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Background: Streptococcus pneumoniae infections can lead to severe morbidity and mortality, especially in patients with invasive pneumococcal disease (IPD). This study evaluated factors associated with pneumococcal disease, pneumococcal vaccine effectiveness, and risk factors for all-cause mortality in hospitalised adults with pneumococcal disease in Singapore. Methods: Retrospective case-control study of patients tested for pneumococcal disease with streptococcal urinary antigen testing and at least one sterile site culture, during their admission to a tertiary hospital in Singapore from 2015 to 2017. Patients were defined as cases of IPD or non-IPD, or as controls, based on laboratory results and clinical diagnoses. Multivariable models were constructed to determine factors associated with IPD/non-IPD, and risk factors for mortality from pneumococcal disease. Vaccine effectiveness against IPD/non-IPD was estimated using a variation of the test-negative design. Results: We identified 496 pneumococcal disease cases, of whom 92 (18.5%) had IPD. The mean age of cases was 69.1 ± 15.4 years, and 65.5% were male. Compared with controls (N = 9181), IPD patients were younger (mean age 61.5 ± 16.3 years, vs 72.2 ± 16.1 years in controls; p < 0.001) and with less co-morbidities [median Charlson's score 1 (IQR 0-4), vs 3 (1-5) in controls; p < 0.001]. IPD patients also had the highest proportions with intensive care unit (ICU) admission (20.7%), inpatient mortality (26.1%) and longest median length of stay [9 (IQR 8-17) days]. On multivariable analysis, IPD was negatively associated with prior pneumococcal vaccination (adjusted relative risk ratio = 0.20, 95%CI 0.06-0.69; p = 0.011). Risk factors for mortality among pneumococcal disease patients were ICU admission, diagnosis of IPD, age ≥ 85 years and Charlson's score > 3. Conclusion: Patients with pneumococcal disease (especially IPD) were younger and had less co-morbidities than controls, but had higher risk of severe clinical outcomes and mortality. Pneumococcal vaccination effectiveness against IPD was estimated to be about 80%, and should be encouraged among high-risk patients.

Li et al. reported health care worker (HCW) deaths from coronavirus disease (COVID-19) ( 1 ). HCWs are at risk of COVID-19 from nosocomial transmission and community acquisitions ( 2 ). Since the first imported case of COVID-19 from Wuhan, China, on January 23, 2020, the number of locally acquired COVID-19 cases has increased in Singapore. To break the chain of disease transmission, Singapore implemented the 'Circuit Breaker' measures between April 07, 2020 and June 01, 2020 ( 3 ). The measures included the closure of nonessential workplaces and schools, suspension of religious activities, movement restrictions, mandatory use of face masks in public areas, and safe distancing measures ( 3 ). Since the lifting of the measures on June 02, 2020, hospitals have resumed non-COVID-19related clinical services including clinically-indicated elective surgeries and chronic disease clinics. Furthermore, with the gradual resumption of economic activities and essential travel, an increase in the community transmission of COVID-19 can be expected.Early identification of COVID-19-infected HCWs can detect viral transmission, determine the effectiveness of control measures, and prevent onward transmission to patients and co-workers in healthcare settings ( 1 , 4 , 5 ). At the 1600-bed Tan Tock Seng Hospital (TTSH) and its co-located 330-bed National Centre for Infectious Disease (NCID), the designated center for emerging infectious disease outbreaks including COVID-19, a comprehensive staff sickness surveillance system has been implemented for > 10,0 0 0 HCWs ( 6 ). The system initially comprised an online temperature and sickness reporting platform and medical screening for COVID-19 in unwell HCWs working in COVID-19-related work areas at the TTSH's Emergency Department or NCID's COVID-19 Screening Center (SC). In preparation for the easing of "Circuit Breaker" measures, the HCW sickness surveillance system was enhanced to include SARS-CoV-2 swab testing for all HCWs with fever or symptoms of acute respiratory infection (ARI) from May 06, 2020 regardless of exposure risk. In addition to NCID's SC, TTSH's Occupational Health Clinic (OHC) also performed SARS-CoV-2 swab testing for all HCWs with fever or ARI symptoms. HCWs who had attended a primary care clinic near their homes were required to be tested for SARS-CoV-2 either at the clinic or the OHC. We compare the epidemiology of sick HCWs and describe the effectiveness of the enhanced HCW ARI surveillance program in COVID-19 detection, in the last month of the "Circuit Breaker" and the first month after the lifting of the "Circuit Breaker".We present data from May 06, 2020 to June 30, 2020 corresponding to the 4 weeks before (period A) and after (period B) the lifting of the 'Circuit Breaker' on June 02, 2020. A total of 997 sickness episodes from 874 HCWs (434 in period A and 440 in period B) were included ( Figure 1 ). The median age was 31