Socioeconomic bias in influenza surveillance.

Individuals in low socioeconomic brackets are considered at-risk for developing influenza-related complications and often exhibit higher than average influenza-related hospitalization rates. This disparity has been attributed to various factors, including restricted access to preventative and therapeutic health care, limited sick leave, and household structure. Adequate influenza surveillance in these at-risk populations is a critical precursor to accurate risk assessments and effective intervention. However, the United States of America's primary national influenza surveillance system (ILINet) monitors outpatient healthcare providers, which may be largely inaccessible to lower socioeconomic populations. Recent initiatives to incorporate Internet-source and hospital electronic medical records data into surveillance systems seek to improve the timeliness, coverage, and accuracy of outbreak detection and situational awareness. Here, we use a flexible statistical framework for integrating multiple surveillance data sources to evaluate the adequacy of traditional (ILINet) and next generation (BioSense 2.0 and Google Flu Trends) data for situational awareness of influenza across poverty levels. We find that ZIP Codes in the highest poverty quartile are a critical vulnerability for ILINet that the integration of next generation data fails to ameliorate.

Equalizing access to pandemic influenza vaccines through optimal allocation to public health distribution points.

Vaccines are arguably the most important means of pandemic influenza mitigation. However, as during the 2009 H1N1 pandemic, mass immunization with an effective vaccine may not begin until a pandemic is well underway. In the U.S., state-level public health agencies are responsible for quickly and fairly allocating vaccines as they become available to populations prioritized to receive vaccines. Allocation decisions can be ethically and logistically complex, given several vaccine types in limited and uncertain supply and given competing priority groups with distinct risk profiles and vaccine acceptabilities. We introduce a model for optimizing statewide allocation of multiple vaccine types to multiple priority groups, maximizing equal access. We assume a large fraction of available vaccines are distributed to healthcare providers based on their requests, and then optimize county-level allocation of the remaining doses to achieve equity. We have applied the model to the state of Texas, and incorporated it in a Web-based decision-support tool for the Texas Department of State Health Services (DSHS). Based on vaccine quantities delivered to registered healthcare providers in response to their requests during the 2009 H1N1 pandemic, we find that a relatively small cache of discretionary doses (DSHS reserved 6.8% in 2009) suffices to achieve equity across all counties in Texas.

Stockpiling Ventilators for Influenza Pandemics.

In preparing for influenza pandemics, public health agencies stockpile critical medical resources. Determining appropriate quantities and locations for such resources can be challenging, given the considerable uncertainty in the timing and severity of future pandemics. We introduce a method for optimizing stockpiles of mechanical ventilators, which are critical for treating hospitalized influenza patients in respiratory failure. As a case study, we consider the US state of Texas during mild, moderate, and severe pandemics. Optimal allocations prioritize local over central storage, even though the latter can be deployed adaptively, on the basis of real-time needs. This prioritization stems from high geographic correlations and the slightly lower treatment success assumed for centrally stockpiled ventilators. We developed our model and analysis in collaboration with academic researchers and a state public health agency and incorporated it into a Web-based decision-support tool for pandemic preparedness and response.

Preparedness in Long-Term Care: A Novel Approach to Address Gaps in Evacuation Tracking.

With an aging population, the number of elderly individuals residing in long-term care (LTC) facilities will continue to grow and pose unique challenges to disaster preparedness and response. With this rapidly growing vulnerable population, it becomes imperative to identify enhanced and novel preparedness strategies and measures. LTC residents not only have complicated medical needs, including the timing of dispensing multiple medications, but frequently have cognitive and mobility deficits as well. In nearly every major disaster, elderly populations have suffered disproportionate morbidity and mortality. This is often due to elderly evacuees getting overlooked in the chaos of an initial response. Instituting measures to rapidly recognize this population in a crowd during an evacuation will reduce their risk. This commentary reviews the LTC facility evacuation challenges of the 2013 explosion of the West Fertilizer Company plant in West, Texas, and offers a novel solution of mandating the wearing of pink vests by all nursing home residents in case of an evacuation. The pink vests quickly alert disaster rescue and response workers of LTC residents with special needs. (Disaster Med Public Health Preparedness. 2017;11:28-30).

Metabolism and Residues of 2,4-Dichlorophenoxyacetic Acid in DAS-40278-9 Maize (Zea mays) Transformed with Aryloxyalkanoate Dioxygenase-1 Gene.

DAS-40278-9 maize, which is developed by Dow AgroSciences, has been genetically modified to express the aryloxyalkanoate dioxygenase-1 (AAD-1) protein and is tolerant to phenoxy auxin herbicides, such as 2,4-dichlorophenoxyacetic acid (2,4-D). To understand the metabolic route and residue distribution of 2,4-D in DAS-40278-9 maize, a metabolism study was conducted with 14C-radiolabeled 2,4-D applied at the maximum seasonal rate. Plants were grown in boxes outdoors. Forage and mature grain, cobs, and stover were collected for analysis. The metabolism study showed that 2,4-D was metabolized to 2,4-dichlorophenol (2,4-DCP), which was then rapidly conjugated with glucose. Field-scale residue studies with 2,4-D applied at the maximum seasonal rate were conducted at 25 sites in the U.S. and Canada to measure the residues of 2,4-D and free and conjugated 2,4-DCP in mature forage, grain, and stover. Residues of 2,4-D were not detectable in the majority of the grain samples and averaged <1.0 and <1.5 µg/g in forage and stover, respectively. Free plus conjugated 2,4-DCP was not observed in grain and averaged <1.0 µg/g in forage and stover.

Optimizing distribution of pandemic influenza antiviral drugs.

We provide a data-driven method for optimizing pharmacy-based distribution of antiviral drugs during an influenza pandemic in terms of overall access for a target population and apply it to the state of Texas, USA. We found that during the 2009 influenza pandemic, the Texas Department of State Health Services achieved an estimated statewide access of 88% (proportion of population willing to travel to the nearest dispensing point). However, access reached only 34.5% of US postal code (ZIP code) areas containing <1,000 underinsured persons. Optimized distribution networks increased expected access to 91% overall and 60% in hard-to-reach regions, and 2 or 3 major pharmacy chains achieved near maximal coverage in well-populated areas. Independent pharmacies were essential for reaching ZIP code areas containing <1,000 underinsured persons. This model was developed during a collaboration between academic researchers and public health officials and is available as a decision support tool for Texas Department of State Health Services at a Web-based interface.

Organophosphate antidote auto-injectors vs. traditional administration: a time motion study.

Organophosphates may be used as weapons in chemical attacks on civilian or military populations. Antidotes are available to counter the effects of organophosphates, but they must be administered shortly after exposure. Timing required to administer organophosphate antidotes using traditional equipment vs. auto-injectors has not been studied. This study is intended to quantify and compare the time required to administer organophosphate antidotes using traditional equipment vs. auto-injectors in different treatment conditions. The study was a randomized, un-blinded design. There were 62 participants assigned to one of three groups: Mark I, ATNAA (antidote treatment nerve agent auto-injector), and traditional needle/syringe; however, the results from only 56 participants could be analyzed. Injection trials were videotaped. Subjects also completed a 14-item survey containing demographic questions, perceived ease of injection, receipt of prior training, and preferred training format for organophosphate treatment. Injection time differentials were compared using one-way analysis of variance; post hoc evaluation was performed using the Scheffe test with Bonferroni correction. Fifty-six subjects completed this study. The ATNAA required less time to administer than the Mark I or traditional needle/syringe devices (p < .001). There was no difference in time to administer the Mark I auto-injectors vs. a traditional needle/syringe. There were no differences between injection time and occupation, receipt of prior training, wearing of personal protective equipment, or perceived ease of injection device use. The use of auto-injectors shortens response time for administering organophosphate antidote treatment. An ATNAA auto-injector can be administered in less than half the time it takes to administer a single injection using a needle and syringe or two injections using a Mark I. Mark I can be administered in approximately the same amount of time it takes to administer a single injection using a needle and syringe. The difference between injection time for the ATNAA and needle and syringe would have been even larger if two injections were given with the needle and syringe. The wearing or absence of personal protective equipment does not affect injection time.

Using social network analysis to understand Missouri's system of public health emergency planners.

OBJECTIVES: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: While Missouri public health emergency planners maintain large and varied emergency preparedness networks, there are opportunities for strengthening existing ties and seeking additional connections.

Occupational physician perceptions of bioterrorism.

The rationale for most preparedness training of healthcare professionals is based on the assumption that most persons infected following a biological incident will present first to emergency departments of acute care facilities or to ambulatory settings such as private physician offices, and such incidences would be recognized, appropriately treated, and reported to the local health departments. However, an alternative first point of contact is industry, a location where workers gather and disperse on a regular and documented basis, and require healthcare. In industry there are health professionals responsible for the health, safety and on-site well-being of the workforce and surrounding community; these professionals are in a position for early recognition, surveillance, and isolation. Targeted education must be provided to these health professionals. To address perceptions of risk and preferred educational delivery methods for bioterrorism and emerging infections-related materials, a survey of occupational physicians was performed during the spring of 2001. Within the 2 months following the September 11 terrorist attack and subsequent anthrax bioterrorism event, and before release of any results from the first survey, a follow-up mail survey was initiated in November 2001. Response rate to the pre- and post-September 11 survey were 58% (n = 56) and 33% (n = 33), respectively. No significant demographic differences were observed between the respondents of the pre- and post-surveys. Perceptions of likelihood of another bioterrorism event increased between surveys, as would be expected; however, a tendency to believe that it would not happen locally persisted. Even though over 90% of the physicians had received immediate training following September 11, additional training/education needs were demonstrated. Although training and education modules can be designed without information based on the population that can be on the receiving end, it rarely accomplishes its goal. Results from this survey can serve as a base for designing various levels of targeted training and educational material specific to the perceived need, method of obtaining information and the format considered to be most conducive for learning. Potential consequences from lack of bioterrorism preparedness due to low perception of need and threat awareness need to be addressed.

Theoretical perspectives on public communication preparedness for terrorist attacks.

The experience of federal health authorities in responding to the mailed anthrax attacks in the Fall of 2001 sheds light on the challenges of public information dissemination in emergencies. Lessons learned from the Fall of 2001 have guided more recent efforts related to crisis communication and preparedness goals. This article applies theories and evidence from the field of communication to provide an orientation to how public health communication can best contribute to the preparedness effort. This theoretical orientation provides a framework to systematically assess current recommendations for preparedness communication.

Bioterrorism risk perceptions and educational needs of public health professionals before and after September 11, 2001: a national needs assessment survey.

The study objectives were to compare local public health professionals' bioterrorism risk perceptions, the extent of bioterrorism preparedness training, and to describe preferred methods for delivery of preparedness education in the United States. National needs assessments were conducted via a mailed survey to 3,074 local public health departments in October 2000 and November 2001. Compared to a survey conducted in October 2000, the perceived risk of a bioterrorism attack in the United States increased dramatically after September 11 (p < 0.0001); however, 57% of respondents believed one was unlikely to occur within their own community. Public health professionals perceive their own communities to be at low risk for a bioterrorism event. Ongoing, updated, standardized bioterrorism preparedness education is needed.

Infection control practitioners' perceptions and educational needs regarding bioterrorism: results from a national needs assessment survey.

BACKGROUND: The perceived threat that biological weapons will be used in an act of terror against the United States has escalated sharply since the discovery of anthrax-tainted letters after the terrorist attacks of September 11, 2001. These events underscore the critical nature of health care and public health preparedness and the need to augment infection control practitioner education and training. METHODS: Between October 2000 and August 2001 a national needs assessment was conducted by use of a 35-question survey. The survey measured infection control practitioners' (ICPs') perception of the risk for bioterrorism in the United States and in their community, the proportion of ICPs with prior training in bioterrorism preparedness, and preferences for delivery media of future bioterrorism education. RESULTS: The assessment of the perceived threat of bioterrorism in the United States during the next 5 years (P =.022) and in the ICPs' work community (P <.001) revealed significant regional differences. Only half (56%) of the respondents reported prior training in bioterrorism preparedness. Respondents reported that the 2 most common barriers to receiving training were lack of training opportunities (70.2%) or no dedicated work time for training (19.4%). CONCLUSIONS: The results of this study indicate an urgent need for more resources and opportunities for clinical education in bioterrorism preparedness that will provide continuing education credit. Successful bioterrorism education will require a variety of instructional designs and media delivery methods to address ICPs' preferences and needs.

Terrorism from a public health perspective.

The use of biological and chemical weapons as agents of warfare and terrorism has occurred sporadically, but recent events demonstrate the increasing risk and possibility that terrorist groups with grievances against the government or groups may employ them. Historically, most evaluations of the potential risk for biological weaponry have focused on the military, but the recent release of anthrax in the United States demonstrates that civilian populations are also at risk. More likely than not, most bioterrorism events will be of a small scale; however, agents such as Bacillus anthracis and Yersinia pestis could leave hundreds of thousands dead or incapacitated. The impact of the attack will depend on a number of variables, including the agent used, method of dispersal, and the responsiveness of the public health system. With any large-scale event, the public health infrastructure will be called upon to deal with mass casualties and the "worried well."