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Sporadic clusters of healthcare-associated coronavirus disease 2019 (COVID-19) occurred despite intense rostered routine surveillance and a highly vaccinated healthcare worker (HCW) population, during a community surge of the severe acute respiratory coronavirus virus 2 (SARS-CoV-2) B.1.617.2 δ (delta) variant. Genomic analysis facilitated timely cluster detection and uncovered additional linkages via HCWs moving between clinical areas and among HCWs sharing a common lunch area, enabling early intervention.

Sporadic clusters of health care-associated COVID-19 infection occurred in a highly vaccinated health care-workers and patient population, over a 3-month period during ongoing community transmission of the B.1.617.2 variant. Enhanced infection-prevention measures and robust surveillance systems, including routine-rostered-testing of all inpatients and staff and usage of N95-respirators in all clinical areas, were insufficient in achieving zero health care-associated transmission. The unvaccinated and immunocompromised remain at-risk and should be prioritized for enhanced surveillance.

Background: During the COVID-19 pandemic, distinguishing dengue from COVID-19 in endemic areas can be difficult, as both may present as undifferentiated febrile illness. COVID-19 cases may also present with false-positive dengue serology. Hospitalisation protocols for managing undifferentiated febrile illness are essential in mitigating the risk from both COVID-19 and dengue. Methods: At a tertiary hospital contending with COVID-19 during a dengue epidemic, a triage strategy of routine COVID-19 testing for febrile patients with viral prodromes was used. All febrile patients with viral prodromes and no epidemiologic risk for COVID-19 were first admitted to a designated ward for COVID-19 testing, from January 2020 to December 2021. Results: A total of 6103 cases of COVID-19 and 1251 cases of dengue were managed at our institution, comprising a total of 3.9% (6103/155,452) and 0.8% (1251/155,452) of admissions, respectively. A surge in dengue hospitalisations in mid-2020 corresponded closely with the imposition of a community-wide lockdown. A total of 23 cases of PCR-proven COVID-19 infection with positive dengue serology were identified, of whom only two were true co-infections; both had been appropriately isolated upon admission. Average length-of-stay for dengue cases initially admitted to isolation during the pandemic was 8.35 days (S.D. = 6.53), compared with 6.91 days (S.D. = 8.61) for cases admitted outside isolation (1.44 days, 95%CI = 0.58–2.30, p = 0.001). Pre-pandemic, only 1.6% (9/580) of dengue cases were admitted initially to isolation-areas; in contrast, during the pandemic period, 66.6% (833/1251) of dengue cases were initially admitted to isolation-areas while awaiting the results of SARS-CoV-2 testing. Conclusions: During successive COVID-19 pandemic waves in a dengue-endemic country, coinfection with dengue and COVID-19 was uncommon. Routine COVID-19 testing for febrile patients with viral prodromes mitigated the potential infection-prevention risk from COVID-19 cases, albeit with an increased length-of-stay for dengue hospitalizations admitted initially to isolation.

Candida infections of the central nervous system (CNS) are rare. We report a case of Candida glabrata meningitis successfully treated with combination antifungal therapy followed by step-down therapy with fluconazole. New-onset hypercalcaemia, an uncommon side effect of the prolonged fluconazole treatment, prompted early treatment cessation. A negative cerebrospinal fluid (CSF) β-d-glucan supported the decision of treatment cessation despite incomplete resolution of CSF biochemical parameters. No disease relapse was encountered after 2 years post-treatment.

During the COVID-19 pandemic, distinguishing dengue from cases of COVID-19 in endemic areas can be difficult. In a tertiary hospital contending with COVID-19 during a dengue epidemic, a triage strategy of routine COVID-19 testing for febrile patients with viral prodromes was used. All febrile patients with viral prodromes and no epidemiologic risk for COVID-19 were first admitted to a designated ward for COVID-19 testing, where enhanced personal protective equipment was used by healthcare workers until COVID-19 was ruled out. From January to May 2020, 11,086 admissions were screened for COVID-19; 868 cases of COVID-19 were diagnosed in our institution, along with 380 cases of dengue. Only 8.5% (943/11,086) of suspected COVID-19 cases were concurrently tested for dengue serology due to a compatible overlapping clinical syndrome, and dengue was established as an alternative diagnosis in 2% (207/10,218) of suspected COVID-19 cases that tested negative. There were eight COVID-19 cases with likely false-positive dengue serology and one probable COVID-19/dengue coinfection. From April to May 2020, 251 admissions presenting as viral prodromes with no respiratory symptoms were screened; of those, 15 cases had COVID-19, and 2/15 had false-positive dengue IgM. Epidemiology investigations showed no healthcare-associated transmission. In a dengue epidemic season coinciding with a COVID-19 pandemic, dengue was established as an alternative diagnosis in a minority of COVID-19 suspects, likely due to early availability of basic diagnostics. Routine screening of patients with viral prodromes during a dual outbreak of COVID-19 and dengue enabled containment of COVID-19 cases masquerading as dengue with false-positive IgM.

Background: In the ongoing coronavirus disease 2019 (COVID-19) pandemic, resuming provision of surgical services poses a challenge given that patients may have acute surgical pathologies with concu...

During this coronavirus disease 2019 (COVID-19) pandemic, physicians have the important task of risk stratifying patients who present with acute respiratory illnesses. Clinical presentation of COVID-19, however, can be difficult to distinguish from other respiratory viral infections. Thus, identifying clinical features that are strongly associated with COVID-19 in comparison to other respiratory viruses can aid risk stratification and testing prioritization especially in situations where resources for virological testing and resources for isolation facilities are limited. In our retrospective cohort study comparing the clinical presentation of COVID-19 and other respiratory viral infections, we found that anosmia and dysgeusia were symptoms independently associated with COVID-19 and can be important differentiating symptoms in patients presenting with acute respiratory illness. On the other hand, laboratory abnormalities and radiological findings were not statistically different between the two groups. In comparing outcomes, patients with COVID-19 were more likely to need high dependency or intensive care unit care and had a longer median length of stay. With our findings, we emphasize that epidemiological risk factors and clinical symptoms are more useful than laboratory and radiological abnormalities in differentiating COVID-19 from other respiratory viral infections.

Introduction Antibiotic stewardship programmes (ASPs) can improve patient outcomes by prospective audit and feedback with interventions. However, adherence to ASP interventions is not mandatory. Identifying factors associated with improved adherence may help to enhance ASP recommendations and activities. Methods A retrospective cohort study was conducted, comprising all ASP interventions performed as part of the prospective audit and feedback strategy in our institution (an acute tertiary-care hospital in Singapore) from January 2016 to July 2018. Adherence to ASP intervention was ascertained based on documented compliance with the recommended interventions within 48 h. Factors associated with adherence to ASP interventions, such as patient demographics, clinical condition, type of infection, and characteristics of ASP interventions were identified using the χ2 test for categorical variables. On multivariate analysis, factors independently associated with adherence to ASP intervention were identified using logistic regression. Results Adherence to ASP intervention was 81.9% (5758/7028). On univariate and multivariate analysis, interventions coupled with direct communication via phone call (adjusted odds ratio [aOR] 1.61, 95% CI 1.23–2.08) were associated with higher odds of adherence, whereas admission to a surgical unit, intervention involving carbapenem use, and recommendation to de-escalate or discontinue antibiotics were associated with lower odds of adherence to ASP interventions. Conclusion Although adherence rates to ASP interventions were relatively high, interventions made to the surgical unit and recommendations related to carbapenem use were not so well received. Interventions communicated verbally via phone call were well received, highlighting the need for a close working relationship between ASP teams and hospital physicians.

While health-related quality of life (HRQoL) is an important component of patient-centred care, few studies have looked at the association between HRQoL and outcomes while on OPAT. From 2014 to 2017, we conducted a prospective cohort study of all patients referred to Singapore General Hospital's (SGH) OPAT service. At baseline, we collected sociodemographic, clinical, and treatment-related factors for OPAT recipients. We also measured baseline HRQoL using the EuroQoL EQ5D-3 L. We evaluated the association between HRQoL and the following outcomes: complications experienced while on OPAT, early termination requiring readmission during planned course of OPAT, all-cause readmission 30 days after completion of OPAT, and return to work while on OPAT. We used chi-squared test for univariate analysis and cox regression for multivariate analysis. From 2014 to 2017, 1213 patients received OPAT at our centre. Of those, 13.2% (160/1213) developed complications. About 10% (132/1213) of patients were readmitted while on OPAT and OPAT was terminated early. Amongst patients who completed OPAT (N = 1081), about 3.6% (39/1081) were readmitted within 30 days after OPAT completion. About half (50.8%, 278/547) returned to work while on OPAT. On multivariate analysis, patients with perfect health-related quality of life (HRQoL) (adjusted relative risk, aRR = 0.62, 95%CI = 0.45-0.85) were less likely to experience complications, had lower risk of OPAT termination (aRR = 0.57, 95%0.38-0.86), and were more likely to return to work while on OPAT (aRR = 1.94, 95%CI = 1.30-2.89). HRQoL at baseline was significantly associated with lower risk of complications and early OPAT termination, as well as greater likelihood of return to work while on OPAT.

Our objective was to evaluate the impact of an access-enhanced health screening intervention on screening adherence in a rental-flat community. In Singapore, public rental flats provide heavily subsidised rentals for the needy who cannot afford to own their own homes; with a majority of Singaporeans (≥85%) staying in owner-occupied public housing. We observed trends in health screening adherence and health behaviours among residents of a multi-ethnic public rental-flat community in Singapore from 2013 to 2017, after participation in a free, access-enhanced multi-modality screening programme in 2011. Residents staying in neighbouring owner-occupied housing who participated in the same screening programme served as a basis of comparison. A total of 478 rental-flat residents and 505 owner-occupied flat residents participated. In the rental-flat community, hypertension screening rates improved from 18.3% (24/131) in 2013, to 61.2% (52/85) in 2015 and 44.2% (34/77) in 2017 (p < .001). For diabetes, rates improved from 26.2% (43/164) → 47.0% (54/115) → 49.5% (45/91; p < .001). For dyslipidaemia screening, rates improved from 18.2% (31/170) → 39.6% (38/96) → 47.5% (38/80; p < .001). In the owner-occupied community (n = 505), screening rates largely remained stagnant (hypertension: 52.2% → 75.0% → 54.5%, p = .059; diabetes: 66.0% → 56.5% → 66.7%, p = .434; dyslipidaemia: 53.1% → 50.0% → 57.1%, p = .818). In the rental-flat community, unhealthy behaviours increased from 2013 to 2017, with higher proportions of overweight (30.4% → 24.8% → 52.1%, p < .001), higher smoking (11.7% → 36.9% → 32.5%, p < .001) and higher drinking rates (1.4% → 0.7% → 8.1%, p < .001). This shift was also reflected in the owner-occupied community, with higher percentages of overweight and higher drinking rates (p < .001).

Retrospective contact tracing, enabled by the use of automated visitor-management systems and digital contact tracing, together with rapid antigen detection (RAD) for SARS-CoV-2 among visitors staying ≥ 30 minutes, identified COVID-19 cases in < 0.01% (6/72 605) of hospital visitors to a large hospital campus over an 8-week study period. The potential for nosocomial transmission of SARS-CoV-2 from hospital visitors was thus very low, and could be further mitigated by universal mask-wearing among staff and visitors.

Objectives Since December 2019, COVID-19 has caused a worldwide pandemic and Singapore has seen escalating cases with community spread. Aggressive contact tracing and identification of suspects has helped to identify local community clusters, surveillance being the key to early intervention. Healthcare workers have contracted COVID-19 infection both at the workplace and community. We aimed to create a prototype staff surveillance system for the detection of acute respiratory infection (ARI) clusters amongst our healthcare workers (HCWs) and describe its effectiveness. Methods/Results A prototypical surveillance system was built on existing electronic health record infrastructure. Over a 10-week period, we investigated 10 ARI clusters amongst 7 departments. One of the ARI clusters was later determined to be related to COVID-19 infection. We demonstrate the feasibility of syndromic surveillance to detect ARI clusters during the COVID-19 outbreak. Conclusion The use of syndromic surveillance to detect ARI clusters amongst HCWs in the COVID-19 pandemic may enable early case detection and prevent onward transmission. It could be an important tool in infection prevention within healthcare institutions.

We read with interest the study by Izquierdo et al. that reported a lower proportion of patients with concurrent asthma and COVID-19, compared to other chronic diseases [1]. During the ongoing pandemic, various studies have also observed a lower occurrence of persons with asthma amongst hospitalised COVID-19 cases [2, 3]. Several hypotheses have been postulated to account for these observations, including lower susceptibility to COVID-19 amongst patients with asthma [2, 3] and a remission in rates of common circulating respiratory viral infections (RVIs) [4]. RVIs are potential triggers of asthma exacerbations and may cause a loss of asthma control [5]. During the COVID-19 pandemic, community-wide public health measures introduced to reduce transmission of SARS-CoV-2, such as universal masking and social distancing, may reduce community transmission of common RVIs [4], potentially decreasing the frequency and severity of asthma exacerbations and hence reducing hospitalisations. However, patients may demonstrate a higher threshold to seek care due to fear of nosocomial transmission during the pandemic. Significant community transmission of SARS-CoV-2 may thus confound causal interpretation of trends in asthma hospitalisations. While the ongoing pandemic provides a rare opportunity to ascertain the impact of public-health measures on hospitalisations for asthma exacerbations, such observations are only possible in areas that have mitigated community transmission and maintained public-health interventions over a sustained duration., A sustained reduction in asthma admissions with PCR-proven respiratory viral infections coincided with the widespread adoption of public health measures, including social distancing and wearing of face coverings, during a pandemic.

The COVID-19 pandemic and associated response have undoubtedly had a dramatic multidimensional impact on healthcare services globally, severely disrupting care for many chronic diseases [1, 2]. Direct impact on communicable diseases such as tuberculosis (TB), especially in developing countries disproportionally affected by TB, is not yet fully understood but is very likely to put National TB Programmes under immense pressure and lead to an increase in TB deaths of 8% - 20% in the near future [3–5]. This predicted increase is largely caused by delays in diagnosis and treatment of new TB cases due to non-pharmaceutical interventions implemented nationally and globally, in order to contain virus transmission [3, 6–8]. Combined COVID-19 and TB infection also poses a challenge from various perspectives [9]. It is anticipated that the number of co-infected patients increases as the pandemic progresses., Sustainable support from healthcare bodies is needed to preserve TB laboratory capacity and maintain personnel and skills to minimise negative effects of the COVID-19 pandemic on laboratory services severely disrupted in early months of pandemic.

Background In Singapore, a densely urbanised Asian society, more than 80% of the population stays in public housing estates and the majority (90%) own their own homes. For the needy who cannot afford home ownership, public rental flats are available. Staying in a public rental flat is associated with higher hospital readmission rates and poorer access to health services. We sought to examine sociodemographic factors associated with hospital admissions and emergency room visits amongst public rental flat residents. Methods We surveyed all residents aged ≥60 years in a public rental housing precinct in central Singapore in 2016. Residents self-reported their number of emergency room visits, as well as hospitalisations, in the past 6 months. We obtained information on residents’ sociodemographic characteristics, medical, functional and social status via standardised questionnaires. We used chi-square to identify associations between emergency room visits/hospitalisations and sociodemographic characteristics, on univariate analysis; and logistic regression for multivariate analysis. Results Of 1324 contactable residents, 928 participated in the survey, with a response rate of 70.1%. A total of 928 residents participated in our study, of which 59.5% were male (553/928) and 51.2% (476/928) were ≥ 70 years old. Around 9% (83/928) of residents had visited the emergency room in the last 6 months; while 10.5% (100/928) had been admitted to hospital in the past 6 months. On multivariable analysis, being religious (aOR = 0.43, 95%CI = 0.24–0.76) and having seen a primary care practitioner in the last 6 months (aOR = 0.46, 95%CI = 0.27–0.80) were independently associated with lower odds of emergency room visits, whereas loneliness (aOR = 1.96, 95%CI = 1.13–3.43), poorer coping (aOR = 1.72, 95%CI = 1.01–3.03) and better adherence (aOR = 2.23, 95%CI = 1.29–3.83) were independently associated with higher odds of emergency room visits. For hospitalisations, similarly poorer coping (aOR = 1.85, 95%CI = 1.12–3.07), better adherence (aOR = 1.69, 95%CI = 1.04–2.75) and poorer functional status (aOR = 1.85, 95%CI = 1.15–2.98) were all independently associated with higher odds of hospitalisations, whereas those who were religious (aOR = 0.62, 95%CI = 0.37–0.99) and those who were currently employed (aOR = 0.46, 95%CI = 0.37–0.99) had lower odds of being hospitalised. Conclusion In this public rental flat population, functional status, coping and adherence, and having a religion were independently associated with emergency room visits and hospitalisation. Residents who had seen a primary care practitioner in the last 6 months had lower odds of visiting the emergency room.

Outpatient parenteral antibiotic therapy (OPAT) can facilitate early discharge; however, not all offered OPAT can accept. We assessed factors associated with acceptance of OPAT in a large Asian tertiary hospital cohort. From 2014 to 2017, we reviewed all referrals to Singapore General Hospital's (SGH) Outpatient Parenteral Antibiotic Therapy (OPAT) service. We compared differences in sociodemographic and clinical factors between patients who opted for OPAT and those who declined, using chi-square test for univariate analysis and logistic regression for multivariate analysis. From 2014 to 2017, a total of 1406 OPAT referrals were made. Of these, 95.9% (1349/1406) were deemed suitable for OPAT. Amongst those suitable, 90.0% (1213/1349) accepted OPAT treatment. On multivariate analysis, being independently ambulant (aOR = 3.46, 95%CI = 2.21-5.37) was independently associated with higher odds of acceptance for OPAT; whereas, patients with peripheral vascular disease had lower odds of accepting OPAT (aOR = 0.32, 95%CI = 0.16-0.62). Lower socioeconomic status (SES) was closely associated with rejection of OPAT, with markers of both individual-level SES (subsidized ward class) and area-level SES (staying in a public rental flat) being independently associated with lower odds of OPAT preference. Distance and travel time were not associated with OPAT acceptance. The top reasons for rejecting OPAT were lack of caregiver (n = 35), mobility issues (n = 24), financial issues (n = 24), and difficulty caring for the line (n = 21). Comorbidities, mobility, and financial issues are important factors to consider when determining suitability for OPAT. More can be done to improve accessibility of OPAT amongst lower-income patients and those staying in lower-SES areas.

BackgroundUnderstanding the drivers of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission is crucial for control policies, but evidence of transmission rates in different settings remains limited.MethodsWe conducted a systematic review to estimate secondary attack rates (SARs) and observed reproduction numbers (Robs) in different settings exploring differences by age, symptom status, and duration of exposure. To account for additional study heterogeneity, we employed a beta-binomial model to pool SARs across studies and a negative-binomial model to estimate Robs.ResultsHouseholds showed the highest transmission rates, with a pooled SAR of 21.1% (95% confidence interval [CI]:17.4–24.8). SARs were significantly higher where the duration of household exposure exceeded 5 days compared with exposure of ≤5 days. SARs related to contacts at social events with family and friends were higher than those for low-risk casual contacts (5.9% vs 1.2%). Estimates of SARs and Robs for asymptomatic index cases were approximately one-seventh, and for presymptomatic two-thirds of those for symptomatic index cases. We found some evidence for reduced transmission potential both from and to individuals younger than 20 years of age in the household context, which is more limited when examining all settings.ConclusionsOur results suggest that exposure in settings with familiar contacts increases SARS-CoV-2 transmission potential. Additionally, the differences observed in transmissibility by index case symptom status and duration of exposure have important implications for control strategies, such as contact tracing, testing, and rapid isolation of cases. There were limited data to explore transmission patterns in workplaces, schools, and care homes, highlighting the need for further research in such settings.

We report the nationwide experience with solid organ transplant (SOT) and hematopoietic stem cell transplant (HSCT) recipients diagnosed with coronavirus disease 2019 (COVID-19) in Spain until 13 July 2020. We compiled information for 778 (423 kidney, 113 HSCT, 110 liver, 69 heart, 54 lung, 8 pancreas, 1 multivisceral) recipients. Median age at diagnosis was 61 years (interquartile range [IQR]: 52-70), and 66% were male. The incidence of COVID-19 in SOT recipients was two-fold higher compared to the Spanish general population. The median interval from transplantation was 59 months (IQR: 18-131). Infection was hospital-acquired in 13% of cases. No donor-derived COVID-19 was suspected. Most patients (89%) were admitted to the hospital. Therapies included hydroxychloroquine (84%), azithromycin (53%), protease inhibitors (37%), and interferon-β (5%), whereas immunomodulation was based on corticosteroids (41%) and tocilizumab (21%). Adjustment of immunosuppression was performed in 85% of patients. At the time of analysis, complete follow-up was available from 652 patients. Acute respiratory distress syndrome occurred in 35% of patients. Ultimately, 174 (27%) patients died. In univariate analysis, risk factors for death were lung transplantation (odds ratio [OR]: 2.5; 95% CI: 1.4-4.6), age60 years (OR: 3.7; 95% CI: 2.5-5.5), and hospital-acquired COVID-19 (OR: 3.0; 95% CI: 1.9-4.9).