A measles IgM rapid diagnostic test to address challenges with national measles surveillance and response in Malaysia

INTRODUCTION

A lateral flow rapid diagnostic test (RDT) enables detection of measles specific immunoglobulin M (IgM) antibody in serum, capillary blood, and oral fluid with accuracy consistent with enzyme immunoassay (EIA). The objectives of the study were: 1) to assess measles RDT inter-reader agreement between two clinic staff; 2) to assess the sensitivity and specificity of the measles RDT relative to standard surveillance testing in a low transmission setting; 3) to evaluate the knowledge, attitudes, and practices of staff in clinics using the RDT; and 4) to assess the impact of RDT testing on the measles public health response in Malaysia.

MATERIALS AND METHODS

The clinic-based prospective evaluation included all suspected measles cases captured by routine measles surveillance at 34 purposely selected clinics in 15 health districts in Malaysia between September 2019 and June 2020, following day-long regional trainings on RDT use. Following informed consent, four specimens were collected from each suspected case, including those routinely collected for standard surveillance [serum for EIA and throat swabs for quantitative reverse transcriptase polymerase chain reaction (RT-qPCR)] together with capillary blood and oral fluid tested with RDTs during the study. RDT impact was evaluated by comparing the rapidity of measles public health response between the pre-RDT implementation (December 2018 to August 2019) and RDT implementation periods (September 2019 to June 2020). To assess knowledge, attitudes, and practices of RDT use, staff involved in the public health management of measles at the selected sites were surveyed.

RESULTS

Among the 436 suspect cases, agreement of direct visual readings of measles RDT devices between two health clinic staff was 99% for capillary blood (k = 0.94) and 97% for oral fluid (k = 0.90) specimens. Of the total, 45 (10%) were positive by measles IgM EIA (n = 44, including five also positive by RT-qPCR) or RT-qPCR only (n = 1), and 38 were positive by RDT (using either capillary blood or oral fluid). Using measles IgM EIA or RT-qPCR as reference, RDT sensitivity using capillary blood was 43% (95% CI: 30%-58%) and specificity was 98% (95% CI: 96%-99%); using oral fluid, sensitivity (26%, 95% CI: 15%-40%) and specificity (97%, 95% CI: 94%-98%) were lower. Nine months after training, RDT knowledge was high among staff involved with the public health management of measles (average quiz score of 80%) and was highest among those who received formal training (88%), followed by those trained during supervisory visits (83%). During the RDT implementation period, the number of days from case confirmation until initiation of public response decreased by about 5 days.

CONCLUSION

The measles IgM RDT shows >95% inter-reader agreement, high retention of RDT knowledge, and a more rapid public health response. However, despite ≥95% RDT specificity using capillary blood or oral fluid, RDT sensitivity was <45%. Higher-powered studies using highly specific IgM assays and systematic RT-qPCR for case confirmation are needed to establish the role of RDT in measles elimination settings.

Personalised management of Chronic Obstructive Pulmonary Disease (COPD): Malaysian consensus algorithm for appropriate use of inhaled corticosteroid (ICS) in COPD patients

BACKGROUND

Regarding the long-term safety issues with the use of inhaled corticosteroids (ICS) and the clinical predominance of dual bronchodilators in enhancing treatment outcomes in chronic obstructive pulmonary disease (COPD), ICS is no longer a "preferred therapy" according to the Global Initiative for Chronic Obstructive Lung Disease except on top of a dual bronchodilator. This has necessitated a change in the current therapy for many COPD patients.

OBJECTIVE

To determine a standardised algorithm to reassess and personalise the treatment COPD patients based on the available evidence.

METHODS

A consensus statement was agreed upon by a panel of pulmonologists in from 11 institutes in Malaysia whose members formed this consensus group.

RESULTS

According to the consensus, which was unanimously adopted, all COPD patients who are currently receiving an ICS-based treatment should be reassessed based on the presence of co-existence of asthma or high eosinophil counts and frequency of moderate or severe exacerbations in the previous 12 months. When that the patients meet any of the aforementioned criteria, then the patient can continue taking ICS-based therapy. However, if the patients do not meet the criteria, then the treatment of patients need to be personalised based on whether the patient is currently receiving long-acting beta-agonists (LABA)/ICS or triple therapy.

CONCLUSION

A flowchart of the consensus providing a guidance to Malaysian clinicians was elucidated based on evidences and international guidelines that identifies the right patients who should receive inhaled corticosteroids and enable to switch non ICS based therapies in patients less likely to benefit from such treatments.

Occupational radiation exposure to anesthetists from fluoroscopic projections during orthopedic operative procedures

PURPOSE

The role of anesthetists during orthopedic fluoroscopic procedures exposes them to radiation. We conducted a prospective, descriptive study to estimate the radiation exposure to anesthetists during procedures over a six-month period in the orthopedic trauma operating theatres which had the most fluoroscopic usage.

MATERIALS AND METHODS

Thermoluminescent dosimeter (TLD) chips were placed two metres away from the radiation source, in three positions to simulate the anesthetist's position in the operating theatre during the fluoroscopic procedures as well as their radiation safety practices. The three positions were above the lead gown, behind the lead gown and behind the protective lead screen. The fourth TLD chip was assigned as a control measure to account for background radiation. The radiation exposure was measured at every end of each month during the period of six consecutive months. The TLD chips were sent to the Malaysian Institute for Nuclear Technology (MINT) for the analysis.

RESULTS

From the study, the annual exposure without a protective shield at a 2 metre distance from the projection source was estimated to be 0.70 milliSievert (mSv)/year. With the use of lead gowns and protective lead screens, the annual exposure was estimated to be 0.08 mSv / year. All the radiation levels measured were within the maximum permissible dose of 50 mSv / year.

CONCLUSIONS

During fluoroscopic assisted orthopedic procedures, the anesthetists in UKMMC are exposed to a small amount of radiation which is well below the annual maximum permissible limit as determined by local and international regulatory bodies.

Hospital-acquired Clostridium difficile infection among patients with type 2 diabetes mellitus in acute medical wards

BACKGROUND

Clostridum difficile (C. difficile) infection is increasingly seen among hospitalised patients with type 2 diabetes mellitus but its rate and associated risk factors are not known. We aimed to determine the rate and characteristics of hospital-acquired C. difficile infection in subjects with type 2 diabetes mellitus admitted into acute medical wards.

METHODS

Our prospective cross-sectional study involved 159 patients with established type 2 diabetes mellitus admitted into acute medical wards who developed a hospital-acquired C. difficile infection. Stools were tested for C. difficile toxins using a toxin A/B kit and a toxin A kit. Clinical features, laboratory findings, types of antibiotics, and use of a proton pump inhibitor were examined for their association with the infection.

RESULTS

Thirteen subjects were positive for toxin A and one for toxin B. Using univariable analysis, we found that patients with type 2 diabetes mellitus and hospital acquired C. difficile infection were younger (mean 53.8 years, p=0.02), had diarrhoea and abdominal pain (p=0.001) but no fever. Sepsis (p=0.02) and use of a proton pump inhibitor (p=0.01) were more commonly implicated as the cause of the infection. Of the various types of antibiotics prescribed, carbapenem (28.6% vs 4.1%, p=0.01) and metronidazole (42.9% vs 19.3%, p=0.04) were significantly associated with hospital acquired C. difficile infection.

CONCLUSIONS

Patients with type 2 diabetes mellitus admitted into acute medical wards and who developed hospital-acquired C. difficile infection have distinct characteristics.

Maxillofacial trauma with emphasis on soft-tissue injuries in Malaysia

Soft-tissue injuries with or without facial bone involvement are the most common presentation following maxillofacial trauma. The objective of this study was to look at the distribution, pattern and type of soft-tissue injury in relation to aetiology. Records of patients over a period of 5 years (1998-2002), who sustained maxillofacial injuries and were treated at Kajang Hospital, a secondary referral hospital, were reviewed. Out of 313 patients with maxillofacial injuries, 295 patients sustained soft-tissue injuries. Males (79%) between 21 and 30 years old (34%) were the majority of patients. Road-traffic accident was the main cause of soft-tissue injuries (75%) with motorcycle accident being the most frequent (40%). The upper lips (23%) and the lower lips (18%) were the most common extraoral site involved, while the labial mucosa and sulcular areas, both accounting for 21%, were the most common intraoral sites. Stringent road-traffic regulations should be practiced in developing countries, as morbidity arising from road-traffic accidents poses a national economic and social problem.

Incidental radiological findings ofsusukin the orofacial region

Susuk, or charm needles, are inserted and worn subcutaneously in the face and other parts of the body, as they are believed to enhance beauty and youth, and for many other reasons such as treatment of headache, aches and pains in the joints, back or abdomen. The practice of inserting susuk is a traditional belief, genuinely cultural and superstitious, and common in the south-east Asian region. We present 13 cases of susuk, which was found incidentally on the radiographs as the patients came for various types of treatment at our centre.

Deletion and translocation of chromosome 11q13 sequences in cervical carcinoma cell lines

Molecular genetic studies on HeLa cell-derived nontumorigenic and tumorigenic hybrids have previously localized the HeLa cell tumor-suppressor gene to the long arm of chromosome 11. Extensive molecular and cytogenetic studies on HeLa cells have shown chromosome band 11q13 to be rearranged in this cell line. To determine whether q13 rearrangement is a nonrandom event in cervical carcinomas, six different human papilloma virus (HPV)-positive (HeLa, SiHa, Caski, C4-I, Me180, and Ms751) and two different HPV-negative (C33A and HT3) cell lines were studied. Long-range restriction mapping using a number of q13-specific probes showed molecular rearrangements within 75 kb of INT2 probe in three HPV-positive cell lines (HeLa, SiHa, and Caski) and in an HPV-negative cell line (HT3). FISH using an INT2 YAC identified a breakpoint within the sequences spanned by this YAC in two of the cell lines, HeLa and Caski. INT2 cosmid derived from this YAC showed deletion of cosmid sequences in two other cell lines, SiHa and C33A. These two cell lines, however, retained cosmid sequences of Cyclin D1, a probe localized 100 kb proximal to INT2. Deletions being the hallmark of a tumor-suppressor gene, we conclude that the 100-kb interval between the two cosmids might contain sequences of the cervical carcinoma tumor-suppressor gene.

The Mentakab hypertension study project. Part V--Drug compliance in hypertensive patients

Poor compliance with drug treatment is a barrier to effective management of hypertension. Drug compliance behaviour of 168 patients were studied, their drug compliance was measured by the pill-counting method. The prevalence of non-compliance with medication was 26%. Thirteen variables were examined for their association with compliance; these were age, sex, duration of hypertension since diagnosis, adequacy of blood pressure control, complexity of drug regimen and side-effect of drug, history of previous admission for hypertension related reason, patient's knowledge of hypertensive complications, patient's belief that drug was 'panas' or 'san', previous use of traditional treatment for hypertension, patient's fatalistic attitude, their social support and satisfaction with the health services. None of these variables were significantly related to compliance (p greater than 0.05) except adequacy of blood pressure control. The performance of patient self-report was compared with pill-count as a measure of drug compliance; it was poorly predictive of non-compliance (sensitivity = 71%, specificity = 50%). An inverse relationship was found between non-compliance with medication and patient subsequent drop-out rate. Patients who were compliant were more likely to remain on treatment and vice versa. As a measure of drug compliance, detection of drop-out compared well with pill-count (sensitivity 97%, specificity 66%, positive predictive value 89%, negative predictive value 88%).