Jeffrey Wasserman

Non-pharmaceutical public health interventions for pandemic influenza: an evaluation of the evidence base

BackgroundIn an influenza pandemic, the benefit of vaccines and antiviral medications will be constrained by limitations on supplies and effectiveness. Non-pharmaceutical public health interventions will therefore be vital in curtailing disease spread. However, the most comprehensive assessments of the literature to date recognize the generally poor quality of evidence on which to base non-pharmaceutical pandemic planning decisions. In light of the need to prepare for a possible pandemic despite concerns about the poor quality of the literature, combining available evidence with expert opinion about the relative merits of non-pharmaceutical interventions for pandemic influenza may lead to a more informed and widely accepted set of recommendations. We evaluated the evidence base for non-pharmaceutical public health interventions. Then, based on the collective evidence, we identified a set of recommendations for and against interventions that are specific to both the setting in which an intervention may be used and the pandemic phase, and which can be used by policymakers to prepare for a pandemic until scientific evidence can definitively respond to planners needs.MethodsBuilding on reviews of past pandemics and recent historical inquiries, we evaluated the relative merits of non-pharmaceutical interventions by combining available evidence from the literature with qualitative and quantitative expert opinion. Specifically, we reviewed the recent scientific literature regarding the prevention of human-to-human transmission of pandemic influenza, convened a meeting of experts from multiple disciplines, and elicited expert recommendation about the use of non-pharmaceutical public health interventions in a variety of settings (healthcare facilities; community-based institutions; private households) and pandemic phases (no pandemic; no US pandemic; early localized US pandemic; advanced US pandemic).ResultsThe literature contained a dearth of evidence on the efficacy or effectiveness of most non-pharmaceutical interventions for influenza. In an effort to inform decision-making in the absence of strong scientific evidence, the experts ultimately endorsed hand hygiene and respiratory etiquette, surveillance and case reporting, and rapid viral diagnosis in all settings and during all pandemic phases. They also encouraged patient and provider use of masks and other personal protective equipment as well as voluntary self-isolation of patients during all pandemic phases. Other non-pharmaceutical interventions including mask-use and other personal protective equipment for the general public, school and workplace closures early in an epidemic, and mandatory travel restrictions were rejected as likely to be ineffective, infeasible, or unacceptable to the public.ConclusionThe demand for scientific evidence on non-pharmaceutical public health interventions for influenza is pervasive, and present policy recommendations must rely heavily on expert judgment. In the absence of a definitive science base, our assessment of the evidence identified areas for further investigation as well as non-pharmaceutical public health interventions that experts believe are likely to be beneficial, feasible and widely acceptable in an influenza pandemic.

Developing and Interpreting Models to Improve Diagnostics in Developing Countries

Developing a strategy for investment in diagnostic technologies requires an understanding of the need for, and the health impact of, potential new tools, as well as the necessary performance characteristics and user requirements. In this paper, we outline an approach for modelling the health benefits of new diagnostic tools.

Branding Behavior: The Strategy behind the TruthSM Campaign

The American Legacy Foundations truth SM campaign uses a branding strategy to change adolescent and young adults attitudes and behavior and to encourage them to adopt a nonsmoking lifestyle. This strategy and its execution represent an evolution from previous antismoking social marketing efforts. It offers lessons not only for future antismoking campaigns, but also for social marketing aimed at preventing or controlling many other youth risk behaviors. The persuasive mechanisms by which truths branding strategy works need to be understood within the context of existing social psychological theories of attitude and belief formation, as well as behavior change. Brand equity is a central measure of the truth campaigns strategy. We describe a new brand equity scale based on previous work in advertising research and present data from a campaign tracking survey. We conclude that the campaign has high brand equity among its target audience, 12- to 17-year-olds, and has changed important attitudes and beliefs related to smoking. Future research will investigate the relationships among brand equity, relevant intervening variables, and smoking behavior.

Giving EMS Flexibility In Transporting Low-Acuity Patients Could Generate Substantial Medicare Savings

Some Medicare beneficiaries who place 911 calls to request an ambulance might safely be cared for in settings other than the emergency department (ED) at lower cost. Using 2005-09 Medicare claims data and a validated algorithm, we estimated that 12.9-16.2xa0percent of Medicare-covered 911 emergency medical services (EMS) transports involved conditions that were probably nonemergent or primary care treatable. Among beneficiaries not admitted to the hospital, about 34.5xa0percent had a low-acuity diagnosis that might have been managed outside the ED. Annual Medicare EMS and ED payments for these patients were approximately

Achieving public health legal preparedness: how dissonant views on public health law threaten emergency preparedness and response

1xa0billion per year. If Medicare had the flexibility to reimburse EMS for managing selected 911 calls in ways other than transport to an ED, we estimate that the federal government could save

The Role of Law in Public Health Preparedness: Opportunities and Challenges

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The State of Innovative Emergency Medical Service Programs in the United States

560xa0million or more per year, while improving the continuity of patient care. If private insurance companies followed suit, overall societal savings could be twice as large.

Should Payment Policy Be Changed to Allow a Wider Range of EMS Transport Options

BACKGROUNDnEffective management of modern public health emergencies requires the coordinated efforts of multiple agencies representing various disciplines. Organizational culture differences between public health (PH) and emergency management (EM) entities may hinder inter-agency collaboration. We examine how PH and EM differ in their approach to PH law and how such differences affect their collaboration towards PH preparedness.nnnMETHODSnWe conducted 144 semi-structured interviews with local and state PH and EM officials between April 2008 and November 2009. Thematic qualitative analysis in ATLAS.ti was used to extract characteristics of each agencys approach to PH legal preparedness.nnnRESULTSnTwo conflicting approaches to the law emerge. The PH approach is characterized by perceived uncertainty regarding legal authority over preparedness planning tasks; expectation for guidance on interpretation of existing laws; and concern about individual and organizational liability. The EM approach reveals perception of broad legal authority; flexible interpretation of existing laws; and ethical concerns over infringement of individual freedoms and privacy.nnnCONCLUSIONSnDistinct interpretations of preparedness law impede effective collaboration for PH preparedness. Clarification of legal authority mandates, designation within laws of scope of preparedness activities and guidance on interpretation of current federal and state laws are needed.

Could we have covered more people at less cost? Technically, yes; politically, probably not.

We report the results of a study designed to assess and evaluate how the law shapes the public health systems preparedness activities. Based on 144 qualitative interviews conducted in nine states, we used a model that compared the objective legal environment with how practitioners perceived the laws. Most local public health and emergency management professionals relied on what they perceived the legal environment to be rather than on an adequate understanding of the objective legal requirements. Major reasons for the gap include the lack of legal training for local practitioners and the difficulty of obtaining clarification and consistent legal advice regarding public health preparedness. Narrowing the gap would most likely improve preparedness outcomes. We conclude that there are serious deficiencies in legal preparedness that can undermine effective responses to public health emergencies. Correcting the lack of legal knowledge, coupled with eliminating delays in resolving legal issues and questions during public health emergencies, could have measurable consequences on reducing morbidity and mortality.

Assessing Entrepreneurship in Governmental Public Health

Abstract Background. The primary objective of this study was to determine how EMS organizations that are piloting patient-centered treatment and transport protocols are approaching the challenges of implementation, reimbursement, and quality assurance. We were particularly interested in determining if these pilot efforts have raised any patient safety concerns. Methods. We conducted a set of discussions with a small group of key EMS stakeholders regarding the status of pioneering efforts to develop and evaluate innovative approaches to EMS in the United States. Results. We had discussions with 9 EMS agencies to better understand their innovative programs, including: the history of their service policy and procedure for transports that do not require emergency department care; the impact of their innovative program on service costs and/or cost savings; any reimbursement issues or changes; patient safety; patient satisfaction; and overall impression as well as recommendations for other EMS systems considering adoption of this policy. Conclusions. In general, EMS systems are not reimbursed for service unless the patient is transported to an ED. Spokespersons for all nine sites covered by this project said that this policy creates a powerful disincentive to implementing pilot programs to safely reduce EMS use by directing patients to more appropriate sites of care or proactively treating them in their homes. Even though private and public hospitals and payers typically benefit from these programs, they have been generally reluctant to offer support. This raises serious questions about the long-term viability of these programs.