Public Health Preparedness: What Is It and What Can We Do to Improve It Christopher Nelson, Ph'D'

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Public Health Preparedness What Is It and What
Can We Do to Improve It?Christopher Nelson,
Ph.D.
This presentation reflects the authors judgments
and has not been subjected to RAND quality
assurance review.
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In Spite of Federal Investment, There Is Little
Consensus About What PHEP Is

• Over 7 billion in federal investment since 2001
  in state/local readiness
• Yet, we cannot say whether or not communities are
  ready
• It is difficult to improve a system you cant
  define

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Several Factors Make PHEP Difficult to
Characterize

• Large-scale public health emergencies are,
  fortunately, rare
• Few opportunities to use real-world data to
  identify key components
• PHEP involves coordination in a large
  decentralized national public health system
• Community characteristics, threat profiles vary
  considerably across communities

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Talk Draws Upon 5 Years of RAND Research

• RAND is a nonprofit, nonpartisan research
  organization, founded in 1946
• Most PHEP work has been through ASPR State and
  Local program
• Also VA, RWJF, NTI, private sector
• Over four dozen projects completed or underway
• Discrete, but related projects in four core areas
• Developing tools to assist preparedness efforts
• Identifying exemplary practices and lessons
  learned
• Pandemic influenza preparedness
• Advancing measurement, standards, and evaluation
  
• Work characterized by collaboration and frequent
  interaction with ASPR/CDC and state/local
  partners

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RAND Convened an Expert Panel to Develop a
Definition of Preparedness
What is apublic healthemergency?
What capabilitiesand resourcesare required?
Who needsto beinvolved?
Panel included thought leaders from public
health, hospitals/clinicalmedicine, emergency
management, community preparedness
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Panel Included Thought Leaders in Public Health,
Health, Emergency Management, Community
Preparedness

• James Gilmore III (chair)
• Georges Benjamin, MD, FACP
• Mark Ghilarducci
• Lewis Goldfrank, MD
• Lawrence Gostin, JD
• Shelley A. Hearne, DrPH
• Nathaniel Hupert, MD, MPH

• James J. James, MD, DrPH, MHA
• Ana-Marie Jones
• Kenneth W. Kizer, MD, MPH
• Howard Koh, MD, MPH
• John Lumpkin, MD, MPH
• Courtney Magnus

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Key Questions

• What is public health emergency preparedness
  (PHEP)?
• Whose job is it?
• What capabilities and capacities are most
  essential?
• What progress have we made? What remains to be
  done?

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The Definition of Preparedness

• Public health emergency preparedness (PHEP) is
  the capability of the public health and health
  care systems, communities, and individuals, to
  prevent, protect against, quickly respond to,
  and recover from health emergencies, particularly
  those whose scale, timing, or unpredictability
  threatens to overwhelm routine capabilities.
• Preparedness involves a coordinated and
  continuous process of planning and implementation
  that relies on measuring performance and taking
  corrective action.

Nelson, Lurie, Wasserman Zakowski (2007)
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Panel Adopted the All Hazards Approach
Infectious Disease
Earthquake
Typhoon
Bioterrorist Attack
Flood
Hurricane
Tsunami
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However, Emergencies Are Defined by Consequences,
Not Causes
Hazards

• Overwhelms routine capabilities
• Scale
• Rapid onset
• Uncertainty

Emergency
Vulnerabilities
Avoid focusing on the disaster du jour
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Actual and Likely Consequences of Some
Large-Scale Public Health Emergencies
Davis, Rough, et al (2007)
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Key Characteristics of Public Health Emergencies

• Agent/cause
• Number/location of people affected
• Severity
• Timeline
• Availability of countermeasures, other resources
• Population resilience
• Degree of uncertainty
• Adapted from Parker, Nelson, et al (2009)

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Key Questions

• What is public health emergency preparedness
  (PHEP)?
• What capabilities and capacities are most
  essential?
• Whose job is it?
• What progress have we made? What remains to be
  done?

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PHEP Involves Preventing, Responding to, and
Recovering From Public Health Emergencies
3
1
2
Recovery
Prevention
Response
Reducehazards
Prevention
Recovery
Response
Emergency
Prevention
Reducevulnerabilities
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PHEP Involves Preventing, Responding to, and
Recovering From Public Health Emergencies

• Expert and Fully Staffed Workforce
• Operations-ready workers volunteers
• Leadership
• Accountability Quality Improvement
• Testing operational capabilities
• Performance management
• Financial tracking

• Preplanned and Coordinated Rapid-Response
  Capability
• Health risk assessment
• Legal climate
• Roles responsibilities
• Incident Management
• Public engagement
• Epidemiology
• Laboratories
• Countermeasures mitigation strategies
• Mass health care
• Public Info/Communication
• Robust supply chains

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Prevention Can Reduce Both Hazards and
Vulnerabilities

• Poor prior health status increases odds of harm
  from public health emergencies
• Health risk assessment can provide strong
  priors for response
• Target rapid assessment activities
• Pre-identify communication challenges
• Etc.
• Considerable overlap with routine health promotion

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Panel Emphasized Operational Capabilities

• Capability Capacity Skill/Experience
• Having staff, equipment, plans does not mean you
  can use them
• Includes both individual skill and ensemble
  skills

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Responses Often Require Adaptation in Response to
Novel and Changing Circumstances
Select, combine, and adapt building blocks to
match incident
Operatewarehouse
Nelson C, E Chan, et al (2007)
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Where Possible, Emergency Response Should Be
Built Upon Routine Systems

• PHEP should involve scalable responses based,
  where possible, on muscle memory from routine
  practices
• E.g., Use of STD hotline staff to staff PIC
  hotline during public health emergencies
  (Lotstein et al, 2008)
• E.g., Biosurveillance systems can be built upon
  and integrated with routine disease surveillance
  systems (CDC National Biosurveillance Strategy)
• Can aid in routine diagnosis

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Preparedness to Respond Involves Continuous
Measurement and Improvement

• PHEP practices also need to be exercised in order
  to develop and maintain proficiency
• Few plug-and-play interventions most require
  considerable mutual adaptation
• Measurement and process improvement methods help
  . . .
• Diagnose problems
• Implement plan for improvement

How dreadful knowledge of the truth can be when
there is no help in the truth -Sophocles
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Key Questions

• What is public health emergency preparedness
  (PHEP)?
• What capabilities and capacities are most
  essential?
• Whose job is it?
• What progress have we made? What remains to be
  done?

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Governmental Public Health Agencies are
Ultimately Responsible....
Public Health Other Government Agencies
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. . . But PHEP Is Co-produced by a Range of
Community Partners
EmergencyManagement
Hospitals and Health CareProviders
Communities
Private-SectorEmployersand Business
Law Enforcement
NongovernmentalOrganizations
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. . . And Public Health Is Often Not in the Lead
Govt Public Health
Hospitals and Health CareProviders
Communities
Private-SectorEmployersand Business
Law Enforcement
NongovernmentalOrganizations
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Some Lessons on Building Partnerships

• Public health is often not in the lead
• Specific, focusing scenarios can help mobilize
  partnerships (Willis, et al., 2009)
• Successful PHEP partnerships often build upon
  pre-existing partnerships (Willis, et al., 2009)
• Personal relationships matter, but partnerships
  need to be formalized to hedge against staff
  turnover (Willis, et al., 2009)

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Key Questions

• What is public health emergency preparedness
  (PHEP)?
• What capabilities and capacities are most
  essential?
• Whose job is it?
• What progress have we made? What remains to be
  done?

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We Lack the Tools for Rigorous Gap Assessment,
Yet Its Clear That Theres Been Progress

• Reports from CDC, TFAH, and elsewhere show clear
  progress in developing capacities
• Staff e.g., Doubling in PHEP epis between
  2001 and 2006 (CDC, 2008)
• Labs e.g., from 83 LRN labs able to test
  chem/bio agents in 2001 to 110 in 2007 (CDC,
  2008)
• Plans Improvements in specificity/flexibility
  of countermeasure dispensing plans (Willis, et
  al., 2009)
• Progress in building relationships across sectors
• CRI (Willis, et al, 2009)
• Bring new disciplines and perspectives into
  health departments (Lurie, Wasserman, Nelson,
  2006)

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Its Clear That Theres Been Progress Though We
Lack Tools for Rigorous Assessment

• Changes in culture
• Growing comfort with NIMS and ready-fire-aim
  decision-making (Lurie, Wasserman Nelson, 2006)
• Improvements in engagement with private sector
  (Willis, et al., 2009)
• Initial progress in developing measures of
  operational capability
• FY2009 Cooperative Agreement guidance

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Remaining Gaps (Selected)

• Understanding and improving crisis
  decision-making
• Addressing the combination of an aging PH
  workforce and funding cuts/economic downturn
• Improving approaches for engaging communities and
  the private sector in PHEP
• Improving federal-state-local coordination and
  coordination between DHS and DHHS
• Others.....

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Moving Forward Generating Knowledge About PHEP

• Tools for understanding PHEP processes as a
  baseline for improvement (Nelson, Beckjord, et
  al., 2008 Lotstein, et al., 2008)
• Help define what aspects of PHEP are most
  critical to study
• More consistent ways to collect and learn from
  information gathered during exercises and
  incidents (Nelson, Beckjord, et al., 2008
  Nelson, Lurie Wasserman, 2007b)
• Process improvement as a source of knowledge
  generation (Lotstein, et al., 2008)

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Moving Forward Using and Applying Knowledge
About PHEP

• There are few plug-and-play interventions
  most require considerable mutual adaptation
• Local design and process improvement can
  provide a framework for adapting innovations to
  state/local contexts

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Moving Forward Understanding and Improving
Crisis Decision-making

• Need to understand components of crisis
  decision-making and feasible opportunities for
  regular practice (see Parker et al., 2008)
• RAND team is developing a simple simulation on
  resource allocation
• Initial rounds teach and test ability to
  implement simple algorithms
• Subsequent rounds introduce scarcity,
  uncertainty, difficult tradeoffs
• Underlying models can provide ongoing feedback to
  players, simulating real-world conditions

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Moving Forward Tackle Big Policy Issues in PHEP

• How to develop performance standards and measures
  that balance consistency with need for legitimate
  variation across states/locals
• POD standards provide one possible approach
  (Nelson, Chan, et al., 2008)
• How to balance investments in prevention/protectio
  n and response/recovery
• How to balance routine-surge vs. singular
  capabilities
• Allocation of scarce resources/standard of care

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Selected Readings (1)

• Nelson C, N Lurie, J Wasserman, S Zakowski.
  2007. Conceptualizing and Defining Public Health
  Emergency Preparedness. American Journal of
  Public Health, 97(S1).
• Parker A, C Nelson et al. 2009. Measuring
  Crisis Decision-making for Public Health
  Emergencies. http//www.rand.org/pubs/working_pape
  rs/WR577/
• Lotstein D, M Seid, K Ricci, K Leuschner, P
  Margolis, N Lurie. 2008. Using Quality
  Improvement Methods To Improve Public Health
  Emergency Preparedness PREPARE For Pandemic
  Influenza. Health Affairs, 27(5) w328-w339.
• Nelson C, E Beckjord, D Dausey, E Chan, N Lurie,
  D Lotstein. 2008. How Can We Strengthen the
  Evidence Base for Public Health Emergency
  Preparedness? Disaster Medicine and Public
  Health Preparedness. 2(4) 1-4.

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Selected Readings (2)

• Nelson C, E Chan, E Sloss, L Caldarone, A
  Pomeroy. 2007. New Tools for Assessing State
  and Local SNS Readiness. http//www.rand.org/pubs/
  working_papers/WR455/
• Willis H, C Nelson, et al. 2009. Initial
  Evaluation of the Cities Readiness Initiative.
  http//www.rand.org/pubs/technical_reports/TR640/
• CDC. 2008. Public Health Preparedness
  Mobilizing State by State. http//www.bt.cdc.gov
  /publications/feb08phprep/
• Nelson C, N Lurie, J Wasserman. 2007b.
  Assessing Public Health Emergency Preparedness
  Concepts, Tools, and Challenges. Annual Review
  of Public Health. 2812.1-12.18.
• Lurie N, J Wasserman C Nelson. 2006. Public
  Health Preparedness Evolution of Revolution?
  Health Affairs, 25935-945.
• Davis L, J Rough, G Cecchine, A Schaefer L
  Zeman. 2007. Hurricane Katrina Lessons for
  Army Planning and Operations. RAND. MG-603.

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Many thanks to the health departments and their
staff who participated in these activities.This
work would not have been possible without the
vision and invaluable assistance and support of
William Raub, Matthew Minson, Lara Lamprecht,
Stephanie Dulin, and many others. RAND
Collaborators Ed Chan, Nicole Lurie, Jeffrey
Wasserman, Andrew Parker, Shoshana Shelton, David
Dausey, Jeanne Ringel, Debra Lotstein and others
http//www.rand.org/health/centers/healthsecurity/