The 2003 SARS outbreak and its impact on infection control practices

The spatiotemporal analysis of the population migration network in China, 2021

Population migration is a critical component of large-scale spatiotemporal models of infectious disease transmission. Identifying the most influential spreaders in networks is vital to controlling and understanding the spreading process of infectious diseases. We used Baidu Migration data for the whole year of 2021 to build mobility networks. The nodes of the network represent cities, and the edges represent the population flow between cities. By applying the k-shell decomposition and the Louvain algorithm, we could get the k-shell values for each city and community partition. Then, we identified the most efficient nodes or pathways in a complex network by generating random networks. Furthermore, we analyzed the eigenvalue of the migration matrix to find the nodes that have the most impact on the network. We also found the consistency between k-shell value and eigenvalue through Kendall's τ test. The main result is that in Spring Festival and National Day, the network is at higher risk of an infectious disease outbreak and the Yangtze River Delta is at the highest risk of an epidemic all year around. Shanghai is the most significant node in both k-shell value and eigenvalue analysis. The spatiotemporal property of the network should be taken into account to model the transmission of infectious diseases more accurately.

The impact of COVID-19 on the experiences of patients and their family caregivers with medical assistance in dying in hospital

BACKGROUND

The COVID-19 pandemic and its containment measures have drastically impacted end-of-life and grief experiences globally, including those related to medical assistance in dying (MAiD). No known qualitative studies to date have examined the MAiD experience during the pandemic. This qualitative study aimed to understand how the pandemic impacted the MAiD experience in hospital of persons requesting MAiD (patients) and their loved ones (caregivers) in Canada.

METHODS

Semi-structured interviews were conducted with patients who requested MAiD and their caregivers between April 2020 and May 2021. Participants were recruited during the first year of the pandemic from the University Health Network and Sunnybrook Health Sciences Centre in Toronto, Canada. Patients and caregivers were interviewed about their experience following the MAiD request. Six months following patient death, bereaved caregivers were interviewed to explore their bereavement experience. Interviews were audio-recorded, transcribed verbatim, and de-identified. Transcripts were analyzed using reflexive thematic analysis.

RESULTS

Interviews were conducted with 7 patients (mean [SD] age, 73 [12] years; 5 [63%] women) and 23 caregivers (mean [SD] age, 59 [11] years; 14 [61%] women). Fourteen caregivers were interviewed at the time of MAiD request and 13 bereaved caregivers were interviewed post-MAiD. Four themes were generated with respect to the impact of COVID-19 and its containment measures on the MAiD experience in hospital: (1) accelerating the MAiD decision; (2) compromising family understanding and coping; (3) disrupting MAiD delivery; and (4) appreciating rule flexibility.

CONCLUSIONS

Findings highlight the tension between respecting pandemic restrictions and prioritizing control over the dying circumstances central to MAiD, and the resulting impact on patient and family suffering. There is a need for healthcare institutions to recognize the relational dimensions of the MAiD experience, particularly in the isolating context of the pandemic. Findings may inform strategies to better support those requesting MAiD and their families during the pandemic and beyond.

Healthcare workers, epidemic biological risks - recommendations based on the experience with COVID-19 and Ebolavirus

Infectious disease outbreaks frequently cause illness and death among Healthcare Workers (HCWs). We compare strategies from recent, past and ongoing outbreak measures used to protect HCWs, including those facing additional challenges such as racial disparities, violence and stigmatization. Outbreaks and pandemics superimposed on countries with preexisting crises have also affected emergency response to these viral outbreaks. Strategies to protect HCWs include adherence to recommended infection prevention and control measures; new technology such as rapid point-of-care tests and remote monitoring; adopting national public health preparedness plans to ensure the supply and allocation of PPE, staff, and testing supplies; occupational health and mental health support services. Lessons learned from recent pandemics should be used by Infection Prevention and Control and Occupational Health staff to refine preparedness plans to protect HCWs better.

Nanoprotection from SARS-COV-2: would nanotechnology help in Personal Protection Equipment (PPE) to control the transmission of COVID-19?

The coronavirus disease 2019 (COVID-19) has caused a worldwide outbreak. The severe acute respiratory syndrome coronavirus 2 virus can be transmitted human-to-human through droplets and close contact where personal protective equipment (PPE) is imperative to protect the individuals. The advancement of nanotechnology with significant nanosized properties can confer a higher form of protection. Incorporation of nanotechnology into facemasks can exhibit antiviral properties. Nanocoating on surfaces can achieve self-disinfecting purposes and be applied in highly populated places. Moreover, nano-based hand sanitizers can confer better sterilizing efficacies with low skin irritation as compared to alcohol-based hand sanitizers. The present review discusses the incorporation of nanotechnology into nano-based materials and coatings in facemasks, self-surface disinfectants and hand sanitizers, in the hope to contribute to the current understanding of PPE to combat COVID-19.

Myocardial injuries among patients with COVID-19: a systematic review

This is a systematic review of the literature specifically aimed to explore myocardial injury in coronavirus disease-19 (COVID-19) patients who were hospitalized with severe complicated infections. The medical literature was examined through the large medical databases, including Medline, Ovid, PubMed, and Embase, over the last year between January 2020 and May 2021. The search terms used were a combination of "myocardial injury" AND "COVID-19" AND "Hospitalization". Then we applied a step to filter the results to select original research articles only evaluating the myocardial injuries in severe COVID-19 hospitalized patients. Selected trials mentioned the type of myocardial injury detected with the infection. A total of 245 articles were extracted. Considering the exclusion of ineligible articles, 42 articles appeared. A total of 42 articles were eligible and were included in the review. These studies included a total of 4326 COVID-19 patients. The 30-day mortality was found to be associated with increased cardiac troponin and myocardial infarction could be a systemic reaction rather than the direct action of COVID-19. Patients with myocardial injury were significantly older and with co-morbid conditions. Studies also found a correlation of higher concentrations of cardiac enzymes with disease severity and increased in-hospital mortality. Myocardial injury was a significant predictor for severe COVID-19 infection and in-hospital mortality. Cardiac enzymes should be monitored in hospitalized patients with severe COVID-19 infections.

Preparing for future waves and pandemics: a global hospital survey on infection control measures and infection rates in COVID-19

A survey of hospitals on three continents was performed to assess their infection control preparedness and measures, and their infection rate in hospital health care workers during the COVID-19 pandemic. All surveyed hospitals used similar PPE but differences in preparedness, PPE shortages, and infection rates were reported.

Middle East Respiratory Syndrome Coronavirus

The past two decades have witnessed the emergence of three zoonotic coronaviruses which have jumped species to cause lethal disease in humans: severe acute respiratory syndrome coronavirus 1 (SARS-CoV-1), Middle East respiratory syndrome coronavirus (MERS-CoV), and SARS-CoV-2. MERS-CoV emerged in Saudi Arabia in 2012 and the origins of MERS-CoV are not fully understood. Genomic analysis indicates it originated in bats and transmitted to camels. Human-to-human transmission occurs in varying frequency, being highest in healthcare environment and to a lesser degree in the community and among family members. Several nosocomial outbreaks of human-to-human transmission have occurred, the largest in Riyadh and Jeddah in 2014 and South Korea in 2015. MERS-CoV remains a high-threat pathogen identified by World Health Organization as a priority pathogen because it causes severe disease that has a high mortality rate, epidemic potential, and no medical countermeasures. MERS-CoV has been identified in dromedaries in several countries in the Middle East, Africa, and South Asia. MERS-CoV-2 causes a wide range of clinical presentations, although the respiratory system is predominantly affected. There are no specific antiviral treatments, although recent trials indicate that combination antivirals may be useful in severely ill patients. Diagnosing MERS-CoV early and implementation infection control measures are critical to preventing hospital-associated outbreaks. Preventing MERS relies on avoiding unpasteurized or uncooked animal products, practicing safe hygiene habits in health care settings and around dromedaries, community education and awareness training for health workers, as well as implementing effective control measures. Effective vaccines for MERS-COV are urgently needed but still under development.

Futures market and the contagion effect of COVID-19 syndrome

The paper aims to investigate the existence of financial contagion between China and its major trading partners during the ongoing COVID-19 pandemic using the multivariate ADCC-EGARCH model. The analysis results reveal significant financial contagion in most developed and emerging markets having significant trade relationships with China during COVID-19 syndrome. The evidence about financial contagion is vital for regulators and different classes of market participants for varying purposes, and hence the results should find practical implications similar to policymakers, investors, and risk managers.

Epidemiological characteristics and trends of notifiable infectious diseases in China from 1986 to 2016

Background

Since the 1980s, China has undergone significant social change and the incidence of infectious diseases has also changed considerably. Here, we report the epidemiological features and changes in notifiable infectious diseases in China from 1986 to 2016 to explore the factors contributing to the successful control of infectious diseases and the challenges faced in the prevention and control of infectious diseases.

Methods

The data of notifiable infectious diseases in China from 1986 to 2016 were collected from the monthly analysis report of the National Infectious Disease Surveillance System. Joinpoint regression models were used to examine incidence and mortality trends from 1986 to 2016. IBM SPSS Statistics version 22.0, Excel 2010 and R x64 3.5.2 were used for data analysis.

Results

A total of 132 858 005 cases of notifiable infectious diseases were reported over these 31 years, with an average yearly incidence of 342.14/100 000. There were 284 694 deaths with an average yearly mortality rate of 0.73/100 000. The overall incidence and overall mortality of notifiable infectious diseases both showed a "U" distribution (ie, a decrease, stable, an increase, stable again). The top five diseases in terms of incidence were hand, foot and mouth disease, viral hepatitis, tuberculosis, other infectious causes of diarrhea and dysentery, accounting for 78.0% of all reported cases. The top five causes of death were HIV/AIDS, rabies, tuberculosis, viral hepatitis and epidemic encephalitis B, which accounted for 76.07% of all mortalities. The diseases with the top five fatality rates were rabies, H5N1, H7N9, HIV/AIDS and plague, with rates of 91.06%, 66.07%, 38.51%, 25.19% and 10.31%, respectively.

Conclusions

This analysis will benefit the future monitoring of infectious diseases and public health measures in China.

Knowledge and preparedness of healthcare providers towards bioterrorism

Background

Several emergent circumstances require healthcare providers to recognize the unusual and dangerous and pathogenic agents. An in-depth literature review showed that studies about bioterrorism preparedness amongst healthcare providers are lacking. Therefore, this study aimed to investigate the knowledge and preparedness level of first emergency respondents towards bioterrorism events.

Methods

This study has a cross-sectional design and was carried out at the Emergency departments and poison control centers/clinical laboratories three in major tertiary care hospitals in Riyadh, Saudi Arabia. The subjects were randomly selected to complete the self-administered questionnaire to collect study outcomes.

Results

A total of 1030 participants were included in the final data analysis. The mean knowledge score in the basic concepts of bioterrorism and introductory clinical presentations of bioterrorism-related agents was 4.92 ± 1.86 out of 12 points.

Moreover, the findings showed a mean knowledge score of 22.80 ± 3.92 out of 38 in the bioterrorism preparedness and governing policies and procedures. Respondents who received previous training in bioterrorism preparedness had a significantly higher number of perceived benefits than those not sure and without prior training (z = − 2.67, p = 0.008) and (z = − 4.4, p < 0.0001), respectively. About 79.4% of participants did not have previous training in bioterrorism preparedness, but 68.7% expressed willingness in the institution’s response and control to assist in a bioterrorist attack incident.

Conclusion

Although healthcare professionals have reported their desire to help in bioterrorism events, they need to enhance their knowledge of bioterrorism preparedness.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06442-z.

Pragmatic Recommendations for Infection Prevention and Control Practices for Healthcare Facilities in Low- and Middle-Income Countries during the COVID-19 Pandemic

Infection prevention and control (IPC) strategies are key in preventing nosocomial transmission of COVID-19. Several commonly used IPC practices are resource-intensive and may be challenging to implement in resource-constrained settings. An international group of healthcare professionals from or with experience in low- and middle-income countries (LMICs) searched the literature for relevant evidence. We report on a set of pragmatic recommendations for hospital-based IPC practices in resource-constrained settings of LMICs. For cases of confirmed or suspected COVID-19, we suggest that patients be placed in a single isolation room, whenever possible. When single isolation rooms are unavailable or limited, we recommend cohorting patients with COVID-19 on dedicated wards or in dedicated hospitals. We also recommend that cases of suspected COVID-19 be cohorted separately from those with confirmed disease, whenever possible, to minimize the risk of patient-to-patient transmission in settings where confirmatory testing may be limited. We suggest that healthcare workers be designated to care exclusively for patients with COVID-19, whenever possible, as another approach to minimize nosocomial spread. This approach may also be beneficial in conserving limited supplies of reusable personal protective equipment (PPE). We recommend that visitors be restricted for patients with COVID-19. In settings where family members or visitors are necessary for caregiving, we recommend that the appropriate PPE be used by visitors. We also recommend that education regarding hand hygiene and donning/doffing procedures for PPE be provided. Last, we suggest that all visitors be screened for symptoms before visitation and that visitor logs be maintained.

Assessing the quality of primary healthcare for diabetes in China: multivariate analysis using the China Health and Retirement Longitudinal Study (CHARLS) Database

OBJECTIVE

To assess the quality of primary healthcare (PHC) for patients with diabetes in China from 2011 to 2015.

SETTING

This study analysed data on 1006, 1472 and 1771 participants with diabetes who were surveyed in 2011, 2013 and 2015, respectively, in the China Health and Retirement Longitudinal Study, a nationally representative survey conducted in 29 provinces of China.

OUTCOME MEASURES

The study measured the proportions of patients with diabetes who received diabetes-related health education, examinations and treatments, as well as the hospital admission rate due to diabetes of these patients. Multilevel logistic regression was used to adjust sociodemographic variables.

RESULTS

According to the multivariate analysis, the proportion of patients who received diabetes-related health education decreased significantly (OR=0.74, 95% CI 0.61 to 0.90), and the proportion of those receiving examinations and treatments remained unchanged from 2011 to 2015. Diabetes-related hospitalisation increased from 4.01% in 2011 to 6.08% in 2013 (OR=1.47, 95% CI 0.97 to 2.22), and recurrent hospitalisations increased from 18.87% in 2011 to 28.45% in 2015 (OR=1.78, 95% CI 1.44 to 2.20). The proportions of patients with diabetes-related and recurrent hospitalisations in western China were higher than those in the east (OR=1.80, 95% CI 1.13 to 2.87; OR=1.92, 95% CI 1.50 to 2.45).

CONCLUSIONS

Nationally, the analysis of patient-reported process and outcome indicators cannot confirm that the quality of PHC has improved in China during 2011-2015. Regional disparities in primary diabetes care require urgent resource allocation to western China. Establishing a national quality registry for PHC, which transparently reports outcomes by region and social-economic position, is essential for countries sharing the challenge of improving both quality and equity of PHC.

Review a brief history of coronaviruses in Thailand

As with many countries around the world, Thailand is currently experiencing restrictions to daily life as a consequence of the worldwide transmission of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). SARS-CoV-2 is the third respiratory syndrome coronavirus to be introduced into Thailand, following previous importation of cases of the severe acute respiratory syndrome coronavirus (SARS) and the Middle East respiratory syndrome coronavirus (MERS). Unlike SARS and MERS, SARS-CoV-2 was able to establish local transmission in Thailand. In addition to the imported coronaviruses, Thailand has a number of endemic coronaviruses that can affect livestock and pet species, can be found in bats, as well as four human coronaviruses that are mostly associated with the common cold. This article seeks to review what is known on both the endemic and imported coronaviruses in Thailand.

Convalescent plasma therapy for coronavirus infection: experience from MERS and application in COVID-19

The emergence of the COVID-19 pandemic has resulted in a very large number of infections and high number of mortality. There is no specific therapeutic options that are approved for clinical use. Administration of convalescent plasma as a possible therapy was used in the case of viral pneumonia including SARS and influenza. There have been multiple studies of COVID-19 patients utilizing convalescent plasma. These studies employed different dosage levels and different regiments, were observational and lacked control arms, and had variable outcomes. Two of these studies used plasma with anti-SARS-CoV-2 titers of >1:640 to >1:1000. A recent randomized controlled clinical trial showed no benefit of convalescent plasma in patients with severe diseases. However, the study was terminated early and thus further clinical trials are needed to show efficacy in patients with COVID-19 infection.

Biopsychosocial and Spiritual Implications of Patients With COVID-19 Dying in Isolation

Critically ill patients with the Coronavirus disease 2019 (COVID-19) are dying in isolation without the comfort of their family or other social support in unprecedented numbers. Recently, healthcare teams at COVID-19 epicenters have been inundated with critically ill patients. Patients isolated for COVID-19 have had no contact with their family or loved ones and may have likely experienced death without closure. This situation highlights concerns about patients’ psychological and spiritual well-being with COVID-19 and their families, as they permanently part ways. While palliative care has advanced to adequately address these patients’ needs, the COVID-19 pandemic presents several barriers that force healthcare teams to deprioritize these essential aspects of patient care. The severe acute respiratory syndrome (SARS) outbreak in 2003 gave us a glimpse of these challenges as these patients were also isolated in hospitals. Here, we discuss the importance of the biopsychosocial spiritual model in end-of-life care and its implications on patients dying with COVID-19. Furthermore, we outline an integrative approach to address the unique and holistic needs of critically ill patients dying with COVID-19. These include intentional and increased coordination with trained palliative care staff, early and frequent goals of care including discussion of end-of-life plans, broader use of technology to improve connectedness, and shared decision making with patients’ families.

Breaking the chain of transmission within a tertiary health service: An approach to contact tracing during the COVID-19 pandemic

BACKGROUND

Tertiary referral health service.

INTERVENTION(S)

An approach to hospital based contact tracing is described along with tools employed to streamline the process and including the development of an outbreak management team (OMT) for each contact trace.

RESULTS

Forty-one OMTs occurred, involving 23 HCW and 18 patient index cases. The total furloughed HCWs arising from these contact traces was 383, with individual contact traces furloughing a mean (range) of 10 (0-80) HCWs. Importantly, 15 furloughed HCWs subsequently became COVID-19 positive during their 14-day isolation period, showing the importance of the contact tracing process and the ability to remove workers from the workplace before they become infectious.

CONCLUSIONS

A standardised, streamlined contact tracing procedure in healthcare settings ensures any impacts of COVID-19 positive cases are consistently managed. This response framework may be of use to other health services and help reduce the transmission of COVID-19 in the workplace.

The Potential Role of Super Spread Events in SARS-COV-2 Pandemic; a Narrative Review

Coronaviruses, members of Coronaviridae family, cause extensive epidemics of vast diseases like severe acute respiratory syndrome (SARS) and Coronavirus Disease-19 (COVID-19) in animals and humans. Super spread events (SSEs) potentiate early outbreak of the disease and its constant spread in later stages. Viral recombination events within species and across hosts lead to natural selection based on advanced infectivity and resistance. In this review, the importance of containment of SSEs was investigated with emphasis on stopping COVID-19 spread and its socio-economic consequences. A comprehensive search was conducted among literature available in multiple electronic sources to find articles that addressed the "potential role of SSEs on severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) pandemic" and were published before 20^th of August 2020. Overall, ninety-eight articles were found eligible and reviewed. Specific screening strategies within potential super spreading host groups can also help to efficiently manage severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) epidemics, in contrast to the partially effective general restriction measures. The effect of SSEs on previous SARS epidemics has been documented in detail. However, the respective potential impact of SSEs on SARS-COV-2 outbreak is composed and presented in the current review, thereby implying the warranted effort required for effective SSE preventive strategies, which may lead to overt global community health benefits. This is crucial for SARS-COV-2 pandemic containment as the vaccine(s) development process will take considerable time to safely establish its potential usefulness for future clinical usage.

Healthcare-Associated SARS-CoV-2 Transmission-Experiences from a German University Hospital

During the current severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, healthcare systems worldwide have to prevent nosocomial SARS-CoV-2 transmission while maintaining duty of care. In our study, we characterize the transmission dynamic of SARS-CoV-2 in inpatients and healthcare workers (HCWs) at the University Hospital Münster (UHM) in northwest Germany. We identified 27 cases of healthcare-associated SARS-CoV-2 infections (4 inpatients and 23 HCWs) who had contact with patients and/or HCWs without the use of adequate PPE. The contacts of these index cases were followed up for SARS-CoV-2 infection after unprotected exposure and a quantitative measure of probability of becoming infected, the attack rate, was calculated. In addition, transmission was evaluated in the context of infection control measures established during the pandemic and we compared the epidemiological data of all index cases, including symptoms and Ct values of virology test results. The overall attack rate in the hospital setting was 1.3% (inpatients 0.9%, HCWs 1.6%). However, during an outbreak, the attack rate was 25.5% (inpatients 20.0%, HCWs 29.6%). For both scenarios, HCWs had a higher attack rate illustrating their role in healthcare-associated SARS-CoV-2 transmission. Taken together, our experiences demonstrate how infection control measures can minimize the transmission of SARS-CoV-2 in the healthcare setting.

Design of an air isolation and purification (AIP) desk for medical use and characterization of its efficacy in ambient air isolation and purification

The incidences of nosocomial infections (NIs) are increasing throughout the world, especially for those airborne diseases caused by pathogens or air particulates that float in air. In this study, we designed and manufactured a desk for clinic consultation room air purification and air isolation between doctor and patient. The air isolation and purification (AIP) desk has a high efficiency particulate air (HEPA) filter on the tope and several primary efficiency filters on the sides for air purification. The air circulating between inlet and outlet forms a wind-curtain between doctor and patient. The Computational Fluid Dynamics (CFD) model was used to calculate the speed of the air flow and the angle of sampler. We tested the air purification function of the AIP desk in rooms sized about 3.6 × 2.8 × 2.8 m (L × W × H) and found that the AIP desk could significantly remove the tested air pollutants like smoke particulates and microorganisms like Staphylococcus albus (S. albus)and human adenovirus type 5 (HAdV-5). The wind-curtain can significantly block the exhale air of patient being transmitted to the respiratory area of doctor setting in the opposite of AIP desk. Thus, the AIP desk can be used in hospital setting to reduce the risk of NIs and protect both doctors and patients.

Use of medical face masks versus particulate respirators as a component of personal protective equipment for health care workers in the context of the COVID-19 pandemic

Currently available evidence supports that the predominant route of human-to-human transmission of the SARS-CoV-2 is through respiratory droplets and/or contact routes. The report by the World Health Organization (WHO) Joint Mission on Coronavirus Disease 2019 (COVID-19) in China supports person-to-person droplet and fomite transmission during close unprotected contact with the vast majority of the investigated infection clusters occurring within families, with a household secondary attack rate varying between 3 and 10%, a finding that is not consistent with airborne transmission. The reproduction number (R0) for the SARS-CoV-2 is estimated to be between 2.2-2.7, compatible with other respiratory viruses associated with a droplet/contact mode of transmission and very different than an airborne virus like measles with a R0 widely cited to be between 12 and 18. Based on the scientific evidence accumulated to date, our view is that SARS-CoV-2 is not spread by the airborne route  to  any significant extent and the use of particulate respirators offers no advantage over medical masks as a component of personal protective equipment for the routine care of patients with COVID-19 in the health care setting. Moreover, prolonged use of particulate respirators may result in unintended harms. In conjunction with appropriate hand hygiene, personal protective equipment (PPE) used by health care workers caring for patients with COVID-19 must be used with attention to detail and precision of execution to prevent lapses in adherence and active failures in the donning and doffing of the PPE.

A multi centre randomized open label trial of chloroquine for the treatment of adults with SARS-CoV-2 infection in Vietnam

Background: COVID-19 is a respiratory disease caused by a novel coronavirus (SARS-CoV-2) and causes substantial morbidity and mortality. There is currently no vaccine to prevent COVID-19 or therapeutic agent to treat COVID-19. This clinical trial is designed to evaluate chloroquine as a potential therapeutic for the treatment of hospitalised people with COVID-19. We hypothesise that chloroquine slows viral replication in patients with COVID-19, attenuating the infection, and resulting in more rapid decline of viral load in throat/nose swabs. This viral attenuation should be associated with improved patient outcomes. Method: The study will start with a 10-patient prospective observational pilot study following the same entry and exclusion criteria as for the randomized trial and undergoing the same procedures. The main study is an open label, randomised, controlled trial with two parallel arms of standard of care (control arm) versus standard of care with 10 days of chloroquine (intervention arm) with a loading dose over the first 24 hours, followed by 300mg base orally once daily for nine days. The study will recruit patients in three sites in Ho Chi Minh City, Vietnam: the Hospital for Tropical Diseases, the Cu Chi Field Hospital, and the Can Gio COVID hospital. The primary endpoint is the time to viral clearance from throat/nose swab, defined as the time following randomization until the midpoint between the last positive and the first of the negative throat/nose swabs. Viral presence will be determined using RT-PCR to detect SARS-CoV-2 RNA. Discussion: The results of the study will add to the evidence-based guidelines for management of COVID-19. Given the enormous experience of its use in malaria chemoprophylaxis, excellent safety and tolerability profile, and its very low cost, if proved effective then chloroquine would be a readily deployable and affordable treatment for patients with COVID-19. Trial registration: Clinicaltrials.gov NCT04328493 31/03/2020.

Will healthcare workers improve infection prevention and control behaviors as COVID-19 risk emerges and increases, in China?

Background

COVID-19 arise global attention since their first public reporting. Infection prevention and control (IPC) is critical to combat COVID-19, especially at the early stage of pandemic outbreak. This study aimed to measure level of healthcare workers’ (HCW’) self-reported IPC behaviors with the risk of COVID-19 emerges and increases.

Methods

A cross-sectional study was conducted in two tertiary hospitals. A structured self-administered questionnaire was delivered to HCWs in selected hospitals. The dependent variables were self-reported IPC behavior compliance; and independent variables were outbreak risk and three intent of infection risk (risk of contact with suspected patients, high-risk department, risk of affected area). Chi-square tests and multivariable negative binomial regression models were employed.

Results

A total of 1386 participants were surveyed. The risk of outbreak increased self-reported IPC behavior on each item (coefficient varied from 0.029 to 0.151). Considering different extent of risk, HCWs from high-risk department had better self-reported practice in most IPC behavior (coefficient ranged from 0.027 to 0.149). HCWs in risk-affected area had higher self-reported compliance in several IPC behavior (coefficient ranged from 0.028 to 0.113). However, HCWs contacting with suspected patients had lower self-reported compliance in several IPC behavior (coefficient varied from − 0.159 to − 0.087).

Conclusions

With the risk of COVID-19 emerges, HCWs improve IPC behaviors comprehensively, which benefits for better combat COVID-19. With the risk (high-risk department and affected area) further increases, majority of IPC behaviors achieved improvement. Nevertheless, under the risk of contact with suspected patients, HCWs show worse IPC behaviors. Which may result from higher work load and insufficient supplies and resources among these HCWs. The preparedness system should be improved and medical assistance is urgently needed.

Middle East Respiratory Syndrome Coronavirus and Severe Acute Respiratory Syndrome Coronavirus

Emerging infectious diseases continue to be of a significant importance worldwide with the potential to cause major outbreaks and global pandemics. In 2002, the world had witnessed the appearance of the severe acute respiratory syndrome coronavirus in China which disappeared abruptly within 6 months. About a decade later, a new and emerging novel coronavirus named the Middle East respiratory syndrome coronavirus (MERS-CoV) was described in a patient from Saudi Arabia. These two coronaviruses shared multiple similarities in the epidemiology, clinical presentations, and posed challenges in its prevention and management. Seven years since its discovery, MERS-CoV continues to be a lethal zoonotic pathogen capable of causing severe pneumonia with high case fatality rates and the ability to cause large health care-associated outbreaks.

Chapter of Gastroenterologists professional guidance on risk mitigation for gastrointestinal endoscopy during COVID-19 pandemic in Singapore

In this paper, we aimed to provide professional guidance to practising gastrointestinal (GI) endoscopists for the safe conduct of GI endoscopy procedures during the current coronavirus disease 2019 (COVID-19) pandemic and future outbreaks of similar severe respiratory tract infections in Singapore. It draws on the lessons learnt during the severe acute respiratory syndrome (SARS) epidemic and available published data concerning the COVID-19 pandemic. It addresses measures before, during and after endoscopy that must be considered for both non-infected and infected patients, and provides recommendations for practical implementation.

China's achievements and challenges in improving health insurance coverage

China has undertaken waves of healthcare reforms to keep pace with its rapid economic growth. By 2011, universal health insurance coverage was successfully achieved through the creation of a basic social medical insurance system. Growing economic power, extensive government subsidies, and strategies for program implementation are critical to that achievement. However, the breadth and depth of coverage varies considerably across insurance schemes and localities. The disjointed insurance scheme led to inequality in coverage, accessibility, and affordability of medical services, lopsided allocation of health resources, and increasing medical expenditures, and these remain crucial challenges for healthcare insurance coverage. This paper describes societal conditions, polices, achievements and challenges in improving health insurance coverage in China. Thailand's experience in universal health insurance coverage and its implications for China's new medical reform are also discussed. Solutions including sustainable increases in government investment, transformation of payment methods, reinforcement of primary health care delivery and the referral system, and standardization of benefits packages are strongly recommended to address challenges in China's long-running medical reform.

Infection control influence of Middle East respiratory syndrome coronavirus: A hospital-based analysis

BACKGROUND

Middle East respiratory syndrome coronavirus (MERS-CoV) caused multiple outbreaks. Such outbreaks increase economic and infection control burdens. We studied the infection control influence of MERS-CoV using a hospital-based analysis.

METHODS

Our hospital had 17 positive and 82 negative cases of MERS-CoV between April 1, 2013, and June 3, 2013. The study evaluated the impact of these cases on the use of gloves, surgical masks, N95 respirators, alcohol-based hand sanitizer, and soap, as well as hand hygiene compliance rates.

RESULTS

During the study, the use of personal protective equipment during MERS-CoV compared with theperiod before MERS-CoV increased dramatically from 2,947.4 to 10,283.9 per 1,000 patient-days (P<.0000001) for surgical masks and from 22 to 232 per 1,000 patient-days (P <.0000001) for N95 masks. The use of alcohol-based hand sanitizer and soap showed a significant increase in utilized amount (P<.0000001). Hand hygiene compliance rates increased from 73% just before the occurrence of the first MERS case to 88% during MERS cases (P = .0001). The monthly added cost was $16,400 for included infection control items.

CONCLUSIONS

There was a significant increase in the utilization of surgical masks, respirators, soap and alcohol-based hand sanitizers. Such an increase is a challenge and adds cost to the healthcare system.

Effect of Different Instructional Methods on Contamination and Personal Protective Equipment Protocol Adherence among Veterinary Students

Proper use of personal protective equipment (PPE) is crucial to prevent disease spread. Recent studies in human medicine have shown disconcerting inconsistencies in the use of PPE in hospital wards. In this study, we compared the effect of three instructional methods for PPE use on contamination and protocol adherence among veterinary students. Students were divided into three groups according to the instructional method to which they had access (instructional video, wall chart, or both). They underwent an isolation exercise consisting of donning, patient examination (mock patient prepared with contamination marker), and doffing. Student contamination after the exercise was evaluated using UV light. Videos of student performance were reviewed for errors committed. Results showed that the number of students with contamination was higher in the group who only had access to video instruction than in the two other groups. The number of students with contamination on forearms, hands, and wrists was higher in the group who only had access to charts. Disinfecting gloves between doffing steps was the most frequently omitted step. The number of students who touched the environment with unprotected areas of their bodies was higher in the group who only had access to video instruction than in the other two groups. In conclusion, video instruction was less effective in achieving PPE protocol adherence among veterinary students than was instruction with a chart or chart-video combination. Incorporating video instruction as part of the instructions may be valuable to reinforce individual steps of donning and doffing.

Ebola Virus Training: A Needs Assessment and Gap Analysis

In response to the 2014 Ebola virus disease outbreak, the Worker Training Program embarked on an assessment of existing training for those at risk for exposure to the virus. Searches of the recent peer-reviewed literature were conducted for descriptions of relevant training. Federal guidance issued during 2015 was also reviewed. Four stakeholder meetings were conducted with representatives from health care, academia, private industry, and public health to discuss issues associated with ongoing training. Our results revealed few articles about training that provided sufficient detail to serve as models. Training programs struggled to adjust to frequently updated federal guidance. Stakeholders commented that most healthcare training focused solely on infection control, and there was an absence of employee health-related training for non-healthcare providers. Challenges to ongoing training included funding and organizational complacency. Best practices were noted where management and employees planned training cooperatively and where infection control, employee health, and hospital emergency managers worked together on the development of protective guidance. We conclude that sustainable training for infectious disease outbreaks requires annual funding, full support from organizational management, input from all stakeholders, and integration of infection control, emergency management, and employee health when implementing guidance and training.

Improving knowledge and compliance with infection control Standard Precautions among undergraduate nursing students in Jordan

Introduction

The recent emergence and reemergence of infectious diseases have made the knowledge and practice of standard infection control precautions in developing countries more important than ever. However, schools of nursing in Jordan do not have a prescribed curriculum in Standard Precautions.

Purpose

To test the effectiveness of using of an online education module and a learning contract on knowledge and compliance with infection control Standard Precautions among undergraduate nursing students in Jordan.

Methods

A sample of 256 undergraduate nursing students participated in an online education module in infection control Standard Precautions. A pretest–posttest design tested effectiveness using an online questionnaire (Questionnaires for Knowledge and Compliance with Standard Precautions) before and after the online instruction.

Results

Initially, subjects reported low levels of knowledge and compliance with Standard Precaution practices and relatively few (15.2%) had high scores. Compliance with Standard Precautions was somewhat better (27%). Significant differences in the mean scores of knowledge and compliance between pretest and posttest were found.

Conclusion

Online instruction offers a consistent and effective method to include Standard Precautions into nursing education. Organizations that oversee nursing in Jordan have the option to strengthen all nursing curricula by mandating a standardized infection control curricula across all schools of nursing.

Epidemiological features of and changes in incidence of infectious diseases in China in the first decade after the SARS outbreak: an observational trend study

Background

The model of infectious disease prevention and control changed significantly in China after the outbreak in 2003 of severe acute respiratory syndrome (SARS), but trends and epidemiological features of infectious diseases are rarely studied. In this study, we aimed to assess specific incidence and mortality trends of 45 notifiable infectious diseases from 2004 to 2013 in China and to investigate the overall effectiveness of current prevention and control strategies.

Methods

Incidence and mortality data for 45 notifiable infectious diseases were extracted from a WChinese public health science data centre from 2004 to 2013, which covers 31 provinces in mainland China. We estimated the annual percentage change in incidence of each infectious disease using joinpoint regression.

Findings

Between January, 2004, and December, 2013, 54 984 661 cases of 45 infectious diseases were reported (average yearly incidence 417·98 per 100 000). The infectious diseases with the highest yearly incidence were hand, foot, and mouth disease (114·48 per 100 000), hepatitis B (81·57 per 100 000), and tuberculosis (80·33 per 100 000). 132 681 deaths were reported among the 54 984 661 cases (average yearly mortality 1·01 deaths per 100 000; average case fatality 2·4 per 1000). Overall yearly incidence of infectious disease was higher among males than females and was highest among children younger than 10 years. Overall yearly mortality was higher among males than females older than 20 years and highest among individuals older than 80 years. Average yearly incidence rose from 300·54 per 100 000 in 2004 to 483·63 per 100 000 in 2013 (annual percentage change 5·9%); hydatid disease (echinococcosis), hepatitis C, and syphilis showed the fastest growth. The overall increasing trend changed after 2009, and the annual percentage change in incidence of infectious disease in 2009–13 (2·3%) was significantly lower than in 2004–08 (6·2%).

Interpretation

Although the overall incidence of infectious diseases was increasing from 2004, the rate levelled off after 2009. Effective prevention and control strategies are needed for diseases with the highest incidence—including hand, foot, and mouth disease, hepatitis B, and tuberculosis—and those with the fastest rates of increase (including hydatid disease, hepatitis C, and syphilis).

Funding

Chinese Ministry of Science and Technology, National Natural Science Foundation (China).

A healthy degree of suspicion: A discussion of the implementation of transmission based precautions in the emergency department

Background

Emergency department (ED) presentations have increased significantly domestically and internationally. Swift identification and implementation of transmission based precautions (TBP) for patients known or suspected of having an epidemiologically important pathogen is important. ED staff, particularly triage nurses, are pivotal in detecting and preventing infection, including healthcare associated infections (HAI).

Methods

MEDLINE, CINAHL, PubMed and Ovid were searched for articles published between 2004 and 2015 using key search terms: infection control/prevention and emergency department(s), triage, and transmission based precautions and emergency department(s), and triage, to identify common themes for discussion. Systematic review/meta-analysis was not in the scope of this exploration.

Findings

Themes were identified relating to HAI and ED practices and grouped into: assisted detection of conditions for which TBP is required, ED and TBP, mass-causality event/bioterrorism/pandemic/epidemic, infection control not TBP and multi-resistant organisms not TBP. The literature is heavily influenced by worldwide epidemic/pandemics and bioterrorist risks resulting in increased awareness of the importance of swift identification of syndromes that require TBP, but only in these situations.

Conclusion

Implementation of appropriate TBP, changing triage practices, training and measures to assist decision-making could assist in preventing HAI in the ED context. A systematic quantitative review of the literature is recommended to guide practice change research.

Hospital Resource Utilization and Patient Outcomes Associated with Respiratory Viral Testing in Hospitalized Patients

Results suggest that health care providers do not use viral test results in making management decisions.

Testing patients for respiratory viruses should guide isolation precautions and provide a rationale for antimicrobial drug therapies, but few studies have evaluated these assumptions. To determine the association between viral testing, patient outcomes, and care processes, we identified adults hospitalized with respiratory symptoms from 2004 through 2012 at a large, academic, tertiary hospital in Canada. Viral testing was performed in 11% (2,722/24,567) of hospital admissions and was not associated with reduced odds for death (odds ratio 0.90, 95% CI 0.76–1.10) or longer length of stay (+1 day for those tested). Viral testing resulted in more resource utilization, including intensive care unit admission, but positive test results were not associated with less antibiotic use or shorter duration of isolation. Results suggest that health care providers do not use viral test results in making management decisions at this hospital. Further research is needed to evaluate the effectiveness of respiratory infection control policies.

Macro Domain from Middle East Respiratory Syndrome Coronavirus (MERS-CoV) Is an Efficient ADP-ribose Binding Module: CRYSTAL STRUCTURE AND BIOCHEMICAL STUDIES

The newly emerging Middle East respiratory syndrome coronavirus (MERS-CoV) encodes the conserved macro domain within non-structural protein 3. However, the precise biochemical function and structure of the macro domain is unclear. Using differential scanning fluorimetry and isothermal titration calorimetry, we characterized the MERS-CoV macro domain as a more efficient adenosine diphosphate (ADP)-ribose binding module than macro domains from other CoVs. Furthermore, the crystal structure of the MERS-CoV macro domain was determined at 1.43-Å resolution in complex with ADP-ribose. Comparison of macro domains from MERS-CoV and other human CoVs revealed structural differences in the α1 helix alters how the conserved Asp-20 interacts with ADP-ribose and may explain the efficient binding of the MERS-CoV macro domain to ADP-ribose. This study provides structural and biophysical bases to further evaluate the role of the MERS-CoV macro domain in the host response via ADP-ribose binding but also as a potential target for drug design.

Trend of urban-rural disparities in hospital admissions and medical expenditure in China from 2003 to 2011

OBJECTIVES

To assess the trend of urban-rural disparities in hospital admissions and medical expenditure between 2003 and 2011 in the context of Chinese health-care system reform.

METHODS

The data were from three different national surveys: the Third National Health Services Survey in 2003, the Fourth National Health Services Survey in 2008 and the national health-care reform phased assessment survey in 2011. There were 151421, 143380 and 48356 respondents aged 15 years or older in 2003, 2008 and 2011, respectively.

RESULTS

The health insurance coverage expanded considerably from 27.7% in 2003 to 96.4% in 2011 among respondents aged 15 years or older. Hospitalization rate increased rapidly from 4.1% in 2003 to 9.6% in 2011. Urban respondents had higher hospital admissions than rural respondents, and the RR (95% CI) of hospitalization was 1.23 (1.17-1.30), 1.06 (1.02-1.10) and 1.16 (1.10-1.23) in 2003, 2008 and 2011, respectively. The urban-rural disparity in hospital admissions significantly narrowed over time. Urban respondents had a higher admission rate if insured and a lower admission if not insured than their rural counterparts. Of the six medical expenditure measures, the disparities in reimbursement rate and the proportion of hospitalization direct cost to the total consumer spending significantly narrowed.

CONCLUSIONS

The health insurance coverage has been continually expanding and health service utilization has been substantially improved. Urban-rural disparities have been narrowed but still exist. Therefore, policy-makers should focus on increasing investment and reimbursement levels, developing a uniform standard health insurance system for urban and rural residents and improving the medical assistance system.

Influenza infection screening tools fail to accurately predict influenza status for patients during pandemic H1N1 influenza season

BACKGROUND

Following the severe acute respiratory syndrome outbreak in 2003, hospitals have been mandated to use infection screening questionnaires to determine which patients have infectious respiratory illness and, therefore, require isolation precautions. Despite widespread use of symptom-based screening tools in Ontario, there are no data supporting the accuracy of these screening tools in hospitalized patients.

OBJECTIVE

To measure the performance characteristics of infection screening tools used during the H1N1 influenza season.

METHODS

The present retrospective cohort study was conducted at The Ottawa Hospital (Ottawa, Ontario) between October and December, 2009. Consecutive inpatients admitted from the emergency department were included if they were ≥18 years of age, underwent a screening tool assessment at presentation and had a most responsible diagnosis that was cardiac, respiratory or infectious. The gold-standard outcome was laboratory diagnosis of influenza.

RESULTS

The prevalence of laboratory-confirmed influenza was 23.5%. The sensitivity and specificity of the febrile respiratory illness screening tool were 74.5% (95% CI 60.5% to 84.8%) and 32.7% (95% CI 25.8% to 40.5%), respectively. The sensitivity and specificity of the influenza-like illness screening tool were 75.6% (95% CI 61.3% to 85.8%) and 46.3% (95% CI 38.2% to 54.7%), respectively.

CONCLUSIONS

The febrile respiratory illness screening tool missed 26% of active influenza cases, while 67% of noninfluenza patients were unnecessarily placed under respiratory isolation. Results of the present study suggest that infection-control practitioners should re-evaluate their strategy of screening patients at admission for contagious respiratory illness using symptom- and sign-based tests. Future efforts should focus on the derivation and validation of clinical decision rules that combine clinical features with laboratory tests.

Quantifying the risk of respiratory infection in healthcare workers performing high-risk procedures

This study determined the risk of respiratory infection associated with high-risk procedures (HRPs) performed by healthcare workers (HCWs) in high-risk settings. We prospectively studied 481 hospital HCWs in China, documented risk factors for infection, including performing HRPs, measured new infections, and analysed whether HRPs predicted infection. Infection outcomes were clinical respiratory infection (CRI), laboratory-confirmed viral or bacterial infection, and an influenza infection. About 12% (56/481) of the study participants performed at least one HRP, the most common being airway suctioning (7·7%, 37/481). HCWs who performed a HRP were at significantly higher risk of developing CRI and laboratory-confirmed infection [adjusted relative risk 2·9, 95% confidence interval (CI) 1·42–5·87 and 2·9, 95% CI 1·37–6·22, respectively]. Performing a HRP resulted in a threefold increase in the risk of respiratory infections. This is the first time the risk has been prospectively quantified in HCWs, providing data to inform occupational health and safety policies.

Insufficient preparedness of primary care practices for pandemic influenza and the effect of a preparedness plan in Japan: a prefecture-wide cross-sectional study

Background

Cases of emerging infectious diseases, including H5N1 influenza, H7N9 influenza, and Middle East Respiratory Syndrome, have been reported in recent years, and the threat of pandemic outbreaks persists. In Japan, primary care is the frontline against emerging infectious diseases in communities. Although the importance of pandemic preparedness in primary care has been highlighted previously, few studies have thus far investigated the preparedness among primary care practices (PCPs) or differences in the preparedness of different institutional settings. We examined PCP preparedness and response to the 2009 influenza pandemic in Japan, and explored the role of a pandemic preparedness plan during the pandemic.

Methods

We used a survey questionnaire to assess how well individual PCPs in Okinawa, Japan, were prepared for the 2009 influenza pandemic. The questionnaire was mailed to all eligible PCPs (N = 465) in Okinawa, regardless of their institutional setting. In addition, we assessed the differences in the preparedness of clinics and hospitals and determined whether the national preparedness plan affected individual preparedness and response. Data were analyzed using descriptive and logistic regression analyses.

Results

A total of 174 (37.4%) PCPs responded to our survey. In general, high-level personal protective equipment (PPE) such as N95 masks (45.4%), gowns (30.5%), and eye protection (21.3%) was stocked at a low rate. Clinic-based PCPs were significantly less prepared than hospital-based PCPs to provide N95 masks (OR 0.34), gowns (OR 0.15), and eye protection (OR 0.18). In addition, only 32.8% of PCPs adopted an adequate business continuity plan (BCP). After controlling for institutional setting, reading the national preparedness plan was significantly associated with establishment of a BCP (OR 5.86), and with knowledge of how to transfer a swab specimen to a local medical laboratory (OR 5.60).

Conclusions

With regard to PPE availability, PCPs (especially clinic-based PCPs) were not adequately prepared for the influenza pandemic. Awareness of the national pandemic preparedness plan is likely to promote prefecture-wide implementation of BCPs and surveillance activity.

The spreading frontiers of avian-human influenza described by the free boundary

In this paper, a reaction-diffusion system is proposed to investigate avian-human influenza. Two free boundaries are introduced to describe the spreading frontiers of the avian influenza. The basic reproduction numbers r 0 F (t) and R 0 F (t) are defined for the bird with the avian influenza and for the human with the mutant avian influenza of the free boundary problem, respectively. Properties of these two time-dependent basic reproduction numbers are obtained. Sufficient conditions both for spreading and for vanishing of the avian influenza are given. It is shown that if r 0 F (0) < 1 and the initial number of the infected birds is small, the avian influenza vanishes in the bird world. Furthermore, if r 0 F (0) < 1 and R 0 F (0) < 1, the avian influenza vanishes in the bird and human worlds. In the case that r 0 F (0) < 1 and R 0 F (0) > 1, spreading of the mutant avian influenza in the human world is possible. It is also shown that if r 0 F (t 0) ⩾ 1 for any t 0 ⩾ 0, the avian influenza spreads in the bird world.

Using sensor networks to study the effect of peripatetic healthcare workers on the spread of hospital-associated infections

BACKGROUND

Super-spreading events, in which an individual with measurably high connectivity is responsible for infecting a large number of people, have been observed. Our goal is to determine the impact of hand hygiene noncompliance among peripatetic (eg, highly mobile or highly connected) healthcare workers compared with less-connected workers.

METHODS

We used a mote-based sensor network to record contacts among healthcare workers and patients in a 20-bed intensive care unit. The data collected from this network form the basis for an agent-based simulation to model the spread of nosocomial pathogens with various transmission probabilities. We identified the most- and least-connected healthcare workers. We then compared the effects of hand hygiene noncompliance as a function of connectedness.

RESULTS

The data confirm the presence of peripatetic healthcare workers. Also, agent-based simulations using our real contact network data confirm that the average number of infected patients was significantly higher when the most connected healthcare worker did not practice hand hygiene and significantly lower when the least connected healthcare workers were noncompliant.

CONCLUSIONS

Heterogeneity in healthcare worker contact patterns dramatically affects disease diffusion. Our findings should inform future infection control interventions and encourage the application of social network analysis to study disease transmission in healthcare settings.

Antibiotic resistance amongst healthcare-associated pathogens in China

The People's Republic of China, commonly known as China, comprises approximately one-fifth of the world's population. Because of the expanding size and density of its population and the frequent interaction of people with animals, China is a hotspot for the emergence and spread of new microbial threats and is a major contributor to the worldwide infectious disease burden. In recent years, the emergence and rapid spread of severe acute respiratory syndrome (SARS) generated considerable interest in the Chinese healthcare system and its infection control and prevention measures. This review examines antibiotic misuse and the status of antibiotic resistance in the Chinese healthcare system. China has high rates of antibiotic resistance driven by misuse of these agents in a healthcare system that provides strong incentives for overprescribing and in a country where self-medication is common. Tuberculosis remains a serious problem in China, with a high prevalence of multidrug-resistant and extensively drug-resistant strains. Drug resistance amongst nosocomial bacteria has been on a rapid upward trend with a strong inclination towards multidrug resistance. There is a need for effective infection prevention and control measures and strict use of antibiotics in China to control the rise and spread of antibiotic resistance in the country.

Organizational and Command Aspects for Coordinating the Public Health Response to an Outbreak of Acute Renal Failure, Republic of Panama, 2006

The Ministry of Health of Panama (MINSA) received several reports of ill persons who had clinical presentations of acute renal insufficiency or failure during September and October 2006. On 01 October 2006, the MINSA formally asked the Pan-American Health Organization (PAHO) and the US Centers for Disease Control and Prevention (CDC) to assist with the investigation. Additional agencies involved in the response included the US Food and Drug Administration (FDA), the Gorgas Institute for Health Studies (GIHS), and the Social Security Health System (SSHS) of Panama. Through a joint effort, the MINSA, CDC, FDA, GIHS, SSHS, and PAHO were able to characterize the illness, identify the etiological agent, identify the population-at-risk, and launch an unprecedented media and social mobilization effort to prevent additional cases.

International outbreak responses may require familiarity with basic emergency management principles beyond technical or scientific considerations. The management, logistical capabilities, team interaction, and efficiency of outbreak investigations can be enhanced substantially by having staff already familiar with common operational frameworks for incident responses. This report describes the inter-agency coordination and organizational structure implemented during an international response to identify the cause of an outbreak of acute renal failure in Panama.

Exotic imported travel-related infections in Japan

Human social and economic activities as well as changes in the global environment are responsible for outbreaks of emerging and re-emerging infectious diseases. We have encountered 5 cases of asymptomatic schistosomiasis in Japanese travelers who were exposed to cercariae-contaminated freshwater in east Africa. Because all 5 travelers showed normal results upon their return medical examination, Schistosoma, which is not indigenous to Japan, was unfortunately not suspected as the causative agent of this chronic and silent infection. In addition, in 2008, we experienced 2 Japanese cases in an exotic and local pandemic of human trichinellosis which was associated with eating raw soft-shelled turtles in Taiwan. The cause of this emerging pandemic can be attributed to the traditional custom of eating raw soft-shelled turtles. It is important for all travelers to understand that anyone at anytime can be exposed to the threat of a pandemic; therefore, the first step for all travelers is to be aware of worldwide endemicity and keep up to date on the infectious diseases that are prevalent. Concurrently, it is important to identify the presence of slowly and silently expanding infectious diseases and establish surveillance systems to detect not only serious emerging infectious diseases but also chronic and silent infections.

New mothers' experiences of social disruption and isolation during the severe acute respiratory syndrome outbreak in Hong Kong

In Hong Kong during the severe acute respiratory syndrome outbreak of 2003, sustained uncertainty caused daily stress for residents for > 3 months. Expectant women experienced unexpected social disruption and isolation within their day-to-day life that have not been described in their own voice. The purpose of this study was to describe the experiences of women who became mothers during the outbreak and the ways in which these experiences impacted their early post-partum mothering. A phenomenological research design was chosen. The participants' responses then led the interview process. As the women's experiences had many similarities, saturation was reached after eight interviews. Four themes emerged: living with uncertainty, intense vigilance, isolation, and disrupted expectations. The participants spoke of disrupted daily routines as they tried to eliminate their risk of contracting this disease, including relationship difficulties with their spouse. None of the women had the birth experience they had hoped for because of changes in hospital practices.

Special article: personal protective equipment for care of pandemic influenza patients: a training workshop for the powered air purifying respirator

Virulent respiratory infectious diseases may present a life-threatening risk for health care professionals during aerosol-generating procedures, including endotracheal intubation. The 2009 Pandemic Influenza A (H1N1) brings this concern to the immediate forefront. The Centers for Disease Control and Prevention have stated that, when performing or participating in aerosol-generating procedures on patients with virulent contagious respiratory diseases, health care professionals must wear a minimum of the N95 respirator, and they may wish to consider using the powered air purifying respirator (PAPR). For influenza and other diseases transmitted by both respiratory and contact modes, protective respirators must be combined with contact precautions. The PAPR provides 2.5 to 100 times greater protection than the N95, when used within the context of an Occupational Safety and Health Administration-compliant respiratory protection program. The relative protective capability of a respirator is quantified using the assigned protection factor. The level of protection designated by the APF can only be achieved with appropriate training and correct use of the respirator. Face seal leakage limits the protective capability of the N95 respirator, and fit testing does not assure the ability to maintain a tight face seal. The protective capability of the PAPR will be defeated by improper handling of contaminated equipment, incorrect assembly and maintenance, and improper don (put on) and doff (take off) procedures. Stress, discomfort, and physical encumbrance may impair performance. Acclimatization through training will mitigate these effects. Training in the use of PAPRs in advance of their need is strongly advised. "Just in time" training is unlikely to provide adequate preparation for groups of practitioners requiring specialized personal protective equipment during a pandemic. Employee health departments in hospitals may not presently have a PAPR training program in place. Anesthesia and critical care providers would be well advised to take the lead in working with their hospitals' employee health departments to establish a PAPR training program where none exists. User instructions state that the PAPR should not be used during surgery because it generates positive outward airflow, and may increase the risk of wound infection. Clarification of this prohibition and acceptable solutions are currently lacking and need to be addressed. The surgical hood system is not an acceptable alternative. We provide on line a PAPR training workshop. Supporting information is presented here. Anesthesia and critical care providers may use this workshop to supplement, but not substitute for, the manufacturers' detailed use and maintenance instructions.

The impact of matching vaccine strains and post-SARS public health efforts on reducing influenza-associated mortality among the elderly

Public health administrators do not have effective models to predict excess influenza-associated mortality and monitor viral changes associated with it. This study evaluated the effect of matching/mismatching vaccine strains, type/subtype pattern changes in Taiwan's influenza viruses, and the impact of post-SARS (severe acute respiratory syndrome) public health efforts on excess influenza-associated mortalities among the elderly. A negative binomial model was developed to estimate Taiwan's monthly influenza-associated mortality among the elderly. We calculated three winter and annual excess influenza-associated mortalities [pneumonia and influenza (P&I), respiratory and circulatory, and all-cause] from the 1999-2000 through the 2006-2007 influenza seasons. Obtaining influenza virus sequences from the months/years in which death from P&I was excessive, we investigated molecular variation in vaccine-mismatched influenza viruses by comparing hemagglutinin 1 (HA1) of the circulating and vaccine strains. We found that the higher the isolation rate of A (H3N2) and vaccine-mismatched influenza viruses, the greater the monthly P&I mortality. However, this significant positive association became negative for higher matching of A (H3N2) and public health efforts with post-SARS effect. Mean excess P&I mortality for winters was significantly higher before 2003 than after that year [mean +/- S.D.: 1.44+/-1.35 vs. 0.35+/-1.13, p = 0.04]. Further analysis revealed that vaccine-matched circulating influenza A viruses were significantly associated with lower excess P&I mortality during post-SARS winters (i.e., 2005-2007) than during pre-SARS winters [0.03+/-0.06 vs. 1.57+/-1.27, p = 0.01]. Stratification of these vaccine-matching and post-SARS effect showed substantial trends toward lower elderly excess P&I mortalities in winters with either mismatching vaccines during the post-SARS period or matching vaccines during the pre-SARS period. Importantly, all three excess mortalities were at their highest in May, 2003, when inter-hospital nosocomial infections were peaking. Furthermore, vaccine-mismatched H3N2 viruses circulating in the years with high excess P&I mortality exhibited both a lower amino acid identity percentage of HA1 between vaccine and circulating strains and a higher numbers of variations at epitope B. Our model can help future decision makers to estimate excess P&I mortality effectively, select and test virus strains for antigenic variation, and evaluate public health strategy effectiveness.

Quantification of the severity of an outbreak in human infection control

BACKGROUND

The severity of an outbreak is a priority in decision-making for human infection control. However, there have been no reports on how to quantify the severity of an outbreak.

METHODS

We propose a simple method to measure the severity of an infectious disease outbreak. It involves scoring the severity of clinical signs, the transmission of the infection, the number of cases, and the infection source.

RESULTS

The method was evaluated using the data available at the early stage of some recent outbreaks of infectious diseases, including the influenza A (H1N1) pandemic in 2009, and the evaluation supports the design idea.

CONCLUSION

The method is practical for rating the severity of an infectious disease outbreak, though it should be optimized. It could also be used to judge whether an event constitutes a public health emergency of international concern (PHEIC) or not.