A Framework for Response Escalation and Emergency Response Asset Management.

The Centers for Disease Control and Prevention (CDC) responds to public health emergencies at various levels within its organization. Overtime, CDC's response capabilities have matured across the organization due to years of emergency management investment and experience across the agency. In 2019, CDC began to implement the Graduated Response Framework to formalize an approach for managing public health emergencies that recognizes its response capabilities and meets the evolving needs of the country. This brief report summarizes CDC's Graduated Response Framework structure, and how response management escalates and de-escalates according to resource needs and complexity.

U.S. Preparedness and Response to Increasing Clade I Mpox Cases in the Democratic Republic of the Congo - United States, 2024.

Clade I monkeypox virus (MPXV), which can cause severe illness in more people than clade II MPXVs, is endemic in the Democratic Republic of the Congo (DRC), but the country has experienced an increase in suspected cases during 2023-2024. In light of the 2022 global outbreak of clade II mpox, the increase in suspected clade I cases in DRC raises concerns that the virus could spread to other countries and underscores the importance of coordinated, urgent global action to support DRC's efforts to contain the virus. To date, no cases of clade I mpox have been detected outside of countries in Central Africa where the virus is endemic. CDC and other partners are working to support DRC's response. In addition, CDC is enhancing U.S. preparedness by raising awareness, strengthening surveillance, expanding diagnostic testing capacity for clade I MPXV, ensuring appropriate specimen handling and waste management, emphasizing the importance of appropriate medical treatment, and communicating guidance on the recommended contact tracing, containment, behavior modification, and vaccination strategies.

The cardinal rules: Principles of personal protective equipment for high-consequence infectious disease events.

In recognition of an increasing number of high-consequence infectious disease events, a group of subject-matter experts identified core safety principles that can be applied across all donning and doffing protocols for personal protective equipment.

COVID-19 Response Roles among CDC International Public Health Emergency Management Fellowship Graduates.

Since 2013, the US Centers for Disease Control and Prevention has offered the Public Health Emergency Management Fellowship to health professionals from around the world. The goal of this program is to build an international workforce to establish public health emergency management programs and operations centers in participating countries. In March 2021, all 141 graduates of the fellowship program were invited to complete a web survey designed to examine their job roles and functions, assess their contributions to their country's COVID-19 response, and identify needs for technical assistance to strengthen national preparedness and response systems. Of 141 fellows, 89 successfully completed the survey. Findings showed that fellowship graduates served key roles in COVID-19 response in many countries, used skills they gained from the fellowship, and desired continuing engagement between the Centers for Disease Control and Prevention and fellowship alumni to strengthen the community of practice for international public health emergency management.

Prioritizing homelessness in emergency medicine education: A concept paper.

Patients experiencing homelessness visit the emergency department (ED) often and have worse clinical outcomes. Caring for this patient population is complex, challenging, and resource-intensive. Emergency medicine (EM) education is lacking in formal curricula on the topic of homelessness, despite benefits for resident morale and patient care. Our goals were to identify a gap in EM education and training of the intersection of housing and health and propose educational topics and teaching methods to be included in residency curricula. Methodology was based on the development of a didactic session at the 2021 SAEM Annual Meeting. A needs assessment was performed through a review of medical education literature, a national survey of EM residency curricula, the individual curricula utilized by respective team members, and perspective from the team's own individual experiences with teaching about homelessness. Topics presented were chosen through discussion between the authors and determined to be common and relevant and cover a broad spectrum of content. The four presented topics included the intersection of COVID-19 and housing, the impact of LGBTQIA+ status on homelessness, housing status related to health system utilization and health outcomes, and housing inequity as a means of perpetuating structural racism. Suggestions for education of these topics included case-based learning, journal clubs, simulation, collaboration with social work, quality improvement projects, and engagement with community leaders. The ED is uniquely positioned to encounter the impacts of homelessness on health. Emergency physicians should be prepared to effectively care for these patients with complex social needs. Structured learning on this topic would benefit EM resident growth and lead to better patient care through improved screening, recognition of risk factors, and use of social resources.

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.

Covert Brain Infarction in Emergency Department Patients: Prevalence, Clinical Correlates, and Treatment Opportunities.

STUDY OBJECTIVE: Covert brain infarctions are focal lesions detected on brain imaging consistent with ischemia in the absence of a history of overt stroke or neurologic dysfunction. Covert brain infarctions are associated with an increased risk of future stroke. We evaluated the prevalence of covert brain infarctions in patients undergoing computed tomography (CT) in the emergency department (ED), as well as clinician response to the findings. METHODS: Patients aged more than 50 years who underwent CT of the head and were seen and discharged from our ED from January to September 2018 were identified. Patients with a history of stroke, or prior brain imaging with ischemia, were excluded. Patient data and clinician response (patient notification, neurology referral, and risk factor modification) were collected. RESULTS: We included 832 patients, with an average age of 62 years, and 50% of the patients were women. Covert brain infarctions were present in 11% of patients (n=95). Only 9% of patients with covert brain infarctions were clearly made aware of the finding. Of the patients with covert brain infarctions, 27% were already on aspirin and 28% on a statin. Aspirin was added for 2 patients, and statin medication was not started on any patient. The blood pressure medication was added or adjusted for 2 patients with covert brain infarctions. The neurology department was consulted for 9% of the patients with covert brain infarctions. CONCLUSION: The prevalence of covert brain infarctions in patients older than 50 years presenting to the ED who underwent CT of the head and were subsequently discharged from the ED was 11%. Only 9% of these patients were made aware of the finding, with minimal intervention for stroke prevention at the time of their visit. Interventions targeting this population should be considered.

A Survey of COVID-19 Preparedness Among Hospitals in Idaho.

BACKGROUND: SARS-CoV-2 has been implicated in the largest recorded coronavirus outbreak to date. Initially, most COVID-19 cases were in China, but the virus has spread to more than 184 countries worldwide, and the United States currently has more cases than any other country. OBJECTIVE: With person-to-person spread expanding in the United States, we describe hospital preparedness for managing suspected and confirmed COVID-19 patients. DESIGN: Cross-sectional survey focused on various elements of respiratory disease preparedness. SETTING: Critical access hospitals (CAHs) and acute-care hospitals (ACHs) in Idaho. METHODS: The electronic survey was sent to infection preventionists (IPs) and nurse administrators in 44 hospitals in Idaho. RESULTS: Overall, 32 (73%) hospitals responded to the survey. Participating facilities reported their preparedness with respect to existing, formalized structures for managing infectious disease incidents-specifically COVID-19-as well as availability of resources, such as isolation rooms and personal protective equipment, for safely managing suspected and confirmed COVID-19 cases. CONCLUSIONS: Hospitals covered by the survey had varying levels of preparedness for managing COVID-19 cases, with differences across the various categories of interest in this study. Although the study reveals strengths, including in application of emergency management and infection control frameworks, it also suggests that other areas, such as consistent implementation of federal guidelines and requirements for infection prevention, are potential areas for strengthening preparedness for SARS-CoV-2 and other respiratory pathogens with pandemic potential.

A cross-sectional survey of measles preparedness in critical-access hospitals of Idaho.

BACKGROUND: Patients with measles can precipitate outbreaks in health care facilities where they seek care. Rural critical-access hospitals (CAHs) may be at higher risk of outbreaks given their size and potentially limited infection prevention resources. METHODS: We surveyed CAHs in Idaho to ascertain their levels of preparedness for managing measles cases. A 25-item questionnaire was sent to infection preventionists at all 27 Idaho CAHs. The questionnaire covered organizational structure, resources for managing measles cases, and hospital policies for ensuring immunity among health care workers. RESULTS: A total of 22 (82%) CAHs responded, reporting varying availability of facilities and resources for managing measles cases and disparate procedures for testing clinical samples and providing vaccines to nonimmune, exposed staff. DISCUSSION: With measles incidence on the rise in the United States, our survey found that most of the responding hospitals had the basic organizational structure for facility-wide prevention and management efforts in case a patient with suspected or confirmed measles presented to that facility. Most of the hospitals also had at least some available resources to manage measles cases, as well as policies for ensuring immunity to measles among at least some groups of health care workers. CONCLUSIONS: This study provides initial perspectives on measles preparedness among Idaho CAHs, despite limited generalizability. Future studies should explore whether self-reported preparedness measures reflect the ability of the CAHs to control measles spread when cases present for care.

Developing a Personal Protective Equipment Selection Matrix for Preventing Occupational Exposure to Ebola Virus.

In response to the 2014 Ebola outbreak in West Africa and resulting cases in the United States, the Occupational Safety and Health Administration developed a personal protective equipment selection matrix to help employers protect workers from exposure to Ebola virus in the event of additional US cases. Now, the world's second largest Ebola outbreak on record continues to expand in the Democratic Republic of Congo, where more than 70 Ebola-infected healthcare workers serve as reminders of the importance of robust infection prevention measures in keeping infectious disease responders from becoming victims themselves. Toward facilitating preparedness for cases associated with the ongoing or future outbreaks, this article discusses the matrix of personal protective equipment recommendations. The matrix applies to a variety of job tasks in health care, laboratories, waste handling, janitorial services, travel and transportation, and other sectors where workers may be exposed to the Ebola virus during outbreak events. A discussion of the information sources and decision-making process for developing the matrix forms the basis of the recommendations. The article then emphasizes challenges and considerations for formulating the matrix, including identifying information sources to help characterize occupational exposures, aligning recommendations among stakeholders with varying viewpoints, and balancing worker protections with feasibility concerns. These considerations highlight issues that remain relevant for preparedness efforts ahead of future US cases of Ebola or other emerging infectious diseases.

Respiratory Protection Against Emerging Infectious Diseases: Face Masks, Respirators, and Tools for Choosing Between Them.

The scientific literature reflects considerable debate over which types of respiratory protective devices (RPDs) are appropriate for protecting workers against exposure to infectious bioaerosols, including during outbreaks of emerging diseases. Some evidence suggests that face masks may offer similar protection to respirators, while other studies have found marked disparities in the protectiveness of these types of devices. Previous reviews have called for more information, chiefly in the form of clinical trials, to better inform decision making about RPDs. However, alternative approaches to respirator selection, including control banding tools that match groups of similar hazards to appropriate control measures, may be useful in choosing RPDs for workers with potential bioaerosol exposures on the job. These tools, while offering more streamlined approaches to RPD selection, come with challenges of their own, including questions about how to allocate different RPDs to different workers. This article reviews arguments on both sides of the face mask-respirator divide and considers the use of control banding tools in the context of preparedness for serious emerging infectious disease outbreaks.

Zika virus in workers: Considerations for ongoing exposure prevention.

Since at least 2015, a major Zika virus epidemic has impacted the Americas and the Caribbean. There is an ongoing risk of Aedes mosquito-borne transmission in more than 90 countries and territories worldwide. In these areas, as well as in places that are not experiencing active outbreaks, workers in a variety of jobs may be exposed to the virus. In addition to outdoor workers in places with ongoing, vector-borne transmission who may be exposed when bitten by Zika-infected mosquitoes, biomedical researchers studying the virus and health care workers and staff in clinical laboratories may encounter blood and infectious body fluids from infected individuals, including travelers from Zika virus-affected areas. Because of potentially serious health outcomes, including reproductive effects, sometimes associated with Zika, the Occupational Safety and Health Administration and National Institute for Occupational Safety and Health previously issued guidance to help US employers protect workers from exposure to the virus on the job. This commentary summarizes the details of these recommendations and explains their rationale, which is important to understand when adapting and implementing workplace controls to prevent occupational Zika virus exposures and infections at individual worksites. The industrial hygiene hierarchy of controls, including elimination and substitution, engineering controls, administrative controls, and safe work practices, and personal protective equipment, serves as a framework for infection prevention practices for at-risk workers discussed here.

Boryl-functionalized σ-alkynyl and vinylidene rhodium complexes: synthesis and electronic properties.

The synthesis, reactivity, and properties of boryl-functionalized σ-alkynyl and vinylidene rhodium complexes such as trans-[RhCl(=C=CHBMes2)(PiPr3)2] and trans-[Rh(C≡CBMes2)(IMe)(PiPr3)2] are reported. An equilibrium was found to exist between rhodium vinylidene complexes and the corresponding hydrido σ-alkynyl complexes in solution. The complex trans-[Rh(C≡CBMes2)(IMe)(PiPr3)2] (IMe=1,3-dimethylimidazol-2-ylidene) was found to exhibit solvatochromism and can be quasireversibly oxidized and reduced electrochemically. Density functional calculations were performed to determine the reaction mechanism and to help rationalize the photophysical properties of trans-[Rh(C≡CBMes2)(IMe)(PiPr3)2].

Diverse reactions of N-heterocyclic carbenes with an alkynylborane and isolation of a reactive zwitterionic borataallene.

Ethynyldimesitylborane (1) is synthesised via salt elimination and its reactivity towards NHCs is studied. Depending on their size, NHCs attack either at the boron atom or at the ß-alkynyl carbon atom. Steric control over the reaction was probed by reactions with N-heterocyclic carbenes yielding a carbene-borane adduct (2), a 1-boraindane (3), and the first structurally characterised borataallene (4).

Voluntary STD testing and treatment program at a metropolitan correctional facility: evaluation of test acceptability and associated risk factors.

Few studies have addressed challenges of diagnosis and treatment of sexually transmitted diseases (STDs) within correctional facilities. Initiatives that screen all inmates can be cost-prohibitive, while symptom-based screening undoubtedly fails to recognize significant numbers of asymptomatically infected persons. This study discusses a voluntary STD screening and treatment program developed at the Douglas County (Nebraska) Department of Corrections where student volunteers interviewed, screened, and educated 456 inmates. Inmate urine samples and interview responses about risk behaviors and motivators for participation in the screening program were analyzed. The results support the ongoing project method to screen and treat inmates in the community correctional facility. Risk factor analysis suggests that targeted testing and treatment efforts may have a role in providing cost-effective care for STD among the incarcerated population.

Effect of radiotherapy techniques (IMRT vs. 3D-CRT) on outcome in patients with intermediate-risk rhabdomyosarcoma enrolled in COG D9803--a report from the Children's Oncology Group.

PURPOSE: To compare the dosimetric parameters of intensity-modulated radiotherapy (IMRT) and three-dimensional conformal radiotherapy (3D-CRT) in patients with intermediate-risk rhabdomyosarcoma and to analyze their effect on locoregional control and failure-free survival (FFS). METHODS AND MATERIALS: The study population consisted of 375 patients enrolled in the Children's Oncology Group protocol D9803 study, receiving IMRT or 3D-CRT. Dosimetric data were collected from 179 patients with an available composite plan. The chi-square test or Fisher's exact test was used to compare the patient characteristics and radiotherapy parameters between the two groups. The interval-to-event outcomes were estimated using the Kaplan-Meier method and compared using log-rank tests. Cox proportional hazards regression analysis was used to examine the effect of the treatment technique on FFS after adjusting for primary site and risk group. RESULTS: The median follow-up time was 5.7 and 4.2 years for patients receiving 3D-CRT and IMRT, respectively. No differences in the 5-year failure of locoregional control (18% vs. 15%) or FFS (72% vs. 76%) rates were noted between the two groups. Multivariate analysis revealed no association between the two techniques and FFS. Patients with primary tumors in parameningeal sites were more likely to receive IMRT than 3D-CRT. IMRT became more common during the later years of the study. Patients receiving IMRT were more likely to receive >50 Gy, photon energy of ≤6 MV, and >5 radiation fields than those who received 3D-CRT. The coverage of the IMRT planning target volume by the prescription dose was improved compared with the coverage using 3D-CRT with similar target dose heterogeneity. CONCLUSIONS: IMRT improved the target dose coverage compared with 3D-CRT, although an improvement in locoregional control or FFS could not be demonstrated in this population. Future studies comparing the integral dose to nontarget tissue and late radiation toxicity between the two groups are warranted.

Differential habitat use and niche partitioning by Pseudomonas species in human homes.

Many species of Pseudomonas have the ability to use a variety of resources and habitats, and as a result Pseudomonas are often characterized as having broad fundamental niches. We questioned whether actual habitat use by Pseudomonas species is equally broad. To do this, we sampled extensively to describe the biogeography of Pseudomonas within the human home, which presents a wide variety of habitats for microbes that live in close proximity to humans but are not part of the human flora, and for microbes that are opportunistic pathogens, such as Pseudomonas aeruginosa. From 960 samples taken in 20 homes, we obtained 163 Pseudomonas isolates. The most prevalent based on identification using the SepsiTest BLAST analysis of 16S rRNA (http://www.sepsitest-blast.de) were Pseudomonas monteilii (42 isolates), Pseudomonas plecoglossicida, Pseudomonas fulva, and P. aeruginosa (approximately 25 each). Of these, all but P. fulva differed in recovery rates among evaluated habitat types (drains, soils, water, internal vertebrate sites, vertebrate skin, inanimate surfaces, and garbage/compost) and all four species also differed in recovery rates among subcategories of habitat types (e.g., types of soils or drains). We also found that at both levels of habitat resolution, each of these six most common species (the four above plus Pseudomonas putida and Pseudomonas oryzihabitans) were over- or under-represented in some habitats relative to their contributions to the total Pseudomonas collected across all habitats. This pattern is consistent with niche partitioning. These results suggest that, whereas Pseudomonas are often characterized as generalists with broad fundamental niches, these species in fact have more restricted realized niches. Furthermore, niche partitioning driven by competition among Pseudomonas species may be contributing to the observed variability in habitat use by Pseudomonas in this system.