Adopting a "Digital First" Mindset for Workplace Safety and Health in Singapore.

Digital and technological solutions constitute a key enabler to achieving better workplace safety and health outcomes. Fundamentally, the success of their implementation is underscored by a need for employers, employees, industry stakeholders and policymakers to collaborate in adopting a "digital first" mindset. This review provides a background on the evolution of work and the workforce in post-independence Singapore, and introduces pertinent local workplace safety and health trends. It delves into how a "digital first" approach may be adopted and effected, followed by challenges and opportunities in the digitalization of Singapore's workplace safety and health landscape. Illustrative examples are used to highlight applications of digital and technological solutions in the control of occupational hazards. In our discussion, workplace strategies are built around the hierarchy of controls framework, whereas worker-related strategies are divided into workspace optimization for productivity/performance enhancement, training/education, and instituting surveillance/open reporting mechanisms. We demonstrate that with an open and forward-looking mind, and well-executed change management, we will be able to capitalize on technological advances to improve work and working conditions for all workers.

Improvements in work productivity among patients with inflammatory arthritis and osteoarthritis in the first six months after diagnosis: an inception cohort study.

OBJECTIVES: Reduced work productivity (WP), measured by work productivity loss (WPL) and work disability (WD), is common in patients with inflammatory arthritis (IA) and osteoarthritis (OA) but is not well characterised. We aimed to assess if there were any improvements in WP (WPL and WD) from diagnosis (T1) to six months later (T2) and to explore associations between WP at T2 and health status at T1 among these patients. METHODS: Patients were surveyed for work characteristics, work ability, WP and health status including physical functioning and vitality at T1 and T2. Associations between WP at T2 and health status at T1 were explored using regression models. RESULTS: Patients with IA (n=109) were younger than those with OA (n=70) (mean age: 50.5 vs. 57.7 years). The median WPL score decreased from 30.0 to 10.0 in patients with IA and from 20.0 to 0.0 in patients with OA, while the proportion reporting WD decreased from 52.3% to 45.3% in patients with IA and increased from 52.2% to 56.5% in patients with OA from T1 to T2. Physical functioning at T1 (coefficient = -0.35) was significantly associated with WPL at T2. Vitality at T1 (coefficient = 0.03) was associated with WD at T2. CONCLUSIONS: Greater improvements in WP were observed among patients with IA than those with OA in the first six months after diagnosis. This provides a basis for healthcare professionals to aim for greater improvements in work and health status for patients with IA.

Factors Influencing the Uptake of Seasonal Influenza Vaccination among Community-Dwelling Older Adults during COVID-19: A Mixed Methods Study.

Background: Despite making the influenza vaccine accessible and affordable, vaccination rates remained low among community-dwelling older adults. Therefore, this study aimed to explore the factors influencing vaccine uptake and the impact of COVID-19 on vaccine uptake among community-dwelling older adults in Singapore. Methods: A mixed methods study involving a survey and semi-structured interviews were conducted between September 2020 and July 2021. Community-dwelling older adults aged ≥ 65 years were recruited from 27 Community Nurse Posts. Data on participants' demographics, health condition(s), vaccination status, attitudes towards influenza infections and vaccinations, willingness to pay, intention for future vaccination and source of information were collected via the survey. Semi-structured interviews were conducted to understand vaccination experiences, key enablers and barriers, and the impact of COVID-19 on vaccine uptake. All interviews were analysed using Braun and Clarke's thematic analysis. Quantitative data were analysed using descriptive statistics, chi-square tests and multinomial logistic regressions. Results: A total of 235 participants completed the survey. Living arrangement was a statistically significant contributing factor for influenza vaccine uptake (ꭓ2= -0.139; p = 0.03). Participants who lived alone were 2.5 times more likely to be vaccinated than those living with others (OR = 2.504, 95% CI: 1.294-4.842, p = 0.006). Avoidance of getting infected (82.5%), avoidance of transmission to others (84.7%), and advice from healthcare professionals to receive vaccination (83.4%) were key enablers, while concerns about possible side effects (41.2%), the effectiveness of the vaccine (42.6%), and not having enough information (48.1%) were barriers. Twenty participants were interviewed. The findings were congruent with the survey results. Five themes were identified as follows: (1) Perceived importance of influenza vaccination, (2) Sphere of influence, (3) Healthcare schemes and medical subsidies, (4) Psychological impediments, and (5) Inconsistent emphases at various touch points. Conclusions: Greater public health efforts are needed to reach out to the larger population of older adults of different living arrangements and those concerned about the possible side effects and effectiveness of the influenza vaccine. Healthcare professionals need to provide more information to address these concerns, especially during COVID-19, to encourage vaccine uptake.

A hospital-based return-to-work programme in Singapore.

Return to Work (RTW) programmes have become imperative in manpower scarce countries. This paper describes a RTW programme in a Singapore tertiary hospital, reports patient outcomes and discusses the practicality and effectiveness of the programme. Seventy-three workers participated in the programme over a two-year period. A statistically significant increase in work ability and self-perceived overall health status from first contact with worker (baseline) to discharge was observed. Continued programme participation till first RTW was associated with higher work ability and self-perceived overall health status at baseline. The RTW Coordinator-anchored multidisciplinary model which provided holistic support to the worker and addressed stakeholder interests were central to the programme's success. Greater awareness of RTW programme benefits will improve sustained participation. Our RTW programme features, implementation experiences and participant reported effectiveness may inform the development of improved return to work models.

The Outcomes of App-Based Health Coaching to Improve Dietary Behavior Among Nurses in a Tertiary Hospital: Pilot Intervention Study.

BACKGROUND: At the workplace, health care workers face multiple challenges in maintaining healthy dietary behaviors, which is the major factor behind obesity. A hospital-wide mass health screening exercise showed an increasing trend in the prevalence of obesity and median BMI from 2004 to 2019, as well as a higher crude obesity rate among shift workers. OBJECTIVE: We aimed to evaluate the effectiveness of mobile app-based health coaching and incentives for achieving weight loss from better dietary choices among hospital nurses. METHODS: We conducted a pilot study from June 2019 to March 2020, involving the use of a health-coaching app by 145 hospital nurses over 6 months. Weight and BMI were self-reported, and food scores were calculated. Data among overweight nurses, shift work nurses, and incentive groups were analyzed. RESULTS: A total of 61 nurses were included in the final analysis. Of these 61 nurses, 38 (62%) lost weight. The median percentage weight loss was 1.2% (IQR 0%-2.9%; P<.001), and the median decrease in BMI was 0.35 (IQR -0.15 to 0.82; P<.001), but they were not clinically significant. The median improvement in the food score was 0.4 (IQR 0-0.8). There was no difference between the incentive and nonincentive groups. A total of 49 (34%) participants engaged for ≥8 weeks. CONCLUSIONS: The study demonstrated an association between the use of app-based health coaching and the attainment of some weight loss in nurses, without a significant improvement in the food score. Incentives may nudge on-boarding, but do not sustain engagement.

Proposed Data-Driven Approach for Occupational Risk Management of Aircrew Fatigue.

BACKGROUND: Fatigue is pervasive, under-reported, and potentially deadly where flight operations are concerned. The aviation industry appears to lack a standardized, practical, and easily replicable protocol for fatigue risk assessment which can be consistently applied across operators. AIM: Our paper sought to present a framework, supported by real-world data with subjective and objective parameters, to monitor aircrew fatigue and performance, and to determine the safe crew configuration for commercial airline operations. METHODS: Our protocol identified risk factors for fatigue-induced performance degradation as triggers for fatigue risk and performance assessment. Using both subjective and objective measurements of sleep, fatigue, and performance in the form of instruments such as the Karolinska Sleepiness Scale, Samn-Perelli Crew Status Check, Psychomotor Vigilance Task, sleep logs, and a wearable actigraph for sleep log correlation and sleep duration and quality charting, a workflow flagging fatigue-prone flight operations for risk mitigation was developed and trialed. RESULTS: In an operational study aimed at occupational assessment of fatigue and performance in airline pilots on a three-men crew versus a four-men crew for a long-haul flight, we affirmed the technical feasibility of our proposed framework and approach, the validity of the battery of assessment instruments, and the meaningful interpretation of fatigue and work performance indicators to enable the formulation of safe work recommendations. CONCLUSION: A standardized occupational assessment protocol like ours is useful to achieve consistency and objectivity in the occupational assessment of fatigue and work performance.

Personal protective equipment-related occupational dermatoses during COVID-19 among health care workers: A worldwide systematic review.

BACKGROUND: Occupational dermatoses caused by personal protective equipment (PPE) in the ongoing COVID-19 pandemic are emerging occupational health challenges that must be promptly and effectively addressed to ease burden on our health care workers. OBJECTIVE: A systematic review was conducted to determine common PPE-related dermatoses, affected body sites, and implicated occupational contactants. We further proposed solutions to mitigate this problem. METHODS: Online databases were searched for articles on PPE-related dermatoses in health care workers during the COVID-19 pandemic written in English and published from January 1, 2020, to January 30, 2021. RESULTS: Sixteen studies, including a total of 3958 participants, were included. The most common dermatoses were xerosis, pressure-related erythema, and contact dermatitis, mainly affecting the face and hands. The most widely implicated contactants were increased frequency of hand hygiene, gloves, N95 masks, and goggles. Proposed solutions were categorized as individual self-care, protection of the workforce, and long-term preventive measures. CONCLUSION: Through measures such as regular basic skin care education, early access to specialty clinics via telemedicine, and designing of better-fit PPE, the challenges posed by PPE-related occupational dermatoses can be significantly reduced.

COVID-19 and Return-To-Work for the Construction Sector: Lessons From Singapore.

Singapore's construction sector employs more than 450,000 workers. During the height of the COVID-19 pandemic in Singapore from April to June 2020, migrant workers were disproportionately affected, including many working in the construction sector. Shared accommodation and construction worksites emerged as nexuses for COVID-19 transmission. Official government resources, including COVID-19 epidemiological data, 43 advisories and 19 circulars by Singapore's Ministries of Health and Manpower, were reviewed over 8 month period from March to October 2020. From a peak COVID-19 incidence of 1,424.6/100,000 workers in May 2020, the incidence declined to 3.7/100,000 workers by October 2020. Multilevel safe management measures were implemented to enable the phased reopening of construction worksites from July 2020. Using the Swiss cheese risk management model, the authors described the various governmental, industry, supervisory and worker-specific interventions to prevent, detect and contain COVID-19 for safe resumption of work for the construction sector.

Containment of COVID-19 and reduction in healthcare-associated respiratory viral infections through a multi-tiered infection control strategy.

BACKGROUND: During the ongoing COVID-19 pandemic, healthcare-associated transmission of respiratory viral infections (RVI) is a concern. To reduce the impact of SARS-CoV-2 and other respiratory viruses on patients and healthcare workers (HCWs) we devised and evaluated a multi-tiered infection control strategy with the goal of preventing nosocomial transmission of SARS-CoV2 and other RVIs across a large healthcare campus. METHODS: From January-June 2020, a multi-tiered infection control strategy was implemented across a healthcare campus in Singapore, comprising the largest acute tertiary hospital as well as four other subspecialty centres, with more than 10,000 HCWs. Drawing on our institution's experience with an outbreak of Severe Acute Respiratory Syndrome (SARS) in 2003, this strategy included improved patient segregation and distancing, and heightened infection prevention and control (IPC) measures including universal masking. All symptomatic patients were tested for COVID-19 and common RVIs. RESULTS: A total of 16,162 admissions campus-wide were screened; 7.1% (1155/16,162) tested positive for COVID-19. Less than 5% of COVID-19 cases (39/1155) were initially detected outside of isolation wards in multi-bedded cohorted wards. Improved distancing and enhanced IPC measures successfully mitigated onward spread even amongst COVID-19 cases detected outside of isolation. COVID-19 rates amongst HCWs were kept low (0.13%, 17/13,066) and reflected community acquisition rather than nosocomial spread. Rates of healthcare-associated-RVI amongst inpatients fell to zero and this decrease was sustained even after the lifting of visitor restrictions. CONCLUSION: This multi-tiered infection control strategies can be implemented at-scale to successfully mitigate healthcare-associated transmission of respiratory viral pathogens.

Utilizing the electronic health records to create a syndromic staff surveillance system during the COVID-19 outbreak.

OBJECTIVES: Since December 2019, COVID-19 has caused a worldwide pandemic and Singapore has seen escalating cases with community spread. Aggressive contact tracing and identification of suspects has helped to identify local community clusters, surveillance being the key to early intervention. Healthcare workers (HCWs) have contracted COVID-19 infection both at the workplace and community. We aimed to create a prototype staff surveillance system for the detection of acute respiratory infection (ARI) clusters amongst our HCWs and describe its effectiveness. METHODS: A prototypical surveillance system was built on existing electronic health record infrastructure. RESULTS: Over a 10-week period, we investigated 10 ARI clusters amongst 7 departments. One of the ARI clusters was later determined to be related to COVID-19 infection. We demonstrate the feasibility of syndromic surveillance to detect ARI clusters during the COVID-19 outbreak. CONCLUSION: The use of syndromic surveillance to detect ARI clusters amongst HCWs in the COVID-19 pandemic may enable early case detection and prevent onward transmission. It could be an important tool in infection prevention within healthcare institutions.

The impact of healthcare worker influenza vaccination on nosocomial influenza in a tertiary hospital: an ecological study.

BACKGROUND: To protect hospitalized patients, who are more susceptible to complications of influenza, seasonal influenza vaccination of healthcare workers (HCW) has been recommended internationally. However, its effectiveness is still being debated. To assess the effectiveness of HCW influenza vaccination, we performed an ecological study to evaluate the association between healthcare worker influenza vaccination and the incidence of nosocomial influenza in a tertiary hospital within Singapore between 2013 and 2018. METHODS: Nosocomial influenza was defined as influenza among inpatients diagnosed 7 days or more after admission by laboratory testing, while healthcare worker influenza vaccination rate was defined as the proportion of healthcare workers that was vaccinated at the end of each annual seasonal vaccination exercise. A modified Poisson regression was performed to assess the association between the HCW vaccination rates and monthly nosocomial influenza incidence rates. RESULTS: Nosocomial influenza incidence rates followed the trend of non-nosocomial influenza, showing a predominant mid-year peak. Across 2,480,010 patient-days, there were 256 nosocomial influenza cases (1.03 per 10,000 patient-days). Controlling for background influenza activity and the number of influenza tests performed, no statistically significant association was observed between vaccination coverage and nosocomial influenza incidence rate although a protective effect was suggested (IRR 0.89, 95%CI:0.69-1.15, p = 0.37). CONCLUSION: No significant association was observed between influenza vaccination rates and nosocomial influenza incidence rates, although a protective effect was suggested. Aligning local HCW vaccine timing and formulation to that of the Southern Hemisphere may improve effectiveness. HCW vaccination remains important but demonstrating its effectiveness in preventing nosocomial influenza is challenging.

Work disability in rheumatic diseases: Baseline results from an inception cohort.

AIM: We aimed to characterize work disability in patients with newly diagnosed rheumatic diseases and compare work characteristics between patients with rheumatic diseases and controls without rheumatic diseases at diagnosis. METHODS: Patients with inflammatory arthritis (IA) and osteoarthritis (OA), surrogates for autoimmune and non-autoimmune rheumatic diseases, respectively, and controls of working age were surveyed at diagnosis. Patients with rheumatic diseases who were employed before symptom onset were characterized as having work disability if they reported reduced work ability and productivity while remaining in the same job as before symptom onset, changed to a less demanding job or stopped working/retired. Work characteristics at diagnosis were compared between rheumatic diseases patients and controls. RESULTS: The unemployment rate before symptom onset was lower in patients with IA (20%) compared to patients with OA (32%). Among patients with IA and OA who were employed before symptom onset, 59% and 43% reported work disability, respectively (P = .04). The unemployment rate at diagnosis was comparable in patients with IA (26%) and higher in patients with OA (38%) compared to controls (29%). Employed patients with IA and OA, when compared with controls, reported poorer work ability (score: 37 vs 39 vs 41, P < .01; proportion with poor/moderate work ability: 48% vs 33% vs 21%, P < .01) and greater work productivity loss (score: 32 vs 29 vs 17, P < .01) at diagnosis. CONCLUSION: Rheumatic diseases impose significant work disability at diagnosis, highlighting the need for identification and interventions targeting work disability early in the course of disease.

Containment of COVID-19 cases among healthcare workers: The role of surveillance, early detection, and outbreak management.

OBJECTIVE: Staff surveillance is crucial during the containment phase of a pandemic to help reduce potential healthcare-associated transmission and sustain good staff morale. During an outbreak of SARS-COV-2 with community transmission, our institution used an integrated strategy for early detection and containment of COVID-19 cases among healthcare workers (HCWs). METHODS: Our strategy comprised 3 key components: (1) enforcing reporting of HCWs with acute respiratory illness (ARI) to our institution's staff clinic for monitoring; (2) conducting ongoing syndromic surveillance to obtain early warning of potential clusters of COVID-19; and (3) outbreak investigation and management. RESULTS: Over a 16-week surveillance period, we detected 14 cases of COVID-19 among HCWs with ARI symptoms. Two of the cases were linked epidemiologically and thus constituted a COVID-19 cluster with intrahospital HCW-HCW transmission; we also detected 1 family cluster and 2 clusters among HCWs who shared accommodation. No transmission to HCWs or patients was detected after containment measures were instituted. Early detection minimized the number of HCWs requiring quarantine, hence preserving continuity of service during an ongoing pandemic. CONCLUSIONS: An integrated surveillance strategy, outbreak management, and encouraging individual responsibility were successful in early detection of clusters of COVID-19 among HCWs. With ongoing local transmission, vigilance must be maintained for intrahospital spread in nonclinical areas where social mingling of HCWs occurs. Because most individuals with COVID-19 have mild symptoms, addressing presenteeism is crucial to minimize potential staff and patient exposure.

Preventing Intra-hospital Infection and Transmission of Coronavirus Disease 2019 in Health-care Workers.

Coronavirus disease 2019 poses an occupational health risk to health-care workers. Several thousand health-care workers have already been infected, mainly in China. Preventing intra-hospital transmission of the communicable disease is therefore a priority. Based on the Systems Engineering Initiative for Patient Safety model, the strategies and measures to protect health-care workers in an acute tertiary hospital are described along the domains of work task, technologies and tools, work environmental factors, and organizational conditions. The principle of zero occupational infection remains an achievable goal that all health-care systems need to strive for in the face of a potential pandemic.

A retrospective review of tuberculosis exposure among health care workers in a tertiary hospital.

BACKGROUND: We evaluated tuberculosis (TB) acquisition rate and risk factors among health care workers (HCWs) exposed to index TB patients. METHODS: We performed a retrospective cohort study on exposed HCWs from August 2016 to January 2018 at a tertiary hospital in Singapore. Demographic factors and TB exposure episodes per HCW were obtained. A modified Poisson regression model was used to identify factors associated with TB infection. RESULTS: A total of 32 TB exposure events occurred during the study period. A total of 881 HCWs with 1,536 exposure episodes were screened with QuantiFERON-TB Gold In-tube assay (QFT-GIT) at baseline and 8 weeks. A total of 129 (14.6%) HCWs had positive QFT-TB at baseline, whereas 22 (2.5%) HCWs had QFT-GIT conversion, with a latent TB infection (LTBI) rate of 1.14 cases per 100 exposure episodes per year. Foreign nationality, non-Chinese ethnicity, and age above 40 years were independently associated with baseline LTBI, whereas having >2 TB exposure episodes and working in internal medicine, medical subspecialties, and psychiatry wards were associated with QFT-GIT conversion. DISCUSSION: The QFT-GIT conversion rate among screened HCWs is low. Foreign HCWs with LTBI likely came from countries with higher TB transmission. Targeted prevention of repeated TB exposures can reduce QFT-GIT conversion. CONCLUSIONS: The study results will guide TB contact tracing protocols in health care institutions.

Returning Aircrew with Chronic Hepatitis B Back to Flying While on Nucleos(t)ide Analogues.

BACKGROUND: Chronic Hepatitis B (CHB) remains a major cause of morbidity in several parts of the world. Aircrew with immune-active hepatitis are unfit for flying duties due to the risk of acute hepatic decompensation; those who have begun on treatment are generally also disqualified from flying duties due to the potential side effects of antiviral treatment. As treatment endpoints for nucleos(t)ide analogues (NUC) are typically achieved after prolonged therapy, aircrew treated for CHB may be subjected to an extended period of flying restriction.METHODS: We present a retrospective case series of seven aircrew who were returned to flying duties while on varying combinations of NUC for the treatment of CHB. All seven aircrew were comanaged by the flight surgeon and hepatologist, reviewed by a panel of flight surgeons, and had achieved normalized liver function tests prior to resumption of flying duties; two out of the seven aircrew had detectable serum Hepatitis B virus (HBV) DNA when reinstated back to flying duties. Only one aircrew member experienced side effects from the NUC treatment. This was promptly evaluated and managed prior to resumption of flying duties to ensure flight safety.DISCUSSION: Aircrew with CHB infection can be safely allowed back to flying duties, especially when their conditions have been well controlled via treatment with any of the NUC regimes. While there are limited studies evaluating the use of NUC in aircrew performing flight duties, our study has shown that NUC are generally well tolerated and have a good safety profile which is compatible with flying duties.Tan D, Kwan C, Tan BBC, Gan WH. Returning aircrew with chronic Hepatitis B back to flying while on nucleos(t)ide analogues. Aerosp Med Hum Perform. 2019; 90(1):37-42.

Photorefractive keratectomy in young Asian aviators with low-moderate myopia.

INTRODUCTION: The high prevalence of myopia among Asians led the Republic of Singapore Air Force (RSAF) to introduce photorefractive keratectomy (PRK) as a means of enlarging its pilot recruitment pool at the end of 2005. This study aims to address the efficacy and safety of PRK performed on young Asian patients with low-moderate myopia, as well as audit the RSAF's corneal refractive surgery (CRS) program. METHODS: This is a retrospective case series of 149 eyes of 76 consecutive patients that underwent PRK as part of the RSAF CRS program over the 5-yr period from 1 January 2006 to 31 December 2010. RESULTS: The median patient age was 21 yr (range, 18-26 yr) and the mean preoperative spherical equivalent (SE) refraction was -3.39 - 1.19 D. Of the patients, 96.1% were men and all were of Asian origin. At the 12-mo follow-up, 98.5% of eyes had an uncorrected distance visual acuity (UDVA) of < or = 0.00 LogMAR, 100.0% of eyes had an SE refraction of within + 0.50 D of intended correction, and 2.300% of eyes had a loss of corrected distance visual acuity (CDVA) of 0.20 LogMAR. The cumulative incidence of retreatments was 6.7% and cumulative incidence of grade II or worse corneal haze requiring retreatment was 6.0%. Refractive stability was achieved at 3 mo postsurgery. CONCLUSION: The results of this study suggest that PRK performed within the context of a stringent and structured CRS program on young Asian eyes with low-moderate myopia is both efficacious and safe, with refractive stability achieved by 3 mo.

Lymphocytic follicles and aggregates are a determinant of mucosal damage and duration of diarrhea.

CONTEXT: Nonspecific changes (nonspecific chronic inflammation) in patients with chronic diarrhea represent the commonest diagnosis in colorectal biopsy interpretation, but these changes are of little clinical significance. OBJECTIVE: To find, within this group, histologic and immunohistologic diagnostic criteria to predict the duration and resolution of diarrhea. DESIGN: Detailed clinical features and histologic findings were analyzed in a cohort of 47 patients with chronic diarrhea, with near-normal histology and no clear-cut known etiologic agent. Immunohistochemistry to mast cells (CD117) and Treg cells (FOXP3) was also assessed in 39 patients. RESULTS: Increased number of lymphoid follicles and aggregates, increased number of mast cells, and paucity of Treg were the statistically significant key findings (P  =  .003, P  =  .008, and P  =  .04, respectively). The duration of diarrhea was correlated with the number of large lymphoid follicles and aggregates (P  =  .001, r  =  .48), number of total lymphoid follicles and aggregates (P  =  .003, r  =  .43), density of lymphoid follicles and aggregates (P  =  .009, r  =  .38), and total lymphoid follicles and aggregates per biopsy (P  =  .004, r  =  .42) and the number of mast cells (P  =  .001, r  =  .52). The number of mast cells and Treg cells showed significant difference between resolved and unresolved cases (P  =  .001 and P  =  .01 respectively). CONCLUSIONS: Lymphocytic follicles and aggregates colitis, previously regarded as of negligible diagnostic significance, allows the prediction of the behavior of chronic diarrhea in a subset of patients with nonspecific changes on colonic biopsy. The increased number of mast cells and paucity of Treg cells further helps to identify such unresolved cases.