A Public Health Laboratory Information System in Support of Health Emergencies: The Nebraska Public Health Laboratory COVID-19 Experience.

OBJECTIVES: Public health laboratories (PHLs) are essential components of US Public Health Service operations. The health information technology that supports PHLs is central to effective and efficient laboratory operations and overall public health response to infectious disease management. This analysis presents key information on how the Nebraska Public Health Laboratory (NPHL) information technology system evolved to meet the demands of the COVID-19 pandemic. MATERIALS AND METHODS: COVID-19 presented numerous, unforeseen information technology system challenges. The most notable challenges requiring changes to NPHL software systems and capability were improving efficiency of the laboratory operation due to high-volume testing, responding daily to demands for timely data for analysis by partner systems, interfacing with multiple testing (equipment) platforms, and supporting community-based specimen collection programs. RESULTS: Improvements to the NPHL information technology system enabled NPHL to perform >121 000 SARS-CoV-2 polymerase chain reaction tests from March 2020 through January 2022 at a sustainable rate of 2000 SARS-CoV-2 tests per day, with no increase in laboratory staffing. Electronic reporting of 62 000 rapid antigen tests eliminated paper reporting and extended testing services throughout the state. Collection of COVID-19 symptom data before specimen collection enabled NPHL to make data-driven decisions to perform pool testing and conserve testing kits when supplies were low. PRACTICE IMPLICATIONS: NPHL information technology applications proved essential for managing health care provider workload, prioritizing the use of scarce testing supplies, and managing Nebraska's overall pandemic response. The NPHL experience provides useful examples of a highly capable information technology system and suggests areas for additional attention in the PHL environment, including a focus on end users, collaboration with various partners, and investment in information technology.

Outbreak of SARS-CoV-2 B.1.617.2 (Delta Variant) in a Youth Camp Associated With Community Spread, Nebraska, June-July 2021.

OBJECTIVES: During June-July 2021, an outbreak of SARS-CoV-2 occurred among attendees of a summer youth camp in Nebraska. We assessed the factors that contributed to onward transmission of disease. METHODS: The Four Corners Health Department conducted an outbreak investigation and recorded both laboratory-confirmed and self-reported cases of SARS-CoV-2 and mitigation measures employed. We generated sequences on positive specimens, created an epidemic curve to assist with outbreak visualization, and examined epidemiologic, genomic, and laboratory outcomes. RESULTS: Evaluation of 3 index cases led to the identification of 25 people with COVID-19 who interacted directly with the camp. Contact tracing revealed an additional 18 cases consistent with onward community transmission. Most (24 of 35, 68.5%) vaccine-eligible community cases were not vaccinated. We sequenced 8 positive specimens; all were identified as the Delta variant. Precamp planning incorporated local health officials who recommended wearing face masks, practicing social distancing, and using attendee cohorts to limit mixing of people involved in various activities. CONCLUSION: Low vaccination levels and poor face mask-wearing habits among attendees resulted in secondary and tertiary spread of SARS-CoV-2 and severe outcomes among young adults. This outbreak of COVID-19 at a youth camp highlights the importance of vaccination and use of other measures to interrupt opportunities for SARS-CoV-2 spread in the community and shows that vaccinated people remain vulnerable to infection when in an environment of high exposure to SARS-CoV-2. Proactive case identification and interruption of chains of transmission can help decrease the number of cases and avoid further severe outcomes.

Factors associated with delaying medical care: cross-sectional study of Nebraska adults.

BACKGROUND: Delayed medical care may result in adverse health outcomes and increased cost. Our purpose was to identify factors associated with delayed medical care in a primarily rural state. METHODS: Using a stratified random sample of 5,300 Nebraska households, we conducted a cross-sectional mailed survey with online response option (27 October 2020 to 8 March 2021) in English and Spanish. Multiple logistic regression models calculated adjusted odds ratios (aOR) and 95% confidence intervals. RESULTS: The overall response rate was 20.8% (n = 1,101). Approximately 37.8% of Nebraskans ever delayed healthcare (cost-related 29.7%, transportation-related 3.7%), with 22.7% delaying care in the past year (10.1% cost-related). Cost-related ever delay was associated with younger age [< 45 years aOR 6.17 (3.24-11.76); 45-64 years aOR 2.36 (1.29-4.32)], low- and middle-income [< $50,000 aOR 2.85 (1.32-6.11); $50,000-$74,999 aOR 3.06 (1.50-6.23)], and no health insurance [aOR 3.56 (1.21-10.49)]. Transportation delays were associated with being non-White [aOR 8.07 (1.54-42.20)], no bachelor's degree [≤ high school aOR 3.06 (1.02-9.18); some college aOR 4.16 (1.32-13.12)], and income < $50,000 [aOR 8.44 (2.18-32.63)]. Those who did not have a primary care provider were 80% less likely to have transportation delays [aOR 0.20 (0.05-0.80)]. CONCLUSIONS: Delayed care affects more than one-third of Nebraskans, primarily due to financial concerns, and impacting low- and middle-income families. Transportation-related delays are associated with more indicators of low socio-economic status. Policies targeting minorities and those with low- and middle-income, such as Medicaid expansion, would contribute to addressing disparities resulting from delayed care.

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.

Investigation of a SARS-CoV-2 B.1.1.529 (Omicron) Variant Cluster - Nebraska, November-December 2021.

The B.1.1.529 (Omicron) variant of SARS-CoV-2 (the virus that causes COVID-19) was first detected in specimens collected on November 11, 2021, in Botswana and on November 14 in South Africa;* the first confirmed case of Omicron in the United States was identified in California on December 1, 2021 (1). On November 29, the Nebraska Department of Health and Human Services was notified of six probable cases† of COVID-19 in one household, including one case in a man aged 48 years (the index patient) who had recently returned from Nigeria. Given the patient's travel history, Omicron infection was suspected. Specimens from all six persons in the household tested positive for SARS-CoV-2 by reverse transcription-polymerase chain reaction (RT-PCR) testing on December 1, and the following day genomic sequencing by the Nebraska Public Health Laboratory identified an identical Omicron genotype from each specimen (Figure). Phylogenetic analysis was conducted to determine if this cluster represented an independent introduction of Omicron into the United States, and a detailed epidemiologic investigation was conducted. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.§.

Quarantine Elimination for K-12 Students With Mask-on-Mask Exposure to SARS-CoV-2.

OBJECTIVES: With layered mitigation strategies, there are low rates of secondary transmission of severe acute respiratory syndrome coronavirus 2; therefore, quarantine after close-contact exposure to severe acute respiratory syndrome coronavirus 2 in the kindergarten through 12th grade (K-12) setting further disrupts in-person learning with uncertain benefit. We explored the impact of eliminating quarantine for students with mask-on-mask exposures to coronavirus disease 2019 (COVID-19) on associated secondary transmission in schools. METHODS: This observational study was conducted in a large K-12 public school district in Omaha, Nebraska (August 1, 2020, to March 15, 2021). We assessed primary and secondary COVID-19 infections in teachers and staff, frequency of quarantine for students and staff, and the impact of eliminating quarantine on secondary transmission in mask-on-mask exposure settings. RESULTS: A total of 18 632 and 19 604 students and 2855 staff attended in-person learning in the fall and spring semesters, respectively; 1856 primary infections were among students and staff. Despite 3947 student quarantines in the fall and 1689 student quarantines in the first 10 weeks of spring semester instruction, there were only 2 cases of secondary transmission. A local policy change removed quarantine requirements for students with mask-on-mask exposure to COVID-19. Required quarantines in the spring semester reduced by 41% per primary infection compared with the fall; no student who qualified to avoid quarantine developed a secondary infection. CONCLUSIONS: School-based COVID-19 transmission was exceptionally low in this large K-12 Nebraska school district. Elimination of student quarantine after masked exposure to COVID-19 within school was not associated with secondary transmission. Elimination of unnecessary quarantine elimination may help maximize in-person learning in the 2021-2022 school year.

A Conversation with Tonja Frank.

As most students return to in-person learning this fall, a school nurse discusses her experiences amid the ongoing COVID crisis.

Telehealth genetic services during the COVID-19 Pandemic: Implementation and patient experiences across multiple specialties in Nebraska.

The COVID-19 pandemic has altered the delivery of genetics services. In response to the pandemic, our genetics department offered telehealth visits to all outpatients, regardless of their physical proximity to Omaha, Nebraska. Traditionally, our department did not offer telehealth visits to patient's homes or to patients who lived in close proximity to a genetics clinic. Therefore, we designed a survey to gain insight into the patient experience with remote genetic counseling appointments during the pandemic. Any patient referred to see a genetics provider in pediatrics, prenatal, adult, or cancer between March 16, 2020 and October 28, 2020 was eligible for the study. The survey included both quantitative and qualitative measures to assess patient demographics, patient experience, stressors during the COVID-19 pandemic, and anxiety and depression. We hypothesized that patients would report they received quality care by telehealth despite the presence of COVID-19-related stressors or anxiety/depression. From the 143 survey participants, 80% had their first telehealth appointment during the pandemic. The vast majority (96%) reported that they felt like they received quality care by telehealth. Additionally, more than 93% of participants strongly or somewhat agreed that their genetic providers were attentive to their emotional needs, medical needs, and privacy. Since March 2020, participants reported experiencing several COVID-19-related stressors including fear of illness (86%), feelings of isolation (45%), and safety concerns (33%). Relatively low levels of depressive and anxiety symptoms were recorded using the HADS questionnaire. Despite the prevalence of COVID-19 stressors, depression, and/or anxiety, our participants felt they received quality care via telehealth. In fact, 51% agree that they prefer to receive future genetics services virtually. These results suggest the value of telehealth as an alternative service delivery model, even for local patients, and should be offered for future appointments, beyond the COVID-19 pandemic.

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.

Responding to a Pandemic: COVID-19 Projects in the Malone Center.

As the scope and scale of the COVID-19 pandemic became clear in early March of 2020, the faculty of the Malone Center engaged in several projects aimed at addressing both immediate and long-term implications of COVID-19. In this article, we briefly outline the processes that we engaged in to identify areas of need, the projects that emerged, and the results of those projects. As we write, some of these projects have reached a natural termination point, whereas others continue. We identify some of the factors that led to projects that moved to implementation, as well as factors that led projects to fail to progress or to be abandoned.

Utility of repeat testing for COVID-19: Laboratory stewardship when the stakes are high.

As the coronavirus disease 2019 (COVID-19) continues to circulate, testing strategies are of the utmost importance. Given national shortages of testing supplies, personal protective equipment, and other hospital resources, diagnostic stewardship is necessary to aid in resource management. We report the low utility of serial testing in a low-prevalence setting.

Characteristics of SARS-CoV-2 Transmission among Meat Processing Workers in Nebraska, USA, and Effectiveness of Risk Mitigation Measures.

The coronavirus disease (COVID-19) pandemic has severely impacted the meat processing industry in the United States. We sought to detail demographics and outcomes of severe acute respiratory syndrome coronavirus 2 infections among workers in Nebraska meat processing facilities and determine the effects of initiating universal mask policies and installing physical barriers at 13 meat processing facilities. During April 1-July 31, 2020, COVID-19 was diagnosed in 5,002 Nebraska meat processing workers (attack rate 19%). After initiating both universal masking and physical barrier interventions, 8/13 facilities showed a statistically significant reduction in COVID-19 incidence in <10 days. Characteristics and incidence of confirmed cases aligned with many nationwide trends becoming apparent during this pandemic: specifically, high attack rates among meat processing industry workers, disproportionately high risk of adverse outcomes among ethnic and racial minority groups and men, and effectiveness of using multiple prevention and control interventions to reduce disease transmission.

Social Support During COVID-19: Perspectives of Breastfeeding Mothers.

Introduction: Effective social support can have a critical influence on a mother's ability to initiate and continue breastfeeding. Coronavirus disease (COVID-19) has created unprecedented barriers for breastfeeding mothers to obtain various types of support: emotional, instrumental, informational, and appraisal. However, no research has evaluated the influence the pandemic has had on breastfeeding supports. The purpose of this study was to explore perceptions of social support among breastfeeding mothers during the COVID-19 pandemic. Materials and Methods: A cross-sectional phenomenological approach was taken utilizing semistructured interviews (March-June 2020) with currently breastfeeding mothers (n = 29). Data were analyzed through a process of immersion and crystallization. Results: Mothers are still able to obtain each type of support, however, support has been negatively influenced by the pandemic. Mothers reported experiencing increased stress and isolation and had an immense desire to receive in-person support from peers, family, childcare providers, and lactation specialists. Furthermore, mothers of multiple children felt if they did not already have breastfeeding knowledge from previous experiences they would be unsuccessful in breastfeeding due to their current lack of support. Conversely, a majority of mothers felt the pandemic had positively influenced their breastfeeding journeys due to concerns of formula shortages and extended maternity leaves. Finally, mothers were concerned about safely expressing breast milk on their return to work. Conclusion: Mother's ability to obtain breastfeeding support has been negatively impacted by the pandemic due to the inability to engage with individuals in-person and the lack of access to childcare. First-time mothers may be at higher risk of early breastfeeding cessation due to lack of support. However, breastfeeding journeys have also been positively influenced by allowing mothers more time at home with their child. Resources are needed to support expressing breast milk in the workplace during COVID-19.

The COVID-19 Response in Nebraska: How Students Answered the Call.

The Student Response Team at the University of Nebraska Medical Center answered the statewide call to assist local health departments during the coronavirus disease 2019 (COVID-19) pandemic. As a voluntary student-led effort, the SRT assisted health departments to conduct contact tracing, monitor social media, and educate the public. Their experience demonstrates how students can increase the public health surge capacity of local health departments while gaining applied experience during public health emergencies. This call-to-action commentary proposes that SRTs should be formed, trained, and deployed through academic institutions across the nation and the globe, during and beyond the current pandemic.

Airborne Transmission Route of COVID-19: Why 2 Meters/6 Feet of Inter-Personal Distance Could Not Be Enough.

The COVID-19 pandemic caused the shutdown of entire nations all over the world. In addition to mobility restrictions of people, the World Health Organization and the Governments have prescribed maintaining an inter-personal distance of 1.5 or 2 m (about 6 feet) from each other in order to minimize the risk of contagion through the droplets that we usually disseminate around us from nose and mouth. However, recently published studies support the hypothesis of virus transmission over a distance of 2 m from an infected person. Researchers have proved the higher aerosol and surface stability of SARS-COV-2 as compared with SARS-COV-1 (with the virus remaining viable and infectious in aerosol for hours) and that airborne transmission of SARS-CoV can occur besides close-distance contacts. Indeed, there is reasonable evidence about the possibility of SARS-COV-2 airborne transmission due to its persistence into aerosol droplets in a viable and infectious form. Based on the available knowledge and epidemiological observations, it is plausible that small particles containing the virus may diffuse in indoor environments covering distances up to 10 m from the emission sources, thus representing a kind of aerosol transmission. On-field studies carried out inside Wuhan Hospitals showed the presence of SARS-COV-2 RNA in air samples collected in the hospitals and also in the surroundings, leading to the conclusion that the airborne route has to be considered an important pathway for viral diffusion. Similar findings are reported in analyses concerning air samples collected at the Nebraska University Hospital. On March 16th, we have released a Position Paper emphasizing the airborne route as a possible additional factor for interpreting the anomalous COVID-19 outbreaks in northern Italy, ranked as one of the most polluted areas in Europe and characterized by high particulate matter (PM) concentrations. The available information on the SARS-COV-2 spreading supports the hypothesis of airborne diffusion of infected droplets from person to person at a distance greater than two meters (6 feet). The inter-personal distance of 2 m can be reasonably considered as an effective protection only if everybody wears face masks in daily life activities.