A Cross-Sectional Evaluation of the Virtual Outpatient Management of People With Mpox.

Background: To report on the implementation and outcomes of a virtual ward established for the management of mpox during the 2022 outbreak, we conducted a 2-center, observational, cross-sectional study over a 3-month period. Methods: All patients aged ≥17 years with laboratory polymerase chain reaction-confirmed monkeypox virus managed between 14 May and 15 August 2022, at the Hospital for Tropical Diseases at University College London Hospitals National Health Service (NHS) Foundation Trust and sexual health services at Central North and West London NHS Foundation Trust, were included. Main outcomes included the proportion of patients managed exclusively on the virtual ward, proportion of patients requiring inpatient admission, proportion of patients with human immunodeficiency virus, and duration of lesion reepithelialization. Results: Among confirmed cases (N = 221), 86% (191/221) were managed exclusively on the virtual ward, while 14% (30/221) required admission. Treatment for concomitant sexually transmitted infections was provided to 25% (55/221) of patients, antibiotics for other infective complications to 16% (35/221), and symptomatic relief to 27% (60/221). The median time from onset to complete lesion reepithelialization and de-isolation was 18 days (range, 8-56 days). Eleven percent (24/221) of individuals disengaged from services within 4 days of testing. Conclusions: The virtual ward model facilitated safe and holistic outpatient management of mpox, while minimizing admissions. This approach could serve as a model for future outbreak responses.

A Virtual Assessment Model for At-Home Evaluation of Suspected Viral Hemorrhagic Fever Cases.

The Sudan virus disease outbreak in 2022 prompted the Denver Health High-Risk Infection Team (HITeam) to evaluate and implement novel strategies to respond to viral hemorrhagic fever (VHF) events. To improve the VHF response, HITeam members developed a virtual assessment model (VAM) for at-home evaluation of individuals who are suspected of having a VHF. The VAM incorporates aspects of care that would normally be rendered in a high-level isolation unit-including assessment and monitoring, specimen collection, provider consultation, patient and family teaching, and pharmaceutical intervention-into a mobile framework in which team members respond to a suspected case at the individual's home. Building this capability allows for more thorough assessment of a suspect case in the field, as well as the postponement of a decision about activation of the high-level isolation unit until more information is available. Development, testing, and implementation of the VAM required input from an interdisciplinary group of partners that demonstrated the ability of nurses, physicians, laboratorians, paramedics, emergency medical technicians, and public health personnel to integrate into 1 cohesive care team. The resulting model recenters VHF care on the patient by allowing the care team to gather critical information in an environment that is more comfortable for the suspect case while keeping communities safe and lowering exposure risks. The VAM has long-term sustainability implications for global VHF programs and provides solutions for broader challenges in healthcare by modeling cost-effective, patient-centered care within the highly nuanced subspecialty of special pathogen care.

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

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

Development and implementation of a clinical decision support system tool for the evaluation of suspected monkeypox infection.

Monkeypox virus was historically rare outside of West and Central Africa until the current 2022 global outbreak, which has required clinicians to be alert to identify individuals with possible monkeypox, institute isolation, and take appropriate next steps in evaluation and management. Clinical decision support systems (CDSS), which have been shown to improve adherence to clinical guidelines, can support frontline clinicians in applying the most current evaluation and management guidance in the setting of an emerging infectious disease outbreak when those guidelines are evolving over time. Here, we describe the rapid development and implementation of a CDSS tool embedded in the electronic health record to guide frontline clinicians in the diagnostic evaluation of monkeypox infection and triage patients with potential monkeypox infection to individualized infectious disease physician review. We also present data on the initial performance of this tool in a large integrated healthcare system.

Review of Emergency Medical Services Vulnerability to High Consequence Infectious Disease in the United States.

Purpose: Emergency medical services (EMS) responders are a group of medically skilled professionals who perform a wide range of essential medical services within a community including emergency response, patient transport, and mobile integrated healthcare. The proper functioning of the EMS system is paramount to the well-being of the medical system and public health. The intent of this paper is to review current EMS standards and practice to determine the danger a high consequence infectious disease (HCID) may pose to these healthcare workers and the community. Areas Addressed: Through the review of EMS practice several areas were identified as vulnerabilities to the EMS network. These vulnerabilities consisted of the lack of standardized licensing practice, inconsistent medical direction, and the inability to properly implement the use of personal protective equipment (PPE). The compounding of these vulnerabilities allows for HCIDs to pose a serious threat to EMS personnel with the possibility of devastating and crippling the EMS infrastructure within the US. Discussion: The vulnerabilities identified must be addressed both to protect EMS providers and to enhance the resilience of the US healthcare system. Ways to address the identified vulnerabilities should focus on improving the EMS curriculum and increasing minimum levels of education for first responders. Targeting minimum education and training standards could be the most effect method of reducing the dangers of HCIDs to EMS systems.

Experience of a novel community testing programme for COVID-19 in London: Lessons learnt.

We describe the London community testing programme developed for COVID-19, audit its effectiveness and report patient acceptability and patient adherence to isolation guidance, based upon a survey conducted with participants.Any patients meeting the Public Health England (PHE) case definition for COVID-19 who did not require hospital admission were eligible for community testing. 2,053 patients with suspected COVID-19 were tested in the community between January and March 2020. Of those tested, 75 (3.6%) were positive. 88% of patients that completed a patient survey felt safe and 82% agreed that community testing was preferable to hospital admission. 97% were able to remain within their own home during the isolation period but just 41% were able to reliably isolate from other members of their household.The London community testing programme allowed widespread testing for COVID-19 while minimising patient transport, hospital admissions and staff exposures. Community testing was acceptable to patients and preferable to admission to hospital. Patients were able to reliably isolate in their home but not from household contacts. The authors believe in the importance, feasibility and acceptability of community testing for COVID-19 as a part of a package of interventions to mitigate a second wave of infection.

Integration of aeromedicine in the response to the COVID-19 pandemic.

There is limited guidance on the use of helicopter medical personnel to facilitate care of critically ill COVID-19 patients. This manuscript describes the emergence of this novel virus, its mode of transmission, and the potential impacts on patient care in the unique environment of rotor wing aircraft. It details the development of clinical and operational guidelines for flight crew members. This allows other out-of-hospital clinicians to utilize our framework to augment or supplement their own for the current response effort to COVID-19. It further serves as a road map for future response to the care of high consequence infectious disease patients.

Middle East respiratory syndrome coronavirus (MERS-CoV) - Surveillance and testing in North England from 2012 to 2019.

BACKGROUND: Middle East respiratory syndrome coronavirus (MERS-CoV) emerged in Saudi Arabia in 2012 and caused an epidemic in the Middle East. Public Health England (PHE) Manchester is one of the two PHE centres in the UK that perform testing for MERS-CoV. The results of the PHE Manchester MERS surveillance from 2012 to 2019 are presented in this report. METHODS: Retrospective data were collected for returning travellers from the Middle East fitting the PHE MERS case definition. Respiratory samples were tested for respiratory viruses and MERS-CoV using an in-house RT-PCR assay. RESULTS: Four hundred and twenty-six (426) samples from 264 patients were tested for MERS Co-V and respiratory viruses. No MERS-CoV infections were identified by PCR. Fifty-six percent of samples were PCR positive for viral or bacterial pathogen with Influenza A as the predominant virus (44%). Sixty-two percent of all patients had a pathogen identified with the highest positivity from sputum samples. Patients with multiple samples demonstrated a 100% diagnostic yield. CONCLUSIONS: Although no cases of MERS were identified, the majority of patients had Influenza infection for which oseltamivir treatment was indicated and isolation warranted. Sputum samples were the most useful in diagnosing respiratory viruses with a 100% diagnostic yield from patients with multiple samples.

A unified personal protective equipment ensemble for clinical response to possible high consequence infectious diseases: A consensus document on behalf of the HCID programme.

The importance of appropriate personal protective equipment (PPE) as a component of healthcare worker (HCW) protection was highlighted during the Ebola virus disease (EVD) outbreak in West Africa. The large number of HCW deaths in Africa was in part due to lack of resources or prior training in PPE usage. As part of the Ebola legacy, the High Consequence Infectious Disease (HCID) programme was initiated by NHS England and Public Health England (PHE) to improve preparedness for Ebola and other infections that not only endanger the life of the patient, but also pose particular dangers to HCWs. A systematic review identified national standardisation of PPE protocols as a priority, but recognised that a lack of safety data limited the ability to mandate any one protocol. A simulation-based exercise was developed to assess the safety of PPE ensembles in use in the UK during first assessment of a patient with a possible HCID. A mannequin was adapted to expose volunteer HCWs to synthetic bodily fluids (vomit, sweat, diarrhoea and cough), each with a different coloured fluorescent tracer, invisible other than under ultraviolet (UV) light. After exposure, HCWs were examined under UV lights to locate fluorescent contamination, and were screened again after removing PPE (doffing) to detect any personal contamination. The exercise was videoed, allowing retrospective analysis of contamination events and user errors. The simulation testing identified significant HCW contamination events after doffing, related to protocol failure or complications in PPE doffing, providing conclusive evidence that improvements could be made. At a workshop with an expert stakeholder group, the data were examined and a unified PPE ensemble agreed. This ensemble was then tested in the same simulation exercise and no evidence of any HCW contamination was seen after doffing. Following further review by the working group, a consensus agreement has been reached and a unified 'HCID assessment PPE' ensemble, with accompanying donning and doffing protocols, is presented here.