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Myopericarditis is a rare complication of vaccination. However, there have been increasing reports of myopericarditis following COVID-19 vaccination, especially among adolescents and young adults. We aimed to characterise the incidence of myopericarditis following COVID-19 vaccination, and compare this with non-COVID-19 vaccination.We did a systematic review and meta-analysis, searching four international databases from Jan 1, 1947, to Dec 31, 2021, for studies in English reporting on the incidence of myopericarditis following vaccination (the primary outcome). We included studies reporting on people in the general population who had myopericarditis in temporal relation to receiving vaccines, and excluded studies on a specific subpopulation of patients, non-human studies, and studies in which the number of doses was not reported. Random-effects meta-analyses (DerSimonian and Laird) were conducted, and the intra-study risk of bias (Joanna Briggs Institute checklist) and certainty of evidence (Grading of Recommendations, Assessment, Development and Evaluations approach) were assessed. We analysed the difference in incidence of myopericarditis among subpopulations, stratifying by the type of vaccine (COVID-19 vs non-COVID-19) and age group (adult vs paediatric). Among COVID-19 vaccinations, we examined the effect of the type of vaccine (mRNA or non-mRNA), sex, age, and dose on the incidence of myopericarditis. This study was registered with PROSPERO (CRD42021275477).The overall incidence of myopericarditis from 22 studies (405 272 721 vaccine doses) was 33·3 cases (95% CI 15·3-72·6) per million vaccine doses, and did not differ significantly between people who received COVID-19 vaccines (18·2 [10·9-30·3], 11 studies [395 361 933 doses], high certainty) and those who received non-COVID-19 vaccines (56·0 [10·7-293·7], 11 studies [9 910 788 doses], moderate certainty, p=0·20). Compared with COVID-19 vaccination, the incidence of myopericarditis was significantly higher following smallpox vaccinations (132·1 [81·3-214·6], p0·0001) but was not significantly different after influenza vaccinations (1·3 [0·0-884·1], p=0·43) or in studies reporting on various other non-smallpox vaccinations (57·0 [1·1-3036·6], p=0·58). Among people who received COVID-19 vaccines, the incidence of myopericarditis was significantly higher in males (vs females), in people younger than 30 years (vs 30 years or older), after receiving an mRNA vaccine (vs non-mRNA vaccine), and after a second dose of vaccine (vs a first or third dose).The overall risk of myopericarditis after receiving a COVID-19 vaccine is low. However, younger males have an increased incidence of myopericarditis, particularly after receiving mRNA vaccines. Nevertheless, the risks of such rare adverse events should be balanced against the risks of COVID-19 infection (including myopericarditis).None.

Background We report the results of INICC surveillance study from 2013 to 2018, in 664 intensive care units (ICUs) in 133 cities, of 45 countries, from Latin-America, Europe, Africa, Eastern-Mediterranean, Southeast-Asia, and Western-Pacific. Methods Prospective data from patients hospitalized in ICUs were collected through INICC Surveillance Online System. CDC-NHSN definitions for device-associated healthcare-associated infection (DA-HAI) were applied. Results We collected data from 428,847 patients, for an aggregate of 2,815,402 bed-days, 1,468,216 central line (CL)-days, 1,053,330 mechanical ventilator (MV)-days, 1,740,776 urinary catheter (UC)-days. We found 7,785 CL-associated bloodstream infections (CLAB), 12,085 ventilator-associated events (VAE), and 5,509 UC-associated urinary tract infections (CAUTI). Pooled DA-HAI rates were 5.91% and 9.01 DA-HAIs/1,000 bed-days. Pooled CLAB rate was 5.30/1,000 CL-days; VAE rate was 11.47/1,000 MV-days, and CAUTI rate was 3.16/1,000 UC-days. P aeruginosa was non-susceptible (NS) to imipenem in 52.72% of cases; to colistin in 10.38%; to ceftazidime in 50%; to ciprofloxacin in 40.28%; and to amikacin in 34.05%. Klebsiella spp was NS to imipenem in 49.16%; to ceftazidime in 78.01%; to ciprofloxacin in 66.26%; and to amikacin in 42.45%. coagulase-negative Staphylococci and S aureus were NS to oxacillin in 91.44% and 56.03%, respectively. Enterococcus spp was NS to vancomycin in 42.31% of the cases. Conclusions DA-HAI rates and bacterial resistance are high and continuous efforts are needed to reduce them.

Background Ageing population is a major health care problem all over the world. In Singapore, as of 2020, senior citizen (65 years and above) consists of 15.2 % of total population. By 2030, one in five Singaporeans will be more than 65 years old. Thus, nursing home (NH) is an important pillar of a health care system. Nursing home staff are in the front line to manage common infections. However, the inexperience and the lack of guidance have led to inappropriate transfer to acute hospitals. Infectious Diseases Community Program (IDCP) is the project to enhance partnerships with NHs. We work with NHs to develop, adapt, and implement appropriate processes related to infection control, prevention, and management. One of our objectives is the enhancement of assessment and appropriate evaluation of fever. The aim is to reduce the inappropriate admissions to acute hospitals. Methods Fever and desaturation pathway (figure 1) was developed by IDCP team. Six participating NHs adopted the pathway and trained their staff. The study was approved by NHG domain specific review board (DSRB). Hospital records were reviewed. We compared the rate of inappropriate admission from 2015-2017 which serve as a baseline and 2019-2020. The wash-out period was 2018 when NHs were implementing the pathway. Inappropriate admission is defined as < ! 1. Admission is against advanced care planning / preferred plan of care or 2. Criteria in the pathway are not met on admission, 48 hours later and no other medical reason for admission. Figure 1 Results Total number of fever transfers was 950 in 2015-2017 and 688 in 2019-2020. Number of inappropriate admissions was 115 in 2015-2017 and 50 in 2019-2020. Inappropriate admission was 12.11% in 2015-2017 and 7.27 % in 2019-2020 (table 1). Figure 2 shows the rate of inappropriate admissions of six participating NHs from 2015-2020. There is a decreasing trend after the pathway has been implemented in 2018. Table 1 Figure 2 Conclusion Adopting fever and desaturation pathway has reduced the rate of inappropriate admission in six participating NHs in Singapore. However, there is an increasing trend in inappropriate admission in 2020. This could be due to the lack of isolation facility in the NHs during the COVID-19 pandemic. We are continuing the implementation of the pathway to the rest of the NHs in the western region of Singapore. Disclosures All Authors: No reported disclosures.

Background Staphylococcus aureus bacteraemia (SAB) remains a common infection with significant mortality, ranging from 20 to 40%. Understanding the risk factors for adverse outcomes in this infection will better prognosticate and guide patient management and disposition. Methods We prospectively recruited and examined 634 consecutive patients with laboratory-confirmed SAB. They were characterised in terms of baseline demographics, clinical profile, and laboratory findings at the time of SAB diagnosis. Sensitivity testing was carried out to identify patients who had methicillin-resistant (MRSA) or methicillin-sensitive Staphylococcus aureus (MSSA) infection. All patients were followed up prospectively for clinical outcomes including in-hospital mortality, and sites of metastatic infection. Univariate and multivariable logistic regression was used to identify risk factors associated with mortality in hospitalised patients with SAB. Results The overall mortality was 5.8% (n=37). There were no significant differences in gender, but patients who died tended to be 11 years older on average (69.6±14.9 years vs 58.1±18.2 years, p< 0.001). Diabetes mellitus, prior history of structural heart disease, haemodialysis and recent surgery had not been significantly associated with mortality in our cohort. Amongst the patients who died, MRSA infection was significantly more common (45.9% vs 24.8%, p=0.004). On multivariable logistic regression, older age (adjusted OR 1.05, 95%CI 1.02-1.07) and MRSA infection (adjusted OR 2.04, 95%CI 1.01 – 4.09) remained independently associated with mortality. We did not demonstrate an association with prolonged fever or bacteraemia and in-hospital mortality. Conclusion Amongst hospitalised patients with SAB, the mortality was low (5.8%). Older age and MRSA infection were the most important risk factors identified in association with mortality. Disclosures All Authors: No reported disclosures.

Background The COVID-19 pandemic represents one of the greatest ever challenges for healthcare. In the UK and beyond, acute medical units (AMUs) are the first point of assessment and care for the majority of medical inpatients. By their design and systems, they inevitably played an important role in the COVID-19 response but to date little has been published on how the COVID-19 pandemic has affected how AMUs have reorganised their resources, processes and structure. Methods This retrospective study in August 2020 of 10 AMUs across Europe and Australasia used a standardised questionnaire to investigate existing practice and structure of AMUs, the national context of local hospital experience, changes to practice during the COVID-19 pandemic and views regarding future practice. Results Changes to AMU structure, process and organisation are described in two contexts: preventing and controlling the spread of COVID-19 and adding value to the patient9s acute care journey in the local context. We describe novel practices that have arisen and highlight areas of concern. Conclusions The AMUs were able to adapt to meet the demands of acute care delivery during the first wave of the COVID-19 pandemic. Operational planning and prioritisation of resources must be optimised to ensure sustainability of these services for future waves.

For 20 years, the Global Outbreak Response and Alert Network (GOARN) has been a leader in the coordination of international outbreak response. On the premise that no single institution can provide all capacities required to successfully respond to a complex public health emergency or fulfil all outbreak response training needs, GOARN embarked on a capacity building journey that draws on the unique strengths of more than 250 partner institutions. Through extensive engagement and collaboration, GOARN Partners have created a bespoke, multifaceted, 3-tiered training programme which has evolved over the last 15 years and enhanced the competencies of thousands of multidisciplinary outbreak responders around the world.

Background: We examined whether existing licensed pharmacotherapies could reduce the spread of coronavirus disease 2019 (COVID-19). Methods: An open-label parallel randomized controlled trial was performed among healthy migrant workers quarantined in a large multi-storey dormitory in Singapore. Forty clusters (each defined as individual floors of the dormitory) were randomly assigned to receive a 42-day prophylaxis regimen of either oral hydroxychloroquine (400 mg once, followed by 200 mg/day), oral ivermectin (12 mg once), povidone-iodine throat spray (3 times/day, 270 μg/day), oral zinc (80 mg/day)/vitamin C (500 mg/day) combination, or oral vitamin C, 500 mg/day. The primary outcome was laboratory evidence of SARS-CoV-2 infection as shown by either: (1) a positive serologic test for SARS-CoV-2 antibody on day 42, or (2) a positive PCR test for SARS-CoV-2 at any time between baseline and day 42. Results: A total of 3037 asymptomatic participants (mean age, 33.0 years; all men) who were seronegative to SARS-CoV-2 at baseline were included in the primary analysis. Follow-up was nearly complete (99.6%). Compared with vitamin C, significant absolute risk reductions (%, 98.75% confidence interval) were observed for oral hydroxychloroquine (21%, 2–42%) and povidone-iodine throat spray (24%, 7–39%). No statistically significant differences were observed with oral zinc/vitamin C combination (23%, –5 to +41%) and ivermectin (5%, –10 to +22%). Interruptions due to side effects were highest among participants who received zinc/vitamin C combination (6.9%), followed by vitamin C (4.7%), povidone-iodine (2.0%), and hydroxychloroquine (0.7%). Conclusions: Chemoprophylaxis with either oral hydroxychloroquine or povidone-iodine throat spray was superior to oral vitamin C in reducing SARS-CoV-2 infection in young and healthy men.

In early phases of the COVID-19 pandemic in Singapore, Risk Communication and Community Engagement (RCCE) with large, diverse communities of migrant workers living in high-density accommodation was slow to develop. By August 2020, Singapore had reported 55,661 cases of COVID-19, with migrant workers comprising 94.6% of the cases. A system of RCCE among migrant worker communities in Singapore was developed to maximize synergy in RCCE. Proactive stakeholder engagement and participatory approaches with affected communities were key to effective dissemination of scientific information about COVID-19 and its prevention.

Background By estimating N95 respirator demand based on simulated epidemics, we aim to assist planning efforts requiring estimations of respirator demand for the healthcare system to continue operating safely in the coming months. Methods We assess respiratory needs over the course of mild, moderate and severe epidemic scenarios within Singapore as a case study using a transmission dynamic model. The number of respirators required within the respiratory isolation wards and intensive care units was estimated over the course of the epidemic. We also considered single-use, extended-use and prolonged-use strategies for N95 respirators for use by healthcare workers treating suspected but negative (misclassified) or confirmed COVID-19 patients. Results Depending on the confirmed to misclassified case ratio, from 1:0 to 1:10, a range of 117.1 million to 1.1 billion masks are required for single-use. This decreases to 71.6-784.4 million for extended-use and 12.8-148.2 million for prolonged-use, representing a 31.8-38.9% and 86.5-89.1% reduction, respectively. Conclusion An extended-use policy should be considered when short-term supply chains are strained but planning measures are in place to ensure long-term availability. With severe shortage expectations from a severe epidemic, as some European countries have experienced, prolonged use is necessary to prolong supply.

Highlights • Nosocomial infection is an ongoing concern in the COVID-19 outbreak. • Assessing the cost and health outcomes of an extended screening strategy using a branching process infection model • In the base case analysis, an R0 of 2.5 and incubation period of 4 days, an estimated 239 cases could be averted over 150 days • The expanded screening criteria can help to identify and promptly isolate positive COVID cases in a cost-saving manner • The proposed screening criteria should be considered to mitigate nosocomial transmission risk within healthcare facilities., Objectives Nosocomial infection is an ongoing concern in the COVID-19 outbreak. The effective screening of suspected cases in the healthcare setting is therefore necessary, enabling the early identification and prompt isolation of cases for epidemic containment. We aimed to assess the cost and health outcomes of an extended screening strategy, implemented in Singapore on 07 February 2020, which maximizes case identification in the public healthcare system. Methods We explored the effects of the expanded screening criteria which allows clinicians to isolate and investigate patients presenting with undifferentiated fever or respiratory symptoms or chest x-ray abnormalities. We formulated a cost appraisal framework which evaluated the treatment costs averted from the prevention of secondary transmission in the hospital setting, as determined by a branching process infection model, and compared these to the costs of the additional testing required to meet the criteria. Results In the base case analysis, an R0 of 2.5 and incubation period of 4 days, an estimated 239 (95% CI: 201-287) cases could be averted over 150 days within the hospital setting through ESC. A corresponding $2.36 (2 – 2.85) million USD costs could be averted with net cost savings of $124 000 (95% CI: -334 000–516 000). In the sensitivity analyses, when positive identification rates (PIR) were above 7%, regardless of R0 and incubation period, all scenarios were cost-saving. Conclusion The expanded screening criteria can help to identify and promptly isolate positive COVID cases in a cost-saving manner or within acceptable cost margins where the costs incurred from the testing of negative patients could be negated by the averted costs. Outbreak control must be sustainable and effective; the proposed screening criteria should be considered to mitigate nosocomial transmission risk within healthcare facilities.

Background Preprint manuscripts, rapid publications and opinion pieces have been essential in permitting the lay press and public health authorities to preview data relating to coronavirus disease 2019 (COVID-19), including the range of clinical manifestations and the basic epidemiology early on in the pandemic. However, the rapid dissemination of information has highlighted some issues with communication of scientific results and opinions in this time of heightened sensitivity and global concern. Main text Rapid publication of COVID-19 literature through expedited review, preprint publications and opinion pieces are important resources for the medical scientific community. Yet the risks of unverified information loom large in times when the healthcare community is desperate for information. Information that has not been properly vetted, or opinion pieces without solid evidence, may be used to influence public health policy decisions. We discuss three examples of unverified information and the consequences in this time of high anxiety surrounding COVID-19. Conclusions In an era when information can be widely and swiftly disseminated, it is important to ensure that the scientific community is not an inadvertent source of misinformation. This will require a multimodal approach, with buy-in from editors, publishers, preprint servers, authors and journalists. The landscape of medical publications has changed, and a collaborative approach is required to maintain a high standard of scientific communications.

To determine the effectiveness of our messaging for hand hygiene compliance by profession, we conducted a hospital-wide survey followed by profession-specific focus group discussions to investigate impact, perceptions and areas for improvement. Results showed a good understanding that hand hygiene is a crucial part of the infection-prevention programme; however, the acceptance and impact of messages varied between professions and required tailoring. Motivation, use of influential role models and social cohesion should be considered when designing profession-specific messages to improve infection-prevention-related change uptake among healthcare professional groups.

Coronavirus Disease 2019 (COVID-19) serology has an evolving role in the diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. However, its use in hospitalized patients with acute respiratory symptoms remains unclear. Hospitalized patients with acute respiratory illness admitted to an isolation ward were recruited. All patients had negative nasopharyngeal swab polymerase chain reaction (PCR) for SARS-CoV-2. Serological studies using four separate assays (cPass: surrogate neutralizing enzyme-linked immunosorbent assay [ELISA]; Elecsys: N-antigen based chemiluminescent assay; SFB: S protein flow-based; epitope peptide-based ELISA) were performed on stored plasma collected from patients during the initial hospital stay, and a convalescent visit 4-12 weeks later. Of the 51 patients studied (aged 54, interquartile range 21-84; 62.7% male), no patients tested positive on the Elecsys or cPass assays. Out of 51 patients, 5 had antibodies detected on B-cell Epitope Assay and 3/51 had antibodies detected on SFB assay. These 8 patients with positive serological test to COVID-19 were more likely to have a high-risk occupation (p = 0.039), bacterial infection (p = 0.028), and neutrophilia (p = 0.013) during their initial hospital admission. Discrepant COVID-19 serological findings were observed among those with recent hospital admissions and bacterial infections. The positive serological findings within our cohort raise important questions about the interpretation of sero-epidemiology during the current pandemic. NUHS Clinician Scientist Program (NCSP)award to G. B. C.

The complete picture regarding transmission modes of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is unknown. This review summarises the available evidence on its transmission modes, our preliminary research findings and implications for infection control policy, and outlines future research directions. Environmental contamination has been reported in hospital settings occupied by infected patients, and is higher in the first week of illness. Transmission via environmental surfaces or fomites is likely, but decontamination protocols are effective in minimising this risk. The extent of airborne transmission is also unclear. While several studies have detected SARS-CoV-2 ribonucleic acid in air samples, none has isolated viable virus in culture. Transmission likely lies on a spectrum between droplet and airborne transmission, depending on the patient, disease and environmental factors. Singapore’s current personal protective equipment and isolation protocols are sufficient to manage this risk.

Background Klebsiella pneumoniae liver abscess (KLA) is emerging worldwide due to hypermucoviscous strains with a propensity for metastatic infection. Treatment includes drainage and prolonged intravenous antibiotics. We aimed to determine whether oral antibiotics were noninferior to continued intravenous antibiotics for KLA. Methods This noninferiority, parallel group, randomized, clinical trial recruited hospitalized adults with liver abscess and K. pneumoniae isolated from blood or abscess fluid who had received ≤7 days of effective antibiotics at 3 sites in Singapore. Patients were randomized 1:1 to oral (ciprofloxacin) or intravenous (ceftriaxone) antibiotics for 28 days. If day 28 clinical response criteria were not met, further oral antibiotics were prescribed until clinical response was met. The primary endpoint was clinical cure assessed at week 12 and included a composite of absence of fever in the preceding week, C-reactive protein Results Between November 2013 and October 2017, 152 patients (mean age, 58.7 years; 25.7% women) were recruited, following a median 5 days of effective intravenous antibiotics. A total of 106 (69.7%) underwent abscess drainage; 71/74 (95.9%) randomized to oral antibiotics met the primary endpoint compared with 72/78 (92.3%) randomized to intravenous antibiotics (risk difference, 3.6%; 2-sided 95% confidence interval, −4.9% to 12.8%). Effects were consistent in the per-protocol population. Nonfatal serious adverse events occurred in 12/72 (16.7%) in the oral group and 13/77 (16.9%) in the intravenous group. Conclusions Oral antibiotics were noninferior to intravenous antibiotics for the early treatment of KLA. Clinical Trials Registration NCT01723150.

PURPOSE OF REVIEW: The coronavirus disease (COVID-19) pandemic has resulted in necessary modifications of infection control policies and practices in acute healthcare facilities globally. This is often accompanied by infrastructure modifications, ward redesignations, as well as healthcare staff redeployments and changes to infection prevention and control (IPC) practices. We review the potential for both negative and positive impacts these major changes can have on nosocomial transmission of multidrug-resistant organisms (MDROs). RECENT FINDINGS: Healthcare facilities around the world have reported outbreaks of MDROs during the COVID-19 pandemic. In contrast some centres have reported a decrease in baseline rates due to a number of possible factors. SUMMARY: While implementing crucial preventive measures for COVID-19, is it important to consider any collateral effects of changes in IPC and antimicrobial stewardship program (ASP) practices. The disruption caused to IPC and ASP practices during the pandemic are likely to see a counter intuitive increase in transmission of MDROs.

Objective: To demonstrate the efficacy of the SafeZone UVC (Ushio Inc., Japan) 222 nm ultraviolet C (UVC) light to reduce bacterial burden in pressure ulcers (PUs) in human patients. This research is the first human clinical trial using 222 nm UVC in eradicating bacteria in human wounds. Method: Patients with Stage 2 or 3 (as defined by the revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System) sacral or gluteal pressure ulcers (PUs) were subjected to four sessions of 222 nm UVC light therapy over two weeks. Pre- and post-UVC therapy, wound cultures were taken and quantitative analysis of bacterial colony forming units (CFU) were performed. Results: A total of 68 UV light sessions across 16 different patients were conducted. Of these sessions, 59 (87.0%) sessions showed a reduction in CFU counts, with 20 (29.4%) showing complete eradication of bacteria. Bacteria identified included meticillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa and Klebsiella Pneumoniae. The overall median reduction in CFU of the 68 sessions was 78.9%. No adverse events were reported in any of the UV sessions. Conclusion: In this study, 222 nm UVC light was safe and effective in reducing bacterial CFU counts in sacral and gluteal PUs across numerous different species of bacteria.

Background Migrant worker dormitories—residential complexes where 10–24 workers share living spaces—account for the majority of cases of SARS-CoV-2 infection in Singapore. To prevent overspill of transmission to the wider population, starting in early April 2020, residents were confined to their dormitories while measures were put in place to arrest the spread of infection. This descriptive study presents epidemiological data for a population of more than 60 000 migrant workers living in two barracks-style and four apartment-style dormitories located in western Singapore from April 3 to June 10, 2020. Methods Our report draws from data obtained over the first 50 days of outbreak management in order to describe SARS-CoV-2 transmission in high-density housing environments. Cumulative counts of SARS-CoV-2 cases and numbers of housing units affected were analyzed to report the harmonic means of harmonic means of doubling times and their 95% confidence intervals (CI). Results Multiple transmission peaks were identified involving at least 5467 cases of SARS-CoV-2 infection across six dormitories. Our geospatial heat maps gave an early indication of outbreak severity in affected buildings. We found that the number of cases of SARS-CoV-2 infection doubled every 1.56 days (95% CI 1.29–1.96) in barracks-style buildings. The corresponding doubling time for apartment-style buildings was 2.65 days (95% CI 2.01–3.87). Conclusions Geospatial epidemiology was useful in shaping outbreak management strategies in dormitories. Our results indicate that building design plays an integral role in transmission and should be considered in the prevention of future outbreaks.

Objective In the outpatient setting, antibiotics such as ceftriaxone, ertapenem, daptomycin and meropenem (for patients with end-stage kidney disease) are generally, administered via once-daily infusions. It is common practice to administer these antibiotics over 30-minutes even though the manufacturers' product summaries, recommend use of rapid infusions. In February 2017, we switched to rapid infusion as part of a continuous quality improvement effort to improve our outpatient services. Method We conducted a prospective observational study of the safety and efficacy of rapid infusions of ceftriaxone, ertapenem, daptomycin and meropenem between February 2017 and June 2018 at the Outpatient Parenteral Antibiotic Therapy centre, National University Hospital, Singapore . Data collected included patient, demographics, antibiotic indications, treatment duration, treatment outcomes, vascular access and infusion-related adverse events. Results A total of 4326 doses were administered via rapid infusion to 184 patients: ceftriaxone (doses=2616, n=105), ertapenem (doses=1584, n=76), meropenem (doses= 84, n=2) and daptomycin (doses=42, n=1). There were no rapid infusion-related adverse reactions for any patients during the entire treatment duration. Conclusion The rapid administration of intravenous ceftriaxone, ertapenem, meropenem and daptomycin in an outpatient setting is clinically safe and well tolerated.

Summary To determine the variation in practices on meticillin-resistant Staphylococcus aureus (MRSA) surveillance and management of MRSA-colonized patients amongst 17 acute healthcare facilities in Singapore, the Ministry of Health convened a sharing session with Infection Prevention and Control Leads. All hospitals practised close to universal MRSA entry swabbing in keeping with national policy. There were, however, major variations in the response to both positive and negative surveillance swabs across facilities including the role of routine antiseptic bathing and MRSA decolonization. Most undertaking decolonization considered its role to be in ‘bioburden reduction’ rather than longer-term clearance.

Background: Multiple major health organisations recommend the use of extracorporeal membrane oxygenation (ECMO) support for COVID-19-related acute hypoxaemic respiratory failure. However, initial reports of ECMO use in patients with COVID-19 described very high mortality and there have been no large, international cohort studies of ECMO for COVID-19 reported to date. Methods: We used data from the Extracorporeal Life Support Organization (ELSO) Registry to characterise the epidemiology, hospital course, and outcomes of patients aged 16 years or older with confirmed COVID-19 who had ECMO support initiated between Jan 16 and May 1, 2020, at 213 hospitals in 36 countries. The primary outcome was in-hospital death in a time-to-event analysis assessed at 90 days after ECMO initiation. We applied a multivariable Cox model to examine whether patient and hospital factors were associated with in-hospital mortality. Findings: Data for 1035 patients with COVID-19 who received ECMO support were included in this study. Of these, 67 (6%) remained hospitalised, 311 (30%) were discharged home or to an acute rehabilitation centre, 101 (10%) were discharged to a long-term acute care centre or unspecified location, 176 (17%) were discharged to another hospital, and 380 (37%) died. The estimated cumulative incidence of in-hospital mortality 90 days after the initiation of ECMO was 37·4% (95% CI 34·4–40·4). Mortality was 39% (380 of 968) in patients with a final disposition of death or hospital discharge. The use of ECMO for circulatory support was independently associated with higher in-hospital mortality (hazard ratio 1·89, 95% CI 1·20–2·97). In the subset of patients with COVID-19 receiving respiratory (venovenous) ECMO and characterised as having acute respiratory distress syndrome, the estimated cumulative incidence of in-hospital mortality 90 days after the initiation of ECMO was 38·0% (95% CI 34·6–41·5). Interpretation: In patients with COVID-19 who received ECMO, both estimated mortality 90 days after ECMO and mortality in those with a final disposition of death or discharge were less than 40%. These data from 213 hospitals worldwide provide a generalisable estimate of ECMO mortality in the setting of COVID-19. Funding: None.

An explanation is required for the re-emergence of COVID-19 outbreaks in regions with apparent local eradication. Recent outbreaks have emerged in Vietnam, New Zealand and parts of China where there had been no cases for some months. Importation of contaminated food and food packaging is a feasible source for such outbreaks and a source of clusters within existing outbreaks. Such events can be prevented if the risk is better appreciated.

Background On January 30, COVID-19 was declared a Public Health Emergency of International Concern—a week after Singapore’s first imported case and 5 days before local transmission. The National University Hospital (NUH) is Singapore’s third largest hospital with 1200 beds, heavy clinical workloads, and major roles in research and teaching. Main body With memories of SARS still vivid, there was an urgent requirement for the NUH Division of Infectious Diseases to adapt—undergoing major reorganization to face rapidly changing priorities while ensuring usual essential services and standards. Leveraging on individual strengths, our division mobilized to meet the demands of COVID-19 while engaging in high-level coordination, strategy, and advocacy. We present our experience of the 60 days since the nation’s first case. During this time, our hospital has managed 3030 suspect cases, including 1300 inpatients, 37 confirmed cases, and overseen 4384 samples tested for COVID-19. Conclusion Complex hospital adaptations were supported by an unprecedented number of workflows and coordination channels essential to safe and effective operations. The actions we describe, aligned with international recommendations and emerging evidence-based best practices, may serve as a framework for other divisions and institutions facing the spread of COVID-19 globally.