource-limited healthcare setting with high endemicity.

METHODS

Three phases of infection control interventions were implemented in a University-affiliated hospital between 1-January-2004 and 31-December-2012. The first phase of baseline period, defined as the first 48-months of the study period, when all MRSA patients were managed with standard precautions, followed by a second phase of 24-months, when a hospital-wide hand hygiene campaign was launched. In the third phase of 36-months, contact precautions in open cubicle, use of dedicated medical items, and 2% chlorhexidine gluconate daily bathing for MRSA-positive patients were implemented while hand hygiene campaign was continued. The changes in the incidence rates of hospital-acquired MRSA-per-1000-patient admissions, per-1000-patient-days, and per-1000-MRSA-positive-days were analyzed using segmented Poisson regression (an interrupted time series model). Usage density of broad-spectrum antibiotics was monitored.

RESULTS

During the study period, 4256 MRSA-positive patients were newly diagnosed, of which 1589 (37.3%) were hospital-acquired. The reduction of hospital-acquired MRSA per 1000-patient admissions, per 1000-patient-days, and per 1000-MRSA-positive-days from phase 1 to 2 was 36.3% (p<0.001), 30.4% (p<0.001), and 19.6% (p = 0.040), while the reduction of hospital-acquired MRSA per 1000-patient admissions, per 1000-patient-days, and per 1000-MRSA-positive-days from phase 2 to 3 was 27.4% (p<0.001), 24.1% (p<0.001), and 21.9% (p = 0.041) respectively. This reduction is sustained despite that the usage density of broad-spectrum antibiotics has increased from 132.02 (phase 1) to 168.99 per 1000 patient-days (phase 3).

CONCLUSIONS

Nosocomial transmission of MRSA can be reduced with hand hygiene campaign, contact precautions in open cubicle, and 2% chlorhexidine gluconate daily bathing for MRSA-positive despite an increasing consumption of broad-spectrum antibiotics.

High burden of extended-spectrum β-lactamase-positive Escherichia coli in geriatric patients

Few studies have described how an expanding elderly population influences the burden of antimicrobial resistance in micro-organisms. This study aimed to investigate trends in age-stratified extended-spectrum β-lactamase (ESBL)-positive Escherichia coli metrics in relation to an ageing population. The antimicrobial resistance database of E. coli from a healthcare region in Hong Kong from 2003 to 2012 was retrospectively reviewed. Future trends in age-stratified ESBL metrics were predicted up to 2022. Susceptibility results of clinical E. coli isolates from patients aged 0–74 years (n = 17 853) and aged ≥75 years (n = 17 047) were analysed. For the period 2003–2012, 23.7 % of the hospital admissions were of patients aged ≥75 years. However, approximately half of the annual ESBL-positive E. coli isolates were recovered from patients aged ≥75 years, being 55.0 % (233/424) in 2003 and 56.0 % (639/1142) in 2012. During this period of time, the annual prevalence and cumulative incidence of ESBL-positive E. coli in patients aged ≥75 years were significantly higher than in patients aged 0–74 years. From 2012–2022, it is predicted that ESBL-positive E. coli prevalence among patients aged 0–74 years and ≥75 years would increase from 25.4 % to 50.2 % and from 30.8 % to 70.0 %, respectively. In 2022, the predicted ESBL-positive E. coli cumulative incidence would be 63.7 per 10 000 admissions and 178.7 per 10 000 admissions among patients aged 0–74 years and ≥75 years, respectively. In conclusion, a rapidly expanding elderly population would substantially add to the burden of ESBL.

Trends in ischaemic heart disease hospitalisation and case fatality in the Hong Kong Chinese population 2000-2009: a secondary analysis

OBJECTIVES

This study examines the recent trends in ischaemic heart disease (IHD) incidence and case fatality in Hong Kong and explores the possible risk factors.

DESIGN

Retrospective observational study.

SETTING

All public hospitals in Hong Kong.

OUTCOME MEASURES

Incidence rate was defined as the number of IHD inpatient episodes divided by the size of the corresponding population. Short-term and long-term case fatality rate was defined as deaths from all causes occurring within 30 and 31-365 days, respectively, divided by the number of IHD inpatient episodes among the corresponding population.

METHODS

Poisson and logistic regression models were used to examine the IHD incidence and short-term/long-term case fatality trends, respectively, for different age and sex groups.

RESULTS

IHD incidence was stable in most age groups. However, the incidence in men aged 15-24, 35-44 and ≥85 years showed increasing trends, whereas the incidence in men aged 55-64 years and women aged 35-74 years showed decreasing trends. Overall, the short-term/long-term case fatality rates were unchanged over time for both sexes. Short-term case fatality showed increasing trends in women aged 65-74 and ≥85 years, while long-term case fatality in men aged 55-64 and 75-84 years and women aged ≥75 years showed increasing trends.

CONCLUSIONS

Hong Kong trends resembled those in the USA, England and Wales, showing stable or slow decline in the IHD rates, while increasing trends were observed for some age groups, particularly young adults. Public health promotion efforts should focus on reducing cardiovascular risk factors, such as hypertension prevalence.

Weather, season, and daily stroke admissions in Hong Kong

Previous studies examining daily temperature and stroke incidence have given conflicting results. We undertook this retrospective study of all stroke admissions in those aged 35 years old and above to Hong Kong public hospitals from 1999 through 2006 in order to better understand the effects of meteorological conditions on stroke risk in a subtropical setting. We used Poisson Generalized Additive Models with daily hemorrhagic (HS) and ischemic stroke (IS) counts separately as outcomes, and daily mean temperature, humidity, solar radiation, rainfall, air pressure, pollutants, flu consultation rates, day of week, holidays, time trend and seasonality as predictors. Lagged effects of temperature, humidity and pollutants were also considered. A total of 23,457 HS and 107,505 IS admissions were analyzed. Mean daily temperature had a strong, consistent, negative linear association with HS admissions over the range (8.2-31.8°C) observed. A 1°C lower average temperature over the same day and previous 4 days (lags 0-4) being associated with a 2.7% (95% CI: 2.0-3.4%, P < .0.0001) higher admission rate after controlling for other variables. This association was stronger among older subjects and females. Higher lag 0-4 average change in air pressure from previous day was modestly associated with higher HS risk. The association between IS and temperature was weaker and apparent only below 22°C, with a 1°C lower average temperature (lags 0-13) below this threshold being associated with a 1.6% (95% CI:1.0-2.2%, P < 0.0001) higher IS admission rate. Pollutant levels were not associated with HS or IS. Future studies should examine HS and IS risk separately.

Older people with diabetes have higher risk of depression, cognitive and functional impairments: implications for diabetes services

OBJECTIVES

To examine the relationship between diabetes and impairments in functional and cognitive status as well as depression in older people.

DESIGN

Cross-sectional study.

SETTING

Elderly Health Centres (EHC) in Hong Kong.

PARTICIPANTS

66,813 older people receiving baseline assessment at EHC in 1998 to 2001.

MEASUREMENTS

Diabetes status was defined by self-report and blood glucose tests. Functional status was assessed by 5 items of instrumental activities of daily living (IADL) and 7 items of activities of daily living (ADL). Cognitive status was screened by the Abbreviated Mental Test-Hong Kong version (AMT). Depressive symptoms were screened by the Geriatric Depression Scale-Chinese version (GDS).

RESULTS

Among the subjects, 10.4% reported having regular treatment for diabetes, 3.4% had diabetes but were not receiving regular treatment, and 86.2% did not have diabetes. After controlling for age, sex and education level, those having regular treatment for diabetes were 1.7 times more likely (OR=1.65, 95% CI: 1.51-1.80) to have functional impairment, 1.3 times more likely (OR=1.28, 95% CI: 1.11-1.48) to have cognitive impairment and 1.3 times more likely (OR=1.35, 95% CI: 1.25-1.46) to have depression, than older people without diabetes.

CONCLUSION

Older people with diabetes may be less capable of managing the disease than the younger ones as a result of increased risk of both physical and cognitive impairment. This study provided further evidence for the need of an international consensus statement regarding care of diabetes in older people.

The impact of epidemic outbreak: the case of severe acute respiratory syndrome (SARS) and suicide among older adults in Hong Kong

BACKGROUND

Previous studies revealed that there was a significant increase in suicide deaths among those aged 65 and over in 2003. The peak coincided with the majority of SARS cases being reported in April 2003.

AIMS

In this paper we examine the mechanism of how the SARS outbreak resulted in a higher completed suicide rate especially among older adults in Hong Kong.

METHODS

We used Qualitative data analysis to uncover the association between the occurrence of SARS and older adult suicide. Furthermore, we used a qualitative study based on the Coroner Court reports to provide empirical evidence about the relationship between SARS and the excessive number of suicide deaths among the elderly.

RESULTS

SARS-related older adult suicide victims were more likely to be afraid of contracting the disease and had fears of disconnection. The suicide motives among SARS-related suicide deaths were more closely associated with stress over fears of being a burden to their families during the negative impact of the epidemic. Social disengagement, mental stress, and anxiety at the time of the SARS epidemic among a certain group of older adults resulted in an exceptionally high rate of suicide deaths.

CONCLUSIONS

We recommend that the mental and psychological well-being of the community, in particular older adults, be taken into careful account when developing epidemic control measures to combat the future outbreak of diseases in the community. In addition, it is important to alert family members to vulnerable individuals who are at potential risk because of their illnesses or anxieties.

Hot weather warning might help to reduce elderly mortality in Hong Kong

While there was evidence on the relationship between extreme hot weather and the increase in mortality, particularly from ischaemic heart disease (IHD) and cerebrovascular disease (stroke), some researchers suggested that early warning systems might reduce mortality. In this study, the relationship between Very Hot Weather Warning (VHWW) and mortality was examined in the context of Hong Kong, which has a sub-tropical climate. An observational study was conducted on the daily number of deaths due to IHD and stroke in the Hong Kong elderly population (aged 65 or above) during summer (May-September) in 1997-2005. Totals of 4,281 deaths from IHD and 4,764 deaths from stroke occurred on days with maximum temperature reaching/exceeding 30.4 degrees C. Multiple linear regression models were used to study the association between VHWW and the daily mortality rates from IHD and from stroke, respectively. Results showed that absence of VHWW was associated with an increase of about 1.23 (95% CI: 0.32, 2.14) deaths from IHD and 0.97 (95% CI: 0.02, 1.92) deaths from stroke among the elderly per day. Public education is required to inform the elderly to take appropriate preventive measures and to remind the public to pay more care and attention to the elderly on days which are not considered to be stressful to the general public. Warning systems tailored for the elderly could also be considered.

A revisit on older adults suicides and Severe Acute Respiratory Syndrome (SARS) epidemic in Hong Kong

BACKGROUND

The Severe Acute Respiratory Syndrome (SARS) outbreak in 2003 had an enormous impact on Hong Kong society and the suicide rate was also at its historical high, 18.6 per 100,000. The most significant increase was found among the older adults aged 65 or above.

METHODS

Poisson Regression Models were used to examine impact of the SARS epidemic on older adults suicides in Hong Kong. A complete set of the suicide statistics for the period 1993-2004 from the Coroners' Court were made available for the analysis. Chi-square test was used to compare the profile of the older adult suicide cases in the pre-SARS, peri-SARS and post-SARS periods.

RESULTS

It showed an excess of older adults suicides in April 2003, when compared to the month of April of the other years. A trough, instead of the usual summer peak, was observed in June, suggesting some of the older adults suicides might have been brought forward. On a year basis, the annual older adult's suicide rates in 2003 and 2004 were significantly higher than that in 2002, suggesting the suicide rate did not return to the level before the SARS epidemic. Based on the Coroners' suicide death records, overall severity of illness, level of dependency and worrying of having sickness among the older adult suicides were found to be significantly different in the pre-SARS, peri-SARS and post-SARS periods.

CONCLUSION

The SARS epidemic was associated with an increase in older adults' suicide rate in April 2003 and some suicide deaths in June 2003 might have been brought forward. Moreover, an increase in the annual older adults' suicide rate in 2003 was observed and the rate in 2004 did not return to the level of 2002. Loneliness and disconnectedness among the older adults in the community were likely to be associated with the excess older adults' suicides in 2003. Maintaining and enhancing mental well being of the public over the period of epidemic is as important as curbing the spread of the epidemic. Attention and effort should also be made to enhance the community's ability to manage fear and anxiety, especially in vulnerable groups over the period of epidemic to prevent tragic and unnecessary suicide deaths.

A prediction rule for clinical diagnosis of severe acute respiratory syndrome

A prospective study was undertaken to identify clinical, radiographical, haematological and biochemical profiles of severe acute respiratory syndrome (SARS) patients. A prediction rule, which demarcates low from high risk patients for SARS in an outbreak situation was developed. A total of 295 patients with unexplained respiratory illnesses, admitted to Queen Mary Hospital, Hong Kong SAR, China, in March to July 2003, were evaluated for clinical, radiological, haematological and alanine transaminase (ALT) data daily for 3 days after hospitalisation. In total, 44 cases were subsequently confirmed to have SARS by RT-PCR (68.2%) and serology (100%). The scoring system of attributing 11, 10, 3, 3 and 3 points to the presence of independent risk factors, namely: epidemiological link, radiographical deterioration, myalgia, lymphopenia and elevated ALT respectively, generated high and low-risk (total score 11-30 and 0-10, respectively) groups for SARS. The sensitivity and specificity of this prediction rule in positively identifying a SARS patient were 97.7 and 81.3%, respectively. The positive and negative predictive values were 47.8 and 99.5%, respectively. The prediction rule appears to be helpful in assessing suspected patients with severe acute respiratory syndrome at the bedside, and should be further validated in other severe acute respiratory syndrome cohorts.

Estimation of reporting delay and suicide incidence in Hong Kong

This paper uses a semi-parametric method to examine the reporting delay distribution in suicides in Hong Kong reporting system. The data arise from a rightly truncated situation in which only suicide cases registered before a specific time are known to have occurred; otherwise they are not recorded in the known death files even if they have occurred. It is shown that the poisoning-related suicide deaths have a longer reporting delay than other suicide methods. By modelling the reporting delay function, a Horvitz-Thompson-type estimator is suggested to adjust for reporting delay and to provide a more timely estimate of the suicide incidences for monitoring the suicide problem in Hong Kong. Based on these analyses, we recommended a suitable cut-off date to collect suicide cases occurring in the previous year and reported before this date in Hong Kong.

Monitoring the severe acute respiratory syndrome epidemic and assessing effectiveness of interventions in Hong Kong Special Administrative Region

OBJECTIVE

To estimate the infection curve of severe acute respiratory syndrome (SARS) using the back projection method and to assess the effectiveness of interventions.

DESIGN

Statistical method.

DATA

The daily reported number of SARS and interventions taken by Hong Kong Special Administrative Region (HKSAR) up to 24 June 2003 are used.

METHOD

To use a back projection technique to construct the infection curve of SARS in Hong Kong. The estimated epidemic curve is studied to identify the major events and to assess the effectiveness of interventions over the course of the epidemic.

RESULTS

The SARS infection curve in Hong Kong is constructed for the period 1 March 2003 to 24 June 2003. Some interventions seem to be effective while others apparently have little or no effect. The infections among the medical and health workers are high.

CONCLUSIONS

Quarantine of the close contacts of confirmed and suspected SARS cases seems to be the most effective intervention against spread of SARS in the community. Thorough disinfection of the infected area against environmental hazards is helpful. Infections within hospitals can be reduced by better isolation measures and protective equipments.