Last data update: Nov 04, 2024. (Total: 48056 publications since 2009)
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Trends in the Use of Telehealth During the Emergence of the COVID-19 Pandemic - United States, January-March 2020.
Koonin LM , Hoots B , Tsang CA , Leroy Z , Farris K , Jolly T , Antall P , McCabe B , Zelis CBR , Tong I , Harris AM . MMWR Morb Mortal Wkly Rep 2020 69 (43) 1595-1599 In February 2020, CDC issued guidance advising persons and health care providers in areas affected by the coronavirus disease 2019 (COVID-19) pandemic to adopt social distancing practices, specifically recommending that health care facilities and providers offer clinical services through virtual means such as telehealth.* Telehealth is the use of two-way telecommunications technologies to provide clinical health care through a variety of remote methods.(†) To examine changes in the frequency of use of telehealth services during the early pandemic period, CDC analyzed deidentified encounter (i.e., visit) data from four of the largest U.S. telehealth providers that offer services in all states.(§) Trends in telehealth encounters during January-March 2020 (surveillance weeks 1-13) were compared with encounters occurring during the same weeks in 2019. During the first quarter of 2020, the number of telehealth visits increased by 50%, compared with the same period in 2019, with a 154% increase in visits noted in surveillance week 13 in 2020, compared with the same period in 2019. During January-March 2020, most encounters were from patients seeking care for conditions other than COVID-19. However, the proportion of COVID-19-related encounters significantly increased (from 5.5% to 16.2%; p<0.05) during the last 3 weeks of March 2020 (surveillance weeks 11-13). This marked shift in practice patterns has implications for immediate response efforts and longer-term population health. Continuing telehealth policy changes and regulatory waivers might provide increased access to acute, chronic, primary, and specialty care during and after the pandemic. |
Video telemedicine experiences in COVID-19 were positive, but physicians and patients prefer in-person care for the future
SteelFisher GK , McMurtry CL , Caporello H , Lubell KM , Koonin LM , Neri AJ , Ben-Porath EN , Mehrotra A , McGowan E , Espino LC , Barnett ML . Health Aff (Millwood) 2023 42 (4) 575-584 To help inform policy discussions about postpandemic telemedicine reimbursement and regulations, we conducted dual nationally representative surveys among primary care physicians and patients. Although majorities of both populations reported satisfaction with video visits during the pandemic, 80 percent of physicians would prefer to provide only a small share of care or no care via telemedicine in the future, and only 36 percent of patients would prefer to seek care by video or phone. Most physicians (60 percent) felt that the quality of video telemedicine care was generally inferior to the quality of in-person care, and both patients and physicians cited the lack of physical exam as a key reason (90 percent and 92 percent, respectively). Patients who were older, had less education, or were Asian were less likely to want to use video for future care. Although improvements to home-based diagnostic tools could improve both the quality of and the desire to use telemedicine, virtual primary care will likely be limited in the immediate future. Policies to enhance quality, sustain virtual care, and address inequities in the online setting may be needed. |
Trends in engagement with CDC's coronavirus self-checker and guidance provided to users in the United States between March 23, 2020 - April 19, 2021
Shah AB , Oyegun E , Hampton WB , Neri A , Maddox N , Raso D , Sandhu P , Patel A , Koonin LM , Lee L , Roper L , Whitfield G , Siegel DA , Koumans EH . J Med Internet Res 2023 25 e39054 BACKGROUND: In 2020, at the onset of the COVID-19 pandemic, the United States experienced surges in healthcare needs, which challenged capacity throughout the healthcare system. Stay-at-home orders in many jurisdictions, cancellation of elective procedures, and closures of outpatient medical offices disrupted patient access to care. To inform symptomatic persons about when to seek care and potentially help alleviate the burden on the healthcare system, Centers for Disease Control and Prevention (CDC) and partners developed the CDC Coronavirus Self-Checker ("Self-Checker"). This interactive tool assists individuals seeking information about COVID-19 to determine the appropriate level of care by asking demographic, clinical, and nonclinical questions during an online "conversation." OBJECTIVE: This paper describes user characteristics, trends in use, and recommendations delivered by the Self-Checker between March 23, 2020, and April 19, 2021, for pursuing appropriate levels of medical care depending on the severity of user symptoms. METHODS: User characteristics and trends in completed conversations that resulted in a care message were analyzed. Care messages delivered by the Self-Checker were manually classified into three overarching conversation themes: (1) seek care immediately; (2) take no action, or stay home and self-monitor; and (3) conversation redirected. Trends in 7-day averages of conversations and COVID-19 cases were examined with development and marketing milestones that potentially impacted Self-Checker user engagement. RESULTS: Among 16,718,667 completed conversations, the Self-Checker delivered recommendations for 69.27% (n=11,580,738) of all conversations to "take no action, or stay home and self-monitor"; 28.8% (n=4,822,138) of conversations to "seek care immediately"; and 1.89% (n=315,791) of conversations were redirected to other resources without providing any care advice. Among 6.8 million conversations initiated for self-reported sick individuals without life-threatening symptoms, 59.21% resulted in a recommendation to "take no action, or stay home and self-monitor." Nearly all individuals (99.8%) who were not sick were also advised to "take no action, or stay home and self-monitor." CONCLUSIONS: The majority of Self-Checker conversations resulted in advice to take no action, or stay home and self-monitor. This guidance may have reduced patient volume on the medical system; however, future studies evaluating patients' satisfaction, intention to follow the care advice received, course of action, and care modality pursued could clarify the impact of the Self-Checker and similar tools during future public health emergencies. |
CDC's Flu on Call simulation: Testing a national helpline for use during an influenza pandemic
Koonin LM , Sliger K , Kerr J , Bullen-Austin L , Graeden E , Farris K , Ionta C , Krause D , Patel A . Health Secur 2020 18 (5) 392-402 During an influenza pandemic, healthcare facilities are likely to be filled to capacity, leading to delays in seeing a provider and obtaining treatment. Flu on Call is a collaborative effort between the US Centers for Disease Control and Prevention and partners to develop a toll-free telephone helpline to reduce the burden on healthcare facilities and improve access to antivirals for people who are ill during an influenza pandemic. This study tested the feasibility of Flu on Call during a 1-day simulation using a severe pandemic scenario. Trained volunteer actors placed calls to the helpline using prepared scripts that were precoded for an expected outcome ("disposition") of the call. Scripts represented callers who were ill, those calling for someone else who was ill, and callers who were only seeking information. Information specialists and medical professionals managed the calls. Results demonstrated that Flu on Call may effectively assist callers during a pandemic, increase access to antiviral prescriptions, and direct patients to the appropriate level of care. Overall, 84% of calls exactly matched the expected call disposition; few calls (2%) were undermanaged (eg, the caller was ill but not transferred to a medical professional or received advice from the medical professional that was less intensive than what was warranted). Callers indicated a high level of satisfaction (83% reported their needs were met). Because of the high volume of calls that may be received during a severe pandemic, the Flu on Call platform should evolve to include additional triage channels (eg, through internet, chat, and/or text access). |
Strategies to Inform Allocation of Stockpiled Ventilators to Healthcare Facilities During a Pandemic.
Koonin LM , Pillai S , Kahn EB , Moulia D , Patel A . Health Secur 2020 18 (2) 69-74 During a severe pandemic, especially one causing respiratory illness, many people may require mechanical ventilation. Depending on the extent of the outbreak, there may be insufficient capacity to provide ventilator support to all of those in need. As part of a larger conceptual framework for determining need for and allocation of ventilators during a public health emergency, this article focuses on the strategies to assist state and local planners to allocate stockpiled ventilators to healthcare facilities during a pandemic, accounting for critical factors in facilities' ability to make use of additional ventilators. These strategies include actions both in the pre-pandemic and intra-pandemic stages. As a part of pandemic preparedness, public health officials should identify and query healthcare facilities in their jurisdiction that currently care for critically ill patients on mechanical ventilation to determine existing inventory of these devices and facilities' ability to absorb additional ventilators. Facilities must have sufficient staff, space, equipment, and supplies to utilize allocated ventilators adequately. At the time of an event, jurisdictions will need to verify and update information on facilities' capacity prior to making allocation decisions. Allocation of scarce life-saving resources during a pandemic should consider ethical principles to inform state and local plans for allocation of ventilators. In addition to ethical principles, decisions should be informed by assessment of need, determination of facilities' ability to use additional ventilators, and facilities' capacity to ensure access to ventilators for vulnerable populations (eg, rural, inner city, and uninsured and underinsured individuals) or high-risk populations that may be more susceptible to illness. |
A control banding framework for protecting the US workforce from aerosol transmissible infectious disease outbreaks with high public health consequences
Sietsema M , Radonovich L , Hearl FJ , Fisher EM , Brosseau LM , Shaffer RE , Koonin LM . Health Secur 2019 17 (2) 124-132 Recent high-profile infectious disease outbreaks illustrate the importance of selecting appropriate control measures to protect a wider range of employees, other than those in healthcare settings. In such settings, where routine exposure risks are often high, control measures may be more available, routinely implemented, and studied for effectiveness. In the absence of evidence-based guidelines or established best practices for selecting appropriate control measures, employers may unduly rely on personal protective equipment (PPE) because of its wide availability and pervasiveness as a control measure, circumventing other effective options for protection. Control banding is one approach that may be used to assign job tasks into risk categories and prioritize the application of controls. This article proposes an initial control banding framework for workers at all levels of risk and incorporates a range of control options, including PPE. Using the National Institutes of Health (NIH) risk groups as a surrogate for toxicity and combining the exposure duration with the exposure likelihood, we can generate the risk of a job task to the worker. |
An assessment of state laws providing gubernatorial authority to remove legal barriers to emergency response
Sunshine G , Thompson K , Menon AN , Anderson N , Penn M , Koonin LM . Health Secur 2019 17 (2) 156-161 Legal Perspectives is aimed at informing healthcare providers, emergency planners, public health practitioners, and other decision makers about important legal issues related to public health and healthcare preparedness and response. The articles describe these potentially challenging topics and conclude with the authors' suggestions for further action. The articles do not provide legal advice. Therefore, those affected by the issues discussed in this column should seek further guidance from legal counsel. Readers may submit topics of interest to the column's editor, Lainie Rutkow, JD, PhD, MPH, at lrutkow@jhu.edu. Governors play a fundamental role in emergency preparedness and can help facilitate rapid responses to emergencies. However, laws that operate successfully under normal circumstances can inadvertently create barriers during emergencies, delaying a timely response. State laws could thus limit, or even prohibit, necessary response efforts. To combat this risk, legislatures have passed emergency powers laws in each state granting governors the authority to declare a state of emergency and to exercise certain emergency powers to meet the needs of the emergency. Researchers conducted a 50-state legal assessment, which identified and examined state laws that give governors the discretion to modify existing laws or create new laws to respond effectively to any type of declared emergency. This article outlines the findings of that assessment, which identified 35 states that explicitly permit governors to suspend or amend both statutes and regulations; 7 states in which governors are permitted to amend regulations during a declared emergency but are not explicitly authorized to modify or remove statutes; and 8 states and the District of Columbia that provide no explicit authority to governors to change statutes or regulations during a declared emergency. The article also provides examples of how this power has been used in the past to demonstrate the utility and scope of this authority in a variety of public health threats. |
Pharmacist Views on Alternative Methods for Antiviral Distribution and Dispensing During an Influenza Pandemic
SteelFisher GK , Benson JM , Caporello H , Koonin LM , Patel A , Ben-Porath E , Blendon RJ . Health Secur 2018 16 (2) 108-118 Antiviral drugs are likely to be a frontline countermeasure needed to minimize disease impact during an influenza pandemic. As part of pandemic influenza preparedness efforts, the Centers for Disease Control and Prevention, in coordination with state health departments, has plans in place to distribute and dispense antiviral drugs from public stockpiles. These plans are currently under review and include evaluation of the benefits of commercial distribution and dispensing through community pharmacies. To ensure this alternative distribution and dispensing system is viable, it is critical to assess pharmacist acceptability and to understand the pharmacist perspective on dispensing these antivirals during a response. In this study, we examine community pharmacist reactions to the proposed alternative antiviral distribution and dispensing system using a nationally representative survey of pharmacists. Overall, pharmacists were highly receptive to this alternative system and voiced a willingness to participate personally, and most thought their own pharmacy would participate in such an effort. This was true across pharmacists with different personal and professional backgrounds, as well as those in different pharmacy settings. However, sizable shares of pharmacists said they were worried about facing shortages of the antivirals, the risk of exposure to disease for themselves and their families, managing their usual patients who need their prescriptions filled for medications other than antivirals, keeping order in the pharmacy, and potential liability concerns. These findings should be interpreted as an indication of acceptability of the concept, encouragement for the next steps in alternative distribution and dispensing system design, and a guide to potential barriers that may need to be addressed proactively. |
Estimating weekly call volume to a national nurse telephone triage line in an influenza pandemic
Adhikari BB , Koonin LM , Mugambi ML , Sliger KD , Washington ML , Kahn EB , Meltzer MI . Health Secur 2018 16 (5) 334-340 Telephone nurse triage lines, such as the Centers for Disease Control and Prevention's (CDC) Flu on Call((R)), a national nurse triage line, may help reduce the surge in demand for health care during an influenza pandemic by triaging callers, providing advice about clinical care and information about the pandemic, and providing access to prescription antiviral medication. We developed a Call Volume Projection Tool to estimate national call volume to Flu on Call((R)) during an influenza pandemic. The tool incorporates 2 influenza clinical attack rates (20% and 30%), 4 different levels of pandemic severity, and different initial "seed numbers" of cases (10 or 100), and it allows variation in which week the nurse triage line opens. The tool calculates call volume by using call-to-hospitalization ratios based on pandemic severity. We derived data on nurse triage line calls and call-to-hospitalization ratios from experience with the 2009 Minnesota FluLine nurse triage line. Assuming a 20% clinical attack rate and a case hospitalization rate of 0.8% to 1.5% (1968-like pandemic severity), we estimated the nationwide number of calls during the peak week of the pandemic to range from 1,551,882 to 3,523,902. Assuming a more severe 1957-like pandemic (case hospitalization rate = 1.5% to 3.0%), the national number of calls during the peak week of the pandemic ranged from 2,909,778 to 7,047,804. These results will aid in planning and developing nurse triage lines at both the national and state levels for use during a future influenza pandemic. |
Timely antiviral administration during an influenza pandemic: Key components
Koonin LM , Patel A . Am J Public Health 2018 108 S215-s220 Prompt treatment of ill persons with influenza antivirals will be an important part of a future pandemic influenza response. This essay reviews key lessons learned from the 2009 H1N1 pandemic and the changing landscape of antiviral drug availability, and identifies and describes the multiple components needed to ensure the timely administration of antiviral drugs during a future pandemic. Fortunately, many of these planning efforts can take place before a pandemic strikes to improve outcomes during a future public health emergency. |
Contraception as a medical countermeasure to reduce adverse outcomes associated with Zika virus infection in Puerto Rico: The Zika Contraception Access Network Program
Romero L , Koonin LM , Zapata LB , Hurst S , Mendoza Z , Lathrop E . Am J Public Health 2018 108 S227-s230 The Zika Contraception Access Network established a network of 153 physicians across Puerto Rico as a short-term emergency response during the 2016-2017 Zika virus outbreak to provide client-centered contraceptive counseling and same-day contraception services at no cost for women who chose to prevent pregnancy. Between May 2016 and August 2017, 21 124 women received services. Contraception was used as a medical countermeasure to reduce adverse Zika-related reproductive outcomes during the outbreak and may be considered a key strategy in other emergencies. |
Scripted surge pharmacy pandemic exercise: Testing vaccine administration and antiviral dispensing
Sokolow LZ , Patel A , Koonin LM , Graitcer SB . Health Secur 2018 16 (4) 262-273 In 2015, the Centers for Disease Control and Prevention (CDC) collaborated with the National Association of County and City Health Officials (NACCHO) to develop and conduct the Scripted Surge Pharmacy Pandemic Exercise to assess the capacity of pharmacies to administer vaccines and dispense medications during a severe influenza pandemic and to evaluate their various approaches to this activity. A mass merchant pharmacy and a supermarket pharmacy were recruited in 2 different states. At each pharmacy, 2 consecutive 90-minute exercise runs were completed in which actors, simulating patients, presented themselves to the pharmacy counter and requested a vaccine and/or prescription(s). Each run was slightly different in terms of patient flow, staffing, and physical configuration. Individual plays were timed, and a quality assessment was conducted as each patient left the store. Despite the complexities of the pandemic scenario, the number of vaccines administered and prescriptions dispensed surpassed what that pharmacy could typically accomplish during current peak hours of operation. Furthermore, the number of requests successfully processed increased between the first and second runs at each site, suggesting that processing efficiency improved with practice and experience. Few unexpected outcomes were observed, most of which were attributable to exercise artificialities, and they were judged unlikely to occur under real-world scenarios and routine pharmacy practice. The experience gained from this exercise indicates that pharmacies can likely play an important role in improving access to vaccinations and medications during a future pandemic. |
Cost-effectiveness of increasing access to contraception during the Zika virus outbreak, Puerto Rico, 2016
Li R , Simmons KB , Bertolli J , Rivera-Garcia B , Cox S , Romero L , Koonin LM , Valencia-Prado M , Bracero N , Jamieson DJ , Barfield W , Moore CA , Mai CT , Korhonen LC , Frey MT , Perez-Padilla J , Torres-Munoz R , Grosse SD . Emerg Infect Dis 2017 23 (1) 74-82 We modeled the potential cost-effectiveness of increasing access to contraception in Puerto Rico during a Zika virus outbreak. The intervention is projected to cost an additional $33.5 million in family planning services and is likely to be cost-saving for the healthcare system overall. It could reduce Zika virus-related costs by $65.2 million ($2.8 million from less Zika virus testing and monitoring and $62.3 million from avoided costs of Zika virus-associated microcephaly [ZAM]). The estimates are influenced by the contraception methods used, the frequency of ZAM, and the lifetime incremental cost of ZAM. Accounting for unwanted pregnancies that are prevented, irrespective of Zika virus infection, an additional $40.4 million in medical costs would be avoided through the intervention. Increasing contraceptive access for women who want to delay or avoid pregnancy in Puerto Rico during a Zika virus outbreak can substantially reduce the number of cases of ZAM and healthcare costs. |
Early identification and prevention of the spread of Ebola - United States
Van Beneden CA , Pietz H , Kirkcaldy RD , Koonin LM , Uyeki TM , Oster AM , Levy DA , Glover M , Arduino MJ , Merlin TL , Kuhar DT , Kosmos C , Bell BP . MMWR Suppl 2016 65 (3) 75-84 In response to the 2014-2016 Ebola virus disease (Ebola) epidemic in West Africa, CDC prepared for the potential introduction of Ebola into the United States. The immediate goals were to rapidly identify and isolate any cases of Ebola, prevent transmission, and promote timely treatment of affected patients. CDC's technical expertise and the collaboration of multiple partners in state, local, and municipal public health departments; health care facilities; emergency medical services; and U.S. government agencies were essential to the domestic preparedness and response to the Ebola epidemic and relied on longstanding partnerships. CDC established a comprehensive response that included two new strategies: 1) active monitoring of travelers arriving from countries affected by Ebola and other persons at risk for Ebola and 2) a tiered system of hospital facility preparedness that enabled prioritization of training. CDC rapidly deployed a diagnostic assay for Ebola virus (EBOV) to public health laboratories. Guidance was developed to assist in evaluation of patients possibly infected with EBOV, for appropriate infection control, to support emergency responders, and for handling of infectious waste. CDC rapid response teams were formed to provide assistance within 24 hours to a health care facility managing a patient with Ebola. As a result of the collaborations to rapidly identify, isolate, and manage Ebola patients and the extensive preparations to prevent spread of EBOV, the United States is now better prepared to address the next global infectious disease threat.The activities summarized in this report would not have been possible without collaboration with many U.S. and international partners (http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/partners.html). |
Assessing the capacity of the US health care system to use additional mechanical ventilators during a large-scale public health emergency
Ajao A , Nystrom SV , Koonin LM , Patel A , Howell DR , Baccam P , Lant T , Malatino E , Chamberlin M , Meltzer MI . Disaster Med Public Health Prep 2015 9 (6) 1-8 OBJECTIVE: A large-scale public health emergency, such as a severe influenza pandemic, can generate large numbers of critically ill patients in a short time. We modeled the number of mechanical ventilators that could be used in addition to the number of hospital-based ventilators currently in use. METHODS: We identified key components of the health care system needed to deliver ventilation therapy, quantified the maximum number of additional ventilators that each key component could support at various capacity levels (i.e., conventional, contingency, and crisis), and determined the constraining key component at each capacity level. RESULTS: Our study results showed that US hospitals could absorb between 26,200 and 56,300 additional ventilators at the peak of a national influenza pandemic outbreak with robust pre-pandemic planning. CONCLUSIONS: The current US health care system may have limited capacity to use additional mechanical ventilators during a large-scale public health emergency. Emergency planners need to understand their health care systems' capability to absorb additional resources and expand care. This methodology could be adapted by emergency planners to determine stockpiling goals for critical resources or to identify alternatives to manage overwhelming critical care need. |
Clinician beliefs and attitudes regarding use of respiratory protective devices and surgical masks for influenza
Pillai SK , Beekmann SE , Babcock HM , Pavia AT , Koonin LM , Polgreen PM . Health Secur 2015 13 (4) 274-80 While influenza transmission is thought to occur primarily by droplet spread, the role of airborne spread remains uncertain. Understanding the beliefs and attitudes of infectious disease physicians regarding influenza transmission and respiratory and barrier protection preferences can provide insights into workplace decisions regarding respiratory protection planning. Physicians participating in the Infectious Diseases Society of America's Emerging Infections Network were queried in November 2013 to determine beliefs and attitudes on influenza transmission. A subset of physicians involved in their facility's respiratory protection decision making were queried about respirator and surgical mask choices under various pandemic scenarios; availability of, and challenges associated with, respirators in their facility; and protective strategies during disposable N95 shortages. The majority of 686 respondents (98%) believed influenza transmission occurs frequently or occasionally via droplets; 44% of respondents believed transmission occurs via small particles frequently (12%) or occasionally (32%). Among the subset of respondents involved in respiratory protection planning at their facility, over 90% preferred surgical masks during provision of non-aerosol-generating patient care for seasonal influenza. However, for the same type of care during an influenza pandemic, two-thirds of respondents opted for disposable N95 filtering facepiece respirators. In settings where filtering facepiece (disposable) N95 respirators were in short supply, preferred conservation strategies included extended use and reuse of disposable N95s. Use of reusable (elastomeric facepiece) respirator types was viewed less favorably. While respondents identified droplets as the primary mode of influenza transmission, during a high-severity pandemic scenario there was increased support for devices that reduced aerosol-based transmission. Use of potentially less familiar respirator types may partially relieve shortages of disposable N95s but also may require significant education efforts so that clinicians are aware of the characteristics of alternative personal protective equipment. |
Infectious disease physician assessment of hospital preparedness for Ebola virus disease
Polgreen PM , Santibanez S , Koonin LM , Rupp ME , Beekmann SE , Del Rio C . Open Forum Infect Dis 2015 2 (3) ofv087 BACKGROUND: The first case of Ebola diagnosed in the United States and subsequent cases among 2 healthcare workers caring for that patient highlighted the importance of hospital preparedness in caring for Ebola patients. METHODS: From October 21, 2014 to November 11, 2014, infectious disease physicians who are part of the Emerging Infections Network (EIN) were surveyed about current Ebola preparedness at their institutions. RESULTS: Of 1566 EIN physician members, 869 (55.5%) responded to this survey. Almost all institutions represented in this survey showed a substantial degree of preparation for the management of patients with suspected and confirmed Ebola virus disease. Despite concerns regarding shortages of personal protective equipment, approximately two thirds of all respondents reported that their facilities had sufficient and ready availability of hoods, full body coveralls, and fluid-resistant or impermeable aprons. The majority of respondents indicated preference for transfer of Ebola patients to specialized treatment centers rather than caring for them locally. In general, we found that larger hospitals and teaching hospitals reported higher levels of preparedness. CONCLUSIONS: Prior to the Centers for Disease Control and Prevention's plan for a tiered approach that identified specific roles for frontline, assessment, and designated treatment facilities, our query of infectious disease physicians suggested that healthcare facilities across the United States were making preparations for screening, diagnosis, and treatment of Ebola patients. Nevertheless, respondents from some hospitals indicated that they were relatively unprepared. |
Potential demand for respirators and surgical masks during a hypothetical influenza pandemic in the United States
Carias C , Rainisch G , Shankar M , Adhikari BB , Swerdlow DL , Bower WA , Pillai SK , Meltzer MI , Koonin LM . Clin Infect Dis 2015 60 Suppl 1 S42-51 BACKGROUND: To inform planning for an influenza pandemic, we estimated US demand for N95 filtering facepiece respirators (respirators) by healthcare and emergency services personnel and need for surgical masks by pandemic patients seeking care. METHODS: We used a spreadsheet-based model to estimate demand for 3 scenarios of respirator use: base case (usage approximately follows epidemic curve), intermediate demand (usage rises to epidemic peak and then remains constant), and maximum demand (all healthcare workers use respirators from pandemic onset). We assumed that in the base case scenario, up to 16 respirators would be required per day per intensive care unit patient and 8 per day per general ward patient. Outpatient healthcare workers and emergency services personnel would require 4 respirators per day. Patients would require 1.2 surgical masks per day. RESULTS AND CONCLUSIONS: Assuming that 20% to 30% of the population would become ill, 1.7 to 3.5 billion respirators would be needed in the base case scenario, 2.6 to 4.3 billion in the intermediate demand scenario, and up to 7.3 billion in the maximum demand scenario (for all scenarios, between 0.1 and 0.4 billion surgical masks would be required for patients). For pandemics with a lower attack rate and fewer cases (eg, 2009-like pandemic), the number of respirators needed would be higher because the pandemic would have longer duration. Providing these numbers of respirators and surgical masks represents a logistic challenge for US public health agencies. Public health officials must urgently consider alternative use strategies for respirators and surgical masks during a pandemic that may vary from current practices. |
Estimates of the demand for mechanical ventilation in the United States during an influenza pandemic
Meltzer MI , Patel A , Ajao A , Nystrom SV , Koonin LM . Clin Infect Dis 2015 60 Suppl 1 S52-7 An outbreak in China in April 2013 of human illnesses due to avian influenza A(H7N9) virus provided reason for US public health officials to revisit existing national pandemic response plans. We built a spreadsheet model to examine the potential demand for invasive mechanical ventilation (excluding "rescue therapy" ventilation). We considered scenarios of either 20% or 30% gross influenza clinical attack rate (CAR), with a "low severity" scenario with case fatality rates (CFR) of 0.05%-0.1%, or a "high severity" scenario (CFR: 0.25%-0.5%). We used rates-of-influenza-related illness to calculate the numbers of potential clinical cases, hospitalizations, admissions to intensive care units, and need for mechanical ventilation. We assumed 10 days ventilator use per ventilated patient, 13% of total ventilator demand will occur at peak, and a 33.7% weighted average mortality risk while on a ventilator. At peak, for a 20% CAR, low severity scenario, an additional 7000 to 11 000 ventilators will be needed, averting a pandemic total of 35 000 to 55 000 deaths. A 30% CAR, high severity scenario, will need approximately 35 000 to 60 500 additional ventilators, averting a pandemic total 178 000 to 308 000 deaths. Estimates of deaths averted may not be realized because successful ventilation also depends on sufficient numbers of suitably trained staff, needed supplies (eg, drugs, reliable oxygen sources, suction apparatus, circuits, and monitoring equipment) and timely ability to match access to ventilators with critically ill cases. There is a clear challenge to plan and prepare to meet demands for mechanical ventilators for a future severe pandemic. |
Estimating the United States demand for influenza antivirals and the effect on severe influenza disease during a potential pandemic
O'Hagan JJ , Wong KK , Campbell AP , Patel A , Swerdlow DL , Fry AM , Koonin LM , Meltzer MI . Clin Infect Dis 2015 60 Suppl 1 S30-41 Following the detection of a novel influenza strain A(H7N9), we modeled the use of antiviral treatment in the United States to mitigate severe disease across a range of hypothetical pandemic scenarios. Our outcomes were total demand for antiviral (neuraminidase inhibitor) treatment and the number of hospitalizations and deaths averted. The model included estimates of attack rate, healthcare-seeking behavior, prescription rates, adherence, disease severity, and the potential effect of antivirals on the risks of hospitalization and death. Based on these inputs, the total antiviral regimens estimated to be available in the United States (as of April 2013) were sufficient to meet treatment needs for the scenarios considered. However, distribution logistics were not examined and should be addressed in future work. Treatment was estimated to avert many severe outcomes (5200-248 000 deaths; 4800-504 000 hospitalizations); however, large numbers remained (25 000-425 000 deaths; 580 000-3 700 000 hospitalizations), suggesting that the impact of combinations of interventions should be examined. |
Systems for rapidly detecting and treating persons with ebola virus disease - United States
Koonin LM , Jamieson DJ , Jernigan JA , Van Beneden CA , Kosmos C , Harvey MC , Pietz H , Bertolli J , Perz JF , Whitney CG , Halpin AS , Daley WR , Pesik N , Margolis GS , Tumpey A , Tappero J , Damon I . MMWR Morb Mortal Wkly Rep 2015 64 (8) 222-5 The U.S. Department of Health and Human Services (HHS), CDC, other U.S. government agencies, the World Health Organization (WHO), and international partners are taking multiple steps to respond to the current Ebola virus disease (Ebola) outbreak in West Africa to reduce its toll there and to reduce the chances of international spread. At the same time, CDC and HHS are working to ensure that persons who have a risk factor for exposure to Ebola and who develop symptoms while in the United States are rapidly identified and isolated, and safely receive treatment. HHS and CDC have actively worked with state and local public health authorities and other partners to accelerate health care preparedness to care for persons under investigation (PUI) for Ebola or with confirmed Ebola. This report describes some of these efforts and their impact. |
US hospital preparedness for obstetrics patients with possible Ebola
Meaney-Delman D , Koonin LM , Jamieson DJ . Am J Obstet Gynecol 2015 212 (4) 417-9 Since early March 2014, >20,000 probable and suspect cases of Ebola virus disease (EVD) have been reported in Guinea, Sierra Leone, and Liberia, with more than 8000 deaths reported as of Jan. 4, 2015.1 Although pregnancy data are limited, reports of pregnant women with EVD in this2,3 and previous4,5 outbreaks describe very high maternal, fetal, and neonatal death rates. The diagnosis of EVD remains rare in the United States with only 4 confirmed cases and none among pregnant women. Because the greatest risks for exposure to Ebola virus remain residence in or travel to countries with wide-spread Ebola virus transmission, pregnant women should continue to be screened regarding recent international travel and potential exposure to Ebola virus.4,6 | Health care providers who care for pregnant women should identify those women who are at risk for EVD and, as described by Minkoff and Ecker,7 have an obligation to ensure safe, prompt, and appropriate care. Pregnant women who have traveled recently from a country with wide-spread Ebola virus transmission (http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/case-counts.html) or have had exposure to a person with EVD within the past 21 days and who are exhibiting EVD-compatible signs or symptoms8 (fever, severe headache, muscle pain, weakness, fatigue, diarrhea, vomiting, abdominal pain, or unexplained hemorrhage) require isolation, triage, and appropriate evaluation. While being evaluated, pregnant women require continuous access to care.7,9 The vast majority of pregnant women (even those with recent travel to countries with wide-spread Ebola virus transmission) do not have EVD; therefore, it is critical that there be no delay or interruption in care, and it is equally important that other diagnoses are considered while an evaluation for possible EVD is being conducted. This editorial addresses considerations for pregnant women with epidemiologic risk factors for EVD and highlights recent efforts to prepare US hospitals and clinicians for the care of pregnant women with possible EVD. |
Leveraging partnerships among community pharmacists, pharmacies, and health departments to improve pandemic influenza response
Rubin SE , Schulman RM , Roszak AR , Herrmann J , Patel A , Koonin LM . Biosecur Bioterror 2014 12 (2) 76-84 Response to public health emergencies requires coordination across multiple sectors and effective use of existing resources in communities. With the expanded role of community pharmacists in public health during the past decade, their participation in response to emergencies has become increasingly important. Local health departments play a lead role in local public health emergency responses, and their ability to develop and leverage partnerships has become increasingly vital given their funding and personnel shortages. This article offers insight and recommendations on how local health departments can most effectively develop and maintain relationships with community pharmacies and pharmacists that will allow for a more coordinated and resourceful public health response to emergencies, and specifically to pandemic influenza outbreaks. Additionally, state and local health departments should reach out to pharmacies in a synchronized way to incorporate them into their pandemic influenza planning and response efforts. As pharmacists continue to expand their role as part of the public health system, pharmacy staff can be active participants with public health agencies to improve community public health emergency response. |
Broadening access to medical care during a severe influenza pandemic: the CDC Nurse Triage Line project
Koonin LM , Hanfling D . Biosecur Bioterror 2013 11 (1) 75-80 The impact of a severe influenza pandemic could be overwhelming to hospital emergency departments, clinics, and medical offices if large numbers of ill people were to simultaneously seek care. While current planning guidance to reduce surge on hospitals and other medical facilities during a pandemic largely focuses on improving the "supply" of medical care services, attention on reducing "demand" for such services is needed by better matching patient needs with alternative types and sites of care. Based on lessons learned during the 2009 H1N1 pandemic, the Centers for Disease Control and Prevention and its partners are currently exploring the acceptability and feasibility of using a coordinated network of nurse triage telephone lines during a pandemic to assess the health status of callers, help callers determine the most appropriate site for care (eg, hospital ED, outpatient center, home), disseminate information, provide clinical advice, and provide access to antiviral medications for ill people, if appropriate. As part of this effort, the integration and coordination of poison control centers, existing nurse advice lines, 2-1-1 information lines, and other hotlines are being investigated. |
Novel framework for assessing epidemiologic effects of influenza epidemics and pandemics
Reed C , Biggerstaff M , Finelli L , Koonin LM , Beauvais D , Uzicanin A , Plummer A , Bresee J , Redd SC , Jernigan DB . Emerg Infect Dis 2013 19 (1) 85-91 The effects of influenza on a population are attributable to the clinical severity of illness and the number of persons infected, which can vary greatly between seasons or pandemics. To create a systematic framework for assessing the public health effects of an emerging pandemic, we reviewed data from past influenza seasons and pandemics to characterize severity and transmissibility (based on ranges of these measures in the United States) and outlined a formal assessment of the potential effects of a novel virus. The assessment was divided into 2 periods. Because early in a pandemic, measurement of severity and transmissibility is uncertain, we used a broad dichotomous scale in the initial assessment to divide the range of historic values. In the refined assessment, as more data became available, we categorized those values more precisely. By organizing and prioritizing data collection, this approach may inform an evidence-based assessment of pandemic effects and guide decision making. |
Selecting nonpharmaceutical strategies to minimize influenza spread: the 2009 influenza A (H1N1) pandemic and beyond
Barrios LC , Koonin LM , Kohl KS , Cetron M . Public Health Rep 2012 127 (6) 565-71 Shortly after the influenza A (H1N1) 2009 pandemic began, the U.S. government provided guidance to state and local authorities to assist decision-making for the use of nonpharmaceutical strategies to minimize influenza spread. This guidance included recommendations for flexible decision-making based on outbreak severity, and it allowed for uncertainty and course correction as the pandemic progressed. These recommendations build on a foundation of local, collaborative planning and posit a series of questions regarding epidemiology, the impact on the health-care system, and locally determined feasibility and acceptability of nonpharmaceutical strategies. This article describes recommendations and key questions for decision makers. |
CDC's 2009 H1N1 Vaccine Pharmacy Initiative in the United States: implications for future public health and pharmacy collaborations for emergency response
Koonin LM , Beauvais DR , Shimabukuro T , Wortley PM , Palmier JB , Stanley TR , Theofilos J , Merlin TL . Disaster Med Public Health Prep 2011 5 (4) 253-255 During the 2009 H1N1 influenza pandemic, the CDC contacted the 50 state, New York City, and District of Columbia health departments and the health department in Puerto Rico through the Association of State and Territorial Health Officials (ASTHO), to discuss distributing 2009 H1N1 influenza vaccine directly to large pharmacy chains (“pharmacies”) to supplement state vaccination efforts. By the end of December 2009, most states had opened vaccination to all members of the public and a vaccine surplus was projected. All but three states opted to take part in this CDC 2009 H1N1 Vaccine Pharmacy Initiative.* The CDC subsequently invited the largest 15 US pharmacies (by prescription share) to participate, 12 of these pharmacies expressed interest and 10 ultimately participated.1 From December 2009-February 2010, the CDC distributed 5 483 900 doses of 2009 H1N1 vaccine to these pharmacy chains; they in turn, distributed it to more than 10 700 retail stores nationwide. The amount of 2009 H1N1 vaccine that the CDC directly distributed to pharmacy chains comprised approximately 23% of all vaccine distributed during the same time period to the same states and accounted for approximately 4.3% of all 2009 H1N1 vaccine distributed during October 2009-February 2010. Approximately 10% of adults who received 2009 H1N1 influenza vaccine reported getting vaccinated at a pharmacy.2 This included vaccinations given with vaccine provided to pharmacies by state health officials and directly by the CDC (Figure). |
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