Global dengue importation: a systematic review.

BACKGROUND: Importation of dengue following globalization presents an emerging threat to global health. However, evidence on global geographical sources and the potential of dengue importation globally are lacking. This study aims to systematically review the sources of dengue importation globally and the risk of dengue outbreaks globally. METHODS: This systematic review was conducted in accordance to Cochrane's PRISMA guidelines. Articles published through 31 December 2019 with laboratory-confirmed dengue imported cases were consolidated from PubMed, EMBASE and Scopus. Sources of dengue importation reported worldwide were analysed by country and geographical regions. Sources of dengue importation into United States of America and Europe specifically were also analysed. RESULTS: A total of 3762 articles were found. Among which, 210 articles-documenting 14,972 imported dengue cases with reported sources-were eligible. 76.3% of imported cases worldwide were from Asia. 15.7%, 5.6%, 2.0% and 0.1% were imported from the Americas, Africa, Oceania and Europe regions respectively. Imported dengue cases in the U.S. were from Americas (55.3%), Asia (34.7%), Africa (6.7%) and Oceania (3.3%). Imported dengue cases in Europe were from Asia (66.0%), Americas (21.9%), Africa (10.8%) and Oceania (1.1%). CONCLUSION: The potential of dengue outbreaks occurring globally, especially among non-endemic regions with dengue-susceptible populations is high. With the expansion of Aedes mosquito population globally due to global warming and globalisation, dengue importation constitutes an emerging global health security threat.

Impact of travel ban implementation on COVID-19 spread in Singapore, Taiwan, Hong Kong and South Korea during the early phase of the pandemic: a comparative study.

BACKGROUND: The COVID-19 pandemic has elicited imposition of some form of travel restrictions by almost all countries in the world. Most restrictions currently persist, although some have been gradually eased. It remains unclear if the trade-off from the unprecedented disruption to air travel was well worth for pandemic containment. METHOD: A comparative analysis was conducted on Singapore, Taiwan, Hong Kong and South Korea's COVID-19 response. Data on COVID-19 cases, travel-related and community interventions, socio-economic profile were consolidated. Trends on imported and local cases were analyzed using computations of moving averages, rate of change, particularly in response to distinct waves of travel-related interventions due to the outbreak in China, South Korea, Iran & Italy, and Europe. RESULTS: South Korea's travel restrictions were observed to be consistently more lagged in terms of timeliness and magnitude, with their first wave of travel restrictions on flights departing from China implemented 34 days after the outbreak in Wuhan, compared to 22-26 days taken by Singapore, Taiwan and Hong Kong. South Korea's restrictions against all countries came after 91 days, compared to 78-80 days for the other three countries. The rate of change of imported cases fell by 1.08-1.43 across all four countries following the first wave of travel restrictions on departures from China, and by 0.22-0.52 in all countries except South Korea in the fifth wave against all international travellers. Delayed rate of change of local cases resulting from travel restrictions imposed by the four countries with intrinsic importation risk, were not observed. CONCLUSIONS: Travel restriction was effective in preventing COVID-19 case importation in early outbreak phase, but may still be limited in preventing general local transmission. The impact of travel restrictions, regardless of promptness, in containing epidemics likely also depends on the effectiveness of local surveillance and non-pharmaceutical interventions concurrently implemented.

Impact of the coronavirus disease 2019 pandemic on irritable bowel syndrome.

BACKGROUND AND AIM: Gastrointestinal manifestations of the coronavirus disease 2019 (COVID-19) pandemic may mimic irritable bowel syndrome (IBS), and social distancing measures may affect IBS patients negatively. We aimed to study the impact of COVID-19 on respondents with self-reported IBS. METHODS: We conducted an anonymized survey from May to June 2020 in 33 countries. Knowledge, attitudes, and practices on personal hygiene and social distancing as well as psychological impact of COVID-19 were assessed. Statistical analysis was performed to determine differences in well-being and compliance to social distancing measures between respondents with and without self-reported IBS. Factors associated with improvement or worsening of IBS symptoms were evaluated. RESULTS: Out of 2704 respondents, 2024 (74.9%) did not have IBS, 305 (11.3%) had self-reported IBS, and 374 (13.8%) did not know what IBS was. Self-reported IBS respondents reported significantly worse emotional, social, and psychological well-being compared with non-IBS respondents and were less compliant to social distancing measures (28.2% vs 35.3%, P = 0.029); 61.6% reported no change, 26.6% reported improvement, and 11.8% reported worsening IBS symptoms. Higher proportion of respondents with no change in IBS symptoms were willing to practice social distancing indefinitely versus those who deteriorated (74.9% vs 51.4%, P = 0.016). In multivariate analysis, willingness to continue social distancing for another 2-3 weeks (vs longer period) was significantly associated with higher odds of worsening IBS. CONCLUSION: Our study showed that self-reported IBS respondents had worse well-being and compliance to social distancing measures than non-IBS respondents. Future research will focus on occupational stress and dietary changes during COVID-19 that may influence IBS.

The Double-Edged Sword of Military Response to Societal Disruptions: A Systematic Review of the Evidence for Military Personnel as Pathogen Transmitters.

Given their lack of immunity and increased exposure, military personnel have the potential to serve as carriers or reservoirs for infectious diseases into or out of the deployment areas, but, to our knowledge, the historical evidence for such transmission events has not previously been reviewed. Using PubMed, we performed a systematic review of published literature between 1955 and 2018, which documented evidence for military personnel transporting infectious pathogens into or out of deployment areas. Of the 439 articles screened, 67 were included for final qualitative and quantitative review. The data extracted from these articles described numerous instances in which thousands of military service members demonstrated potential or actual transmission and transportation of multiple diverse pathogens. These data underscore the immense importance preventive medical professionals play in mitigating such risk, how their public health efforts must be supported, and the importance of surveillance in protecting both military and civilian populations.

Evidence for Cross-Protection Against Subsequent Febrile Respiratory Illness Episodes From Prior Infections by Different Viruses Among Singapore Military Recruits 2009-2014.

BACKGROUND: Few studies have evaluated the relative cross-protection conferred by infection with different groups of viruses through studies of sequential infections in humans. We investigated the presence of short-lived relative cross-protection conferred by specific prior viral infections against subsequent febrile respiratory illness (FRI). METHODS: Men enlisted in basic military training between December 2009 and December 2014 were recruited, with the first FRI as the study entry point. ResPlex II assays and real-time polymerase chain reaction assays were used to detect viral pathogens in nasal wash samples, and survival analyses were performed to determine whether infection with particular viruses conferred short-lived relative cross-protection against FRI. RESULTS: Prior infection with adenovirus (hazard ratio [HR], 0.24; 95% confidence interval [CI], .14-.44) or influenza virus (HR, 0.52; 95% CI, .38-.73) conferred relative protection against subsequent FRI episode. Results were statistically significant even after adjustment for the interval between enlistment and FRI (P < .001). Adenovirus-positive participants with FRI episodes tended to be protected against subsequent infection with adenovirus, coronavirus, enterovirus/rhinovirus, and influenza virus (P = .062-.093), while men with influenza virus-positive FRI episodes tended be protected against subsequent infection with adenovirus (P = .044) and influenza virus (P = .081). CONCLUSION: Prior adenovirus or influenza virus infection conferred cross-protection against subsequent FRI episodes relative to prior infection due to other circulating viruses.

Association between micronutrient deficiency and acute respiratory infections in healthy adults: a systematic review of observational studies.

BACKGROUND: Acute respiratory infections (ARI), including the common cold causes significant morbidity and economical losses globally. Micronutrient deficiency may increase ARI incidence risk and its associated duration and severity among healthy adults, but evidence are inconclusive. This study aims to systematically review all observations on the association between single micronutrient deficiency and ARI incidence, duration and severity in healthy adults. METHODS: Systematic literature searches were conducted in PubMed, Cochrane Library, Embase and Scopus databases. Eligible studies were assessed for the reporting and methodological quality. Adjusted summary statistics with their relevant 95% confidence intervals or interquartile ranges were extracted for the outcomes of interest. RESULTS: The literature search identified 423 unique studies. Of which, only eight studies were eligible and included in the final review. Only vitamin D deficiency (VDD) was observed among these eight studies. There were no eligible studies that focused on the association between other single micronutrient deficiency and ARI. The review found mixed observations on ARI incidence, and a lack of evidence on its associated severity to conclude the association between VDD and these outcomes. However, existing evidence consistently suggested that VDD is likely to lead to longer ARI duration (median duration in days: deficient group, 4 to 13; non-deficient groups, 2 to 8). CONCLUSION: This review found that VDD may be associated to longer ARI duration, but its effect on ARI incidence and its associated severity among healthy adults remains inconclusive. This review also highlighted the lack of a consistent regional and/or global definition for micronutrient sufficiency, and that future studies should explore and conclude the association between other micronutrient deficiency and ARIs in healthy adults before considering supplementation for ARI prevention and management.

Progress and Challenges towards Point-of-Care Diagnostic Development for Dengue.

Dengue detection strategies involve viral RNA, antigen, and/or antibody detection. Each strategy has its advantages and disadvantages. Optimal, user-friendly, rapid diagnostic tests based on immunochromatographic assays are pragmatic point-of-care tests (POCTs) in regions where dengue is endemic where there are limited laboratory capabilities and optimal storage conditions. Increasingly, there is a greater public health significance for a multiplexing assay that differentiates dengue from Zika or pathogens with similar clinical presentations. Although there have been many assay/platform developments toward POCTs, independent validation and implementation remain very limited. This review highlights the current key progress and challenges toward the development of a dengue POCT.

Assessing changes in knowledge, attitude and practices on dengue diagnosis and management among primary care physicians after the largest dengue epidemic in Singapore.

BACKGROUND: Dengue results in high morbidity and mortality globally. The knowledge, attitude and practices (KAP) of dengue management, including diagnosis, among primary care physicians (PCPs) are important to reduce dengue transmission and burden. However, there is a lack of understanding on the impact of dengue epidemic on dengue management. Hence, the aim of this study is to examine the changes in KAP on dengue management among PCPs before and after the largest dengue epidemic in 2013 in Singapore. METHODS: Surveys were mailed to 2000 and 1514 PCPs registered under the Singapore Medical Council in March of year 2011 and 2014, respectively. Survey data were then collected between April and June of that year. Chi-square or Fisher's exact test was used for comparing categorical variables. A multivariate logistic regression model was implemented to determine independent factors for frequent use of dengue diagnostic tests (DDTs). All tests were conducted at 5% level of significance. Adjusted odds ratio and corresponding 95% confidence intervals were reported, where applicable. Qualitative data were descriptively coded for themes and analysis. RESULTS: Among PCPs surveyed in 2011 and 2014, 89.9% and 86% had good knowledge on dengue management respectively. The usage of DDTs had increased significantly in 2014 (N = 164;56%) as compared to 2011 (N = 107;29.5%) in both private and public clinics (p < 0.001). Dengue Duo point-of-care test (POCT) kits was independently associated with frequent use of DDTs (adjusted odds ratio = 2.15; 95% confidence interval = 1.25-3.69). There was a significant reduction in referral of dengue patients to hospital (31.4% in 2011; 13.3% in 2014; p < 0.001), and a significant increase in frequency of clinic follow-ups (18.4% in 2011; 28.5% in 2014; p = 0.003). One key theme highlighted was that dengue management can be improved with availability of POCT kit, better awareness of the disease and any revised clinical guidelines. CONCLUSION: The knowledge on dengue management remained high, while the attitude and practices, particularly on the usage of DDTs improved significantly after a large epidemic. Furthermore, PCPs had more confident in managing dengue patients in primary care settings and in educating patients on the importance of vector control and dengue warning signs to reduce dengue transmission and burden.

The epidemiology and transmission of methicillin-resistant Staphylococcus aureus in the community in Singapore: study protocol for a longitudinal household study.

BACKGROUND/AIM: Methicillin-resistant Staphylococcus aureus (MRSA) is one of the most common multidrug-resistant organisms in healthcare settings worldwide, but little is known about MRSA transmission outside of acute healthcare settings especially in Asia. We describe the methods for a prospective longitudinal study of MRSA prevalence and transmission. METHODS: MRSA-colonized individuals were identified from MRSA admission screening at two tertiary hospitals and recruited together with their household contacts. Participants submitted self-collected nasal, axilla and groin (NAG) swabs by mail for MRSA culture at baseline and monthly thereafter for 6 months. A comparison group of households of MRSA-negative patients provided swab samples at one time point. In a validation sub-study, separate swabs from each site were collected from randomly selected individuals, to compare MRSA detection rates between swab sites, and between samples collected by participants versus those collected by trained research staff. Information on each participant's demographic information, medical status and medical history, past healthcare facilities usage and contacts, and personal interactions with others were collected using a self-administered questionnaire. DISCUSSION/CONCLUSION: Understanding the dynamics of MRSA persistence and transmission in the community is crucial to devising and evaluating successful MRSA control strategies. Close contact with MRSA colonized patients may to be important for MRSA persistence in the community; evidence from this study on the extent of community MRSA could inform the development of household- or community-based interventions to reduce MRSA colonization of close contacts and subsequent re-introduction of MRSA into healthcare settings. Analysis of longitudinal data using whole-genome sequencing will yield further information regarding MRSA transmission within households, with significant implications for MRSA infection control outside acute hospital settings.

Critical care for dengue in adult patients: an overview of current knowledge and future challenges.

PURPOSE OF REVIEW: This review aims to update and summarize the current knowledge about clinical features, management, and risk factors of adult dengue patients requiring intensive care with consequently higher risk of mortality. RECENT FINDINGS: Increasingly, there are more adult dengue patients who require intensive care. This may be due to a shift in epidemiology of dengue infection from mainly a pediatric disease toward adult disease. In addition, multiorgan dysfunction was observed to be a key risk factor for ICU admission and mortality. This may be due to older adults having preexisting comorbidities that potentially predispose to have multiple severe organ impairment. Interventions remain largely supportive but also require more evidence-based trials and treatment protocols. SUMMARY: These findings highlight the common clinical manifestations of adult dengue patients and the challenges of clinical management in ICU. Risk factors for prediction of adult dengue patients who require ICU are available, but they lack validation and consistent study design for meta-analysis in future. Early recognition of these risk factors, with close monitoring and prompt clinical management, remains critical to reduce mortality.

Risk factors for febrile respiratory illness and mono-viral infections in a semi-closed military environment: a case-control study.

BACKGROUND: Febrile respiratory illness (FRI) results in substantial burden in semi-closed environments. Tackling risk factors may reduce transmission and infection. However, risk factors involved in one setting may not be generalizable in all settings due to differences in climate, residential environment, population genetic and cultural backgrounds. This study aims to identify risk factors of FRI and mono-viral infections in a tropical military environment. METHODS: From year 2009 to 2012, military personnel with temperature ≥37.5 °C, cough and/or sore throat, and personnel with no fever or no respiratory symptoms were recruited as cases and controls, respectively. Subjects provided nasal wash specimens and answered a standardized questionnaire. Resplex assays were used to determine the viral etiologies. Descriptive, univariate and multivariate analyses of the variables were performed using appropriate descriptive tests and logistic regression modelling, respectively, with R program. RESULTS: A total of 7,743 FRI cases and 1,247 non-FRI study controls were recruited. Increasing age [adjusted odds ratio (AOR) = 1.03; 95 % confidence interval (CI) = 1.01-1.05], recruit camp (AOR = 4.67; 95 % CI = 3.99-5.46) and smoker (AOR = 1.31; 95 % CI = 1.13-1.52) were independent risk factors of FRI. Malay ethnicity was positively associated with influenza A(H1N1)pdm09 (AOR = 1.50; 95 % CI = 1.04-2.15) and coxsackie/echovirus (AOR = 1.67; 95 % CI = 1.19-2.36) mono-infection. Significant contact risk factors were stay-out personnel with ill household member (AOR = 4.96; 95 % CI = 3.39-7.24), and stay-in personnel with ill bunkmate and household member (AOR = 3.55; 95 % CI = 2.57-4.91). Staying in camp with none ill in bunk and at home was a protective factor against FRI (AOR = 0.80; 95 % CI = 0.64-0.99). These contact risk factors were similarly observed for the five most common viruses detected, namely adenovirus, rhinoviruses, influenza A and B, and coxsackie/echovirus. CONCLUSION: Increasing age, smoker, recruit-camp, stay-out personnel with ill household members and stay-in personnel with ill bunkmates were independent risk factors of FRI in a semi-closed military environment. Early identification and isolation of ill personnel from their bunk may be effective to prevent and reduce transmission and disease burden.

Current knowledge, attitude and behaviour of hand and food hygiene in a developed residential community of Singapore: a cross-sectional survey.

BACKGROUND: Diarrhoea incidence has been increasing progressively over the past years in developed countries, including Singapore, despite the accessibility and availability to clean water, well-established sanitation infrastructures and regular hygiene promotion. The aim of this study is to determine the current knowledge, attitude and behaviour of hand and food hygiene, and the potential risk factors of diarrhoea in a residential community of Singapore. METHODS: A cross-sectional study was conducted within a residential area in the west of Singapore from June to August 2013. A total of 1,156 household units were randomly sampled and invited to participate in an interviewer-assisted survey using standardised questionnaires. Descriptive, univariate and multivariate analyses were performed using descriptive statistics, Fisher's Exact test and multivariate logistic regression modelling, respectively. R program was used for all statistical analysis. All tests were conducted at 5% level of significance with 95% confidence intervals (CI) reported where applicable. RESULTS: A total of 240 units (20.8%) consented and responded to the survey invitation. About 77% of the expected knowledge and attitude were observed in at least 80% of the participants, compared to only about 31% of the expected behaviours and practises. Being single [adjusted odds ratio (AOR) = 2.29; 95% CI = 1.16-4.48], having flu in the past six month (AOR = 3.24; 95% CI = 1.74-6.06), preferred self-medication (AOR = 2.07; 95% CI = 1.06-4.12) were risk factors of diarrhoea. Washing hands with water before attending to children or sick persons (AOR = 0.30; 95% CI = 0.11-0.82), washing hands with water (AOR = 0.16; 95% CI = 0.05-0.45) and water with soap (AOR = 0.29; 95% CI = 0.12-0.72) after attending to children or sick persons, and hand washing between 30 s to a minute (AOR = 0.44; 95% CI = 0.20-0.90) were protective factors against diarrhoea. CONCLUSIONS: Good knowledge and attitude of the participants did not positively translate into high compliance and motivation to perform good hygiene practices. This observation may have resulted in a significant extent on the increasing diarrhoea incidences. Current interventions may be improved with more active community partnership among the residents, schools and the relevant social organizations, to raise awareness on the importance of compliance to good hygiene practices, and the risk factors of diarrhoea. A large case-control study would be required to validate these findings in future.

Early clinical and laboratory risk factors of intensive care unit requirement during 2004-2008 dengue epidemics in Singapore: a matched case-control study.

BACKGROUND: Dengue infection can result in severe clinical manifestations requiring intensive care. Effective triage is critical for early clinical management to reduce morbidity and mortality. However, there is limited knowledge on early risk factors of intensive care unit (ICU) requirement. This study aims to identify early clinical and laboratory risk factors of ICU requirement at first presentation in hospital and 24 hours prior to ICU requirement. METHOD: A retrospective 1:4 matched case-control study was performed with 27 dengue patients who required ICU, and 108 dengue patients who did not require ICU from year 2004-2008, matched by year of dengue presentation. Univariate and multivariate conditional logistic regression were performed. Optimal predictive models were generated with statistically significant risk factors identified using stepwise forward and backward elimination method. RESULTS: ICU dengue patients were significantly older (P=0.003) and had diabetes (P=0.031), compared with non-ICU dengue patients. There were seven deaths among ICU patients at median seven days post fever. At first presentation, the WHO 2009 classification of dengue severity was significantly associated (P<0.001) with ICU, but not the WHO 1997 classification. Early clinical risk factors at presentation associated with ICU requirement were hematocrit change ≥20% concurrent with platelet <50 K [95% confidence-interval (CI)=2.46-30.53], hypoproteinemia (95% CI=1.09-19.74), hypotension (95% CI=1.83-31.79) and severe organ involvement (95% CI=3.30-331). Early laboratory risk factors at presentation were neutrophil proportion (95% CI=1.04-1.17), serum urea (95% CI=1.02-1.56) and alanine aminotransferase level (95% CI=1.001-1.06). This predictive model has sensitivity and specificity up to 88%. Early laboratory risk factors at 24 hours prior to ICU were lymphocyte (95% CI=1.03-1.38) and monocyte proportions (95% CI=1.02-1.78), pulse rate (95% CI=1.002-1.14) and blood pressure (95% CI=0.92-0.996). This predictive model has sensitivity and specificity up to 88.9% and 78%, respectively. CONCLUSIONS: This is the first matched case-control study, to our best knowledge, that identified early clinical and laboratory risk factors of ICU requirement during hospitalization. These factors suggested differential pathophysiological background of dengue patients as early as first presentation prior to ICU requirement, which may reflect the pathogenesis of dengue severity. These risk models may facilitate clinicians in triage of patients, after validating in larger independent studies.

IgG, IgM, and Nonstructural Protein 1 Response Profiles after Receipt of Tetravalent Dengue Vaccine TAK-003 in a Phase 2 Randomized Controlled Trial.

The profiles of vaccine-induced dengue antibodies may differ from those produced following natural infection and could potentially interfere with the interpretation of diagnostic tests. We assessed anti-dengue IgG and IgM antibodies, and nonstructural protein 1 antigen profiles in the serum of adults who received a single dose of the tetravalent dengue vaccine TAK-003 as either an initially developed high-dose formulation or the standard approved formulation in a phase 2 study in Singapore (#NCT02425098). Immunoglobulin G and IgM profiles during the first 30 days postvaccination varied by baseline serostatus (microneutralization assay). Nonstructural protein 1 antigen was not detected in the serum of any participants. Vaccine-induced IgG and IgM antibodies can affect serological confirmation of subsequent dengue infection in vaccinees. These results highlight the limitations of using serological tests for dengue diagnosis, particularly in a postvaccination setting, and emphasize the need for more sensitive antigen- and molecular-based testing for accurate dengue diagnosis.

Factors of COVID-19 Vaccine Perception among Transport Drivers in Singapore: A Cross-Sectional Pilot Study.

Transport drivers have high risk of exposure to SARS-CoV-2 during COVID-19 pandemic. Vaccines can reduce disease severity. However, COVID-19 vaccine perception among transport drivers is unknown. To identify the key factors influencing vaccine perception of transport drivers in Singapore, a cross-sectional pilot study was conducted. One hundred four completed survey responses were collected between September 2021 and February 2022. Using multivariable logistic regression, education, general vaccine knowledge and attitude, practice of social distancing, misinformation of rare vaccine side effects, and perceiving the pandemic situation to be severe were independently associated with vaccine perception. Despite high vaccination coverage, there were substantial poor vaccine perception, vaccine hesitancy, and unwillingness to take third dose. Vaccination rate may thus not be an accurate reflection of true vaccine acceptance. Communication strategies need to focus on correcting knowledge gaps, instilling collectivist attitudes, and highlighting the importance of vaccination over social distancing to enhance booster uptake rate.

A novel bidirectional LSTM deep learning approach for COVID-19 forecasting.

COVID-19 has resulted in significant morbidity and mortality globally. We develop a model that uses data from thirty days before a fixed time point to forecast the daily number of new COVID-19 cases fourteen days later in the early stages of the pandemic. Various time-dependent factors including the number of daily confirmed cases, reproduction number, policy measures, mobility and flight numbers were collected. A deep-learning model using Bidirectional Long-Short Term Memory (Bi-LSTM) architecture was trained on data from 22nd Jan 2020 to 8 Jan 2021 to forecast the new daily number of COVID-19 cases 14 days in advance across 190 countries, from 9 to 31 Jan 2021. A second model with fewer variables but similar architecture was developed. Results were summarised by mean absolute error (MAE), root mean squared error (RMSE), mean absolute percentage error (MAPE), and total absolute percentage error and compared against results from a classical ARIMA model. Median MAE was 157 daily cases (IQR: 26-666) under the first model, and 150 (IQR: 26-716) under the second. Countries with more accurate forecasts had more daily cases and experienced more waves of COVID-19 infections. Among countries with over 10,000 cases over the prediction period, median total absolute percentage error was 33% (IQR: 18-59%) and 34% (IQR: 16-66%) for the first and second models respectively. Both models had comparable median total absolute percentage errors but lower maximum total absolute percentage errors as compared to the classical ARIMA model. A deep-learning approach using Bi-LSTM architecture and open-source data was validated on 190 countries to forecast the daily number of cases in the early stages of the COVID-19 outbreak. Fewer variables could potentially be used without impacting prediction accuracy.

The knowledge, attitudes and practices of hand, foot, and mouth disease prevention strategies amongst parents and educators of children under 5 years amidst COVID-19 pandemic: A cross-sectional study.

Background: Hand, foot, and mouth disease (HFMD) is endemic in Singapore. Prevention efforts have been ramped up since major outbreaks in the early 2000's. This study aims to assess the current knowledge, and attitudes towards and practise (KAP) levels of HFMD prevention strategies (HFMD-PS) amongst parents and teachers of children under 5 years amidst the COVID-19 pandemic. Methods and results: A convenience sample of 240 teachers and 404 parents responded to a self-administered standardised questionnaire between mid-October and December 2020. A scoring framework was used to assess responses in the 'knowledge', 'attitude', and 'practice' domains. A multivariable analysis was adjusted for ethnicity and attitudes towards getting children to follow proper handwashing steps and regularly disinfecting children's toys amongst parents, knowledge about HFMD's infectious period, and the responses to a child turning symptomatic in the childcare centre amongst teachers. Existing levels of knowledge and attitudes of parents and teachers were not high, and only a small proportion practised high levels of prevention measures (99 parents and 28 teachers). Key facilitators for a higher practise level in parents include the following: (1) awareness of regular liquid soap's efficacy as a disinfectant, (2) toy cleaning before and after playtime, and (3) the cleaning agent used for this practise. Teachers had no significant factors associated with higher practise levels. Conclusion: This study suggested potential gaps between positive knowledge and attitudes towards prevention strategies and their actual adoption levels in homes and childcare centres during COVID-19 pandemic. These evidences suggest the importance of continuous promotion of HFMD prevention practise in homes and childcare centres, even amidst pandemics.

Knowledge, attitudes and practices of dengue prevention between dengue sustained hotspots and non-sustained hotspots in Singapore: a cross-sectional study.

Dengue sustained hotspots (SHS) have resulted in a significant public health burden. In our study, we aimed to (1) compare knowledge, attitudes and practices (KAP) scores between SHS and non-sustained hotspots (NSHS); and (2) identify and describe gaps and factors associated with KAP of dengue prevention among SHS residents residing in Singapore. A cross-sectional study with convenience sampling was conducted using digital survey in randomly selected SHS and NSHS residential areas, consisting of residents aged 21 or older and who had been residing in their existing housing unit in 2019 and 2020. Chi-square test and T-test were used for comparison analysis of categorical and continuous variables, respectively. A total of 466 respondents completed the self-administered, anonymous survey. There were no significant difference in mean scores for Knowledge [SHS(24.66) vs. NSHS(24.37); P: 0.18], Attitudes [SHS(10.38) vs NSHS(10.16); P: 0.08] and Practices [SHS(9.27) vs NSHS(8.80); P: 0.16] sections. Significant SHS-associated factors identified were age group 41-50 years old [95%CI: 1.25-5.03], Malay (95%CI: 0.17-0.98), up to secondary school education (95%CI: 0.07-0.65), private condominium (95%CI: 1.17-3.39), residing in same household unit for 2-5 years (95%CI: 2.44-6.88), respondents who know that mosquito can breed in open container with stagnant water (95%CI: 0.06-0.98), disagree that reducing Aedes mosquitoes is the only way to prevent dengue: (95%CI: 1.19-3.00) and go to clinic/hospital even without severe symptoms: (95%CI: 0.39-0.95). These independent factors associated with dengue sustained hotspots may influence the risk of dengue transmission in residential areas.