Preparing for Pandemics and Other Health Threats: Societal Approaches to Protect and Improve Health.

This Viewpoint discusses 3 areas in need of progress regarding societal approaches to pandemics and other health threats: a renaissance in public health; robustness of primary health care; and resilience of individuals and communities, with higher levels of trust in government and society.

Crisis Standards of Care.

Nursing considerations during states of emergency.

COVID-19 pandemic preparedness: A practical guide from clinical pharmacists' perspective.

PURPOSE: To describe our hospital pharmacy department's preparation for an influx of critically ill patients during the coronavirus disease 2019 (COVID-19) pandemic and offer guidance on clinical pharmacy services preparedness for similar crisis situations. SUMMARY: Personnel within the department of pharmacy at a medical center at the US epicenter of the COVID-19 pandemic proactively prepared a staffing and pharmacotherapeutic action plan in anticipation of an expected surge in admissions of critically ill patients with COVID-19 and expansion of acute care and intensive care unit (ICU) capacity. Guidance documents focusing on supportive care and pharmacotherapeutic treatment options were developed. Repurposing of non-ICU-trained clinical pharmacotherapy specialists to work collaboratively with clinician teams in ICUs was quickly implemented; staff were prepared for these duties through use of shared tools to facilitate education and practice standardization. CONCLUSION: As challenges were encountered at the initial peak of the pandemic, interdisciplinary collaboration and teamwork was crucial to ensure that all patients were proactively assessed and that their respective pharmacotherapeutic regimens were optimized.

Health technology assessment applied to emergency preparedness: a new perspective.

Emergency preparedness is a continuous quality improvement process through which roles and responsibilities are defined to effectively anticipate, respond to, and recover from the impact of emergencies. This process results in documented plans that provide a backbone structure for developing the core capacities to address health threats. Nevertheless, several barriers can impair an effective preparedness planning, as it needs a 360° perspective to address each component according to the best evidence and practice. Preparedness planning shares common principles with health technology assessment (HTA) as both encompass a multidisciplinary and multistakeholder approach, follow an iterative cycle, adopt a 360° perspective on the impact of intervention measures, and conclude with decision-making support. Our "Perspective" illustrates how each HTA domain can address different component(s) of a preparedness plan that can indeed be seen as a container of multiple HTAs, which can then be used to populate the entire plan itself. This approach can allow one to overcome preparedness barriers, providing an independent, systematic, and robust tool to address the components and ensuring a comprehensive evaluation of their value in the mitigation of the impact of emergencies.

Leveraging natural history biorepositories as a global, decentralized, pathogen surveillance network.

The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic reveals a major gap in global biosecurity infrastructure: a lack of publicly available biological samples representative across space, time, and taxonomic diversity. The shortfall, in this case for vertebrates, prevents accurate and rapid identification and monitoring of emerging pathogens and their reservoir host(s) and precludes extended investigation of ecological, evolutionary, and environmental associations that lead to human infection or spillover. Natural history museum biorepositories form the backbone of a critically needed, decentralized, global network for zoonotic pathogen surveillance, yet this infrastructure remains marginally developed, underutilized, underfunded, and disconnected from public health initiatives. Proactive detection and mitigation for emerging infectious diseases (EIDs) requires expanded biodiversity infrastructure and training (particularly in biodiverse and lower income countries) and new communication pipelines that connect biorepositories and biomedical communities. To this end, we highlight a novel adaptation of Project ECHO's virtual community of practice model: Museums and Emerging Pathogens in the Americas (MEPA). MEPA is a virtual network aimed at fostering communication, coordination, and collaborative problem-solving among pathogen researchers, public health officials, and biorepositories in the Americas. MEPA now acts as a model of effective international, interdisciplinary collaboration that can and should be replicated in other biodiversity hotspots. We encourage deposition of wildlife specimens and associated data with public biorepositories, regardless of original collection purpose, and urge biorepositories to embrace new specimen sources, types, and uses to maximize strategic growth and utility for EID research. Taxonomically, geographically, and temporally deep biorepository archives serve as the foundation of a proactive and increasingly predictive approach to zoonotic spillover, risk assessment, and threat mitigation.

Crisis Standards of Care Implementation at the State Level in the United States.

INTRODUCTION: In 2009, the Institute of Medicine published guidelines for implementation of Crisis Standards of Care (CSC) at the state level in the United States (US). Based in part on the then concern for H1N1 pandemic, there was a recognized need for additional planning at the state level to maintain health system preparedness and conventional care standards when available resources become scarce. Despite the availability of this framework, in the years since and despite repeated large-scale domestic events, implementation remains mixed. PROBLEM: Coronavirus disease 2019 (COVID-19) rejuvenates concern for how health systems can maintain quality care when faced with unrelenting burden. This study seeks to outline which states in the US have developed CSC and which areas of care have thus far been addressed. METHODS: An online search was conducted for all 50 states in 2015 and again in 2020. For states without CSC plans online, state officials were contacted by email and phone. Public protocols were reviewed to assess for operational implementation capabilities, specifically highlighting guidance on ventilator use, burn management, sequential organ failure assessment (SOFA) score, pediatric standards, and reliance on influenza planning. RESULTS: Thirty-six states in the US were actively developing (17) or had already developed (19) official CSC guidance. Fourteen states had no publicly acknowledged effort. Eleven of the 17 public plans had updated within five years, with a majority addressing ventilator usage (16/17), influenza planning (14/17), and pediatric care (15/17), but substantially fewer addressing care for burn patients (9/17). CONCLUSION: Many states lacked publicly available guidance on maintaining standards of care during disasters, and many states with specific care guidelines had not sufficiently addressed the full spectrum of hazard to which their health care systems remain vulnerable.

State Preparedness for Crisis Standards of Care in the United States: Implications for Emergency Management.

State governments and hospital facilities are often unprepared to handle a complex medical crisis, despite a moral and ethical obligation to be prepared for disaster. The 2019 novel coronavirus disease (COVID-19) has drawn attention to the lack of state guidance on how hospitals should provide care in a crisis. When the resources available are insufficient to treat the current patient load, crisis standards of care (CSC) are implemented to provide care to the population in an ethical manner, while maintaining an ability to handle the surge. This Editorial aims to raise awareness concerning a lack of preparedness that calls for immediate correction at the state and local level.Analysis of state guidelines for implementation of CSC demonstrates a lack of preparedness, as only five states in the US have appropriately completed necessary plans, despite a clear understanding of the danger. States have a legal responsibility to regulate the medical care within their borders. Failure of hospital facilities to properly prepare for disasters is not a new issue; Hurricane Katrina (2005) demonstrated a lack of planning and coordination. Improving disaster health care readiness in the United States requires states to create new policy and legislative directives for the health care facilities within their respective jurisdictions. Hospitals should have clear directives to prepare for disasters as part of a "duty to care" and to ensure that the necessary planning and supplies are available to their employees.

'I can see clearly now': clarifying the role of psychiatry in global disaster.

OBJECTIVE: First, to review the principles and practice of disaster psychiatry, in light of recent global events. Second, to identify opportunities for research. METHOD: A literature review of the MEDLINE database, UpToDate and the Cochrane Library was conducted. Reference lists were also reviewed. RESULTS: Psychiatrists are well-positioned to contribute to positive outcomes at all stages of the disaster response. These contributions derive from their roles as doctors, mental illness specialists and clinical leaders. CONCLUSION: A novel framework for the psychiatrist's contributions was proposed. Specific knowledge of disaster psychiatry may be worthwhile, and establishment of a public disaster psychiatry centre is reasonable. Research should further examine the role of tele-psychiatry and pursue a best practice for community and front-line employee psychological preparedness.

Simulation Innovation: A Novel Simulation Guide for Building Community Simulation Capacity in Pandemic Preparedness.

STATEMENT: The coronavirus disease 19 (COVID-19) pandemic, caused by severe acute respiratory distress syndrome coronavirus 2, has spread globally and requires effective preparedness within healthcare institutions. The British Columbia Simulation Network COVID-19 Simulation Guide was created to disseminate information throughout the province of British Columbia, Canada, and to allow simulation educators, from novice to expert, to participate in COVID-19 simulations. As of July 15, 2020, the guide had been downloaded 465 times from the British Columbia Simulation Network website, with downloads in 41 countries around the world. The guide has been frequently updated and revised to reflect evolving guidelines as new knowledge about COVID-19 was established.

A Commons for a Supply Chain in the Post-COVID-19 Era: The Case for a Reformed Strategic National Stockpile.

Policy Points Reflecting on current response deficiencies, we offer a model for a national contingency supply chain cell (NCSCC) construct to manage the medical materials supply chain in support of emergencies, such as COVID-19. We develop the following: a framework for governance and response to enable a globally independent supply chain; a flexible structure to accommodate the requirements of state and county health systems for receiving and distributing materials; and a national material "control tower" to improve transparency and real-time access to material status and location. CONTEXT: Much of the discussion about the failure of the COVID-19 supply chain has centered on personal protective equipment (PPE) and the degree of vulnerability of care. Prior research on supply chain risks have focused on mitigating the risk of disruptions of specific purchased materials within a bounded region or on the shifting status of cross-border export restrictions. But COVID-19 has impacted every purchase category, region, and border. This paper is responsive to the National Academies of Sciences, Engineering and Medicine recommendation to study and monitor disasters and to provide governments with course of action to satisfy legislative mandates. METHODS: Our analysis draws on our observations of the responses to COVID-19 in regard to acquisition and contracting problem-solving, our review of field discussions and interactions with experts, a critique of existing proposals for managing the strategic national stockpile in the United States a mapping of the responses to national contingency planning phases, and the identification of gaps in current national healthcare response policy frameworks and proposals. FINDINGS: Current proposals call for augmenting a system that has failed to deliver the needed response to COVID-19. These proposals do not address the key attributes for pandemic plan renewal: flexibility, traceability and transparency, persistence and responsiveness, global independence, and equitable access. We offer a commons-based framework for achieving the opportunities and risks which are responsive to a constellation of intelligence assets working in and across focal targets of global supply chain risk. CONCLUSIONS: The United States needs a "commons-based strategy" that is not simply a stockpile repository but instead is a network of repositories, fluid inventories, and analytic monitoring governed by the experts. We need a coordinated effort, a "commons" that will direct both conventional and new suppliers to meet demands and to eliminate hoarding and other behaviors.

Clinical and Ethical Considerations in Allocation of Ventilators in an Influenza Pandemic or Other Public Health Disaster: A Comparison of the 2007 and 2015 New York State Ventilator Allocation Guidelines.

OBJECTIVES: During an influenza or coronavirus disease 2019 (COVID-19) pandemic that results in acute respiratory distress, the number of available ventilators will not meet demand. In 2007, the New York State Task Force on Life and the Law and Department of Health released draft Guidelines for ethical allocation of ventilators for adults. In 2015, updated guidelines were released to ensure that: (1) revisions reflect the public's values and (2) the triage protocol is substantiated by evidence-based clinical data. We summarize the development and content of the 2015 Guidelines compared with the 2007 version, emphasizing new/revised aspects of the ethical considerations and clinical protocol. METHODS: We compared the 2007 and 2015 guidelines, with particular emphasis on the ethical issues and clinical protocols. RESULTS: The 2015 Guidelines retained much of the ethical and clinical framework of the 2007 draft. The triage protocol was revised using evidence-based clinical data. Patients with the highest likelihood of short-term survival with ventilator therapy have priority access. Protocol consists of exclusion criteria, the sequential organ failure assessment (SOFA) score, and periodic clinical assessments. Guidance is provided on secondary triage criteria. Other forms of medical intervention/palliative care and review of triage decisions are discussed. CONCLUSIONS: The 2015 Guidelines reflect advances in medicine and societal values and provide an evidenced-based framework to save the most lives. The framework could be adapted in other emergencies, such as the COVID-19 pandemic, that require ventilators.

Rapid urban health security assessment tool: a new resource for evaluating local-level public health preparedness.

Urbanisation will be one of the defining demographic trends of the 21st century-creating unique opportunities for sustainable capacity development, as well as substantial risks and challenges for managing public health and health emergencies. Plans and policies for responding to public health emergencies are generally framed at higher levels of governance, but developing, improving and sustaining the capacities necessary for implementing these policies is a direct function of local-level authorities. Evaluating local-level public health capacities is an important process for identifying strengths and weaknesses that can impact the preparedness for, detection of and response to health security threats. However, while various evaluations and assessments exist for evaluating capacities at other levels, currently, there are no readily available health security assessments for the local-level. In this paper, we describe a tool-the Rapid Urban Health Security Assessment (RUHSA) Tool-that is based on a variety of other relevant assessments and guidance documents. Assessing capacities allow for local-level authorities to identify the strengths and weaknesses of their local health security systems, create multiyear action plans and prioritise opportunities for improving capacities, effectively engage with development partners to target resources effectively and develop compelling narratives and a legacy of leadership. While the RUHSA Tool was not designed to be used in the midst of a public health emergency, such as the ongoing COVID-19 pandemic, it may also be adapted to inform a checklist for prioritising what capacities and activities a city needs to rapidly develop or to help focus requests for assistance.