Uniformed Services University of the Health Sciences

“Learning to Care for Those in Harm’s Way”

Board of Regents Quarterly Meeting

May 15, 2020 BOARD OF REGENTS UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES 210th MEETING

May 15, 2020 | 8:00 a.m. Hosted virtually (online) | Bethesda, MD

MEETING AGENDA

OPEN MEETING

8:00 a.m.: Meeting Call to Order Designated Federal Officer Ms. Sarah Marshall

8:00 - 8:05 a.m.: Opening Comments Chair, Board of Regents, Uniformed Services University of the Health Sciences (USU) Dr. Jonathan Woodson

8:05 - 8:10 a.m.: Matters of General Consent Declaration of Board Actions Dr. Woodson

8:10 - 8:20 a.m.: Board Actions Degree Conferrals, Hébert School of Medicine (SOM) Dean Dr. Arthur Kellermann Degree Conferrals, Postgraduate Dental College (PDC) Executive Dean Dr. Thomas Schneid Degree Conferrals, College of Allied Health Science (CAHS) Acting Dean Dr. Lula Pelayo

Faculty Appointments and Promotions, SOM Dean Dr. Kellermann Faculty Appointments and Promotions, PDC Dean Dr. Schneid

Faculty Recognition, GSN Dean Dr. Romano

8:20 - 8:40 a.m.: Office of the USU President Report President, USU Dr. Richard Thomas

8:40 – 8:50 a.m.: Office of the Assistant Secretary of Defense (Health Affairs) Report ASD (HA) HON Thomas McCaffery

8:50 - 9:05 a.m.: School of Medicine Report Dean, SOM Dr. Arthur Kellermann

9:05- 9:20 a.m.: Graduate School of Nursing Report Dean, GSN Dr. Carol Romano

9:20 - 9:35 a.m.: Postgraduate Dental College Report Dean, PDC Dr. Thomas Schneid

9:35 - 9:50 a.m.: College of Allied Health Sciences Acting Dean, CAHS Dr. Lula Pelayo

9:50 - 9:55 a.m.: Office of Accreditation and Organizational Assessment Assistant Vice President Mr. Steve Henske

10:05 - 10:15 a.m.: Office of the Vice President for Finance and Administration Vice President Mr. Walt Tinling

10:15 - 10:20 a.m.: USU Brigade Report Brigade Commander CAPT Sean Hussey

10:20 - 10:25 a.m.: Closing Comments Board Chair Dr. Woodson

CLOSED MEETING

10:30a.m. – 10:50 a.m.: Active Investigations. A report on active investigations at the University will be provided to the Board. The report will contain sensitive personnel information, may involve accusing a person of a crime or censuring an individual, and may disclose investigatory records.

Personnel Actions. A report on significant personnel actions will be provided to the Board and will contain sensitive personnel information and material that relates solely to the internal personnel rules and practices of the University. BOARD OF REGENTS UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES 210th MEETING

May 15, 2020 | Bethesda, Maryland (virtual)

TABLE OF CONTENTS

Governing Documents • TAB 1 … Charter • TAB 2 … Membership Balance Plan • TAB 3 … Bylaws • TAB 4 … Current Membership

Administrative Documents • TAB 5 … Board Meeting Calendar • TAB 6 … Closed Session Determination • TAB 7 … Federal Register Notice

Matters of General Consent • TAB 8 … Chair’s Opening Comments • TAB 9 … Previous Meeting Minutes • TAB 10 … Declaration of Board Actions

Board Actions • TAB 11 … Degree Conferrals, F. Edward Hébert School of Medicine • TAB 12 … Degree Conferrals, Postgraduate Dental College • TAB 13 … Degree Conferrals, College of Allied Health Sciences • TAB 14 … Faculty Appointments and Promotions, Hébert School of Medicine • TAB 15 … Faculty Appointments and Promotions, Postgraduate Dental College • TAB 16 … Faculty Recognition, Inouye Graduate School of Nursing

Reports to the Board of Regents • TAB 17 … University President • TAB 18 … Assistant Secretary of Defense (Health Affairs) • TAB 19 … Hébert School of Medicine • TAB 20 … Inouye Graduate School of Nursing • TAB 21 … Postgraduate Dental College • TAB 22 … College of Allied Health Sciences • TAB 23 … Accreditation and Organizational Assessment • TAB 24 … Vice President for Finance and Administration • TAB 25 … University Brigade Commander Supplemental Documents • TAB 26 … Supplement TAB 1 Charter Charter Board of Regents, Uniformed Services University of the Health Sciences

1. Committee’s Official Designation: The Committee will be known as the Board of Regents, Uniformed Services University of the Health Sciences (“the Board”).

2. Authority: The Secretary of Defense, pursuant to 10 U.S.C. § 2113a and in accordance with the Federal Advisory Committee Act (FACA) (5 U.S.C., Appendix) and 41 C.F.R. § 102-3.50(a), established this non-discretionary Board.

3. Objectives and Scope of Activities: The Board shall assist the Secretary of Defense in an advisory capacity in carrying out the Secretary’s responsibility to conduct the business of the Uniformed Services University of the Health Sciences (“the University”).

4. Description of Duties: The Board shall provide advice and recommendations on academic and administrative matters critical to the full accreditation and successful operation of the University.

5. Agency or Official to Whom the Committee Reports: The Board reports to the Secretary of Defense and the Deputy Secretary of Defense, through the Under Secretary of Defense for Personnel and Readiness (USD(P&R)), who may act upon the Board’s advice and recommendations.

6. Support: The Department of Defense (DoD), through the Office of the USD(P&R), provides the necessary support for the Board and ensures compliance with the requirements of the FACA, the Government in the Sunshine Act of 1976 (5 U.S.C. § 552b) (“the Sunshine Act”), governing Federal statutes and regulations, and established DoD policies and procedures.

7. Estimated Annual Operating Costs and Staff Years: The estimated annual operating cost, to include travel, meetings, and contract support, is approximately $252,279.00. The estimated annual personnel cost to the DoD is 1.3 full-time equivalents.

8. Designated Federal Officer: The Board's Designated Federal Officer (DFO), pursuant to DoD policy, shall be a full-time or permanent part-time DoD officer or employee designated in accordance with DoD policies and procedures.

The Board's DFO is required to be in attendance at all Board and subcommittee meetings for the entire duration of each and every meeting. However, in the absence of the Board’s DFO, a properly approved Alternate DFO, duly designated to the Board in accordance with DoD policies and procedures, shall attend the entire duration of all Board or subcommittee meetings.

The DFO, or the Alternate DFO, calls all Board meetings; prepares and approves all meeting agendas; and adjourns any meeting when the DFO, or the Alternate DFO, determines adjournment to be in the public interest or required by governing regulations or DoD policies and procedures.

9. Estimated Number and Frequency of Meetings: The Board meets at the call of the Board’s DFO, in consultation with the Board’s Chair. The Board shall meet at least once a quarter.

10. Duration: The need for this advisory function is on a continuing basis; however, this charter is subject to renewal every two years.

1 Charter Board of Regents, Uniformed Services University of the Health Sciences

11. Termination: The Board terminates upon rescission of 10 U.S.C. § 2113a.

12. Membership and Designation: Pursuant to 10 U.S.C. § 2113a(b), the Board shall be composed of 15 members, appointed or designated as follows:

a. nine persons outstanding in the fields of health care, higher education administration, or public policy, who shall be appointed from civilian life by the DoD Appointing Authorities;

b. the Secretary of Defense, or his or her designee, who shall be an ex-officio member;

c. the Surgeons General of the Uniformed Services, who shall be ex-officio members; and

d. the President of the University, who shall be a non-voting, ex-officio member.

As directed by 10 U.S.C. § 2113a(c), the term of office of each member of the Board (other than ex- officio members) shall be six years except that:

a. any member appointed to fill a vacancy occurring before the expiration of the term for which his or her predecessor was appointed shall be appointed for the remainder of such term; and,

b. any member whose term of office has expired shall continue to serve until his orhersuccessor is appointed.

In accordance with 10 U.S.C. § 2113a(d), one of the members of the Board (other than an ex- officio member) shall be designated as Chair by the DoD Appointing Authorities and shall be the presiding officer of the Board.

Board members who are not ex-officio members shall be appointed by the DoD Appointing Authorities, and their appointments will be renewed on an annual basis according to DoD policies and procedures. No member, unless approved by the DoD Appointing Authorities, may serve more than two consecutive terms of service on the Board, to include its subcommittees, or serve on more than two DoD federal advisory committees at one time.

Members of the Board who are not full-time or permanent part-time Federal officers or employees will be appointed as experts or consultants, pursuant to 5 U.S.C. § 3109, to serve as special government employee (SGE) members. Board members who are full-time or permanent part-time Federal officers or employees will be appointed, pursuant to 41 C.F.R. § 102-3.130(a), to serve as regular government employee (RGE) members.

All members of the Board are appointed to provide advice on the basis of their best judgment without representing any particular point of view and in a manner that is free from conflict of interest.

Pursuant to 10 U.S.C. § 2113a(e), Board members (other than ex-officio members), while attending conferences or meetings or while otherwise performing their duties as members, shall be entitled to receive compensation at a rate to be fixed by the Secretary of Defense. Each member is reimbursed

2 Charter Board of Regents, Uniformed Services University of the Health Sciences

for travel and per diem as it pertains to official business of the Board.

13. Subcommittees: The DoD, when necessary and consistent with the Board’s mission and DoD policies and procedures, may establish subcommittees, task forces, or working groups to support the Board. Establishment of subcommittees will be based upon a written determination, to include terms of reference, by the DoD Appointing Authorities or the USD(P&R) as the Board’s Sponsor. All subcommittees operate under the provisions of the FACA, the Sunshine Act, governing Federal statutes and regulations, and DoD policies and procedures.

Such subcommittees shall not work independently of the Board and shall report all their recommendations and advice solely to the Board for its thorough discussion and deliberation at a properly noticed and open meeting, subject to the Government in the Sunshine Act. Subcommittees, task forces, or working groups have no authority to make decisions and recommendations, verbally or in writing, on behalf of the Board. Neither the subcommittee nor any of its members may provide updates or reports directly to the DoD or any Federal officer or employee. If a majority of Board members are appointed to a particular subcommittee, then that subcommittee may be required to operate pursuant to the same notice and openness requirements of the FACA which govern the Board’s operations.

The appointment of individuals to serve on Board subcommittees shall be approved by the DoD Appointing Authorities for a term of service of one-to-four years, with annual renewals, in accordance with DoD policy and procedures. No member shall serve more than two consecutive terms of service on the subcommittee without prior approval from the DoD Appointing Authorities. Subcommittee members, if not full-time or permanent part-time Federal officers or employees, shall be appointed as an expert or consultant pursuant to 5 U.S.C. § 3109 to serve as an SGE member. Subcommittee members who are full-time or permanent part-time Federal officers or employees shall be appointed pursuant to 41 C.F.R. § 102-3.130(a) to serve as an RGE member.

Each subcommittee member is appointment to provide advice on the basis of his or her best judgment without representing any particular point of view and in a manner that is free from conflict of interest.

All subcommittees operate under the provisions of FACA, the Sunshine Act, governing Federal statutes and regulations, and established DoD policies and procedures.

Individuals who are appointed as subcommittee leaders in accordance with DoD policy shall serve a one-to-two year term of service, with annual renewal, provided the leadership term of service does not exceed the member’s approved subcommittee appointment.

14. Recordkeeping: The records of the Board and its subcommittees shall be managed in according with General Record Schedule 6.2, Federal Advisory Committee Records, or other approved agency records disposition schedule, and the appropriate DoD policies and procedures. These records will be available for public inspection and copying, subject to the Freedom of Information Act of 1966 (5 U.S.C. § 552, as amended).

15. Filing Date: May 2, 2019

3 TAB 2 Membership Balance Plan Membership Balance Plan Board of Regents, Uniformed Services University of the Health Sciences

Agency: Department of Defense (DoD)

1. Authority: The Secretary of Defense, pursuant to 10 U.S.C. § 2113a and in accordance with the Federal Advisory Committee Act (FACA) (5 U.S.C., Appendix) and 41 C.F.R. § 102-3.50(a), established the non-discretionary Board of Regents, Uniformed Services University of the Health Sciences (“the Board”).

2. Mission/Function: The Board shall assist the Secretary of Defense in an advisory capacity in carrying out the Secretary’s responsibility to conduct the business of the Uniformed Services University of the Health Sciences (“the University”). The Board shall provide advice and recommendations on academic and administrative matters critical to the full accreditation and successful operation of the University.

3. Points of View: Pursuant to 10 U.S.C. § 2113a(b), the Board shall be composed of 15 members, appointed or designated as follows:

a. nine persons outstanding in the fields of health care, higher education administration, or public policy, who shall be appointed from civilian life by the DoD Appointing Authorities;

b. the Secretary of Defense, or his or her designee, who shall be an ex-officio member;

c. the Surgeons General of the Uniformed Services, who shall be ex-officio members; and

d. the President of the University, who shall be a non-voting, ex-officio member.

Board members who are not ex-officio members shall be appointed by the DoD Appointing Authorities and their appointments will be renewed on an annual basis according to DoD policies and procedures. No member, unless approved by the DoD Appointing Authorities, may serve more than two consecutive terms of serve on the Board, to include its subcommittees, or serve on more than two DoD federal advisory committees at one time.

Members of the Board who are not full-time or permanent part-time Federal officers or employees will be appointed as experts or consultants, pursuant to 5 U.S.C. § 3109, to serve as special government employee (SGE) members. Board members who are full-time or permanent part-time Federal officers or employees will be appointed, pursuant to 41 C.F.R. § 102-3.130(a), to serve as regular government employee (RGE) members.

All members of the Board are appointed to provide advice on the basis of their best judgment without representing any particular point of view and in a manner that is free from conflict of interest.

The DoD has found that viewing the complex issues facing the Department through a multidisciplinary advisory committee provides the Department and, more importantly, the American public with a broader understanding of the issues on which to base subsequent policy decisions.

4. Other Balance Factors: NA

1 Membership Balance Plan Board of Regents, Uniformed Services University of the Health Sciences

5. Candidate Identification Process: The DoD, in selecting potential candidates for the Board, reviews the educational and professional credentials of individuals with extensive professional experience in the areas of health care, higher education administration, or public policy.

The Designated Federal Officer (DFO), in consultation with the Office of the Assistant Secretary of Defense for Health Affairs (ASD(HA)), and their professional staffs, as well as through recommendations by current members of the Board. The DFO, consulting with the ASD(HA), reviews the credentials of each individual and narrows the list of potential candidates. During the review, he or she strives to achieve a balance between the educational and professional credentials of the individuals and the subject matter likely to be reviewed by the Board. The ASD(HA), based on the approval of the Secretary of Defense, is the Secretary of Defense representative to the Board.

After the list of candidates has been narrowed, it is forwarded to the USD(P&R) for further scrutiny and formal nomination to the Secretary of Defense, the Deputy Secretary of Defense, and/or the Committee Management Officer for the Department of Defense (CMO) (“DoD Appointing Authorities”). Once the USD(P&R) has narrowed the list of candidates and before formal nomination to the Appointing Authorities, the list will undergo a review by the DoD Office of the General Counsel and the Advisory Committee Management Officer (ACMO) to ensure compliance with the Board’s statute, charter, and membership balance plan. Following this review, the ACMO forwards the list of potential nominees for approval by the DoD Appointing Authorities.

The DoD Appointing Authorities shall approve the appointment of members to the Board (other than ex-officio members) for a six-year term of service, except those Board members appointed to fill a vacancy occurring before the expiration of the term for which the predecessor was appointed shall be appointed for the remainder of such term. Any Board member whose term of office has expired shall continue to serve until the successor is appointed. No member may serve more than two consecutive terms of service without approval from the DoD Appointing Authorities.

Following approval by the DoD Appointment Authorities, the candidates are required to complete the necessary appointment paperwork, to include meeting ethics requirements stipulated by the Office of Government Ethics for advisory committee members. All appointment paperwork must be submitted to the appropriate DoD offices and processed at the earliest opportunity in accordance with DoD policy and procedures. If the required paperwork is not processed in accordance with DoD policy and procedures, the member will not be able to participate in any Board-related work or deliberation until all of his or her appointment processing actions are completed.

Membership vacancies for the Board and any subcommittees will be filled in the same manner as described in this section.

6. Subcommittee Balance: The DoD, when necessary and consistent with the Board’s mission and DoD policies and procedures, may establish subcommittees, task forces, or working groups to support the Board.

Individuals considered for appointment to any subcommittee of the Board may come from the Board itself or from new nominees, as recommended by the USD(P&R) and based upon the subject matters

2 Membership Balance Plan Board of Regents, Uniformed Services University of the Health Sciences

under consideration. Pursuant to DoD policy and procedures, the USD(P&R) shall follow the same procedures used for selecting and nominating individuals for appointment consideration by the DoD Appointing Authorities.

Subcommittee members will be appointed for a term of service of one-to-four years, subject to annual renewals; however, no member will serve more than two consecutive terms of service on the subcommittee unless previously authorized by the DoD Appointing Authorities. Subcommittee members, if not full-time or permanent part-time Federal officers or employees, shall be appointed as experts or consultants pursuant to 5 U.S.C. § 3109 to serve as SGE members. Subcommittee members, if not full-time or permanent part-time Federal officers or employees shall serve as RGE members pursuant to 41 C.F.R. § 102-3.130(a).

7. Other: As nominees are considered for appointment to the Board, the DoD adheres to the Office of Management and Budget’s Revised Guidance on Appointment of Lobbyists to Federal Committees, Boards, and Commissions (79 FR 47482; August 13, 2014) and the rules and regulations issued by the Office of Government Ethics.

8. Date Prepared/Updated: May 2, 2019

3 TAB 3 Bylaws

TAB 4 Current Membership BOARD OF REGENTS UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES

CURRENT MEMBERSHIP

NAME TITLE TERM EXP Ronald R. Blanck, D.O. Member, Board of Regents June 20, 2019c Honorable Sheila P. Burke, R.N., M.P.A. Member, Board of Regents July 19, 2023c GEN Richard Cody, USA, Ret Member, Board of Regents November 4, 2025 Michael M.E. Johns, M.D. Member, Board of Regents June 20, 2019c Kenneth P. Moritsugu, M.D., M.P.H. Member, Board of Regents June 20, 2019c Leo E. Rouse, D.D.S. Member, Board of Regents May 13, 2021b Honorable Gail R. Wilensky, Ph.D. Member, Board of Regents June 20, 2019a Honorable Jonathan Woodson, M.D. Chair, Board of Regents June 20, 2025b Thomas P. McCaffery, M.P.P. Secretary of Defense Designee and Ex officio Assistant Secretary of Defense for Health Affairs* Richard W. Thomas, M.D., D.D.S. President, USU** Ex officio LTG Raymond S. Dingle, MS, USA Surgeon General, United States Army Ex officio VADM Bruce Gillingham, MC, USN Surgeon General, United States Navy Ex officio Lt Gen Dorothy A. Hogg, USAF, NC Surgeon General, United States Air Force Ex officio VADM Jerome M. Adams, USPHS Surgeon General of the United States Ex officio

Gen Thomas R. Morgan, USMC (Ret) Military Advisor to the Board Advisor LTG Ronald J. Place, MC, USA Director, Defense Health Agency Advisor Brig Gen Paul Friedrichs, USAF, MC Joint Staff Surgeon Advisor RDML James L. Hancock, MC, USN Medical Officer of the Marine Corps Advisor Brig Gen Shanna Woyak, USAF, NC Director, National Capital Region Advisor Medical Directorate COL Andrew Barr, MC, USA Director, Walter Reed National Military Advisor Medical Center Thomas W. Travis, M.D., M.P.H. Senior Vice President, Southern Region Advisor William M. Roberts, M.D., M.B.A. Senior Vice President, Western Region Dean, F. Advisor Arthur L. Kellermann, M.D., M.P.H. Edward Hébert School of Medicine Advisor Carol A. Romano, Ph.D., R.N. Dean, Daniel K. Inouye Graduate School of Advisor Nursing Thomas R. Schneid, D.M.D., M.S. Executive Dean, Postgraduate Dental College Advisor Lula W. Pelayo, Ph.D., M.S.N., R.N. Acting Dean, College of Allied Health Sciences Advisor CAPT Danielle Wooten, MSC, USN Director, Armed Forces Radiobiology Research Advisor Institute Mark E. Peterson, J.D. Legal Advisor to the Board of Advisor Jeffrey L. Longacre, M.D. Regents Executive Secretary Sarah Marshall Designated Federal Officer

a – currently serving predecessor’s term; b – currently serving first term; c – currently serving second term *The Secretary of Defense or designee is by statute an ex officio member. **The President, USU is a non-voting ex officio member as defined by statute. TAB 5 Board Meeting Calendar Board of Regents Uniformed Services University of the Health Sciences

Board Meeting Calendar (2020-2021)

*Note: all meetings will occur at USU Bethesda Campus unless stated otherwise

Preparatory Session Meeting of Record

Friday, May 15, 2020 Monday, August 3, 2020 Tuesday, August 4, 2020 Monday, November 2, 2020 Tuesday, November 3, 2020 Monday, February 1, 2021 Tuesday, February 2, 2021 Thursday, May 14, 2021 Friday, May 15, 2021 Monday, August 2, 2021 Tuesday, August 3, 2021 Monday, November 1, 2021 Tuesday, November 2, 2021

**Saturday, May 16, 2020 – Class of 2020 Commencement**

Faculty Packet Due Dates (2020)

*Note: packets not received by due date will not be presented at Board meeting

Meeting of Record Faculty Packets Due to CHR February 4, 2020 December 23, 2019 May 15, 2020 April 3, 2020 August 4, 2020 June 23, 2020 November 3, 2020 September 22, 2020

As of April 2020 TAB 6 Closed Session Determination

TAB 7 Federal Register Notice TAB 8 Chair’s Opening Comments Board Chair’s Opening Comments

• Welcome

• Board of Regents Bylaws

• Next Board of Regents meeting – May 2020 o August 3-4, 2020 (USU Campus- San Antonio offsite postponed)

• Regent Terms o Two submissions submitted

• Calendar for 2020 and 2021 Board meetings found at Tab 5

• Closed session following the open session o active investigations o personnel actions

TAB 9 Previous Meeting Minutes TAB 10 Declaration of Board Actions

PROPOSED FACULTY RECOMMENDATIONS ELECTRONIC VOTE BOR LIST

DEPARTMENT/NAME PROPOSED RANK ACTION/CURRENT DUTY STATION Primary Appointments (Billeted)

SCHOOL OF MEDICINE

PREVENTIVE MEDICINE AND BIOSTATISTICS

OKECH, Bernard Associate Professor Appointment/ PhD, MPH Non-Tenured USUHS

SINGER, Darrell Associate Professor Appointment/ MD, MPH Non-Tenured USUHS

SURGERY

REMICK, Kyle Professor Appointment/ MD Non-Tenured USUHS

UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES GRADUATE EDUCATION OFFICE, SOM 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814-4799 www.usuhs.edu

February 19, 2020

MEMORANDUM FOR: Dr. Saibal Dey, Ph.D., Associate Dean for Graduate Education Dr. Jeffrey Longacre, M.D., COL, MC, USA (Ret), Vice President for External Affairs

FROM: Dr. Andrew Snow, Ph.D., Assistant Dean for Graduate Education, USUHS

SUBJECT: 2020 Board of Regents Award Recipient Recommendation

As you know, the Board of Regents (BoR) Award is the highest honor a USU student can receive. This year, four graduate students slated to graduate by May were nominated by their respective Program Directors for the BoR Award: Omni Cassidy (MPS), Patrick LaBreck (EID), Nikki McCormack (NES), and Erin Sheffels (MCB).

I assembled a Selection Committee comprised of one faculty representative from each of our six graduate programs. The Committee included Dr. Anwar Ahmed (PMB), CAPT Anthony Artino (HPE), Dr. Marjan Holloway (MPS), Dr. Sharon Juliano (NES), Dr. Edward Mitre (EID), and Dr. Galina Petukhova (MCB). I supervised the application review process on behalf of the Graduate Education Office as a non-voting participant. Committee members were asked to carefully review each application and rank each nominee from 1-4 based on criteria articulated in the program announcement, focusing on scholarship, leadership, and service.

The Selection Committee met today and came prepared to discuss each nominee and explain their rankings. Although the entire Committee agreed that all four nominees were truly outstanding, two exceptional candidates emerged: Omni Cassidy and Erin Sheffels. It is important to note that the exemplary accomplishments of each student reflect significant differences in their home programs and the nature of their dissertation work. After a lengthy and thoughtful discussion, however, the Committee recommended that both students are equally deserving, and both should be named as co-winners.

To my knowledge there is no precedent for naming more than one BoR Award winner from an individual school. Therefore, based on consensus from a majority of Committee members, we are delighted to recommend Dr. Omni Cassidy as the recipient of the 2020 BoR Award for the USU Graduate Program.

It is difficult to overstate the many remarkable contributions these fine graduate students have made to advance the mission of our University, reflecting incredible research productivity, dedication, and selfless service. On behalf of the Selection Committee and GEO, I look forward to seeing Dr. Cassidy recognized as the BoR Award winner at Commencement this year. I also hope we may find some way of recognizing Erin Sheffels as a very close runner-up; I am grateful for any opportunity to highlight the awe-inspiring graduate students that represent the very best of USU.

Sincerely,

Andrew Snow, Ph.D. Assistant Dean for Graduate Education Associate Professor, Department of Pharmacology & Molecular Therapeutics

Learning to Care for Those in Harm’s Way Omni Cassidy

Work: (301) 295-0581 E-mail: [email protected]

EDUCATION Uniformed Services University of the Health Sciences, Bethesda, MD (Oct 2014 - present) Degree Sought: Ph.D.; Program: Clinical Psychology; Anticipated Graduation: May 2019

Uniformed Services University of the Health Sciences (USUHS), Bethesda, MD (Aug 2012- Oct 2014) Degree: M.S.; Program: Clinical Psychology

Washington University in St. Louis, St. Louis, MO (July 2006 - May 2010) Degree: B.A. (with honors in psychology); Major: Psychology; Minor: Women & Gender Studies

SELECTED HONORS & AWARDS • Ruth L. Kirschstein National Research Service Award (NRSA) to Promote Diversity in Health-Related Research, National Institute of Minority Health and Health Disparities, National Institutes of Health, 1F31MD010675-01 (2016) • USUHS Intramural Student Training Grant, T0723825 (2016, 2015) • National Science Foundation Social, Behavioral, Economic Sciences Summer Research Fellow, University of Miami (2008) • Psi Chi - International Honor Society in Psychology (2008)

SELECTED RESEARCH EXPERIENCES Graduate Student-Research Assistant, Center for Health Disparities, and the Developmental Laboratory for Eating and Weight Disorders, USUHS Bethesda, MD (Aug 2012 - present) Advisors: Tracy Sbrocco, Ph.D. & Marian Tanofsky-Kraff, Ph.D.

Research Assistant, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of HealthIUSUHS, Bethesda, MD (July 2010 - July 2012) Supervisors: Marian Tanofsky-Kraff, Ph.D., Jack Yanovski, M.D., Ph.D.

SELECTED MANUSCRIPTS & PUBLICATIONS Shomaker, LB, Kelly, NR, Pickworth, CK, Cassidy, OL, Radin, RM, Shank, LM, Vannucci, A, Thompson, KA, Armaiz-Flores, SA, Brady, SM, Demidowich, AP, Galescu, OA, Courville, AB, Olsen, C, Chen, KY, Stice, E, Tanofsky-Kraff, M, Yanovski JA. (2016) A randomized controlled trial to prevent depression and ameliorate insulin resistance in adolescent girls at-risk for type 2 diabetes. Annals of Behavioral Medicine (in press).

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Cassidy 2

Tanofsky-KraffM, Crosby RD, Vannucci A, Kozlosky M, Shomaker LB, Brady SM, Sbrocco T, Pickworth CK, Stephens M, Young JF, Olsen CH, Kelly NR, Radin R, Cassidy 0, Wilfley DE, Reynolds JC, Yanovski JA. (2016). Effect of adapted interpersonal psychotherapy versus health education on mood and eating in the laboratory among adolescent girls with loss of control eating. International Journal of Eating Disorders, 49(5), 490-498.

Schvey, NB, Shomaker, LB, Kelly, NR, Pickworth CK, Cassidy, 0, Galescu, 0, Demidowich, AP, Brady, SM, Tanofsky-KraffM, Yanovski, JA. (2015). Pressure to be thin and iInsulin sensitivity among adolescents. Journal of Adolescent Health. Journal of Adolescent Health, 58(1), 104-110.

Pivarunas, B, Kelly, NR, Pickworth, CK, Cassidy, 0, Radin, RM, Shank, LM, Vannucci, A, Courville, AB, Chen, KY, Tanofsky-Kraff, M, Yanovski, JA, Shomaker, LB. (2015) Mindfulness and eating behavior in adolescent girls at risk for type 2 diabetes. International Journal of Eating Disorders, 48, 563-569.

Shank, LM, Tanofsky-Kraff, M, Nelson, EE, Shomaker, LB, Ranzenhofer, LM, Hannallah, LM, Field, SE, Vannucci, A, Bongiorno, OM, Brady, SM, Condarco, T, Demidowich, A, Kelly, NR, Cassidy, 0, Simmons, WK, Engel, SG, Pine, DS, Yanovski, JA. (2014). Attentional bias to food cues in youth with loss of control eating. Appetite, 87, 68-75.

Cassidy, 0., Eichen D., Burke, N. L., Patmore, 1., Shore, A., Radin, R. M., Sbrocco, T., Shomaker, L. B., Mirza, N., Young, J. F., Wilfley, D. E., Tanofsky-Kraff, M. (under blind review)

Cassidy, 0, Sbrocco, T, Tanofsky-Kraff, M. (2014). Utilising non-traditional research designs to explore culture-specific risk factors for eating disorders in African-American adolescents. Advances in Eating Disorders: Theory, Research and Practice, 3(1), 91-102.

Cassidy, 0, Sbrocco, T, Vannucci, A, Nelson, B, Heimdal, J, Mirza, N, Wifley, DE, Osborn, R, Shomaker, L, Young, JF, Waldron, H, Carter, M, Jackson-Bowen, 0, Tanofsky-Kraff, M. (2014). Adapting Interpersonal Psychotherapy for the Prevention of Excessive Weight Gain in Rural African American girls. Journal of Pediatric Psychology [Special Issue on Innovative Treatment and Prevention Programs Addressing Pediatric Obesity], 38(9), 965-977.

Shank, L. M., Tanofsky-Kraff, M., Nelson, E. E., Shomaker, L. B., Ranzenhofer, L. M., Hannallah, L. M., Field, S. E., Vannucci, A., Bongiorno, D. M., Brady, S. M., Condarco, T., Demidowich, A., Kelly, N. R., Cassidy, 0., Simmons, W. K., Engel, S. G., Pine, D. S., Yanovski, J. A. (2014). Attentional bias to food cues in youth with loss of control eating. Appetite, 87, 68-75.

Cassidy, 0. L., Matheson, B., Osborn, R., Vannucci, A., Kozlosky, M., Shomaker, L. B., Yanovski, S. Z., Tanofsky-Kraff, M. (2012). Loss of control eating in African-American and Caucasian youth. Eating Behaviors, 13(2), 174-178.

1499 Massachusetts Avenue NW #1314 Chandler Washington, D.C. 20005 904.651.3553 M Bennett [email protected] ENS, MC, USN

____ Uniformed Services University of the Health Sciences Education M.D. Candidate 2016 - PRESENT, BETHESDA, MD

Georgetown University B.S. Biology 2010 - 2014, WASHINGTON, D.C.

____ Military History Naval Hospital Jacksonville / Research Assistant for Public Health Directorate FEB 2016 - MAY 2016, JACKSONVILLE, FL Immunization and screening chart review to inform provider behavior at the hospital and affiliated branch clinics, shadowed Family Medicine providers

Naval Support Activity Saratoga / Public Affairs Officer & Executive Assistant to the Commanding Officer MAY 2015 - JAN 2016, SARATOGA SPRINGS, NY Managed schedule of commanding officer and base facilities, accountable for medical readiness of over 30 sailors, coordinated and performed funeral honors for local military veterans

Naval Nuclear Power Training Unit / Student Officer MAR 2015 - MAY 2015, BALLSTON SPA, NY Trained as Engineering Officer of the Watch, the leader of a watch team charged with the safe operation of a nuclear power plant

Naval Nuclear Power Training Command / Student Officer SEP 2014 - FEB 2015, GOOSE CREEK, SC Studied graduate level nuclear engineering and physics, graduated with honors

Naval Reserve Officer Training Corps, GWU Consortium / Midshipman AUG 2010 - MAY 2014, WASHINGTON, D.C.

Chandler M. Bennett 2

____ USU/WRNMMC Expeditionary Craniofacial Trauma Course Certifications & Licensure JUN 2019 8 hour course of otolaryngology, neurosurgery, ophthalmology, OMFS, and plastic surgery lectures and correlated cadaveric dissection

USMLE Step 2 CK- Pass, Score 269 MAY 2019

Advanced Trauma Life Support MAR 2019

Advanced Life Support FEB 2019

Basic Life Sup port FEB 2019

USMLE Step 1- Pass, Score 257 JAN 2019

SAPR Victim Advocate Course JUL 2015

40 hour certification course to serve as Sexual Assault Prevention and Response Victim Advocate

____ Alpha Omega Alpha Honor Medical Society / USU HS, Maryland Gamma Honors & Awards Chapter 2019 Awarded to 16% of class for scholastic achievement, professionalism, leadership, community service, and research. Gold Humanism Honor Society / USUHS Chapter 2019 Peer nominated honor society that promotes humanism in medicine. Dean’s Award for Academic Excellence / Clinical Clerkships 2019 Awarded to students that earned Honors in all core clerkships Dean’s Award for Academic Excellence / Pre -Clerkship Courses 2019 Awarded to students that earned Honors in all pre-clerkship courses Cervantes Award for International Surgery Travel / USU HS, Department of Surgery 2019 Awarded to two senior medical students for academic excellence, leadership, surgical promise, and advanced Spanish language skills to complete a surgical

Prepared February 2020

Chandler M. Bennett 3 clerkship with the Escuela Médico Militar in Mexico City, Mexico. Academic Honors / GWU NROTC 2010-2014, WASHINGTON, D.C.

National Leadership Award / Military Order of the Purple Heart 2014 National leadership award for NROTC midshipmen

Navy Reserve Officer Training Corps Scholarship / GWU NROTC 2010-2014, WASHINGTON, D.C.

National Defense Service Medal 2014

Dean’s List / Georgetown University 2010-2012, WASHINGTON, D.C.

Voyage of Discovery Awardee / National Italian American Foundation 2013, CALABRIA, ITALY Awarded a scholarship to travel to Italy for historical and cultural education

Arabic Language Intensive Study Scholarship / Project Global Officer, Qasid Institute 2012, AMMAN, JORDAN Intensive language study and travel scholarship

____ Graduation Committee Chairman / USUHS SOM, Class of 2020 Leadership MAY 2019 - PRESENT Student leader for commencement activities including oversight of a budget of approximately $30,000

Co-Lead of the Cadaver Memorial Ceremony Committee / Gold Humanism Honor Society, USUHS Chapter JUN 2019 Planned and executed a c eremony to commemorate donors and provide an opportunity for first year medical students to reflect on their experience working with cadavers

Visiting Professor Student Coordinator / Alpha Omega Alpha Honor Medical Society, USUHS, Maryland Gamma Chapter MAY 2019 – PRESENT Host a visiting professor on campus for teaching, leadership and interaction with medical students, residents and fellows to promote educational excellence, continued pursuit of learning, and AOA Honor Medical Society on campus.

Prepared February 2020

Chandler M. Bennett 4

Site Leader / Int ernal Medicine & Psychiatry Clerkship, Walter Reed National Military Medical Center SEPT 2018 - DEC 2018 Served as staff-student liaison for non-academic issues, including student well- being and malt reatment issues for 12 students

Student Leader / Navy Medicine Operational Training Center Summer Experience AUG 2017 Served as leader of five medical students for a two -week operational medicine course in Pensacola, FL

Co-President / Obstetrics & Gynecology Student Interest Group, USUHS SOM DEC 2016 - DEC 2017 Planned and executed regular meetings and educational opportunities for medical students interested in obstetrics and gynecology

Battalion Operations Officer / Naval Reserve Officer Training Corps, GWU Consortium 2010-2014, WASHINGTON, D.C. Student coordinator for all training and athletic events for the battalion of 130 midshipmen, produced weekly instructional letters

____ American Academy of Otolaryngology-Head and Neck Surgery / Student Professional Member Memberships 2019 - PRESENT Association of Military Surgeons of the United States / Student Member 2018 - PRESENT

American Association of Neurological Surgeons / Student Member 2018 - PRESENT

American Academy of Family Physicians / Student Member 2018 - PRESENT

American College of Obstetrics and Gynecology / Student Member 2018 - PRESENT

Prepared February 2020

Chandler M. Bennett 5

____ Preceptor / Medical Interviewing, USUHS SOM SEP 2019 - OCT 2019 Educational Activities Taught medical interviewing skills to first year medical students through instruction, standardized patient simulation, and inpatient demonstration at WRNMMC

____ Chandler Bennett; Michael Eliason, MD; Marco Ayala, MD. Differentiating Presentations Vagal Nerve Schwannoma from Cervical Sympathetic Chain Schwannoma: A Case Report and Review of the Literature. USUHS Founders’ Day, Bethesda, MD. September 2019.

Chandler Bennett; Sara Robinson, MD; Sandra Van Horn, MD; Janine Danko, MD. Idiopathic CD4 Lymphocytopenia with Disseminated Histoplasmosis and Pulmonary Cryptococcosis: A Case Report. D.C. ACP, Washington, D.C. May 2019.

Chandler Bennett; Sara Robinson, MD; Sandra Van Horn, MD; Janine Danko, MD. Idiopathic CD4 Lymphocytopenia with Disseminated Histoplasmosis and Pulmonary Cryptococcosis: A Case Report. USUHS Research Days. Bethesda, MD. May 2019.

____ A review of tracheostomy clinical factors and outcomes at multiple Active Projects institutions / WRNMMC site / PI: Phillip Weissbrod, MD, Assistant Professor of Surgery, UCSD MAY 2019 - PRESENT Assisting Dr. Michael Orestes with data collection and analysis for multi-institute retrospective chart review study to increase power of previous UCSD investigation

USU/WRNMMC Expeditionary Craniofacial Trauma Manual / USU Capstone Project APR 2019 - PRESENT Working with educational technologies team and subspecialty surgeons to create manual for procedures taught at accompanying annual course

Prepared February 2020

Chandler M. Bennett 6

____ Applicant Interviewer / USUHS School of Medicine SEP 2019 Community Activities Interviewed prospective incoming medical students and completed evaluations for review by the admissions committee

Student Representative / Names and Honors Committee, USUHS JUN 2019 – PRESENT Collaborate with upper leadership to facilitate appropriate recognition and awards of USU faculty, staff and students.

Healer’s Art / USUHS 2017 15 hour curriculum in recognizing, valuing, enhancing and preserving the human dimension of health care

Student Volunteer / Global Health Interest Group, USUHS 2017, Mary’s Center, Washington D.C. Helped provide health care as a clerk under a staff physician, seeing patients and assisting with procedures in a primarily Spanish-speaking women’s clinic

Tutor / Kings School 2015 - 2016, Corinth, NY Tutored middle and high school students in STEM at a rural school

ICU and ED Volunteer / Saratoga Hospital 2015 - 2016, Saratoga Springs, NY, Managed ambulatory admissions to the ED, escorted visitors to ICU and ED

Medical Translator / Spanish Catholic Charities Clinic 2011 - 2014, Washington, D.C. Translated for providers at a clinic for an under-served Spanish-speaking population

Teaching Assistant / Ecology 2014, Georgetown University, Washington, D.C.

Student Volunteer Leader / Hogar de Niños 2008 - 2010, San Cristobal, Dominican Republic Worked at an orphanage to repair and update facilities and provide mentorship to the children, served as student leader in 2010

Prepared February 2020 UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES DANIEL K. INOUYE GRADUATE SCHOOL OF NURSING 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814­4799 www.usuhs.edu/gsn

March 27, 2020

MEMORANDUM FOR PRESIDENT, USU

THROUGH: USU BOARD OF REGENTS

SUBJECT: Daniel K. Inouye Graduate School of Nursing (GSN) Graduates for April 1, 2020

The following Daniel K. Inouye Graduate School of Nursing students are scheduled to complete their respective programs on April 1, 2020 and have met all academic, clinical, and scholarly requirements for graduation. The Dean requests that the President, USU, award the following students the Doctor of Nursing Practice, or the Master of Science degrees.

Master of Science in Nursing candidates

Last Name First Name Rank Service Branch Program Lentz Mark Maj USAF AGCNS

Doctor of Nursing Practice candidates

Last Name First Name Rank Service Branch Program Knight Albert MAJ USA AGCNS Birkle Amber MAJ USA FNP/WHNP Brown Angelyn MAJ USA FNP/WHNP Costa Diana MAJ USA FNP/WHNP Edwards Yashika Maj USAF FNP Fernandez Edwin Maj USAF FNP Frazier Virginia Maj USAF FNP Geiger Joshua CPT USA FNP Gibbons Vonya MAJ USA FNP Last Name First Name Rank Service Branch Program Hervey Sarah LCDR USN FNP/WHNP Horne Miranda LCDR USN FNP Jessup Michael Maj USAF FNP Martin Margaret MAJ USA FNP/WHNP Obia Geoffrey Maj USAF FNP Prince Marita MAJ USA FNP Robertson Nicholas Capt USAF FNP/WHNP Scott Megen LCDR USN FNPWHNP Simmons Matthew Capt USAF FNP Steadman Christopher LCDR USN FNP Thorp Regina MAJ USA FNP/WHNP Vieson Adrienne Capt USAF FNP/WHNP Watson Matthew MAJ USA FNP Briones Rebecca Maj USAF PMH Clark Donelle Capt USAF PMH Flynn Dennis MAJ USA PMH Moore Jamie LT USN PMH Nguyen Billy LT USN PMH Peterson Jasmine MAJ USA PMH Spesard- Nicole USAF PMH Langfield Capt Everage Melissa Capt USAF WHNP/FNP Kimmel Leigh Maj USAF WHNP Shawell Jazmin Capt USAF WHNP

631%23'%63 (MKMXEPP]WMKRIHF] 631%23'%630% 0% (EXI  ______Carol A. Romano, PhD, RN, FAAN Dean and Professor

______Richard W. Thomas, MD, DDS, FACS President

______Date UNIFORMED SERVICES UNIVERSllYOF THE HEALTH SCIENCES DEPARTMENT OF FAMILY MEDICINE 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814-4799 www.usuhs.edu

March 26, 2020

MEMORANDUM FOR THE CHAIR, BOARD S, U S THROUGH: Dean �cho ;,fti . c � � SUBJECT: Recommendation of Fourth-Year Students, Class of2020

Jn accordance with SOM-DPM-006-20 I 5 subject: USUHS School of Medicine (SOM) Medical Student Promotions Committee, dated 21 August 2015, the Student Promotions Commiuee electronically reviewed fourth-year students on 26 March 2020. The Committee unanimously recommends that those students whose names appear on the Certification List be awarded the degree ofDoctor ofMedicine and enter graduate medical education, provided that all remaining academic requirements are met or officiallywaived.

This letter ofrecommendation does not preclude the Dean, School of Medicine. from removing any student listed herein for cause.

Patrick Hickey, MD Colonel, Medical Corps, US Army Chair, Student Promotions Committee

Attachment CLASS OF 2020 RECOMMENDED FOR GRADUATION

Abraham, Vivek Matthew Green-Lott, Ashley-Marie Adams, Eric Sharold Greenwell, Abigail Affrin, Zachary Cyrus Gutierrez, Marc R. Aleman-Reyes, David Han, Rachel Hyeun Alindogan, Aaron Harding, Michael Corwin Andersen, Stephanie Grace Haynes, Zachary Ashcroft, Cody Ross Hegeman, Erik Michael Barrett, Elizabeth Colleen Heyda, Lauren Margaret Bathon, Kathleen Elizabeth Horch, Matthew John Beall, Steven Christopher Husson, Christopher Michael Bell, Devin Ingersoll, Jared Andrew Bennett, Chandler Marie Jensen, Maxwell Black, John M. Johnson, Kenneth James Blereau, Claude Jones, Nolan Neil Blotter, Jacob Kelly, Hannah Bodily, Brent Mitchell Kenney, Lauren Elizabeth Bott, Quinn Daniel Kim, Shawn Kyungsun Brady, Derek Paul Kimbrough, Marilyn Elaine Brown, Aaron Jeffrey Kissinger, Ryan Wilgus Burgo-Sanchez, Christian Alexander Kostenko, Michael Anatoly Campbell, Leonie Tara Kravitz, Shena Alisa Campbell, Rachael Doreena Lamb, Courtney Alexandra Capen, Steven Francis Lau-Eglinton, Kyrra Capo-Dosal, Gerardo Enrique Lawson, Michael Jeremy Chen, Eric Le, Jim Diamond Chilbert, Joseph Adam Lee, Rebecca Clark, Neil Gordon Lemieux, Renee Susan Cook, Stacy Lynn Li, Alexander Dan Fong Cox, Anthony Raymond Lieb, David Allen Cui, Min Lindefjeld, Jon Kristian Danchi, Henry Graeme Lindley, John Randal Daniel, Ashton Delois Little, Matthew Christopher Davis, Gerrit Warren Lockett, Casey Joseph Dela Cruz, Marco Jose Marcelo, Raymundo Dempsey, Kaitlyn Nichole McCartney, Marianne Andrea Denley, Billy Cameron McGirr, Matthew John Drenckhahn, Jeremy Thomas McMillan, Elizabeth Campbell Ediger, David Mears, Charles Jeremy Eker, Jessica Merfeld, Joseph Thomas Elliott, Jeffrey Scott Meyers, Brittany Anne Erwin, Casey Rae Minor, Cody Austin Evans, David Conor Mongold, Sarah Michelle Flagg, Candace Moran, Nicholas Anthony Ford, Nathaniel Dean Murphy, Conner David Frankford, Stone Alan Nelson, Jessica Lynn Frost, Fredrick Charles Newkirk, Russell Ernest George, Matthew William O’Leary, Thomas Ryan Giblin, Sydney A. O’Neil, Taylor Gibson, Steven James Osborne, Katey Della-Giustina Gonsolin, Caitlin Nicole Park, Sanghwa Esther Gray, Lawrence Charles Peer, Jerry Andrew

Learning to Care for Those in Harm’s Way Pekny, Carissa Janine Tshudy, Michael Phillips, Virginia Ann Ursua, Francesca Picciano, Natalie Van Decar, Spencer Pratico, David Vanier, Alan Purmalek, Monica Maigol Vazquez, Philip Michael Radloff, Steven A. Villareal, Charisse N. Raffetto, Emily Rose Wade, Christian Raneses, Eli Thomas Wade, Eleanor Elizabeth Ray, Tyler John Wait, Tirzah Reffett, Taylor Rebecca Ward, James Ross Richter, Joshua Watkins, Bradley Rigo, Paolo Quentin Welch, Matthew Clay Rogan, Valencia Denise Welker, Olivia Montooth Rowden, Samantha Nicole White, Paige Sanchez, John Wilkin, Danielle Scaramella, Stephanie Williams, Jordan Scheanon, Phillip Winland, Ama Schirding, Stephanie Wolfgramm, Sionetufui Schmidt, Gregory Stickler Wolinsky, Rachel Ann Scott, Jasmine Alexandra Woodard, Catherine Anne Shaw, Krista Wright, Sarah Louise Smart, Derek Wyse, Jacob Mickey Sommerfeldt, John Yang, Johnny Staak, Brian Yu, Jonathan Sumpter, Ryan Yuan, Kyle Taylor, Benjamin Michael Yue, Ivan Liu Thomas, Mary Ann Zerhusen, Timothy Tribull, Jenna Zuazo, Artemisa Anais Tornbom, Tora Jean Zven, Sidney Troung, Lydia Cam

______Richard W. Thomas, MD, DDS, FACS President

______Date

Learning to Care for Those in Harm’s Way UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES DANIEL K. INOUYE GRADUATE SCHOOL OF NURSING 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814-4799 www.usuhs.edu/gsn

March 31, 2020

MEMORANDUM FOR PRESIDENT, USU

THROUGH: USU BOARD OF REGENTS

SUBJECT: Daniel K. Inouye Graduate School of Nursing (GSN) Graduates for May 1, 2020

1. The following Daniel K. Inouye Graduate School of Nursing students are scheduled to complete their respective programs on May 1, 2020 and have met all academic, clinical, and scholarly requirements for graduation. The Dean requests that the President, USU, award the following students the Doctor of Nursing Practice degree.

Doctor of Nursing Practice candidates:

Last Name First Name Rank Service Program Abraham Ryan Capt USAF RNA Anderson Lorren Maj USAF RNA Balazs Jason LT USN RNA Bautista Joy LT USN RNA Beasley Larry LT USN RNA Blais Jean-Frederick LT USN RNA Bokan Melissa LCDR USN RNA Camp Julia LT USN RNA Crissman Kyle Maj USAF RNA Curtis Brian LT USN RNA Dan Devon LT USN RNA Dunston Shaun LT USN RNA Garcia Raephael LT USN RNA Haines Melissa Capt USAF RNA Moore Jeremy LT USN RNA Nagle Kelly LT USN RNA Nevonen Gregory LT USN RNA O'Donnell Stacey Maj USAF RNA Papenfuss Erika LT USN RNA Parker Hannah LT USN RNA Last Name First Name Rank Service Program Paul Uriah LT USN RNA Payne Christopher LT USN RNA Sternbaum David LT USN RNA Tio Keenart LT USN RNA Vance Amanda Capt USAF RNA Wilson Daisha Capt USAF RNA

2. The following Daniel K. Inouye Graduate School of Nursing student is scheduled to complete his program on May 16, 2020 and has met all academic, clinical, and scholarly requirements for graduation. The Dean requests that the President, USU, award the following student the Doctor of Nursing Practice degree.

Doctor of Nursing Practice candidate

Last Name First Name Rank Service Branch Program Patterson Aaron LCDR USPHS RNA

______Carol A. Romano, PhD, RN, FAAN Dean and Professor

______Richard W. Thomas, MD, DDS, FACS President

______Date UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814-4712

20 April 2020

MEMORANDUM FOR PRESIDENT, UNIFORMED SERVICES UNIVERSITY

SUBJECT: Approval of Degree Candidates, USU Class of 2020 (Addendum 1)

On 20 April 2020, a majority endorsement was reached by the USU Board of Regents for graduation of the candidates as proposed by the Deans of the School of Medicine (SOM) and Graduate School of Nursing (GSN).

Please find 1) the attached list of students per SOM Dean Kellermann’s memo dated 17 April 2020 to codify two medical students not on the original scroll for graduation 1 April 2020 (due to inter-service transfers), and 2) the attached list of students per GSN Dean Romano’s 31 March 2020 memo noting a 1 May 2020 graduation for the Nurse Anesthesia Doctor of Nursing Practice students.

As noted in the Deans’ memos, the students listed for the 1 April 2020 and 1 May 2020 conferrals have successfully completed all the requirements for graduation. These lists received a majority endorsement by the Board, have been endorsed by the Board of Regents Chair, and are pending your approval for degree conferral.

Please sign and date at the bottom of the SOM 17 April 2020 memo and the GSN 31 March 2020 memo and return to me for distribution.

Respectfully,

Jeffrey Longacre, MD Executive Secretary USU Board of Regents

Learning to Care for Those in Harm’s Way

UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES DEPARTMENT OF FAMILY MEDICINE 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814-4799 www.usuhs.edu

April 17, 2020

MEMORANDUM FOR THE CHAIR, BOARD OF REGENTS, USUHS THROUGH: Dean, School of Medicine

SUBJECT: Recommendation of Fourth-Year Students, Class of 2020

In accordance with SOM-DPM-006-2015 subject: USUHS School of Medicine (SOM) Medical Student Promotions Committee, dated 21 August 2015, the students whose names appear on the Certification list be awarded the degree of Doctor of Medicine and enter graduate medical education with the effective date as listed.

This letter of recommendation does not preclude the Dean, School of Medicine, from removing any student listed herein for cause.

Patrick Hickey, MD Colonel, Medical Corps, US Army Chair, Student Promotions Committee

Attachment

CLASS OF 2020 RECOMMENDED FOR GRADUATION EFFECTIVE 16 MAY 2020

Chandler, Molly Chien, Kevin Kelly, Connor Vu, Patricia Yuan, Lucy

CLASS OF 2020 RECOMMENDED FOR GRADUATION EFFECTIVE 1 APRIL 2020

Lundstrom, Morgan Schirding, Joel

Learning to Care for Those in Harm’s Way

UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES DEPARTMENT OF FAMILY MEDICINE 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814­4799 www.usuhs.edu

April 17, 2020

MEMORANDUM FOR THE CHAIR, BOARD OF REGENTS, USUHS

THROUGH: Dean, School of Medicine (MKMXEPP]WMKRIHF]%VXLYV0/IPPIVQERR1(14, %VXLYV0/IPPIVQERR1(14, (EXI  SUBJECT: Recommendation of Fourth-Year Students, Class of 2020

In accordance with SOM-DPM-006-2015 subject: USUHS School of Medicine (SOM) Medical Student Promotions Committee, dated 21 August 2015, the students whose names appear on the Certification list be awarded the degree of Doctor of Medicine and enter graduate medical education with the effective date as listed.

This letter of recommendation does not preclude the Dean, School of Medicine, from removing any student listed herein for cause.

Patrick Hickey, MD Colonel, Medical Corps, US Army Chair, Student Promotions Committee

Attachment CLASS OF 2020 RECOMMENDED FOR GRADUATION EFFECTIVE 16 MAY 2020

Chandler, Molly Chien, Kevin Kelly, Connor Vu, Patricia Yuan, Lucy

CLASS OF 2020 RECOMMENDED FOR GRADUATION EFFECTIVE 1 APRIL 2020

Lundstrom, Morgan Schirding, Joel

______Richard W. Thomas, MD, DDS, FACS President

______Date

Learning to Care for Those in Harm’s Way TAB 11 Degree Conferrals Hébert School of Medicine

UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814-4799 www.usuhs.edu

April 16, 2020

MEMORANDUM FOR: PRESIDENT, USUHS

THROUGH: CHAIR, BOARD OF REGENTS

THROUGH: DEAN, SCHOOL OF MEDICINE

SUBJECT: List of Graduate Students in the Department of Preventive Medicine and Biostatistics (PMB) who are Expected to Graduate on June 18, 2020

The following Graduate Education students are expected to complete the necessary requirements for the following Master Degree Programs in the Department of Preventive Medicine and Biostatistics: Master of Health Administration and Policy (MHAP), Master of Public Health (MPH), and Master of Tropical Medicine and Hygiene (MTM&H).

Master of Health Administration & Policy (MHAP) candidates:

MAJ Adriana F. Castro, USA LTC Jeffrey R. Limjuco, USA CPT Jonathan P. Gray, USA LTJG Brett E. Nary, USN LTJG Doudoubite Korabou, USN LTC Demarcio L. Reed, USA LT Emily K. Lane, USN LTJG Tavis J. Silvey, USN LTJG Jessica Lee, USN LT Christopher P. Stills, USN

Master of Public Health (MPH) candidates:

CPT Sung S. Baek, USA Capt Sharon J. Laughter, USAF MAJ Christopher R. Dunbar, USA MAJ Brianna M. Marion, USA LCDR Rebecca J. Free, USPHS Maj Rhona L. Merrera, USAF CDR Laura C. Gilstrap, USN MAJ Jeffrey M. Milch, USA MAJ Amber K. Gruters, USA LCDR Nathan A. Moss, USN Maj Scott T. Hulse, USAF Maegan M. Paxton Willing MAJ Aimee M. Hunter, USA LCDR Aliye Z. Sanou, USN CDR David A. Jackson, USPHS CDR Amanda R. Self, USN MAJ Joseph S. Jones, USA LT Marlon Q. Tingzon, USN Capt John W. Kieffer, USAF 2LT Jeanny H. Wang, USA LCDR Alison B. Lane, USN Maj Richard C. Zanetti, USAF

Master of Tropical Medicine and Hygiene (MTM&H) candidate:

Maj David R. Sayers, USAF

Learning to Care for Those in Harm’s Way

Saibal Dey, PhD Associate Dean for Graduate Education

Approved / Not Approved

______Richard W. Thomas, MD, DDS, FACS President

UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814-4799 www.usuhs.edu

April 16, 2020

MEMORANDUM FOR: PRESIDENT, USUHS

THROUGH: CHAIR, BOARD OF REGENTS

THROUGH: DEAN, SCHOOL OF MEDICINE

SUBJECT: Conferral of Graduate Degrees

The following Graduate Education students are scheduled to complete their respective programs on May 15, 2020 and have met all the academic requirements for graduation. The Associate Dean requests that the President, USUHS, award the following students their respective Master of Health Professions Education, Master of Science, and Doctor of Philosophy degrees.

Master of Health Professions Education candidates:

Courtney A. Judd, Department of Medicine Walter B. Kucera, Department of Medicine Kerry P. Latham, Department of Medicine Sunny J. Yauger, Department of Medicine

Master of Science candidate:

William H. Horne IV, Molecular and Cell Biology Graduate Program

Doctor of Philosophy candidates:

Chelsi R. Beauregard, Emerging Infectious Diseases Graduate Program Fernanda P. De Oliveira, Department of Medical and Clinical Psychology Julia A. Garza, Department of Medical and Clinical Psychology Britney L. Hardy, Emerging Infectious Diseases Graduate Program Sybil D. Mallonee, Department of Medical and Clinical Psychology Nikki M. McCormack, Neuroscience Graduate Program Alexandria N. Morettini, Department of Medical and Clinical Psychology Adrian C. Paskey, Emerging Infectious Diseases Graduate Program Shemona Rattila, Molecular and Cell Biology Graduate Program Erin M. Sheffels, Molecular and Cell Biology Graduate Program Deborah M. Stiffler, Emerging Infectious Diseases Graduate Program Patricia A.T. Vu, Physician Scientist Program - Neuroscience Graduate Program

Saibal Dey, PhD Associate Dean for Graduate Education

Learning to Care for Those in Harm’s Way

Approved / Not Approved

______Richard W. Thomas, MD, DDS, FACS President

UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814-4799 www.usuhs.edu

April 15, 2020

MEMORANDUM FOR RICHARD W. THOMAS, MD, DDS, FACS, PRESIDENT, USUHS

Through: Chair, Board of Regents

SUBJECT: Certification of Graduate Student

The graduate student listed below is presented for certification to receive the Master of Health Professions Education degree effective upon your approval:

Courtney A. Judd

MASTER OF HEALTH PROFESSIONS EDUCATION

Department of Medicine

Attached is the candidate’s Thesis Approval Form. Also attached are the certification of authorized use of Copyrighted materials, Thesis Title Page, Thesis Abstract, and Curriculum Vitae.

Arthur L. Kellermann, MD, MPH Dean, USUHS, School of Medicine

Attachments: As stated

Learning to Care for Those in Harm’s Way UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES DEPARTMENT OF MEDICINE 4301 JONES BRIDGE ROAD BETH ESDA, MARYLAND 20814-4799 www.usuhs.edu

March 4, 2020

APPROVAL SHEET

Title of Thesis: The Impact of Military Pediatrics: Assessing Clinical, Leadership, Deployment, and Humanitarian Experience among Pediatric-trained Graduates from the Uniformed Services University of the Health Sciences (USU)

Name of Candidate: Lt Col Courtney A. Judd, MD, MPH

03/04/2020

THESIS AND ABSTRACT APPROVED:

DATE: 3/ tf/ J-t) rro 1 J Ronald M. Cervero, PhD CommitteeADEPARTMENT OF MEDICINE

Steven J. Durning, MD, PhD DEPARTMENT OF MEDICINE Thesis Advisor

J/LI/ ZD2.0 ~1e~r,~~ DEPARTMENT OF MEDICINE Thesis Advisor

Learning to Care for Those in Harm's Way

The Impact of Military Pediatrics: Assessing Clinical, Leadership, Academic, and

Operational Experience among Pediatric-Trained Graduates from the Uniformed Services

University of the Health Sciences (USU)

by

Col(s) Courtney A. Judd, MD, MPH

Thesis submitted to the Faculty of the Health Professions Education Graduate Program Uniformed Services University of the Health Sciences In partial fulfillment of the requirements for the degree of Master of Health Professions Education 2020

ABSTRACT

The Impact of Military Pediatrics: Assessing Clinical, Leadership, Academic, and

Operational Experience among Pediatric-Trained Graduates from the Uniformed Services

University of the Health Sciences (USU)

Courtney Judd, Master of Health Professions Education, 2020

Thesis directed by: Steven Durning, MD, PhD, Director, Graduate Programs in Health

Professions Education (HPE) and Holly Meyer, PhD, Associate Director of Student

Affairs, Graduate Programs in HPE

Problem: Our main objective was to describe the outcomes of USU graduates who pursued training in pediatrics, and therefore to begin to quantify the contributions that military pediatricians make to the military medical mission and the broader

Department of Defense (DoD) mission.

Methods: We utilized Long-Term Career Outcome Study (LTCOS) data to perform a retrospective, descriptive analysis of USU alumni survey responses, specifically inquiring into the career outcomes and operational experiences among those graduates who pursued training in pediatrics. We grounded our research in the before, during, and after conceptual framework, focusing mainly on the “after” time period for the purposes of this thesis.

iv

Results: We describe the contributions of USU-trained pediatricians to the clinical, leadership, academic, and operational realms, as they are reported by USU alumni. In doing so, we find that pediatric-trained USU graduates fill significant clinical responsibilities, serve across the full breadth of possible military medical leadership positions, and achieve notable academic milestones, as evidenced by academic promotions and publications. Additionally, 40% of surveyed USU-trained pediatricians have completed at least one deployment, and 35% have taken part in at least one humanitarian mission.

Conclusions: USU-trained pediatricians make important contributions to the military. We discuss the importance of our findings related to the career outcomes and operational experiences among USU pediatric-trained graduates. Finally, we propose future areas of inquiry that will further allow us to discover the full breadth of contributions that are made by uniformed pediatricians.

v March 2020 CURRICULUM VITAE

COURTNEY ANNE JUDD, M.D., M.P.H. Lieutenant Colonel, Medical Corps, United States Air Force

Current Positions: Vice Chair for Education, Department of Pediatrics Assistant Professor of Pediatrics F. Edward Hébert School of Medicine Uniformed Services University of the Health Sciences

Department of Pediatrics 4301 Jones Bridge Road Bethesda, MD 20814 (301) 295-2396 [email protected]

Education and Training: 2017 – 2020 Master’s in Health Professions Education Graduate Program, Uniformed Services University of the Health Sciences, Bethesda, MD; degree May 2020 2016 – 2019 Air War College (via correspondence), Air University; completed June 2019 2010 – 2012 Fellowship, General Academic Pediatrics, University of South Florida, Tampa, FL 2010 – 2012 Master of Public Health (M.P.H.), University of South Florida, Tampa, FL 2003 – 2006 Residency, Pediatrics, San Antonio Uniformed Services Health Education Consortium (SAUSHEC), San Antonio, TX 1999 – 2003 Doctor of Medicine (M.D.), University of Virginia School of Medicine, Charlottesville, VA 1995 – 1999 Bachelor of Science (B.S.), The College of William and Mary, Williamsburg, VA; summa cum laude

Academic Appointment: Jan. 2014 – Present Assistant Professor of Pediatrics, Uniformed Services University of the Health Sciences (USUHS), Bethesda, MD

Professional Experience: 2019 – Current Vice Chair for Education, Department of Pediatrics, USU 2018 – Current Consultant for General Pediatrics to the Air Force Surgeon General Advise the AFMOA Maternal Child Consultant in general pediatrics issues, including: provision of expert advice on training issues, Air Force and DoD policy, Clinical Practice Guidelines, Air Force Medical Home, and standards of care CV Continued, Courtney Judd, M.D.

2017 – Current Director, Education Section, Department of Pediatrics, USUHS, Bethesda, MD 2016 – Current Assistant Professor of Pediatrics, USUHS, Bethesda, MD 2016 – Current Pediatric Hospitalist, Pediatrics, Walter Reed National Military Medical Center (WRNMMC), Bethesda, MD Core faculty within the hospitalist group, providing clinical care and teaching for medical students and residents on the Inpatient Pediatric Unit at WRNMMC 2013 – 2016 Associate Program Director, Pediatrics, SAUSHEC, San Antonio, TX 2012 – 2016 Academic Pediatrician, San Antonio Military Medical Center, San Antonio, TX Clinical teaching in general pediatric outpatient clinic, pediatric inpatient unit, and newborn nursery; Hospitalist, 1/3 clinical time on inpatient ward, 2013-2014 2007 – 2010 General Pediatrician, Hickam Air Force Base, HI Provided outpatient care for 3,000 military dependents; Medical Liaison for Child Development Center; Family Advocacy Representative; Clinical Practice Guideline Champion for Asthma 2006 – 2007 Chief Resident, Department of Pediatrics, SAUSHEC, San Antonio, TX Administrative and educational oversight for 41 pediatric residents

Military Deployment:

April – November 2014 455th Air Expeditionary Wing, in support of OEF, Craig Joint Theater Hospital, Bagram Airfield, Afghanistan Sole pediatrician at Role III hospital

Honors and Awards:

Academic Honors and Awards:

2020 Gold Humanism Honor Society, selected by current student members 2019 Dean’s Impact Award, Uniformed Services University of the Health Sciences 2012 Best College of Public Health Poster Presentation Award, Graduate Student, University of South Florida Research Day 2012 Student Research Excellence Award, University of South Florida Graduate Student Research symposium 2011 Phi Kappa Phi Honor Society, University of South Florida 2002 Alpha Omega Alpha Honor Medical Society, University of Virginia 1999 – 2003 Generalist Scholars Program, University of Virginia 1999 – 2003 Air Force Health Professions Scholarship Program 1998 Phi Beta Kappa Society, Alpha Chapter, The College of William and Mary

2 UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814-4799 www.usuhs.edu

April 15, 2020

MEMORANDUM FOR RICHARD W. THOMAS, MD, DDS, FACS, PRESIDENT, USUHS

Through: Chair, Board of Regents

SUBJECT: Certification of Graduate Student

The graduate student listed below is presented for certification to receive the Master of Health Professions Education degree effective upon your approval:

Walter B. Kucera

MASTER OF HEALTH PROFESSIONS EDUCATION

Department of Medicine

Attached is the candidate’s Thesis Approval Form. Also attached are the certification of authorized use of Copyrighted materials, Thesis Title Page, Thesis Abstract, and Curriculum Vitae.

Arthur L. Kellermann, MD, MPH Dean, USUHS, School of Medicine

Attachments: As stated

Learning to Care for Those in Harm’s Way THESIS APPROVAL

COPYWRIGHT STATEMENT

v Fundamentals of Anorectal Technical Skills: Using Deliberate Practice with Adaptive and

Perceptual Learning for Surgical Education

By

Walter B. Kucera, MD

Thesis submitted to the Faculty of the Health Professions Education Graduate Program,

Uniformed Services University of the Health Sciences, in partial fulfillment of the requirements

for the degree of Master’s in Health Professions Education 2020

Purpose: This thesis seeks to evaluate the efficacy of the Fundamentals of Anorectal Technical

Skills course through the lens of adaptive and perceptual learning theory and deliberate practice theory. By exploring the effects of the course on different levels of learners, we aim to advance this course as a solution to fill a gap in current training curricula. The course is designed to be a low-cost solution through repurposing of equipment and minimal use of disposable items.

Additionally, this thesis seeks to encourage additional research into the use of adaptive and perceptual learning for surgical education.

Methods: We examined validity evidence for the assessment tool used before and after the course. Using the theory of deliberate practice examined through the lens of competency-based education, we divide the learners into groups of novice and experienced practitioners. The effects of the training on the groups were then assessed before and after the course.

Results: Previous procedural experience in anorectal procedures provides a better predictor of performance on multiple-choice quizzes for diagnosis and management of anorectal conditions than did training level or departmental affiliation. Using the prior procedural volume to stratify learners, the novice group was able to approach the diagnostic and procedural confidence level of the experienced group by the end of the training.

Conclusions: The Fundamentals of Anorectal Technical Skills course provides a low-cost way to teach the basics of anorectal pathology and procedures in a concise period of time. The benefits of this course are especially pronounced for novice learners, who can approach the confidence and quiz levels of experienced practitioners through an adaptive- and perceptual- learning based didactic session and deliberate practice in the hand-on portion.

Walter B. Kucera, M.D. [email protected] [email protected]

Current General Surgery Chief Resident 2019-present Position Walter Reed National Military Medical Center, Bethesda, MD Education General Surgery Residency, Walter Reed National Military Medical Center, 2015-2020 Bethesda, MD. Candidate for Masters in Health Professions Education, Uniformed 2017-2020 Services University of the Health Sciences, Bethesda, MD. Surgical Education/Simulation Fellowship, National Capital Region 2017-2018 Simulation Consortium, Bethesda, MD. General Surgery Internship, Walter Reed National Military Medical Center, 2014-2015 Bethesda, MD. Doctor of Medicine, Wake Forest School of Medicine, Winston-Salem, NC. 2010 -2014 Bachelor of Science in Biology cum laude. Davidson College, Davidson, NC 2006-2010 Academic Clinical Teaching Fellow 2015-present Appointments Department of General Surgery, Walter Reed National Military Medical Center/Uniformed Services University of the Health Sciences, Bethesda, MD Military United States Navy Medical Corps Officer 2014-present Service Walter Reed National Military Medical Center, General Surgery Intern and Resident United States Navy Reserve Medical Corps Officer 2010-2014 Certification Virginia Board of Medicine 2015 and Licensure Advanced Trauma Life Support Instructor 2018 Stop the Bleed Instructor 2017 Professional American College of Surgeons, Resident Member 2014-present Memberships American Society of Colon and Rectal Surgeons, Candidate Member 2016-present and Activities Association of Military Surgeons of the United States, Resident Member 2015-present Society of Gastrointestinal and Endoscopic Surgeons, Candidate Member 2019-present Committee SAGES Education Council Educational Business and Technology Group, 2019-present Assignments Member Honors and American College of Surgeons Committee on Trauma Navy Regional 2018 Awards Abstract Competition Winner COL David G. Burris Award, 16th World Congress of Endoscopic Surgery, 2018 Seattle, WA Phi Beta Kappa, North Carolina Gamma Chapter, Davidson, NC 2010 Davidson College Class of 1958 Scholarship and Davidson Honor 2006-2010 Scholarship, Davidson College, Davidson, NC Peer-Reviewed 1) Kucera WB, Jezior JR, Duncan JE. Management of Post-Traumatic Recto-Vesical/Urethral Publications Fistulas: Case Series of Complicated Injuries in Wounded Warriors and Review of the Literature, Mil Med (2017) 182: e1835-1839. 2) Kucera WB, Nealeigh MD, Dunkin BJ, Ritter EM, Gardner AK. The SAGES Flexible Endoscopy Course for Fellows: A Worthwhile Investment in Furthering Surgical Endoscopy. Surg Endosc (2019) 33: 1189-1195. 3) Nealeigh MD, Kucera WB, Bradley MJ, Jessie EM, Sweeney WB, Ritter EM, Rodriguez CJ. Surgery at Sea: Exploring the Training Gap for Isolated Military Surgeons. J Surg Educ (2019) Walter B Kucera, M.D.

Page 2 of 2

76: 1139-1145. 4) Kucera W, Nealeigh M, Franklin B, Bowyer M, Sweeney WB, Ritter EM. Fasciotomy Improvement Through Recognition of Errors Course: A Focused Needs Assessment for Error Management Training for Lower Extremity Fasciotomy Performance. J Surg Educ (2019) 76: 1303-1308. 5) Ohmer M, Durning SJ, Kucera W, Nealeigh M, Ordway S, Mellor T, Mikita J, Howle A, Krajnik S, Konopasky A, Ramani D, Battista A. Clinical Reasoning in the Ward Setting: A Rapid Response Scenario for Residents and Attendings. MedEdPORTAL (2019) 15: 10834 Oral National/International Meetings Presentations Fundamentals of Anorectal Technical Skills 16MAR2018 2018 Annual American College of Surgeons Surgical Simulation Summit, Chicago, IL Improving Fasciotomy Performance: A Focused Needs Assessment for 11APR2018 Military Surgeon Simulation Training 2018 Military Surgical Symposium of the 16th World Congress of Endoscopic Surgery, Seattle, WA Fasciotomy Improvement Through Recognition of Errors Course: A 21OCT2018 Focused Needs Assessment for Error Management Training for Lower Extremity Fasciotomy Performance, 2018 Excelsior Military Surgery Society Meeting at the American College of Surgery Clinical Congress, Boston, MA. Grand Rounds Presentations Building a Better Mousetrap: Applying Selection science to Military Residency Selection, Department of Surgery, Uniformed Services 11DEC2019 University/Walter Reed National Military Medical Center Poster National/International Meetings Presentations Traumatic Pelvic GI-GU Fistula in Wounded Warriors: Case Series of 01JUN2015 Complicated Injuries with Complex Surgical Solutions 2015 American Society of Colon and Rectal Surgeons Annual Scientific Meeting, Boston, MA Maintaining Confidence: A 6-Month Follow-Up of the SAGES Flexible 13APR2018 Endoscopy Course 16th World Congress of Endoscopic Surgery, Seattle, WA Interval Colorectal Cancer Following Virtual Colonoscopy: Incidence in 21MAY2018 a Single Institution 2018 American Society of Colon and Rectal Surgeons Annual Scientific Meeting, Nashville, TN Fundamentals of Anorectal Technical Skills: A Concise Course for 21MAY2018 Various Levels of Learners 2018 American Society of Colon and Rectal Surgeons Annual Scientific Meeting, Nashville, TN Entero-Urachal Fistula: An Uncommon Presentation of Crohn’s Disease 2020 American Society of Colon and Rectal Surgeons Annual Scientific 08JUN2020 Meeting, Boston, MA

UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814-4799 www.usuhs.edu

April 15, 2020

MEMORANDUM FOR RICHARD W. THOMAS, MD, DDS, FACS, PRESIDENT, USUHS

Through: Chair, Board of Regents

SUBJECT: Certification of Graduate Student

The graduate student listed below is presented for certification to receive the Master of Health Professions Education degree effective upon your approval:

Kerry P. Latham

MASTER OF HEALTH PROFESSIONS EDUCATION

Department of Medicine

Attached is the candidate’s Thesis Approval Form. Also attached are the certification of authorized use of Copyrighted materials, Thesis Title Page, Thesis Abstract, and Curriculum Vitae.

Arthur L. Kellermann, MD, MPH Dean, USUHS, School of Medicine

Attachments: As stated

Learning to Care for Those in Harm’s Way

The author hereby certifies that the use of any copyrighted material in the thesis manuscript entitled:

Exploring Mentorship in Military Medicine through the Undergraduate Medical Education perspective

is appropriately acknowledged and, beyond brief excerpts, is with the permission of the copyright owner.

Col Kerry Latham, USAF, MC, FS MHPE Uniformed Services University Date 03/18/2020

Exploring Mentorship in Military Medicine through the Undergraduate Medical Education perspective

by

Col Kerry Latham, USAF, MC, FS

Thesis submitted to the Faculty of the Health Professions Education Graduate Program Uniformed Services University of the Health Sciences In partial fulfillment of the requirements for the degree of Masters in Health Professions Education 2019

ABSTRACT

Exploring Mentorship in Military Medicine through the Undergraduate Medical Education perspective

Kerry Latham, MD 2019

Thesis directed by: Paul A. Hemmer, MD, MPH Col (ret), USAF, MC Professor and Vice Chair, Educational Programs Department of Medicine Uniformed Services University of the Health Sciences and Steven J Durning, MD, PhD, FACP Professor of Medicine and Pathology Director, Graduate Programs in Health Professions Education (HPE) Vice Chair, Department of Medicine Uniformed Services University of the Health Sciences

Purpose: This thesis seeks to explore mentorship in military medicine. Mentorship is thought to be critical to professional development and advancement for physicians.

Methods: Using data from the American Association of Medical College’s Graduate

Questionnaire, a survey sent to all medical students prior to graduation, items were coded as related to mentorship, guidance, and support and analyzed to compare responses of female and male students from graduating USU classes of 2010-2017.

Results: No significant difference was found between experiences of female and male survey respondents. Equitable experiences were consistent across time for the eight years of the study.

Conclusions: The UME cohorts at USUHS do not report experiencing disparity in perceptions of mentorship. It is reassuring that there is equity in military UME. Mentorship and equity should be studied at all levels of physician development. Kerry Latham, MD, FACS Colonel USAF, MC, FS Joint Base Andrews 11th Surgical Operations Squadron Commander 1060 W. Perimeter Rd, JBA 20762 [email protected] [email protected]

______

Education Air War College Distance Learning, USAF PME 2012 – 2015 Craniofacial Surgery Fellowship, Seattle Childrens Hospital, 2010 – 2011 Seattle, WA Plastic Surgery Residency, JMH, Miami FL 2005 – 2007 General Surgery Residency, WHMC, San Antonio, TX 2000 – 2005 Uniformed Services University of the Health Sciences, MD 1996 – 2000 B.A. Psychology, Princeton University, Princeton, NJ 1992 – 1996

Educational Activities Expeditionary Craniofacial Trauma Course Director 2018 Global Health 1 course student USUHS 2018 Expeditionary Craniofacial Trauma Course Director 2017 Enrolled in Masters of HPE USU 2017 – present USUHS Flap Course Instructor 2017 Faculty Advisor for the USU chapter of AWS 2017 – present Accepted for USU Masters HPE starting July 17 2017 – present ATLS Instructor USU and DMRTI 2016 – present OSCHE examiner; transitional interns 2015 C-Stars Preceptor 2012 – present American Society of Plastic Surgery In Service Exam Author 2012 – present AO North America Faculty for CMF 2010 – present Plastic Surgery Faculty for OMS resident rotators 2010 – present Plastic Surgery Faculty for ENT resident rotators 2010 – present Plastic Surgery Faculty for General Surgery resident rotators 2010 – present Plastic Surgery Faculty for Urology resident rotators 2010 – present Plastic Surgery Faculty for Medical Student rotators 2010 – present Reviewer, Journal of Craniofacial Surgery 2010 – present Reviewer Military Medicine 2010 – present

Publications

1. Kerry Latham MD, W. Brian Perry MD, and Melanie Richards MD. Lateral Neck mass in a Young Woman. Young woman. Current Surgery. Vol. 63(1) Jan 2006, pp. 24-26. 2. Latham, Kerry MD; Fernandez, Sarah MD; Iteld, Larry MD; Panthaki, Zubin MD; Armstrong, Milton B. MD; Thaller, Seth MD Pediatric Breast deformity, J of Craniofacial Surgery. 17(3) May 2006 pp 454-467. 3. Kerry Latham, MD, Silvio Podda, MD, and S Anthony Wolfe, MD. Melanocytic Neuroectodermal Tumor of Infancy: Excision and primary palatal repair at 7 months of age. J of Craniofacial Surgery. Vol. 18 (2) March 2007 pp 450-54. 4. Nathan N, Latham K, Cooper J, Perlyn C, Gozlan I, Thaller SR Anthropometry of the external ear in children with cleft lip and palate in comparison to age-matched controls. Journal of Craniofacial Surgery. 2008 Sep 19 (5): pp.1391-5. 5. Sreeramoju P, Porbandarwalla NS, Arango J, Latham K, Dent DL, Stewart RM, Patterson JE. “Recurrent Skin and Soft Tissue Infections due to Methicillin-resistant Staphylococcus Aureus requiring Operative Debridement.” American Journal of Surgery. 2011 Feb; 2011(2): pp. 216-20. E-pub 6. Liu, D, Latham, K and Gruss, JG Nasal Lining Mobilization for Primary and Secondary Palatoplasty. Journal of Craniofacial Surgery 22(6): Nov 2011, pp 2241-2243. 7. Latham, Kerry, Brehm , Walter, and Danny Sharon “Comparing Fitness Performance Before and After Breast Reduction Surgery.”. Military Medicine Vol 176, No.11, November 2011, pp. 1351-1354. 8. Valerio, I, Basile, P, Howard, R, Latham, K, Armonda, R, Severson, M, and Kumar, A. “Advanced Cranial Reconstruction in the War Wounded: Indications and Applications for an Intracranial Free Flap.” Conference Paper. AAHS ASPN ASRM 2012 Annual Meeting, Jan 2012. 9. Birgfeld, CB, Saltzman, BS, Luquetti, DV, Latham, K, Starr, JR, Heike, C, “Comparison of Two-Dimensional and Three-Dimensional Images for Phenotypic Assessment of Craniofacial Microsomia” The Cleft Palate- Craniofacial Journal. May 2013; 50 (3), pp305-14. 10. Latham K Review of ‘Aesthetic Reconstruction of the Child’s Nose’ by Dr. Gary Burget, Chicago, IL: Gary Burget; 2012:1-382. J of Craniofacial Surgery July 2013 Vol 24(4) p 1494. 11. Latham, Kerry, Ed Buchanan, Dan Suver, Joe Gruss Neurofibromatosis of the Head and Neck: Classification and Surgical Management. Plastic and Reconstructive Surgery. Mar 2015, 135(3), pp. 845-55. 12. Latham, K Valerio,I Burget, G, Martin, B and VanderKolk, C. A Case of Subtotal Nasal Reconstruction: A Brave Afghan-American Woman’s Care in the Military Health System. Plastic and Reconstructive Surgery- Global Open. Vol 3(7) July 2015, p. e447. 13. Rendon JL, Hammer D, Sabino J, Martin B, Latham K, Fleming ME, Valerio IL. Restoration of Full Thickness Soft Tissue Defects with Spray Skin Epidermal Regenerative Technology in Conjunction with Dermal Regenerate. Plastic and reconstructive surgery. 2015 Oct 1;136(4S):74. 14. IL Valerio, D Hammer, J Rendon, BD Martin, K Latham, M Fleming. “Combination Regenerative Modalities in the Reconstruction of Traumatic Soft Tissue Defects: Application of Spray Skin Technology with Dermal Regenerate Templates.” Tissue Engineering Part A 21, S111-S111. 2015 15. D Hammer, J GreeenIII, CE Crecelius, K Latham, IL Valerio. “ The Use of Autogenous Fat Grafting to Address Craniomaxillofacial Volume Loss and Contour Deficits Secondary to War Trauma.” Tissue Engineering Part A 21, 2015 S149-S149. 16. Mundinger GS, Latham K, Friedrich J, Louie O, Said H, Birgfeld C, Ellenbogen R, Hopper RA. Management of the Repeatedly Failed Cranioplasty Following Large Postdecompressive Craniectomy: Establishing the Efficacy of Staged Free Latissimus Dorsi Transfer/Tissue Expansion/Custom Polyetheretherketone Implant Reconstruction. Journal of Craniofacial Surgery. 2016 Nov 1;27(8): pp.1971-7. 17. Valerio IL, Hammer DA, Rendon JL, Latham KP, Fleming ME. A Case Report of the First Nonburn-related Military Trauma Victim Treated with Spray Skin Regenerative Therapy in Combination with a Dermal Regenerate Template. Plastic and Reconstructive Surgery–Global Open. 2016 Dec 1;4(12):e1082. 18. Hammer D, Rendon JL, Sabino J, Latham K, Fleming ME, Valerio IL. Restoring full-thickness defects with spray skin in conjunction with dermal regenerate template and split-thickness skin grafting: a pilot study. Journal of Tissue Engineering and Regenerative Medicine. 2017 Jan 1. 19. Knox JA, Nelson DA, Latham KP, Kurina LM. Objective Effects of Breast Reduction Surgery on Physical Fitness. Annals of plastic surgery. 2018 Jan 1;80(1): pp.14-7. 20. Farber SJ, Latham KP, Kantar RS, Perkins JN, Rodriguez ED. Reconstructing the Face of War. Military medicine. 2019 Jul 1;184(7-8):e236-46. 21. Herrick-Reynolds K, Brooks D, Wind G, Jackson P, Latham K. Military Medicine and the Academic Surgery Gender Gap. Military medicine. 2019 Jun 26. 22. Latham, Kerry et al “Uniformed Services University Medical Student Mentorship Experiences and Gender From 2010 to 2017.” Accepted for publication MILMED Nov 2019 23. Book Chapter: Kerry Latham MD, Marcello Layaco BA, Efraim Arias BA, and `Milton B Armstrong, MD

UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814-4799 www.usuhs.edu

April 15, 2020

MEMORANDUM FOR RICHARD W. THOMAS, MD, DDS, FACS, PRESIDENT, USUHS

Through: Chair, Board of Regents

SUBJECT: Certification of Graduate Student

The graduate student listed below is presented for certification to receive the Master of Health Professions Education degree effective upon your approval:

Sunny J. Yauger

MASTER OF HEALTH PROFESSIONS EDUCATION

Department of Medicine

Attached is the candidate’s Thesis Approval Form. Also attached are the certification of authorized use of Copyrighted materials, Thesis Title Page, Thesis Abstract, and Curriculum Vitae.

Arthur L. Kellermann, MD, MPH Dean, USUHS, School of Medicine

Attachments: As stated

Learning to Care for Those in Harm’s Way

COPYRIGHT STATEMENT

The author hereby certifies that the use of any copyrighted material in the thesis

manuscript entitled: Reliability in Healthcare Simulation Setting: A Definitional Review

is appropriately acknowledged and, beyond brief excerpts, is with the permission of the

copyright owner.

______

Sunny J. Yauger

March 19, 2020

DISCLAIMER

The views presented here are those of the author and are not to be construed as

official or reflecting the views of the Uniformed Services University of the Health

Sciences, the Department of Defense or the U.S. Government.

v

RELIABILITY IN HEALTHCARE SIMULATION SETTING:

A DEFINITIONAL REVIEW

by

Sunny Yauger, BS, CHSE

Thesis submitted to the Faculty of the Health Professions Education Graduate Program Uniformed Services University of the Health Sciences In partial fulfillment of the requirements for the degree of Master in Health Professions Education 2020

RELIABILITY IN HEALTHCARE SIMULATION: A DEFINTIONAL REVIEW

Advisers: Abigail Konopasky, PhD and Alexis Battista, PhD, MBA

ABSTRACT

Background: The construct of reliability in health professions education serves as a

measure of the congruence of interpretation across assessment tools. When used as an assessment strategy, healthcare simulation serves to elicit specific participant behaviors sought by medical educators. In healthcare simulation, reliability often refers to the ability to

consistently reproduce a simulation and that reproducing a simulation setting can consistently

expose participants to the same conditions, thus achieving simulation reliability. However, some

articles have expressed that simulations are vulnerable to error stemming from design conceptualization to implementation, and the impact of social factors when participants interact and engage with others during participation. The purpose of this definitional review is to examine how reliability has been conceptualized and defined in healthcare simulation, and how the attributes of simulations may present challenges for the traditional concept of reliability in

health professions education.

Method: Data collection and analysis was approached through a constructivist

perspective and grounded theory strategies. Articles between 2009-2019 were filtered applying

keywords related to simulation development and design. Data winnowing was structured around

a framework viewing simulation as a social practice where participants interact with simulation

setting attributes.

Results: Reliability is not directly defined but described by how simulation setting

attributes influence setting reliability, specifically by performance of a simulated participants and their interactions with simulation design attributes. To mitigate errors, training approaches and strategies are designed to refine simulated participant performance. Different lexical terms related to reliability describe the process of how reliability is achieved.

Conclusion: Simulation setting reliability is supposed to provide participants fair and trustworthy conditions to achieve performance competency set by medical educators. However, from a social constructivist perspective, simulation setting reliability is dependent in the manner in which simulated participants are trained to achieve performance reliability.

Sunny Yauger

Email: [email protected]

Country of Citizenship: United States of America Veterans' Preference: No Highest Grade: GS-0301-12 Contact Current Employer: Yes

AVAILABILITY Job Type: Permanent Work Schedule: Full Time

WORK EXPERIENCE Employer Name: Department of Simulation (40hrs/week) Dates: 9/2016-Present Fort Belvoir Community Hospital (FBCH) Grade Level: GS-12

Supervisor: James Nederostek (757) 641-5809 (Permission to contact) Title: Simulation Program Chief (Acting) • Provide expertise, leadership, consultation, and technical expertise and assistance to staff when detailed to supervisory tasks • Responsible for planning, developing, implementing, evaluating and tracking education programs in regard to curriculum and instruction implementation to inform and stimulate program initiatives • Lead and develop education training initiatives informed by learning theories and education methodologies • Disseminate education tools using enterprise learning and content management system • Apply qualitative research strategies and analysis for program implementation evaluation to inform education plan modifications • Develop department annual equipment and budget requests

Employer Name: Department of Simulation (40hrs/week) Dates: 3/2014-9/2016 Fort Belvoir Community Hospital (FBCH) Grade Level: GS-12

Supervisor: Paul Johnson (912) 980-4922 (Permission to contact) Title: Simulation Program Specialist • Implemented and facilitated education design based on need assessments • Coordinated education resources to support military training initiatives • Created and sustained a culture that encourages commitment to quality service and high performance to meet customer needs • Facilitated dual accreditation from the American College of Surgeons and Society for Simulation in Healthcare

Employer Name: Department of Simulation (40hrs/week) Dates: 5/2008-3/2014 Fort Belvoir Community Hospital Grade Level: GS-11

Supervisor: Dana Dones (757) 544-8234 (Permission to contact) Title: Simulation Program Administrator • Maintained training database • Trained personnel on simulator software interfaces, simulation-based educational methodologies while providing consultation and technical expertise throughout the duration of the training

Employer Name: Gastroenterology Clinic (40hrs/week) Dates: 3/2005-5/2008 Walter Reed Army Medical Center Grade Level: GS-09

Supervisor: Adeline Barksdale (240) 338-1031 (Permission to contact) Title: Health Science Specialist • Educate patients on endoscopic preparatory procedures through illustrations and implemented a process to help serve customers more effectively. • Developed and implemented a standard operating procedure for the clinic • Enrolled over 600 human patient subjects into a gastroenterology research study Page 1 of 2

Employer Name: Surgical Intensive Care Unit (40hrs/week) Dates: 9/2003-3/2005 Walter Reed Army Medical Center Grade Level: GS-09

Title: Medical Support Assistant • Processed clinical administrative and workflow needs for clinical staff supporting the wounded combat service members and families • Supported organizational policies and practices designed to enhance diversity in the organization • Applied systematic evaluation methods to assess program processes, outputs, and outcomes

CERTIFICATIONS AND LICENSES Certified Healthcare Simulation Educator (CHSE), License 161176 2016 Healthcare Modeling and Simulation Certificate, Naval Post Graduate School 2014

EDUCATION Master Health Professions Education (candidate) Uniformed Services University of the Health Sciences, 2020 projected completion

Bachelor of Science, Biology George Mason University, 2002

GRANTS AND AWARDS Gateway Debriefing Skills Workshop Grant, Center for Medical Simulation 2019 Associate Investigator for a JPC-1 Grant 2016 Appreciation Award, Daniel K. Inouye Graduate School of Nursing, USUHS 2015 Healthcare Simulation Administrator Award, Army’s Central Simulations Committee 2015

PROFESSIONAL MEMBERSHIPS AND ACADEMIC ASSOCIATIONS Society for Simulation in Healthcare 2016-Present Adjunct Professor, Daniel K. Inouye Graduate School of Nursing 2015-Present National Capital Region Simulation Consortium 2014-Present Army Central Simulation Committee 2008-Present

JOB-RELATED TRAINING Debriefing with Good Judgement Workshop, Center for Medical Simulation, 2019 Healthcare Simulation Facilitator Development Course, Fort Belvoir Community Hospital 2018 Human Resources Management for Supervisors, Civilian Human Resource Center 2016 Continuing Education in Health Sciences, Northern Virginia Community College 2011

PROFESSIONAL PUBLICATIONS AND CREATIVE PRODUCTIONS Byrd, K. A., & Yauger, S. (2012, May). Verification and validation of a patient simulator for test and evaluation of a laser doppler vibrometer. In SPIE Defense, Security, and Sensing (pp. 837111-837111). International Society for Optics and Photonics.

REFERENCES Shad Deering, COL (R), MD, FACOG Medical Director, Santa Rose Simulation Center Christus Santa Rosa Health System, San Antonio, TX Cell: (253) 720-4035

Joseph Lopreiato, MD MPH Associate Dean for Simulation Education, Val G Hemming Simulation Center Uniformed Service University of the Health Sciences, MD Cell: (301) 275-5638

Jeffery Mikita, COL, MD Chief, Medical Modernization and Simulation Division Education & Training Directorate, Defense Healthcare Agency, Falls Church, VA Cell: (301) 204-9480

Page 2 of 2 UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814-4799 www.usuhs.edu

April 15, 2020

MEMORANDUM FOR RICHARD W. THOMAS, MD, DDS, FACS, PRESIDENT, USUHS

Through: Chair, Board of Regents

SUBJECT: Certification of Graduate Student

The graduate student listed below is presented for certification to receive the Master of Science degree effective upon your approval:

William H. Horne IV

MASTER OF SCIENCE

Molecular and Cell Biology Graduate Program

Attached is the candidate’s Thesis Approval Form. Also attached are the certification of authorized use of Copyrighted materials, Thesis Title Page, Thesis Abstract, and Curriculum Vitae.

Arthur L. Kellermann, MD, MPH Dean, USUHS, School of Medicine

Attachments: As stated

Learning to Care for Those in Harm’s Way

The impact of desiccation and freezing on gamma radiation survival in microorganisms

by

William Hill Horne IV

Thesis submitted to the Faculty of the Molecular and Cell Biology Graduate Program, Uniformed Services University of the Health Sciences in partial fulfillment of the requirements for the degree of Master of Science 2020 ABSTRACT

The impact of desiccation and freezing on gamma radiation survival in microorganisms

William H. Horne IV, M.S., 2020

Thesis directed by: Michael J. Daly Ph.D., Department of Pathology

Gamma radiation and desiccation cause oxidative stress in microorganisms,

mediated by reactive oxygen species (ROS) generated by abiotic and metabolic

mechanisms. During irradiation, ROS are produced in cells by water radiolysis; during desiccation, by exposure to atmospheric oxygen and dysfunctional metabolic processes.

Bacteria and yeasts that are radiation-resistant are typically also desiccation-resistant and share a great antioxidant capacity. This thesis considers how different physicochemical environments that affect cellular water content and state influence radiation resistance.

The gamma radiation survival metrics of eight model microorganisms (three vegetative bacterial strains (Escherichia coli, Acinetobacter baumannii, Lactobacillus plantarum), three bacterial spore strains (Bacillus megaterium, Bacillus thuringiensis, Bacillus subtilis), and two budding yeast strains (Saccharomyces cerevisiae EXF-6761 and S. cerevisiae EXF-6218)) are reported for the following physicochemical states: as liquid cultures irradiated on wet ice (0oC); as frozen-aqueous cultures irradiated on dry ice (-

79oC); as desiccated cells at room temperature irradiated on wet ice; and as frozen- desiccated cells irradiated on dry ice. The survival data show that desiccating or freezing

vii most vegetative cells before irradiation extends their resistance to gamma radiation. In contrast, Bacillus spores with naturally low intracellular water contents did not display increased radiation resistance upon desiccation or freezing; and L. plantarum, which lacks antioxidant enzymes, only displayed increases in radiation resistance upon freezing.

The phenomenon of desiccation- and freezing-facilitated radiation resistance is important to the applied scientific disciplines of radiation sterilization by promoting new protocols to optimize sterilization yields, biodefense by demonstrating the dangers frozen and desiccated biological agent preparations pose to current protection measures, and space exploration by understanding how environmental conditions in space could facilitate microorganism survival against cosmic radiation and unintended transportation between worlds.

viii

William Hill Horne IV [email protected]

Objectives To mold Army Officers with an understanding and appreciation for science and the scientific method, using knowledge and experience gained through obtaining a Master’s degree in Molecular and Cell Biology.

Civilian Education University of Pittsburgh April 2003; Bachelor of Science • Majored in Chemistry with a Biological Sciences option • Conducted research into methods of monitoring dopamine levels in the brain

University of North Carolina School of Medicine August 2004 – June 2007; Withdrew • Significant coursework on anatomy, physiology, microbiology, biochemistry, and pathology • Withdrew due to waning interest in practicing medicine

Military Education Chemical Basic Officer Leader Course June 2011 • Focused on CBRN Defense concepts, tactics, techniques, and procedures • Earned Technician level certification on handling of Hazardous Materials

Chemical Captain’s Career Course April 2015 • Focused on Army leadership and CBRN policy • Received Advanced Chemical and Biological training at Dugway Proving Grounds • Earned Defense Support of Civil Authority Level II certification

Academic/Research Employment Research Technician; December 2007 – March 2008 University of North Carolina at Chapel Hill; 104 Airport Drive, Campus Box 1045, Chapel Hill, NC 27599 Processed standard and biological samples for analysis. Adapted and developed processing procedures, worked with numerous chemical agents, and recorded and analyzed experiment results.

Instructor; October 2003 – March 2004 Sylvan Learning Center; 20 Northfield Center, Whiteville, NC 28472 Provided supplemental teaching to grade- and high-school students. Focused on teaching mathematics, but provided lessons in reading and writing, as well.

Teaching Assistant; September 2000 – December 2000 University of Pittsburgh; 100 Craig Hall, Pittsburgh, PA 15260 Worked as a student teacher in the university’s Undergraduates Teaching Undergraduates program. With three other UTU members, organized and taught a Chemistry 110 Lab section.

Awards and Publications • Graduated Magna Cum Laude from University of Pittsburgh • Published Author; “The Need to Conserve Water during CBRN Decontamination.” Army Chemical Review. PB 3-15-1, pages 27, 30; Summer 2015. • Earned Honor Graduate during Captain’s Career Course UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814-4799 www.usuhs.edu

April 15, 2020

MEMORANDUM FOR RICHARD W. THOMAS, MD, DDS, FACS, PRESIDENT, USUHS

Through: Chair, Board of Regents

SUBJECT: Certification of Graduate Student

The graduate student listed below is presented for certification to receive the Doctor of Philosophy degree effective upon your approval:

Chelsi R. Beauregard

DOCTOR OF PHILOSOPHY

Emerging Infectious Diseases Graduate Program

Attached is the candidate’s certification of successful completion of the Final Examination. Also attached are the Dissertation Approval Form, certification of authorized use of Copyrighted materials, Dissertation Title Page, Dissertation Abstract, and Curriculum Vitae.

Arthur L. Kellermann, MD, MPH Dean, USUHS, School of Medicine

Attachments: As stated

Learning to Care for Those in Harm’s Way UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES SCHOOL OF MEDICINE GRADUATE PROGRAMS Graduate Education Office (A 1045), 4301 Jones Bridge Road, Bethesda, MD 20814

FINAL EXAMINATION/PRIVATE DEFENSE FOR THE DEGREE OF DOCTOR OF PHILOSOPHY IN THE EMERGING INFECTIOUS DISEASES GRADUATE PROGRAM

Name of Student: Chelsi Beauregard

Date of Examination: March 27, 2020 Time: 1:30 PM Place: Room A2015

DECISION OF EXAMINATION COMMITTEE MEMBERS:

PASS FAIL

Digitally signed by SCHAEFER.BRIA SCHAEFER.BRIAN.C.126024530 N.C.1260245305 5 ______Date: 2020.03.27 15:54:09 -04'00' ____X ____ Dr. Brian C. Schaefer DEPARTMENT OF MICROBIOLOGY & IMMUNOLOGY Committee Chairperson

BRODER.CHRISTO Digitally signed by BRODER.CHRISTOPHER.C.122 PHER.C.122864708 8647086 ______6 Date: 2020.03.27 17:29:31 -04'00' ____X ____ Dr. Christopher C. Broder DEPARTMENT OF MICROBIOLOGY & IMMUNOLOGY Dissertation Advisor

Digitally signed by Joseph Joseph Mattapallil Date: 2020.03.27 ______Mattapallil 16:00:59 -04'00' ____X ____ Dr. Joseph Mattapallil DEPARTMENT OF MICROBIOLOGY & IMMUNOLOGY Committee Member

LOWY.ROBERT Digitally signed by LOWY.ROBERT.J.1229101400 .J.1229101400 Date: 2020.03.27 17:21:44 -04'00' ______X ____ Dr. Robert Joel Lowy The ARMED FORCES RADIOBIOLOGY RESEARCH INSTITUTE (AFRRI) Committee Member

COPYRIGHT STATEMENT

The author hereby certifies that the use of any copyrighted material in the

dissertation manuscript entitled: "ADVANCEMENTS IN MAMMALIAN

COMPARATIVE IMMUNOLOGY- DEVELOPING NEW TOOLS AND

INVESTIGATING THE INNATE IMMUNE RESPONSE TO CEDAR VIRUS" is

appropriately acknowledged and, beyond brief excerpts, is with the permission of the copyright owner.

Chelsi Beauregard

May 15th, 2020

DISCLAIMER

The views presented here are those of the author and are not to be construed as

official or reflecting the views of the Uniformed Services University of the Health

Sciences, the Department of Defense or the U.S. Government.

vi

ADVANCEMENTS IN MAMMALIAN COMPARATIVE IMMUNOLOGY-

DEVELOPING NEW TOOLS AND INVESTIGATING THE INNATE IMMUNE

RESPONSE TO CEDAR VIRUS.

by

Chelsi Ryan Beauregard

Dissertation submitted to the Faculty of the Emerging Infectious Disease Graduate Program Uniformed Services University of the Health Sciences In partial fulfillment of the requirements for the degree of Doctor of Philosophy 2020

ABSTRACT

Advancements in mammalian comparative immunology-developing new tools and investigating

the innate immune response to Cedar virus

Chelsi Ryan Beauregard, Doctor of Philosophy, 2020

Thesis directed by:

Christopher C Broder, PhD

Professor and Chair, Department of Microbiology and Immunology and

Brian Schaefer, PhD

Professor, Department of Microbiology and Immunology

Emerging viruses pose a serious threat to public health. Virtually all of the recent emerging virus outbreaks have come from human-wildlife interactions. These wildlife animals that harbor a virus are referred to as reservoirs. When the same virus then enters a human host however, overwhelming pathogenesis is often observed. Bats are the reservoirs for many of these zoonotic viruses. For example, Pteropus sp bats are the source of Hendra (HeV) and Nipah virus (NiV). Both of these viruses cause severe disease with high mortality rates that are often a

result of immunopathogenesis. Cedar virus (CedV) belongs to the same genus as HeV and NiV

but is non-pathogenic. Here, CedV is used as a model for HeV and NiV to study human-bat

comparative immunology. Because bats are the natural reservoirs of so many viruses, it is important to investigate how they are able to tolerate virus infections. A major goal of the

present research is to develop a new technology that could allow a comparison of the human

immune response to that of the viral reservoir. We use lentiviral transduction of two viral

oncogenes, v-Raf and v-Myc, to immortalize macrophages isolated from murine blood. The

resulting cell lines exhibit surface markers consistent with mature murine macrophages, most notably CD11b and F4/80. These cells are IFNγ responsive and capable of phagocytosis.

Further, the cell lines are cytokine independent, which is important when working with species for which commercially available cytokines do not exist.

We also investigate the NF-κB response to CedV. This pathway is activated during many

types of infections and is responsible for the subsequent activation of many pro-inflammatory

genes. To compare the NF-κB response in P. alecto (reservoir) to that of humans (host) we use

kidney fibroblast cell lines from P. alecto (PaKi and PaKiT) and the human cell lines HEK 293T

and MRC-5. We find that the activation of NF-κB in PaKi cells is overall less robust than in the

human cell lines. Additionally, we find activation of NF-κB occurs sooner after CedV infection

in PaKiT cells than in HEK 293T cells. Moreover, we detect more viral protein in PaKi cells

than MRC-5 cells. This is consistent with our data that show blocking the NF-κB pathway yields

a higher viral titer and more detectable virus within the cells.

A20 expression is activated by the NF-κB pathway. Upon expression, A20 serves as a

negative regulator of the pathway. We demonstrate that CedV induces robust A20 expression,

and upon further analysis, that the CedV phosphoprotein (P), is sufficient for this activation.

Remarkably, this CedV induced expression is independent of the activation of NF-κB.

Alternative splicing is a process by which mRNA is edited to include or exclude different introns

and exons of the RNA transcript to create a unique protein isotype. We determine that this CedV mediated A20 expression occurs even in biallelic A20 exon 3 knockout cells. This suggests the

A20 we are detecting during infection is a unique isoform of A20 which does not contain exon 3.

The abundance of different protein isotypes from a given gene can be altered during infections.

However, virus mediated splicing that results in a unique host protein is novel. Thus, through this dissertation work, I have developed a new tool with comparative immunology potential, contributed to henipavirus comparative immunology with existing tools, and described a novel way viruses may alter a host’s cellular biology. Curriculum Vitae CHELSI R. BEAUREGARD, PHD CANDIDATE

[email protected] (603) 325-2809

EDUCATION 2009-2012 Marist College, BS, Biomedical Sciences, School of Science, Poughkeepsie, NY 12601 2013-2020 Uniformed Services University, School of Medicine, Bethesda, MD 20814 Area of Specialization: Viral Immunology Dissertation: Advancements in mammalian comparative immunology- developing new tools and investigating the innate immune response to Cedar virus. •Synopsis is included as an appendix PhD Advisors: Brian C. Schaefer PhD and Christopher C. Broder PhD

AWARDS AND HONORS • 2018 Henry Jackson Foundation John W. Lowe Office of Technology Transfer Commendation • 2018 Trainee Abstract Award from the American Association of Immunologists. • 2018 Uniformed Services University (USU) Vice President for Research Travel Award. • 2008-2012 Marist College Presidential Scholarship.

PUBLICATIONS Laing ED, Sterling SL, Weir DL, Beauregard CR, Smith IL, et al. Enhanced Autophagy Contributes to Reduced Viral Infection in Black Flying Fox Cells. Viruses. 2019; 11. *Upon completion of dissertation, my work will be published as two peer-reviewed, scientific papers. Each paragraph of the appendix is a brief summary of the work that will be reported for one paper.

PATENTS / LICENSES Beauregard CR, and Schaefer, BC. 2019. US Provisional Patent 62/645,092 Immortalization of Splenic and Peripheral Blood Macrophages Using a Multi-Cistronic v-Raf/v-Myc Lentivirus US Provisional Patent 62/645,092. March 19, 2018. Final Patent filed March 19, 2019. •License agreement: Applied Biological Materials Inc.2019 C57BL/J6 mouse wild type macrophage cell lines from spleen and blood immortalized using methodology in above patent.

1

ORAL PRESENTATIONS 2018 Beauregard CR, Broder CC, and Schaefer, BC. Cedar Virus Mediated Induction of NF- κB and Its Negative Regulator A20 in Humans and Its Natural Reservoir, Pteropus alecto. American Society for Virology (ASV), July 2018, College Park, MD.

2018 Beauregard CR, Broder CC, and Schaefer, BC. Immortalization of splenic and peripheral blood macrophages using a multi-cistronic v-Raf/v-Myc lentivirus. American Association of Immunologists (AAI), May 2018, Austin, Texas.

POSTER PRESENTATIONS 2018 Beauregard CR, Broder CC, and Schaefer, BC. Immortalization of splenic and peripheral blood macrophages using a multi-cistronic v-Raf/v-Myc lentivirus. American Association of Immunologists, May 2018, Austin, Texas. 2018 Beauregard CR, Broder CC, and Schaefer, BC. Immortalization of splenic and peripheral blood macrophages using a multi-cistronic v-Raf/v-Myc lentivirus. Uniformed Services University Research Week, May 2018, Bethesda, MD. *Poster Presentation Finalist

TEACHING EXPERIENCE Research mentor 2017 USU Summer Research Training Program (USRTP) mentor of Joshua Rich. 2015 USU Graduate student mentor of Oladimeji Abegunrin Instructor 2017-2018 USRTP instructor in Cutting Edge Research “Host and Reservoir Immune Responses to Emerging Viruses,” Uniformed Services University, Bethesda, MD Teaching Assistant 2016-17 Microbiology laboratory, first year medical students, USU, Bethesda, MD 2010-12 Microbiology laboratory, Marist College, Poughkeepsie, NY

VOLUNTEER WORK AND UNIVERSITY SERVICE 2014- 17 Student Ambassador for Uniformed Services University EID graduate program. 2016-17 AAAS/SSE STEM weekly volunteer, Burnt Mills Elementary School, Spanish Immersion Program, Silver Spring, MD

2

Appendix

Synopsis of PhD work The incidence of emerging infectious diseases is increasing. Most of these diseases are caused by viral spillovers from wildlife. Typically, these host animals, known as reservoirs, harbor a pathogen but do not develop symptoms of disease. The immunological characteristics of viral reservoirs can inform ways in which pathology can be decreased or avoided in the host. Unfortunately, relatively little is known about the immune response in reservoirs of emerging viruses as they are typically non-laboratory animals. Bats, in particular, are the suspected or confirmed reservoirs for most of the recent outbreaks of highly pathogenic viruses. In our laboratories we aim to model the highly pathogenic Hendra and Nipah viruses. To do this we use the closely related but non-pathogenic Henipavirus, Cedar virus. Bats (Pteropus sp.) are reservoirs for all three of the above named viruses. We use Pteropus alecto and human cell lines to investigate differences in the activation of the immunomodulatory NF-κB pathway as well as one of its important regulators, A20 (TNFAIP3). We have shown that although Pteropus alecto cell lines are capable of mounting an NF-κB response, they do not do so during Cedar virus infection. On the other hand, human cell lines mount a robust response. Additional data show that the NF-κB response aides in decreasing viral load. Most recently, we found that Cedar virus, specifically the Cedar virus P protein, is able to induce alternative splicing of A20 in human T-cells resulting in a novel A20 isotype. Uniquely, this induction occurs independent of the NF-κB response.

Our ultimate goal is to compare bat and human immune responses to viruses in a myeloid cell line. There were no good model systems for making myeloid cell lines from non- laboratory species. We developed a new technology that uses the v-raf and v-myc oncogenes in a BSL-2 compatible lentivirus to immortalize mature macrophages from murine blood. The resulting cell line has no species specific cytokine dependency. Many reservoirs are protected species and have small blood volumes. This technology, unlike others, uses a simple blood draw rather than an invasive bone marrow procedure. Additionally, fewer than 100,000 white blood cells are required as starting material. Our resulting cell line was extensively characterized. The cells have the cell surface marker phenotype and functional characteristics of a mature, differentiated macrophages and can therefore, be used to assess important properties of the macrophage response to zoonotic, viral infection.

3

UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814-4799 www.usuhs.edu

April 15, 2020

MEMORANDUM FOR RICHARD W. THOMAS, MD, DDS, FACS, PRESIDENT, USUHS

Through: Chair, Board of Regents

SUBJECT: Certification of Graduate Student

The graduate student listed below is presented for certification to receive the Doctor of Philosophy degree effective upon your approval:

Fernanda P. De Oliveira

DOCTOR OF PHILOSOPHY

Department of Medical and Clinical Psychology

Attached is the candidate’s certification of successful completion of the Final Examination. Also attached are the Dissertation Approval Form, certification of authorized use of Copyrighted materials, Dissertation Title Page, Dissertation Abstract, and Curriculum Vitae.

Arthur L. Kellermann, MD, MPH Dean, USUHS, School of Medicine

Attachments: As stated

Learning to Care for Those in Harm’s Way

2

COPYRIGHT STATEMENT

The author hereby certifies that the use of any copyrighted material in the dissertation manuscript entitled: Shame, Guilt, and Suicide: A Mixed Methods Study of Psychiatric Inpatients at Risk for Suicide is appropriately acknowledged and, beyond brief excerpts, is with the permission of the copyright owner.

______

Fernanda Pinheiro De Oliveira

31 July 2019

5

Shame, Guilt, and Suicide: A Mixed Methods Study of Psychiatric Inpatients at Risk for Suicide

by

Fernanda Pinheiro De Oliveira

Doctoral proposal submitted to the Faculty of the Medical and Clinical Psychology Graduate Program Uniformed Services University of the Health Sciences In partial fulfillment of the requirements for the degree of Doctor of Philosophy 2020

ABSTRACT

Title of Dissertation: Shame, Guilt, and Suicide: A Mixed Methods Study of Psychiatric

Inpatients at Risk for Suicide

Fernanda Pinheiro De Oliveira, Doctor of Philosophy, 2020

Thesis directed by: Dr. Marjan Ghahramanlou-Holloway, Suicide Care, Prevention, and

Research Initiative, Department of Medical and Clinical Psychology, USUHS

BACKGROUND: Shame and guilt have been empirically examined in the context of suicide; however, inconsistencies in uniformly defining and measuring these emotions exist and lead to contradictory findings. Advancing our understanding of the role of shame and guilt in the trajectory toward suicidal thoughts/actions has important research and practice implications.

PURPOSE: (1) To qualitatively explore common themes of shame and guilt within suicide narratives shared during psychotherapy; and (2) To quantitatively determine the association among shame, guilt, suicide-related distorted cognitions, dysregulated emotions, and problematic social problem-solving.

METHODS: A cross-sectional, retrospective, mixed methods, and exploratory sequential design was employed. Selected baseline randomized controlled trial (RCT) data from 58 suicidal service members and adult dependents admitted for inpatient psychiatric care and randomized into the treatment arm of the RCT were used. Qualitative analyses focused on patients’ transcribed

6

suicide narratives. Magnitude ratings quantified the intensity and relevance of shame and guilt; the ratings were carried over to answer a series of research questions, using regression models.

RESULTS: Shame (and not guilt) was consistently more likely to be referenced. Shame referenced a tendency toward negative self-appraisal and failure to meet expectations within culturally-ascribed roles, whereas guilt referenced familial functioning difficulties. Shame and guilt were connected to intrapunitive motivations for suicide, burdensomeness, and hopelessness.

Avoidance, sensation seeking, rumination, and self-directed injury were notable emotion regulation strategies. Impulsive/careless problem solving was reported in the aftermath of shame and/or guilt. A model with shame, guilt, and age and sex as covariates was significantly associated with limited awareness of emotions, such that lower shame magnitude, greater guilt magnitude, younger age, and male sex were associated with lower awareness of emotions.

Second, a model with shame and guilt was significantly associated with lack of emotional clarity, such that greater shame and guilt magnitudes were significantly associated with greater lack of emotional clarity. Notably, shame and guilt were never individually significantly associated with any of the dependent variables in any model.

DISCUSSION: Shame and guilt themes and their interrelatedness support the notion that these two emotions play a meaningful role in the etiology and maintenance of suicidal behaviors.

Despite a number of limitations, this study has generated well-informed hypotheses and a series of research and clinical recommendations, based on a grounded theory approach, to guide future investigations.

7

De Oliveira Curriculum Vitae

Fernanda P. De Oliveira, Capt, USAF Malcolm Grow Medical Clinics & Surgery Center (MGMCSC), Joint Base Andrews, MD (240) 857-7186 • [email protected]

EDUCATION

 Doctor of Philosophy, Clinical Psychology (2015 – 2020) Uniformed Services University (APA Accredited), Bethesda, MD Dissertation Topic: Shame and Guilt: A Mixed Methods Study of Psychiatric Inpatients at Risk for Suicide (Dissertation Defended: 31 July 2019) Research Assistantship:  Suicide Care, Prevention, and Research Initiative with Marjan Holloway, Ph.D. (2015 – 2020)

 Bachelor of Science, Psychology (2010 - 2012) University of Georgia, Athens, GA

 Associate of Science, Psychology (2009 - 2010) Georgia Perimeter College, Dunwoody, GA

INTERNSHIP TRAINING  Clinical Psychology, MGMCSC (APA Accredited), JB Andrews, MD

Other Internship Experiences  Stepped Care Working Group Member at the Mental Health Access to Care Summit, Air Force Medical Readiness Agency (AFMRA) North (25 – 28 Feb 2020)  Mental Health Flight Representative at the 11th Medical Operations Squadron Resiliency Tactical Pause (Aug – Sep 2020)

RECENT HONORS AND AWARDS  APA Society for Military Psychology Student Dissertation Award - $1,500 (2019)  Military Suicide Research Consortium (MSRC) Travel Award (2018, 2019) - $1,000  Beck Institute Student Scholarship Award (2018) - $500 PUBLICATIONS Peer-Reviewed Papers Mallonee, S., Tate, L., De Oliveira, F., & Ruiz, A. (in press). Development and Trial Implementation of a 30-Day Outpatient Program for Subthreshold PTSD. Military Medicine. Ribeiro, S., LaCroix, J. M., De Oliveira, F., Novak, L., Lee-Tauler, S., Darmour, C., Perera, K. U., Goldston, D., Weaver, J. J., Soumoff, A., & Ghahramanlou-Holloway, M. (2018). The link between posttraumatic stress disorder and functionality among individuals psychiatrically hospitalized following a suicide-related event. Healthcare, 6(3), 95-108. Book Chapter De Leon, P. H., De Oliveira, F. P., & Puente, A. (2019). Future directions in theory, research, practice, and policy. In S. M. Evans (Ed.), APA Handbook of Psychopharmacology. Washington, DC: American Psychological Association.

PRESENTATIONS Symposiums DeLeon, P. H., Kelly, J. F., Clark Harvey, L. O., & De Oliveira, F. P. (August 2018). Getting involved in the policy process: Challenges, successes, and strategies. Discussant at the 126th annual conference of the American Psychological Association, San Francisco, CA. Rodriguez-Menendez, G., Rom-Rymer, B., Hoover, M., Walker, L., DeLeon, P. H, & De Oliveira, F. P. (August 2018). Toward a new model: Predoctoral training in clinical psychopharmacology.

1 De Oliveira Curriculum Vitae

Discussant at the 126th annual conference of the American Psychological Association, San Francisco, CA. National Paper Presentations (2019, 1st Author Only) De Oliveira, F., Bond, A., Darmour, C., Burke, D.J., Lee-Tauler, S., Jeschke, E.A., LaCroix, J.M., Perera, K.U., Goldston, D., Soumoff, A., Weaver, J., & Ghahramanlou-Holloway, M. (April 2019). A qualitative examination of shame and guilt among psychiatric inpatients admitted following a suicide-related crisis. Paper presented at the 52nd Annual American Association of Suicidology Conference, Denver, CO. De Oliveira, F., Bond, A., Darmour, C., Burke, D., Lee-Tauler, S., Jeschke, E.A., LaCroix, J.M., Perera, K.U., Goldston, D., Soumoff, A., Weaver, J., & Ghahramanlou-Holloway, M. (April 2019). Learning about shame, guilt and emotion regulation through a qualitative analysis of suicide attempt narratives shared during psychotherapy. Paper presented at the 52nd Annual American Association of Suicidology Conference, Denver, CO.

GRADUATE EXPERIENCES Externships  Fort Belvoir Community Hospital (Jun 2017 – Aug 2017, Jun 2018 – May 2019)  Malcolm Grow Medical Clinics & Surgery Center (Sep 2017 – May 2018)  Mt. Washington Pediatric Hospital (May 2016 – May 2017) Teaching Assistantships  Affective Bases of Behavior with David Krantz, Ph.D. (Feb – May 2019)  Cognitive Behavior Therapy II with Marjan Holloway, Ph.D. (Aug 2018 – Oct 2018)  Clinical Assessment with Layne Bennion, Ph.D. (Aug 2016 – May 2018) Other Graduate Experiences  Peer Reviewer for the Military Health System Research Symposium breakout sessions on Predicting & Managing Suicide Risk & Related Conditions (Apr 2020)  Peer Reviewer for the American Association of Suicidology Conferences (Nov 2017, Oct 2018)  Study Assessor for Randomized Controlled Trial of Massed Cognitive Processing Therapy for Posttraumatic Stress Disorder at Fort Belvoir Community Hospital (Nov 2018 – May 2019)  Study Therapist for Randomized Controlled Trial of the Comprehensive Behavioral (ComB) Model of Treatment for Trichotillomania at the Clinical Psychology Research Lab in American University (Jan 2018 – May 2019)  Invited Instructor teaching Comprehensive Behavioral Model for the Treatment of BFRBs at the Pediatric Outpatient Behavioral Health Clinic at Fort Belvoir Community Hospital (4 Oct 2018)  Assistant to the Chair of the NATO Human Factors & Medicine Research Task Group 277, Leadership Tools for Suicide Prevention in Brussels, Belgium (10-12 Sep 2018)  Division 55 Programming Co-Chair for the APA Annual Convention in Washington, DC for Division 55, American Society for the Advancement of Pharmacotherapy (Aug 2017 – 2018)  Student Advocacy Committee Member for MPS Department (2018)  Preceptor for Communication Skills Workshop in Family Medicine/Pediatrics Clerkship Orientation week for 2nd year medical students (Sep 2017, May 2018)  Training Supervisor for Chaplains-CARE Workshop with Suicide CPR Initiative (5-9 Feb 2018)  Peer Reviewer for the Journal Psychological Services from the APA Division 18, Psychologists in Public Service (Jul – Aug 2017)

CURRENT MEMBERSHIPS  American Psychological Association, Student Member (2014 – Present) o Division 55, American Society for the Advancement of Pharmacotherapy (2017 – Present) o Division 19, Military Psychology (2015 – Present)  American Association of Suicidology, Student Member (2016 – Present)

2 UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814-4799 www.usuhs.edu

April 15, 2020

MEMORANDUM FOR RICHARD W. THOMAS, MD, DDS, FACS, PRESIDENT, USUHS

Through: Chair, Board of Regents

SUBJECT: Certification of Graduate Student

The graduate student listed below is presented for certification to receive the Doctor of Philosophy degree effective upon your approval:

Julia A. Garza

DOCTOR OF PHILOSOPHY

Department of Medical and Clinical Psychology

Attached is the candidate’s certification of successful completion of the Final Examination. Also attached are the Dissertation Approval Form, certification of authorized use of Copyrighted materials, Dissertation Title Page, Dissertation Abstract, and Curriculum Vitae.

Arthur L. Kellermann, MD, MPH Dean, USUHS, School of Medicine

Attachments: As stated

Learning to Care for Those in Harm’s Way UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES SCHOOL OF MEDICINE GRADUATE PROGRAMS Graduate Education Office (A 1045), 4301 Jones Bridge Road, Bethesda, MD 20814

FINAL EXAMINA TIONIPRIV ATE DEFENSE FOR THE DEGREE OF DOCTOR OF PHILOSOPHY IN THE DEPARTMENT OF MEDICAL AND CLINICAL PSYCHOLOGY

Name of Student: Julia Garza

Date of Examination: July 10, 2019 Time: 11:00 AM Place: Room B3004

DECISION OF EXAMINATION COMMITTEE MEMBERS:

PASS FAIL

~ V DEPARTMENT OF MEDICAL & CLINICAL PSYCHOLOGY Committee Chairperson

DEPARTMENT OF MEDICAL & CLINICAL PSYCHOLOGY Dissertation Advisor

~~ / Dr. Natasha Schvey DEPARTMENT OF MEDICAL & CLINICAL PSYCHOLOGY Committee Member

kUl)y J Dr. Jing Wang CENTER FOR THE STUDY OF TRAUMATIC STRESS Committee Member UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES SCHOOL OF MEDICINE GRADUATE PROGRAMS Graduate Education Office (A 1045), 4301 Jones Bridge Road, Bethesda, MD 20814

APPROVAL OF THE DOCTORAL DISSERTATION IN THE DEPARTMENT OF MEDICAL AND CLINICAL PSYCHOLOGY

Title of Dissertation: "The Impact of Behavioral and Psychosocial Protective Factors on Health Outcomes in Heart Failure Patients: A Structured Equation Model Analysis"

Name of Candidate: Julia Garza Doctor of Philosophy Degree July 10,2019

DISSERTATION AND ABSTRACT APPROVED:

DATE:

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~ DEPARTMENT OF MEDICAL & CLINICAL PSYCHOLOGY Committee Chairperson

CAL & CLINICAL PSYCHOLOGY Dissertation Advisor

rY\,.t.t, .~ I'JG.V\ z» z._v Dr. Natasha Sch\TeY DEPARTMENT OF MEDICAL & CLINICAL PSYCHOLOGY Committee Member

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The author hereby certifies that the use of any copyrighted material in the thesis manuscript

entitled:

"The Impact of Behavioral and Psychosocial Protective Factors on Health Outcomes in Heart

Failure Patients: A Structural Equation Model"

is appropriately acknowledged and, beyond brief excerpts, is with the permission of the

copyright owner.

Julia A. Garza

June 26, 2019

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Aq Title of Thesis: The Impact of Behavioral and Psychosocial Protective Factors on Health Outcomes in.Heart Failure Patients: A Structural Equation Model

Julia A. Garza, Doctor of Philosophy in Clinical Psychology, 2020

Thesis supervised by: David S. Krantz, Ph.D., Primary Faculty Advisor, Department of Medical

and Clinical Psychology

Objective: Heart failure (HF) rates have continued to increase, despite decreases in the incidence

of heart disease. In addition to health consequences ofHF, it contributes a staggering financial

cost to the individual, caregiver, and the broader health care. One significant component of the

total cost and burden is frequent hospitalizations. HF research has suggested the importance of

behavioral and psychological risk factors, but there has also been increased examination of

protective factors that may reduce the progression ofHF and improve overall prognosis. This

study aims to determine if psychosocial or behavioral protective factors predict improved long-

term health status and decreased hospitalizations in HF patients. The present study used a

Structural Equation Model (SEM) approach to examine the impact of protective factors on

outcomes in HF patients. Method and Results: This study is based on previously collected data

from the Behavioral Triggers of Heart Failure (BETRHEART) study. One hundred and fifty participants were administered self-report measures on psychosocial (e.g., positive affect, optimism, self-efficacy, social support, coping styles), and behavioral variables (e.g., medication adherence, sleep quality, physical activity, adherence to a healthy diet), at the baseline assessment and up to a total of 39 months. The Kansas City Cardiomyopathy Questionnaire

v (KCCQ) was also administered at the baseline and subsequent follow-up assessments to evaluate

HF symptoms and health status. Data on hospitalizations were collected over the entire 39-month

study period. SEM was conducted to determine whether the two theoretical factors

"Psychosocial Protective Factor" and "Behavioral Protective Factor" predict hospitalizations and

KCCQ health status at a 9-month and up to a 39-month follow-up. Results of a confirmatory

factor analysis indicated some of the items/measures had low factor loadings and were removed

based on model fit statistics. "Psychosocial Protective Factor" was comprised of significant

items measuring positive affect, optimism, self-efficacy, acceptance-based coping, and coping

through spirituality. Items for the "Behavioral Protective Factor" did not have adequate factor

loadings, so Medication Adherence, Sleep Quality, and Adherence were retained as three

separate behavioral factors. Next, the SEM results indicated that only the Psychosocial Protective

Factor, but not the three behavioral factors, were predictive of short-term (9-month) KCCQ

Clinical Summary scores. Neither the Psychosocial Protective Factor nor the three behavioral

factors predicted longer-term (up to 39-months) effects. Additional analyses found that the

POMS- Vigor-Activity subscale was the strongest predictor of short-term KCCQ Clinical

Summary scores out of all of the psychosocial protective variables. Discussion: A construct representing psychosocial protective variables is predictive of relatively short-term self-reported health status, but neither health status nor hospitalizations at 39 months. In this study, behavioral factors were not a significant predictor of any of the measures of HF outcomes. This study suggests that fostering a combination of positive affect, optimism, self-efficacy, and adaptive coping styles may help reduce HF symptom burden and improve health status for at least up to 9 months.

vi CURRICULUM VITAE

Julia A. Garza, LT, MSC, USN Professional email: [email protected] Personal email: [email protected]

EDUCATION

• UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES, Bethesda, MD o Doctoral Candidate o Master's of Science in Clinical Psychology, 2018

• UNIVERSITY OF NORTH TEXAS, Denton, TX o Bachelor of Art (Magna Cum Laude) in Psychology, 2012 o Minor: Drug Abuse and Addictions

• CENTRAL TEXAS COLLEGE, Killeen, TX o Associate of Art in Interdisciplinary Studies, 2011

PROFESSIONAL CREDENTIALS Diploma in Mountain Medicine, DiMM (MAR2019)

PROFESSIONAL EXPERIENCE Military Student Representative 2018-2019 UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES Bethesda, MD • Served as the liaison between students and faculty at monthly faculty meetings and curriculum meetings. Also served as an additional representative at Student Advocacy Committee meetings within the department.

Student Advisory Committee (Cohort Representative) 2016-2017 UNIFORMED SERVICES UNIVERSITY OF THE HEAL TH SCIENCES Bethesda, MD • Consolidated concernsfrom the remainder of the cohort and presented them at monthly student advisory committee meetings to be addressed furtherat facultymeetings.

Research Associate 2013-2015 SOUTH TEXAS RESEARCH ORGANIZATIONAL NETWORK GUIDING STUDIES ON TRAUMA AND RESILIENCE Fort Hood, TX • Administered semi-structured clinicalhealth interviews and sleep interviews under supervision of a licensed psychologist with active duty service members. • Administered neuropsychological assessments through the usage of portions of the Delis-Kaplan Executive Function System test (D-KEFS) and Cambridge Neuropsychological Test Automated Battery (CANTAB). • Assisted with recruitment of active duty service members for research studies. • Completed biological sample collection and processing in part of a larger research study that examined biomarkers for PTSD in active duty service members.

OTHER ASSIGNMENTS Intern, Navy Clinical Psychology 2019-2020 NAVAL MEDICAL CENTER PORTSMOUTH Portsmouth, VA

PROFESSIONAL SOCIETIES • AP A Division 19, Military Psychology, student affiliate_Dec 2015- Present • APA Division 38, Health Psychology, student affiliate Dec 2015- Present • APA Division 53, Society of Clinical and Child and Adolescent Psychology, Student Affiliate Jan 2018 - Present • APA Division 54, Society of Pediatric Psychology, student affiliate Feb 2018 - Present • Association for Behavioral and Cognitive Therapists (ABCT) Feb 2018 - Present • Society of Behavioral Medicine Feb 2019 - Present • APA Division 47, Exercise and Sport Psychology Mar 2019 - Present

SELECTED PUBLICATIONS Landoll, R., Elmore, C., Weiss, D., & Garza, J. (2019). Training Issues in Pediatric Primary Care. In R. D. Friedberg & J. K. Paternostro (Eds.), Cognitive Behavioral Therapyfor Pediatric Medical Conditions. Springer Nature.

Landoll, R., Goodie, J., Eklund, K., Mallonee, S., Garza, J., & Martinez, H. (2018). Out of the Classroom, Into the Field: Piloting an Interprofessional Experiential Exercise. Training and Education in Professional Psychology.

SELECTED PRESENTATIONS De Oliveira, F., Martinez, H., Garza, J., Mallonee, S., Clark, L., & Ghahramanlou-Holloway, M. (2017). Teaching cognitive behavior therapy through standardized patients and simulation learning: An implementation model and case report. Poster presented at the annual convention of the Association for Behavioral and Cognitive Therapies, (2017), San Diego, CA.

Garza, J.A., Schvey, N., Goodie, J., Krantz, D.S., Dimond, A.J. (2019) Positive and Negative Affect and the Mediating Effect of Perceived Stress on Health in Heart Failure Patients. Poster presented at the annual convention of the Society of Behavioral Medicine, (2019), Washington, D.C.

Malloonee, S., Garza, J., Martinez, H., Eklund, K., Landoll, R., & Goodie, J. (2018). Lessons Learnedfrom the Development and Implementation of an Interprofessional Experiential Exercisefor Military Clinical Psychology Graduate Students. Poster presented at the annual convention of the Association for Behavioral and Cognitive Therapies (2018), Washington, D.C. UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814-4799 www.usuhs.edu

April 15, 2020

MEMORANDUM FOR RICHARD W. THOMAS, MD, DDS, FACS, PRESIDENT, USUHS

Through: Chair, Board of Regents

SUBJECT: Certification of Graduate Student

The graduate student listed below is presented for certification to receive the Doctor of Philosophy degree effective upon your approval:

Britney L. Hardy

DOCTOR OF PHILOSOPHY

Emerging Infectious Diseases Graduate Program

Attached is the candidate’s certification of successful completion of the Final Examination. Also attached are the Dissertation Approval Form, certification of authorized use of Copyrighted materials, Dissertation Title Page, Dissertation Abstract, and Curriculum Vitae.

Arthur L. Kellermann, MD, MPH Dean, USUHS, School of Medicine

Attachments: As stated

Learning to Care for Those in Harm’s Way

Bacterial Warfare: Polymicrobial Interactions to Control Staphylococcus aureus

by

Britney Lashawn Hardy

Dissertation submitted to the Faculty of the Emerging Infectious Disease Graduate Program Uniformed Services University of the Health Sciences In partial fulfillment of the requirements for the degree of Doctor of Philosophy 2020

TITLE OF DISSERTATION

Bacterial Warfare: Polymicrobial Interactions to Control Staphylococcus aureus

Britney L Hardy, Doctor of Philosophy, 2020

Thesis directed by: D. Scott Merrell, Ph.D. Professor, Department of Microbiology and Immunology

ABSTRACT

The advent of high-throughput sequencing revealed that humans serve as an

important ecological niche to hundreds of bacterial species. Within the host,

microorganisms must compete for limited nutrients and space, a type of “Bacterial

Warfare”. Essential to this competition is the ability of some bacterial species to directly inhibit or kill competitors to prevent the colonization of incoming microbes, such as

Staphylococcus aureus. S. aureus primarily colonizes the nasal cavity, and numerous studies suggest that microbial species-specific interactions impact S. aureus nasal colonization status. A single commensal species, Corynebacterium pseudodiphtheriticum, has been found to be an important determinant of S. aureus nasal colonization in multiple molecular nasal microbiota-based studies, and application of C. pseudodiphtheriticum alone results in S. aureus eradication from the nasal cavity. Given that molecular epidemiology microbiota studies have shown that C. pseudodiphtheriticum greatly impacts S. aureus nasal colonization, we sought to characterize the molecular mechanism that governs the interaction between these two bacterial species. By taking a reductionist approach, we demonstrated that C. pseudodiphtheriticum mediates bactericidal activity against S. aureus in a strain-specific manner via the action of a secreted factor(s). Through the use of a high throughput screen of transposon mutant strains, we demonstrated that the loss of a S. aureus-specific virulence pathway conferred resistance to killing. Indeed, mutant strains that were deficient in Agr Quorum Sensing activity, or synthesis of downstream effector, the phenol soluble modulins, were resistant to killing.

Assessment of the bioactivity of the anti-S. aureus factor(s) revealed that in addition to

their killing activity, they disrupted biofilms, increased cell permeability, and rescued the

mortality of S. aureus-infected Galleria mellonella caterpillars. Utilizing multiple genetic

and biochemical approaches, we identified C. pseudodiphtheriticum-specific genes

associated with anti-S. aureus activity and determined that the anti-S. aureus factor(s) is

likely a small glycosylated peptide(s) that we hypothesized to be a novel antimicrobial

peptide. Finally, we demonstrated that multiple clinically isolated bacterial species

possesses anti-S. aureus activity, and that some of these species produced secreted anti-S.

aureus compounds. En masse, these data show that polymicrobial interactions are far

more multifaceted that initially appreciated and encourage the continued study of these interactions as they have the potential to reveal novel therapeutics or pharmacological targets.

Curriculum Vitae Britney Hardy [email protected] 240-476-2814 Work Address: Uniformed Services University of the Health Sciences Microbiology and Immunology Department 4301 Jones Bridge Road Bethesda, Maryland, 20814 [email protected] Education: 2014-Present Uniformed Services University of the Health Sciences Emerging Infectious Diseases PhD Candidate, GPA 3.8 Expected Finish: April 2020

2008- 2012 University of Maryland, College Park B.S. Biological Sciences: Microbiology Professional History: 2014- Present Emerging Infectious Disease PhD Candidate, USUHS Advisor: Douglas S. Merrell Dissertation: Corynebacterium pseudodiphtheriticum mediates bactericidal activity against Staphylococcus aureus.

2012-2014 Faculty Research Assistant, University of Maryland College Park Advisor: Daniel C. Stein Project: Invasion and attachment of N. gonorrhoeae to human cervical cells.

2007- 2012 Molecular Biology Science Technician, GIFVL, USDA Advisor: Janet P. Slovin Project: Abiotic Stress response in diploid strawberry, Fragaria vesca. Teaching Experience: 2015-2018 Teaching Assistant Medical Microbiology, USUHS 2011-2012 Undergraduate Teaching Assistant, University of Maryland College Park Fall 2011 STEM Fellow, National Science Foundation Awards and Achievements: May 2019 Emma Bockman Memorial Award, 1st Place June 2018 ASM Maryland Branch Brown Award, 1st Place May 2018 Emma Bockman Memorial Award, Honorable Mention May 2018 USUHS Research Days, Oral Presentation, 1st Place May 2018 Three-Minute Thesis, Maryland Competition, 1st Place April 2018 Three-Minute Thesis, USUHS Competition, 1st Place May 2010 College Park Scholars, Life Sciences Citation 2008-2012 President’s Scholarship 2009-2012 Dean’s List Leadership Positions 2019-Present ASM Young Ambassador, Maryland July 2019 Microbial Toxins and Pathogenicity Gordon Research Seminars, Chair 2017- Present ASM Student Branch Activities Chair, USUHS Branch 2017-2018 Graduate Student Council, EID Representative Memberships: 2017-Present American Society for Microbiology 2012 Sigma Alpha Omicron Microbiology Society

Curriculum Vitae Britney Hardy [email protected] 240-476-2814 Mentoring: Summer 2018 Arshia Arora Summer Intern High School Student, Holton Arms Academy. Project: Polymicrobial interaction assays identify bacterial species that inhibit Methicillin-resistant Staphylococcus aureus.

Fall 2016 Scott Schaffer Rotation Student, USUHS. Project: Polymicrobial interaction assays identify bacterial species that inhibit Methicillin-resistant Staphylococcus aureus.

Summer 2016 Katharine Hewlett Summer Intern High School Student, Holton Arms Academy. Project: Polymicrobial interaction assays identify bacterial species that inhibit Methicillin-resistant Staphylococcus aureus. Volunteer Activities 2018-2020 Outbreak Exhibit Volunteer, Smithsonian Museum of Natural History 2016, 2018 ASM Booth, USA Science and Engineering Festival Funding: 2019 ASM Student Travel Award 2018 Carl Storm Fellowship 2018 ASM Microbe Minority Student Travel Award 2016-Present USU T0 Graduate Student Grant

Publications: 1. Blum FC, Hardy BL, Bishop-Lilly KA, Frey KG, Hamilton T, Whitney JB, Lewis MG, Merrell DS, Mattapallil JJ. Microbial Dysbiosis During Simian Immunodeficiency Virus Infection is Partially Reverted with Combination Anti-retroviral Therapy. Scientific Reports. March 2020. 2. Hardy BL, Bansal G, Hewlett KH, Arora A, Schaffer SD, Kamau E, Bennett JW, Merrell DS. Antimicrobial Activities of Clinically Isolated Bacterial Species against Methicillin-Resistant Staphylococcus aureus (MRSA). Frontiers in Microbiology Research Topics: Interspecies Interactions: Effects On Virulence And Antimicrobial Susceptibility Of Bacterial And Fungal Pathogens. Front. Microbiol., 15 January 2020 | https://doi.org/10.3389/fmicb.2019.02977. 3. Hardy BL, Dickey SW, Plaut R, Riggins DP, Stibitz S, Otto M, Merrell DS. Corynebacterium pseudodiphtheriticum exploits Staphylococcus aureus virulence components in a novel polymicrobial defense strategy. mBio. 10:e02491-18. 4. Miles Shana M. Hardy BL, Merrell DS. Investigation of the microbiota of the reproductive tract in women undergoing a total hysterectomy and bilateral salpingo-oopherectomy. Fertility and Sterility, Volume 107, Issue 3, 813-820. 5. Stein DC, LeVan A, Hardy BL, Wang LC, Zimmerman L, Song W. Expression of Opacity Proteins Interferes with the Transmigration of Neisseria gonorrhoeae across Polarized Epithelial Cells. Gorvel JP, ed. PLoS ONE. 2015;10(8):e0134342.

Oral Presentations: 1. July 2019. Hardy BL, Dickey SW, Plaut R, Riggins DP, Stibitz S, Otto M, Merrell DS. International Conference on Bacilli and Gram-Positive Bacteria. 2. June 2019. Hardy BL, Dickey SW, Plaut R, Riggins DP, Stibitz S, Otto M, Merrell DS. American Society for Microbiology, Microbe 2019 General Meeting. 3. March 2019. Hardy BL, Dickey SW, Plaut R, Riggins DP, Stibitz S, Otto M, Merrell DS. American Society for Microbiology, Washington D.C Branch Meeting. 4. July 2018. Hardy BL, Dickey SW, Plaut R, Riggins DP, Stibitz S, Otto M, Merrell DS. Curriculum Vitae Britney Hardy [email protected] 240-476-2814 Microbial Toxins and Pathogenicity- Gordon Research Seminars Corynebacterium pseudodiphtheriticum exploits Staphylococcus aureus virulence components to compete for the human nasal colonization niche 5. June 2018. Hardy BL, Dickey SW, Plaut R, Riggins DP, Stibitz S, Otto M, Merrell DS. American Society for Microbiology Maryland Branch Meeting Corynebacterium pseudodiphtheriticum exploits Staphylococcus aureus virulence components in a novel polymicrobial defense strategy 6. May 2018. Hardy BL, Dickey SW, Plaut R, Riggins DP, Stibitz S, Otto M, Merrell DS. USUHS Research Days, Graduate Student Colloquium Title: Corynebacterium pseudodiphtheriticum exploits Staphylococcus aureus virulence components to compete for the human nasal colonization niche

Poster Presentations: 1. July 2019. Hardy BL, Dickey SW, Otto M, Merrell DS. Bacterial Warfare: A Human Commensal Mediates Potent Bactericidal Activity against Staphylococcus aureus. International Conference on Bacilli and Gram-Positive Bacteria. 2. June 2019. Hardy BL, Dickey SW, Otto M, Merrell DS. Bacterial Warfare: A Human Commensal Mediates Potent Bactericidal Activity against Staphylococcus aureus. American Society for Microbiology Microbe Meeting Poster Session. 3. June 2019. Blum FC, Hardy BL, Bishop-Lilly KA, Frey KG, Hamilton T, Whitney JB, Lewis MG, Merrell DS, Mattapallil JJ. Intestinal dysbiosis in simian immunodeficiency virus (SIV) infected rhesus macaques is partially reversed by antiretroviral therapy. American Society for Microbiology Microbe Meeting Poster Session 4. July 2018. Hardy BL, Dickey SW, Plaut R, Riggins DP, Stibitz S, Otto M, Merrell DS. Microbial Toxins and Pathogenicity Gordon Research Seminars Corynebacterium pseudodiphtheriticum exploits Staphylococcus aureus Virulence Components to Compete for the Human Nasal Colonization Niche 5. June 2018. Hardy BL, Dickey SW, Plaut R, Riggins DP, Stibitz S, Otto M, Merrell DS. American Society for Microbiology Microbe Meeting Poster Session Corynebacterium Pseudodiphtheriticum Exploits Staphylococcus aureus Virulence Components to Compete for the Human Nasal Colonization Niche 6. May 2018. Hardy BL, Dickey SW, Plaut R, Riggins DP, Stibitz S, Otto M, Merrell DS. USUHS Research Days, Poster Presentation Corynebacterium Pseudodiphtheriticum Exploits Staphylococcus aureus Virulence Components to Compete for the Human Nasal Colonization Niche 7. June 2017. Hardy BL, Hewlett KH, Schaffer SD, Kamau E, Bennett JW, and Merrell DS. American Society for Microbiology Microbe Meeting Poster Session Polymicrobial Interaction Assays Identify Bacterial Species that Inhibit Methicillin-Resistant Staphylococcus aureus (MRSA). 8. May 2017. Hardy BL, Hewlett KH, Schaffer SD, Kamau E, Bennett JW, and Merrell DS. USUHS Research Days, Poster Presentation Polymicrobial Interaction Assays Identify Bacterial Species that Inhibit Methicillin-Resistant Staphylococcus aureus (MRSA). 9. February 2013. Hardy BL, Stein DC. Mid-Atlantic Microbial Pathogenesis Meeting, Poster Presentation Role of Opacity (Opa) Proteins on N. gonorrhoeae Attachment and Invasion of Human Cervical Cells. 10. April 2011. Hardy BL, Slovin JP. UMCP Undergraduate Research Day, Poster Presentation Abiotic Stress Response in Diploid Strawberry, Fragaria vesca. UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814-4799 www.usuhs.edu

April 15, 2020

MEMORANDUM FOR RICHARD W. THOMAS, MD, DDS, FACS, PRESIDENT, USUHS

Through: Chair, Board of Regents

SUBJECT: Certification of Graduate Student

The graduate student listed below is presented for certification to receive the Doctor of Philosophy degree effective upon your approval:

Sybil D. Mallonee

DOCTOR OF PHILOSOPHY

Department of Medical and Clinical Psychology

Attached is the candidate’s certification of successful completion of the Final Examination. Also attached are the Dissertation Approval Form, certification of authorized use of Copyrighted materials, Dissertation Title Page, Dissertation Abstract, and Curriculum Vitae.

Arthur L. Kellermann, MD, MPH Dean, USUHS, School of Medicine

Attachments: As stated

Learning to Care for Those in Harm’s Way UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES SCHOOLOF MEDICINE GRADUATE PROGRAMS Graduate Education Office (A 1045), 4301 JonesBridge Road, Bethesda, MD 20814

FINAL EXAMINA TIONIPRIV ATE DEFENSE FOR THE DEGREE OF DOCTOR OF PHILOSOPHY IN THE DEPARTMENT OF MEDICAL AND CLINICAL PSYCHOLOGY

Name of Student: Sybil Mallonee

Date of Examination: December 12,2018 Time: 8:00 AM Place: Room B4004 cw~mATION COMMITmill,S FAIL

Dr. David Krantz DEPARTMENT OF MEDICAL & CLINICAL PSYCHOLOGY Committee Chairperson

~~CAL & CLmICALPSY~~LOGY Dissertation Advisor Dffi1;~~ ~ DEPARTMENT OF MEDICAL & CLINICAL PSYCHOLOGY Committee Member / Dr. Cara Olsen DEPARTMENT OF PREVENTIME MEDICINE & BIOSTATISTICS Committee Member

--- - - _. ------UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES SCHOOLOF MEDICINE GRADUATE PROGRAMS Graduate Education Office (A 1045), 4301 JonesBridge Road, Bethesda, MD 20814

APPROVAL OF THE DOCTORAL DISSERTATION IN THE DEPARTMENT OF MEDICAL AND CLINICAL PSYCHOLOGY

Title of Dissertation: "Individual Changes in the Spouse and Service Member during Deployment and the Impact on the Couple's Reintegration"

Name of Candidate: Sybil Mallonee Doctor of Philosophy Degree December 12,2018

DISSERTATION AND ABSTRACT APPROVED:

DATE:

F MEDICAL & CLINICAL PSYCHOLOGY Committee Chairperson

DEPARTMENT OF MEDICAL & CLINICAL PSYCHOLOGY Dissertation Advisor

~~ 'S-, '~~cM6 Dr: )TIleBel1t1ion DEPARTMENT OF MEDICAL & CLINICAL PSYCHOLOGY Committee Member

Dr. Cara Olsen DEPARTMENT OF PREVENTIME MEDICINE & BIOSTATISTICS Committee Member COPYRIGHT STATEMENT

The author hereby certifies that the use of any copyrighted material in the dissertation manuscript entitled: Individual Changes in the Spouse and Service Member during

Deployment and the Impact on the Couple's Reintegration is appropriately acknowledged and, beyond brief excerpts, is with the permission of the copyright owner.

flonee

CPT Sybil Mallonee, MA

[May 15th, 2020]

DISCLAIMER

The views presented here are those of the author and are not to be construed as

official or reflecting the views of the Uniformed Services University of the Health

Sciences, the Department of Defense or the U.s. Government.

III Individual Changes in the Spouse and Service Member during Deployment and the

Impact on the Couple's Reintegration

by

CPT Sybil Mallonee, M.A.

Dissertation submitted to the Faculty ofthe Medical & Clinical Psychology Graduate Program Uniformed Services University of the Health Sciences In partial fulfillment of the requirements for the degree of Doctor of Philosophy 2020 ABSTRACT

Title of Dissertation: Individual Changes in the Spouse and Service Member during

Deployment and the Impact on the Couple's Reintegration

Sybil Mallonee, Ph.D. Candidate, 2020

Thesis directed by: David Riggs, Ph.D., MPS Department Chair

Military spouses experience many unique stressors and protective factors during deployments that are dependent on specific characteristics of the deployment, the environment, and the couple. These stressors and protective factors impact the development of changes in the spouse and service member, and influence how these changes affect the couple during their reintegration post-deployment.

The purpose of this study was to evaluate how these factors affected the spouse's growth during deployment, and subsequently how changes during the deployment, such as growth in the spouse, impacted the reunion period. The present study utilized retrospective cross-sectional self-report data from the spouse and service members who completed the 2011 wave of the Millennium Cohort Study and had experienced a deployment together (N = 6,832). In addition, for a portion of the study the sample was limited to only those who had completed a deployment within the last 12 months (N =

1,558), in order to capture those still in the post-deployment reunion phase.

Findings indicated that protective factors (e.g., self-mastery, social support, and frequent communication with service member) were more likely to be related to spousal growth than the proposed stressors (e.g., number and length of deployment, worry about the service member, stressful communication, and having more children). However,

IV change variables, such as spousal growth, were not significantly related to reunion stress when controlling for covariates. The only variables that did have a significant

relationship with reunion stress were the perceived mental health quality of life of both the spouse and service member, such that poorer perceived mental health was associated with more reunion stress. The final analyses of this study explored the possible

moderating effect that self-mastery of the spouse and service member would have on the

proposed change variables. However, only one relationship was significant, and it

suggested that at higher levels of mastery there is a weaker relationship between growth

and reunion stress.

The results from the present study have identified key factors that may have

important implications for developing interventions. These include the ability to better

direct preventative measures both to increase spousal growth and to decrease reunion

stress. Improving the spouse's available support systems during the deployment and

ensuring adequate communication between the service member and spouse both may

increase spousal growth. Additionally, directly addressing the mental health of both the

spouse and the service member during the reunion period may be a key component of

interventions and preventive measures to reduce stress as the couple reunites. Future

research should confirm these results and examine these suggested preventative measures

in a longitudinal study.

v S. D. Mallonee 1 of 9

Curriculum Vitae

Sybil D. Mallonee (nee Hamm), M.A. CPT U. S. Army

PERSONAL DATA

Professional Address: 430-1Jones Bridge Rd, Bethesda, MD 20814-4799

Email: [email protected]

EDUCATION Uniformed Services University of the Health Sciences (USU) Aug. 2015- present Ph.D. Candidate in Clinical Psychology (APA Accredited) Doctoral Dissertation Topic: "Individual changes during deployment and their impact on reintegration." Under the direction of David Riggs, Ph.D.; Completed January 2019

University of Missouri-Kansas City July 2012 Master's in counseling, Emphasis in Mental Health

University of Missouri-Kansas City July 2010 Bachelor of Arts in Psychology, Summa Cum Laude (GPA 4.0)

CONTINUINGEDUCATION BLS trained and certified, EMDR phase I trained, TF-CBT trained, CPT trained, certified Parent-Aid and Mentor, 2-day Transgender Conference, Pediatric Biofeedback, Trichotillomania trained and certified, PE trained

CLINICAL EXPERIENCE Doctoral Program Internship Tripier Army Medical Center October 2019-0ctober 2020 Honolulu, HI Conducted intakes, provided individual, group, and family therapy to Service Members and their families using CPT, Gottman, biofeedback, and CBT treatments. Conducted psychological assessments and triages for Service Members and their families. Supervised behavioral health technicians in CPT group and during walk-in clinic. Conducted military specialty evaluations, including chapter evaluations and school evaluations. Received weekly individual and group supervision and didactic training.

USUHS Doctoral Program Practica Steven A. Cohen Military Family Clinic at Easterseals September 2018- April 2019 Silver Spring, M.D. Hours: 153 S. D. Mallonee 20f9

Conducted intakes, provided individual therapy to veterans and their family using CBT, CBT-I, and CPT, both in-person and via telehealth. Co-facilitated a telehealth CBT for stress management group, and provided Gottman couples therapy. Received weekly individual and group supervision that included reviews of videotaped sessions and feedback on direct observation of sessions using the Cognitive Therapy Rating Scale. Supervisor: Anneke Vandenbroek, Ph.D., ABPP

Walter Reed National Military Medical Center September 2017· August 2018 Bethesda, MD Hours: 203.5 Conducted intakes, and provided individual therapy to Service Members, veterans, and dependents using cognitive behavioral therapy, supportive therapy, cognitive processing therapy, acceptance and commitment therapy, and cognitive behavioral therapy for insomnia. Conducted aeromedical evaluations. Co-facilitated a problem- solving therapy group and a process military sexual trauma group. Conducted screens for PTSD groups. Participated in biofeedback sessions for Service Members with PTSD. Used the MCMI, MMPI, PAl, Rorschach, Connor's Continuous Performance Test, WAIS-IV, and the Rotter Incomplete Sentence Blank to create psychodiagnostic test reports. At times I administered these tests, and at other times I worked closely with a psychometric technician. Received weekly supervision that included reviews of videotaped sessions and feedback on direct observation of sessions. Supervisors: Augusto Ruiz, Psy.D., Brandy Hellman, Psy.D., Elizabeth Lynch, Psy.D.

u.S. Military Academy June 2017-July 2017 West Point, NY Hours: 69 Provided training, and daily small and large group supervision of Cadet counselors. Small group supervision of two Cadet counselors who staffed their cases from the previous day. Large group supervision included ten Cadets and the supervisors of the other small groups. During large group supervision, relevant issues from the small groups were discussed and specific techniques were taught. Techniques taught included behavior management, stress relaxation, and challenging negative thinking. Was on call for Cadet counselors to help them assess for suicide and homicide risk, as needed. Conducted exit interviews for Cadets leaving West Point. Provided individual therapy to Cadets in garrison and in the field on issues related to sexual assault, depression, and adjustment related concerns. Conducted command and medical directed evaluations regarding safety concerns of Cadets and then communicated the results of this evaluation along with recommendations back to command or the medical referral. Participated in regular briefings and consultations with command. Received daily supervision on clinical cases, supervision of Cadets, and on military professional development based on direct observation of clinical skills and command consultations. Supervisor: LTC Andrew Hagemaster, Ph.D.

Mt. Washington Pediatric Hospital Sept. 2016· June 2017 Baltimore, MD Hours: 207 S. D. Mallonee 30f9

Conducted neuropsychological testing with children and adolescents, including concussion evaluations. Wrote integrative reports after case conceptualization. Participated in feedback sessions and intake interviews. Assisted other externs and interns in test administration with patients by showing them how to administer, and then observing them and providing feedback. Mentored undergraduate volunteers and trained them on how to score neuropsychological tests. Consulted across departments with physical therapists and physicians, and also with outside personnel such as teachers and school counselors. Received weekly individual supervision based on direct observation. Tests administered and scored include the following: Autism Spectrum Diagnostic Observation Schedule, Second Edition (ADOS-2) Beery-Buktenica Developmental Test of Visual-Motor Integration, Sixth Edition (Beery-VMI) Bracken Basic Concept Scale: Expressive & Receptive California Verbal Learning Test Comprehensive Test of Phonological Processing, Second Edition (CTOPP-2) Conners Continuous Performance Test, Third Edition (CPT-3) Conners Continuous Auditory Test of Attention, Third Edition (CATA-3) Delis-Kaplan Executive Function System (DKEFS) Expressive Vocabulary Test, Second Edition (EVT-2) Gray Oral Reading Tests - Fifth Edition (GORT-5) Grooved Pegboard Test ImPACT Test Nelson-Denny, A Developmental Neurological Assessment, Second Edition (NEPSY-2) Personality Assessment Inventory-Adolescent (PAl-A) Peabody Picture Vocabulary Test, Fourth Edition (PPVT-4) Rey Complex Figure Test (RCFT) Stanford Binet, Fifth Edition (SB-5) Test of Everyday Attention for Children (TEA-CH) Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV) Wechsler Intelligence Scale for Children, Fifth Edition (WISC-V) Wechsler Individual Achievement Test, Third Edition (WIAT-III) Wechsler Memory Scale, Fourth Edition (WMS-IV) Wide Range Assessment of Memory and Learning, Second Edition (WRAML-2) Woodcock Johnson, Fourth Edition (WJ-IV) Wechsler Preschool and Primary Scale of Intelligence, Third Edition (WPPSI-III) Supervisor: Danielle Raines, PsyD

Psychiatric Institute of Washington June 2016-Aug. 2016 Washington D.C. Hours: 75 Provided individual and group therapy to inpatient adults and adolescents. Gained experience in the administration of brief psychotherapies, crisis assessment and management, and knowledge and skills and process groups with severely mentally ill patients. Gained significant experience in working in multidisciplinary teams of nurses, psychiatrists, medical technicians, social workers and psychologists. Received weekly

__j S. D. Mallonee 40f9 individual and group supervision. Supervision of group therapy was based on direct observation of sessions. Supervisor: Jennifer Kahler, PsyD

Additional USUHSClinical Experience Therapist: Comprehensive Behavioral Treatment of Trichotillomania May 2018 -present Washington D.C. Hours: 61 Conducted a 12-session protocol for five adults with trichotillomania as part of a randomized controlled trial of the cognitive behavioral protocol. Received extensive initial training on the protocol and weekly group supervision to ensure protocol compliance and to receive additional training. All sessions were video recorded and were reviewed for quality assurance and for research purposes.

Therapist: Developmental Research on Eating & Weight Behavior Feb. 2016- Feb. 2017 Bethesda, MD Hours: 18 Conducted 12-week psychoeducation groups for adolescent boys. Group topics included domestic violence, alcohol and drugs, sun safety, nutrition and body image, gang violence and nonviolent conflict resolution, and depression and suicide. Conducted intakes with group participants. Received weekly group supervision, and direct observation of group and intakes. Supervisor: Marian Tanofsky-Kraff, Ph.D.

USUHSNational Patient Simulation Center Sept. 2015- Present Silver Spring, MD Hours: 1per month Conducted intake/diagnostic interviews, risk assessments, administered structured interviews, projective tests, and cognitive and intellectual tests (e.g., Rorschach, TAT, HTP, WAIS-IV, RBANS, WMS-IV, WRAT, & SCID-II,), and wrote reports for these sessions. Provided feedback to patients and wrote two comprehensive psychological evaluation reports. Also conducted CBT, CPT, CBT-D, and Brief Dynamic therapies. Participated in and passed an observed structured clinical exam, where my clinical and assessment skills were evaluated over two days of direct observation. Paid actors served as simulated patients at this facility. Received individual and group supervision of videotaped sessions. Supervisors: Layne Bennion Ph.D. (Maj., USAF (Ret.)), Marjan Holloway, Ph.D., Jeannette Witter, Ph.D.

Prior Clinical Experience Synergy Services, Inc. (LPC) Jan. 2012 - July 2015 Kansas City, MO Hours: 40/week Provided outpatient therapy to individual adults and teenagers (1406 hours) with PTSD and other comorbid disorders. Also provided couples/families (57 hours) therapy. Provided group therapy (1831 hours) and assessments for both female and male domestic violence offenders. Developed program for men who solicited prostituted S. D. Mallonee 50f9 women and facilitated monthly classes for this program. Received weekly individual (133 hours) and group supervision.

Midtown Psychological Services (Parent Aid) May 2011 - September 2012 Kansas City, MD Hours: 20/week Supervised visits between parents and children and worked one on one with parents to improve their parenting skills. Wrote reports for Children's Division and testified as needed.

RESEARCH EXPERIENCE Graduate Research Assistant, Uniformed Services University Fall 2015-current Responsibilities: Updated program evaluation survey at the Center for Deployment Psychology to improve its reliability, validity, and consistency across programs based on literature searches and reviews of available program evaluation measures. Conducting multiple research projects utilizing the Family Member Millennium Cohort data in order to better understand the impact of deployments and deployment transition programs on military families. Conducting a qualitative study of factors impacting service member's delays in seeking behavioral health treatment.

Student Research Assistant, University of Missouri-Kansas City Fall 2009 "A content analysis of the portrayal of cardiovascular disease in U.S. television over a 2- year period." Responsibilities: Literature searches, article reviews, manuscript editing

Student Research Assistant, University of Missouri-Kansas City Spring/Summer 2008 "Relationship between adolescents sports participation and delinquency." Responsibilities: Under the supervision Conrad Mueller, PhD I used national data that had previously been gathered and used SPSS to analyze the relationship between adolescent sports participation and delinquency. At the end of this project I wrote a paper and a poster on my research findings as well. Then Dr. Mueller and I did another project that was a more detailed extension of the project I did in order to present the data at a national conference in Philadelphia. For this project I helped him with writing the proposal, organizing the data for analysis, and then with writing the paper and poster for a presentation that occurred in 2010 at the biennial meeting of the Society for Research on Adolescents in Philadelphia.

Student Research Assistant, Saint Louis University Summer 2007 "Comparison of Adult and Neonatal Immune Response to Respiratory Viral Infections." Responsibilities: Mouse model of viral infection (intranasal inoculation, daily body weight, ear punch, and harvest lung), cell culture of adherent epithelial cells, cell counting with hemocytometer, viral plaque assay, RNA isolation, RNA concentration by S. D. Mallonee 60f9

A260, Agarose gel electrophoresis, Microarray (probe labeling, hybridization, and analysis).

MANUSCRIPTS IN PREPARATION

Mallonee,S., Riggs, D., Stander, V. (in preparation). Service member and spouse changes during deployment which impact reunion stress.

MANUSCRIPTS SUBMITTED FOR PUBLICATION

Mallonee,S., Stander, V., Riggs, D. (submitted). Factors associated with personal growth in spouses of deployed service members. Submitted to Journal of Family Psychology

PUBLICATIONS

Articles (Peer-Reviewed)

Mallonee,S., Tate, L., De Oliveira, F., Ruiz, A. (in press). Development and trial implementation of a 30-day outpatient program for subthreshold PTSD. Submitted to Military Medicine.

Landoll, R., Goodie, J.L., Eklund, E., Mallonee,S., Garza, J., Martinez, H.R. (in press). Out of the classroom, into the field: Piloting an interdisciplinary experiential exercise. Accepted for publication in Training and Education in Professional Psychology

Mallonee,S., Phillips, J., Holloway, K., Riggs, D. (2018). Training providers in the use of evidence-based treatments: A comparison of in-person and online delivery modes. Learning and Teaching, 17(1), 61-72, doi: 10.1177/1475725717744678

Book Chapters

Riggs, D. S., Paxton, M. M., Mallonee,S., Rosen, C., Wiltsey-Stirman, S., & Dorsey, S. (in press). Training and implementation of evidence-based psychotherapies for PTSD. Chapter to appear in D. Forbes, C. Monson, & L. Berliner (Eds.) Effective Treatments for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies, Third Edition.

Riggs, D. S., & Mallonee, S. (2017). Barriers to Care for the Complex Presentation of Post-traumatic Stress Disorder and Other Post-combat Psychological Injuries. In Handbook of Military Psychology (pp. 33-44). New York: Springer.

PRESENTATIONS

Paxton, M. M., Birman, S., Sacks, M., Weinstock, M., Phillips, J., Mallonee,S., ... Riggs, D. S. (May 2019). Online Training for CBT-Depression Results in Greater S. D. Mallonee 70f9

Increases in Knowledge and Perceived Readiness Compared to In-Person Trainings. Poster presented at the 31st Association for Psychological Sciences Annual Convention, Washington, DC.

Mallonee, S., Giron, C., Riggs, D., Stander, V. (May 2019). Personal growth in spouses of deployed service members: Stressors and protective factors. Poster presented at the annual convention of the Association for Psychological Sciences, Washington, DC.

Mallonee, S., Garza, J., Martinez, H., Eklund, K., Landoll, R., Schimmels, J., ... Goodie, J. (November 2018). Lessons learned from the development and implementation of an interprofessional experiential exercise for military psychology graduate students. Poster presented at the annual convention of the Association for Behavioral and Cognitive Therapies, Washington, DC.

De Oliveira, F., Martinez, H., Garza, J., Mallonee, S., Clark, L., & Ghahramanlou- Holloway, M. (November 2017). Teaching cognitive behavior therapy through standardized patients and simulation learning: An implementation model and case report. Poster presented at the annual convention of the Association for Behavioral and Cognitive Therapies, San Diego, CA.

Mallonee, S., Phillips, J., Holloway, K., Riggs, D. (November 2017). Training providers in the use of evidence-based treatments: A comparison of in-person and online delivery modes. Panel presentation for 50 participants at the annual convention of the International Society of Traumatic Stress Studies, Chicago, IL.

TEACHING ASSISTANTSHIPS Assessment 111-SIM Center Spring 2019 Observed first year graduate students practice assessment skills on practice patients at the USUHS Simulation Center. Facilitated group supervision after practice sessions and provided individual time-stamped feedback.

Preceptor: Communication Skills Workshop May & September 2018 Silver Spring, MD Hours: 10 Supervised simulated patient encounters as part of the Communication Skills Workshop for the Clerkship Orientation week for 2nd year medical students at USUHS; Provided in- person individual clinical feedback and recommendations to medical students on motivational interviewing and general counseling techniques; Collaborated with Family Medicine, Psychiatry, Pediatrics, and Clinical Psychology faculty members as part of a preceptor dyad team.

Brief Dynamic Winter 2017/2018 Observed second year graduate students practice Brief Dynamic therapy on a practice patient at the USUHS Simulation Center. Facilitated group supervision both before and after each practice session. Provided individual supervision and weekly written feedback to students based on direct observation of their clinical skills and clinical S. D. Mallonee 8 of 9

notes. Received regular direct supervision and observation of my supervision of other students by licensed psychologist.

Cognitive Behavioral Therapy II Fall 2017 Helped create plan for class and for Simulation Center visits. Observed second year graduate students practice Cognitive Behavioral Therapy for Depression and Cognitive Processing Therapy at the USUHS Simulation Center. Facilitated group supervision both before and after each practice session. Supervision prior to their session was primarily psychoeducation based. Supervision after each practice session was process based. Provided individual supervision and written feedback to students based on direct observation of their clinical skills. Received regular direct supervision and observation of my supervision of other students by licensed psychologists.

Cognitive Behavioral Therapy I Spring 2017 Observed first year graduate students practice Cognitive Behavioral Therapy (CBT) on practice patients at the USUHS Simulation Center. Facilitated group supervision both before and after each practice session. Provided individual supervision to students based on direct observation of their clinical skills. Received regular direct supervision and observation of my supervision of other students by licensed psychologists.

Public Policy Spring, Summer, & Winter 2017/2018 Assisted in coordinating weekly speakers for class. Introduced speakers to class and provided speaker with coin of appreciation after class. Was available for students to answer any questions or concerns about the class.

MILITARY PROFESSIONAL EXPERIENCES Army Teaching Assistant June 2018- May 2019 Provided mentorship to potential Army applicants regarding graduate school at USUHS, opportunities for psychologists within the Army, and with their application process. Provided mentorship to current and incoming USUHS students, regarding progressing through the program, and military development.

Bushmaster Training Exercise October 2017 Ft. Indiantown, PA Practiced planning for, setting up, and running a COSC with actors as patients. Conducted a unit needs assessment of actual units present for field exercise. Received real time feedback from military providers on implementation of both exercises. Briefed command on the disposition of patients seen in COSC, and on results of unit needs assessment.

Brigade Psychology Summer Experience July- August 2017 1st BCT,. 101st Airborne, Ft. Campbell, KY S. D. Mallonee 9 of 9

Shadowed Brigade Psychologist and received mentorship. Participated in intakes and psycho-educational groups for high risk Soldiers, and resident didactics with psychology resident. Observed drill sergeant, CID special investigator, recruiter, and sniper evaluations. Observed chapter 13, 14, and 5-17 evaluations and was shown how to complete a DA 3822. Attended high risk meetings, interdisciplinary case conference meetings, and staff meetings. Observed command consultations and participated in regular brigade walkabouts.

Medical Logistics Officer November 2013 to July 2015 139th MED BDE (Reserve Unit, Independence, MO) Planned and executed trainings for Soldiers, created Standard Operating Procedures for programs responsible for, and supervised Soldiers in the programs responsible for. Additional titles and programs responsible for included Platoon Leader, Medical Maintenance Officer, Physical Security Officer, Lodging-in-Kind Coordinator, and Expert Field Medical Badge (EFMB) Training Officer. Created entire EFMB training program for unit, increased unit's annual evaluation in both medical maintenance and in physical security.

LEADERSHIP EXPERIENCES Board Member-Student Committee January 2018 - January 2019 District of Columbia Psychological Association Will attend three board meetings to represent student committee interests and opinions; will support two other student board members during their three months as primary board member. Will assist in planning, organizing, and executing strategic plan for the DC Psychological Association, assist in planning and executing tasks related to conferences, newsletters, and outreach. Appoint, manage, and connect student campus representatives from universities in the National Capital Region. Coordinated each of these tasks among the fellow student board members, who each shared in duties. Received direct mentorship from senior board members. Assisted in transition to new student board members, and advocated for change within larger DCPA board in order to help the next board members have a smoother transition. Developed continuation book for new student board members, with details regarding successes and lessons learned from the last year.

Student Advocacy Committee Representative September 2017- January 2018 Uniformed Services University Attended monthly meetings with representatives from each cohort and the faculty to address concerns of the students within the department. Received regular feedback from my cohort on their concerns and communicated these concerns effectively in the committee.

INTERPROFESSIONAL EXPERIENCES S. D. Mallonee 10 of 9 Emory Global Health Case Competition March 2018 & 2019 Emory University, Rollins School of Public Health Worked on an interprofessional team of medical, infectious disease, public health, and psychology students to solve a global public health challenge within one week. Won second place in competition with 30 international universities.

Interprofessional Hotspotting Team November 2017-February 2018 Uniformed Services University Participated in an interdisciplinary team of nursing, medical, and psychology students which was guided by a nurse and social worker to help improve the care received by local patients with complex dual diagnoses.

HONORS AND AWARDS Spring 2019 Won second place at Emory Global Health Competition

Spring 2015 Army Commendation Medal

Summer 2014 Army Achievement Medal

Spring 2009 Dean's List, University of Missouri-Kansas City

Fall 2008 Dean's List, University of Missouri-Kansas City

Summer 2007 Pfizer's Excellence in Research Award

Professional Affiliations

Associations of Military Surgeons of the United States 2019-present

Associations for Behavioral and Cognitive Therapies 2017-present

Association for Psychological Sciences 2016 - 2018

Psi Chi Member: International Honor Society in Psychology 2009 - present UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814-4799 www.usuhs.edu

April 15, 2020

MEMORANDUM FOR RICHARD W. THOMAS, MD, DDS, FACS, PRESIDENT, USUHS

Through: Chair, Board of Regents

SUBJECT: Certification of Graduate Student

The graduate student listed below is presented for certification to receive the Doctor of Philosophy degree effective upon your approval:

Nikki M. McCormack

DOCTOR OF PHILOSOPHY

Neuroscience Graduate Program

Attached is the candidate’s certification of successful completion of the Final Examination. Also attached are the Dissertation Approval Form, certification of authorized use of Copyrighted materials, Dissertation Title Page, Dissertation Abstract, and Curriculum Vitae.

Arthur L. Kellermann, MD, MPH Dean, USUHS, School of Medicine

Attachments: As stated

Learning to Care for Those in Harm’s Way

IDENTIFICATION OF NOVEL TARGETS TO TREAT SPINAL MUSCULAR

ATROPHY

by

Nikki M. McCormack

Dissertation submitted to the Faculty of the Neuroscience Graduate Program Uniformed Services University of the Health Sciences In partial fulfillment of the requirements for the degree of Doctor of Philosophy 2020

i ABSTRACT

Identification of novel targets to treat spinal muscular atrophy

Nikki M. McCormack, Doctor of Philosophy in Neuroscience, 2020

Thesis directed by: Barrington G. Burnett, PhD, Associate Professor, Department of

Anatomy, Physiology, and Genetics

Spinal muscular atrophy (SMA) is a debilitating neuromuscular disease that is one of the leading genetic causes of infant mortality. SMA is caused by insufficient levels of survival motor neuron (SMN) protein and is characterized by the loss of lower motor neurons in the anterior horn of the spinal cord and denervation-dependent muscle atrophy. Patients present with severe muscle weakness and fail to achieve normal motor milestones. Recently approved treatments for SMA, nusinersen and gene therapy, prolong lifespan, but only a small subset of patients have improvements in their motor function. Therefore, there is a critical need to develop additional treatments that can act either alone or in combination with current treatments to improve disease outcomes in all patients. Here, we aimed to identify novel genetic modifiers of SMN protein and molecular pathways in skeletal muscle that could be targeted to improve motor function.

Using a genome-wide RNAi screen, we found that knockdown of WDR33,

CPSF1, and THOC3, all components of RNA processing machinery, increase SMN protein levels. Knockdown of WDR33 and THOC3, but not CPSF1 increases export of

ii

SMN mRNA to the cytoplasm allowing for increased translation. We also found that knockdown of Neuralized-2 (Neurl2), an E3 ligase, increases SMN protein. We show that

Neurl2 ubiquitinates SMN and that reduction of Neurl2 stabilizes SMN protein levels.

Given that SMA mice have fewer and smaller muscle fibers, and that SMN deficiency impairs myoblast fusion, we sought to identify how loss of SMN impairs myoblast fusion. We found that SMN deficiency reduces expression of myomaker and myomixer, two muscle-specific fusion molecules, in SMA mouse muscle and in SMN- deficient myoblasts. Ectopic expression of myomixer in SMA mice increases myofiber number and improves motor function and further improved muscle histopathology and motor function when administered in combination with an SMN-increasing therapy.

These studies provide evidence of novel pathways that can act in combination with current therapies to further improve disease outcomes.

iii Nikki M. McCormack [email protected]

EDUCATION Uniformed Services University of the Health Sciences, Bethesda, MD Ph.D. Candidate in Neuroscience, August 2015-present GPA: 4.00

Temple University Honors Program, College of Science & Technology, Philadelphia, PA Bachelor of Science, May 2015 Major: Biochemistry Minor: Neuroscience Research GPA: 3.35

AWARDS AND HONORS • President, USU Graduate Student Council (August 2018-July 2019) I served as the conduit between the graduate student body and the Graduate Education Committee. I met regularly with the School of Medicine Deans to address student issues and improve student life. I assisted in the organization of orientation, interviewing days, Research Days, and the Graduate Student Appreciation Week and in the execution of the annual graduate student Climate Survey. I also re-wrote the GSC bylaws to expand the student council to allow for more student involvement. • Emma L. Bockman Memorial Award Honorable Mention (May 2019) • Dean’s Certificate of Appreciation (November 2018) • Temple University Dean’s List (Spring 2014, Spring 2015) • Temple University Merit Scholarship Fall 2011-Spring 2015

RESEARCH EXPERIENCE Graduate Student, Uniformed Services University (May 2016-present) Principle Investigator: Barrington G. Burnett My thesis project is examining novel pathways to treat spinal muscular atrophy. I used cellular and molecular techniques to determine the mechanism by which genetic modifiers of the survival motor neuron (SMN) protein, identified in an RNAi screen, increase levels of the protein. I also examined how low levels of SMN protein impairs myoblast fusion and found reduced levels of myomaker and myomixer in both SMA mouse muscle and in SMN-deficient myoblasts.

Undergraduate Researcher, Temple University (August 2013-April 2015) Shriners Hospitals Pediatric Research Center Principle Investigator: Tanya S. Ferguson My project involved examining therapeutic treatments for a mouse model of cerebral palsy. I used behavioral tests to assess the motor and cognitive abilities of the mice before and after treatment. I also used immunohistochemistry to examine cellular changes in the brain after treatment.

TEACHING Teaching Assistant, Uniformed Services University Introduction to Neuroscience (Fall 2017, Fall 2018, Fall 2019) I attended lectures and held review sessions for graduate students prior to exams.

Foundation in Medicine, Lecture on Precision Medicine (Fall 2018) I helped facilitate and developed questions for an interactive, flipped-classroom environment for medical students.

MENTORING Samantha Scott, USU Neuroscience MD/PhD Student (Spring 2019) Elizabeth Bergman, USU Neuroscience Graduate Student (Winter 2019) Salman Izadjoo, USU Molecular and Cell Biology Graduate Student (Summer 2018) Hannah Deines, Summer Intern, West Point Academy (Summer 2018) Anahita Shiva, Summer Intern, Cornell University (Summer 2018)

INVITED LECTURES 1. Examining impaired muscle development in spinal muscular atrophy. USU Comprehensive Student Research Training Program Cutting Edge Research Seminar Series (July 2019). 2. The role of SMN in muscle development. USU Summer Research Training Program Cutting Edge Research Seminar Series (June 2018).

UNIVERSITY ACTIVITIES Names and Honors Committee Member, Uniformed Services University (October 2017-present) I review and vote on submissions for granting honorary degrees and University awards and for the naming of facilities or buildings after individuals or groups.

Neuroscience Representative, USU Graduate Student Council (August 2017-July 2018) I served as the conduit between students in the neuroscience program and the Graduate Student Council. I assisted with the organization of orientation, interviewing days, and other graduate student events.

PUBLICATIONS Peer-reviewed articles 1. Lischka, F. W., Efthymiou, A, Zhou, Q., Nieves, M. D., McCormack, N. M., Wilkerson, M. D., Sukumar, G., Dalgard, C. L., Doughty, M. L. Neonatal mouse cortical but not isogenic human astrocyte feeder layers enhance the functional maturation of induced pluripotent stem cell-derived neurons in culture. Glia 2018, 66 (4), 725-748. 2. Moritz, K. E., McCormack, N. M., Abera, M. B., Viollet, C., Yauger, Y. J., Sukumar, G., Dalgard, C., Burnett, B. G. The role of the immunoproteasome in interferon-gamma- mediated microglia activation. Scientific Reports 2017, 7 (1), 9365. Submitted manuscripts 3. Khayrullina, G., Moritz, K. E., Schooley, J. F., Fatima, N., Viollet, C., McCormack, N. M., Smyth, J. T., Doughty, M. L., Dalgard, C. L., Flagg, T. P., Burnett, B. G. SMN- deficiency disrupts SERCA2 expression and intracellular Ca2+ signaling in cardiomyoctyes from SMA mice and patient-derived iPSCs. Under review.

Manuscripts in preparation 4. McCormack, N. M., Burnett, B. G. SMN-deficiency slows myoblast fusion through downregulation of myomaker and myomixer expression. In preparation. 5. McCormack, N. M., Abera, M. B., Arnold E. S., Gibbs, R. M., Hwang, R., Fischbeck, K. H., Beuhler, E., Burnett, B. G. A high-throughput genome-wide RNAi screen identifies novel modifiers of survival motor neuron (SMN) protein. In preparation.

POSTERS AND PRESENTATIONS 1. McCormack, N. M., Burnett, B. G. Myomaker and myomixer rescue fusion of SMN- deficient myoblasts. Poster Presentation at USU Neuroscience Open House, Bethesda, MD (December 2019) 2. McCormack, N. M., Burnett, B. G. Myomaker and myomixer rescue fusion of SMN- deficient myoblasts. Poster Presentation at CureSMA Researcher Conference. Selected for 5 minute Poster Highlight talk. Anaheim, CA. (June 2019) 3. McCormack, N. M., Survival motor neuron deficiency alters myomaker and myomixer expression to impair muscle development in spinal muscular atrophy. Podium Presentation. USU Research Days Graduate Student Colloquium, Bethesda, MD. (May 2019) 4. McCormack, N. M. Making bigger muscle. USU 3 Minute Thesis Competition, Bethesda, MD. (April 2019) 5. McCormack, N. M., Burnett, B. G., Myomaker rescues fusion of SMN-deficient myoblasts. Poster Presentation at CureSMA Researcher Conference, Dallas, TX. (June 2018) 6. McCormack, N. M., The role of SMN in muscle development. USU Neuroscience Seminar Series, Bethesda, MD. (May 2018) 7. McCormack, N. M., Muscle development in spinal muscular atrophy. USU 3 Minute Thesis Competition, Bethesda, MD. (April 2018) 8. McCormack, N. M., Abera, M. B., Villalon, E., Wilson, K., Lorson, C. L., Marugan, J. J., Burnett, B. G., ML372 blocks SMN ubiquitination and improves spinal muscular atrophy pathology in mice. Poster Presentation at Keystone Symposia on Ubiquitin Signaling, Tahoe City, CA. (January 2018) 9. McCormack, N. M., Abera, M. B., Villalon, E., Lorson, C. L., Burnett, B. G. ML372 blocks SMN ubiquitination and improves spinal muscular atrophy pathology in mice. Poster Presentation at USU Neuroscience Open House, Bethesda, MD (December 2017) 10. McCormack, N. M., Moritz, K. E., Abera, M. B., Burnett, B. G., SMN modulates calcium homeostasis. Poster Presentation at CureSMA Researcher Conference, Orlando, FL. (June 2017) 11. Abera, M. B., McCormack, N. M., Tanaka, H., Burnett, B. G., Post-translational modifications that alter SMN protein levels. Poster Presentation at CureSMA Researcher Conference, Orlando, FL. (June 2017)

PROFESSIONAL SOCIETIES Society for Neuroscience (2014-present)

VOLUNTEERING Brain Awareness Week, National Museum of Health and Medicine (March 2018) Using a hands-on activity, I taught children about the basic components of a neuron and how neuroscience is important for their everyday lives. UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814-4799 www.usuhs.edu

April 15, 2020

MEMORANDUM FOR RICHARD W. THOMAS, MD, DDS, FACS, PRESIDENT, USUHS

Through: Chair, Board of Regents

SUBJECT: Certification of Graduate Student

The graduate student listed below is presented for certification to receive the Doctor of Philosophy degree effective upon your approval:

Alexandria N. Morettini

DOCTOR OF PHILOSOPHY

Department of Medical and Clinical Psychology

Attached is the candidate’s certification of successful completion of the Final Examination. Also attached are the Dissertation Approval Form, certification of authorized use of Copyrighted materials, Dissertation Title Page, Dissertation Abstract, and Curriculum Vitae.

Arthur L. Kellermann, MD, MPH Dean, USUHS, School of Medicine

Attachments: As stated

Learning to Care for Those in Harm’s Way UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES SCHOOL OF MEDICINE GRADUATE PROGRAMS Graduate Education Office (A 1045), 4301 Jones Bridge Road, Bethesda, MD 20814

FINAL EXAMINATIONIPRN ATE DEFENSE FOR THE DEGREE OF DOCTOR OF PHILOSOPHY IN THE DEPARTMENT OF MEDICAL AND CLINICAL PSYCHOLOGY

Name of Student: Alexandria Morettini

Date of Examination: December 18,2019 Time: 9:00 AM Place: Room B3004

DECISION OF EXAMINATION COMMITTEE MEMBERS:

PASS FAIL

Dr. Je y uinlan DEPARTMENT OF MEDICAL & CLINICAL PSYCHOLOGY Committee Chairperson

r DICAL & CLINICAL PSYCHOLOGY Dissertation Advisor

1.1&Sch~ / DEPARTMENT OF MEDICAL & CLINICAL PSYCHOLOGY Committee Member

ehlmoos RVICES RESEARCH PROGRAM UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES SCHOOLOF MEDICINE GRADUATE PROGRAMS Graduate Education Office (A 1045), 4301 Jones Bridge Road, Bethesda, MD 20814

APPROVAL OF THE DOCTORAL DISSERTATION IN THE DEPARTMENT OF MEDICAL AND CLINICAL PSYCHOLOGY

Title of Dissertation: "Prescription of Psychotropic Medications by Providers Treating Children of Military Service Members"

Name of Candidate: Alexandria Morettini Doctor of Philosophy Degree December 18, 2019

DISSERTATION AND ABSTRACT APPROVED:

DATE:

Dr. Je Quinlan DEPARTMENT OF MEDICAL & CLINICAL PSYCHOLOGY Committee Chairperson

~. IZ/I~119 2~#Dr. Marl Tano ky-Kraff DEPARTMENT OF MEDICAL & CLINICAL PSYCHOLOGY Dissertation Advisor

Dr. Natasha Schvey DEPARTMENT OF MEDICAL & CLINICAL PSYCHOLOGY

e oos VICES RESEARCH PROGRAM COPYRIGHT STATEMENT

The author hereby certifies that the use of any copyrighted material in the dissertation manuscript entitled: “Prescription of psychotropic medications by providers treating children of military service members” is appropriately acknowledged and, beyond brief excerpts, is with the permission of the copyright owner.

______

Alexandria Morettini Medical and Clinical Psychology Department Uniformed Services University Date: 4 December 2019

Prescription of Psychotropic Medications by Providers Treating Children of Military Service

Members

by

Alexandria N. Morettini

Dissertation submitted to the Faculty of the Medical and Clinical Psychology Graduate Program Uniformed Services University of the Health Sciences In partial fulfillment of the requirements for the degree of Doctor of Philosophy 2020

ABSTRACT

Title of Dissertation: Prescription of Psychotropic Medications by Providers Treating Children of

Military Service Members

Alexandria N. Morettini

Thesis directed by: Marian Tanofsky-Kraff, Ph.D., Department of Medical and Clinical

Psychology

Children1 of military service members are at greater risk for a variety of health and mental health

conditions than their civilian counterparts. While studies have examined the health disparities

faced by these military children, few have sought to explore the type and quality of treatment

these children receive once they have received a mental health diagnosis. Popular approaches in treating various mental health disorders can include supportive therapy, evidence-based therapies, and psychopharmacology, in addition to other less frequently used treatments (e.g., dance or movement therapy, art therapy, hypnotism). A common source of entry into mental health care is through Primary Care Providers. This project examined the type of treatment chosen by Primary Care Providers for these military youth who present to Primary Care Clinics both in the Direct and Purchased Care Military Healthcare System with mental disorders.

1 The terms youth and children will be used to refer to both adolescents and younger children unless otherwise specified.

Utilizing EPIC Project Data on healthcare reimbursement claims, potential differences in prescription of psychotropic medications and referrals to specialty mental health care between child beneficiaries seen in the Direct and Purchased Care systems were examined. Sex differences in rates of psychotropic prescriptions and follow up mental health care were also studied. Finally, receiving care in a designated Health Professionals Shortage Area was looked at as a potential moderating factor between care setting and the type of treatment a child receives.

Children seen in Direct Care who had attention- and mood-related disorders received psychotropic prescriptions at significantly higher rates than those in Purchased Care (Attention:

OR=1.718,], p<.0001; Mood: OR=2.084, p<.0001). In Direct Care, children in all diagnostic categories received follow up specialty mental health care at significantly lower rates than those in Purchased Care (Attention: OR=0.504, p<.0001; Anxiety: OR=0.703, p<.0001; Mood:

OR=0.254, p<.0001; Conduct: OR=0.469, p<.0001). Among all children regardless of care setting, females received medication at a significantly lower rate than males (OR=0.725, p<.0001) and received follow up specialty mental health care at significantly higher rates than males (OR=1.379, p<.0001). Being in a Health Professionals Shortage Area was found to moderate the relationship between care setting and receiving follow up mental health care in both

Direct (OR=1.154, p=.03) and Purchased Care (OR=1.043, p=.03). These differences suggest there are practice discrepancies between providers practicing within and outside of Military

Treatment Facilities. Further, female and male dependents of active duty service members tend to receive different modalities of treatment for mental illnesses. Future studies should seek to elucidate sources of these inconsistencies. Curriculum Vitae

ALEXANDRIA MORETTINI [email protected]

EDUCATIONAL HISTORY

Uniformed Services University of the Health Sciences, Bethesda, MD Expected May 2020 Ph.D. Candidate in Clinical Psychology Dissertation: Prescription of Psychotropic Medications by Providers Treating Children of Military Servicemembers Advisor: Marian Tanofsky-Kraff, Ph.D. APA-Accredited

California State University, San Marcos, CA 2003-2005 Bachelor of Arts in Psychology, cum laude

Morehead State University, Morehead, KY 2002 Major: Psychology

PROFESSIONAL EXPERIENCE

Walter Reed National Military Medical Center September 2019-Present Clinical Psychology Resident Supervisors: Richard Bergthold, Psy.D. • Apply graduate learning to fulltime patient care in inpatient, outpatient, and internal medicine settings

The Neurology Center June 2017-April 2019 Clinical Psychology Extern Supervisors: Jesse Brand, Ph.D., ABPP-CN; Anne Newman, Ph.D., ABPP-CN • Administered cognitive testing to NFL players to assess baselines to be used in player’s union settlement • Planned and utilized neuropsychological testing to determine cognitive functioning in geriatric patients • Wrote neuropsychological reports and provided recommendations given level of cognitive functioning

St. Elizabeth’s Hospital Neuropsychology June 2018-October 2018 Clinical Psychology Extern Supervisor: Sidney Binks, Ph.D., ABPP-CN • Planned and administered neuropsychological batteries to determine psychological competency • Completed forensic reports for pre- and post-trial prisoners with mental illness and disability

Expressive Therapy Center June 2017-May 2018 Clinical Psychology Extern Supervisor: David Drowos, Psy.D. • Evaluated, determined appropriate intervention, and provided counseling for families and couples • Co-facilitated child therapy groups with children between ages five and sixteen

Naval Special Warfare Center, San Diego July 2017-August 2017 Clinical & Operational Psychology Extern Supervisor: Eric Rogers, Ph.D. ALEXANDRIA MORETTINI 1 Curriculum Vitae

• Provided assessment and selection support for naval special warfare programs

Naval Health Clinic Annapolis June 2016-June 2017 Clinical Psychology Practicum Student Supervisor: LCDR Steven Porter, Psy.D. • Planned and provided over 100 face-to-face hours of psychotherapeutic intervention for adults • Evaluated 15 students for fitness-for-duty and reported commissioning status to Brigade Medical Officer • Conducted 240 neuropsychological baseline concussion screenings for incoming students at USNA • Amassed over 600 hours of supervision and training in clinical psychology

Children’s National Health System Eating Disorders Clinic June 2016-August 2016 Clinical Psychology Practicum Student Supervisor: Darlene Atkins, Ph.D. • Wrote clinical intake notes for adolescents referred for disordered eating • Provided therapy for individual clients with eating disorder diagnoses • Participated in group and individual supervision • Attended interdisciplinary treatment team meetings

Val G. Hemming Simulation Center September 2015-Present Clinical Psychology Practicum Student Supervisor: Layne Bennion, Ph.D.; Marjan Holloway, Ph.D.; Jeanette Witter, Ph.D. • Provided therapy to individual clients using Cognitive Behavioral Therapy and Brief Dynamic Psychotherapy techniques • Conducted clinical intake and triage interviews • Administered and scored psychological assessments • Wrote clinical progress notes, intake and triage reports, and assessment reports • Participated in group supervision and case conceptualization

Naval Consolidated Brig October 2010-July 2014 Mental Health Technician, Sex Offender & Drug Treatment Programs • Conducted intake assessments for pretrial and adjudicated prisoners • Provided treatment planning and advising for prisoners • Administered and scored psychological tests for each prisoner entering treatment • Led weekly sex offender and alcohol and drug education groups • Facilitated 12-week alcohol and drug therapy group • Co-facilitated 24-month sex offender and 12- month violent offender therapy groups • Wrote patient progress notes and performed quarterly interdisciplinary feedback to offenders in treatment

Combat Stress Control Clinic, Bagram Afghanistan January 2010-August 2010 Mental Health Technician • Conducted crisis intake and triage assessments for military and civilian members in combat zone • Facilitated psychoeducational group sessions including stress and anger management and smoking cessation • Managed recuperative treatment, teaching coping skills to military members in short-term residential program (Freedom Restoration Center)

ALEXANDRIA MORETTINI 2 Curriculum Vitae

• Provided educational and preventative presentations to units of up to 200 service members for topics such as suicide prevention and reintegration • Traveled to remote FOBs to provide mental health support and consultation for bases without dedicated mental health services

Alcohol and Drug Abuse Prevention and Treatment Program, Scott AFB January 2008-January 2010 Alcohol and Drug Abuse Counselor • Received 300 hours of direct supervision by an LCSW, Psychiatrist, and Clinical Psychologist in individual and group therapy leading to certification • Conducted alcohol and drug use screenings and assessments • Planned, coordinated, and provided multiphasic individual and group treatments for adults • Utilized motivational interviewing to provide Alcohol Brief Counseling to servicemembers who had an alcohol-related incident • Facilitated treatment team meetings with command and interdisciplinary medical team • Wrote substance use psychological reports • Directed weekly alcohol safety and awareness class for new Airmen

Mental Health Clinic, Scott AFB March 2007-January 2008 Mental Health Technician • Conducted phone triages and crisis intakes • Led psychoeducational groups including smoking cessation, anger and stress management, and relaxation • Provided command briefings for suicide awareness and prevention, base newcomer’s, and medical group orientation

University of California San Diego Medical Center September 2004-December 2004 Hospital-Based Psychiatric Services Volunteer • Provided social skills training for patients hospitalized for severe mental illness

CERTIFICATIONS

Certified Alcohol and Drug Counselor 2009-2015 International Certification and Reciprocity Consortium (IC&RC)

Certified Correctional Supervisor 2013-2015 American Correctional Association

INTERVENTION AND ASSESSMENT TRAINING

• Doctoral Courses [Intervention] o Foundations of Psychotherapy; CBT I; CBT II; Psychodynamic Therapy; Group Therapy • Doctoral Courses [Assessment] o Psychopathology; Clinical Assessment I; Clinical Assessment II; Clinical Assessment III; Neuropsychology • Training Workshops [Intervention] o Interpersonal Psychotherapy Workshop o Combat and Operational Stress Control ALEXANDRIA MORETTINI 3 Curriculum Vitae

• Assessments Administered [Alphabetical Listing] Alcohol Use Disorders Identification Test (AUDIT); Booklet Category Test; Boston Naming Test; Brief Visuospatial Memory Test-Revised (BVMT-R); California Verbal Learning Test; Clock Drawing Test; Continuous Performance Test (CPT); Controlled Oral Word Association Test; Dean-Woodcock Sensory-Motor Battery; Delis-Kaplan Executive Function System (D-KEFS); Dementia Rating Scale-2 (DRS-2); Finger Tapping; Grip Strength; Grooved Pegboard; Interpersonal Behavior Survey (IBS); Medical Symptoms Validity Test (MSVT); Mini Mental Status Exam (MMSE); Minnesota Multiphasic Personality Inventory, Second Edition (MMPI-2) and Restructured Form (MMPI-2-RF); Millon Clinical Multiaxial Inventory, Third Edition (MCMI-III); Personality Assessment Inventory (PAI); PTSD Checklist-Military Version (PCL-M); Repeatable Battery for Neuropsychological Status (RBANS); Rey Complex Figure Test; Rorschach; Static-99; Test of Memory Malingering (TOMM); Test of Premorbid Functioning (TOPF); Test of Variables of Attention (TOVA); Texas Functional Living Scale (TFLS); Trail Making Test A & B; Wechsler Adult Intelligence Scales, Fourth Edition (WAIS-IV); Wechsler Abbreviated Scale of Intelligence (WASI); Wechsler Memory Scale, Fourth Edition (WMS-IV); Wide Range Achievement Test 4 (WRAT4); Wisconsin Card Sort Test; Word Choice Test

RESEARCH EXPERIENCE

Developmental Research Laboratory on Eating and Weight Behaviors August 2015-Present Doctoral Student-Research Associate Advisor: Marian Tanofsky-Kraff, Ph.D. • Co-facilitated Interpersonal Psychotherapy groups for adolescents with overweight for POMC-A study • Taught Health Education group for POMC-A study on preventing obesity in youth • Attended team supervision meetings and contribute to the scientific research on interpersonal relationships and weight-related behaviors

California State University, San Marcos October 2004-June 2005 Research Assistant Advisor: P. Wesley Schultz, Ph.D. • Contributed to scientific manuscript writing and editing • Assisted with social marketing projects • Provided administrative assistance for research • Administered computer-based Implicit Association Tests

TEACHING EXPERIENCE

Uniformed Services University of the Health Sciences Teaching Assistant • Clinical Assessment I (Fall 2016); Clinical Assessment II (Winter 2016); Clinical Assessment III (Spring 2017; Spring 2019) • Psychopathology (Fall 2017) • Cognitive Behavioral Therapy (Spring 2018) • Navy TA (2018-2019)

California State University San Marcos, Department of Psychology Teaching Assistant • Introductory Statistics 2004

ALEXANDRIA MORETTINI 4 Curriculum Vitae

PUBLICATIONS AND PRESENTATIONS

1. Morettini, A., Schvey, N., Gillmore, D., & Tanofsky-Kraff, M. (Manuscript in press). Eating disorders and disordered eating in the military family. In LeGrange, D., Goldschmidt, A., & Tortolani, C. (Eds.) Adapting Evidence-Based Treatments for Eating Disorders for Novel Populations and Settings. New York, NY: Routledge. 2. Higgins Neyland, M. K., Burke, N. L., Schvey, N. A., Pine, A., Quattlebaum, M., Leu, W., Morettini, A., Gillmore, D., LeMay-Russell, S., Wilfley, D. E., Stephens, M., Sbrocco, T., Yanovski, J. A., Jorgensen, S., Klein, D. A., Olsen, C. H., Quinlan, J., & Tanofsky-Kraff, M. (Manuscript under submission). An Examination of the Links among Parental Deployment, Disordered Eating, and Depression in Prevention-Seeking Adolescent Military Dependents. 3. Quattlebaum, M., Burke, N. L., Higgins Neyland, K., Leu, W., Schvey, N. A., Pine, A., Morettini, A., LeMay- Russell, S., Wilfley, D. E., Stephens, M., Sbrocco, T., Yanovski, J. A., Jorgensen, S., Olsen, C., Klein, D., Quinlan, J., & Tanofsky-Kraff, M. (2019). Sex Differences in Eating Related Behaviors and Psychopathology among Adolescent Military Dependents at Risk for Adult Obesity and Eating Disorders. Eating Behaviors. 33, 73-77. 4. Schvey NA, Blubaugh I, Morettini A, Klein, DA. (2017). Military family physicians’ readiness for treating patients with gender dysphoria. JAMA Internal Medicine, 177(5), 727-729. 5. Schvey NA, Morettini A, Blubaugh IM, Klein DA. (2017). Military family physicians’ readiness for treating patients with gender dysphoria. Journal of Adolescent Health. 60(2S1):16.

Abstracts

1. Shank, L. M., Higgins Neyland, M., Klein, D., Jorgensen, S., Burke, N. L., Sbrocco, T., Leu, W., Gillmore, D., Schvey, N. A., Morettini, A., Olsen, C. H., Stephens, M., Haigney, M. C., Yanovski, J. A., Quinlan, J., & Tanofsky-Kraff, M. (August, 2019). Loss of Control Eating, Adiposity, and Metabolic Health in Adolescent Military Dependents with Overweight and Obesity. Military Health System Research Symposium Annual Meeting. 2. Pearlman, A. T., Schvey, N. A., Pine, A., Quattlebaum, M., Higgins Neyland, M. K., Leu, W., Morettini, A., Gillmore, D., Burke, N. L., Wilfley, D. E., Sbrocco, T., Stephens, M., Jorgensen, S., Klein, D., Quinlan, J., & Tanofsky-Kraff, M. (May, 2019). Associations between Family Weight-Based Teasing and Psychosocial Functioning among Adolescent Military Dependents. Association for Psychological Science Annual Meeting. 3. Morettini, A., Koehlmoos, T., Patel, A., Banaag, A., Quinlan, J., & Tanofsky-Kraff, M. (March, 2019). Mental Health Diagnoses Among Children of Military Servicemembers. Society of Behavioral Medicine Annual Meeting. 4. Leu, W., Burke, N. L., Higgins Neyland, M. K., Quattlebaum, M., Pine, A., Schvey, N. A., LeMay-Russell, S., Morettini, A., Jorgenson, S., Wilfley, D. E., Stephens, M., Sbrocco, T., Yanovski, J. A., David Klein, D., Quinlan, J., & Tanofsky-Kraff, M. (March, 2019). Coping Patterns in Relation to Emotional Eating Among Female and Male Adolescent Military Dependents at High Risk for Eating Disorders and Adult Obesity. The International Conference on Eating Disorders. 5. Higgins Neyland, M. K., Burke, N. L., Schvey, N. A., Abigail Pine, Quattlebaum, M., Leu, W., Morettini, A., Byrne, B., Wilfley, D., Stephens, M., Sbrocco, T., Yanovski, J. A., Klein, D., Quinlan, J., & Tanofsky-Kraff, M. (April, 2018). Parental Deployment and its Association with Disordered Eating among Adolescent Military Dependents Seeking Prevention of Eating Disorders and Adult Obesity. The International Conference on Eating Disorders. 6. Quattlebaum, M., Burke, N. L., Leu, W., Schvey, N. A., Pine, A., Morettini, A., Byrne, B., Wilfley, D., Stephens, M., Sbrocco, T., Yanovski, J. A., Klein, D., Quinlan, J., & Tanofsky-Kraff, M. (April, 2018). Characteristics of Female and Male Adolescent Military Dependents Seeking Prevention of Eating Disorders and Adult Obesity. The International Conference on Eating Disorders. 7. Pine, A., Burke, N. L., Schvey, N. A., Quattlebaum, M., Leu, W., Morettini, A., Byrne, B., Wilfley, D., Stephens, M., Sbrocco, T., Yanovski, J. A., Klein, D., Quinlan, J., & Tanofsky-Kraff, M. (April, 2018). Anxiety and Loss of

ALEXANDRIA MORETTINI 5 Curriculum Vitae

Control (LOC) Eating in Relation to Interpersonal Model Components among Adolescent Military Dependents Seeking Prevention of Eating Disorders and Adult Obesity. The International Conference on Eating Disorders.

OTHER PROFESSIONAL EXPERIENCE, HONORS, AND AWARDS

• Peer Reviewer - International Journal of Eating Disorders, European Eating Disorders Review • American Psychological Association Member • Psi Chi Honor Society • John L. Levitow Airman Leadership Award • CMSgt Lewis Dunlap AMC Mental Health Airman of the Year 2009 • Army and Air Force Commendation Medals • Air Force Achievement Medal • Airman of the Quarter - March 2009 and July 2012 • California State University Dean’s List 2003-2005 • Morehead State University Dean’s List 2002

ALEXANDRIA MORETTINI 6 UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814-4799 www.usuhs.edu

April 15, 2020

MEMORANDUM FOR RICHARD W. THOMAS, MD, DDS, FACS, PRESIDENT, USUHS

Through: Chair, Board of Regents

SUBJECT: Certification of Graduate Student

The graduate student listed below is presented for certification to receive the Doctor of Philosophy degree effective upon your approval:

Adrian C. Paskey

DOCTOR OF PHILOSOPHY

Emerging Infectious Diseases Graduate Program

Attached is the candidate’s certification of successful completion of the Final Examination. Also attached are the Dissertation Approval Form, certification of authorized use of Copyrighted materials, Dissertation Title Page, Dissertation Abstract, and Curriculum Vitae.

Arthur L. Kellermann, MD, MPH Dean, USUHS, School of Medicine

Attachments: As stated

Learning to Care for Those in Harm’s Way UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES SCHOOL OF MEDICINE GRADUATE PROGRAMS Graduate Education Office (A 1045), 4301 Jones Bridge Road, Bethesda, MD 20814

FINAL EXAMINATION/PRIVATE DEFENSE FOR THE DEGREE OF DOCTOR OF PHILOSOPHY IN THE EMERGING INFECTIOUS DISEASES GRADUATE PROGRAM

Name of Student: Adrian Paskey

Date of Examination: February 27, 2020 Time: 11:00AM Place: Room B4004

DECISION OF EXAMINATION COMMITTEE MEMBERS:

PASS FAIL

Dr. D. Scott Merrell DEPARTMENT OF MICROBIOLOGY & IMMUNOLOGY Committee Chairperson

1/ ~ .-1 I .1.../-

Dissertation Advisor

Dr. Christopher C:-Br()der·· DEPARTMENT OF MIQ OBIOLOGY & IMMUNOLOGY Committee Member

Dr. Clifton L. Dalgard DEPARTMENT OF ANATOMY, PHYSIOLOGY & GENETICS Committee Member

6

High throughput sequencing and discovery of novel bat viruses: insights for biosurveillance in an

important virus reservoir

by

Adrian Caroline Paskey

Dissertation submitted to the Faculty of the Emerging Infectious Diseases Graduate Program Uniformed Services University of the Health Sciences

ABSTRACT

High throughput sequencing and discovery of novel bat viruses: insights for biosurveillance in an important virus reservoir

Adrian Caroline Paskey, Doctor of Philosophy, 2020

Thesis directed by: Kimberly A. Bishop-Lilly, Ph.D., Adjunct Assistant Professor, Department of Microbiology and Immunology

Bats are rich reservoirs of viruses, including viruses associated with several high-consequence zoonoses. High-throughput sequencing and hybridization-based target enrichment sequencing were used to characterize the virome of a captive colony of fruit nectar bats, lesser dawn bats

(Eonycteris spelaea) in Singapore through a longitudinal study, and a wild bat population of cyclops roundleaf bats (Hipposideros cyclops) in Uganda. Through the use of viral RNA extracted from bat swabs, we evaluated the utility of external and internal swab sites for biosurveillance and discovered novel viruses by shotgun and enrichment sequencing. Several viruses cataloged in this study are related to viruses that have previously crossed the species barrier from bats to humans, or other incidental intermediate hosts. To our knowledge, this is the first study that combined probe-based viral enrichment with high-throughput sequencing to create a viral profile from multiple swab sites on individual bats as a cohort. It was necessary to develop a new pipeline for the bioinformatic analysis of our samples, as well as a normalization technique to make comparisons among samples.

7

We hypothesized that some viruses may persist within the captive colony of bats long-term, as opposed to decreasing below the level of detection in the absence of migration and new, naive bats. This work demonstrated distinct temporal patterns of the lesser dawn bat virome and also led to the discovery of novel viruses in both lesser dawn bats and cyclops roundleaf bats. We found that noninvasive surveillance methods that target the body of bats not only detected viruses shed within the colony, but also represented viral populations dispersed throughout the entire colony. This new knowledge of persistent viral families should inform future directions for biosurveillance of viruses that have the potential to cross the species barrier from bats to humans or other amplifying hosts.

Perhaps most immediately relevant, the knowledge that a rubella-like virus circulates in equatorial African bats should be used to inform decisions with regard to the World Health

Organization’s plan to eliminate human rubella virus. Through this work, we evaluated and developed new tools for use in wet-lab and computational components of biosurveillance, and implemented them to generate a framework for future public health-related efforts.

8

Adrian Paskey Email: [email protected] Telephone: 717-448-6805

Education PhD in Emerging Infectious Diseases at the Uniformed Services University of the Health Sciences Thesis advisor: Dr. Kimberly Bishop-Lilly, Head of Genomics & Bioinformatics Department at the Biological Defense Research Directorate, Navy Medical Research Center - Frederick, MD

Bachelor of Science, Biological Sciences and Health Professions Option and Spanish Minor Science Research Distinction Undergraduate Certificate Program (completed thesis available on record with the Penn State Eberly College of Science) The Pennsylvania State University, class of2015 (GPA 3.7)

Publications - Bennett*, Paskey*, Ebinger* et al., Relatives of rubella virus in diverse mammals portend challenges for global rubella eradication. Nature, under revision (*shared first author) - Paskey et al., Detection of recombinant Rousettus bat coronavirus GCCDC I in lesser dawn bats (Eonycteris spelaea) in Singapore, in preparation - Paskey et al., The temporal RNA virome patterns of a Lesser Dawn Bat (Eonycteris spelaea) colony revealed by deep sequencing. Virus Evolution. 2020 - Paskey et al., Enrichment Post-Library Preparation Enhances the Sensitivity of High- Throughput Sequencing-Based Detection and Characterization of Viruses from Complex Samples. BMC Genomics. 2019 - LaBreck et al., Conjugative Transfer of a Novel Staphylococcal Plasmid Encoding the Biocide Resistance Gene, qacA. Frontiers in Microbiology. 2018

Presentations & Posters - Viruses 2020 - Novel Concepts in Virology (Barcelona, Spain). Novel insights for biosurveillance of bat-borne viruses, poster, 2020 - NICBR Winter Virology Symposium (Frederick, MD). Novel insights for biosurveillance of bat-borne viruses, oral presentation, 2020 - American Society for Virology (Minneapolis, Minnesota). Deep sequencing to track temporal patterns of the Eonycteris spelaea virome, oral presentation for Viral Discovery session, 2019 - American Society for Microbiology Biothreats meeting and DC Branch Spring Symposium (Washington, D.C.). Probe-Based Viral Enrichment and Deep Sequencing to Track Temporal Patterns of the Bat Virome in Southeast Asia, poster and Peer-to-peer oral presentations, 2019 - Penn State Undergraduate Research Expo. Antibiotic Tolerance of Staphylococcus aureus Persister Cells & Efficacy of Antibiotics in Treating S. aureus Persister Cells, posters, 2014 and 2015 - Manuscript and poster acknowledgements, Racial Differences Among Factors Associated with Participation in Clinical Research Trials, J Racial and Ethnic Health Disparities and presented at Women's Health Congress 2015

1 Adrian Paskey Email: [email protected] Telephone: 717-448-6805

Skills Advanced Spanish Data analysis (R, Stata, Minitab, Excel) CLC and Command line bioinformatics DNAIRNA extraction Illumina sequencing PacBio sequencing Oxford Nanopore sequencing Experience giving clinical research surveys Grant writing Light microscope and TEM Media preparation (TSBYE, TSAYE, etc.) PCRandqPCR Chromatography Cell culture Public Health & Science Member of the Student American Society for Microbiology, USUHS 2018-2020 Outbreak! Volunteer at the Smithsonian National Museum of Natural History 2018-2019 Judged Fairfax County Regional Science and Engineering Fair 2019 Judged Prince William-Manassas Regional Science Fair 2018 Three Minute Thesis Competition participant, USUHS 2018 Junior Achievement STEM Panelist 2017 Research Scholar, Lehigh Valley Health Network Dept. of Emergency Medicine 2014 Celtic Hospice Volunteer 2012-2013 Intern for Centre County Veterans' Affairs 2012-2013 Volunteered at Hospital Matemo-Infantil Virgin de Rosio, Seville Spain 2013 American Red Cross Disaster Assessment Team Member 2010-2015 Science LionPride (Ambassadors club to Eberly College of Science, Penn State)

Leadership Organized and convened Student & Postdoc ASM DC Branch Meeting 2020 President, Student American Society for Microbiology, USUHS 2019

Awards American Society for Virology Student Travel Award 2019 CureGear Student Travel Award 2019 Sanford Fellowship in Tropical Medicine 2018-2019 Recipient of Student Leader Scholarship, Penn State University 2012,2013,2014 Best Presentation Award, LVHN Research Scholar Poster Exhibition 2014

Other Community Involvement Pianist, Walkersville High School production of The Music Man (Frederick, 2020 MD) Women in Biology member, Frederick chapter 2019-present Vocalist and Pianist, Living Water Band (Frederick, MD) 2018-present

2 Adrian Paskey Email: [email protected] Telephone: 717-448-6805 Assistant Coach for Girls on the Run, Frederick County, MD Fall 2018, 2019 Vocalist, Evensong Band (Bethesda, MD) 2015-2017 Contemporary Music Coordinator, St. Paul's United Methodist Church 2011-2015

3

------UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814-4799 www.usuhs.edu

April 15, 2020

MEMORANDUM FOR RICHARD W. THOMAS, MD, DDS, FACS, PRESIDENT, USUHS

Through: Chair, Board of Regents

SUBJECT: Certification of Graduate Student

The graduate student listed below is presented for certification to receive the Doctor of Philosophy degree effective upon your approval:

Shemona Rattila

DOCTOR OF PHILOSOPHY

Molecular and Cell Biology Graduate Program

Attached is the candidate’s certification of successful completion of the Final Examination. Also attached are the Dissertation Approval Form, certification of authorized use of Copyrighted materials, Dissertation Title Page, Dissertation Abstract, and Curriculum Vitae.

Arthur L. Kellermann, MD, MPH Dean, USUHS, School of Medicine

Attachments: As stated

Learning to Care for Those in Harm’s Way UNIFORMED SERVICES UNIVERSITYOF THE HEALTHSCIENCES SCHOOL OF MEDICINE GRADUATE PROGRAMS Graduate Education Office (A 1045), 4301 Jones Bridge Road, Bethesda, MO 20814

FINAL EXAMINATION/PRIVATE DEFENSE FOR THE DEGREE OF DOCTOR OF PHILOSOPHY H IN TE MOLECULAR AND CELL 8 IOLOGY GRADUATE PROGRAM

Name of Student: Shemona Rattila

Date of Examination: January21, 2020 Time: 2:00 PM Place: Room 83 144

DECISION OF EXAMINATION COMMITTEE MEMBERS:

PASS FAIL ✓ DEPARTMENT OF OBSTRETICS & GYNECOLOGY Commi - iei=P .J Dr. Gabriela Dveksler DEPARTMENT OF PATHOLOGY Dissertation Advisor ✓ Dr. Syed Viqar DEPARTMENT OF OBSTRETICS & GYNECOLOGY Committee Member

Dr. Xin Xiang DEPARTMENT OF BIOCHEMISTRY & MOLECULAR BIOLOGY Committee Member

Dr. Melissa Austin US BUREAU OF MEDICINE & SURGERY CommitteeNAVY Member

ii UNIFORMED SERVICES UNIVERSITY OF THEHEALTH SCIENCES SCHOOL OF MEDICINE GRADUATE PROGRAMS Graduate Education Office (A 1045), 4301 Jones Bridge Road, Bethesda, MD 20814

APPROVAL OF THE DOCTORAL DISSERTATION IN THE MOLECULAR AND CELL BIOLOGY GRADUATE PROGRAM

Title of Dissertation: "Characterization of the interactions of pregnancy-specific glycoprotein I (PSG 1) with extravillous trophoblasts and endothelial ccJls"

Name of Candidate: Shemona Ranila Doctor of Philosophy Degree January 21, 2020

DISSERTATION AND ABSTRACT APPROVED:

DATE:

�&? --- DEPARTMENT OF OBSTRETICS & GYNECOLOGY

Commin.e CW Dr. Gabriela Dveksler DEPARTMENT OF PATHOLOGY Dissertation Advisor

Dr. Viqar Syed DEPARTMENT OF OBSTRETICS & GYNECOLOGY Committee Member

Dr. Xin Xiang DEPARTMENT OF BIOCHEMISTRY & MOLECULAR BIOLOGY Committee Member

Dr. Melissa Austin US NAVY BUREAU OF MEDICINE & SURGERY Committee Member

iii The author hereby certifies that the use of any copyrighted material in the thesis manuscript entitled:

“Characterization of the interactions of pregnancy-specific glycoprotein 1 (PSG1) with extravillous trophoblasts and endothelial cells” is appropriately acknowledged and, beyond brief excerpts, is with the permission of the copyright owner.

Shemona Rattila Molecular and Cell Biology Program/ Department of Pathology Uniformed Services University of Health Sciences March 24, 2020

iv Characterization of the interactions of pregnancy-specific glycoprotein 1 (PSG1) with extravillous trophoblasts and endothelial cells

by Shemona Rattila

Dissertation submitted to the Faculty of the Graduate Degree Program in Molecular and Cellular Biology of the Uniformed Services University of the Health Sciences in partial fulfillment of the requirements for the degree of Doctor of Philosophy 2020

i ABSTRACT

Title of Dissertation: Characterization of the interactions of pregnancy-specific glycoprotein 1 (PSG1) with extravillous trophoblasts and endothelial cells

Author: Shemona Rattila

Program and year: Molecular and Cell Biology, 2020

Thesis advisor: Gabriela Dveksler, PhD Professor Departments of Pathology, Uniformed Services University of the Health Sciences 4301 Jones Bridge Road, Bethesda, Maryland 20814

Pregnancy-specific glycoproteins are secreted predominantly by the syncytiotrophoblast of the placenta. Humans have ten protein-coding PSG genes (PSG1-

PSG9, and PSG11), and PSG1 is the most highly expressed throughout pregnancy. PSG1 has been previously reported to have immunomodulatory and pro-angiogenic functions.

While the immunoregulatory role of PSG1 has been extensively studied, a potential role of this protein in the processes of placenta development has not been investigated. Our laboratory has previously determined that PSG1 binds to extravillous trophoblasts

(EVTs) and endothelial cells (ECs) and we hypothesized that PSG1 could contribute to placental invasion and angiogenesis through the interaction with these cells. To characterize the interaction of PSG1 with EVTs, I focused my studies on the functions of

EVTs that facilitate placenta formation, including adhesion, migration, and decidual invasion. PSG1 has four immunoglobulin-like domains, and I generated recombinant

PSG1 and its single domains for my studies. I showed that PSG1 induces a dose- dependent adhesion of two immortalized human EVT cell lines (HTR8/SVneo and

v Swan71). In addition, I showed that PSG1-mediated adhesion is integrin α5β1-dependent in both normoxic and low oxygen environments as observed in the first-trimester placenta. The interaction between PSG1 and α5β1 is direct and was confirmed using

PSG1 purified from the serum of pregnant women. Furthermore, I showed that both the N and B2 domains of PSG1 interact with integrin α5β1. PSG1-mediated adhesion leads to the formation of focal adhesion structures and focal adhesion kinase phosphorylation and we observed that PSG1 simultaneously binds to heparin and to α5β1. Therefore, our current model predicts that PSG1 becomes incorporated into the decidual extracellular matrix and mediates the adhesion of EVTs. I also determined that the EVT cell lines had enhanced migratory activity when seeded on a PSG1-coated surface, although no differences were observed in their invasive capacity when compared to the control.

Interestingly, the serum concentration of PSG1 is lower in African-American women diagnosed with early- and late-onset pre-eclampsia (PE), a pregnancy complication characterized by inadequate invasion by the EVTs, compared to their respective healthy- controls only when the fetus was a male, suggesting a complex association of PSG1 with

PE.

PSG1 was shown to induce endothelial tube formation, which was abolished by treatment with heparinase. To elucidate the mechanism behind the pro-angiogenic activity of PSG1,

I investigated the interaction between PSG1 and heparan sulfate (HS). I showed that the positively charged amino acids in the 43-59 region of the B2 domain of this protein interact with HS. In addition, the pro-angiogenic activity of PSG1 on ECs and EVTs in vitro and in mouse aortic ring assays ex vivo is dependent on the B2 domain of this protein. The multistep process of angiogenesis includes cell migration, proliferation, and

vi remodeling of the matrix through protease production. While PSG1 enhanced the migration of ECs, it did not affect the migration of EVTs. Interestingly, PSG1 enhanced matrix metalloproteinase (MMP)-2 secretion by EVTs but not by ECs. The observed effects on migration and MMP production suggest that there is a difference in the mechanism of PSG1-mediated pro-angiogenic action on EVTs and ECs. I observed that all human PSGs bind to heparan sulfate proteoglycans despite their differences in the amino acid sequence of the B2 domains. Furthermore, PSG9 and PSG6 induce endothelial tube formation as observed with PSG1, indicating that this activity may be conserved among all human PSGs. In conclusion, I have identified integrin α5β1 as a new receptor for PSG1, which mediates increased adhesion and migration of EVTs, and determined that the B2 domain of this protein interacts with HSPGs and mediates its pro- angiogenic functions. These studies indicate that PSG1 plays a significant role in placental biology and may have therapeutic potential for the treatment of pregnancy complications in which it is found at lower than normal levels, such as in PE.

vii Shemona Rattila [email protected]

Highly motivated cell and molecular biologist with specialization in mammalian cell culture, Summary cell-based assays, protein biochemistry, and microbiology. Passionate about learning new scientific skills. Enthusiastic team player adept at providing leadership while also learning from fellow team members. Uniformed Services University of Health Sciences, Bethesda, MD. Education Ph.D. Candidate in Molecular and Cell Biology. Graduated in March, 2020 University of Dhaka, Dhaka, Bangladesh M.S. Microbiology, 2009. B.Sc. Microbiology, 2007.

Graduate program in Molecular and Cell Biology, Uniformed Services University of Health tSciences, Bethesda, MD, USA. 2013-Present Project 1: The roles of pregnancy-specific glycoprotein 1 (PSG1) in the functions of extravillous trophoblasts (EVTs) during placenta formation: I have identified that the interaction between PSG1 and integrin α5β1 mediates the adhesion of EVTs to the uterus and activates the focal adhesion kinase, enhancing cell migration, which subsequently leads to normal placentation. In addition, I Research have found that African-American women diagnosed with early-onset and late-onset preeclampsia, a pregnancy pathology characterized by shallow trophoblast invasion, have lower serum PSG1 concentration. Therefore, I suggested that the reduced expression of PSG1 should be considered in the context of preeclampsia as a potential therapy. I have recently published a research article describing this finding. Project 2: Mechanism of PSG1-mediated proangiogenic function: With mutational analysis, I have identified that the B2 domain of PSG1 binds to cell surface heparan sulfate proteoglycans and induces in vitro tube formation in endothelial cells and EVTs, indicating PSG1’s role in angiogenesis during placentation. Currently, I am writing a manuscript of this finding, which I am planning to submit to the FASEB Journal within a few weeks. Project 3: PSG9-mediated immune modulation during pregnancy: We have shown that PSG9, anoth- er member of the human PSG group, is an inducer and an activator of the immune tolerance inducing cytokine TGFβ1. We have demonstrated that PSG9 induces the differentiation FoxP3+ regulatory T cells, which are important for the maintenance of immune tolerance during pregnancy. I was partly involved in this project and published a research article as a co-author. Georgetown University, Department of Biology, Washington, DC, USA. 2012-2013 Project: Investigation of the genes important for cell wall biosynthesis in the pathogenic fungus, Candida glabrata: I have successfully performed screening of a library containing 27 thousand transposon insertion mutants of Candida glabrata for genes that confer altered resistance/sensitivity to caspofungin, an antifungal drug. In the initial screening, I was able to identify 16 genes that increased tolerance and 48 genes that caused increased sensitivity upon disruption. I was partly involved in this project and published a research article as a co-author. Department of Microbiology, University of Dhaka, Bangladesh. 2008-2009. Project: Antibacterial activity of Piper betle extract against common food-borne pathogens: I have shown that the ethanol extract of Betel leaf (Piper betle L.) has antibacterial activity against some foodborne pathogens, including Vibrio cholerae ATCC 6395, E. coli ATCC 25922, E. coli O157:H7 NCTC 12049, Shigella dysenteriae-1 MJ-84 and Staphylococcus aureus ATCC 25923 with minimum inhibitory concentrations 0.625 to 0.75 µg/ml. The betel leaf extract was found to be very stable at higher pH and temperature, suggesting the potential use of the extract as a natural food preservative. I have published a research article about this finding as a co-author. Shemona Rattila Rattila, S., Dunk, C.E., Im, M., Grichenko, O., Zhou, Y., Cohen, M., Yanez-Mo, M., Blois, S.M., Publications Yamada, K.M., Erez, O., Gomez-Lopez, N., Lye, S.J., Hinz, B., Romero, R., and Dveksler, G. (2019). Interaction of pregnancy-specific glycoprotein 1 with integrin α5β1 is a modulator of extravillous trophoblast functions. Cells 2019, 8, 1369.

Rattila, S., Kleefeldt, F., Ballesteros, A., Beltrame, J.S., Ribeiro, M.L., Ergun, S, and Dveksler, G. (2020). Pro-angiogenic effects of pregnancy-specific glycoproteins in endothelial and extravillous trophoblasts. Manuscript is submitted to Reproduction.

Rosenwald, A.G., Arora, G., Ferrandino, R., Gerace, E.L., Mohammednetej, M., Nosair, W., Rattila, S., Subic, A.Z., and Rolfes, R. (2016). Identification of genes in Candida glabrata conferring altered responses to Caspofungin, a cell wall synthesis inhibitor. G3 (Bethesda) 6:2893–2907. doi:10.1534/g3.116.032490.

Jones, K., Ballesteros, A., Mentink-Kane, M., Warren, J., Rattila., S., Malech, H., Kang, E., and Dveksler, G. (2016). PSG9 stimulates increase in FoxP3+ regulatory T-cells through the TGF-β1 pathway. PLoS One. 11(7): e0158050. doi: 10.1371/journal.pone.0158050. Hoque, M.M., Rattila, S., Shishir, M.A., Bari, M.L., Inatsu, Y., and Kawamoto, S. (2011). Anti- bacterial activity of ethanol extract of Betal leaf (Piper betle L.) against some food borne patho- gens. Bangladesh J Microbiol. 28 (2): 58-63.

•Culturing a wide variety of human cell lines: CHO, HEK293T, trophoblast cell lines- HTR8/SVneo Technical and Swan71, endothelial cell lines HMEC, HEEC and HUVEC. Skills •Cell based assays: wound healing, invasion, and in vitro tube formation. •Recombinant protein production, purification, and their functional analysis using enzyme-linked immunosorbent assay (ELISA). •Operating and handling BD LSR II Flow cytometer, fluorescence imaging system Leica AF6000 and digital slide scanner Zeiss Azio Scan.Z1. •Immunoblotting, PCR, qPCR, Site directed mutagenesis and Cloning. •Basic techniques in microbiology

Posters •Rattila, S., Warren, J., Yanez-Mo, M., Dell, A. and Dveksler, G. Pregnancy-specific glycoprotein 1 interacts with extravillous trophoblasts and endothelial cells through its binding to integrin α5β1. 2016. The American Society for Reproductive Immunology 36th Annual meeting. Balti-more, MD.

Academic •Dean’s Award for the academic excellence in B.Sc. •Sumitomo scholarship presented by Sumitomo Corporation , Japan, for the academic excellence in Awards the Secondary School Certificate Examination. •Higher Secondary Certificate Examination under Bangladesh Government Education Board, Rajshahi.

Refferences Gabriela Dveksler, PhD T John Wu, PhD Viqar Syed, PhD (Thesis Supervisor) (Thesis Committee Chair) (Thesis Committee Member) Professor Professor Associate Professor Department of Pathology, Uniformed Department of Obstetrics and Department of Obstetrics and Services University of Gynecology, Uniformed Services Gynecology, Uniformed Services Health Sciences University of Health Sciences. University of Health Sciences Bethesda, MD-20814, USA Bethesda, MD-20814, USA Bethesda, MD-20814, USA (301)295-3332 (301)295-9691 (301)295-3128 [email protected] [email protected] [email protected] UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814-4799 www.usuhs.edu

April 15, 2020

MEMORANDUM FOR RICHARD W. THOMAS, MD, DDS, FACS, PRESIDENT, USUHS

Through: Chair, Board of Regents

SUBJECT: Certification of Graduate Student

The graduate student listed below is presented for certification to receive the Doctor of Philosophy degree effective upon your approval:

Erin M. Sheffels

DOCTOR OF PHILOSOPHY

Molecular and Cell Biology Graduate Program

Attached is the candidate’s certification of successful completion of the Final Examination. Also attached are the Dissertation Approval Form, certification of authorized use of Copyrighted materials, Dissertation Title Page, Dissertation Abstract, and Curriculum Vitae.

Arthur L. Kellermann, MD, MPH Dean, USUHS, School of Medicine

Attachments: As stated

Learning to Care for Those in Harm’s Way UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES SCHOOL OF MEDICINE GRADUATE PROGRAMS Graduate Education Office (A 1045), 4301 Jones Bridge Road, Bethesda, MD 20814

FINAL EXAMINATIONIPRIV ATE DEFENSE FOR THE DEGREE OF DOCTOR OF PHILOSOPHY IN THE MOLECULAR AND CELL BIOLOGY GRADUATE PROGRAM

Name of Student: Erin Sheffe1s

Date of Examination: March 17, 2020 Time: 1:00 PM Place: Room C2015

DECISION OF EXAMINATION COMMITTEE MEMBERS:

PASS FAIL rdvu. Xi,. M ]A" ~ V\ Dr. Teresa Dunn DEPARTMENT OF BIOCHEMISTRY Committee Chairperson

)< ~d Dr. Robert Kortum DEPARTMENT OF PHARMACOLOGY Dissertation Advisor

,~Cr:AIldfeW Snow - DEPARTMENT OF PHARMACOLOGY

CO~

Dr.RaCheiCOX DEPARTMENT OF BIOCHEMISTRY Committe~ ~r rJf: dI t

APPROVAL OF THE DOCTORAL DISSERTATION IN THE MOLECULAR AND CELL BIOLOGY GRADUATE PROGRAM

Title of Dissertation: "The RasGEFs SOSI and SOS2 are Potential Therapeutic Targets in RASDriven Cancers"

Name of Candidate: Erin Sheffels Doctor of Philosophy Degree March 17, 2020

DISSERTATION AND ABSTRACT APPROVED:

DATE:

~y, V1A V--u '" VI Dr. Teresa Dunn DEPARTMENT OF BIOCHEMISTRY Committee Chairperson

Dr. Robert Kortum DEPARTMENT OF PHARMACOLOGY Dissertation Advisor

1\ ew Snow EPARTMENTOFPHARMACOLOGY Committee Member

Dr. Rachel Cox DEPARTMENT OF BIOCHEMISTRY

~;~er Po. :J.~iJ (v';;Wt~) Dr. Ii Luo NATIONAL INSTITUTES OF HEALTH Committee Member

The RasGEFs SOS1 and SOS2 are Potential Therapeutic Targets in RAS-Driven Cancers

by

Erin Sheffels

Dissertation submitted to the Faculty of the Molecular and Cell Biology Graduate Program Uniformed Services University of the Health Sciences In partial fulfillment of the requirements for the degree of Doctor of Philosophy 2020

ABSTRACT

The RasGEFs SOS1 and SOS2 are Potential Therapeutic Targets in RAS-Driven

Cancers:

Erin Sheffels, Doctor of Philosophy, 2020

Thesis directed by: Robert L. Kortum, M.D., Ph.D., Assistant Professor, Department of

Pharmacology and Molecular Therapeutics

The RAS family of genes—HRAS, NRAS, and KRAS—are mutated in about a third of human cancers, with limited treatment options available. Wild-type RAS isoforms cooperate with mutant RAS to promote oncogenic signaling to downstream effectors, proliferation, and transformation. Activation of wild-type RAS involves the

RAS guanine nucleotide exchange factors (RasGEFs) SOS1 and SOS2, creating a dependence on upstream signaling despite constitutive activation of mutant RAS. Two models have been established for activation of wild-type RAS in RAS-mutated cancer. In the first model, constitutively active mutant RAS increases the activity of SOS through an allosteric RAS binding site. The increased activity of SOS leads to activation of wild-type

RAS. In the second model, wild-type RAS is activated by receptor tyrosine kinase (RTK) signaling through SOS. RTK-mediated wild-type RAS signaling supplements mutant

RAS signaling to downstream effects. These models are not mutually exclusive, and both have been demonstrated in RAS-driven cancer cells. However, the relative contribution vi

of each model to wild-type RAS activation and the roles of SOS1 and SOS2 in each model are unknown. We confirmed the previously established requirement for SOS1 in

KRAS-driven proliferation and demonstrated its role in proliferation driven by HRAS and NRAS. We also showed that SOS1 is necessary for RAS-driven transformation for all RAS isoforms. Proliferation required both SOS1 GEF activity and its allosteric RAS binding site, indicating that feedback from RAS to SOS1 is important for mutant-RAS driven proliferation (model 1).

We established a distinct role for SOS2 in mutant RAS-driven signaling as well, despite the perception in the field that SOS2 is redundant to SOS1. Using anchorage- independent growth assays, we showed that SOS2 is required for KRAS-driven transformation, but not HRAS-driven transformation, and intermediately required for

NRAS-driven transformation. We found that SOS2 was critical for RTK-stimulated wild- type RAS and PI3K activation in mouse embryonic fibroblasts expressing mutant RAS and in RAS-mutated cancer cells, regardless of isoform (model 2). We showed that

KRAS-mutated cells were more sensitive to PI3K inhibition than HRAS- and NRAS- mutated cells, paralleling their dependence on SOS2. The hierarchical dependence on

PI3K activity also paralleled the abilities of the RAS isoforms to activate PI3K, with

KRAS activating PI3K poorly and HRAS activating PI3K well. We propose that KRAS- mutated cells require wild-type RAS to activate PI3K due to the relative inability of

KRAS to activate PI3K. Thus, SOS2 contributes to KRAS-driven transformation by activating PI3K through wild-type RAS, protecting cells from anoikis.

Combined inhibition of PI3K and MEK limits KRAS-mutated tumor growth and promotes apoptosis. Unfortunately, high toxicities from direct inhibition of both

vii

pathways prevent the use of this therapeutic strategy in patients. Indirect blocking of

PI3K signaling through inhibition of specific RTKs is effective but resistance mechanisms arise through activation of other RTKs. SOS2 is a common intermediate of

RTKs and SOS2 inhibition is unlikely to cause toxicity in adults, since SOS2 is not necessary for normal cell function. We found that SOS2 deletion synergized with MEK inhibition to limit KRAS-driven anchorage-independent growth, serving as an indirect

PI3K inhibition. Overall, we demonstrated that both SOS1 and SOS2 are potential therapeutic targets in RAS-driven cancers. Due to the stronger requirement for SOS2 over SOS1 in KRAS-driven cancers, we propose that developing inhibitors for SOS2 in addition to current SOS1 inhibitors will improve treatment efficacy. Our results also demonstrate the importance of using three-dimensional anchorage-independent growth assays to evaluate potential targets.

viii Erin Sheffels

CONTACT INFORMATION

Department of Pharmacology and Molecular Therapeutics (301) 295-2102 phone Uniformed Services University of the Health Sciences (763) 486-9684 cell 4301 Jones Bridge Road [email protected] Bethesda, MD 20814

EDUCATION

2015-2020 Ph.D., Molecular and Cell Biology, Uniformed Services University of the Health Sciences Dissertation Title: The RasGEFs SOS1 and SOS2 are Potential Therapeutic Targets in RAS-Driven Cancers Dissertation Advisor: Robert L. Kortum, M.D., Ph.D.

2010-2014 B.A., Biochemistry and Molecular Biology, Reed College Thesis Title: Characterization of telomerase products in Xenopus laevis tissue extracts Thesis Advisor: Janis Shampay, Ph.D.

HONORS AND AWARDS

2019 HJF Fellowship in Medical Sciences 2019 Certificate of Appreciation for contributions to the teaching of USUHS School of Medicine’s Foundations Module 2017 Vice President of Research Travel Award 2014 Phi Beta Kappa induction

PROFESSIONAL SERVICE AND LEADERSHIP

2019-2020 Teaching Assistant for School of Medicine Remedial Biochemistry 2019, 2020 Teaching Assistant for Basic Science in Clerkships 2019 Lab Coordinator for Science, Service, Medicine, Mentoring (S2M2) Jr. 2019-2020 President of the Biomedical Educator Student Interest Group 2018-2019 Teaching Assistant for Alterations of Signal Transduction in Disease 2018-2019 Vice President of the Biomedical Educator Student Interest Group 2018 MCB GEO Open House Coordinator 2017, 2018 USRTP Student Mentor

PUBLICATIONS

1. Erin Sheffels, Nancy E. Sealover, Chenyue Wang, Do Hyung Kim, Isabella A. Vazirani, Elizabeth Lee, Elizabeth Tyrell, Deborah K. Morrison, Ji Luo, and Robert L. Kortum. Oncogenic RAS isoforms show a

1 Erin Sheffels

hierarchical requirement for the guanine nucleotide exchange factor SOS2 to mediate cell transformation. Science Signaling. 2018 September 4; 11(546).

2. Erin Sheffels, Nancy E. Sealover, Patricia L. Theard, and Robert L. Kortum. Anchorage-independent growth conditions reveal a differential SOS2 dependence for transformation and survival in RAS-mutant cancer cells. Small GTPases. 2019 May 7; 1-12.

3. Elizabeth M. Terrell, David E. Durrant, Daniel A. Ritt, Nancy E. Sealover, Erin Sheffels, Russell Spencer- Smith, Dominic Esposito, Yong Zhou, John F. Hancock, Robert L. Kortum, Deborah K. Morrison. Distinct Binding Preferences between Ras and Raf Family Members and the Impact on Oncogenic Ras Signaling. Molecular Cell. 2019 October 3.

RECENT PRESENTATIONS

Poster: 3D culture conditions reveal therapeutic signaling vulnerabilities in RAS-mutant cancer cells. Erin Sheffels, Nancy E. Sealover, Patricia L. Theard, and Robert L. Kortum. ASCB/EMBO Annual Meeting. Washington, D.C. December 2019.

Poster: Anchorage-independent growth conditions reveal a differential SOS2 dependence for transformation and survival in RAS-mutant cancer cells. Erin Sheffels, Nancy E. Sealover, Patricia L. Theard, and Robert L. Kortum. National Cancer Institute 12th Annual Combined Retreat. NCI, Frederick, MD. November 2019.

Oral: RAS Guanine Nucleotide Exchange Factor SOS2 is a Potential Therapeutic Target in KRAS-Mutated Cancers. Erin Sheffels. USU Research Days, Graduate Student Colloquium. USU, Bethesda, MD. May 2019.

Poster: Oncogenic Ras isoforms show a hierarchical requirement for SOS2 to drive transformation. Erin Sheffels, Nancy E. Sealover, Chenyue Wang, Do Hyung Kim, and Robert L. Kortum. ASBMB Special Symposium: Frontiers in Ras Pathobiology and Drug Discovery. September 2018.

Poster: Oncogenic Ras isoforms show a hierarchical requirement for Sos2-dependent PI3K activation to drive transformation. Erin Sheffels, Nancy E. Sealover, Chenyue Wang, Do Hyung Kim, Isabella A. Vazirani, Elizabeth Lee, Elizabeth Tyrell, Deborah K. Morrison, Ji Luo, and Robert L. Kortum. USU Research Days. USU, Bethesda, MD. May 2018.

PROFESSIONAL SOCIETIES

2016-present American Association for the Advancement of Science

VOLUNTEER POSITIONS

2015-present Center Representative, USO Warrior and Family Center Bethesda 2011-present Mentor, FIRST Robotics Team 2498

2 UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814-4799 www.usuhs.edu

April 15, 2020

MEMORANDUM FOR RICHARD W. THOMAS, MD, DDS, FACS, PRESIDENT, USUHS

Through: Chair, Board of Regents

SUBJECT: Certification of Graduate Student

The graduate student listed below is presented for certification to receive the Doctor of Philosophy degree effective upon your approval:

Deborah M. Stiffler

DOCTOR OF PHILOSOPHY

Emerging Infectious Diseases Graduate Program

Attached is the candidate’s certification of successful completion of the Final Examination. Also attached are the Dissertation Approval Form, certification of authorized use of Copyrighted materials, Dissertation Title Page, Dissertation Abstract, and Curriculum Vitae.

Arthur L. Kellermann, MD, MPH Dean, USUHS, School of Medicine

Attachments: As stated

Learning to Care for Those in Harm’s Way UNIFORMED SERVICES UNNERSnY OF THE HEALTH SCIENCES SCHOOL OF MEDICINE GRADUATE PROGRAMS Graduate Education Office (A 1045), 4301 Jones Bridge Road, Bethesda, MD 20814

FINAL EXAMINATION/PRN ATE DEFENSE FOR THE DEGREE OF DOCTOR OF PHILOSOPHY IN THE EMERGING INFECTIOUS DISEASES GRADUATE PROGRAM

Name of Student: Deborah Stiffler

Date of Examination: December 12,2019 Time: 10:00 AM Place: Room A2074

DECISION OF EXAMINATION COMMITTEE MEMBERS:

PASS FAIL

/~---~~~J L Dr. Stephen Davies DEPARTMENT OF MICROBIOLOGY & IMMUNOLOGY Committee Chairperson

i.-: Dr. V. Ann Stewart DEPARTMENT OF MICROBIOLOGY & IMMUNOLOGY Dissertation Advisor

Dr. Kim Williamson DEPARTMENT OF MICROBIOLOGY & IMMUNOLOGY Committee Member

~'nr:J"el1Il'e;Rusiecki -X- DEPARTMENT OF PREVENTIVE MEDICINE & BIOSTATISTICS Committee Member

. ------UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES SCHOOL OF MEDICINE GRADUATE PROGRAMS Graduate Education Office (A 1045), 4301 Jones Bridge Road, Bethesda, MD 20814

APPROVAL OF THE DOCTORAL DISSERTATION IN THE EMERGING INFECTIOUS DISEASES GRADUATE PROGRAM

Title of Dissertation: "Evaluation of Factors Associated with Increased Plasmodiumfalciparum Gametocyte-Specific Transcripts in Two Populations from Sub-Saharan Africa"

Name of Candidate: Deborah Stiffler Doctor of Philosophy Degree December 12, 2019

DISSERTATION AND ABSTRACT APPROVED:

DATE:

Dr. Stephen Davies DEPARTMENT OF MICROBIOLOGY & IMMUNOLOGY Committee Chairperson

Dr. V. Ann Stewart DEPARTMENT OF MICROBIOLOGY & IMMUNOLOGY Dissertation Advisor

Dr. Kim Williamson DEPARTMENT OF MICROBIOLOGY & IMMUNOLOGY Committee Member COPYJUGHTSTATEMENT

The author hereby certifies that the use of any copyrighted material in the dissertation manuscript entitled: "Evaluation of Factors Associated with Increased Plasmodium

Jalciparum Gametocyte-Specific Transcripts in Two Populations from Sub-Saharan

Africa" is appropriately acknowledged and, beyond brief excerpts, is with the permission of the copyright owner.

Deborah M. Stiffler

May 15,2020

DISCLAIMER

The views presented here are those of the author and are not to be construed as official or reflecting the views of the Uniformed Services University of the Health

Sciences, the Department of Defense or the U.S. Government.

Vlll

------EVALUATION OF FACTORS ASSOCIATED WITH INCREASED

PLASMODIUM FALCIPARUM GAMETOCYTE-SPECIFIC TRANSCRIPTS IN

TWO POPULATIONS FROM SUB-SAHARAN AFRICA

by

Deborah M. Stiffler

Dissertation submitted to the Faculty of the Emerging Infectious Diseases (EID) Graduate Program Uniformed Services University of the Health Sciences In partial fulfillment of the requirements for the degree of Doctor of Philosophy 2020 ABSTRACT

Evaluation of Factors Associated with Increased Plasmodiumjalciparum Gametocyte-

Specific Transcripts in Two Populations from sub-Saharan Africa

Deborah M. Stiffler, Doctor of Philosophy, 2020

Thesis directed by: V. Ann Stewart, D.V.M., Ph.D., Professor, Department of Preventive

Medicine and Biostatistics, Division of Tropical Public Health

Malaria is a major cause of morbidity and mortality in sub-Saharan Africa due to the high prevalence of the protozoan parasite, Plasmodiumjalciparum in that region.

Molecular methods for malaria detection can be useful in identifying individuals with sub-microscopic infections, especially those who harbor the sexual and transmissible gametocyte life stage. To identify individuals with sub-microscopic P.jalciparum gametocytemias, we developed a panel of qPCR assays that quantify gametocyte stage- specific RNA transcripts. These assays were validated using both highly synchronized cultured gametocytes and a small subset of human field samples before being used to characterize gametocyte carriage in two larger human study populations.

In the first study population, gametocyte transcripts were quantified in adults from the Kisumu region of Kenya who had asymptomatic malaria infections and were seeking voluntary testing for HIV. In this population, approximately 20% of individuals had detectable gametocyte-specific transcripts. Additionally, in individuals who were

IX previously found to be malaria positive, HIV positivity was associated with an increased risk of gametocyte positivity (relative risk = 1.820). Among gametocyte positive individuals, those who were HIV-positive had higher copy numbers of gametocyte transcripts. These data suggest that HIV-positive individuals may be at a higher risk of transmitting malaria to mosquitoes, although standard membrane feeding assays are needed to confirm that the increase in transcripts correlates to an increase in infectivity.

In the second study population, these assays were used to characterize gametocyte transcripts and asexual transcripts in children under 5 years of age who had been treated with artemether-lumefantrine (AL) for uncomplicated malaria. In this cohort, we found that AL differentially affects gametocyte and asexual ring-stage transcripts, and that a majority of children maintained ring-stage transcripts through the period of follow-up.

Although the epidemiological significance of this is not yet known, these findings suggest that AL may not be capable of full clearance of P.jalciparum infections. Several factors were also associated with gametocyte transcript positivity at one- or two-weeks post-treatment, including a higher gametocyte burden during the first 48 hours of follow- up, and a large drop in hemoglobin levels in the first week of follow-up.

Overall, these data highlighted the utility of this qPCR panel in detecting stage- specific transcripts and provide important insight into potential risk factors for P. falciparum gametocyte carriage in regions with high malaria transmission.

x Deborah M. Stiffler [email protected]

EDUCATION

UniformedServices University of the Health Sciences Bethesda, Maryland Ph.D., Emerging Infectious Diseases Program May2020 Dissertation Title: "Evaluation of factorsassociated with increased Plasmodium falciparum gametocyte carriage in two populations fromsub-Saharan Africa"

St. Mary's College of Maryland St. Mary's City,Maryland B.A. in Biology, with minor in Music Performance,cum laude May2010

RESEARCH EXPERIENCE

Dartmouth College Hanover, New Hampshire Graduate Student, Molecularand CellularBiology Program 2012-2013 • Proficientin techniques such as ELISA, conventional PCR, RT-qPCR, gel electrophoresis, DNA and RNA extraction, and mammalian cell culture • Experienced working with murine models, performing orbital bleeds, tailvein injections, intradermal and intraperitonealinjections, dissection techniques, and bone marrow isolation

Johns HopkinsUniversity Scho ol of Medicine Baltimore, Maryland Research Technologist,Center for InheritedDisease Research 2011-2012 • Conducted Illumina Infinium, Golden Gate, and BeadXpress genotypingassays, closely tracking projects to maintain a high level of qualitycontrol

St. Mary's College of Maryland St. Mary's City,Maryland St.Mary's Project Capstone withDr. SamanthaElliott 2009-2010 • Designed and conducted year-long capstone research thesis titled "Survival assays in EL T-2 and EL T-7 knockdown Caenorhabditise/egans infectedwith Pseudomonas aeruginosa"

HONORS AND AWARDS

Third Place Winner and "People's Choice" Audience Favorite Award, Three Minute Thesis Competition, UniformedServices Universityof the Health Sciences, 2018

SanfordResearch Fellowship in Tropical Medicine, Uniformed ServicesUniversity of the Health Sciences, 2016

Board of Trustees Award, St. Mary's College of Maryland, 2010

Deborah Stiffler 1 PEER-REVIEWED PUBLICATIONS

Elliott SL, Sturgeon CR, Travers DM, Montgomery Me. Mode of bacterial pathogenesis determines phenotype in elt-2 and elt-Z RNAi Caenorhabditis elegans. Dev Comp Immunol. 2011 May;3S(S):S21-4. Epub 2010 Dec 17.

MANUSCRIPTSIN PREPARATION

Stiffler OS,Kifude CM,Rockabrand OM,Oyieko JN,Luckhart S,Stewart VA."HIV-l Infection Increases the Prevalence and Quantity of Plasmodium falciparum Gametocyte-Specific RNA Transcripts in Chronically Malaria Infected Adults in Western Kenya,"expected submission January 2020.

CONFERENCEPRESENTATIONS

"Measuring Gene Expression to Evaluate the Effect of Artemether-Lumefantrine on Parasitemia and Gametocytemia in Zambian Children with Uncomplicated P. falciparum Malaria," Poster presented at the Future of Malaria Research Symposium, 18 November 2019, and at the 68th Annual Meeting of the American Society for Tropical Medicine and Hygiene, National Harbor, Maryland, 23 November 2019.

"Quantification of stage-specific Plasmodium falciparum gametocyte RNAtranscripts to evaluate the impact of HIVstatus on gametocytemia in Western Kenya," Poster presented for the Young Investigator's Competition and at the 67th Annual Meeting ofthe American Society for Tropical Medicine and Hygiene, New Orleans, Louisiana, 28-29 October 2018.

"Characterizing Plasmodium falciparum gametocyte gene expression in a cohort of asymptomatically-infected adults in Western Kenya," Poster presented at the 66th Annual Meeting of the American SOCietyfor Tropical Medicine and Hygiene, Baltimore, Maryland, 8 November 2017.

"Amechanistic approach to understanding the effects of HIV-related inflammation on Plasmodium falciparum gametocyte development." Poster presented at the 66th Annual Meeting of the American Society for Tropical Medicine and Hygiene, Baltimore, Maryland, 7 November 2017.

TEACHINGEXPERIENCE

Uniformed Services University of the Health Sciences Bethesda, Maryland Department of Preventative Medicine and Biostatistics 2013-present Division of Tropical Public Health • Assisted with teaching the diagnosis of parasites to a wide audience, including medical students, entomologists, and infectious disease clinicians • Prepared teaching materials for laboratory experiences, including parasite samples and demonstration slides

Deborah Stiffler 2 UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814-4799 www.usuhs.edu

April 15, 2020

MEMORANDUM FOR RICHARD W. THOMAS, MD, DDS, FACS, PRESIDENT, USUHS

Through: Chair, Board of Regents

SUBJECT: Certification of Graduate Student

The graduate student listed below is presented for certification to receive the Doctor of Philosophy degree effective upon your approval:

Patricia Anh Thu Vu

DOCTOR OF PHILOSOPHY

Physician Scientist Program/ Neuroscience Graduate Program

Attached is the candidate’s certification of successful completion of the Final Examination. Also attached are the Dissertation Approval Form, certification of authorized use of Copyrighted materials, Dissertation Title Page, Dissertation Abstract, and Curriculum Vitae.

Arthur L. Kellermann, MD, MPH Dean, USUHS, School of Medicine

Attachments: As stated

Learning to Care for Those in Harm’s Way

COPYRIGHT STATEMENT

The author hereby certifies that the use of any copyrighted material in the dissertation manuscript entitled: Functional Changes in Mouse Behavior Following Three Different

Models of Traumatic Brain Injury is appropriately acknowledged and, beyond brief excerpts, is with the permission of the copyright owner.

______

Patricia Anh Thu Vu, 2d Lt, USAF, MSC

March 24, 2020

DISCLAIMER

The views presented here are those of the author and are not to be construed as official or reflecting the views of the Uniformed Services University of the Health Sciences, the

Department of Defense or the U.S. Government.

ix

FUNCTIONAL CHANGES IN MOUSE BEHAVIOR FOLLOWING THREE DIFFERENT

MODELS OF TRAUMATIC BRAIN INJURY

by

Patricia Anh Thu Vu, 2d Lt, USAF, MSC

Dissertation submitted to the Faculty of the Neuroscience Graduate Program Uniformed Services University of the Health Sciences In partial fulfillment of the requirements for the degree of Doctor of Philosophy 2020 ABSTRACT

Functional Changes in Mouse Behavior Following Three Different Models of Traumatic Brain

Injury

Patricia Anh Thu Vu, MD, PhD, 2020

Thesis Advisor: Dr. Joseph T. McCabe, PhD

Mild traumatic brain injury (mTBI) remains a challenge for military and veteran health systems as well as global health. Pre-clinical models that better represent the mechanism of different types of mTBI are needed for elucidating the physiological consequences of injury and their behavioral outcomes. Thus, three closed-head mTBI mouse models were utilized to assess the effects of common types of mTBI seen in service members: blast-induced traumatic brain injury (BTBI), single concussive brain injury (CBI), and frontal repetitive CBI (frCBI). After

BTBI and CBI, mice showed transient hypoactivity in home-cage activities 24 hours post-injury

(PI), which returned to baseline by 48 to 72 hours PI. BTBI mice demonstrated hypoactivity in the open field (OF) and decreased anxiety at 24 hours PI. CBI mice, in contrast, demonstrated decreased anxiety at 24 and 72 hours PI in the OF. frCBI resulted in decreased freezing behavior in response to the fear conditioning context and cue. Sex differences were noted with male mice showing less freezing behavior than female mice. Hyperactivity in the OF and elevated zero maze (EZM) was seen in all frCBI mice. In the EZM, uninjured female mice that were exposed to foot-shocks showed increased anxiety relative to non-shocked mice; however, shocked injured female frCBI mice did not demonstrate the same behavioral change. In summary, a single BTBI or CBI resulted in transient hypoactivity that may indicate a window of increased need to rest and vulnerability to repeat injury. Some differences were observed between BTBI and CBI mice; however, direct comparisons were not possible. Hyperactivity in frCBI mice may be impulsive in nature and may be mediated by neuroinflammatory changes. There was increased inflammation in cortical regions underlying the locations of direct impact in frCBI mice. Pre-clinical models continue to provide valuable insight into the mechanisms by which debilitating symptoms occur as well as provide evidence for a window of time during which repeated injury can result in worse outcomes. Data from such models have huge implications in improving return-to-duty policies to promote recovery in service members who have sustained mTBI and to prevent further injury. Patricia Anh Thu Vu Second Lieutenant, United States Air Force, Medical Service Corps [email protected]

Education

Uniformed Services University Jun 2013-May 2020 • Doctor of Medicine • Doctor of Philosophy, Neuroscience

University of California, Irvine Sep 2009-Jun 2011 • Bachelor of Science, Neurobiology • Summa Cum Laude

De Anza College Sep 2007-Aug 2009 • Completed academic units for transfer

Research Experience

Neuroscience PhD Candidate, PI: Dr. Joseph McCabe Aug 2014-Mar 2020 Uniformed Services University, Bethesda, Maryland • Designed mouse models of traumatic brain injury • Performed histological studies of post-mortem brain tissue • Assessed for biomarkers implicated in neuroinflammation post-injury • Assessed for behavioral outcomes post-injury

Student Research Assistant, PI: Dr. Ron Frostig Mar 2011-Mar 2013 University of California, Irvine • Studied neuroplasticity of sensory cortex in pre-clincial rodent model for stroke • Performed behavioral, surgical, and histological experiments

Educational Activities

Traumatic Brain Injury Course, Guest Lecturer 5 Jan 2017 Uniformed Services University, Bethesda, Maryland • Taught 9 Neuroscience PhD Students about the implications of the orexin system in excessive daytime sleepiness following traumatic brain injury

The Princeton Review, MCAT Organic Chemistry Instructor Oct 2012-Mar 2013 Irvine, California • Frequency: Approximately once a week for 2 hours • Taught basic principles of Organic Chemistry to 15-20 undergraduate students Professional Membership and Service

USU Volunteer Digest Coordinator & Editor Apr 2019-Mar 2020 Uniformed Services University, Bethesda, Maryland • Worked with medical/graduate students and residents to promote community service • Facilitated mentorships and collaborations between medical students and residents • Created and distrubuted monthly volunteer newsletter with information on events • Served as point of contact for students interested in volunteer opportunities

Graduate Student Council, Representative Aug 2016-Aug 2017 Uniformed Services University, Bethesda, Maryland • Represented graduate student interest in Neuroscience and MD/PhD Programs • Advocated for graduate students in meetings with the Dean of the School of Medicine • Edited and improved Dean’s Climate Survey to better capture academic environment • Created a checklist for MD/PhD students to facilitate academic transitions • Organized social events to boost graduate student morale and sense of community

Publications

Peer reviewed: Vu PA, Tucker LB, Liu J, McNamara EH, Tran T, Fu AH, Kim Y, McCabe JT. Transient disruption of mouse home cage activities and assessment of orexin immunoreactivity following concussive- or blast-induced brain injury. Brain Res. 2018 Dec 1;1700:138-151. doi: 10.1016/j.brainres.2018.08.034. Epub 2018 Aug 31.

Abstracts and Presentations

Posters: National/International Meetings Vu PA, Tucker LB, Liu J, McNamara EH, Tran T, Fu AH, Kim Y, McCabe JT. Transient disprution of home cage activities and assessment of orexin immunoreactivity following concussive or blast- induced brain injury. Poster presented at: Society for Neuroscience Annual Meeting; 2016 12-16 Nov; San Diego

Local/Regional Meetings Moberly B, MD, Vu P, Gray J, MD, Shimeall W, MD. With Bated Breath: Pulmonary Embolism as the Presenting Sign of Systemic Lupus Erythematosus in a Young, Active Duty Patient. Poster presented at: 2018 U.S. Navy ACP Chapter Meeting; 2018 30 Nov-1 Dec; Uniformed Services University of the Health Sciences, Maryland

Vu PA, Tucker LB, Liu J, McNamara EH, Tran T, Fu AH, Kim Y, McCabe JT.Transient disruption of home cage activities and reduction in orexin immunoreactivity following concussive or blast- induced brain injury. Poster presented at: National Capital Area TBI Research Symposium; 2016 4-5 Apr; Bethesda, Maryland

Vu 2 of 2 TAB 12 Degree Conferrals Postgraduate Dental College UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES POSTGRADUATE DENTAL COLLEGE SOUTHERN REGION OFFICE 2787 WINFIELD SCOTT ROAD, SUITE 220 JBSA FORT SAM HOUSTON, TEXAS 78234-7510 https://www.usuhs.edu/pdc

9 March 2020

MEMORANDUM FOR: PRESIDENT, USUHS

THROUGH: BOARD OF REGENTS

SUBJECT: Certification of Postgraduate Dental Students

The Postgraduate Dental College students listed below are scheduled to complete their programs of instruction by June 30, 2020. It is requested that the Executive Dean be authorize to award or withhold the Master of Science in Oral Biology degree based upon their successful completion of program requirements. The 2020 Postgraduate Dental College students and their research projects are listed below:

Army Postgraduate Dental School

COMPREHENSIVE DENTISTRY – FORT BRAGG, NC

LTC Elizabeth R. Oates, DC, USA – Evaluation of the Fit and Accuracy of RPD Frameworks Using Two Different Types of Impressions Materials and CAD/CAM Technology

MAJ Ross K. Cook, DC, USA – The Use of a Pressure Cooker to Achieve Sterilization for an Expeditionary Environment

MAJ Jason C. LaCourse, DC, USA – The Anti-Bacterial Efficacy of Activated Charcoal Toothbrushes on S. Mutans

CPT(P) Adam D. Bennett, DC, USA – Assessing Changes in Opioid Prescribing Habits of the US Army Dental Corps Providers Following Completion of Opioid Prescriber Safety Training

CPT Wing Tat Chan, DC, Canadian Forces – Knowledge and Utilization of Direct Pulp Capping Procedures Among Dentists

CPT Tania M. Sanchez Dominguez, DC, USA – Opioid Prescription Rate by Military Dentists in Fort Bragg, NC 2009-2018

CPT Andrew Seun, DC, USA – Effect of Storage Temperature on Tensile Bond Strength of a Self-Etch Dentin Bonding Agent

COMPREHENSIVE DENTISTRY – FORT HOOD, TX

MAJ Lloyd Alexander Ancman, DC, USA – Prevalence of Early Childhood Caries and Its Related Risk Factors in the United States Military Dependent Pediatric Population

Learning to Care for Those in Harms’ Way MAJ Daniel D. Becker, DC, USA – Differences in Shear Bond Strength Between Resin Composites and Glass Ionomers in the Open Sandwich Technique Using Different Generations of Adhesives

MAJ George Louis Hauser, DC, USA – Evaluation of Vitamin D Deficiency, Dental Caries, and Inflammatory Bowel Disease Within the Active Duty Population

MAJ Jesse Benjamin Norris, DC, USA – Polishability of Four Composite CAD/CAM Materials

MAJ Jarred Lloyd Price, DC, USA – CEREC Omnicam Image Quality Following Multiple Cycles of Dry Heat Sterilization

MAJ Donald George Rice, DC, USA – Fracture Resistance to Oblique Forces of Titanium-Based Implant Supported Lithium Disilicate Monolithic Crowns

MAJ Steffan Thomas, DC, Canadian Forces – The Histological Analysis of Tooth Cementum Annulations to Determine Age and Season of Death of Active Duty Military Personnel: A Comparative Study Using Brightfield, Polarizing and Phase Contrast Microscopy

COMPREHENSIVE DENTISTRY – SCHOFIELD BARRACKS, HI

MAJ Gamal A. Baker, DC, USA – Patient-Perceived Success of Three Common Prostheses in Oral Appliance Therapy of Obstructive Sleep Apnea

MAJ Christie Inae Lee, DC, USA – Comparison of Degree of Conversion of Bulk-Fill Composites and Filtek Supreme Ultra as the Conventional Composite

MAJ Mitchell James Lee Oliver, DC, USA – The Effect of Depth-of-Cure on the Flexural Strength of Dental Bulk-Fill Composites

CPT Taylor Akiko Gaerlan Tokunaga, DC, USA – In-Vitro Comparison of Fracture and Fatigue Resistance Between Implant-Supported Restorations Utilizing CAD/CAM System TiBase

ENDODONTICS – FORT BRAGG, NC

MAJ Kony Park, DC, USA – Evaluation of Re-Treatability of 3 Endodontic Sealers: AH Plus, EndoSequence BC Sealer, and HiFlow EndoSequence BC Sealer

MAJ Alexandra Rihani, DC, USA – A Survey of Surgical Trends Among Military Endodontists

CPT Matthew Massey, DC, USA – A Survey of Decision Making Analysis When MB2 Cannot be Located in Maxillary First Molars

ENDODONTICS – FORT GORDON, GA CPT Jose R. Burgos, DC, USA – Root Canal Treatment Versus Vital Pulp Therapy After Carious Exposure: An Analysis of the Cost-Effectiveness in the United States

CPT Kristel Burgos, DC, USA – Assessment of Patient's Perception of CBCT and Endodontic Treatment

CPT Khine Christine Zin Htet, DC, USA – Regaining Patency with Bioceramics During Retreatments Based on Method of Sealer Placement CPT Jason Michael Umbach – Surface Integrity of Orthograde MTA Obturation Following Targeted Endodontic Microsurgery

PERIODONTICS – FORT GORDON, GA

MAJ Daniel J. Broadway, DC, USA – Ridge Preservation: Evaluation of Keratinized Tissue Width

MAJ Alicia Y. Choi, DC, USA – Laser Ridge Preservation: A Proof-of-Principle Pilot Study

CPT Anthony A. Vargas, DC, USA – Time of Exposure: A Major Factor in the Attachment of Bacteria

CPT James P. Wilson, DC, USA – Frequency of Adequate Mesiodistal Space and Faciolingual Alveolar Width for Implant Placement at Human Anterior Tooth Positions

PROSTHODONTICS – FORT GORDON, GA

MAJ Joshua Thomas Sparks, DC, USA – Non-Thermal Gas Plasma Treatment of Diamond Coated Dental Burs

MAJ Joshua Rand Waldron, DC, USA – Effect of Anodized Titanium Abutments on Color of Lithium Disilicate Implant Crowns

CPT Ryan James Coello, DC, USA – The Effect of Arch Form on Connector Size Requirements in Long Span Anterior Zirconia Fixed Dental Prostheses

CPT Jenny Juyung Oh, DC, USA – The Effect of Various Cleaning Methods on Resin Bond Strength of Saliva-Contaminated Ceramic Surfaces

Naval Postgraduate Dental School Navy Medicine Professional Development Center Bethesda, MD

COMPREHENSIVE DENTISTRY

CDR Andrew D. Silvestri, DC, USN – The Effects of Computer-Aided Antero-Posterior Forehead Movement on Ratings of Facial Attractiveness

LCDR Sara A. Chilcutt, DC, USN – The Effects of a Therapy Dog Intervention on Distress in Adult Patients Undergoing Dental Procedures: A Pilot Study

LCDR Christian P. Lares, DC, USN – Fracture Resistance of All Ceramic Restorations on Mandibular First Molars After Endodontic Access and Repair

LCDR Omeed A. Rezaie Tirabadi, DC, USN – Stress and Burnout in Post-Graduate Dental Residency Training

LCDR Jennifer C. Steigerwald, DC, USN – Evaluating and Describing Changes in Heart Rate Variability in Patients Treated for Moderate Obstructive Sleep Apnea

LCDR David S. Yi, DC, USN – Stress and Burnout in Dental Residents LT Wei Liu, DC, USN – Effect of Ultrasonic Vibration on the Presence of Voids in Core Buildup Materials

ENDODONTICS

LCDR Alyse D. Fleming, DC, USN – The Effect of Smear Layer on Endodontic Outcomes

LCDR Kristofer S. Harris, DC, USN – Chairside Sterilization of Files and Gutta-Percha Cones Using 8.25% Sodium Hypochlorite

LCDR Ryan A. Hershey, DC, USN – Comparison in Utilizing the Reference Calibration Method and Standard Calibration Method for Digital Calibration of Periapical Intraoral Radiographs

LCDR Michael J. Lewis, DC, USN – Outcome of Endodontically Treated Teeth Diagnosed with “Cracked Tooth”

LCDR Russell L. Neal, DC, USN – Comparative Evaluation of Preoperative Methylprednisolone or Ibuprofen on Anesthetic Efficacy of Inferior Alveolar Nerve Blocks in Patients with Symptomatic Irreversible Pulpitis

ORAL AND MAXILLOFACIAL PATHOLOGY

LCDR Kerry B. Baumann, DC, USN – Distribution of Human Tongue Fat and Obstructive Sleep Apnea

LCDR Matthew E. Seedall, DC, USN – Next Generation Sequencing to Identify Molecular Driver Events in Salivary Acinic Cell Carcinomas

OROFACIAL PAIN

Maj John E. Dinan, USAF, DC – Pain Catastrophizing in the Orofacial Pain Population

PERIODONTICS LCDR Eric R. Draper, DC, USN – Systemic Versus Tissue-Specific Immunity During Early Initiating Events of Chronic Graft-Versus-Host Disease

LCDR Thien T. Nguyen, DC, USN – Dental Erosion and Gingival Health in US Service Members and Retirees Diagnosed with Gastroesophageal Reflux Disease

LT Allison D. Weinberg, DC, USN – Characterization of Titanium Implant Surface after ND:YAG Laser Treatment

PROSTHODONTICS LCDR Gabrielle K. Jung, DC, USN – In-Vitro Analysis of Attachment of Candida Albicans to Denture Base Acrylic Resin Fabricated by Three Different Methods

LT Diewitt Duong, DC, USN – Effect of Arch Form on the Accuracy of Intraoral Scanners CDR Air Force Postgraduate Dental School

COMPREHENSIVE DENTISTRY – KEESLER AFB, MS Maj Alisha Chantell Brown, USAF, DC – Composite Warming Effects on the Mechanical Properties of Bulk Fills

LCDR Scott Daniel Eckhart, USCG – The Erosive Potential of Sugar-Free Waters on Cervical Dentin

MAJ Iwona Rusiecka, DC, Canadian Forces – Marginal Fit Comparison of Crowns Fabricated with Two CAD/CAM Systems

CPT Jamie L. Greenwell, DC, USA – Effect of Diode Laser Irradiation on Resin-Dentin Microtensile Bond Strength

COMPREHENSIVE DENTISTRY – JBSA LACKLAND, TX

Lt Col Kibrom T. Mehari, USAF, DC – Bond Strength of Resin Cements to Zirconia After Surface Treatments

Maj Darin Bateman, USAF, DC – Comparative Evaluation of Cone Beam Computed Tomography (CBCT)

LCDR Andrew J. Knudson, DC, USN – Devising a Manpower Model from USAF Recruit Dental Needs

Capt Job Torres-Gomez, USAF, DC – Management of Dental Anxiety via Distraction Technique

Capt Nicole Wirth, USAF, DC – Efficacy of Various Sterilization Techniques on Diamond-Coated Dental Burs

ENDODONTICS – KEESLER AFB, MS

Maj Scott Arthur Bryant, USAF, DC – A Comparison of Single Cone Obturation Quality and Sealer Waste Between Three Sealer Application Techniques

Maj Jason Allen Rose, USAF, DC – Evaluation of Extra-Canal Apical Tissue Pressure Generated by the Gentle Wave System Compared to Three Traditional Techniques

ENDODONTICS – JBSA LACKLAND, TX

Maj Andrea L. DuFour, USAF, DC – Targeted Endodontic Microsurgery Trepine Bur and Endodontic Microsurgery Carbide Bur Root End Appearance After Resection in Porcine Teeth

Maj Bracken Gamble Smith, USAF, DC – Targeted Endodontic Microsurgery: Implications of the Greater Palatine Artery PROSTHODONTICS – JBSA LACKLAND, TX

Maj Troy M. Decker, USAF, DC – Effect of Axial Wall Height and Total Occlusal Convergence on Retention of Lithium Disilicate Adhesively Bonded to Lithium Discilicate

Maj Joshua M. Nardone, USAF, DC – Effect of Axial Wall Height and Total Occlusal Convergence of VITA Enamic Implant Abutments on the Retention of Adhesively Bonded VITA Enamic Crowns

Maj Melissa S. Thomas, USAF, DC – Three-Dimensional Accuracy of Implant Placement Related to the Use of Guide Sleeves

Maj Jessamy J. Thornton, USAF, DC – Oxirane/Acrylate Interpenetrating Network Resins Using Multifunctional Oxiranes and Difunctional Acrylates

Maj Joshua A. Vess, USAF, DC – A Prospective Analysis of the Embedded Health Engagement Team Concept: New Horizons 2019

TRI-SERVICE ORTHODONTIC RESIDENCY PROGRAM – JBSA LACKLAND, TX

MAJ Andrea C. Alicea, DC, USA – An In-Vitro Study on Aligner Rotational "Lag" with In-Office Clear Aligner Therapy

Maj Andrew P. Benfield, USAF, DC – Shear Bond Strength Between Opal Seal and Flash Free Brackets

LCDR Gregory M. Gittleman, USN, DC – The Flipped Classroom in Orthodontic Residency Programs

MAJ James P. Martineau, DC, USA – The Effectiveness of Cleaning and Sterilizing Reciprocal Orthodontic Interproximal Reduction Strips for Patient Re-use: A Comparative Study

Maj Duy Q. Nguyen, USAF, DC – Effects of Toothbrush Abrasion on Biofilm Retention in Thermoplastic Orthodontic Appliances

Capt John R. Ensley, USAF, DC – The Effect of Vaping on Force Degradation of Orthodontic Elastomeric Chain

If requested by the Board, copies of research manuscripts will be available upon completion of the program.

Respectfully,

Thomas R. Schneid, DMD, MS Executive Dean and Professor Postgraduate Dental College TAB 13 Degree Conferrals College of Allied Health Sciences

UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES COLLEGE OF ALLIED HEALTH SCIENCES 2787 WINFIELD SCOTT ROAD, BLDG 2398 JBSA FT. SAM HOUSTON, TEXAS 78234

April 15, 2020

MEMORANDUM FOR PRESIDENT UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES

THROUGH: BOARD OF REGENTS

SUBJECT: College of Allied Health Sciences (CAHS) Graduates

The College of Allied Health Sciences’ students identified on page two through five of this document are projected to complete the indicated program, meeting all academic, clinical and scholarly requirements to graduate in May 2020, for the degree indicated. The Dean, CAHS, requests the President of the Uniformed Services University of the Health Sciences, award the following students the Associate or Bachelors of Science in Health Sciences degree, as listed, pending completion of degree requirements.

______Lula Westrup Pelayo. Ph.D., RN, FAAN Richard W. Thomas, MD, DDS, FACS Chief Academic Officer and Dean, CAHS President

Approved / Not Approved ______Date

College of Allied Health Sciences Projected Graduates – May 2020

Last Name First Name Initial Branch Rank Degree Program/Major

Aiello Matthew A. Army E-4 BSHS Medical Laboratory Technician Alston Robert F. Army E-3 ASHS Public Health Technician Ausman Cameron D. Navy E-5 ASHS Public Health Technician Bagaporo Theresa M. Army E-5 BSHS Medical Laboratory Technician Education & Training Banlaoi Kathleen M. Navy E-6 ASHS Administration & Leadership Boddy Mark L. Navy E-5 ASHS Public Health Technician Bonagofski Luke G. Army E-3 BSHS Medical Laboratory Technician Browder Sean M. Navy E-5 ASHS Public Health Technician Butler Hayley N. Navy E-4 ASHS Public Health Technician Calhoun Malia C. Navy E-2 ASHS Public Health Technician Castillo Isaiah J. Navy E-4 ASHS Public Health Technician Castrillon Erick Army E-4 ASHS Medical Laboratory Technician Cedillo Jacob N. Army E-4 BSHS Medical Laboratory Technician Chen Jia Li Navy E-3 ASHS Medical Laboratory Technician Chen Li Si Navy E-3 BSHS Medical Laboratory Technician Cherian Rebeca V. Army E-4 BSHS Medical Laboratory Technician Contreras Abigael A. Army E-4 ASHS Occupational Therapy Assistant Dancel Angelica I. Navy E-4 BSHS Medical Laboratory Technician Air Davidson Kasey C. Force E-5 BSHS Neurodiagnostic Technician Education & Training Day Julia A. Navy E-5 ASHS Administration & Leadership Decoudres Jasmine C. Army E-5 ASHS Occupational Therapy Assistant Delgadillo Giovanni Army E4 BSHS Medical Laboratory Technician Air Dickert Amanda M. Force E-4 BSHS Nuclear Medicine Technician Air Estrada Carina Force E-5 BSHS Nuclear Medicine Technician Flores Plinio J. Navy E-3 BSHS Medical Laboratory Technician Gambito Marvin A. Navy E-6 ASHS Public Health Technician Education & Training Garcia Samuel L. Army E-6 ASHS Administration & Leadership

Last Name First Name Initial Branch Rank Degree Program/Major Garner Terrill R. Army E-5 BSHS Medical Laboratory Technician Glover Denzel E. Army E-4 BSHS Medical Laboratory Technician Godwin Jacqueline M. Army E-6 ASHS Occupational Therapy Assistant Harden Desiree D. Army E-5 BSHS Nuclear Medicine Technician Hernandez Rafaela Navy E-5 ASHS Public Health Technician Horton Zoe C. Army E-3 ASHS Medical Laboratory Technician Hughes Andrew P. Navy E-3 BSHS Medical Laboratory Technician Iselaiye Olabisi A. Army E-4 ASHS Public Health Technician Jackson Maya A. Army E-3 ASHS Public Health Technician Education & Training Jones Morgann K. Army E-6 ASHS Administration & Leadership Jubay Ramir D. Navy E-3 BSHS Medical Laboratory Technician Kociuba Brittany G. Army E-4 BSHS Medical Laboratory Technician Lewis Erin N. Army E-4 BSHS Medical Laboratory Technician Air Little Aleah J. Force E-4 ASHS Occupational Therapy Assistant Marcotte Dane S. Navy E-5 ASHS Public Health Technician Public Health Technician Martinez Joel J. Navy E-5 ASHS Matthews Sashni-Cole A. Navy E4 ASHS Histology Technician Coast McVeigh Joseph J. Guard E-6 ASHS Public Health Technician Mosley Trey E. Army E-4 ASHS Occupational Therapy Assistant Navarrete Mario Army E-4 BSHS Medical Laboratory Technician Education & Training Nichols Daniel S. Army E-6 BSHS Administration & Leadership Niles Ronald Navy E-3 ASHS Public Health Technician Medical Laboratory Technician Oh Sunkyo Army E-4 ASHS Olden Kevin J. Navy E-5 BSHS Public Health Technician Oyewusi Adegbite O. Navy E-5 BSHS Public Health Technician Paditsone Devon A. Navy E-3 BSHS Medical Laboratory Technician Partridge Zachary L. Army E-2 ASHS Public Health Technician Paz Mario A. Army E-4 BSHS Medical Laboratory Technician Perez Brannon M. Army E-4 BSHS Medical Laboratory Technician Potersnak Heather R. Navy E-4 BSHS Histology Technician

Last Name First Name Initial Branch Rank Degree Program/Major Ramirez Emmanuel Army E-4 BSHS Nuclear Medicine Technician Rowatt Matthew C. Army E-5 BSHS Medical Laboratory Technician Sallie John M. Army E-4 ASHS Occupational Therapy Assistant Air Sarmiento Ellaine A. Force E-3 BSHS Histology Technician Schultz Sawyer E. Navy E-3 BSHS Medical Laboratory Technician Seals Zachary O. Navy E-4 ASHS Public Health Technician Solarzano - Saravia Marilin J. Army E-2 ASHS Public Health Technician Solis Mandi R. Army E-4 BSHS Medical Laboratory Technician Soto Brandon Army E-4 ASHS Public Health Technician Stahl Cortney D. Army E-4 ASHS Medical Laboratory Technician Tapia Brandon L. Army E-3 ASHS Medical Laboratory Technician Taylor Andrew L. Army E-4 BSHS Nuclear Medicine Technician Thing Anjali Army E-4 BSHS Medical Laboratory Technician Tolliver Brian K. Army E-2 ASHS Medical Laboratory Technician Tomaneng Karyn K. Navy E-6 BSHS Public Health Technician Tomlin Kyle M. Navy E-6 ASHS Occupational Therapy Assistant Tomolac Geneva M. Army E-4 BSHS Medical Laboratory Technician Varela Raul Army E-4 BSHS Medical Laboratory Technician Velasquez Mandi A. Army E-2 ASHS Medical Laboratory Technician Vitela Cynthia J. Army E-3 BSHS Medical Laboratory Technician Washington Aaron C. Navy E-4 ASHS Public Health Technician Wiedeman Alec C. Army E-1 ASHS Medical Laboratory Technician Williams Romario B. Army E-3 ASHS Public Health Technician Wolfe Angelica M. Navy E-4 BSHS Medical Laboratory Technician Air Woods Briana E. Force E-4 ASHS Neurodiagnostic Technician Education & Training Wyatt Keith E. Army E-7 ASHS Administration & Leadership Air Young Taylor S. Force E-4 BSHS Nuclear Medicine Technician Zaccone Christopher J. Army E-3 ASHS Medical Laboratory Technician Zapata- Velasquez Jazmine Army E-3 ASHS Medical Laboratory Technician

Last Name First Name Initial Branch Rank Degree Program/Major

Zheng Kevin K. Navy E-3 BSHS Medical Laboratory Technician

Ziegler Robert A. Army E-4 BSHS Medical Laboratory Technician

TAB 14 Faculty Appointments and Promotions Hébert School of Medicine

UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES OFFICE OF THE DEAN 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814-4799 www.usuhs.edu

April 1, 2020

MEMORANDUM FOR BOARD OF REGENTS

SUBJECT: Faculty Appointments

The attached are recommendations made by the Committee of Appointments, Promotions and Tenure at a meeting on March 12th, 2020. I respectfully recommend that you approve these recommendations and forward them to the President of the University for further action.

Sincerely,

Arthur L. Kellermann, MD, MPH Professor and Dean, School of Medicine

Attachments

Learning to Care for Those in Harm’s Way PROPOSED FACULTY RECOMMENDATIONS May 15, 2020 BOR LIST

DEPARTMENT/NAME PROPOSED RANK ACTION/CURRENT DUTY STATION

Primary Appointments (Billeted)

FAMILY MEDICINE

LEGGIT, Jeffrey Professor Promotion/ MD Non-Tenured USUHS

MEDICINE

PAZGIER, MARZENA Associate Professor Request for tenure/ PhD With Tenure USUHS

MICROBIOKOGY AND IMMUNOLOGY

MATTAPALLIL, Joseph Professor Promotion/ PhD With Tenure USUHS

PEDIATRICS

JUDD, Courtney Clinical Associate Professor Promotion/ Lt Col, USAF, MC Non-Tenured USUHS

PREVENTIVE MEDICINE AND BIOSTATISTICS

KRAHL, Pamela Associate Professor Promotion/ CAPT, MC, USN Non-Tenured USUHS

PSYCHIATRY

COZZA, Kelly Professor Promotion/ MD Non-Tenured USUHS

SURGERY

ALTAMAR, Hernan Associate Professor Promotion/ CAPT, MC, USN Non-Tenured USUHS

DEPARTMENT/NAME PROPOSED RANK ACTION/CURRENT

DUTY STATION Primary Appointments (Non-Billeted)

DERMATOLOGY

WONG, Emily Associate Professor Promotion Lt Col, USAF, MC Non-Tenured JBSA-Lackland, TX

FAMILY MEDICINE

BAIRD, Drew Associate Professor Promotion/ LTC, MC, USA Non-Tenured Fort Hood, TX

LENNON, Robert Adjunct Associate Professor Promotion/ LCDR, MC, USN Non-Tenured Jacksonville, FL

MEDICINE

BRILL, David Clinical Associate Professor Promotion/ MD Non-Tenured Takoma Park, MD

DAVENPORT, Eddie Associate Professor Appointment/ Lt Col, USAF, MC Non-Tenured Lackland AFB, TX

GABLE, Preston Clinical Associate Professor Promotion/ MD Non-Tenured San Diego, CA

GRAYBILL, Sky Associate Professor Promotion/ LTC, MC, USA Non-Tenured Ft. Sam Houston, TX

TRACY, Heather Clinical Associate Professor Promotion/ CDR, MC, USN Non-Tenured San Diego, CA

WALTER, Robert Associate Professor Promotion/ MAJ, MC, USA Non-Tenured Ft. Sam Houston, TX

MILITARY AND EMERGENCY MEDICINE

SCHAUER, Steven Associate Professor Promotion/ MAJ, MC, USA Non-Tenured Ft. Sam Houston, TX

WEDMORE, Ian Associate Professor Promotion/ MD Non-Tenured Tacoma, WA

NEUROLOGY

KENNEY, Kimbra Professor Promotion/ MD Non-Tenured Bethesda, MD

DEPARTMENT/NAME PROPOSED RANK ACTION/CURRENT

DUTY STATION OBSTETRICS AND GYNECOLOGY

BARBIER, Heather Associate Professor Promotion/ Lt Col, USAF, MC Non-Tenured Las Vegas, NV

HEATON, Jason Associate Professor Promotion/ CAPT, MC, USN Non-Tenured San Diego, CA

PLOWDEN, Torie Associate Professor Promotion/ LTC, MC, USA Non-Tenured Fort Bragg, NC

THAGARD, Andrew Associate Professor Promotion/ Maj, USAF, MC Non-Tenured Portsmouth, VA

WEIR, Larissa Associate Professor Promotion/ Lt Col, USAF, MC Non-Tenured Ft. Sam Houston, TX

WILSON, Karen Associate Professor Promotion/ LTC, MC, USA Non-Tenured Fort Bragg, NC

PEDIATRICS

BARZILAY, Ezra Adjunct Associate Professor Appointment/ MD Non-Tenured Atlanta, GA

GARDNER, Ruth Clinical Associate Professor Promotion/ LCDR, MC, USN Non-Tenured Jacksonville, FL

LIESEMER, Kirk Clinical Associate Professor Promotion/ LTC, MC, USA Non-Tenured Tacoma, WA

MIKLES, Bethany Clinical Associate Professor Promotion/ Lt Col, USAF, MC Non-Tenured Portsmouth, VA

SPENCER, Steven Clinical Professor Promotion/ COL, MC, USA Non-Tenured Ft. Sam Houston, TX

STUDER, Matthew Associate Professor Promotion/ COL, MC, USA Non-Tenured Tacoma, WA

PSYCHIATRY

LEE, Paul Clinical Associate Professor Appointment/ MD Non-Tenured Tripler AMC, HI

SURGERY

GIFFORD, Shaun Associate Professor Promotion/ Lt Col, USAF, MC Non-Tenured Fairfield, CA

DEPARTMENT/NAME PROPOSED RANK ACTION/CURRENT

DUTY STATION

KHAN, Anjum Adjunct Professor Promotion/ MD Non-Tenured Silver Spring, MD

LEVI, Benjamin Adjunct Associate Professor Appointment/ MD Non-Tenured Ann Arbor, MI

OSBORN, David Associate Professor Promotion/ LTC, MC, USA Non-Tenured Bethesda, MD

POSNER, Matthew Associate Professor Promotion/ LTC, MC, USA Non-Tenured West Point, NY

REED-MALDONADO, Amanda Associate Professor Appointment/ LTC, MC, USA Non-Tenured Medical Center, HI

SANTOMAURO, Michael Associate Professor Promotion/ CDR, MC, USN Non-Tenured San Diego, CA

SCHUETTE, Albert Clinical Associate Professor Appointment/ CDR, MC, USN Non-Tenured Bethesda, MD

SERRA, Marc Clinical Associate Professor Appointment/ LTC, DC, USA Non-Tenured Tacoma, WA

SHIRLEY, Eric Adjunct Associate Professor Promotion/ MD Non-Tenured Portsmouth, VA

Secondary Appointments (Billeted)

PHYSICAL MEDICINE AND REHABILITATION

LEGGIT, Jeffrey Professor Appointment/ MD Non-Tenured USUHS

EMERGING INFECTIOUS DISEASES

PAZGIER, Marzena Associate Professor Promotion/ PhD Non-Tenured USUHS

PEDIATRICS

COZZA, Stephen Professor Appointment/ MD Non-Tenured USUHS

TAB 15 Faculty Appointments and Promotions Postgraduate Dental College UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES POSTGRADUATE DENTAL COLLEGE SOUTHERN REGION OFFICE 2787 WINFIELD SCOTT ROAD, SUITE 220 JBSA FORT SAM HOUSTON, TEXAS 78234-7510 https://www.usuhs.edu/pdc

26 March 2020

MEMORANDUM FOR BOARD OF REGENTS

SUBJECT: Faculty Appointments and Promotions, Postgraduate Dental College

Attached are the recommendations made by the Postgraduate Dental College’s Committee on Appointments and Promotions (PDC CAP) at meetings held on 6 January 2020 and 6 March 2020. I request that you endorse these recommendations and forward them to the President of the University for further action.

Digitally signed by SCHNEID.THOMA SCHNEID.THOMAS.R.1028588689 S.R.1028588689 Date: 2020.03.26 13:44:15 -05'00'

Thomas R. Schneid, DMD, MS Executive Dean and Professor Postgraduate Dental College

Attachments

Learning to Care for Those in Harms’ Way

PROPOSED FACULTY RECOMMENDATIONS May 15, 2020 BOR LIST

DEPARTMENT/NAME PROPOSED RANK ACTION/CURRENT DUTY STATION

Primary Appointments (Non-Billeted)

AIR FORCE POSTGRADUATE DENTAL SCHOOL

DUVALL, Nicholas Professor Promotion Lt Col, USAF, DC Non-Tenure Eglin AFB, FL

RAY, Jarom Professor Promotion/ Lt Col, USAF, DC Non-Tenure JBSA Lackland, TX

ARMY POSTGRADUATE DENTAL SCHOOL

DUTNER, Joseph Associate Professor Promotion/ LTC, DC, USA Non-Tenure Fort Gordon, GA

JOHNSON, Thomas Professor Promotion/ LTC, DC, USA Non-Tenure Fort Gordon, GA

JONES, Rachell Adjunct Associate Professor Appointment PhD Non-Tenure Fort Hood, TX

NAVAL POSTGRADUATE DENTAL SCHOOL

HAMLIN, Nicholas Professor Appointment/ LCDR, DC, USN Non-Tenure Bethesda, MD

HAWKINS, James Associate Professor Promotion/ LCDR, DC, USN Non-Tenure Bethesda, MD

KIM, Jeffrey Associate Professor Appointment/ PhD Non-Tenure Bethesda, MD

RUDMANN, Michael Associate Professor Promotion/ CAPT, DC, USN Non-Tenure Bethesda, MD TAB 16 Faculty Recognition Inouye Graduate School of Nursing

UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES DANIEL K. INOUYE GRADUATE SCHOOL OF NURSING 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814-4799 www.usuhs.edu/gsn

February 25, 2020

MEMORANDUM FOR NAMES & HONORS COMMITTEE

SUBJECT: Request for Emeritus ProfessorAppointment forLinda Wanzer, DNP, RN, COL (Ret), CNOR, FAAN

Dr Linda Wanzer, Professorof Nursing, retired fromthe University in December, 2019. By this memo, I am requesting that she be appointed Emeritus Professorof Nursing. Dr. Wanzer has been a member of the Graduate School of Nursing (GSN) since 2002 when she was nominated by the Army and selected by the GSN faculty to serve as the founding director of the new Clinical Nurse Specialist (CNS) program. She served as Director/Chair forover 17 years first as an Active Duty Army officer (retiringas an 0-6 in 2007), andthe final10 years as a Federal Civilian. Over the years she steadily progressedin academic rankfrom Assistant Professorto Associate Professorin 2012, and then to Full Professorin 2017. As a member of the GSN facultyDr. Wanzer has made numerous sustained administrative, teaching and service contributions to the GSN andthe University.

In response to shiftingnational nursing priorities, Linda has driven three major curricular transformations in the CNS program. The current Adult Gerontology CNS (AGCNS) curriculum is unique in that it is rigorous, but remains deliberately flexible (currently the curriculum remains focused preparing Advanced Practice Nurses [APNs] for the perioperative environment). An exceptional mentor, Dr. Wanzer's alumni and current and formerfaculty form a unique community of clinicians, scholars and healthcare leaders; many former students and faculty are serving with distinction in very senior leadership roles.

In 2006, the USU President recognized Dr. Wanzer'sleadership skills when he hand-selected her to serve as Interim Dean of the GSN during a period of significantturbulence/turmoil in the GSN. She provided desperately needed stability and calm during that era and in 2006 was awarded the Uniformed Services UniversityOutstanding Service Award forher leadership. Dr. Wanzer has also lead in other, less publically visible roles as well. Over the past decade she has served twice, for a total of over 4 years as the ProgramDirector "lead director", a group that coordinates almost every aspect of the academic programs in the GSN. They develop the student schedules, negotiate faculty teaching assignments, develop, execute and review all evaluations (course, annual, alumni) and revise curriculumas needed. In her role as lead director, in 2010, she co-chaired a major initiative to prepare faculty to support Evidence Based Practice projects, a significant learningcurve forfaculty prepared as researchers (PhD) or clinicians (Master of Science). Dr. Wanzer also served on all three Doctor of Nursing Practice (DNP) Taskforces, helping to create one of the most innovative DNP curricula in the country. Most recently, Dr. Wanzer led a major effort to streamline/organize the DNP Project enterprise, standardizing facultyand student work in this critical student deliverable. Dr. Wanzer was recognizedfor her

Learning to Care for Those in Harm's Way

TAB 17 University President Report USU Board of Regents President’s Report May 15, 2020

Richard W. Thomas, MD, DDS President

as of 1 May 2020 Issue Updates

Education and Training Research Leadership Development

• Graduation of 2020 Students • Highlighted projects • Accountability • Practice Management • Funded projects • COVID Update Brief (CUB) Guidelines • After Action Review

• Bioethics Guidance • COVID Campaign Plan

• Student COVID Response • USU Direct Support • Resilience Survey Training • Reintegration planning • Prep for next new normal

Clinical Practice Guidelines Student COVID Response Training

Capability 1

• Appropriate PPE Utilization (Additional training will be provided by the facility you work at)

Capability 2

• Basic Understanding of COVID-19

Capability 3

• Effective Patient Communication (decreasing fear/anxiety)

Capability 4

• Screening Patients

Capability 5

• Obtaining Vitals

Capability 6

• Responding to a Medical Emergency (Please just indicate the training you previously completed.) USU COVID-19 Research Highlights

• Epidemiology, Immunology and Clinical Characteristics of Emerging Infectious Diseases with Pandemic Potential (EPICC-EID) – Infectious Disease Clinical Research Program (IDCRP) – first and largest DoD COVID- 19 clinical characterization study – study design adopted by the VAHS • Adaptive COVID-19 Treatment Trial (ACTT) - NIAID-led Multicenter, Adaptive, Randomized Blinded Controlled Trial of the Safety and Efficacy of Investigational Therapeutics for the Treatment of COVID-19 in Hospitalized Adults - IDCRP as hub for Military Treatment Facilities’ participation • “Javits Center Study” COVID-19 Antibody Prevalence in Military Personnel Deployed to New York • NIAID-USU collaborative research consortium "Defining genetic determinants of susceptibility to severe COVID19 infection" • User assessment and validation of a web-based COVID-19 self-triage platform using pre-designed health scripts • Simulation of patient care with COVID-19 patients • Evaluation of novel ventilators

7 Active COVID-19 Research Projects

USU Daily Accountability USU COVID-19 After Action Review Letter of Instruction USU COVID-19 Campaign Plan Letter of Instruction USU Direct Support to COVID Pandemic

White House Office of Science and Technology Policy • Developing model for projecting resource needs using intel analysis • Collaborating with DTRA, FEMA, and DHHS Department of State • Planning and facilitating COVID evacuations (Wuhan, Diamond Princess) Joint Staff Surgeon’s Office • Clinical analysis and review of surveillance data, treatment protocols, and research to shape force health protection guidelines and strategic planning Department of Health and Human Services • Assist with Federal policy development and guideline management Defense Health Agency • DMEC worked with J-7 on medical ethics guidelines Mt. Sinai Hospital • Disaster Medicine provide consultation and training on triage and handling of COVID-19 patients Tri-Service MTFs • Clinicians and students (medical and nursing) providing clinical support across the country at multiple MTFs

Sequenced Reopening Plan

Phase III Objectives 1.On campus educational and research activities restored (100%) Operations at Full Scale Phase III 2.USU is operating fully mission capable (100%) Readiness for Next Pandemic 3.Defeat the threat Full Key Actions Operating - Teleworking restored to pre-pandemic conditions - Non-essential travel restrictions removed - Operational field training resumes Capability - Hand hygiene and respiratory etiquette sustained - Monitor epidemiologic data for evidence of subsequent spike - Common areas re-opened Phase II Objectives Transition Criteria 1.Reintegrate the population into the University Sustained 14 Day Decrease in 2.Mitigate the risk of any potential resurgence Phase II Positive Reported Cases/% 3.Adapting to new normal Positive tests Enhanced Key Actions Operating - Teleworking continues (50% of workforce) - Shared surfaces frequently sanitized Capability - Protect the vulnerable population (100% telework) - Gatherings limited to < 50 personnel - RC leaders redesign workspace and workflow as necessary - On campus academic and research activities restored (75%) University Operations University Phase I Objectives Transition Criteria 1.Safeguard the population. Phase I 2.Monitoring and evaluating disease trends Sustained 14 Day Decrease in 3.Protect the University Mission. Positive Reported Cases/% Positive tests Initial Key Actions Operating - Maximize physical distancing (90 % of workforce) - Prioritize strategic communication - Capture disease and surveillance data (100%) - Gatherings limited to < 10 personnel Capability - Physical distancing and cloth coverings enforced - Common areas slowly opened and evaluated - Restricted non-essential government travel - Daily accountability of personnel (100%)

PRE-DECISIONAL – FOUO – PRE-DECISIONAL Current As Of: 23 APR 20 15 TAB 18 Assistant Secretary of Defense (Health Affairs) Report

TAB 19 Hébert School of Medicine Report Uniformed Services University of the Health Sciences Board of Regents

Board Brief

Submitted by: Arthur L. Kellermann, M.D., M.P.H. Date: May 2020

Title & Department: Dean, School of Medicine Phone 301-295-3016

Purpose: Information X Action

Subject: Dean’s Report: School of Medicine (SoM)

Notable Achievements: • The School of Medicine is heavily involved in the COVID fight. Appendix A summarizes the School’s contributions and capabilities in research, education, service and leadership. • Most of the Class of 2020 graduated & promoted 6 weeks early in a Virtual Commencement Ceremony. Additional virtual ceremonies are planned for our graduate programs and the few medical students who could not graduate early for various reasons: https://usupulse.blogspot.com/2020/03/200-new-doctors-advanced-practice.html • The SoM Class of 2020 has completed a focused COVID prep curriculum. All members of the Classes of 2021 and 2022 completed it by April 15. Many of are already actively contributing to the COVID-19 response in the National Capital Region (NCR) and all are engaged in independent study and/or academic DL activities. • COL Kevin Chung (Chair, MED), Lt Col Renee I. Matos and interdisciplinary colleagues across the MHS have produced the first MHS’ first Clinical Management Guidelines for COVID-19. The second edition CMG was released on April 14. https://www.google.com/search?q=DoD%20COVID- 19%20PRACTICE%20MANAGEMENT%20GUIDE&cad=h • First USU-JTS hosted COVID-19 Performance Improvement Conference was held on April 2. The call is modeled after the weekly DoD JTS calls, it is intended to facilitate bidirectional exchange of clinical information and performance improvement during the COVID-19 pandemic. Activity of this sort is a hallmark of a “learning healthcare system.” • Dr. Christopher Broder (MIC) and HJF receive the 2020 Impact Award from the Federal Laboratory Consortium for Technology Transfer for “Public Health Impact: Countermeasures for Highly Pathogenic Emerging Henipaviruses.” • Major Polio vaccine paper based on research Dr. Michael Daly (PAT) published in PLoS ONE. Entitled, “A novel gamma radiation-inactivated Sabin-based polio vaccine”, the technique uses a biological property Daly identified in Deinococcus radiodurans. • USU Medical Student satisfaction with the quality of their medical education among the highest in the nation. In fact, we literally top the chart on the AAMC’s 2020 Mission Management Tool. Responses to this question are derived from each school’s annual Graduation Questionnaire (see Appendix B).

Dean’s Office Updates:

Academic Affairs: • Faced with the impending COVID-19 national emergency, the Office of Academic Affairs office swiftly pivoted our curriculum to distance learning (DL). Our efforts are guided by two core principles: 1) Ensure the health and safety of the campus community, and 2) Ensure the continuity of our academic programs to support the MHS’ mission. A key element of both is to keep our community connected – virtually. (see photo at end of this report) • Our Executive Curriculum Committee and its various subcommittees expeditiously reviewed every curriculum modification forwarded to them from the Office of Medical Education and continues to meet several days each week to review, refine and approve modifications as they arise. To ensure that we remain compliant with evolving and contingent national standards, the Office of Academic Affairs is closely monitoring LCME and AAMC's Education Tele-conferences and White papers during this time of crisis.

Recruitment and Admissions: • Our first “Virtual Second Look” was held April 3. It attracted over 130 participants. Our keynote speaker was COL (ret) Mark Kortepeter, a longtime USU faculty member, who spoke about his 27-year career as an Army Infectious Disease physician. His presentation could not have been more timely and relevant as he related his experiences working as a military physician investigating the COVID-19 pandemic, WMD in Iraq, and the 2001 Anthrax attacks. His memories of serving as Deputy Commander for the U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID) and a biodefense consultant for the White House, the Army Surgeon General, NATO, and the WHO inspired our guests. • National Collegiate Emergency Medical Services Foundation Conference, Feb 2020. With the help of LtCol Leslie Vojta and MAJ Laura Tilley (MEM) and current SOM students, we conducted five (5) interactive workshops at this huge national meeting. Students learned how to triage combat casualties and how to provide ATLS level care in an operational setting. Over 200 conference attendees participated in our workshops. • Virtual Recruiting: Although COVID-19 has halted our ability to visit universities and colleges, it has not frozen our efforts. Over the past few weeks, we have hosted Virtual Open Houses with students throughout the nation, and we participated in the AAMC Virtual Medical School Recruitment Fair on March 27. Prior to the COVID emergency, our recruiting team and Military Medicine Ambassadors (MMAs) participated in over 47 events around the country, including Student National Medical Association (SNMA) conferences in Philadelphia and Atlanta; National Hispanic Medical Association Conferences in California; Texas Association of Advisors for the Health Professions Conference; Stanford University Minority Medical Alliance Conference; Columbia University’s Latino Medical Student Association Pre-Health Fair in New York City and many other colleges and universities. • Admissions: During the 2020 Admissions Cycle, we interviewed more than 600 applicants. The Admissions Committee has also completed deliberations and rendered decisions for all eligible candidates. All 171 seats within the School of Medicine are currently full; however, over the next few months we and every other medical school expect to receive some declinations as applicants with multiple offers of acceptance commit to a single school. Concerned about months of news reports and social media chatter about MHS cutbacks and potential GME reductions, we have 183 outstanding applicants poised and ready to come off of our waitlist. For applicants currently holding seats in the Class of 2024, the average GPA for the class is a 3.7 and the average MCAT score is 510. The total number of applicants holding offers of acceptance from races and ethnicities underrepresented in medicine is currently 19. We are also holding positions for 73 women, 30 first-generation college graduates, and 54 prior military service/veterans. • Enlisted to Medical Degree Preparatory Program (EMDP2): o Eight of the inaugural EMDP2 class of ten were among 168 members of this year’s graduating class on 1 April 2020. Three are entering Emergency Medicine residencies, one Family Medicine, one Pathology, one PM&R, one Psychiatry, and one Transitional Year Internship. o The Long Term Career Outcomes Study (LTCOS) Team recently partnered with us to track EMDP2 graduates and evaluate their performance in medical school. Preliminary findings shows that although EMDP2 students have slightly lower pre-matriculation MCAT scores (average of 505 versus 509 for the average class), their overall academic performance in medical school is similar to their peers. Moreover, they tend to assume a disproportionate number of leadership roles. o Fifty (50) Servicemembers in EMDP2 Cohorts 5 and 6 are currently enrolled at George Mason University. Due to COVID-19, GMU transitioned to online coursework after the spring break. EMDP2 students also transitioned; however, their classes are being delivered synchronously with live videoconferencing. 25 members of Cohort 5 are scheduled to complete the program in May. 17 have been offered seats in USU’s class of 2024 and 4 are currently waitlisted. Selections have been made for Cohort 7. Hopefully, they will begin their studies in July 2020.

Medical Student Affairs (OSA): • Class of 2020 o Fourteen senior students participated in the civilian match (1 in the Urology Match and 13 in the NRMP). The majority matched to their first choice programs. USU grads disproportionately match in Critical Wartime Shortage Specialties. (Appendix C). o Three seniors (2d Lt Nathanial Ford, 2LT Jeremy Lawson, ENS Sarah Wright) were selected to participate in NASA/Johnson Space Center's prestigious Aerospace Medicine Clerkship program. Unfortunately, it was cancelled this year due to the pandemic. • Class of 2021 o The class completed the majority of their Bedside, Bench and Beyond (B3) curriculum and have begun their early senior rotation via distance learning. For the class, 98% have taken USMLE step 1. Based upon available results, the first time pass rate is 98% with a mean score of 225. Twenty-eight students have been elected to Alpha Omega Alpha (AOA). Twenty-six have been inducted into the Gold Humanism Honor Society. o Class of 2021 students are currently engaged in an array of distance learning (DL) courses, non-patient care clinical activities (e.g., telehealth, preventive medicine), and Capstone projects. o Faculty in the SOM are working to develop a number of new, innovative DL activities for student engagement until they can return to patient-contact clinical rotations. o The Executive Curriculum Committee (ECC) approved modifications to the post- clerkship curriculum that will hopefully return students to clinical rotations in June 2020, effectively compete for GME positions, and graduate in May 2021. o 2d Lt Jacob Altholz was re-elected to serve as the National Delegate for Medical Education for the Organization of Student Representatives of the AAMC. o 2LT Melissa Walsh is serving on the Student Leadership Group of the American College of Cardiology. • Class of 2022 o Students had completed 2 clerkship rotations before being called back to the NCR. A revised clerkship year schedule has students engaged in DL clinical activities until they can return to a modified schedule of clinical rotations in June 2020. • Class of 2023 o Students continue to progress through the Neuroscience module; the smooth transition to DL has garnered positive feedback from students and faculty. o Faculty are collaborating to modify the GI module to maximize distance learning, while achieving goals and objectives for the module. Some required activities that cannot be transitioned to DL will occur over the summer months. o ENS Ofir Nevo has been selected to participate in the AAMC's RISE: Developing Future Leaders in Academic Medicine Seminar in July 2020.

Capstone Scholarship: • A record number (N=119) in the Class of 2020 completed scholarly projects during their time at the University. 50 presented their work at military medical meetings through the year, including the MHSRS, USU's Founder's Day, and the AMSUS meeting. Others presented at specialty society meetings. • On May 13-14, more than 100 medical, graduate and GSN students will present their work using a novel "On-Line" poster forum – an electronic gallery of posters that will include narrative descriptions by each student of their project! Participants in our USU Research Days Celebration will be able to view these anytime from anywhere. Award for research excellence will be awarded.

Office of the Commandant (OCS): • Through the month of March, we recalled students from both Class 2020 and 2022 from rotations all over the world and ensured their safe return to the NCR. • We developed online and voice accountability processes to ensure not only physical but emotional accountability of all the students. • Executed the early graduation of 161 Class of 2020 students, including ensuring their new Oaths of Office were official and signed effective April 1. • At the writing of this report, have over 60 new Class 2020 graduates working at MTFs throughout the NCR in support of efforts to combat the pandemic.

National Capital Consortium (NCC)/Graduate Medical Education: • NCC Anesthesiology Residents won the 12th Annual DC Jeopardy Competition. Participants included residents from GWU Hospital and MedStar Georgetown Hospital. • NCC Internal Medicine Residents and Faculty won awards during the Navy American College of Physicians (ACP) Meeting in Portsmouth, VA, January 17-18. These included: o Navy ACP Resident Teacher of the Year - LT Michael Roth o Navy ACP Chapter Teacher of the Year - Dr. Richele Corrado o Navy ACP VADM Nathan Young Leader Award - LCDR Mary Andrews o Navy ACP Master Teacher - CDR Manish Singla • LCDR Alison Lane, NCC Infectious Disease fellow received the USU Department of Medicine Jay P. Sanford Grant for her manuscript: Effectiveness of alcohol based hand sanitizers in reducing bacterial colonization of stethoscope. • NCC Neurology Residency Faculty, Dr. Jonathan Bresner and Dr. Margaret Swanberg were awarded the A.B. Baker Teaching Award from the American Academy of Neurology in recognition of teaching excellence in Neurology. CPT Tim Malone was 1 of 10 Neurology residents chosen nationally for the Enhanced Resident Leadership Program. • NCC Pediatrics Gastroenterology Program Director, Lt Col Nylund, Program Director won the overall USAF Achievement in Clinical Research Award. • NCC Obstetrics & Gynecology Resident, LT Allison Eubanks, MC, USN was recently named recipient of ACOG's Donald F. Richardson Memorial Prize Paper Award. This is an annual award given to just two ACOG Junior Fellows for the two best scientific papers presented at all ACOG district meetings.

Graduate Education Office (GEO): • Graduate Admissions: This February, GEO held a one-day “Open House” and interviewed 73 applicants for five graduate programs. Among those interviewed, six were active duty personnel and the rest are civilians with career objectives that align with USU’s academic mission. • Virtual Learning: All programs have successfully implemented distance learning for current coursework. Classroom lectures and interactive sessions are being delivered through Google Hangouts, Adobe Connect, and Pre-recorded lectures (e.g. PowerPoint). With few exceptions (e.g., COVID-19 and DoD time-critical research) most grad students are practicing “tele- science.” All thesis and dissertation committee meetings, candidacy exams, private and public defenses are being held using distance learning tools. Journal clubs and research presentations are also moving forward utilizing distance learning resources. • Pass/Fail Option Adopted for Spring Quarter Grades: GEO has established a pass/fail grading option for graded courses in the Spring quarter. Graduate programs may elect to make this option available to their students subject to accreditation requirements and student’s individual needs. This option should help relieve the stress related to working in suboptimal conditions.

Diversity and Inclusion: • CPT Rachel Han, USU SOM Class of 2020, is the runner-up in the prose category of the Irvin D. Yalom, M.D. Literary Award given by the Pegasus Physician Writers at Stanford. In her piece, “The Manic Korean Patient: Refusing Labs” She was also awarded an American Psychiatric Association (APA) Medical Student Travel Scholarship to attend the (now- canceled) 2020 annual meeting of the APA. CPT Han will begin her psychiatry residency this summer at the National Capital Consortium. Her manuscript is available at: http://www.pegasusphysicians.com/programs-awards/literaryaward.

Good News:

Anesthesiology (ANE): • CDR Arlene Hudson, Chair of ANE, led subject matter expert team for Joint Acquisition Task Force “Hack - A – Vent” project. Project received 173 proposal of innovative low cost ventilators designs to address the gap in ventilator capacity for COVID 19 pandemic. Team selected top 5 for testing and development. Currently working with selected innovators to refine prototype and conduct performance testing of new ventilator prototypes in a large animal lab. Among the innovative ideas is conversion of BiPAP S/T devices to ventilators. This project was recently completed and a manuscript has been submitted for publication. • Mungunsukh Ognoon, PhD, Postdoctoral Fellow, submitted and abstract for MHSRS 2020 conference: “Clinical and Genetic Study of Exertional Rhabdomyolysis: Comparing Cases with Single versus Recurrent Episodes.”

Anatomy, Physiology & Genetics (APG): • This years’ Capital Area TBI meeting was very successful. It was largely organized by Dr. Kimberly Byrnes in coordination with CNRM, and many faculty participated in presentations and organized discussion groups. DJ Bradshaw and Kathleen Whitling, won awards, and Adedunsola Obasa was selected for a platform presentation. • Dr. Jeremy Smyth's lab published two manuscripts. The first, published in the Biology Open describes how changes in cellular calcium transport cause heart failure. The second, published in the Journal of Visualized Experiments describes protocols for live and in vivo analysis of cell division.

Medicine (MED): • COL Kevin Chung, Professor and Chairperson of Medicine, First US treatment of critically ill COVID patient with Seraph blood purification device under Emergency Use Expanded Access pathway. • COL Patrick O'Malley, Professor of Medicine and Associate Dean of Clinical Affairs, has started a tele-health elective with 4th year students to support WRNMMC Internal Medicine Ambulatory Clinics. • Maj Ellen Im, Assistant Professor of Medicine and Director of Advanced Clerkship Program in Internal Medicine, is offering an Online elective around COVID-19 and other key skills for advanced clerkship students (e.g, transfers of care). • In concert with PACOM, and in collaboration with GSN, the Department of Medicine sponsored a 7-day clerkship experience in American Samoa for 3 of USU’s 2nd year Medical Students in December 2019. The goals were to orient to the medical system, the Samoan culture, and understand disease morbidity and clinical care in an austere setting. • Dr. Lisa Shank was presented with the 2019 American Psychosomatic Society (APS) Young Investigator Colloquium Award for her recognized potential as a “rising star” in research while working in the MED Military Cardiovascular Outcomes Research Center. • Lt Col Brian Neubauer, Associate Professor, was selected as next Program Director for the SAUSHEC Internal Medicine (IM) Residency Program. This is the largest residency in the DoD with 96 integrated Army/Air Force positions, offering educational experiences at SAMMC, Wilford Hall Ambulatory Surgical Center, and UTHSC San Antonio. • On February 4, Dr. Robert Goldstein, Professor of Medicine & Physiology, received the MED John F. Maher Award for his original research in the field of Cardiology. His research, published in the Journal of Cardiac Failure, is “Hemodynamic Effects of Late Sodium Current Inhibitors in a Swine Model of Heart Failure.” • Dr. Holly Meyer, Assistant Professor of Medicine, was accepted into the AAMC Leadership Education and Development (LEAD) Program. • COL Jessica Bunin, Associate Professor, is leading a mitigation working group in support of FEMA/HHS All of Government Ventilator Task Force created by the White House. She was also named consultant to DHA for ventilator usage and allocation.

Military and Emergency Medicine (MEM): • Dr. Gillian Schmitz, Assistant Professor of Military and Emergency Medicine, led a multidisciplinary team of physician educators as well as enlisted and civilian staff to certify 169 third-year medical students in Advanced Cardiac Life Support. • MEM faculty and others also led MS3s in peer-supported discussions of leadership encounters during the clerkship period and methods of managing future conflicts. • Due to Force Health Protection concerns for faculty and students, MFP 201 "Operation Gunpowder" was postponed. We are working on contingency plans to meet learning goals & objectives for the overall Military Medicine 200 post-clerkship module, which includes MFP 201 and MFP 202 "Operation Bushmaster,” currently planned for October.

Microbiology (MIC): • Dr. Chris Broder, Professor and Chairperson of Microbiology, and Dr. Eric Laing, Postdoctoral Fellow, are expanding their existing serological multiplex assay to add SARS- CoV-2 and related CoVs to their multiplex assay. • Dr. Christopher Broder and colleagues have developed the first-ever treatment, the monoclonal antibody m102.4, that prevents Hendra and Nipah viruses from causing potentially lethal infections. This treatment is safe, well-tolerated, neutralizes the virus. The study’s findings were published in The Lancet Infectious Diseases journal on February 3, and the following article was published by the Coalition for Epidemic Preparedness Innovations (CEPI). https://cepi.net/news_cepi/cepi-funded-nipah-virus-vaccine-candidate-first-to-reach- phase-1-clinical-trial/

Medical and Clinical Psychology (MPS): • Two courses taught to MPS students include tele-behavioral health interactions with standardized patients. COVID-19 factors into both patient presentations. • 100% of USU clinical psychology students matched or were previously accepted into APA accredited internship sites. All got their number one choice. This is remarkable success. • LT Kyna Pak was awarded the 2019 Junior Navy Psychologist of the Year. She graduated from USU in 2018 and is currently stationed at Twentynine Palms, CA. • CPT Kathryn Eklund, a recent MPS graduate, was selected for the 2020 APA Division 19 (Military Psychology) Society Leadership Program. • LTJG Keen Seong Liew and 2nd Lt Amanda Murray were selected to represent USU and participate in the American Association for the Advancement of Science Catalyzing Advocacy in Science and Engineering (AAAS CASE) Workshop. • Matthew Thompson and Laura Novak, civilian MPS students, have been granted the 2020 Military Suicide Research Consortium (MSRC) Research Training Day Fellowship.

Obstetrics and Gynecology (OBG): • Lt Col Bart Staat, Dept Char, is leading DHA’s OB COVID Clinical Community. He is also assisting the AFMS with contingency planning for COVID surge at small/remote MTFs.

Pathology (PAT): • Dr. Charles Via, Professor of Pathology, has been awarded an NIH R21 grant award entitled "Mapping the genes that predispose to murine lupus."

Pediatrics (PED): • CDR Chris Foster was awarded the Council on Medical Student Education in Pediatrics (COMSEP) Teaching and Education Award. This award is presented annually to a single individual drawn from medical schools across the USA and Canada. • Dr. Allison Malloy, has served as one of the key advisors to WRNMMC to develop and implement COVID-19 response plans. Dr. Malloy's USU research focuses on immune response maturation to respiratory viruses (primarily RSV) and uses both rodent models and human cord blood, which may be relevant to understanding the unique epidemiology being observed with COVID-19. • USU PED is collaborating with WRNMMC Pediatrics to supervise advanced clinical rotation students to manage tele-health appointments for their patients. • Lt Col Cade Nylund won the 2019 Air Force Medical Service, Outstanding Achievement in Medical Research Award. Lt Col Nylund has lead numerous studies of the epidemiology and outcomes of multi-drug resistant enteric infections, pediatric gastrointestinal diseases, and intersection between perturbations in the microbiome with allergic/autoimmune conditions and obesity. • LCDR Sebastian Lara, is currently providing 30 days of clinical backfill support to Naval Hospital Sigonnella. A shortage of pediatric staff required mobilization of CONUS based pediatricians to ensure coverage to both labor & delivery, inpatient, and outpatient services. Military Pediatricians help DOD forward-deploy the global force. • Dr. Joseph Lopreiato, Director of Val Hemming Simulation Center, received the Greenberg-Serwint Award for Outstanding Leadership in Medical Education at the Pediatric Academic Association Association’s regional meeting in Charlottesville, VA in Feb 2020. • Col (sel) Courtney Judd has been inducted into the Gold Humanism Society, in honor of her thoughtful contributions to the teaching and practice of humanistic medicine.

Pharmacology (PHA): • Dr. Regina Day, Professor of Pharmacology, received notice that a grant titled “Mechanisms of Captopril Protection against Hematopoietic Radiation Injury, Advanced Development" VP000264-01 will be funded by the Department of Defense Joint Program Committee 7 Radiation Health Effects Research Program. • Dr. Vijay Singh, Professor of Pharmacology, received notice that his grant proposal titled “Biomarkers for the development of BIO 301 as a prophylactic radiation countermeasure for the acute and delayed effects of radiation exposure” will be funded by the Department of Defense Joint Program Committee-7.

Preventive Medicine and Biostatistics (PMB): • Dr. Tracey Koehlmoos, Associate Professor, was selected as the 2020 Outstanding Alum of University of South Florida College of Public Health. • Dr. Celia Byrne (PI), Associate Professor, and Dr. Jennifer Rusiecki (Co-Investigator), Associate Professor, were recently notified that their application to the CDMRP, BCRP Breakthrough Award was recommended for funding of $2 million over 4 years. Their research studies Polycyclic Aromatic Hydrocarbons (PAHs) and Breast Cancer Risk among Active Duty Women in the US Military. They will work with colleagues at Columbia U.

Physical Medicine and Rehabilitation (PMR): • MAJ Gbabe-Alabi recently supported the EURCOM Global Health Engagement mission at Irpin Military Hospital in Kiev, Ukraine. • On January 23, The MIRROR team hosted the Tri-Service Post-Op Rehabilitation Protocol Development Conference. The all-day meeting served as a consensus conference of subject- matter experts within Ortho, PT, Sports Medicine, PMR, and Research Scientists. • PMR received a $40,000 donation from the Broussard Family Trust to further Servicemember education, training, and travel. The Geneva Foundation is managing the donation. • John “Brock” Heller, a Data and Infomatics Official, presented “Data and Analytics Infrastructure to Advance Musculoskeletal Injury Rehabilitation Research” at the 15th Annual EWI Meeting. • The Occupational Therapy Clinic at Walter Reed has been utilizing the Telehealth system during the COVID-10 virus crisis. According to patients it saves them time, gas, driving, parking, and the technology is efficient and simple. • Dr. Steven Cohen's "Pain Management Best Practices from Multispecialty Organizations during the COVID-19 Pandemic and Public Health Crises" was published in Pain Medicine. An expert panel was convened that included pain management experts from the military, Veterans Health Administration, and academia. In these guidelines, a framework was provided for pain practitioners and institutions to balance the often-conflicting goals of health care providers and patients while assuring access to pain management services.

Psychiatry (PSY): • Drs. David Benedek, Robert Ursano, Joshua Morganstein and Stephen Cozza are collaborating with DHA and The White House All of Government Task Force to assist the National Association of Broadcasters in developing a public messaging campaign to address community mental health and wellbeing needs during the COVID-19 Pandemic. • Dr. Joshua Morganstein serves as Chair of the American Psychiatric Association Disaster Committee, now functioning as a Task Force. They are providing consultation to APA members, District Branches and partner professional organizations including the AMA, ACP and others to support patient care and mental health during the COVID-19 pandemic. • Behavioral health surveillance of military healthcare responders is being conducted aboard the USNS Comfort to quantify stress responses in Military Healthcare Providers supporting civilian pandemic operations. • At the request of NYC’s Mt. Sinai hospital and USU Leadership, Drs. David Benedek and Robert Ursano are participating on a consultation team providing knowledge and resources to address issues of healthcare worker wellbeing, crisis standards of care implementation and psychological effects on the health community. • At WRNMMC, USU PSY faculty have created a wellness/resilience outreach team for healthcare workers in the triage tent and the Emergency Department. We are providing behavioral telehealth to patients and staff in WRNMMC’s Outpatient Clinics • Dr. Stephen Cozza joined other members of the NASEM Committee on Military Family Well-Being as they presented conclusions and recommendations from their recent report entitled "Strengthening the Military Family Readiness System for a Changing American Society" (published in September 2019) to Mrs. Holly Milley and other senior service spouses at Gen Milley's quarters in Fort Myer, VA.

Surgery (SUR): • Surgical faculty clinically engaged at WRNMMC supporting COVID-19 response including critical care. • Philip Spreadbrough, a Surgery Research Fellow, was awarded the inaugural Surgeon Vice Admiral Walker Trophy at the Joint Hospital Group (South West) conference. He was chosen for this award based on the work completed on the effect of tourniquets while here at USUHS in collaboration with Dr. Thomas Davis. Surgeon VAdm Walker was an International Scholar at the Department of Surgery in 1992. • The following publication is set to print after multiple years of effort: The Blue Book: Military-Civilian Partnerships for Trauma Training, Sustainment, and Readiness • Dr. Scott Tintle and the Transplantation Outcome Research Collaborative for the Hand (TORCH) Team is has received full funding from DoD office of the CDMRP for their project: RT190094 - “Assessing the Comparative and Longitudinal Benefits of Vascularized Composite Allotransplantation of the Hand”

Center for Deployment Psychology (CDP): • CDP has created a COVID-19 Resource Page featuring new content to assist providers grappling with the pandemic. It includes content related to telehealth, working with specific patient populations, and responses to social distancing/ isolation. The site is updated regularly with new content: https://deploymentpsych.org/covid19-bhresources • CDP supported USU's Department of Medical and Clinical Psychology during the COVID- 19 pandemic as they moved to distance learning (DL) by preparing online classroom space, meeting individually with MPS faculty members, sharing lessons learned regarding DL, supporting classes and moving simulated patient encounters to an online format. • CDP is answering daily RFIs from providers, clinics, agencies and organizations both inside the MHS and DoD from outside of DoD. Common requests are for educational materials on provider stress and self-care, modifying behavioral health treatment due to COVID-19 stress/anxiety, and social isolation • Star Behavioral Health Providers Program expanded to 10 additional states in the Midwest and Northeast. CDP, in collaboration with the National Guard Bureau and Purdue University, trains civilian behavioral health providers in military cultural awareness and evidence-based treatments. A web-based registry allows prospective military clients to find SBHP-trained providers in their area. • CDP launched the first of 7 insomnia treatment training workshops and consultation groups for Behavioral Health Consultants embedded in MHS primary care clinics.

Center for Neuroscience and Regenerative Medicine (CNRM): • On Jan 15, 2020, Dr. Daniel Perl and Dr. David Brody met in London with senior UK Military medical command officials, including Air Vice-Marshall Alastair Reid, the UK's Surgeon General and other leaders in the UK’s Defense Medical Services to discuss acute and long-term effects of military TBI on Service Members, and how DoD and UK counterparts could work together to better address these issues. • Dr. Daniel Perl and the USU Brain Tissue Repository are highlighted in an article on military TBI and brain donation for TBI research set to appear in People Magazine. The story is available on their website and should appear in stores soon. People Magazine has the largest circulation of any magazine in the US, and is regularly seen by 46.6 million readers.

Center for Rehabilitation Sciences Research (CRSR): • On January 16, Dr. Paul Pasquina, Director, CRSR, delivered an overview of CRSR’s Musculoskeletal (MSK) portfolio to the Joint Program Committee-5(JPC-5)/Military Operational Medicine Research and Clinical and Rehabilitative Medicine Research Programs (JPC-8) at the Review and Analysis meeting in Fort Detrick. • On January 22, Ms. Melissa Hewitt presented a poster at the Extremity Warfighter Injuries 15th Annual Meeting in Washington, DC. Her poster, "Distribution of Prosthetic Feet Prescribed to Service Members with Unilateral Transtibial Limb Loss at WRNMMC" reported on the work that she began as an intern describing the prescription of prosthetic feet to service members with lower extremity limb loss. • The following talks and posters were presented at the American Physical Therapy Association Combined Section Meeting on February 12-15 in Denver, CO: o Dr. Elizabeth Russell Esposito - “Comparing and contrasting patient and clinician perspectives on returning to duty following extremity trauma” o Dr. Elizabeth Russell Esposito - “Identification of Factors that Influence Return to Duty” o WRNMMC Physical Therapy Team - “Assessment of the Usability of the Rehabilitative Lower-Limb Orthopedic Accommodating-Feedback Device”

Center for the Study of Traumatic Stress (CSTS): • CSTS has developed a resource website with customized public mental health education fact sheets to help families, healthcare personnel, military and community leaders, and businesses plan for, and respond to, the Coronavirus global outbreak. The department has shared the resources with national, federal and international partners and widely disseminated them throughout their networks. https://www.cstsonline.org/resources/resource-master- list/coronavirus-and-emerging-infectious-disease-outbreaks-response • Drs. Brian Flynn and Joshua Morganstein are serving as members of Federal Disaster Behavioral Health (FDBH) COVID-19 Mitigation Group, disseminating customized disaster mental health education materials and adapting training programs now being used across the interagency space to enhance resilience of families, healthcare workers, and communities during the pandemic. • CSTS has tailored knowledge products to support HCW well-being and patient support to: DHA Operations, the Army Directors of Psych Health and to the Army, Navy, and Air Force family advocacy communities. They are also collaboratively developing knowledge products re: stress management with Army Public Health Command • CSTS is providing consultation and presentations to inform leadership of the 8-nation International Initiative for Mental Health Leadership (IIMHL) to support the sharing of resources and best practices in global pandemic mental health response.

Defense and Veterans Center for Integrative Pain Management (DVCIPM): • The Defense Health Agency Procedural Instruction (#6025.33) - Acupuncture Practice in Military Medical Treatment Facilities (MTFs) was signed February 20, 2020. This is the first MHS regulation on an integrative health technique for pain management. DVCIPM was the originator and sponsor of this Instruction.

Infectious Disease Clinical Research Program (IDCRP): • CAPT Timothy Burgess, Director of DoD/NIH's Infectious Disease Clinical Research Program was selected to represent DoD in a COVID-19, White House Advisory Committee coordinated by HHS addressing a Treatment Guidelines Panel. • IDCRP is playing a key role in coordinating COVID-19 related clinical trials within the MHS (Appendix A)

Murtha Cancer Center Research Program (MCCRP): • MCCRP has established with NCI a contingency plan if needed to transfer all clinical oncology patients from MCC/WRNMMC to NCI Clinical Center on short notice • MCCRP has approved requests from MEDCENs and MTFs to allow our Clinical Research Coordinators at these sites to shift their research work from cancer to COVID-19. • MCCRP accepted a request from NIH and USU TAGC to provide MCCRP biobank expertise, advice, and support as they receive COVID-19 blood samples from Italy to further our molecular and genomics understanding of the disease.

National Center for Disaster Medicine and Public Health Preparedness (NCDMPH): • NCDMPH collaborated with Emory University to beta test a web-based COVID-19 self- triage tool (www.C19check.com). • NCDMPH is leading a collaborative group of USU and Military Health System experts to provide leaders of NYC’s Mount Sinai Health System with information on DoD work in human performance and mental health support in periods of stress. • ENS Kristen Burnham and her student team were recently awarded the prestigious AΩA Medical Student Service Leadership Project Grant, for a 3 year project to expand trauma training skills to high school teachers using the First-Aid for Severe Trauma (FAST) training program. This project will be mentored by Drs. Craig Goolsby, CAPT Robert Liotta, and Martin Ottolini.

Surgical Critical Care Initiative (SC2i): • SC2i is mining historical clinical databases from critically ill combat injured patients to develop a variety of clinical decision support tools (predictive models) that are relevant to COVID-19 conditions such as ARDS, sepsis, pneumonia, “cytokine storm syndrome” and ventilator usage. SC2i is also analyzing a cohort of patients with ARDS to further understand the role cytokines play in the inflammatory response associated with COVID-19. • SC2i’s Molecular Core laboratory has been accredited by the Accreditation Committee of the College of American Pathologists (CAP). The laboratory is now one of only 70 CAP-accredited biorepository facilities worldwide.

Val Hemming Simulation Center (SIM): • Ms. Betsy Weissbrod has developed and pilot-tested additive manufacturing capabilities to produce face shields, masks, and ventilator tubing to address shortages in PPE. • Working with USU Pediatrics (PED) and Family Medicine (FAM) we have implemented “Virtual OSCEs” to substitute to Observed Standardized Clinical Examinations (OSCEs). • We successfully transitioned virtual clinical skills evaluations for students in the core clerkships of family medicine, pediatrics and psychiatry. This allowed grades to be awarded and students to complete their core clerkships despite COVID-19 restrictions.

Virtual “Dialog with the Dean,” hosted by the Faculty Senate, 17 APR, 2020

USU SoM alum, Astronaut Drew Morgan, safe on earth after 272 days in space. His flight surgeon, (L) Dr. Richard Scheuring, is wearing his USU “Operation Bushmaster” faculty cap! USU School of Medicine Support in the Fight Against COVID-19

Research • A Multicenter, Adaptive, Randomized Blinded Controlled Trial of the Safety and Efficacy of Investigational Therapeutics for the Treatment of COVID-19 in Hospitalized Adults - IDCRP is the hub for the MHS, working with the NIH’s National Institute for Allergy and Infectious Diseases (NIAID), partners across the DoD and U.S. Government. • Epidemiology, Immunology and Clinical Characteristics of Emerging Infectious Diseases with Pandemic Potential (EPICC-EID) - the IDCRP is conducting this prospective study to discern how COVID-19 and other diseases spread and evolve, in order to prevent them. • Human genetic factors that influence COVID-19 disease susceptibility and severity – USU’s The American Genome Center (TAGC) is collaborating with NIAID to identify genetic variations associated with the human immune response to SARS-CoV-2 infection. • Selection and testing of low cost, innovative ventilators. This work, under the auspices of USU’s program in Shock and Organ Support (SOS) is spearheaded by CDR Arlene Hudson (ANE) and funded by JATF. It will evaluate 5-10 ventilators developed for rapid deployment into the clinical environment. In addition, a SoM team is partnering with MIT to test and evaluate a novel ventilator modality for submission through the SOF COVID-19 Related Innovation Challenge Portal. • 3D printed N95 masks. ANE is collaborating with USU RAD and the University of MD. Pending FDA determination on EUA, the group will submit a QI project proposal at WR in collaboration with Children's National Medical Center and Washington Hospital Center. • ANE and U Penn are jointly evaluating COVID transmission during endotracheal intubation. • Develop an animal model for preclinical testing of novel therapeutics. Dr. Teodor-Doru Brumeanu (MED) and Prof. Sofia Casares (WRAIR and MED) are carrying out experiments to determine if humanized mice express the human ACE2 protein receptor, the entry point for the SARS-CoV-2 virus. If so, collaborators at Ft. Detrick will attempt to infect the mice. • Accelerated testing of antibodies and other therapeutic agents to block viral entry. Dr. Marzena Pazgier (MED) is expressing recombinant fragments of the viral proteins to generate high resolution three-dimensional structures and carry out structure/function studies. This project is expected to illuminate biological mechanisms. • Dr. Chris Broder and Dr. Eric Laing (MIC) are adding SARS-CoV-2 and 9 other related CoVs to their existing serological multiplex assay. This will allow them to determine what effect, if any, do pre-existing coronavirus antibodies have on COVID-19 disease severity. • Dr. Ed Mitre (MED) is setting this a longitudinal and prospective SARS-CoV-2 seroconversion study among healthcare workers at WRNMMC. They will be followed over a one year period, with weekly symptom questionnaires and monthly blood draws for serology. • Age-based maturation of the immune response to respiratory virus infection - Dr. Allison Malloy (PED) is conducting animal model and human (in vitro) research studying flu and RSV. She hopes to apply these techniques to SARS-CoV-2 at USAMRIID's BSL3 facility. • First US treatment of critically ill COVID patient with Seraph blood purification device COL Kevin Chung (MED) used it under FDA’s Emergency Use Expanded Access pathway. • Successful beta test a web-based COVID-19 self-triage tool (C19check.com). USU’s National Center for Disaster Medicine and Public Health collaborated with Emory U. A free “white label” MHS version tailored for DHA offered to DoD. It has opted to build its own. • The Surgical Critical Care Initiative (SC2i) is mining historical clinical databases from critically ill combat injured patients to develop a variety of clinical decision support tools that are highly relevant to COVID-19 outcomes, such as ARDS, sepsis, pneumonia, “cytokine storm syndrome” and ventilator usage. SC2i is also analyzing a cohort of patients with ARDS to discern inflammatory responses associated with COVID-19. • A method to safely inactivate microbes and viruses while maintaining immunogenicity for new vaccines - Michael Daly (PAT) created this technology • Technology to enable miniaturization and point-of-care testing. Dennis Grab (PAT) has a sensitive method for protein and nucleic acid detection of various microbes and viruses. • Topical treatment of pseudofolliculitis barbae, a skin condition that impairs proper fitting of respirators LTC Sunghun Cho (DER) is investigating a promising medication. • Additive manufacturing to produce face shields, masks, and ventilator tubing to address shortages in PPE. Val Hemming Sim Center has developed and pilot-tested a local approach • A Covid-19 Airway Management Isolation Chamber (CAMIC). 2LT Joseph Krivda, a USU med student is a pivotal member of a WRNMMC team creating a device to enable safe use of aerosolizing airway management strategies such as nebulizers and BIPAP.

Education/training • Just-in-time instructional training videos for non-ICU physicians and nurses. covid19toolbox.com a free website, has already been accessed >50K times across 80 countries. Some elements have been viewed 100K times. • USU’s Distance Learning Lab played a key role in helping our faculty quickly pivot their basic science and clinical curricula from lectures and small groups to distance learning. This was necessary to enable remote teaching of USU medical students • COL Patrick O'Malley (MED) has started a tele-health elective with 4th year students to support WRNMMC Internal Medicine Ambulatory Clinics. USU PED is collaborating with WRNMMC Pediatrics to supervise advanced clinical rotation students to manage tele-health appointments for their patients. • Maj Ellen Im (MED) is offering an Online elective around COVID-19 and other key skills for advanced clerkship students (e.g, transfers of care) • Two courses taught to Medical and Clinical Psychology (MPS) students include tele- behavioral health interactions with standardized patients (i.e., Sim Center actors). Both COVID-19 factors in the patient presentations. The SoM’s departments of Pediatrics (PED) and Family Medicine (FAM) are now implementing “Virtual OSCEs” as a safe substitute to Observed Standardized Clinical Examinations (OSCEs) in the Hemming Sim Center • SoM’s Center for Deployment Psychology (CDP) has created a COVID-19 Resource Page featuring new content to assist providers and patients in light of the pandemic. It includes content related to general telehealth concerns, working with specific patient populations, and responses to social distancing/ isolation. The site is updated regularly with new content https://deploymentpsych.org/covid19-bhresources

Clinical service • USU SoM’s Class of 2020 graduated 6 weeks early to join the COVID fight • SoM faculty extensively support patient care in the NCR. For example, the Walter Reed MICU is being regularly staffed by 3 USU billeted officers: COL Kevin Chung; COL Jessica Bunin and LTC Jacob Collen. WRNMMC’s Ob/Gyn service is strongly supported by Dr Katarina Shvartsman, Dr Ernest Lockrow and Lt Col Bart Staat. Dr Wheat is providing clinical services at Ft Belvoir rather than Walter Reed due to shortage of OB/GYNs there. • WhatsApp chat group involving >150 DoD providers across the enterprise organized to share COVID-19 treatment protocols and discuss management options real time • Murtha Cancer Center Research Program established with NCI a contingency plan to transfer clinical oncology patients from MCC/WRNMMC to NCI Clinical Center if needed on short notice (25 March 2020). • Behavioral health surveillance of military healthcare responders aboard the USNS Comfort initiated to quantify stress responses in Military Health Care Providers supporting civilian healthcare pandemic operations (PSY) • At WRNMMC, USU PSY has created a wellness/resilience outreach team for healthcare workers in the triage tent and the ED. We are providing behavioral telehealth to patients in the WRNMMC Outpatient Clinic (and to also to WRNMMC healthcare workers) • Center for Deployment Psychology (CDP) is answering daily RFIs from providers, clinics, agencies and organizations both inside the MHS and DoD from outside of DoD. Common requests are for educational materials on provider stress and self-care, modifications to behavioral health treatment due to COVID-19 stress/anxiety, and social isolation

Expertise (consulting/advising/representing) • DoD COVID 19 Practice Management Guide – This USU led effort, coordinated by COL Kevin Chung, was swiftly adopted by DHA. The second edition is nearing completion. • COL Jess Bunin (MED) named consultant to DHA for ventilator usage and allocation. She is also serving on WRNMMC’s “Monitored Emergency Use of Unregistered and Experimental Interventions (MEURI)” Scientific Review Committee • MAJ Laura Tilley (MEM) is serving on the Defense Health Agency/Tri-Service Emergency Services Clinical Consortium and is working on COVID protocols & policies • Lt Col Bart Staat is leading DHA’s OB COVID Clinical Community. He is also assisting AFMS with contingency planning for COVID surge at small / remote MTFs • USU Center for the Study of Traumatic Stress (CSTS) is supporting COVID-19 mental and behavioral health with educational materials, presentations and "just in time" consultations for healthcare providers, families and leaders within DoD, the VA, health systems across the Nation (e.g. Mt Sinai, NYU, National Assoc of State Mental Health Program Directors, American Psychiatric Association) and several allied nations. • CSTS has tailored knowledge products to support HCW well-being and patient support to: DHA Operations, the Army Directors of Psych Health and to the Army, Navy, and Air Force family advocacy communities. They are also collaboratively developing knowledge products re: stress management with Army Public Health Command • USU’s NCDMPH is leading a collaborative group of USU and Military Health System experts to provide leaders of NYC’s Mount Sinai Health System with information on DoD work in human performance and mental health support in periods of stress • Numerous USU faculty members have published COVID-related editorials and commentaries in the medical literature regarding the value of the MHS in the COVID fight

MISSION Provide High Quality Medical Education as Judged by Your Recent Graduates Uniformed Services University of the Health Sciences F. Edward Hebert School of Medicine 4 Benchmarked against All Medical Schools Special Report Table of Contents

Evaluation of Medical School Experiences (Percent Evaluation of Medical School Clerkships (Percent Responding Good or Excellent, 2017-2019) Responding Agree/Strongly Agree, 2017-2019)

Rate the Quality of Rate the Quality of Rate the Quality of Rate the Quality of Rate the Quality of Rate the Quality of Percentile Educational Educational Educational Educational Educational Educational Experiences in Family Experiences in Internal Experiences in Experiences in Experiences in Experiences in General Basic Science Content Had Overall, I am Satisfied with the Medicine Clinical Medicine Clinical Obstetrics-Gynecology Pediatrics Clinical Psychiatry Clinical Surgery Clinical Sufficient Illustrations of Quality of my Medical Clerkships Clerkships Clinical Clerkships Clerkships Clerkships Clerkships Clinical Relevance Education 96.3% 93.4% 90.6% 95.5% 90 93.2% 96.4% 88.8% 94.9% 94.5% 89.8% 89.5% 95.1%

80 90.2% 95.0% 86.3% 93.0% 93.5% 87.3% 86.6% 94.0% 93.9% 70 88.7% 93.8% 84.6% 91.1% 92.0% 86.0% 82.7% 93.1% 83.6% 60 87.4% 93.1% 83.0% 89.4% 90.3% 84.6% 79.4% 91.9%

50 86.4% 92.3% 80.7% 88.1% 89.1% 83.1% 76.7% 90.2%

40 84.9% 90.9% 78.7% 86.0% 86.9% 81.5% 74.0% 89.5%

30 82.6% 90.0% 75.8% 84.5% 85.4% 80.1% 70.8% 87.9%

20 78.3% 87.6% 72.9% 81.4% 82.9% 77.8% 68.3% 85.8%

10 74.9% 82.9% 68.4% 77.7% 79.6% 73.6% 65.3% 82.0%

Mean 84.9% 91.0% 79.7% 86.8% 87.7% 82.3% 77.0% 89.5% Valid N 139 139 139 139 139 139 139 139

Note: The percentile distributions include reported zero values but exclude missing values. Source: AAMC Graduation Questionnaire Staff Contact: For report questions, contact Ron Espiritu or Hershel Alexander, PhD, at [email protected].

______Missions Management Tool 2020 1

Class 2020 Match Results

(Updated 23 Mar 20 to reflect addition of civilian match results)

88% of USU students matched to their first choice specialty

• USAF = 92% match to specialty • USN = 92% match to specialty • USA = 85% match to specialty (w/ 75% of those matched to 1st choice specialty also matched to 1st choice location)

12% did not match into their first choice specialty • OBGYN (4), EM (2), Psych (1), Peds (2), ENT (2), Rads (2), Derm (1), Path (1), Gen Surg (1), PMR (1), Ophtho (1), Ane (2), Neurosurgery (1) • 18 students placed into military preliminary year training positions; 1 student matched to civilian prelim position

13/172 (8%) of students continued into the civilian match

• Up from ten (10) in class of 2019; and nine (9) in the class of 2018 • Specialties include: EM (2), Urology (1), Psych (1), Anesthesia (4), Gen Surgery (3), Neurosurgery (1), FM (2 = PHS students) • Service breakdown USAF (7), USA (3), USN (1), PHS (2) • Civilian match results: 11/13 students matched to civilian program in specialty selected at JSGMESB, as listed in bullet 2. However, one did not match in neurosurgery but scrambled and secured a civilian PGY prelim year. One other did not match in ANE & unsuccessfully scrambled; USAF is placing in a military PGY1 position.

Final Specialty Distribution Class of 2020

Total # Percent National Specialty students of class match Emergency Medicine 20 12% 9% Family Medicine 18 10% 9% Internal Medicine 19 11% 19% Psychiatry & Med/Psych 16 9% 6% General Surgery 11 6% 6% Anesthesia 9 5% 5% Radiology 10 6% <1% Orthopedics 7 4% 4% Pediatrics 7 4% 10% OB/GYN 5 3% 6% Urology 4 2% <1% Otolaryngology 4 2% 1% Neurosurgery 1 <1% 1% Ophthalmology 2 1% <1% Pathology 2 1% 1% Dermatology 1 <1% <1% Neurology 1 <1% 2% Physical Medicine & Rehab 1 <1% <1% Transitional Year 27 16% 4% PGY 1 Medicine or Peds 6 3.5% 8% PGY 1 Surgery 1 <1% 2%

Note: 12 of the 27 students purposefully selected TY internships for 3 reasons: 1) Early career goals in Flight or Dive Med, 2) Restrictions on specialty applications to PGY2 level only (e.g. Anesthesia, Ophthalmology & Occ Med in USN; Derm in USAF and USN), 3) Persistent specialty indecision. The other 15 did not match to desired specialty. During their transitional year they will either: a) reapply and match; b) match in a different specialty or c) enter service at end of TY as general medical officers or operational medical officers (e.g., Dive or Flight Med; brigade or battalion surgeon). School of Medicine 2020 Graduation Awards

Board of Regents Award, School of Medicine ENS Chandler Bennett Omni Cassidy, PhD

Vice Admiral James A. Zimble Valedictorian Awards ENS Chandler Bennett ENS Ama Winland

Association of Military Surgeons of the United States (AMSUS) 2d Lt Marc Gutierrez

United States Army Surgeon General Award 2LT David Ediger

United States Navy Surgeon General Award ENS Ama Winland

United States Air Force Surgeon General Award 2d Lt Taylor O’Neil

United States Public Health Service Surgeon General Award ENS Michael Harding

Association of the United States Army (sponsored by the Association of the United States Army) 2LT Katey Osbourne

Navy League Award (sponsored by the National Capital council of the Navy League) ENS Sarah Wright

Air Force Association Award (sponsored by the Nation’s Capital Chapter of the Air Force Association) 2d Lt Jeremy Mears

School of Medicine Esprit de Corps 2d Lt Marc Gutierrez

Faculty Awards

School of Medicine Outstanding Civilian Educator Award David Mears, PhD

School of Medicine Outstanding Biomedical Educator Award Tracy Sbrocco, PhD

Carol Johns Medal Martin Ottolini, MD

William P. Clements Award Lt Col Grigory Charny

TAB 20 Inouye Graduate School of Nursing Report

Board of Regents Brief

Submitted by: Carol A. Romano, PhD, RN, FAAN Date: April 14, 2020

Title & School: Dean, Graduate School of Nursing Phone: 301-295-9004

Purpose: Information Action ______

Subject: Dean’s Report – Graduate School of Nursing

Education

General Information

• US News 2020 National rankings of Best Graduate Nursing School ranked the GSN doctor of nursing practice program (DNP) #25 and the masters of science in nursing program (MSN) #40 of 603 schools surveyed, based on 14 indicators. Our programs are in the top 5% and top 10 % respectively. These rankings are an increase from 2019 (#32 to #25 for DNP and #41 to #40 for MSN.) The GSN nurse anesthesia program ranks #4 of 112 accredited graduate programs.

• 2019 GSN Annual Report Info graph “GSN by the Numbers” Attached.

• The 2020 Graduating class includes 3 PhD students, 59 DNP and 1 MSN student for a total of 62 graduates, bringing the overall number of GSN alumni to 1005 (262 DNPs, 698 MSNs and 45 PhDs).

• All graduating 2019 FNP & WHNP students passed their specialty certification on first attempt.

• 2020 DNP Project summary. In 2020, GSN DNP students completed a total of 22 DNP Projects at 17 Military Treatment Facilities. Number of projects by theme: o Two: Behavioral Health o Six: Pain Management o Eight: Patient Safety: Evidence Based Practice Clinical Performance o Two: Patient Safety: High Risk Procedures and Process Evaluation o One: Improving Care Systems o Three: Women’s Health

May 2020

GSN Response to 2020 COVID-19 National Emergency

• Accelerated Graduation: All students due to graduate in May completed graduation requirements early: 1 APRIL (FNP and AGCNS) and 1 MAY (RNA). Virtual graduation and awards ceremony planned and executed very successfully.

• Transition to fully online content delivery: on March 16, 2020. All faculty teleworking. Faculty and administrative staff evaluating instructional software purchases to assist in distance learning efforts, particularly for coursework that requires simulation and use of standardized patients. May-July access to cadaver lab lost; exploring software options and creative redesign.

• Class of 2021: Nurse Practitioners awaiting orders to PCS to MTFs to complete Phase II training. Summer courses launched early with flexible due dates and adjustments to clinical assignments.

• Class of 2022: Spring semester ends 24 April. Students on stand by for clinical need at D.C.VA or Walter Reed April 24-Mary 11. Curriculum content shifted to continue virtually May 11.

• Class of 2023 (incoming): APRN and PhD arrivals delayed by DoD travel restriction. Original start date 1 May revised to potentially as late as 24 August with DoD travel ban of June 30. Faculty actively working on curriculum adjustments. Designing options for curricular models for 1 July & 24 Aug start dates.

• Military Sexual Assault Course: Online modules completed, but clinical simulation event involving 220+ students transitioned to virtual event with 24 hours notice. Videotaped 2 events and debriefed all students with SAMFE/SAFE in virtual small groups.

• GSN COVID-19 Training Course: developed in collaboration with SOM and disseminated to faculty and students. Total of 202 participants have completed; all students in classes of 2020, 21 and 22, and 13 faculty. Course modules:

o Understanding COVID 19 & Patient Screening o Stopping the Spread & Best Practices on PPE (Additional training will be provided by the facility you work at) o Take Care of Yourself and Your Family o Effective Patient Communication (decreasing fear/anxiety) o Medical Emergency Training

May 2020

Leadership and Service

General Information

• Commander Naval Surface Force Atlantic hosted USU faculty, SOM, GSN and psychology post-doctoral fellows and interns from Naval Medical Center Portsmouth for a visit to Naval Station Norfolk. Students and faculty actively engaged with sailors, medical staff, and ship leadership with presentation from Master Chief Goodrich and guided tours of three surface ships by CNSL Force Master Chief.

• Dr. Elizabeth Kostas-Polston was invited to consult with Defense Health Board (DHB) on contraceptive services and military field practices for preventing genitourinary infections; she is also providing consultation to AF/A1 Barrier Analysis Working Group (AFBAWG) Women’s Initiative Team (WIT) leading a multi-faceted effort to change AF policies to increase retention for female employees in the AF.

• Navy perioperative specialty leaders and BUMED staff requested collaboration with the GSN Clinical Nurse Specialist (CNS) faculty to design and deploy a West Coast High Level Disinfection Program that mirrors the annual USU program. A briefing to USN BUMED specialty leaders about GSN CNS program resulted in new Navy training billets for matriculation in 2021.

• USU GSN nurse anesthesia faculty collaborated with US Army graduate program in nurse anesthesia (USAGPAN) on a comparative analysis of the 2 military anesthesia programs at the American Association of Nurse Anesthetists annual conference.

GSN Response to 2020 COVID-19 National Emergency

• GSN alum (2000) - Col. Virginia Garner, Board certified Nurse practitioner is the Command Surgeon leading the Air Force Global Strike Command (AFGSC) fight against COVID-19.

• GSN planning for potential to request from D.C. VA for nursing support for COVID-19 in intensive care. Faculty assigned to assess need and coordinate RN student response to “pair” with ICU VA nurses for staffing relief and learning opportunity about VA health care system. Students volunteered and will be scheduled for 1 week rotations (April 20-May 14) with faculty on site for assistance, ventilator management as student resource. Pending VA request for surge capacity.

Research and Scholarship

• Dr. Elizabeth Kostas-Polston’s study, “Military Readiness in Active Duty Military Women - The Impact of the Availability of Water and Basic Sanitation on Hygiene and Urogenital

May 2020

Health” was funded by the Military Women’s Health Research Colloquium. Phase III. MWHRC-USU ($1,375,000).

• Dr. Jouhayna Bajjani-Gebara was appointed as principal investigator for a CDMRP grant for “Adjustment Disorders in the US Military: Addressing Gaps in Knowledge and Practice.” CDMRP ($1,136,400).

• Dr. Candy Wilson’s "Military Women's Health Summit" was funded by the Military Women's Research Colloquium, MWHRC-USU, $65,000

Publications/Presentations

• AGCNS faculty collaborated on four TSNRP poster and podium presentations and guided a student to a third place poster award at the 2020 Association of periOperative Registered Nurses Conference

• AGCNS faculty collaborated on four TSNRP poster and podium presentations and guided a student to a third place poster award at the 2020 Association of periOperative Registered Nurses Conference

• Archer, H.A., Johnson, H.L. & Toedt, M. (2020). Academic-Clinical Partnerships in Clinical Education. National Congress of American Indians Tribal Nations Policy Summit, 116th Congress Executive Council, Crystal City, VA. (Invited)

• Rodriguez, J., Hooper, G. (2020). Adenosine Triphosphate-Bioluminescence Technology as an Adjunct Tool to Validate Cleanliness of Surgical Instruments. (Conference canceled due to Covid-19)

• Schramm, J., Taylor, L., Uranga, T., Birkle, A. Thorp, R. (2020, March 26-28). Introducing APRN students in the Armed Forces to the Power of Transdisciplinary Integrative Methodologies [Poster session cancelled]. STTI/NLN Nursing Education Research Conference, Washington, DC. https://www.sigmanursing.org/connect-engage/meetings-events/nerc

• Williams, J, Taylor, L. & Seibert, D. (March 26-2020) Disruptive Education for the 21st Century: Bringing Telehealth Clinic to the Pathophysiology Classroom; STTI/NLN Nursing Education Conference, March 26th 2020 (Conference canceled due to Covid-19)

• Hays, S.,Johnson, H. & Taylor, L.A. (In press). A Toddler with Sudden Onset Tremors and Change In Temperament, The Journal for Nurse Practitioners.

• Marsh, E.,Uranga, T., & Mark, A. L. (2020, April). Managing Anxiety and Stress Amid COVID-19, [electronic newsletter]. CANA Member e-Letter.

May 2020 • Williamson, J. Vulvovaginitis. (In Press) In A. Hollier, 4th Edition , Clinical Guidelines in Primary Care. Lafayette, LA: Advanced Practice Education Associates.

• Wilson, C. (March 2020) Care needs of the active military after aeromedical evacuation: The efficacy of an animal-assisted intervention to reduce biological and psychological stress. SNRS 2020 (Conference canceled due to Covid-19)

Faculty & Staff

• Consistent with GSN 1100B policy Honorary Professor of Nursing title was designated for Federal Nursing Service Council Chief Nurses: RDML Tina Davidson (Navy), RADM Aisha Mix (USPHS), and Dr. Beth Taylor (VA).

• Two military faculty promoted: Lt Col Regina Owen, LTC Jacob Deeds; Lt Col John Williamson selected for Colonel

• PMHNP faculty selected and in process in CHR.

• 5 Faculty Vacancies:

1. Assistant/Associate/Professor nurse anesthesia (CRNA) 2. Assistant/Associate/Professor Family Nurse Practitioner (FNP) 3. Assistant/Associate/Professor Psychiatric-Mental Health Nurse Practitioner (PMHNP) 4. Assistant/Associate/Professor Clinical Nurse Specialist (AGCNS) 5. Assistant/Associate/Professor PhD programs;

• 7 Staff Vacancies: 1. Budget Analyst 2. Dean’s Secretary 3. 3 program support specialists 4. Management program analyst 5. Education technician

• 3 positions temporarily filled with contractors while awaiting GS replacements 1. Education Technician 2. Program Support Specialists (x2)

• GSN working with CHR to process selected hires for 2 other vacancies.

May 2020 GSN By The Numbers | 2019

213 Full Time Students Ranked Ranked 7 Part Time Students #32 #4 DOCTOR OF NURSE NURSING ANESTHESIA PRACTICE Program Options

Students by Specialty AGCNS (DNP) AGCNS (MSN) FNP WHNP RNA PMHNP PHD 3 3 72 7 91 27 17 PROGRAM 45 GRADUATES 942 ALUMNI DEGREES | 40 DNP • 2 MSN • 3 PHD

99% Faculty with Doctoral Degrees • 41% Faculty are Alumni

DIVERSITY OF STUDENT BODY OF STUDENT DIVERSITY

FEMALE MALE GSN By The Numbers | 2019

f 15 Faculty fellowships in 5 professional organizations 5 Faculty members on 12 journal editorial boards

18 Faculty reviewers for 32 journals 130 Faculty publications, presentations and posters 4 Jonas Scholars • 2 Robert Wood Johnson Scholars 100% $2M $5.3M

SCHOLARSHIP & LEADERSHIP & LEADERSHIP SCHOLARSHIP New Grant Active Grant APRN Dollars Funding CERTIFICATION PASS RATE

1957 Average Clinical Hours per Student

119 CLINICAL SITES OPERATIONAL EXPERIENCES OPERATIONAL 3 OPERATIONAL READINESS ELECTIVE TRAININGS

Dive Medicine & Water Rescue Military Mountain Medicine Cold Weather & Avalanche

CLINICAL & CLINICAL 56 Students Trained 51 Students Trained Medicine 16 Students Trained

116 GSN Students Trained • 123 Students Trained University-Wide GSN By The Numbers | 2019

213 Full Time Students Ranked Ranked 7 Part Time Students #32 #4 DOCTOR OF NURSE NURSING ANESTHESIA PRACTICE Program Options

Students by Specialty AGCNS (DNP) AGCNS (MSN) FNP WHNP RNA PMHNP PHD 3 3 72 7 91 27 17 PROGRAM 45 GRADUATES 942 ALUMNI DEGREES | 40 DNP • 2 MSN • 3 PHD

99% Faculty with Doctoral Degrees • 41% Faculty are Alumni

DIVERSITY OF STUDENT BODY OF STUDENT DIVERSITY

FEMALE MALE GSN By The Numbers | 2019

f 15 Faculty fellowships in 5 professional organizations 5 Faculty members on 12 journal editorial boards

18 Faculty reviewers for 32 journals 130 Faculty publications, presentations and posters 4 Jonas Scholars • 2 Robert Wood Johnson Scholars 100% $2M $5.3M

SCHOLARSHIP & LEADERSHIP & LEADERSHIP SCHOLARSHIP New Grant Active Grant APRN Dollars Funding CERTIFICATION PASS RATE

1957 Average Clinical Hours per Student

119 CLINICAL SITES OPERATIONAL EXPERIENCES OPERATIONAL 3 OPERATIONAL READINESS ELECTIVE TRAININGS

Dive Medicine & Water Rescue Military Mountain Medicine Cold Weather & Avalanche

CLINICAL & CLINICAL 56 Students Trained 51 Students Trained Medicine 16 Students Trained

116 GSN Students Trained • 123 Students Trained University-Wide TAB 21 Postgraduate Dental College Report Uniformed Services University of the Health Sciences Board of Regents

Board Brief

Submitted by: Thomas R. Schneid, DMD, MS Date: May 15, 2020

Title & Department: Executive Dean, Postgraduate Dental Phone: 210-299-8506 College (PDC)

Purpose: Information X Action

Subject: PDC Dean’s Report

Significant Issues:

1. The COVID-19 pandemic has dominated the PDC agenda for a significant period of time since the last meeting. Specific issues impacted are listed below:

- The PDC staff in San Antonio initiated full-time teleworking, effective March 18, 2020.

- The PDC Executive Dean and the Deans of the Army, Navy, and Air Force Postgraduate Dental Schools have regularly participated in the American Dental Education Association’s United States and Canadian Dental School Deans’ Forum where updates on COVID-19 dental education-related issues have been discussed.

- PDC-affiliated dental residencies provided only urgent, emergent or mission-essential care in compliance with ASD (HA) memo directing that elective surgical, invasive, and dental procedures in Military Treatment Facilities be postponed for 60 days.

- Commission on Dental Accreditation (CODA) guidance: 1) Cancellation/postponement for 1 year of any scheduled Site Visit. This will affect 3 Army residencies at Fort Gordon, previously scheduled for Site Visits in August of 2020. 2) A report was required from all CODA-accredited programs on COVID-19 related temporary implementation of Distance Learning. Reports were filed by the Services and copies provided to the USU Assistant Vice President for Accreditation and Organizational Assessment. 3) Reporting requirements for “Temporary Flexibility in Accreditation Standards to Address Interruption of Education Reporting Requirements Resulting From COVID-19 for the Class of 2020” were released on April 14, 2020. Applicable programs are drafting reports for submission.

- All 7 PDC-affiliated training locations are expected to complete training on June 30, 2020, as scheduled.

- On April 20, 2020, The Secretary of Defense issued “Modification and Reissuance of DoD

Response to Coronavirus Disease 2019-Travel Restrictions”. This order stops movement through June 30, 2020, including travel for permanent change of station relocation for incoming students. The Service dental deans are pursuing waivers through their chains of command in order to allow students to arrive at training locations in time to start date the new academic year on July 1, 2020.

- Uncertainty regarding dental school graduation dates/board exams/dental licensing may impact new accession of military dentists. The potential impact on timely start for PGY1 programs is yet to be determined. The American Dental Education Association (ADEA) submitted a letter to the National Governors’ Association on April 8, 2020 to request consistent relief of licensing requirements for students scheduled to graduate in 2020.

- The PDC is actively participating in the USU COVID-19 After-Action Review (AAR) and Pandemic Campaign Plan ad hoc Planning Committee.

- Significant COVID-19 Pandemic-related cancellations: 1) ADEA annual meeting to include Council of Deans Meeting. 2) Federal Services Dental Educators’ Workshop. 3) PDC involvement in USU Research Week. 4) USU-hosted interdisciplinary version of the Stanford Clinical Instruction faculty development course scheduled to be held in San Antonio.

2. Seventy-seven Army, Navy, Air Force, US Coast Guard, and Canadian Forces students at the seven PDC-affiliated training locations are projected to earn Master of Science in Oral Biology degrees. Graduates will receive diplomas, pending completion of all degree requirements, and endorsement and approval by the Board and the President, USU. Due to the current pandemic, formats for presentation ceremonies are under evaluation, but will most likely be conducted virtually or in venues where physical distancing can be maintained. The link to the USU virtual commencement has been provided as an example to the Service Deans as they confront alternative ceremony options. At the completion of this academic year, USU will have awarded a total of 547 Masters of Science degrees to program graduates. One additional student will require an added 3-6 months in training to complete requirements.

3. The Substantive Change Request and Teach-Out Plan for the closure of the Air Force Endodontics and AEGD-2 Comprehensive Dentistry residencies at Keesler Air Force Base was submitted previously to the Middle States Commission on Higher Education (MSCHE) via the USU Assistant Vice President for Accreditation and Organizational Assessment. Final dispensation from MSCHE should be released following their April 30, 2020 meeting. No impact on the University’s accreditation status is anticipated.

4. Research activities of note: Associate Dean for Dental Research (ADDR) initiatives

- The PDC, in collaboration with Naval Medical Research Unit, San Antonio, was granted a dental-focused breakout session at the Military Health System Research Symposium (MHSRS), scheduled for August 2020.

- The ADDR visited the Comprehensive Dentistry Residency at Fort Hood TX and presented Research Design lectures which employed assigned readings in conjunction with Sakai-based audio-visual presentations.

- The ADDR continued pursuit of Memoranda of Agreement for research collaborations with The Ohio State University College of Public Health and The University of Kentucky College of Dentistry.

- The ADDR held discussions with the Sleep Medicine Department at JBSA-Lackland, TX concerning development of an interprofessional medical-dental research program.

- The ADDR is actively involved as the primary PDC representative for the USU Strategic Planning subcommittee for Research.

- Highlights of MS Degree Research: The Endodontics Residency at Joint Base San Antonio Lackland TX, has consistently excelled in conducting outstanding dental research. All six graduates from the classes of 2017, 2018, and 2019 have published their Masters of Science in Oral Biology research in peer-reviewed journals. Four of the publications were featured as cover articles, including the publication in the May 2020 edition of the International Endodontic Journal, which is the highest “Impact Factor” endodontic journal in publication and gave the USU international recognition.

5. Faculty activities/initiatives of note: Associate Dean for Faculty Affairs (ADFA) initiatives

- The ADFA is actively involved as the primary PDC representative for USU Strategic Planning on subcommittees for Leadership and Education.

- The ADFA is currently serving on the USU Registrar’s Coordination Committee and the USU Distributed Learning Working Group.

6. Tri-Service Center for Oral Health Studies (TSCOHS) update: 1) The Director and Assistant Director were nominated by the Navy and Air Force and selected by the Defense Health Agency to serve on the Technical Evaluation Team for the Source Selection Evaluation Board for the Active Duty Dental Program. 2) TSCOHS submitted two abstracts to MHSRS that highlight the role of military dentistry in dental readiness and deployed environments.

7. Col James Knowles will succeed Col Jay Graver as the next Dean of the Air Force Postgraduate Dental School (AFPDS). Col Knowles has served as the Associate Dean, AFPDS, since 2018, and Associate Professor of Comprehensive Dentistry since 2016. He currently serves as the Consultant for General Dentistry to the Air Force Surgeon General.

Current & Future Concerns:

Funding/Budget Estimate/Fiscal Impact:

Staffing Impact:

Board Action Requested:

TAB 22 College of Allied Health Sciences Report Uniformed Services University of the Health Sciences Board of Regents Board Brief

Submitted by: Lula W. Pelayo, Ph.D. RN, FAAN Date: April 15, 2020

Title & Department: Acting Dean, College of Allied Health Sciences Phone: 210-299-8529

Purpose: Information X Action X

Subject: CAHS Brief

Significant Issues:

Information:

Education & Training:

The total enrollment for CY 2020 is roughly 2100 with an average daily census of 1062. This number includes 196 new student enrollments for programs added last USU BoR.

Students have enrolled in programs as follows (in order of addition to the CAHS): -Education and Training Administration and Leadership (A, N, AF) -Preventive Medicine Technician (A, N) -Nuclear Medicine Technician (A, N, AF) -Medical Laboratory Technician (A, N) -Histology Technician (AF, N) -Urology Technician (AF, N) -Neurodiagnostics Technology (AF, N) -Critical Care Air Transport (AF - Stand Alone Course) -Nutrition Science (A, AF) -Cytology Technician (A) -Occupational Therapy Technician (A, N) -Radiologic Technician (A, N, AF) -Independent Duty Corpsman - Submarine (N) -Paramedic (A) -Independent Duty Corpsman - Surface (N)

Students are enrolling in the following approved Programs; Implementation is Summer 2020 -Respiratory Technician (A, N) -Cardiovascular Technician (N) -Cardiopulmonary Laboratory Apprentice (AF) In April 2020, the COVID 19 situation impacted Service’s student resulting in the following programs having cohort cancellations and postponements: - Nutrition Science (A, AF) - Occupational Therapy Technician (A, N) - Health Physics (A) - Independent Duty Corpsman - Submarine (N)

Additionally, the Army has divested from the Additional Skill Identifier “M2”, Cytology Technician. As a result, the offerings in Cytology Technician (A) program are suspended.

Total faculty appointments increased to 293 -4 Professors (< 1.3% of faculty) -1 Associate Professor -288 Assistant Professors and below

Graduates Calendar Year 2019 Total degrees awarded/recommended: 117 -71 Army; 43 Navy; 1 Air Force -84 ASHS and 34 BSHS degrees

May 2020 Total degrees awarded/recommended: 88 -49 Army; 31 Navy; 7 Air Force; 1 Coast Guard -46 ASHS and 42 BSHS degrees

Research & Scholarship:

CAHS continues to be invited frequently by industry leading entities and individuals for presentation and discussion of our innovative educational administration model. Conference & Presentations this period included the following:

- 6 Mar Texas A&M AgriLife Extension Service Meeting on Veterinary Technician Credentialing - 8 Mar Council of College and Military Educators - 17 Apr Medical Airmen Degree Work Group (MAD-WG) with CAHS, AETC, CCAF and Air University - 21 Apr Army Paramedic Advisory Board

Other areas of Service Support interest in various stages of exploration are:

METC Phase II (DHA) CHAMP Warrior Nutrition (USU) Special Forces Medic and Corpsman (JSOMTC) Army Licensed Vocational Nurse (MEDCoE) Veterinary Technician (MEDCoE) Veterinary Food Inspection Specialist (MEDCoE) Action:

In accordance with USU PPM 008-2019, Establishment of New Academic Programs, and as detailed in the supplemental information of this report, one new program is proposed for implementation at the next available iteration. This is the:

1. Ophthalmic Technician (USA and USAF) – This is an Interservice Training Review Organization (ITRO) consolidated program, with two Services participating, executed at the METC. The Army track is accredited through the International Council of Accreditation and the Air Force track is accredited with the Accreditation Council on Optometric Education. Credentialing is afforded via the American Optometric Association and the Joint Commission on Allied Health Personnel in Ophthalmology. The program is currently executed with the community College of the Air Force. This course is proposed at 19 semester hours in the Major for the Army and 18 semester hours for Major in the Air Force students. The degree plan is for 60 hours for both Services.

It is requested that the BoR concur with the recommendation to implement the Army and Air Force Ophthalmic Technician programs at the next available iteration, which is projected to be 10 August 2020.

Current & Future Concerns: No significant concerns at the time of submission. Funding/Budget Estimate/Fiscal Impact: DHA is funding this program. Staffing Impact: No significant concerns at the time of submission. Board Action Requested: Action 1. As of 13 April 2020 UNCLASSIFIED

Learning to Care for Those in Harm’s Way

USU / CAHS Update

Dr. Lula Westrup Pelayo Acting Dean

1 UNCLASSIFIED USU / CAHS Status Update Learning to Care for Those in Harm’s Way

• Fourteen active programs, w/ three more approved pending start dates, w/USU as academic institution of record.

• USU BoR scheduled to be briefed on Army / Air Force Ophthalmic Tech Program on 15 May 2020.

• USU supporting Service Requirements with METC Branch Campus, and four Other Instructional Sites (MEDCoE, NMFSC x 2, USAFSAM)

• Courses w/ USU equites, request prospective coordination during development (Notional POI)

2 UNCLASSIFIED CAHS Status Update Learning to Care for Those in Harm’s Way

Program Implementation Date Student Load Army Navy Air Force FY 17 ETAL 17-Apr-17 60 35 20 5 FY 18 Prev Med 13-Mar-18 233 147 86 0 Nuc Med Tech 11-Jul-18 22 8 4 10 Med Lab Tech 27-Jul-18 650 443 207 0 Incremental New Student Load for FY 18 905 FY 19 Histotechnician 4-Mar-19 13 0 6 7 Urology Tech 20-Mar-19 19 0 12 7 Neurodiagnostic Tech 27-Mar-19 10 0 5 5 Nutrition Care 28-May-19 144 113 0 31 Cytotechnologist 31-Jul-19 7 7 0 0 Occupational Therapy 5-Aug-19 39 35 4 0 Radiology Tech 26-Aug-19 423 229 90 104 Incremental New Student Load for FY 19 655

3 UNCLASSIFIED Proposed New Academic Programs Learning to Care for Those in Harm’s Way

Proposed Student Program Army Navy Air Force Implementation Date Load FY 20 Respiratory Therapist 8-Jun-20 119 90 29 0 Cardiovascular Technician 1-Jul-20 20 0 20 0 Cardiopulmonary Laboratory Apprentice 6-Jul-20 57 0 0 57 Student Program Proposed BoR Date Army Navy Air Force Load Ophthalmic Technician 15-May-20 92 45 0 47 Pharmacy Technician 4-Aug-20 346 142 96 108 Dental Laboratory 4-Aug-20 90 21 28 41 Hospital Corpsman Basic 4-Aug-20 4300 0 4300 0 Incremental New Student Load for FY 20 5024 FY 21 Surgical Technologist TBD 510 259 165 86 Dental Assistant TBD 288 0 0 288 Med Lab Assistant TBD 157 0 0 157 Incremental New Student Load for FY 21 955

4 College of Allied Health Sciences JBSA-Fort Sam Houston, TX 78234

Purpose: To update the USU President on the Army / Air Force Ophthalmic Technician (OPHT) Program. Value Proposition: FY 20 Projected Student load is 39 Army and 47 Air Force for a Bottom Line: total student load of 86 students / year. - CAHS is preparing to implement the Army / Air Force OPHT OPHT fracked curriculum is 19 semester hours / student for Army program IAW the approved METC transition plan. and 18 semester hours/ student for Air Force. The anticipated USU BoR date is: May 2020. - USU/CAHS academic sharing model preserves programmatic Vol Ed value / sem hour is $250 / sem hr accreditation with the International Council of Accreditation Army: 39 x 19 = 741 sem hours (Army) and the Accreditation Council on Optometric Education Air Force: 47 x 18 = 846 sem hours (Air Force). 741 sem hours + 846 sem hours = 1,587 sem hrs - The program is currently with Community College of the Air x $250 / sem hr = $396,750 in Vol Ed (USD P&R) value Force. provided at minimal cost.

Way Ahead: CAHS continues phasing in Sec 724 of the 2017 Accreditation & Credentialing: NDAA, awarding undergraduate credit to enlisted programs. The Army track is accredited by the International Council of Accreditation and the Air Force track is accredited with the Accreditation Council on Optometric Education

Student Population: Credentialing is afforded via the American Optometric This is an initial entry training (IET) school for both Army and Association and the Joint Commission on Allied Health Personnel Air Force Students. Beyond Service specific basic training, there in Ophthalmology. are no current academic prerequisites or degree conferral requirements.

Resources: POC: This program is fully resourced by the DHA & the METC. Mr. Dennis Kilian /ADUS/ CAHS (210) 299-8526

10 April 2020 DEFENSE HEALTH AGENCY MEDICAL EDUCATION AND TRAINING CAMPUS 3176 CPL JOHNSON ROAD JBSA-FORT SAM HOUSTON, TEXAS 78234-1247

Dean, Academic Affairs January 21, 2020

MEMORANDUM FOR DEAN, UNIFORMED SERVICES UNIVERSITY COLLEGE OF ALLIED HEALTH SCIENCES, JBSA-FORT SAM HOUSTON, TEXAS 78234

SUBJECT: Request for Degree Plan Evaluation of Ophthalmic Technician Program

In order to continue the progress and success of the partnership between Medical Education and Training Campus (METC) and the Uniformed Services University College of Allied Health Sciences (USUCAHS), the Dean of Academic Affairs requests the Ophthalmic Program (Army, Air Force) be evaluated for inclusion in the USUCAHS catalog.

The Ophthalmic Technician Program provides didactic and practical training in tasks relating to ocular screening, diagnosis, and treatment to include optical devices and surgical interventions. Patient education and interaction, basic clinical administration, care of instruments and equipment, and operating room protocol are also covered. Subjects include anatomy and physiology, medical ethics, ocular pathology, pharmacology, optics, refractive surgery, vision and specialty testing, and aseptic technique.

The Air Force Ophthalmic Apprentice program is accredited by the Accreditation Council on Optometric Education. The Army Eye Specialist program is accredited by the International Council of Accreditation.

Point of contact for this request is CMSgt Erlinda Schommer at (210) 808-1250 or email [email protected].

RICHARD A. VILLARREAL COL, SP, USA Dean Academic Affairs Ophthalmic Technician (OPHT) Program Projected starts: 5 programed for FY 20 Projected students per start: 39 Army for FY 20 47 USAF for FY 20 86 total for FY 20

Services: Army / Air Force

Program length: Phase I is 8 weeks at Fort Sam Houston (METC), followed a 5 week Phase II clinical practicum at select Army or Air Force hospital locations.

FY 2020

Location(s): SATX

Phase II Coorindaited by METC at 9 DHA hospital locations.

Location(s): Texas, Kentucky, Colorado, Virginia, Washington, and North Carolina

Admissions requirements:

Army

Curriculum Planning Document

Title: ______Ophthalmic Technician___

Scope: x New x Undergrad Grad Modify Undergrad Grad x Degree Degree x Major (15 – 30 sem hr) Major (15 – 30 sem hr) Minor (12 – 15 sem hr) Minor (12 – 15 sem hr) Course(s) Course(s)

Magnitude: Total Courses __8___ Total Semester Hours __26____

Description: The Ophthalmic Technician Program prepares Service Members to function as entry-level Ophthalmic Technicians in fixed and deployable medical facilities, performing tasks associated with ocular health and vision care. Upon completion of this program, the student is expected to provide competent Ophthalmic Technician Assistant services in the areas of patient evaluation, treatment, documentation, health promotion, and injury prevention under the supervision of a qualified licensed Doctor of Optometry or Ophthalmology within a variety of clinical and field environments. Technical proficiency in all skills required to fulfill the role of an entry-level ophthalmic technician is required to complete this course. This is a two phase program, with phase one occurring at the METC Branch Campus, Fort Sam Houston, Texas; phase two occurs at a Defense Health Agency (DHA) coordinated clinical facility, in accordance with respective Service requirements.

Design: Select all the following that apply to this curriculum proposal:

Didactic Laboratory Clinical/Internship Traditional X Traditional Traditional 2 hrs out:1 hr in Some preparation required No preparation required Factor = 14 Factor = 28 Factor = 45* X Modified Modified X Modified 1hr out:1 hr in No preparation required Some preparation required Factor = 28 Factor = 42 Factor = 30 Highly Modified Simulated Simulated No preparation required Factor = 28 with some prep Factor = 45* with no prep Factor = 42 = 42 with no prep Factor = 30 with some prep Blended / On-line Alternative Instructional Equivalents must be identified Factor = 15 *in some circumstances, the federal definition of a credit hour allows a factor of 30 for clinical courses that require a minimum number of clock hours of student participation.

Prefix # Title Design Factor OPHT 1201 Intro to Ophthalmic Care Mod Didactic 28 OPHT 1102 Ocular Pathology, Trauma, and Pharmacology Mod Didactic 28 OPHT 1203 Optics Mod Didactic w/ lab 28 OPHT 2101 Introduction to Ophthalmic Surgery Mod Didactic w/ lab 28 OPHT 2502 Fundamentals of Patient Screening & Ancillary Testing Mod Didactic w/ lab 28 OPHT 2104 Optometric Care in a Deployed Setting (Army) Mod Didactic w/Lab 28 OPHT 2703 Clinical Practicum (Army) Mod Didactic w/ Lab 30 OPHT 2713 Clinical Practicum (Air Force) Mod Didactic w/ Lab 30 Feasibility Analysis (Ophthalmic Technician)

Student Projection

Projected Iterations per year: __5___ Projected Students per Iteration: __24___

Faculty Projection

Ratios: Didactic: max of 30:1 Laboratory: max of 8:1+ Clinical/Internship: max of 2:1+ +Programmatic accreditation requirements supersede the established CAHS required student-faculty ratios

Faculty: 24:1 6:1 6:1 7 Didactic Laboratory Clinical/Internship Total

Explain: Instructors for this program are resourced thru the Army / USAF Requirements Resources Analysis, adjusted regularly, via the Interservice Training Requirements Office (ITRO), supporting Service manning requirements. As Service requirements change, so do available on-hand instructors and associated teaching facilities. Program currently has 8 instructors.

Facility Projection

Total Facility Requirement: 1 6 11 Didactic Laboratory Clinical/Internship Classroom(s) Facility(s) Facility(s) MOU_N/A_ MOU____ Explain: Didactic & laboratory facilities for this program were constituted via BRAC 2005, implemented in 2010. These resources are budgeted via the Defense Health Agency's Medical Education & Training Campus, Fort Sam Houston, TX. Clinical sites are funded via the DHP budget at clinic sites, worldwide.

Funding Projection

Funding: CAHS/USU x Other METC/Services

Adequate: x Yes No

Explain: This is a DHA / J-7 BAG 6 funded program. USU J-8 coordinat ed with DHA J-8 for resourcing.

Feasible: Student Faculty Facility Funds x Yes No x Yes No x Yes No x Yes No

I have reviewed the Curriculum Planning Document and the Feasibility Analysis and find this proposal to be: x Acceptable pending approval of coursework by the CAHS Curriculum Committee. Unacceptable as reported.

______Signature Date Curriculum Proposal

The following CAHS personnel met in quorum as a committee on ______10 April 2020___to discuss and vote on the proposed and attached CAHS curriculum:

Title: Ophthalmic Technician

Proposed Curriculum Sponsor: Lt Col Brian Blanchard

Committee Membership

Program Sponsor: Lt Col Brian Blanchard X Yes □ No □ Abstain

Curriculum Committee Member: MAJ Brittany Ellis X Yes □ No □ Abstain

Curriculum Committee Member: Aldrin Augustus, CPO, USN X Yes □ No □ Abstain

Curriculum Committee Member: HM1 Delon Lewis, HM1, USN X Yes □ No □ Abstain

Curriculum Committee Member: Michael Bowe-Rahming, LT, USN X Yes □ No □ Abstain

Curriculum Committee Member: Aldrin Augustus, CPO, USN X Yes □ No □ Abstain

Curriculum Committee Member: Stephanie Shishido, SSgt, USAF X Yes □ No □ Abstain

Curriculum Committee Member: Suzan Bowman, PhD X Yes □ No □ Abstain

Curriculum Committee Chair: Dennis Kilian □ Yes □ No X Abstain

Dean ______□ Approve □ Remediate □ Reject Signature Date

Comments: This program has dual accreditation. For the Army track accreditation is via the International Council of Accreditation and the Air Force Track is via Accreditation Council on Optometric Education. The program will shift Institutional sponsorship from Air University to USU. TAB 23 Office of Accreditation and Organizational Assessment Report MIDDLE STATES COMMISSION ON HIGHER EDUCATION

MAY 2020 ACCREDITATION UPDATE Accreditation Report: Summary Current Events

• Keesler AFB Master’s in Oral Biology Program closure: MSCHE Board action - 30 April 2020

• Committee on Accreditation of Healthcare Management Education (CAMHE) Site visit 11 -13 March 2020 – went exceptionally well

• final report not received yet

• Site visit Outbrief: all standards met but 4 partials

• Maximum 10 year re-accreditation anticipated

• Upcoming 2020 reaccreditation on-site visits: AAALAC (Lab Animal); CODA/Ft. Gordon (Dental); and CEPH (Public Health) Remain undecided

• MSCHE President change: Dr. Perfetti replaces retiring Dr. Sibolski –July 2020

2 Department of Education and Middle States Commission COVID-19 Actions

• Early March 2020, both DOE & MSCHE relaxed rules for conducting on-site accreditation visits temporarily allowing virtual site visits

• Accreditation Agencies must however publish guidelines first

• Middle States Commission in early April 2020 requested institutions to report the following changes:

• Temporary measures to move on site learning to online distance education

• Modifications to the academic calendar for the current or future academic terms

• To establish agreement(s) with other institutions to accommodate students academic needs

3 USU Accreditation Timeline

CODA-Ft Gordon CODA- Jun Schofield CODA-Ft CEPH ACGME Hood Barracks COA-DNP LCME Dec Jan Sep CAHME Jun Jan Oct Mar

2020 2020 2021 2022 2023 2024 2024

Jan Sep Jun Mar Jan Jan MSCHE ACS/AEI CODA- ABET NCR AAALAC Bethesda Jun Jan Sep CODA- APA/CoA CODA-Ft Keesler Bragg TAB 24 Vice President for Finance and Administration Report Uniformed Services University of the Health Sciences Board of Regents

Board Brief

Submitted by: Walter W. Tinling Date: 21 April 2020

Title & Department: Vice President, Finance & Administration Phone: 295-3083

Purpose: Information √ Action

Subject: Resource Management Report

Significant Issues:

USU will face resource challenges in the upcoming fiscal years due to budget and program reductions stemming from the Defense Wide Review (discussed below), however, FY2020 resources are considered adequate to cover mission requirements.

Current and Future Concerns:

Budget: As of the end of the 2nd Quarter FY2020 USU obligated $85M of $127M O&M (67%). As a result of the slowdown of non-coronavirus research and other activities, travel limitations and teleworking, USU is no longer projecting a shortfall in FY2020. Resources are anticipated to be adequate through the remainder of the fiscal year.

Defense Wide Review: DWR 1.0 reductions in FYDP 2021-2025 included reductions of $90M O&M ($10M in FY2021 and $20M/year in FY2022-FY2025) and $24M/year in RDT&E FY2021-FY2025. The reductions are programmatic and are expected to continue in subsequent years (e.g., FY2026 and beyond). USU is evaluating the impact of these changes, as well as awaiting final Congressional decision on these Department-proposed reductions.

DWR 2.0 reductions for FYDP 2022-2026 are currently in deliberation. The DHA presented its briefing to CAPE/CMO on March 17th, with a plan to reduce DHP resources by approximately $2.2B/year. The plan largely protected direct and purchased care (~$250M of Private Sector Care was targeted for potential benefit reductions) and facility infrastructure. In order to satisfy the bogey, substantial reductions had to be levied against other accounts such as RDT&E, Procurement and MILCON.

The March 17th proposed reduction of 80% of the DHP RDT&E portfolio was not concurred by USD,R&E (who preferred a proportionate 6% reduction to the program) and CAPE/CMO

directed the DHA to re-look at prioritizing RDT&E programs. In recent workgroup discussions to derive a 1-to-N list of priorities, USU’s research programs were prioritized with the lowest rankings. The programs most at risk are the Cancer COEs (Breast, GYN and Prostate Cancer) and AFRRI’s radiation research as they would be reduced in either the 6% or 80% scenario. In the 80% scenario, all or nearly all of USU’s research funding would be eliminated. USU continues to be engaged in the discussions.

Fiscal Guidance Reduction: In addition to the DWR 1.0 and pending DWR 2.0 actions, USU’s O&M program was reduced in the budget cycle based on Fiscal Guidance shortfalls, $3.4M in FY2021 and $3.0M in FY2022.

COVID-19 Funding: USU has received $9M to date for research supporting the Adaptive COVID-19 Treatment Trial (ACTT) and Epidemiology, Immunology and Clinical Characteristics of Emerging Infectious Diseases with Pandemic Potential (EPICC) studies. $20M for these two studies will be sent. In addition $200K has been approved for ventilator technology research/technology maturation.

Funding for several other USU COVID-related studies is also under review by DHA.

Acquisition Actions in Response to COVID-19: Guidance has been received regarding no cost extensions of federal assistance awards (OMB guidance of M-20-17) as well as CARES Act Section 3610, allowing payment for certain contractors who cannot work onsite. The ACQ office is in communication with our contract and federal assistance partners.

POM 22 Actions: MOAs for the rebalancing of Civilian Personnel FTEs and realignment of the Military Training Network from USU to DHA are finalized. USU submitted a POM emerging issue (only one unfunded issue was allowed) for biotechnology/biofabrication. In total, DHA received 7 issues from the Components for consideration. Scoring and voting on the issues is expected in the next 4 weeks.

Procurement Management Review (PMR): The PMR Team was onboard USU for 3 weeks in March. In the out-brief they cited many recommendations regarding document maintenance, close out procedures, and other post-award administrative actions. USU has not prioritized these actions as a result of several staffing shortages (explained below), but is planning to mitigate with the use of contractor personnel. The PMR report is expected be received in about 6 months, the time lag due to the PMR’s shortage of acquisition personnel.

Audit: NSTR. Audit activity, document sampling and quarterly financial statement verifications continue.

Staffing Impact:

Staffing continues to be challenging, particularly in the acquisition department. The ACQ Department is at a critical manning level, with only 55% of positions filled. There is a

government-wide shortage of GS-1102 Contract Specialists. The recent reductions in DAWIA (Defense Acquisition Workforce Improvement Act) funding for training and development (a casualty of the DWR reductions) will only exacerbate the problem. USU’s DAWIA funding allotment of ~$65K is being reduced to $5K annually.

ACQ focus has been directed towards contracts and awards as follows: 1) direct COVID-19 support; 2) expiring funds (FY20 O&M and FY 19 RDT&E); 3) exercising option periods so that current contracts are not lost; and 4) renewals and modifications in cases where additional funding is required to maintain operations.

Mitigation efforts include bridging and extension of current contract awards, utilization of No Cost Extensions, and optimizing use of GPC micropurchase and BPAs.

Board Action Requested: No Board action requested at this time.

" For I nfor mation Only" COMPARISON OF ANNUAL APPROPRIATIONS As of 31 M arch 2020 '($000)

FY 2016 FY 2017 FY 2018 FY 2019 FY 2020 FY 2021

Obj ect Class Plan O&M Personnel Compensati on $ 67,844 $ 65,312 $ 64,167 $ 88,122 $ 64,174 $ 75,092 Personnel Benef i ts $ 19,950 $ 18,914 $ 19,082 $ 23,368 $ 18,516 $ 20,600 Severance Pay $ - $ - $ - $ - $ - $ - Travel $ 7,010 $ 8,447 $ 8,515 $ 9,245 $ 8,958 $ 8,822 Transportation $ 32 $ 255 $ 261 $ 214 $ 271 $ 276 Rent, Comm & Utilities $ 965 $ 1,223 $ 1,250 $ 512 $ 1,303 $ 1,329 Printing $ 35 $ 26 $ 26 $ 26 $ 28 $ 29 Other Servi ces $ 38,196 $ 34,875 $ 34,879 $ 51,351 $ 47,045 $ 46,981 Supplies $ 7,896 $ 9,845 $ 11,053 $ 10,397 $ 10,909 $ 10,924 Equipment $ 6,459 $ 5,874 $ 6,734 $ 5,658 $ 6,639 $ 6,734 Land and structures $ 8,208 $ 18,403 $ 16,957 $ 10,986 $ 12,147 $ 12,307 Grants/Stipends $ 54,884 $ 60,035 $ 68,714 $ 45,892 $ 56,111 $ 30,013 Financial Transfer $ - $ - $ - $ - $ - Claims $ 12 $ - $ - $ - $ - $ -

T otal O& M $ 210,051 $ 223,209 $ 231,638 $ 245,771 $ 226,101 $ 213,107

Pr ocur ement $ 5,898 $ 3,362 $ 10,509 $ - $ 435 $ 452

Carryover $ 6,148 $ 42,074 $ 6,440 $ - $ - $ -

RDT&E, DHP $ 56,651 $ 76,718 $ 97,732 $ 91,426 $ 125,456 $ 113,487

RDT&E, GDF $ 65,161 $ 50,181 $ 84,230 $ 86,188 $ - $ -

JIF - NO YEAR FUNDS $ - $ 186 $ - $ 1,988 $ -

GRAND TOTAL $ 343,909 $ 395,730 $ 430,549 $ 425,373 $ 351,992 $ 327,046 " For I nfor mation Only" COMPARISON OF ANNUAL APPROPRIATIONS As of 31 December 2019 '($000)

FY 2016 FY 2017 FY 2018 FY 2019 FY 2020 FY 2021

Obj ect Class Plan O&M Personnel Compensati on $ 67,844 $ 65,312 $ 64,167 $ 88,122 $ 64,174 $ 75,092 Personnel Benef i ts $ 19,950 $ 18,914 $ 19,082 $ 23,368 $ 18,516 $ 20,600 Severance Pay $ - $ - $ - $ - $ - $ - Travel $ 7,010 $ 8,447 $ 8,515 $ 9,245 $ 8,958 $ 8,822 Transportati on $ 32 $ 255 $ 261 $ 214 $ 271 $ 276 Rent, Comm & Utilities $ 965 $ 1,223 $ 1,250 $ 512 $ 1,303 $ 1,329 Printing $ 35 $ 26 $ 26 $ 26 $ 28 $ 29 Other Servi ces $ 38,196 $ 34,875 $ 34,879 $ 51,351 $ 47,045 $ 46,981 Supplies $ 7,896 $ 9,845 $ 11,053 $ 10,397 $ 10,795 $ 10,924 Equipment $ 6,459 $ 5,874 $ 6,734 $ 5,658 $ 6,639 $ 6,734 Land and structures $ 8,208 $ 18,403 $ 16,957 $ 10,986 $ 12,147 $ 12,307 Grants/Stipends $ 54,884 $ 60,035 $ 68,714 $ 45,892 $ 51,150 $ 30,013 Financial Transfer $ - $ - $ - $ - $ - Claims $ 12 $ - $ - $ - $ - $ -

Total O&M $ 210,051 $ 223,209 $ 231,638 $ 245,771 $ 221,026 $ 213,107

Pr ocur ement $ 5,898 $ 3,362 $ 6,603 $ - $ 435 $ 452

Carryover $ 6,148 $ 42,074 $ 6,440 $ - $ - $ -

RDT& E, DHP $ 56,651 $ 76,718 $ 97,732 $ 90,996 $ 125,456 $ 113,487

RDT& E, GDF $ 65,161 $ 50,181 $ 84,230 $ 83,457 $ - $ -

JI F - NO YEAR FUNDS $ - $ - $ 186 $ 1,988 $ - $ -

GRAND TOTAL $ 343,909 $ 395,544 $ 426,829 $ 422,212 $ 346,917 $ 327,046

R:\Meetings\2020\May 2020\VFA\FY20 Annual Appropriation by Object Class Report for BOR as of 31-Mar-20... Budget & Program Reductions Board of Regents Brief May 2020 Program Offsets FY2020-FY2025

$(000) O&M FY20 FY21 FY22 FY23 FY24 FY25 SUM CIVPAY 1,496 1,482 1,513 1,545 1,582 1,623 9,241 HPSP 1,955 2,023 2,091 2,164 2,275 2,387 12,895 CIVPAY 1,327 1,873 1,912 1,953 1,993 2,069 11,127 SUP/EQP 1,509 2,011 2,189 2,287 2,389 10,385 FIS Guid 3,430 3,018 6,448 SUP/MAT 763 763 DWR 10,000 20,000 20,000 20,000 20,000 90,000 O&M TOTAL 5,541 20,317 30,545 27,851 28,137 28,468 140,859

RDT&E 6.1 4,093 4,175 4,259 4,344 4,441 21,312 6.3 10,000 10,000 10,000 10,000 10,000 50,000 RDT&E TOTAL 14,093 14,175 14,259 14,344 14,441 71,312

GRAND TOTAL 5,541 34,410 44,720 42,110 42,481 42,909

FY20-FY25 TOTAL 212,171 What is not known at this time is the out of the Defense Wide Review (DWR 2.0) An additional 6% reduction to the Fourth Estate Top Line ~$2.2B Pre-Decisional FOUO

2 BACK UP

3 Outline

• Program and Budget Overview (PPBES) • USU Program Growth and Total Obligations FY1998-FY2019 • FY2020 Budget Challenges and Required Offsets • FY2021 President’s Budget • FY22-FY26 Programmatic Reduction Drivers of Change • Program Offsets Required in FYDP • Summary

4 PPBESDoD Planning, Programing, Budgeting Execution System (PPBES)

FY BUDGET

PLANNING PROGRAMMING BUDGETING

NATIONAL E SECURITY STRATEGY ASSESSMENTS DHP MPG BUDGET PRESIDENT’S PREPARATION/ BUDGET X REVIEW CINCs NATIONAL DECISIONS E AGENCIES DEFENSE SERVICES STRATEGY C PROGRAM OSD/OMB CONGRESS OBJECTIVES BUDGET U WORLD NATIONAL MEMORANDUM SUBMIT SITUATION MILITARY (POM) T STRATEGY I OSD COMP/OMB OSD - CAPE REVIEW REVIEW O OSD PLANNING APPROPRIATION N

STRATEGIC/JOINT PROGRAM RESOURCE PLANNING DECISION MANAGEMENT JOINT STAFF GUIDANCE (SPG/JPG) MEMORANDUM DECISION ASSESSMENTS & (RMD) (RMD) FISCAL GUIDANCE Future Strategy $ 2-7 yrs in future $ 2-3 yrs in future Today

5- 5 PPBES Timeline PPBES Timeline

President submits first Monday in February

FY19 FY20 FY21 FY22 FY23 FY24 FY25 FY26 Execution Year POM 22 Budget Programming Years

Year Future Years Defense Plan (FYDP)

5- 6 Program Growth 2004-2018 Cumulative from 2006 Baseline $ M 3,000 +$2.6B 2,500

2,000

1,500

1,000

500

0 FY06 FY07 FY08 FY09 FY10 FY11 FY12 FY13 FY14 FY15 FY16 FY17 FY18 FY19 FY20 FY21 FY22 FY23 FY24 USU Program Growth 2004 - 2020

8 USU Total Obligations • Direct and Reimbursable FY1998 – FY2019

TOTAL OBLIGATIONS FY98 - FY19 600 556.9

500 471

426.9

400

290.6 290.7 300 269 AMOUNT ($M)

200 180.3 142.9 147.3 116.7 86.3 89.1 100

0 FY98 FY99 FY00 FY01 FY02 FY03 FY04 FY05 FY06 FY07 FY08 FY09 FY10 FY11 FY12 FY13 FY14 FY15 FY16 FY17 FY18 FY19 FISCAL YEAR (FY)

9 Middle States • Total Obligations FY1998 – FY2019 Total FY2019 - $556,888,883

MIDDLE STATES OBLIGATIONS FY98 - FY19 350

300

250

200

150 AMOUNT ($M)

100

50

0 FY98 FY99 FY00 FY01 FY02 FY03 FY04 FY05 FY06 FY07 FY08 FY09 FY10 FY11 FY12 FY13 FY14 FY15 FY16 FY17 FY18 FY19 FISCAL YEAR (FY)

Research Instruction Operation/Maintenance of Plant Institutional Support Academic Services Student Services Scholarships & Fellowships

10 Actions necessary to balance FY20 budget • Financial actions/realignments to increase O&M trade space • FCC increased to 4.6% (from 4.0%) • VPR federal civilian labor realigned from BAG 6 to RDT&E (mid-year, in April 2020). FY2021 will be full-year in RDT&E.

• Programs reduced in FY2020 • CGHE. Reduced $2.7M in BAG 6 ($1.0M provided in BAG 3) • MCC. Reduced by $1.9M in BAG 1 • TSNRP. Reduced $4M ($3.7M research funded in late Sep 2019) • CDP. Reduced $1.2M

• Programs deferred to FY2021 (funded late in FY2019) • MOC2, MHSSPACS, OPSS, Faculty Development/HPE

11 Programmatic Changes

Drivers of Change: A. Resource Management Decisions (RMDs) B. Fiscal Guidance Reduction C. Full Time Equivalents (FTE) Rebalancing D. Defense Wide Review (DWR)

USU Approach ₋ Prioritize accreditation and academic programs: SOM, GSN, PGDC, & CAHS ₋ Recognize “Must Fund” bills: Civilian salaries; Facilities infrastructure ₋ Defense Wide Review Program reductions must be considered in context of other POM21-25 changes (RMDs, Fiscal Guidance & FTE rebalancing) ₋ Target programs: New Starts, “Work For Others” (e.g., support to non-USU PIs and Programs with large sub-awards to other institutions), in the context of no new tools e.g., RIF authority, early retirement programs etc.

Pre-Decisional FOUO

12 Drivers of Change: (A) Resource Management Decisions (RMDs)

A. RMDs 1. OSD COMP CIVPERS Inflation adjustment FY20-FY25 O&M BAGs (1,3,4,6,7) (-$20.4M) 2. Congressional Mark Under Execution of BAG 6 Education and Training FY20-FY25 (-$24M)

Pre-Decisional FOUO

13 Drivers of Change: (B) Fiscal Guidance Reduction

B. Fiscal Guidance Reduction 1. DHP Fiscal Guidance Shortfall FY21 – FY22 (-$6.4M) O&M • Murtha Cancer Center FY21 (-$3.5M), FY22 ($3.0M)

Pre-Decisional FOUO

14 Drivers of Change: (C) FTEs (Full Time Equivalents)

C. FTEs: FTE #s and $s must be aligned, O&M and RDT&E (net zero to the bottom line, programs won’t see it that way) 1. USU CIVPERS Execution and Budget are misaligned due to history • FTE reductions not achieved • Failure to recognize directed program growth 2. O&M realignments to CIVPERS required • Impacts all Operations and Maintenance (O&M) BAGs (1,3,4,6,7) • Impacts FY20 – FY25 and the out-years • Cumulative realignments FY20-FY25 to O&M all BAGs (-$60.1M) 3. RDT&E realignments to CIVPERS required • Impacts most of the RDT&E funded Centers (program dollars to CIVPERS) • Impacts FY20-FY25 and the out-years • Cumulative realignments to CIVPERS FY20-FY25 (-$21.1M)

Pre-Decisional FOUO

15 USU FTE Controls, Actuals, & Projections Phase 2 + 40 Reimbursable FTEs 800

775

750

725

Hiring Freeze 700 + Post Docs to HJF 675

650

625 FY08 FY09 FY10 FY11 FY12 FY13 FY14 FY15 FY16 FY17 FY18 FY19 FY20 FY21 FY22 FY23 FY24 FY25 FY26 OSD COMP CONTROLS UPDATED 669 669 669 682 682 736 734 727 700 673 652 652 755 755 755 755 755 755 755 ACUTALS/PROJECTION 671 682 731 761 770 753 701 671 763 748 758 744 737 760 760 760 760 760 760 OSD COMP CONTROLS 669 669 669 682 682 736 734 727 700 673 652 652 OSD COMP CONTROLS PHASE 2 755 795 795 795 795 795 795

16 Drivers of Change: (D) Defense Wide Review (DWR)

D. DWR reductions (FY21-FY25) 1. O&M (-$10M) in FY21, (-$20M) in FY22-FY25. (-$90M FYDP) • Impact limited to BAG 6 (all other BAGs (1,3,4,7) tapped out from RMDs and FTE rebalancing actions  Department of Defense Medical Ethics Center (DMEC) - eliminated  National Center for Disaster Medicine and Public Health (NCDMPH) - eliminated  Interagency Institute for Federal Health Care Executives (IAIFHCE) - eliminated  Tri-Service Nursing Program (TSNRP) -- eliminated  Center for Deployment Psychology (CDP) – reduced 20% in FY21; eliminated FY22  Center for the Study of Traumatic Stress (CSTS) – reduced by 70%

2. RDT&E (-$14M) per year (-$71.3M FYDP) • ILIR (eliminated) (-$20M FYDP) • RDT&E Program Element 6.3 (-$50M FYDP)  COE Cardiac Care (New Start in FY20) (-$1.5M per year / 50% reduction)  COE Pain Center of Excellence (-$1.5M per year / 30% reduction)  Health Services Research (-$1M per year / 50% reduction)  Technology Transforming the War Fighter (TTW/TRP) (-$6M per year / 75% reduction)

Pre-Decisional FOUO

17 “J” Book Bag 6 Example

18 DWR O&M Reductions as laid into the President’s Budget (BAG 6, by Object Class) ($K) OCC Title FY21 FY22 Travel and Transportation of (324) (324) Persons Supplies and Materials (49) (109) Grants, Subsidies, and (8,435) (18,166) Contributions Other Services from Non- (1,192) (1,401) Federal Sources TOTAL ($10,000) ($20,000)

Pre-Decisional FOUO

19 Summary

• RMD reductions and FTE rebalancing implemented in FY2020, reflected in the FY2020 Defense Appropriation and have out-year consequences

• Fiscal Guidance reductions reflected in the FY2021 President’s Budget • DWR reductions reflected in President’s Budget and in the program of record (FYDP). President’s Budget locked Dec 20, reductions “booked” before SECDEF made final decisions in DWR process. President’s budget is due to Congress (House) on February 3rd

• Reductions are not ‘a fait accompli’

o Strong justifications, and rebuttals have been provided to DEPSECDEF o Congress has history of restoring R&D reductions, but not O&M

• Other Concerns o Loss of ILIR in the DWR process confounds the plan for FTE rebalancing o GS and WG pay raise for FY20 of 3.5% is not resourced in the FY20 budget (denial of facts)

Pre-Decisional FOUO

20 USU Program Growth 2004 - 2020

21 22 DWR O&M Reductions by Program

23 DWR O&M Reductions by Program (BAG 6) FY21 $10M Proposal Program / Center Reduction Eliminate / Reduce DMEC (982) E NCDMPH (1,032) E IAIFHCE (258) E TSNRP (6,464) E CDP (1,265) R (18%) Total (10,000) FY22-25 $20M Proposal Program / Center Reduction Eliminate / Reduce DMEC (982) E NCDMPH (1,032) E IAIFHCE (258) E TSNRP (6,464) E CDP (7,259) E CSTS (4,005) R (71%) Total (20,000) 24 TAB 25 University Brigade Report Uniformed Services University Board of Regents

Board Brief

Submitted by: CAPT Sean Hussey Date: 19 May 2020

Title & Department: Brigade Commander Phone: 295-9654

Purpose: Information

Subject: Brigade Update

The USU Brigade continues to fully support the University’s mission of educating and training health professionals while upholding the Commander’s values of accountability, leadership, integrity and transformation. The following key updates are of note for the USU Board of Regents:

1. HEADQUARTERS COVID-19 SUPPORT o Established University-wide online Accountability tool via Google sheets. Military Personnel Office and HQ Company Commander managing daily accountability. o Brigade Operations established template for 2x/week Commander’s Update Brief, External Support Request Tracker, Campaign Plan template, and Return-to-Work outline. Provide daily SITREP to NSAB on COVID-19 status. o CMC collaborated with NSAB leadership to maximize USU enlisted Auxiliary Support Force as well as enlisted support to USU Security team. o Conducting 100% telework since 17 March to include MILPO office, Operations, Professor of Military Science, and Command Deck activities. o Managing all active duty Exception-to-Policy (ETP) requests for travel. o Current University Emergency Manager is an active duty enlisted member in Ops. He departs later this year and the Air Force will not be backfilling the position. Recommend University look to hire full-time, civilian Emergency Manager.

2. COMMANDANTS’ PRIORITIES o Worked tirelessly with Services to successfully generate orders and promote all graduates from School of Medicine on April 1. o All Graduate School of Nursing officers who were eligible graduated on April 1. Nurse Anesthetists will graduate on May 1. Worked with Services to allow graduates to remain at current Phase 2 sites to support COVID-19 operations. o Coordinated with MTFs in NCR to place recently graduated medical students in support roles at WRNMMC, Fort Belvoir, Quantico, Fort Meade and the DC VA. o Developing COAs for incoming students in both the SoM and GSN given the potential altered timelines for student arrival and beginning of the academic year.

3. TRAINING o Summer Operational Experience for Class of 2023 has been cancelled. Working with OSA/SoM on potential leadership training options during June. o Operation Gunpowder 2019 cancelled. Brigade Operations continues to plan with Dept of Military of Emergency Medicine for Operation Bushmaster for October 2020. o Brigade standing by to receive first wave of Army Combat Fitness Test equipment from Army Headquarters. Plan to utilize and implement training once daily operations returns to normal.

4. BRIGADE POLICIES/INITIATIVES o Brigade generated Public Service Announcement for Sexual Assault Awareness and Prevention Month (April) and published online. o Brigade Commander issued policy relaxing grooming standards for all services during COVID-19 pandemic. o Readiness Assessment for Mission (RAM) online resiliency tool distributed late March. 160 responses. Stress level not significantly changed from January. o Brigade Commander communicating 2x/week via email with Brigade-All providing updates on University/Service/DoD information. o Re-addressing Headquarters staff structure to support Headquarters Company Commander, Operations, and PMS office.

Current & Future Concerns: Appropriate staffing of expanded organizational construct. University Emergency Manager position. Funding/Budget Estimate/Fiscal Impact: Minimal as most staff restructuring will be re- allocated from existing manpower. However, contract/GS positions may be preferred, especially for Emergency Manager. Staffing Impact: Brigade will staff above actions internally. Board Action Requested: None

Tab 26 Supplement Uniformed Services University of the Health Sciences Board of Regents

Board Brief

Submitted by: Dr. William Roberts Date: April 2020

Title & Department: Senior Vice President Western Region Phone: 619-532-9522

Purpose: Information: X Action

Subject: In-Progress Review (FEB20-MAY20)

Significant Issues: None

• *SVP-W, Chair, along with members of the Vice President for Research Search Committee, conducted face-to-face interviews of six semifinalist candidates 5-6 March. Followup discussions led to determination of finalists who will be invited back for a likely all-day scripted event (grand rounds/job talk, meetings (deans, Fac Senate research cmte, VPs, PRS interview, etc) on campus. This next phase will be scheduled as soon as conditions permit. • * The Indo-Pacific Research Alliance for Military Medicine (IPRAMM), co-chaired by SVP-W and Dr. Bruce Doll, has grown by two member organizations, Nellis AFB and Sandia National Laboratory, and continues to meet monthly for teleconferences. Instead of the planned 3-day F2F at Lawrence Livermore in early May, IPRAMM will instead meet virtually on 7 May for a half-day session to continue development of the IPRAMM Strategic Plan under guidance of Dr. Shoemaker. Participants from IndoPacom (incl SG), TSNRP, PNNL, LLNL, TAMC, NHRC, USU OGC, and NH Guam continue to dial in consistently to monthly teleconferences; the April tcon had impressive attendance to include the INDOPACOM Surgeon, representation from DHA J-9, WRAIR, all Western Region MTFs, and two National Labs. In an effort to identify collaborative opportunities, several members gave summaries of their organization’s COVID-19 related research efforts. Notably, the INDOPACOM Surgeon directly sought the help of the alliance for specific capabilities to support INDOPACOM amid the COVID-19 pandemic, identifying IPRAMM as a unique and powerful resource. • *CoS-W continues to co-chair USU’s Distributed Learning Working Group at USU. The group is actively seeking to understand and collate strengths and opportunities after the transition to 100% distance learning at USU in March 2020, as a critical component to the USU enterprise pandemic AAR. • SVP and CoS USU-W met virtually in early April with DHA J-7 (Brig Gen Fligge) and her Deputy (COL Mikita) to update POA&M for enterprise education and training collaborative efforts. Priorities were reset, USU and DHA E&T Senior Strategy group members were advised, and the plan is to reengage in June unless real world events mitigate in favor of postponement.

Support to Faculty

• USU-W continues to support USU Faculty in the Western Region (to include CAPT(sel) Natalie Burman, MC, USN, dually hatted as NMCSD staff pediatrician/fac dev faculty; and interim Regional Assoc Dean USU SoM), and is working with USU Main Campus (Drs. Durning and Cervero) to identify candidates for the USU Programs in Education Leadership.

Current & Future Concerns: N/A Funding/Budget Estimate/Fiscal Impact: N/A Staffing Impact: N/A Board Action Requested: None

UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES DEPARTMENT OF FAMILY MEDICINE 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814-4799 www.usuhs.edu

May 6, 2020

MEMORANDUM FOR THE CHAIR, BOARD OF REGENTS, USUHS Arthur L. Kellermann, MD, Digitally signed by Arthur L. THROUGH: Dean, School of Medicine Kellermann, MD, MPH MPH Date: 2020.05.08 14:49:08 -04'00' SUBJECT: Recommendation of Fourth-Year Students, Class of 2020

In accordance with SOM-DPM-006-2015 subject: USUHS School of Medicine (SOM) Medical Student Promotions Committee, dated 21 August 2015, the Student Promotions Committee electronically met and reviewed fourth-year students on 6 May 2020. The Committee recommends that those students whose names appear on the Certification List be awarded the degree of Doctor of Medicine and enter graduate medical education, provided that all remaining academic requirements are met or officially waived.

This letter of recommendation does not preclude the Dean, School of Medicine, from removing any student listed herein for cause.

Patrick Hickey, MD Colonel, Medical Corps, US Army Chair, Student Promotions Committee

Attachment CLASS OF 2020 RECOMMENDED FOR GRADUATION EFFECTIVE 16 MAY

Chang, Hanna. Meyer, Johanna S. Skaggs, Nicole L.

Learning to Care for Those in Harm’s Way

UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES POSTGRADUATE DENTAL COLLEGE 2787 WINFIELD SCOTT RD., SUITE 220 JBSA FORT SAM HOUSTON, TX 78234-7510 www.usuhs.edu

11 May 2020

MEMORANDUM FOR USUHS BOARD OF REGENTS

FROM: Executive Dean, Postgraduate Dental College

SUBJECT: Amendment of Graduation Memo for May 15, 2020 Meeting

1. The Memo entitled, “Certification of Postgraduate Dental Students” dated 9 March 2020 has been amended.

2. Major Jessamy J. Thornton, USAF, DC will be unable to complete all requirements for graduation by the scheduled program completion date of 30 June 2020 and therefore, has been removed from the amended memo entitled, “Certification of Postgraduate Dental Students” dated 11 May 2020.

3. Major Thornton, though progressing well, requires additional time to complete clinical requirements due to approved medical leave.

4. It is anticipated that she will complete all graduation requirements by early fall and, once completed, she will be presented to a future Board of Regents meeting with request for graduation endorsement.

Respectfully,

Thomas R. Schneid, DMD, MS Executive Dean

Learning to Care for Those in Harm’s Way UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES POSTGRADUATE DENTAL COLLEGE SOUTHERN REGION OFFICE 2787 WINFIELD SCOTT ROAD, SUITE 220 JBSA FORT SAM HOUSTON, TEXAS 78234-7510 https://www.usuhs.edu/pdc

11 May 2020

MEMORANDUM FOR: PRESIDENT, USUHS

THROUGH: BOARD OF REGENTS

SUBJECT: Certification of Postgraduate Dental Students

The Postgraduate Dental College students listed below are scheduled to complete their programs of instruction by June 30, 2020. It is requested that the Executive Dean be authorize to award or withhold the Master of Science in Oral Biology degree based upon their successful completion of program requirements. The 2020 Postgraduate Dental College students and their research projects are listed below:

Army Postgraduate Dental School

COMPREHENSIVE DENTISTRY – FORT BRAGG, NC

LTC Elizabeth R. Oates, DC, USA – Evaluation of the Fit and Accuracy of RPD Frameworks Using Two Different Types of Impressions Materials and CAD/CAM Technology

MAJ Ross K. Cook, DC, USA – The Use of a Pressure Cooker to Achieve Sterilization for an Expeditionary Environment

MAJ Jason C. LaCourse, DC, USA – The Anti-Bacterial Efficacy of Activated Charcoal Toothbrushes on S. Mutans

CPT(P) Adam D. Bennett, DC, USA – Assessing Changes in Opioid Prescribing Habits of the US Army Dental Corps Providers Following Completion of Opioid Prescriber Safety Training

CPT Wing Tat Chan, DC, Canadian Forces – Knowledge and Utilization of Direct Pulp Capping Procedures Among Dentists

CPT Tania M. Sanchez Dominguez, DC, USA – Opioid Prescription Rate by Military Dentists in Fort Bragg, NC 2009-2018

CPT Andrew Seun, DC, USA – Effect of Storage Temperature on Tensile Bond Strength of a Self-Etch Dentin Bonding Agent

COMPREHENSIVE DENTISTRY – FORT HOOD, TX

MAJ Lloyd Alexander Ancman, DC, USA – Prevalence of Early Childhood Caries and Its Related Risk Factors in the United States Military Dependent Pediatric Population

Learning to Care for Those in Harms’ Way MAJ Daniel D. Becker, DC, USA – Differences in Shear Bond Strength Between Resin Composites and Glass Ionomers in the Open Sandwich Technique Using Different Generations of Adhesives

MAJ George Louis Hauser, DC, USA – Evaluation of Vitamin D Deficiency, Dental Caries, and Inflammatory Bowel Disease Within the Active Duty Population

MAJ Jesse Benjamin Norris, DC, USA – Polishability of Four Composite CAD/CAM Materials

MAJ Jarred Lloyd Price, DC, USA – CEREC Omnicam Image Quality Following Multiple Cycles of Dry Heat Sterilization

MAJ Donald George Rice, DC, USA – Fracture Resistance to Oblique Forces of Titanium-Based Implant Supported Lithium Disilicate Monolithic Crowns

MAJ Steffan Thomas, DC, Canadian Forces – The Histological Analysis of Tooth Cementum Annulations to Determine Age and Season of Death of Active Duty Military Personnel: A Comparative Study Using Brightfield, Polarizing and Phase Contrast Microscopy

COMPREHENSIVE DENTISTRY – SCHOFIELD BARRACKS, HI

MAJ Gamal A. Baker, DC, USA – Patient-Perceived Success of Three Common Prostheses in Oral Appliance Therapy of Obstructive Sleep Apnea

MAJ Christie Inae Lee, DC, USA – Comparison of Degree of Conversion of Bulk-Fill Composites and Filtek Supreme Ultra as the Conventional Composite

MAJ Mitchell James Lee Oliver, DC, USA – The Effect of Depth-of-Cure on the Flexural Strength of Dental Bulk-Fill Composites

CPT Taylor Akiko Gaerlan Tokunaga, DC, USA – In-Vitro Comparison of Fracture and Fatigue Resistance Between Implant-Supported Restorations Utilizing CAD/CAM System TiBase

ENDODONTICS – FORT BRAGG, NC

MAJ Kony Park, DC, USA – Evaluation of Re-Treatability of 3 Endodontic Sealers: AH Plus, EndoSequence BC Sealer, and HiFlow EndoSequence BC Sealer

MAJ Alexandra Rihani, DC, USA – A Survey of Surgical Trends Among Military Endodontists

CPT Matthew Massey, DC, USA – A Survey of Decision Making Analysis When MB2 Cannot be Located in Maxillary First Molars

ENDODONTICS – FORT GORDON, GA CPT Jose R. Burgos, DC, USA – Root Canal Treatment Versus Vital Pulp Therapy After Carious Exposure: An Analysis of the Cost-Effectiveness in the United States

CPT Kristel Burgos, DC, USA – Assessment of Patient's Perception of CBCT and Endodontic Treatment

CPT Khine Christine Zin Htet, DC, USA – Regaining Patency with Bioceramics During Retreatments Based on Method of Sealer Placement CPT Jason Michael Umbach – Surface Integrity of Orthograde MTA Obturation Following Targeted Endodontic Microsurgery

PERIODONTICS – FORT GORDON, GA

MAJ Daniel J. Broadway, DC, USA – Ridge Preservation: Evaluation of Keratinized Tissue Width

MAJ Alicia Y. Choi, DC, USA – Laser Ridge Preservation: A Proof-of-Principle Pilot Study

CPT Anthony A. Vargas, DC, USA – Time of Exposure: A Major Factor in the Attachment of Bacteria

CPT James P. Wilson, DC, USA – Frequency of Adequate Mesiodistal Space and Faciolingual Alveolar Width for Implant Placement at Human Anterior Tooth Positions

PROSTHODONTICS – FORT GORDON, GA

MAJ Joshua Thomas Sparks, DC, USA – Non-Thermal Gas Plasma Treatment of Diamond Coated Dental Burs

MAJ Joshua Rand Waldron, DC, USA – Effect of Anodized Titanium Abutments on Color of Lithium Disilicate Implant Crowns

CPT Ryan James Coello, DC, USA – The Effect of Arch Form on Connector Size Requirements in Long Span Anterior Zirconia Fixed Dental Prostheses

CPT Jenny Juyung Oh, DC, USA – The Effect of Various Cleaning Methods on Resin Bond Strength of Saliva-Contaminated Ceramic Surfaces

Naval Postgraduate Dental School Navy Medicine Professional Development Center Bethesda, MD

COMPREHENSIVE DENTISTRY

CDR Andrew D. Silvestri, DC, USN – The Effects of Computer-Aided Antero-Posterior Forehead Movement on Ratings of Facial Attractiveness

LCDR Sara A. Chilcutt, DC, USN – The Effects of a Therapy Dog Intervention on Distress in Adult Patients Undergoing Dental Procedures: A Pilot Study

LCDR Christian P. Lares, DC, USN – Fracture Resistance of All Ceramic Restorations on Mandibular First Molars After Endodontic Access and Repair

LCDR Omeed A. Rezaie Tirabadi, DC, USN – Stress and Burnout in Post-Graduate Dental Residency Training

LCDR Jennifer C. Steigerwald, DC, USN – Evaluating and Describing Changes in Heart Rate Variability in Patients Treated for Moderate Obstructive Sleep Apnea

LCDR David S. Yi, DC, USN – Stress and Burnout in Dental Residents LT Wei Liu, DC, USN – Effect of Ultrasonic Vibration on the Presence of Voids in Core Buildup Materials

ENDODONTICS

LCDR Alyse D. Fleming, DC, USN – The Effect of Smear Layer on Endodontic Outcomes

LCDR Kristofer S. Harris, DC, USN – Chairside Sterilization of Files and Gutta-Percha Cones Using 8.25% Sodium Hypochlorite

LCDR Ryan A. Hershey, DC, USN – Comparison in Utilizing the Reference Calibration Method and Standard Calibration Method for Digital Calibration of Periapical Intraoral Radiographs

LCDR Michael J. Lewis, DC, USN – Outcome of Endodontically Treated Teeth Diagnosed with “Cracked Tooth”

LCDR Russell L. Neal, DC, USN – Comparative Evaluation of Preoperative Methylprednisolone or Ibuprofen on Anesthetic Efficacy of Inferior Alveolar Nerve Blocks in Patients with Symptomatic Irreversible Pulpitis

ORAL AND MAXILLOFACIAL PATHOLOGY

LCDR Kerry B. Baumann, DC, USN – Distribution of Human Tongue Fat and Obstructive Sleep Apnea

LCDR Matthew E. Seedall, DC, USN – Next Generation Sequencing to Identify Molecular Driver Events in Salivary Acinic Cell Carcinomas

OROFACIAL PAIN

Maj John E. Dinan, USAF, DC – Pain Catastrophizing in the Orofacial Pain Population

PERIODONTICS LCDR Eric R. Draper, DC, USN – Systemic Versus Tissue-Specific Immunity During Early Initiating Events of Chronic Graft-Versus-Host Disease

LCDR Thien T. Nguyen, DC, USN – Dental Erosion and Gingival Health in US Service Members and Retirees Diagnosed with Gastroesophageal Reflux Disease

LT Allison D. Weinberg, DC, USN – Characterization of Titanium Implant Surface after ND:YAG Laser Treatment

PROSTHODONTICS LCDR Gabrielle K. Jung, DC, USN – In-Vitro Analysis of Attachment of Candida Albicans to Denture Base Acrylic Resin Fabricated by Three Different Methods

LT Diewitt Duong, DC, USN – Effect of Arch Form on the Accuracy of Intraoral Scanners CDR

Air Force Postgraduate Dental School

COMPREHENSIVE DENTISTRY – KEESLER AFB, MS Maj Alisha Chantell Brown, USAF, DC – Composite Warming Effects on the Mechanical Properties of Bulk Fills

LCDR Scott Daniel Eckhart, USCG – The Erosive Potential of Sugar-Free Waters on Cervical Dentin

MAJ Iwona Rusiecka, DC, Canadian Forces – Marginal Fit Comparison of Crowns Fabricated with Two CAD/CAM Systems

CPT Jamie L. Greenwell, DC, USA – Effect of Diode Laser Irradiation on Resin-Dentin Microtensile Bond Strength

COMPREHENSIVE DENTISTRY – JBSA LACKLAND, TX

Lt Col Kibrom T. Mehari, USAF, DC – Bond Strength of Resin Cements to Zirconia After Surface Treatments

Maj Darin Bateman, USAF, DC – Comparative Evaluation of Cone Beam Computed Tomography (CBCT)

LCDR Andrew J. Knudson, DC, USN – Devising a Manpower Model from USAF Recruit Dental Needs

Capt Job Torres-Gomez, USAF, DC – Management of Dental Anxiety via Distraction Technique

Capt Nicole Wirth, USAF, DC – Efficacy of Various Sterilization Techniques on Diamond-Coated Dental Burs

ENDODONTICS – KEESLER AFB, MS

Maj Scott Arthur Bryant, USAF, DC – A Comparison of Single Cone Obturation Quality and Sealer Waste Between Three Sealer Application Techniques

Maj Jason Allen Rose, USAF, DC – Evaluation of Extra-Canal Apical Tissue Pressure Generated by the Gentle Wave System Compared to Three Traditional Techniques

ENDODONTICS – JBSA LACKLAND, TX

Maj Andrea L. DuFour, USAF, DC – Targeted Endodontic Microsurgery Trepine Bur and Endodontic Microsurgery Carbide Bur Root End Appearance After Resection in Porcine Teeth

Maj Bracken Gamble Smith, USAF, DC – Targeted Endodontic Microsurgery: Implications of the Greater Palatine Artery PROSTHODONTICS – JBSA LACKLAND, TX

Maj Troy M. Decker, USAF, DC – Effect of Axial Wall Height and Total Occlusal Convergence on Retention of Lithium Disilicate Adhesively Bonded to Lithium Discilicate

Maj Joshua M. Nardone, USAF, DC – Effect of Axial Wall Height and Total Occlusal Convergence of VITA Enamic Implant Abutments on the Retention of Adhesively Bonded VITA Enamic Crowns

Maj Melissa S. Thomas, USAF, DC – Three-Dimensional Accuracy of Implant Placement Related to the Use of Guide Sleeves

Maj Joshua A. Vess, USAF, DC – A Prospective Analysis of the Embedded Health Engagement Team Concept: New Horizons 2019

TRI-SERVICE ORTHODONTIC RESIDENCY PROGRAM – JBSA LACKLAND, TX

MAJ Andrea C. Alicea, DC, USA – An In-Vitro Study on Aligner Rotational "Lag" with In-Office Clear Aligner Therapy

Maj Andrew P. Benfield, USAF, DC – Shear Bond Strength Between Opal Seal and Flash Free Brackets

LCDR Gregory M. Gittleman, USN, DC – The Flipped Classroom in Orthodontic Residency Programs

MAJ James P. Martineau, DC, USA – The Effectiveness of Cleaning and Sterilizing Reciprocal Orthodontic Interproximal Reduction Strips for Patient Re-use: A Comparative Study

Maj Duy Q. Nguyen, USAF, DC – Effects of Toothbrush Abrasion on Biofilm Retention in Thermoplastic Orthodontic Appliances

Capt John R. Ensley, USAF, DC – The Effect of Vaping on Force Degradation of Orthodontic Elastomeric Chain

If requested by the Board, copies of research manuscripts will be available upon completion of the program.

Respectfully, '

Digitally signed by SCHNEID.THOMA SCHNEID.THOMAS.R.1028588689 S.R.1028588689 Date: 2020.05.11 15:25:46 -05'00'

Thomas R. Schneid, MD, MS Executive Dean and Professor Postgraduate Dental College

UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES COLLEGE OF ALLIED HEALTH SCIENCES 2787 WINFIELD SCOTT ROAD, BLDG 2398 JBSA FT. SAM HOUSTON, TEXAS 78234

May 7, 2020

MEMORANDUM FOR PRESIDENT USU

THROUGH: BOARD OF REGENTS

SUBJECT: Addendum to CAHS List of Projected Graduates – May 2020

Due to an administrative oversight and no fault of the individual, the student identified below was inadvertently omitted from the College of Allied Health Sciences’ list of graduates projected to graduate May 2020.

The student completed the indicated program, meeting all academic, clinical and scholarly requirements to graduate in May 2020, for the degree indicated. The Dean, CAHS, requests the President, USU, award the student the Associate of Science in Health Sciences degree for the degree listed.

Last Name First Name Initial Branch Rank Degree Program/Major

Bradshaw David J Army E-3 ASHS Medical Laboratory Technician

______Lula Westrup Pelayo, Ph.D., RN, FAAN Richard W. Thomas, MD, DDS, FACS Acting Dean, CAHS President

Approved / Not Approved ______Date DoD COVID-19 PRACTICE MANAGEMENT GUIDE Clinical Management of COVID-19

This Practice Management Guide does not supersede DoD Policy.

It is based upon the best information available at the time of publication. It is designed to provide information and assist decision making. It is not intended to define a standard of care and should not be construed as one. Neither should it be interpreted as prescribing an exclusive course of management. It was developed by experts in this field. Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of this guideline is responsible for evaluating the appropriateness of applying it in the setting of any particular clinical situation. The Practice Management Guide is not intended to represent TRICARE policy. Further, inclusion of recommendations for specific testing and/or therapeutic interventions within this guide does not guarantee coverage of civilian sector care. Additional information on current TRICARE benefits may be found at www.tricare.mil or by contacting your regional TRICARE Managed Care Support Contractor.

Leads: Lt Col Renée I. Matos and COL Kevin K. Chung 4-13-2020

FOR OFFICIAL USE ONLY DoD COVID-19 PRACTICE MANAGEMENT GUIDE

Clinical Management of COVID-19 To consolidate resources and optimize the management for patients requiring clinical care during the global COVID-19 pandemic.

First Publication Date: 23 March 2020 Publication Date: 13 April 2020 Supersedes PMG Dated 23 March 2020

TABLE OF CONTENTS

Background ...... 2 Clinical Presentation ...... 2 Planning and Preparation ...... 3 Screening and Triage (Early Recognition of Patients with COVID-19) ...... 9 Immediate Implementation of Infection Prevention & Control (IPC) Measures and Personal Protective Equipment (PPE)...... 10 Collection of Specimens for Laboratory Diagnosis ...... 11 Management of Mild COVID-19: Symptomatic Treatment & Monitoring ...... 12 Management of Severe COVID-19: Oxygen Therapy and Monitoring ...... 15 Management of Severe COVID-19: Treatment of Co-Infections ...... 16 Management of Critical COVID-19: Acute Respiratory Distress Syndrome (ARDS) ...... 17 Management of Critical Illness and COVID-19: Prevention of Complications ...... 19 Management of Critical Illness and COVID-19: Septic Shock and Cardiac Arrest ...... 23 Imaging of COVID-19: Radiology Department Guidance and Imaging Findings ...... 25 Adjunctive therapies for COVID-19: Treatment Protocols ...... 28 Caring for Special Populations with COVID-19: Pregnancy, Nursing Mothers, Infants, Children and the Elderly ...... 31 Palliative Medicine During the COVID-19 Pandemic ...... 39 Implications of COVID-19 on Surgical Care ...... 43 Operational Considerations for COVID-19: Planning and Preparation ...... 47 Mental Health and Wellness in COVID-19 Clinical Management...... 49 Emergency Management Services and Ground Transport of Persons with COVID-19 ...... 50 En Route Critical Care Considerations of Persons with COVID-19 ...... 55 Whole of Government Response in Coordination of Resources...... 56 Other Considerations Related to COVID-19 ...... 56 References ...... 57 Appendix A: Mask Guidance, Precautions, and PPE Visuals for Use During Short Supplies ...... 65 Appendix B: Example Triage Protocols during COVID-19 Pandemic ...... 74 Appendix C: COVID-19 Intubation Pre-Entry Checklist ...... 76 Appendix D: COVID-19 Intubation Protocol ...... 77 Appendix E: COVID-19 Cognitive Aids for Intubation ...... 78 Appendix F: Adult Prone Positioning Protocol Example ...... 81 Appendix G: Transport Ventilator Set Up Guide ...... 84 Appendix H: Sample Protocols for Various Intensive Care Unit (ICU) Management ...... 86 Appendix I: Enteral Nutrition Care Pathway for Patients with COVID-19 ...... 88 Appendix J: DHA Quick Reference Guide to Virtual Health and Telephone Encounters...... 89 Appendix K: List of Contributors ...... 90

Clinical Management of COVID-19

BACKGROUND

Coronavirus disease 2019 (COVID-19) is a respiratory illness caused by a novel coronavirus (SARS-CoV-2). COVID- 19 was first described in Wuhan, China in December 2019 and is now a global pandemic. Most of those affected have milder illness (80%), 15% will be severely ill (most often some degree of hypoxemic respiratory failure) and 5% will require critical care interventions.(1) Of those who are critically ill, most require early intubation and mechanical ventilation. Other complications include septic shock and multi-organ failure, including acute kidney injury and cardiac injury.(2) Older age and comorbid diseases, such as COPD, hypertension and diabetes increase risk of death.(3, 4) The virus is highly contagious and spread via respiratory droplets, direct contact, and if aerosolized, airborne routes. The intent of this publication is to provide clinicians and military medical treatment facilities (MTFs) with best practices based on latest evidence to optimize DoD response to the current COVID-19 pandemic.

CLINICAL PRESENTATION & CLINICAL COURSE

1. Incubation period: ~4 days (interquartile range: 2 to 7 days).(5) Some studies have estimated a wider range for the incubation period; data for human infection with other coronaviruses (e.g. MERS-CoV, SARS-CoV) suggest that the incubation period may range from 2-14 days. 2. Frequently reported symptoms of patients admitted to the hospital: (3, 6-10) • Fever (77–98%) • Cough (46%–82%) • Myalgia or fatigue (11–52%) • Shortness of breath (SOB) (3-31%) • GI symptoms, such as diarrhea and nausea (~50% and may precede respiratory symptoms) • Anosmia, hyposmia, or dysgeusia (30-66%) 3. Among 1,099 hospitalized COVID-19 patients, fever was present in 44% at hospital admission, and developed in 89% during hospitalization.(11) 4. Less commonly reported symptoms: sore throat, headache, cough with sputum production and/or hemoptysis, and lower respiratory tract signs and symptoms. 5. Risk factors for severe illness are not yet clear, although older patients and those with chronic medical conditions may be at higher risk for severe illness.(12) 6. Pregnant women: Based on limited data, pregnant women do not appear to be at higher risk for severe disease. Emerging reports from the United States suggest that pregnant women may be at higher risk of atypical presentation with severe disease and preterm labor.(13-16) 7. Children: Overall, an estimated 5% presented with severe illness. In China, COVID-19 made up between 1.5- 2% of acute respiratory admissions. Children included in the study had a median age of 7 years. Along with the typical symptoms described, emesis and diarrhea appear to be prominent with the virus found in stool samples suggesting fecal-oral transmission. Critically ill children have presented with ARDS, septic shock, encephalopathy and myocarditis. Co-infections with other respiratory viruses or bacteria common. Limited information is available about the clinical presentation, clinical course, and risk factors for severe COVID-19 in children.(5, 17-22) 8. Prolonged detection of SARS-CoV-2 RNA has been reported in respiratory specimens (up to 22 days after illness onset) and stool specimens (at least 30 days after illness onset).(17, 18) 9. Clinical presentation among cases of COVID-19 varies in severity from asymptomatic infection to fatal illness. Several reports suggest the potential for clinical deterioration during the second week of illness (range: 5 – 13 days).(3, 8) 10. Acute hypoxemic respiratory failure developed in 17–29% of hospitalized patients. Secondary infection developed in 10%, with a median time from symptom onset to of respiratory failure of 8 days.(3, 6, 7) 11. Approximately 20-30% of hospitalized patients with COVID-19 and pneumonia have required critical care. Compared to patients not admitted to an intensive care unit (ICU), critically ill patients were older (median

Guideline Only/Not a Substitute for Clinical Judgment 2

Clinical Management of COVID-19 age 66 years vs. 51 years), and were more likely to have underlying co-morbid conditions (72% vs 37%).(3, 7) 12. Among critically ill patients admitted to an ICU, 11–64% received high-flow oxygen therapy and 47-71% received mechanical ventilation. A small proportion (3-12% of ICU patients) have also been supported with extracorporeal membrane oxygenation (ECMO).(6, 7, 12) 13. Other reported complications include cardiac injury, sudden cardiac death, arrhythmia, septic shock, liver dysfunction, acute kidney injury, and multi-organ failure.(23) 14. A case fatality rate of 2.3% has been reported among confirmed cases of COVID-19 in China.(12) However, the majority of these cases were hospitalized patients, so this mortality estimate is likely biased upward. Among hospitalized patients with pneumonia, the case fatality proportion has been reported as 4–15%.(3, 6, 7) In a report from one Chinese hospital, 61.5% of critically ill patients with COVID-19 had died by day 28 of ICU admission. Among all critically ill COVID-19 patients in China, the reported case fatality proportion was 49%.(2) 15. As of 2 Apr 20, the Italian government COVID-19 surveillance group reported 12,550 deaths due to COVID- 19, of which 83.4% >70 yr, 11.5% 60-69 yr, 3.8% 50-59 yr, 0.8% 40-49 yr, 0.2% 30-39 yr, 0.05% <30 yr. Approximately 50% of all deaths had >3 pre-existing co-morbidities (hypertension, type 2 diabetes, ischemic heart disease, atrial fibrillation). https://www.epicentro.iss.it/en/coronavirus/bollettino/Report- COVID-2019_2_april_2020.pdf

Figure 1. Clinical Courses of Major Symptoms and Outcomes and Duration of Viral Shedding [from Zhou, et al.; Lancet (2020)].(4)

PLANNING AND PREPARATION

Facility Incident Command and Systems. 1. A command structure with clearly defined roles and lines of communication should be defined prior to a pandemic and can be part of these exercises.(24, 25) These structures should have the ability to coordinate expansion or restriction of critical care resources through implementation of Contingency and Crisis Standards of Care (CSC) in conjunction with Unit medical directors, help coordinate “just in time” training as well as regional expert consultation (i.e. tele-consultation with critical care, infectious disease, or other specialists), facilitate the flow of critical equipment and patients, and coordinate CSC changes on both a local and regional level liaise with the community as transition depends on regional, not just local, healthcare utilization. 2. Establish and Manage Crisis/Contingency Standards of Care Guideline Only/Not a Substitute for Clinical Judgment 3

Clinical Management of COVID-19 a. CSC are “a substantial change in usual healthcare operations and the level of care it is possible to deliver, which is made necessary by a pervasive (e.g., pandemic influenza) or catastrophic (e.g., earthquake, hurricane) disaster.”(26) b. The establishment of the CSC should enable specific legal and regulatory protections for health care providers when having to operate under conditions of limited medical resources and alternate models of care. For reference, DODI 6200.03 allows for establishment of a CSC within the DoD. c. Design and implementation of these standards for each agency should remain flexible based on each situation and should be tiered (i.e. normal operations, contingency, crisis) and have specific triggers to engage. In general contingency when >120% typical capacity and crisis when >150-200% capacity though this may be revised down or up depending on availability of staff, equipment, and space. d. Contingency Standards of Care are usually more similar to typical care standards with most staff working in their usual environments but with expanded clinical responsibilities. When Crisis Standard is invoked it would typically trigger significantly altered staffing models as described below. e. CSC should be developed by multi-disciplinary groups and collated by the Incident Command Center (ICC) and should be individualized to a facility. A list of topics that should be included: • Authority and triggers for enacting escalating from usual to contingency then CSC • Emergency credentialing & scope of practice changes as CSC escalate (nursing, physician, etc) • Alterations in practice allowed (limiting documentation, changes in work hours and locations, changes in location of patient care and monitoring requirements 3. Establish clear lines of communication (LOC) to ensure: a. The ability to maintain power, particularly at austere or atypical sites of care. b. The ability to rapidly download a transferrable version of clinical information to follow patients through the system. c. That the systems exist to efficiently share this information with staff. d. That communication be consistent, from designated sources, and information be trusted by staff.(27-29) 4. Establish Patient Tracking and Re-unification systems: a. Command centers should also help plan and coordinate a system for patient tracking, identification, and the ability to communicate with family members and next of kin regarding status and location of loved ones who may be restricted from visitation.(29) 5. Establish security, access points, and “clean” areas with access restricted: a. Given high levels of stress, limited resources, potentially crowded living conditions, and considerable anxiety surrounding pandemic disease, coordination with security both for a facility and the ICU should be included in the planning process. b. Establish “satellite” units in alternative locations to care for critically ill patients unaffected by the pandemic to group contagious patients, cohort staff, and protect non-infected patients.(30) c. Consider allocating “high risk” staff (underlying medical conditions, age >60) to these sections. d. Consider access to specialty care that may be needed in these sections with screening as patients enter. e. Establish single or controlled points of entry for every facility and initiate screening procedures for possibly infected patients at entrances. 6. Coordination of re-prioritization of clinical duties: a. Limitation of non-urgent care, well visits, routine visits or imaging b. Focus on urgent care, but ensure a process for providing necessary routine care when unsafe to defer c. Care should be primarily virtual unless a face-to-face visit is necessary as determined by the care team d. Consider consolidating face-to-face care to specific sites and transition others to virtual care only e. Closely track access and demand and adjust as necessary f. If prolonged, give consideration to designating satellite sites to continue routine, but necessary care g. Coordinate re-allocation of assets off loaded by limitations to areas of need (Critical Care, Inpatient care, Initial triage, and Urgent/Emergency Care).(31) h. Limit administrative, educational and academic duties to those necessary to directly support patient care i. Frequently message to patients and staff any changes in services, clinic hours, entry procedures, etc. to manage their expectations

Guideline Only/Not a Substitute for Clinical Judgment 4

Clinical Management of COVID-19

Figure 2. A framework outlining the conventional, contingency, and crisis surge responses. PACU: post-anesthesia care unit. [from Christian, et al.; Chest (2014)].(32)

7. Develop Recall Roster for all assets (nursing, physician, housekeeping, dietary, security, admin, etc) and triggers for re-calling those who may be needed from remote work. 8. Consider logistic/ancillary support needs when determining “Essential Personnel” for tasks including: a. Disposal of personal protective equipment (PPE) and cleaning both “dirty” rooms and shared spaces. These tasks should be prioritized and will be in very high demand.(33) b. Allocation of adequate space for safe, respectful care of the deceased.(34) c. Designating locations and facilities to shelter and feed families of ill patients, staff members, and even families of staff members to augment and limit the up to 40-50% absenteeism anticipated with illness, school/childcare closure, and fear.(30, 31)

Preparing Critical Care Resources & Teams. 1. Staffing. Many MTFs have reduced staffing capabilities to support their ICUs. However, in a global pandemic requiring care for a surge of critically ill patients, additional staffing models should be considered. Although tele critical care resources should be optimized, there may still be significant deficits in critical care trained healthcare workers. a. Staff Shortages: i. Preparation also needs to be made to compensate for reduced staffing. Illness, fatigue, fear, and care giver duties, particularly with school/daycare closure, limit staff availability with some estimates as high as 60% absenteeism.(30, 35) ii. Augmenting staffing initially with increased “mandated overtime” should be avoided as long as possible to avoid early staff burn out. iii. Facility based alteration of staffing ratios (i.e. less provider staff in the inpatient setting overnight) may help reduce staff burden while maintaining reasonable coverage in keeping with typical hospital processes. iv. Strategies listed above may mitigate (facility based child care, cohort care teams, etc.) but Guideline Only/Not a Substitute for Clinical Judgment 5 Clinical Management of COVID-19 planning should consider at least a 25-40% reduction in staff availability. Additional recommendations to augment staff availability include:(36)  A PPE officer (can be trained non-clinical staff) to train and monitor PPE and staff exposure on each ward  Mental health support or “resiliency teams” with focus on staff wellness and support  Team “Safety officers” to monitor/ensure breaks, hydration, toileting and nutrition v. Critical Care. The Society of Critical Care Medicine (SCCM) recommends staffing models to support expanded critical care bed capacity in the event of a global pandemic (https://www.sccm.org/Blog/March-2020/United-States-Resource-Availability-for-COVID-19), which includes use of multiple non-ICU trained healthcare workers (noted in red in Figure 3). The staff noted in green are recommended to be ICU trained and experienced, and include: (37)  Critical Care Physician  Respiratory Therapist  Advanced Practice Providers (APP)  Critical Care Nurse (CCRN or experienced active RN working in critical care)  In facilities without intensivists, critical care teams may be directed by anesthesiologists, pulmonologists, hospitalists, or others with experience caring for critically ill patients.(37)  Staffing for the roles in red could include but are not limited to those with some previous critical care training or experience and could include:

Figure 3. Based on SCCM Tiered Critical Care Staffing Strategy for Pandemic, adjusted by DoD expert consensus. APP: advanced practice provider; RT: respiratory therapist; CRNA: certified registered nurse anesthetist; MD/DO: physician. (37) o Non-ICU physician: anesthesiologists, hospitalists, general surgeons or others with experience caring for critically ill patients o CRNA, CAA, MD/DO: Residents from medical or surgical specialties (with appropriate supervision and graduated responsibility) or other medical or surgical staff preferably with experience in inpatient medicine o Non-ICU nurse tiered from best to least suited:(36) 1. RN currently working in progressive care units (telemetry or step down units) 2. Ambulatory care setting with previous ICU experience (preferably within 3 years) 3. Paramedics, EMTs or RNs and medical assistants/LPN that work in urgent care vii. Step-down Care/Intermediate Care Ward (ICW). Figure 4 provides a framework staffing model for patients requiring more intensive support but not mechanical ventilation/vasopressor support, or those at imminent risk of requiring mechanical ventilation/vasopressor support, such as could be managed in a step-down unit. Ideally, this team would be led by an experienced hospitalist or intensivist who oversees the care of physician-led teams. Ideally, these staffing models would be supported by a minimum of two teams working no longer than 12-hour shifts. (30) In the setting of COVID-19, these are likely patients that would be hospitalized in fixed Guideline Only/Not a Substitute for Clinical Judgment 6

Clinical Management of COVID-19 facilities by not in ICUs.

Figure 4. Tier 2 Staffing Strategy for Step-down Level Care during a Pandemic

viii. Routine Inpatient/Ward Care. Figure 5 provides a framework staffing model for inpatient routine medicine care, with an ideal team led by an experienced hospitalist or physician with hospital experience. In the setting of COVID-19, these would likely be patients housed in “off site” facilities with limited resources (e.g., tents, gyms, convention centers, etc).

Figure 5. Tier 3 Staffing Strategy for Routine Ward Level Care during a Pandemic

vii. Pediatric Care. For MTFs that have a large footprint of pediatric providers (pediatric residencies, pediatric intensivists, pediatricians, pediatric nursing), there should be consideration to flex pediatric age range up to 30 in the Contingency Stage. This will leverage appropriate expertise to care for young adults, which is common both for these providers especially in the military, and offload patient numbers from the adult care teams. For smaller MTFs that have minimal pediatric beds, minimal pediatricians (i.e., Family Practice caring for children), there should be consideration of diverting inpatient pediatric patients to dedicated children's hospitals. This decision should be made based on available community capacity and there should be communication with local facilities to strategically plan for patient distributions. MTFs must still maintain dedicated non-COVID-19 medical missions, and should not sacrifice care in other areas (e.g., use NICU beds/ventilators for adult patients if needed in the NICU). b. Privileging Options. In accordance with national standards for accreditation, local leadership may cross- level providers to provide patient care, treatment and services necessary as a life-saving or harm reducing measures, provided the care, treatment, and services are within the scope of the individual's license without modification of existing privileges. Disaster privileges can only be granted to volunteer licensed independent practitioners when the organization’s Emergency Operations Plan has been activated. During

Guideline Only/Not a Substitute for Clinical Judgment 7

Clinical Management of COVID-19 emergencies, providers undergoing “just in time” training for work outside their normal areas may work within the scope of their individual licensure and do not require privilege modification, addition or supervision. Privileging authorities may award disaster privileges on activation of their emergency management plans consistent with provisions established in DHA PM 6025.13, Volume 4. 2. Staff Training. a. ICU “Just in time training” for augmentees are available at https://www.sccm.org/covid19, https://www.chestnet.org/Guidelines-and-Resources/COVID-19/On-Demand-e-Learning, https://www.chestnet.org/Guidelines-and-Resources/COVID-19/Updates-and-Resources, https://www.sccm.org/disaster, and https://covid19toolbox.com. b. Training and augmentation platforms. • If local expertise is not available, utilization of existing DHA teleconsultation platforms (PATH, ADVISOR) may augment capabilities. • Places with ICU care should develop brief local ICU orientation models focusing on safety practices, unit hierarchy, protocols, and consultative relationships (brief, max 4-8 hours). • Training platforms for provider and nursing augmentees should focus on remote learning resources to provide baseline didactic training such as those above or those locally developed. c. Critical care considerations for pregnant women online training is available at: https://www.smfm.org/critical-care/cases/new-2019. d. DHE Clinical RN Refresher Training Packet was released with the intent of helping to refresh inpatient nursing experience. (https://info.health.mil/edu/Pages/COVID.aspx) e. PPE; Donning and doffing officers should be assigned to train and monitor, which can be personnel pulled from non-clinical roles (administrators, support staff, etc.) that can fulfill a vital safety role after being trained. Training video: https://www.youtube.com/watch?v=bG6zISnenPg (38) 3. Equipment and Consumables. Daily assessment of ventilators, ventilator circuits, PPE, fluids, and sedating medication should be tracked with equipment burn rates estimated and updated as information is available. a. Consider creating intubation/procedure packs with all necessary equipment and supplies to avoid going in and out of the room repeatedly. b. Consider alternative options to reduce and re-use critical items such as PPE and ventilator circuits. Encourage sharing local policies and solutions as they become available. c. Consider utilization of anesthesia ventilators when expanding into OR or PACU areas, but ensure some remain in reserve based on facility needs for acute, non-COVID-19 emergencies. d. Inventory management. • Develop a list of key inventory to include PPE, ventilators and supporting equipment, fluids, key medications, fluids, nutrition, IV and other vascular access supplies, etc. • Assign personnel to develop a tracking system and publish regularly to ICC. Utilize models to predict inventory burn rate. A sample PPE utilization calculator available at: https://www.chestnet.org/Guidelines-and-Resources/Resources/Essential-Institutional-Supply- Chain-Management-in-the-Setting-of-COVID-19-Pandemic (39) 4. Space: a. ICU Contingency Units. Many modern ICUs have rooms capable of holding two patients, though typically are single use. These spaces need to be assessed to house appropriate ventilators, suction, and monitoring, but if so equipped, should be utilized first. Co-locating COVID-19 patients as much as possible will increase the efficiency of staff and supply use. If these spaces are exhausted, other monitored, ventilator capably areas may be available to use as alternative ICU rooms (OR, PACU, etc). b. Ward Cohorting: Consideration should be given to establishing COVID-19 wards. Clean barriers on open units similar to chemical “hot lines” can be used. This includes cohorting staff to “COVID-positive” or “COVID-negative” teams based on which cohort they are caring for to reduce transmission. If possible, COVID-19 inpatient care should be limited to specific areas of the hospital with designated travel routes reserved for flow of COVID-19 positive patients.

Establishment of a DoD Case Registry for Clinical Performance Improvement. 1. Systematic collection and iterative analysis of key clinical data is essential to optimize delivery of care. Guideline Only/Not a Substitute for Clinical Judgment 8

Clinical Management of COVID-19 2. This should be executed urgently in the context of an approved, directed performance improvement initiative, in the setting of a learning health system.

SCREENING AND TRIAGE: EARLY RECOGNITION OF PATIENTS WITH COVID-19

1. Screening: Screen and isolate all patients with suspected COVID-19 at the first point of contact with the health care system (ER/clinic/drive-through screening/labor and delivery). Establish processes for how to handle people screening positive at entrances. Processes should be clear and easy to follow and be standardized across facilities within the Local Command. It is also recommended to direct low-risk patients to drive-through screening facilities as available to reduce exposure and conserve PPE in MTFs. 2. Triage: Triage patients using standardized triage tools and initiate the appropriate disposition decision depending on the clinical setting. Ensure standard protocols established in cooperation with Infectious Disease and Public Health that are clear and easy for staff to follow. Try to keep protocols aligned with national (CDC) and local (state or municipal) guidance and update regularly as new guidance emerges. Triage should be conducted telephonically or in a designated outdoor or dirty area when possible. Staff evaluating patients face-to-face should be pre-identified and outfitted and trained on appropriate PPE. Patients can pre-screen themselves using available self-checkers from the CDC and other organizations. a. A potentially useful tool for initial categorization of clinical severity and aiding in triage is the National Early Warning Score (NEWS). This is a clinically derived score easily measured in a triage area, clinic, emergency department or other initial assessment environment. It consists of the parameters listed below. (Figure 6)

Figure 6. National Early Warning Score (NEWS).(40)

b. The score ranges from 0-21 and higher scores have been demonstrated to correlate with worsened mortality. A score of above 5 increases the likelihood of eventual ICU level of care.(40) c. NEWS in COVID-19 has distinct advantages over qSOFA which can underestimate the severity of presentation if confusion, and hypotension are absent as they often are in COVID-19 patients.

3. Initial treatment of hospitalized inpatients consists of optimized supportive and symptomatic care in the ward or intensive care unit. Patients with increased risk of severe disease and mortality include:  Age >60  Diabetes mellitus  Hypertension Guideline Only/Not a Substitute for Clinical Judgment 9

Clinical Management of COVID-19  Immunosuppression  Cardiopulmonary disease 4. Patients may present with mild symptoms but have high risk of deterioration and should be admitted to a designated unit for close monitoring. 5. Mild Illness. For mild illness, hospitalization may not be required unless concern about rapid deterioration. Isolation to contain/mitigate virus transmission should be prioritized. Safe home care can be performed according to CDC guidance (https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-home-care.html). 6. ICU Admission Criteria. ICU admission and exclusion criteria may be a fluid decision based on the facility. Given that allocation of dedicated ICU beds and surge capabilities amongst individual hospitals are variable, each hospital should provide a specific plan regarding ICU admission/exclusion criteria. This could be based on the percentage of resources utilized (e.g., beds, ventilators). An example plan is provided below.

Figure 7. Example of an ICU Surge Plan (from the San Antonio Veteran’s Affairs Hospital)

IMMEDIATE IMPLEMENTATION OF APPROPRIATE Infection Prevention Control (IPC) MEASURES/PPE

1. All employees working in inpatient units, ambulatory clinic spaces, and procedural areas should wear a surgical face mask, at all times, while in their respective clinical care settings. Such requirements align with current policies from leading healthcare systems, including the University of Nebraska. Additional information can be found at the following link: https://www.nebraskamed.com/sites/default/files/documents/covid-19/surgical- mask-policy-and-faq-nebraska-med.pdf. See Appendix A for PPE donning/doffing and mask use. 2. Appropriate use of PPE plays an important role in the prevention of disease transmission, however ensuring appropriate work practice and environmental controls are in place is critical. In addition to implementing the PPE guidelines provided below, MTFs should adhere to the following essential practices: a. Screen all visitors and healthcare workers before entry into the healthcare facility b. Implement restricted visitation policies for the facility (refer to example provided by Emory Healthcare: http://www.emoryhealthcare.org/covid/index.html c. Practice social distancing d. Adhere to frequent hand hygiene and wear a surgical or cloth mask at all times.

Guideline Only/Not a Substitute for Clinical Judgment 10

Clinical Management of COVID-19

Figure 8. PPE Recommendations for the MHS (Adapted for the MHS using CDC guidelines accessed 31 MAR 2020: https://www.cdc.gov/coronavirus/2019-CoV/hcp/index.html) ; PAPR, powered air-purifying respiratory; PPE, personal protective equipment; PUI, patient under investigation; High-risk Area - Areas with a Level 3 Travel Health Notice identified by the CDC Visit www.cdc.gov/coronavirus/2019-ncov/travelers/after-travel-precautions.html for current list.

Special Situations: ED staff and outpatient healthcare workers with any patient encounter with a PUI: Follow Category 2.

COLLECTION OF SPECIMENS FOR LABORATORY DIAGNOSIS

1. Triage: Patients should be triaged and initial testing optimally performed in a manner separated from the general patient population such as in a tent or designated area within a facility. Initial laboratory collection will include nasopharyngeal swab for COVID-19 testing and additional tests as indicated. 2. Specimen Collection: Collect specimens from the upper respiratory tract (URT), as viral density/load is highest in the nasal cavity and nasopharynx. Nasopharygeal swabs are preferred compared to washings or other methods, as these increase the risk of aerosolization and transmission of the virus. If unable to collect from the URT, consider collecting specimens from the lower respiratory tract (LRT) using expectorated sputum or endotracheal aspirate. Testing for other viral infections such as influenza should be obtained, or if available a respiratory viral panel (i.e. Biofire). Avoid bronchoscopy and nasal endoscopy to minimize aerosolization.(41) 3. Confirming COVID-19: a. Diagnosis of COVID-19 is primarily confirmed by nucleic acid amplification techniques (NAAT) of SARS-CoV- 2. The most common tests are real-time reverse transcriptase polymerase chain reaction (RT-PCR) tests, but other NAATs (in-situ hybridization and others) are also used. b. The CDC’s PCR assay received emergency use authorization (EUA) on 3Mar20. Since then numerous

Guideline Only/Not a Substitute for Clinical Judgment 11

Clinical Management of COVID-19 commercial laboratories and universities have developed assays with subsequent approval.(42) c. These assays are, in general, highly specific, but the sensitivity may depend on the disease process (mild upper respiratory infection vs severe pulmonary disease) and the site of specimen collection. At this time there are few data available to assess sensitivity of these assays and even fewer data to evaluate the assays based on clinical specimen type. d. Nasopharyngeal swab specimens are most commonly recommended as noted above; however in an intubated patient tracheal aspirates should also be obtained. The majority of data on sensitivity of NAATs from different specimen sites are from retrospective, descriptive data from cohorts of Chinese patients with COVID-19. One manuscript describing 1070 specimens from 205 patients with COVID-19 suggested that LRT samples were most likely to be positive for viral RNA.(43) e. Consider retesting if clinical suspicion for COVID-19 remains (false-negative results possible). f. Comparing sensitivity of nucleic acid testing to the experience of Chinese and other researchers may have limitations. The WHO assay uses RNA-dependent RNA polymerase, whereas the CDC assay targets genes which target viral nucleocapsid genes (N genes). One non-peer reviewed publication suggested that the nucleocapsid assays have higher sensitivity than the WHO assay. As a result, any data on sensitivity from a NAAT performed under the WHO assay (to include reports from China) may underestimate sensitivity of assays in the United States.(44) g. Serologic assays are being developed to assess antibody response to COVID-19 infection. As of 3 April the FDA issued the first EUA for an IgG/IgM assay for SARS CoV-2. It remains unclear whether presence of IgG can serve as a correlate of immunity. 4. Hospitalized Patients: In hospitalized patients with confirmed COVID-19, repeated URT and LRT samples can be collected to demonstrate viral clearance. The frequency of specimen collection will depend on local epidemic characteristics and resources. In a clinically recovered patient, two negative tests at least 24 hours apart is recommended. 5. Personal Protective Equipment (PPE): Use appropriate PPE for specimen collection (droplet and contact precautions for URT specimens; airborne precautions for LRT specimens). 6. For pregnant and recently postpartum patients: COVID-19 testing of symptomatic women may need to be prioritized due to need for inpatient care with delivery and ongoing outpatient visits, to enable access to specialized care, to allow appropriate maternal PPE, and appropriate care for the newborn. 7. Co-infection: Dual infections with other respiratory viral and bacterial infections have been found in SARS, MERS and COVID-19 patients. As a result, a positive test for a non-COVID-19 pathogen does not rule out COVID-19. At this stage, detailed viral and microbiologic studies are needed in all suspected cases.

MANAGEMENT OF MILD COVID-19: SYMPTOMATIC TREATMENT AND MONITORING

1. Overall management: The mainstay of treatment for mild cases of COVID-19 is supportive care. 2. Disposition: Those with mild disease may be managed as an outpatient, but the determination of outpatient vs inpatient care should be individualized based on consideration of symptom severity, risks for adverse outcomes (e.g., underlying illness and age), and the patient’s social context: a. Their access to resources such as food and other necessities for daily living b. Their access to appropriate caregivers or ability to engage in self-care c. Their ability to engage in symptom and public-health monitoring d. The transmission risk within the home (e.g., the availability of a separate bedroom to minimize sharing of immediate living spaces; their access to PPE such as gloves and a facemask; their ability to adhere to home isolation, respiratory and hand hygiene, and environmental cleaning; and household members at increased risk for COVID-19 complications).(12, 45, 46) 3. Monitoring for symptomatic progression: Monitoring for the evolution of symptoms may be conducted by healthcare providers or public-health personnel, depending on local policy. a. Although 81% of patients in a Chinese case series had mild symptoms, those who progressed to more severe disease were hospitalized a median of 7-11 days after the onset of illness.(4, 6, 47) Therefore, close monitoring for symptomatic progression through the second week of illness is important for Guideline Only/Not a Substitute for Clinical Judgment 12

Clinical Management of COVID-19 non-hospitalized patients. b. Close monitoring should be emphasized in patients aged ≥ 60 years, those who reside in nursing homes or long-term-care facilities, and/or those with underlying medical comorbidities that may increase their risk for disease progression, to include: cardiovascular disease, cerebrovascular disease, chronic respiratory diseases including moderate-to-severe asthma, chronic kidney disease, chronic liver disease, diabetes, severe obesity (BMI ≥ 40 kg/m2), hypertension, cancer, immunocompromising conditions, and pregnancy.(6, 12, 47-50) Telehealth follow-up may be an option for these patients. 4. Home care guidance: Healthcare providers may provide patients and caregivers with available CDC guidance: a. Preventing the Spread of Coronavirus Disease in Homes and Residential Communities (https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-prevent-spread.html) b. What to Do If You Are Sick (https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/steps-when-sick.html) c. Caring for Someone at Home (https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/care-for-someone.html) d. Caring for Yourself at Home (https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/caring-for-yourself-at-home.html)

Figure 9. CDC Home Care Management Recommendations for COVID-19 Patients (website above). (46)

5. Medication management: The impact of drugs affecting the renin-angiotensin-aldosterone system (RAAS), such as angiotensin-converting-enzyme inhibitors (ACE-Is), angiotensin-receptor-blockers (ARBs), and non- steroidal anti-inflammatory drugs (NSAIDs), on clinical outcomes in patients with COVID-19 is unclear. (51) a. ACE-Is and ARBs: • Angiotensin-converting enzyme 2 (ACE2) is the cellular binding target for SARS-CoV2, and some preclinical studies suggest that RAAS inhibitors may upregulate ACE2 expression, though this effect is not uniform, and there is insufficient data regarding upregulation in humans.(52) The theoretical concern that RAAS inhibitors may increase the binding sites and infectivity of SARS-CoV2 is countered by the hypothesis that increased levels of ACE2 may help mitigate virus-induced lung injury as well as the known risk of withdrawal of RAAS inhibition in patients with underlying cardiovascular disease.(53) • The American College of Cardiology, American Heart Association, and Heart Failure Society of Guideline Only/Not a Substitute for Clinical Judgment 13

Clinical Management of COVID-19 America issued a joint statement that there was no experimental or clinical data to suggest a beneficial or adverse impact of ACE-Is, ARBs, or other RAAS antagonists in patients with COVID-19. As such, continuation, discontinuation, or initiation of these agents should be based on standard clinical indications and an individual patient’s clinical presentation and hemodynamic status, irrespective of a diagnosis of COVID-19.(54) b. NSAIDs: • The FDA patient advisory states that there is no scientific evidence connecting the use of NSAIDs, like ibuprofen, with worsening COVID-19 symptoms.(55) • The World Health Organization (WHO) does not recommend against the use of NSAIDs. • Acetaminophen is recommended for fever control when ibuprofen is not necessary. 6. Targeted therapy: There are currently no approved or proven targeted therapies for the treatment of COVID- 19. While the majority of clinical trials are focused on hospitalized patients, there are a growing number of clinical trials targeting mild, outpatient cases and investigating the use of repurposed antiviral, antimalarial, and immunomodulatory agents as well as other agents, such as traditional Chinese medicines (www.clinicaltrials.gov). 7. Discontinuation of home isolation: Clinicians should contact local military public health and/or local/state health departments regarding criteria for discontinuation of home isolation and establish clear and easy-to- follow protocols to guide staff, patients, and commands on return to work/duty criteria.(46) Local implementation of discontinuation strategies may be based on availability of testing supplies, laboratory capacity, and community access to testing. Local authorities may also consider differential application of discontinuation strategies to unique populations based on their risk for transmission to susceptible contacts (e.g., following a test-based strategy for healthcare workers or those living in congregate settings, such as nursing-home residents or basic trainees, vs a non-test-based strategy for the general population). Military bases or units may have administrative requirements for service members to be able to return to work/duty independent of clinical standards. Examples of such protocols can be found in Appendix B. The CDC has established two major approaches: a. Non-test-based strategy: This strategy is predicated on the time since recovery and illness onset. Persons with COVID-19 who have symptoms and were directed to care for themselves at home may discontinue home isolation under the following conditions: • At least 3 days (72 hours) have passed since recovery, defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, SOB), and • At least 7 days have passed since symptoms first appeared. b. Test-based strategy: This strategy is contingent on the availability of ample testing supplies and laboratory capacity as well as convenient access to testing. Patients may discontinue home isolation under the following conditions: • Resolution of fever without the use of fever-reducing medications and • Improvement in respiratory symptoms (e.g., cough, shortness of breath) and • Negative results from two consecutive negative molecular assays for SARS-CoV2, obtained via nasopharyngeal swab, at least 24 hours apart.(56)

MANAGEMENT OF SEVERE COVID-19: OXYGEN THERAPY AND MONITORING

1. Give supplemental oxygen therapy immediately to patients with respiratory distress, hypoxemia, or shock and target SpO2 92-96%, although maintaining SpO2 above 88% may be acceptable in certain cases.(57, 58) Hyperoxia (PaO2 >225mmHg) should be avoided and is associated with worse outcomes.(59) 2. Begin with low flow nasal cannula (1-6 L/min) followed by high flow nasal cannula (HFNC, 5-30 L/min, see Figure 10). Place surgical mask over patients face and nasal cannula to minimize aerosolization of particles. 3. Some COVID-19 patients have presented with significant hypoxia but low PaCO2. These patients can tolerate this well with just supplemental O2. For these patients, consider not intubating solely for hypoxia, rather use other typical indications such as severe distress and/or hypercarbia. (60) 4. Recommendations are evolving regarding risk:benefit, but favor HFNC over bi-level positive airway pressure Guideline Only/Not a Substitute for Clinical Judgment 14

Clinical Management of COVID-19 (BIPAP)/noninvasive ventilation (NIV) if early intubation and mechanical ventilation is not possible. HFNC is a more effective intervention for the non-invasive management of hypoxemic respiratory failure and is less aerosolizing than BIPAP. (41) 5. Awake proning of non-intubated patients is currently being performed at some hospitals across the world.(61) A retrospective study of 15 non-intubated, hypoxemic patients placed in the prone position showed improvement of oxygenation. The effects were not sustained upon supine positioning.(62) See Appendix F for full protocol for prone positioning of non-intubated patients. 6. For children, use of nasal prongs or nasal cannula may be better tolerated, but the goal is to target SpO2 >94% during resuscitation, and >90% once stable. 7. Aggressive fluid resuscitation may worsen oxygenation and outcomes in both children and adults, so in the absence of shock, fluid boluses should be minimized. 8. Avoid nebulizers, as metered dose inhalers are recommended for staff protection/avoidance of aerosols.(41) 9. For intubated patients who progress to Acute Respiratory Distress Syndrome (ARDS) and a PaO2/FiO2 ratio<150, recommend early proning and consideration for transfer to an extracorporeal membrane oxygenation (ECMO) center if possible. Prone patients may require paralysis with cisatricurium but resources may dictate per individual facility. 10. Admission studies and labs: Consider the labs/studies in Table 1 for diagnosis, prognosis and risk stratification (and/or safety of agents) for all hospitalized patients with confirmed COVID-19/PUI. 11. Do not allow ICU visitors for IPC purpose during a pandemic except under exigent circumstances. 12. Facilities should assess daily operational status via huddle of equipment including ventilators, medications (e.g. induction agents and paralytics), and staffing (including respiratory therapists, physicians and nursing) and initiate contingency or crisis standards of care as appropriate.

Table 1. Laboratory and Study Considerations for Hospitalized Patients with COVID-19 (or PUI) Recommended Daily Labs: • Complete Blood Count (CBC) with diff (trend neutrophil-lymphocyte ratio, NLR)* • Complete metabolic panel (CMP) • CPK Recommend on Admission (may repeat q2-3 days if abnormal or with clinical deterioration) • D-dimer, PT/PTT, Fibrinogen • Ferritin/CRP/ESR • LDH • IL-6 • Vitamin D-25 Hydroxy, Zinc-RBC • Troponin (if suspect acute coronary syndrome or heart failure) • SARS-CoV-2 test, Biofire rapid viral testing • Electrocardiogram (ECG) (daily with severe infection) • Portable CXR If Clinically Indicated • Blood cultures • Tracheal aspirates for intubated patients • Viral serologies if LFTs are elevated if clinically indicated (HBV sAb/cAb/sAg, HCV Ab, HIV q/2 Ab/Ag) • For acute kidney injury (i.e. serum creatinine >0.3 above baseline), send urinalysis and spot urine protein:creatinine) • Procalcitonin * https://emcrit.org/pulmcrit/nlr/

Resource Limitations for Oxygen Delivery and Mechanical Ventilation 1. As the COVID-19 pandemic places additional strain on available resources, the supplies of available ventilators may not meet clinical demand of patients in respiratory failure in need of invasive positive pressure ventilation (IPPV). Facilities should assess respiratory support operational status daily to account for equipment including ventilators, medications (induction agents, anxiolytics, sedatives, analgesics and paralytics), and staffing (respiratory therapists, providers and nurses). 2. Facilities must be prepared with alternate methods to support patients requiring IPPV in the event the number of patients with respiratory failure exceeds the number of ventilators. Alternate strategies in a crisis resource- limited clinical environment include the following:(63-66) Guideline Only/Not a Substitute for Clinical Judgment 15

Clinical Management of COVID-19 a. Deliver manual breaths via a manual resuscitator (“self-inflating bag”). b. Transport mechanical ventilators may be used for prolonged ventilation of stable patients in the MTF (e.g. Impact 754 and 731 transport ventilators, see Appendix G), but need to be used with a viral filter. c. Ventilators in storage (Home Station Medical Response materiel, War Reserve Material, and national stockpiles) d. Anesthesia gas machines capable of providing controlled ventilation or assisted ventilation outside of the traditional use for anesthetic indication. e. NIV ventilators can be used for invasive mechanical ventilation, but should only be used if the standard ventilator supply is exhausted and it is confirmed with the manufacturer (e.g V60) that they are invasive capable and can deliver prescribed breaths. In this case, a HEPA filter should be inserted into the expiratory limb to prevent aerosolization. 3. Conserve accessories used with ventilators, but use viral filters if available. Consider extending the duration of use of breathing circuit supplies and in-line heat and moisture exchangers for treating individual patients.(63) 4. Civilian industry efforts to rapidly develop ventilators as well as evolving respiratory support technologies and techniques may provide additional options in the future. 5. In accordance with professional society consensus statements, U.S. Public Health Service Commissioned Corps, and FDA guidance:(63, 64, 66) a. Use FDA-cleared conventional/standard full-featured ventilators to support patients with respiratory failure. b. Use one ventilator per patient, matching ventilator settings with the patient’s individual respiratory requirements. c. While ventilators may have mechanical capacity to split circuits to support multiple patients, it is excessively difficult to safely implement. There is insufficient body of evidence to support consistent application of this practice. Neither research using animals and test lungs nor case reports of crisis or contingency application of this technique establish clinical safety.

MANAGEMENT OF SEVERE COVID-19: TREATMENT OF CO-INFECTIONS

1. Clinical judgment and patient severity will dictate provider decision on early antibiotic therapy. 2. Procalcitonin levels have been low in COVID-19 with minimal bacterial co-infections reported except in pediatric patients where >80% are reported to be elevated.(67) 3. Post-mortem results reported from China suggest concern for Aspergillus pulmonary infections. 4. Consider empiric antimicrobials for intubated patients with COVID-19. Recommend antibiotic guidance as per ATS/IDSA Community Acquired Pneumonia (CAP) guidelines or as per critical care or infectious disease consultation.(68) As a starting point upon intubation, Table 2 can be used until consultation is available: 5. Recommend obtaining blood cultures and tracheal aspirate prior to initiation of antibiotics if feasible. 6. As noted in section on diagnostic testing, co-detection of other respiratory pathogens has been observed with SARS-CoV-2. For example, Stanford researchers recently provided rapid communication of experience with 562 SARS-CoV-2 tests; of 49 positive SARS-COV-2 results, 11 (22.4%) also had a co- infection, and of 127 positive for other viruses, 11 (8.66%) had a SARS-COV-2 co-infection. (https://medium.com/@nigam/higher-co-infection-rates-in-COVID-19-b24965088333)

Table 2. Empiric Antimicrobial Considerations for Intubated COVID-19 Patients (or PUI) Starting Antibiotic Regimen No comorbidities or immunosuppression or risk • Ceftriaxone† 2 g once daily, and factors for MRSA or Pseudomonas aeruginosa* Azithromycin† 500 mg once daily

Guideline Only/Not a Substitute for Clinical Judgment 16

Clinical Management of COVID-19

With comorbidities‡ • Cefepime 1-2 g every 8-12 hours, and Azithromycin† 500 mg once daily OR • Piperacillin-Tazobactam 4.5 g every 6-8 hours, and Azithromycin† 500 mg once daily Definition of abbreviations: MRSA = methicillin-resistant Staphylococcus aureus *Risk factors include prior respiratory isolation of MRSA or P. aeruginosa or recent hospitalization AND receipt of parenteral antibiotics (in the last 90 d). If concern for MRSA, add Vancomycin 15-20 mg/kg q 8-12 hours (usually 2g/dose) †If Ceftriaxone not available, replace with Ampicillin/Sulbactam 3 g q6h; If Azithromycin not available, replace with Doxycycline 100 mg q12h ‡Comorbidities include chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancy; immunodeficiency/asplenia.

MANAGEMENT OF CRITICAL COVID-19: ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)

Endotracheal Intubation 1. Intubation should be performed early for a number of reasons, including the rapid disease progression, but also the additional time required to prepare for intubation in full PPE. 2. Intubation has the highest risk of aerosolization and exposure to COVID-19 of all procedures, and the person performing intubation is most at risk.(41) For this reason, the most experienced person should perform endotracheal intubation to reduce exposure to the healthcare team and all team members should be in appropriate PPE with powered air purifying respirator (PAPR) during intubation. If PAPR is unavailable, an appropriate alternative may be the M50 CBRN gas mask. If these options are not available, N95, hair cover, gown, double gloves, face shields, goggles, and shoe covers should be used, along with a protective clear plastic cover over the patient to optimize protection for the providers. Consider intubation teams and limit the number of staff members during airway manipulation to reduce unnecessary exposure. (https://www.apsf.org/news-updates/perioperative-considerations-for-the-2019-novel-coronavirus-covid-19/) 3. A pre-intubation checklist is encouraged, which should include supplies to be brought inside the room by specific team members and others that should remain outside the room. Appendix C provides an example intubation checklist (adapted from University of Washington). Note: a disposable stethoscope should be used to avoid viral transfer and staff should touch as little as possible in the room to avoid fomites. 4. For patients with a normal airway assessment, awake intubation should be avoided and modified RSI with sufficient muscle relaxation is strongly encouraged. For patients with difficult airways, good preparation of airway devices and detailed intubation plans should be made in advance.(69) 5. Some centers have advocated for further reducing exposure during pre-oxygenation and ventilation through preparing an additional COVID-19 Intubation Pack, in addition to intubation meds, a video laryngoscope (if used, or direct laryngoscopy), and a non-vented BiPAP mask. The following video demonstrates the set-up: (https://youtu.be/C78VTEAHhWU). 6. Appendix D provides a framework for intubation with medications and doses, although this is not a substitute for clinical judgement. 7. Additional cognitive aids have been developed and might be useful. Appendix E provides examples.

Management of ARDS 1. Non-invasive ventilation (NIV). It is recommended to avoid NIV because of increased aerosolization generated by the facemask and lack of an exhalation filter. If there is an exception to this such as patients that chronically use NIV or DNI patients, these patients will require airborne isolation regardless of ICU/acute care status. 2. High-flow nasal cannula (HFNC). Although an area of controversy, early expert opinion favors HFNC over other NIV modalities (https://emcrit.org/ibcc/COVID-19/#high_flow_nasal_cannula) because it appears to be well tolerated and less aerosolizing. There is presently no definitive evidence that HFNC augments transmission of virus, however HFNC will disperse air farther the higher the flow is set, (but not as far as CPAP). (70) A surgical mask should be placed over the HFNC in an effort to minimize aerosolization risk. Consider intubation for higher flow rates (>30 L/min), especially if the patient is not in a negative pressure room. 3. Helmet ventilation. The helmet can be connected to either a BiPAP circuit or a HFNC circuit (up to 60 L of Guideline Only/Not a Substitute for Clinical Judgment 17

Clinical Management of COVID-19 flow) to increase the PEEP that the patient receives.(71, 72) The helmet has a tight seal around the neck and should decrease the amount of leak usually seen with mask interface NIV (such as BiPAP and CPAP). In one study comparing helmet to mask NIV with ARDS, there was a decreased rate of intubations.(72) There has been concern that CO2 washout was inefficient using the helmet,(73) but a follow up study did not support that concern.(71) Helmet ventilation can prevent aersolizing the virus. 4. Mechanical Ventilation. COVID-19 does not appear to cause substantially reduced lung compliance as is typical with ARDS, but rather atelectasis and interstitial pneumonia. Physicians in Italy have described severe hypoxia with decent pulmonary compliance. (http://www.ventilab.org/2020/02/29/ventilazione- meccanica-e-polmonite-da-coronavirus/) a. Target an ARDSnet lung-protective strategy (4-8 mL/kg ideal body weight), and lower inspiratory pressures (plateau pressure <30 cm H2O).(58, 74) i. Start with 6 mL/kg ideal body weight tidal volume and titrate to as high as 8 mL/kg as long as the lungs are compliant. ii. In patients with moderate to severe ARDS, suggest titrating to a higher PEEP as tolerated. PEEP tables are available to guide titration: http://www.ardsnet.org/tools.shtml iii. In younger children, maximal PEEP setting is 15 cm H2O as higher PEEP can result in decreased cardiac output. b. Permissive hypercapnia ensuring adequate hemodynamics and a pH >7.15 may be tolerated c. Humidification will likely be needed to manage thick secretions. However, keep in mind the risk of aerosolization associated with breaking the circuit to change heat and moisture exchangers (HME) if this is all that is available. Ventilators with heated humidifiers do not require breaking the circuit to humidify the inspiratory limb and are preferred. Consider clamping the ETT during any circuit breaks. 5. Proning. Evidence has shown that patients who are unable to adequately ventilate in the supine position may benefit from being placed in the prone position to improve oxygen saturation (PaO2), pulmonary mechanics, and arterial blood gases (ABGs).(75-79) Anecdotal reports from Italy and Singapore have found that patients with COVID-19 usually respond well to early pronation.(61) a. Prone positioning requires proper sedation/pain medications and paralytic agents if necessary. b. Length of pronation cycle should be a minimum of 16 hours in the prone position with a return to supine positioning at least once a day. c. Prone positioning should be performed as clinically indicated within the first 24 hours of the diagnosis of severe hypoxemia. d. Recommend use of a manual proning protocol with coordination if mechanical beds are not available. Appendix F provides an example protocol, which was adapted from University Medical Center in Las Vegas, NV. Additional protocols (including videos) are available.(80) e. Pregnancy is not a contraindication for proning or neuromuscular blockade.(81) 6. Neuromuscular Blockade. In patients with moderate-severe ARDS (PaO2/FiO2<150), neuromuscular blockade by continuous infusion should not be routinely used, but may be considered in the setting of worsening hypoxia or hypercapnia and in situations where the patient's respiratory drive cannot be managed with sedation alone resulting in ventilator dyssynchrony and lung decruitment. 7. Airway suctioning. Use in-line catheters for airway suctioning and clamp endotracheal tube when disconnection is required (for example, transfer to a transport ventilator). Avoid disconnecting the patient from the ventilator, which results in loss of PEEP and atelectasis. 8. Bronchoscopy. Routine diagnostic bronchoscopy (including nasal endoscopy or any instrumentation of this area) is not recommended. It is not necessary for the diagnosis of viral pneumonia and should be avoided to minimize aerosolization. Tracheal aspirate samples for diagnosis of COVD-19 are usually sufficient. If bronchoscopy is required for another reason, it should be performed with the same level of PPE as recommended for intubation.

Guideline Only/Not a Substitute for Clinical Judgment 18

Clinical Management of COVID-19

Figure 10. General Schema for Respiratory Support in Patients with COVID-19 (https://i1.wp.com/emcrit.org/wp- content/uploads/2020/03/respsup.jpg?resize=713%2C600&ssl=1).

9. Inhaled nitric oxide and prostacyclin. There is no evidence for routine use of inhaled nitric oxide, prostacyclin or other selective pulmonary vasodilators in acute respiratory failure. However, during emerging infectious disease outbreaks when resources are exhausted, inhaled nitric oxide and prostacyclin may be considered as a temporizing measure when patients develop refractory hypoxemia despite prone ventilation, or in the presence of contraindications to proning or ECMO. 10. Extracorporeal Membrane Oxygenation (ECMO). In settings with access to expertise in ECMO, consider referral of patients who have refractory hypoxemia despite lung protective ventilation who are otherwise appropriate candidates. For more information: https://www.elso.org/COVID-19.

MANAGEMENT OF CRITICAL ILLNESS AND COVID-19: PREVENTION OF COMPLICATIONS

Cardiovascular Disease (CVD) Among 44,672 confirmed COVID-19 cases, those with CVD, diabetes (DM) and hypertension (HTN) suffered from an increased case-fatality rate -10.5% for CVD, 7.3% for DM, 6.0% for HTN vs 2.3% overall. Furthermore there several published reports suggesting SARS-CoV2 infection leading to exacerbation of CVD conditions, or CVD complications.(4, 47, 82)

1. Troponins and Basic Natriuretic Peptide (BNP) Evaluation. Elevated troponin is common (especially high sensitivity troponin), which is a strong predictor of mortality. Mild troponin elevation often does not represent a type-I (plaque rupture) myocardial infarction. Troponin value, velocity of change in troponin level, and echocardiographic imaging should guide the management of the elevated troponin, although current opinion advises that troponin and BNP should only be measured if clinical evaluation suggests acute coronary syndrome or heart failure.(83) 2. Electrocardiogram (ECG). Recommend ECG in suspected or acute coronary syndrome. May consider of obtaining from cardiac tele-monitoring screen. Guideline Only/Not a Substitute for Clinical Judgment 19

Clinical Management of COVID-19 3. Echocardiogram. An echocardiogram should only be ordered if it is likely to provide clinical benefit. Consider repeat echocardiograms only for clear change in clinical status. Point of Care Ultrasound (POCUS) exams may be used to screen/triage patients. Transesophageal echocardiogram (TEE) requests should only be considered when no other alternative imaging modalities are available. 4. Acute Myocardial Injury. a. Definition: An algorithm for the interpretation of myocardial injury is provided for reference and is based on the 4th Universal Definition of Myocardial Infarction (http://www.onlinejacc.org/content/72/18/2231). b. Incidence and Prognosis: Recent reports found that up to 19% of hospitalized patients with COVID-19, have a combination of elevated cardiac biomarkers, in addition to electrocardiographic and echocardiographic abnormalities.(3, 4, 6, 84) There are two patterns of myocardial injury, one pattern of a continued rise with inflammatory markers, and a second pattern similar to the pattern seen in patients with predominantly cardiac symptoms.(85) Myocardial injury appears to be a late manifestation (up to 14 days from illness onset) and has been found to be independently associated with an increased risk of mortality.(4, 84) c. Evaluation: There may be a role for the use of Cardiac Computed Tomography (CCTA) as a non-invasive means to rule out significant coronary pathology as a cause of myocardial injury. Assessment for the appropriateness of testing and imaging protocols should be made in conjunction with a consulting Cardiologist and Radiologist as capabilities are site specific. 5. Myocarditis. a. Incidence: In a case series of 150 patients with COVID-19 patients, nearly 10% of deaths were attributed to myocarditis with circulatory failure, and in 33% of cases it was believed to have contributed as a mechanism for multisystem organ failure.(82) b. Diagnosis: There is currently no role for endocardial biopsy. POCUS at initial evaluation to help protocol TTE. Serial TTE/POCUS only if it will impact management. c. Management: Supportive care depending on hemodynamic status. Case reports on different treatment strategies (glucocorticoid and IVIG) but none are validated by clinical trials. 6. Acute Coronary Syndrome. a. Incidence: Based on available published data, there is a potential symptom overlap between acute coronary syndrome and COVID-19 infection.(2) b. Evaluation: Goal is to differentiate acute plaque rupture, demand related ischemia or myocarditis. Recommendation is for cardiology consultation when unable to determine etiology. i. ST segment elevation on the 12 lead EKG has been reported in the absence of coronary thrombosis or spasms in COVID-19 patients. The mechanism for these EKG changes is uncertain but is felt to be attributable to myocarditis vs possible endothelial dysfunction with micro thrombus formation.(23, 86) Confirmation of a wall motion abnormality, indicating regional myocardial ischemia, can be made with POCUS prior to invasive angiography to aid selecting a revascularization strategy. c. Management: Once the diagnosis of acute coronary syndrome is made, medical management should be coordinated with cardiology. i. Cardiac Catheterization Laboratory Considerations: As most Cath labs are either normal or positive pressure rooms, the benefits of invasive therapeutics must be weighed against the transmission risk to staff and patients. Deferral of invasive management can be considered based on these factors in favor of medical stabilization if needed. Right heart catheterization, pericardiocentesis, and intra- aortic balloon pump placement can be done at bedside when appropriate. Fibrinolytics protocols should be reviewed institutionally with cardiology to discuss care plans if strained resources.(87) 7. Cardiac Arrhythmias. a. Incidence: Common CV manifestation in COVID-19 patients. Current cases series report an occurrence of unspecified arrhythmias in 17% of hospitalized patients with COVID-19 (44% of ICU patients vs 7% non ICU patients).(4) The new onset of malignant tachyarrhythmias in combination with acute myocardial injury should raise suspicion for potential underlying myocarditis.(2) b. Management: Follow ACLS protocols. Cardiology consultation. In patients with atrial fibrillation requiring cardioversion, CCTA may be preferred over TEE to rule out left atrial appendage or intracardiac thrombus. Guideline Only/Not a Substitute for Clinical Judgment 20

Clinical Management of COVID-19 8. Heart Failure and Cardiomyopathy. a. Incidence: In a recent report it was observed that 23% of patients with COVID-19 had presentations consistent with heart failure. More frequently observed in patients who did not survive the hospitalization (51.9% vs 11.7%).(4) Fulminant cardiomyopathy can occur and is thought to be a late feature described in patients recovering from respiratory failure. Cardiogenic shock and cardiac arrest contributes to 7-33% of deaths.(82) b. Mechanism: SARS-CoV-2 is thought to infect host cells through ACE2 to cause COVID-19, while also causing damage to the myocardium, although specific mechanisms are uncertain. (88) c. Management: In the absence of high grade AV block or unstable bradycardia, cardiogenic shock, or acute kidney injury (AKI), guideline directed medical therapies should be continued in patients with heart failure. Assessment of continuation of these therapies should be determined on a frequent basis depending on the patient’s clinical status. As discussed, continuation of ACE-I/ARB therapy in patients with COVID-19 is recommended at this time.(54)

Acute Kidney Injury 1. The reported incidence of AKI with COVID-19 varies from 0.5% to 19.1%.(4-7, 89, 90) This wide range is likely due to in part to the definition of AKI used and to the population studied. Rates of severe AKI requiring renal replacement therapy (RRT) range from 1.4% to 9%.(6, 7) Mortality is increased in patients with AKI, a relationship that appears to be dose-dependent based on AKI severity.(90) 2. The etiology of AKI in COVID-19 is predominantly acute tubular necrosis in the setting of multi-organ failure and shock. However, there have been unpublished reports of SARS-CoV-2 being isolated from urine and observed on kidney pathology. In conjunction with evidence that hematuria and proteinuria are common findings in COVID-19, this suggests that direct viral injury to the kidney may also play a role.(90) 3. The standard of care for critically ill patients with severe AKI is continuous RRT (CRRT). The dose of CRRT is the same as that recommended for other critically ill patients: 25mL/kg/hr.(90, 91) 4. If a MTF admits a large number of patients, it is likely that there will be a shortage of CRRT supplies. If this occurs, slow low efficiency dialysis (SLED) should be considered. SLED is a hybrid therapy that utilizes standard dialysis machines. 5. Regardless of the modality of RRT used, special attention should be paid to volume status and ultrafiltration, consistent with the goals of a restrictive fluid strategy. 6. The preferred location of a dialysis catheter is the right jugular vein, followed by a femoral vein, followed by the left jugular vein.(91) The subclavian vein should be avoided. 7. Patient with COVID-19 are hypercoagulable and will likely require anticoagulants to maintain filter patency. Regional anticoagulation with citrate is preferred, however this should only be done by centers that are already familiar with the technique given the risks of hypocalcemia and citrate toxicity. Second line anti- coagulation is heparin. This topic is reviewed extensively in section 5.3 of the Kidney Disease: Improving Global Outcomes Guidelines on AKI.(91) Other methods to improve filter patency are to increase blood flow (up to 400 mL/min), periodic 100mL flushes of the circuit, and pre-filter replacement fluid (if doing continuous veno-venous hemofiltration).

Hematology 1. There is emerging evidence that many severe COVID-19 patients are hypercoagulable with varying degrees of DIC. Microthrombosis may play a significant role in end organ damage and specifically in the lung pathology causing mico pulmonary embolic with severe hypoxemia. Therefore, there should be some consideration for anticoagulation in severe COVID-19 patients in the ICU, especially those with elevated d-dimer and fibrinogen, decreasing platelets, coagulation derangements, RV dysfunction, increasing dead space (ETCO2 - PaCO2 gradient) and/or hypoxemia recalcitrant to PEEP. 2. Strongly recommend discussing use of anticoagulation and/or thrombolytics with an intensivist if this is suspected. Also recommend continued surveillance for DVTs and pulmonary emboli.

Nutrition 1. Nutrition care decisions are based on the patients’ clinical presentation and the need to limit healthcare provider’s exposure to patients, minimize contamination of equipment, and avoid transport. Guideline Only/Not a Substitute for Clinical Judgment 21

Clinical Management of COVID-19 2. Oral and enteral routes of nutrition are preferred. See Appendix I for Enteral Nutrition Pathway. 3. Ensure patients deficient in Vitamin D and Zinc are properly supplemented.(92-101) 4. Ensure patients get adequate amount of Vitamin A and Vitamin C either in their diet or other route of nutritional support.(102, 103) 5. Enteral Nutrition (EN) for COVID-19 Patients: a. Consult a Registered Dietitian locally or via virtual health b. Give early enteral nutrition (ideally within the first 24-36 hours of admission or within 12 hours of intubation), including patients on ECMO c. Prefer gastric feeding for ease of placement and potential to use an existing NGT or OGT d. Energy supply should target 15-20 kcal/kg actual body weight; target protein content is 1.2-2.0 g/kg daily. e. Choose an nutrition formula based on facility availability and patient’s medical presentation: https://www.nutritioncare.org/Guidelines_and_Clinical_Resources/EN_Formula_Guide/EN_Adult_Formulas/ f. Note: A standard high-protein (>20% protein) polymeric isosmotic enteral formula is recommended pending no renal insufficiency and normal GI function g. Assess for risk of malnutrition/refeeding syndrome; if present, start at 25% of caloric goal (monitor serum phosphate, magnesium & potassium) h. Continuous infusion is recommended; start nutrition at a slow rate (10ml-20ml/hr) and advance to goal as tolerated (ideally within 3-7 days of initiation) i. If patient is to be placed in the prone position, raise HOB 10-25%. Patients in prone position generally tolerate gastric feedings j. Monitor fluid intake closely k. Consider medications that provide calories and adjust tube feeding rate as needed: Propofol (1.1kcal/ml); Dextrose (3.4kcal/ml); Glycerol (4.3kcal/ml) l. See The American Society for Parenteral and Enteral Nutrition’s (ASPEN) Resources for Clinicians Caring for Patients with Coronavirus: https://www.nutritioncare.org/Guidelines_and_Clinical_Resources/Resources_for_Clinicians_Caring_for_Patients_with_Coronavirus/

Table 3. Prevention of Complications Anticipated outcome Interventions Reduce days of  Use weaning protocols that include daily assessment for readiness to breathe spontaneously invasive mechanical  Minimize continuous or intermittent sedation, targeting specific titration endpoints (light sedation unless ventilation contraindicated) or with daily interruption of continuous sedative infusions Reduce incidence of  Oral intubation is preferable to nasal intubation in adolescents and adults ventilator-associated  Keep patient in semi-recumbent position (head of bed elevation 30–45º) pneumonia  Use a closed suctioning system; periodically drain and discard condensate in tubing  Use a new ventilator circuit for each patient; once patient is ventilated, change circuit if it is soiled or damaged, but not routinely  Change heat moisture exchanger when it malfunctions, when soiled, or every 5–7 days Reduce incidence of  Use pharmacological prophylaxis (low molecular-weight heparin [preferred if available] or heparin 5000 venous units subcutaneously twice daily) in adolescents and adults without contraindications. For those with thromboembolism contraindications, use mechanical prophylaxis (intermittent pneumatic compression devices) Reduce incidence of  Use a checklist with completion verified by a real-time observer as reminder of each step needed for catheter-related sterile insertion and as a daily reminder to remove catheter if no longer needed bloodstream infection Reduce incidence of  Turn patient every 2 hours pressure ulcers Reduce incidence of  Give early enteral nutrition (within 24–48 hours of admission) stress ulcers and  Administer histamine-2 receptor blockers or proton-pump inhibitors in patients with risk factors for GI gastrointestinal (GI) bleeding. Risk factors for GI bleeding include mechanical ventilation for ≥ 48 hours, coagulopathy, renal bleeding replacement therapy, liver disease, multiple comorbidities, and higher organ failure score Reduce incidence of  Actively mobilize the patient early in the course of illness when safe to do so ICU-related weakness

6. If unable to initiate EN due to failed EN trial with appropriate gastric tube placement, use of prokinetic agent, and/or postpyloric tube placement, or EN is contraindicated (ileus, SBO, Mesenteric ischemia, high pressure respiratory pressure etc.), consult Registered Dietitian locally or via virtual health immediately for possible parenteral nutrition (PN) initiation. For patients with COVID-19, the threshold to utilize PN may be lower than other critically ill patients.

Guideline Only/Not a Substitute for Clinical Judgment 22

Clinical Management of COVID-19 Other 1. Implement the following interventions in Table 3 below to prevent complications associated with critical illness. These interventions are limited to feasible recommendations and are based on Surviving Sepsis or other guidelines and have been adapted from the WHO guidelines for COVID-19.

MANAGEMENT OF CRITICAL ILLNESS AND COVID-19: SEPTIC SHOCK & CARDIAC ARREST

Recognition of Septic Shock. 1. Recognize septic shock in adults when infection is suspected or confirmed AND vasopressors are needed to maintain mean arterial pressure (MAP) 60-65 mmHg AND lactate is ≥ 2 mmol/L, in absence of hypovolemia.(57, 104) 2. Recognize septic shock in children with any hypotension (systolic blood pressure [SBP] < 5th percentile or > 2 SD below normal for age) or two or more of the following: altered mental state; bradycardia or tachycardia (HR < 90 bpm or > 160 bpm in infants and HR < 70 bpm or > 150 bpm in children); prolonged capillary refill (> 2 sec) or feeble pulses; tachypnea; mottled or cold skin or petechial or purpuric rash; increased lactate; oliguria; hyperthermia or hypothermia. 3. Standard care includes early recognition and the following treatments within 1 hour of recognition: antimicrobial therapy, and initiation of fluid bolus and vasopressors for hypotension (Surviving Sepsis Guidelines). The use of central venous and arterial catheters should be based on resource availability and individual patient needs. Detailed guidelines from the Surviving Sepsis Campaign and WHO are available for the management of septic shock in adults and children. 4. Due to physiologic changes in pregnancy, standard risk scoring systems are less predictive for sepsis in pregnancy, although the Modified Early Obstetric Warning Score (MEOWS) has a sensitivity of 89% and a specificity of 79% in predicting morbidity in the obstetric population.(105, 106)

Septic Shock Resuscitation. 1. For septic shock in adults: give 250–500 mL crystalloid fluid as rapid bolus in first 15–30 minutes and reassess for signs of fluid overload after each bolus.(104) 2. For septic shock in children, give 10–20 mL/kg crystalloid fluid as a bolus as quickly as possible using a manual push and reassess for signs of fluid response after each bolus.(107) 3. Avoid Excessive Fluid Resuscitation. The cause of death from COVID-19 is most often ARDS and subsequent complications, which may be exacerbated by fluid administration. (2) Patients usually present with normal lactate and blood pressure, but some patients do suffer from superimposed bacterial septic shock. Conservative fluid therapy consistent with FACTT trial should be considered for patients with evidence of hypoperfusion and a history suggestive of total body hypovolemia (e.g. prolonged nausea/vomiting and diarrhea).(108) Consider use of point of care ultrasound (POCUS) to guide fluid resuscitation and prevent volume overload. If there is no response to fluid loading or signs of volume overload appear (e.g. jugular venous distension, crackles on lung auscultation, pulmonary edema on imaging, or hepatomegaly in children), then reduce or discontinue fluid administration. 4. Resuscitation endpoints include perfusion targets (e.g., MAP 60-65 mmHg in adults; urine output > 0.5 mL/kg/hr in adults or 1 mL/kg/hr in children; improved level of consciousness; and lactate). 5. In pregnant women, (>18 weeks gestation or when the uterus reaches the umbilicus) compression of the inferior vena cava can cause a decrease in venous return and cardiac preload and may result in hypotension and hypoperfusion. For this reason, pregnant women with sepsis and or septic shock should be placed in the left lateral decubitus position at 30 degrees to off-load the inferior vena cava. Respiratory failure and sepsis are managed similarly to non-pregnant adults. 6. Clinical trials conducted in resource-limited studies comparing aggressive versus conservative fluid regimens suggest higher mortality in patients treated with aggressive fluid regimens. 7. Do not use hypotonic crystalloids, starches, or gelatins for resuscitation. 8. Vasopressors should be administered when shock persists during or after fluid resuscitation to maintain MAP goal 60-65 mmHg.

Guideline Only/Not a Substitute for Clinical Judgment 23

Clinical Management of COVID-19 9. If central venous catheters are not available, vasopressors can be given through a peripheral IV, but use a large vein and closely monitor for signs of extravasation and local tissue necrosis. If extravasation occurs, stop infusion, aspirate as much as possible, and consider subcutaneous phentolamine. Vasopressors can also be administered through intraosseous needles. 10. If signs of poor perfusion and cardiac dysfunction persist despite achieving MAP target with fluids and vasopressors, consider an inotrope such as dobutamine. 11. Norepinephrine is considered first-line treatment in adult patients; epinephrine or vasopressin can be added to achieve the MAP target. Vasopressors are safe in pregnancy and MAP goal is >65 mmHg. 12. Angiotensin II (Giapreza) is a vasopressor that may provide benefit in vasodilatory refractory shock as a third-line or fourth line agent. 13. In children, epinephrine is considered first-line treatment, while norepinephrine can be added if shock persists despite optimal dose of epinephrine.

Rapid Response and Code Blue. 1. A local Protected Code Blue and Rapid Response Team (RRT) Protocol should be developed for resuscitating COVID-19 patients that is peer-reviewed and based on the best available data and evidence. It should be updated based on performance improvement data and experience. 2. Protecting healthcare workers is a major priority. The main strategies include efficient placement of appropriate PPE, minimizing personnel in the room, and regular training. 3. Medical personnel should be trained appropriately regarding the expectations, roles, and responsibilities for the individual participants, as outlined below. Mock simulated scenarios should be regularly used to practice these clinical situations. 4. For activation of a RRT or Code Blue on a suspected or confirmed COVID-19 patient, the following are recommended: a. Donning of enhanced PPE in an expeditious fashion should be performed with a PPE Buddy to confirm the appropriate infection control procedures. b. Entry to a patient’s room during a RRT or Code Blue should be minimized to essential personnel. c. The patient should be assessed by the most senior medical staff available to determine appropriate management and disposition, unless deferred by the responsible staff. d. If a patient starts to decompensate or is found unresponsive, the initial responder should prioritize the placement of a closely available surgical mask on the patient. e. Chest compressions during cardiopulmonary resuscitation (CPR) is aerosol generating. Before commencing CPR, all medical personnel should wear airborne PPE, including PAPR if able. If available, an automated compressor device should be used to minimize personnel and exposure. f. Depending on local availability of resources, consider modifying the protocol for bringing the crash cart into the room. Due to the high risk of aerosol generation that occur during these clinical events, attempts should be made to minimize the degree and amount of door opening that occurs. g. If not intubated, a non-rebreather mask should immediately be placed on the patient for apneic oxygenation. Depending on local protocol, a bag-valve mask (BVM) with a viral filter may be considered if using a two-person technique. h. If the patient is connected to a ventilator, attempt to remain connected and adjust the settings to replicate the bag-valve mask delivery of oxygen, unless airway obstruction or ventilator malfunction is suspected. Consider adjusting the set respiratory rate to 10 breaths per minute during CPR. Alternatively, or if it is felt that the patient is not getting adequate ventilation through the ventilator, the ETT can be clamped and the patient can be disconnected from the ventilator and connected to a bag at which point the ETT can be unclamped for traditional bag ventilation. i. Focus on potentially reversible conditions (H’s and T’s): DOPE (Displacement of breathing tube, Obstruction, Pneumothorax, Equipment failure) mnemonic for sudden hypoxia, and identification and treatment of shockable rhythm. Consider use of portable ultrasound and obtain a blood gas. j. Avoid prolonged codes in patients with cardiac arrest. Consider discontinuation after 20 minutes. 5. The following table identifies best practices based on a “Minimum, Better, Best” model, as the COVID-19 outbreak could ultimately result in limited resources based on observational data from other countries. The Guideline Only/Not a Substitute for Clinical Judgment 24

Clinical Management of COVID-19 goal is to achieve all elements of each category, as “Good” equates with the minimum standard-of-care while “Best” equates with the most ideal condition.

Table 4. Minimum-Better-Best Paradigm for Limited Code Blue Minimum Better Best Develop a script for clinician that Discuss & document with every Discuss & document with every incorporates unique circumstances & patient; patient’s medical power of attorney ethical considerations if worsening

Advance Directives (MPOA) if patient unable to speak pandemic. Ideally, with DNRs for Involvement of Palliative Care for for self those who might code due to high risk refractory shock/respiratory failure Educate current Code Team members about who should respond Directed announcement ONLY to Early activation Alert mechanism to “Overhead Code Blue” to COVID- COVID-19 Code Team 19 patients Airborne/Negative ISO; Droplet for room; Infection Control Gatekeeper; Use of PPE Checklist PPE / Precautions Minimize door opening Door remains closed

Communication Whiteboard for written instructions; Vocera; Speakerphone in room; Personal communication devices; (via PAPRs or individuals Closed-loop Gatekeeper Dedicated audiovisual devices outside room) Rotate 2 individuals who don’t leave Rotate 2 individuals who don’t leave Automated compressor device (e.g. room and accomplish multiple tasks CPR room LUCAS) for high risk patients based on pre-established priorities Two standard functioning PIVs for all Early placement of central access Tibial IO (if needed) IV access COVID-19 patients before potential arrest Specialized cart/kit containing Dedicated Code Cart for COVID-19 For high-risk patients: consider early appropriate meds, modular packs of ICU and wards; placement of defib pads in room or equipment, and designated ACLS Equipment Accounting for Code Carts to ensure on patient, or prepositioning the defibrillator; appropriate backups Code Cart outside patient room Dedicated COVID-19 ward: US, EKG machine, portable CXR NRB mask immediately over patient BVM with viral filter and ETCO2 Strict adherence to COVID-19 Airway mask Consider LMA placement by trained Intubation Protocol (see “Intubation” protocol) and experienced personnel Early intubation BEFORE arrest Ongoing review and regular familiarization with Protected Code Regular practice and policy updates One-time practice with all members Blue policy; to all members of the COVID-19 Simulation/Practice of the COVID-19 response teams Development of “Mock COVID-19 response team Code Blue” scenarios and ppt

Patient Transport. 1. If COVID-19 is widespread in the community, surgical masks should be considered for ALL patients irrespective of COVID-19 status. 2. The movement of patients with COVID-19 should be limited with all efforts made to ensure the patient is initially admitted to the appropriate location. 3. If patient transport is necessary: a. Non-intubated patients should be transferred wearing a surgical mask over their oxygen delivery device which may include nasal prongs or a non-rebreather mask up to 15 L/min. b. Staff should wear airborne PPE. c. Once a patient is admitted to the ICU, transport outside of the ICU should be limited. If transport is required, then coordination should occur to ensure safety standards are maintained. d. Hallways must be cleared where possible and only essential staff should accompany the patient. Staff not involved in the transfer should not come within 6 feet of the patient. e. Intubated patients should have closed circuits with a viral filter in situ and cuff pressure should be maintained to avoid air leaks.

IMAGING OF COVID-19: RADIOLOGY DEPARTMENT GUIDANCE & IMAGING FINDINGS

Imaging findings have been widely reported in the context of COVID-19 but local policies for when and how to use imaging are widely variable and must take into consideration many site-specific, regional and organizational Guideline Only/Not a Substitute for Clinical Judgment 25

Clinical Management of COVID-19 factors. Imaging exams for non-COVID-19 patients will be impacted as facilities work to limit avoidable exposures for patients and healthcare workers. The American College of Radiology (ACR) has consolidated generalizable guidance for imaging department workflow, COVID-19 imaging findings and standardized reporting on its “ACR COVID-19 Clinical Resources for Radiologists” page which is updated regularly.(109)

Radiology Department Guidance for Rescheduling Exams. 1. The ACR fully supports CDC guidance advising medical facilities to “reschedule non-urgent outpatient visits.” These include but are not limited to the following imaging procedures: (109) • Screening mammography • Lung cancer screening Computed Tomography (CT) • Non-urgent radiography, fluoroscopy, CT, US, and MRI exams • Non-urgent or elective image-guided procedures 2. The Society for Breast Imaging (SBI) and the American Society of Breast Surgeons (ASBrS) agree that medical facilities postpone all breast screening exams including screening mammography, ultrasound and MRI effective immediately as of 26Mar20. (110, 111) • FDA’s Division of Mammography Quality Standards (DMQS) has issued guidance for specific scenarios covering facilities that either decide to close, cannot schedule an annual medical physicist survey or continue to operate and have non-compliance citations due to circumstances outside their control. (112) • FDA temporarily postponed domestic routine surveillance facility inspections on 18Mar20. (113) 3. If rescheduling exams, Radiology departments should work directly with referring providers to ensure only non-urgent studies are delayed. All other imaging exams should continue as scheduled or be accelerated in order to expedite necessary imaging prior to local/regional incidence of COVID-19 increases with a corresponding influx of COVID-19 patients expected to occupy more healthcare resources.

Use of Imaging for COVID-19 1. The ACR, Society for Thoracic Radiology (STR) and the American Society of Emergency Radiology (ASER) recommend that CT should not be used to screen or as a first-line test to diagnose COVID-19. (114) 2. Imaging should be reserved for cases where it will impact management or in order to evaluate for urgent/emergent alternative diagnoses. (115) 3. The reported sensitivity of Chest CT for COVID-19 ranges from 80-90% and the reported specificity ranges from 60-70%. (116, 117) • A normal chest CT does not mean a patient does not have COVID-19; a normal imaging study should not keep a patient from being quarantined if they meet other clinical criteria. • An abnormal CT is not specific for COVID-19 and it does not obviate the need for confirmatory laboratory testing. (118) 4. Screening questionnaire for symptoms or significant exposure history should be repeated by the Radiology front desk personnel. 5. Infection control and PPE: When imaging is performed on patients who are positive or suspected positive for COVID-19, consider implementing the following infection control precautions. (115) • Portable imaging is preferred when possible, preferably using a portable x-ray machine dedicated for imaging COVID-19 suspected/positive patients [N.B. when possible, similar designation of other radiology equipment (e.g. ultrasound, CT and MRI) specifically for imaging COVID-19 suspected/positive patients should be made to limit cross contamination. • Imaging should be performed nearest to the patient location to minimize exposure • Droplet precautions should be employed for all patients who are positive or suspected positive for COVID-19. Patients should be masked throughout the imaging exam and deep cleaning of all surfaces is performed afterward by someone wearing proper PPE. • Airborne precautions are reserved for patients undergoing aerosol-generating procedures (bronchoscopy, intubation, nebulization, or open suction). • Healthcare providers (technologist, nurse, etc.) should wear appropriate PPE (gloves, mask, eye- shield and possibly gown depending on the possibility of close or direct contact with the patient)

Guideline Only/Not a Substitute for Clinical Judgment 26

Clinical Management of COVID-19 • Record a census of other patients and staff present at the time of the patient visit, should the patient later test positive for COVID-19 6. When performing image-guided procedures on patients who are positive or suspected positive for COVID-19, consider implementing the following infection control precautions: (119) • Store all PPE in secure locations with limited access, implement inventory controls, and clearly define PPE to be used based on patient status. • Identify a dedicated room to perform procedures on PUIs and COVID-19-positive patients. An air- negative room is strongly recommended if available. • Empty rooms designated for procedures on COVID-19-suspected/confirmed patients of all non- essential equipment and supplies to avoid contamination. • Create a staffing plan designed to preserve physician and staff availability if individuals become exposed and sick. Consider backup teams. • Minimize staff in the procedure room. • Develop clear plans for removing and disposing contaminated PPE. • Have a clear exit plan for COVID-19-suspected/confirmed patients to minimize staff exposure. • Ensure staff scrubs are changed and lead aprons are cleaned with EPA-approved disinfectants.

Imaging Findings of COVID-19 on Chest Radiographs 1. If imaging is part of a pre-hospital assessment of COVID-19 positive or PUI patients, portable x-ray is preferred (preferably using a dedicated portable x-ray machine to limit cross contamination). 2. In one study of 64 patients, baseline chest radiograph (CXR) had a sensitivity of 69%. (120) 3. Bilateral consolidation and ground glass opacities were the most common findings (59% and 41% respectively) in a peripheral and lower lung distribution (51% and 63% respectively). 4. Severity of CXR findings peak at 10-12 days from date of symptom onset. (120)

Imaging Findings of COVID-19 on Chest Computed Tomography (CT). 1. CT findings of COVID-19 overlap with findings of other viral pneumonias including influenza, H1N1, SARS (Severe Acute Respiratory Syndrome caused by a unique coronavirus) and MERS (Middle East Respiratory Syndrome caused by a unique coronavirus). 2. CT findings of COVID-19: (116, 121-124) • Extent - bilateral, multilobar • Distribution – peripheral and basilar or random • Characterization – rounded or peripheral ground glass opacities (GGO) without or with septal thickening (“crazy paving” pattern), consolidation, central low attenuation (reverse halo sign of organizing pneumonia) 3. Lymphadenopathy, pleural effusions and a nodular pattern are not common. 4. CT finding severity peak from 6-11 days after symptom onset. (125, 126) 5. Standardized reporting guidelines were developed and endorsed by the Radiological Society of North America (RSNA), the Society of Thoracic Radiology and the American College of Radiology. (127) • Consultation with clinical colleagues at each institution is suggested to establish a mutual approach. • If features of COVID-19 are discovered incidentally on exams performed for other indications, contact referring providers to discuss the possibility of viral infection and consider using the more general term “viral pneumonia” in the differential diagnosis. However, if after discussion COVID-19 is felt to be likely, then the authors suggest using one of the four structured reporting categories listed below. 6. Structured reporting categories for COVID-19 on chest CT. • Typical appearance 1. Findings: Peripheral, bilateral GGO with or without consolidation or visible septal lines (“crazy paving”); multifocal rounded GGO; reverse halo sign or other signs of organizing pneumonia (later in disease). 2. Suggested reporting language: “Commonly reported imaging features of COVID-19 pneumonia are present. Other processes such as influenza pneumonia and organizing

Guideline Only/Not a Substitute for Clinical Judgment 27

Clinical Management of COVID-19 pneumonia, as can be seen with drug toxicity and connective tissue disease, can cause a similar imaging pattern.” • Indeterminate appearance 1. Findings: Absent typical features AND multifocal, diffuse, perihilar or unilateral GGO with or without consolidation lacking a specific distribution; lacking a rounded or peripheral characterization; few very small GGO non-rounded and non-peripheral. 2. Suggested reporting language: “Imaging features can be seen with COVID-19 pneumonia, though are nonspecific and can occur with a variety of infectious and noninfectious processes.” • Atypical appearance 1. Findings: Absent typical or indeterminate features AND isolated lobar or segmental consolidation without GGO, discrete small nodules (centrilobular or “tree-in-bud”), lung cavitation, smooth interlobular septal thickening with pleural effusion. 2. Suggested reporting language: “Imaging features atypical or uncommonly reported for COVID-19 pneumonia. Alternative diagnoses should be considered.” • Negative for pneumonia 1. Findings: No CT features to suggest pneumonia. 2. Suggested reporting language: “No CT findings present to indicate pneumonia. (Note: CT may be negative in the early stages of COVID-19.)”

ADJUNCTIVE THERAPIES FOR COVID-19: TREATMENT PROTOCOLS

Note: All therapies are investigational and none are proven as the literature is evolving quickly. No FDA unapproved medications should be routinely recommended for use outside of a randomized clinical trial. Additionally, there is no evidence for use of the following medications for outpatients or mildly ill patients. Use of these resources for that purpose should be discouraged through prescribing restricted to critical care, infectious disease, or rheumatology physicians. For up to date information on medications and pharmacy information, the American Society of Health-System Pharmacists (ASHP) website has a number of regularly updated resources at: https://www.ashp.org/Pharmacy-Practice/Resource-Centers/Coronavirus.

Ethics of Clinical Research during a Pandemic: There is genuine uncertainty in the expert medical community over whether proposed off-label and investigational treatments are beneficial. Randomized, placebo-controlled trials (RCT) are the gold standard for determining if an experimental treatment can benefit patients. Some may question whether it is ethical to deprive patients of an agent that could potentially prevent or treat COVID-19, given the high mortality rate among critically ill patients and lack of known and available treatment options. A Committee of National Academies of Science, Engineering, and Medicine reviewed and conducted an analysis of the clinical trials conducted during the 2014–2015 Ebola virus disease outbreak in West Africa and found the that the RCT was an ethical and appropriate design to use, even in the context of the Ebola epidemic. The position of “equipoise”—genuine uncertainty in the expert medical community over whether a treatment will be beneficial—“is the ethical basis for assigning only some participants to receive the agent. If the relative risks and benefits of an agent are unknown, participants who receive the experimental agent may receive a benefit or may be made worse off. Providing the experimental agent to all would expose all participants to potentially harmful effects.” (128)

Steroids. 1. There is a strong consideration to avoid routine steroids based on early data out of China as well as other studies related to Middle Eastern Respiratory Syndrome Coronavirus (MERS-CoV) which have shown that steroids delay viral clearance.(129) 2. However, new consensus guidelines recommend considering methylprednisolone for intubated COVID-19 patients with ARDS.(57, 130) 3. Steroids may be indicated for vasopressor-refractory shock, asthma, COPD exacerbation, or for antenatal therapy at risk for preterm birth from 24-34 weeks of gestation (see Pregnancy Section). Guideline Only/Not a Substitute for Clinical Judgment 28

Clinical Management of COVID-19

Remdesivir. 1. Remdesivir is an investigational intravenous drug with broad antiviral activity that inhibits viral replication through premature termination of RNA transcription and has in-vitro activity against SARS-CoV-2 and in-vitro and in-vivo activity against related betacoronaviruses. It has been tested in humans against Ebolavirus disease, where it was not found to be superior to other therapies in the PALM RCT.(131) It has shown promise in vitro and in animal models for coronavirus infection.(132-134) 2. National Institute of Allergy and Infectious Diseases (NIAID) is leading a multicenter adaptive design randomized placebo-controlled trial of candidate therapies for COVID-19, initially focused on comparing Remdesivir to placebo “A Multicenter, Adaptive, Randomized Blinded Controlled Trial of the Safety and Efficacy of Investigational Therapeutics for the Treatment of COVID-19 in Hospitalized Adults.” MAMC, NMCSD, BAMC, NMCP and WRNMMC MTFs are participating sites through IDCRP. Potentially eligible candidates are adult DoD Health Care Beneficiaries meeting inclusion criteria (SARS-CoV-2 positive with evidence of pneumonia with oxygen saturation of ≤94% on room air or requiring supplemental oxygen or mechanical ventilation). Exclusion criteria include alanine aminotransaminase (ALT) or aspartate aminotransaminase (AST) levels >5 times the upper limit of normal, stage 4 severe chronic kidney disease or a requirement for dialysis [i.e., estimated glomerular filtration rate <30]. (https://clinicaltrials.gov/ct2/show/NCT04280705) 3. Gilead has two Phase 3 randomized open-label trials of remdesivir (5-days vs. 10-days vs. standard of care) open to enrollment for adults with COVID-19, radiographic evidence of pneumonia and oxygen saturation of ≤94% on room air (severe disease: https://clinicaltrials.gov/ct2/show/NCT04292899) or >94% on room air (moderate disease: https://clinicaltrials.gov/ct2/show/NCT04292730). Exclusion criteria include ALT or AST levels >5 times the upper limit of normal, participation in another clinical trial of an experimental treatment for COVID-19, requirement for mechanical ventilation, or creatinine clearance <50 mL/min.. 4. Remdesivir is potentially available under compassionate expanded use from Gilead for pregnant patients or patients <18 years with severe pneumonia: [email protected] to initiate the process. Please note that the site must first be enrolled before a patient can be considered and the process may take several days to weeks. [email protected]. From Gilead’s website; “Compassionate use requests must be submitted by a patient’s treating physician. Gilead is currently assessing requests on an individual basis and require, at a minimum, that the patient be hospitalized with confirmed COVID-19 infection with significant clinical manifestations.” For information, including inclusion and exclusion criteria, visit: https://clinicaltrials.gov/ct2/show/NCT04323761. 5. USAMMDA Force Health Protection Division has established an expanded access treatment Investigational New Drug (IND) with a limited number of treatment courses of Remdesivir for Active Duty Service Members CONUS/OCONUS (and Federal civilian and contract employees deployed OCONUS while in support of operational forces) meeting inclusion criteria. “Intermediate-Size Patient Population Expanded Access Protocol for Treatment of Coronavirus Disease 2019 (COVID-19) with Remdesivir.” Clinicians should contact USAMMDA FHP Division to determine eligibility to receive product, 24-hour international telephone: +1-301-401-2768.

Chloroquine (CQ) and Hydroxychloroquine (HCQ). 1. FDA gave Emergency Use Authorization (EUA) for use in COVID-19 patients on 28 Mar 2020: https://www.fda.gov/media/136534/download 2. These drugs have been used as anti-malarial prophylaxis and to treat autoimmune conditions. 3. BLUF: No high-quality evidence exists to support use at present. Potential toxicities include QTc prolongation, risk for arrhythmias, and retinal pigmentation and vision loss. 4. In vitro studies have reported antiviral activity against SARS-CoV and more recently against SARS-CoV-2. Mouse studies for SARS-CoV demonstrated improved lung pathology without reduction in viral titers; similar animal studies for SARS-CoV-2 have not yet been completed. Recent studies conducted in China indicate in vitro activity of these agents against SARS-CoV-2, and a small survey in French patients showed reductions in viral load. An additional preliminary report on chloroquine clinical activity was released by investigators in China, but detailed information is pending.(134-137) Both CQ and HCQ concentrate in the lung. Optimal dosing needed to reach adequate concentrations in lung tissue for treatment of COVID-19 are unknown; modeling has suggested high doses might be required.(137) Despite showing in vitro antiviral activity, prior clinical trials demonstrated

Guideline Only/Not a Substitute for Clinical Judgment 29

Clinical Management of COVID-19 no benefit of CQ against other viral infections such as dengue virus, chikungunya, influenza, and HIV, though none investigated the use of chloroquine for coronavirus infection.(138-141) In a non-human primate study, hydroxychloroquine appeared to paradoxically enhance chikungunya infection.(142) 5. A report of 20 treated COVID-19 patients who received HCQ alone and in combination with azithromycin suggested that treatment was associated with viral load reduction over 6 days, compared to a nonrandomized control group, and were more pronounced in patients who received the combination; clinical impact was not assessed and methodologic issues limit the strength of the observation.(143) A brief report of a Chinese study of 100 COVID-19 patients suggested clinical improvement (“improved lung images, time to viral negative conversion, and shortening of disease course”) with CQ or HCQ treatment versus an unspecified control; methodologic details were absent from the report, limiting the strength of conclusions.(144) If these comparisons are substantiated after availability of adequate additional data, this would be the first time chloroquine or hydroxychloroquine was found to be effective for the clinical management of a viral infection. 6. Hydroxychloroquine/chloroquine are associated with QTc prolongation. Given the short duration of treatment the small risk of drug-induced arrhythmia may be acceptable. Prior to initiation of therapy a 12 lead EKG should be performed. Consider alternative therapy in subjects with known Long QT syndrome; discontinue combination with other QT prolonging drugs if QTC >500msec (or >530-550msec if QRS >120msec).(143, 144) 7. Several clinical trials have been initiated/are planned to study CQ/HCQ for treating or preventing COVID-19. 8. A variety of dosing regimens have been reported in use, including: Hydroxychloroquine 400 mg PO BID x 1 days, then 200 mg PO BID x4 days.

Lopinavir/Ritonavir. 1. Coronavirus cellular infectivity and replication are dependent on virally-encoded and cellular protease activity. Clinically used protease inhibitors effective for HIV and HCV infection have been examined for potential utility in treatment of SARS, MERS, and COVID-19, but are currently not recommended. 2. Unconfirmed media reports from China suggested this combination to be effective for COVID-19 treatment. However, on 18 March 2020, RCT results were reported that found no benefit in patients who received lopinavir/ritonavir compared to standard care for treatment of severe disease.(145-147) 3. Do not use in combination with amiodarone (fatal arrhythmia), quetiapine (severe coma), or simvastatin (rhabdomyolysis).

Host-directed anti-inflammatory strategies. ARDS and sepsis, life-threatening downstream complications of COVID- 19, and many other infectious and non-infectious conditions, remain significant unmet therapeutic gaps. Historically, numerous anti-inflammatory and anti-cytokine agents, as well as many other drug candidates, have been tested and failed to meaningfully affect morbidity and mortality in ARDS, sepsis and/or septic shock.

Anti-IL6 monoclonal antibodies. 1. A variety of therapies are being administered to severely ill patients in China and elsewhere. One that is receiving substantial attention currently is an anti-IL6 receptor humanized monoclonal antibody, tocilizumab (Actemra®), which was added to the treatment guidelines published by China’s National Health Commission (4 Mar 20) to treat serious coronavirus patients with lung damage. 2. Tocilizumab and sarilumab are licensed in US for treatment of giant cell arteritis, rheumatoid arthritis, and cytokine release syndrome following CAR-T therapy. They carry a black box warning for risk of severe, potentially fatal, infections. 3. No high-quality evidence currently exists to support use. Some reports from China have suggested elevated IL6 levels are associated with severe disease in COVID-19 infection, though other reports have not found the same association. Tocilizumab has been used in Italy according to anecdotal reports and an unpublished uncontrolled case series from China treated 21 hypoxemic patients with tocilizumab 400 mg IV x1 and reported improvement in respiratory parameters.(52, 148) 4. Manufacturer-supported US randomized controlled trials of tocilizumab and sarilumab are planned.

Convalescent Plasma. 1. Convalescent plasma from patients who have recovered from SARS CoV-2 infection has been proposed as a potential therapy for patients with severe COVID-19.(149) Although no clinical trials have been conducted to Guideline Only/Not a Substitute for Clinical Judgment 30

Clinical Management of COVID-19 date, prior use of convalescent plasma for patient with SARS CoV1, MERS CoV, and influenza H1N1 demonstrated benefit for recipients of plasma from patients who recovered from these infections. In a preliminary, uncontrolled case series in China, 5 patients were given plasma from patients that had recovered from COVID-19 with improvement in clinical status.(150) 2. As of 3 April, the FDA has authorized the use of convalescent plasma to treat “serious or life threatening” COVID-19 disease under Investigational New Drug (IND) protocols.(151) Requests may be made by email and there is a number to call for expedited use. The following website provides instructions for requests: https://www.fda.gov/vaccines-blood-biologics/investigational-new-drug-ind-or-device-exemption-ide- process-cber/investigational-covid-19-convalescent-plasma-emergency-inds a. Severe disease is defined by the FDA as follows: dyspnea, RR>30 breaths/min, SpO2 <93% on RA, PaO2:FiO2 ratio of <300, or increases in lung infiltrations by >50% within 24-48 hours. b. Life threatening disease is defined by the FDA as follows: respiratory failure, septic shock, or multiple organ dysfunction or failure.

Several additional agents are under investigation and information is expected to emerge rapidly. Discernment of benefits and harms from novel therapies will require diligent attention to quality of evidence reported.

CARING FOR SPECIAL POPULATIONS: Pregnancy, Nursing Mothers, Infants, Children, and the Elderly

Caring for Pregnant Women during the COVID-19 Pandemic 1. Based on limited data, pregnant women do not appear to be at higher risk for severe disease. Emerging reports from the United States suggest that pregnant women may be at higher risk of atypical presentation with severe respiratory morbidity and preterm labor.(13-16) Clinical findings in reported cases were similar in cases of non-pregnant adults. Pregnant women experience immunologic and physiologic changes that make them more susceptible to viral respiratory infections.(14) Pregnant women are at greater risk for severe illness, morbidity, or mortality compared with the general population, as is observed with other related coronavirus infections.(15, 16) Pregnant women should receive the same care as those not pregnant in regards to screening, radiology studies, laboratory evaluations and critical care. 2. Pregnancy care should be considered non-elective. 3. The report to WHO from China suggests pregnant women were not at increased risk for severe disease.(152) More recent literature has suggested that pregnant women may be at increased risk of being asymptomatic carriers and developing more severe forms of the disease. (13, 15, 16) 4. Pregnancy complications: Pregnancy in the setting of a COVID-19 infection is associated with higher rates of miscarriage (39.1%), preterm birth less than 37 weeks (24.3%), preeclampsia (16.2%), cesarean delivery (84%), increased incidence of neonatal admission (57.2%) and perinatal death (11.1%) Some cases of preterm birth were iatrogenic and not due to spontaneous preterm labor. (14, 15) 5. Providers are encouraged to enroll patients confirmed with COVID-19 in pregnancy or deemed persons under investigation should be considered for enrollment in the Pregnancy Coronavirus Outcomes Registry (PRIORITY) (https://priority.ucsf.edu/). 6. Health care providers should be familiar with the physiologic changes of pregnancy that make pregnant women more susceptible to some respiratory infections. a. Immune modulation of pregnancy b. Pregnant women are more susceptible to respiratory failure and can decompensate quickly (especially in the third trimester) due to 20% decrease in functional residual capacity. c. Respiratory changes: Pregnancy is a metabolically compensated respiratory alkalosis i. Normal pregnancy ABG pH 7.4-7.47 ii. Normal pregnancy PaO2 75-106 mm Hg (PaO2 increases by 30 mm Hg) iii. Normal pregnancy PaCO2 26-32 mm Hg (PaCO2 decreases by 30 mmHg) iv. Normal pregnancy HCO3 18-21 d. A PaCO2 in pregnancy of 35 to 45 is ABNORMAL in pregnancy, and signifies impaired ventilation and impending respiratory compromise.

Guideline Only/Not a Substitute for Clinical Judgment 31

Clinical Management of COVID-19 e. Critical care considerations for pregnant women; online training available at https://www.smfm.org/critical-care/cases/new-2019 7. Screening Guidelines: American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal- Fetal Medicine (SMFM) algorithm for outpatient assessment and management for pregnant women with suspected or confirmed novel coronavirus (COVID-19): https://www.acog.org/- /media/project/acog/acogorg/files/pdfs/clinical-guidance/practice-advisory/covid-19- algorithm.pdf?la=en&hash=2D9E7F62C97F8231561616FFDCA3B1A6 8. Risk of vertical transmission: Case series to date suggest no evidence of vertical transmission, similar to other viral respiratory illnesses, such as influenza.(14, 15) 9. Changes to routine OB care during COVID-19 pandemic: To decrease opportunities of exposure to coronavirus OB providers should be taking steps to reduce patient encounters and optimize TeleHealth visits and home blood pressure monitoring. Guidance for practice has been published and we recommend developing plans at each MTF to standardize changes in Prenatal Care. (153) 10. Intrapartum Care during COVID-19 pandemic: a. Screen all patients and support person(s) according to ACOG SMFM as above. b. Recommend a designated staff member at the front of the unit to verbally screen for URI symptoms, diagnosis of COVID-19 or PUI within the past 2 weeks. c. Any patient with fever, cough, or respiratory symptoms (+/- fever) should put on a surgical mask and be evaluated by a nurse or provider (and put in a room). d. All birthing partners should be screened. If they have any symptoms they should NOT be admitted to L&D and directed to appropriate testing or medical care as indicated. e. Recommend screening patients and their birthing partner (support person) by phone the day before scheduled inductions or cesarean delivery to determine if either person has: i. Symptoms fever, cough, or respiratory symptoms (+/- fever) ii. Been diagnosed with COVID-19 (based on positive COVID-19 test) within 2 weeks iii. Been designated as a COVID-19 PUI within the past 2 weeks f. If a patient screens positive to any of the above prior to scheduled delivery (IOL or CD), evaluate to determine if re-scheduling in 2-3 days is feasible to allow for results of COVID-19 testing. g. For COVID-19 positive patients with mild or moderate symptoms not requiring immediate care, it is important to recognize that the severity of disease peaks in the second week, so planning delivery prior to that time is optimal. h. If a birth partner (support person) has a fever, cough, or respiratory symptoms (+/- fever) (or confirmed COVID-19 positive or PUI), they should not come to L&D, and will not be admitted to L&D as a support person. i. Visitors are limited to one (healthy) support person during the entire admission. (153) j. Support persons of a COVID-19 positive or PUI mother should wear a mask during their hospital stay, and are restricted to the patient room (should not visit hospital areas outside patient room). They should use the bathroom in the patient room, and should have all meals brought to the room. k. Routine preop labs for scheduled cases should be drawn on procedural day to minimize hospital trips. 11. Care for the pregnant patient with PUI or COVID 19 a. Admission: Patients with suspected or confirmed COVID-19 should be admitted to a unit capable of caring for the respiratory needs of the patient as well as provide appropriate fetal monitoring as clinically indicated. Patient should be in isolation per hospital and CDC guidance. i. Pregnant women should be admitted to the hospital for treatment of COVID symptoms if there is concern about respiratory status (02 requirement to maintain saturations above 92%, increased work of breathing, RR> 24 breaths per minute), tachycardia > 110 bpm, dehydration, obstetric concerns. b. COVID-19 may be associated with a transaminitis and thrombocytopenia, this is an important consideration when assessing women with a hypertensive disorder to determine if she has features of preeclampsia or HELLP syndrome.

Guideline Only/Not a Substitute for Clinical Judgment 32

Clinical Management of COVID-19 c. Guidance for treatment: Aggressive infection control, testing for COVID-19, testing for co-infection, oxygen therapy as needed, avoidance of fluid overload, empiric antibiotics (due to risk of superimposed bacterial risk), fetal and uterine contraction monitoring for viable pregnancies, early mechanical ventilation for progressive respiratory failure, individualized delivery planning, Maternal Fetal Medicine (MFM) consultation, Pulmonology, Critical Care and Infectious disease involvement as indicated. Team based management is recommended. Consider early transfer to higher level facility if unable to provide services at MTF.(154) d. Chloroquine and Hydroxychloroquine are well tolerated in pregnancy and human data in exposed pregnancies do not suggest harm.(155) e. Remdesivir is not studied in pregnancy and no human or animal data could be found. (155) f. Imaging: Necessary radiographic studies should not be withheld from a pregnant patient. Fetal risk of anomalies, growth restriction or abortion have not been reported with radiation exposure of less than 50 mGy, a level above the range of exposure for most diagnostic procedures. 12. Delivery: Timing of delivery, in most cases, should not be dictated by maternal COVID-19 infection. For women infected early in pregnancy who recover, no alteration to the usual timing of delivery is necessary. For women infected in the third trimester who recover, it is reasonable to attempt to postpone delivery (if no other medical indications arise) either until a negative COVID-19 testing result is obtained or quarantine status is lifted in an attempt to avoid transmission to the neonate. In general, COVID-19 infection itself is not an indication for delivery. Recommend health care team wear appropriate PPE during delivery and delivery should occur in a negative pressure room. Skin to skin care following delivery is not recommended. In cases of severe maternal infection with a term infant, care teams may consider avoiding delayed cord clamping to minimize the risk of transmission to the neonate. 13. Cardiac arrest: in pregnancy should be managed similar to cardiac arrest in non-pregnant adults. If pregnancy is ≥ 20 weeks (uterus at or above the umbilicus), significant aortocaval compression exists. Left uterine displacement is recommended during high-quality CPR, with resuscitative cesarean delivery (perimortem cesarean delivery) if ROSC not achieved by 4-5 minutes. Resuscitative cesarean delivery should be performed at the bedside (do not move to the OR).(156) 14. Antenatal surveillance: Gestational age appropriate fetal monitoring should be part of the initial assessment of any women with respiratory symptoms. Continuous fetal monitoring in the setting of severe illness should be considered only when delivery would not compromise maternal health, or as another noninvasive measure of maternal status. For women who recover from an acute infection, antepartum testing later in the pregnancy is not needed. 15. Ultrasound consider a detailed level 2 anatomic survey for women following recovery from a first trimester infection and a fetal growth assessment in the third trimester for women who recover from an infection later in pregnancy (later second trimester and third trimester infections) due to lack of data on teratogenic risk. 16. Follow up after diagnosis of COVID-19: When patient is discharged from the hospital a plan for follow up should be established. Recommend follow up with patients via phone or video telehealth assessments 5-7 days after discharge. Return precautions should be reviewed with the patient prior to discharge If patients symptoms worsen arrangements should be made for patient to be seen in person by a health care provider to assess clinical status. 17. PPE Considerations during COVID Pandemic for Pregnancy: a. Screen positive patients or Patients Under Investigation (PUI): i. PPE during admission: Surgical mask for all patients with symptoms or COVID-19+/PUI. Airborne precautions: N95 masks and droplet PPE (Gown, gloves, mask/face shield) for all healthcare workers (HCW). b. Screen negative patients: i. PPE during delivery: Surgical mask and droplet PPE (Gown, gloves, mask/face shield) should be used during all patients in the second stage. N95 Mask could be considered for the surgical team for any cesarean section as there is the potential risk of requiring intubation during the surgery. Provider discretion and individual MTF PPE availability can be considered.(153)

Guideline Only/Not a Substitute for Clinical Judgment 33

Clinical Management of COVID-19 Table 5. Suggested PPE During Obstetric Care (153) Care situation Surgical mask Droplet PPE N-95 mask or PAPR (gown, gloves, surgical mask/ face shield) Patient (cloth mask acceptable if no resp sx) X X Provider during routine encounters

Provider during patient encounters with URI X symptoms Provider during patient encounters with X X suspected or confirmed COVID-19

c. Women who are COVID-19+ or PUI should wear a surgical mask at all times as clinically able. d. Women who are COVID-19+ or PUI should be placed in an isolation room. Airborne infection isolation rooms (negative pressure rooms), if available, can be used if performance of aerosolizing procedures is anticipated. In general, isolation rooms with droplet precautions are recommended. e. Proper donning and doffing of PPE takes time. Training in the use of PPE should emphasize safety of healthcare workers, recognizing that clinical response times may be slowed by these precautions. f. Proper donning and doffing procedures should be reviewed and practiced frequently; Recommend simulated patient transfers (e.g. from L&D to OR). g. Recommend posting diagrams and checklists in areas where donning and doffing will occur. h. Have an observer witness donning/doffing when possible. i. Anticipate emergencies as best as possible; plan ahead and proactively intervene for situations that could result in emergent cesarean delivery (e.g. Category II FHR), early peds notification. 18. Considerations for VISITORS to L&D and ANTEPARTUM/POSTPARTUM a. One designated (healthy) support person during the entire admission, easily identifiable by L&D staff. Consider a colored wrist band for identification. Support person should be screened as above, wear a mask, and remain restricted to the patient room for mothers that are COVID-19 positive or PUI. b. No children < 16 years permitted. c. Additional visitors for end-of life situations or bereavement (e.g. IUFD) may be considered/evaluated on a case-by-case basis. d. All efforts should be made to limit the movement of COVID-19 positive/PUI women from one care area to another. Consider postpartum care in the same room as delivery if possible. e. If increased prevalence of disease and community transmission is present, individual MTFs could consider a no visitation policy to minimize potential exposure of staff and patients. 19. Anesthesia Considerations for Intrapartum Care a. Recommend early epidural to minimize need for general anesthesia in the event of an emergent cesarean. b. COVID-19 is not a contraindication to neuraxial anesthesia. c. Anticipate emergencies as best as possible; plan ahead and proactively intervene for situations that could result in emergent cesarean delivery (e.g. Category II FHR tracing). d. Recommend limiting exposure of trainees to COVID+/PUI, with experienced staff providing care. 20. Postpartum Care a. Women should be notified that in order to limit the risk of infection to themselves, staff and other patients, mothers and infants should be discharged in an expedited and safe fashion. Vaginal deliveries – goal of discharge on postpartum day 1 (same day for select women). Cesarean deliveries – goal of discharge on postpartum day 2. Home blood pressure monitoring devices may be needed. b. All postpartum visits, including wound checks, should be via telehealth. Can optimize by uploading photos through EMR/patient portals. 21. Obstetric medications a. Use caution and consult a MFM physician prior to using Indomethacin, Nifedipine, or Terbutaline. b. Betamethasone/Dexamethsasone for fetal maturation – given the association between steroids and worsening morbidity of viral pneumonia, specifically COVID-19, steroids for fetal maturation should be used judiciously. AVOID late preterm steroids 34-46 weeks in COVID+/PUI patients.

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Clinical Management of COVID-19 c. Magnesium sulfate is recommended for fetal neuroprotection for anticipated preterm delivery <32 weeks or for seizure prophylaxis for preE with severe features. Given potential respiratory complications, use judiciously in the setting of severe respiratory symptoms. Magnesium sulfate may be used in patients with mild-moderate symptoms, may consider single 4 gm bolus. 22. Pregnant patient work restrictions: Delivery is a unique scenario in the COVID-19 pandemic. Hospital admissions for delivery are anticipated around the patient’s due-date. In anticipation of hospital admission for delivery, if feasible and mission permitting, consider having pregnant women work from home at 37 weeks (2 weeks prior to 39 weeks or 2 weeks prior to anticipated delivery), and practice strict social isolation during this time. (153) Strict social isolation is encouraged for the entire family unit. The goal is to limit risk of exposure around the time of delivery. Depending on mission requirements and increasing disease burdens, such accommodations may not be possible but should be considered.(153) 23. Pregnant health care workers: Facilities consider limiting exposure of pregnant healthcare personnel (HCP) to patients with confirmed or suspected COVID-19 infection, especially during higher-risk procedures such as aerosol generating procedures (intubation, extubation, BiPAP, high flow nasal cannula, nebulized medications and second stage of labor) if feasible based on staffing availability. With ongoing stresses in the MHS and increasing disease burdens, such accommodations may not be possible.

Caring for Infants and Mothers with COVID-19: IPC and Breastfeeding 1. Current evidence is inconclusive about in utero transmission of SARS-CoV-2 from mothers with COVID-19 to their newborns. Vertical transmission does not appear to occur, but perinatal infection leading to severe manifestations has been documented. It is unknown whether newborns with COVID-19 are at increased risk for severe complications, but transmission after birth via contact with infectious respiratory secretions is a concern.(157) 2. To reduce the risk of post-natal transmission from mother to infant, the CDC and American Academy of Pediatrics recommends consideration of temporarily separating a symptomatic PUI or COVID-19 positive mothers from her infant (e.g. separate rooms). In the absence of more definitive data, this decision should reflect an individualized risk - benefit consideration for the mother and infant, cognizant of the potential for delayed maternal-child bonding and impaired breastfeeding. This will require an additional healthy (non-infected) adult to care for the infant while separated from mother. 3. COVID-19 positive postpartum mothers as well as postpartum PUIs will be counseled about the risks and benefits of colocation vs. separation. 1. If a postpartum PUI mother elects to be separated from infant and then her test is negative for COVID- 19, the mother and infant can be reunited and ‘room in.’ 2. Postpartum COVID-19+ or PUI mothers who elect to co-locate (also referred to as ‘rooming in’) with their infants should be instructed to wear a facemask at all times. They will also practice hand hygiene before each feeding and wear gloves during infant contact. They will also be encouraged to wash any skin that may come in contact with the infant (e.g. breasts, chest, arms, etc.). They will be encouraged to limit other close contact with the infant(s) and a separate non-infected caregiver should be present to help care for the infant. This separate non-infected caregiver should perform a majority of the infant’s care. While not breastfeeding, infants should be kept greater than 6 feet away from the mother within the room, per CDC guidance.

Pumping / Expressed Breast Milk (158) 1. Mothers who wish to breastfeed should be provided with a dedicated breast pump. (https://consultqd.clevelandclinic.org/managing-pregnancy-during-the-covid-19-pandemic/) 2. Postpartum patients who are pumping should follow CDC guidelines on equipment use and feeding. 3. Collecting Milk: a. Wipe the surface where syringes/bottles will be placed after collection with a germicidal disposable wipe, and cover surface with clean paper towel or cloth. b. Mother will wash hands and breasts before use and cleaning equipment before and after use. Mother will wear a mask while pumping. c. Mother collects breast milk by hand or by pump into clean syringes or bottles then ensures Guideline Only/Not a Substitute for Clinical Judgment 35

Clinical Management of COVID-19 syringe/bottle cap is secured. The outside of the container will be wiped with a germicidal disposable wipe. A label in then placed to identify date, time, and patient. d. Transport and storage of breast milk from isolation room to common refrigerated storage should follow strict infection control procedures per hospital policy.

Infants 1. Infants born to mothers with confirmed COVID-19 should be considered PUIs. 2. All infants born to mothers with suspected or confirmed COVID-19 should, if the infants clinical condition allows, be bathed immediately following delivery. 3. If local resources allow, PUI infants should be tested at ~24 hours with repeat testing at 48 hours. 4. All elective procedures to include circumcision should be deferred while infant is a PUI. 5. If hearing tests can be performed outpatient, it is acceptable to defer until COVID-19 testing is negative. If it is not easily available outpatient, ensure proper disinfection measures are used when cleaning audiology equipment.

Neonatal Intensive Care Unit (159) 1. COVID-19 positive postpartum mothers and their household contacts should not be allowed to visit in the NICU until they meet the following requirements: a. Resolution of fever without antipyretics for 72 hours. b. Improvement in respiratory symptoms c. Negative results of a molecular assay for detection of SARS-CoV-2 from at least 2 consecutive nasopharyngeal swab specimens collected at least 24 hours apart. 2. Any infant who has symptoms that meet criteria for NICU admission will be assessed by the NICU team and admitted to a COVID-19 cohort pod or other segregated section of the unit. 3. For care teams assigned to infants requiring CPAP, SiPAP or undergoing aerosolizing procedures such as intubation, full PPE including N95 (or PAPR), eye shields, gown, hair cover, and gloves should be worn when caring handling the infant. 4. Patients requiring nasal cannula or those who are intubated on mechanical ventilation (closed circuit) require contact/droplet precautions when handling to include surgical mask, gown, hair cover, and gloves. a. Per WHO guidance for clinical management of COVID-19, “newer high-flow nasal cannula (HFNC) and non-invasive ventilation (NIV) systems with food interface fitting do not create widespread dispersion of exhaled air and therefore should be associated with low risk of airborne transmission.” These patients could be cared for with contact/droplet precautions only (to include facemask) but could consider N95 (or PAPR) if readily available.

Newborn Visitation 1. No visitors experiencing cough, fever, or shortness of breath should be allowed in any care setting. 2. For NICU: COVID-19 positive persons or their household contacts should not be allowed to visit until they meet the following requirements: a. Resolution of fever without antipyretics for 72 hours b. Improvement in respiratory symptoms c. Negative results of a molecular assay for detection of SARS-CoV-2 from at least 2 consecutive nasopharyngeal swab specimens collected at least 24 hours apart. d. Entrance to other family support personnel should be determined on a case by case basis. 3. For Labor and Delivery, Post-partum / Newborn Nursery: each COVID-19 positive or PUI postpartum mother may be allowed to have one support person with her who must remain with her throughout the admission. This support person should be isolated to the post-partum room and not traveling elsewhere in the hospital. a. If the mother chooses to co-locate with the infant, the support person should help with infant care. b. If the mother chooses to be separated from her infant, the support person may help with the infant’s care when they are brought to the room. c. AAP recommends that well newborns, defined as negative molecular testing and asymptomatic, can receive circumcision. Newborns who are PUIs are not eligible for elective circumcision.

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Clinical Management of COVID-19 Newborn Discharge 1. After hospital discharge, a mother with COVID-19 is advised to maintain a distance of at least 6 feet from the newborn, and when in closer proximity, to use a mask and hand-hygiene for newborn care until: a. She is afebrile for 72 hours without use of antipyretics; and b. At least 7 days have passed since symptoms first appeared. 2. A mother with COVID-19 whose newborn requires ongoing hospital care should maintain separation until: a. She is afebrile for 72 hours without use of antipyretics; and b. Her respiratory symptoms are improved; and c. Negative results are obtained from at least two consecutive SARS-CoV-2 nasopharyngeal swab test collected ≥ 24 hours apart. https://www.cdc.gov/coronavirus/2019-ncov/hcp/inpatient-obstetric-healthcare-guidance.html University of Washington Handling of Breast Milk of COVID-19 Mothers (https://covid-19.uwmedicine.org/Pages/default.aspx) https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/

Caring for Children with COVID-19 1. Children (0-18 years) with COVID-19 are more likely to remain asymptomatic or have mildly symptomatic disease. Severe symptoms requiring admission for supplemental oxygen have been described in up to 10% of symptomatic children, particularly those under the age of 5, with the highest risk in those under 12 months of age. The mortality rate appears to be extremely low. As of 2 April 2020, there have been 0 pediatric deaths in Italy (age <19 years) and 1 pediatric death in Spain (age <14yrs old) due to COVID-19. Sporadic reports of infant and child deaths in the United States have occurred in the lay press. One study out of China reported only one death in 2,143 pediatricspatients with COVID-19.(21) 2. The intersection with chronic pediatric respiratory conditions such as asthma, cystic fibrosis, and chronic lung disease, and with the attendant increased risk of severe disease, is unknown. 3. Respiratory virus co-infections and secondary bacterial infections are possible. In addition, the detection of a non-COVID-19 virus does not exclude COVID-19 infection. There are anecdotal, but as yet unpublished reports from Seattle Children’s Hospital of co-infection with Rhinovirus/Enterovirus but the clinical impact is unknown. 4. During periods of community transmission and in the absence of targeted therapy for mild and moderate disease, the decision to test children for SARS-CoV-2 is driven by resource availability, infection prevention and control principles, and epidemiologic contact tracing or hot-spot case finding. 5. Pediatric symptoms, if present, are similar to common viral respiratory infections with a majority of symptoms affecting the upper airway. This differs from adults, who tend to have lower respiratory symptoms most prominent. (18, 21) a. Fever 80-95% – majority <24hr duration (for COVID-19, CDC defines fever as 100°F) b. (Dry) cough 45-80% c. Myalgias or fatigue 10-45% d. Pharyngitis 10-40% e. Rhinorrhea and/or congestion 10-30% f. Diarrhea 10-20% g. Dyspnea or hypoxemia 5-10% 6. Most labs are normal to include inflammatory markers (ESR, CRP), chemistries, kidney and hepatic function. White blood cell count is typically normal but may be low. Procalcitonin may be elevated but might suggest co-infection.(67) 7. When imaging is abnormal in children with COVID-19, CXR reveals non-specific increased lung markings or patchy infiltrates, and chest CT reveals glass opacities and halo signs.(67) 8. Treatment of severe disease remains supportive, to include critical care interventions as required. Enrollment in clinical trials, or compassionate use of experimental therapies, should be considered for children with severe disease just as they would be for severely affected adults. There is no evidence to suggest that prophylaxis is necessary or effective for the majority of children. 9. Remdesivir is available from the manufacturer for children <18 years as compassionate use (see adjunctive therapies section above for more information).

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Clinical Management of COVID-19 10. Children appear to efficiently shed the virus, even if asymptomatic. RNA viral load is detectable in respiratory secretions for up to 2 weeks and in stool for up to 4 weeks.(160, 161) 11. Given the prolonged duration of shedding of respiratory viruses in children, during periods of community transmission of SARS-CoV-2, it may be prudent to assume symptomatic children are infected, unless proven otherwise from an infection control standpoint - an issue particularly relevant to caregivers from vulnerable

risk populations.

Caring for Older Persons with COVID-19 1. COVID-19 can result in severe disease and death among older adults. Data from China and Italy suggest that the majority of deaths have occurred among adults aged ≥60 years, especially those with underlying health conditions. In the United States, 8 out of 10 deaths have been in adults above age 65. Mortality rates in patients > 85 have ranged 10-27%, and 4-11% among patients 65-84 years.(48, 162) 2. Older adults, especially those that are frail and have multiple comorbidities, may not present with the typical syndrome of fever, fatigue, or cough. Atypical presentation of disease includes tachypnea, delirium, malaise, myalgias, and diarrhea early in the disease course; fever was not as prominent in several cases.(163) 3. Older adults are the highest risk patient group. 4. Have a high index of suspicion for COVID-19 in those patients not at their baseline, especially those residing in long term care facilities who present with respiratory difficulties, changes in vital signs other than temperature or other signs of infection or sepsis. 5. Ensure that care for the older adult and severely ill is in keeping with their goals of care, advance directives and patient and family wishes. 6. Conversations regarding goals of care should continue to be part of routine care. 7. Patients should be informed about their condition & their prognosis (if desired), in a way easy to understand. 8. If the patient is unable to communicate meaningfully, ensure that a surrogate decision maker or health care agent has been identified in accordance with state law based on facility location. 9. All providers should provide basic symptom management, perform routine discussions about goals of care and code status in seriously ill patients. If complex symptom management or difficult discussions surrounding goals of care or code status arise, consult a palliative medicine subspecialist if available at your institution. 10. Symptom management: Aggressive control of symptoms such as pain, dyspnea, or other symptoms relieves unnecessary suffering, which is crucial for all patients regarding of age, function, comorbidities and prognosis. a. Pain • Acetaminophen should be used first, typically 500mg every 6 hours as needed. • If acetaminophen is insufficient, and other modalities such as topical agents are ineffective, start an opioid for moderate to severe pain (drug, dose, route, and frequency should be individualized and based on symptom severity, kidney/liver function and prior opioid exposure: See Table 7). Consider local supply in drug selection to mitigate risk of drug shortage. • Start a stimulant laxative, such as Senna 8.6mg PO daily, if prescribing an opioid to prevent constipation. Titrate to effect. Escalate bowel regimen as needed, with a goal of one soft bowel movement at minimum every other day. b. Dyspnea • If providing supportive care and supplemental oxygen is ineffective for management of severe dyspnea, a low-dose opioid may be used to help alleviate symptoms. 11. Communication challenges may be exacerbated by the use of PPE. In patients with sensory impairments it is important to remember to eliminate or minimize background noise, state information slowly, and avoid yelling. It may be helpful to display information in writing. Hearing aids/glasses should be worn if available. 12. Older adults, especially those with cognitive impairment, when ill, hospitalized, or placed in a new environment may become anxious, agitated or less interactive. Delirium, a diagnosis not exclusive to older adults, manifests as acute onset inattention, disorganized thinking and an altered level of consciousness. Delirium may be seen any patient, especially those with severe infection, and those requiring mechanical ventilation. Hyperactive delirium (delirium with agitation) may make management and risk mitigation challenging in those diagnosed with COVID-19. (164)

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Clinical Management of COVID-19 a. Early recognition and management of delirium is important. Regular delirium screening should occur using validated methods such as the Confusion Assessment Method, bCAM, or the 4AT (www.the4AT.com).(165, 166) b. Risk factors for delirium include older age, sensory impairment (vision and hearing), history of dementia, nursing home patients, and those with serious infection.(167) c. Management of Delirium: (168, 169)  Prevention of delirium is the best strategy. Strategies include maintaining normal circadian rhythms, exposure to natural light, regular reorientation, mobilization, treating pain, fever, and nausea, maintaining oxygenation, avoiding constipation and urinary retention, and performing medication reconciliation to minimize potentially inappropriate medications. Ensure basic needs are met for food and water.  Standard non-pharmacological approaches such as frequent reorientation, family at bedside, hospital environmental manipulation (maintenance of day/night cycle, appropriate use of TV and lights), calming music, phone calls from family, and professional sitters should be employed but may not be feasible in an isolation setting.  In patients with hyperactive delirium, try nonpharmacological techniques first.  Current evidence does not support routine use of antipsychotics in management of delirium.(170)  If severe agitation occurs, and nonpharmacological approaches have not been effective or more rapid control is needed for the safety of the patient or others, antipsychotics may be used but are off- label. When using an antipsychotic, use the lowest effective dose for the shortest amount of time. Of note, all antipsychotics carry a FDA Black Box warning due to an increase in mortality when used in patients with dementia. The patient should be monitored closely for side effects such as QTc prolongation and over sedation. • Some examples of antipsychotics are Quetiapine 25mg - 50mg PO, Olanzapine 2.5mg - 5mg PO/IM, and Haldol 0.25mg -1mg IV d. Cautious use of antipsychotic medication is needed especially in patients with movement disorders such as Parkinson’s disease and Lewy Body Dementia as this class of medication may exacerbate extrapyramidal symptoms. Quetiapine is preferred if antipsychotic medications are needed in patients with movement disorders given its lower risk of extrapyramidal symptoms.(171) Any patient is at risk for acute dystonic reaction to antipsychotic medications. 13. Many older adults will recover from their illness, and it is important to not forget other complications such as hospital-associated deconditioning, falls and wounds. Standard of care should be provided for these other common complications alongside supportive care for COVID-19. Prompt mobilization and therapy should be started, when able, in accordance with infection control practices. Focusing on other treatable conditions should continue alongside supportive care for COVID-19.

PALLIATIVE MEDICINE DURING THE COVID-19 PANDEMIC

Palliative medicine can assist at all stages of contingency/crisis planning. Prepare for increased use of symptom management resources including opioids (morphine IV and PO, hydromorphone IV and PO, oxycodone PO, fentanyl IV and transdermal), and benzodiazepines. Consider dedicated space for end-of-life care beds. Where possible, symptom management resources should be de-conflicted with highly utilized intensive care medications use to prevent and adapt to shortages (e.g. consider higher use of non-opioid sedation in the ICU to preserve opioids for palliation in active dying and ventilator de-escalation use).

Goals of Care Discussions (Adapted from vitaltalk.org COVID-19 Open Source Resources. www.vitaltalk.org) 1. Eliciting a patient’s goals of care is integral to providing the best and most appropriate medical care and can improve resource allocation during a time of scarcity. Engage patients proactively in goals of care discussions informed by personal values and clinical context. 2. Treat patients and their families with respect and compassion. Quickly and effectively elicit a patient’s concerns, values, and preferences with a few key statements. Table 6 offers suggestions and examples to help guide your conversations. Guideline Only/Not a Substitute for Clinical Judgment 39

Clinical Management of COVID-19

Table 6. Difficult Conversations and Scripts for Communicating with Patients and Families What the patient/family says What you may say Admitting a Patient How bad is this?  From the information I have now and from my exam, your situation is serious enough that you should be in the hospital. We will know more in the coming hours to days, and we will update you. Who else should know about your/their situation and how will they know? Is my grandfather going to make it?  I imagine you are scared. Here’s what I can say: because he is 90, and is already dealing with other illnesses, I worry that he is at risk of dying if this worsens in the hospital. While it is too soon to say for certain, what worries you most about that? Are you saying that no one can visit me?  I know it is hard to not have visitors. The risk of spreading the virus to other vulnerable people is so high that they and those they contact will be in more danger if they come into the hospital. I wish things were different. How can you not let me in for a visit?  The risk of spreading the virus is so high that I am sorry to say we cannot allow visitors. We can help you be in contact electronically. I wish I could let you visit, because I know it’s important, but it is not possible now. When things aren’t going well, goals of care discussion, code status discussions I want everything possible. I want to live.  We are doing everything we can. This is a tough and scary situation for many of us. Could we step back for a moment so I can learn more about you? What do I need to know about you to do a better job taking care of you? I don’t think my grandfather would  Well, let’s pause and talk about your concern. Can you tell me what we should know to have wanted this. take the best care of him? I don’t want to end up being a  Thank you, it is very important for me to know that. Can you say more about what you vegetable or on a machine. mean? I am not sure what my grandfather  You know, many people find themselves in the same boat. This is a hard situation. To be wanted – we never spoke about it. honest, given his overall condition now, I worry that further treatments may not be successful in preventing him from dying. In a situation like that, I have recommended that we allow a natural death. That could be hard to hear. What do you think? When coping needs to be boosted, or emotions are running high I’m scared.  This is such a tough situation. I think anyone would be scared. Could you share more with me? I need some hope.  Tell me about the things you are hoping for? I want to understand more. You people are incompetent!  I can see you are not happy with things. I am willing to do what is in my power to improve things for you. What could I do that would help? I want to talk to your boss.  I can see you are frustrated. I will ask my boss to come by as soon as they can. Please realize that they are juggling many things right now. Do I need to say my goodbyes?  I'm hoping that's not the case and I worry time could indeed be short. What is most pressing on your mind?

Symptom Management Guidelines (Adapted from BC Centre for Palliative Care COVID-19 Resources and Information, bc-cpc.ca/cpc) 1. Patients with COVID-19 infections experience many of the same symptoms as other patients: dyspnea, oral secretions, anxiety and pain. Symptom management should be individualized based on clinical status. The following recommendations are initial guidelines and will require titration and adjustment based on patient response or progression of symptoms. a. Dyspnea – dyspnea can present as anxiety – treat the dyspnea!  Non-pharmacologic management for shortness of breath: • Positioning • Cool room temperatures • Removing restrictive clothing • Avoid bedside fan for patients with COVID-19. Consider bronchodilator therapy (MDI preferred in COVID-19), fluid overload therapies (furosemide if fluid overloaded), and heart rate control if >120 BPM. The mainstay of comfort care in severe dyspnea is opioids--all opioids (morphine, hydromorphone, oxycodone, fentanyl) have the ability to relieve dyspnea and can be helpful for cough as well. Limit use of tramadol and codeine which are not as helpful.  Pharmacologic management for shortness of breath: • Opioids help relieve acute respiratory distress and agitation and can contribute to energy conservation for mild-moderate dyspnea. When dosed effectively to control dyspnea, they do not contribute to a hastened death. • Treat and reassess. IV opioids works within 10-15 min, oral opioids within 30-45 min.  Goals for treatment: respiratory rate <25, minimal use of accessory muscles, resolution of pursed

Guideline Only/Not a Substitute for Clinical Judgment 40

Clinical Management of COVID-19 lip breathing, nasal flaring, and retractions or subjective dyspnea. O2 sat is not a goal of treatment! Patient comfort is the goal.  See Table 7 for recommended opioid dosing. If the dose does not work, increase it! b. Respiratory Secretions/Congestion Near End of Life  Discuss congestion and secretions with family and bedside staff. Pharyngeal secretions are normal at end of life and rarely require treatment. A productive cough may benefit from mucolytics or opioids (Table 6). The “death rattle” or “wind over waves” is a normal part of dying and is not uncomfortable for the patient. Limit oropharyngeal suction as this may cause the patient distress and provide no benefit-- secretions are usually far beyond the scope of a Yankauer. The noise is due to loss of normal swallowing as the body shuts down.  Reduce or stop saline infusions which are no longer beneficial.  Medications may include:  Glycopyrolate 0.4 mg SQ/IV q4H PRN  If severe and refractory to above medications, consider:  Furosemide 20 mg SQ/IV q2h PRN with close monitoring of response.

Table 7. Opioid Dosing to Relieve Dyspnea and Pain in Adults Intermittent Dosing Dosing for Opioid Naïve Patient (patient not on opioid therapy) (For frail, elderly patients, begin at low end of any range) Morphine  15 mg tablet ½ to 1 tab PO q 3 hours prn OR 5 mg SQ/IV q1H PRN shortness of breath (SQ/IV can be given as frequently as q30min PRN) Hydromorphone  2 mg tablet ½ to 1 tab PO q 3 hours prn OR 0.4-0.8 mg SQ/IV q1H PRN shortness of breath (SQ/IV can be given as frequently as q30min PRN)  If more than 6 PRN doses of opioid in 24 hours: Consider a basal opioid such as MSContin 15 mg PO BID. If patient unable to make needs known, consider SCHEDULED dosing of the immediate release opioid (q4H or 6H for frail elderly) AND continue PRN dose.

TITRATE UP AS NEEDED for relief of dyspnea and/or pain Dosing for Patients ALREADY Taking Opioids Applies to any opioid  Continue previous opioid, consider increasing dose by 25%  To manage breakthrough symptoms: Start PRN opioid at 10% of total daily (24 hour) opioid dose.  PRN q1H for PO and q30mins for SQ/IV PCA Infusion Dosing: For alert patients who need IV opioids (unable to take PO or with severe symptoms) PCA Infusion Pump Dosing for Opioid Naïve Patient NOT Already Taking Opioids

Opioid Bolus Dose Basal Rate (if severe symptoms)

MORPHINE 1.5 mg q10mins 1-2 mg/hour HYDROMORPHONE 0.2 mg q10mins 0.1 – 0.3 mg/hour FENTANYL 20 micrograms q10mins 10-25 micrograms/hr

Titrate the basal rate and bolus dose to effect. If using more than 1 rescue dose/hour, increase the basal rate for improved symptom control. PCA Infusion Pump Strategy for Patient ALREADY Taking Opioids  For patients on chronic opioid therapy, rotate their long acting medication into the basal rate of your PCA. Titrate to effect.  Bolus doses may be given q10 to 15min PRN; if the patient is NOT able to use the button, add a nurse administered bolus order of 5 mg IV q 2 hour prn for morphine PCAs and 0.8 mg IV q 2 hour prn for hydromorphone PCAs.  Example titration: You start a morphine PCA at 1 mg/hr basal rate with 1 mg q 15 minutes rescue. The patient presses the button every 15 minutes and says he “feels nothing” and continues to be short of breath. Increase the rescue dose to 2 mg and reassess.  Adjust bolus doses to 50-100% of new continuous infusion rate (e.g. Bolus dose of 2-4 mg q15min PRN for new rate of 4mg/h).  New rate can be reassessed for adjustment again in 3-4 hours.

c. Anxiety • Patients with dyspnea will often have associated fear and anxiety-- opioids are the first line of treatment. The following adjuncts may be helpful in refractory anxiety: • Lorazepam 0.5 – 1 mg PO/IV q1-4H PRN, consider scheduling Q4H if goals are for comfort- directed care and the patient is requiring frequent PRN dosing. • For severe anxiety or shortness of breath in the ICU: • Midazolam 1 – 4 mg SQ/IV q30min PRN, consider scheduling Q4H if goals are for comfort- directed care and the patient is requiring frequent PRN dosing. Guideline Only/Not a Substitute for Clinical Judgment 41

Clinical Management of COVID-19 d. Delirium • Delirium, either hypoactive or agitation, is common in hospitalized patients and can be associated with significant distress of family members and bedside staff as well as increased risk of self-harm. Avoid benzos in this setting. Treat underlying causes of delirium if possible: urinary retention, constipation, dehydration, severe infection or pain. • Haloperidol 0.5 mg PO OR 0.5 – 1 mg IV q4H PRN. Consider scheduling the medication Q4H if requiring frequent PRN dosing. Titrate dose in 0.5mg increments. • Olanzapine 2.5 – 5 mg PO qHS and q8 hr PRN. This comes as a regular or oral dissolving tablet and can be titrated.

e. Constipation • Use of opioids will cause constipation. If the patient has more than 24 hours to live:  Start a stimulant laxative, such as Senna 8.6mg PO daily if they are tolerating PO.  PRN enema if unable to take PO and patient uncomfortable from distention • Escalate bowel regimen as needed, with a goal of one soft bowel movement at minimum every other day.

Palliative Ventilator De-Escalation (Adapted from “Palliative Ventilator De-escalation Recommendations for COVID-19 Positive or PUI. Developed by Bartlett, Christi for The University of Kansas Health System) 1. A subset of patients with COVID-19 infection will progress to refractory respiratory failure. Patients expected to die imminently should be transitioned to best supportive care (“comfort measures”). 2. Have an open goals of care conversation with the patient, family and/or surrogate decision maker. Explain that despite medical interventions, the patient is nearing end of life. Palliative Medicine services throughout the Department of Defense are available to help guide these discussions if needed. 3. The endotracheal tube will remain in place and the ventilator circuit will remain intact to reduce the risk of COVID-19 exposure to bedside staff at the time of de-escalation. (Nota Bene: You are not “pulling the plug.” You are providing comfort during the body’s natural death.) 4. Pre-medicate with opioids as listed above in Table 7. Have additional medication ready at bedside should symptoms escalate. Pre-Procedure. 1. Make arrangements with leadership to determine if any family will be allowed on the unit and discuss plan with family. 2. Prepare family that prognosis can be as short as a few minutes but as long as a few days. Patients who are COVID-19 positive with severe ARDS are likely on the shorter range. 3. Deactivate defibrillators first. A magnet can also be placed over the device if needed to deactivate. Consultation or discussion with a cardiology service may be necessary. 4. Ensure no paralytic medications are on board. 5. Code status should be DNR/ comfort measures only for patients at the end of life. 6. Discontinue tube feeds. 7. If patient is on dialysis, disconnect and remove machinery from room. Procedure. 1. Confirm correct patient and plan for de-escalation with appropriate surrogate decision maker. 2. Turn off alarms and change room monitor to comfort care setting or turn off if family is present. 3. If a continuous opioid infusion is in place, continue THE SAME medication. All opioids contribute to relief of pain/dyspnea. 4. If the patient is already on a continuous opioid infusion, double current drip rate and order bolus doses of 100- 200% of drip rate to be given q10min PRN. Use bedside infusion to provide boluses whenever possible. 5. If the patient is opioid naïve and not on a continuous infusion, begin with morphine 5mg IV or hydromorphone 0.5 – 1 mg IV q10min PRN. If possible, bring at least four doses into patient room for ventilator de-escalation. 6. Order midazolam 2-4 mg q10min PRN or lorazepam 2 mg q30min PRN for anxiety/breathlessness. If patient is already on a midazolam continuous infusion, double current rate and give boluses of 100-200% of drip rate available q10min PRN. Use bedside infusion to provide boluses PRN. Guideline Only/Not a Substitute for Clinical Judgment 42

Clinical Management of COVID-19 7. Pre-medicate with an opioid bolus as above (100% of drip rate) 10 minutes prior to de-escalation. 8. Pre-medicate with 2 – 4 mg of midazolam 10-15 min or 1 – 2 mg of IV lorazepam or prior to de-escalation. 9. Recommend glycopyrrolate 0.4 mg IV q4H PRN for secretions. 10. If patient requires sedative medication (propofol, precedex, etc) for comfort, continue as ventilator is weaned. 11. Stop vasopressors prior to weaning ventilator. 12. Ensure that patient appears comfortable prior to reducing ventilator settings. Titrate to comfort to palliate signs of discomfort: grimacing, agitations, or labored respirations. 13. For agitation/delirium management, consider Haloperidol 0.5 – 1 mg IV q30mins PRN. 14. If patient is obtunded and expected to die abruptly after ventilator is weaned, recommend immediate reduction in ventilator settings to pressure support 5/5 and room air. Bolus opioid and benzodiazepine aggressively as needed to ensure comfort. 15. If the patient is alert, consider a gradual reduction in ventilator settings. Decrease FiO2 to 40%, PEEP to 10, RR to 16. Recheck patient comfort and re-bolus opioids as needed to achieve comfort. Reduce to Peep 5, and FiO2 to 0.21. 16. Once the ventilator is set at PS 5/5 and FiO2 of 21%, leave endotracheal tube in place and leave the ventilator circuit intact for the end of life. 17. Continue to re-bolus opioids, benzodiazepines and sedation as needed to ensure comfort.

IMPLICATIONS OF COVID-19 ON SURGICAL CARE

Key Considerations for Surgical Operations and Personnel Force Protection: Protection of personnel and patients from disease transmission Mission Capability: Maintaining capability to provide safe and effective surgical care when required Mission Support: Support of the healthcare community response to COVID-19 through preservation of critical resources and re-deployment of personnel Surgical Decision Making and Triage. 1. Elective surgical care should be restricted to reduce risks of transmission between patients and healthcare personnel. This includes outpatient clinical encounters, inpatient surgical procedures and all other interactions that can be accomplished through other means (virtual encounters, non-operative techniques) or deferred/delayed without unacceptable morbidity or risk. 2. MTFs should establish a review process to triage surgical care based on health protection conditions, patient factors, local and regional healthcare capacity, and logistic constraints. This process must be informed by day to day assessments of the changing environment, led by a senior surgeon, and include multidisciplinary representation. a. Flexibility should be maintained to provide medically-necessary or time-sensitive surgical treatment such as cancer care, limb salvage, and infectious source control. The associated risk of COVID-19 transmission to patients and staff, availability of hospital resources, and potential increase in morbidity/mortality associated with delayed surgical care should be considered in the adjudication of these cases. b. The time sensitivity, medical necessity, resource utilization, and expected post-operative inpatient care resources should be considered for each case at the local level, preferably the Department/Service Chief or, in the deployed setting, the senior trauma surgeon. c. Given the known presence of asymptomatic viral shedding for COVID-19 infected individuals, MTFs should consider pre-operative screening and testing prior to performing surgery. 3. Additional guidance on surgical decision making and triage has been developed by the American College of Surgeons and can be found at: https://www.facs.org/covid-19/clinical-guidance.

Perioperative Care of COVID-19 Positive Patients and PUIs Overview. 1. For purposes of perioperative care, patients should be treated as presumed COVID-19 positive if they have symptoms/exposure history that warrants testing. PUI patients at MTFs without an urgent indication for surgery should ideally be tested for COVID-19 before any operative intervention. Guideline Only/Not a Substitute for Clinical Judgment 43

Clinical Management of COVID-19 a. Emergency surgery (i.e. hemorrhage or contamination control) should NEVER be delayed for COVID-19 concerns. b. Any surgical patients considered PUI should be medically managed to the greatest extent possible prior to surgery in order to allow time for confirmatory testing. c. Optimally, an OR or cluster of ORs should be predesignated with a distinct antechamber to maintain separation from non COVID-19 patients. If a negative pressure OR is not available, consult with facilities to ensure air handling is routed through a HEPA filter. d. In the deployed setting, when possible, designate a single OR for PUI/COVID-19 positive surgical care and minimize unnecessary supplies and equipment in that room. This surgical suite should undergo terminal cleaning after each case. 2. All patient interaction with COVID-19 positive or PUI patients will be performed with airborne and contact precautions, including eye protection: a. N95 mask with surgical mask over the N95 mask, consider PAPR for aerosol generating procedures. b. Eye protection consisting of goggles, full face shield/mask worn over N95, or plastic disposable wrap- around glasses. Eyeglasses alone are not adequate. c. Gown, double gloves, hair cover, shoe covers 3. Remove all PPE except N95 mask before exiting the room. Surgical scrubs should be changed after each case. Perioperative Care. 1. Surgeries and procedures on COVID-19 positive patients and PUIs should occur in a negative pressure room or an OR equipped with HEPA-rated filters on all air outflow vents. 2. The anesthesia provider should attempt to remove all necessary medications and equipment from the carts prior to bringing the patient into the room. Avoiding contamination of the carts/machine should be prioritized over wasting consumable supplies. 3. Anesthesia providers should not expect routine breaks during the case. Consider leaving cell phones, smart watches, and other personal devices out of the OR. Ensure there’s a way to communicate/call for assistance organic to the OR room. 4. Place a HME/HEPA filter between the Y-piece of the breathing circuit and the patient's mask, endotracheal tube or laryngeal mask airway. The gas sampling line must exit the circuit proximal (closer to the machine) than the filter. The ASA/APSF recommends adding a second HME/HEPA filter on the expiratory limb before entering the anesthesia machine. 5. For sedation cases, a procedural/OR mask should be placed on the patient over the oxygen source. If a gas sampling line is used to monitor end tidal CO2, ensure a filter is used prior to gases entering the machine. The filter found in most epidural kits may be placed in-line and provide adequate machine protection. For sedation procedures that instrument the esophagus (TEE, EGDs) and generate high volume aerosolized secretions, intubation may be the best way to limit room exposure. Alternately, a Procedural Oxygen Mask may limit room exposure where intubation is contraindicated. 6. When transporting a ventilated patient, ensure a HEPA filter is placed between the ETT and the Ambu bag. Connect the Ambu bag to the ETT prior to opening the door in the negative pressure room. Likewise, ensure the door is closed when returning the patient before switching to the ventilator. The same filter may also be used on the exhalation loop of the anesthesia machine. 7. For pediatric patients or patients in whom the additional dead space or weight of the filter may be problematic, the HEPA filter can be placed on the expiratory end of the corrugated breathing circuit before expired gas enters the anesthesia machine. Again, ensure the gas sampling line is protected from contaminating the anesthesia machine. 8. When transporting patients to and from the OR, a “clean” person who does not contact the patient should accompany the team to safely interact with the environment (e.g. open doors or elevators). 9. Patients on the ward should be transported directly to the OR by the anesthesia team. If assistance is needed with transport, every attempt should be made to use someone from the care team (nurse, surgeon, technician, etc.) to minimize staff exposure. Intraoperative Care. 1. For sedation cases, a procedural/OR mask should be placed on the patient over the oxygen source. If a gas sampling line is used to monitor end tidal CO2, ensure a filter is used prior to gases entering the machine. The Guideline Only/Not a Substitute for Clinical Judgment 44 Clinical Management of COVID-19 filter found in most epidural kits may be placed in-line and provide adequate machine protection. For sedation procedures that instrument the esophagus (TEE, EGDs) and generate high volume aerosolized secretions, intubation may be the best way to limit room exposure. Alternately, a Procedural Oxygen Mask may limit room exposure where intubation is contraindicated. 2. Use disposable covers whenever possible (e.g., plastic sheets for surfaces, long ultrasound probe sheath covers) to reduce droplet and contact contamination of equipment and other environmental surfaces. 3. When performing laryngoscopy and intubation: a. If a negative pressure OR is unavailable, consider intubating the patient in a negative pressure room and then transporting to the OR after intubation. b. Wear full PPE. c. Ensure all non-essential personnel are given the chance to leave the room if possible before performing the procedure. d. Wear double gloves and shed outer gloves after intubation to minimize subsequent environmental contamination. e. Designate the most experienced anesthesia professional available to perform intubation. f. Consider rapid sequence intubation (RSI)/avoid awake fiberoptic bronchoscope (FOB)/avoid mask ventilation if possible. g. Consider video laryngoscopy to maximize first-attempt intubations. h. Ensure the HME/HEPA filter is attached to the exhalation limb or at the Y-piece of the circuit (sampling line should be post filter). i. Outer gloves may be used to wrap disposable portions of airway equipment after use. 4. Continue to wear full PPE for duration of case. 5. Any external equipment (e.g., ultrasound machine, GlideScope, etc.) needed for the case should be draped to the greatest extend possible and not removed until the room is terminally cleaned. 6. Consider having a runner positioned outside the OR to pass medications and supplies into the room. 7. Routine breaks for OR personnel should be avoided to limit exposure and conserve PPE. 8. Cell phones, pagers, and personal effects should be left outside the OR to decrease cross-contamination. Ensure help can be obtained using the OR phone. Postoperative Care. 1. Non-ICU patients should recover in a PACU negative pressure room. If a suitable recovery room isn’t available, the OR may substitute until ready for Phase II. 2. Remove all PPE before exiting the room except N95 mask. Avoid touching hair or face & perform hand hygiene. 3. The room should be cleaned in accordance with the designated processes for terminally cleaning rooms for a highly infectious agent. 4. Once the patient has left the operating room, leave as much time as possible prior to subsequent patient care to allow removal of airborne infectious contamination. Consult with physical facilities for the air exchange of each procedural room and the wait time required to provide 99.9% efficiency. Additional Recommendations and Guidance. 1. Recommend establishing Intubation Teams consisting of providers with a high degree of comfort with PPE and airway skills. Teams should bring their own PPE, intubating drugs, and airway equipment to avoid delays while limited or unfamiliar PPE is made available. During the pandemic, any emergency airway should be treated as potentially COVID-19 positive and full PPE worn. 2. Continual updates on the care of surgical patients during the COVID-19 pandemic can be found here: https://www.asahq.org/in-the-spotlight/coronavirus-covid-19-information

Surgical Care of COVID-19 Positive Patients and PUIs 1. Aerosol generating procedures (AGPs) are common to certain surgical specialties and techniques. These high- risk activities include: a. Laparoscopy – In the absence of ultrafiltration of aerosolized particles in released CO2, laparoscopy carries a risk of spreading COVID-19, and should only be used in selected cases where clinical benefit substantially exceeds the risk of viral transmission (Intercollegiate Surgery Guidelines: https://www.rcsed.ac.uk/news- public-affairs/news/2020/march/intercollegiate-general-surgery-guidance-on-covid-19-update) Guideline Only/Not a Substitute for Clinical Judgment 45

Clinical Management of COVID-19 • Depending on resources, consider selective initial non-operative management of acute uncomplicated appendicitis and cholecystitis with antibiotics. In evaluating the available resources, recognize that the failure rate of non-operative management of these diseases is not insignificant and may result in prolonged hospitalization. (Intercollegiate Surgery Guidelines: https://www.rcsed.ac.uk/news-public-affairs/news/2020/march/intercollegiate-general-surgery-guidance-on- covid-19-update) b. Endoscopy – Endoscopic procedures should only be undertaken in an emergency, given the elevated risk of aerosol-based transmission. c. Head and Neck surgery – Tracheotomy is a high-risk procedure for transmission of viral particles. Unless there is an emergent need for a surgical airway, elective tracheotomy should be postponed until the patient has stable pulmonary status, (not sooner than 2-3 weeks from intubation), and, preferably, with negative COVID-19 testing.(10) • If a tracheotomy is performed on a PUI/COVID-19 patient, routine tracheotomy tube changes should be delayed until after active disease resolves or the patient tests negative. 2. Operative planning a. Surgeons and non-essential staff should not be present in the OR for either intubation or extubation unless necessary for patient safety. b. Only essential staff should be present in the OR during surgery, and should all be wearing enhanced droplet PPE at minimum. c. Laparoscopy (SAGES: https://www.sages.org/recommendations-surgical-response-covid-19/) • CO2 insufflation should be set to the lowest effective pressure, and a filtration device should be used for CO2 release if available. • Release all pneumoperitoneum via filtration device (if available) prior to specimen removal, port removal, or converting to open surgery. • Avoid venting insufflation from the ports during surgery. d. Open surgery • Electrocautery should be set to the lowest effective setting and a smoke evacuator used if available. e. All PPE (except N95 mask) should be removed in the OR prior to exiting post-operatively. Surgical scrubs should be changed immediately at the conclusion of the case. • Cloth surgical caps should not be worn in PUI cases. • Shoes should be disinfected routinely after each case. f. Chest tubes and surgical drains are all potential sources of aerosolized droplets, and enhanced precautions should be taken during placement, manipulation, or removal.

Trauma and Surgical Combat Casualty Care Considerations 1. Deployed medical/surgical capability is a limited and mission-critical asset that must be preserved to reduce risk to the force and mission. To that end, all reasonable attempts should be made to preserve medical and surgical capability on the battlefield. 2. All trauma/injured patients should be presumed positive/PUI in the downrange setting until they can be ruled out (by testing or risk factor assessment). a. Trauma team members should all wear airborne and contact precautions, including eye protection for PPE until the patient is ruled out for COVID-19. b. Unnecessary individuals in the trauma bay should be minimized. c. Individuals should remove all PPE (except N95 mask) prior to exiting the resuscitation area. • Any clothing worn in the resuscitation bay/ATLS area should be removed after PUI patient contact and immediately cleaned • Commanders should modify uniform requirements as necessary to allow for multiple rapid clothing changes to avoid cross contamination. d. All equipment in the resuscitation bay and ATLS area (i.e. x-ray, ultrasound, instrument packs, etc.) must be terminally cleaned after every PUI encounter. e. Non-intubated patients who cannot be ruled out for COVID-19 should have a surgical mask applied during transport between the resuscitation bay and CT scanner and during any transit within the facility.

Guideline Only/Not a Substitute for Clinical Judgment 46

Clinical Management of COVID-19 Patients requiring oxygen should have a non-rebreather mask applied instead of a simple face mask. f. All PUIs requiring admission should be kept in isolation rooms (if available) until ruled out or ready for discharge (to quarantine facilities). 3. Staffing risk reduction a. Aerosol producing procedures should have only necessary staff members present in the room (i.e. intubation, chest tube placement, etc.), and all staff must wear enhanced droplet precaution PPE. b. Each facility should consider options to minimize staff members entering the resuscitation area. This could include the use of runners or pass-through windows for deliveries from pharmacy, lab, etc. c. All visitors should be restricted during the initial phase of resuscitation, and based on risk, may be restricted throughout the entire hospitalization at the discretion of the Commander. 4. Consultations and therapies should be performed as needed and not delayed solely because a casualty is pending COVID-19 rule-out. This includes specialty and subspecialty consultations, routine nursing care (i.e. pressure injury reduction, oral care, etc.), radiology, lab analyses, and physical/occupational/speech therapy.

OPERATIONAL CONSIDERATIONS FOR COVID-19: PLANNING AND PREPARATION

Providing safe and effective care in the deployed setting during an infectious disease pandemic is particularly challenging given limited resources, close living conditions, and delays in test results and supply arrival. The DOD GCP PI & ID 3551-13 provide a wealth of information, guidelines, and mitigation strategies for a pandemic, but are not tailored to the risks, needs and nuances of COVID-19. This section focuses on the unique aspects of dealing with the COVID-19 pandemic in the deployed environment. Collaboration between base commanders and medical teams is an essential component of pandemic response to limit infection spread while caring for the ill and injured.

Division of Labor for Quarantine and Isolation. 1. Quarantine: This is a medically-supported command function to separate high risk individuals from the general population following a potential exposure. Commanders are responsible for establishing and maintaining quarantine facilities within their area of responsibility (AOR), and each unit is responsible to identify at-risk personnel based on best medical guidance. 2. Isolation: This is a command-supported medical function to care for those with infection. These patients are identified by symptoms (i.e. fever, cough, dyspnea, diarrhea, etc.) following an exposure (typically within the past 14 days), and may be identified de novo or from quarantine. The duration of isolation is defined by resolution of symptoms and negative testing. Because service members are not deployed with a family, even mildly symptomatic patients, who would typically be returned to the care of their family in the garrison setting, become the responsibility of the medical team.

Physical Requirements and Logistics of Quarantine and Isolation. 1. Quarantine: Quarters must be provided for persons suspected of having exposure to COVID-19 in an effort to prevent spread of the disease to other service members (SM). These quarters must be separate from the general population and must have their own dedicated toilet and shower facilities. Meals must be provided to quarantined individuals, and they must be checked regularly (i.e. via telephone) to ensure they remain asymptomatic. If symptoms develop, medical personnel should be notified to arrange evaluation and potential transfer to medical isolation. Quarantined individuals should remain in their designated quarters unless directed otherwise. Personnel should be designated to do laundry for quarantined individuals. Dirty laundry should be placed in a sealed disposable plastic bag by the quarantined member and then handled with gloves by laundry personnel. Laundry should be placed in the washing machine without handling the clothes, and the bag discarded in an appropriate receptacle. Asymptomatic PUIs typically should remain quarantined for 14 days. The 14 day quarantine resets if any member of the quarantine group develops symptoms, has a positive test result, or with any new addition to the quarantine group. Any member who develops symptoms or receives a positive test result should be immediately evaluated and moved to medical isolation. To avoid excessively prolonged quarantines, every effort should be made to keep quarantined individuals in the smallest possible groups; individual quarters are the ideal quarantine environment. Any

Guideline Only/Not a Substitute for Clinical Judgment 47

Clinical Management of COVID-19 personnel interacting with or evaluating quarantined individuals must wear appropriate PPE. 2. Isolation: Patients who become symptomatic or test positive should become the primary responsibility of the medical team. Medical teams will need to plan for patient monitoring, treatment, housing, meal, and hygiene facilities. Based on the demand, commanders may need to consider assigning additional non- medical personnel to assist with these tasks. Isolated patients should be classified by symptoms as asymptomatic, mild, moderate, or severe, which will determine the required level of care. Any personnel interacting or evaluating patients in isolation must wear appropriate PPE. a. Asymptomatic/Mild Symptoms: In CONUS locations these patients may be sent home for self-care and outpatient follow-up. In the deployed setting family support is absent and self-isolation is not feasible, so medical teams should coordinate with command to establish appropriate isolation housing with routine medical oversight and documentation. Symptom progression should result in medical reevaluation. There must be a clear and universally-accessible communication plan for notifying the duty medical personnel of a change in patient condition. b. Moderate Symptoms: These patients require hospital ward admission. These facilities may be located within the MTF or established separately near the MTF; if available, negative pressure facilities should be reserved for aerosol producing procedures. A COVID-19 positive patient should not share a room with a non-COVID-19 patient. c. Severe Symptoms: These patients require ICU admission for hemodynamic monitoring/treatment or severe respiratory symptoms. ICU care should be performed where the greatest medical capability exists, but should not result in joint cohorting of COVID-19 positive/negative patients. Negative pressure facilities should be used (if available) during aerosol producing procedures.

Unique Limitations in the Austere Environment 1. Ventilator: COVID-19 may result in ARDS which can be challenging to manage even with the best facilities and equipment; in the deployed setting, providers may only have transport ventilators with limited capabilities. It is important to recognize this limitation and prepare accordingly. Medical teams should train and exercise protocols for prone positioning and pharmacologic paralysis which have proven mortality benefit if used early in ARDS. 2. Medications: At present, there is no specific treatment for COVID-19. Deployed providers may not have access to compassionate use or trial medications, and should be familiar with the supportive care measures described elsewhere in this document. Additionally, the Society of Critical Care Medicine, ARDSNet, and other professional societies provide continuously updated guidelines on their websites. Providers should work closely with pharmacy and logistics leadership to ensure adequate stocks of all commonly required medications, including antimicrobials, sedation, and paralytics. 3. PPE: Supply chain challenges have led to PPE shortages worldwide. Fortunately most units are deployed with CBRNE equipment which can be used for filtration and staff protection. Staff must be proficient at proper donning, doffing, and cleaning techniques. 4. Hygiene: The austere environment lends itself to rapid spread of infectious disease. Commands should emphasize the importance of handwashing/sanitizing, cleaning quarters, and appropriate social distancing. 5. Testing: Epidemiologic data is critical for command decision making, therefore commanders may need to divert resources to ensure rapid case identification and intervention. MTFs should not use non-DOD laboratories for testing unless approved by their AOR HQ. 6. Transportation: Units must coordinate with PMC to ensure safe and efficient movement of patients and/or testing samples around theater. Patients should be treated in place unless their clinical condition necessitates a higher level of care; unnecessary patient movement should be avoided to minimize personnel and resource exposure and transmission risk. 7. Housekeeping and Cleaning Services: Cleaning protocols must be established to ensure adequate sanitization occurs in quarantine, isolation, and medical facilities, as well as workspaces and quarters of those moved to quarantine/isolation status. PPE should be worn by cleaning personnel and disposed of in a manner that avoids the potential for cross-contamination. 8. Mortuary Affairs and Casualty Liaison Teams: While the COVID-19 mortality rate is expected to be low in the typical deployed population, teams should be prepared for increased demands and requirements.

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Clinical Management of COVID-19

MENTAL HEALTH AND WELLNESS IN COVID-19 CLINICAL MANAGEMENT

General Considerations for Healthcare Workers, Support Staff, and other Frontline Workers 1. Prioritize healthy routines (i.e., nutrition, hydration, sleep, exercise). 2. Social distancing, infection control, and isolation present a significant barrier to our usual approach to care, requiring innovative approaches. 3. Communication – words matter now more than ever. Clear and consistent messaging from leadership, between team members, and to patients and family is vital during this crisis. 4. The psychological consequences of this pandemic will be experienced in the present and will have lingering effects on many in society. 5. Resources for leaders in support of Healthcare Workers can be found at: https://www.cstsonline.org/covid- 19/supporting-healthcare-workers

General Mental Health Care for Patients with known or suspected COVID-19 1. Use telehealth and virtualization tools as much as possible for mental health assessments and ongoing care of isolated patients. Promptly identify all COVID-19 patients with known mental illness and consult behavioral health to assist with ongoing care. 2. Recognize isolation as a barrier to communication. Patients should be kept informed as to what is happening, what is likely to happen, and next steps in their care. 3. Give patients information and a sense of control in the midst of a stressful and confusing situation. Consider virtual approaches to making regular updates to patients. 4. Anticipate patient concerns and misconceptions. Common themes include “what if I can’t get a ventilator when I need one?”, “what if I infected my family?”, “will I die alone?”, and external stressors such as job loss or housing insecurity. 5. Healthcare systems should establish easily accessible pathways for referrals to mental health for family members of patients admitted for COVID-19. 6. Attend to negative impacts of isolation by facilitating virtual connection with providers, family, and loved ones as much as possible. 7. Resources to help in caring for Patients and Families can be found at: https://www.cstsonline.org/covid- 19/caring-for-patients-and-families

For Medical Providers 1. Self-care is important for providers, patients, and families. Basic needs such as proper sleep, nutrition and hydration, regular exercise, and regular breaks sustain performance and enhance decision-making. 2. Connect to a sense of unified purpose; foster hope, fortitude, and tolerance in self and others. 3. Amplify positive stories and stories about competent efforts by self and colleagues. Encourage perceptions of competence among staff, especially junior and/or less experienced colleagues. 4. Recognize and attend to signs of burnout in self and others – out of character sadness, frustration, irritability, isolation/disconnectedness, substance use, and lack of self-care. 5. Focus on what can be controlled – checklists, routines, self-care; and accept what cannot be controlled. 6. Promote a climate where it is acceptable for team members to talk about difficult events (death, triage, errors), as avoidance and fear of such thoughts are associated with greater long-term mental health problems. 7. Establish a routine of regular team meetings as an opportunity to pass good information, but also as an opportunity for an emotional check. Maintain a climate where it is okay to not be okay and offer peer support when needed. 8. Identify a team member with the responsibility for communicating with family, particularly sharing bad news or death notification. Consider rotating this responsibility. 9. Resources for Healthcare Worker Self Care can be found at: https://www.cstsonline.org/covid-19/healthcare- worker-self-care

For Mental Health Providers

Guideline Only/Not a Substitute for Clinical Judgment 49

Clinical Management of COVID-19 1. Provide proactive support to front line workers where possible. Ideally, in the form of a behavioral health outreach team with established relationships to points of contact to facilitate increased utilization of outreach team during times of peak stress. Teams should be organized to ensure rounds occur for every shift every day. 2. Be certain not to overlook groups such as janitorial staff, transport, food service, and others who make the medical system run, and who are likely experiencing significant distress. 3. Behavioral health care teams should be empowered to facilitate additional mental health care for those in need, especially those who have had negative experiences. 4. Tailor resources and support as much as is feasible – and plan on changing/adapting resources with the unfolding realities of the medical mission. Flexibility is important. 5. Supportive care of healthcare workers is different from usual clinical care, and includes: a. Check in with the physicians, nurses, technicians, and support staff. b. Ask questions (examples include: What's working well this week? What are your biggest struggles this week? What would make things better?). c. Link with support services, such as Red Cross, providing food and beverages. d. Provide information on normal distress reactions and adaptive responses. e. Promote positive peer support and facilitate connections. f. Make connections during a calm time. Do not interrupt urgent patient care or sign-out. g. Find a quiet space to talk when things are chaotic. h. Ensure individuals have access to safe spaces and emotional/spiritual support. 6. Unique issues to consider when supporting front line workers: a. Be aware of the potential for moral distress in providers making difficult and potentially life or death triage and management decisions. b. Be aware of potential concerns of individual front line workers including single parents, dual healthcare worker families, families with serious medical issues, workers living separate from their families, and community stigma of being “infected” as examples. 7. Resources for Mental Health Support for Patients can be found at: https://www.cstsonline.org/covid- 19/mental-health-support

EMERGENCY MANAGEMENT SERVICES AND GROUND TRANSPORT OF PERSONS WITH COVID-19

Dispatch Screening for COVID-19 1. Persons assigned to EMS and first responder dispatch function should complete key question interrogation and dispatch resources accordingly. Dispatchers should reference the EMS COVID-19 questionnaire when obtaining information from 911 callers (Table 8). EMS systems may become strained due to an influx of 911 calls regarding known or suspected COVID-19 transmission or infection. In areas where EMS resources are overwhelmed by 911 call volumes, the following should be considered: a. EMSand/orFireDispatch shouldtriage 911 callsandprioritizeresponsesaccordingly(e.g. if a patient calls reporting signs and symptoms consistent with COVID-19, but denies respiratory distress and other complaints suggestive of a life-threatening condition (i.e. chest pain, etc.), ambulance services should be directed to an alternative, higher- acuity call. b. If EMS arrives on scene and determines that a patient does not have a life-threatening condition relating to the potential exposure to, or signs and symptoms of, COVID-19, EMS crews should contact On-line Medical Control to discuss non-transport and/or alternative transport destinations. If non-transport is approved, EMS Dispatch should direct the EMS crew to a higher-acuity 911 call. Refusal of Transport /Treat and Release should be coordinated with local On-line Medical Control c. Callers using the 911 system for questions or concerns regarding COVID-19 testing (e.g. sites, locations, and decisions regarding testing criteria) should be diverted to established local, county, or state COVID-19 call centers. Installations and facilities should consult with their local EMS Medical Directors regarding protocols and policies pertaining to call diversion for information-only requests from 911 callers.

Pre-Arrival Screening or Initial Patient Assessment of Suspected COV-19 Patients. (For utilization by EMS/Fire Guideline Only/Not a Substitute for Clinical Judgment 50 Clinical Management of COVID-19 Department Dispatch OR Responding Crews) 1. If the below information was not obtained by Dispatch, First Responders (EMS/Fire) should begin their initial assessment from at least six feet away if patient presentation allows. If the patient reports symptoms consistent with a respiratory illness, EMS personnel should don appropriate PPE, and place a surgical-type mask on the patient. 2. If the patient’s condition allows, to minimize the risk of exposure, one individual should approach the patient, place a surgical-type mask on him/her, and complete the COVID-19 screening questionnaire/ initial assessment. Additional EMS/Fire personnel should be contacted for support only as required. 3. If EMS personnel are first on-scene, and it is determined that the patient has symptoms of a respiratory illness (Box 1) and risk factors for COVID-19 (Box 2), Dispatch should be contacted to minimize response by additional units (Fire and Law Enforcement) to reduce the risk of exposure.

EMS Refusal of Transport 1. Purpose: Identify patients that do not require EMS transport to a hospital or alternate facility during the COVID-19 pandemic, in order to accomplish the following: 1) Minimize disease transmission to the community and health care system; 2) Protect first responders and health care providers and; 3) Preserve the health care system functionality by not overwhelming emergency resources. 2. Transport decision and final destination versus non-transport with self-care should be considered by EMS Medical Directors, partnering with MTF leadership, to develop local policies. The following are provided as recommendations: a. Careful consideration for EMS Non-Transport should be given for pediatric patients, pregnant females, or patients who are immunocompromised. Discussion with Online Medical Control is advised. b. The below assessment tool is to inform the necessity to transport an adult patient when the patient reports symptoms related to COVID-19. c. If a patient is not transported, he/she should be directed to contact 911 if he/she develops significant shortness of breath, chest pain, the inability to tolerate oral intake, or is unable to schedule follow-up with an appropriate health care provider/facility. Table 8. Emergency Medical System Pre-Arrival Screening for COVID-19 Does the patient have:

BOX 1 BOX 2  Has the patient traveled to a CDC Health Advisory Level 2 or  Fever (or are they hot to the touch) Level 3 country in the last 14 days?  Cough (https://wwwnc.cdc.gov/travel/notices) AND  Are they currently under investigation or isolation for COVID-  Shortness of Breathing or Difficulty Breathing 19 by public health or other medical professionals?  Other flu-like symptoms (sore throat, runny nose,  Have they been in close contact with an individual who is body aches, chills, or anosmia/dysgeusia) known to be sick with, or under public health/medical professional investigation/isolation for COVID-19?

If the patient meets at least one criteria item from Box 1 and Box 2, see below:

 Instruct the individual to isolate him/herself from close contact with others until EMS arrives.  Notify First Responders (to include Fire and Law Enforcement) that the patient meets pre- arrival screening criteria for COVID- 19. Advise donning of appropriate PPE prior to patient contact.  Follow local agency policies to limit multi-unit responses.  Transport Agencies will contact the receiving facility as soon as possible, preferably prior to transport (See EMS TRANSPORT OF PERSONS UNDER INVESTIGATION OR PATIENTS WITH CONFIRMED COVID-19). . Table adapted from the Southwest Texas Regional Advisory Council (STRAC); EMS Pre-Arrival Screening for Coronavirus 2019-nCOV - V1.2, issued 02/07/2020.

Table 9. Emergency Management System Patient Considerations for Non-Transport in COVID-19 PATIENT CONSIDERATION FOR NON-TRANSPORT:

Guideline Only/Not a Substitute for Clinical Judgment 51

Clinical Management of COVID-19

INITIAL ASSESSMENT WITH VITAL SIGNS

(initial encounter should ideally be by a single provider in appropriate PPE from a distance of 6 feet)

∙ Temp < 39.4C (103F) ∙ GCS 15, Alert & Oriented ∙ HR < 100 bpm ∙ SpO2 > 90% ∙ Respiratory Rate 10-30 ∙ Well appearing, speaks in full sentences, ambulatory ∙ Viral sx: cough, sore throat, body aches, nasal/chest congestion

PATIENT MEDICAL HISTORY & PRESENTATION

∙ Age < 50 years ∙ Non-diabetic ∙ Non-Immunocompromised ∙ No known respiratory disease ∙ No known cardiac disease

LIVING ARRANGEMENTS

∙ Has appropriate support system at home ∙ Patient has means for follow-up

IF THE PATIENT IS IN A PUBLIC LOCATION ∙ Place a surgical mask on the patient. ∙ Discourage the use of public transportation. ∙ Instruct the patient to directly transport themselves home while minimizing exposure to others/the community.

Personal Protective Equipment (PPE) for Emergency Medical Services Personnel. 1. EMS personnel providing care for a patient with COVID-19/PUI should utilize the following PPE: a. N-95 or higher level respirator or facemask (if a respirator is not available). N-95 respirators or respirators that offer a higher level of protection should be used when performing an aerosol- generating procedure. b. Eye protection: goggles or a disposable face shield that fully covers the front and sides of the face should be worn. Personal eyeglasses and contact lenses are not adequate eye protection. c. A single pair of disposable patient examination gloves. Gloves should be changed if they tear or become heavily contaminated. d. An isolation gown. If there are shortages of gowns, they should be prioritized for aerosol- generating procedures, and high-contact patient care activities that allow transfer of pathogens (e.g. moving the patient to the stretcher). 2. If providing patient care, drivers should wear all recommended PPE. After completing patient care and before entering an isolated driver’s compartment, drivers should remove and dispose of PPE and perform hand hygiene to avoid soiling the compartment. If the transport vehicle does not have an isolated driver’s compartment, drivers should remove face shields or goggles, gowns and gloves, and perform hand hygiene. A respirator or facemask should continue to be used during transport. 3. On arrival, after the patient is released to the accepting facility, EMS personnel should remove and discard PPE and perform hand hygiene. Used PPE should be discarded in accordance with routine procedures.

EMS Transport of PUIs or Patients with Confirmed COVID-19 to a Healthcare Facility. 1. A facemask should be worn by the patient for source control. 2. EMS personnel should notify the receiving healthcare facility when patient has an exposure history, signs or symptoms suggestive of COVID-19 so appropriate infection control precautions are taken before arrival. 3. Family members and other contacts of patients with possible COVID-19 should not ride in the transport vehicle, if possible. If riding in the transport vehicle, they should wear a facemask. When possible, use vehicles that have isolated driver and patient compartments to provide separate ventilation to each area. e. Close the door/window between these compartments before bringing the patient on board. f. During transport, vehicle ventilation in both compartments should be on non-recirculated mode to maximize air changes that reduce potentially infectious particles in the vehicle. g. If the vehicle is without an isolated driver compartment and ventilation must be used, open the outside air vents in the driver area and turn on the rear exhaust ventilation fans to the highest setting. This will create a negative pressure gradient in the patient compartment. 4. Follow facility procedures for transfer of the patient (e.g. wheel the patient directly into an exam room).

EMS Transport in Resource-Limited Environments. 1. During the pandemic, MTFs and civilian EMS services may become inundated with critically ill patients, exceeding MTF treatment and transport capabilities. It is strongly recommended that EMS Medical Directors partner with MTF leadership to discuss disaster response contingency plans relating to inter-facility transports. Nationally Registered Paramedics (NRPs), with approval and guidance from local EMS Medical Directors, are Guideline Only/Not a Substitute for Clinical Judgment 52

Clinical Management of COVID-19 authorized to transport critically ill patients via ambulance. The following are ambulance staffing recommendations to be utilized according to staffing capabilities and patient acuity:

GOOD

If the patient: Crew (in addition to the EMT/NRP driver): is not ventilated and has no more than two intravenous Paramedic (IV) or intraosseous (IO) pump infused medications is not ventilated and has ≥3 IV/IO pump infused meds Paramedic AND Critical Care Registered Nurse (CCRN) OR Certified Emergency Nurse (CEN) is ventilated and has ≤2 IV/IO pump infused meds Paramedic x 2 OR Paramedic AND Respiratory Therapist (RT) is ventilated and has ≥3 IV/IO pump infused meds Paramedic x 2 AND CCRN OR CEN OR Paramedic, RT, AND CCRN OR CEN is ventilated and has three or more IV/IO pump infused If NRPs are unavailable, consider utilizing MTF CCAT Teams OR hybrid transport medications teams consisting of a CCRN, Critical Care Technician and a RT. All patient transports should have 2 EMTs on board to assist with ambulance operations.

BETTER

If the patient: Crew (in addition to the EMT/NRP driver): References: ventilated with IV/IO infusion NRP trained in ventilator management ALS standards Commission on Accreditation of medication, but no central Medical Transport Systems (CAMTS) 11th Edition lines or arterial lines ABG should be obtained within 30 minutes of https://www.camts.org/standards/ transport. If time allows, patient should be placed on transport ventilator for at least 15 minutes prior to https://jts.amedd.army.mil/assets/docs/cpgs/Prehospit transport. al_En_Route_CPGs/Standard_Medical_Operating_Guid elines_(SMOG)_for_Critical_Care_Flight_Paramedics_20 20.pdf Procedure A-XII is ventilated with central line, At least 2 providers trained at the NRP level or above Emergency Critical Care standards CAMTS 11th or arterial line, or chest tube (physician (MD/DO), physician’s assistant (PA), nurse Edition practitioner (NP), or registered nurse (RN)) https://www.camts.org/standards/

Primary care provider requirement: > 3 years ED, ICU, or critical care experience.

Above criteria AND Above requirements AND 1 crew member must be an Intensive Care Standards CAMTS 11th Edition complex ventilator settings OR RN with Certified Flight RN, Critical Care RN, or https://www.camts.org/standards/ > 4 IV/IO infusions Certified Transport Registered Nurse within 2 years of hire, or equivalent national certification. Para 1.2.3 Critical Care Transport Team Association of Critical Care Transport-Critical Care At least 1 critical care transport provider shall be Transport Standards-Version 1.0 ©2016 (AACT is licensed as a MD/DO, PA, APRN, or RN with a professional organization recommendation but documented competency and experience in the not a certifying organization.) provision of critical care in a tertiary critical care unit, commensurate with the type and acuity of patient requiring transport.

BEST If the patient: Crew (in addition to the driver): requires critical care Military or civilian trained and equipped critical care transport crew (Ground, Rotary, or Fixed Wing)

2. Additional considerations for interfacility transport include: a. On-line Medical Control. On-line Medical Control must be available for the transport of critically ill patients. b. Training. Personnel involved in interfacility transports should be trained on ambulances, facility transport ventilators, infusion pumps and all required equipment. Additionally, NRPs with critical care training: Critical Care Paramedic Program (CCEMT-P), Certified Critical Care Paramedics (C-CCPs), Certified Flight Guideline Only/Not a Substitute for Clinical Judgment 53

Clinical Management of COVID-19 Paramedics (FP-Cs), or individuals with previous critical care experience should be tasked as primary transport personnel given their increased education/experience. c. Ventilators. NRPs and RNs should be deemed proficient in ventilator operation and management by the local EMS Medical Director prior to performing patient transport. Ventilated patients should be transported with physician documented orders which detail ventilator settings. All patients will be monitored with wave-form capnography. If a BVM is utilized for transport, or if use of the BVM becomes necessary during transport, a positive-end expiratory pressure (PEEP) valve must be applied and dialed to the ventilator PEEP setting. Ventilators and BVMs should be equipped with HEPA filters. d. Intravenous/intraosseous Infusions. Many pre-hospital NRP infusions are currently delivered without the use of an infusion pump (epinephrine, norepinephrine, dopamine, amiodarone, and magnesium sulfate), however any infusion for an interfacility transfer should be on an infusion pump. Medications not detailed in the formulary outlined by EMS protocols are authorized with a written physician order. Orders should specify the name of the medication, the drug concentration, and the infusion rate. Infusions must be initiated by the sending facility. Infusions will be maintained at the physician-prescribed dosing regimen. Alterations to dosing regimens require authorization from a physician, preferably, On-line Medical Control. Rapid deterioration in patient clinical status negates the requirement for physician authorization (e.g. vasopressor titration). e. Prior to placing a transport request, MTF in-patient units should communicate with local EMS Medical Directors or attending Emergency Department physicians to determine transport capabilities. If possible, patient documentation (to include compact discs containing images) should be prepared prior to transport crew arrival. 3. Prior to placing a transport request, MTF in-patient units should communicate with local EMS Medical Directors or attending Emergency Department physicians to determine transport capabilities. If possible, patient documentation (to include compact discs containing images) should be prepared prior to transport crew arrival. 4. If trained healthcare personnel are severely limited, local Medical Directors should partner with MTF and Logistics leadership to discuss the use of licensed drivers/ government owned vehicles to transport of low acuity patients.

EMS Personnel Precautions for Procedures. 1. Prior to the initiation of any patient care, all crew members must don appropriate PPE as outlined above. 2. If a nasal cannula is in place, or will be used, the surgical mask should be placed over the top of the nasal cannula. An oxygen mask can be used on the patient if clinically indicated. 3. If patient presentation allows, EMS personnel providing care to a patient suspected of having COVID-19 should contact Medical Director before initiating an aerosol-generating procedure. These aerosolized procedures include: a. Bag Valve Mask (BVM) Ventilations b. Endotracheal (ET) Intubation/Supraglottic Airway (SGA) c. Oropharyngeal Suctioning d. Continuous Positive Airway Pressure Ventilations (CPAP) e. Cardiopulmonary Resuscitation (CPR) 4. Nebulized medications for known or suspected COVID-19 patients should be withheld given the risk of virus transmission. It is recommended that local Medical Directors work with MTF leadership to obtain single-use albuterol metered-dose inhalers with spacers for prehospital use. If an aerosol-generating procedure is required/recommended, the doors to the patient compartment of the ambulance should remain open to allow ventilation of the area during these procedures. If the ambulance is equipped with an HVAC system it should remain on during patient transport. 5. If used, BVMs, SGAs, and ET tubes should have a HEPA filter attached. If the EMS agency has access to ventilators, units should contact the specific ventilator manufacturer for additional guidelines and to obtain part numbers for compatible HEPA filters.

Guideline Only/Not a Substitute for Clinical Judgment 54 Clinical Management of COVID-19 Mechanical CPR. 1. While mechanical CPR devices have not been approved for routine use in the USAF; the American College of Cardiology’s recommendation to use mechanical CPR devices on PUIs or patients with confirmed COVID-19 who arrest (https://www.acc.org/latest-in-cardiology/articles/2020/03/19/13/14/cvd-in-the- setting-of-covid-19-coronavirus-considerations-to-prepare-patients-providers-health-systems). 2. Local Medical Directors & EMS/Fire Leadership are responsible for ensuring personnel education of device indications/contraindications, application, and cleaning, which should be documented in training records. 3. Devices should be cleaned according to CDC recommendations for known or suspected COVID-19 patients. 4. Contact the device manufacturer for additional recommendations. Cleaning EMS Transport Vehicles After Transporting a PUI or Patient with Confirmed COVID-19. 1. After transporting the patient, leave the rear doors of the transport vehicle open to allow for sufficient air changes to remove potentially infectious particles. The time to complete transfer of the patient to the receiving facility and complete all documentation should suffice. 2. When cleaning the vehicle, EMS clinicians should wear a disposable gown and gloves. A face shield or facemask and goggles should be worn if splashes or sprays during cleaning are anticipated. 3. Clean and disinfect reusable patient-care equipment before reuse according to manufacturer’s instructions. 4. Routine cleaning and disinfection procedures (e.g. use of cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant for emerging viral pathogens) are appropriate. 5. Ensure disinfection procedures are followed consistently, to include the provision of adequate ventilation when chemicals are in use. Doors should remain open when cleaning the vehicle. Follow-up for EMS Personnel after Caring for a PUI or Patient with Confirmed COVID-19. 1. Local public health and infectious disease authorities should be notified about the patient so that appropriate follow-up monitoring can occur. 2. EMS personnel who have been exposed to a patient with suspected or confirmed COVID-19 should notify their chain of command to ensure appropriate follow-up. 3. EMS agencies should develop local policies for assessing exposure risk and the management of EMS personnel potentially exposed to COVID-19. Decisions for monitoring and quarantine should be made in consultation with public health and infectious disease authorities. 4. EMS personnel should be alert for fever or respiratory symptoms (e.g. cough, shortness of breath, sore throat). If symptoms develop, it is recommended that they self-isolate and notify their public health authority to arrange for evaluation.

EN ROUTE CRITICAL CARE CONSIDERATIONS FOR PERSONS WITH COVID-19

1. Per TRANSCOM Instruction 41-02, patients with known or suspected exposure to, or an active infection with, a CDC defined High Consequence Infectious Disease or novel or CDC “Category A” disease shall be treated in place unless an exception to policy (ETP) is granted. Relevant authorities that must concur with or approve the ETP are detailed in the TRANSCOM instruction. “Treat in place” is the plan unless otherwise directed. 2. Current CDC guidance for transport is largely based on SARS and MERS and is not yet reflective of the evolving information on COVID-19.(172) While CDC guidance does not advocate for use of biocontainment units for patients, the CDC’s recommendation for airborne precautions and selection of aircraft with optimal airflow characteristics to reduce risk to aircrew/front end is challenging in airframes used for AE/CCATT transport. After review of published airflow characteristics for the C-130, C-17, KC-135 and KC- 10, CDC and National Strategic Research Institute aerosol scientists recommended against transporting symptomatic patients in an open aircraft. Therefore, AMC recommended to TRANSCOM that any mission generated to transport COVID-19 patients on DoD aircraft use biocontainment, except as a last resort. 3. If an ETP is granted for patient movement, contract civilian air ambulance such as Phoenix Air Group is the

Guideline Only/Not a Substitute for Clinical Judgment 55 Clinical Management of COVID-19 first choice. They have access to single patient units and also operate the State Department’s Portable Bio- Containment Modules (PBCM, formerly known as the CBCS). DoD owns and operates Transport Isolation Units (TIS) for biocontainment. Both the TIS and the PBCM are multi-place units capable of transporting up to 4 litter patients. The PBCM has better engineering controls to manage airborne transmissible pathogens and would be preferred for patient transport. In either case, patients should be moved in biocontainment transport units with specially trained AE and CCAT teams rather than using usual AE mechanisms. 4. Patients with known or suspected exposure to, or an active infection with a pathogen that is not a novel or CDC “Category A” disease may be transported within the PM system, utilizing standard transmission-based precautions in accordance with AFI 48-307, Vol.1, En-Route Care and Aeromedical Evacuation Operations. Movement should be requested when it is essential to provide appropriate care, while seeking to minimize opportunities for transmission of pathogens within and between theaters and countries.

WHOLE OF GOVERNMENT RESPONSE IN COORDINATION OF RESOURCES

On 13 Mar 2020, President Trump declared a nationwide emergency under Sec. 501(b) of the Stafford Act, increasing support to HHS in this role as the lead federal agency for the federal government’s response to the COVID-19 pandemic. Under this declaration, FEMA, in coordination with HHS, was empowered to assist state, local, tribal, territorial governments and other eligible entities to access resources made available through the Stafford Act.

HHS has many resources to leverage in the federal response to COVID-19, including the Strategic National Stockpile (SNS). The SNS has ventilators, medications, personal protective equipment and other important equipment and supplies that may be requested for COVID-19 response where state and local resources are overwhelmed or anticipated to be overwhelmed. SNS depots are located around the country by region. There is a Defense Coordinator at regional FEMA offices to coordinate requests to/from civilian and military hospitals and other entities for resources. MTFs can identify anticipated shortages and push a request through their local unit Crisis Action Team to the Regional FEMA Defense Coordinator for items in the SNS. It is recommended that facilities leverage available resources before running out of critical items such as PPE.

HHS link to Resources: https://www.phe.gov/emergency/Tools/Pages/default.aspx HHS Regional Emergency Coordinators Contact List: https://www.phe.gov/Preparedness/responders/rec/Pages/default.aspx State FEMA Office contacts: https://www.fema.gov/emergency-management-agencies

OTHER CONSIDERATIONS RELATED TO COVID-19

Facilities. Medical Heating, Ventilation and Air Conditioning (HVAC) Systems. 1. DHA Facilities Enterprise recommends maintaining building ventilation systems in balance and compliant. Attempts to adjust without professional mechanical engineering support may cause harm and rework later. 2. Medical facilities (hospitals/clinics) or administrative facilities are recommended not to alter the HVAC system operations or filtration in any way due to the outbreak of COVID-19. 3. Building maintenance personnel should not be exposed to COVID-19 unless they are physically in the same room as an infected person or come in contact with surfaces that have not been disinfected ( such as air filters). No special COVID-19 PPE is required for maintenance personnel unless they are charged with disinfecting surfaces or working where infected persons may have deposited live virus. In those cases, the maintenance personnel should follow CDC guidelines. 4. Although it is not known exactly how long the virus can survive on a surface outside the human carrier, some reports suggest up to 4 days on some materials. 5. If a maintenance worker becomes infected with COVID-19, it is recommend to clean all surfaces the worker may have been in contact with for the past 7 days. A review of all work orders completed by the infected maintenance staff will aid in discovering where and when the employee contacted other surfaces. 6. Altering HVAC systems should not reduce the spread of the virus. DHA Facilities Enterprise does NOT recommend increasing filter media MERV rated filters to HEPA nor installing UV if it is being done purely in Guideline Only/Not a Substitute for Clinical Judgment 56

Clinical Management of COVID-19 hope of stopping the spread of COVID-19. MTFs should not add higher rated filters to existing HVAC systems without proper engineering management since the HVAC system may become imbalanced which could result in loss of isolation rooms. Care must to be taken not to exceed the design performance of the HVAC as it will likely reduce equipment life with little or no positive impact.

REFERENCES

1. TeamNCPERE. Vital surveillances: the epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) – China. China CDC Weekly. 2020;2(8):113-22. 2. Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H, et al. Clinical course and outcomes of critically ill patients with SARS- CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med. 2020. 3. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497-506. 4. Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020. 5. Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med. 2020. 6. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA. 2020. 7. Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020;395(10223):507-13. 8. Holshue ML, DeBolt C, Lindquist S, Lofy KH, Wiesman J, Bruce H, et al. First Case of 2019 Novel Coronavirus in the United States. N Engl J Med. 2020;382(10):929-36. 9. Pan L, Mu M, Ren HG, Yang P, Sun Y, Wang R, et al. Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: a descriptive, cross-sectional, multicenter study. 2020. 10. American Academy of Otolaryngology-Head and Neck Surgery Coronavirus Disease 2019: Resources 2020 [Available from: https://www.entnet.org/content/coronavirus-disease-2019-resources. 11. Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia. N Engl J Med. 2020. 12. Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19): Center for Disease Control (CDC); 2020 [updated March 7, 2020. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html#foot09. 13. Breslin N, Baptiste C, Miller R, Fuchs K, Goffman D, Gyamfi-Bannerman C, et al. COVID-19 in pregnancy: early lessons. Am J Obstet Gynecol MFM. 2020:100111. 14. Chen H, Guo J, Wang C, Luo F, Yu X, Zhang W, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. Lancet. 2020;395(10226):809-15. 15. Di Mascio D, Khalil A, Saccone G, Rizzo G, Buca D, Liberati M, et al. Outcome of Coronavirus spectrum infections (SARS, MERS, COVID 1 -19) during pregnancy: a systematic review and meta-analysis. Am J Obstet Gynecol MFM. 2020:100107. 16. Mullins E, Evans D, Viner RM, O'Brien P, Morris E. Coronavirus in pregnancy and delivery: rapid review. Ultrasound in Obstetrics & Gynecology.n/a(n/a). 17. Kam KQ, Yung CF, Cui L, Lin Tzer Pin R, Mak TM, Maiwald M, et al. A Well Infant with Coronavirus Disease 2019 (COVID-19) with High Viral Load. Clin Infect Dis. 2020. 18. Cai J, Xu J, Lin D, Yang Z, Xu L, Qu Z, et al. A Case Series of children with 2019 novel coronavirus infection: clinical and epidemiological features. Clin Infect Dis. 2020. 19. Wei M, Yuan J, Liu Y, Fu T, Yu X, Zhang ZJ. Novel Coronavirus Infection in Hospitalized Infants Under 1 Year of Age in China. JAMA. 2020. 20. Cui Y, Tian M, Huang D, Wang X, Huang Y, Fan L, et al. A 55-Day-Old Female Infant infected with COVID 19: presenting with pneumonia, liver injury, and heart damage. J Infect Dis. 2020. 21. Dong Y, Mo X, Hu Y, Qi X, Jiang F, Jiang Z, et al. Epidemiological Characteristics of 2143 Pediatric Patients

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Clinical Management of COVID-19 84. Shi S, Qin M, Shen B, Cai Y, Liu T, Yang F, et al. Association of Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in Wuhan, China. JAMA Cardiology. 2020. 85. Clerkin KJ, Fried JA, Raikhelkar J, Sayer G, Griffin JM, Masoumi A, et al. Coronavirus Disease 2019 (COVID-19) and Cardiovascular Disease. Circulation.0(0). 86. Hu H, Ma F, Wei X, Fang Y. Coronavirus fulminantmyocarditis treated with glucocorticoid and human immunoglobulin. European Heart Journal. 2020. 87. Welt FGP, Shah PB, Aronow HD, Bortnick AE, Henry TD, Sherwood MW, et al. Catheterization Laboratory Considerations During the Coronavirus (COVID-19) Pandemic: From ACC’s Interventional Council and SCAI. Journal of the American College of Cardiology. 2020. 88. Zheng YY, Ma YT, Zhang JY, Xie X. COVID-19 and the cardiovascular system. Nat Rev Cardiol. 2020. 89. Arentz M, Yim E, Klaff L, Lokhandwala S, Riedo FX, Chong M, et al. Characteristics and Outcomes of 21 Critically Ill Patients With COVID-19 in Washington State. JAMA. 2020. 90. Cheng Y, Luo R, Wang K, Zhang M, Wang Z, Dong L, et al. Kidney disease is associated with in-hospital death of patients with COVID-19. Kidney International. 2020. 91. Kellum JA, Lameire N, Aspelin P, Barsoum RS, Burdmann EA, Goldstein SL, et al. Improving global outcomes (KDIGO) acute kidney injury work group. KDIGO clinical practice guideline for acute kidney injury. Kidney International Supplements. 2012;2:1-138. 92. Bergman P, Lindh AU, Bjorkhem-Bergman L, Lindh JD. Vitamin D and Respiratory Tract Infections: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. PLoS One. 2013;8(6):e65835. 93. Cannell JJ, Vieth R, Umhau JC, Holick MF, Grant WB, Madronich S, et al. Epidemic influenza and vitamin D. Epidemiol Infect. 2006;134(6):1129-40. 94. Holick MF. The vitamin D deficiency pandemic: Approaches for diagnosis, treatment and prevention. Rev Endocr Metab Disord. 2017;18(2):153-65. 95. Martineau AR, Jolliffe DA, Hooper RL, Greenberg L, Aloia JF, Bergman P, et al. Vitamin D supplementation to prevent acute respiratory tract infections: systematic review and meta-analysis of individual participant data. BMJ. 2017;356:i6583. 96. McCarthy MS, Elshaw EB, Szekely BM, Raju D. A Prospective Cohort Study of Vitamin D Supplementation in AD Soldiers: Preliminary Findings. Mil Med. 2019;184(Suppl 1):498-505. 97. Rondanelli M, Miccono A, Lamburghini S, Avanzato I, Riva A, Allegrini P, et al. Self-Care for Common Colds: The Pivotal Role of Vitamin D, Vitamin C, Zinc, and Echinacea in Three Main Immune Interactive Clusters (Physical Barriers, Innate and Adaptive Immunity) Involved during an Episode of Common Colds-Practical Advice on Dosages and on the Time to Take These Nutrients/Botanicals in order to Prevent or Treat Common Colds. Evid Based Complement Alternat Med. 2018;2018:5813095. 98. Dabbagh-Bazarbachi H, Clergeaud G, Quesada IM, Ortiz M, O'Sullivan CK, Fernandez-Larrea JB. Zinc ionophore activity of quercetin and epigallocatechin-gallate: from Hepa 1-6 cells to a liposome model. J Agric Food Chem. 2014;62(32):8085-93. 99. Prasad AS. Zinc is an Antioxidant and Anti-Inflammatory Agent: Its Role in Human Health. Front Nutr. 2014;1:14. 100. te Velthuis AJW, van den Worm SHE, Sims AC, Baric RS, Snijder EJ, van Hemert MJ. Zn2+ Inhibits Coronavirus and Arterivirus RNA Polymerase Activity In Vitro and Zinc Ionophores Block the Replication of These Viruses in Cell Culture. PLOS Pathogens. 2010;6(11):e1001176. 101. Xue J, Moyer A, Peng B, Wu J, Hannafon BN, Ding W-Q. Chloroquine Is a Zinc Ionophore. PLOS ONE. 2014;9(10):e109180. 102. Biesalski HK, Nohr D. Importance of vitamin-A for lung function and development. Mol Aspects Med. 2003;24(6):431-40. 103. Higdon J, Drake V, Angelo G, Delage B, Carr A, Michels A. Vitamin C. Linus Pauling Institute. Reviewed December 2018 [Available from: https://lpi.oregonstate.edu/mic/vitamins/vitamin-C

Clinical Management of COVID-19 106. Chebbo A, Tan S, Kassis C, Tamura L, Carlson RW. Maternal Sepsis and Septic Shock. Crit Care Clin. 2016;32(1):119-35. 107. Weiss SL, Peters MJ, Alhazzani W, Agus MSD, Flori HR, Inwald DP, et al. Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children. Pediatr Crit Care Med. 2020;21(2):e52-e106. 108. Comparison of Two Fluid-Management Strategies in Acute Lung Injury. New England Journal of Medicine. 2006;354(24):2564-75. 109. American College of Radiology (ACR) COVID-19 Clinical Resources for Radiologists, updated 27 March 2020 2020 [Available from: https://www.acr.org/Clinical-Resources/COVID-19-Radiology-Resources. 110. Society of Breast Imaging (SBI) statement on breast imaging during the COVID-19 pandemic, updated 26 March 2020 2020 [Available from: . https://www.sbi-online.org/Portals/0/Position%20Statements/2020/society-of- breast-imaging-statement-on-breast-imaging-during-COVID19-pandemic.pdf. 111. American Society of Breast Surgeons (ASBrS) and ACR joint statement on breast screening exams during the COVID-19 pandemic, updated 26 March 2020 2020 [Available from: https://www.breastsurgeons.org/docs/news/2020-03-26-ASBrS-ACR-Joint-Statement.pdf. 112. Mammography Quality Standards Act (MQSA) inspection information related to COVID-19, updated 27 March 2020 2020 [Available from: https://www.fda.gov/radiation-emitting-products/mammography-quality- standards-act-and-program/mqsa-inspection-information-related-covid-19. 113. Coronavirus (COVID-19) update: FDA focuses on safety of regulated products while scaling back domestic inspections, updated 18 March 2020 2020 [Available from: https://www.fda.gov/news-events/press- announcements/coronavirus-covid-19-update-fda-focuses-safety-regulated-products-while-scaling-back-domestic. 114. ACR recommendations for the use chest radiography and computed tomography (CT) for suspected COVID- 19 infection, updated 22 March 2020 2020 [Available from: https://www.acr.org/Advocacy-and-Economics/ACR- Position-Statements/Recommendations-for-Chest-Radiography-and-CT-for-Suspected-COVID19-Infection. 115. Mossa-Basha M, Meltzer CC, Kim DC, Tuite MJ, Kolli KP, Tan BS. Radiology Department Preparedness for COVID-19: Radiology Scientific Expert Panel. Radiology. 2020:200988. 116. Ai T, Yang Z, Hou H, Zhan C, Chen C, Lv W, et al. Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases. Radiology. 2020:200642. 117. Bai HX, Hsieh B, Xiong Z, Halsey K, Choi JW, Tran TML, et al. Performance of radiologists in differentiating COVID-19 from viral pneumonia on chest CT. Radiology. 2020:200823. 118. Xie X, Zhong Z, Zhao W, Zheng C, Wang F, Liu J. Chest CT for Typical 2019-nCoV Pneumonia: Relationship to Negative RT-PCR Testing. Radiology. 2020:200343. 119. Society of Interventional Radiology COVID-19 Planning, updated 23 March 2020 2020 [Available from: https://www.sirweb.org/practice-resources/toolkits/covid-19-toolkit/covid-19-planning/. 120. Wong HYF, Lam HYS, Fong AH-T, Leung ST, Chin TW-Y, Lo CSY, et al. Frequency and Distribution of Chest Radiographic Findings in COVID-19 Positive Patients. Radiology.0(0):201160. 121. Chung M, Bernheim A, Mei X, Zhang N, Huang M, Zeng X, et al. CT Imaging Features of 2019 Novel Coronavirus (2019-nCoV). Radiology. 2020;295(1):202-7. 122. Fang Y, Zhang H, Xu Y, Xie J, Pang P, Ji W. CT Manifestations of Two Cases of 2019 Novel Coronavirus (2019- nCoV) Pneumonia. Radiology. 2020;295(1):208-9. 123. Ng M-Y, Lee EY, Yang J, Yang F, Li X, Wang H, et al. Imaging Profile of the COVID-19 Infection: Radiologic Findings and Literature Review. Radiology: Cardiothoracic Imaging. 2020;2(1):e200034. 124. Song F, Shi N, Shan F, Zhang Z, Shen J, Lu H, et al. Emerging 2019 Novel Coronavirus (2019-nCoV) Pneumonia. Radiology. 2020;295(1):210-7. 125. Pan F, Ye T, Sun P, Gui S, Liang B, Li L, et al. Time Course of Lung Changes On Chest CT During Recovery From 2019 Novel Coronavirus (COVID-19) Pneumonia. Radiology. 2020:200370. 126. Wang Y, Dong C, Hu Y, Li C, Ren Q, Zhang X, et al. Temporal Changes of CT Findings in 90 Patients with COVID-19 Pneumonia: A Longitudinal Study. Radiology. 2020:200843. 127. Simpson S, Kay FU, Abbara S, Bhalla S, Chung JH, Chung M, et al. Radiological Society of North America Expert Consensus Statement on Reporting Chest CT Findings Related to COVID-19. Endorsed by the Society of Thoracic Radiology, the American College of Radiology, and RSNA. Radiology: Cardiothoracic Imaging. 2020;2(2):e200152. Guideline Only/Not a Substitute for Clinical Judgment 62

Clinical Management of COVID-19 128. National Academies of Sciences, Engineering, and Medicine. Integrating clinical research into epidemic response: The Ebola experience. Washington DC: The National Academies Press; 2017. 129. Lee N, Allen Chan KC, Hui DS, Ng EK, Wu A, Chiu RW, et al. Effects of early corticosteroid treatment on plasma SARS-associated Coronavirus RNA concentrations in adult patients. J Clin Virol. 2004;31(4):304-9. 130. Mo P, Xing Y, Xiao Y, Deng L, Zhao Q, Wang H, et al. Clinical characteristics of refractory COVID-19 pneumonia in Wuhan, China. Clin Infect Dis. 2020. 131. Mulangu S, Dodd LE, Davey RT, Jr., Tshiani Mbaya O, Proschan M, Mukadi D, et al. A Randomized, Controlled Trial of Ebola Virus Disease Therapeutics. N Engl J Med. 2019;381(24):2293-303. 132. de Wit E, Feldmann F, Cronin J, Jordan R, Okumura A, Thomas T, et al. Prophylactic and therapeutic remdesivir (GS-5734) treatment in the rhesus macaque model of MERS-CoV infection. Proceedings of the National Academy of Sciences. 2020:201922083. 133. Sheahan TP, Sims AC, Leist SR, Schafer A, Won J, Brown AJ, et al. Comparative therapeutic efficacy of remdesivir and combination lopinavir, ritonavir, and interferon beta against MERS-CoV. Nat Commun. 2020;11(1):222. 134. Wang M, Cao R, Zhang L, Yang X, Liu J, Xu M, et al. Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro. Cell Res. 2020;30(3):269-71. 135. Dong L, Hu S, Gao J. Discovering drugs to treat coronavirus disease 2019 (COVID-19). Drug Discov Ther. 2020;14(1):58-60. 136. Liu J, Cao R, Xu M, Wang X, Zhang H, Hu H, et al. Hydroxychloroquine, a less toxic derivative of chloroquine, is effective in inhibiting SARS-CoV-2 infection in vitro. Cell Discov. 2020;6:16. 137. Yao X, Ye F, Zhang M, Cui C, Huang B, Niu P, et al. In Vitro Antiviral Activity and Projection of Optimized Dosing Design of Hydroxychloroquine for the Treatment of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS- CoV-2). Clin Infect Dis. 2020. 138. De Lamballerie X, Boisson V, Reynier JC, Enault S, Charrel RN, Flahault A, et al. On chikungunya acute infection and chloroquine treatment. Vector Borne Zoonotic Dis. 2008;8(6):837-9. 139. Paton NI, Lee L, Xu Y, Ooi EE, Cheung YB, Archuleta S, et al. Chloroquine for influenza prevention: a randomised, double-blind, placebo controlled trial. Lancet Infect Dis. 2011;11(9):677-83. 140. Sperber K, Louie M, Kraus T, Proner J, Sapira E, Lin S, et al. Hydroxychloroquine treatment of patients with human immunodeficiency virus type 1. Clin Ther. 1995;17(4):622-36. 141. Tricou V, Minh NN, Van TP, Lee SJ, Farrar J, Wills B, et al. A randomized controlled trial of chloroquine for the treatment of dengue in Vietnamese adults. PLoS Negl Trop Dis. 2010;4(8):e785. 142. Roques P, Thiberville SD, Dupuis-Maguiraga L, Lum FM, Labadie K, Martinon F, et al. Paradoxical Effect of Chloroquine Treatment in Enhancing Chikungunya Virus Infection. Viruses. 2018;10(5). 143. Gautret P, Lagier J-C, Parola P, Hoang VT, Meddeb L, Mailhe M, et al. Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial. International Journal of Antimicrobial Agents. 2020. 144. Gao J, Tian Z, Yang X. Breakthrough: Chloroquine phosphate has shown apparent efficacy in treatment of COVID-19 associated pneumonia in clinical studies. Biosci Trends. 2020;14(1):72-3. 145. Cao B, Wang Y, Wen D, Liu W, Wang J, Fan G, et al. A Trial of Lopinavir-Ritonavir in Adults Hospitalized with Severe Covid-19. N Engl J Med. 2020. 146. Liu F, Xu A, Zhang Y, Xuan W, Yan T, Pan K, et al. Patients of COVID-19 may benefit from sustained lopinavir- combined regimen and the increase of eosinophil may predict the outcome of COVID-19 progression. Int J Infect Dis. 2020. 147. Yao TT, Qian JD, Zhu WY, Wang Y, Wang GQ. A systematic review of lopinavir therapy for SARS coronavirus and MERS coronavirus-A possible reference for coronavirus disease-19 treatment option. J Med Virol. 2020. 148. Xu X, Han M, Li T, Sun W, Wang D, Fu B, et al. Effective Treatment of Severe COVID-19 Patients with Tocilizumab. 2020. 149. Tiberghien P, de Lambalerie X, Morel P, Gallian P, Lacombe K, Yazdanpanah Y. Collecting and evaluating convalescent plasma for COVID-19 treatment: why and how. Vox Sang. 2020. 150. Shen C, Wang Z, Zhao F, Yang Y, Li J, Yuan J, et al. Treatment of 5 Critically Ill Patients With COVID-19 With Convalescent Plasma. JAMA. 2020. 151. Tanne JH. Covid-19: FDA approves use of convalescent plasma to treat critically ill patients. BMJ. Guideline Only/Not a Substitute for Clinical Judgment 63

Clinical Management of COVID-19 2020;368:m1256. 152. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19). 28 February 2020. 2020 [Available from: https://www.who.int/publications-detail/report-of-the-who-china-joint-mission-on-coronavirus- disease-2019-(covid-19). 153. Boelig RC, Manuck T, Oliver EA, Di Mascio D, Saccone G, Bellussi F, et al. Labor and Delivery Guidance for COVID-19. Am J Obstet Gynecol MFM. 2020:100110. 154. Rasmussen SA, Smulian JC, Lednicky JA, Wen TS, Jamieson DJ. Coronavirus Disease 2019 (COVID-19) and Pregnancy: What obstetricians need to know. Am J Obstet Gynecol. 2020. 155. ReproTox [Available from: www.reprotox.org. 156. Jeejeebhoy FM, Zelop CM, Lipman S, Carvalho B, Joglar J, Mhyre JM, et al. Cardiac Arrest in Pregnancy: A Scientific Statement From the American Heart Association. Circulation. 2015;132(18):1747-73. 157. Fan C, Lei D, Fang C, Li C, Wang M, Liu Y, et al. Perinatal Transmission of COVID-19 Associated SARS-CoV-2: Should We Worry? Clin Infect Dis. 2020. 158. Center for Disease Control and Prevention. Pregnancy & Breastfeeding: Information about Coronavirus Disease 2019 2020. 159. CDC. Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings 2020 [Available from: https://www.cdc.gov/coronavirus/2019- ncov/hcp/inpatient-obstetric-healthcare-guidance.html. 160. To KK, Tsang OT, Chik-Yan Yip C, Chan KH, Wu TC, Chan JMC, et al. Consistent detection of 2019 novel coronavirus in saliva. Clin Infect Dis. 2020. 161. Xu Y, Li X, Zhu B, Liang H, Fang C, Gong Y, et al. Characteristics of pediatric SARS-CoV-2 infection and potential evidence for persistent fecal viral shedding. Nature Medicine. 2020. 162. CDC. COVID-19 People Who Need Extra Precautions: Older Adults 2020 [updated 3/21/20. Available from: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older- adults.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fspecific- groups%2Fhigh-risk-complications%2Folder-adults.html. 163. D'Adamo H, Yoshikawa T, Ouslander JG. Coronavirus Disease 2019 in Geriatrics and Long-term Care: The ABCDs of COVID-19. J Am Geriatr Soc. 2020. 164. British Geriatric Society. BGS statement on the COVID-10 pandemic [Available from: https://www.bgs.org.uk/bgs-statement-on-the-covid-19-pandemic. 165. Han JH, Wilson A, Vasilevskis EE, Shintani A, Schnelle JF, Dittus RS, et al. Diagnosing delirium in older emergency department patients: validity and reliability of the delirium triage screen and the brief confusion assessment method. Ann Emerg Med. 2013;62(5):457-65. 166. Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990;113(12):941-8. 167. Lindroth H, Bratzke L, Purvis S, Brown R, Coburn M, Mrkobrada M, et al. Systematic review of prediction models for delirium in the older adult inpatient. BMJ Open. 2018;8(4):e019223. 168. Statement from the British Geriatrics Society. Managing delirium in confirmed and suspected cases [Available from: https://www.bgs.org.uk/resources/coronavirus-managing-delirium-in-confirmed-and-suspected- cases. 169. Hwang U, Malsch AJ, Biese KJ, Inouye SK. Preventing and Managing Delirium in Older Emergency Department Patients During the COVID-19 Pandemic. Journal of Geriatic Emergency Medicine. 2020;1(4):Supplement 1. 170. Neufeld KJ, Yue J, Robinson TN, Inouye SK, Needham DM. Antipsychotic Medication for Prevention and Treatment of Delirium in Hospitalized Adults: A Systematic Review and Meta-Analysis. J Am Geriatr Soc. 2016;64(4):705-14. 171. Farah A. Atypicality of atypical antipsychotics. Prim Care Companion J Clin Psychiatry. 2005;7(6):268-74. 172. CDC. Guidance on Air Medical Transport for SARS Patients [cited 2020. Available from: https://www.cdc.gov/sars/travel/airtransport.html.

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APPENDIX A : MASK GUIDANCE, PRECAUTIONS, & PPE VISUALS FOR USE DURING SHORT SUPPLIES

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Standard Precautions FOR THE CARE OF ALL PATIENTS Includes Blood, Body Fluids, Secretions, Excretions, and Contaminated Items

Wash hands BEFORE and AFTER patient care regardless of whether gloves are worn. - Wash hands immediately after gloves are removed and between patient contacts.

Wear gloves when touching blood, body fluids, secretions, excretions, and contaminated items. - Put on clean gloves just before touching mucous membranes and non-intact skin.

Wear mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and patient care activities that are likely to generate splashes or sprays of blood/body fluids.

Wear gown to protect skin and prevent soiling of clothing during procedures and patient care activities that are likely to generate splashes or sprays of blood & body fluids. Remove soiled gown as promptly as possible and wash hands.

Take care to prevent injuries when using needles, scalpels, and other sharp instruments or devices; when handling sharp instruments after procedures; when cleaning used instruments; and when disposing of used needles.

Use mouthpieces, resuscitation bags, or other ventilation devices as an alternative to mouth- to- mouth resuscitation.

Cover your cough and sneeze with tissues or cough and sneeze into your sleeve.

Avoid touching your face (eyes, nose and mouth) with unclean hands.

Clean and disinfect shared patient equipment.

Use aseptic technique.

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Clinical Management of COVID-19 PPE Visuals for Use During Supply Shortages The following visuals are provided by Emory University, and are available as printable PDFs at the following link: https://med.emory.edu/departments/medicine/divisions/infectious-diseases/serious- communicable-diseases-program/covid-19-resources/conserving-ppe.html

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APPENDIX B : EXAMPLE TRIAGE PROTOCOLS DURING COVID-19 PANDEMIC

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APPENDIX C : COVID-19 INTUBATION PRE-ENTRY CHECKLIST*

For Providers: To bring inside room:

Iside room Place a priority on rapid airway placement with video laryngoscopy (ie Glidescope) to create distance between operator and patient’s airway, avoidance of BVM and NIV due to risk of aerosolization:

☐Airway Supplies: o ETT (7, 7.5, 8 for adults, appropriate size for children) with syringe for cuff o Glidescope or C-MAC (facilitate intubation from a distance) o Appropriate stylet o Bougie o OG tube with syringe, lube and tape o OP/NP airway o Colorimetric end-tidal CO2 detector o Suction setup ☐Disposable stethoscope ☐Sani-wipes (should be located inside room)

Keep outside room (on standby):

☐Back up Airway Supplies: o Appropriate size laryngoscope blades (Mac 3 & 4 for adults) and handle (disposable preferred) o Stylet o BVM (avoid if possible due to risk of aerosolization of pathogen) ☐Airway cart (never bring in room) ☐EZ-IO

For Nursing: ☐RSI meds kit IV fluid ☐Restraints ☐Foley ☐ABG syringe ☐Post-intubation meds: o propofol o fentanyl o phenylephrine o norepinephrine drip

For Respiratory Therapy: ☐Ventilator with appropriate filters ☐ET securing device ☐Waveform capnography adapter ☐Viral filter for Ambubag

*Adapted from University of Washington (https://covid-19.uwmedicine.org/)

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APPENDIX D : COVID-19 INTUBATION PROTOCOL

•Evaluate airway to ensure normal airway anatomy •Determine whether direct laryngoscope or video laryngoscope will be the fastest method (both should be available); Sufficient muscle relaxant should be used to abolish cough reflexes •Determine intubation medications (Recommend: Ketamine 2mg/kg; Rocuronium* 1 mg/kg) *Succinylcholine 1 mg/kg Plan may also be used provided no contraindications (e.g. hyperkalemia)

•Optimize patient position in the "sniffing" position •Optimize bed height •For obese patients, the "ramped" position should be used Position

•100% FiO2 for 5 minutes (avoid BiPAP or bagging if possible) •If possible, use nasal cannula covered by filtered BiPAP mask without insufflating the BVM •Alternative Pre-Ox: Jackson-Reese bag with viral filter; NRB over mask; NC.HFNC under mask; BVM with viral filter/PEEP valve Pre - •Prepare BVM and airway with a high-efficiency particulate air (HEPA) filter placed between the mask and the breathing circuit or the respiratory bag, and one at the expiratory end of the breathing circuit Oxygenate

•IV/IO access patent •Full cardiorespiratory monitors in place •Pulse oximeter and BP cuff on opposite arms •Equipment available and working (Suction, Airway and adjuncts, Back-up Plan - include cricothyroidotomy kit) Prepare •Prepare for cardiovascular instability during intubation (availability of IVF bolus & pressors, e.g. Phenylephrine)

•Push intubation meds AFTER physician to nurse order and nurse reply •Avoid BVM, but if neccessary, bag with low tidal volume/high frequency to maintain oxygenation & reduce exposure • If difficult intubation is encountered, use external laryngeal manipulation or bougie to improve chance of success Paralyze •If tracheal intubation fails, place a 2nd generation laryngeal mask and attempt fiberoptic bronchoscope

•Inflate cuff prior to first breath and then Secure tube •Confirm proper tube position (direct visualization, continuous waveform capnography, CXR) •Collect all airway devices in a double-sealed bag and implement proper disinfection during disposal Post- •Ongoing sedation Intubation •VAP prevention: HOB elevated, oral swab, cuff pressures 20-30, NG/OG

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APPENDIX E : COVID-19 COGNITIVE AIDS FOR INTUBATION

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pressure

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APPENDIX F : ADULT PRONE POSITIONING PROTOCOL EXAMPLE*

*Adapted from University Medical Center (Las Vegas, NV)

Procedure for patient preparation prior to proning: 1. Obtain an order from the Fellow or Attending physician to place patient in the prone position. The order should include: a. Proper sedation/pain medications and paralytic agents if necessary. b. Length of time for each pronation cycle (patient should be in prone position a minimum of 16 hours, with a return to the supine position at least once a day). c. Prone positioning should be performed within the first 24 hours of the diagnosis of severe hypoxemia. 2. Explain proning procedure and benefits to patient and family members when present. 3. Prior to proning patient, make sure the following criteria have been met and necessary equipment is made available: a. Patient is mechanically ventilated via a secured endotracheal tube (ETT) with inline suction. b. RT is at bedside to evaluate securement of ETT with commercial tape and to place bite block as needed. Twill may be used in addition to the tape if additional securement is needed. Do not secure ETT with a commercial securement device (i.e. Hollister). c. Confirm patient intravenous access including central and arterial lines; verify lines are secure in place. d. Remove ECG leads from anterior of torso; obtain new leads to place posteriorly once patient is prone. Electrocardiogram leads can be placed in the lateral limb position (left and right deltoid midaxillary line and left and right 12th intercostal space at the midaxillary line). The virtual lead (V1 or chest lead) can be placed on the dorsal surface. e. Consider adhesive foam pads (i.e. Mepilex) to apply to boney prominences such as forehead, bilateral shoulders, chest, iliac crests and knees to prevent pressure ulcers. f. Obtain positioning pillows, blanket rolls or foam prone positioning kit from materials management or supply room. g. Continuous SpO2 monitoring. h. Foley catheter and oral gastric tube secured in place. i. Use fecal management system if needed. j. It is reasonable to provide enteral feedings while patient is in prone position. Elevation of head of bed in reverse Trendelenburg position helps reduce the risk of gastric aspiration. Post pyloric tubes are preferred. k. Lubricate patient’s eyes prior to proning, then every six hours and as needed (Provider order needed). l. Assess and document pain and provide adequate sedation and pain management throughout the procedure. m. Patients may also require neuromuscular blocking agent during proning. n. Remove head board and ensure bed brake is on. o. RT will perform and document a complete vent check including auscultation of bilateral lung sounds, ventilator settings, ETT positioning/depth, patient tidal volumes and ETT cuff pressures pre and post turn.

Procedure of manual pronation: 1. Assemble a minimum of a 5-person team consisting of at least on RT and the patient’s RN. RT is to manage airway protection at the head of the bed and the other team members are positioned on either side of the bed to manually prone the patient. A fellow or attending physician should be present for the first turn. 2. Correctly position all tubes, taking into account the direction of the turn. 3. Lines inserted in the upper torso are aligned with either shoulder, exception is chest tubes or large bore tubes. 4. Tubes in the lower torso are aligned with either leg and extended off the bed. 5. Always initially turn the patient in the direction of the ventilator.

Procedure for proper patient positioning (see diagram below): 1. Head and Neck positioning:

Place patient’s head on a foam head positioner, which allows for the patient’s head in a neutral position. Otherwise, support the patient’s head in a rotated position paying attention to avoid pressure to the eyes and ears. Provide range of motion to the patient’s head at least every hour, maintaining ETT tube alignment. Reposition head every two hours, head should be turned to the up are while in swimmer’s pose, to avoid traction on the brachial plexus. Coordinate with RT to be present to maintain the airway while repositioning the head every two hours. This may

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Clinical Management of COVID-19 require positioning the ventilator at the head of the bed rather than on one side of the bed to allow for the head reposition. Raise the head enough to provide for proper spinal alignment: avoid hyperextension or flexion of the cervical spine. Ensure the eyes have no pressure on the orbits and ears are properly aligned, flat and not folded.

2. Arm positioning:

If using foam prone positioning kit, place patient’s arms in foam positioners. While the patient is in a side lying position, gently position the arms in a swimmer’s pose. The simmers pose entails the up are is in a supported, flexed position at the level of the shoulder and the down arm is parallel to the body in a position of comfort. When the arm is in the up position, keep the shoulder in a neutral position, abducted to 90 degrees and the elbow flexed at 90 degrees. Utilize pillows or blanket rolls to prevent hyperextension of the shoulder and to ensure the weight of the arm is supported. Note: Head position should be turned to the up arm while in swimmer’s pose, to avoid traction on the brachial plexus.

a. Alternate the arm and head position every two hours with the patient in a side lying position and provide passive range of motion exercise to all joints of the upper and lower extremities.

3. Patient positioning: a. Manually reposition the patient a minimum of every 2 hours with a slight right lateral-pillow support position (20-30°) to prone (flat) to a slight left lateral-pillow supported position (20-30°) and back to prone position. The use of automatic bed rotation is not a replacement for manual repositioning.

Note: When placing the patient in the lateral-pillow support position, coordinate head and arm in the up position toward the tilted side (Do not use foam wedges for lateral turns).

b. During lateral turns inspect the skin and positioning of the tubes, lines and catheters (tubing and penis) and reposition accordingly, i.e. Foley catheters, chest tubes, IV lines, etc.

4. Leg positioning:

While in prone and/or lateral prone position float the knees with a pillow (be careful not to cause hyperextension of the hip), and place a foam roller, pillow or blanket roll under the ankle area to elevate the toes and prevent tension on the tendons in the foot and ankle region.

5. Tilt the patient into reverse Trendelenburg:

Goal is 30 degrees, as patient tolerates.

6. Alternative position of the arms for comfort or if swimmer’s position is contraindicated.

For example, the patient, family or PT/OT one-time evaluation report history of rotator cuff tear, stroke, nerve damage, osteoarthritis of shoulder complex, history of clavicle fracture, hyper flexible joints.

a. Arms can be left in the side lying position aligned with the body and repositioned ever two hours to a slightly abducted positon.

Patient monitoring and care: 1. Time patient is prone/supine:

a. It is recommended in the literature that patient is placed in the prone position for a minimum of 16 hours. The timing for prone cycling requires a physician order and is always situational. Patients should be returned to supine position for up to four hours, once per day preferably early AM to allow the interdisciplinary team time to assess while in supine position. While in supine position, reassessment of oxygenation, skin assessment and other relevant exam elements should occur. If the patient does not tolerate being supine (i.e. requiring increased ventilator settings, decreasing PaO2/FiO2 ration, hemodynamically unstable or decreasing SpO2/PaO2) return patient to the prone position. b. Patients in prone position should receive the same standard of care as a patient that is supine (i.e. oral Guideline Only/Not a Substitute for Clinical Judgment 82

Clinical Management of COVID-19 care, urinary catheter care, skin care, eye care, suctioning, etc.). c. Discuss supine position tolerance and PaO2/FiO2 ratio in bedside report and during interdisciplinary rounds. d. Ongoing assessment of how the patient is tolerating prone therapy and repositioning; documentation of all vital signs, capnography, patient and family education, length of time prone, patient’s response to turning supine, any adverse events that occur and changes in the patient’s condition. e. Primary RN will coordinate with RT to re-secure ETT when the patient is supine and assist with turns, checking cuff pressures and tube placement before and after repositioning the patient; coordinate with radiology for chest x-ray when supine. f. Monitor all tubes, lines, drains and catheters throughout the repositioning process and continue airway management, suctioning oral and ETT secretions. g. Continue to evaluate enteral nutrition tolerance and maintain reverse Trendelenburg to help prevent ventilator associated pneumonia (VAP). h. RT to change ETT tape at least once a day or more frequently if necessary due to facial swelling. i. PaO2/FiO2 ratios should be calculated every day and when ventilator settings have been changed in order to identify candidates for returning to the supine position early.

Consider discontinuation of the prone position if: 1. The patient no longer shows a positive response to the position change or mechanical ventilation support has been optimized. 2. The patient’s PaO2/FiO2 ratio is >200 on less than 50% FiO2 and PEEP ≤10 cm of water.

Complications related to prone positioning: 1. Unplanned extubation a. Lines pulled b. Tubes kinked c. Hemodynamic instability d. Facial edema e. Pressure ulcers f. Aspiration g. Corneal abrasions

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APPENDIX G : TRANSPORT VENTILATOR SET UP GUIDE

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APPENDIX H : SAMPLE PROTOCOLS FOR VARIOUS ICU MANAGEMENT

Intubation Mechanical Ventilation

COVID Proning

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APPENDIX I : ENTERAL NUTRITION CARE PATHWAY FOR PATIENTS WITH COVID-19

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APPENDIX J : DHA QUICK REFERENCE GUIDE TO VIRTUAL HEALTH AND TELEPHONE ENCOUNTERS

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APPENDIX K : LIST OF CONTRIBUTORS

Contributors t Col Renée I. Matos, MC, USAF CDR Joseph Kotora, MC, USN COL Kevin K. Chung, MC, USA CAPT Mark G. Lieb Lt Col Wesley M. Abadie, MC, USAF CAPT Robert Liotta, MC, USN Maj David M. Anderson, MC, USAF Maj David A. Lindholm, MC, USAF Col Michelle K. Anton, MC, USAF COL Frederick Lough, MC, USA Maj Bracken Armstrong, MC, USAF CDR Monica A. Lutgendorf, MC, USN COL David M. Benedek, MC, USA LCDR Donovan L Mabe, MC, USN CDR John Benjamin, MC, USN CDR Frank Margaron, MC, USN LTC Matthew A. Borgman, MC, USA Col Leslie Matesick, MC, USAF Maj Sarah Bowe, MC, USAF CAPT Ryan C. Maves, MC, USN Lt Col Saunya N. Bright, BSC, USAF CDR Sean Mckay, MC, USN Laura R. Brosch, RN, PhD Maj Krista Mehlhaff, MC, USAF Robert F. Browning, MD Maj Eric Meyer, MC, USAF COL Jessica L. Bunin, MC, USA COL Stephanie Meyer, USA CAPT Timothy H. Burgess, MC, USN CDR Kelly Mokay, USN Maj Denise Campbell, USAF CAPT Joshua C. Morganstein, USPHS LTC Vincent Capaldi, MC, USA COL Clinton K. Murray, MC, USA Col Francis R. Carandang, MC, USAF Lt Col Jason F. Okulicz, MC, USAF Julia Christopher, DO COL Neil Page, MC, USA LTC Jacob Collen, MC, USA COL Jeremy C. Pamplin, MC, USA LTC Christopher Colombo, MC, USA LTC P. Gabriel Peterson, MC, USA Ms. Polyxeni Combs, MS LTC Wylan C. Peterson, MC, USA Helen Crouch, MPH, CIC, FAPIC Ms. Rhonda Podojil CAPT Konrad L. Davis, MC, USN Mr. Joseph Procaccino, JD, MFS LTC Sally DelVecchio, MC, USA Lt Col Jamie Rand, MC, USAF COL Sean N. Dooley, MC, USA MAJ Tyler Reese, MC, USA COL Jeremy Edwards, MC, USA CAPT Robert Ricca, MC, USN CAPT Eric Elster, MC, USN Daniel J. Ross, MD, DDS MAJ Emilio Fentanes, MC, USA Col James B. Sampson, MC, USAF CDR Jamie Fitch, MC, USN LCDR David C. Shih, MC, USN Ms. Sarah Flash Bich-Thuy T. Sim, MD LTC Shannon C. Ford, MC, USA Maj Erica Simon, MC, USAF MAJ Brian Foster, MC, USA COL William Smith, MC, USA Lt Col Brian J. Gavitt, MC, USAF LCDR Scott Snyder, MC, USN Dr. James Giordano, PhD Col Barton C. Staat, MC, USAF Mr. Joshua Girton, JD, LLM, MBA CPT Bryan Stepanenko, MC, USA Mark Haigney, MD Lt Col Ian Stewart, MC, USAF LTC Mitchell Hamele, MC, USA Mr. Randy W. Stone, JD COL Bonnie H. Hartstein, MC, USA Maj Mary Stuever, MC, USAF Maj Alison Helfrich, MC, USAF Col Deena E. Sutter, MC, USAF COL Brian A. Hemann, MC, USA COL Timothy L. Switaj, MC, USA Maj Minette Herrick, USAF Lt Col Bryan D. Szalwinski, MC, USAF Mrs. Jennifer Hesch, JD MAJ Matthew Timlin, MC, USA COL Patrick Hickey, MC, USA Mary C. Vance, MD, MSc Mr. Roy Hirchak Maj Robert Walter, MC, USAF Vincent B. Ho, MD, MBA CDR Lauren A. Weber, MC, USN Col David Hsieh, MC, USAF James C. West, MD CDR Ashley E. Humphries, MC, USN Mr. Bryan T. Wheeler, JD Maj John Hunninghake, MC, USAF Col James Frederick Wiedenhoefer, MC, USAF MAJ Nikhil A. Huprikar, MC, USA Alison C. Wiesenthal, MD Col (Ret) Mylene T. Huynh, MD, MPH Col Leslie Wood, MC, USAF CAPT Elliot Jessie, MC, USN COL Gary H. Wynn, MC, USA COL Matthew R. Jezior, MC, USA Col Heather Yun, MC, USAF CDR Michael J. Kavanaugh, MC, USN CAPT Luke Zabrocki, MC, USN Lt Col Jeremy Kilburn, MC, USAF Mr. Michael J. Zleit, JD Thomas D. Kirsch, MD, MPH

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Guideline Only/Not a Substitute for Clinical Judgment 91 DEPARTMENT OF DEFENSE UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814-4799

DMEC Bioethics Case File

Department of Defense Medical Ethics Center (DMEC) COVID-19 Pandemic - Bioethics Guidance

Date:

20 April 2020 (Version 4)

Working Group Members:

COL Frederick Lough, MC, USA, MD, FACS CAPT Ryan C. Maves, MC, USN, MD, FCCP, FCCM, FIDSA COL Jeremy V. Edwards, MC, USA, DO, HEC-C, FAAP LTC Vincent F. Capaldi, II, MC, USA, ScM, MD, FAPA, FACP Prof. James Giordano, PhD, MPhil Mr. Joseph Procaccino, Jr., JD, MFS Ms. Polyxeni Combs, MS Mr. Joshua Girton, JD, LLM, MBA

Issue:

What ethical guidelines should be used by the health care professionals at Defense Health Agency (DHA) Military Treatment Facilities (MTFs) in the Triage and Treatment of patients with COVID-19?

Recommendations:

Situation:

The COVID-19 pandemic outbreak is a global phenomenon that has impacted all countries and citizens, while straining public health systems to an unprecedented level in recent times. In the next few weeks, it is possible that health care professionals at MTFs could face major ethical challenges in dealing with the COVID-19 pandemic. It is the DMEC’s position, that the number and complexity of the ethical questions will be greatly reduced if the MTFs are adequately prepared for the forthcoming COVID-19 crisis. The following are suggested approaches to be adopted by the staff at MTFs to prepare for this eventuality. This document is not to be interpreted as mandatory Department of Defense (DoD)/Health Affairs (HA)/DHA Policy in any way, but rather a consolidation of pragmatic references and suggestions to assist front line MTF health care professionals navigate this challenging COVID-19 Pandemic in real time. The preparation includes the establishment of a COVID-19 Triage Planning Committee, wide ranging communication both within the MTF and also with assigned MTF Legal Advisors and local civilian medical facilities, and the creation of an ethical decision making apparatus. Adoption of these organizational recommendations will limit the number of ethical questions and problems faced by the command, health care professionals, and staff, while simultaneously assisting in the effective resolution of the ethical issues that do inevitably occur.

Obviously the COVID-19 outbreak is an incredibly dynamic and evolving pandemic, which may quickly require modified guidance as the situation changes. Importantly, the following non-prescriptive ethical considerations must be operationalized in concert with the controlling DoD COVID-19 Practice Management Guide, other DHA guidance, and in coordination with the assigned MTF Legal Advisor/DHA Office of General Counsel (OGC). During these challenging times it is incumbent on all military health care professionals to remain flexible and conduct themselves according to the highest ethical standards. The DMEC stands ready to assist, at any time, as ethical challenges arise.

Underlying Ethical Principles and Corresponding Duties:

The DMEC has already provided, as part of the inaugural version of the DoD COVID-19 Practice Management Guide (Pages 36 and 37), initial guidance on the appropriate ethical frameworks to consider in specifically referencing The Hastings Center Ethical Framework (https://www.thehastingscenter.org/ethicalframeworkcovid19/), The Society of Critical Care Medicine (SCCM) Emergency Resources (https://www.sccm.org/disaster), and the National Academy of Medicine (NAM) Discussion Paper on crisis management of scarce medical resources (https://nam.edu/duty-to-plan-health-care-crisis-standards-of-care-and-novel- coronavirus-sars-cov-2/). Two other recently published and insightful commentaries, which bear consideration by MTF Directors and MTF health care professionals in the analysis of the prevailing ethical principles, appear in the New England Journal of Medicine (NEJM) (https://www.nejm.org/doi/full/10.1056/NEJMsb2005114) and The Journal of the American Medical Association (JAMA)(https://jamanetwork.com/journals/jama/fullarticle/2763953).

The following supplemental guidance is offered by the DMEC as a means to provide a transparent, equitable, and consistent approach to the allocation of scarce medical resources during the COVID-19 pandemic. The development and implementation of these processes requires an intentional commitment to our shared ethical responsibility to hold in primary regard the health, safety and dignity of patients. The allocation of scarce medical resources should be developed in a manner that is: accountable, transparent, and trustworthy; promotes solidarity and mutual responsibility; affords equitable response to needs; and remains sensitive to the values of the community and respects their perspectives and input.

During periods of limited medical resources, there exists a fundamental tension between a patient-centered approach to medical treatment under normal conditions, and the public- centered/force-protection approach of medical treatment under crisis conditions. An ethically- sound framework for MTFs during a scarce medical resource crisis acknowledges two competing sources of moral authority that must be navigated and balanced: (1) the duty to care for individual patients that is based upon and sustains the ethical foundation of the medical profession; and (2) the duty to equitably distribute the benefits of limited goods, services and resources to society.

2 From these primary duties, obligations to plan, safeguard, and guide the institutions of medical care can be formulated. The obligation to plan and manage uncertainty, and to anticipate and respond to foreseeable ethical challenges that may be present, requires a proactive approach to develop comprehensive and equitable triage processes and decision-matrices. The obligation to safeguard our patients and health care professionals requires identification of vulnerable patient and staff populations, a recognition of the potential for occupational risks, threats and harms, and mandates institutional development of comprehensive risk assessment and mitigation strategies and tactics. The obligation to guide the institution and the larger military medical enterprise requires that MTFs develop proactive contingency planning to meet increasing demands for care under circumstances of medical resource scarcity. Triage plans need to be focused on all elements of patient care, from the Emergency Room to ward to Intensive Care and to discharge. Particular attention must be focused on discharge planning. Failure in this area will lead to overcrowding in the facility and complicate every challenge facing the MTF leadership and staff. Complex ethical challenges will be amplified should fear and distrust become rooted in an MTF.

As noted in The Hastings Center Ethical Framework, planning committees should incorporate representation from local Medical Ethics Committees to provide insight to, and planning for, the moral distress that health care professionals are likely to experience during crisis conditions. Moral distress may be exacerbated by feelings of social isolation and disruptions in normal routines, social distancing, and concern for personal/family safety and well-being during times of crisis. Resources should be expanded so as to enable ethically sound allocation in support of health care professionals prior to, during, and following times of crisis. This includes opportunities for structured debriefing after critical events, and ongoing engagement to promote community connectedness based, in part, upon reflection and fostering of professional and personal meaning engendered by individuals’ experience. Additionally, existing support/morale programs should be fortified to develop and maintain resilience among health care professionals and their patients. The United States Military Medical Corps has faced these same challenges during the wars in both Iraq and Afghanistan. Recognizing the stresses placed on the health care professionals, and using all means available to address these issues, will protect and maintain the health care force.

Finally, within the MTFs, in both CONUS and OCONUS alike, it is critical to note that there are occasions when unique military circumstances define the ethical responsibilities and actions of military health care professionals, when necessary and appropriate. These exigencies are explained in the recently published “A Code of Ethics for Military Medicine” article in the American Military Surgeons of the United States (AMSUS) Journal (https://academic.oup.com/milmed/advance- article/doi/10.1093/milmed/usaa007/5803039?searchresult=1). Distinctions in certain ethical obligations of military and civilian medicine derive from the oath taken by military health care professionals to their function within military units, and in consideration of the military mission.

3 Ethical Frameworks and Triage Models:

With regard to the specific medical care to be provided to MTF patients, the details of various medical areas are already discussed in the overarching DoD COVID-19 Practice Management Guide. Therefore, specific recommendations regarding initial evaluation, hospital admission, initial treatment, general medical ward care, transfer to the Intensive Care Unit (ICU), consideration for ventilator care, pregnancy, pediatric care, surgery, resuscitation, and other specified medical areas can/should be addressed by reference to the DoD COVID-19 Practice Management Guide. In addition, MTF health care professionals should consult currently existing military medicine publications when seeking to tailor appropriate triage procedures in accordance with principles contained in war-time response protocols during this COVID-19 pandemic. Specifically, the following document can provide an exemplary foundation upon which to craft such triage procedures: Chapter 3, Mass Casualty and Triage, Emergency War Surgery, 5th Edition, 2018, (https://www.cs.amedd.army.mil/borden/FileDownloadpublic.aspx?docid=744757d4-660d- 432b-9286-9565c70f7e2b).

Ethical questions and triage decisions are influenced by, and should be sensitive and responsive to local and situational factors, as well as state laws and regulations. Each MTF should evaluate its individual capability and the local COVID-19 situation. An MTF’s response will be modified by the level of need(s) incurred during periods of Conventional Capacity, Contingency Capacity, and Crisis Capacity. It is also suggested that each MTF should hold simulation drills to practice the facility response to relevant COVID-19 contingencies and exigencies. Smaller MTFs, with more limited intensive care medical resources, should be regarded as (short-term) Treat and Evacuate Centers. This is similar to the status and function(s) of Forward Surgical Teams (FSTs) that have been employed with great success in both Iraq and Afghanistan. Conversely, larger MTFs will typically have significantly greater flexibility to adjust care, the use of space, health care professionals, and medical resources as the situations demand. The MTF Director, Triage Planning Committee, and Medical Ethics Committee, and other relevant parties, can/should assist in the ongoing decisions of triaging care in accordance with triage protocols employed on the battlefield. Similar techniques are applicable in the current COVID-19 pandemic. To reiterate, great attention needs to be focused on the ultimate placement of patients, whether to the next more capable referral center, skilled nursing facilities, home care, or hospice. Failure to address these difficult challenges risks the MTF being overwhelmed.

Roles and Responsibilities:

MTF Director: - Establish a Triage Planning Committee to coordinate all aspects of the MTF response. - Assess all available resources, space, personnel and materials. - Adopt and follow the DoD COVID-19 Practice Management Guide. - Coordinate with major local military units, Base Commander, military police/fire department, and Base EMS. - Meet regularly with all senior staff to provide updates on the real-time status of the MTF. 4 - Establish a Communications Center, with rapid connections to regional military referral centers, local civilian referral centers, Base Commander, local large unit commands, and military clinics that refer patients.

MTF Chief of Staff: - Coordinates with all major service directors, to include but not limited to the following: - Medicine; - Surgery; - Nursing; - Pulmonary; - Emergency Service; - Infectious Disease; - Intensive Care Unit; - Pediatrics/OB; - Psychology; - Medical Service Corps; and - Chaplain/Religious Services.

MTF Medical Ethics Committee: - Monitor local response protocols and DHA recommendations as the situation evolves. - Provide guidance to MTF Director, Triage Planning Committee, and MTF health care professionals. - Smaller MTFs should identify a senior health care professional to be the lead Medical Ethics Officer. This individual will provide a resource for health care professionals, as well as the MTF leadership as the situation evolves. - Coordinate with DMEC for case specific assistance.

MTF Senior Medical Service Corps Officer: - Coordinates admission/discharge, record keeping, and pharmacy services. - Monitors status of supplies, re-supply, and medical evacuation (paramount in smaller facilities). - Establishes a Discharge Team to coordinate this critical function.

MTF Legal Advisor: - Advises MTF Director, Triage Planning Committee, and Medical Ethics Committee on relevant jurisdictional laws and regulations. - Maintains awareness of newly issued legal guidance to ensure no patients are unfairly discriminated against based on categorical exclusions (i.e. age, comorbidities, etc.), to specifically include the recent HHS Bulletin on the treatment of patients with underlying disabilities in the COVID-19 context (https://www.hhs.gov/sites/default/files/ocr-bulletin-3-28-20.pdf). - Coordinate with DHA OGC to ensure consistency with the prevailing federal/state laws and DoD/HA/DHA/Service regulations.

5 Establishment of Triage Planning Committees:

Each MTF should develop either a local, or regional (for smaller or jointly located facilities), Triage Planning Committee as the institutional oversight body that will be charged with creating the specific MTF triage SOPs, establishing the pertinent inclusion and exclusion criteria, and ultimately serving as the final arbitrator for difficult scarce medical resource allocation decisions (situation and time permitting). Whether or not those triage SOPs should, or should not, include a reliance on quantitative metrics, such as a Sequential Organ Failure Assessment (SOFA) score, or similar physiologically-based scoring, is unresolved at this point in time amongst the prevailing experts. Many leading civilian medical facilities are utilizing SOFA scores as part of their treatment decisions in an attempt to anchor on an objective physiologically-based scoring system in evaluating similarly situated patients. However, other highly regarded professional medical societies have opined that such scoring systems are unlikely to predict critical care outcomes with sufficient accuracy, in particular patients suffering from COVID-19, or be a useful basis for triage decisions based upon the current protocol cut points. In reference, a recent elucidating article was published by The Hastings Center to tease out these competing tensions more specifically, with particular emphasis dedicated to patients with underlying medical conditions or comorbidities (https://www.thehastingscenter.org/disabusing-the-disability-critique-of-the-new-york-state- task-force-report-on-ventilator-allocation/).

Consequently, additional medical/science evidence-based factors may also be utilized in creating triage SOPs that achieve the maximum benefit outcome, while not unfairly discriminating against specific patients (i.e., patient’s age, patient’s comprehensive health status, state of patient’s illness, prognosis for patient’s recuperation, patient’s likely response benefit from a medical intervention, medical facility’s availability of space, current or anticipated status of medical facility’s personnel and resources, current or anticipated care trajectory of aggregated patients, the effect of Do Not Resuscitate (DNR) orders, Advanced Directives, and/or Health Care Power of Attorney documents, etc.).

As noted in the recent New England Journal of Medicine (NEJM) commentary, there are four general ethical values that may assist in guiding allocation decisions of scarce medical resources during the COVID-19 pandemic: 1) Maximize benefits; 2) Equitable treatment; 3) Promotion of instrumental values; and 4) Priority to the vulnerable. Maximization of benefits can be understood in various ways, to include saving the most lives or saving the most life- years by giving priority to those likely to survive the longest. Equitable treatment dictates that similar patients (e.g., patients with identical triage scores) should be treated equally via a transparent and consistent method. Possible approaches to allocation include random selection (e.g., lottery) or first-come, first-served. Equitability would also mandate that in most scenarios all COVID-19 patients and non-COVID-19 patients are subject to the same triage procedures. Promotion of instrumental values recognizes a potential preference given to those who can save others and those that contribute to public/national safety and security. Priority to the vulnerable recognizes that priority might be given to younger, or pregnant patients who will have lived the shortest lives if they were to die untreated.

6 Triage Planning Committees within individual MTFs or within pre-specified regions should be established immediately. The position of this recommendation is aligned with the Society for Critical Care Medicine (SCCM) with regard to the purpose of the Triage Planning Committee: 1) It facilitates a patient’s medical team to advocate on behalf of their patient without a conflict of interest; 2) The designation of a Triage Planning Committee provides consistency, transparency, and fairness in the decision-making process; and 3) The presence of a Triage Planning Committee may assist in the mitigation of burnout and stress that inevitably is experienced by frontline health care professionals during a crisis.

1. Triage Planning Committees should be established to have ultimate oversight of scarce medical resource allocation decisions (situation and time permitting). Triage Planning Committees should be charged with establishing pre-defined triage SOPs for Conventional Capacity, Contingency Capacity, and Crisis Capacity.

2. The Triage Planning Committee should have, at a minimum, two senior clinicians with experience in tertiary triage (such as Critical Care, Trauma Surgery, Emergency Medicine, etc.), a member of the Medical Ethics Committee, and a member of the community, if available, feasible, and legally permissible. Where available, a Palliative Care provider and a Pastoral Care provider should also be included.

3. Clinical Treatment Teams should not be responsible for making triage decisions (situation and time permitting). Instead, each MTF should develop Triage Teams prior to the onset of medical resource scarcity.

4. Triage Teams, at a minimum, should be comprised of a Triage Officer, a nurse with acute care experience, and an administrative staff member. If available, feasible, and legally permissible, Triage Teams should also include a member of the Medical Ethics Committee, a representative from Pastoral Care, and a representative member of the community.

5. Responsibilities of the Triage Team should include initial assessment of a priority score, matching priority score to available resources, and communicating this information back to the Clinical Treatment Teams. The Triage Team and Clinical Treatment Team should work collaboratively in determining the best approach to informing patients and families regarding allocation decisions.

6. The Triage Team should receive the patient’s age but no other patient demographics or identifiers. The Triage Team should be apprised of the patient’s clinical condition and other medical information relevant to prognostication. All Triage Team consults should be documented and a record of all patients reviewed and decisions made should be maintained according to MTF SOPs. A process for regular review and appeal of Triage Team decisions should also be established at the MTF level to ensure fairness and accountability.

7. It is also critical to ensure that these incredibly difficult allocation decisions regarding the anticipated scarcity of medical resources are made in conjunction with the counsel 7 and guidance of the assigned MTF Legal Advisor in order to ensure consistency with the prevailing federal and state laws and regulations.

In general, effective planning should consider three broad categories: Conventional Capacity, Contingency Capacity, and Crisis Capacity. Conventional Capacity refers to the period during which space, staff, and supplies are consistent with daily practices within the institution. Resources should be allocated normally when readily available. Careful stewardship of resources by institutional leadership is prudent to preserve supply if contingency or crisis scenarios are anticipated. Contingency Capacity refers to the period during which extreme resource scarcity is present and a shift from “first come/first served” to a triage model occurs. Access to resources remains fluid and is subject to reallocation among patients as circumstances require. Triage Planning Committees are utilized to systematically review and allocate resources based upon application of exclusion criteria, assessment of mortality risk and likelihood of benefit, and utilization of time-limited trials. Crisis Capacity refers to an extreme scenario in which all critical resources (ICU beds, ventilators, etc.) are in use and new patients are triaged. Under these circumstances, it is ethically permissible to divert life-sustaining treatment from a patient who is deemed less likely to benefit from the ongoing application of limited resources toward a patient more likely to survive. This is a consideration to be taken with the greatest respect for human life and dignity. This recommendation also requires consistency with individual state law.

Special Considerations in the COVID-19 Pandemic:

Cardiopulmonary Resuscitation (CPR):

Health care professionals have an a priori duty to provide potentially life-saving treatments, to include cardiopulmonary resuscitation (CPR) even in the context of some degree of personal risk. According to the United States Centers for Disease Control and Prevention (CDC), CPR in COVID-19 patients is currently considered a medium-risk exposure event. In such a context, it is reasonable to assess the potential risks to health care professionals against the potential benefit to the patient. Additionally, it is necessary to allow clinicians to don appropriate personal protective equipment (PPE) prior to entering the room of a decompensating patient, with the understanding that this may delay their response. Code teams should consist of the minimum necessary number of personnel in the room and must all be in proper PPE prior to entry. Virtual health assets should be considered to augment resuscitation teams which allows for minimization of exposure of personnel and use of PPE.

Palliative Care:

Patients who do not receive critical care resources must not be neglected and all reasonably available supportive and comfort-oriented care should continue to be provided for all patients, as clinically appropriate. Families should be compassionately informed of the rationale for medical decision-making. The shift in roles that patients and their surrogates typically play in the decision-making process represents a significant deviation from normal clinical practice. This shift carries with it an obligation to both to clearly communicate clinical rationale and to provide the best possible care for all patients within the constraints of the crisis. The role of 8 palliative medicine should be considered at all stages of contingency/crisis planning and resources/processes for effective palliation of patients should be established prior to resource scarcity. Rationing decisions may come into conflict with patient Advance Directives, and the assigned MTF Legal Advisor should be consulted for resolution.

Investment in teleconsultation capabilities for real-time long-distance consultation is advised due to scarcity of formally trained palliative medicine specialists available to the Department of Defense (DoD). Additionally, due to the unique isolation conditions placed upon families of critically ill and end-of-life patients, facilities should investigate and develop means for remote communication between loved ones and patients in isolation. This can be achieved using off- the-shelf programs on tablets, phones, or laptop computers.

Moral Distress and Spiritual Care:

With evolving changes to standards of care and pervasive uncertainty, health care professionals may be frequently faced with moral distress related to decisions and actions that feel counter to their training and values. In anticipation of this approaching crisis, and to preserve a ready medical force, support resources including chaplaincy, behavioral health resources, and peer support networks should be maximized. Ongoing education and communication with staff on the status of their facility, the status of medical resources, and the overall planning process allows transparency and alignment of focus on the COVID-19 pandemic.

Special Consideration for Health Care Professionals and First Responders:

In the current COVID-19 pandemic, relief efforts and clinical care have been hampered by shortages of critically-needed PPE for health care professionals. In addition to the baseline risk of living in affected communities, health care professionals are at risk for frequent, often intense exposure to grievously-ill patients with COVID-19 on a regular basis. This increased risk may serve to demoralize frontline health care professionals, especially in light of PPE shortages. As such, increased consideration in triage situations for health care professionals involved in the COVID-19 response is considered appropriate. This preference should apply to all health care professionals involved in the care of infected patients, including not just bedside nurses and physicians, but also medical technicians (including Medics and Corpsmen), clerical staff in emergency departments and inpatient units; respiratory therapists; first responders including emergency medical technicians; and housekeeping staff involved in the cleaning of hospital spaces occupied by patients with COVID-19. This is done both with the hope that these personnel may recover and return to care for others, and also as a compact with those who place their own health and life at risk, a concept that should resonate with the military community. Each MTF should determine a plan for how to operationalize these considerations.

Special consideration for Active Duty Military:

Whether or not the patient's status as an active duty service member should give them triage priority in responsive care over other MHS beneficiaries, from a health force protection perspective, is a legitimate variable for consideration by the MTF leadership. However, if an MTF has lost responsive care capacity to the point that non-active duty patients will be 9 relegated to a lower treatment category versus active duty service members, then that triage procedure should be widely communicated to that impacted patient population in order to allow those beneficiaries to potentially consider alternate care options from the outset at local civilian medical facilities. Again, that possibility underscores and reinforces the importance of MTFs immediately establishing good lines of communication with their civilian medical facilities counterparts in their local geographic areas. Each MTF should determine a plan for how to operationalize these considerations.

Conclusion:

The COVID-19 pandemic continues to be an incredibly dynamic and evolving global health emergency. Issues and procedures will evolve and require refinement as more information becomes available about the nature and breadth of the disease. However, being familiar with the most recent counsel and guidance from the experts in the field will assist all medical leaders in implementing the best possible policies and treatment decisions for both individual patients and the society at large. MTFs are encouraged to utilize enterprise-level resources (e.g., DMEC and service-specific Office of the Surgeons General Consultants (OTSG) for Medical Ethics) to augment their ability to proactively address and respond to these ethically challenging times.

Closing Remarks:

Please feel free to re-engage with the DMEC for additional assistance and guidance if these issues require further discussion towards resolution. DMEC POCs are Mr. Joshua Girton, DMEC Deputy Director ([email protected]), and Ms. Poly Combs, DMEC Program and Management Analyst ([email protected]).

10 References:

- N. Berlinger, PhD, et al., “Ethical Framework for Health Care Institutions & Guidelines for Institutional Ethics Services Responding to the Coronavirus Pandemic,” The Hastings Center, 16 March 2020, available at https://www.thehastingscenter.org/news/the-hastings-center-produces-guidance-for- ethical-practice-in-responding-to-covid-19/ - “Emergency Resources: COVID-19,” The Society of Critical Care Medicine (SCCM), SCCM Website, current as of 2 April 2020, available at https://www.sccm.org/disaster - J. Hick, MD, et al., “Duty to Plan: Health Care, Crisis Standards of Care and Novel Coronavirus SARS-CoV-2,” National Academy of Medicine (NAM), 5 March 2020 , available at https://nam.edu/duty-to-plan-health-care-crisis-standards-of-care-and- novel-coronavirus-sars-cov-2/ - E. Emanuel, MD, PhD, et al., “Fair Allocation of Scarce Medical Resources in the Time of COVID-19,” New England Journal of Medicine (NEJM), 23 March 2020, available at https://www.nejm.org/doi/full/10.1056/NEJMsb2005114 - D. White, MD, MAS; D. Lo, MD, “A Framework for Rationing Ventilators and Critical Care Beds During the COVID-19 Pandemic,” The Journal of the American Medical Association (JAMA), 27 March 2020, available at https://jamanetwork.com/journals/jama/fullarticle/2763953 - R. Thomas, MG, USA (Ret.), MD, DDS, MSS, FACS, et al., “A Code of Ethics for Military Medicine,” The Association of Military Surgeons of the United States (AMSUS) Journal, 11 March 2020, available at https://academic.oup.com/milmed/advance- article/doi/10.1093/milmed/usaa007/5803039?searchresult=1 - Chapter 3, Mass Casualty and Triage, Emergency War Surgery, 5th Edition, 2018, available at https://www.cs.amedd.army.mil/borden/FileDownloadpublic.aspx?docid=744757d4- 660d-432b-9286-9565c70f7e2b - HHS Bulletin: Civil Rights, HIPAA and COVID-19, HHS Website, 28 March 2020, available at https://www.hhs.gov/sites/default/files/ocr-bulletin-3-28-20.pdf - J. Fins, MD, MACP, FRCP, “Disabusing the Disability Critique of the New York State Task Force Report on Ventilator Allocation,” The Hastings Center, 1 April 2020, available at https://www.thehastingscenter.org/disabusing-the-disability-critique-of-the- new-york-state-task-force-report-on-ventilator-allocation/

11 4/29/2020 USUHS SoM Student COVID-19 Response Training

USUHS SoM Student COVID-19 Response Training

USUHS SoM Students, During this time of national crisis, we want to ensure you are ready to help. Below are the capabilities that we anticipate MTFs will need from you. You will note that your USUHS training has already prepared you for most of the capabilities listed, but there are a few areas that require additional attention.

When you have checked off each task please submit this form.

Thank you in advance for your completing this training to ensure you are ready to care for those in harm's way - it's why USUHS exists.

* Required

Email address *

Your email

CAPABILITY 1: Appropriate PPE Utilization (Additional training will be provided by the facility you work at) *

Carefully review this PDF: https://drive.google.com/file/d/1ws3AqAjv3-H- E28AOCXG7ToPJwaLE9E8/view?usp=sharing

Watch this 30 minute video on N95 usage: https://www.youtube.com/watch? v=6qkXV4kmp7c

https://docs.google.com/forms/d/e/1FAIpQLScDetI5AzN2X1aw_kWBCt4fz3w4wJRvMsA03zeeOwGnmObOIQ/viewform 1/3 4/29/2020 USUHS SoM Student COVID-19 Response Training

CAPABILITY 2: Basic Understanding of COVID-19 *

Review pages 2 and 7-9 of this DoD Guidance on COVID-19: https://drive.google.com/open?id=12i_jXyUJpuWjgTnBZ0bPeKme9hlvnOHB (there is other good info as well - we recommend you save a copy)

Respiratory failure is the leading cause of COVID-19 related mortality - make sure you are familiar with the signs of respiratory distress in patients you are working with: https://www.hopkinsmedicine.org/health/conditions-and-diseases/signs-of- respiratory-distress

CAPABILITY 3: Effective Patient Communication (decreasing fear/anxiety) *

Refresh yourself on the EEC: https://drive.google.com/open? id=17jaslD6ajdiYgSfL2Vwrbg-Kqwu6b0FE (effective communication matters!)

Review this link, specifically details for providers: https://www.cstsonline.org/resources/resource-master-list/coronavirus-and- emerging-infectious-disease-outbreaks-response

Download the Psychological First Aid App (Search "PFA") and make sure you are ready to decrease stress (for further training check out: learn.nctsn.org/enrol/index.php? id=38)

CAPABILITY 4: Screening Patients *

Review this COVID-19 Screening tool. Be prepared to adjust to the tools used at your site: www.c19check.com

CAPABILITY 5: Obtaining Vitals *

You already know the fundamentals. Please watch this video on measuring vitals with a machine: https://www.youtube.com/watch?v=hQpdwipj578

https://docs.google.com/forms/d/e/1FAIpQLScDetI5AzN2X1aw_kWBCt4fz3w4wJRvMsA03zeeOwGnmObOIQ/viewform 2/3 4/29/2020 USUHS SoM Student COVID-19 Response Training

CAPABILITY 6: Responding to a Medical Emergency (Please just indicate the training you previously completed.)

BLS Complete

ALS Complete

ATLS Complete

Next

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UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES OFFICE OF THE PRESIDENT 4301 JONES BRIDGE ROAD BETHESDA, MARYLAND 20814-4712 www.usuhs.edu

14 April 2020

MEMORANDUM FOR THE CABINET

SUBJECT: USU Pandemic Campaign Plan – Letter of Instruction (LOI)

1. Purpose: The purpose of this LOI is to lay out the tasks, process, responsibilities and timelines for the development and coordination of a USU Pandemic Campaign Plan (PCP) that is immediately applicable to the COVID-19 crisis and forms the foundation for a standing USU Operations Plan (OPLAN) that will guide actions in future public health emergencies.

2. Background: The COVID-19 pandemic has created major challenges to the Military Health System and to USU, and the University has been deeply involved in supporting the war against the pandemic across the nation in each of the University’s principal strategic domains: Education, Research and Leadership. As the response to the pandemic continues to grow more complex and involves more organizations and people, we at USU must become focused and disciplined in our support to national and DoD requests. That requires us to develop and implement a USU PCP

3. Mission: The mission of the USU PCP is to provide an overarching University-level structure to govern and coordinate USU’s contributions to the “whole of society” pandemic response, ensuring that we appropriately triage requests for support and that we advance pandemic-related initiatives in the most effective manner possible.

4. PCP Structure: The USU PCP will conform to the doctrinal DoD and Joint Staff template, modified as required by the University’s multifaceted mission and capabilities. The structure of the USU PCP is at Annex A to this LOI.

5. PCP Principles: The USU PCP will be based on several key principles, including:

a. Timeliness and Urgency. The PCP must be developed quickly in order to ensure that it has value to the University as the pandemic progresses and as we prepare for a possible “second wave” at the end of 2020.

b. Integration. The PCP will be developed and managed at the University level, with University assets providing:

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i. Overall direction and priorities.

ii. Supporting Functions, including:

a) Resource analysis (VFA). b) Research coordination (VPR). c) External affairs including strategic communications (VPE). d) Legal advice (OGC). e) Medical ethics considerations (DMEC). f) Inspector General issues (IG). g) Services

iii. Integrating IT and data-sharing platforms for initiatives and collaborations being conducted at Responsibility Center levels (CIO).

iv. Coordination of collaboration with external stakeholders, including inter alia DHA, HA, OSD, NIH, CDC, EOP and others as required.

c. Decentralized Execution. The development and execution of specific pandemic- related initiatives will be primarily the purview of the University’s Responsibility Centers (RCs). For the purposes of the PCP and this LOI, these RCs include:

i. USU’s four schools and colleges. ii. The Council of Center Directors (CCD). iii. AFRRI. iv. Selected centers, programs, consortia and initiatives based on requests for support from either within USU or from external stakeholders.

d. Analysis / Prioritization of Support. As we have seen already, the volume and complexity of requests for support, coupled with USU-generated initiatives – will overwhelm our capacity. Therefore, it is vital that we establish Pandemic Support Priorities (PSPs) that will allow us to bring our capabilities to bear on the pandemic in the most effective manner possible. These PSPs will be defined in the PCP.

e. Flexibility. The PCP must strike a balance between being both definitive and adaptable – providing guidance to the RCs and the external community while remaining sufficiently agile to respond to unforeseen developments in the pandemic or unique and fast-moving opportunities for the University to contribute.

f. Transparency. The PCP must ensure transparency and information sharing across the University.

g. Attainability. Given the urgency of the pandemic and our own capabilities, each initiative must be carefully weighed to ensure that it makes a direct and

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measurable contribution to the current “wave” of the pandemic or helps position the U.S. for a second wave.

6. Responsibilities:

a. USU Lead. The overall lead for USU in the development of the PCP is the USU Chief of Staff.

b. Integrated Planning Team (IPT). To support the planning process, the existing USU Operations staff will be augmented by an IPT that will be responsible for the development of the PCP. For the purposes of managing the application of the USU pandemic Campaign Plan to the COVID-19 response, the IPT will consist of:

i. Mr. Allen Middleton (Chair) ii. Dr. Chris Shoemaker iii. CAPT Sean Hussey iv. LTC Jake Bustoz v. Major Monty Edwards vi. A dedicated representative from each CIO.

c. USU PCP ad hoc Planning Committee with the primary duty of reviewing the draft(s) of the PCP and providing suggested revisions that reflect the positions of the RC principles. The PCP Planning Committee will consist of:

i. The USU Chief of Staff (Chair). ii. The IPT. iii. Empowered representatives from the four schools and colleges. iv. The Director of the CCD. v. The Director of AFRRI. vi. Others as determined by the Chair, including representatives from organizations external to USU when appropriate.

d. Responsibility Centers. The deans of the schools and colleges and the leaders of the other USU RCs as defined above should establish their own internal pandemic response coordinating bodies to assist the RC leaders in the execution of the overall USU PCP and in RC supporting plans. These coordinating bodies should be populated to support responses to future pandemics as well.

7. Timelines: Because of the urgency of the defeat of COVID-19, the following timelines and milestones apply (D-Day is the approval of the LOI by the President, USU):

Task Date Responsibility LOI approval D Chief of Staff IPT formation D+1 Chair, IPT Paras 1,2 drafted and circulated D+2 IPT Planning committee meeting #1 D+3 Chief of Staff

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Paras 1,2 revised. Paras 3a, 3b drafted and D+8 IPT circulated Planning committee meeting #2 D+10 Chief of Staff Paras 3a, 3b revised. Para 3c drafted and D+15 IPT circulated IPR to USU President D+16 Chief of Staff, IPT Planning committee meeting #3 D+17 Chief of Staff Para 3c revised. Paras 4,5 drafted and circulated D+22 IPT Planning committee meeting #4 D+24 Chief of Staff Completed plan briefed to USU President D+27 Chief of Staff, IPT PCP published D+30 Chief of Staff

8. Conclusion: The COVID-19 pandemic is creating unprecedented stress on the global health community, on U.S. health institutions and facilities, on the MHS and on USU. The women and men of the University have already made significant contributions to the “whole of society” battle against the novel virus, and we must now position ourselves to be responsibly responsive in the ongoing fight. The PCP is an important element in that overall goal and will prepare the University not just for the current crisis but for future public health emergencies.

Richard W. Thomas, MD, DDS, FACS President

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Annex A USU Pandemic Campaign Plan Format

Unclassified Copy No. _____ of _____ copies Uniformed Services University Date/Time Group of Signature COVID-19 Campaign Plan

References:

a. USG guidance documents (e.g. White House COVID-19 plan) b. DoD guidance documents c. NORTHCOM guidance documents d. HA guidance documents

COMMAND RELATIONSHIPS. USU is a direct report to the Assistant Secretary of Defense for Health Affairs. It is a tenant organization within the U.S. Naval Activity, Bethesda. USU lies within the NORTCOM AOR.

1. Situation.

a. Strategic Guidance. What has anybody in our chain of command told us what to do, including:

1. Strategic Objectives and Tasks Assigned to USU.

2. Constraints, including resources.

b. “Enemy”: COVID-19 Summary.

1.

2.

3.

c. “Friendly Forces”: Institutions with which USU can and is collaborating.

d. Assumptions. Projections about the future that are both credible and critical to the efficacy of the plan.

2. Mission. What do we do, to whom do we do it and why is it important. (e.g. Uniformed Services University (USU) together with its partners, anticipates, plans, and prepares for pandemic related events and response operations within the National Capital Region (NCR) or a defined Area of Responsibility (AOR), and when directed or authorized provides critical

5

medical and scientific capabilities within the USNORTHCOM AOR to contribute to the defense and security of the United States and its interests.)

3. Operations.

a. President’s Intent. (Concept and end state – what do we ultimately seek in the campaign?)

b. Phases.

1. Phase 1: Protect: Description and USU tasks and initiatives 2. Phase 2: Defend: Description and USU tasks and initiatives 3. Phase 3: Defeat: Description and USU tasks and initiatives 4. Phase 4: Sustain: Description and USU tasks and initiatives

c. Tasks to Responsibility Centers.

1. College of Allied Health Sciences a) b) c) d) 2. Graduate School of Nursing a) b) c) d) 3. Postgraduate Dental College a) b) c) d) 4. School of Medicine a) b) c) d) 5. AFRRI a) b) c) d) 6. Brigade a) b) c)

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d) 7. Council of Center Directors a) b) c) d) 8. The Griffith Institute, including DMEC a) b) c) d) 9. 10. 11. 12.

4. Logistics.

a. Resources

b. Facilities

c. Personnel

5. Command and Communications.

a. Command.

1. Command Relationships.

2. Delegation of Authority.

b. Communications.

1. Internal.

2. External.

3. Strategic Communications

Signed ______(President)

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ANNEXES: As required

DISTRIBUTION:

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