From SARS in 2003 to H1N1 in 2009: lessons learned from Taiwan in preparation for the next pandemic

Impact of COVID-19 pandemic on neurodevelopmental outcomes of premature infants: a retrospective national cohort study

OBJECTIVE

To compare the neurodevelopmental outcomes of preterm infants before and during the COVID-19 pandemic.

DESIGN

Premature infants born in 2018 were assigned to the pre-pandemic group, while those born in 2019 were assigned to the during-pandemic group.

SETTING

Nationwide cohort study.

PATIENTS

Very low birthweight premature infants registered in the Taiwan Premature Infant Follow-up Network database.

INTERVENTIONS

Anti-epidemic measures, including quarantine and isolation protocols, social distancing, the closure of public spaces and restrictions on travel and gatherings during COVID-19 pandemic.

MAIN OUTCOME MEASURES

Outcomes were measured by Bayley Scales of Infant and Toddler Development Third Edition at corrected ages of 6, 12 and 24 months old. Generalised estimating equation (GEE) was applied to incorporate all measurements into a single model.

RESULTS

Among the 1939 premature infants who were enrolled, 985 developed before the pandemic, while 954 developed during the pandemic. Premature infants whose development occurred during the pandemic exhibited better cognitive composite at the corrected age of 6 months (beta=2.358; 95% CI, 1.07 to 3.65; p<0.001), and motor composite at corrected ages of 12 months (beta=1.680; 95% CI, 0.34 to 3.02; p=0.014). GEE analysis showed that infants who had grown during the pandemic achieved higher scores in cognitive composite (beta=1.416; 95% CI, 0.36 to 2.48; p=0.009).

CONCLUSION

Premature infants in Taiwan who developed during the pandemic showed better neurodevelopment compared with those born before the pandemic.

Trend Analysis of Inpatient Medical Adverse Events in Taiwan (2014-2020): Findings From Taiwan Patient Safety Reporting System

OBJECTIVES

Medical adverse event (MAE) reporting and management are essential for patient safety campaigns. An epidemiological assessment of MAE trends is crucial for understanding the effectiveness of patient safety improvement efforts. This study analyzed the trends of inpatient MAEs, focusing on MAE incidence and harm severity.

METHODS

Longitudinal secondary data (over 2014-2020) on MAEs reported by 18 hospitals were retrieved from the Taiwan Patient-safety Reporting system. The numbers and incidence rates (per 1000 inpatient days) of reported MAEs were calculated. The harm severity levels of six major MAE categories were analyzed. Trend and generalized estimating equation analyses were conducted to investigate changes in MAE patterns.

RESULTS

Trend analyses revealed significant decreasing trends in the number (4763-3107 per year; Jonckheere-Terpstra test = -1.952, P = 0.05) and incidence rates (0.92-0.62 per 1000 inpatient days; β = -0.5017, P = 0.00) of harmful MAEs over 7-year study period. Among the most frequently reported MAEs, tube-related events exhibited the most significant decreasing trend (28%-23.8%; Jonckheere-Terpstra test = -2.854, P = 0.00). The reported numbers, incidence rates, and severity of falls and tube-related events dropped significantly.

CONCLUSIONS

By analyzing representative longitudinal MAE data, this study demonstrated the effectiveness of nationwide patient safety improvement campaigns in Taiwan. Our data reveal significant reductions in the reported numbers, incidence rates, and severity of several major MAEs. Specifically, our data indicate significant reductions in the incidence and severity of tube-related events, which can be beneficial for patient safety improvement efforts.

Modelling a two-stream emergency department segregation and admission system from COVID-19 early rapid antigen testing: A pilot study

OBJECTIVE

Many factors influence patient flow through an ED, including streaming, treatment spaces and staff resources. This pilot study explored and compared real time patient flow using a single-stream system versus varying configurations of possible two-stream systems using computer simulation.

METHODS

Simulation modelling was used to assess the delay in treatment of a rapid-antigen-tested-based, two-stream model for patient flow through ED during the peak phase of the COVID pandemic.

RESULTS

Modelling two-stream configuration for all patients (minimum time to be seen for both COVID-positive and COVID-negative patients) showed that in the case study ED, a two-stream system and linked changes in bed configuration for managing the risks of infection can impact delays in treatment.

CONCLUSIONS

Data-driven modelling within specific clinical settings can inform the (in)efficiency of patient flow processes and help clinicians and managers make evidence-based decisions about patient transition through EDs. This can assist with reconfiguration of ED patient streaming particularly during periods of unique need, such as the recent COVID-19 pandemic.

Analysis of effectiveness and outcome of traumatic brain injury treatment in ED during COVID-19 pandemic: A multicenter in Taiwan

The coronavirus disease 2019 has become a threat to global healthcare because of its rapid spread and evolution. In severe cases, the initial management of the disease is mainly supportive therapy and mechanical ventilation. Therefore, we investigated whether a modified emergency department workflow affects the efficacy will influence the efficacy and patient outcomes of traumatic brain injury (TBI) in Taiwan. This retrospective observational study used the Chang Gung Research Database in Taiwan from 7 hospitals in the Chang Gung Memorial Hospital System. Clinical index parameters and treatment efficiencies were analyzed between the locally transmitted period (January 20, 2020-June 7, 2020, period 2) and the community spread period (May 19, 2021-July 27, 2021, period 4) with the same interval of the pre-pandemic in 2019 as a reference period. During the locally transmitted period, only the time interval for patients who had to wait for a brain CT examination was, on average, 7.7 minutes shorter, which reached statistical significance. In addition, the number of TBI patients under 18 years of age decreased significantly during the community spread period. The "Door to the operating room (OR)," with polymerase chain reaction (PCR) testing, was on average 109.7 minutes slower than without the PCR testing in the reference period 2019. TBI treatment efficiency was delayed because of the PCR test. However, the surgical volume and functional outcome during these 2 periods were statistically insignificant compared to the pre-pandemic period because the spread of the virus was well controlled and hospital capacity was increased.

The Impact of School Closures during COVID-19 Lockdown on Visual-Motor Integration and Block Design Performance: A Comparison of Two Cohorts of Preschool Children

The COVID-19 outbreak has led to the closure of educational institutions, which may prevent children from attaining skills essential for learning, such as visual-motor integration (VMI) and visuospatial constructional ability (often reflected with the Block Design Test, BDT). This study compares VMI and BDT performance between a pre-pandemic cohort (children who attended preschool in late 2019) and a post-pandemic cohort (those physically attending preschool for the first time at the end of 2021). Participants were children attending government preschools with similar syllabi catered for low-income families. The pre-pandemic cohort was part of an earlier study (n = 202 for VMI and n = 220 for BDT) before lockdowns commenced in March 2020. The post-pandemic cohort comprised 197 children who completed the Beery-VMI and 93 children who completed the BDT. Compared to the pre-pandemic cohort, the post-pandemic cohort had significantly lower mean Beery-VMI scores (t(397) = 3.054, p = 0.002) and was 3.162-times more likely to have a below average Beery-VMI score (OR = 3.162 (95% CI 1.349, 7.411)). The post-pandemic cohort also had significantly lower BDT scores than the pre-pandemic cohort (t(311) = -5.866, p < 0.001). In conclusion, children with disrupted conventional preschool education due to the COVID-19 lockdowns were more likely to have below-average VMI and lower BDT scores.

COVID-19 community assessment hubs in Ireland: A study of staff and patient perceptions of their value

BACKGROUND

Critical care bed capacity per capita in Ireland is among the lowest in Europe. The COVID-19 pandemic has put additional strain on an over-stretched healthcare system. COVID-19 community assessment hubs (CAHs) were established to prevent unnecessary admission to acute hospitals and to reduce infection spread.

OBJECTIVE

The aim of this study was to assess the effectiveness and acceptability of CAHs and identify how the service might be improved or adapted for possible future use.

DESIGN

This was a mixed methods study, incorporating co-design with clinical stakeholders. Data collection was via an online survey and semistructured telephone interviews with staff and patients conducted between January and May 2021.

SETTING AND PARTICIPANTS

Thirty-one patients completed the survey and nine were interviewed. Twenty interviews were conducted with staff.

RESULTS

The findings suggest that the CAH model was successful in providing a dedicated pathway for assessing patients with COVID-19 symptoms, whilst mitigating the risk of infection. Patients were particularly positive about the timely, comprehensive and holistic care they received, as well as the accessibility of the clinics and the friendly attitudes of the staff. Staff welcomed the training and clinical protocols which contributed to their feelings of safety and competency in delivering care to this cohort of patients. They also highlighted the benefits of working in a multidisciplinary environment. Both staff and patients felt that the hubs could be repurposed for alternative use, including the treatment of chronic diseases.

DISCUSSION

This study describes staff and patients' experiences of these hubs. An unexpected outcome of this study is its demonstration of the true value of effective multidisciplinary working, not only for the staff who were deployed to this service but also for the patients in receipt of care in these hubs.

CONCLUSION

This multidisciplinary patient-centred service may provide a useful model for the delivery of other services currently delivered in hospital settings.

PATIENT OR PUBLIC CONTRIBUTION

An earlier phase of this study involved interviews with COVID-19-positive patients on a remote monitoring programme. The data informed this phase. Several of the authors had worked in the CAHs and provided valuable input into the design of the staff and patient interviews.

Psychological impact, coping behaviors, and traumatic stress among healthcare workers during COVID-19 in Taiwan: An early stage experience

OBJECTIVE

This study investigated the psychological impact on, coping behaviors of, and traumatic stress experienced by healthcare workers during the early stage of the COVID-19 pandemic and formulated effective support strategies that can be implemented by hospitals and government policymakers to help healthcare staff overcome the pandemic.

METHODS

This cross-sectional study recruited clinical healthcare workers at a regional hospital in Nantou County, Taiwan. The questionnaire collected personal characteristics, data on the impact and coping behaviors of the pandemic, and Impact of Event Scale-Revised (IES-R). A total of 354 valid questionnaires were collected. The statistical methods employed were univariate and multivariate stepwise regression, and logistic regression.

RESULTS

Perceived impact and coping behaviors were found to be moderate in degree, and traumatic stress was lower than that in other countries. However, our data identified the following subgroups that require special attention: those with young age, those living with minor children, nurses, those with self-rated poor mental health, and those with insufficient COVID-19-related training.

CONCLUSION

Managers should pay particular attention to helping healthcare workers in high-risk groups, strengthen COVID-19 training, provide adequate protective equipment and shelter, and offer psychological counseling.

Disaster Preparedness: Hospital Pharmacy Strategy for Prioritized Inventory Management and Drug Procurement on Vancouver Island

Disaster events can increase demand for medication supplies and interfere with supply chains, leading to compromised care in hospitals. Providing an organized response to an additional surge of disaster-related patients requires pre-planned emergency management procedures. Hospital pharmacists can address this with prioritized drug procurement and inventory management strategies which may improve the availability of key medications for a disaster response. Previous disaster events have provided insight on medications used to treat disaster-related injuries and exacerbations of medical conditions in emergency departments. This article provides a detailed description of Vancouver Island's hospital pharmacy strategy for the procurement and minimum stock levels of high priority medications in preparation for a disaster.

The implications of the COVID-19 pandemic for long term care facilities

PURPOSE OF REVIEW

Despite advances in infection prevention and control and breakthroughs in vaccination development, challenges remain for long-term care facilities (LTCFs) as they face a likely future of emerging infectious diseases. To ensure the safety of LTCF residents from the current and future pandemics, we identify lessons learned from the coronavirus disease 2019 (COVID-19) experience for improving future prevention and response efforts.

RECENT FINDINGS

In addition to high disease susceptibility among LTCF residents, LTCF vulnerabilities include a lack of pandemic preparedness, a lack of surge capacity in human, material and testing resources, and poorly designed buildings. External sources of vulnerability include staff working in multiple LTCFs and high COVID-19 rates in surrounding communities. Other challenges include poor cooperation between LTCFs and the other components of health systems, inadequately enforced regulations, and the sometimes contradictory interests for-profit LTCFs face between protecting their residents and turning a profit.

SUMMARY

These challenges can be addressed in the post-COVID-19 period through systemic reforms. Governments should establish comprehensive health networks that normalize mechanisms for prediction/preparedness and response/recovery from disruptive events including pandemics. In addition, governments should facilitate cooperation among public and private sector health systems and institutions while utilizing advanced digital communication technologies. These steps will greatly reduce the threat to LTCFs posed by emerging infectious diseases in future.

State and citizen responsiveness in fighting a pandemic crisis: A systems thinking perspective

Management scholars have recognized organizational responsiveness among the essential capabilities of social organizations. It becomes essential for a social change to occur during a crisis, where the uncertainty or environmental dynamism is high. However, a social change cannot be successful unless constituent subsystems of a social organization exhibit responsiveness. Using systems theory, we conceptualize 'nation' as a social system and examine its responsiveness towards environmental uncertainly, taking an example of the COVID-19 pandemic. How can state and citizen community responsiveness help fight a pandemic crisis? We test these direct and moderating effects on data representing 14 countries. We perform a hierarchical regression analysis on the restructured, balanced country-wise panel data. Our findings highlight the importance of state and community interaction effects in controlling pandemic growth. Accordingly, we claim that only a collaborative approach by citizen communities with the respective governments will enable handling an uncertain situation.

An Easy-to-Use Public Health-Driven Method (the Generalized Logistic Differential Equation Model) Accurately Simulated COVID-19 Epidemic in Wuhan and Correctly Determined the Early Warning Time

Introduction

Modeling on infectious diseases is significant to facilitate public health policymaking. There are two main mathematical methods that can be used for the simulation of the epidemic and prediction of optimal early warning timing: the logistic differential equation (LDE) model and the more complex generalized logistic differential equation (GLDE) model. This study aimed to compare and analyze these two models.

Methods

We collected data on (coronavirus disease 2019) COVID-19 and four other infectious diseases and classified the data into four categories: different transmission routes, different epidemic intensities, different time scales, and different regions, using R2 to compare and analyze the goodness-of-fit of LDE and GLDE models.

Results

Both models fitted the epidemic curves well, and all results were statistically significant. The R2 test value of COVID-19 was 0.924 (p &lt; 0.001) fitted by the GLDE model and 0.916 (p &lt; 0.001) fitted by the LDE model. The R2 test value varied between 0.793 and 0.966 fitted by the GLDE model and varied between 0.594 and 0.922 fitted by the LDE model for diseases with different transmission routes. The R2 test values varied between 0.853 and 0.939 fitted by the GLDE model and varied from 0.687 to 0.769 fitted by the LDE model for diseases with different prevalence intensities. The R2 test value varied between 0.706 and 0.917 fitted by the GLDE model and varied between 0.410 and 0.898 fitted by the LDE model for diseases with different time scales. The GLDE model also performed better with nation-level data with the R2 test values between 0.897 and 0.970 vs. 0.731 and 0.953 that fitted by the LDE model. Both models could characterize the patterns of the epidemics well and calculate the acceleration weeks.

Conclusion

The GLDE model provides more accurate goodness-of-fit to the data than the LDE model. The GLDE model is able to handle asymmetric data by introducing shape parameters that allow it to fit data with various distributions. The LDE model provides an earlier epidemic acceleration week than the GLDE model. We conclude that the GLDE model is more advantageous in asymmetric infectious disease data simulation.

Interaction between science advice and policymaking in time of COVID-19: a French perspective

Background

In the coronavirus disease 2019 (COVID-19) context, many governments relied on scientific consultative bodies to advise their policy, but their contribution remains poorly documented. This article aims to fill this gap by reviewing the role played by the French High Council for Public Health (HCSP) in the French government’s response to COVID-19.

Methods

We studied the time distribution of the COVID-19 guidelines produced by the HCSP until November 2020, computed their delay of production and analyzed the thematic areas they cover. To assess their use by the authorities, we looked for references to these guidelines in the regulatory texts, protocols and press communicates issued by national and local authorities until January 2021.

Results

The HCSP was strongly demanded with 102 guidelines produced following 97 official requests and two self-referrals. Most of them (N = 43) concerned protective measures to constrain the infection, while health inequalities and mental health were poorly addressed. Timing was very constraint as half of the guidelines were requested within 4 days. In total, 73% of the guidelines were used by policymakers to implement new obligations or within communication toward the public at national and local levels.

Conclusions

This article informs on the HCSP’s contribution during the crisis and stresses the difficulties it encountered to provide quality recommendations in very short times. It prompts governments to enlarge the competencies of their advisory boards and to consider the multidimensional aspects of health in policy design.

Perceptions of teachers towards COVID appropriate behaviors for school children in coastal South India

COVID appropriate behavioral measures need to be followed once school reopens. School teachers being in the forefront could substantiate the feasibility of suggested safety measures. This study aimed to assess teachers’ perceptions towards COVID appropriate behaviors for children with school reopening and compare their mean scores between public versus private schools and across school boards. We conducted an observational school-based study of teachers over two months. Perceptions were scored using a five-point Likert symmetric agree to disagree scale. Results were expressed as proportions and analyzed using an independent sample t-test. Of the 547 teachers surveyed, most (> 90%) agreed to the suggested social distancing and hygiene measures. There was a significant difference in perception scores between private versus public schools and across boards regarding i) reducing the academic syllabus, ii) adopting a cloud-based system to integrate online-offline learning, and iii) conducting meetings online. In addition, measures such as i) teaching classes on alternate days with a limited number of children, ii) arranging benches/desks to maintain six feet distance between students, iii) dealing with psychological stress by counselors, and iv) arrangement with local hospitals for medical services were significant statistically across school boards. To conclude, most schoolteachers agreed with the need for social distancing and hygiene measures for children. There was a significant difference in perceptions between public versus private schools and across boards regarding academic syllabus, integration of online-offline student learning, number of children per class, the timing of classes, student seating arrangement, and medical/psychological guidance availability.

Managing surgical patients with a COVID-19 infection in the operating room: An experience from Indonesia

Background

The Coronavirus and the COVID-19 pandemic in 2020 have significantly impacted hospital care, including surgery practice. Hospitals must balance patient care, staff safety, resource availability, and medical ethics. Differences in community infection trends, national policies, availability of resources and technology, plus local circumstances may make uniform management impossible globally. This paper described the practical workflow of emergency COVID-19 surgery in a tertiary referral national hospital in Indonesia.

Method

This study focused on the process of preparation for COVID-19 surgery from March 2020-March 2021. We also described the available facilities in terms of equipment and human resources.

Results

Steps of COVID-19 surgery preparations were described, such as the setup of general and infectious triage in the emergency department, development of preoperative screening protocol for COVID-19, designation of a specialized COVID-19 operating room and surgical staff, changes in preoperative surgery and anesthesia workflow, development of checklists and postoperative monitoring on staff health.

Conclusions

Changes in the workflow are essential during the pandemic for safe surgery. These changes require a multidisciplinary approach, communication, and a continued willingness to adapt. We recommend local adaptation of our general workflow for emergency surgery during an epidemic or pandemic.

Digital Solutions to Alleviate the Burden on Health Systems During a Public Health Care Crisis: COVID-19 as an Opportunity

The COVID-19 pandemic has generated unprecedented and sustained health management challenges worldwide. Health care systems continue to struggle to support the needs of the majority of infected individuals that are either asymptomatic or have mild symptoms. In addition, long-term effects in the form of long-lasting COVID-19 symptoms or widespread mental health issues aggravated by the pandemic pose a burden on health care systems worldwide. This viewpoint article considers aspects of digital health care solutions and how they can play an ongoing role in safely addressing gaps in the health care support available from initially and repeatedly overwhelmed providers and systems. Digital solutions can be readily designed to address this need and can be flexible enough to adapt to the evolving management requirements of various stakeholders to reduce COVID-19 infection rates, acute hospitalizations, and mortality. Multiplatform solutions provide a hybrid model of care, which can include mobile and online platforms accompanied by direct clinician input and feedback. Desirable components to be included are discussed, including symptom tracking, patient education, well-being support, and bidirectional communication between patients and clinicians. Customizable and scalable digital health platforms not only can be readily adapted to further meet the needs of employers and public health stakeholders during the ongoing pandemic, but also hold relevance for flexibly meeting broader care management needs into the future.

The experience of executing preventive measures to protect a nursing home in Taiwan from a COVID-19 outbreak

PURPOSE

We share our strategies for preventing the COVID-19 outbreak in a nursing home in Taiwan.

METHODS

We compared the number of outpatient department visits, the days of prescription from the outpatient department, the number of emergency department visits of the nursing home residents and staff, the number of admissions, and the days of admission of the residents for respiratory tract infection treatment between 2019 and 2020 to examine the effect of our preventive measures in the nursing home. Residents and staff who continuously lived and worked in the nursing home from 2019 to 2020 were included. The differences in outcomes between 2019 and 2020 were examined using paired sample t tests. The multivariate analyses were presented through generalized estimating equation analysis.

RESULTS

A cohort of 183 residents and 127 staff was included and their electronic medical documentation was analyzed in two periods: January-September 2019 and January-September 2020. These residents had lower numbers of outpatient department visits (P < 0.001), days of prescription from the outpatient department (P < 0.001), number of emergency department visits (P < 0.001), number of admissions (P < 0.001), and days of admission (P < 0.001) to treat respiratory tract infections from January-September 2020 than January-September 2019. These staff members had lower numbers of outpatient department visits (P = 0.015) and days of prescription from the outpatient department (P = 0.009) to treat respiratory tract infections from January-September 2020 than January-September 2019.

CONCLUSION

The association between our preventive measures and decreasing the risk of respiratory tract infection in nursing home residents and staff could be found. Sharing these experiences is valuable, as they provide important insights related to clinical practice during the COVID-19 pandemic.

A mixed methods protocol to evaluate the effectiveness and acceptability of COVID-19 Community Assessment Hubs

Background: Ireland's health system has been under significant strain due to staff shortages and inadequate capacity. Critical care bed capacity per capita in Ireland is among the lowest in Europe, thus, the coronavirus disease 2019 (COVID-19) pandemic has put additional strain on an over-stretched system. COVID-19 Community Assessment Hubs (CAHs) were established to mitigate unnecessary admission to acute hospitals, and reduce infection spread by supporting COVID-19 positive or suspected positive patients to isolate at home, or in isolation facilities. There is some evidence that similar assessment centres may be a successful triage strategy to reduce burden on hospital and acute care. Aim : The aim of this study is to evaluate the impact of COVID-19 Community Assessment Hubs on service delivery in two regions in Ireland during the pandemic. Methods: A mixed-methods approach will be used, incorporating co-design to engage stakeholders and ensure informed data capture and analysis. Online surveys will assess CAH patients' experiences of access to and quality of care. Clinical patient data from CAHs will be collected and analysed using multinomial logistic regression to check for association with patient demographics and COVID-19 symptoms, and CAH early warning scores and outcomes (Transfer to Emergency Department, Transfer to isolation unit, Sent home with care plan). Semi-structured interviews will be conducted with: patients to elicit an in-depth understanding of experiences and acceptability of attending CAHs; and staff to understand challenges, benefits, and effectiveness of CAHs. Interview data will be analysed using thematic analysis. Discussion: This study will provide valuable insights from both patient and staff perspectives on the operation of CAHs. We will evaluate the effectiveness and acceptability of CAHs and propose areas for improvement of the service. This will contribute to international literature on the use of community assessment centres during infectious disease pandemics.

How Gameful Experience Affects Public Knowledge, Attitudes, and Practices Regarding COVID-19 Among the Taiwanese Public: Cross-sectional Study

Background

In 2019, with the COVID-19 pandemic sweeping across the globe, public health systems worldwide faced severe challenges. Amid the pandemic, one simulation game, Plague Inc., has received substantial attention. This game has indirectly drawn greater public attention to public health issues by simulating pathogen transmission and disease symptoms.

Objective

Against this backdrop, this research investigates whether the gameful experience of Plague Inc. has indirectly affected public knowledge, attitudes, and practices (KAP) regarding COVID-19.

Methods

An online survey was conducted through social networking services in Taiwan from May 6-28, 2020.

Results

A total of 486 subjects participated in this study, of which 276 (56.8%) had played Plague Inc. This study had several findings. First, participants who had played Plague Inc. demonstrated higher levels of knowledge (P=.03, median 7, IQR 7-8) and attitudes (P=.007, median 8, IQR 7-8) than participants who had not played Plague Inc. (knowledge: median 7, IQR 6-8; attitude: median 7, IQR 6-8). Second, there was a significant correlation between creative thinking (ρ=.127, P=.04) and dominance (ρ=.122, P=.04) in attitude. Finally, there was a significant correlation between creative thinking (ρ=.126, P<.001) and dominance (ρ=.119, P=.049) in practice.

Conclusions

Serious games highlighting the theme of pathogen transmission may enhance public knowledge and attitudes regarding COVID-19. Furthermore, the creative thinking and dominance involved in gameful experiences may act as critical factors in public attitudes and practices regarding COVID-19. These findings should be further verified through experimental research in the future.

Facing the Coronavirus Pandemic: An Integrated Continuing Education Program in Taiwan

This study aimed to identify knowledge gaps regarding coronavirus disease 2019 (COVID-19) and develop an integrated educational program for healthcare workers. First, we designed and validated ten multiple-choice questions to identify knowledge gaps among healthcare workers. Within one month of the online test and curriculum offering, 5533 staff had completed the test, with a completion rate of 84.97%. There were 2618 healthcare workers who answered the pre-test 100% correctly. Those who did not answer the pre-test 100% correctly took multiple tests after learning through the online teaching materials. Eventually, 5214 staff passed the test (pre-test or post-test with 100% correct answers). The result showed that all staff had a low correct rate for personal protective equipment (PPE) use recommendations. The Infection Control Center conducted training sessions for hospital staff on how to wear protective clothing. Information on the selection and use of PPE for infection prevention was provided, and participants were allowed time to practice and familiarize themselves with the correct way to wear PPE. Moreover, the Department of Education and Research continued updating the online learning materials based on the most important updated peer-reviewed published articles. The attending teaching physicians helped to search, translate, and take notes on articles in the local language (traditional Chinese) for other colleagues to read easily. We expect to increase learning opportunities for healthcare workers, even during uncertain times such as the current coronavirus pandemic through (1) the hospital-wide course announcements, (2) the continuous placement of test questions and learning files on the digital learning platform, (3) the placement of journal highlights in cloud folders, and (4) the use of the digital learning platform on mobile phones accessible outside the hospital.

A mixed methods protocol to evaluate the effectiveness and acceptability of COVID-19 Community Assessment Hubs

Background: Ireland's health system has been under significant strain due to staff shortages and inadequate capacity. Critical care bed capacity per capita in Ireland is among the lowest in Europe, thus, the coronavirus disease 2019 (COVID-19) pandemic has put additional strain on an over-stretched system. COVID-19 Community Assessment Hubs (CAHs) were established to mitigate unnecessary admission to acute hospitals, and reduce infection spread by supporting COVID-19 positive or suspected positive patients to isolate at home, or in isolation facilities. There is some evidence that similar assessment centres may be a successful triage strategy to reduce burden on hospital and acute care. Aim : The aim of this study is to evaluate the impact of COVID-19 Community Assessment Hubs on service delivery in one region in Ireland. Methods: A mixed-methods approach will be used, incorporating co-design to engage stakeholders and ensure informed data capture and analysis. Online surveys will assess CAH patients' experiences of access to and quality of care. Clinical patient data from CAHs will be collected and analysed using multinomial logistic regression to check for association with patient demographics and COVID-19 symptoms, and CAH early warning scores and outcomes (Transfer to Emergency Department, Transfer to isolation unit, Sent home with care plan). Semi-structured interviews will be conducted with: patients to elicit an in-depth understanding of experiences and acceptability of attending CAHs; and staff to understand challenges, benefits, and effectiveness of CAHs. Interview data will be analysed using a thematic analysis approach. Discussion: This study will provide valuable insights from both patient and staff perspectives on the operation of CAHs. We will evaluate the effectiveness and acceptability of CAHs and propose areas for improvement of the service. This will contribute to international literature on the use of community assessment centres during infectious disease pandemics.

Evidence-based review of safe theatre practice during the COVID-19 pandemic beyond personal protective equipment

INTRODUCTION

COVID-19 remains a threat for a fear of a second pandemic. Emergency orthopaedic operations are still among the most commonly performed procedures with increased risk of transmission of SARS CoV-2 to the patients and the healthcare workers. The aim of this study was to present the evidence available into best practices limiting the spread of COVID-19 in healthcare setting during current and future pandemics.

METHODS

A review of the literature was performed in multiple databases (PubMed, the Cochrane Library, Google Scholar, World Health Organization and Centers for Disease Control), using 'COVID-19' with other relevant keywords in different combinations. Owing to the limited and heterogenous evidence available, data were presented in a narrative manner.

FINDINGS

From the evidence gathered it was noted that a multimodal approach to minimising pathogen transmission is required. This primarily comprises the wider engineering and administrative controls to reduce the concentration of the pathogen and to separate staff and patients from it. Theatre isolation and traffic control bundling, theatre flow and logistics, ventilation and waste management form a pivotal role in the environmental/engineering controls. Administrative measures include policies for both patients and staff. For patients, isolation and preoperative screening are of utmost value. For staff, testing for COVID-19, risk assessment, redeployment and provision of persona; protective equipment, together with the necessary training are important administrative controls.

CONCLUSION

We believe these measures are likely to improve the sustainability of resources and can be carried to elective settings in order to return to some form of normality and help to mitigate the effects of future pandemics.

Containing SARS-CoV-2 in hospitals facing finite PPE, limited testing, and physical space variability: Navigating resource constrained enhanced traffic control bundling

The COVID-19 outbreak has led to a focus by public health practitioners and scholars on ways to limit spread while facing unprecedented challenges and resource constraints. Recent COVID-19-specific enhanced Traffic Control Bundling (eTCB) recommendations provide a cogent framework for managing patient care pathways and reducing health care worker (HCW) and patient exposure to SARS-CoV-2. eTCB has been applied broadly and has proven to be effective in limiting fomite and droplet transmissions in hospitals and between hospitals and the surrounding community. At the same time, resource constrained conditions involving limited personal protective equipment (PPE), low testing availability, and variability in physical space can require modifications in the way hospitals implement eTCB. While eTCB has come to be viewed as a standard of practice, COVID-19 related resource constraints often require hospital implementation teams to customize eTCB solutions. We provide and describe a cross-functional, collaborative on-the-ground adaptive application of eTCB initially piloted at two hospitals and subsequently reproduced at 16 additional hospitals and health systems in the US to date. By effectively facilitating eTCB deployment, hospital leaders and practitioners can establish clearer 'zones of risk' and related protective practices that prevent transmission to HCWs and patients. We outline key insights and recommendations gained from recent implementation under the aforementioned constraints and a cross-functional team process that can be utilized by hospitals to most effectively adapt eTCB under resource constraints.

Adaptations and Innovations to Minimize Service Disruption for Patients with Severe Mental Illness during COVID-19: Perspectives and Reflections from an Assertive Community Psychiatry Program

Changes to community psychiatry during COVID-19 are unprecedented and without clear guidelines. Minimizing disruption, ensuring quality care to the already vulnerable people with serious mental illness is crucial. We describe and reflect our adaptations and innovations at one community psychiatry program, based on three key principles. In (i) Defining and maintaining essential services while limiting risk of contagion, we discuss such strategies and ways to assess risks, implement infection control, and other creative solutions. In (ii) Promoting health and mitigating physical and mental health impacts, we reflect on prioritizing vulnerable patients, dealing with loss of community resources, adapting group programs, and providing psychoeducation, among others. In (iii) Promoting staff resilience and wellness, we describe building on strength of the staff early, addressing staff morale and avoiding moral injury, and valuing responsive leadership. We also identify limitations and potential further improvements, mindful that COVID-19 and similar crises are likely recurring realities.

How health systems approached respiratory viral pandemics over time: a systematic review

BACKGROUND

Several healthcare systems facing respiratory viral infections outbreaks, like COVID-19, have not been prepared to manage them. Public health mitigation solutions ranging from isolation of infected or suspected cases to implementation of national lockdowns have proven their effectiveness for the outbreak's control. However, the adjustment of public health measures is crucial during transition phases to avoid new outbreaks. To address the need for designing evidence-based strategies, we performed a systematic review to identify healthcare systems interventions, experiences and recommendations that have been used to manage different respiratory viral infections outbreaks in the past.

METHODS

PubMed, Web of Science, Scopus and Cochrane were searched to retrieve eligible studies of any study design, published in English until 17 April 2020. Double-blinded screening process was conducted by titles/abstracts and subsequently eligible full texts were read and pertinent data were extracted. When applicable, quality assessment was conducted for the included articles. We performed a narrative synthesis of each implemented public health approaches.

RESULTS

We included a total of 24 articles addressing the public health approaches implemented for respiratory viral infections outbreaks for COVID-19, influenza A H1N1, MERS and severe acute respiratory syndrome . The identified approaches are ascribable to two main categories: healthcare system strategies and healthcare provider interventions. The key components of an effective response on respiratory viral outbreaks included the implementation of evidence-based contextual policies, intrahospital management actions, community healthcare facilities, non-pharmaceutical interventions, enhanced surveillance, workplace preventive measures, mental health interventions and communication plans.

CONCLUSION

The identified healthcare system strategies applied worldwide to face epidemics or pandemics are a useful knowledge base to inform decision-makers about control measures to be used in the transition phases of COVID-19 and beyond.

Controlling urban traffic-one of the useful methods to ensure safety in Wuhan based on COVID-19 outbreak

Coronavirus disease 2019 (COVID-19) broke out in Wuhan, China. As of March 9, 2020, this epidemic has occurred in 102 countries and caused 3584 deaths with global serious concern. To cope with the outbreak, Chinese governments have strictly controlled urban traffic at all levels, especially in Wuhan. This article firstly reviews the urban traffic situation from January 23, 2020 to March 8, 2020, including safety problems of urban public transportation, traffic control methods, and emergency public transportation planning. Based on this, we present some emergency traffic control measures that are very urgent in the early stage of epidemic. Between cities, we strongly recommend blocking and controlling the flow of traffic in the early stage of epidemic. Inside a city, it is imperative to suspend the public transports, block all roads, restrict private cars, and close bridges and tunnels. Material isolation transfer stations are suggested to be established. A number of public transports should be organized to ensure transport of medical workers, patients, and daily necessities. We also give suggestions about the long-term planning and improvement methods. Considering the great success China has achieved in fighting COVID-19, we believe that this article offers a valuable reference of urban traffic control.

Translating Scientific Knowledge to Government Decision Makers Has Crucial Importance in the Management of the COVID-19 Pandemic

In times of epidemics and humanitarian crises, it is essential to translate scientific findings into digestible information for government policy makers who have a short time to make critical decisions. To predict how far and fast the disease would spread across Hungary and to support the epidemiological decision-making process, a multidisciplinary research team performed a large amount of scientific data analysis and mathematical and socioeconomic modeling of the COVID-19 epidemic in Hungary, including modeling the medical resources and capacities, the regional differences, gross domestic product loss, the impact of closing and reopening elementary schools, and the optimal nationwide screening strategy for various virus-spreading scenarios and R metrics. KETLAK prepared 2 extensive reports on the problems identified and suggested solutions, and presented these directly to the National Epidemiological Policy-Making Body. The findings provided crucial data for the government to address critical measures regarding health care capacity, decide on restriction maintenance, change the actual testing strategy, and take regional economic, social, and health differences into account. Hungary managed the first part of the COVID-19 pandemic with low mortality rate. In times of epidemics, the formation of multidisciplinary research groups is essential for policy makers. The establishment, research activity, and participation in decision-making of these groups, such as KETLAK, can serve as a model for other countries, researchers, and policy makers not only in managing the challenges of COVID-19, but in future pandemics as well.

Coronavirus pandemic: applying a whole-of-society model for the whole-of-the world

During a pandemic, a national government is often considered solely responsible for dealing with the outbreak with local-based policies. A whole-of-society approach to a pandemic is evidence-based and used successfully in countries with a history of pandemic infections. This collaborative approach assumes that no single entity has the capacity to successfully manage the dynamic, complex problems that arise in a pandemic environment. Application of the whole-of-society model globally would provide a more harmonious and concerted response with mutual and synergistic benefits to all affected nations. Central entities within the model include; Civil society, business and government. These are addressed at the community, local government and sub-national level. Nine essential services are also identified including Health, Defence, Law & Order, Finance, Transport, Telecommunication, Energy, Food, and Water. A continuing cycle of readiness, response and recovery of services encapsulates this model. Pandemics affect the whole of the world, a global whole-of-society approach is therefore needed to tackle them.

Is Lockdown Bad for Social Anxiety in COVID-19 Regions?: A National Study in The SOR Perspective

Lockdown measures have been widely used to control and prevent virus transmission in pandemic regions. However, the psychological effects of lockdown measures have been neglected, and the related theoretical research lags behind the practice. The present study aimed to better understand the mechanism of social anxiety in pandemic regions where the lockdown measures were imposed, based on the conceptual framework of the Stimulus-Organism-Response (SOR). For that, this research investigated how lockdown measures and psychological distance influenced social anxiety in the pandemic region. The Chinese national data was analyzed for the outcome. The results showed that (1) psychological distance mediated the relationship between pandemic COVID-19 severity and social anxiety, (2) lockdown measures buffered the detrimental effect of the COVID-19 pandemic severity on social anxiety, (3) lockdown measures moderated the mediation effect of psychological distancing on social anxiety caused by the COVID-19 pandemic. In conclusion, under the SOR framework, the lockdown measures had a buffer effect on social anxiety in pandemic regions, with the mediating role of psychological distancing.

School closure and management practices during coronavirus outbreaks including COVID-19: a rapid systematic review

In response to the coronavirus disease 2019 (COVID-19) pandemic, 107 countries had implemented national school closures by March 18, 2020. It is unknown whether school measures are effective in coronavirus outbreaks (eg, due to severe acute respiratory syndrome [SARS], Middle East respiratory syndrome, or COVID-19). We undertook a systematic review by searching three electronic databases to identify what is known about the effectiveness of school closures and other school social distancing practices during coronavirus outbreaks. We included 16 of 616 identified articles. School closures were deployed rapidly across mainland China and Hong Kong for COVID-19. However, there are no data on the relative contribution of school closures to transmission control. Data from the SARS outbreak in mainland China, Hong Kong, and Singapore suggest that school closures did not contribute to the control of the epidemic. Modelling studies of SARS produced conflicting results. Recent modelling studies of COVID-19 predict that school closures alone would prevent only 2-4% of deaths, much less than other social distancing interventions. Policy makers need to be aware of the equivocal evidence when considering school closures for COVID-19, and that combinations of social distancing measures should be considered. Other less disruptive social distancing interventions in schools require further consideration if restrictive social distancing policies are implemented for long periods.

School closure and management practices during coronavirus outbreaks including COVID-19: a rapid systematic review

In response to the coronavirus disease 2019 (COVID-19) pandemic, 107 countries had implemented national school closures by March 18, 2020. It is unknown whether school measures are effective in coronavirus outbreaks (eg, due to severe acute respiratory syndrome [SARS], Middle East respiratory syndrome, or COVID-19). We undertook a systematic review by searching three electronic databases to identify what is known about the effectiveness of school closures and other school social distancing practices during coronavirus outbreaks. We included 16 of 616 identified articles. School closures were deployed rapidly across mainland China and Hong Kong for COVID-19. However, there are no data on the relative contribution of school closures to transmission control. Data from the SARS outbreak in mainland China, Hong Kong, and Singapore suggest that school closures did not contribute to the control of the epidemic. Modelling studies of SARS produced conflicting results. Recent modelling studies of COVID-19 predict that school closures alone would prevent only 2-4% of deaths, much less than other social distancing interventions. Policy makers need to be aware of the equivocal evidence when considering school closures for COVID-19, and that combinations of social distancing measures should be considered. Other less disruptive social distancing interventions in schools require further consideration if restrictive social distancing policies are implemented for long periods.

Recommendations for protecting against and mitigating the COVID-19 pandemic in long-term care facilities

The COVID-19 outbreak has drawn heightened attention from public health scholars researching ways to limit its spread. Much of the research has been focused on minimizing transmission in hospitals and in the general community. However, a particularly vulnerable community that has received relatively little attention is elders residing in long-term care facilities (LTCFs). In this article we address this relative lack of attention, arguing that enhanced traffic control bundling (eTCB) can and should be adopted and implemented as a means of protecting LTCF residents and staff. Enhanced TCB has been widely applied in hospital settings and has proven effective at limiting droplet and fomite transmissions both within hospitals and between hospitals and the general community. By effectively adapting eTCB to LTCF conditions, particularly by incorporating compartmentalization within zones plus active surveillance, COVID-19 transmission into and throughout LTCFs can be minimized, thereby saving numerous lives among an especially vulnerable population.

Interrupting COVID-19 transmission by implementing enhanced traffic control bundling: Implications for global prevention and control efforts

We argue that enhanced Traffic Control Bundling (eTCB) can interrupt the community-hospital-community transmission cycle, thereby limiting COVID-19’s impact. Enhanced TCB is an expansion of the traditional TCB that proved highly effective during Taiwan’s 2003 SARS outbreak. TCB’s success derived from ensuring that Health Care Workers (HCWs) and patients were protected from fomite, contact and droplet transmission within hospitals.

Although TCB proved successful during SARS, achieving a similar level of success with the COVID-19 outbreak requires adapting TCB to the unique manifestations of this new disease. These manifestations include asymptomatic infection, a hyper-affinity to ACE2 receptors resulting in high transmissibility, false negatives, and an incubation period of up to 22 days. Enhanced TCB incorporates the necessary adaptations. In particular, eTCB includes expanding the TCB transition zone to incorporate a new sector – the quarantine ward. This ward houses patients exhibiting atypical manifestations or awaiting definitive diagnosis. A second adaptation involves enhancing the checkpoint hand disinfection and gowning up with Personal Protective Equipment deployed in traditional TCB. Under eTCB, checkpoint hand disinfection and donning of face masks are now required of all visitors who seek to enter hospitals.

These enhancements ensure that transmissions by droplets, fomites and contact are disrupted both within hospitals and between hospitals and the broader community. Evidencing eTCB effectiveness is Taiwan’s success to date in containing and controlling the community-hospital-community transmission cycle.

2019 novel coronavirus disease (COVID-19) in Taiwan: Reports of two cases from Wuhan, China

We reported two cases with community-acquired pneumonia caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) who returned from Wuhan, China in January, 2020. The reported cases highlight non-specific clinical presentations of 2019 novel coronavirus disease (COVID-19) as well as the importance of rapid laboratory-based diagnosis.

Application of Chinese Medicine in Acute and Critical Medical Conditions

Western medicine is routinely used in developed nations as well as in Eastern countries, where traditional medicine is frequently used by a selection of patients or family member as a complement to mainstream Western medicine. Chinese medicine plays an important role in the treatment of chronic diseases, especially when Western medicine is not very effective. Many published reports have shown that Chinese medicine could also be successfully used in the management of acute and critical illnesses. Chinese medicine has a holistic view of the human body, and emphasizes individualization based on body balance and mind-body interaction and employs herbal medicines and acupuncture. This review paper gives a brief overview of Chinese medicine theory and therapeutic modality and then addresses the application of Chinese medicine in the treatment of acute and critical medical conditions, including epidemics. Using this ancient therapy as a complementary medicine, the management of serious medical conditions, such as SARS, acute heart diseases, and ischemic cerebral stroke, are presented. In order to promote more widespread application of Chinese medicine, well-designed controlled clinical trials are urgently needed to prove its safety and effectiveness.

Centennial review of influenza in Taiwan

The history of influenza in Taiwan can be traced up to the 1918 H1N1 Spanish flu pandemic, followed by several others including the 1957 H2N2, 1968 H3N2, and the 2009 new H1N1. A couple of avian influenza viruses of H5N1 and H7N9 also posed threats to the general public in Taiwan in the two recent decades. Nevertheless, two seasonal influenza A viruses and two lineages of influenza B viruses continue causing annual endemics one after the other, or appearing simultaneously. Their interplay provided interesting evolutionary trajectories for these viruses, allowing us to computationally model their global migrations together with the data collected elsewhere from different geographical locations. An island-wide laboratory-based surveillance network was also established since 2000 for systematically collecting and managing the disease and molecular epidemiology. Experiences learned from this network helped in encountering and managing newly emerging infectious diseases, including the 2003 SARS and 2009 H1N1 outbreaks.

Segmented regression analysis of emergency departments patient visits from Septicemia in Taiwan

Background

The protocol for early goal-directed therapy (EGDT) is effective for improving both the costs and outcomes of septicemia treatment, including a significant reduction in case fatality. However, this complicated protocol may have a downside. Furthermore, the Joint Taiwan Critical Care Medicine Committee has launched a nationwide educational program after the publication of the Surviving Sepsis Campaign (SSC) to improve the overall survival rate from septicemia in the emergency care system of Taiwan.

Objectives

To assess the impact of the EGDT protocol and SSC education programs on island-wide septicemia-related emergency department (ED) visits.

Methods

Segmented regression techniques were utilized to assess the differences in annual rates and changes in septicemia-related ED visits between 1998 and 2012. We considered annual incidence of two medical comorbidities as potential confounders: metastatic malignant neoplasms and malignant neoplasms of the lymphatic and hematopoietic tissues.

Results

The EGDT protocol was associated with decreased septicemia-related ED visits in 2002 (level change; p < 0.001), while the SSC education program led to a slight increase in septicemia-related ED visits in 2007 (slope change; p < 0.001). For the EGDT protocol, the number of patient visits decreased by 32.9% after the protocol was implemented in 2002 compared with the expected number without the intervention. For the SSC education program, the number of patient visits increased by 20.2% (compared with the predicted number) in 2007 after the education program was implemented.

Conclusions

The EGDT protocol and SSC education program were associated with significant immediate changes and lagged intervention effects on island-wide septicemia-related ED visits.

Diagnosis and Assessment of Microbial Infections with Host and Microbial MicroRNA Profiles

MicroRNAs (miRNAs) encoded by viral genome or host have been found participating in host-microbe interactions. Differential expression profiles of miRNAs were shown linking to specific disease pathologies which indicated its potency as diagnostic/prognostic biomarkers of infectious disease. This was emphasized by the discovery of circulating miRNAs which were found to be remarkably stable in mammalian biofluids. Standardized methods of miRNA quantification including RNA isolation should be established before they will be ready for use in clinical practice.

Which recommendations are considered essential for outbreak preparedness by first responders?

BACKGROUND

Preparedness is considered essential for healthcare organizations to respond effectively to outbreaks. In the current study we aim to capture the views of first responders on what they consider key recommendations for high quality preparedness. Furthermore, we identified the recommendations with the highest urgency from the perspective of first responders.

METHODS

We chose a multistep approach using a systematic Delphi procedure. Previously extracted recommendations from scientific literature were presented to a national and two international expert panels. We asked the experts to score the recommendations based on relevance for high quality preparedness. In addition we asked them to choose the ten most urgent recommendations.

RESULTS

Starting with 80 recommendations from scientific literature, 49 key recommendations were selected by both international expert panels. Differences between both panels were mainly on triage protocols. In addition, large differences were found in the selection of the ten most urgent recommendations.

CONCLUSIONS

In this study infectious disease experts selected a set of key recommendations representing high quality preparedness and specified which ones should be given the highest urgency when preparing for a future crisis. These key recommendations can be used to shape their preparedness activities.

Challenges of Treating Adenovirus Infection: Application of a Deployable Rapid-Assembly Shelter Hospital

This article outlines the evolution of a rescue team in responding to adenovirus prevention with a deployable field hospital. The local governments mobilized a shelter hospital and a rescue team consisting of 59 members to assist with rescue and response efforts after an epidemic outbreak of adenovirus. We describe and evaluate the challenges of preparing for deployment, field hospital maintenance, treatment mode, and primary treatment methods. The field hospital established at the rescue scene consisted of a medical command vehicle, a computed tomography shelter, an X-ray shelter, a special laboratory shelter, an oxygen and electricity supply vehicle, and epidemic prevention and protection equipment. The rescue team comprised paramedics, physicians, X-ray technicians, respiratory therapists, and logistical personnel. In 22 days, more than 3000 patients with suspected adenovirus infection underwent initial examinations. All patients were properly treated, and no deaths occurred. After emergency measures were implemented, the spread of adenovirus was eventually controlled. An emergency involving infectious diseases in less-developed regions demands the rapid development of a field facility with specialized medical personnel when local hospital facilities are either unavailable or unusable. An appropriate and detailed prearranged action plan is important for infectious diseases prevention. (Disaster Med Public Health Preparedness. 2018;12:109-114).

Toward a collaborative model of pandemic preparedness and response: Taiwan's changing approach to pandemics

BACKGROUND

Over time, as newly emerging infectious diseases have become increasingly common and more easily spread, it has become clear that traditional response mechanisms have proven inadequate to the task of prevention and control.

PURPOSE

To explore whether enhanced cooperation with local government and community institutions can effectively supplement traditional state-centric public health epidemic responses.

METHODS

Drawing on Taiwan as a case study, we assess the role of the whole-of-society approach to epidemic response as arises from the collaborative governance literature. The approach calls for enhanced cooperation, trust building, resource sharing and consensus-oriented decision making among multiple levels of government, business, non-profits, and the public in general.

RESULTS

The Taiwan case illustrates the benefits of the whole-of-society approach. Enhanced cooperation between state, local government and non-state institutions, particularly neighborhood committees, has resulted in a strengthened, holistic epidemic preparedness and response infrastructure.

CONCLUSION

The Taiwan case provides evidence that by implementing the whole-of-society approach to pandemic preparedness and response governments can enhance their ability to manage future outbreaks. We recommend that governments beyond Taiwan's borders seriously consider adopting this approach.

The Influenza A Virus Non-structural Protein NS1 Upregulates The Expression of Collagen Triple Helix Repeat Containing 1 Protein

Influenza A virus (IAV) infection induces a strong immune response and regulates the expression of many host proteins. The collagen triple helix repeat containing 1 (CTHRC1) protein is a secreted protein that exhibits increased expression during the viral infection process. However, the regulatory function of IAV on CTHRC1 expression is obscure. In this study, we investigated the effect of IAV on CTHRC1 expression and its regulatory mechanism. A total of 106 serum specimens from healthy people and 80 serum specimens from patients infected with IAV were collected. The CTHRC1 levels in the sera from the IVA patients and healthy individuals were measured using an enzyme-linked immunosorbent assay (ELISA), and the differences were statistically analysed. A549 cells were infected with the IAV or delNS1 virus. Additionally, A549 cells were cotransfected with a eukaryotic non-structural NS1 protein gene expression plasmid and the CTHRC1 gene promoter reporter plasmid (pCTHRC1-Luc), and, the luciferase activities were assessed. The CTHRC1 mRNA and protein expression were detected using reverse transcription-polymerase chain reaction (RT-PCR) and Western blotting, respectively. The serum CTHRC1 level was significantly higher in the IAV patients than in the healthy individuals. IAV upregulated the CTHRC1 mRNA and protein expression. The non-structural NS1 protein specifically activated CTHRC1 gene promoter activity and upregulated CTHRC1 mRNA and protein expression. The activation function had a dose-dependent effect, indicating that influenza virus upregulated CTHRC1 expression through its NS1 protein.

Predictive Symptoms and Signs of Laboratory-confirmed Influenza: A Prospective Surveillance Study of Two Metropolitan Areas in Taiwan

Influenza infection poses annual threats and leads to significant morbidity and mortality. Early diagnosis is the key to successful treatment. Laboratory-based diagnosis has various limitations. Diagnosis based on symptoms or signs is still indispensable in clinical practice. We investigated the symptoms or signs associated with laboratory-confirmed influenza.A prospective study across 2 influenza seasons was performed from June 2010 to June 2012 at 2 branches (Taipei and Lin-Kou) of Chang Gung Memorial Hospital. Patients who visited outpatient clinics with suspected acute respiratory tract infection were sampled by throat swab or nasopharyngeal swab. RT-PCR and/or virus culture were used as a reference standard. We used logistic regression to identify the symptoms or signs associated with laboratory-confirmed influenza infection. We also evaluated the performance metrics of different influenza-like illness used in Taiwan, the USA, and WHO.A total of 158 patients were included in the study. The prevalence of influenza infection was 45% (71/158). Fever, cough, rhinorrhea, sneezing, and nasal congestion were significant predictors for influenza infection. Whereas fever + cough had a best sensitivity (86%; confidence interval [CI] 76%-93%), fever + cough and sneezing had a best specificity (77%; CI 62%-88%). Different case definitions of influenza-like illness had comparable accuracy in sensitivity and specificity.Clinical diagnosis based on symptoms and signs is useful for allocating resources, identifying those who may benefit from early antiviral therapy and providing valuable information for surveillance purpose.

Middle East Respiratory Syndrome Corona Virus (MERS CoV): The next steps

Developing countries are at risk of importing Middle East Respiratory Syndrome Corona Virus (MERS CoV) from the Middle East. Hospitals in the Middle East currently reporting the disease are staffed by immigrants. In the current hot spots for MERS CoV a sizeable portion of the population is from other countries, but many of these countries have yet to detect any importation of MERS CoV. To assess the disease transmission in these countries, supplemental surveillance strategies are urgently needed beyond the currently recommended measures. A few strategies to address the situation are: (i) improving preparedness with enhanced surveillance in particular regions; (ii) targeting certain sentinel groups for surveillance in hot spots; and (iii) limited use of serosurveillance. Recovered, immune patients can be employed to give patient care during outbreaks.