Four Patients with #COVID19 and #Tuberculosis, #Singapore, April–May 2020 (Emerg Infect Dis., abstract)

[Source: US Centers for Disease Control and Prevention (CDC), Emerging Infectious Diseases Journal, full page: (LINK). Abstract, edited.]

Volume 26, Number 11—November 2020 | Research Letter

Four Patients with COVID-19 and Tuberculosis, Singapore, April–May 2020

Sai Meng Tham, Wei Yang Lim, Chun Kiat Lee, Jerold Loh, Arthi Premkumar, Benedict Yan, Adrian Kee, Louis Chai, Paul Anantharajah Tambyah, and Gabriel Yan

Author affiliations: National University Health System, Singapore

 

Abstract

Coronavirus disease (COVID-19) and tuberculosis (TB) developed in 4 foreign workers living in dormitories in Singapore during April–May 2020. Clinical manifestations and atypical radiographic features of COVID-19 led to the diagnosis of TB through positive interferon-gamma release assay and culture results. During the COVID-19 pandemic, TB should not be overlooked.

Keywords: SARS-CoV-2; COVID-19; Tuberculosis; Singapore.

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#Perceptions of #public on the #COVID19 #outbreak in #Singapore: a qualitative content analysis (J Pub Health, abstract)

[Source: Journal of Public Health, full page: (LINK). Abstract, edited.]

Perceptions of public on the COVID-19 outbreak in Singapore: a qualitative content analysis

Shefaly Shorey, Emily Ang, Amira Yamina, Clarence Tam

Journal of Public Health, fdaa105, https://doi.org/10.1093/pubmed/fdaa105

Published: 10 July 2020

 

ABSTRACT

Background

Singapore is among the several countries affected by the COVID-19 outbreak. The outbreak has elicited panic and unease among Singapore’s public. This study aimed to analyze the comments left on local media news outlets to find common concerns and discuss potential new measures that can be developed to reduce panic and support for Singapore’s public during and beyond COVID-19.

Methods

A qualitative content analysis on the comments on relevant news articles from the Facebook pages of six online local news publications dated from 23 January 2020 to the 3 April 2020 was carried out.

Results

Five common themes were derived 1: fear and concern (35.42%), 2 panic buying and hoarding (21.21%), 3 reality and expectations about the situation (20.24%), 4 staying positive amid the ‘storm’ (10.07%) and 5 worries about the future (5.01%). The analysis revealed that fear and concern were the main reasons behind the public’s responses.

Conclusion

Clear communication between the government and the public is one of the best ways to maintain calm among the public and to contribute to greater social cooperation. Timely updates and support measures from the government further help to maintain social peace and cohesion.

coronavirus, COVID-19, pandemic, Singapore, qualitative content analysis

Issue Section: Original Article

Keywords: SARS-CoV-2; COVID-19; Society; Singapore.

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#Detection of #air and #surface #contamination by #SARS-CoV-2 in #hospital #rooms of infected patients (Nat Commun., abstract)

[Source: Nature Communications, full page: (LINK). Abstract, edited.]

Detection of air and surface contamination by SARS-CoV-2 in hospital rooms of infected patients

Po Ying Chia, Kristen Kelli Coleman, […] for the Singapore 2019 Novel Coronavirus Outbreak Research Team

Nature Communications volume 11, Article number: 2800 (2020)

 

Abstract

Understanding the particle size distribution in the air and patterns of environmental contamination of SARS-CoV-2 is essential for infection prevention policies. Here we screen surface and air samples from hospital rooms of COVID-19 patients for SARS-CoV-2 RNA. Environmental sampling is conducted in three airborne infection isolation rooms (AIIRs) in the ICU and 27 AIIRs in the general ward. 245 surface samples are collected. 56.7% of rooms have at least one environmental surface contaminated. High touch surface contamination is shown in ten (66.7%) out of 15 patients in the first week of illness, and three (20%) beyond the first week of illness (p = 0.01, χ2 test). Air sampling is performed in three of the 27 AIIRs in the general ward, and detects SARS-CoV-2 PCR-positive particles of sizes >4 µm and 1–4 µm in two rooms, despite these rooms having 12 air changes per hour. This warrants further study of the airborne transmission potential of SARS-CoV-2.

Keywords: SARS-CoV-2; COVID-19; Singapore.

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#Assessment of #Proficiency of #N95 #Mask #Donning Among the General #Public in #Singapore (JAMA Netw Open, summary)

[Source: JAMA Network Open, full page: (LINK). Summary, edited.]

Assessment of Proficiency of N95 Mask Donning Among the General Public in Singapore

Wesley Yeung, MBBS1,2; Kennedy Ng, MBBS3; J. M. Nigel Fong, MBBS4; et al. Judy Sng, MBBS5; Bee Choo Tai, PhD5; Sin Eng Chia, MBBS5

Author Affiliations: 1 University Medicine Cluster, National University Hospital, Singapore; 2 Laboratory for Computational Physiology, Harvard-MIT Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge; 3 Division of Medical Oncology, National Cancer Centre Singapore, Singapore; 4 Division of Medicine, Singapore General Hospital, Singapore; 5 Saw Swee Hock School of Public Health, National University of Singapore, Singapore

JAMA Netw Open. 2020;3(5):e209670. doi:10.1001/jamanetworkopen.2020.9670

___

Introduction

With the advent of the coronavirus disease 2019 (COVID-19) pandemic, mask-wearing  among the general public has become commonplace, leading to a worldwide shortage.1  However, there is little data on mask-wearing proficiency in the general public. A single  study performed in the US after Hurricane Katrina, when individuals donned masks for  mold remediation, found that only 24% of participants demonstrated proper technique.2  Incorrectly worn masks may not confer effective protection against COVID-19. We  conducted this cross-sectional study to evaluate the proficiency of members of the  Singapore public in wearing N95 masks, which the local government distributed to  households in 2014 as part of an emergency preparedness program3 targeted at episodes  of haze. The duck-bill foldable N95 mask (3M VFlex 9105) was selected for ease  of mailing and was distributed along with pictorial instructions.

(…)

Keywords: SARS-CoV-2; COVID-19; PPE; Facemasks; Singapore.

——

#Community-acquired viral #respiratory #infections amongst hospitalized inpatients during a #COVID19 #outbreak in #Singapore: co-infection and clinical outcomes (J Clin Virol., abstract)

[Source: Journal of Clinical Virology, full page: (LINK). Abstract, edited.]

Journal of Clinical Virology | Available online 19 May 2020, 104436 | In Press, Journal Pre-proof

Community-acquired viral respiratory infections amongst hospitalized inpatients during a COVID-19 outbreak in Singapore: co-infection and clinical outcomes

Liang En Wee a,b, Kwan Ki Karrie Ko c,d, Wan Qi Ho e, Grace Teck Cheng Kwek e, Thuan Tong Tan b, Limin Wijay a,b

a Singhealth Infectious Diseases Residency, Singapore; b Department of Infectious  Diseases, Singapore General Hospital, Singapore; c Department of Microbiology, Singapore General Hospital, Singapore; d Department of Molecular Pathology, Singapore  General Hospital, Singapore; e Division of Medicine, Singapore General Hospital, Singapore

Received 1 May 2020, Accepted 10 May 2020, Available online 19 May 2020.

DOI: https://doi.org/10.1016/j.jcv.2020.104436

 

Highlights

  • Common viruses caused two-fifths of respiratory-illness-related hospitalizations, amidst a COVID-19 outbreak.
  • The co-infection rate between SARS-CoV-2 and other respiratory viruses was low, at 1.4%.
  • No increased morbidity or mortality with COVID-19 co-infections.
  • In-hospital mortality and intubation lower for COVID-19 compared with other respiratory viruses.

 

Abstract

Aims

During the ongoing COVID-19 outbreak, co-circulation of other common respiratory viruses can potentially result in co-infections; however, reported rates of co-infections for SARS-CoV-2 vary.

We sought to evaluate the prevalence and etiology of all community acquired viral respiratory infections requiring hospitalization during an ongoing COVID-19 outbreak, with a focus on co-infection rates and clinical outcomes.

Methods

Over a 10-week period, all admissions to our institution, the largest tertiary hospital in Singapore, were screened for respiratory symptoms, and COVID-19 as well as a panel of common respiratory viral pathogens were systematically tested for. Information was collated on clinical outcomes, including requirement for mechanical ventilation and in hospital mortality.

Results

One-fifth (19.3%, 736/3807) of hospitalized inpatients with respiratory symptoms had a PCR-proven viral respiratory infection; of which 58.5% (431/736) tested positive for SARS-CoV-2 and 42.2% (311/736) tested positive for other common respiratory viruses. The rate of co-infection with SARS-CoV-2 was 1.4% (8/431); all patients with co-infection had mild disease and stayed in communal settings. The in-hospital mortality rate and proportion of COVID-19 patients requiring invasive ventilation was low, at around 1% of patients; these rates were lower than patients with other community-acquired respiratory viruses admitted over the same period (p < 0.01).

Conclusion

Even amidst an ongoing COVID-19 outbreak, common respiratory viruses still accounted for a substantial proportion of hospitalizations. Coinfections with SARS-CoV-2 were rare, with no observed increase in morbidity or mortality.

Keywords: SARS-CoV-2; COVID-19; Singapore.

——

Connecting #clusters of #COVID19: an #epidemiological and #serological #investigation (Lancet Infect Dis., abstract)

[Source: The Lancet Infectious Diseases, full page: (LINK). Abstract, edited.]

Connecting clusters of COVID-19: an epidemiological and serological investigation

Sarah Ee Fang Yong, MMed †, Danielle Elizabeth Anderson, PhD †, Wycliffe E Wei, MPH, Junxiong Pang, PhD, Wan Ni Chia, PhD, Chee Wah Tan, PhD, Yee Leong Teoh, MMed, Priyanka Rajendram, MPH, Matthias Paul Han Sim Toh, MMed, Cuiqin Poh, MPH, Valerie T J Koh, MPH, Joshua Lum, BA, Nur-Afidah Md Suhaimi, PhD, Po Ying Chia, MRCP, Mark I-Cheng Chen, PhD, Shawn Vasoo, MRCP, Benjamin Ong, FRCP, Prof Yee Sin Leo, FRCP, Prof Linfa Wang, PhD †, Vernon J M Lee, PhD  †

Published: April 21, 2020 | DOI: https://doi.org/10.1016/S1473-3099(20)30273-5

 

Summary

Background

Elucidation of the chain of disease transmission and identification of the source of coronavirus disease 2019 (COVID-19) infections are crucial for effective disease containment. We describe an epidemiological investigation that, with use of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) serological assays, established links between three clusters of COVID-19.

Methods

In Singapore, active case-finding and contact tracing were undertaken for all COVID-19 cases. Diagnosis for acute disease was confirmed with RT-PCR testing. When epidemiological information suggested that people might have been nodes of disease transmission but had recovered from illness, SARS-CoV-2 IgG serology testing was used to establish past infection.

Findings

Three clusters of COVID-19, comprising 28 locally transmitted cases, were identified in Singapore; these clusters were from two churches (Church A and Church B) and a family gathering. The clusters in Church A and Church B were linked by an individual from Church A (A2), who transmitted SARS-CoV-2 infection to the primary case from Church B (F1) at a family gathering they both attended on Jan 25, 2020. All cases were confirmed by RT-PCR testing because they had active disease, except for A2, who at the time of testing had recovered from their illness and tested negative. This individual was eventually diagnosed with past infection by serological testing. ELISA assays showed an optical density of more than 1·4 for SARS-CoV-2 nucleoprotein and receptor binding domain antigens in titres up to 1/400, and viral neutralisation was noted in titres up to 1/320.

Interpretation

Development and application of a serological assay has helped to establish connections between COVID-19 clusters in Singapore. Serological testing can have a crucial role in identifying convalescent cases or people with milder disease who might have been missed by other surveillance methods.

Funding

National Research Foundation (Singapore), National Natural Science Foundation (China), and National Medical Research Council (Singapore).

Keywords: SARS-CoV-2; COVID-19; Diagnostic tests; Singapore; Cluster of cases; Serology.

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Responding to the #COVID19 #outbreak in #Singapore: #Staff #Protection and Staff #Temperature and #Sickness #Surveillance Systems (Clin Infect Dis., abstract)

[Source: Clinical Infectious Diseases, full page: (LINK). Abstract, edited.]

Responding to the COVID-19 outbreak in Singapore: Staff Protection and Staff Temperature and Sickness Surveillance Systems

Htet Lin Htun, MPH, Dwee Wee Lim, MPH, Win Mar Kyaw, MPH, Wan-Ning Janis Loh, MCom, Lay Tin Lee, MSc, (OM), Brenda Ang, MPH, Angela Chow, PhD

Clinical Infectious Diseases, ciaa468, https://doi.org/10.1093/cid/ciaa468

Published: 21 April 2020

 

Abstract

Background

Coronavirus disease 2019 (COVID-19) is an emerging infectious disease caused by 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 January 23,2020.

Methods

We conducted a cross-sectional study, from January 23,2020 to February 23,2020, among healthcare workers to evaluate the effectiveness of the staff protection and surveillance strategy in TTSH, a 1600-bed multidisciplinary acute-care hospital co-located with the 330-bed National Centre for Infectious Diseases (NCID). As of February 23,2020, TTSH/NCID has managed 76% of confirmed COVID-19 cases in Singapore. The hospital adopted a multi-pronged 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 hospital-wide fever and sickness surveillance, with 1,524 frontline staff working in COVID-19 areas under close surveillance. Among frontline staff, a median of eight staff illness episodes was seen per day, and 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.

COVID-19, novel coronavirus, surveillance, healthcare workers

Issue Section: Major Article

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This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Keywords: SARS-CoV-2; COVID-19; HCWs; Singapore.

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#Presymptomatic #Transmission of #SARS-CoV-2 — #Singapore, January 23–March 16, 2020 (MMWR Morb Mortal Wkly Rep., abstract)

[Source: US Centers for Disease Control and Prevention (CDC), MMWR Morbidity and Mortality Weekly Report, full page: (LINK). Abstract, edited.]

Presymptomatic Transmission of SARS-CoV-2 — Singapore, January 23–March 16, 2020

Early Release / April 1, 2020 / 69

Wycliffe E. Wei, MPH1,2; Zongbin Li, MBBS1; Calvin J. Chiew, MPH1; Sarah E. Yong, MMed1; Matthias P. Toh, MMed2,3; Vernon J. Lee, PhD1,3

Corresponding author: Vernon J. Lee, Vernon_Lee@moh.gov.sg.

1 Ministry of Health, Singapore; 2 National Centre for Infectious Diseases, Singapore; 3 Saw Swee Hock School of Public Health, Singapore.

All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Suggested citation for this article: Wei WE, Li Z, Chiew CJ, Yong SE, Toh MP, Lee VJ. Presymptomatic Transmission of SARS-CoV-2 — Singapore, January 23–March 16, 2020. MMWR Morb Mortal Wkly Rep. ePub: 1 April 2020. DOI: http://dx.doi.org/10.15585/mmwr.mm6914e1

 

Summary

  • What is already known about this topic?
    • Preliminary evidence indicates the occurrence of presymptomatic transmission of SARS-CoV-2, based on reports of individual cases in China.
  • What is added by this report?
    • Investigation of all 243 cases of COVID-19 reported in Singapore during January 23–March 16 identified seven clusters of cases in which presymptomatic transmission is the most likely explanation for the occurrence of secondary cases.
  • What are the implications for public health practice?
    • The possibility of presymptomatic transmission increases the challenges of containment measures. Public health officials conducting contact tracing should strongly consider including a period before symptom onset to account for the possibility of presymptomatic transmission. The potential for presymptomatic transmission underscores the importance of social distancing, including the avoidance of congregate settings, to reduce COVID-19 spread.

 

Abstract

Presymptomatic transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), might pose challenges for disease control. The first case of COVID-19 in Singapore was detected on January 23, 2020, and by March 16, a total of 243 cases had been confirmed, including 157 locally acquired cases. Clinical and epidemiologic findings of all COVID-19 cases in Singapore through March 16 were reviewed to determine whether presymptomatic transmission might have occurred. Presymptomatic transmission was defined as the transmission of SARS-CoV-2 from an infected person (source patient) to a secondary patient before the source patient developed symptoms, as ascertained by exposure and symptom onset dates, with no evidence that the secondary patient had been exposed to anyone else with COVID-19. Seven COVID-19 epidemiologic clusters in which presymptomatic transmission likely occurred were identified, and 10 such cases within these clusters accounted for 6.4% of the 157 locally acquired cases. In the four clusters for which the date of exposure could be determined, presymptomatic transmission occurred 1–3 days before symptom onset in the presymptomatic source patient. To account for the possibility of presymptomatic transmission, officials developing contact tracing protocols should strongly consider including a period before symptom onset. Evidence of presymptomatic transmission of SARS-CoV-2 underscores the critical role social distancing, including avoidance of congregate settings, plays in controlling the COVID-19 pandemic.

Keywords: SARS-CoV-2; COVID-19; Singapore.

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#Interventions to #mitigate early spread of #SARS-CoV-2 in #Singapore: a modelling study (Lancet Infect Dis., abstract)

[Source: The Lancet Infectious Diseases, full page: (LINK). Abstract, edited.]

Interventions to mitigate early spread of SARS-CoV-2 in Singapore: a modelling study

Joel R Koo, BSc, Alex R Cook, PhD, Minah Park, PhD, Yinxiaohe Sun, MSc, Haoyang Sun, BSc, Jue Tao Lim, MSc, Clarence Tam, PhD, Borame L Dickens, PhD

Published: March 23, 2020 | DOI: https://doi.org/10.1016/S1473-3099(20)30162-6

 

Summary

Background

Since the coronavirus disease 2019 outbreak began in the Chinese city of Wuhan on Dec 31, 2019, 68 imported cases and 175 locally acquired infections have been reported in Singapore. We aimed to investigate options for early intervention in Singapore should local containment (eg, preventing disease spread through contact tracing efforts) be unsuccessful.

Methods

We adapted an influenza epidemic simulation model to estimate the likelihood of human-to-human transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in a simulated Singaporean population. Using this model, we estimated the cumulative number of SARS-CoV-2 infections at 80 days, after detection of 100 cases of community transmission, under three infectivity scenarios (basic reproduction number [R0] of 1·5, 2·0, or 2·5) and assuming 7·5% of infections are asymptomatic. We first ran the model assuming no intervention was in place (baseline scenario), and then assessed the effect of four intervention scenarios compared with a baseline scenario on the size and progression of the outbreak for each R0 value. These scenarios included isolation measures for infected individuals and quarantining of family members (hereafter referred to as quarantine); quarantine plus school closure; quarantine plus workplace distancing; and quarantine, school closure, and workplace distancing (hereafter referred to as the combined intervention). We also did sensitivity analyses by altering the asymptomatic fraction of infections (22·7%, 30·0%, 40·0%, and 50·0%) to compare outbreak sizes under the same control measures.

Findings

For the baseline scenario, when R0 was 1·5, the median cumulative number of infections at day 80 was 279 000 (IQR 245 000–320 000), corresponding to 7·4% (IQR 6·5–8·5) of the resident population of Singapore. The median number of infections increased with higher infectivity: 727 000 cases (670 000–776 000) when R0 was 2·0, corresponding to 19·3% (17·8–20·6) of the Singaporean population, and 1 207 000 cases (1 164 000–1 249 000) when R0 was 2·5, corresponding to 32% (30·9–33·1) of the Singaporean population. Compared with the baseline scenario, the combined intervention was the most effective, reducing the estimated median number of infections by 99·3% (IQR 92·6–99·9) when R0 was 1·5, by 93·0% (81·5–99·7) when R0 was 2·0, and by 78·2% (59·0 −94·4) when R0 was 2·5. Assuming increasing asymptomatic fractions up to 50·0%, up to 277 000 infections were estimated to occur at day 80 with the combined intervention relative to 1800 for the baseline at R0 of 1·5.

Interpretation

Implementing the combined intervention of quarantining infected individuals and their family members, workplace distancing, and school closure once community transmission has been detected could substantially reduce the number of SARS-CoV-2 infections. We therefore recommend immediate deployment of this strategy if local secondary transmission is confirmed within Singapore. However, quarantine and workplace distancing should be prioritised over school closure because at this early stage, symptomatic children have higher withdrawal rates from school than do symptomatic adults from work. At higher asymptomatic proportions, intervention effectiveness might be substantially reduced requiring the need for effective case management and treatments, and preventive measures such as vaccines.

Funding

Singapore Ministry of Health, Singapore Population Health Improvement Centre.

Keywords: SARS-CoV-2; COVID-19; Singapore; Quarantine.

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#Investigation of three #clusters of #COVID19 in #Singapore: implications for #surveillance and response measures (Lancet, abstract)

[Source: The Lancet, full page: (LINK). Abstract, edited.]

Investigation of three clusters of COVID-19 in Singapore: implications for surveillance and response measures

Rachael Pung, MSc *, Calvin J Chiew, MPH *, Barnaby E Young, MB BChir, Sarah Chin, MPH, Mark I-C Chen, PhD, Hannah E Clapham, PhD et al.

Published: March 16, 2020 / DOI: https://doi.org/10.1016/S0140-6736(20)30528-6

 

Summary

Background

Three clusters of coronavirus disease 2019 (COVID-19) linked to a tour group from China, a company conference, and a church were identified in Singapore in February, 2020.

Methods

We gathered epidemiological and clinical data from individuals with confirmed COVID-19, via interviews and inpatient medical records, and we did field investigations to assess interactions and possible modes of transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Open source reports were obtained for overseas cases. We reported the median (IQR) incubation period of SARS-CoV-2.

Findings

As of Feb 15, 2020, 36 cases of COVID-19 were linked epidemiologically to the first three clusters of circumscribed local transmission in Singapore. 425 close contacts were quarantined. Direct or prolonged close contact was reported among affected individuals, although indirect transmission (eg, via fomites and shared food) could not be excluded. The median incubation period of SARS-CoV-2 was 4 days (IQR 3–6). The serial interval between transmission pairs ranged between 3 days and 8 days.

Interpretation

SARS-CoV-2 is transmissible in community settings, and local clusters of COVID-19 are expected in countries with high travel volume from China before the lockdown of Wuhan and institution of travel restrictions. Enhanced surveillance and contact tracing is essential to minimise the risk of widespread transmission in the community.

Funding

None.

Keywords: COVID-19; SARS-CoV-2; Singapore.

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