Large-scale Public Health Emergencies Research Articles

Evolving Need for Alternative Triage Management in Public Health Emergencies: A Hurricane Katrina Case Study

In many countries, traditional medical planning for disasters developed largely in response to battlefield and multiple casualty incidents, generally involving corporal injuries. The mass evacuation of a metropolitan population in the aftermath of Hurricane Katrina evolved into life-and-death triage scenarios involving thousands of patients with nontraumatic illnesses and special medical needs. Although unprecedented in the United States, triage management needs for this disaster were similar to other large-scale public health emergencies, both natural and human-generated, that occurred globally in the past half-century. The need for alternative triage-management processes similar to the methodologies of other global mass public health emergencies is illustrated through the experience of disaster medical assistance teams in the first 3 days following Katrina's landfall. The immediate establishment of disaster-specific, consensus-based, public health emergency-related triage protocols-developed with ethical and legal expertise and a renewed focus on multidimensional, multifactorial matrix decision-making processes-is strongly recommended.

Exposure to War as a Risk Factor for Mental Disorders

While large-scale national psychiatric epidemiologic studies have been conducted in Western industrialized nations [1–3], studies in the Arab world have generally been limited to smaller populations [4–6]. In addition, while exposure to war as a risk factor for the development of mental disorders in military populations has previously been described [7,8], the effect of war upon first onset of a range of mental disorders in civilian populations at a national level has not been explored. Over the last quarter-century, advances in psychiatric diagnostic classification, the development of fully structured diagnostic interviews, and the refinement of household survey technology have led to greater understanding of the epidemiology of psychiatric illness in the Western hemisphere. With the publication of the Diagnostic and Statistical Manual, 3rd edition [9], the American Psychiatric Association truly operationalized the diagnostic criteria for psychiatric disorders. Based on these criteria, Robins and colleagues created the Diagnostic Interview Schedule (DIS)—the first fully structured diagnostic interview that could be administered by trained lay persons [10]. The DIS was administered to over 20,000 individuals in the Epidemiologic Catchment Area Study, a landmark community-based survey of mental health disorders conducted in selected neighborhoods in five United States communities [1]. Widespread dissemination of the Epidemiologic Catchment Area study results led to replication studies in other countries and the development of other structured diagnostic interviews. The most widely used of these is the World Health Organization Composite International Diagnostic Interview (WHO CIDI), developed to encourage cross-national research by integrating the validated methodological approach of the DIS with the WHO's International Classification of Diseases [11]. The sophisticated study of disasters—war is one type of human-made disaster—and their impact on mental health is also relatively recent [12]. More than 29 armed conflicts are occurring now around the globe involving 25 countries [13]. The public health response to large-scale public health emergencies and catastrophes requires consideration of the mental disorders (e.g., post-traumatic stress disorder, depression), distress (e.g., sleep disturbance, fear, changes in economic behaviors such as purchasing houses), and health risk behaviors (e.g., increased alcohol and smoking, evacuation behaviors) of those exposed [14,15]. Linked Research Article This Perspective discusses the following new study published in PLoS Medicine: Karam EG, Mneimneh ZN, Dimassi H, Fayyad JA, Karam AN, et al. (2008) Lifetime prevalence of mental disorders in Lebanon: First onset, treatment, and exposure to war. PLoS Med 5(4): e61. doi:10.1371/journal.pmed.0050061 In a survey of 2,857 adults in Lebanon, Elie Karam and colleagues found a lifetime prevalence of any DSM-IV psychiatric disorder of 25.8%.

Assessing Public Health Emergency Preparedness: Concepts, Tools, and Challenges

Policymakers are increasingly seeking to determine whether the federal government's recent investments in public health preparedness have left the public health system better prepared to respond to large-scale public health emergencies. Yet, there remain questions about how to define "public health emergency preparedness," how much preparedness is enough, and how preparedness can be measured and assessed. This chapter identifies the key challenges associated with measuring public health preparedness and reviews approaches currently in use. We also identify some emerging measurement techniques that might help address some of these challenges.

Conceptualizing and Defining Public Health Emergency Preparedness

Since September 11, 2001, and the anthrax attacks that followed, a substantial federal investment—totaling well in excess of $5 billion—has been made to increase our nation’s ability to prepare for, and respond to, public health emergencies. Yet despite anecdotal reports suggesting that progress has been made, it is unclear whether these investments have left the nation better prepared to respond to a bioterrorist attack, pandemic influenza, or any other large-scale public health emergency. This situation is not because of a shortage of measures of preparedness. Over the past 5 years, federal agencies, state health departments, and various nongovernmental organizations have proposed and implemented myriad measures of public health emergency preparedness. But these efforts have not resulted in a clear picture of the nation’s preparedness owing to ambiguous and uncertain preparedness goals, a lack of agreement about what the measures should aim at and how they should be interpreted, and a weak system of accountability for producing results.1 Measures often vary considerably across agencies and shift dramatically from year to year, leaving state and local health officials, businesses, nonprofits, and citizens confused and perplexed by a maze of overlapping and sometimes contradictory requirements, checklists, and ideas about what constitutes preparedness.2–4 What our nation needs in order to bring coherence to the debate is a clear definition of public health emergency preparedness and an articulation of the key elements that characterize a well-prepared community. In this editorial, we propose a candidate definition of public health emergency preparedness and describe its key elements. Both the definition and the elements were developed by a diverse panel of experts convened by RAND in February 2007. We propose the following definition: public health emergency preparedness (PHEP) is the capability of the public health and health care systems, communities, and individuals, to prevent, protect against, quickly respond to, and recover from health emergencies, particularly those whose scale, timing, or unpredictability threatens to overwhelm routine capabilities. Preparedness involves a coordinated and continuous process of planning and implementation that relies on measuring performance and taking corrective action. In developing the definition, we considered what constitutes a public health emergency, what public health emergency preparedness requires, and who is involved in it.

Developing the State of Connecticut emergency credentialing programme for healthcare professionals

The failure of the emergency response system, healthcare delivery organisations and multiple levels of government to work together to provide adequate medical response during Hurricanes Katrina and Rita demonstrates the need to develop a coordinated and national approach to recruiting, pre-qualifying and credentialing healthcare professionals who are willing to volunteer during a large-scale disaster or public health emergency. Inadequately prepared to continue normal operations in the face of the enormity of the Gulf Coast disaster, which destroyed or disabled hospitals and other vital infrastructure, in addition to generating large numbers of patients, individual healthcare organisations in the Gulf Coast region had no hope of expanding their personnel surge capability and operational capacity. Public health and infectious disease clinical experts continue to express concern over predictions that the next influenza pandemic could affect 15–40 per cent of the US population through hospitalisations and outpatient visits. Hospital emergency management plans should therefore include a strategy for the integration of volunteer healthcare personnel who are prepared to assist with meeting the challenges of a sudden surge in patient volume.

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

BackgroundGovernments 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.MethodsThe authors conducted a case study based on interviews with 26 government, business, and academic participants in this collaboration.ResultsThe 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.ConclusionAs 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.

A Short Medical School Course on Responding to Bioterrorism and Other Disasters

The events of 9/11 highlighted the limitations of the United States health care system in responding to large-scale public health emergencies. The key for an effective response to any mass casualty event is preparedness; thus, the education of medical students has become a priority. The Association of American Medical Colleges (AAMC) recommended that the nation's medical schools should thoroughly educate students about the public health and emergency services systems to ensure coordinated responses to weapons of mass destruction or other public health threats. In response, The Texas A&M University System Health Science Center College of Medicine, partnering with the Defense Institute for Medical Operations (DIMO), developed a one-week block of required (but not graded) instruction, the "Leadership Course in Disaster Response," first given in 2003-04 to 72 second-year students and taught by six military experts from DIMO. The course goal is to (1) educate students on resources available for regional disaster response; (2) define principles of resource management in disaster response; (3) identify specific agents associated with bioterrorism; and (4) understand the psychosocial aspects of disasters. The course was well received, and the 2004-05 session was improved, based on student and faculty feedback. The authors describe the details of the course (specifically, how the course was tailored to fit the AAMC guidelines), changes in students' knowledge and attitudes, and how the course was improved.

Readiness and response to public health emergencies: Help needed Now from professional nursing associations

HETRAGEDYOFSEPTEMBER11,anthraxattacks,and severe acute respiratory syndrome (SARS) andother recent infectious disease outbreaks have heightenedour awareness of the need for health care system readinessand response capabilities. At the same time, the economicrealities of our modern health care system are reflected incost-containmentstrategiestowardlow-volumeinventories,reduced bed availability, downsizing of staff, and a shift tooutpatient services (American Hospital Association, 2002).Decreased reimbursement structures and workforce short-ageshavediminishedthehealthcaresystem’sabilitytomeetminimum patient demands, let alone the surge of patientsthatwouldbeexpectedinamass-casualtyincident.Further-more, the infrastructure needed for detection and responsefrom the public health sector has been seriously eroded bydecades of insufficient funds. Agencies within the Depart-ment of Health and Human Services (HHS) have beenworking to address readiness and response capabilities, butprivateorganizationsandprofessionalassociationsalsohavea role to play.In keeping with the Public Health Security and Bioter-rorismPreparednessandResponseActof2002,HHSdevel-opedadepartment-widestrategicplantodelineateitsprior-ities. Within the plan, the Centers for Disease Control(http://www.bt.cdc.gov)andHealthResourcesandServicesAdministration(HRSA;http://www.hrsa.gov/bioterrorism.htm) have strategic activities in education, training, licen-sure, and credentialing for the public health care workforceand for hospital readiness. The Agency for Healthcare Re-search and Quality also has strategic activities related to ed-ucationandtraining,aswellasusesofinformationtechnol-ogy and electronic communication networks (Phillips,Burstin,Dillard,CPhillips,Dillard,&Burs-tin, 2002).HHS’s working definition of health surge capacity is theability a health care system has to rapidly expand beyondnormal services to meet the increased demand for medicalcareandpublichealthservicesthatwouldberequiredtocarefor patients in the event of a large-scale public health emer-gency or disaster. Needed resources include beds, personneltostaffthebeds,equipment,abilitytotransportvictimsandpersonnel, and the ability to provide ongoing care. All as-pects of surge capacity present challenges, but the demandfor qualified health care personnel is particularly complex.Although nursing is not the only health profession expe-riencing a workforce shortage, nursing is vital to any large-scale demand for care. Nationally, there are 2,694,540 li-censed registered nurses, or 808 registered nurses per100,000 people (HRSA, 2000). These numbers are insuffi-cient to meet current capacity needs and would be woefullyinadequateintheeventofamass-casualtyincident.Amass-casualty event would require mobilization of additionalnurses from outside the affected jurisdiction. Such a mobi-lization,however,wouldhavetoovercomeissuesofcreden-tialing and licensing. When licensed health care cliniciansarrivedasGoodSamaritansandvolunteeredafter9/11,hos-pital administrators turned them away because they did nothave the proper credentials.Nurses must collaborate and coordinate and train for fu-ture crises. Issues of competency, standards, and mecha-nismsforeducationandtrainingmustbeapprovedtocertifyqualified nurses for mass-casualty events. A major step wastaken in March 2001, when the International Nursing Co-alition for Mass Casualty Education (INCMCE) wasfoundedtoensureacompetentnurseworkforceinresponseto mass-casualty incidents. The INCMCE consists of orga-nizational representatives from schools of nursing, nursingaccreditingbodies,nursingspecialtyorganizations,andgov-ernmentalagencies.InJuly2003,INCMCEdevelopedasetof national, consensus-based, validated competencies for allentry-level nurses (INCMCE, 2003).Nursesmustalsoinitiatesystemsthatpromotetheirabil-ity to respond in the next crisis. In 1998, President Clintonsigned Presidential Decision Directive/NSC-63 (WhiteHouse, 1998), which established a national strategy for en-suring critical infrastructure protection, primarily cyberse-curity. In 2003, President Bush replaced PDD-63 withHomeland Security Presidential Directive 7 (White House,2003),whichidentifiedtherolesofthehealthcareandpub-lic health sectors. Specifically, it charged the sector-specificagencies to “collaborate with appropriate private sector en-tities and continue to encourage the development of infor-