Superposition of COVID-19 waves, anticipating a sustained wave, and lessons for the future.

The 2019 coronavirus (COVID-19), also known as SARS-CoV-2, is highly pathogenic and virulent, and it spreads very quickly through human-to-human contact. In response to the growing number of cases, governments across the spectrum of affected countries have adopted different strategies in implementing control measures, in a hope to reduce the number of new cases. However, 5 months after the first confirmed case, countries like the United States of America (US) seems to be heading towards a trajectory that indicates a health care crisis. This is in stark contrast to the downward trajectory in Europe, China, and elsewhere in Asia, where the number of new cases has seen a decline ahead of an anticipated second wave. A data-driven approach reveals three key strategies in tackling COVID-19. Our work here has definitively evaluated these strategies and serves as a warning to the US, and more importantly, a guide for tackling future pandemics. Also see the video abstract here https://youtu.be/gPkCi2_7tWo.

Tenure and Turnover Among State Health Officials From the SHO-CASE Survey: Correlates and Consequences of Changing Leadership.

OBJECTIVE: To examine characteristics associated with tenure length of State Health Officials (SHOs) and examine reasons and consequences for SHO turnover. DESIGN: Surveys of current and former SHOs linked with secondary data from the United Health Foundation. SETTING: Original survey responses from SHOs in the United States. PARTICIPANTS: Respondents included SHOs who served between 1973 and 2017. MAIN OUTCOME MEASURES: Tenure length and consequences of SHO turnover. RESULTS: Average completed tenure among SHOs was 5.3 years (median = 4) and was shorter in recent time periods compared with decades prior. Older age at appointment (ß = -0.109, P = .005) and those holding a management degree (ß = -1.835, P = .017) and/or a law degree (ß = -3.553, P < .001) were each associated with shorter SHO tenures. State Health Officials from states in the top quartile for health rankings had significantly longer average tenures (ß = 1.717, P = .036). Many former SHOs believed that their tenure was too short and reported that their departure had either a significant or very large effect on their agency's ability to fulfill its mission. CONCLUSIONS: State Health Official tenures have become shorter over time and continue to be shorter than industry chief executive officers and best practice recommendations from organizational researchers. States have an opportunity to consider and address how factors within their control influence the stability of the SHO position.

Factors Associated With Continuous Improvement by Local Boards of Health.

BACKGROUND: The continuous improvement function, 1 of the 6 public health governance functions, can be usefully applied in the context of local boards of health (LBoHs) operations to target self-improvements. PURPOSE: The purpose of this study was to determine the engagement level of LBoHs in continuous improvement efforts and to identify factors associated with this function. METHODS: Negative binomial regression was performed to analyze data from the 2015 Local Board of Health National Profile. The LBoH taxonomy was used as the guiding model. The taxonomy includes 6 governance functions as structural domains and LBoHs' characteristics and strengths as the central or seventh domain. RESULTS: For the 17 items that comprise the continuous improvement domain, the mean of the dichotomous responses was 4.97 (SD = 3.41). The negative binomial regression analysis showed that the overall summary scale for the other 5 governance domains and the LBoHs' other strengths domain had a significant positive association with the governance domain continuous improvement domain (incidence rate ratio [IRR] = 1.05, P < .001). The 5 individual scales for the governance domains also had significant positive associations with the continuous improvement domain, which included the governance functions of policy development (IRR = 1.13, P < .001), resource stewardship (IRR = 1.18, P < .001), legal authorization (IRR = 1.09, P < .001, partnership engagement (IRR = 1.12, P < .001), and oversight (IRR = 1.29, P < .001). The scale for other characteristics and strengths also showed positive association with continuous improvement (IRR = 1.14, P < .001). CONCLUSION: The findings of this study revealed that there was room for improvement in LBoHs' engagement in the continuous improvement governance function. The results also identified other governance functions and LBoHs' characteristics as factors associated with their continuous improvement.

Impact of Local Boards of Health on Local Health Department Accreditation, Community Health Assessment, Community Health Improvement Planning, and Strategic Planning.

INTRODUCTION: Local health departments (LHDs) are increasingly using national standards to meet the challenges presented by the complex environments in which these agencies operate. Local boards of health (LBoHs) might play an instrumental role in improving LHDs' engagement in activities to meet these standards. OBJECTIVES: To assess the impact of LBoH performance of governance functions on LHDs having a current (completed within 5 years) community health assessment (CHA), community health improvement plan (CHIP), strategic plan, and level of engagement in the Public Health Accreditation Board (PHAB) accreditation program. METHODS: Binary and multinomial logistic regression models were used to analyze linked data from 329 LHDs participating in both the 2015 Local Board of Health Survey and the 2016 National Profile of LHDs Survey. RESULTS: Higher performance of LBoH governance functions, measured by an overall scale of LBoH taxonomy consisting of 60 items, had a significant positive effect on LHDs having completed CHA (P < .001), CHIP (P = .01), and strategic plan (P < .001). LHDs operating in communities with a higher score on the overall scale of LBoH taxonomy had significantly higher odds (P = .03) of having higher level of participation in the PHAB national voluntary accreditation program-that is, being accredited, having submitted application for accreditation, or being in the e-PHAB system (eg, by submitting a letter of intent). CONCLUSIONS: LBoHs serve as governance bodies for roughly 71% of LHDs and can play a significant role in encouraging LHDs' participation in these practices. That positive influence of LBoHs can be seen more clearly if the complexity and richness of LBoH governance functions and other characteristics are measured appropriately. The study findings suggest that LBoHs are a significant component of the public health system in the United States, having positive influence on LHDs having a CHA, CHIP, strategic plan, and participation in accreditation.

Perceptions of Public Health 3.0: Concordance Between Public Health Agency Leaders and Employees.

CONTEXT AND BACKGROUND: The newest era of public health, deemed "Public Health 3.0," supports cross-sector collaborations to address social determinants of health. These activities often require collaborations with nontraditional public health entities. As this new era begins, it is important to understand perceptions of the public health workforce with regard to Public Health 3.0. OBJECTIVE: To assess perceptions of support toward Public Health 3.0 activities by the public health workforce, identify characteristics associated with support, and measure concordance in support between agency directors and the general workforce. DESIGN: This cross-sectional study utilizes the 2017 Public Health Workforce Interests and Needs Survey to understand support and concordance regarding Public Health 3.0 activities by a nationally representative sample of governmental public health employees. Logistic regression models are used to identify characteristics associated with support of each 3.0 activity and concordance. MAIN OUTCOME MEASURES: Governmental public health employees' opinions on how involved their agency should be in the K-12 education system, the economy, the built environment, transportation, housing, social connectedness, and health equity within their jurisdiction and concordance in support of involvement between agency directors and the general workforce. RESULTS: Overall, individual perceptions supporting involvement were highest for health equity and social connectedness and lowest for transportation. Supervisory status, education, and being at a local health department were associated with greater odds of supporting all 3.0 activities. Concordance with agency directors was greatest among other executives relative to nonsupervisors. CONCLUSIONS: There is overall generally high support of many 3.0 activities, but there are gaps in agreement by supervisory status, gender, race/ethnicity, education, role type, and jurisdiction. Findings may help support agency leaders in better communicating the role of their agencies in Public Health 3.0 activities, and workforce education regarding such activities may be necessary for the success of Public Health 3.0's success.

Big City Health Officials' Conceptualizations of Health Equity.

CONTEXT: Senior health officials of local health departments are uniquely positioned to provide transformational leadership on health disparities and inequities. OBJECTIVE: This study aimed to understand how senior health officials in large US cities define health equity and its relationship with disparities and characterize these senior health officials' perceptions of using health equity and disparity language in local public health practice. DESIGN: In 2016, we used a general inductive qualitative design and conducted 23 semistructured interviews with leaders of large local health departments. Thematic content analysis was conducted using NVivo 11. PARTICIPANTS: A purposive sample of senior health officials from Big Cities Health Coalition cities. RESULTS: Health equity was conceptualized fairly consistently among senior health officials in big cities. Core elements of these conceptualizations include social and economic conditions, the input and redistribution of resources, equity in practice, values of justice and fairness, and equity as an outcome to be achieved. Senior health officials saw health disparity and health inequity as distinct but related concepts. Relationships between concepts included disparities data to identify and prioritize inequities, inequities creating health disparities, health equity to eliminate disparities, and disparities becoming inequities when their root causes are unjust. Some respondents critiqued health equity terminology for representing a superficial change, being inaccessible, and being politically loaded. CONCLUSIONS: Understanding how senior health officials conceptualize health equity and disparities can focus policy priorities, resources, and the scope of work undertaken by local health departments. Having a common language for health equity allows for policy and resource advocacy to promote the health of marginalized populations.

The public health emergency management system in China: trends from 2002 to 2012.

BACKGROUND: Public health emergencies have challenged the public health emergency management systems (PHEMSs) of many countries critically and frequently since this century. As the world's most populated country and the second biggest economy in the world, China used to have a fragile PHEMS; however, the government took forceful actions to build PHEMS after the 2003 SARS outbreak. After more than one decade's efforts, we tried to assess the improvements and problems of China's PHEMS between 2002 and 2012. METHODS: We conducted two rounds of national surveys and collected the data of the year 2002 and 2012, including all 32 provincial, 139 municipal, and 489 county CDCs. The municipal and county CDCs were selected by systematic random sampling. Twenty-one indicators of four stages (preparation, readiness, response and recovery) from the National Assessment Criteria for CDC Performance were chosen to assess the ten-year trends. RESULTS: At the preparation stage, organization, mechanisms, workforce, and stockpile across all levels and regions were significantly improved after one decade's efforts. At the readiness stage, the capability for formulating an emergency plan was also significantly improved during the same period. At the response stage, internet-based direct reporting was 98.8%, and coping scores were nearly full points of ten in 2012. At the recovery stage, the capabilities were generally lower than expected. CONCLUSIONS: Due to forceful leadership, sounder regulations, and intensive resources, China's PHEMS has been improved at the preparation, readiness, and response stages; however, the recovery stage was still weak and could not meet the requirements of crisis management and preventive governance. In addition, CDCs in the Western region and counties lagged behind in performance on most indicators. Future priorities should include developing the recovery stage, establishing a closed feedback loop, and strengthening the capabilities of CDCs in Western region and counties.

Improving Culture, One Quality Improvement Project at a Time.

CONTEXT: A culture of quality improvement (QI) values collaboration, transparency, and staff empowerment. Organizations exhibiting a culture of QI are more likely to engage in QI. OBJECTIVE: We examined whether local health departments' (LHDs') participation in a longitudinal, experiential QI training program changes QI culture. DESIGN: Prior to and following participation in a QI training program, all employees of participating LHDs were asked to complete an 8-item survey assessing components of QI culture on a 5-point scale. INTERVENTION: From 2010 to 2015, multidisciplinary teams from North Carolina LHDs participated in sequential cohorts of a 6-month QI training program, during which the teams completed a QI project. MAIN OUTCOME MEASURE: We dichotomized culture survey responses, with 4 or 5 being "Supportive." We compared adjusted proportions, using linear regression, clustering at LHD, and controlling for cohort. RESULTS: Data from 42 LHDs were included. At baseline, 7.8% responded that their LHD had a supportive culture for all 8 components, compared with 12% at follow-up (P < .001), adjusted for cohort and clustering by LHD. At follow-up, the percentage of employees responding that their LHDs had supportive cultures increased for all components of culture including communication by 4.1% (95% CI: 2.0%-6.2%), problem solving by 2.9% (95% CI: 1.6%-5.5%), team work by 5.2% (95% CI: 2.5%-7.8%), vision by 4.3% (95% CI: 1.1%-7.5%), performance measures by 5.6% (95% CI: 1.6%-9.6%), recognition by 4.7% (95% CI: 1.4%-8.0%), for conflict by 5.5% (95% CI: 1.7%-9.4%), and alignment by 5.8% (95% CI: 2.3%-9.2%). CONCLUSIONS: Engagement with structured QI training programs-and perhaps simply completing QI projects-can cause small, but important changes in organizations' cultures, thus increasing engagement in future QI and improving overall care and services. The article demonstrates that when LHDs participate in a longitudinal, experiential QI training program, their cultures of QI improve. Local health departments participating in similar training programs might experience similar improvements in culture, increasing subsequent participation in QI projects and improving related health outcomes.

Public health issues in the 21st century: National challenges and shared challenges for the Maghreb countries.

In the 21st century, public health is not only about fighting infectious diseases, but also contributing to a "multidimensional" well-being of people (health promotion, non-communicable diseases, the role of citizens and people in the health system etc.). Six themes of public health, issues of the 21st century will be addressed. Climate change is already aggravating already existing health risks, heat waves, natural disasters, recrudescence of infectious diseases. Big data is the collection and management of databases characterized by a large volume, a wide variety of data types from various sources and a high speed of generation. Big data permits a better prevention and management of disease in patients, the development of diagnostic support systems and the personalization of treatments. Big data raises important ethical questions. Health literacy includes the abilities of people to assess and critique and appropriate health information. Implementing actions to achieve higher levels of health literacy in populations remains a crucial issue. Since the 2000s, migration flows of health professionals have increased mainly in the "south-north" direction. India is the country with the most doctors outside its borders. The USA and the UK receive 80% of foreign doctors worldwide. Ways have been identified to try to regulate the migratory phenomena of health professionals around the world. The mobilization of citizen, health system users and patient associations is a strong societal characteristic over the last 30 years. In a near future, phenomena will combine to increase the need for accompaniment of patient or citizen to protect health, such increase of the prevalence of chronic diseases, reinforcement of care trajectories, medico-social care pathways, and importance of health determinants. Interventional research in public health is very recent. It is based on experimentation and on the capitalization of field innovations and uses a wide range of scientific disciplines, methods and tools. It is an interesting tool in the arsenal of public health research. It is essential today to be able to identify the multiple challenges that health systems will face in the coming years, to anticipate changes, and to explore possible futures.

Daily Total Physical Activity and Incident Stroke: The Japan Public Health Center-Based Prospective Study.

BACKGROUND AND PURPOSE: There is limited evidence on the association between total physical activity and stroke in Asian populations experiencing a greater burden of hemorrhagic stroke than Western populations. We aimed to understand their optimal level of physical activity for stroke prevention. METHODS: A total of 74 913 Japanese people 50 to 79 years of age without histories of cardiovascular disease or cancer were followed from 2000 to 2012. RESULTS: During the 698 946 person-years of follow-up, we documented a total of 2738 incident cases of stroke, including 1007 hemorrhagic strokes (747 intraparenchymal and 260 subarachnoid hemorrhages) and 1721 ischemic strokes (1206 nonembolic and 515 embolic infarctions). Individuals in the second or third metabolic equivalents of task-hours per day quartile had the lowest risks of total stroke (hazard ratio [HR], 0.83; 95% confidence interval [CI], 0.75-0.93), intraparenchymal hemorrhage (HR, 0.79; 95% CI, 0.64-0.97), subarachnoid hemorrhage (HR, 0.78; CI, 0.55-1.11), and nonembolic infarction (HR, 0.78; CI, 0.67-0.92), whereas those in the fourth quartile had the lowest risk of embolic infarction (HR, 0.76; CI, 0.59-0.97). Cubic spline graphs revealed a steep decrease in stroke risk (30% risk reduction) from the lowest level to a plateau at 5 to 10 metabolic equivalents of task-hours per day (50th percentile). The associations of total physical activity level with hemorrhage stroke showed U or J shape, which were because of vigorous-intensity activities, whereas the association with ischemic stroke showed L shape. CONCLUSIONS: For Japanese people, moderate levels of total physical activity, particularly achieved by moderate-intensity activities, may be optimal for stroke prevention because excessive vigorous-intensity activities might not be beneficial or even disadvantageous for prevention of hemorrhagic stroke.

Perceived Facilitators and Barriers to Local Health Department Workers' Participation in Infectious Disease Emergency Responses.

CONTEXT: Local health departments play a key role in emergency preparedness and respond to a wide range of threats including infectious diseases such as seasonal influenza, tuberculosis, H1N1, Ebola virus disease, and Zika virus disease. To successfully respond to an infectious disease outbreak, local health departments depend upon the participation of their workforce; yet, studies indicate that sizable numbers of workers would not participate in such a response. The reasons why local health department workers participate, or fail to participate, in infectious disease responses are not well understood. OBJECTIVE: To understand why local health department workers are willing, or not willing, to report to work during an infectious disease response. DESIGN: From April 2015 to January 2016, we conducted 28 semistructured interviews with local health department directors, preparedness staff, and nonpreparedness staff. SETTING: Interviews were conducted with individuals throughout the United States. PARTICIPANTS: We interviewed 28 individuals across 3 groups: local health department directors (n = 8), preparedness staff (n = 10), and nonpreparedness staff (n = 10). MAIN OUTCOME MEASURES: Individuals' descriptions of why local health department workers are willing, or not willing, to report to work during an infectious disease response. RESULTS: Factors that facilitate willingness to respond to an infectious disease emergency included availability of vaccines and personal protective equipment; flexible work schedule and childcare arrangements; information sharing via local health department trainings; and perceived commitments to one's job and community. Factors that hinder willingness to respond to an infectious disease emergency included potential disease exposure for oneself and one's family; logistical considerations for care of children, the elderly, and pets; and perceptions about one's role during an infectious disease response. CONCLUSION: Our findings highlight opportunities for local health departments to revisit their internal policies and engage in strategies likely to promote willingness to respond among their staff. As LHDs face the persistent threat of infectious diseases, they must account for response willingness when planning for and fielding emergency responses. Our findings highlight opportunities for local health departments to revisit their internal policies and engage in strategies likely to promote response willingness to infectious disease emergencies among their staff.

Trends in infectious disease incidence among children in Afghanistan at a time of public health services expansion.

This study reviewed trends in the incidence of common communicable diseases among children under five years in Afghanistan between 2005 and 2013, a period of expansion of public health services. New visits to outpatient clinics constituted the denominator for calculating proportions. In 2013, almost three-quarters of all new visits of children to public health services were for an infectious disease, with respiratory infections the most common. Because of inconsistent data collection for some infections early in the period, the trend for infectious diseases as a whole cannot be estimated. However, there was a statistically significant downward trend in the proportion of new visits that were diagnosed as one of the 11 leading communicable diseases from 74.5% in 2005 to 62.1% in 2013 (P < 0.001). There was no difference in communicable disease patterns between provinces, but a higher per capita consultation rate was associated with a higher proportion of the leading infections (P = 0.008). Recent improvements in maternal health, hygiene, and preventive services may have had an impact in reducing the burden of infections.

[Contribution of Health Care Research to Establishing Social Equality in Health and Health Care Opportunities]. / Der Beitrag der Versorgungsforschung zur Chancengerechtigkeit in der Gesundheit und in der Versorgung.

Social inequalities in health and health care services represent issues of major concern. Findings in this area reveal inequalities in health and health care indicating disadvantages for individuals with a low socioeconomic background. Although the health care system plays a marginal role in the explanation of inequalities in health, health services research can be an important part in the development of equal health opportunities. The current article describes the causal associations between social inequalities, health inequalities and the health care service. Health services research can make a contribution to increasing equal opportunities in health and health care service. Against this background, we discuss the existing potential and need of research in the area of health services.

[Medical Care for Homeless People - Individual Right and a Social Duty for an Inclusive Society]. / Medizinische Versorgung für wohnungslose Menschen - individuelles Recht und soziale Pflicht statt Exklusion.

Homelessness is a social phenomenon of increasing frequency in Germany and of high relevance for an inclusive society. Its expression is both caused psychosocially and moderated socioeconomically, often with negatively reinforcing feedback-loops. This overview describes health effects and strategies for improvement, using the example of the "Mainzer Modell". The comprehensive availability of adequate medical care are both an individual right and a social duty for an inclusive society.

Balancing Tribal Sovereignty and the Role of Interjurisdictional Partnerships in Oklahoma.

CONTEXT: Oklahoma has a history of strong partnerships with their tribal health leaders and tribal communities. In 2012, the Oklahoma State Department of Health (OSDH) established the Office of the Tribal Liaison, as Oklahoma has 39 tribal nations in the state, of which 38 are federally recognized. The Office of the Tribal Liaison is responsible for promoting relationships with Oklahoma Tribal Nations and implementing the OSDH Tribal Consultation policy. SETTING: The strength of the partnership between the OSDH and the Tribal Nations enabled a new collaboration during an event hosted by a tribal casino event center that brought tattoo artists to provide tattoos to patrons over 3 days. Licensure issues that crossed the jurisdiction boundaries of the OSDH emerged before the event, which required the OSDH, Indian Health Service, and the Tribal Nation to work together to protect the public's health. The 3 jurisdictions drew upon their previously established partnership, OSDH's tribal consultation policy, and their open and trusting relationship to come together quickly to protect the public's health. CONCLUSIONS: This event and interjurisdictional partnership highlighted the importance of adopting the "Spectrum of Processes for Collaboration and Consensus-Building" model as outlined by Orenstein et al to help guide and support state, tribal, and federal collaborations. This case example highlights the opportunities for collaboration between different regulatory public health and tribal bodies to improve the communities' health.

Multisector Health Policy Networks in 15 Large US Cities.

CONTEXT: Local health departments (LHDs) have historically not prioritized policy development, although it is one of the 3 core areas they address. One strategy that may influence policy in LHD jurisdictions is the formation of partnerships across sectors to work together on local public health policy. DESIGN: We used a network approach to examine LHD local health policy partnerships across 15 large cities from the Big Cities Health Coalition. SETTING/PARTICIPANTS: We surveyed the health departments and their partners about their working relationships in 5 policy areas: core local funding, tobacco control, obesity and chronic disease, violence and injury prevention, and infant mortality. OUTCOME MEASURES: Drawing on prior literature linking network structures with performance, we examined network density, transitivity, centralization and centrality, member diversity, and assortativity of ties. RESULTS: Networks included an average of 21.8 organizations. Nonprofits and government agencies made up the largest proportions of the networks, with 28.8% and 21.7% of network members, whereas for-profits and foundations made up the smallest proportions in all of the networks, with just 1.2% and 2.4% on average. Mean values of density, transitivity, diversity, assortativity, centralization, and centrality showed similarity across policy areas and most LHDs. The tobacco control and obesity/chronic disease networks were densest and most diverse, whereas the infant mortality policy networks were the most centralized and had the highest assortativity. Core local funding policy networks had lower scores than other policy area networks by most network measures. CONCLUSION: Urban LHDs partner with organizations from diverse sectors to conduct local public health policy work. Network structures are similar across policy areas jurisdictions. Obesity and chronic disease, tobacco control, and infant mortality networks had structures consistent with higher performing networks, whereas core local funding networks had structures consistent with lower performing networks.