Multisystem inflammatory syndrome in adults: Characteristics, treatment, and outcomes.

Following the rapidly increasing number of multisystem inflammatory syndromes in children (MIS-C), a similar clinical scenario has been observed in adult patients. Although its prevalence is low and probably related to underdiagnosis, its development can be associated with high mortality. Multisystem inflammatory syndrome in adults (MIS-A) can develop following both asymptomatic and symptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and in previously healthy people. Like MIS-C, MIS-A is a multisystem disease that can involve the cardiovascular, respiratory, gastrointestinal, dermatologic, hematologic, and neurologic systems. In addition to the clinical manifestations, the diagnosis of MIS-A requires laboratory evidence of inflammation and SARS-CoV-2 infection. The appropriate treatment for MIS-A remains unclear; anti-inflammatory agents, including intravenous immunoglobulin and corticosteroids, are commonly used. However, there are still many unknowns regarding MIS-A. Further studies are needed to determine the true prevalence, pathogenesis, and effective treatment for MIS-A.

Long COVID: An inevitable sequela of SARS-CoV-2 infection.

At present, there are more than 560 million confirmed cases of the coronavirus disease 2019 (COVID-19) worldwide. Although more than 98% of patients with severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) infection can survive acute COVID, a significant portion of survivors can develop residual health problems, which is termed as long COVID. Although severe COVID-19 is generally associated with a high risk of long COVID, patients with asymptomatic or mild disease can also show long COVID. The definition of long COVID is inconsistent and its clinical manifestations are protean. In addition to general symptoms, such as fatigue, long COVID can affect many organ systems, including the respiratory, neurological, psychosocial, cardiovascular, gastrointestinal, and metabolic systems. Moreover, patients with long COVID may experience exercise intolerance and impaired daily function and quality of life. Long COVID may be caused by SARS-CoV-2 direct injury or its associated immune/inflammatory response. Assessment of patients with long COVID requires comprehensive evaluation, including history taking, physical examination, laboratory tests, radiography, and functional tests. However, there is no known effective treatment for long COVID. Based on the limited evidence, vaccines may help to prevent the development of long COVID. As long COVID is a new clinical entity that is constantly evolving, there are still many unknowns, and further investigation is warranted to enhance our understanding of this disease.

Out-of-hospital cardiac arrest and in-hospital mortality among COVID-19 patients: A population-based retrospective cohort study.

BACKGROUND/PURPOSE: Predictors for out-of-hospital cardiac arrest (OHCA) in COVID-19 patients remain unclear. We identified the predictors for OHCA and in-hospital mortality among such patients in community isolation centers. METHODS: From May 15 to June 20, 2021, this cohort study recruited 2555 laboratory-confirmed COVID-19 patients admitted to isolation centers in Taiwan. All patients were followed up until death, discharge from the isolation center or hospital, or July 16, 2021. OHCA was defined as cardiac arrest confirmed by the absence of circulation signs and occurring outside the hospital. Multinomial logistic regressions were used to determine factors associated with OHCA and in-hospital mortality. RESULTS: Of the 37 deceased patients, 7 (18.9%) had OHCA and 30 (81.1%) showed in-hospital mortality. The mean (SD) time to OHCA was 6.6 (3.3) days from the symptom onset. After adjusting for demographics and comorbidities, independent predictors for OHCA included age ≥65 years (adjusted odds ratio [AOR]: 13.24, 95% confidence interval [CI]: 1.85-94.82), fever on admission to the isolation center (AOR: 12.53, 95% CI: 1.68-93.34), and hypoxemia (an oxygen saturation level below 95% on room air) (AOR: 26.54, 95% CI: 3.18-221.73). Predictors for in-hospital mortality included age ≥65 years (AOR: 10.28, 95% CI: 2.95-35.90), fever on admission to the isolation centers (AOR: 7.27, 95% CI: 1.90-27.83), and hypoxemia (AOR: 29.87, 95% CI: 10.17-87.76). CONCLUSIONS: Time to OHCA occurrence is rapid in COVID-19 patients. Close monitoring of patients' vital signs and disease severity during isolation is important, particularly for those with older age, fever, and hypoxemia.

Monkeypox: An emerging global threat during the COVID-19 pandemic.

The emergence of the monkeypox outbreak in early 2022 has posed a new global health threat. As of July 8, 2022, 9069 laboratory-confirmed cases have been reported, and most of them are from non-endemic countries. The monkeypox virus is an enveloped double-stranded DNA virus, and preliminary genetic data suggest that the 2022 monkeypox virus belongs to the West African clade. In the current outbreak, human-to-human transmission has been the primary transmission mode. Although direct skin-to-skin contact with lesions during sexual activities can spread the virus, it remains unclear whether monkeypox can spread through sexual contact, specifically through contaminated body fluids. The typical presentation of monkeypox includes prodromal symptoms, followed by a rash that usually begins within 1-3 days of symptom onset, and the skin lesions can last for 2-4 weeks and then gradually resolve. However, the monkeypox outbreak in 2022 may exhibit atypical features. A definite diagnosis of monkeypox virus infection requires nucleic acid amplification testing via the polymerase chain reaction method. Supportive care is essential, and antiviral therapy is not considered for all affected patients, but recommended for those at highrisk for severe diseases. The mitigation of monkeypox outbreaks include enhanced case detection, case isolation, contact tracing, and post-exposure vaccination. In conclusion, the current monkeypox outbreak is a new threat during the COVID-19 pandemic. Clinicians should be aware of this new situation, which presents a different scenario from those of prior outbreaks. Global health systems should develop effective strategies to mitigate the spread of monkeypox.

The implications of the COVID-19 pandemic for long term care facilities.

PURPOSE OF REVIEW: Despite advances in infection prevention and control and breakthroughs in vaccination development, challenges remain for long-term care facilities (LTCFs) as they face a likely future of emerging infectious diseases. To ensure the safety of LTCF residents from the current and future pandemics, we identify lessons learned from the coronavirus disease 2019 (COVID-19) experience for improving future prevention and response efforts. RECENT FINDINGS: In addition to high disease susceptibility among LTCF residents, LTCF vulnerabilities include a lack of pandemic preparedness, a lack of surge capacity in human, material and testing resources, and poorly designed buildings. External sources of vulnerability include staff working in multiple LTCFs and high COVID-19 rates in surrounding communities. Other challenges include poor cooperation between LTCFs and the other components of health systems, inadequately enforced regulations, and the sometimes contradictory interests for-profit LTCFs face between protecting their residents and turning a profit. SUMMARY: These challenges can be addressed in the post-COVID-19 period through systemic reforms. Governments should establish comprehensive health networks that normalize mechanisms for prediction/preparedness and response/recovery from disruptive events including pandemics. In addition, governments should facilitate cooperation among public and private sector health systems and institutions while utilizing advanced digital communication technologies. These steps will greatly reduce the threat to LTCFs posed by emerging infectious diseases in future.

Taiwan's Response to Influenza: A Seroepidemiological Evaluation of Policies and Implications for Pandemic Preparedness.

OBJECTIVES: To evaluate class suspension and mass vaccination implemented among Taipei schoolchildren during the 2009 influenza pandemic and investigate factors affecting antibody responses. METHODS: We conducted 2 cohort studies on: (1) 972 schoolchildren from November 2009-March 2010 to evaluate pandemic policies and (2) 935 schoolchildren from November 2011-March 2012 to verify factors in antibody waning. Anti-influenza H1N1pdm09 hemagglutination inhibition antibodies (HI-Ab) were measured from serum samples collected before vaccination, and at 1 and 4 months after vaccination. Factors affecting HI-Ab responses were investigated through logistic regression and generalized estimating equation. RESULTS: Seroprevalence of H1N1pdm09 before vaccination was significantly higher among schoolchildren who experienced class suspensions than those who did not (59.6% vs 47.5%, p<0.05). Participating in after-school activities (adjusted odds ratio [aOR]=2.47, p=0.047) and having ≥3 hours per week of exercise (aOR=2.86, p=0.019) were significantly correlated with H1N1pdm09 infection. Two doses of the H1N1pdm09 vaccine demonstrated significantly better antibody persistence than 1 dose (HI-Ab geometric mean titer: 132.5 vs 88.6, p=0.047). Vaccine effectiveness after controlling for preexisting immunity was 86% (32%-97%). Exercise ≥3 hours per week and preexisting immunity were significantly associated with antibody waning/maintenance. CONCLUSIONS: This study is the first to show that exercise and preexisting immunity may affect antibody waning. Further investigation is needed to identify immune correlates of protection.

National surveillance of antimicrobial susceptibilities to dalbavancin, telavancin, tedizolid, eravacycline, omadacycline and other comparator antibiotics and serotype distribution of invasive Streptococcus pneumoniae isolates in adults: results from the Surveillance of Multicenter Antimicrobial Resistance in Taiwan (SMART) programme in 2017-2020.

OBJECTIVES: The aim of this study was to investigate the trends in serotypes and in vitro antimicrobial susceptibility of Streptococcus pneumoniae causing adult invasive pneumococcal disease (IPD) to dalbavancin, telavancin, tedizolid, eravacycline, omadacycline and other comparator antibiotics from 2017-2020 following implementation of the 13-valent pneumococcal conjugate vaccine (PCV-13) and during the COVID-19 (coronavirus disease 2019) pandemic. METHODS: During the study period, 237 S. pneumoniae isolates were collected from non-duplicate patients, covering 15.0% of IPD cases in Taiwan. Antimicrobial susceptibility testing was performed using a Sensititre® system. A latex agglutination method (ImmuLex™ Pneumotest Kit) was used to determine serotypes. RESULTS: Susceptibility rates were high for vancomycin (100%), teicoplanin (100%) and linezolid (100%), followed by ceftaroline (non-meningitis) (98.3%), moxifloxacin (94.9%) and quinupristin/dalfopristin (89.9%). MIC50 and MIC90 values of dalbavancin, telavancin, tedizolid, eravacycline and omadacycline were generally low. Non-vaccine serotype 23A was the leading cause of IPD across the adult age range. Isolates of serotype 15B were slightly fewer than those of PCV-13 serotypes in patients aged ≥65 years. The overall case fatality rate was 15.2% (36/237) but was especially high for non-PCV-13 serotype 15B (21.4%; 3/14). Vaccine coverage was 44.7% for PCV-13 and 49.4% for the 23-valent pneumococcal polysaccharide vaccine (PPSV-23), but was 57% for both PCV-13 and PPSV-23. CONCLUSION: The incidence of IPD was stationary after PCV-13 introduction and only dramatically decreased in the COVID-19 pandemic in 2020. The MIC50 and MIC90 values of dalbavancin, telavancin, tedizolid, eravacycline, omadacycline were generally low for S. pneumoniae causing adult IPD.

Nationwide surveillance of antimicrobial resistance in invasive isolates of Streptococcus pneumoniae in Taiwan from 2017 to 2019.

BACKGROUND/PURPOSE: Streptococcus pneumoniae causes pneumonia and other invasive diseases, and is a leading cause of mortality in the elderly population. The present study aimed to provide current antimicrobial resistance and epidemiological profiles of S. pneumoniae infections in Taiwan. METHODS: A total of 252 nonduplicate S. pneumoniae isolates were collected from patients admitted to 16 hospitals in Taiwan between January 2017 and December 2019, and were analyzed. The minimum inhibitory concentration of antibiotics was determined using the Vitek 2 automated system for antimicrobial susceptibility testing. Furthermore, epidemiological profiles of S. pneumoniae infections were analyzed. RESULTS: Among the strains analyzed, 88% were recognized as invasive pneumococcal strains. According to the Clinical and Laboratory Standards Institute criteria for non-meningitis, the prevalence of penicillin-non-susceptible S. pneumoniae demonstrated a declining trend from 43.6% in 2017 to 17.2% in 2019. However, the rate of penicillin-non-susceptible S. pneumoniae was 85.7% based on the criteria for meningitis. Furthermore, the prevalence of ceftriaxone-non-susceptible S. pneumoniae was 62.7% based on the criteria for meningitis. Isolates demonstrated higher susceptibility toward doripenem and ertapenem than toward meropenem and imipenem. An increased rate of non-susceptibility toward levofloxacin was observed in southern Taiwan (15.1%) and elderly patients (≥65 years; 11.4%). Most isolates were susceptible to vancomycin and linezolid. CONCLUSION: Empirical treatment with ceftriaxone monotherapy for pneumococcal meningitis should be carefully monitored owing to its high non-susceptibility rate. The susceptibility rates of most isolates to penicillin (used for treating non-meningitis pneumococcal diseases), carbapenems (ertapenem and doripenem), respiratory quinolones (moxifloxacin and levofloxacin), vancomycin, and linezolid suggested the potential of these antibiotics in treating pneumococcal diseases in Taiwan.

Learning from the past: Taiwan's responses to COVID-19 versus SARS.

OBJECTIVES: To evaluate the prevalence of infection prevention behaviors in Taiwan-wearing facemasks and alcohol-based hand hygiene (AHH)-and compare their practice rates during SARS and COVID-19. METHODS: We surveyed 2328 Taiwanese from July 29 to August 6, 2020, assessing demographics, information sources, and preventive behaviors during the 2003 SARS outbreaks, 2009 pandemic influenza H1N1, COVID-19, and with post-survey intentions. Characteristics associated with the practice of preventive behaviors in 2020 were identified through logistic regression. RESULTS: Preventive behaviors were conscientiously practiced by 70.2% of participants. Compared with 2003 SARS/2009 H1N1, the percentages of facemask use (66.6% vs 99.2% [indoors], P < 0.001) and on-person AHH (44.2% vs 65.4% [hand sanitizers], P < 0.001) significantly increasedduring 2020 COVID-19. Highest adherence to preventive behaviors in 2020 was among females (adjusted odds ratio [aOR], 1.72), those receiving government COVID-19 information (aOR, 1.52), participants recruited from primary-care clinics (aOR, 1.43), and those who practiced AHH during 2003 SARS/2009 H1N1 (aOR, 1.37). CONCLUSIONS: Government leadership, healthcare providers risk communication, and public cooperation rapidly mitigated the spread of COVID-19 in Taiwan even before vaccination. Future global efforts must implement such population-based preventive behaviors at a level above the viral-transmission-threshold, particularly in areas with fast-spreading SARS-CoV-2 variants.

The impact of the coronavirus disease 2019 epidemic on notifiable infectious diseases in Taiwan: A database analysis.

INTRODUCTION: The impact of the COVID-19 pandemic on the incidence of notifiable infectious diseases (NIDs) in Taiwan remains unclear. MATERIALS AND METHODS: The number of cases of NID (n = 42) between January and September 2019 and 2020 were obtained from the open database from Taiwan Centers for Disease Control. RESULTS: The number of NID cases was 21,895 between January and September 2020, which was lower than the number of cases during the same period in 2019 (n = 24,469), with a decline in incidence from 102.9 to 91.7 per 100,000 people in 2019 and 2020, respectively. Fourteen airborne/droplet, 11 fecal-oral, seven vector-borne, and four direct-contact transmitted NID had an overall reduction of 2700 (-28.1%), 156 (-23.0%), 557 (-54.8%), and 73 (-45.9%) cases, respectively, from 2019 to 2020. Similar trends were observed for the changes in incidence, which were 11.5 (-28.4%), 6.7 (-23.4%), 2.4 (-55.0%), and 0.3 (-46.2%) per 100,000 people for airborne/droplet, fecal-oral, vector-borne, and direct-contact transmitted NID, respectively. In addition, all the 38 imported NID showed a reduction of 632 (-73.5%) cases from 2019 to 2020. In contrast, 4 sexually transmitted diseases (STDs) showed an increase of 903 (+7.2%) cases from 2019 to 2020, which was attributed to the increase in gonorrhea (from 3220 to 5028). The overall incidence of STDs increased from 52.5 to 56.0 per 100,000 people, with a percentage change of +6.7%. CONCLUSION: This study demonstrated a collateral benefit of COVID-19 prevention measures for various infectious diseases, except STDs, in Taiwan, during the COVID-19 epidemic.

Protecting Healthcare Workers During the Coronavirus Disease 2019 (COVID-19) Outbreak: Lessons From Taiwan's Severe Acute Respiratory Syndrome Response.

During major epidemic outbreaks, demand for healthcare workers (HCWs) grows even as the extreme pressures they face cause declining availability. We draw on Taiwan's severe acute respiratory syndrome (SARS) experience to argue that a modified form of traffic control bundling (TCB) protects HCW safety and by extension strengthens overall coronavirus disease 2019 (COVID-19) epidemic control.

Recommendations for protecting against and mitigating the COVID-19 pandemic in long-term care facilities.

The COVID-19 outbreak has drawn heightened attention from public health scholars researching ways to limit its spread. Much of the research has been focused on minimizing transmission in hospitals and in the general community. However, a particularly vulnerable community that has received relatively little attention is elders residing in long-term care facilities (LTCFs). In this article we address this relative lack of attention, arguing that enhanced traffic control bundling (eTCB) can and should be adopted and implemented as a means of protecting LTCF residents and staff. Enhanced TCB has been widely applied in hospital settings and has proven effective at limiting droplet and fomite transmissions both within hospitals and between hospitals and the general community. By effectively adapting eTCB to LTCF conditions, particularly by incorporating compartmentalization within zones plus active surveillance, COVID-19 transmission into and throughout LTCFs can be minimized, thereby saving numerous lives among an especially vulnerable population.

Interrupting COVID-19 transmission by implementing enhanced traffic control bundling: Implications for global prevention and control efforts.

We argue that enhanced Traffic Control Bundling (eTCB) can interrupt the community-hospital-community transmission cycle, thereby limiting COVID-19's impact. Enhanced TCB is an expansion of the traditional TCB that proved highly effective during Taiwan's 2003 SARS outbreak. TCB's success derived from ensuring that Health Care Workers (HCWs) and patients were protected from fomite, contact and droplet transmission within hospitals. Although TCB proved successful during SARS, achieving a similar level of success with the COVID-19 outbreak requires adapting TCB to the unique manifestations of this new disease. These manifestations include asymptomatic infection, a hyper-affinity to ACE2 receptors resulting in high transmissibility, false negatives, and an incubation period of up to 22 days. Enhanced TCB incorporates the necessary adaptations. In particular, eTCB includes expanding the TCB transition zone to incorporate a new sector - the quarantine ward. This ward houses patients exhibiting atypical manifestations or awaiting definitive diagnosis. A second adaptation involves enhancing the checkpoint hand disinfection and gowning up with Personal Protective Equipment deployed in traditional TCB. Under eTCB, checkpoint hand disinfection and donning of face masks are now required of all visitors who seek to enter hospitals. These enhancements ensure that transmissions by droplets, fomites and contact are disrupted both within hospitals and between hospitals and the broader community. Evidencing eTCB effectiveness is Taiwan's success to date in containing and controlling the community-hospital-community transmission cycle.