Time series modeling for syndromic surveillance

BACKGROUND: Emergency department (ED) based syndromic surveillance systems identify abnormally high visit rates that may be an early signal of a bioterrorist attack. For example, an anthrax outbreak might first be detectable as an unusual increase in the number of patients reporting to the ED with respiratory symptoms. Reliably identifying these abnormal visit patterns requires a good understanding of the normal patterns of healthcare usage. Unfortunately, systematic methods for determining the expected number of (ED) visits on a particular day have not yet been well established. We present here a generalized methodology for developing models of expected ED visit rates. METHODS: Using time-series methods, we developed robust models of ED utilization for the purpose of defining expected visit rates. The models were based on nearly a decade of historical data at a major metropolitan academic, tertiary care pediatric emergency department. The historical data were fit using trimmed-mean seasonal models, and additional models were fit with autoregressive integrated moving average (ARIMA) residuals to account for recent trends in the data. The detection capabilities of the model were tested with simulated outbreaks. RESULTS: Models were built both for overall visits and for respiratory-related visits, classified according to the chief complaint recorded at the beginning of each visit. The mean absolute percentage error of the ARIMA models was 9.37% for overall visits and 27.54% for respiratory visits. A simple detection system based on the ARIMA model of overall visits was able to detect 7-day-long simulated outbreaks of 30 visits per day with 100% sensitivity and 97% specificity. Sensitivity decreased with outbreak size, dropping to 94% for outbreaks of 20 visits per day, and 57% for 10 visits per day, all while maintaining a 97% benchmark specificity. CONCLUSIONS: Time series methods applied to historical ED utilization data are an important tool for syndromic surveillance. Accurate forecasting of emergency department total utilization as well as the rates of particular syndromes is possible. The multiple models in the system account for both long-term and recent trends, and an integrated alarms strategy combining these two perspectives may provide a more complete picture to public health authorities. The systematic methodology described here can be generalized to other healthcare settings to develop automated surveillance systems capable of detecting anomalies in disease patterns and healthcare utilization

Examining Terrorism Attacks and Regional Preparedness in the United States

After the 9/11 terrorist attacks, the U.S. government renewed efforts to prepare for future attacks. Despite research on federal and state government preparedness, there was a lack of scholarship on trends in terrorist attacks at the local level. The purpose of this quantitative descriptive study was to examine trends in terrorism attacks in the United States between 2001 and 2018 and determine whether significance exists between characteristics of the terrorism incidents (weapon used, target type) and region. The conceptual framework included Grundmann’s risk management and Tomuzia et al.’s risk assessment scenario models. Answering the research questions entailed examining trends in terrorist attacks in the United States between 2001 and 2018 (number of incidents, injuries, fatalities), including relationships by region, weapon used, and target type. Secondary data from the Global Terrorism Database underwent analysis using ARIMA models for time-series data and chi-square and post hoc analyses for categorical level data. There was an examination of type of weapon used and target type for differences between regions. Findings revealed that trends in terrorist attacks for injuries did not differ across time; however, trends in terrorist attacks for fatalities decreased over time. Changes in terrorist attacks by region were significantly related to weapon used and target type. Findings may lead to positive social change by helping policymakers understand future targets and characteristics of terrorist attacks, potentially improving preparedness and thereby reducing injuries and death. Future research is needed to confirm and expand the findings, including studies on terrorist attacks against the United States on foreign soil, such as those directed at U.S. embassies

Are EMS Prepared to Respond to a Pandemic or Bioterrorist Attack?

The 2019 Coronavirus (COVID-19) pandemic increased America’s awareness of the amount of death and damage to the economy that pandemics and bioterrorism can cause. Additionally, the COVID-19 pandemic exposed significant shortfalls in national preparedness for a pandemic or bioterrorism event. The purpose of this study is to evaluate the current preparedness level of Emergency Medical Services (EMS) personnel in the United States to prepare for, respond to, mitigate, and recover from a natural or manufactured pandemic across the United States. The significance of this study is an accurate picture of preparedness for pandemic and bioterrorism events by American EMS systems. This preparedness level can be compared to the desired preparedness posture to address the delta between desired and observed preparedness. The theoretical foundation for this quantitative research project was based on multiple streams theory and utilized descriptive and inferential statistics. The research questions focused on the current preparedness of EMS providers to effectively respond to a pandemic or bioterrorist attack and possible improvements to current EMS practices that would improve the effectiveness of future responses. The study population consisted of 398 (N – 398) individual and currently credentialed EMS providers representing various prehospital certification levels from all types of EMS systems through an electronic standardized ethically reviewed questionnaire. A chi-square test of statistical significance and inferential statistical analysis revealed a statistically significant difference in the perception of EMS providers in various demographic categories and their perception of preparedness to respond to a pandemic or bioterrorist attack

FORCEnet an analysis of the Trident Warrior 2003 exercise

Since the country has moved into the Information Age, the military forces have been moving towards network based operations. The rapid expansion of the internet and information technology (IT) has led to the emerging theory of Network- Centric Warfare (NCW). The Naval Services instantiation of NCW is FORCEnet. "FORCEnet is the "glue" that binds together Sea Strike, Sea Shield, and Sea Basing. It is the operational construct and architectural framework for naval warfare in the Information Age, integrating warriors, sensors, command and control, platforms, and weapons into a networked, distributed combat force. FORCEnet will provide the architecture to increase substantially combat capabilities through aligned and integrated systems, functions, and missions. Sea Power 21 is a comprehensive attempt to address the ramifications of the Information Age revolution. The framework of the Sea Power 21 vision is composed of the following elements: Sea Basing, Sea Shield and Sea Strike. The enabler of this vision or the "glue" that holds it all together is FORCEnet. FORCEnet is "the operational construct and architectural framework of naval warfare in the information age that integrates Warriors, sensors, networks, command and control, platforms, and weapons into a networked, distributed combat force that is scaleable across all levels of conflict from seabed to space and sea to land." The Trident Warrior 03 exercise was then developed as a means to measure its success and to acquire data from which future exercises can be measured against. FORCEnet is still in its infancy and many people have different views on what exactly it is and how it should be implemented to achieve those goals. The intent of this thesis was not to answer those questions per se, but provide a realistic analysis of what worked during the TW03 exercise and what did not. This should provide a baseline for further Trident Warrior exercises so as to avoid the same mistakes in the future. The military has a ways to go before it can fully realize a truly networked-centric armed forces, but TW03 was the beginning and the lessons learned from it will pay dividends in realizing that fully networked goal.http://archive.org/details/forcenetnnalysis109451392Major, United States Marine CorpsApproved for public release; distribution is unlimited

Disaster management and its economic implications

Das Ziel dieser Arbeit ist es, aktuelle Forschungsschwerpunkte im Bereich des Katastrophenmanagements in der Operational Research Literatur aufzuzeigen. Katastrophenmanagement umfasst in diesem Zusammenhang einerseits Naturkatastrophen wie geophysikalische und hydro-meteorologische Katastrophen, technologische Katastrophen wie industrielle Unfälle, Transportunfälle und sonstige Unfälle, und andererseits die verschiedenen Formen des Terrorismus, allgemeinen Terrorismus sowie Bioterrorismus. Da die Anzahl und das Ausmaß von Katastrophen immer weiter zunehmen ist auch eine immer größere Notwendigkeit für die Entwicklung, den Einsatz und die wirtschaftliche Beurteilung der jeweiligen Strategien gegeben. Der erste Teil dieser Arbeit gibt einen Überblick über die Literatur im Bereich des Katastrophenmanagements und umfasst Simulation, Katastrophenmanagement in Krankenhäusern und die Rolle von Versicherungen im Katastrophenmanagementprozess. Im zweiten Teil wird eine Taxonomie entwickelt, deren Kategorien auf den Modellen und Ergebnissen der Literatur beruhen. Einerseits werden allgemeine Modelleigenschaften wie die Ebene im Katastrophenmanagementprozess, der Modelltyp und die Anwendungsgebiete der Modelle untersucht. Andererseits stellen die Art der Intervention und die Anwendbarkeit für die unterschiedlichen Katastrophenklassen weitere Kategorien der Taxonomie dar. Es wurden 90 Artikel, die beispielhaft für die Forschungsrichtungen im Bereich des Katastrophenmanagements der letzten 25 Jahre stehen, ausgewählt, und entsprechend den jeweiligen Kategorien der Taxonomie zugeordnet. Das Hauptaugenmerk der Taxonomie liegt auf der wirtschaftlichen Analyse, die wirksamkeitsbezogene, ressourcenbezogene und kostenbezogene Parameter umfasst. Es wird gezeigt ob und welche wirtschaftliche Analyse wie beispielsweise die Kosten-Nutzwert- Analyse, die Kosten-Wirksamkeits-Analyse und die Kosten-Nutzen-Analyse angewendet wird um die in den Artikeln beschriebenen Interventionen zu evaluieren. Es wird gezeigt, dass erhebliche Verbesserungen für die verschiedenen Katastrophentypen und in den verschiedenen Situationen erzielt werden können. Eingeschränkte Datenverfügbarkeit schränkt in vielen Fällen die Einsetzbarkeit der Modelle in realen Situationen ein. Im Allgemeinen ist erkennbar, dass Kooperation und Koordination zwischen den beteiligten Einheiten ausschlaggebend für den zeitgerechten und effizienten Einsatz der knappen Ressourcen sind. Oftmals erzielt der gemeinsame Einsatz mehrerer Maßnahme ein deutlich besseres Ergebnis als der Einsatz von lediglich einem einzigen Instrument. Die Taxonomie unterstreicht dass trotz der großen Fülle an Literatur im Bereich des Katastrophenmanagements nur wenige Autoren auf die Kosten-Nutzwert-Analyse, die Kosten-Wirksamkeits-Analyse und die Kosten-Nutzen-Analyse als Hilfsmittel zur wirtschaftlichen Analyse zurückgreifen. In Zukunft, um Interventionen erfolgreich evaluieren zu können oder die beste aus mehreren Interventionen bestimmen zu können wird es immer wichtiger werden, diese Art von wirtschaftlichen Analysen anzuwenden.This thesis intends to demonstrate current research directions in the field of disaster management in the Operational Research literature. Disaster management in this context comprises the management of natural, such as geophysical and hydro-meteorological, and technological disasters, such as industrial accidents, transportation accidents, and miscellaneous accidents, as well as the management of the different terrorism forms, general terrorism and bioterrorism. As the occurrence of disasters is getting more and more frequent and the accumulated loss of these events is getting higher and higher, there is a strong need for the development, implication and economic evaluation of strategies to counter these disasters. In the first part of the thesis, a general overview of the literature is given, including a focus on simulation, disaster management in hospitals, and the role of insurances in the disaster management process. The second part encompasses the taxonomy which focuses on models and outcomes presented in the literature. As a result of the review of the literature, appropriate categories for the disaster management taxonomy are derived. On the one hand, an overview of general model features, i.e., the level of disaster management, model type and methods of application is given. On the other hand, the type of intervention used and the practicability for different disaster types are discussed. 90 papers, illustrative main examples of the research directions of the last 25 years, were selected for deeper investigation and classified according to the main criteria analyzed in the articles. The main focus of the taxonomy lies on the economic analysis, which encompasses effectiveness-related, resource-related, and cost-related parameters and shows the type of economic analysis used in the literature. We analyze whether economic analysis, i.e., costutility, cost-effectiveness, and cost-benefit are used to investigate different interventions and what type of analysis has been chosen by the authors. Policy implications and results show that considerable improvements can be achieved for different disastrous events and in different situations. Limited data availability constrains the outcomes of the models and their applicability to real-world situations. In general, cooperation and coordination of the entities involved are crucial to guarantee timely and efficient assignment of scarce resources. Furthermore, different authors confirm that a combination of various measures often achieves a better outcome than if tools are used autonomously. The taxonomy has underlined that although there exists a vast disaster management literature dealing with various problems related to mitigation, preparedness, response and recovery from disasters, there are only a few authors evaluating the actions taken through economic analyses such cost-utility, cost-effectiveness, or cost-benefit analysis. In the future, to be able to evaluate interventions, or to figure out the most effective intervention among several interventions, it is crucial to stronger rely on the abovementioned economic analyses

Assessment of public health infrastructure to determine public health preparedness

CHDS State/LocalSince September 2001, health threats associated with acts of terrorism have become an area of increasing concern. The Strategy for Homeland Security stresses the need for a robust public health component to quickly respond to and recover from attacks and other emergencies. The assumption that public health is an optimal system that simply needs to be aimed in new directions is fundamentally flawed. Public health baseline requirements for responding to threats are not as well understood as they might be. The purpose of this research is to help establish a common and accurate measure for assessing the public health infrastructure. Using the case study of Union County, New Jersey this thesis surveys the activities public health agencies are expected to perform; compares performance to target objectives; and employs a manpower matrix as a model for determining staffing requirements for local public health. This study argues that that the goal of sustainable funding for public health begins with an accurate measure of the capacities of the system in relation to demands placed upon it. Without such a measure public health will continue to fail in its primary functions and lack the capacity to meet Homeland Security goals.http://archive.org/details/assessmentofpubl109452962Health Officer, County of Unio

Urban Terrorism: Strategies for Mitigating Terrorist Attacks Against the Domestic Urban Environment

This study identifies strategies to mitigate the impact of terrorist attacks against the domestic urban environment. It uses multiple qualitative research methods to identify patterns of attack used by terrorists against urban targets in the United States and suggest ways for policymakers to mitigate the effects of a terrorist attack through not only physical, but also organizational, political, legal, and social strategies. It uses case analysis, literature review, and interviews with experts in domestic terrorism preparedness to develop and suggest solutions. Terrorism, as with other criminal acts, can best be met by implementing strategies to mitigate the impact of this form of crime. Governments are simultaneously confronted with a rapidly growing number of potential terrorist targets that must be secured, and constrained by democratic principles from utilizing many technological devices to secure those targets. Creating an effective security system that protects against a wide range of terrorist attacks while it continues to afford a maximum exercise of democratic freedoms and privileges is a formidable task. Several broad, theory-based categories of defending urban spaces are considered. This study builds on past research and extends defensible space theory with careful consideration of the special challenges in dealing with terrorist attacks. The potential for terrorist attack is reviewed, and an understanding of who the domestic urban terrorists are, why they may attack the urban built environment, what might they attack, and what can be done about it is developed. Recommendations for public policy and future research are presented

Bioterrorism Hardening: An Exploratory Study of EMTs Preparedness and Practices

The 2001 anthrax attacks heightened awareness of the possibility of weaponizing biological agents such as Ebola, anthrax, and smallpox and hence, the Bioterrorism Act of 2002 to prevent biological attacks and reduce bioterrorism threats and vulnerabilities. However, the 2014 Ebola epidemic raised concerns about unpreparedness for bioterrorism within the healthcare community and about secondary infections from healthcare workers. Using Kingdon\u27s conceptualization of multiple streams as the foundation, the purpose of this case study was to explore the nature of bioterrorism threats and the level of preparedness of Emergency Medical Technicians (EMTs) who were involved in the 2014 Ebola epidemic in a New Jersey County for biological attacks and avoidance or reduction of secondary infections. Data were collected from 18 individuals through interviews and from emergency response documents. The data were inductively coded and subjected to thematic analysis. The emergent themes indicated that although there was an abundance of bioterrorism preparedness policies and programs dating back to the 2001 anthrax attacks, the response to the 2014 Ebola epidemic revealed inadequate bioterrorism preparedness practices. The study participants identified insufficient knowledge of bioagents and lack of regular training as factors that prevented enhanced preparedness practices. Participants suggested that improved training opportunities, interagency collaborations, and better funding would improve bioterrorism preparedness practices. The social change implications of this study include increased funding for bioterrorism preparedness to harden EMTs and the creation of public awareness of bioagents for improved 911 calls and emergency response practices

International Society for Disease Surveillance Conference 2011: Building the Future of Public Health Surveillance: Building the Future of Public Health Surveillance

Daniel Reidpath - ORCID: 0000-0002-8796-0420 https://orcid.org/0000-0002-8796-04204pubpub1117

Adaptation to the Health Consequences of Climate Change as a Potential Influence on Public Health Law and Policy: From Preparedness to Resilience

Because the health effects of climate change are likely to be significant and far-reaching, a key component of climate change adaptation will be our public health infrastructure. Perhaps counter-intuitively, recent emphasis in public health law on preparedness for extraordinary events may be to the detriment of our ability to cope with the health impacts of climate change. While existing emergency preparedness law will necessarily be an important backdrop for health-focused climate change adaptation efforts (especially with regard to natural disasters and infectious disease outbreaks), the focus on emergency preparedness in recent years does not necessarily situate us well for handling the substantial, but slowly emerging, intensification of more routine health threats that we expect to see as an impact of climate change. This paper examines the likely demands of climate change on public health infrastructure, law, and policy and argues that the adaptation response to climate change has the potential to improve public health infrastructure in ways that will better position us to handle routine needs as they intensify and to move public health law and policy toward an approach that emphasizes “resilience” rather than “preparedness.” Three case studies are used to illustrate the current public health law and policy response to the types of health threats that we are likely to see in the U.S. as a consequence of climate change: (1) the incompatibility of the strategic national stockpile of pharmaceutical and medical supplies with the needs of disaster victims following Hurricane Katrina; (2) privacy-based barriers to public health surveillance programs seeking to track trends in pediatric asthma; and (3) conflicts over the use of pesticides for vector control to fight West Nile Virus in the United States. Upon delving more deeply into these three examples, a picture emerges of the ways in which climate change weighs in on some of the key concerns of public health and public health law. Because the health threats associated with climate change are likely to exacerbate underlying health disparities (in that they are particularly concerning for vulnerable subpopulations such as the poor, city-dwellers, the elderly, and those who suffer from chronic health conditions), climate change adaptation will raise issues of health equity and put pressure on the traditional divide between public and private responsibility for health. Because the health impacts of climate change are predominantly local in nature but are likely to overwhelm local resources, climate change adaptation will require us to revisit jurisdictional issues regarding the funding and control of health programs to emphasize adequate support for community-based responses. Responding to severe health threats that are not immediately urgent, will require new ways of thinking about the balance between individual rights and community needs that go beyond reliance on the concept of a public health “emergency” to override more deliberative processes. Finally, because some measures that might be used to adapt to the impacts of climate change will pose potential risks of their own, adaptation planning will raise the challenge of informing public choices about risk in the context of complex risk-risk trade-offs. I argue that, taken together, these considerations have the potential to move public health law toward a new approach that emphasizes “resilience” rather than “preparedness.” This approach would be deliberative, equity-driven, and community-based, and would seek to balance respect for lay values with correction of facts regarding the various risks involved