This study provides survey results from state and territorial public health preparedness directors regarding antiviral shortages during the 2022-2023 respiratory viral season.

Between Fall 2020 and Spring 2021, the Association of State and Territorial Health Officials conducted 2 rapid queries to collect information from the field regarding the status of COVID-19 case investigation and contact tracing (CI/CT) programs and practice. These short surveys were distributed to senior deputies in state and territorial health agencies, yielding a response rate of 45.8% (November 2020) and 40.7% (April 2021). Findings indicated that CI/CT staff roles and assigned functions varied across jurisdictions, as did staffing levels/capacity, approaches for linking individuals to social supports, and program changes that were planned or underway. Agency-reported staffing levels/capacity and programmatic challenges changed over time, highlighting the dynamic nature of CI/CT program practice and implementation. While findings from the surveys cannot be generalized to the national level, they provide critical insights from the field on CI/CT program implementation, challenges, and changes in response to the evolving COVID-19 epidemic in the United States.

Increasing COVID-19 infection rates and the prospect of a significant fall surge are concerning to state and territorial public health leaders. Health officers are charged with preparing for ongoing management of the pandemic while addressing pushback against public health mitigation efforts and public sentiment that the pandemic is “over.” While hospitalizations continue to remain manageable as of June 2022, now is the time for public health officials to prepare for responses to upcoming surges of COVID-19 in tandem with other seasonal respiratory viruses such as influenza and respiratory syncytial virus. Experts have learned a great deal about effective prevention, mitigation, and management of COVID-19 over the last 2 years to help guide future efforts. Planning for future response should draw upon evidence-based prevention efforts and what has worked in the past 2 years. A “Technical Package” of Effective Public Health Approaches to Managing COVID-19 This article summarizes approaches to preventing COVID-19 infection with an eye toward sustained management of COVID-19 in the fall of 2022 and beyond. We bundle these interventions into a “technical package,” a set of recommendations to the field to guide future public health responses to COVID-19. ASTHO technical packages are based on evidence-based interventions, promising practices, subject matter expert recommendations, and—where it exists—consensus from the field. Technical packages are not intended to be comprehensive but instead help prioritize efforts toward what works to address a particular problem, such as COVID-19, and establish a focused and proactive approach to technical assistance. The ASTHO technical package to support the sustained management of COVID-19 comprises 5 major categories, described as follows, with additional details outlined in the Table. Increase immunization rates and capacity: Vaccines, both the primary series and booster dose, are critical tools to prevent severe illness from COVID-19 infection. Engaging health care providers, who are often the trusted source of information for individuals who have questions about vaccines or who may be hesitant, is an established evidence-based practice for addressing vaccine hesitancy. Expanded availability of vaccine in health care settings will be particularly important in pediatric COVID-19 vaccination. National data already indicate a preference for pediatric COVID-19 vaccination in medical settings,1 and vaccination can serve as an important opportunity for families to reengage their children in well childcare following the pandemic shutdowns. States can identify and address financial, access, and administrative barriers to participation in the COVID-19 vaccination program. They can also work with their state Immunization Information Systems (IIS) to review immunization data use and exchange policies to identify potential barriers and leverage the IIS reminder and recall function so that medical practices can easily identify and outreach to patients who are not fully vaccinated. Identify and address COVID-19 health disparities: Population-based data are foundational to public health practice. Having the capability to identify disparities in case numbers, hospitalizations, death, vaccination status, and access to therapeutics by race, ethnicity, and urban/rural differences is essential to guide redistribution of interventions and services, target outreach, and inform public policy. Health equity cannot be realistically addressed without accurate and complete race and ethnicity data in all public health data sets. States can consider engaging health information exchanges in matching public health data sets with vital statistics and other data sources; incentivize medical providers and commercial laboratories to provide more complete race and ethnicity data; and expand the use of the social vulnerability index to identify vulnerable rural populations at a greatest risk of poor COVID-19 outcomes. Expand the capacity and scope of the public health workforce: Response to the COVID-19 pandemic should include health agency efforts to sustain their investments to support, expand, and increase the effectiveness of the public health workforce. Investment in community-based public health workers (eg, community health workers [CHWs], promotoras, peer recovery coaches) has been widely recognized as an evidence-based approach to improving individual and community health and addressing health disparities.2 Their ability to build trust and relationships in underserved communities is essential to successful public health work in the future. Community-based public health workers have a deep understanding of their communities through lived experience, which makes them uniquely qualified to address social and behavioral determinants of health. Early contact tracing needs led to widespread use of CHWs through contractual and temporary hiring. This capacity could be sustained and redirected to other aspects of public health by standardizing CHW job descriptions, salary ranges, and supervision structures in state/local human resources systems and by partnering with local and national community-based organizations. More broadly, states can conduct workforce surveys and update workforce policies, including sick leave policies. Prepare the public to make risk-based decisions: The availability of highly effective COVID-19 vaccinations has dramatically reduced the risk of severe disease and death, and effective therapeutic agents are widely available for individuals at high risk who can be quickly treated after confirmed infection. Home COVID-19 testing now provides an accessible and convenient mechanism for early diagnosis. The use of these important assets in the COVID-19 response must be communicated to the public through succinct messaging guided by audience testing. Variation in community transmission, and the risk associated with certain behaviors, should be made clear so that individuals can make their own decisions about avoiding gatherings, social distancing, or wearing masks. In addition, new social norms of staying home when sick or wearing a mask when exposed should be reinforced with expanded workforce sick leave benefits and periodic, localized use of testing, contact tracing, and mask wearing requirements during disease surges. Implement environmental interventions in schools, workplaces, and other congregate indoor settings: Infectious diseases such as COVID-19 can spread through the inhalation of airborne particles and aerosols. Environmental interventions to reduce COVID-19 spread in confined workplaces such as meat and poultry processing facilities were highly successful early in the pandemic.3 There is broad consensus that improving indoor air quality in school buildings can reduce the risk of COVID-19 spread among students and teachers.4 Many school systems are now working to upgrade their HVAC systems, and similar approaches could be considered in long-term care facilities. Wastewater surveillance is an emerging community surveillance system that could be particularly useful in self-contained water treatment system settings such as large international airports and correctional facilities. TABLE - ASTHO Technical Package on COVID-19 Sustained Management Strategies Objective Potential Indicators Mechanisms Levels of Influence Increase immunization rates and capacity Provider enrollment in COVID-19 vaccine program Practices with ability to link to IIS for vaccination status Provide enrollment incentives Remove administrative burdens to enrollment Enable IIS reminder and recall functions CDC State immunization managers State medical and primary care associations Identify and address COVID-19 health disparities State public health dashboards Completeness of data reports to CDC State and federal data quality measures and benchmarks State disease reporting laws and requirements Data set comparisons and matching Reporting incentives and penalties Provider education Race and ethnicity definitions and standards Electronic transmission capabilities State HIEs State Medicaid agency State FQHC associations State medical and primary care associations CDC, ONC, CMS, OMB, HRSA National public health associations (CSTE, APHL) Expand the capacity and scope of the public health workforce CHW job descriptions, salary ranges, supervision structures in state/local HR system State CHW registries (NACHW) State and local workforce surveys State contracts with CBOs Retention/career ladders Evidence-based practice recommendations Workforce reorganization New funding lines and resources Redirection of existing funding Attrition planning Third party reimbursement State HR systems State contract policies State employee health plans National associations (NACHW, APHA) CDC HHS Office of Minority Health Prepare the public to make risk-based decisions COVID-19 vaccination rates COVID-19 therapeutics utilization rates New state policies, including the expansion of sick leave benefits Public polling COVID-19 community indicators Tax and other incentives for employers to expand benefits Required benefits standards for employers CDC Employer groups Implement environmental interventions in schools, workplaces, and other congregate and indoor settings Infection rates in congregate settings School closures Resources for environmental enhancements Regulatory and statutory requirements Participation in EPA clean air in buildings challenge CDC NIOSH EPA ASHRAE Abbreviations: APHA, American Public Health Association; APHL, Association of Public Health Laboratories; ASHRAE, American Society of Heating, Refrigerating and Air-Conditioning Engineers; CBO, community-based organization; CDC, Centers for Disease Control and Prevention; CHW, community health worker; CMS, Centers for Medicare & Medicaid Services; CSTE, Council of State and Territorial Epidemiologists; EPA, Environmental Protection Agency; FQHC, federally qualified health center; HIE, health information exchange; HR, human resources; HRSA, Health Resources and Services Administration; IIS, Immunization Information System; NACHW, National Association of Community Health Workers; NIOSH, National Institute for Occupational Safety and Health; ONC, Office of the National Coordinator for Health Information Technology; OMB, Office of Management and Budget. Conclusion State and territorial health officials have been tasked with addressing many challenges throughout the COVID-19 response. The considerations listed earlier are not comprehensive. A wide range of other strategies and approaches, such as the use of pharmacies for adult COVID-19 vaccination, have clearly been effective but have not been formally researched or evaluated. Several public health policy interventions have had unintended consequences, and external factors such as worldwide shortages of personal protective equipment and testing materials were never anticipated. The approaches in this technical package provide tangible, evidence-based actions for states and territories to consider as they plan for sustained and improved management of COVID-19 for fall 2022 and beyond.

Objective The study aimed to evaluate the cost-effectiveness of obtaining preoperative type and screens (T/S) for common endonasal skull base procedures, and determine patient and hospital factors associated with receiving blood transfusions. Study Design Retrospective database analysis of the 2006 to 2015 National (nationwide) Inpatient Sample and cost-effectiveness analysis. Main Outcome Measures Multivariate regression analysis was used to identify factors associated with transfusions. A cost-effectiveness analysis was then performed to determine the incremental cost-effectiveness ratio (ICER) of obtaining preoperative T/S to prevent an emergency-release transfusion (ERT), with a willingness-to-pay threshold of $1,500. Results A total of 93,105 cases were identified with an overall transfusion rate of 1.89%. On multivariate modeling, statistically significant factors associated with transfusion included nonelective admission (odds ratio [OR]: 2.32; 95% confidence interval [CI]: 1.78-3.02), anemia (OR: 4.42; 95% CI: 3.35-5.83), coagulopathy (OR: 4.72; 95% CI: 2.94-7.57), diabetes (OR: 1.45; 95% CI: 1.14-1.84), liver disease (OR: 2.37; 95% CI: 1.27-4.43), pulmonary circulation disorders (OR: 3.28; 95% CI: 1.71-6.29), and metastatic cancer (OR: 5.85; 95% CI: 2.63-13.0; p <0.01 for all). The ICER of preoperative T/S was $3,576 per ERT prevented. One-way sensitivity analysis demonstrated that the risk of transfusion should exceed 4.12% to justify preoperative T/S. Conclusion Routine preoperative T/S does not represent a cost-effective practice for these surgeries using nationally representative data. A selective T/S policy for high-risk patients may reduce costs.

Objective Determine the effect of patient demographics and surgical approach on patient outcomes after tracheal resection in the management of thyroid cancer. Study Design Systematic review and meta-analysis. Methods Systematic review of literature was performed using PubMed, Embase, and Cochrane Library to identify patients with thyroid carcinoma who underwent tracheal resection. Pooled estimates for patient demographics, presenting findings, complications, and outcomes are determined using random-effects meta-analyses. Results Ninety-six relevant studies encompassing 1,179 patients met inclusion criteria. Meta-analysis pooled rates of complications: 1.7% (confidence interval [CI] 0.8-2.5;P < .001;I-2= 1.85%) airway complications, 2.8% (CI 1.6-3.9;P < .001;I-2= 13.34%) bilateral recurrent laryngeal nerve paralysis, 2.2% (CI 1.2-3.1;P < .001;I-2= 6.72%) anastomotic dehiscence. Circumferential resection pooled estimates major complications, locoregional recurrence, distal recurrence, overall survival: 14.1% (CI 8.3-19.9;P < .001;I-2= 35.26%), 15% (CI 9.6-20.3;P < .001;I-2= 38.2%), 19.7% (CI 13.7-25.8;P < .001;I-2= 28.83%), 74.5% (CI 64.4-84.6;P < .001;I-2= 85.07%). Window resection estimates: 19.8% (CI 6.9-32.8;P < .001;I-2= 18.83%) major complications, 25.6% (CI 5.1-46.1;P < .014;I-2= 84.68%) locoregional recurrence, 15.6% (CI 9.7-21.5;P < .001;I-2= 0%) distal recurrence, 77.1% (CI 58-96.2;P < .001;I-2= 78.77%) overall survival. Conclusion Management of invasive thyroid carcinoma may require tracheal resection to achieve locoregional control. Nevertheless, postoperative complications are not insignificant, and therefore this risk cannot be overlooked when counseling patients perioperatively.Laryngoscope, 2020

PURPOSE:Perform an evidence-based review to determine the utility of indocyanine green fluorescence (ICG) to detect sentinel lymph nodes (SLN) in patients with head and neck melanoma compared to blue dye or radiocolloid injection (RI).MATERIALS AND METHODS:A systematic review of the literature was performed to identify patients with head and neck melanoma managed with ICG fluorescence. PubMed, Embase, and Cochrane Library databases were searched. Included studies were assessed for level of evidence. Patient demographics and data on SLN identification were determined.RESULTS:Twenty-two studies encompassing 399 patients (75% male, 25% female, average age 57.1 years) met inclusion criteria. Publications comprised of two case reports, four retrospective case series, twelve cohort studies, and four clinical trials. Most common site of melanoma was scalp/temple/forehead (35%), cheek/midface (22%), and ear (17%) with an average Breslow thickness of 3.32 mm. SLN was identified in 80.7% (n = 201/249) of patients using ICG-RI, 85.2% (n = 75/88) using RI alone, and 63.4% (n = 52/82) using blue dye-RI.CONCLUSIONS:ICG-99mTc-nanocolloid hybrid tracer may be a superior alternative to blue dye + adiocolloid and has theoretical advantages compared to RI alone. Additional prospective randomized controlled trials are needed to further compare these methods and obtain data on false negative rates, operating room time, and cost effectiveness to fully elucidate the utility of ICG-99mTc-nanocolloid over current methods used for SLN identification in this patient population.

Introduction Transdermal fentanyl is a continuous release opioid delivery system intended for use in opioid-tolerant patients requiring around-the-clock opioid therapy. The purpose of this study is to identify the most common indications for transdermal fentanyl prescriptions in active duty US military personnel, and determine whether these prescriptions meet US Food and Drug Administration (FDA) labelling. Methods Active duty US military personnel initiating transdermal fentanyl therapy with prescriptions filled at Military Health System pharmacies between 2015 and 2019 were identified in the Military Data Repository. Electronic health records were searched for patient demographic information, clinical information and prescription data. A total of 225 patients with complete data were identified. Results The most common reason for transdermal fentanyl initiation was chronic non-cancer musculoskeletal pain. Among patients with non-cancer pain, 36% received their initial prescription from an internal medicine/primary care provider, and 35% did not meet published US FDA criteria for opioid tolerance prior to treatment initiation. There was an 81% decrease in patients initiating therapy between 2015 and 2019. Conclusions While a substantial minority of transdermal fentanyl prescriptions to US military personnel did not meet FDA guidelines on appropriate use, the overall number of prescriptions fell dramatically over the study period. This suggests that automated profile review or additional targeted policies to limit transdermal fentanyl prescribing are unnecessary at this time.

Context: Case investigation and contact tracing are fundamental public health strategies for controlling and preventing the spread of infectious diseases. Although the principles behind these strategies are not new, the capacity and operational requirements needed to support disease investigation during the SARS-CoV-2 (COVID-19) pandemic are unprecedented. This article analyzes the implementation of case investigation and contact tracing in controlling COVID-19 transmission during the early stages of the US pandemic response (January 20 through August 31, 2020). Program Implementation: Governmental public health agencies mobilized to expand case investigation and contact tracing programs in the early months of the pandemic. In doing so, they encountered a range of challenges that included rapidly scaling up the workforce; developing and subsequently revising guidance and protocols specific to COVID-19 as more was learned about the virus over time; defining job functions; encouraging public acceptance of and participation in case investigation and contact tracing; and assessing the utility of these activities during both the containment and mitigation phases of outbreak response. COVID-19 case investigation and contact tracing programs presented an array of opportunities for health departments to innovate, especially around technology to support public health efforts, as well as opportunities to address health equity and advance community resilience. Conclusion: Lessons learned from disease intervention specialists, guidance and resources from federal agencies and national partners, and peer-to-peer exchange of promising practices can support jurisdictions encountering early implementation challenges. Further research is needed to assess COVID-19 case investigation and contact tracing program models and innovations, as well as strategies for implementing these activities during containment and mitigation phases.

PURPOSE:Evaluate trends in mortality due to acute epiglottitis before and after adoption of Haemophilus influenza Type b vaccination (Hib) in pediatric and adult populations.MATERIALS AND METHODS:Patients who died from acute epiglottis from 1979 to 2017 identified using National Vital Statistics System. Mortality rates calculated using age-adjusted US census data expressed in rate per 100,000 individuals. Trends analyzed using the National Cancer Institute Joinpoint Regression Program (version 4.7.0; Bethesda, Maryland).RESULTS:1187 epiglottitis-related deaths were identified over thirty-nine years. Total deaths decreased from 65 in 1979 to 15 in 2017. Adult deaths accounted for 63.5% and decreased from 0.015 per 100,000 individuals (24 deaths) in 1979 to 0.006 per 100,000 individuals (14 deaths) in 2017. Best fitting log-liner regression model showed APC of -3.5% (95% CI, -4.2 to -2.7%) from 1979 to 2017. Pediatric and adolescent deaths accounted for 443 (37.3%) deaths, decreasing from 0.064 per 100,000 individuals (41 deaths) in 1979 to 0.001 per 100,000 individuals (1 death) in 2017. APC was -11.1% (95% CI, -13.8% to -8.3%) in 1979 to 1990; 46.5% (95% CI, -16.6% to 157.3%) in 1990 to 1993; -61.6% (95% CI, -88% to 23%) in 1993 to 1996; and 1.1% (95% CI, -2.4% to 4.7%) in 1996 to 2017.CONCLUSIONS:Mortality from acute epiglottitis decreased after widespread adoption of Hib vaccination in the US. Adults are now more likely than children to die of acute epiglottitis. Further research including multi-institutional cohort studies must be done to elucidate causative factors contributing to remaining cases of mortality.

Objectives: Determine the utility of preoperative imaging and the optimal course of management for congenital floor of mouth (FOM) cysts in infants. Methods: A systematic review of the literature was performed conforming to PRISMA guidelines. Pubmed, Embase and Cochrane Library databases were queried to identify cases of infants with congenital floor of mouth masses. Patient demographics, presenting findings, imaging, management, complications, and outcomes were determined. Results: 85 patients were evaluated. 98% of patients presented at 16 months of age or younger. The most common presenting symptom was submental mass or swelling, 31.3%. Among the patients that underwent imaging, the suspected diagnosis obtained from imaging findings was consistent with the final pathologic diagnosis 59% of the time reported and inaccurate 34% of the time. There were multiple definitive treatment modalities described in the literature review including surgical excision, 82.3%, marsupialization, 12.9%, chemical injection 2.3%, sclerotherapy 1.2%,% and radiation, 1.2%. Recurrence rate after initial definitive treatment was as follows, surgical excision, 8.8%, marsupialization, 80%, sclerotherapy, 100%, chemical injection, 50%, and radiation, 100%. Conclusion: Preoperative imaging studies should not be relied upon alone to determine suspected pathology and subsequent management in pediatric patients with FOM masses. It may be beneficial for these patients to undergo primary surgical excision regardless of imaging studies or suspected pathology. Needle aspiration offers limited addition to pathologic diagnosis and should only be performed in the setting of acute symptomatic management. Surgical excision should be considered as definitive treatment modality in all patients with FOM masses, regardless of the suspected diagnosis of ranula. Further multi-institutional cohort studies could be invaluable to elucidate definitive treatment guidelines in this patient population.

Importance: There is controversy surrounding the management of orbital roof fractures. Guidelines with regard to when to operate and type of reconstruction are lacking. Categorizing these data will help clinicians make informed decisions about the management of orbital roof fractures and avoid preventable complications. Objective: To perform a systematic review evaluating underlying causes, associated complications, and management of orbital roof fractures including reconstructive options in the general population of children and adults. Evidence Review: A systematic review using the PubMed, EmBase, Cochrane, and MEDLINE databases identified relevant studies for inclusion. Studies were included from 1987 to 2017. Demographics, symptoms, management, reconstruction, and outcomes were reported following preferred reporting items for systematic reviews and meta-analyses guidelines. Inclusion criteria included articles discussing management of traumatic orbital roof fractures across all ages. Included studies were assessed for level of evidence. Findings: Forty-seven studies encompassing 526 patients met inclusion criteria. There were 28 case reports, 15 retrospective case series and 4 retrospective cohort studies. The most common etiologies were motor vehicle accidents (39.5%), falls (30.3%), and assault (11.8%). Periorbital ecchymosis, exophthalmos, and dystopia were the most common initial symptoms. In total, 60.0% of patients underwent surgical repair and 40% of patients were managed conservatively. The most common surgical approach was bicoronal (94.8%), followed by a superolateral orbital rim approach and transpalpebral (5.1%). A variety of grafting materials were utilized, including titanium miniplates (46.2%), bone graft (37.7%), porous polyethylene (2.8%), and silastic implants (2.8%). Overall patients undergoing surgery were adults with clinical symptoms including exophthalmos, diplopia, and gaze restriction as well as patients with dura exposure. Most patients undergoing surgery were those with concomitant fractures. The most common fractures among the surgical patients were frontal bone (32.2%), ethmoid (25.2%), and zygomaticomaxillary complex/zygoma (12.2%). Conclusions and Relevance: Management of orbital roof fractures varies based on individual clinical features including the presence of exophthalmos, gaze restriction, and concomitant injuries such as dural tears. Surgically, bicoronal approaches were performed most commonly along with reconstruction utilizing titanium miniplates. Conservative management was more common among the pediatric population. This systematic review demonstrates both conservative and surgical measures can lead to positive outcomes in appropriately selected patients.

In the last decade, national, state, and local public health surveillance and data systems began a major shift toward modernization. COVID-19 reminds us why this shift has been and remains a priority. Public health surveillance is critical to providing the intelligence needed to safeguard the public's health. While the scientific principles of epidemiology that drive surveillance remain constant, surveillance methods, practices, systems, and infrastructure must continuously evolve to address these increasingly complex threats. As our nation tackles the COVID-19 pandemic, policy makers across the country are using surveillance data to make decisions that have profound effects on the public's health, as well as the economy of the country. At the same time, an unprecedented number of citizens are using that same data, every day, to understand what is happening around them and to make decisions about how to protect their loved one's health. Early elements of US public health surveillance can be traced to Rhode Island in the 1740s, where colonial law required tavern owners to report contagious diseases among patrons, including specific reporting requirements for smallpox, yellow fever, and cholera.1 Although the data and methods available to health officials today far surpass what was available to their 18th-century counterparts, our nation's surveillance system infrastructure is still plagued by long-standing, obstinate challenges. Fortunately, in recent years, local, state, and federal agencies have partnered with the broader public health community to develop approaches to address these challenges. The COVID-19 pandemic has underscored the importance of these efforts, highlighting the need for accelerated action and increased investments in this space. Building a 21st-Century Public Health Surveillance System In the last decade, recognizing the need for dedicated efforts to build a core public health data infrastructure, national public health organizations began collective work to improve data systems and support the secure and efficient flow of data across jurisdictions and levels of government. Led by the Council of State and Territorial Epidemiologists, public health partners developed and released the Driving Public Health in the Fast Lane report, which outlines a series of clear recommendations for a modern, innovative infrastructure.2 It is an essential component to the long-term success of our nation's surveillance infrastructure, along with Centers for Disease Control and Prevention's (CDC's) Roadmap for Data Modernization, which focuses on transforming its data, technology, and workforce capabilities.3 To further modernize plans, the Association of State and Territorial Health Officials convened a group of state and territorial health agency leaders in January 2020 to advise on challenges and opportunities facing health jurisdictions. The core elements set forth by these reports and convenings delineate some of the critical work still ahead of us in a COVID-19 and post-COVID-19 world and include the need for the following: Coordinated policies, consensus-based standards, and decision making across states, CDC, and federal partners to develop interoperable systems that allow for efficient data exchange. Enterprise-level information technology and data infrastructure that supports cloud-based platforms and real-time data automation. A system-wide environment of innovation that enables new public-private partnerships with health care providers, technology companies, and other entities to create new tools that empower communities, patients, and consumers. Significant, sustained resources are required to translate these recommendations into action. In fiscal year 2020, a federal spending bill dedicated $50 million in funding for the CDC's efforts to modernize public health data systems. Hopefully, this represents the beginning of the $1 billion proposed appropriation the CDC will require over the next 10 years to accomplish this critical mission. COVID-19 Reinforces the Need for Data Modernization A national strategy founded on local, state, and territorial data modernization has never been more crucial than in the face of the COVID-19 pandemic. Complete surveillance data, analysis, and seamless data exchange are vital to improving public health's ability to more accurately gauge and respond to health threats, especially among vulnerable or underserved communities. Elected officials and policy makers need these same data to inform health policy frameworks and remain informed about societal consequences of the pandemic and the response to it. Complete data elements Incomplete data and resulting difficulties have been underscored and made more apparent during the pandemic. Incomplete reporting of critical elements, such as race and ethnicity, symptom status, and health outcomes, challenges our ability to characterize epidemiologic trends and resource demands at the national level.4 Completeness of data reported into public health systems is often reliant on information submitted by providers. Ideally, increased investment and policy changes will support development of comprehensive electronic data exchange between public health and health care organizations. These systems could then be much more rapidly modified when new reporting requirements arise. Data analysis Granular analyses of data are required to improve decision making and focused community interventions. Easy access and contextualized display of real-time information increase transparency and can assist the public in making data-driven choices about their daily interactions and habits. While public health personnel are stretched thin during the pandemic response, collaborations with academic partners may provide much-needed capacity to support epidemiologic analyses and translation of data into action.5 Such public health and academic partnerships should be strengthened. Data sharing Secure and timely data exchange between public health, laboratories, and health care providers is critical for the detection of and response to evolving disease patterns. Expert recommendations6 have urged public health departments to leverage increased federal flexibilities governing information exchange during the COVID-19 emergency,7 assert public health legal authorities, and define a clear minimum data set when initiating data exchange efforts. With regard to cross-jurisdictional data exchange, protocols from HIV/AIDS and STI programs may serve as models for the secure and ethical sharing of information for cross-border case investigations. In the Near Future While CARES Act investments are notable, they are not sufficient to modernize public health data systems in a comprehensive manner. Congress rightly funded states to enhance and update their epidemiology and laboratory capacity for the COVID-19 response, but to achieve a cohesive core public health data system, specific and sustained funding will remain paramount. Over the coming years, the governmental public health community must continue pushing for innovative partnerships with the private sector, including in new ways that combine governmental public health and private sector expertise to build a safe, secure environment to test new ideas. For instance, while we still have much to learn about smartphone COVID-19 exposure notification apps built for the joint Apple/Google application interface, it is clear such partnerships can yield significant benefit and potentially lead to huge advancements for the nation's health. It is equally clear that, like any good investment for long-term benefit, public health data modernization will require an initial down payment when we emerge from our current COVID-19 crisis, and sustained funding thereafter.

Background: Outbreaks of infections in healthcare negatively impact patient outcomes and experience. Transparency is critical to engendering trust and optimizing health. Consistent guidance is not available regarding when to report a possible outbreak of healthcare-associated infections (HAIs) to public health and when to notify a limited population or to publicly disclose the occurrence of HAI. Recent analyses of state public health policies revealed that most states address reporting of outbreaks using terms such as clusters, unusual occurrences, or incidences over baseline. Specific wording about healthcare outbreaks or guidance for notifying patients or public is often absent. Thus, HAI outbreak notification and disclosure guidance and practices vary significantly around the country. A best-practice guidance document will provide clarity for when such reporting should occur. Methods: The Council for Outbreak Response: HAI and Antimicrobial-Resistant Pathogens (CORHA) has undertaken the task of developing this guidance by forming a multidiscipline policy work group with representation from its partner organizations. This work group has been tasked with creating a general framework that will guide notification and disclosure in the context of a possible HAI outbreak. The draft guidance document has been developed over several months of telephone and in-person conferences among work group members. Results: The standardized actions stemming from the guiding principles and recommended practices for conducting step 1 (immediate notification, initial and critical communications that occur when an outbreak is first suspected), were arranged in a table format with rows representing stakeholders and constituents to be notified and columns demonstrating the actions to be taken (Fig. 1). As an investigation progresses, notification should be revisited, especially if an investigation’s scope expands. The principles and practices for step 2 (expanded notification) have also been drafted in a table format. Next, the draft guidance addresses step 3 (public disclosure), outlining indications, practical guidance, and considerations in an outline and/or summary format. Real-world examples demonstrating application of the framework are being developed as supplementary resources to the framework. Current work group activities include engaging bioethicists, media reporters and patient advocates to review and comment on the guidance to ensure that it is clear, consistent and practical. Discussion: The draft guidance provides a framework for standardized actions for HAI outbreak notification and disclosure in a stepwise fashion, modeling public health practices and grounded in bioethical principles. The final product will provide valuable, practical advice for effectively sharing information with affected or potentially affected individuals and their caregivers in a timely manner. Funding: None Disclosures: Dawn Terashita reports that her spouse has received honoraria rom the speaker’s bureaus of Novo Nordisk and Abbott.

Inadequate resuscitation leads to death or brain injury. Recent recommendations for resuscitation team training to complement knowledge and skills training highlighted the need for development of an effective team resuscitation training session. This study aimed to evaluate and revise an interprofessional team training session which addressed roles and performance during provision of paediatric resuscitation, through incorporation of real-time, real team simulated training episodes. This study was conducted applying the principles of action research. Two cycles of data collection, evaluation and refinement of a 30-40 minute resuscitation training session for doctors and nurses occurred. Doctors and nurses made up 4 groups of training session participants. Their responses to the training were evaluated through thematic analysis of rich qualitative data gathered in focus groups held immediately after each training session. Major themes included the importance of realism, teamwork, and reflective learning. Findings informed important training session changes. These included; committed in-situ training; team diversity; realistic resources; role flexibility, definition and leadership; increased debriefing time and the addition of a team goal. In conclusion, incorporation of interprofessional resuscitation training which addresses team roles and responsibilities into standard medical and nursing training will enhance preparedness for participation in paediatric resuscitation.

Deep space neck abscess is one of the leading causes of pediatric emergency consultation for the Pediatric Otolaryngologists. These infections often require prompt surgical incision and drainage. However, in recent years, many patients have been successfully managed with intravenous antibiotics and careful observation. Computed tomography (CT) of the neck is the most common imaging modality for the evaluation of possible neck abscesses in children, which often requires sedation or general anesthesia. With the increasing concern for ionizing radiation exposure in children, the utilization of CT has come under increasing …

The National Alliance for Radiation Readiness (NARR) is an alliance of 16 national member organizations that have banded together to serve as the collective "voice of health" in radiological preparedness through: • participation in national dialogues on radiological emergency issues; • provision of thoughtful feedback on documents, policies, and guidelines; and • convening of partners to raise awareness of and resolve radiological emergency issues. NARR benefits from the intersection and interaction of public health, radiation control, healthcare, and emergency management professionals--all with an interest in bolstering the nation's preparedness for a radiological or nuclear incident. NARR is able to provide a unique perspective on radiological and nuclear preparedness by creating multi-disciplinary workgroups to develop guidance, recommendations, and provide subject matter feedback. NARR aims to build response and recovery capacity and capabilities by supporting the sharing of resources and tools, including technical methods and information through the development of an online clearinghouse. NARR also aims to identify and disseminate best practices, as well as define and educate on the roles and responsibilities of local, state, and federal government and the numerous agencies involved with the response to a radiological emergency.

The National Alliance for Radiation Readiness (NARR) is an alliance of 16 national member organizations that have banded together to serve as the collective voice of health in radiological preparedness through:participation in national dialogues on radiological emergency issues;provision of thoughtful feedback on documents, policies, and guidelines; andconvening of partners to raise awareness of and resolve radiological emergency issues. NARR benefits from the intersection and interaction of public health, radiation control, healthcare, and emergency management professionalsall with an interest in bolstering the nation's preparedness for a radiological or nuclear incident. NARR is able to provide a unique perspective on radiological and nuclear preparedness by creating multi-disciplinary workgroups to develop guidance, recommendations, and provide subject matter feedback. NARR aims to build response and recovery capacity and capabilities by supporting the sharing of resources and tools, including technical methods and information through the development of an online clearinghouse. NARR also aims to identify and disseminate best practices, as well as define and educate on the roles and responsibilities of local, state, and federal government and the numerous agencies involved with the response to a radiological emergency.

Objectives: In this review, we discuss the physiology, pathophysiology, and clinical role of troponin, lactate, and B-type natriuretic peptide in the assessment and management of children with critical cardiac disease. Data Source: MEDLINE, PubMed. Conclusion: Lactate, troponin, and B-type natriuretic peptide continue to be valuable biomarkers in the assessment and management of critically ill children with cardiac disease. However, the use of these markers as a single measurement is handicapped by the wide variety of clinical scenarios in which they may be increased. The overall trend may be more useful than any single level with a persistent or rising value of more importance than an elevated initial value.

BACKGROUND:Aiming for and ensuring effective patient safety is a major priority in the management and culture of every health care organization. The pediatric intensive care unit (PICU) has become a workplace with a high diversity of multidisciplinary physicians and professionals. Therefore, delivery of high-quality care with optimal patient safety in a PICU is dependent on effective interprofessional team management. Nevertheless, ineffective interprofessional teamwork remains ubiquitous.METHODS:We based our review on the framework for interprofessional teamwork recently published in association with the UK Centre for Advancement of Interprofessional Education. Articles were selected to achieve better understanding and to include and translate new ideas and concepts.FINDINGS:The barrier between autonomous nurses and doctors in the PICU within their silos of specialization, the failure of shared mental models, a culture of disrespect, and the lack of empowering parents as team members preclude interprofessional team management and patient safety. A mindset of individual responsibility and accountability embedded in a network of equivalent partners, including the patient and their family members, is required to achieve optimal interprofessional care. Second, working competently as an interprofessional team is a learning process. Working declared as a learning process, psychological safety, and speaking up are pivotal factors to learning in daily practice. Finally, changes in small steps at the level of the microlevel unit are the bases to improve interprofessional team management and patient safety. Once small things with potential impact can be changed in one's own unit, engagement of health care professionals occurs and projects become accepted.CONCLUSION:Bottom-up patient safety initiatives encouraging participation of every single care provider by learning effective interprofessional team management within daily practice may be an effective way of fostering patient safety.