Objectives: Many healthcare workers and patients in intensive care units of Sardjito Hospital, a referral and academic hospital in Yogyakarta, Indonesia, were infected with SARS-CoV-2 in June–August 2021, during the second wave of the COVID-19 pandemic. Much evidence has shown that SARS-CoV-2 persists on hospital environmental surfaces and medical equipment. We investigated the potential sources of virus in our cases, particularly environmental contamination. Methods: Environmental screening for SARS-CoV-2 was conducted using RT-PCR of swabs collected from case-related medical equipment and hospital surfaces. We examined the environmental cleaning method in these areas as well. Results: We swabbed medical equipment in close contact with patient droplets such as the ventilator, the high-flow nasal cannula, the nebulizer, and suction equipment, as well as some environmental surfaces near the patient, such as the bed rail, air conditioning unit, and portable HEPA-filter outlet. Among 19 samples, genetic material of SARS-CoV-2 was detected only on a sample from a nebulizer. The point of contamination was on the outer body of that nebulizer, which indicated that the contact transmission source might be from patient droplets and/or inadequate cleaning. No more positive results emerged from our screening, indicating that the environmental cleaning was adequate. The IPC team recommended that we no longer use nebulizers for COVID-19 patients and that the cleaning procedure be improved, particularly after the device is used. Conclusions: Environmental screening for SARS-CoV-2 can be used to support investigations of inpatient COVID-19 outbreaks in hospitals. Adequate cleaning and care procedures for medical equipment are very important in preventing the transmission of SARS-CoV-2 in the hospital setting.

Objectives: To determine the factors influencing COVID-19 prevention practices among healthcare personnel. Methods: The sample consisted of healthcare personnel working in the emergency department, inpatient wards, and the outpatient department in 250 Rajavithi hospitals selected using a purposive sampling method. Data were collected using questionnaires that were validated by 5 experts and had a content validity index of 0.83. The reliability of the questionnaires was 0.91. Data were analyzed using descriptive statistics and multiple regression. Results: Study participants had good attitudes toward behaviors, subjective norms, perceived behavioral control, and intention to prevent COVID-19. In addition, perceived behavioral control was the only factor that statistically predicted intention to perform COVID-19 infection prevention and may explain 25.6% of the variability of intention (P < .001). Conclusions: Based on the results of this study, relevant authorities, including wards and infection control units, should support perceived behavioral control among registered nurses to encourage COVID-19 prevention practices.

Objectives: The disruptions wrought by COVID-19 have spurred the development of vaccines at a pace unprecedented in global history. We have witnessed vaccine development from in vivo testing to population-wide implementation in just under 1 year. Singapore’s vaccination rate of 80%, attained at the start of September 2021, marks a milestone. It signals that plans to shift from a “zero transmission” approach to an endemic “living with COVID-19” approach is headed in the right direction, albeit cautiously and with some uncertainty. Although we ask ourselves at what rate our society should be reopened, we acknowledge that such questions are not easily answered because newer variants are proving more transmissible and, possibly, vaccine resistant compared to earlier variants. Methods: COVID-19 vaccination milestones were plotted. A timeline was used to map key events of Singapore’s vaccination strategy in terms of legislation, logistics and operations, vaccination eligibility, vaccination sites, and measures implemented to encourage vaccine uptake. These factors were compared with Singapore’s vaccination rate from December 2020 to early September 2021. Results: The successful vaccination strategy in Singapore has been explored in 4 main areas: good leadership and evidence-based decision making, use of communications, utilizing existing logistics, and an ever-ready primary care. Conclusions: As we transition to our second year of combating COVID-19, emerging variants, spread despite vaccination, and the contesting voices of antivaxxers pose new challenges. Vaccine-generated immunity is only one, albeit an important, element of a comprehensive COVID-19 strategy. The strategy must also entail surveillance, self-testing, contact tracing, quarantine, legislation, financial support, and strengthened social responsibility. As providers of vaccination and translators of upstream evidence and policy decisions in the community, primary care providers should be involved early in decision making regarding interventions in the community because they can foresee challenges on the ground. Let us put our continued trust in primary care providers to contribute to making Singapore a COVID-19–resilient nation.

Objectives: In early 2021, when the COVID-19 vaccine was scarce in Vietnam, healthcare workers (HCWs) were prioritized for vaccination due to high risk of occupational exposure. However, there is some COVID-19 vaccine hesitancy within HCW communities. Assessing COVID-19 severity among vaccinated and nonvaccinated HCWs would contribute essential information to assure people of vaccine effectiveness and reduce vaccine hesitancy. Methods: We conducted a descriptive cross-sectional study at the National Hospital for Tropical Diseases in Hanoi, Vietnam, from May to June 2021. Clinical and epidemiological data from HCWs with positive polymerase chain reaction (PCR) results were collected. The severity of symptoms were classified according to Vietnam Ministry of Health guideline (Decision no. 3416 issued  July 14, 2021) into 5 categories: asymptomatic, mild, moderate, severe, and critical conditions Results: Overall, 25 HCWs qualified for this study (14 women and 11 men), with a median age of 31 years. Among them, 3 HCWs were infected due to community exposure, and the rest were infected due to occupational exposure. Also, 3 HCWs received the Astra Zeneca vaccine before being infected with SARS-CoV-2 (one fully vaccinated with 2 doses and the other 2 had had the first dose). Categorized by the severity of infection, 28% were asymptomatic, 44% had mild symptoms, 20% had moderate symptoms, and 8% experienced severe symptoms. All 3 vaccinated HCWs showed only mild symptoms. Cough and sore throat were the main symptoms recorded (60%), followed by fever (56%). Blood test results did not show significant differences between the severe and mild COVID-19 groups. Conclusions: COVID-19 vaccination reduced the severity of COVID-19 in this small sample of HCWs. Full COVID-19 vaccination is strongly recommended for HCWs to reduce the spread of COVID-19 and to limit the number of cases with severe disease.

Objectives: The infection prevention team (IPT) was tasked with providing technical guidance for the construction and setup of a community treatment facility in 3 weeks at a Formula 1 (F1) racing pit to house elderly SARS-CoV-2–positive cases. Methods: The facility was setup with 737 beds including an isolation unit and a resuscitation bay. The multidisciplinary team decided on zone segregation (ie, green and hot zones) and discussed the clean–dirty workflow. IPC measures were revisited, especially regarding the layout of the donning and doffing station, as the facility expanded to accommodate patients with more comorbidities and those who needed dialysis. IPC training for nominated infection control liaison officers (ICLOs) was conducted using a “train the trainer” approach for mask fitting, hand hygiene, donning and doffing of personal protective equipment (PPE). Enhanced IPC measures, including weekly audit and staff surveillance, were mandatory, and monitoring was performed according to MOH guidelines. Linen and waste management and the cleaning and disinfection process were established at the beginning of the project. Results: Construction was completed within 3 weeks. The setup was completed in November 2021 for 737 beds. There were 758 admissions during the 4-month operation. In total, 12 trained ICLOs oversaw the training of 200 healthcare workers. They conducted 12 IPC audits and provided feedback to all staff. Compliance with PPE practices was inconsistent, and findings were shared during daily after-action reviews for improvement. The greatest challenges were converting the F1 facility to a healthcare facility, training staff with no IPC knowledge, and monitoring IPC on the ground. The trained ICLOs were successful in implementing, practicing, and monitoring IPC measures with minimal assistance from the infection prevention team. Conclusions: Operation began on November 5, 2021, and ceased on March 9, 2022. The community treatment facility construction, setup, and operations were completed within a short timeframe due to the efforts of various stakeholders. We faced many challenges, but we managed to implement and uphold IPC standards from beginning to end.

Objectives: COVID-19 cases continue to climb in the community from the SARS-CoV-2 δ (delta) variant wave. To prepare for cases that may be nosocomial or detected late, the infection prevention team constructed a ‘hot ward’ tool kit to guide implementation of infection control measures. Methods: We engaged the NUH Facilities Management ventilation engineers to understand every ward’s mechanical ventilation setup. With this information, we created of “green” and “hot” zones within ward. After conducting assessments on individual wards, we created the “hot ward” tool kit: (1) 38 ward floor plans indicating ventilation setup, “green” zones, and “hot” zones; (2) a risk matrix to guide ward actions based on cycle threshold (Ct) value and duration of exposure; and (3) “hot ward” checklists. The tool kit was presented to infectious disease clinicians on the infection prevention team and senior nursing leaders for input and guidance. To ensure that these plans were practical, we conducted numerous site walks with HOD and ward nurse managers (ie, for the ICUs and psychiatric units). Finally, the tool kit was shared in a meeting with key stakeholders and senior leaders. It was also uploaded to the NUH COVID-19 quick-reference intranet page for easy staff access. Results: The tool kit was used by 2 general wards when cases of confirmed COVID-19 were detected among patients. Overall, the tool kit helped HOD and nurse managers with the immediate actions required and it provides useful guidance for the infection prevention team to assess and guide decisions regarding whether a ward lockdown is necessary. Conclusions: Although the guidance was useful, from the site walk we learned that the mechanical ventilation system of some wards is shared, making it challenging to prevent cross contamination between wards because any shared ventilation between unmasked areas can be pose a risk for both patients and staff. Additional measures were instituted to mitigate this risk.

Objectives: The treatment of infected knee arthritis in patients with coexisting joint destruction, including superimposed advanced arthritis or chronic osteomyelitis, is challenging. We investigated the outcomes of 2-stage primary total knee arthroplasty (TKA) for evolutive infected arthritis with coexistent joint destruction. Methods: We retrospectively reviewed the cases of 50 patients from 5 hospitals who presented with infected arthritis of the knee and were treated with 2-stage TKA: debridement and antibiotic-loaded articulating cement spacer (ALCS) insertion as the first stage and TKA as the second stage. We recorded demographics, laboratory results, and radiographic findings including Kellgren-Lawrence classification (KL) for knee arthritis. Outcomes including infection eradication, knee range of motion (ROM), and patient-reported outcome measures were evaluated. Results: The patient cohort had a mean age of 71.8 years (range, 40–86); they were followed for an average of 4.1 years (range, 2.2–13.3). Also, 40 patients showed KL grade 4, whereas 10 patients showed grade 3. A pathogen was identified in 38 cases (73.1%); methicillin-resistant staphylococci infections (N = 16) and Candida spp infections (N = 7) were the 2 most common types. Constrained prostheses were used in 10 cases (20%). Stem augmentations were used in 15 cases (36.0%) and block augmentations were used in 8 cases (19.0%). One patient had recurrent infection after TKA, so the eradication rate was 98%. After 2-stage TKA, the mean knee ROM was 119.4° (range, 80°–140°) and the mean Knee Society (KS) knee score was 90.4, the average KS function score was 84.7, the average Hospital for Special Surgery (HSS) score was 87.2, and the average Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score was 16.7. The KS function scores (P = .029) and the WOMAC scores (P = .022) were significantly better in 17 patients who underwent ALCS insertion within 30 days of infection diagnosis compared to the other 33 patients. Conclusions: The 2-stage primary TKA for patients with infected knee arthritis with coexisting joint destruction showed satisfactory outcomes with a low infection recurrence. However, constrained prostheses or augmentation use may be necessary. Notably, some functional scores were better in the group that underwent ALCS insertion relatively early after the infection diagnosis.

Objectives: We compared rates of myopericarditis adverse events and evaluated potential risk factors of development. We compared rates of dermatological–neurological adverse events (severe and serious) with other adverse events in a specific population of deployed US military personnel who received or did not receive ACAM2000 vaccine (ie, Vaccinia smallpox live vaccine). Methods: Up to 20,000 military personnel recipients were enrolled in a prospective observational cohort study: up to 15,000 ACAM2000 recipients in cohort 1 and up to 5,000 military personnel who were eligible for ACAM2000 vaccination but were not vaccinated due to recent vaccination or characteristics of their contacts in cohort 2. Enrollment was at a 3:1 ratio, respectively. Serum specimens and data were collected at the initial visit and 10 days later (cf, window of 6–17 days). Study participants with evidence, either clinical or laboratory, of possible myopericarditis were referred to a blinded independent review committee for further evaluation and adjudication. The primary analysis was logistic regression with adjudicated myopericarditis as the dependent variable and age, sex, race, and exercise regimen as the independent variables. Results: Initial data and serum specimens were obtained from 14,667 participants (cohort 1, N = 10,825; cohort 2, N = 3,842). According to protocol, 2 visits were completed by 12,110 participants (cohort 1, N = 8,945; cohort 2, N = 3,165), and 125 participants (cohort 1, N = 111; cohort 2, N = 14) were referred for myopericarditis adjudication, of whom 1 had confirmed myocarditis, 5 had suspected myocarditis, 1 had suspected pericarditis, and 54 (cohort 1, N = 44; cohort 2, N = 10) had subclinical myopericarditis. The unadjusted myopericarditis rates were 5.7 per 1,000 (95% CI, 4.3–7.5) for cohort 1 and 3.2 per 1,000 (95% CI, 1.7–5.8) for cohort 2. The unadjusted and adjusted odds ratios for myopericarditis for cohort 1 and cohort 2 were 1.8 (95% CI, 0.9–3.6) and 1.3 (95% CI, 0.6–2.6), respectively. At least 1 serious adverse event was experienced by 117 participants (1.1%) in cohort 1 and 13 (0.3%) in cohort 2. No serious and severe neurological or dermatological adverse events were reported. Conclusions: ACAM2000 vaccination was associated with a modest but nonsignificant increase in the risk of myopericarditis in this prudently screened, young and healthy service-member population. The adjusted OR was 1.3 and the unadjusted OR was 1.8. Overall, all but 7 cases were subclinical. Citation: Faix DJ, Gordon DM, Perry LN, et al. Prospective safety surveillance study of ACAM2000 smallpox vaccine in deploying military personnel. Vaccine 2020;38:7323–7330.

Objectives: Severe streptococcal infections are invasive, re-emerging infections that rapidly worsen and lead to death. Not only group A Streptococcus (GAS) but also group g Streptococcus (GGS) are the causative agents of this infection. Moreover, GGS produces hemolytic toxins, proteolytic toxins, and other toxins like GAS. Furthermore, drug-resistant Streptococcus spp, like other pathogenic bacteria, are on the rise worldwide. However, drug resistance has not been studied extensively in invasive GGS. Therefore, we investigated the drug susceptibility of GGS clinical isolates that are closely related to fulminant streptococcal infections. Methods: We used GGS strains isolated from sterile sites of invasive infections at a hospital in Nagoya City, Japan, from 2017 to 2021. Bacterial identification and drug-susceptibility testing were performed using a VITEK-2 system. Results: Overall, 53 strains were included in the study. The GGS strains examined in this study were resistant to 3 different antibiotics (erythromycin, clindamycin, and minocycline). Also, 18 strains (34%) were resistant to erythromycin, 9 (17%) were resistant to clindamycin, and 18 (34%) were resistant to minocycline. Moreover, there were 5 strains (9.4%) of 2-drug–resistant bacteria and 8 strains (15.1%) of 3-drug–resistant bacteria. Conclusions: Acquired resistance not only to individual antibiotics but also to multiple antibiotics suggests that GGS tends to become multidrug resistant. Continued surveillance of the drug susceptibility of GGS as a potential cause of fulminant streptococcal infections will be necessary in the future.

Objectives: SARS-CoV-2 is a novel and highly infectious virus. An effective response requires rapid training of healthcare workers (HCWs). We measured the change in knowledge related to COVID-19 and associated factors before and after training of HCWs in Vietnam. Methods: A quasi-experimental design was used to evaluate HCW knowledge related to prevention and control of SARS-CoV-2 before and after attending a 2-day training-of-trainers course. Between June and September 2020, 963 HCWs from 194 hospitals in 21 provinces received the training. HCW knowledge was assessed using a 20-item questionnaire consisting of multiple-choice questions at the beginning and closing of the training course. A participant received 1 point for each correct answer. He or she was considered to have improved knowledge the posttest score was higher than the pretest score with a score ≥15 on the posttest. We applied the McNemar test and logistic regression model to test the level of association between demographic factors and change in knowledge of COVID-19. Results: Overall, 100% of HCWs completed both the pretest and posttest. At baseline, only 14.7% scored ≥15. Following the training, 78.4% scored ≥15 and 64.3% had improved knowledge according to the predetermined definition. Questions related to the order of PPE donning and doffing and respiratory specimen collection procedures were identified as having the greatest improvement (44.6% and 60.7%, respectively). Being female (OR, 1.5; 95% CI, 1.1–2.0), having a postgraduate degree (OR, 2.5; 95% CI, 1.4–4.4), working in a nonmanager position (OR, 1.5; 95% CI, 1.1–2.1), previous contact with a COVID-19 patient (OR, 1.5; 95% CI, 1.1–2.0), and working in northern Vietnam (OR, 2.0; 95% CI, 1.4–2.6), were associated with greater knowledge improvement. Conclusions: Most HCWs demonstrated improved knowledge of COVID-19 prevention and control after attending the training. Particular groups may benefit from additional training: those who are male, leaders and managers, those who hold an undergraduate degree, and those who work in the southern provinces.

Objectives: Cryptococcus infection is one of the major human immunodeficiency virus (HIV)–related opportunistic infections, and the CD4 count falls below 100 per µL. Primary treatment for HIV-associated cutaneous cryptococcosis is amphotericin B (AmB) plus flucytosine. Methods: We present the case of a man with advanced HIV disease who developed whole-body cutaneous lesions yet improved with high-dose fluconazole alone. Results: A 33-year-old Asian man with a medical history of pulmonary tuberculosis and cryptococcal meningitis with complete treatment, injection drug use, and HIV infection with default of antiretroviral treatments (ART) 3 years earlier, presented to the emergency department with fever, oral thrush, and 30-pound weight loss over 6 weeks. He also had plaques, multiple hard papulonodules with central ulceration, and macular skin lesions all over his body of varying size. Blood cultures were negative for bacteria growth, but fungal microscopy of the blood culture showed unspecific hypha. Histopathology examination of the skin biopsy showed a classic “soap bubble” appearance, which is associated with Cryptococcus infection. Laboratory values revealed anemia (8.6 g/dL), leukopenia (2.9 ×109/L), lymphopenia (58/µL), and thrombocytopenia (145 ×109/L). The CD4 cell count was 18/µL, and the serum viral load was 638.665 copies/mL. Lumbar puncture could not be performed due to patient refusal. Treatment with high-dose fluconazole (1,200 mg) for 3 months was initiated and is planned to continue with consolidation and maintenance dose. ART was administered 4 weeks after starting antifungal therapy. His fever resolved and slow regression of the skin lesions occurred after treatment was given. Conclusions: Cutaneous cryptococcosis was assessed by biopsy of the cutaneous lesion, which is essential to confirming the diagnosis. In the case of cryptococcosis, skin infection may indicate a further progression of advanced HIV disease. In HIV-infected patients with Cryptococcus findings in any part of the body, a lumbar puncture should be considered to rule out central nervous system infection. Although neither AmB nor flucytosine was given due to unavailability in this area, the patient improved. In resource-limited settings, high-dose fluconazole alone may be useful as an alternative treatment, although it is also very challenging.

Objectives: Medical devices and the hospital environment can be contaminated easily by multidrug-resistant bacteria. The effectiveness of cleaning practices is often suboptimal because environmental cleaning in hospitals is complex and depends on human factors, the physical and chemical characteristics of environment, and the viability of the microorganisms. Ultraviolet-C (UV-C) lamps can be used to reduce the spread of microorganisms. We evaluated the effectiveness of an ultraviolet-C (UV-C) device on terminal room cleaning and disinfection. Methods: The study was conducted at an ICU of a medical center in Taiwan. We performed a 3-stage evaluation for the effectiveness of UV-C radiation, including pre–UV-C radiation, UV-C radiation, and a bleaching procedure. The 3 stages of evaluation were implemented in the ICU rooms from which a patient had been discharged or transferred. We collected the data from adenosine triphosphate (ATP) bioluminescence testing, colonized strains, and their corresponding colony counts by sampling from the environmental surfaces and air. We tested 8 high-touch surfaces, including 2 sides of bed rails, headboards, footboards, bedside tables, monitors, pumping devices, IV stands, and oxygen flow meters. Results: In total, 1,696 environmental surfaces and 72 air samples were analyzed. The levels of ATP bioluminescence and colony counts of isolated bacteria decreased significantly after UV-C radiation and bleaching disinfection for both the environmental and air samples (P < .001). Resistant bacteria (vancomycin-resistant Enterococcus, VRE) were commonly isolated on the hard-to-clean surfaces of monitors, oxygen flow meters, and IV pumps. However, they were also eradicated (P < .001). Conclusions: UV-C can significantly reduce environmental contamination by multidrug-resistant microorganisms. UV-C is an effective device to assist staff in cleaning the hospital environment.

Objectives: In healthcare facilities, environmental reservoirs of CPE are associated with CPE outbreaks. In the newly built NCID building, we studied the introduction of CPE in the aqueous environment. Methods: We sampled the aqueous environments (ie, sink, sink strainer, and shower drain-trap with Copan E-swabs and sink P-trap water) of 4 NCID wards (ie, 2 multidrug-resistant organism (MDRO) wards and 2 non-MDRO wards). Two sampling cycles (cycle 1, June–July 2019 and cycle 2, September–November 2019) were conducted in all 4 wards. Cycle 3 (November 2020) was conducted in 1 non-MDRO ward to investigate CPE colonization from previous cycles. Enterobacterales were identified using MALDI-TOF MS and underwent phenotypic (mCIM and eCIM) and confirmatory PCR tests for CPE. Results: We collected 448, 636, and 96 samples in cycles 1, 2, and 3, respectively. MDRO and non-MDRO wards were operational for 1 and 7 months during the first sampling cycle. The CPE prevalence rates in MDRO wards were 1.67% (95% CI, 0.46% – 4.21%) in cycle 1 and 1.76% (95% CI, 0.65% – 3.80%) in cycle 2. In the aqueous environments in MDRO wards, multiple species were detected (cycle 1: 2 K. pneumoniae, 1 E. coli, and 1 S. marcescens; cycle 2: 5 K. pneumoniae and 1 R. planticola), and multiple genotypes were detected (cycle 1: 3 blaOXA48; cycle 2: 5 blaOXA48 and 1 blaKPC). The CPE prevalence in non-MDRO wards was 1.92% (95% CI, 0.53%–4.85%) in cycle 1. The prevalence rate increased by 5.51% (95% CI, 1.99%–9.03%) to 7.43% (95% CI, 4.72%–11.04%; P = .006) in cycle 2, and by another 2.98% (95% CI, −3.82% to 9.79%) to 10.42% (95% CI, 5.11% – 18.3%; P = .353) in cycle 3. Only blaOXA48 S. marcescens were detected in all cycles (except 1 blaOXA48 K. pneumoniae in cycle 2) in the non-MDRO ward. Conclusions: CPE established rapidly in the aqueous environment of NCID wards, more so in MDRO wards than non-MDRO wards. Longitudinal studies to understand the further expansion of the CPE colonization and its impact on patients are needed.

Objectives: High-touch surface (HTS) cleaning is critical to prevent healthcare-associated infections. However, HTS definitions and cleaning frequency vary across guidelines. We conducted a scoping review of published guidelines on HTS definitions and recommended cleaning frequency in inpatient wards. Methods: We searched national and societal guidelines on Google and PubMed using the following search terms: [(environmental cleaning/disinfection/housekeeping/sanitization), (hospital/healthcare/infection control prevention/inpatient/acute care), and (practice/guideline/guidance/methodology/protocol)]. We compared the guidelines’ HTS definitions, recommended cleaning frequency, and supporting evidence. Results: In total, 9 environmental cleaning guidelines were included: Centers for Disease Control and Prevention (CDC 2020); Asia Pacific Society of Infection Control (APSIC 2013); International Society for Infectious Diseases (ISID 2018); Joint Commission Resources (JCR 2018); National Health Service, United Kingdom (NHSUK 2021); Public Health Agency, Northern Ireland (PHANI 2016); Public Health Ontario, Canada (PHOC 2018); National Health and Medical Research Council, Australia (NHMRC 2019); Ministry of Health, Singapore (MOH 2013). These 6 guidelines identified 31 types of HTS: bed rails and frames [mentioned by 6 of 6 guidelines]; call bells, doorknobs and handles (5 of 6 guidelines); bedside tables and handles, light switches, overbed and tray tables, and sinks and faucet handles (4 of 6 guidelines); chairs and chair arms, edges of privacy curtains, IV infusion pumps and poles, keyboards, medical equipment, monitoring equipment, and telephones (3 of 6 guidelines); assist bars, counters, elevator buttons, toilet seats and flushes, transport equipment, and wall areas around the toilet (2 of 6 guidelines); and bedpan cleaners, beds, blankets, commodes/bedpans, dispensers, documents, mattresses, monitors, mouse, pillows, and touch screens (1 of 6 guidelines). The JCR, NHMRC, NHSUK guidelines did not define HTSs. The 6 guidelines recommended at least daily cleaning for HTSs, but ISID, JCR, and NHSUK guidelines did not mention HTS cleaning frequency. The CDC guidelines further specified at least once daily cleaning for inpatient wards and private toilets and twice daily for public or shared toilets. None of the guidelines cited any references for HTS cleaning frequency recommendations. Conclusions: There is no uniformity in HTS definitions among 6 guidelines, and the recommended HTS cleaning frequency in these guidelines was not supported by published evidence. Studies exploring optimal cleaning frequency of HTSs are needed.

Objectives: HCWs are recommended to wipe the computers with alcohol wipes before clinical use. Compliance assessment by direct observation is resource intensive. We used ATP measurement as a surrogate to assess the compliance to preutilization cleaning of computers. Methods: We conducted a pilot study to determine the median relative light unit (RLU) value reflective of preutilization cleaning of the computers. We identified values of <250, 250–500, and >500 RLU to reflect cleaned, probably cleaned, and not cleaned computers, respectively. Subsequently, we conducted a cross-sectional study of the computers in the inpatient wards in Tan Tock Seng Hospital and National Centre for Infectious Diseases. Using 3M Clean-Trace ATP swabs, we tested 5 computers in each ward: 2 computers on wheels, 2 from the nursing station, and 1 at the patients’ room entrance. All analyses were conducted using STATA version 15 software. Results: Between October 4 and 10, 2021, we collected 219 samples from 219 computers. Among them, 44 (20.1%) were cleaned, 49 (22.4%) were probably cleaned, and 126 (57.5%) computers were not cleaned. Higher compliance to computer cleaning was observed in COVID-19 wards [85 ATP samples; cleaned, 37 (43.5%); probably cleaned, 26 (30.6%); not cleaned, 22 (25.9%)] compared with non–COVID-19 wards [134 ATP samples; cleaned, 7 (5.2%); probably cleaned, 23 (17.2%); not cleaned, 104 (77.6%)] (P < .01). No significant difference was observed in compliance with cleaning computers between the ICU [30 ATP samples; cleaned, 7 (23.3%); probably cleaned, 4 (13.3%); not cleaned, 19 (63.3%)] and general wards [189 ATP samples; cleaned, 37 (19.6%); probably cleaned, 45 (23.8%); not cleaned, 107 (56.6%)] (P = .47). Conclusions: ATP swab tests can be used as a surrogate marker to assess compliance to pre-utilization cleaning of computers. Enhanced awareness of environmental hygiene may explain the higher compliance to computer cleaning observed in COVID-19 wards.

Objectives: We evaluated the disinfecting efficacy of atomized ionless hypochlorous acid water (CLFine) against pathogenic microorganisms in an isolation room. Methods: The study was conducted in an isolation room of Kurume University Hospital. CLFine with available chlorine concentrations of 40 ppm and 300 ppm as test substances and purified water as control were atomized with an ultrasonic atomizer (CLmistL). The 40 ppm and 300 ppm of CLFine were atomized at the atmospheric available chlorine concentrations of ~0.03 ppm and 0.1~0.2 ppm, respectively, and purified water was atomized in the same manner as CLFine. Petri dishes with Staphylococcus aureus, Bacillus cereus spores, Bacillus subtilis spores and Aspergillus ruber were allocated in the room, then CLFine or purified water was atomized. Sampling was performed at 3 and 5 hours after the start of atomization, and the bacterial counts were measured. The study was carried out either with air conditioning turned “on” or “off” because atmospherically available chlorine concentration is affected by ventilation. Results: When the air conditioning was turned on, purified water showed a slight reduction of bacterial counts by 0.9 log or less at 5 hours after the atomization. When CLFine was used, 40 ppm greatly reduced the counts of Staphylococcus aureus by 5.1~5.4 logs reduction at 5 hours after the atomization, but no distinctive efficacy was observed against other microorganisms. On the other hand, 300 ppm caused a significant reduction of the bacterial counts for all the microorganisms at 5 hours after the atomization (P < .001 vs purified water). The same results were observed in the environment with the air conditioning turned off. Conclusions: Our data suggest that CLFine effectively disinfects pathogenic microorganisms and can contribute to maintaining the hygienic environment of hospital rooms. This study was funded as contracted research by NIPRO Corporation with the approval of the ethics committee (study no. 21229).

Objectives: To quantify the microorganism burden of rehabilitation gym equipment surfaces as well as to assess the effectiveness of patient’s practice of hand hygiene and our current disinfection methods to reduce burden and transmission of microorganisms during rehabilitation sessions. Methods: A prospective study of environmental contamination using microbiology culture in Khoo Teck Puat Hospital Geriatric Medicine Outpatient Rehabilitation Gym. Results: For both the control and intervention group, the total aerobic bacterial count on the gym equipment after patient use is significant and increase up to 360 CFU per swab. In the control and intervention groups, the total aerobic bacterial counts on the gym equipment before patients’ use were negligible (<10 CFU per swab). The total aerobic bacterial count of the equipment remained negligible (<10 CFU per swab) after patient use and immediate disinfection. We detected discrepancies between the results of the total aerobic bacterial count after patient use between the control and intervention groups. Conclusions: Outpatient rehabilitation gyms are potential reservoirs of microorganisms, which may further contribute to the transmission of healthcare-associated pathogens. In this study, an intervention in which cleaning equipment was wiped with alcohol wipes was effective in reducing microorganism transmission in the rehabilitation gym environment and should be considered as part of our infection control strategy. The additional step of involving our patients in using hand rub before the start of their therapy sessions can provide additional benefit in reducing microorganism transmission only if patients adhere to the World Health Organization (WHO) recommended 7 steps of proper hand rub. Good patient education on hand hygiene is equally as important as that for healthcare professionals to control environmental contamination.

Objectives: Cohort and epidemiology studies have previously revealed potential associations between air pollution exposure and acne vulgaris. However, the molecular mechanisms that drive these associations are not currently well understood. In this study, we compared the molecular signatures of acne and PM2.5-exposed skin to infer whether common underlying biological mechanisms exist. Methods: Acne microarray data sets were downloaded from GEO. RMAExpress was used for microarray normalization, and TMeV was used to identify differential expressed genes (DEGs). A random-effects model in MetaVolcanoR was used to determine fold changes and P values. DEGs of PM2.5-exposed skin-cell models were obtained from the literature. DEGs were compared using GeneOverlap and a custom R script. Analyses of pathways, upstream regulators, and causal networks were conducted using ingenuity pathway analysis (IPA). Results: The molecular signatures of acne skin and the effect of PM2.5 on skin in vitro were compared at 3 levels: (1) gene expression, (2) pathway activity, and (3) upstream regulators. Significant concordant overlaps of both upregulated (P < 3e-23) and downregulated DEGs (P< .005) were observed in acne skin and PM2.5-exposed keratinocytes. However, for the PM2.5-exposed 3D skin model, significant overlap with acne skin was only observed for upregulated DEGs (P < 8e-14). Fold changes of DEGs in both acne and PM2.5-exposed data sets showed significant correlation (Pearson correlation coefficient > 0.6; P < .001). An IPA analysis identified 13 pathways commonly enriched in acne and PM2.5 data sets, including IL17, IL6, Toll receptor PPAR, LXR–RXR, and acute-phase response pathways. Common upstream regulators were further identified including TNFα, NFκB, CAMP, AhR, and IL17A. Finally, causal network analysis revealed several potential hub regulators shared in acne pathogenesis and PM2.5-exposed skin, including HIF1α, TNF, IL1α, and CCL5. Conclusions: Our analysis revealed significant concordant molecular signatures between acne and PM2.5-exposed skin. Biological insights from this study offer clues that build the causal links between air pollution and acne pathogenesis.

Objectives: Pollution exposure is associated with several dermatological conditions including acne, atopic dermatitis, and psoriasis. Antimicrobial peptides (AMPs) are key effectors of innate defense, and some AMPs are involved in inflammatory skin conditions. In this study, we aimed to characterize expression changes of human AMPs under different in-vitro pollution exposures. Methods: RNA-seq profiling was conducted on normal human primary epidermal keratinocytes (NHEK) treated with either a vehicle control, or benzo[a]pyrene (BaP) and on pigmented living skin equivalent models (pLSE) treated with either a vehicle control, ozone, or vehicle exhaust. Differential expressed genes (DEGs) were identified with R scripts. DEGs of PM2.5 were obtained from the literature and the GEO database. Also, 180 human AMP genes were obtained from a UDAMP database. UpSetPlot was used to plot DEGs overlaps. MetaVolcano was used to identify frequently changed AMPs. Results: We used in-house and published transcriptome profiles to identify AMP genes that displayed altered expression under in-vitro pollution exposure. Of the 180 AMP genes under investigation, 37 showed significant changes in expression in at least 1 of the 5 experiments. Using MetaVolcano, 13 AMP genes were identified to be frequently and consistently changed. Several AMPs associated with inflammation and skin diseases were frequently upregulated, including S100A8, S100A9, LCN2, HBD3, RNASE7, and CXCL1. Only 3 frequently downregulated AMP genes were identified, including CXCL14, which is reported to be a noninflammatory AMP that is highly expressed in healthy skin and is downregulated in skin diseases. Conclusions: The data sets suggest that expression of both proinflammatory and homeostatic AMPs can be perturbed by pollution. These findings provide new clues to explain how pollution affects skin innate defense, host–microbe interactions and contributes to abnormal skin conditions. Normalizing aberrant AMP expression may be a potential approach to treat pollution associated skin disorders in the future.

Objectives: Surgical handwashing is one of the most important measures to prevent surgical site infection (SSI). We evaluated the effectiveness of the intervention program on surgical handwashing compliance of healthcare workers (HCWs) at Hung Vuong Hospital. Methods: This research was conducted from July 2019 to November 2019 in 3 phases. In the first phase, we determined the surgical handwashing compliance rate before the intervention. In the second phase, we implemented an intervention bundle as follows. We provided reminders of compliance in the form of video screen and automatic timers at surgical handwashing sinks. We provided links and QR codes for online access and live streaming of instructional videos on implementation of the hospital’s surgical hand sanitation procedures in the surgical handwashing area. We conducted direct monitoring to remind and guide HCWs to follow the procedures in combination with camera surveillance to accurately reflect compliance. Finally, we provided feedback in multiple steps: feedback to individual, feedback to head of department or department heads, cited names in briefings and sent names to the general planning department to suspend surgery privileges. In the third phase, we re-evaluated the surgical handwashing compliance rate after the intervention. Results: The total number of surgical handwashing checklists observed before and after the intervention was 787. The surgical handwashing compliance rate improved significantly from 48.8% to 71.8% (PR, 2.7; 95% CI, 1.98–3.57; P < .01). The compliance rate in camera monitoring also increased from 22.1% to 57.9% (PR, 4.8; KTC 95%, 3.14–7.47; P < .01). The compliances rates of both surgeons and scrub nurses improved significantly after the intervention (P < .01). Conducting the new surgical handwashing procedure increased from 90.2% to 99.5% after this intervention. Conclusions: This intervention program improved surgical handwashing compliance of HCWs.