Tuberculosis in older adults: case studies from four countries with rapidly ageing populations in the western pacific region.

BACKGROUND: The Western Pacific Region has one of the fastest-growing populations of older adults (≥ 65 years) globally, among whom tuberculosis (TB) poses a particular concern. This study reports country case studies from China, Japan, the Republic of Korea, and Singapore reflecting on their experiences in managing TB among older adults. FINDINGS: Across all four countries, TB case notification and incidence rates were highest among older adults, but clinical and public health guidance focused on this population was limited. Individual country reports illustrated a range of practices and challenges. Passive case finding remains the norm, with limited active case finding (ACF) programs implemented in China, Japan, and the Republic of Korea. Different approaches have been trialled to assist older adults in securing an early diagnosis, as well as adhering to their TB treatment. All countries emphasised the need for person-centred approaches that include the creative application of new technology and tailored incentive programs, as well as reconceptualisation of how we provide treatment support. The use of traditional medicines was found to be culturally entrenched among older adults, with a need for careful consideration of their complementary use. TB infection testing and the provision of TB preventive treatment (TPT) were underutilised with highly variable practice. CONCLUSION: Older adults require specific consideration in TB response policies, given the burgeoning aging population and their high TB risk. Policymakers, TB programs and funders must invest in and develop locally contextualised practice guidelines to inform evidence-based TB prevention and care practices for older adults.

Airborne SARS-CoV-2 surveillance in hospital environment using high-flowrate air samplers and its comparison to surface sampling.

Reliable methods to detect the presence of SARS-CoV-2 at venues where people gather are essential for epidemiological surveillance to guide public policy. Communal screening of air in a highly crowded space has the potential to provide early warning on the presence and potential transmission of SARS-CoV-2 as suggested by studies early in the epidemic. As hospitals and public facilities apply varying degrees of restrictions and regulations, it is important to provide multiple methodological options to enable environmental SARS-CoV-2 surveillance under different conditions. This study assessed the feasibility of using high-flowrate air samplers combined with RNA extraction kit designed for environmental sample to perform airborne SARS-CoV-2 surveillance in hospital setting, tested by RT-qPCR. The success rate of the air samples in detecting SARS-CoV-2 was then compared with surface swab samples collected in the same proximity. Additionally, positive RT-qPCR samples underwent viral culture to assess the viability of the sampled SARS-CoV-2. The study was performed in inpatient ward environments of a quaternary care university teaching hospital in Singapore housing active COVID-19 patients within the period of February to May 2020. Two types of wards were tested, naturally ventilated open-cohort ward and mechanically ventilated isolation ward. Distances between the site of air sampling and the patient cluster in the investigated wards were also recorded. No successful detection of airborne SARS-CoV-2 was recorded when 50 L/min air samplers were used. Upon increasing the sampling flowrate to 150 L/min, our results showed a high success rate in detecting the presence of SARS-CoV-2 from the air samples (72%) compared to the surface swab samples (9.6%). The positive detection rate of the air samples along with the corresponding viral load could be associated with the distance between sampling site and patient. The furthest distance from patient with PCR-positive air samples was 5.5 m. The airborne SARS-CoV-2 detection was comparable between the two types of wards with 60%-87.5% success rate. High prevalence of the virus was found in toilet areas, both on surfaces and in air. Finally, no successful culture attempt was recorded from the environmental air or surface samples.

Responding to COVID-19: how an academic infectious diseases division mobilized in Singapore.

BACKGROUND: On January 30, COVID-19 was declared a Public Health Emergency of International Concern-a week after Singapore's first imported case and 5 days before local transmission. The National University Hospital (NUH) is Singapore's third largest hospital with 1200 beds, heavy clinical workloads, and major roles in research and teaching. MAIN BODY: With memories of SARS still vivid, there was an urgent requirement for the NUH Division of Infectious Diseases to adapt-undergoing major reorganization to face rapidly changing priorities while ensuring usual essential services and standards. Leveraging on individual strengths, our division mobilized to meet the demands of COVID-19 while engaging in high-level coordination, strategy, and advocacy. We present our experience of the 60 days since the nation's first case. During this time, our hospital has managed 3030 suspect cases, including 1300 inpatients, 37 confirmed cases, and overseen 4384 samples tested for COVID-19. CONCLUSION: Complex hospital adaptations were supported by an unprecedented number of workflows and coordination channels essential to safe and effective operations. The actions we describe, aligned with international recommendations and emerging evidence-based best practices, may serve as a framework for other divisions and institutions facing the spread of COVID-19 globally.

COVID-19 and ischemic stroke: a systematic review and meta-summary of the literature.

Acute ischemic stroke (AIS) is a life-threatening complication of coronavirus disease 2019 (COVID-19) infection. Increasing reports suggest an association between COVID-19 and AIS, although the underlying mechanism remains uncertain. We performed a systematic review to characterize the clinical characteristics, neuroimaging findings, and outcomes of AIS in COVID-19 patients. A literature search was performed in PubMed and Embase using a suitable keyword search strategy from 1st December 2019 to 29th May 2020. All studies reporting AIS occurrence in COVID-19 patients were included. A total of 39 studies comprising 135 patients were studied. The pooled incidence of AIS in COVID-19 patients from observational studies was 1.2% (54/4466) with a mean age of 63.4 ± 13.1 years. The mean duration of AIS from COVID-19 symptoms onset was 10 ± 8 days, and the mean NIHSS score was 19 ± 8. Laboratory investigations revealed an elevated mean D-dimer (9.2 ± 14.8 mg/L) and fibrinogen (5.8 ± 2.0 g/L). Antiphospholipid antibodies were detected in a significant number of cases. The majority of AIS neuroimaging patterns observed was large vessel thrombosis, embolism or stenosis (62.1%, 64/103), followed by multiple vascular territory (26.2%, 27/103). A high mortality rate was reported (38.0%, 49/129). We report the pooled incidence of AIS in COVID-19 patients to be 1.2%, with a high mortality rate. Elevated D-dimer, fibrinogen and the presence of antiphospholipid antibodies appear to be prominent in COVID-19 patients with concomitant AIS, but further mechanistic studies are required to elucidate their role in pathogenesis.

Quantifying test-retest variability of natural and suppressed citric acid cough thresholds and urge to cough ratings.

INTRODUCTION: The citric acid cough reflex test (CRT) is used to quantify cough sensitivity and evaluate the effects of cough therapies and antitussive medications. This study quantifies the test-retest variability of natural and suppressed citric acid cough thresholds and urge to cough ratings in healthy individuals. METHODS: Healthy adults (n = 16) inhaled increasing concentrations of citric acid (0.01-3.2 mol/L) on three alternate days (1, 3, 5) until C2 cough thresholds (i.e. two consecutive coughs within 3 s) or the highest concentrations of citric acid was reached. Participants were instructed to "cough if you need to" in the natural cough condition, and "try not to cough" in the suppressed cough condition. Following each inhalation, participants were asked to rate their urge to cough (UTC) using a modified Borg Scale. RESULTS: Natural cough thresholds (NCTs) increased across days 1-3 (0.87 doubling concentrations, 95% CI, 0.28, 1.44, p = 0.004) and 1-5 (0.87 doubling concentrations, 95% CI, 0.33, 1.41, p = 0.004). Suppressed cough thresholds (SCTs) increased across days 1-5 (0.64 doubling concentrations per day, 95% CI, 0.03, 1.22, p = 0.04). After taking the effect of day into account, NCTs and SCTs varied within-participants by 0.75 (95% CI, 0.53, 0.93) and 0.78 (95% CI, 0.55,0.98) doubling concentrations respectively. UTC ratings at NCT, or SCT did not significantly increase across days 1-3 or 1-5. Sub-threshold (0.05 mol/L) UTC ratings increased across days 1-3 (-1.43 ratings per day, 95% CI, -2.31, -0.5, p = 0.005) and 1-5 (-1.71 ratings per day, 95% CI, -2.59, -0.79, p = 0.001). UTC ratings at NCT, SCT, and sub-threshold varied within-participants after taking into account the effect of day by 1.34 (95% CI, 1.03, 1.71), 1.47 (95% CI, 1.10, 1.91) and 1.20 (95% CI, 0.91, 1.50) ratings. CONCLUSIONS: Natural and suppressed cough thresholds and UTC ratings are subject to test-retest variability. These data are important for the use of citric acid CRT as an outcome measure in longitudinal cough research, as they facilitate interpretation of whether changes in citric acid cough thresholds across days reflect true changes in cough sensitivity, rather than an artefact of repeating the test.

A systematic review of methods of citric acid cough reflex testing.

INTRODUCTION: This systematic review summarises and appraises methods of citric acid cough reflex testing (CRT) documented in published literature. METHODS: Electronic databases, MEDLINE, EMBASE, CINAHL, PsychINFO, Scopus were searched up to and including 11th February 2018. Studies reporting a method of citric acid CRT, published in peer-reviewed journals in English or Spanish, were assessed for the inclusion criteria. Of the selected studies, information on the instrumentation and CRT protocol was extracted. RESULTS: A total of 129 studies were included. Instrumentation and protocols differed widely across studies. Reporting of methods of citric acid CRT was sub-standard, with many crucial methodological components omitted from published manuscripts, preventing their full replication. CONCLUSIONS: Considerable methodological variability exists for citric acid CRT in published literature. The findings suggest that caution is warranted in comparing citric acid cough thresholds across studies. Full replication of previously published methods of citric acid CRT is limited due to crucial elements of the citric acid CRT protocol being omitted from published manuscripts. These findings have implications on the use of citric acid CRT in clinical and pharmaceutical studies to evaluate the effects of antitussive medications and cough therapies.

Detection of hospital environmental contamination during SARS-CoV-2 Omicron predominance using a highly sensitive air sampling device.

Background and objectives: The high transmissibility of SARS-CoV-2 has exposed weaknesses in our infection control and detection measures, particularly in healthcare settings. Aerial sampling has evolved from passive impact filters to active sampling using negative pressure to expose culture substrate for virus detection. We evaluated the effectiveness of an active air sampling device as a potential surveillance system in detecting hospital pathogens, for augmenting containment measures to prevent nosocomial transmission, using SARS-CoV-2 as a surrogate. Methods: We conducted air sampling in a hospital environment using the AerosolSenseTM air sampling device and compared it with surface swabs for their capacity to detect SARS-CoV-2. Results: When combined with RT-qPCR detection, we found the device provided consistent SARS-CoV-2 detection, compared to surface sampling, in as little as 2 h of sampling time. The device also showed that it can identify minute quantities of SARS-CoV-2 in designated "clean areas" and through a N95 mask, indicating good surveillance capacity and sensitivity of the device in hospital settings. Conclusion: Active air sampling was shown to be a sensitive surveillance system in healthcare settings. Findings from this study can also be applied in an organism agnostic manner for surveillance in the hospital, improving our ability to contain and prevent nosocomial outbreaks.

COVID-19 associated parotitis.

While Coronavirus 2019 (COVID-19) typically presents with respiratory tract symptoms, atypical manifestations have been reported. We present a case of a 46-year-old man who presented with fever but no respiratory tract symptoms, and later develops bilateral parotitis. We review the literature for all other reported cases of parotitis and describe common features of these cases. It is important to consider COVID-19 in cases of parotitis, as this impacts patient management and ensures important infection control measures are undertaken.