Characterization of Unlinked Cases of COVID-19 and Implications for Contact Tracing Measures: Retrospective Analysis of Surveillance Data.

BACKGROUND: Contact tracing and intensive testing programs are essential for controlling the spread of COVID-19. However, conventional contact tracing is resource intensive and may not result in the tracing of all cases due to recall bias and cases not knowing the identity of some close contacts. Few studies have reported the epidemiological features of cases not identified by contact tracing ("unlinked cases") or described their potential roles in seeding community outbreaks. OBJECTIVE: For this study, we characterized the role of unlinked cases in the epidemic by comparing their epidemiological profile with the linked cases; we also estimated their transmission potential across different settings. METHODS: We obtained rapid surveillance data from the government, which contained the line listing of COVID-19 confirmed cases during the first three waves in Hong Kong. We compared the demographics, history of chronic illnesses, epidemiological characteristics, clinical characteristics, and outcomes of linked and unlinked cases. Transmission potentials in different settings were assessed by fitting a negative binomial distribution to the observed offspring distribution. RESULTS: Time interval from illness onset to hospital admission was longer among unlinked cases than linked cases (median 5.00 days versus 3.78 days; P<.001), with a higher proportion of cases whose condition was critical or serious (13.0% versus 8.2%; P<.001). The proportion of unlinked cases was associated with an increase in the weekly number of local cases (P=.049). Cluster transmissions from the unlinked cases were most frequently identified in household settings, followed by eateries and workplaces, with the estimated probability of cluster transmissions being around 0.4 for households and 0.1-0.3 for the latter two settings. CONCLUSIONS: The unlinked cases were positively associated with time to hospital admission, severity of infection, and epidemic size-implying a need to design and implement digital tracing methods to complement current conventional testing and tracing. To minimize the risk of cluster transmissions from unlinked cases, digital tracing approaches should be effectively applied in high-risk socioeconomic settings, and risk assessments should be conducted to review and adjust the policies.

Assessing the impact of non-pharmaceutical interventions on the transmissibility and severity of COVID-19 during the first five months in the Western Pacific Region.

While most countries in the Western Pacific Region (WPR) had similar trajectories of COVID-19 from January to May, their implementations of non-pharmaceutical interventions (NPIs) differed by transmission stages. To offer a better understanding for an implementation of multidisciplinary policies in COVID-19 control, we compared the impact of NPIs by assessing the transmissibility and severity of COVID-19 in different phases of the epidemic during the first five months in WPR. In this study, we estimated the piecewise instantaneous reproduction number (R t ) and the reporting delay-adjusted case-fatality ratio (dCFR) of COVID-19 in seven WPR jurisdictions: Hong Kong Special Administrative Region, Japan, Malaysia, Shanghai, Singapore, South Korea, and Taiwan. According to the results, implementing NPIs was associated with an apparent reduction of the piecewise R t in two epidemic waves in general. However, large cluster outbreaks raised the piecewise R t to a high level. We also observed relaxing the NPIs could result in an increase of R t . The estimated dCFR ranged from 0.09% to 1.59% among the jurisdictions, except in Japan where an estimate of 5.31% might be due to low testing efforts. To conclude, in conjunction with border control measures to reduce influx of imported cases which might cause local outbreaks, other NPIs including social distancing measures along with case finding by rapid tests are also necessary to prevent potential large cluster outbreaks and transmissions from undetected cases. A comparatively lower CFR may reflect the health system capacity of these jurisdictions. In order to keep track of sustained disease transmission due to resumption of economic activities, a close monitoring of disease transmissibility is recommended in the relaxation phase. The report of transmission of SARS CoV-2 to pets in Hong Kong and to mink in farm outbreaks highlight for the control of COVID-19 and emerging infectious disease, the One Health approach is critical in understanding and accounting for how human, animals and environment health are intricately connected.

Examining the Gaps and Issues of End-of-Life Care among Older Population through the Lens of Socioecological Model-A Multi-Method Qualitative Study of Hong Kong.

End-of-life (EOL) care for terminal illness and life-limiting conditions is a sector in the health service spectrum that is drawing increased attention. Despite having the world's longest life expectancy and an ever-escalating demand for long-term care, Hong Kong's EOL care was underdeveloped. The current study aims to provide a holistic picture of gaps and issues to EOL care in Hong Kong. Data collection was conducted using a multi-method qualitative approach that included focus groups and in-depth interviews with key informants and stakeholders, and longitudinal case studies with patients and families. Deductive thematic analysis was used to examine service gaps in current EOL care through the lens of a socioecological model where gaps and issues in various nested, hierarchical levels of care as well as the relationships between these levels were studied in detail. Using the model, we identified gaps and issues of EOL care among older populations in Hong Kong at the policy, legal, community, institutional, as well as intrapersonal and interpersonal levels. These include but are not limited to a lack of overarching EOL care policy framework, ambiguity in the legal basis for mental incapacity, legislative barriers for advance directives, inadequate capacity, resources, and support in the community to administer EOL care, inadequate knowledge, training, and resources for EOL care in health and social care sectors, inadequate medical-social interface, general reluctance and fear of death and dying, as well as the cultural interpretation of filial piety that may lengthen the suffering of the dying patients. Findings highlight the multi-level gaps and issues of EOL care in a place where western and eastern culture meet, and shed light on how best to design more effective and comprehensive policy interventions that will likely have a more sustainable and instrumental impact on facilitating person-centered EOL care during the end of life.

MicroRNA changes in rat mesentery and serum associated with drug-induced vascular injury.

Regulatory miRNAs play a role in vascular biology and are involved in biochemical and molecular pathways dysregulated during vascular injury. Collection and integration of functional miRNA data into these pathways can provide insight into pathogenesis at the site of injury; the same technologies applied to biofluids may provide diagnostic or surrogate biomarkers. miRNA was analyzed from mesentery and serum from rats given vasculotoxic compounds for 4 days. Fenoldopam, dopamine and midodrine each alter hemodynamics and are associated with histologic evidence of vascular injury, while yohimbine is vasoactive but does not cause histologic evidence of vascular injury in rat. There were 38 and 35 miRNAs altered in a statistically significant manner with a fold change of 2 or greater in mesenteries of fenoldopam- and dopamine-dosed rats, respectively, with 9 of these miRNAs shared. 10 miRNAs were altered in rats given midodrine; 6 were shared with either fenoldopam or dopamine. In situ hybridization demonstrated strong expression and co-localization of miR-134 in affected but not in adjacent unaffected vessels. Mesenteric miRNA expression may provide clarity or avenues of research into mechanisms involved in vascular injury once the functional role of specific miRNAs becomes better characterized. 102 miRNAs were altered in serum from rats with drug-induced vascular injury. 10 miRNAs were commonly altered in serum from dopamine and either fenoldopam or midodrine dosed rats; 18 of these 102 were also altered in mesenteries from rats with drug-induced vascular injury, suggesting their possible utility as peripheral biomarkers.

Examining factors associated with the length of short-term disability-free days among workers with previous short-term disability episodes.

OBJECTIVE: The purpose of this study is to examine the timing of short-term disability recurrence among workers who have previously experienced a short-term disability episode. METHODS: The dataset comes from a Canadian resource sector company's 2003 to 2006 short-term disability leave and human resource datasets. The multi-year dataset consists of the records of 3593 employees who experienced at least on short-term disability episode between 2003 and 2006. RESULTS: The overall 1-year disability-free rate was 72.1% ± 1.6%. About half of workers with previous disability episodes for mental/behavioral disorders were disability free for more than 800 days. In contrast, about 50% of workers with previous disability episodes for physical disorders were disability free for more than 1300 days. CONCLUSIONS: These findings suggest the majority of workers with previous short-term disability episodes for mental/behavioral disorders remain disability free for more than 2 years. However, the duration of disability free days for these workers is half that of other workers with previous episodes.

Assessing the mental health service needs of the homeless: a level-of-care approach.

OBJECTIVE: A level-of-care needs assessment was undertaken at Ontario's largest shelter to establish homeless clients' mental health service needs and identify service gaps. METHODS: A level-of-care planning model was applied to data on 356 men. Assessments included the Colorado Client Assessment Record and a Service Needs and Use Questionnaire. RESULTS: Among the clients, 32% (N=105) were recommended for weekly support, 38% (N=125) for Intensive Case Management or Assertive Community Treatment, and 9% (N=29) for 24-hour supervision in a residential care facility. Despite on-site health services, half the men did not have their level of service need met. CONCLUSION: The wide range of unmet specialized mental health needs suggests that interventions of different structure and service intensity may be required for this population. A level-of-care planning model may be a helpful tool for ensuring homeless clients are matched to appropriate services and supports.

Examining the comparative incidence and costs of physical and mental health-related disabilities in an employed population.

OBJECTIVE: To address gaps in knowledge about disability rates and costs of short-term disability by answering the following questions: (1) what is the incidence and the costs of short-term disability episodes related to mental disorders? and (2) how do these figures compare with those of short-term disability episodes related to physical disorders? METHODS: The data set comes from a Canadian resource sector company's 2003-2006 short-term disability leave and human resource data sets. The multi-year data set consists of 33,913 records for all nonseasonal employees. The study focused on all episodes that began in 2003, 2004, or 2005. There are 12,407 unique employees represented. RESULTS: The overall disability rate was 14.5 episodes/100 person-years. The top five primary categories of disability episodes were respiratory disorder (2.3/100 person-years), musculoskeletal disorder (1.9/100 person-years), mental/behavioral disorder (2.1/100 person-years), injury (2.0/100 person-years), and digestive disorder (1.3/100 person-years). The mean disability episode was 33 days, and the mean cost was $9027/episode. Highest episode costs were associated with mental/behavioral disorder-related episodes ($18,000/episode), and the lowest costs were for respiratory disorders ($3000/episode). CONCLUSIONS: The results underscore that although disability related to mental/behavioral disorders may not comprise the largest proportion of cases, they represent the largest costs.

Factors associated with short-term disability episodes.

OBJECTIVE: This study examines factors associated with a mental/behavioral disorder-related short-term disability episode versus a physical disorder-related disability episode using administrative longitudinal data. METHODS: Logistic regression models were used to estimate the association between worker characteristics and different types of disability episodes. RESULTS: A previous disability episode is significantly associated with a current disability. Nevertheless, mental/behavioral disorders are related to higher odds of another episode. A worker with a previous disability episode related to a mental/behavioral disorder is almost 7x more likely to have another disability episode related to a mental disorder/behavioral disorder. CONCLUSIONS: One of the critical factors associated with a disability episode is a history of a previous disability episode. Relapse is a critical factor and should be considered in the design of occupational health programs.

Examination of factors associated with the mental health status of principals.

The rise in globalization, new technologies and changes in workforce demographics have created new work environments. As a result, countries around the world are seeking to restructure their educational systems to better prepare future generations for the challenges that they will face in this new labour market. These trends have also introduced new and increased demands on the educational sector and especially school principals who are responsible for the quality of education in schools. This study examines the association between mental health status and self-reported working conditions of principals. Our findings highlight potential mental health problems among principals. The results provide evidence that their satisifaction with their work characteristics are associated with their mental health status. They also indicate areas in which school boards may be well positioned to address some of the potential organizational difficulties encountered by this group.

Specialized home treatment versus hospital-based outpatient treatment for first-episode psychosis: a randomized clinical trial.

OBJECTIVE: This pilot study compared the effectiveness of specialized care that was home based versus hospital based for individuals experiencing their first psychotic episode. METHOD: A randomized controlled trial design was used. A total of 29 subjects were interviewed at baseline, 3 and 9 months. Repeated measures analysis of variance was employed to test for statistically significant changes over time within and between groups with regard to community psychosocial functioning and symptom severity. RESULTS: Our findings indicate that subjects in both the home-based and hospital-based programmes significantly improved with regard to symptoms and community functioning over time. However, the rates of change over time were not significantly different between the two programmes. There was a statistically significant difference between programmes with regard to the proportion of subjects with less than two visits (i.e. either did not attend their first assessment or attended follow-up visits after their assessment). CONCLUSIONS: This was a modest pilot study and the sample was too small to allow definitive conclusions to be drawn. However, the results raise questions about differences in initial treatment engagement. They suggest the need for additional research focusing on interventions that promote initial treatment seeking.

Collaborative mental health care for the homeless: the role of psychiatry in positive housing and mental health outcomes.

OBJECTIVE: Factors associated with positive outcomes for homeless men referred to a shelter-based collaborative mental health care team were examined. METHOD: A chart review of 73 clients referred over 12 months was completed. Two outcome measures were examined, clinical status and housing status, 6 months after their referral to the program. RESULT: Among the referred clients, the prevalence of severe and persistent mental illness and substance use disorders was 76.5% and 48.5%, respectively. At 6 months, 24 clients (35.3%) had improved clinically, and 33 (48.5%) were housed. Logistic regression identified 2 factors associated with clinical improvement: the number of visits with a psychiatrist and treatment adherence. The same 2 factors were associated with higher odds of housing, and presence of substance use disorder was associated with lower odds of housing at 6-month follow-up. CONCLUSION: Care by a mental health specialist is positively associated with improved outcomes. Strategies to improve treatment adherence, access to mental health specialists, and innovative approaches to treatment of substance use disorders should be considered for this population. Having a psychiatrist as a member of a shelter-based collaborative care team is one possible way of addressing the complex physical and mental health needs of homeless individuals.