Stockpiling supplies for the next influenza pandemic

Face masks to fight against COVID-19 pandemics: A comprehensive review of materials, design, technology and product development

The outbreak of COVID-19 has created renewed attention on research and large scale manufacturing of face masks. In the last two decades, usage of face masks for respiratory protection has gained increased importance as a measure to control the maladies and fatalities due to exposure to particulate pollutants and toxic pathogens. Numerous variants of surgical and high-performance respirator masks are available in the market, and yet the fibrous materials science researchers, manufacturers and public health agencies are making concerted efforts towards improvising them with respect to self-sterilisability, facial fit, thermo-physiological comfort, reusability and biodegradability, while maintaining or rather enhancing the filtration efficiency. This review article presents a compendium of materials, design and performance standards of existing face masks, as well as elaborates on developments made for their performance enhancement. The criticality of inculcation of good hygiene habits and earnest compliance to correct mask donning and doffing practices has also been highlighted. This review is expected to make valuable contributions in the present COVID-19 scenario when donning a face mask has become mandatory.

3D-Printed Microfluidics Potential in Combating Future and Current Pandemics (COVID-19)

Coronavirus disease (COVID-19) emerged in China in December 2019. In March 2020, the WHO declared it a pandemic leading to worldwide lockdowns and travel restrictions. By May, it infected 4,789,205 and killed 318,789 people. This led to severe shortages in the medical sector besides devastating socio-economic effects. Many technologies such as artificial intelligence (AI), virtual reality (VR), microfluidics, 3D printing, and 3D scanning can step into contain the virus and hinder its extensive spread. This article aims to explore the potentials of 3D printing and microfluidic in accelerating the diagnosis and monitoring of the disease and fulfilling the shortages of personal protective equipment (PPE) and medical equipment. It highlights the main applications of 3D printers and microfluidics in providing PPE (masks, respirators, face shields, goggles, and isolation chambers/hoods), supportive care (respiratory equipment) and diagnostic supplies (sampling swabs & lab-on-chip) to ease the COVID-19 pressures. Also, the cost of such technology and regulation considerations are addressed. We conclude that 3D printing provided reusable and low-cost solutions to mitigate the shortages. However, safety, sterility, and compatibility with environmental protection standards need to be guaranteed through standardization and assessment by regulatory bodies. Finally, lessons learned from this pandemic can also help the world prepare for upcoming outbreaks.

Availability of personal protective equipment and infection prevention supplies during the first month of the COVID-19 pandemic: A national study by the APIC COVID-19 task force

Background

SARS-CoV-2, the virus that causes COVID-19 disease was first discovered in China in December, 2019. The disease quickly spread globally, with the first US case identified in January, 2020; it was declared a pandemic on March 11, 2020. Soon after, anecdotal reports indicated that many US hospitals and healthcare facilities were running low on personal protective equipment (PPE) and supplies.

Methods

An online survey was administered to all Association for Professionals in Infection Control and Epidemiology members in March, 2020 to assess access to PPE, hand hygiene products, and disinfection supplies.

Results

In all, 1,201 infection preventionists participated. Participants reported running a bit low to almost being out of all PPE types. More had sufficient gloves (63.4%) compared to all other PPE types (P < .001 for all). Face shields and N95 respirators were the least available (13.6% and 18.2% had sufficient supplies, respectively; p < .001 for all). Many (66.9%) had sufficient hand soap, but far fewer had sufficient hand sanitizer (29.5%, X² = 211.1, P < .001). Less than half (45.4%, n = 545) had sufficient disinfection supplies.

Conclusions

Many US healthcare facilities had very low amounts of PPE, hand hygiene products, and disinfection supplies early on during the pandemic. A lack of these supplies can lead to occupational exposures and illness as well as healthcare-associated transmission of COVID-19 and other diseases.

Developing a methodology to collect empirical data that informs policy and practices for stockpiling personal protective equipment

BACKGROUND

Personal protective equipment (PPE) are stockpiled across the nation to offset supply depletion during public health emergencies. Stockpiled PPE inventories vary across the United States by type, model, quantity, and the conditions in which they are stored. Over the past decade, federal, state, and local stockpile managers have had concerns for the viability of aging PPE.

METHODS

To understand factors that may affect stockpiled PPE, we explored the breadth of stockpile storage conditions and respirator and surgical gown inventories through collaboration with the national PPE community, qualitative observations collected at 10 different US stockpiles, and by compiling stockpile PPE inventories and climate data from a convenience sample of US stockpiles.

RESULTS

The aggregated inventory from 20 stockpiles is reported, accounting for approximately 53 million respirators. Most respirators (69% or 35.8 million) have been stored between 5 and 10 years. Upon visiting 10 stockpile facilities, we report on the storage conditions observed and summarize the storage environment data collected.

CONCLUSIONS

This is the first study to identify common PPE types, inventories, and storage conditions across federal, state, and local government stockpile facilities as well as health care organization-managed caches. These findings will be leveraged to guide the development of sampling protocols for air-purifying respirators and surgical gowns in US stockpiles to understand the performance viability after long-term storage.

Zero tolerance for complacency by government of West African countries in the face of COVID-19

A novel Coronavirus (SARS-CoV-2) causing a cluster of respiratory infections (Coronavirus Disease 2019, COVID-19) first discovered in Wuhan, China, is responsible for a new illness that has been found to affect the lungs and airways of patients with associated symptoms of fever, cough and shortness of breath. In the light of few cases recorded so far in West Africa there is tendency for complacency. The region needs to make strategic plans based on available evidence to enable them effectively deal with this rapidly evolving pandemic. At this very moment countries like China, Italy, France, Spain, Iran, UK and many others are witnessing sustained and intensive community transmission of this virus and increasing numbers of severe disease and death particularly among elderly patients with other comorbidities. The reality of the seriousness of this pandemic is alarming. Government of member states of ECOWAS need to prepare themselves by building capacity as well as implement evidenced-based steps to mitigate this rapidly evolving pandemic by testing persons presenting with symptoms (fever, cough and shortness of breath), isolating and treating those found positive, tracing and quarantining contacts, implementing social distancing as well as optimizing human and material endowment to allow healthcare workers offer safe quality clinical care for affected patients to prevent secondary infection among healthcare workers.

Elastomeric Half Mask Respirators: An Alternative to Disposable Respirators and a Solution to Shortages during Public Health Emergencies

During public health emergencies such as an influenza pandemic, disposable filtering facepiece respirator (FFR) shortages have a significant impact on the national response, affecting many types of workplaces that rely on respiratory protection. During the COVID-19 pandemic, severe FFR shortages led the CDC to publish strategies for optimizing the supply of N95 FFRs. These strategies included the extended use and limited reuse of FFRs, wearing decontaminated FFRs, wearing respirators that meet an international respirator standard, or wearing FFRs that were past their manufacturer-designated shelf life. An additional strategy to mitigate supply shortages that was highlighted during the COVID-19 pandemic was to wear reusable respirators, such as elastomeric half mask respirators (EHMRs), or powered air-purifying respirators, which can be cleaned, disinfected, and reused. A decade of nationwide initiatives to increase the utility of EHMRs in healthcare settings were realized during the COVID-19 pandemic as EHMRs became more well-known and were used in healthcare settings for respiratory protection. This expanded use of EHMRs led to an increase in federal procurement, research, guidance, and private sector research and development of innovative EHMR designs by manufacturers to respond to workers' needs for both respiratory protection and source control. This paper describes the role of reusable EHMRs before and during the COVID-19 pandemic, and reviews past and current research, to inform successful EHMR implementation in healthcare and first responder settings.

Maintaining efficient logistics and supply chain management operations during and after coronavirus (COVID-19) pandemic: learning from the past experiences

The outbreak of the novel coronavirus (COVID-19) forced the governing bodies across the world to ban all kinds of travel involving the movement of people. However, the policymakers have been working hard to mobilize the movement of essential goods and services considering its importance in containing the pandemic. It signifies how important the establishment and maintenance of logistics and supply chain management (LSCM) operations are, both during the containment and the successive periods. Motivated with the paramount importance of LSCM operations during the rapid spread of the novel coronavirus (COVID-19) across the globe, this paper critically reviews the existing literature closely related to it. The main aim is to identify and enhance the understanding of the logistical characteristics that play a vital role during pandemics. The selection of the literature was done using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) methodology. The classification of the selected literature was done using a tripartite framework. Results show that researchers have focused mostly on "Post-event" (48.24%) management of logistical operations followed by the "Pre-event" (31.76%) and least in the "Integrated" (20%.) approaches. Furthermore, the analysis of the results provided useful insights that are discussed in detail. Also, twelve key areas have been identified that need due attention to improve the overall efficiency of the LSCM operations. We believe that the findings from this paper would be useful to the decision-makers and other stakeholders, as far as, maintaining efficient LSCM operations during as well after the pandemics are concerned.

Emergency Medical Services Personnel's Pandemic Influenza Training Received and Willingness to Work during a Future Pandemic

Objective: Identify determinants of emergency medical service (EMS) personnel's willingness to work during an influenza pandemic. Background: Little is known about the willingness of EMS personnel to work during a future influenza pandemic or the extent to which they are receiving pandemic training. Methods: EMS personnel were surveyed in July 2018 - Feb 2019 using a cross-sectional approach; the survey was available both electronically and on paper. Participants were provided a pandemic scenario and asked about their willingness to respond if requested or required; additional questions assessed their attitudes and beliefs and training received. Chi-square tests assessed differences in attitude/belief questions by willingness to work. Logistic regressions were used to identify significant predictors of response willingness when requested or required, controlling for gender and race. Results: 433 individuals completed the survey (response rate = 82.9%). A quarter (26.8%, n = 116) received no pandemic training; 14.3% (n = 62) participated in a pandemic exercise. Significantly more EMS personnel were willing to work when required versus when only requested (88.2% vs 76.9%, X2 = 164.1, p < .001). Predictors of willingness to work when requested included believing it is their responsibility to work, believing their coworkers were likely to work, receiving prophylaxis for themselves and their family members, and feeling safe working during a pandemic. Discussion: Many emergency medical services personnel report lacking training or disaster exercises related to influenza pandemics, and a fair percentage are unwilling to work during a future event. This may limit healthcare surge capacity and could contribute to increased morbidity and mortality. Findings from this study indicate that prehospital staff's attitudes and beliefs about pandemics influence their willingness to work. Pre-event training and planning should address these concerns.

Distributed Manufacturing of Open Source Medical Hardware for Pandemics

Distributed digital manufacturing offers a solution to medical supply and technology shortages during pandemics. To prepare for the next pandemic, this study reviews the state-of-the-art of open hardware designs needed in a COVID-19-like pandemic. It evaluates the readiness of the top twenty technologies requested by the Government of India. The results show that the majority of the actual medical products have some open source development, however, only 15% of the supporting technologies required to produce them are freely available. The results show there is still considerable research needed to provide open source paths for the development of all the medical hardware needed during pandemics. Five core areas of future research are discussed, which include (i) technical development of a wide-range of open source solutions for all medical supplies and devices, (ii) policies that protect the productivity of laboratories, makerspaces, and fabrication facilities during a pandemic, as well as (iii) streamlining the regulatory process, (iv) developing Good-Samaritan laws to protect makers and designers of open medical hardware, as well as to compel those with knowledge that will save lives to share it, and (v) requiring all citizen-funded research to be released with free and open source licenses.

Quality Assurance Sampling Plans in US Stockpiles for Personal Protective Equipment: A Computer Simulation to Examine Degradation Rates

Medical countermeasure stockpiles in the United States are designed to support healthcare workers and the public during public health emergencies; they include supplies of personal protective equipment (PPE). As part of typical PPE manufacturing processes, appropriate test methods are used to ensure that the devices provide adequate protective performance. At the time of manufacture, performance is often measured and weighed against an objective standard of quality, resulting in a pass or fail attribute being assigned to individual PPE items and thence to production lots. Incorporating periodic performance testing for stockpiled PPE can ensure that they maintain their protective qualities and integrity over time while in storage. There is an absence of guidance regarding how to design quality assurance programs for stockpiled PPE. The applicability of the Lot Quality Assurance Sampling (LQAS) approach to stockpiled PPE was examined in a previous study that compared and contrasted different sample sizes in recovering the true percentage of defective units in large lots in the LQAS framework. The current study carries this line of inquiry forward by integrating PPE degradation over time and comparing different sampling time intervals in recovering the true underlying degradation rate. The results suggest that product degradation is more easily detected when tested at shorter time intervals and for higher degradation rates. They further suggest that sampling interval groupings can be made based on the proficiency with which they recover the true underlying degradation rate.

A General Framework to Test and Evaluate Filtering Facepiece Respirators Considered for Crisis Capacity Use as a Strategy to Optimize Supply

During a public health emergency, respirator shortages can have a profound impact on the national response, such as for the current coronavirus disease 2019 (COVID-19) pandemic. Due to a severe shortage of respirators (particularly filtering facepiece respirators [FFRs]), there may be contexts in which understanding the performance of FFRs that are approved for use as part of a crisis capacity strategy is desired. This includes FFRs that are not covered under the National Institute for Occupational Safety and Health (NIOSH) Respirator Approval Program because they have been stored past their designated shelf life, have been decontaminated, or are approved by international certification bodies other than NIOSH. The purpose of this document is to provide a general framework to assess the performance of FFRs that are only being used as a crisis capacity strategy. The intended audience are those who are responsible for managing large amounts of FFRs. This framework includes a four-step process consisting of: 1) defining the population of FFRs to be sampled; 2) providing sampling strategy options; 3) inspecting and testing the sampled units; and 4) evaluating the results. In addition to the four-step process, we provide an example of how NIOSH recently evaluated the quality of FFRs sampled from ten U.S. stockpiles.

Quality Assurance Sampling Plans in US Stockpiles for Personal Protective Equipment

Personal protective equipment (PPE) stockpiles in the United States were established to facilitate rapid deployment of medical assets to sites affected by public health emergencies. Large quantities of PPE were introduced into US stockpiles because of the need to protect healthcare and other professionals during these events. Because most stockpiled PPE was acquired during, or immediately following, large-scale public health events, such as pandemic influenza planning (2005-20080), SARS (2003), H1N1 (2009-10), and Ebola (2014-15), aging PPE poses a significant problem. PPE such as N95 filtering face piece respirators were not designed to be stored for long periods, and much of the currently stored PPE has exceeded its manufacturer-assigned shelf life. Given the significant investment in the procurement and storage of PPE, along with projections of consumption during public health emergencies, discarding large quantities of potentially viable PPE is not an attractive option. Although shelf-life extension programs exist for other stockpiled medical assets, no such option is currently available for stockpiled PPE. This article posits stockpile quality assurance sampling plans as a mechanism through which shelf-life extension programs for stockpiled PPE may be achieved. We discuss some of the nuances that should be considered when developing a plan tailored to stockpiles and provide basic decision tools that may be used in the context of a quality assurance program tailored to stockpiled PPE. We also explore basic information by comparing and contrasting different sample size options.

A tolerability assessment of new respiratory protective devices developed for health care personnel: A randomized simulated clinical study

BACKGROUND

U.S. health care personnel (HCP) have reported that some respiratory protective devices (RPD) commonly used in health care have suboptimal tolerability. Between 2012 and 2016, the U.S. National Institute for Occupational Safety and Health, and the Veterans Health Administration collaborated with two respirator manufacturers, Company A and B, to bring new RPD with improved tolerability to the U.S. health care marketplace. The purpose of this study was to compare the tolerability of four new prototype RPD to two models commonly used in U.S. health care delivery.

METHODS

A randomized, simulated workplace study was conducted to compare self-reported tolerability of four new prototype RPD (A1, A2, B1, and B2) worn by HCP and two N95 control respirators commonly used in U.S. health care delivery, the 1870 and 1860, manufactured by 3M Corporation. A new survey tool, the Respirator Comfort, Wearing Experience, and Function Instrument (R-COMFI), developed previously in part for the current study, was used as the primary outcome metric. With a maximum total score of 47, lower R-COMFI scores reflected better self-reported tolerability. Poisson regression analyses were used to estimate prototype relative risks compared to controls.

RESULTS

Conducted between 2014 and 2015 in two inpatient care rooms at the North Florida/South Georgia Veterans Health System, among 383 participants who enrolled, 335 (87.5%) completed the study. Mean total R-COMFI scores for the 3M 1870, 3M 1860, and prototypes A1, A2, B1, and B2 were 8.26, 9.36, 5.79, 7.70, 6.09, and 5.71, respectively. Compared to the 3M 1870, total R-COMFI unadjusted relative risks (RR) and 95 percent confidence intervals (CI) were A1 (RR 0.70, CI 0.60, 0.82), A2 (RR 0.93, CI 0.82, 1.06), B1 (RR 0.74, CI 0.64, 0.85), and B2 (RR 0.69, CI 0.60, 0.80). Compared to the 3M 1860, prototype total R-COMFI unadjusted RR and 95 percent CI were A1 (RR 0.62, CI 0.53, 0.72), A2 (RR 0.82, CI 0.73, 0.93), B1 (RR 0.65, CI 0.57, 0.74), and B2 (RR 0.61, CI 0.53, 0.70). Similarly, models adjusted for demographic characteristics showed that prototypes A1, B1, and B2 significantly improved tolerability scores compared to both controls, while prototype A2 was significantly improved compared to the 3M 1860.

CONCLUSIONS

Compared to the 3M 1870 and 3M 1860, two RPDs commonly used in U.S. health care delivery, tolerability improved for three of four newly developed prototypes in this simulated workplace study. The R-COMFI tool, used in this study to assess tolerability, should be useful for future comparative studies of RPD.

Ultraviolet germicidal irradiation of influenza-contaminated N95 filtering facepiece respirators

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Ultraviolet light can significantly reduce viable influenza on N95 respirators.

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Ultraviolet decontamination of N95 respirators can vary between models.

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Straps of N95 respirators are challenging to decontaminate using ultraviolet light.

Background

Safe and effective decontamination and reuse of N95 filtering facepiece respirators (FFRs) has the potential to significantly extend FFR holdings, mitigating a potential shortage due to an influenza pandemic or other pandemic events. Ultraviolet germicidal irradiation (UVGI) has been shown to be effective for decontaminating influenza-contaminated FFRs. This study aims to build on past research by evaluating the UVGI decontamination efficiency of influenza-contaminated FFRs in the presence of soiling agents using an optimized UVGI dose.

Methods

Twelve samples each of 15 N95 FFR models were contaminated with H1N1 influenza (facepiece and strap), then covered with a soiling agent—artificial saliva or artificial skin oil. For each soiling agent, 3 contaminated FFRs were treated with 1 J/cm² UVGI for approximately 1 minute, whereas 3 other contaminated FFRs remained untreated. All contaminated surfaces were cut out and virus extracted. Viable influenza was quantified using a median tissue culture infectious dose assay.

Results

Significant reductions (≥3 log) in influenza viability for both soiling conditions were observed on facepieces from 12 of 15 FFR models and straps from 7 of 15 FFR models.

Conclusions

These data suggest that FFR decontamination and reuse using UVGI can be effective. Implementation of a UVGI method will require careful consideration of FFR model, material type, and design.

Findings from an Assessment and Inventory of a Regional, Decentralized Stockpile

Stockpiles can aid with healthcare surge that occurs after a disaster, and experts recommend that these caches be assessed at least annually to ensure supply integrity. The purpose of this study was to assess a regional stockpile to determine its viability and readiness. An assessment was performed in the summer and fall of 2016 on a regionally funded stockpile that was decentralized through a regional network of 15 local hospitals. Each supply was assessed to determine whether the correct amount was present, if it was in a safe and usable condition (ie, deployable), and whether it had expired. Stockpiled materials were categorized by the type of supply or equipment for analysis. The percent of deployable materials was calculated for each item, each category of supplies, and for the entire cache. Almost all sites (93.3%, n = 14) reported that they inventory their cache at least once a year. On average, 60.1% of each site's cache materials were present and deployable (range: 22.1%-87.5%). The best-maintained supplies included personal protective equipment (79.4% deployable) and general medical supplies (73.5% deployable). Decontamination equipment and pediatric supplies had the lowest percentages of deployability (29.0% and 37.7%, respectively). Although almost all sites claimed to assess the stockpile annually, results from this study indicate that almost half of the supplies are either missing or in an unusable condition. This not only represents wasted resources, but it could also hinder disaster response, leading to increased morbidity and mortality. Facilities may need to invest in infrastructure to maintain stockpiled materials after purchase to ensure viability.

Best Practices for Healthcare Facility and Regional Stockpile Maintenance and Sustainment: A Literature Review

Preparing for mass casualty incidents is essential to maximizing community resilience. Many US-based organizations and regions have developed stockpiles of medications, supplies, and equipment for mass casualty incident preparedness. The Centers for Disease Control and Prevention (CDC) assess and manage federally stockpiled materials, but hospitals, healthcare systems, and regional organizations are responsible for maintaining locally owned caches. The CDC has protocols for assessing and managing the Strategic National Stockpile, but no such guidance exists for local or geographical/regional stockpiles. This article outlines best practices and recommendations identified in the literature related to maintaining and sustaining a local or regional stockpile. Recommendations are provided on the timing and procedures for assessing, inventorying, storing, managing, tracking, and deploying materials stockpiled on site, in a trailer, or in a warehouse. In addition, alternative approaches for maintaining a local or regional cache, such as vendor- or user-managed inventory methods, are addressed. Management of local or regional caches requires an investment in infrastructure and training but is necessary to ensure the integrity of stockpiled medication and supplies and to enable rapid and appropriate activation during a mass casualty incident. Hospitals, healthcare systems, businesses, academic institutions, public health agencies, organizations, and regions can use the recommendations here to develop protocols or policies to properly manage their existing stockpiles, which should minimize costs related to damaged supplies.

Hospital influenza pandemic stockpiling needs: A computer simulation

BACKGROUND

A severe influenza pandemic could overwhelm hospitals but planning guidance that accounts for the dynamic interrelationships between planning elements is lacking. We developed a methodology to calculate pandemic supply needs based on operational considerations in hospitals and then tested the methodology at Mayo Clinic in Rochester, MN.

METHODS

We upgraded a previously designed computer modeling tool and input carefully researched resource data from the hospital to run 10,000 Monte Carlo simulations using various combinations of variables to determine resource needs across a spectrum of scenarios.

RESULTS

Of 10,000 iterations, 1,315 fell within the parameters defined by our simulation design and logical constraints. From these valid iterations, we projected supply requirements by percentile for key supplies, pharmaceuticals, and personal protective equipment requirements needed in a severe pandemic.

DISCUSSION

We projected supplies needs for a range of scenarios that use up to 100% of Mayo Clinic-Rochester's surge capacity of beds and ventilators. The results indicate that there are diminishing patient care benefits for stockpiling on the high side of the range, but that having some stockpile of critical resources, even if it is relatively modest, is most important.

CONCLUSIONS

We were able to display the probabilities of needing various supply levels across a spectrum of scenarios. The tool could be used to model many other hospital preparedness issues, but validation in other settings is needed.

Impact of an Education Intervention on Missouri K-12 School Disaster and Biological Event Preparedness

BACKGROUND

A 2011 nationwide school pandemic preparedness study found schools to be deficient. We examined the impact of a school nurse educational intervention aimed at improving K-12 school biological event preparedness.

METHODS

Missouri Association of School Nurses (MASN) members were e-mailed a survey link in fall 2013 (ie, preintervention), links to online education modules (ie, intervention) in late fall, and a postintervention survey link in spring, 2014. School biological event readiness was measured using 35 indicators, for a possible score range of 0-35. A paired t-test compared pre- to postintervention preparedness scores.

RESULTS

A total of 133 school nurses (33.6% response rate) completed a survey; 35.3% of those (N = 47) completed both pre- and postintervention survey that could be matched. Pre- and postintervention preparedness scores ranged from 5 to 28.5 (x‾ = 13.3) and 6.5 to 25 (x‾ = 14.8), respectively. Postintervention scores were significantly higher than preintervention scores for those who watched at least 1 module (t = -2.3, p < .05).

CONCLUSION

The education intervention was effective at improving school preparedness, though the impact was small. The education intervention needs to be reassessed, especially in regard to providing a longer intervention period.

Potential demand for respirators and surgical masks during a hypothetical influenza pandemic in the United States

Background. To inform planning for an influenza pandemic, we estimated US demand for N95 filtering facepiece respirators (respirators) by healthcare and emergency services personnel and need for surgical masks by pandemic patients seeking care.

Methods. We used a spreadsheet-based model to estimate demand for 3 scenarios of respirator use: base case (usage approximately follows epidemic curve), intermediate demand (usage rises to epidemic peak and then remains constant), and maximum demand (all healthcare workers use respirators from pandemic onset). We assumed that in the base case scenario, up to 16 respirators would be required per day per intensive care unit patient and 8 per day per general ward patient. Outpatient healthcare workers and emergency services personnel would require 4 respirators per day. Patients would require 1.2 surgical masks per day.

Results and Conclusions. Assuming that 20% to 30% of the population would become ill, 1.7 to 3.5 billion respirators would be needed in the base case scenario, 2.6 to 4.3 billion in the intermediate demand scenario, and up to 7.3 billion in the maximum demand scenario (for all scenarios, between 0.1 and 0.4 billion surgical masks would be required for patients). For pandemics with a lower attack rate and fewer cases (eg, 2009-like pandemic), the number of respirators needed would be higher because the pandemic would have longer duration. Providing these numbers of respirators and surgical masks represents a logistic challenge for US public health agencies. Public health officials must urgently consider alternative use strategies for respirators and surgical masks during a pandemic that may vary from current practices.

Clinician Beliefs and Attitudes Regarding Use of Respiratory Protective Devices and Surgical Masks for Influenza

While influenza transmission is thought to occur primarily by droplet spread, the role of airborne spread remains uncertain. Understanding the beliefs and attitudes of infectious disease physicians regarding influenza transmission and respiratory and barrier protection preferences can provide insights into workplace decisions regarding respiratory protection planning. Physicians participating in the Infectious Diseases Society of America's Emerging Infections Network were queried in November 2013 to determine beliefs and attitudes on influenza transmission. A subset of physicians involved in their facility's respiratory protection decision making were queried about respirator and surgical mask choices under various pandemic scenarios; availability of, and challenges associated with, respirators in their facility; and protective strategies during disposable N95 shortages. The majority of 686 respondents (98%) believed influenza transmission occurs frequently or occasionally via droplets; 44% of respondents believed transmission occurs via small particles frequently (12%) or occasionally (32%). Among the subset of respondents involved in respiratory protection planning at their facility, over 90% preferred surgical masks during provision of non-aerosol-generating patient care for seasonal influenza. However, for the same type of care during an influenza pandemic, two-thirds of respondents opted for disposable N95 filtering facepiece respirators. In settings where filtering facepiece (disposable) N95 respirators were in short supply, preferred conservation strategies included extended use and reuse of disposable N95s. Use of reusable (elastomeric facepiece) respirator types was viewed less favorably. While respondents identified droplets as the primary mode of influenza transmission, during a high-severity pandemic scenario there was increased support for devices that reduced aerosol-based transmission. Use of potentially less familiar respirator types may partially relieve shortages of disposable N95s but also may require significant education efforts so that clinicians are aware of the characteristics of alternative personal protective equipment.

Comparative Cost of Stockpiling Various Types of Respiratory Protective Devices to Protect the Health Care Workforce During an Influenza Pandemic

Specific guidance on the size and composition of respiratory protective device (RPD) stockpiles for use during a pandemic is lacking. We explore the economic aspects of stockpiling various types and combinations of RPDs by adapting a pandemic model that estimates the impact of a severe pandemic on a defined population, the number of potential interactions between patients and health care personnel, and the potential number of health care personnel needed to fulfill those needs. Our model calculates the number of the different types of RPDs that should be stockpiled and the consequent cost of purchase and storage, prorating this cost over the shelf life of the inventory. Compared with disposable N95 or powered air-purifying respirators, we show that stockpiling reusable elastomeric half-face respirators is the least costly approach. Disposable N95 respirators take up significantly more storage space, which increases relative costs. Reusing or extending the usable period of disposable devices may diminish some of these costs. We conclude that stockpiling a combination of disposable N95 and reusable half-face RPDs is the best approach to preparedness for most health care organizations. We recommend against stockpiling powered air-purifying respirators as they are much more costly than alternative approaches.

Physiologic and other effects and compliance with long-term respirator use among medical intensive care unit nurses

BACKGROUND

Long-term use of respiratory protection may be necessary, but compliance may be low, and physiologic effects have not been well evaluated.

METHODS

Ten nurses participated; physiologic effects, subjective symptoms, and compliance with wearing an N95 alone or with a surgical mask overlay were assessed. Longitudinal analysis based on multivariate linear regression models assessed changes in outcome variables (CO2, O2, heart rate, perceived comfort items, compliance measures, and others). Analyses compared changes over time, and compared wearing only an N95 to wearing an N95 with a surgical mask overlay.

RESULTS

Most nurses (90%, n = 9) tolerated wearing respiratory protection for two 12-hour shifts. CO(2) levels increased significantly compared with baseline measures, especially when comparing an N95 with a surgical mask to only an N95, but changes were not clinically relevant. Perceived exertion; perceived shortness of air; and complaints of headache, lightheadedness, and difficulty communicating also increased over time. Almost one-quarter (22%) of respirator removals were due to reported discomfort. N95 adjustments increased over time, but other compliance measures did not vary by time. Compliance increased on day 2, except for adjustments, touching under the N95, and eye touches.

CONCLUSION

Long-term use of respiratory protection did not result in any clinically relevant physiologic burden for health care personnel, although many subjective symptoms were reported. N95 compliance was fairly high.

Personal protective equipment use and allocation in home health during disasters

BACKGROUND

Home health preparedness for disasters is imperative, including the need to identify essential resources to protect home health professionals from exposure during an event. Access to personal protective equipment (PPE) is expected to be limited during a disaster, and PPE distribution and allocation needs to be prearranged to minimize infection transmission risk. This article outlines the appropriate use and allocation of PPE for home health agencies as part of disaster planning.

METHODS

A literature review and Internet search were conducted in July-August 2010. A spreadsheet was created delineating the best practices related to PPE use and allocation identified by each source. Recommendations were divided into themes/domains for simplification and clarity.

RESULTS

A total of 46 articles, planning documents/reports, and Web-based training programs were identified and screened. Of these, 28 were deemed relevant, including 12 journal articles and 16 published reports, book chapters, planning documents, or training programs. Themes for PPE use and allocation in home health during disasters in the literature included identifying the types of PPE used in home health, determining PPE needs, storing PPE, allocating PPE when resources are limited or depleted, disposing of PPEl, and educating staff.

CONCLUSION

Having access to the correct types and quantities of PPE during a disaster will be essential to home health agencies. The information presented in this article can assist home health agencies in developing emergency management plans that address planning issues related to PPE.

The "biosecuritization" of healthcare delivery: examples of post-9/11 technological imperatives

This paper develops the concept of "biosecuritization" to describe new instantiations of the technological imperative in healthcare. Many discourses and practices surrounding hospitals' new investments in information and communication technologies tend to revolve around security provision. Often times, however, scenarios of extreme and exceptional circumstances are used to justify the implementation of identification and tracking technologies that may be more about managerial control than patient care. Drawing upon qualitative research in 23 U.S. hospitals from 2007 to 2009, our analysis focuses on hospitals' deployment of identification and location technologies that manage patients, track personnel, and generate data in real-time. These systems are framed as aiding in the process of managing supplies and medications for pandemic flu outbreaks, monitoring exposure patterns for infectious diseases, and helping triage or manage the location and condition of patients during mass casualty disasters. We show that in spite of the framing of security and emergency preparedness, these technologies are primarily managerial tools for hospital administrators. Just as systems can be used to track infection vectors, those same systems can be used on a daily basis to monitor the workflow of hospital personnel, including nurses, physicians, and custodial staff, and to discipline or reward according to performance. In other words, the biosecuritization modality of the technological imperative leads to the framing of medical progress as the "rationalization" of organizations through technological monitoring, which is intended to promote accountability and new forms of responsibilization of healthcare workers.

Health service resource needs for pandemic influenza in developing countries: a linked transmission dynamics, interventions and resource demand model

We used a mathematical model to describe a regional outbreak and extrapolate the underlying health-service resource needs. This model was designed to (i) estimate resource gaps and quantities of resources needed, (ii) show the effect of resource gaps, and (iii) highlight which particular resources should be improved. We ran the model, parameterized with data from the 2009 H1N1v pandemic, for two provinces in Thailand. The predicted number of preventable deaths due to resource shortcomings and the actual resource needs are presented for two provinces and for Thailand as a whole. The model highlights the potentially huge impact of health-system resource availability and of resource gaps on health outcomes during a pandemic and provides a means to indicate where efforts should be concentrated to effectively improve pandemic response programmes.

Preventing the soldiers of health care from becoming victims on the pandemic battlefield: respirators or surgical masks as the armor of choice

The respiratory protective equipment necessary to protect health care workers from the novel swine-origin influenza A (H1N1) virus is not known. The knowledge gap created by this unanswered question has caused substantial debate and controversy on a global scale, leading public health organizations to feel pressured into issuing decisive recommendations despite a lack of supportive data. Changes in clinical practice caused by public health guidance during such high-profile events can be expected to establish a new standard of care. Also possible is an unforeseen gradual transition to widespread N95 respirator use, driven by public health pressures instead of science, for all outbreaks of influenza or influenza-like illness. Therefore, public health organizations and other influential institutions should take care to avoid making changes to established practice standards, if possible, unless these changes are bolstered by sound scientific evidence. Until definitive comparative effectiveness clinical trials are conducted, the answer to this question will continue to remain elusive. In the meantime, relying on ethical principles that have been substantiated over time may help guide public health and clinical decisions.

Investment decisions in influenza pandemic contingency planning: cost-effectiveness of stockpiling antiviral drugs

BACKGROUND

The threat of an influenza pandemic has led to stockpiling of antiviral drugs in order to mitigate a plausible outbreak. If the stockpile would be used in relation to the recent pandemic alert, an investment decision about renewing the stock for a possible subsequent pandemic is essential. The decision should include cost-effectiveness considerations.

METHODS

We constructed a cost-effectiveness analysis in the Dutch context, explicitly including risk of an outbreak. Outcomes from a dynamic transmission model, comparing an intervention with a non-intervention scenario, were input in our health economic calculations.

RESULTS

Stockpiling was cost-effective from the health-care perspective if the actual risk is 37% for 30 years. If less than 60% of the population would take the antiviral drugs or the attack rate is about 50%, the investment would not be cost-effective from this perspective.

CONCLUSION

Risk perception, realistic coverage among population and size of a pandemic are crucial parameters and highly decisive for the investment decision.