A SARS-CoV-2 outbreak in a public order and safety training facility in England, June 2021

BACKGROUND

The public order and safety (POS) sector remains susceptible to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks, as workplace attendance is typically compulsory and close physical contact is often needed. Here, we report on a SARS-CoV-2 outbreak with an attack rate of 39% (9/23), which occurred between 19 and 29 June 2021 among a cohort of new POS recruits participating in a mandatory 18-week training programme in England.

METHODS

The COVID-OUT (COVID-19 Outbreak investigation to Understand Transmission) study team undertook a multidisciplinary outbreak investigation, including viral surface sampling, workplace environmental assessment, participant viral and antibody testing, and questionnaires, at the two associated training facilities between 5 July and 24 August 2021.

RESULTS

Environmental factors, such as ventilation, were deemed inadequate in some areas of the workplace, with carbon dioxide (CO2) levels exceeding 1,500 ppm on multiple occasions within naturally ventilated classrooms. Activities during safety training required close contact, with some necessitating physical contact, physical exertion, and shouting. Furthermore, most participants reported having physical contact with colleagues (67%) and more than one close work contact daily (97%).

CONCLUSIONS

Our investigation suggests that site- and activity-specific factors likely contributed to the transmission risks within the POS trainee cohort. Potential interventions for mitigating SARS-CoV-2 transmission in this POS training context could include implementing regular rapid lateral flow testing, optimizing natural ventilation, using portable air cleaning devices in classrooms, and expanding use of well-fitted FFP2/FFP3 respirators during activities where prolonged close physical contact is required.

A SARS-CoV-2 outbreak investigation at a storage and distribution centre in England: an assessment of worker- and workplace-related risk factors

An outbreak of SARS-CoV-2 (1 March to 10 May 2021) with an attack rate of 26.5% among approximately 1150 workers at a storage and distribution centre in England prompted a multidisciplinary outbreak investigation (5 May to 6 August 2021), with the aim of better understanding worker- and workplace-related risk factors for viral transmission in the warehousing sector. Overall, environmental factors (e.g., ventilation, humidity and temperature) were assessed to be appropriate at the facility. Nevertheless, 39 (51.3%) surface samples from across the site tested positive for low/ very low levels of SARS-CoV-2 RNA (Ct value ≥ 32.0 for all). Among the study participants, of whom 35.6% were confirmed or suspected cases, 95.5% reported having received COVID-19 prevention training, 100.0% reported handwashing, and 80.0% reported use of face coverings at work. Notably, 43.9% and 19.0% reported working with a symptomatic and a positive contact respectively. Furthermore, 80.5% and 46.3% had concerns regarding reduction in their income and future unemployment, respectively, due to self-isolation. The findings of this study suggest that, in addition to targeted workplace infection control measures and tailored work area specific risk assessments, an enhanced and equitable sick leave policy may help limit presenteeism and viral transmission in large workplaces.

Surface sampling for SARS-CoV-2 RNA in workplace outbreak settings in the UK, 2021-22

AIMS

To utilize environmental surface sampling to evaluate areas of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) contamination within workplaces to identify trends and improve local coronavirus disease 2019 (COVID-19) control measures.

METHODS AND RESULTS

Surface sampling was undertaken at 12 workplaces that experienced a cluster of COVID-19 cases in the workforce between March 2021 and March 2022. A total of 7.4% (61/829) samples collected were positive for SARS-CoV-2 RNA by the quantitative PCR (qPCR) with only 1.8% (15/829) of samples identified with crossing threshold (Ct) values <35.0. No sample returned whole-genome sequence inferring RNA detected was degraded.

CONCLUSIONS

Few workplace surface samples were positive for SARS-CoV-2 RNA and positive samples typically contained low levels of nucleic acid. Although these data may infer a low probability of fomite transmission within the workplace, Ct values may have been lower at the time of contamination. Workplace environmental sampling identified lapses in COVID-19 control measures within individual sites and showed trends throughout the pandemic.

A SARS-CoV-2 outbreak in a plastics manufacturing plant

BACKGROUND

A SARS-CoV-2 outbreak with an attack rate of 14.3% was reported at a plastics manufacturing plant in England.

METHODS

Between 23^rd March and 13^th May 2021, the COVID-OUT team undertook a comprehensive outbreak investigation, including environmental assessment, surface sampling, molecular and serological testing, and detailed questionnaires, to identify potential SARS-CoV-2 transmission routes, and workplace- and worker-related risk factors.

RESULTS

While ventilation, indicated using real-time CO₂ proxy measures, was generally adequate on-site, the technical office with the highest localized attack rate (21.4%) frequently reached peaks in CO₂ of 2100ppm. SARS-CoV-2 RNA was found in low levels (Ct ≥35) in surface samples collected across the site. High noise levels (79dB) were recorded in the main production area, and study participants reported having close work contacts (73.1%) and sharing tools (75.5%). Only 20.0% of participants reported using a surgical mask and/or FFP2/FFP3 respirator at least half the time and 71.0% expressed concerns regarding potential pay decreases and/or unemployment due to self-isolation or workplace closure.

CONCLUSIONS

The findings reinforce the importance of enhanced infection control measures in manufacturing sectors, including improved ventilation with possible consideration of CO₂ monitoring, utilising air cleaning interventions in enclosed environments, and provision of good-quality face masks (i.e., surgical masks or FFP2/FFP3 respirators) especially when social distancing cannot be maintained. Further research on the impacts of job security-related concerns is warranted.

Investigation of a SARS-CoV-2 Outbreak at an Automotive Manufacturing Site in England

Workplace-related outbreaks of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continue to occur globally. The manufacturing sector presents a particular concern for outbreaks, and a better understanding of transmission risks are needed. Between 9 March and 24 April 2021, the COVID-19 (coronavirus disease 2019) Outbreak Investigation to Understand Transmission (COVID-OUT) study undertook a comprehensive investigation of a SARS-CoV-2 outbreak at an automotive manufacturing site in England. The site had a total of 266 workers, and 51 SARS-CoV-2 infections. Overall, ventilation, humidity, and temperature at the site were assessed to be appropriate for the number of workers and the work being conducted. The company had implemented a number of infection control procedures, including provision of face coverings, spacing in the work, and welfare areas to allow for social distancing. However, observations of worker practices identified lapses in social distancing, although all were wearing face coverings. A total of 38 workers, including four confirmed cases, participated in the COVID-OUT study. The majority of participants received COVID-19 prevention training, though 42.9% also reported that their work required close physical contact with co-workers. Additionally, 73.7% and 34.2% had concerns regarding reductions in future income and future unemployment, respectively, due to self-isolation. This investigation adds to the growing body of evidence of SARS-CoV-2 outbreaks from the manufacturing sector. Despite a layered COVID-19 control strategy at this site, cases clustered in areas of high occupancy and close worker proximity.

Molecularly Imprinted Chitosan-Based Thin Films with Selectivity for Nicotine Derivatives for Application as a Bio-Sensor and Filter

This study reports the feasible use of chitosan as a thin film biosensor on the very sensitive quartz crystal micro balance system for detection of blends of multiple templates within a single matrix. The development of chitosan-based thin film materials with selectivity for nicotine derivatives is described. The molecular imprinting of a combination of nicotine derivatives in N-diacryloyl pipiradine-chitosan-methacrylic acid copolymer films on quartz crystal resonators was used to generate thin films with selectivity for nicotine and a range of nicotine analogues, particularly 3-phenylpyridine. The polymers were characterized by spectroscopic and microscopic evaluations; surface area, pore size, pore volume using Breuner-Emmet-Teller method. Temperature characteristics were also studied. The swelling and structure consistency of the Chitosan was achieved by grafting with methylmethacrylic acid and cross-linking with N-diacrylol pipiradine. A blend of 0.002 g (0.04 mmol) of Chitosan, 8.5 μL Methylmethacrylic Acid and 1.0 mg N-diacrylol pipradine (BAP) presented the best blend formulation. Detections were made within a time interval of 99 s, and blend templates were detected at a concentration of 0.5 mM from the Quartz crystal microbalance resonator analysis. The successful crosslinking of the biopolymers ensured successful control of the swelling and agglomeration of the chitosan, giving it the utility potential for use as thin film sensor. This successful crosslinking also created successful dual multiple templating on the chitosan matrix, even for aerosolized templates. The products can be used in environments with temperature ranges between 60 °C and 250 °C.

Discovery of Icenticaftor (QBW251), a Cystic Fibrosis Transmembrane Conductance Regulator Potentiator with Clinical Efficacy in Cystic Fibrosis and Chronic Obstructive Pulmonary Disease

Mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) ion channel are established as the primary causative factor in the devastating lung disease cystic fibrosis (CF). More recently, cigarette smoke exposure has been shown to be associated with dysfunctional airway epithelial ion transport, suggesting a role for CFTR in the pathogenesis of chronic obstructive pulmonary disease (COPD). Here, the identification and characterization of a high throughput screening hit 6 as a potentiator of mutant human F508del and wild-type CFTR channels is reported. The design, synthesis, and biological evaluation of compounds 7-33 to establish structure-activity relationships of the scaffold are described, leading to the identification of clinical development compound icenticaftor (QBW251) 33, which has subsequently progressed to deliver two positive clinical proofs of concept in patients with CF and COPD and is now being further developed as a novel therapeutic approach for COPD patients.

Safety and efficacy of the cystic fibrosis transmembrane conductance regulator potentiator icenticaftor (QBW251)

Background:

This is the first-in-human study of icenticaftor, an oral potentiator of the cystic fibrosis (CF) transmembrane conductance regulator (CFTR) channel. Restoration of CFTR activity has shown significant clinical benefits, but more studies are needed to address all CFTR mutations.

Methods:

Safety, pharmacodynamics/pharmacokinetics of icenticaftor were evaluated in a randomized, double-blind, placebo-controlled study in healthy volunteers. Efficacy was assessed in adult CF patients with ≥1 pre-specified CFTR Class III or IV mutation (150 and 450 mg bid), or homozygous for F508del mutation (450 mg bid). Primary efficacy endpoint was change from baseline in lung clearance index (LCI_2.5). Secondary endpoints included %predicted FEV₁ and sweat chloride level.

Results:

Class IV mutations were present in 22 patients, Class III in 2 (both S549N), and 25 were homozygous for F508del. Icenticaftor was well-tolerated in healthy and CF subjects with no unexpected events or discontinuations in the CF groups. The most frequent study-drug related adverse events in CF patients were nausea (12.2%), headache (10.2%), and fatigue (6.1%). Icenticaftor 450 mg bid for 14 days showed significant improvements in all endpoints versus placebo in patients with Class III and IV mutations; mean %predicted FEV₁ increased by 6.46%, LCI_2.5 decreased by 1.13 points and sweat chloride decreased by 8.36 mmol/L. No significant efficacy was observed in patients homozygous for a single F508del.

Conclusions:

Icenticaftor was safe and well-tolerated in healthy volunteers and CF patients, and demonstrated clinically meaningful changes in lung function and sweat chloride level in CF patients with Class III and IV CFTR mutations.

ClinicalTrials.gov: NCT02190604

What do hospital staff in the UK think are the causes of penicillin medication errors?

BACKGROUND

Medication errors are a potential major threat to patient's health, and allergic reactions occurring in patients with known allergies are an important preventable form of adverse drug event. The use of penicillin antibiotics in patients who are allergic to penicillin, in particular, is a major concern.

AIM

To survey staff attitudes and beliefs to incidents involving penicillin allergic patients who are prescribed and administered penicillin antibiotics.

SETTING

A 650 bed teaching hospital in England.

METHOD

Using individual and (focus) group interview proceedings with a purposive sample of doctors, nurses and pharmacists, an electronic questionnaire was administered hospital wide to all clinical staff. No reminders were issued.

MAIN OUTCOME MEASURES

Clinical staff's views on the causes of penicillin medication errors.

RESULTS

The electronic survey was completed by 235 members of the clinical staff. Half the respondents definitely considered themselves knowledgeable about which antibiotics contain penicillin medicines, though approximately 90 % of respondents considered that misinformation or lack of knowledge on which antibiotics contain penicillin medicines was an issue for some or most colleagues. Various organisational issues such as the use of red wrist bands, the wearing of red tabards by the nurse during the medicines round, and a busy work environment were recurrently highlighted as systems factors that could be improved upon.

CONCLUSION

Our study elucidated concerns amongst clinical staff relating to the scenario of a penicillin allergic patient receiving a penicillin antibiotic. The resulting local learning and feedback about staff beliefs pertaining to this one specific type of error will be used to consider the nature and type of local action to be taken to help improve patient safety.

The presence of drug in control samples during toxicokinetic investigations--a Novartis perspective

During a submission procedure, the validity of a few dietary toxicity studies was questioned because low levels of the drug were detected among control toxicokinetic samples. Although several lines of reasoning suggested that these findings arose from ex vivo contamination, the Regulatory Authority stated that it was not possible to establish a no-effect-level in any of the studies and so the submission was withdrawn. In response, Novartis conducted a thorough review and modification of the procedures involved in the collection and analysis of toxicokinetic samples to minimize such contamination in future studies. Ongoing monitoring of contamination in toxicology studies has subsequently revealed that although it was not possible to completely eliminate the problem, the new procedures together with an increasing awareness of the issue have considerably reduced the incidence of contamination. The process of contamination and its control was also modeled in a feeding study in mice. This provided good evidence that the detection of drug in control samples in the previous studies originated from external sources and not from in vivo exposure.

Bronchial response to histamine after inhaled propranolol and atropine in monkeys

To investigate the nature of the variable response to inhaled histamine in monkeys, we performed dose-response curves in a group of 10 anesthetized Macaca mulatta monkeys before and after administration of propranolol and atropine in inhaled doses sufficient to produce significant beta-adrenergic and cholinergic blockade of airway smooth muscle. Animals were studied in a volume-displacement body plethysmograph and changes in pulmonary resistance (RL), dynamic compliance (Cdyn), frequency (f) and tidal volume (VT) were plotted against inhaled histamine concentration (0.016 to 64 mg/ml). Sensitivity to histamine was assessed by the concentrations producing a 50% increase in RL and a 50% decrease in Cdyn. A wide range of sensitivity (0.44 to 3.3 mg/ml for RL, 0.47 to 11.3 mg/ml for Cdyn) was found in this small group of animals, and this was not influenced by prior inhalation of propranolol. Atropine inhalation resulted in a marked decrease in sensitivity in all animals but did not reduce the variability of response.

Platelet sequestration in lung with hemorrhagic shock and reinfusion in dogs

We compared red blood cell (RBC) and platelet transit through the pulmonary vascular bed under control conditions (n = 8) and during hemorrhagic shock (n = 8) in anesthetized spontaneously breathing dogs, using a modification of the indicator-dilutor technique. Platelets and RBCs from each animal were labeled with 51Cr and 99mTc, respectively, and were rapidly injected into the right atrium while blood was sampled from the ascending aorta. The mean transit time (MTT), volume of distribution, and percent recovery for RBCs and platelets were calculated, as was the percent extraction of platelets. We found 1) the the difference between RBC and platelet MTT increased (p less than 0.01), 2) that the percent extraction of platelets increased (p less than 0.001), and 3) that the percent recovery of platelets fell (p less than 0.01) during the shock period. These values all returned to control levels after reinfusion of the shed blood. The relationship between a transient reduction in blood flow and platelet extraction was then studied in a third group of dogs (n = 5) where inflation of a balloon in the inferior vena cava was used to reduce cardiac output (CO). These studies showed that platelet extraction was inversely related to CO. We conclude that the increased platelet sequestration seen in the lung during hemorrhagic shock is primarily related to decreased blood flow.