Safeguarding people living in vulnerable conditions in the COVID-19 era through universal health coverage and social protection.

The COVID-19 pandemic is unprecedented. The pandemic not only induced a public health crisis, but has led to severe economic, social, and educational crises. Across economies and societies, the distributional consequences of the pandemic have been uneven. Among groups living in vulnerable conditions, the pandemic substantially magnified the inequality gaps, with possible negative implications for these individuals' long-term physical, socioeconomic, and mental wellbeing. This Viewpoint proposes priority, programmatic, and policy recommendations that governments, resource partners, and relevant stakeholders should consider in formulating medium-term to long-term strategies for preventing the spread of COVID-19, addressing the virus's impacts, and decreasing health inequalities. The world is at a never more crucial moment, requiring collaboration and cooperation from all sectors to mitigate the inequality gaps and improve people's health and wellbeing with universal health coverage and social protection, in addition to implementation of the health in all policies approach.

Chemical, Biological, Radiological, Nuclear, and Explosive (CBRNE) Science and the CBRNE Science Medical Operations Science Support Expert (CMOSSE).

A national need is to prepare for and respond to accidental or intentional disasters categorized as chemical, biological, radiological, nuclear, or explosive (CBRNE). These incidents require specific subject-matter expertise, yet have commonalities. We identify 7 core elements comprising CBRNE science that require integration for effective preparedness planning and public health and medical response and recovery. These core elements are (1) basic and clinical sciences, (2) modeling and systems management, (3) planning, (4) response and incident management, (5) recovery and resilience, (6) lessons learned, and (7) continuous improvement. A key feature is the ability of relevant subject matter experts to integrate information into response operations. We propose the CBRNE medical operations science support expert as a professional who (1) understands that CBRNE incidents require an integrated systems approach, (2) understands the key functions and contributions of CBRNE science practitioners, (3) helps direct strategic and tactical CBRNE planning and responses through first-hand experience, and (4) provides advice to senior decision-makers managing response activities. Recognition of both CBRNE science as a distinct competency and the establishment of the CBRNE medical operations science support expert informs the public of the enormous progress made, broadcasts opportunities for new talent, and enhances the sophistication and analytic expertise of senior managers planning for and responding to CBRNE incidents.

Missed opportunities: Do states require screening of children for health conditions that interfere with learning?

METHODS: Investigators reviewed websites of state departments of health and education, and legislation for all 50 states and DC. For states with mandated screenings and a required form, investigators applied structured analysis to assess HBL inclusion. RESULTS: No state mandated that schools require screening for all 7 HBLs. Less than half (49%) required comprehensive school health examinations and only 12 states plus DC required a specific form. Of these, 12 of the forms required documentation of vision screening, 11 of hearing screening, and 12 of dental screening. Ten forms asked about asthma and 9 required documentation of lead testing. Seven asked about general well-being, emotional problems, or mental health. None addressed hunger. When including states without comprehensive school health examination requirements, the most commonly required HBL screenings were for vision (80% of states; includes DC), hearing (75% of states; includes DC) and dental (24% of state; includes DC). CONCLUSION: The lack of state mandated requirements for regular student health screening represents a missed opportunity to identify children with HBLs. Without state mandates, accompanying comprehensive forms, and protocols, children continue to be at risk of untreated health conditions that can undermine their success in school.

Acts of terrorism and mass violence targeting schools : Analysis and implications for preparedness in the USA.

To enhance the preparedness of US schools to acts of terrorism and mass violence, the landscape of threats against schools must first be understood. This includes exploring the global trends of acts of terrorism against schools, as well as looking specifically at the history of terrorism and acts of mass violence against schools domestically. This paper conducts a review of two databases in order to look at the trends in acts of terrorism and mass violence carried out against schools, and provides recommendations for domestic school preparedness based on this information.

Disaster prepared: How federal funding in the USA supports health system and public health readiness.

Federal funding for health and medical preparedness in the USA has created an important foundation for preparing the health and medical systems to respond to a wide range of hazards. A declining trend in funding for these preparedness activities threatens to undo the progress that has been made over the last decade and reduce the state of readiness to respond to the health and medical impacts of disasters.

Climate Change and Health on the U.S. Gulf Coast: Public Health Adaptation is Needed to Address Future Risks.

The impacts of climate change on human health have been documented globally and in the United States. Numerous studies project greater morbidity and mortality as a result of extreme weather events and other climate-sensitive hazards. Public health impacts on the U.S. Gulf Coast may be severe as the region is expected to experience increases in extreme temperatures, sea level rise, and possibly fewer but more intense hurricanes. Through myriad pathways, climate change is likely to make the Gulf Coast less hospitable and more dangerous for its residents, and may prompt substantial migration from and into the region. Public health impacts may be further exacerbated by the concentration of people and infrastructure, as well as the region's coastal geography. Vulnerable populations, including the very young, elderly, and socioeconomically disadvantaged may face particularly high threats to their health and well-being. This paper provides an overview of potential public health impacts of climate variability and change on the Gulf Coast, with a focus on the region's unique vulnerabilities, and outlines recommendations for improving the region's ability to minimize the impacts of climate-sensitive hazards. Public health adaptation aimed at improving individual, public health system, and infrastructure resilience is urgently needed to meet the challenges climate change may pose to the Gulf Coast in the coming decades.

The Medical Home and Care Coordination in Disaster Recovery: Hypothesis for Interventions and Research.

In postdisaster settings, health care providers encounter secondary surges of unmet primary care and mental health needs that evolve throughout disaster recovery phases. Whatever a community's predisaster adequacy of health care, postdisaster gaps are similar to those of any underserved region. We hypothesize that existing practice and evidence supporting medical homes and care coordination in primary care for the underserved provide a favorable model for improving health in disrupted communities. Elements of medical home services can be offered by local or temporary providers from outside the region, working out of mobile clinics early in disaster recovery. As repairs and reconstruction proceed, local services are restored over weeks or years. Throughout recovery, major tasks include identifying high-risk patients relative to the disaster and underlying health conditions, assisting displaced families as they transition through housing locations, and tracking their evolving access to health care and community services as they are restored. Postdisaster sources of financial assistance for the disaster-exposed population are often temporary and evolving, requiring up-to-date information to cover costs of care until stable services and insurance coverage are restored. Evidence to support disaster recovery health care improvement will require research funding and metrics on structures, processes, and outcomes of the disaster recovery medical home and care coordination, based on adaptation of standard validated methods to crisis environments.

Coverage of the ebola virus disease epidemic in three widely circulated United States newspapers: implications for preparedness and prevention.

BACKGROUND: Widespread media attention about Ebola influences public awareness and interest, yet there is limited research on what aspects of Ebola have and have not been communicated through the media. METHODS: We examined the nature and extent of coverage about Ebola in the three most widely circulated United States (U.S.) daily newspapers. Between September 17, 2014 and October 17, 2014, 301 articles about Ebola in The New York Times, USA Today, and The Wall Street Journal were identified and coded. RESULTS: The most common topic was coverage of cases in the United States (39%), followed by the outbreak in Africa (33.6%). CONCLUSION: This is the first study to describe coverage of the Ebola epidemic in widely circulated U.S. newspapers. A substantial portion of the American public is concerned about being infected with Ebola virus disease (EVD). In this study, a large emphasis was placed on death tolls and the cases in the United States. Much more can be done to educate readers about relevant aspects of the Ebola epidemic, including how Ebola is and is not transmitted.

Disaster medicine and public health preparedness of health professions students: a multidisciplinary assessment of knowledge, confidence, and attitudes.

OBJECTIVE: This study assessed disaster medicine knowledge and competence and perceived self-efficacy and motivation for disaster response among medical, nursing, and dental students. METHODS: Survey methodology was used to evaluate knowledge, comfort, perceived competency, and motivation. Also, a nonresponder survey was used to control for responder bias. RESULTS: A total of 136 responses were received across all 3 schools. A nonresponder survey showed no statistical differences with regard to age, gender, previous presence at a disaster, and previous emergency response training. In spite of good performance on many knowledge items, respondent confidence was low in knowledge and in comfort to perform in disaster situations. Knowledge was strong in areas of infection control, decontamination, and biological and chemical terrorism but weak in areas of general emergency management, role of government agencies, and radiologic events. Variations in knowledge among the different health professions were slight, but overall the students believed that they required additional education. Finally, students were motivated not only to acquire more knowledge but to respond to disaster situations. CONCLUSIONS: Health care students must be adequately educated to assume roles in disasters that are a required part of their professions. This education also is necessary for further disaster medicine education in either postgraduate or occupational education. As students' performance on knowledge items was better than their perceived knowledge, it appears that a majority of this education can be achieved with the use of existing curricula, with minor modification, and the addition of a few focused subjects, which may be delivered through novel educational approaches.

Twenty-five years of child and family homelessness: where are we now?

Family homelessness emerged as a major social and public health problem in the United States during the 1980s. We reviewed the literature, including journal articles, news stories, and government reports, that described conditions associated with family homelessness, the scope of the problem, and the health and mental health of homeless children and families. Much of this literature was published during the 1980s and 1990s. This raises questions about its continued applicability for the public health community. We concluded that descriptions of the economic conditions and public policies associated with family homelessness are still relevant; however, the homeless family population has changed over time. Family homelessness has become more prevalent and pervasive among poor and low-income families. We provide public health recommendations for these homeless families.

Medical planning and response for a nuclear detonation: a practical guide.

This article summarizes major points from a newly released guide published online by the Office of the Assistant Secretary for Preparedness and Response (ASPR). The article reviews basic principles about radiation and its measurement, short-term and long-term effects of radiation, and medical countermeasures as well as essential information about how to prepare for and respond to a nuclear detonation. A link is provided to the manual itself, which in turn is heavily referenced for readers who wish to have more detail.

Rural and suburban population surge following detonation of an improvised nuclear device: a new model to estimate impact.

BACKGROUND: The objective of the study was to model urban evacuation into surrounding communities after the detonation of an improvised nuclear device (IND) to assist rural and suburban planners in understanding and effectively planning to address the effects of population surges. METHODS: Researchers developed parameters for how far evacuees would travel to escape disasters and factors that would influence choice of destination from studies of historical evacuations, surveys of citizens' evacuation intentions in hypothetical disasters, and semistructured interviews with key informants and emergency preparedness experts. Those parameters became the inputs to a "push-pull" model of how many people would flee in the 4 scenarios and where they would go. RESULTS: The expanded model predicted significant population movements from the New York City borough of Manhattan and counties within 20 km of Manhattan to counties within a 150-mi radius of the assumed IND detonation. It also predicted that even in some communities located far from Manhattan, arriving evacuees would increase the population needing services by 50% to 150%. CONCLUSIONS: The results suggest that suburban and rural communities could be overwhelmed by evacuees from their center city following an IND detonation. They also highlight the urgency of educating and communicating with the public about radiation hazards to mitigate panic and hysteria, anticipating the ways in which a mass exodus may disrupt or even cripple rescue and response efforts, and devising creative ways to exercise and drill for an event about which there is great denial and fatalism.

Health care system planning for and response to a nuclear detonation.

The hallmark of a successful response to a nuclear detonation will be the resilience of the community, region, and nation. An incident of this magnitude will rapidly become a national incident; however, the initial critical steps to reduce lives lost, save the lives that can be saved with the resources available, and understand and apply resources available to a complex and dynamic situation will be the responsibility of the local and regional responders and planners. Expectations of the public health and health care systems will be met to the extent possible by coordination, cooperation, and an effort to produce as consistent a response as possible for the victims. Responders will face extraordinarily stressful situations, and their own physical and psychological health is of great importance to optimizing the response. This article illustrates through vignettes and supporting text how the incident may unfold for the various components of the health and medical systems and provides additional context for the discipline-related actions outlined in the state and local planners' playbook.

Medical response to a nuclear detonation: creating a playbook for state and local planners and responders.

For efficient and effective medical responses to mass casualty events, detailed advanced planning is required. For federal responders, this is an ongoing responsibility. The US Department of Health and Human Services (DHHS) prepares playbooks with formal, written plans that are reviewed, updated, and exercised regularly. Recognizing that state and local responders with fewer resources may be helped in creating their own event-specific response plans, subject matter experts from the range of sectors comprising the Scarce Resources for a Nuclear Detonation Project, provided for this first time a state and local planner's playbook template for responding to a nuclear detonation. The playbook elements are adapted from DHHS playbooks with appropriate modification for state and local planners. Individualization by venue is expected, reflecting specific assets, populations, geography, preferences, and expertise. This playbook template is designed to be a practical tool with sufficient background information and options for step-by-step individualized planning and response.

Health care savings attributable to integrating guidelines-based asthma care in the pediatric medical home.

OBJECTIVE: To estimate savings to health care system of a best-practice asthma intervention in primary care for inner-city children. METHODS: Data were analyzed from National Heart, Lung and Blood Institute (NHLBI) Guidelines-based initial (n=244) and follow-up (n=202) asthma assessments of patients who received enhanced treatment in primary care. Savings were calculated using cost-of-illness model and compared with program cost. RESULTS: Patients were about equally distributed between African American and Hispanic children (mean age = 7 years; range 36 months-19 years). Of those with persistent asthma, 36% had been prescribed a controller medication. This significantly improved on follow-up (p<.01). There were significant reductions in asthma severity (p<.05) and emergency department use (p<.01), and near-significant reduction in asthma hospitalizations (p=.059). CONCLUSION: Total annual savings attributable to clinical outcomes was $4,202,813 or $4,525 per patient with asthma. Total annual cost of the implementation was $390,169 or $420 per asthma patient. Conservatively estimated savings exceeded cost of intervention by nearly 11 to 1.

The recovery divide: poverty and the widening gap among Mississippi children and families affected by hurricane Katrina

It presents information to policymakers based on Mississipi's hurricane incident in 2006 about the health and social service needs of displaced and impacted populations living in transitional community-based settings that had been heavily damaged or destroyed by disasters.

Children as bellwethers of recovery: dysfunctional systems and the effects of parents, households, and neighborhoods on serious emotional disturbance in children after Hurricane Katrina.

BACKGROUND: Over 160,000 children were displaced from their homes after Hurricane Katrina. Tens of thousands of these children experienced the ongoing chaos and uncertainty of displacement and transiency, as well as significant social disruptions in their lives. The objectives of this study were to estimate the long-term mental health effects of such exposure among children, and to elucidate the systemic pathways through which the disaster effect operates. METHODS: The prevalence of serious emotional disturbance was assessed among 283 school-aged children in Louisiana and Mississippi. These children are part of the Gulf Coast Child & Family Health Study, involving a longitudinal cohort of 1079 randomly sampled households in the two states, encompassing a total of 427 children, who have been interviewed in 4 annual waves of data collection since January 2006. The majority of data for this analysis was drawn from the fourth round of data. RESULTS: Although access to medical care for children has expanded considerably since 2005 in the region affected by Hurricane Katrina, more than 37% of children have received a clinical mental health diagnosis of depression, anxiety, or behavior disorder, according to parent reports. Children exposed to Hurricane Katrina were nearly 5 times as likely as a pre-Katrina cohort to exhibit serious emotional disturbance. Path analyses confirm the roles played by neighborhood social disorder, household stressors, and parental limitations on children's emotional and behavioral functioning. CONCLUSIONS: Children and youth are particularly vulnerable to the effects of disasters. They have limited capacity to independently mobilize resources to help them adapt to stressful postdisaster circumstances, and are instead dependent upon others to make choices that will influence their household, neighborhood, school, and larger social environment. Children's mental health recovery in a postdisaster setting can serve as a bellwether indicator of successful recovery or as a lagging indicator of system dysfunction and failed recovery.