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June 6 - The Consumer Financial Protection Bureau has expanded its Consumer Complaint Database to include state-by-state information. The CFPB also added complaints about money transfers and credit reporting to the database.
This data puts valuable information in the hands of consumers to help them understand what is happening in their states, said CFPB Director Richard Cordray. And by adding credit reporting and money transfer complaints to the Consumer Complaint Database, we are making these important markets more transparent and accountable to all consumers.
The expanded Consumer Complaint Database is available at: www.consumerfinance.gov/complaintdatabase.
Users can easily track, sort, search and download complaints listed in the Consumer Complaint Database. In March, the database expanded from more than 19,000 credit card complaints to nearly 90,000 complaints on credit cards, mortgages, student loans, bank accounts and services, and other consumer loans, like auto loans. As of today, the database contains about 113,000 complaints. The live database updates nightly; so as the CFPB handles more complaints, more are added.
The database allows the public to see what consumers complained about and why. It includes the type of complaint, the date of submission and the company that the complaint concerns. A consumers identity and other personal information are not included. Complaints are listed in the database only after the company responds to the complaint or after they have had the complaint for 15 days, whichever comes first. The CFPB uses the complaints along with other information, such as the timeliness of the companys response, in a variety of ways, for example, to help prioritize complaints for investigation.
State Data
The Consumer Complaint Database update will add a new field to every complaint the state it came from. While five-digit ZIP code information self-identified by the consumer has always been included in the complaint information, adding the state helps people more easily localize data. The state field also includes the District of Columbia, U.S. territories, and the military post office addresses of servicemembers.
According to the database, the top states per capita by mortgage complaints are: 1) New Hampshire, 2) Maryland, 3) the District of Columbia, 4) Georgia, and 5) Florida.
The top states per capita by credit card complaints are: 1) the District of Columbia, 2) Delaware, 3) Maryland, 4) New York, and 5) New Jersey.
And, the top states per capita by bank account and service complaints are: 1) the District of Columbia, 2) Delaware, 3) New Jersey, 4) Rhode Island, and 5) Maryland.
Credit Reporting
The CFPB is also adding more than 6,000 credit reporting complaints to the database. The bureau will add new complaints as they come in and are processed. The CFPB began taking credit reporting complaints in October 2012.
Credit reporting companies, which include what are popularly called credit bureaus or credit reporting agencies, are private businesses that track a consumers credit history and other consumer transactions. The credit reports they generate and the three-digit credit scores that are based on those reports play an increasingly important role in the lives of American consumers. The consequences of errors in a consumer report can be catastrophic for a consumer, shutting him or her out of credit markets.
When submitting a complaint about credit reporting, consumers can select from five common issues, which are all searchable on the updated database:
Money Transfers
Money transfers, the latest category of complaints that the CFPB began accepting in April, are also being updated to the Consumer Complaint Database.
Money transfer complaints include domestic or international wire transfers. Each year, consumers in the United States send abroad tens of billions of dollars to family members, friends and businesses through international wire transfers, also known as remittances. Prior to the passage of the Dodd-Frank Wall Street Reform and Consumer Protection Act, international money transfers were generally excluded from existing federal consumer protection regulations.
When submitting a money transfer complaint, consumers can select from the following six common issues, which are all searchable on the updated database:
The CFPB encourages the public, including consumers, analysts, developers, data scientists and companies that serve consumers, to analyze, augment and build on the public database to develop ways for consumers to access the complaint data.
To submit a complaint, consumers can:


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Doctorsofpopculture |
Candy May Net $130 Mil That Tori Won't Get
Candy Spelling makes Joan Crawford seem like Mother Teresa. -
Battle of the Bootays
Yes... they're both really hot- but one isn't able to do long division. -
Haley Joel Mugs for Cop Cam
Haley and Mel Gibson should do an after school special with one another. -
Haley Joel Mugs for Cop Cam
He and Mel Gibson should do a movie together -
Pirate Beauty Back for More Booty
Love Keira - love Johnnie- love Orlando- but we have no clue why he's with sickly Kate Bosworth -
Dane Surrounded by Babes
Dane loves the ladies -
A Silent Simpson Parties On
We have no idea who is going to buy this record. Then again, we have no idea how 75,000 people… -
Is Britney Having a Girl?
This little girl is going to have one question for her mom- -
Nick Shacks Up With Vanessa
Jessica must want to die- while Nick is moving in with Vanessa- she is about to be dumped by John… -
Is Halle Still On Cloud 9?
We love Chris and Halle

subset: commoncrawl


text:
Remind MeTCMDb Archive MaterialsView all archives (1)
DVDs from TCM Shop
3:10 to Yuma A sheriff must run the... MORE > $29.95 Regularly $29.95 Buy Now
Screenplay Info
powered by AFI
Based on the short story "Three Ten to Yuma" by Elmore Leonard in Dime Western Magazine (Mar 1953).
Please support TCMDB by adding to this information.
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E90 Site Sponsors - Products, sales, group buys and more
Get the latest news, products, specials and group buys for your E90/E91/E92/E93 from the site sponsors! Have a question for a sponsor, post it here. Click here to view all the site sponsors and see what they are offering! |
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Personalize 'N Stitch 2.0 B2229
License: | Free to try |
Price: |
Rated: |
Downloads: | 89 |
Op. System: | Windoows All |
Last updated: | 2011-04-20 |
File size: | 88.22 MB |
Publisher: | www.amazingdesigns.com |
Editor`s review: Personalize 'N Stitch
Enjoy personalizing your embroidery projects with the wide assortment of lettering and monograms found in Personalize ´N Stitchâ"¢ 2.0! Easy-to-use wizards help even beginners create monograms and single or multiple line text in minutes. Plus, merge your lettering with your own design or one of 600 FREE built-in designs . FEATURES Personalize ´N Stitch 2.0 makes it easy to create lettering that´s perfect for your projects Rotate, re-size, recolor and reposition letters, monograms or entire lines of text Reshape text into 11 envelope styles including arcs and pennants Adjust density and pull compensation Choose one of 12 fill stitches for larger text Unlimited undo allows you to experiment freely with different effects Detailed built-in help section and our famous free and friendly telephone or e-mail tech support
Digitize 'N Stitch
Automatically create unique applique, cross-stitch, border, and embroidery designs with just a few c...


text:
Lt. Governor Tim Murray took a tour of the construction in Dedham Square on Wednesday, and was very excited about the developments. Massachusetts invested $1.7 million in order to renovate the infrastructure in Dedham. And Lt. Gov. Murray was happy to see that small businesses were still strong in the area.
"My very recollections of this area date back to...prior being in state government... as a practicing attorney," Lt. Gov. Murray said. "I had a chance to walk down with a fellow attorney and I got to see that this was a vibrant business district."
Lt. Gov. Murray expressed the importance of the project because it was creating construction jobs in the area. And he was certain that after the project was complete, it will bring in a significant amount of pedestrian traffic for the local businesses in Dedham Square.
"One of the key issues that we keep hearing from small businesses, that are in business districts like this... are issues that deal with traffic, pedestrian friendly environments, and permits," Lt. Gov. Murray said.
And officials are promising that the construction will resolve those issues. But it will still take some time for completion.
According to the planning committee, the curbs in Dedham Square should be completed by this fall. However, the town will have to wait for Spring 2013 in order for the project to be considered complete.
Dedham Square Construction Expected To Be Done by Spring 2013
Lt. Gov. Murray took a tour of Dedham Square to take a look at the latest developments.
+ Leave a Comment
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In order that Southern Virginia Regional Medical Center may be in compliance with Title VI, Civil Rights Acts of 1964, all patients being admitted to the hospital will be assigned a room and bed on the basis of space available and without regard to race, color, national origin, or handicap. Failure of the hospital to comply with federal laws may result in a withdrawal of federal funds for services rendered to patients receiving governmental assistance.
We want to make your hospital stay as comfortable as possible. It is important to us that you are satisfied with the services and care you receive at our hospital. If you encounter a problem or have a complaint, please ask to speak with the nursing director or designee for your unit.
During your visit to Southern Virginia Regional Medical Center you deserve the best service possible. If you have a concern or suggestion to express, we want to hear from you. Feel free to send us a message through Contact Us.


text:
Cindy writes:
Hi Peter. I gone through too much pain in recent years from lupus /
fibro / degenerative disk disease and now am waking with hip and
occasional shoulder pain. I have a very firm 2 sided sealy excellent
condition mattress with a 3 inch Talalay mattress topper you
recommended last year. It has helped but not enough now. I cannot
stand anything you sink into at all an love the feel of latex. I
was looking at your mattresses and wondered if you would advise a
firm full latex mattress? I don't know if you sink into a firm one.
I am 5'7 240 and my husband 6' 300. I don't know if the very firm
mattress is what is now causing pressure points under the latex
topper? Please advise with all acceptable recommendations.
Thank you very much for time!
Hi Cindy,
It would be the extra firm mattress causing the pain, but it is a good choice for supporting your combined weights.
You have a couple of options.
If the mattress isn't already too high, add a Dunlop or medium Talalay topper to the mix.
You would put it under the soft topper you already have. I would suggest 2".
Another option is a latex mattress....6" or 8"
The 6" is a solid Dunlop core, which should be all you'll need.
The 8" models are that 6" core with 2" of Talalay in your choice of soft, medium or firm.
But given that you already have the 3" soft topper, the 6" core is all you need.
Here are links to the latex mattresses and latex toppers.
Phone: 1-888-732-5923
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Featuring 100% All- Natural Talalay Latex Mattress Toppers...UPS Free Delivery Anywhere In the US & Canada
Are you a Fan? "Like" us on Facebook


text:
Himalayan Wonder FF'13
$ 23.31(Himalayan Wonder Assessment) This Himalayan First Flush blend is from the up-and-coming tea-growing district of t... -
Jungpana White FF'13
$ 41.24Not the usual excellent Jungpana standard. It would be difficult to distinguish this lovely white tea from a... -
Giddapahar Special FF'13
$ 17.48A lovely, well-balanced, harmonious tea with all the trappings of First Flush character; strong, assertive, but re...
Thurbo Moonlight FF'13
$ 65.52Another "Moonlight sonata." This tea has a light, ethereal quality that is easy-to-appreciate for its quiet,... -
Indian Masala Chai Tea
$ 13.33a This Organic Herbal Tulsi Masala Chai blend is one of the first products aimed at bringing traditional Indian masa... -
Green Tea Samples
Starts at: $ 2.00
Unsure of which green tea would suit you best, order our Green Tea sampler pack (10 gram each) and taste all the g...


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Welcome to the Monastery | |
PerlMonks |
Re^4: How does perl-thanks work?by marto (Chancellor) |
on Dec 17, 2013 at 15:24 UTC ( #1067480=note: print w/ replies, xml ) | Need Help?? |
Indeed, that aspect isn't covered in this documentation. It is not uncommon for mailing lists (especially high volume/technical ones) to be moderated in this fashion. If I get time this evening I'll submit changes to this documentation clarifying usage and what to expect. Update: ... and report the broken links on http://dev.perl.org/perl5/. Done.
In Section
Seekers of Perl Wisdom


text:
Post-game wrap: Heels humble Hokies 48-34, send them to worst start since 1992
OK, I've filed all my stories. Here's my game story. And here's Aaron McFarling's column.
Now for a few more notes and quotes …
Follow me on Twitter and Facebook.
** Frank Beamer summed up his thoughts on the game like this, and Tech fans will probably agree with him on this take:
"I don't think it's time for excuses," he said. "I think it's time for results.
The results aren't pretty. Virginia Tech is 3-3 after Saturday's 48-34 loss to North Carolina, the earliest in a season the Hokies have had three losses since 1992. Tech went 2-8-1 that year, mind you.
"I never thought we would be considered an average team by any means," cornerback Antone Exum said. "That's not what we're about."
** I out-lined the defensive shortcomings in the game story, but here they are in bullet points:
- Tech gave up 533 yards, the second time it has given up more than 500 yards this year. The Hokies have given up 495 yards or more in losses to Pittsburgh, Cincinnati and now, North Carolina.
- 339 of those yards came on the ground. That's the third-most against a Tech team under Beamer and the most by a team that wasn't primarily running the option.
- Tar Heels tailback Giovani Bernard gashed the Hokies' defense for 262 rushing yards, breaking the previous high by an individual against Tech, when Wake Forest's Josh Harris ran for 241 yards in 2010. Bernard had 10 runs of 10 or more yards.
- The Tar Heels' 48 points were the most the Hokies had allowed in a league game since joining the ACC, easily surpassing the 38 that Georgia Tech scored in 2006.
- UNC had never scored more than 24 points in any of the last eight meetings with Virginia Tech. It had 28 at halftime.
- UNC's 48 points were the most by either team in the history of the series.
"I came to Virginia Tech because we're known to play great defense," defensive end James Gayle said. "I feel like we let the team down."
The biggest problem? Missed tackles, which defensive coordinator Bud Foster called "pitiful."
"We're not making plays in space," he said. "Our defense is designed to have a free hitter. And when you have your free hitter there, you'd like him to make a play. Right now we're not making that play. We're missing that and it's going for big plays after that."
"You say, 'They're minor things, they're minor things,'" Exum said. "But too many minor things add up to something major."
The game story essentially deals with the defensive problems, so read that.
** I will point out one crucial play that came in the second quarter, though. North Carolina had a fourth-and-one at its own 38 to start the second quarter. The Heels raced to the line and snapped it quickly.
Bernard basically ran off tackle for a 62-yard touchdown untouched, giving UNC a 21-14 lead.
Gayle said afterward that it was a look Tech hadn't seen. Foster said that was nonsense.
"We had the defense in there and we had practiced that," Foster said. "So that's a copout. Just go execute. Just go perform."
** What's the mood in the locker room? Down? Angry?
"I think a little bit of both," Exum said. "Guys are angry that we're not performing as well as we should. We're losing games. Kind of down and disappointed. But I think it's my job as well as a couple others to be a leader, to stay upbeat, to stay confident and let the guys know that this isn't the end. We're going to keep continuing to fight, continuing to get better. We'll get this thing together."
** North Carolina won despite being flagged 15 times for 126 yards. Tech would have liked to have seen a few more thrown.
"I felt like they were holding all day today, to be honest," Gayle said.
Foster noted Tech's inability to keep leverage or make tackles in the open field, but couldn't help but agree with Gayle.
"I saw a couple [holds] early," he said. "There was one critical play on the first drive and their tackle made the best tackle of the day on Jack Tyler. We should use that as a guide and a technique for us, defensively."
** Now, to the offense. The final stats don't look bad, but the overall consistency of the group, particularly in the second half, was still a big shortcoming.
Quarterback Logan Thomas broke out of a season-long slump, throwing for a career-high 354 yards and two touchdowns. In a role reversal, he had to answer questions about what it was like for the defense not to hold up its end of the bargain.
"It's tough," Thomas said. "They've done it for us plenty of times. We understand."
The Hokies took a step forward by scoring points in the first quarter for the first time in four weeks, racing down the field and getting into the end zone on a 13-yard run by Thomas, Tech's first opening-drive touchdown this year.
Thomas had a solid game, completing 26 of 49 passes and hooking up with Marcus Davis and Corey Fuller on touchdowns of 50 and 63 yards, respectively, to keep the Hokies in the game.
Fuller had 143 yards on five catches, Demitri Knowles had 83 yards on six catches and Davis 66 yards on three catches.
"I thought our line did a terrific job handling them, giving me time to throw," said Thomas, who was sacked once and threw one interception on a deep ball.
It was the most points for the Hokies in a losing effort since a 52-49 loss to California in the 2003 Insight Bowl.
** BUT, the running game was abysmal. Tech couldn't establish the run, then abandoned it late when facing a huge deficit. The Hokies' 40 rushing yards were the team's fewest since the season opener in 2007 against East Carolina, when they had 33.
Thomas led the team with 20 rushing yards. Michael Holmes was the leading rusher with only 19 yards.
He lost a costly fumble early in the third quarter, having the ball ripped away by North Carolina linebacker Travis Hughes near midfield. The Tar Heels would capitalize with a touchdown, turning an eight-point lead into 15.
"The guy rips the ball out and a couple plays later, they're in the end zone," Beamer said, fixating on the play afterward. "Just big turnarounds."
** Wide receiver Dyrell Roberts somehow held on to a pass on the Hokies' first drive, having his helmet knocked off with an illegal hit by North Carolina's Tim Scott. He stayed in but would ultimately leave with what was later diagnosed as a concussion.
Roberts played one more drive and had a critical error. A busted coverage left him open, streaking up the left sideline. Thomas zipped a pass right to him, but it went through his hands and bounced off his facemask on third down, leading to a punt.
Roberts left the game and had a towel over his head on the sideline. He changed into street clothes for the second half.
** North Carolina's Sean Tapley returned a first quarter kickoff 94 yards for a touchdown, the first time a team has done so against Virginia Tech since Syracuse in 1993.
The Hokies had gone 237 games without giving up a kick return for a touchdown, what was the longest active streak in the country.
Virginia Tech answered later with a 93-yard kick return for a touchdown by Knowles, the first of his career. It was the Hokies' second touchdown in the return game this year.
** Here are a few more dot, dot, dots …
- Virginia Tech had been 13-0 since joining the ACC in league road games in the state of North Carolina, including a 4-0 mark in Chapel Hill.
- Tech had won 23 straight road conference openers, a streak that dated back to its time in the Southern Conference.
- Thomas' rushing touchdown in the first quarter was the 15th of his career, breaking a tie with Bruce Arians and moving him into fourth place on Virginia Tech's career list for a quarterback. Michael Vick is up next, with 16.
- Antoine Hopkins started at defensive tackle alongside his brother, Derrick. It's the first time they had started side-by-side since last year's Clemson game, when Antoine tore his ACL.
- Running back Tony Gregory didn't travel because of a knee injury. Linebacker Tariq Edwards did not make it because of a death in the family.
- Safety Michael Cole (Cave Spring) led the team with 11 tackles.
** Lastly, Foster put the gravity of the situation into context with this quote. I'm guessing no Virginia Tech fans would have thought this was an issue coming into the year.
"We're 1-1 in the league on our side," Foster said. "We've still got a lot to play for, with the meat of our schedule still ahead of us. We've got to play well just to make a bowl game.
"We're going to take it one at a time. We can't look beyond that. We're going to play … one … game … at a time. One play at a time. One series at a time. One game at a time. That's what we've got to get back to doing. Getting back to playing with passion, playing with trust, having trust in each other. I think that's an issue a little bit right now from our side of it. I think guys are looking around rather than going and making a play.
"We've got to go earn our success. I think what's happened over the years. We've got to be careful that we think it's just going to happen. And how we've made it happen is we've earned it. There are teams that have probably been more talented than us in the past, but we out-willed them, out-efforted them, we out-fought them, whatever it may be. And we've got to get back to doing those things."


text:
Alamo Colleges Education Services is a secure portal connecting Faculty, Staff & Students to Academic Resources, Email, and other Online Resources.
Support Contacts Helpdesk (210) 485-0555 Weather Line (210) 485-0189
ACES login
Apply for Admission
Business Office
Financial Aid
Tuition and Fees
Police Department
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To help students and parents with applying for state and federal financial aid for college, the Alamo Colleges is offering free sessions to provide information and one-on-one assistance in understanding the financial... Read More >
Friends, family, partners and those invested in the Scobee Education Center were gathered this week to remember and celebrate the lives of the Challenger crew that were tragically lost 28 years ago, on Jan. 28, 1986. Read More >
This week, Alamo Colleges Foundation received a $20,000 gift from the Odelia B. McCarley Charitable Trust to establish the Odelia B. McCarley Nursing Endowed Scholarship. Read More >
The Alamo Colleges is partnering with Weatherford International Limited to provide job training Read More >
Recipients of the Alamo Colleges Semmes Success Scholarship were honored at a recent reception in the Koehler House at San Antonio College. Read More >
The new Schedule Planner in ACES lets you build a class schedule that fits your busy life. No more searching for classes one by one... Read More >
The Nancy Smith Hurd Foundation has awarded $250,000 to the Alamo Colleges Foundation to add to the Nancy Smith Hurd Endowed Scholarship for nursing, pre-nursing and allied health students. Read More >
Finalists Selected in Northeast Lakeview College President Search Read More >
Eleanor Alvarez Major: ASL Interpreter GPA: 3.51San Antonio College
In 2007 Eleanor Alvarez received her GED. Eleanor is the first in her family to attend college. She is an ASL interpreter major. Recently, Eleanor was inducted into the Phi Theta Kappa Beta Nu chapter at San Antonio College. The Four hallmarks of PTK are: Scholarship, Leadership, Fellowship, and Service. I would like to address how Eleanor excels in each of these hallmarks. Scholarship-Eleanor has been enlightened with the realization that scholarship is more than just receiving– scholarship is what you give back to society once you have succeeded. Leadership– When participating in Phi Theta Kappa Projects, Eleanor does not dictate to others what needs to be done; instead, she takes the initiative and leads by example. Fellowship–Eleanor extends her warm smile and personality everywhere she goes. She enjoys being a friend as well as making friends. Service-As a chapter member, Eleanor chose to serve her community service hours at the Phi Theta Kappa Food Pantry. Eleanor's self –satisfaction comes from being able to see the people that benefit from her efforts.Eleanor has volunteered in different events and activities on campus and in the community, showing her generosity, determination and positive character. Eleanor has dared to go beyond her own expectations, and is a true inspirational student for all of us who have the pleasure to interact with her. Eleanor has the desire to improve her life through the power of education and I have no doubt that she will go far and reach any goals she sets for herself.On a personal note, she is the proud mother of two teenage daughters – Yes, Eleanor knows a challenge. Her gratifying moments are when her daughters' speak of college and their career choices. As a mother, she sets a wonderful example for them. Eleanor's face beams when her daughter's say to her, "We're proud of you mom." San Antonio College is proud of you too, Eleanor. Congratulations!


text:
Porta Westfalica (gorge)
The Porta Westfalica, also known as the Westphalian Gap, is a gorge and water gap, where the Weser river runs through the passage between the mountain chains of the Wiehengebirge in the west and the Wesergebirge (part of the Weserbergland) in the east. It is located in the district of Minden-Lübbecke in North Rhine-Westphalia, Germany.
Since 1973 Porta Westfalica is also the name of a town, which was established by merging fifteen villages surrounding the gorge. Since 2006 it is a National Geotope.[1]
The name "Porta Westfalica" is Latin language term, and means "Gate to Westphalia". Coming from the north, the gorge is the entry to the region of Westphalia. Despite the Latin name the term was not coined in Roman times, but by scholars of the 19th century.
High above the gorge on the west side is a large six-sided stone structure that can be seen from a considerable distance; this is the Emperor William I Memorial, erected in honour of Kaiser Wilhelm I. and dedicated in 1896.
- ^ Homepage of the City of Porta Westfalica retrieved on 27. January 2011
External links[edit]
Media related to [[commons:Category:|]] at Wikimedia Commons


text:
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- 01-03-2013, 01:12 AM #2If you want to know something about flash player go to this blog flash-video-player.blogspot.com
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text:
Trick Trick & The Curse Of The Yung Berg Chain: Trick Trick Breaks Down The Whole Story From Start To Finish "I Take The Chain Home. I Put It In The Closet. What Im Gonna Do With It? Wear It. Its Fake"Description: VladTV reports "Detroit OG Trick Trick breaks down the entire Yung Berg chain snatching story from start to finish" |
Total Views : 163,355 Video Added : 2008-11-18 Video Code:
. | . |


text:
- 24-hour front desk
- Self parking
- Business services
- Total number of rooms - 40
- Number of floors - 2
- Bar/lounge
- Free parking
Expedia.co.uk is available 24 hours on 0203 027 8675 or from outside the UK on +44 203 027 8675. Calls are charged at your local rate. However costs may vary depending on your service provider and from mobile phones.
×If you find the same hotel for a cheaper price elsewhere online, we'll refund you the difference. Terms and Conditions apply (applies to pre-paid bookings ONLY).
×About the neighborhood: Maumee
On the Maumee River, Maumee is a suburb of Toledo, Ohio. The city boasts public parks, an indoor theater, and a summer fair and parade. Maumee showcases its historic homes and commercial buildings (some dating to the 1840s) in two historic districts listed in the National Register of Historic Places, with landmarks such as the Wolcott House and the House of 4 Pillars.
Situated near the airport, in Maumee, this hotel is close to Maumee Antique Mall, Maumee Sports Mall, and Lucas County Recreation Center. Also nearby are Stranahan Theater and South Toledo Golf Club.
Americas Best Value Inn provides a bar/lounge, free parking, a 24-hour front desk, and self parking.
Televisions come with premium satellite channels. Guestrooms also feature complimentary wireless Internet access, refrigerators, and microwaves.
Within 10 minutes
The closest major airports to Americas Best Value Inn are:
Toledo, OH (TOL-Toledo Express) - 12.2 km / 7.6 mi
Detroit, MI (DTW-Detroit Metropolitan Wayne County) - 75.3 km / 46.8 mi
The preferred airport for Americas Best Value Inn is Detroit, MI (DTW-Detroit Metropolitan Wayne County).
Distances are calculated in a straight line from the property's location to the point of interest or airport and may not reflect actual travel distance.
Distances are displayed to the nearest 0.1 mile and kilometre.


text:
A sexy peacock. A sexy sundial. A sexy poppy. A sexy bedspread. A sexy four-leaf clover. A sexy flag. A stick of sexy rock. A sexy Flump. A sexy ladybird. If Alistair Campbell really wanted the
DOES __name__ DESERVE TO BE #__position__? SHARE IT!
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I'm going to add pictures from Tuesday's Silent Gathering soon. In the meantime enjoy this preview of the Vogue November cover, featuring Marion Cotillard, Penélope Cruz, Nicole Kidman and Kate Hudson. Many thanks Kelly for the heads up.
Your thoughts?
- Marion on Oprah next Wednesday!, posted on November 14, 2009
- First still of "Nine", posted on November 7, 2008
- Vogue Scans, posted on October 20, 2009
- More pictures from Silent Gathering, posted on October 15, 2009
- More 'Nine' Promotion, posted on November 7, 2009


text: Tao trio Edit History Talk0 7,403pages on this wiki Category page Revision as of 13:20, April 6, 2013 by Wattz2000 (Talk | contribs) (diff) ← Older revision | Latest revision (diff) | Newer revision → (diff) The Tao trio is a term to the three powerful legendary Pokémon of the Unova Region: Reshiram, Zekrom, and Kyurem. Kyurem Zekrom Reshiram Pages in category "Tao trio" The following 3 pages are in this category, out of 3 total. K KyuremR ReshiramZ Zekrom Categories: Legendary Pokémon


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- Courtney said...
"4. You know that the Terrible Two's have nothing on the Tempestuous Three's or the WTF Four's"
Two gets a bad rep due to 3 and 4's awesome PR campaign. - Glow said...
The WTF Fours. I love it.
I beg to differ with number one. Call me a bad mom, but sweatpants, popcorn, a movie and my husband sounds AWESOME compared to screaming and boogers and peanut butter. So, yes, I would have it some other way. Since I have kids and I CAN'T have it any other way, I will continue to love on them and hug on them and smother on them all my affection every waking hour I can!
- HerMelness Speaks said...
You work spit-up into your overall 'look'.
- MOMS OF ZECK said...
Hey I just discovered your blog.. Visit mine I am a cancer(ic) mom of a 3 yr old. I would love to hear your story to compare with mine. BTW my son and I just moves from VA to Istanbul due to a family members cancer ..to support her...
write me at firstname.lastname@example.com


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How to send note via AppleScript
Just save this script in the Users/username/Library/Scripts/ folder and make sure the script menu is running.
To use it, just select text in an application (Safari, TextEdit, Mail...) and then run the script from the script menu. The text will be saved in a text file on the desktop and then opened with BlueTooth File Exchange to send the BT phone.
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text:
Return of the Trequartista
"The moment we signed [Riccardo] Saponara it was obvious we'd play with a 4-3-1-2 and not 4-3-3. Milan are planning a return to that tactic," Adriano Galliani told Sky Sport Italia earlier this week. So is the tactical switch a backward step or a move in the right direction as the Rossoneri look to play more expansive football next season?
During the course of the last campaign, the Milan front office were keen to stress the strategy that they would be implementing across all levels of the youth sector. It would be based on the 4-3-3 set-up adopted by the senior squad, and would run through the various youth teams in a bid to prepare the youngsters to seamlessly move through the ranks.
However, it would appear that the club have gone back on that plan, with the Rossoneri set to re-introduce the trequartista role into the team as of next season. Saponara, 21, has been lauded as the perfect player to take up that position, having enjoyed a successful season with Empoli.
The Italy under-21 international is expected to make his debut in the European Championships on Saturday against Israel, and it will be interesting to see how he copes in that environment with the pressure mounting from those at his new club.
Galliani has noted on several occasions that the youngster reminds him of Kaka, and it is easy to see why. Saponara has both an eye for an assist and goal, while demonstrating a real change in pace with the ball at his feet.
Equally capable of accelerating past his marker as he is of using trickery to find another way, it does indeed appear to be a wise investment. Yet is it not a risky strategy to change the complexion of the team and rest your hopes on a player untested in Serie A?
Kaka had been linked with a move back to the club again this week, but Galliani has made it clear that due to both his age and wage demands, the Brazilian will not return to San Siro. Instead, he discussed the possibility of using Kevin-Prince Boateng in that position, while also looking at alternatives in the transfer market, namely Alessandro Diamanti.
- Milan deny Kaka interest
With a wide selection of midfielders to choose from, Massimiliano Allegri may well benefit from the decision to resort back to the old formation. It would allow Riccardo Montolivo to dictate the play from a deeper role, while also introducing some creative spark behind Stephan El Shaarawy and Mario Balotelli.
By deploying two combative midfielders either side of Montolivo, similar to how Milan currently set up, it would allow the full-backs to provide greater width and stretch the play, as legendary former players have done in the history of the club.
A criticism of Allegri over the course of his tenure is the one-dimensional nature of his sides. While Zlatan Ibrahimovic was more than capable of dealing with the pressure of having play continuously go through him, Balotelli has since picked up the mantel.
However, add a central creative hub to the mix and it could transform Milan into a more dynamic, exciting and unpredictable outfit. The decision may have arrived after pressure from Silvio Berlusconi, but it may well be the right move.
Excited by Saponara's introduction into the team? Which tactical formation would you prefer?
For all the latest Milan and Serie A news, you can follow me on Twitter @italiafooty


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Neil Nenner
Born in a kibbutz in Northern Israel in 1977, Neil studied industrial design at Shenkar College of Design, Israel's leading design school.
An accomplished mountain climber and sailor, Neil's design is often inspired by his outdoor passions. Among his current urban furniture designs for Tel Aviv boulevards is an above ground seating that invites the user to climb and sit on the trees !
One of the founders of Gaga and Design, Neil plays a prominent role in the design and direction of the company which specializes in the use of traditional weaving techniques for contemporary furniture.
In addition to his own design work, Neil teaches at Shenkar College of Design.


text:
01. Barroom Hero
02. Fightstarter Karaoke
03. John Law
04. Regular Guy
05. 3rd Man In
06. Career Opportunities (Live)
07. Never Alone
08. Take It Or Leave It
09. Eurotrash
10. Front Seat
11. Denial
12. Billy's Bones
13. Road Of The Righteous
15. Cadence To Arms (Live)
16. Do Or Die (Live)
17. In The Streets Of Boston (Live)
18. Never Alone (Live)
19. Get Up (Live)
20. Far Away Coast (Live)
21. Boys On The Docks (Live)
22. Skinhead On The MTBA (Live)
23. I've Had Enough (Live)
24. White Riot (Live)
Epitaph > Artists > Dropkick Murphys > The Singles Collection, Vol. 1 |
The Singles Collection, Vol. 1
Dropkick Murphys
Great collection of early, raw tracks from the catchy Boston combo. Originally released in Europe under the title The Early Years-Underpaid and Out of Tune, this album contains hard to find or out-of-print material from the bands early 7" singles and EP's. The last song on this album is an exclusive live recording from the Boston Pride show in November of 1997, the last show the band ever played at the infamous Rat in Boston.
BAD RELIGION RELEASE TRUE NORTH More
Social Distortion Announce Additional... More
PENNYWISE REUNITES WITH JIM LINDBERG More
No: #80428
US Rel. Date: 05/23/2000
EU Rel. Date: 05/23/2000
Type: Full
Altercation Zine
Transworld Stance
Average Fan Rating: 4.00


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Shakespeare: The Illustrated and Updated Edition
$49.99 | International Version Ships in 6-13 days Freight Free |
Bill Bryson's Shakespeare pairs one of history's most celebrated writers with one of the most popular writers in the English language today. In this elegant, updated, illustrated edition, the superstitions, academic discoveries and myths surrounding the life of one of the world's greatest poets are evoked through a series of full-color paintings, drawings, portraits, documents and photographs. Bryson also discusses the recent discoveries of the Cobbe portrait and the remains of Shakespeare's first theatre in Shoreditch.The centuries of mysteries, half-truths and downright lies about Shakespeare are deftly explored, as Bryson draws a picture that includes many aspects of the poet's life, making sense of the man behind the masterpieces. In a journey down the streets of Shakespeare's time, Bryson brings to life the hubbub of Elizabethan England and delights in details of his folios and quartos, poetry and plays. He celebrates the glory of Shakespeare's language and his ceaseless inventiveness, which gave us hundreds of now indispensable phrases, images and words.
Collect Fly Buys when you purchase this titleAuthor | |
Format | Hardback |
Pages | 256 |
Dimensions | 229mm x 178mm x 28mm |
Publisher | HarperCollins Publishers Inc |
Release Date | 1 Nov 2009 |


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The emergence of 2009 H1N1 influenza and the ensuing dilemmas regarding personal protective equipment (PPE) for healthcare personnel highlighted challenges in healthcare delivery policy at institutional, state, regional, and national levels as well as policies about the relevant standards and certification processes. This chapter highlights issues regarding standards and policies for PPE for healthcare personnel and summarizes the experience and literature on the 2009 H1N1 pandemic relevant to PPE. The chapter also provides the committee's recommendations on the next policy and regulatory steps needed to address the current challenges and improve PPE for healthcare personnel.
As described in Chapter 1 (with more detail provided in Box 5-1), a number of state and federal agencies and organizations have regulatory, standards-setting, and policy responsibilities regarding PPE for healthcare personnel. This section highlights several recent and ongoing efforts with potential impact on PPE for healthcare personnel, some of which require further attention and action.
Two recent regulatory changes implemented by the Occupational Safety and Health Administration (OSHA) impact workplace access to
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OCR for page 133
Policy Research and Implementation:
Healthcare Systems, Standards,
and Certification
The emergence of 2009 H1N1 influenza and the ensuing dilemmas
regarding personal protective equipment (PPE) for healthcare personnel
highlighted challenges in healthcare delivery policy at institutional, state,
regional, and national levels as well as policies about the relevant stan-
dards and certification processes. This chapter highlights issues regard-
ing standards and policies for PPE for healthcare personnel and
summarizes the experience and literature on the 2009 H1N1 pandemic
relevant to PPE. The chapter also provides the committee's recommenda-
tions on the next policy and regulatory steps needed to address the cur-
rent challenges and improve PPE for healthcare personnel.
As described in Chapter 1 (with more detail provided in Box 5-1), a
number of state and federal agencies and organizations have regulatory,
standards-setting, and policy responsibilities regarding PPE for health-
care personnel. This section highlights several recent and ongoing efforts
with potential impact on PPE for healthcare personnel, some of which
require further attention and action.
Recent and Ongoing Changes to Standards and Regulations
Two recent regulatory changes implemented by the Occupational
Safety and Health Administration (OSHA) impact workplace access to
OCR for page 133
PPE and voluntary consensus standards. A Final Rule, issued in Novem-
ber 2007, requires employers to provide PPE at no cost to their em-
ployees; this change took the burden of responsibility off the employees,
who in some cases had been paying for their own protective equipment
(29 Code of Federal Regulations [CFR] 1910.132; OSHA, 2007). In Sep-
tember 2009, a Final Rule was promulgated to address various revisions
of the voluntary consensus standards as they applied to several types of
PPE, including eye and face protection (29 CFR 1910.133), head protec-
tion (29 CFR 1910.135), and foot protection (29 CFR 1910.136; OSHA,
2009). Because many consensus standards are updated on a regular basis,
the new OSHA regulations state that the employer needs to supply PPE
that meets the current voluntary consensus standard or either of the past
two versions of that standard; thus employers do not have to purchase
new PPE every time a consensus standard is revised.
In October 2009, the National Institute for Occupational Safety and
Health (NIOSH) proposed total inward leakage (TIL) requirements for
the certification of negative-pressure, tight-fitting respirators. The new
regulation would require that half-facepiece, air-purifying respirators
(including filtering facepiece respirators such as the N95 respirator) be fit
tested to an anthropometrically selected panel of wearers. Respirators
would need to be able to achieve an acceptable fit to a wide range of
faces. Two public meetings have been held, and the docket for public
comments closed in September 2010 (NIOSH, 2010a). NIOSH will eval-
uate the comments received and may then release a final standard. The
goal is to improve the fit of respirators.
In 2009, California became the first state in the nation to issue a stan-
dard requiring employers to protect healthcare personnel from influenza
and other viral respiratory diseases when it promulgated its aerosol-
transmissible diseases standard (California Code of Regulations, 2010).
This standard uses Centers for Disease Control and Prevention (CDC)
guidelines and terminology to classify whether an aerosol-transmissible
disease requires droplet precautions (use of face masks is permitted) or
requires aerosol precautions (respiratory protection is required using
N95s at a minimum, and where aerosol-generating procedures are per-
formed, a powered air-purifying respirator [PAPR] or greater level of
protection is required) (Siegel et al., 2007). Thus, by adopting the CDC
guidelines, healthcare employers in California would, for example, pro-
tect personnel against seasonal influenza using face masks, while expo-
sures to measles virus would require respirators (N95s or greater). For
novel or unknown pathogens (e.g., the 2009 H1N1 pandemic influenza
OCR for page 133
virus), the California standard sets the default protection level at airborne
precautions where use of respirators would be required (California Code
of Regulations, 2010).
Recent efforts have also focused on voluntary consensus standards
development and on third-party conformity assessment. ASTM Interna-
tional announced in April 2010 the establishment of a working group that
will develop test methods to assess the effectiveness of antimicrobial
gloves (ASTM International, 2010a). Additionally, a task group within
the subcommittee on consumer rubber products has begun developing
standards that focus on preventing the transfer of microorganisms
through the use of antimicrobial agents (ASTM International, 2010c).
Furthermore, an ASTM International subcommittee is focused on devel-
oping a product certification process for protective clothing and equip-
ment that would include an option for third-party independent
verification that the product met the relevant performance standards
(ASTM International, 2010b).
Existing Standards, Guidelines, and Certification Processes
Food and Drug Administration (FDA)
Medical device legislation beginning in 1937 and amended in 1976 makes
the FDA the principal agency for clearing personal protective equipment (PPE)
for use by healthcare personnel. PPE devices used in healthcare environments
are considered medical devices and are regulated as either Class I or Class II
devices. Class I devices are considered low risk to the user, and the basic re-
quirement is that the manufacturer meet general standards for good manufactur-
ing processes. Some Class I devices require that the manufacturer provide a
510(k) submission and demonstrate that the device meets specific voluntary
standards and is substantively equivalent to a similar "predicate" device currently
on the market. Examples of Class I devices that require a 510(k) submission in-
clude surgeon and examination gloves. Class II devices are considered interme-
diate risk and must be cleared through the 510(k) process before they are
allowed to be marketed. Surgical gowns, face masks, and respirators are also
categorized as Class II devices.
The FDA does not conduct tests on medical devices; the agency reviews
data submitted by manufacturers to demonstrate that the product has been
tested (by the manufacturer or an independent testing organization) to meet
specified consensus standards. Respirators are required to be certified by the
National Institute for Occupational Safety and Health (NIOSH) and must meet
additional requirements for flammability and fluid protection. The FDA does not
have any specific PPE requirements for protection against infectious diseases
such as influenza. Therefore, masks and respirators have requirements that are
OCR for page 133
specifically geared for surgical room use, not for protection against influenza or
other viral respiratory diseases. The FDA has begun clearing such devices that
make claims for antiviral protection.
FDA regulations are designed to control the manufacture and sale of PPE.
These regulations do not specifically apply to employers or employees. Require-
ments regarding the use of PPE in the healthcare workplace are overseen by the
Occupational Safety and Health Administration (OSHA), along with state and
local agencies and employers.
National Institute for Occupational Safety and Health
NIOSH is the principal governmental agency with responsibility for testing
and certifying respirators. The National Personal Protective Technology Labora-
tory (NPPTL) establishes the testing requirements and performs tests on respira-
tors submitted by manufacturers. Testing and certification requirements are
incorporated in the Code of Federal Regulations (42 CFR Part 84). Once a respi-
rator is certified, the manufacturer is not required to resubmit the device for fur-
ther testing unless modifications are made.
NIOSH respirator testing and certification requirements are specific to the
type of respirator (e.g., air-purifying, self-contained breathing apparatus) and are
not specific to the type of workplace where they will be used. There is no specific
certification of respirators for healthcare personnel or for protection against infec-
tious agents such as influenza. However, as discussed in Chapter 3, NPPTL staff
and other researchers have studied the performance of certified filters against
nanoparticles that would be applicable to virons and also have conducted some
research with antiviral filters. The NIOSH certification process does not evaluate
or indicate the efficacy of antiviral treatments that may be applied to filters on
certified respirators.
NIOSH does not certify other forms of PPE, such as gloves and goggles, that
would be relevant to the protection of healthcare personnel. NIOSH staff do par-
ticipate in the development of voluntary consensus standards for other PPE and
perform some research in these areas (IOM, 2010).
Occupational Safety and Health Administration
OSHA has the primary responsibility for enforcing the proper use of PPE in
the workplace, including in healthcare facilities. The two main regulations rele-
vant to PPE use by healthcare personnel relevant to viral respiratory diseases
are 29 CFR 1910.134, which governs the use of respirators, and 29 CFR
1910.132, which governs the use of PPE other than respirators. All respirators
used by healthcare personnel must be NIOSH certified, and their use must be
part of a respiratory protection program that includes attention to issues regarding
medical clearance, fit testing (where applicable), and training. OSHA requires
that other types of PPE meet specified voluntary consensus standards (in some
cases—e.g., for eye and face protection—OSHA regulations include additional
specifications as noted in 29 CFR 1910.133). OSHA does not have specific stan-
dards covering the use of PPE by healthcare personnel and does not require that
such PPE be cleared by the FDA.
Other Agencies and Organizations
A number of other organizations also impact the use of PPE by healthcare
personnel. The Centers for Disease Control and Prevention (CDC) provides in-
OCR for page 133
fection control guidance, including guidance on the use of respirators and masks
by healthcare personnel for protection against influenza. During the 2009 H1N1
pandemic, the CDC infection control guidelines for healthcare personnel during
seasonal influenza (which recommend droplet infection control precautions, e.g.,
a face mask for non-aerosol–generating procedures) were changed to recom-
mend airborne precautions involving the use of respirators (respirators are rec-
ommended for aerosol-generating procedures in both). However, some state
health agencies or local healthcare facilities continued to recommend face masks
consistent with seasonal influenza guidelines for the use of respirators and
masks. In summer 2010, the CDC guidelines were revised to reflect the seasonal
infection control precautions based on availability of an effective vaccine and
updated knowledge about the risk of hospitalization and death from 2009 H1N1
influenza (CDC, 2010).
The Joint Commission provides accreditation for many hospitals and a varie-
ty of other employers of healthcare personnel, such as home healthcare agen-
cies. The use of PPE is included in the Joint Commission's requirements for
State and local health agencies provide guidance and licensing to employers
of healthcare personnel. These agencies provide assistance to employers in the
case of pandemic influenza that may include stockpiling of PPE and offering
guidance on what type of PPE is appropriate for specific tasks.
Standards development organizations (such as the American National Stan-
dards Institute and ASTM International) work through professional organizations
and standards development committees to develop voluntary consensus stan-
dards that specify testing methods and performance expectations. Standards-
development committees include experts who represent manufacturers, employ-
ers, users, and government regulators. Each standards-development organiza-
tion has its own rules about the balance of these committees and voting. Most
standards must be updated on a regular basis (e.g., 5 years) or they are with-
drawn. Standards may specify whether PPE must be tested by an independent
third party or whether the manufacturer can perform the testing.
Moving Forward on PPE Standards and Certification
Many of the issues that require activity by regulatory agencies for
worker protection regarding PPE use during pandemic influenza involve
respirators and masks. Face (eye), hand, and body protection issues all
involve barriers, such as goggles or face shields, gloves, and gowns,
which should provide an adequate barrier against influenza transmission
provided that they cover the exposed area.
A major challenge in preventing influenza transmission continues to
be clarifying the modes of transmission (Chapter 2). Occupational safety
and health principles emphasize the importance of protecting the worker,
particularly when dealing with hazards of unknown severity or health
OCR for page 133
impacts. For novel respiratory viruses, the committee reiterates the
statements in the 2008 Institute of Medicine report regarding transmis-
sion of influenza A: "[w]ithout knowing the contributions of each of the
possible route(s) of transmission, all routes must be considered probable
and consequential" (IOM, 2008, p. 53).
As reiterated throughout this report, PPE is one part of a comprehen-
sive infection control program that includes engineering, administrative,
and workplace controls, including vaccination. Because transmission of
influenza occurs in the community and does not just occur in healthcare
settings from patients and coworkers, vaccination—when effective—is a
preventive measure that offers protection that is not tied to a specific
workplace setting or on-the-job practices and equipment.
Face Masks and Face Shields
As discussed throughout this report, one of the most contentious is-
sues regarding PPE to prevent influenza transmission is the use of masks
versus respirators. Protection of healthcare personnel is paramount in
these discussions. For employers, the issues to consider include purchase
and training costs. As discussed in Chapter 3, more research is needed to
determine the extent and nature of the protection that face masks and
face shields can provide against viral respiratory disease transmission; a
role in providing contact and droplet spray has been suggested but re-
mains unclear. As information becomes available that clarifies the PPE
role that face masks and face shields play in preventing transmission of
viral respiratory diseases, voluntary consensus standards and certification
processes will need to be developed, implemented, and refined so that
healthcare personnel and other consumers will have information on the
effectiveness of these products.
OSHA's respiratory protection standard (29 CFR 1910.134) includes
requirements for the selection, use, and maintenance of respirators.
Since face masks are not respirators, they are not covered by this stan-
dard. OSHA general PPE standard (29 CFR 1910.132) applies to face
shields and face masks; however, specific performance standards or other
design or performance criteria for these products are not included in this
OSHA regulation. To move forward with this issue, OSHA could work
with other agencies and organizations to identify relevant voluntary
consensus standard requirements and consider if selection, mainten-
ance, storage, and inspection requirements for face masks and face
OCR for page 133
shields should be detailed in OSHA regulations to provide further protec-
tion for healthcare personnel.
Fit and fit testing Several significant policy and regulatory issues exist
regarding respirator fit and fit testing that could impact healthcare worker
safety and health in the midst of an influenza pandemic or an outbreak of
a novel viral respiratory disease. During an emergency situation, em-
ployers may run out of respirators that have been fit tested on personnel
and may be unable to obtain additional supplies from the same manufac-
turer or an emergency stockpile. If supplies of other types of respirators
are available, then OSHA requirements stipulate the need for repeat fit
testing with the new type of respirator to ensure proper fit and protection
(29 CFR 1910.134). The challenge during an emergency situation could
be the need to do fit testing for large numbers of workers in a short pe-
riod of time. Therefore, a user seal check or other quick method of de-
termining the fit of a respirator needs to be developed and recommended
by NIOSH and/or OSHA as a temporary measure to be used during
emergencies until the required fit testing can be completed.
A second issue is that the current NIOSH respirator certification pro-
gram has no requirement for a TIL test for filtering facepiece respirators
(e.g., many N95 respirators). Therefore, a respirator may be NIOSH cer-
tified for filtration efficiency, but have poor-fitting characteristics and be
unable to fit a large number of workers. When health agencies or em-
ployers stockpile respirators, they may choose devices based on cost and
availability but may not have the knowledge about how well the device
will fit their population. This issue became widely recognized during the
2009 H1N1 pandemic when a California stockpile of respirators was
used and healthcare personnel could not obtain a satisfactory fit (NIOSH,
2010b). The proposed respirator TIL regulations would assist in ad-
dressing this issue and provide employers and workers with better fit-
ting respirators.
PAPRs During an influenza pandemic, some healthcare personnel who
do not normally wear respirators may need to wear them. These individ-
uals are unlikely to be able to obtain a respirator fit test in a timely man-
ner. In addition, some individuals may have facial hair or other facial
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features that do not allow them to be fitted adequately to a typical N95 or
other tight-fitting respirator. These individuals would need to be assigned
a loose-fitting PAPR. These types of respirators provide forced-flow fil-
tered air but currently have high noise levels that are not conducive to
healthcare tasks and patient interactions, including speech perception and
listening to chest sounds. Efforts are underway by the National Personal
Protective Technology Laboratory (NPPTL) to develop regulations for
testing and approving lower flow PAPRs that would provide acceptable
respiratory protection in a healthcare environment but emit less noise and
thus be more useful for healthcare work that requires communication
with patients. Expediting these efforts is critical to improving PPE for
healthcare personnel.
Aerosol-transmissible disease standard As noted above, California
adopted an aerosol-transmissible diseases standard in 2009 (California
Code of Regulations, 2010). The standard includes a list of diseases and
pathogens that require airborne precautions as outlined by CDC, includ-
ing "novel or unknown pathogens" (California Code of Regulations,
2010). The scope of airborne precaution measures includes the require-
ment for "at least the use of an N95 respirator" (Jensen et al., 2005). Dur-
ing the 2009 H1N1 pandemic, the California standard was the only
workplace standard in the United States that required a mandatory level
of worker protection to be provided to healthcare personnel. Other state
and local health departments had access to the CDC and OSHA guid-
ance, but practices at healthcare facilities varied in whether and when
they followed airborne or droplet infection control precautions. In May
2010, OSHA issued a Federal Register notice requesting information on
occupational exposure to infectious agents in health care and related set-
tings (e.g., laboratories, medical examiner offices) (OSHA, 2010).
OSHA needs to work toward the development of an aerosol-
transmissible diseases standard that would provide adequate protection
for healthcare personnel and that would, in situations of unknown or
novel pathogens, default to providing full respiratory protection until
more was known about the lethality or contagiousness of the disease.
Other regulatory issues To gain approval for marketing as a medical
device, the Food and Drug Administration (FDA) stipulates that the res-
pirators must be NIOSH certified and meet flammability and fluid pro-
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tection standards; these standards are not relevant for most situations in
which workers must be protected from influenza. During the recent pan-
demic, the FDA identified non-cleared respirators that would be accepta-
ble for healthcare personnel. To alleviate this issue for future crises, the
FDA could consider a separate 510(k) requirement that allows manufac-
turers to market any appropriate NIOSH-certified respirator during an
influenza pandemic. This would rapidly allow all certified respirators to
be available for use by healthcare personnel.
The arrival of novel H1N1 influenza A in 2009 was accompanied by
a number of policy questions relevant to PPE. The lack of precise infor-
mation about the modes of influenza transmission, the contagiousness,
the virulence of novel H1N1 influenza A, the at-risk population, and the
efficacy of different devices in preventing transmission led to a variety of
recommendations at different times by federal and local government
public health agencies. Delayed and/or disparate recommendations often
led to confusion among healthcare personnel and their employers, who
had to decide what to tell personnel about what type of PPE to wear and
when. In addition, little research was available to guide health system
officials in making decisions about the quantities of various types of PPE
needed to protect their workforce. A major problem encountered was a
slow response in tailoring recommendations as more knowledge about
virulence and affected populations became available.
The committee looked to two examples of response to 2009 H1N1
(New York City [NYC] and Northern Virginia), with information pro-
vided by committee members, workshop speakers, and individual inter-
views. Northern Virginia hospitals, for example, developed standardized
infection control policies that included a definition of high-risk workers.
To address supply chain shortfalls, the 14 member hospitals of the
Northern Virginia Hospital Alliance (NVHA) agreed to follow CDC res-
pirator guidelines until no longer practical. As a matter of practice, hos-
pitals modified the CDC guidelines in regards to PPE requirements for
non-high-risk workers, especially as it became clear in fall 2009 that the
virulence of 2009 H1N1 was similar to seasonal influenza viruses (Per-
sonal communication, Zachary Corrigan, NVHA, 2010).
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In NYC, the fire department emphasized the need for paramedics and
emergency medical technicians to use N95 respirators as they work in
the pre-hospital environment where environmental controls do not exist.
When the H1N1 virus first emerged, the NYC Department of Health and
Mental Hygiene and the New York State department of health initially
recommended N95 respirators but then scaled back the recommendations
to face masks to be consistent with seasonal influenza recommendations
once it was determined that the virulence and transmissibility were simi-
lar to seasonal influenza. However, once CDC published its interim in-
fection control guidance in October 2009, the New York city and state
departments of health revised their guidance to be consistent with the
federal recommendations for N95 respirators. In anticipation of the
second wave of H1N1 returning in Fall 2009, the city health department,
working with the NYC Office of Emergency Management, convened
regular healthcare emergency planning meetings to improve hospital and
primary care preparedness. The NYC health department also put in place
a program to provide additional N95 respirators from a local government
stockpile for healthcare facilities experiencing supply shortages during
the 2009 pandemic (Personal communication, David Prezant, New York
City Fire Department).
PPE Policies During the Novel H1N1 Influenza Pandemic
During the initial phase of the 2009 H1N1 influenza pandemic, in-
fection control guidelines from some of the major public health organiza-
tions differed, primarily as related to respiratory protection (Table 5-1).
The World Health Organization (WHO) recommended standard and
droplet precautions (including a face mask, a gown, gloves, eye protec-
tion, and hand hygiene) for those working in direct contact with patients,
and additional precautions for aerosol-generating procedures, including
wearing a facial particulate respirator (WHO, 2009). The WHO recom-
mendations took into account the need for sustainability in a variety of
countries and encouraged each country to issue its own guidelines. CDC
recommended a fit tested, disposable N95 respirator or better for health-
care personnel who enter the rooms of patients in isolation with sus-
pected or confirmed novel H1N1 influenza (CDC, 2009b). For
emergency medical responders, CDC recommended a fit tested, dispos-
able N95 respirator for those personnel "who are in close contact" with
patients with confirmed or suspected 2009 H1N1, for personnel "en-
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gaged in aerosol generating activities," and for personnel involved in the
"interfacility transfer" of patients with suspected or confirmed 2009 H1N1
(CDC, 2009a). The Public Health Agency of Canada used a tiered ap-
proach that recommended N95 use for aerosol-generating procedures
with direct patient contact only (PHAC, 2009a,b,c,d).
Overview of Recent Policy Research
Research on healthcare policies and their implementation is lacking
as it pertains to the use of PPE. Given the many PPE policy issues during
TABLE 5-1 Overview of 2009–2010 H1N1 Policies and Practices
Regarding Personal Protective Equipment and H1N1 Influenza
CDC CDC Health
Guidance Guidance CDC Agency of
4/29/09 10/15/09 Guidance for Canada
Novel Novel Seasonal Guidance
Pandemic Pandemic Influenza WHO for Novel
Influenza Influenza 9/20/10 Guidance H1N1
Recommended Standard Standard Adhere to Standard Tiered
level of infection and contact and droplet standard and droplet approach
control precautions precautions and droplet precautions
precautions and eye precautions
Recommended NIOSH- NIOSH- Face mask Face mask Face mask
respiratory certified certified except for except for except for
PPE N95 N95 aerosol- aerosol- aerosol-
respirator respirator generating generating generating
procedures, procedures procedures
use N95 or
Did the respi- Yes— Yes— Yes— Yes Yes
ratory PPE direct care direct care direct care
recommenda- versus versus versus
tion differ by indirect indirect aerosol-
work task? patient patient generating
contact contact procedures
NOTE: CDC = Centers for Disease Control and Prevention; NIOSH = National Institute
for Occupational Safety and Health; PPE = personal protective equipment; WHO =
World Health Organization.
SOURCES: CDC (2009a,b); PHAC (2009a,b,c,d); WHO (2009).
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viewed the literature and the guidelines on PPE use from many countries,
and then estimated the numbers of PPE ensembles that would be required
during a pandemic, using information on the type of pandemic, type of
healthcare worker, and numbers of PPE ensembles per classification per
day. They estimated (using OSHA recommendations) that four sets
(N95, gloves, gowns, and goggles) would be used per day by high-risk
healthcare personnel, who are defined as persons performing high-risk
procedures, such as intubations, suctioning, and manipulating respiratory
equipment. Two sets of appropriate PPE was the estimate for medium-
and low-risk healthcare personnel (this included an N95 respirator for
medium-risk and a surgical mask for low-risk workers). The researchers
also estimated that two surgical masks would be required for every in-
patient and one for every out-patient. They then estimated the total num-
bers of PPE required for a 300-bed hospital during an 8-week pandemic—
nearly 20,000 N95 respirators, 122,000 surgical masks, 21,000 goggles
and gowns, and 172,000 pairs of gloves would be needed. This study
provides an initial start on the question of estimated quantities, but is
theoretical and based only on published recommendation guidelines. The
methodology is logical, but needs to be validated. Data on actual use of
PPE by a hospital is needed to compare the accuracy of the predictions.
A study comparing single-use versus reusable surgical gowns high-
lights another area of discussion regarding costs and quantity of supplies.
Baykasoglu and colleagues (2009) conducted a cost/benefit study that
considered a number of factors, including laundry, sterilization, and
waste disposal costs, as well as the extent of protection and functionality.
The study determined that the single-use sets had higher benefits, but
when costs were considered, the more expensive reusable sets had higher
benefit/cost ratios. This area of research and modeling could provide
practical insights, particularly as effective decontamination processes
become defined.
H1N1 Experiences with Use of PPE by Healthcare Personnel
Evidence of transmission to healthcare personnel was reported dur-
ing the pandemic, indicating the need for comprehensive PPE policies.
Santos and colleagues (2010) examined an NYC hospital's absentee
records for 3 months (April through June 2009) and compared the results
with the same periods in 2007 and 2008. The researchers found that
healthcare personnel in the adult and pediatric emergency departments
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had the highest infection rate per department. The peak of influenza in
healthcare personnel was noted to have lagged slightly behind the peak
in the general public.
The literature on policies put in place during 2009 H1N1 will likely
grow in the next several years. At this point only a few articles have been
published that focus on PPE use during the initial phases of H1N1. Early
in the epidemic, Perez-Padilla and colleagues (2009) reported their expe-
rience in Mexico City. They focused on the clinical presentation of
H1N1, but also noted information on the transmission of disease to
healthcare personnel. The report noted that 22 of 190 workers who be-
came infected had been involved in caring for the first 3 H1N1 patients
in a series of 18 patients admitted during the first month of the pandemic
in spring 2009. These included 19 out of 104 emergency department
workers who had been within 2 meters of a patient or had direct contact
with a patient. These 22 workers had mild to moderate disease, and none
required hospitalization. The hospital then instituted strict infection con-
trol measures, including N95s, gowns, gloves, goggles, and hand hy-
giene, and noted that no additional workers became ill with influenza-
like illness, although 26 did have varied respiratory symptoms and were
treated with oseltamavir.
Focus group discussions with a group of infection preventionists in
the United States pointed out the logistical issues that were faced in the
first months of the pandemic in trying to fit test a large number of staff
(Rebmann and Wagner, 2009) as well as the challenges in determining
whether and when to recommend the use of face masks or respirators. Of
the focus group participants, approximately one-third said that PPE-use
guidelines changed at their facilities about halfway through the event.
A survey of healthcare epidemiologists, administrators, and other
members of the Society for Healthcare Epidemiology of America in May
2009 found that 19.3 percent of respondents strongly agreed and 52.7
percent agreed that "the recommendation for airborne precautions for
suspected H1N1 cases was appropriate at the beginning of the H1N1 cri-
sis" at his or her institution (Lautenbach et al., 2010, p. 3). When asked
whether airborne precautions for suspected cases were appropriate
throughout the H1N1 crisis, 7.5 percent strongly agreed and 17.5 percent
agreed. Supplies of N95s were a concern with some respondents; 16.9
percent disagreed and 8.8 percent strongly disagreed with the statement
that "N95 masks were readily available throughout the H1N1 crisis at my
institution" (Lautenbach et al., 2010, p. 3).
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Changes in PPE guidelines were an issue for healthcare personnel in
Australia, as identified in a questionnaire and focus group study (Corley
et al., 2010). Healthcare staff reported confusion over the changing re-
quirements and noted that this led to staff feeling "undervalued" and
"unprotected." Discomfort in wearing a respirator for a 12-hour shift
with maybe a 1- to 1.5-hour break was noted as a challenge, as was the
considerable amount of time spent on donning and doffing PPE.
The need to reinforce education and communication about PPE and
other infection control processes for pre-hospital healthcare personnel,
including paramedics, was noted as one of the key lessons learned in the
H1N1 pandemic by a group reviewing the response in Victoria, Australia
(Smith et al., 2009).
Prior to the 2009 H1N1 pandemic, simulations and other planning ef-
forts included a focus on PPE issues and policies. Phin and colleagues
(2009) assessed a 24-hour simulation exercise in England and high-
lighted PPE cost and procurement issues as well as issues involving the
storage of PPE supplies and increases in the amount of trash generated.
The exercise noted unnecessary staff movement related to delivery of
supplies and provision of services that also impacted PPE use. A review
of emergency plans in three Ontario hospitals noted a number of PPE
issues, including addressing fit testing requirements; regular training,
including practice drills; stockpiling, warehousing, and inventory man-
agement; and storage and maintenance of PPE (Amaratunga et al., 2007).
An extensive planning effort by a task force of the European Society of
Intensive Care Medicine addressed a range of policy issues related to
pandemic planning, including the need to develop protocols for safe per-
formance of procedures (including aerosol-generating procedures) that
might put personnel at risk (Sprung et al., 2010). Training regarding PPE
and an organizational culture that promotes safety were also discussed.
Preparations and implementation of infection control plans for 2009
H1N1 influenza brought into sharp focus the efforts by healthcare pro-
fessionals, emergency planners, professional associations, healthcare fa-
cilities, policy makers, government agencies, labor unions, and others to
address PPE policies and logistics. Articles continue to be published on
the recent experience and the challenges and successes in providing face
masks, respirators, and other PPE to healthcare personnel. As lessons
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learned during that experience continue to add to the body of knowledge,
incorporating this information into research, policy, and practice efforts
will be important. In the initial phases of an epidemic or pandemic—
when there are many unknowns about the virus or agent—one of the
challenges is to determine PPE policy and then to adapt those policies as
information is gained on the severity, transmission, and nature of the dis-
ease with an emphasis on communicating those changes. Standards-
setting, regulatory, training, and research efforts continue to move to-
ward improved respiratory protection, and recent work has begun to fo-
cus on the specifics of how to tailor PPE devices and PPE training to
address the specific needs of healthcare personnel.
This chapter has provided an overview of the many policy and regu-
latory issues relevant to developing and improving PPE for healthcare
personnel. The committee's findings (outlined in Box 5-2) and research
needs and recommendations (below) point to the many opportunities
available, making now a particularly urgent time to build on recent expe-
riences and needs and to move forward with the policy research and reg-
ulatory changes that will improve protection for healthcare personnel.
The committee highlights the following research needs:
• Lessons learned from the 2009 H1N1 policies relevant to
PPE: Case studies of the implementation of 2009 H1N1 PPE-
related policies should be gathered and evaluated.
• PPE supply estimates: Studies are needed that compare theoret-
ical models of estimating quantities of PPE for emergency pre-
paredness with recent experience to inform future public health
• Cost-effectiveness research: Research is needed into cost-
effectiveness issues relevant to PPE, including issues of disposa-
ble and reusable equipment.
• Impact of public health guidance: Prospective research efforts
should examine the impact of public health guidance on PPE
compliance by state, local, and health system policy; clinical
practice; and costs.
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• Public health guidance regarding personal protective equipment (PPE)
use for protection from novel viral respiratory infections needs to be
timely, flexible, and consistent and should require the appropriate PPE
based on what is known at the time about transmission and virulence.
• Public health policy regarding PPE use for healthcare personnel's pro-
tection from viral respiratory infections needs to recognize that trans-
mission occurs in the community from family and friends as well as in
the work environment from patients and coworkers. Recognition of this
fact is the foundation for an aggressive vaccination program for health-
care personnel.
Recommendation: Move Forward on Better Fitting Respirators
NPPTL should continue rulemaking processes for TIL regu-
lations that require respirators to meet fit criteria. To im-
prove consumer and purchaser information on fit capa-
bilities, NIOSH should establish a website to disseminate fit
test results for specific respirator models on an anthropomet-
ric (NIOSH) test panel, where such data exist.
Recommendation: Clarify PPE Guidelines for Outbreaks of
Novel Viral Respiratory Infections
NIOSH, other CDC divisions, OSHA, and other public
health agencies should develop a coordinated process to
make, announce, and revise consistent guidelines regarding
the use of PPE to be worn by healthcare personnel during a
verified, sustained national/international outbreak of a novel
viral respiratory infection. The agencies should tailor their
guidance in a timely and coordinated manner as the viru-
lence, contagiousness, and affected populations are further
Recommendation: Standards and Certification for Face Masks
and Face Shields
NIOSH, OSHA, and standards-development organizations
should develop the standards and certification processes
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needed to assess the performance of face masks and face
shields as PPE. The development of standards and certifica-
tion processes should be guided by research regarding their
efficacy as PPE.
• OSHA and CDC should clarify that face masks are
governed by the general PPE standard (29 CFR
1910.132) and not by the respiratory protection stan-
dard (29 CFR 1910.134).
• NIOSH should work with other agencies and standards-
setting organizations to develop voluntary consensus
standards and independent third-party testing and
certification processes for face shields and face
masks, with specific tests for assessing prevention of
transmission of viral respiratory diseases.
Recommendation: Establish PPE Regulations for Healthcare
CDC, including NIOSH, and OSHA should develop and
promulgate guidelines and regulations that are consistent re-
garding the use of PPE by healthcare personnel for influenza
and other viral respiratory diseases:
• To assist employers in complying with the OSHA
PPE standard, OSHA should specify the voluntary
consensus standards that are required to be met for
non-respirator PPE (e.g., gowns, gloves, face shields,
face masks) in the event of influenza and other viral
respiratory diseases.
• OSHA, with input from CDC and other agencies and
organizations, should work toward promulgating an
aerosol-transmissible diseases standard that would
include prevention of the transmission of influenza
and other viral respiratory diseases.
As noted throughout the chapters, this report is an update of a prior
IOM report. In surveying the landscape of research that has been con-
ducted since the 2008 report and even in the wake of the 2009 H1N1 in-
fluenza pandemic, the committee was struck by the lack of urgency in
addressing the basic, applied, and clinical research questions that, if an-
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swered, would go a long way toward improving preparedness and pre-
vention against future influenza epidemics and pandemics and outbreaks
of other respiratory viral agents. Looking back is often a way to propel
efforts in moving forward. The committee hopes that this review will
jumpstart and strengthen improvements in PPE for healthcare personnel
that could be relevant to a range of viral respiratory diseases.
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