Real-time forecasting the trajectory of monkeypox outbreaks at the national and global levels, July-October 2022.

BACKGROUND: Beginning May 7, 2022, multiple nations reported an unprecedented surge in monkeypox cases. Unlike past outbreaks, differences in affected populations, transmission mode, and clinical characteristics have been noted. With the existing uncertainties of the outbreak, real-time short-term forecasting can guide and evaluate the effectiveness of public health measures. METHODS: We obtained publicly available data on confirmed weekly cases of monkeypox at the global level and for seven countries (with the highest burden of disease at the time this study was initiated) from the Our World in Data (OWID) GitHub repository and CDC website. We generated short-term forecasts of new cases of monkeypox across the study areas using an ensemble n-sub-epidemic modeling framework based on weekly cases using 10-week calibration periods. We report and assess the weekly forecasts with quantified uncertainty from the top-ranked, second-ranked, and ensemble sub-epidemic models. Overall, we conducted 324 weekly sequential 4-week ahead forecasts across the models from the week of July 28th, 2022, to the week of October 13th, 2022. RESULTS: The last 10 of 12 forecasting periods (starting the week of August 11th, 2022) show either a plateauing or declining trend of monkeypox cases for all models and areas of study. According to our latest 4-week ahead forecast from the top-ranked model, a total of 6232 (95% PI 487.8, 12,468.0) cases could be added globally from the week of 10/20/2022 to the week of 11/10/2022. At the country level, the top-ranked model predicts that the USA will report the highest cumulative number of new cases for the 4-week forecasts (median based on OWID data: 1806 (95% PI 0.0, 5544.5)). The top-ranked and weighted ensemble models outperformed all other models in short-term forecasts. CONCLUSIONS: Our top-ranked model consistently predicted a decreasing trend in monkeypox cases on the global and country-specific scale during the last ten sequential forecasting periods. Our findings reflect the potential impact of increased immunity, and behavioral modification among high-risk populations.

Common Behaviors and Faults When Doffing Personal Protective Equipment for Patients With Serious Communicable Diseases.

BACKGROUND: The safe removal of personal protective equipment (PPE) can limit transmission of serious communicable diseases, but this process poses challenges to healthcare workers (HCWs). METHODS: We observed 41 HCWs across 4 Ebola treatment centers in Georgia doffing PPE for simulated patients with serious communicable diseases. Using human factors methodologies, we obtained the details, sequences, and durations of doffing steps; identified the ways each step can fail (failure modes [FMs]); quantified the riskiness of FMs; and characterized the workload of doffing steps. RESULTS: Eight doffing steps were common to all hospitals-removal of boot covers, gloves (outer and inner pairs), the outermost garment, the powered air purifying respirator (PAPR) hood, and the PAPR helmet assembly; repeated hand hygiene (eg, with hand sanitizer); and a final handwashing with soap and water. Across hospitals, we identified 256 FMs during the common doffing steps, 61 of which comprised 19 common FMs. Most of these common FMs were above average in their riskiness at each hospital. At all hospitals, hand hygiene, removal of the outermost garment, and removal of boot covers were above average in their overall riskiness. Measurements of workload revealed that doffing steps were often mentally demanding, and this facet of workload correlated most strongly with the effortfulness of a doffing step. CONCLUSIONS: We systematically identified common points of concern in protocols for doffing high-level PPE. Addressing FMs related to hand hygiene and the removal of the outermost garment, boot covers, and PAPR hood could improve HCW safety when doffing high-level PPE.We identified ways that doffing protocols for high-level personal protective equipment may fail to protect healthcare workers. Hand hygiene, removing the outermost garment, boot covers, and respirator hood harbored the greatest risk and failed in similar ways across different hospitals.

Variability in the Duration and Thoroughness of Hand Hygiene.

We observed 354 hand hygiene instances across 41 healthcare workers doffing personal protective equipment at 4 hospital-based biocontainment units. We measured the duration and thoroughness of each hand hygiene instance. Both parameters varied substantially, with systematic differences between hospitals and differences between healthcare workers accounting for much of the variance.

Design Strategies for Biocontainment Units to Reduce Risk During Doffing of High-level Personal Protective Equipment.

BACKGROUND: Few data exist to guide the physical design of biocontainment units, particularly the doffing area. This can impact the contamination risk of healthcare workers (HCWs) during doffing of personal protective equipment (PPE). METHODS: In phase I of our study, we analyzed simulations of a standard patient care task with 56 trained HCWs focusing on doffing of high-level PPE. In phase II, using a rapid cycle improvement approach, we tested different balance aids and redesigned doffing area layouts with 38 students. In phase III, we tested 1 redesigned layout with an additional 10 trained HCWs. We assessed the effectiveness of design changes on improving the HCW performance (measured by occurrence and number of risky behaviors) and reducing the physical and cognitive load by comparing the results from phase I and phase III. RESULTS: The physical load was highest when participants were removing their shoe covers without any balance aid; the use of a chair required the lowest physical effort, followed by horizontal and vertical grab bars. In the revised design (phase III), the overall performance of participants improved. There was a significant decrease in the number of HCW risky behaviors (P = .004); 5 risky behaviors were eliminated and 2 others increased. There was a significant decrease in physical load when removing disposable shoe covers (P = .04), and participants reported a similar workload in the redesigned doffing layout (P = .43). CONCLUSIONS: Through optimizing the design and layout of the doffing space, we reduced risky behaviors of HCWs during doffing of high-level PPE.

Turbidity reduction in drinking water by coagulation-flocculation with chitosan polymers.

Turbidity reduction by coagulation-flocculation in drinking water reduces microbes and organic matter, increasing effectiveness of downstream treatment. Chitosan is a promising household water coagulant, but needs parameters for use. This study tested the effects of chitosan dose, molecular weight (MW), degree of deacetylation (DD), and functional groups on bentonite and kaolinite turbidity reduction in model household drinking water. Higher MW or DD produced greater reductions. Highest reductions were at doses 1 and 3 mg/L by MW >50,000 or >70% DD (residual turbidity <5 NTU). Higher doses did not necessarily continually increase reduction. For functional groups, 3 mg/L produced the highest reductions by lactate, acetate, and HCl, and lower reductions of kaolinite than bentonite. Doses where the point of zero charge was observed clustered around 3 mg/L. Chitosan reduced clay turbidity in water; effectiveness was influenced by dose, clay type, MW, DD, and functional groups. Reduction did not necessarily increase with MW. Bentonite had a broader effective dose range and higher reduction at the optimal dose than kaolinite. Chitosans with and without functional groups performed similarly. The best of the studied doses was 3 mg/L. Chitosans are promising for turbidity reduction in low-resource settings if combined with sedimentation and/or filtration.

Human Factors Risk Analyses of a Doffing Protocol for Ebola-Level Personal Protective Equipment: Mapping Errors to Contamination.

Background: Doffing protocols for personal protective equipment (PPE) are critical for keeping healthcare workers (HCWs) safe during care of patients with Ebola virus disease. We assessed the relationship between errors and self-contamination during doffing. Methods: Eleven HCWs experienced with doffing Ebola-level PPE participated in simulations in which HCWs donned PPE marked with surrogate viruses (ɸ6 and MS2), completed a clinical task, and were assessed for contamination after doffing. Simulations were video recorded, and a failure modes and effects analysis and fault tree analyses were performed to identify errors during doffing, quantify their risk (risk index), and predict contamination data. Results: Fifty-one types of errors were identified, many having the potential to spread contamination. Hand hygiene and removing the powered air purifying respirator (PAPR) hood had the highest total risk indexes (111 and 70, respectively) and number of types of errors (9 and 13, respectively). ɸ6 was detected on 10% of scrubs and the fault tree predicted a 10.4% contamination rate, likely occurring when the PAPR hood inadvertently contacted scrubs during removal. MS2 was detected on 10% of hands, 20% of scrubs, and 70% of inner gloves and the predicted rates were 7.3%, 19.4%, 73.4%, respectively. Fault trees for MS2 and ɸ6 contamination suggested similar pathways. Conclusions: Ebola-level PPE can both protect and put HCWs at risk for self-contamination throughout the doffing process, even among experienced HCWs doffing with a trained observer. Human factors methodologies can identify error-prone steps, delineate the relationship between errors and self-contamination, and suggest remediation strategies.

Assessing Viral Transfer During Doffing of Ebola-Level Personal Protective Equipment in a Biocontainment Unit.

Background: Personal protective equipment (PPE) protects healthcare workers (HCWs) caring for patients with Ebola virus disease (EVD), and PPE doffing is a critical point for preventing viral self-contamination. We assessed contamination of skin, gloves, and scrubs after doffing Ebola-level PPE contaminated with surrogate viruses: bacteriophages MS2 and Φ6. Methods: In a medical biocontainment unit, HCWs (n = 10) experienced in EVD care donned and doffed PPE following unit protocols that incorporate trained observer guidance and alcohol-based hand rub (ABHR). A mixture of Φ6 (enveloped), MS2 (nonenveloped), and fluorescent marker was applied to 4 PPE sites, approximating body fluid viral load (Φ6, 105; MS2, 106). They performed a patient care task, then doffed. Inner gloves, face, hands, and scrubs were sampled for virus, as were environmental sites with visible fluorescent marker. Results: Among 10 HCWs there was no Φ6 transfer to inner gloves, hands, or face; 1 participant had Φ6 on scrubs at low levels (1.4 × 102). MS2 transfer (range, 101-106) was observed to scrubs (n = 2), hands (n = 1), and inner gloves (n = 7), where it was highest. Most (n = 8) had only 1 positive site. Environmental samples with visible fluorescent marker (n = 21) were negative. Conclusions: Among experienced HCWs, structured, observed doffing using ABHR protected against hand contamination with enveloped virus. Nonenveloped virus was infrequent on hands and scrubs but common on inner gloves, suggesting that inner gloves, but not necessarily ABHR, protect against hand contamination. Optimizing doffing protocols to protect against all types of viruses may require reinforcing careful handling of scrubs and good glove/hand hygiene with effective agents.

Disinfection of bacteriophage MS2 by copper in water.

Households that lack piped water supply are often forced to meet water needs by storing in the home, leaving water vulnerable to contamination by viruses. Storage in copper containers can potentially prevent this type of contamination, but the inactivation kinetics of viruses by copper need to be described to make appropriate storage recommendations. This work characterized inactivation kinetics of bacteriophage MS2 as a surrogate for enteric viruses by dissolved ionic copper in water. Reduction of MS2 increased with increasing doses of copper. At 0.3 mg/L, there was a 1.8-log10 reduction of MS2 within 6 h. At 1 and 3 mg/L, 2-2.5 log10 inactivation could be achieved between 6 and 24 h. Parameters for the Chick-Watson, Hom, and One Hit-Two Population models of inactivation were calculated and evaluated, all of which demonstrated strong goodness-of-fit and predictability at various contact times. Copper inactivates MS2 under controlled conditions at doses between 0.3 and 3 mg/L. Although requiring longer contact times than conventional disinfectants, it is a candidate for improving the safety of stored drinking water.

Disinfection of Escherichia coli and Pseudomonas aeruginosa by copper in water.

When households lack access to continuous piped water, water storage in the home creates opportunities for contamination. Storage in copper vessels has been shown to reduce microbes, but inactivation kinetics of enteric bacteria in water by copper alone needs to be understood. This work characterized inactivation kinetics of Escherichia coli and Pseudomonas aeruginosa by dissolved ionic copper in water. Reductions of E. coli and P. aeruginosa increase with increasing dose. At 0.3 mg/L, there was a 2.5 log10 reduction of E. coli within 6 hours. At 1 and 3 mg/L, the detection limit was reached between 3 and 6 hours; maximum reduction measured was 8.5 log10. For P. aeruginosa, at 6 hours there was 1 log10 reduction at 0.3 mg/L, 3.0 log10 at 1 mg/L, and 3.6 log10 at 3 mg/L. There was no significant decline in copper concentration. Copper inactivates bacteria under controlled conditions at doses between 0.3 and 1 mg/L. E. coli was inactivated more rapidly than P. aeruginosa. Copper at 1 mg/L can achieve 99.9% inactivation of P. aeruginosa and 99.9999997% inactivation of E. coli over 6 hours, making it a candidate treatment for stored household water.

Factors affecting continued use of ceramic water purifiers distributed to tsunami-affected communities in Sri Lanka.

OBJECTIVES: There is little information about continued use of point-of-use technologies after disaster relief efforts. After the 2004 tsunami, the Red Cross distributed ceramic water filters in Sri Lanka. This study determined factors associated with filter disuse and evaluate the quality of household drinking water. METHODS: A cross-sectional survey of water sources and treatment, filter use and household characteristics was administered by in-person oral interview, and household water quality was tested. Multivariable logistic regression was used to model probability of filter non-use. RESULTS: At the time of survey, 24% of households (107/452) did not use filters; the most common reason given was breakage (42%). The most common household water sources were taps and wells. Wells were used by 45% of filter users and 28% of non-users. Of households with taps, 75% had source water Escherichia coli in the lowest World Health Organisation risk category (<1/100 ml), vs. only 30% of households reporting wells did. Tap households were approximately four times more likely to discontinue filter use than well households. CONCLUSION: After 2 years, 24% of households were non-users. The main factors were breakage and household water source; households with taps were more likely to stop use than households with wells. Tap water users also had higher-quality source water, suggesting that disuse is not necessarily negative and monitoring of water quality can aid decision-making about continued use. To promote continued use, disaster recovery filter distribution efforts must be joined with capacity building for long-term water monitoring, supply chains and local production.

A post-implementation evaluation of ceramic water filters distributed to tsunami-affected communities in Sri Lanka.

Sri Lanka was devastated by the 2004 Indian Ocean tsunami. During recovery, the Red Cross distributed approximately 12,000 free ceramic water filters. This cross-sectional study was an independent post-implementation assessment of 452 households that received filters, to determine the proportion still using filters, household characteristics associated with use, and quality of household drinking water. The proportion of continued users was high (76%). The most common household water sources were taps or shallow wells. The majority (82%) of users used filtered water for drinking only. Mean filter flow rate was 1.12 L/hr (0.80 L/hr for households with taps and 0.71 for those with wells). Water quality varied by source; households using tap water had source water of high microbial quality. Filters improved water quality, reducing Escherichia coli for households (largely well users) with high levels in their source water. Households were satisfied with filters and are potentially long-term users. To promote sustained use, recovery filter distribution efforts should try to identify households at greatest long-term risk, particularly those who have not moved to safer water sources during recovery. They should be joined with long-term commitment to building supply chains and local production capacity to ensure safe water access.

Evaluating Fecal Indicator and Pathogen Relationships in Sewage Impacted Surface Waters to Blend with Reclaimed Water for Potable Reuse in North Carolina.

Surface waters used for drinking water supply often receive upstream wastewater effluent inputs, resulting in de facto wastewater reuse for drinking water and recreation. As populations grow, demands on water supplies increase. As this trend continues, it creates the need to understand the risks associated with such reuse. In North Carolina, potable reuse has been proposed as a combination of at least 80% surface water with up to 20% tertiary-treated, dual-disinfected, reclaimed wastewater, which is then stored for 5 days and further treated using conventional drinking water treatment methods. The state of North Carolina has set standards for both intake surface water and for the reclaimed water produced by wastewater utilities, using indicator microorganisms to measure compliance. The goal of this study was to quantify fecal indicator microorganisms, specifically E. coli, coliphages, and C. perfringens as well as key pathogens, specifically Salmonella spp. bacteria, adenoviruses, noroviruses, and the protozoan parasites Cryptosporidium and Giardia, in two types of water representing potential candidates for potable reuse in North Carolina, (1) run of river surface water and (2) sewage-impacted surface waters, with the purpose of determining if there are predictive relationships between these two microorganism groups that support microbial indicator reliability.

Effects of air temperature and relative humidity on coronavirus survival on surfaces.

Assessment of the risks posed by severe acute respiratory syndrome (SARS) coronavirus (SARS-CoV) on surfaces requires data on survival of this virus on environmental surfaces and on how survival is affected by environmental variables, such as air temperature (AT) and relative humidity (RH). The use of surrogate viruses has the potential to overcome the challenges of working with SARS-CoV and to increase the available data on coronavirus survival on surfaces. Two potential surrogates were evaluated in this study; transmissible gastroenteritis virus (TGEV) and mouse hepatitis virus (MHV) were used to determine effects of AT and RH on the survival of coronaviruses on stainless steel. At 4 degrees C, infectious virus persisted for as long as 28 days, and the lowest level of inactivation occurred at 20% RH. Inactivation was more rapid at 20 degrees C than at 4 degrees C at all humidity levels; the viruses persisted for 5 to 28 days, and the slowest inactivation occurred at low RH. Both viruses were inactivated more rapidly at 40 degrees C than at 20 degrees C. The relationship between inactivation and RH was not monotonic, and there was greater survival or a greater protective effect at low RH (20%) and high RH (80%) than at moderate RH (50%). There was also evidence of an interaction between AT and RH. The results show that when high numbers of viruses are deposited, TGEV and MHV may survive for days on surfaces at ATs and RHs typical of indoor environments. TGEV and MHV could serve as conservative surrogates for modeling exposure, the risk of transmission, and control measures for pathogenic enveloped viruses, such as SARS-CoV and influenza virus, on health care surfaces.

Survival of surrogate coronaviruses in water.

The emergence of a previously unknown coronavirus infection, Severe Acute Respiratory Syndrome (SARS), demonstrated that fecally contaminated liquid droplets are a potential vehicle for the spread of a respiratory virus to large numbers of people. To assess potential risks from this pathway, there is a need for surrogates for SARS coronavirus to provide representative data on viral survival in contaminated water. This study evaluated survival of two surrogate coronaviruses, transmissible gastroenteritis (TGEV) and mouse hepatitis (MHV). These viruses remained infectious in water and sewage for days to weeks. At 25 degrees C, time required for 99% reduction in reagent-grade water was 22 days for TGEV and 17 days for MHV. In pasteurized settled sewage, times for 99% reduction were 9 days for TGEV and 7 days for MHV. At 4 degrees C, there was <1 log(10) infectivity decrease for both viruses after four weeks. Coronaviruses can remain infectious for long periods in water and pasteurized settled sewage, suggesting contaminated water is a potential vehicle for human exposure if aerosols are generated.

Virus transfer from personal protective equipment to healthcare employees' skin and clothing.

We evaluated a personal protective equipment removal protocol designed to minimize wearer contamination with pathogens. Following this protocol often resulted in virus transfer to hands and clothing. An altered protocol or other measures are needed to prevent healthcare worker contamination.

Tertiary treatment and dual disinfection to improve microbial quality of reclaimed water for potable and non-potable reuse: A case study of facilities in North Carolina.

Treated wastewater is increasingly of interest for either nonpotable purposes, such as agriculture and industrial use, or as source water for drinking water supplies; however, this type of advanced treatment for water supply is not always possible for many low resource settings. As an alternative, multiple barriers of physical, chemical and biological treatment with lower cost and simpler operation and maintenance have been proposed as more globally applicable. One such water reclamation system for both non-potable and potable reuse, is that approved by the State of North Carolina "for Type 2" reclaimed water (NCT2RW). NC Type 2 potable reuse systems consist of a sequence of tertiary treatment to produce well oxidized reclaimed water that is then then further treated by two steps of disinfection, typically UV radiation and chlorination. In this case study, the log10 microbial reduction performance of NCT2RW producing water reclamation facilities is evaluated. Based on the results presented here, NCT2RW consistently achieved high (6 for bacteria, 4 for virus and 4 for protozoan parasite surrogates) log10 reductions using the NC proposed treatment methods. Additionally, lower but significant log10 reduction performance was also documented for protozoan parasites and human enteric viruses.

Design strategies to improve healthcare worker safety in biocontainment units: learning from ebola preparedness.

OBJECTIVE: To identify ways that the built environment may support or disrupt safe doffing of personal protective equipment (PPE) in biocontainment units (BCU). DESIGN: We observed interactions between healthcare workers (HCWs) and the built environment during 41 simulated PPE donning and doffing exercises. SETTING: The BCUs of 4 Ebola treatment facilities and 1 high-fidelity BCU mockup.ParticipantsA total of 64 HCWs (41 doffing HCWs and 15 trained observers) participated in this study. RESULTS: In each facility, we observed how the physical environment influences risky behaviors by the HCW. The environmental design impeded communication between trained observers (TOs) and HCWs because of limited window size or visual obstructions with louvers, which allowed unobserved errors. The size and configuration of the doffing area impacted HCW adherence to protocol, and lack of clear demarcation of zones resulted in HCWs inadvertently leaving the doffing area and stepping back into the contaminated areas. Lack of standard location for items resulted in equipment and supplies frequently shifting positions. Finally, different solutions for maintaining balance while removing shoe covers (ie, chair, hand grips, and step stool) had variable success. We identified the 5 key requirements that doffing areas must achieve to support safe doffing of PPE, and we developed a matrix of proposed design strategies that can be implemented to meet those requirements. CONCLUSIONS: Simple, low-cost environmental design interventions can provide structure to support and improve HCW safety in BCUs. These interventions should be implemented in both current and future BCUs.

E. coli CB390: An alternative E. coli host for simultaneous detection of somatic and F+ coliphage viruses in reclaimed and other waters.

Somatic and F+ coliphages have been identified and validated as virus indicators of fecal contamination in ground water by US EPA and more recently they are being considered for use in managing both marine and fresh recreational water and wastewater discharges. Studies documenting their usefulness as viral indicator in reclaimed water sources in the USA are limited. However, simultaneous detection of both somatic and F+ coliphages on a single E. coli host is preferred over their separate analysis because both are abundant in wastewater, they may respond differently to wastewater reclamation treatment processes, and separate analysis for each group in separate host bacteria adds complexity and cost. In this study, a new total coliphage host (E. coli CB390, CECT9198) was evaluated for its ability to detect somatic, F+ coliphages, and total coliphages by US EPA Methods 1601 and 1602. No statistical difference was found in the detection coliphages in spiked phosphate buffered saline samples or in natural waters; additionally, no statistical difference was found between the detection of total coliphages by Methods 1601 and 1602.

Survival of an Enveloped Virus on Toys.

Children's toys may carry respiratory viruses. Inactivation of a lipid-enveloped bacteriophage, Φ6, was measured on a nonporous toy at indoor temperature and relative humidity (RH). Inactivation was approximately 2log10 after 24 hours at 60% RH and 6.8log10 at 10 hours at 40% RH. Enveloped viruses can potentially survive on toys long enough to result in exposures.

Survival and disinfection of an enveloped surrogate virus on Tyvek suits used for health care personal protective equipment.

The survival and disinfection of bacteriophage Φ6, an enveloped surrogate virus, was evaluated on Tyvek suits used as health care personal protective equipment. After 6 hours there was 2-log10 inactivation of virus on Tyvek suits at both 40% and 60% relative humidity. Both hypochlorite and quaternary ammonium produced a >3.21- and >4.33-log10 reduction of the virus, respectively, after 1-minute contact time. Enveloped viruses can survive on Tyvek suits beyond the length of a single patient care encounter, but they can be inactivated by chemical disinfectants.