Institute of Infectious Diseasesand Epidemiology

Oct 2013 – Mar 2014

A year has gone by since the inception of IIDE. It was an ambitious plan, but we have overcome many challenges and achieved much. Our first Scientific Advisory Board meeting has just concluded with acclaimed experts from Europe and the US. This is timely to reflect and strategise on developing IIDE into an international leader in the field of infectious diseases and epidemiology.

Yours sincerely,

Prof Leo Yee SinDirector, Institute of Infectious Disease and EpidemiologyClinical Director, Communicable Disease CentreSenior Consultant, Department of Infectious DiseasesTan Tock Seng Hospital

2014 at IIDE was kIck startED wIth thE Inaugural scIEntIfIc aDvIsory BoarD (saB) MEEtIng.

Message

Professor Alison Holmes, and A/Professor Derrick Heng. The meeting culminated in a research seminar, where recent findings were shared.

The key objective of the SAB meeting was to review IIDE’s research strategy and identify areas of strength and areas for improvement. A report and recommendations from the SAB board will be used to help IIDE achieve its long term goals. At the core of this is IIDE’s aim to be a centre of excellence for Infectious Diseases and Epidemiology by the time the new National Centre (NCID) building is complete in 2018. Stay tuned for more updates!

from the Director

This meeting was an invaluable opportunity to consult with eminent infectious disease researchers from around the world. Professor Leo Yee Sin, Dr Mark Chen and our clinicians spent 3 days in intensive and wide-ranging discussion with our SAB members - Professor Frederick Hayden, Professor Thomas Quinn,

Moving into the future of research with new dimensions and strategies

From left: Dr Ng Oon Tek, Prof Thomas Quinn, Ms Joy Chan, Prof Leo Yee Sin, Dr Mark Chen, Adj A/Prof Brenda Ang, Prof Alison Holmes, A/Prof Derrick Heng, Adj A/Prof Angela Chow

Outbreak and Pandemic ProgrammeIn collaboration with the Ministry of Foreign Affairs (MFA) and the Nanyang Technological University (NTU), IIDE hosted 24 foreign delegates from the Middle East, South Asia, Africa and Eastern Europe for an outbreak preparedness event.

Keynote speaker Prof Leo Yee Sin shared the lessons learnt from outbreaks during her time at TTSH and the changes that resulted from these. The visit ended with a tour of the Communicable Disease Centre and TTSH’s Emergency Department to see first-hand the specifically designed facilities to manage outbreak and pandemic situations.

past EvEnts

In Oct 2013 IIDE hosted infectious disease and epidemiology expert Professor David Heymann; a visit organised in collaboration with the National University of Singapore (NUS), Academy of Medicine and Society of Infectious Disease (Singapore).

Prof Heymann’s insightful lecture provided an opportunity to study the lessons learnt from the SARS outbreak and elucidate the key challenges posed by emerging infections such as MERS-CoV and influenza H7N9.

Annual Meeting of the American Society of Tropical Medicine and Hygiene (ASTMH)The STOP-Dengue team represented IIDE at the 62nd ASTMH meeting in Washington, DC.,USA, November 2013. Principal Investigator Dr David Lye and research fellows Dr Victor Gan and Dr Tun Linn Thein were selected to present three oral and five poster presentations. These included presentations on IIDE’s progress in the early detection of severe dengue illness.

Spotlight

After six years of working at the Communicable Disease Centre (CDC), she has carved out a niche for herself as an up-and-coming Infectious Disease Nurse.

During the early years of her nursing career, SSN Imrana encountered the sting of social stigma from her association with CDC and its role as the national HIV and outbreak centre. Experiencing this first-hand, she has emerged with new perspectives on patients, society, and herself. This has driven her to greater personal and professional growth.

Spurred by the transition of HIV to a chronic, treatable condition, SSN Imrana decided to pursue this interest further with an Advanced Diploma in Nursing (Chronic Disease Management).

Being at the forefront of any disease outbreak, Infectious Disease Nurses play a key role in reaching out to the community, educating patients, and maintaining constant vigilance, believes SSN Imrana.

thE thought of BEIng at thE forEfront of a natIonal DIsEasE outBrEak DoEsn’t Daunt sEnIor staff nursE IMrana.

Lessons from SARS and MERS-CoV

To commemorate World AIDS Day 2013, a two-day fundraising event was held in December 2013. The event increased awareness about HIV, and promoted acceptance and support for people living with HIV.

In line with the theme of The Gift of Giving, the Singapore Association of Mental Health (SAMH) was adopted as the beneficiary for proceeds from the sale of handicrafts made by people living with HIV, volunteers and IIDE colleagues.

World AIDS Day 2013 – The Gift of Giving

Engaging the Youth of TodayOver 80 students from the Saint Joseph’s Institution (SJI) joined us in the battle against the spread of infectious diseases by learning more about the history and biology of infectious diseases.

The 2-day programme held on March 10 and 11, conducted by Dr Lee Cheng Chuan (Senior Consultant, Tan Tock Seng Hospital), broadened the students’ understanding on global health issues on infectious diseases and enriched their sense of social responsibility.

The 3 hour session also included a visit to our Patient Care Centre where they appreciated the patient-centered programmes organised for our patients living with HIV/AIDS to enhance their social integration and strengthen their self-confidence.

One Week Intensive Training on Qualitative Research TechniquesIn the last week of January 2014, IIDE, NUS’s Saw Swee Hock School of Public Health, and FHI 360 jointly organised a seminar on qualitative research techniques, funded by the Ministry of Education. This marked IIDE’s first international collaboration with FHI 360 as well as IIDE’s first seminar on qualitative research – an area of research which IIDE believes will be critical to understanding the complex factors behind human and organisational behaviours of relevance to improving health.

Antimicrobial resistance (AMR) is a major public health concern. About 25 000 patients die from selected multi-drug resistant bacteria in European Union each year.1 In the United States, infections with pathogens resistant to antimicrobials cost the health-care system in excess of US$ 20 billion annually and generate more than 8 million additional hospital days.2

Development of some degree of antimicrobial resistance may be inevitable. Microbial populations come under selection pressure in the presence of antimicrobials and resistant strains are more likely to survive. However, this natural process is exacerbated by inappropriate use of antimicrobial agents in patient populations and animal husbandry. Suboptimal infection control practices facilitate spread of resistant organisms at a local or institutional level. Additionally, the development pipeline of new antimicrobial agents has diminished in favour of medication for chronic diseases, resulting in limited treatment options for emerging resistant bacteria.

The problem of antibiotic resistance is not confined to organisms acquired in hospitals. Urinary tract infection (UTI) is a frequent condition encountered in the community and physicians usually treat UTI empirically because uropathogens and their antimicrobial susceptibility are considered predictable. However, there is evidence of antimicrobial resistance amongst community-acquired uropathogens. A 2001 prospective study conducted in community clinics in Singapore3 showed that 21% and 1.5% of E. coli isolates

Educational articlE

upcoming EvEnts

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14 June 2014

ASEAN Dengue Day

23 – 27 June 2014

Outbreak Investigations and Management Course

10 JuLY 2014

ASID and Singapore ID CRN Symposium

26 – 29 August 2014

4th Asia-Pacific Dengue Workshop

26 – 27 september 2014

Singapore Health & Biomedical Congress (SHBC)

23 – 24 OCtOber 2014

Global Initiative on Sharing All Influenza Data (GISAID)

29 nOvember 2014

Singapore AIDS Conference

1 June – 31 DeCember 2014

APEC Training Course

Antimicrobial Resistance

were resistant to cotrimoxazole and ciprofloxacin respectively. Though not

directly comparable due to differences in study design, a 2009 study on

community-acquired uropathogens at a local polyclinic reported higher proportions

of antimicrobial resistance; 38.8% of E. coli isolates were resistant to cotrimoxazole and 24.4% to ciprofloxacin.4 Patients with community acquired resistant uropathogens require a long time for symptoms resolution and have higher rates of bacteriuria than patients with susceptible strains.5 One approach in treating cystitis and limiting the development of antibiotic resistance is to select first-line antibiotics shown to be effective (such as nitrofurantoin 100mg twice daily for 5 days, success 93%; and co-trimoxazole 160mg/800mg twice daily or trimethoprim 100mg twice daily for 3 days, success 90-100%), and reserving ciprofloxacin and beta-lactams as second-line antibiotics.6

A significant proportion of antibiotics is prescribed in the community7 and we should continue to emphasise the appropriate use of antimicrobials in community-based practices. Patients may have misperceptions about antimicrobial use and have strong expectations that their doctors prescribe them for minor infections. There is a strong need to educate the general public on appropriate use of antibiotics and equip our doctors with tools to help manage patients’ expectations. For example, use of physical examination and running commentary is a proposed strategy to help influence acceptance of non-antibiotic treatment.8

There may also be a lack of awareness of the potential harms of inappropriate antimicrobial use. A systematic review demonstrated that individuals prescribed an antibiotic in primary care for a respiratory or urinary infection developed bacterial resistance to that antibiotic for up to 12 months.9 This increases the carriage of organisms resistant to first-line antibiotics in the population and may lead to increased use of second-line antibiotics.

Accurate information about prevalence and distribution of pathogens and their antimicrobial susceptibility is essential to guide antimicrobial prescribing. While hospitals capture antibiotic resistance patterns of organisms cultured in its laboratories, these patterns may overestimate resistance patterns for community-acquired infections. Physicians will benefit from updated antibiotic prescribing guidelines for common infections seen in the community. The cost of regular microbiological cultures limits the availability of laboratory data to inform local antibiotic practice guidelines. This may be overcome by having a network of interested primary care doctors performing fixed number of urine and throat swabs at regular intervals to establish a local community-based surveillance network to generate good quality data to inform practice.

References1. European Centre for Disease Prevention and Control. The

bacterial challenge: time to react. 2009.2. Roberts RR, Hota B, Ahmad I, et al. Hospital and societal

costs of antimicrobial-resistant infections in a Chicago teaching hospital: implications for antibiotic stewardship. Clin Infect Dis. 2009; 49: 1175-84.

3. Ti TY, Kumarasinghe G, Taylor MB, et al. What is true community-acquired urinary tract infection? Comparison of pathogens identified in urine from routine outpatient specimens and from community clinics in a prospective study. Eur J Clin Microbiol Infect Dis. 2003; 22: 242-5.

4. Bahadin J, Teo SS and Mathew S. Aetiology of community-acquired urinary tract infection and antimicrobial susceptibility patterns of uropathogens isolated. Singapore Med J. 2011; 52: 415-20.

5. McNulty CA, Richards J, Livermore DM, et al. Clinical relevance of laboratory-reported antibiotic resistance in acute uncomplicated urinary tract infection in primary care. J Antimicrob Chemother. 2006; 58: 1000-8.

6. Hooton TM. Clinical practice. Uncomplicated urinary tract infection. The New England Journal of Medicine. 2012; 366: 1028-37.

7. Nathwani D and Davey P. Antibiotic prescribing--are there lessons for physicians? QJM : monthly journal of the Association of Physicians. 1999; 92: 287-92.

8. Mustafa M, Wood F, Butler CC and Elwyn G. Managing expectations of antibiotics for upper respiratory tract infections: a qualitative study. Ann Fam Med. 2014; 12: 29-36.

9. Costelloe C, Metcalfe C, Lovering A, Mant D and Hay AD. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ. 2010; 340: c2096

By Dr WONG Chia Siong (Consultant) and Dr David LYE, (Head of Training and Education), Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital

- some thoughts on community-acquired infections

nEwsroom

IIDE Research in 2013Building up on our research efforts in infectious diseases and epidemiology, we published over 90 papers in scientific journals and made 40 conference presentations in 2013. Some of our publications are listed below.

External Visitors

• ProfLeoYeeSin Director, IIDE; Clinical Director, CDC; Senior Consultant, TTSH

• AdjA/ProfBrendaAngSzePeng Senior Consultant, TTSH

• MsAsnahBinteSuptoo Patient Service Associate, TTSH

• MrChewSheeTeck Staff Nurse I, TTSH

Dr Kenji KuboJapanese Red Cross SocietyWakayama Medical Centre, Japan21 October 2013

Dr Satoko OtsuJapanese Red Cross Society Wakayama Medical Centre, Japan21 October 2013

Prof Helen WardImperial College London, UK6 December 2013

Dr Jon OtterKing’s College London, UK20 March 2014

Professor Herman GoossensUniversity of Antwerp, Belgium08 April 2014

Dr Hiroshi YoshimuraEmbassy of Japan in Thailand, 18 March 2014

stay in touch

Feedback and Comments We would like to hear from you! For suggestions or comments regarding the IIDE newsletter, please email: iide_cme@ttsh.com.sg.

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Editorial Team • Dr Wong Chia Siong • Dr Barnaby Young • RN Amy John • Ms Chloe Lim • Ms Koh Yi Ting

awards & accoladEs

National Day Awards (Long Service Medal)

• MsJunidahBteAziz@GohKuiNgoh Senior Staff Nurse II, TTSH

• MsMaheswarid/oPKandasamy Nurse Manager I, TTSH

• MsRohanaBteKhalid Senior Staff Nurse I, TTSH

• MsSVJayalakshmi Senior Assistant Nurse I, TTSH

Protection of Public Health & Safety Awards – Excellent Team Player Awards Dr Yung Chee Fu received the Excellent Team Player Award at the first ever Excellent Stakeholder and Partnership Awards (ESPA) organised by the Health Sciences Authority (HSA) in recognition of his work for the Vaccines Adverse Events Sentinel Surveillance Program.

1. South East Asia Infectious Disease Clinical Research Network. Effect of double dose oseltamivir on clinical and virological outcomes in children and adults admitted to hospital with severe influenza: double blind randomised controlled trial. BMJ. 2013; 346: f3039.

2. Herrero LJ, Sheng KC, Jian P, et al. Macrophage migration inhibitory factor receptor CD74 mediates alphavirus-induced arthritis and myositis in murine models of alphavirus infection. Arthritis and rheumatism. 2013; 65: 2724-36.

3. Ng OT, Laeyendecker O, Redd AD, et al. HIV type 1 polymerase gene polymorphisms are associated with phenotypic differences in replication capacity and disease progression. The Journal of Infectious Diseases. 2014; 209: 66-73.

4. Marimuthu K, Ng TM, Teng C, et al. Risk factors and treatment outcome of ertapenem non-susceptible enterobacteriaceae bacteraemia. The Journal of Infection. 2013; 66: 294-6.

5. Group S-LS, Boyd MA, Kumarasamy N, et al. Ritonavir-boosted lopinavir plus nucleoside or nucleotide reverse transcriptase inhibitors versus ritonavir-boosted lopinavir plus raltegravir for treatment of HIV-1 infection in adults with virological failure of a standard first-line ART regimen (SECOND-LINE): a randomised, open-label, non-inferiority study. Lancet. 2013; 381: 2091-9.

6. Molton JS, Tambyah PA, Ang BS, Ling ML and Fisher DA. The global spread of healthcare-associated multidrug-resistant bacteria: a perspective from Asia. Clinical Infectious Diseases : an official publication of the Infectious Diseases Society of America. 2013; 56: 1310-8.

7. Thein TL, Leo YS, Fisher DA, et al. Risk factors for fatality among confirmed adult dengue inpatients in Singapore: a matched case-control study. PloS one. 2013; 8: e81060.

8. Rivino L, Kumaran EA, Jovanovic V, et al. Differential targeting of viral components by CD4+ versus CD8+ T lymphocytes in dengue virus infection. Journal of Virology. 2013; 87: 2693-706.