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[...]there is no clear and comprehensive formal description available detailing the various skills necessary for the current-day HE to be successful, nor is there a list of the training resources that are currently available. A comprehensive list of HE skills and competencies are listed in Table 1; they are categorized into those that apply to HEs practicing in any healthcare setting (basic) and those that apply to HEs in specialized settings such as academic centers or who have a specific career focus such as antimicrobial stewardship or quality (advanced).TABLE 1 CORE Competencies for the Healthcare Epidemiologist (HE).a Role: Epidemiologist Competency Area Knowledge Skill Basic (B)/Advanced (A) Surveillance Understand processes and definitions (including interpretation, implementation, and the limitations) associated with HAI surveillance Effectively conduct HAI surveillance B Understand the differences between HAI surveillance definitions and clinical definitions for infectious syndromes Distinguish between HAI surveillance and clinical definitions for infectious syndromes B Understand the importance and type of data used to calculate rates for HAIs and other patient adverse events Ability to identify outcome data (numerator) and exposure data (denominator) B Knowledge of the role of different event rate calculations and the value of risk-adjusted data Calculate event rates and perform risk adjustment Rate calculation: B; Risk-adjustment: A Understand the value of and methods for comparing surveillance data across institutions/settings and against population-based data sets Use national and state benchmarking data to assess institution’s performance and target areas for improvement B Understand basic principles and methods of surveillance for common non-HAI patient adverse events. Conduct basic surveillance for patient safety events (eg, falls, pressure ulcers, medication adverse events) A Data Management Assess data management resources available at an institution for performing healthcare epidemiology and public HAI reporting activities Leverage data management resources to obtain needed information B Understand processes for validation of HAI surveillance data Perform internal validation of HAI surveillance data B Understand how to select HAI surveillance software and to maximize utilization of this software to meet program needs A Role: Subject Matter Expert Competency Area Knowledge Skill Basic (B)/Advanced (A) Infectious Diseases/Pathogen Transmission Understand modes of transmission of infectious pathogens Apply isolation precautions correctly for specific infections or conditions based on mode of transmission B Understand the presentation and diagnosis of common infectious syndromes: Hand hygiene and asepsis Isolation precautions Disinfection and sterilization Device reprocessing Environmental cleaning Occupational health-related issues and procedures Immunization ( HCP and patient) Infected HCP assessment Blood borne pathogen exposure management Communicable disease exposure management Environmental infection control, including air handling and facility water supply issues Apply appropriate infection control practices B Understand infection control issues related to construction in healthcare facilities Conduct an infection control risk assessment and implement preventive measures for specific projects B Be familiar with products used in healthcare that may have infection prevention implications (eg, antibiotic-impregnated devices) Impartially evaluate products for potential implementation B Outbreak Investigation Understand methods used to identify an outbreak Correctly identify when an outbreak has occurred B Know the steps of an effective outbreak investigation Apply steps of an outbreak investigation including developing a case definition, identifying cases, creating a line listing, creating epidemic curves and collecting and evaluating specimens and cultures B Understand when a formal risk factor study is needed and how to select the appropriate study design (eg, case control vs. cohort) for an outbreak investigation Identify appropriate controls where applicable, and generate exposure ratios, relative risks, or odds ratios and confidence intervals B Know when and how to communicate with facility administrators, risk management, public affairs, clinical staff and patients/families about the need for, progress of, and outcome of an outbreak investigation Appropriately involve relevant stakeholders in outbreak investigation efforts B Understand the potential role of molecular typing of microbial isolates in an outbreak investigation Utilize molecular typing methods appropriately and correctly interpret typing results A Microbiology and Laboratory Diagnostics Understand how to appropriately obtain and interpret microbiologic cultures Distinguish between infection, colonization, and contamination of culture specimens B Understand Clinical and Laboratory Standards Institute (CLSI) recommendations for making an institutional antibiogram Develop and interpret an antibiogram at least annually in conjunction with microbiology leadership B Understand options for rapid diagnostic testing in the microbiology lab including when such testing should be utilized and how to interpret test results Assist the laboratory in decisions regarding implementation of rapid diagnostic testing and appropriately incorporate results into infection prevention interventions B Understand options for molecular testing in the microbiology lab including when such testing should be utilized Assist the lab in selecting and implementing molecular testing and appropriately incorporate results into infection prevention interventions B Understand test characteristics (eg, sensitivity, specificity, positive and negative predictive value) and that a change in testing methodology may result in an apparent change in incidence or prevalence of an infection or pathogen Assess and interpret test characteristics for a given diagnostic test; compare the performance characteristics of different testing methodologies used in clinical laboratories, including but not limited to culture-based methods, infectious serology, rapid diagnostics and molecular assays.

New Jersey was among the first states impacted by the COVID-19 pandemic, with one of the highest overall death rates in the nation. Nevertheless, relatively few reports have been published focusing specifically on New Jersey. Here we report on molecular, clinical, and epidemiologic observations, from the largest healthcare network in the state, in a cohort of vaccinated and unvaccinated individuals with laboratory-confirmed SARS-CoV-2 infection. We conducted molecular surveillance of SARS-CoV-2-positive nasopharyngeal swabs collected in nine hospitals from December 2020 through June 2022, using both whole genome sequencing (WGS) and a real-time RT-PCR screening assay targeting spike protein mutations found in variants of concern (VOCs) within our region. De-identified clinical data were obtained retrospectively, including demographics, COVID-19 vaccination status, ICU admission, ventilator support, mortality, and medical history. Statistical analyses were performed to identify associations between SARS-CoV-2 variants, vaccination status, clinical outcomes, and medical risk factors. A total of 5007 SARS-CoV-2-positive nasopharyngeal swabs were successfully screened and/or sequenced. Variant screening identified three predominant VOCs, including Alpha (n = 714), Delta (n = 1877), and Omicron (n = 1802). Omicron isolates were further sub-typed as BA.1 (n = 899), BA.2 (n = 853), or BA.4/BA.5 (n = 50); the remaining 614 isolates were classified as “Other”. Approximately 31.5% (1577/5007) of the samples were associated with vaccine breakthrough infections, which increased in frequency following the emergence of Delta and Omicron. Severe clinical outcomes included ICU admission (336/5007 = 6.7%), ventilator support (236/5007 = 4.7%), and mortality (430/5007 = 8.6%), with increasing age being the most significant contributor to each (p < 0.001). Unvaccinated individuals accounted for 79.7% (268/336) of ICU admissions, 78.3% (185/236) of ventilator cases, and 74.4% (320/430) of deaths. Highly significant (p < 0.001) increases in mortality were observed in individuals with cardiovascular disease, hypertension, cancer, diabetes, and hyperlipidemia, but not with obesity, thyroid disease, or respiratory disease. Significant differences (p < 0.001) in clinical outcomes were also noted between SARS-CoV-2 variants, including Delta, Omicron BA.1, and Omicron BA.2. Vaccination was associated with significantly improved clinical outcomes in our study, despite an increase in breakthrough infections associated with waning immunity, greater antigenic variability, or both. Underlying comorbidities contributed significantly to mortality in both vaccinated and unvaccinated individuals, with increasing risk based on the total number of comorbidities. Real-time RT-PCR-based screening facilitated timely identification of predominant variants using a minimal number of spike protein mutations, with faster turnaround time and reduced cost compared to WGS. Continued evolution of SARS-CoV-2 variants will likely require ongoing surveillance for new VOCs, with real-time assessment of clinical impact.

The neutralizing capacities of monoclonal antibodies used to treat COVID-19 and of those recovered from previously infected and vaccinated individuals against SARS-CoV-2 variants of concern (VOCs) remain important questions. We report on a nosocomial outbreak caused by a SARS-CoV-2 R.1 variant harboring an E484K mutation among 81 unvaccinated inpatients and health care professionals. Examining the neutralizing capacity of monoclonal antibodies (MAbs) used to treat COVID-19, as well as antibodies recovered from unvaccinated, previously vaccinated, and infected individuals, against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants of concern (VOCs) remains critical to study. Here, we report on a SARS-CoV-2 nosocomial outbreak caused by the SARS-CoV-2 R.1 variant harboring the E484K mutation in a 281-bed psychiatric facility in New Jersey among unvaccinated inpatients and health care professionals (HCPs). A total of 81 inpatients and HCPs tested positive for SARS-Cov-2 by reverse transcription (RT)-PCR from 29 October 9 to 30 November 2020. The R.1 variant exhibits partial or complete resistance to two MAbs in clinical use, as well as 2 receptor binding domain MAbs and 4 N-terminal domain (NTD) MAbs. NTD MAbs against pseudovirus harboring single characteristic R.1 mutations highlight the role of S255F in loss of activity. Additionally, we note dampened neutralization capacity by plasma from individuals with previous SARS-CoV-2 infection or sera from vaccinated individuals. The relative resistance of the R.1 variant is likely lower than that of B.1.351 and closer to that of P.1 and B.1.526. The R.1 lineage has been reported in 47 states in the United States and 40 countries. Although high proportions exhibited symptoms (26% and 61% among patients and HCPs, respectively) and relative antibody resistance, we detected only 10 R.1 variants from over 2,900 samples (~0.34%) collected from January to October 2021. Among 3 vaccinated individuals previously infected with R.1, we observed robust neutralizing antibody responses against SARS-CoV-2 wild type and VOCs. IMPORTANCE The neutralizing capacities of monoclonal antibodies used to treat COVID-19 and of those recovered from previously infected and vaccinated individuals against SARS-CoV-2 variants of concern (VOCs) remain important questions. We report on a nosocomial outbreak caused by a SARS-CoV-2 R.1 variant harboring an E484K mutation among 81 unvaccinated inpatients and health care professionals. We note high attack rates with symptoms in nearly 50% of infected individuals, in sharp contrast to an unrelated institutional outbreak caused by the R.1 variant among a vaccinated population. We found little evidence of significant community spillover. This variant exhibits partial or complete resistance to two monoclonal antibodies in clinical use and dampened the neutralization capacity of convalescent-phase plasma from individuals with previous infection or sera from vaccinated individuals. Among three vaccinated individuals previously infected with R.1, we observed robust neutralizing antibody responses against SARS-CoV-2 wild type and VOCs. These findings underscore the importance of vaccination for prevention of symptomatic COVID-19 disease.

Hospitals are increasingly consolidating into health systems. Some systems have appointed healthcare epidemiologists to lead system-level infection prevention programs. Ideal program infrastructure and support resources have not been described. We informally surveyed 7 healthcare epidemiologists with recent experience building and leading system-level infection prevention programs. Key facilitators and barriers for program structure and implementation are described.

Hydroxychloroquine has been touted as a potential COVID-19 treatment. Tocilizumab, an inhibitor of IL-6, has also been proposed as a treatment of critically ill patients. In this retrospective observational cohort study drawn from electronic health records we sought to describe the association between mortality and hydroxychloroquine or tocilizumab therapy among hospitalized COVID-19 patients. Patients were hospitalized at a 13-hospital network spanning New Jersey USA between March 1, 2020 and April 22, 2020 with positive polymerase chain reaction results for SARS-CoV-2. Follow up was through May 5, 2020. Among 2512 hospitalized patients with COVID-19 there have been 547 deaths (22%), 1539 (61%) discharges and 426 (17%) remain hospitalized. 1914 (76%) received at least one dose of hydroxychloroquine and 1473 (59%) received hydroxychloroquine with azithromycin. After adjusting for imbalances via propensity modeling, compared to receiving neither drug, there were no significant differences in associated mortality for patients receiving any hydroxychloroquine during the hospitalization (HR, 0.99 [95% CI, 0.80-1.22]), hydroxychloroquine alone (HR, 1.02 [95% CI, 0.83-1.27]), or hydroxychloroquine with azithromycin (HR, 0.98 [95% CI, 0.75-1.28]). The 30-day unadjusted mortality for patients receiving hydroxychloroquine alone, azithromycin alone, the combination or neither drug was 25%, 20%, 18%, and 20%, respectively. Among 547 evaluable ICU patients, including 134 receiving tocilizumab in the ICU, an exploratory analysis found a trend towards an improved survival association with tocilizumab treatment (adjusted HR, 0.76 [95% CI, 0.57-1.00]), with 30 day unadjusted mortality with and without tocilizumab of 46% versus 56%. This observational cohort study suggests hydroxychloroquine, either alone or in combination with azithromycin, was not associated with a survival benefit among hospitalized COVID-19 patients. Tocilizumab demonstrated a trend association towards reduced mortality among ICU patients. Our findings are limited to hospitalized patients and must be interpreted with caution while awaiting results of randomized trials. Trial Registration: Clinicaltrials.gov Identifier: NCT04347993.

No detailed description available for \"Basic Organometallic Chemistry\".

No detailed description available for \"Basic Organometallic Chemistry\".

After considering the evidence available and the relative merits as well as problems with the AHA recommendations, we believe that the recommendations for prophylaxis should be eliminated or changed to optional for all conditions other than previous valvular surgery, previous endocarditis, and congenital cyanotic heart disease.[PUBLICATION ABSTRACT]