Clinical manifestations and risk factors of campylobacter gastroenteritis in children in Taiwan.

BACKGROUND: Campylobacteriosis is a common cause of bacterial gastroenteritis worldwide. This study aimed to investigate the potential risk factors, clinical and laboratory manifestations of children with campylobacteriosis under five years old in Taiwan. METHODS: This retrospective case-control study was conducted in ten major hospitals in Taiwan from 2014 to 2017. Laboratory tests and stool specimen were collected and analyzed together with questionnaire survey. Multivariate stepwise logistic regression model was used for identification of risk factors. RESULTS: A total of 64 campylobacteriosis cases were included with a median age of 25 months. We observed a less prolonged vomiting (p = 0.047), more bloody (p < 0.001) and mucoid (p = 0.005) stools, and lower AST levels (p = 0.020) in patients with campylobacteriosis. Lower parental educational attainment (p < 0.001), direct contact with acute gastroenteritis patients (p < 0.001), as well as diarrhea in the mutually cared children (p = 0.007) were linked to campylobacteriosis. Consumption of municipal water (p < 0.001), milk (OR 0.34, 95% CI 0.118-0.979), and soft beverages (OR 0.41, 95% CI 0.192-0.888) were identified as protective factors, while consuming takeout food (p = 0.032) and seafood (p = 0.019) increased risk of campylobacteriosis. CONCLUSIONS: Shorter vomiting duration, bloody and mucoid stool, and less elevated AST levels are manifestations suggestive of campylobacteriosis. Risk factors of campylobacteriosis were low parental educational attainment, direct contact with acute gastroenteritis patients, diarrhea in mutually cared children, takeout food and seafood intake. Potential protective factors include municipal water, milk, and soft beverage intake.

A comprehensive evaluation of COVID-19 policies and outcomes in 50 countries and territories.

The COVID-19 pandemic struck the world unguarded, some places outperformed others in COVID-19 containment. This longitudinal study considered a comparative evaluation of COVID-19 containment across 50 distinctly governed regions between March 2020 and November 2021. Our analysis distinguishes between a pre-vaccine phase (March-November 2020) and a vaccinating phase (December 2020-November 2021). In the first phase, we develop an indicator, termed lockdown efficiency (LE), to estimate the efficacy of measures against monthly case numbers. Nine other indicators were considered, including vaccine-related indicators in the second phase. Linear mixed models are used to explore the relationship between each government policy & hygiene education (GP&HE) indicator and each vital health & socioeconomic (VH&SE) measure. Our ranking shows that surveyed countries in Oceania and Asian outperformed countries in other regions for pandemic containment prior to vaccine development. Their success appears to be associated with non-pharmaceutical interventions, acting early, and adjusting policies as needed. After vaccines have been distributed, maintaining non-pharmacological intervention is the best way to achieve protection from variant viral strains, breakthrough infections, waning vaccine efficacy, and vaccine hesitancy limiting of herd immunity. The findings of the study provide insights into the effectiveness of emerging infectious disease containment policies worldwide.

Clinical and epidemiological features in hospitalized young children with acute gastroenteritis in Taiwan: A multicentered surveillance through 2014-2017.

BACKGROUND/PURPOSE: Acute gastroenteritis (AGE) remains a significant health issue in children. The worldwide evolution of pediatric AGE pathogens had been recorded since the introduction of rotavirus vaccine. Ten years after the rotavirus vaccine was introduced to the private sectors in Taiwan, a nationwide study was conducted to elucidate the epidemiological changes among major AGE pathogens. METHODS: From January 2014 to December 2017, children younger than 5 years old, hospitalized with AGE at 10 hospitals across Taiwan were enrolled. Stool specimens were tested for Salmonella spp., Campylobacter spp., Clostridiodes difficile, norovirus, and rotavirus by polymerase chain reaction (PCR). The epidemiological and clinical information was collected. RESULTS: Enteric pathogen were detected in 1983 (42.2%) of 4700 subjects, with Salmonella spp. (12.5%) being the leading cause of AGE, followed by norovirus (11.2%), rotavirus (8.7%), C. difficile (4.2%), Campylobacter spp. (1.0%), and a mixture of at least 2 of 5 above-mentioned pathogens (4.6%). The case distributions varied across different regions. In eastern Taiwan, rotavirus (21/131, 16.0%) remained the most common pathogen detected. The rotavirus vaccine uptake rate is significantly lower in patients with rotavirus AGE. Besides, rotavirus AGE frequently occurred in children with foreign parent(s), Taiwanese indigenous people, and those with the household monthly income < NT$ 60,000. CONCLUSION: Salmonella spp. and norovirus were two major pathogens of pediatric AGE in Taiwan during 2014-17. Providing low-to middle-income households with free rotavirus vaccine nationwide and an industry-led act to reduce salmonellosis should be considered by the authorities.

Clinical characteristics and risk factors for children with norovirus gastroenteritis in Taiwan.

BACKGROUND: Norovirus is a common acute gastroenteritis (AGE) pathogen across all age groups worldwide, which is difficult to differentiate from other pathogens. This study aimed to understand the clinical characteristics and risk factors of norovirus gastroenteritis among children in Taiwan. METHODS: A prospective AGE surveillance study was conducted in children aged ≤5 years who were hospitalized in 10 major hospitals in Taiwan between 2014 and 2017. The non-AGE control group included healthy children who were matched based on age, gender, season, and geographic area. RESULTS: Overall, 674 norovirus gastroenteritis patients were enrolled. Fever (p < 0.001), mucoid stool (p < 0.001), and bloody stool (p < 0.001) occurred less frequently among norovirus gastroenteritis patients. Norovirus gastroenteritis patients yielded lower CRP values on admission (21.78 ± 36.81 vs. 46.26 ± 58.12 mg/L, p < 0.001) than non-norovirus controls. Norovirus gastroenteritis patients were associated with higher direct contact rates with AGE patients within 1 week (30.5% vs. 0.97%, p < 0.001), lower hand wash rates before meals (21.6% vs. 15.4%, p = 0.001), lower human milk (15.8% vs. 19.8%, p = 0.045) and guava consumption rates (17.8% vs. 24.3%, p = 0.002) than non-AGE participants. CONCLUSIONS: Body temperature, stool characteristics, and CRP value can help distinguish the norovirus from other pathogens. The major risk factor of norovirus AGE is contact with AGE patient. Higher frequency of hand wash, human milk, and guava intake may be protective against norovirus gastroenteritis.

Nonpolio Enterovirus Activity during the COVID-19 Pandemic, Taiwan, 2020.

In Taiwan, lower nonpolio enterovirus activity during the coronavirus disease pandemic in 2020 compared with 2014-2019 might be attributable to adherence to nonpharmaceutical interventions. The preventable fraction among unexposed persons indicated that 90% of nonpolio enterovirus activity might have been prevented during 2014-2019 by adopting the same measures enforced in 2020.

Clinical and economic impact of intensive care unit-acquired bloodstream infections in Taiwan: a nationwide population-based retrospective cohort study.

OBJECTIVES: To estimate the clinical and economic impact of intensive care unit-acquired bloodstream infections in Taiwan. DESIGN: Retrospective cohort study. SETTING: Nationwide Taiwanese population in the National Health Insurance Research Database and the Taiwan Nosocomial Infections Surveillance (2007-2015) dataset. PARTICIPANTS: The first episodes of intensive care unit-acquired bloodstream infections in patients ≥20 years of age in the datasets. Propensity score-matching (1:2) of demographic data, comorbidities and disease severity was performed to select a comparison cohort from a pool of intensive care unit patients without intensive care unit-acquired infections from the same datasets. PRIMARY AND SECONDARY OUTCOME MEASURES: The mortality rate, length of hospitalisation and healthcare cost. RESULTS: After matching, the in-hospital mortality of 14 234 patients with intensive care unit-acquired bloodstream infections was 44.23%, compared with 33.48% for 28 468 intensive care unit patients without infections. The 14-day mortality rate was also higher in the bloodstream infections cohort (4323, 30.37% vs 6766 deaths, 23.77%, respectively; p<0.001). Furthermore, the patients with intensive care unit-acquired bloodstream infections had a prolonged length of hospitalisation after their index date (18 days (IQR 7-39) vs 10 days (IQR 4-21), respectively; p<0.001) and a higher healthcare cost (US$16 038 (IQR 9667-25 946) vs US$10 372 (IQR 6289-16 932), respectively; p<0.001). The excessive hospital stay and healthcare cost per case were 12.69 days and US$7669, respectively. Similar results were observed in subgroup analyses of various WHO's priority pathogens and Candida spp. CONCLUSIONS: Intensive care unit-acquired bloodstream infections in critically ill patients were associated with increased mortality, longer hospital stays and higher healthcare costs.

The effect of preventing subclinical transmission on the containment of COVID-19: Mathematical modeling and experience in Taiwan.

The control strategies preventing subclinical transmission differed among countries. A stochastic transmission model was used to assess the potential effectiveness of control strategies at controlling the COVID-19 outbreak. Three strategies included lack of prevention of subclinical transmission (Strategy A), partial prevention using testing with different accuracy (Strategy B) and complete prevention by isolating all at-risk people (Strategy C, Taiwan policy). The high probability of containing COVID-19 in Strategy C is observed in different scenario, had varied in the number of initial cases (5, 20, and 40), the reproduction number (1.5, 2, 2.5, and 3.5), the proportion of at-risk people being investigated (40%, 60%, 80%, to 90%), the delay from symptom onset to isolation (long and short), and the proportion of transmission that occurred before symptom onset (<1%, 15%, and 30%). Strategy C achieved probability of 80% under advantageous scenario, such as low number of initial cases and high coverage of epidemiological investigation but Strategy B and C rarely achieved that of 60%. Considering the unsatisfactory accuracy of current testing and insufficient resources, isolation of all at-risk people, as adopted in Taiwan, could be an effective alternative.

Long-term effectiveness of pentavalent and monovalent rotavirus vaccines against hospitalization in Taiwan children.

BACKGROUND: Two rotavirus vaccines (RV1 and RV5) are available on the private market in Taiwan, not included in national immunization program. Scanty reports evaluated the rotavirus vaccine effectiveness (VE) in Asian countries. METHODS: From February 2014-July 2017, we conducted a prospective case-control study in ten hospitals in Taiwan. Case-patients included children aged 8-59 months, and hospitalized with laboratory-confirmed rotavirus acute gastroenteritis (AGE). For each case patient, up to four controls, rotavirus-negative AGE or non-AGE illnesses, respectively, were matched by gender, age and enrolled date. Vaccination history was confirmed through vaccination card or hospital record. VE was calculated as (1 - odds ratio of vaccination) × 100%. RESULTS: Totally 4248 AGE patients and 2242 non-AGE controls were enrolled. A total of 330 case-patients with rotavirus AGE, 1226 rotavirus-negative AGE controls and 1122 non-AGE controls were included for analysis. Unvaccinated rate was 85.15% for rotavirus-positive cases, 42.9% for rotavirus-negative controls, and 34.31% for non-AGE controls. VE of two-dose RV1 was 84.9% (95% confidence interval [CI]:77.7%, 90.1%) for rotavirus-negative AGE and 88.9% (95% CI: 83.4%, 92.8%) for non-AGE controls, while VE of three-dose RV5 was 92.5% (95% CI: 85.1%, 96.7%) and 96.4% (95% CI: 91.9%, 98.6%), respectively. For respective vaccine, VEs were not significantly different in term of rotavirus genotypes. VEs of both vaccines declined <80% in children aged three years by combined controls. CONCLUSIONS: Both vaccines provided excellent and sustained protection against rotavirus AGE hospitalization in children in Taiwan, but the effectiveness declined slightly in children aged three years.

Collateral Benefit of COVID-19 Control Measures on Influenza Activity, Taiwan.

Taiwan has strictly followed infection control measures to prevent spread of coronavirus disease. Meanwhile, nationwide surveillance data revealed drastic decreases in influenza diagnoses in outpatient departments, positivity rates of clinical specimens, and confirmed severe cases during the first 12 weeks of 2020 compared with the same period of 2019.

Policy-driven revolution of prescription record in outpatient use of fluoroquinolones.

OBJECTIVE: A policy initiated in 2001 by Taiwan's National Health Insurance (NHI) Administration has effectively reduced outpatient antibiotic use except fluoroquinolones (FQs). The influence of differential regulation policy of narrow-spectrum versus broad-spectrum FQs on the prescriptions is unknown. METHODS: This study analyzed the claim records of oral FQs prescription at outpatient visits during 2000-2010 using the NHI Research Database and compared prescriptions for narrow-spectrum FQs, which are inactive against Streptococcus pneumoniae and lack formulary restriction, with those for broad-spectrum FQs. RESULTS: Oral antibiotics were prescribed in 13.3% of visits and FQs accounted for 2.2% of them. During the study period the population-based rates of FQ prescription visits to children decreased, which was offset by increased use in the adult and geriatric populations (all p < 0.001). The most common encoded diagnoses for all FQs were urinary tract infection (19.2%) and sinusitis (10.9%), skin/bone/joint infections (7.9%), and lower respiratory tract infections (LRTI, 4.8%). Narrow-spectrum FQs accounted for 88.4% of all FQ prescriptions. Up to 95.4% of visits from patients with sinusitis and 34.3% of those with LRTI used narrow-spectrum FQs, while S. pneumoniae is an important etiology. Otorhinolaryngologists in non-hospital-based clinics prescribed most of narrow-spectrum FQs to patients with sinusitis or LRTI. CONCLUSIONS: We found debatable prescription of narrow-spectrum FQ based on claim records, particularly for LRTI and sinusitis, possibly due to the lack of formulary restriction. Additional efforts are needed to improve the appropriate selection of optimal FQs.

Fungal Diseases in Taiwan-National Insurance Data and Estimation.

The burden of fungal diseases based on the real-world national data is limited. This study aimed to estimate the Taiwan incident cases with selected fungal diseases in 2013 using the National Health Insurance Research Database (NHIRD) which covered 99.6% of the 23.4 million population. Over 80,000 incident cases were found and the majority were superficial infections including vulvovaginal candidiasis (477 per 100,000 adult women) and oral candidiasis (90 cases per 100,000 population). Common potentially life-threating fungal diseases were Pneumocystis pneumonia (5.35 cases per 100,000 population), candidemia (3.68), aspergillosis (2.43) and cryptococcal meningitis (1.04). Of the aforementioned cases cancer patients contributed 30.2%, 42.9%, 38.6% and 22.2%, respectively. Of 22,270 HIV-infected persons in NHIRD in 2013, four common diseases were Pneumocystis pneumonia (28.3 cases per 1000 HIV-infected patients), oral candidiasis (17.6), esophageal candidiasis (6.06) and cryptococcal meningitis (2.29). Of pulmonary aspergillosis 32.9% occurred in patients with chronic pulmonary diseases and 26.3% had a prior diagnosis of tuberculosis. There are some notable gaps related to insurance claim data. Cutaneous, urinary tract and eye fungal infections were not captured.

Burden of Severe Norovirus Disease in Taiwan, 2003-2013.

Background: Despite the increasingly recognized role of norovirus in global acute gastroenteritis (AGE), specific estimates of the associated disease burden remain sparse, primarily due to limited availability of sensitive norovirus diagnostics in the clinical setting. We sought to estimate the incidence of norovirus-associated hospitalizations by age group in Taiwan using a previously developed indirect regression method. Methods: AGE-related hospitalizations in Taiwan were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes abstracted from a national database; population data were provided from the Department of Household Registration Affairs. Population and hospitalizations were aggregated by month and year (July 2003-June 2013) and grouped by age: <5 years, 5-19 years, 20-64 years, and ≥65 years. Monthly counts of cause-unspecified AGE hospitalizations were modeled as a function of counts of known causes, and the residuals were then analyzed to estimate norovirus-associated hospitalizations. Results: Over the study period, an annual mean of 101400 gastroenteritis-associated hospitalizations occurred in Taiwan (44 per 10000 person-years), most of which (83%) had no specified cause. The overall estimated rate of norovirus-associated hospitalizations was 6.7 per 10000 person-years, with the highest rates in children aged <5 years (63.7/10000 person-years). Predicted norovirus peaked in 2006-2007 and 2012-2013. Conclusions: Our study is one of the first to generate a population-based estimate of severe norovirus disease incidence in Asia, and highlights the large burden of norovirus in Taiwan, particularly in children. Predicted peak norovirus seasons coincided with the emergence of new strains and resulting pandemics, supporting the validity of the estimates.

Intussusception-related Hospitalizations Among Infants Before and After Private Market Licensure of Rotavirus Vaccines in Taiwan, 2001-2013.

INTRODUCTION: Rotavirus is a leading cause of acute gastroenteritis among Taiwanese children. Two globally licensed rotavirus vaccines recommended for inclusion in routine immunization programs that have been available for private market use in Taiwan since 2006 have been associated with a low risk of intussusception in postmarketing studies conducted in several countries. Our objective was to examine trends and characteristics of intussusception hospitalizations in Taiwan among children <12 months of age before and after rotavirus vaccine licensure to provide updated baseline and early postlicensure data. METHODS: We extracted data on intussusception-related hospitalizations among children <12 months of age during 2001-2013 from the National Health Insurance Research Database. We examined patient demographics, clinical outcome and hospitalization trends, focusing on recommended ages for rotavirus vaccination (6-14, 15-24 and 25-34 weeks). We compared mean hospitalization rates for prevaccine licensure years 2001-2005 with those for postvaccine licensure years 2007-2013 using Poisson regression analysis. RESULTS: During 2001-2013, 1998 intussusceptions hospitalizations were recorded. The mean age of hospitalization was 33 weeks. Almost all children recovered; 3 deaths occurred. The overall intussusception hospitalization rate was 75.1 per 100,000; seasonality was not evident. Hospitalization rates were greatest in children ≥25 weeks of age and occurred more frequently in boys. Prevaccine and postvaccine licensure trends in annual hospitalization rates did not significantly differ. However, mean hospitalization rates were lower during the postvaccine licensure period for children <12 months of age (rate ratio: 0.84, 95% confidence interval: 0.76-0.92) with the greatest decline among children 25-34 weeks of age (rate ratio: 0.66, 95% confidence interval: 0.55-0.78). CONCLUSIONS: Infant intussusception in Taiwan occurs at a rate within the range of other Asian countries is rare among children <3 months of age, has a male predominance and does not have a clear seasonality pattern. We did not observe a postlicensure increase in intussusception hospitalization rates in children 6-14 weeks of age.