Alicia A. Livinski

Allocation of scarce resources after a nuclear detonation: setting the context

The purpose of this article is to set the context for this special issue of Disaster Medicine and Public Health Preparedness on the allocation of scarce resources in an improvised nuclear device incident. A nuclear detonation occurs when a sufficient amount of fissile material is brought suddenly together to reach critical mass and cause an explosion. Although the chance of a nuclear detonation is thought to be small, the consequences are potentially catastrophic, so planning for an effective medical response is necessary, albeit complex. A substantial nuclear detonation will result in physical effects and a great number of casualties that will require an organized medical response to save lives. With this type of incident, the demand for resources to treat casualties will far exceed what is available. To meet the goal of providing medical care (including symptomatic/palliative care) with fairness as the underlying ethical principle, planning for allocation of scarce resources among all involved sectors needs to be integrated and practiced. With thoughtful and realistic planning, the medical response in the chaotic environment may be made more effective and efficient for both victims and medical responders.

Medical Planning and Response for a Nuclear Detonation: A Practical Guide

This article summarizes major points from a newly released guide published online by the Office of the Assistant Secretary for Preparedness and Response (ASPR). The article reviews basic principles about radiation and its measurement, short-term and long-term effects of radiation, and medical countermeasures as well as essential information about how to prepare for and respond to a nuclear detonation. A link is provided to the manual itself, which in turn is heavily referenced for readers who wish to have more detail.

Methodology: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement

BACKGROUND Natural disasters, industrial accidents, terrorism attacks, and pandemics all have the capacity to result in large numbers of critically ill or injured patients. This supplement provides suggestions for all those involved in a disaster or pandemic with multiple critically ill patients, including front-line clinicians, hospital administrators, professional societies, and public health or government officials. The field of disaster medicine does not have the required body of evidence needed to undergo a traditional guideline development process. In result, consensus statement-development methodology was used to capture the highest-caliber expert opinion in a structured, scientific approach. METHODS Task Force Executive Committee members identified core topic areas regarding the provision of care to critically ill or injured patients from pandemics or disasters and subsequently assembled an international panel for each identified area. International disaster medicine experts were brought together to identify key questions (in a population, intervention, comparator, outcome [PICO]-based format) within each of the core topic areas. Comprehensive literature searches were then conducted to identify studies upon which evidence-based recommendations could be made. No studies of sufficient quality were identified. Therefore, the panel developed expert opinion-based suggestions that are presented in this supplement using a modified Delphi process. RESULTS A total of 315 suggestions were drafted across all topic groups. After two rounds of a Delphi consensus-development process, 267 suggestions were chosen by the panel to include in the document and published in a total of 12 manuscripts composing the core chapters of this supplement. Draft manuscripts were prepared by the topic editor and members of the working groups for each of the topics, producing a total of 11 papers. Once the preliminary drafts were received, the Executive Committee (Writing Committee) then met to review, edit, and promote alignment of all of the primary drafts of the manuscripts prepared by the topic editors and their groups. The topic editors then revised their manuscripts based on the Executive Committees edits and comments. The Writing Committee subsequently reviewed the updated drafts and prepared the final manuscripts for submission to the Guidelines Oversight Committee (GOC). The manuscripts subsequently underwent review by the GOC, including external review as well as peer review for the journal publication. The Writing Committee received the feedback from the reviewers and modified the manuscripts as required. CONCLUSIONS Based on a robust and transparent process, this project used rigorous methodology to produce clinically relevant, trustworthy consensus statements, with the aim to provide needed guidance on treatment and procedures for practitioners, hospital administrators, and public health and government officials when addressing the care of critically ill or injured patients in disasters or pandemics.

Resource-Poor Settings: Infrastructure and Capacity Building: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement

BACKGROUND Planning for mass critical care (MCC) in resource-poor or constrained settings has been largely ignored, despite their large populations that are prone to suffer disproportionately from natural disasters. Addressing MCC in these settings has the potential to help vast numbers of people and also to inform planning for better-resourced areas. METHODS The Resource-Poor Settings panel developed five key question domains; defining the term resource poor and using the traditional phases of disaster (mitigation/preparedness/response/recovery), literature searches were conducted to identify evidence on which to answer the key questions in these areas. Given a lack of data upon which to develop evidence-based recommendations, expert-opinion suggestions were developed, and consensus was achieved using a modified Delphi process. RESULTS The five key questions were then separated as follows: definition, infrastructure and capacity building, resources, response, and reconstitution/recovery of host nation critical care capabilities and research. Addressing these questions led the panel to offer 33 suggestions. Because of the large number of suggestions, the results have been separated into two sections: part 1, Infrastructure/Capacity in this article, and part 2, Response/Recovery/Research in the accompanying article. CONCLUSIONS Lack of, or presence of, rudimentary ICU resources and limited capacity to enhance services further challenge resource-poor and constrained settings. Hence, capacity building entails preventative strategies and strengthening of primary health services. Assistance from other countries and organizations is needed to mount a surge response. Moreover, planning should include when to disengage and how the host nation can provide capacity beyond the mass casualty care event.

The Perfect Storm of Information: Combining Traditional and Non-Traditional Data Sources for Public Health Situational Awareness During Hurricane Response

Background: Hurricane Isaac made landfall in southeastern Louisiana in late August 2012, resulting in extensive storm surge and inland flooding. As the lead federal agency responsible for medical and public health response and recovery coordination, the Department of Health and Human Services (HHS) must have situational awareness to prepare for and address state and local requests for assistance following hurricanes. Both traditional and non-traditional data have been used to improve situational awareness in fields like disease surveillance and seismology. This study investigated whether non-traditional data (i.e., tweets and news reports) fill a void in traditional data reporting during hurricane response, as well as whether non-traditional data improve the timeliness for reporting identified HHS Essential Elements of Information (EEI). Methods: HHS EEIs provided the information collection guidance, and when the information indicated there was a potential public health threat, an event was identified and categorized within the larger scope of overall Hurricane Issac situational awareness. Tweets, news reports, press releases, and federal situation reports during Hurricane Isaac response were analyzed for information about EEIs. Data that pertained to the same EEI were linked together and given a unique event identification number to enable more detailed analysis of source content. Reports of sixteen unique events were examined for types of data sources reporting on the event and timeliness of the reports. Results: Of these sixteen unique events identified, six were reported by only a single data source, four were reported by two data sources, four were reported by three data sources, and two were reported by four or more data sources. For five of the events where news tweets were one of multiple sources of information about an event, the tweet occurred prior to the news report, press release, local government\emergency management tweet, and federal situation report. In all circumstances where citizens were reporting along with other sources, the citizen tweet was the earliest notification of the event. Conclusion: Critical information is being shared by citizens, news organizations, and local government representatives. To have situational awareness for providing timely, life-saving public health and medical response following a hurricane, this study shows that non-traditional data sources should augment traditional data sources and can fill some of the gaps in traditional reporting. During a hurricane response where early event detection can save lives and reduce morbidity, tweets can provide a source of information for early warning. In times of limited budgets, investing technical and personnel resources to efficiently and effectively gather, curate, and analyze non-traditional data for improved situational awareness can yield a high return on investment.

Influenza seasonality goes south in the Yucatan Peninsula: The case for a different influenza vaccine calendar in this Mexican region

INTRODUCTION While vaccination may be relatively straightforward for regions with a well-defined winter season, the situation is quite different for tropical regions. Influenza activity in tropical regions might be out of phase with the dynamics predicted for their hemispheric group thereby impacting the effectiveness of the immunization campaign. OBJECTIVE To investigate how the climatic diversity of Mexico hinders its existing influenza immunization strategy and to suggest that the hemispheric vaccine recommendations be tailored to the regional level in order to optimize vaccine effectiveness. METHODS We studied the seasonality of influenza throughoutMexico by modeling virological and mortality data.De-trended time series of each Mexican state were analyzed by Fourier decomposition to describe the amplitude and timing of annual influenza epidemic cycles and to compare with each the timing of the WHOs Northern and Southern Hemispheric vaccination schedule. FINDINGS The timings of the primary (major) peaks of both virological and mortality data for most Mexican states are well aligned with the Northern Hemisphere winter (December-February) and vaccine schedule. However, influenza peaks in September in the three states of the Yucatan Peninsula. Influenza-related mortality also peaks in September in Quintana Roo and Yucatan whereas it peaks in May in Campeche. As the current timing of vaccination in Mexico is between October and November, more than half of the annual influenza cases have already occurred in the Yucatan Peninsula states by the time the Northern Hemispheric vaccine is delivered and administered. CONCLUSION The current Northern Hemispheric influenza calendar adopted for Mexico is not optimal for the Yucatan Peninsula states thereby likely reducing the effectiveness of the immunization of the population. We recommend that Mexico tailor its immunization strategy to better reflect its climatologic and epidemiological diversity and adopt the WHO Southern Hemisphere influenza vaccine and schedule for the Yucatan Peninsula.

Evolution of a search: the use of dynamic twitter searches during superstorm sandy.

Background: Twitter has emerged as a critical source of free and openly available information during emergency response operations, providing an unmatched level of on-the-ground situational awareness in real-time. Responders and survivors turn to Twitter to share information and resources within communities, conduct rumor control, and provide a “boots on the ground” understanding of the disaster. However, the ability to tune out background “noise” is essential to effectively utilizing Twitter to identify important and useful information during an emergency response. Methods: This article highlights a two-prong strategy in which the use of a Twitter list paired with subject specific Boolean searches provided increased situational awareness and early event detection during the United States Department of Health and Human Services (HHS), Office of the Assistant Secretary for Preparedness and Response (ASPR) response to Superstorm Sandy in 2012. To maximize the amount of relevant information that was retrieved, the Twitter list and Boolean searches were dynamic and responsive to real-time developments, evolving health threats, and the informational needs of decision-makers. Conclusion: The use of a Twitter list combined with Boolean searches led to enhanced situational awareness throughout the HHS response. The incorporation of a dynamic search strategy over the course of the HHS Sandy response, allowed for the ability to account for over-tweeted information, changes in event related conversation, and decreases in the return of relevant information.

Data sharing in PLOS ONE: An analysis of Data Availability Statements

A number of publishers and funders, including PLOS, have recently adopted policies requiring researchers to share the data underlying their results and publications. Such policies help increase the reproducibility of the published literature, as well as make a larger body of data available for reuse and re-analysis. In this study, we evaluate the extent to which authors have complied with this policy by analyzing Data Availability Statements from 47,593 papers published in PLOS ONE between March 2014 (when the policy went into effect) and May 2016. Our analysis shows that compliance with the policy has increased, with a significant decline over time in papers that did not include a Data Availability Statement. However, only about 20% of statements indicate that data are deposited in a repository, which the PLOS policy states is the preferred method. More commonly, authors state that their data are in the paper itself or in the supplemental information, though it is unclear whether these data meet the level of sharing required in the PLOS policy. These findings suggest that additional review of Data Availability Statements or more stringent policies may be needed to increase data sharing.

The Culture of Biosafety, Biosecurity, and Responsible Conduct in the Life Sciences: A Comprehensive Literature Review

Introduction: Managing biological risks requires an organizational culture that holistically ensures the biosafety, biosecurity, and biocontainment of infectious disease agents and toxins, in addition to conducting science in a responsible manner, complying with relevant laws, regulations, guidelines, and policies, as well as emphasizing norms, values, and beliefs of the entire life sciences profession. Methods: Drawing upon the Federal Experts Security Advisory Panels (FESAPs) 2014 recommendation to “strengthen a culture that emphasizes biosafety, laboratory biosecurity, and responsible conduct in the life sciences,” we undertook a comprehensive literature review of the culture of biosafety, biosecurity, and responsible conduct in the life sciences, including metrics by which to evaluate interventions at the organizational level. Results: We identified 4031 unique citations published from January 2001 to January 2017 by searching the MEDLINE/PubMed, Scopus, Web of Science, and Global Health databases. In addition, a subset of 326 articles was reviewed in full. Discussion: We found that while there were discussions in the literature about specific elements of culture (management systems, leadership and/or personnel behavior, beliefs and attitudes, or principles for guiding decisions and behaviors), there was a general lack of integration of these concepts, as well as limited information about specific indicators or metrics and the effectiveness of training or similar interventions. Conclusion: We concluded that life scientists seeking to foster a culture of biosafety and biosecurity should learn from the substantial literature in analogous areas such as nuclear safety and security culture, high-reliability organizations, and the responsible conduct of research, among others.

Both hemispheric influenza vaccine recommendations would have missed near half of the circulating viruses in Madagascar

Influenza immunization still poses a critical challenge globally and specifically for tropical regions due to their complex influenza circulation pattern. Tropical regions should select the WHOs Northern Hemisphere or Southern Hemisphere recommended vaccine composition based on local surveillance. Analyses of influenza immunization effectiveness have neglected to account for the proportion of circulating viruses prevented from causing infection each year. We investigate this question for Madagascar, where influenza vaccines are not widely available.