High Consequence Infectious Diseases Research Articles

A practical approach to preparing your ICU for epidemics and pandemics.

Major outbreaks of infectious diseases, including epidemics and pandemics, are increasing in scope and frequency, threatening public health and straining the capacity of health systems worldwide. High-consequence infectious diseases (HCIDs), including highly pathogenic respiratory viruses and viral hemorrhagic fevers, are both contagious and virulent, and these pathogens thus are topics of special concern for pandemic planning. The COVID-19 pandemic demonstrated how a major disease outbreak can negatively impact all aspects of hospital functioning. Identification of patients with HCIDs needs careful clinical evaluation and coordination with public health authorities. Staff safety and patient care require appropriate infection prevention precautions, including personal protective equipment. Surges of ill patients may lead to significant strain, with increased ICU patient mortality. Strategies to reduce the impact of surge appear to reduce mortality, such as tiered staffing models and load-leveling across health systems. Pandemics and HCIDs are a significant threat to global health, and ICUs play a major role in the care of affected patients. Critical care professionals must work to ensure that our hospitals are prepared to identify and care for these patients in advance of the next emergency.

A bacteriophage-based validation of a personal protective equipment doffing procedure to be used with high-consequence pathogens.

To determine if the high-level personal protective equipment used in the treatment of high-consequence infectious diseases is effective at stopping the spread of pathogens to healthcare personnel (HCP) while doffing. Personal protective equipment (PPE) is fundamental to the safety of HCPs. HCPs treating patients with high-consequence infectious diseases use several layers of PPE, forming complex protective ensembles. With high-containment PPE, step-by-step procedures are often used for donning and doffing to minimize contamination risk to the HCP, but these procedures are rarely empirically validated and instead rely on following infection prevention best practices. A doffing protocol video for a high-containment PPE ensemble was evaluated to determine potential contamination pathways. These potential pathways were tested using fluorescence and genetically marked bacteriophages. The experiments revealed existing protocols permit contamination pathways allowing for transmission of bacteriophages to HCPs. Updates to the doffing protocols were generated based on the discovered contamination pathways. This updated doffing protocol eliminated the movement of viable bacteriophages from the outside of the PPE to the skin of the HCP. Our results illustrate the need for quantitative, scientific investigations of infection prevention practices, such as doffing PPE.

A response to Gibbs et al., Category A waste processing and disposal is a critical weakness in the United States response plans for outbreaks of high consequence infectious diseases

A response to Gibbs et al., Category A waste processing and disposal is a critical weakness in the United States response plans for outbreaks of high consequence infectious diseases

High-consequence infectious diseases: the conception and development of a multi-disciplinary, interprofessional simulation training programme

High-consequence infectious diseases (HCIDs) represent a group of acute infectious diseases with the potential to impact healthcare systems and public health profoundly. Effective management requires a system-based strategy focused on early detection, initiation of infection prevention and control measures, and appropriate use of personal protective equipment (PPE). Inadequate training in the safe use of HCID PPE, and lack of familiarity with key processes such as HCID waste and spills management, exacerbates the risk posed to healthcare workers (HCWs). Enhanced training opportunities are required to ensure that staff are equipped with the necessary knowledge and capabilities to protect themselves from pathogen exposure and infection. To create a bespoke interprofessional HCID simulation training programme. A detailed learning needs analysis was undertaken, which identified multiple areas amenable to educational intervention. A full-day HCID simulation programme was developed, providing HCWs the opportunity to practice and gain proficiency in various domains. Six interprofessional participants took part in the HCID simulation programme pilot. All six (100%) participants felt that the stated learning objectives had been achieved, and five and one participants found the programme to be extremely useful (83%) or very useful (17%), respectively. Following refinement based on pilot feedback, a further six courses have been run for 38 participants, of whom 97% found the programme to be extremely useful or very useful. The development of a training intervention in the low-frequency, high-risk field of HCIDs had a positive impact. Given the disproportionate impact on HCWs at times of HCID outbreaks, more investment is needed to keep the workforce upskilled.

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.

Protecting Frontline Nurses: What will it take? A review of policy, practice and lessons learned from High Consequence Infectious Diseases like Ebola and COVID-19

The significance of failing to protect frontline health workers, especially nurses cannot be overstated. Inadequate personal protection, psychosocial support and emergency training put our frontline of defense in jeopardy. When comparing death by occupation early evidence showed that nurses constituted the largest percentage of health workforce deaths. Other severe consequences like high levels of resignation, burnout and other signs of mental distress are a warning that health systems require fundamental change to protect and retain our frontline of health security. This is equally true in settings with both high and lower resources. Those at the frontlines pay a heavy price responding to infectious disease outbreaks, but it does not have to be. This paper outlines key issues and potential strategies to ensure our health workers have the right environment, competence, tools, and support to protect themselves and society when needed most. Using an umbrella review, this paper sought to review the extant literature and identify the best way forward. Failure to learn from recent events such as the 2014-2016 West Africa Ebola outbreak and the COVID-19 pandemic could further exacerbate health worker shortages and our collective ability to prevent, detect and respond effectively. Protecting frontline health workers requires a multi-faceted approach including well-defined policies, adoption of best practices and continuous learning. The focus should move from broad policies and benchmarks to specific, tangible actions, including standard guidelines and protocols that use an All-Hazards Approach. Taking concrete steps to improve protection with national and local accountability that ensures adequate safety standards will be key. Moreover, continuous learning and investment in health system strengthening are needed. The return on investment in preparedness and protection are clear. COVID-19 has shown the devastating economic and social impact of failing to be prepared. Investment is needed in innovation, including new personal protective equipment (PPE) technology, resilient supply chains that move beyond “just-in time” procurements, and competency-based experiential learning that simulates complex emergencies, in “real world” settings as much as is possible. Learning from history, including nursing pioneers, is essential. Outbreaks begin in communities. Close community engagement and understanding of the social determinants of health for which those on the margins pay the heaviest price is central to nursing. Since this paper focuses on protection of frontline health workers, it would be remiss not to revisit nursing’s role in caregiving. This paper presents examples from 19th and 20th century nursing leaders who developed community- and person-centered models of care, led the development of hygiene and sanitation standards and examples which highlight the critical role of nurses at the frontlines. Nursing has historically been community- and person-centered. Serving as the communities’ first line of healthcare, nursing pioneers like Florence Nightengale and Lillian Wald offer guidance which is still valuable in our modern, highly connected world. Applying lessons from both our recent and past experiences to develop robust systems for health workforce protection and preparedness is a health security priority. Now, as COVID-19 becomes an endemic disease for which an effective vaccine is available, is the time to harness these lessons learned, develop more robust standards and accountability for emergency protection and health workforce protection, without which history will repeat itself.

Measuring hospital resilience before and during the COVID-19 pandemic

Organizational resilience scales have been adapted to the hospital context. To prepare for high consequence infectious diseases (HCID), the Long Hospital Resilience Scale (L-HRS; N=48) was tested in two German hospitals in 2019 and the Short Hospital Resilience Scale (S-HRS; N=317) after the first wave of COVID-19. Results show reliability of both the long and the short version. The L-HRS is associated with satisfaction with hospital preparation for HCID. S-HRS shows a perceived better adaptation of hospitals during COVID-19 and is related to higher self-efficacy of hospital staff. Both scales identify opportunities to promote resilience at various levels in the hospital.

A51Educational effectiveness of a high-consequence infectious disease training course using ultraviolet simulation

High-consequence infectious diseases (HCID) are pathogens which spread easily between people, have high mortality rates, and lack effective treatment [1]. Examples include Ebola and Lassa fever. Most emerging pandemics, including COVID-19, are initially classified as HCID. Assessment of patients with suspected HCID infection is an advanced procedural skill requiring application of enhanced infection control measures including patient isolation, personal protective equipment, and decontamination. There is a risk of healthcare worker infection if procedures are not followed [2]. HCID often present in non-specialist centres; there is a need for an accessible, educationally effective HCID course for NHS staff. We developed a course for clinicians in infectious disease and emergency medicine, in collaboration with the Health & Safety Executive and clinicians in the UK-HCID network. The course uses a blended approach; theoretical components are taught with online learning. Practical components are taught with high-fidelity, multidisciplinary simulation using VIOLET, a mannequin which coughs, vomits and sweats ultraviolet markers ( Ultraviolet tracers are used to replicate contact and airborne transmission of infectious pathogens in simulation scenarios Between 01/12/22 and 01/04/23, 57 specialized clinicians participated. All participants passed post-course competency-based practical assessments. Participants demonstrated significant gains in knowledge between pre- and post-course tests (mean score 61% vs. 83%, This is the first HCID simulation course internationally using ultraviolet markers to allow visualization of contamination. The course appears to be an effective educational intervention and improves learner confidence in PPE use. Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable.

The PATH to PPE Mastery - Programme for Assessment and Training in HCID (High Consequence Infectious Diseases) PPE (Personal Protective Equipment), Mastery

High Consequence Infectious Diseases (HCIDs), have the potential to cause pandemics and require particular focus for preparedness due to their high mortality rates. The application of Personal Protective Equipment (PPE) for HCIDs is complex and carries significant risk of Health Care Worker (HCW) contamination if done incorrectly. Previous reviews have reported a lack of information on the nature of training provided and the ideal timing of repeat training to best retain skills. Simulation Based Mastery Learning (SBML) is a methodology for skill acquisition which encompasses deliberate practice and repeated assessment until the learner achieves a pre-set Mastery standard. SBML has been demonstrated to improve competence, skill retention and patient outcomes in other clinical procedures. SBML has not been previously studied or utilised in HCID PPE training. We aimed to increase the likelihood of safe clinical practice by evidencing that Lothian modified SBML for PPE effectively prepares our priority learners. A quasi-experimental within group post-test design was used. Learners undertook a modified SBML programme which included two-hour asynchronous and two-hour synchronous components. 11 learners (10 infectious diseases registrars and 1 infectious diseases consultant) were enrolled in the programme with 8 completing all stages, all of whom achieved the Mastery passing standard. The resources were highly rated by learners with the exemplar videos of skills highlighted as particularly useful. Self-assessed preparedness for each skill increased following pre-learning and synchronous sessions. Modified SBML can be used as an effective methodology for the training and assessment of HCWs in the donning and doffing of HCID PPE.

A review of new challenges and solutions to the timely and effective implementation of clinical research responses to high priority diseases of epidemic and pandemic potential: A scoping review protocol

Background: Conducting and implementing clinical research response during pandemic and epidemic diseases outbreaks are often fraught with challenges due to their unprecedented nature. In previous research, challenges to the implementation of clinical research responses during pandemic and epidemic outbreaks were identified and solutions suggested. While the emergence of the Covid-19 pandemic has, on one hand, highlighted new and unresolved challenges, several novel solutions such as the Randomised Evaluation of Covid-19 Therapy (RECOVERY) trial were also implemented and reported in the literature. This scoping review, therefore, aims to synthesise and update solutions to the barriers affecting the implementation of clinical research responses during new, emerging or re-emerging diseases of pandemic and epidemic potential, to further inform strategies that would enhance pandemic and epidemic preparedness and response. Methods: This scoping review will be conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analysis- Extension for Scoping Reviews (PRISMA-ScR). Search will be conducted in six scientific databases: Ovid MEDLINE, Ovid Global Health, OVID PsycINFO, Ovid Embase, Scopus Epistemonikos, and complemented by a grey literature search in Google Scholar. Terms related to clinical trial, high consequence infectious diseases and the PEARLES domains will be used in the search. Two reviewers will independently screen retrieved articles in Rayyan software. Descriptive data of studies will be extracted into a pre-developed Microsoft Excel template while qualitative data related to the PEARLES solutions or barriers will be coded in NVivo. Results will be synthesised thematically and presented in a narrative style. Conclusions: This scoping review will synthesise new and updated solutions to the PEARLES challenges encountered during the implementation of clinical research responses to high consequence epidemics and pandemics. Furthermore, it will examine how challenges and proposed solutions identified prior to the emergence of Covid-19 have been addressed and tested in real time.

Validation of the STERIS Amsco 630LS steam sterilizer autoclave for inactivation of category a medical waste from patients with high-consequence infectious diseases.

Hospitals caring for patients with high-consequence pathogens may need to safely manage large volumes of category A waste. Using biological indicators to assess for successful sterilization, autoclave cycle parameters that would inactivate 4 categories of waste were identified and validated utilizing a STERIS Amsco 630LS Steam Sterilizer.

Category A waste processing and disposal is a critical weakness in the United States response plans for outbreaks of high consequence infectious diseases

Category A waste processing and disposal is a critical weakness in the United States response plans for outbreaks of high consequence infectious diseases

Role of the PANDORA-ID-Net Consortium in epidemiology, diagnostics and clinical management of emerging and re-emerging high consequence infectious diseases (HCID), in Africa

Role of the PANDORA-ID-Net Consortium in epidemiology, diagnostics and clinical management of emerging and re-emerging high consequence infectious diseases (HCID), in Africa

Literature review of physiological strain of personal protective equipment on personnel in the high-consequence infectious disease isolation environment

Heat strain and dehydration can affect an individual's physical and mental performance. The purpose of this review was to examine the literature for the impact of heat strain on health care workers (HCWs) who care for patients with high-consequence infectious diseases (HCIDs) while wearing personal protective equipment (PPE), discuss the risks of impaired safety caused by heat strain and dehydration in HCID environments, identify attempts to combat PPE-related heat strain, recognize limitations, and provide suggestions for further research. A literature search was performed in PubMed orMEDLINE and Google Scholar. Authors screened abstracts for inclusion criteria and reviewed articles if the abstracts were considered to include information relevant to the aim. The search terms yielded 30 articles that were sorted based on environment setting, physiological impact, and interventions. The safety of theHCWs and patients can be enhanced through the development and usage of cooler, more comfortable PPE materials and ensembles to help slow the rate of dehydration and support the regulation of core body temperature. Heat strain caused by wearing PPE is an occupational health concern for HCWs in the high-risk environment, that is, HCID care. Future studies are needed to develop innovative PPE ensembles that can reduce heat strain and improve well-being.

Scenario-Based Collaboration: Identifying the Role of the NSW Biocontainment Centre in the Response to High Consequence Infectious Diseases

Introduction:The New South Wales (NSW) Biocontainment Centre (NBC) is the first high-level isolation unit in Australia. This state-wide referral facility, located at Westmead Hospital, Sydney, will provide care for patients with high-consequence infectious diseases (HCIDs), including viral hemorrhagic fevers (VHF). In preparation, a tabletop exercise with key stakeholders was held to introduce and socialize the NBC’s capacity to support NSW’s preparedness for the management of a patient with HCID.Method:Invitations were provided to key stakeholders within Westmead Hospital (facility executive, emergency and ICU services, security, switchboard); NSW Preparedness and Response Branch; retrieval services; peripheral hospitals; pediatric hospital network; and NSW Public health units (state and district).The scenario presented was an unwell patient with suspected VHF arriving at a peripheral hospital emergency department.Discussion during the four-hour long exercise was facilitated with directed questions and injects, and was recorded. Recommendations and key learnings from the exercise and debrief provided opportunities to enhance current response assumptions.Results:Forty-five people participated both face-to-face and virtually. Participant discussion showed increasing appreciation of patient presentations to any part of the NSW health system and available assistance. Recommendations included: enhanced access to NBC support with a direct “1-800 number”, coordination for communication, treatment, and transport, and if required, deployment of an NBC team to peripheral sites. Areas for future collaborative work were identified.Conclusion:This exercise successfully achieved collaboration of key stakeholders to develop an updated, comprehensive and robust plan for management of HCID patients within NSW, regardless of their presentation site. It has created an opportunity to brainstorm and optimize how the NBC can interact with other agencies to maximize the NSW HCID response.

High consequence infectious diseases in Europe - the need for an expert clinical support service

High consequence infectious diseases in Europe - the need for an expert clinical support service

The 2022 monkeypox outbreak: A UK military perspective.

With the emergence of SARS-CoV-2 and now monkeypox, the UK Defence Medical Services have been required to provide rapid advice in the management of patients with airborne high consequence infectious diseases (A-HCID). The Defence Public Health Network (DPHN) cadre, consisting of closely aligned uniformed and civilian public health specialists have worked at pace to provide evidence-based recommendations on the clinical management, public health response and policy for monkeypox, with military medicine and pathology clinicians (primarily infectious disease physicians and medical microbiologists). Military environments can be complicated and nuanced requiring specialist input and advice to non-specialists as well as unit commanders both in the UK and overseas. DPHN and military infection clinicians have close links with the UK National Health Service (NHS) and the UK Health Security Agency (UKHSA), allowing for a dynamic two-way relationship that encompasses patient management, public health response, research and development of both UK military and national guidelines. This is further demonstrated with the Royal Air Force (RAF) Air Transport Isolator (ATI) capability, provided by Defence to support the UK Government and UKHSA. Military infectious disease clinicians are also embedded within NHS A-HCID units. In this manuscript we provide examples of the close interdisciplinary working of the DPHN and Defence clinicians in managing military monkeypox patients, co-ordinating the public health response, advising the Command and developing monkeypox policy for Defence through cross-government partnership. We also highlight the co-operation between civilian and military medical authorities in managing the current outbreak.

Validation of personal protective equipment ensembles, incorporating powered air-purifying respirators protected from contamination, for the care of patients with high-consequence infectious diseases

The UK High-Consequence Infectious Diseases (HCID) Network of high-level isolation units provides care for patients with contact- or airborne-transmissible highly infectious and highly dangerous diseases. In most HCID units, the healthcare workers (HCWs) wear personal protective equipment (PPE) ensembles incorporating a powered air-purifying respirator (PAPR) for head and respiratory protection. Some PAPRs have components worn outside/over other PPE, necessitating decontamination of re-usable elements. Two alternative PAPRs, with all re-usable elements worn under PPE, were trialled in this study. To undertake scenario-based testing of PAPRs and PPE to determine usability, comfort and ability to remove contaminated PPE without personal cross-contamination. Trained healthcare volunteers (N=20) wearing PAPR/PPE ensembles were sprayed with ultraviolet fluorescent markers. They undertook exercises to mimic patient care, and subsequently, after doffing the contaminated PPE following an established protocol, any personal cross-contamination was visualized under ultraviolet light. Participants also completed a questionnaire to gauge how comfortable they found the PPE. The ensembles were tested under extreme 'worst case scenario' conditions, augmented by physical and manual dexterity tests. Participating volunteers considered the exercise to be beneficial in terms of training and PPE evaluation. Data obtained, including feedback from questionnaires and doffing buddy observations, supported evidence-based decisions on the PAPR/PPE ensemble to be adopted by the HCID Network. One cross-contamination event was recorded in the ensemble chosen; this could be attributed to doffing error, and could therefore be eliminated with further practice.

Clinical features and management of individuals admitted to hospital with monkeypox and associated complications across the UK: a retrospective cohort study

The scale of the 2022 global mpox (formerly known as monkeypox) outbreak has been unprecedented. In less than 6 months, non-endemic countries have reported more than 67 000 cases of a disease that had previously been rare outside of Africa. Mortality has been reported as rare but hospital admission has been relatively common. We aimed to describe the clinical and laboratory characteristics and outcomes of individuals admitted to hospital with mpox and associated complications, including tecovirimat recipients. In this cohort study, we undertook retrospective review of electronic clinical records and pathology data for all individuals admitted between May 6, and Aug 3, 2022, to 16 hospitals from the Specialist and High Consequence Infectious Diseases Network for Monkeypox. The hospitals were located in ten cities in England and Northern Ireland. Inclusion criteria were clinical signs consistent with mpox and MPXV DNA detected from at least one clinical sample by PCR testing. Patients admitted solely for isolation purposes were excluded from the study. Key outcomes included admission indication, complications (including pain, secondary infection, and mortality) and use of antibiotic and anti-viral treatments. Routine biochemistry, haematology, microbiology, and virology data were also collected. Outcomes were assessed in all patients with available data. 156 individuals were admitted to hospital with complicated mpox during the study period. 153 (98%) were male and three (2%) were female, with a median age of 35 years (IQR 30-44). Gender data were collected from electronic patient records, which encompassed full formal review of clincian notes. The prespecified options for data collection for gender were male, female, trans, non-binary, or unknown. 105 (71%) of 148 participants with available ethnicity data were of White ethnicity and 47 (30%) of 155 were living with HIV with a median CD4 count of 510 cells per mm3 (IQR 349-828). Rectal or perianal pain (including proctitis) was the most common indication for hospital admission (44 [28%] of 156). Severe pain was reported in 89 (57%) of 156, and secondary bacterial infection in 82 (58%) of 142 individuals with available data. Median admission duration was 5 days (IQR 2-9). Ten individuals required surgery and two cases of encephalitis were reported. 38 (24%) of the 156 individuals received tecovirimat with early cessation in four cases (two owing to hepatic transaminitis, one to rapid treatment response, and one to patient choice). No deaths occurred during the study period. Although life-threatening mpox appears rare in hospitalised populations during the current outbreak, severe mpox and associated complications can occur in immunocompetent individuals. Analgesia and management of superimposed bacterial infection are priorities for patients admitted to hospital. None.

Summary of the National Advisory Committee on Immunization (NACI) Rapid Response: Updated interim guidance on Imvamune in the context of ongoing monkeypox outbreaks.

During the period of monkeypox community transmission and restricted vaccine supply in the summer of 2022, Canadian provinces and territories and a number of vaccine stakeholders indicated the need for consistent national guidance on pre-exposure vaccination (including the identification of priority populations for pre-exposure vaccination programs) and guidance on the potential use of dose-sparing strategies. The National Advisory Committee on Immunization (NACI) High Consequence Infectious Disease Working Group reviewed data on the status of the monkeypox outbreak along with additional published and non-published evidence regarding the safety, immunogenicity and protection offered by Imvamune®. NACI approved updated recommendations on September 16, 2022, and on September 23, 2022 it released updated interim guidance on the use of Imvamune in the context of the ongoing monkeypox outbreak. During periods of adequate vaccine supply, NACI recommended that Imvamune pre-exposure vaccination should be offered as a two-dose primary series, with at least 28 days between the two sub-cutaneous doses. When supply is limited, guidance was provided for the use of dose sparing strategies, including extended dosing intervals and fractional intradermal dosing to maximize vaccine coverage for those at highest risk of exposure to the monkeypox virus. The updated NACI recommendations provide additional guidance on the use of Imvamune for the management of the 2022 monkeypox outbreak in Canada and may be considered to maximize vaccine coverage in outbreak settings when supply is limited.