Rising to the Challenge: The Ebola Outbreak in Sierra Leone and How Insights Into One Nongovernmental Organization's Response Can Inform Future Core Competencies.

Nongovernmental organizations (NGOs) play a critical humanitarian role in the developing world. Over 100 NGOs currently operate in Sierra Leone, a country in West Africa that ranks 183 out of 187 in the United Nation's Human Development Index. Following a brutal 11-year war that ended in January 2002, the country has been unsuccessful at building a sufficiently resourced, robust, and anticipatory public health and medical care infrastructure. Consequently, Sierra Leone suffers from high levels of poverty, infant mortality, and limited access to safe drinking water, as well as morbidity from malnutrition, diarrheal diseases, hepatitis A, cholera, and typhoid fever. Large international NGOs such as Doctors Without Borders have attempted to fill the void left by fragile and fragmented government health services but have been overwhelmed and saturated by the continual spread of Ebola virus disease and growing numbers of cases and deaths. Smaller NGOs endeavored to assist during this crisis as well. One of them, Caritas, has actively sought public health knowledge and has applied public health principles to reduce and contain Ebola virus disease transmission. The Ebola outbreak illuminates the importance of building basic public health capabilities within the core competences of NGOs.

The changing face of crises and aid in the Asia-Pacific.

Both US foreign policy and global attention attest to the strategic, economic, and political importance of Asia. Yet, the region faces urgent challenges that must be addressed if it is to remain stable and prosperous. The densely populated countries of the Asia-Pacific are beleaguered by poverty, population displacement, decreasing access to potable water and adequate sanitation, and high rates of disease morbidity and mortality. New and reemerging diseases known to have originated in Asia over the past decades have spread globally by international trade, tourism, worker migration, and agricultural exportation. Unremitting naturally occurring and man-made disasters have strained Southeast Asia's already fragile disaster and public health response infrastructures and the essential services they provide (eg, surveillance, vaccination, maternal and child health, and mental health programs). Following disasters, governments often contract with the broader humanitarian community (eg, indigenous and international NGOs) and seek the assistance of militaries to provide essential services. Yet, their roles and capabilities in addressing acute and chronic health issues in the wake of complex disasters remain unclear. Current mechanisms of nation-state and outside organization interaction, including dissimilar operational platforms, may limit true partnership on behalf of the health security mission. Additionally, concerns regarding skill sets and the lack of standards-based training raise questions about the balance between developing internal response capabilities and professionalizing external, deployable resources. Both the mega-disasters that are forecast for the region and the global health security threats that are expected to emanate from them require an increased focus on improving the Asia-Pacific's emergency preparedness and response posture.

Pre-launch evaluation checklist for online health-promoting communities.

BACKGROUND: Despite the apparent potential of online health-promoting communities (OHPC), there is limited guidance available for developers on the basic design features that contribute to successful applications. The aim of this study was to develop a checklist for a pre-launch evaluation of OHPCs incorporating the perspectives of both the user and the health services communities. METHODS: The study was based on an action research design. Constructs previously applied to evaluate information system success were used as the basis for checklist development. The constructs were adapted for the OHPC context and formatively evaluated in a case study project. Evaluation data were collected from participatory observations and analyzed using qualitative methods. RESULTS: The initial OHPC checklist included the constructs information quality, service quality, and subjective norms. The contextual adaptation of the information quality construct resulted in items for content area, trust, and format; the adaptation of the service quality construct in items for staff competence, prompt service and empathy; and the adaptation of the subject norms construct in items for social facilitation, interconnectivity and communication. The formative evaluation demonstrated the critical need to balance the autonomy of the online community with the professional control of health services quality expressed in the information and service quality constructs. CONCLUSIONS: A pre-launch OHPC evaluation checklist has been designed for use in practical development of health promotion web resources. Research on instruments for OHPC evaluations is warranted.

Design of an online health-promoting community: negotiating user community needs with public health goals and service capabilities.

BACKGROUND: An online health-promoting community (OHPC) has the potential to promote health and advance new means of dialogue between public health representatives and the general public. The aim of this study was to examine what aspects of an OHPC that are critical for satisfying the needs of the user community and public health goals and service capabilities. METHODS: Community-based participatory research methods were used for data collection and analysis, and participatory design principles to develop a case study OHPC for adolescents. Qualitative data from adolescents on health appraisals and perspectives on health information were collected in a Swedish health service region and classified into categories of user health information exchange needs. A composite design rationale for the OHPC was completed by linking the identified user needs, user-derived requirements, and technical and organizational systems solutions. Conflicts between end-user requirements and organizational goals and resources were identified. RESULTS: The most prominent health information needs were associated to food, exercise, and well-being. The assessment of the design rationale document and prototype in light of the regional public health goals and service capabilities showed that compromises were needed to resolve conflicts involving the management of organizational resources and responsibilities. The users wanted to discuss health issues with health experts having little time to set aside to the OHPC and it was unclear who should set the norms for the online discussions. CONCLUSIONS: OHPCs can be designed to satisfy both the needs of user communities and public health goals and service capabilities. Compromises are needed to resolve conflicts between users' needs to discuss health issues with domain experts and the management of resources and responsibilities in public health organizations.

Assessing a decade of public health preparedness: progress on the precipice?

September 11 and the subsequent anthrax attacks marked the beginning of significant investment by the federal government to develop a national public health emergency response capability. Recognizing the importance of the public health sector's contribution to the burgeoning homeland security enterprise, this investment was intended to convey a "dual benefit" by strengthening the overall public health infrastructure while building preparedness capabilities. In many instances, federal funds were used successfully for preparedness activities. For example, electronic health information networks, a Strategic National Stockpile, and increased interagency cooperation have all contributed to creating a more robust and prepared enterprise. Additionally, the knowledge of rarely seen or forgotten pathogens has been regenerated through newly established public health learning consortia, which, too, have strengthened relationships between the practice and academic communities. Balancing traditional public health roles with new preparedness responsibilities heightened public health's visibility, but it also presented significant complexities, including expanded lines of reporting and unremitting inflows of new guidance documents. Currently, a rapidly diminishing public health infrastructure at the state and local levels as a result of federal budget cuts and a poor economy serve as significant barriers to sustaining these nascent federal public health preparedness efforts. Sustaining these improvements will require enhanced coordination, collaboration, and planning across the homeland security enterprise; an infusion of innovation and leadership; and sustained transformative investment for governmental public health.

Age as a determinant for dissemination of seasonal and pandemic influenza: an open cohort study of influenza outbreaks in Östergötland County, Sweden.

An understanding of the occurrence and comparative timing of influenza infections in different age groups is important for developing community response and disease control measures. This study uses data from a Scandinavian county (population 427.000) to investigate whether age was a determinant for being diagnosed with influenza 2005-2010 and to examine if age was associated with case timing during outbreaks. Aggregated demographic data were collected from Statistics Sweden, while influenza case data were collected from a county-wide electronic health record system. A logistic regression analysis was used to explore whether case risk was associated with age and outbreak. An analysis of variance was used to explore whether day for diagnosis was also associated to age and outbreak. The clinical case data were validated against case data from microbiological laboratories during one control year. The proportion of cases from the age groups 10-19 (p<0.001) and 20-29 years old (p<0.01) were found to be larger during the A pH1N1 outbreak in 2009 than during the seasonal outbreaks. An interaction between age and outbreak was observed (p<0.001) indicating a difference in age effects between circulating virus types; this interaction persisted for seasonal outbreaks only (p<0.001). The outbreaks also differed regarding when the age groups received their diagnosis (p<0.001). A post-hoc analysis showed a tendency for the young age groups, in particular the group 10-19 year olds, led outbreaks with influenza type A H1 circulating, while A H3N2 outbreaks displayed little variations in timing. The validation analysis showed a strong correlation (r = 0.625;p<0.001) between the recorded numbers of clinically and microbiologically defined influenza cases. Our findings demonstrate the complexity of age effects underlying the emergence of local influenza outbreaks. Disentangling these effects on the causal pathways will require an integrated information infrastructure for data collection and repeated studies of well-defined communities.

Swedish nursing and medical students' high vaccination adherence during the influenza A (H1N1) pandemic 2009: insights for pandemic preparedness.

The aim of this study was to analyze Swedish health science student decision-making regarding vaccination against pandemic influenza during a national mass vaccination campaign. A questionnaire was distributed to 430 students during the influenza A (H1N1) pandemic in 2009. The data from medical and nursing students were compared and a multiple logistic regression model was applied to identify items independently associated with the decision to be vaccinated. The overall survey response rate was 90%. More medical (93.2%) than nursing students (84.8%) reported that they had received the vaccine (p < 0.01). Only the perception that benefits can outweigh possible side effects was significantly (p < 0.001) associated with the decision to get vaccinated. We recommend that, during pandemics, health science universities focus vaccination information for students on objective risk communication. It should be taken into account that the pandemic information provided by authorities to the general public also affects health care students.

Requirements and design of the PROSPER protocol for implementation of information infrastructures supporting pandemic response: a Nominal Group study.

BACKGROUND: Advanced technical systems and analytic methods promise to provide policy makers with information to help them recognize the consequences of alternative courses of action during pandemics. Evaluations still show that response programs are insufficiently supported by information systems. This paper sets out to derive a protocol for implementation of integrated information infrastructures supporting regional and local pandemic response programs at the stage(s) when the outbreak no longer can be contained at its source. METHODS: Nominal group methods for reaching consensus on complex problems were used to transform requirements data obtained from international experts into an implementation protocol. The analysis was performed in a cyclical process in which the experts first individually provided input to working documents and then discussed them in conferences calls. Argument-based representation in design patterns was used to define the protocol at technical, system, and pandemic evidence levels. RESULTS: The Protocol for a Standardized information infrastructure for Pandemic and Emerging infectious disease Response (PROSPER) outlines the implementation of information infrastructure aligned with pandemic response programs. The protocol covers analyses of the community at risk, the response processes, and response impacts. For each of these, the protocol outlines the implementation of a supporting information infrastructure in hierarchical patterns ranging from technical components and system functions to pandemic evidence production. CONCLUSIONS: The PROSPER protocol provides guidelines for implementation of an information infrastructure for pandemic response programs both in settings where sophisticated health information systems already are used and in developing communities where there is limited access to financial and technical resources. The protocol is based on a generic health service model and its functions are adjusted for community-level analyses of outbreak detection and progress, and response program effectiveness. Scientifically grounded reporting principles need to be established for interpretation of information derived from outbreak detection algorithms and predictive modeling.

Population-based simulations of influenza pandemics: validity and significance for public health policy.

OBJECTIVE: To examine the validity and usefulness of pandemic simulations aimed at informing practical decision-making in public health. METHODS: We recruited a multidisciplinary group of nine experts to assess a case-study simulation of influenza transmission in a Swedish county. We used a non-statistical nominal group technique to generate evaluations of the plausibility, formal validity (verification) and predictive validity of the simulation. A health-effect assessment structure was used as a framework for data collection. FINDINGS: The unpredictability of social order during disasters was not adequately addressed by simulation methods; even minor disruptions of the social order may invalidate key infrastructural assumptions underpinning current pandemic simulation models. Further, a direct relationship between model flexibility and computation time was noted. Consequently, simulation methods cannot, in practice, support integrated modifications of microbiological, epidemiological and spatial submodels or handle multiple parallel scenarios. CONCLUSION: The combination of incomplete surveillance data and simulation methods that neglect social dynamics limits the ability of national public health agencies to provide policy-makers and the general public with the critical and timely information needed during a pandemic.

The case for transforming governmental public health.

Changing threats to the public's health necessitate a profound transformation of the public health enterprise. Despite recent attention to the biodefense role of public health, policymakers have not developed a clear, realistic vision for the structure and functionality of the governmental public health system. Lack of leadership and organizational disconnects across levels of government have prevented strategic alignment of resources and undermined momentum for meaningful change. A transformed public health system is needed to address the demands of emergency preparedness and health protection. Such transformation should include focused, risk-based resource allocation; regional planning; technological upgrades; workforce restructuring; improved integration of private-sector assets; and better performance monitoring.