Ethical frameworks should be applied to computational modelling of infectious disease interventions.

This perspective is part of an international effort to improve epidemiological models with the goal of reducing the unintended consequences of infectious disease interventions. The scenarios in which models are applied often involve difficult trade-offs that are well recognised in public health ethics. Unless these trade-offs are explicitly accounted for, models risk overlooking contested ethical choices and values, leading to an increased risk of unintended consequences. We argue that such risks could be reduced if modellers were more aware of ethical frameworks and had the capacity to explicitly account for the relevant values in their models. We propose that public health ethics can provide a conceptual foundation for developing this capacity. After reviewing relevant concepts in public health and clinical ethics, we discuss examples from the COVID-19 pandemic to illustrate the current separation between public health ethics and infectious disease modelling. We conclude by describing practical steps to build the capacity for ethically aware modelling. Developing this capacity constitutes a critical step towards ethical practice in computational modelling of public health interventions, which will require collaboration with experts on public health ethics, decision support, behavioural interventions, and social determinants of health, as well as direct consultation with communities and policy makers.

"I realized I was not alone": A mixed-methods investigation of the implementation of Ubuntu groups to reduce burnout and social isolation in an allopathic medical School in the Southeastern United States.

PURPOSE/BACKGROUND: Healthcare providers experience higher rates of workplace burnout, a reality highlighted by the COVID-19 pandemic. In response, small groups, inspired by South African philosophy, Ubuntu, were introduced to decrease burnout and social isolation and build community and belonging. This study examines how participation in these groups can impact these measures. METHODS: In this mixed-methods study, trained facilitators led small groups that utilized story-sharing to foster connections within the group and broader community. Quantitative and qualitative data were analyzed separately and merged to identify convergence. RESULTS: Three main qualitative themes emerged: 1) seeking and building connections and community, 2) curiosity, learning, and growing, and 3) open-hearted and thriving. These themes were linked to quantitative outcomes, showing a statistically significant decrease in social isolation among staff/faculty and students. Furthermore, faculty/staff exhibited reduced burnout compared to students, while students reported increased feelings of belonging. CONCLUSION: Participation in Ubuntu groups positively influenced students' sense of belonging, reduced faculty/staff burnout, and alleviated social isolation for all participants. Future research should explore the potential of this intervention to further promote wellness on medical campuses. Programs emphasizing the well-being of individuals, including faculty, staff, and students, are crucial for supporting the overall health of medical communities and the wider society.

Effect of etranacogene dezaparvovec on quality of life for severe and moderately severe haemophilia B participants: Results from the phase III HOPE-B trial 2 years after gene therapy.

INTRODUCTION: For people with haemophilia B (PwHB), bleeding may occur despite prophylaxis, negatively affecting health-related quality of life (HRQoL). The pivotal phase 3 HOPE-B trial investigating the adeno-associated virus gene transfer product, etranacogene dezaparvovec (EDZ), demonstrated sustained factor IX (FIX) activity and bleed protection in PwHB with baseline FIX levels ≤2%. AIM: Assess how EDZ affects HRQoL in HOPE-B trial participants. METHODS: HRQoL was evaluated using generic and disease-specific patient reported outcomes (PROs) including the EQ-5D-5L and the Hem-A-QoL questionnaires. Mean domain and total scores were compared 6 months pre- and the first 2 years post-EDZ administration using repeated measures linear mixed models. The percentage of participants with minimal clinically important improvements in HRQoL was also evaluated. RESULTS: Two years post-EDZ, there were nominally significant increases in the least squares (LS) mean score for the EQ-5D-5L Index Value (.04; p = .0129), reflecting better HRQoL. Nominally significant decreases in the LS mean scores, reflecting better HRQoL, were also found for the Hem-A-QoL total score (-6.0; p < .0001) and the Treatment (-13.94; p < .0001), Feelings (-9.01; p < .0001), Future (-6.45; p = .0004) and Work/School (-5.21; p = .0098) domains. The percentage of participants with ≥15-point improvement ranged from 45.83% (95% CI: 31.37%, 60.83%) for Treatment to 13.89% (95% CI: 4.67%, 29.50%) for Family Planning. Results were similar for Year 1. CONCLUSION: In conclusion, gene therapy with EDZ improved HRQoL in the first and second years in several Hem-A-QoL domains, including Treatment, Feelings, Work/School and Future domains, whereas improvement in other aspects of HRQoL were not demonstrated.

Ethical dilemma arises from optimizing interventions for epidemics in heterogeneous populations.

Interventions to mitigate the spread of infectious diseases, while succeeding in their goal, have economic and social costs associated with them. These limit the duration and intensity of the interventions. We study a class of interventions which reduce the reproduction number and find the optimal strength of the intervention which minimizes the final epidemic size for an immunity inducing infection. The intervention works by eliminating the overshoot part of an epidemic, and avoids a second wave of infections. We extend the framework by considering a heterogeneous population and find that the optimal intervention can pose an ethical dilemma for decision and policymakers. This ethical dilemma is shown to be analogous to the trolley problem. We apply this optimization strategy to real-world contact data and case fatality rates from three pandemics to underline the importance of this ethical dilemma in real-world scenarios.

High connectivity and human movement limits the impact of travel time on infectious disease transmission.

The speed of spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during the coronavirus disease 2019 (COVID-19) pandemic highlights the importance of understanding how infections are transmitted in a highly connected world. Prior to vaccination, changes in human mobility patterns were used as non-pharmaceutical interventions to eliminate or suppress viral transmission. The rapid spread of respiratory viruses, various intervention approaches, and the global dissemination of SARS-CoV-2 underscore the necessity for epidemiological models that incorporate mobility to comprehend the spread of the virus. Here, we introduce a metapopulation susceptible-exposed-infectious-recovered model parametrized with human movement data from 340 cities in China. Our model replicates the early-case trajectory in the COVID-19 pandemic. We then use machine learning algorithms to determine which network properties best predict spread between cities and find travel time to be most important, followed by the human movement-weighted personalized PageRank. However, we show that travel time is most influential locally, after which the high connectivity between cities reduces the impact of travel time between individual cities on transmission speed. Additionally, we demonstrate that only significantly reduced movement substantially impacts infection spread times throughout the network.

If Long-Term Suppression is not Possible, how do we Minimize Mortality for Infectious Disease Outbreaks?

OBJECTIVE: For any emerging pathogen, the preferred approach is to drive it to extinction with non-pharmaceutical interventions (NPI) or suppress its spread until effective drugs or vaccines are available. However, this might not always be possible. If containment is infeasible, the best people can hope for is pathogen transmission until population level immunity is achieved, with as little morbidity and mortality as possible. METHODS: A simple computational model was used to explore how people should choose NPI in a non-containment scenario to minimize mortality if mortality risk differs by age. RESULTS: Results show that strong NPI might be worse overall if they cannot be sustained compared to weaker NPI of the same duration. It was also shown that targeting NPI at different age groups can lead to similar reductions in the total number of infected, but can have strong differences regarding the reduction in mortality. CONCLUSIONS: Strong NPI that can be sustained until drugs or vaccines become available are always preferred for preventing infection and mortality. However, if people encounter a worst-case scenario where interventions cannot be sustained, allowing some infections to occur in lower-risk groups might lead to an overall greater reduction in mortality than trying to protect everyone equally.

Heterogeneity in network structure switches the dominant transmission mode of infectious diseases.

Several recent emerging diseases have exhibited both sexual and nonsexual transmission modes (Ebola, Zika, and mpox). In the recent mpox outbreaks, transmission through sexual contacts appears to be the dominant mode of transmission. Motivated by this, we use an SIR-like model to argue that an initially dominant sexual transmission mode can be overtaken by casual transmission at later stages, even if the basic casual reproduction number is less than one. Our results highlight the risk of intervention designs which are informed only by the early dynamics of the disease.

Cation Adaptive Structures Based on Manganese Cyanide Prussian Blue Analogues: Application of Powder Diffraction Data to Solve Complex, Unprecedented Stoichiometries and New Structure Types.

A Mn(II) salt and A+ CN- under anaerobic conditions react to form 2-D and 3-D extended structured compounds of Am MnII n (CN)m+2n stoichiometry. Here, the creation and characterization of this large family of compounds, for example AMnII 3 (CN)7 , A2 MnII 3 (CN)8 , A2 MnII 5 (CN)12 , A3 MnII 5 (CN)13 , and A2 MnII [MnII (CN)6 ], where A represents alkali and tetraalkylammonium cations, is reviewed. Cs2 MnII [MnII (CN)6 ] has the typical Prussian blue face centered cubic unit cell. However, the other alkali salts are monoclinic or rhombohedral. This is in accord with smaller alkali cation radii creating void space that is minimized by increasing the van der Waals stabilization energy by reducing ∠Mn-N≡C, which, strengthens the magnetic coupling and increases the magnetic ordering temperatures. This is attributed to the non-rigidity of the framework structure due the significant ionic character associated with the high-spin MnII sites. For larger tetraalkylammonium cations, the high-spin Mn sites lack sufficient electrostatic A+ ⋅⋅⋅NC stabilization and form unexpected 4- and 5-coordinated Mn sites within a flexible, extended framework around the cation; hence, the size, shape, and charge of the cation dictate the unprecedented stoichio-metry and unpredictable cation adaptive structures. Antiferromagnetic coupling between adjacent MnII sites leads to ferrimagnetic ordering, but in some cases antiferromagnetic coupling of ferrimagnetic layers are compensated and synthetic antiferromagnets are observed. The magnetic ordering temperatures for ferrimagnetic A2 MnII [MnII (CN)6 ] with both octahedral high- and low-spin MnII sites increase with decreasing ∠Mn-N≡C. The crystal structures for all of the extended structured materials were obtained by powder diffraction.

COVID-19 vaccine coverage targets to inform reopening plans in a low incidence setting.

Since the emergence of SARS-CoV-2 in 2019 through to mid-2021, much of the Australian population lived in a COVID-19-free environment. This followed the broadly successful implementation of a strong suppression strategy, including international border closures. With the availability of COVID-19 vaccines in early 2021, the national government sought to transition from a state of minimal incidence and strong suppression activities to one of high vaccine coverage and reduced restrictions but with still-manageable transmission. This transition is articulated in the national 're-opening' plan released in July 2021. Here, we report on the dynamic modelling study that directly informed policies within the national re-opening plan including the identification of priority age groups for vaccination, target vaccine coverage thresholds and the anticipated requirements for continued public health measures-assuming circulation of the Delta SARS-CoV-2 variant. Our findings demonstrated that adult vaccine coverage needed to be at least 60% to minimize public health and clinical impacts following the establishment of community transmission. They also supported the need for continued application of test-trace-isolate-quarantine and social measures during the vaccine roll-out phase and beyond.

Quantifying the impact of individual and collective compliance with infection control measures for ethical public health policy.

Infectious disease control measures often require collective compliance of large numbers of individuals to benefit public health. This raises ethical questions regarding the value of the public health benefit created by individual and collective compliance. Answering these requires estimating the extent to which individual actions prevent infection of others. We develop mathematical techniques enabling quantification of the impacts of individuals or groups complying with three public health measures: border quarantine, isolation of infected individuals, and prevention via vaccination/prophylaxis. The results suggest that (i) these interventions exhibit synergy: They become more effective on a per-individual basis as compliance increases, and (ii) there is often substantial "overdetermination" of transmission. If a susceptible person contacts multiple infectious individuals, an intervention preventing one transmission may not change the ultimate outcome (thus, risk imposed by some individuals may erode the benefits of others' compliance). These results have implications for public health policy during epidemics.

Permanent Porosity in the Room-Temperature Magnet and Magnonic Material V(TCNE)2.

Materials that simultaneously exhibit permanent porosity and high-temperature magnetic order could lead to advances in fundamental physics and numerous emerging technologies. Herein, we show that the archetypal molecule-based magnet and magnonic material V(TCNE)2 (TCNE = tetracyanoethylene) can be desolvated to generate a room-temperature microporous magnet. The solution-phase reaction of V(CO)6 with TCNE yields V(TCNE)2·0.95CH2Cl2, for which a characteristic temperature of T* = 646 K is estimated from a Bloch fit to variable-temperature magnetization data. Removal of the solvent under reduced pressure affords the activated compound V(TCNE)2, which exhibits a T* value of 590 K and permanent microporosity (Langmuir surface area of 850 m2/g). The porous structure of V(TCNE)2 is accessible to the small gas molecules H2, N2, O2, CO2, ethane, and ethylene. While V(TCNE)2 exhibits thermally activated electron transfer with O2, all the other studied gases engage in physisorption. The T* value of V(TCNE)2 is slightly modulated upon adsorption of H2 (T* = 583 K) or CO2 (T* = 596 K), while it decreases more significantly upon ethylene insertion (T* = 459 K). These results provide an initial demonstration of microporosity in a room-temperature magnet and highlight the possibility of further incorporation of small-molecule guests, potentially even molecular qubits, toward future applications.

Artificial Antiferromagnets Possessing Extended Zero-, One-, Two-, and Three-Dimensional Structures.

Layered (2D) artificial (or synthetic) antiferromagnets are fabricated by atom deposition techniques and possess very thin, nanometer-scale, magnetically ordered layers separated by a very thin nonmagnetic layer that antiferromagnetically couples the magnetic layers. Artificial antiferromagnets were crucial in the discovery of the giant magnetic effect (GMR), which had an incredible impact on the evolution of computer memory and its applications, and nucleated the dawn of spintronics (magnetoelectrics). The fundamental structural motif has been more recently achieved by using synthetic chemical methods that led to insulating artificial antiferromagnets. Examples of magnetically ordered layers that are antiferromagnetic coupled to form artificial antiferromagnets have been extended to isolated ions (0D) as well as extended chain (1D) and extended network 3D structures, and new phenomena and applications are anticipated as insulating antiferromagnets are more effective at propagating spin currents with respect to dielectric materials.

Approximating Quasi-Stationary Behaviour in Network-Based SIS Dynamics.

Deterministic approximations to stochastic Susceptible-Infectious-Susceptible models typically predict a stable endemic steady-state when above threshold. This can be hard to relate to the underlying stochastic dynamics, which has no endemic steady-state but can exhibit approximately stable behaviour. Here, we relate the approximate models to the stochastic dynamics via the definition of the quasi-stationary distribution (QSD), which captures this approximately stable behaviour. We develop a system of ordinary differential equations that approximate the number of infected individuals in the QSD for arbitrary contact networks and parameter values. When the epidemic level is high, these QSD approximations coincide with the existing approximation methods. However, as we approach the epidemic threshold, the models deviate, with these models following the QSD and the existing methods approaching the all susceptible state. Through consistently approximating the QSD, the proposed methods provide a more robust link to the stochastic models.

The Impact of Contact Structure and Mixing on Control Measures and Disease-Induced Herd Immunity in Epidemic Models: A Mean-Field Model Perspective.

The contact structure of a population plays an important role in transmission of infection. Many 'structured models' capture aspects of the contact pattern through an underlying network or a mixing matrix. An important observation in unstructured models of a disease that confers immunity is that once a fraction [Formula: see text] has been infected, the residual susceptible population can no longer sustain an epidemic. A recent observation of some structured models is that this threshold can be crossed with a smaller fraction of infected individuals, because the disease acts like a targeted vaccine, preferentially immunising higher-risk individuals who play a greater role in transmission. Therefore, a limited 'first wave' may leave behind a residual population that cannot support a second wave once interventions are lifted. In this paper, we set out to investigate this more systematically. While networks offer a flexible framework to model contact patterns explicitly, they suffer from several shortcomings: (i) high-fidelity network models require a large amount of data which can be difficult to harvest, and (ii) very few, if any, theoretical contact network models offer the flexibility to tune different contact network properties within the same framework. Therefore, we opt to systematically analyse a number of well-known mean-field models. These are computationally efficient and provide good flexibility in varying contact network properties such as heterogeneity in the number contacts, clustering and household structure or differentiating between local and global contacts. In particular, we consider the question of herd immunity under several scenarios. When modelling interventions as changes in transmission rates, we confirm that in networks with significant degree heterogeneity, the first wave of the epidemic confers herd immunity with significantly fewer infections than equivalent models with less or no degree heterogeneity. However, if modelling the intervention as a change in the contact network, then this effect may become much more subtle. Indeed, modifying the structure disproportionately can shield highly connected nodes from becoming infected during the first wave and therefore make the second wave more substantial. We strengthen this finding by using an age-structured compartmental model parameterised with real data and comparing lockdown periods implemented either as a global scaling of the mixing matrix or age-specific structural changes. Overall, we find that results regarding (disease-induced) herd immunity levels are strongly dependent on the model, the duration of the lockdown and how the lockdown is implemented in the model.

Pressure Dependence of the Magnetic Ordering Temperature (Tc) for the Na2Mn[Mn(CN)6] Noncubic Prussian Blue Analogue.

The pressure dependence of the magnetic properties of rhombohedral Na2Mn[Mn(CN)6] up to 10 kbar has been studied. The magnetic ordering temperature, Tc, for Na2Mn[Mn(CN)6] reversibly increases with increasing applied hydrostatic pressure, P, by 9.0 K (15.2%) to 68 K at 10 kbar with an average rate of increase, dTc/dP, of 0.86 K/kbar. The magnetization at 50 kOe and remanent magnetization, Mr(H), remain constant with an average value of 13,100 ± 200 and 8500 ± 200 emuOe/mol. The coercive field Hcr increases by 12% from 13,400 to 15,000 Oe. The increase and rate of increase of Tc for rhombohedral Na2Mn[Mn(CN)6] are reduced with respect to monoclinic A2Mn[Mn(CN)6] (A = K and Rb), but they are still greater than those of cubic Cs2Mn[Mn(CN)6]. This is attributed to the compression of the MnNC framework bonding without decreasing ∠MnII-N≡C, maintaining the unit cell in accord with cubic A = Cs at lower applied pressures, and not due to reduction in ∠MnII-N≡C, which correlates with increasing Tc that is reported for A = K and Rb as well as Cs at higher applied pressures.

Pressure and temperature dependences of the canting angle and increase in the magnetic ordering temperature, Tc(P), for the weak ferromagnet Li+[TCNE]˙- (TCNE = tetracyanoethylene).

The hydrostatic pressure dependence of the magnetic ordering temperature, Tc(P), for the interpenetrating, diamondoid lattice-structured, weak ferromagnet (= canted antiferromagnet) Li+[TCNE]˙- (TCNE = tetracyanoethylene) reversibly increases from 20.9 to 23.4 K at 9.73 kbar, an increase of 12% with a rate of increase, dTc/dP, of 0.27 K kbar-1. The 5 T magnetization increased by 672% from 186 emu Oe mol-1 at ambient pressure to an average of 1440 emuOe mol-1 upon application of pressure. The remanent magnetization initially increases 30% from 10.8 to 14.0 emuOe mol-1 from ambient to 0.06 kbar, and increases further by 6% to a maximum of 14.8 emuOe mol-1 at 0.56 kbar before declining by 22% to 11.5 emuOe mol-1 at 9.73 kbar. The pressure-dependent coercive field, Hcr(P), initially decreases by 42% from 31.1 Oe at ambient pressure to 18 Oe at 0.06 kbar, then increases to 52 Oe at 9.73 kbar. The canting angle, α, increases by 28% from 0.52° to 0.66° at 0.06 kbar, then decreases by 23% to 0.51° at 9.73 kbar, as well as increases by 2% from 0.536° to 0.548° from 1.8 to 2.5 K, before decreasing by 79% to 0.117° at 19 K. The interlattice interactions are attributed to be the primary exchange mechanism. Thus, α(T) and α(P) have similar dependencies that are attributed to a competition between an increase and a decrease in the intra- and interlayer C⋯N interlattice separations as the temperature and pressure increases.

Low temperature structures and magnetic interactions in the organic-based ferromagnetic and metamagnetic polymorphs of decamethylferrocenium 7,7,8,8-tetracyano-p-quinodimethanide, [FeCp*2]˙+[TCNQ]˙.

To identify the genesis of the differing magnetic behaviors for the ferro- (FO) and metamagnetic (MM) polymorphs of [FeCp*2][TCNQ] (Cp* = pentamethylcyclopentadienide; TCNQ = 7,7,8,8-tetracyano-p-quinodimethane) the low temperature (18 ± 1 K) structures of each polymorph were determined from high-resolution synchrotron powder diffraction data. Each polymorph possesses chains of alternating S = 1/2 [FeCp*2]˙+ cations and S = 1/2 [TCNQ]˙+, but with differing relative orientations. These as well as an additional paramagnetic polymorph do not thermally interconvert. In addition, the room and low (<70 ± 10 K) temperature structures of the MM polymorph, MMRT and MMLT, respectively, differ from that previously reported at 167 K (-106 °C) MM structure, and no evidence of either phase transition was previously noted even from the magnetic data. This transition temperature and enthalpy of this phase transition for MMRT⇌MM was determined to be 226.5 ± 0.4 K (-46.7 ± 0.4 °C) and 0.68 ± 0.04 kJ mol-1 upon warming, respectively, from differential calorimetry studies (DSC). All three MM phases are triclinic (P1[combining macron]) with the room temperature phase having a doubled unit cell relative to the other two. The lower temperature phase transition involves a small rearrangement of the molecular ions and shift in lattice parameters. These three MM and FO polymorphs have been characterized and form extended 1-D chains with alternating S = 1/2 [FeCp*2]˙+ cations, and S = 1/2 [TCNQ]˙- anions, whereas the fifth, paramagnetic (P) polymorph possesses S = 0 π-[TCNQ]22- dimers. At 18 ± 1 K the intrachain FeFe separations are 10.738(2) and 10.439(3) Å for the FO and MMLT polymorphs, respectively. The key structural differences between FO and MMLT at 18 ± 1 K are the 10% shorter interchain NN and the 2.8% shorter intrachain FeFe separation present for MMLT. Computational analysis of all nearest-neighbor spin couplings for the 18 K structures of FO and MMLT indicates that the intrachain [FeCp*2]˙+[TCNQ]˙- spin couplings (H = -2Si·Sj) are the strongest (4.95 and 6.5 cm-1 for FO and MMLT, respectively), as previously hypothesized, and are ferromagnetic due to their S = 1/2 spins residing in orthogonal orbitals. The change in relative [TCNQ]˙-[TCNQ]˙- orientations leads to a computed change from the ferromagnetic interaction (0.2 cm-1) for FO to an antiferromagnetic interaction (-0.1 cm-1) for MMLT in accord with its observed antiferromagnetic ground state. Hence, the magnetic ground state cannot be solely described by the dominant magnetic interactions.

Large age shifts in HIV-1 incidence patterns in KwaZulu-Natal, South Africa.

Recent declines in adult HIV-1 incidence have followed the large-scale expansion of antiretroviral therapy and primary HIV prevention across high-burden communities of sub-Saharan Africa. Mathematical modeling suggests that HIV risk will decline disproportionately in younger adult age-groups as interventions scale, concentrating new HIV infections in those >age 25 over time. Yet, no empirical data exist to support these projections. We conducted a population-based cohort study over a 16-y period (2004 to 2019), spanning the early scale-up of antiretroviral therapy and voluntary medical male circumcision, to estimate changes in the age distribution of HIV incidence in a hyperepidemic region of KwaZulu-Natal, South Africa, where adult HIV incidence has recently declined. Median age of HIV seroconversion increased by 5.5 y in men and 3.0 y in women, and the age of peak HIV incidence increased by 5.0 y in men and 2.0 y in women. Incidence declined disproportionately among young men (64% in men 15 to 19, 68% in men 20 to 24, and 46% in men 25 to 29) and young women (44% in women 15 to 19, 24% in women 20 to 24) comparing periods pre- versus post-universal test and treat. Incidence was stable (<20% change) in women aged 30 to 39 and men aged 30 to 34. Age shifts in incidence occurred after 2012 and were observed earlier in men than in women. These results provide direct epidemiological evidence of the changing demographics of HIV risk in sub-Saharan Africa in the era of large-scale treatment and prevention. More attention is needed to address lagging incidence decline among older individuals.

Concurrency measures in the era of temporal network epidemiology: a review.

Diseases spread over temporal networks of interaction events between individuals. Structures of these temporal networks hold the keys to understanding epidemic propagation. One early concept of the literature to aid in discussing these structures is concurrency-quantifying individuals' tendency to form time-overlapping 'partnerships'. Although conflicting evaluations and an overabundance of operational definitions have marred the history of concurrency, it remains important, especially in the area of sexually transmitted infections. Today, much of theoretical epidemiology uses more direct models of contact patterns, and there is an emerging body of literature trying to connect methods to the concurrency literature. In this review, we will cover the development of the concept of concurrency and these new approaches.

Emergency Department Adaptations to COVID-19.

BACKGROUND: The COVID-19 pandemic creates unique challenges for healthcare systems. While mass casualty protocols and plans exist for trauma-induced large-scale resource utilization events, contagious infectious disease mass casualty events do not have such rigorous procedures established. COVID-19 forces Emergency Departments (EDs) to simultaneously treat seriously ill patients and evaluate large influxes of 'worried well'-while maintaining both staff and patient safety. METHODS: The objectives of this project are to create an avenue to evaluate large surges of patients while minimizing hospital-acquired infections. After identifying areas for improvement and anticipating potential failures, we devised eight healthcare delivery innovations to address those areas and meet our objectives: (1) Parallel ED Lanes (2) Universal Respiratory Precautions (3) Respiratory Drive Through (RDT) (4) Medical Company (5) Provider Triage (6) ED Quarterback Patient Liaison (EDQB) (7) Virtual Registration (8) Virtual Ward. RESULTS: To date, no staff members have contracted COVID-19 within the ED footprint. Our RDT has seen 16,994 patients and the medical company 1,109. Provider triage has redirected 465 patients, while our EDQB has interacted with 532 and redirected 93 patients for same-day appointments with their Primary Care Manager (PCM). CONCLUSION: The system of care establish at our Military Treatment Facility (MTF) has been effective in maximizing staff and patient safety, while providing a new patient-centered healthcare delivery apparatus.