Background. During Taiwan's severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Omicron outbreak in 2022, pediatric coronavirus disease 2019 (COVID-19) encephalitis cases surged, resulting in multiple fatalities. We investigated patient characteristics and mortality risk factors. Method. Using the Brighton Collaboration criteria, we identified 289 suspected pediatric COVID-19 encephalitis cases diagnosed between April and December 2022 by linking the national surveillance, remdesivir application, immunization, and death registries. We analyzed clinical data and viral genotypes, then used univariate and multivariate logistic regressions to assess mortality risk factors. Results. We identified 75 encephalitis cases: 50 (67%) were male, with a median age of 5 years (interquartile range [IQR]: 3-8 years), 45 (60%) had no comorbidities, and 23 (31%) had received at least 1 dose of the COVID-19 vaccine. The median interval from symptom onset to medical attention was <1 day (IQR: 0-1 day). Fourteen cases (19%) died after a median hospital stay of 3 days (IQR: 1-5 days). All sequenced viruses matched the circulating Omicron subvariants. In univariate analysis, age <5 years was associated with increased mortality (odds ratio [OR] & 6.05; 95% confidence interval [CI] & 1.53-24.00). Multivariate analysis showed a nonsignificant trend (adjusted OR & 3.64; 95% CI & 0.81-16.40) after adjustment for sex, comorbidities, and vaccination. Conclusions. During the Omicron wave, the number of pediatric COVID-19 encephalitis cases progressed rapidly and mortality was high, particularly among children <5 years of age, regardless of comorbidities. We recommend COVID-19 vaccination and monitoring for signs of COVID-19 encephalitis in young children.

To understand the extent of SARS-CoV-2 transmission and immunity during Taiwan's first major COVID-19 outbreak in 2021, we conducted a seroepidemiological investigation using blood donor specimens. A total of 5000 residual blood samples were randomly selected from donors aged 17-65 years across six geographic regions during April 25-July 3 (week 17-week 26), 2021. This time period spanned from the beginning of the surge to six weeks after its peak. Serologic testing using Roche Elecsys® assays measured antibodies against nucleocapsid (N) and spike (S) proteins. Infection-induced seropositivity, defined as having both anti-N and anti-S antibodies, was detected in only one individual (0.02%, 95% confidence interval (CI): 0-0.06%). Blood having only anti-S antibody, indicating vaccine-induced immunity, was observed in 5.2% of samples (95% CI: 4.6-5.8%). The findings suggest that SARS-CoV-2 infection prevalence remained low in the community at the time, with seropositivity primarily reflecting early stages of vaccine rollout. This study demonstrates the value of blood donor-based serosurveillance for estimating infection and vaccine-induced immunity, and informs future policy for public health monitoring.

Influenza remains a clinically significant viral cause of community-acquired pneumonia in adults. Without timely antiviral treatment, severe influenza complicated by pneumonia may lead to poorer outcomes. However, the effect of empiric antiviral treatment on serious or life-threatening influenza is not well documented from clinical trials. We performed a retrospective study of patients with severe influenza complicated by pneumonia as confirmed by bronchoalveolar lavage polymerase chain reaction (PCR) in intensive care units at a tertiary hospital in Taiwan from 2009 to 2019. We collected demographic and clinical data from medical records. We compared survival outcomes between those with or without empiric antiviral treatment (before or after PCR diagnosis) with the Cox proportional hazard model. Of the 77 patients enrolled in this study, the survival rates were higher among those treated empirically with antivirals before diagnostic test results were obtained than for those who were not (P = 0.024). Compared with the nonempiric treatment group, the empiric antiviral treatment group had a 68.3% lower risk of death. Meanwhile, the risk of death increased by 3.8% for each unit increase of acute physiology and chronic health evaluation (APACHE) III score. Empiric antiviral treatment of influenza may lead to a better survival rate. For patients with suspected severe influenza, antiviral medication should be initiated as soon as possible without waiting for laboratory confirmation of influenza virus infection.

We investigated a fatal case of primary amoebic meningoencephalitis from an indoor surfing center in Taiwan. The case was detected through encephalitis syndromic surveillance. Of 56 environmental specimens, 1 was positive for Naegleria fowleri ameba. This report emphasizes the risk for N. fowleri infection from inadequately disinfected recreational waters, even indoors.

We investigated a COVID-19 cluster involved seven case-patients lived in a high-rise building in September 2021. We used a simplified tracer-gas experiment and virus sequencing to establish the link between case-patients. Vertical transmission among vertically aligned apartments on different floors in a building was the most likely route of transmission.

We investigated 2 acute cases and 1 previous case of Seoul hantavirus infection in workers in a feeder rodent breeding farm in Taiwan. Prevalence of hantavirus IgG among the tested feeder rats was 37.5%. Appropriate prevention measures, including using disinfection protocols and personal protective equipment, are crucial to lowering risk.

Background In Taiwan, medical providers are required to report all acute hepatitis C (AHC) patients to National Notifiable Disease Surveillance System (NNDSS). Identifying factors associated with AHC may inform the strategies to prevent the spread of hepatitis C virus (HCV). We used the national surveillance data to assess gender difference in risk factors associated with AHC in Taiwan and propose control measures in at-risk groups. Methods We conducted a nationwide case–control study using data from NNDSS and AHC case investigation questionnaires, for the period of March 6, 2014–December 31, 2016. Cases were AHC confirmed in NNDSS; controls were reported AHC with negative HCV nucleic acid test and negative serum anti-HCV antibody. We used bivariate analysis to identify characteristics and risk exposures for AHC and conducted gender stratified analyses. Results We identified 602 AHC cases (66.9% males, median age 48 years) and 90 controls. Older age, male gender (OR: 1.85, 95% CI: 1.18–2.90), history of viral hepatitis (OR: 7.93, 95% CI:1.91–32.88), history of sexually transmitted infections (OR: 21.02, 95% CI: 2.90–152.43), and having healthcare-associated risk exposures (OR: 2.02, 95% CI: 1.25–3.25) were associated with AHC. Stratified analyses showed receiving intravenous infusion, history of hepatitis B, syphilis, and human immunodeficiency virus infection were risk factors for male AHC; receiving hemodialysis was risk factor for females. Conclusions Our study demonstrates risk factors for AHC in Taiwan with gender difference. Proper infection control practices in healthcare settings and interventions targeting male patients with HIV and other STIs, remain crucial to prevent individuals from AHC.

Background: COVID-19 and influenza have similar clinical presentations that can range from mild to severe disease. The World Health Organization recommends that countries use existing influenza surveillance to monitor COVID-19 transmission in communities. We aim to describe the surveillance and investigation of COVID-19 at the early stage of the pandemic in Taiwan.Methods: In February 2020, the Taiwan Centers for Disease Control enhanced COVID-19 surveil-lance through its existing influenza surveillance. We retrospectively tested patients for SARS-CoV-2 who had symptoms of severe complicated influenza but were negative in influenza testing. We conducted an epidemiological investigation and contact tracing for the index pa-tient and secondary cases to prevent virus transmission.Results: We identified the first COVID-19 patient on February 15 through enhanced COVID-19 surveillance. He had no history of traveling abroad and an unclear history of contact with COVID-19 cases. He presented with influenza-like illness on January 27 and was hospitalized from February 3 to 15. We identified 39 close contacts of the index patient, including 11 family members and 28 healthcare workers. In total, four close family contacts of the index patient tested positive for SARS-CoV-2. An additional 84 close contacts of the four secondary cases were identified and traced; none was diagnosed with COVID-19.Conclusions: We recommend enhancing COVID-1 9 surveillance by testing patients with influenza-like illness. To prevent the spread of COVID-19, we recommend using appropriate personal protective equipment when in close contact with patients who present with influenza-like illness or when caring for patients with pneumonia of unknown etiology.Copyright 2023, Taiwan Society of Microbiology. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

To the Editor—We thank Lai and Wei [1] for their interest in our work [2]. First, to inform clinical practice, our clinical diagnosis–based inclusion criteria simulate the timing of antiviral treatment in real-world settings (“when indicated, should not be delayed until the results of diagnostic testing are available for persons at high risk of complications”) as recommended by the Infectious Diseases Society of America (IDSA), the US Centers for Disease Control and Prevention (CDC), and the Infectious Diseases Society of Taiwan [3]. We did not have access to laboratory data of patients (molecular assays, rapid influenza diagnostic testing, or concomitant bacterial culture). However, the laboratory diagnosis–based inclusion criteria proposed by Lai and Wei [2] had been used in a previous clinical study (N = 1113) [4]. In keeping with our findings, the study showed that inhaled zanamivir is not inferior to oral oseltamivir for shortening the duration of fever or viral shedding [4]. Second, propensity score stratification controlled the confounding from multiple comorbidities (including those covered by the Charlson comorbidity index) [5]. There is no need to further match the Charlson comorbidity index again. Third, our study was designed to detect the superiority of oral oseltamivir over inhaled zanamivir (reference). We cautiously concluded that inhaled zanamivir is not inferior to oral oseltamivir, because analysis of the main outcome was in favor of inhaled zanamivir but the difference did not reach statistical significance (adjusted hazard ratio [aHR] for influenza-related hospitalization or death: 1.01; 95% confidence interval [CI]: .96–1.16). Prespecified subgroup analyses of the high-risk groups, elderly individuals aged 65 years and older (aHR: 1.14; 95% CI: 1.05–1.25) or those with chronic lung diseases (aHR: 1.23; 95% CI: 1.08–1.41) further strengthen this conclusion. Fourth, patients with consciousness disturbance or low inspiration effort have a propensity score (probability) (of assignment to oral oseltamivir) approaching 1.0. Such patients were excluded from analyses during trimming (exclusion of the extreme 2.5% in both tails of propensity score distribution) and will not cause a selection bias. Finally, to avoid repeatedly counting the same individuals, we only include the first outpatient visit of each eligible patient with a diagnosis of influenza during the same influenza season. We considered influenza episodes (of the same individual) in different influenza seasons (with different viral strains) as independent events. Propensity score weighting balanced any duplicated counting of the baseline characteristics.

We investigated a cluster of SARS-CoV-2 infections in a quarantine hotel in Taiwan in December 2021. The cluster involved 3 case patients who lived in nonadjacent rooms on different floors. They had no direct contact during their stay. By direct exploration of the space above the room ceilings, we found residual tunnels, wall defects, and truncated pipes between their rooms. We conducted a simplified tracer-gas experiment to assess the interconnection between rooms. Aerosol transmission through structural defects in floors and walls in this poorly ventilated hotel was the most likely route of virus transmission. This event demonstrates the high transmissibility of Omicron variants, even across rooms and floors, through structural defects. Our findings emphasize the importance of ventilation and integrity of building structure in quarantine facilities.

Background Meta-analyses of individual patient data from randomized, controlled trials show that early oseltamivir treatment for influenza cut the risk of pneumonia and hospitalization by 44% and 63%, respectively. However, data on the effectiveness of inhaled zanamivir in preventing hospitalization and death are lacking. Methods This nationwide, population-based, cohort study included all outpatients treated with inhaled zanamivir or oral oseltamivir within 48 hours after a clinical diagnosis of influenza before and after the rollout of inhaled zanamivir as the first-line antiviral in Taiwan. The main outcome was influenza-related hospitalization or death within 14 days. Those who developed the outcome within 2 days were excluded from analyses. Propensity score stratification was used to control confounding from covariates. Results A total of 865 032 eligible influenza outpatients were included in the analysis. The risk of developing the main outcome (adjusted hazard ratio [aHR], 1.01; 95% confidence interval [CI], .96 to 1.06) did not differ between the inhaled zanamivir group (n = 595 897, 68.9%, the reference) and the oral oseltamivir group (n = 269 135, 31.1%). Prespecified analysis on high-risk subgroups further showed that inhaled zanamivir is not inferior to oral oseltamivir in either patients aged >= 65 years (aHR, 1.14; 95% CI: 1.05 to 1.25) or patients with chronic lung diseases (aHR, 1.23; 95% CI: 1.08 to 1.41). Conclusions Inhaled zanamivir is not inferior to oral oseltamivir as outpatient treatment in preventing influenza-related hospitalization or death for patients whose conditions do not require hospitalization within 2 days. For outpatients at higher risk of influenza complications, early (within 48 hours) start of antiviral therapy with inhaled zanamivir is not inferior to early start of oral oseltamivir in preventing subsequent influenza-related hospitalization or death.

Background: Healthcare-associated outbreaks of hepatitis C virus (HCV) infection pose serious risks of harm to patients. During May-July 2017, the Taiwan Centers for Disease Control were notified of four patients with acute HCV infection in a respiratory care ward (RCW). To prevent further infection, an investigation was conducted to identify the transmis-sion route and risk factors for infection. Methods: We tested patients and staff members of the RCW for HCV, reviewed medical re-cords, observed infection control practices on-site, and undertook a case-control study. We defined cases as individuals who had stayed in the RCW 2 weeks to 6 months prior to the lab-oratory diagnosis date of the first case and were infected with HCV after admission. Patients who were hospitalized during the same period but whose HCV tests were negative were selected as controls. We used Mann-Whitney U test to compare the frequency of injections among cases and controls. Results: Of 19 staff and 29 patients, we identified four case-patients and one patient with chronic hepatitis C whose HCV RNA similarity was >98%. Compared to the 12 controls, the case-patients received more injections per day (4.4 vs. 0.1; p Z 0.01). The RCW lacked desig-nated areas and standardized workflows for injection preparation. Disinfection of the environ-ment and equipment was inadequate, which could possibly lead to blood contamination of the environment and parenteral medications. Conclusion: HCV infection was associated with frequent injections and infection control lapses. Healthcare workers should follow safe injection practices and reduce injection fre-quency to prevent HCV transmission.

One of the possible ways to end the SARS-CoV-2 pandemic is to develop COVID-19 vaccine and effective vaccination strategies. Some COVID-19 vaccines have been authorized for emergency use in a number of countries, and are currently in use around the world. These include an adenovirus-based vaccine (Astra-Zeneca), and two messenger RNA (mRNA) vaccines (mRNA-1273, manufactured by Moderna; BNT162b2, manufactured by Pfizer-BioNTech). These vaccines have been shown to be adequate in preventing SARS-CoV-2 infection, minimizing disease incidence, severity and mortality, according to current pre-licensure vaccine efficacy research and post-licensure vaccine effectiveness evaluations. Specific local reactions are common adverse reactions after receiving these vaccinations, and serious adverse events occur infrequently. However, more data is required after global vaccination to estimate long-term efficacy and protection in real-world condition, as well as the effects of vaccine against virus variants. Currently, the majority of studies indicate that vaccination protects people from COVID-19 and the benefits outweigh the risks. To reduce COVID-19-related morbidity and mortality, we encourage people who are prioritized in the immunization program to get vaccines as soon as possible.

False-negative rapid influenza diagnostic test (RIDT) results could mislead physicians to exclude an influenza diagnosis. We sought to evaluate the association between negative RIDT and intensive care unit (ICU) admission. We reviewed data from hospitalized adults with laboratory-confirmed influenza virus infections in a tertiary referral hospital in Taiwan from July 2009 to February 2011. The diagnosis was documented by real-time PCR or virus culture. Of 134 hospitalized adults infected with influenza virus, 38 (28%) were admitted to the ICU. Compared with RIDT-positive patients, the percentage of ICU admission was significantly higher among RIDT-negative patients (46% versus 13%, P < 0.001). The RIDT-negative patients had higher percentages of lower respiratory symptoms and more chest radiograph infiltrates. The time interval between the RIDT and antiviral treatment was longer in RIDT-negative than RIDT-positive patients (1.94 days versus 0.03 days, P < 0.001). Among patients presenting with mild illness, only a negative RIDT and delayed antiviral treatment were associated with ICU admission after adjusting for potential confounding factors. To conclude, patients with a negative RIDT were more likely to have severe disease and a delay in initiating antiviral treatment. Our findings should help improve treatment outcomes of hospitalized patients with influenza infection.

Salmonella is a leading cause of foodborne outbreaks in Taiwan. On 27 April 2018, a salmonellosis outbreak among customers of a restaurant was reported to the Taiwan CDC. We investigated the outbreak to identify infection sources and prevent further transmission. We interviewed ill customers and their dining companions. We conducted a case-control study to identify foods associated with the illness. Case-patients were those who had diarrhoea within 72 h after eating at the restaurant during 16-27 April 2018. Specimens, food samples and environmental samples were collected and tested for enteric pathogens. Salmonella isolates were analysed with pulse-field gel electrophoresis and whole-genome sequencing. We inspected the restaurant sanitation and reviewed kitchen surveillance camera recordings. We identified 47 case-patients, including one decedent. Compared with 44 controls, case-patients were more likely to have had a French toast sandwich (OR: 102.4; 95% CI: 18.7-952.3). Salmonella Enteritidis isolates from 16 case-patients shared an indistinguishable genotype. Camera recordings revealed eggshell contamination, long holding time at room temperature and use of leftovers during implicated food preparation. Recommendations for restaurant egg-containing food preparation are to use pasteurised egg products and ensure a high enough cooking temperature and long enough cooking time to prevent Salmonella contamination.

On January 30, a 44-year-old female without a history of traveling from China was confirmed as a COVID-19 patient. The patient reported fever, cough, myalgia, and headache on January 27. Her 44-year-old husband, who just returned from Wuhan, China on January 12, had mild upper respiratory symptoms on January 21. On January 30, the Taiwan Centers for Disease Control conducted epidemiological investigation to explore the source and magnitude of this outbreak. Of 31 close contacts (10 from households, 19 from hospital, and 2 other contacts), six (19%) developed symptoms during the 14-day postexposure follow-up period, but none were tested positive for SARS-CoV-2. This cluster comprised two cases of COVID-19, with transmission by infector from Wuhan (the husband). We recommend that suspected COVID-19 patients from epidemic region should be notified, isolated and tested promptly. Close contacts of confirmed COVID-19 cases, particularly household contacts, should be quarantined and tested as early as possible to detect COVID-19 infection and prevent community spreading.

To understand the epidemiological and clinical characteristics of patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection in Taiwan, we analyzed data from the National Notifiable Disease Surveillance System and epidemiological case investigation reports. We included all real-time reverse-transcription polymerase chain reaction (real-time RT-PCR) confirmed cases of coronavirus disease-2019 (COVID-19) from Jan 21 to Feb 14, 2020, and followed up until Feb 27, 2020. Eighteen cases were confirmed and all survived. Median follow-up period was 24.5 days (range: 14-35). Of them, 16 (88.9%) were imported cases, and 2 (11.1%) were infected by imported cases within household. Their median age was 52 years (range: 21-74); 8 (44.4%) were men, and 9 (50%) had comorbidities. Symptoms included cough (72.2%), fever (66.7%), rhinorrhea (22.2%) and diarrhea (11.1%); one patient (5.5%) was asymptomatic. According to the WHO definition of clinical syndromes associated with SARS-CoV-2, there were 8 (44.4%), 9 (50.0%), and 1 (5.6%) categorized as mild, moderate, and severe illness, respectively. At the end of follow-up, 9 cases met the criteria of discontinuation of isolation and 8 of them were discharged. The median time from admission to discontinuation of isolation was 21 days (range: 13-31) and the median duration of persistent RT-PCR positivity was 14 days (range: 4- 22) and 15 days (range: 4-24) for upper and lower respiratory samples, respectively. The first 18 cases of COVID-19 in Taiwan were all imported or importation related, which were related to the early phase of COVID-19 epidemic. Because viral clearance may take more than 2 weeks, management plans for patients with mild illness is necessary to ensure the best use of medical care capacities during the ongoing COVID-19 pandemic.

Facing the pandemic of emerging infectious diseases, in addition to non-pharmaceutical interventions, an effective drug can slow the spread of the epidemic and reduce the impact, which is an important weapon before the vaccine coming to fruition. Initially, the research of COVID-19 drug treatment was mainly based on the experience and development of the treatment for other coronavirus infections (SARS, MERS), for example, remdesivir, hydroxychloroquine/chloroquine, lopinavir/ritonavir and interferon. According to the result of the latest large randomized clinical trial, Taiwan Food and Drug Administration had conditionally approved remdesivir on May 30, 2020, for the treatment of severe SARS-CoV-2 infection. Although the virus was cleared in the initial small-scale studies of hydroxychloroquine/chloroquine treatment, a larger retrospective study found that hydroxychloroquine did not reduce the risk of death or intubation in patients with SARS-CoV-2 infections, furthermore, might cause side effects. Low-dose steroids (dexamethasone) was found to reduce the risk of mortality among patients with severe SARS-CoV-2 infections, which was currently the treatment option with the strongest scientific evidence. Before the best treatment evidence appears, medical personnel should avoid being affected by rumors or exaggerated messages, and should provide experimental treatments with the best available evidence, ethical approval and patient's informed consent. The government and scientific societies should also systematically collect patients' treatment information and effectively analyze these valuable treatment experiences.

Introduction: For most Americans, health insurance is obtained through employers. Health insurance coverage can lead to better health outcomes, yet disparities in coverage exist among workers with different sociodemographic and job characteristics. This study compared uninsured rates among workers with different work arrangements. Methods: Data from the 2010 and 2015 National Health Interview Survey-Occupational Health Supplements were used to capture a representative sample of the U.S. civilian, non-institutionalized population. Associations between work arrangement and lack of health insurance were analyzed, adjusting for covariates. Analyses were performed during 2016-2018. Results: The percentage of workers aged 18-64 years without health insurance coverage decreased significantly by 6.8% among workers in all work arrangement categories between 2010 and 2015. However, workers in nonstandard work arrangements were still more likely than standard workers to have no health insurance coverage. In 2015, for workers to have no health insurance the ORs were 4.92 (95% CI=3.91, 6.17) in independent, 2.87 (95% CI=2.00, 4.12) in temporary or contract, and 2.79 (95% CI=0.34, 0.41) in other work arrangements. Standard full-time workers in small establishments and standard part-time workers were also more likely to have no health insurance coverage (OR=2.74, 95% CI=2.27, 3.31, and OR=1.65, 95% CI=1.25, 2.18, respectively). Conclusions: Important disparities in health insurance coverage among workers with different work arrangements existed in 2010 and persisted in 2015. Further research is needed to monitor coverage trends among workers. (C) 2019 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

Background. We describe a measles outbreak and control measures implemented at a privately operated detention facility housing US Immigration and Customs Enforcement detainees in 2016. Methods. Case-patients reported fever and rash and were either laboratory-confirmed or had an epidemiological link to a laboratory- confirmed case-patient. Immunoglobulin G (IgG) avidity and plaque reduction neutralization tests distinguished between primary acute and reinfection case-patients. Measles-specific IgG was measured to assess detainee immunity levels. We compared attack rates (ARs) among detainees and staff, between IgG-negative and IgG-positive detainees, and by detainee housing units and sexes. Results. We identified 32 measles case-patients (23 detainees, 9 staff); rash onsets were during 6 May-26 June 2016. High IgG avidity and neutralizing-antibody titers > 40 000 to measles (indicating reinfection) were identified in 18 (95%) and 15 (84%) of 19 tested case-patients, respectively. Among 205 unit A detainees tested for presumptive immunity, 186 (91%) had detectable IgG. Overall, the AR was 1.65%. ARs were significantly higher among detainees in unit A (7.05%) compared with units B-F (0.59%), and among male (2.33%) compared with female detainees (0.38%); however, ARs were not significantly different between detainees and staff or between IgG-negative and IgG-positive detainees. Control measures included the vaccination of 1424 of 1425 detainees and 190 of 510 staff, immunity verification for 445 staff, case-patient isolation, and quarantine of affected units. Conclusions. Although ARs were low, measles outbreaks can occur in intense-exposure settings, despite a high population immunity, underscoring the importance of high vaccination coverage and containment in limiting measles transmission.