Global Public Health Database Support to Population-Based Management of Pandemics and Global Public Health Crises, Part II: The Database.

This two-part article examines the global public health (GPH) information system deficits emerging in the coronavirus disease 2019 (COVID-19) pandemic. It surveys past, missed opportunities for public health (PH) information system and operational improvements, examines current megatrend changes to information management, and describes a new multi-disciplinary model for population-based management (PBM) supported by a GPH Database applicable to pandemics and GPH crises.

Global Public Health Database Support to Population-Based Management of Pandemics and Global Public Health Crises, Part I: The Concept.

This two-part article examines the global public health (GPH) information system deficits emerging in the coronavirus disease 2019 (COVID-19) pandemic. It surveys past, missed opportunities for public health (PH) information system and operational improvements, examines current megatrend changes to information management, and describes a new multi-disciplinary model for population-based management (PBM) supported by a GPH Database applicable to pandemics and GPH crises.

Australasian disasters of national significance: an epidemiological analysis, 1900-2012.

BACKGROUND: A regional epidemiological analysis of Australasian disasters in the 20th century to present was undertaken to examine trends in disaster epidemiology; to characterise the impacts on civil society through disaster policy, practice and legislation; and to consider future potential limitations in national disaster resilience. METHODS: A surveillance definition of disaster was developed conforming to the Centre for Research on the Epidemiology of Disasters (CRED) criteria (≥10 deaths, ≥100 affected, or declaration of state emergency or appeal for international assistance). The authors then applied economic and legislative inclusion criteria to identify additional disasters of national significance. RESULTS: The surveillance definition yielded 165 disasters in the period, from which 65 emerged as disasters of national significance. There were 38 natural disasters, 22 technological disasters, three offshore terrorist attacks and two domestic mass shootings. Geographic analysis revealed that states with major population centres experienced the vast majority of disasters of national significance. Timeline analysis revealed an increasing incidence of disasters since the 1980s, which peaked in the period 2005-2009. Recent seasonal bushfires and floods have incurred the highest death toll and economic losses in Australasian history. Reactive hazard-specific legislation emerged after all terrorist acts and after most disasters of national significance. CONCLUSION: Timeline analysis reveals an increasing incidence in natural disasters over the past 15 years, with the most lethal and costly disasters occurring in the past 3 years. Vulnerability to disaster in Australasia appears to be increasing. Reactive legislation is a recurrent feature of Australasian disaster response that suggests legislative shortsightedness and a need for comprehensive all-hazards model legislation in the future.

The rational clinician in a pandemic setting.

Pandemic (H1N1) 2009 influenza has generated many controversies in Australia around case definitions, laboratory diagnosis, case management, medical logistics and travel restrictions. Our experience as clinical advisers in the Victorian Department of Human Services Emergency Operations Centre suggests the following: Case definitions may change frequently, and will tend to become more clinically specific over time. Early in a pandemic, laboratory diagnosis plays a critical role in case finding and pathogen identification. Later in the pandemic, standardised case management applied to well crafted case definitions should reduce reliance on the diagnostic laboratory in clinical management. The diagnostic laboratory will remain critical to monitoring disease surveillance, pathogen virulence, and drug susceptibility. Medical logistics will continue to challenge pandemic managers as the health sector struggles to do the most good for the greatest number of people. Travel restrictions remain scientifically controversial public health recommendations. Issues of scalability (escalation and de-escalation of the response) relating to virus lethality need to be resolved in current pandemic planning.

Emergency department surge capacity: recommendations of the Australasian Surge Strategy Working Group.

For more than a decade, emergency medicine (EM) organizations have produced guidelines, training, and leadership for disaster management. However, to date there have been limited guidelines for emergency physicians (EPs) needing to provide a rapid response to a surge in demand. The aim of this project was to identify strategies that may guide surge management in the emergency department (ED). A working group of individuals experienced in disaster medicine from the Australasian College for Emergency Medicine Disaster Medicine Subcommittee (the Australasian Surge Strategy Working Group) was established to undertake this work. The Working Group used a modified Delphi technique to examine response actions in surge situations and identified underlying assumptions from disaster epidemiology and clinical practice. The group then characterized surge strategies from their corpus of experience; examined them through available relevant published literature; and collated these within domains of space, staff, supplies, and system operations. These recommendations detail 22 potential actions available to an EP working in the context of surge, along with detailed guidance on surge recognition, triage, patient flow through the ED, and clinical goals and practices. The article also identifies areas that merit future research, including the measurement of surge capacity, constraints to strategy implementation, validation of surge strategies, and measurement of strategy impacts on throughput, cost, and quality of care.

Evidence-based decision-making (part 1): Origins and evolution in the health sciences.

Evidence is defined as data on which a judgment or conclusion may be based. In the early 1990s, medical clinicians pioneered evidence-based decision-making. The discipline emerged as the use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine required the integration of individual clinical expertise with the best available, external clinical evidence from systematic research and the patient's unique values and circumstances. In this context, evidence acquired a hierarchy of strength based upon the method of data acquisition. Subsequently, evidence-based decision-making expanded throughout the allied health field. In public health, and particularly for populations in crisis, three major data-gathering tools now dominate: (1) rapid health assessments; (2) population based surveys; and (3) disease surveillance. Unfortunately, the strength of evidence obtained by these tools is not easily measured by the grading scales of evidence based medicine. This is complicated by the many purposes for which evidence can be applied in public health: strategic decision-making, program implementation, monitoring, and evaluation. Different applications have different requirements for strength of evidence as well as different time frames for decision-making. Given the challenges of integrating data from multiple sources that are collected by different methods, public health experts have defined best available evidence as the use of all available sources used to provide relevant inputs for decision-making.

Evidence-based decision-making (part II): applications in disaster relief operations.

Recognized limitations to data in disaster management have led to dozens of initiatives to strengthen data gathering and decision-making during disasters. These initiatives are complicated by fundamental problems of definitions of terms, ambiguity of concepts, lack of standardization in methods of data collection, and inadequate attempts to strengthen the analytic capability of field organizations. Cross-cutting issues in needs assessment, coordination, and evaluation illustrate additional recurring challenges in dealing with evidence in humanitarian assistance. These challenges include lack of agency expertise, dyscoordination at the field level, inappropriate reliance on indicators that measure process rather than outcome, flawed scientific inference, and erosion of the concept of minimum standards. Decision-making in disaster management currently places a premium on expert or eminence-based decisions. By contrast, scientific advances in disaster medicine call for evidence-based decisions whose strength of evidence is established by the methods of data acquisition. At present, disaster relief operations may be data driven, but that does not mean that they are soundly evidence-based. Options for strengthening evidence-based activities include rigorously adhering to evidenced-based interventions, using evidence-based tools to identify new approaches to problems of concern, studying model programs as well as failed ones to identify approaches that deserve replication, and improving standards for evidence of effectiveness in disaster science and services.

Delayed recognition of excess mortality in West Timor.

INTRODUCTION: In September 1999, militia-initiated violence in East Timor forced the displacement of approximately 290,000 persons to West Timor in Indonesia. Whereas the security and health status of the East Timorese in East Timor had been well-monitored, by contrast, the health status of 150,000 refugees in approximately 200 camps in West Timor was essentially unknown. The death of a child during transfer from a refugee camp there to a United Nations transit camp prompted further investigation. METHODS: The present study population was the largest West Timorese camp of 14,088 refugees. Despite security constraints, a rapid epidemiological assessment was undertaken. Retrospective analysis of camp mortality data, key informant interviews and environmental assessment were included. RESULTS: A crude mortality rate of 2.3/10,000/day and an under 5 year mortality rate of 10.3/10,000/day were found. Environmental sanitation, personal hygiene, water quality and vector control were inadequate. International aid agencies provided medical care with variable case definitions, no treatment protocols, non-standard treatment practices, inappropriate antibiotic use, variable referral practices and no secondary prevention. Syndromic diagnoses of causes of dealth guided recommendations for interventions. Follow-up reports indicated that excess camp mortality was eliminated within a month. CONCLUSIONS: All conflict-affected populations must have an ongoing examination of essential health data to identify urgent unmet needs, guide appropriate health interventions and monitor progress. Sentinel health events must be promptly reported and investigated. Syndromic diagnoses are useful in targeting life-saving public health interventions. All humanitarian health assistance must have transparency, technical supervision and peer review to ensure compliance with minimum standards.

Professionalization of disaster medicine--an appraisal of criterion-referenced qualifications.

The landmark Humanitarian Response Review, commissioned by the United Nations Emergency Relief Coordinator in 2005, has catalyzed recent reforms in disaster response through the Inter-Agency Standing Committee. These reforms include a "cluster lead" approach to sectoral responsibilities and the strengthening of humanitarian coordination. Clinical medicine, public health, and disaster incident management are core disciplines underlying expertise in disaster medicine. Technical lead agencies increasingly provide pre-deployment training for selected health personnel. Moreover, technical innovations in disaster health sciences increasingly are disseminated to the disaster field through multi-agency initiatives, such as the Standardized Monitoring and Assessment of Relief and Transitions (SMART) initiative. The hallmark qualification of competency to render an informed opinion in the health specialties remains specialty board certification in North American healthcare traditions, or specialty society fellowship in British and Australasian healthcare traditions. However, disaster incident management training lacks international consensus on hallmark qualifications for competency. Disaster experience is best characterized in terms of months of full-time, hands-on field service. Future practitioners in disaster medicine will see intensified efforts to define competency benchmarks across underlying core disciplines as well as key field performance indicators. Quantitative decision-support tools are emerging to assist disaster planners and medical coordinators in their personnel selection.

The Surge Capacity for People in Emergencies (SCOPE) study in Australasian hospitals.

OBJECTIVES: To measure physical assets in Australasian hospitals required for the management of mass casualties as a result of terrorism or natural disasters. DESIGN AND SETTING: A cross-sectional survey of Australian and New Zealand hospitals. PARTICIPANTS: All emergency department directors of Australasian College for Emergency Medicine (ACEM)-accredited hospitals, as well as private and non-ACEM accredited emergency departments staffed by ACEM Fellows in metropolitan Sydney. MAIN OUTCOME MEASURES: Numbers of operating theatres, intensive care unit (ICU) beds and x-ray machines; state of preparedness using benchmarks defined by the Centers for Disease Control and Prevention in the United States. RESULTS: We found that 61%-82% of critically injured patients would not have immediate access to operative care, 34%-70% would have delayed access to an ICU bed, and 42% of the less critically injured would have delayed access to x-ray facilities. CONCLUSIONS: Our study demonstrates that physical assets in Australasian public hospitals do not meet US hospital preparedness benchmarks for mass casualty incidents. We recommend national agreement on disaster preparedness benchmarks and periodic publication of hospital performance indicators to enhance disaster preparedness.

Avian influenza pandemic threat and health systems response.

Avian influenza is a panzootic and recurring human epidemic with pandemic potential. Pandemic requirements for a viral pathogen are: a novel virus must emerge against which the general population has little or no immunity; the new virus must be able to replicate in humans and cause serious illness; and the new virus must be efficiently transmitted from person to person. At present, only the first two conditions have been met. Nonetheless, influenza pandemics are considered inevitable. Expected worldwide human mortality from a moderate pandemic scenario is 45 million people or more than 75% of the current annual global death burden. Although mathematical models have predicted that an emerging pandemic could be contained at its source, this conclusion remains controversial among public health experts. The Terrestrial Animal Health Code and International Health Regulations are enforceable legal instruments integral to pandemic preparedness. Donor support in financial, material and technical assistance remains critical to disease control efforts - particularly in developing countries where avian influenza predominately occurs at present. Personal protective equipment kits, decontamination kits and specimen collection kits in lightweight, portable packages are becoming standardized. Air transport border control measures purporting to delay importation and spread of human avian influenza are scientifically controversial. National pandemic plans prioritize beneficiary access to antiviral drugs and vaccines for some countries. Other medical commodities including ventilators, hospital beds and intensive care units remain less well prioritized in national plans. These resources will play virtually no role in care of the overwhelming majority of patients worldwide in a pandemic. Prehospital care, triage and acute care all require additional professional standardization for the high patient volumes anticipated in a pandemic.

Rapid epidemiological assessment of health status in displaced populations--an evolution toward standardized minimum, essential data sets.

Rapid epidemiological assessment (REA) has evolved over the past 30 years into an essential tool of disaster management. Small area survey and sampling methods are the major application. While REA is protocol driven, needs assessment of displaced populations remains highly non-standardized. The United Nations and other international organizations continue to call for the development of standardized instruments for post-disaster needs assessment. This study examines REA protocols from leading agencies in humanitarian health assistance across an evaluation criteria of best-practice attributes. Analysis of inconsistencies and deficits leads to the derivation of a Minimum Essential Data Set (MEDS) proposed for use by relief agencies in post-disaster REA of health status in displaced populations. This data set lends itself to initial assessment, ongoing monitoring, and evaluation of relief efforts. It is expected that the task of rapid epidemiological assessment, and more generally, the professional practice of post-disaster health coordination, will be enhanced by development, acceptance, and use of standardized Minimum Essential Data Sets (MEDS).

A strategic plan for disaster medicine in Australasia.

Disaster epidemiology reveals epidemic increases in incidence of disasters. Rare disasters with catastrophic consequences also threaten modern populations. This paper profiles natural disasters, transportation incidents, emerging infectious diseases, complex disasters and terrorism for their historical and future potential impact on Australasia. Emergency physicians are in a position to assume leadership roles within the disaster management community in Australasia. The Australasian College for Emergency Medicine is in a position to lead medical specialty advances in disaster medicine in Australasia. To optimize its impact in disaster medicine, the specialty and its College have opportunities for advances in key areas of College administration, intra and interinstitutional representation, disaster preparedness and planning, disaster relief operations, education and training programs, applied clinical research, and faculty development.

Site management of health issues in the 2001 World Trade Center disaster.

The terrorist destruction of the World Trade Center led to the greatest loss of life from a criminal incident in the history of the United States. There were 2,801 persons killed or missing at the disaster site, including 147 dead on two hijacked aircraft. Hundreds of buildings sustained direct damage or contamination. Forty different agencies responded with command and control exercised by an incident command system as well as an emergency operations center. Dozens of hazards complicated relief and recovery efforts. Five victims were rescued from the rubble. Up to 1,000 personnel worked daily at the World Trade Center disaster site. These workers collectively made an average of 270 daily presentations to health care providers in the first month post-disaster. Of presentations for clinical symptoms, leading clinical diagnoses were ocular injuries, headaches, and lung injuries. Mechanical injury accounted for 39% of clinical presentations and appeared preventable by personal protective equipment. Limitations emerged in the site application of emergency triage and clinical care. Notable assets in the site management of health issues include action plans from the incident command system, geographic information system products, wireless application technology, technical consensus among health and safety authorities, and workers' respite care.

From complex emergencies to terrorism--new tools for health-sector coordination in conflict-associated disasters.

Inter-agency coordination in humanitarian assistance dates as a discipline from the 1960s. The United Nations, Red Cross, governmental, and non-governmental agencies have evolved different mechanisms to achieve it. Present practices in field-based, inter-agency coordination of the health sector remain variable and non-standardized. International experiences in coordination of humanitarian assistance reveal numerous issues of jurisdiction, authority, capacity, and competency. New tools to help overcome these issues in the health-sector coordination include binding principles of engagement, protocols for the assumption of responsibilities, standardized minimum essential data sets, and health-sector component summaries.

Rapid epidemiological assessment of health status in displaced populations--an evolution toward standardized minimum, essential data sets.

Rapid epidemiological assessment (REA) has evolved over the past 30 years into an essential tool of disaster management. Small area survey and sampling methods are the major application. While REA is protocol driven, needs assessment of displaced populations remains highly non-standardized. The United Nations and other international organizations continue to call for the development of standardized instruments for post-disaster needs assessment. This study examines REA protocols from leading agencies in humanitarian health assistance across an evaluation criteria of best-practice attributes. Analysis of inconsistencies and deficits leads to the derivation of a Minimum Essential Data Set (MEDS) proposed for use by relief agencies in post-disaster REA of health status in displaced populations. This data set lends itself to initial assessment, ongoing monitoring, and evaluation of relief efforts. It is expected that the task of rapid epidemiological assessment, and more generally, the professional practice of post-disaster health coordination, will be enhanced by development, acceptance, and use of standardized Minimum Essential Data Sets (MEDS).