Broward County is the second most populous county in Florida, 17^th most populous in the United States, with almost 1.9 million people and 10% of Florida's residents. We are home to an international airport, ranked 19^th in the U.S. in total passenger traffic and a seaport, which is the cruise ship capital of the world. We have 15.4 million annual visitors. We are a majority/minority community.  Our population is 37% White, 30% Black, and 30% Hispanic of any race (U.S. Census).  One-third of our residents are foreign born.  Nearly 15% of our residents are living below the poverty level.  The Florida Department of Health in Broward County (DOH-Broward) is part of the state of Florida’s integrated Department of Health.  Broward County saw its first case of COVID-19 in early March, 2020 and has seen more than 110,500 positive cases, 1,687 deaths and 6,824 resident and 97 non-resident hospitalizations to date.  DOH-Broward stood up its Incident Management Team (IMT) on January 29, 2020. A majority of Broward County’s initial cases were in residents and staff at long term care (LTC) facilities.  Cases among residents and staff still occur today.  Prior to and during an incident, DOH-Broward’s Public Health Preparedness (PHP) staff ensures that all staff receive risk-specific training as well as other trainings such as medical countermeasures and personal protective equipment (PPE). During new employee orientation, new employees are assigned to risk groups based on job assignment.  All new employees receive training on donning and doffing as part of new employee orientation.  All DOH-Broward staff that are medically cleared to use PPE are trained on the proper use of PPE and respiratory mask prior to and during their annual fit-test (N-95 level).  DOH-Broward utilizes quantitative fit testing to ensure individuals are issued the proper N-95 respirator that ensures a tight-fitting seal. The goal of the practice was to ensure public health responder safety through training and proper use of PPE.

Broward County has an estimated population of 1,952,778 with 63.1% white, 30.2% black and 6.7% other.  Ethnicity for Broward County’s population is 31.1% Hispanic, 34.8% non-Hispanic and 38.7 unknown.  COVID cases have disproportionately affected the elderly and people with underlying medical conditions.  In accordance with DOH-Broward’s Responder Safety and Health plan, “prior to and during an incident, DOH-Broward’s Safety officer will work with subject matter experts to identify responder safety and health resource requirements, such as equipment. DOH-Broward will complete medical screening to ensure that the responder is physically, and to the greatest extent possible, mentally fit to deploy to a disaster area. DOH-Broward will create recommendations to responders for personal protective equipment (PPE) based on the identified risks. Note- DOH-Broward staff participates in risk-specific training on hazard awareness and recognition, communication of potential personal risks, and proper use of PPE, prior to and as needed at the time of the incident (Just in time training)”.  DOH-Broward stood up its Incident Management Team (IMT) on January 29, 2020.  DOH-Broward’s Public Health Preparedness (PHP) staff ensures that all staff receives risk-specific training as well as other training such as medical countermeasures and personal protective equipment (PPE). Planning objectives included ensuring that all at-risk employees fit testing is up-to-date and if not, be provided a new fit test in a timely manner and that newly identified at-risk employees be provided medical screening and fit testing. DOH-Broward utilizes quantitative fit testing to ensure individuals are issued the proper N-95 respirator that ensures a tight-fitting seal. PHP staff arranged for a contractor to conduct 8 training sessions on the proper use of PPE for DOH-Broward employees in February, 2020.  In early March, 2020, Broward County experienced its first cases of COVID and by mid-March, cases began to increase in congregate settings and within the staff of LTC facilities.  In response, PHP staff worked with the Agency for Healthcare Administration (AHCA) to provide ongoing fit testing and PPE didactic training to AHCA staff entering affected LTC facilities.  External contractors conducting COVID testing at testing sites and in the field and the Florida National Guard assigned to work at testing sites also required fit testing. DOH-Broward has one designated fit testing room.  Due to the increased demand for fit testing, a second room was set-up with the proper equipment to conduct fit testing.  Normally, PHP staff conduct approximately 20 fit tests per month.  The number of tests able to be conducted per day was doubled by adding a second fit testing room.  During the five-month period of January 2, 2020 – April 27, 2020, 350 didactic fit testing sessions were conducted or an average of 57 per month. 14 individuals were tested in January, 54 in February, 232 in March and 51 in April. All individuals tested also received didactic PPE training and practiced proper donning and doffing.  To date, none of these individuals have become COVID positive while using PPE. As N95 respirators became more and more difficult to purchase, KN95s (which do not require fit testing) and, in some cases KN95s in combination with face shields, are now being issued.

The goal of the practice was to ensure public health responder safety through training and proper use of PPE.  The DOH-Broward IMT stood up on January 29, 2020.  Planning objectives included ensuring that all at-risk employees fit testing is up-to-date and if not, be provided a new fit test in a timely manner and that newly identified at-risk employees be provided medical screening and fit testing. DOH-Broward utilizes quantitative fit testing to ensure individuals are issued the proper N-95 respirator that ensures a tight-fitting seal. PHP staff arranged for a contractor to conduct 8 training sessions on the proper use of PPE for DOH-Broward employees in February, 2020.  In early March, 2020, Broward County experienced its first cases of COVID and by mid-March, cases began to increase in congregate settings and within the staff of LTC facilities.  In response, PHP staff worked with AHCA to provide ongoing fit testing and PPE didactic training to AHCA staff entering affected LTC facilities.  AHCA local leadership would send an email to PHP staff to schedule the training for staff that would be required to inspect LTC facilities, which was then scheduled and conducted generally on the same day. DOH-Broward PHP staff also provide ongoing fit testing and PPE didactic training to External contractors conducting COVID testing at testing sites and in the field as well as the Florida National Guard assigned to work at testing sites.  Proper use of PPE training and opportunities to don and doff were also conducted.  DOH-Broward PHP staff also issued the proper PPE to all those who were fit tested during this process.  The addition of a second fit testing room enabled scheduled and non-scheduled individuals to be fit-tested and trained in a timely basis.

DOH-Broward and AHCA initially conducted joint investigations of cases of COVID at LTC facilities.  ACHA staff had not previously been fit tested nor had they been trained on the proper use of PPE.  ACHA did not have the capability to fit test.  When a LTC facility was in need of evaluation and/or training on infection control practices, DOH-Broward epidemiology staff would notify our Facilities lead who would notify ACHA.  ACHA would then send an email to DOH-Broward PHP staff with their staff’s names which needed fit testing and PPE.  DOH-Broward PHP staff would then schedule the individuals.  PHP staff provided the fit testing and training for ACHA representatives and subsequently issued proper PPE to them.  This process was also used with the Florida National Guard and contractors who would be working at testing sites.  When fit testing and training was required for larger numbers of individuals, a second fit room was set to help accomplish this in a timely manner.  While waiting to be fit tested, chairs were placed outside at a minimum of 6 feet apart, with individuals wearing face coverings.  This allowed PHP staff to move through the process quickly.  Once completed, a training video on the proper use of PPE and in person demonstration was accomplished in a very large auditorium with appropriate PPE being worn and social distancing provided by spacing out the training recipients.  The relationship between AHCA and DOH-Broward has been significantly strengthened as a result of this partnership.