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Recycling of ‘single use’ PPE through time-delay or disinfection methods

Suggestion:
Many hospitals will face PPE shortages in the coming weeks. Shortages of N95 filtering facemask respirators (FFRs) will be most impactful, but also standard masks, gowns and plastic face shields. Stockpiling of used PPE should be commenced NOW so that they will be available for re-use after disinfection. While using a mask that another has already used may be unappealing, it is probably preferable to no mask.

We could set up lidded buckets/ bins for USED, UN-SOILED N95 FFRs, standard masks, gowns and face shields in some areas in the department, then seal and label bags with the date. PPE could even be directly inspected for soiling, with discarding of soiled items, and placement of individual items in separate labelled ziplock bags.

In the event of a complete PPE shortage, once these bags have been sealed for approx. 1 week, they could likely be considered "COIVD-19" free. The longer they are stored, the greater the confidence of no COVID-19 infectious risk and if we (hopefully) never need them they can be dumped.

In addition, various disinfection techniques have been tested for these PPE. There will soon be guidelines on practical, effective disinfection solutions which we can apply to the stockpile of PPE for recycling.

Summary of available literature:
An analysis of the use of hygiene measures and personal protective equipment (PPE) during the early phase of spread of COVID-19 in January 2020 in Wuhan province of China compared healthcare worker infection rates in wards using different infection control precautions (1). Three wards using ‘higher precautions’ of N95 masks and ‘frequent’ hand washing were retrospectively compared to three wards with ‘lower precautions’ of no masks and ‘occasional’ hand washing.

Despite a higher exposure odds ratio of 8.33 in the ‘higher precautions group’, this group had no infections in 278 workers compared to 10 infections in 217 in the ‘lower precautions’ group. Caution should be taken attributing the lower rates of infection solely to N95 masks, as the ‘lower precautions’ had an undefined lower rate of hand washing and presumably greater degree of face-touching in the absence of masks as a physical barrier or mental reminder. However, this will still contribute to demand for facemasks, particularly N95.

Historically, influenza spread was believed to occur through droplets or contact with infected secretions(2). Quantitative air sampling of healthcare facilities suggest that small airborne particles could contribute to influenza exposure(3). Surgical masks provide barrier protection from droplets, but do not prevent aerosolized spread of infection.

The CDC advised N95 masks when caring for novel influenza associated with severe disease(4). However, it must be noted in meta-analyses and randomised trials N95 masks have not been shown to reduce influenza-like-illness compared to surgical masks in a healthcare setting (5,6). Ad hoc attempts at PPE, such as cloth face masks are likely to provide no benefit to prevent viral respiratory illness compared to no-mask(7).

A 2013 survey of the Infectious Diseases Society of America (IDSA) Emerging Infections Network (EIN) found that, among doctors involved planning for influenza protection, 9% believed influenza is ‘frequently’ transmitted by small-particle aerosols and 34% believed this occurred ‘occasionally’, with 52% considering aerosol transmission to occur rarely or never.

When asked about PPE preferences during a severe pandemic scenario (associated with ≥1% mortality), 67% preferred N95 respirators for providing routine care for influenza patients(8). For a “hypothetical setting where N95-level protection was recommended but there was a shortage of N95 respirators; the scenario included a circulating influenza strain with high mortality and no available vaccine”. In this scenario, the most-to-least endorsed strategies were: Extended use of N95 masks, reuse of N95 masks, use of Powered Air-purifying Respirators, use of surgical masks and use of elastomeric respirators.

A multi-site survey published in March 2020 of attitudes of hospital workers to options for FFRs in a high mortality influenza pandemic explored acceptance towards reuse of FFRs after UV light decontamination. It found that reuse of FFR after decontamination was preferable to reuse of FFR without decontamination which was preferable to no FFR. All sites had high (80%+) agreement that UV decontamination would mitigate FFR shortages in a severe pandemic (9).

The Centre for Disease control has specific recommendations for optimising facemask supply in a crisis such as the COVID-19 pandemic (10). Need for mask usage should be reduced by rapid isolation of suspected infected patients. Consideration can be given to using stockpiled N95 masks beyond their shelf-life, although they may not function optimally. The use of surgical and N95 masks should be prioritised by activity type, with healthcare providers remaining 6 feet from symptomatic patients not requiring masks, and those going within 3 feet providing care wearing surgical masks if the patient is masked and wearing N95 masks if the patient is not masked. In addition, mask usage could be prioritized for those most at risk of complication of infection.

Where supplies of N95 masks are depleted, the CDC provides recommendations on extended and limited reuse of N95 masks(11).
  • Extended use refers to wearing a mask for multiple encounters with infected patients without removing the mask and would be recommended when caring for multiple patients with the same respiratory infection and patients are grouped in the same waiting area/ ward.
  • Reuse refers to using the same mask for multiple encounters but removing ‘doffing’ it after each encounter and reapplying ‘donning’ it for the next encounter. This is commonly done for pathogens where contact transmission is not a concern.

Extended use is favoured as it involves less touching of the mask and therefore less contact transmission risk. Length of use is generally dictated by contamination or the mask or practical issues, such as need to eat, rather than a maximum number of hours. A cleanable face shield worn over the N95 will reduce contamination and extend use time.

Reuse is limited by recommendations to discard the mask after contact with a patient infected with a disease requiring contact precautions (such as COVID-19). Allowing for this, a face shield worn over the mask should extend it’s usability period. Between uses, it is suggested to hang used respirators in a designated storage area or keep them in a clean, breathable container such as a paper bag between uses. The CDC suggests masks should not be shared and only used by one individual. A study of the effect of multiple donnings on the facial fit of N95 masks has suggested that after 5 consecutive donnings the facial fit of the mask can be reduced(12).

Fisher et al estimated the influenza contamination level for the entire external surface of an FFR resulting from aerosols in a healthcare setting(13). It ranged from 10-100,000 viruses, depending on different scenarios using airborne influenza concentrations published in the literature.

An assessment of the stability of COVID-19 on different surfaces found COVID-19 is undetectable by 96 hours on cardboard, copper, plastic and stainless steel (14). A previous study on the survival of a surrogate coronavirus for SARS on PPE found that the virus was detectable for up to 24 hours after inoculation on N95 masks (15).

A recent pandemic simulation estimated that 7.3 billion N95 masks could be needed in the United States alone(16). The Institute of Medicine (IOM) projected in 2006 that a 6-week influenza pandemic would require 90 million N95 Filtering Facepiece Respirators (FFRs) (17). The IOM considered the feasibility of reusing N95 masks, stating that any method decontaminating a disposable N95 must remove the pathogen, be harmless to the user, and not compromise the integrity of the various parts of the respirator. It determined at the time that no effective decontamination strategy existed. Since then, multiple methods of decontamination have been tested.

Decontamination methods
  1. Alcohols cannot be used as they remove the electrostatic charge from the filtration media, degrading the ability to filter particles.
Other methods which have demonstrated utility include:

Ultraviolet Germicidal Irradiation (UVGI) has been described in several studies(18–21). In laboratory conditions, masks contaminated with influenza and soiled with mucin and sebum were exposed to 1 J/cmsq resulting in significant reductions in viable influenza virus in 12 of 15 masks models, equivalent to fully disinfecting masks with the highest level of influenza contamination in a healthcare setting predicted by Fisher et al(13,20,22).

This method is already in use for the COVID-19 pandemic in the university of Nebraska Medical centre(23). Healthcare workers write their names on the masks before they use them, then place in paper bags when they are removed. The bags are brought to a UV light room for treatment at ‘three times the concentration of UV light needed to kill coronaviruses’ for 3-5 minutes. Masks are returned to bags with healthcare workers names on them.

Main benefits: Fast (1-20 minutes total), No chemical residue risk
Main Limitations: requires specialised UV equipment most hospitals don’t have.

Microwave Steam Bags (MSB) are commercially available products marketed for disinfection of breastfeeding supplies, and use a standard home microwave. Use of MSB on N95 masks resulted in saturation of three mask models with hydrophilic layers, however three other mask models had a log 3 (99.9%) reduction in bacteriophage MS2(24). After 3 treatment cycles no significant change in filtration was identified.

A similar study using microwave steam without a bag resulted in a log 4 (99.99%) reduction in H1N1 virus on 93% of samples and the authors recommended a standardised reservoir, such as these MSBs, would increase uniformity of steam coverage(25). Similar results were reported by Lore et al and Bergman et al with no deleterious effect of microwave generated steam on the filtration performance of N95 FFRs (19,26). Both Bergman et al. and Viscusi et al. found fit of the FFR models used in their investigations to be unaffected by the use of microwave generated steam(26,27).

Main Benefits: Easily accessible inexpensive materials, No caustic chemicals
Main Limitations: Needs 1 hour plus drying time

Other options include:
  • Bleach (Viscusi 2009)
  • Autoclave (Lore 2015) (Viscusi 2011) - autoclaving is highly destructive process for some FFR models
  • Ethelene oxide gas (Viscusi 2009)
  • Vaporised hydrogen dioxide (Viscusi 2011)

Cleaning is considered a necessary step prior to disinfection to ensure that soiling materials do not interfere with the decontamination process. Commercially available wipes have been shown to be effective for clearing mucin and S. Aureus from N95 masks, with hypochlorite containing wipes resulting in significant disinfection with minimal reduction in filtration ability of masks(28).

Standard protocols have been described for bleach bath disinfection of reusable respirators(29). These could possibly be adapted as low tech, relatively low effort to disinfect batches of ‘single-use’ PPE

Even without an established feasible and reliable method to actively disinfect PPE, ‘passive temporal disinfection’ could be considered. Stability testing of COVID-19 on various surfaces identified that no viable virus remained on plastic and stainless steel after 72 hours with shorter times to no viable virus on copper and plastic(14). A previous study on the survival of a surrogate coronavirus for SARS on PPE found that the virus was detectable for up to 24 hours after inoculation on N95 masks. Although a definitive safe time threshold where no viable virus remains has yet to be established, there will be a time when masks can be re-used without significant risk of COVID-19.

Conclusion
Shortages of N95 FFRs and other PPE are likely in the very near future. Several methods have been successfully tested for decontamination of FFRs without degrading filtration ability or fit of these masks.
Feasibility and safety of decontamination methods has not been definitively established. Optimal methods are likely to vary with numerous factors including local preferences and resource availability.
The time to start stockpiling used PPE is NOW while plans for how best to decontaminate and reuse these vital resources are finalised.

References
  1. Wang X, Pan Z, Cheng Z. Association between 2019-nCoV transmission and N95 respirator use. J Hosp Infect [Internet]. 2020 Mar 3; Available from: http://dx.doi.org/10.1016/j.jhin.2020.02.021
  2. Glen Mayhall C. Hospital Epidemiology and Infection Control. Lippincott Williams & Wilkins; 2012. 1600 p.
  3. Bischoff WE, Swett K, Leng I, Peters TR. Exposure to influenza virus aerosols during routine patient care. J Infect Dis. 2013 Apr;207(7):1037–46.
  4. Website [Internet]. [cited 2020 Mar 19]. Available from: http://www.cdc.gov/flu/avianflu/h7n9-infection-control.htm
  5. Smith JD, MacDougall CC, Johnstone J, Copes RA, Schwartz B, Garber GE. Effectiveness of N95 respirators versus surgical masks in protecting health care workers from acute respiratory infection: a systematic review and meta-analysis. CMAJ. 2016 May 17;188(8):567–74.
  6. Long Y, Hu T, Liu L, Chen R, Guo Q, Yang L, et al. Effectiveness of N95 respirators versus surgical masks against influenza: A systematic review and meta-analysis. J Evid Based Med [Internet]. 2020 Mar 13; Available from: http://dx.doi.org/10.1111/jebm.12381
  7. MacIntyre CR, Seale H, Dung TC, Hien NT, Nga PT, Chughtai AA, et al. A cluster randomised trial of cloth masks compared with medical masks in healthcare workers [Internet]. Vol. 5, BMJ Open. 2015. p. e006577–e006577. Available from: http://dx.doi.org/10.1136/bmjopen-2014-006577
  8. Pillai SK, Beekmann SE, Babcock HM, Pavia AT, Koonin LM, Polgreen PM. Clinician Beliefs and Attitudes Regarding Use of Respiratory Protective Devices and Surgical Masks for Influenza. Health Secur. 2015 Jul;13(4):274–80.
  9. Nemeth C, Laufersweiler D, Polander E, Orvis C, Harnish D, Morgan SE, et al. Preparing for an Influenza Pandemic: Hospital Acceptance Study of Filtering Facepiece Respirator Decontamination Using Ultraviolet Germicidal Irradiation. J Patient Saf [Internet]. 2020 Mar 12; Available from: http://dx.doi.org/10.1097/PTS.0000000000000600
  10. CDC. Coronavirus Disease 2019 (COVID-19) [Internet]. Centers for Disease Control and Prevention. 2020 [cited 2020 Mar 20]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/crisis-alternate-strategies.html
  11. CDC - Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings - NIOSH Workplace Safety and Health Topic [Internet]. 2020 [cited 2020 Mar 20]. Available from: https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html
  12. Bergman MS, Viscusi DJ, Zhuang Z, Palmiero AJ, Powell JB, Shaffer RE. Impact of multiple consecutive donnings on filtering facepiece respirator fit. Am J Infect Control. 2012 May;40(4):375–80.
  13. Fisher EM, Noti JD, Lindsley WG, Blachere FM, Shaffer RE. Validation and application of models to predict facemask influenza contamination in healthcare settings. Risk Anal. 2014 Aug;34(8):1423–34.
  14. van Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med [Internet]. 2020 Mar 17; Available from: http://dx.doi.org/10.1056/NEJMc2004973
  15. Casanova L, Rutala WA, Weber DJ, Sobsey MD. Coronavirus survival on healthcare personal protective equipment. Infect Control Hosp Epidemiol. 2010 May;31(5):560–1.
  16. Carias C, Rainisch G, Shankar M, Adhikari BB, Swerdlow DL, Bower WA, et al. Potential demand for respirators and surgical masks during a hypothetical influenza pandemic in the United States. Clin Infect Dis. 2015 May 1;60 Suppl 1:S42–51.
  17. Institute of Medicine, Board on Health Sciences Policy, Committee on the Development of Reusable Facemasks for Use During an Influenza Pandemic. Reusability of Facemasks During an Influenza Pandemic: Facing the Flu. National Academies Press; 2006. 106 p.
  18. Lindsley WG, Martin SB Jr, Thewlis RE, Sarkisian K, Nwoko JO, Mead KR, et al. Effects of Ultraviolet Germicidal Irradiation (UVGI) on N95 Respirator Filtration Performance and Structural Integrity. J Occup Environ Hyg. 2015;12(8):509–17.
  19. Lore MB, Heimbuch BK, Brown TL, Wander JD, Hinrichs SH. Effectiveness of three decontamination treatments against influenza virus applied to filtering facepiece respirators. Ann Occup Hyg. 2012 Jan;56(1):92–101.
  20. Mills D, Harnish DA, Lawrence C, Sandoval-Powers M, Heimbuch BK. Ultraviolet germicidal irradiation of influenza-contaminated N95 filtering facepiece respirators. Am J Infect Control. 2018 Jul;46(7):e49–55.
  21. Viscusi DJ, Bergman MS, Eimer BC, Shaffer RE. Evaluation of five decontamination methods for filtering facepiece respirators. Ann Occup Hyg. 2009 Nov;53(8):815–27.
  22. Fisher EM, Shaffer RE. A method to determine the available UV-C dose for the decontamination of filtering facepiece respirators. J Appl Microbiol. 2011 Jan;110(1):287–95.
  23. Kolata G. As Coronavirus Looms, a Hospital Begins Sterilizing Masks for Reuse [Internet]. 2020 [cited 2020 Mar 21]. Available from: https://www.nytimes.com/2020/03/20/health/coronavirus-masks-reuse.html
  24. Fisher EM, Williams JL, Shaffer RE. Evaluation of Microwave Steam Bags for the Decontamination of Filtering Facepiece Respirators [Internet]. Vol. 6, PLoS ONE. 2011. p. e18585. Available from: http://dx.doi.org/10.1371/journal.pone.0018585
  25. Heimbuch BK, Wallace WH, Kinney K, Lumley AE, Wu C-Y, Woo M-H, et al. A pandemic influenza preparedness study: use of energetic methods to decontaminate filtering facepiece respirators contaminated with H1N1 aerosols and droplets. Am J Infect Control. 2011 Feb;39(1):e1–9.
  26. Bergman MS, Viscusi DJ, Heimbuch BK, Wander JD, Sambol AR, Shaffer RE. Evaluation of Multiple (3-Cycle) Decontamination Processing for Filtering Facepiece Respirators [Internet]. Vol. 5, Journal of Engineered Fibers and Fabrics. 2010. p. 155892501000500. Available from: http://dx.doi.org/10.1177/155892501000500405
  27. Viscusi DJ, Bergman MS, Novak DA, Faulkner KA, Palmiero A, Powell J, et al. Impact of three biological decontamination methods on filtering facepiece respirator fit, odor, comfort, and donning ease. J Occup Environ Hyg. 2011 Jul;8(7):426–36.
  28. Heimbuch BK, Kinney K, Lumley AE, Harnish DA, Bergman M, Wander JD. Cleaning of filtering facepiece respirators contaminated with mucin and Staphylococcus aureus. Am J Infect Control. 2014 Mar;42(3):265–70.
  29. Bessesen MT, Adams JC, Radonovich L, Anderson J. Disinfection of reusable elastomeric respirators by health care workers: a feasibility study and development of standard operating procedures. Am J Infect Control. 2015 Jun;43(6):629–34.
  30. Salter WB, Kinney K, Wallace WH, Lumley AE, Heimbuch BK, Wander JD. Analysis of residual chemicals on filtering facepiece respirators after decontamination. J Occup Environ Hyg. 2010 Aug;7(8):437–45.
submitted by Gibs_is_anim_dom to medicine

Red Flood Halloween Intermission: California

GENERALS BEWARE; YOU’RE IN FOR A SCARE

Happy Halloween everyone! Today we’ll be touring a nation that will be somewhat rare to see. The USA is having a lot of work done on expanding its paths and lore for 0.3 and beyond, but given some of the recent teasers and the time of year, it’s time to focus on one of the unlikely countries that can rise in the mod’s timeframe.
What exactly leads to the birth of California as an independent country will unfortunately be left behind the curtain for now, but we have plenty of content to cover while you’re waiting. After all, regardless of how the nation is born, it will be birthed in war and conflict. Please don’t be topical, please don’t be topical...

Background

In 1934, the journalist and author Upton Sinclair ran his ill-fated gubernatorial campaign. Running under the Jobless Progressive Party ticket, and convinced one of his competitors, Raymond L Haight, to endorse him. Not every supporter of this Angelino reporter was happy about voting Sinclair, but most didn’t want to vote for Raymond. With the socialists and communists endorsing Sinclair (in part due to some events in federal politics), there’s only one other place for dissident votes to go: the politically-activated horror author Edward Longstreet Bodin and his Spiritualist Party.
As in our timeline, Sinclair loses, receiving 1,089,989 votes to Frank Merriam’s 1,138,629. The Spiritualists received 100,840, leading to much outcry about third-party votes, and with such a close result, Sinclair calls for a recount... but he’s immediately denied. Things only get worse from there - due to the instability caused by [REDACTED], Frank calls off the 1938 election in a very contentious decision that draws ire from Sinclair’s wing of things. Through this entire time, however, Bodin is making connections, especially in the Hollywood elite. His unique set of views grows very popular in a time where conventional politics continue to flounder, especially with the publication of Scare Me! in 1939, but we’ll cover him later.
Then, due to [REDACTED], California exits the Union and Frank’s position becomes untenable. He resigns and the Riverside Council is formed - a temporary power-sharing agreement in a city chosen as a compromise between the three biggest power bases in California, and also pointedly one with an Anglophone name. They will soon run new elections and the winner is…

The United Front wins

To say nothing of the previous years of economic crisis in America, California goes through massive disruptions even in the small time window that the Riverside Council is in power. Operating a barely legitimate institution, the previous political establishment decides that to secure the democratic future of California as a whole, it is necessary to create a coalition ticket with the state Revived Democratic Party and the Republican Party, who come together haphazardly in a couple of days as they prepare for election day. Having the big names of the Californian political establishment work together can indeed be enough to secure a victory for the establishment. This spells the end of Bodin and Sinclair’s best chance to take power in the crisis, with the former destined for his usual obscurity and the latter an exile to the east. The primary things that this United Front will do as a government will be to secure Californian democracy and deal with a new pressing issue - handling the Mormons in the Eastern California Desert, where a wave of colonists from a neighboring country are agitating for annexation. But of course, once the worst of California’s early days pass, the United Front is not long for this world, and both sides will squabble for power over who is really upholding the government’s ideals. The California Senate then can decide whether to stick with the Democrats or side with the Republicans. If one sides with the Republicans, they can expect relatively minimal government, the use of the United States dollar as the local Californian currency, and protection of individual freedoms. On the other side, the platform of the Democrats is a mixed one, where a bigger government ensures Social Security but protects the segregationist lifestyle in California, making sure to keep the Mexicans and Blacks of the state down. However, one thing that both parties can agree on, at the end of the day, is upholding democracy, and protecting the institutions that keep that democracy great... like the Electoral College. However, the path the story takes changes a lot if Sinclair is elected instead…

Okay, now this is EPIC;

Upton Sinclair’s great victory had come. He was waiting for this for years now, and finally he had gotten the record straight. Perhaps it is time to finally End Poverty in California? Regardless, Sinclair has many problems to deal with. The revolution through the ballot has many enemies, on top of what the United Front has to deal with. Hollywood is plotting, the Democrats and Republicans are uppity, and overall, the corporate-dominated regime here is keeping the good people of California poor. No longer -- for his program, the EPIC program, will result in a V-shaped recovery that no one has ever seen before and a country for the common man. The federal policies that were cut short by [REDACTED] are only the beginning. Public works unlike anything seen before, to get the country working again. Tax reform to shake the foundations of the economy and build a new apparatus of relief and aid. Other idealistic policies like guaranteed pensions. Through raising up the poor of California so they can work and advocate for themselves, Sinclair’s administration will guarantee the dream of 1934 will not fade into the night. With his enemies left eating crow, Sinclair’s work will continue on as he attempts to build a better society from the scraps of the great American Experiment. But if you want a splash of drama, perhaps you’d like to…

SCARE ME!

The harshest thing the Anglo-Saxons had ever been through was over. The great races of the Western World realize that they’re in for a scary time as ghosts, ectoplasm, werewolves and other creatures from ancient astronauts to paranormal beings have been plaguing them and placing them in this great horror. The fall of the largest Anglo-Saxon country in the world was largely due to the plotting of Catholics and Communists - sometimes, God forbid, both - and now Edward Longstreet Bodin has called for the great spirits in California to rise from their mediocrity and reach Enlightenment. He will open a breach from the Physical world to investigate other realms of consciousness. Through a massive alliance with people like Arthur “The Voice” Bell, L Ron Hubbard, and other mystics and New Age weirdos, Ed Bodin, the reincarnation of Jean Bodin, has now managed a slim electoral victory - perhaps with some paranormal help… The important part is that while Bodin’s “Spiritualist Party” is now in power, it is really only nominally. In reality, he is leading more of a gigantic coalition of multiple spiritual movements collectively called the Spiritualists, largely rich Anglo-Saxons living in Southern California. The first thing he will do as President is change the flag to a compromise idea designed by Arthur “The Voice” Bell, one related to Protestant Mysticism and the idea of the Christ’s Church of the Golden Rule. Another initial policy is immediate investigations into Physical matters such as the existence of werewolves, ghosts, etc. Eventually though, his ideas grow more and more profound and strike further into the realms of the unconscious and spiritual conscious, reaching deeper layers of understanding, where he and his buddies begin to have Great Ideas. Eventually, at his final focus, he proclaims a War against the Hidden Rulers, essentially entailing a total war against those that exploit the population for the gains of an Alien population. (In-game this entails a number of events... and a big purge).

FOREIGN POLICY, MILITARY TREES

Regardless of who holds absolute power at the end of the day, California will have to consider its military and foreign policy as a new country. On top of industrial and resource development, there’s the wider question of what the Californian military will look like as it takes shape, especially their doctrine. Needless to say, there are benefits for each depending on what posture you take towards the rest of the continent. Speaking of that, there are a number of questions to ask about where you’ll be putting that military once it’s armed. Militarism and expansionism may not always be the most popular policy, but whether to protect the Californian frontiers or to secure resources for the nation, you might find yourself having to be proactive. After all, the industry and population of California have been severed from the wider continental economy that was the United States, and it may prove fatal to go without that. And that’s to say nothing of how the more radical paths might see their neighbors...
That wraps up the diary for now. As 0.3 gains steam, we hope to bring other long-awaited previews to you in the near future.
submitted by RagyTheKindaHipster to RedFloodMod