Public Health Emergency Preparedness System Research Articles

The European experience with testing and surveillance during the first phase of the COVID-19 pandemic

BackgroundCOVID-19 pandemic provides a unique opportunity to learn the challenges encountered by public health emergency preparedness systems, both in terms of problems encountered and adaptations during and after the first wave, as well as successful responses to them.ResultsThis work draws on published literature, interviews with countries and institutional documents as part of a European Centre for Disease Prevention and Control project that aims to identify the implications for preparedness measurement derived from COVID-19 pandemic experience in order to advance future preparedness efforts in European Union member states. The analysis focused on testing and surveillance themes and five countries were considered, namely Italy, Germany, Finland, Spain and Croatia. Our analysis shown that a country’s ability to conduct testing at scale was critical, especially early in the pandemic, and the inability to scale up testing operations created critical issues for public health operations such as contact tracing. Countries were required to develop new strategies, approaches, and policies under pressure and to review and revise them as the pandemic evolved, also considering that public health systems operate at the national, regional, and local level with respect to testing, contact tracing, and surveillance, and involve both government agencies as well as private organizations. Therefore, communication among multiple public and private entities at all levels and coordination of the testing and surveillance activities was critical.ConclusionWith regard to testing and surveillance, three capabilities that were essential to the COVID-19 response in the first phase, and presumably in other public health emergencies: the ability to scale-up testing, contact tracing, surveillance efforts; flexibility to develop new strategies, approaches, and policies under pressure and to review and revise them as the pandemic evolved; and the ability to coordinate and communicate in complex public health systems that operate at the national, regional, and local level with respect and involve multiple government agencies as well as private organizations.

Pandemic preparedness systems and diverging COVID-19 responses within similar public health regimes: a comparative study of expert perceptions of pandemic response in Denmark, Norway, and Sweden

BackgroundNational responses to the COVID-19 pandemic depend on national preparedness systems that must be understood as components of global public health emergency preparedness systems, governed and coordinated through the World Health Organization’s 2005 International Health Regulations. The pandemic has raised the question of why countries belonging to similar public health regimes, coordinated through the same global system, responded differently to the same threat. Comparing the responses of Denmark, Sweden and Norway, countries with similar public health regimes, the paper investigates to what degree national differences in COVID-19 policy response reflect significant differences in the policy preferences of national expert groups.ResultsWe employ a structured case comparison of Denmark, Norway, and Sweden to analyze their’ politico-administrative pandemic preparedness systems and policy responses during the first wave of the COVID-19 pandemic. We use the results of an interdisciplinary expert survey completed in 2020 to analyze expert perceptions in two ways. First, we analyze expert perceptions of COVID-19 responses while controlling for national COVID-19 trajectories and experts’ characteristics. Second, we analyze the distribution and effect of dominant global expert-held ideas across countries, showing the importance of dominant ideas for experts’ perceptions and preferences for COVID-19 response.ConclusionThe study finds no evidence indicating that COVID-19 policy variation between the most similar cases of Denmark, Norway, and Sweden are the result of differences in the policy preferences of national expert groups. Instead, our study highlights the importance of other factors than cross-national expert dissensus for explaining variation in pandemic response such as the politico-administrative organization of pandemic preparedness systems. Further, we find that expert support for dominant ideas such as a ‘focused protection strategy’ is associated with consistent policy preferences across locational, disciplinary, and geographic affiliations. Recognition of the latter should be a part of future discussions about how global ideas of pandemic preparedness are diffused transnationally and embedded in national politico-administrative systems.

Exploring the Ethical Dimensions of All-Hazards Public Health Emergency Preparedness in Canada

Introduction:With increasing disaster risks from extreme weather, climate change, and emerging infectious diseases, the public health system plays a crucial role in community health protection. The disproportionate impacts of disaster risks demonstrate the need to consider ethics and values in public health emergency preparedness (PHEP) activities. Established PHEP frameworks from many countries do not integrate ethics into operational approaches.Aim:To explore the ethical dimensions of all-hazards public health emergency preparedness in Canada.Methods:A qualitative study design was employed to explore key questions relating to PHEP. Six focus groups, using the Structured Interview Matrix (SIM) format, were held across Canada with 130 experts from local, provincial, or federal levels, with an emphasis on local/regional public health. An inductive approach to content analysis was used to develop emergent themes, and iteratively examined based on the literature. This paper presents analyses examining the dimensions of ethics and values that emerged from the focus group discussions.Results:Thematic analysis resulted in the identification of four themes. The themes highlight the importance of proactive consideration of values in PHEP planning: challenges in balancing competing priorities, the need for transparency around decision-making, and consideration for how emergencies impact both individuals and communities.Discussion:Lack of consideration for the ethical dimensions of PHEP in operational frameworks can have important implications for communities. If decisions are made ad-hoc during an evolving emergency situation, the ethical implications may increase the risk for some populations, and lead to compromised trust in the PHEP system. The key findings from this study may be useful in influencing PHEP practice and policy to incorporate fairness and values at the core of PHEP to ensure readiness for emergencies with community health impacts.

Public Health Emergency Preparedness System Evaluation Criteria and Performance Metrics: A Review of Contributions of the CDC-Funded Preparedness and Emergency Response Research Centers.

The US Centers for Disease Control and Prevention (CDC)-funded Preparedness and Emergency Response Research Centers (PERRCs) conducted research from 2008 to 2015 aimed to improve the complex public health emergency preparedness and response (PHEPR) system. This paper summarizes PERRC studies that addressed the development and assessment of criteria for evaluating PHEPR and metrics for measuring their efficiency and effectiveness. We reviewed 171 PERRC publications indexed in PubMed between 2009 and 2016. These publications derived from 34 PERRC research projects. We identified publications that addressed the development or assessment of criteria and metrics pertaining to PHEPR systems and describe the evaluation methods used and tools developed, the system domains evaluated, and the metrics developed or assessed. We identified 29 publications from 12 of the 34 PERRC projects that addressed PHEPR system evaluation criteria and metrics. We grouped each study into 1 of 3 system domains, based on the metrics developed or assessed: (1) organizational characteristics (n = 9), (2) emergency response performance (n = 12), and (3) workforce capacity or capability (n = 8). These studies addressed PHEPR system activities including responses to the 2009 H1N1 pandemic and the 2011 tsunami, as well as emergency exercise performance, situational awareness, and workforce willingness to respond. Both PHEPR system process and outcome metrics were developed or assessed by PERRC studies. PERRC researchers developed and evaluated a range of PHEPR system evaluation criteria and metrics that should be considered by system partners interested in assessing the efficiency and effectiveness of their activities. Nonetheless, the monitoring and measurement problem in PHEPR is far from solved. Lack of standard measures that are readily obtained or computed at local levels remains a challenge for the public health preparedness field. (Disaster Med Public Health Preparedness. 2019;13:626-638).

Public Health System Research in Public Health Emergency Preparedness in the United States (2009-2015): Actionable Knowledge Base.

In 2008, the Institute of Medicine released a letter report identifying 4 research priority areas for public health emergency preparedness in public health system research: (1) enhancing the usefulness of training, (2) improving timely emergency communications, (3) creating and maintaining sustainable response systems, and (4) generating effectiveness criteria and metrics. To (1) identify and characterize public health system research in public health emergency preparedness produced in the United States from 2009 to 2015, (2) synthesize research findings and assess the level of confidence in these findings, and (3) describe the evolution of knowledge production in public health emergency preparedness system research. Search Methods and Selection Criteria. We reviewed and included the titles and abstracts of 1584 articles derived from MEDLINE, EMBASE, and gray literature databases that focused on the organizational or financial aspects of public health emergency preparedness activities and were grounded on empirical studies. We included 156 articles. We appraised the quality of the studies according to the study design. We identified themes during article analysis and summarized overall findings by theme. We determined level of confidence in the findings with the GRADE-CERQual tool. Thirty-one studies provided evidence on how to enhance the usefulness of training. Results demonstrated the utility of drills and exercises to enhance decision-making capabilities and coordination across organizations, the benefit of cross-sector partnerships for successfully implementing training activities, and the value of integrating evaluation methods to support training improvement efforts. Thirty-six studies provided evidence on how to improve timely communications. Results supported the use of communication strategies that address differences in access to information, knowledge, attitudes, and practices across segments of the population as well as evidence on specific communication barriers experienced by public health and health care personnel. Forty-eight studies provided evidence on how to create and sustain preparedness systems. Results included how to build social capital across organizations and citizens and how to develop sustainable and useful planning efforts that maintain flexibility and rely on available medical data. Twenty-six studies provided evidence on the usefulness of measurement efforts, such as community and organizational needs assessments, and new methods to learn from the response to critical incidents. In the United States, the field of public health emergency preparedness system research has been supported by the US Centers for Disease Control and Prevention since the release of the 2008 Institute of Medicine letter report. The first definition of public health emergency preparedness appeared in 2007, and before 2008 there was a lack of research and empirical evidence across all 4 research areas identified by the Institute of Medicine. This field can be considered relatively new compared with other research areas in public health; for example, tobacco control research can rely on more than 70 years of knowledge production. However, this review demonstrates that, during the past 7 years, public health emergency preparedness system research has evolved from generic inquiry to the analysis of specific interventions with more empirical studies. Public Health Implications: The results of this review provide an evidence base for public health practitioners responsible for enhancing key components of preparedness and response such as communication, training, and planning efforts.

Applying a Behavioral Model Framework for Disaster Recovery Research in Local Public Health Agencies: A Conceptual Approach.

The local public health agency (LPHA) workforce is at the center of the public health emergency preparedness system and is integral to locally driven disaster recovery efforts. Throughout the disaster recovery period, LPHAs have a primary responsibility for community health and are responsible for a large number of health services. In the face of decreasing preparedness funding and increasing frequency and severity of disasters, LPHAs continue to provide essential disaster life cycle services to their communities. However, little is known about the confidence that LPHA workers have in performing disaster recovery-related duties. To date, there is no widely used instrument to measure LPHA workers' sense of efficacy, nor is there an educational intervention designed specifically to bolster disaster recovery-phase efficacy perceptions. Here, we describe the important role of the LPHA workforce in disaster recovery and the operational- and efficacy-related research gaps inherent in today's disaster recovery practices. We then propose a behavioral framework that can be used to examine LPHA workers' disaster recovery perceptions and suggest a research agenda to enhance LPHA workforce disaster recovery efficacy through an evidence-informed educational intervention.

A peer assessment approach for learning from public health emergencies.

As an alternative to standard quality improvement approaches and to commonly used after action report/improvement plans, we developed and tested a peer assessment approach for learning from singular public health emergencies. In this approach, health departments engage peers to analyze critical incidents, with the goal of aiding organizational learning within and across public health emergency preparedness systems. We systematically reviewed the literature in this area, formed a practitioner advisory panel to help translate these methods into a protocol, applied it retrospectively to case studies, and later field-tested the protocol in two locations. These field tests and the views of the health professionals who participated in them suggest that this peer-assessment approach is feasible and leads to a more in-depth analysis than standard methods. Engaging people involved in operating emergency health systems capitalizes on their professional expertise and provides an opportunity to identify transferable best practices.

Changes in immunization program managers' perceptions of programs' functional capabilities during and after vaccine shortages and pH1N1.

We surveyed U.S. immunization program managers (IPMs) as part of a project to improve public health preparedness against future emergencies by leveraging the immunization system. We examined immunization program policy and Immunization Information System (IIS) functionality changes as a result of the Haemophilus influenzae type B (Hib) vaccine shortage and pandemic influenza A(H1N1) (pH1N1). Evaluating changes in immunization program functionalities and policies following emergency response situations will assist in planning for future vaccine-related emergencies. We administered three consecutive surveys to IPMs from 64 state, city, and territorial jurisdictions in 2009, 2010, and 2012. We compared IPMs' responses across either two or three years (e.g., changes in response or consistent responses across years) using McNemar's test. Immunization programs maintained increases in functionality related to communication systems with health-care providers during this period. Immunization programs often did not maintain changes to IIS functionalities made from 2009 to 2010 (e.g., identifying high-risk and priority populations, tracking adverse events, and mapping disease risk) in the post-pandemic period (2010-2012). About half of IPMs reporting additional IIS functionality in identifying high-risk populations from 2009 to 2010 reported no longer having this function in 2012. There was an 18% decline in respondents reporting geographic information systems risk-mapping capability in IIS from 2010 to 2012. Because of the Hib vaccine shortage and pH1N1, immunization program needs and efforts changed to address evolving situations. The lack of sustained increases in resources or system functions after the pandemic highlights the need for comprehensive, sustainable public health emergency preparedness systems and related resources.

Willingness of the local health department workforce to respond to infectious disease events: empirical, ethical, and legal considerations.

According to the Institute of Medicine, the local health department workforce is at the hub of the public health emergency preparedness system. A growing body of research has pointed to troubling attitudinal gaps among local health department workers, a vital response cohort, regarding willingness to respond to emergent infectious disease threats, ranging from naturally occurring pandemics to bioterrorism events. A summary of relevant literature on the empirical evidence, ethical norms, and legal standards applicable to the willingness of public health professionals to respond to an infectious disease emergency is presented. Recommendations are proposed for future work to be done to bring the relevant empirical, ethical, and legal considerations together to develop practical guidance for the local response to infectious disease emergencies.

Lessons About the State and Local Public Health System Response to the 2009 H1N1 Pandemic

Identify lessons about the public health emergency preparedness system from after action report/improvement plans (AAR/IPs) authored by state and local health departments following the 2009 H1N1 influenza pandemic. Potentially generalizable findings were collected during a workshop attended by representatives from the Centers for Disease Control and Prevention (CDC), state and local public health departments, and other organizations that prepared 2009 H1N1AAR/IPs. Workshop participants included state and local health department personnel who had submitted AAR/IPs to the CDC for review. Workshop participants were asked to consider the question: What did you hear from other jurisdictions that resonated with your own experience and could be a generalized finding? Workshop discussions revealed potential lessons concerning: (1) situational awareness during the initial response; (2) resource mobilization and legal authority; (3) the complexity of vaccine distribution and administration; (4) balancing emergency response and routine operations; (5) communication and coordination among the many independent actors in the public health system; and (6) incident management in a long-duration incident. The response to the 2009 H1N1 influenza pandemic provides an opportunity to learn about the public health system's emergency response capabilities and to identify ways to improve preparedness for future events. Perhaps the most important lessons from the 2009 H1N1 response reveal the complexity of coordinating actions among the many different actors, institutions, sectors, and disciplines involved in the public health system. While the response to the pandemic engendered creative "on the spot" solutions, continued effort is needed to better understand and manage the identified challenges.

Using Learning Collaboratives to Improve Public Health Emergency Preparedness Systems

Using Learning Collaboratives to Improve Public Health Emergency Preparedness Systems

Applying behavioral science to workforce challenges in the public health emergency preparedness system

When disasters and other broad-scale public health emergencies occur in the United States, they often reveal flaws in the pre-event preparedness of those individuals and agencies charged with responsibility for emergency response and recovery activities. A significant contributor to this problem is the unwillingness of some public health workers to participate in the requisite planning, training, and response activities to ensure quality preparedness. The thesis of this article is that there are numerous, empirically supported models of behavior change that hold potential for motivating role-appropriate behavior in public health professionals. The models that are highlighted here for consideration and prospective adaptation to the public health emergency preparedness system (PHEPS) are the Transtheoretical Model of Intentional Behavior Change (TTM) and Motivational Interviewing (MI). Core concepts in TTM and MI are described, and specific examples are offered to illustrate the relevance of the frameworks for understanding and ameliorating PHEPS-based workforce problems. Finally, the requisite steps are described to ensure the readiness of organizations to support the implementation of the ideas proposed.

Public Health-Specific National Incident Management System Trainings: Building a System for Preparedness

Local health departments (LHDs) are at the hub of the public health emergency preparedness system. Since the 2003 issuance of Homeland Security Presidential Directive-5, LHDs have faced challenges to comply with a new set of all-hazards, 24/7 organizational response expectations, as well as the National Incident Management System (NIMS). To help local public health practitioners address these challenges, the Centers for Disease Control and Prevention-funded Johns Hopkins Center for Public Health Preparedness (JH-CPHP) created and implemented a face-to-face, public health-specific NIMS training series for LHDs. This article presents the development, evolution, and delivery of the JH-CPHP NIMS training program. In this context, the article also describes a case example of practice-academic collaboration between the National Association of County and City Health Officials and JH-CPHP to develop public health-oriented NIMS course content.

Ready, Willing, and Able: A Framework for Improving the Public Health Emergency Preparedness System

Every society is exposed periodically to catastrophes and public health emergencies that are broad in scale. Too often, these experiences reveal major deficits in the quality of emergency response. A critical barrier to achieving preparedness for high-quality, system-based emergency response is the absence of a universal framework and common language to guide the pursuit of that goal. We describe a simple but comprehensive framework to encourage a focused conversation to improve preparedness for the benefit of individuals, families, organizations, communities, and society as a whole. We propose that constructs associated with the well-known expression "ready, willing, and able" represent necessary and sufficient elements for a standardized approach to ensure high-quality emergency response across the disparate entities that make up the public health emergency preparedness system. The "ready, willing, and able" constructs are described and specific applications are offered to illustrate the broad applicability and heuristic value of the model. Finally, prospective steps are outlined for initiating and advancing a dialogue that may directly lead to or inform already existing efforts to develop quality standards, measures, guidance, and (potentially) a national accreditation program.

Information intermediaries for emergency preparedness and response: A case study from public health

Information intermediaries play a critical role in information supply chains for emergency preparedness. Yet, their responsibilities have not been adequately examined in the literature. Using a state public health department as an exemplar, we explore the roles and challenges experienced by one intermediary organization as it faced the unique challenges of deploying a public health emergency preparedness system. We further discuss the influence of stakeholder participation and commitment, inter-organizational collaboration, issues related to organizational structure and resources, and the challenges specific to developing and institutionalizing an IT system for emergency preparedness. Based on the public health case, a set of propositions focused on trust, coordination, information sharing and incentive alignment are developed to illustrate the role of information intermediaries.

Using Social Network Analysis to Understand Missouri's System of Public Health Emergency Planners

Effective response to large-scale public health threats requires well-coordinated efforts among individuals and agencies. While guidance is available to help states put emergency planning programs into place, little has been done to evaluate the human infrastructure that facilitates successful implementation of these programs. This study examined the human infrastructure of the Missouri public health emergency planning system in 2006. The Center for Emergency Response and Terrorism (CERT) at the Missouri Department of Health and Senior Services has responsibility for planning, guiding, and funding statewide emergency response activities. Thirty-two public health emergency planners working primarily in county health departments contract with CERT to support statewide preparedness. We surveyed the planners to determine whom they communicate with, work with, seek expertise from, and exchange guidance with regarding emergency preparedness in Missouri. Most planners communicated regularly with planners in their region but seldom with planners outside their region. Planners also reported working with an average of 12 local entities (e.g., emergency management, hospitals/ clinics). Planners identified the following leaders in Missouri's public health emergency preparedness system: local public health emergency planners, state epidemiologists, the state vaccine and grant coordinator, regional public health emergency planners, State Emergency Management Agency area coordinators, the state Strategic National Stockpile coordinator, and Federal Bureau of Investigation Weapons of Mass Destruction coordinators. Generally, planners listed few federal-level or private-sector individuals in their emergency preparedness networks. While Missouri public health emergency planners maintain large and varied emergency preparedness networks, there are opportunities for strengthening existing ties and seeking additional connections.