Small Outbreaks Research Articles

RARE CASE OF OSTEOSARCOMA IN THE JAW AND ONCOLOGIC PRETREATMENT MANAGEMENT

A 59-year-old female patient complained of a painless swelling in the mandible from the past 20 days. During the examination, an increase of volume in the half right mandible was noticed; in the intraoral examination a nodule with a smooth surface and a solid consistency was observed in the same region. Radiographic images depicted a poorly delimited mixed area of the region with a sun ray aspect. An incisional biopsy was performed, and the histopathologic examination revealed mesenchymal neoplasia with spindle cell proliferation and bulky ovoid permed by small outbreaks of organized osteoid compatible with osteosarcoma. Osteosarcoma is a malignant lesion of mesenchymal cells in gnathic bones and represents 6% to 8% of all lesions of this region. After the diagnosis, oncologic pretreatment and extraction of the condemned dental elements that had poor hygiene and periodontal impairment were performed, with the aim of avoiding infections during the oncologic treatment.

The neglected role of Faith-based Organizations in prevention and control of COVID-19 in Africa.

The COVID-19 pandemic has exposed health system weaknesses of economically wealthy countries with advanced technologies. COVID-19 is now moving fast across Africa where small outbreaks have been reported so far. There is a concern that with the winter transmission will grow rapidly. Despite efforts of African Governments to promptly establish mitigating measures, rural areas, especially in sub-Saharan Africa, risk being neglected. In those settings, faith-based and other non-governmental organizations, if properly equipped and supported, can play a crucial role in slowing the spread of COVID-19. We describe our experience in two rural health facilities in eSwatini and Ethiopia highlighting the struggle towards preparedness and the urgency of international support to help prevent a major public health disaster.

The role of textiles as fomites in the healthcare environment: a review of the infection control risk.

BackgroundInfectious diseases are a significant threat in both healthcare and community settings. Healthcare associated infections (HCAIs) in particular are a leading cause of complications during hospitalisation. Contamination of the healthcare environment is recognised as a source of infectious disease yet the significance of porous surfaces including healthcare textiles as fomites is not well understood. It is currently assumed there is little infection risk from textiles due to a lack of direct epidemiological evidence. Decontamination of healthcare textiles is achieved with heat and/or detergents by commercial or in-house laundering with the exception of healthcare worker uniforms which are laundered domestically in some countries. The emergence of the COVID-19 pandemic has increased the need for rigorous infection control including effective decontamination of potential fomites in the healthcare environment. This article aims to review the evidence for the role of textiles in the transmission of infection, outline current procedures for laundering healthcare textiles and review studies evaluating the decontamination efficacy of domestic and industrial laundering.MethodologyPubmed, Google Scholar and Web of Science were searched for publications pertaining to the survival and transmission of microorganisms on textiles with a particular focus on the healthcare environment.ResultsA number of studies indicate that microorganisms survive on textiles for extended periods of time and can transfer on to skin and other surfaces suggesting it is biologically plausible that HCAIs and other infectious diseases can be transmitted directly through contact with contaminated textiles. Accordingly, there are a number of case studies that link small outbreaks with inadequate laundering or infection control processes surrounding healthcare laundry. Studies have also demonstrated the survival of potential pathogens during laundering of healthcare textiles, which may increase the risk of infection supporting the data published on specific outbreak case studies.ConclusionsThere are no large-scale epidemiological studies demonstrating a direct link between HCAIs and contaminated textiles yet evidence of outbreaks from published case studies should not be disregarded. Adequate microbial decontamination of linen and infection control procedures during laundering are required to minimise the risk of infection from healthcare textiles. Domestic laundering of healthcare worker uniforms is a particular concern due to the lack of control and monitoring of decontamination, offering a route for potential pathogens to enter the clinical environment. Industrial laundering of healthcare worker uniforms provides greater assurances of adequate decontamination compared to domestic laundering, due to the ability to monitor laundering parameters; this is of particular importance during the COVID-19 pandemic to minimise any risk of SARS-CoV-2 transmission.

Refection on our leadership during COVID‐19: challenging our resilience

Refection on our leadership during COVID‐19: challenging our resilience

Emerging Aedes-borne infections in southern Switzerland: Preparedness planning for surveillance and intervention

BackgroundThe Preparedness Plan for Surveillance and Interventions on Emerging Vector-Borne Diseases (VBDs) in Southern Switzerland outlines the strategy for preventing and managing potential outbreaks, as well as the surveillance and control activities with a specific focus on Aedes-borne diseases transmitted by Aedes albopictus mosquitoes. The objective of the plan is to provide Public Health Authorities with a framework of preventive and control measures according to the situation and level of epidemic risks. Material and methodsThe plan is divided into various phases representing the different steps for all potential situations, ranging from no vectors and no transmission risk to epidemic levels with multiple autochthonous/local cases of hospitalization (and deaths) until the end of the epidemic. An algorithm presents how decisions are taken to move from one phase of the plan to another, with detailed activities for different partners and strategies for each specific phase. ResultsThe different phases of the plan include activities on disease surveillance and clinical case management, on vector surveillance and control, communication and coordination of activities. The plan is divided into five phases of activities and decision levels. From phase 0 (no cases) to phase 1 (low number of local cases, less than 5), phase 2 (small outbreak with more than 5 local cases), phase 3 (epidemic) and phase 4 (return to no more cases). ConclusionThe plan has been approved by the cantonal authorities and will be submitted to federal authorities. The required implementation tests will begin shortly.

Production and Characterization of Cholera toxin-like Enterotoxin by a Non-Ol Vibrio cholerae Isolated from Food

Non-O1 V.cholerae caused small localized outbreaks of diarrhoeal diseases and produced cholera toxin-like enterotoxins, heat-stable enterotoxins and thermostable direct hemolysin-like hemolysins. In this paper, we reported on the production of a cholera toxin-like enterotoxin of a non-01 strain isolated from food in Taiwan and the bioactivity and thermostability of this toxin. Production of toxin was optimum by stationary culture in casamino acid yeast extract lincomycin medium incubated at 30℃. This toxin was heat-labile and its cytotonic activity as assayed by Chinese hamster ovary cell was neutralized by anti-cholera toxin antiserum. However, this toxin failed to produce lines of identity with the anti-cholera toxin antiserum in a double gel diffusion assay.

Clinical and Economic Outcomes of Genome Sequencing Availability on Containing a Hospital Outbreak of Resistant Escherichia coli in Australia.

To evaluate the outbreak size and hospital cost effects of bacterial whole-genome sequencing availability in managing a large-scale hospital outbreak. We built a hybrid discrete event/agent-based simulation model to replicate a serious bacterial outbreak of resistant Escherichia coli in a large metropolitan public hospital during 2017. We tested the 3 strategies of using whole-genome sequencing early, late (actual outbreak), or not using it and assessed their associated outbreak size and hospital cost. The model included ward dynamics, pathogen transmission, and associated hospital costs during a 5-month outbreak. Model parameters were determined using data from the Queensland Hospital Admitted Patient Data Collection (N= 4809 patient admissions) and local clinical knowledge. Sensitivity analyses were performed to address model and parameter uncertainty. An estimated 197 patients were colonized during the outbreak, with 75 patients detected. The total outbreak cost was A$460 137 (US$317 117), with 6.1% spent on sequencing. Without sequencing, the outbreak was estimated to result in 352 colonized patients, costing A$766 921 (US$528 547). With earlier detection from use of routine sequencing, the estimated outbreak size was 3 patients and cost A$65 374 (US$45 054). Using whole-genome sequencing in hospital outbreak management was associated with smaller outbreaks and cost savings, with sequencing costs as a small fraction of total hospital costs, supporting the further investigation of the use of routine whole-genome sequencing in hospitals.

Cross-infection of adenovirus among medical staff: A warning from the intensive care unit in a tertiary care teaching hospital in China

RationaleIn 2019, a small HAdV55-associated outbreak of adenovirus infection occurred among the intensive care unit (ICU) staff in Xiangya Hospital of Central South University in Hunan Province, China, during the treatment of a patient. ObjectiveTo investigate the characteristics of a nosocomial adenovirus outbreak in an ICU. MethodsWe evaluated all the patients treated and the medical staff working in the ICU from August 1 to September 4, 2019. We further performed an epidemiological and molecular analysis for this outbreak from patient to healthcare workers and between healthcare workers. After the outbreak, we adopted exposure prevention and droplet prevention measures based on standard precautions. Measurements and main resultsBetween August 1 and August 27, 2019, 27 cases of human adenovirus cross-infection were reported in our institution. Among the cases, eleven were doctors (41%), eleven were nurses (41%), three were respiratory therapists (11%), and two were caregivers (7%). The attack rate was 28.4%, and the fatality rate was 0. The results showed that contact with the index case, lack of hand hygiene or gloving adherence were risk factors for infection after adenovirus exposure. After taking specific precautions, no new cases of infection have appeared since August 27. ConclusionsOur results show that HAdV55 in a single patient had strong transmission potential in an intensive care unit with adequate facilities and standardized operation. We provide convincing evidence indicating that attention could be highlighted on the role of standard and specific precautions for controlling the spread of adenovirus in ICUs.

Route-coupled pathogenicity and immunogenicity of vaccinia virus variant inoculated mice

Vaccinia virus had played a key role in the global smallpox eradication. However, in case of mass vaccination with various Vaccinia virus strains severe side effects were revealed sometimes ending up with lethal outcomes, especially in immunocompromised humans. Hence, in 1980 the World Health Organization recommended to cancel smallpox vaccination after declaring about smallpox eradication. Over the last 40 years, human population virtually lost immunity not only against smallpox, but also against other zoonotic orthopoxvirus infections, such as monkeypox, cowpox, buffalopox, and camelpox. All of them pose a represent increasing threat to human health and heighten a risk of emerging highly contagious viruses due to natural evolution of previous zoonotic orthopoxviruses. In order to prevent development of small outbreaks into spreading epidemics and, thus, to decrease a risk of emergence due to natural evolution of highly pathogenic for humans orthopoxviruses, efforts should be applied to develop safe new generation live vaccines based on Vaccinia virus with target virulence genes inactivation. These strains should be examined in laboratory animal models inoculated via different routes. Currently, Vaccinia virus often becomes attenuated to create live recombinant vaccines due to inserting target DNA sequences into the virus virulence genes resulting in their inactivation. Vaccinia virus strain LIVP used in the Russian Federation as smallpox vaccine as well as derivative attenuated variant LIVP-GFP created by using genetic engineering methods with inactivating its thymidine kinase gene were examined. Such viruses were intracerebrally inoculated into suckling mice at doses of 101 or 102 PFU/animal for neurovirulence assessment. Adult mice were infected intranasally, subcutaneously or intradermally at doses of 107 or 108 PFU/animal and clinical manifestations were analyzed for 14 days. On the 28th day after the onset, blood serum samples were collected from individual mice to measure virus specific antibody level by using ELISA. It was shown that recombinant Vaccinia virus strain LIVP-GFP displayed markedly lowered neurovirulence and pathogenicity for mice as compared to parental LIVP. Finally, intradermal route turned out to demonstrate the most safe and effective profile for immunization with both examined Vaccinia virus strains.

Epidemiological investigation of an outbreak of food poisoning in an officers’ mess

Background: Foodborne infection is a major cause of illness and death worldwide, having long term effects on children’s growth; and considerable illness, heavily affecting healthcare systems. To investigate an outbreak of food poisoning which occurred in an officers’ mess.Methods: A retrospective cross-sectional descriptive study was carried out in the setting of an officers’ mess in an army unit. Standard statistical methods such as calculation of percentage and Chi square were utilized for analysis.Results: It was observed that seven (63.6364%) cases were amongst officers, 3 (27.2727%) cases were among ladies and 1 (9.0909%) case was amongst ORs. 100% cases occurred within 9 to 20 hours of consuming the food.Conclusions: A small scale outbreak of food poisoning occurred in an officers’ mess in a military establishment. Clinically the most likely causative organism was suspected to be Salmonella typhimurium. No microbiological confirmation could be carried out as no food sample was available for the same.

Soil salinity and aridity specify plague foci in the United States of America

Plague is a deadly zoonosis that periodically reemerges as small outbreaks in geographically limited foci where the causative agent Yersinia pestis may reside in soil. We analyzed a dataset of 1.005 carefully documented plague cases that were georeferenced over 113 years in peer-reviewed literature in the contiguous United States. Plotting outbreaks by counties defined as plague foci on geographical maps, we observed a significant co-localization of plague outbreaks with high soil salinity measured by an electric conductivity of >4 dS/ m−1 and aridity measured by an aridity index <0.5. Thus, we identified aridity and soil salinity as significantly associated with ecological risk factors for relapsing plague in the contiguous United States. These results reveal two evolutive parameters that are partially associated with anthropic activities, complicating the epidemiology of plague in the contiguous United States. Exploiting aridity and soil salinity data may help in the surveillance of evolving plague foci in the contiguous United States.

Is it or is it not? Lessons learned from a case of suspected vaccine strain measles

Objective:Measles continues to be a threat to Australia. While post‐eradication risks are low, imported measles cases from overseas travellers who are non‐immune can cause small outbreaks. This case report discusses the challenge of identifying wild‐type measles in an individual who was recently vaccinated with measles‐containing vaccine (MCV). Methods:A positive polymerase chain reaction (PCR) result for measles for an adult who had recently received a measles‐containing vaccine was notified. Investigation revealed no known epidemiological link, recent overseas travel or contact with recent measles cases during the incubation period. Results:The results of the initial sequencing to distinguish between wild‐type and vaccine‐strain measles were inconclusive. A decision was made to re‐run the genotyping, collect additional specimens and quarantine the case until a definitive result was obtained. Sequencing and genotyping revealed that this indeed was a wild‐type measles strain. Conclusions:Changing epidemiology of measles means distinguishing between wild‐type and vaccine–strain measles has become a new challenge. Implications for public health:The reflection of the public health management of this case has provided a valuable teaching tool for public health professionals globally, particularly in low incidence measles countries.

Insecticides resistance status in Aedes aegypti and Aedes albopictus from Lahore, Pakistan

Aedes‐borne disease in Pakistan drew the attention after the dengue outbreak in Lahore in 2011, leaving thousands hospitalized and around 300 deaths. Since then many small and big outbreaks have been reported from various parts of the country. The only available and mostly used mosquito control strategy in Pakistan is the use of neurotoxic chemicals. Pyrethroid deltamethrin and permethrin were extensively used for adults’ control along with organophosphate temephos as a larvicide during and after the outbreaks. This study was designed to find the efficacy of the insecticides in use for Aedes control as well as other insecticides of the same or different classes. Preliminary results after WHO‐like tube tests or CDC‐bottle tests showed that both Aedes aegypti and Aedes albopictus are susceptible to larvicide OP temephos, IGR pyriproxifen and adulticide OP malathion while they are resistant to all classes of pyrethroids tested (deltamethrin, permethrin, etofenprox, alphacypermethrin). Genotyping assays showed low kdr frequencies while assays to find the expression of P450s and other enzymes related to resistance are underway. Sequencing of the voltage gated sodium channel gene will give us a better picture about the mutations in the IIS6 and IIIS6 regions which plays an important role in pyrethroids sensitivity. This study will assist the authorities to design future control strategies.Support or Funding InformationThe study is part of PhD thesis of the presenting author Rafi ur Rahman, who receives monthly scholarship from TWAS and CNPq. No additional funding is provided to the laboratory or the student.

Hand Foot and Mouth Disease (HFMD) in a 3 Years Old Boy in Bangladesh: A Case Report

Hand, foot &amp; mouth disease (HFMD) is a contagious and emerging infectious disease caused by picorna viridae family. It was first reported in New Zealand in 1957 is caused by Coxsackie virus A16 (CVA16), human enterovirus 71 (HEV71) and occasionally by Coxsackie virus A6 and Coxsackie virus A10, are also associated with HFMD and herpangina. Though only small scale outbreaks have been reported from United States, Europe, Australia Japan and Brazil for the first few decades, since 1997 the disease has noticeably changed its character as noted in different Southeast Asian countries. In recent years Bangladesh also faces some cases of HFMD. Though HFMD is a mild disease but in rare cases may develop neurological complications. Early detection and good clinical assessment can prevent the fatal progression and also can reduce morbidity and mortality regarding HFMD.&#x0D; Bangladesh Journal of Infectious Diseases 2019;6(2):53-55

Measles outbreak in Dubrovnik-Neretva County, Croatia, May to June 2018.

In May 2018, measles was introduced in the Dubrovnik region by an adult who recently travelled to Kosovo*. Control measures and an outbreak investigation were implemented: 15 epidemiologically-linked cases met the outbreak case definition of a visitor/resident of Dubrovnik-Neretva County with laboratory-confirmed measles and symptom onset beginning on May 19. New cases were identified through hospitals and primary care physicians. Throat swabs, urine and/or serum samples were collected from outbreak cases. RT-PCR detection of viral RNA and IgM/IgG was used to confirm infection. The median age of cases was 33 years, with one 8 month-old infant. Vaccination status was unknown for 9 cases, three were unvaccinated, one case had history of one dose and two cases reported receiving two doses of measles-containing vaccine. There were 11 hospitalisations and one person developed pneumonia. Control teams undertook an extensive search of contacts and implemented a range of control measures. Despite the outbreak occurring at the beginning of the summer tourism season, it was contained and did not spread to neighbouring regions. With continuing measles transmission in Europe, even small outbreaks create a burden on the health system in countries which have eliminated measles, and illustrate the importance of maintaining high immunisation coverage.

Changes in the Transmission Dynamic of Chikungunya Virus in Southeastern Senegal.

In Senegal, chikungunya virus (CHIKV) is maintained in a sylvatic cycle and causes sporadic cases or small outbreaks in rural areas. However, little is known about the influence of the environment on its transmission. To address the question, 120 villages were randomly selected in the Kedougou region of southeastern Senegal. In each selected village, 10 persons by randomly selected household were sampled and tested for specific anti-CHIKV IgG antibodies by ELISA. We investigated the association of CHIKV seroprevalence with environmental variables using logistic regression analysis and the spatial correlation of village seroprevalence based on semivariogram analysis. Fifty-four percent (51%–57%) of individuals sampled during the survey tested positive for CHIKV-specific IgG. CHIKV seroprevalence was significantly higher in populations living close to forested areas (Normalized Difference Vegetation Index (NDVI), Odds Ratio (OR) = 1.90 (1.42–2.57)), and was negatively associated with population density (OR = 0.76 (0.69–0.84)). In contrast, in gold mining sites where population density was >400 people per km2, seroprevalence peaked significantly among adults (46% (27%–67%)) compared to all other individuals (20% (12%–31%)). However, traditional gold mining activities significantly modify the transmission dynamic of CHIKV, leading to a potential increase of the risk of human exposition in the region.

Gene flow and Bayesian phylogeography of serogroup C meningococci circulating in Italy.

Hyperinvasive strains of Neisseria meningitidis serogroup C have caused outbreaks of severe disease in Italy. Here, we report the analysis of the migration patterns of C:P1.5-1,10-8:F3-6:ST-11(cc11) meningococcal strains from different Italian regions collected between 2012 and 2017. N. meningitidis genomes were sequenced through the whole genome sequencing (WGS) method and were analyzed using the BIGSdb Genome Comparator tool. The phylogeography was performed using BEAST. The gene flows in Italy were tested by using MacClade. The C:P1.5-1,10-8:F3-6:ST-11(cc11) hyperinvasive meningococcal strain, for the data available at the time of the analysis, from UK reached at first Emilia Romagna region, and then, in 2012, was detected in the outbreak occurred in the port of Livorno. The "Tuscany-outbreak strain" was likely introduced in Italy between 2013 and 2014. Most of the observed gene flow events occurred from the Center to Northern part of Italy. The phylogeographic analysis allowed to track the dissemination of C:P1.5-1,10-8:F3-6:ST-11(cc11) strains in the country.

Heatwaves and dengue outbreaks in Hanoi, Vietnam: New evidence on early warning.

Many studies have shown associations between rising temperatures, El Niño events and dengue incidence, but the effect of sustained periods of extreme high temperatures (i.e., heatwaves) on dengue outbreaks has not yet been investigated. This study aimed to compare the short-term temperature-dengue associations during different dengue outbreak periods, estimate the dengue cases attributable to temperature, and ascertain if there was an association between heatwaves and dengue outbreaks in Hanoi, Vietnam. Dengue outbreaks were assigned to one of three categories (small, medium and large) based on the 50th, 75th, and 90th percentiles of distribution of weekly dengue cases during 2008-2016. Using a generalised linear regression model with a negative binomial link that controlled for temporal trends, temperature variation, rainfall and population size over time, we examined and compared associations between weekly average temperature and weekly dengue incidence for different outbreak categories. The same model using weeks with or without heatwaves as binary variables was applied to examine the potential effects of extreme heatwaves, defined as seven or more days with temperatures above the 95th percentile of daily temperature distribution during the study period. This study included 55,801 dengue cases, with an average of 119 (range: 0 to 1454) cases per week. The exposure-response relationship between temperature and dengue risk was non-linear and differed with dengue category. After considering the delayed effects of temperature (one week lag), we estimated that 4.6%, 11.6%, and 21.9% of incident cases during small, medium, and large outbreaks were attributable to temperature. We found evidence of an association between heatwaves and dengue outbreaks, with longer delayed effects on large outbreaks (around 14 weeks later) than small and medium outbreaks (4 to 9 weeks later). Compared with non-heatwave years, dengue outbreaks (i.e., small, moderate and large outbreaks combined) in heatwave years had higher weekly number of dengue cases (p<0.05). Findings were robust under different sensitivity analyses. The short-term association between temperature and dengue risk varied by the level of outbreaks and temperature seems more likely affect large outbreaks. Moreover, heatwaves may delay the timing and increase the magnitude of dengue outbreaks.

Listeriosis Outbreak in South Africa: A Comparative Analysis with Previously Reported Cases Worldwide.

Listeria species are Gram-positive, rod-shaped, facultative anaerobic bacteria, which do not produce endospores. The genus, Listeria, currently comprises 17 characterised species of which only two (L. monocytogenes and L. ivanovii) are known to be pathogenic to humans. Food products and related processing environments are commonly contaminated with pathogenic species. Outbreaks and sporadic cases of human infections resulted in considerable economic loss. South Africa witnessed the world’s largest listeriosis outbreak, characterised by a progressive increase in cases of the disease from January 2017 to July 2018. Of the 1060 laboratory-confirmed cases of listeriosis reported by the National Institute of Communicable Diseases (NICD), 216 deaths were recorded. Epidemiological investigations indicated that ready-to-eat processed meat products from a food production facility contaminated with L. monocytogenes was responsible for the outbreak. Multilocus sequence typing (MLST) revealed that a large proportion (91%) of the isolates from patients were sequence type 6 (ST6). Recent studies revealed a recurrent occurrence of small outbreaks of listeriosis with more severe side-effects in humans. This review provides a comparative analysis of a recently reported and most severe outbreak of listeriosis in South Africa, with those previously encountered in other countries worldwide. The review focuses on the transmission of the pathogen, clinical symptoms of the disease and its pathogenicity. The review also focuses on the major outbreaks of listeriosis reported in different parts of the world, sources of contamination, morbidity, and mortality rates as well as cost implications. Based on data generated during the outbreak of the disease in South Africa, listeriosis was added to the South African list of mandatory notifiable medical conditions. Surveillance systems were strengthened in the South African food chain in order to assist in preventing and facilitating early detection of both sporadic cases and outbreaks of infections caused by these pathogens in humans.

Knowledge, attitudes and practices of healthcare workers during the early COVID-19 pandemic in a main, academic tertiary care centre in Saudi Arabia.

As the Middle East respiratory syndrome coronavirus (MERS-CoV) continues to occur in small outbreaks in Saudi Arabia, we aimed to assess the knowledge, attitudes and intended practices of healthcare workers (HCWs) during the early stage of the COVID-19 pandemic and compare worry levels with previous findings during the MERS-CoV outbreak in 2015. We sent an adapted version of our previously published MERS-CoV questionnaire to the same cohort of HCWs at a tertiary hospital in Saudi Arabia. About 40% of our sample had previous experience with confirmed or suspected MERS-CoV patients, and those had a significantly higher knowledge score (13.16 ± 2.02 vs. 12.58 ± 2.27, P = 0.002) and higher adherence to protective hygienic practices (2.95 ± 0.80 vs. 2.74 ± 0.92, P = 0.003). The knowledge scores on COVID-19 were higher in the current cohort than the previous MERS-CoV outbreak cohort (68% vs. 79.7%, P < 0.001). HCWs from the current cohort who felt greater anxiety from COVID-19 compared to MERS-CoV were less likely to have been exposed to MERS-CoV infected/suspected cases (odds ratio (OR) = 0.646, P = 0.042) and were less likely to have attended the hospital awareness campaign on COVID-19 (OR = 0.654, P = 0.035). We concluded that previous experience with MERS-CoV was associated with increased knowledge and adherence to protective hygienic practices, and reduction of anxiety towards COVID-19.