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Summary Background Upper respiratory tract infections (URTI) account for the highest proportion of non-urgent visits to the emergency department (ED), resulting in unnecessary antibiotic use. Aim This study sought to understand the determinants of antibiotic prescribing for URTI among 130 junior physicians in a busy adult ED in Singapore. Methods Forty-four Likert-scale statements were developed with reference to a prior qualitative study, followed by an anonymous cross-sectional survey among ED junior physicians. Data analysis was performed with factor reduction and multivariable logistic regression. Findings One-in-six (16.9%) physicians were high antibiotic prescribers (self-reported antibiotic prescribing rate of >30% of URTI patients). After adjusting for place of medical education and years of practice as a physician, perceived over-prescribing of antibiotics in the ED (adjusted odds ratio (OR) 2.37, 95% confidence interval (CI) (1.15, 4.86), P=0.019) and perceived compliance with the antibiotic prescribing practices in the ED (adjusted OR 2.10, 95% CI (1.02, 4.30), P=0.043) were positively associated with high antibiotic prescribing. In contrast, high antibiotic prescribers were 6.67 times (95% CI (1.67, 25.0), P=0.007) less likely to treat and manage patients with URTI symptomatically and 7.12 times (95% CI (1.28, 39.66), P=0.025) more likely to depend on diagnostic tests to prescribe antibiotics than the regular antibiotic prescribers. Conclusion Organizational-related factors (organizational norms and culture) were strong determinants of antibiotic prescribing practices for uncomplicated URTI in the ED. Other contributing factors include diagnostic uncertainty and knowledge gaps. Role-modelling of institutional best practice norms and clinical decision support tools based on local epidemiology can optimize antibiotic prescribing in the ED.

Objectives To determine the prevalence of COVID-19 in the context of a secondary pneumonia surveillance program targeted at low-risk patients; and to identify clinical characteristics associated with COVID-19. Study Design This is a retrospective cohort study. Methods This study is conducted in Tan Tock Seng Hospital, a University affiliated 1600-bed public hospital in Singapore. Patients with pneumonia admitted under our Enhanced Pneumonia Surveillance (EPS) program from 7 February 2020 to 20 March 2020 were included. Relevant clinical variables were collated. Results Out of 1295 patients admitted under our EPS program, 47 (3.6%) patients tested positive for COVID-19. The prevalence of a radiologist-reported normal chest X-ray (CXR) in the COVID-19 positive group was 62.8% compared to 6.2% in the COVID-19 negative group. In patients with a normal CXR, a low normal white blood cell count (WBC) and minimal C-reactive protein (CRP) elevation were associated with COVID-19. Conclusions The pick-up rate of COVID-19 pick-up rate in low-risk patients with pneumonia is 3.6%. However, at least 7.9% of patients who were isolated had a normal CXR. For patients with pneumonia-like illness at presentation but a normal CXR, higher WBC and CRP values may guide early de-isolation. Ultimately, this informs resource allocation for both COVID-19 and non-COVID-19 clinical services., Highlights • A secondary, pneumonia surveillance program can complement screening of suspect cases. • An unintended consequence of this program was capturing of patients with normal Chest X-rays. • White blood cell count and C-reactive protein levels may guide early de-isolation in this group of patients. • Results of a pneumonia surveillance system can inform future hospital resource management.

Background Appropriate antibiotic prescribing is key to combating antimicrobial resistance. Upper respiratory tract infections (URTIs) are common reasons for emergency department (ED) visits and antibiotic use. Differentiating between bacterial and viral infections is not straightforward. We aim to provide an evidence-based clinical decision support tool for antibiotic prescribing using prediction models developed from local data. Methods Seven hundred-fifteen patients with uncomplicated URTI were recruited and analysed from Singapore’s busiest ED, Tan Tock Seng Hospital, from June 2016 to November 2018. Confirmatory tests were performed using the multiplex polymerase chain reaction (PCR) test for respiratory viruses and point-of-care test for C-reactive protein. Demographic, clinical and laboratory data were extracted from the hospital electronic medical records. Seventy percent of the data was used for training and the remaining 30% was used for validation. Decision trees, LASSO and logistic regression models were built to predict when antibiotics were not needed. Results The median age of the cohort was 36 years old, with 61.2% being male. Temperature and pulse rate were significant factors in all 3 models. The area under the receiver operating curve (AUC) on the validation set for the models were similar. (LASSO: 0.70 [95% CI: 0.62–0.77], logistic regression: 0.72 [95% CI: 0.65–0.79], decision tree: 0.67 [95% CI: 0.59–0.74]). Combining the results from all models, 58.3% of study participants would not need antibiotics. Conclusion The models can be easily deployed as a decision support tool to guide antibiotic prescribing in busy EDs.

This cross-sectional, secondary data analysis examines the association between cigarette smoking and self-reported health-related quality of life (HRQoL) in adult survivors of Adolescent and Young Adult Cancer. Pooled data for survivors of Adolescent and Young Adult Cancer (N = 1495) were drawn from the 2016 and 2017 Behavioral Risk Factor Surveillance Survey. Binary logistic regression models were utilized to examine independent associations between each of the four HRQoL domains (i.e., self-related general health, activity limitation days, poor physical, and mental health days) and cigarette smoking. Of the 1495 Adolescent and Young Adult Onset Cancer Survivors (AYAO-CS) in this study, approximately 30% reported currently smoking cigarettes. Relative to never smokers, the odds of reporting fair/poor general health were significantly higher for current and former smokers: (OR = 3.95, 95% CI: 2.08–7.50) and (OR = 2.51, 95% CI: 1.46–4.32), respectively. Likewise, current smokers were significantly more likely to report frequent days of poor physical health (OR = 2.79, 95% CI: 1.38–5.65). The study findings suggest a significant cross-sectional association between cigarette smoking and poor health-related quality of life in adult survivors of adolescent and young adult cancer. These findings, although cross-sectional, underscore the need for prospective studies to examine the longitudinal association between HRQoL and cigarette smoking among cancer survivors. Findings also help establish both the need for smoking cessation programs and the importance of effective strategies for addressing HRQoL issues among cancer survivors.

Background Coronavirus disease 2019 (COVID-19) is an emerging infectious disease caused by a novel coronavirus (SARS-CoV-2) and first reported in Wuhan, China, in December 2019. Since the severe acute respiratory syndrome (SARS) outbreak in 2003, Tan Tock Seng Hospital (TTSH) in Singapore has routinely fit-tested staff for high-filtration N95 respirators and established Web-based staff surveillance systems. The routine systems were enhanced in response to Singapore’s first imported COVID-19 case on 23 January 2020. Methods We conducted a cross-sectional study from 23 January to 23 February 2020 among healthcare workers to evaluate the effectiveness of the staff protection and surveillance strategy in TTSH, a 1600-bed multidisciplinary acute-care hospital colocated with the 330-bed National Centre for Infectious Diseases (NCID). As of 23 February 2020, TTSH/NCID has managed 76% of confirmed COVID-19 cases in Singapore. The hospital adopted a multipronged approach to protect and monitor staff with potential COVID-19 exposures: (1) risk-based personal protective equipment, (2) staff fever and sickness surveillance, and (3) enhanced medical surveillance of unwell staff. Results A total of 10 583 staff were placed on hospitalwide fever and sickness surveillance, with 1524 frontline staff working in COVID-19 areas under close surveillance. Among frontline staff, a median of 8 staff illness episodes was seen per day; almost 10% (n = 29) resulted in hospitalization. None of the staff was found to be infected with COVID-19. Conclusions A robust staff protection and health surveillance system that is routinely implemented during non–outbreak periods and enhanced during the COVID-19 outbreak is effective in protecting frontline staff from the infection.

BACKGROUND Maternal pre-postnatal psychosocial distress increases the risk for childhood allergic disease. This may occur through a host immunity pathway that involves intestinal secretory immunoglobulin A (sIgA). Experimental animal models show changes in the gut microbiome and immunity of offspring when exposed to direct or prenatal maternal stress, but little is known in humans. OBJECTIVE We determined the association between maternal depression and stress symptom trajectories and infant fecal sIgA concentrations. METHODS 1043 term infants from the Canadian Healthy Infant Longitudinal Development (CHILD) birth cohort were studied. Trajectories of maternal perceived stress and depression were based on scored scales administered in pregnancy and postpartum. sIgA was quantified in infant stool (mean age 3.7 months) with Immundiagnostik ELISA. Linear regression and logistic regression were employed to test associations. RESULTS Very low fecal sIgA concentrations were more common in infants of mothers in the antepartum and persistent depression trajectories (6% and 2% of women, respectively). Independent of breastfeeding status at fecal sampling, infant antibiotic exposure or other covariates, the antepartum depressive symptom trajectory was associated with reduced mean infant sIgA concentrations (β=-0.07, P

Antimicrobial stewardship programmes (ASPs) in hospitals are predominantly led by specific ASP physicians and pharmacists. Limited studies have been conducted to appreciate non-ASP-trained hospital pharmacists' perspectives on their roles in antimicrobial stewardship. Focus group discussions (FGDs) were conducted with 74 pharmacists, purposively sampled from the 3 largest acute-care public hospitals in Singapore, to explore facilitators and barriers faced by them in antimicrobial stewardship. Applied thematic analysis was conducted and codes were categorised using the social-ecological model (SEM). At the intrapersonal level, pharmacists identified themselves as reviewers for drug safety before dispensing, confining to a restricted advisory role due to lack of clinical knowledge, experience, and empowerment to contribute actively to physicians' prescribing decisions. At the interpersonal level, pharmacists expressed difficulties conveying their opinions and recommendations on antibiotic therapy to physicians despite frequent communications, but they assumed critical roles as educators for patients and their caregivers on proper antibiotic use. At the organisational level, in-house antibiotic guidelines supported pharmacists' antibiotic interventions and recommendations. At the community level, pharmacists were motivated to improve low public awareness and knowledge on antibiotic use and antimicrobial resistance. These findings provide important insights into the gaps to be addressed in order to harness the untapped potential of hospital pharmacists and fully engage them in antimicrobial stewardship. National Medical Research Council (NMRC) Published version This work was supported by the National Medical Research Council Singapore, Health Services Research Grant, Grant number: NMRC/HSRG/0083/2017).

Background Singapore’s healthcare system presents an ideal context to learn from diverse public and private operational models and funding systems. Aim To explore processes underpinning decision-making for antibiotic prescribing, by considering doctors’ experiences in different primary care settings. Methods Thirty semi-structured interviews were conducted with 17 doctors working in publicly funded primary care clinics (polyclinics) and 13 general practitioners (GP) working in private practices (solo, small and large). Data were analysed using applied thematic analysis following realist principles, synthesised into a theoretical model, informing solutions to appropriate antibiotic prescribing. Results Given Singapore’s lack of national guidelines for antibiotic prescribing in primary care, practices are currently non-standardised. Themes contributing to optimal prescribing related first and foremost to personal valuing of reduction in antimicrobial resistance (AMR) which was enabled further by organisational culture creating and sustaining such values, and if patients were convinced of these too. Building trusting patient-doctor relationships, supported by reasonable patient loads among other factors were consistently observed to allow shared decision-making enabling optimal prescribing. Transparency and applying data to inform practice was a minority theme, nevertheless underpinning all levels of optimal care delivery. These themes are synthesised into the VALUE model proposed for guiding interventions to improve antibiotic prescribing practices. These should aim to reinforce intrapersonal Values consistent with prioritising AMR reduction, and Aligning organisational culture to these by leveraging standardised guidelines and interpersonal intervention tools. Such interventions should account for the wider systemic constraints experienced in publicly funded high patient turnover institutions, or private clinics with transactional models of care. Thus, ultimately a focus on Liaison between patient and doctor is crucial. For instance, building in adequate consultation time and props as discussion aids, or quick turnover communication tools in time-constrained settings. Message consistency will ultimately improve trust, helping to enable shared decision-making. Lastly, Use of monitoring data to track and Evaluate antibiotic prescribing using meaningful indicators, that account for the role of shared decision-making can also be leveraged for change. Conclusions These VALUE dimensions are recommended as potentially transferable to diverse contexts, and the model as implementation tool to be tested empirically and updated accordingly.

BackgroundWe assessed the preferences and trade-offs for social interactions, incentives, and being traced by a digital contact tracing (DCT) tool post lockdown in Singapore.MethodsWe conducted a discrete choice experiment (DCE) among visitors of a large public hospital in Singapore between July 2020 – February 2021. Respondents were sampled proportionately by gender and four age categories (21 – 80 years). The DCE questionnaire had three attributes (1. Social interactions, 2. Being traced by a DCT tool, 3. Incentives to use a DCT tool) and two levels each. The final dataset comprised 3839 respondents after dropping 53 with “irrational” responses. Panel fixed conditional logit model was used to analyze the data.ResultsRespondents were more willing to trade being traced by a DCT tool for social interactions than incentives and unwilling to trade social interactions for incentives. The proportion of respondents preferring no incentives and could only be influenced by their family members increases with age. Among proponents of monetary incentives, the preferred median value for a month’s usage of DCT tools amounted to S$10 (USD7.25) and S$50 (USD36.20) for subsidies and lucky draw.ConclusionsDCE can be used to elicit profile-specific preferences to optimize the uptake of DCT tools during a pandemic. Social interactions are highly valued by the population, who are willing to trade them for being traced by a DCT tool during the COVID-19 pandemic. Although a small amount of incentive is sufficient to increase the satisfaction of using a DCT tool, incentives alone may not increase DCT tool uptake.

Movement of patients in a health care network poses challenges for the control of carbapenemase-producing Enterobacteriaceae (CPE). We aimed to identify intra- and interfacility transmission events and facility type-specific risk factors of CPE in an acute-care hospital (ACH) and its intermediate-term and long-term-care facilities (ILTCFs). Serial cross-sectional studies were conducted in June and July of 2014 to 2016 to screen for CPE. Whole-genome sequencing was done to identify strain relatedness and CPE genes (blaIMI, blaIMP-1, blaKPC-2, blaNDM-1, and blaOXA-48). Multivariable logistic regression models, stratified by facility type, were used to determine independent risk factors. Of 5,357 patients, half (55%) were from the ACH. CPE prevalence was 1.3% in the ACH and 0.7% in ILTCFs (P = 0.029). After adjusting for sociodemographics, screening year, and facility type, the odds of CPE colonization increased significantly with a hospital stay of ≥3 weeks (adjusted odds ratio [aOR], 2.67; 95% confidence interval [CI], 1.17 to 6.05), penicillin use (aOR, 3.00; 95% CI, 1.05 to 8.56), proton pump inhibitor use (aOR, 3.20; 95% CI, 1.05 to 9.80), dementia (aOR, 3.42; 95% CI, 1.38 to 8.49), connective tissue disease (aOR, 5.10; 95% CI, 1.19 to 21.81), and prior carbapenem-resistant Enterobacteriaceae (CRE) carriage (aOR, 109.02; 95% CI, 28.47 to 417.44) in the ACH. For ILTCFs, presence of wounds (aOR, 5.30; 95% CI, 1.01 to 27.72), respiratory procedures (aOR, 4.97; 95% CI, 1.09 to 22.71), vancomycin-resistant enterococcus carriage (aOR, 16.42; 95% CI, 1.52 to 177.48), and CRE carriage (aOR, 758.30; 95% CI, 33.86 to 16,982.52) showed significant association. Genomic analysis revealed only possible intra-ACH transmission and no evidence for ACH-to-ILTCF transmission. Although CPE colonization was predominantly in the ACH, risk factors varied between facilities. Targeted screening and precautionary measures are warranted. Agency for Science, Technology and Research (A*STAR) Ministry of Health (MOH) Published version This study was funded by a Singapore Ministry of Health’s Communicable Diseases Public Health Research Grant (CDPHRG/0008/2014) and an Agency for Science, Technology, and Research (A*STAR) grant (IAF311018). The funders had no role in study design, data collection and interpretation, or the decision to submit the work for publication.

We studied the performance of an algorithm combining multiplex polymerase chain reaction with phenotypic detection of extended-spectrum β-lactamases and carbapenemases directly from positive blood culture bottles in patients with gram-negative bacteremia and found good concordance with routine cultures. Such an algorithm may be a tool to improve time to optimal therapy in patients with gram-negative bacteremia.

Seasonal influenza can cause severe illness leading to intensive care unit (ICU) admission and death.To define the clinical and epidemiological features of severe seasonal influenza infection and factors associated with mortality.A retrospective review was conducted on all patients with laboratory-confirmed influenza infection who were either admitted into the ICU or died in the two largest tertiary hospitals in Singapore from 2011-2015.Of 520 patients included in our study, 423 (81.3%) had influenza A infection and the rest with influenza B. Of patients with influenza A infection, 70.0% (296/423) were subtyped, of whom 24.0% (71/296) had A/H1N1pdm2009 and 76.0% (225/296) had A/H3N2. The median age of patients was 72 years (IQR 61-82). Males constituted 53.1% (276/520). Median Charlson comorbidity index score was 1 (IQR 0-3). About 70% had physical or radiological evidence of pneumonia upon admission. In-hospital mortality was 58.1% (302/520). On multiple logistic regression analysis, factors positively associated with mortality were age ≥65 years (adjusted odds ratio, aOR = 3.64, 95%CI 2.21-5.99, p 0.001), malignancy (aOR = 2.53, 95%CI 1.12-5.73; p = 0.026), and hypoalbuminemia (aOR = 2.16, 95%CI 1.26-3.73; p = 0.005), while antiviral therapy (aOR = 0.33, 95%CI 0.17-0.63; p 0.001) and ventilation (aOR = 0.23, 95% CI 0.13-0.39; p 0.001) were negatively associated.Patients with severe seasonal influenza infection were characterized by advanced age, hypoalbuminemia and presence of pneumonia on admission. Age ≥65 years, malignancy, and hypoalbuminemia were associated with increased mortality, and antiviral therapy and ventilation with decreased mortality.

Objective Real-time locating systems (RTLS) enable contact tracing and hand hygiene reminders, to improve hospital safety. Successful implementation requires healthcare personnel (HCP) to carry RTLS tags continuously. We assessed for determinants of HCP’s willingness to use RTLS tags during routine inpatient care, and evaluated concerns using mixed-methods analysis. Materials and Methods We conducted a cross-sectional study in the 330-bed purpose-built National Centre for Infectious Diseases in Singapore, from January 15 through February 4, 2020. The anonymous survey comprised 24 questions based on constructs from behavioral models and an open-ended question. Principal component analysis was performed to derive the latent factor structure applied in the multivariable logistic regression analysis. Concerns were analyzed using thematic analysis. Results Of 260 HCP (nurses [40.8%], ancillary and administrative staff [23.1%], allied health professionals [18.5%], and physicians [17.7%]), 75% were willing to use the RTLS tag. After adjusting for age, gender, healthcare professional group, and duration of practice, the acceptance of the use of the RTLS tag (adjusted OR 11.28 [95% CI 4.39–29.00], P Conclusion More communications on the intentions and data protection standards of the RTLS, and accessory enhancements for HCP’s convenient and sustained use of the RTLS tag are crucial, to optimize RTLS’s usefulness during the COVID-19 pandemic.

ObjectiveTo measure the psychological well-being of healthcare workers (HCWs) during this COVID-19 pandemic and examine the experiences of the subgroup of participants who were also HCWs during the 2003 SARS epidemic.DesignAnonymous online survey adapted from a similar study conducted during the SARS epidemic, disseminated from July 2020 to August 2020.SettingNine healthcare institutions across Singapore ranging from primary care, community care, tertiary care and specialised referral centres.ParticipantsEmployees working in the participating healthcare institutions.ResultsOf 3828 survey returns, 3616 had at least one completed item on the questionnaire. Majority were female (74.7%), nurses (51.7%), foreign-born (53.2%) and not working in the tertiary care setting (52.1%). The median score on the Impact of Events Scale (IES) was 15 (IQR 23) and 28.2% of the sample scored in the moderate/severe range. 22.7% of the participants were also HCWs during SARS and more than half of them felt safer and better equipped in the current pandemic. 25.2% of SARS HCWs and 25.9% of non-SARS HCWs had moderate/severe IES scores (p=0.904). After adjusting for age, marital status, parity and length of work experience, racial minority groups and living apart from family were independent predictors of high IES regardless of prior SARS epidemic experience. Daily exposure to confirmed or suspect COVID-19 cases increased the odds of high IES for non-SARS HCWs only.Conclusions and relevanceOverall, while 28% of HCWs in our study suffered from significant trauma-related psychological symptoms regardless of prior experience with the SARS epidemic, those with prior experience reported feeling safer and better equipped, finding the workload easier to manage, as well as having more confidence in their healthcare leaders. We recommend for more trauma-informed support strategies for our HCWs especially those from racial minority groups, who are foreign-born and isolated from their families.

Objective: We assessed the performance of influenza-like illness (ILI) case definitions by the Centers for Disease Control and Prevention (CDC), European Centers for Disease Control and Prevention and World Health Organization (WHO) in the tropics where seasonal patterns of respiratory viruses in acute upper respiratory tract infections (AURTIs) are ill-defined. Methods: Clinical data and samples for respiratory multiplex polymerase chain reaction test were collected from 717 consecutive patients attending an emergency department in Singapore for uncomplicated AURTI in 2016-2018. Results: Influenza (20.6%), rhinoviruses (14.4%), and coronaviruses (3.6%) were the most common viral pathogens identified. Biannual peaks with year-round activity were identified for influenza. Although higher rhinovirus activity was observed in inter-influenza seasonal periods, rhinoviruses and coronaviruses circulated year-round without distinct seasonal patterns. During high influenza activity months, the CDC and WHO ILI case definitions had moderate-to-high positive likelihood ratio (LR+) of 3.8-6.8 and 4.5-10.7, respectively, for ruling in influenza. They had moderately-high LR + of 3.3-3.8 and 3.9-4.6 for diagnosing influenza during other months. The ILI case definitions had high specificity (77.2%- 85.4%) for rhinoviruses and coronaviruses. Conclusion: The CDC and WHO ILI case definitions can be applied to clinically diagnose influenza in the tropics, regardless of the time of the year. Published version This work was supported by the National Healthcare Group Singapore’s Clinician Scientist Career Scheme [NHG-CSCS/15005].

The purpose of this study was to investigate the relationship between different levels of physical activity (light, moderate, and vigorous), physical health, happiness, and depression among older adults with diabetes. Using data from the National Social Life, Health and Aging Project (NSHAP) Wave 3, the results indicate that moderate and/or vigorous physical activity is more effective than light physical activity for promoting physical health and happiness and lowering depression of older adults with diabetes. This study suggests that activity professionals and therapists working with older adults with diabetes need to encourage their participation in physical activity as well as adjust a level of physical activity intensity that is tailored to participants’ needs and expectations.

BackgroundEarly diagnosis is crucial in securing optimal outcomes in the HIV care cascade. Recent HIV infection (RHI) serves as an indicator of early detection in the course of HIV infection. Surveillance of RHI is important in uncovering at-risk groups in which HIV transmission is ongoing. The study objectives are to estimate the proportion of RHI among persons newly-diagnosed in 2013–2017, and to elucidate epidemiological factors associated with RHI in Singapore.MethodsAs part of the National HIV Molecular Surveillance Programme, residual plasma samples of treatment-naïve HIV-1 positive individuals were tested using the biotinylated peptide-capture enzyme immunoassay with a cutoff of normalized optical density ≤ 0.8 for evidence of RHI. A recent infection testing algorithm was applied for the classification of RHI. We identified risk factors associated with RHI using logistic regression analyses.ResultsA total of 701 newly-diagnosed HIV-infected persons were included in the study. The median age at HIV diagnosis was 38 years (interquartile range, 28–51). The majority were men (94.2%), and sexual route was the predominant mode of HIV transmission (98.3%). Overall, 133/701 (19.0, 95% confidence interval [CI] 16.2–22.0%) were classified as RHI. The proportions of RHI in 2015 (31.1%) and 2017 (31.0%) were significantly higher than in 2014 (11.2%). A significantly higher proportion of men having sex with men (23.4, 95% CI 19.6–27.6%) had RHI compared with heterosexual men (11.1, 95% CI 7.6–15.9%). Independent factors associated with RHI were: age 15–24 years (adjusted odds ratio [aOR] 4.18, 95% CI 1.69–10.31) compared with ≥55 years; HIV diagnosis in 2015 (aOR 2.36, 95% CI 1.25–4.46) and 2017 (aOR 2.52, 95% CI 1.32–4.80) compared with 2013–2014; detection via voluntary testing (aOR 1.91, 95% CI 1.07–3.43) compared with medical care; and self-reported history of HIV test(s) prior to diagnosis (aOR 1.72, 95% CI 1.06–2.81).ConclusionAlthough there appears to be an increasing trend towards early diagnosis, persons with RHI remain a minority in Singapore. The strong associations observed between modifiable behaviors (voluntary testing and HIV testing history) and RHI highlight the importance of increasing the accessibility to HIV testing for at-risk groups.

We conducted latent class analyses to identify women with homogeneous combinations of lifestyle and behavioral variables and tested whether latent classes were prospectively associated with diabetes incidence for women with or without baseline obesity. A total of 64,710 postmenopausal women aged 50-79years without prevalent diabetes at baseline (years 1993-1998) were followed until 2018 with a mean follow-up of 14.6years (sd = 6.4). Lifestyle variables included smoking, diet quality, physical activity, and sleep quality. Psychosocial variables included social support, depression, and optimism. Multivariable Cox proportional hazards regression models tested associations between latent classes and diabetes incidence controlling for age, race/ethnicity, and education. During follow-up, 8076 (12.4%) women developed diabetes. For women without baseline obesity, five latent classes were identified. Compared with a lower risk referent, diabetes incidence was higher in classes characterized by high probability of multiple lifestyle and psychosocial risks (HR = 1.45; 95% CI 1.28, 1.64), poor diet and exercise (HR = 1.23; 95% CI 1.13, 1.33), and psychosocial risks alone (HR = 1.20; 95% CI 1.12, 1.29). For women with baseline obesity, four latent classes were identified. Compared with a lower risk referent, diabetes incidence was higher for women with obesity in classes characterized by high probability of multiple lifestyle and psychosocial risks (HR = 1.48; 95% CI 1.32, 1.66), poor diet and exercise (HR = 1.32; 95% CI 1.19, 1.47), and intermediate probabilities of multiple risks (HR = 1.17; 95% CI 1.05, 1.30). Diabetes prevention efforts that focus on diet and exercise may benefit from attention to how lifestyle behaviors interact with psychosocial variables to increase diabetes risks, and conversely, how psychological or social resources may be leveraged with lifestyle changes to reduce the risk for women with and without obesity.

Funding: Bioinformatics and Computational Biology analyses were supported by the University of St Andrews Bioinformatics Unit that is funded by a Wellcome Trust ISSF award (grant 097831/Z/11/Z). M.T.G.H is supported by the Scottish Infection Research Network and Chief Scientist Office through the Scottish Healthcare Associated Infection Prevention Institute consortium funding (CSO Reference: SIRN10). Objectives Methicillin-resistant Staphylococcus aureus(MRSA) has spread across countries and healthcare settings, with different ecological niches for different clones. It is crucial to understand the comparative epidemiology of MRSA clones between healthcare settings, and independent factors associated with colonization of specific clones. Methods We conducted annual cross-sectional surveillance studies in a network comprising an acute-care hospital and six closely-affiliated intermediate- and long-term care facilities in Singapore, in June-July, 2014-2016. 5,394 patients contributed 16,045 nasal, axillary and groin samples for culture and MRSA isolates for whole genome sequencing. Multivariable multilevel multinomial regression models were constructed to assess for independent factors associated with MRSA colonization. Results MRSA clonal complex(CC) 22 was more prevalent in the acute-care hospital(n=256/493; 51.9%) and intermediate-care(n=348/634; 54.9%) than long-term care(n=88/351; 25.1%) facilities, with clones besides CC22 and CC45 being more prevalent in long-term care facilities(n=144/351; 41.0%) (P

Background Streptococcus pneumoniae infections can lead to severe morbidity and mortality, especially in patients with invasive pneumococcal disease (IPD). This study evaluated factors associated with pneumococcal disease, pneumococcal vaccine effectiveness, and risk factors for all-cause mortality in hospitalised adults with pneumococcal disease in Singapore. Methods Retrospective case-control study of patients tested for pneumococcal disease with streptococcal urinary antigen testing and at least one sterile site culture, during their admission to a tertiary hospital in Singapore from 2015 to 2017. Patients were defined as cases of IPD or non-IPD, or as controls, based on laboratory results and clinical diagnoses. Multivariable models were constructed to determine factors associated with IPD/non-IPD, and risk factors for mortality from pneumococcal disease. Vaccine effectiveness against IPD/non-IPD was estimated using a variation of the test-negative design. Results We identified 496 pneumococcal disease cases, of whom 92 (18.5%) had IPD. The mean age of cases was 69.1 ± 15.4 years, and 65.5% were male. Compared with controls (N = 9181), IPD patients were younger (mean age 61.5 ± 16.3 years, vs 72.2 ± 16.1 years in controls; p p p = 0.011). Risk factors for mortality among pneumococcal disease patients were ICU admission, diagnosis of IPD, age ≥ 85 years and Charlson’s score > 3. Conclusion Patients with pneumococcal disease (especially IPD) were younger and had less co-morbidities than controls, but had higher risk of severe clinical outcomes and mortality. Pneumococcal vaccination effectiveness against IPD was estimated to be about 80%, and should be encouraged among high-risk patients.

Summary Meticillin-resistant Staphylococcus aureus (MRSA) is prevalent in extended care facilities. We conducted a quasi-experimental before–after study in a 100-bed rehabilitation hospital, from January 2013 to June 2019. Universal chlorhexidine bathing was implemented throughout the period, with intranasal octenidine for MRSA colonizers added from September 2017. Interrupted time-series with segmented regression analysis revealed that after adjusting for at-admission MRSA colonization and hand hygiene compliance, a constant trend was observed pre implementation of intranasal octenidine (adjusted mean coefficient: 0.012; 95% confidence interval: –0.037 to 0.06), with an immediate decrease with implementation (–2.145; –0.248 to –0.002; P = 0.033), followed by a significant reduction in MRSA acquisition post implementation (–0.125; –0.248 to –0.002; P = 0.047).

Background: Streptococcus pneumoniae infections can lead to severe morbidity and mortality, especially in patients with invasive pneumococcal disease (IPD). This study evaluated factors associated with pneumococcal disease, pneumococcal vaccine effectiveness, and risk factors for mortality among hospitalised adults with pneumococcal disease in Singapore. Methods: Retrospective case-cohort study of patients tested for pneumococcal disease with streptococcal urinary antigen testing and at least one sterile site culture, during their admission to a tertiary hospital in Singapore from 2015-2017. Patients were defined as cases of IPD or non-IPD, or as controls, based on laboratory results and clinical diagnoses. Multivariable models were constructed to determine factors associated with IPD/non-IPD, and risk factors for mortality from pneumococcal disease. Vaccine effectiveness against IPD/non-IPD was estimated using a variation of the test-negative design. Results: We identified 496 pneumococcal disease cases, of whom 92 (18.5%) had IPD. The mean age of cases was 69.1±15.4yrs, and 65.5% were male. Compared with controls (N=9,181), IPD patients were younger (mean age 61.5±16.3yrs, vs 72.2±16.1yrs in controls; p3.Conclusion: Patients with pneumococcal disease (especially IPD) were younger and had less co-morbidities than controls, but had higher risk of severe clinical outcomes and mortality. Pneumococcal vaccination was negatively associated with IPD and should be encouraged among high-risk patients.

In May 2019, we investigated monkeypox in a traveler from Nigeria to Singapore. The public health response included rapid identification of contacts, use of quarantine, and postexposure smallpox vaccination. No secondary cases were identified. Countries should develop surveillance systems to detect emerging infectious diseases globally. Published version

Background In early 2020, coronavirus disease (COVID-19) emerged and spread by community and nosocomial transmission. Effective contact tracing of potentially exposed health care workers is crucial for the prevention and control of infectious disease outbreaks in the health care setting. Objective This study aimed to evaluate the comparative effectiveness of contact tracing during the COVID-19 pandemic through the real-time locating system (RTLS) and review of the electronic medical record (EMR) at the designated hospital for COVID-19 response in Singapore. Methods Over a 2-day study period, all admitted patients with COVID-19, their ward locations, and the health care workers rostered to each ward were identified to determine the total number of potential contacts between patients with COVID-19 and health care workers. The numbers of staff-patient contacts determined by EMR reviews, RTLS-based contact tracing, and a combination of both methods were evaluated. The use of EMR-based and RTLS-based contact tracing methods was further validated by comparing their sensitivity and specificity against self-reported staff-patient contacts by health care workers. Results Of 796 potential staff-patient contacts (between 17 patients and 162 staff members), 104 (13.1%) were identified by both the RTLS and EMR, 54 (6.8%) by the RTLS alone, and 99 (12.4%) by the EMR alone; 539 (67.7%) were not identified through either method. Compared to self-reported contacts, EMR reviews had a sensitivity of 47.2% and a specificity of 77.9%, while the RTLS had a sensitivity of 72.2% and a specificity of 87.7%. The highest sensitivity was obtained by including all contacts identified by either the RTLS or the EMR (sensitivity 77.8%, specificity 73.4%). Conclusions RTLS-based contact tracing showed higher sensitivity and specificity than EMR review. Integration of both methods provided the best performance for rapid contact tracing, although technical adjustments to the RTLS and increasing user compliance with wearing of RTLS tags remain necessary.

A retrospective cohort study was conducted to investigate the duration and risk factors for persistence of meticillin-resistant Staphylococcus aureus (MRSA) colonization among known carriers who were re-admitted to hospital. MRSA carriage persisted in a high proportion of known carriers up to two years after their last date of discharge, and re-admission screening should be performed for at least this duration. A targeted screening approach should focus on older patients with a history of long inpatient stays, who are at higher risk of persistent carriage. Timely discharge planning is important in reducing the risk of persistent MRSA colonization among known carriers.

Background An outbreak of gastroenteritis (GE) occurred in community-dwelling adults in the Central Region of urban Singapore, in May 2016. Objectives To investigate the cause of the outbreak. Study Design We conducted a case-cohort study on GE patients linked to the outbreak who presented to the emergency department of a tertiary-care hospital near the outbreak area, from 18 May to 11 June 2016. Stools were tested for gastrointestinal pathogens including rotavirus antigen and positive rotavirus samples were subject to genotyping. Results A total of 57 adult GE patients, with a median age of 40 (range 18 to 84) years, were included. Predominant symptoms were diarrhoea (98.2%), vomiting (64.9%), and abdominal discomfort (38.6%). Age 65 years and above (Adjusted OR 21.78, 95% CI 1.49–318.84; P = 0.02) was the only predictor of admission, after adjusting for comorbidities and clinical severity. Molecular microbiological investigations confirmed that the outbreak was caused by a novel human-bovine reassortant strain of rotavirus G8P[8] with DS-1-like backbone. Exposure to the market in the outbreak area was strongly associated with rotavirus infection (OR 46.14; 95% CI 43.04–49.25, P Conclusions This is the first report of an outbreak of rotavirus G8P[8] in adults in an urban community that is not waterborne. Transmission was likely through fomites in the market and its surrounding areas, via consumption or contact with contaminated food items purchased from the market, and from person-to-person. The potential for novel G8P[8] strains to cause outbreaks cannot be overemphasized.

Current knowledge of methicillin-resistant Staphylococcus aureus (MRSA) colonisation in relation to epidemiological characteristics is incomplete. We conducted a cross-sectional study at an acute-care tertiary infectious diseases hospital of MRSA isolates identified through routine surveillance from January 2009 to December 2011. We randomly selected 205 MRSA isolates (119 inpatients) from 798 isolates (427 inpatients) for molecular profiling using multilocus sequence typing. Multilevel multinomial logistic regression was used to estimate odds ratio (OR) assessing the predilection of MRSA strains for anatomic sites, and associations of strains with human immunodeficiency virus (HIV) infection. The most frequent sequence types (STs) were 239, 22 and 45. The proportion of ST22 increased over the sampling period, replacing ST239 as the dominant lineage. However, ST239 remained the most prevalent among HIV-seropositive individuals who were six times more likely to be colonised with this strain than non-HIV patients (adjusted OR (aOR) 6.44, 95% confidence interval (CI) 1.94–21.36). ST45 was >24 times more likely to be associated with perianal colonisation than in the nares, axillae and groin sites (aOR 24.20, 95% CI 1.45–403.26). This study underlines the clonal replacement of MRSA in Singapore as previously reported but revealed, in addition, key strain differences between HIV-infected and non-infected individuals hospitalised in the same environment. This research received no specific grant from any funding agency, commercial or not-for-profit sectors.

Friends provide important social contexts for student development. Research has shown that adolescent friends are similar to each other in their interest and values for different school subjects. Yet our current understanding does not extend to knowing whether selection, deselection, or socialization processes are responsible for this phenomena. Without this knowledge, it is very difficult for parents, teachers, and schools to know how and when to intervene. This study investigated selection, deselection, and socialization effects on adolescent students’ task values for academic (languages, math and science, and social sciences) and non-academic subject areas (the arts and physical education). A social network approach was used to examine two waves of annual data collected from school-based networks of adolescents in the first and second years of high school education in Finland (N = 1419; female = 48.6%; mean age at first measurement point = 16). The results revealed that adolescents tended to select friends with similar levels of task values (friend selection) for the arts and physical education, but friends did not become more similar in these areas over time (friend socialization). In contrast, there was evidence of friend socialization, but not friend selection, for the academic school subjects. Across all subjects, differences in task values did not predict friendship dissolution (friend deselection). These findings suggest that to a significant extent, students make agentic choices in developing friendship with schoolmates based on their task values in non-academic subjects. The resultant friend contexts that individuals created, in turn, affected their task values in academic subject areas. These results shed light on the complexity of friend effect mechanisms on task values at the subject domain-specific level.

Background: The first autochthonous Zika virus (ZIKV) outbreak in Singapore was detected in August 2016. We report an analysis of the correlation of clinical illness with viremia and laboratory parameters in this Asian cohort. Methods: We conducted a prospective longitudinal cohort study of patients with a positive blood ZIKV polymerase chain reaction (PCR) result who were admitted to Tan Tock Seng Hospital, Singapore, for isolation and management. Results: We included 40 patients in our study. Rash was present in all patients, while 80% (32/40) had fever, 62.5% (25/40) myalgia, 60% (24/40) conjunctivitis and 38% (15/40) arthralgia. The median duration of viremia was 3.5 days (IQR: 3–5 days). Patients with viremia of ≥4 days were more likely to have prolonged fever compared to those with viremia of less than 4 days (95% versus 63%, p=0.01), but had no significant correlation with other clinical signs and symptoms, or laboratory investigations. However, 21 patients (53%) had hypokalemia despite the absence of gastrointestinal symptoms. Conclusion: Although fever correlated with duration of viremia, 30% of patients remained viremic despite defervescence. Laboratory abnormalities such as leukopenia or thrombocytopenia were not prominent in this cohort but about half the patients were noted to have hypokalemia. Published version

Background Good hand hygiene (HH) prevents health care-associated infections. We compared psychosocial and organizational factors associated with HH compliance and perceived need for improvement among physicians, nurses, and allied health professionals (AHPs). Methods We conducted a mixed-methods study in a 1,600-bed adult tertiary-care hospital in Singapore. Seven focus group discussions were conducted and data were analyzed using thematic analysis. The subsequent cross-sectional survey involved 1,064 staff members. Principal components analysis was performed to derive the latent factor structure that was applied in multivariable analyses. Results All staff members acknowledged that HH was an integral part of their work, but were noncompliant due to competing priorities. Physicians were forgetful but appreciated reminders. Nurses were intrinsically motivated for HH. After adjusting for gender, staff category, seniority, and dermatitis history, having positive knowledge-attitudes-behaviors (odds ratio [OR], 1.44; 95% confidence interval [CI], 1.23-1.69), personal motivators-enablers (OR, 1.60; 95% CI, 1.38-1.86), and emotional motivators (OR, 1.62; 95% CI 1.40-1.88) were positively associated with good HH compliance. Women (OR, 3.91; 95% CI, 1.37-11.11), seniors (OR, 2.88; 95% CI, 1.08-7.68), nurses (OR, 4.05; 95% CI, 1.51-10.87), and staff with personal motivators-enablers for HH (OR, 1.60; 95% CI, 1.08-2.37) were more likely to perceive a need for improvement. Conclusions Factors influencing self-reported HH differed between health care professional groups. Group-specific interventions are needed to improve compliance.

Singapore experienced its first documented Zika virus outbreak in 2016. We identified clinical and laboratory parameters that increase the probability for Zika or dengue virus infection. Early during the illness, combinations of key parameters obtained through clinical assessment and hematologic tests can help distinguish between these infections.

ObjectiveTo assess the temporal trend and identify risk factors associated with the absence of previous HIV testing prior to their diagnosis among HIV-positive persons in Singapore.Study designCross-sectional.Setting and participantsWe analysed data of HIV-positive persons infected via sexual transmission, who were notified to the National HIV Registry in 2012–2017.OutcomesEpidemiological factors associated with the absence of HIV testing prior to diagnosis were determined separately for two groups of HIV-positive persons: early and late stages of HIV infection at diagnosis.Results2188 HIV-positive persons with information on HIV testing history and CD4 cell count were included in the study. The median age at HIV diagnosis was 40 years (IQR 30–51). Nearly half (45.1%) had never been tested for HIV prior to their diagnosis. The most common reason cited for no previous HIV testing was ‘not necessary to test’ (73.7%). The proportion diagnosed at late-stage HIV infection was significantly higher among HIV-positive persons who had never been tested for HIV (63.9%) compared with those who had undergone previous HIV tests (29.0%). Common risk factors associated with no previous HIV testing in multivariable logistic regression analysis stratified by stage of HIV infection were: older age at HIV diagnosis, lower educational level, detection via medical care and HIV infection via heterosexual transmission. In the stratified analysis for persons diagnosed at early-stage of HIV infection, in addition to the four risk factors, women and those of Malay ethnicity were also less likely to have previous HIV testing prior to their diagnosis.ConclusionTargeted prevention efforts and strategies are needed to raise the level of awareness of HIV/AIDS and to encourage early and regular screening among the at-risk groups by making HIV testing more accessible.

We investigated the temporal trends of short-term mortality (death within 1 year of diagnosis) and cause-specific deaths in human immunodeficiency virus (HIV)-infected persons by stage of HIV infection at diagnosis. We also assessed the impact of late diagnosis (LD) on short-term mortality.Epidemiological records of HIV-infected Singapore residents from the National HIV Registry were linked to death records from the Registry of Births and Deaths for observational analyses. Newly-diagnosed HIV cases with available cluster of differentiation 4 count at time of diagnosis in a 5-year period from 2012 to 2016 were included in the study. Hazard ratios (HRs) and 95% confidence interval (CI) of LD for all deaths excluding suicides and self-inflicted or accidental injuries, and HIV/ acquired immunodeficiency syndrome (AIDS)-related deaths occurring within 1 year post-diagnosis were calculated using Cox proportional hazards regression models with adjustment for age at HIV/AIDS diagnosis. Population attributable risk proportions (PARPs) were then calculated using the adjusted HRs.Of the 1990 newly-diagnosed HIV cases included in the study, 7.2% had died by end of 2017, giving an overall mortality rate of 2.16 per 100 person-years (PY) (95% CI 1.82-2.54). The mortality rate was 3.81 per 100 PY (95% CI 3.15-4.56) in HIV cases with LD, compared with 0.71 (95% CI 0.46-1.05) in non-LD (nLD) cases. Short-term mortality was significantly higher in LD (9.1%) than nLD cases (1.1%). Of the 143 deaths reported between 2012 and 2017, 58.0% were HIV/AIDS-related (nLD 28.0% vs LD 64.4%). HIV/AIDS-related causes represented 70.4% of all deaths which occurred during the first year of diagnosis (nLD 36.4% vs LD 74.7%). The PARP of short-term mortality due to LD was 77.8% for all deaths by natural causes, and 87.8% for HIV/AIDS-related deaths.The mortality rate of HIV-infected persons with LD was higher than nLD, especially within 1 year of diagnosis, and HIV/AIDS-related causes constituted majority of these deaths. To reduce short-term mortality, persons at high risk of late-stage HIV infection should be targeted in outreach efforts to promote health screening and remove barriers to HIV testing and treatment.

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is a growing clinical problem in rehabilitation hospitals, where patients stay for extended periods for intensive rehabilitation therapy. In addition to cutaneous sites, the nares could be a source for nosocomial MRSA transmission. Decolonization of nasal and cutaneous reservoirs could reduce MRSA acquisition. We evaluated the effectiveness of topical intranasal octenidine gel, coupled with universal chlorhexidine baths, in reducing MRSA acquisition in an extended-care facility. Methods: We conducted a quasi-experimental before-and-after study from January 2013 to June 2019. All patients admitted to a 100-bed rehabilitation hospital specialized in stroke and trauma care in Singapore were screened for MRSA colonization on admission. Patients screened negative for MRSA were subsequently screened at discharge for MRSA acquisition. Screening swabs were obtained from the nares, axillae, and groin and were cultured on selective chromogenic agar. Patients who tested positive for MRSA from clinical samples collected >3 days after admission were also considered to have hospital-acquired MRSA. Universal chlorhexidine baths were implemented throughout the study period. Intranasal application of octenidine gel for MRSA colonizers for use for 5 days from admission was added to the hospital’s protocol beginning in September 2017. An interrupted time series with segmented regression analysis was performed to evaluate the trends in MRSA acquisition before the intervention (January 2013–July 2017) and after the intervention (September 2017–June 2019) with intranasal octenidine. August 2017 was excluded from the analysis because the intervention commenced midmonth. Results: In total, 77 observational months (55 before the intervention and 22 after the intervention) were included. The mean monthly MRSA acquisition rates were 7.0 per 1,000 patient days before the intervention and 4.4 per 1,000 patient days after the intervention (P < .001), with a mean number of patient days of 2,516.3 per month before the intervention and 2,427.2 per month after the intervention (P = .0172). The mean monthly number of MRSA-colonized patients on admission to the hospital decreased from 24.8 before the intervention to 18.7 after the intervention (P < .001). Mean monthly hand hygiene compliance rate increased significantly from 65.7% before the intervention to 87.4% after the intervention (P < .001). After adjusting for the number of MRSA-colonized patients on admission and hand hygiene compliance rates, a constant trend was observed from January 2013 to July 2017 (adjusted mean coefficient, 0.012; 95% CI, −0.037 to 0.06), with an immediate drop in September 2017 (adjusted mean coefficient, −2.145; 95% CI, −0.248 to −0.002; P = .033), followed by a significant reduction in MRSA acquisition after the intervention from September 2017 through June 2019 (adjusted mean coefficient, −0.125; 95% CI, -4.109 to -0.181; P = .047). Conclusions: Topical intranasal octenidine, coupled with universal chlorhexidine baths, can reduce MRSA acquisition in extended-care facilities. Further studies should be conducted to validate the findings in other healthcare settings.Funding: NoneDisclosures: None

Background: The risk factors for methicillin-resistant Staphylococcus aureus (MRSA) colonization can differ between acute-care, subacute-care, and long-term care facilities, but comparative information is lacking. We compared risk factors for MRSA colonization contemporaneously between an acute-care hospital (ACH) and its affiliated intermediate- and long-term care facilities (ILTCFs). Methods: Serial cross-sectional studies were conducted in a 1,600-bed tertiary-care ACH and its 6 affiliated ILTCFs in Singapore, in June–July 2014–2016. Separate nasal, axillary, and groin swabs were taken and cultured for MRSA. MRSA isolates were subject to whole-genome sequencing. Clinical and epidemiological data were obtained from medical records. To account for clustering, multivariable 2-level multinomial logistic regression models were constructed to assess factors associated with colonization of specific MRSA clones, in the ACH and ILTCFs, respectively. Results: In total, 8,873 samples from 2,985 patients in the ACH and 7,172 samples from 2,409 patients and residents in ILTCFs were included in the study. Patients and residents in the ILTCFs (29.7%) were more likely to be colonized with MRSA than patients in the ACH (12.6%) (P < .0001). The predominant MRSA clones were clonal complexes (CC)22 (n = 692, 46.7%) and CC45 (n = 494, 33.4%), contributing to 80% of MRSA isolates. For ACH patients, after adjusting for age, gender, comorbidities, prior exposures to antibiotics and percutaneous devices, presence of wounds, and screening year, prior MRSA carriage in the preceding 12 months was the strongest predictor of colonization with all MRSA clones: CC22 (aOR, 14.71; 95% CI, 6.17–34.48); CC45 (aOR, 7.75; 95% CI, 2.70–22.22); and others (aOR, 22.22; 95% CI, 3.83–125.00). Hospital stay >14 days was also positively associated with colonization with MRSA CC22 (aOR, 2.67; 95% CI, 1.22–5.88), but not the other clones. For ILTCF patients and residents, after adjusting for age, comorbidities, prior exposure to antibiotics, presence of wounds, and screening year, prior MRSA carriage was a significant predictor of colonization with MRSA CC22 (aOR, 2.72; 95% CI, 1.35–5.46), and CC45 (aOR, 2.36; 95 % CI, 1.06–5.24), but not with other clones. Additionally, prior exposure to a percutaneous device and being male were respectively positively associated with colonization by MRSA CC22 (aOR, 2.70; 95% CI, 1.19–6.17) and CC45 (aOR, 2.17; 95% CI, 1.11–4.26). Conclusions: Prior MRSA carriage was a common risk factor for colonization with the predominant MRSA clones in both the ACH and ILTCFs. Hospital stay >14 days and exposure to percutaneous devices were additional risk factors for CC22 colonization in the ACH and ILTCFs, respectively. Pre-emptive contact precautions for prior MRSA-carriers on admission and active screening for long-stayers in the ACH could prevent intra- and interinstitutional MRSA transmission.Funding: NoneDisclosures: None

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is highly prevalent in Singapore hospitals. The Ministry of Health (MOH) has set a reduction of MRSA bacteremia as a key performance indicator for publicly funded hospitals, resulting in the adoption of various strategies to achieve this goal. Decolonization regimens have been implemented in different institutions with variable outcomes. In Tan Tock Seng hospital (TTSH), octenidine was chosen instead of chlorhexidine for its gentler action on the skin, and nasal octenidine was chosen instead of mupirocin (which has a high resistance rate) for nasal decolonization. Methods: All patients admitted to TTSH are screened for MRSA on admission. Patients who are either colonized or infected with MRSA are either placed in isolation rooms (when available) or are placed in cohorts in MRSA wards. The Department of Infection Prevention and Control (IPC) keeps a database of all patients with positive cultures for MRSA, including bacteremia. We used this database to implement and evaluate targeted strategies in such MRSA wards. In January 2018 we began a pilot project in 1 ward, whereby all patients had intranasal octenidine gel applied twice a day for 5 days, as well as daily octenisan baths throughout their stay in the ward. The outcome of interest was MRSA bacteremia occurring ≥3 days after admission. This quasi-experimental before-and-after study was conducted from January 2016 to September 2019 with January 2018 excluded as a washout month. Results: In total, 44 observational months (24 months before the intervention 20 months after the intervention) and 4,309 patients were included. In the preintervention period, 12 bacteremia cases occurred among 2,333 patients (0.5%); in the postintervention period, 4 MRSA bacteremia cases occurred in 1,976 patients (0.2%): RR, 0.49 (95% CI, 0.13–1.22), 1-sided P = .07. The rate of MRSA bacteremia was halved, but it did not reach statistical significance due to the small number of cases overall. The products were well tolerated by patients and staff who applied them to nonambulant patients. Conclusions: Octenidine baths and nasal gel reduced risk of MRSA bacteremia in a cohort of MRSA-positive patients, and this strategy may be preferable to the universal use of antiseptic baths.Funding: NoneDisclosures: None

Understanding the change in intention for influenza vaccine among health-care workers (HCWs) is important to increase influenza vaccination uptake. We aimed to investigate the psychosocial beliefs associated with a change in the intention for influenza vaccine. An anonymous cross-sectional survey was distributed to tertiary hospital HCWs in 2016. Of 3007 HCWs, 70% were compliant (vaccinated, with an intention to revaccinate), 8% were resistant (unvaccinated, without intention to vaccinate), 10% had positive change (unvaccinated, but with intention) and 12% had negative change (vaccinated, but without intention). Across HCW groups, medical staff had both the highest proportion receiving all influenza vaccinations in the last 5 years (101, 28.4%), as well as the highest proportion who had never received vaccination (41, 11.5%). With increasing age, HCWs were less likely to have a negative (p = .02) or positive change (p = .06) in intention, compared to the vaccine-resistant group. HCWs were more likely to be compliant or have a positive change in intention to receive influenza vaccine, if they perceived the vaccine as effective, safe, or had a higher frequency of influenza vaccination in the last 5 years (all with p < .05). HCWs who were medical staff, who believed that side effects of the vaccine were common, or had worked for 6 to 10 years (vs 5 years or less) were less likely to be compliant (all with p < .05). In conclusion, older HCWs were more likely to maintain the status quo in their behavior toward influenza vaccination. Influenza vaccination strategies should place emphasis on vaccine effectiveness and safety.

Funding: This research was supported by the Small Innovative Grant (SIG/15033) and Communicable Diseases – Public Health Research Grant (CDPHRG/0008/2014) awarded by the National Healthcare Group and Ministry of Health Singapore respectively. Objectives With the widespread use of antiseptics in healthcare facilities for the prevention of methicillin-resistant Staphylococcus aureus (MRSA) transmission, there are concerns for antiseptic tolerance and resistance. We sought to understand the use of chlorhexidine and octenidine, qac genes carriage and reduced antiseptic susceptibilities. Methods A serial cross-sectional study was conducted in an acute care hospital and three extended-care facilities of a healthcare network in June-July, 2014-2016. Two of the extended-care facilities were exposed to intranasal octenidine and universal daily chlorhexidine/octenidine bathing. The minimum inhibitory concentration (MIC) levels and qac genes were determined by broth microdilution tests and whole genome sequencing respectively. Multivariable logistic regression was used to assess for the independent associations between antiseptic exposures, qac genes and reduced antiseptic susceptibilities. Results A total of 878 MRSA isolates were obtained. There were associations between qacA/B carriage and chlorhexidine (adjusted odds ratio [aOR]: 7.80; 95% confidence interval [CI]: 3.25-18.71) and octenidine (aOR: 11.79; 95%CI: 5.14-27.04) exposures. Chlorhexidine exposure was associated with reduced chlorhexidine susceptibility (MIC≥4mg/L) (aOR: 3.15; 95%CI: 1.14-8.74). Carriage of qacA/B (aOR: 10.65: 95%CI: 4.14-27.40) or qacC (aOR: 2.55; 95%CI: 1.22-5.32) had an association with reduced chlorhexidine susceptibility; while MRSA sequence type modified the association. However, we found no direct association between (i) antiseptics use and qacC carriage, (ii) octenidine exposure and reduced susceptibility and (iii) reduced octenidine susceptibility and qacA/B or qacC carriage. Conclusions Antiseptic exposures were associated with qac genes carriage. Chlorhexidine exposure was associated with reduced chlorhexidine susceptibility, requiring continued surveillance for the emergence of resistance. Postprint

Background: Streptococcus pneumoniae infections can lead to severe morbidity and mortality, especially in patients with invasive pneumococcal disease (IPD). This study assesses factors associated with pneumococcal disease, and risk factors for mortality among hospitalised adults in Singapore.Methods: Retrospective study of patients with pneumococcal disease, based on streptococcal urinary antigen testing and/or sterile site cultures positive for S. pneumoniae , admitted to a tertiary hospital from 2015-2017. IPD and non-IPD cases were compared against a control group of patients, admitted over the same period but with negative results for the abovementioned tests.Results: We identified 496 pneumococcal disease cases, of whom 92 (18.5%) had IPD. The mean age of cases was 69.1±15.4yrs, and 65.5% were male. Compared with controls (N=9,181), IPD patients were younger (mean age 61.5±16.3yrs, vs 72.2±16.1yrs in controls; p3.Conclusion: Patients with pneumococcal disease (especially IPD) were younger and had less co-morbidities than controls, but had higher risk of severe clinical outcomes and mortality. Pneumococcal vaccination was negatively associated with IPD and should be encouraged among high-risk patients.