Identifying determinants of under-five child mortality in northern Togo.

Background: Although global rates of under-five mortality have declined, many low- and middle-income countries (LMICs), including Togo, have not achieved sufficient progress. We aimed to identify the structural and intermediary determinants associated with under-five mortality in northern Togo. Methods: We collected population-representative cross-sectional household surveys adapted from the Demographic Household Survey (DHS) and Multiple Indicator Cluster Survey from women of reproductive age in northern Togo in 2018. The primary outcome was under-five mortality for children born to respondents in the 10-year period prior to the survey. We selected structural and intermediary determinants of health from the World Health Organization Conceptual Framework for Action on the Social Determinants of Health. We estimated associations between determinants and under-five mortality for births in the last 10 years (model 1 and 2) and two years (model 3) using Cox proportional hazards models. Results: Of the 20 121 live births in the last 10 years, 982 (4.80%) children died prior to five years of age. Prior death of a sibling (adjusted hazard ratio (aHR) = 5.02; 95% confidence interval (CI) = 4.23-5.97), maternal ethnicity (i.e. Konkomba, Temberma, Lamba, Losso, or Peul), multiple birth status (aHR = 2.27; 95% CI = 1.78-2.90), maternal age under 25 years (women <19 years: aHR = 2.05; 95% CI = 1.75-2.39; women 20-24 years: aHR = 1.48; 95% CI = 1.29-1.68), lower birth interval (aHR = 1.51; 95% CI = 1.31-1.74), and higher birth order (second or third born: aHR = 1.45; 95% CI = 1.32-1.60; third or later born: aHR = 2.14; 95% CI = 1.74-2.63) were associated with higher hazard of under-five mortality. Female children had lower hazards of under-five mortality (aHR = 0.80; 95% CI = 0.73-0.89). Under-five mortality was also lower for children born in the last two years (n = 4852) whose mothers received any (aHR = 0.48; 95% CI = 0.30-0.78) or high quality (aHR = 0.51; 95% CI = 0.29-0.88) prenatal care. Conclusion: Compared to previous DHS estimates, under-five mortality has decreased in Togo, but remains higher than other LMICs. Prior death of a sibling and several intermediary determinants were associated with a higher risk of mortality, while receipt of prenatal care reduced that risk. These findings have significant implications on reducing disparities related to mortality through strengthening maternal and child health care delivery.

Financial Assistance for Health Security: Effects of International Financial Assistance on Capacities for Preventing, Detecting, and Responding to Public Health Emergencies.

BACKGROUND: Health security funding is intended to improve capacities for preventing, detecting, and responding to public health emergencies. Recent years have witnessed substantial increases in the amounts of donor financial assistance to health security from countries, philanthropies, and other development partners. To date, no work has examined the effects of assistance on health security capacity development over time. This paper presents an analysis of the time-lagged effects of assistance for health security (AHS) on levels of capacity. METHODS: We collected publicly available health security assessment scores published between 2010 and 2019 and data relating to financial AHS. Using validated methods, we rescaled assessment scores on analogous scales to enable comparison and binned them in quartiles. We then used a distributed lag model (DLM) in a Bayesian ordinal regression framework to assess the effects of AHS on capacity development over time. RESULTS: Strong evidence exists for associations between financial assistance and select capacities on a variety of lagged time intervals. Financial assistance had positive effects on zoonotic disease capacities in the year it was disbursed, and positive effects on legislation, laboratory, workforce, and risk communication capacities one year after disbursal. Financial assistance had negative effects on laboratory and emergency response capacities two years after it was disbursed. Financial assistance did not have measurable effects on coordination, antimicrobial resistance (AMR), food safety, biosafety, surveillance, or response preparedness capacities over the timeframe considered. CONCLUSION: Financial AHS is associated with positive effects for several core health security capacities. However, for the majority of capacities, levels of funding were not significantly associated with capacity level, though we cannot fully exclude endogeneity. Future work should continue to investigate these relationships in different contexts and examine other factors that may contribute to capacity development.

Socioeconomic Disparities in Social Distancing During the COVID-19 Pandemic in the United States: Observational Study.

BACKGROUND: Eliminating disparities in the burden of COVID-19 requires equitable access to control measures across socio-economic groups. Limited research on socio-economic differences in mobility hampers our ability to understand whether inequalities in social distancing are occurring during the SARS-CoV-2 pandemic. OBJECTIVE: We aimed to assess how mobility patterns have varied across the United States during the COVID-19 pandemic and to identify associations with socioeconomic factors of populations. METHODS: We used anonymized mobility data from tens of millions of devices to measure the speed and depth of social distancing at the county level in the United States between February and May 2020, the period during which social distancing was widespread in this country. Using linear mixed models, we assessed the associations between social distancing and socioeconomic variables, including the proportion of people in the population below the poverty level, the proportion of Black people, the proportion of essential workers, and the population density. RESULTS: We found that the speed, depth, and duration of social distancing in the United States are heterogeneous. We particularly show that social distancing is slower and less intense in counties with higher proportions of people below the poverty level and essential workers; in contrast, we show that social distancing is intensely adopted in counties with higher population densities and larger Black populations. CONCLUSIONS: Socioeconomic inequalities appear to be associated with the levels of adoption of social distancing, potentially resulting in wide-ranging differences in the impact of the COVID-19 pandemic in communities across the United States. These inequalities are likely to amplify existing health disparities and must be addressed to ensure the success of ongoing pandemic mitigation efforts.

Socio-economic disparities in social distancing during the COVID-19 pandemic in the United States.

Importance: Eliminating disparities in the burden of COVID-19 requires equitable access to control measures across socio-economic groups. Limited research on socio-economic differences in mobility hampers our ability to understand whether inequalities in social distancing are occurring during the SARS-CoV-2 pandemic. Objective: To assess how mobility patterns have varied across the United States during the COVID-19 pandemic, and identify associations with socio-economic factors of populations. Design Setting and Participants: We used anonymized mobility data from tens of millions of devices to measure the speed and depth of social distancing at the county level between February and May 2020. Using linear mixed models, we assessed the associations between social distancing and socio-economic variables, including the proportion of people below the poverty level, the proportion of Black people, the proportion of essential workers, and the population density. Main outcomes and Results: We find that the speed, depth, and duration of social distancing in the United States is heterogeneous. We particularly show that social distancing is slower and less intense in counties with higher proportions of people below the poverty level and essential workers; and in contrast, that social distancing is intense in counties with higher population densities and larger Black populations. Conclusions and relevance: Socio-economic inequalities appear to be associated with the levels of adoption of social distancing, potentially resulting in wide-ranging differences in the impact of COVID-19 in communities across the United States. This is likely to amplify existing health disparities, and needs to be addressed to ensure the success of ongoing pandemic mitigation efforts.

Risk factors associated with failing pre-transmission assessment surveys (pre-TAS) in lymphatic filariasis elimination programs: Results of a multi-country analysis.

Achieving elimination of lymphatic filariasis (LF) as a public health problem requires a minimum of five effective rounds of mass drug administration (MDA) and demonstrating low prevalence in subsequent assessments. The first assessments recommended by the World Health Organization (WHO) are sentinel and spot-check sites-referred to as pre-transmission assessment surveys (pre-TAS)-in each implementation unit after MDA. If pre-TAS shows that prevalence in each site has been lowered to less than 1% microfilaremia or less than 2% antigenemia, the implementation unit conducts a TAS to determine whether MDA can be stopped. Failure to pass pre-TAS means that further rounds of MDA are required. This study aims to understand factors influencing pre-TAS results using existing programmatic data from 554 implementation units, of which 74 (13%) failed, in 13 countries. Secondary data analysis was completed using existing data from Bangladesh, Benin, Burkina Faso, Cameroon, Ghana, Haiti, Indonesia, Mali, Nepal, Niger, Sierra Leone, Tanzania, and Uganda. Additional covariate data were obtained from spatial raster data sets. Bivariate analysis and multilinear regression were performed to establish potential relationships between variables and the pre-TAS result. Higher baseline prevalence and lower elevation were significant in the regression model. Variables statistically significantly associated with failure (p-value ≤0.05) in the bivariate analyses included baseline prevalence at or above 5% or 10%, use of Filariasis Test Strips (FTS), primary vector of Culex, treatment with diethylcarbamazine-albendazole, higher elevation, higher population density, higher enhanced vegetation index (EVI), higher annual rainfall, and 6 or more rounds of MDA. This paper reports for the first time factors associated with pre-TAS results from a multi-country analysis. This information can help countries more effectively forecast program activities, such as the potential need for more rounds of MDA, and prioritize resources to ensure adequate coverage of all persons in areas at highest risk of failing pre-TAS.

Female sex and cardiovascular disease risk in rural Uganda: a cross-sectional, population-based study.

BACKGROUND: Sex-based differences in cardiovascular disease (CVD) burden are widely acknowledged, with male sex considered a risk factor in high-income settings. However, these relationships have not been examined in sub-Saharan Africa (SSA). We aimed to apply the American Heart Association (AHA) ideal cardiovascular health (CVH) tool modified by the addition of C-reactive protein (CRP) to examine potential sex-based differences in the prevalence of CVD risk in rural Uganda. METHODS: In a cross-sectional study nested within a population-wide census, 857 community-living adults completed physical and laboratory-based assessments to calculate individual ideal CVH metrics including an eight category for CRP levels. We summarized sex-specific ideal CVH indices, fitting ordinal logistic regression models to identify correlates of improving CVH. As secondary outcomes, we assessed subscales of ideal CVH behaviours and factors. Models included inverse probability of sampling weights to determine population-level estimates. RESULTS: The weighted-population mean age was 39.2 (1.2) years with 52.0 (3.7) % females. Women had ideal scores in smoking (80.4% vs. 68.0%; p < 0.001) and dietary intake (26.7% vs. 16.8%; p = 0.037) versus men, but the opposite in body mass index (47.3% vs. 84.4%; p < 0.001), glycated hemoglobin (87.4% vs. 95.2%; p = 0.001), total cholesterol (80.2% vs. 85.0%; p = 0.039) and CRP (30.8% vs. 49.7%; p = 0.009). Overall, significantly more men than women were classified as having optimal cardiovascular health (6-8 metrics attaining ideal level) (39.7% vs. 29.0%; p = 0.025). In adjusted models, female sex was correlated with lower CVH health factors sub-scales but higher ideal CVH behaviors. CONCLUSIONS: Contrary to findings in much of the world, female sex in rural SSA is associated with worse ideal CVH profiles, despite women having better indices for ideal CVH behaviors. Future work should assess the potential role of socio-behavioural sex-specific risk factors for ideal CVH in SSA, and better define the downstream consequences of these differences.

Gender equity in mass drug administration for neglected tropical diseases: data from 16 countries.

BACKGROUND: Gender equity in global health is a target of the Sustainable Development Goals and a requirement of just societies. Substantial progress has been made towards control and elimination of neglected tropical diseases (NTDs) via mass drug administration (MDA). However, little is known about whether MDA coverage is equitable. This study assesses the availability of gender-disaggregated data and whether systematic gender differences in MDA coverage exist. METHODS: Coverage data were analyzed for 4784 district-years in 16 countries from 2012 through 2016. The percentage of districts reporting gender-disaggregated data was calculated and male-female coverage compared. RESULTS: Reporting of gender-disaggregated coverage data improved from 32% of districts in 2012 to 90% in 2016. In 2016, median female coverage was 85.5% compared with 79.3% for males. Female coverage was higher than male coverage for all diseases. However, within-country differences exist, with 64 (3.3%) districts reporting male coverage >10 percentage points higher than female coverage. CONCLUSIONS: Reporting of gender-disaggregated data is feasible. And NTD programs consistently achieve at least equal levels of coverage for women. Understanding gendered barriers to MDA for men and women remains a priority.

Analysis of results from the Joint External Evaluation: examining its strength and assessing for trends among participating countries.

BACKGROUND: The Joint External Evaluation (JEE) is part of the World Health Organization's (WHO) new process to help countries assess their ability to prevent, detect and respond to public health threats such as infectious disease outbreaks, as specified by the International Health Regulations (IHR). How countries are faring on these evaluations is not well known and neither is there any previous assessment of the performance characteristics of the JEE process itself. METHODS: We obtained JEE data for 48 indicators collectively across 19 technical areas of preparedness for 55 countries. The indicators are scored on a 1 to 5 scale with 4 indicating demonstrated capacity. We created a standardized JEE index score representing cumulative performance across indicators using principal components analysis. We examined the state of performance across all indicators and then examined the relationship between this index score and select demographic and health variables to better understand potential drivers of performance. RESULTS: Among our study cohort, the median performance on 43 of the 48 (89.6%) indicators was less than 4, suggesting that countries were failing to meet demonstrated capacity on these measures. The two weakest indicators were related to antimicrobial resistance (median score = 1.0, interquartile range = 1.0-2.0) and biosecurity response (median score = 2.0, interquartile range = 2.0-3.0). JEE index scores correlated with various metrics of health outcomes (life expectancy, under-five year mortality rate, disability-adjusted life years lost to communicable diseases) and with standard measures of social and economic development that enable public health system performance in the total sample, but in stratified analyses, these relationships were much weaker in the AFRO region. CONCLUSIONS: We find large variations in JEE scores among countries and WHO regions with many nations still unprepared for the next disease outbreak with pandemic potential The strong correlations between JEE performance and metrics of both health outcomes and health systems' performance suggests that the JEE is likely accurately measuring the strength of IHR-specific, public health capabilities.

Relative household wealth and non-fatal road crashes: analysis of population-representative data of Kenyan adults.

Background: This study aims to examine potential road crash disparities across relative wealth and location of residence in Kenya by analyzing population-representative Demographic and Health Survey data. Methods: Relative wealth was measured by household assets, converted into an index by polychoric principal components analysis. Location and sex-stratified associations between wealth quantiles and crashes were flexibly estimated using fractional polynomial models. Structural equation models were fit to examine whether observed differences may operate through previously identified determinants. Results: In rural areas, crashes were least common for both the poorest men (-5.2 percentage points, 95% CI: -7.3 to -3.2) and women (-1.6 percentage points, 95% CI: -2.9 to -0.4). In urban areas, male crashes were lowest (-3.0 percentage points, 95% CI: -5.2 to -0.8) among the wealthiest, while they peaked in the middle of the female wealth distribution (2.0 percentage points, 95% CI: 0.3-3.8). Male differences operate partially though occupational driving and vehicle ownership. Urban female differences operate partially through household vehicle ownership, but differences for rural women were not explained by modeled determinants. Conclusions: Relative wealth and road crash have opposite associations in rural and urban areas. Especially in rural areas, it is important to mitigate potential unintended effects of economic development.

Bicycle helmet laws and persistent racial and ethnic helmet use disparities among urban high school students: a repeated cross-sectional analysis.

BACKGROUND: Bicycle helmet laws generally increase helmet usage, but few studies assess whether helmet laws reduce disparities. The objective of this study is to assess changes in racial/ethnic disparities in helmet use among high school students in urban jurisdictions where laws were previously determined to increase overall helmet use. METHODS: Log-binomial models were fit to four districts' 1991-2013 Youth Risk Behavior Survey (YRBS) data. Post-regression predictive margins were used to calculate adjusted bicycle helmet use proportions, assess before-to-after changes in race/ethnicity specific helmet use, and estimate changes in disparities from jurisdictions' white subpopulations. RESULTS: Helmet use among white students increased by 10.2 percentage points in two Florida counties (p < 0.001), 20.1 points in Dallas (p < 0.001), and 24.4 points in San Diego (p < 0.001). Increases among African Americans were 6.1 percentage points in the Florida counties (p < 0.001), 8.2 points in Dallas (p < 0.001), and 6.3 points in San Diego (p = 0.070). Use increased among Latino students in the Florida counties (4.3 percentage points, p = 0.016) and Dallas (6.2, p = 0.002), but not significantly in San Diego. San Diego helmet use among Asian students increased by 12.8 percentage points (p < 0.001). Because helmet use increased more for white students, helmet laws were associated with increased disparities. In the Florida counties, disparities increased significantly by 5.9 percentage points for Latino students (p = 0.045). San Diego disparities worsened by 18.1 (p < 0.001), 21.3 (p < 0.001), and 11.6 (p = 0.013) percentage points among African American, Latino, and Asian students respectively. Dallas disparities increased by 11.9 (p = 0.015) and 14.0 (p = 0.003) percentage points among African American and Latino students. Increased disparities generally persisted for follow-up time of at least a decade. Main study limitations include the possibility of helmet use reporting error and limited socioeconomic variables in YRBS datasets. CONCLUSIONS: Helmet use increased across racial/ethnic subpopulations, but greater increases among white students increased disparities. Policymakers should couple laws with other approaches to reduce helmet disparities and cycling injuries.

Charting health system reconstruction in post-war Liberia: a comparison of rural vs. remote healthcare utilization.

BACKGROUND: Despite a growing global emphasis on universal healthcare, access to basic primary care for remote populations in post-conflict countries remains a challenge. To better understand health sector recovery in post-conflict Liberia, this paper seeks to evaluate changes in utilization of health services among rural populations across a 5-year time span. METHODS: We assessed trends in healthcare utilization among the national rural population using the Liberian Demographic and Health Survey (DHS) from 2007 and 2013. We compared these results to results obtained from a two-staged cluster survey in 2012 in the district of Konobo, Liberia, to assess for differential health utilization in an isolated, remote region. Our primary outcomes of interest were maternal and child health service care seeking and utilization. RESULTS: Most child and maternal health indicators improved in the DHS rural sub-sample from 2007 to 2013. However, this progress was not reflected in the remote Konobo population. A lower proportion of women received 4+ antenatal care visits (AOR 0.28, P < 0.001) or any postnatal care (AOR 0.25, P <0.001) in Konobo as compared to the 2013 DHS. Similarly, a lower proportion of children received professional care for common childhood illnesses, including acute respiratory infection (9 % vs. 52 %, P < 0.001) or diarrhea (11 % vs. 46 %, P < 0.001). CONCLUSIONS: Our data suggest that, despite the demonstrable success of post-war rehabilitation in rural regions, particularly remote populations in Liberia remain at disproportionate risk for limited access to basic health services. As a renewed effort is placed on health systems reconstruction in the wake of the Ebola-epidemic, a specific focus on solutions to reach isolated populations will be necessary in order to ensure extension of coverage to remote regions such as Konobo.

Helmet Laws, Helmet Use, and Bicycle Ridership.

PURPOSE: To assess bicycle helmet laws' effect on helmet and bicycle use among U.S. high school students in urban jurisdictions. METHODS: Log-binomial models were fit to Youth Risk Behavior Survey data from five jurisdictions. Adjusted helmet and bicycle use proportions were calculated with post-regression marginal effects. Difference-in-differences were estimated, comparing intervention to concurrent controls. A placebo outcome was used to falsify possible confounding or selection effects. RESULTS: In San Diego and Dallas, helmet use increase increased 10.6 (95% confidence interval [CI] 6.5 to 14.7, p < .001) and 8.1 (95% CI 4.3 to 12.0, p < .001) percentage points more than out-of-jurisdiction controls. Increases in Florida counties were 5.0 (95% CI 1.8 to 8.2, p = .003) and 4.0 (95% CI -.7 to 8.8, p = .098) points against age-based and out-of-jurisdiction controls, respectively. Bicycle use fell 5.5 points in both San Diego (95% CI -9.8 to -1.1, p = .015) and the Florida counties (95% CI -11.5 to .5, p = .075) against out-of-jurisdiction controls, but other comparisons had no significant changes. The placebo outcome never changed significantly. CONCLUSIONS: Laws increased helmet use in all jurisdictions, with limited evidence of reduced cycling. Although sound health policy, laws should be coupled with physical activity promotion.

Mind the Scales: Harnessing Spatial Big Data for Infectious Disease Surveillance and Inference.

Spatial big data have the velocity, volume, and variety of big data sources and contain additional geographic information. Digital data sources, such as medical claims, mobile phone call data records, and geographically tagged tweets, have entered infectious diseases epidemiology as novel sources of data to complement traditional infectious disease surveillance. In this work, we provide examples of how spatial big data have been used thus far in epidemiological analyses and describe opportunities for these sources to improve disease-mitigation strategies and public health coordination. In addition, we consider the technical, practical, and ethical challenges with the use of spatial big data in infectious disease surveillance and inference. Finally, we discuss the implications of the rising use of spatial big data in epidemiology to health risk communication, and public health policy recommendations and coordination across scales.

Disparities in road crash mortality among pedestrians using wheelchairs in the USA: results of a capture-recapture analysis.

OBJECTIVE: This study aims to quantify and describe the burden of fatal pedestrian crashes among persons using wheelchairs in the USA from 2006 to 2012. DESIGN: The occurrence of fatal pedestrian crashes among pedestrians using wheelchairs was assessed using two-source capture-recapture. Descriptive analysis of fatal crashes was conducted using customary approaches. SETTING: Two registries were constructed, both of which likely undercounted fatalities among pedestrians who use wheelchairs. The first used data from the Fatality Analysis Reporting System, and the second used a LexisNexis news search. OUTCOME MEASURES: Mortality rate (per 100 000 person-years) and crash-level, driver-level and pedestrian-level characteristics of fatal crashes. RESULTS: This study found that, from 2006 to 2012, the mortality rate for pedestrians using wheelchairs was 2.07/100 000 person-years (95% CI 1.60 to 2.54), which was 36% higher than the overall population pedestrian mortality rate (p=0.02). Men's risk was over fivefold higher than women's risk (p<0.001). Compared to the overall population, persons aged 50-64 using wheelchairs had a 38% increased risk (p=0.04), and men who use wheelchairs aged 50-64 had a 75% increased risk over men of the same age in the overall population (p=0.006). Almost half (47.6%; 95% CI 42.8 to 52.5) of fatal crashes occurred in intersections and 38.7% (95% CI 32.0 to 45.0) of intersection crashes occurred at locations without traffic control devices. Among intersection crashes, 47.5% (95% CI 40.6 to 54.5) involved wheelchair users in a crosswalk; no crosswalk was available for 18.3% (95% CI 13.5 to 24.4). Driver failure to yield right-of-way was noted in 21.4% (95% CI 17.7 to 25.7) of crashes, and no crash avoidance manoeuvers were detected in 76.4% (95% CI 71.0 to 81.2). CONCLUSIONS: Persons who use wheelchairs experience substantial pedestrian mortality disparities calling for behavioural and built environment interventions.

Analyzing Variability in Ebola-Related Controls Applied to Returned Travelers in the United States.

Public health authorities have adopted entry screening and subsequent restrictions on travelers from Ebola-affected West African countries as a strategy to prevent importation of Ebola virus disease (EVD) cases. We analyzed international, federal, and state policies-principally based on the policy documents themselves and media reports-to evaluate policy variability. We employed means-ends fit analysis to elucidate policy objectives. We found substantial variation in the specific approaches favored by WHO, CDC, and various American states. Several US states impose compulsory quarantine on a broader range of travelers or require more extensive monitoring than recommended by CDC or WHO. Observed differences likely partially resulted from different actors having different policy goals-particularly the federal government having to balance foreign policy objectives less salient to states. Further, some state-level variation appears to be motivated by short-term political goals. We propose recommendations to improve future policies, which include the following: (1) actors should explicitly clarify their objectives, (2) legal authority should be modernized and clarified, and (3) the federal government should consider preempting state approaches that imperil its goals.

Remoteness and maternal and child health service utilization in rural Liberia: A population-based survey.

BACKGROUND: This study seeks to understand distance from health facilities as a barrier to maternal and child health service uptake within a rural Liberian population. Better understanding the relationship between distance from health facilities and rural health care utilization is important for post-Ebola health systems reconstruction and for general rural health system planning in sub-Saharan Africa. METHODS: Cluster-sample survey data collected in 2012 in a very rural southeastern Liberian population were analyzed to determine associations between quartiles of GPS-measured distance from the nearest health facility and the odds of maternal (ANC, facility-based delivery, and PNC) and child (deworming and care seeking for ARI, diarrhea, and fever) service use. We estimated associations by fitting simple and multiple logistic regression models, with standard errors adjusted for clustered data. FINDINGS: Living in the farthest quartile was associated with lower odds of attending 1-or-more ANC checkup (AOR = 0.04, P < 0.001), 4-or-more ANC checkups (AOR = 0.13, P < 0.001), delivering in a facility (AOR = 0.41, P = 0.006), and postnatal care from a health care worker (AOR = 0.44, P = 0.009). Children living in all other quartiles had lower odds of seeking facility-based fever care (AOR for fourth quartile = 0.06, P < 0.001) than those in the nearest quartile. Children in the fourth quartile were less likely to receive deworming treatment (AOR = 0.16, P < 0.001) and less likely (but with only marginal statistical significance) to seek ARI care from a formal HCW (AOR = 0.05, P = 0.05). Parents in distant quartiles more often sought ARI and diarrhea care from informal providers. CONCLUSIONS: Within a rural Liberian population, distance is associated with reduced health care uptake. As Liberia rebuilds its health system after Ebola, overcoming geographic disparities, including through further dissemination of providers and greater use of community health workers should be prioritized.

A peer assessment approach for learning from public health emergencies.

As an alternative to standard quality improvement approaches and to commonly used after action report/improvement plans, we developed and tested a peer assessment approach for learning from singular public health emergencies. In this approach, health departments engage peers to analyze critical incidents, with the goal of aiding organizational learning within and across public health emergency preparedness systems. We systematically reviewed the literature in this area, formed a practitioner advisory panel to help translate these methods into a protocol, applied it retrospectively to case studies, and later field-tested the protocol in two locations. These field tests and the views of the health professionals who participated in them suggest that this peer-assessment approach is feasible and leads to a more in-depth analysis than standard methods. Engaging people involved in operating emergency health systems capitalizes on their professional expertise and provides an opportunity to identify transferable best practices.

Lessons about the state and local public health system response to the 2009 H1N1 pandemic: a workshop summary.

OBJECTIVE: Identify lessons about the public health emergency preparedness system from after action report/improvement plans (AAR/IPs) authored by state and local health departments following the 2009 H1N1 influenza pandemic. DESIGN: Potentially generalizable findings were collected during a workshop attended by representatives from the Centers for Disease Control and Prevention (CDC), state and local public health departments, and other organizations that prepared 2009 H1N1AAR/IPs. PARTICIPANTS: Workshop participants included state and local health department personnel who had submitted AAR/IPs to the CDC for review. MEASURES: Workshop participants were asked to consider the question: What did you hear from other jurisdictions that resonated with your own experience and could be a generalized finding? RESULTS: Workshop discussions revealed potential lessons concerning: (1) situational awareness during the initial response; (2) resource mobilization and legal authority; (3) the complexity of vaccine distribution and administration; (4) balancing emergency response and routine operations; (5) communication and coordination among the many independent actors in the public health system; and (6) incident management in a long-duration incident. CONCLUSIONS: The response to the 2009 H1N1 influenza pandemic provides an opportunity to learn about the public health system's emergency response capabilities and to identify ways to improve preparedness for future events. Perhaps the most important lessons from the 2009 H1N1 response reveal the complexity of coordinating actions among the many different actors, institutions, sectors, and disciplines involved in the public health system. While the response to the pandemic engendered creative "on the spot" solutions, continued effort is needed to better understand and manage the identified challenges.