The Opportunity Cost of COVID for Public Health Practice: COVID-19 Pandemic Response Work and Lost Foundational Areas of Public Health Work.

This article has been temporarily removed by the publisher, Wolters Kluwer, due to a data quality issue. We regret any confusion this may have caused. This article will be published once production is complete on the Public Health Workforce Interest and Needs Survey supplemental issue. CONTEXT: There is little empirical evidence regarding the magnitude of the COVID-19 response across the public health workforce and the extent to which other public health programs were called upon to contribute to the response, potentially leading to less work being done in other public health programs during the COVID-19 pandemic. OBJECTIVES: To assess the composition of the workforce that contributed to the COVID-19 pandemic response during 2020-2022. DESIGN: A large, cross-sectional, nationally representative survey of the state and local public health agency workforce through the Public Health Workforce Interest and Needs Survey (PH WINS). SETTING: Nearly all state health agency-central offices (SHA-COs) and Big City Health Coalition (BCHC) member public health departments as well as a nationally representative sample of other local health departments (LHDs) with more than 25 staff members and serving more than 25 000 people participated in fall 2021. PARTICIPANTS: A sample of all individuals working at each SHA-CO or LHD as part-time or full-time employees, contractors, or other employee types was used. A total of 44 732 responses (35% of eligible respondents) were received. MAIN OUTCOME MEASURE: Main outcomes included the proportion of full-time equivalent (FTE) effort devoted to COVID-19 response work by quarter (Q) from Q1 2020 through Q1 2022. Predictors of interest included individual- and agency-level demographics, most notably an individual's self-reported public health program area. RESULTS: Staffing and hiring for the COVID-19 pandemic response was an ongoing effort that began in 2020 and lasted through 2022. During the pandemic, all public health program areas contributed at least 20% of their workforce time to COVID-19 response, peaking at 47-83% of the staff time, depending on the program area. CONCLUSIONS: There was a considerable public health opportunity cost to the public health systems' large and prolonged COVID-19 response. Persistent understaffing in the public health system remains an important issue.

Rossi's principles of transfusion medicine

ROSSI'S PRINCIPLES OF TRANSFUSION MEDICINE: Transfusion Medicine impacts patients with hematologic, oncologic, and surgical conditions as well as all areas of critical care medicine and multiple areas of chronic care. This book aims to be the single best source for information related to any aspect or application of Transfusion Medicine. Contributors for the sixth edition have once again been drawn from various scientific, medical, and surgical disciplines. Thus, this book ranges from encouraging and managing donors, to collecting and preserving the blood, to matching it to the appropriate recipient, all the way to its clinical uses. It also extends these concepts to implantable tissue and regenerative medicine. Other sample topics covered within the work include: Contemporary issues in donation and transfusion: patient blood management, clinical and technical aspects of blood administration, and donor and patient Hemovigilance. Blood components and derivatives: red blood cell metabolism, preservation and oxygen delivery, blood groups, and composition of plasma. Apheresis, transplantation, and new therapies: hematopoietic growth factors, therapeutic phlebotomy and cellular apheresis, HLA antigens, alleles, and antibodies. How Transfusion Medicine has been affected by the coronavirus pandemic, the role of pathogen reduction and other modern trends. This book serves as a complete and comprehensive resource on Transfusion Medicine for clinicians who prescribe blood, students who expect to enter clinical practice, and for the scientists, physicians, nurses, technologists, and others who assure the quality and availability of blood services. © 2022 John Wiley & Sons Ltd. All rights reserved.

Staffing Up and Sustaining the Public Health Workforce.

OBJECTIVES: Estimate the number of full-time equivalents (FTEs) needed to fully implement Foundational Public Health Services (FPHS) at the state and local levels in the United States. METHODS: Current and full implementation cost estimation data from 168 local health departments (LHDs), as well as data from the Association of State and Territorial Health Officials and the National Association of County and City Health Officials, were utilized to estimate current and "full implementation" staffing modes to estimate the workforce gap. RESULTS: The US state and local governmental public health workforce needs at least 80 000 additional FTEs to deliver core FPHS in a post-COVID-19 landscape. LHDs require approximately 54 000 more FTEs, and states health agency central offices require approximately 26 000 more. CONCLUSIONS: Governmental public health needs tens of thousands of more FTEs, on top of replacements for those leaving or retiring, to fully implement core FPHS. IMPLICATIONS FOR POLICY AND PRACTICE: Transitioning a COVID-related surge in staffing to a permanent workforce requires substantial and sustained investment from federal and state governments to deliver even the bare minimum of public health services.

Patient with Myxedema Coma and Subsequent Iatrogenic Thyrotoxicosis - Role of COVID-19 Pandemic

Introduction: Myxedema coma is a rare presentation of severe hypothyroidism. The low incidence of this life-threatening disease may be attributed to easy availability of TSH testing and thyroid hormone replacement therapy. Well documented cases of thyroiditis and thyrotoxicosis due to SARS-CoV-2 are now available in medical literature. Additionally, COVID-19 pandemic has also caused higher rates of non-compliance with medications and appointments. This has resulted in higher rates of exacerbations of most chronic illnesses, including thyroid diseases. We present a case of myxedema coma and subsequent iatrogenic hyperthyroidism during the COVID-19 pandemic. Clinical Case: 57-year-old male with paroxysmal atrial fibrillation, CHF, CKD stage IV, type 2 diabetes mellitus, hypertension, and post ablative hypothyroidism was found unresponsive at home. Initial vitals were temperature 95.1F, HR 52 beats per minute, RR 14 breaths per min, BP 90/62 mmHg, and glucose 68 mg/dL. There was no evidence of goiter, and he had generalized edema. Initial labs showed hyponatremia, elevated CPK, TSH 111uIU/mL (0.27-4.2 uIU/mL) and free T4 was <0.1 ng/dL (0.93-1.7 ng/dL). He was intubated, needed vasopressor support, and was treated with empiric antibiotics. He was diagnosed with myxedema coma which was treated with 200 mcg IV levothyroxine, and stress dose hydrocortisone. He was extubated on day 4 of hospital admission after which oral levothyroxine 275 mcg daily was initiated, and steroids were tapered off. Patient's pharmacy confirmed that Levothyroxine was not last filled more than eight months ago. Patient was hospitalized 3 weeks later for pneumonia and Levothyroxine dose was further increased to 300 mcg due to persistently elevated TSH levels. Three months later, patient was admitted for Atrial fibrillation in rapid ventricular response with difficult to control tachycardia. His TSH was 0.01 uIU/mL and thyroxine of 1.93 ng/dL despite not taking any medication for 2 weeks. He admitted to not following up with endocrinologist due to the surge in COVID-19 cases. Dose of levothyroxine was decreased to weight-based dose of 225 mcg, and patient discharged with instructions to repeat labs in 6 weeks and follow up with a clinical provider. Conclusion: This case highlights the consequences of under and over replacement of thyroid hormone. Viral illnesses including SARS-CoV-2 can precipitate myxedema coma in patients with severe hypothyroidism. A high index of suspicion is needed to treat this disease in a timely manner. Providers must make allowances for the limitations in our system to function in a pandemic. Prescribing extra medication refills and offering virtual medicine appointments may help lower hospitalizations. Also, understanding the effect of non-thyroidal illness on thyroid function tests and knowing that TSH takes six weeks to normalize after starting/ adjusting thyroid hormone dose will avoid premature adjustment in hormone doses.Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Application of remote videoconferencing to home monitor and support patients with major congenital heart disease during the COVID-19 pandemic

Background and Aim: The COVID-19 pandemic presented unique challenges to global healthcare provision. Face-to-face outpatient care was dramatically reduced as a consequence. This study imple-mented a remote videoconferencing call (VC) service delivered by a mobile app to continue close monitoring of our most vulnerable patients in their home environment. The patient cohort was fol-lowed up at a regional paediatric cardiology centre. Method(s): Patient recruitment began in September 2020, concluding in December 2021. Most participants were identified in the new-born/infant period and consisted of a mixture of cyanotic and acya-notic congenital heart disease. All study participants required regular, frequent outpatient monitoring in usual circumstances. Parents/guardians of identified patients received written and verbal explan-ation of study aims and objectives prior to giving written consent. The videoconferencing interface was delivered by PEXIP Infinity Connect Mobile app and conducted by experienced medical and/or nursing staff. This app was already a well established method of communication within the Regional Paediatric Cardiology Team. Primary outcome measures included admissions to hospital and avoidance of hospital attendances. Clinical proformas including growth parameters and clinical observations was recorded at each vir-tual appointment. Patient and parent related research data was col-lected at the first, fourth and eighth appointment. A select number of patients were given home saturation monitors and weight scales. Result(s): A total of 32 patients were enrolled. 164 VCs were deliv-ered (patient mean = 5.8). The average age at recruitment was 10.8 weeks. 18 patients had surgical intervention during the study period. There were 11 admissions to hospital directly resulting from the VC;the commonest indication was abnormal oxygen sat-urations (45%). 33 hospital attendances were avoided;the com-monest concern reported by parents was difficulty related to infant feeding (36%). Conclusion(s): Qualitative and quantitative measurement tools showed reduction in parental anxiety. The study was well received by par-ticipating families. There was prompt identification of unwell chil-dren on VCs as well as providing advice to prevent unnecessary hospital attendance. Videoconferencing technology proved very user friendly and proved to be a very valuable adjunct to the pro-vision of good patient care during challenging circumstances.

Past local government health spending was not correlated with COVID-19 control in US counties.

CONTEXT: Wide variation in state and county health spending prior to 2020 enables tests of whether historically better state and locally funded counties achieved faster control over COVID-19 in the first 6 months of the pandemic in the Unites States prior to federal supplemental funding. OBJECTIVE: We used time-to-event and generalized linear models to examine the association between pre-pandemic state-level public health spending, county-level non-hospital health spending, and effective COVID-19 control at the county level. We include 2,775 counties that reported 10 or more COVID-19 cases between January 22, 2020, and July 19, 2020, in the analysis. MAIN OUTCOME MEASURE: Control of COVID-19 was defined by: (i) elapsed time in days between the 10th case and the day of peak incidence of a county's local epidemic, among counties that bent their case curves, and (ii) doubling time of case counts within the first 30 days of a county's local epidemic for all counties that reported 10 or more cases. RESULTS: Only 26% of eligible counties had bent their case curve in the first 6 months of the pandemic. Government health spending at the county level was not associated with better COVID-19 control in terms of either a shorter time to peak in survival analyses, or doubling time in generalized linear models. State-level public spending on hazard preparation and response was associated with a shorter time to peak among counties that were able to bend their case incidence curves. CONCLUSIONS: Increasing resource availability for public health in local jurisdictions without thoughtful attention to bolstering the foundational capabilities inside health departments is unlikely to be sufficient to prepare the country for future outbreaks or other public health emergencies.

COVID-19 convalescent plasma experience in the US

Convalescent whole blood, plasma, and serum have been used as passive immune therapy of infectious diseases since the late 1800s. Following favorable reports of safety and clinical improvement after limited use of convalescent plasma (CP) to treat SARS-CoV-2 disease (COVID-19), the United States Food and Drug Administration (FDA) invited investigational use of this product. Single-patient emergency Investigational New Drug Applications (eINDs) were soon followed by an expanded access program (EAP). Data from the EAP led to FDA’s emergency use authorization of COVID-19 CP (CCP). The elements of a CCP program are donor recruitment, prevention of disease transmission at the collection site, donor screening at the collection site, plasma collection, testing plasma for potency, and the use of postdonation information from the donor. These elements are based on practices already used for allogeneic donation generally. Data supporting current CCP potency criteria, which are related to the titer of antibody against SARS-CoV-2, are limited. A report of rates of adverse donor outcomes and product loss exceeding those for non-CCP donations needs further study. Initially high demand for CCP appears to have declined. Regulatory restrictions on eligible recipients may further decrease demand. The effects of vaccination on donor and recipient availability are to be determined. © Annals of Blood. All rights reserved.

Funding Public Health: Achievements and Challenges in Public Health Financing Since the Institute of Medicine's 2012 Report.

OBJECTIVE: The purpose of this study was to review changes in public health finance since the 2012 Institute of Medicine (IOM) report "For the Public's Health: Investing in a Healthier Future." DESIGN: Qualitative study involving key informant interviews. SETTING AND PARTICIPANTS: Purposive sample of US public health practitioners, leaders, and academics expected to be knowledgeable about the report recommendations, public health practice, and changes in public health finance since the report. MAIN OUTCOME MEASURES: Qualitative feedback about changes to public health finance since the report. RESULTS: Thirty-two interviews were conducted between April and May 2019. The greatest momentum toward the report recommendations has occurred predominantly at the state and local levels, with recommendations requiring federal action making less progress. In addition, much of the progress identified is consensus building and preparation for change rather than clear changes. Overall, progress toward the recommendations has been slow. CONCLUSIONS: Many of the achievements reported by respondents were characterized as increased dialogue and individual state or local progress rather than widespread, identifiable policy or practice changes. Participants suggested that public health as a field needs to achieve further consensus and a uniform voice in order to advocate for changes at a federal level. IMPLICATIONS FOR POLICY AND PRACTICE: Slow progress in achieving 2012 IOM Finance Report recommendations and lack of a cohesive voice pose threats to the public's health, as can be seen in the context of COVID-19 emergency response activities. The pandemic and the nation's inadequate response have highlighted deficiencies in our current system and emphasize the need for coordinated and sustained core public health infrastructure funding at the federal level.

Accuracy of Case-Based Seroprevalence of SARS-CoV-2 Antibodies in Maricopa County, Arizona.

We conducted a community seroprevalence survey in Arizona, from September 12 to October 1, 2020, to determine the presence of antibodies to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We used the seroprevalence estimate to predict SARS-CoV-2 infections in the jurisdiction by applying the adjusted seroprevalence to the county's population. The estimated community seroprevalence of SARS-CoV-2 infections was 4.3 times greater (95% confidence interval = 2.2, 7.5) than the number of reported cases. Field surveys with representative sampling provide data that may help fill in gaps in traditional public health reporting. (Am J Public Health. 2022;112(1):38-42. https://doi.org/10.2105/AJPH.2021.306568).

Association Between K-12 School Mask Policies and School-Associated COVID-19 Outbreaks - Maricopa and Pima Counties, Arizona, July-August 2021.

CDC recommends universal indoor masking by students, staff members, faculty, and visitors in kindergarten through grade 12 (K-12) schools, regardless of vaccination status, to reduce transmission of SARS-CoV-2, the virus that causes COVID-19 (1). Schools in Maricopa and Pima Counties, which account for >75% of Arizona's population (2), resumed in-person learning for the 2021-22 academic year during late July through early August 2021. In mid-July, county-wide 7-day case rates were 161 and 105 per 100,000 persons in Maricopa and Pima Counties, respectively, and 47.6% of Maricopa County residents and 59.2% of Pima County residents had received at least 1 dose of a COVID-19 vaccine. School districts in both counties implemented variable mask policies at the start of the 2021-22 academic year (Table). The association between school mask policies and school-associated COVID-19 outbreaks in K-12 public noncharter schools open for in-person learning in Maricopa and Pima Counties during July 15-August 31, 2021, was evaluated.

Inaccuracy of Official Estimates of Public Health Spending in the United States, 2000-2018.

Objectives. To examine the accuracy of official estimates of governmental health spending in the United States.Methods. We coded approximately 2.7 million administrative spending records from 2000 to 2018 for public health activities according to a standardized Uniform Chart of Accounts produced by the Public Health Activities and Services Tracking project. The official US Public Health Activity estimate was recalculated using updated estimates from the data coding.Results. Although official estimates place governmental public health spending at more than $93 billion (2.5% of total spending on health), detailed examination of spending records from state governments shows that official estimates include substantial spending on individual health care services (e.g., behavioral health) and that actual spending on population-level public health activities is more likely between $35 billion and $64 billion (approximately 1.5% of total health spending).Conclusions. Clarity in understanding of public health spending is critical for characterizing its value proposition. Official estimates are likely tens of billions of dollars greater than actual spending.Public Health Implications. Precise and clear spending estimates are material for policymakers to accurately understand the effect of their resource allocation decisions.

US Public Health Neglected: Flat Or Declining Spending Left States Ill Equipped To Respond To COVID-19.

The COVID-19 pandemic has prompted concern about the integrity of the US public health infrastructure. Federal, state, and local governments spend $93 billion annually on public health in the US, but most of this spending is at the state level. Thus, shoring up gaps in public health preparedness and response requires an understanding of state spending. We present state spending trends in eight categories of public health activity from 2008 through 2018. We obtained data from the Census Bureau for all states except California and coded the data by public health category. Although overall national health expenditures grew by 4.3 percent in this period, state governmental public health spending saw no statistically significant growth between 2008 and 2018 except in injury prevention. Moreover, state spending levels on public health were not restored after cuts experienced during the Great Recession, leaving states ill equipped to respond to COVID-19 and other emerging health needs.

Excess Medical Care Spending: The Categories, Magnitude, and Opportunity Costs of Wasteful Spending in the United States

Landmark reports from reputable sources have concluded that the United States wastes hundreds of billions of dollars every year on medical care that does not improve health outcomes. While there is widespread agreement over how wasteful medical care spending is defined, there is no consensus on its magnitude or categories. A shared understanding of the magnitude and components of the issue may aid in systematically reducing wasteful spending and creating opportunities for these funds to improve public health. To this end, we performed a review and crosswalk analysis of the literature to retrieve comprehensive estimates of wasteful medical care spending. We abstracted each source's definitions, categories of waste, and associated dollar amounts. We synthesized and reclassified waste into 6 categories: clinical inefficiencies, missed prevention opportunities, overuse, administrative waste, excessive prices, and fraud and abuse. Aggregate estimates of waste varied from $600 billion to more than $1.9 trillion per year, or roughly $1800 to $5700 per person per year. Wider recognition by public health stakeholders of the human and economic costs of medical waste has the potential to catalyze health system transformation. (Am J Public Health. 2020;110:17431748. https://doi.org/102105/AJPH. 2020.305865)