Background Long-term care facilities (LTCFs) including assisted living facilities (ALFs) are hubs for high transmission and poor prognosis of COVID-19 among the residents who are more susceptible due to old age and comorbidities. Aim Houston Health Department conducted assessments of ALFs within the City of Houston to determine preparedness and existing preventive measures at the facilities. Methods Onsite assessments were conducted at ALFs using a modified CDC Infection Control Assessment and Response (ICAR) Tool. Data was obtained on IPC measures, training, testing, vaccination etc. Data was analyzed, frequencies generated, and bivariate associations determined. Results A total of 118 facilities were assessed and categorized into small scale 46 (39%), medium scale 47 (40%), and large scale 25 (21%). The facilities had 2431 residents and 2290 staff. Thirty-one (26%) facilities reported an outbreak in 2020, while 14 (12%) had an ongoing outbreak. Twenty-three (97%) large-scale and 12 (26%) small-scale facilities had COVID-19 testing program. Vaccination coverage among residents ranged from 99% in large-scale to 40% in small-scale facilities but was smaller among staff at 748 (45%) in large scale, 71 (36%) in small scale, and 193 (45%) in medium scale. While 24 (96%) large-scale and 34 (77%) of small-scale facilities conducted staff training staff on IPC practices, 22 (92%) of large-scale and 19 (56%) of small-scale facility staff demonstrated capacity ( p = 0.01), respectively. Visitor screening was done at 100% of large-scale and 80% of small-scale and the medium-scale ALFs. Discussion Assisted living facilities within the city of Houston are at various levels of preparedness and interventions with respect to COVID-19 response.

Background Vaccine hesitancy threatens a reversal of progress made in tackling vaccine-preventable diseases. The Houston, Texas, Health Department assessed COVID-19 vaccine availability and uptake in these facilities after the emergency use authorization of the COVID-19 vaccines in United States. Population and Methods A facility-based cross-sectional study was conducted using a structured interviewer-administered questionnaire to elicit data on facility demographics, vaccine availability, residents and staff vaccine uptake at time of assessment. The unit of inquiry was the facility. We calculated frequencies and assessed association with facility type. Facilities were classified as: small-scale facilities (SSF) ≤ 10 beds, medium scale (MSF) 11-50 beds, and large-scale (LSF) > 50 beds. Results A total of 118 facilities were enrolled, with 2,431 residents and 2,290 staff. Twenty-five (14.5%) of the facilities were LSF, 47 (39.8%) MSF, and 46 (39.0%) SSF. Overall, 70 (59.3%) facilities had COVID-19 vaccine available. The staff of these facilities were four-times as likely as the patients to be unvaccinated (prevalence ratio= 4.1; 95% CI= 3.7, 4.6) since the vast majority of residents, (86.5%), were vaccinated but less than half of staff (44.2%) were (P < 0.0001). Reasons provided for vaccine hesitancy included fear of side effects from a new vaccine, need to wait and see what happens to others, government distrust, religious beliefs, conspiracy theories among other things.    Discussion The findings supported highlighted a preventable gap in the protection of the elderly in these facilities and prompted a health education campaign tackling vaccine hesitancy and encourage vaccine uptake.

Objective● To demonstrate the importance of a cross-jurisdictional etiquette workgroup in the Texas Southeast region that leverages on the Syndromic Surveillance Consortium● To promote data sharing and communicate the findings of disease to assist rapid investigation and data sharingKey words:ESSENCE (Electronic Surveillance System for Early notification of Community-based Epidemics)IntroductionSyndromic data is shifting the way surveillance has been done traditionally. Most recently, surveillance has gone beyond city limits and county boundary lines. In southeast Texas, a regional consortium of public health agencies and stakeholders in the 13-County area governs the local ESSENCE system. The Houston Health Department, (HHD) is responsible for deploying ESSENCE to the entire region.To effectively monitor the health of the region’s population, a need arose to establish clear guidelines for disease investigation and data sharing triggered by syndromic surveillance across the area. Since Houston’s instance of ESSENCE serves all 13 counties, the consortium instituted a cross- jurisdictional etiquette group. The purpose of the group is to determine the standard protocol for responding to ESSENCE alerts and best practices for data sharing and use among consortium members.MethodsTo achieve these goals, it was determined that a smaller group of stakeholders besides governing officials is needed to provide guidance for regional data sharing and use. The etiquette group was established in the first quarter of 2018 and it included four consortium representatives from the 6/5 south region of Texas. Their first meeting tackled issues relating to data sharing.ResultsThe following products emerged from the activities of the etiquette group within 3 months of its existence:● Publication/presentation guidance/policy to avoid duplication of efforts and misrepresentation of jurisdiction.● Procedure for alert responses●. Instructions for within-systems management of alerts;●. Instructions for events/times of interest (e.g., political convention, Olympics);● Instructions of syndromes of interest/syndrome-specific policies;● Instructions for changing the syndrome definition;● Notification procedures for identification of a single case of reportable disease/important free text element within data.ConclusionsCross jurisdictional workgroups can influence rapid investigations of disease, protect patient health information and promote privacy and data security and confidentiality by establishing set rules/guidelines for data exchange. All 13-counties in the region rely on these guidelines as a standard for responsibly accessing, using and sharing data in the Texas Southeast ESSENCE system.Lessons Learned:● As the etiquette group continues to evolve, there is need for more resources to help foster data use and sharing among jurisdictional partners.● Partner engagement is limited due to ongoing process of configuring the new system ESSENCE.● Since disease has no boundaries, allocation of jurisdictional responsibilities for responding to alerts should be operationalized● Continuous training is essential to ensure all system users adhere to the protocols in place for meaningful data use and data sharing

Objective● To describe findings from the joint collaborative between the Houston Health Department and Houston-based hospitals● To promote cross sectional partnerships and collaborations across health agenciesIntroductionAsymptomatic Bacteriuria (ASB) is defined as the presence of bacteria in the urine of a patient without signs or symptoms of a urinary tract infection (UTI). It is one of the most common reasons for inappropriate antibiotic use in hospitalized patients. Without efforts to check inappropriate use, our communities could see increased numbers of highly resistant bacterial pathogens contributing to the public health threat of antimicrobial resistance. Treatment itself may be associated with subsequent antimicrobial resistance, adverse drug effects, and cost.The Houston Health Department (HHD) has made it a priority to address antibiotic resistance and stewardship by working collaboratively with members of the healthcare community to address this patient safety issue. As such HHD, in conjunction with infectious diseases experts from the HHD Antimicrobial Stewardship Executive Committee formed a joint learning collaborative to work on an asymptomatic bacteriuria stewardship project. The goal of the project was to engage with healthcare professionals across facilities within the Houston area to work collaboratively to help reduce unnecessary testing and treatment of ASB.MethodsThe project is a joint learning collaborative between HHD and selected acute care facilities within the City of Houston. Space was limited to no more than 8 hospitals and enrollment occurred on a first come, first serve basis. Activities conducted as part of the project included a Project Launch meeting held at HHD that was attended by participants, education by project subject matter experts (SMEs), monthly calls with SMEs to provide case-based feedback and intervention tools. The project launch meeting included a brief overview of the project, review of an asymptomatic bacteruria algorithm (referred to as “Kicking UTI” algorithm), instructions on how to classify cases, project timeline and plan implementation. The project timeline was 8 months (this included the Kick off Meeting in month 1, data collection in months 2-4, intervention period during months 5-7, preliminary report in month 4 and final report at month 8. Participants were encouraged to do the interventions in one area (e.g. Emergency Room or a single ward) vs. institution wide. Intervention tools provided included a case classification form with instructions, an electronic form that was pre-formatted for local data collection (using Microsoft Access), and project launch worksheet. The project launch worksheet asked participants about their goals for the project, areas of desired improvements, units/wards to be targeted and key members of the project (e.g. executive champion, project champion, and active participants) at their facility. The agenda for the monthly calls included discussing data collection (i.e. number of cases classified), SME review of challenging cases, and utilization of education and project tools. Finally, onsite visits by the SMEs and HHD representatives were offered to participants to increase local site engagement.ResultsSeven acute care hospitals and 1 rehabilitation facility were enrolled in the collaborative. Participants from the institutions included 11 clinical pharmacists and one nurse. Half of the participants originally targeted emergency departments (ED). The remaining participants conducted interventions on the medical/surgical wards and one facility conducted interventions on the brain injury floor. Additional activities were adapted and added throughout the program period. These included: 1) choice of ward versus ED 2) targeted providers (working with mid-level providers to discourage standard urine testing in the emergency department) and 3) strategies for education. Strategies for education included utilizing nurse practitioners to educate nurses, designing project marketing tools (flyers, posters, and pocket cards), pharmacy rounds, resident orientation and one-to-one education. Site visits were conducted at 3 facilities and included a range of interventions from 1:1 peer to peer discussions to large presentations to medical staff. Outcomes for 3 sites included Pre-project ASB treatment rates of 61% and Post project ASB treatment rates of 24%, representing a 37% decrease in ASB treatment for these sites. In addition, two health systems that participated in the study utilized the information obtained from the project to work with their laboratory departments to change testing practices by increasing the threshold of urine white blood cells required in the sample before reflex to testing for the presence of bacteria.ConclusionsThis project showed that collaboration between a city Health Department and local institutions can be successful in reducing the overtreatment of ASB. HHD facilitated collaboration, assisted with eliminating barriers to knowledge sharing and served as a partner in setting transparent goals. A cross disciplinary approach to promoting patient safety indirectly lead to gains in public health. In person interaction between the Health Department, SMEs, and representatives from local facilities helped to increase engagement throughout the project. The results of this project will be shared on the Health Department website as a way of forging community practices and stretching the role of the health department to serve as an advocate for public health and patient safety. Future projects would benefit from having increased participation from facillity stakeholders to promote institutional sustainability.

Carbapenemase-producing organisms commonly carry a single carbapenemase gene conferring resistant to carbapenems and other β-lactam antibiotics. Here, we report rare cases of multidrug-resistant Pseudomonas aeruginosa, Klebsiella pneumoniae, and Acinetobacter baumannii strains that coproduce multiple carbapenemases and exhibit extensive drug resistance. Such resistant strains are rarely identified in the United States.