Home-made masks with filtration efficiency for nano-aerosols for community mitigation of COVID-19 pandemic.

OBJECTIVES: The novel coronavirus disease 2019 (COVID-19) epidemic that emerged in December 2019 has rapidly evolved in recent months to become a worldwide and ongoing pandemic. Shortage of medical masks remains an unresolved problem. This study aims to investigate the filtration efficiency (FE) of home-made masks that could be used as alternatives for community mitigation of COVID-19. STUDY DESIGN: Experimental observational analytic study. METHODS: The FE of home-made masks and medical masks (as the control) were tested under laminar flow within a scaled air duct system using nebulised NaCl aerosols sized 6-220 nm. The size-resolved NaCl aerosol count was measured using a scanning mobility particle-sizer spectrometer. Home-made masks with an external plastic face shield also underwent a splash test. In addition, the fibre structures of medical masks were studied under an electron microscope after treatment with either 75% alcohol or soap and water at 60 °C. RESULTS: The FE of the home-made masks at 6-200 nm were non-inferior to that of medical masks (84.54% vs 86.94%, P = 0.102). Both types of masks achieved an FE of 90% at 6-89 nm. A significantly higher FE was achieved when one piece of tissue paper was added adjacent to the inner surface of the medical mask than medical mask alone (6-200 nm: 91.64% vs 86.94%, P < 0.0001; 6-89 nm: 94.27% vs 90.54%, P < 0.0001; 90-200 nm: 82.69% vs 73.81%, P < 0.0001). The plastic face shield prevented the home-made mask from fluid splash. The fibre structures of the external surface of medical masks were damaged after treatment with either 75% alcohol or soap and water at 60 °C. CONCLUSIONS: The home-made masks in this study, which were made of one piece of tissue paper and two pieces of kitchen towels, layered from face to external, had an FE at 6-200 nm non-inferior to that of medical mask materials, which had a certified FE of ≥95% at 3 µm. In the current COVID-19 pandemic with the shortage of medical masks, these home-made masks combined with an external plastic shield could be used as an alternative to medical masks for community mitigation. In addition, one piece of tissue paper could be placed adjacent to the inner surface of a medical mask to prolong effective lifespan of the medical mask. These demand reduction strategies could be used to reserve medical masks for use in healthcare and certain high-risk community settings, such as symptomatic persons, caregivers and attendees to healthcare institutions.

Q fever: underdiagnosed in Hong Kong?

We report the first imported case of chronic Q fever with multi-organ involvement seen in Hong Kong. Although the disease is found worldwide, its chronic form is very rare in our locality. Familiarity with the clinical presentation, useful diagnostic tools, and appropriate treatment is necessary for the prevention of the serious morbidity and mortality associated with chronic Q fever. To the best of our knowledge, this article represents the first comprehensive review to compare the local experience with Q fever with international data, and establishes a management approach for this unusual infectious disease while suggesting possible explanations for its exceptionally low incidence in this locality.

Prevention of nosocomial transmission of swine-origin pandemic influenza virus A/H1N1 by infection control bundle.

After the outbreak of severe acute respiratory syndrome in Hong Kong, the importance of preventing nosocomial transmission of respiratory viruses has become a top priority in infection control. During the containment and early mitigation phases of the swine-origin influenza virus (S-OIV) A H1N1 pandemic, an infection control bundle consisting of multiple coherent measures was organised by our infection control team to minimise nosocomial transmission. This included repeated open staff forum achieving high attendance; early recognition of index cases among inpatients by liberal testing; early relief of sick staff from work; directly observed hand hygiene practice during outbreaks; and monitoring of compliance with infection control practice. During the first 100 days (from 1 May to 8 August 2009) when the first 100 laboratory-confirmed patients with S-OIV and 12 infected healthcare workers (HCWs) were identified, a total of 836 asymptomatic exposed persons (184 patients and 652 HCWs) were required to undergo a seven-day medical surveillance. The infection control nurses monitored them for the onset of symptoms. Four (0.48%) exposed persons (one house officer, two non-clinical staff, and one patient) were virologically confirmed with S-OIV. Not wearing a surgical mask either by the exposed persons during contact with the index cases (4/4 vs 264/832, P=0.010) or vice versa (4/4 vs 300/832, P=0.017, Fisher's exact test) were found to be significant risk factors for nosocomial acquisition of S-OIV.

Differential susceptibility of different cell lines to swine-origin influenza A H1N1, seasonal human influenza A H1N1, and avian influenza A H5N1 viruses.

BACKGROUND: The novel swine-origin influenza A H1N1 virus (S-OIV) causes the current pandemic. Its tissue tropism and replication in different cell lines are not well understood. OBJECTIVE: Compare the growth characteristics of cell lines infected by S-OIV, seasonal influenza A H1N1 (sH1N1) and avian influenza A H5N1 (H5N1) viruses and the effect of temperature on viral replication. STUDY DESIGN: Cytopathic effect (CPE), antigen expression by immunofluorescence (IF) and viral load profile by quantitative RT-PCR in 17 cell lines infected by S-OIV, sH1N1 and H5N1 were examined. Comparison of their replication efficiency in chick embryo was performed. The effect of temperature on viral replication in Madin-Darby canine kidney (MDCK) cells was determined by TCID(50) at 33 degrees C, 37 degrees C and 39 degrees C for 5 consecutive days. RESULTS: S-OIV replicated in cell lines derived from different tissues or organs and host species with comparable viral load to sH1N1. Among 13 human cell lines tested, Caco-2 has the highest viral load for S-OIV. S-OIV showed a low viral load with no CPE or antigen expression in pig kidney cell PK-15, H5N1 demonstrated the most diverse cell tropism by CPE and antigen expression, and the highest viral replication efficiency in both cell lines and allantoic fluid. All three viruses demonstrated best growth at 37 degrees C in MDCK cells. CONCLUSION: Cell line growth characteristics of S-OIV, sH1N1 and H5N1 appear to correlate clinically and pathologically with involved anatomical sites and severity. Low replication of S-OIV in PK-15 suggests that this virus is more adapted to human than swine.

Antimicrobial stewardship program directed at broad-spectrum intravenous antibiotics prescription in a tertiary hospital.

The antimicrobial stewardship program (ASP) is a major strategy to combat antimicrobial resistance and to limit its expenditure. We have improved on our existing ASP to implement a sustainable and cost-effective two-stage immediate concurrent feedback (ICF) model, in which the antimicrobial prescription is audited by two part-time infection control nurses at the first stage, followed by "physician ICF" at the second stage. In January 2005, an ASP focused on broad-spectrum intravenous antibiotics was implemented. All in-patients, except from the intensive care, bone marrow transplantation, liver transplantation, pediatric, and private units, being treated with broad-spectrum intravenous antibiotics were included. The compliance to ICF and "physician ICF", antibiotics usage density measured by expenditure and defined daily doses (DDD) were recorded and analyzed before and after the ASP. The overall conformance rate to antibiotic prescription guidelines was 79.4%, while the conformance to ICF was 83.8%. Antibiotics consumption reduced from 73.06 (baseline, year 2004) to 64.01 (year 2007) per 1,000 patient bed-day-occupancy. Our model can be easily applied even in the clinical setting of limited resources.

Successful control of vancomycin-resistant Enterococcus faecium outbreak in a neurosurgical unit at non-endemic region.

Vancomycin-resistant enterococci (VRE) have emerged in many parts of the world, but have only been reported sporadically in Hong Kong. We report an outbreak of vancomycin-resistant Enterococcus faecium (VREfm) in a neurosurgical unit at a tertiary teaching hospital between 3 March and 3 April 2009 in Hong Kong. During the outbreak investigation, clinical samples from 193 (91.5%) of 211 patients who had stayed in the neurosurgical unit and 506 environmental samples were screened for VREfm. Besides the index case, another 3 (1.6%) out of 192 patients were found to be positive for VREfm. Two (0.4%) out of 506 environmental samples were positive for VREfm. All four clinical and two environmental isolates were found to be clonally related by pulse-field gel electrophoresis. The risk factors for nosocomial acquisition of VREfm included advanced age (P=0.047), presence of nasogastric tubing (P=0.002) and tracheostomy (P<0.001), and the use of ß-lactam antibiotics (P<0.001) and vancomycin (P=0.001). Contrary to other VRE outbreaks in which the spread was rapid, the neurosurgical patients' immobilization because of coma and mechanical ventilation dependency, and the vigilant practice of hand hygiene by health-care workers successfully limited the number of secondary cases despite the delayed recognition of the index case. All patients with VREfm were labeled in the hospital network information system so that stringent infection control measures with contact precautions would be carried out once these patients were readmitted to prevent its spread in our locality.

Effect of antibiotics on the bacterial load of meticillin-resistant Staphylococcus aureus colonisation in anterior nares.

Prevalence of hospital-acquired meticillin-resistant Staphylococcus aureus (MRSA) infection or colonisation has been associated with antimicrobial consumption. The impact of antibiotic treatment on nasal colonisation is unknown. We conducted a three-month prospective study of 116 patients with extranasal MRSA infection or colonisation, whose nasal MRSA bacterial loads were determined during and after various antibiotic courses over a period of three weeks. Environmental swabs were also taken from the near patient environment. Concomitant nasal MRSA carriage was observed in 76.7% of extranasal MRSA-colonised or -infected patients. The median nasal MRSA bacterial load increased significantly from 2.78 (range 0-6.15) to 5.30 (range 2.90-8.41) log(10) cfu per swab (cfu/swab) (P<0.001) over 21 days during beta-lactam therapy. It also increased from 0 (range 0-4.00) to 4.30 (range 0-7.46) log(10)cfu/swab (P=0.039) over 14 days during fluoroquinolone therapy. Median bacterial loads were significantly higher for beta-lactam- and fluoroquinolone-treated patients on day 7 [4.78, range 0-7.30], day 14 [4.30, range 0-7.60] and day 21 [5.30, range 2.90-8.41] than controls not receiving antibiotics (P<0.05). These loads then decreased by 2-5log(10)cfu/swab 2 weeks after discontinuation of antibiotics. The environment of patients receiving beta-lactam agents (relative risk: 3.55; 95% confidence interval: 1.30-9.62; P=0.018) or fluoroquinolones (4.32; 1.52-12.31; P=0.008) demonstrated more MRSA contamination than the environment around control patients (0.79; 0.67-0.93; P=0.002). Patients on beta-lactam or fluoroquinolone therapy have increased incidence of MRSA colonisation and higher nasal bacterial loads, and appear to spread their MRSA into the near patient environment.

Effects of osteogenic protein-1 (OP-1, BMP-7) on bone matrix protein expression by fetal rat calvarial cells are differentiation stage specific.

Bone morphogenetic proteins (BMPs) are a group of cytokines that are characterized by their ability to stimulate osteoblast differentiation and bone formation. However, the influence of BMPs on osteoblastic cells at different stages of differentiation is not known. Since bone matrix proteins are differentially regulated during bone formation we have studied the effects of recombinant human osteogenic protein-1 (rhOP-1; BMP-7) on the expression of these proteins by fetal rat calvarial cells (FRCCs) at discrete stages of osteoblast differentiation. Continuous administration of rhOP-1 to FRCCs, beginning at confluence (day 7), produced a dose-dependent increase in the number, size and mineralization of bone-like nodules formed in the presence of vitamin C and beta-glycerophosphate. Within 9 h of administration, rhOP-1 stimulated a 3-fold increase in OPN mRNA which was reflected in a comparable increase in the low phosphorylated, 55 kDa form of osteopontin. In contrast, changes in type 1 collagen, alkaline phosphatase and bone sialoprotein mRNAs followed the differentiation of preosteoblastic cells, and were increased 2-, 4- and 5-fold, respectively, after 8 days (day 15). When administered at intermediate stages of osteoblast differentiation (days 12, 15 and 18) BSP remained refractory to rhOP-1 whereas the ALP was increased almost 2-fold, independent of the constitutive levels of mRNA expression. To determine the effects on osteoblasts, FRCCs were first grown to the bone nodule-forming stage (day 21) before rhOP-1 was administered. Only modest, transient increases in the expression of ALP and OPN mRNAs were evident whereas OC expression was increased more than 3-fold. In contrast, collagen type 1 and BSP mRNA levels were not changed significantly. These results suggest that rhOP-1 increases bone formation by promoting osteoblastic differentiation, as indicated by the increased number of bone forming colonies and by increasing the number of osteoblastic cells in the colonies, but not by increasing matrix production by individual osteoblasts. It is also evident that the regulation of bone matrix proteins by rhOP-1 is dependent upon the differentiated state of the cell.

Influence of osteogenic protein-1 (OP-1;BMP-7) and transforming growth factor-beta 1 on bone formation in vitro.

The bone morphogenetic proteins (BMPs) and transforming growth factor-beta s (TGF-beta s), are a group of structurally related proteins which have been shown to stimulate bone formation in vivo. Since these proteins are concentrated in the organic matrix of bone and would be released during bone resorption, they are likely to have a profound effect on the remodeling bone and may provide a link between bone resorption and bone formation. We are using primary cultures of fetal rat calvarial cells (FRCC) to study the independent and combined effects of OP-1/BMP-7 and TGF-beta 1 on bone cells at different stages of differentiation in order to identify responding cell populations and target genes. We have confirmed prior reports that OP-1 stimulates, while TGF-beta 1 inhibits, osteogenic differentiation in this system. The increase in both number and size of the mineralized nodules induced by OP-1 was accompanied by increased expression of alkaline phosphatase and type I collagen with an induction of bone sialoprotein (BSP) suggesting that OP-1 stimulates both differentiation and clonal expansion of osteoblastic cells. Interestingly, TGF-beta 1 abrogated OP-1 induced nodule formation. Despite these opposing effects on osteogenic differentiation, TGF-beta 1 (Wrana et al, 1991) and OP-1 both stimulated a rapid induction of osteopontin (OPN) mRNA in confluent FRCC cultures enriched in pre-osteoblastic cells. In contrast, when OP-1 was added to nodule-forming cultures which are enriched in osteoblastic cells, there was only a weak induction of OPN. Moreover, while the expression of one marker for mature osteoblasts (BSP) was refractory to OP-1, another (osteocalcin) was markedly stimulated. Thus OP-1 has selective effects on bone matrix protein expression that are dependent on the differentiated state of the cells.

Regulation of osteopontin expression in osteoblasts.

Osteopontin (OPN) is a prominent bone matrix protein that is synthesized by osteoblastic cells. To elucidate the function of OPN in bone we studied the regulated expression of the rat OPN protein during bone formation in vivo and in vitro. OPN mRNA is expressed by preosteoblastic cells early in bone formation, but the highest expression is observed in mature osteoblasts at sites of bone remodelling. A low-phosphorylated, 55-kDa form of OPN is produced by the preosteoblastic cells, whereas osteoblasts produce a highly phosphorylated, 44-kDa protein; the two forms of OPN corresponding to pp69 and pp62 in transformed rat cells. The synthesis of the 55-kDa OPN correlates with the formation of a 'cement' matrix that is synthesized prior to bone deposition, whereas the 44-kDa OPN synthesized by osteoblasts associates rapidly with hydroxyapatite, possibly regulating crystal growth, and may also provide a substratum for osteoclast attachment. Expression of OPN mRNA is upregulated by growth and differentiation factors (PDGF, EGF, TGF-beta and BMP-7/OP-1) and by mechanical stress, which promote bone formation, as well as by osteotropic hormones (retinoic acid and vitamin D3), which can promote bone resorption and remodelling. However, OPN mRNA is down-regulated by bisphosphonates, which abrogate bone resorption. Regulation of OPN expression is, therefore, consistent with a multiplicity of functions for OPN that involve specific structural motifs in both the synthesis and resorption of bone.