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There is no evidence in literature to suggest why, instead of shaving, the facial hair factor cannot be overcome with an under-mask beard cover. The purpose of the study is to describe an innovative potential solution called 'Singh Thattha' technique, where we have used an under-mask beard cover to overcome the facial hair factor for wearing a respirator mask in bearded individuals. |
The technique of applying the under-mask beard cover to cover the beard over the chin and cheeks and tie the knot at the top of the head is called 'Singh Thattha' technique, and pioneered by a transplant surgeon in Manchester. Thattha is the colloquial term used for the beard cover used and the material used for the 1 st case was fabric made of polyester-cotton blend. Using this method the candidate 'passed' the Bitrex QFT Qualitative Fit Test (Macfarlan Smith, Edinburgh, UK) in one attempt wearing a 3M 8833 FFP3 mask. It was mentioned that the 'pass' was with a beard using a beard cover. The material was subsequently switched to a flat elastic rubber sheet (Pilates & Yoga Elastic band©) for a better seal by the author (Fig-1a) . The knot on top of the head could be either over the turban (1b), or over the inner head cloth (1c) depending on which gave the best fit with the FFP3 mask. |
We are reporting the outcomes of the Singh Thattha technique tested by QFT and QNFT: |
A. Singh Thattha technique was adopted by 27 male bearded Sikh dentists in the UK who subjected themselves to Bitrex QFT conducted by certified fit testers to existing industry standards set by British Safety Industry Federation. Data was collected by the British Sikh Dentists Association and submitted to us for analysis. |
B. The technique was further subjected to robust review with a reputed Fit Tester through a Quantitative Fit Test (QNFT) session in Shrewsbury, UK. The QNFT method used was 'Ambient Particle Counting' using AccuFIT9000 S/N; Protocol: INDG 479; Pass Level: 100. Informed consent was obtained, and no participant was allergic to materials used. Participants included 5 male candidates from the bearded Sikh community. |
The results are summarised in Table 1 . |
The |
All 5 male candidates passed QNFT using the Singh Thattha technique. The first 3 candidates passed using 3M 8833 masks, with the knot of the under-mask Thattha tied on the top of the head covered by a cloth (Fig-1c, 2c) . One of these candidates also passed using a 3M 1863 mask with an adhesive dual mural tape (DMT) in its upper inner lining, with the knot of the under-mask Thattha tied directly over the turban. The other two male candidates used FFP3 Stealth Half Masks and passed the QNFT with the under-mask Thattha tied directly over their turban (Fig-2b) . Small numbers precluded a statistical analysis. |
The novel coronavirus known as SarsCoV-2 (Covid-19) pandemic has resulted in a significant loss of lives and impacted resource utilisation [1] . In line of their duty, healthcare workers (HCWs) at forefront of the pandemic have suffered significant mortality. Healthcare providers have come under intense scrutiny to ensure that adequate and appropriate Personal Protective Equipment (PPE) is provided for front-line workers. |
Tight-fitting respirator masks, which depend on a seal of the mask with the wearer's face, are considered as ideal protective RPE for HCWs working in AGP environment involving Covid-19. However, these are not suitable for bearded individuals as evidence has shown that beards will not allow for an optimal face-mask-face seal. Therefore, bearded individuals who are unable to shave due to personal reasons have to rely on alternative RPE such as expensive and cumbersome PAPRs, which may not be ideally suited for the work or training for some of these individuals -notably dentists and surgeons. |
We are offering an innovative solution using an under-mask beard cover called Singh Thattha technique for overcoming the beard factor to enable bearded individuals to wear a respirator mask. |
The under-mask beard cover (Singh Thattha) technique to wear an FFP3 mask was pioneered in Manchester. The technique was adopted and tested by a large number of bearded British Sikh dentists (25/27) who passed the QFT using certified Fit testers. The technique was further tested using robust QNFT in a pilot study and all 5/5 fully bearded men passed the fit test. |
The relatively sturdier masks such as 3M 8833, Stealth half mask P3, JSP Force 8 P3 and GSV Ellipse half mask P3 were best-suited to achieve a competent seal using the Singh Thattha technique. |
The beard-cover we used (Pilates & Yoga Elastic band ©) is rubber material. During the Fit test the different exercises used test that the silicone mask does not slip over the skin. |
In fact, the resistance of the rubber and silicone actually improved the fit in these exercises with the beard cover. |
Facial skin may sweat, but the Thattha material does not and is of an added advantage. Whereas other determinants of face-fit such as face architecture and mask shapes may be irreversible factors governing outcome of the fit test, the beard factor could be overcome by an under-mask beard cover. |
This pilot study opens up possibilities for bearded HCWs looking to safely wear a tight-fitting respirator mask for whom shaving may not be a viable option. In additional to cost-saving implications for healthcare providers, this solution minimises potential risk of re-deployment of some affected individuals who either have no access to alternative PPE, or if the available ones are not conducive to performing for their specific job-roles. |
Whilst a limitation of this study remains small numbers of individuals tested using the under-beard cover technique, it provides encouraging results to pave way for larger scale studies to be conducted. The authors plan to conduct a follow up study with the Singh Thattha technique involving larger numbers of bearded individuals given that the preliminary reports are quite encouraging. |
To summarise, the final arbiter of face-mask fit is a fit test and not the difference in the nuances of the chemistry between the 'mask with face' versus the 'mask with beard cover. Facial hair, albeit an accepted risk factor for facemask leakage, can be overcome by using an under-mask beard cover. Bearded individuals who are unable to shave may have a new innovative technique to be able to wear respirator masks. |
. Whilst a limitation of this study remains small numbers of individuals tested using the under-beard cover technique, it provides encouraging results to pave way for larger scale studies to be conducted. The authors plan to conduct a follow up study with the Singh Thattha technique involving larger numbers of bearded individuals given that the preliminary reports are quite encouraging. |
After the World Health Organization (WHO) declared COVID-19 an international public health emergency (pandemic) on February 11, 2020, COVID-19 vaccines were produced within a year. COVID-19 vaccines were developed in the shortest time in vaccine history, due to remarkable determination in vaccine research, development, and manufacturing. 1 Vaccines against COVID-19 are considered very important to prevent and manage COVID-19 since vaccination is one of the most active and cost-effective health strategies for preventing infectious diseases. 2, 3 More than 200 additional vaccine candidates are being developed, with more than 60 of them in clinical trials. COVAX is a component of the ACT Accelerator, which WHO and collaborators launched in 2020 with aims to bring the COVID-19 pandemic's acute phase to an end. 4 Although substantial progress is being made, there are still significant obstacles in the way of a possible COVID-19 vaccine, one of which is public acceptance. Vaccine acceptance reflects the general public's overall understanding of disease risk, vaccine attitudes, and demand, all of which are important for vaccinations to achieve high vaccination coverage rates, especially for newly emerging infectious diseases. [5] [6] [7] COVID-19 not only has a significant health impact but it also has a significant economic impact that should not be underestimated. 8 It has resulted in a significant decline in workforces and a rise in global unemployment. These negative consequences have prompted pharmaceutical firms to produce a vaccine as soon as possible. Several vaccines to prevent COVID-19 infection were approved in December 2020. 8, 9 Ethiopian authorities choose to employ the Astra Zeneca COVID-19 vaccination through the COVAX Facility. On March 7, 2021, Ethiopia received 2.184 million doses of COVID-19 vaccination. 10 On March 13, 2021, the Ethiopian Ministry of Health officially launched the COVID-19 vaccine at a high-level national event held at Eka Kotebe COVID-19 Hospital, where front-line health workers were vaccinated to kick of the vaccination campaign. 11 Hopes to reduce the negative repercussions of COVID-19 was largely dependent on the timely development of efficacious vaccines and their distribution in an equitable manner. 12, 13 The COVID-19 vaccination trials' rapid development and approval phases resulted in the emergency-use authorization of many safe and successful vaccines, at least for the time being. [14] [15] [16] In the midst of the pandemic crisis, the deployment of COVID-19 vaccines was a ray of hope. However, having access to vaccine programs is one thing, and successfully implementing a mass vaccination campaign is another. 17 COVID-19 vaccination could be jeopardized by issues such as mass production, global distribution, and cost. 18 Furthermore, there are some ambiguities concerning some aspects of the COVID-19 vaccine, such as: Uncertainty about long-term security and the need for regular reformulation amid evidence of SARS-CoV-2 evolution and the appearance of genetic variants. 19, 20 Despite this, people continue to have doubts about vaccine safety and efficacy, including the durability of COVID-19 defense, as many cases of reinfection have been recorded. 21, 22 Vaccine hesitancy and resistance are major issues around the world, causing the World Health Organization (WHO) to list them among the top ten health risks for 2019. 23 Vaccine apprehension has been linked to religious values, personal beliefs, and safety issues based on widespread misconceptions, such as the connection between vaccines and autism, brain injury, and other disorders, according to various reports. 24 Understanding the communities preparedness to receive a COVID-19 vaccination, as well as the major factors affecting their acceptance of the vaccination, would contribute to the development and implementation of efficient COVID-19 vaccination promotion strategies, as well as the current alarming increase in infection. In Ethiopia, this research is the first study conducted to assess the acceptance of vaccination against COVID-19 in my knowledge; no previously published work has been in Ethiopia even if the vaccine does become available. The objective of this study was to measure the level of acceptance of COVID-19 vaccination and its associated factors in Sodo town, Wolaita zone, Southern Ethiopia. |
In Sodo town, a community-based cross-sectional study was conducted from April 1 to 30, 2021. Sodo town has a population of 250,521. Males account for 79,871 (52%) of the population, while females account for 73,650 (48%). The city has three sub-cities, 18 kebeles, three health centers, one Ministry of health-owned hospital, and one private hospital. The city is 160 km from Hawassa, the regional city of South Nation Nationality of people regional state, and 327 km from Addis Ababa, Ethiopia's capital city. 25 |
All individuals aged ≥18 years who lived in Sodo town, Wolaita zone, Southern Ethiopia, were source population and all randomly selected individuals were the study population. |
Individuals aged ≥18 years were included in this study, and people who were seriously ill during the period of data collection and those not willing to participate in the study were excluded. |
Since there has been no prior research on acceptance COVID-19 vaccine in Ethiopia, the best estimate (P) would be 50%. With the following considerations in mind, sample size was calculated using the single https://doi.org/10.2147/IDR.S320771 |
Infection and Drug Resistance 2021:14 population proportion formula with a marginal error of 0.05, a 95% confidence interval, and a p-value of 0.5. Assume a 10% non-response rate for this study, the final sample size of 424 participants was estimated. |
Six kebele were chosen from a total of 18 kebele in Sodo town using a simple random sampling technique by lottery method. A systematic random sampling procedure was used to choose households from the six kebele that were chosen; the first household was selected using a simple random sampling technique, and then others were selected at regular intervals until the required sample size was reached. If there were more than one individual who fulfills the inclusion criteria, one respondent was selected with simple random sampling technique. |
The dependent variable in this study was the intention to accept COVID-19 vaccines. Structured interviewer administers questionnaire was used to collect data. There were three components of the independent variables: 1) sociodemographic factors such as age, gender, religion, educational attainment, and marital status, and place of residence. 2) COVID-19 experience includes, contact with a COVID-19 patient, a member of the household who has been diagnosed with COVID-19, relatives who have been diagnosed with COVID-19, have you been vaccinated for COVID-19, heard about the COVID-19 vaccine, friends who have been diagnosed with COVID-19. 3) Reasons for non-acceptance of COVID-19 vaccines. Questions were adopted from previously published studies. 26 |
Before being moved to SPSS window version 21 for analysis, the data was coded, cleaned, recoded, and entered into epi-data version 3.1. A table and statement were used to present the data. The relationship between independent and dependent variables was investigated using bivariate logistic regression analysis. To control for possible confounding, all variables in the bivariate logistic regression model with a p-value <0.25 were added to the multivariable logistic regression model, and variables in the multiple logistic regression model with a p-value ≤0.05 were considered statistically significant. |
There were a total of 415 who participated in this study with 98% response rate. The mean (± Standard Deviation [SD]) of respondents was 28.2 (±7). Of the 415 respondents more than half 219 (52.8%) were aged 18-29. The majority of participants were male 231 (55.6%) and 193 (46.5%) of participants protestant religious followers. Regarding educational attainment, the highest proportion 199 (48%) of respondents had college and above education level. Related marital status, majority 301 (72.5%) married (Table 1) . |
Participants Experience with COVID-19 |
The majority of the respondents 332 (80%) had never contacted with COVID-19 patient. Three hundred and sixty-two (87.2%) of the 415 respondents said no one in their household had been diagnosed with COVID-19, and 9 of 10 (90.4%) said that no relatives had been diagnosed with COVID-19 ( Table 2) . |
Out of 415 people who took part in the survey, less than half (45.5%) said they would accept COVID-19 vaccines if available, and more than half (54.5%) said they would not. |
Of the 226 participants who were unwilling to accept the COVID-19 vaccines, 134 (59.27%) and 48 (21.2%) were concerned about insufficient data about the vaccines and fear adverse effects of the vaccine (Table 3) . |
Sex, educational status, use of mass media, received any vaccine during childhood, member of household diagnosed with COVID-19, friends have been diagnosed with COVID-19, and have tested for COVID-19 were all found to be significantly correlated with acceptance of the COVID-19 vaccines in a multivariable logistic regression. COVID-19 vaccines were more likely to be accepted by males than females (AOR=2.15, 95% CI: 1.29, 3.56). |
Another factor linked to COVID-19 vaccine acceptance was one's educational level. Those with a college or higher education degree were three times more likely than those with a primary education to accept the COVID-19 vaccine (AOR=3.09, 95% CI: 1.50, 6.37). Respondents who had access to the media were more likely to accept the COVID-19 vaccine than those who did not (AOR=1.97, 95% CI: 1.06, 3.63). Participants who received any vaccine during childhood were more likely to accept COVID-19 vaccine (AOR=5.16, 95% CI: 2.44, 10.92) than who did not receive any vaccine during childhood. Participants who had a family member diagnosed with COVID-19 were more likely to accept the vaccine (AOR=4.40, 95% CI: 2.10, 9.25) than those who did not have a family member diagnosed with COVID-19. Participants whose friends had been diagnosed with COVID-19 were more likely than those whose friends had not been diagnosed with COVID-19 to accept the vaccine (AOR=3.91, 95% CI: 1.52, 10.04). Respondents who had tested for COVID-19 were more likely to accept the vaccine than those who had not tested for COVID-19 (AOR=4.40, 95% CI: 1.70, 11.36) ( Table 4 ). |
COVID-19 vaccines have been launched "the perfect cure" for bringing the current pandemic to an end. Several clinical trials with positive results have recently been released, leading to a number of countries approving specific vaccines for use in Ethiopia vaccination programs. 11 One of the first estimates of COVID-19 vaccine acceptance in Ethiopia is presented in this study. These findings may be used to predict COVID-19 vaccines acceptance. |
The result of the current study reveals that, 189 (45.5%) of participants willing to accept COVID-19 vaccines if available and more than half 226 (54.5%) indicated non-acceptance of COVID-19 vaccines if available. The result of this study was in line with a study done in four states in the United States of America 44.9%. 27 The acceptability of the COVID-19 vaccine was higher in this study than in other countries, with 36.8% in Jordan, 28 37.2% in Hong Kong, 29 and 34.9% among Jordanian university students. 30 The probable reason for the discrepancy between the current result and other studies may be due to sociodemographic, socio-economic, or time differences. |
This study's finding was lower than those of other studies conducted around the world. Knowledge, attitude, and practice towards COVID-19 vaccination acceptance in West India (64.5%), 31 and three researches looked at public acceptance of COVID-19 in China (83.3-91.3) . 32 COVID-19 vaccine was accepted by 79% of the people in Israel. 33 A global survey of potential acceptance of a COVID-19 vaccine with 71.5%, 31 63.5% respondents in the United Kingdom willing to accept COVID-19 vaccine if available, 34 and more than half (52.2%) of the respondents accepts the COVID-19 vaccine in China. 35 According to the results of this study, men were more likely than women to accept the COVID-19 vaccine if it was available. Males are more likely than females to accept COVID-19 vaccines, according to other observational studies. 26, 32, 33 The educational level was also a significant factor in COVID-19 vaccine acceptance. Participants with a college diploma or higher were more likely to accept the COVID-19 vaccine. The possible reason might be, those with a higher level of education (college and above) would have a better chance of accessing knowledge and comprehending it and as a result they will respond and accept the COVID-19 vaccine. Respondents who had access to the mainstream media were more likely to accept the COVID-19 vaccine than those who did not. Most of the time, the COVID-19 vaccine was promoted through the media; those who were informed about the vaccine had a better chance of accepting it, as some respondents said that they do not take the vaccine because there is insufficient information about vaccine and its safety. |
When compared to participants who had not received any vaccination during childhood, respondents who had received any vaccination during childhood were more likely to accept the COVID-19 vaccine if it became available. One possible reason is that people who have received any vaccine have gained more experience and knowledge about the benefits of vaccination; that help participants accept the vaccine to protect them from COVID-19. In comparison to respondents whose member of the household was not diagnosed with COVID-19, the current study showed that participants whose member of the household was diagnosed with COVID-19 were more likely to accept the COVID-19 if it was available. |
Another significant factor was that participants' friends who had been diagnosed with COVID-19 were more likely than participants' friends who had not been diagnosed with COVID-19 to accept the COVID-19 vaccine if it became available. Participants who were tested for COVID-19 were more likely than those who were not to accept the vaccine if it became available. Participants who were tested for COVID-19, participants whose members of the household tested for COVID-19, and respondents' friends who have been diagnosed with COVID-19 may have learned about COVID-19 and its effects on human health, prompting them to seek protection from the COVID-19 vaccine. |
The findings of the current study showed that participants were unwilling to accept the COVID-19 vaccine due to the main reason; concerns about insufficient data about the vaccine's and fear of adverse effects. The results are consistent with those of other research. 26, [32] [33] [34] [35] [36] In a report in Ghana, for example, insufficient evidence about the vaccine's safety and vaccine side effects were the key reasons for people refusing to accept COVID-19 vaccines. 26 The limitation of this study is that it is cross-sectional in nature, making it difficult to draw long-term conclusions. The results of this research were solely based on quantitative techniques, with no other tools such as focus group discussions or in-depth interviews being used to supplement the findings. |
The findings of this study suggest that the acceptance of a COVID-19 vaccine was low. Acceptance of the COVID-19 vaccine was significantly correlated with sex, educational status, use of mass media, received any vaccine during childhood, member of household diagnosed with COVID-19, friends diagnosed with COVID-19, and have tested for COVID-19. To increase public acceptance of the COVID-19 vaccine, the government should work with various stakeholders implementing public education through the mass media about the benefits of getting the COVID-19 vaccine. |
All data are available for this study. |
Ethical clearance was obtained from the Ethical review board of Wolaita Sodo University College of Health Sciences and Medicine. Informed consent was obtained from participants, and this study was conducted in accordance with the declaration of Helsinki. Anonymity and confidentiality were ensured. |
distinguish between COVID-19 and other types of viral pneumonia [9, 10] . In a recent statement from the Fleischner Society, it was hence recommended that only patients with a high pretest probability of disease (moderate to severe clinical features, mild symptoms with risk factors for progression, or high pretest probability only) should undergo CT imaging [11] . |
Our aim was therefore to evaluate the accuracy of CT as a function of clinical symptoms and to estimate pre-and posttest probabilities of COVID-19 after CT imaging for different risk groups. |
We retrospectively included 269 patients who underwent diagnostic chest CT for suspected COVID-19 between March 27 th and April 27 th , 2020. COVID-19 was confirmed or ruled out by RT-PCR. Repeat PCRs were performed in case of a discrepancy between CT and PCR, usually on the same day, with the new test initiated immediately after both CT and initial PCR results were available. This was true for both negative PCR and positive CT and vice versa, provided that patients had not left our institution in the meantime. Similarly, repeat RT-PCR was performed, when RT-PCR results were negative or indeterminate but suspicion of remained. This study was approved by the Institutional Review Board of Charité Universitätsmedizin Berlin. |
Low-dose chest CT scans for suspected COVID-19 were acquired on two different CT scanners of our hospital: an 80-slice scanner (Aquilion Prime, Canon Medical Systems Cooperation, Otowara, Japan) and a 64-slice scanner (Lightspeed VCT, General Electric, Boston, Massachusetts, United States). |
For the Canon Aquilion Prime, imaging parameters were set as followed: tube voltage 100 kV, tube current modulation between 10 and 100 mA, maximum resolution time 0.27s, noise index J o u r n a l P r e -p r o o f Journal Pre-proof 27, pitch factor 1.388 and slice thickness 0.5 mm. Parameters for the Lightspeed VCT were as follows: tube voltage 100 kV, tube current modulation between 10 and 100 mA, 0.35 s maximum resolution time, noise index 39, pitch factor 1.375, and slice thickness 0.625 mm. Iterative reconstruction was used (Canon Aquilion Prime: AIDR 3D; Lightspeed VCT: ASIR) with a lung and a soft tissue kernel (Canon Aquilion Prime: Fc01 and Fc85; Lightspeed VCT: "standard" and "lung") |
All CT images were evaluated manually and data on presence/absence of COVID-19 was assessed. Vital parameters (O 2 saturation, respiratory rate, and body temperature) were taken from the initial admission form or request form for chest CT. Further patient characteristics, such as sex or age, were extracted from our Radiology Information System database. |
All statistical analysis was conducted using the "R" statistical programming language including the "tidyverse" and "lme4" libraries [12] [13] [14] . Variables were expressed as means +/-standard deviation if normally distributed and as median and interquartile range (IQR) if not. Categorical variables were expressed as frequencies and percentages. Normal distribution was tested using the Shapiro-Wilk test. To compare continuous variables, the Wilcoxon rank sum test was used while Pearson's chi-square test or Fisher"s exact test were used to compare categorical variables. |
The diagnostic value of vital parameters was evaluated using receiver operating characteristic (ROC) analysis and compared using the area under the curve (AUC). Buderer"s formula was employed for post-hoc power analysis of our sample size [15] . |
The diagnostic accuracy of CT was calculated through a generalized mixed logistic regression model, adapted from the model proposed by Coughlin et al. [16] , which was extended by a J o u r n a l P r e -p r o o f random intercept to allow adjustment for different scanner types and clinical sites (formula 1). |
Here, Y ij is defined as the binary result of chest CT in each patient. Y ij =1 is suspected COVID-19 |
and Y ij =0 is absence of COVID-19 in CT. X represents a matrix of covariates including the result of the RT-PCR test (X ij =1 confirmed COVID-19, X ij =0 absence of COVID-19 as defined by RT-PCR). β 0 is the intercept, β 1 represents the dichotomous result of RT-PCR, and β k corresponds to Y k for (k=1,…,k) patient characteristics for patient i on site (or scanner) j. The random variation in the intercept is denoted by δ j, while ε ij indicates the error. 95% confidence intervals were calculated trough parametric bootstrapping with 1000 iterations. Pre-and posttest probabilities of COVID-19 were calculated using likelihood ratios. A p-value of p < 0.05 was considered statistically significant. |
A total of 269 patients was included in this retrospective study (155 males (58%) with a median Patient characteristics are summarized in Table 1 . It can be seen, that vital parameters different between patients without COVID-19 and patients with COVID-19, with COVID-19 patients |
showing higher values for CRP, higher body temperature, higher respiratory rate and lower J o u r n a l P r e -p r o o f oxygen saturation. |
The diagnostic value of respiratory rate, body temperature, and blood oxygen saturation was investigated to determine whether these vital parameters alone could be used for the diagnosis of COVID-19, thus reducing the need for CT. |
We found that the median respiratory rate and blood oxygen saturation differed significantly Table 2 provides an overview of CT accuracy as a function of COVID-19 |
pretest probability, and Figure 2 illustrates posttest probabilities for COVID-19 before and after a negative/positive CT result. |
To date, RT-PCR remains the reference standard for the diagnosis of COVID-19, while CT has the advantage of detecting patients with lung infiltrates fast and early. Although the role of chest |
Luo et al. previously investigated the benefit of a scoring system based on the most common imaging findings to improve CT accuracy [5, 18] . They reported score-dependent specificities ranging from 0.23 to 0.95. However, the disadvantage of their approach is that their scoring system requires the patient to undergo a CT first. In our approach, we chose variables that are among the first parameters to be assessed when the patient arrives in the emergency department/hospital. This allows immediate calculation of the pretest probability of COVID-19 |
and subsequent further triage of patients depending on their pretest probability. As a limitation, we have not included other patient information such as medical history, other diseases (especially lung diseases and obesity), laboratory data and medication, as they were not reliably recorded on initial assessment of patients (18) (19) (20) . However, the inclusion of some of these information might have been beneficial, as it could also have allowed for an assessment of the potential severity of the disease course. Leung et al. have shown that chronic obstructive lung disease (COPD) is a risk factor for COVID-19, as the patients affected by both had a more severe course of the disease (19, 20) . Furthermore, several laboratory examinations have were demonstrated to be associated with more severe (e.g. elevated procalcitonin) or even less severe (elevated white blood cell count) disease (21). |
Some studies, which advocated CT as a screening tool, reported surprisingly high sensitivities [5, 18] . Ai et al. found a very high sensitivity of 0.97 for the detection of COVID-19 (higher than our reported values), but a relatively low specificity of 0.25 [5] . In their meta-analysis Xu et al. |
reported similar values for sensitivity (0.92) and specificity (0.25 and 0.33) [18] . While our sensitivity was lower, our specificity was substantially higher. A possible explanation for this may be the low prevalence of confirmed COVID-19 cases in our patient population (12% versus 59% in Ai et al.) and therefore a high proportion of true negative results [5] . However, it has to J o u r n a l P r e -p r o o f be noted that the above-quoted estimates of diagnostic accuracy should be interpreted with caution, as they were obtained in patients with already suspected COVID-19 in a hospital setting and are therefore prone to substantial selection bias [11, 19] . The accuracy, especially the negative predictive value of RT-PCR has been criticized in recent studies. Kucirka et al. |
conducted a meta-analysis and estimated the false negative rate to be 38% by the day of onset of symptoms, which decreased to 20% the third day after onset of symptoms, but then slowly started to increase again [20] . False negative results could therefore also have affected the accuracy of CT in our study, resulting in a high estimate of sensitivity and a low estimate of specificity. |
Our study has several more limitations. Similar to other retrospective studies with COVID-19 data, it was performed in a hospital setting, which probably led to some selection bias. Patients presenting in the emergency department have a higher a priori probability of disease, so the accuracy of the CT is not transferable to an outpatient setting. Selection bias could be further enhanced by the fact that the parameters used for our risk score might also have been used by the physician before referring a patient for CT. The lack of patient information regarding their medical history, laboratory data and ongoing limitation has to be acknowledged as another important limitation of this study In addition, the absolute number of COVID-19 cases confirmed by RT-PCR was relatively low. This small sample size may have affected the pre-test probabilities calculated using our risk score, and estimates of diagnostic accuracy of CT might differ to some degree if repeated in larger cohorts. However, we tried to at least partially correct for this uncertainty by calculating 95% confidence intervals for all estimates of diagnostic accuracy. Furthermore, we observed an overlap for clinical data between the infected and noninfected groups, as shown by the IQR, which likely has an impact on the diagnostic performance J o u r n a l P r e -p r o o f of the model. Also, the inclusion of the pulse rate might have had a positive effect on our calculation of the pre-test probability. However, since it was not reliably documented during initial patient assessment, it could not be included in our analysis. |
A simple score to estimate the pre-test probability of COVID-19 can be calculated using age, sex, O 2 saturation, respiratory rate, and body temperature. Provided that only patients with a high pre-test probability undergo the examination, the accuracy of CT for the detection of COVID-19 might be increased. |
Declarations of interest: None. Table 1 gives an overview of patient characteristics of the overall study population subdivided by absence and presence of COVID-19. It becomes apparent, that the vital parameters body temperature, respiratory rate and oxygen saturation differ between the groups (absence of COVID-19 versus COVID-19), with COVID-19 patients showing higher values for CRP, higher body temperature, higher respiratory rate and lower oxygen saturation. Abbreviations: IQR: |
Interquartile range (in case of non-normal distribution of data); SD: standard deviation (normal distribution of data). Table 2 . Diagnostic accuracy models of CT and CT combined with vital parameters. |
Please indicate if IRB approval was obtained. Even if anonymous if would seem that obtaining information about health and mental health would require ethical approval. In addition, what was put in place in terms of referral to mental health services if needed? Aldo please indicate if the participants received any compensation for their time Under data analysis, please describe in more detail what thematic analysis entails and how this was applied to your study Throughout the findings it seems that P007 is quoted frequently. Please review the findings to ensure that there is diversity in quotes/voices if possible In the discussion the authors note: Even as they were unable to take care of their families financially during quarantine, they contacted their families frequently and supported them by educating them on COVID-19 prevention measures. Did educating family on COVID-19 prevention measures come up in the findings? This was not indicated in the findings that were presented. |
During the interviews did you ask about mental health problems as a result of COVID (or problems with their thinking, feeling or behaviors)? |
Thank you Dr Modesto for your kind comments. |
Thank you Dr Michalopoulos for your valued comments. Please see our responses below: |
Comment 1: Page 7 line 5 please describe what is meant by "negative pressure halls". |
Response: "Negative pressure halls" describe the ventilation controlled characteristics of the residential halls in the facility. We have expanded on this description in our Introduction (lines 147 -149). |
Comment 2: Please indicate if IRB approval was obtained. Even if anonymous if would seem that obtaining information about health and mental health would require ethical approval. |
Response: The SingHealth Centralized Institutional Review Board reviewed our project and determined that the anonymous survey study did not require further ethical deliberation (CIRB Ref: 2020/2561) and it was granted exempt status after review. We have now clarified this under Methods section (lines 184 -186). |
Comment 3: In addition, what was put in place in terms of referral to mental health services if needed? |
Response: The Community Care Facility had a team of mental health workers on site to attend to our patients. We have detailed the team make-up and referral process under our description of the facility (lines 152 -157) . |
Specific to the project, all interviewers were briefed on identifying signs of distress in interviewees. They also had access to refer interviewees to the mental health team on site. We have now descried this under our Methods (lines 209 -212). |
Comment 4: Also please indicate if the participants received any compensation for their time Response: Participation in the interviews was voluntary and participants did not receive any compensation for participation. We have clarified this now in our Methods (lines 194 -198) . |
Comment 5: Under data analysis, please describe in more detail what thematic analysis entails and how this was applied to your study Response: We have expanded on our description of our Data Analysis methods with more detail on thematic analysis (lines 227 -241). |
Comment 6: Throughout the findings it seems that P007 is quoted frequently. Please review the findings to ensure that there is diversity in quotes/voices if possible. |
Response: Thank you for your comment. We have reviewed our selected quotes and replaced some quotes from P007 with that of other participants for diversity of voices. These are in lines 425 -427 and lines 457 -458. |
Comment 7: In the discussion the authors note: Even as they were unable to take care of their families financially during quarantine, they contacted their families frequently and supported them by educating them on COVID-19 prevention measures. Did educating family on COVID-19 prevention measures come up in the findings? This was not indicated in the findings that were presented. |
Response: It would have been more appropriate to term the migrant workers" discussion of COVID-19 prevention measures with their families as a "sharing" rather than "education". We have made this change (line 543) and expanded our Results under the theme of "Staying connected with family" (lines 390 -401) to reflect this. |
Comment 8: During the interviews did you ask about mental health problems as a result of COVID (or problems with their thinking, feeling or behaviors)? |
Response: Thank you for your question. Our initial intent was to study the migrant workers" lived experiences and priorities during and after the crisis with the hope for our results to help inform on planning and services to better meet their needs. While we did not set out to explore mental health problems related to COVID-19, our interviews did surface their worries and how they were coping with these. We are looking to expand our work with the migrant workers in the ongoing pandemic and may take a deeper look into the mental health impact of COVID-19. We greatly appreciate your question and comments. |
Lynn Murphy Michalopoulos, PhD Columbia University School of Social Work USA REVIEW RETURNED 19-Dec-2020 |
Thank you for addressing the concerns from the previous version. I think that the paper is definitely stronger and will make a contribution to the literature. There are two small points for revision. 1) Line 218-please describe in more detail thematic analysis and cite. 2) lines 225-227 please include thoughts and feelings here |
Comment 1: Line 218--please describe in more detail thematic analysis and cite. |
Response: We have expanded our thematic analysis process in further detail in Lines 218 -232 and cited the reference for our process of reflexive thematic analysis |
Lines 218 -232 under Methods: Data Analysis |
We analysed the data using a six-phase guide in reflexive thematic analysis by Braun and Clarke. [23, 24] Initially, authors (KY, HP, YT) read the transcripts several times to familiarise themselves with the content. They then independently used open coding to generate codes on a subset of six transcripts. This process allowed codes related to migrant worker experiences to arise inductively from the data. Then, the authors held discussions to reconcile discrepancies in the assignment of codes and their interpretation. Three broad candidate themes were generated by group codes together: "Experiences and feelings about working in Singapore", "Thoughts, feelings, and experiences during COVID-19", and "Priorities and concerns about the future". A codebook was then developed from consensus which allowed inter-coder clarification that improved reliability of coding. The authors subsequently coded the remaining interviews independently. Consecutive rounds of iterative discussions were conducted to revise and define key themes until all transcripts were coded. The themes and codes were then presented and quotes were added to illustrate them. Edits were made where necessary to correct grammar and omit extraneous words. |
This includes emergency response plans for major emergencies and special protection plans for particularly endangered objects. |
Geoprofiling, also known as geographic profiling or geographic profiling analysis, should be understood as a bundle of methods. "[The] geographic locations of an offender's crimes […] are used to identify and prioritize areas where the offender is likely to live." [1] Geoprofiling in the context of civil security was first adopted by Rossmo in the 1990s as a theme in perpetrator identification. The main function of this investigative methodology is "to prioritise suspects and assist in investigative information management." [2] The differences between the requirements of geoprofiling for police applications and for the fire brigade and rescue services are based on the respective area of responsibility and competence. Emergency location and time are known very precisely; it is not a matter of identifying offenders or reconstructing the course of events or estimating possible further victims in the case of serial offenders. Also in the field of responsibility of the fire brigade and the rescue service there are usually no spatio-temporal connections to preceding or subsequent emergencies. An exception includes "fire devils" and vandalism as well as domestic violence. However, the police investigate this. Fire and rescue services provide care for injured persons in such situations and secure the infrastructure in the event of fire or possibly leaking hazardous substances. Geovisual analysis with geoprofiles in the non-police control centres are used to plan requirements and deployment of forces. A typical question aims at the change of hotspots, e.g. regarding their spatio-temporal stability. Figure 1 shows emergency event's spatial association and aggregation mapped in field cartograms for geoprofiling (a model space) with temporal variances and classified into different density intensity levels. |
Detailed predictive information based on spatio-temporal data analyses can help to plan efficiently, demand-and focus-oriented. The visualisation of spatio-temporal peculiarities represents a value in itself, because humans perceive the predominant part of information optically. In addition, the visualisation can lead to the sensitisation of practitioners in control centres for certain, if necessary, recurring and associated plannable deployment strategies. The mass data analysed for this purpose are past emergencies, i.e. operations involving the fire and rescue services. The mission data are available in their entirety. The aim is to identify significantly spatial, temporal or spatio-temporal aggregations of emergencies visually, and neither to calculate possible nor statistically probable event locations in space (e.g. by using methods of the Kriging family) [4] . |
Aggregations need to be defined and a distinction must be made here between hotpoints and hotspots. |