Delaware Journal of Public Health - Current Research COVID-19, Part 2

Volume 6 | Issue 3

Delaware Journal of

August 2020

Public Health A publication of the Delaware Academy of Medicine / Delaware Public Health Association

FROM CELLS TO SOCIETY: RESEARCH IN THE TIME OF COVID-19

www.delamed.org | www.delawarepha.org

Part 2

Delaware Journal of

Delaware Academy of Medicine

Board of Directors: OFFICERS Omar A. Khan, M.D., M.H.S. President S. John Swanson, M.D. President Elect

Public Health

A publication of the Delaware Academy of Medicine / Delaware Public Health Association

Lynn Jones Secretary David M. Bercaw, M.D. Treasurer Daniel J. Meara, M.D., D.M.D. Immediate Past President Timothy E. Gibbs, M.P.H. Executive Director, Ex-officio DIRECTORS Stephen C. Eppes, M.D. Eric T. Johnson, M.D. Joseph F. Kestner, Jr., M.D. Professor Rita Landgraf Brian W. Little, M.D., Ph.D. Arun V. Malhotra, M.D. John P. Piper, M.D. EMERITUS Robert B. Flinn, M.D. Barry S. Kayne, D.D.S.

Delaware Public Health Association

Advisory Council:

Omar Khan, M.D., M.H.S. President Timothy E. Gibbs, M.P.H. Executive Director Louis E. Bartoshesky, M.D., M.P.H. Gerard Gallucci, M.D., M.H.S. Richard E. Killingsworth, M.P.H. Erin K. Knight, Ph.D., M.P.H. Melissa K. Melby, Ph.D. Mia A. Papas, Ph.D. Karyl T. Rattay, M.D., M.S. William J. Swiatek, M.A., A.I.C.P.

Delaware Journal of Public Health Timothy E. Gibbs, M.P.H. Publisher Omar Khan, M.D., M.H.S. Editor-in-Chief Mia A. Papas, Ph.D. and Steven Stanhope, Ph.D. Guest Editors Liz Healy, M.P.H. Managing Editor Kate Smith, M.D., M.P.H. Copy Editor Suzanne Fields Image Director ISSN 2639-6378

August 2020

Volume 6 | Issue 3

www.djph.org In This Issue we welcome you back to Part B of the DJPH Current Research and COVID-19 issue. This second part further explores both COVID-19 research and that taking place in other areas including VAPING, HPV, and Hepatitis C. As always, we appreciate your readership, and the contributions of our many talented expert authors. Omar A Khan, M.D., M.H.S. Timothy E. Gibbs, M.P.H.

26 | Addressing Health Disparities in Delaware by Diversifying the Next Generation of Delaware’s Physicians Kristyn Mitchell; Franklin Iheanacho; Jacqueline Washington, Ed.D.; Marshala Lee, M.D., M.P.H.

36 | The HensNest: Mass Manufacturing a General Use Face Mask Here in Delaware Catherine Fromen; Whitney Sample; Ajay Prasad; Jenni M. Buckley

4 | Guest Editor Mia A. Papas, Ph.D.; Steven Stanhope, Ph.D.

6 | Reflections from Physician Scientistson the Front Lines of COVID-19 Jennifer N. Goldstein, M.D., M.Sc.; David Chen, M.D., M.P.H.; Vishal Patel, M.D., M.B.A.; Stephanie Guarino, M.D., M.S.H.P.; Navin Vij, M.D., M.S.H.P.

10 | Toolkit for Emotional Coping forHealthcare Staff (TECHS): Helping Healthcare Workers Cope with the Demands of COVID-19 Julia Price, Ph.D.; Nancy Kassam-Adams, Ph.D.; Anne E. Kazak, Ph.D., A.B.P.P.

16 | Well-being Among Healthcare Personnel During the COVID-19 Public Health Crisis Maureen Leffler, D.O., M.P.H.

20 | Humility: a virtue critical to both successful COVID-19 research and patient care Michael T. Vest, D.O.

22 | A Social Network Analysis Approach for Contact Tracing in the Hospital Setting Mina Ostovari, Ph.D.; Lee Pachter, D.O.; David Chen M.D., M.P.H.

40 | Utilizing Partnership Flexibility and Strengths: Key Elements for Driving 3D Printed Face-Shield Production During the COVID-19 Pandemic Tim Mueller, Ph.D.; Tariq Rahman Ph.D.; Vicky Funanage Ph.D.

42 | Innovation and Rapid Mobilization Bring New PAPR Hood to Healthcare Workers on the Frontlines ILC Dover

44 | Overcoming a pandemic: How engineering and modeling techniques are used to inform a health system from preparation to recovery from the COVID-19 pandemic Tze Chiam, Ph.D.; Mia Papas, Ph.D.

50 | Quarantine bubbles – when done right – limit coronavirus risk and help fight loneliness Melissa Hawkins, Ph.D., M.H.S.

52 | COVID-19 and the Vulnerable Sherry A. Maykrantz, Ph.D., C.H.E.S.; Erica H. Weiss, M.P.H., M.S.U.P.; Francine Baker, B.S.

55 | Teaching Public Health During a Pandemic Jody Gan, M.P.H., C.H.E.S.

56 | Epidemiology of Hepatitis C in Delaware Deborah Kahal M.D., M.P.H., F.A.A.C.P.; Gale H. Rutan, M.D., M.P.H., F.A.A.C.P.

62 | Delaware’s HPV vaccination   rates rise with evidence-based intervention implementation Lisa Gruss, M.S., M.B.A.; Lori Saul, R.N., B.S.N.; Sarah Toborowski, B.A.; James Talbott, M.P.A.; Paul Hess

68 | Vaping Among Delaware Youth Rachel Ryding; David Borton, M.A.; Meisje Scales, M.P.H., C.P.S.; Dana Carr, M.P.H.; Helen Arthur, M.H.A.; Lisa M. Moore, M.P.A.; Sharon Merriman-Nai, M.C.

80 | I Signed Up for This Kayla Morrell

81 | COVID-19: An impasse between livelihood and health Karthi Jayakumar

82 | CareVio and Coronavirus: The Front Line for Delaware Medical Students Thomas Marconi

84 | Public Health Implications for the Future: Unifying a Fragmented System Sky Prestowitz, D.O.

86 | A Grief All Its Own Mary Blumenfeld

88 | Delaware COVID - Lexicon  89 | Delaware COVID - Resources 104 | Index of Advertisers

54 | Short Story Mukta Bain

COVER On February 11, 2020 the World Health Organization announced an official name for the disease that is causing the 2019 novel coronavirus outbreak. The new name of this disease is coronavirus disease 2019, abbreviated as COVID-19. Globally, nationally, and locally, one of the most effective prevention measures is to wear a mask.

The Delaware Journal of Public Health (DJPH), first published in 2015, is the official journal of the Delaware Academy of Medicine / Delaware Public Health Association (Academy/DPHA).

only the opinions of the authors and do not necessarily reflect the official policy of the Delaware Public Health Association or the institution with which the author(s) is (are) affiliated, unless so specified.

Submissions: Contributions of original unpublished research, social science analysis, scholarly essays, critical commentaries, departments, and letters to the editor are welcome. Questions? Write ehealy@delamed.org or call Liz Healy at 302-733-3989.

Any report, article, or paper prepared by employees of the U.S. government as part of their official duties is, under Copyright Act, a “work of United States Government” for which copyright protection under Title 17 of the U.S. Code is not available. However, the journal format is copyrighted and pages June not be photocopied, except in limited quantities, or posted online, without permission of the Academy/ DPHA. Copying done for other than personal or internal reference use-such as copying for general distribution, for advertising or promotional purposes, for creating new collective works, or for resale- without the expressed permission of the Academy/DPHA is prohibited. Requests for special permission should be sent to ehealy@delamed.org.

Advertising: Please write to ehealy@delamed.org or call 302-733-3989 for other advertising opportunities. Ask about special exhibit packages and sponsorships. Acceptance of advertising by the Journal does not imply endorsement of products. Copyright © 2020 by the Delaware Academy of Medicine / Delaware Public Health Association. Opinions expressed by authors of articles summarized, quoted, or published in full in this journal represent

Federal funding for public health programs and agencies is critical to keeping our communities healthy and preparing for public health emergencies like the COVID-19 pandemic. Yet, for the past decade, federal investments in public health have declined. The annual appropriations process is our opportunity to increase funding levels for public health programs and agencies, including the Centers for Disease Control and Prevention and the Health Resources and Services Administration: https://www.apha.org/-/media/files/pdf/advocacy/ speak/200611_cdc_hrsa.ashx. In July, the U.S. House of Representatives passed their fiscal year 2021 Labor-HHS-Education appropriations bill, the primary spending bill that supports public health programs, but the Senate has yet to begin work on their bill. With both chambers on recess until Sept. 7, now is the time for public health advocates to contact their members of Congress https://www.apha.org/policies-and-advocacy/advocacy-for-public-health/action-alerts/fy2021 and urge them to prioritize public health funding. The current fiscal year ends on Sept. 30, meaning this will be a priority issue for Congress when they return to Washington, D.C. APHA’s Speak for Health resources https://www.apha.org/policies-and-advocacy/advocacy-forpublic-health/speak-for-health make it easy for advocates like you to: • Urge your elected officials to prioritize public health funding in fiscal year 2021 and in any future COVID-19 response legislation. We strongly encourage personalizing the APHA action alert before sending it, and you can also use it as a script to call and email your members. https://www.apha.org/policies-and-advocacy/advocacy-for-public-health/action-alerts . • Meet virtually with your members of Congress or their staff.

https://www.apha.org/-/media/files/pdf/advocacy/sample_email_requesting_a_meeting.ashx.

• Use APHA’s state fact sheets to discuss local public health funding with them.

https://www.apha.org/policies-and-advocacy/advocacy-for-public-health/speak-for-health/state-fact-sheets.

• Attend a town hall and ask questions to candidates about public health funding using the Public Health on the Ballot question guide,

https://www.apha.org/-/media/files/pdf/advocacy/speak/200624_public-health_on_the_ballot.ashx

or these sample questions:

https://www.apha.org/-/media/files/pdf/advocacy/speak/200309_s4h_sample_forum_questions.ashx .

• Start a discussion about the importance of public health funding on Facebook https://www.apha.org/-/media/files/pdf/advocacy/speak/facebook_guide.ashx or Twitter https://www.apha.org/-/media/files/pdf/advocacy/speak/twitter_guide.ashx. Make sure to use the hashtag #SpeakForHealth! • Submit an op-ed to your local paper. Use our tips for writing an op-ed https://www.apha.org/-/media/files/pdf/advocacy/speak/oped_tips.ashx. If you have questions or need assistance Email mediarelations@apha.org mediarelations@apha.org?subject=Question about public health funding op-ed . • Stay up-to-date on APHA’s advocacy efforts with our monthly Legislative Updates

https://www.apha.org/policies-and-advocacy/legislative-updates and letters to Congress and federal agencies https://www.apha.org/policies-and-advocacy/ advocacy-for-public-health/letters-to-congress-and-federal-agencies .

Funding for public health has been inadequate for too long. Use your voice to Speak for Health and join us in urging Congress to prioritize public health in fiscal year 2021, and beyond. 3

GUEST EDITORS

From cells to communities: Addressing COVID-19 in Delaware through scientific research

Mia A. Papas, Ph.D. and Steven Stanhope, Ph.D.

“Ingenuity, knowledge, and organization alter but cannot cancel humanity’s vulnerability to invasion by parasitic forms of life. Infectious disease which antedated the emergence of humankind will last as long as humanity itself, and will surely remain, as it has been hitherto, one of the fundamental parameters and determinants of human history.” - William H. McNeill, in Plagues and Peoples, 19761 In December of 2019, reports of an outbreak of a new pneumonialike virus originated from Wuhan, China.2 The identified infectious agent, a novel coronavirus, known as SARS-CoV-2, spread rapidly and by mid-January cases were identified beyond China in Japan, Thailand, and South Korea.3 The first case in the United States occurred in a man in his 30s who resided in Washington State and was diagnosed on January 21, 2020.4 By the end of the month, the World Health Organization declared the outbreak a global public health emergency with 9,000 cases worldwide.5 Over the next two months, we witnessed the destabilization of the world economic markets and watched in disbelief as overrun hospitals and soaring death rates in Italy, Spain, and New York City became warning sentinels for the rest of the world. SARS-CoV-2 causes a respiratory illness we now commonly refer to as COVID-19.6 In the seven months since the first case reports, the world has been engulfed in a pandemic totaling over 10 million confirmed cases and 500,000 deaths with 2.65 million cases and 125,000 deaths in the United States as of June 21, 2020.7 Although some countries have successfully slowed the rate of transmission through public health practices, other countries, such as Brazil and the United States, are continuing to report new case rates that are rising exponentially. To understand the challenges the United States has faced in dealing with this pandemic, we need to look to the past. As early as the 1990s, the Centers for Disease Control and Prevention (CDC) as well as many other public health professionals had argued for strengthening the public health infrastructures of our nation in order to protect against novel infectious diseases.8 Central to the strategy of prevention is the concept that it is less costly to anticipate and prevent infectious disease threats than to react to widespread illnesses with expensive treatment and radical containment measures. Unfortunately, in the years prior to the COVID-19 pandemic, the United States has de-funded its public health infrastructure and missed opportunities to anticipate infectious disease threats.9 We are now reacting to this pandemic after repeated underinvestment in essential prevention activities including surveillance, laboratory research and training, epidemiologic investigation, and infection control efforts. This has resulted in both human suffering and widespread economic losses over the past six months that are many times greater than the savings accrued by budget cuts. Without a coordinated national response to provide guidance on a plan to halt the spread of this disease, local city, county, and state governmental agencies, as well as businesses and organizations, have been developing and implementing independent mitigation efforts. This piecemeal response to the pandemic has broadly resulted in uneven assistance to states, funding and supply delays 4 Delaware Journal of Public Health – August 2020

for healthcare providers, inconsistent public health messaging, and insufficient testing capabilities.10 It has also resulted in the continued spread of this disease throughout the United States despite the closure of schools and businesses throughout March and April. In Delaware, the first case of COVID-19 was identified on March 11, 2020.11 Prior to that first case, Delaware state and local government agencies, its healthcare systems, and our academic and technology and research partners had begun preparing for the outbreak. Having watched the toll this virus was taking on our neighbors in New York, New Jersey, and Pennsylvania, swift action by the Governor led to the transition of all schools to virtual learning platforms as well as a general shelter in place order within days after the first case was announced. In addition to the swift action of our state and local government agencies, the scientific, healthcare and business institutions of Delaware came together to develop strategies that allowed for a deeper understanding of the potential impact of COVID-19 on our community in order to develop efforts to mitigate the devastating effects of this disease. As just one example of these efforts, ChristianaCare established a drive through testing site less than 24 hours from the first diagnosed case.12 Since then, additional healthcare systems along with the Delaware Division of Public Health and New Castle County government have expanded diagnostic testing.13 In this edition of the Delaware Journal of Public Health, we have gathered a collection of innovative science occurring throughout our State as we all continue to flatten the curve. We provide a view of public health and medical activities across the continuum of clinical and translational research led by Delaware scientists. Over the past decade, several large research infrastructure programs such as the Idea Network for Biomedical Research Excellence (INBRE) and ACCEL: Delaware Center for Translational Research (DE-CTR) programs have worked to establish a network of education, healthcare, business, technology, research, and public health partners. These partners are a catalyst for connecting various research practices to improve the health of all Delawareans. Investments in this network have allowed for multidisciplinary teams to quickly come together in the face of this pandemic in order to understand disease dynamics, improve diagnosis and treatment, care for the caregivers on the frontlines, and contribute to technological advances that enhance prevention and treatment of COVID-19. The overwhelming response to our call for COVID-19 related research necessitated two volumes of the current edition. In volume 1, we start on the bench by providing insight into the virus itself. The first series of articles describe work to understand the basic virology of this novel virus and to develop methods to enhance diagnostic testing through laboratory-based methods,

serology tests, and molecular diagnostics. The next group of articles move to the bedside, highlighting the importance of developing novel treatments and therapeutics for COVID-19, testing the efficacy of existing pharmaceuticals through rapidly implemented clinical trials, and describing the need for clinical care to address important subpopulations including children, persons with mental health issues, and those with substance abuse use disorders. We then move to public health, and deal with the science of protecting and improving the health of the community. As a science, public health operates in the background of our everyday lives; it is only when disaster strikes that we realize its importance for keeping our communities healthy and safe from harm. In this section, you will read about local research on COVID-19 surveillance, contact tracing, and testing activities. Finally, our healthcare and prevention efforts must focus on the most vulnerable amongst us. Early data from across the nation, including Delaware, has brought a voice to the members of medically underserved communities who are also disproportionately more likely to contract COVID-19.14 We have gathered several examples of the focused efforts occurring throughout the State to examine the impact of the social determinants of health, racial injustice, and homelessness that cause greater divides in the health equity of our communities. You will read about research and actions addressing those disparities through community engagement and frontline social first responders. Volume 2 starts with our frontline healthcare workers. We bring you several articles describing first-hand the experience of the front-line health care workers who have been addressing this pandemic. We focus on their emotional resources and well-being and provide an editorial on the need for humility in practice and in research. In volume 2, you will also read about innovative technologies being manufactured right here in Delaware that expand the supply of personal protective equipment and engineer solutions for resource optimization. In the United States, an anti-science sentiment has been increasing over the past several years.15 COVID-19 has reminded us of the importance of scientifically based health research and practice. Science is our guide to navigate our way out of the havoc created by this devastating virus. Health professionals will continue to work intensely across the State of Delaware and throughout the nation to understand COVID-19 in order to protect the health of the population and minimize the negative impact of this and future diseases. And the rate at which we recover will be directly impacted by the universal empathetic concern we have for each other. Delaware has benefited from the strong commitment of its leaders in government, healthcare, education, business, and technology to improve lives through science and research. These efforts have established a medical and public health network that has come together toward one common human goal: our continued ability to protect and improve the health of the individuals in our community.

REFERENCES 1. McNeill, W. (1976). Plagues and peoples. Garden City, New York: Doubleday/Anchor. 2. Zhu, N., Zhang, D., Wang, W., Li, X., Yang, B., Song, J., . . . Tan, W., & the China Novel Coronavirus Investigating and Research Team. (2020, February 20). A novel coronavirus from patients with pneumonia in China, 2019. The New England Journal of Medicine, 382(8), 727–733. https://doi.org/10.1056/NEJMoa2001017

3. Mallapaty, S. (2020). Scientists fear coronavirus spread in vulnerable nations. Nature, 578, 348. Retrieved from: https://www.nature.com/articles/d41586-020-00405-w https://doi.org/10.1038/d41586-020-00405-w 4. Omer, S. B., Malani, P., & Del Rio, C. (2020, April 6). The COVID-19 pandemic in the US: A clinical update. JAMA, 323(18), 1767–1768. 5. World Health Organization. (2020, Mar 11). Director-General’s opening remarks at the media briefing on COVID-19. Retrieved from: https://www.who.int/dg/speeches/detail/whodirector-general-s-opening-remarks-at-the-media-briefing-on-covid19---11-march-2020 6. Coronaviridae Study Group of the International Committee on Taxonomy of Viruses. (2020, April). The species Severe acute respiratory syndrome-related coronavirus: Classifying 2019nCoV and naming it SARS-CoV-2. Nature Microbiology, 5(4), 536–544. Retrieved from: https://doi.org/10.1038/s41564-020-0695-z 7. Johns Hopkins University and Medicine. (n.d.). Coronavirus resource center: COVID-19 case tracker. Available at: https://coronavirus.jhu.edu/map.html 8. Centers for Disease Control and Prevention. (1994). Addressing emerging infectious disease threats: A prevention strategy for the United States. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service. Retrieved from: https://www.cdc.gov/mmwr/preview/mmwrhtml/00031393.htm 9. Maani, N., & Galea, S. (2020, June). COVID-19 and underinvestment in the public health infrastructure of the United States. The Milbank Quarterly, 98(2), 250–259. Retrieved from https://www.milbank.org/quarterly/articles/covid19-and-underinvestment-in-the-public-health-infrastructure-of-theunited-states/ https://doi.org/10.1111/1468-0009.12463 10. Barry, E. (2020, Mar 15). ‘It’s totally ad hoc’: why America’s Virus response looks like a patchwork. The New York Times. Retrieved from: www.nytimes.com/2020/03/15/us/united-statescoronavirus-response.amp.html 11. Delaware News. (2020, Mar 11). Public health announces first presumptive positive case of coronavirus in Delaware resident. Retrieved from: https://news.delaware.gov/2020/03/11/publichealth-announces-first-presumptive-positive-case-of-coronavirus-indelaware-resident/ 12. Drees, M., Papas, M., Corbo, T., Williams, K., & Kurfuerst, S. (2020). (in press). Identifying community spread of COVID-19 via a free drive-through screening event. Infection Control and Hospital Epidemiology. 13. Delaware News. (2020, May 8). Governor Carney announces significant expansion of statewide testing program for COVID-19. May 8, 2020. Retrieved from: https://news.delaware. gov/2020/05/08/governor-carney-announces-significant-expansionof-statewide-testing-program-for-covid-19/ 14. Williams, D. R., & Cooper, L. A. (2020, May 11). COVID-19 and health equity – a new kind of “herd immunity”. JAMA, 323(24), 2478–2480. https://doi.org/10.1001/jama.2020.8051 15. Otto, S. L. (2012, November). America’s science problem. Scientific American, 307(5), 62–71. https://doi.org/10.1038/scientificamerican1112-62 5

On the front-lines: Healthcare Workers

Reflections from Physician Scientists on the Front Lines of COVID-19 Jennifer N. Goldstein, M.D., M.Sc. Academic Hospitalist, ChristianaCare; Program Director, Research Education, The Value Institute, ChristianaCare David Chen, M.D., M.P.H. Academic Hospitalist, ChristianaCare; Physician Scientist, Value Institute Vishal Patel, M.D., M.B.A. General Internist, ChristianaCare; Physician Scientist, Value Institute Stephanie Guarino, M.D., M.S.H.P. General Internist, ChristianaCare; Physician Scientist, Value Institute Navin Vij, M.D., M.S.H.P. Academic Hospitalist, ChristianaCare; Physician Scientist, Value Institute

ABSTRACT As the largest health system in Delaware, ChristianaCare has been at the forefront of the COVID-19 pandemic. The following is a collection of reflections from physician scientists at the Value Institute at ChristianaCare, all of whom are involved in clinical care as well as research, quality improvement and process improvement. Each reflection describes a different dimension of the complexities, challenges and rewards of delivering care to patients, families, the community, as well as themselves during these unprecedented times. The thoughts and opinions expressed are their own and do not reflect those of ChristianaCare or the Value Institute.

Caring for the COVID Patient David Chen, M.D., M.P.H.

As a hospitalist, I routinely care for patients who are too ill to remain outside of the hospital. I work in coordination with a team of caregivers, and we are accustomed to treating a wide range of unnerving clinical scenarios, including both acute physiological disease as well as subtle layers of pathologies within the social determinants of health. Even so, I found my hands trembling as I walked out of the patient room, unsure of what to make of my first clinical encounter with a patient with confirmed COVID-19. I was concerned for the patient and the uncertain trajectory of the disease itself. I was anxious about the treatment that I was providing, which was based on the best and most current evidence, which in of itself was rapidly evolving. And I was concerned for myself and my co-workers, for our risk of exposure. Were we doing enough to protect ourselves and each other? Over the following weeks as the patient load continued to grow, so did cases among health care providers and staff. In working through my own anxiety and that which was clearly visible on the faces of the nurses, technicians, clerks, housekeepers, and staff whom I saw as colleagues and friends, I struggled to think of a comparable framework that could replicate the web of COVID transmission. Surprisingly, the first thing that came to mind was violence prevention, a topic that is close to my heart as a citizen, activist, and researcher. In fact, the last time I recalled feeling my hands tremble similarly was when holding pressure on a gunshot wound outside my home several years ago, when I lived in the North Side of Wilmington. As a physician scientist at the Value Institute and in partnership with the University of Delaware, my research has focused on the chronic effects of community violence exposure on communities and individuals. I started to find connections and similarities between community-based strategies to prevent violence and those that could potentially prevent the spread of COVID-19. Emerging strategies that address violence as a public health issue borrow epidemiologic principles to model it as a contagion. In this context violence is considered as a disease unto itself, 6 Delaware Journal of Public Health – August 2020

fundamentally propagated from one person to another. Evolving approaches have explored varying intrapersonal and interpersonal dimensions. Transmission through social interactions has been repeatedly demonstrated, particularly within households, across social networks, and with various predisposing and mitigating factors. Some of the most innovative and effective approaches use methods such as Group Violence Intervention to not only create real-time social network models of those at highest risk of firearm violence victimization and perpetration, but to then intervene to mitigate transmission by altering network structure and function. This inspired a project within the Value Institute to model networks of patient and healthcare worker interactions through Electronic Medical Record data to identify cohorts of staff at increased risk of infection and transmission of COVID-19. As I continue my daily work as the medical director for a dedicated COVID unit, I find myself drawing on the lessons of vigilance, resilience, and compassion that neighbors and communities within Wilmington have taught me. I continue to think about trauma-informed ways to establish both psychological and physical safety for all our communities and remain committed to ensuring we all emerge from these days safe and together.

COVID and Primary Care Vishal Patel, M.D., M.B.A.

The COVID-19 pandemic has presented opportunities and challenges in the delivery of primary care. Virtual visits and telehealth were emerging as sources of care delivery prior to the pandemic, but have rapidly become the mainstay of treatment in the outpatient setting for patients with COVID-19 and those with chronic health conditions that require monitoring. The rapid acceleration of the need for this type of care has spurred tremendous innovation at ChristianaCare, and has demonstrated the importance of thoughtful leadership, teamwork and strategic implementation. As a primary care physician, Medical Director, and physician scientist at the Value Institute with a keen interest in process improvement, this historic transition in technology has presented many opportunities for reflection as we continuously work to improve our ability to deliver care.

Telemedicine (video visits and phone visits) has been central in supporting caregivers to respond to the needs of our community members who have contracted COVID-19. ChristianaCare has used this technology for three main roles in primary care: first, to screen and triage patients remotely with cold and flu-like symptoms to determine if COVID-19 testing or a higher level of care is needed; second to provide ongoing and coordinated care for patients with chronic disease who are at high risk for poor outcomes if exposed to COVID-19; third, to provide screening and ongoing to care to healthcare workers that were exposed to or contracted the coronavirus infection. Although the types of services provided at ChristianaCare through virtual care have expanded, the virtual primary care practice was established over a year ago. From March 2019 – Feb 2020, there was only one practice that conducted video visits. Currently, there are over 20 primary care practices and over ten specialty practices that conduct telehealth and video visits. The number of visits performed continues to increase on a weekly basis, and over 9,000 visits have been completed to date. The majority of the visits at the beginning of the telehealth expansion were focused on care of COVID-19 patients. However, as the telehealth initiative has matured, care teams have become more facile in the management of other acute and chronic disease processes. This required tremendous efforts and partnerships from clinical, IT, operational, financial, education, and marketing teams. As a clinical leader, I am cognizant of some limitations and blind spots to this technology that we must address before it can effectively be scaled to its full capacity. Many of the standard medical practice operations are designed based on an in-person care models. As a result, workflows from many domains – from training patients and providers on how to utilize technology, effectively working with a remote team, modifying scheduling tools/processes, reviewing payer telehealth policies and establishing billing practices – must be modified or re-tooled. It will also be important to monitor the quality of the telemedicine services provided and continue to work to enhance the technology and provision of care to enhance patient experience. Lastly, it is important to recognize that access to telehealth services, particularly video visits, is largely dependent on access to broadband internet services. To this end, ChristianaCare has been a national leader, one of 83 health systems in the country, to receive a grant from the Federal Communications Commission (FCC) under the CARES ACT which will specifically be used to increase access to broadband internet access in communities where it is needed. Personally, I have tremendously enjoyed connecting with my patients virtually and modifying my clinical workflow on a daily basis to enhance the patient and provider experience. Reflecting on my experience, I feel that I have spent more time directly communicating with patients and less time focusing on the Electronic Medical Record and other distractions. I feel that patients have been more forthcoming from the comforts of their home. Many primary care visits such as follow up visits for chronic disease management do not require physical exams. Visits to review and adjust medications, review lab results, Medicare annual visits, and diabetes/hypertension management visits translate well to a virtual care option. The question is, will virtual visits continue to be the norm for these types of appointments as we move out of the COVID crisis? These types of visits can effectively be done without patients taking off a few hours from work. Personally, I believe this ‘new’ modality of care delivery will transform the health care industry and that the rapid acceleration, innovation, and adoption of virtual care represents a one of the few silver linings of the COVID pandemic.

Caring for the Non-COVID Patient Jennifer Goldstein, M.D., M.Sc.

As a hospitalist, I care for patients with acute medical illnesses that require hospitalization. During the COVID-19 pandemic, I have been working on non-COVID units, and none of my patients have tested positive for COVID-19 on admission. My primary obligation and goal is to treat the acute medical illnesses for which these patients present. However, a secondary goal is to protect them from unwitting exposure to COVID from care providers, staff and other hospital employees, and to protect others, including myself, from exposure to them, in case they are early in the course of COVID, and tested falsely negative on their arrival to the hospital. To do so, employees practice social distancing, don facemasks and eye protection, and wear scrubs that can be laundered or disposed of. The medicine is the same, but the context has shifted. We are treating patients and protecting patients from us at the same time. The reverse is also true – as we care for them, we consider our own safety in a completely different context. As physicians, before we take the Hippocratic Oath to do no harm, we are taught first to protect ourselves. We learn about using universal precautions, by donning gloves and other protective equipment to prevent the transmission of blood and fluid borne illnesses for all patients, regardless of the true or perceived risk of disease of the patient. These measures were put in place by the Centers for Disease Control in 1987 to remove complex decisionmaking related to self-protection. Providers have been taught since that time to assume every patient is positive for a blood borne illness, and to wear gloves at every encounter. In this new era, we are, to a certain degree, asked to assume the same about COVID-19: that everyone is infected. However, with stores of personal protective equipment (PPE) at risk and evolving recommendations regarding the “correct PPE” to use for each patient and circumstance, decisions about appropriate PPE to use for each patient may require complex decision-making. This takes away from the engrained simplicity of the concept of universal precautions and leads undeniably, to heterogeneity of protective practices that could place providers, hospital staff and patients at risk. In addition to considering exposure risk between patients and providers, hospitalists also must consider exposure to the community once the patient leaves the hospital. Particularly for patients who are being discharged to nursing homes, congregate living facilities, and skilled nursing facilities, providers and health systems must consider the exposure to vulnerable community members. The Centers for Disease Control have provided guidance regarding the need for testing patients (both those admitted for COVID-19 and not) for COVID-19 prior to discharge. However, there are no formal guidelines regarding many nuances of discharge planning. This has led most health care institutions to implement their own practices related to discharge planning. To help understand and delineate best-practices for hospital discharge in the COVID era, national collaborative efforts have been initiated such as HOMERun, a national consortium of 22 hospital systems across the country. As the ChristianaCare site Principle Investigator (PI) for this effort, in collaboration with my co-PI and fellow hospitalist, Surekah Bhamidipati, MD, we have been working to collect and synthesize best practices for discharge of COVID and non-COVID patients to protect them as well as the community. The goal is to define and distribute best practices for hospital discharge so that, in addition to protecting patients, we protect the communities into which they are released. This work has demonstrated the importance of local and national collaboration to help inform and implement best practices for COVID care in Delaware. 7

On the front-lines: Healthcare Workers

The Consequences of COVID: Pediatric Oncology Stephanie Guarino, M.D., M.S.H.P.

Telling a family their child has cancer is gut wrenching and deeply unsettling at any time. Under the best of circumstances, the conversation is choreographed to include social workers, nurses, child life specialists, and supportive family members. Yet on a Saturday morning in the midst of the SARS-CoV-2 pandemic, I found myself having to break this news to a family in full personal protective equipment. Instead of sitting down in a private space, we stood outside the patient’s room in the middle of the hall, only able to see each other’s eyes. My heart dropped as I said, “your son has leukemia,” not mentioning that he would likely face some complications after a delayed presentation fueled by fear of the virus. I watched his mother’s face fall and I knew this was wrong; it shouldn’t be done this way. Her family should be hearing the news with her, holding her hand; instead, she was alone, because hospital visitor policy only allowed one parent at the bedside. COVID-19 is relentless, stripping physicians of their most precious weapons: timely and accurate diagnosis, an empathetic touch, the art of healing, and the feeling of safety while serving others. There have been some positives that have emerged, particularly related to the advancement of telemedicine. As clinical lead of the Sickle Cell Program at the Center for Special Health Care Needs, I take care of a particularly vulnerable group of patients. Because of housing, employment, transportation, or insurance issues, many patients find it difficult to come to clinic appointments. After implementing telemedicine visits, we’ve been able to see a record number of new patients with sickle cell disease, many of whom have been trying to establish care for months. We’ve continued to utilize the Ambulatory Infusion Center for acute care visits to offload the Emergency Department and, in conjunction with the ChristianaCare COVID remote management resources, have kept all our COVID-19 positive patients at home. The worry about each and every one continues to creep in, however. What about my patients who are homeless? Can they call for help if they need it? What about my patients who continue to work in essential jobs? More than 19% of patients with sickle cell disease who also had COVID-19 presented with pain alone, no fever or cough or the other symptoms typically used to screen. Will I be able to recognize those patients who are getting sicker over the phone? How can I best advocate for these patients who might otherwise be overlooked? Meanwhile, the virus has laid bare some of the grim realities of our society and a broken health care system. A recent CDC MMWR report found an overrepresentation of blacks among hospitalized patients (33% vs. 18% in the community), although data is still being collected and analyzed. Based on data from the COVID Racial Tracker, the proportion of both cases of COVID-19 (30%) and deaths (26%) among black patients in Delaware is greater than expected based on their share of the population. The causes of these disparities are multi-factorial and include factors like inadequate access to health care, a lack of paid sick leave in minimum wage essential jobs, and higher rates of underlying chronic conditions, but do not adequately account for the disparities. Make no mistake, health care is not immune to systemic racism and often is one of the places of the most deep-seated biases. Although I will never experience this fear and prejudice firsthand, there is no longer any excuse to continue to ignore it as physicians, as a health care system, or as a country. The World Medical Association’s Declaration of Geneva, a code for doctors across the world, states, “As a member of the medical profession: I solemnly pledge to dedicate my life to the service of humanity; the health and well-being of my patient will be my first 8 Delaware Journal of Public Health – August 2020

consideration…” But what happens when the service of humanity and the practice of medicine require so great a personal sacrifice? “Give me a second,” I told my patient’s mother, and found the family room around the corner. Although yellow caution tape blocked off the entrance, I motioned to her to duck under with me. We sat down, appropriately 6 feet apart, and started the conversation again. We tried to find connection where we could, joking about bad coffee and working from home with kids. When I went back to disinfect the chairs where we broke the rules, I couldn’t shake the deep sense of loss. This moral injury, this feeling of powerlessness to fully heal, the worry that I wasn’t truly connecting with my patients, will leave scars that won’t be fully realized for years.

COVID and Health Policy Navin Vij, M.D., M.S.H.P.

Over the last few months, in my role taking care of hospitalized patients and continuing research focused on vulnerable populations, I have been thinking a great deal about the concept of “what is normal.” The concept has been refined through the reality that in the midst of the COVID pandemic, change is an eternal constant. On a personal level, this has meant a new normal – not just with social distancing from friends or co-workers, but what it has meant for how I interact with my own family. Arriving home from work no longer means simply coming inside the house and embracing my family. The new routine of “cleansing for possible COVID” contains careful removal of all physical articles of clothing and shoes in the garage with a shower and change into clean clothes before I’m truly “back home.” However, despite the new routine for me upon returning home, these moments to have been a reminder to me of how grateful I am to have a place to call home, let alone so many social supports that many of my patients lack. Professionally, I have begun to think about how policy changes have focused greater attention to these realities of vulnerable populations during COVID. Over the last several years, much of my research has focused on patients experiencing homelessness and substance use disorders. COVID, in of itself as a novel infectious virus, has posed a unique threat to those experiencing homelessness, both sheltered and unsheltered. Concurrently, this understanding has led to rapid efforts – both locally in Delaware and nationally – to use alternative forms of shelter (hotels, motels, alternative congregant housing) as well as policy changes around suspending evictions temporarily to help address the continuum of housing insecurity and homelessness. As the country moves to reopen, I am hoping to continue research and community-based work to address the question of “is normal what we really want to return to?” for such vulnerable populations. Prior to COVID, these populations faced enormous difficulty staying healthy, let alone alive. They faced significant challenges to structural social and medical supports that could help address gaps in accessing and utilizing healthcare for better clinical outcomes. As job losses have mounted during the pandemic, the percentage of the US population considered vulnerable may increase, and with it, challenges around these very questions: • What happens to those temporarily housed in motels/hotels? • Where should they go? • What should happen to policy changes and supports for rental assistance or evictions? I hope that the physical pause to “what is normal” in healthcare and its many systems may give us an opportunity to positively reimagine a new normal – one that is better and safer for everyone’s health moving forward.

County Health Rankings & Roadmaps: COVID-19 Resources for Response and Recovery While the County Health Rankings do not measure coronavirus cases nor rank risk of the virus spreading in communities, Rankings data are helpful in providing local context on factors that impact health. To provide this context, the Rankings, in partnership with the University of Chicago’s Center for University Spatial Data Science, have added key factors to the US COVID Atlas, an interactive open-source map. The US COVID Atlas allows users to compare county level data, identify hot spots and see how the virus has spread in communities over time. Learn More About the US COVID Atlas: •

• •

Listen to the US COVID Atlas: Exploring Data to Move to Action webinar which is a part of the County Health Rankings & Roadmaps’ special topic series, Health Equity and Social Solidarity in the Time of Pandemic: Strategies for COVID-19 Response and Recovery Visit the US COVID Atlas Medium Blog where researchers share emerging insights from the Atlas and offer personal reflections. Explore the US COVID-19 Atlas Community a gathering place for the public and clinicians to share ideas and questions

The Rankings have also prepared resources to help with COVID-19 response and recovery, visit, the CHR&R COVID-19 Resources page to see: •

•

•

What Works for Health COVID-19 Strategies: Curated evidence-informed strategies— pulling across Rankings factors including income, education, housing, and more—that communities can consider as they respond to and recover from COVID-19. Action Learning Guides on Data and Equity: Resources designed to provide communities with the guidance, tools, and examples to develop a deeper understanding of data and the underlying factors that create inequities in communities. Special Webinar Series: The Health Equity and Social Solidarity in the Time of Pandemic: Strategies for COVID-19 Response and Recovery webinar series shines a light on challenges facing specific communities and populations affected by COVID-19 and how people are responding with equitable approaches.

9

On the front-lines: Healthcare Workers

Toolkit for Emotional Coping for Healthcare Staff (TECHS): Helping Healthcare Workers Cope with the Demands of COVID-19 Julia Price, Ph.D. Nemours Children’s Health System; Sidney Kimmel Medical School of Thomas Jefferson University Nancy Kassam-Adams, Ph.D. University of Pennsylvania Perelman School of Medicine; The Children’s Hospital of Philadelphia Anne E. Kazak, Ph.D., A.B.P.P. Nemours Children’s Health System; Sidney Kimmel Medical School of Thomas Jefferson University

ABSTRACT In response to the COVID-19 pandemic, healthcare workers (HCWs) are experiencing elevated levels of emotional distress, including traumatic stress, which may continue for months and years to come. To support HCWs, the Center for Pediatric Traumatic Stress created the Toolkit for Emotional Coping for Healthcare Staff (TECHS), a free, online, evidence-supported program. TECHS offers self-assessment tools for traumatic stress reactions and three coping tools that are rooted in cognitive behavioral and family therapy principles. TECHS, which comes in the form of a slide set and a pre-recorded webinar, can be implemented flexibly (e.g., small or large groups, individually, one one-hour administration or multiple shorter sections of time). Ideally, small groups of HCWs engage in TECHS together to help support team resilience. In implementing TECHS in a group, it is important to ensure participation is optional and to review expectations for confidentiality. The purpose of TECHS is to address the emotional needs of HCWs related to the pandemic and to offer a long overdue evidence-informed program that addresses the fourth aim of healthcare, improving the work life of HCWs. Sustaining emotional support programs such as TECHS is critical to maintain a functioning, effective, and healthy workforce across our healthcare institutions.

INTRODUCTION Similar to previous epidemics, healthcare workers (HCWs) across disciplines are exhibiting high rates of anxiety, traumatic stress, sleep problems and depression in response to the COVID-19 pandemic.1,2 Sources of anxiety include concerns about healthcare institutions protecting HCWs from infection, preparing HCWs to provide care in a new or unfamiliar setting, and supporting HCWs as individuals in terms of stress and emotional support.2 Studies from the SARS pandemic suggest that up to one-half of HCWs will experience significant emotional distress, including posttraumatic stress symptoms, which may persist for years.1 Posttraumatic stress symptoms include re-experiencing of a particularly frightening event(s), avoidance of reminders or thoughts of this experience(s), changes in thinking and emotional functioning, and increased arousal (e.g., difficulty sleeping, concentrating, jumpy). Traumatic stress symptoms may occur for a few weeks to months or years following exposure to actual or threatened serious injury, death, or violence.3 Secondary traumatic stress is the response to being exposed to trauma experienced by others, particularly in one’s professional role.4 HCWs on the frontlines of the COVID-19 pandemic are at personal risk for serious illness, are at risk for transmitting this illness to loved ones, and are witnessing immense suffering of patients and their families. To address the emotional needs of frontline HCWs during and following this pandemic, the Center for Pediatric Traumatic Stress developed the Toolkit for Emotional Support for Healthcare 10 Delaware Journal of Public Health – August 2020

Staff (TECHS)5 in March 2020. In this paper we describe this development process and initial activities to disseminate and implement TECHS in the early months of the COVID-19 pandemic in the United States.

INTERVENTION The overarching goals of the TECHS program are (1) to promote use of healthy, evidence-based coping strategies among frontline HCWs experiencing stress related to the COVID-19 pandemic and (2) to facilitate team resilience and connectedness. The two learning objectives of the TECHS program are for HCWs to be able to (1) identify two options for self-assessment of traumatic stress reactions and (2) describe three coping tools for HCWs facing COVID-related stress.

DEVELOPMENT OF TECHS The primary mission of the Center for Pediatric Traumatic Stress is to provide HCWs in pediatric settings with training and interventions to reduce or present traumatic stress responses in patients and families and in providers themselves. TECHS evolved from a conceptual framework and related treatment model that we use in interventions for families of children with cancer, Surviving Cancer Competently Intervention Program (SCCIP).6 SCCIP employs a traumatic stress framework that is rooted in cognitive behavioral and family systems principles. The theory and mechanisms that underlie SCCIP are highly relevant for HCWs facing the COVID-19 pandemic. First, HCWs

in the era of the COVID-19 pandemic face the sudden onset of a remarkably frightening situation, full of unknown but likely challenging and evolving stressors over time, that may include life threat to oneself and others. Second, like others facing potentially traumatic experiences, HCWs on the frontlines of the COVID-19 pandemic may benefit from cognitive behavioral interventions that help them learn to notice and challenge potentially maladaptive thinking and beliefs. Third, social support (from family or colleagues) is key to coping with potentially traumatic events. The team approach to healthcare presents opportunity for HCWs to turn to colleagues for support.

SELF-ASSESSMENT OF TRAUMATIC STRESS REACTIONS As part of TECHS, we developed a self-assessment tool that is an adaptation of a reliable and valid measure of adult acute stress symptoms, the Acute Stress Disorder Scale.7 HCWs using TECHS can rate items on this scale and self-score the tool to learn if their level of traumatic stress reactions is significant. Guidance on accessing the scale (provided free of charge), interpreting the score, and recommending the appropriate level of care for those with significant reactions is included in TECHS.

Tool #1: ABC Model The Adversity-Beliefs-Consequences Model is based on cognitive behavioral therapy and supports HCWs in understanding their own reactions to a specific adverse event (see Figure 1). HCWs select one recent or particularly troubling experience, identify the thoughts or beliefs they had in response to this adversity, and then consider the consequences of this adversity and its related beliefs. Consequences may be positive or negative and may fall in three categories: emotional, behavioral, and/or interpersonal consequences. For example, potential adversities include not having consistent access to proper personal protective equipment or inability to be home to support family due to work demands.

Tool #2: Steps to Reframing The second tool, Steps to Reframing, is also grounded in cognitive behavioral principles of evaluating one’s thoughts and considering alternative ways of thinking (see Figure 1). HCWs are asked to (1) identify the uncontrollable aspects of an adversity, (2) focus on the aspects that are controllable, (3) leverage their strengths and strengths of their colleagues or family, which facilitates (4) shifting the consequences (emotional, behavioral, interpersonal) to a more positive place.

Tool #3: COVID-19 Roadmap The third and final tool, COVID-19 Roadmap, employs an analogy of a journey to encourage HCWs to take a broader perspective on this stressful time. This tool draws from cognitive behavioral principles of challenging all-or-nothing beliefs and perspective taking. For example, HCWs are invited to see beyond the immediate adversity and consider the larger context. This tool asks the HCW to recall where they may have been on the roadmap in the early stages of the COVID-19 pandemic, where they are now, and where they might be at a time in the future. This exercise highlights that this pandemic will have a beginning, middle and an end.

Interpersonal/Team-Based Focus Throughout TECHS, HCWs are encouraged to take an interpersonal and team-based perspective. They are prompted to consider how colleagues, family, and friends might vary in identification of adversities, beliefs and consequences, as well as in each step to reframing. HCWs are also asked to think about where on the COVID-19 Roadmap their colleagues or others might be. Finally, TECHS suggests HCWs reflect on how much they have shared about their own adversities, beliefs, and consequences with others in their life. When delivered in a group format to a team of HCWs or in large group settings, HCWs learn about how others are having similar experiences and reactions. TECHS also offers a common language for teams to use to discuss COVID-related difficulties and stress.

Figure 1. Toolkit for Emotional Coping for Healthcare Staff (TECHS) – ABC Model + Steps to Reframing 11

On the front-lines: Healthcare Workers

Place and Time TECHS is accessible without charge from https://bit.ly/ COVIDhealthcarecoping. It has been delivered exclusively online at the present time due to restrictions imposed by the COVID-19 pandemic. However, it could be used in in-person settings as well and we expect to do so once restrictions are lifted. TECHS was developed by The Center for Pediatric Traumatic Stress, a Treatment and Services Adaptation Center in the National Child Traumatic Stress Network. The Center for Pediatric Traumatic Stress is co-located at Nemours Children’s Health System in Wilmington, DE and at the Children’s Hospital of Philadelphia. We developed and released the first version of TECHS quickly in March 2020 at a time when the spread of COVID-19 in the United States became evident. Minor refinements were completed during initial presentations of TECHS in April 2020. We expect to update it, as needed, to reflect changes in the pandemic trajectory over time. The most recent version of this program is available at https://bit.ly/COVIDhealthcarecoping.

POPULATION The target population of TECHS is frontline HCWs, which includes medical providers (e.g., pediatricians, nurse practitioners), mental health providers (e.g., social workers, psychologists, psychiatrists), nurses, patient service representatives (e.g., check-in and scheduling staff), environmental services staff, security, medical interpreters, emergency medical transport workers, management or leadership staff, and others working in healthcare during the pandemic. While the Center for Pediatric Traumatic Stress focuses on pediatric settings, TECHS was created for HCWs in any healthcare setting, from pediatric to adult care to nursing home and long-term care staff and residential drug treatment facilities. The tools in this toolkit appear to have relevance across cultures and countries; based on interest from international colleagues, TECHS has been translated into Spanish and Japanese. Links to these resources can be found on the aforementioned website.

PURPOSE Quadruple Aims of Healthcare include enhancing patient experience, improving population health, reducing costs, and improving the work life of healthcare providers. Although concerns for burnout and secondary traumatic stress in HCWs have been long-standing, this COVID-19 pandemic highlighted the need for universal emotional supports for HCWs. Such supports must be based in evidence, easily accessible to HCWs, and include guidance on when a higher level or more intense form of emotional supports are indicated. The purpose of TECHS is to address these needs in this time of crisis related to the pandemic and to offer a long overdue evidence-informed program that addresses the fourth aim of healthcare.

IMPLEMENTATION TECHS was designed to optimize flexibility of its use so that busy and stressed HCWs can more easily access this resource. TECHS comes in two formats, a slide set and a pre-recorded webinar. HCWs may choose to review the slide set and/or watch the one-hour webinar all at once, or break TECHS up into smaller chunks (e.g., one tool at a time). The recorded online webinar has been viewed by 2,994 groups or individuals worldwide as of 12 Delaware Journal of Public Health – August 2020

April 13, 2020, when it became available. The Spanish version of the TECHS webinar has been viewed 781 times since it was made available on May 6, 2020. The Japanese version of the TECHS slide set has been downloaded 645 times since it was made available on May 10, 2020. TECHS is optimally used in small groups or healthcare teams of trusted colleagues, because this allows for sharing perspectives and leveraging strengths across individuals. However, group administration is not always feasible, so TECHS is also designed to be used by an individual. TECHS may be administered via live webinar or in-person, facilitated by a mental health professional or other professionals. At Nemours, we conducted a number of small group live webinars for different teams at Alfred I. duPont Hospital for Children and also provided TECHS in a Grand Rounds talk. To maximize the reach of this universal emotional support program, healthcare institutions can offer it during existing meeting times for large and small groups. Offering staff the ability to use TECHS during paid worktime may be especially key to reaching the full range of salaried and hourly staff and those with varying home responsibilities and online access. Repeated review of TECHS is also important, as a way to refresh coping skills and as a way for institutions to demonstrate commitment to the well-being of their staff. Finally, when implementing TECHS in a discussion-based format at a healthcare institution, it is critical that HCWs are not required to share personal information. Some HCWs may choose to seek emotional support from people or services outside of their workplace, whereas others may be interested in sharing their thoughts and feelings about a challenging or scary situation with co-workers and managers. A clear and open discussion about confidentiality should occur at the beginning of any group-based TECHS administration.

EVALUATION As TECHs was initially adapted from an evidence-based intervention in March 2020, there have been no formal evaluations to date. We ask that participants complete a brief, five question pre and post surveys for live webinar administration of TECHS at Nemours. These questions ask HCWs to rate how aware they are of their own level of stress related to COVID-19 and how confident they are in their ability to cope with COVID19-related stress, as well as to rate their knowledge about evidence-supported coping strategies. Most HCWs are reporting high initial levels of confidence in ability to cope with COVIDrelated stress. Future examination of the effectiveness of TECHS should consider how TECHS may enhance or expand existing coping strategies for HCWs and how it may encourage or facilitate team resilience and connectedness.

ADVERSE EFFECTS No adverse effects have been reported for TECHS. TECHS is based on efficacious cognitive behavioral and family systems approaches with proven track records for benefit and low likelihood of risk. Although we have not received any evidence of these, potential adverse effects could include triggering distress in HCWs with pre-existing mental health difficulties and/or HCWs experiencing elevated levels of distress, i.e., when asked to consider their emotional functioning and coping. Some HCWs

may not choose to seek such resources through an employer and may feel uncomfortable to engage in such programs at work. For these reasons, it is crucial that institutions using TECHS carefully consider ways to ensure TECHS is highly accessible and optional. Alternative options for support would also help meet the varying emotional needs and preferences of HCWs. In implementing any universal tool for emotional support and coping, healthcare leaders should develop clear guidelines and processes to support HCWs who may require a higher level of emotional support. The optional self-assessment of traumatic stress reactions included in TECHS allows HCWs to self-score and see brief guidance on determining their potential need for more intense support. Institutions may also offer general guidance about symptoms or emotional or behavioral reactions to stress that might suggest mental health treatment is warranted.

SUSTAINABILITY As a free, online program, TECHS requires minimal resources from healthcare institutions. Keys to sustaining this type of universal program include clear, consistent and repeated messaging from hospital leadership about what TECHS is and how to access it, as well as dedicated time to implement and regularly review these tools. To fully integrate these evidencebased tools into hospital culture, leaders at every level should employ and model use of emotional coping strategies.

PUBLIC HEALTH SIGNIFICANCE The traumatic stress, anxiety, depression and sleep difficulties HCWs are experiencing related to the COVID-19 pandemic are likely to persist and may impact job satisfaction, burnout and workforce readiness over time. The COVID-19 pandemic continues to unfold and the effects of this crisis will last beyond the creation and broad implementation of a vaccine. Moreover, HCWs have long been at risk for traumatic stress and secondary traumatic stress related to delivering healthcare and witnessing suffering and death. Sustaining emotional support programs such as TECHS is critical to maintain a functioning, effective, and healthy workforce across our healthcare institutions.

REFERENCES 1. Maunder, R. G., Leszcz, M., Savage, D., Adam, M. A., Peladeau, N., Romano, D., . . . Schulman, B. (2008, November-December). Applying the lessons of SARS to pandemic influenza: An evidence-based approach to mitigating the stress experienced by healthcare workers. Can J Public Health, 99(6), 486–488. https://doi.org/10.1007/BF03403782 2. Shanafelt, T., Ripp, J., & Trockel, M. (2020, April 7). Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic. JAMA, 323(21), 2133–2134. https://doi.org/10.1001/jama.2020.5893 3. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Retrieved from: https://dsm.psychiatryonline.org/doi/book/10.1176/appi. books.9780890425596 4. Beck, C. T. (2011, February). Secondary traumatic stress in nurses: A systematic review. Archives of Psychiatric Nursing, 25(1), 1–10. https://doi.org/10.1016/j.apnu.2010.05.005 5. Price, J., Kassam-Adams, N., & Kazak, A. E. (2020). Toolkit for Emotional Coping for Healthcare Staff (TECHS). Published by the Center for Pediatric Traumatic Stress. Available at: https://bit.ly/COVIDhealthcarecoping 6. Price, J., Kassam-Adams, N., Alderfer, M. A., Christofferson, J., & Kazak, A. E. (2016). An integrative trajectory model of pediatric medical traumatic stress: An update based on a systematic literature review. Journal of Pediatric Psychology, 41, 86–97. https://doi.org/10.1093/jpepsy/jsv074 7. Bryant, R. A., Moulds, M. L., & Guthrie, R. M. (2000, March). Acute Stress Disorder Scale: A self-report measure of acute stress disorder. Psychological Assessment, 12(1), 61–68. https://doi.org/10.1037/1040-3590.12.1.61

13

The DPH Bulletin

From the Delaware Division of Public Health

July 2020 DPH’s new anti-Vape Toolkit helps youth avoid e-cigarette use Among Delaware middle and high school students, e-cigarette use (vaping) has surpassed their use of regular cigarettes.

Responsible social behaviors needed to prevent additional COVID-19 cases

After detecting a new cluster of COVID-19 cases in the beach area, Governor John Carney delayed Delaware’s Phase 3 economic reopening indefinitely and prohibited sitting or standing at bars in Sussex County beach areas, effective July 3. One hundred positive cases were detected in Rehoboth Beach on June 25, and 12 positive cases were detected in Dewey Beach on June 26. Governor Carney and Division of Public Health (DPH) Director Dr. Karyl Rattay remind Delawareans ages 13 and older to wear face masks in public, as required by the thirteenth modification of the State of Emergency declaration. Individuals should also stay six feet apart from those outside their household, wash hands often, and get tested for COVID-19 even if they do not have symptoms or exposure. These requirements are to prevent widespread infection. “We have lost 507 Delawareans in a short amount of time…from this virus,” Dr. Rattay said. “A future wave has the potential to be so much worse.” The risk of getting COVID-19 is greater the more closely you interact, how long you interact (10 minutes or more), the number of people with whom you interact, if you wear a face covering, and if you are indoors or outdoors (outdoors is safest), Dr. Rattay said. The state is stepping up its business enforcement actions that carry fines and restrictions. “We need everyone to act with a sense of responsibility and community and awareness of the fact that your actions affect your neighbor and vice versa,” Governor Carney said. COVID-19 testing is easy, quick, and free. Workers in industries with frequent public interactions such as the food and retail industry are advised to be tested once per month. Find testing sites at de.gov/gettested.

14 Delaware Journal of Public Health – August 2020

DPH’s new web-based anti-Vape Toolkit, available at VapeFreeDE.com, helps youth avoid initiating e-cigarette use and shares cessation resources. It was designed for teachers, school administrators, parents, health care providers, youth, and community partners who work with youth. The anti-Vape Toolkit includes links to evidencebased curriculums for classroom use, brochures, presentations, youth cessation resources, talking points for parents and providers, and links to model school policies. Delaware’s toolkit is unique, as it offers a social media calendar and DPH prevention messaging for schools to send to parents and students over a 10-week period. The Health Promotion and Disease Prevention Section’s Tobacco Prevention and Control Program and Community Health Services developed the toolkit with input from the Delaware Department of Education, Polytech High School, the Delaware Department of Services for Children, Youth and Their Families’ Division of Prevention and Behavioral Health Sciences, the American Lung Association, and the Division of Alcohol & Tobacco Enforcement.

UD’s Disaster Research Center website saves time researching preparedness

It takes time to comb through emergency preparedness and response research. By sharing research summaries, the University of Delaware’s Disaster Research Center (DRC) hopes to save governments, businesses, and the public precious time. DRC researchers present their findings through topic and theme summaries, short animated videos, and extensive bibliographies. Currently, “Hurricane Evacuation Decision Making” and “Business Recovery” are featured on its website. Visit DRC at www.drc.udel.edu/. Questions can be directed to drc-mail@udel.edu or 302-831-6618.

Prevent heat-related illnesses – stay cool, hydrated, and informed

Stay hydrated in the summer heat Water helps our bodies remove waste, regulate body temperature, and enhance blood volume and brain function. Regularly consuming water, other fluids, and moisture-rich foods hydrates the body. Health experts recommend drinking water consistently instead of reacting to thirst. They maintain that ideally, water should also be our first choice among beverages. A person is drinking enough fluids if they urinate regularly and their urine is pale or clear colored. In the heat, the Centers for Disease Control and Prevention (CDC) recommend drinking more water than usual and to stay in air-conditioned places. Dehydration occurs when fluids and electrolytes that are lost to physical activity, sitting, or illness are not replaced. Symptoms of dehydration are dark urine, thirst, dry mouth, dry lips, headache, and dizziness. During the hot summer months, dehydration can lead to heat exhaustion and heat stroke. Physical activity and humidity can lead to dehydration and heat-related illness. The CDC shares this hydration advice: ● Drink more fluids in the heat regardless of activity.

Do not wait until you are thirsty to drink. Avoid sugary, alcoholic, and very cold drinks.

Heat stress occurs when an overheated person cannot cool down through sweating and their body temperature rises rapidly. Heat stress can be as mild as having a heat rash and heat cramps, or it can lead to the dangerous conditions of heat exhaustion and heat stroke. Heat stroke can damage the brain and other vital organs and cause death or permanent disability without emergency treatment, according to the CDC. “Every year, high temperatures kill more people than hurricanes, lightning, tornadoes, earthquakes, and floods combined,” said Robin M. Ikeda, MD, MPH, CDC Director of the Office of Noncommunicable Diseases, Injury, and Environmental Health. She provides these prevention tips in an online video: ● Stay cool – Go to an air-conditioned place and

wear light, loose-fitting clothing.

● Stay hydrated – Drink more water than usual and

avoid caffeine, alcohol, and carbonation.

● Stay informed – Tune into local heat alerts.

Watch for symptoms of heat stroke and heat exhaustion. Heat stroke is a medical emergency, so call 911 for heat stroke victims.

People at high risk of heat-related illness are: infants, young children; 65 years of age and older; outdoor workers; athletes; low income individuals; and those who are overweight, who take certain medications; and who are ill, especially with heart disease, high blood pressure, poor circulation, or mental illness. Coaches and athletes can take an online course at https://www.cdc.gov/disasters/extremeheat/athletes.html. Businesses can access heat stress resources.

● Drink a sports drink or fruit juice to replace salt

and minerals lost by heavy sweating. Those with diabetes, high blood pressure, or other chronic conditions should talk with their doctor first.

● Drink only enough water to relieve thirst. Too

much water can cause hyponatremia, a potentially fatal drop in sodium levels. Call 911 for severe symptoms such as nausea, vomiting, confusion, seizures, or coma.

Visit these links to stay well in the heat and beyond: ● https://www.cdc.gov/disasters/extremeheat/index.html ● https://dhss.delaware.gov/dhss/dph/dpc/eatright.html.

The DPH Bulletin – July 2020

Page 2 of 2 15

On the front-lines: Healthcare Workers

Wellbeing Among Healthcare Personnel During the COVID-19 Public Health Crisis Maureen Leffler, D.O., M.P.H.

In the face of this unprecedented COVID-19 public health challenge, the people we rely on most, healthcare professionals, are facing deleterious impacts of COVID-19 on their physical, emotional and mental health. Prior to COVID-19, the well-being of healthcare workers was already under duress, as evidenced by high rates of burnout, anxiety, depression, substance abuse and suicidality1–3 among physicians and nurses. The COVID-19 pandemic poses unique threats to the well-being of all healthcare workers4,5 at every level of Shapiro’s wellness hierarchy (Figure 1). Overwhelming clinical demands challenge the clinician’s ability to meet their basic needs such as sleep, nutrition and hydration. In addition, fear of exposure to the infection, becoming ill or spreading infection to family members or patients, and the lack of clarity and evolving guidelines about best practices for PPE use threaten healthcare workers sense of safety. The possibility of hospitals being overwhelmed by COVID-19 patients and having insufficient PPE resources to protect the workforce has led to

Figure 1. Health professional wellness hierarchy6 16 Delaware Journal of Public Health – August 2020

modifications of care delivery and scope of practice that add additional stress. Both the possibility and reality of redeployment creates a loss of control and autonomy, a known driver of burnout.7 Practicing outside one’s typical scope, lack of treatment options, limited resources and caring for critically ill and dying patients who are separated from family and friends challenge healthcare providers’ perception of competency and moral obligation to provide compassionate care.8,9 The rationing of care necessitated by shortages of critical care beds, respirators, and staff has led to dilemmas that fracture a clinician’s moral compass and conflict with their commitment to professional ethical standards. Some healthcare providers have expressed feelings of guilt in the midst of this crisis, which could be exacerbated by messages of appreciation and respect. Expressions of gratitude may conflict with providers’ sense of “not doing enough,” minimizing their ability to feel appreciated.

In parallel to stress on the health care workforce, the COVID-19 pandemic has impacted every dimension of health and wellness on a global level, including the emotional and mental health of individuals and communities.4 Figure 2 illustrates how distinct phases of crises are associated with varying degrees of emotional distress.10 The pre-disaster phase, characterized by fear and anxiety is briefly followed by the impact phase, characterized by self-preservation. During the heroic and honeymoon phases, both associated with more positive emotions, altruism is high; assistance becomes more reliable; optimism grows; and community bonding evolves. As the limits of assistance become clear and stressors persist, there is a growing discouragement and exhaustion. The negative emotional impact and resultant behaviors are magnified during this phase, which can be drawn out, with periods of exacerbation, prior to entering a recovery phase with adjustment to a new normal. The COVID-19 pandemic presents a unique challenge as future waves of infection may interrupt this sequence, making it less predictable. We have seen some of these phases play out in our own community, with shortages of cleaning supplies and food early on, as fear and uncertainty drove communities to horde certain items. Heroism has been celebrated in the media, with stories celebrating essential employees and community acts of altruism. The cumulative effect of the challenges unique to COVID-19, superimposed on an already vulnerable healthcare labor force, is likely to perpetuate the known consequences of burnout, namely anxiety, depression, increased substance abuse, relationship issues, and suicidality. Early data arising from a large study of the mental health impact of COVID-19 on physicians and nurses in China found that large numbers reported having symptoms of depression (50.4%), anxiety (44.6%), insomnia (34%), and distress (71.5%).11 The devastating news of suicides of an EMT12 and emergency physician13 are grim reminders of the emotional trauma suffered by healthcare personnel as they honor their commitment to patient care. Attending to the emotional and mental health of the entire healthcare community as part of our response to COVID-19 needs to remain a top priority, as the impact of this pandemic will be long-lasting, with implications for healthcare providers, as well as for those they care, a phenomenon referred to as the Parallel Pandemic.14 Healthcare workers may employ individual tactics to sustain their well-being during this crisis such as taking care of their basic needs: nutrition, hydration and rest. Further, if they are aware of the risk and symptoms of stress disorders and depression, they can self-monitor and seek support services if they are experiencing prolonged sadness.4 Individuals can seek connection with others and attempt to limit their exposure to sources of stress. During a crisis, individual leadership behaviors can promote and sustain well-being. Presence is critical, and leaders can look for innovative ways to forge connections with their teams, find opportunities to assess needs in an informal way, normalize reactions to stress, model realistic optimism, and demonstrate gratitude and appreciation.5 Additionally, system-level interventions are critical to help mitigate the occupational risks to healthcare workers.6,15 Ideally, infrastructure already exists prior to a crisis to identify and support emotional well-being and mental health needs, and resources can be evaluated for adaptability to the current situation. Organizational leadership can respond with the development of new resources, as necessary, including novel ways to support basic needs and additional mental health and

psychiatric support services.16 The paramount role of effective communication during public health crises was emphasized in the prescient October issue of the Delaware Journal of Public Health17 and has been repeatedly identified as one of the most important contributors to wellbeing among healthcare workers.15 In contrast, ineffective communication exacerbates anxiety and frustrations.8 Effective communication is described as frequent, consolidated, consistent, and provides reliable information which serves to establish trust within the organization. Despite the challenges posed by this global crisis, there is room for some optimism. Although the timeline is uncertain, this pandemic will come to an end, and the majority of our communities will recover without developing chronic mental health disease. Some, in fact, may develop new strengths and skills in response to having faced this crisis. Healthcare workers have been lauded for their altruism and professional dedication,18 which suggests a long-lasting positive shift in community appreciation of healthcare professionals. The provision of health care services has been adapted, modelling flexibility and requiring rapid responses in a system that typically is not nimble. Other positive experiences related to COVID-19 may enhance well-being among healthcare workers, such as forming new collaborations, learning to work across traditional silos, implementing innovative solutions to delivering health care that takes advantage of technology, and developing new tools and skillsets.9 These silver linings alone are not enough to protect healthcare workers from the potential harmful effects of the psychological stress they face. As we begin re-opening, figuring out new boundaries, and loosening restrictions on shelter in place, new anxieties will arise. COVID-19 will continue to threaten the health of our community, undermine our financial security, interfere with our daily lives, and limit our personal freedoms for the foreseeable future. We can expect these stressors to take their toll, with predictable periods of emotional and mental fatigue, and discouragement consistent with the disillusionment phase10 (Figure 2). As we enter the latter phases of the COVID-19 pandemic, the need to consider and care for emotional and mental health needs of healthcare workers may be more pressing than ever. During this phase, the risks of more chronic stress reactions16 (Figure 3), such as clinician turnover, burnout, depression, and suicide persist. Maintaining mental health and psychiatric support should remain a priority, with re-assessment of the specific needs within the organization. In addition, organizations can learn from this experience, in order to prepare for future crises by debriefing with individual units and cataloging successes and opportunities for improvement.15 Highlighting and tending to the well-being needs of our workforce during the pandemic can be a catalyst for meaningful culture change within healthcare. Building on what we have learned, sustaining what we have created and continuing to grow, we can shore up the foundational levels of wellness6 (Figure 1), providing meaningful and continued support to all healthcare workers. Moving forward, we must prioritize the wellbeing of our healthcare workers, thereby reducing the rates of burnout, mental illness and clinician turnover. As we recognize the dedicated, altruistic actions of healthcare workers today, let us also recognize our obligation to insure and sustain their wellbeing, so that they can continue to meet the healthcare needs of our population, and respond to future crises with the same dedication and compassion. 17

On the front-lines: Healthcare Workers Figure 2. Phases of Disaster10

Figure 3. Conceptual model: Stress first aid during and after crisis impacts outcomes Adapted from The Schwartz Center, Patricia Watson, PhD, “Caring for Yourself & Others During the COVID-19 Pandemic: Managing Healthcare Workers’ Stress.”15 18 Delaware Journal of Public Health – August 2020

REFERENCES 1. Shanafelt, T. D., Boone, S., Tan, L., Dyrbye, L. N., Sotile, W., Satele, D., . . . Oreskovich, M. R. (2012, October 8). Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Archives of Internal Medicine, 172(18), 1377–1385. https://doi.org/10.1001/archinternmed.2012.3199 2. Yaghmour, N. A., Brigham, T. P., Richter, T., Miller, R. S., Philibert, I., Baldwin, D. C., Jr., & Nasca, T. J. (2017, July). Causes of death of residents in ACGME-accredited programs 2000 Through 2014: Implications for the learning environment. Acad Med, 92(7), 976–983. https://doi.org/10.1097/ACM.0000000000001736 3. Stack, S. (2004). Suicide risk among physicians: A multivariate analysis. Arch Suicide Res, 8(3), 287–292. https://doi.org/10.1080/13811110490436954 4. Pfefferbaum, B., & North, C. S. (2020, April 13). Mental health and the COVID-19 pandemic. The New England Journal of Medicine. https://doi.org/10.1056/NEJMp2008017 5. Morganstein, J. C. (2020). Annals for hospitalist inpatient notes – preparing for battle: How hospitalists can manage the stress of COVID-19. Annals of Internal Medicine. https://doi.org/10.7326/M20-1897 6. Shapiro, D. E., Duquette, C., Abbott, L. M., Babineau, T., Pearl, A., & Haidet, P. (2019, May). Beyond burnout: A physician wellness hierarchy designed to prioritize interventions at the systems level. The American Journal of Medicine, 132(5), 556–563. https://doi.org/10.1016/j.amjmed.2018.11.028

13. Dean, W. (2020, April 30). Suicides of two health care workers hint at the COVID-19 mental health crisis to come. STAT News. Retrieved from: https://www.statnews.com/2020/04/30/suicides-two-health-careworkers-hint-at-covid-19-mental-health-crisis-to-come/ 14. Dzau, V. J., Kirch, D., & Nasca, T. (2020, May 13). Preventing a parallel pandemic – A national strategy to protect clinicians’ well-being. The New England Journal of Medicine. https://doi.org/10.1056/NEJMp2011027 15. Ripp, J. (2020). Caring for health care workers during crisis. American Medical Association. Retrieved from: https://www.ama-assn.org/system/files/2020-05/caring-for-healthcare-workers-covid-19.pdf 16. Gunnell, D., Appleby, L., Arensman, E., Hawton, K., John, A., & Kapur, N. (2020). …Pirkis, J. (2020) Suicide risk and prevention during the COVID-19 pandemic. The Lancet. Psychiatry, 7(6). https://doi.org/10.1016/S2215-0366(20)30171-1 17. Wojcik, A. (2019). The importance of communication before and during a public health emergency. Delaware Journal of Public Health, 5(4), 28–30. 18. Rosenbaum, L. (2020). Harnessing our humanity – How Washington’s health care workers have risen to the pandemic challenge. The New England Journal of Medicine, 382, 2069–2071. https://doi.org/10.1056/NEJMp2007466

7. West, C. P., Dyrbye, L. N., & Shanafelt, T. D. (2018, June). Physician burnout: Contributors, consequences and solutions. Journal of Internal Medicine, 283(6), 516–529. https://doi.org/10.1111/joim.12752 8. Shanafelt, T., Ripp, J., & Trockel, M. (2020, April 7). Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic. Journal of the American Medical Association, 323(21), 2133–2134. https://doi.org/10.1001/jama.2020.5893 9. Schulte, E. E., Bernstein, C. A., & Cabana, M. D. (2020, July). Addressing faculty emotional responses during the coronavirus 2019 pandemic. The Journal of Pediatrics, 222, 13–14. https://doi.org/10.1016/j.jpeds.2020.04.057 10. DeWolfe, D. J. (2000). Training Manual for Mental Health and Human Service Workers in Major Disasters (2nd ed.) Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services. 11. Lai, J., Ma, S., Wang, Y., Cai, Z., Hu, J., Wei, N., . . . Hu, S. (2020, March 2). Factors associated with mental health outcomes among health care workers exposed to coronavirus disease. JAMA Network Open, 3(3), e203976. https://doi.org/10.1001/jamanetworkopen.2020.3976 12. Watkins, A., Rothfeld, M., Rashbaum, W. K., & Rosenthal, B. M. (2020, April 27). Top E.R. doctor who treated virus patients dies by suicide. New York Times, Retrieved from: http://www.nytimes.com 19

On the front-lines: Healthcare Workers

Humility: a virtue critical to both successful COVID-19 research and patient care Michael T. Vest, D.O.

Assistant Professor, Department of Internal Medicine, Section of Pulmonary and Critical Care Medicine, ChristianaCare Health System; Sidney Kimmel Medical College

“If you are humble, nothing will touch you, neither praise nor disgrace….” - Mother Teresa Healthcare professionals and researchers spend years acquiring expertise in their fields. We learn to pride ourselves on competence and knowing what to do or what questions in a given situation. However, having the humility to recognize to recognize how much we do not know has long been recognized as an asset for even expert physicians.1 In December 2019, an outbreak of atypical pneumonia was reported in Wuhan, China. This disease, now known to be caused by severe acute respiratory syndrome coronavirus 2 (SARSCoV-2), is called coronavirus disease 2019 (COVID-19).2 While recent experiences with outbreaks of Zika virus and Middle Eastern Respiratory Syndrome have increased our awareness of the potential for new viral pathogens, no one has years of experience treating or studying this disease – no one is truly an expert in COVID-19. Yet the impact of this tiny single stranded RNA-enveloped virus on human activity has been truly been humbling. As economic activity throughout the world ground to a halt, the academic medical community rapidly responded to the challenge of a new disease turning out a plethora of medical literature at a very rapid pace. A simple search using the term “COVID-19” on PubMed conducted on June 11, 2020 returned 21,542 publications. Medical societies rapidly issued guidelines for management of patients which emphasized supportive care.3 While much of the literature is low quality evidence (anecdotes, case reports/case series, and hypothesis generating studies), it has played a critical role by not only giving clinicians guidance in how to manage these patients, but also by raising many additional questions that urgently need to be answered with rigorous research. By the time we saw our first case in Delaware, we had learned from analysis of cohorts in China that over 80% of symptomatic patients have relatively mild symptoms, around 14% have more severe symptoms and only about 5% become critically ill.2 This immediately raises the yet to be answered questions: why do some people become critically ill while others are only mildly ill or even asymptomatic? Is the differential response to this infection related to genetic or environment factors or both? If we understand this, will it lead us to interventions that might move more patients from the critically or severely ill categories into the mild category? As time progressed, the medical community began to develop more theories about the pathogenesis of COVID-19. It was proposed that the disease occurred in 3 stages.4 Stage 1 is early 20 Delaware Journal of Public Health – August 2020

infection. Symptoms at this stage are mild and some patients may not progress beyond this stage. Stage 2 is the pulmonary phase where hypoxemia may develop, and also where the host inflammatory response starts to become more of a problem than the virus itself. A small proportion of patients will transition to stage 3 where hyperinflammation from the host response is the main problem and may become fatal. It was also noted that seemed to be thrombosis was more common in patients with COVID-19 than in other critically ill patients.5,6 Again, this knowledge raises additional questions about why some patients progress and others do not, and what interventions might improve outcomes. Our evolving understanding of the pathophysiology of COVID-19 has allowed us to make educated guesses about interventions that may be helpful. For example, early in the disease process antiviral therapies such as Hydroxychloroquine and Remdesivir have been proposed as treatment options. As the disease progresses to the hyperinflammatory stages, steroids and immunomodulatory drugs such as Tocilizumab have been proposed as potential treatments.7 Additionally, some experts have proposed more aggressive prophylaxis against venous thromboembolism than is normally used in hospitalized patients. All of these interventions (with the possible exception of steroids) are currently being evaluated in randomized controlled trials. These trials will not only provide important information on the effectiveness of these interventions, but will also provide critical information on the adverse effects associated with use of these drugs in the COVID-19 patient population. Unfortunately, the history of medicine is full of biologically plausible interventions that ultimately proved to have more harm than benefit (e.g., hormone replacement therapy for the purpose of reducing cardiovascular risk and activated protein C for the treatment of sepsis). Physicians act responsibly by considering if they have equipoise about treatments before enrolling patients in clinical trials. For example, if a physician feels there is sufficient reason to believe that steroids either cause harm or have benefit in COVID-19 then he or she would not have equipoise to allow his or her patient to participate in a trial where the steroids were assigned to be given, or not based on randomization. It is critical that we take a disciplined rigorous approach to studying this disease and some physician-scientists have suggested that these potential interventions should only be used in the setting of clinical trials. However, faced with the urgent need to “do something” – particularly for the 5% of patients who develop life threatening critical illness – and limited clinical research infrastructures, many physicians have decided that limiting these interventions to only patients enrolled in trials is not appropriate. Instead, clinicians are making their best guesses based on incomplete knowledge and trying to do their best for their patients. Therefore, at the same time as we attempt to study these interventions, they are also all being used by clinicians to treat patients. This seems to be true both at large academic centers

where clinical trials are being conducted and in the community. As we treat patients, it is tempting for physicians to become convinced that certain treatments are effective or ineffective based on physiology, pathology, personal experience, and lowquality evidence. This failure to be humble can be particularly tempting for clinicians used to being “the expert” on their disease. Clinically, this can result in significant variation from institution to institution in terms of clinical practice based on the different thought leaders at individual centers. From a research perspective, it can cause loss of equipoise resulting in a chilling effect on recruitment for randomized trials needed to determine which treatments, if any, will ultimately prove effective. In the worstcase scenario, it can result in policy making based on anecdote. It remains critically important to remember that we do not have all the answers yet, and in fact, probably do not even know all the right questions. The challenge of simultaneously “doing something” and figuring out the right thing to do is not unique to the COVID-19 pandemic, but it is amplified under the current circumstances. This challenge can only be met with healthy dose of humility. It is inevitable that some of our best guesses will be wrong. However, being clear about what we do not know will allow us to ask intelligent questions and do the rigorous studies required to find the answers. Ultimately, if we do that, our patients will be the winners.

REFERENCES 1. Chochinov, H. M. (2010, August 10). Humility and the practice of medicine: Tasting humble pie. CMAJ, 182(11), 1217–1218. https://doi.org/10.1503/cmaj.100874

2. Wu, Z., & McGoogan, J. M. (2020, February 24). Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72314 cases from the Chinese Center for Disease Control and Prevention. JAMA, 323(13), 1239–1242. https://doi.org/10.1001/jama.2020.2648 3. Alhazzani, W., Møller, M. H., Arabi, Y. M., Loeb, M., Gong, M. N., Fan, E., . . . Rhodes, A. (2020, June). Surviving sepsis campaign: Guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19). Critical Care Medicine, 48(6), e440–e469. https://doi.org/10.1097/CCM.0000000000004363 4. Siddiqi, H. K., & Mehra, M. R. (2020, May). COVID-19 illness in native and immunosuppressed states: A clinical-therapeutic staging proposal. J Heart Lung Transplant, 39(5), 405–407. https://doi.org/10.1016/j.healun.2020.03.012 5. Llitjos, J. F., Leclerc, M., Chochois, C., Monsallier, J. M., Ramakers, M., Auvray, M., & Merouani, K. (2020, July). High incidence of venous thromboembolic events in anticoagulated severe COVID-19 patients. J Thromb Haemost, 18(7), 1743– 1746. https://doi.org/10.1111/jth.14869 6. Porfidia, A., & Pola, R. (2020, June). Venous thromboembolism in COVID-19 patients. J Thromb Haemost, 18(6), 1516–1517. https://doi.org/10.1111/jth.14842 7. Sanders, J. M., Monogue, M. L., Jodlowski, T. Z., & Cutrell, J. B. (2020, April 13). Pharmacologic treatments for coronavirus disease 2019 (COVID-19): A review. JAMA, 323(18), 1824– 1836. https://doi.10.1001/jama.2020.6019

2020 JOHN SCHOLZ STROKE EDUCATION CONFERENCE October 10 8am – 12:00pm WHERE

Online Register Online: https://tinyurl.com/DSIStroke2020

FEATURING: Smoking / Vaping Cessation Sarah Mullins, MD

Driving After Stroke Jeff Vari, OT

Patient Perspective Bill Funk, MD

Neurointerventional Topics Sudhakar Satti, MD

PA Optics

ToriAnn Yetter, PA-C Elizabeth Masten, PA-C

Racial Disparities and Stroke Mary Cushman, MD

21

On the front-lines: Healthcare Workers

A Social Network Analysis Approach for Contact Tracing in the Hospital Setting Mina Ostovari, Ph.D. Claudine Jurkovitz M.D., M.P.H. Lee Pachter, D.O. David Chen M.D., M.P.H. Value Institute, ChristianaCare

ABSTRACT Since the beginning of the COVID-19 pandemic, the State of Delaware has implemented various strategies including a stay-at-home order, mask-wearing requirements in public places, and community-based testing to control the spread of the disease. Health systems across the U.S. have taken actions including symptom monitoring and screening for visitors and healthcare workers, providing personal protection equipment (PPE), and contact tracing of confirmed infected individuals to provide maximum possible protection for healthcare workers. Despite such efforts, there remains a significant risk of intra-hospital transmission of COVID-19. Healthcare workers who contact patients with COVID-19 or were exposed to the disease in the community may transmit the infection to coworkers in the inpatient setting. In addition to universal and case-based precautions to prevent exposure and disease transmission, contact tracing is essential to minimizing the impact of outbreaks among healthcare workers and the community. A rapid increase in cases can quickly diminish hospital infection control and prevention program capacity to perform high-quality contact tracing. This article will describe an approach using the application of social network analysis (SNA) and Electronic Medical Records (EMR) to enhance the current efforts in COVID-19 contact tracings.

COVID-19 PANDEMIC On January 30, 2019, the World Health Organization (WHO) declared the novel coronavirus outbreak (2019-nCoV) as a Public Health Emergency of International Concern.1 COVID-19 is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, which is highly infectious and can be transmitted from person-to-person in close contacts and through droplets.2 The spread of the virus may also occur through aerosolization by healthcare-related activities and possibly via contaminated surfaces.3 Compared to similar conditions such as SARS and MERS, COVID-19 may have a lower mortality rate4; however, it has a longer incubation period (2 to 14 days) and some patients may never develop symptoms.5 Asymptomatic individuals are those infected by the virus but without symptoms, and though their contribution to the transmission of SARSCoV-2 is not clear,6 some reports have shown that isolating confirmed asymptomatic infected individuals can help eliminate the spread of the virus.7 At this time, the number of confirmed cases in the United States with COVID-19 has surpassed two million with more than 100,000 deaths.8 As of June 12, 2020, in the State of Delaware, more than 9,000 confirmed cases were identified with more than 300 deaths.9 According to the Center for Disease Control and Prevention (CDC), since the beginning of the pandemic, there have been more than 70,000 cases among healthcare workers with more than 300 deaths.10 Early reports of COVID-19 infection among healthcare workers showed wide variability in the rate of confirmed transmission.11 Successful control of the infection in hospital settings depends on several factors including symptom monitoring, appropriate use of PPE for close contacts with patients, identification of healthcare workers with high-risk 22 Delaware Journal of Public Health – August 2020

exposure through contact tracing, and subsequent quarantine of the exposed staff.12 While the number of new cases has been declining in Delaware and some other states, some researchers have warned about a potential second wave of COVID-19 in the fall.13 Therefore, it is essential to learn from the current situation and prepare for future potential outbreaks.

CONTACT TRACING DURING THE PANDEMIC Individuals who have had close contacts with someone infected with SARS-CoV-2 are at a higher risk of becoming infected and potentially infecting others. Prompt monitoring of these individuals is essential to both appropriately quarantine them before they may transmit the virus to secondary contacts as well as to ensure they receive appropriate supportive care.14 This process of high-quality contact tracing, whether in the community or in health systems, is a complicated procedure with high consumption of resources. During the traditional contact tracing procedure, public health officials interview each case and help them recall everyone with whom they have had close contact. Once identified, public health officials will get in touch with the contacts to inform them about their exposure and of precautions to limit the spread.15 An exponentially increasing number of cases can severely impact the ability of public health officials and hospital infection control management to perform effective contact tracing.16 The CDC has provided general guidelines for monitoring and prioritization of individuals for contact tracing.17 Every state across the U.S. has planned accordingly to control the spread of the disease in their community18 including mask requirements in public places, planned phases for reopening,

and enhancing contact tracing procedures. Tech companies like Apple and Google have provided a contact tracing system to public health officials to augment traditional contact tracing methods.19 Despite the potential benefits, this technology might not be implemented effectively and on a large scale.20 While many actions have been taken by public health officials and tech companies, health systems still need to take the lead in controlling the infection in their hospital settings. Contact tracing in the hospital system is managed by the infection control and prevention team and follows a similar approach to contact tracing in the community. There have already been rapid and widespread outbreaks within skilled nursing facilities of COVID-19, partly attributed to the risk of asymptomatic infectivity causing nosocomial transmission within healthcare settings.21 Such incidents can severely strain infection control management and diminish their capacity to control the disease spread when most needed.16

APPLICATION OF SOCIAL NETWORK ANALYSIS IN CONTACT TRACING To augment the contact tracing efficiency in the inpatient setting, we present a methodology using social network analysis (SNA) to develop a contact network of healthcare workers and to detect the intra-system interactions and their frequencies. SNA is a technique that uses graph theory and network analysis to model and quantify the relations among a set of actors (individuals/organizations).22 The analysis methodology includes three main stages: 1) identifying set of actors (nodes), 2) describing the nature of relationships (edges) between the actors, and 3) analyzing the structure of the system.23 Previously, studies had used social network analysis to assess collaboration and communication among healthcare providers using data collected from surveys and interviews.24,25 In recent years, the application of social network analysis has been expanded to be applicable to large-scale data.26 Instead of using surveys and interviews, studies use large-scale health data including administrative claims or electronic medical records (ERM) to identify the actors (nodes) and their relations (edges). Researchers have used the SNA technique in various topics including understanding communication among healthcare workers,24 modeling of the referral patterns among healthcare providers,27,28 and modeling of the collaboration among healthcare providers and the impact on patient outcomes.29,30 When applied in the context of epidemiology, SNA can be referred to as a contact network which represents cases and their contacts linkages during a specific time period.31 Contact networks allow visualization of the potential scenarios or risk factors that can impact an outbreak and provide perspectives about how to address such situations. Previously, SNA has been used to model the spread of nosocomial infections between different hospitals32,33 These studies define a network of hospitals as nodes that are connected through edges defined as patient transfer among the hospitals. A similar approach can be applied to model potential transmission of COVID-19 among healthcare workers in the inpatient setting.

An SNA approach can be applied to health data extracted from Electronic Medical Records (EMR) to develop a contact network of healthcare workers who provided care to patients with COVID-19 in the inpatient setting. This intra-hospital healthcare worker contact network may increase the speed of contact tracing through the automated identification of contacts with no additional hardware investment.34 Such networks may estimate the exposure and susceptibility among healthcare workers and may inform resource allocation in potential future epidemics. Figure 1 presents a simple example of a contact network, which is undirected and unweighted. Nodes represent healthcare workers, and edges represent patients. If two healthcare workers share patients, they are connected. From this network, we can identify some network characteristics, for example, HCW2 is connected to three other providers (SNA degree centrality=3) that can be interpreted as the highest number of connections with other healthcare providers; therefore, if HCW2 is identified as a case, there is a high risk that all three other healthcare workers might have to be quarantined. On the other hand, if HCW1 is identified as a case, only HCW3 and HCW2 are the potential contacts who might need to go under quarantine.

HCW1

HCW2

HCW3

HCW4

Figure 1. An example of a contact network of healthcare workers in the inpatient setting. The nodes represent the healthcare workers (HCW) and the edges show that healthcare workers provide care to shared patients.

Further details can be added to the network, for example, giving weights to the edges based on the number of shared patients/hospital units between the healthcare workers. A similar approach can be taken to model disease outbreaks in different units based on patient locations. Physical unit locations that patients stay in during their in-patient visits can be tracked from the EMR. Based on the transfer of patients to different units, a small-world network of patient transfers between hospital units can be generated. The network characteristics can be utilized to develop probabilistic models to predict disease outbreaks in different hospital units. The SNA approach on EMR data is particularly useful to identify outbreaks caused by healthcare workers providing care to 23

On the front-lines: Healthcare Workers

patients who are asymptomatic but are transmitting the virus prior to diagnosis and isolation. Such patients without symptoms might have been admitted for health reasons other than COVID-19; exposing healthcare providers who were therefore not utilizing the same level of PPE used for patients with confirmed or even suspected COVID-19.

IMPLEMENTATION OF THE SNA APPROACH FOR CONTACT TRACING EMR collects patient data including diagnosis, admission/ discharge date, testing results, procedures performed on the patient, healthcare provider types, and hospital units that patients visit. A de-identified dataset of patients with COVID-19 and their healthcare providers can be developed from the EMR. One method of tracking healthcare worker interaction is through explicit paper logs of patient contact; however tracking a large number of patients and providers requires a cumbersome amount of work for data entering, cleaning, and processing. Another method that can be automated would be tracking healthcare provider location in the hospital through the Radio-Frequency Identification (RFID) devices that connect with providers or other special badges35; however, this requires significant hardware investment and maintenance including RFID badges, RFID readers, and adherence to badge-wearing. Moreover, tracking the location through RFID does not provide information about the type of interaction that the providers had with each other or the patient and is a more invasive method of data collection that may raise privacy concerns. The social network analysis provides tools to apply on large-scale data from the EMR to reasonably approximate contacts among healthcare workers that are at risk for infection transmission. Measures generated from the network analysis, such as describing healthcare workers with the highest number of interactions (high degree centrality in the network), can be used to identify those with a higher possibility of transmitting the disease to others. Further opportunities based on this work include modeling and classification of healthcare workers by risk and simulation of disease transmission across the network based on different scenarios. The findings can inform resource allocation and staffing assignments to reduce the risk of infection. In addition, this approach using de-identified electronic health data protects the privacy of healthcare workers.

PUBLIC HEALTH SIGNIFICANCE To control the spread of the COVID-19, strategies including mask requirements in public places and stay-at-home orders have been issued in states across the U.S. With the decreasing number of cases and deaths, many states are moving toward reopening their economy. Having contact tracing protocols and resources in place is essential to reduce the potential of another surge in the number of cases. Providing solutions to accelerate contact tracing efforts will reduce the cumbersomeness of the process and liberate public health resources for other challenges in the community. 24 Delaware Journal of Public Health – August 2020

REFERENCES 1. World Health Organization. (2020). COVID-19 Timeline. Retrieved from: www.who.int/news-room/detail/27-04-2020-who-timeline---covid-19 2. Chan, J. F., Yuan, S., Kok, K. H., To, K. K., Chu, H., Yang, J., . . . Yuen, K. Y. (2020, February 15). A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: A study of a family cluster. Lancet, 395(10223), 514–523. https://doi.org/10.1016/S0140-6736(20)30154-9 3. van Doremalen, N., Bushmaker, T., Morris, D. H., Holbrook, M. G., Gamble, A., Williamson, B. N., . . . Munster, V. J. (2020, April 16). Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. The New England Journal of Medicine, 382(16), 1564–1567. https://doi.org/10.1056/NEJMc2004973 4. Chen, J. (2020, March). Pathogenicity and transmissibility of 2019-nCoV-A quick overview and comparison with other emerging viruses. Microbes and Infection, 22(2), 69–71. https://doi.org/10.1016/j.micinf.2020.01.004 5. Zou, L., Ruan, F., Huang, M., Liang, L., Huang, H., Hong, Z., . . . Wu, J. (2020, March 19). SARS-CoV-2 viral load in upper respiratory specimens of infected patients. The New England Journal of Medicine, 382(12), 1177–1179. https://doi.org/10.1056/NEJMc2001737 6. Al-Tawfiq, J. A. (2020, May - June). Asymptomatic coronavirus infection: MERS-CoV and SARS-CoV-2 (COVID-19). Travel Medicine and Infectious Disease, 35, 101608. https://doi.org/10.1016/j.tmaid.2020.101608 7. Day, M. (2020, March 23). Covid-19: Identifying and isolating asymptomatic people helped eliminate virus in Italian village. BMJ (Clinical Research Ed.), 368, m1165. https://doi.org/10.1136/bmj.m1165 8. Johns Hopkins Coronavirus Resource Center. (2020). COVID-19 United States cases by county. Retrieved from: https://coronavirus.jhu.edu/us-map 9. Delaware.gov. (2020). Coronavirus. Delaware’s Coronavirus Official Website. Retrieved from: https://coronavirus.delaware.gov/ 10. Centers for Disease Control and Prevention. (2020, Mar). Coronavirus Disease 2019 (COVID-19) in the U.S. Retrieved from: www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html 11. Guan, W., Ni, Z., Hu, Y., Liang, W., Ou, C., He, J., . . . Zhong, N. (2020). Clinical characteristics of 2019 novel coronavirus infection in China. MedRxiv. https://doi.org/10.1101/2020.02.06.20020974 12. Wong, S. C. Y., Kwong, R. T., Wu, T. C., Chan, J. W. M., Chu, M. Y., Lee, S. Y., . . . Lung, D. C. (2020, June). Risk of nosocomial transmission of coronavirus disease 2019: An experience in a general ward setting in Hong Kong. The Journal of Hospital Infection, 105(2), 119–127. https://doi.org/10.1016/j.jhin.2020.03.036

13. Strazewski, L. (2020). Harvard epidemiologist: Beware COVID-19’s second wave this fall. American Medical Association. Retrieved from: www.ama-assn.org/delivering-care/public-health/harvardepidemiologist-beware-covid-19-s-second-wave-fall

25. Mascia, D., Cicchetti, A., Fantini, M. P., Damiani, G., & Ricciardi, W. (2011, July 25). Physicians’ propensity to collaborate and their attitude towards EBM: A cross-sectional study. BMC Health Services Research, 11(1), 172. https://doi.org/10.1186/1472-6963-11-172

14. World Health Organization. (2017). Contact tracing. Retrieved from: www.who.int/news-room/q-a-detail/contact-tracing

26. Barnett, M. L., Landon, B. E., O’Malley, A. J., Keating, N. L., & Christakis, N. A. (2011, October). Mapping physician networks with self-reported and administrative data. Health Services Research, 46(5), 1592–1609. https://doi.org/10.1111/j.1475-6773.2011.01262.x

15. Center for Disease Control and Prevention. (2020). Case investigation and contact tracing : Part of a multipronged approach to fight the COVID-19 pandemic. Retrieved from: www.cdc.gov/coronavirus/2019-ncov/php/principles-contact-tracing.html 16. Daskalaki, I., Hennessey, P., Hubler, R., & Long, S. S. (2007, April). Resource consumption in the infection control management of pertussis exposure among healthcare workers in pediatrics. Infection Control and Hospital Epidemiology, 28(4), 412–417. https://doi.org/10.1086/513121 17. Centers for Disease Control and Prevention. (2020). Contact Tracing. Retrieved from: www.cdc.gov/coronavirus/2019-ncov/php/contact-tracing/ contact-tracing-plan/contact-tracing.html 18. Delaware.gov. (2020). Contact Tracing. Retrieved from: coronavirus.delaware.gov/contact-tracing/ 19. Schumaker, E. (2020). Apple and Google launch digital contact tracing system. ABC News. Retrieved from: abcnews.go.com/Technology/apple-google-launch-digitalcontact-tracing-system/story?id=70789376 20. Servick, K. (2020). COVID-19 contact tracing apps are coming to a phone near you. How will we know whether they work? Science Retrieved from: www.sciencemag.org/news/2020/05/countries-around-worldare-rolling-out-contact-tracing-apps-contain-coronavirus-how 21. Arons, M. M., Hatfield, K. M., Reddy, S. C., Kimball, A., James, A., Jacobs, J. R., . . . Jernigan, J. A., & the Public Health– Seattle and King County and CDC COVID-19 Investigation Team. (2020, May 28). Presymptomatic SARS-CoV-2 infections and transmission in a skilled nursing facility. The New England Journal of Medicine, 382(22), 2081–2090. https://doi.org/10.1056/NEJMoa2008457 22. Scott, J. (1988). Social network analysis. Sociology, 22(1), 109–127. https://doi.org/10.1177/0038038588022001007 23. Blanchet, K., & James, P. (2012, August). How to do (or not to do) ... a social network analysis in health systems research. Health Policy and Planning, 27(5), 438–446. https://doi.org/10.1093/heapol/czr055 24. Creswick, N., Westbrook, J. I., & Braithwaite, J. (2009, December 31). Understanding communication networks in the emergency department. BMC Health Services Research, 9(1), 247. https://doi.org/10.1186/1472-6963-9-247

27. An, C., O’Malley, A. J., Rockmore, D. N., & Stock, C. D. (2018, February 28). Analysis of the U.S. patient referral network. Statistics in Medicine, 37(5), 847–866. https://doi.org/10.1002/sim.7565 28. An, C., O’Malley, A.J., Rockmore, D.N. (2018). Referral paths in the US physician network. Applied network science, 3(1), 20. 29. Ostovari, M., & Yu, D. (2019, September 9). Impact of care provider network characteristics on patient outcomes: Usage of social network analysis and a multi-scale community detection. PLoS One, 14(9), e0222016. https://doi.org/10.1371/journal.pone.0222016 30. Barnett, M. L., Christakis, N. A., O’Malley, J., Onnela, J. P., Keating, N. L., & Landon, B. E. (2012, February). Physician patient-sharing networks and the cost and intensity of care in US hospitals. Medical Care, 50(2), 152–160. https://doi.org/10.1097/MLR.0b013e31822dcef7 31. Chen, Y., Chen, H., & King, C. (2010). Social network analysis for contact tracing. Castillo-Chavez, C., Chen, H., Lober, W.B., Thurmond, M., Zeng, D., eds. Infectious Disease Informatics and Biosurveillance, 27, 339-358. doi:10.1007/978-1-44196892-0_15 32. Ray, M. J., Lin, M. Y., Weinstein, R. A., & Trick, W. E. (2016, October 1). Spread of carbapenem-resistant enterobacteriaceae among Illinois healthcare facilities: The role of patient sharing. Clin Infect Dis, 63(7), 889–893. https://doi.org/10.1093/cid/ciw461 33. Fernández-Gracia, J., Onnela, J. P., Barnett, M. L., Eguíluz, V. M., & Christakis, N. A. (2017, June 7). Influence of a patient transfer network of US inpatient facilities on the incidence of nosocomial infections. Scientific Reports, 7(1), 2930. https://doi.org/10.1038/s41598-017-02245-7 34. Cusumano-Towner, M., Li, D. Y., Tuo, S., Krishnan, G., & Maslove, D. M. (2013, May 1). A social network of hospital acquired infection built from electronic medical record data. J Am Med Inform Assoc, 20(3), 427–434. https://doi.org/10.1136/amiajnl-2012-001401 35. Hellmich, T. R., Clements, C. M., El-Sherif, N., Pasupathy, K. S., Nestler, D. M., Boggust, A., . . . Hallbeck, M. S. (2017, December 1). Contact tracing with a real-time location system: A case study of increasing relative effectiveness in an emergency department. American Journal of Infection Control, 45(12), 1308–1311. https://doi.org/10.1016/j.ajic.2017.08.014 25

On the front-lines: Healthcare Workers

Addressing Health Disparities in Delaware by Diversifying the Next Generation of Delaware’s Physicians Kristyn Mitchell ChristianaCare, Harrington Value Institute Translational Research Intern Franklin Iheanacho ChristianaCare, Harrington Value Institute Translational Research Intern Jacqueline Washington, Ed.D. ChristianaCare, Program Manager of the Harrington Value Institute Community Partnership Fund Marshala Lee, M.D., M.P.H. ChristianaCare, Director of the Harrington Value Institute Community Partnership Fund

The COVID-19 pandemic has shined a light on health disparities in the United States and the impact of the social determinates of health (SDOH). Black Americans have a mortality rate 2.4 times that of whites and this disproportionality is more widespread throughout the United States compared to any other racial/ethnic group.1 COVID-19 disparities are also manifesting in the State of Delaware. As of May 24, 2020, both Non-Hispanic Black and Hispanic/Latino Americans have the highest rate of COVID-19 cases, with a rate of 111.3 and 281.6 cases, respectively, while non-Hispanic Whites have a rate of 38.5.2 These disparities, although startling, are not surprising considering that before the COVID-19 outbreak health disparities were already persistent. For the top ten leading causes of death, when compared to non-Hispanic White Delawareans, non-Hispanic Black Delawareans lead with the highest adjusted mortality rate for seven of the causes of deaths between 2014 and 2018 (see Table 1). The most common comorbidities associated with COVID-19 are hypertension, obesity, and diabetes, all of which disproportionately impact Black and Hispanic/Latin Americans in the United States and Delaware.4,5 Effective strategies must be deployed in the short-term to reduce COVID-related health disparities while simultaneously investing in long-term strategies such as improving workforce diversity to completely eliminate future health disparities. LEADING CAUSES OF DEATH

NON-HISPANIC White

Black

Malignant neoplasms

169.1

181.2

Diseases of the heart

159.4

179.0

Chronic lower respiratory diseases

44.8

32.7

Cerebrovascular diseases

39.2

55.1

Dementia

35.7

41.0

Accidents (unintentional injuries)

44.8

Diabetes mellitus

16.0

32.5

Alzheimer’s disease

25.2

28.4

Nephritis, nephrotic syndrome, and nephrosis

13.3

31.1

Influenza and pneumonia

13.9

12.3

Table 1. Five year age adjusted mortality rate of the top 10 leading causes of death (2014-2018)3 26 Delaware Journal of Public Health – August 2020

STRATEGIES: HEALTH WORKFORCE DIVERSITY PIPELINE INVESTMENTS One strategic approach for improving the SDOH for minority communities and reducing health disparities is to invest in the recruitment of a diverse healthcare workforce. Diverse healthcare workers are uniquely positioned to tackle these dimensional problems for several reasons. For one, a diverse healthcare workforce increases the likelihood that high quality care will be provided to underserved populations and people of color. For example, physicians who self-identified as belonging to an underrepresented minority (URM) group were more likely than their colleagues to practice in high-need areas.6 In a Stanford Study, Black men in Oakland, California were paired with either Black or non-Black physicians. The men seen by Black physicians were more likely to engage with them, and even consent to preventive services like immunizations. Additionally, the Black physicians were more inclined to write detailed notes about their Black patients.7 A diverse health workforce will also strengthen cultural competence throughout the health system. The U.S. healthcare system has largely been built upon the practices of Western medicine. Many healthcare systems are currently poorly equipped to provide culturally competent care to patients from underrepresented backgrounds and to those who believe in nontraditional concepts of illness and treatment. Diversity in our healthcare workforce is an effective strategy to increase patient satisfaction, decease health workforce shortages, improve the cultural competence of health systems, and ultimately decrease health disparities. Although a diverse healthcare workforce is crucial for achieving health equity thus reducing health disparities, there persists an underrepresentation of certain racial/ethnic groups in the United States and Delaware. The Association of American Medical Colleges (AAMC) historically classified four racial/ ethnic groups as underrepresented in medicine: Black Americans, Mexican Americans, Native Americans (which include American Indians, Alaska Natives, and Native Hawaiians) and mainland Puerto Ricans.8 The state of Delaware suffers from an underrepresentation of minority physicians similar to most other states in the United States (see Table 2). These disparities are consistent within the medical school applicant pool, with far less URM students applying to and matriculating into medical school even after Liaison Committee of Medical Education diversity accreditation guidelines were established in 2009.12 As the United States becomes more diverse, action must be taken now to better address health disparities by ensuring that the future physician workforce is more diverse and better reflects the makeup of the communities that they serve.

United States Race/Ethnicity

Non-Hispanic Black

Percentage of active physicians in the USA (2018)9

Percentage of USA population10

5%

13%

Hispanic/Latin

5.8%

18.3%

American Indian, Alaskan native, Native Hawaiian, and pacific Islander

0.4%

1.5%

Asian

17. 1%

5.9%

Non-Hispanic White

56.2%

60.4%

Delaware Race/Ethnicity

Percentage of primary care physicians in DE11

Total population in DE by percentage10

Non-Hispanic Black

6.6%

23%

Hispanic/Latin

4.4%

9.5%

Asian

22.6%

5.9%

White

66.7%

61.9%

Table 2: Percentages of active physicians in USA by race/ethnicity compared to the percentage of US population by race/ethnicity and the percentage of primary care physicians by race/ethnicity in Delaware compared to percentage of Delawareans by race/ethnicity

CURRENT HEALTH WORKFORCE PIPELINE DIVERSITY EFFORTS IN DELAWARE There are increasing efforts from the government, healthcare organizations, and academic institutions nationwide to address the underrepresentation of minorities in health professions and foster strategies for workforce diversification. According to the Institute of Medicine, pipeline programs that support the needs and success of minorities are pivotal for improving healthcare workforce diversity.13 For example, the Human Resources and Services Administration (HRSA) has grant funding for academic institutions to promote recruitment and retention of minorities in the field of nursing. The funding provides academic and financial support, mentorship, community engagement, and clinical and research opportunities.14 Similarly, the Health Sciences Camp at the University of Delaware provides high schoolers from underrepresented backgrounds and firstgeneration college families with a free college immersion experience in the health sciences. Students can engage with faculty and researchers, and also gain exposure to nursing, biotechnology, exercise science, and other health specialties.15 For students particularly interested in pursuing medicine, the Harrington Value Institute Community Partnership (VICP) Fund sponsors a yearlong research internship to support URM students in their pursuit to medical school. Established in

2015, The Harrington Value Institute Community Partnership Fund was established by a donation from the estate of Charles J. Harrington, Ph.D. Dr. Harrington was deeply committed to advancing scholarship and supporting innovative projects that help reduce health care disparities for underserved and disadvantaged populations. The Harrington Value Institute Translational Research Internship prepares recently graduated college students for careers in medicine and translational research by providing enriching research opportunities, clinical shadowing, mentorship, and a curriculum tailored to academic and professional development. The internship is primarily housed at ChristianaCare’s Value Institute, where students engage with physicians, nurses, researchers, community leaders, and other healthcare professionals throughout the health system to enhance their understanding of translational research, public health, the social determinants of health, and medicine. Upon completing the internship, many interns have successfully matriculated into accredited medical schools and left the internship with added confidence and skills that will better prepare them for medical school and clinical research careers.

FUTURE HEALTH WORKFORCE PIPELINE DIVERSITY EFFORTS IN DELAWARE The Harrington VICP Fund plans to expand this opportunity to more underrepresented students in the upcoming years. Additionally, the Harrington VICP Fund also understands the vast array of other common barriers affecting the URM medical school pipeline and has recently created an MCAT Prep Program for students to receive quality preparation for the Medical College Admissions Test (MCAT). According to the AAMC, minority students traditionally do not perform as well as white students on the MCAT, and a major factor contributing to this disparity is lack of financial support for test preparation materials.16,17 Furthermore, the current COVID-19 pandemic and its threats to many underserved communities have intensified students’ financial challenges. Students enrolled in the MCAT Prep Program will have access to a 6-week online Kaplan MCAT course as well as mentoring and peer support during their medical school application process. These students will also be introduced to the concepts of health disparities, social determinants of health, and the importance of cultural competence in caring for their future patients. Upon completing the program, program participants will not only be better prepared candidates for medical school, but they will also be equipped with skills to become culturally humbled leaders in their community. While there are a few strategies in place to increase diversity of the healthcare workforce, there is still much work to be done. Substantial investments are needed to build robust physician pipeline programs for URM students in K-12 and undergraduate levels to ensure a diverse healthcare workforce. Delaware is presented with a unique challenge to its physician pipeline because the state does not have its own medical school. The Harrington VICP is optimistic that many of its program participants will return to practice in Delaware after completing their medical training and commit to careers committed to reducing health disparities. As Delaware’s population continues to diversify, the programs implemented by the Harrington Fund can serve as a guideline for the development of additional URM physician pipeline programs. 27

On the front-lines: Healthcare Workers

REFERENCES 1. APM Research Lab. (n.d.). COVID-19 deaths analyzed by race and ethnicity. Retrieved from: https://www.apmresearchlab.org/covid/deaths-by-race 2. My Healthy Community. (n.d.). Coronavirus (COVID-19) Data Dashboard State of Delaware. Retrieved from: https://myhealthycommunity.dhss.delaware.gov/locations/state 3. Delaware Division of Public Health. (2020, Feb). Delaware Vital Statistics Annual Report 2018. Retrieved from: https://dhss.delaware.gov/dph/hp/files/ar2018_net.pdf 4. Richardson, S., Hirsch, J. S., Narasimhan, M., Crawford, J. M., McGinn, T., Davidson, K. W., . . . Zanos, T. P., & the and the Northwell COVID-19 Research Consortium. (2020, April 22). Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area. JAMA, 323(20), 2052–2059. https://doi.org/10.1001/jama.2020.6775 5. Centers for Disease Control and Prevention. (n.d.). BRFSS Prevalence & Trends Data. Retrieved from: https://www.cdc.gov/brfss/brfssprevalence/ 6. Goodfellow, A., Ulloa, J. G., Dowling, P. T., Talamantes, E., Chheda, S., Bone, C., & Moreno, G. (2016, September). Predictors of primary care physician practice location in underserved urban and rural areas in the United States: A systematic literature review. Acad Med, 91(9), 1313–1321. https://doi.org/10.1097/ACM.0000000000001203 7. Alsan, M., Garrick, O., & Graziani, G. (2019). Does diversity matter for health? Experimental evidence from Oakland. The American Economic Review, 109(12), 4071–4111. https://doi.org/10.1257/aer.20181446 8. American Association of Medical Colleges. (n.d.). Underrepresented in medicine definition. Retrieved from: https://www.aamc.org/what-we-do/mission-areas/diversityinclusion/underrepresented-in-medicine

28 Delaware Journal of Public Health – August 2020

9. American Association of Medical Colleges. (2019). Diversity in Medicine: Facts and Figures 2019. Retrieved from: https://www.aamc.org/data-reports/workforce/interactive-data/ figure-18-percentage-all-active-physicians-race/ethnicity2018#:~:text=race%2Fethnicity%2C%202018-,New%20 section,as%20Black%20or%20African%20American 10. US Census Bureau. (n.d.). United States: Quick Facts. Retrieved from: https://www.census.gov/quickfacts/fact/table/US/PST045219 11. Delaware Department of Health and Social Services. (2018). Primary Care Physicians in Delaware, 2018. Retrieved from: https://dhss.delaware.gov/dhss/files/primarycarestudy.pdf 12. Lett, L. A., Murdock, H. M., Orji, W. U., Aysola, J., & Sebro, R. (2019, September 4). Trends in racial/ethnic representation among US medical students. JAMA Network Open, 2(9), e1910490–e1910490. https://doi.org/10.1001/jamanetworkopen.2019.10490 13. Altman, S. (2016, Feb 22). Promoting diversity. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK350167/ 14. Kukich, D. (2014, Nov 18). Nursing workforce diversity. Retrieved from: http://www1.udel.edu/udaily/2015/nov/nursing-diversity-111814.html 15. Benjamin, A. (n.d.). Pipeline program: Health sciences: University of Delaware. Retrieved from: https://www.chs.udel.edu/pipeline-program/ 16. American Association of Medical Colleges. (2019, Oct 16). MCAT Scores and GPAs for Applicants and Matriculants to U.S. Medical Schools by Race/Ethnicity, 2019-2020. Retrieved from: https://www.aamc.org/system/files/2019-10/2019_FACTS_Table_A-18.pdf 17. American Association of Medical Colleges. (2018, Jun). Using MCAT® Data in 2019 Medical Student Selection. (2018, June). Retrieved from: https://www.aamc.org/system/files/c/2/462316-mcatguide.pdf

51st Annual

Robert O.Y. Warren, MD Memorial Seminar VIRTUAL CONFERENCE Wednesday, November 11, 2020

29

COURSE DESCRIPTION The Robert O.Y. Warren, MD Memorial Seminar was established in honor of Dr. Warren, an outstanding Wilmington pediatrician. Dr. Warren practiced from 1932 until his death in 1968. Dr. Warren was instrumental in forming both the Child Guidance Center and the Child Diagnostic and Development Center, of which he was president. As the physician for Tower Hill School and a member of the Wilmington Public School Board of Education, he was also very active in the area of children’s education. The Delaware Chapter of the American Academy of Pediatrics, the Delaware Academy of Medicine and the Nemours/Alfred I. duPont Hospital for Children co-sponsor this annual continuing education program in order to perpetuate Dr. Warren’s memory. He left us with a legacy of devotion to the health and well-being of children which we strive to convey through this seminar. The Robert O.Y Warren, MD Memorial Seminar is designed to provide primary care providers with information on pediatric medicine that can be used to improve their clinical practice.

LEARNING OBJECTIVES At the conclusion of this program, participants should be able to:

§ Discuss new therapies for atopic dermatitis § Evaluate the use of proactive therapies for moderate to severe atopic dermatitis

§ Identify current treatment for food allergy § Describe the risks and benefits of oral immunotherapy § Develop a treatment plan for severe food allergic reactions

§ Discuss the 2019 GINA guidelines and how they

compare and contrast with NAEPP EPR-3 2007 Asthma Guidelines

§ Identify role and indications for asthma biologic therapies

§ Identify the appropriate PPE to use when evaluating

and caring for patients with suspected or confirmed COVID-19

§ Integrate public health guidance on COVID-19 into pediatric practice and personal life

§ Describe the virology, epidemiology and clinical features of the COVID-19 pandemic

§ Discuss the effects of the COVID-19 pandemic on children and pediatric medicine

§ Discuss the current COVID-19 testing modalities and how to implement them in a clinical practice

30 Delaware Journal of Public Health – August 2020

§ Describe the current state of vaccine development for COVID-19

§ Identify patients at higher risk of contracting COVID-19 and describe the special precautions to take in their clinical care

§ Discuss the management of infants born to mothers with suspected or confirmed COVID-19

§ Describe three features of medical assessment important to consider in the ADHD diagnosis

§ Describe one method of initiating an ADHD stimulant and nonstimulant medication

§ Describe various executive functioning skills including working memory

§ List and discuss interventions that promote executive

functioning skills development with families of children with ADHD

§ Describe indications for nonoperative management of appendicitis

§ Refer patients with umbilical/epigastric hernia for surgical evaluation when indicated

§ Develop a differential diagnosis for back pain in children

§ Develop an initial treatment plan for back pain § Discuss cleft and craniofacial conditions and incidence

D

CE

Program Director

Keynote Speaker

Robert S. Walter, MD, FAAP

Jonathan Spergel, MD, PhD

Pediatrician Brandywine Pediatrics Clinical Associate Professor of Pediatrics Sidney Kimmel Medical College at Thomas Jefferson University

Chief, Section of Allergy Stuart E. Starr Endowed Chair of Pediatrics Children’s Hospital of Philadelphia Professor of Pediatrics Perelman School of Medicine at University of Pennsylvania

Faculty Loren Berman, MD

Karen Ravin, MD

Edward J. Caterson, MD

Neil Rellosa, MD

Pediatric Surgeon Nemours/Alfred I. duPont Hospital for Children Associate Professor of Surgery and Pediatrics Sidney Kimmel Medical College at Thomas Jefferson University

Chief, Division of Plastic Surgery Nemours/Alfred I. duPont Hospital for Children

Colleen Cullinan, PhD

Pediatric Psychologist Division of Behavioral Health Nemours/Alfred I. duPont Hospital for Children

Stuart Mackenzie, MD

Orthopedic Surgeon Nemours/Alfred I. duPont Hospital for Children

James McGough, MD

Child and Adolescent Psychiatrist University of California, Los Angeles (UCLA) Health Professor of Clinical Psychiatry UCLA Semel Institute for Neuroscience and Human Behavior

Chief, Division of Infectious Diseases Nemours/Alfred I. duPont Hospital for Children Clinical Assistant Professor of Pediatrics Sidney Kimmel Medical College at Thomas Jefferson University

Attending Physician Division of Infectious Diseases Nemours/Alfred I. duPont Hospital for Children

Craig Shapiro, MD

Attending Physician Division of Infectious Diseases Nemours/Alfred I. duPont Hospital for Children

Ambika Shenoy, MD

Pediatric Pulmonologist Nemours/Alfred I. duPont Hospital for Children Assistant Professor of Pediatrics Sidney Kimmel Medical College at Thomas Jefferson University

Salwa Sulieman, DO

Attending Physician Division of Infectious Diseases Nemours/Alfred I. duPont Hospital for Children

31

AGENDA Wednesday, November 11, 2020 8 a.m.

Next Generation Atopic Dermatitis Care: Bathing to Biologics – Jonathan Spergel, MD, PhD

9 a.m.

Break

9:15 a.m.

Opening Remarks/Welcome

9:30 a.m.

OLD PROBLEMS, NEW TRICKS Do We Really Have Therapy for Food Allergies? – Jonathan Spergel, MD, PhD Asthma Update: GINA to Biologics – Ambika Shenoy, MD Question and Answer Session | Moderator: Robert S. Walter, MD, FAAP

10:45 a.m.

Break

11 a.m.

INFECTIOUS DISEASE Covid-19 Pandemic – Lessons Learned – Karen Ravin MD, Craig Shapiro MD, Neil Rellosa, MD & Salwa Sulieman, DO Question and Answer Session | Moderator: Robert S. Walter, MD, FAAP

12:15 p.m.

Break

12:45 p.m.

PSYCH Management of ADHD in Pediatric Primary Care – James McGough, MD Smart and Scattered: Understanding Executive Functioning Skills and ADHD – Colleen Cullinan, PhD Question and Answer Session | Moderator: Robert S. Walter, MD, FAAP

2 p.m.

Break

2:15 p.m.

PEDIATRIC PEARLS Pediatric Surgery Pearls – Loren Berman, MD Orthopedic Pearls – Stuart Mackenzie, MD Plastics Pearls – Edward J. Caterson, MD Question and Answer Session | Moderator: Robert S. Walter, MD, FAAP

3:30 p.m.

Adjourn

32 Delaware Journal of Public Health – August 2020

COURSE REGISTRATION Fees: The virtual conference registration fee is $70. Registration: Advance registration is required and should be received by October 28, 2020. All registrations received by this date will be confirmed in writing. Registration is limited and will be honored in the order of the date received. To register: Please complete the registration form found online at www.PedsUniversity.org

Cancellation Policy: A full refund will be given for WRITTEN cancellations received before October 21, 2020. No refunds will be given after this date. Nemours/Alfred I. duPont Hospital for Children is not responsible for any cancellations or change fees assessed by hotels, airlines or travel agencies. Disclosure Policy: As a provider accredited by the ACCME, Nemours must ensure balance, independence, objectivity and scientific rigor in its educational activities. All faculty involved in the development of CME content are required to disclose to Nemours their relevant financial relationships. An individual has a relevant financial relationship if he/she has a financial relationship in any amount occurring in the last 12 months with a commercial interest whose products or services are discussed in the CME activity content over which the individual has control. Nemours has policies in place to resolve potential financial conflicts of interest. Relevant financial relationships will be disclosed to the activity audience. For More Information: Contact Karen Supplee, (302) 651-6758, or karen.supplee@nemours.org

33

GENERAL INFORMATION Site: Due to COVID-19 concerns, this year’s conference will be VIRTUAL. A link to join the conference will be emailed to registrants as the conference date approaches. Accreditation: This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of Nemours, the Delaware Chapter of the American Academy of Pediatrics and the Delaware Academy of Medicine. Nemours is accredited by the ACCME to provide continuing medical education for physicians. Nemours designates this live activity for a maximum of 6.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in this activity.

Americans With Disabilities Act: In accordance with the Americans with Disabilities Act, the duPont Hospital for Children will provide modifications in teaching methodologies to accommodate individual needs. To request disability accommodations, contact the Office of Continuing Medical Education at least 15 days in advance of the program at (302) 651-6750. Commercial Support: This program may be supported in part by unrestricted educational grants in accordance with ACCME Standards. At the time of this printing, a list of commercial supporters was not available. Appropriate acknowledgement will be given to all exhibitors and supporters in conference materials at the time of the meeting.

34 Delaware Journal of Public Health – August 2020

Robert O.Y. Warren, MD Memorial Seminar VIRTUAL CONFERENCE November 11, 2020 Registration Deadline: October 28, 2020 The conference registration fee is $70. Full payment is due with registration. Register with credit card online at www.PedsUniversity.org.

©2020. The Nemours Foundation. ® Nemours is a registered trademark of The Nemours Foundation. J5655 (07/20)

35

Technology and Engineering for Recovery

The HensNest: Mass Manufacturing a General Use Face Mask Here in Delaware Catherine Fromen Assistant Professor, Chemical and Biomolecular Engineering, University of Delaware Whitney Sample Industrial Designer, Mechanical Engineering, University of Delaware Ajay Prasad Chairperson, Mechanical Engineering, University of Delaware Jenni M. Buckley Associate Professor, Mechanical Engineering, University of Delaware

INTRODUCTION In the age of the COVID-19 pandemic, face masks have been universally touted by health care officials as the best practice in non-pharmaceutical intervention to stop the spread of airborne viral transfection.1–3 “Face masks” by definition are a transmission barrier that covers the mouth and nose to limit the number of exhaled particulates from the wearer. These are to be distinguished from “respirators,” such as the clinically rated N95 respirator, which seals tightly to the face when properly fit tested and is designed to protect the wearer from inhaling airborne environmental particulates.4 Despite the distinction in intended utility between face masks and respirators, face masks can also provide protection to the user. How much protection depends on two interrelated factors: the face mask material and the fit to the face. Depending on the material composition, thickness, and layering options, cloth and do-it-yourself (DIY) face masks can demonstrate significant filtration efficiency.4,5 Recent reports have shown that layering materials with mechanical and electrostatic filtration mechanisms (i.e., cotton and silk) have filtering efficiencies equivalent to an N95 and that outperform standard disposable surgical face masks.4 While combinations of materials may combine to efficiently filter aerosols through the mask, they will not work if significant airflow bypasses the mask through leaks between the mask and the face.4,6,7 Materials with high mechanical filtration efficiency often have high internal resistance to airflow, leading to poor breathability and a higher likelihood of leakage around the face. Thus, these interrelated variables of filtration material and face fit are critical when considering what face mask options can simultaneously provide a high degree of comfort/wearabilty and personal protection against inhaled viral droplets. In line with Centers of Disease Control and Prevention (CDC) recommendations promoting the use of face masks for even brief excursions outside of the home, demand for face masks from the general public is expected to continue. Our team is driven to provide an answer to “what is the best DIY face mask option?” and provide practical solutions for personal face masks that afford protection to the wearer, without impacting the supply chain for clinically-rated N95 respirators.

THE HENSNEST FACE MASK DESIGN In response to these critical concerns surrounding mask availability and the need for good face fit, our team has developed an easy-to-manufacture face mask design, called The HensNest (Figure 1). The HensNest design consists of a simple plastic wireframe that can be quickly and cheaply manufactured through 36 Delaware Journal of Public Health – August 2020

additive manufacturing (i.e., 3D printing) and/or injection molding. The plastic wireframe is dishwasher and disinfectant safe, can be packaged and shipped flat for self-assembly by the end user, and accepts a range of filter types, including common household materials such as HEPA furnace filters and shop towels. The most critical aspect of this design is that it lofts the mask away from the face while providing additional curvature to adequately cover the nose. In combination, this design was intended to improve face fit while increasing both comfort and wearer protection. The design has been released to open source platforms (GrabCAD and NIH 3D Print Exchange) and additional information about The HensNest design can be found on our website at: https://me.udel.edu/hensnest-3d-printed-face-mask/ Our on-going research seeks to validate how the HensNest design compares to other DIY face masks, especially in regards to the two major variables: filter material and face fit.

Figure 1. The HensNest face mask consists of a plastic wireframe (left) that is assembled by the user and accepts one of several commonly available household filter media (right). The filter media shown in the image at right is from a household furnace filter. The design can be secured to the face with elastic bands.

RESPIRATORY FIT TESTS Quantitative respirator fit tests have been performed on a single adult subject wearing multiple face masks using professionally rated and calibrated equipment (PortaCount Respirator Fit Tester 8038, TSI Incorporated).8 The Occupational Safety and Health Administration (OSHA) Fast Fit Test Protocol9 was repeatedly performed, which involves the subject performing multiple activities of daily living while wearing the mask, including normal breathing, bending over, turning head side-to-side, and jogging in place. The Fast Fit Test Protocol uses a known concentration of ultrafine salt particles 0.05 to 1.25 µm in diameter (Particle Generator 8026 with Salt Tablets 80311, TSI Incorporated) dispersed into the ambient air to simultaneously quantify the particle concentration outside of and within the mask via a sampling tube. The primary output from fit testing is the “Fit Factor,” defined as the ratio of ambient particulate concentration

to the concentration inside the mask, taken as an average across all activities prescribed by the test. A fit factor of five means that the face mask reduces particulate concentration by a factor of five. Per OSHA protocol, calibration was performed immediately before mask testing. For each mask fit test, a small puncture hole was made at a single location approximately 1 cm lateral to the nostrils and widened sequentially to accommodate the ¼” sampling tubing for the fit tester equipment. The puncture hole was sealed on the interior and exterior side of the mask using provided fittings. Our results shown in Table 1 demonstrate superior fit testing from the HensNest. Typical face masks with ear loops, whether medical-grade surgical masks, sewn cotton face masks, or nonsewn (e.g., bandana) masks, all demonstrated a fit factor of 1.0, which can be interpreted as offering no protection from airborne particles. When outfitted with a single ply of HEPA grade home furnace filter (Filtrete Ultra Allergen Air Filter, 3M Corp), the HensNest face mask demonstrated a fit factor of 8.0, meaning it reduced particle concentrations by 8x from ambient air conditions. Furthermore, the fit factor scaled with the number of material plies, and using 3-ply of the HEPA filter resulted in a fit factor of 23, although the subject did report more difficulty breathing through the mask with additional layers. The filtration protection of the HensNest does not yet match that of an N95 (fit factor 83 from our testing); however, we are continuously refining mask design and filter choice to compete with this benchmark. Additional studies on more individuals are on-going to further improve the HensNest protection. Mask Type

Fit Factor

Surgical Mask

1

HensNest (HEPA, 1 ply)

8

HensNest (HEPA, 3 ply)

23

N95 Respirator

83

Table 1. Results from Fit Testing

BENCH-TOP AEROSOL ASSESSMENTS While quantitative respirator fit tests are the OSHA standard for filtration efficacy, they are destructive to the filter material of the mask9 and only expose the mask to limited environmental conditions. With the intention of accelerating our design iterations on mask geometry and filter media, our team has developed a benchtop model consisting of a single adult face profile attached to physiologically-accurate nasal and upper airway passages (Figure 2). This approach allows us to decouple mask efficiency during exhalation (to protect others) from mask efficiency during inhalation (to protect the wearer). Furthermore, we can assess downstream impacts to the wearer by approximating the location of aerosol deposition in the nose and lung. With this assay, we can expose the model to a controlled concentration of aerosols and evaluate potentially hazardous materials (including aerosols containing viral derivatives) to fully evaluate the mask efficacy, taking into consideration human breathing patterns and lung humidity. These benchtop studies will add a critical new dimension to face mask evaluations that can evaluate true face mask efficiency by combining both face fit and material filtration elements under realistic breathing simulation.

Studies with the HensNest under varied environmental conditions are on-going, with our current results supporting the superior personal protection reported in our human fit testing.

Figure 2. 3D printed airway model for face mask testing. From left to right: nasal and oropharyngeal airspaces with two aerosol sampling ports, mask generating aerosols through mouth outlet, model wearing the HensNest face mask.

HENSNEST IMPACT IN DELAWARE Given our promising findings to date, we believe the HensNest affords a superior DIY option in personal face masks that improves the fit on the wearer and provides upwards of four to eight times more protection compared to cloth masks. We have begun to distribute our design to high risk individuals and frontline workers throughout the state. In addition to our open source design that is available globally, we have scaled local production to provide HensNest face masks throughout the State of Delaware. Through generous donations and essential organizational partners who have donated over $100k in time and materials to the project, we have manufactured over 30,000 units. Stratasys Corp (Eden Praire, MN) and Negri Bossi North America, Inc, (New Castle, DE) have injection molded the plastic wireframes at no cost and have donated all time and materials necessary to do this. Donate Delaware (501c3 pending) has mobilized its volunteer force to package and distribute these mask kits, with The Newark Partnership and several local grocery store chains already requesting bulk orders. The University of Delaware College of Engineering and Department of Mechanical Engineering has generously covered all personnel costs associated with product development, testing, and project management, which at this point includes a team of approximately ten engineers and designers. Our small volunteer team has assembled distribution packages of the facemask, filter material, elastic bands, and a brief set of assembly instructions. We are prioritizing donations in our local community to high risk individuals (elderly and immunocompromised individuals), home caretakers for high risk individuals, and those working in high exposure risk environments (grocery store workers, delivery persons). At the time of this publication, our masks are being used by frontline workers at Delaware Healthcare Facilities, City of Newark, VCA Animal Hospitals, and several local restaurant and grocery stores.

CONCLUSION As face mask use remains our main weapon in fighting the spread of COVID19, continued efforts are needed to improve existing face mask options, develop testing tools to evaluate their efficacy, and introduce more effective face mask options for use by the general public. Our work in the design, testing, and distribution of the HensNest face mask is having an immediate public health in advancing these fundamental aspects of face mask utility and will continue to have impact throughout the state of Delaware. 37

Technology and Engineering for Recovery

REFERENCES 1. Drossinos, Y., & Stilianakis, N. I. (2020). What aerosol physics tells us about airborne pathogen transmission. Aerosol Science and Technology, 54(6), 639–643. https://doi.org/10.1080/02786826.2020.1751055 2. Leung, N. H. L., Chu, D. K. W., Shiu, E. Y. C., Chan, K. H., McDevitt, J. J., Hau, B. J. P., . . . Cowling, B. J. (2020, May). Respiratory virus shedding in exhaled breath and efficacy of face masks. Nature Medicine, 26(5), 676–680. https://doi.org/10.1038/s41591-020-0843-2 3. Esposito, S., Principi, N., Leung, C. C., & Migliori, G. B. (2020). Universal use of face masks for success against COVID-19: Evidence and implications for prevention policies. The European Respiratory Journal. Retrieved from: https://erj.ersjournals.com/content/early/2020/04/27/13993003.01260-2020 4. Konda, A., Prakash, A., Moss, G. A., Schmoldt, M., Grant, G. D., & Guha, S. (2020, May 26). Aerosol filtration efficiency of common fabrics used in respiratory cloth masks. ACS Nano, 14(5), 6339–6347. https://doi.org/10.1021/acsnano.0c03252 5. Rengasamy, S., Eimer, B., & Shaffer, R. E. (2010, October). Simple respiratory protection—Evaluation of the filtration performance of cloth masks and common fabric materials against 20-1000 nm size particles. The Annals of Occupational Hygiene, 54(7), 789–798. 6. Rengasamy, S., & Eimer, B. C. (2012, July). Nanoparticle

38 Delaware Journal of Public Health – August 2020

penetration through filter media and leakage through face seal interface of N95 filtering facepiece respirators. The Annals of Occupational Hygiene, 56(5), 568–580. 7. Holton, P. M., Tackett, D. L., & Willeke, K. (1987, October). Particle size-dependent leakage and losses of aerosols in respirators. American Industrial Hygiene Association Journal, 48(10), 848–854. https://doi.org/10.1080/15298668791385697 8. Rengasamy, S., Shaffer, R., Williams, B., & Smit, S. (2017, February). A comparison of facemask and respirator filtration test methods. Journal of Occupational and Environmental Hygiene, 14(2), 92–103. https://doi.org/10.1080/15459624.2016.1225157 9. Portacount Respirator Fit Tester. https://tsi.com/focus/portacount-respirator-fit-tester-en/

BE PART OF THE SOLUTION

21DAY

RACIAL EQUITY

CHALLENGE Powered by YWCA Delaware and United Way of Delaware

In the wake of the Black Lives Matter movement, America is engaged in a great national conversation regarding racial equity and social justice. But sometimes the hardest part of joining a conversation is knowing how to get started. The good news is, there are plenty of resources just waiting to empower you. The 21-Day Racial Equity & Social Justice Challenge, powered by United Way of Delaware (UWDE) and YWCA Delaware (YWCA), is your chance to build more effective social justice habits, particularly those dealing with issues of race, power, privilege, and leadership, by joining thousands of other Delawareans in a 21-day journey of self-discovery that you complete online, wherever you are comfortable. Registered participants are prompted with a daily e-mail challenge--such as reading an article, listening to a podcast, or watching a video--and are then encouraged to reflect on that content and to relate the situation to their own lives. Participants discover how racial inequity and social injustice impact our community. The goal is to build new understandings and new connections and in so doing, to begin dismantling systemic racism in Delaware. Emails will begin going out to registered participants on Monday, August 17, and continue (Monday –Friday) through Friday, September 4. UWDE and YWCA will also be facilitating conversation in the 21 Day Racial Equity Challenge Facebook group, where participants can discuss the content and engage with others taking the challenge.

What is the Equity Challenge? • • •

•

The 21-day Racial Equity Challenge is a personal commitment to devote 5-30 minutes a day, for 21 days, to learn about the history and impact of racism in Delaware, and the ways that bias, prejudice, privilege, and oppression show up in our everyday lives. With this awareness and understanding of how racism shapes each of our lived experiences, we can all become part of making positive change in our community. The 21-Day Racial Equity Challenge is an enlightening journey, for everyone – no matter where you come from or how you identify yourself. Along with new perspectives, you’ll receive examples and tools of how you can help undo racism and build a more just and equitable community here in Delaware. While we encourage everyone to share their participation with others and to join the conversation, your employee information will remain both private and confidential.

How Does it Work? • • •

Every morning of the 21-Day Racial Equity Challenge, registered participants will receive an email featuring links to readings, videos, and/or podcasts that are 5-30 minutes long. Participants pick one or more of the “challenges” and begin their journey of discovery. Participants can share reflections and “Aha!” moments using the hashtags #unitedforequity, #equitychampions, and #DEequitychallenge, and can follow the conversation on Facebook, Twitter and Instagram. A private, monitored Facebook group will be available for deeper discussions. A downloadable discussion guide will help participants explore topics with friends, family, and colleagues.

For More Information or to Sign Up For The Challenge, visit https://deracialequitychallenge.org/

DISCLAIMER: Neither UWDE nor YWCA bear responsibility for content created by outside parties, including external links and PDFs. Advertisements related to any video, website, or article that may appear are not endorsed by the UWDE or YWCA.

39

Technology and Engineering for Recovery

Utilizing Partnership Flexibility and Strengths: Key Elements for Driving 3D Printed Face-Shield Production During the COVID-19 Pandemic Tim Mueller, Ph.D. Delaware Innovation Space Tariq Rahman Ph.D. Nemours Biomedical Research, Nemours/Alfred I. duPont Hospital for Children Vicky Funanage Ph.D. Nemours Biomedical Research, Nemours/Alfred I. duPont Hospital for Children

In early March as COVID-19 cases steadily mounted, questions quickly arose about ways to minimize clinician exposure and to maximize PPE availability by manufacturing and reusing PPE in novel ways to address shortages. These questions coupled with the pronounced lack of N95 masks (among other products) challenged convention and forced the development of new strategies to 1) lengthen the usability window of standard N95-type masks, and 2) provide additional levels of protection. Clearly, company closures, physical distancing, and the challenge to the medical community from increased patient loads rapidly made new, unprecedented demands on all daily routines. While the challenges that resulted were great on so many fronts, so too was the tremendous catalyst for driving innovation that helped to unite disparate organizations. The resulting innovation that has occurred has been staggering in both magnitude and pace with each output focused on measurably improving the conditions during the pandemic. The complications in forming cross-sector collaborations are numerous and challenging. While potentially daunting, they enable companies and organizations to leverage invaluable new resources, expertise, and networks that may often create unsurmountable barriers to inhouse-only projects. A collaboration occurred in late March as the COVOD-19 pandemic impact was just beginning to be understood. Dr. Vicky Funanage (Nemours Children’s Health System) contacted Dr. Tim Mueller (DuPont & DE Innovation Space) to discuss a project that Nemours had initiated under the direction of Dr. Tariq Rahman, Director of the Nemours Center for Orthopedic Research and Development, to create face shields using 3D printing. Nemours had been assembling disposable face shields from foam and film. However, these were not as robust and were limited due to issues with cleaning. A few plans for 3D-printed face shields were circulating online, but Nemours did not have the ability to 3D print in volume. The face shields would serve two purposes: 1) to be a direct barrier to the transfer of COVID-19 from patient to health care worker, and 2) they would target the critical shortage of N95 face masks in serving as a physical barrier increasing useful life of a typical N95 mask by preventing contamination. Drs. Funanage and Mueller had worked together previously on new technology exploration and quickly decided to address this urgent challenge and to meet the immediate needs of employees and the community. With all the complexity highlighted above, what made this collaboration successful? There are many contributing factors (e.g., resources, 40 Delaware Journal of Public Health – August 2020

technology, communication), but the most impactful was a clear definition of the goal and the rallying of organizational resources to give resolution the highest priority. The basic design of the face shield was available as a download.1 Working together, the Nemours and DuPont teams made some rapid modifications, and the DuPont material Zytel® 3D1000 was chosen for its durability and strength. The goal was to create a reusable shield that could be distributed to frontline health care workers and cleaned as necessary. Creating the final shield had three critical steps: 1) 3D printing and preparing the headband (DuPont team), 2) Cutting the face shield from rolled thermoplastic polymer resin (Nemours and DuPont) 3) Assembling the three pieces – headband, shield, and elastic band (Nemours). A finished shield prototype was evaluated by Nemours/Alfred I. duPont Hospital and deemed acceptable, so the next challenge was to scale up the process to create 4,000 face shields in a timely fashion. This scale of face shield production would require almost 200 one kilogram spools of filament for the 3D printers, and at approximately two hours of print time required per headband, and a lot of printers. Thankfully, DuPont had resin, filamentmaking expertise, and a 3D printing lab at the Experimental Station that was up to the challenge. A team of scientist and technical support experts was assembled, followed by business, legal, and leadership alignment within 24 hours. This example is one of many that highlights DuPont’s commitment to its core values and collaboration in our hometown community2 during the COVID-19 pandemic. The team discussed creating the shields using injection molding, but the goal was to have immediate impact; to create molds and test them for injection molding would have required 6-8 weeks. Therefore, 3D printing was the preferred choice, and the 12 available printers provided the immediate impact. This temporal requirement was critical as the percentage of Delaware emergency room visits for COVID-19 symptoms peaked on April 12, 2020, which was less than 3 weeks after the onset of the project. After some initial performance and model adjustments, the team started production and averaged around 120 headbands per day at the Experimental Station. The method was duplicated at other DuPont sites to meet local needs in both Michigan and

California, where additional capacity was located. After two months, the Delaware collaboration yielded 3,840 completed reusable face shields that were assembled and distributed to Delaware hospitals and some nursing homes (see Figure 1). As the manufacturing and supply chains for face shields began to catch up with demand, it was decided that it was time to shut down the project; this occurred in early June. Feedback from the medical community has been positive, and an additional 23 rolls of filament were manufactured and have recently been sent to CA to continue the manufacturing locally. Nemours/Alfred I. duPont Hospital for Children has been deploying these shields to clinical personnel, and the face shields have shown to be durable and a lifesaver for the frontline workers.

While it may be some time before we go back to “normal,” there is time to reflect on the innovative environment that fosters ways to leverage skills and resources beyond traditionally defined roles. Existing networks are critical to successful outcomes because the challenges of cross-sector collaborations are only magnified in our world of virtual meetings and long-distance engagements. Critical individuals must serve as connectors to bridge the gaps and create avenues using best practices and must be openly transparent about expectations and capabilities. It is important to present with purpose and create the necessary atmosphere of collaboration to target required outcomes. At the project conclusion, not only did this project help our community, it assisted all of those involved to help transition from surviving to thriving, if only a little bit.

ACKNOWLEDGMENTS Brandon Bouchard, Yanyan Cao, Ben D’Achille, Lynda Johnson, James Mikolajczyk, Donchel Powell, Fazel Zare Bidoky, Alex Grant, Christopher Alcantara, Julian Velazquez

REFERENCES 1. Printers, P. R. U. S. A. (n.d.) Downloadable face shield. Retrieved from: https://www.prusaprinters.org/prints/25857-prusa-protective-faceshield-rc3/files

Figure 1. Completed face shield

2. Dupont. (2020, May). An innovative spirit drives community impact in our hometown community. Retrieved from: https://www.dupont.com/news/innovative-spirit-drives-communityimpact-in-wilmington-delaware.html

41

Technology and Engineering for Recovery

Innovation and Rapid Mobilization Bring New PAPR Hood to Healthcare Workers on the Frontlines The shortage of personal protective equipment (PPE) during the coronavirus (COVID-19) outbreak in the United States had a devastating impact on healthcare workers, people, and companies nationwide. Healthcare workers on the frontlines of the infectious disease were met with despair and fear. Patients and families experiencing the impacts of the virus firsthand were faced with doubt and distress. Medical supply and manufacturing companies were challenged to rise to the occasion with creative solutions and innovative methods for expediting design, engineering, manufacturing, and distributing critical supplies. When met with exceptional demand, one company quickly identified that its current PPE supply and production levels would prohibit them from accommodating the demands of the healthcare market. The company, ILC Dover, a world leader in the innovative design and production of engineered products employing high-performance flexible material, rapidly responded to the issue. It deployed its R&D team to design a new powered air purifying respirator (PAPR) hood for workers on the frontlines of the pandemic and expedited the regulatory approval and manufacturing processes.

NEW PAPR HOOD PROVIDES RAPID RELIEF The new healthcare respirator is called Sentinel EZ BioHood™ and was designed to work with ILC Dover’s Sentinel XL® blower system. The launch of Sentinel EZ BioHood™ to the marketplace was a tremendous demonstration of responsibility, innovation, and rapid mobilization in a time of crisis. The accelerated process was made possible by the National Institute for Occupational Safety and Health (NIOSH), which stepped up in a major way, expediting their typical month-long regulatory approval process to one week for the hood. “The entire process, from design to National Institute for Occupational Safety and Health (NIOSH) approval, took only five weeks. The normal NIOSH approval process alone is typically several months,” explained Doug Durney, PPE Product Line Director at ILC Dover. “Sentinel EZ BioHood™ is manufactured in-house at ILC Dover’s headquarters in Frederica, Delaware, using existing materials and equipment.”

DESIGNING WITH A FUNCTION-FIRST MINDSET In fast-paced, high-pressure hospital scenarios, healthcare workers must be able to easily put on and take off PAPRs without any risk of contamination. ILC Dover engineers designed the new hood in response to noted issues with existing PAPRs in the marketplace and customer requests, including: • Is the hood intuitive and easy to train for first-time use? • Can it be worn by providers with facial hair, head coverings, or varying facial structures? • Does it need to be fit-tested? • Will patients be able to see my face clearly, and vice versa? 42 Delaware Journal of Public Health – August 2020

• Can I wear and use a stethoscope while wearing the PAPR? • Will it be comfortable to wear all day long? With these concerns and questions in mind, engineers designed Sentinel EZ BioHood™ with a function-first mindset. Unlike other PAPR hoods, it offers a host of benefits to wearers: It has a breathable neck cuff, can be worn comfortably for long periods of time, and provides exceptional visibility, enabling healthcare workers to provide effective and continued care to patients. The hood’s unique design makes it intuitive to use, easy to clean, store, and workers do not need to be fit-tested to wear it effectively. Beyond comfort and ease-of-use, the hood offers 100x the protection of an N-95 mask, providing superior respiratory protection to healthcare workers and enabling them to provide continued care. Physician Deborah Wingel, who runs a busy primary care practice commented, “When I learned more about ILC Dover PAPR systems, I felt it would be the perfect solution to our problems with protecting healthcare workers from COVID-19. This product offers us 100x the protection of an N95 mask, and I can engage directly with my patients through the clear shield. It requires certain protocols to put on and remove it, but it is worth it to me. It will give me peace of mind while examining my daily patients.” The main features and benefits of Sentinel EZ BioHood™ include: • Superior Personal Protection Equipment • Comfortable to Wear for Long Periods of Time • No Fit-Testing Required for Wearers • Easy to Store • Wide Range of View A Culture of Response for Critical Industries Beyond personal protection, ILC Dover is a world-leader in the innovative design and production of engineered flexible protective solutions for pharmaceutical and biopharmaceutical, flood protection, personal protection, bulk packaging, and aerospace industries. The company’s visionary solutions have improved efficiency while safeguarding people, product, and infrastructure in hazardous conditions through flexible protective solutions since 1947. Fran DiNuzzo, President and CEO of ILC Dover commented, “ILC Dover is no stranger to creating solutions under immense pressure. The company protected American astronauts on the moon and kept healthcare workers safe during Ebola and SARS outbreaks. In addition to the work we are doing to support healthcare workers, we support pharmaceutical customers developing revolutionary medicines; customers who are focused on food production and supply key products for the critical defense and the security of the nation. Our culture of innovation is designed to respond with highly engineered solutions in each customer’s moment of need.” For more information on Sentinel EZ BioHood™ or ILC Dover, visit ilcdover.com

THURSDAY, OCTOBER 22, 2020 8:30 AM—12:00 PM

Because we’re unable to gather in person at this time, we’re holding this CEU/CME offering via ZOOM.

Please Join Us!

TOPICS:

- UTERUS TRANSPLANTATION - OPTIMIZING THE ORGAN DONATION PROCESS - A PHYSICIAN’S PERSPECTIVE - DCD HEART TRANSPLANTATION - ORGAN DONATION IN THE PEDIATRIC SETTING - DONATION AFTER CIRCULATORY DEATH

FACULTY: Paige Porrett, MD, PhD,

Associate Professor of Surgery Director, VCA Transplantation Comprehensive Transplant Institute University of Alabama at Birmingham

Christopher P. Michetti, MD, FACS, FCCM

Associate Chief, Trauma/Acute Care Surgery Inova Trauma Center, Inova Fairfax Hospital, Professor of Surgery, VCU SOM, Inova Campus

Nader Moazami, MD

Professor of Cardiothoracic Surgery Chief, Division of Heart & Lung Transplantation & Mechanical Circulatory Support Department of Cardiothoracic Surgery New York University (NYU) Langone Health

REGISTER HERE: https://www.surveymonkey.com/r/Oct2020Summit Scan QR Code with QR Reader on Phone 43

Technology and Engineering for Recovery

Overcoming a pandemic: How engineering and modeling techniques are used to inform a health system from preparation to recovery from the COVID-19 pandemic Tze Chiam, Ph.D. and Mia Papas, Ph.D. Value Institute, ChristianaCare

ABSTRACT COVID-19, a novel disease that spreads across the globe, has posed multiple challenges to the healthcare systems around the world. Due to the lack of understanding of the spread and management of this disease, one major challenge is for healthcare systems to anticipate the volumes and needs of patients infected with the disease. In order to provide insights into optimal allocation of resources from preparing ChristianaCare for the pandemic to the recovery of the healthcare system, industrial engineering and predictive modeling approaches are used. This paper discusses five interrelated studies that utilize various techniques to inform multiple aspects of the healthcare system in order to be better prepared for the pandemic.

INTRODUCTION As COVID-19 is a novel disease, the lack of understanding of its pathogenesis resulted in limited insight into its management.1 The rampant spread of COVID-19 resulted in drastic increases of patients seeking medical care, both in the intensive care units as well as in the general medical units. Based on the transmission rates of COVID-19 observed in other countries such as China and Italy, it is believed that the US healthcare system will not be sufficiently equipped to provide care for all patients,2,3 due to the potential shortages of critical hospital resources such as hospital beds and ventilators.

one another,7 it is crucial to examine each component of the healthcare system separately and understand the impact of the pandemic on each subsystem. In order to provide such insights, the Value Institute at ChristianaCare engaged in various investigations utilizing industrial engineering and quantitative modeling approaches. Figure 1 illustrates the inter-connectedness among five investigations conducted toward understanding impact of the pandemic to ChristianaCare.

In order to provide insight into resource requirements for healthcare systems, several research groups and commercial companies have developed models to predict the COVID-19 patient admissions, inpatient census, and ventilator needs.4–6 The models developed rely on an epidemiologic compartmental model known as the SIR model, with compartments representing those individuals who transition through stages of being susceptible (S), infective (I), and recovered (R). While these models provide a foundation for understanding disease spread in general, due to the specificity of this disease to specific communities, there is a need to customize predictions based on characteristics local to the hospital catchment area. As a result, building upon the model by Becker and Chivers,4 we developed a model to predict COVID-19 daily patient admit volumes and daily census based on ChristianaCare catchment area characteristics and to allow for flexibility in specifying model parameters based on local assumptions and needs. As the healthcare system is a complex system with many components having dynamic, non-linear relationships with 44 Delaware Journal of Public Health – August 2020

Figure 1: Inter-connectedness of COVID-related investigations toward a complete understanding of pandemic impact to ChristianaCare

EPIDEMIOLOGIC SIR MODEL FOR PREDICTING COVID-19 INPATIENT VOLUMES As the pandemic began to spread, epidemiologists across the globe began developing models to simulate the spread of the coronavirus in order to not only predict mortality and morbidity, but also the number of hospitalized cases, ICU bed and ventilator needs. Epidemiologists and data scientists worked together to make the coding freely available to scientists around the world. These models utilize a traditional epidemiologic SIR framework that attempts to understand spread through how an individual transitions through three states: a susceptible (S) state to the virus, a infectious state (I), and then finally recovery (R) or death. Such SIR framework has been used to understand other the spread of other diseases such as dengue fever and SARS.8 Given the novel COVID-19 disease, many assumptions needed to be made to compute the probabilities that feed these models. First, every individual starts out as being susceptible since there is no evidence of any natural immunity to this virus. Then assumptions are made regarding rate of infection in the population, which changes as mitigation efforts such as school closures, quarantine, and isolation are introduced. And finally, it assumes that once an individual recovers, the individual is no longer susceptible to contracting the virus again. Given these assumptions and the fact that many of them depend upon the characteristics of the local population, a collaboration between the scientists at the Biden School at the University of Delaware and the Value Institute was started to develop a Delaware-specific predictive model utilizing Python coding language that allows for the customization of the prediction. This customization predicts COVID-19 admissions and hospital census based on the demographics of individuals who reside within the catchment area of ChristianaCare, within the framework of the epidemiologic SIR model. This model was developed to predict the daily admit volumes and census of COVID-19 patients in the ICU and non-ICU units, as well as the number of ventilators needed. Eight-day predictions from this model are shared with hospital administrators daily to inform decisions such as beds and ventilator resources allocation, as well as staffing decisions. As an example, Table 1 demonstrates the predictions produced from the model for the week of June 15, 2020.

DISCRETE-EVENT SIMULATION FOR PREDICTING OVERALL INPATIENT VOLUMES A discrete-event simulation (DES) model using Arena Simulation was developed to predict inpatient ICU and non-ICU census as well as overall ventilator needs by COVID-19 and non-COVID-19 patients across the health system. Due to the flexibility of DES, as well as the improved computing speed and memory in modern computers, DES has been increasingly used in healthcare services for problems of increasing size and complexity.9 Used in many healthcare settings including healthcare systems operations, disease progression modeling, screening modeling, and health behavior modeling,10 discreteevent simulation is a class of computer simulation model that utilizes time distributions and process flow derived from the actual system to mimic its behavior.

6/15 New Admits Total COVID patients CHRISTIANA New Admits Total COVID patients WILMINGTON New Admits Total COVID patients 6/16 New Admits Total COVID patients CHRISTIANA New Admits Total COVID patients WILMINGTON New Admits Total COVID patients 6/17 New Admits Total COVID patients CHRISTIANA New Admits Total COVID patients WILMINGTON New Admits Total COVID patients 6/18 New Admits Total COVID patients CHRISTIANA New Admits Total COVID patients WILMINGTON New Admits Total COVID patients 6/19 New Admits Total COVID patients CHRISTIANA New Admits Total COVID patients WILMINGTON New Admits Total COVID patients 6/20 New Admits Total COVID patients CHRISTIANA New Admits Total COVID patients WILMINGTON New Admits Total COVID patients 6/21 New Admits Total COVID patients CHRISTIANA New Admits Total COVID patients WILMINGTON New Admits Total COVID patients

Bed Needs

ICU Beds

Ventilators

10 (10, 11) 54 (53, 57)

3 (3, 3) 23 (22, 24)

1 (1, 1) 10 (10, 10)

7 36

2 15

1 7

3 18

1 8

0 3

11 (10, 12) 57 (55, 61)

3 (3, 4) 24 (23, 25)

1 (1, 1) 10 (10, 11)

7 38

2 16

1 7

4 19

1 8

0 3

11 (10, 13) 60 (56, 65)

3 (3, 4) 25 (24, 27)

1 (1, 2) 11 (11, 12)

7 40

2 17

1 7

4 20

1 8

0 4

12 (11, 13) 63 (58, 69)

4 (3, 4) 26 (25, 28)

1 (1, 2) 12 (11, 12)

8 42

3 17

1 8

4 21

1 9

0 4

12 (11, 14) 66 (60, 74)

4 (3, 4) 28 (26, 30)

1 (1, 2) 12 (11, 13)

8 44

3 19

1 8

4 22

1 9

0 4

13 (11, 15) 69 (62,78)

4 (3, 5) 29 (27, 32)

2 (1, 2) 13 (12, 14)

9 46

3 19

1 9

4 23

1 10

0 4

14 (12, 16) 73 (64, 83)

4 (3, 5) 31 (28, 34)

2 (1, 2) 13 (12, 15)

9 49

3 21

1 9

5 24

1 10

1 4

Table 1. Predictions of new admissions and hospitalized census for ChristianaCare for the week of June 15, 2020 45

Technology and Engineering for Recovery

In this model, patients are broadly categorized into: • COVID-19 patients requiring ICU care • COVID-19 patients requiring ICU care and ventilators • COVID-19 patients requiring non-ICU care • non-COVID-19 patients requiring ICU care • non-COVID-19 patients requiring ICU care and ventilators • non-COVID-19 patients requiring non-ICU care • non-COVID-19 patients requiring non-ICU care and ventilators Each category of patient has its own stochastic properties such as length-of-stay and percent distribution of patients needing ICU level-of-care and/or ventilators. The stochastics associated with rate of arrivals of each patient category was obtained through retrospective data. The predictions obtained through DES provided hospital administrators an eight-day window for short-term decisionmaking on resources allocation (Table 2). This model continues to be updated and refined as we observe new trends from the previous study and non-COVID patient volumes through statistical analysis.

6/15 CHRISTIANA WILMINGTON 6/16 CHRISTIANA WILMINGTON 6/17 CHRISTIANA WILMINGTON 6/18 CHRISTIANA WILMINGTON 6/19 CHRISTIANA WILMINGTON 6/20 CHRISTIANA WILMINGTON 6/21 CHRISTIANA WILMINGTON

Total Beds

ICU Beds

Total Ventilators

629 (551, 706) 159 (136, 194)

66 (51, 84) 10 (6, 16)

45 (35, 54) 7 (2, 14)

626 (536, 702) 153 (124, 184)

67 (48, 84) 10 (6, 15)

44 (33, 54) 7 (2, 14)

626 (557, 704) 151 (121, 185)

65 (45, 81) 10 (6, 17)

44 (36, 55) 7 (1, 14)

634 (582, 730) 157 (131, 187)

68 (52, 90) 11 (6, 18)

45 (33, 59) 7 (2, 13)

638 (594, 746) 151 (136, 193)

71 (58, 89) 11 (6, 18)

47 (33, 59) 8 (2, 13)

630 (594, 720) 150 (130, 191)

71 (57, 91) 12 (7, 17)

49 (34, 67) 8 (2, 17)

629 (575, 689) 146 (129, 176)

72 (54, 93) 12 (8, 17)

48 (33, 64) 8 (2, 12)

Table 2. Projected Total Patient Census (COVID and non-COVID) for the week of June 15, 2020

of a system from one state to another. The transition between two consecutive states is governed by transition probabilities obtained through analysis of retrospective data.11 As a highly versatile model, the Makov model (and its variance) has been used in a wide range of applications, including cost-effectiveness of a healthcare case management program,12 disease burden,13 and evaluation of economic value of cancer treatment.14 Utilizing the Markov model, incorporating predicted COVID-19 patient volumes from the first study above, we predicted the charges for the COVID-19 inpatients assuming future discharged COVID-19 patients would follow similar transitions and probabilities represented in the Markov model developed. The predicted volumes and charges are shared with the Finance department at ChristianaCare to inform financial decision-making.

ARIMA MODEL FOR PREDICTING AMBULATORY VISIT VOLUMES As many health systems in the country utilize various tools to predict COVID-19 inpatient volumes, there is limited research on tools to predict outpatient volumes. At ChristianaCare, COVID-19 outpatient visits include previously hospitalized patients who recovered from COVID-19, and COVID-19 patients needing healthcare but with conditions not meeting criteria to be hospitalized. Some of these patients can be seen virtually while some need to be seen in-person. In this study, we developed an ARIMA model to predict COVID-19 volumes based on three locations that had the highest retrospective visit volumes. These three ambulatory locations also belong to ChristianaCare. ARIMA (Auto Regressive Integrated Moving Average) model is a class of time-series model that utilizes a pattern of growth, rate of change of growth, as well as noise between consecutive time points based on retrospective data, in order to make predictions.15 It has been used in various industries including healthcare. Some healthcare applications include forecasting volumes of cases of epidemic disease,16,17 and hospital daily outpatient visits.18 As all three locations of interest provide healthcare to nonCOVID-19 patients as well, we developed an ARIMA model to predict non-COVID-19 volumes at the same locations as they will continue to provide care to all patients during the pandemic and beyond. Results from these models are provided weekly to clinical and operational leads for decision-making on resources allocation at the locations of interest.

MARKOV MODEL FOR PREDICTING FINANCIAL IMPACT TO HOSPITAL

HUMAN FACTORS PRINCIPLES FOR HEALTH SYSTEM RECOVERY

Due to the unknown impact on hospital finances by the COVID-19 patient population, we developed a Markov model to capture the changes in patients’ health states and levels of care during their hospital stay, as well as the associated charges with each transition. This model is constructed based on a preliminary dataset consisting of all COVID-19 patients hospitalized at ChristianaCare hospitals.

The COVID-19 pandemic has caused outpatient practices to conduct a majority of outpatient consultation appointments through telemedicine instead of on-site visits. In order to resume on-site visits for select patient populations, there is a need for re-designing workflow and physical spaces to allow for social distancing in order to prevent the spread of COVID-19,19 while optimizing providers’ efficiency. In order to accomplish these goals, human factors engineering principles are needed to re-design the clinical systems.

Consisting of a defined state space with discrete states, a Markov model is a stochastic representation of the probable transitions 46 Delaware Journal of Public Health – August 2020

Human factors engineering is a discipline concerned with how humans interact with elements within their environment or system in order to optimize safety and performance. Healthcare is a complex sociotechnical system with complex interactions between humans, humans and technology, humans and artifacts, and humans and tools. Human factors engineering principles have been increasingly used in healthcare in the recent years20 from infection prevention21 to work system analysis.22 In this on-going study, human factors engineering principles will be applied to areas in the outpatient care center such as check-in areas, waiting rooms, exam rooms, and collaborative clinical workspaces. Principles such as mistake proofing that aim to “make the right thing to do the easy thing to do” and “make the wrong things to do the hard things to do” will be employed to ensure an efficient and safe place for both the caregivers and patients. Heuristic evaluations and usability tests with end-users, where relevant, will be used in case of any new technology needed for the design of clinic recovery.

CONCLUSION The use of engineering and predictive modeling techniques in healthcare has been increasingly popular in recent years. As the COVID-19 pandemic is unprecedented, various challenges to the healthcare system ensue, from planning for capacity and finance prior to the onset of the pandemic at the hospital, to re-designing physical spaces for resuming operations as close to normalcy as possible. In order to overcome such challenges, we leveraged industrial engineering and predictive modeling techniques to provide insight for the healthcare system to make data-driven and evidence-based decisions, including resources allocation in the inpatient and outpatient settings, as well as financial decisions.

LIMITATIONS Due to the lack of data and knowledge on the pathogenesis of COVID-19, as well as the challenge of predicting human behavior that will impact the spread of the disease, such techniques and models are developed and used based on current knowledge available in the literature as well as direct observations in the health system. As more knowledge is gained regarding the disease, including seasonality effects, the models described in this paper will be further refined to continue provide insight for on-going decision support for the health system.

ACKNOWLEDGEMENTS SIR Model Project team: Best, E., Bianco, F., Chiam, T., Dobler, G., Fawcett, M., Liu, W., Hicks, L., Papas, M., Singleton, E., Tunguhan, J., Subedi, K., Zhang, Y. DES Model Project team: Chiam, T., Fawcett, M., Kessler, J., Zupick, N. Markov Model Project team: Chiam, T., Gbadebo, A., Jarrold, K., Jurkovitz, C., Papas, M., Poole, C., Voli, M., Zhang, Z.

ARIMA Model Project team: Bollinger, M., Chiam, T., Harrison, C., Li, R., Jarrold, K., Jurkovitz, C., Kerzner, R., Laughery, J., Ndura, K., Papas, M., Teal., C. Human Factors Project team: Alders, V., Jarrold, K., Mount-Campbell, A.

REFERENCES 1. Cao, W., & Li, T. (2020, May). COVID-19: Towards understanding of pathogenesis. Cell Research, 30(5), 367–369. https://doi.org/10.1038/s41422-020-0327-4 2. Li, R., Rivers, C., Tan, Q., Murray, M. B., Toner, E., & Lipsitch, M. (2020, May 1). estimated demand for us hospital inpatient and intensive care unit beds for patients with COVID-19 based on comparisons with Wuhan and Guangzhou, China. JAMA Network Open, 3(5), e208297. https://doi.org/10.1001/jamanetworkopen.2020.8297 3. The Institute for Health Metrics and Evaluation. (2020). New COVID-19 forecasts: US hospitals could be overwhelmed in the second week of April by demand for ICU beds, and US deaths could total 81,000 by July. Retrieved from: http://www.healthdata.org/news-release/new-covid-19-forecasts-ushospitals-could-be-overwhelmed-second-week-april-demand-icu 4. Becker, M., & Chivers, C. (2020). Announcing CHIME, A tool for COVID-19 capacity planning. Predictive Heathcare. Retrieved from: http://predictivehealthcare.pennmedicine.org/2020/03/14/accouncing-chime.html 5. Abir, M., Nelson, C., Chan, E., Al-Ibrahim, H., Cutter, C., Patel, K., & Bogart, A. (2020). RAND critical care surge response tool: an excel-based model for helping hospitals respond to the COVID-19 crisis. https://doi.org/10.7249/tla164-1 6. Qventus. (2020). Localized COVID-19 model and scenario planner. Retrieved from: https://qventus.com/covid-19-model/ 7. Lipsitz, L. A. (2012, July 18). Understanding health care as a complex system: The foundation for unintended consequences. JAMA, 308(3), 243–244. https://doi.org/10.1001/jama.2012.7551 8. Rodrigues, H. S. (2016). Application of SIR epidemiological model: new trends. Retrieved from: http://arxiv.org/abs/1611.02565 9. Allen, M., Spencer, A., Gibson, A., Matthews, J., Allwood, A., Prosser, S., & Pitt, M. (2015). Right cot, right place, right time: improving the design and organisation of neonatal care networks – a computer simulation study. In Health Services and Delivery Research (Vol. 3, pp. 1–128). https://doi.org/10.3310/hsdr03200 10. Zhang, X. (2018, September 4). Application of discrete event simulation in health care: A systematic review. BMC Health Services Research, 18(1), 687. https://doi.org/10.1186/s12913-018-3456-4 11. Sonnenberg, F. A., & Beck, J. R. (1993, October-December). Markov models in medical decision making: A practical guide. Med Decis Making, 13(4), 322–338. https://doi.org/10.1177/0272989X9301300409 47

Technology and Engineering for Recovery

12. Voorst, H., & Arnold, A. E. R. (2020, June). Cost and health effects of case management compared with outpatient clinic follow-up in a Dutch heart failure cohort. ESC Heart Failure, 7(3), 1136–1144. https://doi.org/10.1002/ehf2.12692

18. Luo, L., Luo, L., Zhang, X., & He, X. (2017, July 10). Hospital daily outpatient visits forecasting using a combinatorial model based on ARIMA and SES models. BMC Health Services Research, 17(1), 469. https://doi.org/10.1186/s12913-017-2407-9

13. Estes, C., Chan, H. L. Y., Chien, R. N., Chuang, W. L., Fung, J., Goh, G. B. B., . . . Razavi, H. (2020, April). Modelling NAFLD disease burden in four Asian regions-2019-2030. Alimentary Pharmacology & Therapeutics, 51(8), 801–811. https://doi.org/10.1111/apt.15673

19. Centers for Disease Control and Prevention. (2020). Social distancing. Retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/social-distancing.html

14. Bullement, A., Cranmer, H. L., & Shields, G. E. (2019, December). A review of recent decision-analytic models used to evaluate the economic value of cancer treatments. Applied Health Economics and Health Policy, 17(6), 771–780. https://doi.org/10.1007/s40258-019-00513-3 15. Abugaber, D. (n.d.). Chapter 23: Using ARIMA for time series analysis. Retrieved from: https://ademos.people.uic.edu/Chapter23.html#1_what_is_arima 16. Pan, Y., Zhang, M., Chen, Z., Zhou, M., & Zhang, Z. (2016). An ARIMA based model for forecasting the patient number of epidemic disease. 2016 13th International Conference on Service Systems and Service Management, ICSSSM 2016. https://doi.org/10.1109/ICSSSM.2016.7538560 17. Tandon, H., Ranjan, P., Chakraborty, T., & Suhag, V. (2020). Coronavirus (COVID-19): ARIMA based time-series analysis to forecast near future. Retrieved from: http://arxiv.org/abs/2004.07859

20. Waterson, P., & Catchpole, K. (2016, July). Human factors in healthcare: Welcome progress, but still scratching the surface. BMJ Quality & Safety, 25(7), 480–484. https://doi.org/10.1136/bmjqs-2015-005074 21. Jacob, J. T., Herwaldt, L. A., & Durso, F. T., & the CDC Prevention Epicenters Program. (2018, August). Preventing healthcare-associated infections through human factors engineering. Current Opinion in Infectious Diseases, 31(4), 353–358. https://doi.org/10.1097/QCO.0000000000000463 22. Heiden, S. M., Holden, R. J., Alder, C. A., Bodke, K., & Boustani, M. (2017, October). Human factors in mental healthcare: A work system analysis of a community-based program for older adults with depression and dementia. Applied Ergonomics, 64, 27–40. https://doi.org/10.1016/j.apergo.2017.05.002

PLEASE SAVE THE DATE

Thursday, October 15, 2020 8:00 AM to 12:15 PM

2020 PrEP Conference Details to follow on this virtual conference at www.delawareprep.org and via email.

48 Delaware Journal of Public Health – August 2020

Delaware HIV Consortium Announces PrEP Navigation The Delaware HIV Consortium, in partnership with the Delaware Division of Public Health and Planned Parenthood of Delaware, announces a statewide HIV Pre- Exposure Prophylaxis (PrEP) Navigation program. The purpose of the program is to help at-risk individuals access PrEP, the once a day medication to help prevent HIV infection and to relieve clinical staff from the sometimes-complex process of accessing the medication. The Consortium’s Navigation program focuses on the four tiers required to gain access PrEP: 1. Intake - Educate the patient about PrEP using CDC information, determine if the patient is at-risk, determine insurance coverage or lack of. 2. Prescriber – Help the patient find a convenient prescriber. A list of prescribing clinicians can be found at www.delawareprep.org. This website also contains helpful toolkits for both prescribers and patients to learn more about PrEP. 3. Labs – One of the greatest barriers to date has been the cost of pre-prescription diagnostic work, which can be subject to deductibles and prohibitive out-of-pocket expenses. Thanks to grant support from the LaffeyMcHugh and WAWA Foundation, the Consortium’s Navigation program will cover these expenses for anyone in the program who has lab work done at our contracted provider (until all funds have been expended). 4. Medication – The Consortium’s Navigator will help the participant enroll in the Gilead copay assistance program or one of several other medication assistance programs available. In addition to these services to help individuals access PrEP, the Navigation program also features follow-up to check on patient adherence and continued use of the medication.

To enroll a patient in the Navigation program, clinicians, case managers, social workers, and HIV prevention staff should refer clients to our website, www.delawarehiv.org, or call 302-654-5471 during regular business hours. 49

Regional Partners

Quarantine bubbles – when done right – limit coronavirus risk and help fight loneliness Melissa Hawkins, Ph.D., M.H.S. Director, Public Health Scholars Program, American University, College of Arts & Sciences Department of Health Studies

After three months of lockdowns, many people in the U.S. and around the world are turning to quarantine bubbles, pandemic pods or quaranteams in an effort to balance the risks of the pandemic with the emotional and social needs of life. I am an epidemiologist and a mother of four, three of whom are teenagers in the throes of their risk-taking years. As the country grapples with how to navigate new risks in the world, my kids and I are doing the same. When done carefully, the research shows that quarantine bubbles can effectively limit the risk of contracting SARS-CoV-2 while allowing people to have much needed social interactions with their friends and family. Quaranteams are founded on the idea that people can interact freely within a group, but that group stays isolated from other people as much as possible.

REDUCE RISK IF YOU CAN’T ELIMINATE IT A quaranteam is a small group of people who form their own social circle to quarantine together – and a perfect example of a harm reduction strategy. Harm reduction is a pragmatic public health concept that explicitly acknowledges that all risk cannot be eliminated, so it encourages the reduction of risk. Harm reduction approaches also take into consideration the intersection of biological, psychological and social factors that influence both health and behavior. For example, abstinence-only education doesn’t work all that well. Safe-sex education, on the other hand, seeks to limit risk, not eliminate it, and is better at reducing teen pregnancy and sexually transmitted infection. Quarantine bubbles are a way to limit the risk of getting or transmitting SARS-CoV-2 while expanding social interaction.

MENTAL HEALTH MATTERS TOO Staying indoors, avoiding all contact with friends or family and having food and groceries delivered would be the best way to limit your risk of catching SARS-CoV-2. But the risks of the pandemic extend beyond the harm from infection. Health encompasses mental as well as physical well-being. The negative mental health impacts of the pandemic are already starting to become evident. A recent survey of U.S. adults found that 13.6% reported symptoms of serious psychological distress, up from 3.9% in 2018. A quarter of people 18 to 29 years old reported serious psychological distress, the highest levels of all ages groups. Many people are experiencing anxiety and depression due to the pandemic or were already living with these challenges. Loneliness certainly doesn’t help. Loneliness and social isolation increase the risk for depression and anxiety and can also lead to increases in the risk for serious physical diseases like coronary heart disease, stroke and premature death. 50 Delaware Journal of Public Health – August 2020

Quaranteams, therefore, are not simply a convenient idea because they let people see their friends and family. Isolation poses serious health risks – both physically and mentally – that social bubbles can help alleviate while improving social well-being and quality of life. Managing a virus is all about managing human interactions, and quarantine bubbles work to insulate groups from risk.

SOCIAL NETWORK THEORY SHOWS THAT QUARANTEAMS WORK Social relationships enhance well-being and mental health but they also act as a vehicle for infection transmission. As people around the world emerge from lockdowns, this is the conundrum: How do we increase social interaction while limiting the risk of spread? A recent study used social network theory – how information spreads among groups of people – and infectious disease models to see if quaranteams would work in this pandemic. To do that, the researchers built computer models of social interactions to measure how the virus spread. They built a model of typical behavior, of typical behavior but with only half the number of interactions and of three different social distancing approaches that also had half the number of interactions as normal. The first social distancing scenario grouped people by characteristics – people would only see people of a similar age, for example. The second scenario grouped people by local communities and limited inter-community interaction. The last scenario limited interactions to small social groups of mixed characteristics from various locations – i.e. quarantine bubbles. These bubbles could have people of all ages and from various neighborhoods, but those people would only interact with each other. All of the social distancing measures reduced the severity of the pandemic and were also better than simply reducing interactions at random, but the quaranteam approach was the most effective at flattening the curve. Compared to no social distancing, quarantine bubbles would delay the peak of infections by 37%, decrease the height of the peak by 60% and result in 30% fewer infected individuals overall. Other countries are starting to incorporate quaranteams in their prevention guidelines now that infection rates are low and contact tracing programs are in place. England is the latest country to announce quaranteam guidance with their support bubble policy. New Zealand implemented a quarantine bubble strategy in early May and it seems to have worked. Additionally, a recent survey of 2,500 adults in England and New Zealand found a high degree of support for the policies and high degree of motivation to comply. People in a quarantine bubble need to agree on how much risk is acceptable and establish a set of rules.

HOW TO BUILD A QUARANTINE BUBBLE To make an effective quaranteam, here’s what you need to do. First, everyone must agree to follow the rules and be honest and open about their actions. Individual behavior can put the whole team at risk and the foundation of a quaranteam is trust. Teams should also talk in advance about what to do if someone breaks the rules or is exposed to an infected person. If someone starts to show symptoms, everyone should agree to self-isolate for 14 days. Second, everyone must decide how much risk is acceptable and establish rules that reflect this decision. For example, some people might feel OK about having a close family member visit but others may not. Our family has agreed that we only visit with friends outside, not inside, and that everyone must wear masks at all times. Finally, people need to actually follow the rules, comply with physical distancing outside of the quaranteam and be forthcoming if they think they may have been exposed. Additionally, communication should be ongoing and dynamic. The realities of the pandemic are changing at a rapid pace and what may be OK one day might be too risky for some the next.

THE RISKS OF JOINING A QUARANTEAM Any increase in social contact is inherently more risky right now. There are two important ideas in particular that a person should consider when thinking about how much risk they’re willing to take.

You must be smart and honest when determining how much risk you’re willing to take and who is affected. The first is asymptomatic spread. Current data suggests that at any given time, anywhere between 20% and 45% of people infected with SARS-CoV-2 are asymptomatic or pre-symptomatic and able to transmit the virus to others. The best way to know if someone is infected or not is to get tested, so some people might consider requiring testing before agreeing to join a quaranteam. The second thing to consider is that consequences of getting sick are not the same for everyone. If you or someone you live with has another health condition – like asthma, diabetes, a heart condition or a compromised immune system – the assessment of risk and reward from a quaranteam should change. The consequences of a high-risk person developing COVID-19 are much more serious. One of the greatest difficulties facing both scientists and the public alike is the uncertainty about this virus and what lies ahead. But some things are known. If individuals are informed and sincere in their quaranteam efforts and follow the regular guidance of social distancing, mask wearing and enthusiastic hand-washing, quaranteams can offer a robust and structured middle ground approach to manage risk while experiencing the joy and benefits of friends and family. These are things we could all benefit from these days, and for now, quaranteams may be the best step forward as we emerge from this pandemic together. This article is republished from The Conversation under a Creative Commons license. Read the original article.

51

Regional Partners

COVID-19 and the Vulnerable Sherry A. Maykrantz, Ph.D., C.H.E.S., Salisbury University Erica H. Weiss, M.P.H., M.S.U.P., Health Communications Consultant Francine Baker, B.S., University of the District of Colombia

Today’s global pandemic (COVID-19) is still with us and it will continue to disrupt the normalcy of life for everyone regardless of race, culture, or socioeconomic status until a treatment or vaccine is found.1 How to manage pandemics is recorded in textbooks and taught in public health classes throughout the world. As public health professionals, we know the history of public health and understand the many advances that have been made over centuries. Yet, the United States reached two million positive cases in just four months, serving as the epicenter of the pandemic leading the world in cases and deaths.1,2 Among those most affected by COVID-19 in the U.S. are older individuals and racial and ethnic minorities. With an understanding of disease transmission, more coordinated efforts from federal, state, and local officials, plus a collaboration between public health entities and local businesses, non-profits, and faith communities, cases can begin to level off.

WHO IS VULNERABLE? People Living in Close Quarters Elderly individuals living in nursing or veteran’s homes, prisoners in jails, and people living in urban centers have been dying of COVID-19 at rates that far surpass statewide rates.3,4 This is because COVID-19 infects people at a greater rate when they live in close proximity and have more exposure to the virus.

People with Underlying Health and Medical Conditions Individuals with heart conditions, diabetes, lung problems, obesity, immune system difficulties, and other chronic conditions die of COVID-19 at the highest rates.5 Poor health conditions are often related to socio-economic conditions, such as limited access to healthy foods, health care, health information or insurance; higher stress or depression; and fewer economic resources.

Essential Workers Healthcare workers, grocery store workers, postal workers, social service providers, and factory workers (all “essential workers”) have become infected with COVID-19 at higher rates from higher exposure to the virus.6 Many of these workers die when they don’t have access to personal protective equipment, have underlying conditions, are older, have high-stress levels, or can’t afford health care. In some states, health care personnel account for up to 20% of known coronavirus cases.7 These vulnerabilities, among others, have led to death from COVID-19 at a rate approximately 2.4 times higher for Black Americans than White Americans,5 with a similarly high rate for people who are over the age of 65 years.2,3 To protect these populations, governments must consider the reasons why COVID-19 is infecting these groups at higher rates and communicate action plans to help. 52 Delaware Journal of Public Health – August 2020

TRUST VS. DISTRUST IN THE GOVERNMENT While public health is built on three pillars: to prevent, protect, and promote health for all, addressing a pandemic is a slipperyslope.8 Throughout this pandemic, local governments and vulnerable populations have been detached from the resources they need to respond with robust testing and tracing programs. However, since public health principles consider many layers of protection, even limited resources can be activated to protect the vulnerable, including simple, evidence-based steps to prevent the spread of disease. When considering a public health plan of action, a balance must be struck between individual rights vs. societal rights (delivering the most good for the most people).8 The White House offers general guidelines to manage this pandemic but suggests that each state should do what is best for their own. The Constitution provides the general framework that guides state “powers,”9 but state governors hold the authority to regulate the health and safety of their residents.8,9 Within state guidelines, locally run agencies are allowed to determine additional guidelines if they have more vulnerable people, based on their resources to actively administer public health services at the local level. Additionally, media and social media services play a major role in generating truthful information and dispersing clear public health guidelines among the disinformation that may persist. With all of these layers, delivering carefully considered public health guidelines can be difficult, especially as the COVID-19 virus knows no boundaries. Even with these complicating factors, all individuals should find trust in the CDC’s guidelines, which remains our most reliable resource. When Federal, State, and local information conflicts, you can find trust in a few basic evidence-based principles that the CDC promotes to prevent the spread of disease: clean your hands often, do not touch your face, wear a mask, and stay at least six feet – if not more – from others, stay home if you can, and avoid crowds.2,8

EMPOWERING LOCALITIES WHEN A COORDINATED APPROACH IS ABSENT Consistent communication and modeling safe behaviors by local community leaders are essential practices for infectious disease management. Local authorities and leaders should do everything they can to communicate the importance of wearing a mask while in public spaces to protect the mask wearer, and more importantly, protect others. Cloth masks have been found to help reduce the spread of coronavirus by people who have COVID-19 but don’t know it.10 Countries that have required facemasks, testing, isolation, and social distancing early in the pandemic have had more success slowing the spread of this coronavirus than we have so far in the United States.11,12 It is critical for local officials to collaborate with trusted local nonprofit service providers, business leaders, faith leaders, and local public health professionals to reach vulnerable populations and offer them accurate information to prevent the spread of COVID-19.

When resources are low, local governments and businesses can put greater emphasis on gain-framed communication messages (what can the community gain?)8 to explain the benefits of wearing a mask, cleaning hands, or keeping proper social distance. This strategy is used to explain how the community can play a role in preventing the spread of this virus, or how preventing the spread of the virus can help the economy and jobs. This is an essential component in public health, with much to be gained.2,4,8 As more local officials and their constituents understand the value of upstream public health interventions,8 the more we can do both individually and together to prevent a potentially disastrous second wave of COVID-19, especially within the vulnerable communities impacted the most during these initial months.

CONCLUSION In ideal cases, localities could rely on a coordinated government response with Federal and State investment in testing and contact tracing. In the absence of that, local authorities should be encouraged and supported in using trust-worthy information from the CDC to create powerful local public health messages based on prevention and selfcare. Being prepared and informed is the best approach to help protect vulnerable populations.13 The Maryland Public Health Association (MdPHA) stepped-in to help local authorities in Maryland with the Public Health Action Alliance (PHAA). This newly created volunteer force coordinates highly skilled public health professionals and students residing in Maryland to aid local community leaders, faith communities, school leaders, and nonprofit organizations. Volunteer public health professionals can help reach vulnerable populations with accurate, culturally appropriate, targeted information and resources; teach local leaders and service providers how to offer evidence-based prevention strategies; support contact tracing efforts; aid in employee training and risk communications. They can offer a wide range of public health services, as needed. As we face a likely “second wave” of this virus, local authorities must communicate, frequently, that seemingly simple public health measures outlined by the CDC help protect the economy and the vulnerable.13 Local authorities can continue to create a network of resources to help their constituents practice preventive measures and limit the spread of COVID-19 or even stop it, even in the face of disinformation and forgetfulness.

4. Henry, B. F. (2020, August). Social distancing and incarceration: Policy and management strategies to reduce COVID-19 transmission and promote health equity through decarceration. Health Educ Behav, 47(4), 536–539. https://doi.org/10.1177/1090198120927318 5. APM Research Lab. (2020, Jun). COVID-19 deaths analyzed by race and ethnicity. Retrieved from: https://www.apmresearchlab.org/covid/deaths-by-race 6. Khullar, D. (2020, Jun). The essential workers filling New York’s coronavirus wards. The New Yorker. Retrieved from: https://www.newyorker.com/science/medical-dispatch/the-essential-workers-filling-new-yorks-coronavirus-wards 7. Spencer, J. (2020, Apr). Why we’re tracking every US health worker who dies from coronavirus. The Guardian. Retrieved from: https://www.theguardian.com/us-news/2020/apr/15/why-weretracking-every-us-health-worker-who-dies-from-coronavirus 8. McCann, A. (2020, May). States with the most vulnerable populations to coronavirus. WalletHub. Retrieved from: https://wallethub.com/edu/states-with-the-most-vulnerable-population-to-coronavirus/73821/ 9. Burris, S., Penn, M., Berman, M. L., & Holiday, T. R. (2018). The new public health law: a transdisciplinary approach to practice and advocacy. New York: Oxford University Press. 10. Centers for Disease Control and Prevention. (2020, May). Use cloth face coverings to help slow spread. Retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/diycloth-face-coverings.html 11. Wang, C., Pan, R., Wan, X., Tan, Y., Xu, L., Ho, C. S., & Ho, R. C. (2020, March 6). Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. International Journal of Environmental Research and Public Health, 17(5), 1729. https://doi.org/10.3390/ijerph17051729 12. Gøtzsche, P. C. (2020, May). The coronavirus pandemic: Can we handle such epidemics better? Journal of the Royal Society of Medicine, 113(5), 171–175. https://doi.org/10.1177/0141076820924587 13. Wingate, M. S., Perry, E. C., Campbell, P. H., David, P., & Weist, E. M. (2007, May-June). Identifying and protecting vulnerable populations in public health emergencies: Addressing gaps in education and training. Public Health Rep, 122(3), 422–426. https://doi.org/10.1177/003335490712200319

REFERENCES 1. Johns Hopkins Coronavirus Resource Center. (2020). COVID-19 Map. Retrieved from https://coronavirus.jhu.edu/map.html 2. Centers for Disease Control and Prevention. (2020). Cases in the U.S. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us. html 3. Yourish, K., & Rebecca, K. K. (2020, May 9). One-third of all U.S. coronavirus deaths are nursing home residents or workers. The New York Times. Retrieved from: https://www.nytimes.com/interactive/2020/05/09/us/coronavirus-cases-nursing-homes-us.html 53

Regional Partners

Short Story Mukta Bain University of Maryland Baltimore County

My friend, Megidelawit (Meg) Yirefu, was preparing for the now apparent pandemic back in January. She had seen images coming from Italy and China about how those countries were dealing with the disruption in their society, and it became apparent to her that the U.S. was going to be heading in the same direction. I still remember laughing at her because she had gone to Costco to buy necessary things in the case that we would be sheltering in place. It was only in a matter of a month that life as we knew it would be altered. Meg is studying to be a pharmacist at the University of Maryland’s School of Pharmacy. She and I have been living in our Paradise communities for five years, located in Baltimore, Maryland. As measures to contain the spread of the virus unfolded, it became apparent to her that community support and neighborhood cohesion would be essential to combat this crisis. She decided the best way to do this would be to create a neighborhood mutual aid task force to assist those in the neighborhood who would be the most vulnerable to COVID-19. Eventually, Governor Larry Hogan broadcast that all state public schools will be closed to prevent spreading the virus, and Meg decided Paradise will need our support. I think most people would agree that in times of crisis, neighbors are by far better situated to respond quicker just by the mere fact of proximity.

She recruited a total of five Paradise residents to be part of the taskforce. The mutual aid task force primarily assists senior adults, those with compromised immune systems and individuals with viral symptoms (fever, cough, shortness of breath) who needed to be self-quarantined as much as possible to reduce the risk of transmission as stated by the Centers for Disease Control (CDC). In our Paradise neighborhood, there are about 2,000 residents, many of them are senior citizens, and we needed to aid them during this pandemic. With the help of our local Staples store, we were able to print and distribute 1200 flyers to the Paradise neighborhood. The team published a letter explaining our work and how we could assist residents with various necessary tasks such as getting groceries, picking up prescriptions, social support through the phone, and small errands. Currently, we have twenty volunteers who have signed up to assist their neighbors. We have requests for help to provide gloves, masks, books and entertainment, and emotional support. As our way of life evolves during this pandemic, the mutual aid task force hopes to continue supporting the Paradise community and hopes to create a stronger, healthier, and more resilient community.

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54 Delaware Journal of Public Health – August 2020

Teaching Public Health During a Pandemic Jody Gan, M.P.H., C.H.E.S. Professorial Lecturer, Department of Health Studies, American University

Back when I was still in a classroom with my Introduction to Public Health students, the novel coronavirus emerging in Wuhan, China, provided a timely event to monitor. It gave us an opportunity to apply many basic public-health principles covered in the broad survey course I teach at American University. Fast forward three months and my students and I find ourselves sheltering in our own homes in different time zones, many grappling with challenges to their family’s financial well-being and their own precarious physical and mental health. Despite the disarray, we maintain our twice-weekly connection to continue our study of public health, a previously amorphous field that has suddenly received greater recognition and new appreciation. I struggle with how to teach this course — do we drop everything and focus on the pandemic exclusively? We could easily spend every precious minute dwelling on the testing failures and the lack of solid denominators that are critical to public health decision-making, the confusing health messages and guidance provided by the federal government, the different ways governors handle social distancing in their states, the unacceptable shortage of critical supplies like personal protective equipment (PPE) and ventilators, and the biggerpicture issues surrounding the widening gaps in our public health infrastructure, to name just a few. But, we resist and carefully strike a balance. I have a responsibility to cover the fundamentals of Health 110, both to prepare my students for subsequent classes in their major and for life in the post-COVID-19 world. As early as this summer, those with a basic understanding of public health concepts may be called upon to fill the army of contact-tracers needed to contain this disease in the U.S. However, I also am aware of my students’ fragility. I am sensitive to their heightened unsteadiness during this monumental shake-up and also want the course, and our time together, to provide a much-needed anchor and diversion from all things COVID-19.

public health is woefully underfunded. We also leave space for discussing local responses to the pandemic in my students’ hometowns and their firsthand observations and personal struggles. For their sake and mine, I try to keep things positive. I resist overwhelming them with a blitz of news articles. Instead, I uncover some silver linings of the pandemic. I hope that they’ll make time to absorb both relatable, positive stories like the college students who are replacing vulnerable older adults who have historically been critical community Meals on Wheels volunteers, as well as the much needed boost to telemedicine and other innovations in health care. Tomorrow is our last class. What can I say to wrap up this most extraordinary semester when more conversations are needed to connect the many remaining dots and bring closure to this three-month period when the field of public health has been in the spotlight? Additionally, I feel a responsibility to acknowledge my students’ uncertainty about all that remains nebulous in their own world — is their summer internship or job offer intact, will their family’s finances permit them to continue studying at a private university, and of course the elephant in the room, will they return to campus this fall or continue learning remotely? I will break through the overwhelming awkwardness by telling them what I do know — that together we are living in a moment that will shape our lives forever, that I am proud of them for staying engaged in the course, and that this semester, the final exam is now “open book” with an opportunity for them to connect course concepts to the COVID-19 pandemic. Because of these unexpected learning opportunities and their innate resilience, I am confident that my students will do well. They must, for the field of public health needs them like never before.

So instead, we remain true to the syllabus that I quickly moved to an online format, covering topics assigned to the second half of the semester—the government’s role in creating health laws and policies, the burden on hospital emergency rooms overwhelmed by treating those without access to primary health care, the history of Medicaid and Medicare, and how health care is delivered in other countries. While soldiering on, we make time to connect frightening reports of the day that build upon earlier concepts covered when we were learning together in a classroom with walls — that coronavirus, like other public health challenges, disproportionately affects people of color as do the disastrous disruptions to work and education; that our esteemed Centers for Disease Control and Prevention (CDC) whose many functions and contributions I proudly shared with the students earlier has been stripped of its role in providing expert guidance; and the evidence so clearly before us that 55

Non-COVID-19 Arcticles

Epidemiology of Hepatitis C in Delaware Deborah Kahal M.D., M.P.H., F.A.A.C.P. Gale H. Rutan, M.D., M.P.H., F.A.A.C.P.

ABSTRACT Infection with hepatitis C virus (HCV) is pervasive throughout the United States of America as we fight the ongoing urban and rural opioid epidemics and rising rates of fatal and non-fatal overdoses. While risk factors for incident HCV abound, our country and the State of Delaware have increasing access to highly effective, short-course, curative HCV treatments. Despite unprecedented medical advances for HCV, as well as expanded HCV screening guidelines calling for universal adult HCV screening and screening during every pregnancy, the epidemiology of HCV at the national and statewide levels continues to be lacking. In attempting to gather, interpret, and present the highest quality available data, we conclude that HCV remains a pressing public and individual health concern for Delawareans, and our nation at large. We urge stakeholders in Delaware to make concerted efforts to fill in the many remaining gaps of HCV epidemiology in order to better inform public health resource allocation, educate the public and healthcare professionals regarding viral hepatitis, and ultimately improve the HCV care continuum, spanning from increasing rates of universal HCV screening and diagnosis to linkage to care to treatment initiation all the way to cure and beyond.

INTRODUCTION Hepatitis C viral infection is increasing in the USA and in Delaware, due in large part to the injection opioid epidemic. HCV is usually asymptomatic in the early stages of disease and, consequently, the majority of individuals infected with HCV are unaware of their status. Although often silent until the development of end stage liver disease, HCV-associated mortality is increasing, especially from liver cancer. Worldwide, liver cancer was the 20th most common cause of death in 2016.1 In 2040, it is projected to advance to the 13th most common cause of death, which translates to almost a 70% increase in the number of years of life lost worldwide from liver cancer.1 Viral hepatitis is one of the primary underlying causes of liver cancer.

PREVALENCE AND INCIDENCE IN THE USA It is difficult to accurately estimate the prevalence of HCV in the USA. Estimates of chronic HCV vary widely, from 3.5 million Americans2 to 2.3 million Americans.3 However, the true prevalence of HCV in the USA remains unknown due to many factors detailed below, and despite blood testing in national sampling studies, the national HCV prevalence is likely to be under-estimated. Many high-risk populations, including homeless, institutionalized, incarcerated and undocumented populations, are not accounted for in many prevalence estimates. Therefore, when taking these populations into account, the actual prevalence may be much higher. More people with opioid use disorder (OUD) are getting infected with HCV, and the recently infected are more likely to infect others in the early stages of their OUD. In March 2020, the US Preventive Services Task Force (USPSTF) changed its recommendation for HCV screening from the 1945-1965 birth cohort to universal screening at least once in their lifetime, aged 18-79 years, and to all pregnant females during each pregnancy (B recommendation).4 The committee notes that acute HCV infection has increased approximately 3.8-fold (2010 to 2017) and especially among young adults aged 20 to 39 years who inject drugs. In a commentary on the new USPSTF recommendations, 56 Delaware Journal of Public Health – August 2020

one expert notes that there are an estimated 44,700 new infections annually, and most of those are likely to be younger individuals associated with injection drug use.5 Zibbell and colleagues calculated the annual incidence of reported cases of acute HCV infection using surveillance data from 2004 to 2014. They also reviewed the percentage of admissions to substance use disorder (SUD) treatment facilities. The annual incidence rate of acute HCV infection increased more than twofold (from 0.3 to 0.7 cases/100,000) during that 10-year period. The increase in HCV trended with admissions for injection drug use (IDU) and for people who inject drugs (PWID).6 Zibbell and colleagues conclude: “Substantial increases in the number of persons with opioid use disorders who inject drugs have the potential to thwart the nation’s efforts to control morbidity and mortality associated with HCV infection, consequently undermining the National Academies of Sciences, Engineering, and Medicine’s national strategy for the elimination of hepatitis B and C. It also challenges the Centers for Disease Control and Prevention’s Viral Hepatitis Strategic Plan for 2016 to 2020, which underscores reductions in HCV infections caused by IDU behaviors as a priority area. Integrated health services that include syringe service programs, medication-assisted treatment, and comprehensive HCV testing and linkage to care and treatment of HCV-infected PWID are essential to reduce prevalence and incidence among the population. Increasing access to curative HCV treatment is also a key component of a comprehensive program” (p. 180).6 While HCV prevalence may be decreasing as a result of deaths from late complications of HCV (liver failure, liver cancer) as well as the successful cure of some people with direct acting antiviral (DAA) medications, the rising number of incident HCV cases may outweigh the deaths and cures. Consequently, the overall national prevalence of HCV may be increasing. For example, in the laboratory-derived Mapping Hep C database7 (described

more fully below), “the number of RNA-positive HCV patients increased from 200,066 patients in 2013 to 469,550 in 2016” (p. 1087). This rise in reported HCV represents more than a doubling of cases in three years. However, it is unknown whether that represents increased prevalence and incidence versus improved disease detection from more extensive screening, or both. Deaths from HCV exceed the total number of combined deaths from 60 other infectious diseases, including HIV, pneumonia, and tuberculosis.3 Furthermore, as less than 50% of individuals diagnosed with HCV are linked to care, HCV incidence may be outpacing both cure and death from end-stage disease. Linkage to HCV care may even be in the single digits.8 At five federally qualified health clinics (FQHCs) in Philadelphia, although over 90% of infected individuals received test results showing HCV, only 15% of individuals started therapy for HCV.9

PREVALENCE IN DELAWARE PER NATIONAL HEALTH AND NUTRITION EXAMINATION SURVEY (NHANES) The National Health and Nutrition Examination Survey (NHANES) utilized a statistical model to calculate HCV prevalence as well as to assess HCV mortality and narcotic

overdose mortality from the National Vital Statistics System death records from 1999 to 2016.10 The study authors determined the prevalence estimates of current HCV RNA at the state level. The NHANES sampling frame includes only noninstitutionalized populations, thereby underestimating the prevalence. Findings include a tripling of HCV incidence in recent years due primarily to illicit drug injection and needle sharing during this opioid crisis. They also calculated that subpopulations that are unrepresented in the NHANES-based estimates (incarceration, unsheltered homelessness) account for about 11% of HCV positive RNA prevalence. This assumption of an 11% positive RNA prevalence for chronic HCV was based on literature review of studies in these homeless and incarcerated populations.11 Rosenberg and coauthors10 initially used each state’s prevalence of positive RNA, but then they combined it with cause-specific death rates from HCV infection as well as narcotic overdose to try to ascertain a true prevalence. They also used the American Community Survey from 2012 to 2016 to estimate population denominators for the non-institutionalized population statewide. State-specific HCV mortality on death certificates was reviewed and added to the database, as well as narcotic overdose mortality, the latter of which is an outcome known to correlate with HCV infection.

Figure 1. Change in age-adjusted drug overdose death rates, by state: United States, 2017 and 201813 57

Non-COVID-19 Arcticles

The rate of narcotic overdose mortality in Delaware is increasing. Data from the CDC show that the overdose death rate in Delaware was higher in 2018 than in 2017.12 While there were 14 states where the death rate from overdoses was lower in 2018 than in 2017, Delaware was one of 5 states trending in the opposite direction: more deaths.12 Figure 1 visually represents the problem. In Delaware, using a denominator of 719,400 for the 2016 adult population, the sampling frame from NHANES alone estimated that there are 5600 individuals with positive HCV RNA, (95% confidence intervals 4800-6500). With additional populations not included in the NHANES sampling frame, the number of infected individuals in Delaware increased to 6300 individuals, for a prevalence of 0.86%.10 Bradley et al. also analyzed NHANES laboratory data and found that persons born between 1945 to1965 had the highest prevalence of HCV infection, but that new infections are increasing among the young due to intravenous drug use.13 The prevalence (per 100) and prevalence ratios (PRs in reference to > 1969 cohort) in Delaware per Bradley’s calculations can be viewed in Table 1. The authors conclude that new HCV infections have increased especially among young people who inject drugs and that treating HCV can prevent new transmissions. < 1945 cohort

1945-1969 cohort

>1969 cohort

Prevalence

0.14

1.40

0.55

PRs

0.25

2.54

1.08

Table 1. Prevalence (per 100) of HCV in Delaware per Bradley’s Calculations

PREVALENCE AND ASSOCIATED MORTALITY IN USA AND DELAWARE PER DELAWARE DEPARTMENT OF HEALTH REPORTS AND CENTERS FOR DISEASE CONTROL DATA Although HCV is a reportable infectious disease, it is most certainly underreported due to a variety of factors. The CDC estimates that there are approximately 14 times more acute HCV infections than are reported,14 and some suggest that figure may be an underestimate.13 State-level data of new cases of confirmed chronic HCV are not available for DE on the CDC website. However, there were 50 cases where HCV was listed as the underlying cause of death on death certificates in DE in 2017.13 Thus, a crude estimate of the overall death rate for HCV as the underlying cause of death in DE is 5.3 per 100,000).15 In 2015, 1200 cases of HCV were reported to the DE Dept. of Health (DOH). In 2016, there were 2592 cases of HCV reported.16 Presuming that the cases for 2016 were new cases not previously reported, the calculated incidence rate is 272 cases per 100,000 individuals (0.027%) in DE.16 The numbers of cases in Delaware cannot be compared to national data due to administrative differences in reporting, as the Delaware registry combines both incident and prevalent cases of HCV. Furthermore, the challenge of incomplete data ascertainment persists. According to the Center for Community Research report on HCV Epidemiological Profile prepared by the University of Delaware 58 Delaware Journal of Public Health – August 2020

for the Division of Public Health in December, 2017, there is a bimodal distribution of new HCV cases reported in 2016.16 The highest number of cases was in those over 51 years of age (932 cases), followed by those 20-29 years of age (675 cases) and then those 30-39 years of age (600 cases).16 More than half (52%) of the reported HCV cases in 2016 involve individuals living in New Castle County. However, the incidence rate is higher in Sussex (315.1 per 100,000) and Kent Counties (315.7 per 100,000). The age cohort with the highest rate of HCV is among those 2029 years of age (527.5 per 100,000), although about 1/3 of the individuals reported to the DOH are over 51 years of age.16

PREVALENCE AND ASSOCIATED MORTALITY IN DELAWARE PER HEPVU MAP The HepVu website,3 sponsored by Emory University, combines data from several surveillance studies and presents state-specific data in a clickable map to view HCV prevalence and mortality statistics with further stratification by age, race, sex, and several other demographic factors. This website also visually collates the relationship between HCV and the opioid epidemic. Between 2013 and 2016 in Delaware, there were an estimated 860 of every 100,000 people living with HCV (0.86%) with 6300 unique individuals estimated to be living with HCV.17 During this time, narcotic overdose mortality was 25.78 for every 100,000 people (0.026%). In 2017 in Delaware, there were a total of 49 reported HCV-related deaths, or approximately 5 per 100,000 people (0.005%). At this time, the statewide opioid prescription rate was 68.3 per 100 people.17 Prevalence and Associated Mortality in USA and Delaware per Mapping Hep C Database A commercial web-based site, sponsored by Abbvie Pharmaceuticals, combines two large commercial laboratory datasets of HCV antibody and RNA testing and other laboratory characteristics from 2013-2017. The site lists results by state.18 For Delaware, in 2017 there were: • 36,939 individuals screened with HCV Antibody (Ab) test with 2,916 positive test results. • Extrapolated data estimate that in Delaware there may be as many as 11,490 individuals with a positive HCV Antibody test as of 2017. However, the Antibody test proves exposure only, not active infection. The same map shows a total of 1,913 individuals with detectable HCV RNA, with an extrapolated estimate of 6,732 RNA positive individuals (actively infected) in Delaware. Upon closer review of the Mapping Hep C database, amongst the individuals with detectable HCV RNA, the vast majority (79.4%) were infected with genotype 1 followed by genotype 2 (10.3%), 3 (9.5%), 4 (0.6%) then 5 and 6 combined (0.2%). For 1,749 individuals in Delaware who also had laboratory fibrosis (F) scores available, the distribution (in percentage) is as follows: F0-F1 (51.6%), F2 (21.3%), F3 (9.8%), and F4 (17.3%). This distribution, which is skewed towards the lower end of fibrosis, is important. Per current guidelines, the vast majority can be treated without associated imaging or procedures before initiating drug therapy or after drug therapy for later surveillance.19

• In 2017 there were 428 individuals who were treated (actual data), regardless of the type of therapy. However, there were 47 less individuals treated in 2017 compared to 2016, representing a decrease of 9.9%.18 • Using modeling from the Mapping Hep C site, the year of achieving all World Health Organization (WHO) targets of incidence, diagnosis, and treatment in Delaware would not be until 2038. In Delaware, according to the modeling by Abbvie, 733 infected individuals need to be treated annually to achieve WHO treatment target date of 2030.18 This database has several limitations. Firstly, the database consists solely of patients who have given informed consent (for data sharing). It is not known whether those individuals who have heightened privacy regulations by virtue of Code of Federal Regulation (CFR) 38 or 42 status (Veterans Affairs and alcohol and drug treatment programs, respectively) or incarcerated individuals are included in these data sets. Assuming that these classes of individuals are not included in the above data, the extrapolated estimate of 6,732 infected individuals in Delaware in 2017 may still be a conservative number, considering the higher prevalence of HCV among these unique subpopulations. Moreover, the database only includes datasets derived from two regional, large laboratories, further leading to a likely underrepresentation of the true HCV prevalence in Delaware secondary to incomplete data ascertainment.

PERINATAL TRANSMISSION OF HCV The number of infected individuals may be increasing with both horizontal as well as vertical transmission as more women with OUD are having children born with HCV infection. Between 2009 to 2014, maternal HCV infections nearly doubled among reporting states in the United States.20 In Delaware, the rate of HCV among neonates per 1,000 live births in 2014 was 2.6 – 5.0.20 Overall trends for the US show that the HCV infection rate increased in neonates at delivery from 0.8 per 1,000 live births in 2000 to 4.1 in 2015, but among women with OUD, there were increases from 87.4 to 216.9 among 1,000 live births.21 That represents a 148% increase of HCV infection among women with OUD. Yet, these figures may underestimate the prevalence of OUD and HCV infection due to lack of screening and stigma, among other factors. According to the University of Delaware Hepatitis C Epidemiologic Profile report (Table 39; p. 34), among those 0-9 years of age, the medical claims for Medicaid recipients with HCV diagnoses rose from 20 in 2009 to 51 in 2015; which is about a 2.5 times increase in Medicaid claims in 6 years in the youngest cohort in Delaware.16

MORBIDITY AND MORTALITY FROM HCV AND ITS CONSEQUENCES As stated in the introduction, HCV-associated mortality, especially from liver cancer, is increasing. Rosenberg et al. note that about half of those with chronic HCV develop progressive liver disease, which may include cirrhosis and liver cancer.10 According to the Delaware Cancer Registry, which was started in 1996, liver cancer (hepatocellular cancer) nearly doubled from 2006 to 2015 with 46 cases in 2006 and 74 cases in 2015.16 Thus, these data support the increasing prevalence of manifestations of end stage HCV and the advancing stages of disease without treatment.

OTHER DEMOGRAPHIC FACTORS AND LINKAGE TO HCV CARE What are some of the other demographic characteristics of individuals with HCV in Delaware that may impact access to HCV care and treatment? According to the University of Delaware Hepatitis C Epidemiologic Profile report,16 “patients with HCV are disproportionately likely to be uninsured or Medicaid eligible” (p. 6). Moreover, HCV prevalence is inversely related to income. A report examining the burden of HCV in commercial and managed Medicaid populations (not necessarily in Delaware) found that the overall prevalence rate of HCV is 7.5 times higher in the Medicaid population compared to a commercially insured population.22 If we can assume that those with Medicaid are 7.5 times higher to have HCV than the commercially insured population,22 then the HCV-infected population in Delaware definitely lacks linkage to care and treatment. Few HCV-infected Delawareans have received HCV treatment due to a myriad of contributing factors, one of which may be insurance as mentioned above. Additionally, low levels of HCV treatment in Delaware may be, in part, due to administrative restrictions, as the state did not expand DAA treatment access through the complete elimination of fibrosis restrictions until January 2018.23 Additional historical restrictions including but not limited to the provision that only sub-specialists such as hepatologists or infectious diseases specialists could prescribe DAA therapy and the requirement for patients to provide a recent and/or negative urine drug screen were further barriers in the prescribing and approval of HCV treatment. Limited data on Delaware Medicaid clients receiving HCV prescriptions between 2012-2015 (p. 35; Table 41) demonstrate that prior to 2015 most infected individuals were treated with ribavirin and interferon, whereas the DAAs started to be more widely prescribed in 2015.16 From 2012 to 2015 there were a total of 485 prescriptions for HCV treatment in Delaware (Table 2).16 In 2015, DAAs were first used, probably leading to the increase in therapy that year. There was no searchable information in DE available after 2015 for Medicaid data, however. Stigma is one of the main causes that HCV-infected individuals do not seek care and why linkage to care is so abysmal.24 The experts on the National Academy of Sciences panel conclude: Year

Number with Prescriptions

2012

171

2013

100

2014

69

2015

145

Table 2. Prescriptions for HCV Treatment in Delaware

“Stigma remains difficult to overcome and was raised by [OUD] programs as a perennial problem, as was the potential for additional stigma among people who use drugs and have also been diagnosed with an infectious disease… Stigma … may keep someone from seeking care“ (p. S-10).24 In addition, other factors contribute to a failure of treatment of these infected individuals. Talal et al. note that not only stigma but also the “chaotic lifestyles” that persons with SUD lead may preclude treatment of HCV in a traditional setting.25 59

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They also note that 68-80% of HCV infections in developed countries happen in those with SUD.25 The logical conclusion is to treat these infected individuals where they are located: bring the “medical home” of HCV treatment to them: specifically, in medication assisted treatment (MAT) programs. The participants of the above-referenced National Academy of Sciences monograph24 further conclude: “…there is a great deal to be accomplished at the intersection of opioid use disorder and infectious diseases at many points in the health care system, as well as across society more broadly. It is essential to dismantle the barriers impeding prevention and treatment. Patients, families, and society writ large cannot afford delay, and it is the committee’s hope that the strategies outlined here may alleviate the burden of these dual epidemics” (p. S-15).24

CONCLUSION There have been many different databases and methodologies for estimating the prevalence of HCV in the USA and Delaware. Regarding Delaware, the major databases and methodologies include: NHANES, HepVu, Mapping Hep C, and reported cases to DE DOH. NHANES and HepVu estimate 6300 HCV cases from 2013 to 2016. Mapping Hep C estimates over 6700 cases in 2017, but there were 2592 HCV cases reported to DE DOH in 2016 alone. HCV estimates range from 6300 to over 6700 individuals with all estimates suffering from incomplete data ascertainment leading to the under-reporting of statewide HCV incidence and prevalence. Using the calculations of the Mapping Hep C database, 733 infected individuals in Delaware need to be treated annually to achieve the WHO treatment target date of 2030 for HCV elimination. Yet, not enough Delawareans are receiving treatment. Moreover, even with recent guideline updates to support universal adult HCV screening there is inadequate screening and diagnosis of HCV cases and an HCV care continuum in dire need of improvement. Nevertheless, screening, diagnosis and linkage to care, administrative requirements for prior authorization, stigma, the “chaotic lifestyle” of the HCV-infected individual, and other non-quantifiable factors all lead to under-treatment of HCV in the Delaware population. Since HCV is co-epidemic with the opioid epidemic, it makes sense to treat both OUD and HCV simultaneously at the same site: either at the opioid treatment program (with methadone, buprenorphine/naloxone, or longacting naltrexone) or in primary care clinic (with buprenorphine/ naloxone, or long-acting naltrexone). The provision of HCV care at the client’s pre-existing medical home aids in diminishing stigma and potential barriers to HCV care. Clearly, there is an urgent need to co-locate OUD treatment programs and infectious diseases treatment, especially HCV treatment. Treat both. And treat them now.

REFERENCES 1. Foreman, K. J., Marquez, N., Dolgert, A., Fukutaki, K., Fullman, N., McGaughey, M., . . . Murray, C. J. L. (2018, November 10). Forecasting life expectancy, years of life lost, and all-cause and cause-specific mortality for 250 causes of death: Reference and alternative scenarios for 2016-40 for 195 countries and territories. Lancet, 392(10159), 2052–2090. https://doi.org/10.1016/S0140-6736(18)31694-5 60 Delaware Journal of Public Health – August 2020

2. Liang, T. J., & Ward, J. W. (2018, March 29). Hepatitis C in injection-drug users— A hidden danger of the opioid epidemic. The New England Journal of Medicine, 378(13), 1169–1171. https://doi.org/10.1056/NEJMp1716871 3. About HepVu. (2020). Retrieved from: https://hepvu.org/about/ 4. Owens, D. K., Davidson, K. W., Krist, A. H., Barry, M. J., Cabana, M., Caughey, A. B., . . . Wong, J. B., & the US Preventive Services Task Force. (2020, March 2). Screening for hepatitis C virus infection in adolescents and adults. JAMA, 323(10), 970–975. Retrieved from: https://jamanetwork.com/journals/jama/fullarticle/2762186 https://doi.org/10.1001/jama.2020.1123 5. Rosenberg, E. S., & Barocas, J. A. (2020, March 2). USPSTF’s hepatitis C screening recommendation—A necessary step to tackling an evolving epidemic. JAMA Network Open, 3(3), e200538. https://doi.org/10.1001/jamanetworkopen.2020.0538 6. Zibbell, J. E., Asher, A. K., Patel, R. C., Kupronis, B., Iqbal, K., Ward, J. W., & Holtzman, D. (2018, February). Increases in acute hepatitis C virus infection related to a growing opioid epidemic and associated injection drug use, United States, 2004 to 2014. American Journal of Public Health, 108(2), 175–181. Retrieved from: https://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.2017.304132 https://doi.org/10.2105/AJPH.2017.304132 7. Chirikov, V. V., Marx, S. E., Manthena, S. R., Strezewski, J. P., & Saab, S. (2018, July). Development of a comprehensive dataset of hepatitis C patients and examination of disease epidemiology in the United States, 2013-2016. Advances in Therapy, 35(7), 1087–1102. https://doi.org/10.1007/s12325-018-0721-1 8. Calner, P., Sperring, H., Ruiz-Mercado, G., Miller, N. S., Andry, C., Battisti, L., . . . Schechter-Perkins, E. M. (2019, July 10). HCV screening, linkage to care, and treatment patterns at different sites across one academic medical center. PLoS One, 14(7), e0218388. https://doi.org/10.1371/journal.pone.0218388 9. Coyle, C., Moorman, A. C., Bartholomew, T., Klein, G., Kwakwa, H., Mehta, S. H., & Holtzman, D. (2019, August). The hepatitis C virus care continuum: Linkage to hepatitis C virus care and treatment among patients at an urban health network, Philadelphia, PA. Hepatology (Baltimore, Md.), 70(2), 476–486. https://doi.org/10.1002/hep.30501 10. Rosenberg, E. S., Rosenthal, E. M., Hall, E. W., Barker, L., Hofmeister, M. G., Sullivan, P. S., . . . Ryerson, A. B. (2018, December 7). Prevalence of hepatitis C virus infection in US states and the District of Columbia, 2013 to 2016. JAMA Network Open, 1(8), e186371. Retrieved from: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2719137 https://doi.org/10.1001/jamanetworkopen.2018.6371 11. Hofmeister, M. G., Rosenthal, E. M., Barker, L. K., Rosenberg, E. S., Barranco, M. A., Hall, E. W., . . . Ryerson, A. B. (2019, March). Estimating prevalence of hepatitis C virus infection in the United States, 2013-2016. Hepatology (Baltimore, Md.), 69(3), 1020–1031. Retrieved from: http://www.natap.org/2019/HCV/Hofmeister_et_al-2019-Hepatology.pdf https://doi.org/10.1002/hep.30297 12. Hedegaard, H., Minino, A. M., & Warner, M. (2020) Drug overdose deaths in the United States, 1999–2018. NCHS Data Brief No. 356. Centers for Disease Control and Prevention. National Center for Health Statistics. Retrieved from: https://www.cdc.gov/nchs/data/databriefs/db356-h.pdf

13. Bradley, H., Hall, E. W., Rosenthal, E. M., Sullivan, P. S., Ryerson, A. B., & Rosenberg, E. S. (2020). Hepatitis C virus prevalence in 50 U.S. states and D.C. by sex, birth cohort, and race: 2013-2016. Hepatology Communications, 4(3), 355-370. Retrieved from: https://aasldpubs.onlinelibrary.wiley.com/doi/10.1002/hep4.1457 14. Centers for Disease Control. Viral Hepatitis. Retrieved from: https://www.cdc.gov/hepatitis/statistics/2017surveillance/ TablesFigures-HepC.htm 15. State of Delaware. (2020). Hepatitis C: Metrics. Retrieved from: https://myhealthycommunity.dhss.delaware.gov/locations/state/infectious-disease/hepatitis-c 16. University of Delaware. (2017). Hepatitis C epidemiologic profile. (2017). Retrieved from: https://www.dhss.delaware.gov/dph/dpc/files/dehcvepi2017.pdf 17. HepVu. (2020). Retrieved from: https://map.hepvu.org/map 18. Mapping Hep, C. (2020) Retrieved from: https://mappinghepc.com 19. American Association for the Study of Liver Diseases, Infectious Diseases Society of America. (2019). HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis C. Retrieved from: https://www.hcvguidelines.org/sites/default/files/full-guidancepdf/200206_HCVGuidance_November_06_2019_a.pdf 20. Patrick, S. W., Bauer, A. M., Warren, M. D., Jones, T. F., & Wester, C. (2017). Hepatitis C virus infection among women

giving birth — Tennessee and United States, 2009–2014. MMWR Weekly, 66 (18), 470-473. Retrieved from: https://www.cdc.gov/mmwr/volumes/66/wr/mm6618a3.htm 21. Ko, J. Y., Haight, S. C., Schillie, S. F., Bohm, M. K., & Dietz, P. M. (2019, October 4). National trends in hepatitis C infection by opioid use disorder status among pregnant women at delivery hospitalization— United States, 2000–2015. MMWR Morb Mortal Wkly Rep, 68(39), 833–838. Retrieved from: https://www.cdc.gov/mmwr/volumes/68/wr/mm6839a1.htm https://doi.org/10.15585/mmwr.mm6839a1 22. Johnson, R. L., Blumen, H. E., & Ferro, C. (2015). The burden of hepatitis C virus disease in commercial and managed Medicaid populations. Milliman. Retrieved from: http://careers.milliman.com/uploadedFiles/insight/2015/milliman-hcv-burden.pdf 23. Hepatitis, C. State of Medicaid Access. (2020). Retrieved from: https://stateofhepc.org/wp-content/themes/infinite-child/reports/ HCV_Report_Delaware.pdf 24. National Academies of Sciences, Engineering, and Medicine. (2020). Opportunities to improve opioid use disorder and infectious disease services: Integrating responses to a dual epidemic. Washington, DC: The National Academies Press. Retrieved from: https://doi.org/10.17226/25626 25. Talal, A.H., Thomas, D.L., Reynolds, J.L., & Khalsa, J.H. (2017). Toward optimal control of hepatitis C virus infection in persons with substance use disorders. Ann Intern Med, 166(12), 897-898. https://doi.org/10.7326/M16-2887 Accessed 3/4/2020.

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Delaware’s HPV vaccination rates rise with evidence-based intervention implementation Lisa Gruss, M.S., M.B.A. Quality Insights Lori Saul, R.N., B.S.N. Quality Insights Sarah Toborowski, B.A. Quality Insights

BACKGROUND The Human Papilloma Virus (HPV) is a major factor in cancer incidence, as it causes cancers of the cervix, anus, vulva, vagina, penis, and oropharynx.1 More than 90% of cervical and anal cancers are caused by HPV.2,3 In addition, HPV causes 70% of vaginal/vulvar cancers, 63% of penile cancers, and 70% of oropharyngeal cancers.3 Of the 34,800 HPV-related cancer cases that occur annually in the United States, an estimated 90% could have been prevented with HPV vaccination.2 Nationally and locally, the Centers for Disease Control and Prevention (CDC) and public health agencies are actively engaged in vaccinating adolescents by age 13 to align with recommendations and reporting metrics. Yet in the United States and Delaware, HPV vaccination rates are suboptimal compared to other adolescent vaccination coverage rates. According to data from the 2017 and 2018 National Immunization Survey-Teen (NIS-Teen), Delaware’s ≥1HPV4 coverage rate decreased from 75.3% in 2017, to 73.9% in 2018.5 According to 2018 NIS-Teen, the vaccine coverage rates in Delaware for three recommended adolescent vaccinations are: ≥ 1Tdap: 89.1%, ≥ 1 MenACWY: 85.9%, ≥ 1HPV: 73.9%, and HPV up-to-date (UTD),4 58.4% with a 95% confidence interval.6 To identify effective strategies to increase HPV vaccination rates, the Delaware Department of Health and Social Services, Division of Public Health (DPH) Immunization Program collaborated with the Delaware Cancer Control Program to explore unique ways of creating awareness of the importance of HPV immunization among providers. Specifically, this project focused on providing evidence-based education, Immunization Information System (IIS) support, and technical assistance for local providers.

INTERVENTION The Immunization Program contracted with Quality Insights, a non-profit organization with a mission to utilize data and community solutions to improve healthcare quality.7 Quality Insights developed an evidence-based curriculum founded on the CDC’s “You are the Key to HPV Cancer Prevention” campaign, utilizing both CDC and DPH resources. In addition, Quality Insights conducted a literature review on topics including the benefits of vaccinating at an early age, HPV cancers, long term outcomes and safety, implementation of evidence-based interventions, and utilization of the IIS – known as DelVAX – to improve vaccination rates. The National HPV Vaccination Roundtable action guides and DelVAX user guides were additional resources. 62 Delaware Journal of Public Health – August 2020

James Talbott, M.P.A. Delaware Department of Health and Social Services, Division of Public Health, Immunization Program Paul Hess Delaware Department of Health and Social Services, Division of Public Health, Immunization Program

Quality Insights provided education and training for 30 Vaccines for Children (VFC) practices, whose up-to-date (UTD) HPV coverage rate was below 50%. The educational activity sessions ranged in size from small groups to one-onone training (academic detailing) with providers. DelVAX data was used to create a baseline and to facilitate pre-post education comparison. The retrospective “pre” consisted of the initial coverage assessment, followed by an intervention period of 6 and 12 months. During the intervention period, Quality Insights shared multiple evidence-based workflow modifications with the practices and assisted them in choosing and implementing these into their workflow. Practices utilized a variety of quality improvement strategies categorized as patient-focused, provider-focused, and practice workflow.

Patient-Focused Quality Improvement Strategies to Increase HPV Vaccination Rates, Delaware, 2018-2020 • Patient postcard reminder campaign* • Reminder magnets* • Early education of parents** • Patient/parent reminders for a nurse visit** • Use of resources for patients/parents (patient-facing handouts, posters, videos)** * Services provided by Quality Insights ** Area in which Quality Insights can assist

Provider-Focused Quality Improvement Strategies to Increase HPV Vaccination Rates, Delaware, 2018-2020 • Academic detailing for providers* • HPV education for staff* • Strong provider vaccination recommendation/ bundling** • Focusing conversation on HPV vaccine is cancer prevention** • Provider engagement** • Clinical decision support – provider reminders** • Use of resources for staff (National HPV Vaccination Roundtable Action Guides) * Services provided by Quality Insights ** Area in which Quality Insights can assist

Practice Workflow, Quality Improvement Strategies to Increase HPV Vaccination Rates, Delaware, 2018-2020 • Data reconciliation* • Pocket cards for providers* • Scheduling next immunization appointment/nurse visit at checkout** • Leveraging the IIS (data cleanup, patient inactivation, adding historical records, reports)** • Assigning an HPV campaign champion** • Standing orders** • Patient/parent and staff engagement (t-shirts, small giveaways)** * Services provided by Quality Insights ** Area in which Quality Insights can assist

Quality Insights documented the intervention implementation to improve and sustain rates. Ongoing technical assistance was provided, along with DelVAX support (including assistance with data reconciliation, cleanup and reports), workflow modification implementation, post-training access to HPV-related webinars and podcasts, targeted data-driven social media posts, and a dedicated HPV-immunization webpage. During the post-training phase, a second identical assessment was conducted to evaluate provider vaccination rates.

RESULTS A descriptive analysis was used for this preliminary assessment of outcomes. These efforts yielded an average increase in DelVAX HPV data of 8.1% for one-dose HPV vaccination and 15.5% for UTD HPV vaccination rates for the 13 to 17-year-old cohort over practices engaged for one year. In the following examples, the data and interventions of four practices are summarized.

Practice A At Practice A, a data reconciliation pilot was completed where the electronic health record (EHR) data and DelVAX data were compared and corrections made. A total of 200 patient records were reviewed. There were 69 HPV vaccinations added to DelVAX for 51 unique patients. The data reconciliation alone yielded a 12% increase in UTD HPV vaccination rates and a 3% increase in one-dose HPV vaccination rates (Figure 1). The goal of data reconciliation is to ensure that records in the IIS and EHR match for various reasons: NIS-Teen may switch to using IIS data, to ensure accuracy of IIS data for reporting and use, and to establish accurate baselines. Through this effort, Quality Insights noted that data discrepancies between the IIS and EHR may be due to a move from paper to electronic records, migration to a new EHR, historical records not submitting electronically, and/or contraindications not submitting electronically.

Figure 1. Number of Up-to-Date (UTD) Human Papilloma Virus (HPV) and 1HPV Vaccines Prior to and after Data Reconciliation for Children ages 13 to 17 at Practice A, 2019, Delaware. Source: Delaware Immunization Registry, 2019 (DelVAX uses “1 HPV” and “UTD HPV” terminology)8

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Practice B Utilizing a multimodal approach, Practice B increased its rates by 13% for one-dose HPV vaccination and 35% for UTD vaccination in one year (Figure 2). The practice staff was initially trained and a one-on-one session was provided to a newly hired VFC/immunization coordinator. Practice B received four education interventions throughout the year, along with ongoing technical assistance, review of DelVAX reports, vaccination recommendations and workflow recommendations. The current VFC/immunization coordinator began championing HPV vaccination in the practice, engaging the physicians and staff. Practice B used strategies including DelVAX cleanup and inactivation, immunization goal setting, creating and reviewing DelVAX reports, reminder cards for patients/parents, reminder calls to patients/parents, scheduling next immunization appointments at check-out and physician/staff engagement. The DelVAX reports included AFIX Adolescent and IQIP Adolescent on-demand.

Practice C Practice C demonstrated a 13% increase in its one-dose HPV vaccination rate and a 25% increase in UTD HPV vaccination rate within one year (Figure 3). The practice staff was originally trained, with two one-on-one academic detailing sessions completed for providers. Quality Insights completed a patient reminder campaign for this practice by mailing 31 postcards to patients who were due or overdue for their second or third

dose of HPV vaccine. Practice C received four educational sessions throughout the year which included the nurse and nurse practitioner champions, along with ongoing technical assistance, review of DelVAX reports, and vaccination and workflow recommendations. The practice utilized DelVAX data cleanup, immunization rate goal setting, and additional evidence-based workflow interventions such as strong provider recommendation. The practice is piloting scheduling the nurse visit prior to the patient leaving and performing patient reminders for those visits.

Practice D Practice D demonstrated a 15% increase in its one-dose HPV vaccination rate and a 21% increase in its UTD HPV vaccination rate (Figure 4). The practice staff was trained initially and an academic detailing session was held for the providers. Training was provided for a newly hired immunization/VFC coordinator and data cleanup and patient inactivation was completed. Practice D received six educational interventions throughout the year, along with ongoing technical assistance, review of DelVAX reports, and vaccination and workflow recommendations. In addition to DelVAX data cleanup, Practice D utilized these strategies: immunization rate goal setting, creating and reviewing reports, scheduling nurse visits at checkout, reminder magnets, increased number of patient-facing materials (posters and handouts), and more diligent recommendation and immunization, especially in the younger cohort.

Figure 2. Percentage of Up-to-Date (UTD) Human Papilloma Virus (HPV) and 1HPV Vaccines Given by Practice B to Children Ages 13 to 17, Selected Dates from March 2019 to March 2020, Delaware. Source: Delaware Immunization Registry, 2019-2020 ((DelVAX uses “1 HPV” and “UTD HPV” terminology)8

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Figure 3. Percentage of Up-to-Date (UTD) Human Papilloma Virus (HPV) and 1HPV Vaccines Given by Practice C to Children Ages 13 to 17, Selected Dates from May 2019 to April 2020, Delaware. Source: Delaware Immunization Registry, 2019-2020 ((DelVAX uses “1 HPV” and “UTD HPV” terminology)8

Figure 4. Percentage of Up-to-Date (UTD) Human Papilloma Virus (HPV) and 1HPV Vaccines Given by Practice D to Children Ages 13 to 17, Selected Dates from January 2019 to January 2020, Delaware. Source: Delaware Immunization Registry, 2019-2020 ((DelVAX uses “1 HPV” and “UTD HPV” terminology)8

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DISCUSSION

REFERENCES

Most practices successfully engaged in this project selected more than one evidence-based intervention. While engaged practices used different strategies and workflow modifications, some consistent themes emerged. Practices in which providers were more engaged demonstrated a greater increase in HPV vaccination percentages. Provider engagement manifested in a variety of ways: participation in education and training, championing HPV vaccination, providing strong recommendations for HPV vaccine, answering patient/parental questions, reviewing reports and information from VFC/ immunization coordinators, knowing rates of vaccination, and providing early education to patients/parents using multiple methods of delivery (videos, posters, flyers, handouts). Practices showing the greatest increases in HPV vaccination rates also leveraged the information from DelVAX, utilized data cleanup and patient inactivation, set goals, utilized an HPV Vaccination Champion, and employed workflow modifications based on the IIS data and patient population, using a multi-faceted approach. This information is seen in the literature as well.

1. Cancers associated with human papillomavirus (HPV) | CDC. (2019a, November 19). https://www.cdc.gov/cancer/hpv/basic_info/cancers.htm

A literature review, “HPV Vaccination: Population Approaches for Improving Rates,” published in Human Vaccines and Immunotherapeutics in June 2016, reviewed various evidencebased workflows to increase HPV vaccination rates, including provider assessment and feedback, provider reminders, and reminder-recall. The review concluded that there was evidence to support the use of both reminder-recall and provider assessment and feedback interventions, with better successes noted from interventions that contain multiple components.9 Quality Insights continues to partner with DPH to increase HPV vaccination rates. Currently, Quality Insights is performing data reconciliation for 2,000 patients between the ages of 13 and 17 for a large health system in Delaware. Quality Insights will continue data reconciliation, explore capabilities for e-reminders, and expand training to include strategies for increasing UTD HPV vaccination rates by age 13, and provide support through education, evidence-based interventions, and new DelVAX reports.

DISCLAIMER: This project is in collaboration with the Division of Public Health (DPH) – Comprehensive Cancer Control Program, Immunization and Vaccines for Children, and the Centers for Disease Control and Prevention (CDC). Publication number: DEDPH-HPV-042820

ACKNOWLEDGEMENTS: Robin Cahill and Fred Bailey, Immunization Program; and Heather Brown, Comprehensive Cancer Control Program, Division of Public Health; Comprehensive Cancer Control Program, Delaware Immunization Coalition leadership, and Delaware Cancer Consortium leadership.

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2. HPV cancers are preventable. (2019b, November 13). https://www.cdc.gov/hpv/hcp/protecting-patients.html 3. How many cancers are linked with HPV each year? | CDC. (2019c, August 2). https://www.cdc.gov/cancer/hpv/statistics/cases.htm 4. Trends in vaccination coverage with >= 1 HPV vaccine among adolescents aged 13-17 years by HHS Region, state, selected local area and territory - National Immunization Survey - Teen (NIS - Teen), United States, 2014-2018. (2019f, August 23). https://stacks.cdc.gov/view/cdc/80678 5. Trends in vaccination coverage with >= 1 HPV vaccine among adolescents aged 13-17 years by HHS Region, state, selected local area and territory - National Immunization Survey - Teen (NIS - Teen), United States, 2014-2018. (2019d, August 23). https://stacks.cdc.gov/view/cdc/80679 6. Walker, T. Y., Elam-Evans, L. D., Yankey, D., Markowitz, L. E., Williams, C. L., Fredua, B., . . . Stokley, S. (2019e, August 23). National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 years – United States, 2018. MMWR. Morbidity and Mortality Weekly Report, 68(33), 718–723. Retrieved from https://www.cdc.gov/mmwr/volumes/68/wr/mm6833a2.htm https://doi.org/10.15585/mmwr.mm6833a2 7. Quality Insights - Quality Insights Home. (n.d.). http://www.qualityinsights.org/Home.aspx 8. Delaware Immunization Registry. (n.d.) https://delvax.dhss.delaware.gov/delvax/login.aspx 9. Oliver, K., Frawley, A., & Garland, E. (2016, June 2). HPV vaccination: Population approaches for improving rates. Human Vaccines & Immunotherapeutics, 12(6), 1589–1593. https://doi.org/10.1080/21645515.2016.1139253

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Vaping Among Delaware Youth Rachel Ryding Research Assistant, Center for Drug and Health Studies, University of Delaware David Borton, M.A. Research Assistant, Center for Drug and Health Studies, University of Delaware Meisje Scales, M.P.H., C.P.S. Research Assistant, Center for Drug and Health Studies, University of Delaware

Helen Arthur, M.H.A. Section Chief, Health Promotion and Disease Prevention, Delaware Division of Public Health, Department of Health and Social Services Lisa M. Moore, M.P.A. Director, Tobacco Prevention and Control Program, Delaware Division of Public Health, Department of Health and Social Services

Dana Carr, M.P.H. Senior Advisor for Prevention and Health, Delaware Division of Substance Abuse and Mental Health (DSAMH), Department of Health and Social Services

Sharon Merriman-Nai, M.C. Senior Consultant, Center for Drug and Health Studies at the University of Delaware

INTRODUCTION

Although it is marketed as a safe alternative to smoking, or a strategy to quit smoking, there is limited research to support this claim. Nicotine, in particular, is unsafe to anyone under the age of 25 due to the harm it causes to the developing brain.6 Vaping nicotine is also associated with use of other drugs; specifically, those who vape are much more likely to start using other tobacco products than those who do not vape.6 Some products deliver high concentrations of nicotine which can lead to addiction. In some cases, vaping devices have exploded, causing facial injuries to the user.9 Because vaping is relatively new, the potential long-term effects related to the aerosolizing process are still being researched. In addition to potential chronic impacts, the Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), and other health officials have been investigating an outbreak of e-cigarette or vape product use-associated lung illnesses, known as EVALI. Although they are currently on the decline, as of February 2020 the CDC reported a total of 2,807 cases of EVALI, including 68 confirmed deaths throughout 29 states and Washington, D.C. Vitamin E acetate, an additive found in some THC-containing vape products, appear strongly linked to EVALI, but the CDC warns that there is not enough evidence to rule out the potential impact of other substances.10

Recent years have seen the rise of a new substance, the use of which has yet-unknown long-term consequences. Known colloquially as e-cigarettes, e-cigs, or vaping devices, usage rates have grown exponentially throughout the country over the past decade with increases seen across every demographic group. National Monitoring the Future data from 2019 shows that 25% of 12th graders report having vaped nicotine in the past month, an increase from 11% in 2017,1 and the 2019 National Youth Tobacco Survey estimates that over five million youth are currently using e-cigarettes.2 Vaping takes a number of forms and vaping equipment can be purchased under a number of different names. Some may know vaping devices as e-cigarettes, while others know them as mods; yet others may know them only under a particular brand name such as the extremely popular JUUL. The core of vaping is this: a heating element heats a liquid, turning it into aerosol, which is then inhaled. These liquids can contain a variety of ingredients. Many – but not all – vaping liquids double as tobacco products because they contain nicotine, a tobacco derivative. Other vaping liquids are marijuana-based products; they contain Tetrahydrocannabinol (THC). A common ingredient in vaping liquids is flavoring.3 Hundreds of other flavors are available through third party brands and vape shops can also prepare customized blends of liquid nicotine, flavors, and other liquids for consumers.4 Because vaping devices and products (flavors, liquids, etc.) are not held to the same advertising restrictions as tobacco, vaping is promoted through all traditional advertising mediums including television, print, and web ads. These ads often feature celebrities and are designed to make vaping appear safe yet “cool.” JUUL, which had, until recently, marketed a number of flavors such as Mango and Mint, became the fastest company ever to exceed $10 billion valuation in 2018, largely due to its appeal to youth.5 A Surgeon General’s report suggests that advertising for vaping devices will follow a trend similar to that of cigarettes, leading young people to believe that vaping is normal and acceptable.6 Researchers from the Stanford University Research into the Impact of Tobacco Advertising (SRITA) group found that, despite the company’s claims that they targeted their products to adult smokers, JUUL’s initial marketing campaigns were “patently youth oriented,” employing social media influencers and other figures popular with youth to post about JUUL online.7 Even after the company halted its official social media advertising in late 2018, the product and cult following had become so popular that young users themselves continued to promote JUUL products on social media at an even higher rate than before.8 68 Delaware Journal of Public Health – August 2020

Delaware is no exception to the rising popularity of vaping. Youth survey data indicates that vaping rates continue to climb among Delaware students although rates of cigarette smoking continue to decline. Not only is vaping a concern as a risk behavior in and of itself, but consumption of one substance is frequently associated with increased likelihood for use of other substances.11 Known health risks associated with vaping, unknown risks of long-term use and exposure, and increased risk for polysubstance use converge to create an escalating public health concern. This article provides an overview of vaping among Delaware high school students by exploring the findings of several statewide data sources. We consider the implications of the data, then highlight several policies and promising practices currently underway to address the increasingly prevalent behavior.

YOUTH DATA COLLECTION EFFORTS The Center for Drug and Health Studies at the University of Delaware (CDHS) partners with various State agencies and organizations on research related to substance use, health risk behaviors, and health policy. CDHS conducts several youth surveys which yield data on risk and protective factors regarding wellbeing and behavioral health. On behalf of the Delaware Division of Substance Abuse and Mental Health (DSAMH), CDHS administers the annual Delaware School Survey (DSS). On behalf of the Division of Public Health (DPH), a sister agency to DSAMH in the Delaware Department of Health and Social

Services, the Center administers the Delaware High School Youth Risk Behavior Survey (YRBS) and the Youth Tobacco Survey (YTS) biennially in alternating years. Along with the State Epidemiological Outcomes Workgroup (SEOW), a network that promotes the strategic use of data for prevention efforts (also facilitated by CDHS on behalf of DSAMH), these data sources provide the capacity to monitor experiences and attitudes of Delaware youth. The current study examines vaping and associated data from these surveys.

The Delaware School Surveys (DSS) Administered by CDHS since 1995 with support from State agencies (most recently DSAMH and allocations from the Master Tobacco Settlement), the DSS is designed to collect data regarding substance use, delinquency, risk, and protective factors. There are two versions. The 5th grade questionnaire is designed for younger students and is much briefer than the secondary questionnaire that is administered to 8th and 11th graders. CDHS updates the DSS annually with input from an advisory committee of State and community stakeholders and attempts to engage participation from all public schools throughout Delaware. The annual sample size for the 11th grade is approximately 3,000 - 4,000 students. To decrease survey burden, DSS administration excludes those classes randomly selected to participate in two alternating CDC surveys, the Youth Risk Behavior Survey (YRBS) and the Youth Tobacco Survey (YTS) subsequently described. The secondary DSS includes several questions about students’ vaping behaviors and attitudes, such as the frequency with which students vape, what types of products they vape, and whether students find vaping to be risky. The DSS also asks about students’ relationships with their parents, their sense of connectedness with their school, whether they engage in externalizing behaviors such as assault or property damage, and demographic questions.

Delaware Youth Risk Behavior Survey (YRBS) The purpose of the YRBS is to assess the prevalence of health risk behaviors, identify behavior trends, and improve and inform programs and policies related to youth. The survey was developed in 1990 by the CDC. The CDC conducts a national survey biennially and supports states, large urban regions, tribal organizations, and territories interested in administering the high school survey.12 (The CDC has also develops a middle school survey but relatively few states elect to participate; it has been fielded in Delaware with support from nonprofit and State agencies, most recently from the Department of Services for Children, Youth, and their Families Division of Prevention and Behavioral Health Services.) Through 2019, the YRBS has been administered to students in a randomly selected sample of classes from a census of Delaware public high schools. CDHS customizes a Delaware version of the survey in collaboration with the Division of Public Health and with input from the same advisory group that informs the annual DSS development. In addition to providing data on substance use, the YRBS also provides statewide youth data on health, diet, and sexual activity, as provides comparability to other states’ findings published by the CDC in the Morbidity and Mortality Weekly Report. In 2017, 41 high schools participated, providing a total of 2,933 survey responses in the final dataset.

Youth Tobacco Survey (YTS) Delaware’s Tobacco Prevention and Control Program sponsors the YTS in even-numbered years. The YTS is a collaborative effort of the Delaware Division of Public Health and the CDC and provides data for planning, implementation, and evaluation of effective programs to prevent and reduce tobacco use in Delaware. In recent years, the YTS has included questions related to vaping. The survey is administered by CDHS to students from a random sample of 6th through 12th grade classes in randomly selected public schools in Delaware. The DSS, YRBS, and YTS are voluntary and completed anonymously by students. Parents are notified by letters distributed by school personnel and passive parental permission is obtained prior to survey administration. In addition, students have the right to decline to participate at the time of administration, which is conducted at schools by experienced survey administrators hired and trained through CDHS. Surveys are approved by the University of Delaware Institutional Review Board prior to each cycle of administration. (Additional information is available on the School Surveys page of the CDHS website.) Select variables from each survey are described and analyzed in the following section.

WHAT WE CAN LEARN FROM THE DATA ABOUT YOUTH VAPING IN DELAWARE Rate of Vaping and Related Behaviors Since 2014, the DSS has included questions regarding use of e-cigarettes. In 2014, the question asks how often students used e-cigarettes with six possible responses: never; before, but not in the past year; a few times in the past year; once or twice a month; once or twice a week; or almost every day. In the 2016 survey, this question was expanded to ask students how often they used e-cigarettes or vaping devices. In 2017, this question was split into two distinct questions, one that asked only about e-cigarettes and one that asked only about other vaping devices. In the 2018 and 2019 surveys, a third question was added to the DSS to specifically ask students how often they used JUUL devices as well due to its increase in popularity. The past five years of available data from the DSS illustrate sharp increases in the percentage of students who report ever vaping in their lifetime, in the past year, and in the past month. From 2014 to 2019, the self-reported past month use of any vaping devices (calculated by combining responses from students who used any e-cigarette, JUUL, or other vaping device almost every day, once or twice a week, or once or twice a month) among surveyed 11th grade students in Delaware more than tripled, increasing from 4% to 18%, with parallel increases in past year and lifetime use (see Figure 1). Most recently available YRBS data (2017) suggests that more than a third (35%) of Delaware high school students have used “electronic vapor products” in their lifetime and roughly 13% have used them at least once in the past 30 days. Although the reported YRBS lifetime rate did not change significantly from 2015 to 2017, the reported past month rate represents a decrease in use (from 24% to 13%). Among high school students who report using a vaping device in the past 30 days, 16% report that 69

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Figure 1. Vaping trends among Delaware 11th grade students (%) Delaware School Survey (DSS, 2014-2019).

they bought them at a store, 37% report that they borrowed or bummed them from someone else, and 12% report that a person 18 or older bought the device for them. Findings from the 2018 YTS reveal that one in three students (grades 6th through 12th) have ever used an e-cigarette or vaped and 17% have vaped within the past month. YTS data also indicate that a substantial percentage of students have close friends who vape; of those surveyed, 16% of middle school students and 33% of high school students report that at least one of their four closest friends used a vaping product. There is also a substantial and statistically significant positive correlation between self-reported past month vaping among students and the number of close friends they have who vape. When asked how many of their four closest friends vape, JUUL, or use e-cigarettes, only 3% of students who report none of their close friends vape report vaping themselves in the previous month. As students report that more of their closest friends vape the likelihood of their own vaping rises steadily. Among students who said one of their close friends vape, 20% report vaping in the past 30 days; among students who said four of their close friends vape, the rate of their own vaping in the past 30 days increases to 79%. Survey responses from the 2018 YTS among high school students suggest that most students begin vaping in high school. While 4% of students report that they first tried vaping at the age of 13, that percentage doubles to 8% of students who report that they first tried vaping at the age of 14. Additionally, 7% of students report they vaped for the first time at age 15, 6% at age 16, and 4% at age 17. When compared to YRBS high school data, the age of initiation for vaping is not markedly younger or different from other popular substances such as alcohol or marijuana. The 2019 DSS also includes a question about what students are vaping. Among 11th graders who responded, 21% of students say they used flavored e-liquids, 19% used marijuana, 16% used nicotine, 5% synthetic marijuana, and 4% other drugs. (This is a mark-all-that-apply question and there is substantial overlap among these categories.) 70 Delaware Journal of Public Health – August 2020

Perception of Risk Associated with Vaping The DSS has included a question about students’ perception of risk from vaping since 2016. The percentage of students who believe vaping presents a great risk is clearly increasing, while the percentage of students who think there is no risk is decreasing more slowly (see Figure 2). Notably, the first two years that this question was included on the survey the perception of “no risk” among 11th grade students is actually greater than the perception of “great risk” from using vaping products. When compared to student perceptions of risk associated with other drug and alcohol use, it becomes clear that students still do not believe that vaping is as risky a behavior as most other drug use, with the exception of marijuana use. Approximately a quarter of surveyed 11th grade students report that using an e-cigarette or vaping device presented a great risk of harm, while two-thirds of surveyed students believe that smoking a pack of cigarettes presented a great risk (see Figure 3). Students most commonly report a perceived moderate risk from vaping.

Co-occurrence of Vaping with Other Substance Use (Polysubstance Use) The Polysubstance Venn Diagram (Figure 4) depicts the intersection of multiple substance use among 11th graders. In 2018, more than half (55%) of 11th grade Delaware students responding to the DSS report using some substance in the past year while 45% of students report no past year substance use. Seventeen percent of all 11th graders surveyed report having vaped in the past year. Thirteen percent of 11th graders report both vaping and marijuana use, 15% report vaping and alcohol use, and 12% report vaping and the use of both alcohol and marijuana. Two percent of students report using all of the substances named (alcohol, marijuana, cigarettes, and e-cigarettes), as well as at least one of the substances categorized together as “other drugs” (defined as at least one of the following in the past year: ecstasy, hallucinogens, downers, prescription uppers, street uppers, painkillers, Ritalin, crack, cocaine, heroin, or synthetic marijuana).

Of note, in the 2018 DSS sample, all students who report smoking cigarettes in the past year (6.5%) also report vaping during that period.

Relationship between Vaping and Other Risk and Protective Factors (including ACEs) Prior research indicates that other substance use rates are higher among students who report having experienced one or more adverse childhood experience (ACE).13 YRBS data was analyzed to consider the relationship between vaping and ACEs. The prevalence of past month vaping among high school students increases with the number of ACEs. Seven percent of students who report no ACEs report vaping in the past month, compared to 17% of students with one ACE who vape, and nearly a quarter (24%) of students with two or more ACEs who vape. This disparity is replicated with several individual indicators as well, such as bullying, parental incarceration, and housing instability.

Prior research also indicates that students with a disability are more likely to misuse substances.14 Analysis of 2017 YRBS data substantiates this as students who report having a disability are more likely to report past month rates of vaping than students who do not report having a disability (18% compared to 12%). On a positive note, several protective factors appear associated with reduced rates of vaping. Approximately one in ten students who report that their parents are “always” proud of them, take an interest in them, listen to them, and can be counted on report vaping within the past month; one in four students who report “never” to the same questions report vaping within the past month.

DISCUSSION One of the most noteworthy and alarming characteristics of vaping is the high prevalence and the quickness with which it became so popular among teens. Because these devices are

Figure 2. Trends in perceptions of risk from vaping (%). Delaware School Survey (DSS, 2016-2019).

Figure 3. Perceptions of risk by substance use among 11th graders (%), 2019 Delaware School Survey (DSS).

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report vaping in the past month). This consistently high degree of overlap could be a result of students moving from smoking to vaping, with many of those who continue to smoke cigarettes vaping as well. This is especially troubling given that vaping has been marketed as a strategy to quit smoking traditional cigarettes. Another notable finding is that the rate of past month vaping decreases when comparing the 2015 and 2017 YRBS reports. This is consistent with data from the national YRBS sample during the same time frame and reflected a similar dip in selfreported vaping on the DSS from 2016 to 2017. However, this is counter to the overall DSS trend which shows increases from 4% in 2011 to 18% in 2019. It will be important to review the trend line once the 2019 Delaware YRBS data has been analyzed and released by the CDC. It should be recognized that JUUL entered the market during this period and its use skyrocketed quickly. Anecdotally, we know that many young people did not perceive JUUL to be the same as other e-cigarettes, and survey questions were not amended to specifically ask about JUUL until 2018 (DSS) and 2019 (YRBS). It is possible that this anomaly does not represent an actual decrease in vaping but a gap in the survey questions themselves. Figure 4. Past Year Polysubstance Venn Diagram, 2018 Delaware School Survey, Center for Drug and Health Studies, University of Delaware

relatively new compared to other substances being used by students, longitudinal data about vaping is not yet available. Few data sources, if any, have been tracking the use of vaping devices by students for longer than the past five years. Due to the rapidly evolving nature of vaping devices, survey questions have changed over the years to include more categories of vaping devices; even so, it is possible that survey results still undercount the true prevalence of vaping among youth. It is equally concerning that although an increasing percentage of DSS respondents report a perception of “great risk” from vaping, the prevalence of vaping among students continues to rise. This may be due in part to the “vape culture” that has emerged, which views vaping not as a health behavior but a lifestyle – a perception that has flourished particularly among youth. In a recent social media analysis, researchers found that 45% of individual followers of JUUL were between the ages of 13 and 17.15 YTS data also illustrates that peer activity is associated with a student’s likelihood of vaping; while only 3% of students vape among those who do not have a close friend who vapes, four out of five students vape when they have four close friends who do. It is striking that every student who reports smoking cigarettes, 6.5% of 11th graders, also reports the use of an e-cigarette or vaping device in the 2018 DSS. This does not indicate that all individuals who smoke cigarettes also vape – the degree to which use of cigarettes and vaping devices overlap varies based on the wording of a question asked in a specific survey, the population being surveyed, the timing and frequency of survey administration, and other contextual factors. However, it does suggest that there is a high degree of overlap between cigarette smoking and vaping, which is supported by similar findings in the 2017 11th grade DSS (60% of those who report smoking cigarettes in the past year also report vaping in the past year), the 2019 11th grade DSS (88% of those who report smoking cigarettes in the past year also report vaping in the past year) and the 2017 YRBS (of those who report smoking cigarettes in the past month, 60% 72 Delaware Journal of Public Health – August 2020

Epidemiologists as well as policy makers, practitioners, and prevention specialists are interested in understanding which populations experience disproportionate risk for certain health conditions and behaviors. While there is a high prevalence of vaping among students across all demographic backgrounds and social experiences, the analysis of Delaware data indicates that some student populations are at increased risk for vaping, just as they are for other substance use. YRBS analysis suggests a positive association between students who report ACEs and vaping (students who confirmed experiencing any of the following events: homelessness, incarcerated parent, fighting, being threatened, being bullied, or teen dating violence or sexual violence, were placed in either “1 ACE” or “2 or More ACEs” category depending on the number of different experiences they reported). From this data analysis, we cannot determine if one condition causes the other, or if they are both caused by other factors. But it is an important observation given that we know people who experience one or more ACE are more likely to experience greater risk for health and other challenges throughout their lives. (The association between Delaware youth substance use and ACEs has been discussed more broadly in the SEOW’s annual Delaware epidemiological report.)16 There is also a positive association among vaping and students who report that they have at least one disability. According to the 2019 Delaware State Epidemiological Profile, students who report having a disability are also more likely to report using cigarettes, alcohol, marijuana, and to binge drink than other students.16 As we consider the elevated risk for vaping among certain groups of students, it is important to recognize the key takeaway illustrated by the polysubstance Venn diagram: students who use one substance have a greater risk of using other substances. Not only are students who vape more likely to smoke cigarettes, they are more likely to use alcohol or other drugs, which come with other associated risks. We need to emphasize that the strong correlation between vaping and other substance use does not necessarily indicate a causal relationship between vaping and other health risk behaviors, but this data underscores the need to recognize and leverage shared opportunities for prevention and intervention.

Finally, the analysis highlights a number of protective factors related to parental engagement that are associated with reduced risk for vaping, which is consistent with the literature for reduced risk of other substance use and mental health problems.17

and disciplines is required to address the surge in vaping. In this section, we highlight key collaborative initiatives implemented by Delaware lawmakers, public health officials, tobacco and other substance prevention and control advocates, and educators.

LIMITATIONS

Legislative Responses

There are several limitations to this analysis. Each survey was administered to students in public school settings. It would be valuable to survey students in private school and other settings if the resources to do so were to become available. School participation rates have been declining in Delaware for the three surveys analyzed. Based on communications with other national and state survey administrators, this is not unique to Delaware. CDHS has been collaborating with State funding agencies, educators, and other advocates to: identify and reduce barriers to participation; ensure that data collected is available to support the needs of educators and students; and promote the availability of data for their use. These data support needs assessments, grant applications, program development, strategic planning, and evaluation of sponsored projects. Although the sample sizes reviewed here provide meaningful analysis, if this trend continues, the capacity for future analysis may be jeopardized. There are noted differences among the vaping rates across the three surveys. This may be due to the wording and order of specific questions on a given instrument, the timing of survey administration, participation rates, and differences among samples. Generally, however, the findings reflect overall consistency across instruments as well as with national data sources and when compared to the literature. Longer trend lines and other types of data (for example, focus group data, observational school data, etc.) will help to provide insights into behavior. A challenge with any school-based survey is that it only captures data from students who attend school on a given day. Students who are most likely to experience adversities or engage in risky behavior are also students at greater risk to miss school. Therefore, the reported rates of any risk behavior may be lower than actual prevalence rates. A number of associations have been noted: students who report experiencing ACEs are more likely to report vaping compared to students who do not report ACEs; students who report having a disability are more likely to report vaping compared to students who report no disability; students who report experiencing high rates of parental engagement report lower rates of vaping than students who do not report similar levels of support. However, on the basis of our analyses, we cannot draw conclusions about the nature of these associations, only that they co-occur and that they merit further examination.

DELAWARE’S RESPONSE TO THE SURGE IN VAPING: POLICY AND LEGISLATION, PROMISING PRACTICES, AND RECOMMENDATIONS There are multiple contributing factors to the popularity of vaping among Delaware youth. Just as comprehensive approaches using best practices have reduced traditional cigarette use in Delaware, a comprehensive, coordinated approach from various sectors

Since 2014, several legal remedies have been enacted or amended to help reduce the use of e-cigarettes and related products among Delaware youth. An amendment to the youth access law, which prohibits the sale of tobacco and tobacco products to minors, was expanded to include tobacco substitutes (such as e-cigarettes) on July 1, 2014. Comprehensive policy analysis (for example, that presented in the Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products) posits that raising the minimum legal age of purchase would likely delay smoking initiation, with the possible public health benefits of reducing overall prevalence and premature death.18 In 2019, Delaware became the 12th state to raise the age of sale for tobacco products to 21 years. It is worth noting that the Delaware bill included language that defined “tobacco substitutes” as being those with and without nicotine, reflecting the pervasive use of flavored vape juice and its appeal to teens. As a means of protecting the general public from the effects of secondhand smoke related to vaping, the Clean Indoor Air Act was amended in October 2015 to prohibit the use of electronic smoking devices anywhere that traditional tobacco products could not be used. This includes the prohibition of vaping in common use areas, hospitals, schools, gyms, daycare facilities, restaurants, workplaces, and many other publicly shared spaces. Research indicates that the implementation of excise taxes on traditional cigarettes have been positively associated with some reduction in smoking, especially among younger adults.19 In July 2017, Governor Carney signed Delaware House Bill 242 which added definitions of vaping products, required licensure for the sale of vaping products (similar to that of traditional tobacco vendors), and imposed a tax of five cents per fluid milliliter.

Collaborative Public Health, Prevention, and Education Evidence-based Approaches State agencies, community organizations, and educators are collaborating to raise awareness of vaping among youth and their families. Delaware partners are adopting innovative approaches steeped in evidence. Evidence-based programs, practices, and policies are interventions that have gone through a process of scientific review and the implementation of these interventions (with fidelity) is critical to data-driven decision making. A search of the Results First Clearinghouse Database found several tobacco cessation and prevention strategies that have been designated as “highest rated” – media campaigns, taxes, prevention education, and quitlines among them. When it comes to the use of vaping and traditional tobacco products, evidence-based programs target two points on the continuum – cessation and prevention.

Public Health Campaigns Vape products continue to evolve to be sleeker, more discrete, and more appealing and addicting with unique flavorings and high amounts of nicotine as youth use has skyrocketed. In 2016, the Division of Public Health (DPH) conducted a mass reach media campaign (Don’t Be an E-cig Guinea Pig) to dissuade youth from using e-cigarettes. More recently, based on feedback 73

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from youth focus group participants, DPH has developed new media campaigns for youth to raise awareness that vape products contain as much if not more nicotine than a pack of cigarettes. In addition, the age requirement of the Delaware Quitline has been lowered to 13 years to provide more available cessation resources to youth facing nicotine addiction. The DPH Tobacco Prevention and Control Program (TPCP) has been investing considerable time at Delaware schools in each County to provide education on vaping, especially after the EVALI outbreak.

Educators as Partners: Behavioral Health Multi-Tier Systems of Support in School Settings

DSAMH and their partners created a “driver diagram,” a range of evidence-based interventions to address universal, primary prevention approaches, selected interventions to help a smaller number of students in danger of engaging in risky behavior, and indicated interventions and services for students in need of more structured and intensive support. The Behavioral Health MultiTier System of Support (BH-MTSS) was designed to help schools implement behavioral health approaches that complement and align with their academic Multi-Tiered System of Supports which guide policies, practices, and personnel related to educational and academic achievement.

Vaping is one of a number of youth behavioral health issues that stakeholders throughout Delaware have been working to address. In recent years, advocates across disciplines and sectors have focused on strategies to identify and foster shared protective factors and reduce shared risk factors common to multiple public health concerns. Increased awareness of the negative health impacts of ACEs and trauma has led to initiatives designed to foster resiliency and promote trauma-informed environments in schools and other settings. As part of that process, in 2019, Delaware’s Department of Health and Social Services (DHSS), the Delaware Department of Education (DOE), and Department of Children, Youth, and their Families (DSCYF) embarked on an interagency partnership to conduct school district level needs assessment. DHSS Divisions of Substance Abuse and Mental Health (DSAMH) and Public Health collaborated with DOE and DSCYF’s Division of Prevention and Behavioral Health Services (DPBHS) to create, field, and analyze district level assessments of available resources and existing gaps. The assessments focused on each district’s capacity for and availability of policies, programs, practices (including curriculum), and personnel for a range of topics linked to promoting health, preventing and responding to health concerns, and addressing service needs of students. Topics included behavioral health (both substance use prevention and mental health), physical activity, nutrition, vision, oral health, and asthma. Of the 19 school districts in Delaware, 15 participated in the assessment process in addition to two large charter school networks with student populations over 1,200.

Leveraging several grant funding streams, in 2019-2020 DSAMH provided funds to districts participating in this process to implement prevention-related action plans, in coordination at high schools with the State’s School-Based Wellness Centers. Using the BH-MTSS, several districts identified the sudden and rapid rise of vaping among their students as a particular concern and identified strategies that align with Tier 1 interventions – creating supportive school, peer, and community environments through changing policies and practices to optimally support youth, and a focus on identifying alternative discipline pathways for youth caught vaping at school. Since then, districts and high schools have begun working with their School-Based Wellness Centers and qualified mental health professional staff to screen, refer, and provide behavioral health – both mental health and substance use – treatment and recovery services.

Needs assessments findings show that although districts are addressing health and wellbeing, clear opportunities exist to improve these efforts, including the need to strengthen student supports and professional development relating to substance use. Though the State’s health education regulations set a minimum number of hours dedicated to drug and alcohol education,20 school districts and schools select and implement evidence-based curriculum aligned with their unique needs and student populations. Yet even with this strong State regulation for comprehensive, evidence-based health education, only half of participating districts report providing health education for all student populations. Based on the findings and the final report and recommendations21from the Delaware Youth Drug Prevention Curriculum Task Force (created by Senate Concurrent Resolution 69), DSAMH, DOE, DPBHS, and DPH provided support in the process to align and harmonize curriculum, policy, and practices to improve student health and wellbeing and respond to new and emerging challenges such as vaping. District and State agency representatives met during the summer of 2019 to create plans to address needs related to substance use prevention and behavioral health concerns. To align efforts,

At the Tier 1 level, several districts and high schools are addressing vaping by examining their current health education offerings to ensure that prevention sufficiently addresses this concern and provides evidence-based content aligned with state health education standards, and with similar and complementary approaches to preventing youth substance use. At least four districts and high schools, in partnership with their SchoolBased Wellness Centers, will review their current policies related to vaping and shift to alternatives that promote health, build protective factors, and increase students’ understanding of the effects of vaping. These districts will also use vape detectors as part of their approach to identify students vaping at school. As part of their Tier 2 approaches, these districts will screen to differentiate students potentially in need of intervention services, such as cessation or addiction services for vaping, from those who would benefit from prevention strategies, such as students curious about or experimenting with vaping.

74 Delaware Journal of Public Health – August 2020

Case Study: Creating and Testing a Supportive Model for Vaping Detection and Response Through the needs assessment, POLYTECH School District in Woodside, Delaware identified vaping as its primary area of focus. Members of the school’s leadership, health staff, and wellness center had been seeking innovative approaches to address this pressing issue. Concurrently, the Division of Public Health TPCP had begun the development of a toolkit to serve as a one stop vaping resource for educators, parents, students, and health care providers. In November 2019, the POLYTECH District Wellness Committee and DPH coordinated efforts to develop an online vaping toolkit (www.VapeFreeDE.org). DOE, DSCYF, the Division of Alcohol and Tobacco Enforcement, and the American Lung Association also participated in its development which was supported in part with funds from the

Delaware Cancer Consortium. The toolkit integrates credible and evidence-based resources from the CDC, Food and Drug Administration, the Surgeon General and Public Health Law Center, with meaningful input from students and families. Once developed, POLYTECH agreed to beta-test the toolkit, which they found to be helpful and key to their response to vaping. Recently launched on the Healthy Delaware website, the toolkit has several user-friendly components which include resources for educators such as curriculum, model policies, fact sheets, and presentations; cessation resources; and information for specific audiences (parents, teens, educators, health care providers, etc.). Hard copies of fact sheets, posters, and mirror clings are also available upon request. A unique feature of the toolkit, the social media calendar contains pre-written messages about vaping that can be shared with students and parents throughout the school year. POLYTECH High School was instrumental in shaping the development of the calendar to facilitate consistent and conversations with students and parents about this growing public health challenge. To promote ongoing assessment and updated messaging, the toolkit includes a prominent “Feedback” button that remains visible when exploring all features. Polytech’s vaping initiative is district-wide and is being coordinated by the District Wellness Committee, which is comprised of district office, high school, Wellness Center, and adult education staff members. Although the work began in the high school, portions are being implemented in the adult education division.

Moving Forward: Changing School Policy and Practice to Address Vaping High schools and districts that identified vaping as a priority in their BH-MTSS work will use the online toolkit to conduct customized prevention efforts. Each of the schools and districts, in collaboration with School-Based Wellness Centers, will integrate approaches to provide education and cessation to students and refocus discipline policies from punitive to rehabilitative approaches. For example, students caught vaping will immediately view the Know the Risks presentation22 developed by the CDC and adapted with a voiceover component by DOE. For students who need an approach that integrates cessation, schools will also use the American Lung Association’s Intervention for Nicotine Dependence: Education, Prevention, Tobacco and Health (IN DEPTH), a program which offers an alternative mechanism to in-school suspensions or citations resulting from vaping at school.23 In lieu of punitive disciplinary measures, students will use time during the school day, such as enrichment periods, or after school to participate in INDEPTH’s four, 50-minute comprehensive educational modules on a variety of tobacco-related issues. INDEPTH modules can be accessed in a group or individual setting. Results of a pilot evaluation of the INDEPTH program found that 60% of students surveyed were willing to try quitting the use of nicotine, vaping, or tobacco products after their participation.23 Although implementation of new policies was scheduled to start in Spring 2020, because of the COVID-19 pandemic and the transition to distance learning for Delaware students, plans have been temporarily suspended but will be reevaluated when schools reopen.

RECOMMENDATIONS Despite the magnitude of the issue, State agencies, schools, community organizations, and other stakeholders have collaborated to implement a number of strategies to reduce teen vaping. It is critical to recognize the need for ongoing data collection through instruments such as the Delaware School Survey, the Youth Risk Behavior Survey, and the Youth Tobacco Survey. The data produced will allow public health advocates to continue to monitor rates of vaping and associated health risks that youth experience and support data-driven prevention programs, policies, and evaluation. There are a number of other recommendations to consider as advocates move forward. It is important to take stock and build upon ongoing resources, assets, and activities that are currently in place and working well to promote health and discourage risk. The data presented in this paper illustrate that vaping is associated with other substance use risk behaviors. Additional data has been referenced that illustrate the links between substance use and mental health risks. There are multiple prevention initiatives throughout the state designed to address one or more risks commonly experienced by adolescents and young adults. Coordinating and leveraging these efforts will create a more cohesive approach to preventing multiple issues. Comprehensive, evidence-based health curricula will help to facilitate this coordinated effort. Continued collaboration across sectors and disciplines is key. Approaches that emphasize asset building and protective factors will help youth to build the resilience and skills required to navigate a variety of risk behaviors and challenges they will encounter throughout their lives. Trauma informed school environments and behavioral health multitiered systems of care, already underway in some areas, will allow schools and districts to implement policies that promote health and allow students to practice healthy habits and achieve success. As part of this, shifting away from punitive responses to issues such as vaping will allow schools to redirect problem behaviors so that they become opportunities to develop knowledge and pro-social skills. To facilitate change, it will be critical to ensure that everyone involved has a voice in the process. Youth should be engaged to meaningfully contribute to or even lead any efforts to promote health, as POLYTECH did with the vaping toolkit and corresponding social media calendar. Parents, educators, and others should share in the process as well. Finally, in early 2020, the Delaware Attorney General announced that the state was participating in a multistate coalition to investigate JUUL Labs’ marketing and sales practices which have targeted youth.24 Participating in regional and national efforts to address broader influences that impact vaping behaviors and attitudes will supplement and strengthen the multidisciplinary efforts undertaken by local advocates.

CONCLUSION As the data shows, youth vaping is a significant public health challenge in Delaware and comprehensive measures to educate students and families are required to address it. Advocates across sectors have formed partnerships that provide a foundation for developing evidence-based responses and have initiated several promising programs, including the Vape Free DE online toolkit. Successful efforts should incorporate the voices of teens and their families to inform prevention strategies. Ongoing surveillance is vital to monitor the rate of vaping and other conditions associated with this behavior. 75

Non-COVID-19 Arcticles

ACKNOWLEDGMENTS The authors greatly appreciate the information and assistance provided by the following individuals as we developed this paper: Amelia Hodges (superintendent), Vienna Walker, and Nicholas Johnson (POLYTECH School District); Christine Alois (deputy secretary), Susan Haberstroh, and Sabra Collins (Delaware Department of Education); Fred Gatto and Elizabeth Dubravcic (Division of Public Health, Delaware Department of Health and Social Services); Elizabeth Romero (director, Division of Substance Abuse and Mental Health, Delaware Department of Health and Social Services); Rochelle Lazorchak and Yvonne Bunch (Division of Prevention and Behavioral Health, Delaware Department of Services for Children, Youth and their Families); Laura Rapp (Center for Drug and Health Studies, University of Delaware). We would also like to thank Jim Highberger and Rochelle Brittingham at the Center for Drug and Health Studies who lead the youth surveys explored in this paper. For more information or to review the survey instruments, visit: https://www.cdhs.udel.edu/projects/delaware-focus/delaware-youth-andyoung-adults

REFERENCES 1. National Institute on Drug Abuse. (2019). Monitoring the future 2019 survey results: vaping. Retrieved from: https://www.drugabuse.gov/related-topics/trends-statistics/infographics/monitoring-future-2019-survey-results-vaping 2. Food and Drug Administration and the Centers for Diseases Control and Prevention. (2019). Youth tobacco use: results from the national youth tobacco survey. Retrieved from: https://www.fda.gov/tobacco-products/youth-and-tobacco/youth-tobacco-use-results-national-youth-tobacco-survey 3. Centers for Disease Control and Prevention. (2020). Quick facts on the risks of e-cigarettes for kids, teens, and young adults. Retrieved from: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/QuickFacts-on-the-Risks-of-E-cigarettes-for-Kids-Teens-and-Young-Adults. html#one 4. Food and Drug Administration. (2016). The “deeming rule”: vape shops. Retrieved from: https://www.fda.gov/media/97760/download

8. Jackler, R. J., Ramamurthi, D., & Louis-Ferdinand, N. H. (2019). Rapid growth of JUUL hashtags after the company ceased promotion. Stanford Research into the Impact of Tobacco Advertising, Stanford School of Medicine. Retrieved from: http://tobacco.stanford.edu/tobacco_main/publications/Hashtag_ JUUL_Project_7-22-19F.pdf 9. Rossheim, M. E., Livingston, M. D., Soule, E. K., Zeraye, H. A., & Thombs, D. L. (2019, July). Electronic cigarette explosion and burn injuries, US Emergency Departments 2015-2017. Tobacco Control, 28(4), 472–474. https://doi.org/10.1136/tobaccocontrol-2018-054518 10. Centers for Disease Control and Prevention. (2020). Outbreak of lung injury associated with the use of e-cigarette, or vaping, products. Retrieved from: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html 11. Center for Drug and Health Studies, University of Delaware. (2019). Polysubstance use among 11th graders. Retrieved from: https://www.cdhs.udel.edu/content-sub-site/Documents/Venn%20 Diagram%20Polysubstance%20use%20among%2011th%20grade%20 students.pdf 12. Centers for Disease Control and Prevention. (2018). Youth Risk Behavior Surveillance System (YRBSS). Retrieved from: https://www.cdc.gov/healthyyouth/data/yrbs/index.htm 13. Substance Abuse and Mental Health Services Administration Center for Application of Prevention Technologies. (2018). The role of adverse childhood experiences in substance misuse and related behavioral health problems. Retrieved from: https:// mnprc.org/wp-content/uploads/2019/01/aces-behavioral-healthproblems.pdf 14. Glazier, R. E., & Kling, R. N. (2013, April). Recent trends in substance abuse among persons with disabilities compared to that of persons without disabilities. Disability and Health Journal, 6(2), 107–115. https://doi.org/10.1016/j.dhjo.2013.01.007

5. Reisinger, D. (2018, Oct.). JUUL reached its $10 billion valuation 4 times faster than Facebook. Fortune. Retrieved from: https://fortune.com/2018/10/10/juul-vaping-pen-valuation-vs-facebook/

15. Kim, A. E., Chew, R., Wenger, M., Cress, M., Bukowski, T., Farrelly, M., & Hair, E. (2019, July 1). Estimated ages of JUUL Twitter followers. JAMA Pediatrics, 173(7), 690–692. https://doi.org/10.1001/jamapediatrics.2019.0922

6. U.S. Department of Health and Human Services. (2016). E-cigarette use among youth and young adults. A report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health. Retrieved from: https://www.cdc.gov/tobacco/data_statistics/sgr/e-cigarettes/ pdfs/2016_sgr_entire_report_508.pdf

16. Center for Drug and Health Studies, University of Delaware. (2019). 2019 Delaware Epidemiological Profile. Retrieved from: https://www.cdhs.udel.edu/content-sub-site/Documents/EPI%20Report%202019%20-%20Rev%20-%20102919.pdf 17. Centers for Disease Control and Prevention. (2018). Adolescent school health. Protective factors. Retrieved from: https://www.cdc.gov/healthyyouth/protective/index.htm

7. Jackler, R. J., Chau, C., Getachew, B. D., Whitcomb, M. M., Lee-Heidenreich, J., Bhatt, A. M., . . . Ramamurth, D. (2019). JUUL advertising over its first three years on the market. Stanford Research into the Impact of Tobacco Advertising, Stanford School of Medicine. Retrieved from: http://tobacco.stanford.edu/tobacco_main/publications/JUUL_Marketing_Stanford.pdf

18. Institute of Medicine. (2015). Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Richard J. Bonnie, Kathleen Stratton, and Leslie Y. Kwan, Eds. Retrieved from: https://www.nap.edu/catalog/18997/public-health-implications-ofraising-the-minimum-age-of-legal-access-to-tobacco-products

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19. Sharbaugh, M. S., Althouse, A. D., Thoma, F. W., Lee, J. S., Figueredo, V. M., & Mulukutla, S. R. (2018, September 20). Impact of cigarette taxes on smoking prevalence from 2001-2015: A report using the Behavioral and Risk Factor Surveillance Survey (BRFSS). PLoS One, 13(9), e0204416. https://doi.org/10.1371/journal.pone.0204416 20. Delaware General Assembly. (n.d.). Delaware regulations: Administrative Code: Title 14: 800 851 K to 12 Comprehensive Health Education Program. Retrieved from: https://regulations.delaware.gov/AdminCode/title14/800/851.shtml 21. Delaware Youth Drug Prevention Curriculum Task Force. (2019). 2019 Senate Concurrent Resolution 69 - Delaware Youth Drug Prevention Curriculum Task Force Final Report. Retrieved from: https://delaware.contentdm.oclc.org/digital/collection/p16397coll14/id/177 22. Centers for Disease Control and Prevention. (2019). Know the risks: a youth guide to e-cigarettes. Retrieved from: https://www.cdc.gov/tobacco/basic_information/e-cigarettes/ youth-guide-to-e-cigarettes-presentation.html 23. American Lung Association. (n.d.). INDEPTH: An alternative to suspension or citation. Retrieved from: https://www.lung.org/quit-smoking/helping-teens-quit/indepth 24. Department of Justice. (2020, Feb 25). Attorney General Jennings announces bi-partisan, multistate investigation of JUUL. Delaware NewsRetrieved from: https://news.delaware.gov/2020/02/25/attorney-general-jennings-announces-bipartisan-multistate-investigation-of-juul/

www.VapeFreeDE.org

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Across the nation, gaps in health are large, persistent and increasing—many of them caused by barriers unrelated to healthcare. After all, it's hard to be healthy when faced with challenges related to employment, education, and housing, for example. Health equity means increasing opportunities for everyone to live the healthiest life possible, no matter who we are, where we live, or how much money we make.

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78 Delaware Journal of Public Health – August 2020

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Define health equity in the delivery of healthcare, including cultural competence

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Student Essay Section

I Signed Up for This Kayla Morrell Medical Student, Sidney Kimmel Medical College; DIMER/Branch Campus Student

I signed up for this. My cousin Noah, who has spent the first (and only) 3 months of his life in the hospital, did not. As first-time parents, my uncle and aunt have been faced with a nightmare they couldn’t have even imagined. Not only was Noah born six weeks prematurely, he decided the best time to grace us with his presence was in the middle of a global pandemic. He spent some time in the NICU (Neonatal Intensive Care Unit) and when he finally graduated, his furry big brothers were thrilled by this new squirmy present their parents brought home, even if he made loud noises and smelled funny sometimes. Then, Noah started having difficulty breathing. Their pediatrician recommended they take him straight to the Emergency Room, but once there, they were greeted by disbelief that a pediatrician would send someone in such an at-risk demographic to the ER in the face of the COVID-19 pandemic. They were sent home. Unfortunately, he got worse and by the time they got back to the ER, he had to be intubated. To make matters worse, only one parent was allowed to be with him at a time. They were scared. Seemingly overnight, they, along with the rest of the world, were thrust into a COVID-19 stricken place, with public health terms scattered about and everyone thinking they know best. I signed up for this. They did not. I was able to talk to them (socially-distanced, of course) daily, calming their nerves and offering simple explanations behind the terminology the physicians were using. If I didn’t know it, I looked it up. In a time where medical students can’t directly help on the front lines, but

signed up to help their community, this was an opportunity for me to help those closest to me. And it paid off to see everyone’s relief when Noah was finally home again, although I think the puppies were happier than anyone. Though I might just be finishing up my first year of medical school, I knew that there would be times where I would be risking my own health for the wellbeing of my patients. I can’t say that I expected myself and my peers to be put in the face of a global pandemic this early in our careers; however, I joined the medical field to help my community. It is inspiring to see the way medical professionals before me are banding together to help save the world. I hope to encourage those younger than me in the same way. In a new elementary health curriculum I am creating with Nemours, we did a lesson about COVID-19 on the very last day before schools were closed. The students played Virus Tag to show how easily infection can spread and did an experiment to show how soap helps protect you from germs. To say they loved it would be an understatement. I signed up to help my community in any way possible, even if I’m not yet on the frontlines saving lives. Not only am I inspired by the healthcare professionals paving the way ahead of me, but also by those who are following in my footsteps, albeit they have quite a few years of school to go. But one day when it’s time for Noah to start medical school, I’ll show this to him and say, “Kid, you were literally born for this.”

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80 Delaware Journal of Public Health – August 2020

COVID-19: An impasse between livelihood and health Karthi Jayakumar Medical Student, Philadelphia College of Osteopathic Medicine

It is a well-known fact that in America, socio-economic status may put individuals at a disadvantage in terms of healthcare. These health disparities in the United States have been especially highlighted during the COVID-19 pandemic. This virus has disproportionally affected low income and homeless populations; there is a domino effect on access to healthcare, nutrition and personal hygiene. Those who do not have proper access to one of these things will most likely not have proper access to the rest. Through my work with my family’s non-profit organization, Charity Crossing, I have been able to work with the underprivileged communities in Wilmington, Newark, Dover, and Maryland. I have seen first-hand that lack of proper nutrition places individuals at a higher risk for diabetes and obesity, which come with a host of other comorbidities, including COVID-19.

made us rethink our values and regain perspective. The negatives are certainly undeniable, but globally, people have been lending a helping hand. Hopefully, after this tragedy, people will continue to recognize the value in that helping hand, and never cease to offer support to those who need it. As a future physician, I’m grateful to be a part of this cultural change. I hope to take these life lessons into my practice by understanding the inequities that exist within our current system and actively work to address them to create a more just and accessible system for all American citizens. That is the America I believe in, and the America I hope to see in the future.

During this pandemic, we have launched a No One Hungry Fundraiser that serves meals to those affected by COVID-19, including hospitals, old age homes and various homeless populations in Delaware, Maryland, and Philadelphia suburbs. So far, we have raised $31,500, served 6,132 meals, and plan to distribute 2,000 more by the end of June. Especially in Wilmington, we have been experiencing a higher volume of those coming to receive meals during this pandemic– a testimony for the amount of people experiencing food insecurity. Delaware was quick to provide resources to students that were now unable to secure their school provided meals, and the food banks did a wonderful job supplying to those in need, but this also highlighted a deficit. Those who do not have cars or means of transportation still struggle to receive what is provided for them. While most are able to take shelter in their homes, not everyone has the same luxury. Some are unable to work from home and must work to deliver essential services, while others provide care for those who have fallen ill. Essential workers have been sacrificing their livelihoods as well as putting their families at risk to keep our country running. Parents who are still working also may have to actively seek childcare, which makes social distancing challenging. In addition, the homeless population is extremely vulnerable; in many shelter homes, social distancing is not attainable. To achieve some form of distancing, officials in Las Vegas resorted to painting squares on the concrete parking lot to allow social distancing while sleeping. Other states, including Delaware, were able to take this to the next level and provide housing in vacant hotels. This virus has put the world at an impasse between livelihood and health. It has had a devastating effect, mentally, economically, and socially. The hope is that this will be a blessing in disguise, to unite humanity as we realize that everyone is equally susceptible – no matter the economic, social, or political status. Although we can only hope that a vaccine will be available to offer us some protection, we will never again take for granted the simple act of shaking hands, going to concerts, and attending crowded restaurants and bars. This has truly brought inequalities to light, 81

Student Essay Section

CareVio and Coronavirus: The Front Line for Delaware Medical Students Thomas Marconi Medical Student, Sidney Kimmel Medical College; DIMER Student

I stood in front of the bathroom mirror, glaring at a sentinel gray hair growing from my beard. Me, old? My first grays aren’t supposed to come until intern year! Regardless, here I am, and I can’t help but wonder who I will be when I am full of grays. I often dream of being a fully trained doctor - educating students, collaborating with patients, and caring for my family. At this point in my training, it all seems so far away. By the time I enter that level of my career, medicine will be vastly different. I’ll gather the residents and students around the video screen; the patient, at home, will pop the bluetooth diaphragm on to their chest. We’ll listen to each valve, discussing the physiology playing out before us. I will fondly recall the days of using a tangible stethoscope - an exceedingly simple, yet beautiful instrument that symbolizes the intimate moment of listening to another human’s heartbeat. The thought of the stethoscope ending up in a glass display case hurts the young medical student in me. As I continued to look in the mirror, trying to hang on to that youth - is it a blonde hair? - I was comforted by the thought of my experiences with telemedicine over the last 10 weeks. The trial of which was brought on by the coronavirus pandemic. I was half way through my obstetric and gynecology rotation at Christiana Hospital when coronavirus caused sweeping changes to our daily lives. I was about to enter a two week stretch of labor and delivery when students were removed from the clinical setting. A quintessential landmark of medical school, delivering a baby, is an experience I have yet to obtain. I, like everyone else, found myself trapped at home trying to navigate the unfamiliar world we live in now. I sought an opportunity - some way to contribute to the fight. In March of 2020, that chance arrived - virtually, that is. Myself and other medical students were recruited to CareVio, Christiana’s virtual practice, now tasked to monitor patients with coronavirus. The staff was pieced together, many ousted from the operating room - all of us naive to the virtual world. With the pressure to meet the needs of the Delaware community, we built the plane as we were flying it. Eventually, the medical students found their niche. CareVio utilizes a texting application known as Twistle like “whistle” or do you say it “Twizzle” maybe “Twist-le?” You can ask around, it’s still up for debate. The application gives us the capacity to survey and text hundreds of patients at a time to monitor their symptoms. We, the medical students, utilize it to act as a virtual information desk and triage service for the community. We speak with over 200 patients a day, answering questions, providing recommendations for symptomatic relief, coordinating testing, upgrading patients for virtual doctor visits, and even calling ambulances. Our service provides the next level of continuity of care. Daily monitoring, daily interactions, available 13 hours a day, 7 days a week while the patient sits in the comfort of their own home! The public response has been surreal. “Thank you. This whole process has been very soothing. Delaware has got it together! Be safe! We appreciate you!”-Patient monitored via Twistle 82 Delaware Journal of Public Health – August 2020

“Thank you for this great service! Everyone I encountered during this was caring, empathetic, and professional. I have nothing but the highest praise and gratitude for the wonderful care I received during my illness!!”-Patient monitored via Twistle “Yahoo! I am negative. I just love you to pieces. Thank you so much Thomas. Now you get a new patient that needs you. Please stay safe. You guys have been my guardian angels and I pray you all stay safe, and that this ends sooner than expected.”- Patient monitored via Twistle The last was from an elderly patient who had been cooped up in her home. At the time, testing was severely delayed, and she was left to ruminate if her cough and fever were going to take a turn for the worse. I had been communicating with her for over a week. We talked everyday until finally her result came in - negative! Over the next few days, her condition improved. She and I did not share the traditional patient-doctor relationship I’m not that naive - but I do believe the connection we made was genuine. During this experience, I’ve had continuity with entire families, helped people get psychiatric care, walked someone through the grief of losing multiple family members to the virus, and it all had to be done with a keyboard. It’s not the type of care people are used to, but the results speak for themselves. I’ve realized I will spend more hours in the virtual practice than I will in any other third year rotation. Students have started to master Twistle and are now encouraged to shadow virtual visits. I’ve received education on “webside manner” - how clever is that? - and the tricks of conducting a virtual physical exam, including forceful breathing exercises for auscultation and using a patient’s belly button to help them navigate abdominal palpation. Other techniques, like a lymph node exam, can be led by physician demonstration. The advancement of telemedicine will not just happen because everyone is comfortable using Zoom now, but because a young generation of doctors has been forced to adapt, and we’ve seen a glimpse of what it can be. There is no going back. Even now, it is sufficient to act as an outpatient triage, exceptionally designed to meet our current needs. As technology and patient comfort improves this avenue of care will start to rival its in-person predecessor. As of mid-May we’re still working. Twistle, which started as a crude and buggy platform, has now been refined. We grew from four to eleven trained and independently functioning medical students. All of us are balancing this volunteer work with virtual classrooms and preparing for our boards. Over 2,200 people have enrolled into Twistle and many of them have shared their appreciation for the service we provide. Everyone at CareVio who was expelled from their usual work environment has started to become a little family. This family, a time capsule, is what I will remember most from the pandemic. Not the surgical masks, not the gloves, nor the 6 foot squares duct taped to tiles in the grocery store line. When medical students in the future ask me to recall the events that played out during the coronavirus pandemic, I’ll

tell them about the dedication of Chelsea, a fellow student, who volunteered 70 hours a week to get this service off the ground. I’ll tell them about Zahide, “Z”, a wonderful teacher and friend who solved every single PowerChart problem I had. I’ll tell them about the dozens of masks Tina’s 93-year-old mom made for everyone (mine is peach colored with white roses). Mary Jo’s chocolate covered pretzels and Megan’s hand written cards. That despite the social distancing, I’ll remember how we all came together. Eventually, this pandemic will come to pass, and we will return to a sense of normalcy. A new era of medicine will be ushered in, one that is marked with telemedicine and video visits integrated throughout. We will emerge smarter, sleeker, and more sophisticated. Just today, I received the official word. In four weeks, I’ll be headed back to the clinical setting. With it came the instruction to be clean and shaven so I can don an N95 mask. That’s how I ended up in front of the mirror. My short white coat has been washed and pressed and I’ve cleaned the dust off my stethoscope - it’s not a relic just yet. I’ve seen the foundations of how we will move forward and it comforts me. The traditions of medicine will be safe in the virtual world.

A Message of Gratitude COVID-19 has, and continues, to challenge us all. The impacts are precedent setting, and we want to thank and stand in solidarity with our colleagues who are first responders, healthcare providers, healthcare institutions, long-term care facilities, and public health professionals. From the highest levels of State leadership, to those providing direct care and service, the Delaware response is evidence-based and evolving based on the experience, expertise and planning of front-line health care institutions and professionals, our state partners, new data, and directives from the CDC and other components of the Federal Government. Please join us in taking a moment to thank those who are working tirelessly on behalf of the well-being of all Delawareans.

@delamed1

Delamed.org

@delawarehealth1 deha.org

@dhsa1 dhsa.org

@MedicalSocietyofDelaware medsocdel.org

#thanksdelawarehealthcare 83

Student Essay Section

Public Health Implications for the Future: Unifying a Fragmented System Sky Prestowitz, D.O. Resident, Internal Medicine and Pediatrics, Case Western Reserve University MetroHealth System

When the picture of mass graves in the Bronx, New York shows up in the New York Times daily inbox summary email, it becomes apparent that the United States (US) is experiencing unprecedented times. This comes as a shock in a country that has been fortunate to avoid nationwide domestic crisis for decades. The pandemic is a public health crisis that demands understanding of the current state of public health in America in order to truly understand how our country is managing the situation. The COVID 19 epidemic highlights the importance of understanding Public Health and preventive medicine as a vital component of the American medical system. Over the past few centuries in America, Public Health has been in a process of growth and maturation mirroring the rise of modern government and an increasingly global economy. Public Health emerged as a facet of the nation’s medical system around the turn of the twentieth century. New York City was the location of the first public health department in America in 1866. By 1900, 40 states had developed similar public health departments. By 1912, the Marine Hospital Service was formed, which evolved into the US Public Health Service. Federal involvement in Public Health grew out of these early movements. In 1922 the Children’s Bureau created the first federal program to provide grants to states, establishing a new level of federal influence. As the country marched into the thirties and forties, the federal public health system began to resemble much of what it does today. The current structure of the federal component of public health is of import in this crisis. Right now, the Department of Health and Human Services (HHS) is the umbrella organization at the federal level. The HHS is part of the president’s cabinet which includes 15 different executive departments from the HHS to Veterans Affairs to Transportation to the Treasury and others. Underneath this umbrella there exist familiar organizations that we now consider almost synonymous with modern medicine including the Center for Disease Control (CDC), National Institute of Health (NIH), Food and Drug Administration (FDA), and Center for Medicare and Medicaid Services (CMS). The level of infrastructure and organization that has evolved within each element of the HHS is impressive and inspiring. Yet, digging deeper into government spending elicits a striking incongruency suggesting that this growth was not always adequately proportioned to the growth within the medical system. For example, in 1960 total health expenditures rose from $26.7 billion dollars to $1.3 trillion dollars in 2000. The corresponding increase in public health expenditure was vastly different growing from $192 million to $17 billion. The effects of this incongruent spending raise some questions about the 84 Delaware Journal of Public Health – August 2020

adequacy of available public health resources. To adequately understanding the American Public Health system as it evolved and as it exists today, it is essential to remember that American government is a Federalist system, in which states have a significant degree of autonomy in running their own affairs of both law and public health, among other things. The Civil War is the most blatant example of how our government not a purely top-down or homogenous authority. About 25 years after the end of the Civil War, Congress wrote into law the Epidemic Disease Act of 1890. This law was invoked to prevent a certain practice called “shotgun quarantine” in which one state would claim to quarantine another. This practice used yellow fever outbreaks as a guise for the hidden agenda to create economic advantage. At the time this law was written, the Marine Medical Service – which was funded by the federal government – was given the authority to nullify state and local shotgun quarantines when deemed inappropriate. Although far removed from modern times, this example illustrates the importance of interplay between state autonomy and the federal government. It also points to the imprint that this federalist system has made on the structure of American public health. Exploring modern examples will help to elucidate the ways in which our federalist system still impacts the structure of public health. Consider the Opioid epidemic. Before the current pandemic, this national crisis was at the forefront of public health law-making and effort. The federal and state response to this epidemic reveal the function of public health structure within the US. Steep rises in opioid addiction and related deaths between 2010 and 2014 provoked both federal and state governments to action. The CDC made recommendations to state and local hospital systems mainly via adjustments to their published guidelines. The FDA provided an adjustment to regulations over these medications. The NIH continued to fund and conduct research. And another federal organization called the Drug Enforcement Administration (DEA) acted to close pill mills, or doctors’ offices illegally distributing these drugs. Despite their involvement, these federal systems were mostly limited in their ability to impact change on the ground, leaving the work of response up to the states. States oversaw their own department of justice responsible for related criminal arrests and charges. State medical boards in charge of licensing physicians were more effective at modifying medical practice. In addition, states had the ability to influence hospitals who had their own credentialing and privileging requirements. Despite work to address the opioid epidemic within each individual state, a lack of consistency characterized the national response to the problem. States began building

prescription drug monitoring programs (PDMPs) to track the distribution and consumption of controlled substances. These projects were limited by the inability to share information across state borders. In addition, the financial burden on individual states was great. States became so involved in this work that they began suing opioid producing companies in order to recoup the increased costs and damages related to treating addiction within their communities. If looking for ways to improve, a logical connection would be the possibility of a more uniform response organized and funded by the federal government. A similar argument for more consistent federal leadership can be made in the case of tuberculosis (TB) screening. The US response to TB screening is delegated to state and local public health officials. This lack of federal involvement results in widely variable policies. Under current practices, only 18 states mention that all healthcare workers should be screened for TB and seven of those states recommend hospital workers only. Similarly, only 13 states require all staff and inmates within correctional facilities to be tested. In addition, although 66% of TB within the US is a result of foreign-born individuals, screening for latent and active TB is only required for refugees seeking permanent US residence. Advocates for moving towards more consistent TB screening across states recognize that this would only be possible in the context of increased federal monetary and political support. In the field of public health, concern about this fragmented system has been brewing and has occasionally bubbled to the surface. From 2003 to 2007, Bill Frist became the first physician senator since 1928. During his term as Senator, he wrote an article in the journal Health Affairs which pointed out a need for increased federal involvement to resolve some of this fragmentation. His primary reason for concern arose from evaluation of the anthrax attacks and events of September 11 raising suspicion about future bioterrorism within the United States. In his article he points out that, despite actions in the Bush administration to increase state and local response to biological warfare, there remained an important and unfulfilled role for the federal government to unify a response plan that was dependent on state and local public health capacity. The threat of bioterrorism did not carry enough weight with the country’s political agenda. About 18 years later, Polly Price, professor of law and global health at Emory University, published a paper that addressed the same concerns about the fragmented public health system this Federalist government had produced. Her concern was expressed in the context of federal versus state jurisdiction surrounding quarantine. Her extensive report on the laws and structures that govern quarantine within the US reveal the same dependence on states to make decisions versus a unified federal response. Her paper shows prescient concern for the consequences of a conflict between state and federal government in response to an infectious disease outbreak. Directly quoted she says, “these conflicts can occur when uniformed or excessive panic drives political decisions

in a manner detrimental to effective control of a national epidemic.” The unfortunate events of recent history could not have revealed this fragmentation in a more heartbreaking form of tragedy. As of this writing, there are 34,309 Americans dead and trillions of federal dollars spent to avoid a worse catastrophe. This is not to mention the impending economic depression. In one funny medical cartoon the doctor asks, “which is better: one hour of exercise or 24 hours of death?” Perhaps it would be too cruel to make a corresponding cartoon posing a similar question about public health spending. Benjamin Franklin must be turning in his grave and mourning our decided inattention to his famous quote, “an ounce of prevention is worth a pound of cure.” The evidence of a fragmented public health system is not only obvious, it glares like a violation of what it means to live in America. States are thrown to the wolves to bid in an international market for medical supplies that everyone needs. States even outbid each other in bidding wars that could mean life or death for one hospital nurse, if not hundreds or thousands of patients. States are unable to test individuals, as the country has a severe lack of reagent to perform a basic polymerase chain reaction viral screen. Restaurant doors are closed, businesses are closed, millions of Americans are jobless. Some say hindsight is twenty-twenty and prevention is rarely a priority. But in the light of mind-numbing statistic, inconsolable tears, and thousands of people who were forced to die alone it can’t be too naïve to ask: WHAT WILL WE DO DIFFERENTLY?

RESOURCES Frist, B. (2002). Public Health And National Security: The Critical Role Of Increased Federal Support. Health Affairs, 21(6), 117–130. https://doi.org/10.1377/hlthaff.21.6.117 Price, P. J. (2017). Do State Lines Make Public Health Emergencies Worse? Federal Versus State Control of Quarantine. Emory Law Journal, 67(3), 491–543.

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Student Essay Section

A Grief All Its Own Mary Blumenfeld Sidney Kimmel Medical College, Class of 2022; DIMER/Branch Campus Student

On the morning of Friday, March 20, my sister called me to tell me two things. First, our dad was in isolation because he had been in court for two weeks with another lawyer who had just tested positive for COVID-19. Second, our mom was at Wilmington Hospital, but don’t worry, it wasn’t COVID. I sent messages to a few of my closest friends that I was somewhat worried about my dad having been exposed because, at 67, he was in an at-risk age group. They all responded with optimistic support: “I’m sure he’s going to be okay!” I hadn’t even mentioned my mom being in the hospital because it didn’t seem like a big deal, relatively speaking. She’d been to the hospital numerous times in the past several years and it always turned out to be “nothing,” so to speak. But on Saturday morning, my sister called me again. My sister never calls me, so seeing her name light up on my phone two days in a row was cause for alarm. I braced myself for what was inevitably going to be an update about our dad that I didn’t want to hear, that he had tested positive and was having trouble breathing. “Mar, so I just talked to Mom’s doctor at the hospital. She’s in pretty bad shape. He thinks there’s a good chance she’s not going to make it.” What? Why are we talking about Mom? I thought Dad was the one we were supposed to be worrying about. When I called the hospital, my mom’s doctor confirmed that things were not looking good. “Unfortunately, we can’t allow any visitors in the hospital right now.” Excuse me? My mom is literally about to die and I can’t see her? “If things continue to go downhill, we will allow you to come in to say your goodbyes, but we can only let one visitor in the hospital at a time.” I asked him how long he thought she had left. I was in Center City Philadelphia; I didn’t want to be 45 minutes away when I got the call saying it was time, but I couldn’t exactly go wait at my dad’s house, and I didn’t want to go to my sister’s house because I didn’t want to risk exposing her two young girls. “Honestly,” the doctor said quietly, “I would start driving to Wilmington if I were you.” By the time I got to the hospital, my sister had already been allowed in, which meant my mom’s condition had deteriorated. I knocked loudly on the hospital door, noting its unusual locked state, and a man donning a full suit of PPE came outside to ask what I needed. 86 Delaware Journal of Public Health – August 2020

“My mom. She’s sick. I mean, she’s not sick, she’s dying. I mean, she is sick, but she’s also dying.” I stopped to try to catch my breath and my thoughts. “She’s in there,” I pleaded. “I need to get in there.” He asked me if I had been feeling any flu-like symptoms or had a sore throat recently. “No and no.” “Have you had any shortness of breath?” Only because my mom is dying. “Have you had a fever?” “No.” “Have you been around anyone with a suspected or confirmed case of COVID in the past 14 days?” “No.” “Have you been outside the country in the past 14 days?” “No.” He stepped aside to let me in, and I headed straight back to the information desk and told them who I was there to see. “Have you had any flu-like symptoms?” Seriously? My mom is dying. I didn’t develop flu-like symptoms in the three seconds it took me to get from the entrance to this desk. “No.” “Have you had a sore throat?” “No.” “Have you had any shortness of breath?” “No.” “Have you had a fever?” “No.” “Have you been around anyone with a suspected or confirmed case of COVID in the past 14 days?” “No.” “Have you been outside the country in the past 14 days?” “Still no.” “It looks like your mother already has a visitor. I think it’s your sister, or maybe her sister. She needs to exit the hospital before we can let you up. You’ll need to wait outside away from the entrance, past the walkway.”

My sister and I wouldn’t even both be allowed in the room with our mom in her final moments. How were we supposed to choose which one of us would be with her at the end? Our brothers lived in Minnesota and Arizona; there was no point in them even trying to get home, so at least it was a choice between two rather than four. What an odd thing to be grateful for. Fortunately, my mom’s two sisters lived close enough to meet us where we were waiting outside the parking garage, and we all took turns going in and out to be with her. While one of us was in the hospital, the other three shuffled between sitting and standing and pacing in a construction site about 100 yards away from the hospital entrance, careful to maintain six feet between each of us. An awkward triangle desperately wishing to collapse into a single point. When it was clear that my mom didn’t have much time left, the oxygen mask was removed, the morphine drip was started, and the medical team very graciously decided to let all four of us stay in the room with her until the end under the condition that we all maintained an appropriate distance between each other. My mom died early Sunday morning. Against protocol, the four of us were there next to her, and I am so grateful for that. But we didn’t get to have a proper funeral or sit shiva. We still haven’t been able to hug each other. My brothers haven’t been able to come home. Going through the grieving process in a period of physical and social isolation is a grief all its own. Through this grief, I learned too well how COVID has the ultimate control, capable of invading not only your respiratory tract but every aspect of your life. Somehow these invisible little particles together formed a colossal barricade against the things we might usually take for granted, still invisible but in no way inconsequential. Physiologically, my mom’s death was unrelated to COVID, and yet her death was so intimately tangled with these tiny but formidable particles, a marionette with its strings manipulated by a puppeteer who was both invisible and merciless – an utterly dangerous combination. COVID isn’t what killed my mom, but her death is what made COVID a harrowing – and humbling – reality for me.

Since her death, I have found myself progressively unsettled by the ubiquitous term “social distancing.” My mom and I had a complicated relationship, as many parents and children do, and I distanced myself from her quite a bit during the last few years of her life. She was already unconscious when I got to the hospital, and I realized it had been over a year since I’d last seen her, but what felt worse was that I hadn’t even talked to her since her birthday in November. Truthfully, physical distance often did a lot of good for our relationship, but how hard would it have been to pick up the phone and talk to her for five minutes, even just once a month? I will regret my choice to socially distance myself from her for the rest of my life, so I want to reframe the way I think and talk about the difficult but necessary current distancing practices. We should be distancing ourselves not socially, but physically. Perhaps it’s just a matter of semantics, but the words we choose often have a larger impact on our actions and beliefs than we may think. This is an absolutely critical time to be social. The frenzy around procuring resources and pervasive fear of the unknown have yielded a trend of concern for self over community, which over time will only weaken our ability to fight the virus together. COVID has made room for antisocial and divisive reactions, such as supply hoarding and price gouging, to infiltrate society like opportunistic infections that thrive under conditions of isolation. If we want to make it through this scary and chaotic time, maybe we should focus on the fact that the entire world has a common goal right now. Really, how often is the world united like this? Everyone is anxious, so talk to each other about it. Check in with each other. Use your anxiety as a catalyst for connection rather than conflict. Stick together socially; distance yourselves physically. Write someone a letter, call an old friend, and – please, if you can – call your mom.

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DELAWARE COVID – RESOURCES Centers for Disease Control and Prevention COVIDView: https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html General Guidance: https://www.cdc.gov/coronavirus/2019-nCoV/index.html

Centers for Medicare and Medicaid www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/CurrentEmergencies-page Delaware Coronavirus Dashboard https://coronavirus.delaware.gov/

Frontiers Coronavirus Funding Monitor https://coronavirus.frontiersin.org/covid-19-research-funding-monitor

Johns Hopkins, Coronavirus Resource Center: https://coronavirus.jhu.edu/ Massachusetts General Fast Literature Updates: www.massgeneral.org/news/coronavirus/treatment-guidance/fast-literature-updates

National Academy of Medicine Resources: https://nam.edu/coronavirus-resources/

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DELAWARE COVID – LEXICON A priori Relating to or denoting reasoning or knowledge which proceeds from theoretical deduction rather than from observation or experience.

ACE-2 Protein An enzyme attached to the cell membranes of cells in the lungs, arteries, heart, kidney, and intestines

ADHD Attention Deficit Hyperactivity Disorder

Adaptive Immune System Subsystem of the immune system that is composed of specialized, systemic cells and processes that eliminates pathogens by preventing their growth.

Aerosolization The process or act of converting some physical substance into the form of particles small and light enough to be carried on the air i.e. into an aerosol.

Aggregate A whole formed by combining several (typically disparate) elements.

Agnostic Denoting or relating to hardware or software that is compatible with many types of platforms or operating systems.

Aliquot A portion of a larger whole, especially a sample taken for chemical analysis or other treatment.

Anhedonia Inability to feel pleasure.

Antibodies Antibodies are substances made by the body’s immune system in response to bacteria, viruses, fungus, animal dander, or cancer cells. Antibodies attach to the foreign substances so the immune system can destroy them. IgG: found in all bodily fluids, and are an indication of previous infection. IgM: found in blood and lymph fluid and are the first type of antibody made in response to an infection.

Antigen A toxin or other foreign substance which induces an immune response in the body, especially the production of antibodies.

Apical surface Surface of an epithelial cell that faces the body surface, a body cavity, the lumen of an internal organ or a tubular duct that receives cell secretions.

Assay An assay is an investigative (analytic) procedure in laboratory medicine, pharmacology, environmental biology and molecular biology for qualitatively assessing or quantitatively measuring the presence, amount, or functional activity of a target entity.

Atomistic Viral Particle The atomic parts (neutrons, electrons, protons) of a virus.

Bioinformatics Combination biology, computer science, information engineering, mathematics and statistics to analyze and interpret the biological data.

Bimodal A probability distribution with two different modes. These appear as distinct peaks in the probability density function.

Biomarker A measurable substance in an organism whose presence is indicative of some phenomenon such as disease, infection, or environmental exposure.

Blind Validation Information that may influence the researchers validating the process is withheld. 89

cDNA DNA that is complementary to a given RNA strand, which serves as a template for synthesis of DNA in the presence of reverse transcriptase.

Comorbid The simultaneous presence of two chronic diseases or conditions in a patient. Computational Structural Virology Computer simulations focusing on the structure of a virus.

Concordant In agreement, consistent.

Conjugate Coupled, connected, related.

Convalescent plasma The liquid part of blood that is collected from patients who have recovered from a disease, that contains antibodies to that disease.

Cross-Reactivity Analyses A process of determining if two particles react with one another.

Cryo-electron Microscopy An electron microscopy technique applied on samples cooled to cryogenic temperatures and embedded in an environment of vitreous water.

Cytokine Storm A severe immune reaction in which the body releases too many cytokines into the blood too quickly.

DNA Methylation A biological process by which methyl groups are added to the DNA molecule.

Disintermediate Reduce or eliminate the role of (an intermediary).

Efficacy The ability to produce a desired or intended result.

En bloc All together or all at the same time.

Enteric Feeding Tube A tube surgically placed in the stomach, to be used for nutrition.

Epidemiological Modeling A model of disease transmission in a geographical area.

Epigenetic Relating to or arising from nongenetic influences on gene expression.

Equipoise A balance of forces or interests.

Etiology The cause, set of causes, or manner of causation of a disease or condition.

Exogenous Relating to or developing from external factors.

Frustum The portion of a cone or pyramid which remains after its upper part has been cut off by a plane parallel to its base, or which is intercepted between two such planes.

Genome The set of chromosomes in a gamete or microorganism, or in each cell of a multicellular organism.

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Genomic Surveillance The ongoing systematic collection of data relating to the genome.

Glycan Another term for polysaccharide.

Hematologic Toxicity Decreased counts of blood cells: neutropenia (neutrophils), anemia (red blood cells), leukopenia (white blood cells), lymphopenia (lymphocytes), and/or thrombocytopenia (platelets).

Heterogeneity The quality or state of being diverse in character or content.

Histopathology The study of changes in tissues caused by disease.

Hyperactivation Overactivation.

Hyperinflammatory Overactivation of the inflammatory pathways.

Hypoxic Low oxygen

Immunocomplex The complex formed between an antigen and an antibody.

Immunomodulator A chemical agent (as methotrexate or azathioprine) that modifies the immune response or the functioning of the immune system.

Immunophenotype The proteins expressed by cells.

In silico Conducted or produced by means of computer modeling or computer simulation.

In vitro Performed or taking place in a test tube, culture dish, or elsewhere outside a living organism.

In vivo Performed or taking place in a living organism.

Incidence The probability of occurrence of a given medical condition in a population within a specified period of time.

Lateral Flow Chromatographic Immunoassays Simple devices intended to detect the presence of a target substance in a liquid sample without the need for specialized and costly equipment.

Leukocyte White blood cell.

Limit of detection The lowest quantity of a substance that can be distinguished from the absence of that substance with a stated confidence level.

Lipid bilayer A thin polar membrane made of two layers of lipid molecules. These membranes are flat sheets that form a continuous barrier around all cells.

Lumen The inside space of a tubular structure, such as an artery or trachea.

Lyophilized Primer Freeze-dried molecule that serves as a starting material.

MERS Middle Eastern Respiratory Syndrome 91

Metagenomics The study of genetic material recovered directly from environmental samples.

Monoclonal antibodies An antibody produced by a single clone of cells or cell line and consisting of identical antibody molecules.

Nasogastric Tube A tube inserted in the nose, leading to the stomach, and used for nutrition.

Nasopharyngeal The upper part of the pharynx, including the nose and throat.

Negative Predictive Value The probability that subjects with a negative screening test truly do not have the disease.

Neurocognitive Denoting or relating to the neural processes and structures involved in cognition (thinking).

Nuclear Magnetic Resonance Spectroscopy A technique to observe local magnetic fields around atomic nuclei.

Nucleocapsid The capsid of a virus with the enclosed nucleic acid.

Oligo Sequence/Oligonucleotide Oligonucleotides are short DNA or RNA molecules, oligomers, that have a wide range of applications in genetic testing, research, and forensics

Oropharyngeal Relating to the part of the pharynx that lies between the soft palate and the hyoid bone (the mouth and throat).

Pathogens A bacterium, virus, or other microorganism that can cause disease.

Pathophysiology The disordered physiological processes associated with disease or injury.

Pentameric Ion Channel A transmembrane ion channel which open to allow ions to pass through a cell membrane.

Phenotype The set of observable characteristics of an individual resulting from the interaction of its genotype with the environment.

Polymerase Chain Reaction A method widely used to rapidly make millions to billions of copies of a specific DNA sample, allowing scientists to take a very small sample of DNA and amplify it to a large enough amount to study in detail.

Predictive Power The ability of a scientific theory to generate testable predictions.

Prevalence The proportion of a particular population found to be affected by a medical condition at a specific time.

Proinflammatory State The state of the body when mediators, factors or substances that support or exacerbate inflammation are present.

Prophylaxis/Prophylactic Action taken or substance used to prevent disease.

Quantitative Relating to, measuring, or measured by the number of something rather than its quality.

Reagent A substance or mixture for use in chemical analysis or other reactions.

Restriction endonuclease An enzyme that cleaves DNA into fragments at or near specific recognition sites within molecules known as restriction sites. 92 Delaware Journal of Public Health – August 2020

Retrospective Looking back on, or dealing with past events or situations.

Reverse Transcriptase An enzyme used to generate complementary DNA from an RNA template, a process termed reverse transcription

SARS Severe Acute Respiratory Syndrome

Sensitivity The ability of a test to correctly identify those with the disease (true positive rate).

Seroconversion The time period during which a specific antibody develops and becomes detectable in the blood.

Seroepidemiological Investigation Epidemiological investigations involving the identification of antibodies to specific antigens in populations of individuals

Serological Survey A survey to quantify the proportion of people positive for a specific antibody.

Serology Testing Blood tests to look for antibodies.

Specificity The ability of the test to correctly identify those without the disease (true negative rate).

STEM Science, Technology, Engineering, and Math

Stochastic Randomly determined.

Thromboembolism The obstruction of a blood vessel by a blood clot that has become dislodged from another site in the circulation.

Throughput The amount of material or items passing through a system or process.

Tidal Volume The lung volume representing the normal volume of air displaced between normal inhalation and exhalation when extra effort is not applied. For healthy, young, adults, this amount is approximately 500 mL per inspiration, or 7 mL/kg body mass.

Translational Research The process of applying knowledge from basic biology and clinical trials to techniques and tools that address critical medical needs.

Vacuum Manifold A simple way to process multiple samples using pressure control to assure samples are processed with high reproducibility.

Validation The action of checking or proving the validity or accuracy of something.

Vascular Perfusion The passage of fluid through the circulatory system to an organ or a tissue, usually referring to the delivery of blood to a capillary bed in tissue.

Verification Studies A study to check that the product, service, or system meets requirements and specifications, as well as fulfilling its purpose.

Viral Variant Analysis A study to determine the different parts of a virus, and to determine the similarities and differences of the viruses studied.

Viremia A viral infection of the blood.

X-Ray Crystallography The experimental science determining the atomic and molecular structure of a crystal, in which the crystalline structure causes a beam of incident X-rays to diffract into many specific directions. 93

ISSUE BRIEF

What we are learning from COVID-19 about being prepared for a public health emergency LESSONS WE ALREADY KNEW The novel coronavirus, SARS-CoV-2, the virus that causes COVID-19, emerged in late 2019 and swiftly brought about the worst global public health emergency in a century, inflicting an extraordinary toll on the lives, livelihoods, and well-being of people across the globe. Governments everywhere are now racing to protect their people and contain the damage. As unimaginable as the crisis feels, it was commonly predicted by infectious disease experts.1 Indeed, two years ago, the Centers for Disease Control and Prevention (CDC) posed the critical question in a symposium on the 1918 influenza pandemic: “100 Years Since 1918: Are We Ready for the Next Pandemic?” 2 The presentation prophetically warned of disruptions in medical supplies and services, inadequate ventilator access, high economic costs, and a lengthy vaccine development process. Eventually, this pandemic will be behind us, and there will surely be examinations of the strengths and weaknesses of the world’s response, including in the United States, and how we can be better prepared for the next pandemic emergency. But public health experts already knew much of what needs to be done long before the outbreak began. The COVID-19 crisis has illuminated the critical need for federal, state, local, tribal, and territorial leaders to take steps to shore up the nation’s preparedness for the long term, even as the current response is ongoing. This issue brief lays out four major issue areas that need attention: funding and coordination, medical countermeasures, healthcare readiness, and equity and resilience.

MAY 2020

This issue brief summarizes themes and recommendations covered in greater depth in two recent Trust for America’s Health (TFAH) reports: Ready or Not: Protecting the Public’s Health from Diseases, Disasters and Bioterrorism and The Impact of Chronic Underfunding on America’s Public Health System: Trends, Risks and Recommendations, 2020 as well as work by TFAH’s Promoting Health and Cost Control in States (PHACCS) initiative.

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FUNDING AND COORDINATION The COVID-19 pandemic has exposed the impact of chronic underfunding of America’s public health and emergency preparedness systems. Only five states have over 50 percent of their population served by a comprehensive public health system, leaving 45 states in which less than half of their residents are served by a comprehensive system.3 Furthermore, more than 56,000 local public health jobs were eliminated between 2008 and 2017 — nearly one quarter of the workforce.4 This underfunding has real consequences, as health departments struggle to respond to the biggest public health crisis in a century with archaic technologies and inadequate staffing levels. Building and maintaining a public health system, one capable of effectively protecting and promoting health across the country, requires a significant increase in funding above recent levels, a wise investment considering the much larger costs (in lives, dollars and economic disruption) of responding to uncontrolled epidemics, chronic diseases, environmental dangers, and other crises. The Public Health Leadership Forum, a group of the nation’s top public health thought leaders and practitioners, has called for increasing annual funding by $4.5 billion5 for public health infrastructure in state, territorial, tribal and local public health agencies. Funding increases of this size are necessary to ensure every community is served by a comprehensive public health agency and to enable these agencies to better carry out essential tasks, including disease surveillance and emergency preparedness. Two federal programs, in particular, play critical roles in preparing the country for disasters: the Public Health Emergency Preparedness (PHEP) program, administered by the CDC, and the Hospital Preparedness Program (HPP), administered by the Office of the Assistant Secretary for Preparedness and Response (ASPR) at the U.S. Department of Health and Human Services (HHS). Both are seriously underfunded. Through grants, the PHEP program is a primary way in which the federal government works with state, territorial and local public health departments to prepare for and respond to emergencies. Created after the terrorist attacks of 2001, the program has seen its funding fall by nearly a third since Fiscal Year 2002 — and nearly one half, adjusting for inflation.6 The HPP provides funding and technical assistance to states and territories to help them prepare their hospitals and healthcare systems for disasters. Its funding has fallen by half since FY2003 and over 60 percent when accounting for inflation. The impact of these cuts can be seen throughout the COVID-19 pandemic, as health departments try to track the disease with out-of-date surveillance systems, and hospitals in disease “hot spots” quickly became overwhelmed. Even as we work to improve public health agencies’ baseline readiness, they must also have timely access to additional funding to ramp up operations when emergencies strike without the delays that may accompany congressional deliberations. Two federal programs facilitate this pipeline: the Public Health Emergency Fund and the Infectious Disease Rapid Response Reserve Fund, from which the Secretary of Health and Human Services was able to quickly utilize $105 million7 in the early days of the COVID-19 response. Going forward, these funds should be replenished with new money to maintain balances of at least $2 billion. Finally, as the world responds to and recovers from COVID-19, the U.S. should play an active leadership role, including global health security programs at the CDC, the World Health Organization, and the U.S. Agency for International Development, to be a global partner with other countries and to help develop the core health security capacity of other nations. Investing in global health security will help protect Americans by fighting outbreaks where they begin thereby reducing the likelihood of spread to other countries including the U.S.

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Congress should increase annual funding for state, local, tribal, and territorial infrastructure by $4.5 billion to ensure every community is protected by core components of a comprehensive public health system. At least $ 2 billion should be kept in the Infectious Disease Rapid Response Reserve Fund at all times to enable faster responses to future infectious disease outbreaks. TFAH • tfah.org

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The Public Health Emergency Preparedness (PHEP) program should receive annual funding of at least $824 million and the Hospital Preparedness Program (HPP) should receive at least $474 million in annual funding to rebuild these programs going forward. The White House should create a health security directorate, including senior advisors to the President with public health expertise to advise on health security issues and oversee the national biodefense strategy and interagency responses. The White House should ensure senior advisors to the President have a strong background in public health and/or biodefense and that senior-level interagency cooperation is progressing before, during, and after public health emergencies, including through regular meetings of the Biodefense Steering Committee and Biodefense Coordination Team. The White House, HHS, CDC ASPR, Department of Homeland Security, Federal Emergency Management Administration and the Food and Drug Administration should work together to clarify roles and responsibilities to improve the nation’s emergency preparedness and response capacity. Science needs to govern the nation’s COVID-19 response, led by federal public health experts — including leadership at CDC and the National Institutes of Health. Policy decisions from the federal to the local level should be based on the best available science.

MEDICAL COUNTERMEASURES The COVID-19 pandemic has made crystal clear the importance of a well-resourced and well-run medical countermeasure enterprise. A robust medical countermeasures program consists of the research, development, stockpiling and distribution of medical supplies, drugs, devices, vaccines and other products for use in emergencies. The U.S. must have the surge capacity to be able to facilitate the rapid development and procurement of diagnostic tests and personal protective equipment (e.g., gloves, respirators, goggles, face shields, and gowns), therapeutics, and vaccines—and then distribute them strategically and equitably. Sustained, long-term funding must be made available to support the Public Health Emergency Medical Countermeasures Enterprise, including greater funding for the Biomedical Advanced Research and Development Authority (BARDA), the Strategic National Stockpile (SNS), and the nation’s vaccine infrastructure. Together, these programs help build the pipeline of countermeasures for health security purposes. The Stockpile must be sufficiently equipped to operate when global supply chains are disrupted and just-in-time delivery schedules that work well in normal times cease to function adequately. The shortages of supplies from the SNS during the COVID-19 outbreak are in part due to long-term underfunding of the program.8 Private sector manufacturing surge capacity should be incorporated into proactive public sector planning. Much work needs to be done to foster better coordination between federal, state, local, tribal and territorial governments, as well as with private sector suppliers and healthcare providers. To prevent states from competing with one another to procure vital supplies amid a global emergency, federal agencies must be prepared to proactively assess, and project states’ needs and then leverage their superior purchasing power and logistical capabilities to efficiently deliver needed tools and prevent shortages that cost lives.

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The federal government should provide significant and long-term funding for the entire medical countermeasures enterprise including research, manufacturing, procurement, and distribution. Congress should invest now in shoring up the systems that will be leveraged for distribution and dispensing of a potential COVID-19 vaccine, including immunization information systems, reporting and surveillance structures, training, outreach and education, and ultimately, distribution. The federal government should coordinate between states and supply chain partners to provide situational awareness on needs and supplies during an emergency and offer the option of using the federal government’s buying power to procure supplies and distribute them to states, if needed.

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HEALTHCARE READINESS In a pandemic, particularly one in which a significant number of people who become infected require hospitalization, a top-level concern is healthcare capacity. As we have seen with COVID-19, it is essential that health care systems not become overwhelmed, that healthcare workers and patients are protected from infection, and that health care systems can continue to provide essential non-COVID-19 care. When care facilities become overwhelmed, providers are stretched thin and at greater risk of infection, patients perish who could have been saved and chronic health conditions become acute or fatal due to lack of care. Ensuring that an area’s healthcare system can manage its influx of patients is an essential part of limiting transmission and keeping case fatality rates as low as possible. This requires coordination across the healthcare system to ensure an adequate supply of staff; hospital beds, including intensive care beds; personal protective equipment; medicines; and, ventilators. While preparedness standards exist for individual facilities through the Centers for Medicare and Medicaid Services (CMS)9 and The Joint Commission, systemwide readiness requires external coordination and planning.

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In addition to increasing funding for the Hospital Preparedness Program to promote cooperation between competing healthcare entities and public health, Congress and CMS, in coordination with ASPR, should provide payment incentives and reward facilities that maintain specialized disaster care capabilities. Congress and HHS should work to build surge capacity across the system by establishing an external regulatory body to set, validate, and enforce standards for healthcare facility readiness, stratified by facility type, with authority to impose financial penalties. States should engage healthcare providers, supply chain leaders and coalitions in emergency planning efforts. Local health care systems and public health leaders should coordinate through healthcare coalitions or other mechanisms to improve situational awareness and enable strategic movement of patients, personnel, and supplies. In addition, states should review credentialing standards to ensure facilities are able and ready to receive providers from other states during a surge response. States should adopt policies that promote readiness and surge capacity, such as the Nurse Licensure Compact and the Interstate Medical License Compact.

EQUITY AND RESILIENCE The impact that COVID-19 has on a community depends in part on the underlying health and socio-economic status of its people, two markers that tend to be correlated. While anyone can be at risk for infection from the novel coronavirus, COVID-19 has had a disproportionate impact on communities of color and low-income communities, where factors such as structural inequities, limited economic opportunity and substandard housing have contributed to underlying health, social and economic disparities that put these communities at higher risk for infection and severe outcomes.10 People with chronic lung disease, diabetes, heart disease, and severe obesity, among other characteristics — all of which are correlated with socioeconomic factors — are at particular risk for severe health impact if infected.11 In addition, people of color and lower income Americans have also been disproportionately designated as essential workers during the pandemic, with fewer job protections, placing them at increased risk for COVID-19 exposure.12 These realities illustrate that a vital element of preparedness—and a key defense against any epidemic—is investing in programs that prevent chronic illness and promote health equity. Therefore, efforts to address social determinants of health; reduce health disparities; and improve economic conditions, housing and education—to name a few, need to be part of the efforts to make our country more resilient in the face of a disease outbreak.

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A major challenge highlighted by the COVID-19 crisis is inadequate collection and reporting of data on the degree to which different population groups are being affected during a disease outbreak. Although early data showed disproportionate rates of hospitalization and death among African-American,13 Latino14 and American Indian15 populations, racial and ethnic data was missing in most cases reported to CDC as of April 30.16 HHS, states, healthcare providers and facilities, and public health officials must identify and address barriers to the collection, analysis and regular reporting of detailed demographic data on individuals with COVID-19 in order to equitably respond to this crisis. Without timely data, our public health system cannot effectively understand the pandemic, focus the response on communities most in need, and address the national emergency.

To help control the spread of infection, especially during a pandemic, it is important that people who are feeling ill be able to limit their exposure to others, including to co-workers. Paid sick leave policies allow employees to take time off from work to recover from illness, visit a health care provider, or care for a family member, without fear of lost wages or termination. Without these protections, workers are more likely to come to work when they are sick,17 endangering others and delaying or forgoing medical care. During the H1N1 pandemic of 2009, up to an estimated 7 million individuals were infected as a result of contagious co-workers not staying home from work when ill.18 Further exacerbating employee pressure to report to work is the fact that only three out of every 10 American adults have emergency savings that they could tap if forced to stay home without paid leave.19

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The collection and regular public reporting of demographic data by race, ethnicity, sex, gender identity, age, primary language, socioeconomic status, disability status, county, and other demographic information of cases, hospitalizations, and deaths is essential during all health emergencies. This disaggregated data is vital to identifying impacted areas and partnering with communities on outreach, prevention, and access to care. Congress should provide additional resources to fully modernize public health data surveillance including, enabling electronic case reporting to state health agencies, education of providers on data collection and reporting, and reduction of duplicate reporting systems to the federal government. Congress and the President should provide new and ongoing public health and prevention-focused funding to community-based organizations working in and representative of populations disproportionately impacted by COVID-19, especially in low-income communities and communities of color. Congress and the President should enact a federal law to allow workers to earn at least seven days of job-protected paid sick days per year; during a public health emergency more may be necessary. In the absence of congressional action, states and localities should enact laws to provide paid sick days to their employed residents. The Federal government should ensure access to affordable, high quality and comprehensive healthcare for all Americans, including access to COVID-19 testing, treatment and vaccines. Government at all levels should target funding for programs that address the social determinants of health. Congress should fund CDC and health departments to address social determinants through cross-sector collaboration, policy change, and creating community-clinical linkages. Federal agencies should also strengthen and expand programs that create and preserve affordable housing, improve access to nutrition, expand access to quality education, provide job training opportunities and improve transportation systems — all factors that improve the conditions in people’s lives that impact their health and make communities more resilient during an emergency.

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Conclusion: FUNDING, COORDINATION AND VIGILANCE ARE ALL CRITICAL COMPONENTS OF NATIONAL READINESS The COVID-19 pandemic is a defining event that will shape the lives of billions of people. After the current threat is controlled, it is inevitable that the country’s leaders will awake sometime in the future to early reports of another emerging public health emergency somewhere in the world. It could be weather-related, a terrorist act, or a mysterious disease outbreak. Will we have learned from the COVID-19 pandemic and be better prepared to prevent or mitigate the impact? That is the question we must grapple with even while still in the midst of the current crisis. The COVID-19 crisis must teach us the indelible lesson that preparing for what will inevitably happen is essential, and that core public health capacities and resources must be adequately funded. We must organize our federal government to treat pandemics and other global health emergencies as top-level threats necessitating constant monitoring and preparation—just as we do with wars. This will require a whole-of-government focus and prioritization. When a crisis emerges, every hour carries extraordinarily high stakes measured by the preservation of lives and livelihoods. We must be prepared.

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Endnotes 1 Henig RM. “Experts warned of a pandemic decades ago. ‘Why weren’t we ready?’” National Geographic. April 8, 2020. https://www.nationalgeographic.com/science/2020/04/experts-warned-pandemic-decades-ago-why-not-ready-for-coronavirus/ Accessed April 20, 2020 2 Jernigan D. “100 Years Since 1918: Are We Ready for the Next Pandemic?” Centers for Disease Control and Prevention, 2018. https://www.cdc.gov/flu/ pandemic-resources/1918-commemoration/pdfs/1918-pandemic-webinar.pdf Accessed April 20, 2020 3 Systems for Action. National Longitudinal Survey of Public Health Systems. Robert Wood Johnson Foundation. 2018 http://systemsforaction.org/ national-longitudinal-survey-public-health-systems, Accessed May 7, 2020. 4 New Workforce Survey: Public Health Turnover Could Pose Threat to Community Health. In de Beaumont Foundation, April 30, 2019. https://www. debeaumont.org/news/2019/new-workforce-survey-public-health-turnover-could-pose-threat-to-community-health/ Accessed April 21, 2020. 5 Developing a Financing System to Support Public Health Infrastructure. In RESOLVE, October 2, 2018. https://www.resolve.ngo/docs/phlf_developingafinancingsystemtosupportpublichealth636869439688663025.pdf Accessed April 20, 2020. 6 The Impact of Chronic Underfunding on America’s Public Health System: Trends, Risks, and Recommendations. Washington: Trust for America’s Health, 2020. https://www.tfah.org/report-details/publichealthfunding2020/ Accessed April 20, 2020. 7 Congressional Research Service. Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020. (P.L. 116-123): First Coronavirus supplemental. March 25, 2020 https://fas.org/sgp/crs/misc/R46285.pdf Accessed May 7, 2020. 8 Palmer D. “U.S. medical stockpile wasn’t built to handle current crisis, former director says.” Politico, April 8, 2020. https://www.politico.com/ news/2020/04/08/national-stockpile-coronavirus-crisis-175619 Accessed April 13, 2020. 9 Centers for Medicare & Medicaid Services. Core EP Rule Elements. January 2018 https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Core-EP-Rule-Elements Accessed May 1, 2020. 10 Artiga S, Orgera S, Pham O, and Corallo B. “Growing Data Underscore that Communities of Color are Being Harder Hit by COVID-19.” Kaiser Family Foundation, April 21, 2020. https://www.kff.org/coronavirus-policy-watch/growing-data-underscore-communities-color-harder-hit-covid-19/ Accessed April 30, 2020 11 Groups at Higher Risk for COVID-19. In Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html Accessed April 30, 2020 12 Eligon F, Burch A, Searcey D, and Oppel R. “Black Americans Face Alarming Rates of Coronavirus Infection.” New York Times, April 7, 2020. https://www.nytimes.com/2020/04/07/us/coronavirus-race.html Accessed April 20, 2020 13 COVID-19 in Racial and Ethnic Minority Groups. In Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/needextra-precautions/racial-ethnic-minorities.html Accessed April 30, 2020. 14 Groups at Higher Risk for COVID-19. In Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/groups-at-higher-risk.html Accessed April 30, 2020. 15 Nagle R. “Native Americans being left out of US coronavirus data and labelled as ‘other.’” The Guardian, April 24, 2020. https://www.theguardian. com/us-news/2020/apr/24/us-native-americans-left-out-coronavirus-data Accessed April 30, 2020 16 The COVID Racial Data Tracker. In The COVID Tracking. https://covidtracking.com/race. Accessed April 30, 2020 17 Earned Sick Leave. Washington: Trust For America’s Health, November 2019. https://www.tfah.org/wp-content/uploads/2019/11/TFAH2019-PHACCS-PaidSickLeave-03.pdf. Accessed April 30, 2020. 18 Drago R and Miller K. Sick at work: infected employees in the workplace during the H1N1 epidemic. Washington, DC: Institute for Women’s Policy Research, January 31, 2010. http://www.iwpr.org/publications/pubs/sick-at-work-infected-employees-in-the-workplace-during-the-h1n1-pandemic Accessed April 20, 2020. 19 Pesce NL. “A shocking number of Americans are living paycheck to paycheck.” Marketwatch, January 11, 2020. https://www.marketwatch.com/ story/a-shocking-number-of-americans-are-living-paycheck-to-paycheck-2020-01-07 Accessed April 20, 2020.

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Delaware Journal of

Public Health

Submission Guidelines

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About the Journal Established in 2015, The Delaware Journal of Public Health is a bi-monthly, peer-reviewed electronic publication, created by the Delaware Academy of Medicine/Delaware Public Health Association. The publication acts as a repository of news for the medical, dental, and public health communities, and is comprised of upcoming event announcements, past conference synopses, local resources, peer-reviewed content ranging from manuscripts and research papers to opinion editorials and personal interest pieces, relating to the public health sector. Each issue is largely devoted to an overarching theme or current issue in public health. The content in the Journal is informed by the interest of our readers and contributors. If you have an event coming up, would like to contribute an Op-Ed, would like to share a job posting, or have a topic in public health you would like to see covered in an upcoming issue, please let us know. If you are interested in submitting an article to the Delaware Journal of Public Health, or have any additional inquiries regarding the publication, please contact DJPH Deputy Editor Elizabeth Healy at ehealy@delamed.org, or the Executive Director of The Delaware Academy of Medicine and Delaware Public Health Association, Timothy Gibbs, at tgibbs@delamed.org

Information for Authors Submission Requirements The DJPH accepts a wide variety of submission formats including brief essays, opinion editorials pieces, research articles and findings, analytic essays, news pieces, historical pieces, images, advertisements pertaining to relevant, upcoming public health events, and presentation reviews. If there is an additional type of submission not previously mentioned that you would like to submit, please contact a staff member.

Cover Letters must address the following four article requirements: 1. A description of what the paper adds to current knowledge, in particular with respect to material previously published in DJPH, and if systematic reviews exist on the topic. 2. The public health importance of the paper. 3. One sentence summarizing the main message(s) of the paper, which may be used to disseminate the paper on social media.

The initial submission should be clean and complete, without edits or markups, and contain both the title and author(s) fulls name(s). Submissions should be 1.5 or 4. For individual or group randomized trials, provide the double spaced with a font size of 12. Initial submissions date of trial registration and the NCT number from must also contain a cover letter with concise text www.Clinicaltrials.gov or other approved registry. (maximum 150 words). Once completed, articles In the cover letter only, not in the paper. Do NOT should be submitted via email to Elizabeth Healy at include the trial registration or NCT number in the ehealy@delamed.org as an attachment. Graphics, images, abstract or the body of the manuscript during the info-graphics, tables, and charts, are welcome and initial submission. encouraged to be included in articles. Please ensure that all pieces are in their final format, and all edits and track All manuscripts must be submitted via email to Elizabeth Healy at ehealy@delamed.org. changes have been implemented prior to submission. 102 Delaware Journal of Public Health – August 2020

To view additional information for online submission requirements, please refer to the website for the Delaware Journal of Public Health: https://djph.org/sample-page/submit-an-article/. Submission Length While there is no prescribed word length, full articles will generally be in the 2500-4000-word range, and editorials or brief reports will be in the 1500-2500-word range. If you have any questions regarding the length of a submission, or APA guidelines, please contact a staff member. Copyright Opinions expressed by contributors and authors do not necessarily reflect the opinions of the DJPH or affiliated institutions of authors. Copying for uses other than personal reference or interest without the consent of the DJPH is prohibited. All material submitted alongside written work, including graphics, charts, tables, diagrams, etc., must be referenced properly in accordance with APA formatting. Conflicts of Interest Any conflicts of interest, including political, financial, personal, or academic conflicts, must be declared prior to the submission of the article, or in conjunction with a submission. Conflicts of interest are any competing interests that may leave readers feeling misled or deceived, and/or alter their perception of subject matter. Declared conflicts of interest may be published alongside articles in the final electronic publication.

Additional Documents and Information for Authors Please Note: All authors and contributors are asked to submit a brief personal biography (3 sentences maximum) and a headshot along submissions. These will be published alongside final submissions in the final electronic publication. For pieces with multiple authors, these additional documents are requested for all contributors. Abstracts Authors must submit a structured or unstructured abstract along with their article. The word limit is 200 words, including headings. A title page should be submitted with this abstract as well. Structured abstracts should employ 4-5 headings: Objectives (begins with “To…”) Methods Results Conclusions A fifth heading, Policy Implications, may be used if relevant to the article. Trial Registration information is required for clinical trials and must be included in the final version abstract All abstracts should provide the dates(s) and location(s) of the study is applicable. Note: There is no Background heading.

Nondiscriminatory Language Use of nondiscriminatory language is required in all DJPH submissions. The DJPH reserves the right to reject any submission found to be using sexist, racist, or heterosexist language, as well as unethical or defamatory statements.

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Index of Advertisers Speak for Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 American Public Health Association County Health Rankings & Roadmaps. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 A Robert Wood Johnson Foundation Program The DPH Bulletin July 2020. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Division of Public Health, Department of Health and Social Services 2020 John Scholz Stroke Education Conference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 John Scholze Stroke Education Robert O.Y. Warren MD, Memorial Seminar. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Nemours/Alfred I. duPont Hospital for Children 21 Day Racial Equity Challenge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 United Way of Delaware Organ Donation and Transplantation Summit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Gift of Life Donor Program Delaware PrEP, 2020 PrEP Conference. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Delaware HIV Consortium PrEP Navigation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Delaware HIV Consortium 2020 APA Delaware Fall Conference. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 American Planning Association - Delaware Chapter APHA Press . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 American Public Health Association Basics of Health Equity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Quality Insights A Message of Gratitude . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Delaware Journal of Public Health What are we learning for COVID-19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 Trust for America's Health DJPH Submission Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 Delaware Journal of Public Health

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