Healthcare epidemiology: the current status of planning for pandemic influenza and implications for health care planning in the United States

Improving normothermic machine perfusion and blood transfusion through biocompatible blood silicification

The growing world population and increasing life expectancy are driving the need to improve the quality of blood transfusion, organ transplantation, and preservation. Here, to improve the ability of red blood cells (RBCs) for normothermic machine perfusion, a biocompatible blood silicification approach termed "shielding-augmenting RBC-in-nanoscale amorphous silica (SARNAS)" has been developed. The key to RBC surface engineering and structure augmentation is the precise control of the hydrolysis form of silicic acid to realize stabilization of RBC within conformal nanoscale silica-based exoskeletons. The formed silicified RBCs (Si-RBCs) maintain membrane/structural integrity, normal cellular functions (e.g., metabolism, oxygen-carrying capability), and enhance resistance to external stressors as well as tunable mechanical properties, resulting in nearly 100% RBC cryoprotection. In vivo experiments confirm their excellent biocompatibility. By shielding RBC surface antigens, the Si-RBCs provide universal blood compatibility, the ability for allogeneic mechanical perfusion, and more importantly, the possibility for cross-species transfusion. Being simple, reliable, and easily scalable, the SARNAS strategy holds great promise to revolutionize the use of engineered blood for future clinical applications.

Bolstering health systems to cope with the impacts of climate change events: A review of the evidence on workforce planning, upskilling, and capacity building

BACKGROUND

As global CO2 emissions continue to rise and the 'era of global boiling' takes hold, the health workforce must cope with the challenge of providing care to increasing numbers of patients affected by climate change-related events (e.g., hurricanes, wildfires, floods). In this review, we describe the impacts of these events on the health workforce, and strategies responding to these challenges.

METHODS

This rapid systematic review was guided by the Preferred Reporting Items for Systematic reviews and Meta-Analyses and a registered protocol (PROSPERO CRD42023433610). Eight databases were searched in May 2022 and again in June 2023. Empirical studies discussing climate change and workforce policy, planning, preparedness, and capacity were included. Inductive thematic analysis of extracted data was conducted.

RESULTS

From the 60 included studies, two categories emerged: the impacts of climate events on the health workforce (n = 39), and workforce responses to and preparations for climate events (n = 58). Thirty-seven studies reported on both categories. Four impact themes were identified: absenteeism, psychological impacts, system breakdown, and unsafe working conditions; and six responses and preparations themes: training/skill development, workforce capacity planning, interdisciplinary collaboration, role flexibility, role incentivisation, and psychological support.

CONCLUSION

This review provides an overview of some of the deleterious impacts of climate events on the health workforce, as well as potential strategies for the health workforce to prepare or respond to climate events. Future studies should assess the implementation and effectiveness of these strategies to ensure a continuously improving healthcare system, and a well-supported health workforce.

The role of health systems for health security: a scoping review revealing the need for improved conceptual and practical linkages

BACKGROUND

Practical links between health systems and health security are historically prevalent, but the conceptual links between these fields remain under explored, with little on health system strengthening. The need to address this gap gains relevance in light of the COVID-19 pandemic as it demonstrated a crucial relationship between health system capacities and effective health security response. Acknowledging the importance of developing stronger and more resilient health systems globally for health emergency preparedness, the WHO developed a Health Systems for Health Security framework that aims to promote a common understanding of what health systems for health security entails whilst identifying key capacities required.

METHODS/ RESULTS

To further explore and analyse the conceptual and practical links between health systems and health security within the peer reviewed literature, a rapid scoping review was carried out to provide an overview of the type, extent and quantity of research available. Studies were included if they had been peer-reviewed and were published in English (seven databases 2000 to 2020). 343 articles were identified, of those 204 discussed health systems and health security (high and medium relevance), 101 discussed just health systems and 47 discussed only health security (low relevance). Within the high and medium relevance articles, several concepts emerged, including the prioritization of health security over health systems, the tendency to treat health security as exceptionalism focusing on acute health emergencies, and a conceptualisation of security as 'state security' not 'human security' or population health.

CONCLUSION

Examples of literature exploring links between health systems and health security are provided. We also present recommendations for further research, offering several investments and/or programmes that could reliably lead to maximal gains from both a health system and a health security perspective, and why these should be explored further. This paper could help researchers and funders when deciding upon the scope, nature and design of future research in this area. Additionally, the paper legitimises the necessity of the Health Systems for Health Security framework, with the findings of this paper providing useful insights and evidentiary examples for effective implementation of the framework.

COVID-19 related innovation in Aotearoa/New Zealand mental health helplines and telehealth providers - mapping solutions and discussing sustainability from the perspective of service providers

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic and associated interventions resulted in changes in both the demand and supply of mental health services and necessitated agile adaptation and innovation from service providers.

AIMS

The aim of this study was to explore what innovative solutions were adopted in response to COVID-19 and the pandemic control measures, what opportunities and challenges were associated with these innovations, as well as to critically reflect on the longer-term sustainability of the innovations in the context of Aotearoa/New Zealand mental healthcare.

MATERIALS AND METHODS

We used thematic analysis to analyse the data from the 23 in-depth interviews with helpline employees and general practitioners from 18 service providers that regularly engage in mental healthcare.

RESULTS

Two key themes related to COVID-19 and the pandemic control measures were identified from respondents' accounts. These were "Technological innovations" and "Process innovations" where providers noted types of innovative solutions, and opportunities and challenges associated with those. The themes culminated in a meta theme "Sustainability of changes to service delivery" that appeared consistently in each theme and asks to consider how sustainable these innovative solutions might be in the long-term. Namely, sustainability of innovation was questioned in respect to the (a) innovative solutions being the emergency solutions with little or no impact analysis, (b) "returning back to normal" due to limited future funding and innovation as a sunk cost, and (c) sporadic and inconsistent innovation between service providers that does not contribute to quality and continuity of care from the systems perspective.

CONCLUSION

COVID-19 and the measures of pandemic control were associated with an increase in innovative solutions from service providers. There were both opportunities and challenges associated with these innovative efforts and the sustainability of innovation was questioned. Future research about COVID-19 related innovation of service provision should focus on service user experiences and empirically measure the innovation safety and efficacy.

Triage tool for the rationing of blood for massively bleeding patients during a severe national blood shortage: guidance from the National Blood Transfusion Committee

The emerging COVID-19 pandemic has overwhelmed healthcare resources worldwide, and for transfusion services this could potentially result in rapid imbalance between supply and demand due to a severe shortage of blood donors. This may result in insufficient blood components to meet every patient's needs resulting in difficult decisions about which patients with major bleeding do and do not receive active transfusion support. This document, which was prepared on behalf of the National Blood Transfusion Committee in England, provides a framework and triage tool to guide the allocation of blood for patients with massive haemorrhage during severe blood shortage. Its goal is to provide blood transfusions in an ethical, fair, and transparent way to ensure that the greatest number of life years are saved. It is based on an evidence- and ethics-based Canadian framework, and would become operational where demand for blood greatly exceeds supply, and where all measures to manage supply and demand have been exhausted. The guidance complements existing national shortage plans for red cells and platelets.

Crisis Standards of Care Implementation at the State Level in the United States

Introduction:

In 2009, the Institute of Medicine published guidelines for implementation of Crisis Standards of Care (CSC) at the state level in the United States (US). Based in part on the then concern for H1N1 pandemic, there was a recognized need for additional planning at the state level to maintain health system preparedness and conventional care standards when available resources become scarce. Despite the availability of this framework, in the years since and despite repeated large-scale domestic events, implementation remains mixed.

Problem:

Coronavirus disease 2019 (COVID-19) rejuvenates concern for how health systems can maintain quality care when faced with unrelenting burden. This study seeks to outline which states in the US have developed CSC and which areas of care have thus far been addressed.

Methods:

An online search was conducted for all 50 states in 2015 and again in 2020. For states without CSC plans online, state officials were contacted by email and phone. Public protocols were reviewed to assess for operational implementation capabilities, specifically highlighting guidance on ventilator use, burn management, sequential organ failure assessment (SOFA) score, pediatric standards, and reliance on influenza planning.

Results:

Thirty-six states in the US were actively developing (17) or had already developed (19) official CSC guidance. Fourteen states had no publicly acknowledged effort. Eleven of the 17 public plans had updated within five years, with a majority addressing ventilator usage (16/17), influenza planning (14/17), and pediatric care (15/17), but substantially fewer addressing care for burn patients (9/17).

Conclusion:

Many states lacked publicly available guidance on maintaining standards of care during disasters, and many states with specific care guidelines had not sufficiently addressed the full spectrum of hazard to which their health care systems remain vulnerable.

Surge capacity principles: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement

BACKGROUND

This article provides consensus suggestions for expanding critical care surge capacity and extension of critical care service capabilities in disasters or pandemics. It focuses on the principles and frameworks for expansion of intensive care services in hospitals in the developed world. A companion article addresses surge logistics, those elements that provide the capability to deliver mass critical care in disaster events. The suggestions in this article are important for all who are involved in large-scale disasters or pandemics with injured or critically ill multiple patients, including front-line clinicians, hospital administrators, and public health or government officials.

METHODS

The Surge Capacity topic panel developed 23 key questions focused on the following domains: systems issues; equipment, supplies, and pharmaceuticals; staffing; and informatics. Literature searches were conducted to identify evidence on which to base key suggestions. Most reports were small scale, were observational, or used flawed modeling; hence, the level of evidence on which to base recommendations was poor and did not permit the development of evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. Suggestions from the previous task force were also included for validation by the expert panel.

RESULTS

This article presents 10 suggestions pertaining to the principles that should guide surge capacity and capability planning for mass critical care, including the role of critical care in disaster planning; the surge continuum; targets of surge response; situational awareness and information sharing; mitigating the impact on critical care; planning for the care of special populations; and service deescalation/cessation (also considered as engineered failure).

CONCLUSIONS

Future reports on critical care surge should emphasize population-based outcomes as well as logistical details. Planning should be based on the projected number of critically ill or injured patients resulting from specific scenarios. This should include a consideration of ICU patient care requirements over time and must factor in resource constraints that may limit the ability to provide care. Standard ICU management forms and patient data forms to assess ICU surge capacity impacts should be created and used in disaster events.

Health systems' "surge capacity": state of the art and priorities for future research

CONTEXT

Over the past decade, a number of high-impact natural hazard events, together with the increased recognition of pandemic risks, have intensified interest in health systems' ability to prepare for, and cope with, "surges" (sudden large-scale escalations) in treatment needs. In this article, we identify key concepts and components associated with this emerging research theme. We consider the requirements for a standardized conceptual framework for future research capable of informing policy to reduce the morbidity and mortality impacts of such incidents. Here our objective is to appraise the consistency and utility of existing conceptualizations of health systems' surge capacity and their components, with a view to standardizing concepts and measurements to enable future research to generate a cumulative knowledge base for policy and practice.

METHODS

A systematic review of the literature on concepts of health systems' surge capacity, with a narrative summary of key concepts relevant to public health.

FINDINGS

The academic literature on surge capacity demonstrates considerable variation in its conceptualization, terms, definitions, and applications. This, together with an absence of detailed and comparable data, has hampered efforts to develop standardized conceptual models, measurements, and metrics. Some degree of consensus is evident for the components of surge capacity, but more work is needed to integrate them. The overwhelming concentration in the United States complicates the generalizability of existing approaches and findings.

CONCLUSIONS

The concept of surge capacity is a useful addition to the study of health systems' disaster and/or pandemic planning, mitigation, and response, and it has far-reaching policy implications. Even though research in this area has grown quickly, it has yet to fulfill its potential to generate knowledge to inform policy. Work is needed to generate robust conceptual and analytical frameworks, along with innovations in data collection and methodological approaches that enhance health systems' readiness for, and response to, unpredictable high-consequence surges in demand.

Ethical Considerations for Emergency Care Providers during Pandemic Influenza–Ready or Not…

When an infectious pandemic occurs in the United States, emergency care providers (ECPs) will be on the frontlines caring for infected, potentially infected, and non-infected patients. Logistically, the current emergency care system is not ready for a pandemic, but are the providers ethically ready? Some of the most difficult and challenging issues that will be raised during a pandemic will be ethical in nature. An ECP likely will be confronted with ethical values and value conflicts underlying restriction of liberty, duty to care, and resource allocation.

This report summarizes the ethical concerns and challenges that ECPs face during an infectious pandemic, and raises ethical questions that may arise related to the role of an ECP as a healthcare provider and stakeholder.

Closing schools in response to the 2009 pandemic influenza A H1N1 virus in New York City: economic impact on households

Understanding the effectiveness of a school closure in limiting social interaction and the economic impact of school closure on households is critical when developing guidelines to prevent spread of pandemic influenza. A New York City survey conducted in June 2009 in 554 households affected by the 2009 pandemic influenza H1N1-related school closures showed that, during closure, 30% of students visited at least 1 locale outside their homes. If all the adults in the home were employed, an ill child was less likely to leave home. In 17% of the households, at least 1 adult missed some work because of the closure. If all adults in the home were employed, someone was more likely to take time off work. If other children were in the household, it was less likely that an adult took time off work. The findings of our study will be important when developing future pandemic school-closure guidance.

Pandemic influenza: implications for preparation and delivery of critical care services

In a 5-week span during the 1918 influenza A pandemic, more than 2000 patients were admitted to Cook County Hospital in Chicago, with a diagnosis of either influenza or pneumonia; 642 patients, approximately 31% of those admitted, died, with deaths occurring predominantly in patients of age 25 to 30 years. This review summarizes basic information on the biology, epidemiology, control, treatment and prevention of influenza overall, and then addresses the potential impact of pandemic influenza in an intensive care unit setting. Issues that require consideration include workforce staffing and safety, resource management, alternate sites of care surge of patients, altered standards of care, and crisis communication.

[Mathematical modeling of the novel influenza A (H1N1) virus and evaluation of the epidemic response strategies in the Republic of Korea]

OBJECTIVES

The pandemic of novel influenza A (H1N1) virus has required decision-makers to act in the face of the substantial uncertainties. In this study, we evaluated the potential impact of the pandemic response strategies in the Republic of Korea using a mathematical model.

METHODS

We developed a deterministic model of a pandemic (H1N1) 2009 in a structured population using the demographic data from the Korean population and the epidemiological feature of the pandemic (H1N1) 2009. To estimate the parameter values for the deterministic model, we used the available data from the previous studies on pandemic influenza. The pandemic response strategies of the Republic of Korea for novel influenza A (H1N1) virus such as school closure, mass vaccination (70% of population in 30 days), and a policy for anti-viral drug (treatment or prophylaxis) were applied to the deterministic model.

RESULTS

The effect of two-week school closure on the attack rate was low regardless of the timing of the intervention. The earlier vaccination showed the effect of greater delays in reaching the peak of outbreaks. When it was no vaccination, vaccination at initiation of outbreak, vaccination 90 days after the initiation of outbreak and vaccination at the epidemic peak point, the total number of clinical cases for 400 days were 20.8 million, 4.4 million, 4.7 million and 12.6 million, respectively. The pandemic response strategies of the Republic of Korea delayed the peak of outbreaks (about 40 days) and decreased the number of cumulative clinical cases (8 million).

CONCLUSIONS

Rapid vaccination was the most important factor to control the spread of pandemic influenza, and the response strategies of the Republic of Korea were shown to delay the spread of pandemic influenza in this deterministic model.

Medical response planning for pandemic flu

This quantitative research study evaluates the health care infrastructure necessary to provide medical care in US hospitals during a flu pandemic. These hospitals are identified within the US health care system because they operate airborne infectious isolation rooms. Data were obtained from the 2006 American Hospital Association annual survey. This data file provides essential information on individual US hospitals and identifies the health care capabilities in US communities. Descriptive statistics were evaluated to examine hospitals with the appropriate infrastructure to treat a flu pandemic. In addition, geographic information system software was used to identify geographic areas where essential infrastructure is lacking. The study found 3,341 US hospitals operate airborne infectious isolation rooms, representing 69% of reporting hospitals. The results also indicate that those hospitals with airborne infectious isolation rooms are larger and are located in metropolitan areas. The study has managerial implications associated with local medical disaster response and policy implications on the allocation of disaster resources.

Impact of non-pharmaceutical interventions on URIs and influenza in crowded, urban households

OBJECTIVES

We compared the impact of three household interventions-education, education with alcohol-based hand sanitizer, and education with hand sanitizer and face masks-on incidence and secondary transmission of upper respiratory infections (URIs) and influenza, knowledge of transmission of URIs, and vaccination rates.

METHODS

A total of 509 primarily Hispanic households participated. Participants reported symptoms twice weekly, and nasal swabs were collected from those with an influenza-like illness (ILI). Households were followed for up to 19 months and home visits were made at least every two months.

RESULTS

We recorded 5034 URIs, of which 669 cases reported ILIs and 78 were laboratory-confirmed cases of influenza. Demographic factors significantly associated with infection rates included age, gender, birth location, education, and employment. The Hand Sanitizer group was significantly more likely to report that no household member had symptoms (p < 0.01), but there were no significant differences in rates of infection by intervention group in multivariate analyses. Knowledge improved significantly more in the Hand Sanitizer group (p < 0.0001). The proportion of households that reported > or = 50% of members receiving influenza vaccine increased during the study (p < 0.001). Despite the fact that compliance with mask wearing was poor, mask wearing as well as increased crowding, lower education levels of caretakers, and index cases 0-5 years of age (compared with adults) were associated with significantly lower secondary transmission rates (all p < 0.02).

CONCLUSIONS

In this population, there was no detectable additional benefit of hand sanitizer or face masks over targeted education on overall rates of URIs, but mask wearing was associated with reduced secondary transmission and should be encouraged during outbreak situations. During the study period, community concern about methicillin-resistant Staphylococcus aureus was occurring, perhaps contributing to the use of hand sanitizer in the Education control group, and diluting the intervention's measurable impact.

Perspectives of future physicians on disaster medicine and public health preparedness: challenges of building a capable and sustainable auxiliary medical workforce

BACKGROUND

Although the training of future physicians in disaster preparedness and public health issues has been recognized as an important component of graduate medical education, medical students receive relatively limited exposure to these topics. Recommendations have been made to incorporate disaster medicine and public health preparedness into medical school curricula. To date, the perspectives of future physicians on disaster medicine and public health preparedness issues have not been described.

METHODS

A Web-based survey was disseminated to US medical students. Frequencies, proportions, and odds ratios were calculated to assess perceptions and self-described likelihood to respond to disaster and public health scenarios.

RESULTS

Of the 523 medical students who completed the survey, 17.2% believed that they were receiving adequate education and training for natural disasters, 26.2% for pandemic influenza, and 13.4% for radiological events, respectively; 51.6% felt they were sufficiently skilled to respond to a natural disaster, 53.2% for pandemic influenza, and 30.8% for radiological events. Although 96.0% reported willingness to respond to a natural disaster, 93.7% for pandemic influenza, and 83.8% for a radiological event, the majority of respondents did not know to whom they would report in such an event.

CONCLUSIONS

Despite future physicians' willingness to respond, education and training in disaster medicine and public health preparedness offered in US medical schools is inadequate. Equipping medical students with knowledge, skills, direction, and linkages with volunteer organizations may help build a capable and sustainable auxiliary workforce.

The pandemic influenza planning process in Ontario acute care hospitals

BACKGROUND

There will be little time to prepare when an influenza pandemic strikes; hospitals need to develop and test pandemic influenza plans beforehand.

METHODS

Acute care hospitals in Ontario were surveyed regarding their pandemic influenza preparedness plans.

RESULTS

The response rate was 78.5%, and 95 of 121 hospitals participated. Three quarters (76.8%, 73 of 95) of hospitals had pandemic influenza plans. Only 16.4% (12 of 73) of hospitals with plans had tested them. Larger (chi(2) = 6.7, P = .01) and urban hospitals (chi(2) = 5.0, P = .03) were more likely to have tested their plans. 70.4% (50 of 71) Of respondents thought the pandemic influenza planning process was not adequately funded. No respondents were "very satisfied" with the completeness of their hospital's pandemic plan, and only 18.3% were "satisfied."

CONCLUSION

Important challenges were identified in pandemic planning: one quarter of hospitals did not have a plan, few plans were tested, key players were not involved, plans were frequently incomplete, funding was inadequate, and small and rural hospitals were especially disadvantaged. If these problems are not addressed, the result may be increased morbidity and mortality when a virulent influenza pandemic hits.

Lack of cross-immune reactivity against influenza H5N1 from seasonal influenza vaccine in humans

In a small pilot study, sera from 10 healthy human volunteers were taken pre-vaccine, then 1, 3, and 6 months post-seasonal influenza immunization (using the 2005/2006 Northern hemisphere vaccine: A/New Caledonia/20/99(H1N1)-like, A/California/7/2004(H3N2)-like, and B/Shanghai/361/2002-like strains). Eight out of 10 subjects demonstrated satisfactory HAI titers (> or = 40) after seasonal influenza vaccination between 1 and 6 months post-vaccine. These sera were then tested for inhibitory activity against A/HK/483/97 and A/Thailand/1(KAN-1)/04 H5N1 influenza viruses using standard hemagglutination inhibition and microneutralization assays. In contrast to several other studies in both humans and animals on the cross-immunity between different influenza A viruses, antibodies produced to the influenza A(H1N1) component of the seasonal influenza vaccine showed no cross-reactivity to these avian influenza A(H5N1) viruses. Possible reasons for this contrasting result are discussed.