Outbreak response operations during the US measles epidemic, 2017-19.

BACKGROUND: To 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. METHODS: From 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. RESULTS: We 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. CONCLUSIONS: Measles 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.

Responding to a Mumps Outbreak Impacting Immigrants and Low-English-Proficiency Populations.

OBJECTIVES: To examine outbreak response-associated costs, lessons learned, and challenges encountered during a local health department's response to a mumps outbreak. DESIGN: We conducted semistructured interviews with individuals directly involved in the response to a mumps outbreak and analyzed outbreak response-associated cost data. SETTING: In March-July 2018, a mumps outbreak occurred in Chester County, Pennsylvania. The outbreak primarily affected an immigrant community, some of whom spoke little or no English and were uninsured and/or undocumented. This necessitated an urgent response from the Chester County Health Department, which implemented a variety of public health interventions, including outreach to local health care providers and the execution of vaccination clinics at 2 local mushroom farms where case contacts worked. A total of 39 suspected or confirmed mumps cases were reported in Chester County, and 22 suspected or confirmed cases were reported by 2 neighboring jurisdictions. PARTICIPANTS: Health department employees (n = 7) and community partners (n = 2). Areas of expertise included emergency preparedness, nursing, medicine, disease surveillance, and epidemiology. MAIN OUTCOME MEASURE: Operational challenges encountered and lessons learned during the mumps outbreak response, including outbreak response-associated costs, which could inform other communities' planning and preparedness for outbreaks in similar populations and improve outbreak response operations. RESULTS: Immigration status emerged as a key challenge, which highlighted the importance of building trust through community outreach and partnerships and the need for culturally competent communication. In addition, vaccine availability, accessibility, and cost played a major role in response operations and necessitated the involvement of community partners to mitigate these barriers. Outbreak response-associated costs totaled $35 305. CONCLUSIONS: The challenges that occurred in this outbreak are broadly relevant to outbreaks that affect similar immigrant communities. Health departments that serve such populations can utilize these lessons to develop improved outbreak response plans that account for these challenges.

Southeast Asia Strategic Multilateral Dialogue on Biosecurity.

A strategic multilateral dialogue related to biosecurity risks in Southeast Asia, established in 2014, now includes participants from Singapore, Malaysia, Indonesia, Thailand, Philippines, and the United States. This dialogue is conducted at the nonministerial level, enabling participants to engage without the constraints of operating in their official capacities. Participants reflect on mechanisms to detect, mitigate, and respond to biosecurity risks and highlight biosecurity issues for national leadership. Participants have also identified factors to improve regional and global biosecurity, including improved engagement and collaboration across relevant ministries and agencies, sustainable funding for biosecurity programs, enhanced information sharing for communicable diseases, and increased engagement in international biosecurity forums.

Outbreaks of Hepatitis A in US Communities, 2017-2018: Firsthand Experiences and Operational Lessons From Public Health Responses.

Objectives. To identify and analyze common challenges from multiple US communities affected by the hepatitis A epidemic beginning in March 2017, and to identify operational lessons to support preparedness for similar future public health emergencies.Methods. We conducted semistructured interviews with health officials from 9 city or county health departments to collect the firsthand experience of public health responders. We collected data from January to October 2018 via teleconference. Key informants, whom we purposefully sampled, were senior public health officials who were directly involved in outbreak response or in preparing for potential hepatitis A outbreaks in their communities.Results. Several themes emerged during these discussions, including common challenges and solutions pertaining to sanitation and hygiene infrastructure, hepatitis A vaccination, health workforce availability and surge capacity, communication and stigma, and partnerships and coordination with local law enforcement and other stakeholders.Conclusions. By generating key, evidence-based operational lessons, this study can inform response activities in localities currently experiencing outbreaks as well as community preparedness for possible future outbreaks due to the presence of similar at-risk populations.

Taiwan's Annual Seasonal Influenza Mass Vaccination Program-Lessons for Pandemic Planning.

Rapid medical countermeasure (MCM) dispensing is an important intervention during a public health emergency. In the United States, MCM planning and exercising efforts have largely focused on dispensing therapeutics, with less emphasis on mass vaccination operations that would require additional specialized staff and infrastructure. Difficulties in distributing vaccines during the 2009 H1N1 influenza pandemic highlighted the need for enhanced planning and exercising of plans for conducting mass vaccination campaigns. In Taiwan, seasonal influenza mass vaccination campaigns are conducted annually, which both mitigate the effects of seasonal influenza and serve as functional exercises for mass vaccination operations during a pandemic. To identify lessons that can be applied to mass vaccination planning in the United States and elsewhere, we conducted an in-person observation and data review of Taiwan's annual seasonal influenza mass vaccination efforts in October 2017. We offer findings and recommendations for enhancing preparedness for seasonal and pandemic influenza and other public health emergencies that would require mass vaccination.

Public Health Resilience Checklist for High-Consequence Infectious Diseases-Informed by the Domestic Ebola Response in the United States.

CONTEXT: The experiences of communities that responded to confirmed cases of Ebola virus disease in the United States provide a rare opportunity for collective learning to improve resilience to future high-consequence infectious disease events. DESIGN: Key informant interviews (n = 73) were conducted between February and November 2016 with individuals who participated in Ebola virus disease planning or response in Atlanta, Georgia; Dallas, Texas; New York, New York; or Omaha, Nebraska; or had direct knowledge of response activities. Participants represented health care; local, state, and federal public health; law; local and state emergency management; academia; local and national media; individuals affected by the response; and local and state governments. Two focus groups were then conducted in New York and Dallas, and study results were vetted with an expert advisory group. RESULTS: Participants focused on a number of important areas to improve public health resilience to high-consequence infectious disease events, including governance and leadership, communication and public trust, quarantine and the law, monitoring programs, environmental decontamination, and waste management. CONCLUSIONS: Findings provided the basis for an evidence-informed checklist outlining specific actions for public health authorities to take to strengthen public health resilience to future high-consequence infectious disease events.

Capabilities of global high-level isolation units: A pre-workshop survey.

OBJECTIVE: To assess experience, physical infrastructure, and capabilities of high-level isolation units (HLIUs) planning to participate in a 2018 global HLIU workshop hosted by the US National Emerging Special Pathogens Training and Education Center (NETEC). DESIGN: An electronic survey elicited information on general HLIU organization, operating costs, staffing models, and infection control protocols of select global units. SETTING AND PARTICIPANTS: The survey was distributed to site representatives of 22 HLIUs located in the United States, Europe, and Asia; 19 (86%) responded. METHODS: Data were coded and analyzed using descriptive statistics. RESULTS: The mean annual reported budget for the 19 responding units was US$484,615. Most (89%) had treated a suspected or confirmed case of a high-consequence infectious disease. Reported composition of trained teams included a broad range of clinical and nonclinical roles. The mean number of HLIU beds was 6.37 (median, 4; range, 2-20) for adults and 4.23 (median, 2; range, 1-10) for children; however, capacity was dependent on pathogen. CONCLUSIONS: Responding HLIUs represent some of the most experienced HLIUs in the world. Variation in reported unit infrastructure, capabilities, and procedures demonstrate the variety of HLIU approaches. A number of technical questions unique to HLIUs remain unanswered related to physical design, infection prevention and control procedures, and staffing and training. These key areas represent potential focal points for future evidence and practice guidelines. These data are important considerations for hospitals considering the design and development of HLIUs, and there is a need for continued global HLIU collaboration to define best practices.

Public Health Implementation Considerations for State-Level Ebola Monitoring and Movement Restrictions.

OBJECTIVE: This article describes implementation considerations for Ebola-related monitoring and movement restriction policies in the United States during the 2013-2016 West Africa Ebola epidemic. METHODS: Semi-structured interviews were conducted between January and May 2017 with 30 individuals with direct knowledge of state-level Ebola policy development and implementation processes. Individuals represented 17 jurisdictions with variation in adherence to US Centers for Disease Control and Prevention (CDC) guidelines, census region, predominant state political affiliation, and public health governance structures, as well as the CDC. RESULTS: Interviewees reported substantial resource commitments required to implement Ebola monitoring and movement restriction policies. Movement restriction policies, including for quarantine, varied from voluntary to mandatory programs, and, occasionally, quarantine enforcement procedures lacked clarity. CONCLUSIONS: Efforts to improve future monitoring and movement restriction policies may include addressing surge capacity to implement these programs, protocols for providing support to affected individuals, coordination with law enforcement, and guidance on varying approaches to movement restrictions.

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

OBJECTIVE: 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. DESIGN: 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. SETTING: Frontline hospitals in the NYCH+H health system during and after the 2017-2018 influenza season. PARTICIPANTS: 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. MAIN OUTCOME MEASURES: Operational challenges and lessons from frontline hospitals responding to severe sea-sonal influenza. RESULTS: 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. CONCLUSION: 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.

Current State of Mass Vaccination Preparedness and Operational Challenges in the United States, 2018-2019.

Mass vaccination is a crucial public health intervention during outbreaks or pandemics for which vaccines are available. The US government has sponsored the development of medical countermeasures, including vaccines, for public health emergencies; however, federally supported programs, including the Public Health and Emergency Preparedness program and Cities Readiness Initiative, have historically emphasized antibiotic pill dispensing over mass vaccination. While mass vaccination and pill dispensing programs share similarities, they also have fundamental differences that require dedicated preparedness efforts to address. To date, only a limited number of public assessments of local mass vaccination operational capabilities have been conducted. To fill this gap, we interviewed 37 public health and preparedness officials representing 33 jurisdictions across the United States. We aimed to characterize their existing mass vaccination operational capacities and identify challenges and lessons learned in order to support the efforts of other jurisdictions to improve mass vaccination preparedness. We found that most jurisdictions were not capable of or had not planned for rapidly vaccinating their populations within a short period of time (eg, 1 to 2 weeks). Many also noted that their focus on pill dispensing was driven largely by federal funding requirements and that preparedness efforts for mass vaccination were often self-motivated. Barriers to implementing rapid mass vaccination operations included insufficient personnel qualified to administer vaccinations, increased patient load compared to pill-dispensing modalities, logistical challenges to maintaining cold chain, and operational challenges addressing high-risk populations, including children, pregnant women, and non-English-speaking populations. Considering the expected availability of a severe acute respiratory syndrome coronavirus 2 vaccine for distribution and dispensing to the public, our findings highlight critical considerations for planning possible future mass vaccination events, including during the novel coronavirus disease 2019 pandemic.

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

OBJECTIVE: 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. DESIGN: 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. SETTING: Frontline hospitals in the NYCH+H health system during and after the 2017-2018 influenza season. PARTICIPANTS: 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. MAIN OUTCOME MEASURES: Operational challenges and lessons from frontline hospitals responding to severe seasonal influenza. RESULTS: 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. CONCLUSION: 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.

Influencing Factors in the Development of State-Level Movement Restriction and Monitoring Policies in Response to Ebola, United States, 2014-15.

During the 2014-15 domestic Ebola response, US states developed monitoring and movement restriction policies for potentially exposed individuals. We describe decision-making processes and factors in the development of these policies. Results may help health officials anticipate potential concerns and policy influencers in future infectious disease responses. Thirty individuals with knowledge of state-level Ebola policy development participated in semi-structured interviews conducted from January to May 2017. Interviewees represented 18 jurisdictions from diverse census regions, state political affiliations, and public health governance structures as well as the US Centers for Disease Control and Prevention (CDC). Limited and/or changing guidance and unique state-level public health, legal, and operational environments resulted in variation in policy responses. Federal guidance developed by the CDC was an important information source influencing state-level policy responses, as was available scientific evidence; however, other external factors, such as local events, contributing experts, political environment, public concern, news media, and the influence of neighboring states, contributed to additional variation. Improvements in timing, consistency, and communication of federal guidance for monitoring and movement restrictions at the state level-along with balanced approaches to addressing ethical concerns, scientific evidence, and public concern at the state level-are considerations for policy development for future disease responses.

Clade X: A Pandemic Exercise.

Clade X was a day-long pandemic tabletop exercise conducted by the Johns Hopkins Center for Health Security on May 15, 2018, in Washington, DC. In this report, we briefly describe the exercise development process and focus principally on the findings and recommendations that arose from this project.

Recommendations on How to Manage Anticipated Communication Dilemmas Involving Medical Countermeasures in an Emergency.

National investments to facilitate prompt access to safe and effective medical countermeasures (MCMs) (ie, products used to diagnose, prevent, protect from, or treat conditions associated with chemical, biological, radiological, or nuclear threats, or emerging infectious diseases) have little merit if people are not willing to take a recommended MCM during an emergency or inadvertently misuse or miss out on a recommended MCM during an emergency. Informed by the Expert Working Group on MCM Emergency Communication, the Johns Hopkins Center for Health Security developed recommendations for achieving desired public health outcomes through improved MCM communication based on a review of model practices in risk communication, crisis communication, and public warnings; detailed analysis of recent health crises involving MCMs; and development of a scenario depicting future MCM communication dilemmas. The public's topics of concern, emotional requirements, capacity for processing information, and health needs will evolve as an emergency unfolds, from a pre-event period of routine conditions, to a crisis state, to a post-event period of reflection. Thus, MCM communication by public health authorities requires a phased approach that spans from building up a reputation as a trusted steward of MCMs between crises to developing recovery-focused messages about applying newly acquired data about MCM safety, efficacy, and accessibility to improve future situations.

Lessons from the domestic Ebola response: Improving health care system resilience to high consequence infectious diseases.

BACKGROUND: The domestic response to the West Africa Ebola virus disease (EVD) epidemic from 2014-2016 provides a unique opportunity to distill lessons learned about health sector planning and operations from those individuals directly involved. This research project aimed to identify and integrate these lessons into an actionable checklist that can improve health sector resilience to future high-consequence infectious disease (HCID) events. METHODS: Interviews (N = 73) were completed with individuals involved in the domestic EVD response in 4 cities (Atlanta, Dallas, New York, and Omaha), and included individuals who worked in academia, emergency management, government, health care, law, media, and public health during the response. Interviews were transcribed and analyzed qualitatively. Two focus groups were then conducted to expand on themes identified in the interviews. Using these themes, an evidence-informed checklist was developed and vetted for completeness and feasibility by an expert advisory group. RESULTS: Salient themes identified included health care facility issues-specifically identifying assessment and treatment hospitals, isolation and treatment unit layout, waste management, community relations, patient identification, patient isolation, limitations on treatment, laboratories, and research considerations-and health care workforce issues-specifically psychosocial impact, unit staffing, staff training, and proper personal protective equipment. CONCLUSIONS: The experiences of those involved in the domestic Ebola response provide critical lessons that can help strengthen resilience of health care systems and improve future responses to HCID events.

Enhancing the Diagnosis, Treatment, Surveillance, and Control of Infectious Diseases in the ACA Era.

As US public health faces increasing threats from outbreaks, impending changes to the healthcare landscape in the United States may alter the way that health departments are able to detect and control some of the most common infectious diseases. The Patient Protection and Affordable Care Act (ACA) has made significant changes in the way health care is provided in the United States. While many of the clinical, economic, and policy implications of the ACA are well described, there has been limited analysis of changes, if any, in the surveillance and control of infectious diseases of public health importance-such as tuberculosis, sexually transmitted infections, and HIV-that are anticipated or occurring as the ACA is implemented across the United States. To address these questions, we reviewed the literature for evidence of changing trends and conducted 66 semi-structured, not-for-attribution interviews with 82 participants from healthcare systems; academia; federal, state, and local public health agencies; and professional and nongovernmental organizations across the United States. This analysis identifies several ways in which ACA implementation has not fully addressed the public health needs associated with diagnosis, treatment, surveillance, and control of infectious diseases of public health importance.