Healthcare workers in Singapore infected with COVID-19: 23 January-17 April 2020.

OBJECTIVE: To describe the characteristics of healthcare workers (HCWs) infected with COVID-19 and to examine their sources of exposure. METHODS: A descriptive cross-sectional study using data extracted from the centralized disease notification system comprising individuals confirmed with COVID-19 in Singapore between 23 January and 17 April 2020. Occupation of HCWs was categorized into six categories. Their job nature was classified into "frontline" or "back-end" based on the frequency of direct patient contact, and source of exposure was classified as family/household, social interaction or workplace. Chi-square and median tests were used to identify differences between categorical groups and sample medians, respectively. RESULTS: A total of 88 (1.7%) HCWs were identified from 5,050 cases. Their median age was 35 years. Chinese and Indians constituted 42.0% and 31.8%, respectively, and 43.2% were foreigners. The majority (63.6%) was serving at frontlines handling patient-facing duties, 15.9% were doctors, 11.4% were nurses and 44.3% were ancillary staff. About 81.8% acquired the infection locally, of which 40.3% did not have a clearly identifiable source of exposure. Exposure from the family/household was most common (27.8%), followed by workplace (16.7%) and social interaction (15.3%). All HCWs were discharged well with no mortality; three (3.4%) were ever admitted to intensive care unit and required increased care. CONCLUSION: Healthcare workers accounted for a small proportion of COVID-19 cases in Singapore with favourable outcomes. The possibility of transmission resulting from family/household exposure and social interactions highlights the need to maintain strict vigilance and precautionary measures at all times beyond the workplace.

Temporal Trends and Patient Characteristics Associated With Drug Utilisation After First-Ever Stroke: Insights From Chronic Disease Registry Data in Singapore.

INTRODUCTION: Data on drug utilisation among stroke patients of Asian ethnicities are lacking. The objectives of the study were to examine the temporal trends and patient characteristics associated with prescription of thrombolytic, antithrombotic and statin medications among patients with first-ever stroke. MATERIALS AND METHODS: First-ever ischaemic and haemorrhagic stroke patients admitted to 2 Singapore tertiary hospitals between 2010‒2014 were included. Data were extracted from the National Healthcare Group Chronic Disease Management System. Association between drug utilisation and admission year, as well as characteristics associated with drug use, were explored using multivariable logistic regression. RESULTS: There was an increasing trend in the combined use of all 3 guideline medications in ischaemic stroke patients (P <0.001)-specifically thrombolytic agents (P <0.001), oral antithrombotics (P = 0.002) and statins (P = 0.003) at discharge. Among antithrombotics, the use of clopidogrel (P <0.001) and aspirin-clopidogrel (P <0.001) had increased, whereas prescription of dipyridamole (P <0.001) and aspirin-dipyridamole (P <0.001) had declined. For statins, the increase in atorvastatin prescription (P <0.001) was accompanied by decreasing use of simvastatin (P <0.001). Age, ethnicity and certain comorbidities (hyperlipidaemia, atrial fibrillation and chronic kidney disease) were associated with the combined use of all 3 guideline medications (P <0.05). In haemorrhagic stroke, prescription of statins at discharge were comparatively lower. CONCLUSION: This study reveals changes in prescription behaviour over time in a multiethnic Asian population with first-ever stroke. Patient characteristics including younger age, Malay ethnicity and certain comorbidities (i.e. hyperlipidaemia, atrial fibrillation) were associated with the combined use of all 3 guideline medications among ischaemic stroke patients.

Impact of medication nonadherence on stroke recurrence and mortality in patients after first-ever ischemic stroke: Insights from registry data in Singapore.

PURPOSE: This retrospective cohort study aims to examine adherence to secondary stroke preventive medications and their association with risk of stroke recurrence and mortality in patients after first-ever ischemic stroke. METHODS: Using data from the National Healthcare Group and Singapore Stroke Registry, patients with first-ever ischemic stroke between 2010 and 2014 were included, and categorized based on antithrombotic or statin adherence using the proportion of days covered: high (≥75%), intermediate (50%-74%), low (25%-49%), and very low (<25%). The primary outcome was first recurrent ischemic stroke within a year after hospital discharge, while the secondary composite outcomes were (a) stroke recurrence and all-cause mortality and (b) stroke recurrence and cardiovascular mortality. The Cox proportional hazard model was used to examine the association between medication adherence and outcomes. Adjusted hazard ratios (aHRs) and the corresponding 95% confidence intervals (CIs) were reported. RESULTS: Among ischemic stroke patients prescribed with antithrombotics (n = 1139) or statins (n = 1160) at hospital discharge, about one-third were highly adherent to their medications. Patients with lower medication adherence tended to be younger, were admitted to private ward classes, and were without hypertension. Compared with the patients with high medication adherence, the risk of stroke recurrence was higher in patients with very low antithrombotic (aHR = 4.65; 95% CI: 1.45-14.89) or statin (aHR = 3.44; 95% CI: 0.93-12.74) adherence. Similar findings were observed for the secondary outcomes. CONCLUSIONS: Poor adherence to antithrombotic and statin treatment increases the risk of recurrent stroke and mortality in patients after first-ever ischemic stroke. Further measures are needed to improve medication adherence among stroke survivors.

Incipient Albuminuria in Persons with Newly Diagnosed Type 2 Diabetes Mellitus: A 5-Year Retrospective Cohort Study.

INTRODUCTION: This study aimed to determine the 5-year incidence of albuminuria among Asian persons with newly diagnosed type 2 diabetes mellitus (DM), and to identify the risk factors at diagnosis for progression to albuminuria. MATERIALS AND METHODS: A retrospective 5-year closed cohort study was conducted among 1016 persons aged ≥18 years old who were diagnosed with type 2 DM between 1 January 2007 and 31 December 2009 at primary care facilities in Singapore. The cumulative incidence of progression from normoalbuminuria to albuminuria-termed "progression"-was determined. The risk factors associated with progression were evaluated using multiple logistic regression analysis. RESULTS: A total of 541 (53.2%) participants were men. The mean (SD) onset age of type 2 DM was 54 (11) years. From diagnosis of type 2 DM, the 5-year cumulative incidence of progression was 17.3% and mean (SD) duration to progression was 2.88 (1.23) years. Higher onset age (OR 1.02; 95% CI, 1.00-1.04), history of hypertension (OR, 1.88; 95% CI, 1.32-2.70) and higher glycated haemoglobin (HbA1c) (OR, 1.17; 95% CI, 1.09-1.26) at diagnosis were associated with progression. In addition, being on angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) treatment at baseline modified the effect of hypertension on progression. CONCLUSION: This study highlighted the importance of early screening and treatment of diabetes as well as prevention of hypertension, which could potentially delay the onset of microalbuminuria in persons with type 2 DM. Persons on ACEI or ARB treatment should continue to be monitored regularly for progression to albuminuria.

Predictive factors of developing type 2 diabetes mellitus, Acute Myocardial Infarction and stroke in a cohort with Impaired Fasting Glucose in Singapore.

AIMS: This study describes the incidence and predictive factors for development of Type II Diabetes Mellitus (T2DM), Acute Myocardial Infarction (AMI) and stroke, among subjects with IFG over a five-year period. METHODS: This is a retrospective cohort study of subjects with newly diagnosed IFG from the Singapore National Healthcare Group hospitals and primary care clinics from 1 January 2008 to 31 December 2010. Clinical data were collected over a five-year period from the date of diagnosis. Outcomes of interest were T2DM, AMI and stroke based on first occurrence of the ICD-9 diagnoses from the chronic disease registry. Demographic characteristics, laboratory tests, anthropometric measurements and medical history were adjusted for in the multivariate logistic regression. RESULTS: Out of 2295 eligible subjects, 552(24.1%) developed at least one of the outcomes. 492(21.4%) developed T2DM, 20(0.9%) developed AMI and 62(2.7%) developed stroke. Predictive factors for development of any of the three outcomes included age 40-49 [Adjusted OR=2.25; 95% CI 1.44-3.51], blood pressure of 140/90mmHg and above [Adjusted OR=1.62, 95% CI 1.26-2.10] and BMI of 27.5kg/m2 or more [Adjusted OR=2.35; 95% CI 1.61-3.41]. Females were more likely to develop T2DM [Adjusted OR=1.43; 95% CI 1.10-1.85] but less likely to develop AMI and/or stroke compared to males [Adjusted OR=0.43; 95% CI 0.24-0.76]. CONCLUSIONS: Development of T2DM/AMI/stroke within the first five years of IFG is significantly high for subjects age 40-49 and those with high BMI. Frequency of cardiovascular risk screening, which is currently once every three years, could be increased.

Risk Stratification Model for 30-Day Heart Failure Readmission in a Multiethnic South East Asian Community.

There are limited accurate 30-day heart failure (HF) readmission risk scores using readily available clinical patient information on a well-defined HF cohort. We analyzed 1,475 admissions discharged from our hospital with a primary diagnosis of HF between 2010 and 2012. HF diagnostic criteria included satisfying clinical Framingham criteria, elevated serum N-terminal pro-natriuretic peptide, and evidence of cardiac dysfunction on transthoracic echocardiography. The patients were randomly divided into 2 groups; 60% were used as the derivation cohort and 40% as the validation cohort. Bivariate analysis and logistic regression were used to develop the model. Weighted risk scores were derived from the odds ratio of the logistic regression model. Total risk scores were computed by simple summation for each patient. The 7 significant independent predictors of 30-day HF readmission used to derive the risk scoring tool were the number of previous HF-related admission in the preceding 1 year, index admission length of stay, serum creatinine level, electrocardiograph QRS duration, serum N-terminal pro-natriuretic peptide level, number of Medical Social Service needs, and ß blocker prescription on discharge. The area under the curve was 0.76. Sensitivity and specificity were 78.3% and 60.7%, respectively. The positive predictive value and negative predictive value were 18.9% and 96%, respectively. The actual observed and predicted 30-day heart failure readmission rates matched. In conclusion, we have developed the first 30-day HF readmission risk score, with good discriminatory ability, for an urban multiethnic Asian heart failure cohort with stringent diagnostic criteria. It consists of 7 easily obtained variables.

Projection of prediabetes and diabetes population size in Singapore using a dynamic Markov model.

BACKGROUND: The aim of the present study was to forecast the prevalence and number of adult Singapore residents with prediabetes and diabetes in 2035. METHODS: A dynamic Markov model with nine mutually exclusive states was developed based on the clinical course of diabetes using time-dependent rates and probabilities. A 1-year cycle over a 25-year time horizon from 2010 to 2035 was used in the model. With publicly available data and a chronic disease register, the model forecast annual disease burden by simulating transition of cohorts across different health states using prevalence rates, incidence rates, mortality rates, disease transition, disease detection, and complication rates. An aging index was used in the model in anticipation of population aging to minimize risks of underestimating disease burden. RESULTS: From 2010 to 2035, the number of Singapore residents with prediabetes and diabetes is projected to more than double, from 434 685 to 903 596 and from 373 104 to 823 802, respectively. The prevalence of prediabetes and diabetes will rise steadily from 15.5 % to 24.9 % and from 13.3 % to 22.7 %, respectively. By 2035, a further estimate of 733 174 and 100 250 patients with prediabetes and uncomplicated diabetes, respectively, will remain undiagnosed. The prevalence of detected and undetected complications is forecast to rise from 60.0 % in 2010 to 70.2 % by 2035. CONCLUSION: By 2035, the prevalence of prediabetes and diabetes among Singapore residents aged 21+ years is expected to be one in four and one in five, respectively. There is an impetus to adopt more aggressive interventions to contain disease progression.

Determinants of health-related quality of life among community dwelling elderly.

INTRODUCTION: This study determines the associations between self-reported chronic conditions, limitations in activities of daily living and health-related quality of life (HRQoL) among community dwelling elderly in Singapore. MATERIALS AND METHODS: A population-based cross-sectional survey was conducted among a random sample of 4200 residents from 58 blocks of dwellings in Marine Parade housing estate between April and May 2011. A structured questionnaire was used to collect data on demographic characteristics; chronic disease profile, health screenings, healthcare utilisation, physical activity, activities of daily living (ADL) and functional ability and health related quality of life. Quality of life was assessed using European Quality of life 5 Domain (EQ-5D). Ordinary least squares (OLS) regression was used to identify independent predictors of health related quality of life. RESULTS: A total of 2454 respondents for included for analysis. Most of the respondents were females (57.2%) and aged between 65 and 74 years (48.5%). Among them, 79.1% of the respondents were Chinese. Approximately three-fourth (77.5%) of the survey respondents reported having at least one of the 13 chronic medical conditions; high blood pressure (57.7%), high blood cholesterol (51.6%), diabetes (22.9%) were the most commonly reported conditions. Independent predictors of HRQoL with greatest decrements in EQ-5D index and visual analog scores (VAS) were unemployment, self-reported depression, arthritis and osteoporosis and ADL limitations for activities such as "unable to shower", "unable to do housework" and elderly with depressive symptoms (GDS score≥5). CONCLUSION: The study had identified predictors of HRQoL in elderly Singapore residents and also provides community-based EQ-5D index and VAS scores associated with a wide variety of chronic conditions and ADL limitations.

Association of Socioeconomic Status (SES) and Social Support with Depressive Symptoms among the Elderly in Singapore.

INTRODUCTION: Depression in the elderly is a major public health issue. Socioeconomic status (SES) and social support are strong risk factors for depression. This study aimed to investigate the influence of SES and social support in elderly depression, and the modifying effect of social support on the relationship between SES and depression. MATERIALS AND METHODS: A community-based survey was conducted on residents≥60 years old. Depressive symptoms were determined with scores≥5 using the 15-item Geriatric Depression Scale (GDS). Multivariable logistic regression was performed to determine the odds ratio (OR) of depressive symptoms with respect to SES and social support, and interaction terms between the two variables. RESULTS: Of 2447 responses analysed, 188 (7.8%) respondents had depressive symptoms. Living in 2-room housing, living alone/with a domestic helper, infrequent leisure time with children/grandchildren or being childless, and feeling socially isolated were independently associated with depressive symptoms. Relative to residents living with spouse and children in 4-/5-room housing, the highest ORs for depressive symptoms were those living with spouse and children in 2-room (OR: 3.06, P<0.05), followed by living with children only in 3-room (OR: 2.98, P<0.05), and living alone/with a domestic helper in 4-/5-room (OR: 2.73, P<0.05). Living with spouse only appears to buffer against depressive symptoms across socioeconomic classes, although the effect was not statistically significant. CONCLUSION: Low social support and low SES significantly increased the odds of depressive symptoms. The moderating effect of social support on depression was however not consistent across SES groups. Specific interventions need to target different SES groups to better help older adults at risk of developing depression.

Self-reported chronic diseases and health status and health service utilization--results from a community health survey in Singapore.

OBJECTIVE: To report the extent of self-reported chronic diseases, self-rated health status (SRH) and healthcare utilization among residents in 1-2 room Housing Development Board (HDB) apartments in Toa Payoh. MATERIALS & METHODS: The study population included a convenience sample of residents from 931 housing development board (HDB) units residing in 1-2 room apartments in Toa Payoh. Convenience sampling was used since logistics precluded random selection. Trained research assistants carried out the survey. Results were presented as descriptive summary. RESULTS: Respondents were significantly older, 48.3% reported having one or more chronic diseases, 32% have hypertension, 16.8% have diabetes, and 7.6% have asthma. Median SRH score was seven. Hospital inpatient utilization rate were highest among Indian ethnic group, unemployed, no income, high self-rated health (SRH) score, and respondents with COPD, renal failure and heart disease. Outpatient utilization rate was significantly higher among older respondents, females, and those with high SRH scores (7-10). CONCLUSIONS: The findings confirming that residents living in 1-2 room HDB apartments are significantly older, with higher rates of chronic diseases, health care utilization than national average, will aid in healthcare planning to address their needs.

Geriatric syndromes and depressed mood in lower-income Singaporeans with diabetes: implications for diabetes management and health promotion.

INTRODUCTION: This study aims to determine the association of geriatric syndromes and depressed mood among respondents with diabetes in a lower income community; and their association with self-management, lifestyle behaviour, and healthcare utilisation. This paper focuses primarily on the 114 respondents with diabetes aged 50+ to inform policy formulation at the community level. MATERIALS AND METHODS: A pilot community health assessment was conducted in 4 blocks of 1- and 2-room apartments in Toa Payoh district from July to November 2009. Using a standard questionnaire, interviewers conducted face-to-face interviews with household members on chronic diseases, geriatric syndromes and health-related behaviour. Data were analysed using SPSSv15. RESULTS: A total of 795 respondents were assessed with a response rate of 61.8%. Of 515 (64.8%) aged 50+ analysed in this study, 22.1% reported having diabetes, of whom 31.6% reported being depressed. Respondents with diabetes who reported being depressed had a higher prevalence of geriatric syndromes compared with those non-depressed; i.e. functional decline (30.6% vs 5.1%, P <0.001); falls (33.3% vs 10.3%, P = 0.003); stumbling (30.6% vs 10.3%, P = 0.007); urinary incontinence (33.3% vs 5.1%, P <0.001), progressive forgetfulness (27.8% vs 6.4%, P = 0.002) and poor eyesight (22.2% vs 6.4%, P = 0.014). They were less likely to comply with medications (86.1% vs 97.3%, P = 0.026) and performed exercise (13.9% vs 53.8%, P <0.001). More had hospital admissions (13.9% vs 7.7%); and they had more outpatient visits per person (2.4 visits vs 0.9 visits, P = 0.03) at Specialist Outpatient Clinics. CONCLUSION: Geriatric syndromes were associated with the presence of depressed mood among persons with diabetes in the lower income group. As those with depressed mood had more unfavourable self-management and lifestyle behaviour, and utilise higher healthcare services, diabetes management must take these findings into consideration.

Using spatial accessibility to identify polyclinic service gaps and volume of under-served population in Singapore using Geographic Information System.

Primary care services in Singapore are provided by 18 Government-funded polyclinics and about 1200 private General Practitioners (GPs). This study aims to examine the spatial accessibility to polyclinics and identify service gaps, and suggest optimal sites using Geographic Information System (GIS) to aid in future planning. A national database containing 3.6 million polyclinic visits in 2006 were geo-analysed using ArcView GIS. Patients' travel impedance to the nearest polyclinic was computed using DriveTime to identify areas with the lowest spatial accessibility and highest volume of under-served population. Jurong West and Sembawang were ranked as top areas with poor spatial accessibility to polyclinic services. ArcGIS was used to identify optimal sites with the minimum accumulated distance impedance to this under-served population. If new facilities were set up at these identified sites, volume of visits by Jurong West and Sembawang patients who could access the nearest polyclinics within 4 km Euclidean distance from their residence would total at 123 000 and 93 000, respectively. Future efforts in polyclinic planning should take this into consideration to maximize patients' benefits and minimize patients' travelling costs in order to achieve social equity on healthcare access.

Demographic and lifestyle characteristics associated with non-willingness to participate in health promotion programmes among adults of a lower socioeconomic status in Singapore.

INTRODUCTION/OBJECTIVE: Lower socioeconomic groups have been found to have poorer health outcomes and engage in fewer health promoting behaviours. Understanding the reasons behind adverse lifestyle habits and non-willingness to participate in health promotion programmes among lower socioeconomic groups will enable administrators to modify the programmes and increase participation in this population. This study aimed to determine reasons for non-exercise, smoking and non-willingness to participate, and characteristics associated with non-willingness to participate in health promotion programmes among residents in Singapore. METHOD: A cross-sectional survey was conducted on a purposive sample of residents living in four housing developments of one- and two-room households in Singapore from June to October 2009. The patterns of exercise and smoking, receptiveness towards health promotion programmes and the reasons for non-willingness to participate were elicited. Chi-square tests and logistic regression analysis were performed to identify differences between groups. RESULTS: Seven hundred and seventy-eight responses were analysed. Only 36.1% of respondents were willing to participate in at least one health promotion programme (health screening, talk or workshop). Older respondents aged 45-64 years and more than 65 years were less likely to participate than their younger counterparts (18-44 years). Malays were more likely than Chinese to participate, and respondents who do not exercise were less likely to participate than respondents who exercise (regularly/occasionally). Reasons for non-willingness to participate were 'not interested' and 'no time'. CONCLUSION: Health promotion messages should adapt to the needs and situation of the disadvantaged, to increase participation.

Barriers to patient referral for Complementary and Alternative Medicines and its implications on interventions.

AIM: To study the perceptions of Complementary and Alternative Medicine (CAM) among healthcare professionals and identify factors associated with referral for CAM treatment. METHODS: An anonymous, self-administered survey was conducted in April 2008. All doctors, registered nurses, physiotherapists and occupational therapists in Tan Tock Seng Hospital were invited to participate. Data were analysed using SPSS v15. RESULTS: The overall response rate was 61.9%. Most respondents perceived their knowledge of CAM to be limited and had little personal experiences with CAM. Few had referred a small percentage of their patients for CAM therapies. Nonetheless, 62.2% of respondents believed that CAM would be safe when practiced by trained professionals and only 6.5% agreed that physicians should warn patients against CAM. Respondents who did not refer patients for CAM therapy cited lack of personal knowledge on the subject (53.4%); not knowing a suitable CAM practitioner (29.0%); and not thinking it was necessary (14.6%). The key reasons for referring were patients' preferences (58.0%); efficacy of CAM for specific conditions (39.1%); and when other treatment modalities were unsuccessful (21.9%). Most respondents (82.7%) had favourable attitudes and expressed interest in attending CAM seminars. CONCLUSION: The majority of western-trained healthcare professionals perceived their knowledge of CAM to be low. Most referrals to CAM were made because their patients believed in CAM. Limited personal knowledge and experiences were associated with lower referrals. However, they were interested to know about the common CAM modalities. This suggests the need for more CAM education interventions for healthcare professionals.

Understanding of diabetes mellitus and health-preventive behaviour among Singaporeans.

INTRODUCTION: To study the understanding and perceived vulnerability of diabetes mellitus among Singapore residents, and determine the predictors associated with screening for diabetes mellitus among the people without the condition. MATERIALS AND METHODS: A population-based survey was conducted from December 2004 to October 2005 involving Singapore residents aged 15 to 69 years. Using a standard questionnaire, Health Survey Officers interviewed household members on their understanding and perceived vulnerability of diabetes mellitus and associated cardiovascular risk factors. Data were analysed using SPSS v13. RESULTS: The response rate was 84.5%. Of 2,632 respondents, 291 (11.1%) have diabetes mellitus. Compared to respondents without diabetes, respondents with the disease had better understanding of diabetes and they had favourable health practice of screening for cardiovascular risk factors. Having diabetes mellitus was not associated with a healthier lifestyle. Among non-diabetics, those who had a family history of diabetes had better knowledge and health practices than those who had not. They were significantly more likely to recognise the symptoms and signs (61.5% vs 54.5%) and the causes of diabetes (70% vs 58.2%); and were more likely to have ever tested for diabetes (76.1% vs 60.4%), with P <0.001. Socio-demographic characteristics, family history, understanding and perception on the vulnerability of diabetes were identified as predictors associated with health screening for the disease. CONCLUSION: Among all respondents, better understanding was found to be associated with favourable health-preventive behaviours. However, it did not translate into healthier lifestyle. Cultural and socio-demographic profiles must be factored in for any effort on lifestyle modifications.

Perception of the public towards the mentally ill in developed Asian country.

OBJECTIVE: This study assessed public perceptions and attitudes towards and causal beliefs about mental health problems in Singapore - a multi-racial country in South-East Asia. METHOD: A nation-wide survey using a structured questionnaire was conducted on those aged between 15 and 69 years. RESULTS: The overall response rate was 68.1% with a total of 2,632 respondents. About 38.3% (95% CI, 36.4-40.2) believed that people with mental health problems were dangerous and 49.6% (95% CI, 47.7-51.5) felt that the public should be protected from them. A negative attitude towards mental health problems correlated with greater age and less education. The Chinese were more likely to want to hide their illness should they become mentally unwell while the Malays seemed to have a more tolerant attitude (P = 0.032). CONCLUSION: Public awareness and anti-stigma campaigns should focus on those commonly held misconceptions and target specific populations.