From SARS in 2003 to H1N1 in 2009: lessons learned from Taiwan in preparation for the next pandemic.

In anticipation of a future pandemic potentially arising from H5N1, H7N9 avian influenza or Middle East Respiratory Syndrome, and in large part in response to severe acute respiratory syndrome (SARS) in 2003, the city of Taipei, Taiwan, has developed extensive new strategies to manage pandemics. These strategies were tested during the 2009 H1N1 outbreak. This article assesses pandemic preparedness in Taipei in the wake of recent pandemic experiences in order to draw lessons relevant to the broader international public health community. Drawing on Taiwan and Taipei Centers for Disease Control data on pandemic response and control, we evaluated the effectiveness of the changes in pandemic response policies developed by these governments over time, emphasizing hospital and medical interventions with particular attention paid to Traffic Control Bundling. SARS and H1N1 2009 catalysed the Taiwan and Taipei CDCs to continuously improve and adjust their strategies for a future pandemic. These new strategies for pandemic response and control have been largely effective at providing interim pandemic containment and control, while development and implementation of an effective vaccination programme is underway. As Taipei's experiences with these cases illustrate, in mitigating moderate or severe pandemic influenza, a graduated process including Traffic Control Bundles accompanied by hospital and medical interventions, as well as school- and community-focused interventions, provides an effective interim response while awaiting vaccine development. Once a vaccine is developed, to maximize pandemic control effectiveness, it should be allocated with priority given to vulnerable groups, healthcare workers and school children.

Smoking increases risk of recurrence after successful anti-tuberculosis treatment: a population-based study.

OBJECTIVE: To investigate whether tobacco smoking increases the risk of tuberculosis (TB) recurrence and identify factors associated with TB recurrence among adults who had successfully completed anti-tuberculosis treatment in Taipei, Taiwan. METHODS: Recurrence was defined as a new clinical or microbiological diagnosis of TB requiring the start of a new course of treatment in a patient who had satisfactorily completed treatment for a previous TB episode. Cox proportional hazard models were used to calculate adjusted hazard ratios (aHRs) for recurrence. RESULTS: We followed 5567 adults for recurrence after successful anti-tuberculosis treatment. The mean age was 58.5 years; 62.9% were male. Overall, 84 (1.5%) had a recurrence of TB during follow-up. The incidence of TB recurrence was 4.9 episodes/1000 person-years of follow-up. Cox proportional hazards regression showed that after controlling for other variables, the risk of TB recurrence among subjects who smoked >10 cigarettes a day was double that of never/former smokers. Other independent risk factors significantly associated with TB recurrence were homelessness (aHR 3.75, 95%CI 1.17-12.07), presence of comorbidities (aHR 2.66, 95%CI 1.22-5.79) and a positive acid-fast bacilli smear (aHR 2.27, 95%CI 1.47-3.49). CONCLUSION: Smoking >10 cigarettes a day was significantly associated with TB recurrence. To reduce the risk of recurrence, we recommend including effective measures of smoking cessation in TB control programmes, as recommended by the World Health Organization Stop TB Strategy.

Bacteria killing nanotechnology Bio-Kil effectively reduces bacterial burden in intensive care units.

A contaminated hospital environment has been identified as an important reservoir of pathogens causing healthcare-associated infections. This study is to evaluate the efficacy of bacteria killing nanotechnology Bio-Kil on reducing bacterial counts in an intensive care unit (ICU). Two single-bed rooms (S-19 and S-20) in the ICU were selected from 7 April to 27 May 2011. Ten sets of new textiles (pillow cases, bed sheets, duvet cover, and patient clothing) used by patients in the two single-bed rooms were provided by the sponsors. In the room S-20, the 10 sets of new textiles were washed with Bio-Kil; the room walls, ceiling, and air-conditioning filters were treated with Bio-Kil; and the surfaces of instruments (respirator, telephone, and computer) were covered with Bio-Kil-embedded silicon pads. Room S-19 served as the control. We compared the bacterial count on textiles and environment surfaces as well as air samples between the two rooms. A total of 1,364 samples from 22 different sites in each room were collected. The mean bacterial count on textiles and environmental surfaces in room S-20 was significantly lower than that in room S-19 (10.4 vs 49.6 colony-forming units [CFU]/100 cm(2); P < 0.001). Room S-20 had lower bacterial counts in air samples than room S-19 (33.4-37.6 vs 21.6-25.7 CFU/hour/plate; P < 0.001). The density of microbial isolations was significantly greater among patients admitted to room S-19 than those to room S-20 (9.15 vs 5.88 isolates per 100 patient-days, P < 0.05). Bio-Kil can significantly reduce bacterial burden in the environment of the ICU.

Prognostic factors associated with mortality before and during anti-tuberculosis treatment.

OBJECTIVE: To identify factors associated with death before the start of anti-tuberculosis treatment, and early and late during treatment, among adult Taiwanese with culture-positive pulmonary tuberculosis (PTB). METHOD: All adult culture-positive PTB patients in Taipei, Taiwan, were included in a retrospective cohort study in 2005-2010. RESULTS: Of 4438 patients (mean age 64.6 years, 70.6% male), 76.8% were successfully treated, 5.4% died before start of treatment, 9.0% died within 8 weeks of treatment initiation and 8.8% died >8 weeks after treatment initiation. After controlling for potential confounders, age ≥ 65 years and male sex were associated with higher risks of death at all time periods investigated. High school education or higher reduced the risk of death before the start of and during treatment, while unemployment increased the risk of mortality during treatment. Cavity on chest X-ray and positivity for acid-fast bacilli were associated with lower risk of mortality before the start of treatment. CONCLUSION: To lower mortality among adult culture-positive PTB patients, it is imperative for clinicians to maintain high awareness of TB and provide more intensive care early, especially for men, the elderly and people with lower socio-economic status (e.g., the unemployed and less educated).

DOT associated with reduced all-cause mortality among tuberculosis patients in Taipei, Taiwan, 2006-2008.

OBJECTIVE: To determine whether patients receiving directly observed treatment (DOT) had lower all-cause mortality than those treated with self-administered treatment (SAT) and to identify factors associated with mortality among tuberculosis (TB) patients. DESIGN: All TB patients in Taipei, Taiwan, diagnosed between 2006 and 2008 were included in a retrospective cohort study. RESULTS: Among 3624 TB patients, 45.5% received DOT, which was disproportionately offered to older patients and those with more underlying illness and severe TB disease. After controlling for patients' sociodemographic factors, clinical findings and underlying comorbidities, the odds of death were 40% lower (aOR 0.60, 95%CI 0.5-0.8) among patients treated with DOT than those on SAT. After adjusting for DOT, independent predictors of death included non-Taiwan birth, increasing age, male, unemployment, end-stage renal disease requiring dialysis, malignancy, acid-fast bacilli smear positivity and pleural effusion. CONCLUSION: DOT was associated with lower all-cause mortality after controlling for confounding factors. DOT should be expanded in Taiwan to improve critical treatment outcomes among TB patients.

Taiwan's traffic control bundle and the elimination of nosocomial severe acute respiratory syndrome among healthcare workers.

The traffic control bundle consists of procedures designed to help prevent epidemic nosocomial infection. We retrospectively studied the serial infection control measures to determine factors most effective in preventing nosocomial infections of healthcare workers (HCWs) during the 2003 Taiwanese severe acute respiratory syndrome (SARS) epidemic. Fever screening stations, triage of fever patients, separating SARS patients from other patients, separation of entrances and passageways between patients and HCWs, and increasing hand-washing facilities all demonstrated a protective effect for HCWs (univariate analysis; P<0.05). By multiple logistic regression: (i) checkpoint alcohol dispensers for glove-on hand rubbing between zones of risk, and (ii) fever screening at the fever screen station outside the emergency department, were the significant methods effectively minimising nosocomial SARS infection of HCWs (P<0.05). The traffic control bundle should be implemented in future epidemics as a tool to achieve strict infection control measures.

Gastroenteritis in a Taipei emergency department: aetiology and risk factors.

A matched case-control study was used to determine pathogens and risk factors associated with gastroenteritis in a Taipei Emergency Department. Viruses (40.0%) were the leading cause of gastroenteritis, with noroviruses the most prevalent (33.2%). Bacteria were found in 26.0% of all cases, mostly suspected diarrheagenic E. coli (22.2%), followed by Salmonella spp. (5.4%) and Vibrio parahaemolyticus (4.2%). Giardia lamblia was identified in 16.4% of all cases. Statistical significance was noted for seven risk factors: taking antacids before gastroenteritis (OR = 3.91; 95% CI, 2.13, 7.15), other household members with gastroenteritis (OR = 5.18; 95% CI, 2.09, 12.85), attending a banquet (OR = 1.93; 95% CI, 1.25, 2.98), eating out (OR = 2.35; 95% CI, 1.30, 4.23), drinking bottled water (OR = 1.72; 95% CI, 1.07, 2.75), eating honey peaches (OR = 3.26; 95% CI, 1.24, 8.58), and eating raw oysters (OR = 3.24; 95% CI, 1.02, 10.28). Eating out was identified as the highest risk behavior, as measured by population attributable risk fraction (PAR) (50.9%). Respective PAR values for drinking bottled water, attending a banquet and taking antacids before illness were 19.7%, 19.6% and 17.6%. Of these, additional research on bottled water appears to be the highest priority, because this is the first time it has been identified as a risk factor for gastroenteritis.

Fever of unknown origin in Taiwan.

BACKGROUND: Fever of unknown origin (FUO) is a challenging problem worldwide. There was no prospective study of FUO in the past two decades in Taiwan. A prospective study was conducted. MATERIALS AND METHODS: The prospective study was undertaken from March 2001 to May 2002. All patients fulfilling the modified criteria for FUO, either admitted, referred or consulted in a medical center in southern Taiwan, were enrolled for analysis. RESULTS: A total of 94 cases met the criteria of FUO. The final diagnoses of FUO consisted of 54 infectious diseases (57.4%), 8 hematologic/neoplastic (8.5%), 7 noninfectious inflammatory (7.4%), 8 miscellaneous (8.5%) and 17 undiagnosed (18.1%) cases. The single most common cause of FUO was tuberculosis. Some infectious diseases, such as rickettsiosis and melioidosis, were rarely reported in western countries. Three patients with hemophagocytotic syndrome without ascertainable etiologies were present with FUO in this study. Between the patients with and those without a final diagnosis, the short-term survival (3 months) was compared by the Kaplan-Meier analysis, which revealed no difference. CONCLUSIONS: Mycobacteriosis is still the leading cause of FUO in Taiwan and it is important to identify this treatable disease from all causes of FUO. This study has showed geographical variation among the studies of FUO.

Using an integrated infection control strategy during outbreak control to minimize nosocomial infection of severe acute respiratory syndrome among healthcare workers.

Healthcare workers (HCWs) are at risk of acquiring severe acute respiratory syndrome (SARS) while caring for SARS patients. Personal protective equipment and negative pressure isolation rooms (NPIRs) have not been completely successful in protecting HCWs. We introduced an innovative, integrated infection control strategy involving triaging patients using barriers, zones of risk, and extensive installation of alcohol dispensers for glove-on hand rubbing. This integrated infection control approach was implemented at a SARS designated hospital ('study hospital') where NPIRs were not available. The number of HCWs who contracted SARS in the study hospital was compared with the number of HCWs who contracted SARS in 86 Taiwan hospitals that did not use the integrated infection control strategy. Two HCWs contracted SARS in the study hospital (0.03 cases/bed) compared with 93 HCWs in the other hospitals (0.13 cases/bed) during the same three-week period. Our strategy appeared to be effective in reducing the incidence of HCWs contracting SARS. The advantages included rapid implementation without NPIRs, flexibility to transfer patients, and re-inforcement for HCWs to comply with infection control procedures, especially handwashing. The efficacy and low cost are major advantages, especially in countries with large populations at risk and fewer economic resources.

Residential water supply as a likely cause of community-acquired Legionnaires' disease in an immunocompromised host.

A 69-year-old man with Sweet's syndrome and myelodysplastic syndrome presented with pneumonia and respiratory distress. He had been taking corticosteroids and methotrexate. The diagnosis of Legionnaires' disease was established by the isolation of Legionella pneumophila serogroup 6 from sputum and a fourfold seroconversion of Legionella antibodies to 1:512. Legionella pneumophila serogroup 6 was isolated from faucets in two homes owned by the patient. Strains of Legionella pneumophila serogroup 6 isolated from the patient's sputum and from one home were demonstrated to be genetically identical by pulsed-field gel electrophoresis but different from strains found in the other home and in a hospital outpatient clinic that he visited. This case illustrates an emerging public health issue concerning acquisition of community-acquired Legionnaires' disease from the homes of immunocompromised hosts. This is the first such case reported in Asia.

Increase of mitochondrial DNA in blood cells of patients with Leber's hereditary optic neuropathy with 11778 mutation.

AIMS: To investigate the change of mitochondrial DNA (mtDNA) content in Leber's hereditary optic neuropathy (LHON) with 11778 mutation. METHODS: Mitochondrial DNA content in 27 LHON patients with 11778 mutation, 26 asymptomatic maternal relatives, and 23 normal controls was measured using a competitive polymerase chain reaction (PCR) method. RESULTS: The mean relative content of mtDNA (with respect to the beta actin gene) in LHON patients, asymptomatic maternal relatives, and normal controls was 245.5 (162.3), 238.2 (118.4), and 156.5 (61.6), respectively. There was a statistically significant difference between patients and controls and between relatives and controls. However, no statistically significant difference between patients and unaffected relatives was found. There was no statistically significant difference in the relative content of mtDNA between all males and females carrying 11778 mtDNA mutation CONCLUSION: The results suggest that the increase in mtDNA content in LHON patients with 11778 mtDNA mutation may be due to a compensatory effect for respiratory chain defects of mitochondria. However, the increase of mtDNA content is the result rather than the cause of defective mtDNA. It still cannot explain the pathogenesis of LHON.

Clinicopathologic factors related to apoptosis in retinoblastoma.

PURPOSE: To investigate the presence of apoptosis in retinoblastoma and its correlation with other pathologic and prognostic factors. METHODS: The pathologic and admission records of 25 patients with a pathologically confirmed diagnosis of retinoblastoma were reviewed. TUNEL (TdT dUTP nick end labeling) staining was used to examine apoptosis in the pathologic slides of these 25 patients. The association between apoptosis and clinicopathologic factors was examined with chi-square, Fisher's exact, and Student's t tests. RESULTS: Of the 25 specimens tested, 11 were TUNEL stain-positive for the presence of apoptotic cells. Apoptosis was found more frequently in younger patients and within rosettes, although these associations were not statistically significant. Apoptosis was not associated with tumor invasion or metastasis. CONCLUSION: Apoptotic cells were found in 11 of 25 retinoblastoma specimens. Apoptosis tends to occur in young patients and be distributed within rosettes.

Optimal treatment for distal ureteral calculi: extracorporeal shockwave lithotripsy versus ureteroscopy.

BACKGROUND: The optimal treatment for distal ureteral calculi remains controversial. We present data from our institution to compare the efficacy of extracorporeal shockwave lithotripsy (SWL) and ureteroscopy with different lithotripsy modalities (URSL). METHODS: From January 1994 to September 1997, 954 distal ureteral calculi were treated at our institution using in situ SWL (Siemens Lithostar) in 524 patients and ureteroscopy (Wolf 8.0F instrument and Swiss Lithoclast) in 430 patients. Stone sizes and patient ages were similar in these two groups. RESULTS: In the SWL group, the 3-month stone-free rate was 87%, and the effectiveness quotient (EQ) was 68.7%. In the URSL group, there was a 96% stone-free rate with an EQ of 92.1%. The SWL treatment was more expensive than URSL. CONCLUSION: At our institution, ureteroscopy is more efficacious than SWL for the treatment of distal ureteral calculi. In selected patients who had stones >10 mm with evidence of impaction and severe colic pain, we strongly suggest that URSL is the best choice.

Legionnaires' disease in an immunocompetent young adult.

Infection with Legionella pneumophila (LP) is a rare cause of pneumonia in previously healthy young adults. Pleural effusion is relatively common in Legionnaires' disease but is usually clinically insignificant. Herein we describe an immunocompetent, 19-year-old female with LP respiratory infection that presented with pleural effusion and mild interstitial infiltrates in the lower lungs. She received 3 weeks' treatment with erythromycin and rifampin and recovered completely. Diagnosis was based on serology testing with a four-fold rise of the antibody titer in the acute and convalescent phase. Legionnaires' disease should be considered in the differential diagnosis of culture-negative pleural effusion in immunocompetent young adults.

Visual acuity and contrast sensitivity in different types of posterior capsule opacification.

PURPOSE: To compare the visual acuity (VA) and contrast sensitivity in 2 types of posterior capsule opacification (PCO) in pseudophakic eyes before and after neodymium:YAG (Nd:YAG) capsulotomy and to evaluate vision test results after Nd:YAG capsulotomy. SETTING: Department of Ophthalmology, Taipei Veterans General Hospital, National Yang-Ming University, Taipei, Taiwan. METHODS: Fourteen eyes with fibrosis-type PCO and 15 eyes with Elschnig-pearl-type PCO were enrolled prospectively. Before and 1 week after Nd:YAG capsulotomy, VA and contrast sensitivity were assessed using the illiterate E version of the Bailey-Lovie chart and the Vistech VCTS 6000 chart, respectively. RESULTS: Before capsulotomy, the mean logMAR acuity in the group with Elschnig-pearl-type PCO was 0.47 +/- 0.32 (SD) and in the group with fibrosis-type PCO, 0.17 +/- 0.07. The difference between the 2 groups was significant (P =.002). After capsulotomy, there was no significant between-group difference (P >.05). Before capsulotomy, the contrast sensitivity was significantly worse (P <.01) at all spatial frequencies in the group with pearl-type PCO, especially at 6 cycles per degree. After capsulotomy, there was no significant between-group difference (P >.05) at any spatial frequency. CONCLUSIONS: After cataract surgery, patients with pearl-type PCO had lower VA and contrast sensitivity than those with fibrosis-type PCO. An Nd:YAG capsulotomy improved the VA and contrast sensitivity in patients with both types of PCO.

Eosinophilic meningitis caused by Angiostrongylus cantonensis: report of 17 cases.

PURPOSE: To describe two outbreaks of Angiostrongylus cantonensis infection that occurred in Kaohsiung, Taiwan, during 1998 and 1999, and to characterize the source of the outbreaks and the clinical manifestations of the disease. SUBJECTS AND METHODS: We performed a retrospective cohort study among Thai laborers with eosinophilic meningitis who ate raw snails (Ampullarium canaliculatus), as well as an environmental surveillance of larvae in snails. RESULTS: We enrolled 17 Thai laborers in whom severe headache and eosinophilia developed within 4 to 23 days after eating raw snails. Twelve (71%) developed eosinophilic meningitis. Third-stage larvae were found in the cerebrospinal fluids of 2 patients and in all 12 tested snails. Specific antibodies to A. cantonensis were detected in serum from 16 of the patients and in cerebrospinal fluid from 5 of the patients. Central nervous system manifestations included headache (n = 17 [100%]), fever (n = 11 [65%]), Brudzinski's sign/stiff neck (n = 11 [65%]), hyperesthesia (n = 3 [18%]), cranial nerve palsy (n = 2 [12%]), diplopia (n = 2 [12%]), and ataxia (n = 1 [6%]). Laboratory findings included peripheral eosinophilia (n = 15 [88%]) and cerebrospinal fluid eosinophilia (n = 12 [71%]); elevated immunoglobulin (Ig) E levels (n = 13 [100%]); and transient increases in white blood cell count (n = 7 [41%]) and in serum levels of creatine kinase (n = 7 [41%]), transaminase (n = 3 [18%]), and lactate dehydrogenase (n = 2 [12%]). The severity of illness and eosinophilia were correlated with the number of ingested snails. Meningeal and basal ganglion enhancement was noted on magnetic resonance imaging in several patients. Treatment with mebendazole combined with glucocorticosteroids appeared to shorten the course of the infection, but not the number of relapses. The eosinophil count fell to normal within 3 months, but IgE levels remained elevated for as long as 6 months. All patients recovered with minimal neurologic sequelae. CONCLUSION: Eosinophilic meningitis caused by A. cantonensis should be considered in patients who have headache or central nervous system manifestations after eating raw snails.