Evidence-Based Practice for
Public Health Emergency
Preparedness and Response
Ned Calonge, Lisa Brown, and Autumn Downey, Editors
Committee on Evidence-Based Practices for
Public Health Emergency Preparedness and Response
Board on Health Sciences Policy
Board on Population Health and Public Health Practice
Health and Medicine Division
A Consensus Study Report of
THE NATIONAL ACADEMIES PRESS
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This activity was supported by a contract between the National Academy of Sciences and the Centers for Disease Control and Prevention (Contract #200-2011-38807, Task Order 60). Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
International Standard Book Number-13: 978-0-309-67038-8
International Standard Book Number-10: 0-309-67038-1
Digital Object Identifier: https://doi.org/10.17226/25650
Library of Congress Control Number: 2020943124
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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2020. Evidence-based practice for public health emergency preparedness and response. Washington, DC: The National Academies Press. https://doi.org/10.17226/25650.
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COMMITTEE ON EVIDENCE-BASED PRACTICES FOR PUBLIC HEALTH EMERGENCY PREPAREDNESS AND RESPONSE
BRUCE (NED) CALONGE (Chair), President and Chief Executive Officer, The Colorado Trust
DAVID M. ABRAMSON, Associate Professor and Director, Program on Population Impact Recovery and Resilience (PiR2), New York University School of Global Public Health
JULIE CASANI, Medical Director of Student Health Services, North Carolina State University
DAVID EISENMAN, Professor in Residence, David Geffen School of Medicine and Fielding School of Public Health, Division of General Internal Medicine and Health Services Research, University of California, Los Angeles
FRANCISCO GARCÍA, Deputy County Administrator and Chief Medical Officer, Pima County, and Professor Emeritus of Public Health, University of Arizona
PAUL HALVERSON, Founding Dean and Professor, Richard M. Fairbanks School of Public Health, Indiana University
SEAN HENNESSY, Professor of Epidemiology and of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania
EDBERT HSU, Associate Professor, Department of Emergency Medicine and Associate Director, Office of Critical Event Preparedness and Response, Johns Hopkins University
NATHANIEL HUPERT, Associate Professor of Medicine and Population Health Sciences, Weill Medical College, and Co-Director, Cornell Institute for Disease and Disaster Preparedness, Cornell University
REBECCA A. MAYNARD, University Trustee Chair Professor of Education and Social Policy, University of Pennsylvania
SUZET McKINNEY, Executive Director and Chief Executive Officer, Illinois Medical District
JANE P. NOYES, Professor of Health and Social Services Research and Child Health, School of Health Sciences, Bangor University, United Kingdom
DOUGLAS K. OWENS, Henry J. Kaiser Jr. Professor, Professor of Medicine and Director, Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford University
SANDRA QUINN, Professor, Department of Family Science, School of Public Health, University of Maryland
PAUL SHEKELLE, Founding Director, Southern California Evidence-Based Practice Center, RAND Corporation
ANDY STERGACHIS, Professor of Pharmacy and Global Health, Associate Dean, School of Pharmacy, Director, Global Medicines Program, University of Washington
MITCH STRIPLING, National Director, Emergency Preparedness and Response, Planned Parenthood Federation of America
STEVEN M. TEUTSCH, Adjunct Professor, Fielding School of Public Health, University of California, Los Angeles; and Senior Fellow, Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California
TENER GOODWIN VEENEMA, Professor of Nursing and Public Health, School of Nursing and Bloomberg School of Public Health, Johns Hopkins University
MATTHEW WYNIA, Director, Center for Bioethics and Humanities, University of Colorado
National Academy of Medicine Fellow
MAHSHID ABIR, Director, Acute Care Research Unit, and Associate Professor, Department of Emergency Medicine, University of Michigan; and Senior Physician Policy Researcher, RAND Corporation
LISA BROWN, Study Co-Director
AUTUMN DOWNEY, Study Co-Director
MEGAN KEARNEY, Associate Program Officer (from November 2019)
LEAH RAND, Associate Program Officer (until August 2019)
MATTHEW MASIELLO, Research Associate (until August 2019)
ALEX REPACE, Senior Program Assistant
REBECCA MORGAN, Senior Research Librarian
KATHLEEN STRATTON, Senior Scholar, Board on Population Health and Public Health Practice
ANDREW M. POPE, Senior Director, Board on Health Sciences Policy
LGND, Graphic Design Team
RONA BRIERE, Senior Editor, Briere Associates, Inc.
SGNL Solutions, Science Writer
Commissioned Paper Authors
ETHAN BALK, Center for Evidence Synthesis in Health, Brown University
JEREMY GOLDHABER-FIEBERT, Stanford University
JENNIFER HORNEY, University of Delaware
KARLI KONDO, Portland VA Evidence Synthesis Program
JULIE NOVAK, Wayne State University
SNEHA PATEL, Columbia University
IAN SALDANHA, Center for Evidence Synthesis in Health, Brown University
PRADEEP SOPORY, Wayne State University
MARCIA TESTA, Harvard University
Public Health Emergency Preparedness and Response Subject-Matter Consultants
JESSICA CABRERA-MARQUEZ, Puerto Rico Department of Health
CARINA ELSENBOSS, Public Health Seattle and King County
STEVEN HULEATT, West Hartford-Bloomfield Health District
CHRISTIE LUCE, Florida Department of Health
PATRICK LUJAN, Guam Department of Public Health and Social Services
DAVID NEZ, Navajo Department of Health
PAUL PETERSON, Tennessee Department of Health
LOU SCHMITZ, American Indian Health Commission for Washington State
EDNA QUINONES-ALVAREZ, Puerto Rico Department of Health
Evidence Review Methodology Subject-Matter Consultant
HOLGER SCHÜNEMANN, McMaster University
This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.
We thank the following individuals for their review of this report:
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report, nor did they see the final draft before its release. The review of this report was overseen by ENRIQUETA C. BOND, Burroughs Wellcome Fund, and LINDA C. DEGUTIS, Henry M. Jackson Foundation. They were responsible for making certain that an independent examina-
tion of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.
In 1946 the federal government created the Communicable Disease Center to address the spread of malaria in the United States. Building on prior state and local activities to address infectious disease outbreaks through the development of public health laboratories, coordinated quarantine and isolation efforts, and national efforts that included the creation of the Public Health Service, this early version of what would become the Centers for Disease Control and Prevention (CDC) was initially created in response to what today would be called a “public health emergency.”
Infectious disease control remained a core element of public health practice, and as the nation experienced ongoing challenges with seasonal influenza and other new threats began to emerge, CDC funded a small number of state health departments to develop planning around pandemic influenza and bioterrorism preparedness in the late 1990s. The terrorist attacks of September 11, 2001, followed by the anthrax letters the following month, brought into sharp focus the need for a more substantial commitment to preparing for those emergencies that involve a public health response. The Public Health Security and Bioterrorism Preparedness and Response Act was passed in 2002, and the Center for Preparedness and Response at CDC was created in 2003, with unprecedented new funding for states to support preparedness efforts. Since then, the number of events requiring a public health response has been impressive, and not limited to infectious diseases. These events have involved West Nile virus; severe acute respiratory syndrome; the federal smallpox vaccination program; monkey-pox; the 2004–2005 influenza vaccine shortage; the H1N1 virus (swine flu); Hurricanes Katrina and Harvey; Midwest and Rocky Mountain West floods; California wildfires; several regional national food recalls for E. coli O157, Salmonella, and Listeria; and Ebola virus—just to name those that reached national attention.
Policy makers have recognized the need for rigor in public health’s emergency planning and response activities, but while investments have been made in research, this funding has been sporadic, not well coordinated, and not always focused on the needs of public health practitioners. The result has been a relatively sparse evidence base for public health emer-
gency preparedness and response (PHEPR) practices, reflecting broad variation in research design, implementation, reporting, synthesis, and translation.
Recognizing the substantial benefit for human health that could be realized through an evidence-based approach to identifying those practices that warrant being recommended to PHEPR practitioners, leaders from CDC’s Center for Preparedness and Response commissioned the National Academies of Sciences, Engineering, and Medicine to undertake a study focused on developing an evidence synthesis methodology specific to PHEPR practices and piloting that methodology by evaluating a number of practices important to practitioners in the field. Bringing together experts in research methods and evidence synthesis and leaders and researchers in PHEPR, the study committee created a customized evidence review and synthesis and evidence-to-recommendation methodology that recognizes the value of and utilizes the full body of available research. Creating this methodology thus entailed applying synthesis methods created for both quantitative and qualitative data, as well for more novel evidence categories that encompassed parallel evidence (i.e., evidence regarding the same or similar intervention but in different contexts), mechanistic evidence (i.e., evidence based on an identifiable causal link or pathway, generally previously established in other fields), and case reports and after action reports (prepared as a standard practice in review and evaluation of public health emergency response).
The committee applied this methodology in formulating recommendations and guidance for specific practices in four of CDC’s 15 Preparedness and Response Capabilities1: engaging with and training community-based partners to improve the outcomes of at-risk populations (falls under Capability 1, Community Preparedness); activating a public health emergency operations center (Capability 3, Emergency Operations Coordination); communicating public health alerts and guidance with technical audiences during a public health emergency (Capability 6, Information Sharing); and implementing quarantine to reduce or stop the spread of a contagious disease (Capability 11, Non-Pharmaceutical Interventions). The process by which these four diverse practices were selected was designed in such a way as to ensure that the committee’s evidence synthesis methodology can be applied to other practices that fall under all 15 Capabilities. It was not, however, a prioritization process based on importance; all 15 Capabilities are critical to the preparation for and response to a public health emergency. As it is applied to other practices, the committee is confident its methodology will continue to evolve to provide public health leaders with guidance based on the best available evidence—the key tenet of evidence-based practice.
A NOTE ON COVID-19
In the final weeks of the committee’s work, a public health emergency of international concern emerged with the outbreak of the novel coronavirus responsible for the COVID-19 pandemic. We recognized that each of the practices we had evaluated with our methodology, which were selected roughly 2 years prior to the emergence of this disease, were operative to some extent in the response to this emergency: working with community-based organizations
1 The other 11 Capabilities are Community Recovery (Capability 2), Emergency Public Information and Warning (Capability 4), Fatality Management (Capability 5), Mass Care (Capability 7), Medical Countermeasure Dispensing (Capability 8), Medical Materiel Management and Distribution (Capability 9), Medical Surge (Capability 10), Public Health Laboratory Testing (Capability 12), Public Health Surveillance and Epidemiological Investigation (Capability 13), Volunteer Management (Capability 14), and Responder Safety and Health (Capability 15), as defined in CDC (Centers for Disease Control and Prevention). 2018. Public health emergency preparedness and response capabilities: National standards for state, local, tribal, and territorial public health. https://www.cdc.gov/cpr/readiness/00_docs/CDC_PreparednesResponseCapabilities_October2018_Final_508.pdf (accessed March 11, 2020).
to address the needs of at-risk populations (Chapter 4); activation of an emergency operation center (Chapter 5); communication with health care providers and other technical audiences (Chapter 6); and, of particular note, quarantine (Chapter 7). Although our reviews were not conducted in response to the COVID-19 pandemic, the likely applicability of many of our findings is noteworthy. For example, while it is too soon to conclude definitively whether quarantine is effective at reducing and stopping transmission of this novel coronavirus, the findings from the qualitative evidence synthesis (discussed in Chapter 7) regarding the psychological and financial harms of this practice will undoubtedly be just as relevant to the current quarantine experience as they are to past outbreak scenarios. Given the rapid and evolving nature of the COVID-19 pandemic and the speed at which new studies are being published on non-peer-reviewed, preprint servers, it was not possible at this time to update the committee’s evidence reviews to incorporate studies examining the implementation of the four PHEPR practices reviewed for this study as applied to COVID-19. However, it will be important to expand and update these reviews once the field has rigorously collected, analyzed, and published the relevant data and information.
The emergence of COVID-19 has highlighted critical evidence gaps and lost opportunities to expand the evidence base for these and other PHEPR practices. The lack of interoperable and harmonized data and capacity for local-level monitoring impedes both evidence-based research and response. It reinforces the critical, ongoing need to have processes and programs in place to perform research and evaluation, even in real time, to better inform future decisions. Without these systems in place before, during, and after the unfolding of a disaster, it will be extremely difficult to build the PHEPR evidence base prospectively and retrospectively.
The release of this report in the context of the COVID-19 pandemic puts the challenges of limited research to support evidence-based PHEPR practices in bold relief. The committee’s recommendations around adequate stable funding, robust design and conduct of research studies, development of the research workforce and programs, and a commitment to collaboration between public health practitioners and experienced researchers all are vital to ongoing support of the knowledge development for and implementation of interventions that will better protect the public’s health and minimize the impact of the broad spectrum of emergencies that have and will certainly continue to threaten the security of the nation. The unprecedented costs of COVID-19 show that the nation cannot afford to ignore the calls for these critical investments in public health that have been made by this committee and many others before.
Ned Calonge, Chair
Committee on Evidence-Based Practices for Public Health Emergency Preparedness and Response
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Boxes, Figures, and Tables
B1-2 Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram for the mixed-method review of strategies for engaging with and training community-based partners to improve the outcomes of at-risk populations
B3-2 Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram for the mixed-method review of channels for communicating public health alerts and guidance with technical audiences during a public health emergency
B1-3 Effect of Culturally Tailored Preparedness Training Programs on Improved Attitudes and Beliefs of Community-Based Partner Representatives Regarding Their Preparedness to Meet Needs of At-Risk Individuals
B1-6 Effect of Culturally Tailored Preparedness Training Programs for Community-Based Partners and At-Risk Populations They Serve on Improved Attitudes and Beliefs of Trained At-Risk Populations Regarding Their Preparedness
B1-8 Effect of Community-Based Partner Engagement in Preparedness Outreach Activities Targeting At-Risk Populations on Improved Attitudes and Beliefs of At-Risk Populations Toward Preparedness Behaviors
|AAR||after action report|
|AHRQ||Agency for Healthcare Research and Quality|
|ASPR||Assistant Secretary for Preparedness and Response|
|ASTHO||Association of State and Territorial Health Officials|
|CASP||Critical Appraisal Skills Programme|
|CDC||Centers for Disease Control and Prevention|
|CERQual||Confidence in the Evidence from Reviews of Qualitative Research|
|COE||certainty of the evidence (of effectiveness)|
|CPHP||Center for Public Health Preparedness|
|CPSTF||Community Preventive Services Task Force|
|DECIDE (project)||Developing and Evaluating Communication Strategies to Support Informed Decisions and Practice Based on Evidence|
|DHS||U.S. Department of Homeland Security|
|DoD||U.S. Department of Defense|
|DOI||U.S. Department of the Interior|
|EOC||emergency operations coordination/center|
|EtD||Evidence to Decision (framework)|
|FEMA||Federal Emergency Management Agency|
|GRADE||Grading of Recommendations Assessment, Development and Evaluation|
|HPP||Hospital Preparedness Program|
|HSDL||Homeland Security Digital Library|
|NACCHO||National Association of County & City Health Officials|
|NIEHS||National Institute of Environmental Health Sciences|
|NSF||National Science Foundation|
|PAHPA||Pandemic and All Hazards Preparedness Act|
|PERLC||Preparedness and Emergency Response Learning Center|
|PERRC||Preparedness and Emergency Response Research Center|
|PHAB||Public Health Accreditation Board|
|PHEOC||public health emergency operations center|
|PHEPR||public health emergency preparedness and response|
|PPHR||Project Public Health Ready|
|RCT||randomized controlled trial|
|RoB||risk of bias|
|ROBINS-I (tool)||Risk of Bias in Non-Randomized Studies of Interventions|
|SLTT||state, local, tribal, and territorial|
|USPSTF||U.S. Preventive Services Task Force|
|WHO||World Health Organization|
|WWC||What Works Clearinghouse|