Characteristics of Microbes Most Likely to Cause Pandemics and Global Catastrophes.

Predicting which pathogen will confer the highest global catastrophic biological risk (GCBR) of a pandemic is a difficult task. Many approaches are retrospective and premised on prior pandemics; however, such an approach may fail to appreciate novel threats that do not have exact historical precedent. In this paper, based on a study and project we undertook, a new paradigm for pandemic preparedness is presented. This paradigm seeks to root pandemic risk in actual attributes possessed by specific classes of microbial organisms and leads to specific recommendations to augment preparedness activities.

Clinical management of potential bioterrorism-related conditions.

The agents most likely to be used in bioterrorism attacks are reviewed, along with the clinical syndromes they produce and their treatment.

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.

Absorbing citywide patient surge during Hurricane Sandy: a case study in accommodating multiple hospital evacuations.

STUDY OBJECTIVE: Hospital evacuations have myriad effects on all elements of the health care system. We seek to (1) examine the effect of patient surge on hospitals that received patients from evacuating hospitals in New York City during Hurricane Sandy; (2) describe operational challenges those hospitals faced pre- and poststorm; and (3) examine the coordination efforts to distribute patients to receiving hospitals. METHODS: We used a qualitative, interview-based method to identify medical surge strategies used at hospitals receiving patients from evacuated health care facilities during and after Hurricane Sandy. We identified 4 hospital systems that received the majority of evacuated patients and those departments most involved in managing patient surge. We invited key staff at those hospitals to participate in on-site group interviews. RESULTS: We interviewed 71 key individuals. Although all hospitals had emergency preparedness plans in place before Hurricane Sandy, we identified gaps. Insights gleaned included improvement opportunities in these areas: prolonged increased patient volume, an increase in the number of methadone and dialysis patients, ability to absorb displaced staff, the challenges associated with nursing homes that have evacuated and shelters that have already reached capacity, and reimbursements for transferred patients. CONCLUSION: Our qualitative, event-based research identified key opportunities to improve disaster preparedness. The specific opportunities and this structured postevent approach can serve to guide future disaster planning and analyses.

Embedding Equity into the Hospital Incident Command System: A Narrative Review.

BACKGROUND: Disasters exacerbate health inequities, with historically marginalized populations experiencing unjust differences in health care access and outcomes. Health systems plan and respond to disasters using the Hospital Incident Command System (HICS), an organizational structure that centralizes communication and decision-making. The HICS does not have an equity role or considerations built into its standard structure. The authors conducted a narrative review to identify and summarize approaches to embedding equity into the HICS. METHODS: The peer-reviewed (PubMed, SCOPUS) and gray literature was searched for articles from high-income countries that referenced the HICS or Incident Command System (ICS) and equity, disparities, or populations that experience inequities in disasters. The primary focus of the search strategy was health care, but the research also included governmental and public health system articles. Two authors used inductive thematic analysis to assess commonalities and refined the themes based on feedback from all authors. RESULTS: The database search identified 479 unique abstracts; 76 articles underwent full-text review, and 11 were included in the final analysis. The authors found 5 articles through cited reference searching and 13 from the gray literature search, which included websites, organizations, and non-indexed journal articles. Three themes from the articles were identified: including equity specialists in the HICS, modifying systems to promote equity, and sensitivity to the local community. CONCLUSION: Several efforts to embed equity into the HICS and disaster preparedness and response were discovered. This review provides practical strategies health system leaders can include in their HICS and emergency preparedness plans to promote equity in their disaster response.

Assessment of serosurveys for H5N1.

BACKGROUND: It has been suggested that the true case-fatality rate of human H5N1 influenza infection is appreciably less than the figure of approximately 60% that is based on official World Health Organization (WHO)-confirmed case reports because asymptomatic cases may have been missed. A number of seroepidemiologic studies have been conducted in an attempt to identify such missed cases. METHODS: We conducted a comprehensive literature review of all English-language H5N1 human serology surveys with detailed attention to laboratory methodology used (including whether investigators used criteria set by the WHO to define positive cases), laboratory controls used, and the clades/genotypes involved. RESULTS: Twenty-nine studies were included in the analysis. Few reported using unexposed control groups and one-third did not apply WHO criteria. Of studies that used WHO criteria, only 4 found any seropositive results to clades/genotypes of H5N1 that are currently circulating. No studies reported seropositive results to the clade 2/genotype Z viruses that have spread throughout Eurasia and Africa. CONCLUSIONS: This review suggests that the frequency of positive H5 serology results is likely to be low; therefore, it is essential that future studies adhere to WHO criteria and include unexposed controls in their laboratory assays to limit the likelihood of false-positive results.

A Chief Health Security Officer for Every Academic Health Center: Improving Readiness, Response, Recovery, and Resilience.

Academic health centers (AHCs) require expertise to ensure readiness for health security events, such as cyberattacks, natural disasters, and pandemics, as well as the ability to respond to and recover from these events. However, most AHCs lack an individual to coordinate efforts at an enterprise level across academic and operational units during an emergency; elevate the coordination of individual AHCs with local and state public health entities; and through professional organizations, coordinate the work of AHCs across national and international public health entities. Informed by AHCs' responses to the COVID-19 pandemic and a series of focused meetings in 2021 of the Association of Academic Health Centers President's Council on Health Security, the authors propose creating a new C-suite role to meet these critical needs: the chief health security officer (CHSO). The CHSO would be responsible for the AHC's overall health security and would report to the AHC's chief executive officer or president. The authors describe the role of CHSO in relation to the preparation, response, and recovery phases of public health events necessary for health security. They also propose key duties for this position and encourage institutions to offer training and credentials to facilitate the creation and define the portfolios of CHSO positions at AHCs and beyond.

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.

Operational Recommendations for Scarce Resource Allocation in a Public Health Crisis.

The coronavirus disease 2019 pandemic may require rationing of various medical resources if demand exceeds supply. Theoretical frameworks for resource allocation have provided much needed ethical guidance, but hospitals still need to address objective practicalities and legal vetting to operationalize scarce resource allocation schemata. To develop operational scarce resource allocation processes for public health catastrophes, including the coronavirus disease 2019 pandemic, five health systems in Maryland formed a consortium-with diverse expertise and representation-representing more than half of all hospitals in the state. Our efforts built on a prior statewide community engagement process that determined the values and moral reference points of citizens and health-care professionals regarding the allocation of ventilators during a public health catastrophe. Through a partnership of health systems, we developed a scarce resource allocation framework informed by citizens' values and by general expert consensus. Allocation schema for mechanical ventilators, ICU resources, blood components, novel therapeutics, extracorporeal membrane oxygenation, and renal replacement therapies were developed. Creating operational algorithms for each resource posed unique challenges; each resource's varying nature and underlying data on benefit prevented any single algorithm from being universally applicable. The development of scarce resource allocation processes must be iterative, legally vetted, and tested. We offer our processes to assist other regions that may be faced with the challenge of rationing health-care resources during public health catastrophes.

Estimated Demand for US Hospital Inpatient and Intensive Care Unit Beds for Patients With COVID-19 Based on Comparisons With Wuhan and Guangzhou, China.

Importance: Sustained spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has happened in major US cities. Capacity needs in cities in China could inform the planning of local health care resources. Objectives: To describe and compare the intensive care unit (ICU) and inpatient bed needs for patients with coronavirus disease 2019 (COVID-19) in 2 cities in China to estimate the peak ICU bed needs in US cities if an outbreak equivalent to that in Wuhan occurs. Design, Setting, and Participants: This comparative effectiveness study analyzed the confirmed cases of COVID-19 in Wuhan and Guangzhou, China, from January 10 to February 29, 2020. Exposures: Timing of disease control measures relative to timing of SARS-CoV-2 community spread. Main Outcomes and Measures: Number of critical and severe patient-days and peak number of patients with critical and severe illness during the study period. Results: In Wuhan, strict disease control measures were implemented 6 weeks after sustained local transmission of SARS-CoV-2. Between January 10 and February 29, 2020, patients with COVID-19 accounted for a median (interquartile range) of 429 (25-1143) patients in the ICU and 1521 (111-7202) inpatients with serious illness each day. During the epidemic peak, 19 425 patients (24.5 per 10 000 adults) were hospitalized, 9689 (12.2 per 10 000 adults) were considered in serious condition, and 2087 (2.6 per 10 000 adults) needed critical care per day. In Guangzhou, strict disease control measures were implemented within 1 week of case importation. Between January 24 and February 29, COVID-19 accounted for a median (interquartile range) of 9 (7-12) patients in the ICU and 17 (15-26) inpatients with serious illness each day. During the epidemic peak, 15 patients were in critical condition and 38 were classified as having serious illness. The projected number of prevalent critically ill patients at the peak of a Wuhan-like outbreak in US cities was estimated to range from 2.2 to 4.4 per 10 000 adults, depending on differences in age distribution and comorbidity (ie, hypertension) prevalence. Conclusions and Relevance: Even after the lockdown of Wuhan on January 23, the number of patients with serious COVID-19 illness continued to rise, exceeding local hospitalization and ICU capacities for at least a month. Plans are urgently needed to mitigate the consequences of COVID-19 outbreaks on the local health care systems in US cities.

The demand for inpatient and ICU beds for COVID-19 in the US: lessons from Chinese cities.

Background: Sustained spread of SARS-CoV-2 has happened in major US cities. Capacity needs in Chinese cities could inform the planning of local healthcare resources. Methods: We described the intensive care unit (ICU) and inpatient bed needs for confirmed COVID-19 patients in two Chinese cities (Wuhan and Guangzhou) from January 10 to February 29, 2020, and compared the timing of disease control measures in relation to the timing of SARS-CoV-2 community spread. We estimated the peak ICU bed needs in US cities if a Wuhan-like outbreak occurs. Results: In Wuhan, strict disease control measures were implemented six weeks after sustained local transmission of SARS-CoV-2. Between January 10 and February 29, COVID-19 patients accounted for an average of 637 ICU patients and 3,454 serious inpatients on each day. During the epidemic peak, 19,425 patients (24.5 per 10,000 adults) were hospitalized, 9,689 (12.2 per 10,000 adults) were considered to be in serious condition, and 2,087 patients (2.6 per 10,000 adults) needed critical care per day. In Guangzhou, strict disease control measures were implemented within one week of case importation. Between January 24 and February 29, COVID-19 accounted for an average of 9 ICU patients and 20 inpatients on each day. During the epidemic peak, 15 patients were in critical condition, and 38 were classified as serious. If a Wuhan-like outbreak were to happen in a US city, the need for healthcare resources may be higher in cities with a higher prevalence of vulnerable populations. Conclusion: Even after the lockdown of Wuhan on January 23, the number of seriously ill COVID-19 patients continued to rise, exceeding local hospitalization and ICU capacities for at least a month. Plans are urgently needed to mitigate the effect of COVID-19 outbreaks on the local healthcare system in US cities.

A checklist to improve health system resilience to infectious disease outbreaks and natural hazards.

Recent infectious disease outbreaks, including the ongoing global COVID-19 pandemic and Ebola in the Democratic Republic of the Congo, have demonstrated the critical importance of resilient health systems in safeguarding global health security. Importantly, the human, economic and political tolls of these crises are being amplified by health systems' inabilities to respond quickly and effectively. Improving resilience within health systems can build on pre-existing strengths to enhance the readiness of health system actors to respond to crises, while also maintaining core functions. Using data gathered from a scoping literature review, interviews with key informants and from stakeholders who attended a workshop held in Dhaka, Bangladesh, we developed a Health System Resilience Checklist ('the checklist'). The aim of the checklist is to measure the specific capacities, capabilities and processes that health systems need in order to ensure resilience in the face of both infectious disease outbreaks and natural hazards. The checklist is intended to be adapted and used in a broad set of countries as a component of ongoing processes to ensure that health actors, institutions and populations can mount an effective response to infectious disease outbreaks and natural hazards while also maintaining core healthcare services. The checklist is an important first step in improving health system resilience to these threats, but additional research and resources will be necessary to further refine and prioritise the checklist items and to pilot the checklist with the frontline health facilities that would be using it. This will help ensure its feasibility and durability for the long-term within the health systems strengthening and health security fields.

Influence of Community and Culture in the Ethical Allocation of Scarce Medical Resources in a Pandemic Situation: Deliberative Democracy Study.

BACKGROUND: Stark gaps exist between projected health needs in a pandemic situation and the current capacity of health care and medical countermeasure systems. Existing pandemic ethics discussions have advocated to engage the public in scarcity dilemmas and attend the local contexts and cultural perspectives that shape responses to a global health threat. This public engagement study thus considers the role of community and culture in the ethical apportionment of scarce health resources, specifically ventilators, during an influenza pandemic. It builds upon a previous exploration of the values and preferences of Maryland residents regarding how a finite supply of mechanical ventilators ought to be allocated during a severe global outbreak of influenza. An important finding of this earlier research was that local history and place within the state engendered different ways of thinking about scarcity. OBJECTIVE: Given the intrastate variation in the themes expressed by Maryland participants, the project team sought to examine interstate differences by implementing the same protocol elsewhere to answer the following questions. Does variation in ethical frames of reference exist within different regions of the United States? What practical implications does evidence of sameness and difference possess for pandemic planners and policymakers at local and national levels? METHODS: Research using the same deliberative democracy process from the Maryland study was conducted in Central Texas in March 2018 among 30 diverse participants, half of whom identified as Hispanic or Latino. Deliberative democracy provides a moderated process through which community members can learn facts about a public policy matter from experts and explore their own and others' views. RESULTS: Participants proposed that by evenly distributing supplies of ventilators and applying clear eligibility criteria consistently, health authorities could enable fair allocation of scarce lifesaving equipment. The strong identification, attachment, and obligation of persons toward their nuclear and extended families emerged as a distinctive regional and ethnic core value that has practical implications for the substance, administration, and communication of allocation frameworks. CONCLUSIONS: Maryland and Central Texas residents expressed a common, overriding concern about the fairness of allocation decisions. Central Texas deliberants, however, more readily expounded upon family as a central consideration. In Central Texas, family is a principal, culturally inflected lens through which life and death matters are often viewed. Conveners of other pandemic-related public engagement exercises in the United States have advocated the benefits of transparency and inclusivity in developing an ethical allocation framework; this study demonstrates cultural competence as a further advantage.

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.

Too Many Patients A Framework to Guide Statewide Allocation of Scarce Mechanical Ventilation During Disasters.

The threat of a catastrophic public health emergency causing life-threatening illness or injury on a massive scale has prompted extensive federal, state, and local preparedness efforts. Modeling studies suggest that an influenza pandemic similar to that of 1918 would require ICU and mechanical ventilation capacity that is significantly greater than what is available. Several groups have published recommendations for allocating life-support measures during a public health emergency. Because there are multiple ethically permissible approaches to allocating scarce life-sustaining resources and because the public will bear the consequences of these decisions, knowledge of public perspectives and moral points of reference on these issues is critical. Here we describe a critical care disaster resource allocation framework developed following a statewide community engagement process in Maryland. It is intended to assist hospitals and public health agencies in their independent and coordinated response to an officially declared catastrophic health emergency in which demand for mechanical ventilators exceeds the capabilities of all surge response efforts and in which there has been an executive order to implement scarce resource allocation procedures. The framework, built on a basic scoring system with modifications for specific considerations, also creates an opportunity for the legal community to review existing laws and liability protections in light of a specific disaster response process.

Panalysis: a new spreadsheet-based tool for pandemic planning.

Publicly available influenza modeling tools are of limited use to hospitals and local communities in planning for a severe pandemic. We developed Panalysis, a new tool to estimate the likely healthcare consequences of a pandemic and to aid hospitals in the development of mitigation and response strategies. By way of example, we demonstrate how Panalysis can be used to plan for a 1918-like flu pandemic. We discuss potential future applications of this tool.