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Colleges and universities around the world engaged diverse strategies during the COVID-19 pandemic. Baylor University, a community of ˜22,700 individuals, was one of the institutions which resumed and sustained operations. The key strategy was establishment of multidisciplinary teams to develop mitigation strategies and priority areas for action. This population-based team approach along with implementation of a “Swiss Cheese” risk mitigation model allowed small clusters to be rapidly addressed through testing, surveillance, tracing, isolation, and quarantine. These efforts were supported by health protocols including face coverings, social distancing, and compliance monitoring. As a result, activities were sustained from 1 August to 8 December 2020. There were 62,970 COVID-19 tests conducted with 1,435 people testing positive for a positivity rate of 2.28%. A total of 1,670 COVID-19 cases were identified with 235 self-reports. The mean number of tests per week was 3,500 with approximately 80 of these positive (11 per day). More than 60 student tracers were trained with over 120 personnel available to contact trace, at a ratio of one per 400 university members. The successes and lessons learned provide a framework and pathway for similar institutions to mitigate the ongoing impacts of COVID-19 and sustain operations during a global pandemic.
This paper presents a soft, tendon-driven, robotic glove designed to augment grasp capability and provide rehabilitation assistance for postspinal cord injury patients. The basis of the design is an underactuation approach utilizing postural synergies of the hand to support a large variety of grasps with a single actuator. The glove is lightweight, easy to don, and generates sufficient hand closing force to assist with activities of daily living. Device efficiency was examined through a characterization of the power transmission elements, and output force production was observed to be linear in both cylindrical and pinch grasp configurations. We further show that, as a result of the synergy-inspired actuation strategy, the glove only slightly alters the distribution of forces across the fingers, compared to a natural, unassisted grasping pattern. Finally, a preliminary case study was conducted using a participant suffering from an incomplete spinal cord injury (C7). It was found that through the use of the glove, the participant was able to achieve a 50% performance improvement (from four to six blocks) in a standard Box and Block test.
In industrialized societies unions have traditionally played a key role in regulating the employment relationship and protecting against an unfettered commodification and exploitation of labour. Such exploitation was perceived to pose a threat to workers’ fundamental rights to participate as citizens (Bosch, 2004; Standing, 2011). This was largely achieved through the mechanisms of collective bargaining and industrial action, and by lobbying for a floor of rights for workers in the forms of protective legislation.
However, the ability of unions to effectively represent workers (especially through collective bargaining) has been weakened considerably since the 1960s. There has been a combined shift towards globalism, austerity and neoliberalism, exemplified by a rise in liberal market economies (LMEs), of which ‘freeing up’ of labour markets is a core tenet (Fudge, 2005). LMEs typically adopt labour-market policies that are characterized by a decrease in political support for collective representation of workers and minimal regulation or deregulation of the employment relationship. In tandem with (and probably influenced by) the change to regulatory systems and a weakening of union power, there has been a shift away from the standard employment relationship (SER) (Broughton et al, 2016). The SER is essentially a conceptualization of a traditional model of permanent, fulltime, continuous employment (Arnold and Bongiovi, 2013); however, while this model remains dominant in many countries and employment systems, it is widely accepted that the SER is being steadily eroded. What is emerging in its place is a wide range of alternative or non-standard forms of work (Bobeck et al, 2018) that are much more flexible and fragmented in temporal terms. Examples include zero-hours work, gig work and lowhours contracts. According to the European Commission (2017), upwards of 6 million people in the EU are working on an intermittent and ondemand basis. Research indicates that such work has been associated with higher levels of precarity (Kalleberg, 2009; Burgess et al, 2013).
In Ireland, as in other countries, the trade union movement has experienced a steady decline in density (particularly in the private sector) (CSO, 2019).
Alien species are a driver of biodiversity loss, with impacts of different aliens on native species varying considerably. Identifying the contributions of alien species to native species declines could help target management efforts. Globally, seabirds breeding on islands have proven to be highly susceptible to alien species. The breeding colonies of the pink-footed shearwater (Ardenna creatopus) are threatened by the negative impacts of alien mammals. We combined breeding monitoring data with a hierarchical model to separate the effects of different alien mammal assemblages on the burrow occupancy and hatching success of the pink-footed shearwater in the Juan Fernández Archipelago, Chile. We show that alien mammals affected the rates of burrow occupancy, but had little effect on hatching success. Rabbits produced the highest negative impacts on burrow occupancy, whereas the effects of other alien mammals were more uncertain. In addition, we found differences in burrow occupancy between islands regardless of their alien mammal assemblages. Managing rabbits will improve the reproductive performance of this shearwater, but research is needed to clarify the mechanisms by which alien mammals affect the shearwaters and to explain why burrow occupancy varies between islands.
Among children exposed to elevated maternal depression symptoms (MDS), recent studies have demonstrated reduced internalizing and externalizing problems for those who have attended formal childcare (i.e., center-based, family-based childcare). However, these studies did not consider whether childcare attendance is associated with benefits for the child only or also with reduced MDS. Using a four-wave longitudinal cross-lagged model, we evaluated whether formal childcare attendance was associated with MDS or child behavior problems and whether it moderated longitudinal associations between MDS and child behavior problems and between child behavior problems and MDS. The sample was drawn from a population-based cohort study and consisted of 908 biologically related mother–child dyads, followed from 5 months to 5 years. Attending formal childcare was not associated with MDS or child behavior problems but moderated the association between MDS at 3.5 years and child internalizing and externalizing problems at 5 years as well as between girls’ externalizing problems at 3.5 years and MDS at 5 years. No other moderation of formal childcare was found. Findings suggest that attending formal childcare reduces the risks of behavior problems in the context of MDS but also the risk of MDS in the context of girls’ externalizing problems.
Young women aged 16–24 are at high risk of common mental disorders (CMDs), but the risk during pregnancy is unclear.
To compare the population prevalence of CMDs in pregnant women aged 16–24 with pregnant women ≥25 years in a representative cohort, hypothesising that younger women are at higher risk of CMDs (depression, anxiety disorders, post-traumatic stress disorder, obsessive–compulsive disorder), and that this is associated with low social support, higher rates of lifetime abuse and unemployment.
Analysis of cross-sectional baseline data from a cohort of 545 women (of whom 57 were aged 16–24 years), attending a South London maternity service, with recruitment stratified by endorsement of questions on low mood, interviewed with the Structured Clinical Interview DSM-IV-TR.
Population prevalence estimates of CMDs were 45.1% (95% CI 23.5–68.7) in young women and 15.5% (95% CI 12.0–19.8) in women ≥25, and for ‘any mental disorder’ 67.2% (95% CI 41.7–85.4) and 21.2% (95% CI 17.0–26.1), respectively. Young women had greater odds of having a CMD (adjusted odds ratio (aOR) = 5.8, 95% CI 1.8–18.6) and CMDs were associated with living alone (aOR = 3.0, 95% CI 1.1–8.0) and abuse (aOR = 1.5, 95% CI 0.8–2.8).
Pregnant women between 16 and 24 years are at very high risk of mental disorders; services need to target resources for pregnant women under 25, including those in their early 20s. Interventions enhancing social networks, addressing abuse and providing adequate mental health treatment may minimise adverse outcomes for young women and their children.
To inform the development of a national clinical guideline for Chronic Obstructive Pulmonary Disease (COPD), prioritized by the National Clinical Effectiveness Committee in Ireland, a systematic review was conducted to examine the cost-effectiveness of pulmonary rehabilitation programs (PRPs), outreach programs (OPs), and long-term oxygen therapy (LTOT), compared with usual care.
Medline, Embase, the Cochrane Library and grey literature sources were searched up to 19 June 2018. Studies evaluating cost-effectiveness published post-2008 in English were included. Screening, data extraction, and quality assessment using the Consensus Health Economic Criteria and International Society for Pharmacoeconomics questionnaires were conducted independently by two reviewers. Costs were converted to 2017 Irish Euro using consumer price indices for health and purchasing power parity.
From 8,661 articles identified, seven studies (one comparing both PRPs and LTOT) were included (PRPs: five; OPs: one; LTOT: two). PRP cost-utility analyses (n = 4) reported conflicting results due to considerable heterogeneity in program and study design, with incremental cost-effectiveness ratios (ICERs) ranging between EUR 12,391 and EUR 509,122 per quality adjusted life-year (QALY) gained. The remaining study investigated hospitalizations avoided and found outpatient and community-based PRPs to be dominant, while home-based PRP produced an ICER of EUR 1,913. OPs were found to be less costly, but also less effective. However, the results of the underpinning trial were neither statistically nor clinically significant. LTOT was found to be cost-effective, with ICERs of EUR 17,603 and EUR 26,936 per QALY gained.
Applying a willingness-to-pay threshold of EUR 45,000 per QALY gained, this systematic review found that, compared with usual care, there is inconsistent but generally favorable evidence for PRPs, no clear evidence for the cost-effectiveness of OPs, and that LTOT is likely to be cost-effective. However, there was a lack of methodologically robust studies included in the review and most were not directly transferable to the Irish context.
There are significant challenges to retaining indigenous biodiversity and ecological infrastructure in African cities. These include a lack of formal protection and status for remnant ecologically functional patches rendering them open to ad hoc human settlement, which is in part linked to weak governance and management emerging from complex histories, and competing crisis-ridden demands. Persistent gaps in knowledge and practice mean that the social, economic, development and well-being benefits of ecological infrastructure are not understood or demonstrated. Addressing these challenges requires the adoption of multiple top-down government interventions and bottom-up community and neighbourhood actions. The development of detailed case studies that engage with knowledge generation and sharing at multiple scales through co-learning practices will also help create a much-needed deeper understanding of development options within this context.
To inform the development of a national clinical guideline for Chronic Obstructive Pulmonary Disease (COPD), prioritised by the National Clinical Effectiveness Committee (NCEC) in Ireland, a systematic review was conducted to examine the cost-effectiveness of long-acting beta2-agonists (LABAs) in combination with long-acting muscarinic antagonists (LAMAs) compared with LAMA or LABA monotherapy.
Medline, Embase, the Cochrane Library and grey literature sources were searched up to 19 June 2018. Studies evaluating cost-effectiveness published post-2008 in English were included. Screening, data extraction, and quality assessment using the Consensus Health Economic Criteria (CHEC-list) and International Society for Pharmacoeconomics (ISPOR) questionnaires were conducted independently by two reviewers. Costs were adjusted to 2017 Irish Euro using consumer price indices and purchasing power parity as per national guidelines.
From a total of 8,661 articles identified, nine studies (all cost-utility analyses) were included in the review. Studies ranged from low to high quality and compared LAMA/LABA combination therapy with LAMA monotherapy. The results reported were mixed, ranging from combination therapy being dominated by (that is, more costly and less effective than) LAMA monotherapy to being dominant (that is, less costly and more effective). However, when excluding low quality, less applicable studies, the remaining six studies reported incremental cost-effectiveness ratios (ICERs) of between EUR 2,770 and EUR 26,462 per quality-adjusted life year (QALY) gained. Only one study additionally compared LABA monotherapy as a comparator, reporting combination therapy to be even more cost-effective than in the LAMA monotherapy comparison.
Applying a cost-effectiveness willingness-to-pay threshold of EUR 45,000 per QALY gained, this systematic review found that LAMA/LABA combination therapy is cost-effective compared with LAMA or LABA monotherapy in COPD patients.
Recent advances in the additive manufacturing technology now enable fused filament fabrication of polyetheretherketone (PEEK). A standardized lumbar fusion cage design was 3D printed with different speeds of the printhead nozzle to investigate whether 3D-printed PEEK cages exhibit sufficient material properties for lumbar fusion applications. It was observed that the compressive and shear strength of the 3D-printed cages were 63–71% of the machined cages, whereas the torsion strength was 92%. The printing speed is an important printing parameter for 3D-printed PEEK, which resulted in up to 20% porosity at the highest speed of 3000 mm/min, leading to reduced cage strength. Printing speeds below 1500 mm/min can be chosen as the optimal printing speed for this printer to reduce the printing time while maintaining strength. The crystallinity of printed PEEK did not differ significantly from the as-machined PEEK cages from extruded rods, indicating that the processing provides similar microstructure.
Children with CHD and acquired heart disease have unique, high-risk physiology. They may have a higher risk of adverse tracheal-intubation-associated events, as compared with children with non-cardiac disease.
Materials and methods
We sought to evaluate the occurrence of adverse tracheal-intubation-associated events in children with cardiac disease compared to children with non-cardiac disease. A retrospective analysis of tracheal intubations from 38 international paediatric ICUs was performed using the National Emergency Airway Registry for Children (NEAR4KIDS) quality improvement registry. The primary outcome was the occurrence of any tracheal-intubation-associated event. Secondary outcomes included the occurrence of severe tracheal-intubation-associated events, multiple intubation attempts, and oxygen desaturation.
A total of 8851 intubations were reported between July, 2012 and March, 2016. Cardiac patients were younger, more likely to have haemodynamic instability, and less likely to have respiratory failure as an indication. The overall frequency of tracheal-intubation-associated events was not different (cardiac: 17% versus non-cardiac: 16%, p=0.13), nor was the rate of severe tracheal-intubation-associated events (cardiac: 7% versus non-cardiac: 6%, p=0.11). Tracheal-intubation-associated cardiac arrest occurred more often in cardiac patients (2.80 versus 1.28%; p<0.001), even after adjusting for patient and provider differences (adjusted odds ratio 1.79; p=0.03). Multiple intubation attempts occurred less often in cardiac patients (p=0.04), and oxygen desaturations occurred more often, even after excluding patients with cyanotic heart disease.
The overall incidence of adverse tracheal-intubation-associated events in cardiac patients was not different from that in non-cardiac patients. However, the presence of a cardiac diagnosis was associated with a higher occurrence of both tracheal-intubation-associated cardiac arrest and oxygen desaturation.
Coastal environments are faced with constant habitat modification and biodiversity loss due to human occupation. Estuaries are considered to be highly productive and shelter heterogeneous habitats such as mangrove forests, tidal creeks, tidal mud flats and sandy beaches, which are important for the maintenance of natural resources. The present study aims to evaluate how different shallow juvenile habitats (sandy beaches, mangrove shoreline habitats and dense macrophyte habitats) influence fish during their early life stages in a tropical estuary of Brazil. Monthly samples using a beach seine net from July 2012 to June 2013 were collected in eight shallow areas of the São Mateus River estuary. The fish assemblage comprised mainly juvenile and small-sized fish, which included ecologically and commercially important species. Small recruits of Atherinella brasiliensis and Ctenogobius boleosoma were most abundant in the autumn, while Rhinosardinia bahiensis and Centropomus undecimalis were highly abundant during the winter. The water salinity recorded in the mid and lower estuarine portions was the most important variable for the distribution of A. brasiliensis and Sphoeroides spengleri, whereas Anchovia clupeoides, C. undecimalis, C. parallelus and Gobionellus oceanicus were positively correlated with the water depth of the upper estuarine portion. The fish species T. paulistanus, Genidens genidens and Achirus lineatus were related to the water turbidity in the upper portion. Thus, the heterogeneous shallow water habitats (and their associated environmental parameters) of the São Mateus River estuary are potential nursery grounds for the early life stages of a variety of fish species, which highlights the importance of these areas for local biodiversity management.
There is limited evidence on the prevalence and identification of antenatal mental disorders.
To investigate the prevalence of mental disorders in early pregnancy and the diagnostic accuracy of depression-screening (Whooley) questions compared with the Edinburgh Postnatal Depression Scale (EPDS), against the Structured Clinical Interview DSM-IV-TR.
Cross-sectional survey of women responding to Whooley questions asked at their first antenatal appointment. Women responding positively and a random sample of women responding negatively were invited to participate.
Population prevalence was 27% (95% CI 22–32): 11% (95% CI 8–14) depression; 15% (95% CI 11–19) anxiety disorders; 2% (95% CI 1–4) obsessive–compulsive disorder; 0.8% (95% CI 0–1) post-traumatic stress disorder; 2% (95% CI 0.4–3) eating disorders; 0.3% (95% CI 0.1–1) bipolar disorder I, 0.3% (95% CI 0.1–1%) bipolar disorder II; 0.7% (95% CI 0–1) borderline personality disorder. For identification of depression, likelihood ratios were 8.2 (Whooley) and 9.8 (EPDS). Diagnostic accuracy was similar in identifying any disorder (likelihood ratios 5.8 and 6).
Endorsement of Whooley questions in pregnancy indicates the need for a clinical assessment of diagnosis and could be implemented when maternity professionals have been appropriately trained on how to ask the questions sensitively, in settings where a clear referral and care pathway is available.
Declaration of interest
L.M.H. chaired the National Institute for Health and Care Excellence CG192 guidelines development group on antenatal and postnatal mental health in 2012–2014.
Evidence regarding the association between adolescent internalising symptoms and school non-completion has been limited and inconclusive.
To examine whether depressive and anxious symptoms at secondary school entry predict school non-completion beyond confounders and whether associations differ by baseline academic functioning.
We used logistic regression to examine associations between depressive and anxious symptoms in grade 7 (age 12–14) and school non-completion (age 18–20) in 4962 adolescents.
Depressive symptoms did not predict school non-completion after adjustment, but moderation analyses revealed an association in students with elevated academic functioning. A curvilinear association was found for anxiety: both low and high anxious symptoms predicted school non-completion, although only low anxiety remained predictive after adjustment.
Associations between internalising symptoms and school non-completion are modest. Common school-based interventions targeting internalising symptoms are unlikely to have a major impact on school non-completion, but may prevent non-completion in selected students.
Tidal flexure in ice shelf grounding zones has been used extensively in the past to determine grounding line position and ice properties. Although the rheology of ice is viscoelastic at tidal loading frequencies, most modelling studies have assumed some form of linear elastic beam approximation to match observed flexure profiles. Here we use density, radar and DInSAR measurements in combination with full-Stokes viscoelastic modelling to investigate a range of additional controls on the flexure of the Southern McMurdo Ice Shelf. We find that inclusion of observed basal crevasses and density dependent ice stiffness can greatly alter the flexure profile and yet fitting a simple elastic beam model to that profile will still produce an excellent fit. Estimates of the effective Young's modulus derived by fitting flexure profiles are shown to vary by over 200% depending on whether these factors are included, even when the local thickness is well constrained. Conversely, estimates of the grounding line position are relatively insensitive to these considerations for the case of a steep bed slope in our study region. By fitting tidal amplitudes only, and ignoring phase information, elastic beam theory can provide a good fit to observations in a wide variety of situations. This should, however, not be taken as an indication that the underlying rheological assumptions are correct.
Objectives: The aim of this study was to illustrate the contribution of stakeholder engagement to the impact of health technology assessment (HTA) using an Irish HTA of a national public access defibrillation (PAD) program.
Background: In response to draft legislation that proposed a PAD program, the Minister for Health requested that Health Information and Quality Authority undertake an HTA to inform the design and implementation of a national PAD program and the necessary underpinning legislation. The draft legislation outlined a program requiring widespread installation and maintenance of automatic external defibrillators in specified premises.
Methods: Stakeholder engagement to optimize the impact of the HTA included one-to-one interviews with politicians, engagement with an Expert Advisory Group, public and targeted consultation, and positive media management.
Results: The HTA quantified the clinical benefits of the proposed PAD program as modest, identified that substantial costs would fall on small/medium businesses at a time of economic recession, and that none of the programs modeled were cost-effective. The Senator who proposed the Bill actively publicized the HTA process and its findings and encouraged participation in the public consultation. Participation of key stakeholders was important for the quality and acceptability of the HTA findings and advice. Media management promoted public engagement and understanding. The Bill did not progress.
Conclusions: The HTA informed the decision not to progress with legislation for a national PAD program. Engagement was tailored to ensure that key stakeholders including politicians and the public were informed of the HTA process, the findings, and the advice, thereby maximizing acceptance. Appropriate stakeholder engagement optimizes the impact of HTA.
The cost-effectiveness of Human papillomavirus (HPV)-based primary cervical screening in the Irish healthcare setting is assessed using a decision-analysis approach to inform a decision around changes to the national screening program. Current practices comprises primary screening with liquid-based cytology (LBC) followed by HPV triage, at 3-yearly intervals for ages 25 to 45 years and 5-yearly until age 60 years.
This study assessed changing the primary screening test from LBC to HPV testing, in both an unvaccinated and a vaccinated (against HPV 16/18) cohort. It considered extending the screening interval (to 5-yearly for all), the upper age limit (from 60 to 65 years) and different test sequences (four possible tests were included: HPV, LBC, partial genotyping for HPV16 or HPV 18 and the molecular biomarker p16INK4a/Ki67). A Markov-model for HPV-infection and cervical cancer was developed based on a German cervical screening model (1). The perspective of the healthcare system was adopted and a 5 percent discount rate used.
Strategies using HPV as the primary screening test are more effective than LBC-based strategies. The optimal strategy, at a willingness-to-pay threshold of EUR45,000 per quality-adjusted life year (QALY), for the unvaccinated cohort was HPV-based primary screening with a LBC triage test, at five-yearly intervals from age 25 to 60 years. This strategy is cost saving compared with current practice and cost effective when compared to no screening, with an Incremental cost-effectiveness ratio (ICER) of EUR18,164 per QALY. The optimal strategy for the vaccinated cohort was also HPV primary screening with a LBC triage test, at five-yearly intervals from age 25 to 60 years. While more effective and cost saving compared with current practice, it would not be considered cost effective compared with no screening (ICER of EUR58,745/QALY).
Based on our analyses, HPV-based cervical screening is more effective and cost saving compared with LBC-based screening for both vaccinated and unvaccinated cohorts in an Irish setting.
The Detroit Lakes chain of lakes consists of five basins in northwest Minnesota adjacent to the town of Detroit Lakes. Flowering rush has been established in these basins since the 1960s. We evaluated the distribution of flowering rush in the five basins using a point intercept method, with 830 points distributed in a grid with points 150 m apart. These data were analyzed to determine whether invasive and native species frequencies were different between 2010 and 2011. We also assessed co-occurrence of flowering rush with native hardstem bulrush. The distribution of both flowering rush and hardstem bulrush was unchanged from 2010 to 2011. Flowering rush is invading areas with native plants and not establishing in unvegetated areas. Although flowering rush is found as deep as 4.5 m, it is most frequent at a depth of 1.3 m. We also examined the distribution of biomass and growth across a depth gradient from 0.3 to 3.0 m in 0.3-m intervals. At each 0.3-m interval, three biomass samples were collected at each of 10 transects for a total of 30 samples per depth interval or 300 biomass samples. At each point, leaf height, emergent leaf height, water depth, number of ramets, and number of rhizome buds were counted. Biomass samples were collected in a 0.018-m2 core sampler, sorted to shoots and belowground biomass. We found that flowering rush height and biomass peaked at 1.3 m and declined with greater depth. Bud density was negatively related to water depth. Bud density averaged 300 buds m–2, which was three times the average ramet density (100 ramets m–2).
Poor diet quality contributes to morbidity, including poor brain health outcomes such as cognitive decline and dementia. African Americans and individuals living in poverty may be at greater risk for cognitive decrements from poor diet quality.
Baltimore, MD, USA.
Participants were 2090 African Americans and Whites (57 % female, mean age=47·9 years) who completed two 24 h dietary recalls. We examined cognitive performance and potential interactions of diet quality with race and poverty status using baseline data from the Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study. Healthy Eating Index-2010 (HEI-2010) scores were calculated and interpreted using federal guidelines. A neurocognitive test battery was administered to evaluate cognitive function over several domains.
Linear regression analyses showed that lower HEI-2010 scores were associated with poorer verbal learning and memory (P<0·05) after adjustment for covariates. Diet quality within the sample was poor. Significant interactions of HEI-2010 and poverty status (all P<0·05) indicated that higher diet quality was associated with higher performance on tests of attention and cognitive flexibility, visuospatial ability and perceptual speed among those below the poverty line. No significant race interactions emerged. Higher diet quality was associated with better performance on two measures of verbal learning and memory, irrespective of race and poverty status.
Findings suggest that diet quality and cognitive function are likely related at the population level. Future research is needed to determine whether the association is clinically significant.
The unprecedented Ebola Virus Disease (EVD) outbreak in West Africa, with its first cases documented in March 2014, has claimed the lives of thousands of people, and it has devastated the health care infrastructure and workforce in affected countries. Throughout this outbreak, there has been a critical lack of health care workers (HCW), including physicians, nurses, and other essential non-clinical staff, who have been needed, in most of the affected countries, to support the medical response to EVD, to attend to the health care needs of the population overall, and to be trained effectively in infection protection and control. This lack of sufficient and qualified HCW is due in large part to three factors: 1) limited HCW staff prior to the outbreak, 2) disproportionate illness and death among HCWs caused by EVD directly, and 3) valid concerns about personal safety among international HCWs who are considering responding to the affected areas. These guidelines are meant to inform institutions who deploy professional HCWs. (Disaster Med Public Health Preparedness. 2015;9:586–590)