Designing and conducting tabletop exercises to assess public health preparedness for manmade and naturally occurring biological threats

<p>Abstract</p> <p>Background</p> <p>Since 2001, state and local health departments in the United States (US) have accelerated efforts to prepare for high-impact public health emergencies. One component of these activities has been the development and conduct of exercise programs to assess capabilities, train staff and build relationships. This paper summarizes lessons learned from tabletop exercises about public health emergency preparedness and about the process of developing, conducting, and evaluating them.</p> <p>Methods</p> <p>We developed, conducted, and evaluated 31 tabletop exercises in partnership with state and local health departments throughout the US from 2003 to 2006. Participant self evaluations, after action reports, and tabletop exercise evaluation forms were used to identify aspects of the exercises themselves, as well as public health emergency responses that participants found more or less challenging, and to highlight lessons learned about tabletop exercise design.</p> <p>Results</p> <p>Designing the exercises involved substantial collaboration with representatives from participating health departments to assure that the scenarios were credible, focused attention on local preparedness needs and priorities, and were logistically feasible to implement. During execution of the exercises, nearly all health departments struggled with a common set of challenges relating to disease surveillance, epidemiologic investigations, communications, command and control, and health care surge capacity. In contrast, performance strengths were more varied across participating sites, reflecting specific attributes of individual health departments or communities, experience with actual public health emergencies, or the emphasis of prior preparedness efforts.</p> <p>Conclusion</p> <p>The design, conduct, and evaluation of the tabletop exercises described in this report benefited from collaborative planning that involved stakeholders from participating health departments and exercise developers and facilitators from outside the participating agencies. While these exercises identified both strengths and vulnerabilities in emergency preparedness, additional work is needed to develop reliable metrics to gauge exercise performance, inform follow-up action steps, and to develop re-evaluation exercise designs that assess the impact of post-exercise interventions.</p

What Does Population Health Mean for Public Health?

Dr. James W. Buehler’s research interests center on improving public health systems and services, especially the interface between public health and healthcare systems and the shared objective to advance population health. During the final 18 months of the administration of Mayor Michael Nutter, Dr. Buehler served as the Health Commissioner for the City of Philadelphia, where he directed the Philadelphia Department of Public Health in achieving its mission “to protect and promote the health of all Philadelphians and to provide a safety net for the most vulnerable.” Dr. Buehler\u27s Forum presentation explained the population health objectives of the Affordable Care Act as well as discussed the ACA\u27s requirements for non-profit hospitals. He also identified the key examples of how quality-of-care monitoring and reporting requirements within the federal program promote the Meaningful Use of electronic health records. Presentation: 54:4

Business and public health collaboration for emergency preparedness in Georgia: a case study

BACKGROUND: Governments may be overwhelmed by a large-scale public health emergency, such as a massive bioterrorist attack or natural disaster, requiring collaboration with businesses and other community partners to respond effectively. In Georgia, public health officials and members of the Business Executives for National Security have successfully collaborated to develop and test procedures for dispensing medications from the Strategic National Stockpile. Lessons learned from this collaboration should be useful to other public health and business leaders interested in developing similar partnerships. METHODS: The authors conducted a case study based on interviews with 26 government, business, and academic participants in this collaboration. RESULTS: The partnership is based on shared objectives to protect public health and assure community cohesion in the wake of a large-scale disaster, on the recognition that acting alone neither public health agencies nor businesses are likely to manage such a response successfully, and on the realization that business and community continuity are intertwined. The partnership has required participants to acknowledge and address multiple challenges, including differences in business and government cultures and operational constraints, such as concerns about the confidentiality of shared information, liability, and the limits of volunteerism. The partnership has been facilitated by a business model based on defining shared objectives, identifying mutual needs and vulnerabilities, developing carefully-defined projects, and evaluating proposed project methods through exercise testing. Through collaborative engagement in progressively more complex projects, increasing trust and understanding have enabled the partners to make significant progress in addressing these challenges. CONCLUSION: As a result of this partnership, essential relationships have been established, substantial private resources and capabilities have been engaged in government preparedness programs, and a model for collaborative, emergency mass dispensing of pharmaceuticals has been developed, tested, and slated for expansion. The lessons learned from this collaboration in Georgia should be considered by other government and business leaders seeking to develop similar partnerships

Local Health Departments’ Level of Engagement in Population Mental Health Promotion

Background: Mental health conditions are highly prevalent in the U.S. and are associated with physical health problems. Federal initiatives recognize mental health as a public health priority, and local health departments (LHDs) have been identified as partners to promote population mental health. Little is known, however, about the extent to which LHDs address mental health or how LHD officials perceive mental health as a public health concern. Purpose: To describe the cumulative level of LHDs’ engagement in activities to address population mental health and explore how LHD officials perceive their roles in promoting it. Methods: Module 2 of the 2013 National Profile of Local Health Departments Study (N=505) was used to develop a cumulative measure of LHD engagement in mental health activities. Univariate and bivariate analyses were performed to describe LHDs’ level of mental health activity and identify associated LHD characteristics. Semi-structured in-depth interviews were conducted with 30 LHD officials, audio-recorded, transcribed, and analyzed using thematic content analysis. Results: Over half (55.8%) of LHDs performed ≥1 mental health activities, and 21.2% performed ≥4. LHDs that provided primary care services were most engaged in mental health activities, with 30.4% performing ≥4 and 18.2% performing ≥6. LHD officials perceived mental health as a public health issue and felt community pressure to address it, but encountered barriers related to resources and organizational boundaries. Implications: LHDs might benefit from quality improvement and information sharing resources focused on population mental health promotion. Research should examine LHDs relationships with behavioral health departments and roles within broader social service systems

A Tribute to Joseph Edward Ulrich

This tribute honors Joseph Edward Ulrich, who in thirty-one years on the W&L Law faculty and in recent years as one-called-out-of-retirement, attained legendary status amidst fellow giants Roger Groot, Uncas McThenia, and Lash LaRue

Challenges in defining an optimal approach to formula-based allocations of public health funds in the United States

BACKGROUND: Controversy and debate can arise whenever public health agencies determine how program funds should be allocated among constituent jurisdictions. Two common strategies for making such allocations are expert review of competitive applications and the use of funding formulas. Despite widespread use of funding formulas by public health agencies in the United States, formula allocation strategies in public health have been subject to relatively little formal scrutiny, with the notable exception of the attention focused on formula funding of HIV care programs. To inform debates and deliberations in the selection of a formula-based approach, we summarize key challenges to formula-based funding, based on prior reviews of federal programs in the United States. DISCUSSION: The primary challenge lies in identifying data sources and formula calculation methods that both reflect and serve program objectives, with or without adjustments for variations in the cost of delivering services, the availability of local resources, capacity, or performance. Simplicity and transparency are major advantages of formula-based allocations, but these advantages can be offset if formula-based allocations are perceived to under- or over-fund some jurisdictions, which may result from how guaranteed minimum funding levels are set or from "hold-harmless" provisions intended to blunt the effects of changes in formula design or random variations in source data. While fairness is considered an advantage of formula-based allocations, the design of a formula may implicitly reflect unquestioned values concerning equity versus equivalence in setting funding policies. Whether or how past or projected trends are taken into account can also have substantial impacts on allocations. SUMMARY: Insufficient attention has been focused on how the approach to designing funding formulas in public health should differ for treatment or service versus prevention programs. Further evaluations of formula-based versus competitive allocation methods are needed to promote the optimal use of public health funds. In the meantime, those who use formula-based strategies to allocate funds should be familiar with the nuances of this approach

Syndromic Surveillance and Bioterrorism-related Epidemics

To facilitate rapid detection of a future bioterrorist attack, an increasing number of public health departments are investing in new surveillance systems that target the early manifestations of bioterrorism-related disease. Whether this approach is likely to detect an epidemic sooner than reporting by alert clinicians remains unknown. The detection of a bioterrorism-related epidemic will depend on population characteristics, availability and use of health services, the nature of an attack, epidemiologic features of individual diseases, surveillance methods, and the capacity of health departments to respond to alerts. Predicting how these factors will combine in a bioterrorism attack may be impossible. Nevertheless, understanding their likely effect on epidemic detection should help define the usefulness of syndromic surveillance and identify approaches to increasing the likelihood that clinicians recognize and report an epidemic

Surveillance for Anthrax Cases Associated with Contaminated Letters, New Jersey, Delaware, and Pennsylvania, 2001

In October 2001, two inhalational anthrax and four cutaneous anthrax cases, resulting from the processing of Bacillus anthracis–containing envelopes at a New Jersey mail facility, were identified. Subsequently, we initiated stimulated passive hospital-based and enhanced passive surveillance for anthrax-compatible syndromes. From October 24 to December 17, 2001, hospitals reported 240,160 visits and 7,109 intensive-care unit admissions in the surveillance area (population 6.7 million persons). Following a change to reporting criteria on November 8, the average of possible inhalational anthrax reports decreased 83% from 18 to 3 per day; the proportion of reports requiring follow-up increased from 37% (105/286) to 41% (47/116). Clinical follow-up was conducted on 214 of 464 possible inhalational anthrax patients and 98 possible cutaneous anthrax patients; 49 had additional laboratory testing. No additional cases were identified. To verify the limited scope of the outbreak, surveillance was essential, though labor-intensive. The flexibility of the system allowed interim evaluation, thus improving surveillance efficiency

A population of gamma-ray emitting globular clusters seen with the Fermi Large Area Telescope

Globular clusters with their large populations of millisecond pulsars (MSPs) are believed to be potential emitters of high-energy gamma-ray emission. Our goal is to constrain the millisecond pulsar populations in globular clusters from analysis of gamma-ray observations. We use 546 days of continuous sky-survey observations obtained with the Large Area Telescope aboard the Fermi Gamma-ray Space Telescope to study the gamma-ray emission towards 13 globular clusters. Steady point-like high-energy gamma-ray emission has been significantly detected towards 8 globular clusters. Five of them (47 Tucanae, Omega Cen, NGC 6388, Terzan 5, and M 28) show hard spectral power indices $(0.7 < \Gamma <1.4)$ and clear evidence for an exponential cut-off in the range 1.0-2.6 GeV, which is the characteristic signature of magnetospheric emission from MSPs. Three of them (M 62, NGC 6440 and NGC 6652) also show hard spectral indices $(1.0 < \Gamma < 1.7)$, however the presence of an exponential cut-off can not be unambiguously established. Three of them (Omega Cen, NGC 6388, NGC 6652) have no known radio or X-ray MSPs yet still exhibit MSP spectral properties. From the observed gamma-ray luminosities, we estimate the total number of MSPs that is expected to be present in these globular clusters. We show that our estimates of the MSP population correlate with the stellar encounter rate and we estimate 2600-4700 MSPs in Galactic globular clusters, commensurate with previous estimates. The observation of high-energy gamma-ray emission from a globular cluster thus provides a reliable independent method to assess their millisecond pulsar populations that can be used to make constraints on the original neutron star X-ray binary population, essential for understanding the importance of binary systems in slowing the inevitable core collapse of globular clusters.Comment: Accepted for publication in A&A. Corresponding authors: J. Kn\"odlseder, N. Webb, B. Pancraz