COVID-19 Adult, Childhood, and Adolescent Vaccination Coverage Among Military and Civilian Families, United States.

INTRODUCTION: The COVID-19 pandemic affected the lives of military members and their families, with over 400,000 cases among U.S. military members since the start of the pandemic. The objective of this study is to examine and compare COVID-19 vaccination coverage of military members (active duty and Reserve/National Guard) and their family members (spouses, children, and adolescents) to that of their civilian counterparts using a large, nationally representative study. METHODS: Data from March 2 to May 9, 2022, of the Household Pulse Survey were analyzed for this study (n = 207,758). COVID-19 vaccination status (≥1 dose) was assessed for military members and their spouses, civilians, and children (aged 5 to 11 and 12 to 17 years) from both military and civilian families. Differences between military members, spouses, and their children compared to civilian adults and children were assessed using chi-squared and t-tests. Multivariable logistic regression was used to examine the association between military status and COVID-19 vaccination after controlling for sociodemographic characteristics. Reasons for not getting vaccinated for adults and children from military and civilian families were assessed. RESULTS: Compared to civilian adults and adjusted for sociodemographic characteristics, military members were more likely to be vaccinated (adjusted prevalence ratio = 1.07, 95% CI: 1.01-1.13). Vaccination coverage between active duty and civilian adults differed by subgroups. For example, among military members, COVID-19 vaccination coverage decreased with increasing age, from 87.5% among those aged 18 to 39 years to 56.0% among those aged ≥55 years. In contrast, among civilian adults, vaccination coverage increased with increasing age, from 78.5% among those aged 18 to 39 years to 91.2% among those aged ≥55 years. Military members were also less likely to be vaccinated than their civilian counterparts if they were Hispanic (68.5% vs. 85.2%), had a Bachelor's degree or higher (87.5% vs. 93.8%), or had $100,000 or more in annual household income (76.7% vs. 92.6%). Military members who had anxiety or depression (70.1%) were less likely to be vaccinated compared to civilian adults (84.4%). Military spouses (74.4%) were less likely to be vaccinated than civilian adults (84.7%). Children and adolescents who were homeschooled (35.1%) or had no preventive checkups in the past year (32.4%) were less likely to be vaccinated than their respective counterparts (52.5% and 54.0%, respectively). Military adults compared to civilian adults were more likely to report lack of trust in the government (47.5% vs. 35.2%) and, for children/adolescents, the belief that the vaccine is not needed (42.1% vs. 28.1%) as reasons for non-vaccination. CONCLUSIONS: Despite vaccine mandates and the high vaccination coverage found among the majority of military members, disparities exist in some subgroups. Educational interventions and increased communication from trusted leaders, such as medical providers and commanders, could increase confidence in vaccines among military families. Ensuring access to vaccines, empowering healthcare providers to recommend vaccines, and reminding parents of missed vaccinations or preventive checkups can help improve vaccination coverage. Achieving high vaccination among military members and their families is essential in protecting those in the forefront of the pandemic response and promoting the safety and security of the nation.

Delays in Children's Preventive Health Services During the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVES: Stay-at-home orders, social isolation recommendations, and fear of COVID-19 exposure have led to delays in children's preventive health services during the pandemic. Delays can lead to missed opportunities for early screening and detection of health problems, and increased risks for outbreaks of vaccine-preventable diseases. Understanding prevalence of and reasons for missed, delayed, or skipped preventive health services is important for developing strategies to achieve rapid catch-up of essential health services. METHODS: Using the Household Pulse Survey (n=37,064), a large, nationally-representative household survey fielded from April 14 to May 10, 2021, we examined prevalence of households with children who have missed, delayed, or skipped preventive health services, and factors associated with and reasons contributing to missed, delayed, or skipped preventive health services. RESULTS: About one-quarter of parents had children who missed, delayed, or skipped preventive check-ups in the past year. Delays in children's preventive health services were more common among respondents with higher education, households with greater numbers of children, and children who learned remotely or did not participate in formal education. Main reasons attributed to delayed preventive health services were limited appointments at health providers' offices (42.9%), concern about COVID-19 exposure at health providers' offices (42.2%), and closed health providers' offices due to the pandemic (29.0%). CONCLUSIONS: Physician office closures and concern about COVID-19 exposure resulted in over one-quarter of parents delaying preventive services for their children since the pandemic began. Coordinated efforts are needed to achieve rapid catch-up of preventive services and routine vaccines.

Analysis of False-Negative Human Immunodeficiency Virus Rapid Tests Performed on Oral Fluid in 3 International Clinical Research Studies.

BACKGROUND.: The OraQuick Advance Rapid HIV-1/2 Test is a point-of-care test capable of detecting human immunodeficiency virus (HIV)-specific antibodies in blood and oral fluid. To understand test performance and factors contributing to false-negative results in longitudinal studies, we examined results of participants enrolled in the Botswana TDF/FTC Oral HIV Prophylaxis Trial, the Bangkok Tenofovir Study, and the Bangkok MSM Cohort Study, 3 separate clinical studies of high-risk, HIV-negative persons conducted in Botswana and Thailand. METHODS.: In a retrospective observational analysis, we compared oral fluid OraQuick (OFOQ) results among participants becoming HIV infected to results obtained retrospectively using enzyme immunoassay and nucleic acid amplification tests on stored specimens. We categorized negative OFOQ results as true-negative or false-negative relative to nucleic acid amplification test and/or enzyme immunoassay, and determined the delay in OFOQ conversion relative to the estimated time of infection. We used log-binomial regression and generalized estimating equations to examine the association between false-negative results and participant, clinical, and testing-site factors. RESULTS.: Two-hundred thirty-three false-negative OFOQ results occurred in 80 of 287 seroconverting individuals. Estimated OFOQ conversion delay ranged from 14.5 to 547.5 (median, 98.5) days. Delayed OFOQ conversion was associated with clinical site and test operator (P < .05), preexposure prophylaxis (P = .01), low plasma viral load (P < .02), and time to kit expiration (P < .01). Participant age, sex, and HIV subtype were not associated with false-negative results. Long OFOQ conversion delay time was associated with antiretroviral exposure and low plasma viral load. CONCLUSIONS.: Failure of OFOQ to detect HIV-1 infection was frequent and multifactorial in origin. In longitudinal trials, negative oral fluid results should be confirmed via testing of blood samples.

Bone mineral density changes among HIV-uninfected young adults in a randomised trial of pre-exposure prophylaxis with tenofovir-emtricitabine or placebo in Botswana.

BACKGROUND: Tenofovir-emtricitabine (TDF-FTC) pre-exposure prophylaxis (PrEP) has been found to be effective for prevention of HIV infection in several clinical trials. Two studies of TDF PrEP among men who have sex with men showed slight bone mineral density (BMD) loss. We investigated the effect of TDF and the interaction of TDF and hormonal contraception on BMD among HIV-uninfected African men and women. METHOD: We evaluated the effects on BMD of using daily oral TDF-FTC compared to placebo among heterosexual men and women aged 18-29 years enrolled in the Botswana TDF2 PrEP study. Participants had BMD measurements at baseline and thereafter at 6-month intervals with dual-energy X-ray absorptiometry (DXA) scans at the hip, spine, and forearm. RESULTS: A total of 220 participants (108 TDF-FTC, 112 placebo) had baseline DXA BMD measurements at three anatomic sites. Fifteen (6.8%) participants had low baseline BMD (z-score of <-2.0 at any anatomic site), including 3/114 women (2.6%) and 12/106 men (11.3%) (p = 0.02). Low baseline BMD was associated with being underweight (p = 0.02), having high blood urea nitrogen (p = 0.02) or high alkaline phosphatase (p = 0.03), and low creatinine clearance (p = 0.04). BMD losses of >3.0% at any anatomic site at any time after baseline were significantly greater for the TDF-FTC treatment group [34/68 (50.0%) TDF-FTC vs. 26/79 (32.9%) placebo; p = 0.04]. There was a small but significant difference in the mean percent change in BMD from baseline for TDF-FTC versus placebo at all three sites at month 30 [forearm -0.84% (p = 0.01), spine -1.62% (p = 0.0002), hip -1.51% (p = 0.003)]. CONCLUSION: Use of TDF-FTC was associated with a small but statistically significant decrease in BMD at the forearm, hip and lumbar spine. A high percentage (6.8%) of healthy Batswana young adults had abnormal baseline BMD Further evaluation is needed of the longer-term use of TDF in HIV-uninfected persons. TRIAL REGISTRATION: ClinicalTrials.gov NCT00448669.

CD4(+) cell count, viral load, and drug resistance patterns among heterosexual breakthrough HIV infections in a study of oral preexposure prophylaxis.

We examined CD4 cell count and plasma viral load patterns among Botswana TDF/FTC Oral HIV Prophylaxis Trial (TDF2 study) participants who seroconverted, comparing participants assigned to receive tenofovir/emtricitabine with participants assigned to receive placebo. We also evaluated for antiretroviral drug resistance among the breakthrough HIV infections. Among nine seroconverters assigned to tenofovir/emtricitabine and 24 to placebo, there were no significant differences in their CD4 cell count or viral load profiles over time. Of the four participants who seroconverted on-study while receiving tenofovir/emtricitabine, none became infected as a result of drug-resistant HIV; moreover, no resistance mutations emerged following seroconversion.

Hospital preparedness for emergency response: United States, 2008.

OBJECTIVE: This report is a summary of hospital preparedness for responding to public health emergencies, including mass casualties and epidemics of naturally occurring diseases such as influenza. METHODS: Data are from an emergency response preparedness supplement to the 2008 National Hospital Ambulatory Medical Care Survey, which uses a national probability sample of nonfederal general and short-stay hospitals in the United States. Sample data were weighted to produce national estimates.

Blood pressure measurements at emergency department visits by adults: United States, 2007-2008.

This brief shows that elevated BP readings are much more common at visits to the ED than at visits to outpatient primary care providers. Compared with the 27.0% prevalence found at visits to primary care providers, the combined visit prevalence of severely and moderately elevated BP in EDs is about 43.5%. Disproportionately affected subgroups include patients who are older, male, non-Hispanic black, Medicare beneficiaries, or uninsured.One reason that elevated BP may be observed more frequently in the ED than at visits to primary care providers is that adults in less than optimal general health are more likely to use the ED than those in good health (4). Two national objectives related to prevention of heart disease and stroke are (a) to reduce the proportion of adults with hypertension and (b) to increase the proportion of adults with hypertension whose BP is under control (5). ED visits could provide opportunities to address elevated BP through patient education, initial treatment, and referral to primary care as deemed clinically appropriate.

Ambulatory medical care in rural Haiti.

INTRODUCTION: In 2005, a team of U.S. physicians, nurse practitioners, nurses, pharmacists, emergency medical technicians and lay support personnel provided health services in an isolated town in rural Haiti. METHODS: During one week, the team saw 788 patients. They recorded age, sex, vital signs, diagnoses, and treatments in an electronic database. A descriptive analysis is presented. RESULTS: Intestinal parasitosis was the third most common diagnosis overall, and the most common diagnosis for children. For adults aged 50 years or older, 52% of women and 37% of men had elevated blood pressures, significantly more than adults aged 15-49 years. DISCUSSION: This paper focuses on intestinal parasitosis and hypertension. Periodic anti-helminthic treatment and community sanitation are discussed as ways to reduce the burden of parasites and secondary malnutrition. Challenges to implementing a sustainable antihypertensive program are discussed, including patient education, medication availability and prioritization, and adequate follow-up in a very austere rural setting.

Research using emergency department-related data sets: current status and future directions.

The 2009 Academic Emergency Medicine consensus conference focused on "Public Health in the ED: Surveillance, Screening and Intervention." One conference breakout session discussed the significant research value of health-related data sets. This article represents the proceedings from that session, primarily focusing on emergency department (ED)-related data sets and includes examples of the use of a data set based on ED visits for research purposes. It discusses types of ED-related data sets available, highlights barriers to research use of ED-related data sets, and notes limitations of these data sets. The paper highlights future directions and challenges to using these important sources of data for research, including identification of five main needs related to enhancing the use of ED-related data sets. These are 1) electronic linkage of initial and follow-up ED visits and linkage of information about ED visits to other outcomes, including costs of care, while maintaining de-identification of the data; 2) timely data access with minimal barriers; 3) complete data collection for clinically relevant and/or historical data elements, such as the external cause-of-injury code; 4) easy access to data that can be parsed into smaller jurisdictions (such as states) for policy and/or research purposes, while maintaining confidentiality; and 5) linkages between health survey data and health claims data. ED-related data sets contain much data collected directly from health care facilities, individual patient records, and multiple other sources that have significant potential impact for studying and improving the health of individuals and the population.

National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary.

OBJECTIVE: This report presents the most current (2006) nationally representative data on visits to hospital emergency departments (ED) in the United States. Statistics are presented on selected hospital, patient, and visit characteristics. METHODS: Data are from the 2006 National Hospital Ambulatory Medical Care Survey (NHAMCS), the longest continuously running nationally representative survey of hospital ED utilization. The NHAMCS collects data on visits to emergency and outpatient departments of nonfederal, short-stay, and general hospitals in the United States. Sample data are weighted to produce annual national estimates. RESULTS: In 2006 there were 119.2 million visits to hospital EDs, or 40.5 visits per 100 persons, continuing a long-term rise in both indices. The rate of visits per 100 persons was 36.1 for white persons, 79.9 for black persons, and 35.3 for Hispanic persons. ED occupancy (the count of patients who had arrived, but not yet discharged, transferred, or admitted) varied from 19,000 patients at 6 a.m. to 58,000 at 7 p.m. on an average day nationally. Though overall ED visits increased, the number of visits considered emergent or urgent (15.9 million) did not change significantly from 2005, nor did the number of patients arriving by ambulance (18.4 million). At 3.6 percent of visits, the patient had been seen in the same ED within the previous 72 hours. Median time to see a clinician was 31 minutes. Of all ED visits, 35.6 percent were for an injury. Patients had computerized tomography or magnetic resonance imaging at 12.1 percent of visits, blood drawn at 38.8 percent, an intravenous line started at 24.0 percent, an x ray performed at 34.9 percent, and an electrocardiogram done at 17.1 percent. Patients were admitted to the hospital at 12.8 percent of ED visits in 2006. The ED was the portal of admission for 50.2 percent of all nonobstetric admissions in the United States in 2006, an increase from 36.0 percent in 1996. Patients were admitted to an intensive care unit at 1.9 percent of visits.

Hospital collaboration with public safety organizations on bioterrorism response.

OBJECTIVE: To identify hospital characteristics that predict collaboration with public safety organizations on bioterrorism response plans and mass casualty drills. METHODS: The 2003 and 2004 Bioterrorism and Mass Casualty Supplements to the National Hospital Ambulatory Medical Care Survey examined collaboration with emergency medical services (EMS), hazardous materials teams (HAZMAT), fire departments, and law enforcement. The sample included 112 geographic primary sampling units and 1,110 hospitals. Data were weighted by inverse selection probability, to yield nationally representative estimates. Characteristics included residency and medical school affiliation, bed capacity, ownership, urbanicity and Joint Commission accreditation. The response rate was 84.6%. Chi-square analysis was performed with alpha set at p < 0.05. Logistic regression modeling yielded odds ratios with 95% confidence intervals. RESULTS: During a bioterrorism incident, 68.9% of hospitals would contact EMS, 68.7% percent law enforcement, 61.6% fire departments, 58.1% HAZMAT, and 42.8% all four. About 74.2% had staged mass casualty drills with EMS, 70.4% with fire departments, 67.4% with law enforcement, 43.3% with HAZMAT, and 37.0% with all four. Predictors of drilling with some or all of these public safety organizations included larger bed capacity, nonprofit and proprietary ownership, and JCAHO accreditation. Medical school affiliation was a negative predictor of drilling with EMS. CONCLUSIONS: The majority of hospitals involve public safety organizations in their emergency plans or drills. Bed capacity was most predictive of drilling with these organizations. Medical school affiliation was the only characteristic negatively associated with drilling.

Emergency response planning in hospitals, United States: 2003-2004.

OBJECTIVE: This study presents baseline data to determine which hospital characteristics are associated with preparedness for terrorism and natural disaster in the areas of emergency response planning and availability of equipment and specialized care units. METHODS: Information from the Bioterrorism and Mass Casualty Preparedness Supplements to the 2003 and 2004 National Hospital Ambulatory Medical Care Surveys was used to provide national estimates of variations in hospital emergency response plans and resources by residency and medical school affiliation, hospital size, ownership, metropolitan statistical area status, and Joint Commission accreditation. Of 874 sampled hospitals with emergency or outpatient departments, 739 responded for an 84.6 percent response rate. Estimates are presented with 95 percent confidence intervals. RESULTS: About 92 percent of hospitals had revised their emergency response plans since September 11, 2001, but only about 63 percent had addressed natural disasters and biological, chemical, radiological, and explosive terrorism in those plans. Only about 9 percent of hospitals had provided for all 10 of the response plan components studied. Hospitals had a mean of about 14 personal protective suits, 21 critical care beds, 12 mechanical ventilators, 7 negative pressure isolation rooms, and 2 decontamination showers each. Hospital bed capacity was the factor most consistently associated with emergency response planning and availability of resources.

National Ambulatory Medical Care Survey: terrorism preparedness among office-based physicians, United States, 2003-2004.

OBJECTIVES: This investigation describes terrorism preparedness among U.S. office-based physicians and their staffs in identification and diagnosis of terrorism-related conditions, training methods and sources, and assistance with diagnosis and reporting. METHODS: The National Ambulatory Medical Care Survey (NAMCS) is an annual national probability survey of approximately 3,000 U.S. nonfederal, office-based physicians. Terrorism preparedness items were added in 2003 and 2004. RESULTS: About 40 percent of physicians or their staffs received training for anthrax or smallpox, but less than one-third received training for any of the other exposures. About 42.2 percent of physicians, 13.5 percent of nurses, and 9.4 percent of physician assistants and nurse practitioners received training in at least one exposure. Approximately 56.2 percent of physicians indicated that they would contact state or local public health officials for diagnostic assistance more frequently than federal agencies and other sources. About 67.1 percent of physicians indicated that they would report a suspected terrorism-related condition to the state or local health department, 50.9 percent to the Centers for Disease Control and Prevention (CDC), 27.5 percent to the local hospital, and 1.8 percent to a local elected official's office. Approximately 78.8 percent of physicians had contact information for the local health department readily available. About 53.7 percent had reviewed the diseases reportable to health departments since September 2001, 11.3 percent had reviewed them before that month, and 35 percent had never reviewed them.

National Hospital Ambulatory Medical Care Survey: 2005 emergency department summary.

OBJECTIVE: This report presents the most current (2005) nationally representative data on visits to hospital emergency departments (ED) in the United States. Statistics are presented on selected hospital, patient, and visit characteristics. Selected trends in ED utilization from 1995 through 2005 are also presented. METHODS: Data are from the 2005 National Hospital Ambulatory Medical Care Survey (NHAMCS), the longest continuously running nationally representative survey of hospital ED and outpatient department (OPD) utilization. The NHAMCS collects data on visits to emergency and outpatient departments of nonfederal, short-stay, and general hospitals in the United States. Sample data are weighted to produce annual national estimates. RESULTS: During 2005, an estimated 115.3 million visits were made to hospital EDs, about 39.6 visits per 100 persons. This represents on average roughly 30,000 visits per ED in 2005, a 31 percent increase over 1995 (23,000). Visit rates have shown an increasing trend since 1995 for persons 22-49 years of age, 50-64 years of age, and 65 years of age and over. In 2005, about 0.5 million (0.4 percent) of visits were made by homeless individuals. Nearly 18 million patients arrived by ambulance (15.5 percent). At 1.9 percent of visits, the patient had been discharged from the hospital within the previous 7 days. Abdominal pain, chest pain, fever, and cough were the leading patient complaints, accounting for nearly one-fifth of all visits. Abdominal pain was the leading illness-related diagnosis at ED visits. There were an estimated 41.9 million injury-related visits or 14.4 visits per 100 persons. Diagnostic and screening services were provided at 71.1 percent of visits, and procedures were performed at 47.3 percent of visits. Medications were either given in the ED or prescribed at discharge at 76.7 percent of visits, resulting in 204.9 million drug mentions. On average, patients spent 56.3 minutes waiting to see a physician, and 3.3 hours for the full duration of their ED visit. About 12 percent of ED visits resulted in hospital admission. The average total length of stay for those admitted was 5.2 days, and the leading principal hospital discharge diagnosis was nonischemic heart disease.

Emergency Response Planning in Hospitals, United States: 2003-2004

Objective: This study presents baseline data to determine which hospital characteristics are associated with preparedness for terrorism for terrorism and natural disaster in the areas of emergency response planning and availability of equipment and specialized care units. Methods: Information from the Bioterrorism and Mass Casualty Preparedness Suplements to the 2003 and 2004 National Hospital Ambulatory Medical Care Surveys was used to provide national estimates of variations in hospital emergency response plans and resources by residency and medical shcool affiliation, hospital size, ownership, metropolitan statistical area status, and Joint Commission accreditation. Of 874 sampled hospitals with emergency or outpatient departments, 739 responded for an 84.6 percent response rate. Estimates are presented with 95 percent confidence intervals. Results: About 92 percent of hospitals had revised their emergency response plans since September 11, 2001, but only about 63 percent had addressed natural disasters and biological, chemical, radiological, and explosive terrorism in those plans. Only about 9 percent of hospitals had provided for all 10 of the response plan components studied. Hospitals had a mean of about 14 personal protective suits, 21 critical care beds, 12 mechanical ventilators, 7 negative pressure isolation rooms, and 2 decontamination showers each. Hospital bed capacity was the factor most consistently associated with emergency response planning and availability of resources. (AU)

Terrorism preparedness: have office-based physicians been trained?

BACKGROUND AND OBJECTIVES: Terrorism may have a severe impact on physicians' practices. We examined terrorism preparedness training of office-based physicians. METHODS: The National Ambulatory Medical Care Survey uses a nationally representative multi-stage sampling design. In 2003 and 2004, physicians were asked if they had received training in six Category-A viral and bacterial diseases and chemical and radiological exposures. Differences were examined by age, degree, specialty, region, urbanicity, and managed care involvement. Chi-squares, t tests, and logistic regressions were performed in SUDAAN-9.0, with univariate significance at P<.05 and multivariate significance within 95% confidence intervals. RESULTS: Of 3,968 physicians, 56.3% responded. Forty-two percent were trained in at least one exposure. Primary care specialists were more likely than surgeons to be trained for all exposures. Medical specialists were more likely than surgeons to be trained for smallpox, anthrax, and plague. Physicians ages 55-69 years were less likely than those in their 30s to be trained for smallpox, anthrax, and chemical exposures. Managed care physicians were more likely to be trained for all exposures except botulism, tularemia, and hemorrhagic fever. CONCLUSIONS: Terrorism training frequencies were low, although primary care and managed care physicians reported more training than their counterparts.

Training for terrorism-related conditions in hospitals: United States, 2003-04.

OBJECTIVE: This study estimates baseline data to determine which hospital characteristics are associated with providing terrorism preparedness training to clinical staff. METHODS: Information from a Bioterrorism and Mass Casualty Supplement to the 2003 and 2004 National Hospital Ambulatory Medical Care Surveys was used to provide national estimates of variations in terrorism preparedness training by eight hospital characteristics. Of 874 hospitals in scope, 739 (84.6 percent) responded. Estimates are presented with 95 percent confidence intervals. RESULTS: Hospitals with Joint Commission accreditation were more likely to provide terrorism preparedness training to all types of clinical staff (staff physicians, residents, nurse practitioners, physician assistants, and laboratory staff). Teaching hospitals, medical school affiliation, bed capacity, and urban location were also associated with training staff physicians, residents, nurse practitioners, and physician assistants. Hospitals with residency programs were associated with training only staff physicians and residents. There was more parity across hospital characteristics in training nurses and laboratory staff than for physicians, residents, nurse practitioners, and physician assistants. Joint Commission accreditation was the most consistent factor associated with providing training for all nine exposures studied (smallpox, anthrax, chemical and radiological exposures, botulism, plague, tularemia, viral encephalitis, and hemorrhagic fever).

Bioterrorism and mass casualty preparedness in hospitals: United States, 2003.

OBJECTIVES: This study examined the content of hospital terrorism preparedness emergency response plans; whether those plans had been updated since September 11, 2001; collaboration of hospitals with outside organizations; clinician training in the management of biological, chemical, explosive, and nuclear exposures; drills on the response plans; and equipment and bed capacity. METHODS: The National Hospital Ambulatory Medical Care Survey (NHAMCS) is an annual survey of a probability sample of approximately 500 non-Federal general and short-stay hospitals in the United States. A Bioterrorism and Mass Casualty Supplement was included in the 2003 survey and provided the data for this analysis. RESULTS: Almost all hospitals have plans for responding to natural disasters (97.3 percent). Most have plans for responding to chemical (85.5 percent), biological (84.8 percent), nuclear or radiological (77.2 percent), and explosive incidents (76.9 percent). About three-quarters of hospitals were integrated into community-wide disaster plans (76.4 percent), and 75.9 percent specifically reported a cooperative planning process with other local health care facilities. Despite these plans, only 46.1 percent reported written memoranda of understanding with these facilities to accept inpatients during a declared disaster. Hospitals varied widely in their plans for re-arranging schedules and space in the event of a disaster. Training for hospital incident command and smallpox, anthrax, chemical, and radiological exposures was ahead of training for other infectious diseases. The percentage of hospitals training their staff in any exposure varied from 92.1 percent for nurses to 49.2 percent for medical residents. Drills for natural disasters occurred more often than those for chemical, biological, explosive, nuclear, and epidemic incidents. More hospitals staged drills for biological attacks than for severe epidemics. Despite explosions being the most common form of terrorism, drills for these were staged by only one-fifth of hospitals. Hospitals collaborated on drills most often with emergency medical services, fire departments, and law enforcement agencies.