The Utility and Sustainability of US Ebola Treatment Centers during the COVID-19 Pandemic.

OBJECTIVE: In response to the 2014-2016 West Africa Ebola virus disease (EVD) epidemic, the Centers for Disease Control and Prevention (CDC) designated 56 US hospitals as Ebola treatment centers (ETCs) with high-level isolation capabilities. We aimed to determine ongoing sustainability of ETCs and identify how ETC capabilities have impacted hospital, local, and regional COVID-19 readiness and response. DESIGN: An electronic survey included both qualitative and quantitative questions and was structured into two sections: operational sustainability and role in the COVID-19 response. SETTING AND PARTICIPANTS: The survey was distributed to site representatives from the 56 originally designated ETCs; 37 (66%) responded. METHODS: Data were coded and analyzed using descriptive statistics. RESULTS: Of the 37 responding ETCs, 33 (89%) reported they were still operating while 4 had decommissioned. ETCs that maintain high-level isolation capabilities incurred a mean of $234,367 in expenses per year. All but one ETC reported that existing capabilities (e.g., trained staff, infrastructure) before COVID-19 positively affected their hospital, local, and regional COVID-19 readiness and response (e.g., ETCs trained staff, donated supplies, and shared developed protocols). CONCLUSIONS: Existing high-level isolation capabilities and expertise developed following the 2014-2016 EVD epidemic were leveraged by ETCs to assist hospital-wide readiness for COVID-19 and support response for other local and regional hospitals However, ETCs face continued challenges in sustaining those capabilities for high-consequence infectious diseases.

An Updated Review of Literature for Air Medical Evacuation High-Level Containment Transport During the Coronavirus Disease 2019 Pandemic.

OBJECTIVE: In 2019, our team conducted a literature review of air medical evacuation high-level containment transport (AE-HLCT) of patients infected with high-consequence pathogens. Since that publication, the coronavirus disease 2019 (COVID-19) pandemic has resulted in numerous air medical evacuations. We re-examined the new literature associated with AE-HLCTs to determine new innovations developed as a result of the pandemic. METHODS: A literature search was performed in PubMed/MEDLINE from February 2019 to October 2021. The authors screened abstracts for the inclusion criteria and reviewed full articles if the abstract was relevant to the aim. RESULTS: Our search criteria yielded 19 publications. Many of the early transports of patients with COVID-19 used established protocols for AE-HLCT, which were built from the most recent transports of patients with Ebola virus disease. Innovations from the identified articles are subdivided into preflight considerations, in-flight operations, and postflight operations. CONCLUSION: Lessons gleaned from AE-HLCTs of patients with COVID-19 in the early weeks of the pandemic, when little was known about transmission or the severity of the novel disease, have advanced the field of AE-HLCT. Teams that had never conducted such transports now have experience and processes. However, more research into AE-HLCT is needed, including research related to single-patient portable isolation units as well as containerized/multipatient transportation systems.

Developing a Rapid Response Single IRB Model for Conducting Research During a Public Health Emergency.

Research is foundational for evidence-based management of patients. Clinical research, however, takes time to plan, conduct, and disseminate-a luxury that is rarely available during a public health emergency. The University of Nebraska Medical Center (UNMC) developed a single institutional review board (IRB), with a vision to establish a rapid review resource for a network focused on clinical research of emerging pathogens in the United States. A core aspect of successful initiation of research during a pandemic or epidemic is the ability to operationalize an approach for rapid ethical review of human subject research and conduct those reviews at multiple sites-without losing any of the substantive aspects of ethics review. This process must be cultivated in anticipation of a public health emergency. US guidance for operationalizing IRB review for multisite research in a public health emergency is not well studied and processes are not well established. UNMC sought to address operational gaps and identify the unique procedural needs of rapid response single IRB (RR-sIRB) review of multisite research by conducting a series of preparedness exercises to develop and test the RR-sIRB model. For decades, emergency responder, healthcare, and public health organizations have conducted emergency preparedness exercises to test requirements for emergency response. In this article, we describe 2 types of simulation exercises conducted by UNMC: workshops and tabletops. This effort represents a unique use of emergency preparedness exercises to develop, refine, and test rapid review functions for an sIRB and to validate readiness of regulatory research processes. Such processes are crucial for conducting rapid, ethical, and sound clinical research in public health emergencies.

The Evolution of the National Special Pathogen System of Care.

Infectious disease outbreaks and pandemics have repeatedly threatened public health and have severely strained healthcare delivery systems throughout the past century. Pathogens causing respiratory illness, such as influenza viruses and coronaviruses, as well as the highly communicable viral hemorrhagic fevers, pose a large threat to the healthcare delivery system in the United States and worldwide. Through the Hospital Preparedness Program, within the US Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response, a nationwide Regional Ebola Treatment Network (RETN) was developed, building upon a state- and jurisdiction-based tiered hospital approach. This network, spearheaded by the National Emerging Special Pathogens Training and Education Center, developed a conceptual framework and plan for the evolution of the RETN into the National Special Pathogen System of Care (NSPS). Building the NSPS strategy involved reviewing the literature and the initial framework used in forming the RETN and conducting an extensive stakeholder engagement process to identify gaps and develop solutions. From this, the NSPS strategy and implementation plan were formed. The resulting NSPS strategy is an ambitious but critical effort that will have impacts on the mitigation efforts of special pathogen threats for years to come.

COVID-19 Response Among US Hospitals with Emerging Special Pathogen Programs.

In February 2015, the US Department of Health and Human Services developed a tiered hospital network to deliver safe and effective care to patients with Ebola virus disease (EVD) and other special pathogens. The tiered network consisted of regional special pathogen treatment centers, state- or jurisdiction-designated treatment centers, assessment hospitals able to safely isolate a patient until a diagnosis of EVD was confirmed and transfer the patient, and frontline healthcare facilities able to identify and isolate patients with EVD and facilitate transport to higher-tier facilities. The National Emerging Special Pathogens Training and Education Center (NETEC) was established in tandem to support the development of healthcare facility special pathogen management capabilities. In August 2020, 20 hospitals that previously received an onsite readiness consultation by NETEC were surveyed to assess how special pathogen programs were leveraged for COVID-19 response. All surveyed facilities indicated their programs were leveraged for COVID-19 response in at least 1 of the following ways: NETEC-sponsored resources and training, utilization of patient isolation spaces, specially trained staff, and supplies. Personal protective equipment shortages were experienced by 95% of facilities, with 80% of facilities reporting that special pathogens program personal protective equipment was used to support facility response to COVID-19 admissions. More than half of facilities (63%) reported leveraging biocontainment unit staff to provide training and education to frontline staff during initial response to COVID-19. These findings have implications for planning and investments to avoid the panic-then-forget cycle that hinders sustained preparedness for future special pathogens.

Access, socioeconomic environment, and death from COVID-19 in Nebraska.

Our study assesses whether factors related to healthcare access in the first year of the pandemic affect mortality and length of stay (LOS). Our cohort study examined hospitalized patients at Nebraska Medicine between April and October 2020 who were tested for SARS-CoV-2 and had a charted sepsis related diagnostic code. Multivariate logistic was used to analyze the odds of mortality and linear regression was used to calculate the parameter estimates of LOS associated with COVID-19 status, age, gender, race/ethnicity, median household income, admission month, and residential distance from definitive care. Among 475 admissions, the odds of mortality is greater among those with older age (OR: 1.04, 95% CI: 1.02-1.07) and residence in an area with low median household income (OR: 2.11, 95% CI: 0.52-8.57), however, the relationship between mortality and wealth was not statistically significant. Those with non-COVID-19 sepsis had longer LOS (Parameter Estimate: -5.11, adjusted 95% CI: -7.92 to -2.30). Distance from definitive care had trends toward worse outcomes (Parameter Estimate: 0.164, adjusted 95% CI: -1.39 to 1.97). Physical and social aspects of access to care are linked to poorer COVID-19 outcomes. Non-COVID-19 healthcare outcomes may be negatively impacted in the pandemic. Strategies to advance patient-centered outcomes in vulnerable populations should account for varied aspects (socioeconomic, residential setting, rural populations, racial, and ethnic factors). Indirect impacts of the pandemic on non-COVID-19 health outcomes require further study.

Treating Workers as Essential Too: An Ethical Framework for Public Health Interventions to Prevent and Control COVID-19 Infections among Meat-processing Facility Workers and Their Communities in the United States.

Meat is a multi-billion-dollar industry that relies on people performing risky physical work inside meat-processing facilities over long shifts in close proximity. These workers are socially disempowered, and many are members of groups beset by historic and ongoing structural discrimination. The combination of working conditions and worker characteristics facilitate the spread of SARS-CoV-2, the virus that causes COVID-19. Workers have been expected to put their health and lives at risk during the pandemic because of government and industry pressures to keep this "essential industry" producing. Numerous interventions can significantly reduce the risks to workers and their communities; however, the industry's implementation has been sporadic and inconsistent. With a focus on the U.S. context, this paper offers an ethical framework for infection prevention and control recommendations grounded in public health values of health and safety, interdependence and solidarity, and health equity and justice, with particular attention to considerations of reciprocity, equitable burden sharing, harm reduction, and health promotion. Meat-processing workers are owed an approach that protects their health relative to the risks of harms to them, their families, and their communities. Sacrifices from businesses benefitting financially from essential industry status are ethically warranted and should acknowledge the risks assumed by workers in the context of existing structural inequities.

Best practices of highly infectious decedent management: Consensus recommendations from an international expert workshop.

With the increasing number of highly infectious disease incidents, outbreaks, and pandemics in our society (e.g., Ebola virus disease, Lassa fever, coronavirus diseases), the need for consensus and best practices on highly infectious decedent management is critical. In January 2020, a workshop of subject matter experts from across the world convened to discuss highly infectious live patient transport and highly infectious decedent management best practices. This commentary focuses on the highly infectious decedent management component of the workshop. The absence of guidance or disparate guidance on highly infectious decedent management can increase occupational safety and health risks for death care sector workers. To address this issue, the authorship presents these consensus recommendations on best practices in highly infectious decedent management, including discussion of what is considered a highly infectious decedent; scalability and storage for casualty events; integration of key stakeholders; infection control and facility considerations; transport; care and autopsy; psychological, ethical, and cultural considerations as well as multi-national care perspectives. These consensus recommendations are not intended to be exhaustive but rather to underscore this overlooked area and serve as a starting point for much-needed conversations.

COVID-19 among Indigenous communities: Case studies on Indigenous nursing responses in Australia, Canada, New Zealand, and the United States

Globally, Indigenous Peoples experience disparate COVID-19 outcomes. This paper presents case studies from Aotearoa New Zealand, Australia, Canada, and the United States of America and explores aspects of government policies, public health actions, and Indigenous nursing leadership for Indigenous communities during a pandemic. Government under-performance in establishing Indigenous-specific plans and resources, burdened those countries with higher COVID-19 cases and mortality rates. First, availability of quality data is an essential element of any public health strategy, and involves disaggregated, ethnic-specific data on Indigenous COVID-19 cases, mortality rates, and vaccination rates. When data is unavailable, Indigenous Peoples are rendered invisible. Data sovereignty principles must be utilised to ensure that there is Indigenous ownership and protections of these data. Second, out of necessity, Indigenous communities expressed their self-determination by uniting to protect their Peoples and providing holistic and culturally meaningful care, gathering quality data and advocating. Indigenous leaders used an equity lens that informed national, state, regional, and community-level decisions relating to their Peoples. Third, at the forefront of the pandemic, Indigenous nursing leadership served as a trusted presence within Indigenous communities. Indigenous nurses often led advocacy, COVID-19 testing, nursing care, and vaccination efforts in various settings and communities. Indigenous nurses performed vital roles in a global strategy to reduce Indigenous health inequities during the COVID-19 pandemic and beyond. Fourth, historically, pandemics have heightened Indigenous Peoples' vulnerability. COVID-19 amplified Indigenous health inequities, underscoring the importance of high-trust relationships with Indigenous communities to enable rapid government support and resources. Holistic approaches to COVID-19 responses by Indigenous peoples must consider the wider determinants of wellbeing including food and housing security. Findings from these case studies, demonstrate that Indigenous self-determination, data sovereignty, holistic approaches to pandemic responses alongside with Governmental policies, resources should inform vaccination strategies and future pandemic readiness plans. Finally, in any pandemic of COVID-19-scale, Indigenous nurses' leadership and experience must be leveraged for a calm, trusted and efficient response.

Institutional policies and readiness in management of critical illness among patients with viral hemorrhagic fever.

OBJECTIVE: In response to the 2013-2016 Ebola virus disease outbreak, the US government designated certain healthcare institutions as Ebola treatment centers (ETCs) to better prepare for future emerging infectious disease outbreaks. This study investigated ETC experiences and critical care policies for patients with viral hemorrhagic fever (VHF). DESIGN: A 58-item questionnaire elicited information on policies for 9 critical care interventions, factors that limited care provision, and innovations developed to deliver care. SETTING AND PARTICIPANTS: The questionnaire was sent to 82 ETCs. METHODS: We analyzed ordinal and categorical data pertaining to the ETC characteristics and descriptive data about their policies and perceived challenges. Statistical analyses assessed whether ETCs with experience caring for VHF patients were more likely to have critical care policies than those that did not. RESULTS: Of the 27 ETCs who responded, 17 (63%) were included. Among them, 8 (47%) reported experience caring for persons under investigation or confirmed cases of VHF. Most felt ready to provide intubation, chest compressions, and renal replacement therapy to these patients. The factors most cited for limiting care were staff safety and clinical futility. Innovations developed to better provide care included increased simulation training and alternative technologies for procedures and communication. CONCLUSIONS: There were broad similarities in critical care policies and limitations among institutions. There were several interventions, namely ECMO and cricothyrotomy, which few institutions felt ready to provide. Future studies could identify obstacles to providing these interventions and explore policy changes after increased experience with novel infectious diseases, such as COVID-19.

Airborne Transmission of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2): What We Know.

We examine airborne transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) potential using a source-to-dose framework beginning with generation of virus-containing droplets and aerosols and ending with virus deposition in the respiratory tract of susceptible individuals. By addressing 4 critical questions, we identify both gaps in addressing 4 critical questions with answers having policy implications.

Factors of sexual quality of life in gynaecological cancers: a systematic literature review.

BACKGROUND: The impact of cancer diagnosis and treatment on sexual quality of life (SQoL) is a well-established survivorship issue for gynaecological cancer survivors (GCS), yet little is known on how to intervene. PURPOSE: The aim of this systematic review was to identify the factors explaining the variability in SQoL for GCS. METHODS: We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework and the software Covidence. Electronic databases Scopus, Web of Science, PUBMED and CINAHL were searched for original research on GCS published between 2002 and 2018. We performed a two-stage screening process against selection criteria and quality assessment of individual studies. The Salutogenic Theory and the PRECEDE-PROCEED model were used as theoretical frameworks to identify and categorise factors. RESULTS: The initial search yielded 3,505 articles resulting in a total of 46 studies used to examine the association between factors of SQoL and gynaecological cancers. Our findings suggested that SQoL varies across subgroups based on age, menopausal status, relationship status, and treatment modality. Protective factors included clinicians' knowledge and confidence, preventive medical approach, risk and needs assessment, patient-clinician communication, relationship quality, psychosocial support, symptom management, accessibility of psychosexual care, and self-efficacy in the rediscovery of sexuality. CONCLUSION: Despite the high incidence and long-term impact of sexual health issues on quality of life, supportive care needs are not being met. A better understanding of the evidence base around the factors of SQoL can help health professionals take steps to protect and improve SQoL in GCS.

Assessment of a Program for SARS-CoV-2 Screening and Environmental Monitoring in an Urban Public School District.

Importance: Scalable programs for school-based SARS-CoV-2 testing and surveillance are needed to guide in-person learning practices and inform risk assessments in kindergarten through 12th grade settings. Objectives: To characterize SARS-CoV-2 infections in staff and students in an urban public school setting and evaluate test-based strategies to support ongoing risk assessment and mitigation for kindergarten through 12th grade in-person learning. Design, Setting, and Participants: This pilot quality improvement program engaged 3 schools in Omaha, Nebraska, for weekly saliva polymerase chain reaction testing of staff and students participating in in-person learning over a 5-week period from November 9 to December 11, 2020. Wastewater, air, and surface samples were collected weekly and tested for SARS-CoV-2 RNA to evaluate surrogacy for case detection and interrogate transmission risk of in-building activities. Main Outcomes and Measures: SARS-CoV-2 detection in saliva and environmental samples and risk factors for SARS-CoV-2 infection. Results: A total of 2885 supervised, self-collected saliva samples were tested from 458 asymptomatic staff members (mean [SD] age, 42.9 [12.4] years; 303 women [66.2%]; 25 Black or African American [5.5%], 83 Hispanic [18.1%], 312 White [68.1%], and 35 other or not provided [7.6%]) and 315 students (mean age, 14.2 [0.7] years; 151 female students [48%]; 20 Black or African American [6.3%], 201 Hispanic [63.8%], 75 White [23.8%], and 19 other race or not provided [6.0%]). A total of 46 cases of SARS-CoV-2 (22 students and 24 staff members) were detected, representing an increase in cumulative case detection rates from 1.2% (12 of 1000) to 7.0% (70 of 1000) among students and from 2.1% (21 of 1000) to 5.3% (53 of 1000) among staff compared with conventional reporting mechanisms during the pilot period. SARS-CoV-2 RNA was detected in wastewater samples from all pilot schools as well as in air samples collected from 2 choir rooms. Sequencing of 21 viral genomes in saliva specimens demonstrated minimal clustering associated with 1 school. Geographical analysis of SARS-CoV-2 cases reported district-wide demonstrated higher community risk in zip codes proximal to the pilot schools. Conclusions and Relevance: In this study of staff and students in 3 urban public schools in Omaha, Nebraska, weekly screening of asymptomatic staff and students by saliva polymerase chain reaction testing was associated with increased SARS-CoV-2 case detection, exceeding infection rates reported at the county level. Experiences differed among schools, and virus sequencing and geographical analyses suggested a dynamic interplay of school-based and community-derived transmission risk. Collectively, these findings provide insight into the performance and community value of test-based SARS-CoV-2 screening and surveillance strategies in the kindergarten through 12th grade educational setting.

Author Correction: Aerosol and surface contamination of SARS-CoV-2 observed in quarantine and isolation care.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

The size and culturability of patient-generated SARS-CoV-2 aerosol.

BACKGROUND: Aerosol transmission of COVID-19 is the subject of ongoing policy debate. Characterizing aerosol produced by people with COVID-19 is critical to understanding the role of aerosols in transmission. OBJECTIVE: We investigated the presence of virus in size-fractioned aerosols from six COVID-19 patients admitted into mixed acuity wards in April of 2020. METHODS: Size-fractionated aerosol samples and aerosol size distributions were collected from COVID-19 positive patients. Aerosol samples were analyzed for viral RNA, positive samples were cultured in Vero E6 cells. Serial RT-PCR of cells indicated samples where viral replication was likely occurring. Viral presence was also investigated by western blot and transmission electron microscopy (TEM). RESULTS: SARS-CoV-2 RNA was detected by rRT-PCR in all samples. Three samples confidently indicated the presence of viral replication, all of which were from collected sub-micron aerosol. Western blot indicated the presence of viral proteins in all but one of these samples, and intact virions were observed by TEM in one sample. SIGNIFICANCE: Observations of viral replication in the culture of submicron aerosol samples provides additional evidence that airborne transmission of COVID-19 is possible. These results support the use of efficient respiratory protection in both healthcare and by the public to limit transmission.

A pilot study of core body temperatures in healthcare workers wearing personal protective equipment in a high-level isolation unit.

Personal protective equipment used by healthcare workers to mitigate disease transmission risks while caring for patients with high-consequence infectious diseases can impair normal body cooling mechanisms and exacerbate physiological strain. Symptoms of heat strain (e.g., cognitive impairment, confusion, muscle cramping) are especially harmful in the high-risk environment of high-consequence infectious disease care. In this pilot study, the core body temperatures of healthcare workers were assessed using an ingestible, wireless-transmission thermometer while performing patient care tasks common to a high-level isolation unit setting in powered air purifying respirator (PAPR)-level. The objective was to determine the potential for occupational health hazard due to heat stress in an environmentally controlled unit. Maximum core temperatures of the six participants ranged from 37.4 °C (99.3 °F) to 39.9 °C (103.8°F) during the 4-hr shift; core temperatures of half (n = 3) of the participants exceeded 38.5 °C (101.3 °F), the upper core temperature limit. Future investigations are needed to identify other heat stress risks both in and outside of controlled units. The ongoing COVID-19 pandemic offers unique opportunities for field-based research on risks of heat stress related to personal protective equipment in healthcare workers that can lead to both short- and long-term innovations in this field.

Leveraging a Preexisting Global Infectious Disease Network for Local Decision Making During a Pandemic.

Emerging infectious disease epidemics require a rapid response from health systems; however, evidence-based consensus guidelines are generally absent early in the course of events. Formed in 2017 by 5 high-level isolation units spanning 3 continents, the experience of the Global Infectious Disease Preparedness Network (GIDPN) early in the course of coronavirus disease 2019 (COVID-19) provides a model for accelerating best practice development and improving decision-making in health emergencies. The network served as a platform for real-time, open and transparent information-sharing during unknowns of an active outbreak by clinicians caring for patients, by researchers conducting clinical trials and transmission and infection prevention studies, and by teams advising local and national policy makers. Shared knowledge led to earlier adoption of some treatment modalities as compared to most peer institutions and to implementation of protocols prior to incorporation into national guidelines. GIDPN and similar networks are integral in enhancing preparedness for and response to future epidemics/pandemics.

A Rapid-Response Survey of Essential Workers in Midwestern Meatpacking Plants: Perspectives on COVID-19 Response in the Workplace

The meatpacking industry has faced significant challenges in maintaining a safe and healthy working environment for its employees during the COVID-19 pandemic, which has resulted in worker illness and death, temporary closures of facilities, reductions in production capacity, and consequences throughout the supply chain. We sought to explore the concerns and perceptions of COVID-19 among meatpacking workers in the Midwestern part of the U.S. We conducted an online survey of meatpacking workers in Nebraska, Iowa, Kansas, and Missouri between May 7 and 25, 2020. A total of 585 workers participated (M = 41.3 years, SD = 10.3). More than 72% of workers believed that they were at "high risk" for contracting COVID-19, but less than one half had been tested (42%). Most workers (83%) reported that their employer had instituted some safety measures, but less than one half reported physical distancing on the line (39%), slowing down the line (34%), additional paid time off (28%), or restructuring of shifts (20%). Enforceable standards are needed in the meatpacking industry to reduce COVID-19 transmission. Culturally and linguistically tailored education, paid sick leave, and restructuring of work can reduce the risks of COVID-19 transmission. Transparency on workplace transmission rates is essential to developing strategies to mitigate occupational risks and foster worker trust.