A Large-Scale Points-of-Dispensing Exercise for First Responders and First Receivers in Nassau County, New York

Allocation of scarce resources in a pandemic: rapid systematic review update of strategies for policymakers

OBJECTIVE

In pandemics like COVID-19, the need for medical resources quickly outpaces available supply. policymakers need strategies to inform decisions about allocating scarce resources.

STUDY DESIGN AND SETTING

We updated a systematic review on evidence-based approaches and searched databases through May 2020 for evaluation of strategies for policymakers.

RESULTS

The 201 identified studies evaluated reducing demand for healthcare, optimizing existing resources, augmenting resources, and adopting crisis standards of care. Most research exists to reduce demand (n = 149); 39 higher quality studies reported benefits of contact tracing, school closures, travel restrictions, and mass vaccination. Of 28 strategies to augment resources, 6 higher quality studies reported effectiveness of establishing temporary facilities, use of volunteers, and decision support software. Of 23 strategies to optimize existing resources, 12 higher quality studies reported successful scope of work expansions and building on existing interagency agreements. Of 15 COVID-19 studies, 5 higher quality studies reported on combinations of policies and benefits of community-wide mask policies.

CONCLUSION

Despite the volume, the evidence base is limited; few strategies were empirically tested in robust study designs. The review provides a comprehensive overview of the effects of strategies to allocate resources and provides critical appraisal to identify the best available evidence.

County-Level Planning for Efficient Distribution of Emergency Medical Countermeasures with RealOpt Software

Emergency preparedness systems plan for antibiotic distribution and vaccine administration to respond to public health threats. The arrival of a COVID-19 vaccine underscores the importance of organized logistics for rapid administration to populations. The US Centers for Disease Control and Prevention Cities Readiness Initiative encourages frontline responders from 72 US cities and metropolitan statistical areas to use planning software, such as RealOpt-POD-v8.0.2, to design dispensing operations and predict staffing needs. However, planning can be difficult for local jurisdictions given uncertainty about how long it may take to complete various processes during a dispensing operation, including assessment of countermeasure needs for each person (eg, based on age or pregnancy status) and the careful dispensing of countermeasures and accompanying education. The Union County Health Department in Ohio gathered data on the timing of typical processes for an anthrax medical countermeasures distribution site through a small-scale drill and used these data to parameterize a RealOpt model capable of serving the rural county's population of just over 50,000 people within 24 hours. Results help fill a gap in parameterizing RealOpt-based planning models by highlighting the use of a small-scale drill to inform time estimates, which can be applied to RealOpt as part of county-level planning in advance of larger-scale drills to evaluate dispensing capabilities and effectiveness. The findings provide a methodological basis of future resource typing for adaptable and scalable dispensing, particularly for rural areas. Both the approach and resulting antibiotics dispensing schematic presented here could be tailored to support planning for population-based countermeasure administration to combat emerging pandemics.

Developing Public Health Emergency Response Leaders in Incident Management: A Scoping Review of Educational Interventions

During emergency responses, public health leaders frequently serve in incident management roles that differ from their routine job functions. Leaders' familiarity with incident management principles and functions can influence response outcomes. Therefore, training and exercises in incident management are often required for public health leaders. To describe existing methods of incident management training and exercises in the literature, we queried 6 English language databases and found 786 relevant articles. Five themes emerged: (1) experiential learning as an established approach to foster engaging and interactive learning environments and optimize training design; (2) technology-aided decision support tools are increasingly common for crisis decision-making; (3) integration of leadership training in the education continuum is needed for developing public health response leaders; (4) equal emphasis on competency and character is needed for developing capable and adaptable leaders; and (5) consistent evaluation methodologies and metrics are needed to assess the effectiveness of educational interventions.These findings offer important strategic and practical considerations for improving the design and delivery of educational interventions to develop public health emergency response leaders. This review and ongoing real-world events could facilitate further exploration of current practices, emerging trends, and challenges for continuous improvements in developing public health emergency response leaders.

Multiagency programs with police as a partner for reducing radicalisation to violence

Background

Multiagency responses to reduce radicalisation often involve collaborations between police, government, nongovernment, business and/or community organisations. The complexities of radicalisation suggest it is impossible for any single agency to address the problem alone. Police-involved multiagency partnerships may disrupt pathways from radicalisation to violence by addressing multiple risk factors in a coordinated manner.

Objectives

1.Synthesise evidence on the effectiveness of police-involved multiagency interventions on radicalisation or multiagency collaboration 2.Qualitatively synthesise information about how the intervention works (mechanisms), intervention context (moderators), implementation factors and economic considerations.

Search Methods

Terrorism-related terms were used to search the Global Policing Database, terrorism/counterterrorism websites and repositories, and relevant journals for published and unpublished evaluations conducted 2002-2018. The search was conducted November 2019. Expert consultation, reference harvesting and forward citation searching was conducted November 2020.

Selection Criteria

Eligible studies needed to report an intervention where police partnered with at least one other agency and explicitly aimed to address terrorism, violent extremism or radicalisation. Objective 1 eligible outcomes included violent extremism, radicalisation and/or terrorism, and multiagency collaboration. Only impact evaluations using experimental or robust quasi-experimental designs were eligible. Objective 2 placed no limits on outcomes. Studies needed to report an empirical assessment of an eligible intervention and provide data on mechanisms, moderators, implementation or economic considerations.

Data Collection and Analysis

The search identified 7384 records. Systematic screening identified 181 studies, of which five were eligible for Objective 1 and 26 for Objective 2. Effectiveness studies could not be meta-analysed, so were summarised and effect size data reported. Studies for Objective 2 were narratively synthesised by mechanisms, moderators, implementation, and economic considerations. Risk of bias was assessed using ROBINS-I, EPHPP, EMMIE and CASP checklists.

Results

One study examined the impact on vulnerability to radicalisation, using a quasi-experimental matched comparison group design and surveys of volunteers (n = 191). Effects were small to medium and, aside from one item, favoured the intervention. Four studies examined the impact on the nature and quality of multiagency collaboration, using regression models and surveys of practitioners. Interventions included: alignment with national counterterrorism guidelines (n = 272); number of counterterrorism partnerships (n = 294); influence of, or receipt of, homeland security grants (n = 350, n = 208). Study findings were mixed. Of the 181 studies that examined mechanisms, moderators, implementation, and economic considerations, only 26 studies rigorously examined mechanisms (k = 1), moderators (k = 1), implementation factors (k = 21) or economic factors (k = 4).All included studies contained high risk of bias and/or methodological issues, substantially reducing confidence in the findings.

Authors' Conclusions

A limited number of effectiveness studies were identified, and none evaluated the impact on at-risk or radicalised individuals. More investment needs to be made in robust evaluation across a broader range of interventions.Qualitative synthesis suggests that collaboration may be enhanced when partners take time to build trust and shared goals, staff are not overburdened with administration, there are strong privacy provisions for intelligence sharing, and there is ongoing support and training.

Are US jurisdictions prepared to dispense medical countermeasures through open points of dispensing? Findings from a national study

Communities will rely on open points of dispensing (PODs) for mass dispensing of medical countermeasures following a bioterrorism attack or a pandemic. US Cities Readiness Initiative (CRI) open POD preparedness is assessed using the Technical Assistance Review (TAR) but focuses on oral prophylaxis dispensing; mass vaccination readiness is not well measured. Non-CRI preparedness had not been studied. In 2013 an online questionnaire was sent to all 456 CRIs and a random sample of 500 non-CRIs to measure open POD preparedness and exercise participation. Hierarchical linear regression was used to describe factors associated with higher POD preparedness and exercise participation scores. In total, 257 subjects participated, for a 41% response rate. Almost all open PODs have existing written plans and/or a layout for each site (93.4%, n=240, and 87.0%, n=220). Only half (46.7%, n=120) have an alternative dispensing modality in place, and even fewer (42.6%, n=104) report having adequate staffing. Determinants of open POD preparedness were perceived preparedness, participation in more POD exercises, and more closed POD coverage. Most jurisdictions conducted a full-scale exercise and a staff notification drill (83.7%, n=215 for both). Fewer than half (40.5%, n=104) have conducted a vaccination clinic exercise. Determinants of increased POD exercises were perceived preparedness, years of work experience, community type (nontribal), and larger population. Because successful open POD deployment is critical, jurisdictions need to plan for mass vaccination, use of alternative dispensing modalities, and recruitment strategies to increase POD staffing.

The planning, execution, and evaluation of a mass prophylaxis full-scale exercise in cook county, IL

Increasing threats of bioterrorism and the emergence of novel disease agents, including the recent international outbreaks of H7N9 influenza and MERS-CoV, have stressed the importance and highlighted the need for public health preparedness at local, regional, and national levels. To test plans that were developed for mass prophylaxis scenarios, in April 2013 the Cook Country Department of Public Health (CCDPH) and the Triple Community (TripCom) Medical Reserve Corps (MRC) executed a full-scale mass prophylaxis exercise in response to a simulated anthrax bioterrorism attack. The exercise took place over 2 days and included the TripCom Point-of-Dispensing (POD) Management Team, volunteers from the TripCom MRC, and neighboring public health departments and MRCs. Individuals from the community volunteered as actors during the exercise, while local municipal, police, and fire personnel coordinated their responses to create the most realistic simulation possible. The exercise was designed to test the capacity of TripCom and CCDPH to implement plans for organizing municipal staff and volunteers to efficiently distribute prophylaxis to the community. Based on results from POD clinic flow, accuracy of prophylaxis distribution, and observations from evaluators, the exercise was successful in demonstrating areas that were operationally efficient as well as identifying areas that can be improved on. These include improvements to the just-in-time training for POD staff, the health screening and consent forms handed out to patients, the physical setup of the POD, and the command structure and communication for the management of POD operations. This article demonstrates the need for full-scale exercises and identifies gaps in POD planning that can be integrated into future plans, exercises, and emergency response.

Systematic review of strategies to manage and allocate scarce resources during mass casualty events

STUDY OBJECTIVE

Efficient management and allocation of scarce medical resources can improve outcomes for victims of mass casualty events. However, the effectiveness of specific strategies has never been systematically reviewed. We analyze published evidence on strategies to optimize the management and allocation of scarce resources across a wide range of mass casualty event contexts and study designs.

METHODS

Our literature search included MEDLINE, Scopus, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Global Health, Web of Science, and the Cochrane Database of Systematic Reviews, from 1990 through late 2011. We also searched the gray literature, using the New York Academy of Medicine's Grey Literature Report and key Web sites. We included both English- and foreign-language articles. We included studies that evaluated strategies used in actual mass casualty events or tested through drills, exercises, or computer simulations. We excluded studies that lacked a comparison group or did not report quantitative outcomes. Data extraction, quality assessment, and strength of evidence ratings were conducted by a single researcher and reviewed by a second; discrepancies were reconciled by the 2 reviewers. Because of heterogeneity in outcome measures, we qualitatively synthesized findings within categories of strategies.

RESULTS

From 5,716 potentially relevant citations, 74 studies met inclusion criteria. Strategies included reducing demand for health care services (18 studies), optimizing use of existing resources (50), augmenting existing resources (5), implementing crisis standards of care (5), and multiple categories (4). The evidence was sufficient to form conclusions on 2 strategies, although the strength of evidence was rated as low. First, as a strategy to reduce demand for health care services, points of dispensing can be used to efficiently distribute biological countermeasures after a bioterrorism attack or influenza pandemic, and their organization influences speed of distribution. Second, as a strategy to optimize use of existing resources, commonly used field triage systems do not perform consistently during actual mass casualty events. The number of high-quality studies addressing other strategies was insufficient to support conclusions about their effectiveness because of differences in study context, comparison groups, and outcome measures. Our literature search may have missed key resource management and allocation strategies because of their extreme heterogeneity. Interrater reliability was not assessed for quality assessments or strength of evidence ratings. Publication bias is likely, given the large number of studies reporting positive findings.

CONCLUSION

The current evidence base is inadequate to inform providers and policymakers about the most effective strategies for managing or allocating scarce resources during mass casualty events. Consensus on methodological standards that encompass a range of study designs is needed to guide future research and strengthen the evidence base. Evidentiary standards should be developed to promote consensus interpretations of the evidence supporting individual strategies.