Managing systemic risk in emergency management, organizational resilience and climate change adaptation

PurposeThis paper applies the theory of cascading, interconnected and compound risk to the practice of preparing for, managing, and responding to threats and hazards. Our goal is to propose a consistent approach for managing major risk in urban systems by bringing together emergency management, organisational resilience, and climate change adaptation.Design/methodology/approachWe develop a theory-building process using an example from the work of the Greater London Authority in the United Kingdom. First, we explore how emergency management approaches systemic risk, including examples from of exercises, contingency plans and responses to complex incidents. Secondly, we analyse how systemic risk is integrated into strategies and practices of climate change adaptation. Thirdly, we consider organisational resilience as a cross cutting element between the approaches.FindingsLondon has long been a champion of resilience strategies for dealing with systemic risk. However, this paper highlights a potential for integrating better the understanding of common points of failure in society and organisations, especially where they relate to interconnected domains and where they are driven by climate change.Originality/valueThe paper suggests shifting toward the concept of operational continuity to address systemic risk and gaps between Emergency Management, Organizational Resilience and Climate Change Adaptation.

Linking healthcare and societal resilience during the Covid-19 pandemic.

Coronavirus disease 2019 (Covid-19) has highlighted the link between public healthcare and the broader context of operational response to complex crises. Data are needed to support the work of the emergency services and enhance governance. This study develops a Europe-wide analysis of perceptions, needs and priorities of the public affected by the Covid-19 emergency. An online multilingual survey was conducted from mid-May until mid-July 2020. The questionnaire investigates perceptions of public healthcare, emergency management and societal resilience. In total, N = 3029 valid answers were collected. They were analysed both as a whole and focusing on the most represented countries (Italy, Romania, Spain and the United Kingdom). Our findings highlight some perceived weaknesses in emergency management that are associated with the underlying vulnerability of the global interconnected society and public healthcare systems. The spreading of the epidemic in Italy represented a 'tipping point' for perceiving Covid-19 as an 'emergency' in the surveyed countries. The respondents uniformly suggested a preference for gradually restarting activities. We observed a tendency to ignore the cascading effects of Covid-19 and possible concurrence of threats. Our study highlights the need for practices designed to address the next phases of the Covid-19 crisis and prepare for future systemic shocks. Cascading effects that could compromise operational capacity need to be considered more carefully. We make the case for the reinforcement of cross-border coordination of public health initiatives, for standardization in business continuity management, and for dealing with the recovery at the European level.

The DataHarmonizer: a tool for faster data harmonization, validation, aggregation and analysis of pathogen genomics contextual information.

Pathogen genomics is a critical tool for public health surveillance, infection control, outbreak investigations as well as research. In order to make use of pathogen genomics data, they must be interpreted using contextual data (metadata). Contextual data include sample metadata, laboratory methods, patient demographics, clinical outcomes and epidemiological information. However, the variability in how contextual information is captured by different authorities and how it is encoded in different databases poses challenges for data interpretation, integration and their use/re-use. The DataHarmonizer is a template-driven spreadsheet application for harmonizing, validating and transforming genomics contextual data into submission-ready formats for public or private repositories. The tool's web browser-based JavaScript environment enables validation and its offline functionality and local installation increases data security. The DataHarmonizer was developed to address the data sharing needs that arose during the COVID-19 pandemic, and was used by members of the Canadian COVID Genomics Network (CanCOGeN) to harmonize SARS-CoV-2 contextual data for national surveillance and for public repository submission. In order to support coordination of international surveillance efforts, we have partnered with the Public Health Alliance for Genomic Epidemiology to also provide a template conforming to its SARS-CoV-2 contextual data specification for use worldwide. Templates are also being developed for One Health and foodborne pathogens. Overall, the DataHarmonizer tool improves the effectiveness and fidelity of contextual data capture as well as its subsequent usability. Harmonization of contextual information across authorities, platforms and systems globally improves interoperability and reusability of data for concerted public health and research initiatives to fight the current pandemic and future public health emergencies. While initially developed for the COVID-19 pandemic, its expansion to other data management applications and pathogens is already underway.

Impact of Wearing on Filtration Performance of Electrostatic Filter Face Masks.

Certified disposable respirators afford important protection from hazardous aerosols but lose performance as they are worn. This study examines the effect of wear time on filtration efficiency. Disposable respirators were worn by CSIRO staff over a period of 4 weeks in early 2020. Participants wore the respirator masks for given times up to eight hours whilst working in laboratory/office environments. At that time COVID-19 precautions required staff to wear surgical (or other) masks and increase use of hand sanitizer from dispenser stations. Results obtained from a test group of ten individuals without health preconditions show an increasing number of masks failing with wear time, while the remainder continue to perform nearly unaffected for up to 8 h. Some masks were found to retain filtration performance better than others, possibly due to the type of challenge they were subjected to by the wearer. However, the rate and extent of decay are expected to differ between environments since there are many contributing factors and properties of the aerosol challenge cannot be controlled in a live trial. Penetration and variability increased during wear; the longer the wear time, the more deleterious to particle removal, particularly after approximately 2 h of wear. This behavior is captured in a descriptive statistical model based on results from a trial with this test group. The effectiveness of the masks in preventing the penetration of KCl particles was determined before and after wearing, with the analysis focusing on the most penetrating particles in a size range of 0.3-0.5 µm diameter where respirator masks are most vulnerable. The basic elements of the study, including the approach to filter testing and sample sanitization, are broadly applicable. Conclusions also have applicability to typical commercially available single-use respirator masks manufactured from melt blown polypropylene as they are reliant on the same physical principles for particle capture and electrostatic enhancement was comparable for the particle size range used for detection.

Catastrophic antiphospholipid crisis triggered by anticoagulant switch

Case report - Introduction The COVID-19 pandemic led to drastic changes for some patients on warfarin for venous thromboembolic (VTE) disease and atrial fibrillation. Warfarin monitoring necessitates frequent interaction with healthcare workers, which is sufficiently risky for COVID-19 transmission. As a result, selected patients were swapped over to novel oral anticoagulants (NOACs). Our patient was changed without investigating for antiphospholipid syndrome (APLS);it later transpired he was triple antibody positive. He presented in a crisis and we describe his narrative. Patients on warfarin due to presumed unprovoked venous thromboembolic disease should not be swapped to NOACs without completing, or checking, previous antiphospholipid antibody testing. Case report - Case description A 73-year-old gentleman presented locally in August 2020 with erythema over the anterolateral surface of his left leg. He was initially treated with antibiotics for presumed cellulitis. Within a few days this lesion became necrotic and rapidly spread. At this point, he was transferred to a tertiary rheumatology centre. Within days to weeks, he developed several necrotic lesions affecting his trunk and limbs, with facial sparing noted. Approximately 30—35% of his whole-body surface became involved. He soon developed an oxygen requirement, with CTPA demonstrating lymphocytic interstitial pneumonitis without evidence of pulmonary emboli (PE). Throughout his admission, he had several other pathologies such as hyponatraemia that required level 2 care and severe non-infectious diarrhoea. Skin biopsy identified thrombotic vasculopathy. Serology confirmed triple positive antiphospholipid antibody status and a dsDNA titre of > 400 iU/mL. This was the first-time serology had been undertaken despite a history of three deep vein thrombosis (DVT) episodes and two PE incidents. He had no history of SLE symptoms. His initial management for vasculitis secondary to APLS at the point of limited necrosis consisted of IV methylprednisolone followed by rituximab and PO prednisolone. While there was some delay in the progression of his disease, new areas of necrosis arose, leading to the patient receiving cyclophosphamide. Low molecular weight heparin was used for anticoagulation. This gentleman later developed proteinuria and neurological symptoms, fulfilling the criteria for catastrophic antiphospholipid syndrome. He received plasma exchange, without an improvement. He developed complications from his disease and treatment, including poor wound healing. It became apparent his condition would not improve and active treatments were stopped. He passed away 6 weeks after initial presentation. Prior to his admission to hospital, his warfarin was swapped to a NOAC. This is thought to have been the trigger behind catastrophic thrombosis. Case report - Discussion After excluding other conditions such as necrotising fasciitis, this gentleman was rapidly started on IV methylprednisolone to halt any further progression. This is because glucocorticoids have the greatest evidence base for managing this poorly understood acute disease manifestation. After this failed to manage his condition, he was given a further immunosuppressive agent in the form of rituximab. This was used after his serology confirmed triple antibody status. It was hoped this would stop any further immunological mediated disease progression. Oral prednisolone was started at 40 mg at this stage and kept under review with a tapering schedule. Cyclophosphamide was given within a few days of rituximab, with hope of a quicker onset of action. A careful MDT decision was made on these drug choices, particularly regarding their combined use and appreciating their side effect profiles. Cyclophosphamide has evidence behind its use, especially for those with APLS associated with lupus. While he did not develop any infections related to treatment, his condition progressed. Case reports suggest that plasma exchange can be useful in the management of catastrophic ntiphospholipid syndrome, so the team recommended this. Consent at this stage became tricky due to his altered mental status, but it was felt he did demonstrate capacity for this specific decision. As his condition did not improve after this level of immunosuppression, the team reached the decision that no other treatments would likely change the outcome. He remained on oral steroids for the remainder of his admission. The other management facet of APLS crises pertains to anticoagulation. Low molecular weight heparin was recommended by the haematologists. His NOAC was stopped after the diagnosis was confirmed. Warfarin was restarted later in his admission given he had been well on this for years. Case report - Key learning points This fascinating case exemplifies the importance of completing an antiphospholipid antibody screen for patients who present with unprovoked venous thromboembolic disease. NOACs are commonly used anticoagulant medications. Several case reports have demonstrated that patients with antiphospholipid syndrome experience breakthrough thromboembolic events when treated with NOACs. The highest risk is associated with history of arterial thrombosis and those with triple positive antibody status. Three clinical trials have either been completed or are in the process of investigating whether NOACs sufficiently prevent thromboembolic disease in these patients. The TRAPS study compared rivaroxaban to warfarin in those with triple antibody positive antiphospholipid syndrome. The study was terminated early given that higher adverse events were observed in the rivaroxaban arm (19%, n = 11/59) versus warfarinised patients (3%, n = 2/61). The RAPS study found no difference in thromboembolic risk and results from the ASTRO-APS study looking into apixaban are awaited. There is insufficient evidence to suggest that NOACs prevent VTE in a similar fashion to warfarin, so many still advocate the use of warfarin. The optimal immune management of this acute complication is not well elucidated, with a shortfall in mechanistic pathological understanding. The conference will generate discussion on this subject matter in detail. During the COVID-19 pandemic, it has been observed for patients to change anticoagulation from warfarin to NOACs. Given NOACs do not require monitoring, this medication change reduces the number of interactions patients have with healthcare services. We postulate this change triggered the crisis in our patient, where we suggest continuation of warfarin would have been ideal. This is due to the history of several unprovoked thromboembolic events without a prior antiphospholipid screen being completed. Dissemination of learning points from this case are imperative to ensure decision-making encompasses patients who may have undiagnosed antiphospholipid syndrome.

The Effect of Sanitizing Treatments on Respirator Filtration Performance.

The potential for alcoholic vapors emitted by common sanitizing treatments to deteriorate the (electrostatic) filtration performance of disposable respirator masks has been investigated. Reports in the literature and some standard test methods provide a confusing and ambiguous picture concerning the relevance of this effect. Four different types of exposure were investigated in this study to clarify the effect of alcoholic vapor emissions on respirator masks. These included exposure to saturated vapors, use of hand sanitizers, cleaning of table surfaces and sanitization of masks by spraying them with alcohol-containing solutions. Methods employed were designed to be as real-world oriented as possible while remaining reproducible. Filtration performance and deterioration effects on exposure to the different treatments were determined on three different types of certified commercial respirator masks-a P2 and two KN95 masks. This study provides substantial evidence that disposable respirator masks with an accepted performance rating are seriously compromised from an exposure to saturated alcoholic vapors, can tolerate a one-off spray treatment with an alcoholic solution and retain their attested protection under the influence of alcoholic vapors from the use of hand sanitizer or spray sanitizer. Considering the range of vastly different outcomes obtained from the four treatments investigated, it seems prudent to assess in each case the specific effects of alcoholic solution treatments and vapors on respirator masks before use.

Predicting Infectious Severe Acute Respiratory Syndrome Coronavirus 2 From Diagnostic Samples.

BACKGROUND: Reverse-transcription polymerase chain reaction (RT-PCR) has become the primary method to diagnose viral diseases, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). RT-PCR detects RNA, not infectious virus; thus, its ability to determine duration of infectivity of patients is limited. Infectivity is a critical determinant in informing public health guidelines/interventions. Our goal was to determine the relationship between E gene SARS-CoV-2 RT-PCR cycle threshold (Ct) values from respiratory samples, symptom onset to test (STT), and infectivity in cell culture. METHODS: In this retrospective cross-sectional study, we took SARS-CoV-2 RT-PCR-confirmed positive samples and determined their ability to infect Vero cell lines. RESULTS: Ninety RT-PCR SARS-CoV-2-positive samples were incubated on Vero cells. Twenty-six samples (28.9%) demonstrated viral growth. Median tissue culture infectious dose/mL was 1780 (interquartile range, 282-8511). There was no growth in samples with a Ct > 24 or STT > 8 days. Multivariate logistic regression using positive viral culture as a binary predictor variable, STT, and Ct demonstrated an odds ratio (OR) for positive viral culture of 0.64 (95% confidence interval [CI], .49-.84; P < .001) for every 1-unit increase in Ct. Area under the receiver operating characteristic curve for Ct vs positive culture was OR, 0.91 (95% CI, .85-.97; P < .001), with 97% specificity obtained at a Ct of > 24. CONCLUSIONS: SARS-CoV-2 Vero cell infectivity was only observed for RT-PCR Ct < 24 and STT < 8 days. Infectivity of patients with Ct > 24 and duration of symptoms > 8 days may be low. This information can inform public health policy and guide clinical, infection control, and occupational health decisions. Further studies of larger size are needed.

Comparaison de l'infectivité du coronavirus du syndrome respiratoire aigu sévère 2 chez les enfants et les adultes.

CONTEXTE: Le rôle des enfants dans la propagation et la transmission communautaire du coronavirus du syndrome respiratoire aigu sévère 2 (SRAS-CoV-2) est encore mal compris. Nous visons à quantifier l'infectivité du SRAS-CoV-2 d'échantillons nasopharyngés provenant d'enfants comparativement à ceux provenant d'adultes. MÉTHODES: Nous avons obtenu des écouvillons nasopharyngés de cas adultes et pédiatriques de la maladie à coronavirus 2019 (COVID-19) ainsi que de leurs contacts qui ont obtenu un résultat positif à la présence du SRAS-CoV-2 lors d'un test de dépistage au Manitoba entre les mois de mars et décembre 2020. Nous avons comparé la croissance virale en culture cellulaire, les valeurs de cycle seuil de test d'amplification en chaîne par polymérase couplé à une transcription inverse (RT-PCR) de l'enveloppe (E) du gène du SRAS-CoV-2 et de la dose infectieuse pour 50 % de la culture tissulaire (DICT50/mL) entre les adultes et les enfants. RÉSULTATS: Parmi les 305 échantillons positifs à la présence du SRAS-CoV-2 validés par RT-PCR, 97 échantillons provenaient d'enfants de 10 ans et moins, 78 échantillons d'enfants de 11­17 ans et 130 échantillons d'adultes (≥ 18 ans). On a observé une croissance virale en culture dans 31 % des échantillons, dont 18 (19 %) échantillons d'enfants de 10 ans et moins, 18 (23 %) d'enfants de 11­17 ans et 57 (44 %) d'adultes (enfants c. adultes, rapport de cotes 0,45; intervalle de confiance [IC] à 95 % 0,28­0,72). Le cycle seuil était de 25,1 (IC à 95 % 17,7­31,3) chez les enfants de 10 ans et moins, 22,2 (IC à 95 % 18,3­29,0) chez les enfants de 11­17 ans et 18,7 (IC à 95 % 17,9­30,4) chez les adultes (p < 0,001). La DICT50/mL médiane était considérablement plus faible chez les enfants de 11­17 ans (316, écart interquartile [EI] 178­2125) que chez les adultes (5620, EI 1171­17 800, p < 0,001). Le cycle seuil était un indicateur exact d'une culture positive chez les enfants et les adultes (aire sous la courbe de la fonction d'efficacité du récepteur, 0,87, IC à 95 % 0,81­0,93 c. 0,89, IC à 95 % 0,83­0,96, p = 0,6). INTERPRÉTATION: Comparés aux adultes, les enfants qui ont obtenu un résultat positif à un test de dépistage du SRAS-CoV-2 à l'aide d'un écouvillon nasopharyngé étaient moins susceptibles de présenter une croissance du virus en culture et obtenaient un cycle seuil plus élevé et une concentration virale moins élevée, indiquant que les enfants ne sont pas les principaux vecteurs de la transmission du SRAS-CoV-2.

Infectivity of severe acute respiratory syndrome coronavirus 2 in children compared with adults: CMAJ

BACKGROUND: The role of children in the transmission and community spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is unclear. We aimed to quantify the infectivity of SARSCoV- 2 in nasopharyngeal samples from children compared with adults. METHODS: We obtained nasopharyngeal swabs from adult and pediatric cases of coronavirus disease 2019 (COVID-19) and from their contacts who tested positive for SARS-CoV-2 in Manitoba between March and December 2020. We compared viral growth in cell culture, cycle threshold values from the reverse transcription polymerase chain reaction (RT-PCR) of the SARS-CoV-2 envelope (E) gene and the 50% tissue culture infective dose (TCID50/mL) between adults and children. RESULTS: Among 305 samples positive for SARS-CoV-2 by RT-PCR, 97 samples were from children aged 10 years or younger, 78 were from children aged 11-17 years and 130 were from adults (≥ 18 yr). Viral growth in culture was present in 31% of samples, including 18 (19%) samples from children 10 years or younger, 18 (23%) from children aged 11-17 years and 57 (44%) from adults (children v. adults, odds ratio 0.45, 95% confidence interval [CI] 0.28-0.72). The cycle threshold was 25.1 (95% CI 17.7- 31.3) in children 10 years or younger, 22.2 (95% CI 18.3-29.0) in children aged 11-17 years and 18.7 (95% CI 17.9-30.4) in adults (p < 0.001). The median TCID50/mL was significantly lower in children aged 11-17 years (316, interquartile range [IQR] 178-2125) than adults (5620, IQR 1171 to 17 800, p < 0.001). Cycle threshold was an accurate predictor of positive culture in both children and adults (area under the receiver-operator curve, 0.87, 95% CI 0.81-0.93 v. 0.89, 95% CI 0.83-0.96, p = 0.6). INTERPRETATION: Compared with adults, children with nasopharyngeal swabs that tested positive for SARSCoV- 2 were less likely to grow virus in culture, and had higher cycle thresholds and lower viral concentrations, suggesting that children are not the main drivers of SARS-CoV-2 transmission.

Perceptions of the COVID-19 pandemic in Japan with respect to cultural, information, disaster and social issues.

A questionnaire survey was distributed via the Internet to 600 respondents. Preliminary results revealed that most Japanese people regularly washed their hands and had low resistance to wearing masks even before the COVID-19 pandemic. Internet news was the most common source of information. Half of the respondents said they would "stay at home evacuation" if a disaster occurred during the COVID-19 pandemic, reflecting the strategy promoted to reduce crowding in evacuation shelters. If a state of emergency must be reinstated, one-third of respondents said they could bear it for a few months and another one-third for a few weeks.

Modification of a domiciliary ventilator to increase FiO2: an off-label modification which may be of value in COVID-19.

Although nasal continuous positive airway pressure or non-invasive ventilation is used to manage some patients with acute lung injury due to COVID-19, such patients also demonstrate increased minute ventilation which makes it hard, if the device is used in line with the manufacturer's instructions, to achieve adequate oxygen delivery. In addition, if a hospital contains many such patients, then it is possible that the oxygen requirements will exceed infrastructure capacity. Here we describe a simple modification of two exemplar ventilators normally used for domiciliary ventilation, which substantially increased the fraction of inspired oxygen (FiO2) delivered.

Rapid and sensitive detection of SARS-CoV-2 antibodies by biolayer interferometry.

Serological testing to evaluate antigen-specific antibodies in plasma is generally performed by rapid lateral flow test strips that lack quantitative results or by high complexity immunoassays that are time- and labor-intensive but provide semi-quantitative results. Here, we describe a novel application of biolayer interferometry for the rapid detection of antigen-specific antibody levels in plasma samples, and demonstrate its utility for quantification of SARS-CoV-2 antibodies. Our biolayer interferometry immunosorbent assay (BLI-ISA) utilizes single-use biosensors in an automated "dip-and-read" format, providing real-time optical measurements of antigen loading, plasma antibody binding, and antibody isotype detection. Complete semi-quantitative results are obtained in less than 20 min. BLI-ISA meets or exceeds the performance of high complexity methods such as Enzyme-Linked Immunosorbent Assay (ELISA) and Chemiluminescent Immunoassay. Importantly, our method can be immediately implemented on existing BLI platforms for urgent COVID-19 studies, such as serosurveillance and the evaluation of vaccine candidates. In a broader sense, BLI-ISA can be developed as a novel diagnostic platform to evaluate antibodies and other biomolecules in clinical specimens.

Building Emergency Planning Scenarios for Viral Pandemics: UCL-IRDR Covid-19 Observatory

From the Introduction: The purpose of this report is to provide a systematic, if incomplete, record of the issues connected with the Covid-19 [coronavirus disease 2019] pandemic in order to improve the basis for future emergency planning. Like all large disasters, Covid-19 involves cascading consequences. These need to be factored into future emergency planning scenarios.COVID-19 (Disease);Emergency management--Planning;Epidemics;Coronaviruses

Comparison of commercial assays and laboratory developed tests for detection of SARS-CoV-2.

The global COVID-19 pandemic has led to the rapid development of tests for detection of SARS-CoV-2. Studies are required to assess the relative performance of different assays. Here, we compared the performance of two commercial assays, the cobas® SARS-CoV-2 (Roche Diagnostics) and Xpert® Xpress SARS-CoV-2 (Cepheid®) tests, and a laboratory developed RT-PCR test adapted for use on the Hologic® Panther Fusion® (Hologic®) instrument as well as Bio-Rad and QIAGEN real-time PCR detection systems. Performance characteristics for each test were determined by testing clinical specimens and reference material. All assays detect the pan-Sarbecovirus E (envelope structural protein) gene plus a SARS-CoV-2-specific target. The limit of detection for the E gene target varied from ∼2 copies/reaction to >30 copies/reaction. Due to assay-specific differences in sample processing and nucleic acid extraction, the overall analytical sensitivity ranged from 24 copies/mL specimen to 574 copies/mL specimen. Despite these differences, there was 100 % agreement between the commercial and laboratory developed tests. No false-negative or false-positive SARS-CoV-2 results were observed and there was no cross-reactivity with common respiratory viruses, including endemic coronaviruses.

Quantifying the impact of US state non-pharmaceutical interventions on COVID-19 transmission (preprint)

COVID-19 is an ongoing public health emergency. Without a vaccine or effective antivirals, non-pharmaceutical interventions form the foundation of current response efforts. Quantifying the efficacy of these interventions is crucial. Using mortality data and a classification guide of state level responses, we relate the intensity of interventions to statistical estimates of transmission, finding that more stringent control measures are associated with larger reductions in disease proliferation. Additionally, we observe that transmission increases with population density, but not population size. These results may help inform future response efforts.