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To demonstrate how public health emergency systems can use health systems tools to analyze and learn from critical incidents, we employed a facilitated look-back approach to review the public response to a chemical spill in Charleston, West Virginia. We reviewed official reports, news articles, and other documents; conducted in-person interviews with key public health and emergency response officials and local community stakeholders; and organized a facilitated look-back meeting to identify root causes of the problems that were encountered. The primary response challenges were (1) public distrust stemming from scientific uncertainty about potential harms of chemicals involved in the spill and how this uncertainty was communicated and (2) communication within the public health system, broadly defined. We found that to address inherent uncertainty, health officials should acknowledge uncertainty and tell the public what is known and unknown, and what they are doing to get more information.

To demonstrate how public health systems can use root-cause analysis (RCA) to improve learning from critical incidents, the research team utilized a facilitated look-back meeting to examine the public health systems' response to a Salmonellaoutbreak in the water supply in Alamosa, Colorado. We worked with public health, emergency management agencies, and other stakeholders to identify response challenges related to public health emergency preparedness capabilities, root causes, and lessons learned. The results demonstrate that RCA can help identify systems issues that, if addressed, can improve future responses. Furthermore, RCA can identify more basic issues that go beyond a specific incident or setting, such as the need for effective communication and coordination throughout the public health system, and the social capital needed to support it.

•Case-fatality varied from 14.5% in the first to 0.8% in the fourth pandemic wave.•Vaccines drastically reduced COVID-19 hospitalizations and deaths in Italy.•Before vaccines, non-pharmaceutical interventions contained and mitigated the virus.

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.

The Harvard School of Public Health Center for Public Health Preparedness exercise program has two aims: (1) educating the public health workforce on key public health system emergency preparedness issues, and (2) identifying specific systems-level challenges in the public health response to large-scale events. Rigorous evaluation of 38 public health emergency preparedness (PHEP) exercises employing realistic scenarios and reliable and accurate outcome measures has demonstrated the usefulness of PHEP exercises in clarifying public health workers' roles and responsibilities, facilitating knowledge transfer among these individuals and organizations, and identifying specific public health systems-level challenges.

ABSTRACTObjectives:The Medical Reserve Corps (MRC) is a national network of community-based units created to promote the local identification, recruitment, training, and activation of volunteers to assist local health departments in public health activities. This study aimed to develop a toolkit for MRC coordinators to assess and monitor volunteer units' performance and identify barriers limiting volunteerism.Methods:In 2008 and 2009, MRC volunteers asked to participate in influenza clinics were surveyed in 7 different locations throughout the United States. Two survey instruments were used to assess the performance of the volunteers who were able to participate, the specific barriers that prevented some volunteers from participating, and the overall attitudes of those who participated and those who did not. Validity and reliability of the instruments were assessed through the use of factor analysis and Cronbach's alpha.Results:Two survey instruments were developed: the Volunteer Self-Assessment Questionnaire and the Barriers to Volunteering Questionnaire. Data were collected from a total of 1059 subjects, 758 participated in the influenza clinics and 301 were unable to attend. Data from the 2 instruments were determined to be suitable for factor analysis. Factor solutions and inter-item correlations supported the hypothesized domain structure for both survey questionnaires. Results on volunteers' performance were consistent with observations of both local health departments' staff and external observers.Conclusions:The survey instruments developed for this study appear to be valid and reliable means to assess the performance and attitudes of MRC volunteers and barriers to their participation. This study found these instruments to have face and content validity and practicality. MRC coordinators can use these questionnaires to monitor their ability to engage volunteers in public health activities.(Disaster Med Public Health Preparedness. 2010;4:213-219)

AbstractIntroduction:As proxies for actual emergencies, drills and exercises can raise awareness, stimulate improvements in planning and training, and provide an opportunity to examine how different components of the public health system would combine to respond to a challenge. Despite these benefits, there remains a substantial need for widely accepted and prospectively validated tools to evaluate agencies' and hospitals' performance during such events. Unfortunately, to date, few studies have focused on addressing this need. The purpose of this study was to assess the validity and reliability of a qualitative performance assessment tool designed to measure hospitals' communication and operational capabilities during a functional exercise.Methods:The study population included 154 hospital personnel representing nine hospitals that participated in a functional exercise in Massachusetts in June 2008. A 25-item questionnaire was developed to assess the following three hospital functional capabilities: (1) inter-agency communication; (2) communication with the public; and (3) disaster operations. Analyses were conducted to examine internal consistency, associations among scales, the empirical structure of the items, and inter-rater agreement.Results:Twenty-two questions were retained in the final instrument, which demonstrated reliability with alpha coefficients of 0.83 or higher for all scales. A three-factor solution from the principal components analysis accounted for 57% of the total variance, and the factor structure was consistent with the original hypothesized domains. Inter-rater agreement between participants' self-reported scores and external evaluators' scores ranged from moderate to good.Conclusions:The resulting 22-item performance measurement tool reliably measured hospital capabilities in a functional exercise setting, with preliminary evidence of concurrent and criterion-related validity.

ABSTRACTObjective:Legal preparedness is a critical component of comprehensive public health preparedness for public health emergencies. The scope of this study was to assess the usefulness of combining didactic sessions with a tabletop exercise as educational tools in legal preparedness, to assess the impact of the exercise on the participants’ level of confidence about the legal preparedness of a public health system, and to identify legal issue areas in need of further improvement.Methods:The exercise scenario and the pre- and postexercise evaluation were designed to assess knowledge gained and level of confidence in declaration of emergencies, isolation and quarantine, restrictions (including curfew) on the movement of people, closure of public places, and mass prophylaxis, and to identify legal preparedness areas most in need of further improvement at the system level. Fisher exact test and paired ttest were performed to compare pre- and postexercise results.Results:Our analysis shows that a combination of didactic teaching and experiential learning through a tabletop exercise regarding legal preparedness for infectious disease emergencies can be effective in both imparting perceived knowledge to participants and gathering information about sufficiency of authorities and existence of gaps.Conclusions:The exercise provided a valuable forum to judge the adequacy of legal authorities, policies, and procedures for dealing with pandemic influenza at the state and local levels in Massachusetts. In general, participants were more confident about the availability and sufficiency of legal authorities than they were about policies and procedures for implementing them. Participants were also more likely to report the need for improvement in authorities, policies, and procedures in the private sector and at the local level than at the state level. (Disaster Med Public Health Preparedness. 2009;3:104–110)

Objectives. Improving the ability of local public health agencies to respond to large-scale emergencies is an ongoing challenge. Tabletop exercises can provide an opportunity for individuals and groups to practice coordination of emergency response and evaluate performance. The purpose of this study was to develop a valid and reliable self-assessment performance measurement tool for tabletop exercise participants.Methods. The study population comprised 179 public officials who attended three tabletop exercises in Massachusetts and Maine between September 2005 and November 2006. A 42-item questionnaire was developed to assess five public health functional capabilities: (1) leadership and management, (2) mass casualty care, (3) communication, (4) disease control and prevention, and (5) surveillance and epidemiology. Analyses were undertaken to examine internal consistency, associations among scales, the empirical structure of the items, and inter-rater agreement.Results. Thirty-seven questions were retained in the final questionnaire and grouped according to the original five domains. Alpha coefficients were 0.81 or higher for all scales. The five-factor solution from the principal components analysis accounted for 60% of the total variance, and the factor structure was consistent with the five domains of the original conceptual model. Inter-rater agreement ranged from good to excellent.Conclusions. The resulting 37-item performance measurement tool was found to reliably measure public health functional capabilities in a tabletop exercise setting, with preliminary evidence of a factor structure consistent with the original conceptualization and of criterion-related validity.

The Washington metropolitan area was closely examined to understand how these regional preparedness structures have been organized, implemented, and governed, as well as to assess the likely impact of such regional structures on public health preparedness and public health systems more generally. It was found that no single formal regional structure for the public health system exists in the Washington metropolitan area, although the region is designated by the Department of Homeland Security as the National Capital Region (NCR). In fact, the vast majority of preparedness planning and response activities in this area are the result of voluntary self-organization through both governmental and nongovernmental organizations. Some interviewed felt that this was an optimal arrangement, as personal relationships prove crucial in responding to a public health emergency and an informal response is often more timely than a formal response. The biggest challenge for public health preparedness in the NCR is incorporating all federal government agencies in the area in NCR preparedness planning.

Comparative case studies found that regionalization originated from a crisis or perceived need for a coordinated response, a need to build local public health capacity, or an effort to use federal preparedness funds more efficiently. Regions vary in terms of their congruence with regional structures for partner agencies, such as emergency management agencies, as well as hospital and health services markets and organizational structure. Some focus on building formal organizational relationships to coordinate and sometimes standardize preparedness and response activities or build regional capacity, while others focus on building informal professional networks. Whatever the approach, strong leadership and trust are required for effective planning, emergency response, and sustainability. This article suggests that regionalization improves emergency preparedness by allowing for more efficient use of resources and better coordination and demonstrated progress in terms of planning and coordination; regional capacity-building, training, and exercises; and development of professional networks.

Objective. Survey instruments for evaluating public health preparedness have focused on measuring the structure and capacity of local, state, and federal agencies, rather than linkages among structure, process, and outcomes. To focus evaluation on the latter, we evaluated the linkages among individuals, organizations, and systems using the construct of “connectivity” and developed a measurement instrument.Methods. Results from focus groups of emergency preparedness first responders generated 62 items used in the development sample of 187 respondents. Item reduction and factors analyses were conducted to confirm the scale's components.Results. The 62 items were reduced to 28. Five scales explained 70% of the total variance (number of items, percent variance explained, Cronbach's alpha) including connectivity with the system (8, 45%, 0.94), coworkers (7, 7%, 0.91), organization (7, 12%, 0.93), and perceptions (6, 6%, 0.90). Discriminant validity was found to be consistent with the factor structure.Conclusion. We developed a Connectivity Measurement Tool for the public health workforce consisting of a 34-item questionnaire found to be a reliable measure of connectivity with preliminary evidence of construct validity.

Objectives. The purpose of this study was to review instruments that assess the level of preparedness of state and local public health departments to respond to health threats such as bioterrorism.Methods. The authors examined 27 published population-based instruments for planning or evaluating preparedness that were mostly unavailable in the peer-reviewed literature. Using the Essential Public Health Services framework, the instruments were evaluated for (1) clarity of measurement parameters, (2) balance between structural and process measures, (3) evidence of effectiveness, and (4) specification of an accountable entity.Results. There was a great deal of overlap but little consistency in what constitutes “preparedness” or how it should be measured. Most instruments relied excessively on subjective or structural measures, lacked scientific evidence for measures assessed, and failed to clearly define what entity was accountable for accomplishing the task or function.Conclusion. Strategies for improvement include measure standardization, better interagency communication, and investment in public health practice research to develop the underlying evidence base required for developing quality measures and assessments.

Two examples—the “swine flu affair” in 1976 and the emergence of HIV in the blood supply in the early 1980s—illustrate the difficulties of decision-making in public health. Both cases illustrate trade-offs between product risks and public health benefits, especially with regard to uncertainty in estimates of product risks, public health risks, and the benefits of prevention. The cases also illustrate the tendency of public health policy makers to go all the way or do nothing at all, rather than consider intermediate options that can be adapted as new information emerges. This review suggests three lessons for public health policy makers: (1) be open and honest about scientific uncertainty; (2) communicate with the public, even when the facts are not clear; and (3) consider intermediate, adaptable policy options, such as obtaining more information, thus reducing uncertainty, and building in decision points to reconsider initial policies. Underlying all of these lessons is the need to commission studies to resolve important uncertainties and increase the information base for public communication, and to review regulations and other policy options in the light of the new data that emerge.

This paper reports a panel discussion-Opportunities for and Limitations to Greater Collaboration Across the Disciplines-held at the conference. It highlights the need for greater collaboration between demographers and epidemiologists and notes the institutional and disciplinary challenges to and opportunities for promoting greater cooperation.

This paper is a summary of a panel discussion at the Conference on Epidemiology and Demography held at Georgetown University, in Washington D.C. on February 8-9, 2001. The participants were Al Hermalin, Linda Martin, Mike Stoto, Robert Wallace, Douglas Weed, and Rose Li (who chaired the session). A list of questions similar to the section headings in this paper was prepared in advance of the conference, and each of the participants was asked to address specific issues, although the presentations typically covered a range of topics. This summary also includes comments from the floor.

Prenatal human immunodeficiency virus (HIV) testing and treatment instituted in the 1990s is responsible for a substantial reduction in the number of children diagnosed with AIDS, yet the number of children born with HIV infection remains unacceptably high. To prevent perinatal transmission of HIV, the United States must adopt a goal to test all pregnant women for HIV and to provide optimal treatment for women who test positive and their children. To meet this goal, the United States should adopt a national policy of universal HIV testing with patient notification as a routine component of prenatal care. Adopting this policy will require the establishment of, and resources for, a comprehensive infrastructure. This infrastructure must include education of prenatal care providers, the development and implementation of practice guidelines and the implementation of clinical policies, the development and adoption of performance measures and Medicaid managed care contract language for prenatal HIV testing, efforts to improve coordination of care and access to high-quality HIV treatment, interventions to overcome pregnant women’s concerns about HIV testing and treatment, and efforts to increase use of prenatal care, as described above.

A group convened by the Board on Health Promotion and Disease Prevention of the Institute of Medicine (IOM), in conjunction with the Board on Children and Families of the Commission on Behavioral Social Sciences and Education and the IOM, met to assess the state of the art and science regarding social marketing concepts and strategies in adolescent and minority populations. In summary, the group recognized the importance of promoting healthful behaviors in these populations, but the effectiveness of implementing social marketing approaches to facilitate and sustain behavioral change specific to these two populations remains disappointingly unproven. Despite two decades of empirical research in this area, there remains no firm foundation of scientific theory and empirical research to understand and validate the efficacy of various social marketing programs for these populations. Several research questions emerged from the review of the papers on social marketing in adolescent and minority populations. The Board on Health Promotion and Disease Prevention suggests that these research issues be addressed in future social marketing studies.

In times of crisis, such as during the early 1980s when acquired immune deficiency syndrome (AIDS) was first recognized as a threat to the blood supply, it can be difficult to find reliable evidence upon which to base appropriate public health policies. Unreliable evidence produces substantial scientific uncertainty. Yet despite ambiguity and unanswered questions, decisions must be made and policy established to protect people’s health. The precautionary principle provides important guidelines for public health policy decision making that are of particular value in times of crisis, such as the emergence of a new pathogen: be open and honest about scientific uncertainty; communicate with the public; and consider immediate, adaptable policy decisions. Ongoing research into the important uncertainties and review of policies in light of the data that emerge are crucial to the development of good public policy.

With the history of the U.S. federal budget for fiscal year 1986 as a vehicle, the usual processes in the executive branch and the Congress that establish health research priorities and the unusual developments that have shaped priorities for AIDS are described. In the 3 years between the initial formulation of the AIDS budget and its execution, there were numerous revisions and evidence of poor communication between scientists and policy makers. On the basis of this analysis, two recommendations are made: the director of the National Institutes of Health and the heads of other U.S. Public Health Service agencies should have discretionary funds to use for AIDS activities; and better channels of communication between the Congress, the Public Health Service, and outside biomedical researchers should be established for consultation on priorities for AIDS research.

One of the critical policy questions raised by the AIDS epidemic is the proper size of the United States federal government's commitment to AIDS-related research. The extent of the federal government's investment in AIDS-related research in relation to research investments in cancer, coronary heart disease, and unintentional injuries is examined. Appropriation levels for fiscal year 1986 are divided by indexes of projected disease burden for 1991 to create a research investment ratio for each health impairment. Indexes of disease burden include numbers of total deaths, early deaths, expected life years lost, and discounted life years lost and direct economic costs. Despite the uncertainty about the future of the AIDS epidemic, there is no indication that AIDS is being overfunded relative to cancer and heart disease. Injuries appear to receive relatively low funding priority. Confident conclusions about research priority depend upon resolution of qualitative considerations and better understanding of the dynamics of the AIDS epidemic.