Public Health System Response to Extreme Weather Events.

CONTEXT: Extreme weather events, unpredictable and often far-reaching, constitute a persistent challenge for public health preparedness. OBJECTIVE: The goal of this research is to inform public health systems improvement through examination of extreme weather events, comparing across cases to identify recurring patterns in event and response characteristics. DESIGN: Structured telephone-based interviews were conducted with representatives from health departments to assess characteristics of recent extreme weather events and agencies' responses. Response activities were assessed using the Centers for Disease Control and Prevention Public Health Emergency Preparedness Capabilities framework. Challenges that are typical of this response environment are reported. SETTING: Forty-five local health departments in 20 US states. RESULTS: Respondents described public health system responses to 45 events involving tornadoes, flooding, wildfires, winter weather, hurricanes, and other storms. Events of similar scale were infrequent for a majority (62%) of the communities involved; disruption to critical infrastructure was universal. Public Health Emergency Preparedness Capabilities considered most essential involved environmental health investigations, mass care and sheltering, surveillance and epidemiology, information sharing, and public information and warning. Unanticipated response activities or operational constraints were common. CONCLUSIONS: We characterize extreme weather events as a "quadruple threat" because (1) direct threats to population health are accompanied by damage to public health protective and community infrastructure, (2) event characteristics often impose novel and pervasive burdens on communities, (3) responses rely on critical infrastructures whose failure both creates new burdens and diminishes response capacity, and (4) their infrequency and scale further compromise response capacity. Given the challenges associated with extreme weather events, we suggest opportunities for organizational learning and preparedness improvements.

CGG-repeat length threshold for FMR1 RNA pathogenesis in a cellular model for FXTAS.

Fragile X-associated tremor/ataxia syndrome (FXTAS) is a neurodegenerative disorder that affects carriers of premutation alleles (55-200 CGG repeats) of the fragile X mental retardation 1 (FMR1) gene. The presence of elevated levels of expanded mRNA found in premutation carriers is believed to be the basis for the pathogenesis in FXTAS, but the exact mechanisms by which the mRNA causes toxicity are not known. In particular, it is not clear whether there is a threshold for a CGG-repeat number below which no cellular dysregulation occurs, or whether toxicity depends on mRNA concentration. We have developed a doxycycline-inducible episomal system that allows us to study separately the effects of CGG-repeat number and mRNA concentration (at fixed CGG-repeat length) in neuroblastoma-derived SK cells. Our findings show that there is a CGG-repeat size threshold for toxicity that lies between 62 and 95 CGG repeats. Interestingly, for repeat sizes of 95 CGG and above, there is a clear negative correlation between mRNA concentration and cell viability. Taken together, our results provide evidence for an RNA-toxicity model with primary dependence on CGG-repeat size and secondary dependence on mRNA concentration, thus formally ruling out any simple titration model that operates in the absence of either protein-binding cooperativity or some form of length-dependent RNA structural transition.

Fibroblast phenotype in male carriers of FMR1 premutation alleles.

Fragile X-associated tremor/ataxia syndrome (FXTAS) is an adult-onset neurodegenerative disorder among carriers of premutation expansions (55-200 CGG repeats) of the fragile X mental retardation 1 (FMR1) gene. The clinical features of FXTAS, as well as various forms of clinical involvement in carriers without FXTAS, are thought to arise through a direct toxic gain of function of high levels of FMR1 mRNA containing the expanded CGG repeat. Here we report a cellular endophenotype involving increased stress response (HSP27, HSP70 and CRYAB) and altered lamin A/C expression/organization in cultured skin fibroblasts from 11 male carriers of premutation alleles of the FMR1 gene, including six patients with FXTAS and five premutation carriers with no clinical evidence of FXTAS, compared with six controls. A similar abnormal cellular phenotype was found in CNS tissue from 10 patients with FXTAS. Finally, there is an analogous abnormal cellular distribution of lamin A/C isoforms in knock-in mice bearing the expanded CGG repeat in the murine Fmr1 gene. These alterations are evident even in mouse embryonic fibroblasts, raising the possibility that, in humans, the expanded-repeat mRNA triggers pathogenic mechanisms early in development, thus providing a molecular basis for the neurodevelopmental abnormalities observed in some children and clinical symptoms in some adults who are carriers of premutation FMR1 alleles. Cellular dysregulation in fibroblasts represents a novel and highly advantageous model for investigating disease pathogenesis in premutation carriers and for quantifying and monitoring disease progression. Fibroblast studies may also prove useful in screening and testing the efficacy of therapeutic interventions.

Integrating a framework for conducting public health systems research into statewide operations-based exercises to improve emergency preparedness.

BACKGROUND: Due to the uncommon nature of large-scale disasters and emergencies, public health practitioners often turn to simulated emergencies, known as "exercises", for preparedness assessment and improvement. Under the right conditions, exercises can also be used to conduct original public health systems research. This paper describes the integration of a research framework into a statewide operations-based exercise program in California as a systems-based approach for studying public health emergency preparedness and response. METHODS: We developed a research framework based on the premise that operations-based exercises conducted by medical and public health agencies can be described using epidemiologic concepts. Using this framework, we conducted a survey of key local and regional medical and health agencies throughout California following the 2010 Statewide Medical and Health Exercise. The survey evaluated: (1) the emergency preparedness capabilities activated and functions performed in response to the emergency scenario, and (2) the major challenges to inter-organizational communications and information management. RESULTS: Thirty-five local health departments (LHDs), 24 local emergency medical services (EMS) agencies, 121 hospitals, and 5 Regional Disaster Medical and Health Coordinators/Specialists (RDMHC) responded to our survey, representing 57%, 77%, 26% and 83%, respectively, of target agencies in California. We found two sets of response capabilities were activated during the 2010 Statewide Exercise: a set of core capabilities that were common across all agencies, and a set of agency-specific capabilities that were more common among certain agency types. With respect to one response capability in particular, inter-organizational information sharing, we found that the majority of respondents' comments were related to the complete or partial failure of communications equipment or systems. CONCLUSIONS: Using the 2010 Statewide Exercise in California as an opportunity to develop our research framework, we characterized several aspects of the public health and medical system's response to a standardized emergency scenario. From a research perspective, this study provides a potential new framework for conducting exercise-based research. From a practitioner's perspective, our results provide a starting point for preparedness professionals' dialogue about expected and actual organizational roles, responsibilities, and resource capacities within the public health system. Additionally, the identification of specific challenges to inter-organizational communications and information management offer specific areas for intervention.

Effect of mobile application user interface improvements on minimum expected home visit coverage by community health workers in Mali: a randomised controlled trial.

BACKGROUND: Proactive community case management (ProCCM) has shown promise to advance goals of universal health coverage (UHC). ProCCM community health workers (CHWs) face operational challenges when pursuing their goal of visiting every household in their service area at least twice monthly to proactively find sick patients. We developed a software extension (UHC Mode) to an existing CHW mobile application featuring user interface design improvements to support CHWs in planning daily home visits. We evaluated the effect of UHC Mode on minimum expected home visit coverage. METHODS: We conducted a parallel-group, two-arm randomised controlled trial of ProCCM CHWs in two separate regions in Mali. CHWs were randomly assigned to UHC Mode or the standard mobile application (control) with a 1:1 allocation. Randomisation was stratified by health catchment area. CHWs and other programme personnel were not masked to arm allocation. CHWs used their assigned intervention for 4 months. Using a difference-in-differences analysis, we estimated the mean change in minimum expected home visit coverage from preintervention to postintervention between arms. RESULTS: Enrolment occurred in January 2019. Of 199 eligible CHWs randomised to the intervention or control arm, 196 were enrolled and 195 were included in the analysis. Households whose CHW used UHC Mode had 2.41 times higher odds of minimum expected home visit coverage compared with households whose CHW used the control (95% CI 1.68 to 3.47; p<0.0005). Minimum expected home visit coverage in the UHC Mode arm increased 13.6 percentage points (95% CI 8.1 to 19.0) compared with the control arm. CONCLUSION: Our findings suggest UHC Mode is an effective tool that can improve home visit coverage and promote progress towards UHC when implemented in the ProCCM context. User interface design of health information systems that supports health workers' daily practices and meets their requirements can have a positive impact on health worker performance and home visit coverage. TRIAL REGISTRATION NUMBER: NCT04106921.

Public health response systems in-action: learning from local health departments' experiences with acute and emergency incidents.

As part of their core mission, public health agencies attend to a wide range of disease and health threats, including those that require routine, acute, and emergency responses. While each incident is unique, the number and type of response activities are finite; therefore, through comparative analysis, we can learn about commonalities in the response patterns that could improve predictions and expectations regarding the resources and capabilities required to respond to future acute events. In this study, we interviewed representatives from more than 120 local health departments regarding their recent experiences with real-world acute public health incidents, such as infectious disease outbreaks, severe weather events, chemical spills, and bioterrorism threats. We collected highly structured data on key aspects of the incident and the public health response, particularly focusing on the public health activities initiated and community partners engaged in the response efforts. As a result, we are able to make comparisons across event types, create response profiles, and identify functional and structural response patterns that have import for future public health preparedness and response. Our study contributes to clarifying the complexity of public health response systems and our analysis reveals the ways in which these systems are adaptive to the character of the threat, resulting in differential activation of functions and partners based on the type of incident. Continued and rigorous examination of the experiences of health departments throughout the nation will refine our very understanding of what the public health response system is, will enable the identification of organizational and event inputs to performance, and will allow for the construction of rich, relevant, and practical models of response operations that can be employed to strengthen public health systems.

Local Public Health System Response to the Tsunami Threat in Coastal California following the Tohoku Earthquake.

UNLABELLED: Background On Friday March 11, 2011 a 9.0 magnitude earthquake triggered a tsunami off the eastern coast of Japan, resulting in thousands of lives lost and billions of dollars in damage around the Pacific Rim. The tsunami first reached the California coast on Friday, March 11th, causing more than $70 million in damage and at least one death. While the tsunami's impact on California pales in comparison to the destruction caused in Japan and other areas of the Pacific, the event tested emergency responders' ability to rapidly communicate and coordinate a response to a potential threat. Methods To evaluate the local public health system emergency response to the tsunami threat in California, we surveyed all local public health, emergency medical services (EMS), and emergency management agencies in coastal or floodplain counties about several domains related to the tsunami threat in California, including: (1) the extent to which their community was affected by the tsunami, (2) when and how they received notification of the event, (3) which public health response activities were carried out to address the tsunami threat in their community, and (4) which organizations contributed to the response. Public health activities were characterized using the Centers for Disease Control and Prevention (CDC) Public Health Preparedness Capabilities (PHEP) framework. Findings The tsunami's impact on coastal communities in California ranged widely, both in terms of the economic consequences and the response activities. Based on estimates from the National Oceanic and Atmospheric Administration (NOAA), ten jurisdictions in California reported tsunami-related damage, which ranged from $15,000 to $35 million. Respondents first became aware of the tsunami threat in California between the hours of 10:00pm Pacific Standard Time (PST) on Thursday March 10th and 2:00pm PST on Friday March 11th, a range of 16 hours, with notification occurring through both formal and informal channels. In response to this threat, the activities most commonly reported by the local government agencies included in this study were: emergency public information and warning, emergency operations coordination, and inter-organizational information sharing, which were reported by 86%, 75%, and 65% of all respondents, respectively. When looking at the distribution of responsibility, emergency management agencies were the most likely to report assuming a lead role in these common activities as well as those related to evacuation and community recovery. While activated less frequently, public health agencies carried out emergency response functions related to surveillance and epidemiology, environmental health, and mental health/psychological support. Both local public health and EMS agencies took part in mass care and medical material management activities. A large network of organizations contributed to response activities, with emergency management, law enforcement, fire, public health, public works, EMS, and media cited by more than half of respondents. Conclusions In response to the tsunami threat in California, we found that emergency management agencies assumed a lead role in the local response efforts. While public health and medical agencies played a supporting role in the response, they uniquely contributed to a number of specific activities. If the response to the recent tsunami is any indication, these support activities can be anticipated in planning for future events with similar characteristics to the tsunami threat. Additionally, we found that many respondents first learned of the tsunami through the media, rather than through rapid notification systems, which suggests that government agencies must continue to develop and maintain the ability to rapidly aggregate and analyze information in order to provide accurate assessments and guidance to a potentially well-informed public. CITATION: Hunter JC, Crawley AW, Petrie M, Yang JE, Aragón TJ. Local Public Health System Response to the Tsunami Threat in Coastal California following the Tohoku Earthquake. PLoS Currents Disasters. 2012 Jul 16.