Virtual Peer-to-Peer Learning to Enhance and Accelerate the Health System Response to COVID-19: The HHS ASPR Project ECHO COVID-19 Clinical Rounds Initiative.

Tasked with identifying digital health solutions to support dynamic learning health systems and their response to COVID-19, the US Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response partnered with the University of New Mexico's Project ECHO and more than 2 dozen other organizations and agencies to create a real-time virtual peer-to-peer clinical education opportunity: the COVID-19 Clinical Rounds Initiative. Focused on 3 "pressure points" in the COVID-19 continuum of care-(1) the out-of-hospital and/or emergency medical services setting, (2) emergency departments, and (3) inpatient critical care environments-the initiative has created a massive peer-to-peer learning network for real-time information sharing, engaging participants in all 50 US states and more than 100 countries. One hundred twenty-five learning sessions had been conducted between March 24, 2020 and February 25, 2021, delivering more than 58,000 total learner-hours of contact in the first 11 months of operation.

Evidence of behaviour change during an Ebola virus disease outbreak, Sierra Leone.

OBJECTIVE: To evaluate changes in Ebola-related knowledge, attitudes and prevention practices during the Sierra Leone outbreak between 2014 and 2015. METHODS: Four cluster surveys were conducted: two before the outbreak peak (3499 participants) and two after (7104 participants). We assessed the effect of temporal and geographical factors on 16 knowledge, attitude and practice outcomes. FINDINGS: Fourteen of 16 knowledge, attitude and prevention practice outcomes improved across all regions from before to after the outbreak peak. The proportion of respondents willing to: (i) welcome Ebola survivors back into the community increased from 60.0% to 89.4% (adjusted odds ratio, aOR: 6.0; 95% confidence interval, CI: 3.9-9.1); and (ii) wait for a burial team following a relative's death increased from 86.0% to 95.9% (aOR: 4.4; 95% CI: 3.2-6.0). The proportion avoiding unsafe traditional burials increased from 27.3% to 48.2% (aOR: 3.1; 95% CI: 2.4-4.2) and the proportion believing spiritual healers can treat Ebola decreased from 15.9% to 5.0% (aOR: 0.2; 95% CI: 0.1-0.3). The likelihood respondents would wait for burial teams increased more in high-transmission (aOR: 6.2; 95% CI: 4.2-9.1) than low-transmission (aOR: 2.3; 95% CI: 1.4-3.8) regions. Self-reported avoidance of physical contact with corpses increased in high but not low-transmission regions, aOR: 1.9 (95% CI: 1.4-2.5) and aOR: 0.8 (95% CI: 0.6-1.2), respectively. CONCLUSION: Ebola knowledge, attitudes and prevention practices improved during the Sierra Leone outbreak, especially in high-transmission regions. Behaviourally-targeted community engagement should be prioritized early during outbreaks.

Long-distance effects of epidemics: Assessing the link between the 2014 West Africa Ebola outbreak and U.S. exports and employment.

Although the economic consequences of epidemic outbreaks to affected areas are often well documented, little is known about how these might carry over into the economies of unaffected regions. In the absence of direct pathogen transmission, global trade is one mechanism through which geographically distant epidemics could reverberate to unaffected countries. This study explores the link between global public health events and U.S. economic outcomes by evaluating the role of the 2014 West Africa Ebola outbreak in U.S. exports and exports-supported U.S. jobs, 2005-2016. Estimates were obtained using difference-in-differences models where sub-Saharan Africa countries were assigned to treatment and comparison groups based on their Ebola transmission status, with controls for observed and unobserved time-variant factors that may independently influence trends in trade. Multiple model specification checks were performed to ensure analytic robustness. The year of peak transmission, 2014, was estimated to result in $1.08 billion relative reduction in U.S. merchandise exports to Ebola-affected countries, whereas estimated losses in exports-supported U.S. jobs exceeded 1,200 in 2014 and 11,000 in 2015. These findings suggest that remote disruptions in health security might play a role in U.S. economic indicators, demonstrating the interconnectedness between global health and aspects of the global economy and informing the relevance of health security efforts.

Ebola Response Impact on Public Health Programs, West Africa, 2014-2017.

Events such as the 2014-2015 West Africa epidemic of Ebola virus disease highlight the importance of the capacity to detect and respond to public health threats. We describe capacity-building efforts during and after the Ebola epidemic in Liberia, Sierra Leone, and Guinea and public health progress that was made as a result of the Ebola response in 4 key areas: emergency response, laboratory capacity, surveillance, and workforce development. We further highlight ways in which capacity-building efforts such as those used in West Africa can be accelerated after a public health crisis to improve preparedness for future events.

Reporting Deaths Among Children Aged <5 Years After the Ebola Virus Disease Epidemic - Bombali District, Sierra Leone, 2015-2016.

Mortality surveillance and vital registration are limited in Sierra Leone, a country with one of the highest mortality rates among children aged <5 years worldwide, approximately 120 deaths per 1,000 live births (1,2). To inform efforts to strengthen surveillance, stillbirths and deaths in children aged <5 years from multiple surveillance streams in Bombali Sebora chiefdom were retrospectively reviewed. In total, during January 2015-November 2016, 930 deaths in children aged <5 years were identified, representing 73.3% of the 1,269 deaths that were expected based on modeled estimates. The "117" telephone alert system established during the Ebola virus disease (Ebola) epidemic captured 683 (73.4%) of all reported deaths in children aged <5 years, and was the predominant reporting source for stillbirths (n = 172). In the absence of complete vital events registration, 117 call alerts markedly improved the completeness of reporting of stillbirths and deaths in children aged <5 years.

Knowledge, Attitudes, and Practices Related to Ebola Virus Disease at the End of a National Epidemic - Guinea, August 2015.

Health communication and social mobilization efforts to improve the public's knowledge, attitudes, and practices (KAP) regarding Ebola virus disease (Ebola) were important in controlling the 2014-2016 Ebola epidemic in Guinea (1), which resulted in 3,814 reported Ebola cases and 2,544 deaths.* Most Ebola cases in Guinea resulted from the washing and touching of persons and corpses infected with Ebola without adequate infection control precautions at home, at funerals, and in health facilities (2,3). As the 18-month epidemic waned in August 2015, Ebola KAP were assessed in a survey among residents of Guinea recruited through multistage cluster sampling procedures in the nation's eight administrative regions (Boké, Conakry, Faranah, Kankan, Kindia, Labé, Mamou, and Nzérékoré). Nearly all participants (92%) were aware of Ebola prevention measures, but 27% believed that Ebola could be transmitted by ambient air, and 49% believed they could protect themselves from Ebola by avoiding mosquito bites. Of the participants, 95% reported taking actions to avoid getting Ebola, especially more frequent handwashing (93%). Nearly all participants (91%) indicated they would send relatives with suspected Ebola to Ebola treatment centers, and 89% said they would engage special Ebola burial teams to remove corpses with suspected Ebola from homes. Of the participants, 66% said they would prefer to observe an Ebola-affected corpse from a safe distance at burials rather than practice traditional funeral rites involving corpse contact. The findings were used to guide the ongoing epidemic response and recovery efforts, including health communication, social mobilization, and planning, to prevent and respond to future outbreaks or sporadic cases of Ebola.

Rapid Laboratory Identification of Neisseria meningitidis Serogroup C as the Cause of an Outbreak - Liberia, 2017.

On April 25, 2017, a cluster of unexplained illness and deaths among persons who had attended a funeral during April 21-22 was reported in Sinoe County, Liberia (1). Using a broad initial case definition, 31 cases were identified, including 13 (42%) deaths. Twenty-seven cases were from Sinoe County (1), and two cases each were from Grand Bassa and Monsterrado counties, respectively. On May 5, 2017, initial multipathogen testing of specimens from four fatal cases using the Taqman Array Card (TAC) assay identified Neisseria meningitidis in all specimens. Subsequent testing using direct real-time polymerase chain reaction (PCR) confirmed N. meningitidis in 14 (58%) of 24 patients with available specimens and identified N. meningitidis serogroup C (NmC) in 13 (54%) patients. N. meningitidis was detected in specimens from 11 of the 13 patients who died; no specimens were available from the other two fatal cases. On May 16, 2017, the National Public Health Institute of Liberia and the Ministry of Health of Liberia issued a press release confirming serogroup C meningococcal disease as the cause of this outbreak in Liberia.

Notes from The Field: Ebola Virus Disease Cluster - Northern Sierra Leone, January 2016.

On January 14, 2016, the Sierra Leone Ministry of Health and Sanitation was notified that a buccal swab collected on January 12 from a deceased female aged 22 years (patient A) in Tonkolili District had tested positive for Ebola virus by reverse transcription-polymerase chain reaction (RT-PCR). The most recent case of Ebola virus disease (Ebola) in Sierra Leone had been reported 4 months earlier on September 13, 2015 (1), and the World Health Organization had declared the end of Ebola virus transmission in Sierra Leone on November 7, 2015 (2). The Government of Sierra Leone launched a response to prevent further transmission of Ebola virus by identifying contacts of the decedent and monitoring them for Ebola signs and symptoms, ensuring timely treatment for anyone with Ebola, and conducting an epidemiologic investigation to identify the source of infection.

Notes from the Field: Ebola Virus Disease Response Activities During a Mass Displacement Event After Flooding--Freetown, Sierra Leone, September-November, 2015.

Since the start of the Ebola virus disease (Ebola) outbreak in West Africa, Sierra Leone has reported 8,706 confirmed Ebola cases and 3,956 deaths. During September 15-16, 2015, heavy rains flooded the capital, Freetown, resulting in eight deaths, home and property destruction, and thousands of persons in need of assistance. By September 27, approximately 13,000 flood-affected persons registered for flood relief services from the government. On September 17, two stadiums in Freetown were opened to provide shelter and assistance to flood-affected residents; a total of approximately 3,000 persons stayed overnight in both stadiums (Sierra Leone Ministry of Health and Sanitation, personal communication, September 2015). On the same day the stadiums were opened to flood-affected persons, the Ministry of Health and Sanitation (MoHS) and Western Area Ebola Response Center (WAERC) staff members from CDC, the World Health Organization (WHO), and the African Union evaluated the layout, logistics, and services at both stadiums and identified an immediate need to establish Ebola response activities. The patient in the last Ebola case in the Western Area, which includes Freetown, had died 37 days earlier, on August 11; however, transmission elsewhere in Sierra Leone was ongoing, and movement of persons throughout the country was common.

Cluster of Ebola Virus Disease Linked to a Single Funeral - Moyamba District, Sierra Leone, 2014.

As of February 17, 2016, a total of 14,122 cases (62% confirmed) of Ebola Virus Disease (Ebola) and 3,955 Ebola-related deaths had been reported in Sierra Leone since the epidemic in West Africa began in 2014. A key focus of the Ebola response in Sierra Leone was the promotion and implementation of safe, dignified burials to prevent Ebola transmission by limiting contact with potentially infectious corpses. Traditional funeral practices pose a substantial risk for Ebola transmission through contact with infected bodies, body fluids, contaminated clothing, and other personal items at a time when viral load is high; however, the role of funeral practices in the Sierra Leone epidemic and ongoing Ebola transmission has not been fully characterized. In September 2014, a sudden increase in the number of reported Ebola cases occurred in Moyamba, a rural and previously low-incidence district with a population of approximately 260,000. The Sierra Leone Ministry of Health and Sanitation and CDC investigated and implemented public health interventions to control this cluster of Ebola cases, including community engagement, active surveillance, and close follow-up of contacts. A retrospective analysis of cases that occurred during July 11-October 31, 2014, revealed that 28 persons with confirmed Ebola had attended the funeral of a prominent pharmacist during September 5-7, 2014. Among the 28 attendees with Ebola, 21 (75%) reported touching the man's corpse, and 16 (57%) reported having direct contact with the pharmacist before he died. Immediate, safe, dignified burials by trained teams with appropriate protective equipment are critical to interrupt transmission and control Ebola during times of active community transmission; these measures remain important during the current response phase.

Public Confidence in the Health Care System 1 Year After the Start of the Ebola Virus Disease Outbreak - Sierra Leone, July 2015.

Ensuring confidence in the health care system has been a challenge to Ebola virus disease (Ebola) response and recovery efforts in Sierra Leone (1). A national multistage cluster-sampled household survey to assess knowledge, attitudes, and practices (KAP) related to Sierra Leone's health care system was conducted in July 2015. Among 3,564 respondents, 93% were confident that a health care facility could treat suspected Ebola cases, and approximately 90% had confidence in the health system's ability to provide non-Ebola services, including immunizations, antenatal care, and maternity care. Respondents in districts with ongoing Ebola transmission ("active districts") and respondents with higher educational levels reported more confidence in the health care system than did respondents in nonactive districts and respondents with less education. Active districts were the focus of the Ebola response; these districts implemented intensified social mobilization and communication efforts, and established district response centers, Ebola-specific health care facilities, and ambulances. Greater infrastructure and response capacity might have resulted in higher confidence in the health care system in these areas. Respondents ranked Ebola and malaria as the country's most important health issues. Health system recovery efforts in Sierra Leone can build on existing public confidence in the health system.

Establishment of an Ebola Treatment Unit and Laboratory - Bombali District, Sierra Leone, July 2014-January 2015.

The first confirmed case of Ebola virus disease (Ebola) in Sierra Leone related to the ongoing epidemic in West Africa occurred in May 2014, and the outbreak quickly spread. To date, 8,704 Ebola cases and 3,955 Ebola deaths have been confirmed in Sierra Leone. The first Ebola treatment units (ETUs) in Sierra Leone were established in the eastern districts of Kenema and Kailahun, where the first Ebola cases were detected, and these districts were also the first to control the epidemic. By September and October 2014, districts in the western and northern provinces, including Bombali, had the highest case counts, but additional ETUs outside of the eastern province were not operational for weeks to months. Bombali became one of the most heavily affected districts in Sierra Leone, with 873 confirmed patients with Ebola during July-November 2014. The first ETU and laboratory in Bombali District were established in late November and early December 2014, respectively. T- evaluate the impact of the first ETU and laboratory becoming operational in Bombali on outbreak control, the Bombali Ebola surveillance team assessed epidemiologic indicators before and after the establishment of the first ETU and laboratory in Bombali. After the establishment of the ETU and laboratory, the interval from symptom onset to laboratory result and from specimen collection to laboratory result decreased. By providing treatment to Ebola patients and isolating contagious persons to halt ongoing community transmission, ETUs play a critical role in breaking chains of transmission and preventing uncontrolled spread of Ebola (4). Prioritizing and expediting the establishment of an ETU and laboratory by pre-positioning resources needed to provide capacity for isolation, testing, and treatment of Ebola are essential aspects of pre-outbreak planning.

2008 outbreak of Salmonella Saintpaul infections associated with raw produce.

BACKGROUND: Raw produce is an increasingly recognized vehicle for salmonellosis. We investigated a nationwide outbreak that occurred in the United States in 2008. METHODS: We defined a case as diarrhea in a person with laboratory-confirmed infection with the outbreak strain of Salmonella enterica serotype Saintpaul. Epidemiologic, traceback, and environmental studies were conducted. RESULTS: Among the 1500 case subjects, 21% were hospitalized, and 2 died. In three case-control studies of cases not linked to restaurant clusters, illness was significantly associated with eating raw tomatoes (matched odds ratio, 5.6; 95% confidence interval [CI], 1.6 to 30.3); eating at a Mexican-style restaurant (matched odds ratio, 4.6; 95% CI, 2.1 to ∞) and eating pico de gallo salsa (matched odds ratio, 4.0; 95% CI, 1.5 to 17.8), corn tortillas (matched odds ratio, 2.3; 95% CI, 1.2 to 5.0), or salsa (matched odds ratio, 2.1; 95% CI, 1.1 to 3.9); and having a raw jalapeño pepper in the household (matched odds ratio, 2.9; 95% CI, 1.2 to 7.6). In nine analyses of clusters associated with restaurants or events, jalapeño peppers were implicated in all three clusters with implicated ingredients, and jalapeño or serrano peppers were an ingredient in an implicated item in the other three clusters. Raw tomatoes were an ingredient in an implicated item in three clusters. The outbreak strain was identified in jalapeño peppers collected in Texas and in agricultural water and serrano peppers on a Mexican farm. Tomato tracebacks did not converge on a source. CONCLUSIONS: Although an epidemiologic association with raw tomatoes was identified early in this investigation, subsequent epidemiologic and microbiologic evidence implicated jalapeño and serrano peppers. This outbreak highlights the importance of preventing raw-produce contamination.

Mortality caused by chronic liver disease among American Indians and Alaska Natives in the United States, 1999-2009.

OBJECTIVES: We compared chronic liver disease (CLD) mortality from 1999 to 2009 between American Indians and Alaska Natives (AI/ANs) and Whites in the United States after improving CLD case ascertainment and AI/AN race classification. METHODS: We defined CLD deaths and causes by comprehensive death certificate-based diagnostic codes. To improve race classification, we linked US mortality data to Indian Health Service enrollment records, and we restricted analyses to Contract Health Service Delivery Areas and to non-Hispanic populations. We calculated CLD death rates (per 100,000) in 6 geographic regions. We then described trends using linear modeling. RESULTS: CLD mortality increased from 1999 to 2009 in AI/AN persons and Whites. Overall, the CLD death rate ratio (RR) of AI/AN individuals to Whites was 3.7 and varied by region. The RR was higher in women (4.7), those aged 25 to 44 years (7.4), persons residing in the Northern Plains (6.4), and persons dying of cirrhosis (4.0) versus hepatocellular carcinoma (2.5), particularly those aged 25 to 44 years (7.7). CONCLUSIONS: AI/AN persons had greater CLD mortality, particularly from premature cirrhosis, than Whites, with variable mortality by region. Comprehensive prevention and care strategies are urgently needed to stem the CLD epidemic among AI/AN individuals.

Infectious disease mortality among American Indians and Alaska Natives, 1999-2009.

OBJECTIVES: We described death rates and leading causes of death caused by infectious diseases (IDs) in American Indian/Alaska Native (AI/AN) persons. Methods. We analyzed national mortality data, adjusted for AI/AN race by linkage with Indian Health Service registration records, for all US counties and Contract Health Service Delivery Area (CHSDA) counties. The average annual 1999 to 2009 ID death rates per 100,000 persons for AI/AN persons were compared with corresponding rates for Whites. RESULTS: The ID death rate in AI/AN populations was significantly higher than that of Whites. A reported 8429 ID deaths (rate 86.2) in CHSDA counties occurred among AI/AN persons; the rate was significantly higher than the rate in Whites (44.0; rate ratio [RR] = 1.96; 95% confidence interval [CI] = 1.91, 2.00). The rates for the top 10 ID underlying causes of death were significantly higher for AI/AN persons than those for Whites. Lower respiratory tract infection and septicemia were the top-ranked causes. The greatest relative rate disparity was for tuberculosis (RR = 13.51; 95% CI = 11.36, 15.93). CONCLUSIONS: Health equity might be furthered by expansion of interventions to reduce IDs among AI/AN communities.

Lack of access to treatment as a barrier to HCV screening: a facility-based assessment in the Indian health service.

The US Centers for Disease Control and Prevention recently issued new recommendations to screen persons born between 1945 and 1965 for hepatitis C virus. Federal facilities in the US Indian Health Service were surveyed on knowledge and support for the hepatitis C virus recommendations, as well as barriers and concerns.

Trends in lower respiratory tract infection hospitalizations among American Indian/Alaska Native children and the general US child population.

OBJECTIVE: To describe trends in the rate of hospitalization for lower respiratory tract infection (LRTI) among American Indian/Alaska Native (AI/AN) children and the general US population of children aged <5 years. STUDY DESIGN: This was a retrospective analysis of trends and hospitalization rates for LRTI-associated hospitalizations in 1998-2008 among AI/AN children aged <5 years using the Indian Health Service direct/contract inpatient data, and also among the general population of US children aged <5 years using the Nationwide Inpatient Sample. RESULTS: The 2006-2008 LRTI-associated hospitalization rate for AI/AN children aged <5 years (21.8 per 1000/year) was 32% lower than the 1998-1999 rate, and 1.6-fold higher than the general US children rate (13.8 per 1000/year; 95% CI, 12.8-14.8). Higher rates were seen in AI/AN children aged <5 years in the Alaska and the Southwest regions of the United States (41.2 and 28.0 per 1000/year, respectively). In infants, these rates were 136.4 and 82.4 per 1000/year, respectively, exceeding the rate in the general US infant population (37.1 per 1000/year; 95% CI, 34.3-40.0). The greatest disparity in the LRTI-associated hospitalization rate between AI/AN infants and the general US infant population was seen for pneumonia, with a 3-fold higher rate in AI/AN infants (36.2 per 1000/year vs 12.7 per 1000/year; 95% CI, 11.8-13.6). CONCLUSION: The LRTI-associated hospitalization rate is higher in AI/AN children, particularly infants from Alaska and the American Southwest, compared with the general US child population. Closing this gap will require addressing housing and sanitation inequities and ensuring high immunization rates and access to care.

Frequency and spelling of names in the Sierra Leone Ebola Database.

Although there is no published analysis of surnames and given names used in Sierra Leone, certain names are common and identical names are frequently encountered. This makes disease tracking and contact tracing difficult. During the Ebola outbreak in 2014-2016, deficiencies in public health information systems in Sierra Leone exacerbated data collection difficulties. The study objective was to examine frequency of names recorded in the Viral Hemorrhagic Fever database (VHF) component of the Sierra Leone Ebola Database (SLED). First names and surnames were standardized by a Sierra Leonean linguist. Frequencies of standardized first names, surnames, full names, and initials were analyzed. The most frequent surname was used by 18.2% of VHF records and the most frequent 20 surnames accounted for 74.1%. The most frequent male first name accounted for 5.5% of VHF records and the most frequent female first name for 4.6%. The 20 most frequent full names accounted for 12.4% of records, and the most frequent initials were used in 7.3% of VHF records. A limited number of names are used in Sierra Leone, which poses a challenge to large public health responses. Algorithms that address inconsistent spelling could be used to improve computer-based databases. Databases must also use variables other than name for identification. The lessons learned in this analysis can assist other investigations, particularly those requiring contact tracing to limit disease spread.

Facilitating Real-Time, Multidirectional Learning for Clinicians in a Low-Evidence Pandemic Response.

As COVID-19 was declared a health emergency in March 2020, there was immense demand for information about the novel pathogen. This paper examines the clinician-reported impact of Project ECHO COVID-19 Clinical Rounds on clinician learning. Primary sources of study data were Continuing Medical Education (CME) Surveys for each session from the dates of March 24, 2020 to July 30, 2020 and impact surveys conducted in November 2020, which sought to understand participants' overall assessment of sessions. Quantitative analyses included descriptive statistics and Mann-Whitney testing. Qualitative data were analyzed through inductive thematic analysis. Clinicians rated their knowledge after each session as significantly higher than before that session. 75.8% of clinicians reported they would 'definitely' or 'probably' use content gleaned from each attended session and clinicians reported specific clinical and operational changes made as a direct result of sessions. 94.6% of respondents reported that COVID-19 Clinical Rounds helped them provide better care to patients. 89% of respondents indicated they 'strongly agree' that they would join ECHO calls again.COVID-19 Clinical Rounds offers a promising model for the establishment of dynamic peer-to-peer tele-mentoring communities for low or no-notice response where scientifically tested or clinically verified practice evidence is limited.

Implementation of SARS-CoV-2 Monoclonal Antibody Infusion Sites at Three Medical Centers in the United States: Strengths and Challenges Assessment to Inform COVID-19 Pandemic and Future Public Health Emergency Use.

Monoclonal antibody therapeutics to treat coronavirus disease (COVID-19) have been authorized by the US Food and Drug Administration under Emergency Use Authorization (EUA). Many barriers exist when deploying a novel therapeutic during an ongoing pandemic, and it is critical to assess the needs of incorporating monoclonal antibody infusions into pandemic response activities. We examined the monoclonal antibody infusion site process during the COVID-19 pandemic and conducted a descriptive analysis using data from 3 sites at medical centers in the United States supported by the National Disaster Medical System. Monoclonal antibody implementation success factors included engagement with local medical providers, therapy batch preparation, placing the infusion center in proximity to emergency services, and creating procedures resilient to EUA changes. Infusion process challenges included confirming patient severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positivity, strained staff, scheduling, and pharmacy coordination. Infusion sites are effective when integrated into pre-existing pandemic response ecosystems and can be implemented with limited staff and physical resources.