COVID-19 Disclaimer

Virtually all public aquatic facilities in the country have been closed for a period of time by State Executive Orders due to COVID-19. A number of states and local jurisdictions have or are in the process of issuing directives easing stay at home restrictions. While the CDC has stated that properly treated pool water is not considered a vehicle for transmission of the COVID-19 virus, the risk of transmission remains present at any place of work, and any recreation facility.

The COVID-19 related information posted on this website is based on what is currently available on the virus by the CDC, the US Environmental Protection Agency (EPA), the US Food and Drug Administration (FDA) and various state and local authorities and their respective Orders. All of these are expected to change over time as more is learned. While E&A may update its information periodically, it is impossible for any one organization to keep track of all of these sources and E&A makes no assurance that any information posted on its site is up to the minute or day.

Ellis & Associates wants to emphasize that no measure or combination of measures provide a guarantee against COVID-19 transmission, or the potential liability that may arise as a result. By considering the information below as well as provided by the above sources, however, facilities can provide added levels of protection, mitigate the risk, while providing valuable recreational and educational services to their membership and community.

E&A is not a governmental or public agency. Any directives or guidance from the CDC regarding pool operation would take precedence over any E&A recommendations.

By accessing this document you are agreeing to all of the foregoing. You are also agreeing that neither E&A nor its employees, agents, officers, directors, attorneys, insurers, successors and affiliates are liable in any way for any inaccuracies or errors in this site, or for any damages allegedly incurred as a result of any claimed reliance on this document.

Aquatic Industry Update

lifeguards doing in service training
Aquatic Industry Update

Introduction

The COVID-19 pandemic continues to affect the entire world. Leading the fight against COVID-19 are the Centers for Disease Control (CDC) and the World Health Organization (WHO). Along with these agencies, many other public and private organizations from around the world are working hard to both cope with the disease and help end the pandemic emergency. Ellis & Associates continues to research all of these sources to provide appropriate timely updates in support of its clients and the industry at large.

The information that follows represents our efforts to present best practices based on the available information that continues to evolve. This document represents the most current and accurate information as of the time of publication. However, this information is subject to change – in whole or in part – as new information and guidance is provided.This update addresses the five items listed below:

 

Current COVID-19 Situation

At the time of publication, worldwide – nearly 96 million people have become infected with COVID-19, resulting in over 2 million deaths.  In the United States, over 25 million people have become infected with COVID-19, resulting in about 400,000 deaths.  There may be several active strains of SARS-CoV-2 (the virus that causes COVID-19). For example, two new variant strains (B.1.1.7 and B.1.351) were among those discovered in the past few weeks. Preliminary research is showing that these strains may be as much as 70% more transmissible than currently prevalent strains. This means that one or both may eventually overtake previous strains in world-wide prevalence due to this characteristic.  Fortunately, most experts believe that COVID-19 is not thought to be more severe when caused by these newer strains, but research continues.

 

Vaccines

There are two vaccines authorized for use in the United States and are currently being distributed. These are the Pfizer-BioNTech vaccine (BNT162b2) and the Moderna vaccine (mRNA-1273).  The effectiveness of each is at or near 95%. So far, most scientists believe that these vaccines will provide protection from all currently known strains of SARS-CoV-2, but research continues.  In addition to these vaccines, there are others in use around the world that are not currently approved in the United States.  However, there are four additional vaccine candidates currently being studied. Three of these candidates are in phase 3 clinical trials and one is in phase 2 trials. The three vaccines in phase 3 trials will conclude soon and have results evaluated, beginning between the end of February and April of this year. If approved, these may be available later in the spring of this year, with the remaining available later in 2021 or early 2022 in the United States.

 

Infection

People of all ages can be infected and become sick with COVID-19.  However, infections tend to be more severe for groups with certain medical characteristics.  These include:

  • The elderly
  • The obese
  • Diabetics
  • Sufferers of cardiovascular disease
  • People with respiratory conditions
  • People who smoke or abuse drugs
  • Those with high blood pressure and high cholesterol
  • Immunocompromised individuals
  • People suffering from an unrelated long-term illness

The majority of those infected will have mild to moderate symptoms that can be treated at home and will typically resolve within 2 – 6 weeks.  The most recent research indicates that approximately 40% of those infected show no signs of illness (or simply do not notice the mild symptoms they do have). Current estimates indicate that about 19% of those infected will have severe symptoms which may require hospitalization, ranging from a few days to the duration of the illness. Unfortunately, as many as 20% of those hospitalized will ultimately die of the disease.  However, it is important to remember that the vast majority will survive infection, with the current overall risk of death being at about 1%.

 

Disease Transmission

COVID-19 is spread primarily through person-to-person contact. When an infected person (exhibiting symptoms or someone who is asymptomatic) coughs, sneezes, or speaks, they generate droplets and aerosols which may enter the mouths or noses of people who are nearby. Aerosols containing viral particles may remain in the air for as long as three hours.  If someone breathes in these aerosols (in sufficient quantity), they may become infected. Aerosols and droplets may also contaminate the surfaces of objects in proximity of an infected person.  The disease can be transmitted by a person touching these surfaces and then subsequently touching their face, eyes, nose, or mouth.  SARS-CoV-2 has also been found in the bodily fluids and substances (e.g., saliva, semen, and feces) taken from the infected, in sufficient quantity to possibly cause disease transmission. However more research is needed to determine how likely someone may become infected from this route.

 

Quarantine of the Contagious

Those infected with COVID-19 will likely not show symptoms for 5 – 6 days following exposure but may be contagious about 48 hours before they start to show signs of the illness. The CDC currently recommends a 10 – 14-day quarantine from the onset of symptoms for those with confirmed illness. People who are asymptomatic but have tested positive for COVID-19 should remain quarantined for 10 days following their positive test confirmation.

Those who may have been exposed to COVID-19 should self-quarantine for 10 – 14 days and monitor symptoms (without testing). If exposed to a person with COVID-19, but you are able to get tested on day 5 or later and it comes back negative, self-quarantine can end on day 7, provided no symptoms arise. Though rare, it remains possible to become sick with COVID-19 even after showing no symptoms during the allotted quarantine period.  If symptoms appear after quarantine, self-quarantine until you can see your physician for instructions, including arrangements for testing.

Quarantine recommendations are based upon research that showed declines in replication-competent virus from infected patients with mild-to-moderate symptoms in the days following onset. Replication-competent virus was consistently found to be inadequate to transmit the disease at around 10 days following onset of symptoms (with some instances taking longer). Those with more severe cases showed similar results at around 20 days from onset.

 

Risk of Infection

Most experts agree that the risks of reinfection are low in the months following recovery from COVID-19.  However, emerging evidence suggests that a past infection may not confer long-term immunity.  Most experts agree that a combination of vaccinations and following recommended precautions offers the best chance of controlling COVID-19 and ending the pandemic, perhaps making it something like the annual flu.

 

Recommended Precautions

People can best protect themselves from infection by practicing physical distancing (approximately 6 feet/ 2 meters), frequent washing or sanitizing of hands, and properly wearing a mask when in public.  Remaining at approximately 6 feet/2 meters apart reduces the chance of having a contaminated droplet from an infected person directly reaching you and vice versa. Wearing a mask helps protect others from potential asymptomatic spread  of the virus.  However new research has found that properly wearing a standard cloth mask may reduce your chances of infection by as much as 70%.

Physical contact with potentially infected objects or people should be followed with hand washing or sanitizing. People who sneeze or cough should cover their mouth and nose by using the bend of their elbow or with a disposable tissue, followed by hand washing or sanitizing. Health experts have also advised people to make sure they are current with all non-COVID vaccinations, including the annual Flu vaccine.  This will make catching non-COVID illnesses less likely or at least less severely. This in turn will reduce unnecessary trips to the doctor or the confusion of similar symptoms.

 

Training Safety Guidelines

Personal Protective Equipment (PPE) & Hygeine During Class

Each student should be provided their own medical exam gloves, face covering, and resuscitation mask for use with select skills. These items should not be shared during training. Additional items that should be available are soap and water stations or hand sanitizer, and a means of disinfecting equipment. During pre-service training employers should include any additional PPE training. PPE training  should be conducted during initial training and reinforced through pre-service and in-service activities.

 

Equipment Preparation

All equipment should be properly disinfected before, during, and after class, using a product or active ingredients recognized to be effective.  The EPA provides List N: Disinfectants for Coronavirus (COVID-19) located at: https://www.epa.gov/pesticide-registration/list-n-disinfectants-coronavirus-covid-19.  The CDC and EPA recommend the following six steps for safe and effective disinfection:

  1. Confirm your product is effective against COVID-19
  2. Read and follow the directions provided on the label.
  3. Pre-clean the surface with regular soap and water if the surface is visibly dirty.
  4. Follow the contact time needed for the disinfectant to be effective as stated on the label.  
  5. Properly dispose of gloves and used supplies after cleaning and wash your hands.
  6. Lock up or secure the cleaning product until needed again.

The disinfection process includes:

  • Before Class – Instructors should ensure that equipment has been cleaned and disinfected before use. 
  • During Class – Attendees should be provided a means to disinfect equipment after each use, with particular attention to potentially shared equipment such as manikins, resuscitation masks, BVMs, V-vacs, and NRBs.
  • After Class – Instructors should disinfect equipment immediately after class.

 

Lifeguard and Safety & Health Classes

The following guidelines are designed to minimize the chance of disease transmission during training. These guidelines address how training can be done with physical distancing in place.

  • Anyone associated with the class (instructor, assistants, students, etc.) with a fever and/or other symptoms of COVID-19 should not participate in any classes. Everyone associated with the class should self-screen prior to attending training.
  • A COVID-19 Site Supervisor (could be the Lead Instructor) should be assigned to oversee the Health Check process and to monitor student health during course duration.
  • Students and instructors should be encouraged to frequently wash their hands or use hand sanitizer – at the start of a class, at appropriate times during class, and following class. 
  • Students should be provided with exam gloves and a face covering at the start of class. A means for disinfecting equipment during class should be provided to student for use during class. All equipment should be sanitized between uses. Instructors should facilitate regular hand washing breaks to occur at appropriate times during the class.  If access to soap and water and/or such breaks are not possible, each student should receive hand sanitizer (containing at least 60% ethyl alcohol) for use at appropriate times during class. A supply of replacement hand sanitizer should be maintained and provided if needed.
  • A minimum of 6-feet/ 2 meters of separation of participants and instructors should be maintained whenever possible. When this is not possible, cohort group should be implemented.
  • Exam gloves and face coverings should be worn during land-based training (classroom or otherwise).
  • No person-to-person contact involving simulations for choking, rescue breathing, CPR, EpiPen training, or bleeding control (direct pressure and bandaging). CPR/RB/FBAO related skills should be performed on manikins, including Heimlich maneuver. 
  • Bleeding control practice requires each student to have their own clean gauze pad and gauze roll. To avoid close contact with others, participants should practice bandaging on themselves.
  • EpiPen and other autoinjector practice should be completed with each student using their own thigh with the trainer.
  • each other. Only one participant at a time should use a manikin and AED training device. Equipment should be disinfected by participants between uses. 
  • Participants should use their own resuscitation masks when practicing on a manikin. The manikin and mask/valve should be disinfected following each use.
  • For Layperson CPR training classes, "Compression Only CPR" will be highlighted. When the breathing element is introduced, the student will be instructed to simulate the act of delivering a breath by opening the manikin's airway and saying the word, 'breathe' when practicing.

A Cohort system should be implemented to accommodate the performance of certain skill competency objectives. Cohort system can consist of four (4) to five (5) students. Cohort teams would remain with the same cohort team for duration of the course. Cohort system 1) limits the number of people each trainee comes into contact with and, 2) helps the contact tracer if COVID-19 transmission occurs by containing it within the cohort.

  • While the transmission of any diseases via pool water is extremely unlikely (if chemicals are maintained properly), the pool water should not be used as a means of disinfecting any equipment used during class. 
  • In-water rescue breathing should not be practiced at this time. The simulated GiD should be positioned face up on the rescue tube, the airway opened with the jaw thrust, and the GiD moved rapidly to the extrication point. 
  • PPE training should be included during initial training and again during pre-service training. 
  • Instructors and students are encouraged to continue implementation of wearing face covering during in-service training as well as disinfection at the frequency suggested previously.

 

Emergency Care Safety Guidelines

The infectious disease status of any person (guest or staff) will likely be unknown at the time of an emergency. Individuals in need of care may be asymptomatic, yet potentially infectious. For this reason, first responders should treat all incidents as if the person is infectious. This is not a departure from current OSHA Standard Precaution practices, rather, it is a reinforcement of the need for safety and slight modification of practices. This means that in addition to standard precautions, additional practices and equipment should be used when appropriate.

 

Personal Protective Equipment (PPE) and Hygeine

Personal protective equipment exists to keep healthcare providers, including first responders such as lifeguards and supervisors, and guests safe from disease transmission during assessment and care. The COVID-19 virus has reinforced the need for responders to take appropriate precautions. The airborne transmission of the virus has resulted in the Centers for Disease Control and Prevention (CDC) issuing updated safety guidelines.  The Occupational Safety and Health Administration (OSHA) has further addressed PPE stating that if a piece of equipment is intended to protect employees from a hazard (e.g. airborne disease), it is considered PPE. Employers should make sure all applicable PPE is available in proper sizes, is clean, that workers are trained on its use, and that workers follow established protocols for its use.

Because viruses can be transmitted from the hands of a responder to the face through touch, gloves and masks are used to help prevent disease transmission. Since COVID-19 virus particles have been shown to be suspended in the air during exhalation by infected persons, NIOSH-certified disposable N95 filtering respirators or disposable surgical face masks are recommended for use by healthcare providers. Due to the general lack of availability of N-95 respirators, the need for fit testing, and the necessity for more of these devices for healthcare workers caring for known or suspected COVID-19 infected individuals, first responders such as lifeguards can use a medical mask when responding to an emergency. These masks block large-particle droplets, splashes, sprays, or splatter that may contain germs (viruses and bacteria), keeping them from reaching the mouth and nose of responders. Surgical masks also help reduce exposure of a responder’s saliva and respiratory secretions to others.

Evidence also suggests that the conjunctivae, the mucous membrane that covers the eye, could be exposed to droplets and aerosols from infected persons during close contact. For this reason, eye protection is also required for use by healthcare providers. Because responders will not know the infectious disease status of a guest, and because responders will be in close proximity to guests when providing care (such as during resuscitation), it is recommended that gloves, surgical masks and eye protection be worn by personnel in such situations. Facilities may wish to provide additional PPE to their staff as these become easier to obtain.

 

Individual and Team Personal Protective Kits

Individual response (hip) packs should contain:

  • Medical exam gloves
  • Face covering 
  • Hand sanitizer 
  • Disinfecting wipes
  • Resuscitation mask 
  • Additional PPE to consider: surgical mask, protective eyewear, and Viromax filter in its original packaging

Team response (trauma) bags should contain:

  • Medical exam gloves
  • Protective masks (surgical masks for responder and GiD use) 
  • Protective eyewear (goggles or face shield)
  • Hand sanitizer
  • Disinfecting wipes
  • Various size Bag-Valve-Masks (BVM) w/ HEPA or Viromax filters  
  • Supplemental oxygen support system with non-rebreathing mask
  • Manual suction 
  • Pulse oximeter
  • AED
  • Epinephrine auto injector (where appropriate)

Equipment handling before an incident needs to be done carefully. Individual items such as resuscitation masks, BVMs, and filters should remain in original sealed packaging until needed. The bag itself should be placed in a position that helps avoid droplet contamination (if possible).  Responders need to be familiar with the location of each item in the bag to avoid needing to search through the bag for an item and possibly cross contaminating items.  A labeling system is encouraged. To help avoid possible contamination during a response to an incident, extra supplies should be stored separately from the trauma bags. If multiple Team Response bags are utilized at a facility they should be set-up in the same manner to aid in this process.

 

Supplemental Oxygen Administration

Supplemental oxygen support (SOS) should be provided to any person experiencing serious respiratory distress, supported with pulse ox readings when available. A guest having difficulty breathing should receive SOS via a non-rebreathing (NRB) mask. The NRB is placed on the patient as you would normally.  Once on, secure a medical mask over the NRB. Monitor pulse ox readings and looks for signs of improvement.  If the NRB is removed, ask the patient to put on the medical mask that had been covering the NRB.  Continue to monitor until EMS arrives and takes over.  Properly discard the used NRB and medical mask once you have transferred care.

 

Bag-Valve-Mask and Resuscitation Mask Use

Positive pressure ventilation includes the use of a bag-valve-mask (BVM) or mouth-to-mask rescue breathing during resuscitation. This procedure results in the guest’s expired air being vented from the lungs into the air. The CDC defines this as an aerosol-generating procedure. Without proper filtration, a virus suspended in the expired air of an infected guest poses the potential for transmission to responders. This exists for any virus, but it has come to the forefront as a result of COVID-19 exposure. Because of this potential for airborne transmission, devices (BVM or resuscitation mask) used for ventilation should be equipped with a High Efficiency Particulate Air (HEPA) filter (also called a Viral/Bacteria filter) to clean expired air as it is leaving the device. A HEPA/Viral/Bacteria filter is a small device easily connected between the mask and valve of the device used to provide ventilation.

The Big Easy resuscitation mask has a one-way valve to help keep rescuers safe from bodily fluids, but it does not have a filter capable of providing protection from COVID-19. To protect the rescuer, a HEPA/Viral/Bacteria filter needs to be inserted in this device. E&A has identified the Viromax filter as an effective, inexpensive filter for use. Each BVM and resuscitation mask in operation should have its own filter. It is advisable to have additional filters available to replace any used filters. If these devices are unavailable, compression only CPR with a medical mask placed on the patient during care is advised until equipment arrives.

 

Rescue Breathing in the Water

Since the Viromax filter needs to remain dry prior to use, rescue breathing in the water is impractical and unsafe at this time. The unresponsive guest should be positioned face up on the rescue tube and the airway opened in the hope of return of spontaneous respiration. There should be no delay in rapidly extricating the guest so that further assessment and care by properly protected responders can be initiated on land. For a team responding with a trauma bag, rescue breathing, if needed, can be provided through a BVM (with HEPA or B/V filter, such as the Viromax B/V filter).

 

Performing CPR

Providing compressions as part of CPR is another aerosol-generating procedure. Compressions result in the guest’s expired air being forced from the lungs. For this reason, first responders should use a resuscitation mask with a Viromax filter in the absence of a BVM. If neither ventilation device (with a filter) is available for use, place a medical mask over the guest’s face and perform chest compression only (hands only) CPR until other team members arrive. At that point the medical mask should be removed from the guest’s face and a BVM with HEPA or B/V filter used as part of the resuscitation efforts.

 

Suctioning

Suctioning the airway with a manual device (i.e. V-Vac) places the responder in close proximity to the guest’s mouth. Because of this, the same PPE requirements must be used for proper protection of responders. If the guest has a medical mask in place, remove it and provide suctioning as it would normally be done.

 

Response Protocol for First Responders (Non-aquatic Incidents)

  • Treat all incidents as if the patient is potentially infectious.
  • Team responders should wear required PPE (gloves, medical mask, protective eyewear) before contacting the patient. Personal eyeglasses, contact lenses, or sunglasses are NOT considered adequate eye protection.
  • Scene evaluation and initial assessment (including COVID-19 related questions) of a responsive patient can be started at a distance of 6 feet from the patient. This allows times for the responder to apply proper PPE prior to providing care.
  • Place a medical mask over the face of the patient whenever possible and if tolerated by the patient. 
  • Limit the number of responders to just what is necessary for the incident. In many cases this would be 1 responder. If resuscitation is needed, the team should be limited to just 3 responders (1 for chest compressions; 2 for BVM / O2 ventilation and AED operation). 
  • If a breathing patient needs supplemental oxygen, provide it through the Non-Rebreathing Mask (NRB). Place a medical face mask over the NRB.
  • If alone and CPR or Rescue Breathing is necessary, provide ventilations via resuscitation mask with the Viromax filter. If filter is unavailable, place a medical mask on the patient and provide compression only CPR until the team arrives. Once a team arrives, remove the patient’s medical mask and provide team CPR or AR care, as appropriate, delivering ventilations through the BVM w/ HEPA/Viromax filter attached to oxygen. Use the AED normally. 
  • If airway suctioning is necessary, and the guest has a medical mask, remove the medical mask and use the manual suction device (V-Vac).

 

After Providing Care

Remove and properly dispose of all PPE in a biohazard bag. Wash thoroughly with soap and water (or a hand sanitizer). If using a disposable BVM, the entire device (including the medical grade tubing) should be placed in a biohazard bag. If a resuscitation mask was used, dispose of the entire device in a biohazard bag. If a manual suction device (V-Vac) was used, dispose of the cartridge. Disinfect the device. If an AED or pulse oximeter were used, clean and disinfect the devices. The EPA provides List N: Disinfectants for Coronavirus (COVID-19) located at: https://www.epa.gov/pesticide-registration/list-n-disinfectants-coronavirus-covid-19 .  The CDC and EPA recommend the following six steps for safe and effective disinfection:

  1. Confirm your product is effective against COVID-19
  2. Read and follow the directions provided on the label.
  3. Pre-clean the surface with regular soap and water if the surface is visibly dirty.
  4. Follow the contact time needed for the disinfectant to be effective as stated on the label.  
  5. Properly dispose of gloves and used supplies after cleaning and wash your hands.
  6. Lock up or secure the cleaning product until needed again.

 

General Safety Guidelines

Disinfecting Aquatic Facility Surfaces and Equipment 

Pool water should not be used in an attempt to clean facility surfaces including lounge chairs and railings. Pool water often has contaminants on the surface that could get deposited on these surfaces. Use a proper detergent or soap and water to clean facility surfaces. Disinfect surfaces by using diluted household bleach solutions or a product approved by the EPA on List N. This can be located at: https://www.epa.gov/pesticide-registration/list-n-disinfectants-coronavirus-covid-19. The CDC and EPA recommend the following six steps for safe and effective disinfection:

  1. Confirm your product is effective against COVID-19
  2. Read and follow the directions provided on the label.
  3. Pre-clean the surface with regular soap and water if the surface is visibly dirty.
  4. Follow the contact time needed for the disinfectant to be effective as stated on the label.  
  5. Properly dispose of gloves and used supplies after cleaning and wash your hands.
  6. Lock up or secure the cleaning product until needed again.

To prepare a bleach solution, combine 1/3 cup of bleach (5-9% sodium hypochlorite) per gallon of water. Homemade cleaning solutions made with bleach lose efficacy after 24 hours. For porous surfaces, clean with appropriate cleaners indicated for use on these surfaces.

Prior to cleaning/disinfecting equipment, it is suggested that you reference manufacturers guidance for suggested cleaning/disinfection products and methods.

 

Laundering

Launder potentially contaminated items as soon as possible. If items cannot be immediately laundered, store the items temporarily in a sealed disposable bag. Follow manufacturer’s instructions when laundering items, using the warmest water setting appropriate for the items and dry completely. Trauma bags should be cleaned and disinfected with an EPA approved disinfectant.

 

Resources

The Centers for Disease Control (CDC)
https://www.cdc.gov/coronavirus/2019-ncov/index.html

The World Health Organization (WHO)
https://www.who.int/emergencies/diseases/novel-coronavirus-2019

Johns Hopkins University of Medicine
https://coronavirus.jhu.edu/map.html

National Institutes of Health (NIH)
https://www.nih.gov/health-information/coronavirus

Guidance on Preparing the Workplace
www.osha.gov/Publications/OSHA3990.pdf

Water and Covid-19 Facts
https://www.cdc.gov/coronavirus/2019-ncov/faq.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fphp%2Fwater.html#Pools,-Hot-Tubs,-and-Water-Playgrounds

How to Protect Yourself and Others
www.cdc.gov/coronavirus/2019-ncov/prepare/prevention.html

EPA recognized disinfectants
https://www.epa.gov/pesticide-registration/list-n-disinfectants-coronavirus-covid-19

Cleaning and Disinfecting Your Facility
www.cdc.gov/coronavirus/2019-ncov/community/disinfecting-building-facility.html

Interim Guidance for Emergency Medical Services (EMS) Systems and 911 Public Safety Answering Points (PSAPs) for COVID-19 in the United States
www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-for-ems.html

The EMS Infectious Disease Playbook
https://www.ems.gov/pdf/ASPR-EMS-Infectious-Disease-Playbook-June-2017.pdf

COVID-19 Content: An AHA Compendium
https://professional.heart.org/en/covid-19-content-an-aha-compendium

Interim Guidance for Basic and Advanced Life Support in Adults, Children, and Neonates With Suspected or Confirmed COVID-19
https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.047463