Operational Lessons Research Articles

Digitally managed larviciding as a cost-effective intervention for urban malaria: operational lessons from a pilot in São Tomé and Príncipe guided by the Zzapp system

BackgroundOnce a mainstay of malaria elimination operations, larval source management (LSM)—namely, the treatment of mosquito breeding habitats–has been marginalized in Africa in favour of long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS). However, the development of new technologies, and mosquitoes' growing resistance to insecticides used in LLINs and IRS raise renewed interest in LSM.MethodsA digitally managed larviciding (DML) operation in three of the seven districts of São Tomé and Príncipe (STP) was launched by the Ministry of Health (MOH) and ZzappMalaria LTD. The operation was guided by the Zzapp system, consisting of a designated GPS-based mobile application and an online dashboard, which facilitates the detection, sampling and treatment of mosquito breeding sites. During the operation, quality assurance (QA) procedures and field management methods were developed and implemented.Results12,788 water bodies were located and treated a total of 128,864 times. The reduction impact on mosquito population and on malaria incidence was 74.90% and 52.5%, respectively. The overall cost per person protected (PPP) was US$ 0.86. The cost varied between areas: US$ 0.44 PPP in the urban area, and US$ 1.41 PPP in the rural area. The main cost drivers were labour, transportation and larvicide material.ConclusionDML can yield highly cost-effective results, especially in urban areas. Digital tools facilitate standardization of operations, implementation of QA procedures and monitoring of fieldworkers’ performance. Digitally generated spatial data also have the potential to assist integrated vector management (IVM) operations. A randomized controlled trial (RCT) with a larger sample is needed to further substantiate findings.

Cohort profile: CareConekta: a pilot study of a smartphone application to improve engagement in postpartum HIV care in South Africa

PurposePregnant and postpartum women living with HIV in South Africa are at high risk of dropping out of care, particularly after delivery. Population mobility may contribute to disruptions in HIV...

Implementation and challenges to preventing the re-establishment of malaria in China in the COVID-19 era

BackgroundThe rapid emergence and global spread of COVID-19 have caused substantial global disruptions that have impacted malaria programs worldwide. Innovative strategies to enable countries aiming to eliminate malaria as well as those that are already certified as malaria-free, are needed to address malaria importation in the context of the COVID-19 pandemic. China was certified as malaria-free in 2021 and now aims to prevent the malaria re-establishment. Nonpharmaceutical interventions such as entry screening, quarantining, and health education for individuals returning from international travel during the COVID-19 pandemic present both opportunities and challenges to the management of imported malaria. This study aimed to describe and analyze the operational challenges associated with an integrated surveillance and case management program in which malaria re-establishment prevention measures were incorporated into the COVID-19 program in China.MethodsAfter the integration of malaria re-establishment prevention activities into the COVID-19 program for 10 months in Jiangsu Province, China, a focus-group discussion of public health workers working on preventing malaria re-establishment and controlling COVID-19 was held in June 2021, aiming to explore the operational challenges and lessons learned from the integrated approach.ResultsFrom 01 August 2020 to 31 May 2021, 8,947 overseas travelers with Yangzhou as the final destination underwent 14-day managed quarantine and 14-day home isolation. Of these travelers, 5,562 were from malaria-endemic regions. A total of 26,026 education booklets and materials were distributed to expand malaria-related knowledge. Twenty-two patients with unknown fever were screened for malaria with rapid diagnostic tests, and one patient was confirmed to have imported malaria. The challenges associated with the implementation of the integrated malaria surveillance and case management program include neglect of malaria due to COVID-19, lack of a standard operating procedure for malaria screening, mobility of public health providers, and difficulties in respecting the timeline of the “1–3-7” surveillance strategy.ConclusionsChina’s experience highlights the feasibility of integrated case surveillance and management of existing infectious diseases and new emerging infections. It also demonstrates the importance of a sound public health infrastructure with adequate, trained field staff for screening, testing, contact tracing, and providing health education, all of which are crucial for the success of both malaria re-establishment prevention program and the effective control of COVID-19.

A look ahead to the next decade at US volcano observatories.

Volcano monitoring, eruption response, and hazard assessment at volcanoes in the United States of America (US) fall under the mandate of five regional volcano observatories covering 161 active volcanoes. Working in a wide range of volcanic and geographic settings, US observatories must learn from and apply new knowledge and techniques to a great variety of scientific and hazard communication problems in volcanology. Over the past decade, experience during volcanic crises, such as the landmark 2018 eruption of Kīlauea, Hawaiʻi, has combined with investments and advances in research and technology, and the changing needs of partner agencies and the public, to transform the operations, science, and communication programs of US volcano observatories. Scientific and operational lessons from the past decade now guide new research and growing inter-observatory and external communication networks to meet new challenges and improve detection, forecasting, and response to volcanic eruptions in the US and around the world.

Prepared to Act: Lessons Learned by the Special Pathogens Research Network, Based on Collaborations with the NIAID-Led Adaptive COVID-19 Treatment Trial.

The need for well-controlled clinical trials is fundamental to advancing medicine. Care should be taken to maintain high standards in trial design and conduct even during emergency medical events such as an infectious disease outbreak. In 2020, SARS-CoV-2 emerged and rapidly impacted populations around the globe. The need for effective therapeutics was immediately evident, prompting the National Institutes of Health to initiate the Adaptive COVID-19 Treatment Trial. The Special Pathogens Research Network, made up of 10 Regional Emerging Special Pathogens Treatment Centers, was approached to participate in this trial and readily joined the trial on short notice. By trial closure, the Special Pathogens Research Network sites, making up 19% of all study sites, enrolled 26% of the total participants. The initial resources available and experience in running clinical trials at each treatment center varied from minimal experience and few staff to extensive experience and a large staff. Based on experiences during the first phase of this trial, the Special Pathogens Research Network members provided feedback regarding operational lessons learned and recommendations for conducting future studies during a pandemic. Communication, collaboration, information technology, regulatory processes, and access to resources were identified as important topics to address. Key stakeholders including institutions, institutional review boards, and study personnel must maintain routine communication to efficiently and effectively activate when future research needs arise. Regular and standardized training for new personnel will aid in transitions and project continuity, especially in a rapidly evolving environment. Trainings should include local just-in-time training for new staff and sponsor-designed modules to refresh current staff knowledge. We offer recommendations that can be used by institutions and sponsors to determine goals and needs when preparing to set up this type of trial for critical, short-notice needs.

Operational lessons learned in conducting an international study on pharmacovigilance in pregnancy in resource-constrained settings: The WHO Global Vaccine safety Multi-Country collaboration project

The WHO Global Vaccine Safety Multi-Country Collaboration study on safety in pregnancy aims to estimate the minimum detectable risk for selected perinatal and neonatal outcomes and assess the applicability of standardized case definitions for study outcomes and maternal immunization in low- and middle-income countries (LMICs). This paper documents the operational lessons learned from the study.A prospective observational study was conducted across 21 hospitals in seven countries. All births occurring at sites were screened to identify select perinatal and neonatal outcomes from May 2019 to August 2020. Up to 100 cases per outcome were recruited to assess the applicability of standardized case definitions. A multi-pronged study quality assurance plan was implemented. The impact of the COVID-19 pandemic on site functioning and project implementation was also assessed.Multi-layered ethics and administrative approvals, limited clinical documentation, difficulty in identifying outcomes requiring in-hospital follow-up, and poor quality internet connectivity emerged as important barriers to study implementation. Use of electronic platforms, application of a rigorous quality assurance plan with frequent interaction between the central and site teams helped improve data quality. The COVID-19 pandemic disrupted data collection for up to 6 weeks in some sites.Our study succeeded in establishing an international hospital-based surveillance network for evaluating perinatal and neonatal outcomes using common study protocol and procedures in geographically diverse sites with differing levels of infrastructure, clinical and health-utilization practices. The enhanced surveillance capacity of participating sites shall help support future pharmacovigilance efforts for pregnancy interventions.

Providing social support for inpatients: Insights from a virtual medical student initiative.

Although the COVID-19 pandemic increased social isolation among hospitalised patients given isolation precautions, visitor restrictions and curtailed interactions with healthcare teams, medical students had limited opportunities for involvement in the care of inpatients. We designed a humanistic and narrative medicine intervention to engage medical students in combating social isolation in hospitalised patients during the COVID-19 pandemic at a tertiary care teaching hospital. In our programme, medical students provided virtual social support to hospitalised patients via phone by providing assistance connecting with family members, having informal conversations and check-ins and writing up patient life narratives. From April 2020 to March 2021, we received 126 referrals of potentially isolated patients from inpatient medical teams. Fifty patients accepted and received our intervention, including 26 who completed life narratives. Feedback was positive, demonstrating benefit to medical students in learning about humanism and connecting with patients through their life stories. In addition, patients and medical teams felt more supported. We share key operational lessons and resources to facilitate the implementation of this intervention elsewhere. Our intervention allows medical students to meaningfully contribute to the care of inpatients, support beleaguered inpatient teams and learn important lessons about humanism in medicine. This educational and patient care intervention holds promise in other settings, including beyond the COVID-19 pandemic.

Making Health Insurance Pro-poor: Lessons from 20 Developing Countries

ABSTRACT The last 20 years have seen a substantial growth in research on the extent to which health sector reforms are pro-poor or pro-rich. What has been missing is knowledge synthesis work to derive operational lessons from the empirical research. This article fills the gap for the most popular form of health financing reform, health insurance. Based on publications covering 20 developing countries, we find that health insurance is no panacea for improving equity in the health sector. More importantly, we find certain design elements of health insurance can increase the likelihood of tackling inequality in the health sector in developing countries.

Outbreak response operations during the US measles epidemic, 2017\u201319

BackgroundTo understand operational challenges involved with responding to US measles outbreaks in 2017–19 and identify applicable lessons in order to inform preparedness and response operations for future outbreaks, particularly with respect to specific operational barriers and recommendations for outbreak responses among insular communities.MethodsFrom August 2019 to January 2020, we conducted 11 telephone interviews with 18 participants representing state and local health departments and community health centers that responded to US measles outbreaks in 2017–19, with a focus on outbreaks among insular communities. We conducted qualitative, thematic coding to identify and characterize key operational challenges and lessons identified by the interviewees.ResultsWe categorized principal insights into 5 topic areas: scale of the response, vaccination operations, exclusion policies, community engagement, and countering anti-vaccine efforts. These topics address resource-intensive aspects of these outbreak responses, including personnel demands; guidance needed to support response operations and reduce transmission, such as excluding exposed or at-risk individuals from public spaces; operational challenges and barriers to vaccination and other response activities; and effectively engaging and educating affected populations, particularly with respect to insular and vulnerable communities.ConclusionsMeasles outbreak responses are resource intensive, which can quickly overwhelm existing public health capacities. Early and effective coordination with trusted leaders and organizations in affected communities, including to provide vaccination capacity and facilitate community engagement, can promote efficient response operations. The firsthand experiences of public health and healthcare personnel who responded to measles outbreaks, including among insular communities, provide evidence-based operational lessons that can inform future preparedness and response operations for outbreaks of highly transmissible diseases.

Polymerflood Field Pilot Enhances Recovery of Heavy Oils on the Alaska North Slope

This article, written by JPT Technology Editor Chris Carpenter, contains highlights of paper SPE 201279, “First-Ever Polymerflood Field Pilot To Enhance the Recovery of Heavy Oils on the Alaska North Slope: Producer Responses and Operational Lessons Learned,” by Samson Ning, SPE, Reservoir Experts and Hilcorp Alaska, and John Barnes, SPE, and Reid Edwards, SPE, Hilcorp Alaska, prepared for the 2020 SPE Annual Technical Conference and Exhibition, originally scheduled to be held in Denver, 5-7 October. The paper has not been peer reviewed. The complete paper describes a field pilot project to perform an experiment to validate the use of an advanced polymerflooding technology on the Alaska North Slope. Polymer injectivity of horizontal wells is found to be sufficient to replace reservoir production voidage, although some declines occurred as high-viscosity polymer swept the near-wellbore region. Production data show significant reduction in water cut and increase in oil production rate. No polymer production has been confirmed from the two horizontal producers after 23 months of polymer injection into the two supporting horizontal injectors. Introduction The pilot involves two horizontal injectors (J-23A and J-24A) and two horizontal producers (J-27 and J-28) drilled into the Schrader Bluff NB sand in an isolated fault block of the Schrader Bluff heavy-oil reservoir in the Milne Point field. The lengths of the horizontal wellbores range from 4,200 to 5,500 ft, and the interwell distance is approximately 1,100 ft. Hydrolyzed polyacrylamide (HPAM) polymer injection began on 28 August 2018 using a custom polymer mixing and pumping unit. Polymer-solution quality control is discussed in detail in the complete paper. Injector Performance Since the start of polymer injection, a few shutdown events have occurred that lasted longer than 2 weeks. The first major shutdown took place in September 2018, when a more-than-expected amount of hydrocarbon gas was detected from the source water used to make the polymer solution. The polymer-injection facility was shut down for 3 weeks to modify the pressure-letdown module for operation safety. The second major shutdown occurred in November 2018 for pump and auger repairs. The third major shutdown happened from mid-June through late August of 2019 because of polymer-solution-quality issues. After 2 months of diligent work, the polymer-hydration problem was resolved and improvements made in polymer facilities, operational procedures, and the onsite quality-control process. Polymer-injection operations have been smooth since August 2019 except for a few short shutdowns for equipment maintenance. As of late May 2020, total cumulative polymer injected was 708,000 lbm into the two injectors, and the total amount of polymer solution injected was 1.4 million bbl, approximately 8.8% of the total pore volume in the two flood patterns. Since polymer injection began, injected polymer concentration was mostly between 1,500 and 2,000 ppm to achieve a target viscosity initially set at 45 cp and then reduced to 40 cp.

Abstract PS11-08: Operational standardization and quality assurance yield high acceptance rate for breast MRI in the I-SPY 2 TRIAL

Abstract Background: The I-SPY 2 TRIAL is a multi-site response adaptive clinical trial evaluating novel drug combinations for neoadjuvant treatment of breast cancer. Patients receive four or more MRI studies during treatment, and serial measurement of functional tumor volume (FTV) is used to assess response. Under FDA IDE approval, FTV plays an integral role in adjusting patient randomization and evaluating treatment efficacy. FTV is a quantitative measure that requires stringent standards for image quality and protocol adherence. The I-SPY 2 TRIAL consistently reports a high level of data quality and data acceptance for FTV measurements. We present an overview of MRI operational performance and share lessons learned about maintaining high quality MRI data in a multi-site clinical trial. Methods: Over the 10-year course of the I-SPY 2 TRIAL, workflow has been improved to optimize communication between the Imaging Core Lab (ICL) and sites and to collect details about the MRI that are needed for accurate FTV measurement. A standardized imaging acquisition protocol is distributed to all sites, and new sites submit two test cases for review at site initiation. A scan verification form is required for each MRI study completed at sites to document critical information. Sites submit studies using TRIAD image transfer and de-identification software (American College of Radiology), and data is archived and processed at the ICL. All MRI studies are reviewed by the ICL for protocol adherence as soon as they are submitted, and feedback is provided to sites. Image quality factors including motion, fat suppression, and signal-to-noise ratio are qualitatively assessed. The ICL communicates with sites through a centralized email account, regular Coordinator Calls, and Imaging Working Group meetings to discuss emerging issues and offer ongoing training. The ICL contributes to revisions of study protocols and standard operating procedures. Results: As of June 2020, 3020 patients had been registered in I-SPY 2, 1741 patients randomized to treatment with one of 18 experimental drugs or standard therapy (controls), and a total of 7527 MRI studies were performed. FTV could be calculated for 97% (7317/7527) of MRI studies. Of the 7317 studies where FTV could be calculated, relatively minor issues with image quality or imaging protocol adherence were documented for 28% (2030/7317). These issues included motion artifacts (32%, 659/2030), off-protocol scan duration (21%, 433/2030), off-protocol contrast injection rate (14%, 281/2030), and off-protocol imaging field of view (9%, 191/2030). Conclusion: Breast MRI studies using a variety of scan protocols are well-suited for diagnostic evaluation, including BIRADS categorization, measurement of longest diameter, and assessment of lesion washout. The quantitative measures used in the I-SPY 2 trial require adherence to a specific imaging protocol that is kept consistent for all MRI studies for a single patient. Operational standardization, clear communication with sites, and streamlined workflow yield high quality MRI data across multiple sites and scanners. As a result, FTV is a robust biomarker of response to treatment, and is being used to predict patient response and guide treatment planning. We are actively investigating strategies that will improve FTV accuracy for predicting response and informing guidelines for treatment de-escalation. This will allow the ICL to further standardize and improve image quality and will provide the foundation for testing a variety of imaging biomarkers in the I-SPY 2 TRIAL. Citation Format: Jessica Gibbs, David C Newitt, Margarita Watkins, Wen Li, Lisa Cimino, Clifton Li, Natsuko Onishi, Lisa J Wilmes, Teffany Joy Bareng, Evelyn Proctor, Barbara LeStage, Bev Parker, the I-SPY 2 Coodinators, the I-SPY 2 Imaging Working Group, Nola M Hylton. Operational standardization and quality assurance yield high acceptance rate for breast MRI in the I-SPY 2 TRIAL [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS11-08.

Designing a dangerous unicorn: Lessons from the Theranos case

Until its highly publicized downfall, Theranos was a so-called unicorn with a compelling proposition to popularize routine blood testing by making it more convenient, using a smaller sample of blood, and testing at a lower cost than conventional, often fear-inducing needles. Holmes and Theranos were reliant on the development of new technology to bring their idea to life. Instead, they became perhaps one of the most infamous examples of failed product innovation. In this article, we contend that although character failings and alleged criminal activity could not have been mitigated realistically, valuable strategic and operational lessons can be learned for future technology startups. By conducting a counterfactual thought experiment and examining Theranos through the lens of Design Innovation (DI), we provide evaluations and predictions across strategic and operational constructs from both an internal and external perspective. We use Theranos to demonstrate the value of DI to future technology-driven entrepreneurs, proposing alternative approaches to medical device startups.

Fighting ISIS in Syria: Operation Euphrates Shield and the lessons learned from the al-Bab Battle

ABSTRACT This paper analyses the Operation Euphrates Shield (OES) al-Bab battle and presents the lessons learned. OES started with a mixed force of Free Syrian Army, Turkish special forces and armoured units. During the operation, the aims and the force structure gradually changed, yet not the command structure. When OES aimed to capture al-Bab, ISIS employed conventional active defence strategy. The OES commander’s insistence on employing special forces increased own casualties and al-Bab was seized only after resorting to a conventional urban attack. OES presents tactical and operational lessons for the militaries on structure and execution of operations against an irregular adversary employing conventional means.

Correction to: Survey research with gang and non-gang members in prison: operational lessons from the LoneStar Project

Correction to: Survey research with gang and non-gang members in prison: operational lessons from the LoneStar Project

Mitigating the impact of COVID-19 on oncology: Clinical and operational lessons from a prospective radiation oncology cohort tested for COVID-19

Background and purposeThe COVID-19 pandemic warrants operational initiatives to minimize transmission, particularly among cancer patients who are thought to be at high-risk. Within our department, a multidisciplinary tracer team prospectively monitored all patients under investigation, tracking their test status, treatment delays, clinical outcomes, employee exposures, and quarantines. Materials and methodsProspective cohort tested for SARS-COV-2 infection over 35 consecutive days of the early pandemic (03/19/2020–04/22/2020). ResultsA total of 121 Radiation Oncology patients underwent RT-PCR testing during this timeframe. Of the 7 (6%) confirmed-positive cases, 6 patients were admitted (4 warranting intensive care), and 2 died from acute respiratory distress syndrome. Radiotherapy was deferred or interrupted for 40 patients awaiting testing. As the median turnaround time for RT-PCR testing decreased from 1.5 (IQR: 1–4) to ≤1-day (P < 0.001), the median treatment delay also decreased from 3.5 (IQR: 1.75–5) to 1 business day (IQR: 1–2) [P < 0.001]. Each patient was an exposure risk to a median of 5 employees (IQR: 3–6.5) through prolonged close contact. During this timeframe, 39 care-team members were quarantined for a median of 3 days (IQR: 2–11), with a peak of 17 employees simultaneously quarantined. Following implementation of a “dual PPE policy,” newly quarantined employees decreased from 2.9 to 0.5 per day. ConclusionThe severe adverse events noted among these confirmed-positive cases support the notion that cancer patients are vulnerable to COVID-19. Active tracking, rapid diagnosis, and aggressive source control can mitigate the adverse effects on treatment delays, workforce incapacitation, and ideally outcomes.

Operational stresses on New York City Health+Hospitals Health System frontline hospitals during the 2017-18 influenza season.

Identify operational lessons to support hospital and health system preparedness and response for sea-sonal and pandemic influenza based on firsthand experiences from the 2017-2018 influenza season. We conducted semistructured, retrospective interviews with New York City Health+Hospitals (NYCH+H) personnel to gather firsthand experiences from the 2017-2018 influenza season and evaluated stress data across four operational domains reported by NYCH+H hospitals during the 2017-2018 influenza season. Frontline hospitals in the NYCH+H health system during and after the 2017-2018 influenza season. Interviews conducted with personnel from 5 NYCH+H frontline hospitals. Operational stress data reported by 11 NYCH+H hospitals during the 2017-2018 influenza season. Operational challenges and lessons from frontline hospitals responding to severe seasonal influenza. Operational stresses during the 2017-2018 influenza season varied over the influenza season, between facilities, and across operational domains. Patient surge and staff absenteeism pushed some facilities to their limits, and supply shortages highlighted shortcomings in existing procurement systems. Resources tied to pandemic influ-enza were unavailable without a pandemic declaration. Seasonal influenza poses dynamic operational stresses across health systems and cities, poten-tially causing major impacts outside of declared pandemics. Lessons from NYCH+H can help other hospitals and health systems anticipate operational challenges, but novel solutions are needed to mitigate effects of patient surge and personnel and supply shortages during severe influenza seasons and pandemics. Improved data collection can help health systems better understand operational stresses and challenges across their facilities.

Environmental literacy and deliberative democracy: a content analysis of written submissions to the Irish Citizens’ Assembly on climate change

Amid pressure for climate action worldwide, processes of deliberative democracy are being called upon to address public policy complexities, include citizens in decision-making, restore faith in public institutions and enhance governance processes. The citizens’ assembly model is lauded internationally for the much-needed structure it provides to support bottom-up governance efforts as well as the potential for effective citizen engagement on complex topics. The Irish Citizens’ Assembly, which took place from 2016 to 2018, is heralded as an example of best practice in design and execution. Yet, there is a dearth in analysis of its form, structure, impact and content, particularly in the climate crisis context. This paper examines one element of the deliberative democracy process that aimed to include a wider breadth of publics beyond the 99 citizens randomly selected to take part: the public submissions invited as part of the Citizens’ Assembly process. In total, 1185 submissions were received on the topic of climate change. Our study undertakes a comprehensive content analysis of these submissions. Specifically, we explore (1) the content and concerns foregrounded within the submissions, (2) the frames and rhetorical strategies employed and (3) the stakeholders and scales called upon for climate action. The study identifies trends, preoccupations and salience within the corpus of written submissions and expands our understanding of citizen perceptions of climate science and policy. We offer both operational lessons for others aiming to enact similar deliberative forums as well as communications lessons for wider efforts to deepen public engagement on the climate crisis.

Operational stresses on New York City Health+Hospitals Health System frontline hospitals during the 2017-18 influenza season.

Identify operational lessons to support hospital and health system preparedness and response for sea-sonal and pandemic influenza based on firsthand experiences from the 2017-2018 influenza season. We conducted semistructured, retrospective interviews with New York City Health+Hospitals (NYCH+H) personnel to gather firsthand experiences from the 2017-2018 influenza season and evaluated stress data across four operational domains reported by NYCH+H hospitals during the 2017-2018 influenza season. Frontline hospitals in the NYCH+H health system during and after the 2017-2018 influenza season. Interviews conducted with personnel from 5 NYCH+H frontline hospitals. Operational stress data re-ported by 11 NYCH+H hospitals during the 2017-2018 influenza season. Operational challenges and lessons from frontline hospitals responding to severe sea-sonal influenza. Operational stresses during the 2017-2018 influenza season varied over the influenza season, between facilities, and across operational domains. Patient surge and staff absenteeism pushed some facilities to their limits, and supply shortages highlighted shortcomings in existing procurement systems. Resources tied to pandemic influ-enza were unavailable without a pandemic declaration. Seasonal influenza poses dynamic operational stresses across health systems and cities, potentially causing major impacts outside of declared pandemics. Lessons from NYCH+H can help other hospitals and health systems anticipate operational challenges, but novel solutions are needed to mitigate effects of patient surge and per-sonnel and supply shortages during severe influenza seasons and pandemics. Improved data collection can help health systems better understand operational stresses and challenges across their facilities.

Prevent, Detect, and Treat: The Military's Flexible Approach for a Whole-of-Nation Pandemic Response.

As community transmission of COVID-19 first emerged in the United States and then quickly spread, America's military accepted an important role in responding to the growing pandemic. The Department of Defense (DOD) rapidly mobilized and deployed personnel, expeditionary medical capabilities, supplies, and equipment to hot spots across the country. How does a military with an expeditionary focus and armed for war abroad quickly pivot to support national response efforts to a public health crisis here at home? Coinciding with the DOD's established flexible response methodology, the US Army adapted a three-pronged approach to prevent, detect, and treat COVID-19 while protecting the force and safeguarding the American people. This approach is providing strategic and operational lessons for improving healthcare delivery, informing public health decisions, and allocating healthcare resources for future pandemic response and civil emergency support efforts.

Learning Tactical and Operational Combat Lessons for High-End Warfighting from Counterinsurgency

Using Operation Panther’s Claw as a case study, Nick Reynolds identifies tactical and operational combat lessons from the Helmand campaign that are relevant to warfighting at scale. Future conflicts will be hybrid, will include an asymmetric threat, and are more likely to occur in complex or urban terrain. British forces will have to fight dispersed and in depth. They must be capable of retaining mobility, must have a high level of organic lethality to compensate for the difficulties with establishing mutual support, and be prepared to fight intermingled with regular and irregular enemy forces as operational penetration will be inevitable.