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Interactive Map of US Population 65+ Years Old

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Interactive Map of US Population 65+ Years Old

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Eighty percent of deaths associated with the coronavirus in the United States were in adults aged 65 and older, according to an analysis released Wednesday by the Centers for Disease Control and Prevention (CDC).

"The risk for serious disease and death in COVID-19 cases among persons in the United States increases with age," the CDC said. "Social distancing is recommended for all ages to slow the spread of the virus, protect the health care system, and help protect vulnerable older adults."

The analysis looked at 44 cases from Feb. 12 through March 16 and found that 34 percent of deaths were reported among adults aged 85 and older. Forty-six percent of deaths were reported among those aged 65 to 84. Adults between the ages of 20 and 64 made up 20 percent of the deaths.

Public health officials and experts have warned for weeks that the elderly are at the highest risk of dying from the coronavirus. The analysis lined up with data released by China, which showed 80 percent of deaths there were in adults aged 60 and older.

Elderly people are likely at higher risk because immune systems weaken with age. Older adults are also more likely to have underlying health conditions that exacerbate illness.

The data analyzed by the CDC did not include information on the underlying health conditions of patients.

The CDC recommends that older adults stay home as much as possible and stock at least 30 days of groceries. Those in that age group who do go out should keep space between themselves and others, stay away from people who are sick, and avoid crowds and cruise and air travel.

State and local governments have issued bans on large gatherings of people and implemented other social distancing measures to slow the spread of the coronavirus.

While younger people are less likely to die of COVID-19, the disease caused by the novel coronavirus, experts have urged them to follow social distancing measures to prevent spreading the virus to vulnerable populations.

Young adults with the coronavirus might experience no symptoms, or mild symptoms, meaning they might be unaware they are spreading the disease.

"We cannot have these large gatherings that continue to occur throughout the country for people who are off work, to then be socializing in large groups and spreading the virus," Dr. Deborah Birx, a member of the White House coronavirus task force, said at a briefing Wednesday.

"You have the potential then to spread it to someone who does have a condition that none of us knew about and cause them to have a disastrous outcome," she added.

She also warned Wednesday that early reports out of Italy and France indicate millennials are becoming seriously ill in those countries.

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CDC: 80 percent of US coronavirus deaths are people 65 and older

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Eighty percent of deaths associated with the coronavirus in the United States were in adults aged 65 and older, according to an analysis released Wednesday by the Centers for Disease Control and Prevention (CDC). "The risk for serious disease and death in COVID-19 cases among persons in the United States increases with age," the CDC said.

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This Demographic and Economic Interactive Data Hub helps guide decision-making related to the COVID-19 pandemic. The platform includes key demographic data from the American Community Survey and data on businesses from County Business Patterns.

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New Rutgers Saliva Test for Coronavirus Gets FDA Approval 

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New Rutgers Saliva Test for Coronavirus Gets FDA Approval 

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Emergency use authorization granted for new biomaterial collection approach

Rutgers Professor Andrew Brooks, chief operating officer and director of technology development at RUCDR Infinite Biologics. Photo: Rutgers University

The Food and Drug Administration (FDA) has granted emergency use authorization (EUA) to Rutgers' RUCDR Infinite Biologics and its collaborators for a new collection approach that utilizes saliva as the primary test biomaterial for the SARS-CoV-2 coronavirus, the first such approval granted by the federal agency.

The new saliva collection method, which RUCDR developed in partnership with Spectrum Solutions and Accurate Diagnostic Labs (ADL), will allow for broader population screening than the current method of nose and throat swabs.

"The impact of this approval is significant," said , chief operating officer and director of technology development at RUCDR, who also is a professor in the School of Arts and Sciences Department of Genetics Rutgers University-New Brunswick means we no longer have to put health care professionals at risk for infection by performing nasopharyngeal or oropharyngeal collections. We can preserve precious personal protective equipment for use in patient care instead of testing. We can significantly increase the number of people tested each and every day as self-collection of saliva is more quick and scalable than swab collections. All of this combined will have a tremendous impact on testing in New Jersey and across the United States."

Soon after the Rutgers-ADL team received notification from the FDA on Saturday, the White House's COVID-19 testing task force called Brooks to offer congratulations and support and to ask about any specific hurdles to expanding testing and enabling other laboratories to benefit from the accomplishment.

Shortly after the White House call, the research team was contacted by chief executive officers of some of the world's largest life sciences companies that are involved in COVID-19 testing.

"I have spoken with these companies' leadership to not only share knowledge but to create opportunities for continuing to help innovate during this crisis," Brooks said. "We will work closely with these new partners, the FDA and the White House task force to leverage everything Rutgers has to offer to not only help our community but also make a global impact."

Rutgers University President Robert Barchi called the new saliva test a "herculean effort that is great for the country and the world and by reflection great for our university."

"Saliva testing will help with the global shortage of swabs for sampling and increase testing of patients, and it will not require health care professionals to be put at risk to collect samples," Brooks said. "Saliva testing will also be important for people who are in quarantine because they don't know how long it will be until they are no longer infectious. This will allow health care workers to release themselves from quarantine and safely come back to work.", the founder, chief executive officer and scientific director of RUCDR and a Distinguished Professor also in the Department of Genetics at Rutgers-New Brunswick and at
Rutgers Robert Wood Johnson Medical School.
"The test can help hospital-based and private physicians to accurately assess the infection status of more patients, with RUCDR Infinite Biologics doing the analysis," said

"Rutgers is proud to be on the cutting edge of the fight against the COVID-19 pandemic," said Rutgers Biomedical and Health Sciences Chancellor Brian Strom. "We have long said our researchers and health care employees are working to help make the world well, but never has it been more true than now."

Rutgers University-New Brunswick Chancellor Chris Molloy agrees. "Rutgers has always been on the leading edge of research and discovery. We are proud of the work we do and the positive impact it has on the world."

The FDA's approval of the new saliva testing approach is the second major announcement in recent days from , which launched a genetic testing service for the coronavirus that can test thousands of samples daily. With the new saliva test, that number may increase to tens of thousands of samples daily.

The tests are available to the network, which has partnered with Rutgers University and is New Jersey's most comprehensive health care system, including , University Hospital in Newark and many other facilities, including several county health departments. Robert Wood Johnson University Hospital Starting Wednesday, Rutgers, in partnership with the Middlesex County government and RWJBarnabas Health, will make the test available to county residents at a drive-thru testing facility at 33 Kilmer Road, Edison, New Jersey.

RUCDR Infinite Biologics , which is part of Rutgers' Human Genetics Institute of New Jersey , is the world's largest university-based cell and DNA repository. Its mission is to understand the genetic causes of common, complex diseases and to discover diagnoses, treatments and cures for them. The organization collaborates with researchers in the public and private sectors throughout the world, providing the highest quality bio-banking services and biomaterials, as well as scientific and technical support

Headquartered in Salt Lake City, Utah, Spectrum Solutions and its medical device and services division, Spectrum DNA, focus on innovative, end-to-end product development, manufacturing, and global fulfillment solutions. With concentrated industry expertise, Spectrum DNA specializes in engineering innovative molecular diagnostic solutions that simplify the biosample collection process while offering donors complete physical and digital chain-of-custody. With on-site production facilities, we are a single-source provider of full-service medical device manufacturing, custom and private label packaging, kitting, and direct-to-donor global fulfillment. Our new biosample collection devices, patented technology, and services provide measurable process optimization, unprecedented efficiency, and unmatched global scalability. For more information, please visit www.spectrum-dna.com .

ABOUT ACCURATE DIAGNOSTIC LABS

Accurate Diagnostic Labs is one of the largest privately held, boutique, full-service clinical laboratories in the country. ADL, as a full-service core laboratory, proudly works with various entities on laboratory testing for clinical trial drug development and data repository in various market footprints to progress the field of disease state management and personalized medicine. With our local headquarters based in Central New Jersey, we pride ourselves in working with various healthcare corporations, institutions, health systems, and the local providers in the metropolitan area with the common goal of improving local and national healthcare. For more information on ADL, please call at 732-839-3300 or visit online at www.accuratediagnosticlabs.com

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New Rutgers Saliva Test for Coronavirus Gets FDA Approval

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The Food and Drug Administration (FDA) has granted emergency use authorization (EUA) to Rutgers' RUCDR Infinite Biologics and its collaborators for a new collection approach that utilizes saliva as the primary test biomaterial for the SARS-CoV-2 coronavirus, the first such approval granted by the federal agency.

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If particles from a sneeze can be found up to 8 meters, that is equivalent to 26.2467 feet. 6 feet is 1.8288 meters.

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Acetazolamide Causes Worsening Acidosis in Uncompensated COPD Exacerbations: Increased Awareness Needed for Patient Safety.

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Acetazolamide Causes Worsening Acidosis in Uncompensated COPD Exacerbations: Increased Awareness Needed for Patient Safety.

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WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Acetazolamide given early in the uncompensated setting can worsen acidosis and potentiate clinical deterioration.

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BACKGROUND

Acetazolamide has been studied extensively in post-hypercapnic alkalosis as a tool to facilitate ventilator weaning in chronic obstructive pulmonary disease (COPD). It has also been utilized to facilitate respiratory drive in nonmechanically ventilated patients with COPD. Although this is generally a forgiving intervention, providers must carefully select patients for this medication, as it can cause severe acidosis and deterioration of clinical status in severe COPD cases. The present report describes two cases of patients who developed worsening acidosis and hypercapnia after receiving acetazolamide in acute respiratory failure.

CASE REPORT

Case 1 was a 72-year-old obese male with COPD who was dependent on supplemental oxygen and presented to the emergency department (ED) with acute on chronic hypercapnic respiratory failure. He was given a one-time dose of acetazolamide in the ED for "respiratory failure made worse by severe metabolic alkalosis." His arterial blood gas (ABG) worsened overnight, accompanied by decreased mental status: pH 7.32, paCO ₂ 82 mm Hg, paO ₂ 50 mm Hg, HCO ₃ 41.7 mmol/L, FiO ₂ 32% to pH 7.21, paCO ₂ 91.7 mm Hg, paO ₂ 59 mm Hg, HCO ₃ 36.6 mmol/L, and FiO ₂ 32%. Case 2 was a 62-year-old male with COPD who was dependent on supplemental oxygen and presented to the ED with acute on chronic hypercapnic respiratory failure. He was given acetazolamide in the ED with similar results: ABG on presentation pH 7.37, paCO ₂ 79.3 mm Hg, paO ₂ 77.6 mm Hg, HCO ₃ 45.5 mmol/L, and FiO ₂ 32%. The next morning, ABG was pH 7.29, paCO ₂ 79 mm Hg, paO ₂ 77 mm Hg, HCO ₃ 45.5 mmol/L, and FiO ₂ 32%. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Acetazolamide given early in the uncompensated setting can worsen acidosis and potentiate clinical deterioration.

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PRIME PubMed | Acetazolamide Causes Worsening Acidosis in Uncompensated COPD Exacerbations: Increased Awareness Needed for Patient Safet

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Acetazolamide has been studied extensively in post-hypercapnic alkalosis as a tool to facilitate ventilator weaning in chronic obstructive pulmonary disease (COPD). It has also been utilized to facilitate respiratory drive in nonmechanically ventilated patients with COPD.

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The following points should be covered in the history in an attempt to identify the underlying cause:

Family history of any similar episodes of illness (may indicate inborn error of metabolism).

Family or personal history of diabetes.

Symptoms of undiagnosed diabetes - eg, polyuria, polydipsia or weight loss.

Symptoms of renal failure such as nocturia, polyuria, oliguria, pruritus and anorexia.

Recent history of urinary problems such as nephrolithiasis may indicate RTA.

Recent history of severe or prolonged diarrhoea.

Recent nutritional status.

Alcohol intake.

Any history of deliberate or accidental ingestion of potentially toxic materials or medicines[²].

Occupational/DIY exposure to fumes or solvents.

Visual disturbances such as dimming, photophobia, scotomata or blindness may indicate methanol poisoning. Blurred vision may occur with salicylate poisoning.

Tinnitus or vertigo may occur with salicylate poisoning.

Ask about any chest pain, palpitations, dyspnoea or oedema indicating possible cardiovascular causes for lactic acidosis.

Recent history of confusion, headache or visual changes may indicate poisoning, particularly with methanol or ethylene glycol.

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See also separate Lactic Acidosis and Arterial Blood Gases - Indications and Interpretations articles.

Metabolic acidosis is defined as an arterial blood pH <7.35 with plasma bicarbonate <22 mmol/L. Respiratory compensation occurs normally immediately, unless there is respiratory pathology. Pure metabolic acidosis is a term used to describe when there is not another primary acid-base derangement - ie there is not a mixed acid-base disorder. Compensation may be partial (very early in time course, limited by other acid-base derangements, or the acidosis exceeds the maximum compensation possible) or full.

The Winter formula can be helpful here - the formula allows calculation of the expected compensating pCO ₂:

If the measured pCO ₂ is >expected pCO ₂ then additional respiratory acidosis may also be present.

It is important to remember that metabolic acidosis is not a diagnosis; rather, it is a metabolic derangement that indicates underlying disease(s) as a cause. Determination of the underlying cause is the key to correcting the acidosis and administering appropriate therapy.

It is relatively common, particularly among acutely unwell/critical care patients. There are no reliable figures for its overall incidence or prevalence in the population at large.

There are many causes. They can be classified according to their pathophysiological origin, as below. The table is not exhaustive but lists those that are most common or clinically important to detect.

Increased acid load Excessive loss of gastrointestinal bicarbonate

Diarrhoea

Fistulae of pancreas, biliary tree or intestine

Urinary-gastrointestinal diversion surgery

Cholestyramine

Any cause of lactic acidosis - eg, heart failure, drugs or toxins, inborn errors of metabolism

Ketoacidosis due to diabetes, starvation or alcohol excess

Parenteral or hyperalimentary nutrition

Poisoning with substances that generate acid or prevent its excretion - eg:

Impaired excretion of dietary acid load Excessive loss of renal bicarbonate

Type 2 (proximal) RTA

Acetazolamide or other carbonic anhydrase inhibitors

Renal failure leading to impaired NH4+ production

Hypoaldosteronism in type 4 renal tubular acidosis (RTA)

Impaired excretion of H+ in type 1 (distal) RTA

History

There are no specific symptoms of metabolic acidosis as such. Those that occur are due to the effects of the metabolic derangement on the body, or may give clues to the underlying cause. Patients may notice a subjective sensation of dyspnoea caused by stimulation of the respiratory centre in an attempt to 'blow off' CO ₂ and increase blood pH. Nausea, vomiting and anorexia are frequently present, particularly in children. Metabolic acidosis occurring in children is very rarely due to an inborn error of metabolism (conditions such as moderately severe gastroenteritis being more common).

The following points should be covered in the history in an attempt to identify the underlying cause:

Family history of any similar episodes of illness (may indicate inborn error of metabolism).

Family or personal history of diabetes.

Symptoms of undiagnosed diabetes - eg, polyuria, polydipsia or weight loss.

Symptoms of renal failure such as nocturia, polyuria, oliguria, pruritus and anorexia.

Recent history of urinary problems such as nephrolithiasis may indicate RTA.

Recent history of severe or prolonged diarrhoea.

Recent nutritional status.

Alcohol intake.

Any history of deliberate or accidental ingestion of potentially toxic materials or medicines.

Occupational/DIY exposure to fumes or solvents.

Visual disturbances such as dimming, photophobia, scotomata or blindness may indicate methanol poisoning. Blurred vision may occur with salicylate poisoning.

Tinnitus or vertigo may occur with salicylate poisoning.

Ask about any chest pain, palpitations, dyspnoea or oedema indicating possible cardiovascular causes for lactic acidosis.

Recent history of confusion, headache or visual changes may indicate poisoning, particularly with methanol or ethylene glycol.

Examination

Lethargy, stupor and progression to a state of coma may occur, particularly in cases of poisoning. An intoxicated-appearing patient who has no smell of alcoholic drink on their breath may have ingested ethylene glycol.

Check vital signs, as hypotension may occur due to myocardial suppression in severe acidaemia. Tachypnoea is likely to be present.

In undiagnosed renal failure there may be dryness of mouth, eyes and skin, scratch marks on skin, pallor, drowsiness and fetor.

To detect diabetic ketoacidosis look for evidence of dehydration and smell the patient's breath to detect the presence of ketones (which give off a musty/fruity odour akin to pear drops or nail polish remover).

Look for signs of congestive cardiac failure that may be caused by the acidosis itself, or suggest lactic acidosis as a cause, due to generalised hypoperfusion.

Listen for a pericardial rub which may indicate acute renal failure as the cause.

The presence of tachypnoea without any history of pre-existing cardiorespiratory disease to account for it should strongly suggest metabolic acidosis as the cause of the illness.

Kussmaul's respiration may be noted where there is deep, slowly rhythmic breathing that increases the minute tidal volume.

Children with chronic metabolic acidosis may have growth restriction and show signs of rickets.

Neurological examination may reveal cranial nerve palsies in the case of ethylene glycol poisoning.

Retinal oedema may be noted on fundoscopy in cases of methanol ingestion.

The combination of clinical features of illness and arterial blood gas/plasma bicarbonate results indicate the presence of a metabolic acidosis. Determination of its underlying cause, as outlined in the investigation section below, is crucial to try to optimally treat and correct the acidosis. As such there is no differential diagnosis, rather a list of possible underlying causes to be refuted/confirmed as its cause. See the table above for a list of potential causes.

The first indication of an acidotic problem may be the presence of a low serum bicarbonate on routine U&E testing. This in itself is not enough to confirm an acidosis. The presence of metabolic compensation of respiratory alkalosis, or a laboratory error could account for a low plasma bicarbonate. Arterial blood gases or venous blood gases must be checked to determine the arterial blood pH and confirm the diminution of bicarbonate. pH and pCO₂ values must be interpreted carefully and a judgement made as to whether this is a pure metabolic acidosis or a mixed acid-base disorder. The base excess or base deficit is usually given as a part of the blood gas result and allows a determination of the overall severity of the acidosis, particularly where respiratory compensation complicates the picture.

U&Es help to determine the cause of the acidosis by allowing the calculation of the anion gap (AG) as below:

The normal range: 10-20 mmol/L.

Some laboratories will exclude [K+], in which case the normal range is: 8-16 mmol/L.

Check locally for reference ranges in your laboratory.

It is a measure of the unmeasurable anions not routinely detected by analyser machines. Where the AG is elevated it indicates the presence of an organic acid causing the acidosis - for example, acetoacetic acid and beta-hydroxybutyric acid in diabetic ketoacidosis. The AG helps to determine the likely cause of the acidosis as outlined below.

The cause of a normal AG metabolic acidosis can be narrowed by checking the urinary AG: AG = [Na+] + [K+] − [Cl-]. If negative then the likely cause arises from the gastrointestinal tract; if not then consider renal causes.

AG correlates closely with albumin levels and must be adjusted in hypoalbuminaemia.

Causes of raised, normal and low AG

Raised AG - can be due to low levels of unmeasured cations - eg, hypomagnesaemia, hypocalcaemia. For further causes, see table below.

Normal AG - for causes, see table below.

Low AG - can be the result of raised unmeasured cations such as in hypercalcaemia, hypermagnesaemia, and lithium toxicity. Hyperproteinaemia, hyperlipidaemia and hyperglycaemia can affect AG by falsely depressing measured sodium level. Bromide poisoning may cause Br ions to be mistaken for Cl ions by the autoanalyser, causing inappropriate depression of the AG.

Correlation between anion gap and causes of metabolic acidosis
Elevated AG metabolic acidoses Normal AG metabolic acidoses (hyperchloraemic acidosis)

Gastrointestinal bicarbonate loss - eg, diarrhoea, pancreatic or intestinal fistulae

Renal bicarbonate loss - eg, type 2 RTA

Some causes of renal failure/impairment

Hypoaldosteronism in type 4 RTA

Hyperventilation

Ingestion of ammonium chloride

Use of carbonic anhydrase inhibitors

Parenteral or hyperalimentation feeding

Partially treated diabetic ketoacidosis

Lactic acidosis caused by L-lactate, due to state of hypoperfusion, carbon monoxide/cyanide poisoning, biguanide toxicity. D-lactataemia in short bowel syndrome

Diabetic or alcoholic ketoacidosis caused by acetoacetate/beta-hydroxybutyrate

Renal failure caused by urate, hippurate, sulphate and phosphate

Salicylate poisoning

Methanol or formaldehyde poisoning caused by formate

Ethylene glycol poisoning caused by glycolate and oxalate

Paraldehyde poisoning caused by a variety of organic acids

Sulfur poisoning caused by sulphate

Pyroglutamic acidaemia caused by 5-oxoprolate

Rhabdomyolysis caused by direct proton release from lysed muscle cells

Further general investigations

Elevation of urea and creatinine will indicate that renal failure is the likely cause.

Hyperkalaemia often accompanies a normal AG acidosis, and some cases of acute renal failure.

Potassium may also be elevated in diabetic ketoacidosis but usually minimally so for the degree of acidosis.

Plasma and urinary glucose and ketones need to be checked to look for evidence of diabetic ketoacidosis.

Alcoholic ketoacidosis will show evidence of ketone formation without grossly elevating plasma glucose in most cases. A random alcohol level or expired breath alcometer reading may help to make the diagnosis, along with details from the history.

FBC should be checked but is usually nonspecific and unhelpful, except in the case of severe anaemia, where it is likely that lactic acidosis is the cause, or grossly elevated WCC indicating sepsis or haematological neoplasm.

LFTs should be checked to look for evidence of chronic liver disease, indicating alcohol abuse as a likely aetiology.

Send any appropriate samples for culture, particularly blood and urine if sepsis leading to lactic acidosis is possible.

ECG helps to detect arrhythmias.

Consider CXR to look for evidence of infection/cardiac failure or ingested iron/other radio-opaque toxins.

Investigations for specific causes

Osmotic or osmolar gap. This is the difference between the laboratory-measured osmolality and the calculated osmolarity. Calculated osmolarity can be worked out using one of the formulae below:

Calculated osmolarity = 2[Na mmol/L] + [urea mmol/L] + [glucose mmol/L]

Calculated osmolarity = 2([Na mmol/L] + [K mmol/L]) + [urea mmol/L] + [glucose mmol/L]

Where the osmotic gap is elevated, it indicates a disparity between the actual osmolality (measured by the laboratory) and the calculated osmolarity. This indicates the presence of other osmotically active solutes which are not taken into account in the calculated osmolality. It is normally less than 10-15 mOsmol/kg (see local laboratory for range and bear in mind the different calculations). It is elevated by methanol or ethylene glycol ingestion.

Plasma lactate, where lactic acidosis is a potential cause. Values >2 mmol/L indicate hyperlactataemia and >5 mmol/L indicate definite lactic acidosis.

Plasma salicylate levels. Levels >350 mg/L (2.5 mmol/L) indicate salicylate toxicity. Levels >700 mg/L (5.1 mmol/L) indicate severe toxicity.

Iron levels if there is a suspicion of deliberate or accidental overdose. Levels >300 mg/dL are considered toxic. An abdominal X-ray may be of use if there is suspected ingestion of iron tablets.

Urine microscopy may show the presence of needle-shaped oxalate crystals which is indicative of ethylene glycol toxicity. Usually urine pH will be <5.0-5.5. Alkaline urine in the face of acidosis is usually caused by type 1 RTA or salicylate poisoning.

Patients with metabolic acidosis are often very ill and prone to rapid deterioration. Make your assessment of their condition and its likely cause as quickly and calmly as possible. Arrange any investigations, as above, that will help to reveal its aetiology. Ask for advice from senior colleagues/other appropriate specialties early in the course of the presentation.

General measures

Put the patient in the resuscitation area, or transfer to a high-dependency area as soon as feasible.

Put the patient on an ECG monitor, SaO₂ monitor and BP/HR monitor.

In patients who are clinically unwell and have deteriorating SaO₂ levels or conscious levels, consider intubation and assisted ventilation, after taking senior A&E/medical/anaesthetic advice.

Intubation and ventilation can lead to decompensation and caution is advised. Patients with a metabolic acidosis are relying on their hyperventilation; induction agents and setting the ventilator to a normal respiratory rate may lead to further decompensation.

Get large-bore IV access (a central venous line may be needed) and rehydrate aggressively.

Consider catheterisation to monitor urine output and obtain urine for analysis.

If there is any possibility of drug or toxin ingestion, give initial therapies such as activated charcoal/chelating agents/emetics, dependent on the specific compound ingested and latest local guidelines for poisoning.

Liaise with local or national toxicology/poisoning services if there has been ingestion of a potentially dangerous substance.

Obtain specialist input (usually the on-call general medical team initially) as soon as possible.

Correction of acidosis

Treatment of the underlying cause is the aim. Use of bicarbonate infusions is not recommended, as it can lead to a fatal outcome. It should be used only where advised in cases of poisoning.

Specific therapy for the underlying cause

This is the most important and efficient way to correct the acidosis and improve the patient's outlook. Toxicological/general medicine/renal medicine expertise should be engaged to offer specific therapy for the identified underlying problem.

The major problem is suppression of myocardial contractility and unresponsiveness to catecholamines caused by the acidaemic state. This may lead to a vicious cycle of hypoperfusion, worsening lactic acidosis and further cardiac suppression, causing multi-organ failure. If pH is <7.1-7.2 then cardiac arrhythmias are likely.

This is largely dependent upon the underlying cause and severity of the illness in a given patient. There is no doubt that metabolic acidosis can be life-threatening and carries significant mortality and morbidity. Appropriate initial management and ongoing expert input will improve the outlook for individual patients.

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Metabolic Acidosis. Read about Metabolic acidosis.

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See also separate Lactic Acidosis and Arterial Blood Gases - Indications and Interpretations articles. Metabolic acidosis is defined as an arterial blood pH expected pCO 2 then additional respiratory acidosis may also be present. It is important to remember that metabolic acidosis is not a diagnosis; rather, it is a metabolic derangement that indicates underlying disease(s) as a cause.

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Expert Recommendations for Tracheal Intubation in Critically ill Patients with Noval Coronavirus Disease 2019.

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Expert Recommendations for Tracheal Intubation in Critically ill Patients with Noval Coronavirus Disease 2019.

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national center for biotechnology information

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united states national library of medicine

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Expert Recommendations for Tracheal Intubation in Critically ill Patients with Noval Coronavirus Disease 2019.

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Features, Evaluation, and Treatment of Coronavirus (COVID-19) - StatPearls - NCBI Bookshelf

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Coronavirus disease 2019 (COVID-19) is a highly contagious viral illness caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 has had a catastrophic effect on the world, resulting in more than 6 million deaths worldwide. After the first cases of this predominantly respira…

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Biomedical Advanced Research and Development Authority (BARDA), part of the HHS Office of the Assistant Secretary for Preparedness and Response, was established to aid in securing our nation from chemical, biological, radiological, and nuclear (CBRN) threats, as well as from pandemic influenza (PI) and emerging infectious diseases (EID). BARDA supports the transition of medical countermeasures such as vaccines, drugs, and diagnostics from research through advanced development towards consideration for approval by the FDA and inclusion into the Strategic National Stockpile. BARDA's support includes funding, technical assistance and core services, ranging from a clinical research organization network to Centers for Innovation in Advanced Development and Manufacturing, and a fill-finish manufacturing network. To-date, BARDA has supported 42 FDA approvals for products addressing CBRN, PI, and EID threats.

Our mission is accomplished through successful public-private partnerships with industry to share risk, improve efficiency and accelerate development all while sustaining a marketplace that guarantees continued access to countermeasures vital to our national security. Learn More >>

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Biomedical Advanced Research and Development Authority

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Biomedical Advanced Research and Development Authority (BARDA), part of the HHS Office of the Assistant Secretary for Preparedness and Response, was established to aid in securing our nation from chemical, biological, radiological, and nuclear (CBRN) threats, as well as from pandemic influenza (PI) and emerging infectious diseases (EID).

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Largest Study of Sepsis Cases Among Medicare Beneficiaries Finds Significant Burden

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Largest Study of Sepsis Cases Among Medicare Beneficiaries Finds Significant Burden

# data[].attributes.body
""Most #patients with sepsis arrived at the #hospital with the condition, rather than developing sepsis in the hospital, a possible indicator of success for CMS efforts to reduce hospital-based cases of #sepsis. However, two-thirds of these sepsis patients had a #medical encounter in the week prior to #hospitalization. This finding represents an opportunity for improved education and awareness among patients and #healthcare providers, as well as the need for #diagnostics to detect sepsis early.""

"The study also identified the high costs of treating #sepsis. Although the inpatient costs of care per stay among Medicare beneficiaries decreased between 2012 and 2018, the increase in the number of patients with sepsis led to an estimated overall increase in Medicare spending from $27.7 billion in 2012 to more than $41.5 billion in 2018 for inpatient hospital admissions and subsequent skilled nursing facility care.

The research team also projected future costs by modeling the increasing number of cases and estimates for all payer costs outside the #Medicare population, and concluded that overall costs rose 12-14 percent every two years. Based on that estimate, #inpatient hospital and skilled #nursing care for sepsis care in 2019 may exceed $62 billion."

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U.S. hospitals saw a 40 percent increase in the rate of Medicare beneficiaries hospitalized with sepsis over the past seven years, and in just 2018 had an estimated cost to Medicare of more than $41.5 billion according to an unprecedented study by researchers from the U.S. Department of Health and Human Services.

Sepsis is a life-threatening condition caused by the body's extreme response to an infection. The research team analyzed data from all Medicare beneficiaries from 2012 through 2018. The study included more than 9.5 million inpatient hospital admissions, making this the largest sepsis study based on contemporary Medicare data to be published in the United States. Research team members included the HHS Office of the Assistant Secretary for Preparedness and Response (ASPR), the Centers for Medicare & Medicaid Services (CMS), and collaborators from Acumen LLC of Burlingame, California. The study appears in the journal Critical Care Medicine

Researchers determined that the increase in sepsis was not due to the growing number of American seniors enrolling in Medicare. From 2012 through 2018, the U.S. saw a 22 percent increase in the Medicare enrollment rates but a 40 percent increase in the rate of sepsis-related hospital admissions among beneficiaries.

"Sepsis is a lethal and costly health threat affecting Americans' lives and our economy, yet many Americans may have never heard of it," said HHS Assistant Secretary for Preparedness and Response Dr. Robert Kadlec. "Any infection can lead to sepsis, including infections caused by influenza or emerging diseases like coronaviruses, which makes sepsis a significant concern in public health emergencies."

"This groundbreaking study sheds new light on the sepsis-related challenges faced by patients, providers, and taxpayers alike," said CMS Administrator Seema Verma. "It demonstrates the urgent need for an approach to address a problem that is threatening the health and lives of Medicare beneficiaries. To that end, CMS continues to clear away regulatory obstacles and financial disincentives that have long inhibited the development of life-saving antibiotics capable of treating sepsis patients. Patients suffering from sepsis deserve to see America's full innovative potential mobilized to address this devastating condition."

Most patients with sepsis arrived at the hospital with the condition, rather than developing sepsis in the hospital, a possible indicator of success for CMS efforts to reduce hospital-based cases of sepsis. However, two-thirds of these sepsis patients had a medical encounter in the week prior to hospitalization. This finding represents an opportunity for improved education and awareness among patients and healthcare providers, as well as the need for diagnostics to detect sepsis early.

The analysis explored the impact of sepsis severity on health outcomes for Medicare beneficiaries. Despite declining mortality overall, 10 percent of patients with non-severe forms of sepsis died while in the hospital or within a week of discharge, and 60 percent with non-severe forms of sepsis died within three years.

Outcomes were worse among patients with the most severe form of sepsis known as septic shock. Forty percent of these patients died while in the hospital or within a week of being discharged, and 75 percent died within three years. The risk of sepsis was even greater for patients who had other chronic health conditions and the risk of death in the hospital and within three years was greater among these patients if they developed sepsis.

The study also identified the high costs of treating sepsis. Although the inpatient costs of care per stay among Medicare beneficiaries decreased between 2012 and 2018, the increase in the number of patients with sepsis led to an estimated overall increase in Medicare spending from $27.7 billion in 2012 to more than $41.5 billion in 2018 for inpatient hospital admissions and subsequent skilled nursing facility care.

The research team also projected future costs by modeling the increasing number of cases and estimates for all payer costs outside the Medicare population, and concluded that overall costs rose 12-14 percent every two years. Based on that estimate, inpatient hospital and skilled nursing care for sepsis care in 2019 may exceed $62 billion.

"We were astonished by the study's results," said Rick Bright, Ph.D., a study author, HHS deputy assistant secretary for preparedness and response ( ASPR) and director of the Biomedical Advanced Research and Development Authority ( BARDA) at ASPR. "To save lives in public health emergencies, we must solve sepsis. The findings of this study have implications not only for patient care, particularly after patients are discharged, but also for investments by industry, non-government organizations and government agencies. Solving sepsis requires working together. Because of the health security implications, we are taking a holistic approach to this national threat."

BARDA currently is partnering with industry and academia to develop and encourage adoption of new technologies to detect sepsis earlier as well as to predict and identify the severity of the infections. BARDA also is collaborating with other government agencies and non-government organizations on improved awareness, education, and training for healthcare providers.

CMS has implemented an inpatient bundled sepsis measure in its Inpatient Hospital Quality Reporting Program. This measure is a series of steps to detect and treat sepsis earlier in its course. CMS data have shown that since implementation, organizations that follow all the steps have significantly lower mortality rates for patients diagnosed with severe sepsis and septic shock. The agency is also tackling sepsis in post-acute care settings and is developing a measure for early detection and treatment of healthcare-associated infections, including sepsis in post-acute care settings.

To foster innovation in treating infections that lead to sepsis, CMS is removing barriers to developing new antimicrobial therapies to treat drug-resistant infections. In 2019, CMS finalized an expanded pathway for certain new antibiotics to more quickly receive additional Medicare payments and to increase payments for them. The agency also updated its payments to hospitals to provide them with appropriate resources to treat sick patients with drug-resistant infections. This step helps people who need these medications get access to them.

In addition, to broaden the understanding of the epidemiology of sepsis, CDC continues to assess the adult sepsis burden and identify factors that put people at higher risk for sepsis and has begun a similar effort to assess sepsis burden in children.

CDC has also developed tools for tracking sepsis in individual hospitals to help healthcare facilities assess adult sepsis incidence within their facilities and measure their prevention progress. By working with partners, including the CDC Prevention Epicenters, CDC has invested in innovative ways to improve sepsis early detection and treatment. CDC's national educational campaign, Get Ahead of Sepsis for patients, healthcare professionals, and the general public emphasizes the importance of early recognition, timely treatment, reassessment of antibiotic needs, and prevention of infections.

The study analyzed claims made on behalf of traditional Medicare beneficiaries as well as from Medicare Advantage plans to explore the burden of sepsis in highly impacted populations including older Americans, those with end-stage renal disease, and those who depend on both Medicare and Medicaid.

The publication includes detailed methods that could enable similar analyses of data from patients covered by private insurance, Veterans Affairs, Department of Defense healthcare facilities, and state Medicaid programs that could lead to an even more accurate understanding of how sepsis affects Americans.

The study will be discussed in two free webstreamed sessions at 2 p.m. EST, Feb. 16, and 3:15 p.m. EST, Feb. 17, during the Critical Care Medicine Congress 2020. The study was published in the journal as three articles:
Sepsis Among Medicare Beneficiaries: 1. Sepsis Among Medicare Beneficiaries: 2. Sepsis Among Medicare Beneficiaries: 3. The Methods, Models, and Forecasts of Sepsis, 2012-2018 The Trajectories of Sepsis, 2012-2018 The Burdens of Sepsis, 2012-2018
Learn more about sepsis and find clinical resources from the Centers for Disease Control and Prevention, and explore what BARDA is doing to solve sepsis at drive.hhs.gov/solvingsepsis.html.

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Largest Study of Sepsis Cases among Medicare Beneficiaries Finds Significant Burden

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U.S. hospitals saw a 40 percent increase in the rate of Medicare beneficiaries hospitalized with sepsis over the past seven years, and in just 2018 had an estimated cost to Medicare of more than $41.5 billion according to an unprecedented study by researchers from the U.S. Department of Health and Human Services.

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Centers for Disease Control and Prevention

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COVID-19 guidance, tools, and resources for healthcare workers.

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Abstract

BACKGROUND:

In 2004, a new biomarker sCD14-subtypes (presepsin) was found and its value was shown in the diagnosis and evaluation of sepsis. This article is a brief overview of the new biomarker.

DATA SOURCES:

A literature search using multiple databases was performed for articles, especially meta-analyses, systematic reviews, and randomized controlled trials.

RESULTS:

Compared with other markers, presepsin seems to have a better sensitivity and specificity in the diagnosis of sepsis. Presepsin as a biom1arker is not only suitable for the early diagnosis of sepsis, but also for the assessment of its severity and prognosis.

CONCLUSIONS:

Presepsin has a higher sensitivity and specificity in the diagnosis of sepsis as a new biomarker, and is a predictor for the prognosis of sepsis. More importantly, preseptin seems to play a crucial role as a supplemental method in the early diagnosis of sepsis. Since there is no multicenter study on the relationship between presepsin and sepsis, further studies on the clinical values of presepsin are needed.

KEYWORDS: Presepsin, Sepsis, Diagnosis

INTRODUCTION

Sepsis is a potentially fatal whole-body inflammation (a systemic inflammatory response syndrome or SIRS) caused by severe infection.[ 1] Its clinical manifestations vary with a rapid progression. As a costly disease, sepsis not only lowers patient's living quality, but also increases the mortality significantly.

Sepsis causes millions of deaths globally each year.[ 2] In the United States, sepsis affects approximately 3 per 1 000 people,[ 3] and severe sepsis contributes to more than 200 000 deaths each year.[ 4] Sepsis occurs in 1%-2% of all hospitalized patients and accounts for as much as 25% of ICU cases. Consensus on the treatment of sepsis indicates that early anti-infection treatment should be given before comprehensive treatment. However, due to the existence of non-infectious SIRS in many critical patients, how to differentiate sepsis from SIRS at the early stage has become a hot topic for many years. There are many reported biological markers such as procalcitonin (PCT), interleukins, pro-vasopressin, C-reactive protein (CRP) and myeloid cells expressing triggering receptor-1 (TREM-1).[ 5- 8] The studies of these biomarkers on sepsis concerning the diagnosis, assessment, antibiotic treatment, and prognosis have attracted extensive attention from researchers. Except PCT, however, the clinical values of the other biomarkers are still uncertain or controversial. In 2004, a new biomarker sCD14-subtypes (presepsin) was found[ 9] and its value was shown in the diagnosis and evaluation of sepsis. This article will give a brief overview of this new biomarker.

BIOLOGICAL CHARACTERISTICS OF PRESEPSIN

CD14 is the receptor of lipopolysaccharide-lipopoly-saccharide binding protein (LPS-LBP) complexes. With the help of thinositol lipid structure, the carboxyl terminus of the molecule anchors in cell membrane and transducts the endotoxin signal through the Toll-like receptor-4.[ 10] A series of downstream tyrosine protein kinases and mitogen-activated protein kinase are gradually activated including the nuclear transcription factor NF-κB, thus leading to the release of cytokines such as tumor necrosis factor-α, IFN-γ, IL-1β, IL-8 and IL-6.[ 11] Subsequently, the activation of the secondary inflammatory cascade and acquired immunity stimulate mononuclear macrophages, neutrophils and endothelial cells to release more cytokines and cell adhesion molecules. This could trigger intense and excessive systemic inflammatory response and activate the coagulation and fibrinolytic systems, resulting in SIRS, sepsis shock, disseminated intravascular coagulation (DIC), and multiple organ dysfunction syndrome (MODS).[ 12] CD14 has two forms: membrane-bound CD14 (mCD14) and soluble CD14 (sCD14). The former has a high affinity to LPS, and is mainly expressed on the cell surface of monocytes/macrophages or distributed a little bit on the cell surface of neutrophils. The latter is seen in plasma, and is produced by mCD14 fall-off or cell secretion.[ 13, 14] Two kinds of sCD14 could be detected in the plasma of healthy people at microgram level: 49KD and 55KD. sCD14 plays an important role in mediating the immune responses to LPS of CD14-negative cells such as endothelial cells and epithelial cells. sCD14 is cleaved by cathepsin D and other proteases in plasma[ 15] and the N-terminal fragments of 13kDa constitutes sCD14 subtype (sCD14-ST) which has been named as presepsin recently.[ 16]

ROLE OF PRESEPSIN IN SEPSIS

As a receptor of the LPS-LBP complex, CD14 could activate a series of signal transduction pathways and inflammatory cascades, and lead to systemic inflammatory response.[ 17] Some clinical studies[ 18, 19] on the relationship between sCD14 and sepsis showed that the level of sCD14 increased significantly in patients with sepsis and septic shock compared with healthy people, and the change was significantly related to the severity and prognosis of the disease. The specificity of sCD14 was poor, and the level of sCD14 significantly increased in patients with coronary heart disease, heart failure, liver cirrhosis, high blood glucose and so on. Presepsin is generated as the body response to bacterial infection, and phagocytosis against bacteria may play a major role other than simply give an inflammatory response,[ 15, 20] although it is not clear about how presepsin is produced in the body. Researchers believe that presepsin is likely to be a sepsis diagnostic biomarker with a high sensitivity and specificity. Further studies have shown encouraging results.

DIAGNOSIS

Because of the better sensitivity and specificity,[ 21, 22] PCT, CRP and IL-6 are commonly used as biomarkers in the diagnosis of sepsis, while assessing the severity of infection and guiding the use of antibiotics. But metaanalysis found that the sensitivity and specificity of PCT[ 23, 24] and CRP[ 25] varied in the diagnosis of sepsis. The sensitivity of IL-6 was not high and declined gradually as the time of infection extended.[ 26] These findings questioned their ability to distinguish sepsis from SIRS.

Compared with the other markers, presepsin seems to have a better sensitivity and specificity in the diagnosis of sepsis. Studies[ 27, 28] found that the plasma concentration of presepsin was significantly higher in infected patients than in non-infected patients. Shozushima et al[ 20] found that the concentration of presepsin was 333.5±130.6 pg/mL in the SIRS group, 721.0±611.3 pg/mL in the local infection group, 817.9±572.7 pg/mL in the sepsis group, and 1 992.9±1 509.2 pg/mL in the severe sepsis group. The blood concentration of presepsin among the groups increased sequentially. Spanuth et al[ 21] studied the concentration of presepsin in emergency patients on admission, and they found that it was significantly higher in sepsis patients than in healthy people, and also significantly higher in severe sepsis patients than in sepsis patients. Moreover the concentration of presepsin was positively correlated with APACHE II score and SOFA score. When ROC curve was used to evaluate the value of the four markers in the diagnosis of sepsis, the AUC of presepsin was 0.845. Presepsin was preferred to PCT (0.652), IL-6 (0.672), and CRP (0.815). With 399 pg/mL of presepsin as a cut-off value, the sensitivity of the diagnosis of sepsis was 80.3%, and the specificity was 78.5%. Whereas 600 pg/mL was taken as a cut-off value, the sensitivity for the diagnosis of sepsis was 87.8%, the specificity 81.4%, the positive predictive value 88.6%, and the negative predictive value 80.3%.[ 20] The sensitivity of presepsin for the diagnosis of sepsis was 91.9%, PCT 89.9%, IL-6 88.9%, and blood culture 35.4%.[ 27] The results suggest that presepsin may be advantageous in the diagnosis of sepsis.

Blood culture was performed for 48-72 hours to diagnose sepsis, but the positive rate was low. PCT increased in 4 hours after infection, reached a plateau slowly at 8-24 hours, and peaked one day after infection. Compared with PCT, presepsin increased earlier and faster in patients with sepsis,[ 17] at 2 hours after infection in the CLP sepsis model, peaked at 3 hours, and declined at 4-8 hours.[ 29, 30] It could be detected in the early stage of infection by using the ELISA method.

The rescue principles indicate that sepsis should be diagnosed early (the infection foci should be detected within 6 hours) and treated early (antibiotics treatment given within 1 hour after the diagnosis of sepsis[ 29]). Clinically, sepsis biomarkers with a high sensitivity and specificity are required in addition to rapid detection methods. According to the principles of chemiluminescent enzyme immunoassay, 21 minutes are taken for PATHFAST analysis to detect presepsin. The accuracy of this method is similar to that of ELISA; moreover in this detection, plasma, serum heparin, heparin whole blood, and EDTA anti-coagulated serum can be used as the detection samples.[ 30]

ASSESSMENT OF SEVERITY AND PROGNOSIS

Presepsin as a biomarker is not only suitable for the early diagnosis of sepsis, but also for the assessment of its severity and prognosis. In the ALBIOS trial, 100 patients with severe sepsis and septic shock were subjected to the assessment of the concentrations of presepsin and PCT. The median (Q1-Q3) concentration of presepsin was 2 268 (1 145-4 305) pg/mL in dead patients the first day on admission, which was significantly higher than 1 184 (855-2 158) pg/mL in surviving patients ( P=0.001). On the 7th day, the presepsin level of the surviving patients declined significantly to 974 (674-1 927) pg/mL, and that of the dead patients was 2 551 (1 438-5 624) pg/mL ( P=0.02). Moreover, the level of presepsin was correlated with SOFA score, MOF score and hemodynamic stability. The 90-day mortality in patients with a high level of presepsin was significantly higher than the patients with a low level of presepsin (75% and 42%). Presepsin was superior to PCT in the assessment of prognosis (AUC 0.69 and 0.56, P=0.07).[ 31] Another study showed that the level of presepsin was significantly different between the survival group and the death group, even between the sepsis group, severe sepsis group and septic shock group. Presepsin was better than IL-6, CRP and PCT in assessing the risk of death within 30 days after onset of sepsis.[ 32] When the cut-off value of presepsin was 1 622 pg/mL and the cut-off value of PCT 13.43 ng/mL in PCT group, 23% of the surviving patients could be allocated to the death group, 40% of the dead patients were assigned to the surviving patients. Combined with MEDS and presepsin could reclassify them into the correct groups, indicating that presepsin might have a better ability to predict the risk of death.[ 21]

DEFICIENCY

Preliminary studies have shown that presepsin is highly accurate and specific in the diagnosis of sepsis. It is fast and convenient to detect sepsis and to assess the severity and prognosis of sepsis; but as a receptor, LPS is a component of the gram-negative bacterial cell wall. It is easy to imagine whether presepsin is a predicator for sepsis caused by gram-positive cocci infection. Studies[ 27- 30] have shown that the sensitivities of presepsin, PCT, and IL-6 were 95.5%, 95.5% and 100% in patients with gram-positive bacterial infection, and 77.8%, 86.1% and 88.9% in gram-negative bacterial infection. The sensitivity of presepsin was not different significantly between patients with gram-positive and gram-negative bacterial infections. Additionally, the level of presepsin could be increased in patients with fungal infection, but not in patients with virus infection. There were no immediate reports on presepsin levels of patients with atypical pathogen infection but without mycobacterium tuberculosis infection. A recent study[ 33] has found that in patients with renal failure, the median levels of presepsin in patients with no sepsis ( n=14) and those with sepsis ( n=27) were 1 607 pg/mL (range 454 to 8 516) and 1 523 pg/mL (range 293 to 16 764), respectively. There were no differences between the two groups. However, the median levels of presepsin were significantly different in patients without sepsis and those with sepsis in non-AKI patients, risk patients, and injured patients. It was clear that the diagnosis of presepsin level was affected by the kidney function.

In summary, studies showed that presepsin has a higher sensitivity and specificity in the diagnosis of sepsis as a new biomarker, and is a predictor for the prognosis of sepsis. More importantly, preseptin seems to play a crucial role as a supplemental method in the early diagnosis of sepsis. Since there is no multicenter study on the relationship between presepsin and sepsis, further studies on the clinical values of presepsin are needed.

Footnotes

Funding: None.

Ethical approval: Not needed.

Conflicts of interest: The authors declare that there is no conflict of interest.

Contributors: Zou Q proposed the study, analyzed the data and wrote the first draft. All authors contributed to the design and interpretation of the study and to further drafts.

REFERENCES

4. New York: McGraw-Hill; 2011. Longo Dan Harrison's principles of internal medicine; p. 271. [ Google Scholar]

21. Spanuth E, Ebelt H, Ivandic B, Werdan K. Diagnostic and prognostic value of presepsin (soluble cd14 subtype) in emergency patients with early sepsis using the new assay PATHFAST Presepsin[C]//21st International Congress of Clinical Chemistry and Laboratory Medicine. IFCC-World Lab-Euro Med Lab, Berlin. 2011:15-19. [ Google Scholar]

33. Umemura T, Ishikura H, Nakamura Y, Hoshino K, Nishida T, Kamitani T. Defining the need for a massive transfusion in severe blunt traumatic patients. [ Google Scholar]

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In 2004, a new biomarker sCD14-subtypes (presepsin) was found and its value was shown in the diagnosis and evaluation of sepsis. This article is a brief overview of the new biomarker.A literature search using multiple databases was performed for articles, ...

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Introduction. Sepsis and its consequences such as metabolic acidosis are resulting in increased mortality. Although correction of metabolic acidosis with sodium bicarbonate seems a reasonable approach, there is ongoing debate regarding the role of bicarbonates as a therapeutic option. Methods. We conducted a PubMed literature search in order to identify published literature related to the effects of sodium bicarbonate treatment on metabolic acidosis due to sepsis. The search included all articles published in English in the last 35 years. Results. There is ongoing debate regarding the use of bicarbonates for the treatment of acidosis in sepsis, but there is a trend towards not using bicarbonate in sepsis patients with arterial blood gas . Conclusions. Routine use of bicarbonate for treatment of severe acidemia and lactic acidosis due to sepsis is subject of controversy, and current opinion does not favor routine use of bicarbonates. However, available evidence is inconclusive, and more studies are required to determine the potential benefit, if any, of bicarbonate therapy in the sepsis patient with acidosis.

1. Introduction

Sepsis and septic shock constitute an important cause of morbidity and mortality in the critically ill patient. Metabolic acidosis, including lactic acidosis, is part of the underlying pathophysiology in sepsis and is related to poor prognosis.

The treatment of metabolic acidosis is based on control of the underlying pathophysiologic process and reversal of organ dysfunction. Etiologic treatment is essential in metabolic acidosis, but optimization of oxygen delivery to tissues and reduction of tissue oxygen demand through sedation and mechanical ventilation are parts of the therapeutic strategy. Severe acidemia in sepsis contributes to hemodynamic instability, which is the result of reduced myocardial contractility, arterial vasodilation, and impaired responsiveness to catecholamines. As the effect of alkaline therapy on vasopressor requirements and hemodynamic profile in severe acidosis (pH ≤ 7.15) is unknown, current Surviving Sepsis Campaign guidelines recommend against treatment with bicarbonates. Despite lack of data on the effect of bicarbonate therapy, many intensivists attempt to alkalinize blood with intravenous administration of sodium bicarbonate as part of the treatment of sepsis. However, the benefit of bicarbonate administration in metabolic acidosis in sepsis is controversial and remains a matter of debate in clinical practice.

The aim of this review is to evaluate and summarize the published literature regarding the indications and benefits of sodium bicarbonate administration in septic patients with metabolic acidosis.

2. Methods

We conducted a literature search in the MEDLINE database (January 1980 to March 2015), using the combination of the terms "sepsis," "metabolic acidosis," and "bicarbonates." The literature search included all type of articles, and the bibliography from all relevant extracted manuscripts was reviewed for identification of additional related references.

All identified manuscripts, including reviews, case series, and case reports, were evaluated for relevance, and articles deemed pertinent, current, and representative were included in this review. Publications in languages other than English and without abstract in English were excluded. Two authors evaluated the abstracts of all identified articles (DV and MK) and the full text of letters and case reports. Differences of opinion were resolved by reaching consensus after discussion.

3. Results

The PubMed literature search was conducted in March 2015 and yielded 51 publications.

A prospective, randomized, blinded, crossover study published in 1990 by Cooper et al. assessed bicarbonate administration on 14 intensive care unit (ICU) patients with metabolic acidosis and increased arterial lactate. In this study, each patient received sodium bicarbonate (2 mmol/kg infused over 15 minutes) and equimolar sodium chloride sequentially, in random order. After sodium bicarbonate administration, arterial pH, serum bicarbonate, and arterial blood partial CO ₂ pressure (PaCO ₂) increased, while plasma ionized calcium decreased. Both sodium bicarbonate and sodium chloride transiently increased pulmonary capillary wedge pressure and cardiac output, but mean arterial pressure did not change and hemodynamic responses to sodium bicarbonate and sodium chloride were the same. This study concluded that the hemodynamic and cardiovascular response to catecholamines did not improve with sodium bicarbonate administration [ 1].

Another prospective, randomized, blinded, crossover study published by Mathieu et al. in 1991 assessed bicarbonate administration (1 mmol/kg) for correction of acidemia in ten patients with lactic acidosis, by measuring hemodynamic variables and evaluating tissue oxygenation. Each patient received sequentially sodium bicarbonate and sodium chloride in random order. Sodium bicarbonate administration resulted in increased arterial and venous blood pH, but hemodynamic variables did not improve, and tissue oxygenation, as measured by oxygen delivery, oxygen consumption, oxygen extraction, and transcutaneous oxygen pressure, did not change. The study concluded that sodium bicarbonate did not significantly change hemodynamic profile or worsen tissue oxygenation [ 2].

Another prospective clinical trial published in 2008 by Fang et al. assessed the effects of resuscitation with 5 mL/kg of three different solutions (normal saline versus sodium chloride 3.5% versus sodium bicarbonate 5%) on cardiac function in 94 patients with severe sepsis and showed that although mean arterial pressure and cardiac output improved faster in the sodium bicarbonate group, there was no significant difference between the three groups with regard to pH, lactic acid, cardiac output, heart rate, or 28-day mortality [ 3].

A prospective, observational study by Noritomi et al. in 2009 in ICU patients showed that acidosis in survivors was corrected as a result of decreased lactate and strong ion gap levels, whereas metabolic acidosis did not improve in nonsurvivors [ 4]. A retrospective study published in 2010 by El-Solh et al. compared 36 patients with septic shock versus a group of 36 patients matched for age, site of infection, and predicted mortality who did not receive bicarbonate therapy and showed that duration of the need for mechanical ventilation and ICU length of stay were reduced in patients who received bicarbonates, but the median time until reversal of shock and 28-day mortality did not differ between groups [ 5].

Similarly, a prospective, multicenter observational study on 200 patients with severe acidemia (pH < 7.20) from 5 ICUs in France showed that bicarbonate use varied between 5% and 55% of patients between institutions, bicarbonate administration depended on the medical center, rather than the mechanism of acidemia, and there was no association between bicarbonate administration and outcome [ 6].

Another retrospective analysis by Kim et al. in 2013 analyzed 103 patients with lactic acidosis of multiple causes, including sepsis. Multivariate logistic regression showed that SOFA score and sodium bicarbonate administration were independent factors associated with higher mortality [ 7]. According to this study, lactic acid levels should be checked to evaluate the course of metabolic acidosis in sepsis patients, particularly those with high anion gap, as there is concern that bicarbonates could increase mortality.

A prospective randomized, double-blind, controlled clinical trial by Chen et al. in 2013 assessed the use of sodium bicarbonate in two stages for treatment of lactic acidemia due to hypoperfusion in 65 critically ill patients with septic shock and concluded that bicarbonate therapy significantly improved cardiac index, oxygen delivery, and mixed venous oxygen saturation and resulted in lower incidence of multiple organ dysfunction, shorter duration of mechanical ventilation, shorter ICU and hospital stay, and lower mortality [ 8]. Of note, the study by Chen et al. was published in Chinese but comes with a very detailed abstract in English, and we chose to include it in our review because its findings are markedly different compared to most other published clinical studies on the subject. Data from clinical studies evaluating the use of sodium bicarbonate in sepsis patients with acidosis are summarized in Table 1.

A survey published by Kraut and Kurtz in 2006 clearly shows the uncertainty among clinicians as to whether or not bicarbonates should be given to patients with metabolic acidosis. In this survey, 86% of nephrologists would give bicarbonate for treatment of lactic acidosis, compared to only 67% of intensivists. The authors concluded that the observed variability between physicians shows the need for further studies in order to generate data that could support evidence-based guidelines [ 9].

With regard to reviews, opinion articles, and guidelines, Levraut and Grimaud in 2003 reported a theoretical approach to metabolic acidosis, which should be differentiated to "mineral metabolic acidosis" or "organic metabolic acidosis." The authors concluded that "mineral acidosis" is not related to failure of energy metabolic pathways and could be treated with bicarbonate administration to improve pH, whereas "organic acidosis" is evidence of severe underlying metabolic distress, and management is based on addressing the cause of acidosis, rather than correction of the acid-base imbalance [ 10]. Similarly, a 2004 publication by Cariou et al. summarized the recommendations presented in 2003 based on experts' opinion from 11 international organizations under the auspices of the Surviving Sepsis Campaign. These guidelines do not recommend bicarbonate administration as therapeutic option to improve hemodynamic status or reduce vasopressor requirements in sepsis patients with lactic acidosis and pH > 7.15 [ 11]. Similarly, a review article by Boyd and Walley in 2008 agreed with the Surviving Sepsis guidelines, recommended against bicarbonate use for pH > 7.15, and went even further, recommending a lower threshold for treatment at pH ≤ 7.0. These authors also suggested that bicarbonate-based replacement fluid is preferred to citrate infusion for continuous renal replacement therapy [ 12]. Last, the Surviving Sepsis Campaign guidelines in 2010 proposed a grade 2B recommendation for not using sodium bicarbonate therapy in sepsis patients for the purpose of improving hemodynamic status or reducing vasopressor requirements in hypoperfusion-induced lactic acidemia with pH ≥ 7.15 [ 13].

With regard to experimental data, dog experiments conducted in the 1970s suggest that plasma bicarbonate concentration influences the apparent volume of distribution of bicarbonate so that when bicarbonate is administered, the proportion of bicarbonate passing into the intracellular space increases with decreasing bicarbonate concentration [ 14]. A study by Valenza et al. in 2012 in normoxic, normotensive rats showed that pH decreased with infusion of lactic acid and rose with bicarbonate administration, but the effect of bicarbonate infusion on pH was different with persistent versus transient acid load [ 15]. An earlier study by Arieff et al. showed that bicarbonate administration did not improve hemodynamic parameters or reduce mortality in an animal model of lactic acidosis [ 16]. However, an experimental study by Benjamin et al. on dogs subjected to hemorrhagic shock showed that bicarbonate administration resulted in moderate increase of blood pressure, cardiac index, oxygen delivery index, and oxygen consumption index, but this benefit was not better compared to administration of hypertonic saline [ 17]. Other in vitro experiments performed by Goldsmith et al. in 1997 measured intracellular pH changes in leucocytes from healthy volunteers using a fluorescent intracellular dye and described deleterious effects after alkalinization of the extracellular fluid by giving sodium bicarbonate [ 18]. In addition, an in vitro study on human hepatocytes showed that bicarbonate administration can decrease intracellular pH, and the change in intracellular pH depends on pCO ₂ changes in the fluid surrounding the cells [ 19]. However, a newer study from Denmark evaluated intracellular pH of muscle tissue in healthy volunteers and showed that bicarbonate administration attenuated the reduction of intracellular pH induced by exercise [ 20]. Experimental data related to the use of bicarbonates in sepsis or acidosis are summarized in Table 2.

4. Discussion

Sepsis is a serious, potentially fatal disease commonly seen in intensive care units all over the world. Mortality rate is high (36.7%) in sepsis patients with hypotension only or with elevated lactate ≥ 4 mmol/L only (30%) but is even higher (46.1%) in patients with both hypotension and lactate ≥ 4 mmol/L. Metabolic acidosis is considered a sign of severity of the underlying disease process, and identification of the cause of acidosis is essential in order to initiate timely appropriate therapy. Causes of metabolic acidosis include sepsis, cardiogenic shock, severe hypoxemia, hepatic failure, and intoxication. Most of these conditions share similar pathogenic mechanisms, including reduced oxygen delivery to cells and impaired oxygen consumption in cell mitochondria, yet some conditions are due to more complex derangements. Lactic acidosis in sepsis is a complex process and the associated severe acidemia has important clinical consequences, including hemodynamic instability due to reduced left ventricular contractility, diastolic dysfunction and right ventricular failure, predisposition to cardiac arrhythmias, arterial vasodilation, impaired responsiveness to catecholamines, reduced hepatic blood flow, and impaired oxygen tissue delivery. Metabolic effects of acidosis include reduction of ATP synthesis in the cells, increased ionized calcium levels, and insulin resistance. In severe acidemia (blood pH < 7.1) these effects can result in organ dysfunction and contribute to increased morbidity and mortality. Treatment of lactic acidosis includes recognition and correction of the underlying cause, provision of adequate oxygen tissue delivery, and reduction of oxygen tissue demand through sedation and mechanical ventilation. In addition, although not recommended by published guidelines, ICU clinicians sometimes attempt to increase blood pH with administration of intravenous (IV) sodium bicarbonate. However, persistence of lactic acidosis despite appropriate therapy is associated with very high (up to 90%) mortality [ 21- 24].

Metabolic acidosis can be the result of either a primary increase in hydrogen ion (H⁺) or reduction of bicarbonate concentration. In acute states of metabolic acidosis, respiratory compensation through hyperventilation results in relative reduction of PaCO ₂, whereas in chronic states the human body develops renal compensation through reabsorption of HCO ₃. The etiology of metabolic acidosis is divided into causes resulting in elevated anion gap (AG) and causes that do not. Lactic acidosis is a common cause of high anion gap metabolic acidosis [ 9, 25- 27] and is classified as type A (anaerobic), which is associated with tissue hypoperfusion and denotes a condition of intact mitochondrial function but inadequate oxygen delivery (such as in shock states), or type B (aerobic), wherein oxygen supply is adequate and there is no tissue hypoxia, but acidosis is due to abnormal carbohydrate metabolism, such as in hepatic failure, diabetes, or phenformin intoxication [ 28, 29]. In patients with severe sepsis and septic shock, tissue hypoxia occurs due to reduction of oxygen delivery to peripheral tissues [ 30], while other mechanisms, including reduction of lactate clearance, reduced activation of the pyruvate dehydrogenase complex, and alterations of mitochondrial function contribute to this process.

Normal blood lactate levels in healthy humans are 0.5-1 mmol/L, but "normal" lactate concentrations in patients with critical illness are <2 mmol/L. Hyperlactatemia is defined as mild to moderate when persistent increase in blood lactate concentration (2-4 mmol/L) without metabolic acidosis exists, whereas lactic acidosis is characterized by persistently increased blood lactate levels (>4-5 mmol/L) in association with metabolic acidosis. Acidosis can inhibit lactic acid production by reducing activity of the enzyme phosphofructokinase; therefore correction of metabolic acidosis with sodium bicarbonate may increase lactic acid production by inhibiting this compensatory response [ 31- 34].

Bicarbonate is the main form of CO ₂ in the human body and can be estimated from pH and pCO ₂. Normal pH range is 7.35-7.45 and normal bicarbonate is 21-28 mEq/L. Blood pH is reduced (acidosis) when CO ₂ quantity is elevated and increases (alkalosis) when CO ₂ quantity is reduced or when the quantity of base, such as bicarbonate (), increases in blood. Bicarbonate is secreted and absorbed again (conservation) from the kidneys in response to pH changes and is commonly encountered as sodium bicarbonate (NaHCO ₃). Bicarbonate administration can stimulate superoxide formation, increase proinflammatory cytokine release, and enhance apoptosis and may also result in paradoxic intracellular acidosis due to generation of CO ₂. In clinical use, bicarbonate administration in severe academia may cause volume expansion and hypernatremia but can also result in reduced blood pressure and cardiac output and increased mortality.

If bicarbonate is to be used, it should be administered as slow infusion, and the amount of CO ₂ that is produced should be monitored. In patients with sepsis and severe acidosis undergoing renal replacement therapy, use of bicarbonate-based replacement fluids is recommended. Similarly, chronic bicarbonate replacement is indicated in patients with renal tubular acidosis.

Worldwide, many intensive care clinicians consider bicarbonate therapy as major component in the treatment of sepsis in patients with metabolic acidosis [ 35] and in sepsis patients with pH < 7.20, or, even more so, in patients with pH < 7.0. This therapeutic approach is supported by evidence suggesting that acute acidemia has deleterious effects on organ function. However, although acidemia correction with administration of bicarbonates aims to normalize extracellular and intracellular pH and improve outcome [ 11], several studies suggest that this approach is overly simplistic [ 36] and the impact of bicarbonate administration on restoring hemodynamics, reducing vasopressor requirements, and improving clinical outcomes is unknown [ 21]. In 2000, a comment published in "Chest" by Cuhaci in response to an earlier study by Forsythe and Schmidt [ 36] criticized the suggestion to not routinely use bicarbonates in lactic acidosis and questioned whether rejection of a reasonable therapeutic option is wise, when this option does not cause harm and there are no proven alternative options [ 37]. This comment likely reflects clinical practice, as evidenced by a survey published in 2006, which showed that 67% of 48 intensivists who responded to the survey would give bicarbonate for treatment of lactic acidosis [ 9]. However, the argument that bicarbonate administration does not cause harm is contradicted by the "surviving sepsis guidelines" which state that "Bicarbonate administration has been associated with sodium and fluid overload, an increase in lactate and PCO ₂, and a decrease in serum ionized calcium..." [ 21].

The appropriate treatment of metabolic acidosis, especially organic acidosis (such as lactic acidosis), is controversial, but reduction of acid production via improved oxygen tissue delivery is generally considered the most effective treatment. Aggressive therapy of sepsis is based on appropriate antibiotics and on addressing the causes of acidosis, with fluid resuscitation and restoration of cardiac function. Goals of resuscitation in sepsis with severe metabolic acidosis include maintenance of CVP > 8 mmHg, ScvO ₂ > 70% and normalization of lactate, while bicarbonate administration remains controversial [ 5].

Reasons for the absence of clear benefit from bicarbonate administration include exacerbation of intracellular acidosis due to initial rapid influx of CO ₂, loss of protective effects provided by acidosis against hypoxic damage, the fact that more calcium will bind to albumin instead of H⁺ leading to reduction of ionized calcium which, in turn, decreases cardiac output, and cellular swelling and dysfunction resulting from acceleration of cellular influx of sodium and calcium in response to worsening intracellular acidosis.

Additional risks of sodium bicarbonate administration include increased plasma PaCO ₂, hyperosmolality, hypernatremia, volume overload, and pH overcorrection resulting in metabolic alkalosis. Finally, regarding the amount of bicarbonate needed for correction of metabolic acidosis, there is no simple formula, because many confounding factors can affect acid-base status and bicarbonate volume of distribution. In general, bicarbonate deficit can be calculated using the equation " deficit = (desired ) × 0.5 × body weight" [ 33]. The sodium bicarbonate amount to be administered should be infused over hours, rather than as bolus [ 24, 36, 38, 39]. When decision to administer bicarbonates has been made, clinicians should monitor for adverse effects, facilitate elimination of excess CO ₂ produced, and correct hypocalcemia, because a 10% reduction of plasma calcium level can depress myocardial contractility and reduce vascular responsiveness to catecholamines [ 12].

Sodium bicarbonate increases plasma pH, but this effect is transient and does not correlate with hemodynamic improvement or improved outcomes in sepsis patients; therefore addressing the cause remains the most effective therapy for metabolic acidosis in sepsis. Although acidemia contributes to cardiovascular dysfunction in sepsis, no controlled study has demonstrated hemodynamic improvement with bicarbonate therapy, regardless of the effect on pH, and studies have shown worsening of the metabolic and hemodynamic consequences of acidosis [ 24, 40]. As there are no documented benefits from use of sodium bicarbonate in lactic acidosis related to inadequate tissue perfusion, routine use of sodium bicarbonate has been removed from the Advanced Cardiac Life Support algorithms [ 40]. In agreement with current guidelines, our literature search suggests that although there is debate regarding sodium bicarbonate use for treatment of lactic acidosis in sepsis, currently available evidence does not support the use of bicarbonate in sepsis patients with metabolic acidosis.

5. Conclusions

Routine bicarbonate administration for treatment of lactic acidosis in sepsis is subject to ongoing debate. Published evidence suggests that bicarbonate therapy is not beneficial in cases of metabolic acidosis in sepsis and may even cause harm by worsening intracellular acidosis. Rational treatment of metabolic acidosis in sepsis is directed towards addressing the underlying causes of acidosis and optimizing tissue oxygen delivery through optimization of cardiopulmonary parameters. However, as recent clinical data from China suggest that sodium bicarbonate therapy may actually improve outcome in sepsis patients with acidosis, large, rigorous, well-designed prospective clinical trials are needed to thoroughly assess the value of bicarbonate therapy in this patient population.

Conflict of Interests

The authors declare that there is no conflict of interests regarding the publication of this paper.

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The Use of Sodium Bicarbonate in the Treatment of Acidosis in Sepsis: A Literature Update on a Long Term Debate

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Introduction . Sepsis and its consequences such as metabolic acidosis are resulting in increased mortality. Although correction of metabolic acidosis with sodium bicarbonate seems a reasonable approach, there is ongoing debate regarding the role of bicarbonates as a therapeutic option. Methods .

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Centers for Disease Control and Prevention

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Know the Risks. Spot the Signs. Act Fast.

Sepsis is the body's extreme response to an infection. It is a life-threatening medical emergency.

Sepsis happens when an infection you already have -in your skin, lungs, urinary tract, or somewhere else-triggers a chain reaction throughout your body.

Without timely treatment, sepsis can rapidly lead to tissue damage, organ failure, and death.
Sepsis happens when...image icon Transcript: Sepsis happens when txt icon [TXT 1 1 KB]

What causes sepsis?

When germs get into a person's body, they can cause an infection. If that infection isn't stopped, it can cause sepsis.

Who is at risk?

Anyone can get an infection and almost any infection can lead to sepsis. Certain people are at higher risk:

Adults 65 or older

People with chronic medical conditions, such as diabetes, lung disease, cancer, and kidney disease

People with weakened immune systems

Children younger than one

What are the signs & symptoms?

A patient with sepsis might have one or more of the following signs or symptoms:

I think I might have sepsis. What should I do?

If you are feeling worse or not getting better in the days after surgery, ask your healthcare professional, " Could this be sepsis? "

Similarly, if you have an infection that is not getting better or is getting worse, ask your healthcare professional, "Could this infection be leading to sepsis?"

Page last reviewed:

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Sepsis is a medical emergency. Time matters.

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Know the Risks. Spot the Signs. Act Fast. Sepsis is the body's extreme response to an infection. It is a life-threatening medical emergency. Sepsis happens when an infection you already have -in your skin, lungs, urinary tract, or somewhere else-triggers a chain reaction throughout your body.

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Sepsis is a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. Common signs and symptoms include fever, increased heart rate, increased breathing rate, and confusion. There also may be symptoms related to a specific infection, such as a cough with pneumonia, or painful urination with a kidney infection.

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Our coronavirus (COVID-19) resources provide relevant and authoritative community driven resources from around the world. Aids with real-time monitoring, supports mapping and analysis & increases community preparedness.

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Ventilator Capacity-based Assessment

We assessed the capacity of the U.S. healthcare system to rapidly absorb additional mechanical ventilators during a large-scale PHE using the following steps. First, we identified the key components of the healthcare system needed to effectively deliver ventilation therapy to patients. Secondly, we quantified the maximum number of additional ventilators that each of the key components could effectively support at various capacity levels (i.e., conventional, contingency and crisis). ( 6) According to the Institute of Medicine (IOM), conventional capacity is defined as the usual and normal patient-care where facilities and staff meet their normal goals in providing care. Contingency capacity requires minor adaptation that may have minor consequences for standards of care, but adaptations are not enough to result in significant changes to standards of care. Crisis capacity is defined as a fundamental, systematic change in which standards of care are significantly altered in order to allow treatment of a greater number of patients. ( 6) Third, we determined the constraining key component at each capacity level to determine the system's surge capacity.

Components necessary to provide mechanical ventilation

The four key components necessary to provide ventilation therapy to a patient include the necessary equipment such as ventilators and ancillary supplies including circuits and bacterial filters (supplies), hospital beds equipped for ventilation and comprehensive critical care (space), and specialized medical personnel to manage patients on mechanical ventilators (staff). ( 3) There is also a need for readily accessible and exercised plans to rapidly increase capacity for patients that require mechanical ventilation (systems) ().

Quantification of healthcare components

The estimated number of ventilators that can be used is the key outcome component for this study. Staffed beds are the key input component for space. Specially trained critical care physicians, nurses and respiratory therapists are the key input components for staff. The systems input component, for example planning and communications, is difficult to quantify. Thus, it was not considered in this assessment. As a result, quantification of healthcare input components was limited to the space and staff as outlined below.

Space

Bed space for patients that need mechanical ventilation requires specific functionalities such as electricity, oxygen, suction, medical gas, and monitoring equipment. In acute care hospitals, these functionalities are usually found in critical care or intensive care units. In a large-scale PHE, additional critical care space could be created through the use of intermediate care beds (e.g. step-down beds, post-operative care beds, and emergency care beds) and potentially general ward beds that could be equipped with the functionalities needed to provide ventilation care. ( 3)

To understand the space (i.e., excess beds) available to provide ventilation care at the different capacity levels, we obtained the estimate of staffed beds in the U.S. by bed type ( 7) and calculated the proportion of staffed beds that would be available to treat a surge of patients needing mechanical ventilation. Staffed beds are beds for which trained staffs are on hand and physically available to care for patients. ( 8) Recent data indicate an annual average availability of 32% for both critical care and non-critical care beds. ( 9 - 11) However, the literature suggests that annual averages in bed availability do not reflect weekly and seasonal variation. ( 12) As a result, we assumed a lower 10% to 20% bed availability across all capacity levels to address ventilation need at the peak of an influenza pandemic outbreak (8 - 10 days). Our 10% to 20% bed availability assumption was also informed by expert opinion.

At the conventional capacity level, we assumed only currently staffed but unoccupied critical care beds would be available for use by ventilated patients. At the contingency capacity level, we included staffed but unoccupied intermediate care beds (e.g., step-down beds, postoperative care, and emergency department beds) in our estimate of bed surge capacity. ( 7) At the crisis capacity level, we expanded bed space to staffed but unoccupied general ward beds that could be equipped with capabilities to support ventilated patients. ( 7) We excluded specialty care beds such as neonatal intensive care unit (NICU) beds, nursery beds, psychiatric beds, rehabilitation beds and nursing home beds. These beds were judged by subject matter experts as either unsuitable for general patient needs because they were specific to a patient population (i.e. neonates, newborns, or older adults), or have limited surge capacity. ( 7) We calculated the number of beds available for use by ventilated patients at the peak of an influenza pandemic for each capacity level by multiplying the number of staffed beds in each bed type category (e.g., intermediate, general ward) in the U.S. healthcare system by the previously described 10% - 20% peak bed availability.

Staff

Management of patients on mechanical ventilators requires a team of critical care personnel to optimize clinical outcomes. Personnel trained in the management of patients on mechanical ventilators include critical care physicians, critical care nurses, and respiratory therapists. In a large-scale PHE where critical care personnel are likely to be in short supply, staff capacity could be enhanced at the contingency and crisis capacity levels by: 1) extending provider working hours; 2) increasing patient to provider ratios (i.e. more patients per provider); and 3) augmenting critical care personnel with non-critical care personnel using a two-tier staffing model. In a two-tier staffing model, non-critical care personnel assume the more general aspects of patient care and function under the direct supervision of critical care personnel. ( 13 - 15) However, enhancement of staff capacity could be constrained by: 1) unacceptable extensions of work hours for trained personnel; 2) staff absenteeism due to personal illness or the need to care for others who are ill and; 3) inability to quickly and sufficiently train healthcare personnel who have no prior critical care experience to manage patients on mechanical ventilators.

To calculate the number of staff that would be available to treat a surge of patients on mechanical ventilators, we assumed that: 1) the number of trained medical personnel would correlate with the number of staffed beds maintained by hospitals; 2) medical personnel would work one 12-hour shift per day; and 3) 10% to 20% of medical personnel would be available as surge capacity, consistent with the 10% to 20% staffed bed availability assumption. While we did not take absenteeism of healthcare workers into account explicitly in the model, we did perform a sensitivity analysis to examine the impact of absenteeism on staff availability, as described below. Other staff assumptions were specific to the capacity level. At the conventional capacity level, health provider projections were limited to critical care personnel who primarily manage patients on mechanical ventilators (i.e., critical and pulmonary care physicians, critical care nurses, and respiratory therapists). ( 3) At the conventional capacity level, we assumed a patient to physician ratio of 10:1 to 15:1 ( 17), patient to critical care nurse ratio of 1:1 ( 15), and patient to respiratory therapist ratio of 4:1 to 6:1. ( 18)

At the contingency capacity level, the type of physicians delivering care to ventilated patients were expanded to include other medical specialties such as anesthesiologists, emergency care physicians, and cardio-thoracic surgeons with experience in managing patients on mechanical ventilators. In addition, the ratio of patient to healthcare provider was expanded for respiratory therapists and critical care nurses. At the contingency capacity level, we maintained a patient to physician ratio of 10:1 to 15:1 ( 17), expanded the patient to critical care nurse ratio to 2:1, ( 15) and expanded the patient to respiratory therapist ratio range to 7:1 to 9:1. ( 18)

At the crisis capacity level, critical care personnel were augmented with non-critical care personnel using already described two-tier staffing model. Each supervisory critical care physician would work with up to four non-critical care physicians. Each non-critical care physician would manage up to six patients, providing a patient to critical care physician ratio of 24:1 consistent with the Task Force for Mass Critical Care recommendations for physician two-tier staffing model. For critical care nurses, we assumed that three non-critical care nurses would work under the supervision of a critical care nurse, and each non-critical care nurse would manage up to two patients, providing a range of patient to critical care nurse ratio of 3:1 to 6:1. ( 15) Similarly, for respiratory therapists, we assumed that up to four respiratory extenders would work with a respiratory therapist and each respiratory extender would manage up to three patients, providing a range of patient to respiratory therapist ratio of 10:1 to 12:1. Respiratory extenders could be respiratory therapists working in administrative positions, respiratory therapy students, nurses and other healthcare professionals involved in patient care. ( 14, 15) All of the patient to staff ratios used for contingency and crisis capacity levels in this assessment were previously recommended by the Task Force for Mass Critical Care and Project extreme. ( 13 - 15) Finally, to project the number of medical personnel that would be available at each capacity level, we divided the number of staff in each medical personnel category by the number of shifts per day (two shifts per day), and multiplied the outcome by the 10% to 20% staff availability. This value was then multiplied by the patient to provider ratio to obtain the number of patients that could be treated for each medical personnel category at the peak of an influenza pandemic outbreak.

Sensitivity analysis

We tested the impact of varying the assumptions for space and staff availability on additional ventilation capacity. We varied the bed availability estimate from 10% to 20%, to 20% to 60% in a step-wise fashion across all capacity levels based on the range of bed availability data across U.S hospitals. ( 9 - 11) We also assumed a 20% reduction in staff availability due to staff absenteeism. ( 16) All other factors and assumptions remained the same.

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Assessing the capacity of the healthcare system to use additional mechanical ventilators during a large-scale public health emergency (PHE)

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A large-scale Public Health Emergency (PHE), like a severe influenza pandemic can generate large numbers of critically ill patients in a short time. We modeled the number of mechanical ventilators that could be used in addition to the number of hospital-based ...

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Assessing the Capacity of the US Health Care System to Use Additional Mechanical Ventilators During a Large-Scale Public Health Emergency.

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Assessing the Capacity of the US Health Care System to Use Additional Mechanical Ventilators During a Large-Scale Public Health Emergency.

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RESULTS:

Our study results showed that US hospitals could absorb between 26,200 and 56,300 additional ventilators at the peak of a national influenza pandemic outbreak with robust pre-pandemic planning.

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OBJECTIVE:

A large-scale public health emergency, such as a severe influenza pandemic, can generate large numbers of critically ill patients in a short time. We modeled the number of mechanical ventilators that could be used in addition to the number of hospital-based ventilators currently in use.

METHODS:

We identified key components of the health care system needed to deliver ventilation therapy, quantified the maximum number of additional ventilators that each key component could support at various capacity levels (ie, conventional, contingency, and crisis), and determined the constraining key component at each capacity level.

RESULTS:

Our study results showed that US hospitals could absorb between 26,200 and 56,300 additional ventilators at the peak of a national influenza pandemic outbreak with robust pre-pandemic planning.

CONCLUSIONS:

The current US health care system may have limited capacity to use additional mechanical ventilators during a large-scale public health emergency. Emergency planners need to understand their health care systems' capability to absorb additional resources and expand care. This methodology could be adapted by emergency planners to determine stockpiling goals for critical resources or to identify alternatives to manage overwhelming critical care need.

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Assessing the Capacity of the US Health Care System to Use Additional Mechanical Ventilators During a Large-Scale Public Health Emergency.

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OBJECTIVE: A large-scale public health emergency, such as a severe influenza pandemic, can generate large numbers of critically ill patients in a short time. We modeled the number of mechanical ventilators that could be used in addition to the number of hospital-based ventilators currently in use.

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Centers for Disease Control and Prevention

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During a large-scale public health emergency involving a respiratory disease like COVID-19, federal, state, or local stockpiled ventilators should be deployed in a way that optimizes the effectiveness, efficiency, and equity of this scarce resource. Decisions on the allocation of stockpiled ventilators to facilities should be based on multiple factors, including: ¹

Assessment of need

Determination of facilities' ability to absorb additional ventilators

Ethical considerations to inform how this scarce resource is provided to facilities to save as many lives as possible

Input from state and local leadership, legal and ethical experts, and informed stakeholders

State and local planners can use the strategies in this guide to assist them when allocating ventilators from public health stockpiles to hospitals and other facilities during a pandemic.

Use available surveillance data to predict the number of ventilators needed²

Growth in number of daily cases (increasing, stable, decreasing)

Number of hospitalizations

Percentage of hospitalizations with critical illness requiring critical care

Percentage of critically ill patients needing ventilatory support

Assess the number of ventilators currently available for use by each facility

Ventilators currently not in use or in storage

Ventilators anticipated to be available from surge contracts or sharing agreements

Ventilators in use that may be available for future use

Identify facilities that may have capacity to care for critically ill patients who will need mechanical ventilation (from prior or current assessments).

Quantify the number of additional ventilators each facility can realistically absorb.
Base this estimate on having enough trained and qualified staff, space, and necessary equipment needed for caring for additional patients on mechanical ventilation.

Determine the population size that each hospital serves and assess the capacity of each facility to serve vulnerable and high-risk populations within this area.

Consider whether each hospital serves as a referral hospital/regional hospital or serves a high-density population area, rural area, or underserved populations.

Use ethical principles to guide the development and implementation of ventilator allocation plans.

Will the allocation plan use scarce resources in a manner that will save as many lives as possible?⁵

Does the allocation plan apply criteria consistently across all hospitals/facilities in the jurisdiction?

If ventilators are insufficient to meet the needs of all those who would benefit from them, what are plans for providing care for patients who cannot access them?

Does the plan include ways to clearly and transparently communicate the framework for allocation decisions to facility leadership, stakeholders, and to the general public?

Create distribution plans assuming that once ventilators have been allocated to a facility, they are unlikely to be reallocated.

Ensure that ventilators stockpiled locally are ready to be put into service.

References:

1. Koonin LM, Pillai S, Kahn EB, Moulia D, Patel A. Strategies to inform allocation of stockpiled ventilators to healthcare facilities during a pandemic. Health Secur. 2020;18(2).

2. Ajao A, Nystrom SV, Koonin LM, Patel A, Howell DR, Baccam P, et al. Assessing the capacity of the US health care system to use additional mechanical ventilators during a large-scale public health emergency. Disaster Med Public Health Prep. 2015;9(6):634-41.

3. Zaza S, Koonin LM, Ajao A, Nystrom SV, Branson R, Patel A, et al. A conceptual framework for allocation of federally stockpiled ventilators during large-scale public health emergencies. Health Secur.2016;14(1):1-6.

4. Centers for Disease Control and Prevention; Ventilator Document Workgroup, Ethics Subcommittee of the Advisory Committee to the Director. Ethical considerations for decision making regarding allocation of mechanical ventilators during a severe influenza pandemic or other public health emergency, 2011. Atlanta, GA; 2011.

5. Institute of Medicine Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations. Guidance for establishing crisis standards of care for use in disaster situations: a letter report. Washington DC: National Academies Press (US); 2009.

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During a large-scale public health emergency involving a respiratory disease like COVID-19, federal, state, or local stockpiled ventilators should be deployed in a way that optimizes the effectiveness, efficiency, and equity of this scarce resource.

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Centers for Disease Control and Prevention

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The Personal Protective Equipment (PPE) Burn Rate Calculator (Version 2) [XLS - 2 MB] is a spreadsheet-based model that will help healthcare facilities plan and optimize the use of PPE for response to COVID-19. Non-healthcare facilities such as correctional facilities may also find this tool useful.

To use the calculator, enter the number of full boxes of each type of PPE in stock (gowns, gloves, surgical masks, respirators, and face shields, for example) and the total number of patients at your facility, if applicable. If your facility does not treat COVID-19 patients, leave "patients" row blank. The tool will calculate the average consumption rate, also referred to as a "burn rate," for each type of PPE entered in the spreadsheet. This information can then be used to estimate how long the remaining supply of PPE will last, based on the average consumption rate. Using the calculator can help your facility make order projections for future needs.
System Requirements

Windows* operating system (MS Windows 2000 or newer)

Microsoft Excel (MS Office 2000 or newer)

486 Pentium processor and at least 128MB RAM

2 MB of hard drive storage space

* MS Windows and Office is a copyrighted product produced by Microsoft Corporation, based in Redmond, WA. Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.
Instructions for Downloading
Before loading and starting the PPE Burn Rate Calculator, you may need to change Excel's security level. To do so:

1. Open a blank Excel spreadsheet.

2. Click Tools and then click Macro, choose Security.

3. Set Security Level to Medium.

4. Click OK.

5. Double-click and open PPE Burn Rate Calculator file.

6. When asked to Disable Macros or Enable Macros, click Enable Macros.

Downloading the Files
We recommend downloading and saving the PPE Burn Rate Calculator spreadsheet to your computer before opening the spreadsheet. Taking this step will open the spreadsheet in Excel rather than your web browser.

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tools to track personal protective equipment supply

# data[].attributes.attachment_link.description
The Personal Protective Equipment (PPE) Burn Rate Calculator (Version 2) [XLS - 2 MB] is a spreadsheet-based model that will help healthcare facilities plan and optimize the use of PPE for response to COVID-19. Non-healthcare facilities such as correctional facilities may also find this tool useful.

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Business Oregon | Coronavirus (COVID-19) Resources

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Resources for Oregon businesses looking for assistance in the event of local, regional, or statewide economic impacts due to identified disasters.

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Overview

When health systems are overwhelmed, both direct mortality from an outbreak and indirect mortality from vaccine-preventable and treatable conditions increase dramatically. Countries will need to make difficult decisions to balance the demands of responding directly to COVID-19, while simultaneously engaging in strategic planning and coordinated action to maintain essential health service delivery, mitigating the risk of system collapse. This document expands on the content of the Operational planning guidelines to support country preparedness and response, and provides guidance on a set of targeted immediate actions that countries should consider at national, regional, and local level to reorganize and maintain access to high-quality essential health services for all.

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COVID-19: Operational guidance for maintaining essential health services during an outbreak

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When health systems are overwhelmed, both direct mortality from an outbreak and indirect mortality from vaccine-preventable and treatable conditions increase dramatically. Countries will need to make difficult decisions to balance the demands of responding directly to COVID-19, while simultaneously engaging in strategic planning and coordinated action to maintain essential health service delivery, mitigating the risk of system collapse.

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The Weekly Epidemiological Update provides an overview of the global, regional and country-level COVID-19 cases and deaths, highlighting key data and trends; as well as other pertinent epidemiological information concerning the COVID-19 pandemic. The COVID-19 Weekly Operational Update reports on WHO and partners' actions in response to the pandemic.

Weekly Epidemiological and Operational updates February 2021

Weekly Epidemiological and Operational updates January 2021

Weekly Epidemiological and Operational updates December 2020

Weekly Epidemiological and Operational updates November 2020

Weekly Epidemiological and Operational updates October 2020

Weekly Epidemiological and Operational updates September 2020

Weekly Epidemiological and Operational updates August 2020

Situation reports February 2020

Situation reports January 2020

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Coronavirus Disease (COVID-19) Situation Reports

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The daily Situation Report provides the current COVID-19 epidemiological situation and presents official case and death counts and transmission classifications worldwide. This includes a map, epidemic curve, and table allowing users to explore the latest numbers and trends at global, regional and country levels.

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Centers for Disease Control and Prevention

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Purpose

This interim guidance is based on what is currently known about the coronavirus disease 2019 (COVID-19). COVID-19 is a respiratory illness that can spread from person to person. The outbreak first started in China, but the virus continues to spread internationally and in the United States. The Centers for Disease Control and Prevention (CDC) will update this interim guidance as additional information becomes available.

The following interim guidance may help prevent workplace exposures to COVID-19, in non-healthcare settings. (CDC has provided separate guidance for healthcare settings.) This guidance also provides planning considerations for community spread of COVID-19.

To prevent stigma and discrimination in the workplace, use only the guidance described below to determine risk of COVID-19 infection. Do not make determinations of risk based on race or country of origin and be sure to maintain confidentiality of people with confirmed coronavirus infection. There is much more to learn about the transmissibility, severity, and other features of COVID-19 and investigations are ongoing. Updates are available on CDC's web page.

Preparing Workplaces for a COVID-19 Outbreak

Businesses and employers can prevent and slow the spread of COVID-19. Employers should plan to respond in a flexible way to varying levels of disease transmission in the community and be prepared to refine their business response plans as needed. According to the Occupational Safety and Health Administration (OSHA), most American workers will likely experience low (caution) or medium exposure risk levels at their job or place of employment (see OSHA guidance for employerspdf icon external icon for more information about job risk classifications).

Businesses are strongly encouraged to coordinate with stateexternal icon and localexternal icon health officials so timely and accurate information can guide appropriate responses. Local conditions will influence the decisions that public health officials make regarding community-level strategies. CDC has guidance for mitigation strategiespdf icon according to the level of community transmission or impact of COVID-19.

All employers need to consider how best to decrease the spread of COVID-19 and lower the impact in their workplace. This may include activities in one or more of the following areas:

1. reduce transmission among employees,

2. maintain healthy business operations, and

3. maintain a healthy work environment.

Reduce Transmission Among Employees
Actively encourage sick employees to stay home:

Employees who have symptoms (i.e., fever, cough, or shortness of breath) should notify their supervisor and stay home.

Sick employees should follow CDC-recommended steps. Employees should not return to work until the criteria to discontinue home isolation are met, in consultation with healthcare providers and state and local health departments.

Employees who are well but who have a sick family member at home with COVID-19 should notify their supervisor and follow CDC recommended precautions.

Identify where and how workers might be exposed to COVID-19 at work:

See OSHA COVID-19external icon webpage for more information on how to protect workers from potential exposures and guidance for employerspdf icon external icon , including steps to take for jobs according to exposure risk.

Be aware that some employees may be at higher risk for serious illness, such as older adults and those with chronic medical conditions. Consider minimizing face-to-face contact between these employees or assign work tasks that allow them to maintain a distance of six feet from other workers, customers and visitors, or to telework if possible.

Separate sick employees:

Employees who appear to have symptoms (i.e., fever, cough, or shortness of breath) upon arrival at work or who become sick during the day should immediately be separated from other employees, customers, and visitors and sent home.

If an employee is confirmed to have COVID-19 infection, employers should inform fellow employees of their possible exposure to COVID-19 in the workplace but maintain confidentiality as required by the Americans with Disabilities Act (ADA). The fellow employees should then self-monitor for symptoms (i.e., fever, cough, or shortness of breath).
Educate employees about how they can reduce the spread of COVID-19:

Employees can take steps to protect themselves at work and at home. Older people and people with serious chronic medical conditions are at higher risk for complications.

Follow the policies and procedures of your employer related to illness, cleaning and disinfecting, and work meetings and travel.

Stay home if you are sick, except to get medical care. Learn what to do if you are sick.

Inform your supervisor if you have a sick family member at home with COVID-19. Learn what to do if someone in your house is sick.

Wash your hands often with soap and water for at least 20 seconds. Use hand sanitizer with at least 60% alcohol if soap and water are not available.

Avoid touching your eyes, nose, and mouth with unwashed hands.

Cover your mouth and nose with a tissue when you cough or sneeze or use the inside of your elbow. Throw used tissues in the trash and immediately wash hands with soap and water for at least 20 seconds. If soap and water are not available, use hand sanitizer containing at least 60% alcohol. Learn more about coughing and sneezing etiquette on the CDC website.

Clean AND disinfect frequently touched objects and surfaces such as workstations, keyboards, telephones, handrails, and doorknobs. Dirty surfaces can be cleaned with soap and water prior to disinfection. To disinfect, use products that meet EPA's criteria for use against SARS-CoV-2external icon , the cause of COVID-19, and are appropriate for the surface.

Avoid using other employees' phones, desks, offices, or other work tools and equipment, when possible. If necessary, clean and disinfect them before and after use.

Practice social distancing by avoiding large gatherings and maintaining distance (approximately 6 feet or 2 meters) from others when possible.

Maintain Healthy Business Operations

Identify a workplace coordinator who will be responsible for COVID-19 issues and their impact at the workplace.
Implement flexible sick leave and supportive policies and practices.

Ensure that sick leave policies are flexible and consistent with public health guidance and that employees are aware of and understand these policies.

Maintain flexible policies that permit employees to stay home to care for a sick family member or take care of children due to school and childcare closures. Additional flexibilities might include giving advances on future sick leave and allowing employees to donate sick leave to each other.

Employers that do not currently offer sick leave to some or all of their employees may want to draft non-punitive "emergency sick leave" policies.

Employers should not require a positive COVID-19 test result or a healthcare provider's note for employees who are sick to validate their illness, qualify for sick leave, or to return to work. Healthcare provider offices and medical facilities may be extremely busy and not able to provide such documentation in a timely manner.

Review human resources policies to make sure that policies and practices are consistent with public health recommendations and are consistent with existing state and federal workplace laws (for more information on employer responsibilities, visit the Department of Labor'sexternal icon and the Equal Employment Opportunity Commission'sexternal icon websites).

Connect employees to employee assistance program (EAP) resources (if available) and community resources as needed. Employees may need additional social, behavioral, and other services, for example, to cope with the death of a loved one.

Assess your essential functions and the reliance that others and the community have on your services or products.

Be prepared to change your business practices if needed to maintain critical operations (e.g., identify alternative suppliers, prioritize existing customers, or temporarily suspend some of your operations if needed).

Identify alternate supply chains for critical goods and services. Some good and services may be in higher demand or unavailable.

Talk with companies that provide your business with contract or temporary employees about the importance of sick employees staying home and encourage them to develop non-punitive leave policies.

Talk with business partners about your response plans. Share best practices with other businesses in your communities (especially those in your supply chain), chambers of commerce, and associations to improve community response efforts.

Determine how you will operate if absenteeism spikes from increases in sick employees, those who stay home to care for sick family members, and those who must stay home to watch their children if dismissed from childcare programs and K-12 schools.

Plan to monitor and respond to absenteeism at the workplace.

Implement plans to continue your essential business functions in case you experience higher than usual absenteeism.

Prepare to institute flexible workplace and leave policies.

Cross-train employees to perform essential functions so the workplace can operate even if key employees are absent.

Consider establishing policies and practices for social distancing. Social distancing should be implemented if recommended by state and local health authorities. Social distancing means avoiding large gatherings and maintaining distance (approximately 6 feet or 2 meters) from others when possible (e.g., breakrooms and cafeterias). Strategies that business could use include:

Implementing flexible worksites (e.g., telework)

Implementing flexible work hours (e.g., staggered shifts)

Increasing physical space between employees at the worksite

Increasing physical space between employees and customers (e.g., drive through, partitions)

Implementing flexible meeting and travel options (e.g., postpone non-essential meetings or events)

Downsizing operations

Delivering services remotely (e.g. phone, video, or web)

Delivering products through curbside pick-up or delivery

Employers with more than one business location are encouraged to provide local managers with the authority to take appropriate actions outlined in their COVID-19 response plan based on local conditions.

Maintain a healthy work environment

Consider improving the engineering controls using the building ventilation system. This may include some or all of the following activities:

Increase ventilation rates.

Increase the percentage of outdoor air that circulates into the system.

Support respiratory etiquette and hand hygiene Perform routine environmental cleaning and disinfection: for Perform enhanced cleaning and disinfection after persons suspected/confirmed to have COVID-19 have been in the facility: Advise employees before traveling to take additional preparations: Take care when attending meetings and gatherings: employees, customers, and worksite visitors:

Provide tissues and no-touch disposal receptacles.

Provide soap and water in the workplace. If soap and water are not readily available, use alcohol-based hand sanitizer that is at least 60% alcohol. If hands are visibly dirty, soap and water should be chosen over hand sanitizer. Ensure that adequate supplies are maintained.

Place hand sanitizers in multiple locations to encourage hand hygiene.

Place posters that encourage hand hygiene to help stop the spread at the entrance to your workplace and in other workplace areas where they are likely to be seen.

Discourage handshaking - encourage the use of other noncontact methods of greeting.

Direct employees to visit the coughing and sneezing etiquette and clean hands webpage for more information.

Routinely clean and disinfect all frequently touched surfaces in the workplace, such as workstations, keyboards, telephones, handrails, and doorknobs.

If surfaces are dirty, they should be cleaned using a detergent or soap and water prior to disinfection.

For disinfection, most common EPA-registered household disinfectants should be effective. A list of products that are EPA-approved for use against the virus that causes COVID-19 is available herepdf icon external icon . Follow the manufacturer's instructions for all cleaning and disinfection products (e.g., concentration, application method and contact time, etc.).

Discourage workers from using other workers' phones, desks, offices, or other work tools and equipment, when possible. If necessary, clean and disinfect them before and after use.

Provide disposable wipes so that commonly used surfaces (for example, doorknobs, keyboards, remote controls, desks, other work tools and equipment) can be wiped down by employees before each use. To disinfect, use products that meet EPA's criteria for use against SARS-Cov-2external icon , the cause of COVID-19, and are appropriate for the surface.

Check the CDC's Traveler's Health Notices for the latest guidance and recommendations for each country to which you will travel. Specific travel information for travelers going to and returning from countries with travel advisories, and information for aircrew, can be found on the CDC website.

Advise employees to check themselves for symptoms of COVID-19 (i.e., fever, cough, or shortness of breath) before starting travel and notify their supervisor and stay home if they are sick.

Ensure employees who become sick while traveling or on temporary assignment understand that they should notify their supervisor and promptly call a healthcare provider for advice if needed.

If outside the United States, sick employees should follow company policy for obtaining medical care or contact a healthcare provider or overseas medical assistance company to assist them with finding an appropriate healthcare provider in that country. A U.S. consular officer can help locate healthcare services. However, U.S. embassies, consulates, and military facilities do not have the legal authority, capability, and resources to evacuate or give medicines, vaccines, or medical care to private U.S. citizens overseas.

Carefully consider whether travel is necessary.

Consider using videoconferencing or teleconferencing when possible for work-related meetings and gatherings.

Consider canceling, adjusting, or postponing large work-related meetings or gatherings that can only occur in-person.

When videoconferencing or teleconferencing is not possible, hold meetings in open, well-ventilated spaces.

Resources for more information:

CDC Guidance

Other Federal Agencies and Partners

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Coronavirus Disease 2019 (COVID-19) - Interim Guidance for Businesses and Employers

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This interim guidance is based on what is currently known about the coronavirus disease 2019 (COVID-19). COVID-19 is a respiratory illness that can spread from person to person. The outbreak first started in China, but the virus continues to spread internationally and in the United States.

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The SBA provides low-interest disaster loans to help businesses and homeowners recover from declared disasters.

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COVID-19 Information & Resources - Google

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For information purposes only.
Consult your local medical authority for advice.
Source: World Health Organization

Safety and prevention tips

Common searches related to coronavirus (COVID-19)

Data & insights

Insights from Google Trends

Top searches related to coronavirus

Search interest in coronavirus by country

Resources from Google
Training resources for remote working and learning Find remote job opportunities Stay updated on travel advisories and airline policies Distance learning resources for schools Teach from Home tools for teachers Free premium Hangouts Meet capabilities Resources to help manage through uncertainty Training resources for remote working and learning Free premium Hangouts Meet capabilities

Google's response efforts to COVID-19

Google.org is committing $50 million to the global COVID-19 response.
Learn More about additional COVID-19 response efforts from Google.

COVID-19 Solidarity Response Fund

Part of that $50 million pledge is $5M in matching donations to the UN Foundation's COVID-19 Solidarity Response Fund for the World Health Organization.

We'll match $2 for every $1 you donate.

100% of your donation goes to the UN Foundation for the WHO

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COVID-19 Information & Resources - Google

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For information purposes only.Consult your local medical authority for advice.Source: World Health Organization Safety and prevention tips Common searches related to coronavirus (COVID-19) Top searches related to coronavirus Search interest in coronavirus by country Resources from Google Training resources for remote working and learning Find remote job opportunities Stay updated on travel advisories and airline policies Distance learning resources for schools Teach from Home tools for teachers Free premium Hangouts Meet capabilities Resources to help manage through uncertainty Training resources for remote working and learning Free premium Hangouts Meet capabilities Google.org is committing $50 million to the global COVID-19 response.

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On March 8, 2020, Gov. Kate Brown declared a state of emergency to address the spread of COVID-19 in Oregon. The Oregon Health Authority (OHA) serves as the lead agency for the public health response. The Office of Emergency Management (OEM) coordinates and supports state and local recovery efforts through the Emergency Coordination Center (ECC).

Situation in Oregon

﻿As of 3/30/2020, 8:00 a.m. Updated daily.

Positive
606

Negative

12,277

Total persons tested

12,883

Total deaths

16

County

Positive†

Deaths*

Negative
Total 606 16 12277

Age group

Cases

Ever hospitalized‡

Deaths*
Total 606 140 16

Sex

Cases

Deaths*

Female

335

7

Male

266

9

Not available

5

-

Total 606 16

Hospitalized‡

Cases

Yes

140

No

361

Not provided

105

Total 606

Hospital Capacity

Number

Available adult ICU beds

291

Available adult non-ICU beds

2059

Available pediatric beds

203

Available pediatric ICU beds

67

Available ventilators

765

COVID-19 admissions

132

COVID-19 patients on ventilators

39

† County of residence for cases may change as new information becomes available. If changes occur, we will update our counts accordingly.

*For additional details on individuals who have died from COVID-19 in Oregon, please refer to our press releases.

‡ Ever hospitalized, if available.

Notes:

1. Because community transmission is occurring in Oregon and recommendations on social distancing are in place, as of March 17, 2020, we no longer report daily counts of persons under monitoring.

2. Confirmation by CDC of laboratory results from the Oregon State Public Health Laboratory is no longer required; therefore as of March 15, 2020, we no longer note the number of CDC-confirmed cases.

3. Reporting of travel history is not available for cases reported to OHA by commercial laboratories; therefore as of March 15, 2020, we no longer include information about travel history.

4. As of March 26, 2020, OHA is releasing the daily situational status report, which is produced jointly with Oregon Office of Emergency Management It details the overall picture of the COVID-19 response across government agencies.

﻿Updated daily.

Specimens received at OSPHL on 3/29/2020

52

Test results released by OSPHL on 3/29/2020

70

Specimens pending at OSPHL as of 8:30 p.m. 3/29/2020

54

Total persons tested for COVID-19 at OSPHL since 2/28/2020

2,174

Total persons tested at other laboratories 10,709

Total persons tested 12,883

Notes:

As of March 25, 2020, we are including the number of pending test results available from the Oregon State Public Health Laboratory (OSPHL). The OSPHL serves as the first source of testing during an outbreak and as commercial labs come online, OSPHL increases focus on priority testing. Commercial labs have the ability to conduct testing on an industrial scale, but do not report pending results, therefore we only include pending results from OSPHL.

Governor's Orders and OHA Guidance

Guidance​ from OHA

OHA Emergency Rules​

​​​​​​​​

Resources for the Community

Spread facts, not fear.

Oregon is seeing an increase in incidents of discrimination and harassment related to the COVID-19 virus. It is important that all people, businesses, and other organizations act on facts, not bias or xenophobia. Health officials confirm there are no links between COVID-19 infection and a person's race, color, gender, sexual orientation, gender identity, religion, ability, or national origin. COVID-19 can infect anyone who is exposed to it, and anyone can spread COVID-19.

English Español / Spanish اللغة العربية / Arabic简体中文 / Simplified Chinese繁體中文 / Traditional Chinese Lus Hmoob / Hmong Kajin Majol / Marshallese 한국어 / Korean Русский / Russian Af Soomaali / Somali Tiếng Việt / Vietnamese

In consideration of staffing challenges and health concerns due to COVID-19, Governor Kate Brown announced a statewide closure of Oregon K-12 schools from Monday, March 16 through Tuesday, April 28.

OHA knows we are asking a lot of Oregonians in order to protect those who are particularly vulnerable to this virus, and there is a lot of fear and anxiety in our communities. Educators are the heart of our schools, which in turn are the heart of our communities. In the wake of COVID-19's arrival in Oregon, our schools are facing operational and business challenges.

We stand with the governor and our education partners as they make difficult decisions in response to these operational challenges in their school communities.

Resources from Oregon Department of Education

Child Care Resources from Early Learning Division

In partnership with OHA, the Early Learning Division (ELD) has created new tools for addressing concerns in child care around COVID-19.

Resources from Oregon Higher Education

Guidance on Governor Brown's Executive Order 20-07

Resources from Oregon Department of Agriculture

COVID-19 Resources: Pregnancy and Breastfeeding

Situation in the U.S. and Globally

The Centers for Disease Control and Prevention (CDC) leads the U.S. response. The World Health Organization (WHO) guides the global response.

﻿ Information from CDC Information from WHO

Accessibility: Everyone has a right to know about and use Oregon Health Authority (OHA) programs and services. OHA provides free help. Some examples of the free help OHA can provide are: sign language and spoken language interpreters, written materials in other languages, Braille, large print, audio and other formats. If you need help or have questions, please contact Mavel Morales at 1-844-882-7889, 711 TTY, OHA.ADAModifications@dhsoha.state.or.us.

General questions: COVID.19@dhsoha.state.or.us
Website feedback: Health.Webmaster@dhsoha.state.or.us

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Oregon Health Authority | COVID-19 Updates

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On March 8, 2020, Gov. Kate Brown declared a state of emergency to address the spread of COVID-19 in Oregon. The Oregon Health Authority (OHA) serves as the lead agency for the public health response. The Office of Emergency Management (OEM) coordinates and supports state and local recovery efforts through the Emergency Coordination Center (ECC).

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Nearly every Washingtonian will be impacted by the COVID-19 pandemic. It's ok to ask for help. This page includes resources to help your family stay healthy both physically and mentally, find...

Information about unemployment, workers rights, how to advocate for yourself, and protecting yourself from exposure. Find agencies supporting loss of work, employment status changes, and employee...

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| Washington State Coronavirus Response (COVID-19)

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Nearly every Washingtonian will be impacted by the COVID-19 pandemic. It's ok to ask for help. This page includes resources to help your family stay healthy both physically and mentally, find... Information about unemployment, workers rights, how to advocate for yourself, and protecting yourself from exposure.

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The WIC PreScreening Tool assists applicants in determining whether or not they are potentially eligible to receive WIC benefits. This PreScreening Tool is not an application for WIC benefits. To apply for WIC benefits, you must make an appointment at a WIC local agency in the State or area where you live.

The WIC PreScreening Tool takes approximately 15 minutes to complete.

Check to see if you may be eligible for WIC benefits

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The WIC PreScreening Tool assists applicants in determining whether or not they are potentially eligible to receive WIC benefits. This PreScreening Tool is not an application for WIC benefits. To apply for WIC benefits, you must make an appointment at a WIC local agency in the State or area where you live.

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This page is intended to provide GSBA Members and Washington State's small businesses, nonprofits, and other establishments with financial, operational, and healthcare resources regarding the COVID-19 outbreak.

GSBA is currently working to connect with all of our members to hear about how this situation has impacted their business and understand their needs.
If you know of a resource which should be added to this page or if you want to share how COVID-19 has impacted your workplace, please contact us here.
Relief for Businesses & Nonprofits

Support and direct assistance for your workplace - includes small businesses, nonprofits, performers, freelancers, gig workers, and more

CARES Act (Stimulus Bill)

Congress just passed the CARES Act, the third COVID-19 related assistance bill, with about $2 trillion in support funds, with over $376 billion specifically for small businesses, nonprofits, self-employed people, and independent contractors. The Small Business Committees from the House and Senate have provided the following documents to help employers understand how they can access the resources in the CARES Act. The "Fact Sheet" document outlines the specific funding provided for in the CARES Act. The "Guide" document answers many FAQs relating to the various programs funded by the CARES Act.

Please fill out the Economic Impact Survey if you are business owner, nonprofit, freelancer, gig worker, performer located in King, Pierce, or Snohomish counties. This survey provides the opportunity for you to reach out for help and get "back to business" as quickly as possible. It will help identify the extent of the economic impacts, suggest ways to speed recovery, and support requests for state and federal emergency funding.

Small Business Administration (SBA) - Economic Injury Disaster Loans (EIDL), 7(a) loans, express loans, Lender Match, and more. Includes free resources to help complete loan applications like SCORE, Women's Business Center, Small Business Development Centers, Veterans Business Outreach Center, etc.

Seattle Artists Relief Fund - to assist Greater Seattle's creative professionals such as musicians, DJ's, independent chefs, writers, etc. Started by Ijeoma Oluo, administered by LANGSTON Seattle.

Utility Payment Deferment Programs: Seattle City Light & Seattle Public Utilities, Puget Sound Energy

Tax deferral programs: IRS federal income tax, WA Dept of Revenue, Seattle B&O tax

Financial services: many banks and credit unions have options for their clients. Their advice is to call them directly and work out the best plan for your business. Support includes: 1st Security Bank, Bank of America, BECU, First Financial Northwest Bank, JP Morgan Chase, Salal Credit Union, Umpqua Bank, US Bank, Verity Credit Union, Wells Fargo,

City- and Neighborhood-Specific Funds

Important Info for Employers
What to do and where to turn to if you have employees impacted by COVID-19. Many city/county/state departments have delayed payments, waived fees, and offered assistance for any business/nonprofit impacted by COVID-19. Their advice is often to call directly and set up a personal plan that suits your own needs.
Business.wa.gov - one-stop shop for Washington small businesses on support around COVID-19

Resources for Employees
Access to public benefits, protections against discrimination, specific supports, and more
Official Resources
Info and resources from government departments and agencies broader than the specific needs of small businesses, nonprofits, and other establishments.
Community Resources

GSBA Event Updates

GSBA is committed to do all we can to ensure the safety and well-being of our members, staff, and program participants. As a safety precaution due to the coronavirus outbreak, the GSBA office will be closed until further notice. All GSBA staff members are currently working from home and available via email. The following events have been postponed:

Monday, March 9 - Business Empowerment Workshop: Art of the Business Pitch

Tuesday, March 10 - Young Professionals with Pride

Thursday, March 19 - Business Lunch & Learn

Friday, March 20 - Breakfast & Benefits: New Member Orientation

Thursday, March 26 - T Time: Visibility

Monday, March 30 - Seattle Entrepreneurial Women
Tuesday, March 31 - Business Empowerment Workshop: TRANSparent Inclusion
Monday, April 6- GSBA Business Matchmaker
Wednesday, April 22 - New Member & Volunteer Appreciation Cruise
April 24 - 26- Walla Walla Wine Weekend

Please subscribe to our weekly newsletter, follow us on Facebook, and to receive updates about any changes to upcoming GSBA programs. We will also be sharing information and resources to support small businesses as this situation develops.

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This page is intended to provide GSBA Members and Washington State's small businesses, nonprofits, and other establishments with financial, operational, and healthcare resources regarding the COVID-19 outbreak. GSBA is currently working to connect with all of our members to hear about how this situation has impacted their business and understand their needs.

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Track the virus in your area, and get the latest state and county data on hospitalizations, cases, deaths, tests and vaccinations.

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Return to Awake Mind Home Page

This instrument is based on a factor analytic study of five independently developed mindfulness questionnaires. The analysis yielded five factors that appear to represent elements of mindfulness as it is currently conceptualized.

The five facets are observing, describing, acting with awareness, non-judging of inner experience, and non-reactivity to inner experience. (This psychometric instrument was developed by Ruth Baer at the University of Kentucky and is in the public domain. It has been used in many recent mindfulness research studies.)

Please rate each of the following statements using the scale provided. Click the button that best describes your own opinion of what is generally true for you.

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Five Facet Mindfulness Questionnaire On-Line

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Return to Awake Mind Home Page This instrument is based on a factor analytic study of five independently developed mindfulness questionnaires. The analysis yielded five factors that appear to represent elements of mindfulness as it is currently conceptualized. The five facets are observing, describing, acting with awareness, non-judging of inner experience, and non-reactivity to inner experience.

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Return to Awake Mind Home Page

This instrument is based on a factor analytic study of five independently developed mindfulness questionnaires. The analysis yielded five factors that appear to represent elements of mindfulness as it is currently conceptualized.

The five facets are observing, describing, acting with awareness, non-judging of inner experience, and non-reactivity to inner experience. (This psychometric instrument was developed by Ruth Baer at the University of Kentucky and is in the public domain. It has been used in many recent mindfulness research studies.)

Please rate each of the following statements using the scale provided. Click the button that best describes your own opinion of what is generally true for you.

# data[].attributes.attachment_link.title
Five Facet Mindfulness Questionnaire On-Line

# data[].attributes.attachment_link.description
Return to Awake Mind Home Page This instrument is based on a factor analytic study of five independently developed mindfulness questionnaires. The analysis yielded five factors that appear to represent elements of mindfulness as it is currently conceptualized. The five facets are observing, describing, acting with awareness, non-judging of inner experience, and non-reactivity to inner experience.

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, . Psychologists, however, have had more difficulty explaining exactly One class of Extraversion and Happiness
One of the most robust findings in personality psychology is that people who are more extraverted also tend to feel happier. And by "happier", which I'm using as shorthand, what I really mean is "high activation positive affect", e.g., feeling excited, enthusiastic lively energetic and
why it is that people who are more talkative, bold and assertive experience more happiness than their more quiet, reserved and passive counterparts. structural explanations suggests that it's something that extraverts have that explains their greater happiness. Perhaps extraverts just have a higher biologically determined " set-point" or fixed level of happiness. Or maybe extraverts " get more bang for their buck" and experience a stronger positive reaction when good things happen to them.

A second class of explanations proposes a role for social processes. The social activity hypothesis suggests that since extraverts are more sociable, and social activities tend to be enjoyable, their increased Studies employing a "These studies show that the Smillie and colleagues (2015) first surveyed 225 undergraduates and showed that social wellbeing, a measure of the Consistent with previous research, participants who acted extraverted experienced more positive affect than participants who acted introverted, whether they were naturally more extraverted or introverted. But the key contribution of this study was in revealing that This is interesting - but before extrapolating further, we'll need to consider a couple of limitations. First, like all other studies using the counterdispositional behaviour paradigm, participants were university students. This means that further research is needed before it's safe to generalise that quantity of social activity explains why extraverts tend to feel happier. However, a particularly strong study showed that the amount of time spent in various social situations only explained about a sixth of the relationship between extraversion and positive affect. counter-dispositional behaviour" paradigm present a further difficulty for all of these explanations. In these studies, participants are instructed to act extraverted, act introverted or given no acting instructions during a group discussion task. quantity of social experience can't explain this relationship because all participants spent the same amount of time interacting. And structural explanations also can't explain why simply acting like an extravert is enough to increase one's momentary levels of happiness. This suggests that it's the extraverted behaviours - in other words, what extraverts do - that cause increased happiness. A consistent finding that has emerged is that participants report feeling happier after acting extraverted than after acting introverted, and that surprisingly, this applies for dispositional introverts and extraverts alike!

This still doesn't tell us much about how one gets from being recently published study finally sheds some light on the processes that may be at work here. talkative to feeling excited, but a A Social Quality Explanation
quality of one's social life, explained a third of the relationship between extraversion and positive affect. This effect was driven almost entirely by one dimension of social wellbeing, social contribution, a person's sense of having an influence on their social world, or having something valuable to give to society.

Since the correlational design of Study 1 could not establish causality, Smillie et al. ran a counterdispositional behaviour experiment for Study 2. In groups of 3, 81 undergraduate students completed two fun problem-solving tasks. One participant was instructed to act extraverted (i.e., bold, talkative, energetic, active, assertive, adventurous), another was asked to act introverted (i.e., reserved, quiet, lethargic, passive, compliant, unadventurous), and a third participant was given no acting instructions.

So, it looks like social processes do matter - but instead of the mere amount of time spent with others, it's the perceived contribution to discussion tasks explained 70% of the effect of acting extraverted on positive affect. In other words, participants who were acting extraverted felt happier because they felt that they contributed more to the group activities. qualitative aspects of social experience that help to explain the relationship between extraverted behaviours and positive affect. Specifically, this study suggested that one reason why extraverts (and pseudo-extraverts) feel happier is that extraverts feel that they are contributing more strongly to their social world. A follow-up Honours thesis (not yet published) also replicated this effect and found that it extended to another mediator, social power - an individual's perception of their ability to influence others in a social context.
all people feel happier after acting extraverted. And it's especially important considering that the explanation for the extraversion-happiness link may vary depending on age. For example, as Smillie et al. suggest, it's plausible that social coherence, one's ability to make meaning out of social affairs, could have a stronger effect on positive affect for older adults.

A second limitation is that it's unclear whether the difference in positive affect was due to the happiness-Similarly, at the A final few caveats on whether it's a good idea to act more extraverted. First, extraverted behaviours are most reliably linked to activated positive affect states and are Second, how a person feels is of course only one component of wellbeing, and this research does not say much about the effect of extraverted behaviours on, say, one's perceptions of meaning and purpose in life (although it's also worth noting that boosting effects of acting extraverted, or the happiness- lowering effects of acting introverted. After all, it can't be much fun to be asked to be quiet, Positive Psychology Interest Group Journal Club a few weeks ago, some suggested that the instructions for acting introverted were overly-negative. Maybe - but according to the dominant Big Five descriptive framework of personality, these are more-or-less the terms that describe introverted behaviours. Being introverted does not actually mean being "introspective" or "imaginative", although popular misconceptions abound regarding what introversion is. Should Introverts Act More Extraverted? reserved and unrelated to "deactivated" positive affect states (e.g., calm, positive affect does predict an increased sense of meaning). Smillie et al. do show that extraversion predicts positive affect via one's sense of social contribution - an important aspect of wellbeing - but there is clearly plenty of scope for further research to clarify the nature of the relationship between extraversion and wellbeing more broadly construed. relaxed, at-ease); states that some people may see as more long-lasting, valuable end-goals. lethargic while being dominated by an extraverted participant and another participant who tends to act quite extraverted in this context anyway. Yet, there seems to be a lack of research on how acting extraverted makes other people feel (" affective presence"), compared to how it makes the extravert (or pseudo-extravert) themselves feel.

Third, whereas there's been no evidence to suggest that acting extraverted incurs costs for introverts (interestingly, extraverts do seem to suffer cognitive costs after acting introverted), no research has investigated the long-term effects of counterdispositional behaviour, as it's possible that extended periods of acting extraverted could be more challenging for introverts. Brian Little has a lot more to say about the need for "restorative niches" after acting out of character.

Taken together, however, Smillie et al. contribute a valuable new perspective on why it feels good to be or act like an extravert. And despite the need for further investigation with broader samples, in everyday life, and across longer periods of time, I'm excited by the optimistic view that these studies present. It looks like happiness isn't dependent on a fixed property specific to dispositional extraverts, but is something that anyone can experience more of - and that it might be as simple as strategically choosing to act more extraverted when the situation calls for it.

-- Smillie, L., Wilt, J., Kabbani, R., Garratt, C., & Revelle, W. (2015). Quality of Social Experience Explains the Relation Between Extraversion and Positive Affect. Emotion DOI:
10.1037/emo0000047

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A New Explanation for Why Extraverts Are Happier

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Psychologists, however, have had more difficulty explaining exactly One class of Extraversion and Happiness One of the most robust findings in personality psychology is that people who are more extraverted also tend to feel happier.

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Being an introvert isn't a "good thing" or a "bad thing." It's a personality type, not a value judgment.

Yet introverts are likely to feel out of place at work. The atmosphere can be particularly uncomfortable if they're in a traditional corporate environment that rewards extraverts who thrive in open-space offices, speak their minds regularly (and often loudly), and network as if they were born to the task.

It's not only a matter of comfort. Traditional companies and their managers often celebrate extraverted employees, because they regularly contribute ideas (or at least speak up) during meetings, and are more likely to exhibit a "take-charge" attitude in the workplace.

Moreover, extraverts are rewarded for their personalities. A comprehensive study by Truity Psychometrics LLC has found that, on average, introverts make substantially less money and are asked to supervise fewer employees than extraverts. They're also less likely to be satisfied at work.

Those are obvious reasons for introverts to feel like second-class citizens in the workplace - but they shouldn't. The latest manual that accompanies the highly valued MBTI personality evaluation test reports that the population is split 50-50 between extraverts and introverts.

In other words, half the employees at any large company are introverted; they're simply dominated by their extraverted co-workers and a culture that encourages and rewards that outward behavior.

How does an introvert learn to speak up at work?

The answer can be found in the practice of mindfulness.
Introverts, Confidence, and Mindfulness
There are many reasons why people are introverted. Some of the reasons are innate and stem from the way introverts' brains work, while others are related to the environments and interactions introverts experience throughout their lives.

One thing that introverts tend to have in common is that they do not speak up at work.

Some feel they have nothing valuable to offer, some fear that they'll expose a lack of knowledge or sophistication, and many others simply believe that they're not as (good, smart, experienced, important, worthy - choose one) as their fellow employees and managers who are extraverted.

Those feelings can be summed up in three words: lack of confidence. And that's where mindfulness comes into play.

Mindfulness focuses on living in the moment instead of being burdened by the past or overly worried about the future. Through mindfulness meditation and other techniques, an individual learns - among many other things - to put aside negative experiences that have acted as barriers to self-awareness and self-actualization.

The connection should be obvious. Living fully in the present, instead of dwelling on the past, allows a person to realistically appreciate their abilities and potential contributions to shared projects at work. That self-awareness (without excessive introspection) is what allows an introvert to develop confidence - and to speak up when appropriate.
Fear, Confrontation, and Mindfulness
Fear ensured the survival of our species, enabling our ancestors to properly react to serious threats ranging from dangerous animals to invading armies.

Everyday concerns in the 21st century are usually far more benign, yet our brains are still hardwired to anticipate threats and feel fear. Many situations that motivate extraverts, like meeting new people or speaking in front of a group of superiors, can seem quite threatening to introverts. Some even become paralyzed with fear.

A common response to fear is flight. Introverts who feel fear at work don't normally grab their purses and run for the elevator, but they're likely to withdraw from situations they perceive as threatening, and avoid situations where confrontation, criticism, or embarrassment are viewed as distinct possibilities.

Making small talk at a company-wide meeting or speaking up in front of the boss can be a petrifying experience.

Once again, mindfulness can help put many of these issues to rest. Mindful meditation can also play a large part.

A mindful individual's mental clarity and self-control can easily step in and help out. Regular mindful meditation practice can become a powerful tool in the face of fear. Chatting with a stranger at an industry conference, or suggesting a new product at a meeting with superiors, becomes a specific challenge which can be overcome - and not a scary situation to avoid at any cost.
Living in the Moment
Mindfulness allows us to shed painful memories of past failures - as well as fears of embarrassment or exposure. You can stop "thinking so hard," and allow your knowledge and abilities to simply take over. There's nothing wrong with being introverted or extraverted, but your best chance at standing out at work is through mindfulness practice.

It's a more comfortable - and healthier - way to navigate the corporate landscape.
There's lots more where that came from: Sign up here for my newsletter.

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Being an introvert isn't a "good thing" or a "bad thing." It's a personality type, not a value judgment. Yet introverts are likely to feel out of place at work. The atmosphere can be particularly uncomfortable if they're in a traditional corporate environment that rewards extraverts who thrive in open-space offices, speak their minds regularly (and often loudly), and network as if they were born to the task.

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Everybody loves creativity. Organizations spend large sums of money on programs designed to "unleash creativity"-- from Edward de Bono's lateral thinking program to Tony Buzan's mind-mapping techniques, to Scott Isaksen and Donald Treffinger's creative problem solving Process (CPS). But can creativity really be trained?

In one of the biggest reviews on this topic, Ginamarie Scott and colleagues assessed the effectiveness of 156 training programs and found that 11 forms of training did have some value. The techniques that were particularly effective were those that targeted the cognitive processes underlying creativity, such as idea generation. Likewise, two other studies [see here and here] found that training ideational skills had a positive impact on creative thinking, both alone and in a group brainstorming context.

Another form of creativity training that has shown some positive effects is " relaxation training", which includes exercises such as stretching and breathing. Relaxation training appears to increase creativity by reducing anxiety and freeing the mind from negative thinking. This form of training is related to mindfulness meditation. Indeed, a recent review of the literature found a moderate relationship between creativity and mindfulness-- with the relationship strongest for "open-monitoring" meditation (try this form of meditation here).

In a brand new study, Peter O'Conner and colleagues randomly assigned participants to engage in either (a) ideational-skills training, (b) relaxation-training, or (c) a control condition that involved watching videos about "emotional intelligence".

In the ideational-skill training condition, participants watched an 8-minute video where they learned examples of idea-generating techniques. These techniques included brainstorming ("allowing all ideas to be considered without criticism"), forced relation ("utilizing items in one's immediate surroundings to generate or develop ideas"), checklist ("considering a checklist of three terms - "maximize", "minimize", and "rearrange" - to enhance components of an existing idea, by asking oneself "Can an idea be improved by enlarging, rearranging, or reducing any of its components?""), and catalogue (" referencing a catalogue to stimulate or expand ideas").

In the relaxation-training condition, participants watched a 10-minute video with the same format (featuring the same instructor using slides). However, in this video, the instructors focused on activities designed to relax participants, including meditation, stretching, breathing exercises to breath deeply and slowly, and enhancing awareness of thoughts and feelings (e.g., stress, anxiety) that might inhibit creative performance. The instructor also trained participants in positive self-talk, goal-setting, and visualization to further help them in overcoming stress, anxiety, and worry. These techniques were taken from previously published studies (see here here, and here).

Finally, they tested everyone's creativity by having participants generate as many unusual uses for common objects (e.g., newspaper, paperclip) as possible in two minutes, and having them engage in creative problem solving by recombining common ideas according to unfamiliar patterns. For instance, in one task participants were presented with 10 groups of 10 words and were asked to create as many meaningful grammatical sentences as possible in 10 minutes.
What did they find?
First, they found that both ideation-training and relaxation-training showed increases in creative thinking. Second, they found that two personality traits in particular were related to creative thinking: extraversion and openness to experience. This is consistent with prior research showing that both of these traits are linked to creative thinking. Extraverts are outgoing, excitement-seeking, assertive, enthusiastic, talkative, energetic, and active. Recent research shows that the common theme is " reward sensitivity"-- extraverts tend to be fueled by dopamine, particularly through the reward circuits of the brain that cause them to feel energized by the possibility of " appetitive rewards" in the environment, such as social status, money, and power.

People who are high in openness to experience are imaginative, curious, insightful, artistic, clever, and inventive. In my own research, I've found that openness to experience is the single best predictor of creative achievement. However, we found that the effect of extraversion on lifelong creative achievement wasn't as high. I think that extraversion is more linked to on-the-spot creative thinking than lifelong creative achievement because extraverts are energized by the possibility of achieving external rewards from doing well on a creativity task. The dopamine of extraverts tends to make them more likely to put forth effort when extrinsic motivation is high. But in the long-term, creativity requires many years of personally meaningful work that is more intrinsically motivated.

Which leads to another fascinating finding from their study: while ideational-skills training benefited extraverts more than introverts, relaxation training benefited introverts more than extraverts.

Taken together, these results suggest that creativity can be trained (at least in the short-term), and that personality matters in terms of the effectiveness of the training. Extraverts are probably better suited to ideational-training because this form of training is more stimulating and demands fast thinking. The increased arousal that is likely to result from this form of training is likely to benefit extraverts more than introverts. For instance, on a new test of introversion I developed with the Quiet Revolution team, the two main dimensions of introversion are (a) preference for quiet and reduced stimulation over excitement, and (b) preference for deep, deliberate thinking over quick thinking. In contrast, relaxation-training is more likely to benefit introverts more than extraverts because it helps reduce arousal.

There are obvious practical implications here for organizations that wish to increase creativity in their employees. Brief, online programs can save a lot of costs than bringing in an expensive consultant. Also, as the researchers note, while improvements may only be short-term, short-term improvements can still be valuable. A 10-minute training program may only improve creative performance for the duration of the day, but if implemented at the start of a planning-day, short-term improvements in creativity can still translate into long-term organizational benefits.

To be sure, we still have a long way to go in understanding which training programs increase creativity and why. Also, I believe we need to go beyond measuring creativity in such a brief, on-the-spot, high-pressure way. Many people aren't at their creative best when they are forced to "Be creative!" on the spot, and will be far more creative when given the opportunity to think deeply and reflectively in the comfort of quiet. Nevertheless, this is an important line of research, and at least there is tentative evidence that creativity can be trained, that there are at least two forms of training that are particularly relevant to creative performance (ideation and relaxation), and that personality matters in moderating the effects of creativity training.

© 2016 Scott Barry Kaufman, All Rights Reserved

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Relaxation Benefits Introverts More Than Extraverts in Boosting Creativity

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Everybody loves creativity. Organizations spend large sums of money on programs designed to "unleash creativity"-- from Edward de Bono's lateral thinking program to Tony Buzan's mind-mapping techniques, to Scott Isaksen and Donald Treffinger's creative problem solving Process (CPS). But can creativity really be trained?

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Using video telehealth appointments, you can connect with your VA care teams from anywhere, without traveling and exposing yourself, your family and other Veterans to COVID-19.

VA Video Connect enables you and your VA care team to conduct secure, real-time video visits using the camera on your phone, computer or tablet.

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Coronavirus resources, Virtual appeals hearings, National Vietnam War Veterans Day is March 29

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Using video telehealth appointments, you can connect with your VA care teams from anywhere, without traveling and exposing yourself, your family and other Veterans to COVID-19. VA Video Connect enables you and your VA care team to conduct secure, real-time video visits using the camera on your phone, computer or tablet.

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By Maggie Norris, Donna Rae Siegfried

The anatomical regions (shown) compartmentalize the human body. Just like on a map, a region refers to a certain area. The body is divided into two major portions: axial and appendicular.

The axial body runs right down the center (axis) and consists of everything except the limbs, meaning the head, neck, thorax (chest and back), abdomen, and pelvis. The appendicular body consists of appendages, otherwise known as upper and lower extremities (which you call arms and legs).

Here's a list of the axial body's main regions:

Here's a list of the appendicular body's main regions:

About the Book Author

Erin Odya is an anatomy and physiology teacher at Carmel High School in Carmel, Indiana, one of Indiana's top schools. Maggie Norris is a freelance science writer living in the San Francisco Bay Area.

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The Anatomical Regions of the Body - dummies

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The anatomical regions (shown) compartmentalize the human body. Just like on a map, a region refers to a certain area. The body is divided into two major portions: axial and appendicular. The axial body runs right down the center (axis) and consists of everything except the limbs, meaning the head, neck, thorax (chest and back), ...

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Harvard Health Publishing: Harvard Medical School

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Harvard Health Publishing: Harvard Medical School

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We know a lot more about COVD-19 than we did in 2020 and yet we're still learning. We will continue to provide important updates. You can search previous questions and answers as well as read related blog posts and reference our COVID glossary.

Reliable resources

aerosols: infectious viral particles that can float or drift around in the air. Aerosols are emitted by a person infected with coronavirus - even one with no symptoms - when they talk, breathe, cough, or sneeze. Another person can breathe in these aerosols and become infected with the virus. Aerosolized coronavirus can remain in the air for up to three hours. A mask can help prevent that spread.

antibodies: proteins made by the immune system to fight infections. If the antibodies later encounter the same infection, they help prevent illness by recognizing the microbe and preventing it from entering cells.

antibody test: also known as a serologic test, an antibody test is a blood test that looks for antibodies created by your immune system. An antibody test can indicate if you were previously infected but is not a reliable way to determine whether you are currently infected.

antigen: a substance displayed on the surface of a microbe that stimulates the body to produce an immune response.

antigen test: a diagnostic test that detects specific proteins on the surface of the virus.

booster: an additional dose of COVID-19 vaccine given after protection from the initial vaccine series begins to decline. A homologous booster is the same brand as the initial vaccine; a heterologous booster is a different brand than the initial vaccine.

community spread (community transmission): is said to have occurred when people have been infected without any knowledge of contact with someone who has the same infection

contact tracing: a process that begins with identifying everyone a person diagnosed with a given illness (in this case COVID-19) has been in contact with since they became contagious. The contacts are notified that they are at risk, and may include those who share the person's home, as well as people who were in the same place around the same time as the person with COVID-19 - a school, office, restaurant, or doctor's office, for example. Contacts may be quarantined or asked to isolate themselves if they start to experience symptoms, and are more likely to be tested for coronavirus if they begin to experience symptoms.

containment: refers to limiting the spread of an illness. Because no vaccines exist to prevent COVID-19 and no specific therapies exist to treat it, containment is done using public health interventions. These may include identifying and isolating those who are ill, and tracking down anyone they have had contact with and possibly placing them under quarantine.

diagnostic test: indicates whether you are currently infected with COVID-19. A sample is collected using a swab of your nose, your nose and throat, or your saliva. The sample is then checked for the virus's genetic material (PCR test) or for specific viral proteins (antigen test).

effectiveness: indicates the benefit of a vaccine in the real world.

efficacy: indicates the benefit of a vaccine compared to a placebo in the context of a clinical trial.

epidemic: a disease outbreak in a community or region

flattening the curve: refers to the epidemic curve, a statistical chart used to visualize the number of new cases over a given period of time during a disease outbreak. Flattening the curve is shorthand for implementing mitigation strategies to slow things down, so that fewer new cases develop over a longer period of time. This increases the chances that hospitals and other healthcare facilities will be equipped to handle any influx of patients.

false negative: a test result that mistakenly indicates you are not infected when you are.

false positive: a test result that mistakenly indicates you are infected when you are not.

herd immunity: herd immunity occurs when enough people become immune to a disease to make its spread unlikely. As a result, the entire community is protected, even those who are not themselves immune. Herd immunity is usually achieved through vaccination, but it can also occur through natural infection.

immunity: partial or complete protection from a specific infection because a person has either had that infection previously or has been vaccinated against it.

incubation period: the period of time between exposure to an infection and when symptoms begin

isolation: the separation of people with a contagious disease from people who are not sick

long-haulers: people who have not fully recovered from COVID-19 weeks or even months after first experiencing symptoms.

mitigation: refers to steps taken to limit the impact of an illness. Because no vaccines exist to prevent COVID-19 and no specific therapies exist to treat it, mitigation strategies may include frequent and thorough handwashing, not touching your face, staying away from people who are sick, social distancing, avoiding large gatherings, and regularly cleaning frequently touched surfaces and objects at home, in schools, at work, and in other settings.

mutation: A change to a virus's genetic material that occurs when the virus is replicating. The change is passed on to future generations of the virus.

monoclonal antibodies: laboratory-produced proteins designed to mimic naturally occurring antibodies that target specific antigens on viruses, bacteria, and cancer cells.

mRNA: short for messenger ribonucleic acid, mRNA is genetic material that contains instructions for making proteins.

mRNA vaccines: mRNA vaccines for COVID-19 contain synthetic mRNA. Inside the body, the mRNA enters human cells and instructs them to produce the "spike" protein found on the surface of the COVID-19 virus. The body recognizes the spike protein as an invader, and produces antibodies against it. If the antibodies later encounter the actual virus, they are ready to recognize and destroy it before it causes illness.

pandemic: a disease outbreak affecting large populations or a whole region, country, or continent

physical distancing: also called social distancing, refers to actions taken to stop or slow down the spread of a contagious disease. For an individual, it refers to maintaining enough physical distance (a minimum of six feet) between yourself and another person to reduce the risk of breathing in droplets or aerosols that are produced when an infected person breathes, talks, coughs, or sneezes.

polymerase chain reaction (PCR) test: a diagnostic test that detects the presence of the virus's genetic material.

post-viral syndrome: the constellation of symptoms experienced by COVID-19 long haulers. These symptoms may include fatigue, brain fog, shortness of breath, chills, body ache, headache, joint pain, chest pain, cough, and lingering loss of taste or smell.

presumptive positive test result: a positive test for the virus that causes COVID-19, performed by a local or state health laboratory, is considered "presumptive" until the result is confirmed by the CDC. While awaiting confirmation, people with a presumptive positive test result will be considered to be infected.

quarantine: separates and restricts the movement of people who have a contagious disease, have symptoms that are consistent with the disease, or were exposed to a contagious disease, to see if they become sick

SARS-CoV-2: short for severe acute respiratory syndrome coronavirus 2, SARS-CoV-2 is the official name for the virus responsible for COVID-19.

social distancing: also called physical distancing, refers to actions taken to stop or slow down the spread of a contagious disease. For an individual, it refers to maintaining enough physical distance (a minimum of six feet) between yourself and another person to reduce the risk of breathing in droplets or aerosols that are produced when an infected person breathes, talks, coughs, or sneezes. It is possible to safely maintain social connections while social distancing, through phone calls, video chats, and social media platforms.

spike protein: a protein on the surface of the SARS-CoV-2 virus that binds to and allows the virus to enter human cells.

variant: A virus containing one or more mutations that make it different from a version of the virus that has been circulating.

variants of concern: SARS-CoV-2 viruses with mutations that make them more likely to spread, evade vaccines, or make people sicker.

vector: a harmless capsule. In a vaccine, a vector may be used to deliver a substance into the body in order to prompt an immune response.

virus: a virus is the smallest of infectious microbes, smaller than bacteria or fungi. A virus consists of a small piece of genetic material (DNA or RNA) surrounded by a protein shell. Viruses cannot survive without a living cell in which to reproduce. Once a virus enters a living cell (the host cell) and takes over a cell's inner workings, the cell cannot carry out its normal life-sustaining tasks. The host cell becomes a virus manufacturing plant, making viral parts that then reassemble into whole viruses and go on to infect other cells. Eventually, the host cell dies.
Image: Naeblys/Getty Images
Questions?
Harvard Health Publishing Coronavirus Resource Center Experts
The Harvard Health Publishing team would like to acknowledge the Harvard Medical School experts who have contributed their time and expertise: Steven A. Adelman, MD; Ashwini Bapat, MD; Nicole Baumer, MD, MEd; Suzanne Bertisch, MD, MPH; Joseph R. Betancourt, MD, MPH; Barry R. Bloom, PhD; Emeric Bojarski, MD; Melissa Brodrick, MEd; Andrew E. Budson, MD; Stephanie Collier, MD, MPH; Todd Ellerin, MD; Huma Farid, MD; Elizabeth Pegg Frates, MD; Robert Gabbay, MD, PhD, FACP; Alan Geller, MPH, RN; Ellen S. Glazer, LICSW; David C. Grabowski, PhD; Shelly Greenfield, MD, MPH; Ilona T. Goldfarb, MD, MPH; Peter Grinspoon, MD; Abraar Karan, MD, MPH, DTM&H; Sabra L. Katz-Wise, PhD; Alyson Kelley-Hedgepeth, MD; Anthony Komaroff, MD; Douglas Krakower, MD; Debi LaPlante, PhD; Howard E. LeWine, MD; Dara K. Lee Lewis, MD; Sharon Levy, MD, MPH; Kristina Liu, MD, MHS; Julia Marcus, PhD, MPH; Luana Marques, PhD; Claire McCarthy, MD; Chris McDougle, MD; Babar Memon, MD, MSc; Kristin Moffitt, MD; Uma Naidoo, MD; Janelle Nassim, MD; Justin Neiman; Vikram Patel, MBBS, PhD; Edward Phillips, MD; Shiv Pillai, PhD, MBBS; John Ross, MD, FIDSA; Lee H. Schwamm, MD; Catherine Ullman Shade, PhD, MEd; Howard J. Shaffer, PhD, CAS; Roger Shapiro, MD, MPH; John Sharp, MD; Amy C. Sherman, MD; Robert H. Shmerling, MD; Jacqueline Sperling, PhD; Fatima Cody Stanford, MD, MPH, MPA, FAAP, FACP, FTOS; Dawn Sugarman, PhD; Monique Tello, MD, MPH; Robyn Thom, MD; Karen Turner, OTR/L; Rochelle Wallensky, MD, MPH; Janice Ware, PhD; Bobbi Wegner, PsyD; Scott Weiner, MD; Sarah Wilkie, MS; Anna R. Wolfson, MD.

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Coronavirus Resource Center - Harvard Health

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As coronavirus continues to spread, many questions and answers We know a lot more about COVD-19 than we did in 2020 and yet we're still learning. We will continue to provide important updates. You can search previous questions and answers as well as read related blog posts and reference our ...

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COVID - Coronavirus Statistics - Worldometer

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Daily and weekly updated statistics tracking the number of COVID-19 cases, recovered, and deaths. Historical data with cumulative charts, graphs, and updates.

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Interactive 3D Anatomy - Disease Platform

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The BioDigital Human is the first cloud based virtual model of the human body - 3D human anatomy, disease and treatment, all in interactive 3D.

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Oregon Veterinary Emergency Response Team & Veterinary Disaster Response Team | Oregon Veterinary Medical Association

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AHID also initiated a Veterinary Disaster Response Team to assist local emergency managers care for animals in shelters that may have been injured or become stray due to a disaster. The Veterinary Response Team is made up of a select group of veterinarians and animal health technicians who are also members of OVERT.

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The Governor of each state has designated a State Emergency Response Commission (SERC) that is responsible for implementing EPCRA provisions within its state.

To find the SERC contacts in a particular state, click on the state name:

The following links exit the site Exit

Alabama SERC Contacts

Emergency Management Webpage: https://ema.alabama.gov
Alabama Department of Emergency Management: https://www.adem.state.al.us/MoreInfo/saraIII.cnt

Alaska SERC Contacts

American Samoa SERC Contacts

Arizona SERC Contacts

Arkansas SERC Contacts

California SERC Contacts

Phone: 916-845-8751
Email: Thomas Campbell (thomas.e.campbell@caloes.ca.gov)
SERC Webpage: http://www.caloes.ca.gov/FireRescueSite/Pages/State-Emergency-Response-Commission.aspx
LEPC Webpage: http://www.caloes.ca.gov/FireRescueSite/Pages/HazMat-Business-Plan.aspx

Colorado SERC Contacts

Phone: 303-692-3023
Email: Greg Stasinos (greg.stasinos@state.co.us)

Connecticut SERC Contacts

Gerard P. Goudreau, SERC Chairman
State Emergency Response Commission
79 Elm Street - 4th Floor
Hartford, CT 06106

Phone: 203-589-6585
Email: Gerard P. Goudreau (goudreauassociates@aol.com)

Delaware SERC Contacts

Robert Coupe, SERC Chair / Cabinet Secretary
Delaware's Department of Safety & Homeland Security
SLC: D610
P. O. Box 818
Dover, DE 19903
Phone: 302-744-2677
Fax: 302-739-4874
Email: Robert Coupe (rob.coupe@state.de.us)

A. J. Schall Jr., DEMA Director
Delaware Emergency Management Agency
165 Brick Store Landing Road
Smyrna, DE 19977
Phone: 302-659-2200
Fax: 302-659-6855
Email: A. J. Schall Jr. (a.j.schall@state.de.us)

Renee Hupp
Delaware Emergency Management Agency
165 Brick Store Landing Road
Smyrna, DE 19977
Phone: 302-659-2212
Fax: 302-659-6855
Email: Renee Hupp (renee.hupp@state.de.us)

Website: http://www.dnrec.delaware.gov/SERC/Pages/default.aspx

District of Columbia SERC Contacts

Patricia White, Assistant Director, Plans and Preparedness Directorate
Phone: 202-481-3055
Fax: 202-715-7288
Email: Patricia White (Patrice.white@dc.gov)
Website: http://hsema.dc.gov/

Florida SERC Contacts

Georgia SERC Contacts

Anita Mathis, Georgia LEPC/HMEP Coordinator
Emergency Management and Homeland Security Agency
1000 Indian Springs Drive
Forsyth, Georgia 31029
Phone: 470-225-3829
Email: Anita Mathis (anita.mathis@gema.ga.gov)
Webpage: https://www.gema.ga.gov

Guam SERC Contacts

Phone: 671 3004788 office
Phone: 671 4823669 mobile
Email: Walter S. Leon Guerrero (walter.leonguerrero@epa.guam.gov)
Webpage: http://epa.guam.gov/
Facebook: https://www.facebook.com/guamepa
Twitter: https://twitter.com/GuamEPA

Hawaii SERC Chair

Idaho SERC Contacts

Illinois SERC Contacts

Lori Canterbury
EPCRA Reporting
BRS Hazardous Materials Unit
Phone: 217-558-0559
Fax: 217-557-2145
Email: Lori Canterbury (EMA.Tier2Mgr@illinois.gov)

Indiana SERC Contacts

Iowa SERC Contacts

Julie Waltz, Chair
Private Industry Representative

Phone: 515-725-3231
Email: Tracey Epps (tracey.epps@iowa.gov)

Kansas SERC Contacts

Kentucky SERC Contacts

Email: Michael E. Dossett (michael.e.dossett.nfg@mail.mil)

Phone: 502-607-1682
Email: Sharon D. Goode (sharon.d.goode.nfg@mail.mil)

Tiffany R. Sizemore, SERC Program Manager
101 Minuteman Parkway, Suite 210A
Frankfort, KY 40601

Phone: 502-607-5770
Email: Tiffany R. Sizemore (tiffany.r.sizemore.nfg@mail.mil)

Webpage: https://kyem.ky.gov/Who%20We%20Are/Pages/KERC.aspx
Emergency Management Webpage: https://kyem.ky.gov/Pages/default.aspx

Louisiana SERC Contacts

Phone: 225-925-6113
Webpage: http://www.dps.louisiana.gov/lcnweb.nsf

Maine SERC Contacts

Phone: 207-624-4400
Email: Suzanne Krauss (Suzanne.krauss@maine.gov)

Maryland SERC Contacts
Governor's Emergency Management Advisory Council constitutes Maryland SERC.
Massachusetts SERC Contacts

Michigan SERC Contacts

Minnesota SERC Contacts

Mississippi SERC Contacts

Phone: 601-933-6362
Fax: 601-933-6815
Email: David Shaw (dshaw@mema.ms.gov)
Webpage: http://www.msema.org/library-forms/tier-two-instructions/
Emergency Management Webpage: http://www.msema.org

Missouri SERC Contacts

Phone: 573-526-9237
Email: Paul Kirchhoff (Paul.Kirchhoff@sema.dps.mo.gov)

Montana SERC Contacts

Phone: 406-444-7305
Email: Bob Habeck (bhabeck@mt.gov)

Phone: 406-324-4777
Email: Delila Bruno (dbruno@mt.gov)

Nebraska SERC Contacts

Nevada SERC Contacts

Christina Wilson, Nevada SERC Coordinator
107 Jacobsen Way
Carson City, NV 89711

New Hampshire SERC Contacts

SERC Chair
Chris Sununu
Governor of New Hampshire/SERC Chair

Care of
Perry Plummer
New Hampshire Department of Safety
Fire Safety & Emergency Management
Bureau of Emergency Management
33 Hazen Drive
Concord, NH 03305

New Jersey SERC Contacts

Robert Van Fossen, SERC Co-Chair
Office of Emergency Management
440 East State Street
3 rd floor
Trenton, NJ, 08625

Phone: 609-633-2168
Email: Robert Van Fossen (robert.vanfossen@dep.nj.gov)

New Mexico SERC Contacts

New York SERC Contacts

North Carolina SERC Contacts

Adam Ryan, SERC/EPCRA Coordinator
North Carolina Department of Public Safety
Division of Emergency Management
1636 Gold Star Drive
Raleigh, North Carolina 27607

Phone: 919-436-2746
Email: epcra@ncdps.gov
Webpage: https://www.ncdps.gov/About-DPS/Boards-Commissions/State-Emergency-Response-Commission

North Dakota SERC Contacts

Cody Shulz, Chairman
North Dakota Department of Emergency Services - Division of Homeland Security
P.O. 5511
Bismarck, ND 58506-5511

Phone: 701-328-8100
Fax: 701-328-8181
Email: nddes@nd.gov
Webpage: https://www.nd.gov/des/planning/haz-chem/default.asp

Northern Mariana Islands SERC Contacts

Ohio SERC Contacts

Ohio SERC Co-Chairs:
Craig Butler, Director
Ohio Environmental Protection Agency
50 West Town Street
Columbus, OH 43215

Phone: 614-644-2782
Email: Craig Butler (craig.butler@epa.ohio.gov)

Email: John Born (jborn@dps.ohio.gov)
Program Contacts:
Phone: 614-889-7152
Email: Russ Decker (rjdecker@dps.ohio.gov)

Oklahoma SERC Contacts

Oregon SERC Contacts

Phone: 503-934-8030
Email: Michael Heffner (michael.heffner@state.or.us)

Pennsylvania SERC Contacts

Puerto Rico SERC Contacts

Rhode Island SERC Contacts

Paul D'Abbraccio, SERC Coordinator
State Radiological Safety Officer
Rhode Island Emergency Management Agency

Phone: 401-751-1516
Email: Paul D'Abbraccio (paul.dabbraccio@ema.ri.gov)

South Carolina SERC Contacts

Kim Stenson
Director, SC Emergency Management Division
Chair, SC State Emergency Response Commission
2779 Fish Hatchery Road
West Columbia, SC 29172

Phone: 803-737-8500
Webpage: http://www.scemd.org/planandprepare/disasters/hazardous-materials
Emergency Management Webpage: http://www.scemd.org

South Dakota SERC Contacts

Phone: 605-773-3296 or 800-433-2288
Phone (after hours): 605-773-3231
Fax: 605-773-6035
Email: Trish Kindt (Trish.Kindt@state.sd.us)
Webpage: https://dps.sd.gov/emergency-services/emergency-management
EPCRA Webpage: http://denr.sd.gov/des/gw/SARATitleIII/Sara_Title_III.aspx

Tennessee SERC Contacts

Phone: 615-741-2986
Email: EPCRA.TEMA@tn.gov
Webpage: https://www.tn.gov/tema/

Texas SERC Contacts

Contact: Bryan Becknel, Tech Hazards Unit Supervisor, Preparedness
Texas Department of Public Safety
Texas Division of Emergency Management
Phone: 512-424-5237
Email: Bryan Becknel (bryan.becknel@dps.texas.gov)
Webpage: https://www.tceq.texas.gov/response/serc.html

Utah SERC Contacts

Phone: 801-536-4400
Email: Alan Matheson (amatheson@utah.gov)

Phone: 801-536-4100
Email: Brent Everett (beverett@utah.gov)

Phone: 801-538-3400
Email: Kris Hamlet (krishamlet@utah.gov)

Vermont SERC Contacts

United States Virgin Islands SERC Contacts

Phone: 340-774-3320
Website: http://dpnr.vi.gov/

Virginia SERC Contacts

Mailing address:
P.O. Box 1105
Richmond, VA 23218

Phone: 804-698-4145
Email: va-epcra@deq.virginia.gov
Web: http://www.deq.virginia.gov/Programs/Air/AirQualityPlanningEmissions/SARATitleIII.aspx

Washington SERC Contacts

Chief William "Bill" Whealan, SERC Chair
Email: William "Bill" Whealan (wwhealan@bcfd4.org)

Phone: 253-345-9010
Email: Susan Forsythe (Susan.Forsythe@mil.wa.gov)

Website: https://www.ecology.wa.gov/Regulations-Permits/Reporting-requirements/Emergency-Planning-Community-Right-to-Know-Act/State-Emergency-Response-Commission

West Virginia SERC Contacts

Wisconsin SERC Contacts

For packages use:
2400 Wright Street, Room 213
Madison, Wisconsin 53704

Wyoming SERC Contacts

Wyoming Office of Homeland Security Staff Support to the SERC
Rick Lopez (ricklopez@wyo.gov)

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State Emergency Response Commissions Contacts | US EPA

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The Governor of each state has designated a State Emergency Response Commission (SERC) that is responsible for implementing EPCRA provisions within its state. To find the SERC contacts in a particular state, click on the state name: The following links exit the site Exit Emergency Management Webpage: https://ema.alabama.gov Alabama Department of Emergency Management: https://www.adem.state.al.us/MoreInfo/saraIII.cnt Phone: 916-845-8751 Email: Thomas Campbell (thomas.e.campbell@caloes.ca.gov) SERC Webpage: http://www.caloes.ca.gov/FireRescueSite/Pages/State-Emergency-Response-Commission.aspx LEPC Webpage: http://www.caloes.ca.gov/FireRescueSite/Pages/HazMat-Business-Plan.aspx Phone: 303-692-3023 Email: Greg Stasinos (greg.stasinos@state.co.us) Gerard P.

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State Emergency Response Commission
ORS 453.520 designates the State Fire Marshal as the State Emergency Response Commission (SERC) as required by the Emergency Planning and Community Right to Know Act of 1986 (42 U.S.C. 11001 et seq.).

The Oregon SERC is responsible for:

Designating Emergency Planning Districts (EPDs) throughout Oregon,

Establishing local emergency planning committees (LEPCs) within the EPDs,

Appointing membership to the LEPCs,

Providing review and comment on local community emergency response plans.

The Office of State Fire Marshal has adopted OAR 837 Division 095. These rules designate emergency planning districts as required by the Emergency Planning and Community Right to Know Act (EPCRA) of 1986 (42 U.S.C. Chapter 116, Section 11001 et seq.); and Establishes State Emergency Response Commission Executive Committee and Emergency Planning Districts.

Oregon Administrative Rules 837-095 established the SERC Executive Committee and designated Emergency Planning Districts and Local Emergency Planning Committees. In Oregon, statute identifies the State Fire Marshal as the SERC. The SERC Executive Committee was established to provide input and recommendations to the SERC on activities related to EPCRA. The duties of the SERC Executive Committee are to advise the SERC on designation of emergency planning districts and questions regarding the creation or dissolving of LEPC's, be involved with the review of plans developed by LEPC's, support LEPC efforts to implement EPCRA, and assist with hazardous materials training, education, and outreach activities in support of the SERC and LEPC's.
Hazardous Material Emergency Preparedness Grant
The Oregon SERC receives Hazardous Material Emergency Preparedness grant funds from the DOT Pipeline and Hazardous Materials Safety Administration. The grant funds are used to support planning, training, and exercise projects related to hazardous materials emergency response to transportation incidents. Oregon receives approximately $260,000 annually. At least 80% of those funds are passed through to local first responder agencies. The remaining 20% is utilized by OSFM facilitate additional planning, training and exercise projects.
USDOT Emergency Order regarding Petroleum Crude Carriers, Docket No.DOT-OST-2014-0067

On May 7, 2014, the U.S. Department of Transportation (DOT) issued an Emergency Order requiring all railroads operating trains containing large amounts of Bakken crude oil to notify State Emergency Response Commissions (SERCs) about the operation of these trains through their states.

Effective immediately, the Emergency Order (Docket Number DOT-OST-2014-0067), requires that each railroad operating trains containing more than 1,000,000 gallons of Bakken crude oil, or approximately 35 tank cars, in a particular state to provide the SERC notification regarding the expected movement of such trains through the counties in that state. The notification must include estimated volumes of Bakken crude oil being transported, frequencies of anticipated train traffic and the route through which Bakken crude oil will be transported. The Emergency Order also requires the railroads provide contact information for at least one responsible party at the host railroads to the SERCs. The Emergency Order advises railroads to assist the SERCs as necessary to share the information with the appropriate emergency responders in affected communities.

Emergency Response Guidebooks
The electronic version is available through the USDOT website at
The United States Department of Transportation (USDOT) Emergency Response Guidebook is intended to aid first responders during the initial response to a hazmat incident. The ERG is available in electronic and hardcopy format.

https://www.phmsa.dot.gov/staticfiles/PHMSA/DownloadableFiles/Files/Hazmat/ERG2016.pdf​
T o check the availability of hardcopy ERG's, contact Michael Heffner at 24, 2017 at the Seaside Convention Center. n opportunity to enhance the knowledge and understanding of the Emergency Planning and Community Right to Know Act (EPCRA) and provided valuable information and ideas. There was opportunity for networking with people from across the state involved in LEPC activities, emergency planning, and response to hazardous materials incidents. This conference was hosted by the OSFM and paid for by funds provided by the HMEP Grant. Please see the links below for the presentations that took place this year. Michael.Heffner@state.or.us The Office of State Fire Marshal held the 2017 Oregon SERC/LEPC Conference in Seaside, Oregon on May 22-

This conference was a
2017 Oregon SERC/LEPC Conference Presentations (in order of appearance):

State Emergency Response Commission

Oregon Office of State Fire Marshal

Oregon Office of State Fire Marshal

​​​​​​​​​​​​

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State Emergency Response Commission ORS 453.520 designates the State Fire Marshal as the State Emergency Response Commission (SERC) as required by the Emergency Planning and Community Right to Know Act of 1986 (42 U.S.C. 11001 et seq.).

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earth :: a global map of wind, weather, and ocean conditions

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See current wind, weather, ocean, and pollution conditions, as forecast by supercomputers, on an interactive animated map. Updated every three hours.

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Forms of Emotional and Verbal Abuse You May Be Overlooking

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Forms of Emotional and Verbal Abuse You May Be Overlooking

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There are 3 million cases of domestic violence reported each year. Many more go unreported. Emotional abuse often precedes violence, but is rarely discussed. Both men and women abuse others, and unfortunately, many don't even know it.
Why is Emotional Abuse Hard to Recognize?
Emotional abuse may be hard to recognize because it can be subtle, and because abusers often blame their victims. They may act like they have no idea why you are upset. Additionally, you may have been treated this way in past relationships, so it's familiar to you and harder to recognize. Over time, the abuser will chip away at your self-esteem, causing you to feel guilty, doubt yourself, and distrust your perceptions.

Other aspects of the relationship may work well: The abuser may be loving between abusive episodes, so that you deny or forget them. You may not have had a healthy relationship for comparison, and when the abuse takes place in private, there are no witnesses to validate your experience.
The Personality of an Abuser
Abusers typically want to control and dominate. They use verbal abuse to accomplish this. They are self-centered, impatient, unreasonable, insensitive, unforgiving, and they lack empathy and are often jealous, suspicious, and withholding. To maintain control, some abusers "take hostages," meaning that they may try to isolate you from your friends and family. Their moods can shift from fun-loving and romantic to sullen and angry. Some punish with anger, others with silence - or both. It's usually "their way or the highway."
Are You Being Abused?
Emotional abuse may start out innocuously, but grow as the abuser becomes more assured that you won't leave the relationship. It may not begin until after an engagement, marriage, or pregnancy. If you look back, you may recall tell-tale signs of control or jealousy. Eventually, you and the entire family will "walk on eggshells" and adapt so as not to upset the abuser. Being subjected to emotional abuse over time can lead to anxiety, post-traumatic stress disorder, depression, inhibited sexual desire, chronic pain, or other physical symptoms.

People who respect and honor themselves won't allow someone to abuse them. Many people allow abuse to continue because they fear confrontations. Usually, they are martyrs, caretakers, or pleasers. They feel guilty and blame themselves. Some aren't able to access their anger and power in order to stand up for themselves, while others ineffectively argue, blame, and are abusive themselves, but they still don't know how to set appropriate boundaries.

If you've allowed abuse to continue, there's a good chance that you were abused by someone in your past, although you may not recognize it as such. It could have been a strict or alcoholic father, an invasive mother, or a teasing sibling. Healing involves understanding how you've been abused, forgiving yourself, and rebuilding your self-esteem and confidence.
What is Emotional Abuse?
If you're wondering if your relationship is abusive, it probably is. Emotional abuse, distinct from physical violence (including shoving, cornering, breaking and throwing things, etc.), is speech and/or behavior that's derogating, controlling, punishing, or manipulative. Withholding love, communication, support, or money are indirect methods of control and maintaining power. Passive-aggressive behavior is covert hostility. The passive-aggressor is "a wolf in sheep's clothing." (For tips on how to respond, see " Dealing with a Passive-Aggressive Partner.")

Behavior that controls where you go, to whom you talk, or what you think is abusive. It's one thing to say, "If you buy the dining room set, we cannot afford a vacation," and another to cut up your credit cards. Spying, stalking, and invading your person, space, or belongings is also abusive, because it disregards personal boundaries.

Verbal abuse is the most common form of emotional abuse, but it's often unrecognized, because it may be subtle and insidious. It may be said in a loving, quiet voice, or be indirect - or even concealed as a joke. Whether disguised as play or jokes, sarcasm or teasing that is hurtful is abusive.

Obvious and direct verbal abuse, such as threats, judging, criticizing, lying, blaming, name-calling, ordering, and raging, are easy to recognize. Following are other subtle types of verbal abuse that are just as damaging as overt forms, particularly because they are harder to detect. When experienced over time, they have an insidious, deleterious effect, because you begin to doubt and distrust yourself.

Opposing: The abuser will argue against anything you say, challenging your perceptions, opinions, and thoughts. The abuser doesn't listen or volunteer thoughts or feelings, but treats you as an adversary, in effect saying "No" to everything, so a constructive conversation is impossible.

Blocking: This is another tactic used to abort conversation. The abuser may switch topics, accuse you, or use words that in effect say, "Shut Up."

Discounting & Belittling: This is verbal abuse that minimizes or trivializes your feelings, thoughts, or experiences. It's a way of saying that your feelings don't matter or are wrong.

Undermining & Interrupting: These words are meant to undermine your self-esteem and confidence, such as, "You don't know what you're talking about," finishing your sentences, or speaking on your behalf without your permission.

Denying: An abuser may deny that agreements or promises were made, or that a conversation or other events took place, including prior abuse. The abuser instead may express affection or make declarations of love and caring. This is crazy-making and manipulative behavior, which leads you to gradually doubt your own memory, perceptions, and experience. In the extreme, a persistent pattern is called gaslighting, named after the classic Ingrid Bergman movie, . In it, a husband used denial in a plot to make his wife believe she was losing her grip on reality.
Confronting Abuse
In order to confront the abuse, it's important to understand that the intent of the abuser is to control you and avoid meaningful conversation. Abuse is used as a tactic to manipulate and have power over you. (See " How to Spot Manipulation.") If you focus on the content, you'll fall into the trap of trying to respond rationally, denying accusations, and explaining yourself, and will lose your power. The abuser has won at that point and deflected responsibility for the verbal abuse.

Sometimes, you can deflect verbal abuse with humor. It puts you on equal footing and deprives the abuser of the power they seek in belittling you. Repeating back what is said to you also has an impact, followed by a calm boundary. For example, "Did you say you think that I don't know what doing?" You may get a defiant repetition of the insult. Then follow up with, "I disagree," or "I don't see it that way," or "I know exactly what I'm doing."

In some cases, verbal abuse is best addressed with forceful statements such as, "Stop it," "Don't talk to me that way," "That's demeaning," "Don't call me names," "Don't raise your voice at me," "Don't use that tone with me," "I don't respond to orders," etc. In this way, you set a boundary of how you want to be treated and take back your power. The abuser may respond with, "Or what?" You can say, "I will not continue this conversation."

Typically, a verbal abuser may become more abusive; in which case, you continue to address the abuse in the same manner. You might say, "If you continue, I'll leave the room," and do so if the abuse continues. If you keep setting boundaries, the abuser will get the message that manipulation and abuse won't be effective. The relationship may or may not change for the better, or deeper issues may surface. Either way, you're rebuilding your self-confidence and self-esteem, and are learning important skills about setting boundaries. (See " The Power of Personal Boundaries.")

Abuse can slowly chip away at self-esteem. Usually, both the abuser and the victim in a relationship have experienced shaming in childhood and already have impaired self-esteem. Confronting an abuser, especially in a long-term relationship, can be challenging. It often takes the support and validation of a group, therapist, or counselor to be able to consistently stand-up to abuse. Without it, you may doubt your reality, feel guilty, and fear loss of the relationship or reprisal. If it feels daunting, you can try a different, educative approach. (See Dealing with a Narcissist: How to Raise Self-Esteem and Set boundaries with Difficult People.)

Once you take back your power and regain your self-esteem, you won't allow someone to abuse you. If the abuse stops, a relationship may improve, but for real, positive change, both of you must be willing to risk change.
Build your self-esteem and learn to be assertive by using the tools in my ebooks, 10 Steps to Self-Esteem and How to Speak Your Mind: Become Assertive and Set Limits, and webinar, How to be Assertive. To go deeper and explore the seeds of low-self-esteem, see Conquering Shame and Codependency: 8 Steps to Freeing the True You. ©Darlene Lancer 2010, 2017

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Forms of Emotional and Verbal Abuse You May Be Overlooking

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There are 3 million cases of domestic violence reported each year. Many more go unreported. Emotional abuse often precedes violence, but is rarely discussed. Both men and women abuse others, and unfortunately, many don't even know it. Why is Emotional Abuse Hard to Recognize?

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5 Things You Should Never Do In A 4X4 Vehicle

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Five ways that you could damage your 4x4 while off road. For similar videos, check out this playlist - https://goo.gl/xE4StO New videos every Wednesday, subscribe here - https://goo.gl/VZstk7 5 Things You Should Never Do In A 4X4 or 4WD Vehicle. Never drive on pavement with part-time 4WD, nor with a differential locked.

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8 KNOTS You Need to Know - How to tie knots that you will actually use.

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8 best knots for camping, survival, climbing, hiking, and just everyday life. How to tie these basic knots and when to use them. These are the 8 knots you need to know.

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Getting stuck in the middle of a big pile of snow or on a stretch of ice can be an all-too-common occurrence during the cold winter months. Luckily, we have a few tips and tricks that can get your car free in no time, even if you don't have one of the best vehicles for winter driving. Here are some things you can try if your car is stuck in snow:

1. Clear a path around your tires

Try to dig snow and ice away from the drive tires. You want to free up a few feet in front of and behind the tires so you can move the car back and forth. Also, dig out any snow under the front or middle of your car that is higher than its ground clearance.

Of course a shovel makes this much easier, so try and store one in your trunk along with some other winter emergency items if you plan on driving in snowy conditions.

2. Rock your car free of the snow

Carefully switching from drive to reverse can help dislodge some of the snow around your wheels. "You go into drive, then reverse, then repeat," says Mark Osborne, who oversees Michigan Technological University's Winter Driving School. "But you have to be careful not to wreck your transmission. I put my foot on the brake at the peak of each 'rock,' so the car is motionless when I change gears. It's also helpful to shift to neutral for a second before making the transition."

3. Don't floor the gas

You'll always be tempted to floor it if you're stuck. But don't. Go easy on the pedal to give the vehicle just a little gas for a moment, then let off. Repeat to enhance the needed "rocking" motion. It's momentum that sets you free, not power.

4. Improve traction

If you still can't get your car free, you can next try and improve traction under your wheels. Things such as sandbags, salt, dirt or even kitty litter can be used when your car is stuck in snow. Throw several handfuls under your tires for improved traction, then try the gas again.

5. Get others to help push your car

If you have other people in your car, or friendly onlookers who can help, simply pushing your car out of the snow can be an easy solution. Gently press the gas while the car is being pushed to add additional momentum. Safety always comes first, so make sure you're in forward gear and the ground isn't too slippery for helpers to push.

Always keep a cool head

Whether you're stuck in snow or hit a stretch of ice, try and remain calm. Don't do anything abrupt, like slamming the brakes. "If you do that, you'll transfer your vehicle's weight to your front wheels," Osborne says. "That lightens up the rear, making it likely that your rear end will spin." Instead, Osborne says, gradually let off the gas and hold the steering steady until you've cleared the ice.

If all else fails, an emergency roadside assistance service can give your car a tow. Learn more about the benefits of our Roadside Assistance program here.

Your car getting stuck isn't the only concern when winter comes along. Snowy and icy pavement can lead to accidents. To help you navigate inclement weather this winter, check out our safety tips for driving in a snowstorm.

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Getting stuck in the middle of a big pile of snow or on a stretch of ice can be an all-too-common occurrence during the cold winter months. Luckily, we have a few tips and tricks that can get your car free in no time, even if you don't have one of the best vehicles for winter driving.

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How to Free a Car Stuck in Mud | Breakdown Cover | RAC

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How to free a car stuck in mud. Find out all you need to know with our helpful car breakdown guide. Learn more at the RAC today.

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The 2 Person 72-Hour Elite Emergency Preparedness Kit has all items packed securely in our Multi-Pocket Hiker's Backpack, which contains extra space available for personal items. Each item is hand assembled in the USA into waterproof bags and neatly organized in the backpack for easy access.

The kit includes the following:

Food and Water:
The food and water in this kit are meant to provide nutrition for 2 people for 72-hours until help arrives. These products have a 5-year shelf life.

12 - 400 Calorie Food Bar's (4800 Calories)

12 - 4oz Water Pouches

20 Water Purification Tablet's - each tablet purifies 1 liter of water

Light and Communication:
These products come in handy during a home power outage, car trouble, or other emergency requiring you to leave your home.

AM/FM Radio with Headphones and Batteries

3 LED Rechargeable Flashlight

30 Hour Emergency Candle

12 Hour Emergency Bright Stick

5-in-1 Survival Whistle

Box of Waterproof Matches

Shelter and Warmth:
These supplies will provide protection from outside weather forces. They will protect you from wind, sun, rain, and other harsh conditions you may encounter.

2 Emergency Survival Sleeping Bag's

2 16 Hour Body Warmer's

2 Person Tube Tent with Rope

2 Emergency Poncho's with Hood

Tools:
These items are designed to be useful in disaster situations. They will be a valuable resource when you find yourself faced with navigation, transport, personal protection, or shelter troubles.

16 Function Multi-Tool

Pair of Leather Palm Work Gloves

2 - N95 Respirator Dust Mask's - NIOSH approved

50 Feet of Nylon Rope

Safety Goggles

Sewing Kit

All of our kit items are packed securely in a resealable, waterproof storage bag

Hygiene and Sanitation:
When in a disaster situation it is useful to have access to hygiene products. Staying clean can protect against infection, disease, and depression.

2 - 24 Piece Deluxe Hygiene Kit's

Tooth Brush

Tooth Paste

9 Wet Nap's

Soap

Shampoo/ Conditioner

Dental Floss Pick

Twin Blade Razor

5'' Black Comb

4 Maxi Pads/ Bandage's

Washcloths

Shave Cream

6 Pocket Tissue Pack's

First Aid:
These first aid items can assist with minor injuries and protect against serious health concerns in disaster circumstances.
Additional:
These items are useful for stress relief and activity in strenuous or challenging circumstances.

Notepad

Golf Pencil

Infectious Waste Bag

Survival Playing Cards - 52 cards with valuable survival skills that will educate you in an emergency situation as well as keep you entertained.

Emergency Survival Kit Information:
This survival kit was designed using advice from experts in the emergency preparedness industry. It follows guidelines given by government agencies and non-profit preparedness organizations. This 2-person deluxe emergency kit has a retail value of $170.

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The 2 Person 72-Hour Elite Emergency Preparedness Kit has all items packed securely in our Multi-Pocket Hiker's Backpack, which contains extra space available for personal items. Each item is hand assembled in the USA into waterproof bags and neatly organized in the backpack for easy access.

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Let's say you find yourself lying at the bottom of a ravine with a dirt-filled gash in your leg. According to the Internet, the first thing you want to do is pee on your wound. After all, the common wisdom holds, urine is sterile.

Wrong again, Internet.

Urine is not sterile, even before it comes out of you and gets contaminated by your skin. Bacteria are present at low levels in the urine of healthy people not suffering from a urinary tract infection, Evann Hilt of Loyola University of Chicago reported May 18 at a conference of the American Society for Microbiology. Now, Hilt and her colleagues are figuring out what bacteria make up the normal bladder community and whether a change in that community might trigger urinary problems.

"Now that we know they're there, the question is what are they doing?" Hilt says. Most likely, she says, "it's like any other niche on our body. You have a good flora that keeps you healthy."

It appears that the urban legend about urine being sterile has its roots in the 1950s, Hilt says, when epidemiologist Edward Kass was looking for a way to screen patients for urinary tract infections before surgery. Kass developed the midstream urine test (still used when you pee in a cup) and set a numerical cutoff for the number of bacteria in normal urine: not more than 100,000 colony-forming units (cell clusters on a culture dish) per milliliter of urine. A person tests "negative" for bacteria in their urine as long as the number of bacteria that grow in a lab dish containing the urine falls below this threshold. "It appears that the dogma that urine is sterile was an unintended consequence," Hilt says.

Hilt and her colleagues used a more sensitive growth-culture technique to detect the low levels of bacteria in normal urine, reasoning that maybe some urinary bacteria don't grow readily under the conditions of the standard test. Having already found bacterial genetic material in urine (as did another team), in their latest work they used catheters to collect urine directly from the bladders of 84 women, half of whom had overactive bladder syndrome, which causes patients to have to urinate frequently. They put samples of the urine in lab dishes and let the urine bacteria grow under friendlier conditions. More than 70 percent of the urine samples contained bacteria, including at least 33 types of bacteria (at the genus level) in normal urine. Women with overactive bladders had more types of bacteria in their urine (77 genera), including four species found only in overactive bladder patients.

This finding might provide hope for the 15 percent of women who suffer from overactive bladder; many aren't helped by the standard therapy that treats the condition as purely a muscular problem.

Learning that urine is not sterile also changes the way we think about infection. It had generally been assumed that if there are bacteria in your urinary tract, you have an infection and that's a bad thing. But if there is a normal community of bacteria, we may need to think about the bladder more in the way we have recently learned to think of the gut microbiome, in terms of "healthy" and "unhealthy" mixes of bacteria.

It's not clear anymore what body parts are actually sterile. The placenta was long thought to be, but scientists have just learned that's not true: They found bacteria on the baby's side of the placenta. There's also some evidence that babies are born with bacteria already in their guts, which must have gotten through the placenta.

And what about brains? Surely the braincase is last bacteria-free bastion, protected by the blood-brain barrier.

Sadly, that's not the case either. When I asked neuroscience writer Laura Sanders if our brains are sterile, she promptly said, "Oh, no. The brain's full of all kinds of junk." That includes viruses.

Last year, in fact, researchers reported finding soil bacteria in people's brains. (Before making a dirty-mind joke, these were alpha-proteobacteria normally found in soil, but there's no reason to think soil got into anyone's brain.) The researchers were studying whether people with a compromised immune system from HIV/AIDS might be prone to brain infections. Instead, they found that all the brains they looked at contained bacteria, regardless of HIV status. No one knows how the bacteria get in there, or when. Could they be leftovers from fetal development? Lucky tricksters that make it through the blood-brain barrier? We don't know, and just like for bladders, we don't even know what to consider "normal" yet.

So back to our original question: If urine isn't sterile, does that mean you shouldn't pee on a wound? Well, that was probably never a great idea anyway. If you don't have clean water, you're generally better off letting blood flow flush a wound, bathing it in infection-fighting white blood cells.

But if knowing there are bacteria in urine helps you talk a well-meaning friend out of peeing on you in an emergency, well, you're welcome.
Follow me on Twitter: @GoryErika

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Urine is not sterile, and neither is the rest of you

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Let's say you find yourself lying at the bottom of a ravine with a dirt-filled gash in your leg. According to the Internet, the first thing you want to do is pee on your wound. After all, the common wisdom holds, urine is sterile. Wrong again, Internet.

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Whether you are camping for the first time or you find yourself stranded somewhere due to a natural disaster or zombie apocalypse, it is important to know how to purify water in the wild if you don't have immediate access to store-bought water bottles.

The most reliable method for purifying water is to boil it for 5 to 20 minutes. For other convenient methods, you can carry water purification tablets in your backpack or invest in a commercial water filter, which you would use after drawing water from a clean source-ideally clear, flowing water from a natural spring or stream that is not anywhere near manmade structures.

Read below for more methods for purifying water in the wilderness, and general tips for finding the best water source. Click on image to enlarge.

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Survival 101: 6 Ways to Purify Water in the Wild

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Whether you are camping for the first time or you find yourself stranded somewhere due to a natural disaster or zombie apocalypse, it is important to know how to purify water in the wild if you don't have immediate access to store-bought water bottles.

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Editor's note: This story is the second of two parts. Read part 1 here.
In part 1 in this series, I talked about what you should do if you are lost in the woods for most circumstances. I want to continue on that, specifically dealing with what to do if you are caught in the woods in the wintertime. Winter weather can be much more dangerous in a survival situation, so extra precautions need to be taken in order to survive.
Preparing to Survive in the Winter
Actually, everything I mentioned in the first part of the article applies to surviving in the winter, so don't think of throwing that information out. What I intend to do in this part of the article is to add to that information, not replace it.

The biggest concern in wintertime is keeping warm. Prolonged exposure to freezing temperatures can sap your body's energy reserves, just trying to keep warm. Even so, it's much harder to keep warm in the winter, due to lowered temperatures, high winds, difficulty in finding fuel and difficulty in even starting a fire.

While surviving in any sort of situation is much easier if you have the right equipment and supplies with you, it's even more important in winter. While there are ways of keeping yourself warm, even if you don't have the right clothes with you, it's much harder to do. So, the first part of surviving in the winter is making sure that you are prepared.

Let's start with clothing. There are a lot of people who don't dress appropriately for the cold weather. If you want to wear stylish clothes, that's fine; but don't limit yourself to just having those clothes with you. Ladies, that cute little jacket might look great, but it probably won't keep you warm. If you're wearing a dress or skirt, take blue jeans along, as well. Make sure you take a warm coat, a hat, some gloves and some warm boots with you. That way, if you get caught somewhere, you've got something warmer to put on.
The pack for anybody who wants to be fully prepared for an unexpected emergency
Most clothing loses its insulation value if it becomes wet. Down is the worst for this, making you lose your body heat 300 times faster than if you were naked. The best clothing for retaining body heat if it gets wet is wool. Even when soaking wet, wool still retains 50 percent of its insulating value, and it is the only fabric that will. Keep that in mind when choosing between a wool stocking cap and a polyester one.

It is best to dress in layers if you are trying to keep warm in the winter. Layers provide better insulation, as well as the option of being able to take off layers if you get too warm. Your outer layer should be made of a material that blocks the wind well, or all the insulating layers below it won't be anywhere near as effective.

You'll also need more calories to burn in the cold. Add some high carbohydrate food bars and other snacks to your everyday carry bag. Your body will be burning a lot of calories just to produce heat. While this may seem like a great time to lose weight, your body probably won't be able to convert fat to heat quickly enough. You're better off providing it with some other calories to burn, ensuring that there is enough energy in your body to produce the necessary heat.
Build a Shelter
Finally, you're going to have more trouble starting a fire in the winter than you would in the summer. Dry wood and especially dry tinder is much harder to find. So, you'll need to carry fire starters that can overcome the damp in the wood, as well as including their own tinder. Here are three that I recommend:

Cotton balls soaked in petroleum jelly - Work the petroleum jelly into the cotton ball with the back side of a spoon, until it is well-saturated. Will burn for about three minutes.

Dryer lint and candle wax - Dryer lint and cotton balls are almost the same thing. Make balls out of the lint and put them into the cups of a cardboard egg carton. Pour melted wax into the cups as well, soaking the lint with the wax. The wax doesn't need to totally fill the cup, just to soak the lint. Burn time depends upon how much wax you use.

Black powder and nail polish remover - Put fine black powder (#FFFFg) into a bowl and cover it with oily nail polish remover. You must use the type that has acetone in it, so check the label. Knead the two together, making a putty out of it. Knead this to make a layered ball. The finished fire starter must be stored in an airtight container, as the acetone will try and evaporate out. Once dry, this fire starter loses its effectiveness. This type of fire starter will burn at over 3,000 degrees Fahrenheit for over three minutes, making it great for damp wood.

Depending upon where you are, snowstorms can come upon you quickly. Mountains and trees deny you the ability to see much of the sky, so you might have a storm sneaking up on you and not be able to see it. Whenever you have the opportunity, take a good look around to make sure that you have ample warning of any weather problems that are headed your way. If it doesn't look like you can get out in time, then use your time to prepare a shelter and hunker down. Ultimately, your survival is more important than getting home on time.

While the shelters that I mentioned in the first part of the article are all excellent, even in cold weather, you will be better served by adding to them in the winter. There are three major concerns for cold weather shelters:

Keeping the wind out

Keeping heat in

Acting as a heat reflector

Story continues below video
That pine tree or deadfall may work out great, but adding a space blanket to the outside of it, so that the wind can't get through the branches could make you a lot warmer. The space blanket acts as a heat reflector as well, helping to keep your shelter warm. Another space blanket can be spread behind your fire, so that it can reflect the heat from the fire into your shelter.

If you are using a tent for shelter, you can make it a lot warmer by insulating it. Set the tent up like normal and then cover it with boughs or debris from the forest floor. Pine boughs work extremely well for this, but anything that will create an insulating layer is good. Then, cover the insulation with another windproof layer, whether a space blanket or a tarp. By doing this, you have essentially created an insulated wall to help keep the heat from your fire inside your tent.
Watch Your Activity
The opening in your shelter must be downwind, so that the cold wind will not be blowing into your shelter. Place your fire before the opening, leaving yourself a way of escape. Don't forget a heat reflector behind the fire; you'll be surprised how much it will help.

Dry pine bough tips or leaves can also be put loosely inside your clothing to make an additional layer of insulation. You must use dry ones so that they don't pack down. The idea is to create more air layers between you and the outside air. Pine boughs are excellent for this, as the needles naturally form a lot of air spaces.

It helps to maintain yourself somewhat active in the cold, but you must be careful not to overdo it. Movement helps encourage your body's blood flow, which is the mechanism that is used to move heat from your body's core to the extremities. Failure to move enough can lead to frostbite.

You must be extremely careful to protect your fingers and toes from frostbite. One of the body's defense mechanisms is to cut off or limit blood flow to the extremities when it is cold. It sacrifices those extremities to keep the core part of the body warm. The only problem is that you need those fingers and toes in order to survive.

When you are not working with your hands, make sure that they are kept warm. Gloves or mittens help some, but it is much more effective to put them inside your clothing, where they can be warmed by your body's heat.
Final Considerations
Watch out for excessive activity as this will burn calories that your body needs to keep warm. If you get physically tired from exertion, it makes it much easier for hypothermia to set in. Another risk from excessive movement is sweating. If you sweat in the cold, the sweat can freeze next to your skin, drawing away body heat. Even without freezing, it will make your clothing wet, reducing its insulating value.

If you have to move in the snow, there's a very good chance that you'll find yourself overexerting. Moving through snow, especially deep snow, is extremely difficult. If you can, make yourself some snowshoes out of thin branches and paracord. If you can't do that, strap some boughs to the bottom of your boots. This will work for makeshift show shoes.

You will have no shortage of water in the winter in most locations - that is, as long as there is snow you can melt for water. Typically, you'll only get about one-tenth the volume of water out of snow. When melting water for snow, you must stir it, or you will scald the water, making it taste bad. Don't drink cold water, as it will remove heat from your body. Take the time to warm it, so that it can help keep you warm.

Rescuers will have a harder time finding you in the snow. If the snow is falling, visibility will be limited. Snow also absorbs sound, meaning that gunshots and whistles won't be heard as far away as they normally would. Searchers are aware of this and will search more carefully because of it.

Anything you can do to make yourself more visible will be to your benefit. If you have the kind of space blankets that are blaze orange on one side, make sure you put that side to the outside, as it will be very visible against the white snow. Check it every once in a while to make sure that snow hasn't blown onto it. Reflective space blankets won't be as effective a signal, as the reflection will be lost in the brightness of the snow.

Putting your shelter in an obvious place or one that is highly visible will help the rescuers that are searching for you. While this will make you more exposed to the wind, if you construct your shelter correctly, you can still keep the wind out.

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Surviving In The Woods When You're Lost, Cold And Desperate

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Editor's note: This story is the second of two parts. Read part 1 here . In part 1 in this series, I talked about what you should do if you are lost in the woods for most circumstances. I want to continue on that, specifically dealing with what to do if you are caught in the woods in the wintertime.

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Winter serves up frosted-over beauty, for sure, but also plenty of risk. The season doesn't look kindly upon outdoors people who come to it unprepared or disrespectful of its rigors, and a survival situation this time of year can turn deadly mighty quickly. Here are some basic winter survival tips to bone up on before venturing out into the white stuff!

The Basics of Winter Survival

Whether you're lost on foot in the frozen outback or stuck in a car on a snowed-in road, the essential elements cold-weather survival are the same. You need to stay warm and dry, which means finding or making a shelter and creating a heat source. These need to be your first priorities, as you have to create an environment in which you can hunker down till help arrives or conditions allow you to get to safety. Frostbite and hypothermia can set in quickly if you don't.

Staying alive in the winter wilds also means eating and drinking regularly to maintain your energy stores and regulate your body temperature.

Winter Survival Shelter

If you're a winter recreationist, you'll want a four-season/mountaineering tent. You can get by with a three-season tent in some climates and during shoulder seasons, but skiers, snowshoers, climbers, and other trekkers out and about in the depths of winter need a stronger, better-insulated shelter up for the demands of severe temperatures and biting winds.

Make your tent platform as flat as possible by stomping and grading it with snowshoes, skis, or whatever other tools you have at hand. If you simply plop your tent down on raw snow, you won't just be dealing with annoying slopes or lumpiness: Your sleeping position will become cast rock-hard into the icy surface, which makes for highly uncomfortable sleeping over multiple nights. Secure a tent's guylines with deadmen anchors: stakes, branches, rocks, or other items buried in snow.

In their tried-and-true classic Mountaineering: The Freedom of the Hills, the Mountaineers organization suggests digging a foot-deep pit in front of your tent door and within the vestibule for the purposes of comfortably putting on and taking off boots as well as cooking within during inclement weather.

If you're caught in an emergency situation without a tent, you'll need to build your own shelter. One of the easiest and quickest techniques is to make a snow wall: The United States Marine Corps recommends building a horseshoe-shaped rampart at least three feet high, the open end facing downwind. You can reinforce the wall with branches or ski/trekking poles, and roof it with a tarp or poncho.

Other options include snow caves (which any mountaineer in particular should know how to construct), igloos, fallen-tree bivouacs, and snow trenches.

Situating Your Shelter

You've got to gauge the lay of the land to effectively site your winter shelter. Don't pitch your tent or build your snow shelter at the bottom or mouth of a valley, canyon, or ravine, as cold air tends to spill down these terrain features. Avoid setting up shop in places exposed to prevailing winds or avalanches. If you're jury-rigging your own emergency shelter, take advantage of natural aids when you can: caves, fallen trees, etc. Just make sure your shelter's well ventilated and secured against collapse.

Making a Fire

Fire-starting materials should be a part of your emergency outdoor supplies any time of year. In a waterproof container, pack tinder-for instance, a plug of dryer lint, or little strips of rolled-up newspaper bound by rubber bands-as well as several means of sparking flame: matches, lighter, and a flint and striker.

Natural sources of tinder include dried moss and leaf litter, reserves of which you can sometimes find sheltered under the low-hanging boughs of a densely branched evergreen. Around a generous heap of tinder, build a teepee of small twigs and then kindling of small branches. Light the tinder and gently but steadily blow into it to build up the flames. Add larger wood once the kindling catches.

Your Winter Wardrobe: Clothing & How to Manage It in a Winter Survival Situation

Headed into the winter wilderness, you want to be properly layered: long underwear of polyester or merino wool as a baselayer, fleece over that, and then a waterproof and windproof shell. Wear wool socks, a neck gaiter, and a hat; pack a balaclava so you can protect your face against frostbite if temperatures really drop or winds kick up.

If you're hanging out at camp or stopping along the trail, bundle up: Put a puffy jacket at the top of your pack so you can easily pull it on. If you're traveling, strip to your midlayer or baselayer to avoid working up too much of a sweat: Drenched in perspiration, you're vulnerable to hypothermia. Cut down on sweat and evaporative cooling by putting a vapor barrier-say, a plastic bag-over your socks.

Food & Water

Breaking trail, erecting shelters, gathering firewood: You plow through a lot of energy carrying out the tasks of cold-weather survival, let alone simply staying warm. Reach for those energy-rich snacks frequently: nuts, cheese, salami, chocolate, and the like. Given fats pack twice as many calories per gram as carbs or protein, they make primo winter-camping snack food.

To conserve fuel and minimize cooking time out in the cold, meanwhile, make delicious, just-add-hot-water Mountain House entrees your fortifying meals.

Dehydration's a sneaky threat during winter survival camping. Melting snow's a go-to option for obtaining drinking water, but if you can find ice that's a better source, given its higher moisture content. Remember to boil or otherwise disinfect that snow or ice meltwater before using it for drinking or cooking. Besides using a cooking container over a stove or campfire, you can also melt snow or ice by packing it within a t-shirt or plastic bag, tying that parcel to a tripod of branches near a campfire, and placing a container underneath to collect the drips.

If you can find open water, that's all the better: You don't have to waste fuel or time melting snow and ice. Be careful fetching it, though, from a creek or river, as streamside snow may hide fragile ice or current.

If you'll be spending several nights in a campsite-as you probably will be during a survival situation-consider establishing a protected camp kitchen for preparing meals and water in the lee of a snow wall built against the prevailing wind.

A Few Tidbits on Backcountry Travel in the Winter

Avalanche safety demands its own in-depth treatment for which we don't have the space in this blogpost. It's vital to familiarize yourself with the basics of traveling through avalanche country, as these snowslides can be a mortal threat on surprisingly shallow slopes. (The National Avalanche Center provides online resources well worth checking out.)

In snow-draped landscapes, ridgelines and windward hillsides may provide easier passage than leeward slopes and valley bottoms, which tend to accumulate deep snow.

Winter Survival If You're Stranded in a Vehicle

Many a winter-survival situation doesn't play out on foot in the white wilderness, but in your car along a snowbound roadway. Your vehicle can be stranded anywhere, after all, including right on the Interstate. Let's say, though, that you find yourself stuck in a blizzard on a remote road (for instance, one you're taking to a cross-country ski or snowshoe trailhead). What do you do?

The most important piece of advice is: Stay with your car! You have a much better chance of being rescued if you do, for one thing, and the vehicle also serves as a readymade shelter.

Tie brightly colored cloth to your car's antennae to make it easier for rescuers to find you. At night, keep the dome light on for the same reason.

To stay warm but conserve gas, run the engine for 10 minutes every hour or so. While it's going, the Federal Emergency Management Agency recommends cracking a downwind window for ventilation. It's vital to regularly check on your exhaust pipe to make sure it's cleared of snow; otherwise, you risk poisoning yourself with carbon monoxide.

Stay bundled up, using the extra clothing and blankets in your vehicle survival kit (see below). Floormats and seat covers can provide a little bit of extra insulation in extremely cold conditions.

Stomp out "S.O.S." or "HELP" or form the words with tree boughs in the snow nearby in a place visible from above.

Before a winter roadtrip, make sure your vehicle's in good running order and stocked with emergency supplies (both automotive and survival), and-as always-share your itinerary and route so that others back home have a sense of where you might be in case you do get stranded. (That of course goes for a skiing, snowshoeing, or backpacking trek as well.)

Winter Survival Emergency Kit

In your vehicle and in your pack, you should have the essentials of wilderness survival on hand at all times in case you run into a sticky-err, snowy-situation. Besides the fire-making materials we discussed above, your emergency supplies should include extra food supplies (such as one of our handy Just In Case...® Emergency Food Supply kits), headlamps and flashlights with extra batteries, signaling devices (such as a mirror and a whistle), and a first-aid kit.

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Winter Survival: The Basics for Surviving in the Woods - Mountain House Blog

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Winter serves up frosted-over beauty, for sure, but also plenty of risk. The season doesn't look kindly upon outdoors people who come to it unprepared or disrespectful of its rigors, and a survival situation this time of year can turn deadly mighty quickly.

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Colorado Parks & Wildlife - Hunter Education

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Using the compass in interaction with a map

This is the important lesson, and you should learn it well.
It's when you use both compass and map the compass is really good, and you will be able to navigate safely and accurately in terrain you've never been before without following trails. But it'll take some training and experience, though.

I am not covering map reading here, guess you would have to consult other sources for that, but the lesson will be useful if you have a sense of what a map says.

First, a quick summary of what you will learn in this lesson:

1. Align the edge of the compass with the starting and finishing point.

2. Rotate the compass housing until the orienting arrow and lines point N on the map.

3. Rotate the map and compass together until the red end of the compass needle points north.

4. Follow the direction of travel arrow on the compass, keeping the needle aligned with the orienting arrow on the housing.

Here is our compass again:

The principles are much the same as in lesson 1 but this time, you are using the map to tell you which way is correct instead of your intuition.

Take a map. In our first example, we look at a map made for orienteering, and it is very detailed. Well, not really. We look at a fictitious map I drew myself, but never mind. To the point. You want to go from the trail-crossing at A, to the rock at B. Of course, to use this method successfully, you'll have to know you really are at A.
What you do, is that you put your compass on the map so that the edge of the compass is at A. The edge you must be using, is the edge that is parallel to the direction of travel arrow. And then, put B somewhere along the same edge, like it is on the drawing. Of course, you could use the direction arrow itself, or one of the parallel lines, but usually, it's more convenient to use the edge. At this point, some instructors say that you should use a pencil and draw a line along your course. I would recommend against it. First, it takes a lot of time, but offers no enhancement in accuracy of the method. Second, if you have wet weather, it may destroy your map, or if it is windy, you may loose it. You should keep your map (preferably in a sealed) transparent plastic bag, and if it is windy, tied up, so it can't blow away. But most important is that any drawings may hide important details on the map.
Time to be careful again! The edge of the compass, or rather the direction arrow, must pointfrom Ato B! And again, if you do t his wrong, you'll walk off in the exact opposite direction of what you want. So take a second look. Beginners often make this mistake as well.

Keep the compass steady on the map. What you are going to do next is that you are going to align the orienting lines and the orienting arrow with the meridian lines of the map. The lines on the map going north, that is. While you have the edge of the compass carefully aligned from A to B, turn the compass housing so that the orienting lines in the compass housing are aligned with the meridian lines on the map. During this process, you don't mind what happens to the compass needle.
There are a number of serious mistakes that can be made here. Let's take the problem with going in the opposite direction first. Be absolutely certain that you know where north is on the map, and be sure that the orienting arrow is pointing towards the north on the map. Normally, north will be up on the map. The possible mistake is to let the orienting arrow point towards the south on the map.
And then, keep an eye on the the edge of the compass. If the edge isn't going along the line from A to B when you have finished turning the compass housing, you will have an error in your direction, and it can take you off your course.

When you are sure you have the compass housing right, you may take the compass away from the map. And now, you can in fact read the azimuth off the housing, from where the housing meets the direction arrow.
Be sure that the housing doesn't turn, before you reach your target B!
The final step is similiar to what you did in lesson 1. Hold the compass in your hand. And now you'll have to hold it quite flat, so that the compass needle can turn. Then turn yourself, your hand, the entire compass, just make sure the compass housing doesn't turn, and turn it until the compass needle is aligned with the lines inside the compass housing.
The mistake is again to let the compass needle point towards the south. The red part of the compass needle must point at north in the compass housing, or you'll go in the opposite direction.

It's time to walk off. But to do that with optimal accuracy, you'll have to do that in a special way as well.
Hold the compass in your hand, with the needle well aligned with the orienting arrow. Then aim, as careful as you can, in the direction the direction of travel-arrow is pointing. Fix your eye on some special feature in the terrain as far as you can see in the direction. Then go there. Be sure as you go that the compass housing doesn't turn.
If you're in a dense forest, you might need to aim several times. Hopefully, you will reach your target B when you do this.

At this time, you may want to go out and do some training, so you could check out some suggested exercises.

Unfortunately, sometimes, for some quite often, it is even more complicated. There is something called magnetic declination. And then, for hiking, you wouldn't use orienteering maps. And this is the issue for lesson 3.

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How to use a Compass - Compass and Map interaction

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This is the important lesson, and you should learn it well. It's when you use both compass and map the compass is really good, and you will be able to navigate safely and accurately in terrain you've never been before without following trails. But it'll take some training and experience, though.

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At WeatherPro, we believe that good things happen when people step outside and great things happen to those who are prepared. We strive to empower life's outdoor moments.

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by: ActionNewsJax.com Updated:

Florida Gov. Rick Scott has declared a state of emergency for the state as Hurricane Irma inches closer to the U.S. mainland.

"Hurricane Irma is a major and life-threatening storm and Florida must be prepared," Scott said. "I have continued to be briefed by the Florida Division of Emergency Management on Hurricane Irma and current forecast models have Florida in Irma's path - potentially impacting millions of Floridians."
>> Read more trending news
Irma is packing winds in excess of 130 mph as it heads for key islands in the Caribbean.

Earlier Monday, Irma was a Category 3 but was upgraded to a Category 4 during the National Hurricane Center's 5 p.m. advisory.

Changes in the storm's structure will cause fluctuations in the intensity of the storm.

The storm's center is 490 miles (790 kilometers) east of the Leeward Islands late Monday afternoon. It has maximum sustained winds of 130 mph (215 kph) and is moving west at 13 mph (20 kph).

Emergency officials are warning that Irma could dump up to 10 inches (25 centimeters) of rain, unleash landslides and dangerous flash floods, and generate waves of up to 23 feet (7 meters) as it draws closer.

A hurricane warning has been issued for Antigua and Barbuda, Anguilla, Montserrat, St. Kitts and Nevis, St. Martin, Saba, St. Eustatius, St. Maarten and St. Barts.

A hurricane watch is in effect for Puerto Rico, Vieques, Culebra, the British and U.S. Virgin islands and Guadeloupe.

Read more here.
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Hurricane Irma: State of emergency declared as storm tracks toward Florida

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by: ActionNewsJax.com Updated: Florida Gov. Rick Scott has declared a state of emergency for the state as Hurricane Irma inches closer to the U.S. mainland. "Hurricane Irma is a major and life-threatening storm and Florida must be prepared," Scott said.

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The 988 Lifeline is a national network of local crisis centers that provides free and confidential emotional support to people in suicidal crisis or emotional distress 24 hours a day, 7 days a week in the United States. We're committed to improving crisis services and advancing suicide prevention by empowering individuals, advancing professional best practices, and building awareness.

About The Lifeline

Anyone could be struggling with suicide. Find more specific resources below.

I'm Struggling With Individuals with Neurodivergence

We understand that every struggle is different. Experience the stories of people like you, and how they overcame crisis to find hope and recovery.
read stories of hope & recovery

First, you'll hear an automated message featuring additional options while your call is routed to your local 988 Lifeline network crisis center.

We'll play you a little music while we connect you to a skilled, trained crisis worker.

A trained crisis worker at your local center will answer the phone.

This person will listen to you, understand how your problem is affecting you, provide support, and get you the help you need.

988 Lifeline Center calls are free and confidential, and we're available 24/7.

Show What Happens When You Call The Lifeline

Everyone Plays A Role In Suicide Prevention

Get in touch

Call the Lifeline

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Skip to main content We can all help prevent suicide. The 988 Lifeline provides 24/7, free and confidential support for people in distress, prevention and crisis resources for you or your loved ones, and best practices for professionals in the United States. 988 ¡Los servicios de texto y chat de 988 Lifeline ya están disponibles en español!

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by Aris, a Hotline advocate

Forgiveness can be difficult, and yet many people manage to do this every day with friends, family and coworkers. The path to forgiveness typically involves a wrongdoing, perhaps an apology, and some form of accountability or behavioral change. After this, the person who has been wronged decides that moving forward and "letting it go" is in everyone's best interest, thereby forgiving the initial transgression.

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National Domestic Violence Hotline | Get Help Today | 1-800-799-7233

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by Aris, a Hotline advocate Forgiveness can be difficult, and yet many people manage to do this every day with friends, family and coworkers. The path to forgiveness typically involves a wrongdoing, perhaps an apology, and some form of accountability or behavioral change.

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RAINN | The nation's largest anti-sexual violence organization

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Donate Donate Monthly Honor Someone Give to a Fundraiser Shop for RAINN Plan Your Legacy Donor-Advised Fund Donate Stock Workplace Giving Combined Federal Campaign Corporate Partnerships Take Political Action Volunteer Spread the Word on Social Media Start a Fundraiser Student Activism Tell Your Story Join the Speakers Bureau Request a Speaker Intern at RAINN Work at RAINN Sign-up for News & Alerts

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24/7, confidential crisis support for Veterans and their loved ones. Contact the Veterans Crisis Line: Dial 988 then Press 1, chat online, or text 838255.

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Congress has passed a new law that allows us to offer COVID-19 vaccines to more Veterans and some spouses and caregivers of Veterans. At this time, we still have a limited amount of vaccines. We're working to determine how quickly we can begin to offer vaccines to these other groups.

Please check back often for updates. We appreciate your patience as we prepare to offer more vaccines. If you'd like to get regular updates about COVID-19 vaccines at VA, Sign Up to Stay Informed.

Note: Your employer, pharmacy, or local public health officials may offer you a COVID-19 vaccine. We encourage you to take the first opportunity you have to get a vaccine at the most convenient location for you.

Announcement Expansion Phase 1 is Here!

Eligibility for the Program of Comprehensive Assistance for Family Caregivers (PCAFC) has expanded.

Review the fact sheets to learn more about the expansion.

Fact Sheets available in Spanish & Tagalog/Filipino.

There are several steps in the application process that determine if you qualify.

How do I apply for this program?

You and the Veteran will need to apply together and participate in an application process to determine if you're eligible for the Program of Comprehensive Assistance for Family Caregivers. You'll both need to sign and date the application and answer all questions for your role.

You can apply online right now.
Apply for the program of comprehensive caregiver assistance

You can also apply:
By mail
Fill out a joint Application for the Program of Comprehensive Assistance for Family Caregivers (VA Form 10-10CG).
Download VA Form 10-10CG (PDF)
Mail the form and any supporting documents to:

Program of Comprehensive Assistance for Family Caregivers
Health Eligibility Center
2957 Clairmont Road NE, Suite 200
Atlanta, GA 30329-1647
In person
Bring your completed VA Form 10-10CG to your local VA medical center's Caregiver Support Coordinator. To find the name of your local coordinator, you can:

Go to the VA Caregiver Support Coordinator directory, or
Contact the Caregiver Support Line at 855-260-3274

Do not send medical records along with the application. VA will follow up after the application is received. If you need assistance with completing the application or would like to check the status of your 1010CG application please call 1-855-488-8440, option 3.

Be sure to check back for updates or subscribe to receive email updates and information about VA Caregiver Support Program services.

1099-NEC for Caregiver Stipend Payments

Several Primary Family Caregivers participating in VA's Program of Comprehensive Assistance for Family Caregivers (PCAFC) recently expressed concern over receiving a 1099-NEC form from VA. After researching this matter, VA found that a total of 149 PCAFC Caregivers received a 1099-NEC form. These PCAFC Caregivers were all paid taxable wages in 2020 as providers of bowel and bladder care for their Veteran family member under VA's Spinal Cord Injury or Disorder (SCI/D) Program. The 1099-NEC form received by these 149 PCAFC Caregivers reflected only their bowel and bladder wages.

Bowel and bladder care for Veterans with SCI/D are supportive and necessary medical services when they are unable to manage bowel and bladder functions independently. The clinic of jurisdiction, or VA medical facility, authorizes such care under the Community Care Program to enrolled Veterans with SCI/D who are dependent upon others for bowel and bladder care while residing in the community. Veterans with SCI/D who qualify for bowel and bladder care may receive that care through a home health agency, a family member, or an individually employed caregiver.

Starting Monday, February 8, the Office of Community Care will begin calling the 149 Caregivers to explain why they received the 1099-NEC form and answer any questions they may have.

Announcement for COVID-19

Learn how you can protect, prepare and support yourself and your Veteran loved one through these challenging times with tips on Caregiving During COVID-19 (PDF) and Coronavirus FAQs page. For more information or support call us at 1-855-260-3274.

PCAFC requirements for in-person home visits during the National Emergency related to
Coronavirus Disease-2019 (COVID-19), for information please visit https://www.regulations.gov/*.

We appreciate you and we are here to help you!

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Congress has passed a new law that allows us to offer COVID-19 vaccines to more Veterans and some spouses and caregivers of Veterans. At this time, we still have a limited amount of vaccines. We're working to determine how quickly we can begin to offer vaccines to these other groups.

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Texas Hurricane Harvey (DR-4332) | FEMA.gov

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Thank you for your interest in helping the survivors of Hurricane Harvey, there are other ways to help. When disaster strikes, America looks to FEMA to support survivors and first responders in communities all across the country. We are currently seeking talented and hard-working people to help support the response and recovery.

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Team rubicon volunteers help with Harvey relief efforts CNN News Live

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Team rubicon volunteers help with Harvey relief efforts CNN News Live

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Team Rubicon Helps Hurricane Harvey Victims

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Team Rubicon is a nonprofit group that recruits, trains and deploys military veterans and first responders to disasters in the U.S. and around the globe.

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https://webbrain.com/u/1AYU

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Official websites use .gov

A .gov website belongs to an official government organization in the United States.

Secure .gov websites use HTTPS

A lock ( ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. .

FEMA's veterans have continued serving their country after leaving military service. We proudly recognize and celebrate all veterans this Veterans Day, especially those within our workforce.

Individual Assistance

Grants to disaster survivors (in millions) so far in 2023.

2023 Mitigation Grants

Number of hazard mitigation assistance sub-grants so far in 2023.

2023 Disaster Declarations

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Official websites use .gov A .gov website belongs to an official government organization in the United States. Secure .gov websites use HTTPS A lock ( ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. .

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Disaster relief without collaboration is like trying to win a soccer game with boxes on your head.

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Disaster relief without collaboration is like trying to win a soccer game with boxes on your head.

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Luckily, Crisis Cleanup is here to help!

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Always-Ready Open Source Disaster Relief Mapping and Work Coordination * 27,696 helped * 69 disasters * 5 countries * 776 organizations * 118,085 volunteers * $37.8M impact * Free

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325 TR volunteers are manning the @CrisisCleanup hotline, which has received over 5,000 requests for assistance in response to #Harvey.

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Military vets bring specialized skillset to Harvey response

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Jon Connors, a Marine veteran from New Jersey and the Public Information Officer for Team Rubicon, updates water rescue operations in Houston