NEWS

• THE EBOLA EPIDEMIC – Ebola case counts now total 24,754 (suspected, probable, and confirmed) with 10,236 deaths in the countries with widespread transmission during the 2014-15 epidemic. Last month’s totals were 23,694 cases with 9,589 deaths. Another impact of Ebola: the disruption of routine healthcare in West Africa reduces immunizations in a region where measles is already endemic. Although Ebola mostly affects adults, children would bear the brunt of a measles outbreak in West Africa.

• MEASLES – The 2015 measles outbreak in the US totals 176 cases through March 13.

• DROUGHT UPDATES – The severe drought in US western states raises the question whether we should have a national water policy to guide the sharing of water resources among states.

• NUCLEAR THREATS – National security planners have long emphasized the danger posed by terrorists gaining access to radioactive material, with most scenarios involving sources outside the country. Eric Schlosser describes the lax security at American nuclear weapons facilities that has repeatedly been exposed by peace activists protesting at “secure” industrial and military sites.

TOOLS

• NATIONAL HEALTH SECURITY STRATEGY AND IMPLEMENTATION PLAN 2015-2018

  Assistant Secretary for Preparedness and Response
  Department of Health and Human Services

  The new ASPR planning document is one in a series of national efforts to minimize the health consequences of large-scale emergencies. Strategies account for a broad range of threats, including severe weather, infectious diseases, hazardous material exposures, and terrorist attacks. Dangers are exacerbated by vulnerabilities: at-risk individuals, weak social networks, unprotected critical infrastructure, a lack of training and exercising for health security, and a lack of available countermeasures for emerging infectious diseases. At-risk individuals include children, senior citizens, pregnant women, those with disabilities, those who live in institutionalized settings, are from diverse cultures, have limited English proficiency or are non-English speaking, lack transportation, have chronic medical disorders, or have pharmacological dependency. Health effects of major emergencies are explicitly identified as potential national security threats. Current health security strategies are informed by many factors. Opportunities to improve emergency preparedness depend on the effective operations of the everyday preventive, acute, and chronic healthcare system. Emergency preparedness must compete with numerous other priorities for finite resources. Technology introduces solutions as well as vulnerabilities in emergencies. Real advances in preparedness must be guided by the evidence gained in scientific research. All hazards could be intensified by the apparent increase in extreme weather and climate events.

  Objectives are proposed:
  1. Healthy resilient communities.
  – Promote social connections, partnerships, everyday healthcare quality.
  2. Medical countermeasures and non-pharmaceutical interventions.
  – Emphasize research and development.
  3. Health situational awareness.
  – Identify risks, share data ahead of time and in real time during emergencies, and     exploit information technology.
  4. Integrate public health, healthcare, and emergency management.
  – Promote coalitions that build upon existing services.
  5. Strengthen global health security.
  – Promote global disease prevention, detection, response.

  Priority questions are identified for researchers.
  1. Resilience – How should we use traditional and new media to promote connections in communities? What disaster recovery education activities are effective? What incentives will promote healthcare and human service providers to participate in preparedness activities?
  2. Countermeasures (pharmacologic and nonpharmacologic) – How should we address gaps in healthcare provider preparedness? Promote basic research on countermeasures (antimicrobial resistance, candidate drugs, vaccines, and diagnostics, strategic national stockpiles, personal protective equipment, social distancing, and other community mitigation strategies are priorities).
  3. Situational awareness – How should we optimize the sharing, analysis, and interpretation of data, test methods of decision support, while maintaining privacy and cybersecurity?
  4. Integration of systems – What metrics to evaluate emergency management and coalition performance, particularly for incidents involving children? Priorities include surge capabilities, patient tracking (especially locating at-risk individuals), family reunification, telemedicine, and electronic record compatibility.
  5. Global preparedness – Identify, document, disseminate, and learn from international health security experiences. Alert systems and risk communications are priorities.

  There are educational opportunities for improvement across all areas of preparedness.

  Issues and questions:
  1. All aspects of preparedness must address the unique age specific needs and vulnerabilities for children, while recognizing that pediatric specific resources are limited, and care of children must be well integrated and practiced across general systems of care. The new planning document provides very little pediatric-specific guidance.
  2. How much funding will be available for research, development, and coordinated implementation? As Anthony Biglan points out, very little research provides empirical insight into what interventions work for terrorism, or for large-scale emergencies in general. What are the risk factors? What interventions modify the risk factors? What interventions modify the adverse effects of a disaster? Lack of research funding is a limiting factor.
  3. Timid research strategies generally fail to utilize randomized designs to find out what really works even when funding is available. Disaster researchers should see the healthcare policy commentary by Finkelstein and Taubman on randomized studies to improve healthcare delivery. Only 18% of US health services research published in top journals used randomized designs, compared with 79% of US studies of medical interventions. Sometimes randomized designs in health services research can increase insights about what works without substantial increase in cost or difficulty. Where there is equipoise regarding effectiveness, there is no ethical obstacle to randomization. Where there is capacity constraint, random assignment is equitable. For low risk interventions, waiver of informed consent is appropriate and eligible populations are offered the intervention, avoiding the need for individual recruitment. Randomization may occur at the level of individuals or at the level of organizations across the system. When important variables and results are adequately represented in existing administrative data, no additional information needs to be collected on individual patients. As always, good experimental design, interventions, and data collection must be planned ahead of time.

SCIENCE

• H7N9 INFLUENZA VIRUSES IN CHINA – Surveillance has demonstrated the spread of an avian influenza virus from eastern into southern China. Although sustained human to human transmission has not occurred, the virus has the potential to emerge as a dangerous human pathogen.

• EMERGENCY DEPARTMENT UTILIZATION AFTER THE AFFORDABLE CARE ACT – Emergency department utilization after the affordable care act declined modestly in young adults, with the decrease concentrated among women, weekday visits, nonurgent conditions, and conditions that can be treated in other settings.

Edited by: Dr. Bob Kanter