Effectiveness and safety of menopause treatments: pitfalls of available evidence and future research need

By 2050 more than 1.6 billion women worldwide will be of post-reproductive age, with >75% reporting severe menopausal symptoms. The last few years saw a gradual uplift in public awareness reaffirming the health needs of women with menopause. Still, effective translation of available evidence on menopause treatments is hindered by several methodological limitations and poor research conduct. We argue that a paradigm shift is required in menopause research to address the remaining knowledge gap and guide safe evidence-based care provision. A critical misconception across studies on menopause is the assumption that women represent a homogeneous group who respond similarly to a particular therapy irrespective of their exposure and individual risk factors. We highlight potential solutions to optimize the quality of future research in menopause including adopting robust trial methodology, standardize outcome reporting to capture quality-of-life measures, and improve lay patient and public involvement in future research.

Cost-minimization analysis of oral versus intravenous antibiotic treatment for Klebsiella pneumoniae liver abscess

A cost-minimization analysis was conducted for Klebsiella pneumoniae liver abscess (KLA) patients enrolled in a randomized controlled trial which found oral ciprofloxacin to be non-inferior to intravenous (IV) ceftriaxone in terms of clinical outcomes. Healthcare service utilization and cost data were obtained from medical records and estimated from self-reported patient surveys in a non-inferiority trial of oral ciprofloxacin versus IV ceftriaxone administered to 152 hospitalized adults with KLA in Singapore between November 2013 and October 2017. Total costs were evaluated by category and payer, and compared between oral and IV antibiotic groups over the trial period of 12 weeks. Among the subset of 139 patients for whom cost data were collected, average total cost over 12 weeks was $16,378 (95% CI, $14,620-$18,136) for the oral ciprofloxacin group and $20,569 (95% CI, $18,296-$22,842) for the IV ceftriaxone group, largely driven by lower average outpatient costs, as the average number of outpatient visits was halved for the oral ciprofloxacin group. There were no other statistically significant differences, either in inpatient costs or in other informal healthcare costs. Oral ciprofloxacin is less costly than IV ceftriaxone in the treatment of Klebsiella liver abscess, largely driven by reduced outpatient service costs.Trial registration: ClinicalTrials.gov Identifier NCT01723150 (7/11/2012).

A201 EFFECT OF MIRIKIZUMAB ON BOWEL URGENCY CLINICALLY MEANINGFUL IMPROVEMENT AND REMISSION: RESULTS FROM THE PHASE 3 LUCENT INDUCTION AND MAINTENANCE STUDIES

Background

Bowel urgency (BU) was assessed in mirikizumab (miri) Phase 3 LUCENT studies in moderately-to-severely active UC using the validated Urgency Numeric Rating Scale (UNRS). UNRS measures BU severity in the past 24 hours from 0 (no urgency) to 10 (worst possible urgency). Psychometric evaluation of the UNRS showed Clinically Meaningful Improvement (CMI) is >3 point change; Remission is a score of 0 or 1.

Purpose

This analysis evaluated the proportions of patients in LUCENT studies achieving BU CMI and BU remission.

Method

The modified intent-to-treat (mITT) population (patients receiving ≥1 dose of miri or placebo (PBO); N= 1281) was randomized at induction study baseline in a 3:1 ratio to IV doses of 300mg miri or PBO every 4 weeks (Q4W) during induction (W0, 4, and 8). Patients achieving Clinical Response, measured by Modified Mayo Score (MMS), to miri during induction were re-randomized at W0 of the maintenance study in a 2:1 ratio to subcutaneous (SC) 200mg miri or PBO Q4W through W40 (52 weeks of treatment). Patients recorded their UNRS score daily in an e-diary. Mean weekly UNRS scores were calculated from diary data if ≥4 days of data were available. Rates of BU CMI and BU remission in the miri v PBO groups were compared at W12 (induction) in the mITT population with a baseline UNRS score ≥3, and W52 (maintenance) among miri clinical responders at W12 with a baseline UNRS score ≥3. Cochran-Mantel-Haenszel tests with non-responder imputation for missing values were used for all treatment comparisons.

Result(s)

Patient population: mean age 43 years, 60% male, disease duration 7 years; 63.0% left-sided colitis; 36.3% pancolitis; 46.7% moderate disease (MMS 4-6); 53.2% severe disease (MMS 7-9). Significantly higher proportions of miri versus PBO patients achieved BU CMI (48.7% v 32.2%) and BU remission (22.1% v 12.3%) at W12 (both p<0.001; Table) in the induction study. Similarly, at W40 of maintenance, significantly greater proportion of miri patients achieved BU CMI (65.2% v 41.9%) and BU remission (42.9% v 25.0%) compared to PBO among miri induction responders (both p<0.001; Table).

Image

Conclusion(s)

Miri had a highly significant and clinically meaningful benefit on reducing bowel urgency, one of the most disruptive UC symptoms. The Urgency Numeric Rating Scale usefully quantified the baseline level and change in bowel urgency after treatment across a spectrum of severity.

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Disclosure of Interest

None Declared

1856. Risk factors for mortality amongst hospitalised patients with Staphylococcus aureus bacteraemia – a prospective cohort study

Background

Staphylococcus aureus bacteraemia (SAB) remains a common infection with significant mortality, ranging from 20 to 40%. Understanding the risk factors for adverse outcomes in this infection will better prognosticate and guide patient management and disposition.

Methods

We prospectively recruited and examined 634 consecutive patients with laboratory-confirmed SAB. They were characterised in terms of baseline demographics, clinical profile, and laboratory findings at the time of SAB diagnosis. Sensitivity testing was carried out to identify patients who had methicillin-resistant (MRSA) or methicillin-sensitive Staphylococcus aureus (MSSA) infection. All patients were followed up prospectively for clinical outcomes including in-hospital mortality, and sites of metastatic infection. Univariate and multivariable logistic regression was used to identify risk factors associated with mortality in hospitalised patients with SAB.

Results

The overall mortality was 5.8% (n=37). There were no significant differences in gender, but patients who died tended to be 11 years older on average (69.6±14.9 years vs 58.1±18.2 years, p< 0.001). Diabetes mellitus, prior history of structural heart disease, haemodialysis and recent surgery had not been significantly associated with mortality in our cohort. Amongst the patients who died, MRSA infection was significantly more common (45.9% vs 24.8%, p=0.004). On multivariable logistic regression, older age (adjusted OR 1.05, 95%CI 1.02-1.07) and MRSA infection (adjusted OR 2.04, 95%CI 1.01 – 4.09) remained independently associated with mortality. We did not demonstrate an association with prolonged fever or bacteraemia and in-hospital mortality.

Conclusion

Amongst hospitalised patients with SAB, the mortality was low (5.8%). Older age and MRSA infection were the most important risk factors identified in association with mortality.

Disclosures

All Authors: No reported disclosures.

1008. Implementation of Clinical Pathway for Management of Fever in Nursing Home Residents in Singapore

Background

Ageing population is a major health care problem all over the world. In Singapore, as of 2020, senior citizen (65 years and above) consists of 15.2 % of total population. By 2030, one in five Singaporeans will be more than 65 years old. Thus, nursing home (NH) is an important pillar of a health care system.

Nursing home staff are in the front line to manage common infections. However, the inexperience and the lack of guidance have led to inappropriate transfer to acute hospitals.

Infectious Diseases Community Program (IDCP) is the project to enhance partnerships with NHs. We work with NHs to develop, adapt, and implement appropriate processes related to infection control, prevention, and management. One of our objectives is the enhancement of assessment and appropriate evaluation of fever. The aim is to reduce the inappropriate admissions to acute hospitals.

Methods

Fever and desaturation pathway (figure 1) was developed by IDCP team. Six participating NHs adopted the pathway and trained their staff. The study was approved by NHG domain specific review board (DSRB). Hospital records were reviewed. We compared the rate of inappropriate admission from 2015-2017 which serve as a baseline and 2019-2020. The wash-out period was 2018 when NHs were implementing the pathway.

Inappropriate admission is defined as

&lt; ! 1. Admission is against advanced care planning / preferred plan of care

or

2. Criteria in the pathway are not met on admission, 48 hours later and no other medical reason for admission. Figure 1

Results

Total number of fever transfers was 950 in 2015-2017 and 688 in 2019-2020. Number of inappropriate admissions was 115 in 2015-2017 and 50 in 2019-2020. Inappropriate admission was 12.11% in 2015-2017 and 7.27 % in 2019-2020 (table 1). Figure 2 shows the rate of inappropriate admissions of six participating NHs from 2015-2020. There is a decreasing trend after the pathway has been implemented in 2018. Table 1

Figure 2

Conclusion

Adopting fever and desaturation pathway has reduced the rate of inappropriate admission in six participating NHs in Singapore. However, there is an increasing trend in inappropriate admission in 2020. This could be due to the lack of isolation facility in the NHs during the COVID-19 pandemic. We are continuing the implementation of the pathway to the rest of the NHs in the western region of Singapore.

Disclosures

All Authors: No reported disclosures.

Cost effectiveness of temporary isolation rooms in acute care settings in Singapore

Objectives

To estimate the change to health service costs and health benefits from a decision to adopt temporary isolation rooms that are effective at isolating the patient within a general ward environment. We assess the cost-effectiveness of a decision to adopt an existing temporary isolation room in a Singapore setting.

Method

We performed a model-based cost-effectiveness analysis to evaluate the impact of a decision to adopt temporary isolation rooms for infection prevention. We estimated changes to the costs from implementation, the number of cases of healthcare associated infection, acute care bed days used, they money value of bed days, the number of deaths, and the expected change to life years. We report the probability that adoption was cost-effective by the cost by life year gained, against a relevant threshold. Uncertainty is addressed with probabilistic sensitivity analysis and the findings are tested with plausible scenarios for the effectiveness of the intervention.

Results

We predict 478 fewer cases of HAI per 100,000 occupied bed days from a decision to adopt temporary isolation rooms. This will result in cost savings of $SGD329,432 and there are 1,754 life years gained. When the effectiveness of the intervention is set at 1% of cases of HAI prevented the incremental cost per life year saved is $16,519; below the threshold chosen for cost-effectiveness in Singapore.

Conclusions

We provide some evidence that adoption of a temporary isolation room is cost-effective for Singapore acute care hospitals. It is plausible that adoption is a positive decision for other countries in the region who may demonstrate fewer resources for infection prevention and control.

Systems of support for foreign-born TB patients and their family members

SETTING

Adverse social determinants of health for people who are foreign-born are key drivers of TB-related disparity, particularly in low-incidence countries. Patients diagnosed with infectious TB and their family members must confront psychosocial challenges which may deepen pre-existing health inequities. However, little is known about patient and family members' perspective on these experiences.

OBJECTIVE

To explore the infectious TB experience of patients and family members who are foreign-born.

DESIGN

This study formed one component of an ecologically framed, qualitative case study conducted in Calgary, AB, Canada. Data were collected using semi-structured interviews, chart review and field notes, and analysed thematically.

RESULTS

Eight families were represented in the sample comprised of six patients and 13 family members. Many patients and family members experienced high levels of fear and stress for months following the patient's diagnosis. Isolation was pervasive and multifaceted for both patients and family members. Intra-family support was critical for managing during early stages when the situation was most challenging. Support from outside the family was not prominent and attempts to obtain support from government programmes for paid sick leave and health insurance were mostly unsuccessful.

CONCLUSION

Patients and family members who are foreign-born experience multidimensional isolation as a result of TB stigma, language barriers and poor access to government programmes. TB programmes cannot meet family needs alone and systems of support should be created through collaboration with government institutions, and organisations serving ethnocultural communities.

A Tool to Guide Creation of Products for Risk Communications and Community Engagement (RCCE)

Using best practices to produce creative, relatable, contextualized health messaging contributes to effective risk communication. During emergency disasters, the landscape of mis- and dis-information demands strategic, collaborative approaches across all stakeholders particularly government and the media to ensure effective public messaging. However, tools for new RCCE practitioners and media agencies such as television producers and advertising firms to rapidly create effective RCCE products are currently not readily available. In response to concerns that vaccine hesitancy may become more evident once a significant proportion of the population had been reached, the Ministry of Communications and Information (MCI) in Singapore launched a public health music video on 2 May 2021, making headlines globally and garnering more than 5 million views worldwide. The video aimed to dispel myths and concerns about vaccinations and encouraged citizens to get their vaccination quickly rather than wait. We aimed to evaluate this video as a case study and articulate why it is an example of good practice in risk communications. Working inductively to identify emergent principles of product creation in this case study and analyzing them against existing RCCE frameworks and recommendations helped develop a practical tool to guide the rapid creation of RCCE products by those who may be unfamiliar to RCCE principles. This tool can help new RCCE practitioners and media agencies to produce effective products in times of crisis. The easy-to-use tool provides a brief checklist that guides rapid creation of RCCE products, including criteria for understanding the target audience, message comprehension, development, reach and impact measurement. Given its derivation from existing RCCE frameworks and health literacy concepts, these can potentially be applied across different modalities and diverse cultures. Future work would include validation of these criteria and evaluation of its utility to strengthen RCCE as core in an emergency response.

Risk Communication and Community Engagement During the Migrant Worker COVID-19 Outbreak in Singapore

In early phases of the COVID-19 pandemic in Singapore, Risk Communication and Community Engagement (RCCE) with large, diverse communities of migrant workers living in high-density accommodation was slow to develop. By August 2020, Singapore had reported 55,661 cases of COVID-19, with migrant workers comprising 94.6% of the cases. A system of RCCE among migrant worker communities in Singapore was developed to maximize synergy in RCCE. Proactive stakeholder engagement and participatory approaches with affected communities were key to effective dissemination of scientific information about COVID-19 and its prevention.

Myopericarditis following COVID-19 vaccination and non-COVID-19 vaccination: a systematic review and meta-analysis

Background

Myopericarditis is a rare complication of vaccination. However, there have been increasing reports of myopericarditis following COVID-19 vaccination, especially among adolescents and young adults. We aimed to characterise the incidence of myopericarditis following COVID-19 vaccination, and compare this with non-COVID-19 vaccination.

Methods

We did a systematic review and meta-analysis, searching four international databases from Jan 1, 1947, to Dec 31, 2021, for studies in English reporting on the incidence of myopericarditis following vaccination (the primary outcome). We included studies reporting on people in the general population who had myopericarditis in temporal relation to receiving vaccines, and excluded studies on a specific subpopulation of patients, non-human studies, and studies in which the number of doses was not reported. Random-effects meta-analyses (DerSimonian and Laird) were conducted, and the intra-study risk of bias (Joanna Briggs Institute checklist) and certainty of evidence (Grading of Recommendations, Assessment, Development and Evaluations approach) were assessed. We analysed the difference in incidence of myopericarditis among subpopulations, stratifying by the type of vaccine (COVID-19 vs non-COVID-19) and age group (adult vs paediatric). Among COVID-19 vaccinations, we examined the effect of the type of vaccine (mRNA or non-mRNA), sex, age, and dose on the incidence of myopericarditis. This study was registered with PROSPERO (CRD42021275477).

Findings

The overall incidence of myopericarditis from 22 studies (405 272 721 vaccine doses) was 33·3 cases (95% CI 15·3–72·6) per million vaccine doses, and did not differ significantly between people who received COVID-19 vaccines (18·2 [10·9–30·3], 11 studies [395 361 933 doses], high certainty) and those who received non-COVID-19 vaccines (56·0 [10·7–293·7], 11 studies [9 910 788 doses], moderate certainty, p=0·20). Compared with COVID-19 vaccination, the incidence of myopericarditis was significantly higher following smallpox vaccinations (132·1 [81·3–214·6], p<0·0001) but was not significantly different after influenza vaccinations (1·3 [0·0–884·1], p=0·43) or in studies reporting on various other non-smallpox vaccinations (57·0 [1·1–3036·6], p=0·58). Among people who received COVID-19 vaccines, the incidence of myopericarditis was significantly higher in males (vs females), in people younger than 30 years (vs 30 years or older), after receiving an mRNA vaccine (vs non-mRNA vaccine), and after a second dose of vaccine (vs a first or third dose).

Interpretation

The overall risk of myopericarditis after receiving a COVID-19 vaccine is low. However, younger males have an increased incidence of myopericarditis, particularly after receiving mRNA vaccines. Nevertheless, the risks of such rare adverse events should be balanced against the risks of COVID-19 infection (including myopericarditis).

Funding

None.

Discrepant serological findings in SARS-CoV-2 PCR negative, hospitalised patients with fever and acute respiratory symptoms during the pandemic

BACKGROUND

COVID-19 serology has an evolving role in the diagnosis of SARS-CoV-2 infection. However, its use in hospitalised patients with acute respiratory symptoms remains unclear.

METHODS

Hospitalised patients with acute respiratory illness admitted to an isolation ward were recruited. All patients had negative nasopharyngeal swab polymerase chain reaction (PCR) for SARS-CoV-2. Serological studies using 4 separate assays (cPass: surrogate neutralising ELISA; Elecsys: N-antigen based chemiluminescent assay; SFB: S protein flow-based; epitope peptide-based ELISA;) were performed on stored plasma collected from patients during the initial hospital stay, and a convalescent visit 4-12 weeks later.

RESULTS

Of the 51 patients studied (aged 54, IQR 21-84; 62.7% male), no patients tested positive on the Elecsys or cPass assays. 5/51 patients had antibodies detected on B-cell Epitope Assay, and 3/51 had antibodies detected on SFB assay. These 8 patients with positive serological test to COVID-19 were more likely to have a high-risk occupation (p=0.039), bacterial infection (p=0.028) and neutrophilia (p=0.013) during their initial hospital admission.

CONCLUSION

Discrepant COVID-19 serological findings were observed amongst those with recent hospital admissions and bacterial infections. The positive serological findings within our cohort raise important questions about the interpretation of sero-epidemiology during the current pandemic. This article is protected by copyright. All rights reserved.

Epidemiological, Clinical, and Phylogenetic Characteristics of the First SARS-CoV-2 Transmission in a Nursing Home of Singapore: A Prospective Observational Investigation

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission has resulted in a significant burden among nursing home facilities globally. This prospective observational cohort study aims to define the potential sources of introduction and characteristics of SARS-CoV-2 transmission of the first nursing home facility in Singapore. An epidemiological serial point-prevalence survey of SARS-CoV-2 was conducted among 108 residents and 56 healthcare staff (HCS). In the current study, 14 (13%) residents and two (3.6%) HCS were diagnosed with coronavirus disease 2019 (COVID-19), with a case fatality rate (CFR) of 28.6% (4/14) among the residents. The median age of the infected residents was 86.5 [interquartile range (IQR) 78.5-88] and 85.7% were women. Five residents were symptomatic (35.7%) and the others were asymptomatic (64.3%). A higher proportion of residents who succumbed to COVID-19 had hypertension than those who recovered. The SARS-CoV-2 whole-genome sequencing showed lineage B.6 which is rare globally but common regionally during the early phase of the pandemic. Household transmission is a potential source of introduction into the nursing home, with at least six epidemiologically linked secondary cases. Male residents were less implicated due to the staff segregation plan by block. Among residents, a higher proportion of the non-survivors were asymptomatic and had hypertension compared with survivors.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2013-2018, Adult and Pediatric Units, Device-associated Module

BACKGROUND

We report the results of INICC surveillance study from 2013 to 2018, in 664 intensive care units (ICUs) in 133 cities, of 45 countries, from Latin-America, Europe, Africa, Eastern-Mediterranean, Southeast-Asia, and Western-Pacific.

METHODS

Prospective data from patients hospitalized in ICUs were collected through INICC Surveillance Online System. CDC-NHSN definitions for device-associated healthcare-associated infection (DA-HAI) were applied.

RESULTS

We collected data from 428,847 patients, for an aggregate of 2,815,402 bed-days, 1,468,216 central line (CL)-days, 1,053,330 mechanical ventilator (MV)-days, 1,740,776 urinary catheter (UC)-days. We found 7,785 CL-associated bloodstream infections (CLAB), 12,085 ventilator-associated events (VAE), and 5,509 UC-associated urinary tract infections (CAUTI). Pooled DA-HAI rates were 5.91% and 9.01 DA-HAIs/1,000 bed-days. Pooled CLAB rate was 5.30/1,000 CL-days; VAE rate was 11.47/1,000 MV-days, and CAUTI rate was 3.16/1,000 UC-days. P aeruginosa was non-susceptible (NS) to imipenem in 52.72% of cases; to colistin in 10.38%; to ceftazidime in 50%; to ciprofloxacin in 40.28%; and to amikacin in 34.05%. Klebsiella spp was NS to imipenem in 49.16%; to ceftazidime in 78.01%; to ciprofloxacin in 66.26%; and to amikacin in 42.45%. coagulase-negative Staphylococci and S aureus were NS to oxacillin in 91.44% and 56.03%, respectively. Enterococcus spp was NS to vancomycin in 42.31% of the cases.

CONCLUSIONS

DA-HAI rates and bacterial resistance are high and continuous efforts are needed to reduce them.

Experiences with latent TB cascade of care strengthening for household contacts in Calgary, Canada

SETTING

Identification, assessment, and treatment of latent TB infection (LTBI), collectively known as the LTBI cascade of care, is critical for TB prevention.

OBJECTIVE

The objective of this research, conducted within the ACT4 trial, was to assess and strengthen the LTBI cascade of care for household contacts at Calgary TB Services, a clinic serving a predominately foreign-born population in Western Canada.

DESIGN

Baseline assessment consisted of a retrospective LTBI cascade analysis of 32 contact investigations, and questionnaires administered to patients and health care workers. Four solutions were implemented in response to identified gaps. Solution impact was measured for 6 months using descriptive statistics.

RESULTS

Pre-implementation, 56% of household contacts initiated treatment. Most contacts were lost to care because the tuberculin skin test (TST) was not initiated, or physicians did not recommend treatment. Evening clinics, a patient education pamphlet, a nursing workshop, and treatment recommendation guidelines were implemented. Post-implementation, losses due to LTBI treatment non-recommendation were reduced; however, the overall proportion of household contacts initiating treatment did not increase.

CONCLUSION

Close engagement between researchers and TB programmes can reduce losses in the LTBI cascade. To see sustained improvement in overall outcomes, long-term engagement and data collection for ongoing problem-solving are required.

Fewer losses in the cascade of care for latent tuberculosis with solo interferon-gamma release assay screening compared to sequential screening

Background

Refugees are at increased risk of developing tuberculosis (TB) soon after resettlement. Targeting high-risk populations for latent tuberculosis infection (LTBI) screening and treatment is an important measure towards eliminating TB in low incidence countries, however, there are low rates of screening and treatment completion in the LTBI cascade of care. The authors hypothesized that an interferon-gamma release assay (IGRA) screening strategy would lead to a higher proportion of refugees completing LTBI screening and treatment, compared to sequential screening with tuberculin skin test (TST) and confirmatory IGRA.

Methods

This retrospective cohort study included eligible refugees screened with a sequential strategy versus a solo-IGRA strategy at different time periods from a centralized refugee clinic. The primary outcome was the proportion completing LTBI screening in each cohort.

Results

A total of 471 subjects were included (240 in sequential screening, 231 in solo-IGRA screening). 54% of refugees completed LTBI screening with sequential testing, compared to 85% of those screened with a solo-IGRA. Time to completing screening was also shorter in the solo-QFT group (difference 16.5 days, p < 0.01, 95% confidence interval 9.3, 23.7). There was a higher incidence of LTBI diagnosis in the solo-IGRA group (41 versus 20, p = 0.002). Screening completion was predicted by solo-IGRA screening (aOR 3.74, 95% confidence interval 2.30, 6.09; p < 0.001) and if refugees were privately-sponsored (aOR 2.81, 95% confidence interval 1.53, 5.15; p = 0.001). Treatment completion rates did not differ between groups.

Conclusion

This study has identified fewer dropouts in the LTBI cascade of care if a solo-IGRA strategy is used for screening. An IGRA should be strongly considered as the screening method for refugees arriving in low-incidence settings if resources are available.

Acute medical units during the first wave of the COVID-19 pandemic: a cross-national exploratory study of impact and responses

BACKGROUND

The COVID-19 pandemic represents one of the greatest ever challenges for healthcare. In the UK and beyond, acute medical units (AMUs) are the first point of assessment and care for the majority of medical inpatients. By their design and systems, they inevitably played an important role in the COVID-19 response but to date little has been published on how the COVID-19 pandemic has affected how AMUs have reorganised their resources, processes and structure.

METHODS

This retrospective study in August 2020 of 10 AMUs across Europe and Australasia used a standardised questionnaire to investigate existing practice and structure of AMUs, the national context of local hospital experience, changes to practice during the COVID-19 pandemic and views regarding future practice.

RESULTS

Changes to AMU structure, process and organisation are described in two contexts: preventing and controlling the spread of COVID-19 and adding value to the patient's acute care journey in the local context. We describe novel practices that have arisen and highlight areas of concern.

CONCLUSIONS

The AMUs were able to adapt to meet the demands of acute care delivery during the first wave of the COVID-19 pandemic. Operational planning and prioritisation of resources must be optimised to ensure sustainability of these services for future waves.

Disinfection capabilities of a 222 nm wavelength ultraviolet lighting device: a pilot study

OBJECTIVE

To demonstrate the efficacy of the SafeZone UVC (Ushio Inc., Japan) 222 nm ultraviolet C (UVC) light to reduce bacterial burden in pressure ulcers (PUs) in human patients. This research is the first human clinical trial using 222 nm UVC in eradicating bacteria in human wounds.

METHOD

Patients with Stage 2 or 3 (as defined by the revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System) sacral or gluteal pressure ulcers (PUs) were subjected to four sessions of 222 nm UVC light therapy over two weeks. Pre- and post-UVC therapy, wound cultures were taken and quantitative analysis of bacterial colony forming units (CFU) were performed.

RESULTS

A total of 68 UV light sessions across 16 different patients were conducted. Of these sessions, 59 (87.0%) sessions showed a reduction in CFU counts, with 20 (29.4%) showing complete eradication of bacteria. Bacteria identified included meticillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa and Klebsiella Pneumoniae. The overall median reduction in CFU of the 68 sessions was 78.9%. No adverse events were reported in any of the UV sessions.

CONCLUSION

In this study, 222 nm UVC light was safe and effective in reducing bacterial CFU counts in sacral and gluteal PUs across numerous different species of bacteria.

Training for outbreak response through the Global Outbreak Alert and Response Network

For 20 years, the Global Outbreak Response and Alert Network (GOARN) has been a leader in the coordination of international outbreak response. On the premise that no single institution can provide all capacities required to successfully respond to a complex public health emergency or fulfil all outbreak response training needs, GOARN embarked on a capacity building journey that draws on the unique strengths of more than 250 partner institutions. Through extensive engagement and collaboration, GOARN Partners have created a bespoke, multifaceted, 3-tiered training programme which has evolved over the last 15 years and enhanced the competencies of thousands of multidisciplinary outbreak responders around the world.

Positive impact of oral hydroxychloroquine and povidone-iodine throat spray for COVID-19 prophylaxis: An open-label randomized trial

Background

We examined whether existing licensed pharmacotherapies could reduce the spread of coronavirus disease 2019 (COVID-19).

Methods

An open-label parallel randomized controlled trial was performed among healthy migrant workers quarantined in a large multi-storey dormitory in Singapore. Forty clusters (each defined as individual floors of the dormitory) were randomly assigned to receive a 42-day prophylaxis regimen of either oral hydroxychloroquine (400 mg once, followed by 200 mg/day), oral ivermectin (12 mg once), povidone-iodine throat spray (3 times/day, 270 μg/day), oral zinc (80 mg/day)/vitamin C (500 mg/day) combination, or oral vitamin C, 500 mg/day. The primary outcome was laboratory evidence of SARS-CoV-2 infection as shown by either: (1) a positive serologic test for SARS-CoV-2 antibody on day 42, or (2) a positive PCR test for SARS-CoV-2 at any time between baseline and day 42.

Results

A total of 3037 asymptomatic participants (mean age, 33.0 years; all men) who were seronegative to SARS-CoV-2 at baseline were included in the primary analysis. Follow-up was nearly complete (99.6%). Compared with vitamin C, significant absolute risk reductions (%, 98.75% confidence interval) were observed for oral hydroxychloroquine (21%, 2–42%) and povidone-iodine throat spray (24%, 7–39%). No statistically significant differences were observed with oral zinc/vitamin C combination (23%, –5 to +41%) and ivermectin (5%, –10 to +22%). Interruptions due to side effects were highest among participants who received zinc/vitamin C combination (6.9%), followed by vitamin C (4.7%), povidone-iodine (2.0%), and hydroxychloroquine (0.7%).

Conclusions

Chemoprophylaxis with either oral hydroxychloroquine or povidone-iodine throat spray was superior to oral vitamin C in reducing SARS-CoV-2 infection in young and healthy men.

Routine antiseptic baths and MRSA decolonization: diverse approaches across Singapore's acute-care hospitals

To determine the variation in practices on meticillin-resistant Staphylococcus aureus (MRSA) surveillance and management of MRSA-colonized patients amongst 17 acute healthcare facilities in Singapore, the Ministry of Health convened a sharing session with Infection Prevention and Control Leads. All hospitals practised close to universal MRSA entry swabbing in keeping with national policy. There were, however, major variations in the response to both positive and negative surveillance swabs across facilities including the role of routine antiseptic bathing and MRSA decolonization. Most undertaking decolonization considered its role to be in 'bioburden reduction' rather than longer-term clearance.

Predictors and Clinical Outcomes of Poor Platelet Recovery in Adult Dengue With Thrombocytopenia: A Multicenter, Prospective Study

BACKGROUND

Platelet transfusion is common in dengue patients with thrombocytopenia. We previously showed in a randomized clinical trial that prophylactic platelet transfusion did not reduce clinical bleeding. In this study, we aimed to characterize the predictors and clinical outcomes of poor platelet recovery in transfused and nontransfused participants.

METHODS

We analyzed patients from the Adult Dengue Platelet Study with laboratory-confirmed dengue with ≤20 000 platelets/μL and without persistent mild bleeding or any severe bleeding in a post hoc analysis. Poor platelet recovery was defined as a platelet count of ≤20 000/μL on Day 2. We recruited 372 participants from 5 acute care hospitals located in Singapore and Malaysia between 29 April 2010 and 9 December 2014. Of these, 188 were randomly assigned to the transfusion group and 184 to the control group.

RESULTS

Of 360 patients, 158 had poor platelet recovery. Age, white cell count, and day of illness at study enrollment were significant predictors of poor platelet recovery after adjustment for baseline characteristics and platelet transfusion. Patients with poor platelet recovery had longer hospitalizations but no significant difference in other clinical outcomes, regardless of transfusion. We found a significant interaction between platelet recovery and transfusion; patients with poor platelet recovery were more likely to bleed if given a prophylactic platelet transfusion (odds ratio 2.34, 95% confidence interval 1.18-4.63).

CONCLUSIONS

Dengue patients with thrombocytopenia who were older or presented earlier and with lower white cell counts were more likely to have poor platelet recovery. In patients with poor platelet recovery, platelet transfusion does not improve outcomes and may actually increase the risk of bleeding. The mechanisms of poor platelet recovery need to be determined.

CLINICAL TRIALS REGISTRATION

NCT01030211.

SARS-CoV-2 in migrant worker dormitories: Geospatial epidemiology supporting outbreak management

Background

Migrant worker dormitories—residential complexes where 10–24 workers share living spaces—account for the majority of cases of SARS-CoV-2 infection in Singapore. To prevent overspill of transmission to the wider population, starting in early April 2020, residents were confined to their dormitories while measures were put in place to arrest the spread of infection. This descriptive study presents epidemiological data for a population of more than 60 000 migrant workers living in two barracks-style and four apartment-style dormitories located in western Singapore from April 3 to June 10, 2020.

Methods

Our report draws from data obtained over the first 50 days of outbreak management in order to describe SARS-CoV-2 transmission in high-density housing environments. Cumulative counts of SARS-CoV-2 cases and numbers of housing units affected were analyzed to report the harmonic means of harmonic means of doubling times and their 95% confidence intervals (CI).

Results

Multiple transmission peaks were identified involving at least 5467 cases of SARS-CoV-2 infection across six dormitories. Our geospatial heat maps gave an early indication of outbreak severity in affected buildings. We found that the number of cases of SARS-CoV-2 infection doubled every 1.56 days (95% CI 1.29–1.96) in barracks-style buildings. The corresponding doubling time for apartment-style buildings was 2.65 days (95% CI 2.01–3.87).

Conclusions

Geospatial epidemiology was useful in shaping outbreak management strategies in dormitories. Our results indicate that building design plays an integral role in transmission and should be considered in the prevention of future outbreaks.

Transmission modes of severe acute respiratory syndrome coronavirus 2 and implications on infection control: a review

The complete picture of transmission modes of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is unknown. This review summarises the available evidence of its transmission modes, our preliminary research findings and implications on infection control policy, and outlines future research directions. Environmental contamination has been reported in hospital settings occupied by infected patients, and is higher in the first week of illness. Transmission via environmental surfaces or fomites is likely, but decontamination protocols are effective in minimising this risk. The extent of airborne transmission is also unclear. While several studies have detected SARS-CoV-2 RNA in air samples, none has isolated viable virus in culture. Transmission likely lies on a spectrum between droplet to airborne transmission depending on patient, disease and environmental factors. Singapore's current personal protective equipment and isolation protocols are sufficient to manage this risk.

Rapid publications risk the integrity of science in the era of COVID-19

BACKGROUND

Preprint manuscripts, rapid publications and opinion pieces have been essential in permitting the lay press and public health authorities to preview data relating to coronavirus disease 2019 (COVID-19), including the range of clinical manifestations and the basic epidemiology early on in the pandemic. However, the rapid dissemination of information has highlighted some issues with communication of scientific results and opinions in this time of heightened sensitivity and global concern.

MAIN TEXT

Rapid publication of COVID-19 literature through expedited review, preprint publications and opinion pieces are important resources for the medical scientific community. Yet the risks of unverified information loom large in times when the healthcare community is desperate for information. Information that has not been properly vetted, or opinion pieces without solid evidence, may be used to influence public health policy decisions. We discuss three examples of unverified information and the consequences in this time of high anxiety surrounding COVID-19.

CONCLUSIONS

In an era when information can be widely and swiftly disseminated, it is important to ensure that the scientific community is not an inadvertent source of misinformation. This will require a multimodal approach, with buy-in from editors, publishers, preprint servers, authors and journalists. The landscape of medical publications has changed, and a collaborative approach is required to maintain a high standard of scientific communications.

Resource implications of the latent tuberculosis cascade of care: a time and motion study in five countries

BACKGROUND

The End TB Strategy calls for global scale-up of preventive treatment for latent tuberculosis infection (LTBI), but little information is available about the associated human resource requirements. Our study aimed to quantify the healthcare worker (HCW) time needed to perform the tasks associated with each step along the LTBI cascade of care for household contacts of TB patients.

METHODS

We conducted a time and motion (TAM) study between January 2018 and March 2019, in which consenting HCWs were observed throughout a typical workday. The precise time spent was recorded in pre-specified categories of work activities for each step along the cascade. A linear mixed model was fit to estimate the time at each step.

RESULTS

A total of 173 HCWs in Benin, Canada, Ghana, Indonesia, and Vietnam participated. The greatest amount of time was spent for the medical evaluation (median: 11 min; IQR: 6-16), while the least time was spent on reading a tuberculin skin test (TST) (median: 4 min; IQR: 2-9). The greatest variability was seen in the time spent for each medical evaluation, while TST placement and reading showed the least variability. The total time required to complete all steps along the LTBI cascade, from identification of household contacts (HHC) through to treatment initiation ranged from 1.8 h per index TB patient in Vietnam to 5.2 h in Ghana.

CONCLUSIONS

Our findings suggest that the time requirements are very modest to perform each step in the latent TB cascade of care, but to achieve full identification and management of all household contacts will require additional human resources in many settings.

Carica papaya seed extract slows human sperm

ETHNOPHARMACOLOGICAL RELEVANCE

Traditional healers use Carica papaya seeds as a remedy for diseases and as a contraceptive for men and abortion in women.

MATERIAL AND METHODS

Semen samples from 35 healthy men were allowed to liquefy and subsequently incubated for 60 min in Human Tubular Fluid medium containing 1% bovine serum albumin with aqueous C. papaya seed extract at concentrations of zero, 0.025, 0.25, 2.5, 25, 250 and 2500 μg/ml. Afterwards, sperm were washed and used for assessment of capacitation and acrosome reaction, DNA fragmentation, vitality, motility, reactive oxygen species (ROS) and mitochondrial membrane potential (MMP).

RESULTS

The extract showed no effects on straight-line velocity, linearity, straightness, beat-cross frequency and the percentage of capacitated, acrosome-reacted sperm. In contrast, vitality, total motility, progressive motility, curvilinear velocity, average-path velocity and the percentages of hyper-activated, ROS-positive and MMP-intact sperm decreased significantly (P < 0.05), while the percentage of DNA-fragmented sperm increased (P < 0.05).

CONCLUSIONS

Our data show that aqueous C. papaya seed extract significantly and negatively affects sperm motility parameters crucial for fertility; and thus, poses as a likely candidate for male contraception.

Distinguishing Zika and Dengue Viruses through Simple Clinical Assessment, Singapore

Dengue virus and Zika virus coexist in tropical regions in Asia where healthcare resources are limited; differentiating the 2 viruses is challenging. We showed in a case–control discovery cohort, and replicated in a validation cohort, that the diagnostic indices of conjunctivitis, platelet count, and monocyte count reliably distinguished between these viruses.