Strategies for Strengthening the Resilience of Public Health Systems for Pandemics, Disasters, and Other Emergencies.

OBJECTIVE: The aim of this study was to identify and prioritize strategies for strengthening public health system resilience for pandemics, disasters, and other emergencies using a scorecard approach. METHODS: The United Nations Public Health System Resilience Scorecard (Scorecard) was applied across 5 workshops in Slovenia, Turkey, and the United States of America. The workshops focused on participants reviewing and discussing 23 questions/indicators. A Likert type scale was used for scoring with zero being the lowest and 5 the highest. The workshop scores were analyzed and discussed by participants to prioritize areas of need and develop resilience strategies. Data from all workshops were aggregated, analyzed, and interpreted to develop priorities representative of participating locations. RESULTS: Eight themes emerged representing the need for better integration of public health and disaster management systems. These include: assessing community disease burden; embedding long-term recovery groups in emergency systems; exploring mental health care needs; examining ecosystem risks; evaluating reserve funds; identifying what crisis communication strategies worked well; providing non-medical services; and reviewing resilience of existing facilities, alternate care sites, and institutions. CONCLUSIONS: The Scorecard is an effective tool for establishing baseline resilience and prioritizing actions. The strategies identified reflect areas in most need for investment to improve public health system resilience.

Investigation and Decontamination of an Urban Monkeypox Occurrence.

Before the described monkeypox virus (MPXV) case in this article, limited cases of human MPXV had occurred within the United States. Lessons learned from prior outbreaks contributed to a successful approach to decontamination and containment of an adult case of MPXV in Dallas, Texas. This case report provides an overview of the characteristics of the monkeypox virus, its effects on the human body, and a primary focus on a successful protocol for household decontamination. Additional information is provided on methods related to public relations and information management that were utilized during this incident.

Differences in the Awareness and Knowledge of Radiological and Nuclear Events Among Medical Workers in Japan.

Background: Previous research revealed a lack of comfort and knowledge regarding nuclear and radiological events among medical staff. We investigated the awareness and knowledge of radiological and nuclear events among the Japanese medical staff by comparing differences by occupation (doctors, nurses, and other medical specialists). Methods: We conducted a cross-sectional questionnaire survey among trainees undergoing Japanese disaster medical training courses between July 2014 and February 2016. The differences by occupation were evaluated for all questions on awareness and knowledge concerning disasters or radiological and nuclear events and demographics. Results: Among the occupations, there were significant differences in the willingness to work onsite based on the types of disaster, familiarity with the national disaster medical response system, the accuracy rate of some knowledge about medical practice and the risk, and demographic characteristics such as practical experience and educational degree. The accuracy rates of responses to some questions on knowledge were very low in all occupations. Conclusion: There were significant differences in awareness and knowledge of radiological and nuclear events by occupation. We believe that the results can be used to develop and modify the content of training courses on radiological and nuclear events to make such courses beneficial for each healthcare worker.

Discrimination and Bias in State Triage Protocols Toward Populations With Intellectual Disabilities During the COVID-19 Pandemic.

Individuals with intellectual disabilities face discrimination on a daily basis. The coronavirus disease (COVID-19) pandemic has highlighted the systemic ableism that is embedded within American culture, particularly through health care bias and discrimination. In turn, this creates further marginalization during diagnosis, triage, and treatment of the novel coronavirus. Multiple states have filed complaints against state triage protocols that suggest an abled life is more worthy than a life with a disability. Although many of these protocols have been updated and replaced, generalized triage statements fail to address health care bias that is embedded within the American system. In addition to the existing solutions, proposed solutions to addressing health care bias include integrating social workers into the emergency management process and the overall disaster management field. To combat bias and ableism across the health care system, a social justice perspective that highlights discrimination, inequalities, and inequities in overall individual care must be adopted.

COVID-19 Contact Tracing Solutions for Mass Gatherings.

Mass gatherings and high-density activities, such as sporting events, conventions, and theme parks, are consistently included among highest-risk activities given the increased potential for widespread coronavirus disease 2019 (COVID-19) transmission. A more balanced risk management approach is required because absolute suppression of risk is unrealistic in all facets of life. Contact tracing remains a limiting factor in achieving such a balance. The use of Bluetooth or pairing devices is proposed to address this challenge. This simple approach, when applied in a manner that satisfies privacy and trust concerns, would allow high-risk encounters to be quickly identified, namely those where participants have spent 15 minutes or more within 6 ft of each other per current guidelines. If an attendee later tests positive for COVID-19 and tracing is required, the event organizer can provide a limited list of potential close contacts rather than an exhaustive list of all attendees. Contact tracers can, therefore, limit efforts to this concise group rather than needing to contact thousands of people or conduct mass media communications. Such a system, if institutionalized, supports risk assurance and safety measures for businesses by demonstrating a commitment to staff, customer protection, and ensuring high-risk encounters are logged, reinforcing longer-term societal pandemic resilience.

Environmental Health Workforce - Essential for Interdisciplinary Solutions to the COVID-19 Pandemic.

Interdisciplinary public health solutions are vital for an effective coronavirus disease 2019 (COVID-19) response and recovery. However, there is often a lack of awareness and understanding of the environmental health workforce connections and capabilities. In the United States, this is a foundational function of health departments and is the second largest public health workforce. The primary role is to protect the public from exposures to environmental hazards, disasters, and disease outbreaks. More specifically, this includes addressing risks relating to sanitation, drinking water, food safety, vector control, and mass gatherings. This profession is also recognized in the Pandemic and All-Hazards Preparedness and Advancing Innovation Act of 2019. Despite this, the profession is often not considered an essential service. Rapid integration into COVID-19 activities can easily occur as most are government employees and experienced working in complex and stressful situations. This role, for example, could include working with leaders, businesses, workplaces, and churches to safely reopen, and inspections to inform, educate, and empower employers, employees, and the public on safe actions. There is now the legislative support, evidence and a window of opportunity to truly enable interdisciplinary public health solutions by mobilizing the environmental health workforce to support COVID-19 response, recovery, and resilience activities.

COVID-19 Community Stabilization and Sustainability Framework: An Integration of the Maslow Hierarchy of Needs and Social Determinants of Health.

All levels of government are authorized to apply coronavirus disease 2019 (COVID-19) protection measures; however, they must consider how and when to ease lockdown restrictions to limit long-term societal harm and societal instability. Leaders that use a well-considered framework with an incremental approach will be able to gradually restart society while simultaneously maintaining the public health benefits achieved through lockdown measures. Economically vulnerable populations cannot endure long-term lockdown, and most countries lack the ability to maintain a full nationwide relief operation. Decision-makers need to understand this risk and how the Maslow hierarchy of needs and the social determinants of health can guide whole of society policies. Aligning decisions with societal needs will help ensure all segments of society are catered to and met while managing the crisis. This must inform the process of incremental easing of lockdowns to facilitate the resumption of community foundations, such as commerce, education, and employment in a manner that protects those most vulnerable to COVID-19. This study proposes a framework for identifying a path forward. It reflects on baseline requirements, regulations and recommendations, triggers, and implementation. Those desiring a successful recovery from the COVID-19 pandemic need to adopt an evidence-based framework now to ensure community stabilization and sustainability.

Dallas MegaShelter Medical Operations Response to Hurricane Harvey.

On August 25, 2017, Hurricane Harvey made landfall near Corpus Christi, Texas. The ensuing unprecedented flooding throughout the Texas coastal region affected millions of individuals.1 The statewide response in Texas included the sheltering of thousands of individuals at considerable distances from their homes. The Dallas area established large-scale general population sheltering as the number of evacuees to the area began to amass. Historically, the Dallas area is one familiar with "mega-sheltering," beginning with the response to Hurricane Katrina in 2005.2 Through continued efforts and development, the Dallas area had been readying a plan for the largest general population shelter in Texas. (Disaster Med Public Health Preparedness. 2019;13:33-37).

Expanding Understanding of Response Roles: An Examination of Immediate and First Responders in the United States.

2017 was a record year for disasters and disaster response in the U.S. Redefining and differentiating key response roles like "immediate responders" and "first responders" is critical. Traditional first responders are not and cannot remain the only cadre of expected lifesavers following a mass casualty event. The authors argue that the U.S. needs to expand its understanding of response roles to include that of the immediate responders, or those individuals who find themselves at the incident scene and are able to assist others. Through universal training and education of the citizenry, the U.S. has the opportunity increase overall disaster resiliency and community outcomes following large-scale disasters. Such education could easily be incorporated into high school curriculums or other required educational experiences in order to provide all persons with the knowledge, skills, and basic abilities needed to save lives immediately following a disaster.

Readiness for Radiological and Nuclear Events among Emergency Medical Personnel.

BACKGROUND: Among medical providers, even though radiological and nuclear events are recognized as credible threats, there is a lack of knowledge and fear about the medical consequences among medical personnel which could significantly affect the treatment of patients injured and/or contaminated in such scenarios. This study was conducted to evaluate the relative knowledge, willingness to respond, and familiarity with nuclear/radiological contamination risks among U.S. and Japanese emergency medical personnel. METHODS: An institutional review board-approved anonymous paper survey was distributed at various medical and disaster conferences and medicine courses in Japan and in the U.S. The surveys were written in Japanese and English and collected information on the following four categories: generalized demographics, willingness to manage, knowledge of disaster systems, and contamination risks. RESULTS: A total of 418 surveys were completed and collected. Demographics showed that physicians and prehospital responders were the prevalent survey responders. The majority of responders, despite self-professed disaster training, were still very uncomfortable with and unaware how to respond to a radiological/nuclear event. CONCLUSION: Despite some educational coverage in courses and a limited number of disaster events, it is concluded that there is a lack of comfort and knowledge regarding nuclear and radiological events among the medical community. It is recommended that considerable development and subsequent distribution is needed to better educate and prepare the medical community for inevitable upcoming radiological/nuclear events.

Qualitative Analysis of Surveyed Emergency Responders and the Identified Factors That Affect First Stage of Primary Triage Decision-Making of Mass Casualty Incidents.

INTRODUCTION: After all large-scale disasters multiple papers are published describing the shortcomings of the triage methods utilized. This paper uses medical provider input to help describe attributes and patient characteristics that impact triage decisions. METHODS: A survey distributed electronically to medical providers with and without disaster experience. Questions asked included what disaster experiences they had, and to rank six attributes in order of importance regarding triage. RESULTS: 403 unique completed surveys were analyzed. 92% practiced a structural triage approach with the rest reporting they used "gestalt".(gut feeling) Twelve per cent were identified as having placed patients in an expectant category during triage. Respiratory status, ability to speak, perfusion/pulse were all ranked in the top three. Gut feeling regardless of statistical analysis was fourth. Supplies were ranked in the top four when analyzed for those who had placed patients in the expectant category. CONCLUSION: Primary triage decisions in a mass casualty scenario are multifactorial and encompass patient mobility, life saving interventions, situational instincts, and logistics.

A consensus-based gold standard for the evaluation of mass casualty triage systems.

INTRODUCTION: Accuracy and effectiveness analyses of mass casualty triage systems are limited because there are no gold standard definitions for each of the triage categories. Until there is agreement on which patients should be identified by each triage category, it will be impossible to calculate sensitivity and specificity or to compare accuracy between triage systems. OBJECTIVE: To develop a consensus-based, functional gold standard definition for each mass casualty triage category. METHODS: National experts were recruited through the lead investigators' contacts and their suggested contacts. Key informant interviews were conducted to develop a list of potential criteria for defining each triage category. Panelists were interviewed in order of their availability until redundancy of themes was achieved. Panelists were blinded to each other's responses during the interviews. A modified Delphi survey was developed with the potential criteria identified during the interview and delivered to all recruited experts. In the early rounds, panelists could add, remove, or modify criteria. In the final rounds edits were made to the criteria until at least 80% agreement was achieved. RESULTS: Thirteen national and local experts were recruited to participate in the project. Six interviews were conducted. Three rounds of voting were performed, with 12 panelists participating in the first round, 12 in the second round, and 13 in the third round. After the first two rounds, the criteria were modified according to respondent suggestions. In the final round, over 90% agreement was achieved for all but one criterion. A single e-mail vote was conducted on edits to the final criterion and consensus was achieved. CONCLUSION: A consensus-based, functional gold standard definition for each mass casualty triage category was developed. These gold standard definitions can be used to evaluate the accuracy of mass casualty triage systems after an actual incident, during training, or for research.

Mass casualty triage: an evaluation of the science and refinement of a national guideline.

Mass casualty triage is the process of prioritizing multiple victims when resources are not sufficient to treat everyone immediately. No national guideline for mass casualty triage exists in the United States. The lack of a national guideline has resulted in variability in triage processes, tags, and nomenclature. This variability has the potential to inject confusion and miscommunication into the disaster incident, particularly when multiple jurisdictions are involved. The Model Uniform Core Criteria for Mass Casualty Triage were developed to be a national guideline for mass casualty triage to ensure interoperability and standardization when responding to a mass casualty incident. The Core Criteria consist of 4 categories: general considerations, global sorting, lifesaving interventions, and individual assessment of triage category. The criteria within each of these categories were developed by a workgroup of experts representing national stakeholder organizations who used the best available science and, when necessary, consensus opinion. This article describes how the Model Uniform Core Criteria for Mass Casualty Triage were developed.

Attributes of effective disaster responders: focus group discussions with key emergency response leaders.

METHODS: An effective disaster response requires competent responders and leaders. The purpose of this study was to ask experts to identify attributes that distinguish effective from ineffective responders and leaders in a disaster. In this qualitative study, focus groups were held with jurisdictional medical directors for the 9-1-1 emergency medical services systems of the majority of the nation's largest cities. These sessions were recorded with audio equipment and later transcribed. RESULTS: The researchers identified themes within the transcriptions, created categories, and coded passages into these categories. Overall interrater reliability was excellent (κ = .8). The focus group transcripts yielded 138 codable passages. Ten categories were developed from analysis of the content: Incident Command System/Disaster Training/Experience, General Training/Experience, Teamwork/Interpersonal, Communication, Cognition, Problem Solving/Decision Making, Adaptable/Flexible, Calm/Cool, Character, and Performs Role. The contents of these categories included knowledge, skills, attitudes, behaviors, and personal characteristics. CONCLUSIONS: Experts in focus groups identified a variety of competencies for disaster responders and leaders. These competencies will require validation through further research that involves input from the disaster response community at large.

Evolving need for alternative triage management in public health emergencies: a Hurricane Katrina case study.

In many countries, traditional medical planning for disasters developed largely in response to battlefield and multiple casualty incidents, generally involving corporal injuries. The mass evacuation of a metropolitan population in the aftermath of Hurricane Katrina evolved into life-and-death triage scenarios involving thousands of patients with nontraumatic illnesses and special medical needs. Although unprecedented in the United States, triage management needs for this disaster were similar to other large-scale public health emergencies, both natural and human-generated, that occurred globally in the past half-century. The need for alternative triage-management processes similar to the methodologies of other global mass public health emergencies is illustrated through the experience of disaster medical assistance teams in the first 3 days following Katrina's landfall. The immediate establishment of disaster-specific, consensus-based, public health emergency-related triage protocols-developed with ethical and legal expertise and a renewed focus on multidimensional, multifactorial matrix decision-making processes-is strongly recommended.

A consensus-based educational framework and competency set for the discipline of disaster medicine and public health preparedness.

BACKGROUND: Various organizations and universities have developed competencies for health professionals and other emergency responders. Little effort has been devoted to the integration of these competencies across health specialties and professions. The American Medical Association Center for Public Health Preparedness and Disaster Response convened an expert working group (EWG) to review extant competencies and achieve consensus on an educational framework and competency set from which educators could devise learning objectives and curricula tailored to fit the needs of all health professionals in a disaster. METHODS: The EWG conducted a systematic review of peer-reviewed and non-peer reviewed published literature. In addition, after-action reports from Hurricane Katrina and relevant publications recommended by EWG members and other subject matter experts were reviewed for congruencies and gaps. Consensus was ensured through a 3-stage Delphi process. RESULTS: The EWG process developed a new educational framework for disaster medicine and public health preparedness based on consensus identification of 7 core learning domains, 19 core competencies, and 73 specific competencies targeted at 3 broad health personnel categories. CONCLUSIONS: The competencies can be applied to a wide range of health professionals who are expected to perform at different levels (informed worker/student, practitioner, leader) according to experience, professional role, level of education, or job function. Although these competencies strongly reflect lessons learned following the health system response to Hurricane Katrina, it must be understood that preparedness is a process, and that these competencies must be reviewed continually and refined over time.