Workshop #2: Health and Infection Control Measures During the 2020 Hurricane Season: After-Action Report (AAR)

Participants in the CONVERGE NSF Working Group Workshop 2 (Health) breakout sessions identified that along with populations traditionally considered vulnerable during hurricane season (e.g., special-needs evacuees and the elderly), there will be new vulnerable populations based on their heightened risks from exposure to COVID-19. There is also overlap between these groups of vulnerable evacuees, including individuals with physical, intellectual or developmental disabilities; those with immunodeficiency, chronic, acute, or infectious illnesses; pregnant women and infants; and immigrants, non-English speakers, and other socially vulnerable groups. This indicates a potentially greater number of special-needs evacuees at shelters. Simultaneously, fear of contracting COVID-19, particularly in special-needs populations, will likely worsen the challenges of last-minute arrivals at shelters. There were several public messaging issues related to health that were raised during the breakout session, including: 1. Increasing public awareness around using shelters as a refuge of last resort especially because of the COVID-19 risks of congregate facilities without discouraging people from seeking shelter if they need it. 2. Ensuring that those who are potentially sick understand that some shelters do not have medical treatment, to ensure that they do not make decisions to relocate to a shelter based on medical needs. 3. Alerting the public of their potential ability to obtain additional medical supplies (e.g., longer prescription allowances) when there is an advanced emergency declaration. 4. Conducting pre-disaster: Outreach to community partners for practice drills. 5. Increasing public awareness about shelter compliance requirements to prevent and slow infectious disease spread (e.g., expectations for wearing masks and physically distancing while in the facility or no in-and-out privileges), while avoiding a dampening effect on using shelters where they are the best option for an evacuee. Scarcity continues to be an issue for many shelter needs, and vulnerable populations will need additional space, staff, medications, supplies, and medical assistance. Higher numbers of evacuees are also uninsured or underinsured. In addition, evacuees and staff alike are likely to experience additional psychological strain due to managing a storm event under conditions associated with the current pandemic. Based on these assessments, early preparation has greater urgency—obtaining extra space, staff, and supplies should be ongoing and already in process. Several participants described reaching out to other non-governmental organizations (NGOs) to access additional assistance for individuals in vulnerable groups (e.g., AARP for the elderly or USAA for military or military retirees); establishing those contacts in the pre-event phases was recommended. Advance identification of vulnerable individuals to engage in social work to create evacuation plans for them before an emergency was also advised. Many experts have advised increased use of telehealth (e.g., for pregnant mothers). Pre-event dissemination of recommendations for those at greater risk from contracting the COVID-19 and encouraging sheltering with family or friends over evacuating to a congregate shelte

Workshop #1: Vulnerable Populations & Planning Considerations for the 2020 Hurricane Season: After Action Report (AAR)

This workshop shed light on the challenges and importance of adapting current hurricane season planning. Coexisting with COVID-19 will pose even more challenges for hurricane season responses. Suggested adaptations include identifying further shelter spaces to reduce the numbers of evacuees per building (for required social distancing), create isolation spaces to protect populations vulnerable to COVID-19, and quarantine those who are symptomatic. Some strategies being considered include modifying existing shelters (e.g. schools, by using classrooms) and using hotels, dormitories, and other large vacant spaces (e.g., stores and convention centers). Along with identifying new shelter options comes modifying procedures for screening, triage, and enforcing social distancing and other prevention methods in shelters, as well as transportation considerations. The additional burdens on the population due to COVID-19— economic, psychological, social, health, and workforce—create an even greater need for collaboration between nonprofit social service organizations and public health agencies. The current burden of COVID-19 on the public health, emergency, healthcare, and volunteer workforce is also a concern; strategies to protect workers from COVID-19 and to identify additional staff are being considered. Effective public messaging will also be crucial moving forward. Workshop participants identified many subpopulations who would be considered vulnerable in this compound hurricane-pandemic scenario. The more typical vulnerable populations still exist based on the impacts of a hurricane: individuals in evacuation zones with inadequate or unsafe housing and low incomes; with disabilities or sensory impairments, mental health, or substance dependence; and who experience social bias or racism, domestic violence, and other exploitation. These vulnerable populations are compounded by those who are vulnerable to COVID-19 complications, including immunosuppressed individuals, the elderly, pregnant women, infants, and others with chronic conditions such as asthma or COPD. Additional considerations will need to be made for mixed-age families, as well as caregivers and family members of the aforementioned vulnerable groups if isolation is a strategy. General approaches being considered are creating vulnerable population registries and pre-registration for all evacuees to identify sheltering needs upfront and triaging to different shelter types based on those identified needs. However, it was brought up that any evacuee could be considered at risk for, or a carrier of, COVID-19; plans will have to factor that in

Workshop #5: Workforce: Evacuations, Shelter Staffing, Workforce Structure, Capacity, PPE, and Telemedicine: After-Action Report (AAR)

Participants in the breakout sessions for the CONVERGE COVID-19 Working Group’s Workshop 5 (Workforce) identified several issues, including unique staffing challenges for this compound event, needed training revisions to address shelter protocols specific to COVID-19, additional staffing needs based on the unusual use of congregate and non-congregate shelters to address COVID-19 risks, and the increased need for ancillary services for staff and volunteers during and after an event. Ensuring shelter operations are maintained despite COVID-19 will require adequate staffing. Layoffs, furloughs and hiring freezes have affected base employee numbers, where many jurisdictions rely on county and city employees, along with volunteers, to staff shelters. Shelter staffing could be further limited by the exclusion of employees who may be medically vulnerable because of underlying health conditions or at higher risk based on their age. In addition, staff may be reluctant to report to shelter assignments over fear of exposure to COVID-19; they could opt to stay home or refuse shelter assignments. To mitigate these risks, shelters must implement physical distancing and other specialized procedures to limit potential exposure, which, in turn will lead to greater needs in staffing (e.g., atypical sanitation work to minimize potential exposure to COVID-19) and resources (e.g., personal protective equipment)—not only to ensure the safety of both shelter staff and evacuees, but also to alleviate staff fears and concerns. In light of the compound nature of this hurricane season during an ongoing pandemic, there will be additional responsibilities and stressors for hurricane shelter staff and volunteers that indicate additional training needs. Many jurisdictions require that city or county employees serve as essential staff during disasters and receive annual training for these roles. However, this training does not address how to respond during a hurricane-pandemic event. Additional training components are needed; however, many jurisdictions have already hosted their annual training sessions. The use of congregate and non-congregate shelters imposes unusual staffing requirements that affect the logistics of workforce staffing. More congregate shelter locations will be needed to achieve distancing requirements and non-congregate sheltering also may be used to shelter evacuees who are medically vulnerable—both will create additional staffing demands, in some cases, highly specialized (e.g., onsite medical personnel). In addition, further clarity is needed about who will staff non-congregate shelters (e.g., hotel workers or traditional shelter staff). Participants also identified ancillary resources needed to support and protect staff (e.g., call centers to support individuals seeking information). While technology can be an important resource (e.g., touch-free intake devices and telehealth systems), potential power and internet disruptions create limitation. Staff also will need medical and epidemiological support to monitor symptoms and track outbreaks within the shelters. Ensuring the psychological well-being of shelter staff and evacuees also will require atypical ancillary resources

Workshop #3: Transportation and Sheltering Logistics During the 2020 Hurricane Season: After-Action Report (AAR)

Participants in the CONVERGE COVID-19 Working Group’s Workshop 3 on Logistics breakout sessions identified key issues that included population considerations, training needs, continuity of operations and resources still available, site planning (i.e., feeding, registration, shelter design, resources, family unity), facility requirements, and supplies needed during a hurricane evacuation. Operational safety measures and population considerations were mentioned throughout the workshop. This included the need for identifying additional resources, facilities, and staffing to be able to ensure safety is a priority while accommodating social distancing recommendations and the needs of vulnerable populations and staff. Workshop participants emphasized the need to identify new partnerships for critical services and alternative site locations for sheltering to increase evacuation and sheltering capacity. This entailed the need for reassessing existing contracts with transportation and sheltering to ensure they are still operational and have the staffing and resources to support the logistical needs for evacuating vulnerable populations and the public to shelters. In addition to identifying what is needed for logistical planning there is a need for understanding facility requirements, availability of buildings and needed supplies for operating non-congregate and congregate shelters. Infrastructure and shelter design were discussed to provide context on how jurisdictions are providing support in their shelter operations that maintains infection control measures, social distancing and keeping family units together. Staffing and training needs for both transportation and shelter operations was a concern and various ideas were proposed as solutions. Questions were raised in the workshop about designing infrastructure in the future that would allow us to have an increased number of facilities for sheltering during a hurricane, or to serve as a refuge of last resort. What does the registration process look like during this hurricane season? How do you handle the demand for personal protective equipment (PPE) and other supplies needed to reduce the risk of contracting COVID-19? A few participants highlighted the need for logistical procedures and guidelines for pet evacuation and pet-friendly shelters along with service animals

Workshop #6: Psychological Adjustment for the 2020 Hurricane Season during COVID-19 Pandemic: After-Action Report (AAR)

Participants in the CONVERGE COVID-19 Working Group’s Workshop #6 on Psychological Adjustment breakout sessions discussed the critical threats to psychological health and well-being facing shelter staff, volunteers, and clients in the 2020 hurricane season. It is widely recognized that people are approaching the 2020 hurricane season under unusual levels of stress. The COVID-19 pandemic has created chronic stressors that individuals are already managing in addition to addressing new acute fears like –will I get sick if I go to a shelter? These new and exacerbated stressors are a risk for higher levels of burnout, compassion fatigue, and ill-being. Addressing these chronic and acute concerns requires several complementary strategies. First, clear and consistent messaging and training are needed to reduce the uncertainty before and during a sheltering event. Additionally, workers need to be given the resources to better manage their psychological health in the form of adaptive coping strategies. Within a shelter environment, staff and clients should have reliable access to free and confidential psychological health services .Of course, there are considerable barriers to influencing workers’ and clients’ psychological health. Resources are limited; there is not enough time, space, money, or staff/volunteers to take advantage of every recommendation. In addition to these limited resources, stigmas still exist around psychological ill-being that may prevent people from seeking needed resources. Finally, the social distancing that is required during COVID-19 has eroded traditional social support structures that people traditionally use to cope with stress and uncertainty. Combatting these barriers requires creativity to find low-cost, high-impact strategies to protect individuals’ psychological health. In this After-Action Report, we address each of these considerations in greater detail and provide resources to freely available flyers, brochures, posters, webinars, training, and published press articles

Workshop #4: Public Messaging: Risk Communication for Disaster Preparedness, Evacuation, and Sheltering: After-Action Report (AAR)

Participants in the breakout sessions for the CONVERGE COVID-19 Working Group’s Workshop 4 (Public Messaging) identified key issues that included the need to provide timely and effective communication to the public, increasing awareness around using shelters as a refuge of last resort, addressing the risks associated with COVID-19 exposure at shelters, and using various inclusive forms of public messaging to reach a wide audience. Workshop participants emphasized the importance of timely and effective communications to support informed decision making. There is ongoing concern over balancing the need to communicate the risks of COVID-19 exposure as it relates to evacuation shelters (to create public awareness and informed decision making) and the potential to create unnecessary fear. This balance will entail clear and consistent communications from regional, state, and local authorities. The messaging also will need to emphasize that shelters are a last resort option and to highlight the importance of personal preparedness. This includes “know your zone” and “know your home.” For some people, staying at their house and not evacuating could be less risky than going to an evacuation shelter; messaging to create this public awareness is essential. One proposal was to encourage people to reach out to family and friends preemptively, identifying evacuation plans that avoiding shelters in advance of the hurricane season. Public messaging also should include information on how personal preparedness kits should be adjusted or augmented to account for the additional hazards this hurricane season from COVID-19. Workshop participants simultaneously recognized that COVID-19 has already created additional burdens on the population that might impede evacuees from adequately preparations. Based on these conversations, early communication and preparedness are urgently needed. In addition to identifying what should be communicated to the public, participants also discussed the types of questions the public might ask and what data will be used to respond. They suggested that effective communications should include awareness of underlying fears and other emotions that the public may experience. It is critical that shelter management guidelines—such as social distancing and mask requirements—are communicated to the public to increase transparency and to provide information on what will be expected. Suggested items to mention to the public before a hurricane makes landfall include, but are not limited to, what resources will be available at shelters (e.g., will masks be provided or will they need to bring their own), what the intake process will involve, and how people will be isolated if they appear symptomatic or have been identified as COVID-positive. Furthermore, information regarding evacuation shelters will require a greater degree of specificity for medically fragile individuals and other vulnerable populations

pirfenidone in patients with idiopathic pulmonary fibrosis and more advanced lung function impairment

Abstract Background Patients with idiopathic pulmonary fibrosis (IPF) demonstrate a range of lung function impairment. However, the efficacy of antifibrotics compared with placebo has not been assessed in patients with more advanced disease. This post-hoc analysis investigated the efficacy and safety of pirfenidone versus placebo in patients with IPF and more advanced lung function impairment, defined as percent predicted forced vital capacity (%FVC)  Methods Patients randomised to pirfenidone 2,403 mg/day or placebo in the ASCEND (NCT01366209) and CAPACITY (NCT00287716; NCT00287729) trials with more advanced baseline lung function impairment (pirfenidone, n = 90; placebo, n = 80) were included. Mortality, lung function, hospitalisation, exercise capacity and dyspnoea were investigated over 52 weeks. Results At Week 52 versus placebo, pirfenidone was associated with significantly lower risks of all-cause mortality (hazard ratio [HR] 0.28; 95% confidence interval [CI] 0.09–0.86; p=0.0180), ≥10% absolute %FVC decline or all-cause mortality (HR 0.40; 95% CI 0.23–0.69; p=0.0006) and ≥10% absolute %FVC decline or respiratory-related hospitalisation or all-cause mortality (HR 0.46; 95% CI 0.28–0.76; p=0.0018). At Week 52, median treatment differences favouring pirfenidone were 36.7 m for 6-min walk distance and −8.0 points for the University of California—San Diego Shortness of Breath Questionnaire total score. Treatment-emergent adverse events (TEAEs) led to discontinuation in 14.4% and 21.3% of patients with pirfenidone and placebo, respectively. Conclusion Pirfenidone demonstrated clinically relevant benefits across multiple domains in patients with IPF and more advanced disease without an increased risk of discontinuation due to TEAEs. Clinical trials registration clinicaltrials. gov (ASCEND: NCT01366209; CAPACITY: NCT00287716; NCT00287729)

Genetic association study of QT interval highlights role for calcium signaling pathways in myocardial repolarization.

The QT interval, an electrocardiographic measure reflecting myocardial repolarization, is a heritable trait. QT prolongation is a risk factor for ventricular arrhythmias and sudden cardiac death (SCD) and could indicate the presence of the potentially lethal mendelian long-QT syndrome (LQTS). Using a genome-wide association and replication study in up to 100,000 individuals, we identified 35 common variant loci associated with QT interval that collectively explain ∼8-10% of QT-interval variation and highlight the importance of calcium regulation in myocardial repolarization. Rare variant analysis of 6 new QT interval-associated loci in 298 unrelated probands with LQTS identified coding variants not found in controls but of uncertain causality and therefore requiring validation. Several newly identified loci encode proteins that physically interact with other recognized repolarization proteins. Our integration of common variant association, expression and orthogonal protein-protein interaction screens provides new insights into cardiac electrophysiology and identifies new candidate genes for ventricular arrhythmias, LQTS and SCD

Periodic Active Case Finding for TB: When to Look?

OBJECTIVE: To investigate the factors influencing the performance and cost-efficacy of periodic rounds of active case finding (ACF) for TB. METHODS: A mathematical model of TB dynamics and periodic ACF (PACF) in the HIV era, simplified by assuming constant prevalence of latent TB infection, is analyzed for features that control intervention outcome, measured as cases averted and cases found. Explanatory variables include baseline TB incidence, interval between PACF rounds, and different routine and PACF case-detection rates among HIV-infected and uninfected TB cases. FINDINGS: PACF can be cost-saving over a 10 year time frame if the cost-per-round is lower than a threshold proportional to initial incidence and cost-per-case-treated. More cases are averted at higher baseline incidence rates, when more potent PACF strategies are used, intervals between PACF rounds are shorter, and when the ratio of HIV-negative to positive TB cases detected is higher. More costly approaches, e.g. radiographic screening, can be as cost-effective as less costly alternatives if PACF case-detection is higher and/or implementation less frequent. CONCLUSION: Periodic ACF can both improve control and save medium-term health care costs in high TB burden settings. Greater costs of highly effective PACF at frequent (e.g. yearly) intervals may be offset by higher numbers of cases averted in populations with high baseline TB incidence, higher prevalence of HIV-uninfected cases, higher costs per-case-treated, and more effective routine case-detection. Less intensive approaches may still be cost-neutral or cost-saving in populations lacking one or more of these key determinants

SCN5A mutations in 442 neonates and children: genotype-phenotype correlation and identification of higher-risk subgroups.

Aims To clarify the clinical characteristics and outcomes of children with SCN5A-mediated disease and to improve their risk stratification. Methods and results A multicentre, international, retrospective cohort study was conducted in 25 tertiary hospitals in 13 countries between 1990 and 2015. All patients ≤16 years of age diagnosed with a genetically confirmed SCN5A mutation were included in the analysis. There was no restriction made based on their clinical diagnosis. A total of 442 children {55.7% boys, 40.3% probands, median age: 8.0 [interquartile range (IQR) 9.5] years} from 350 families were included; 67.9% were asymptomatic at diagnosis. Four main phenotypes were identified: isolated progressive cardiac conduction disorders (25.6%), overlap phenotype (15.6%), isolated long QT syndrome type 3 (10.6%), and isolated Brugada syndrome type 1 (1.8%); 44.3% had a negative electrocardiogram phenotype. During a median follow-up of 5.9 (IQR 5.9) years, 272 cardiac events (CEs) occurred in 139 (31.5%) patients. Patients whose mutation localized in the C-terminus had a lower risk. Compound genotype, both gain- and loss-of-function SCN5A mutation, age ≤1 year at diagnosis in probands and age ≤1 year at diagnosis in non-probands were independent predictors of CE. Conclusion In this large paediatric cohort of SCN5A mutation-positive subjects, cardiac conduction disorders were the most prevalent phenotype; CEs occurred in about one-third of genotype-positive children, and several independent risk factors were identified, including age ≤1 year at diagnosis, compound mutation, and mutation with both gain- and loss-of-function