Doubling the number of health graduates in Zambia: estimating feasibility and costs

<p>Abstract</p> <p>Background</p> <p>The Ministry of Health (MoH) in Zambia is operating with fewer than half of the human resources for health (HRH) necessary to meet basic population health needs. Responding urgently to address this HRH crisis, the MoH plans to double the annual number of health training graduates in the next five years to increase the supply of health workers. The feasibility and costs of achieving this initiative, however, are unclear.</p> <p>Methods</p> <p>We determined the feasibility and costs of doubling training institution output through an individual school assessment framework. Assessment teams, comprised of four staff from the MoH and Clinton Health Access Initiative, visited all of Zambia's 39 public and private health training institutions from 17 April to 19 June 2008. Teams consulted with faculty and managers at each training institution to determine if student enrollment could double within five years; an operational planning exercise carried out with school staff determined the investments and additional operating costs necessary to achieve expansion. Cost assumptions were developed using historical cost data.</p> <p>Results</p> <p>The individual school assessments affirmed the MoH's ability to double the graduate output of Zambia's public health training institutions. Lack of infrastructure was determined as a key bottleneck in achieving this increase while meeting national training quality standards. A total investment of US$58.8 million is required to meet expansion infrastructure needs, with US$ 35.0 million (59.5%) allocated to expanding student accommodation and US$23.8 million (40.5$ 58.0 million over the five-year scale-up period. Total cost of expansion is estimated at US$ 116.8 million over five years.</p> <p>Conclusions</p> <p>Historic underinvestment in training institutions has crippled Zambia's ability to meet expansion ambitions. There must be significant investments in infrastructure and faculty to meet quality standards while expanding training enrollment. Bottom-up planning can be used to translate national targets into costed implementation plans for expansion at each school.</p

Meeting human resources for health staffing goals by 2018: a quantitative analysis of policy options in Zambia

<p>Abstract</p> <p>Background</p> <p>The Ministry of Health (MOH) in Zambia is currently operating with fewer than half of the health workers required to deliver basic health services. The MOH has developed a human resources for health (HRH) strategic plan to address the crisis through improved training, hiring, and retention. However, the projected success of each strategy or combination of strategies is unclear.</p> <p>Methods</p> <p>We developed a model to forecast the size of the public sector health workforce in Zambia over the next ten years to identify a combination of interventions that would expand the workforce to meet staffing targets. The key forecasting variables are training enrolment, graduation rates, public sector entry rates for graduates, and attrition of workforce staff. We model, using Excel (Office, Microsoft; 2007), the effects of changes in these variables on the projected number of doctors, clinical officers, nurses and midwives in the public sector workforce in 2018.</p> <p>Results</p> <p>With no changes to current training, hiring, and attrition conditions, the total number of doctors, clinical officers, nurses, and midwives will increase from 44% to 59% of the minimum necessary staff by 2018. No combination of changes in staff retention, graduation rates, and public sector entry rates of graduates by 2010, without including training expansion, is sufficient to meet staffing targets by 2018 for any cadre except midwives. Training enrolment needs to increase by a factor of between three and thirteen for doctors, three and four for clinical officers, two and three for nurses, and one and two for midwives by 2010 to reach staffing targets by 2018. Necessary enrolment increases can be held to a minimum if the rates of retention, graduation, and public sector entry increase to 100% by 2010, but will need to increase if these rates remain at 2008 levels.</p> <p>Conclusions</p> <p>Meeting the minimum need for health workers in Zambia this decade will require an increase in health training school enrolment. Supplemental interventions targeting attrition, graduation and public sector entry rates can help close the gap. HRH modelling can help MOH policy makers determine the relative priority and level of investment needed to expand Zambia's workforce to target staffing levels.</p

Protecting Privacy in DNA Sequencing

As researchers predict that whole human genome sequencing may soon cost just $1,000, down from an estimation of$2.5 billion in 2000, observers caution that DNA sequencing may carry significant privacy risks. To balance the need for privacy regulation and scientific research with a technology that has the potential to revolutionize medicine, the Presidential Commission for the Study of Bioethical Issues, an influential group of leaders in disciplines ranging from medicine to law, recently issued a new report recommending improved industry self-regulation and government oversight of DNA sequencing. The Commission laid out a framework for industry self-regulation in order to address privacy issues including confidentiality, anonymity, and data security. These measures would include a clear determination of who can have access to genome data and for what purposes the data can be used. The Commission also noted that persons who collect genome samples should develop a robust consent process and communicate both data access and permissible use policies to individuals who provide their DNA. Further, the Commission recommended that persons in the possession of genome data, whether in research, clinical, or commercial settings, should establish professional ethical standards of confidentiality in their data use. To protect individuals, genome sequencing data should be wiped clean of information that could be used to determine an individual’s identity, such as Social Security numbers or home addresses. While encouraging increased industry self-regulation, the report also suggested that the government should play a stronger role in ensuring adequate privacy protection. The Commission report noted that current federal genetic privacy laws constitute only a patchwork and do not cover the whole spectrum of genome privacy issues. For example, although the Genetic Information Nondiscrimination Act prohibits employers and health insurers from discriminating based on genetic information, these protections do not cover discrimination elsewhere, such as in long-term care insurance or in athletic and educational settings. The Commission called for federal and state governments to establish a “floor of privacy protections” that would prohibit genome sequencing without an individual’s consent. The report indicated that around fifty percent of states do not have laws that explicitly prevent a person from collecting another’s whole genome information secretly—such as from saliva on a discarded coffee cup, to use an example noted in the report—and analyzing it through a commercial vendor without consent. Such a privacy floor could standardize privacy protections in this and similar situations. The Commission also found that federal law may treat the same data differently depending on the context, leading to inconsistencies in regulation and enforcement. For instance, the Health Insurance Portability and Accountability Act (HIPAA) would regulate the collection of a whole genome sequence for clinical care, whereas the Federal Policy for the Protection of Human Subjects would govern the same data collected for research purposes. To ensure that informed consent forms are sufficiently robust, the Commission recommended that the Office for Human Research Protections or another federal agency develop “clear and consistent guidelines for informed consent forms.” According to the report, new privacy regulations may benefit the genome sequencing industry, as current privacy concerns may be preventing scientific advances. Overcoming privacy concerns may motivate more individuals to donate their genes for research, thereby expanding the pool of genetic data. More available data could increase discovery and innovation as, for example, researchers would be able to correlate traits with genes more effectively. The Commission crafted its report and accompanying recommendations while remaining mindful of what it previously identified as five ethical principles: “public beneficence, responsible stewardship, intellectual freedom and responsibility, democratic deliberation, and justice and fairness.” To ensure both privacy and scientific progress, the Commission advised that industry self-regulation and government oversight should play different but complementary roles in ensuring data protection. It suggested that all public and private actors should design policies that ensure privacy while still enabling future research progress as well as clinical and commercial advances. University of Pennsylvania President Dr. Amy Gutmann is the current Chair of the Bioethics Commission which issued the report. Professor Anita L. Allen, the Henry R. Silverman Professor of Law at Penn Law, is also a member of the Commission

States Waiting to Decide on Medicaid Expansion

The U.S. Supreme Court’s controversial ruling on the constitutionality of President Obama’s health care reform may reduce the number of new Medicaid enrollees by as many as six million people, according to Congressional Budget Office (CBO) estimates. With over half of all states still undecided, however, the final number of new enrollees may depend on the results of political debates that are now being waged on the campaign trail and in state capitals around the United States. The Patient Protection and Affordable Care Act (ACA) mandated a Medicaid expansion that the law’s supporters intended would widen Medicaid and CHIP coverage to up to seventeen million more people by 2022. The Supreme Court ruled, however, that the federal government could not compel states to expand Medicaid by withholding federal money to existing programs. With individual states now having the power to opt out of Medicaid expansion due to the Supreme Court’s decision, the CBO has estimated that the likely number of new enrollees will drop from seventeen million to eleven million in 2022. Currently, twelve states and the District of Columbia have indicated that they will participate in the expansion, and six states have declined to participate. Thirty-two states have yet to make a clear commitment either way. Much of the substantive debate in states has focused on the budgetary implications of the expansion. If a state opts into the ACA’s Medicaid expansion, the state will be required to expand Medicaid eligibility to 133% of the federal poverty level starting in 2014. This level may be far above current Medicaid eligibility levels for some states. States generally pay a certain percentage of Medicaid costs, but the federal government would cover 100% of costs of Medicaid expansion for the first three years, and thereafter it would gradually scale back support to 90% by 2020, at which point support would remain at the same percentage for subsequent years. This plan means that states would have to pay a small percentage of the costs of providing coverage to additional people during the first decade the expansion, but would have to shoulder more of the burden after that. Several Republican governors — including Rick Scott of Florida and Rick Perry of Texas — have claimed that the expansion would hurt their states financially by costing billions of dollars. However, proponents of Medicaid expansion point to a report from the White House’s Council of Economic Advisers in 2009 that found that state governments might actually save money because of the Medicaid expansion. Besides getting large federal subsidies, states would no longer have to pay for as much uncompensated emergency care. Further, hospitals would no longer have to absorb as much costs for uncompensated care, which can drive up the price of care for all other payers, including state Medicaid programs. A report from the Urban Institute estimates that states would save a total of up to $129 billion by opting into the Medicaid expansion. In accepting Medicaid expansion, many Democratic governors have focused on its impact on the uninsured rather than its purported budgetary benefits. When Connecticut Governor Dannel Malloy announced his support for the expansion in June, he said that 500,000 additional people would gain coverage in his state after the Medicaid expansion and other ACA insurance reforms took effect. Other governors who have supported the expansion have made similar statements. Proponents for expansion also point to a recent research paper published in the New England Journal of Medicine which found that the Medicaid expansions that took place in Arizona, Maine, and New York between 2001 and 2002 saved 2,840 deaths for every 500,000 adults covered, corresponding to a 6.1% reduction in the relative risk of death among adults. Still, even a few Democratic governors have expressed concern about the financial impact of expansion. In September, for example, Arkansas Governor Mike Beebe, a Democrat, announced his tentative support of the Medicaid expansion only after he was given assurances that he could fully opt-out of the program if it proved too expensive. It is unclear to what extent state decisions will be made based on political considerations instead of cost-benefit evaluations. Notably, nearly all states that have pledged to participate in the Medicaid expansion have a Democratic executive branch, with only one being run by an independent. So far, Republican executives lead all of the states publicly rejecting the expansion. Further, nearly all eighteen states that made their Medicaid expansion positions clear did so within a week of the Supreme Court decision. Only one state has announced its intentions since that time. Federal health administration officials have said that there is no deadline for states to accept the Medicaid expansion. Many states still on the fence have governors who appear to be waiting until after the November election to make a decision. Republican presidential candidate Mitt Romney has signaled that he would work to repeal the ACA if elected, so some governors may be waiting to see if the election indicates what the people want in terms of health care reform and Medicaid expansion

Protecting Privacy in DNA Sequencing

As researchers predict that whole human genome sequencing may soon cost just $1,000, down from an estimation of$2.5 billion in 2000, observers caution that DNA sequencing may carry significant privacy risks. To balance the need for privacy regulation and scientific research with a technology that has the potential to revolutionize medicine, the Presidential Commission for the Study of Bioethical Issues, an influential group of leaders in disciplines ranging from medicine to law, recently issued a new report recommending improved industry self-regulation and government oversight of DNA sequencing. The Commission laid out a framework for industry self-regulation in order to address privacy issues including confidentiality, anonymity, and data security. These measures would include a clear determination of who can have access to genome data and for what purposes the data can be used. The Commission also noted that persons who collect genome samples should develop a robust consent process and communicate both data access and permissible use policies to individuals who provide their DNA. Further, the Commission recommended that persons in the possession of genome data, whether in research, clinical, or commercial settings, should establish professional ethical standards of confidentiality in their data use. To protect individuals, genome sequencing data should be wiped clean of information that could be used to determine an individual’s identity, such as Social Security numbers or home addresses. While encouraging increased industry self-regulation, the report also suggested that the government should play a stronger role in ensuring adequate privacy protection. The Commission report noted that current federal genetic privacy laws constitute only a patchwork and do not cover the whole spectrum of genome privacy issues. For example, although the Genetic Information Nondiscrimination Act prohibits employers and health insurers from discriminating based on genetic information, these protections do not cover discrimination elsewhere, such as in long-term care insurance or in athletic and educational settings. The Commission called for federal and state governments to establish a “floor of privacy protections” that would prohibit genome sequencing without an individual’s consent. The report indicated that around fifty percent of states do not have laws that explicitly prevent a person from collecting another’s whole genome information secretly—such as from saliva on a discarded coffee cup, to use an example noted in the report—and analyzing it through a commercial vendor without consent. Such a privacy floor could standardize privacy protections in this and similar situations. The Commission also found that federal law may treat the same data differently depending on the context, leading to inconsistencies in regulation and enforcement. For instance, the Health Insurance Portability and Accountability Act (HIPAA) would regulate the collection of a whole genome sequence for clinical care, whereas the Federal Policy for the Protection of Human Subjects would govern the same data collected for research purposes. To ensure that informed consent forms are sufficiently robust, the Commission recommended that the Office for Human Research Protections or another federal agency develop “clear and consistent guidelines for informed consent forms.” According to the report, new privacy regulations may benefit the genome sequencing industry, as current privacy concerns may be preventing scientific advances. Overcoming privacy concerns may motivate more individuals to donate their genes for research, thereby expanding the pool of genetic data. More available data could increase discovery and innovation as, for example, researchers would be able to correlate traits with genes more effectively. The Commission crafted its report and accompanying recommendations while remaining mindful of what it previously identified as five ethical principles: “public beneficence, responsible stewardship, intellectual freedom and responsibility, democratic deliberation, and justice and fairness.” To ensure both privacy and scientific progress, the Commission advised that industry self-regulation and government oversight should play different but complementary roles in ensuring data protection. It suggested that all public and private actors should design policies that ensure privacy while still enabling future research progress as well as clinical and commercial advances. University of Pennsylvania President Dr. Amy Gutmann is the current Chair of the Bioethics Commission which issued the report. Professor Anita L. Allen, the Henry R. Silverman Professor of Law at Penn Law, is also a member of the Commission

States Waiting to Decide on Medicaid Expansion

The U.S. Supreme Court’s controversial ruling on the constitutionality of President Obama’s health care reform may reduce the number of new Medicaid enrollees by as many as six million people, according to Congressional Budget Office (CBO) estimates. With over half of all states still undecided, however, the final number of new enrollees may depend on the results of political debates that are now being waged on the campaign trail and in state capitals around the United States. The Patient Protection and Affordable Care Act (ACA) mandated a Medicaid expansion that the law’s supporters intended would widen Medicaid and CHIP coverage to up to seventeen million more people by 2022. The Supreme Court ruled, however, that the federal government could not compel states to expand Medicaid by withholding federal money to existing programs. With individual states now having the power to opt out of Medicaid expansion due to the Supreme Court’s decision, the CBO has estimated that the likely number of new enrollees will drop from seventeen million to eleven million in 2022. Currently, twelve states and the District of Columbia have indicated that they will participate in the expansion, and six states have declined to participate. Thirty-two states have yet to make a clear commitment either way. Much of the substantive debate in states has focused on the budgetary implications of the expansion. If a state opts into the ACA’s Medicaid expansion, the state will be required to expand Medicaid eligibility to 133% of the federal poverty level starting in 2014. This level may be far above current Medicaid eligibility levels for some states. States generally pay a certain percentage of Medicaid costs, but the federal government would cover 100% of costs of Medicaid expansion for the first three years, and thereafter it would gradually scale back support to 90% by 2020, at which point support would remain at the same percentage for subsequent years. This plan means that states would have to pay a small percentage of the costs of providing coverage to additional people during the first decade the expansion, but would have to shoulder more of the burden after that. Several Republican governors — including Rick Scott of Florida and Rick Perry of Texas — have claimed that the expansion would hurt their states financially by costing billions of dollars. However, proponents of Medicaid expansion point to a report from the White House’s Council of Economic Advisers in 2009 that found that state governments might actually save money because of the Medicaid expansion. Besides getting large federal subsidies, states would no longer have to pay for as much uncompensated emergency care. Further, hospitals would no longer have to absorb as much costs for uncompensated care, which can drive up the price of care for all other payers, including state Medicaid programs. A report from the Urban Institute estimates that states would save a total of up to $129 billion by opting into the Medicaid expansion. In accepting Medicaid expansion, many Democratic governors have focused on its impact on the uninsured rather than its purported budgetary benefits. When Connecticut Governor Dannel Malloy announced his support for the expansion in June, he said that 500,000 additional people would gain coverage in his state after the Medicaid expansion and other ACA insurance reforms took effect. Other governors who have supported the expansion have made similar statements. Proponents for expansion also point to a recent research paper published in the New England Journal of Medicine which found that the Medicaid expansions that took place in Arizona, Maine, and New York between 2001 and 2002 saved 2,840 deaths for every 500,000 adults covered, corresponding to a 6.1% reduction in the relative risk of death among adults. Still, even a few Democratic governors have expressed concern about the financial impact of expansion. In September, for example, Arkansas Governor Mike Beebe, a Democrat, announced his tentative support of the Medicaid expansion only after he was given assurances that he could fully opt-out of the program if it proved too expensive. It is unclear to what extent state decisions will be made based on political considerations instead of cost-benefit evaluations. Notably, nearly all states that have pledged to participate in the Medicaid expansion have a Democratic executive branch, with only one being run by an independent. So far, Republican executives lead all of the states publicly rejecting the expansion. Further, nearly all eighteen states that made their Medicaid expansion positions clear did so within a week of the Supreme Court decision. Only one state has announced its intentions since that time. Federal health administration officials have said that there is no deadline for states to accept the Medicaid expansion. Many states still on the fence have governors who appear to be waiting until after the November election to make a decision. Republican presidential candidate Mitt Romney has signaled that he would work to repeal the ACA if elected, so some governors may be waiting to see if the election indicates what the people want in terms of health care reform and Medicaid expansion

When a Home is Not a Home: MultiDrug-Resistant Organism (MDRO) Colonization and Environmental Contamination in 28 Nursing Homes (NHs)

Abstract Background The majority of healthcare-associated infections due to MDROs occur in the post-discharge setting. Understanding MDRO spread and containment in NHs can help identify infection prevention activities needed to care for vulnerable patients in a medical home setting. Methods We conducted a baseline point prevalence study of MDRO colonization in residents of 28 Southern California NHs participating in a decolonization trial. In Fall 2016, residents were randomly sampled to obtain a set of 50 nares and skin (axilla/groin) swabs from each NH. Nasal swabs were processed for MRSA and skin swabs were processed for MRSA, VRE, ESBL, and CRE. In addition, environmental swabs were collected from high touch objects in resident rooms (bedrail, call button/TV remote, door knobs, light switch, bathroom) and common areas (nursing station, table, chair, railing, and drinking fountain). Results A&nbsp;total of 2,797 body swabs were obtained from 1400 residents. Overall, 48.6% (N&nbsp;=&nbsp;680) of residents harbored MDROs. MRSA was found in 37% of residents (29.5% nares, 24.4% skin), followed by ESBL in 16% (Table&nbsp;1). Resident MDRO status was only known for 11% of MRSA (59/518), 18% ESBL (40/228), 4% VRE (4/99), and none of the CRE (0/13) carriers. Colonization did not differ between long stay (48.8%, 534/1094) vs. post-acute (47.7%, 146/306) residents (P&nbsp;=&nbsp;NS), but bedbound residents were more likely to be MDRO colonized (58.7%, 182/310) vs. ambulatory residents (45.7%, 497/1088, P&nbsp;&lt;&nbsp;0.001). A&nbsp;total of 560 environmental swabs were obtained with 93% of common areas and 74% of resident rooms having an MDRO+ object with an average of 2.5 and 1.9 objects found to be contaminated (Table&nbsp;2). Conclusion One in two NH residents are colonized with MDROs, which is largely unknown to the facility. MDRO carriage is associated with total care needs, but not long stay status. Environmental contamination in resident rooms and common areas is common. The burden of MDRO colonization and contamination is sufficiently high that universal strategies to reduce colonization and transmission are warranted. Disclosures J. A.&nbsp;McKinnell, Allergan: Research Contractor, Scientific Advisor and Speaker’s Bureau, Consulting fee, Research support and Speaker honorarium; Achaogen: Research Contractor, Scientific Advisor and Shareholder, Research support; Cempra: Research Contractor and Scientific Advisor, Research support; Theravance: Research Contractor, Research support; Science 37: Research Contractor, Salary; Expert Stewardship, LLC: Board Member and Employee, Salary; Thermo Fisher: Scientific Advisor, Salary; 3M: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; L. Miller, 3M: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; R. D.&nbsp;Singh, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; 3M: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; J. Mendez, Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; R. Franco, Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; G. Gussin, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; L’Oreal: Consultant, Consulting fee; J. Chang, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; 3M: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; T. D.&nbsp;Dutciuc, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; 3M: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; R. Saavedra, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; K. Kleinman, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Molnlycke: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; 3M: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; E. M.&nbsp;Peterson, Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; L. Heim, Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; 3M: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; A. Miner, Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; M. Estevez, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; 3M: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; H. Custodio, Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; S. Yamaguchi, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; J. Nguyen, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; A. Varasteh, Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Sage Product: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; B. Launer, 3M: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; S. Agrawal, Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; T. Tjoa, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; 3M: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; J. He, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; 3M: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; S. Park, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; S. Tam, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; 3M: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; S. K.&nbsp;Gohil, Sage Products: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; Clorox: Receipt of contributed product, Conducting studies in healthcare facilities that are receiving contributed product; S. S.&nbsp;Huang, Sage Products: Receipt of contributed product, Conducting studies in which participating healthcare facilities are receiving contributed product (no contribution in submitted abstract), Participating healthcare facilities in my studies received contributed product; Xttrium Laboratories: Receipt of contributed product, Conducting studies in which participating healthcare facilities are receiving contributed product (no contribution in submitted abstract), Participating healthcare facilities in my studies received contributed product; Clorox: Receipt of contributed product, Conducting studies in which participating healthcare facilities are receiving contributed product (no contribution in submitted abstract), Participating healthcare facilities in my studies received contributed product; 3M: Receipt of contributed product, Conducting studies in which participating healthcare facilities are receiving contributed product (no contribution in submitted abstract), Participating healthcare facilities in my studies received contributed product; Molnlycke: Receipt of contributed product, Conducting studies in which participating healthcare facilities are receiving contributed product (no contribution in submitted abstract), Participating healthcare facilities in my studies received contributed produc