Struggling to resume childhood vaccination during war in Myanmar: evaluation of a pilot program.

BACKGROUND: After the military coup in Myanmar in February 2021, the health system began to disintegrate when staff who called for the restoration of the democratic government resigned and fled to states controlled by ethnic minorities. The military retaliated by blocking the shipment of humanitarian aid, including vaccines, and attacked the ethnic states. After two years without vaccines for their children, parents urged a nurse-led civil society organization in an ethnic state to find a way to resume vaccination. The nurses developed a vaccination program, which we evaluated. METHODS: A retrospective cohort study and participatory evaluation were conducted. We interviewed the healthcare workers about vaccine acquisition, transportation, and administration and assessed compliance with WHO-recommended practices. We analyzed the participating children's characteristics. We calculated the proportion of children vaccinated before and after the program. We calculated the probability children would become up-to-date after the program using inverse survival. RESULTS: Since United Nations agencies could not assist, private donations were raised to purchase, smuggle into Myanmar, and administer five vaccines. Cold chain standards were maintained. Compliance with other WHO-recommended vaccination practices was 74%. Of the 184 participating children, 145 (79%, median age five months [IQR 6.5]) were previously unvaccinated, and 71 (41%) were internally displaced. During five monthly sessions, the probability that age-eligible zero-dose children would receive the recommended number of doses of MMR was 92% (95% confidence interval [CI] 83-100%), Penta 87% (95% CI 80%-94%); BCG 76% (95% CI 69%-83%); and OPV 68% (95% CI 59%-78%). Migration of internally displaced children and stockouts of vaccines were the primary factors responsible for decreased coverage. CONCLUSIONS: This is the first study to describe the situation, barriers, and outcomes of a childhood vaccination program in one of the many conflict-affected states since the coup in Myanmar. Even though the proportion of previously unvaccinated children was large, the program was successful. While the target population was necessarily small, the program's success led to a donor-funded expansion to 2,000 children. Without renewed efforts, the proportion of unvaccinated children in other parts of Myanmar will approach 100%.

Comparative epidemiology of bacteraemia in two ageing populations: Singapore and Denmark.

Burden of bacteraemia is rising due to increased average life expectancy in developed countries. This study aimed to compare the epidemiology and outcomes of bacteraemia in two similarly ageing populations with different ethnicities in Singapore and Denmark. Historical cohorts from the second largest acute-care hospital in Singapore and in the hospitals of two Danish regions included patients aged 15 and above who were admitted from 1 January 2006 to 31 December 2016 with at least 1 day of hospital stay and a pathogenic organism identified. Among 13 144 and 39 073 bacteraemia patients from Singapore and Denmark, similar 30-day mortality rates (16.5%; 20.3%), length of hospital stay (median 14 (IQR: 9-28) days; 11 (6-21)), and admission rate to ICU (15.5%; 15.6%) were observed, respectively. Escherichia coli, Klebsiella pneumoniae, and Staphylococcus aureus ranked among the top four in both countries. However, Singaporeans had a higher proportion of patients with diabetes (46.8%) and renal disease (29.5%) than the Danes (28.0% and 13.7%, respectively), whilst the Danes had a higher proportion of patients with chronic pulmonary disease (18.0%) and malignancy (35.3%) than Singaporeans (9.7% and 16.2%, respectively). Our study showed that top four causative organisms and clinical outcomes were similar between the two cohorts despite pre-existing comorbidities differed.

0D van der Waals interfacial ferroelectricity.

The dimensional limit of ferroelectricity has been long explored. The critical contravention is that the downscaling of ferroelectricity leads to a loss of polarization. This work demonstrates a zero-dimensional ferroelectricity by the atomic sliding at the restrained van der Waals interface of crossed tungsten disufilde nanotubes. The developed zero-dimensional ferroelectric diode in this work presents not only non-volatile resistive memory, but also the programmable photovoltaic effect at the visible band. Benefiting from the intrinsic dimensional limitation, the zero-dimensional ferroelectric diode allows electrical operation at an ultra-low current. By breaking through the critical size of depolarization, this work demonstrates the ultimately downscaled interfacial ferroelectricity of zero-dimensional, and contributes to a branch of devices that integrates zero-dimensional ferroelectric memory, nano electro-mechanical system, and programmable photovoltaics in one.

Rapid Production of Carbon Nanotube Film for Bioelectronic Applications.

Flexible electronics have enormous potential for applications that are not achievable in standard electronics. In particular, important technological advances have been made in terms of their performance characteristics and potential range of applications, ranging from medical care, packaging, lighting and signage, consumer electronics, and alternative energy. In this study, we develop a novel method for fabricating flexible conductive carbon nanotube (CNT) films on various substrates. The fabricated conductive CNT films exhibited satisfactory conductivity, flexibility, and durability. The conductivity of the conductive CNT film was maintained at the same level of sheet resistance after bending cycles. The fabrication process is dry, solution-free, and convenient for mass production. Scanning electron microscopy revealed that CNTs were uniformly dispersed over the substrate. The prepared conductive CNT film was applied to collect an electrocardiogram (ECG) signal, which showed good performance compared to traditional electrodes. The conductive CNT film determined the long-term stability of the electrodes under bending or other mechanical stresses. The well-demonstrated fabrication process for flexible conductive CNT films has great potential in the field of bioelectronics.

Curing Regime-Modulating Insulation Performance of Anhydride-Cured Epoxy Resin: A Review.

Anhydride-cured bisphenol-A epoxy resin is widely used in the support, insulation and sealing key components of electrical and electronic equipment due to their excellent comprehensive performance. However, overheating and breakdown faults of epoxy resin-based insulation occur frequently under conditions of large current carrying and multiple voltage waveforms, which seriously threaten the safe and stable operation of the system. The curing regime, including mixture ratio and combination of curing time and temperature, is an important factor to determine the microstructure of epoxy resin, and also directly affects its macro performances. In this paper, the evolution of curing kinetic models of anhydride-cured epoxy resin was introduced to determine the primary curing regime. The influences of curing regime on the insulation performance were reviewed considering various mixture ratios and combinations of curing time and temperature. The curing regime-dependent microstructure was discussed and attributed to the mechanisms of insulation performance.

Mesoscopic sliding ferroelectricity enabled photovoltaic random access memory for material-level artificial vision system.

Intelligent materials with adaptive response to external stimulation lay foundation to integrate functional systems at the material level. Here, with experimental observation and numerical simulation, we report a delicate nano-electro-mechanical-opto-system naturally embedded in individual multiwall tungsten disulfide nanotubes, which generates a distinct form of in-plane van der Waals sliding ferroelectricity from the unique combination of superlubricity and piezoelectricity. The sliding ferroelectricity enables programmable photovoltaic effect using the multiwall tungsten disulfide nanotube as photovoltaic random-access memory. A complete "four-in-one" artificial vision system that synchronously achieves full functions of detecting, processing, memorizing, and powering is integrated into the nanotube devices. Both labeled supervised learning and unlabeled reinforcement learning algorithms are executable in the artificial vision system to achieve self-driven image recognition. This work provides a distinct strategy to create ferroelectricity in van der Waals materials, and demonstrates how intelligent materials can push electronic system integration at the material level.

Economic and fast electro-flotation extraction of heavy metals from wastewater.

Fast electroflotation extraction of heavy metals from wastewater is described. The results of experimental investigations of the extraction of iron, aluminium and chromium hydroxides from aqueous solutions in the presence of surfactants of various natures and ions of calcium by electroflotation are presented. It was found that the presence of Ca2+ in the solution at a concentration of 0.5 g/L reduced the degree of electroflotation extraction of Al(OH)3, Fe(OH)3, Cr(OH)3 regardless of the nature of the electrolyte. The addition of surfactants in the system in the presence of Ca2+ increased the amount of extraction of the dispersed phase. The greatest effect is achieved with the help of anionic surfactant sodium dodecyl sulphate, while the degree of extraction reached 98%. The high efficiency of the process of electroflotation extraction of the dispersed phase was due to the hydrophobization of the particle surface owing to the adsorption of surfactants on the surface of hydroxides. The recent method is useful to treat wastewater contaminated with aluminium, iron and chromium metal ions. The reason is that this method is very fast working within 20 min; Moreover, pH 7.0 working made this method ideal for utilisation in natural water treatment economically.

Standards of liver cirrhosis care in Central Australia.

BACKGROUND: Liver cirrhosis and hepatocellular carcinoma (HCC) are highly prevalent in Australia's Northern Territory. Contributing factors include high levels of alcohol consumption, viral hepatitis and metabolic syndrome. Rural Aboriginal residents form a significant proportion of the Central Australian population and present a challenge to traditional models of liver care. HCC surveillance and variceal screening are core components of liver cirrhosis management. AIM: To assess participation in HCC and variceal surveillance programmes in a Central Australian liver cirrhosis patient cohort. METHODS: Retrospective cohort study of patients with liver cirrhosis presenting to Alice Springs Hospital, Australia between January 1, 2012 and December 31, 2017. Demographic data, disease severity, attendance at hepatology clinics, participation in variceal and/or HCC surveillance programmes was recorded. Regression analyses were conducted to assess factors associated with two independent outcomes: Participation in HCC and variceal surveillance. RESULTS: Of 193 patients were identified. 82 patients (42.4%) were female. 154 patients (80%) identified as Aboriginal. Median Model for End-stage Liver Disease Score at diagnosis was 11. Alcohol was the most common cause of cirrhosis. Aboriginal patients were younger than non-Aboriginal patients (48.4 years vs 59.9 years, P < 0.001). There were similar rates of excess alcohol intake (72.6% vs 66.7%, P = 0.468) and obesity (34.5% vs 38.4%, P = 0.573 across non-Aboriginal and Aboriginal cohorts. 20.1% of patients took part in HCC surveillance and 42.1% of patients completed variceal screening. Aboriginal patients were less likely to engage with either HCC surveillance (OR: 0.38, 95%CI: 0.16-0.9, P = 0.025) or undergo variceal screening (OR: 0.31, 95%CI: 0.14-0.65, P = 0.002). CONCLUSION: HCC or variceal surveillance programmes had less uptake amongst Aboriginal patients. Greater emphasis needs to be placed on eliminating cultural obstacles to accessing hepatology services.

Intranasal octenidine for methicillin-resistant Staphylococcus aureus (MRSA) carriers and universal octenidine bathing reduced MRSA acquisition in an acute-care general ward.

In this quasi-experimental before-and-after study in a methicillin-resistant staphylococcus aureus (MRSA) high-prevalence acute-care dermatology ward from August 2016 to November 2018, patients admitted during intervention period who received additional topical intranasal octenidine were 63% less likely to acquire MRSA than those receiving universal daily octenidine bathing alone during baseline period (aOR, 0.37; 95% CI, 0.14-0.98).

Sociodemographic and clinical factors, visit expectations and driving factors for emergency department attendance for uncomplicated upper respiratory tract infection.

BACKGROUND: Upper respiratory tract infections (URTIs) account for substantial non-urgent ED attendances. Hence, we explored the reasons for such attendances using a mixed-methods approach. METHODS: We interviewed adult patients with URTI who visited the second busiest adult ED in Singapore from June 2016 to November 2018 on their expectations and reasons for attendance. A structured questionnaire, with one open-ended question was used. Using the Andersen's Behavioural Model for Healthcare Utilisation, the topmost reasons for ED attendances were categorised into (1) contextual predisposing factors (referral by primary care physician, family, friends or coworkers), (2) contextual enabling factors (convenience, accessibility, employment requirements), (3) individual enablers (personal preference and trust in hospital-perceived care quality and efficiency) and (4) individual needs (perceived illness severity and non-improvement). Multivariable multinomial logistic regression was used to assess associations between sociodemographic and clinical factors, patient expectations for ED visits and the drivers for ED attendance. RESULTS: There were 717 patients in the cohort. The mean age of participants was 40.5 (SD 14.7) years, 61.2% were males, 66.5% without comorbidities and 40.7% were tertiary educated. Half had sought prior medical consultation (52.4%) and expected laboratory tests (55.7%) and radiological investigations (46.9%). Individual needs (32.8%) and enablers (25.1%) were the main drivers for ED attendance. Compared with ED attendances due to contextual enabling factors, attendances due to other drivers were more likely to be aged ≥45 years, had prior medical consultation and expected radiological investigations. Having a pre-existing medical condition (adjusted OR (aOR) 1.78, 95% CI 1.05 to 3.04) and an expectation for laboratory tests (aOR 1.64, 95% CI 1.01 to 2.64) were associated with individual needs while being non-tertiary educated (aOR 2.04, 95% CI 1.22 to 3.45) and having pre-existing comorbidities (aOR 1.79, 95% CI 1.04 to 3.10) were associated with individual enablers. CONCLUSIONS: Meeting individual needs of perceived illness severity or non-improvement was the topmost driver of ED visits for URTI, while contextual enabling factors such as convenience was the lowest. Patients' sociodemographic and clinical factors and visit expectations influence their motivations for ED attendances. Addressing these factors and expectations can alleviate the overutilisation of ED services.

Case Report: Children with Severe Nutritional Rickets in the Naga Region in Northwest Myanmar, on the border with India.

Rickets is an often-neglected, painful, and disabling childhood condition of impaired bone mineralization. In this case series we describe a cluster of 29 children with severe, painful bone deformities who live in the very remote region of Nagaland in northwest Myanmar. Children were found to have low 25-hydroxyvitamin D, elevated parathyroid hormone, and elevated alkaline phosphatase levels, consistent with nutritional rickets secondary to vitamin D deficiency, calcium deficiency, or a combination of the two. After treatment with vitamin D3 and calcium carbonate, significant improvement was seen in symptoms, biochemistry, and radiography. This is the first report of nutritional rickets in Myanmar in more than 120 years. Vitamin D and calcium supplementation, and food fortification for pregnant women and young children may be required to prevent this potentially devastating disease.

Mass drug administration for the acceleration of malaria elimination in a region of Myanmar with artemisinin-resistant falciparum malaria: a cluster-randomised trial.

BACKGROUND: To contain multidrug-resistant Plasmodium falciparum, malaria elimination in the Greater Mekong subregion needs to be accelerated while current antimalarials remain effective. We evaluated the safety, effectiveness, and potential resistance selection of dihydroartemisinin-piperaquine mass drug administration (MDA) in a region with artemisinin resistance in Myanmar. METHODS: We did a cluster-randomised controlled trial in rural community clusters in Kayin (Karen) state in southeast Myanmar. Malaria prevalence was assessed using ultrasensitive quantitative PCR (uPCR) in villages that were operationally suitable for MDA (villages with community willingness, no other malaria control campaigns, and a population of 50-1200). Villages were eligible to participate if the prevalence of malaria (all species) in adults was greater than 30% or P falciparum prevalence was greater than 10% (or both). Contiguous villages were combined into clusters. Eligible clusters were paired based on P falciparum prevalence (estimates within 10%) and proximity. Community health workers provided routine malaria case management and distributed long-lasting insecticidal bed-nets (LLINs) in all clusters. Randomisation of clusters (1:1) to the MDA intervention group or control group was by public coin-flip. Group allocations were not concealed. Three MDA rounds (3 days of supervised dihydroartemisinin-piperaquine [target total dose 7 mg/kg dihydroartemisinin and 55 mg/kg piperaquine] and single low-dose primaquine [target dose 0·25 mg base per kg]) were delivered to intervention clusters. Parasitaemia prevalence was assessed at 3, 5, 10, 15, 21, 27, and 33 months. The primary outcomes were P falciparum prevalence at months 3 and 10. All clusters were included in the primary analysis. Adverse events were monitored from the first MDA dose until 1 month after the final dose, or until resolution of any adverse event occurring during follow-up. This trial is registered with ClinicalTrials.gov, NCT01872702. FINDINGS: Baseline uPCR malaria surveys were done in January, 2015, in 43 villages that were operationally suitable for MDA (2671 individuals). 18 villages met the eligibility criteria. Three villages in close proximity were combined into one cluster because a border between them could not be defined. This gave a total of 16 clusters in eight pairs. In the intervention clusters, MDA was delivered from March 4 to March 17, from March 30 to April 10, and from April 27 to May 10, 2015. The weighted mean absolute difference in P falciparum prevalence in the MDA group relative to the control group was -10·6% (95% CI -15·1 to -6·1; p=0·0008) at month 3 and -4·5% (-10·9 to 1·9; p=0·14) at month 10. At month 3, the weighted P falciparum prevalence was 1·4% (0·6 to 3·6; 12 of 747) in the MDA group and 10·6% (7·0 to 15·6; 56 of 485) in the control group. Corresponding prevalences at month 10 were 3·2% (1·5 to 6·8; 34 of 1013) and 5·8% (2·5 to 12·9; 33 of 515). Adverse events were reported for 151 (3·6%) of 4173 treated individuals. The most common adverse events were dizziness (n=109) and rash or itching (n=20). No treatment-related deaths occurred. INTERPRETATION: In this low-transmission setting, the substantial reduction in P falciparum prevalence resulting from support of community case management was accelerated by MDA. In addition to supporting community health worker case management and LLIN distribution, malaria elimination programmes should consider using MDA to reduce P falciparum prevalence rapidly in foci of higher transmission. FUNDING: The Global Fund to Fight AIDS, Tuberculosis and Malaria.

Epidemiology and Transmission of Carbapenemase-Producing Enterobacteriaceae in a Health Care Network of an Acute-Care Hospital and Its Affiliated Intermediate- and Long-Term-Care Facilities in Singapore.

Movement of patients in a health care network poses challenges for the control of carbapenemase-producing Enterobacteriaceae (CPE). We aimed to identify intra- and interfacility transmission events and facility type-specific risk factors of CPE in an acute-care hospital (ACH) and its intermediate-term and long-term-care facilities (ILTCFs). Serial cross-sectional studies were conducted in June and July of 2014 to 2016 to screen for CPE. Whole-genome sequencing was done to identify strain relatedness and CPE genes (blaIMI, blaIMP-1, blaKPC-2, blaNDM-1, and blaOXA-48). Multivariable logistic regression models, stratified by facility type, were used to determine independent risk factors. Of 5,357 patients, half (55%) were from the ACH. CPE prevalence was 1.3% in the ACH and 0.7% in ILTCFs (P = 0.029). After adjusting for sociodemographics, screening year, and facility type, the odds of CPE colonization increased significantly with a hospital stay of ≥3 weeks (adjusted odds ratio [aOR], 2.67; 95% confidence interval [CI], 1.17 to 6.05), penicillin use (aOR, 3.00; 95% CI, 1.05 to 8.56), proton pump inhibitor use (aOR, 3.20; 95% CI, 1.05 to 9.80), dementia (aOR, 3.42; 95% CI, 1.38 to 8.49), connective tissue disease (aOR, 5.10; 95% CI, 1.19 to 21.81), and prior carbapenem-resistant Enterobacteriaceae (CRE) carriage (aOR, 109.02; 95% CI, 28.47 to 417.44) in the ACH. For ILTCFs, presence of wounds (aOR, 5.30; 95% CI, 1.01 to 27.72), respiratory procedures (aOR, 4.97; 95% CI, 1.09 to 22.71), vancomycin-resistant enterococcus carriage (aOR, 16.42; 95% CI, 1.52 to 177.48), and CRE carriage (aOR, 758.30; 95% CI, 33.86 to 16,982.52) showed significant association. Genomic analysis revealed only possible intra-ACH transmission and no evidence for ACH-to-ILTCF transmission. Although CPE colonization was predominantly in the ACH, risk factors varied between facilities. Targeted screening and precautionary measures are warranted.

Risk prediction models to guide antibiotic prescribing: a study on adult patients with uncomplicated upper respiratory tract infections in an emergency department.

BACKGROUND: Appropriate antibiotic prescribing is key to combating antimicrobial resistance. Upper respiratory tract infections (URTIs) are common reasons for emergency department (ED) visits and antibiotic use. Differentiating between bacterial and viral infections is not straightforward. We aim to provide an evidence-based clinical decision support tool for antibiotic prescribing using prediction models developed from local data. METHODS: Seven hundred-fifteen patients with uncomplicated URTI were recruited and analysed from Singapore's busiest ED, Tan Tock Seng Hospital, from June 2016 to November 2018. Confirmatory tests were performed using the multiplex polymerase chain reaction (PCR) test for respiratory viruses and point-of-care test for C-reactive protein. Demographic, clinical and laboratory data were extracted from the hospital electronic medical records. Seventy percent of the data was used for training and the remaining 30% was used for validation. Decision trees, LASSO and logistic regression models were built to predict when antibiotics were not needed. RESULTS: The median age of the cohort was 36 years old, with 61.2% being male. Temperature and pulse rate were significant factors in all 3 models. The area under the receiver operating curve (AUC) on the validation set for the models were similar. (LASSO: 0.70 [95% CI: 0.62-0.77], logistic regression: 0.72 [95% CI: 0.65-0.79], decision tree: 0.67 [95% CI: 0.59-0.74]). Combining the results from all models, 58.3% of study participants would not need antibiotics. CONCLUSION: The models can be easily deployed as a decision support tool to guide antibiotic prescribing in busy EDs.

Use of a Real-Time Locating System for Contact Tracing of Health Care Workers During the COVID-19 Pandemic at an Infectious Disease Center in Singapore: Validation Study.

BACKGROUND: In early 2020, coronavirus disease (COVID-19) emerged and spread by community and nosocomial transmission. Effective contact tracing of potentially exposed health care workers is crucial for the prevention and control of infectious disease outbreaks in the health care setting. OBJECTIVE: This study aimed to evaluate the comparative effectiveness of contact tracing during the COVID-19 pandemic through the real-time locating system (RTLS) and review of the electronic medical record (EMR) at the designated hospital for COVID-19 response in Singapore. METHODS: Over a 2-day study period, all admitted patients with COVID-19, their ward locations, and the health care workers rostered to each ward were identified to determine the total number of potential contacts between patients with COVID-19 and health care workers. The numbers of staff-patient contacts determined by EMR reviews, RTLS-based contact tracing, and a combination of both methods were evaluated. The use of EMR-based and RTLS-based contact tracing methods was further validated by comparing their sensitivity and specificity against self-reported staff-patient contacts by health care workers. RESULTS: Of 796 potential staff-patient contacts (between 17 patients and 162 staff members), 104 (13.1%) were identified by both the RTLS and EMR, 54 (6.8%) by the RTLS alone, and 99 (12.4%) by the EMR alone; 539 (67.7%) were not identified through either method. Compared to self-reported contacts, EMR reviews had a sensitivity of 47.2% and a specificity of 77.9%, while the RTLS had a sensitivity of 72.2% and a specificity of 87.7%. The highest sensitivity was obtained by including all contacts identified by either the RTLS or the EMR (sensitivity 77.8%, specificity 73.4%). CONCLUSIONS: RTLS-based contact tracing showed higher sensitivity and specificity than EMR review. Integration of both methods provided the best performance for rapid contact tracing, although technical adjustments to the RTLS and increasing user compliance with wearing of RTLS tags remain necessary.

Seasonal influenza-associated intensive care unit admission and death in tropical Singapore, 2011-2015.

BACKGROUND: Seasonal influenza can cause severe illness leading to intensive care unit (ICU) admission and death. OBJECTIVE: To define the clinical and epidemiological features of severe seasonal influenza infection and factors associated with mortality. STUDY DESIGN: A retrospective review was conducted on all patients with laboratory-confirmed influenza infection who were either admitted into the ICU or died in the two largest tertiary hospitals in Singapore from 2011-2015. RESULTS: Of 520 patients included in our study, 423 (81.3%) had influenza A infection and the rest with influenza B. Of patients with influenza A infection, 70.0% (296/423) were subtyped, of whom 24.0% (71/296) had A/H1N1pdm2009 and 76.0% (225/296) had A/H3N2. The median age of patients was 72 years (IQR 61-82). Males constituted 53.1% (276/520). Median Charlson comorbidity index score was 1 (IQR 0-3). About 70% had physical or radiological evidence of pneumonia upon admission. In-hospital mortality was 58.1% (302/520). On multiple logistic regression analysis, factors positively associated with mortality were age ≥65 years (adjusted odds ratio, aOR = 3.64, 95%CI 2.21-5.99, p < 0.001), malignancy (aOR = 2.53, 95%CI 1.12-5.73; p = 0.026), and hypoalbuminemia (aOR = 2.16, 95%CI 1.26-3.73; p = 0.005), while antiviral therapy (aOR = 0.33, 95%CI 0.17-0.63; p < 0.001) and ventilation (aOR = 0.23, 95% CI 0.13-0.39; p < 0.001) were negatively associated. CONCLUSIONS: Patients with severe seasonal influenza infection were characterized by advanced age, hypoalbuminemia and presence of pneumonia on admission. Age ≥65 years, malignancy, and hypoalbuminemia were associated with increased mortality, and antiviral therapy and ventilation with decreased mortality.