The purpose of this document is to highlight practical recommendations to assist acute care hospitals to prioritize and implement strategies to prevent ventilator-associated pneumonia (VAP), ventilator-associated events (VAE), and non-ventilator hospital-acquired pneumonia (NV-HAP) in adults, children, and neonates. This document updates the Strategies to Prevent Ventilator-Associated Pneumonia in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA), and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

Background: Healthcare facilities have experienced many challenges during the COVID-19 pandemic, including limited personal protective equipment (PPE) supplies. Healthcare personnel (HCP) rely on PPE, vaccines, and other infection control measures to prevent SARS-CoV-2 infections. We describe PPE concerns reported by HCP who had close contact with COVID-19 patients in the workplace and tested positive for SARS-CoV-2. Method: The CDC collaborated with Emerging Infections Program (EIP) sites in 10 states to conduct surveillance for SARS-CoV-2 infections in HCP. EIP staff interviewed HCP with positive SARS-CoV-2 viral tests (ie, cases) to collect data on demographics, healthcare roles, exposures, PPE use, and concerns about their PPE use during COVID-19 patient care in the 14 days before the HCP’s SARS-CoV-2 positive test. PPE concerns were qualitatively coded as being related to supply (eg, low quality, shortages); use (eg, extended use, reuse, lack of fit test); or facility policy (eg, lack of guidance). We calculated and compared the percentages of cases reporting each concern type during the initial phase of the pandemic (April–May 2020), during the first US peak of daily COVID-19 cases (June–August 2020), and during the second US peak (September 2020–January 2021). We compared percentages using mid-P or Fisher exact tests (α = 0.05). Results: Among 1,998 HCP cases occurring during April 2020–January 2021 who had close contact with COVID-19 patients, 613 (30.7%) reported ≥1 PPE concern (Table 1). The percentage of cases reporting supply or use concerns was higher during the first peak period than the second peak period (supply concerns: 12.5% vs 7.5%; use concerns: 25.5% vs 18.2%; p Conclusions: Although lower percentages of HCP cases overall reported PPE concerns after the first US peak, our results highlight the importance of developing capacity to produce and distribute PPE during times of increased demand. The difference we observed among selected groups of cases may indicate that PPE access and use were more challenging for some, such as nonphysicians and nursing home HCP. These findings underscore the need to ensure that PPE is accessible and used correctly by HCP for whom use is recommended.

Funding: None

Disclosures: None

This paper introduces a formal definition of a Cyber-Physical System (CPS) in the spirit of the CPS Framework proposed by the National Institute of Standards and Technology (NIST). It shows that using this definition, various problems related to concerns in a CPS can be precisely formalized and implemented using Answer Set Programming (ASP). These include problems related to the dependency or conflicts between concerns, how to mitigate an issue, and what the most suitable mitigation strategy for a given issue would be. It then shows how ASP can be used to develop an implementation that addresses the aforementioned problems. The paper concludes with a discussion of the potentials of the proposed methodologies.

This SHEA white paper identifies knowledge gaps and challenges in healthcare epidemiology research related to coronavirus disease 2019 (COVID-19) with a focus on core principles of healthcare epidemiology. These gaps, revealed during the worst phases of the COVID-19 pandemic, are described in 10 sections: epidemiology, outbreak investigation, surveillance, isolation precaution practices, personal protective equipment (PPE), environmental contamination and disinfection, drug and supply shortages, antimicrobial stewardship, healthcare personnel (HCP) occupational safety, and return to work policies. Each section highlights three critical healthcare epidemiology research questions with detailed description provided in supplementary materials. This research agenda calls for translational studies from laboratory-based basic science research to well-designed, large-scale studies and health outcomes research. Research gaps and challenges related to nursing homes and social disparities are included. Collaborations across various disciplines, expertise and across diverse geographic locations will be critical.

Background: In February 2019, the Orange County Health Care Agency (OCHCA) identified an outbreak of Candida auris, an emerging fungus that spreads rapidly in healthcare facilities. Patients in long-term acute-care hospitals (LTACHs) and skilled nursing facilities that provide ventilator care (vSNFs) are at highest risk for C. auris colonization. With assistance from the California Department of Public Health and the Centers for Disease Control and Prevention, OCHCA instituted enhanced surveillance, communication, and screening processes for patients colonized with or exposed to C. auris. Method: OCHCA implemented enhanced surveillance by conducting point-prevalence surveys (PPSs) at all 3 LTACHs and all 14 vSNFs in the county. Colonized patients were identified through axilla/groin skin swabbing with C. auris detected by PCR and/or culture. In facilities where >1 C. auris colonized patient was found, PPSs were repeated every 2 weeks to identify ongoing transmission. Retrospective case finding was instituted at 2 LTACHs with a high burden of colonized patients; OCHCA contacted patients discharged after January 1, 2019, and offered C. auris screening. OCHCA tracked the admission or discharge of all colonized patients, and facilities with ongoing transmission were required to report transfers of any patient, regardless of colonization status. OCHCA tracked all patients discharged from facilities with ongoing transmission to ensure that accepting facilities conducted admission surveillance testing of exposed patients and implemented appropriate environmental and contact precautions. Result: From February–October 2019, 192 colonized patients were identified. All 3 LTACHs and 6 of 14 VSNFs had at least 1 C. auris–colonized patient identified on initial PPS, and 2 facilities had ongoing transmission identified on serial PPS. OCHCA followed 96 colonized patients transferred a total of 230 times (an average of 2.4 transfers per patient) (Fig. 1) and 677 exposed patients discharged from facilities with ongoing transmission (Fig. 2). Admission screening of 252 exposed patients on transfer identified 13 (5.2%) C. auris–colonized patients. As of November 1, 2019, these 13 patients were admitted 21 times to a total of 6 acute-care hospitals, 2 LTACHs, and 3 vSNFs. Transferring facilities did not consistently communicate the colonized patient’s status and the requirements for isolation and testing of exposed patients. Conclusion: OCHCA oversight of interfacility transfer, though labor-intensive, improved identification of patients colonized with C. auris and implementation of appropriate environmental and contact precautions, reducing the risk of transmission in receiving healthcare facilities.

Funding: None

Disclosures: None

Background: In July 2017, the Ethiopian Public Health Institute (EPHI) launched an antimicrobial resistance (AMR) surveillance network at 4 sentinel laboratories. The National Clinical Bacteriology and Mycology Laboratory (NRL) at EPHI performs monthly confirmatory testing on a subset of isolates submitted by these sites. We assessed the existing confirmatory testing program to identify gaps and develop solutions, including a monitoring and evaluation (M&E) system. Methods: We assembled a technical working group (TWG) of key stakeholders. Laboratory site visits included workflow observation, process mapping, document review, and technologist interviews. Proposed solutions to observed gaps were drafted in formats consistent with their intended application. Feedback from the TWG was incorporated into final drafts. Available AMR network staff members were trained remotely, and they will train remaining staff. Results: Table 1 describes major gaps and solutions identified. Conclusions: Confirmatory testing provides a mechanism to evaluate laboratory testing proficiency, target improvements, and estimate surveillance data quality, yet standardized methods were lacking. Our efforts highlight key components of confirmatory testing programs and provide a model for use in laboratories with similar needs.

Funding: None

Disclosures: None

The magnetic resonance imaging (MRI) appearance of the brain and spinal cord in humans with neuroangiostrongyliasis (NA) due to Angiostrongylus cantonensis infection has been well reported. Equivalent studies in animals are lacking. This case series describes clinical and MRI findings in 11 dogs with presumptively or definitively diagnosed NA. MRI of the brain and/or spinal cord was performed using high-field (1.5 T) or low-field (0.25 T) scanners using various combinations of transverse, sagittal, dorsal and three-dimensional (3D) T1-weighted (T1W), transverse, sagittal and dorsal T2-weighted (T2W), T2W fluid-attenuated inversion recovery (FLAIR) and T2*-weighted (T2*W) gradient echo (GRE), dorsal T2W short tau inversion recovery (STIR) and post-gadolinium transverse, sagittal, dorsal and 3D T1W and transverse T2W FLAIR sequences. In 4/6 cases where the brain was imaged, changes consistent with diffuse meningoencephalitis were observed. Evidence of meningeal involvement was evident even when not clinically apparent. The spinal cord was imaged in 9 dogs, with evidence of meningitis and myelitis detected in regions consistent with the observed neuroanatomical localization. Pathognomonic changes of neural larva migrans, as described in some human patients with NA, were not detected. NA should be considered in the differential diagnosis of dogs with MRI evidence of focal or diffuse meningitis, myelitis and/or encephalitis, especially in areas where A. cantonensis is endemic. If not precluded by imaging findings suggestive of brain herniation, cerebrospinal fluid (CSF) collection for cytology, fluid analysis, real-time polymerase chain reaction (qPCR) and enzyme-linked immunosorbent assay (ELISA) testing should be considered mandatory in such cases after the MRI studies.

The structure and kinematics of the broad line region in quasars are still unknown. One popular model is the disk-wind model that offers a geometric unification of a quasar based on the viewing angle. We construct a simple kinematical disk-wind model with a narrow outflowing wind angle. The model is combined with radiative transfer in the Sobolev, or high velocity, limit. We examine how angle of viewing affects the observed characteristics of the emission line. The line profiles were found to exhibit distinct properties depending on the orientation, wind opening angle, and region of the wind where the emission arises.

At low inclination angle (close to face-on), we find that the shape of the emission line is asymmetric, narrow, and significantly blueshifted. As the inclination angle increases (close to edge-on), the line profile becomes more symmetric, broader, and less blueshifted. Additionally, lines that arise close to the base of the disk wind, near the accretion disk, tend to be broad and symmetric. Single-peaked line profiles are recovered for the intermediate and equatorial wind. The model is also able to reproduce a faster response in either the red or blue sides of the line profile, consistent with reverberation mapping studies.

We studied the response of naturalized kudzu plants to simulated herbivory at three locations: Delaware (DE), Pennsylvania (PA), and North Carolina (NC). At the DE and PA sites, plant mortality after the first yr was 14 and 50%, respectively, and was highest for plants that had a small starting root crown size. At both sites, 50 and 75% leaf and shoot clipping, and drilling one or two large holes from the root crown into roots, had no effect on aboveground biomass. In NC, all plants survived for 3 yr. Plants subject to 50% vine removal at this site showed significant decrease in aboveground biomass compared to the control, but 50% leaf cutting and root drilling had no effect. In the greenhouse, kudzu seedlings grown in 60 and 100% light compensated for 50% leaf removal, but 75% damage reduced aboveground biomass. Plants survived for 1 to 2 mo in 0% direct light, but only one of 53 plants survived to the end of the experiment. Results suggest that established kudzu plants are able to compensate for biomass removal, seedlings can survive for several weeks without light, and that effective biocontrol might require more than 2 to 3 yr of continuous damage.