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Background

Governments may be overwhelmed by a large-scale public health emergency, such as a massive bioterrorist attack or natural disaster, requiring collaboration with businesses and other community partners to respond effectively. In Georgia, public health officials and members of the Business Executives for National Security have successfully collaborated to develop and test procedures for dispensing medications from the Strategic National Stockpile. Lessons learned from this collaboration should be useful to other public health and business leaders interested in developing similar partnerships.

Methods

The authors conducted a case study based on interviews with 26 government, business, and academic participants in this collaboration.

Results

The partnership is based on shared objectives to protect public health and assure community cohesion in the wake of a large-scale disaster, on the recognition that acting alone neither public health agencies nor businesses are likely to manage such a response successfully, and on the realization that business and community continuity are intertwined. The partnership has required participants to acknowledge and address multiple challenges, including differences in business and government cultures and operational constraints, such as concerns about the confidentiality of shared information, liability, and the limits of volunteerism. The partnership has been facilitated by a business model based on defining shared objectives, identifying mutual needs and vulnerabilities, developing carefully-defined projects, and evaluating proposed project methods through exercise testing. Through collaborative engagement in progressively more complex projects, increasing trust and understanding have enabled the partners to make significant progress in addressing these challenges.

Conclusion

As a result of this partnership, essential relationships have been established, substantial private resources and capabilities have been engaged in government preparedness programs, and a model for collaborative, emergency mass dispensing of pharmaceuticals has been developed, tested, and slated for expansion. The lessons learned from this collaboration in Georgia should be considered by other government and business leaders seeking to develop similar partnerships.

SYNOPSIS

Given the need for public health professionals well trained in emergency preparedness and response, students in public health programs require ample practical training to prepare them for careers in public health practice. The Harvard School of Public Health Center for Public Health Preparedness has been instrumental in the creation and implementation of a course entitled, “Bioterrorism: Public Health Preparedness and Response.” This course features lectures on specific applications of public health practice in emergency preparedness and response. In addition, it provides students the opportunity to operationalize and apply their knowledge during an interactive tabletop exercise. In light of their university affiliations and expertise in providing preparedness training, other Academic Centers for Public Health Preparedness have the opportunity to be instrumental in providing similar training to graduate students of public health.

SYNOPSIS

While awareness of bioterrorism threats and emerging infectious diseases has resulted in an increased sense of urgency to improve the knowledge base and response capability of physicians, few medical schools and residency programs have curricula in place to teach these concepts. Public health agencies are an essential component of a response to these types of emergencies. Public health education during medical school is usually limited to the non-clinical years. With collaboration from our local public health agency, the Emory University School of Medicine developed a curriculum in bioterrorism and emerging infections. By implementing this curriculum in the clinical years of medical school and residency programs, we seek to foster improved interactions between clinicians and their local public health agencies.

The 2002 Olympic Winter Games were held in Utah from February 8 to March 16, 2002. Following the terrorist attacks on September 11, 2001, and the anthrax release in October 2001, the need for bioterrorism surveillance during the Games was paramount. A team of informaticists and public health specialists from Utah and Pittsburgh implemented the Real-time Outbreak and Disease Surveillance (RODS) system in Utah for the Games in just seven weeks. The strategies and challenges of implementing such a system in such a short time are discussed. The motivation and cooperation inspired by the 2002 Olympic Winter Games were a powerful driver in overcoming the organizational issues. Over 114,000 acute care encounters were monitored between February 8 and March 31, 2002. No outbreaks of public health significance were detected. The system was implemented successfully and operational for the 2002 Olympic Winter Games and remains operational today.

State health agencies have assumed a leadership role in responding to the major public health issues raised by the AIDS epidemic. Directors of State health agencies (State health officers) have asserted their influence at the national level as well as at the State level. The Association of State and Territorial Health Officials (ASTHO), and especially ASTHO'S AIDS Committee, has served as the primary vehicle through which State health officers communicate their views to the Federal Government and vice versa. To date, ASTHO has held four national conferences on AIDS. Each one has brought together Federal, State, and local officials, advocacy groups, and other public health experts, and each has resulted in practical recommendations to public health departments on how to implement their AIDS programs most effectively. Although State health agencies have responded differently to the epidemic, many have adopted innovative, and sometimes unpopular, approaches. State health agencies' responses to the AIDS epidemic are governed partly by environmental factors, including the views of political leaders in the State, the strength of concerned advocacy groups, and the number of AIDS cases in the State. Despite their different approaches, State health officers have agreed that education is the most important tool in their programs to prevent human immunodeficiency virus (HIV) infections. The rapidly changing AIDS epidemic has required State health agencies to be flexible in their approaches to controlling the epidemic. State health officers' evolving views about HIV testing and partner notification are two examples of how new information about the epidemic has affected States' HIV control programs.

During the 2001 anthrax attacks, public health agencies faced operational and communication decisions about the use of antibiotic prophylaxis and the anthrax vaccine with affected groups, including postal workers. This communication occurred within an evolving situation with incomplete and uncertain data. Guidelines for prophylactic antibiotics changed several times, contributing to confusion and mistrust. At the end of 60 days of taking antibiotics, people were offered an additional 40 days' supply of antibiotics, with or without the anthrax vaccine, the former constituting an investigational new drug protocol. Using data from interviews and focus groups with 65 postal workers in 3 sites and structured interviews with 16 public health professionals, this article examines the challenges for public health professionals who were responsible for communication with postal workers about the vaccine. Multiple factors affected the response, including a lack of trust, risk perception, disagreement about the recommendation, and the controversy over the military's use of the vaccine. Some postal workers reacted with suspicion to the vaccine offer, believing that they were the subjects of research, and some African American workers specifically drew an analogy to the Tuskegee syphilis study. The consent forms required for the protocol heightened mistrust. Postal workers also had complex and ambivalent responses to additional research on their health. The anthrax attacks present us with an opportunity to understand the challenges of communication in the context of uncertain science and suggest key strategies that may improve communications about vaccines and other drugs authorized for experimental use in future public health emergencies.

Abstract:

Background:

Since the tragic events experienced on September 11, 2001, and other recent events such as the hurricane devastation in the southeastern parts of the country and the emergent H1N1season, the need for a competent public health workforce has become vitally important for securing and protecting the greater population.

Objective: The primary objective of the study was to assess the training needs of the U.S. Mexico border states public health workforce.

Methods:

The Arizona Center for Public Health Preparedness of the Mel and Enid Zuckerman College of Public Health at The University of Arizona implemented a border-wide needs assessment. The online survey was designed to assess and prioritize core public health competencies as well as bioterrorism, infectious disease, and border/binational training needs.

Results:

Approximately 80% of the respondents were employed by agencies that serve both rural and urban communities. Respondents listed 23 different functional roles that best describe their positions. Approximately 35% of the respondents were primarily employed by state health departments, twenty-seven percent (30%) of the survey participants reported working at the local level, and 19% indicated they worked in other government settings (e.g. community health centers and other non-governmental organizations). Of the 163 survey participants, a minority reported that they felt they were well prepared in the Core Bioterrorism competencies. The sections on Border Competency, Surveillance/Epidemiology, Communications/Media Relations and Cultural Responsiveness, did not generate a rating of 70% or greater on the importance level of survey participants.

Conclusions:

The study provided the opportunity to examine the issues of public health emergency preparedness within the framework of the border as a region addressing both unique needs and context. The most salient findings highlight the need to enhance the border competency skills of individuals whose roles include a special focus on emergency preparedness and response along the US-Mexico border.

In 1995, the National Library of Medicine (NLM) and the Public Health Service (PHS) recommended that special attention be given to the information needs of unaffiliated public health professionals. In response, the National Network of Libraries of Medicine (NN/LM) Greater Midwest Region initiated a collaborative outreach program for public health professionals working in rural east and central Iowa. Five public health agencies were provided equipment, training, and support for accessing the Internet. Key factors in the success of this project were: (1) the role of collaborating agencies in the implementation and ongoing success of information access outreach projects; (2) knowledge of the socio-cultural factors that influence the information-seeking habits of project participants (public health professionals); and (3) management of changing or varying technological infrastructures. Working with their funding, personnel from federal, state, and local governments enhanced the information-seeking skills of public health professionals in rural eastern and central Iowa communities.

Responding to public health emergencies requires rapid and accurate assessment of workforce availability under adverse and changing circumstances. However, public health information systems to support resource management during both routine and emergency operations are currently lacking. We applied scenario-based design as an approach to engage public health practitioners in the creation and validation of an information design to support routine and emergency public health activities. Methods: Using semi-structured interviews we identified the information needs and activities of senior public health managers of a large municipal health department during routine and emergency operations. Results: Interview analysis identified twenty-five information needs for public health operations management. The identified information needs were used in conjunction with scenario-based design to create twenty-five scenarios of use and a public health manager persona. Scenarios of use and persona were validated and modified based on follow-up surveys with study participants. Scenarios were used to test and gain feedback on a pilot information system. Conclusion: The method of scenario-based design was applied to represent the resource management needs of senior-level public health managers under routine and disaster settings. Scenario-based design can be a useful tool for engaging public health practitioners in the design process and to validate an information system design.

Background

Inappropriate use of antibiotics by individuals worried about biological agent exposures during bioterrorism events is an important public health concern. However, little is documented about the extent to which individuals with self-identified risk of anthrax exposure approached physicians for antimicrobial prophylaxis during the 2001 bioterrorism attacks in the United States.

Methods

We conducted a telephone survey of randomly selected members of the Pennsylvania Chapter of the American College of Emergency Physicians to assess patients' request for and emergency physicians' prescription of antimicrobial agents during the 2001 anthrax attacks.

Results

Ninety-seven physicians completed the survey. Sixty-four (66%) respondents had received requests from patients for anthrax prophylaxis; 16 (25%) of these physicians prescribed antibiotics to a total of 23 patients. Ten physicians prescribed ciprofloxacin while 8 physicians prescribed doxycycline.

Conclusion

During the 2001 bioterrorist attacks, the majority of the emergency physicians we surveyed encountered patients who requested anthrax prophylaxis. Public fears may lead to a high demand for antibiotic prophylaxis during bioterrorism events. Elucidation of the relationship between public health response to outbreaks and outcomes would yield insights to ease burden on frontline clinicians and guide strategies to control inappropriate antibiotic allocation during bioterrorist events.

After reports of the intentional release of Bacillus anthracis in the United States, epidemiologists, laboratorians, and clinicians around the world were called upon to respond to widespread political and public concerns. To respond to inquiries from other countries regarding anthrax and bioterrorism, the Centers for Disease Control and Prevention established an international team in its Emergency Operations Center. From October 12, 2001, to January 2, 2002, this team received 130 requests from 70 countries and 2 territories. Requests originated from ministries of health, international organizations, and physicians and included subjects ranging from laboratory procedures and clinical evaluations to assessments of environmental and occupational health risks. The information and technical support provided by the international team helped allay fears, prevent unnecessary antibiotic treatment, and enhance laboratory-based surveillance for bioterrorism events worldwide.

Problem

Strong leadership and management skills are crucial to finding solutions to the human resource crisis in health. Health professionals and human resource (HR) managers worldwide who are in charge of addressing HR challenges in health systems often lack formal education in leadership and management.

Approach

Management Sciences for Health (MSH) developed the Virtual Leadership Development Program (VLDP) with support from the United States Agency for International Development (USAID). The VLDP is a Web-based leadership development programme that combines face-to-face and distance-learning methodologies to strengthen the capacity of teams to identify and address health challenges and produce results.

Relevant changes

The USAID-funded Leadership, Management and Sustainability (LMS) Program, implemented by MSH, and the USAID-funded Capacity Project, implemented by IntraHealth, adapted the VLDP for HR managers to help them identify and address HR challenges that ministries of health, other public-sector organizations and nongovernmental organizations are facing.

Local settings

Three examples illustrate the results of the VLDP for teams of HR managers:

1. the Uganda Protestant and Catholic Medical Bureaus

2. the Christian Health Association of Malawi

3. the Developing Human Resources for Health Project in Uganda.

Lessons learnt

The VLDP is an effective programme for developing the management and leadership capacity of HR managers in health.

This article proposes and discusses legal and administrative preparations for a bioterrorist attack. To perform the duties expected of public health agencies during a disease outbreak caused by bioterrorism, an agency must have a sufficient number of employees and providers at work and a good communications system between staff in the central offices of the public health agency and those in outlying or neighboring agencies and hospitals. The article proposes strategies for achieving these objectives as well as for removing legal barriers that discourage agencies, institutions, and persons from working together for the overall good of the community. Issues related to disease surveillance and special considerations regarding public health restrictive orders are discussed.

Public health and medical professionals are expected to be well prepared for emergencies, as they assume an integral role in any response. They need to be aware of planning issues, be able to identify their roles in emergency situations, and show functional competence. However, media perceptions and non-empirical publications often lack an evidence base when addressing this topic. This study attempted to assess the competencies of various health professionals by obtaining quantitative data on the state of bioterrorism preparedness and response competencies in Australia using an extensive set of competencies developed by Kristine Gebbie from the Columbia University School of Nursing Center for Health Policy with funding from the US Centres for Disease Control and Prevention. These competencies reflect the knowledge, capabilities, and skills that are necessary for best practice in public health. Sufficient data were collected to enable comparison between public health leaders, communicable disease specialists, clinicians (with and without medical degrees), and environmental health professionals. All health professionals performed well. However, the primary finding of this study was that clinicians consistently self-assessed themselves as lower in competence, and clinicians with medical degrees self-assessed themselves as the lowest in bioterrorism competence. This has important implications for health professional training, national benchmarks, standards, and competencies for the public health workforce.

Information science and technology are critical to the modern practice of public health. Yet today's public health professionals generally have no formal training in public health informatics--the application of information science and technology to public health practice and research. Responding to this need, the U.S. Centers for Disease Control and Prevention (CDC) recently developed, tested, and delivered a new training course in public health informatics. The course was designed for experienced public health program managers and included sessions on general informatics principles and concepts; key information systems issues and information technologies; and management issues as they relate to information technology projects. This course has been enthusiastically received both at the state and federal levels. We plan to develop an abbreviated version for health officers, administrators, and other public health executives.

SYNOPSIS

The Nevada State Health Division developed a local academic-practice partnership with the University of Nevada Reno's Master of Public Health Program to assess the bioterrorism risk communication, information, response, and training needs of professional and public stakeholder groups throughout Nevada. Between October 16, 2002, and April 13, 2004, 22 needs assessment focus groups and 125 key informant interviews were conducted to gather information on the diverse needs of the stakeholders. The themes that emerged from these activities included the need for effective pre-event education and training; a coordinated and responsive public health preparedness infrastructure; honest, accurate, and timely communication in the event of a bioterrorism situation; and appropriate information dissemination methods and technology. The data collected through this needs assessment gave the Nevada State Health Division vital information to plan public health preparedness initiatives. The establishment of local academic-practice partnerships for states without a Centers for Disease Control and Prevention-funded Academic Center for Public Health Preparedness is an effective way for health departments to develop their public health preparedness infrastructure while simultaneously training the future public health workforce.

Health emergency planning for preparedness and response against acts of terrorism, including the malfeasant threat or actual release of biological agents designed to harm others, has assumed a higher level of concern for most western nations, including Canada, following the explosive attacks in the United States on September 11, 2001. These terrorist attacks were followed by an outbreak of anthrax infections. The Bacillus anthracis spores in these attacks were dispersed by using regular postal services in the United States. In addition to the unsettling sense of social vulnerability that resulted from these attacks, a greater appreciation that the integration of public health, emergency health and social services with security activities was required to fully address the need to protect the health and other interests of the citizens. Collaborative work among regional, provincial, territorial, federal and international authorities within these domains is emerging as an effective response to the risk management of bioterrorism. The following is a brief description of the health framework for preparedness and response, and the biological agents of major concern in terrorism.

Costs can be estimated by identifying functional pathways toward achieving all 8 core capacities and global indicators.

The revised International Health Regulations (IHR [2005]) conferred new responsibilities on member states of the World Health Organization, requiring them to develop core capacities to detect, assess, report, and respond to public health emergencies. Many countries have not yet developed these capacities, and poor understanding of the associated costs have created a barrier to effectively marshaling assistance. To help national and international decision makers understand the inputs and associated costs of implementing the IHR (2005), we developed an IHR implementation strategy to serve as a framework for making preliminary estimates of fixed and operating costs associated with developing and sustaining IHR core capacities across an entire public health system. This tool lays the groundwork for modeling the costs of strengthening public health systems from the central to the peripheral level of an integrated health system, a key step in helping national health authorities define necessary actions and investments required for IHR compliance.

After public notification of confirmed cases of bioterrorism-related anthrax, the Centers for Disease Control and Prevention’s Emergency Operations Center responded to 11,063 bioterrorism-related telephone calls from October 8 to November 11, 2001. Most calls were inquiries from the public about anthrax vaccines (58.4%), requests for general information on bioterrorism prevention (14.8%), and use of personal protective equipment (12.0%); 882 telephone calls (8.0%) were referred to the state liaison team for follow-up investigation. Of these, 226 (25.6%) included reports of either illness clinically confirmed to be compatible with anthrax or direct exposure to an environment known to be contaminated with Bacillus anthracis. The remaining 656 (74.4%) included no confirmed illness but reported exposures to “suspicious” packages or substances or the receipt of mail through a contaminated facility. Emergency response staff must handle high call volumes following suspected or actual bioterrorist attacks. Standardized health communication protocols that address contact with unknown substances, handling of suspicious mail, and clinical evaluation of suspected cases would allow more efficient follow-up investigations of clinically compatible cases in high-risk groups.

Background

Vaccines have virtually eliminated many diseases, but public concerns about their safety could undermine future public health initiatives.

Objective

To determine Canadians' attitudes and knowledge about vaccines, particularly in view of increasing public concern about bioterrorism and the possible need for emergency immunizations after weaponized anthrax incidents and the events of September 11, 2001.

Method

A 20-question survey based on well-researched dimensions of vaccine responsiveness was telephone-administered to a random sample of N = 1330 adult Canadians in January, 2002.

Results

1057 (79.5%) completed the survey. Respondents perceived vaccines to be highly effective and demonstrated considerable support for further vaccine research. However, results also indicate a lack of knowledge about vaccines and uncertainty regarding the safety.

Conclusions

Support for vaccines is broad but shallow. While Canadians hold generally positive attitudes about vaccines, support could be undermined by widely publicized adverse events. Better public education is required to maintain support for future public health initiatives.

SYNOPSIS

Local health departments (LHDs) are at the hub of the public health emergency preparedness system. Since the 2003 issuance of Homeland Security Presidential Directive-5, LHDs have faced challenges to comply with a new set of all-hazards, 24/7 organizational response expectations, as well as the National Incident Management System (NIMS). To help local public health practitioners address these challenges, the Centers for Disease Control and Prevention-funded Johns Hopkins Center for Public Health Preparedness (JH-CPHP) created and implemented a face-to-face, public health-specific NIMS training series for LHDs. This article presents the development, evolution, and delivery of the JH-CPHP NIMS training program. In this context, the article also describes a case example of practice-academic collaboration between the National Association of County and City Health Officials and JH-CPHP to develop public health-oriented NIMS course content.

As part of efforts to develop training and career development experiences to enhance leadership skills among public health officials, the Public Health Foundation, Association of State and Territorial Health Officials, National Association of County Health Officials, United States Conference of Local Health Officers, and Public Health Practice Program Office, Centers for Disease Control and Prevention, conducted a training needs assessment survey in 1988. Fifty-five State and territorial health officers were asked about potential knowledge, skills, and abilities (KSAs) that a prospective or new health officer might require in performing his or her job. Thirty-eight health officers returned completed questionnaires, a 69 percent response rate. For each KSA, respondents assigned scores from 1 (low) to 5 (high) to three different variables: the KSA's importance to job, as an initial ability of a new health officer, and as a desired ability for someone in that job. Of 78 KSAs, those scoring in the top 25 percent for importance to job were identified, and individual composite scores were calculated using the formula: (importance to job) x (desired ability minus initial ability). The top 10 mean composite scores ranged from 7.55 to 10.40 and were in five competence areas: public image (working with the community) (3 KSAs); policy development and program planning (3 KSAs); interpersonal skills (2 KSAs); agency management (1 KSA); and legal issues (1 KSA). These skills are not commonly acquired in schools of medicine or public health. Public health agencies should develop programs to assure that persons with leadership potential are identified early and given guided experiences and mentors, as well as specific training and education. Additional studies of public health officers are needed to develop and strengthen leadership KSAs among new health officers.

Background

Despite extensive evidence on the magnitude of intimate partner violence (IPV) as a public health problem worldwide, insubstantial progress has been made in the development and implementation of sufficiently comprehensive health services. This study aimed to implement, evaluate and adapt a published protocol for the screening and management of IPV and to recommend a model of care that could be taken to scale in our underdeveloped South African primary health care system.

Methods

Professional action research utilised a co-operative inquiry group that consisted of four nurses, one doctor and a qualitative researcher. The inquiry group implemented the protocol in two urban and three rural primary care facilities. Over a period of 14 months the group reflected on their experience, modified the protocol and developed recommendations on a practical but comprehensive model of care.

Results

The original protocol had to be adapted in terms of its expectations of the primary care providers, overly forensic orientation, lack of depth in terms of mental health, validity of the danger assessment and safety planning process, and need for ongoing empowerment and support. A three-tier model resulted: case finding and clinical care provision by primary care providers; psychological, social and legal assistance by ‘IPV champions’ followed by a group empowerment process; and then ongoing community-based support groups.

Conclusion

The inquiry process led to a model of comprehensive and intersectoral care that is integrated at the facility level and which is now being piloted in the Western Cape, South Africa.

Although the American public health system has made major contributions to life expectancy for residents of this country over the past century, the system now faces more complex health problems that require comprehensive approaches and increased capacity, particularly in local and State public health agencies. To strengthen the public health system, concerted action is needed to meet these five critical needs: First, the knowledge base of public health workers needs to be supplemented through on-the-job training and continuing education programs. To this end, self-study courses will be expanded, and a network of regional training centers will be established throughout the country. Second, communities need dynamic leadership from public health officials and their agencies. To enhance leadership skills and expand the leadership role of public health agencies, focused personal leadership development activities, including a Public Health Leadership Institute, and national conferences will provide a vision of the future role of public health agencies. Third, local and State public health agencies need access to data on the current health status of the people in their communities and guidance from the nation's public health experts. To improve access to information resources, state-of-the-art technologies will be deployed to create integrated information and communication systems linking all components of the public health system. Fourth, local and State agencies need disease prevention and health promotion plans that target problems and develop strategies and the capacity to address them.(ABSTRACT TRUNCATED AT 250 WORDS)

SYNOPSIS

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.