Melinda Moore

Strengthening laboratory systems in resource-limited settings.

Considerable resources have been invested in recent years to improve laboratory systems in resource-limited settings. We reviewed published reports, interviewed major donor organizations, and conducted case studies of laboratory systems in 3 countries to assess how countries and donors have worked together to improve laboratory services. While infrastructure and the provision of services have seen improvement, important opportunities remain for further advancement. Implementation of national laboratory plans is inconsistent, human resources are limited, and quality laboratory services rarely extend to lower tier laboratories (eg, health clinics, district hospitals). Coordination within, between, and among governments and donor organizations is also frequently problematic. Laboratory standardization and quality control are improving but remain challenging, making accreditation a difficult goal. Host country governments and their external funding partners should coordinate their efforts effectively around a host countrys own national laboratory plan to advance sustainable capacity development throughout a countrys laboratory system.

Regional Infectious Disease Surveillance Networks and their Potential to Facilitate the Implementation of the International Health Regulations

The International Health Regulations (IHR) 2005 present a challenge and opportunity for global surveillance and control of infectious diseases. This article examines the opportunity for regional networks to address this challenge. Two regional infectious disease surveillance networks, established in the Mekong Basin and the Middle East, are presented as case studies. The public-private partnerships in the networks have led to an upgrade in infectious disease surveillance systems in capacity building, purchasing technology equipment, sharing of information, and development of preparedness plans in combating avian influenza. These regional networks have become an appropriate infrastructure for the implementation of the IHR 2005.

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 Medicines 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.

Prioritizing Environmental Health Risks in the UAE

This article presents the results of a comparative environmental risk-ranking exercise that was conducted in the United Arab Emirates (UAE) to inform a strategic planning process led by the Environment Agency-Abu Dhabi (EAD). It represents the first national-level application of a deliberative method for comparative risk ranking first published in this journal. The deliberative method involves a five-stage process that includes quantitative risk assessment by experts and deliberations by groups of stakeholders. The project reported in this article considered 14 categories of environmental risks to health identified through discussions with EAD staff: ambient and indoor air pollution; drinking water contamination; coastal water pollution; soil and groundwater contamination; contamination of fruits, vegetables, and seafood; ambient noise; stratospheric ozone depletion; electromagnetic fields from power lines; health impacts from climate change; and exposure to hazardous substances in industrial, construction, and agricultural work environments. Results from workshops involving 73 stakeholders who met in five separate groups to rank these risks individually and collaboratively indicated strong consensus that outdoor and indoor air pollution are the highest priorities in the UAE. Each of the five groups rated these as being among the highest risks. All groups rated soil and groundwater contamination as being among the lowest risks. In surveys administered after the ranking exercises, participants indicated that the results of the process represented their concerns and approved of using the ranking results to inform policy decisions. The results ultimately shaped a strategic plan that is now being implemented.

Response to the 2009-H1N1 influenza pandemic in the Mekong Basin: surveys of country health leaders

BackgroundSoon after the 2009-H1N1 virus emerged as the first influenza pandemic in 41 years, countries had an early opportunity to test their preparedness plans, protocols and procedures, including their cooperation with other countries in responding to the global pandemic threat. The Mekong Basin Disease Surveillance cooperation (MBDS) comprises six countries - Cambodia, China (Yunnan and Guangxi Provinces), Lao Peoples Democratic Republic, Myanmar, Thailand and Vietnam - that formally organized themselves in 2001 to cooperate in disease surveillance and control. The pandemic presented an opportunity to assess their responses in light of their individual and joint planning. We conducted two surveys of the MBDS leadership from each country, early during the pandemic and shortly after it ended.ResultsOn average, participants rated their countrys pandemic response performance as good in both 2009 and 2010. Post-pandemic (2010), perceived performance quality was best for facility-based interventions (overall mean of 4.2 on a scale from 1 = poor to 5 = excellent), followed by surveillance and information sharing (4.1), risk communications (3.9) and disease prevention and control in communities (3.7). Performance was consistently rated as good or excellent for use of hotlines for case reporting (2010 mean of 4.4) and of selected facility-based interventions (each with a 2010 mean of 4.4): using hospital admission criteria, preparing or using isolation areas, using PPE for healthcare workers and using antiviral drugs for treatment. In at least half the countries, the post-pandemic ratings were lower than initial 2009 assessments for performance related to surveillance, facility-based interventions and risk communications.ConclusionsMBDS health leaders perceived their pandemic responses effective in areas previously considered problematic. Most felt that MBDS cooperation helped drive and thus added value to their efforts. Surveillance capacity within countries and surveillance information sharing across countries, longstanding MBDS focus areas, were cited as particular strengths. Several areas needing further improvement are already core strategies in the 2011-2016 MBDS Action Plan. Self-organized sub-regional cooperation in disease surveillance is increasingly recognized as an important new element in global disease prevention and control. Our findings suggest that more research is needed to understand the characteristics of networking that will result in the best shared outcomes.

Using exercises to improve public health preparedness in Asia, the Middle East and Africa

BackgroundExercises are increasingly common tools used by the health sector and other sectors to evaluate their preparedness to respond to public health threats. Exercises provide an opportunity for multiple sectors to practice, test and evaluate their response to all types of public health emergencies. The information from these exercises can be used to refine and improve preparedness plans. There is a growing body of literature about the use of exercises among local, state and federal public health agencies in the United States. There is much less information about the use of exercises among public health agencies in other countries and the use of exercises that involve multiple countries.ResultsWe developed and conducted 12 exercises (four sub-national, five national, three sub-regional) from August 2006 through December 2008. These 12 exercises included 558 participants (average 47) and 137 observers (average 11) from 14 countries. Participants consistently rated the overall quality of the exercises as very good or excellent. They rated the exercises lowest on their ability to identifying key gaps in performance. The vast majority of participants noted that they would use the information they gained at the exercise to improve their organization’s preparedness to respond to an influenza pandemic. Participants felt the exercises were particularly good at raising awareness and understanding about public health threats, assisting in evaluating plans and identifying priorities for improvement, and building relationships that strengthen preparedness and response across sectors and across countries. Participants left the exercises with specific ideas about the most important actions that they should engage in after the exercise such as improved planning coordination across sectors and countries and better training of health workers and response personnel.ConclusionsThese experiences suggest that exercises can be a valuable, low-burden tool to improve emergency preparedness and response in countries around the world. They also demonstrate that countries can work together to develop and conduct successful exercises designed to improve regional preparedness to public health threats. The development of standardized evaluation methods for exercises may be an additional tool to help focus the actions to be taken as a result of the exercise and to improve future exercises. Exercises show great promise as tools to improve public health preparedness across sectors and countries.

Learning from Exemplary Practices in International Disaster Management: A Fresh Avenue to Inform U.S. Policy?

The devastation of the U.S. Gulf Coast by Hurricane Katrina in August 2005 sparked widespread reconsideration of U.S. disaster management practices. While most of this inquiry has drawn on U.S. disaster experiences, countries throughout the world are also struck by natural disasters. We hypothesized that the disaster management experiences in other countries could represent a potentially valuable source of insight for the United States. Therefore, we identified and examined exemplary practices in disaster prevention/preparedness, response, and recovery/redevelopment from thirteen natural disasters in eleven countries, focusing in particular on areas that were problematic during the Hurricane Katrina response. Interviews with recognized international disaster management experts validated our preliminary assessments from these experiences and provided additional insights not gleaned from the literature. We discuss seven lessons from our analyses: (1) Different models, but common principles, underlie effective coordination; (2) Community participation is critical at all phases of the disaster management cycle; (3) Both technology and public awareness contribute to effective early warning; (4) Disaster management should be evidence-based when possible; (5) An early orientation to long-term recovery can be important; (6) Countries can and should learn from previous disaster experience; and (7) Disaster management solutions must be appropriate to the local setting. We also offer and discuss three recommendations: (1) Institutionalize the process of learning from international disaster management; (2) Apply relevant practices from international experience; and (3) Systematically define, identify, document and archive exemplary practices. We conclude that it is appropriate for the United States to learn from its past experiences, draw on the world of experience across borders, and prepare for the future. Our study offers concrete steps that can be taken in this direction.

Community planning for pandemic influenza: lessons from the VA health care system.

BACKGROUND Coordination and communication among community partners-including health departments, emergency management agencies, and hospitals-are essential for effective pandemic influenza planning and response. As the nations largest integrated health care system, the US Department of Veterans Affairs (VA) could be a key component of community planning. PURPOSE To identify issues relevant to VA-community pandemic influenza preparedness. METHODS As part of a VA-community planning process, we developed and pilot-tested a series of tabletop exercises for use throughout the VA system. These included exercises for facilities, regions (Veterans Integrated Service Networks), and the VA Central Office. In each, VA and community participants, including representatives from local health care facilities and public health agencies, were presented with a 3-step scenario about an unfolding pandemic and were required to discuss issues and make decisions about how the situation would be handled. We report the lessons learned from these pilot tests. RESULTS Existing communication and coordination for pandemic influenza between VA health care system representatives and local and regional emergency planners are limited. Areas identified that would benefit from better collaborative planning include response coordination, resource sharing, uneven resource distribution, surge capacity, standards of care, workforce policies, and communication with the public. CONCLUSIONS The VA health system and communities throughout the United States have limited understanding of one anothers plans and needs in the event of a pandemic. Proactive joint VA-community planning and coordination-including exercises, followed by deliberate actions to address the issues that arise-will likely improve pandemic influenza preparedness and will be mutually beneficial. Most of the issues identified are not unique to VA, but are applicable to all integrated care systems.

Building community resilience: what can the United States learn from experiences in other countries?

OBJECTIVES Community resilience (CR) is emerging as a major public policy priority within disaster management and is one of two key pillars of the December 2009 US National Health Security Strategy. However, there is no clear agreement on what key elements constitute CR. We examined exemplary practices from international disaster management to validate the elements of CR, as suggested by Homeland Security Presidential Directive 21 (HSPD-21), to potentially identify new elements and to identify practices that could be emulated or adapted to help build CR. METHODS We extracted detailed information relevant to CR from unpublished case studies we had developed previously, describing exemplary practices from international natural disasters occurring between 1985 and 2005. We then mapped specific practices against the five elements of CR suggested by HSPD-21. RESULTS We identified 49 relevant exemplary practices from 11 natural disasters in 10 countries (earthquakes in Mexico, India, and Iran; volcanic eruption in Philippines; hurricanes in Honduras and Cuba; floods in Bangladesh, Vietnam, and Mozambique; tsunami in Indian Ocean countries; and typhoon in Vietnam). Of these, 35 mapped well against the five elements of CR: community education, community empowerment, practice, social networks, and familiarity with local services; 15 additional practices were related to physical security and economic security. The five HSPD-21 CR elements and two additional ones we identified were closely related to one another; social networks were especially important to CR. CONCLUSIONS While each disaster is unique, the elements of CR appear to be broadly applicable across countries and disaster settings. Our descriptive study provides retrospective empirical evidence that helps validate, and adds to, the elements of CR suggested by HSPD-21. It also generates hypotheses about factors contributing to CR that can be tested in future analytic or experimental research.

Will routine annual influenza prevention and control systems serve the United States well in a pandemic

OBJECTIVE To assess the extent to which the systems in place for prevention and control of routine annual influenza could provide the information and experience needed to manage a pandemic. METHODS The authors conducted a qualitative assessment based on key informant interviews and the review of relevant documents. RESULTS Although there are a number of systems in place that would likely serve the United States well in a pandemic, much of the information and experience needed to manage a pandemic optimally is not available. CONCLUSIONS Systems in place for routine annual influenza prevention and control are necessary but not sufficient for managing a pandemic, nor are they used to their full potential for pandemic preparedness. Pandemic preparedness can be strengthened by building more explicitly upon routine influenza activities and the public health systems response to the unique challenges that arise each influenza season (eg, vaccine supply issues, higher than normal rates of influenza-related deaths).