Scientific research and product development in the United States to address injuries from a radiation public health emergency.

The USA has experienced one large-scale nuclear incident in its history. Lessons learned during the Three-Mile Island nuclear accident provided government planners with insight into property damage resulting from a low-level release of radiation, and an awareness concerning how to prepare for future occurrences. However, if there is an incident resulting from detonation of an improvised nuclear device or state-sponsored device/weapon, resulting casualties and the need for medical treatment could overwhelm the nation's public health system. After the Cold War ended, government investments in radiation preparedness declined; however, the attacks on 9/11 led to re-establishment of research programs to plan for the possibility of a nuclear incident. Funding began in earnest in 2004, to address unmet research needs for radiation biomarkers, devices and products to triage and treat potentially large numbers of injured civilians. There are many biodosimetry approaches and medical countermeasures (MCMs) under study and in advanced development, including those to address radiation-induced injuries to organ systems including bone marrow, the gastrointestinal (GI) tract, lungs, skin, vasculature and kidneys. Biomarkers of interest in determining level of radiation exposure and susceptibility of injury include cytogenetic changes, 'omics' technologies and other approaches. Four drugs have been approved by the US Food and Drug Administration (FDA) for the treatment of acute radiation syndrome (ARS), with other licensures being sought; however, there are still no cleared devices to identify radiation-exposed individuals in need of treatment. Although many breakthroughs have been made in the efforts to expand availability of medical products, there is still work to be done.

Health technology assessment applied to emergency preparedness: a new perspective.

Emergency preparedness is a continuous quality improvement process through which roles and responsibilities are defined to effectively anticipate, respond to, and recover from the impact of emergencies. This process results in documented plans that provide a backbone structure for developing the core capacities to address health threats. Nevertheless, several barriers can impair an effective preparedness planning, as it needs a 360° perspective to address each component according to the best evidence and practice. Preparedness planning shares common principles with health technology assessment (HTA) as both encompass a multidisciplinary and multistakeholder approach, follow an iterative cycle, adopt a 360° perspective on the impact of intervention measures, and conclude with decision-making support. Our "Perspective" illustrates how each HTA domain can address different component(s) of a preparedness plan that can indeed be seen as a container of multiple HTAs, which can then be used to populate the entire plan itself. This approach can allow one to overcome preparedness barriers, providing an independent, systematic, and robust tool to address the components and ensuring a comprehensive evaluation of their value in the mitigation of the impact of emergencies.

COVID-19: Opportunity to Re-Imagine Our Response to a National Medical Crisis.

The US is facing the most significant health challenge since the 1918-1919 flu pandemic. A response commensurate with this challenge requires engaged leadership and organization across private and public sectors that span federal agencies, public and private healthcare systems, professional organizations, and industry. In the trauma and emergency care communities, we have long discussed the tension between competition in healthcare and the need for regional cooperation to respond to large-scale disasters. The response to COVID-19 has required unprecedented coordination of private and public sector entities. Given the competitive nature of the US health system, these sectors do not regularly work together despite the requirement to do so during a national emergency. This crisis has exposed how structural aspects of the present healthcare system have limited our ability to rapidly transition to a whole-nation response during a national crisis. We propose a renewed focus on the intersection of the healthcare system and national security, with the express goal of creating a public-private partnership focused on leveraging our healthcare infrastructure to support the national security interests of the US.

The Crosscutting Benefits of Hospital Emergency Preparedness Investments to Daily Operations: A Hospital Senior Leadership Perspective.

Hospitals are an integral part of community resiliency during and after a disaster or emergency event. In addition to community-level planning through healthcare coalitions, hospitals are required to test and update emergency plans to comply with accreditation standards at their own expense. Justifying costs related to investments in emergency preparedness can be a barrier, as these events are relatively rare. Little is known about the crosscutting benefits of investments in daily operations including patient care. This study investigated whether hospital investments in emergency preparedness had a perceived impact on daily operations from a senior leadership perspective. Using a cross-sectional study design, a 39-item survey was emailed and mailed to chief executive officers of all 105 Nebraska hospitals. Most respondents indicated that drills and exercises, staff training, and updating emergency plans had a positive impact on daily operations. A relatively small proportion (≤11%) of respondents indicated that costs of buying decontamination equipment, personal protective equipment, and costs associated with staff training and drills/exercises had a negative impact on daily operations. No differences were noted between rural and urban locations or between hospitals that allocate funds in the budget versus those that do not. The majority of hospitals in our study are likely to continue to invest over the next 3 years, inferring a sincere commitment by hospital senior leadership to continue to invest in emergency preparedness. Future research using longitudinal design and objective measures of investments and daily benefits is needed to support a business case for hospital preparedness.

Living in a Multi-Risk Chaotic Condition: Pandemic, Natural Hazards and Complex Emergencies.

Humans are living in an uncertain world, with daily risks confronting them from various low to high hazard events, and the COVID-19 pandemic has created its own set of unique risks. Not only has it caused a significant number of fatalities, but in combination with other hazard sources, it may pose a considerably higher multi-risk. In this paper, three hazardous events are studied through the lens of a concurring pandemic. Several low-probability high-risk scenarios are developed by the combination of a pandemic situation with a natural hazard (e.g., earthquakes or floods) or a complex emergency situation (e.g., mass protests or military movements). The hybrid impacts of these multi-hazard situations are then qualitatively studied on the healthcare systems, and their functionality loss. The paper also discusses the impact of pandemic's (long-term) temporal effects on the type and recovery duration from these adverse events. Finally, the concept of escape from a hazard, evacuation, sheltering and their potential conflict during a pandemic and a natural hazard is briefly reviewed. The findings show the cascading effects of these multi-hazard scenarios, which are unseen nearly in all risk legislation. This paper is an attempt to urge funding agencies to provide additional grants for multi-hazard risk research.

Comparing predisaster mitigation grant spending with postdisaster assistance spending: Are mitigation investments saving federal dollars?

This work is a companion paper to "Quantifying the Relationship Between Predisaster Mitigation Spending and Major Disaster Declarations for US States and Territories." Mitigation is a relatively new undertaking, especially for local jurisdictions, within the United States disaster policy. The Disaster Mitigation Act of 2000 (DMA 2000) requires local jurisdictions to plan for and implement mitigative strategies in order to access federal grant funding options for emergency management. After DMA 2000 went into effect in the mid-2000s, a supporting study by the Multi-Hazard Mitigation Council (MMC 2005) found that on average, mitigation projects yielded a benefit-cost ratio of 4:1 at the local level.1 This paper evaluates and compares predisaster mitigation spending and postdisaster assistance spend-ing at the state and FEMA Regional levels, hypothesizing that as mitigation spending increases, postdisaster spend-ing should decrease. The results however indicate the opposite, with most states showing increasing in both types of spending over time.

An introduction to economic studies, health emergencies, and COVID-19.

The COVID-19 pandemic has created widespread harm and disruption. Countries have implemented unprecedented measures to protect the lives and livelihoods of their inhabitants. The scope and composition of these responses are shaped, in part, by research and analysis about the estimated economic impacts of the COVID-19 Pandemic and proposed responses to it. This analysis outlines basic features and principles involved in economic studies, specifically economic impact studies and economic evaluations, which have formed a significant part of the ever-increasing evidence base about COVID-19. This analysis introduces economic studies in this context, highlighting what they can do, their limitations, and key steps involved in conducting them. It highlights examples of economic analysis focused on COVID-19 and on health emergencies and disasters more broadly. Knowing how economic studies are conducted, and their limitations, will help introduce how their findings can be a useful, usable, and used part of efforts to tackle this global health crisis.